IR 05000206/1979001
| ML13323A667 | |
| Person / Time | |
|---|---|
| Site: | San Onofre  |
| Issue date: | 12/21/1979 |
| From: | Gagliardo J, Hunter D, Martin T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE) |
| To: | |
| Shared Package | |
| ML13323A653 | List: |
| References | |
| 50-206-79-01, 50-206-79-1, NUDOCS 8003280445 | |
| Download: ML13323A667 (70) | |
Text
U. S. NUCLEAR REGULATORY COMMISSION OFFICE OF INSPECTION AND ENFORCEMENT PERFORMANCE APPRAISAL BRANCH Report N /79-01 Docket No. 50-206 Licensee:
Southern California Edison Company 2244 Walnut Grove Avenue Rosemead, California 91770 Facility Name: San Onofre Nuclear Generating Station, Unit 1 Inspection At: San Onofre Site,.San Clemente, California, and Southern California Edison Company General Offices, Rosemead, California Inspection Cond cted:11 February 5 -
16, 1979 Inspectors:
j
'
_
J.\\E. Gag ardo Date D. R. Hunter Date T. T. Martin Date Accompanying Personnel:
J. D. Woessner, PAT (Observer)
L. Canter, Region V
.~F. M'ller, Region V Approved By:
A
&.\\E. Gagli rdo, Acting Chief, Date Performance Appraisal Branch Division of Reactor Construction Inspection Office of Inspection and Enforcement, Headquarters Inspection Summary Inspection on February 2-16, 1979 (Report No. 50-206/79-01)
.
Areas Inspected: Announced performance appraisal inspection of management controls associated with control of plant operations, review and audit of licensed activities, engineering design/design change and modifications, corrective action system, training 9003R2801
inservice inspection and testing, committee activities, maintenance, QA audits, procurement and safety and security controls. The inspection involved 111 inspector-hours on-site and 99 inspector-hours in the licensee's general offices by three NRC Performance Appraisal Inspection Specialist Results:
Of the eleven areas inspected, no items of noncompliance or deviations were identified in four areas; seven apparent items of noncompliance were identified in seven areas (infraction - failure to issue procedures and inadequate procedures, paragraphs 3 and 8; infraction -
failure of off-site committee to perform all required audits, paragraph 9; deficiency - failure to issue a corrective action request, paragraph 6; deficiency - failure to provide a retraining program for maintenance personnel, paragraph 7; deficiency -
failure of the on-site committee to submit written determinations to the Plant Manager, paragraph 9; deficiency failure to provide a written comprehensive preventative maintenance program, paragraph 10; and deficiency -
failure of the fire brigade to meet monthly and failure to have a live fire fighting demonstration in 1978, paragraph 13); and one deviation was found in one area (failure to include the required features of ANSI N18.7 in the off-site committee charter, paragraph 9).
DETAILS 1. Persons Contacted The following lists (by title) the individuals contacted during this inspection. The matrix to the right of the listing indicates the areas (number corresponds to paragraph number in the report) for which that individual provided significant input. Other individuals were contacted during the inspection but the extent of their input to the inspection effort was not significant to the findings reported in this repor Title of Individual - General Office 3 4 5 6 7 8 9 10
12 13
- Vice President, Engineering & Construction _
- Vice President, Power Supply X
X
- Vice President, Advanced Engineering X X X X
- General Superintendent
- Manager of Material Services Manager of Engineering Design X X Manager of Nuclear Fuel Supply X
X Manager of Power Supply Department Services Manager of Steam Generation X
X
+*Manager,,Quality Assurance X X X X X X X Manager of Environmental Affairs X
- Manager, Generation Engineering Services X X X
Procurement Manager -
General Offices X
+*Manager, Nuclear Generation X X X X X X X X
X X Manager, Generation Maint. & Plans X
- Chief of Nuclear Engineering X X X
X Chief of Development & Environmental En X
..
Chief of Contract Construction Management X
Project Quality Assurance Supervisor X X X X X X X
- Project Manager X
Project Engineer X
+*Nuclear Engineer X
- Staff Engineer, Nuclear Generation (2)
X X
X Group Leader, Electrical Design X X X
QA/QC Supervisor X
X Project Purchasing Agent X
X Procurement Supervisor X
X Senior Engineering, Power Supply X
X
+ Project Quality Assurance Engineer X X X
Quality Assurance Engineer (2)
X X X
Engineer, Engineering & Construction (2)
X Group Leader, Mechanical Design X
Supervisor of Methods & Procedures X
-2 Title of Individual - General Office 3 4 5 6 7 8 9 10
12 13 Administrator of Power Supply Services X X X
Administrator of Safety & Occupational Health X
Supervising Safety Engineer X
Fire Equipment Inspector X
Secretary, Nuclear Audit & Review Committee X
- Director of Security X
X
- Security Supervisor X
On-Site
+*Plant Manager X X X X X X X X X X X
+ Superintendent X X X X X X X X X
+ Supervising Engineer X X X X X X X
+ Station Administrative Supervisor X
Supervisor of Plant Security X
X Supervisor of Plant Maintenance X X X
Supervisor of Chemistry/Radiological Protection X X X X X
X X
Supervisor of Plant Instrumentation X
X X X
X X
+ Lead Watch Engineer X X X X X X X X
+ QA/QC Supervisor X
X X X
X X QA Engineers (2)
X X X X Nuclear Engineer X X X
+
Plant Engineer (3)
X X
Assistant Nuclear Engineer X
X Watch Engineer (3)
X X X
X X
X Warehouse Supervisor X
Chemistry/Radiological Protection Eng X X
Assistant Chemistry/Radiological Protection Engineer X
Security Officer X
X Maintenance Foreman (2)
X X X
Chemistry/Radiological Protection Foreman X
X Nuclear Control Operator (4)
X X X
X X
X Chemistry/Radiological Protection Technician (2)
X X
Maintenance Machinist X
Maintenance.Electrician (2)
X Instrument Technician (3)
X X
Maintenance Mechanic X
Assistant Control Operator X
Fire Equipment Inspector X
X
+Attended the exit meeting at the site on February 9, 197 *Attended the exit meeting at the General Offices on February 16, 197.
Inspection Scope and Objectives This report documents the inspection by the NRC/IE Performance Appraisal Branch (PAB) of the licensee's management controls of licensed activitie The objective of the inspection was to determine how the licensee performs licensed activities, the results of which will provide input to the PAB evaluation of licensees from a-national perspectiv The inspection effort covered licensed activities in selected functional areas. In each of the functional areas the inspectors reviewed written policies, procedures, and instructions; interviewed selected personnel and reviewed selected records and documents to determine whether:
a. the licensee had written policies, procedures, or instructions to provide management controls in the subject area; b. the policies, procedures, and instructions of (a) above, were adequate to assure compliance with regulatory requirements; the licensee personnel who had responsibilities-in the subject area were adequately qualified, trained, and retrained to perform their responsibilities; d. the individuals assigned responsibilities in the subject area under stood their responsibilities; and e. the requirements of the subject area had been implemented to achieve compliance and activities sampled had been appropriately documente The inspection findings in each of the selected areas are presented in subsequent numbered paragraphs. The findings in each area are presented in two part The first part contains the enforcement findings which
'document any identified items of noncompliance, deviations, or unresolved items. The corrective action for these findings will be evaluated by the Region V office, which will also-process enforcement action and close out the items. The second part of each area addresses other lesser inspection findings and is entitled "Observations". These are observa tions that the inspectors believe to be of sufficient significance to be considered in the subsequent evaluation of the licensee's performanc The observations include the perceived strengths and weaknesses in the licensee's management controls for which-there may be no well-defined regulatory requirement or guidance. The observations also include information about the licensee or his management controls which cannot be categorized as a strength or weakness, but are items which could be of significance in evaluating management control systems if they are later found to be generic to licensees having success in the subject area, or to those licensees having problems in the are The observations in this report have been classified into one of the above three categories. The classification is indicated at the end of each observation by a code letter in parenthese The code letter "S" is used to indicate a perceived strength, the code *letter "W" is used to indicate a perceived weakness, and the code letter "I" denotes an informational item. Since there is no regulatory basis for most of these observations, enforcement action relative to the observations is not appropriate, and the licensee is not required to take any action regarding them. The licensee is requested, however, to review the observations, with particular emphasis to those categorized as weaknesses, to determine their application to his management controls and quality assurance program in maintaining or improving his organizational effectiveness regarding the safety of his operatio. Review of Plant Operations The objective of this portion of the inspection was to determine the adequacy of the management controls over licensed activities associated with plant operation a. Documents Reviewed (1) FSAR, Amendment 0, Quality Assurance Program, Section (2) San Onofre Nuclear Generating Station (SONGS) 1 Quality Assurance Manua (3) SONGS 1 Administrative Controls Technical Specification (TS), Section (4) Station Orders Fire Protection, S-A-2, Rev. 1 Routine Lubrication, S-A-4, Rev. Unit Startup and Shutdown Records, S-A-7, Rev. Records, S-A-9, Rev. Station Inspections and Housekeeping, S-A-10, Rev. Assignment of Responsibility by Key Personnel, S-A-105, Rev. Equipment Outages, S-A-107, Rev. Admittance to the Station, S-A-108, Rev. Station Documents, Preparation,.Revision and Review, S-A-109, Rev. Station Quality Assurance Organization, S-A-112, Rev. Instructions, Procedures, and Drawings, S-A-114, Rev. Test Control, S-A-116, Rev. Inspection, Test, and Operating Status, S-A-118, Rev. Review and Internal Communication of Operational and Safety Information, S-A-122, Rev. Diesel and Turbine Lube Oil and Diesel Lube Oil Testing, S-E-7, Rev. Station Inspection Plan, S-E-117, Rev. Containment Sphere Integrity and Access, S-E-207, Rev. Request for Equipment Repair, S-M-103, Rev. Control of Lifted Leads and Jumpers, S-0-9, Rev. Major System and Plant Disturbances, S-0-101, Rev. Reactor Standard for Operation, S-0-104, Rev. Locking of Critical Valves, S-0-108, Rev. Equipment Testing Before and After Maintenance, S-0-111, Rev. (5) Station Procedures
.
Plant Equipment Operator's Inspections and Duties, S-0-1, Rev..
Assistant Control Operator's Inspections and Duties,
.
S-0-2, Rev..
Control Operator's Inspections and Duties, S-0-3, Rev..
Auxiliary Feedwater Pump Operation and Testing, S-2-13, Rev..
Battery Charger Operation, S-6-30, Rev..
Plant Startup From Cold Conditions to Minimum Load, S-3-1.1, Rev. 1.
Emergency Shutdown, S-3-5.1, Rev..
Battery Charger Testing Required During Refueling Shutdown, S-I-1.22, Rev..
Nuclear Instrumentation Power Range Channel(s)
Percent Power Amplifier Gain Adjustment, S-II-1.12, Rev. Boron Analysis, S-III-1.1, Rev. Discovery of Unauthorized Personnel in Protected or Vital Areas, S-IV-2.7, Rev..
Thermal Power Determination, S-V-1.9, Rev. Liquid Radioactive Waste Releases, S-VII-1.15, Rev. (6)
Division Orders Orders - General, D-A-.
General Orders, Procedures, and Instructions, D-A-Organization Meetings, D-A-Admittance to Generating Stations, D-A-10 and D-N-Equipment and Performance Testing--General, D-E-San Onofre Reporting Requirements, D-N-Reporting of Defects and Nonconformances for Nuclear Facilities, D-N-Equipment Checkoff Procedures, 0-0 Operation During Major Disturbances, D-0 Findings (1) Items of Noncompliance Technical Specification 6.8.1 states that written procedures and administrative policies shall be established, implemented, and maintained that meet or exceed the requirements and recom mendations of Sections 5.1 and 5.3 of ANSI N18.7-1976, Administrative Controls for Nuclear Power Plant ANSI N18.7-1976, section 5.3, recommends (5.3.1) procedure scope and (5.3.2) content. Additionally, specific recommenda tions are made in the areas of (5.3.3) systems procedures, (5.3.4) general procedures, (5.3.5) maintenance procedures; (5.3.5) radiation control procedures, (5.3.7) calibration and
-7 test procedures, (5.3.8) chemical-radiochemical procedures, (5.3.9) emergency procedures, and (5.3.10) test and inspection procedure Division Order, D-A-2, Station Documents, section 6, and Station Order, S-A-109, Station Document - Preparation, Revision and Review, section I. B., provided administrative guidance for station documents. The guidance required that the station documents shall be prepared in a format that produces the most clear, concise, and effective instruction; and that all pertinent information gained from past operating history, experience, and manufactures recommendations shall be include A review of selected station orders and procedures revealed the following inconsistencie Station orders (S-A-2, S-A-4, S-A-7, S-A-9, S-0-106, S-0-108, and S-0-109) did not contain all the features required by ANSI N18.7-1976 (scope and content).
Station orders (S-E-7, S-E-108, S-E-116, S-E-207, and S-0-106) did not contain the Technical Specification references as appropriat Administrative guidance was not provided in the station orders (S-A-109, S-A-114, and S-A-104) which referenced the Technical Specifications requirements for changes to safety-related procedure These failures to satisfy the requirements and recommendations of section 5.3 of ANSI N18.7-1976 constitutes an item of noncom pliance pursuant to Technical Specification 6.8.1 and is an infractio (2) Deviations Non (3) Unresolved Items (a) TS 6.5.1.6(d), requires that the Onsite Safety Review Committee (OSRC) review all proposed changes or modi fications to plant systems or equipment that affect nuclear safety, and TS 6.5.1.7(a) requires that the OSRC recommend to the plant manager written approval or disapproval of the items considere CFR 50.59(a)(1)(i) indicates that a licensee may make changes in the facility as described in the safety analysis report without prior commission approval, unless the proposed change, test or experiment involves a change in the technical specifications incorporated in the license or is an unreviewed safety question. 10 CFR
50.59(b)(2) indicates that records of changes in the facility and procedures made pursuant to this section to the extent that such changes constitute changes in the facility as described in the safety analysis report shall be maintained and these records shall include a written safety evaluation which provides the basis for the deter mination that the change does not constitute an unreviewed safety questio ANSI N18.7-1972, Section 5.1.5, and ANSI N18.7-1976, Section 5.2.6, require independent verification of the tagging of temporary modifications, jumpers, and lifted leads as appropriate to insure correct implementatio ANSI N18.7-1972, Section 6.1(5) and ANSI N18.7-1976, Section 5.2.6 address returning equipment to service, verification, and documenting functional acceptabilit A review of Station order, S-0-9, Control of Temporary Modifications, which provided the control and documen tation of lifted leads, jumpers installed, changes to trip point settings, and temporary bypass line installation, did not insure the following requirements were addressed and satisfied as appropriat The review of.the proposed modification by the ORS The determination of the need for a review in accordance with 10 CFR 50.5 The independent verification of tagging of temporary modifications, jumpers and lifted leads as appropriate to insure correct implementatio The return of equipment to service, verification, and documentation of functional acceptabilit This matter is an unresolved item. (79-01-01)
(b) TS 6.2.2, Facility Staff, requires that the facility organization shall be as shown in Figure.6.2.2.2. A review of the actual plant organization and personnel interviews revealed that the licensee had established the position of Supervisor of Plant Operations (SPO) as described in the station order (S-A-105) and this position was currently being filled by a licensed senior reactor operator which was not in accordance with Figure 6.2. of T The interfaces between the Supervisor of Plant Operations (SPO) and the Superintendent of Maintenance and Operations (SMO) were described by the Station Order (S-A-105).
-9 This matter is an unresolved item (79-01-02) pending NRR action on the licensee request for a change to the Technical Specification c. Observations The following observations include general information items and perceived strengths and weaknesses in the licensee's management controls which may not have specific regulatory requirements, but will provide the basis for subsequent performance evaluations (Reference paragraph 2).
(1) Division orders were provided at the corporate level which placed requirements upon the plant staff through the Plant Manager. The requirements were either implemented directly or station orders were established to implement the requirements of the orders.(I)
(2) The control of specific plant operations at the station was established by the plant staff. The plant procedures developed for the control of plant operation were approved by the Manager Nuclear Generation.(I)
(3) The corporate chain of command for control of plant operations included three tiers of management below the Vice President, Power Supply. Personnel interviews indicated that this organi zation forced the plant management to be more persuasive concerning program changes and funding. The corporate managers interviewed were aware of the plant operating problems and activities.(I)
(4) Personnel interviews revealed that the Manager - Nuclear Generation delegated responsibilities for critical areas to specific operations engineers in his staff. These responsi bilities included correspondence, procedure reviews, communi cations, and engineering.(I)
(5) Procedure review and personnel interviews revealed that the Manager - Nuclear Generation was responsible for overall plant operations, maintenance, engineering support, safety and envi ronmental improvements. The Manager - Nuclear Generation had been the plant superintendent for twelve (12) years and was intimately knowledgeable of the plant and plant problems.(I)
(6) Plant problems were identified and communicated to upper management informally. Routine meetings held at all levels of management were open to surfacing plant problems. Interviews indicated that the oral communications were.extremely open between site and corporate personne Plant personnel were aware of their rights to independently pursue safety issues with the NRC although the specific rights under 10 CFR 19 were not well known. The operators interviewed were specifically aware of the union grievance procedure available to them.(I)
- 10 (7) The Manager - Nuclear Generation utilized certain informal methods to communicate with the plant manager and follow the plant statu.
Memorandum system
Frequent oral communication
.
Weekly site visits
.
Routine management meetings
.
Review of OSRC minutes(I)
(8) The Manager - Nuclear Generation represented the company on its joint nuclear ventures with other industry representatives.(I)
(9) The operations organization consisted of plant equipment operators, control room operators, watch engineers, supervisor plant operations, superintendent of maintenance and operations, and plant manager. The plant manager reported directly to the Manager -
Nuclear Generation.(I)
(10) Interviews with plant management revealed that the company utilized pre-employment security checks and the new employees were maintained on a six-month probation period. A formal monthly employee evaluation was utilized as determined by the individual's supervisor during the probation period.(I)
(11) Staffing of the operating group generally included experienced personne The operating shifts included a number of newer personnel as a result of a turnover during a previous strike of approximately 80 day The staff turnover rate had been minimal subsequent to the extended strike.(I)
(12)
Plant personnel promotion practices followed a specific program with the following attribute Apprentice program Promotion of supervisors from inside the compan Hiring and promoting experienced engineer Hiring operators from outside when no qualified employee bids for the jo Nuclear plant equipment operator (PEO)
training included five steps over an eighteen month period including a practice reactor operator examination (written and oral).(S)
(13) A four-shift rotation was used by the licensee with a fifth shift available for relief function Hours of duty were contained in the union agreement, which included three eight hour shifts daily.(I)
(14) Operator training was conducted onshift and also during scheduled overtime. Interviews indicated that the training included procedure reviews, study periods (overtime), and monthly tests to maintain and evaluate operator proficiency.(I)
(15) Refueling outages included contracted fuel handling activities.(I)
(16) Plant outage planning was performed by the plant staff with minimal input from corporate personnel.(I)
(17) Corporate and contract personnel were routinely utilized to perform design and modification activities.(I)
(18) Site radiation/chemistry technicians were routinely supplemented during major outages by mobile licensee personnel trained in these disciplines.(I)
(19) Shift relief and manning requirements were dictated by administrative procedures which required log and plant status reviews. The minimum shift compliment (TS -and procedural)
included the watch engineer (first line supervisor - SRO), the control room operator (bargaining unit -
RO/SRO), the assistant control room operator (bargaining unit -
RO), and the plant equipment operator (bargining unit - PE Interviews revealed that shift turnover proceeded smoothly. The shift compliment routinely included an additional operator.(I)
(20)
The shift fire brigade consisted of two plant operators and three security officers. The assistant control room operator (RO) functioned as the Fire Brigade Chief and the plant equip ment operator and three security officers as the brigade member The watch engineer (SRO) and the control room operator (SRO/RO)
were available for routine plant operation or safe plant shutdown.(I)
(21) The watch engineer was designated as the individual qualified in radiation protection supervision (as required by TS) and the site emergency director during the back shifts (as required by the site emergency plan). The licensee considered the SRO training and retraining program adequate to maintain proficiency
-
in these areas.(I)
(22) The call-in method of professional and.supervisory personnel, other than required by the emergency plan, was provided through informal instructions to the watch engineers.(W)
(23) Administrative controls were established for the control of test and measuring equipment, special processes, and security and visitor control.(I)
(24) Liquid radioactive waste releases were controlled by station orders S-E-204, Radioactive Liquid and Gas Waste Disposal, and procedure S-VII-1.15, Liquid Radioactive Waste Releases. The
-12 specific authorization of the Radiation Protection Supervisor or the Watch Engineer was needed (by signature) prior to a liquid release.(I)
(25) The plant engineering department was assigned responsibility (S-E-114) to review equipment failures and unusual operating transients; and then, to provide technical advice and corrective action recommendations to plant management.(I)
(26) The mechanics of crane operation was addressed in station order S-M-104. Interviews revealed that the specific operation requirements for the cranes were covered within various proce dures such as those for reactor head removal, fuel handling, and cask handling.(I)
(27) Station order S-0-104, Reactor Standard for Operations, provided administrative control for the return of the reactor to operation following a reactor trip. This order also required the adherence to the Technical Specifications and the operators to believe plant instrumentation and respond conservativel Interviews revealed that the licensee personnel understood these requirements.(I)
(28) The licensee used standing orders, night orders, and special operating instructions for outage planning. Interviews revealed that the licensee utilized a system of informal work (hot)
sheets to request items to be completed.(W)
(29) "Acknowledgement of information" forms were utilized to distribute reading material to the plant staff. The administra tive control of forms was not fully formalized, nor did they insure the material was read and understood, as appropriate, prior to the return of equipment to service or the assuming of shift duties by an operator.(W)
(30) The safety related equipment, components, and systems were classified in station order S-A-112, Station Quality Assurance Organization, and all activities associated with the listed items were considered safety related. The plant quality listing (Q-List) was maintained and controlled within the Quality Assurance Progra The station "Q-List" was administratively controlled by the corporate engineering and quality assurance group The requirements of the Quality Assurance Program were included in the individual stations orders and procedures, as appropriat These orders and procedures were reviewed by the onsite review committee (OSRC) and approved by the plant manager.(I)
(31) The review of routine plant operations to assure safe operation was performed informally through trending by engineering, morning meetings, and presentations to the OSRC by department heads.(W)
-13 (32) General plant housekeeping and cleanliness was addressed in station order S-A-10, Station Inspections and Housekeeping, which included specific cleaning/housekeeping assignments.(I)
(33) Inspection requirements were established in the station orders (S-A-118, Inspection, Test and Operation Status; S-A-116, Test Control; S-E-117, Station Inspection Plan; and S-0-111, Equipment Testing Before and After Maintenance).
The inspection program was under review and revision in order to improve the inspection of safety related activities. A recent onsite audit of this activity revealed a number of program inadequacies which the licensee was evaluating and developing corrective action. The licensee had completed a training program for selected plant staff members to provide a better understanding of the safety-related inspection requirement The review of procedures relative to operational activities, such as returning equipment to service following maintenance and the performing of post maintenance functional/service ability testing, revealed that inspections were specifically required in station order S-0-111, Equipment Testing Before and After Maintenance. Guidance for selection of a test procedure and development of the appropriate acceptance criteria based on the specific maintenance activity was not provided in the station orders. Personnel interviews revealed that the actual inspections of testing activities following maintenance were minima The above item constitutes an item of noncompliance with Criterion X of Appendix B -to 10 CFR 50 as amplified in the San Onofre Unit 1, Quality Assurance Program, Chapter 10, Inspections. This items was identified by the licensee during a recent audit and corrective actions had been initiated.(W)
(34) The safety-related equipment status was generally noted in the control room operator log book, including short-term and long term equipment outages. Equipment cleared for maintenance activities was specified by a clearance.procedure (title, number) and logged in the control room log book. A copy of the outstanding maintenance requests were available to shift personne The status of testing and surveillance activities were routinely followed by the responsible supervisor or engineer. A watch engineer was assigned as the compliance engineer to insure all operations surveillance and testing had been completed. A system of tags, magnetic devices, and markers which was not proceduralized was utilized by the operations group to identify abnormal equipment status. These tags and markers were used in addition to the control room log books and workmen protection tag The overall program of maintaining accurate, up-to-date, equipment status was informal.(W)
-14 (35) Station order S-A-116, Test Control, established the administrative controls for surveillance testing and delegated responsibility of the testing activities to specific engineers and supervisors.(I)
(36) The Temporary Modification Log, located in the control room, was reviewed weekly by the watch engineer assigned to compliance; but the log was not routinely reviewed by the control room operators during shift relief and turnover.(W)
(37) The licensee did not use a status board for continuous indication and control of safety-related equipment. Safety related equipment system status was determined through the review of a number of documents such as the control room log books, jumper logs, outstanding maintenance orders and equip ment outage sheets.(W)
(38) Station orders (S-A-107, Equipment Outages; S-M-103, Request for Equipment Repair; and S-0-111, Equipment Testing Before and After Maintenance) established administrative controls for removal of equipment from servic Tagging, draining, and venting operations were controlled routinely by the control room operator with the assistant control room operator (ACO) or the plant equipment operator (PEO) performing the activit Clearance checksheets were utilized in some cases for removal and return of equipment from/to service. When clearance check sheets were not utilized the activities were not documente For those equipment control activities not covered by existing written procedures, the determination of the need for the development of procedures/checklists was left to the plant staff (operators, watch engineers,.supervisors).
Formal administrative guidance was not provided for this determinatio The definition of "as appropriate" (ANSI N18.7-1972 and 1976)
was not provide Interviews revealed that the control room operator controlled the actual removal and return of equipment to/from servic The activity was considered to be within the job skills of the control room operators.(W)
(39) The control/locking of critical valves was controlled by station order S-0-108, Locking of Critical Valves, which included the locking of safety-related equipment during normal operation and refueling condition The method of making changes to the position or administrative controls of locked valves appeared questionable in that the station order did not specifically address the methodology
-15 utilized for making the changes which constituted changes to safety-related procedures in accordance with Technical Specifi cation 6.8. The station orders required specific permission and documentation of a change but did not address the require ments for performing the chang Interviews with plant personnel determined that they were cognizant of the requirements for making procedure changes, including the provision that the proposed procedure change involved no change of intent and also required the prior approval of two members of the OSRC.(W) Review and Audit of Licensed Activities The objective of this portion of the inspection was to determine the adequacy of the licensee's management controls for reviewing, monitoring and auditing the performance of licensed activities by all levels of managemen Documents Reviewed (1) Job descriptions for the following positions:
.
Manager of Steam Generation
.
Manager, Quality Assurance
.
Manager, Nuclear Generation
.
Project Quality Assurance Supervisor
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Plant Manager Supervising Engineer Superintendent Supervisor of Plant Maintenance Watch Engineer
.
Control Operator (2) Station Quality Assurance Organization, Station Order S-A-111, Rev. (3) Engineering Section Responsibilities, Station Order S-E-114, Rev. (4) Station Logs, Steam Generation Division Order No. D-All (Revised January 6, 1975).
(5) Plant Equipment Operator's Inspections and Duties, Operating Instructions S-0-1, Rev. (6) Control Operator's Inspections and Duties, Operating Instruction S-0-3, Rev. (7) Reactor Standard for Operation, Station Order S-0-104, Rev. (8) Quality Assurance Manual, Chapter (9) Authorities and Duties of QA Personnel, Quality Assurance Procedure (QAP) No. N1.03, Rev. (10)
Stop Work Procedure, QAP No. N2.03, Rev. (11)
QA Reporting of Activities of SONGS 1, QAP No. N2.04, Rev. (12)
Reporting of QA Program Status and Adequacy to Senior Management, QAP N2.06, Rev. (13)
Reporting of Quality Trends, QAP No. N2.07, Rev. (14)
Functional Description of the Responsibilities of the Manager, Nuclear Generation, memorandum from Manager, Nuclear Generation to Manager of Steam Generation, November 15, 197 b. Findings (1) Items of Noncompliance Non (2) Deviations Non (3) Unresolved Items In revision 4 to Chapter 1 of the Quality Assurance Manual, the licensee's organization was revised to have the Vice President, Advanced Engineering, report to the Senior Vice President and thence to the President who has the ultimate responsibility for th operational Quality Assurance Progra Technical Specification (TS) Figure 6.2.1.1 showed the Vice President (Advanced Engineering) as reporting directly to the President. The licensee had submitted a request for a TS change to revise Figure 6.2.1.1 to show the organization as modifie The inspector noted, as in paragraph 3 of this report, that if the proposed TS change was not approved, the licensee would be in noncompliance. This item has been identified as an unresolved item. (79-01-03)
c. Observations The following observations include general information items and perceived strengths and weaknesses in the licensee's management controls which may not have specific regulatory requirements, but will provide the basis for subsequent performance evaluations (Reference paragraph 2).
-17 (1) The President had delegated (in writing) responsibilities to the vice presidents to sign various types of outgoing correspon dence (to NRC) as a representative of the compan The vice presidents who were interviewed stated that they reviewed all incoming and outgoing NRC correspondence, even that which they did not sign.(S)
(2) The Manager, Nuclear Generation, had issued division orders to communicate requirements and guidance to his staff.(S)
(3) The watch engineers had prepared a detailed listing of their responsibilities and reporting requirements which was based on a review of all applicable procedures and instructions.(S)
(4) Based on the interviews held with selected site and corporate managers, the inspector found that the extent of management's review of operating records was as follow (a) Top level managers (vice presidents) did not routinely review plant operating records other than a daily report of operating status. They did receive weekly and quarterly reports of activities in their areas of control.(I)
(b) The Manager, Nuclear Generation, routinely reviewed the Watch Engineer's Log, NRC correspondence, daily reports of plant status and outage report His review was documented by initialing a route slip.(S)
(c) The Plant Manager and Superintendent routinely reviewed the Watch Engineer's Log, daily checklists, shutdown (outage) records and the monthly summary reports of opera
- tions and surveillance test performance which were prepared by the department supervisors.(S) No other operating records were routinely reviewed and the.above reviews were not documented.(W)
(d) The Supervising Engineer reviewed no operating records on a routine basis.(W)
(e) The Chemistry and Radiation Protection Supervisor routinely reviewed the daily chemical analysis sheets and he weekly reviewed the staff's exposure records. The review of the exposure records was documented by his initialing the records. The review of the chemical analysis sheets was not documented.(W)
(5) Based on interviews with selected site and corporate managers, the inspector found that management'4 review of inspection/
audit reports and other correspondence was as follow (a) The vice presidents received copies of NRC inspection reports and the responses thereto. They did not, however, review audit reports or licensee event reports (LER's).(W)
(b) The managers in the operational line to the Plant Manager had received and reviewed QA and Nuclear Audit and Review Committee (NARC) audit reports and the responses thereto.(S)
(c) The Manager, Nuclear Generation did not routinely receive reports of QA Surveillance activities.(W)
(d) The Plant Manager received and reviewed responses to NRC requests (NRR generic review requests, IE Bulletins, etc.), but he noted that he received these responses after they were issued, unless his staff had prepared the response.(W)
(6) Based on interviews with selected site and corporate managers and on the review of selected records, the inspector found that licensee management routinely held staff meetings to communicate with their staff (a) The Vice President, Power Supply, held weekly meetings with his staff. The meetings were documented.(S)
(b) The Manager of Steam Generation held bimonthly meetings with his plant managers to discuss problems and planned activities. These meetings were documented.(S)
(c) The Manager, Nuclear Generation, stated that he held no routine staff meetings. Special meetings were called as needed.(W)
(d) The Plant Manager held meetings with the operating staff each morning to discuss any identified problems and projected activities.(S)
(e) The Chemistry and Radiation*Protection Supervisor rotated job assignments of his staff on a monthly basis. He held a changeover meeting with his staff to effect the changes and keep his staff apprised of problems and ongoing activities.(S)
(7) The Vice President, Power Supply; the Manager of Steam Generation; and the Manager, Nuclear Generation stated that they periodically visited the site to observe activities but they did not document the visits or formally report visit findings to site management. The Plant Manager toured the facility daily but did not document the tour or problem areas identified.(W)
(8) The responsibilities of the licensee's management staff were contained in written job descriptions and in specific procedures and instructions under which the manager is assigned specific
responsibilities. The job descriptions were very general in'
nature and did not provide specific guidance on the key facets of the manager's duties, responsibilities and line of authority.(W)
(9) The Appendix B requirement to periodically evaluate the adequacy (effectiveness) of the QA Program was satisfied by the performance of an audit by an independent consultant.(S) The independent auditor performed a quantitative analysis of such things as items of noncompliances, licensee event reports, etc.; but a qualitative analysis of these indicators was not performed.(W)
(10)
Licensee management periodically reviewed the implementation of the training program, but they did not evaluate the adequacy or:
effectiveness of the program.(W)
(11)
Staff and management individuals who were interviewed stated that the licensee had no formal requirement to review identified problem areas (as identified in inspection/audit reports, LER's, etc.) for possible generic implication. Most of them indicated, however, that such generic reviews were conducted.(I)
(12)
No formal system had been established to assure that license amendments and TS changes were received by the personnel responsible for implementing the changes, nor was there assur ance that superseded pages were properly disposed.(W)
(13)
No formal system had been established to assure the prompt distribution of changes in regulations, guides and standards to the personnel having a need to know about the changes.(W)
(14)
Plant management had no formal system.for assuring that appropriate plant staff were informed of problems identified by the staff, by QA, or by other outside organizations such as NARC or NRC. Station Incident 'Reports (SIRs) were routed to the staff with an "Acknowledgement of Information Form," but NRC inspection reports and QA and NARC audit reports were not routinely.routed to the staff. Staff members who were inter viewed stated that they would like to have an opportunity to review these reports.(W)
5. Design, Engineering, and Modification The objective of this portion of the inspection was to determine the adequacy of management controls associated with engineering, design changes, and modification a. Documents Reviewed (1) FSAR, Amendment 0, Quality Assurance Progra (2) San Onofre Nuclear Generating Station (SONGS) 1 Quality Assurance Manua (3) SONGS 1 Administrative Controls Technical Specification (TS), Section (4) Station Orders
.
Assignment of Responsibility of Key Personnel, S-A-125, Rev..
Quality Assurance Organization, S-A-111, Rev. Station Quality Assurance Program, S-A-112, Rev..
-Procurement Document Control S-A-113, Rev. Instructions, Procedures, and Drawings, S-A-114, Rev. Engineering Section Responsibilities, S-E-114, Rev. Design Control and Review, S-E-116, Rev. Control of Lifted Leads and Jumpers, S-0-9, Rev. (5) Engineering and Construction Procedure Configuration Design Changes Made During Facility Operation, 26-7-16, New, August 10, 197 Performing Inspections for SONGS 1, 2, and 3, 26-8-6, New, October 11, 197 Preparation, Checking, Revision, Approval, and Release of Drawings and Revisions Developed by SCE for SONGS 1, 2, and 3, 26-8-7, New, November 30, 197 Review and Approval of Supplies, Engineering Con struction, Engineering Construction Drawings, Design Change Notices and Review for SONGS 1, 2, and 3, 26-8-19, New, November 30, 197 Specifications and Addenda by Southern California Edison for SONGS 1, 2, and 3, 26-20-3, November 30, 197.
Specifications and Addenda by. Engineering Construction for SONGS 1, 2, and 3, 26-20-9, New, November 30, 197 General Controls for Safety-Related Welding, 26-30-2, New, March 8, 197.Engineering and Construction Quality Assurance Procedures Program, 41-1-0, January 25, 197 Establishment of Engineering and Construction Quality Assurance Procedures, 41-1-3, May 8, 197 Assignment and Maintenance of Engineering and Construction Procedures, 41-1-4, September 19, 197 Control of QA Classification of Equipment, Components, Material and Services for SONGS 1, 2, and 3, 26-7-8, Rev. Design Criteria Manual, 26-7-13, August 4, 197.
Preparation, Review, Approval, and Release of Design Configuration Changes, 26-7-14, New, November 20, 197.
Performing Final Design Analysis, 26-7-15, Rev. (6) Quality Assurance Procedure Manual
.
Quality Assurance Review of Specifications, QAP N3.01, Rev. Quality Assurance Review of Drawings, QAP N3.02, Rev..
Status of Regulatory Guides, QAP N3.03, Rev..
Procedures, QAP N5.01, Rev. Quality Assurance Review of Startup Test Instructions and Test Procedures, QAP N11.01, Rev. (7) Quality Assurance Manual
.
Organization, Chapter 1, Rev..
Quality Assurance Program, Chapter 2, Rev. Design Control, Chapter 3, Rev. Instructions, Procedures, and Drawings, Chapter 5, Rev. (8) Quality Assurance Manual, Amendment 1 Organization, Chapter 1, Rev. Quality Assurance Program, Chapter 2, Rev. Design Control, Chapter 3, Rev. Instructions, Procedures, and Drawings, Chapter 5, Rev. b. Findings (1) Items of Noncompliance Non (2) Deviations Non (3) Unresolved Items Non c. Observations The following observations include general information items and perceived strengths and weaknesses in the licensee's management controls which may not have specific regulatory requirements, but will provide the basis for subsequent performance evaluations (Reference paragraph 2).
-22 (1) Safety related design changes were normally performed by corporate personnel since the required expertise (e.g. seismic, etc.) was not available at the site. Design changes could be performed by the site engineering grou Personnel interviews revealed that the site and corporate personnel understood the design control and review procedures; although certain aspects of the system were informal at the site.(I)
(2) The licensee utilized a Project Manager to accomplish major modifications/design changes to the facility. The organization generally pooled expertise under a project manager and utilized Engineering and Construction Department procedures to perform the design work.(I)
(3) The licensee had developed detailed written procedures for design control in the corporate engineering and construction department.(S)
(4) The Quality Assurance group was formally involved with the design control and review activities performed by the corporate levels in the engineering and construction department.(I)
(5) At the plant the licensee assigned a design control engineer to follow design changes and to make a quarterly report of design change status to the engineering supervisor.(I)
(6) The supervising engineer managed the design changes at the site and assigned a project engineer to provide interface coordina tion and to follow the work activities. The project engineer coordinated the work activities with the supervisor in charge of the installation. The design control engineer reported to the supervising engineer and was responsible for reviewing the safety evaluations of all design changes.(I)
(7) The responsibilities of the project engineer onsite also included technical review, and followup of the correction of design.,deficiencie Personnel interviews revealed that the project engineer understood his responsibilities.(I)
(8) Communications between members of the engineering group at the site and at the corporate offices appeared to be satisfactor Interviews revealed that the communication channels were free and open.(I)
(9) The design change review and approval at the site and corporate office appeared acceptable and included onsite, offsite, and NRC approvals as appropriate.(I)
-23 (10) The licensee utilized a Design Criteria Manual (DCM) for each system to establish, meet, and maintain the design basis requirements. Interviews revealed that the engineers utilized the DCM during design control and review, and that the individ uals understood the use of the manual for insuring and main taining adequate system design criteria.(S)
(11) Implementation of design changes at the site by outside contractor personnel was performed in accordance with a written contract which included QA/QC requirements. The licensee QA group audited the contractor organization, and the implementa tion of the design change activity.(I)
(12) Procedure reviews and personnel interviews revealed that the licensee utilized "Acknowledgement of Information" forms to relate design change information to the shift operators and supervisors. The adequacy of the system was questionable in that the shift personnel were not required to sign for their review and understanding of the information prior to assuming shift duties. The licensee also routinely logged completed design changes in the control room log book but this method of providing knowledge of plant status was not formally controlled.(W)
(13) Implementation of design changes at the site by licensee personnel was performed via the maintenance system and included the generation of the appropriate procedures. During the maintenance activities the implementation of quality control requirements including generation of hold points, inspection requirements, and other verification activities were informa The design change.package, including implementing procedures was not routinely provided to the quality assurance department for review and approval.(W)
(14) The review of station order, S-E-116, Design Control and Review revealed that engineering field changes to design change packages were authorized with the approval of two OSRC members and subsequent OSRC review. Interviews revealed that this authority was intended for correcting minor procedural discrepancies, and not for modification to design in the field without prior OSRC approval.(W)
(15) Safety-related design changes were routinely initiated at the site or in the corporate licensing group. All safety-related design changes initiated at the site were processed through the Steam Generation Division for approval in accordance with station order S-E-116, Design Control and Revie The Steam Generation Division did not have procedures to provide guidance for the review and approval of design changes, but personnel interviews revealed that staff engineers were knowledgeable of the requirements for this activit General administrative procedures, Station Order S-E-116, Design Control and Review and S-E-114, Engineering Section Responsibilities, established site requirements for design control, review, and assigned responsibilities. The procedures for design control were being reviewed and upgraded at the time of the inspection.(W)
(16) The quality assurance department was not formally in the design review process at the site. The QA personnel were apprised of the design change package if they were present at the OSRC meeting when the change package was being reviewed. The QA personnel were not required for an OSRC quorum and might not necessarily attend all OSRC meetings.(W)
6. Corrective Action System and Management of Generic Issues The objective of this portion of the inspection was to determine the adequacy of the licensee's corrective action system and management of generic issue a. Documents Reviewed (1) Administrative Controls, Technical Specifications (TSs)
Section 6 (2) Quality Assurance Program Plan, SONGS Unit 1, Final Safety Analysis Report, Appendix D (App. 0)
(3) Quality Assurance Manual, SONGS Unit 1 (4) Reporting of Quality Trends, Quality Assurance Procedure (QAP) N2.07, Rev. 2 (5) Reporting to the NRC in accordance with 10 CFR 21, QAP N2.08, Rev. 0 (6) Instructions for Completing the Nonconformance Report (NCR),
QAP N15.01, Rev. 7 (7) Reporting to the NRC of Deficiencies Found in Design and Construction, QAP N15.04, Rev. 7 (8) Instructions for Completing the Corrective Action Request (CAR), QAP N16.03, Rev. 5 (9) Corrective Action Status Log, QAP N16.04, Rev. 5 (10)
Deficient Records, QAP N17.03, Rev. 2 (11)
Request for Equipment Repair, Station Order S-M-103, Rev. 2 (12)
Fire Prevention and Equipment Inspection Report, dated 4-9
-25 (13) Quality Trend Reports, 2nd and 3rd Quarters of 1978 (14) Nonconforming Materials, Parts, Components or Operations, Station Order S-A-119, Rev. 4 (15)
Quality Assurance Corrective Action, Station Order S-A-120, Rev. 5 (16) Request for Equipment Repair, PSSD 104, NEW 3/70 (17)
Station Incident Report, PSSO 14, Revision 10/77 (18) San Onofre Reporting Requirements, Division Order D-N1, Revised October 5, 1977 (19)
Reporting of Substantial Safety Hazards, Station Order S-A 127, Rev. 1 (20) Reports to the Nuclear Regulatory Commission, Station Order S-E-101 (21) QA Organization Policy/Procedures Manual, Processing SONGS 1 Nonconformance Reports, E&C 26-10-5 (22) Processing Corrective Action Requests, E&C 26-80-9 (23)
Documenting, Evaluating and Reporting Problems Pursuant to 10 CFR 21 and 10 CFR 50.55(e), E&C 40-9-9 (24) Reporting of Defects and Nonconformances for Nuclear Facilities, DN-4 Findings (1) Items of Noncompliance During the review of licensee records, the inspector found that the Fire Hose Inspection Report, dated April 9, 1978, had documented problems with the use and storage of fire hoses. Specifically, fire hoses had been found missing from reels in the Feedwater Pump, 480 Volt Switchgear, and Auxiliary Building areas; and the hoses had been used by contractor personnel for jobs other than fire. The Maintenance Supervisor had been notified, the hoses returned to their proper storage, and the contractor advised in writing relative to the correct use of this equipmen The Quality Assurance Manual required the use of the Corrective Action Request to document conditions adverse to maintaining the capability of the fire protection package to perform its intended function. This document ensured corrective action would be tracked to completion, that the appropriate levels of
-26 management would be informed and that the data would be avail able for trending. Discussions with the Fire Hose Inspector and his management failed to demonstrate adequate knowledge of the Quality Assurance Manual requirements, as they relate to the fire protection packag With respect to the problems identified by the Fire Hose Inspector on April 9, 1978, a Corrective Action Request was not utilized. That failure to adhere to the requirements of Criterion XVI of Appendix B to 1OCFR50 as amplified by the Quality Assurance Manual is an item of noncompliance and is a deficienc (2) Deviations Non (3) Unresolved Items Non c. Observations The following observations include general information items and perceived strengths and weaknesses in the licensee's management controls which may not have specific regulatory requirements, but will provide the basis for subsequent performance evaluations (Reference paragraph 2).
(1) Any station employee could request repairs by filling out a Request for Equipment Repair form. The.Watch Engineer reviewed the request, determined if it had merit and warranted corrective action, assigned a priority, and forwarded the revised request to the Supervisor of Plant Operations. The Watch Engineer had further responsibility for notifying the Supervisor of Plant Operations should a repair request affecting safety-related equipment or plant reliability not be acted upon in a reasonable period. Following repair completion, the request form was revised to reflect the work done and material used; one copy of the request was filed and one was returned to the request originator. (S)
No formal system of trending problems documented by Request for Equipment Repair forms was identified. Further, problems with equipment affecting power generation and requiring immediate correction might never be documented on this form or made available for trending, since the repairs might be completed before the form could be filed.(W)
(2) Deviations of personnel or equipment operations from operating instructions or acceptance standards were reported to the Plant Manager and documented on a Station Incident Repor The Plant Manager was responsible for the preparation and
-27 transmittal of all notifications and reports required by Technical Specifications which might result from this initial report. Corrective action was normally documented and tracked to completion outside the formal systems controlled by.the QA organization. Station Incident Reports were reviewed by the Onsite Review Committee (OSRC), the Manager, Nuclear Generation, and the Nuclear Audit and Review Committee (NARC).
Normally the Manager, Nuclear Generation, would review any report to the NRC prior to its issuance, where time allowe The staff of the Manager, Nuclear Generation, performed trend analysis of the numbers of Station Incident Reports generated per year by category of error. The results of this analysis were made available to the NARC.(S)
(3) Station Incident Reports were also utilized to document evaluation of conditions reported by any station employee which might be considered defects meeting the definitions of 10CFR21. The Plant Manager was required to discuss these matters with the OSRC and the NARC then reviewed the resulting documentation.(S)
(4) Deviations of a characteristic of a material, part, component or procedure from that specified in a design disclosure document were treated as nonconformances and documented on Nonconformance Reports (NCRs).
Deficiencies in documentation which rendered the quality of an item indeterminate were handled in the same manner. All licensee personnel were responsible for identifying nonconformances once discovered. Nonconforming material could not be used unless adequately dispositione Disagreements as to whether a problem constituted a nonconform ance were referred to the Manager, Quality Assurance. NCRs generated at the station were reviewed by the OSRC. The QA organization was responsible for the control, logging, status tracking and closeout audit of NCRs.(S) NCRs did not normally have due dates.(W)
(5) Conditions adverse to quality discovered as a result of a review, audit, inspection or surveillance activity were documented on a Corrective Action Request (CAR). Management could evoke the CAR system for other significant adverse conditions which warrant the utilization of a formalized corrective action system. Once initiated, the CAR could not be invalidated except by the originator or his superviso The QA organization was responsible for the control, logging, status tracking and closeout audit of CARs. CARs normally had due dates with timely completion routinely less than 60 days.(S)
(6) The QA organization maintained a non-automated Corrective Action Status log encompassing both the CAR and NCR system The master log status was updated on a day-to-day basi Corrective action items open in excess of 60 days were con sidered delinquent and were displayed on the General Office Status Board, which was updated at least weekly. Weekly meetings were held where appropriate, between the QA organi zation and other departments currently responsible for corrective action, to obtain timely closeout.(S)
(7) The site QA/QC Supervisor produced a quarterly Quality Trend Report for the corporate Project QA Supervisor. The report listed numbers of Corrective Action Requests and Nonconformance Reports generated by various organizational elements.(I) The trend analysis involved a comparison of numbers in each category to the previous quarter alone and did not appear to focus on the substance of the identified problems.(W)
(8) Both the OSRC and the NARC had open item tracking systems to monitor the status of items pending resolution or response.(S)
(9) At least one station supervisor maintained a response tracking system for NRC identified Items of Noncompliance, Deviations and Unresolved Items, plus NRC generated Bulletins and Circulars. The Manager, Quality Assurance, tracked enforce ment item response.(S)
(10) Discussions with site Maintenance and Instrumentation and Control personnel indicated they were unfamiliar with require ments to prepare or initiate CARs and NCRs on detection of problems meeting the prerequisites for these systems.(W)
(11) The procedure for handling deficient records was at odds with the procedure for handling nonconformances; in that, the engineer responsible for the problem resolution was directed in the former to attempt informal resolution which bypassed the use of a CAR. This practice would make trending of similar problems impossible.(W) Training The objective of this portion of the inspection was to detemine the adequacy of the licensee's management of-training activities, both on site and in the corporate office Documents Reviewed The following documents were reviewed in this area:
(1) Administrative Controls, Technical Specifications Section 6 (2) Quality Assurance Program Plan, SONGS Unit 1 Final Safety Analysis Report Appendix D (3) Quality Assurance Manual, SONGS Unit 1
-29 (4) Qualification and Certification of Inspection, Examination and Testing Personnel, QAP N1O.10, Rev. 3 (5) Indoctrination of Quality Assurance Personnel, QAP N2.05, Rev. 1 (6) Fire Protection Program Review, BTP APCSB 9.5-1, SONGS Unit 1, March 1977 (7) Fire Protection, Division Order D-A-13, May 1974 (8) Fire Protection, Station Order S-A-2, Rev. 17 and 18 (9) Personnel Training, Station Order S-A-126, Rev. 3 (10) Engineering and Construction QA Training Procedure, E&C 19 17-20, Rev. 2 (11) Operator Requalification Program, SONGS Unit 1, Rev. 1 (12) Annual Career Development Guide.,19-135, Rev. 1/79 (13) Skills Inventory, Civil/Structural Design Section, a Worksheet (14) E&C Training Control System, Training Activities Worksheet, E2-054A & B, New 9/78 (15) Training Program, Engineering System Design, 1979 (16) Training and Development Catalog, January 1979 to December 1979, Employee Development Division (17) Steam Generation Division, Induction Checklist for all Employees, PSSD 18, Rev. 1/76 (18) Engineering Development Program, Station Order S-E-14, Rev. 3 (19) Authorities and Duties of QA Personnel, QAP N1.03 (20)
SCE Quality Assurance Organization Training Plan and Budget 1979 (21) Engineering Development Program, DE-14 (22) Qualifications of Maintenance Personnel, DM-10 (23) Engineering and Construction QA Training Procedures, E&C 19 17-20 (24) Company Support of Education, Corporate Policy Statement 18.1 (25) Employee Performance Appraisal, Placement and Potential Evaluation, Corporate Policy Statement 19.10.12 (26) Employee Development, Corporate Policy Statement 19.1 (27) Edison Educational Assistance Program, Corporate Policy Statement 19.17.20 b. Findings (1) Items of Noncompliance During the review of licensee documents describing programs for personnel training at the station, the inspector found that no formal training program for Maintenance personnel was described. Discussions with site maintenance supervision indicated their belief that the employment and promotion practices utilized by the licensee ensured personnel were competent in the skills required of their jobs. The training sequence utilized by the licensee before employment at the site was an apprentice type program, where an individual was trained, tested and promoted to sequentially higher skill and responsibility level Since this training was received prior to employment on site, it was not included in the document describing formal training programs at the statio The licensee's Technical Specification 6.4.1 requires the establishment of training programs to maintain proficienc Discussions with maintenance supervision indicated a retraining program for maintenance personnel had not been-establishe The extent of retraining provided maintenance personnel as described to the inspector was the routine performance of the man's job and "tailboard" safety briefings held by the manis supervisor. The failure to establish a retraining program for maintenance personnel as required by TS 6. was an item of noncompliance and is a deficienc (2) Deviations Non (3) Unresolved Items The Engineering and Construction Quality Assurance Training procedure required personnel affected by specific Quality Assurance procedure changes to be trained following issuance of revisions. The inspector reviewed training records for several revisions of Quality Assurance procedures. Records were unavailable at the time of the inspection to demonstrate several individuals had received the required training. It appeared that these individuals may have missed the planned and executed original training sessions. Whether the records had yet to be filed or the training never received was undeter mined. This is an unresolved item (79-01-04).
- 31 c. Observations The following observations include general information items and perceived strengths and weaknesses in the licensee's management controls which may not have specific regulatory requirements, but will provide the basis for subsequent performance evaluations (Reference paragraph 2).
(1) A corporate organization entitled the Employee Development Division was responsible for the development and administration of training programs offered company wide. These programs included formal inhouse skill and management courses and corres pondence courses. The division also was responsible for the administration of the company's Educational Assistance program and the Employee Performance Appraisal program.(I)
(2) The company published a list of training and educational opportunities available to corporate employees locally. The company provided funds for college courses. Supervisors were provided a catalog of additional courses that employees might need. Participants were required to prepare written critiques of courses for which the company had paid.(I)
(3) A number of training programs were established at the station; each administered by the department having functional responsi bility for the subject being taught.(I)
(4) The site Training Administrator was responsible for the dayto day implementation of the Reactor Operator, Operator Requalifica tion, and Senior Reactor Operator training programs. The incumbent was'a Watch Engineer and licensed SRO who had been appointed to the position 2 weeks prior to the inspection.(I)
Historically, the position had reportedly been subject to a high turnover rate. There was no established career path for this position and no permanently assigned administrative or clerical help for the position.(W)
(5) Each operator was responsible for maintaining his personal operations experience record. The Training Supervisor (Training Administrator) was charged with the responsibility to audit the resulting records on a regular basis to insure adequate records were being maintained.(I) The last recorded audit was March 1977 with historical intervals between audits varying from 2 months to about 1 year.(W)
(6) Discussions with the Training Administrator indicated instructors could review examinations before teaching; lesson plans were not required but were usually provided; student critiques of instruction were not solicited formally; and instructor performance was not subject to routine performance appraisal.(W)
(7) Neither the Plant Manager or the Superintendent regularly attended requalification training sessions or participated in
-32 examinations.(W) Both individuals were licensed, but were exempted from these requirements by the approved Operator Requalification Program.(I)
(8) Quality Assurance audits of operator training were examinations for compliance with licensee procedures and reportedly did not address the adequacy or effectiveness of the effort.(W)
(9) Operators reported the requalification training lacked the originality or newness necessary to challenge them. Tests and study material reportedly required upgrading to reflect current system configurations and actual operations.(W)
(10) Historically, engineers assigned to the site had been encouraged to participate in operator training and become licensed operator The engineers reported.their work load precluded their routine participation in this training.(I)
(11) The licensee did not utilize simulators for operator initial or requalification training.(W)
(12) The licensee did not conduct formal trend analysis of requalification training examination grades.(W)
(13) The Security Office training program was administered by a full time training officer with active participation by corporate security personnel.(S)
(14) Most station maintenance personnel completed the company's apprentice program before permanent assignment on site.(S) The thrust of the station maintenance training effort was directed toward maintaining proficiency through informal On-the-Job Training (OJT) and occasional informal seminars by equipment manufacturer technical representatives, as available. OJT documentation was not collected as such, but could be obtained by a review of repair documentation resulting from each job.(W)
(15) Several individuals both within and outside the maintenance staff indicated maintenance personnel needed additional training in the administrative interface requirements between the Maintenance department and the Operations department.(I)
(16) The Instrumentation and Test department updated individual training files by routinely rotating job assignments and extracting the resulting work experiences from the daily activity files.(S)
(17) Both the Maintenance and the Instrumentation and Test departments upgraded workers to the foreman position and rotated the assign ment to provide training for the individuals.(S) Otherwise, advancement to a supervisory position had historically preceeded training for the position.(I)
.-33 (18) New employee indoctrination programs utilized formal.docu mentated procedures to ensure the employee was aware of his obligations and opportunities within the company.(S)
(19) Four of seventeen individuals quizzed on their rights and obligations under 10CFR19 were unfamiliar with its content.(W)
(20) With the exception of the Operations department training programs, no station training program appeared to encompass all the recommendations for Retraining and Replacement training of Section 5.5 of ANSI N18.1-197 Most failed to provide means for appropriate evaluation of the program effectiveness.(W)
(21) The licensee's program for Quality Assurance (QA) training provided for initial indoctrination and procedure revision training. The responsibility for providing this training had been assigned to each department having staff with QA responsi bility.(I)
Neither the QA or Engineering and Construction departments' training programs provided for retraining in QA procedures to ensure proficiency was maintained in their use if those procedures were not subject to a revision.(W) The QA department did perform a biennial review of active procedures to determine if revisions were needed; which that organization believed had some training effect.(S)
(22) QA personnel were sequenced through their initial indoctrina tion by following a checklist. The indoctrination included introductions to the documents which established job require ments, a guided self study of those documents, an oral examina tion on document content, and finally documentation of indoctrination completion and approval.(I)
(23) Following employment, new Engineering Design personnel were interviewed to develop "individual skills inventory" document The Engineering Design department reviewed the resulting docu ments to determine the inhouse training programs to be offere Initial indoctrination was normally performed by the individuals'
supervisor and may or may not have utilized checklists.(I)
(24) During the annual individual performance appraisal, the individual's supervisor determined what additional experience and training was necessary to optimize that individuals'
development. The resulting recommendations were collated into the annual department Training Plan and Budget; which once approved, became the year's training plan.(I)
(25) Reportedly, training experience was not a prerequisite for any promotion.(I)
-34 8. Inservice Inspections and Inservice Testing of Pumps and Valves The objective of this portion of the inspection was to determine the extent of management's control over the Inservice Inspection (ISI)
Program and the program for the Inservice Testing (IST) of Pumps and Valve Documents Reviewed (1) Administrative Control of Inservice Inspection, Station Order SE122, Rev. (2) Inservice Inspection, General Requirements, Engineering Procedure SV2.1 (3) Inservice Inspection of Class 1 Components, Engineering Procedure SV2.1 (4) Inservice Inspection of Class 2 Components, Engineering Procedure SV2.1 (5) Inservice Inspection of Class 3 Components, Engineering Procedure SV2.1 (6) Inservice Testing of Pumps, Engineering Procedure SV2.14, Rev. (7) Inservice Testing of Valves, Engineering Procedure SV2.15, Rev. (8) Inservice Testing of Pumps and Valves, Operating Instruction 533.2 (9) Inspection Repair and Testing of Pressurizer Relief Valves 532 and 533, Maintenance Procedure SI (10)
Main Steam Safety and Power Operated Relief Valve Testing and Maintenance, Maintenance Procedure S1 (11)
Maintenance of Pressurizer and Steam Generator Safety Valves, Station Order SM (12)
Inspection of, Repair and Testing of Pressurizer Relief Valves 532 and 533, QC Inspection Procedure SXII (13)
Completed data sheet (QC Procedure SXIIl.3) for lift test of Pressurizer Relief Valve 532 (September 1978).
(14)
Completed data sheet (QC Procedure SXII1.3) for lift test of Pressurizer Relief Valve 533 (October 1978)
(15)
Data sheets for IST-results of all pumps for 197 Findings (1) Items of Noncompliance The requirements for the inservice testing of pumps and valves were detailed in the procedures referenced in 8.a(6), 8.a(7)
and 8.a(8) above. The inspector found, however, that the licensee had issued no procedures for the performance of required pump testing such as vibration measurements and bearing temperature measurements. The inspector also found that the inservice testing (lift test) of the pressurizer relief valves was detailed in Maintenance Procedure SI (Reference 8.a(9) above). This latter procedure did not con tain quantitative acceptance criteria for acceptable lift pressures. Acceptable lift pressures for the pressurizer relief valves were given in Station Order SM3, but this station order was not referenced by Procedure 511. Section 5.3 of ANSI N18.7 1976 states in part, "Activities affecting safety at nuclear power plants shall be described by written procedures of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions and procedures. These procedures shall include appropriate quantitative or qualitative acceptance criteria for determining that important activities have been satisfactorily accomplished."
The above descrepancies are further examples of the noncompliance with the requirements of TS 6.8.1 which is detailed in para graph 3.b(l) of this repor (2) Deviations Non (3) Unresolved Items Non c. Observations The following observations include general information items and perceived strengths and weaknesses in the licensee's management controls which may..not have specific regulatory requirements, but will provide the basis for subsequent performance evaluations (Reference paragraph 2).
(1) The Station Engineering Department had performed the following functions with regard to ISI activitie (a). Prepared the outage plans and schedule (b) Reviewed ISI procedure (c) Reviewed the calibration records of ISI measurement equipmen (d) Verified the qualifications of the ISI inspector (e) Reviewed inspection data sheet (f) Prepared the ISI report.(I)
(2) The QA Department had performed the following functions with regard to ISI activitie (a) Audited the QA Program of the ISI contractor and his implementation of same as part of their vendor qualifi cation activitie (b) Reviewed ISI procedure (c) Reviewed calibration records of ISI measurement equipmen (d) Verified the qualifications of the ISI inspector (e) Reviewed inspection data sheets.(I)
(3) The OnSite Review Committee (OSRC) had reviewed the followin (a) Outage plans and schedule (b) ISI procedures (programmatic versus technical review).
(c) ISI report (after it has been issued).(I)
(4) Station Engineering personnel and QA personnel stated that they had observed (monitor) ISI activities, although there were no specific requirements to do so.(S)
(5) Licensee representatives stated that indications identified during the inspections were documented in Nonconformance Reports (NCR's) and were handled under station procedures governing the use of the NCR.(S)
(6) Licensee personnel involved in the ISI program had received appropriate training in NDE techniques, but specific training and retraining requirements in this area had not been established.(W)
(7) Licensee representatives stated that pressure testing following the repair of pressure boundary defects was determined by the Authorized Inspector (AI).
No responsibilities had been assigned to licensee individuals in this area.(I)
(8) The QA organization performed extensive audits and reviews of ISI activities, but they did not specifically audit or review the IST of pumps and valves. A QA supervisor stated that this area had received limited coverage under their routine audit program.(W)
-37 (9) The licensee had no formal procedures/instructions which detailed responsibilities in the following areas that are addressed by ASME XI, Section IWA 140 (a) Review and approval of the ISI program and changes theret (b) Review of inspector qualifications.(W)
(10)
The licensee's procedures which control ISI activities did not include the following features:
(a) Requirements to review the calibration records of inspection equipmen (b) Responsibilities for informing the Authorized Inspector of the progress of preparatory work and notifying him in advance of when components will be ready for inspection.(W)
(11)
Licensee representatives stated that no licensee personnel had been certified to perform visual examinations.(W)
(12)
The licensee had no formal procedures or instructions which detailed the following responsibilities with regard to inservice testing (IST) of pumps and valve (a) Review and approval of the IST Program and changes theret (b) Review and approval of implementing procedure (c) Verification of the calibration of all instruments used in IST on a regular basi (d) Establishment of reference values for the parameters being measured and assuring that the acceptance criteria were correctly established based on these reference value (e) Review and evaluate test result (f) Verification of compliance with test program requirements.(W)
(13)
Licensee representatives stated that they had not verified the qualifications of the Authorized Inspectors (AI).(W)
(14)
The majority of the IST of pumps and valves was performed by Station Engineering personne These activities were not proceduralized and the results were not routinely reviewed by station management and OSRC.(W)
(15)
The Manager, Nuclear Generation, stated that he had not reviewed the results of IST activities or verified completion of the program.(W)
(16)
The data sheets for the lift tests of pressurizer relief valves 532 and 533, which were performed in September 1978 and October 1978, were not dated. A handwritten Equipment Repair Summary Sheet, which was attached to the above data sheets, was dated.(W) Committee Activities The objective of this portion of the inspection was to determine the extent and adequacy of the overview of licensed activities by the onsite and the offsite committee a. Documents Reviewed (1) Nuclear Audit and Review Committee Manual of Operations, Re, January 10, 197 (2) Organization and Responsibilities of the Unit 1 OnSite Review Committee and Units 2 and 3 Procedures Review Committee, Station Order SA110, Rev. (3) Quality Assurance Manual, Chapters 1, 2, 5 and 1 (4) Nuclear Audit and Review Committee (NARC) Meeting Minutes for meetings 178 through 678 and 17 (5) NARC audit schedules for 1978 and 197 (6) Reports of all NARC audits conducted in 197 (7) OnSite Review Committee (OSRC) Meeting Minutes for all 1978 meeting (8) The following Corrective Action Requests (CAR's):
G80 G81 G83 P121 P131 through P170 (9) Nuclear Control Board (NCB) Meeting Minutes for meetings held on June 28, 1978 and December 19, 197 (10)
The following QA audit reports:
S01977 501178 SO14378 (11)
NARC Audit Report, Mr. P. J. West to Mr. K. P. Baskin, February 17, 197 b. Findings (1) Items of Noncompliance (a) During the review of OnSite Review Committee (OSRC)
activities, the inspector found that the OSRC reviewed all procedures and procedure changes. The review was initiated by routing each procedure and procedure change to OSRC members with a special procedure review form. This form identified the procedure to which it was attached and provided space for the committee members to indicate their approval or disapproval of the procedure. The form also provided space for the final approval of the procedure (or achange) by the Plant Manager. The review form did not, however, provide for a written safety evaluation of those procedures or procedure changes subject to 10CFR50.59 review. Upon completion of the above review, the proce dures and procedure changes were dispositioned at the next OSRC meeting. The OSRC meeting minutes listed the proce dures and procedure changes which were reviewed and approved. The minutes did not contain safety evaluations for the procedures nor did they indicate that the committee reviewed the procedures/changes for a determination with regard to an unreviewed safety questio TS 6.5.1.6.a requires that the OSRC shall be responsible for reviewing all procedures required by TS 6.8 and changes thereto. TS 6.5.1.7.b requires that OSRC shall render determinations in writing to the Plant Manager with regard to whether or not the items reviewed under TS 6.5.1. through e. constitute an unreviewed safety questio The licensee's failure to provide written determinations to the Plant Manager regarding the unreviewed safety question issue for procedures and procedure changes constitutes an apparent item of noncompliance against TS 6.5.1.7.b and is an infractio (b) During the review of the audits performed by and for the Nuclear Audit and Review Committee (NARC), the inspector found that the NARC audit which was performed in the area of training in 1978 (Reference 9.a.(11)) reviewed only the requalification training of licensed operators. The audit did not include a review of the performance training and qualification of other staff members such as the craftsmen, technicians and nonlicensed operator TS 6.5.2.8 requires that facility activities shall be audited under the cognizance of NARC and that these audits shall include the performance, training and qualifications of the entire facility staff at least once per year. It also requires an annual audit of the conformance of facility operations to all provisions contained in the TS and applicable license condition The inspector also found that the licensee had not audited facility operations for conformance to TS 3.3.4 (Hydrazine Addition Tank) in 1978. Another auditor assigned to audit TS 3.3.1 had noted in his audit report that the checkoff list used to document compliance with TS 3.3.4 only required a "check mark" to indicate that the tank was operable (solution level and concentration within specifi cations). Discussions with the auditor and a review of the audit report indicated that conformance with TS 3.3.4 was not verified during the audi The licensee's failure to audit the performance, training and qualifications of the entire facility staff in 1978 and his failure to audit conformance to TS 3.3.4 in 1978 constitute an apparent item of noncompliance against the requirements of TS 6.5.2.8 and is an infractio (2) Deviations ANSI Standard N18.7 1972 establishes guidance on the activities of the independent review and audit group. Section 4.2.1 of this standard requires that a written charter shall be prepared for the review and audit group which contains a mechanism for initiating review and audit activities and identifies the management position to which reviewers and auditors repor The licensee had prepared a written charter (Reference 9.a.(l))
which detailed NARC (the licensee's independent review and audit group) activities and generally conformed to Section 4.2.1 of N18.7. The charter did not, however, describe the mechanism used for initiating NARC audits nor did it identify the management position to which NARC auditors in the QA organization report when they were performing NARC audit Since the licensee had committed to ANSI N18.7 1972 in Appendix D to the FSAR, the above discrepancy in the NARC charter constitutes an apparent deviation from the licensee's commitmen (3) Unresolved Items (a) The inspector found that the minutes to NARC meeting 178 had been issued in 20 days as compared to the 14 days required by TS 6.5.2.10.b. The licensee had identified this noncompliance and had initiated corrective action by issuing a Corrective Action Request (CAR G86). During NARC meeting 378, this issue was discussed by the committee and was closed based on a telephone conversation between the licensee and RV. The RV representative had agreed with the licensee that the issue was not reportable. The licensee representatives apparently misinterpreted this position to mean that it was not a TS violation and thus did not require any additional action. The issue was thus closed and no further corrective action was taken. This
-41 issue has been identified as an unresolved item (No. 79 01-05) pending completion of corrective action and the requisite committee review (b) The inspector found that NARC did not review procedures or procedure changes, nor were they required to review them under TS 6.5.2.7. However, Sections 4.3.1 and 4.3.3 of ANSI N18.7 -
1972Property "ANSI code" (as page type) with input value "ANSI N18.7 -</br></br>1972" contains invalid characters or is incomplete and therefore can cause unexpected results during a query or annotation process. require that the independent review and audit group (which is NARC) shall receive and review the safety evaluations of procedure changes and any proposed procedure changes which may involve an unreviewed safety question. Since the licensee is committed to ANSI N1 by Appendix D to his FSAR, NARC's failure to review procedure changes (and their safety evaluations) is an apparent deviation from their above commitment to N1 Licensee representatives argued that TS 6.5.2.7 established the review requirement of NARC and takes precedence over the requirements of ANSI N18.7 -
1972Property "ANSI code" (as page type) with input value "ANSI N18.7 -</br></br>1972" contains invalid characters or is incomplete and therefore can cause unexpected results during a query or annotation process.. The inspector indicated that this issue would be identified as an unre solved item (No. 79-01-06) and would be referred to NRC management for resolutio c. Observations The following observations include general information items and perceived strengths and weaknesses in the licensee's management controls which may not have specific regulatory requirements, but will provide the basis for subsequent performance evaluations (Reference paragraph 2).
(1) On-Site Review Committee (OSRC)
(a) The licensee had issued a charter (reference 9.a.(2))
defining OSRC review responsibilities, but no other written procedures or instructions had been issued describing OSRC activities.(W) Alternate members had been appointed in writing.(S)
(b) In addition to the reviews required by the TS, the OSRC was routinely reviewing the following:
NRC correspondence, including inspection reports and responses; IE Bulletins/Circulars and responses; and NRR requests and response NCR's and CAR's generated by on-site organizations All LER's and Station Incident Reports (SIR's)
Monthly summary reports from the on-site departments which describe operations and'surveillance activities 0 Minutes of previous meetings
-42 NARC meeting minutes and NARC audit reports(S)
(c) The Plant Manager (OSRC Chairman) made the decisions regarding the special material that was to be reviewed by the committee.(I)
(d) Review material of a general, non-technical nature was presented to the committee by the secretary. Special material (like design changes, etc.) was formally presented by the appropriate supervisor or a member of his staff.(S)
(e) The committee members who were interviewed stated that items such as procedures, procedure changes and design changes were routed to the members for review prior to the meeting, but final approval on these items was made by the committee in a meeting.(S)
(f) The regular monthly meetings of OSRC were scheduled in advance, but no meeting agenda or formal notice was prepared and distributed to the members. Special meeetings were called by verbal contact with the members, and again no agenda was prepared.(W)
(g) Committee members who were interviewed stated that the TS requirement to investigate TS violations was satisfied by individual supervisors. When the supervisor determined that an issue constituted a TS violation, he would bring it to the committee's attention through the issuance of a CAR or SIR. The committee's review of the CAR's and SIR's was documented in the meeting minutes, but the minutes did not specifically identify those CAR's and SIR's which involved a TS violation. The report to management, that is required by TS 6.5.1.6.e to address recommendations to prevent recurrence, was the CAR or SIR. The committee did not review operating activities to verify that departmental supervisors had identified all TS violations to OSRC.(W)
No guidance had been issued to assure that all TS violations would be identified and presented to the Committee for review in accordance with TS 6.5.1.6.e, nor had responsi bilities been assigned for the preparation of the required report. In the interviews with the control operators regarding the reporting of identified TS violations, the operators said that the violation would be reported (verbally) to their watch engineer. They were not aware of the Station Incident Report (SIR) which must be prepared to document the violation for management and OSRC review.(W)
(h) The committee members who were interviewed said that the committee will often pursue the generic implications of issues under review, but this was not done routinely, and any generic review that was done had not been documente They also said that they did not specifically look for generic implications to be addressed in the LER's or the responses to inspection and audit reports that they reviewed.(W)
(i) The activities of the OSRC were audited by the on-site QA organization, and a QA engineer stated that he had attended all committee meetings.(S) QA did not, however, routinely receive a copy of the committee's meeting minutes.(W)
(j)
The OSRC charter did not contain the following features:
.
Definition of the operating activities to be reviewed by the Committee to satisfy TS 6.5.1..
Provisions for introducing material to the Committee for revie.
Guidance on what constitutes an unreviewed safety questio.
Requirements to review prior meeting minute.
Requirements to review all 30-day LER'.
Requirements to review NRC inspection reports and responses theret.
Requirements to review QA and NARC audit reports and the responses theret.
Requirements to review IE Bulletins and the responses
theret Requirements to review QA Manual and QA Procedure Changes.(W)
(k) The OSRC was not routinely reviewing the following:
CAR's (G Series) generated by the General Office organizations
.
QA Audit Reports
.
QA Manual Changes QA Procedure Changes(W)
(1) Written responsibilities had not been assigned to an individual to act as committee secretary for the purpose of recording committee activities and preparing meeting minutes. An on-site engineer had been orally assigned these responsibilities.(W)
-44 (m)
No tickler system was being maintained by site management or General Offices management to verify that all material required to be reviewed had been reviewed by the committe Licensee representatives stated that they rely on NARC's audit of OSRC activities to provide this overview.(W)
(n) OSRC members who were interviewed stated that the committee did not review specific operating records to satisfy the TS 6.5.1.6.f requirement to review plant operations for potential safety hazard They noted that each member did this as part of his routine job responsibilities and significant problems would be presented to the committee by the member. One member said that he felt this was a QA or NARC function.(W)
(o) The OSRC did not perform or require routine trend analyses beyond those required by the QA procedures (reference 4.a.(13)).(W)
(p) Committee members had received no formal instructions or training in their review responsibilities.(W)
(q) When asked to discuss the scope of their review, the OSRC members who were interviewed failed to indicate that their review of material such as design changes, procedure changes and TS violations was for the purpose of determining if they constituted an unreviewed safety question. Further, the OSRC members who were interviewed could not adequately define what constituted an unreviewed safety question. The individuals who were interviewed stated that the committee did not routinely address the issue of an unreviewed safety question during their meeting reviews.(W)
(r) The OSRC had no mechanism for following to completion the identified corrective action of the noncompliance, deficien cies, or other problems reviewed by the committee.(W)
(2) Nuclear Audit and Review Committee (NARC)
(a) The licensee had issued a charter (reference 9.a.(l))
which defined the review and audit responsibilities of the NARC; appointed alternate members; and described the functions of the NARC Secretary.(S) No other procedures or instructions had been issued which describe NARC activities.(W)
(b) NARC meetings were called by distributing a formal meeting notice and agenda to each member. Copies of the material to be reviewed was also submitted with the agenda. The members who were interviewed said that the notice/agenda distribution was timely and enabled prior review of the materia The material to be reviewed by NARC was formally presented to the committee by a member of the organization responsible for the material.(S)
-45 (c) The NARC members who were interviewed were generally knowledgeable of what constituted an unreviewed safety question.(S)
(d) NARC audit assignments were made by the Chairman and the Secretary. About one-fourth of the audits were performed by NARC members and the remainder were performed by the QA organization. The NARC member assignments were rotated each year.(I)
(e) The NARC Secretary was formally appointed from the QA organization and was to serve in that capacity for a term of one year; although the current secretary had been in that position in excess of that period.(S)
(f) NARC had reviewed all of the material required by TS 6.5.2.7 and the NARC charter.(S) The committee had not, however, reviewed the following on a routine basi The minutes of previous NARC meeting Responses to deficiencies identified in the audit reports of the audits performed by QA for NAR QA audit reports or the responses to the Records of major maintenance, modification, or test activities with the exception of the ISI Report.(W)
(g) The following items were noted regarding the NARC audit program as implemented by NARC member Audit plans were not routinely prepared for prior approva Auditors were not certified to be qualified (ANSI N45.2.23).
Audited organizations were routinely notified ofthe schedule and scope of the audits by telephone call Pre-audit conferences were not routinely hel Deficiencies were not routinely investigated to identify the cause and extent of corrective action require Corrective action requests were not issued for deficiencies identified by the NARC members; however, they were carried on the NARC Open Items Lis.
The format and content of the audit reports were not consistent with that used by Q Followup and reaudit was done as part of the next audit in that area which may be one to two years later.(W)
(h) Alternate members were not routinely issued the notice/
agenda packages. Some of the members who were interviewed stated that they routinely reviewed the agenda material with their alternate, but the remainder indicated that no effort was made to keep the alternate informed unless his services were anticipated.(W)
(i) When asked to discuss the scope of their review, most of the NARC members who were interviewed indicated that they were looking for unreviewed safety questions (USQ), but some of the members did not indicate that determination of the USQ issue was part of their review.(W)
(j) NARC reviewed all LER's; NRC inspection reports; reports of audits performed by the QA organization for NARC; and OSRC minutes and the SIR's contained therein.(S) However, the committee had reviewed no other operating records.(W)
(k) NARC meeting minutes were prepared by the NARC Secretary who attended the meetings as a recorder. The minutes were approved by the NARC Chairman and distributed to the members and Nuclear Control Board (NCB).(S) The minutes were not reviewed and approved at a subequent NARC meeting.(W)
(1) NARC reviewed the quantative trend analyses on CAR's and NCR's which were performed by the QA organization and the quantitative trend analysis performed by the Steam Supply Division of SIR's. The committee did not require or perform any other trend analyses on a routine basis.(W)
(m) In addition to the charter deficiencies cited in paragraph 9.b.(2), the charter did not include the following feature Provisions for taking followup action, including reaudit of deficient area Requirements to review the status of the audit program semiannually Policy on the use of subcommittees (the licensee planned to use a subcommittee for Units 2 and 3 activities).
Requirements to review the audit reports of the committe Guidance on what constitutes an unreviewed safety questio Guidance regarding the preparation, performance and reporting of NARC audit activities (see 9.c.(2)(g)).(W)
-47 (n) No formal training or instructions had been given to committee members and alternate members regarding the committee's review and audit responsibilities. One NARC member who was interviewed said that new members should receive such training/instructions.(W)
(o) No formal system had been established to assure that all required material had been reviewed or audited by the committee. The members who were interviewed said that they rely on the QA audits of NARC activities to provide this overview. NARC had no system for the followup and verification of the completion of the indicated corrective action for noncompliances, deficiencies or other problems reviewed by the committee.(W)
(p) The individuals who were interviewed indicated that the committee did not provide overview of the completion of the NARC audit program with the exception of the review of the completed audit reports during a meeting in late spring of each year. It is noted that the failure to semiannually review the status of the audit program as recommended in ANSI N18.7 -
1972Property "ANSI code" (as page type) with input value "ANSI N18.7 -</br></br>1972" contains invalid characters or is incomplete and therefore can cause unexpected results during a query or annotation process., contributed to the item of noncompliance cited in paragraph 9.b(l)(b).(W)
(q) The NARC members who were interviewed stated that the committee did not routinely observe activities on sit They said that the committee had met approximately once each year at the site, and that individual members had occasionally attended OSRC meetings. During the above visits, ongoing activities were not observed. It was also noted that the NARC audits involved a review of records as opposed to actual observations of activities.(W)
(r) Audit findings from audits performed by NARC members were not routinely entered into the corrective action syste The deficiencies were entered into the NARC Open Item List. The NARC auditors had no responsibility to followup and verify the corrective action of the identified deficien cies. The open items were closed out based on input from the site indicating that the corrective action had been completed. The corrective action would not be verified until the next audit in that area which, because of the rotating schedule, would probably be performed by a different auditor.(W)
(3) Nuclear Control Board (NCB)
(a) The members (vice presidents) of the NCB who were interviewed said that they received and reviewed NARC meeting agenda, minutes and reports.(I)
(b) The NCB had been meeting every six months as required by the TS.. During the meetings, the NCB reviewed the followin.
NARC meetings and activities as summarized by the NARC Chairma.
QA activities, NRC inspection findings, QA audit findings and LER's as summarized by the Manager, Quality Assuranc.
Highlights of station operations and SIR's as summarized by the Manager of Steam Generatio.
Licensing activities (including TS changes) as summarized by the Manager, Generation Engineering Services.(S)
(c) In discussions regarding the NCB's review and reporting requirements (TS 6.5.3.5.a -
requires formal submittal of safety analysis report on violations of TS), the board members who were interviewed said that they did not believe there had been any TS violations. The inspector found that there had been several identified TS violations in 1978 and a safety analysis report had not been issued by NCB in all cases. The licensee subsequently (March 1, 1979) contacted NRR regarding the intent of TS 6.5.3. In a letter to the licensee, dated March 5, 1979 from M D. L. Ziemann (NRR), the licensee was informed that TS 6.5.3.5.a shall not be interpreted to impose requirements beyond those of TS 6.9, "Reporting Requirements."
With this interpretation the licensee was not in noncompliance.(I)
(d) The NCB used a ballot review technique to review proposed TS changes prior to their formal submittal to NRR. The TS changes were subsequently reviewed in a board meeting which was after the TS change had been formally submitted to NRR. It is noted that NRR has taken a position (with regard to on-site committee reviews) that approval based on only a ballot review is not acceptable. This item will be referred to NRC management to obtain a position on the acceptability of the NCB's ballot review practice as discussed above.(W)
1 Maintenance The objective of this portion of the inspection was to determine the adequacy of management controls associated with corrective and preventive maintenance activitie a. Documents Reviewed (1) Quality Assurance Program, Amendment D to the FSA (2) San Onofre Nuclear Generating Station (SONGS) 1 Quality Assurance Manua (3) SONGS 1 Administrative Controls Technical Specifications, Section (4) Station Orders and Procedure (a) Request for Equipment Repair, S-M-102, Rev. (b) Equipment Outages, S-A-107, Rev. (c) Equipment Testing Before and After Maintenance, S-0-111, Rev. (d) Test Control S-A-116, Rev. (e) Station Quality Assurance Program, S-A-112, Rev. (f) Station Documents, Preparation, Revision and Review, S-A-109, Rev. (g) Instructions, Procedures, and Drawings, S-A-114, Rev. (h) Station Inspection Plan, S-E-117, Rev. (i) General Maintenance Procedure, S-I-i, Rev. (j)
Fire Protection, S-A-2, Rev. 1 (k) Routine Lubrication, S-A-4, Rev. (1) Control of Test and Measuring Equipment, S-I-2.12, Rev. (in)
Control of Special Processes, S-M-104, Rev. (n) Station Inspection and Housekeeping, S-A-10, Rev. (o) Safety Precautions in Confined Areas, S-A-10, Rev. (p) Fire Prevention During Open Flame Processes, S-M-105, Rev. (q) Maintenance of Pressurizer and Steam Generator Safety Valves, S-M-3, Rev. (r) Battery and Charger Testing Required During Refueling Shutdown, S-I-1.22, Rev. (5) Division Orders (a) Work Authorization, D-A-1 (b) Equipment Performance, D-E-b. FRiev4s (1) Items of Noncompliance The review of the licensee's corporate and site orders, site procedures, and interviews with maintenance personnel revealed that a comprehensive formal preventive maintenance program had not been establishe This program should have included safety-related pumps, valves, and equipmen The licensee performed routine testing of safety-related pumps and valves in accordance with the license requirements, routine inspection and maintenance activities on certain equipment based on experience, and routine lubrication of certain safety related equipmen Appendix A to USNRC Regulatory Guide 1.33, Rev. 1, Section 9.6, recommends that preventive maintenance schedules should be
-50 developed for inspections of equipment, replacement of such items as filters and strainers, and inspection of replacement of parts that have a specific lifetime, such as wear ring Technical Specification 6.8.1 specifies that written procedures and administrative' policies shall be established, implemented and maintained that meet or exceed the requirements and recom mendations of Appendix "A" of USNRC Regulatory Guide 1.33, Re, Quality Assurance Program Requirements (Operation).
The lack of a formal preventive maintenance program (written procedures and policies) which included all appropriate inspec tion requirements of safety-related pumps, valves, and other equipment is an item of noncompliance pursuant to Technical Specification 6.8.1 and is a deficienc (2) Deviations Non (3) Unresolved Items (a) The review of the plant maintenance procedures and interviews with maintenance personnel revealed that certain safety-related maintenance activities, which would be performed during backshifts and require immediate attention, may be performed outside normal procedural controls. Station Order S-M-103, Request for Equipment Repair, did not provide administrative controls for
"emergency" maintenance activitie Amendment D to the FSAR, Quality Assurance Program, Section D.5, requiredthat safety-related maintenance items that were not covered by existing instructions must have special instructions provided. These special instruc tions must be reviewed by the Onsite Review Committee (OSRC) and approved by the Station Superintenden Section 0.6 specified that written and approved documents must be available at the location where the prescribed activity was to be performed prior to initiation of the activit Appendix A to USNRC Regulatory Guide 1.33, Rev. 1, Section 9a, 9c, and 9e, specify that maintenance should be properly preplanned and performed in accordance with written proce dures, documented instructions, or drawings as appropriate to the circumstance Procedures for repair or replace ment of equipment should be prepared prior to beginning work, and general procedures for the control of maintenance, repair, replacement, and modification work should be prepare The specific administrative guidance in the area of
"emergency maintenance" to assure adequate management control of those safety-related activities, including documentation and review was not apparen This is an unresolved item. (79-01-07)
(b) The review of the plant station orders and procedures and interviews with maintenance personnel revealed that post maintenance testing requirements (acceptance and return to service criteria) was routinely established by discussions between the maintenance and operating personne Station Order 5-0-111, Testing Before and After Maintenance required testing of equipment prior to and following maintenance activities. Station Order S-A-116, Test Control, required testing of equipment cataloged in the Quality Listing (S-A-112) and Technical Specifications; furthermore, the test was required to be performed in accordance with written procedures and include acceptance limits within which the structure, system, and component under test must meet to be considered serviceabl Personnel interviews revealed that the Technical Specification and/or ASME,Section XI, testing were routinely used to verify operability following maintenance activities; and the tests did not include additional acceptance criteria, as appropriate, for the specific maintenance activity which was performe The administrative controls did not appear to provide specific requirements and guidance for the development of post maintenance testing requirement Criterion V of Appendix B to 10 CFR 50 requires that procedures.shall include the appropriate quantitative or qualitative acceptance criteria for determining that important activities have been satisfactorily accomplishe ANSI N18.7-1976, Section 5.3.10, Test and Inspection Procedures, requires that test procedures shall contain a description of objectives; acceptance criteria that will be used to evaluate the results; prerequisites for performing the tests including special conditions; limiting conditions; special equipment or calibrations required; and documentation and evaluatio This is an unresolved ite (79-01-08)
c. Observations The following observations include general information items and perceived strengths and weaknesses in the licensee's management
-52 controls which may not have specific regulatory requirements, but will provide the basis for subsequent performance evaluations (Reference paragraph 2).
(1) The maintenance program at the station was established and controlled by the plant staff. The procedures developed for maintenance activities were approved by the Manager - Nuclear Generation. The specific controls for plant maintenance activities were the responsibility of the-Superintendent of Maintenance and Operations (SMO) who reported directly to the Plant Manager. The Supervisor of Maintenance and the Super visor of Instrument and Control reported to the SMO and directed the mechanical-electrical and instrument departments activities respectively.(I)
(2) Communications between the plant and.the corporate personnel was established and maintained through meetings and frequent telephone communications between the Plant Manager's staff and the staff of the Manager - Nuclear Generation.(I)
(3) Division orders, station orders, and station procedures were established to control safety-related maintenance activitie The requirements of the quality assurance program were contained within the station orders, procedures, and the staff training/
qualifications. The specific responsibilities and authorities of the maintenance department were provided in a number of station orders and procedure All safety-related maintenance activities were controlled locally at the plan (a) Use of Checklists Procedure reviews and personnel interviews revealed that the direction for the use of checklists were provided for removal of certain equipment from service. In most cases the licensee was also using the checklists for returning the equipment to service; although, no formal requirement was apparent for this activity. The need for the use of checklists was routinely determined by the control room operator.(W)
(b) Equipment Clearances Procedure reviews and personnel interviews revealed that the licensee provided a formal program for clearing equipment for workman protection. Safety-related equip ment clearance procedures were utilized by the control operators under the cognizance of the watch engineer Approved procedures were available in some cases; but routinely the control room operator developed and imple mented the clearance procedures. This activity was considered by the licensee to be within the qualifications and skills of the control room operators, therefore, the formal procedures were not required under TS 6. The formal program for independent inspection of the equipment clearance and return to service activities was not apparent to assure items (valves, bypasses, jumpers, fuses, etc.) affected during the maintenance activity were returned to normal service (Reference 3.c.(33)).(W)
(4) General job descriptions were available describing the plant maintenance positions. Interviews indicated that specific job descriptions, responsibilities, and authorities needed to be established and formalized.(W)
(5) The maintenance department staffing appeared to be adequat The staff was stable and had generally worked at the facility for a number of years and possessed substantial experience at the first and second line supervisory levels. The staffing appeared to meet the requirements of the Technical Specifica tions. The maintenance staff was being utilized to support the Units 2 and 3 startup program to supplement their workforce and to obtain on-the-job trainin Additional support was provided as needed during outages from the licensee mobile maintenance crews. The maintenance depart ment normally worked a forty-hour week with overtime scheduled as necessary to maintain the plant equipmen Interviews revealed that the maintenance supervisor had not been appointed for Units 2/3, and the Unit 1 maintenance supervisor was functioning in this position.(W)
(6) The maintenance department procedures were prepared, reviewed, and approved in accordance with the Technical Specifications 6.8.1. Additionally, the procedures were approved by the Manager of Nuclear Generation. All procedures were reviewed every two years.(I)
(7) Procedure.reviews revealed that most maintenance activities were formally addressed by administrative controls and mainte nance procedures which included the following area (a) Cognizance of maintenance activities by the operations and maintenance department personnel utilizing an established and documented maintenance priority classification procedur (b) Identification of maintenance and inspection personnel performing the activity was documented on the work request form and the repair summary sheet (c) Description of the repairs completed was provided on the work request form and the repair summary sheet (d) Maintenance activity was reviewed by supervision prior to and subsequent to the activit (e) Control of measuring and test equipment was addressed, by reference to the appropriate station order with the equip ment used documented on the procedure/maintenance work reques (f) Control of replacement parts was addressed by reference to the appropriate station order and the parts used were documented on the maintenance work reques (g) Fire protection requirements was addressed by reference to the appropriate station orde (h) Control of special processes was addressed by reference to the appropriate station orde (i) Control of cleaning fluids was addressed by the station order (j) Equipment testing before and after maintenance and test control was addressed and coordinated with the watch engineer utilizing the established station order (k) Equipment classification as safety-related was addressed in the station order (1) Equipment inspection, test, and operating status was addressed by reference to the appropriate station orde Interviews revealed that the supervisor and foremen were cognizant of these requirements.(I)
(8) Plant maintenance activities were divided into three general categories; routine, expedite, and preventive. These activ ities were controlled by approved station orders.(I)
(9) The review of selected maintenance department station orders and procedures revealed that certain aspects of the maintenance activities did not appear to be formally addressed, and included the following activitie (a) The activity level which required a detailed written procedure including the method of determining the need for a procedure was not formalize (b) The development of inspection and/or hold points during routine maintenance activities was not formalized and implemented. A sampling of safety-related activities was not required to be inspected, including the inspection of safety-related activities being performed in accordance with detailed written procedures or checklists and those being performed within the skills of the craftsmen. The inspector noted that the licensee had conducted an audit during the previous refueling outage which identified inadequacies in the
-55 inspection program. Staff training was performed and corrective actions were in progress. The area of inspec tion requirements were discussed at the management exi (c) The apparent lack of formal documentation of the evaluation, cause, and corrective action for each safety-related failure was not established. The maintenance form and the equipment repair summary sheets only specified the descrip
,tion of the repairs made to the equipmen (d) Determination of the qualification of the maintenance personnel performing the activity was made by the super visors and foreman and no formal method existed to assure the craftsman maintained continued proficiency, with exception of the foreman-worker relationshi (e) Development and designation of QA/QC hold points for use with an inspection checklist was developed informally by the supervisors and/or forema (f) Notification of the radiation protection group of the maintenance activity was performed by the maintenance and operations departments and was generally informa (g) Special procedure'and mockup training was determined by supervisors and was generally informa (h) Housekeeping and cleanliness during specific maintenance procedures was not specifically addressed in the mainte nance administrative procedures and was handled informally by the maintenance supervisors and/or forema (i) The method for making temporary change to approved maintenance procedures was not specifically addressed in the maintenance administrative procedures. Interviews revealed that the maintenance personnel were cognizant of the requirements of the Technical Specifications for procedure change (j)
Maintenance package assembly, review, storage; and appropriate cross-reference to support the documentation for the activity was not specifically addressed. The inspector noted that a specific log review and record search would provide the appropriate documents. Interviews revealed that the licensee understood the record storage syste (k) Failure trending and long term corrective action appears to be informal and depends largely on personnel familiarity with the equipment and memory. The inspector was informed that a computerized program for failure trending was being formulated and would possibly be available in about two year Interviews revealed that the. possibility existed that the maintenance supervisor would be transferred to
-56 Units 2/3 and his personal knowledge of Unit 1 would be lost from the day-to-day maintenance activities, including trendin Personnel interviews revealed that these areas were considered as part of the individual responsibilities of a maintenance craftsman or supervisor. Routine morning meetings were held by the licensee to provide review, preparation, and coordination of the maintenance activities and to assure these activities were adequately addressed.(W)
Quality Assurance Audits The objective of this portion of the inspection was to determine the adequacy of the licensee's Quality Assurance (QA) Audit Program and to verify the implementation of the progra Documents Reviewed (1) Quality Assurance Manual, Chapters 1, 2 and 1 (2)
QA Organization Audits - Scheduling, Planning, Perfor mance, Documentation and Followup, Quality Assurance Procedure (QAP) No. N18.04, Rev. 1 (3) Qualification of QA Organization Auditors, QAP N N18.05, Rev. (4) Participation of Technical Personnel From Other Depart ments on Audit Teams, QAP No. N18.07, Rev. (5) Stop Work Procedure, QAP No. N2.03, Rev. (6) Reporting of Quality Trends, QAP No. N2.07, Rev. (7) The following QA audit reports (a) SOI-01-77 (b) SOI-9-77 (c) SOI-1-78 (d) SOI-43-78 (e) SOI-46-78 through SOI-55-78 (f) SOI-01-79 through SOI-05-79 (g) SOI GRIP-3-78 (8) SCE -
SONGS 1 Audit Schedule No. 79-01 (9) QA Log Assignment No. 133*(and attached audit schedule)
(10)
QA Program for San Onofre-1, a review by John W. Flora, March 10, 197 Findings (1) Items of Noncompliance Non (2) Deviations Non (3) Unresolved Items Non c. Observations The following observations include general information items and perceived strengths and weaknesses in the licensee's management controls which may not have specific regulatory requirements, but will provide the basis for subsequent performance evaluations (Reference paragraph 2).
(1) The licensee had developed and implemented a QA audit program which was consistent with the guidance of ANSI N45.2.12 1977.(S)
(2) The licensee had developed and implemented a program for auditor qualifications and certifications which was consisten with the guidance of ANSI N45.2.23. The program included a review and recertification of auditors annually.(S)
(3) All QA auditors and supervisors had received formal training in a lead auditor course.(S)
(4) Audit plans were prepared by the auditor and were reviewed and approved by the auditor's supervisor.(S) Checklists were not used.(W)
(5) All QA audits were announced. The supervisor of the organi zation being audited was notified by a telephone call from the auditor or lead auditor.(S)
(6) Deficiencies which were identified during QA audits were documented in Corrective Action Request (CAR) forms and were followed by the corrective action system. Other audit findings were addressed in a section of the audit report entitled
"Recommendations."
There was no formal followup of these recommendations, but the individuals who were interviewed stated that the recommendations would be reaudited during subsequent audits.(S)
(7) QA Audit reports were prepared in accordance with the guidance given in QAP No. N18.04. The reports were reviewed by the applicable QA Supervisor and were approved by the Project QA
-58 Supervisor. The approved QA audit reports were distributed by the QA Manager to the QA organization, the Plant Manager, the Manager, Nuclear Generation, and the supervisor responsible for the audited area. QA audit reports and the applicable CAR's were reviewed by the Plant Manager. He generally assigned the responsibility for prepartion of the response to the Engineering Group.(S)
(8) The response to the QA audit reports and the proposed corrective action on the CAR's was reviewed by QA supervision and was approved by-the QA Manager. The QA engineers had used a log system in which they recorded the "effective date" for the completion of the indicated corrective action on the CAR's. The log entries were used to followup and verify the completion of the corrective action.(S)
(9) The QA personnel who were interviewed stated that management's attitude toward QA and the support given to the QA organization was very good. They also noted that the attitude of the plant staff toward QA had improved considerably over the past few years.(I)
(10)
The onsite QA organization used a QA surveillance program to audit and monitor ongoing activities such as refueling opera tions. Surveillance reports were distributed to the Plant Manager, Project QA Supervisor and the applicable QA Superviso Identified deficiencies were documented on CAR's.(S)
(11)
In addition to routine audits against the criteria of 10 CFR 50, Appendix B, the QA organization also performed audits for the Nuclear Audit and Review Committee (NARC). Since the NARC audits were against TS requirements and the QA audits were against Appendix B criteria,.the licensee did not audit func tional areas such as maintenance. The functional areas were covered on a piecemeal basis under the audits of each Appendix B criteria or applicable TS.(I)
(12)
The QA supervisors and engineers who were interviewed stated that a pre-audit conference was not routinely conducted despite the fact that the QAP N18.04 states that a brief pre-audit conference shall be conducted at the audit site as considered necessary. Several of the above individuals stated that the scope of the audit was discussed during the telephone notifica tion of the appropriate supervisor.(W)
(13)
QAP No. N18.04 provided guidance regarding the conditions under which the auditor can deviate from the approved audit pla Individuals who were interviewed were only marginally familiar with this provision.(W)
(14)
The licensee had established stop work authority in Section 2.1.6.9 of the QA Manual and in QAP No. N2.03. The QA
individuals who were interviewed were weak in their knowledge of the above policies. Some of them were not aware that they had such authority.(W)
(15)
The QA personnel who were interviewed indicated that there existed no written requirement to pursue the generic implica tions of problem areas which are identified in the audit process, but they felt that this was being done by all auditors.(I)
(16)
Licensee representatives stated that the effectiveness of the QA Program was determined with the aid of an audit that was performed by a contractor every three years. During the last such audit (see ll.a.(10)), the auditor quantified and trended such things as the number of cited items of noncompliance, LER's, etc. The auditor did not, however, perform a qualita-.
tive analysis of the data by analyzing the nature and cause of the noncompliance or LER's.(W)
(17)
The licensee was performing routine quantitative trend analyses on repetitive deficiencies identified in CAR's, NCR's (Non conformance Reports) and SIR's (Station Incident Reports). No other trending was being performed on a routine basis.(W)
(18)
QA audit reports were routed to selected department supervisors but were not routinely routed or made available to the rest of the plant staff. Plant staff personnel interviewed also noted that NARC audit reports are not made available to them. Several plant staff members said that they would like to have the audit reports made available to them.(W)
(19)
The QA organization had no formal tickler system to track and assure the timely submittal of QA audit reports and the responses to the audit reports. They had an Audit Log which was used to record the audi-t status but the individuals interviewed did not indicate that it was used for assuring the timeliness of reports and responses thereto.(W)
(20)
The licensee had no formal program for re-evaluating the qualifications of an approved vendor based on repetitive failures.(W)
(21)
The on-site QA organization did not routinely receive copies of the report of NARC audits performed by NARC auditors. The QA engineers also stated that they did not see NRC inspection reports. The QA/QC Supervisor received NRC inspection reports, but did not receive the responses thereto.(W)
(22)
An individual who was interviewed noted that the CAR's which were prepared to document identified QA audit deficiencies were attached to the audit report and received the same time consuming review as the report. He felt that the CAR's should be.issued immediately after the problem was identified to effect timely pursuit of corrective action.(W)
-60 (23) The QA audit program which was scheduled for 1978 had not been completed at the time of this inspection. QA management was aware of this problem and had initiated measures to complete the audits which had not been performed.(W)
(24) In reviewing selected audit reports, the inspector found that the scope of the audit program was not sufficient to cover all of the requirements of the program. For example, the audit of corrective action verified the followup of CAR's and NCR's after they had been initiated. The audit did not, however, verify that all problems areas which require the initiation of a CAR or NCR had actually resulted in the issuance of same. A similar problem was identified in the scope of the audits of the testing activities associated with plant maintenance and the Fire Protection Program.(W)
1 Procurement The objective of this portion of the inspection was to determine the adequacy of management controls associated with procuremen a. Documents Reviewed The following documents were reviewed:
(1) Quality Assurance Program Plan, SONGS Unit 1 Final Safety Analysis Report Appendix 0 (2) Quality Assurance Manual, SONGS Unit 1 (3) Bid Proposed Evaluation, QAP N4.01, Rev. 1 (4) Procurement Quality Assurance Requirements, QAP N4.02, Rev. 1 (5) Supplementary Procurement Checklist for Spare and Replacement Part QA Requirements, QAP N4.03, Rev. 1 (6) Supplementary Checklist for Procurement by Unique Order Method, QAP N.04, Rev. 1 (7) Bidder Prequalification and Capability Evaluation, QAP N7.01, Rev. 8 (8) Quality Assurance Review of Proposed Bidders Lists, QAP N7.05, Rev. 0 (9) Case Data Exchange Program, QAP N7.06, Rev. 0 (10) Source Inspection, QAP N10.01, Rev. 2 (11) Receiving Inspection, QAP N10.02, Rev. 2 (12) Clerical Checklist for QA Orders, PSSO(l) 332 NEW 3/78
-61 (13) Steam Generation Division Field Order, PSSD 211, Rev. 11-72 (14) Store Procedures, Division Order D-C2, Revised August 16, 1966 (15) Procurement Document Control, Station Order 5-A-113, Rev. 6 (16) Safety Related Purchase Order Worksheet, PSSO(1) 232 NEW 10/78 (17) Preparation and Review of Procurement Specifications, Engineering Procedure S-V-2.21, January 19, 1978 (18) Procurement of Material and Services, Material Control Procedure S-XI-1.5, NEW (19) Receiving, Inventory and Shipment of Fuel, Station Order S-3-104, Rev. 8 (20) Quality Assurance Review of Specifications, QAP N3.01 (21) Control of Procurement Documents for Analysis of Consulting Services for SONGS 1, 2 and 3, E&C 37-26-12 (22) Request for Bids, Evaluation of Supplier Proposals, Award Recommendation and Procurement Change Order Request for SONGS 1, 2 and 3, E&C 37-26-14 (23) Technical Prequalification of Vendors, E&C 37-30-57 (24) Procurement of Spare Parts, E&C 37-30-65 (25) Procurement Document Control, DN-2 b. Findings (1) Items of Noncompliance Non (2) Deviations Non (3) Unresolved Items Non c. Observations The following observations include general information items and perceived strengths and weaknesses in the licensee's management controls which may not have specific regulatory requirements, but will provide the basis for subsequent performance evaluations (Reference paragraph 2).
-62 (1) The licensee had procedures for the control of purchased items, qualification of personnel, qualification of vendors and requirements for vendors to comply with 1OCFR21.(S)
(2) Personnel interviewed by the inspector appeared, in general, to be knowledgeable of their position responsibilities and procure ment procedures.(S)
(3) Field orders for materials or services had to be approved by the immediate supervisor of the person preparing the orde The concurrence, by initials, of both the Unit Superintendent and the Warehouse Supervisor was required for the order to be processed.(I)
(4) Service requests exceeding $2,500 were subject to competitive bids unless the service was performed under a blanket order.(I)
(5) The station engineering staff reviewed all field orders, determined if they were safety-related, and documented their determination directly on the field order form.(I)
(6) Requisitions were prepared by the station administrative staff from the field orders and accompanying documents. Purchase orders were prepared from the requisition package by the corpo rate Procurement Division. Safety related requisitions and purchase orders were reviewed for adequacy by the ordering supervisor, a station engineer and the Resident Quality Assur ance Engineer. The licensee utilized administrative checklists to ensure all requirements of the purchasing activity were satisfied in the appropriate sequence.(I)
(7) Component and equipment specifications which must be developed for an order were subject to both peer and supervisory review.(I)
(8) Normally only those companies prequalified by the licensee from a financial, technical and quality assurance aspect were allowed to bid on a potential order. The licensee maintained a Qualified Bidders List (QBL). Additions were made to the list after station engineering or corporate engineering certified the technical qualifications, the QA organization certified the quality assurance capability and the Procurement Division certified the financial qualifications of the prospective bidder. Deletions were made to the list as a result of the bidders failure to perform, lack of current certifications or failure to gain recertification as a result of the licensee's periodic audits and surveys.(S)
(9) The "Clerical Checklist for QA Orders" appeared deficient in that it did not force the review of the Purchase Order by a station engineer or specifically address the requirement to generate bid specifications where the purchase would require a request for bids.(W)
-63 (10) Where safety related purchases were only available as "off the shelf" items, detailed technical and quality requirements were replaced by specific licensee tests or inspections which confirmed the items capability to perform as required.(I)
(11) Normally the jobsite QA organization prepared the detailed receipt inspection plans following the receipt of the approved purchase order package. The site QA/QC Supervisor had four QA Engineers and one Contract Engineer reporting to him at the time of the inspection.(S)
(12) The licensee was a member of the Coordinating Agency for Supplier Evaluation (CASE).
The licensee utilized the CASE Register to identify and exchange audit reports for review in lieu of performing his own survey. CASE exchange data was also utilized to preplan audits and surveys to ensure the strengths and weaknesses of a company were identified. The licensee was required to submit at least ten reports for listing in the CASE Register and to maintain at least ten listings current to retain active membership.(I)
(13) The licensee's procedures allowed reductions in the paper review process required for bidder prequalification, and a complete waiver of current QA capability evaluations required for bid award, if the bidder had an NRC-approved Topical QA Program and where implementation of that program had been verified by the NRC as reported by the latest quarterly Licensee Contractor and Vendor Inspection Status Report.(I)
(14) QA and engineering evaluations of bid proposals were initially performed on unpriced copies of those proposals.(I)
(15) The Procurement Division was responsible to coordinate communi cations with bidders during the proposed evaluation period.(I)
Discussions with Procurement Division personnel indicated some might be unaware of this requirement.(W)
(16) The Procurement Division was debugging a computer based
"Supplier Information System" (SIS) at the time of the inspec tion. SIS was designed to provide ready access to information on the historical performance of a supplier.(I)
(17) Management of procurement activities and the administration of contracts associated with nuclear fuels were handled by the Nuclear Fuel Supply Department instead of the Procurement Division.(I)
(18) Requests for deviations from the purchase order by the supplier were routed to the responsible engineering and QA departments for evaluation, approval or rejection. Changes to a purchase order were subject to the same approval path required by the original purchase orde Correspondence with vendors concerning purchase orders were handled through the Procurement Division.(I)
-64 (19) Receipt inspections were performed by station personnel representing the ordering department per detailed inspection plans prepared by site QA engineers. Noncompliance identified during the inspection were forwarded to the Resident QA Engineer who prepared the required NCR documents.(I)
1 Management of Safety and Security Controls The objective of this portion of the inspection was to determine the extent and adequacy of management's overview of safety and security areas including (1) Plant Security; (2) Fire Prevention; and (3) Radiation Protectio a. Documents Reviewed The following documents were reviewed in this area:
(1) Administrative Controls, Technical Specifications Section 6 (2) Quality Assurance Manual, SONGS Unit 1 (3) Fire Protection Program Review, BTP APCSB 9.5-1, SONGS Unit 1, March 1977 (4) Fire Protection, Division Order D-A 13, May 22, 1974 (5) Fire Protection, Station Order S-A-2, Rev. 18 (6) Fire Prevention and Equipment Inspection Report, dated 4-9-78 (7) Fire Brigade Meeting Agenda for 1978, memorandum to Watch Engineers, dated December 1, 1977 (8) Safety, Station Order S-A-1, Rev. 4 (9) Testing for Presence of Explosive Mixtures of Hydrogen Gas, Station Order S-0-8, Rev. 3 (10)
Fire Prevention During Open Flame Processes, Station Order S-M-105, Rev. 2 (11) Admittance to the Station, Station Order S-A-108, Rev. 5 (12)
Fire Prevention Manual (13)
Accident Prevention Manual Findings (1) Items of Noncompliance During the review of licensee documents and records related to
- the station Fire Brigade, the inspector found that records of required monthly meetings were incomplete. A detailed review of these records and discussions with station personnel indi cated that a number of individual shift meetings had either been missed or not documented during the year 1978 and that no monthly Fire Brigade meetings were held from 9/10/78 to 11/2/7 Discussion with station and corporate personnel indicated that no live fire fighting training exercises were conducted during 1978 at the station. Further, it was reported that the-last live fire demonstration 'was probably held in the year 1972 and that few fire brigade members had actual experience in fighting a real fir Technical Specification 6.8.1 states, in part:
"Written procedures and administrative policies shall be... implemented...
that meet or exceed the requirements and recommendations of...
Paragraph 2.2.1 of Fire Protection Program Review, BTP APCSB 9.5-1... "
Paragraph 2.2.1 of BTP APCSB 9.5-1 states, in part:
"The administrative procedures used to formally implement the Fire Protection Program are as follows:
Division Order D-A-13, Fire Protection Program...
Station Order S-A-2, Fire Protection Division Order D-A-13 states, in part:
"This Division Order outlines procedures to be used by generating stations for fire protection,... "
Paragraph I.C. states in part:
"Demonstra-.
tions in hose handling, extinguisher operation and fire fighting shall be held on Company property at least once each year. The fire fighting demonstration should include an approved flame simulation of an oil fire. The simulation is necessary to minimize the demonstration's environmental impact, and prior approval by the local Air Pollution Control District is required."
Station Order S-A-2, Revision 17, paragraph IV B states, in part:
"Monthly meetings shall be held for training purpose The training will include fire fighting with portable fire extinguishers, the use of hose lines, ventilation of buildings, salvage operations, rescue operations, and the special aspects of fighting fires in controlled areas."
The failure to hold or document monthly Fire Brigade meetings for training as required by Station Order S-A-2 and the failure to conduct live fire fighting demonstrations at least each year as required by Division Order D-A-13 is an item of noncompliance pursuant to TS 6.8.1 and is a deficienc (2) Deviations Non (3) Unresolved Items Non c. Observations The following observations include general information items and perceived strengths and weaknesses in the licensee's management controls which may not have specific regulatory requirements, but will provide the basis for subsequent performance evaluations (Reference paragraph 2).
(1) Station Order S-A-2 required everyone assigned to the station to be familiar with the content of the Fire Prevention Manual
-66 (FPM).(S)
Reportedly only supervisors and above received copies of the FPM. No one questioned could remember being tested on the content of the FPM.(W)
(2) The maintenance department was charged with the responsibility for the actual performance or coordination of fire protection package surveillance The Fire Committee Chairman, currently a maintenance foreman, was further required to perform a monthly inspection of the station property for fire hazards. A cor porate Fire Equipment Inspector performed routine inspections and tests of fire equipment. Representatives of Nuclear Mutual Limited annually witnessed a fire drill and the conduct of Fire Pump pressure and flow capability tests.(I)
(3) The station Fire Committee was composed of representatives of various site department Its function was largely advisory, issuing recommendations in the form of approved meeting minutes which were discussed at the monthly meeting of supervisors.(I)
(4) The shift Assistant Control Operator (ACO) was trained and required to function as the Fire Brigade Chief. The shift Con trol Operator (CO) was not an assigned member of the Fire Bri gade and therefore, not required to participate in Fire Brigade practice drills. Licensee overtime rules allowed COs to work as ACOs without first requiring them to be trained as Fire Brigade Chiefs. Discussions with several COs failed to indicate any real concern on their part that they could handle the job; although they acknowledged there existed no specific program to ensure they maintain expertise in the ACO job.(W)
(5) Outside fire fighting assistance was provided by the Camp Pendleton Fire Department, whose crews were trained to fight all types of fires including those involving radioactive material. (S)
(6) Open flame permits were required for open flame operations in the vicinity of flammable materials. Fire watches, when required, were maintained for a minimum of 30 minutes following completion of open flame operations.(S)
(7) The corporate fire protection committee maintained and revised the FPM, investigated fires, and provided corporate guidance on fire protection policy matters. There was no direct connection between the corporate and station fire protection committees.(I)
(8) Technical Specifications require the Fire Brigade training pro gram to meet or exceed the requirements of Section 27 of the National Fire Protection Association Code - 1976. There are no requirements in the portions of Section 27 applicable to training; this section contains only recommendations. The licensee's Fire Brigade training program did not require comple tion of a specified program of instruction as a condition of membership in the brigade, as recommended by Section 27.(W)
-67 (9) The licensee had extended the QA program to encompass the fire protection package and the fire prevention program.(S)
(10)
During major plant outages, the station Chemistry and Radiation Protection staff was supplemented by chemical and radiation pro tection technicians from division forces. Returning outage per sonnel received a one day refresher in Health Physics practices.(I)
(11)
The site security organization routinely upgraded security officers to supervisory positions to provide shift management during the absence of the assigned Lead Security Officer. This provided the opportunity to evaluate these officers in a super visory role. There was no established career pattern for station security personnel.(I)
(12)
The corporate security group recruited security personnel and recommended those individuals which they felt qualified for station assignment The corporate security group annually audited station security, reporting the results to the NARC.(S)
(13) Security officers were employees of the licensee, initially qualified in firearms and requalified every six months, with specific training in the legal requirements of their job.(S)
(14) Post assignments were based on the roll of dice. The supervis ing officer made periodic unannounced visits to each post during the shift.(S)
(15)
Security officers initially received 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of Health Physics training.(S)
(16)
All station personnel received yearly security indoctrinations which were followed by examinations.(S)
14. Unresolved Items Unresolved items are matters about which more information is required in order to ascertain whether they are acceptable items, items of non compliance, or deviations. The unresolved items identified in this inspection are listed belo Number Subject Paragraph 79-01-01 Control of Temporary Modifications 3.b.(3)(a)
79-01-02 Organizational Discrepancy 3.b.(3)(b)
79-01-03 Organizational Discrepancy 4.b.(3)
79-01-04 Training Records 7.b.(3)
79-01-05 Review of TS Violation 9.b.(3)(a)
79-01-06 NARC Review of Procedures 9.b.(3)(b)
79-01-07 Emergency Maintenance Administrative lo.b.(3)(a)
Controls 79-01-08 Post Maintenance Testing Criteria 10.b.(3)(b)
-68 1 Exit Interview The inspectors met with the licensee representatives (denoted in paragraph 1) at the conclusion of the on-site portion of the inspection on February 9, 1979 and at the conclusion of the general office portion of the inspection on February 16, 1979. The lead inspector summarized the purpose and scope of the inspection. The inspectors then discussed the enforcement findings of the inspection which are detailed in section b. (Findings) for each of paragraphs 3 through 13 in this report. The inspectors also discussed the most significant of the observations reported in section c. (Observations) of paragraphs 3 through 1 Licensee repre sentatives had no significant questions or comments regarding the findings which were discussed.