IR 05000206/1987011
| ML13323B249 | |
| Person / Time | |
|---|---|
| Site: | San Onofre  |
| Issue date: | 05/29/1987 |
| From: | Fish R, Good G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML13323B248 | List: |
| References | |
| 50-206-87-11, 50-361-87-10, 50-362-87-11, NUDOCS 8706160377 | |
| Download: ML13323B249 (8) | |
Text
U. S. NUCLEAR REGULATORY COMMISSION
REGION V
Report Nos. 50-206/87-11, 50-361/87-10 and 50-362/87-11 Docket Nos.50-026, 50-361 and 50-362 License Nos. DPR-13, NPF-10 and NPF-15 Licensee: Southern California Edison Company P. 0. Box 800 2244 Walnut Grove Avenue Rosemead, California 91770 Facility Name:
San Onofre Nuclear Generating Station, Units 1, 2 and 3 Inspection at:
San Onofre Site, San Diego County, California Inspection Conducted:
April 27-29, 1987 Inspector:
5 9-7
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G. M. Good, Emergency Preparedness Analyst Date Signed
Approved by:
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P R. F. Fish, Chief Date S4gn'ed Emergency Preparedness Section Summary:
Inspection on April 27-29, 1987 (Report Nos. 50-206/87-11, 50-361/87-10 and 50-362/87-11)
Areas Inspected:
Unannounced, followup inspection to evaluate the Corporate Document Management program and information contained in the licensee's March 30, 1987 letter to ascertain whether Technical Specification 6.8.1.e had been violated when an incomplete (missing page(s)) Emergency Plan Implementing Procedure was found at several controlled locations, including two Emergency Response Facilities (Unresolved Item (87-04-01)).. Inspection procedure 92701 was used for the inspectio Results:
No deficiencies or violations of NRC requirements were identifie Unresolved item 87-04-01 was close PDR ADOCK 05000206 a
DETAILS 1. Persons Contacted C. Brendel, Supervisor, Corporate Document Management (CDM) Operations J. Buckus, CDM Clerk R. Burke, Training Instructor L. Camacho, CDM Coordinator D. Dack, Quality Assurance (QA) Engineer J. Harmon, Supervisor, QA J. Henderson, CDM Clerk D. Larson, CDM Clerk A. Melville, Supervisor, CDM Center D. Peacor, Manager, Station Emergency Preparedness (SEP)
J. Shivertaker, Supervisor, CDM Reprographics 2. Background During a routine inspection conducted on March 2-6, 1987 (Inspection Report Nos. 50-206/87-04, 50-361/87-05 and 50-362/87-06), an incomplete Emergency Plan Implementing Procedure (EPIP) was found at three controlled locations, including two Emergency Response Facilities (ERFs).
Approximately fifty percent (50%) of the uncontrolled (pink) copies were also found to be missing the same page. Page 22 of 26 of S0123-VIII-10,
"Emergency Coordinator Duties", was found to be missing from the controlled "white copy" EPIP books located in the Unit 1 Operations Support Center (OSC), the Emergency.Operations Facility (EOF) and the Resident Inspector's office. Subsequent to the inspection, the licensee found that page 13 of the same procedure was also missing from the "white copy" located in the EO In an effort to provide additional information, Southern California Edison (SCE) sent a letter to the NRC (Document Control Desk) on March 30, 1987. The letter stated in part that:
Since this finding was discovered late in the inspection, insufficient time existed for SCE to evaluate the discrepancy and provide information to the inspector on the subject nor did the inspector have an opportunity to evaluate the reproduction and distribution process associated with EPIPs....
SCE has an exemplary quality control program for the reproduction of procedures that minimizes the impact of random errors introduced by human error or equipment malfunction....
SCE believes that there are no reasonable or credible corrective actions which could be taken to significantly improve the proces Based on the results of the March 2-6, 1987 inspection and the information contained within the licensee's March 30, 1987 letter, it was determined that an evaluation of the licensee's CDM program was needed to ascertain whether any NRC requirements had been violated (i.e., an isolated problem as opposed to a programmatic breakdown). This issue was identified as Unresolved Item 87-04-0 Specific details related to this issue can be found in Sections 6, 7 and 8 of the aforementioned inspection report. Scope of Inspection The inspector conducted a review of the following areas:
1) CDM Operations (General); 2) Document Reproduction; 3) Document Distribution, and; 4) Quality Assurance (QA) activities related to the CDM progra Inspection activities for each area have been summarized belo CDM Opertions (General):
Interviewed CDM Supervisory personnel; examined CDM Procedures; reviewed CDM personnel training; toured COM facilitie B. Document Reproduction:
Interviewed Reprographics Supervisor and 3 of the 5 clerks responsible for document reproductio C. Document Distribution:
Interviewed applicable CDM Superviso D. QA Activities:
Discussed QA Department's involvement with CDM program with QA Supervisor; reviewed QA Audit reports; interviewed QA Engineer responsible for emergency preparedness matters; reviewed and discussed CDM internal audit report In addition to the above, the inspector determined what, if any, corrective actions had been taken/adopted since the March 2-6, 1987 inspection. This information was solicited from the functional areas of CDM, QA and SE.
CDM A. General Operations Inspection into this area did not disclose any negative finding Procedures for CDM operation appear to be sufficient. Procedures have been established for training CDM personnel and training has been conducted. Procedures and training of reprographics personnel has been addressed separately, in B. below. No corrective actions have been taken in this area since the March 2-6, 1987 inspectio B. Document Reproduction Since missing pages from procedures appeared to indicate a problem with document reproduction, inspection effortwas concentrated in this area. This theory was also supported by the.licenseels March 30, 1987 letter in which they state that randomly sampled copies for pagination failed to identify missing-ages-ani,hat it appared that there had been "random" machine error5Win the feelding sand reproduction proces Regarding general operations of the reprographics group, the inspector was informed that personnel coverage included two shifts (day and swing) per day, five days a week and one day shift on Saturday. The swing and Saturday shifts are covered by one clerk
and one supervisor. According to CDM supervisory personnel, by procedure, CDM has 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> to process and duplicate EPIPs; however, a self-imposed time limit of 4-8 hours has been established. Both
"white" (controlled) and "pink" (uncontrolled) copies are duplicated at the same time. The number of required copies was reported to be dependent on the particular procedure number, with some needing as many as 70 copie The inspection disclosed that S0123-VIII-10, the procedure that was found with missing pages, was submitted along with two other EPIPs on a Friday afternoon at approximately.3:00 p.m. This meant that a majority of the effort would have been accomplished on the Friday swing shift. According to the Reprographics Supervisor, this situation would not have represented any additional pressure for the clerk(s), since the activity level/workload is usually fairly constan The inspector found that training for reprographicsclerks consisted of viewing an orientation tape (required for all CDM personnel) and receiving instructions on the operation of the photocopy machine The inspector was informed that there were no procedures which addressed document reproduction. When asked about the percentage of documents which are normally checked for pagination/copy quality, the Reprographics Supervisor informed the inspector that about 4 or 5 out of 20 is normally checked. This equates to 20 to 25%.
During the inspection it was necessary to discuss the type of photocopying machines being used by the Reprographics Departmen The models possessed at the time of the March 1987 inspection had the capability to electronically verify source document page coun Each page of the document is fed for every copy which is made. That is, for 70 copies, the procedure is cycled through page by page 70 times. All of the Reprographics Department personnel who were interviewed agreed that these machines were "tired". The machines were.known to randomly miscount and misfee Subsequent to the March 2-6, 1987 inspection, the 8 year contract with the copy machine supplier was terminated and a new contract with another supplier was established. The two new machines also have the capability to electronically verify source document page
..counts; however, on the smaller of the two models, the operator must push a button in order to get this information. The most notable difference between the former and the new machines is that the new machines.cycle the procedure through once for every 12 copies. It would appear that this could significantly reduce the potential for miscounting or misfeeding problems. Licensee personnel stated that the contract transfer had no connection to the-problems identified during the March 2-6, 1987 inspection and that the transfer was already in progress at that tim The inspector interviewed three of the five clerks who operate the photocopying machines. Each of the three clerks was asked to describe his own method for reproducing documents, including the percentage of pagination/copy quality checks. As part of each
interview, the clerks were asked to perform a pagination check on a procedure supplied by the inspector. Two pages had been removed from the procedure prior to the interviews. Additionally, each of the clerks was asked what he knew about this problem (missing pages)
and how he learned of the proble The following represents a summary of the results of the interview The percentage of copies which are checked for pagination ranged from 1.5 to 5 or 6 percent. This is different than the 20 to 25%
indicated by their Supervisor. Two of the.clerks indicated that the number of documents checked depended on the workload. Fewer were checked during periods of heavy workload. One individual stated that he would normally rely on the machine to verify the page coun None of the three clerks who were interviewed found both missing pages during the pagination test. Two clerks identified one missing page and one clerk did not identify any. The clerks' knowledge of the problem varied. One clerk stated that he had recently heard about the problem via "floor gossip". One clerk stated that he learned about it during an informal discussion with CDM Managemen The other clerk stated that he had been required to read and sign-off on a bulletin which described what had occurred. Of the three CDM Supervisors who were interviewed, none were aware of any bulletin or memorandum, therefore, a copy could not be produce No corrective actions had been taken in the area of document reproduction since the March 2-6, 1987 inspection. As previously mentioned, the contract transfer was not connected to this issu C. Document Distribution Inspection into this area disclosed that procedures for field distribution personnel do not include the requirement to check documents prior to updating manuals, procedure books, et Subsequent to the March 2-6, 1987 inspection, field distribution personnel have been spot checking documents during their distribution runs. This spot check prior to filing has not been proceduralized and appeared to be dependent on individual initiative. It should be noted that the spot check was proposed by field distribution personne. Quality Assurance Quality control measures are conducted by both the QA Department and CD The QA Department has conducted ten audits of CDM activities within the last eighteen months. The inspector reviewed several audit report None of the audit reports identified problems with missing pages from documents. However, since audit procedures do not specifically require the auditors to perform random page checks at various locations, the QA Department's ability to identify this problem might be somewhat limite Discussions with QA Department personnel disclosed that checks of this nature were not being consistently performed by all auditors. The QA Department had not taken any corrective actions subsequent to the March 2-6, 1987 inspectio Internal CDM audits (surveillances) are conducted on a monthly basis by field distribution personne During these audits procedures/drawings, etc. are randomly sampled. The audits verify the presence of a given document and verify current revision. The audits do not specifically provide for a check of procedure completeness. The inspector verified that these audits were being conducted. Subsequent to the March 2-6, 1987 inspection, the EPIPs have been emphasized during the monthly surveillance CDM also utilizes Document Quality Audit (DQA) forms as a mechanism for users to identify and inform CDM of any document deficiencies. If a problem with a controlled document is identified in.one location, it is considered to be a fluke. If a second problem is identified in another location, a complete redistribution is performed. CDM personnel stated that these forms are monitored by the field distribution personnel; however, problems identified by users are also reported via telephon According to the licensee's March 30, 1987 letter, only one or two procedures per month are identified by users -as having problems. It was not determined whether the problems reported by telephone were included in this figure. It was beyond the scope of this inspection to determine the percentage of employees with the initiative (or knowledge) to inform CDM, verbally or in writing, of the existence of document error.
Emergency Preparedness SEP was contacted during this inspection to determine whether they had taken any actions subsequent to the March inspection. The SEP Manager stated that a step had been added to one of their department desk top procedures requiring a 10% spot check of the "pink" copy EPIPs which are distributed by SEP personne "Pink" copy EPIP books located in the ERFs had not been checked to determine whether there were any other procedures with missing page. Areas for Improvement Based on the results of this inspection, two areas where improvements could be made were identifie A. The administrative program for the control of all procedures does not include a procedure that addresses the completeness of documents. There are no written procedures within the reproduction/distribution process to assure that documents are complete prior to being file B. Management could be more effective at making their expectations known to employees. Employees did not know that their supervisor expected them to check pagination on 20-25% of the-copies they ra Additionally, management could be more effective at communicating problems to employees. Communicating the importance of quality and the potential consequences of poor quality can help to mitigate future problems
6 Exit Interview The inspector held an exit interview with the licensee on April 29, 1987 to discuss the preliminary findings of the inspection. The attachment to this report identifies the licensee personnel who were present at the meeting. Mr. R. Huey, NRC Senior Resident Inspector, also attended the meeting. The inspector discussed the findings as described in Sections 4-6 and discussed the concerns described in Section 7. -The licensee was informed that the inspector's findings supported the licensee's theory that the problem was due to inadequate page checks/equipment errors, as described in the licensee's March 30, 1987 letter. tEven though the licensee had expressed an opinion that this part of the program could not be improved, the inspector noted that some improvements had been mad However, the inspector stated that it appeared that additional corrective actions might be appropriate, based on the findings. Disposition of Unresolved Item 87-04-01 was not specifically addressed. -Regarding the concerns described in Section 7, the inspector indicated that she was interested in the licensee's response to them. The licensee agreed to such a response with the manner of the response to be determined during the week following the inspectio On May 7, 1987 a telephone conversation was held between the inspector, the Deputy Station Manager and the Materials and Administration Manage During the conversation, the licensee responded to each of the inspector's concerns. The actions being taken by the licensee, as described during the telephone conversation, resolve the inspector's concerns identified during this inspection. Unresolved item 87-04-01 is considered close........III...................:
ATTACHMENT EXIT INTERVIEW ATTENDEES C. Brendel, Supervisor, CDM Operations C. Couser, Compliance Engineer 0. Dack, QA Engineer P. Dooley, Supervisor, Corporate Emergency Planning A. Melville, Supervisor, CDM Center D. Peacor, Supervisor SEP R. Plappert, Supervisor,-Compliance D. Schone, Manager, Site QA J. Shields, Supervisor, Buildings and Services K. Slagle, Manager, Materials and Administration M Wharton, Deputy Station Manager 0. Williams, ManagerCorporate Document Services W. Zintl, Manager, Compliance Scoe0aagr ieQ 0hedSprioBidnsadSrie