IR 05000255/1978030
| ML18044A676 | |
| Person / Time | |
|---|---|
| Site: | Palisades  |
| Issue date: | 01/17/1980 |
| From: | Foster L, Gagliardo J, Sinkule M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML18044A675 | List: |
| References | |
| 50-255-78-30-01, 50-255-78-30-1, NUDOCS 8003270005 | |
| Download: ML18044A676 (48) | |
Text
' *
Report No.:
Docket No.:
Licensee:
Facility Name:
Inspection At:
U. S. NUCLEAR REGULATORY COMMISSION OFFICE OF INSPECTION AND ENFORCEMENT PERFORMANCE APPRAISAL BRANCH 5_0-255/78-30 (Supplement)
50-255 Consumers Power Company 212 West Michigan Avenue Jackson, Michigan 49201 Palisades Nuclear Power Station Palisades Site, Covert, Michigan, and Consumers Power Company Corporate Office, Jackson, Michigan Inspection conducted:
November 27-30 and December 1, 1978 Inspectors:
L. E. Foster M. v. Sinkule T. T. Martin J. E. Gagliardo Accompanying Personn 1: Hunter, Region III Jorgensen, Region III Approved By:
ag iardo, Acting Chief Perf orman e Appraisal Branch Division of Reactor Construction Inspection Office of Inspection and Enforcement, Headquarters
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"t *
- DETAILS Persons Contacted The following lists (by title) the individuals contacted during this inspectio 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 inpu Other individuals were contacted during the inspection but the extent of their input to this inspection effort was not significant to the findings reported in this repor Paragraph Numbers Title of Individual
4 5
7
9
11
13
15
+Executive Vice President of Energy Supply
- +Vice President of Production and Transmission
- +Nucleat Licensing Administrator Nuclear Licensing Coordinator
- Manager Production Nuclear System Evaluation Program Adminis-trator
- +Director of Quality Assurance, Production AND Transmission
- Quality Assurance Administrator, Operations Staff Engineer Project Engineer Senior Supervisory Engineer Plant Superintendent (Palisades)
Operations Supervisor (Palisades)
Plant Health Physicist (Palisades)
Instrument and Control Engineer (Palisades)
- +Director of Operating Services Construction Coordinating Administrator Senior Welding Engineer Senior Engineer
- Manager System Protection &
Laboratory Services Department Supervisor of Non-destructive Testing Services
- Executive Manager, Engineering &
Construction, Transmission &
Plant Modifications Executive Director, Environmental &
Project Services x
x x
x x
x x
x x
x x x x
x x
x x
x x x
x x
x x x x
x x x x
x x
x x x
x x
x x
x x x x x x x x
x x x
x x x x
x x
x
,
-2-ParagraEh Numbers Title of Individual
4
6
8
10
12
14
Manager Generating Plant Modifi-x cations Director Project Engineering Services x Director of Quality Assurance x
Testing Section Head x
Engineering Supervisor x
Project Superintendent x
Generating Plant Modifications Supervisor x
Nuclear and Reliability Section Head x
- Audit and Administrative Section Head x
- Director of Purchasing x
Purchasing Representative x
+Director of Nuclear Activities x
x x x x Supervisory Engineer Technical Superintendent (Palisades) x x x Quality Assurance Engineer (Palisades)
x Field Supervisor -
Construction (Palisades)
x Maintenance Superintendent (Palisades)
x x x Quality Control Supervisor (Palisades)
x x x x Administrative Supervisor (Palisades)
x x
- Training Administrator x
Quality Assurance Administrator -
Services x x Corporate Health Physicist x
x Vice President - General Services x
x Director of Property Protection x
x Senior Vice President of Personnel and Public Affairs x
x Reliability and Performance Administrator x
General Health Physicist (Palisades)
x x
Radiation Protection Supervisor (Palisades)
x x x Security Supervisor (Palisades)
x x x Engineer/Technologist (Palisades)
x Quality Assurance Superintendent (Palisades)
x x x x x
- Technical Engineer (Palisades)
x x
Document Control Office Clerk (Palisades)
x x Training Coordinator II (Palisades)
x x
-3-ParagraEh Numbers Title of Individual
4
6
8
10
12
14
Electrical Maintenance Engineer (Palisades)
x Operational Reactor Physics Administrator x
Operations Superintendent (Palisades)
x x
- ';-Security x
Maintenance Training Supervisor (Palisades)
x Training Coordinator (Palisades)
x
- '*General Supervisor, Nuclear Fuels x
Licensing Engineer x
- '*Staff Health Physics (Palisades)
x x
General Supervisor, Property Protection Engineering (Palisades)
x x
Plant Personnel Director (Palisades)
x x
Chemistry and Radiation Protection, Senior Technician x
x Shift Supervisor (Palisades)
x x Shift Supervisor (Palisades)
x x Control Room Operator (Palisades)
x x Control Room Operator (Palisades)
x x
- '*Attended the exit interview at the Corporate Office on December 1, 197 +Attended the exit interview at the Corporate Office on January 11, 197 *
~
-4-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 objectives 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 area 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: the licensee had written policies, procedures or instructions to provide management controls in the subject area; 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; the individuals assigned responsibilities in the subject area understood their responsibilities; and the requirements of the subject area had been implemented to achieve compliance and activities sampled had been appropriately documente The enforcement findings which document any identified items of noncompliance, deviations or unresolved items are not included in this supplemental report as they were transmitted by Report No. 50-255/78-30 dated January 23, 197 RegionilI office will evaluate corrective actions for these finding The findings addressed in this supplemental report address other lesser inspection findings and are entitled "Observations".
These are observations 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 guidanc 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 categorie 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
-5-perceived weakness, and the code letter "I" denotes an informational ite Since there may be 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 the 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 operation. *
-6-Design, Engineering and Modifications The objective of this portion of the inspection was to determine the adequacy of management controls associated with engineering, design changes and modification Documents Reviewed (1)
QA Program Policy No. 3 "Design Control" (2)
QA Program Procedure for Operations No. 3-51 "Design Control" (3)
Design Criteria Checklist, Attachment "A", to QAPP 3-51 (4)
QA Program Procedure for Design and Construction No. 3-1, "Design Document Preparation" (5)
QA Program Procedure for Design and Construction No. 3-2, "Design Change Control" (6)
QAPD&C No. 3-3, "Design Verification and Interface Control" (7)
QAPP for D and C No. 3-4, "Major Modifications" (8)
QAPP for Operations No. 3-52, "Major Modifications" (9)
QAPP for Operations No. 3-53, "Minor Modifications" (10)
QAPP for Operations No. 3-54, "Selection and Qualification of Items and Services" (11)
Production and Transmission Operating Services Department Procedure No. 05D-08, "Control of Plant Modifications" (12)
Palisades Nuclear Plant Administrative Procedures Nos. 9.0 and 9.1 "Plant Modifications" and 9.2 "Equipment Specifications and Minor Field Changes" (13)
Field Modification Packages Number T-FC-402-2 and T-FC-402-3
"Containment Purge Valves T-Ring Holding Pressure Test" and
"T-Ring Siesmic Air System Leak Test" Findings (1)
Items of Noncompliance None.
-7-(2)
Deviations Non (3)
Unresolved Items Non Observation (1)
The engineering and design organizational structure was typical of that observed at other plant Personnel interviewed appeared knowledgeable of their responsibilities and procedures.(I)
(2)
Most major design and engineering projects had been contracted to outside agencies; however, the licensee had a Design Services Group which performed some conceptual designs and engineering of non-safety related systems.(I)
(3)
The Corporate Office was involved in four major design and engin-eering project Namely, the design of new fuel, fuel racks, rad waste disposal, and reactor internal Extensive interfacing with major contractors and suppliers was being performed by the licensee. (S)
(4)
Procedures had been developed to control design, engineering and modification projects and appeared adequat Each group prepared their own procedures which were reviewed by interfacing groups.(S)
(5)
Design reviews were performed on contractors work packages and in-house prepared document Results of these reviews were evaluated and pertinent information was incorporated into the work packages.(S)
(6)
The QA Department, Division of Engineering and Construction performed QA functions during design, engineering and modification wor Nine QA engineers were assigned to this department.(S)
(7)
The Operating Services Department provided engineering support to the operating plan This department had five sections comprised of 50 people, 42 which are engineers.(S)
(8)
Site engineering personnel performed the Safety Evaluation required for engineering change Committees also reviewed to assure that all engineering criteria was being met and whether the change involved an Unreviewed Safety Question.(S)
(9)
Modifications were classified as "Major" and "Minor", however, both received an evaluation to determine if other systems were involved and whether the modifications encompassed an Unreviewed Safety Question.(S)
-8-(10)
Major modifications were assigned to the Corporate Office and minor modifications were assigned to plant technical personnel.(I)
(11)
Corporate Project Engineer did not follow the major modifications to final completion and testing; therefore, if problems arose after turnover to the site, sometimes a new Project Engineer was assigned to the project, or the project was reassigned as a
"minor" modification.(W)
(12)
The assigned new Project Engineer may not be familiar with the original engineering assumptions, decisions and evaluations made during the original modification.(W)
(13)
Coordination between the Corporate Office and site personnel during major modification programs, from original conception to final test and acceptance, was not being fully evaluated by corporate management to assure effectiveness.(W)
(14)
Modification packages were reviewed by a test group who prepared the test procedures and performed the test Test results were evaluated to assure that all test results met the test criteria.(S)
(15)
The QC group at the site reported to the technical superintenden This QC group consisted of three people including the superviso It was questionable if these three people could perform all of their assigned functions in an in-depth manner and if they had the technical expertise to cover all disciplines.(W)
(16)
QC personnel were not deeply involved in maintenance activities and did not appear to be spending enough time observing plant activities.(W)
(17)
Corporate Office evaluations of QA/QC operations appeared to be lacking in that no trending analysis of QA/QC findings were being performed to determine generic problem areas and the effectiveness of the departments.(W)
-9-Inservice Inspection and Special Processes The objective of this portion of the inspection was to determine the extent of management's controls over the Inservice Inspection (ISI) Program and Special Processe Documents Reviewed (1)
Quality Assurance Procedure for Operations No. 10-52, Rev. 2, dated 10/2/78, "Inservice Inspection" (2)
Operating Service Department Procedure No. OSD-25, "Preservice and Inservice Inspection" (3)
Results of ISI during Outage Number 4 (4)
Eddy Current Testing of Steam Generator Tubes, Plan No. 77-020P (5)
Procedure NDT-ET-02 Findings (1)
Items of Noncompliance Non (2)
Deviations Non (3)
Unresolved Items Non Observations (1)
The licensee had formed their own Inservice Inspection (ISI)
group which reported to the Operating Services Department.(S)
(2)
Advanced planning for future ISI outages was being performed by the ISI group.(S)
(3)
Present ISI work has been contracted out to Southwest Research Institute (SwRI) and the work was being overviewed by the licensee's ISI group. (I)
(4)
The ISI master plan was developed by the ISI group and they performed all coordinating activities with SwR Previous ISI results were evaluated by the ISI group.(S)
-10-(5)
ISI personnel were being trained both in-house and by outside agencies; however, no formal scheduled training or retraining program was observed.(W)
(6)
Personnel interviewed appeared to be technically qualified, knowledgeable and showed exceptional interest in ISI, special processes, and nondestructive examination The licensee appeared to have the potential for a well organized and efficient organi-zation. (S)
(7)
The nondestructive examination and special process group reported to the Operating Services Department.(I)
(8)
The licensee had approximately 65 qualified welders and have their own laboratory for qualification and testing of personnel and procedures.(S)
(9)
The licensee has not been performing trend analysis on welding problem Evaluation of welding failures and causative factors could probably reduce welding problems by applying preventative corrective measures.(W)
(10)
Eddy Current Testing of the Palisades steam generators was performed by licensee personne Full size mockups were utilized to prove out the procedures and to resolve technical problems prior to performing the Eddy Current Testing.(S)
t
-11-Procurement The objective of this portion of the inspection was to determine the adequacy of management controls associated with procuremen Documents Reviewed (1)
QAPP -
4-52 -
"Consulting Services (2)
OSDP -
32 -
"Procurement Control for Services" (3)
OSDP -
33 -
"Procurement Control for Materials" (4)
QAPP -
4-51 -
"New Equipment and Materials" (5)
QAPP -
7-51 -
"Source Surveillance" (6)
QAPP -
7-52 -
"Qualified Suppliers" (7)
Volume XIII of Administrative Procedures (8)
OSDP -
15 -
"Preparation of Purchase Specifications" (9)
OSDP -
17 -
"Technical Evaluation of Suppliers" Findings (1)
Items of Noncompliance Non (2)
Deviations Non (3)
Unresolved Items Non Observations (1)
Procedures appeared to be adequate and provided for control of documentation, purchase orders, vendor surveillance, inspection, shipping, receiving, and storage.(S)
(2)
Several groups (site and corporate) had initiated procurement document The Operating Service Department developed technical information to be included in procurement documents and transmitted this information to the requisition enginee QA departments, plant superintendent and department heads reviewed and approved the documents prior to being submitted to the purchasing departmen Prior to submitting to bidders, the documents were reviewed by a purchasing QA specialist.(S)
(3)
Procurement documents reviewed were signed off as required by the procedure. (S)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
-12-Revisions to procurement documents and specifications were reviewed and approved by the originator.(S)
QA department reviewed the contract prior to submittal to the bidder and provided input.(S)
Bid and pre-award conferences had been held and were attended by procurement, engineering and QA personnel.(S)
Based on discussions with procurement and technical personnel, the procurement personnel reverted all engineering problems back to the engineering department for resolutio Procurement and engineering personnel stated that procurement did not make tech-nical decisions.(S)
Vendor inspections and evaluations of suppliers were performed by the QA department who then prepared an approved bidders list.(S)
Personnel interviewed appeared qualified and knowledgeable of the procedures and their responsibilities.(S)
The bidders list at the site was not current; however, action had been initiated to have the list updated.(W)
Storage area for spare parts which require environmental control had not been finalized; however, plans were being prepared to provide an environmentally controlled storage area.(W)
The Fuels Division was procuring new fuel and had performed all technical review QA technical audits and plant surveillance were being performed by the QA department at the vendors plan This procurement contract was being followed very closely by the licensee's technical staff.(S)
-13-Plant Operations The objective of this portion of the inspection was to determine the adequacy of the licensee's management controls in the area of licensed activitie Documents Reviewed The documents reviewed during this inspection are listed in the original report (50-255/78-30). Enforcement Findings (1)
Items of Noncompliance Non (2)
Deviations Non (3)
Unresolved Items One (1) unresolved item was identified and addressed in the original report (50-255/78-30). Observations (1)
The operations organization consisted of auxiliary operators, control room operators, shift supervisors, operations supervisor, operations superintendent, and plant superintenden The plant superintendent reported directly to the Vice-President, Production and Transmissio The plant had organized an additional shift crew comprised of a shift supervisor, control room operators and auxiliary operators which allows each group to rotate into training status.(S)
(2)
Turnover and experience of personnel at the plant as recalled by the Plant Superintendent was as follows:
12 out of 20 auxiliary operators had less than 18 months experience with Consumers Power Company (CPC); 8 out of 10 Chemistry Technicians had less than 12 months experience with CPC; and 6 out of 9 Radiation Control Technicians had less than 12 months experience with (CPC).
Reportedly, the turnover of auxiliary operators, radiation control personnel and chemistry technicians was due to staffing of the Midland plant and promotions within the company.(!)
(3)
The operation was conducted by the use of written procedures, daily written orders, procedure changes, management meetings, written directives, daily verbal communications between corporate managers, plant management and plant supervisors.(S)
-14-(4)
Corporate Departmental procedures had been developed to delineate the requirements for implementing company policy and the NRC License Conditions.(S)
(5)
Administrative procedures (A.P.) had been developed at the plant level specifying the requirements to implement departmental procedures, quality assurance program and NRC License conditions.(S)
(6)
An administrative procedure had not been developed at the site level for control of work activities by outside organization A licensee representative stated that in practice a CPC engineer was assigned responsibility for these activities to ensure that personnel were properly trained and that existing administrative procedures for control of work were followed.(W)
(7)
The jumper control procedure, Administrative Procedure A.P. 4.124 did not ensure that the requirements of 10 CFR 50.59 and ANSI N18.7-1972 would be me (Unresolved Item, See IE Report 50-255/
78-30).(W)
(8)
Two discrepancies identified in administrative procedures were as follows:
(a)
A.P. 2.2.5 required that key personnel changes be described in semiannual repor The requirements for this report had been deleted from the Technical Specifications, therefore, the requirement was not applicable; and (W)
(b)
A.. P. 1.0 refers to A.P. 10.2.1.3.2 for information on temporary changes to procedure This reference should be A.P. 10.3.1.(W)
(9)
Discussions with RIII inspectors and licensee management indicated that plant employees had been concerned in the past with radiation safety problem As an attempt to bridge communication gaps between employees and management, corporate and plant management had implemented special measures to ensure that they were made aware of these types of problem Considering this background information, the following observations are offered.(S)
(a)
A licensee representative stated that a recent survey conducted at the plant indicates that employees were not convinced that management truly had the desire to hear employee problem He stated that more study will be performed in this area.(I)
(b)
Of five supervisors and control room operators interviewed, one expressed doubt of management's sincerity in efforts to establish an effective communications feedback system.CI)
(c)
The Manager of Production, Nuclear, indicated that he or his assistant communicated daily with plant management and that weekly trips were made to the Palisades Plant.(I)
-15-(d)
The Plant Superintendent indicated that he conducted meetings with his superintendents daily.(S)
(e)
The Operations Superintendent indicated he had not had a formal meeting with the Shift Supervisors for approximately four (4) month He also stated that it was his intention to have a meeting with the Shift Supervisors every six (6)
to eight (8) weeks and that he communicated daily with the supervisors.(W)
(10)
All personnel interviewed indicated that resources were available to operate and maintain the reactor in adequate repai One person stated the Company did not cut corners where reactor safety was involved, (S) however, it was sometimes difficult to get correction of an industrial safety issue in a timely manner.(W)
(11)
The Plant Superintendent stated that he has a fixed budget for operating and maintaining the plant, however, he did have flexi-bility for implementing modification He also stated that corporate managers were receptive to providing additional resources for safety related modifications, but it was incumbent on the plant personnel to present an accurate proposal.(S)
(12)
Generally, personnel interviewed felt that technical support in engineering and the reactor physics area was good.(S)
One manager stated that coordination of "minor modifications" with the Operating Services Department (OSD) was "flustrating". (I)
(13)
The inspector reviewed the management by objective statements of the Manager of Nuclear Production and the Plant Superintenden Of the seven (7) items on the list of the Manager, Nuclear Produc-tion, five (5) pertained to resources and production, one pertained to reducing the industrial accident rate and one involved reducing the number of outstanding deficiencies.(W)
(14)
It appeared that corporate managers were involved in the filling of all key positions at the plant.(S)
(15)
There was no formal method for motivating employee A corporate manager stated that motivation of employees was accomplished by providing training and keeping them informed of activities and policy which pertained to them.(I)
(16)
No formal system existed for keeping track of personnel errors.(W)
(17)
A formal personnel appraisal system had been implemented.(S)
(18)
No formal guidelines had been established for disciplinary actio Discipline was handled on a case-by-case basis.(W)
-16-(19)
Management personnel appeared to be involved in the operation of the facility and appeared knowledgeable of facility problems and enforcement activities of the NRC regarding Palisades.CS)
(20)
Management personnel were aware of the large number of deficiencies listed in the "Deficiency Report Summary" because this item was reflected in the objective list of the "Management by Objectives" summary. (S)
(21)
Plant supervisors and control room operators appeared knowledgeable of the requirements for operating and maintaining the reacto They appeared knowledgeable of their responsibilitie Control room operators and supervisors were specifically questioned in the areas of reactor shutdown authority, control room accessibility and manning requirements.(S)
l
-17-Plant Maintenance The objective of this portion of the inspection ~as to determine the adequacy of the licensee's management controls in the maintenance are Documents Reviewed The documents reviewed during this inspection are listed in IE Report 50-255/78-3 Enforcement Findings (1)
Items of Noncompliance Non (2)
Deviations Non (3)
Unresolved Items One (1) unresolved item was identified and was discussed in detail in the original report (50-255/78-30). Observations (1)
Maintenance activities at the plant were managed by the same corporate group that was responsible for plant operation The Plant Superintendent was responsible for maintenance at the plant leve The Maintenance Superintendent was the supervisor in charge of maintenance activities at the plant and he reported to the Plant Superintenden The site maintenance organization consists of mechanical, electrical, and planning section The electrical and mechanical sections consisted of several groups, each with a supervisor in charge who reported to the mechanical or electrical section superviso Instrument and control mainten-ance were performed by a group within the electrical sectio During outages, the Palisades Maintenance force was supplemented by traveling crews of licensee personne These crews normally received radiation training and work direction from plant supervisors.(I)
(2)
An administrative procedure had been developed which delineated the requirements for control and documentation of maintenance activities.(S)
(3)
Discussions with personnel indicated that safety-related maintenance was performed by use of written procedures with the cognizance of operations personnel.(S)
-18-C4)
One of the five operations personnel interviewed felt that the Maintenance Department was slow in responding to items requiring repair; was unable to keep pace with the number of modification packages being generated; and priority for Preventive Maintenance exceeded that for most routine maintenance items which do not directly affect reactor operations.CI)
C5)
A number of personnel interviewed stated that adequate resources were available to ensure that safety related equipment was main-tained in operational condition.(S)
C6)
The Maintenance Superintendent had the authority to change priority established by the work request originator.CW)
C7)
Reportedly, a preventive maintenance pro~ram had been implemente The Maintenance Superintendent stated that approximately 40% of maintenance manhours were utilized on implementation of the program.CS)
C8)
Reportedly, Palisades was participating in the Nuclear Plant Reliability Data System CNPRDS).
This system provides failure data to participating utilities.CS)
C9)
Supervisors interviewed indicated that rules governing emergency maintenance were adhered to.CS)
(10)
Reportedly, the maintenance staff at Palisades had been increased in size due to increased maintenance coverage on off shift One maintenance supervisor stated that approximately 50% of the electrical and mechanical personnel had been at the Palisades Plant for less than 18 months.CI)
(11)
The Maintenance Superintendent conducted meetings with maintenance personnel on a routine basis.(S)
(12)
Maintenance records were being stored for periods up to two years in cabinets which did not meet the requirements of ANSI N45.2.9, 1974, Section 5.6 (Unresolved Item, see IE Report 50-255/78-30).(W)
(13)
The Quality Control Group at the site consisted of a supervisor and two inspector It was their responsibility to review main-tenance work orders; inspect maintenance activities; review procedures; and inspect surveillance activities performed by operations.(I)
-19-Audits The objective of this portion of the inspection was to determine the adequacy of the licensee's management controls over the audit progra Documents Reviewed The documents reviewed during this inspection are listed in the original report (50-255/78-30). Enforcement Findings (1)
Items of Noncompliance Non (2)
Deviations Non (3)
Unresolved Items One (1) unresolved item was identified and was addressed in the original report (50-255/78-30).
~-
Observations (1)
Quality Assurance Department (QAD) Audits (a)
The QAD, Production and Transmission (P & T) was responsible for conducting audits to satisfy the provisions of the CPC QA Progra These audits consisted of scheduled and unsched-uled (surveillance) audit The Director of QA, P & T reported to the Vice President, P & T and had two administrators reporting to him, the QA Administrator of Operations and Administrative Service Personnel in the Operations audit group were located at the plant and were responsible for performing the majority of the audits conducted at the Plan The Services Audit personnel were located at the Corporate offices and were responsible for performing the majority of the audits of the Corporate support groups.(!)
(b)
Department procedures had been developed to implement the requirements of CPC QA Progra Lead auditors were required to meet the qualifications of ANSI N45.2.23.(S)
(c)
Eleven (11) scheduled audits and approximately fifty (50)
surveillance audits had been performed, prior to this inspec-tion, in 1978 involving activities at the Palisades Plant.(!)
-20-(d)
The 1978-1979 schedule for QAD audits included the following areas:
Inservice inspections; eddy current examinations; steam generator tube deplygging and sleeving; quality control; activities of the Plant Review Committee; security; control of measuring and test equipment; selection and qualification of safety related items; procurement control; training; operations; health physics; operations; records control; identification and control of materials, parts, components during handling, shipping and storage; design control; fire protection; test control, quality CQ) list; new fuel receipt; document control; fuel handling; and procedures, instructions and drawings.CI)
Ce)
The inspector reviewed the audit log for 1978 for audits conducted by QAD, P & T, Services Section and found that audits had been performed in the following areas in 1978:
Security; records and document control; supplier qualifi-cations; implementation of the Corrective Action System; QA participation in design process, procedures development, and procurement control; minor modifications; QA program procedures; evaluations for continuance of various contracts; and P & T interface activities on major modifications.CI)
(f)
Audits were announced and conducted according to a yearly audit plan with the use of checklists approved by the lead auditor.CS)
Cg)
Unscheduled or surveillance audits were conducted at the corporate offices and at the plant on various activities.(S)
Ch)
Audits were documented in audit reports and distributed to responsible manager Surveillance audits were documented, however, the report distribution was not as extensive as scheduled audits.CI)
Ci)
Auditing personnel were independent from personnel conducting the activities according to the organizational structur A licensee representative expressed a concern that personnel who normally perform surveillance audits also conducted the yearly QA audit for a particular functional area.CW)
(2)
Technical Audits Ca)
The Operating Services Department (OSD), P & T and the Nuclear Activities Department CNAD), P & T performed the technical audits in addition to their normal dutie These audits were performed to satisfy audit requirements delineated in the Technical Specifications.CI)
Cb)
Department procedures had been established which provided for scheduled audits.(S)
-21-(c)
The scope of the Technical Audit Program included:
Plant operations; maintenance; instrument and controls; chemistry; modifications; training; reactor physics; fuel and reactor intervals; and health physics.(I)
(d)
The Technical Audit Program did not ensure that all aspects of Technical Specification requirements or applicable require-ments will be reviewed over a specified time period.(W)
(e)
Audits were conducted in accordance with yearly audit plans utilizing checklists approved by the lead auditor, however, all rules that applied to QA audits did not apply to technical audit For instance, independence of auditors was not required by department procedures (See unresolved item, IE Report 50-255/78-30).
In addition, Department procedures did not require technical audit lead auditors to be qualified to the requirements of ANSI N45.2.23.(W)
(f)
Department Procedure NAD-10 did not require audit that reports be transmitted to OS OSD personnel were responsible for administration of the Technical Audit Progra This item had previously been identified, however, procedures had not been upgrade In practice, the audit reports were transmitted to OSD.(W)
(g)
The NRC had identified during a previous inspection that technical audits were not being performed in 197 It appeared that the planned audits were being performed in 1978.(S)
(h)
A licensee representative, responsible for technical audits, stated that improvements were being made in the area of technical audits, however, he was not satisfied with the scope and depth of the audits.CS)
(i)
The Director of NAD was unable to determine the status of technical audits without first contacting his section heads.(W)
(j)
The Technical Audit Program did not provide for unannounced inspections.(W)
(3)
Observation which pertain to both QA and Technical Audit Programs (a)
The administration of the Technical Audit Program was not coordinated with the administration of the QA Audit Program.(W)
(b)
Technical audits were designed to include an indepth review of the adequacy of the program in a particular area while the QA audits were to verify implementation.(I)
-22-(c)
Managers interviewed appeared cognizant of the administrative channels established by CPC involving stop work authority and appeared to have a good attitude toward Quality Assurance.(S)
(d)
All audit findings were listed on a corrective action tracking system and followed by QA There were thirty-nine (39)
audit findings for year 1976 that had not been correcte These items appeared to be low priority items.(W)
(e)
QA program reviews were conducted by an outside contractor and had not lead to substantial changes in the audit programs.(W)
-23-Training The objective of this portion of the inspection was to determine the adequacy of the licensee's management of training activities, both on-site and in the corporate office Documents Reviewed (1)
Consumers Power Company Quality Assurance Manual for Nuclear Power Plants, Revision 5 (2)
Consumers Power Company Quality Assurance Program Policy No. 2, Quality Assurance Program, Revision 4 (3)
Consumers Power Company Quality Assurance Program Procedures for Operations, Nos. 2-53 and 2-54 (4)
Palisades Plant Technical Specifications, Section 6.0, Admini-strative Controls, thru Amendment 35 (5)
Palisades Nuclear Power Plant Administrative Procedure, No. 13, Master Training Plan, Revision 13 (6)
Maintenance Department Flow Chart, Revision 8 (7)
Selected Site and Corporate Department Training Procedures (8)
Selected Site and Corporate Job Descriptions (9)
Selected Site and Corporate Individual Employee Training Records Findings (1)
Items of Noncompliance Two (2) items of noncompliance were identified and are discussed in the original inspection report (50-255/78-30).
(2)
Deviations Non (3)
Unresolved Items Two (2) unresolved items were identified and are discussed in the original inspection report (50-255/78-30.
- *
-24-Observations The following observations include general information items and the 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 evaluation (1)
The licensee had established and documented minimum training and retraining requirements for corporate and site employee Depart-ment heads were responsible for determining employee training needs beyond the minimum requirements matri Employees could request company support of their participation in outside training and/or education program No formal mechanism was identified that informed employees of the availability of approved outside course The company's philosophy supported individual initiatives which were job related. (S)
(2)
Position description and qualification documents had been develope Position responsibilities and formal education and/or experience requirements were identified on documents reviewed by the inspecto (S)
Discussions with corporate and site supervisors failed to demonstrate a connection between these documents and the.established training progra Further, promotion or transfer did not require meeting training matrix requirements as a prerequisite. (W)
(3)
Training program elements included initial orientation, security, radiation protection, fire protection, industrial safety, procedures familiarization, quality assurance, rules and regulations, license, specific skills and on-the-job training, public affairs, supervisory, and management trainin These elements were taught by personnel reporting to no less than three Vice President No individual or committee was identified as having overall company responsi-bility for coordination of course offerings, administering or appraising the current training program, or recommending changes to support current or future training needs. (W)
(4)
Maintenance Skill Centers had been established for the training of repairmen away from their normal work location Site training of repairmen involved periodic rotation into an off-shift training assignment on a six week cycle. (S)
(5)
Site procedures required On-the-Job Training (OJT) for operators, technicians and repairme Interviews with site supervisors indicated that each department had some program for OJT; but no uniform site program existed which was formally described and required, as a minimum, the documentation of job participation under the supervision of an experienced worker, performance appraisal, and initial and periodic recertification of adequacy of learned skills. (W)
-25-(6)
The site offered an SRO certification program for non-license candidates encompassing all the training given an SRO. (S)
(7)
QA Lead Auditor training, which appeared to meet N45.2.23 require-ments, was provided by a contractor with certification following OJT and an interview by the Director of Q Lead Auditor and Auditor training for technical auditors was provided inhouse, but the Lead Auditor training did not meet N45.2.23 requirement (W)
(8)
Site procedures established the format for lesson plans, assigned responsibility for their development and review, and required that a central file of lesson plans be establishe The site lesson plan file was accessible by other groups within the company to reduce redundant development effort. (S)
(9)
Training records were maintained by hand and compute The computer file did not reflect all training received by an employee due to reported limitations in record lengt Hand maintained records were sometimes duplicated by the Training Coordinator and individual Department Heads. (W)
(10)
Routine appraisals of the training program adequacy were provided by trainees thru written critique Neither the Site Superintendent nor the Training Coordinator routinely monitored classroom activitie Discussions with the Site Training Coordinator indicated new instructors were not subject to appraisal under trial classroom condition At the time of the inspection, site supervision had failed to verify that all required training for the past year had been received. (W)
(11)
The training program was subject to site QA audits for administra-tive requirements and corporate technical audits for adequac Recent corporate Health Physics and site QA department involvement in site training activities could pose future problems regarding the required independence of the auditor A noted lack of administrative guidance in this area could further contribute to this problem. (W)
(12)
At the time of this inspection, the site Training Coordinator (T/C) reported directly to the Plant Superintenden (This was contrary to T. S. requirements.)
The site T/C had a small staff of instructors supplemented by site supervisors who doubled as instructors in their area of expertis The corporate T/C had no line responsibility for site training or for the formal appraisal of the effectiveness of the site training organizatio The corporate T/C had a staff of instructors who provided skill training, developed training programs, supplemented site training staffs and wrote procedure The corporate training staff was expanding to provide additional services. Frequent conferences
~-I
- ,
(13)
(14)
(15)
-26-between the corporate T/C and the various site T/Cs had reportedly improved program uniformity, staff cooperation and organizational effectivenes (I)
The company's current training program was less than two years old. Personnel in a number of departments had yet to complete the first training cycl The need for the cyclic training program was indicated by several individuals' demonstrated lack of familiarity with subjects reportedly taught over a year ag (W)
Employees universally expressed opinions that reflected a belief that the company strongly supports employee training. (S)
Although not a formalized part of the company's training program, several examples of lateral transfers, reportedly designed to broaden individual background, were identifie (S)
Company turnover rate was extremely low, but transfers and promo-tions, along with the manning of Midland, had severely reduced the site's level of expertis This effect had been pronounced for the Maintenance and Health Physics departments. (W)
-27-1 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 Documents Reviewed (1)
Consumers Power Company Quality Assurance Manual for Nuclear Power Plants, Revision 5 (2)
Consumers Power Company Quality Assurance Program Procedures for Operation, Nos. 7.1 and 1 (3)
Palisades Plant Technical Specifications, Section 6.0, Admin-istrative Controls, thru Amendment 35 (4)
Palisades Nuclear Plant Administrative Procedures, Nos. 7, 12 and
(5)
Consumers Power Company Accident Prevention Manual (6)
Selected Site and Corporate procedures for Safety and Security Controls, including site procedures and forms for the Radiation Work Permit (RWP) and Maintenance Order (MO) systems (7)
Selected Site and Corporate records relative to Health Physics, Fire Protection and Security program implementation Findings (1)
Items of Noncompliance Non (2)
Deviations Non (3)
Unresolved Items Non Observations The following observations include general information items and the 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 evaluation..
-28-(1)
Health Physics (a)
The Health Physics organization was established with the site department holding operational responsibility and reporting directly to the Plant Superintenden The corporate department held functional responsibility and reported directly to the Director of Nuclear Activitie The Plant Superintendent reported to the Manager of Production - Nuclear, who then reported in parallel with the Director of Nuclear Activities to the Vice President of Production and Transmission. (I)
(b)
The Corporate Health Physics Department provided consultation and support services to the site, and reportedly enhanced the uniformity of operations at the company's various nuclear sites. At the time of this inspection, the corporate depart-ment was conducting a trial program of inhouse processing of redundant sets of personnel dosimetr If the results of inhouse development were consistent with contractor reports and provided significant improvement in turn-around time, a decision to do all personnel dosimetry at corporate offices could be implemente (I)
(c)
The Site Health Physics Department was composed of three groups: Radiation Protection, Radiological Material Control and Plant Environmenta These groups were headed by super-visors who reported to the Plant Health Physicis The Plant Health Physicist was also responsible for the admini'-
stration of the Site Emergency Pla Interviews with site personnel indicated that of fices of the group supervisors were not in the technician's normal worksplaces and that first line supervision responsibility fell to the senior technicians. (W)
(d)
The site utilized a concept, entitled "RWP Exempt", which allowed plant individuals, who had demonstrated knowledge of Health Physics instrumentation, practices and procedures, to be allowed access to restricted areas without an RW This concept was under review and could be revised. (W)
(e)
Procedure reviews and interviews with site supervisors indicated that several departments held responsibility for contaminated area cleanup; but no clear guidelines for division of this responsibility were identifie RWP and MO closure did require a cleanup of subject areas, but did not specifically require a contamination survey prior to the supervisor's signatur Interviews with several supervisors failed to clarify this issue. (W)
-29-(f)
The experience level of the Site Health Physics Department had reportedly been severely reduced by promotions and transfers to man the Midland facility, and finally by the inability to hire experienced technician The latter problem was attributed by company employees to a company policy preventing the payment of interview or moving expenses to new technicians, who were neither a part of the union or the professional staf A recent move to three shift coverage had compounded the problem. (W)
(g)
The adequacy of the company's Health Physics program had previously been the subject of employee allegation Inter-views with site employees indicated their belief that conditions had since improved and that the problem was a failure of the Health Physics Department's internal and external communications. Employees interviewed believed that some Health Physics supervisors may have over-emphasized the paper aspects of the program. One supervisor expressed concern that the department had lost credibility when the company did not take a firm stand against NRC on a question which the individual felt the department had adequately addressed. (W)
(2)
Fire Protection (a)
Functional responsibility for Fire Protection rested with the Vice President of General Service Operational respon-sibility for this area was held by the Plant Superintenden (I)
(b)
The Fire Protection program was subject to Technical Audits conducted for the Offsite Safety Review Committe Fire Brigade training included hands on training at the site, under the direction of a corporate specialist, and monthly fire drills. (S)
(c)
Interviews indicated that those aspects of the Fire Pro-tection program, not included in the Technical Specifications, were not considered safety-related and were not subject to QA overview. (W)
(3)
Security (a)
Site security was provided by a contract guard forc Supervision and management of the security force was provided by the contracto The contract was administered by company officials under the Vice President of General Services; while day to day control was exercised at the site by a Security Operations Supervisor, who reported to the Plant Superintendent through the Administrative Superviso *
-30-The site monitored contractor performance, requested action through the contractor supervisor, and resolved larger matters through corporate level contact (I)
(b)
Security forces were trained by the contractor while site personnel were trained in security by company personne Interviews with site employees not actively involved in security indicated a lack of knowledge of the qualifications and training of the security personnel, which raised questions in their minds regarding the adequacy of the security forc The recent high turnover rate of contractor security personnel had been cut in half by management actio This had reduced company employee concerns relative to the adequacy of security personnel and the dissemination of security informatio (I)
-
,,.
t_*
-31-1 Corrective Action System and Management of Generic Issues The inspector conducted a review of the licensee's corrective action system and management of generic issues to determine the adequacy of this program and to verify proper implementatio Documents Reviewed (1)
Consumers Power Company Quality Assurance Manual for Nuclear Power Plants, Revision 5 (2)
Consumers Power Company Quality Assurance Program Policy No. 16, Corrective Action, Revision 4 (3)
Consumers Power Company Quality Assurance Program Policy No. 20, Program Reporting, Revision 4 (4)
Consumers Power Company Quality Assurance Procedure for Operations, Nos. 15-51, 16-51 and 16-52 (5)
Palisades Plant Technical Specifications, Section 6.0, Administra-tive Controls, thru Amendment 35 (6)
Palisades Nuclear Plant Administrative Procedures, Nos. 3.4, and 15 (7)
Corrective Action Status Reporting System User's Manual (8)
Selected Site and Corporate procedures and forms for problem identification and corrective action, including the Maintenance Work Order system (9)
Selected Corrective Action System records, listings and status reports Findings (1)
Items of Noncompliance Non (2)
Deviations Non (3)
Unresolved Items Non Observations The following observations include general information items and the 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 evaluation (1)
The company had established a computerized "Corrective Action Status Reporting System" for the documentation and tracking of problems and their corrective action Significant or repetitive problems identified by site or corporate personnel, the QA Depart-ment, outside contractors, NRC inspectors or management,.onsite and offsite safety review committees, or the industry could be entered into and tracked by the syste In addition, activities requiring timely response, such as commitments to outside organi-zations or work assignments, could be entered and tracked by the system. (S)
(2)
Events or conditions without safety significance, those that occur randomly, or those that were of such a minor nature that corrective maintenance was sufficient to resolve the issue were not normally documented in this system; but were documented by Maintenance Orders. (I)
(3)
Basically, problems that were entered into the system progresses logically through stages of event or condition identification and documentation; description and immediate corrective action review and approval; reportability review and the appropriate reporting; evaluation and corrective action proposal; proposal review and approval; 10 CFR 21 reportability determination and the appropriate reporting; corrective action implementation and documentation; action review and approval; documentation package review for completion; and finally, document package storage for a minimum of six year The computerized document status tracking system was initiated by the problem identifier or by the initial reviewe The system was updated during each of the following activitie Assignment of the evaluator, evaluation due date and priority Assignment of responsibility for corrective action imple-mentation, correction due date and priority Approval of completed corrective action Review for document package completeness Monthly during the document's active life (S)
(4)
The QA Department tracked and reported the status of documents within the syste The QA Department received copies of document packages following screening for reportability per Technical
'*
-33-Specifications, following review for reportability per 10 CFR 21, and following approval of implemented corrective actio Each document package was assigned to a QA Engineer who followed its progress, was cognizant of its status, and reported encountered roadblocks in problem resolution to managemen The QA Department issued monthly status reports for all active documents within the system to the Vice President - Production and Transmissio Monthly mini-reports were issued to the individual who initiated the document and to those having current responsibility for document actio This report included status of only those documents for which the individual or their department had cogni-zanc Quarterly status meetings were conducted to resolve difficulties encountered in the timely correction of problem The QA Department was responsible for conducting semi-annual audits of the system to assure procedure compliance and for establishing a "Trend Analysis Program" to identify significant programmatic problems needing management attention. (S)
(5)
Problems determined reportable by Technical Specifications or Title 10 of the Code of Federal Regulations were coordinated by a single department in the corporate headquarters. (I)
(6)
Problems requiring review or approval by onsite or offsite safety review committees, in accordance with the Technical Specifications or committee charters, were forwarded for their review following problem evaluation and proposal of corrective actio The results of the semi-annual audit by QA were reviewed by the Offsite Safety Review Committee. (I)
(7)
The licensee had made plans to remove problems identified in the area of Security and certain areas of Fire Protection from QA Department overvie These plans evolved from a corporate deter-mination that these subjects were not safety-relate A licensee representative stated that equivalent overview would be maintaine (W)
(8)
At the time of the inspection, a formal "Trend Analysis Program" had not been implemented, but data was being collected to enable future targeting of management resource This problem could have been the result of the newness of the QA Program, but all the aspects of that program should have been implemented by June, 1978. (W)
(9)
Interviews with site and corporate personnel indicated that the number of active and overdue corrective action items had grown so large as to be unmanageable, and that personnel accountability had been los Upper management was aware of these problems and appeared to be actively pursuing resolution. (W)
-34-(10)
No mechanism had been established to control site QA Engineer workload relative to corrective action system followup, but the department supervisor stated that the size of the department did not warrant formal mechanisms to prevent overloading. (I)
(11)
Problems identified by individuals could not be killed by immediate supervisors without written explanation to the individual and to the QA departmen In the case of human failures, evaluation and corrective action assignments were made to personnel who caused the problem; thereby, providing a mechanism for supervised self analysis and upgrading. (S)
(12)
The company's suggestion plan was a rewards system, preventing its use for anonymous problem feedbac The company's "Open Line" column in the employee's paper did provide a potential for this feedback. (I)
-35-1 Review and Audit of Licensed Activities The objective of this portion of the inspection was to determine the adequacy of the licensee's control over the review and audit of licensed activitie Documents Reviewed (1)
Selected job descriptions of off-site and on-site managers (2)
Quality Assurance Program Policies No. 2, 18 and 24 (3)
Summary reports of the following corporate audit (a)
GE-Apollo Audit of September 8-26, 1975 (b)
Nuclear Audit and Testing Company, Inc., Audit of April 20 -
July 15, 1976 (c)
GE/NSS Audit of June 12 - July 21, 1978 Findings (1)
Items of Noncompliance Non (2)
Deviations Non (3)
Unresolved Items One (1) unresolved item was identified and discussed in the original report (50-255/78-30). Observations (1)
The licensee had written policies or procedures which specified the general responsibilities of most of the managers on-site and in the corporate office The policies and procedures which were reviewed, however, did not contain specific instructions regarding the review and audit of licensed activities. (W)
(2)
Corporate managers and directors were required to issue periodic reports (resumes) of operations or activities to top managemen (S)
(3)
The managers interviewed were generally knowledgeable of their responsibilities and reporting requirements. (S)
(4)
No responsibilities had been assigned to perform a trend analysis of performance indicator QA was developing a computerized trend analysis program. (W)
__,
--*
-36-(5)
The training program was audited for implementation, but it was not reviewed and audited for adequacy and effectiveness. (W)
(6)
Top level management had reviewed inspection reports, audit reports, committee minutes, some LER's, and summary reports/
resumes; however, they did not routinely review operating record (W)
(7)
The Manager of Production - Nuclear had routinely reviewed several operating records and had received daily and monthly reports of operation He had also reviewed inspection reports, audit reports, LER's, committee minutes and selected DR's. (S)
(8)
Corporate management periodically visited the site to observe activities, but they did not routinely document the visits or formally report their findings and observations to site manage-ment. (W)
(9)
The Plant Superintendent had attempted to tour the plant daily, but he did not document his tours. (W)
(10)
All of the managers interviewed said that they held periodic meetings with their staffs to review operating activities and problems. (I)
(11)
QA surveillance reports were not routinely communicated to corporate management. (W)
(12)
The plant Superintendent did not routinely review operating records, and for those records which he had reviewed, the review was not documented. (W)
(13)
Audit and QA surveillance reports were forwarded to the indivi-duals responsible for taking corrective action The responsible individual was required to prepare a DR for the identified defi-ciencie Management did not verify the issuance of the required DR's nor did they followup on the completion of the indicated corrective action when a DR was issued. (W)
(14)
Site management's responsiblities did not specify requirements regarding the types of information that was to be communicated to their staff There was evidence, however, that plant records and documents were communicated to the plant staff and that they were informed about daily operations and plant problems. (S)
(15)
Corrective action system status reports were sent to responsible managers periodically. (S)
~-----*-*-----~.
-37-(16)
The Technical Audit Program had received no overview from QA, SARB or management other than those responsible for the performance of the audit This was a possible cause for the problems which had been identified by RIII and the unresolved item identified during this inspection. (W)
(17)
The QA Division ha dmet with the VP of P&T and his staff quarterly to discuss the status of the corrective action system and other QA issues. (S)
(18)
Findings from the biennial corporate audits were entered into corrective action system and had been the basis for several QA program changes. (S)
.. - _.. /*-.
r---~-
-38-1 Committee Activities The objective of this portion of the inspection was to determine the adequacy of management controls over committee activitie Documents Reviewed (1)
"SARB Charter", Production and Transmission Department Procedure No. 19-51 (2)
"PRC Charter", Administrative Procedure (3)
Minutes of SARE meetings in 1978 (4)
Selected minutes of PRC meetings in 1978 (5)
Selected QA-05 review sheets for PRC reviews conducted in 1978 (6)
Selected review sheets of SARE reviews in 1978 Findings (1)
Items of Noncompliance Non (2)
Deviations Non (3)
Unresolved Items Two (2) unresolved items were identified and are addressed in the original report (50-255/78-30). Observations (1)
Off-Site Committee (SARB)
(a)
The licensee had issued a charter which defined the TS requried responsibilities except the review of technical audits of the Fire Protection Program. (S)
(b)
The SARB Charter also contained instructions on the following item Ballot reviews Handling of conflicts of interest Use of specialists or subgroups Meeting notices Minority reports Conduct of the meetings Review of meeting minutes (c)
The SARE Charter did not contain the followin (S)
'*
- ...... -- -- -
-39-Requirements to review any indication of an unantici-pated deficiency in some aspect of design or operation of safety-related structure, systems or components (Nl8. 7 -
1972)
Requirements for conducting trend analysis Guidance on what constitutes an unreviewed safety question Responsibility assigned to assure TS requirements on meeting frequency is met Guidance on reviewing the audit program implementation Requirement to periodically evaluate the effectiveness (adequacy) of the QA program Guidance and responsibilities for following open items Responsibility for assuring that all required documents have been received by the committee for review Provisions for assuring that the members having expertise in an area being reviewed is present at the meeting in which the issue is reviewed or has voted on the issue by approving the review sheet Requirements to pursue the matter of generic implications for problems under review Directions from management regarding issues which can (or cannot) be reviewed by ballot Requirements to followup on the corrective actions to problems which were reviewed Requirements to review the following item NRC inspection reports and responses thereto IEB's/IEC's and their responses Responses to audit reports Guidance on what documents are to be reviewed to assure review of all violations of codes, statutes, regulations, TS and procedures Requirements to periodically visit the site and observe licensee activities (W)
-40-(d)
The licensee had issued no other procedures or instructions governing SARB. activities. (W)
(e)
SARB members appeared to be well qualified and collectively had the expertise requried by TS. (S)
(f)
SARB members were each given a reference book which contains such things as the TS, regulations and the charter. (S)
(g)
SARB members had received no formal training or informal instructions regarding their review responsibilities. (W)
(h)
Specific questions regarding the details of an individual SARB member's review of documents indicated that they did not specifically review the issues for possible unreviewed safety questions. (W)
(i)
SARB members interviewed understood the ballot review process which was one of the committee's primary means of review.(S)
(j)
Members interviewed indicated that the SARB meetings were open and not dominated by any individuals or groups. (S)
(k)
Interviewed members discussed the ways in which violations were reviewed, but indicated that no efforts were taken to assure that all violations will be reviewe They relied on PRC for this function and reviewed PRC activities. (W)
(1)
Two of the interviewed SARB members,wtated that corrective action system status was reviewed annually instead of the required semi-annual frequenc SARB was actually briefed semi-annually. (W)
(m)
Review of SARB records indicated that all required reviews had apparently been performed.(S)
(n)
Interviews with SARB members indicated that there was apparently no effort to specifically review the safety evaluations of procedure changes and facility changes. (W)
(o)
The committee did not perform or require any trend analysis of problems. (W)
(p)
The committee did not review LER's, audit reports, inspection reports or violations for generic implications. (W)
(q)
The committee had no tickler or followup system to follow the corrective action for problems which had been reviewed by them. (W)
-41-(r)
The committee had no system which would assure that all material required to be reviewed had been reviewed. (W)
(s)
The committee reviewed QA and technical audit reports, but did not verify implementation of the audit programs. (W)
(t)
Previous incidents of dissenting opinions in SARB had been resolved to the satisfaction of the members interviewed. (S)
(u)
Members interviewed felt that material for review was sub-mitted to them in a timely manner. (S)
(v)
The results of ballot reviews were reported to the committee by a status report. (S) These items were not routinely dis-cussed by the SARB in a meeting. (W)
(w)
A committee member noted that his periodic appraisal was not reflective of his performance on SARB but only on his regularly assigned dutie This practice could be counterproductive (x)
in assuring a thorough review effort by SARB members. (W)
A committee member collectively tried safety question".
legal departmen to the committe noted during his interview that SARB had to determine what was an "unreviewed They had discussed this issue with their (S) No position or guidance had been given (W)
(2)
On-Site Committee (PRC)
(a)
The licensee had a PRC charter which defined all of the TS required responsibilities. (S)
(b)
The PRC charter also contained the following instructions/
guidanc Appointments and use of a PRC Secretary Use of subgroups Defined "unreviewed safety question" Gave authority to interview individuals and gave access to records Established the content of meeting minutes and the means for approval of minutes Distribution of meeting minutes Described QA-05 ballot approval procedures
-42-Provided for special investigation efforts (S)
(c)
The PRC charter did not contain the following item Guidance on the records, documents and activities to be reviewed to detect potential nuclear safety hazards in plant operations (TS 6.5.1.6.f)
Requirements to review the plant security plan and its implementing procedures Requirements to review the emergency plan and its implementing procedures Requirements to review the fire protection plan and its implementing procedures Requirements to review changes to the QA Program and the QA Procedures Requirements to review 30-day LER's Requirements to review NRC inspection reports and responses thereto Requirements to review QA and technical audit reports and responses thereto Guidance on calling PRC meetings and responsibility to assure that TS required meeting frequency is met Requirements for the review and approval of the PRC meeting minutes by the committee Requirements and responsibility for assuring that all required documents are reviewed by the committee Responsibility assigned for reporting disagreements between the Plant Superintendent and the committee (W)
(d)
The licensee had no other written procedures or instructions governing PRC activities. (W)
(e)
PRC membership was established by the TS and the membership conformed to that requirement. (I)
(f)
PRC members who were chosen to be the reviewers on QA-05 reviews had been those who were collectively the most qualified to review the subject material.(S)
-43-(g)
No formal training or instructions had been given to PRC members regarding their review responsibilities. (W)
(h)
PRC members indicated they did not routinely review safety evaluations. (W)
(i)
PRC members were aware of the "unreviewed safety question" (USQ) definition and generally appeared more knowledgeable on the USQ than the SARB members. (S)
(j)
The PRC's review of plant operations for potential nuclear safety hazards included a review of the following documents:
Outage reports Burnup reports Chem data sheets DR' s and ER ' s Weekly report of plant operations (routed to members by the Operations Superintendent)
(I)
(k)
The PRC's required review of TS violations was accomplished by the review of DR' There was, however, no routine audit of these activities to assure that all TS violations were identified on DR's and subsequently reviewed by PRC. (W)
(1)
The TS requirement for PRC to prepare a report on TS viola-tions covering "evaluation and recommendations to prevent recurrence" was satisfied by the information required in the DR and ER form Several of the DR's which were reviewed had a "N/A" in the space for action to prevent recurrenc (W)
(m)
The committee had no formal trend analysis program. (W)
(n)
Specific points of the unreviewed safety questions issue were not reviewed during committee discussions. (W)
(o)
The PRC did not review audit reports of QA surveillance reports. (W)
(p)
The PRC did not review their meeting minutes for accurac (W)
(q)
The PRC did not review identified problem areas for generic implications. (W)
(r)
One PRC member interviewed expressed concern that the PRC may not get involved in the review of modifications early enough. (W)
-1
-44-1 Management of Inspection and Audit Report Findings Documents Reviewed (1)
Distribution lists NLlP and NL2P (2)
Selected Deficiency Reports (DR's) and Event Reports (ER's)
(3)
Record of Notice of Violation postings (4)
Selected Forms 40 which were used to remind departmental supervisors of corrective action commitments (5)
Selected minutes of exit interviewed held by NRC/IE inspectors in 1978 (6)
Radiation Protection Department's reading file (7)
Training records for Radiation Protection Department for 1978 (8)
QA Department commitment log (9)
"Allegations by Palisades Plant Employees of Poor Radiation Protection Practices", investigation report dated July 6, 1978 Findings (1)
Items of Noncompliance Non (2)
Deviations Non (3)
Unresolved Items Non Observations (1)
The distribution of inspection and audit reports and the responses thereto was defined by distribution lists. (S)
(2)
The responsiblities for preparing responses to NRC inspection reports had been established in a memorandum of understanding between the Manager of Production - Nuclear and the Nuclear Licensing Administrator. (I)
-45-(3)
The licensee had no other written procedures or instructions regarding the handlini of inspection and audit reports finding Specifically, there were no procedures which addressed the following item (a)
Guidance on the information to be included in responses to inspection reports (b)
Requirements for a tickler system to assure timely responses (c)
Guidance on addressing possible generic implications in the responses (d)
Requirements to distribute the response to the individuals responsible for taking the indicated corrective action (e)
Requirements to investigate or audit the areas with identified deficiencies to determine the existence of generic weaknesses in that area (f)
Requirements to enter all adverse findings, unresolved items and areas of concern into the corrective action system (W)
(4)
Personnel who perform activities in this area were qualified by virtue of their position within the licensee's organization. (I)
(5)
No formal training or instructions had been given in this area (W)
(6)
Site and corporate personnel who had distribution or response preparation responsibilities were aware of their responsibili-ties. (S)
(7)
The distribution of inspection reports and audit reports appeared to be adequate. (S)
(8)
The posting of NRC Notices of Violation was controlled by the on-site Technical Enginee There was not posting of these notices in the corporate offices. (I)
(9)
There were no requirements to audit or reaudit areas found to be deficient in inspection or audit report Special audits were initiated based on identified problems in the security area, but no special audits were initiated as a result of the previously identified radiation protection problem Special reviews of this area had been performed by a group of licensee employees appointed by VP-P&T (See 14.a(9) above).(W)
(10)
Efforts were not routinely made to determine possible generic weaknesses or problems relative to identified deficiencies in audit or inspection reports. (W)
-
-46-(11)
Corrective action for identified deficiencies was tracked by the corrective action system as a result of the DR or ER that was issue No one was assigned by the responsibility to verify that a DR or ER had been prepared. (W)
(12)
Unresolved items and items of noncompliance were not routinely entered into the corrective action system. (W)
(13)
QA had initiated a commitment log to follow inspection report items for which a committed completion date was give Other items without a committed completion date were not followed. (I)
(14)
No responsibilities had been assigned for performing a trend analysis on audit and inspection findings. (W)
(15)
Preliminary inspection findings which are discussed during exit interviews were documented and submitted to management for infor-mation. (S)
(16)
The site Technical Engineer had been using a special form (40) to advise site personnel of their responsibility to effect corrective action to inspection report findings. (I)
(17)
Site supervisors were using reading files to keep their staffs informed on inspection report findings and responses. (S) The reading files were also used for QA audit report findings but were not routinely used for technical audit findings. (W)
(18)
The on-site QA organization had been using QA surveillance checks to review areas for possible deficiencies or generic weaknesse QA surveillance results were reported to site management. (S)
(19)
The audit schedule at the Palisades site had not been modified based on inspection finding Individuals interviewed said that the schedules at other sites had been modified based on inspection findings, but this practice had not been implemented at Palisade (W)
(20)
QA surveillance schedules had been modified as a result of inspection findings. (S)
(21)
The on-site QA Superintendent did not receive copies of Technical Audit Reports. (W)
-47-1 NRC Communications Documents Reviewed (1)
Distribution lists NLlP and NL2P (2)
Annual Report dated March 2, 1978 Findings (1)
Items of Noncompliance Non (2)
Deviations Non (3)
Unresolved Items Non Observations (1)
The licensee had no procedures or instructions regarding the handling of communications between the licensee and NRC. (W)
(2)
The responsibility for responding to the various types of NRC communications was outlined in a memorandum of understanding between the Manager of Production - Nuclear and the Nuclear Licensing Administrator. (I)
(3)
Requirements to prepare responses to NRC communications were identified to individuals through AIR' Individuals who were interviewed indicated that these notices had been timely. (S)
(4)
License and TS changes were distributed to applicable licensee personnel by the Nuclear Licensing Administrator through the on-site Technical Enginee There was no overview of review of the adequacy of the distribution by the Plant Superintendent or Manager of Production - Nuclear. (W)
(5)
The licensee had no formal program for distributing changes in the federal regulations and NRC Regulatory Guides. (W)
(6)
Other NRC licenses such as reactor operator license, SNM license and by-product licenses were not controlled or monitored by the Nuclear Licensing Administrator. (I)
(7)
FSAR changes were reported in the annual report *and were con-trolled by the Nuclear Licensing Administrator. (I)