IR 05000267/1987031

Insp Rept 50-267/87-31 on 871030-1103.No Violations or Deviations Noted.Major Areas Inspected:Licensee Action on Violation 267/8619-03 Re Corrective Action Request Program

ML20237A472
Person / Time
Site:	Fort Saint Vrain
Issue date:	12/09/1987
From:	Farrell R, Westerman T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:
Shared Package
ML20237A467	List: IR 05000267/1987031 ML20237A464
References
50-267-87-31, NUDOCS 8712150028
Download: ML20237A472 (10)

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APPENDIX U.S. NUCLEAR REGULATORY COMMIS! ION

REGION IV

NRC Inspection Report: 50-267/87-31 Operating License: DPR-34 Docket: 50-267 i Licensee: Public Service Company of Colorado (PSC) l 2420 West 26th Avenue, Suite 15c I Denver, Colorado 80211

Facility Name: Fort St. Vrain Nuclear Generating Station (FSV)

Inspection At: FSV, Platteville, Colorado Inspection Conducted: October 30 through November 3, 1987 j Inspector: '

- A [7 - f- 8 7 R. E. Farrell, Senior Resident Inspector (SRI) Date -

Approved: /J - f- F 7 T. F. Westerman,' Chief, Project Section B Date i

Inspection Summary Inspection Conducted October 30 through November 3, 1987 (Report 50-267/67-31)

Area Inspected: The senior resident inspector made a special unannounced I inspection of the licensee accion on NRC Violation 267/8619-03 (corrective action request program).

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Results: Within the one area inspected, no violations or deviations were l Identifie l 8712150029 971210 PDR O

ADOCK 05000267 PDR l

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DETAILS Persons Contacted Principal Licensee Employees

• F. Borst, Manager, Support Services / Radiation Protection

• L. Brey, Manager, Nuclear Licensing and Fuels

• M. Ferris, Manager, QA Operations

• Fuller, Station Manager

• J. Gramling, Supervisor, Nuclear Licensing Operations

• R. Heggen, Supervisor, Engineering Support i

• M. Holmes, Manager, Nuclear Licensing l

• F. Novachek, Manager, Technical / Administrative Services

• Purnell, Licensing

• J. Reesy, Staff Assistant, Nuclear Engineering Division L. Sutton, Supervisor, Auditing

1. • P. Tomlinson, Manager, QA >

• D. Waret. bourg, Manager, Nuclear Engineering

1. • R. Williams Jr. , Vice President, Nuclear Operations

• Denotes those attending the exit interview conducted November 3, 198 # Denotes those attending the exit interview conducted November 12, 198 . Licensee Action on NRC Violation 267/8619-03 (Corrective Action Request fCAR) Program)

The NRC SRI reviewed:

. NRC Inspection Report 50-267/86-19, conducted June 23-27, 1986 ;

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Licensee response letter (P-86578), Tomlinson to Gagliardo, dated October 27, 1986

. Procedure Q-16, Issue 8,' effective December 31, 1986, " Corrective Action System"

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Licensee's list of open CARS, dated October 27, 1987

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. Licensee's Nuclear Facility Safety Committee 1986 audit of the CAR program

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Licensee's historical progress since July 1986, reducing open CARS

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Selected CARS, management corrective action requests (MCARs), and quality deficiency reports (QDRs), as listed The licensee has made significant progress reducing the backlog of open CAR This progress has been made sir.iultaneously with the implementation

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of an aggressive quality assurance audit progra The numerical history of the CAR backlog is as follows:

CARS Issued CARS Closed Month In Month In Month CARS Open July 1986 9 9 108 August 1986 24 9 123 j September 1986 53 9 167 3 October 1986 12 29 150  :

November 1986 12 30 132 l December 1986 5 51 86 January 1987 1 25 62 February 1987 6 17 51  ;

March 1987 0 22 29 1 April 1987 14 3 40 May 1987 23 3 60 .

June 1987

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4 11 53 July 1987 0 5 48 {

August 1987 2 3 47

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September 1987 2 9 40 October 1987 2 0 42

A review of the NFSC audit of corrective action, NFSC C-86-02, December 1986, revealed that at the time of the audit, the average' age of an open CAR was 253 days with the median age being 75 days. The audit termed this age excessive and the licensee in presentations to the NRC staff has repeatedly identified 180 days.as the current target for oldest open CARS as a first step in reducing the excessive CAR age identified in NRC Inspection Report 50-267/86-1 '

The open CAR log, dated October 27, 1987, revealed the following:

. 22 open CARS with average age of 278 days I l

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2 open MCARs with a total of 18 open discrepant items, average age of )

open items is 184 days j

. 65 open QDRs with average age of 93 days The licensee, while making significant progress, still has several very old items on the open CAR list. Also, some of this progress on the

, backlog has been achieved by transferring items being tracked to a commitment tracking system, thus, closing the CA Additionally, many new items which would have previously been CARS are now QDR The list of .

open CARS, dated October 27, 1987, includes the'following: i i

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4-CAR Number Description Days Open CAR-85-097 Specific penetration seals 812 throughout the plant are not labeled with the corresponding '

seal number used in the procedur CAR-86-003 Deficiencies in Specifications 1-N-2 656 and 93-I-170 CAR-86-014 Records center personnel do not 637 receive adequate training for performance of their dutie CAR-86-053 Excessive delay for permanent 568 implementation of TCRs via the change notice system.

l l CAR-86-093 Master calibration schedule- 449 not performing designated function.

l CAR-86-105 During EQ walkdown of October 1985, 439 deficiencies were identified which .

are listed in SEMAP1, these ]

deficiencies have not been addressed for their effect on safety-related equipmen CAR-86-152 Direct charges do not include 496 the work order numbe CAR-86-166 Surveillance procedures do not 398 properly address requirements of interim Technical Specification CAR-86-197 NFSC needs an expert in 323 instrumentation and contro . CAR-87-001 No method to notify cognizant 265 people for reporting purposes when radiation effluent monitors are inoperative or when monitors have received maintenance that ..

would necessitate recalibratio '

CAR-87-012 During the course-of unescorted 190 access audit, numerous discrepancies were found,in the personnel files used.for justifying access to FS ..

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CAR-87-013 Inadequate NED determination and 180 QA verification of shelf-life materials during procuremen MCARs87-001 and 87-002 are listed below followed by each of the discrepant items identified and still ope An MCAR is directed to senior management to assure adequate response to the discrepant conditio MCAR Number Description Days Open MCAR-87-001 Inadequate shelf-life progra MCAR-87-001 (1) NED evaluation of PSC snubber 201 sho MCAR-87-001 (2) NED evaluation of suspect materials 201 in Ebasco warehous MCAR-87-001 (3) Development and implementation of 201 Ebasco warehouse procedure MCAR-87-001 (4) Issuance of P-5 to control shelf- 201 life material in satellite warehouse MCAR-87-001 (5) NED training to STD-2 MCAR-87-001 (6) PEP VI-I closure criteria 201 developmen MCAR-87-001 (7) Response to QAC-87-1112 (results 201 of follow-up).

MCAR-87-002 Results procedural implementation 174 deficiencie MCAR-87-002 (IB) Lack of training / qualification 174 on program for results contract personne MCAR-87-002 (3) Lack of a program for educating 174 out-of-tolerance conditions for installed instrumentatio MCAR-87-002 (4-1) Lack of a program for evaluating 174 out-of-tolerance conditions for maintenance and test equipment.

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MCAR-87-002 (5) Methodology used for alignment of 174 RMS does not provide for traceability to NB MCAR-87-002 (7) Acceptance criteria on surveillance 174 changed without a procedure deviation repor MCAR-87-002 (8) Data base change request increased 174 l calibration frequency of instrument l

without evidence that instrument had been in calibration for two successive calibration MCAR-87-002 (10) As found source data is not taken 174 on ESR-8.1.2C- MCAR-87-002 (11) Pressure indicator not calibrated 174 by a Technical Specification /

surveillance request was used to evaluate the acceptable operable-conditions of SR 5.2.7CD- MCAR-87-002 (12) Test equipment and standards- 174 history files (calibration

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documentation) are incomplet MCAR-87-002 (13) Data base change request / safety 174 l evaluations are not maintained in l the records center.

l l MCAR-87-002 (14) Test Equipment and standards were 174 l not referenced on pertinent  !

I surveillance requirements as required.

l QDRs are according to licensee Procedure Q-16, "A written report which provides a mechanism for identification and correction of conditions adverse to quality noted during audit / surveillance / monitoring activities which: (1) are based on objective evidence, (2) are a violation of i l approved or committed to requirements, and/or (3) are of sufficient concern to merit written report submittal to the affected organization."

! The following QDRs are included in the licensee's log, dated October 27, 1987, as open:

QDR Number Description Days Open QDR-87-013 Implementive procedures have not been 231 I established for qualifying and training all levels of plant staff personne :

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QDR-87-018 Purchase orders do not identify 172 limitation for use of the ite QDR-87-020 Procedure does not identify procure- 172 ment process for distributors /subtier supplier QDR-87-022 Safeguard QDR-87-025 QA training activities not incorporated =168 in QA scheduling and planning progra QDR-87-027 QA personnel training and qualification 168 files are not current per FSV Administrative Procedures Manual G-7, Issue 1 QDR-87-045 Monitoring activities are too brie !

QDR-87-046 Inconsistencies in NRC Form 398s and 162 l

applications for.a license.

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QDR-87-047 There is no procedure for controlling 158 l computer codes used by the nuclear l licensing and fuels divisio QDR-87-048 There is no procedure for control of 158 security and other softwar QDR-87-049 Computer codes are being procured from 158 l unapproved suppliers.

l QDR-87-050 There is no procedure for controlling 158 software, including procurement of softwar QDR-87-051 STD-1 does not identify how to handle 158 status sensitive item QDR-87-053 Q-16 does not allow all individuals to 151 generate corrective actio The NRC SRI noted the following in a review of selected open CARS, MCARs, and QDRs:

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CAR-85-097 was scheduled for completion October 31, 1987, but was

, delayed due to unanticipated circulator.and fire outage However, l- this item, which originally dealt with unlabeled fire penetration seals and ultimately caused'the identification and placement of approximately 300 missing fire penetration seals,-has had seven corrective action schedule extensions prior to October 31, 1987.

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. CAR-86-093 identified a problem with instruments not being calibrated on schedule, some as much as 9 years late. Significant work has been accomplished on this CAR with completion for December 31, 1987, j schedule '

. CAR-86-105 identified that deficiencies identified in the 1985 equipment walkdowns to support the environmental qualification of i equipment program (EQ) were not addressed if not directly related to j E Corrective action to assure safety related equipment operability I was accomplished prior to plant startup. The subsequent walkdowns I still being accomplished are to identify lesser deficiencies  !

requiring correction . CAR-86-166 identified that Surveillance Procedures SR 4.1.1.E-X/

4.1.1.F-4-X/4.1.3.C-X, Issue 2 and SR 4.1.1F.2-R, Issue 1, do not address calibration of control rod drive cavity and motor instrumentation as required by interim Technical Specification 3 Surveillance 4.1.1.F.4. These procedures have been drafted and are in the review / approval process. These procedures will not be q required until the next refueling outage sometime in late 1988 or i early 198 . CAR-87-001 identified that no mechanism exists to notify cognizant personnel when effluent radiation monitors are inoperative or require recalibration due to maintenance having been performed on the These monitors are covered by numerous Technical. Specifications, including: LC0.4.2.9(b), LC0 4.4.1, LC0 4.4.3, SR 5.2.11, ELC0 8.1.1, ELC0 8.1.2, and ELC0 8.1.3. The latest dated document in the CAR file presented to the SRI by the licensee is dated September 14, 1987, and indicates that corrective action cannot be implemented until after the nuclear engineering division changes the classification of the radiation monitors to allow the monitors special attention. This CAR has been open for more than 265 days, and additionally identifies.that inoperable or out of calibration 1 radiation monitors were the subject of an NRC Notice of Violation )

(267/8621-01). Corrective action has not been implemente '

l . CAR-87-012 identified problems in documentation used to grant ,

unescorted access to protected and vital areas'of the plant. The l l security forc:a re %.,nded with an action plan and implementation schedule that concluded on October 31, 198 The SRI determined that although the corrective action is not yet complete, substantial l progress has been made and corrective action should soon be 1 complete The SRI did note that this CAR file indicated that the i same problem had been identified as CAR-85-030.in 198 . MCAR-87-001 identified 8 discrepant items in the licensee's .j shelf-life program. The shelf-life program was implemented in I response to CAR-86-158 opened September 26, 198 The discrepancies '

i identified in MCAR-87-001 were programmatic involving all'

safety-related items issued from the plant stores and having a

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shel f-li fe. This MCAR is still open and as late as October 20, 1987, QA identified: (a) a lack of completion commitments, (b) nonconformance reports and hold tags not being generated in a timely manner for material with expired shelf-life, (c) engineering not evaluating expiring shelf-life material for use in a timely manner, and (d) on September 9,1987, material with a shelf-life, which expired in 1984, was issued for a safety-related applicatio . MCAR-87-002 identified 18 discrepant conditions in the performance of the results (instrumentation and controls) department. This MCAR was issued on May 6, 1987. Five of the eighteen discrepant items identified by this MCAR are closed. QA has received acceptable responses to all other discrepant items which will be closed following a QA followup to verify implementatio i

. QDR-87-013, issued March 10, 1987, identified that.a training program i has not been established for managers, supervisors, and professional / technical personnel as required by Section 5.3 of ANSI N18.1-1971, " Selection and Training of Nuclear Power Plant Personnel." The licensee's Technical Specification 7.1.1. requires that each member of the facility staff meet or exceed the requirements of ANSI N18.1-1971. The original commitment date to complete corrective action was July 22, 1987. This date was later changed to August 31, 1987, and is currently December 31, 198 While the licensee shows substantial effort to resolve the open CARS, MCARs, and QDRs, the average age of open CARS and MCARs is still excessiv Summary .

When the CAR program was inspected in NRC Inspection Report 50-267/86-19, '

there were three apparent. problems:

. The Quality Assurance Division was not identifying problem . If a problem was identified, the responsibl-e organization did not accept responsibility for corrective action or did not agree with the findin l l

. In those cases where corrective action was taken, it generally was <

inadequate or incomplet '

The CAR program, as it exists at the time of this inspection, is J significantly improve . The quality assurance organization has become very active in  ;

identifying problems, recommending solutions, and also identifying . j improvement items to enhance the various nuclear operations '

(Production, Engineering, Licensing and Fuels, and Quality Assurance)

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. Corrective action, when taken, is thorough and effec'tive. Action to prevent recurrence is eviden The remaining problem (in corrective action) is the amount of time required (in many cases) to reach agreement within the responsible organization as to the existence and extent of a problem and as to the ,

appropriate course of corrective action ]

Management attention should be directed to the reduction of time required to determine and commence appropriate corrective action following identification of deficiencies in nuclear operations activitie The corrective action program at.FSV shows significant improvement in ,

17 months. Additional improvement is needed to bring to closure the complex and/or broad scope deficiencies. Consequently, NRC Viciation 267/8619-03 remains open pending additional licensee action to reduce the age of open corrective action items and to reduce the time required to close corrective action item . Exit Meeting Exit meetings were conducted on November 3 and 12, 1987, attended by those identified in paragraph 1. At these times, the SRI reviewed the scope and findings of the inspectio !

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