IR 05000275/1990029
| ML20059E509 | |
| Person / Time | |
|---|---|
| Site: | Diablo Canyon  |
| Issue date: | 08/24/1993 |
| From: | Huey F NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| References | |
| OLA-2-I-MFP-069, OLA-2-I-MFP-69, NUDOCS 9401110241 | |
| Download: ML20059E509 (18) | |
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U. 5. NUCLEAR REGULATORY COW 4ISSION
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REGION V
poay Report Nos.
50-275/90-29 and 50-323/90-29 Docket Hos.
50-275 and 50-323
'93 OCT 28 P6 :21 License Nos.
OPR-80 and DPR-82
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Licensee:
Pacific Gas and Electric Company
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C 77 Beale Street San F'ar.cisco, California 94106 i
Facility Name:
Diablo Canyon Units 1 aad 2 Inspection at:
Diablo Canyon Site, San Luis Obispo County, California inspectionConducted: November 27-30, 1990 December 17-21 1990 January 7-11,1991 Inspectors:
C. Myers, Resident Inspector M. Royack, Reactor Inspector M.
o
,C tojtoNRC Approved by:
to b7d /
F uR. Huey, rection Date Mgned We f,,
I Engineering SUPMARY:
Inspection on November 27-30, 1990, December 17-21, 1990 and January 7-11, H 91 (Report Nos.50-275/90-29 and 50-323/90-29)
AREAS INSPECTED Announced inspection to follow-up on mechanical maintenance reasuring and test equipment issues.
Inspection module 35750 was used as guidanea for the inspection.
Results:
One unresolved item was identified in the areas inspected. The unresolved item involved the apparent lack of timely issuance of a nonconformance report to effect corrective action for rtcurring deficiencies in the control of measuring and test equipment, and overall conformance with M&TE program controls.
Individual discrepancies discussed throu'hout the report contributed to the situation and involved repetitivs cases of problems with following M&TE procedures, improper dispositioning of Action Requests and QualityEvaluations,andfailuretocorrectrecurringdeficiencies.
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DETAILS h
1.
Scope P
o This inspection reviewed the programmatic controls and implementation of the Measuring and Test Equipment (M&lE) program with emphasis in the mechanical maintenance area.
Inspectors reviewed individual M&TE deficiencies to evaluate their effects on safety.
Inspectors performed reviews of PG&E surveillances and audits, performed field inspections of M&TE facilities, and interviewed management, Quality Assurance (QA),
Quality Control (QC), and Maintenance Department personnel.
Inspectors performed detailed reviews of licensee Action Requests (AR), Quality Evaluations (QEs), and M&TE documentation to determine the correction status of licensee identified deficiencies in M&TE.
2.
Major Findings and Conclusions This inspection resulted in the following findings and conclusions.
The bases for each of these are developed in detail in the subsequent paragraphs of this report.
Licensee audits and surveillances of the control of measuring and a.
test equipment in the mechanical maintenance department have identified significant documentation deficiencies since 1985.
The licensee response to this problem has been slow.
b.
Licensee personnel did not deal effectively with the overall findings of their own audits and surveillances.
This lack of effective corrective action was recognized in another licensee audit in May.
1990. However, effective corrective actions were still not taken.
The licensee had inappropriately closed a 1987 nonconformance report which identified M&TE deficiencies without assuring that the root cause was identified and effective corrective actions were implemented to preclude recurrence.
The licensee had not used the established nonconformance report c.
system to address the recurrent nature of these deficiencies.
d.
The examination of M&TE controls conducted during this inspection confirmed the continuing nature of M&TE dormentation deficiencies in merMnical maintenance.
Some of the deficiencies identified were rudily apparent, and should have been found prior to the inspection by the licensee.
3.
Review of Surveillances and Audits Inspectors reviewed the results of the following licensee surveillances and audits of the Measuring and Test Equipment program:
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7 - wua - E [l' mu - , ?Y W573) Y [j~jyQ pmnm4 $ [:]7 }p{t. *Ofi* ) 2, y7MbC* 4 * * ' N0iSEmn0J 40lym933 syjg _- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. -
. _ _ - _ - -. . - r Measuring and Test Equipment (NECS-C) & Maintenance Prograa (DCPP) -. ,., Audit 89616P.Lreport date May 5, 1989.
Control of Measuring and Test Equipnent Audit 89625P, report date - June 23, 1989.
_ ,_ _ , Control of Measuring _ and Test Equipment (I & C),(Control and - Calibration of Performance Monitoring Equipment I&C)andControl of Measuring and Test Equipment (ISI/WDE) Audit 89635P report date November 9,1989.
Mechanical Maintenance Surveillance Report QCS 89-175, report date - December 5, 1989.
' Calibration and Control of Mechanical M&TE iurveillance QCS - 90-030, report date April. 12, 1990.
Qualtsy(QP & A) 90-126, report date May Performance'and Assessment Maintenance Branch Surveillance - Report 30, 1990.
Mechanical Maintenance Control of Measuring and Test Equipment - audit 90812T report date June 6, 1990.
The inspectors found that licensee audit and surveillance reports had identified significant deficiencies in mechanical maintenance issuance and control of MATE.
Inspector findings as a result of field inspections, discussed in Paragraph 3, confirmed that some of the deficiencies, previously identified by the Ifcensee, still existed and had not been corrected.
. l a.
Quality Control Surveillance QCS 89-175 , , QCS 89-175 had identified significant deficiencies which resulted in nine action requests being issued to address individual , discrepancies. Problems included several-cases of failure to i follow procedures, which resulted in lack of torque verification after M&TE vse, not using the required logs to document M&TE issuance, incomplete log entries, and M&TE use not documented on i work orders. The audit report indicated that a mechanical maintenance foreman stated there had been numerous discussions at-all management levels to rectify the situation. It does not appear, however, that to the NRC inspectors whether any substantial action was taken to correct the situation as a result of those management discussions.
b.
Quality Control Surveillance No. QCS 90-030 Surveillance QCS 90-030 had been performed by QC to evaluate-mechanical maintenance M&TE and corrective action taken since the above surveillance. The assessment found that not'all requirements of upper tier procedures had been implemented into mechanical calibration procedures. Mechanical calibration procedures (MP M-53 series) were " generic" rather than device specific, and the working . . . - -
. . ... -. -.... . .. - ...... . . - - - - . . l -, level mechanical calibration procedures 'were; inadequate in instruction detail. The surveillance also identified a wide range of errors in- ' ?- a sampling of 80 quality records associated with the calibration of ' M&TE. Discrepancies included "as found" and."as left" data not recorded, standards not identified. accuracy ratios exceeded, " reviewed by" and " calibrated by" signatures missing, accuracy requirement discrepancies. and restrictions on~ usable' range not, documented.
The audit found inadequate follow-up on out-of-tolerance (00T) M&TE usage. Of 39 action requests for 00T MATE _ usage.: ten had historical searches which exceeded the required time-limits of 14 - days. The audit report concluded that the discrepancies indicated.
serious programatic weaknesses that could impact safe plant operation and reliability or could have significant regulatory.. impact and that, overall, the mechanical maintenance M8TE program was not effective in attaining the desired level of quality. Ten action requests were issued as a result of the surveillance.
The sumary of results of the surveillance stated that "many of the.
program administrator's corrective actions during the last year only-corrected the symptoms of the probims and not their causes thus allowing problems to recur."
The inspectors found that, alth'ough the audit ide..tified significant recurring deficiencies for which previous corrective action was inadequate, no Action Requests (ARs).-Quality Evaluations (QEs), or Audit Finding Reports (AFRs) were written specific to the problem of inadequate corrective action for significant deficiencies.- The inspector found that no written response was required to address the overall conclusions of the surveillance report. These conclusions were based on the auditor's evaluation of the significance of the individual observed deficiencies as indicators of the effectiveness of the program in achieving its quality objectives. Individual deficiencies were addressed under subsequent Action Requests.
Apparently, the licensee did not recognire that the' programatic weaknesses, which allowed the-individual deficiencies to occur, required correction. Therefore, the programmatic weaknesses were not adequately dealt with to preclude recurrence.- Quality Performance and Assessme':t Surveillance Report No.
c.
QP&A 90-126 The Quality Assurance organization had performed audit QP & A 90-126 because of the significant number of discrepancies identified by QC in mechanical maintenance M&TE controls.
Audit QP&A 90-126, performed in Hay,1990, identified the following discrepancies.
- A review of audit report 85230-P (1985) showed that se'veral of the discrepancies identified in the'QC surveillance QCS.90-030 had been previously identified by QA. Specific discrepancies were:
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__. _ - _ - . .. , .- lack of-history searches / evaluations for cut-of toleranc2 - M&TE; . lack of program provisions for describing MATE t - calibration; calibration checkout and calibration logs not complete.
- and contained errors; use of torque wrench without proper reverification; - inadequate record keeping for on hold /out-of-tolerance - M8TE; ' Master List' not being properly maintained; - lack of evaluations fur consistently out-of-tolerance - MATE; as found data not being documented; - questionable personnel qualification and record - requirements; Nine previous QEs identified similar types of problems. The -
QEs reviewed were: 00007123, 00007147, Q0005359. 00006760, Q0006560, Q0006533, Q0006536, Q0006335, and Q0006138.
Five of the above QEs initiated in the 1988-1989 time frame-
were closed out prior to QC surveillance 90-30. Therefore, it
is significant to note that QC observed a repetition of - previously identified problems, (QC subsequently re-documented l these discrepancies on AR).
Exa7 es of these recurring l
problems included-l QE-0005359/AR-A0182655: use 'of torque' wrenches outside ~ - their useable range; QE-Q0006742/AR-A0184939: out of tolerance evaluations - exceeding time limitations; QEs-00006533,QE-Q0006536/AR-A0184939/AFR-84-192: - out-of-tolerance evaluations not being performed; AFR-84-191/AR-A0181518: as found data not recorded - prior to making M&TE adjustments;
Examples of other currently open problems identified in 1988-89, which were also found to be repetitive and re-documented on AR by QC, included: ) ) QE-Q0006560/AR A-A0184106/AFR-85-389: calibration check-out.
- logs not being maintained; QE-00007123/AR-A0183542: problems related to M&TE issuance - and record keeping.
QP&A 90-126 demonstrates that the auditor recognized that M&TE deficiencie:; had been identified frequently since 1985 and that i effective corrective action to preclude recurrence had not been taken. However, it was not clear that the auditor's findings were recognized and dealt with effectively by management. Apparently, no nonconformance report was written.
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Quality Assurance Audit 90812T ) Audit 90812T was conducted during the period of June 20 ' August 9.- ..
1990 as a result of the deficient.tes discussed above. The audit?
resulted in the issuance of six QE-AFRs and eight action requests '- i five with quality evaluations pending. lThe~ audit" findings included ! the following deficiencies: i R i The accuracy of two' step block gages designed and - i fabricated by the licensee did not comply with the required 4:1 accuracy ratio.
I M&TE descriptions. identification and calibration due - i dates were not always recorded on work orders.. Seven of i 20 work oNiers reviewed did not contain required i } infomation.
i . - . ! Dial indicators which were clsssified as " maintenance - ! only" (uncalibrated) tre being used by mechanical
i maintenance to establish compliance with quantitative-j specifications.
! The Justification For Use (JFU) for. a 0111on Tension - ] Dynamometer contained a math error.
j ! Methods and calibration standards for calibrating the'- l - i vernier calipers. levels, and vernier height gages were j not prescribed in approved plant procedures.
I Mechanical maintenance did not maintain vendor manuals' - l for most of the equipment they were responsible for calibrating. Because of that, tool room personnel could
} not describe or refer to recognized practices and methods j of calibration.
' i ! The inspectors concluded, based on documented audit and ..
surveillance results. that significant deficiencies in mechanical ' maintenance M&TE program implementation, procedural compliance.- root cause analysis and corrective action have existed for-some'. l . ! time. Audit and surveillance results indicated that >he recurring problems were, again, recognized and documnted by both Quality
! Assurance and Quality Control Departments. The inspectors concluded j that long standing and recurring deficiencies with Mechanical l Maintenance M&TE existed. The licensee did not effectively provide
l for, nor addreis, the effectiveness of corrective actions needed
to preclude recurrence, i
j The audit additionally identified and stated that "QC's slow l response to continue to pursue and investigate known problems l i further to reach conclusions and cor---* ' deficiencies was
considered weak." Again, no actic' e: ut, nonconfomance - i i report, or finding wa* identified . action on the part j of QC.
In section 3.2 the audit wenti. led that "several of the discrepancies were previously identified in past.P91 -
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_ _ _ _ - _ _ _ _ _ _ _ _ _ _ ___ calibraticn audits," yet no findings specific to inaoIquate ' corrective action for recurring deficiencies were issted.' The inspectors concluded that audit findings did not address concerns - s that appeared to be contributory to the recurring deficiencies.- - This is an example of inadequate corrective action.
4.
Ineffective Use of the Nonconfo-mance Reporting System Audit 90812T identified that a previous NCR on MATE, NCR DC0-87.QA-N001, was closed. No new NCR was initiated as a result of the significant findings.during that audit. The audit report stated in section 4.0 that " findings identified by the audit team showed that M has not full implemented the corrective actions required by NCR DC0-87-QA-N001.{ It further stated that "although a plan had been developed and instituted, as required by the NCR, several program weaknesses related to implementation were observed by the auditors." It stated that the 1987 NCR was closed based on the objective evidence that a corrective action plan had been impismented; however, implementation was not verified to be-completed or effective at the time of NCR closure.
The inspectors found that Audit 90812T in Section 4.0, Effectiveness Evaluation, identified that implemented corrective actions required by NCR DCO-87-@-N001 for Machanical Maintenance M&TE were not inplemented. Yet the NCR was closed and no action request was written ' to investigate the root cause of the failure to implement the NCR
required action. NPAP C-12. Revision 19. Identification ard Resolution of Problems and Monconformances " section 5.2.1 requires in part that an action request be written for "any deviation of a procedure... Failure , to implement NCR corrective action for significant conditions adverse i to quality would constitute a deviation from a procedure (QAP-15-B).
Furthermore, NPAP C-12, section 5.4.3.?, requires a nonconformance report to be initiated for a potential nonconfomance. Quality Assurance Procedure QAP-15-8 Paragraph 2.1 defines a nonconformance, in part, as a " quality problem which has occurred at a frequency which indicates that past action to prevent recurrence was ineffective and additional management attention is deemed necessary." However, the inspector found that no NCR had been initiated as a result of the audit findings. This issue regarding compliance with procedures for identifying significant conditions adverse to quality is considered an unresolved item.
(50-275/90-29-01).
In response to the inspector's concerns, the licensee initit.ted NCR fDC0-90-m-N089 to address the repetitive nature of the findings'in this area and the lack of prior NCR initiation.
5.
Inspection of M&TE Facilities ' The inspectors perfomed field inspections of Mechanical Electrical, and ISC Measuring and Test Equipment facilities.
The inspectors noted that the I&C facility was a strength. The facility was large, well organized, and well equipped. Foremen and Supervising i Technicians interviewed were knowledgeable of the facility, procedures and requirements. Calibration procedures were detailed and well written.
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The mechanical and 01::ctrical fac111tiss. although adequate. were , marginal la some areas. The' Unit I mechanical facility tas very small- '. and allows little room for calibration and checkout of equipment. There was no space (due to size) for separate storage of out-of-service / ' out-of-tolerance and ready for use MSTE. Because the contents of cabinets and storage. 'Vidmars" were not well marked, the tool clerk had trouble locating some equipment. The Unit 1 tool crib was immediately adjacent to the M8TE room. During backshift the inspectors noted that the M8TE room was open and unattended while the tool clerk was in the j tool crib.
Unit 1 M&TE Facility The inspectors performed a review of the MSTE issue log in the Unit 1 M8TE facility for recently issued MATE. The facility used a manual log ! in lieu of the PINS computer module for issue and return of MSTE. The ' following deficiencies were identified and brought to the attention of department supervfston for resolutfon.
a.
Micrometer #40. was checked out on 11/6/90 and was not logged as being checked back in. The tool was located in the room. The tool clerk stated that someone had apparently forgotten to check the , tool in upon return.
In the event that no clerk is available, the job foremar is to ensure that all applicable information is documented on hard copy forins for input into the M87E Module at a later time.
b.
Torque wrench #133 was checked et on 6/18/90 and verified at 120 inch-lbs. The calibration reverification upon return on 6/28/90 was done at 30 inch-lbs. No explanation for the difference was provided in the log.
The inspector found inconsistencies regarding the required check data in the verification and reverification procedures._ MP MS3.1 " Calibration of Torque idrenches and Torque Wrench Testers."' Revision 10. section 7.3.2 a. requires verification be accomplished > by * Setting the specified value. OR the midpoint of the range, on the torque wrench."
Section 7.4 T requires "The specific value OR range calibration shall be reverified when returned after use."
Mechanical staff stated the " normal" pra-tice was to verify and reverify at the specific value that the torque wrer-h was to be ' used for in the field. The procedural incorsistencies.and work-practices appear to need reevaluation.
Torque wrench fl?3 was subsequently checkad out on 8/3/90 to be c.
used on work order R-39845.
It wa; declared lost in the log en 11/19/50 No post-job torque reverification was done._ Mechanical maintenance staff were not able to produce ojective evidence that-the lack of reverification had been known or acknowledged by supervisory personnel, l r - -- ' l .
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The " precision yes/no" block was not filled out upon. issue.
' '- of torque wrench #137 for one job.
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The " precision yes/no" block and the "0A yes/no block" was4:t filled out for the 5 lb weight set f130 checked out on'2/7/90.
f.
Micrometer set fl95 was e.issing f rom the M&TE room.- Subsequent investigation revealed that the entire f et.was in the Unit-2 cold machine shop tool room but had not been properly checked out of the - Unit I room. This was an example of inadequate control of M8TE.
g.
1he " precision yes/no block" and tFe "QA yes/no block" were not filled out for pressure gage #237 checked out and returned on 12/12/90. Lacking documentation..it was indeterminate whether the first level review of whether the M&TE was appropriate for the job was condt.cted.
h.
The " precision yes/no block" and the "QA yes/no block" for pyrometer #241, checked out on 12/7/90, was not filled out.
1.
The " precision yes/no block" for torque wrench #290, checked out on 12/5/90, was not filled out.
j.
The "QA yes/no block" for micrometer #298, checked out on 11/02/90, was not filled out, k.
There was no post-job-torque reverification for torque wrench #417 checked out on 10/P/90.
1.
Torque wrench f4, issued on 3/8/90, for a quality precision job, was verified at a torque value of 96 inch-lbs. Upon return, on the same date, the reverification was done at 178 ft-lbs.. The log sheet was annotated with a note that the torque was changed at the job site.
m.
Torque wrench f5, checked out on 3/7/90,'was verified.at 30 ft-1bs.
The reverification upon return on 3/12/90 was done at 22 ft-lbs.
No explanation was noted in the log. Additionally, the " precision yes/no block? and the *0A yes/no block" were not filled out. The specified instrument use range was 320 - 1000 inch-lbs :.J the verifications were.in ft-lbs. The use of consistent ~ units would. reduce the potential for error.
n.
Toroue wrench #7, issued and returned on 3/27/90, was n rified at C1 it-lbs. The reverification upon return was done at 122 ft-lbs.
j No explanation for the difference was noted in the log.
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,, f y 9 : The inspectors concluded that' adherence to pr:graa and procedure l - requirements for the control of'ETE continue to be a problem area L i and that the deficiencies had potential to affect. safety.. Althoughi . individual deficiencies may have been technically justifiable on a case by case basis, the safety. affect of numerous recurring deficiencies-was indeterminate.
The deficiencies identified were siellar to:long standing deficiencies referred to'in the' audits-and surveillances - c.iscussed above, and are additional manifestations of inadequate ETE control and corrective action.
Unit 2 Cold Machine Shop Tool Room.
- . . Inspectors performed an inspection of the Unit 2 cold machine shop tool-
room with a QC Surveillance Supervisor.
The facility used a manual check out log in' lieu of the PIMS computer y module. The tool room and the ETE area in the rear of the tool room wert. generally neat and clean.. The following deficiencies were identified and discussed with department supervision:- a.
TN person manning the facility for issue and checkout'of tools and MTE stated that he was just standing Lin for the qualified tool clerk and that he did not really know about the ETE in'the room.
,1 facility attendants-are responsible for issue, return, i. pection, and verification and reverification.. Verification and ' reverification requires the'same knowled User qualification is addressed by AP D-752, Ee as users. Calibration and Control of . Measuring and Test Equipment (Electrical and Mechanical Maintenance)," Revision.10, section.4.1.4.. however,4the procedure ' is silent on qualification of attendants. The lack'of. program . requirements for facility attendant training and the'use'of i " unqualified" personnel in this facility is.. considered:a weakness, b.
A "Vidmar" storage unit in the ETE room had numerous-blank: " calibration stickers" and " maintenance only" stickers.
The ' inspector.was told that no calibration was done at'that particular.
facility.
The inspector questioned why uncontrolled blank l calibration stickers were in a facility which performs no calibration. The iten was. referred to the-mechanical maintenance foreman for investigation and resoluti- : -The poor control of; calibration stickers is considered a weakness.~ An out of calibration Ainor Digicon 11 temperature indicator c.
(serial #7916) was stored along side calibrated indicators. The.
practice has potential:to result in inadvertent use of.uncalibrated indicators.
d.
A1nor Digicon II indicater serial #8946 was calibrated for use withl probe #205, however the padded carrying case for indicator serial
- 8946 had probe #202 stored in the case.
The storage of probes ~ should be evaluated. The conservative practice'in use in the.I-& C department was to lead seal the probe to the indicator that-it was calibrated with to prevent inadvertent mixing of. probes and indicators.
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_ _ _ _ _ _ - _ _ - ) Electrical Maintenance MTE Storage Facility I*' A walkthrough inspection of the electrical MTE storage facility was
peiformed with a QC Surveillance Supervisor.
The facility was well organized, neat, and clean.
The facility attendant was knowledgeable of the facility and equipment.
The following deficiency was identified and ' discussed.
One terminal crimping tool, TB WT-021, selected at random, in the presence of the QC inspector and Toel Maintenance Clerk-was found broken.
The crimping tool ratchet spring was loose and prevented the tool from ", ratcheting.
The calibration requirement for the tool is addressed by MP E-54.8, " Calibration of Crimping Tools," Revision 1.
A reccrd search indicated that the tool was last used on safety-related work request C0070675, activity 1, on 3/28/90.
Discussions with the tool clerk
indicated that in some cases MTE could have been used in the shop (to j < make extension cords, inspectors quest oned the adequacetc) without go ng throu i return process.
The of M TE control with mechanical maintenance management and based on t ese discussions, consideredthecontrolofM&TEinthisfacIlityaweakness.
The licensee
subsequently issued Action Request A0211834 to document the deficiency.
The tool was tagged and removed from service. Quality Evaluation Q0008224 was issued to evaluate the deficiency and address the potential for . inadequate control of M&TE within the facility. The licensee stated that ' they were recalling all keys to the facility and would rekey and reissue keys to insure adequate control.
The inspector reviewed work request i C0070675, activity,1, and determined that QC had hold points that enveloped ' all uses of the crimping tool for the safety-job. QC hold points were , established and properly signed of f for verifying the crimping tool ! was correct and in calibration, witnessing the crimping, and inspecting
i the crimped connection.
The inspector considered that the licensee took ! appropriate action.
Based upon the results of the above inspections, it was clear to the a inspectors that the licensee needs to pay more attention to the actual '
conditions and circumstances existing in the MTE control and issue locations.
, ] 6.
Review of MTE Action Requests and Quality Evaluations { a.
Action Request A0183542 Inadequate Calibration Records f This AR, initiated on March 18, 1990, documented multiple i calibration record deficiencies. Quality Evaluation Q0007642 was i initiated on May 25, 1990 to implement corrective action <. perform a root cause analysis and The action was assigned to the
t Mechanical Maintenance Planning Group with a due date of June 26, j 1990.
No progress or action was documented for the AR or QE as of December 1990.
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-.. . . -. -- -. _ _ _ _ . ! Since the acticn was six-(6) months overdue, the inspectors held-J.
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discussions-with mechanical caintenance supervision to determine' ' what actions had been taken to: 1) correct;the specific records'
i .thathadidentifieddeficiencies(the80recordsaudited);s2) survey .. ! other M&TE quality records to identify the full scope.of the.
deficiencies; and 3) implement corrective action to prevent j ' ' ' recurrence .enance supervisory personnel were unable to provide ' , ! objectivs
- e of corrective action for-this AR.
! ! This is an additional example of probless in implementation.of-the- , i nonconformance reporting and corrective action program.
l b.
Action Request A0119306, Torque Bar Wrench Used Beyond Calibration
Due Date
This AR involved torque bars found out-of calibration during the'
i stud tensioning on steam generator 2-2 by Westinghouse. An-i out-of-call.5 ration PG&E torque bar was being used for the.
I pretension torquin Four torque bars were at the job site.. Two j Westinghouse bars,g.one out-of-calibration, one with the calibration date unreadable; and two PG&E bars, one out-of-calibration and one 4' in calibration.
The action request deferred corrective action to
} Westinghouse NCR # PEG-88-00003 and was closed on that basis. The-
NCRtechnicallyjustifiedtheadequacyof-toolaccuracybased'on- ' its use as a pt aliminary in process check.
Stud elongation was
measured by ultrasonic testing to satisfy design requirements.
, Inspectors noted that neither the AR nor the NCR addressed the { -
following i . The root cause and recurrence control for-failure to follow ' - j safety related maintenance procedures; r . l The failure of the MTE control system that allowed - i uncalibratedM&TEtobeissuedtothejob.
i The presence of three (3) tools with expired or' indeterminate - calibrationdatesonthejobsite.-
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The performance of a historical search to insure the - ! uncalibrated M&TE was not used for other safety-related-jobs.
A failure to address programmatic controls and root cause analysis may
! be contributory to recurring deficiencies.
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i Action Requests A0170122. A0170117, A0169757, A0170386, A0170368, ] c.
j AD169776, A0168780.
! The ARs involved failure to record issue of M&TE, failure to i perform required torque verifications and failure to record M&TE
used on work orders. QualityEvaluationQ0007123 was written for ' corrective action and closed on July 11 1990.
The closure was-based on Mechanical Maintenance personne,l receiving training in
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. . . i course MG 0140 and MG 0170 covering precedures AP 0752,: - l " Calibration:and Control of~ Measuring and Test Equipment: i '(Calibration of Torque Wrenches and Torque Wrench Testers."
' Electrical and Mechanical Maintenance),"'and MP M-53.1,. , ! Ig a i
The inspector reviewed both master lesson plans provided by
-
- - - training..The courses were an overview which did not:specifically ' i relate to identified deficiencies.. Because of-the number of i deficiencies (as discussed in section 2 of this report) identified'
since the training was conducted, the_ inspectors concluded that
corrective action and recurrence control was inadequate, t ! d.
Action Request A0202680 - Overtorque of. spent fuel pit pump 1-2 ' !, suction flange bolts.
' t i The bolts were torqued to 308.ft-lbs rather than the correct 250.
i ft-1bs because vendor dt..ing requirements were not incorporated . l into the work order, as re no quality evaluation was quired by procedures.' The AR stated that
} required and closed the AR on the i technical basis that discussions with the vendor indicated that the l overtorque would have no adverse'affects on the pump casing and-t j suction nozzle.
The root cause of the deficiency " failure to ' incorporated vendor requirements into work orders"'was:not
! addressed or recognized as,a quality concern requiring a quality .
evaluation.. ' . { NPAP C-12. " Identification and Resolution 'of Problems and i Nonconformances " Revision 19 section 5.4.1 a.3, requires a i QualityEvaluatIonwhenanactivityisnotperformedinaccordance i with established requirement (s) or results are unsatisfactory.
i Examples include: test failures, violation of program requirements, .;
unapproved deviations from procedures,'and failure.to meet l Technical Specificatian requirements.
! } This is an additional example of inadequate corrective action'and-recurrence control. After identification by the inspector the , t licensee concurred with the' finding and subsequently issued Quality.
, l Evaluation Q0008220 to address the deficiency. The QE appeared: ,' i appropriate to address the deficiency.
> l e.
Action Request A0184108 - Failure to perform a biennial review of Mechanical Maintenance M&TE for calibration. frequency, device , ! condition, and device accuracy.
The review was required by AP D-752, section 4.1.2.c.
The AR identified that standards M-M-36S and M-M-120 had not been reviewed i in four (4) years and that standard M-M-365 was rusted and had a scratches on surfaces that were critical to its use as a standard.
i The AR referenced Quality Evaluations Q0007873, Q0007876, and i Q0007882 and did not address corrective action for the rust problem ( with standard M-M-365.
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Action Request.A0187423 - Torque. readings during calibration and.
- testing'which varied dependent on the type of adapters:that.were c
used.
j i Various; type socket adapters'gave'different resulting torques vs-applied torque depending on the adapter used.. Tests by 1&C calibration-personnel indicated,that.the variations were app'Nobar" licable' to Snap-on,.Proto, and Williams adapters, but not with the , adapters made by the manufacturer of. the calibration laboratory , i standards.
Action taken included requiring all calibration of . torque wrenches to be.done with "Nobar" adapters, segregating all adapters with anomalies, and referring the problem to the PG&E-i Technological and Ecological Services (TES) fer analysis.- i As a result of the review of this' adapter issue.and interviews withL Mechanical Maintenance. craft..regarding the use of adapters, the .insp' crows foot" adapters.ectors identified a new concern re arding thei of Procedure M M-54.1:Rev. 5. Bolt Torquing, Paragraph 7.3.'1.a requires that if a torque multiplier, a crowfoot'or other adaptors-are to be used, the' wrench shall be calibrated with and without.the adaptor attached. However,:the-i inspector found that no equivalent requirement was' contained in Procedure AP D-4-50 " Calibration and Control of Measuring and Test ' Equipment" which controlled the' issuing of torque wrenche from the , tool room. MP M-53.1, " Calibration of Torque Wrenches and Torque Wrench Testers," Revision 5, provides'no instructions regarding i verification and re-verification when torque multipliers, special.
. adapters}ons,"and limitations for the use of adapters did not , crows feet" are used. ( Conversion-tables.
or restrict . . appear to be documented in approved procedures for use by.
l calibration'and field personnel.
Furthermore,Lin review of a ' sample of -the tool room issue logs for 1990, the inspector found'no I documentation of the dual calibration required for. issue of tor l wrenches with adaptors. :In discussions with licensee QC and. 'que maintenance ersonnel the. inspector'found that crowfoot adaptors ' were routine y used for torquing fasteners with difficult access.
However, the control established over the required calibration was-inconsistent.
The inspector expressed his concern reoarding the aparent lack of ~ . . control over the use of crowfoot adaptors to the mechanical maintenance manager.
The manager committed to correct the weakness.
, in their procedural controls and documentation, and indicated that additinnal training of maintenance personnel on the proper use of.
crowfoot adaptors would be implemented.
The inspector considered the weakness to be indicative of.a lack of attention to detail in the effective implementation of M&TE controls.
Furthermore, the inspectors found that the mechanical maintenance.
foreman was unaware of the repeated observations by QC of improper - - -.
,43 g,-eye'm z w.s - '*w*8T "8*N'#
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use of " crows foot". adapters. Despite repeated' instances in which QC corrected the improper activity in process, an AR was not initiated ' s j. t ' by QC.
The inspector found this to be an example of a weakness on the part of QC to elevate their observations of individual '
deficiencies and pursue programatic implications.
, _ _.,.. 7.
Additional Observations a.
Temperature Correction - - . = .
The inspector found that the licensee had not determined the effect , of temperature on the accuracy of torque wrenches.
Procedare NPAP D-5 " Control of Measuring and Test Equipment," Paragraph 4.2.4, I requires that when inaccuracy due to environmental effects cannot be avoided during u:2 of the equipment, correction factors shall be determined and applied. The inspector found that, although- .
+ calibrated at room temperatures, some torque wrenches had been used - in environments of 130-140F.- The licensee had not determined the'
effect of elevated temperature on the accuracy of the, torque wrench - in these applications.
In response to the inspector's concern the licensee obtained informal test results which: identified that the torque wrench did maintain its required accuracy at elevated temperatures. Further,' the licensee committed to review the adequacy of their calibration I controls for equipment used in.high temperature environments.
) The inspector found the licensee's initial actions'to be adequate.
' b.
Preformatted Data Sheets The inspector found that previous QC surveillances'had found examples of data sheets for micrometer calibrations which had been preformatted with as-found data.
Expected values of-as-found data had been typed onto a master form and photocopied in lieu of actual data measured.
In discussions with the mechanical maintenance technician who perfomed the calibration, the inspector found that the as found data had been.. prefomatted to expedite the calibration data recording by minimizing handwritter: 2ntries.
The inspector found that this practice was not authorized by procedure and that it appeared to be isolated to two micrometer calibrations.
In response to the inspector's concern the licensee indicated that the improper documentation practice had been eliminated by requiring handwritten entry of actual measured values.
The inspector found the licensee action to be adequate.
c.
Management Review of QC Findings The inspector reviewed NCR DCO-90-QA-N004 which dealt with an apparent lack of ownership of certain event-related problems which delayed corrective actions.
The' inspector found that the licensee had recently implemented daily reporting to senior plant management - -.
_ _ _. _ . - -.,. 1 of QC identified problems to assure cwnership efIthe problem was clearly assigned for timely resolution. iThe inspector observed .. - o g that the senior management level review was. informational only and: was not part of the quality program established for elevating , problems for-increased management attention.
The inspector. .._' n.. _ ' acknowledged the benefiri'ntended'by the review but cautioned
-- licensee management-to ensure that the-review did not exert undue..
influence over or be assumed to be an equivalent to, the established ~ processing of q,uality problems in accordance with program and procedure requirements.
_ d.
Computer Access E In discussions with maintenance personnel sthe~ inspector _found that some of the personnel did not have ability to personally initiate an-
AR using the licensee's computer based system.
The inspector. subsequently found that due to current system limitations, only 50% . i of department personnel had computer access authorization codes.
I Without computer access, individuals were required to notify their - foreman of deficiencies, who would subsequently initiate the AR.- The inspector expressed his concern that the current practice did not encourage problem identification nor provide feedback to the' initiator on the evaluation of the problem... The' licensee acknowledged t.se' current systen limitations ~ and committed to review the adequacy of their program for initiating ARs.
8.
Unresolved Item An unresolved item is a matter about which more infomation 'is' required to ascertain whether it is an acceptable item, a deviation, or a . violation. - An unresolved item is identified on'page six. (6),' paragraph (4) of this inspection report.
' ' 9.
Exit Interview Theinspectorsmetwi{h'licenseemanagement'denstedinParagraph1on December 21,'1990 and January' 11,1991.- The scope of the inspection and findings were discussed.
The licensee acknowledged the findings and cowiitted to complete their review of the identified deficiencies in.
the centrol of M&TE under MCR #DCO-90-P9f-N089 by 2/28/91. with any corrective actions identified and initiated by 3/31/91.. , R r . ... .. . .. - -
-. . - . .. - - - - -. - _. . _ - _ . . ATTACHMENT A . . PERSONNEL-CONTACTED Licensee Personnel: j l
- J. Townsend, Vice President, NPG, Plant Manager.
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- W. Barkhuff, Quality Contr 1 Manager
- T. Bennett, Senior Power Production EngineerMechanical Maintenance Department
- C. Seward,11, Regulatory Cc s11ance Engineer
<
- M. O' Con -
- R. Willis, Mechanical Maintenance General Foreman
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- M. McCann, I & C. General Foreman
- D. Carver, I & C, Supervising Technician R. Cramins, QC, Verification Section ' pervisor:
i J. Griffity, QC Surveillance SupervisorK. Mcdonald, QA, Auditor ' Sen R. McVicker, A. Celino, Machinist J. Strahl, Mechanical Maintenance Foreman i , R. Howard, Electrical Foreman J. Guyette, Tool Maintenance Clerk
J. Bonner, QC specialist l '
- B. Griffin, Asst. Plant Manager, Maintenance Services
,
- A. Young, Sr. QA Supervisor
Attended exit meeting - NRC Personnel:
- P. Narbut
- K. Johnston
, ' u The inspectors also held discussions with other licensee and contractor personnel during the course of the inspection.
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- ATTACHMENT B <- DOCUMENTATION AND PROCEUUkES REVIEWED AP C-4053,: Revision 14, Use of PIMS Work Order Module-AP D-450, Revision 4, Calibration and' Control of Measuring'and Test Equipment q AP D-752, Revision 10, Calibration and Control of Measure and Test' Equipment < l (Electrical and Mechanical Maintenance) NPAP A-802, Revision 5, Quality Control Department Stop Work uthority [ . NPAP D-5, Revision 6, Control of Mechanical, Electrical' and Instrument and.' Control Measurement, Test and Performance Monitoring ~ Equipment. i NPAP C-12, Revision 19, Identification and Resolution'of Problems and Nonconformances \\ t QAP-12A, Revision 8/29/89, Control and Calibration of Measuring and Test-Equipment QAP-128. Revision 11/10/89, Control and Calibration'of. Performance MonitoringL Equipment . l MP M-53.1, Revision 5, Calibration of Torque Wrenches and Torque 'in'ich ,i . -, testers MP M-53.2, Revision 3, Calibration of Dutside and Depth Micrometers'
MP M-53.3, Revision 2, Calibration of Bench Scale With Single 8eam MP M-53.4, Revision 0, Calibration of Hydraulic Torque Wrenches FSAR Section 17.7, Revision 1, Control.of Purchased Material,LEquipment.-and w l Services ! FSAR Section 17.12, Revision 1, Control' of Measurina.and Test Ec;.:ipment - IEEE Std 498, 1980, Requirements for the Calibration and Control of Measuring and Test Equipment Used in the Construction and Maintenance of-Nuclear Power ' Generation Stations ' S 45.2, 1971, Quality Assurance Program Requirements for Nuclear Power' ANSI N45.2.8, 1975, Supplementary Quality Assurance Requirements for the Construction Phase of Nuclear Power PlantsInstallation, Insp _
ANSI N18.7 OperationalPhaseofNuclearPowerPlants1976, Administrative Controls and Q I . 4 }}