IR 05000280/1990010
| ML18153C193 | |
| Person / Time | |
|---|---|
| Site: | Surry  |
| Issue date: | 04/11/1990 |
| From: | Jape F, Jury K, Moore R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | |
| Shared Package | |
| ML18153C192 | List: |
| References | |
| 50-280-90-10, 50-281-90-10, NUDOCS 9004240444 | |
| Download: ML18153C193 (8) | |
Text
Report Nos.:
UNITED STATES NUCLEAR REGULATORY COMMISSION
REGION II
101 MARIETTA STREET, ATLANTA, GEORGIA 30323 50-280/90-10 and 50-281/90-10 Licensee: Virginia Electric and Power Company Glen Allen, VA 23060 Docket Nos.:
50-280 and 50-281 License Nos.: DPR-32 and DPR-37 Facility Name:
Surry 1 and 2 Inspection Conducted~ 5 - 9, 1990 Inspectors~
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K. Jury 1/&'IIY {}
Date Signed
'I /10 /20 Date Signed SUMMARY Scope:
This routine, unannounced inspection was conducted in the areas of licensee quality verification activit Results:
_ In the areas inspected, violations or deviations were not identifie The technical quality of QA audits has gradually improved over the previous two year Audits are more technically based and routinely use technical specialist The audit finding closure process now verifies effectiveness of implemented corrective action Trending activities have been implemented which increased the licensee ability to identify plant problem The categorization of trend information, analysis of trends, and effectiveness verification of corrective action for adverse trends required further developmen In 1989, several station level self-assessment programs were initiated. These programs contributed to a substantial increase in licensee self-assessment capability and demonstrate management emphasis on improved performanc *
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REPORT DETAILS I.Persons Contacted Licensee Employees *W. Benthal, Supervisor, Licensing
- R. Bilyeu, Licensing Engineer P. Detine, Supervisor, Quality Performance D. Erickson, Superintendent, Health Physics
- E. Grecheck, Assistant Station Manager
- D. Hart, Supervisor, Quality Audits M. Kansler, Station Manager
- T. Kendzia, Supervisor, Safety Engineering.Nuclear
- R. MacManus, Supervisor, Engineering Programs J. McCarthy, Superintendent, Operations D. Miller, Radiological Engineer F. Nowak, Engineer, SEN J. Ogren, Superintendent, Maintenance A. Price, Supervisor, Quality Assurance
- G. Smith, Manager, Quality Assurance T. Sowers, Superintendent, Engineering Other licensee employees contacted during this inspection included, engineers, mechanics, technicians, and administrative personne *NRC Resident Inspectors
- B. Holland, Senior Resident Inspector
- J. York, Resident Inspector
- Attended exit interview Inspection of Quality Verification Function (35702)
The purpose of this inspection was to assess the licensee self-assessment or quality verification activit In the context of this inspection report, se 1 f-assessment and quality veri fi cation are synonymous and represent the capability of the licensee to self-identify and correct functional and programatic deficiencie Licensee self-assessment of Surry includes the traditional QA organization audit and surveillance activities, performance based observation of routine activity, quarterly self-assessments, and functional area internal self-assessment activitie Overall the traditional QA activities have improved, particularly the corrective action closure process for QA finding In conjunction with self-assessment activities initiated in 1989, the licensee self-assessment capability has improve Due to the short implementation period for the newer activities, their impact on improving plant performance was not yet eviden Quality Assurance Auditing In order to assess the QA organization's effectiveness in identifying safety-significant technical issues and timely resolution, the inspector reviewed selected audits, procedures, and trending data, as well as conducting interviews with QA management and line personne The QA auditing organization has taken significant steps to implement a performance-based QA function at the sit Audits were more comprehensive and utilized increased technical expertis Eight audits performed in 1989 used technical specialists. Audit findings and escalation activities were trended, QA verified effectiveness of corrective action implementation prior to closeout of findings rather than merely verification of correction performance. These activities demonstrated an overall improvement in QA audit activit However, some elements of the audit activity required further improvemen As discussed in the following paragraphs, audits lack documented qualitative analysis of audited activities. Additionally, although management involvement has resulted in a decreased utilization of the QA audit finding escalation process, the number of audit findings presently involved in the escalation process demonstrated that problems with station and corporate responsiveness are not fully resolve The licensee's corrective action and QA audit program are delineated in Nuclear Quality Assurance Standards NODS-QA-DI, Revision 4, and NODS-QA-02, Revision 4 respectivel To assess the licensee's auditing effectiveness, two recently completed audits, S89-09 lnservi ce Inspection, and S90-0l Emergency Preparedness, were reviewe The ISi audit, which utilized a technical specialist, was a comprehensive, technical audit. Although the audit was an improvement over previous years' audits, neither the audit report nor the checklist consistently provided qualitative result For example, the report and checklist wotild document that procedures and activities were reviewed or audited, yet they did not contain ~ssessment of their adequac Qualitative analysis is an essential element of a performance based audit, as well as an essential feedback to management for resource allo~ation. * Review of a~dit checklists indicated that in some cases analysis was performed, however this was not documented in the audit repor It was not evident therefore if this performance analysis
- was communicated to managemen The Emergency Preparedness audit appeared to be a thorough, well-conducted audit although it also lacked the qualitative analysis. With the exception of non-documented qualitative analysis, audit performance has improved at the sit As part of the QA organization's emphasis regarding effective and timely corrective action implementation, CAR's are utilized to
~ddress deficiencies in this proces A CAR is an audit finding or observation which has been escalated due to untimely response or corrective action, inadequate response, and/or ineffective corrective actio Audit findings, as well as CARs, are closely tracked by Q Reports and trend data are issued to site and corporate management partially as a result of QA management organizational change *
The rate at which CARs were written had increased fo 11 owing QA management changes in 198 The increase was representative of more technical findings requiring more complex resolution, QA requiring timely and thorough responses to findings, and QA now verifying corrective action effectiveness prior to finding closur In late 1989 and early 1990 QA issued several memorandums to management regarding the high number of escalations due to inadequate response or corrective action performance by responsible station or corporate organization Subsequently, management issued notifications to station and corporate organizations emphasizing the need to respond adequately to QA audit findings thereby preventing the initiation of the escalation or CAR proces The decline in the number of CARs issued following this action indicated that management involvement provided a positive impact on station performance in this are The continued utilization of the escalation process however demonstrated that station and corporate responsiveness to QA audit findings requires continued attention and improvemen Trending Trending activity at Surry was performed separately for QA corrective action requests (CARs) and station deviation reports (SDRs).
A program to trend QA audit findings was to be implemented in April, 199 Review of current trend activities included the Fourth Quarter 1989 CAR Trend Report and 4 recent SDR Trend Report In general,
collection of information for both trending activities was well developed; however, analysis of trends and feedback from corrective actions was not fully effectiv The 4th Quarter CAR report provided for each CAR:
the level of escalation, escalation or1 issuance reason, department responsible, explanation, and statu Additionally, there is a breakdown of CARs by responsible department, by cause, and by mont This information and data was useful for individual CAR summarization as well as intradepartmental us However, the only data on which analysis was performed was esca 1 ati on reaso Apparently, there is no trend analysis performed by sµbject area, interdepartmental causal
~elationships, nor a qualitative assessment of escalation reason This analysis could provide management more useful information to iriitiate effective corrective action and correct adverse trends. The audit finding trending which is to be implemented in April, 1990, may be the appropriate mechanism to accomplish this more comprehensive analysis. A potential weakness of this new trending activity is that the group within QA who is to perform the trending function is not directly involved with the auditing activity. The audit group, which initiates the finding, assigns root cause, and closes the finding will not be involved in this trendin More effective trend analysis could be achieved if the trending function was accomplished by the auditing group due to their greater familiarity with identified issue **
Station deviation report trending was performed on a quarterly basis until November 1989, at which time the frequency was changed to monthl This trending has been providing management with an abundance of data regarding the number of SDRs written in a specific are SDRs were categorized in the trend reports by general cause, type, and subject are The December 1989, SOR Trend Report listed 23 apparent trends, demonstrating the licensee was collecting SOR trend information and had established a method of categorizing this informatio The large number of trend categories and variety of information evaluated indicated that further refinement of trend identification methodology was required for more definitive problem identification via trend informatio Analysis of SOR trends and corrective action effectiveness verification was not consistently performe For example, there was no analysis evident of the previously referenced 23 apparent trends based on safety significance or root cause of the trend. These trend categories included inadequate pump and valve maintenance and repetitive SDRs on charging and boric acid pump There was no clear feedback mechanism established to correlate the effectiveness of initiated corrective actions on adverse trends i.~.
no requirement for an evaluation of corrective action effectivenes For example, the December 1989, SOR Trend Report recommended a review of programs implemented to reduce personnel error related SDR There was no documentation demonstrating this effectiveness review was conducted, indicating the lack of a feedback process within the trending activit This is sim-ilar to a previously identified weakness in the QA corrective action process which closed a QA finding following implementation without verification of the effectiveness of the corrective action in correcting the adverse conditio As previously discussed (~aragraph 2a), this we~kness was adequately addressed in the QA corrective action process *. As the trending activities are also problem identification and correction activities, a feedback mechanism fs also an essential element of this proces In conclusion, trending activities have been implemented at Surry and provide an additi ot1al element of the station self-assessment capability. A considerable amount of information is being collected and trends are being identifie It was not clear that the information was being categorized in a manner to most effectively identlfy adverse plant condition For those trends identified, analysis was not consistently performed, and for corrective actions implemented there was no apparent feedback mechanism to verify the effectiveness of corrective action **
_,:: __
5 Overview Self-Assessment Activities Self-assessment activities encompassing all plant functional areas included Performance Based Surveillances (PBSs) and Quarterly
. Self-assessment The PBSs consist of peer level review of routine plant activities by a functionally independent grou The peer level surveillances were performed by a section of the QA organization. The group focussed on a functional area such as Maintenance, Operations, or Health Physics, for a period of time, occasionally up to six weeks, observing routine activitie Review of PBS documentation and discussion with responsible QA personnel indicated the focus of the surveillances was work practices not compliance to plant commitment The PBSs provided a detailed review of a particular activit Conclusions generally related to job hindrances, procedure deficiencies, human factors problems,
. hardware deficiencies and work practice The surveillances made no distinction between safety related and non-safety related activitie No overall assessment of performance was made regarding conformance to plant, industry, or regulatory requirement The purpose of this surveillance activity appeared to be the identification of working level obstacles to effective task performanc This performance based activity provided a process level review rather than product level review of functional area activities. In this regard the PBSs expand the potential for identifying performance problems and therefore provide an element of the licensee self-assessment capabilit An overview self-assessment of licensee activities was accomplished
- by the Quarterly Self.;.Assessment A corporate level procedure, NODS-ADM-16, Self-Assessments of Corporate and Station Functions, Revision 0, was issued August 1, 1989, to provide guidance for this routine self-assessment activity. The first assessment performed was for the fourth quarter of 1989 and was based on INPO performance objectives and criteri This was a two week, nine member team performance based inspectio Review of the inspection report indicated this was a thorough review of plant.activities in all functional area The methodology and format of the quarterly self-assessment will vary to provide different assessment perspective For example, the fourth quarter 1989 assessment emulated the INPO assessment methodology, the first quarter 1990 assessment included SALP format and methodology and will encompass a review of all
$tation and corporate audit findings, deficiency reporting systems, observation activities, violations, and INPO findings to identify performance trend The quarterly self-assessment program provides an additional element of licensee $elf-assessment capability and improved potential for self identification of problem **
6 Functional Area Self-Assessment Activity The inspector also reviewed self-assessment within the functional area The level of internal self-assessment activities varies for each are Discussions with management personnel and review of policy documentation demonstrated management's emphasis on self-assessment at all levels of plant activit Engineering self-assessment activities include six month post-implementation modification reviews, outage critiques, evaluation of modification field changes and a Management Problem Review Team (MPRT).
These activities provide various levels of engineering self-assessmen The MPRT conducted routine reviews of plant problem reports PPR Inadequate control of these corporate generated prob 1 em reports was i den ti fi ed as a weakness in the previous SALP report (NRC Inspection Report No. 50-280,281/89-16).
Review of the MPRT meeting notes dated February 23, 1990, indicated improved control and management involvement in the PPR process *
Post implementation reviews examine the effectiveness of modifications in resolving the original proble Field change evaluations attempt to identify deficient performance in the design development proces An Engineering Quality Plan dated January 10, 1990, initiated a policy of proactive self-assessment activity within Engineerin Engineering supervisor performance goals include development of self-assessment methodology in 199 Within this functional area the present self-assessment activity is limited in scop Initiatives to promote development of internal self-assessment activities demonstrate an awareness of the need for proactive self-assessment in Engineerin Self-assessment of th~ operati~ns and maintenance functional areas was accomplished primarily by the QA organization mechanisms rather than internal activity. Other than the check operator program, which is an ongoing* peer level review of routine operations activities, operations did not utilize_ any routine self-assessment activitie Maintenance initi~ted a barriers program in 1988 which identifies barriers to maintenance task performance *
. Health Physics developed a comprehensive internal self-assessment program during 198 Procedure HP-10.0.10, Radiation Protection Surveillance and Evaluation Program, dated September 19, 1989, established the requirements, methods, and responsibilities for thfs self-assessment progra Each Health Physics program e.g., ALARA, Contamination Control, Radioactive Effluent, etc., has a procedure addressing program evaluatio Each distinct HP area was required to be evaluated annuall Review of evaluation procedures. and documentation of evaluations indicated this self-assessment program provided an effective mechanism for evaluation and improvement in plant Health Physics activitie v
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In conclusion, the licensee has increased their self-assessment capability during 198 The quality of-QA Audit and corrective action activity has improved and new self-assessment programs outside of the traditional QA functions were initiate At this early implementation stage, the impact of these programs on overall plant performance improvement was not yet eviden The improvement of existing quality verification activities, initiation of new programs, and ongoing development of functional area self-assessment activities demonstrates management's emphasis on improving plant self-assessment capabilit.
Exit Interview The inspection scope and results were summarized on March 9, 1990, with those persons indicated in paragraph The inspectors described the areas inspected and discussed in detail the inspection results listed belo Proprietary information is not contained in this repor *
Dissenting comments were not received from the licensee.