IR 05000285/1998002
| ML20217D456 | |
| Person / Time | |
|---|---|
| Site: | Fort Calhoun  |
| Issue date: | 03/25/1998 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20217D423 | List: |
| References | |
| 50-285-98-02, 50-285-98-2, NUDOCS 9803300022 | |
| Download: ML20217D456 (15) | |
Text
,
.
ENCLOSURE 2 U.S. NUCLEAR REGULATORY COMMISSION
REGION IV
Docket No.: 50-285 License No.: DPR-40 Report No.: 50-285/98-02 Licensee: Omaha Public Power District Facility: Fort Calhoun Station Location: Fort Calhoun Station FC-2-4 Ad P.O. Box 399, Hwy. 75 - North of Fort Calhoun Fort Calhoun, Nebraska Dates: February 9-13,1998, with in-office inspection continuing until March 2,1998 Inspectors: L. E. Ellershaw, Senior Reactor inspector, Maintenance Branch C. E. Johnson, Senior Reactor inspector, Maintenance Branch Approved By: Dr. Dale A. Powers, Chief, Maintenance Branch Division of Reactor Safety
..
ATTACHMENT: Supplemental Information
,
!
9903300022 990325 "~
.x I
.
.
-2-EXECUTIVE SUMMARY Fort Calhoun Station NRC Inspection Report 50-285/98-02 Two NRC Region IV inspectors performed an inspection using the guidance of NRC Inspection Procedure 35701 to ensure that the licensee was implementing a quality assurance program that was in conformance with the Technical Specifications, regulatory requirements, commitments, and industry guides and standard Ooerations
-
Quality assurance organizational and program changes had been documented appropriately. The quality assurance management incumbents met the requirements for
- the positions held (Section 07.1).
. In general, findings in condition reports, quality assurance audits, and surveillance reports were appropriately dispositioned in accordance with site procedures. However, Surveillance H12-96-1, pertaining to radiation protection, was initiated in December 1995 but was never issued. This failure to properly control a planned quality assurance activity to assure that identified concerns were documented, distributed, evaluated, and resolved was a weakness (Section 07.2.2).
. The failure to ensure that a quality assurance lead auditor had completed the quality assurance auditor qualification manual prior to conducting quality-related audits was a violation of Technical Specification 5.8.1 (Section O7.2.2).
. Two examples of a violation of Technical Specification 5.8.1 were identified where the licensee failed to immediately initiate a condition report (1) the licensee's identification that a quality assurance lead auditor was not qualified in accordance with the required training program, and (2) the licensee's identification that a quality assurance surveillance report was not issued (Section 07.2.2).
. The inspectors determined from review of 3 case files that the nuclear safety concerns program had been adequately implemented for 2 of these employee concerns. In regard to the third case file, a violation was identified where the licensee failed to immediately initiate a condition report when it was identified that a surveillance report had not been issued (Section 07.2.2).
EnoineenD9
- - An observation was made regarding the methodology used for tracking assessment report findings. The methodology was not proceduralized prior to August 1997, and a potential to fail to track and evaluate assessment report findings existed. As a result of this observation, licensee management committed to conduct a review of all self assessments performed within 18 months prior to the issuance of Guideline FCSG-4,
...
P-3-
,,
.* Performance of Self Assessments." This review is to identify any failures to initiate a condition reports for assessment-identified conditions adverse to quality r
(Section 07.2.2).
e-
%
.
As.A. -
.
'.
-4 . .
Bgoort Details .
Summarv of Plant Status
. The plant operated at full power during the onsite inspection perio I. Operations 07 LQuality Assurance in Operations 107,1. Quality Assurance Prooram Review (35701)
Lac 'Insoection Scooe The inspectors performed a limited review of the licensee's quality assurance organization and program to determine if the February 1996 organizational and procedural changes had been correctly implemented, and if these changes were reflected in the Technical Specifications and other program documents (e.g., Updated Safety Ana!ysis Report).
l
. The review was performed by evaluating applicable documentation, and through interviews with licensee personne . Observations and Findinas
= The inspectors determined that organizational charts had been updated indicating the
. change The inspectors verified that the quality assurance management incumbents met the requirements for the organizational positions that they filled. The inspectors determined
_
that the realignments did not degrade the position functions involve The inspectors also verified that the Technical Specifications submittai for the reorganizational changes, had been sent to and ultimately approved by the NR . ' Conclusions
- The inspectors concluded that quality assurance organizational and program changes a had been documented appropriately. The quality assurance management incumbents j, . appropriately met the requirements for th'e positions that they filled.
r
. ,
.
'
.
5--
07.2 'Oualitv' Assurance Prooram imolementation (35701)
~ 07.2.1 Personnel interviews Inspection Scope The inspectors conducted interviews with quality assurance personnel, nuclear engineers, engineering personnel, and quality assurance management (current and -
past) to determine their views on the quality assurance program changes and its implementatio Observations and Findings During the interviews, the inspectors determined the following: .j
. .lt was evident that most personnel perceived the existence of past problems in the quality assurance departmen . The quality assurance organizational changes were viewed as improvements by most personne . All personnel were routinely encouraged to identify problems through the condition reporting process which, when coupled with a lower threshold, had resulted in a significant increase in the number of condition reports being issue . Support from management was generally considered good; however, in one instance regarding a fire protection audit, management was perceived by two
. individuals as not being responsive to a request for technical suppor .' The working environment in the quality assurance department was considered goo . One person indicated that findings considered important by audit team members
. were not always included in audit reports. The individual stated, however, that l none of those findings met the threshold for the initiation of condition report ]
1 Management had expressed to the quality assurance staff, their expectatior:s for E _ the quality assurance organization, and for initiating condition report ;
- The inspectors also discussed future plans and management's expectations with the current quality assurance / quality control manager. The manager presented the quality -
assurance departments "get well" plan to the inspectors, which was currently being i
~ implemented. The inspectors considered the plan to be appropriat l
.
I
!
-
<
.l
- J
,
.
-6- , Conclusions in general, quality assurance personnel viewed the quality assurance program recent organizational changes as improvement .2.2 Review of Condition Reoorts. Quality Assurance Audits. Surveillances. Nuclear Safety Concerns Proaram (NSCP) Case Files. and Assessments Insoection Scope The inspectors reviewed selected condition reports, quality assurance audits, surveillance reports, three NSCP case files, and an engineering assessment to verify the proper implementation of the quality assurance program, and to verify that NSCP concerns were being appropriately investigated, documented, and resolve Observations and Findinas faDdition Reoorts In general, the inspectors determined that condition report findings and corrective actions were appropriately identified and documented in accordance with Standing Order SO-R-2, " Condition Reporting and Corrective Action," Revision 6, with the exception of an untimely Condition Report (CR-97-00967), and the lack of a condition report for an identified discrepanc During review of Condition Report CR-97-00967, the inspectors noted that licensee training personnel had identified that a quality assurance lead auditor was not administratively qualified as required by Quality Assurance Manual QAM-13, " Training and Certification of Audit Personnel," Revision 3. The subject auditor had been independently conducting audits since August 1994. Quality Assurance Manual QAM-13, references ANSI N45.2.23-1978, and the quality assurance / quality control training program master plan, which specified the training requirements for quality assurance auditors and lead auditors. Step 3.1.1 states, in part, that auditors shall have, or be given, appropriate training or orientation to develop their competence for performing required audits. These requirements were also reflected in the quality assurance qualification manual. Completion of these requirements satisfy the initial training ]
requirements prior to independently performing auditor or lead auditor functions, and was i part of the quality assurance auditors' certification and qualification proces '
The inspectors were informed by licensee training personnel, that the quality assurance lead auditor had previously taken training from an outside source (General Physics).
This training had not been documented (waiver authorization recuest) in the training records to indicate approval by management as an equivalent substitution. The inspectors were shown the auditors' certificates of training by General Physics for the
!
l
.
.
7-courses taken. The inspectors were later provided with a waiver authorization request (dated during the inspection) that indicated quality assurance management's acceptance and approval of the General Physics training as an equivalent to the minimum core j training requirements. However, the licensee did not provide the inspectors with evidence that the auditor's qualification manual had been complets i The inspectors'
review of the auditor's records, determined no concern in regard to the auditor's qualifications to perform or lead an audit. However, as part of the qualification process, the licensee did not ensure that the quality assurance auditor qualification manual had been completed. Moreover, the licensee could not locate or find evidence that the manual had been develope !
The licensee's failure to ensure that the quality assurance lead auditor had completed the quality assurance auditor qualification manual prior to conducting quality-related audits was a violation (50-285/9802-01).
The inspectors questioned licensee training personnel about when the issue (incomplete l
auditor qualifications) was identified, and when the condition report was initiated. The inspectors were informed that this issue was identified approximately 2 months before the initiation date (August 4,1997) of the condition report. The inspectors questioned why it took so long to initiate the condition report. Training personnel indicated that the 4 quality assurance / quality control manager was notified of this issue, but did not take action because quality assurance management did not agree with the training department. The quality assurance organization concluded that the lead auditor was qualified; however, the quality assurance / quality control manager incicated to training personnel that the issue would be reviewed. During that time period, the )
'
quality assurance lead auditor performed quality-related audits. Training personnel informed the inspectors that several months had passed and a condition report had not been initiated by quality assurance; therefore, training personnel initiated Condition Report CR-97-0096 Standing Order S0-R-2 states, in part, a condition report shall be initiated immediately upon determining that any of the criteria (e.g., failures, documentation deficiencies, events identified or suspected of being adverse to quality) in Section 2.2 are me Initiation of a condition report shall not be delayed pending investigation or review of possible options for resolving the condition. Contrary to Standing Order SO-R-2, the licensee's failure to initiate a condition report in a timely manner upon identification that a quality assurance lead auditor was not qualified in accordance with the required training program was the first example of violation (50-285/9802-02).
b.2 OA Surveillance Reoorts The inspectors reviewed 3 surveillance reports. In general, the inspectors determined '
that findings within the text of the surveillance reports, were appropriately documented, with the exception of Quality Assurance Surveillance Report H12-96-1,
.
.
-8-The inspectors noted that the 1995 Master Surveillance Schedule showed that Dosimetry Surveillance Plan H-12 had been scheduled for completion in December 199 However, the 1996 Surveillance Schedule showed that the dosimetry surveillance had not been performed during December 1995. As each month went by without the surveillance being performed, a notation was made in the schedule indicating that the surveillance would be continued to the next month. The March 1996 surveillance schedule showed that the dosimetry surveillance would be rolled in;o Audit 58 (Radiation Protection and ALARA). This audit was performed during March and completed on April 1,1996; however, there was no reference to the surveillance plan requirements being incorporated therei The inspectors also noted that the surveillance schedule referred to Surveillance File Letter 96-OOA-012. The surveillance file letter, which was unsigned but dated
-
February 1,1996, stated that the dosimetry surveillance was initiated du.ing December 1995, but was postponed until January 1996. The surveillance file letter also stated that no condition reports or formal recommendations resulted from the surveillance activitie The file letter and the attached unsigned and undated quality assurance surveillance plan did, however, identify two concerns associated with the licensee's recent use of an outside dosimetry laboratory. The concerns stated that because the outside laboratory used a generic algorithm, as opposed to the site-specific algorithm, there was a possibility that radiation exposures could be higher and that management's radiation exposure goals might require an adjustment. In addition, the file letter also stated that the quality of the outside laboratory's processing might not meet mcnagement's expectations due to the high number of findings identified during the accreditation process. The file letter and surveillance plan also stated that the concerns had been discussed with cognizant management personne While the surveillance had apparently been performed, it appeared that the surveillance report had not been issued, and the two concerns were not addressed in Audit 58. The inspectors noted that the person who performed the surveillance was also the lead auditor for Audit 58. The inspectors asked licensee personnelif there was any documentation that the two concerns identified in the surveillance had ever been reviewed or evaluated to assess validity or impact. No documentation was locate l As a result of the inspectors' questioning, the surveillance-identified concerns were presented to appropriate radiation protection personnel for evaluation. A response was generated in letter to file CHP-98-015, dated February 12,1998, and signed by the I corporate health physicist. The response, while acknowledging the validity of the (
concerns, stated that both issues had been recognized during the vendor evaluation ;
process. It further stated that both issues were of no concern to the radiation protection ,
group because the vendor's generic algcrithm was well within the National Voluntary l Laboratory Accreditation Program criteria, and the vendor's history of dosimetry processing had been thoroughly evaluated during the vendor evaluation process. The response appropriately addressed the two concerns identified in the surveillance repor i
.
.
-9-Quality Assurance Manual QAM-11. " Conduct of QA Surveillances," Revision 11, addressed responsibilities, implementation, and control of surveillances. Section required that regular surveillances be planned and scheduled, and that the manager af quality assurance and quality control track and document completion of regular surveillances on a monthly basis. Surveillance H12-96-1 had been properly planned and scheduled. However, management oversight was not effective in ensuring the proper completion. The surveillance had been performed but the report was never signed by the person that performed the surveillance. The inspectors considered this failure to properly control a planned quality assurance activity (i.e., surveillance) to assure that identified concerns would be documented, distributed to cognizant personnel, evaluated in a timely fashion, and resolved, to be a weaknes Refer to Section 07.2.2.b.3 for additional discussion pertaining to Surveillance H12-96- b.3 IHLCP_ Case Files The inspectors found that the NSCP was staffed by an NSCP coordinator and a cler The inspectors were informed that most of the reviewed concems were investigated by the NSCP coordinator. However, personnel from other departments could also investigate employee concerns when assigne The inspectors reviewed three NSCP concerns and determined that the first two concerns appeared to be adequately investigated, documented, and resolved. The latter concern was related to a quality assurance surveillance report which had not been issued as discussed previously above in Section O7.2.2. The NSCP investigated this issue, and concluded that it could not be determined why this surveillance report was not issued. At no time did either the NSCP or the quality assurance organization initiate a condition report i dicating that a quality document had not been issued. Contrary to Standing Order SO-R-2, the licensee's failure to initiate a l condition report immediately upon identification that a quality assurance surveillance report was not issued was a second example of violation (50-285/9802-02).
b.4 Self-Assessment Reoort The inspectors selected assessment report, " Erosion / Corrosion Program," for evaluation in terms of assessment-identified issues / findings and followup activities. The erosion / corrosion program assessment report was dated May 2,1997, and was initiated on April 24,1997. The assessment was performed as a result of the April 21,1997, failure of the fourth stage High Pressure Extraction Steam System Elbow S-25. The licensee's assessment team consisted of personnel from Omaha Public Power District, ;
South Texas Project, Duke Power Co., Duke Engineering Co., Altos Engineering, Inc., !
and the Electric Power Research Institute (EPRI). The assessment reviewed the I licensee's erosion / corrosion program against industry standards and EPRI's Document ;
NSAC-202L, " Recommendations for an Effective Flow-Accelerated Corrosion Program," l i
Revision ,
______________J
.
.
-10-The assessment was critical of the licensee's erosion / corrosion program and concluded that the licensee consistently missed opportunities to identify high wear systems by not using the plant event database information maintained by the CHECKWORKS Users Group (CHECKWORKS is an EPRI analytical model developed for use as an aid to erosion / corrosion programs). In addition, the assessment team identified 31 recommendations and 18 finding Standing Order SO-R-2 defined what constituted conditions adverse to quality and required immediate initiation of a condition report. It was clear to the inspectors, that many, if not all of the findings, met the criteria established by the standing order. The inspectors asked the licensing representative to provide information to show that the assessment findings had been properly documented in condition reports. The inspectors were informed that the assessment findings were incorporated into existing Condition Report CR-97-00445, dated April 21,1997. The inspectors could not ascertain the identity of the assessment findings during the review of the condition report. Information about this concern was assembled into a matrix consisting of a series of action status sheets, with each action status sheet representing an identified condition. It was explained to the inspectors that the matrix was a mechanism, used by the person responsible for the condition report, to provide status and assure that each of the l identified findings would be addressed. Also, rather than listing each finding as a l separate action item within the condition report, licensee personnel stated that it was ;
appropriate to create one action item that would encompass all of the assessment report findings. This action item was identified by licensee personnel as Action item 9. The inspectors noted that Action item 9 stated," Appropriately address the findings and l conclusions of the self assessment team." Action item 9 appeared to be the only link between the condition report and the assessment report findings. The inspectors, upon further data review and telephone discussions with the responsible engineer, determined that the 18 findings identified in Report CR-97-0445 could be tracked in order for them to be properly addressed. The inspectors observed that this tracking methodology was not proceduralized. Thus, without the assistance of the responsible engineer, it was a difficult task and could allow for a failure to properly track assessment findings. The inspectors presented this information to licensee personnel as an observatio '
The inspectors became aware of a previous NRC Inspection Report (50-285/97-13)in which a violation was documented for a failure to initiate a condition report for an engineering self assessment-identified condition adverse to quality. The licensee ;
responded to the violation by letter, dated October 31,1997, and stated that
'
management's expectations were that condition reports shall be written when adverse conditions and weaknesses are identified during self assessments. The licensee also issued Fort Calhoun Station Guideline FCSG-4, " Performance of Self Assessments," in August 1997, to clarify that identified adverse conditions and weaknesses are to be documented in condition reports. The licensee's response further stated that all self assessments conducted since the issuance of the guideline in August 1997, had incorporated the guidanc ,
.
.
-11-The licensee's response was not sufficiently broad, in that, it didn't address the potential for the existence of similar conditions in self assessments performed prior to the issuance of Guideline FCSG- As a result of this observation, and in consideration with the previously identified violation, licensee management committed, during the exit meeting on February 13, 1998, to conduct a review of all self assessments performed within 18 months prior to the issuance of Guideline FCSG-4. This review is to identify any failures to initiate condition reports for assessment-identified conditions adverse to quality, Conclusions in general, the inspectors concluded that findings in condition reports, quality assurance audits, and surveillance reports were appropriately dispositioned in accordance with site procedures. One exception related to Surveillance H12-96-1, pertaining to radiation protection, which identified two concerns, but the report was never issue The failure to ensure that a quality assurance lead auditor had completed the quality assurance auditor qualification manual was a violatio Two examples of a violation were identified where the licensee failed to immediately initiate a condition report in accordance with Standing Order SO-R-2: (1) the licensee's identification that a quality assurance lead auditor was not qualified in accordance with the required training program, and, (2) the licensee's identification that a quality assurance surveillance report had not been issue The inspectors concluded from review of three case files that the nuclear safety concerns program had been adequately implemented for two of three employee concerns, in regard to the third case file, a violation was identified where the licensee failed to immediately initiate a condition report wher; it was identified that a quality assurance surveillance report had not been issue An observation was made regarding the methodology used for tracking assessment report findings. The methodology was not proceduralized prior to August 1997, and a potential to fail to track and evaluate assessment report findings existed. As a result of this observation, licensee management committed to conduct a review of all self assessments performed within 18 months prior to the issuance of Guideline FCSG- This review is to identify any failures to initiate condition reports for assessment-identified conditions adverse to qualit .3 Procedure Review (35701)- Insoection Scooe The inspectors briefly reviewed various procedures relating to the quality assurance and corrective action programs to determine their adequacy.
,. .
.. .. .. .. . .
_ - .. . _ . .
. .
.. . . .
.
. . . . . .. . .
.
.
-12-The inspectors also reviewed Procedure NOD-QP-38, " Nuclear Safety Concerns,"
Revision 3, which identified the methods and responsibilities for documenting, investigating, and resolving any nuclear safety / quality concem b. Observations and Findings in general, the procedures reviewed were determined to be adequate; however, the inspectors made two observations:
- There was no guidance on how to implement Paragraph 4.6.7, in Standing Order SO-R-2, which requires the corrective action group to provide feedback to condition report originator . Condition reports did not automatically default to the originator for revie Interviews with licensee personnel indicated that there was a chance that they might not see the proposed or completed corrective action The licensee's corrective action group was informed of these observations by the inspectors. The inspectors were informed that these observations would be reviewe With the exception of the two observations given above, the inspectors determined that NSCP Procedure NOD-QP-3B was adequat c. Conclusions From a brief seview, the inspectors determined that the quality assurance, corrective action, and NSCP procedures were adequat V. Management Meetinas X1 Exit Meeting Summary The inspectors presented the inspection results to members of licensee management at the conclusion of the inspection on February 13,1998, and on March 2,1998, by telephone. The licensee personnel acknowledged the findings presente The inspectors asked the licensee personnel whether any materials examined during the inspection should be considered proprietary. No proprietary information was identifie As a result of an observation, licensee management committed to conduct a review of all self assessments performed within 18 months prior to the issuance of Guideline FCSG-4,
" Performance of Self Assessments." This review was to identify any failures to initiate condition reports for assessment-identified conditions adverse to qualit _ _
.
.*
..
ATTACHMENT SUPPLEMENTAL INFORMATION PARTIAL LIST OF PERSONS CONTACTED Licensee R. Acker, Senior Lead Auditor, Quality Assurance R. Andrews, Division Manager, Nuclear Services G. Bishop, Acting Manager, Nuclear Assessments C. Brunnert, Nuclear Safety Review Group Specialist G. Cavanaugh, Station Licensing Engineer J. Chase, Plant Manager S. Chomos, Auditor-in-Training, Quality Assurance S. Gambhir, Division Manager, Engineering and Operations Support
. S. Gebers, Manager, Radiation Protection J. Glantz, Senior Lead Auditor, Quality Assurance A. Gurtis, Nuclear Engineer, Quality Assurance B. Hansher, Supervisor, Station Licensing R. Haug, Corporate Health Physics R. Hawkins, Senior Lead Auditor, Quality Assurance j T. Herman, Senior Lead Auditor, Quality Assurance i R. Jaworski, Manager, Design Engineering, Nuclear L. Kusek, Supervisor, Quality Control B. Lisocyj, Engineer, Station Engineering E. Matzke, Station Licensing Engineer A. Pattel, Nuclear Safety Review Group Specialist R. Phelps, Manager, Station Engineering H. Sefick Manager, Security Services D. Spires, Manager, Quality Assurance / Quality Control M. Tesar, Manager, Corrective Action Group J. Tills, Manager, Nuclear Licensing J. Zelfel, Senior Lead Auditor, Quality Assurance NBC V, Gaddy, Resident inspector W. Walker, Senior Resident inspector INSPECTION PROCEDURES USED 35701 Quality Assurance Program Review
i
.
....
-2-ITEMS OPENED, CLOSED, AND DISCUSSED Ooened 50-285/9802-01 VIO Failure to ensure that a quality assurance auditor had completed the quality assurance auditor qualification manual 50-285/9802-02 VIO Two examples where the licensee failed to initiate condition reports ,
DOCUMENTS REVIEWED Conddion Reports
- CR-97-00474 CR 96-00599 CR-97-00143 CR-96-01103 CR-96-00940 CR-96-00553 CR-96-00569 CR-96-00598 CR-96-00628 Audd Reports Quality Assurance Audit Report 58," Radiation Protection and ALARA," April 19,1996
' Quality Assurance Audit 62, " Performance Training and Qualification of Facility Staff," dated June 4,1996 Emergent Quality Assurance Audit Report Reorganization, dated July 25,1996 Quality Assurance Audit Report 49," Chemical Control," August 20,1996 LQuality Assurance Audit 45," Corrective Action," dated June 26,1997 Quality Assurance Audit Report 68," Station Engineering," October 1,1997 Quality Assurance Audit 45," Corrective Action," dated January 9,1998 Surveillance Reports M-96-1, ," Corrective Maintenance,". dated February 15,1996
' Z-96-5;" Condition Report Program," dated September 18,1996
-
..
%
.\.
.- _ _
.
.
3-H12-96-1, " Dosimetry Surveillance"
- File Letters 96-OQA-012, dated February 1,1996 CHP-98-015, dated February 12,1998 Assessments Erosion / Corrosion Program Assessment Report, May 2,1997 Procedures Standing Order SO-R-2 Condition Reporting and Corrective Action, Revision 6 NOD-QP-38 Nuclear Safety Concerns, Revision 3
,
QAM-1 Control of the Quality Assurance Manual, Revision 5 QAM-2 Control of Quality Assurance Documents and Records, Revision 13 QAM-4 Quality Assurance Training, Revision (Deleted)
QAM-11 Conduct of Quality Assurance Surveillances, Revision 11 QAM-13 Training and Certification of Audit Personnel, Revision 2 and 3 Guideline FCSG-4 Performance of Self Assessments, Revision 2 Nuclear Safety Concerns Proaram Case Files NSCP 96-0001 NSCP 97-0004 NSCP 97-0011'
Miscellaneous Master Surveillance Schedules for 1995 and 1996
Internal Audit Schedule for 1997, Revision 3 l'
i