IR 05000293/1987020
| ML20214S119 | |
| Person / Time | |
|---|---|
| Site: | Pilgrim |
| Issue date: | 05/28/1987 |
| From: | Eapen P, Hunter J, Napuda G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20214S104 | List: |
| References | |
| 50-293-87-20, NUDOCS 8706090140 | |
| Download: ML20214S119 (8) | |
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U.S. NUCLEAR REGULATORY COMMISSION
REGION I
Report No.
50-293/87-20 l
Docket No.
50-293 License No.
DRP-35 Licensee:
Boston Edison Company M/C Nuclear 800 Boylston Street Boston, Massachusetts 02199 Facility Name:
Pilcrim Nuclear Power Station Inspection At:
Plymouth and Braintree, Massachusetts Inspection Conducted: April 27 - May 1, 1987 Inspectors:
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'G.gNapuda, Lead Reactor Engineer (ate /
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QA3, OB, Division of Reactor Safety
Y?h7 G M dnter, III, Reactor Engineer d' ate AS, 08, Division of Reactor Safety Approved by.
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2 th h Dr. P. K. Eapph, Chief, date v
Quality Assurance Section, 08, Division of Reactor Safety Inspection Summary:
Routine unannounced inspection on April 27 - May 1, 1987 (Report No. 50-293/87-20)
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Areas Inspected: Quality Aesurance Program for corrective action, QA/QC overview and management involvement.
Results:
No items of noncompliance were identified.
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C706090140 870528 PDR ADOCK 05000293
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DETAILS 1.0 Persons Contacted Boston Edison Company M/C Nuclear M. Andrews, Quality Control (QC) Engineer - Quality Assurance Department (QAD)
- S. Bibo, Audit Group Leader (Acting) - QAD
- F. Famulari, QC Group Leader - QAD
- T. Ferris, Licensing Engineer
- P. Hamilton, Compliance Group Leader (Acting)'
J. Howard, VP - Nuclear Engineering and Quality Assurance
- S. Hudson, Operations Section Manager G. Kelly, QC Engineer - QAD A. Marquardt, Consultant (Quadrex Corp.)
- C. Mathis, Deputy to VP - Nuclear Engineering
- F. Schellenger, Quality Engineering Group Leader - QAD
- R. Sherry, Chief Maintenance Engineer R. Swanson, Nuclear Engineering Department Manager United States Nuclear Regulatory Commission (USNRC)
- T. Kim, Resident Inspector
- Denotes those present at the exit meeting held on May 1, 1987.
During the course of the inspection, other licensee technical, operations, I
QA/QC and administrative personnel were contacted.
2.0 Corrective Action Program 2.1 Program Implementation The basic requirements for implementing a corrective action program are described in 10 CFR Appendix B, Critu.ia XVI; ANSI N18.7-1976 and the Boston Edison Quality Assurance Manual (BEQAM) Volume II. The inspector reviewed the licensee's program and procedures listed in Attachment A, with an emphasis on the Nonconformance Report (NCR)
process, and verified that controls:
Ensure problems are reported to appropriate management levels
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and to the NRC, when required.
l Establish actions and responsibilities to resolve problems.
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Prioritize problems by safety significance.
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Establish a formal followup of corrective action.
Require consideration of potential generic concerns and root
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causes.
The ' inspector reviewed the NCRs listed in Attachment A, that were generated by Quality Control (QC) personnel during inspections and observations for completeness, proper significance determination, disposition, Quality Assurance (QA) and Engineering involvement and approval and closeout.
2.2 Findings and Conclusions The licensee uses at least five different methods to initiate corrective action and evaluate problems.
A licensee contractor (Raytheon Service Company) performed a Corrective Action Systems Evaluation and presented their results and recommendation to the licensee on April 15, 1987.
The licensee was in general agreement with the recommendations and the need for - continued attention to develop a more streamlined corrective action system. As a result of the Raytheon evaluation and the licensee's dedication to develop a more efficient and effective system, licensee management created a Corrective Action Task Force. This task force would consist of QA, Engineering and Operations personnel.
The Task Force will be responsible for enluating and incorporating the recommendations of the Raytheon study into a more streamlined and workable corrective action system. The final selection of the task force members has not yet been accomplished. The adequacy and timeliness of the improve-ments to the corrective action system will be reviewed in future inspections.
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While reviewing the NCRs, the inspector noticed many inconsistencies in determining the significance of the problems.
Like NCRs would one day be marked significant and the next day marked not significant.
The Quality Control (QC) personnel making the determinations were not consistently evaluating the significance of the NCRs in accordance with procedures. The licensee, prior to this inspection,
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identified that the BEQAM and procedures N0P83A14 and NOP83A9 required that all NCRs for installed equipment be classified significant.
The fact that some of these NCRs were not marked
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significant further demonstrates that the QC personnel were not aware of or did not understand procedural requirements controlling the NCR process.
Upon identifying the discrepancies the licensee initiated action to revise the BEQAM and applicable procedures
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to clarify the determination of significance as it applies to reporting requirement [
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The determination of significance of the NCRs is important because it drives the Management Corrective Action Request (PCAR) process which provides a means to evaluate rcot causes and determine i
appropriate actions to preclude recurrence. The MCAR is requirtd to be generated for all NCRs marked significant. Upon identifying that all NCRs written for installed equipment should have been significant and therefore had an MCAR initiated, the licensee wrote an MCAR for the NCRs generated since September 30, 1986 (when the procedure went into effect). Subsequently, a change to the BEQAM was initiated and the MCAR was not issued pending revision of the BEQAM and applicable implementing procedures.
The change
.o the BEQAM will clarify that only NCRs reportable per 10 CrR 50.72/.73 or potentially reportable per 10 CFR 21 are significant under the reportability category.
During discussions with the 1.censee management on this subject the QC Group Leader also committed to review all NCRs generated since January 1,1986 to ensure that the correct significance determination was made and that MCARs were written when required. Any misclassi-fication made by QC will be changed and the appropriate actions will be taken to initiate root cause analysis through the MCAR process.
The NCRs reviewed by the inspector were generally complete, adequately dispositioned and they received the required QA and Engineering review and approvals. Those NCRs marked significant were being tracked by the MCAR process and in some cases also by the
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Failure and Malfunction (F&MR) process.
Those improperly marked as not significant will be reviewed as mentioned above.
The inspector determined that in two instances, for NCRs86-132 and 86-126, no significance or potential 10 CFR 21 reportability determinations were made.
These NCRs were closed out by the licensee.
The inspector verified that each NCR was adequately evaluated and tracked for root cause analysis and prevention of recurrence. Therfore, the above are considered isolated cases since the other NCRs reviewed were complete.
The inspector determined that procedures N0P83A14, QAD15.01, N0P83A9 and possibly others have not been updated to reflect past organiza-tional changes.
As a result certain organizations were not quite sure of their responsibilities in the corrective action process. The process of review of NCRs for initiation of F&MRs was also not *11 defined.
While reviewing the BEQAM, Section 16, Corrective Action, the inspector determined that action 16.2.6 required the deparneat which originates an F&MR to also evaluate each condition to determine significance.
The BEQAM goes on to define the term significant and lists conditions adverse to quality which are significant.
The Nuclear Operations Procedure 8305, Ju w 2, 1984, requires that the definition of significant from the PEQAM be used for evaluating F&MRs.
The Nuclear Operation Department Pi grim Nuclear Power Station Procedure 1.3.2.4, Failure and Malfunction
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9 Reports, since September 19, 1986, however, utilizes INP0 Sigr.ificant Screening Criteria to determine significance.
This item is unre-i solved pending licensee assessment of (1) the adequacy of the INP0 criteria versus the BEQAM significance criteria and (2) consistency between the BEQAM and the applicable procedures to reflect the method being utilized to determine significance.
(50-293/87-20-01)
Based on the review of the NCRs and discussions with the licensee, the inspector concluded that the licensee's management is involved in assuring quality as evidenced by the dedication to develop a more efficient and effective corrective action system and the plan to review those NCRs generated since January 1, 1986 to ensure proper significance determination and root cause analysis.
However, licensee management attentien is required to improve the quality of QC personnel training so that QC could be more effective in evaluating the significance of an NCR.
3.0 QA/QC Involvement and Overview Various staffing charts, schedules, plans, logs and reports were reviewed to assess the adequacy of QA/QC staff. The licensee actions to assure adequate QA/QC overview during peak work loads (e.g.
during the current outage) were discussed with onsite and offsite management.
The Quality Assurance Department (QAD) consists of a Quality Engineering
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Group, and an Audit Group located at the offsite corporate offices; and, a Surveillance Monitoring Group and an Operations Quality Control Group located onsite. The supervisors (Leaders) of each group report to the QA Manager who reports directly to the Vice President-Nuclear Engineering and Quality Assurance.
The Quality Engineering Group's responsibilities include vendor control and review of documents such as purchase orders and procedures.
The Audit Group conducts internal offsite and onsite audits required by the Technical Specifications and QA program. The Surveillance Monitoring Group conducts a second level of review / observation of selected ongoine activities associated with plant operations.
The Operations Quality Control Group is concerned mainly with first level examinations /
inspections but also conducts surveillances of ongoing activities such as the Diesel Generator overhaul and breaker maintenance performed by contractors.
The Quality Engineering Group uses contracted services for audits /
surveillance of vendors as a supplement to its staff. An example of this was the audit (87-23) for the manufacturer of the Emergency Diesel Generators.
The schedule for this audit was advanced by seven months shortly after the group became aware of deficient parts supplied by this vendor.
This audit was a comprehensive review of the vendor's manufact-uring process, engineering change controls and implementation of their commercial quality assurance program and it resulted in a number of findings. Corrective actions for these findings were being requested from
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the vendor using the Surveillance Finding Report (SFR) system of corrective action. The QE group is on distribution for issued corrective action documents such as Material Receiving Inspection Reports (MRIRs) and Nonconformance Reports (NCRs). These documents are analyzed and filed as appropriate in specific vendor folios and the information is used for decisions such as retention on the approved supplier listing and additional auditing or surveillance.
The Audit Group has in plemented innovative Systems Function Audits, patterned after the NRC Safety System Functional Inspection (SSFI)
technique.
Two of three such audits scheduled for 1987 have been completed and the goal is to conduct four annually. Another enhancement to the audit process is the use of the American Society of Quality Control (ASQC) Matrix of Quality Program Elements beginning with the 1987-88 cycle.
This matrix is based on the technique of auditing a given functional activity / area using selected checklist attributes / char-acteristics from appropriate quality elements.
The Surveillance Monitoring Group was recently established to improve the effectiveness of the QA/QC overview effort.
This second level overview effort follows the basic premises of this function in that the personnel represent a broad spectrum of expertise, including operational experience, and the staffs time is dedicated to observation / review of ongoing activities. A schedule has been developed 4.nd implemented.
However, it does not exclude the performance of " moment of opportunity" (unscheduled)
monitoring of any desired activity.
The Operations Quality Control Group conducts first level examinations, inspections and/or observations of specific work and certain second level surveillances.
Inspection points are not normally inserted into work instructions / procedures but this desirable practice has recently been instituted for work associated with the overhaul of
"B" Emergency Diesel Generator.
Normally, work requests are reviewed and selected ones are annotated to notify QC prior to the start of work.
Inspection is then accomplished using checklists or the selected instruction work steps. The group staff has been augmented by 29 contracted persons for the current outage to provide adequate first level overview of the scheduled work.
Also, since the start of tnis outage, at least one QC inspector was assigned to each backshift when there was work activity.
3.1 Findings and Conclusions The Quality Engineering Group is fulfilling its responsibilities adequately. A positive indicator is the timely reaction to problems with the Commercial Grade Emergency Diesel Generator replacement parts supplied
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by the vendor, t
The innovations to the audit program aid to improve the effectiveness of
this third level overview effort.
Those audit checklists reviewed exhibited a comprehensive approach.
The reports were explicit and
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well written, and corrective action was adequate and timely. A noteworthy program feature is the liberal use of technical specialists.
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The Surveillance Monitoring Group is the most significant enhancement made to the overall QA/QC overview effort. The dynamic aspects of this second level overview effort when coupled with the full-time dedication of sufficient staff are adequate to improve the effectiveness of day-to-day QA/QC overview.
The level of QC overview was commendable and their presence was readily noticeable during most activities.
Their awareness of work status, types of identified deficiencies and problems, and corrective action followup l
demonstrated experience, knowledge and dedication to quality.
Management involvement and support was evident by the commitment of resources and program enhancements.
The QA/QC overview effort is on a positive trend and ongoing management involvement and support assure further improvement.
No violations were identified.
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4.0 Unresolved Items Unresolved items are matters about which more information is required in order to ascertain whether they are acceptable, deviations or violations.
An unresolved item is discussed in paragraph 2.
5.0 Management Meetings Licensee management was informed of the scope and purpose of the inspection at the entrance meeting conducted April 27, 1987.
The findings of the inspection were discussed with licensee representatives during the course of the inspection.
An exit meeting was conducted on May 1, 1987 at the conclusion of the inspection (see paragraph 1 for attendees) at which time the licensee management was informed of the inspection results.
At no time during this inspection was written material provided to the licensee. The licensee did not indicate that proprietary information was involved within the scope of this inspectio ATTACHMENT A 1.0 References / Requirements 10 CFR 21, 10 CFR 50.72, 10 CFR 50.73 10 CFR 50, Appendix B Boston Edison Quality Assurance Manual, Volume II ANSI N18.7-1976, QA for the Operations Phase of Nuclear Power Plants Regulatory Guide 1.33, Revision 2, QA Program Requirements (Operation)
2.0 Procedures NOP83A14 Nonconformance Report Process, October 18, 1986 N0P83A9 Management Corrective Action Process, September 30, 1986 NOP8305 The Failure and Malfunction Report Process, June 2,1984 N00 1.3.24 Failure and Malfunction Reports, September 19, 1986 and January 22, 1987 QAD 15.02 Preparation of Failure and Malfunction Reports, March 28, 1986 QAD 15.01 Control of Nonconforming Material, November 1, 1985 QAD 16.06 Evaluation of Significance, September 30, 1986 QAD 16.07 Management Corrective Action Request, March 28, 1986 3.0 Nonconformance Reports87-125, 124, 123, 122, 126, 121, 119, 118, 117, 116, 114, 113, 111, 86, 82, 55, 54, 223, 222, 221, 220, 219, 217, 216, 212, 207, 204, 202, 195, 193, 137, 80 and 185 86-132, 126 and 72 4.0 Management Corrective Action Reports 87-04, 09, 10, 12, 13, 14, 15. 16, 17, 18, 19 and 20 5.0 Office Memorandums QAD-87-518, Corrective Action Task Force Weekly Progress Report, April 24, 1987 NTSM-87-53, Corrective Action System Meeting Minutes, April 16, 1987 QAD-87-514, MCARs Issued for Every NCR for Installed Equipment, April 22, 1987 187-69, MCAR 87-004, April 2, 1987 i
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