IR 05000327/1987026
| ML20235H337 | |
| Person / Time | |
|---|---|
| Site: | Sequoyah  |
| Issue date: | 06/23/1987 |
| From: | Belisle G, Russell Gibbs, Julian C, Moore L, Runyan M, Casey Smith, Wright R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | |
| Shared Package | |
| ML20235H322 | List: |
| References | |
| 50-327-87-26, 50-328-87-26, EA-85-049, EA-85-059, EA-85-49, EA-85-59, EA-87-002, EA-87-2, NUDOCS 8707150105 | |
| Download: ML20235H337 (24) | |
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UNITED STATES o
NUCLEAH REGULATORY COMMISSION
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j 101 MARIETTA STREET, NM.
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t ATI. ANT A. GEORGI A 30323
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Report Nos.:
50-327/87-26 and 50-328/87-26 l
Licensee:
Tennessee Valley Authority 6N 38A Lookout Place 1101 Market Street Chattanooga, TN 37402-2801 Docket Nos..
50-327 and 50-328 License Nos.:
DPR-77 and DPR-79 Facility Name:
Sequoyah 1 and 2 Inspection Conducted: April 27 - May 1, 1987 Inspectors:
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I R. W. Wright 77/
M d-2 3-87 Approved by:
C.A.Juliaf2hief Date Signed
Operations Programs Branch l
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SUMMARY I
Scope:
This routine, announced inspection was conducted
.n the areas of licensee action on previously identified enforcement matters, corrective action, and licensee action on previously identified inspection findings.
Results:
No violations or deviations were identificd.
8707150105 870706 PDR ADOCK 05000327 G
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REPORT DETAILS
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Persons Contacted Licensee Employees W. Alkire, Mechanical Engineering, Division of Nuclear Engineering (DNE)
R. Bailey, Civil Engineering, DNE J. Baker, Civil Engineering, DNE j
J. Barnes, Engineering Assurance (EA) Training Staff
- B. Bates, Quality Assurance (QA) Evaluator, Division of Nuclear Quality Assurance (DNQA)
V. Bianco, Nuclear Engineering, DNE
- J. Blackburn, Manager, QA, DNQA
- C. Brimer, Assistant Project Engineer, DNE W. Brown, Mechanical Engineering, DNE T. Burdette, Special Assistant to The Deputy Manager J. Calvert, Plant Operating Review Staff (PORS) Engineer
- A. Capozzi, Manager, Engineering Assurance, DNE R. Cochran, Division of Nuclear Safety and Licer. sing (DNS&L)
- M. Cooper, Licensing Engineer, Compliance C. Crownover, Quality Surveillance (QS) Unit Supervisor
- J. Curry, Project Administrative Staff, DNE R. Daniels, Mechanical Engineering, DNE E. Doherty, EA R. Edlund, Nuclear Engineering, DNE W. Elliot, Nuclear Engineering, DNE
- H. Fisher, Modifications Section Manager, Division of Nuclear Construction (DNC)
- T. Flippo, QS Supervisor G. Gupta, Electrical Engineering, DNE
- T. Lee, Licensing Engineer, DNS&L S. Miller, PDRS Engineering Aide
- B. Patterson, Maintenance Superintendent R. Phillips, Mechanical Engineering, DNE
- H. Rankin, Manager of Projects l
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- D. Reagan, Nuclear Engineer, DNS&L R. Reeves, Electrical Engineering, DNE
- R. Rodgers, PDRS Supervisor
- R. Rudder, Project Engineering Administrative Assistant, DNE J. Smalley, QA Engineer A. Smith, Electrical Engineering, DNE
- J. Smith, Nuclear Engineer, P0RS
- R. Smith, Quality Investigations Manager J. Stitt, Condition Adverse to Quality Report (CAQR) Coordinator
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- J. Sullivan, Supervisor, PORS R. Weir, Nuclear Engineering, DNE
- C. Whittemore, Licensing Engineer, Compliance D. Widner, Modifications Branch
D. Wilson, Project Engineer, DNE Other licensee employees contacted included office personnel.
Other Organizations
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T. Disse, Stone and Webster j
i NRC Resident Inspectors
- M. Branch, Sequoyah Start-Up Coordinator K. Jenison, Senior Resident Inspector
- Attended Exit Interview Abbreviations AI
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Administrative Instruction ARPR -
Action Required to Prevent Recurrence BFEP -
Browns Ferry Engineering Project Black and Veatch B&V
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BLEP -
Bellefonte Engineer:ing Project Condition Adverse to Quality CAQ
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CAQR -
Condition Adverse to Quality Report CAR -
Corrective Action Reiquest CATS -
Commitment Action Tracking System Drawing Deviation DD
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Discrepancy Report DR
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Estimated Completion Date ECD
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Engineering Change Notice ECN
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ERCW -
Essential Raw Cooling Water Identification Date ID
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INPO -
Institute of Nuclear Power Operations LER -
Licensee Event Report MTU -
Mechanical Test Unit Nonconforming Items Report NCI
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Nonconformance Report NCR
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NQAM -
Nuclear Quality Assurance Manual Operations Engineering OE
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PGCE -
Potential Generic Condition Evaluation Problem Identification Report
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PRO -
Probable Reportable Occurrence Schedule of Activities Prior to Unit 2 Startup P-2
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Quality Control QC.
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RIMS -
Records Information Management System Sequoyah Activity List SAL
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L SCR Significant Condition Report
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SFDR -
Site Fuel Discrepancy Report SFSR -
Site Fuel Status Report SNPP -
Sequoyah Nuclear Performance Pian SQEP -
Sequoyah Engneering Procedure SQN --
Sequoyah Nuclear Facility Shift Technical Advisor STA
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TROI -
Tracking and Reporting of Open Items Tennessee Valley Authority TVA
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WBEP -
Watts Bar Engineering Project l
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Work Plan WR Work Request
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2.
Exit Interview l
The inspection scope and findings were summarized on May 1,1987, with those persons indicated in paragraph 1 above. The inspector described the areas inspected and discussed in detail the inspection findings.
No dissenting comments.were received from the licensee.
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Unresolved Item:
Medium Voltage Circuit Breaker Sizing, Paragraph 13 The licensee did not identify as proprietary any of the materials provided to or reviewed by the inspectors during this inspection.
3.
Licensee Action on Previously Identified Enforcement Matters l
a.
(0 pen) Severity Level IV Violations 50-327, 328/82-16-01, 83-27-01, 83-27-04, and 85-04-01.
Another violation relating to corrective action is discussed in NRC Inspection Report Nos. 50-327/86-53 and 50-328/86-53. A notice of violation was not issued with this inspection report since this violation is being considered for escalated enforcement action.
Inspection Report Nos. 50-327/86-53 and 50-328/86-53 detailed problems with six deficiencies that had been identified during TVA auditing activities. These items were in escalation for senior TVA management resolution. The inspector reviewed the status of these deficiencies.
Four of the deficiencies had been resolved and were considered closed.
One deficiency (QSS-A-84-0011-002) had the corrective action plan clearly delineated. The auditing group had not verified that the corrective action was accomplished.
The remaining item (relative to Browns Ferry, QSS-A-86-0001-002) was scheduled to be completed by December 31, 1986; however, this date was extended by the audited group until July 1, 1987. This date was established in a memorandum (R42 870421 922) from H. P. Pomrehn to G. W. Killian, dated April 24, 1987. This matter was discussed wit h DNQA management personnel. Additional inspection will be required in this area.
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4-b.
(Closed) Severity Level V Violation 50-327, 328/86-41-01: Failure to Handle a Corrective Action Request In Accordance With Established Procedures.
The licensee's response dated September 29, 1986, was considered acceptable by Region II.
The inspector reviewed corrective actions stated in this response. The CAR was written due to inadequacies in the processing of HCO-CAR-86-003.
This CAR has been closed by the licensee.
l The inspector concluded that the licensee had corrected the previous problem and developed corrective actions to preclude recurrence of similar problems. Corrective actions stated in the licensee response have been implemented.
4.
Unresolved Items
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Unresolved items are matters about which more information is required to determine whether they are acceptable or may involve violations or deviations. 'One new unresolved item identified during this inspection is discussed in paragraph 13, 5.
Corrective Action Program Problems had been identified by the NRC relative to corrective actions for TVA identified problems. These problems were identified to TVA in NRC correspondence dated November 24, 1986 (NRC Inspection Report Nos.
50-327/86-53 and 50-328/86-53).
TVA developed a CAQ program and implemented this program at SQN on February. 23, 1987. The purpose of this inspection was to review the' implementation of this program. An entrance meeting was conducted at TVA Corporate offices and TVA personnel presented information on this program.
The inspectors were also informed during this presentation that two reviews of the CAQ program had been performed by TVA personnel. Based on these reviews, procedural controls for the CAQ program were going to be modified on May 15, 1987.
Planned changes included improving the flow of CAQRs in the CAQ process, improved generic reviews, adjustments to the scope of the program, clarification of previously identified NRC concerns, and improvements in the escalation process. Further changes to the program were also tentatively scheduled for Jane 30, 1987.
During this meeting, TVA management was questioned as to if they felt the CAQ program was ready to be inspected.
Neither a positive nor negative response was received to this question.
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6.
Auditing Activities i
i Since October 1,1986, DNQA has conducted 49 audits (audit reports have been issued) of which 17 were related to SQN activities.
The inspector reviewed the following specific audits:
Audit:
QSQ-A-87-0007 Audit Dates:
January 28 - February 9,1987 Audit Subject:
Inspection Audit Issue'Date:
March 11, 1987 Audit Deviations:
Audit:
QSS-A-87-0003 Audit Dates:
November 3-24, 1986 Audit Subject:
External Radiation Control Audit Issue Date:
December 23, 1986 Audit Deviations:
(five related to Sequoyah)
Audit:
QSS-A-87-0006 Audit Dates:
January 12 - February 17, 1987 Audit Subject:
Health Physics Instrumentation Audit Issue Date:
March 18, 1987 Audit Deviations:
Audit:
QSS-A-87-0008 Audit Dates:
January 26-February 9,1987
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Audit Subject:
Operating Status, Operating Instructions, Shift Operations Audit Issue Date:
March 5, 1987 Audit Deviations:
Audit:
QSS-A-87-0004 Audit Dates:
October 27, 29; November 4, 6, 7, 10, 12-14,-17-21; December 3-5, 10, 1986 Audit Subject:
Inservice Inspection (Pumps and Valves)
Audit Issue Date:
January 9, 1987 Audit Deviations:
Audit:
QSQ-A-87-0001 Audit Dates:
October 14-30, 1986 Audit Subject:
Inservice Inspection (ISI)
Nondestructive Examination (NDE)
Audit Issue Date:
November 26, 1986
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Audit Deviations:
Audit:
QSQ-A-87-0002 Audit Dates:
October 6-27, 1986 Audit Subject:
Welding and Nondestructive Examination Audit Issue Date:
November 26, 1986 Audit Deviations:
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Audit:
QSQ-A-87-0003 Audit Dates:
October 14-28, 1986 Audit Subject:
Mechanical Maintenance Audit Issue Date:
November 26, 1986 Audit Deviations:
Audit:
QSQ-A-87-0005 Audit Dates:
December 15, 1986 - January 6, 1987 Audit Subject:
Correction of Deficiencies Audit Issue Date:
February 3, 1987 Audit Deviations:
Audit:
QSQ-A-87-0006 Audit Dates:
January 21 - February 2,1987 Audit Subject:
Plant Housekeeping Audit Issue Date:
February 24, 1987 Audit Deviations:
. Audit:
QSQ-A-87-0008 Audit Dates:
February 23 - March 4, 1987 Audit Subject:
Environmental Qualification of Safety-Related Equipment Audit Issue Date:
March 30, 1987 Audit Deviations:
Audit:
QSS-A-86-0023 Audit Dates:
September 8 - October 3, 1986
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Audit Subject:
Radiological Environmental Effluent Monitoring and RARC, Radiological Effluent Monitoring and Environmental Dose Assessment Audit Issue Date:
October 30, 1986 Audit Deviations:
11 (five applicable to Sequoyah)
The inspector verified that these audits were conducted in accordance with TVA administrative controls. The inspector verified that audit deviations were also being resolved in accordance with TVA administrative controls.
The inspector reviewed audit deviation status from a TROI list dated April 28, 1987.
The status of audit QSQ-A-87-0001, deficiency 001 appeared to have some administrative inaccuracies on TROI.
These perceived inaccuracies were brought to the attention of DNQA personnel.
Audit QSQ-A-87-0003, deficiency D01 corrective actions were scheduled for completion as stated in correspondence from H L. Abercrombie to G. W.
Killian dated December 31, 1986.
An auditor was verifying corrective action and identified that the corrective action had not been completed within the established timeframes.
The inspector questioned the auditor as to his actions since the corrective action was not completed.
The auditor stated that the corrective action was approximately 90 percent complete and would probably be completed within the week. The inspector discussed this with DNQA management personnel.
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Within this area, no violations or deviations were identified.
7.
CAQ Program The licensee introduced a new corrective action program in procedure AI-12 (Part I), Corrective Action, Revision 0, dated February 20, 1987.
This procedure established a consolidated corrective action reporting system, replacing most of the previous problem-identifying reports with CAQRs.
The issuance of this procedure implemented the NQAM, Part I, Section 2.16, Revision 2.
CAQRs were first reported using this program on February 23, 1987. At the time of the inspection, approximately 750 CAQRs had been initiated, of which 85 had been closed out.
The licensee performed several reviews of the CAQR system to determine whether the program was working and what steps could be taken to improve it.
The first effort (performed by a special Assistant to the Deputy Manager) was to review new CAQRs to determine if the problems identified conformed to the formal definition of a CAQR delineated in AI-12 (Part I). It was determined that five percent of the CAQRs were outside the scope of the CAQR definition. This is a low percentage considering the newness of the program.
The scope of this initial review was expanded to include an overview of general participation and compliance. Approximately 60 percent of the CAQRs were written by non-QA organizations.
The licensee felt that this was a positive sign.in that the CAQR program was increasing the participation of
line organizations in the corrective action process.
On the negative side; however, it was discovered that some elements were not being I
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accomplished within the timeframes delineated by AI-12 (Part I).
This appeared to be especially prevalent with generic reviews which required participation from other sites.
Several recommendations were made based on this ceview including designating and training management reviewers to increase CAQR accuracy and CAQR program standardization.
This recommendation was being implemented during the week of this NRC inspection; therefore, an assessment of its effectiveness could not be made.
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l A second review had recently been completed by DNQA to evaluate the degree l
of compliance with the CAQR system.
The preliminary results from this review indicated that the statusing, tracking, and trending process for CAQRs was successful and that good communications had been established i
between corporate and site CAQR coordinators. This review also determined that a distinction was not being made between major and minor CAQRs.
Approximately 28 percent of the CAQRs were identifying receipt
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documentation problems which in essence do not constitute CAQs.
It was felt that the large documentation-type CAQR numbers were overloading the system by increasing the open CAQR backlog. Also, it was determined that many CAQR administrative elements transferred to DNE were not being accomplished within procedural timeframes.
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A third licensee effort, contingent on the first two, was to identify any procedural changes which could make the program more effective.
Revision 3 to NQAM, Part I, Section 2.16 is scheduled to be implemented by May 15, 1987, and is to include among other items the provision for designated management reviewers, improvements to the generic review process, clarification of what should be identified as a CAQR, correction of procedural inconsistencies, and the addition of time limits for the escalation process.
The inspector reviewed the following 85 CAQRs which had been closed: (each
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CAQR is prefixed by SQP 87-0) 001, 003, 005, 012, 028, 032, 037, 041, 044, l
047, 053, 054, 055, 058, 059, 067, 071, 078, 081, 082, 087, 090, 101, 107,
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109, 110, 112, 117, 128, 137, 140, 141, 144, 146, 148, 153, 154, 155, 174,
213, 214, 218, 229, 231, 234, 248, 254, 255, 266, 274, 281, 287, 291, 305,
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310, 311, 312, 317, 321, 338, 339, 341, 358, 394, 398, 402, 451, 470, 479, 510, 520, 554, 575, 583, 586, 587, 598, 603, 604, 612, 614, 625, 651, 656, and 675. The closure of each CAQR appeared to be justifiable. In several cases closure was based on the invalidity of the CAQR, the redundancy of the problem since it was already represented in another CAQR, or the transfer of responsibility of the item to the corporate office.
Many closed CAQRs were of the missing-documentation type described earlier which the licensee intends to eliminate with the next revision to the program.
In general, the closed CAQRs represented low significance problems; consequently, an assessment of the ability of the CAQ system to handle items of larger significance was not possible. Specific problems noted by the inspector in this review included missed review timeframes, failure to perform root cause or generic reviews wb;n the CAQR was determined to affect operability, failure to perform ioot case analysis when it appeared prudent, inadequate root case analysis which appeared to be nothing more than a restatement of the problem, and documentation in the CAQR files which was confusing and contradictory. These problems were mostly isolated and had been identified by previous licensee reviews.
Corrective action was in progress consequently a violation is not warranted.
The inspector's general conclusion was that the CAQR system appears to be effective in closing out uncomplicated, administrative, and insignificant problems.
What is of greater concern to the NRC with respect to making a restart determination is the effectiveness of the CAQ program to correct safety-significant problems.
The inspector selected 15 open CAQRs which either were officially designated significant or were clearly important to safety.
Items of this nature have not yet been processed completely through the CAQ system; consequently, a final NRC assessment of the effectiveness of the CAQ program from the standpoint of this inspection must be indeterminant.
Nevertheless, this review revealed potentially serious problems which corroborated the licensee's own findings in this area and accentuated the need to implement the licensee's proposed programmatic revisions previously discusse.
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The following is a list of open CAQRs reviewed and a brief description of any problems which were evident:
SQP 870030; the first response was unacceptable as it listed a
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L completion date of " prior to Unit 2 startup." This was changed to
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June 6, 1987.
SQP 870073; the scheduled completion date of March 27 was revised to May 1.
SQT 870039; this CAQR documents a problem with the range of
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temperatures in the main steam valve room, resulting in variations in main steam safety valve set point pressures.
It was identified February 28, 1987, but as of April 21, 1987, a determination as to whether it affects operability had not been made. As a result, most time elements were not met.
There was no indication of a projected completion date.
SQP 870093; no comments.
SQP 870094; this CAQR, dealing with piping. system geometry which did not match physical piping drawings, had several reviews which did not meet procedural time limits.
SQP 870095; late review times.
SQP 870096; this item was reported February 27, 1987, and a root cause analysis was determined appropriate on March 27 (which was a late determination). As of April 21, the root cause analysis did not appear in the file.
Based on the CAQR initiation date, the root cause analysis should have been completed by April 8.
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SQP 870097; no comments.
SQP 870142; the response for root cause analysis and recurrence control was due April 8, but was not in the package.
SQP 870158; this CAQR was determined to be significant on March 27, 1987, by DNE, but PORS later determined it to be not significant.
Most review times were late.
SQP 870222; this CAQR describes a problem where post-modification testing was not performed to test the capability of a splice on the 6.9 kV/480V distribution transformers supplying ERCW pumping station motor control centers. A justification for continued operations was signed March 19, 1987, based on no evidence that the splice was improperly installed. It was determined that a root cause analysis and recurrence control analysis was not needed, which is questionable in this case. Also, corrective action or estimated completion dates were not stated in the package.
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SQP 870267; the root cause analysis for this CAQR was nothin5 more than a restatement of the original problem.
l SQP 870363; no comments.
SQP' 870367; the documentation for this CAQR did not include sufficient details to inspect this item.
L The effectiveness of the CAQ program will be reinspected at a later date.
l Clearly, many problems exist with the CAQ program, but the licensee has 1.
been aggressive in monitoring the progress since its inception, and has L
generated corrective action plans which appear consistent with the l
problems identified.
Within this area, no violations or deviations were identified.
8.
Site Surveillance and Surveillance Deficiencies l
l During the inspection, a brief SQN Surveillance Program review was conducted.
The review was conducted by interview with+ the site l-l Surveillance Supervisor and included discussing the staffing of the two surveillance branches, reviewing surveillance scheduling, and discussing surveillance deficiency dispositions. The interview revealed two areas of
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weakness in the program:
The current staffing plan includes a supervisor and 14 surveillance i
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evaluators and technicians, The six technician positions are filled
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by rotating site QC personnel through the positions on a nine month temporary basis.
This policy provides QC personnel with a larger program overview and provides flexibility in the organization.
The other positions in the organization are intended to provide a stable work force to accomplish the site surveillance program.
Currently, only three positions are filled by permanent TVA employees and four positions are filled by contractor personnel. This lack of stability in the organization has been recognized as a problem by the site i
Surveillance Supervisor and action is being taken to correct this j
condition. Four offers have been made to fill permanent positions of j
which three had been accepted at the time of this inspection.
The Surveillance Supervisor does not maintain an outstanding site l
surveillance deficiency list. This makes it difficult to determine the backlog of items for closecut and also prohibits random item follow-up to assure corrective actions are progressing satisfactorily.
l Prior to the new CAQ system, surveillance deficiencies were reported and resolved via DRs and CARS.
In order to determine the adequacy of TVA's j
corrective action in this area, the inspector conducted a review of the j
status af DRs and CARS. In addition, a detailed evaluation of 12 DRs was
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performed.
This review resulted in the following conclusions:
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l There are 41 CARS outstanding on site. The oldest of these date.
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back to early 1986.
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There are 89 DRs outstanding on site with the oldest dating back
.to 1985.
Detailed review of 12 DRs revealed that corrective action for 10 DRs is progressing satisfactorily.
Corrective action for the other two DRs was noted to be wea'k. The details of the 12 DRs are as follows:
SQ-DR-86-165R SQ-DR-86-219R
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SQ-DR-86-242R SQ-DR-86-267R Corrective Action SQ-DR-86-283R For These DRs is SQ-DR-86-288R Progressing Satisfactorily.
SQ-DR-86-302R SQ-DR-87-008R SQ-DR-87-037R SQ-DR-87-041R SQ-DR-86-02-017R:
This DR was identified in a surveillance conducted
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during the period from November 27 to December 20, 1985. The DR reported that valves installed in the Auxiliary Air System under Work Order WP8669 had not been tested in accordance with original design and testing requirements (TVA-27 pre-operations test).
The DR was issued on February 25, 1986.
On February 25, 1986, commitment tracking assigned corrective action to the Office of Engineering (DE) (now DNE) with a
commitment date of April 1, 1986. On March 26, 1986, the project manager,
OE, issued a letter to design services specifying a corrective action plan and establishing a corrective action completion date of May 1,1986. On April 2, 1986, the site QA Manager issued a letter concurring in the corrective action plan and stating that QA followup would be required. On May 5,1986, the site QA Manager issued a delinquent memorandum to OE concerning completion of corrective action. On May 30, 1986, the site QA Manager issued a second delinquent memorandum concerning completion of
corrective action, which also stated that if a response was not received by June 9, 1986, the DR would be upgraded to a CAR.
On May 30, 1986, OE issued a memorandum to the Site Director outlining a different corrective action plan and requesting transfer of DR responsibility to the MTU.
On June 18, 1986, QA issued a memorandum to the MTV requesting MTV's detailed corrective action plan. On July 7,1986, the site QA manager issued a delinquent corrective action memo to the MTU. On August 20, 1986, a note was issued from MTU to QA which discussed the need for a change in the corrective action plan. The note, further, stated that corrective action should be assigned to DNE.
A new ECD of September 30, 1986, was
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established.
On August 21, 1986, a note was issued from DNE to QA
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agreeing that DNE should have action assigned to them and stating that DNE would re-evaluate the original testing and would provide retest
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requirements.
On August 28, 1986, a note was issued from QA to DNE confirming that the action was assigned to DNE and the new corrective action plan was due September 30, 1986. On October 6,1986, a memorandum was issued from the site QA Manager to DNE stating that correction action was delinquent. On October 30, 1986, a second delinquent memorandum was issued from QA to DNE.
On November 26, 1986, a note was issued from DNE
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to QA stating that there were unresolved technical issues and requested an extension for the corrective action plan until December 12, 1986. The extension was granted by QA. QA subsequently issued a meeting notice to all involved organizations establishing a meeting on the DR on January 22, 1987.
There were no additional actions filed in the DR package as of April 30, 1987.
SQ-DR-86-184R: This DR reported that vibratic n analysis had not been (
accomplished for the hanger modification documented by WP12203 on the
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Waste System and the ERCW system.
The DR was issued September 18, 1986.
On October 21, 1986, DNE issued a response to the DR which included a detailed plan of action to review other modifications for lack of
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vibration analysis and other post modification testing, compile a list of deficient modf fications, submit this list to the vibration analysis branch for review, and issue instructions to complete corrective actions.
The response stated that all actions to determine the scope of the problem would be completed by October 31, 1986. On October 23, 1986, a memorandum
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was issued from the site QA manager to DNE accepting the DNE response to the DR.
On October 28, 1986, an internal note within QA was issued discussing this problem relative to restart of the unit. As of April 30, 1987, (6 months later) no additional corrective action status was filed in
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the DR package.
- Within this area, no violations or deviations were identified.
9.
Site Fuel Discrepancy Reports, Site Fuel Status Reports, and Probable Reportable Occurrences (PR0s)
The inspector reviewed those aspects of the problem identification and correction process associated with SFSRs and PR0s.
There were no open items on the SFDR and SFSR reporting systems, no fuel activity for
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approximately two years, and all future discrepancies associated with site fuel will use the CAQ system. The PRO system evaluates abnormal cperating events or conditions for deportability and impact on plant operability.
This system functions as a
conduit for identified abnormal events / conditions to plant corrective action systems such as LERs, CAQRs, and work requests. The PR0s provided tracking of long term corrective action not assigned to LERS or CAQRs by the CATS, which is a site specific tracking system. For example, PRO items are directed to the responsible plant group for corrective action evaluation and projected completion dates. For long term corrective actions the corrective action completion date is entered into the CATS.
There was no specified escalation action for late completions and no periodic trending of PR0 items.
Significant operability or deportability items are passed to the CAQ or LER systems and closed out on the PRO system.
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i The inspector reviewed the implementation of the PRO program. Following the initiation of a PRO the evaluation by the-Plant Operations Review
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Staff ' (PORS) for deportability was timely and evaluations documented adequately.
The corrective action responses associated with the PR0s I
reviewed by the inspector were documented and clearly written. The data base reviewed included PR0s written 'since June 1986. This totaled 508:
items for the indicated. time period of which 68 became LERs. At the date of this inspection there were approximately 98 open PRO items with correc-
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tive actions incomplete.
Approximately 25 percent of these PR0s were u
late, exceeding the corrective action due date specified by the cognizant organization. - The subject of the open items ranged from required revi-
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sions to operating and test instructions to relatively minor hardware i-changes.
The items of greater merit were ' tied into the SAL and P-2 schedule via the CATS listing and a due date of " prior to Unit 2 Startup."
The percentage of late PR0s appeared to be due to the concentration of work effort on those issues directly associated with Unit 2 startup,
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leaving those items of lesser priority for later completion.
The following list illustrates the types of items which initiate PR0s and-l the timeliness of the initial deportability evaluation.
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PRO:
1-86-128 Opened:
June 6, 1986
. Closed:
June 19, 1986 Subject:
Snubber support for cold leg accumulator inoperable.
PRO:
1-86-130 Opened:
June'10, 1986 Closed:
July 10,1986 Subject:
Improper coating of reactor coolant pump motor.
PRO:
1-86-131 Opened:
June 13,1986 Closed:
July 7, 1986 Subject: Motor driven fuel oil pump on diesel generator not
{
producing adequate discharge pressure.
PRO:
1-86-166 Opened:
July 15, 1986
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i Closed:
August 13, 1986 Subject:
Solenoids not able to be locally timed as required by Surveillance Instruction.
PR0:
1-86-343 Opened:
December 2, 1986 Closed:
December 24, 1986
>
Subject:
Volume Control Tank isolation valve will not begin to close-until Reactor Water Storage Tank isolation valves are full open - source of low boron concentration water when high concentration source is required.
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PRO:
1-86-350 Opened:
December 6, 1986 Closed:
January 8, 1987 Subject:
Phase A containment isolation valves not response time tested.
The previous list illustrates the low threshold of deportability in the PRO system. The significant items which enter the system are issued as LERs and passed to the Licensing group for further action. The completion of.the PRO process is constrained by the 30 day reporting period required for reportable events.
The commitments within each LER are assigned a tracking number via the Nuclear Control Office (NCO number).
The'
inspector reviewed those PR0s-associated LERs which were open at the date of this inspection.
No late commitments are noted for those LERs reviewed.
The P0RS consisted of six engineers to perform deportability reviews, two contractors that write LERs, and two engineering aides for administrative work. All engineers were required to complete STA training. This staff appeared adequate to provide the necessary reviews of abnormal plant events and conditions.
Within this area, no violations or deviations were identified.
10.
Sequoyah Activities List (SAL) Item No. 356, Perform a Review (ONE-EA) of NCRs/SCRs Impacting Restart The SAL as described in the SNPP is the list used by the licensee to track and close those items requiring completion prior to restart. SAL Item No.
356 was identified as a QA issue which was closed on April 28, 1987. The NRC inspector reviewed the subject SAL package (prepared in accordance with Standard Practice SQA 190) to determine if the documentation present was adequate and justified closure of this item. Attachment 1, entitled
" Items to be Completed or Evaluated Prior to Startup" to memorandum B25 870220 085 is a listing of NCR/SCR status (i.e. complete, determined not required for restart, or scheduled) and is dated February 20, 1987.
Examination of Attachment 1 and discussion with the document's preparer revealed that it was not up to date and was only a listing of NCRs/SCRs j
identified up to approximately March 4, 1986.
All NCRs/SCRs written
thereafter were supposed to have been placed in the P-2 planning schedule,
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However, there was no documentation in the package to indicate that anyone
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i had ascertained that all NCRs/SCRs written during the interim March 4, l
1986, to February 23,1987 (Initiation date of CAQRs) were indeed in the P-2 schedule.
When asked why; responsible design and engineering assurance personnel stated that their commitment did not include this full scope of work. They explained that the licensee personnel who prepare SAL J
work descriptions for the SNPP use very brief, concise titles that i
sometimes can unintentionally make the scope of an item appear larger if taken literally.
The NRC inspector stated that, based on the Region's literal interpretation of the licensee's commitment currently described in the SNPP for SAL item No. 356, this item had been prematurely closed since
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'l there was no documentary evidence in the package assuring that all
~NCRs/SCRs written after March 4, 1986, were in the P-2. schedule. The.
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inspector also stated that if it was the. licensee's true intention not include this time frame in its NCR/SCR review, then the subject SNPP description of work involved would. have to be revised to be more definitive,. describing the actual scope of work completed. The NRC will review this concern during subsequent inspections in support of Sequoyah restart.
Within this area, no violations or deviations were identified.
.11.
Sequoyah Open Items List Evaluation of the Sequoyah Open Itams Listing for NCRs (TROI printout dated April 24,1987) indicated several old -issues were still open, many
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of which had been evaluated and their corrective action was deemed necessary prior to restart.
One of the oldest, significant NCRs, NCRSQNCEB8022 entitled, " Incorrect Valve Weights" (a restart item) was-a first identified on July 24, 1980, for Unit 1 only. Revision 1 issued. to the NCR on May 23, 1983, essentially identifies the same problem condition and corrective action, but was revised because the original handwritten NCR was determined to be not in a useable form.
Revision 2, issued on March 23, 1984, included Unit 2 in its scope of work and was more definitive in the corrective action required.
Revision 3 issued on October 10, 1985, included three problems requiring reanalysis.
A TVA
' technical review determined that the correction action. specified by Revision 3, which called for a -100 percent valve validation program for Unit 1, had not been adequately documented and therefore was not complete.
i Additionally, the technical review found that the ARPR as stated in
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Revision 3 did not assure that discrepancies between piping did not still exist. The above mentioned technical concerns along with the subject NCR have been identified by CAQR No. SQT 870475 and the entire matter will be handled under this CAQR.
TVA has shown improvement by recognizing inadequate corrective actions and ARPR; however, TVA is still deficient in the time required to correct identified discrepancies. This NCR serves as another example of the licensee's lack of timeliness to perform corrective action.
Within this area, no violations or deviations were identified.
12.
Sequoyah Administrative Instruction (AI)-12, Part II i
Page two of this instruction lists the various historical reporting and
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documentation mechanisms for identifying any suspected abnormal plant CAQ.
Examination of the Sequoyah TROI listing dated April 24, 1987 - (which contained only CARS, CQs, DRs, NCRs, SCRs, PIRs, OE audits, DNQA audits, NRC violations, B&V findings, and INP0 findings) revealed that several of the above AI-12 deficiency reporting mechanisms were included on the subject TROI computer printout.
The inspector was concerned that the total population of open CAQs would increase significantly above that reported by the licensee for SQN with the addition of these other missirig old CAQ system discrepancies.
The inspector inquired specifically why PR0s, DDs and NCIs were not included in the TROI printout.
It was
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determined that PR0s generated eventually wind up in another CAQ reporting system.
For example, minor iteins were handled by work requests (WRs),
more significant PR0s became LERs and currently become CAQRs. Discussions with DNE/ Modifications Branch personnel and examination of SQEP-43, Control of Drawing Deviations and AI-25 (Part II), Drawing Deviations indicate that the DD's significance determines the path it will follow.
If it affects Technical Specification operability it becomes a PR0 and is transferred to the LER or CQAR system as rentioned above.
Those insignificant DDs that can be resolved through normal plant procedures do not require DNE review. Other DDs are reviewed for validity and should a CAQ be identified, a CAQR is initiated and DNE performs an engineering review and initiates-preparation of an ECN package to resolve the l
deviation. Discussion revealed that when DDs are reviewed for validity, approximately 2 percent are determined significant, 68 percent are determined insignificant and 30 percent are determined non-drawing
deviations.
In summary, DDs appear to be transferred from one deficiency
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system to another and therefore are accountable.
Discussions with responsible licensee representatives indicated that NCIs are primarily used in the construction / modification area for the identification of receiving inspection deficiencies.
In that this deficient item is identified, tagged and/or segregated and not accepted for installation in the plant, there does not appear to be a need to consider this type of CAQ for restart of the units.
It is essential -that the licensee screen all historical deficiency reporting systems to assure that all open CAQs are included in the total discrepancy population from which the licensee can identify those significant issues required to be completed prior to restart.
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13.
Implementation of NRC Order EA 85-49 NRC Order EA 85-49 was issued on June 14, 1985, to address a breakdown in TVA's management controls for evaluating and reporting potentially significant problems.
The Order required TVA management to review procedures at each nuclear operating facility to determine the adequacy with which reviews are performed for potentially significant safety problems. For problems of this type identified by DNE, the Order mandated the implementation of the following corrective actions:
Immediate report to plant management.
Expeditious evaluation for appropriate action.
Reviewed for potential generic condition.
Corrected.
Additional requirements mandated by the order included, among others, a plan for revising procedures as appropriate, and a plan for training of all personnel involved in implementing the revised procedures.
The inspector conducted a review of implementing procedures for tne corrective action program to determine conformance with requirements of
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the Order. and the approved QA program.
The following program documents were reviewed by the inspector during this effort:
Nuclear Quslity Assurance Manual, part 1, Section 2.16, Corrective Action.
NEP-9.1, Corrective Action, Revision 1, Attachment 8.
EN DES-EP 1.26, Nonconformances - Reporting and Handling by EN DES.
EN DES-EP 1.48, Preparation of Failure Evaluations / Engineering
Reports of Deficient Conditions for Nuclear Plants, Revision 2.
EN DES-EP 1.52, Potential Generic Conditions Adverse to Quality -
Identifying and Investigating, Revision 0.
SQA 118, Processing of Nonconformance Reports or Conditions Adverse to Quality Received From Division of Nuclear Engineering Prior to Implementation of AI-12 (Part 1), Revision 9.
SQA 84, Potential Reportable Occurrences, Revision 6.
SQEP-10, Procedure for CAQ Trend Analysis, Revision 0.
Attachment 8' to NEP-9.1, Revision 1, delineates the procedure to be used for the disposition of problems identified by DNE prior to the can' version of the corrective action program to the CAQR process. This conversion occurred on February 23, 1987. Procedure NEP 9.1, Attachment 8, provides for the identification of a significant CAQ and its documentation on a SCR.
Time frames have been. established for notification of the Site Director, and performance of other corrective actions mandated by the Order. Based on a review of the administrative controls delineated in the procedures, the inspector concluded that adequate management controls appear to have been developed to implement the requirements of NRC Order EA'85-49.
Because of organizational changes within TVA, the inspector identified inconsistencies in the lower-tiered engineering implementing procedures.
These inconsistencies' were not seen as seriously impairing adequate implementation of the Order.
However, these procedures will require revision to accurately depict organizational responsibilities, levels of authority, and lines of internal and external communication interfaces for all organizations presently involved in the CAQ.
The inspector conducted an interview with DNE-EA personnel to determine the degree of involvement of this organization in performing the quality oversight function of engineering activities. 'The inspector determined that EA Audit 87-02, was conducted during October 20-24, 1986, to evaluate the SQEP activities related to documentation and control of the corrective action and modification process.
The results of the audit of the
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corrective action program identified several deviations from procedural requirements.
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Specifically EA audit 87-02 review a sample of 18 SCRs, PIRs, and associated documentation initiated since January 1986 and indicated i
the following problems:
a.
Corrective action, Part B of the SCR, is required to be completed within 60 days of issue of SCR.
No record could be located which i
indicates corrective action has been established on the SCR form, Part B, within the required 60 days for the following:
SCR Issue Date PIR Issue Date SQNMEB8634 8/06/86 SQNMEB8637 8/07/86 SQNMEB8651 8/13/86 SQNMEL8638 8/07/86 SQNCEM8611 2/14/86 SQNCEB8637 8/07/86 SQNCEB8619 3/07/86 SQNCEB8634 6/30/86 SQNNEB8604 R1 5/19/86 SQNEEB8645 5/23/86 SQNEEB8630 4/24/86 b.
NEP-9.1 and former OEP-17 require that SCRs be issued immediately upon identification.
The following SCR indicates it was not issued in a timely manner:
SCR ID Date Issue Date SQNCEB8634 6/18/86 7/21/86 c.
RIMS numbers for PGCE memorandums are to be entered on block 11 of the SCR form, and potential generic evaluations are required to be completed within 14 days of the PGCE memorandum. A review of SCRs, Engineering Reports (ERs), and associated PGCE memorandums indicated the following:
SCR Issue Date Problem SQNMEB8634 8/06/86 PGCE memorandum RIMS number not entered on block 11 of SCR form and no evidence that the PGCE memorandum was ever issued.
SQNCEB8634 7/14/86 PGCE memorandum RIMS number not entered on block 11 of SCR form.
No evidence that PGCE memorandum was responded to oy WBEP or BLEP.
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s SQNNEB8601 2/21/86 No evidence that PGCE memorandum (B45 860224 254)
has been responded to by addressees,
~SQNNEB8602 2/21/86 No evidence that PGCE memorandum (B45 860224 253)
has been responded to by addressees.
SQNNEB8604 RI.
5/19/86 No evidence that PGCE memorandum (B45 860311 261)
has been responded to by adaressees.
In addition, there is no evidence that the ER was revised to accomodate the revised scope of Revision 1 of the SCR.
SQNEEB8665 8/29/86 No evidence that indicates that the PGCE memorandum was responded to by BFEP.
SQNEEB8645 5/23/86 No evidence that the PGCE memorandum (B43 860523 914) has been responded to by the addressees.
d.
Numerous SCRs/PIRs indicate an 090999 date for scheduled closure or completion of corrective action in TROI.
Examples are:
PIR SQNMEB8637, PIR SQNMEB8638, PIR SQNMEB8641, SCR SQNMEB8634, SCR SQNNEB8604 RI.
The memorandum that transmitted the audit fiadings to D. W. Wilson, Project Engineer, Sequoyah Engineering Project, DNE, was dated November 26, 1986, and requested a response within 30 days of the date of the memorandum. The inspector noted that the formal response from the Project Engineer was dated April 2, 1987.
However, the Project Engineer in the interim transmitted a directive dated February 26, 1987, to all design disciplines regarding corrective actions to be taken to prevent recurrence of the audit findings. The inspector was informed that additional time was required by DNE to fully assess the scope of the identified deficiency.
The inspector conducted interviews with engineering personnel from various engineering disciplines to ascertain the root cause of the problems assigned to them for corrective action, and the adequacy of the developed corrective action plans. The project engineer, in his response to EA, stated that the root causes for the identified deficiencies were primarily lack of understanding and inadequate instructions.
In discussions with the engineers, the inspector determined that with the exception of the Mechanical Engineering branch all other
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disciplines had inadequate corrective action trending and tracking programs at the discipline level. The Nuclear Engineering branch did not have a program for tracking the resolution of deficiencies within that discipline.
The inspector stated that while various administrative processes such as SCR, PIR, etc. facilitate the documentation of identified problems, development and implementation of corrective ' action plans can only be facilitated by an efficient corrective action trending and tracking program to ensure completion of timely corrective action. The integrity of the data base used by senior management to assess the overall effectiveness of the corrective action program is-directly impacted by the efficiency with which resolution of problems is monitored at the discipline level.
The inspectors had earlier identified numerous errors and/or ommissions in the TROI data base, which is used by senior management to assess overall effectiveness.of the corrective action program.
The inspector concluded that whfle lack of understanding and/or inadequate instruction may have contributed to the problems identified by EA, the primary cause was inadequate management controls to efficiently trend and track identified problems to a timely resolution at the dircipline level.
TVA management, in the following documents, have initiated corrective actions to specifically address this program weakness:
TVA memorandum from C. A. Chandley, Chief Mechanical Engineer, to those listed, Subject: Mechanical Engineering Branch (MEB)
Policy Memorandum MPM 86-08-MEB On-Project Conditions Adverse to Quality Program, Revision 1, dated March 4, 1987.
TVA memorandum from J. A.
Kirkebo DSC-P, Sequoyah, to those listed, Subject. MEB Policy Memorandum MPM 86-08-On-Project Conditions Adverse to Quality (CAQ) Program - Revision 1, dated April 15, 19~7.
TVA memorandum from S. A. White, Manager of Nuclear Power, to those listed, Subject: Corrective Actions for Conditions Adverse to Quality, dated April 15, 1987.
J. A. Kirkebo's memorandum refers to the corrective action program within the Mechanical Engineering branch and its apparent success in processing CAQs. He further directed that actions be taken at the discipline levels to develop and implement a comparable system, or advise on an alternate process.
Mr.
White's memorandum requires the assignment of specific I
experienced individuals from each organization to function as management reviewers. These individuals will be trained and provided with selection criteria for assessing the validity of CAQs presently being generated and which are included in the CAQ process data base.
For deficiencies which existed prior to the implementation of the CAQ process on February 23, 1987, team reviews will be performed to assess their validity and relative importance.
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All the above actions are intended to improve the integr'ity of the management information system, i.e.,
the TROI data base.
The establishment of a tracking program for the resolution of problems at the discipline levels should facilitate successful implementation of the corrective action program within DNE.
Additionally, with the resulting improvement in the integrity of the TROI data base, adequate corporate management controls will axist over TVA's integrated trending and tracking system.
A review of TVA calculation SQNAPS 008, "Short Circuit Study Medium Voltage System," by NRC consultants identified deficiencies with the 6.9 kV Class IE and Non-Class IE electrical systems. A Technical Evaluation Report dated March 23, 1987, was prepared by the consultants to document their findings that the installed 6.9 kV circuit breakers on the unit and shutdown boards are undersized for the available symmetrical fault current.
They further documented that the installation does not conform to industry codes and standards.
The NRC is currently evaluating the findings of the consultants and will issue a Safety Evaluation Report upon completion of this evaluation.
The inspector conducted interviews with licensee engineering personnel and reviewed objective evidence to determine if this deficiency was being dispositioned in accordance with NRC Order EA 85-49.
The inspector determined that this problem was initially identified by TVA in 1980.
Corrective action was never implemented to correct the identified deficiencies. A problem identification report, PIR SONEEB 8666, dated December 24, 1986, was prepared to document the deficiency on the 6.9 kV unit boards (Non Class IE), and to initiate I
corrective action for this deficiency.
Licensee management has identified this problem as not significant and is using an administrative process for disposition of the problem that does not appear to implement the requirements of the Order. Identification of this problem as significant would require its disposition via an SCR, and would require performing the necessary independent reviews and assessment for NRC deportability that the order requires.
The failure to disposition this deficiency via the SCR process appears contrary to the assessment of the safety significance reached by the NRC and does not appear to meet the requirements of the Order.
Objective evidence of licensee corrective actions regarding the deficiency on the 6.9 kV shutdown boards (Class IE system) was not p esented to the inspector for review.
He was informed that a package was presently being prepared for transmittal to the NRC including circuit breaker vendor's certified test data to assure adequate rating of the 6.9 kV circuit breakers. The inspector also was informed that prior discussions with NRC staff had occurred regarding this issue. Because of the inconclusive nature of licensee corrective actions regarding the 6.9 kV Class IE system; and the apparent inadequate disposition of the deficiency on the 6.9 kV o_......
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l Non-Class IE system; this issue has been identified as an unresolved
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item.
j Based on reviews of objective evidence and discussions with licensee engineering personnel, the inspector concluded that implementation of l
the requirements of NRC Order EA 85-49 was less than effective, prior to implementing the CAQ system on February 23, 1987, as evidenced by
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deficiencies identified in EA Audit 87-02.
With respect to l
implementing requirements of NRC Order EA 85-49 subsequent to the CAQ program implementation, the CAQ program evaluation results identified in paragraph 7 of this report reflected that additional TVA action for resolution and additional NRC inspection will be i
required prior to closure of NRC Order EA 85-59. Within this area, l
one unresolved item was identified.
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The NRC, through the review of TVA calculation SQNAPS 008, "Short Circuit Study Medium Voltage System," determined that the 6.9 kV shutdown and unit board circuit breakers are under rated for the i
available symmetrical fault current.
1his determination has been
!
s documented in SAIC Technical Evaluation Report dated March 23, 1987, l
and on the associated Safety Evaluation.
TVA's management has been i
aware of these deficiencies since 1980.
However, disposition of j
these deficiencies in accordance with the requirements of NRC Order
l EA 85-49 was not undertaken until December 24, 1986. The corrective
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actions presently being taken for the disposition of the unit boards
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I deficiencies does not appear to meet f he requirements of the Order.
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The disposition of the deficiencies associated with the shutdown
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l board is inconclusive; however, there is an ongoing review of this issue by the Office of Special Projects. Until completion of review l
by the Office of Special Projects, this is identified as Unresolved l
Item 50-327, 328/87-26-01 6.
Licensee Actions on Previously Identified Inspection Findings (92701)
a.
(Closed)
Inspector Followup Item 327, 328/85-04-02:
Division of Nuclear Quality Assurance Instruction Discontinuities.
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The inspector reviewed current administrative controls related to auditing activities and verified that the previously identified
discontinuities have been corrected.
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l b.
(Closed)
Inspector Followup Item 327, 328/86-41-02:
Storage and Control of Quality Assurance Records during Review.
The licensee's response dated November 3, 1986, was considered
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acceptable by Region II.
The licensee included administrative
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controls for QA records in procedure QMI 717.1, handling QA records, Revision 0, dated November 23, 1986.
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c.
(Closed)
Inspector Followup Item 327, 328/87-04-01:
Division of j
Nuclear Engineering (DNE) and Division of Nuclear Construction (DNC)
)
Procedural Adherence to the Nuclear Quality Assurance Manual (NQAM).
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The inspector reviewed two licensee matrices, one correlating the QA Topical fleport to DNE procedures and the other from the NQAM to DNE procedures. This was a spot check of approximately five percent of the total number of items.
Only items considered clear nonconformances were in the process of being revised.
This item is closed based on the understanding that other identified areas of partial noncompliance of DNE procedures to the NQAM and QA Topical
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Report will be incorporated into future revisions of DNE procedures.
The portion of the inspector followup item concerning DNC procedures was deleted in consideration of the fact that DNC utilizes plant procedures.
d.
(Closed) Inspector Followup Item 327, 328/87-04-02: Site Procedural
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Adherence to the Nuclear Quality Assurance Manual The inspectors. reviewed current revisions to existing procedures and verified that NQAM requirements had been incorporated into site procedures,
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