IR 05000327/1990008
| ML20042E111 | |
| Person / Time | |
|---|---|
| Site: | Sequoyah  |
| Issue date: | 04/04/1990 |
| From: | Brady J, Linda Watson NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | |
| Shared Package | |
| ML20042E110 | List: |
| References | |
| 50-327-90-08, 50-327-90-8, 50-328-90-08, 50-328-90-8, NUDOCS 9004200138 | |
| Download: ML20042E111 (24) | |
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UNITED STATES
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o NUCLEAR RE:ULATORY COMMISSION.
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101 MARIETTA STREET,N.W.
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AT LANTA, GEORGI A 30323
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Report Nos.:
50-327/90-08 and 50-328/90-08
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l Licensee:
Tennessee Valley Authority
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6N38 A Lookout Place.
1101 Market Street.
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Chattanooga,-TN 37402-2801
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l Docket Nos.:
50-327 and 50-328.
License Nos.:
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Facility Name:
Sequoyah 1 and 2-
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Inspection Conducted: February 26'- March 2,1990
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Team Leader: [I[Md M
//O gj3. 8. Bradygroject Engineer Date Signed
~i Team Members:
S. Burris, Senior Resident Inspector
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K. Ivey,-Resident Inspector
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D. Loveless, Resident Inspector
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Approved by: Mh'A/M V!Y Go I
L. J/ Watson, Chief, Project Section 1 Date Signed TVA Projects Division
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Office of Nuclear Reactor Regulation
SUMMARY
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Scope:
This announced inspection was conducted to determine whether the licensee had.
r developed a comprehensive corrective action program to identify, follow, and correct safety-related problems. The inspection reviewed operational events,
' internally identified problems, QA audits, NRC inspection findings, the
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employee concern-program and concerns brought by external persons or organizations, and special ' reports by internal organizations or other
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organizations.
lt Results:
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'The intpectors' concluded that - the corrective action. program was adequate to '
L identify, follow,- and correct safety-related problems.
The inspectors-1.
concluded for each of the areas reviewed that issues were adequately-identified; L
- and entered into the corrective action program and that tracking to completion
and. trending of these issues was being accomplished.
Corrective actions
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reviewed. were adequate to resolve the problems.
The inspectors concluded that
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the overall approach and attitude toward resolution of problems at the site was'
good.
Several examples of corrective action procedure ambiguities were noted ~
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i 9004200138 900404 I
PDR ADOCK 05000327 i
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t in the criteria for when a condition adverse to quality report should be
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prepared..
The licensee acknowledged this concern and intends to review the criteria for when these reports are required to ensure that. ambiguities are
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removed.
The licensee informed the inspectors that an improved program will be j
implemented in the.near future which will make preparation of corrective action i
forms easier.
The difficulty in properly filling out the forms was viewed by.
.i the licensee as' a barrier to further improvement in the existing program.
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REPORT DETAILS I
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Persors Contacted
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Licensee Employees _
~J. Bynu.n, Vice President, Nuclear Power Production
- W._Byrd, Acting Site Directori 1.
-*C. Vondra, Plant Manager
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- R.
Beecken,: Maintenance Manager-
- J.-Boy.les,. Employee _ Concerns Program Manager
- M. Burzynski,: Site Licensing Manager ~
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- M. Cooper, Compliance.' Licensing Manager
- T. Flippo, Quality Assurance Manager
- J.: Gates, Technical-Support Manager
- J. Holland, Corrective Action Program. Manager
- R. Lumpkin,LSite: Quality Manager
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- R. Proffitt, Licensing Engineer-
-R. Rogers, Supervisor-Engineering Support Section M. - Sullivan, Radiological Controls Manager
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S. Spencer, Licensing Engineer
- P. Trudel, Site Project Engineer
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NRC Employees
- B. A. Wilsori, Assistant Director, TVA Projects
- L.LJ. Watson, Chief, Project Section.1-
- K M._.Jenison, Senior Resident Inspector-
- P. E. Harmon, Senior Resident Inspector
- Attended exit interview Acronyms ~ and initialisms used in this report are listed in the last
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l 2.
Corrective Action.(92720)
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The corrective action program at' Sequoyah is defined in Administrative Instruction AI-12 (Part. III), Corrective Action, Revision 2, which -
implements -the requirements ~ of 10 : CFR 50, Appendix B, Criterion XVI,.
Corrective Action.-
This instruction establishes the overall requirements and responsibilities for the' corrective ~ action program. 'This program consists of administrative control programs and the CAQR program.
The specific controls for each of the ' administrative control ' programs are described in separate documents which are referenced in AI-12.
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CAQs reported on documents in the administrative:conth.4 program, as a
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. minimum, are required to be promptly identified, documented,' evaluated, corrected, tracked, and trended.
The administrative control programs consist of:
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Work Requests 2.
Potential) Reportable Occurrences 3..
_ Drawing-Discrepancies 4.
Radiological ~ Awareness Report 5.
Housekeeping Deficiencies 6.
Test Deficiencies 7.
Problem Reporting Documents'
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NQA Audit: Reports (C0TS)-
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QA Surveillance Reports (C0TS)
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QC' Inspection Rejections (Inspection Reports and COTS)
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Licensee Event. Reports-q 12.
Security. Degradation / Incident Report-
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CAQRs are used to' document CAQs which require additional management review-and attention.
CAQs documented in -one:of the -above programs whichLmeet:
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the criteria establised in AI-12 (Part III). section' 2.1 are required-to have a CAQR initiated with-the exception of LERs/ Reportable PR0s.
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2.1 further breaks down the threshold L requirements foria CAQR into
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hardware CAQs-and nonhardware CAQs.
Once uan item:is determined to meet j
the CAQR threshold a CAQR-PRD form.is -initiated.1 AI-12 -(Part III)
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specifies requirements-for. immediate-notification of licensee; organizations depending on whether =: operability or reportability is affected, whether criteria for an abnormal -event 11s met c or whether a
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security problem is involved.
The CAQR' is reviewed' by-the Management j
Review Committee :within three days ofm the date L the initiator signs the j
CAQR-PRD form.
The MRC -is.made up of Esenior level. site managers who j
perform a general review of the CAQR including determination of validity, a
potential reportability, and potentialn ffect on operability.- They also a
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assign responsibilty.for.the corrective actions associated with the CAQR.
Changes to a CAQR are required to be coordinated: with the -initiator.
Valid CAQRs are entered into the TROI system by the CAQ Coordinator and 3"
distributed to the appropriate organizations for. determinations (operability, reportability, etc.) and initiation of corrective action.
t CAQRs that are determined by the Site Quality Manager - to be a QA.
Programmatic Deficiency are classified as significant.
QA Programmatic q+
Deficiencies are associated.with items' that occur at 'a frequency. which
indicate' that past corrective action was lacking or ineffective, or when widespread noncompliance with procedural requirements -could negate QA program effectiveness.
CAQRs that ere reportable are1 also classified as significant.-
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i AI-12 (Part III) section 2.9.4 requires that corrective action for CAQRs, including scheduled completion date, be developed by the assigned organization and approved by the appropriate organizations identified in section 2.15 within 30 days from the date of CAQR origination.
Criteria j
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3 for cause analysis, corrective and preventive actions, and potential generic implications are also specified in this section.. AI-12 (Part:III)
Section 2.12 defines criterial for escalation' of CAQRs when additional
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management attention is necessary to resolve disagreements or-to ensure that timeliness and effectiveness requirements are met.
Independent.
verification of corrective action is required of the QA organization-for s gnificant CAQRs, CAQRs' initiated by QA, and hardware CAQRs.
i Management is kept informed. of CAQR status on a monthly' basis by.
corrective action status reports prepared by the SQM The; SQM ~ also'is
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responsible for trending.of CAQRs.-
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The; inspectors reviewed the areasilisted below to determine 4 whether management controls' had, been established for the-tracking and resolution
of identified problems, and to ensure that the program. as described'in-l AI-12 (Part III) was properly implemented.
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Operational Events 4l The-inspector reviewed the ten event investigation reports listed below' to determine the accuracy and adequacy of the report.
The inspector found that the licensee reviewed the event to determine
reportability, root cause assessment, and corrective actions.
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ten event reports reviewed met the administrative requirements-of AI-18.18, Reporting of Abnormal Events.
The inspector found that the
' items identified in the event repots were properly _ evaluated as L
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reports required by AI-12 (Part III).
J 11-88-228 II-88-327 II-89-032 II-89-049 11-89-066 11-89-79
- i 11-89-92.
11-89-103 II-89-152 II-90-019
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The inspector reviewed Potential Reportable Occurrences 1-89-109, 1-89-151, 1-89-189, 1-89-191, 1-89-202, 1-89-212, 1-90-041, 2-89-130, 2-89-132 and 2-89-152.
The inspector reviewed the circumstances
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surrounding each event; verified that the notifications. required by.
AI-18, Plant Reporting Requirements, file package 18 were:made in the
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appropriate time frames;' verified that SQA 84, Revision 8, Potential Reportable Occurrences, Attachment 1, Parts A through 'D had been-
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completely filled out and properly evaluated; and verified that.the events which were reportable were reported in the proper format
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The : inspector alsa determined,that conditions. adverse to quality had been properly identified and evaluated as required by
. AI-12 (Part III) requirements and that. tracking and trending of PRO'r
were being accomplished.
No. violations or deviations were identified.
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Internally Identified' Problems
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- This portion of; the inspection-was conducted to determine whether management controls - were established for the tracking and resolution
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of problems identified internally-by the licensee.
This inspection
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included. sample reviews to determine if: CAQs were adequately =
identified and if corrective actions were implemented.
The areas i
included - in this review were the: administrative control programs
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- described' in AI-12 -(Part III),. requests for engineering assistar ce,
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and theLsystems engineering organization l including action plans.
(1) Administrative Control Programs
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The ' corrective action program described in-AI-12 (Part III)
consists of. the CAQR - program and administrative control programs.
The inspector reviewed the-procedures governing'the
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following administrative control 1 programs to ' determine whether
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the programs. included prompt. fdentification, evaluation, correction, and tracking of CAQs.
Work Requests
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Drawing Discrepancies
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Radiological Awareness-Reports
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Housekeeping Deficiencies-
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Test Deficiencies
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Problem Reporting Documents
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Security Degradation / Incident Reports
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a No defiencies were identified.during the review.
The inspector noted, -however,- that inadequacies in the, trending. of ' the j
administrative control programs had been addressed in.recent NRC l
inspection reports and that URI - 327,' 328/90-03-05 had been'
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issued to follow the - concern.- - A CAQR-' (SQP900062) had been issued by the licensee as discussed -in paragraph 2.c to address
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the lack of trending for test deficiencies, housekeeping deficiencies, potential reportable occurrences,. and drawing
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discrepancies.
Accordingly, trending of the administpative control programs will be resolved by followup of the URI by the i.
resident-inspectors.
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The-inspector reviewed a. sample of four items from each of the
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administrative control ' programs. listed aboveL to verify implementation -of the corrective action process.. The inspector?
noted; that in each : case issues were-promptly reviewed ~ and evaluated for CAQs; CAQRs were written.where required; and where
- CAQRs were not required, -corrective action plans were -
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established and implemented.
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t No deficiencies were identified during-this review;,however,'one-concern was. raised.
The inspector noted,that most procedural violations = did not result in CAQRs and that the threshold for.
generating a CAQR for procedural violations; appeared to vary _
between the different programs.. Examples of_this-concern were l
noted on Radiological Awareness-Reports, Housekeeping-Deficiencies, _ Problem. Reporting Documents, Security '.
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Degradation / Incident' Reports, and ~ NRC Violations.
In each example where a procedure violation; occurred, the issue was
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addressed in the ACPs, was tracked and corrected, and no.CAQR
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Lwas written except as noted in paragraph-2.b.3:below.
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AI-12 (Part III), Section 2.1.2, _Nonhardware CAQs,. includes the following criteria for initiating a CAQR:
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Failure to comply; with procedures, _ instructions, or regulatory requirements.
. Minor 'cr infrequent'
noncompliance -with administrative detail such= as documentation 'or timeframes should be documented inLother:
administrative control. programsfinstead. of - on a CAQR where'no adverse impact on quality is apparent.
The inspector noted that the above-requirement could be strictly interpreted resulting in. almost allifailures to.icomplyf with
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procedures _ requiring a CAQR.
The inspector. discussed this requirement with licensee personnel'
and managers.
The inspector was _ told that' procedure violations would normally be addressed by an administrative control 1 program and that an
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adverse trend-in procedure violations would result' in a CAQR.
Interviews with plant management from1various departments resulted in many different descriptions of what this criteria-meant.
Descriptions included only safety. riunificant items, safety related items, and. items that affected quality'or the safety of the plant.
All admitted that the requirement was-hard to interpret. The inspector noted that the words " minor",.
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" infrequent", " administrative detail", and when no adverse
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impact on quality is apparent" as used in this requirement
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During the sample review the inspector noted no-instances where the failure to initiate a -
CAQR because of this interpretation resulted in incomplete f
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At the exit meeting, the ' inspectors
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discussed this concern witn licensee management and noted that
- f the planned revision' to ' AI-12 (Part III). scheduled for-l implementation in the near future provided a good opportunity to
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clarify this requirement.
The. inspector concluded that 'the licensee had administratiJe k
control: programs in place and implemented to ' ensure the timely identification of problems and completion of corrective actions.
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(2) Engineering Requests i
The inspector reviewed the licensee's-program 1for requesting
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engineering assistance to determine if Lissues that were passed between organizational interfaces were properly ; identified: as'
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required by AI-12 (Part III).
Sequoyah Engineering Procedure
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SQEP-65, External Interface Control, < established methods by-a
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which plantt organizations request.information; from Site.
Engineering.
Engineering / plant organizations. request quality.
information on a P-QIR.
The: inspector' reviewed the four P-QIRs
listed below and verified that CAQs were properly identified and
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evaluated as-required by AI-12 (Part III).
PQIRNEEMGSQPQA90001R0 Evaluation of Fuel Pool Cleaning Support IFPCH-526'
PQIRNECEBSQPM0DSA9002R Conduit: Supports Installed Using Ramset
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Anchors PQIRNEEESQPTS90004R0 Accuracies;for RVLIS Instrumentation
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PQIRNESQPMTBSYS89044R0 Replacement of RHR Check Valves Internal Bolting
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(3) Systems Engineering
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Systems Engineering functions as a central review and evaluation organization for plant systems.
As a. result, systems engineers
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should be aware of. problems which -have an affect on their y
systems.
The inspector reviewed the. licensee's system i
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engineering - function to ' determine if problems identified to
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systems engineering and internally generated within systems engineering 1were ' appropriately evaluated:and included in :the -
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corrective action program:as required by AI-12-(Part III).
i The Systems Engineering organization is divided into five n
functional groups, each group having -responsibility for certain
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systems.
This functional. relationship is listed in Appendix C
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of SQA-168, Conduct of Technical Support. -This organization was y
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a central' source of information for.other site personni that have to deal' with plant systems.
The: systems engineers;are assigned direct responsibility for two : to four systems I
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They arec tasked withL improving their ~assignedJ
systems' reliability by:
Performing ' system walkdowns to maintain correct status of l
material condition and to initiate corrective. action; L
Trending. important system. parameters. to-identify deteriorating system performance; Initiating corrective actions prior to.a failure or forced ~
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outage; and.
t Reviewing the myriad of paperwork associated with the.
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systems-to improve the. quality of work.and instruction.
.i The. inspector determined that 'information received by Systems -
Engineering was typically already in the form.of a.CAQ document.
The inspector interviewed eight-system engineers and three.
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supervisors.- During these interviews, the inspector determined
that ' information originating in 1 Systems: Engineering was1
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initially documented in the engineers' system notebook..'Each
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system engineer then reports these items to his1 supervisor;in
the engineer's monthly report.
. Monthly reports-are then
combined and condensed into. a monthly report for the Technical-
Support Superintendent, i
The. inspector reviewed several issues taken > from.the system
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notebooks and determined that they..had been documented. in the
monthly reports.
Examples of the x items reviewed are listed below:
Resin Loss from the Condensate, Demineralizers to the Hig' '
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Crud Tanks.
Freeze Protection for the Sense Lines ? to, the : RWST I
Inadequate.
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RCS Inleakage into the Cold Leg Accumulators.
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Backu'p Diesel Generator Battery - Low Voltage Software Control Problems on P-250.
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Inadequate Setup of Intermediate Range Detectors.
This review showed that the items originally identified and
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documented in the system engineers' notebook were being
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For.this reason - the -inspector focused his review to items that were
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identified in the monthly report from the_ system engineers to their respective supervisor.
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The.following is aflist of items reported.in individual engineers monthly reports.
The inspector: reviewed.the items to i
determine that they were properly evaluated in accordance with the Corrective Action System as : defined' in AI-12 (PartillI).
The items listed in.the " Resolutions" ~ column below are the documented entries into the program. -Those listed as "Not a
CAQ" were determined by the licensee not to-be conditions-
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adverse to: quality, f and. therefore, a corrective ' action. document =
was-not:- needed.. All were found; satisfactory except the~ one noted below..
Condition Adverse to' Quality Resolution Thru Wall leak'on 4 inch line in
- CAQR SQP900036 Fire Protection, t
Drawing Inconsistency 'in Fire
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Protection System.
89 DD 4560 FCV-87-22 Failed Maximum Stroke SI-166.1/DN-1 Time.
. January 1990-Differential Pressure Close-to Not'a CAQ Alert Range on CCS Pumps.
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Spent Fuel Pit' Gate Seal Air ~
CAQR SQP 900012:
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Supply Problems.
Refueling Water Purification Pumps WR 8 273896 Mechanical Seal Leakage.
Auxiliary Building Airborne Leakage WR-B 285584.
Problems.
B 775718
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B'215781~
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Excess Letdown Heat' Exchanger WR B 758097 Leaked Profusely When'Placed in-
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Service.
SI Pump 1B-B High Delta Pressure Not a CAQ r
Results in Increased Test Frequency.
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N-31 Power Channel' Poor Response -
Not a CAQ Issued JC0 for Operability.
Unit 2 Incore Detector. Failure.
WR B 238159
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Condition Adverse to Quality Resolution (cont'd)
-Significant Inaccuracies in SI-38/DN-1.
l Prediction of ECP Unit 1.
December 12, 1989
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Implementations of_ Corrections to-Not a CAQ -
Feedwater Flow.-
Performed Under RTI-1 Uptrend in the Amount' of'" Crud"
'Not'a CAQ in Unit 2 RCS Samples.
Repeated Oil Leaks With'Feedwater WR B781345 Pump. Systems.
ECN-6193 CPd Overload on TSC Computers
'CAQR SQP890475 3 Circuit Detector Switches-to Banks WR B 768026 of Annunciators Disabled.
CAQR SQP 900112 The inspector reviewed the. above event associated with thei3 circuit detector switches to - banks of annunciators which were disabled.
This Levent involved the failure to __ return equipment to operable status after performance: of -maintenance.
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the event, WR B792969" had : been writte_n to -repair a system electrical.groundc W_ ork.had been completed and the electricians had notified-the SOS 'that: the system had been: returned to
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service.
0n January 18,'1990:during a control room annunciator system (system 55) walkdown', the system engineer found 3 circuit detector switches.to banks-of 25 annunciators each in a disabled condition.
The.50S immediately called the Electrical Foreman to J
'the ~ Control Room, and confirmed 1with him that the alarm blocks were inoperable. 'WR B-768026 was submitted. to cover lamp out
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indications and loose contact. blocks-in the' cabinet.
1 The inspector _ discussed the event with the system engineer, who I
agreed that corrective action: shouldialso have been initiated for the problem of inadequate work _ instructions and/or failure to follow the instructions on the original WR.
A CAQR-PRD form
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was initiated and' approved by the' Management Review-Committee '
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e the next day (CAQR-SQP 900112).
The fact that a. CAQR had not-
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been issued appeared to result from confusion over the-same CAQR l
procedural criteria discussed in paragraph 2.b.1.
- i The inspector also reviewed-SQA-211, Formalized Action Plan.
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The inspector noted that the' procedure ~ did not require the g
individual to prepare CAQ documents as needed for the action ll a
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plan items.
This requirement is, however,z required by.AI-12 (Part III).
A 'recent violatio.n pertaining to-freezing of the RWST level transmitters cited the inappropriate use of an action
-- plan-instead of a CAQR-to address a deficient condition.
The inspector reviewed the following action plans and determined-
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that the action plan and/or line.' items were either not a CAQ or had AI-12 (Part III) administrative _ control _ program documents-associated with them. _ This review represented approximately a.
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10 percent review of.the current-outstanding action-plans.
'AFW Level Control Valves Rod Position Indication System Main Steam Check ~ Valves-Fuel Transfer System Airborne in the Auxiliary _ Bldg.
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Although no regulatory deficiencies were identified in these
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specific action plans, the inspector notedLone possible problem j
with the SQA-211 ' action plan program,-
The-system engineer is i
required to review ACP items along with all other available data l
pertaining to his assigned systems for deficient conditions. LIn-i reviewing this information, the systems engineer:is essentially I
conducting a horizontal review lacrossiall_ these programs for adverse trends. - The findings are-documented in the system engineer's notebook.
Action plansLin some cases are initiated j
based on these reviews.
The inspector' reviewed AI-12 (Part III).
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sections 2.1.1.E -and 2.1.2 E which address the need for a CAQR-l when deficient conditions occur at a-rate which could indicate
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corrective action was inadequate or whenJconfirmed adverse
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trends are identified by trend analysis.
The inspector _noted j
that a system engineer's review could 1dentify.an _ adverse '.
- i horizontal trend, but result' in an action plan being generated i
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instead of a CAQR.
The action. plan program as defined by
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SQA-211 does not adequately define its, relationship to-AI-12
-(Part III). and may lead to a CAQR_ not being generated when one
is required.
The licensee acknowledged this concern. and
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intends to -review this area to determine if additional clarity is needed to ensure that a-CAQR is prepared when one is -
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needed.
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With the exception of the item discuss _ed above, all items-reviewed from the system engineer monthly reports and from action plans were adequately evaluated for corrective action as i
required by AI-12 (Part III).
No violations or deviations were ' identified.
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QA Audits / Surveillance-The. inspector reviewed the_following Quality' Assurance. Audit reports =
to determine whether audit findings were adequately dispositioned as
required by AI-12 (Part III):
SQA 89913 Correction of Deficiencies
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SQA 88902 ' Correction of Deficiencies and Corrective Action 1 SQA 89003'. Operating Experience and Feedback-
-$QA 890011 QA Records', Document Control, and' Corrective of:
. Deficiencies-The1 inspector sampled the deficiencies noted-in'the' audit reports and.
determined - that ~ these deficiencies were haridled in = accordance with-C the requirements; of AI-12 (Part III). _ The inspector noted thatL the audit reports aopeared:to be thorough.in the areas reviewed.- The inspector also noted that the audit reports had' findings in relation.
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to CAQRs Linvalidated by the Site Director.
These audits. determined that the site director's justification forDinvalidation 'of _the subject-CAQRs;was not adequate.. TheLinspectors can'sidered this auditi finding ' to exemplify that QA ' audit? activities :are. adequately.
a independent from the site line organization.
The inspector sampled-
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the corrective actions for the invalidatedLCAQR findings and found-t them adequate to resolve -the problem.. iThese: corrective actions;
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involved providing adequate documentation. ofE the. reason for invalidation, t
The inspector reviewed-the following quality assurance monitor-reports to determine whether findings were' adequately-dispositioned-as required'by AI-12 (Part III):
'QSQ-M-90-0140 CAQ Program - Trending QSQ-M-90-56 ACP Security Degradation / Reporting Incident QSQ-M-90-101 ACP - Test Deficiencies
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QSQ-M-90-109 ACP - Housekeeping'
i QSQ-M-90-122 ACP - PR0s-QSQ-M-90-123 ACP - Drawing Discrepancies i
QSQ-M-89-1309 CAQ Program Determinations and Escalation OSQ-M-89-1223 CAQ Program - Trending Q5Q-M-89-741 CAQ Program QSQ-M-89-907 Operability-and Reportability' Determinations QSQ-M-89-1225 CAQ Closure
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QSQ-M-89-1275 CAQ Program QSQ-M-89-635 CAQ Program - Trending QSQ-M-90-50 CAQ Program Survey The inspector found that all findings for.the areas sampled were
processed as required-by AI-12 (Part III).
The inspector noted that the findings from QSQ-M-90-101,109,122, and 123 resulted in CAQR
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' ACP programs. for test deficiencies, housekeeping, PR0s, and drawing discrepancies.
The inspector also noted that-this issue was the subject of URI 327, 328/90-03-05, Trending, which was being resolved by the licensee with the. resident inspectors.
.The inspector discusse'd the trending and' monitoring activities'with licensee ~~ personel., The inspector reviewed. the escalation list for CAQRs and noted _ that 22'CAQRs were in first-level escalation, 3 were-in second level escalation, and-I was in third level escalation.
The fact'that a significantly fewer number were in~second and third level.
escalation as compared to first level escalation. indicated that the-escalation process was working in-resolving conflicts associated'with corrective action.
The inspector reviewed various printouts from the TROI system' and determined that CAQRs were being adequately tracked z
and trended.
The inspector concluded that' QA activities in-the corrective action area were sufficiently broad to verify implementation of the program.
No violations or deviations were identified.~
d.
NRC Inspection Findings-This ' portion of the inspection was conducted to cietermine 'whether_
management controls were established for the tracking and resolution
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of. problems identified by NRC violations and unresolved items.
This
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included a sample review of the implementation of the licens'ee's
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program.
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The inspector held discussions with licens'ee personnel and reviewed
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procedure -SLS-SIL-02-R2, Handling of NRC Inspections and Inspection Reports.
The inspector noted that a Licensing Engineer is assigned to each NRC inspection and is responsible for coordinating all aspects of the inspection.
The assigned engineer is also responsible
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for ensuring that all problems are addressed, including ' the initiation of a CAQR when required.. Also, all personnel involved are responsible for initiating a CAQR, in accordance with AI-12 (Part III), if required during the course of an NRC inspection.
The inspector reviewed a sample of _NRC inspection. findings to -
d determine whether the issues met the definition of a CAQ givent in
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AI-12 (Part III) and whether licensee personnel had initiated CAQRs when required.
The following violations and unresolved items were
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reviewed:
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VIO 89-18-03 URI 89-03-01 VIO 89-25-01 URI 89-18-07 l
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From this review the inspector-concluded that CAQRs had been; initiated where required; however, the inspector noted one. example (VIO-327, 328/89-25-01) where a CAQR was not' issued for 'a procedure'
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violation. This concern-is discussed in' detail in paragraph 2.b.1.
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The inspector. concluded that the licenseo had an established program to ensure that CAQs arising from; NRC inspection findings were-addressed and corrective. actions taken.- The inspector also verified ~
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Completion of the
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corrective actions _ for NRC inspection' findings will be verified
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during routin'e ;NRC Inspections.
No violations or'. deviations' were identified.
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Employee Concern ' Program and' Concerns Brought by External-Persons or Organizations Thei licensee has-an employee concerns: program to process concerns
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expressed _ by employees.,This program receives concerns'from current employees ~ and also receives concerns.from employees' (permanent and
- contractor) during required exit interviews upon Ltermination of employment which, could result in CAQs, The licensee also receives
' industry information from external persons and' organizations through the Nuclear Experience Review program which could result in CAQs.
In addition, _ the licensee.has contract services such as metallurgical / failure analysis, chemical analysis', and oil analysis which could provide results that would lead to CAQs.
The inspector discussed the handling of employee concerns with the Employee Concerns Program site representative.'. The' Employee: Concerns.
Program files listed below, which were selectedEbased on concerns raised by departing employees or contractors', were' reviewed to ensure that concerns were processed in accordance with AI-12 (Part'III).
ECP-89-SQ-E15 Unit 2 Steam Generator Snubbers The inspector noted that'CAQR SQP 890396 was written to address these concerns and that DCR 3394 was written to address changing y
the type of snubber being used.
-ECP-89-SQ-E75 Violation of Purchase Procedures CAQR SQP 880010 had been previously issued addressing similar concerns, however this file addressed the ' continuation of the problem.
QA monitoring activities had been scheduled to confirm continuation of the problem.
ECP-89-SQ-F41 Forgery of SNM Inventory Signatures CAQR SQP 890435 and CAQR SQP 890528'were issued to address this-issue.
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ECP-89-SQ-K15 Equipment Qualification Not Maintained--
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L QA' Audit SQA 89910 of April 28, 1989 addressed ~this issue.
Two CAQRs', two PRDs, and 3 COTSs were issued as a result of the.
audit.
The inspector found that all ~ issues from each.of these files were adequately addressed in the' AI-12 (Part III) program.- Investigation; of these concerns was thorough.
Whenever possible' the Employee Concerns Program is positively interfacing with the-line organization, in the factual investigation 1and generation of corrective action-
documents for : CAQs generated ~ as a result. of concerns. raised by,
exiting. employees.
'This allowed the limited -- Employee Concerns <
Program resources to overview the. investigation L of concerns : raised -
through' this-program. --In the SNM case, that overview resulted :in. an-additional CAQR.beira written.
The inspectorireviewed.the' licensee's-Nuclear - ExperienceL Review Program -as outlined - in -- administrative procedure STD '.-3.1, Revision 0, " Managing the Nuclear Experience Review Program".
This program receives inpet from and -evaluates experience gained from TVA's Nuclear Power Program, other nuclear utilities, the NRC, INPO,'
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i architect engineers and constructors, equipment' suppliers, and others-a within the nuclear industry..The: inspector reviewed an NER: computer printout which listed all inputs into the:NER process which. included.
j NRC ins, INPO -documents,. vendort identified issues ' (Technical y
Bulletins), and TVA. generated reports - (i.e.,: event ~ reports,' ' Pros,
etc.).
This printout also identified;the-disposition' for each ~1ssue.
i The inspector was able to: determine from this printout that the!AI-12-i (Part III) corrective action program was being properly used.for--
issues or concerns received by the licensee from outside organizations.
A review of. specific itemstrelating to vendor supplied information and 10 CFR121 reports which were processed through the NER program was conducted by the Lresident inspectors Jin a
inspection 327, 328/90-06. The results of'that review are documented ~
i in paragraph' 13 of that inspection -report; LIn discussion.with the-resident inspector,- the inspector was)able to determine for the 11 j
issues reviewed by the resident inspectors that all were-properly-1 dispositioned through the NER program a's required by: AI-12. (Part -
III).
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The inspector selected several areasc in which -the licensee use'
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s external persons or organizations to provide services to determine if
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CAQs identified by these organizations were properly dispositioned as-required by AI-12 (Part III).
The inspector reviewed the licensee's
program for sampling and testing of chemicals', metals, received
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parts, and part failure analysis.
The inspector selected two of the most recent chemistry problems found at Sequoyeh and reviewed these items to determine whether.the
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administrative and procedural! controls had been properly implemented for the occurrences reviewed.
-t (1) On' December 19, 1989, - CAQR. SQA-88067901,. Revision 1,1 was initiated' which identified-a violation of TS: for effluent
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monitoring (TS-6.8.1h) in which POTC procedures were 'not being t
reviewed asirequired by TS 6.5.1A. -'The initiator stated'that an
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'offsite' TVA organization, - such as POTC,Lwhich - provides
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Regulatory Guide 4.15 effluent analysis must be reviewed by a site designated qualift;d reviewer.
The = site: chemistry group stated' that only site procedures were subject to TS 6.5.1A review requirements and POTC, procedures are independentlyJaudited to provide compliance with TSL 6.8.1h-services; therefore,:they recommended that.the CAQR be closed as-j
" invalid'T.
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This recommendation wasi rejected by QA and a meeting was: held l
between QA,?on-site chemistry and corporate chemistry to develop i
a corrective action plan which was outlined as follows:
'l Develop a TS-interpretation for each TS procedure process,
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TS 6.5.1A and TS 6.8.1h, to clearly define the off-site procedures subject-to the TS.
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The root cause-analysis found fthat POTC procedures. which _
j implement site effluent monitoring TS were not given-a technical
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review by a site-qualified reviewer.
The extent ofLthe. problem j
~ limited to POTC procedures - which ' implemented TS was requirements.
As corrective action the= POTC was added - to the A' ceptable l
c Suppliers List (ASC) as Vendor' ID No. 03847423 and-verified by QA on March 14, 1989.
The CAQR was closed on Mcrch 17, 1989, i
(2) Diesel fuel oil samples, including onej from the EDG 1BB 7-day tank, were provided to Southwest Research Institute for
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determination of-the feasibility. of cleaning versesi replacement
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of the oil.
Results from the laboratory.found, that the diesel fuel oil in the 7-day = tank needed replacement based on; the j
failure of the " accelerated stability" Lest, which was. analyzed
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in accordance with ASTM D2274 -(1988);
After receiving this I
information the licensee generated a CAQR-(SQP 900053)-due to failing to meet a Technical Specification requirement -
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(4.8.1.1.2.c) which was based on this~ " accelerated stability" i
test per ASTM D2274 (1970) requirement.
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The licensee collected 3 additional samples and sent these samples to the original-lab and two additional laboratories for analysis.
The results from all 3 labs found this second sample to be within the limits for accelerated. stability, -however,
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witnessing of the test methods-found that the-samples were being tested' in accordance with a. later-version of the ASTM standard andu therefore-a more stringent filterIrequirement was being
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used.
In. addition,: the test _ methodology was not being strictly
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adhered to.during the performance of the test.
The licensee determined that these testLproblems were' reportable
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to: the NRC..-The licensee ~ issued an LER and-took immediate -
corrective ' action. to evaluate: the, operability of the: EDG fuel; systems (Justification for Continued Operation).
The identified-fuel oils were replaced. and-corrective ' action to prevent recurrence Af this-testing' problem was implemented.
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The licensee did' not ide' ntify: any_-conditions which fell into the-specific category - of. metallurgical or failure analysis related to off-site ' inspection ' or ; review. - However, -the inspector reviewed =
several CAQRs : dealing with metallurgical. testing.andTreviewed :the l
results. of the chemical: and mechanical properties testing associated
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with the licensee's response to'NRC Bulletin-87-02, Fastener Testing
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to Determine'- Conformance With - Applicable Material Specifications.
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The-CAQRs reviewed dealt with the test failure of. supplied equipment for a dedication package and testing associated'with a fe.ilure-of
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supplied equipment.
Each review was performed-to verify that the
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licensee correctly identified, the original problem and initiated the proper procedural : documentation: i_ncluding; appropriate-CAQ
documentation as required.-
The:: inspectors? review 'of each item -is discussed below.
(1) Failure during torquing of a Knudsen ' Company wpplied 1/4 inch -
bolt on a saturable - transformer,- resulted. in the licensee
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performing a failure analysis on the broken part.
The. licensee-
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generated a CAQR (SQP 871709) and performed an evaluation of the t
failed stud,' which found that.there was - noL '! material defect".
However, the -stress applied during the-torquing was-too high.
Evaluation of - the remaining bolts found - that they were seismically and structurally. not 'affected and;therefore were still suitable for -service'(based on? engineering evaluation and-analysis of vendor and test supp1_ied data).
(2) While trying to certify material supplied by the Mueller Brass
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Company in accordance with-dedication package requirements, the licensee sent 21 pieces-of supplied components for testing.
The
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vendor, Mueller Brass Company, supplied numerous. items for use in the plant.
Of the 21' pieces sent for testing it-was found -
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that only 8 met the required ASTM spe'cification (SAE J513).
The licensee placed the._ order on hold and notified the company in -
question.
Subsequent licensee review determined that all of the parts' should be returned -to the vendor.
The appropriate
-documentation was-generated.
Review of the licensee's documentation did not identify any additional comments.
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(3) The licensee selected a sample for each of the' various fastener-groups identified in NRC.Bulletin 87-02 in conjunction with an NRC -inspector.
The fasteners were> then, sent to Singleton Materials Engineering Laboratory and - Central - Laboratories Services Branch for mechanical testing and chemical analysis.
The inspector reviewed the sample size, methodology,-and results q
- of the testing.
Based -on the. licensee's do6umentation, the-
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inspector agrees with the-methods and technique used to select -
and test L the - population' of. material. 'The ' inspector also
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reviewed the test results andethose condition' adverse.to quality.
- reportsJwhich. were -issued during this' process for those items..
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which.did not meet the acceptance. criteria.
The CAQRs appeared
to be-of sufficient detail. and depth to' identify the. scope. of l
the problems. at Sequoyah with regards to the response to -
The -CAQRs reviewed were properly initiated,
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tracked, and resolved as required-by AI-12~(Part III).
t No violations-or deviations were' identified.
f.
Special Reports by Internal Organizations or Other Organizations
The licensee has several internal review' organizations which conduct inspections / reviews' of Sequoyah activities which could - provide findings which -would lead to or be : identified as -.CAQs, These organizations are the Nuclear Managers Review Group, the' Independent Safety Engineering Group / Independent _ Safety ' Engineering, : and. the Nuclear Safety' Review Board.
External organizations which ~ could provide the' licensee reports that may contain or lead-to CAQs are the-Institute of Nuclear Power ~0perations', the i Authorized -NuclearL Insurer, and outside organizations contracted - to perform. a1 service such as Westinghouse.
The inspector reviewed administrative; procedure ON9-STD 1.1.1,
Revision 0, " Nuclear Safety Oversight" which identified. that the purpose of the NMRG was to submit for_ approval and review,7 schedules and ' topics based on past performances or on requests from senior
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management.
Due to a licensee reorganization, the ISEG function was moved from the licensing organization to the NMRG and renamed as
Independent Safety Engineering.. As a result, NMRG:through ISELis tasked with performing independent reviews of safety engineering functions as described in NUREG. 0737 (ISEG/ISE), which include
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reviews, surveillance.of plant' activities, and examination of p~1 ant operating experience reviews.
These reviews are promulgatedTin the
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form of a report and submitted to senior management for distribution L
and notification of NMRG and.ISE findings.
In addition to conducting the review, the NMRG manager will review corrective action plans, make recommendations on ISE findings and observations to the-affected
organization, track corrective action, and perform follow-up reviews.
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The inspector reviewed NMRG reports NMR-89-003-ASR, R-89-04-NPS and l
R-89-03-SQN.- 8ased on this~ review, the inspector found that items were properly addressed as required by AI-12,(Part III).
However,
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L one item noted in report NMR-89-003-ASR, item 188-08-I-01 originally a
identified ai voltage ' control problem associated with the:Intertie
Bank-found' during an outage in 1988.. Although the inspector did not technically review this specific : item, the inspector did review the-
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administrative - controls / associated with the closure of this = item.
Item 88-08-I-01 wassidentified and tracked through several monthly reports, however=the'last' monthly report to discuss this item.was thel e
March 1989 report.
Discussions with the'11censee's staff found that-
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the item was identified:for closure on the staff's tracking program..
i The inspector reviewed the administrative controls which governed the
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activities performed by ISEG/ISE.
The' procedures. reviewed were ONP'
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STD 1.1-1, Revision 1, Nuclear -Safety Oversight and SQA-117,..
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Revision 7, Responsibility of Independent Safety Engineering.
The'
inspector. verified that:
Lines of authority were clearly defined and identified;
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controls for the conduct of specific activities'were identified;
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the group was performing those functions as Lidentified-within-Technical Specification (TS) 6.2.3.
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l-controls by reviewing ISEG/ISE monthly reports; issued-fromL l
January 1989 to the present.
The ISEG/ISE reports containedfnumerous l
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l findings with. recommendations and several items which were categorized as conditions adverse sto quality, requiring-a CAQR.
The
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inspector reviewed several.of these findings and.the associated CAQRs and found that the issues were identified, tracked and: resolved (for those items closed) in accordance with the-administrative control procedures and AI-12 (Part III).
Based on this. review 'of-the administrative program and monthly activities reports,L the-inspector
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did not identify any outstanding items or. concerns.
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The inspector reviewed the minutes of NSRB meetings for the below
l listed dates to determine if items identified by NSRB were being adequately processed as required by AI-12 (Part III).
June 22, 1989
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August 25,-1989 September 13, 1989-j August 28, 1989 i
December 18, 1989 January 11, 1990 February 22, 1990-1 1 -
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The. inspector: discussed the operation of the NSRB with the NSRB
chai rman. and: secretary.. The inspector determined that because NSRB
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functions as an overview committee most comments: made by NSRB' are j
general-in: nature.
These comments involve refinement of existing.
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programs or additional areas-or subjects lwhich'should be considered
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to raise the standard of plant _ performance.
As such,-the inspector
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was unable toifind any specific items from the meeting' minutes which
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directly: affected corrective -actions _ for AI-12 (Part III) identified
items or items 'which ~ should have -been entered into the corrective
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action program. ' NSRB functions as a direct line review group for TS.
changes and license ammendments.
In :these. areas, NSRB c had - a -
i significant direct _effect on the end product.
The inspector' reviewed' the report 1 from the 1989 INP0 Linspection-and discussed selected-items with senior plant management.
.The= inspector i
determined that a11' items had been properly l evaluated against AI-12'
(Part III) criteria, that existing corrective action. documentation
existed or were generated for the required items, and-that these-
_ items were being tracked in the TROI system.
.The inspector discussed findings from the ANI finspector with both licensee personnel and the ANI -inspector. :The inspector determined
from the interview with the ANI. inspector and from a sample of the-
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documented findings that cil items meeting AI-12 criteria'were being-addressed and' tracked,as required..The inspector found that most ANI findingsLwere addressed by CAQRs rather than ACP-~1tems.
l The inspector reviewed a ' sample of 'outside contract reports which were sent to TVA. - The reports listed below were reviewed to ensure
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that items identified were addressed lns required by AI-12-(Part III).
Bechtel Report TV-72-104A on Cable Trays i
This particular item addressed the approach to analysis used tin I
relation to corrective _ actions specified in CAQR -SQP; 890524.
The inspector determined that this item Was adequately = addressed
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through the CAQR.
Westinghouse Reports TVA-90-862 E01 Review TVA-89-675 Feedwater Bypass Valve Controllers TVA-89-639 Steam Generator Upper Support Splice Plate Thru Holes
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Westec-- Independent Review for Response to NRC GL 88-14, Instrument Air i
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h AI-12 ( Part III) was contained in the Bechtel cable tray report and
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appeared to be properly'dispositioned.
No violations-or deviations were identified.
g.
Management Review Con.mittee Meeting Each inspector atten'ded ai Management Review Committee meeting in -
which CAQR-PRD forms generated the previous day and potential CAQRs l
were discussed. -The inspectors determined that the management review.-
I committee functioned as - described,in. AI-12 (Part III) which included:
reviewing { the CAQR-PRD form for the' classification: of the CAQ:
identified, potential reportability, and. potential' affect on..
operability.
The inspectors-noted that the responsibility-for action
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on valid CAQRs/PRDs.wasE discussed and properly assigned per the
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requirements of AI-12 (Part_III) section 2.4.1.H.
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During the course of. the inspection, the inspectors discussed the t
operation of the Management ' Review-Committee with several of the members.
The inspectors noted from these discussions and observance of the meetings that ambiguities :in the CAQR criteria-of AI-12 (Part III) have caused-some problems-in' classification of items.
Similar problems were discussed in paragraphs 2.b.1, 2.b.3, and 2.d above.
A similar problem' was observed by the; inspectors at one of the i
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Management Review Committee meetings-and'is discussed below.~
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While. working on the: temperature indicators (TI's) for.the' Waste-l Gas Compressors it was noted that the actual plant configuration
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J F was different than the system drawings.
The drawing:for the.WGC
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system shows TI-77-96'(Waste Gas' Compressor "A") to be on the
.j right side of the WGC'. control panel.
However, the correct TI for this instrument is located on the left side of the' panel and
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is labeled TI-77-111. ' The cWGC unit "B" tis: are apparently..
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reversed in relation-to. indicator. location and labeling with the
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unit ' "A" tis.
The 11icensee-had initiated drawing deviation 90DD4722 which specified-that the. label:' tags - for the two instruments in question would -be changed in accordance with' Tag Request T025014 and ~T025015. 'WR B792207 was-also issued to-j clear drawing deviation 900D4722 by either verifying that' the
lines were correct or by swapping-the leads at -the gauges.
l During the management review committee 2 meeting it was decided '
that.since this item was already covered -by the DD and WR and-
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did not involve a safety system, a CAQR'was not required.
AI-12 (Part III), Section -2.1.1.G, requires that any condition found which requires a plant. configuration change shall be documented-
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as a CAQR.
The inspector discussed this item with a member of j
the Management Review Committee.
The inspector determined that
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this - item had no safety' significance.
However. - it is an additional indicator thatL the CAQR. criteria - defined in AI-12
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(Part III) may be ambiguous to the users of the procedure.'
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No violations or deviations were-identified.
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to identify, follow, and' correct safety-related problems.:.Although the number.of items sampled.was low l compared with' the overall number of items?
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'in 'the corrective action-' program,: the~ sample was sufficiently broad to l
conclude that. the! overall : approach and attitudeL toward resolution of problems at the site was. gt.nd.
TheLinspectors concluded for each of the
areas reviewed that issues were adequately. identified and entered into the-t corrective action orogram, and 'that tracking and trending Lof items was '
being accomplished.
Corrective actions reviewed were adequate' to' resolve
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the problems.
Several' examples were. noted where ambiguities--in the' AI-12.
l criteria for CAQRs may have resulted in CAQRs not being : issued.. : The-licensee acknowledged this-concern and intends to review the' criteria for t
CAQRs to ensure that ahbiguities are ~ removed. "The' licensee informed the j
inspectors that an improved program will be implemented in the-near future
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which will make preparation of corrective action 1 forms easier. LThe a
difficulty in properly filling out the forms was viewed by the licensee.as -
a barrier to further improvement in the existing program.
3.
Exit Interview (30703)
y The inspection scope and findings were summarized;or. March 2,1990 with i
those persons indicated in paragraph 1.
-The Team Leader described < the'
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areas inspected and discussed' in detail.the inspection-findings.
The licensee acknowledged the inspection. findings ~ and did not. identify as
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proprietary any of the material reviewed by the-inspectors -during the
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inspection.
4.
List of Acronyms and Initialisms
ACP Administrative Control Program
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AI Administrative Instruction i
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ANI Authorized-Nuclear Insurer
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ASTM -
American Society of Testing and Materials'
CAQ -
Condition Adverse to Quality CAQR -
Conditions Adverse to Quality Report s
CFR
. Code of Federal Regulations
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COTS -
Correct-On-The-Spot CPU Central Processing Unit
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DCR Design Change Request-
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Drawing Discrepancy EDG Emergency Diesel Generator
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Emergency Operating Instruction
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GOI General Operating Instruction
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GL Generic Letter
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IN Information Notice
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INP0 -
Institute of Nuclear Power Operation-IR Inspection' Report
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ISEG -
Independent Safety Engineering Group ISE Independent Safety Engineering
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Justification for Continued Operations-LER ~-
Licensee Event Report LCO Limiting Condition ~for Operation
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MRC - -
Management Review Committee.
NER :-
Nuclear Experience Review
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NMRG -
Nuclear Managers Review' Group NQA -
Nuclear Quality Assurance-NRC -
. Nuclear' Regulatory Commission.
NSRB -
Nuclear Safety Review Board
'PORS -
Plant Operation Review Staff
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POTC -
Power Operations Training-Center P-QIR-Plant Quality Information Request PRD Problem Reporting Document.
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PRO -
-Potentially. Reportable Occurrence QA Quality Assurance
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QC Quality Control
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SAE Society of Automotive Engineers
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SNM Special Nuclear Material:
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SOS Shift Operating Supervisor
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Sequoyah Standard-Practice - Administrative
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SQEP -
Sequoyah Engineering Procedure SQM Site Quality Manager
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TI Technical Instruction
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TROI -
Tracking Open Items TS-Technical Specifications.
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URI Unresolved Item
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VIO Violation
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WGC Waste Gas Compressor
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WR Work Request-
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