IR 05000334/1999006

Insp Repts 50-334/99-06 & 50-412/99-06 on 990809-13 & 990823-27.Violations Noted.Major Areas Inspected:Licensee Corrective Action Program Implementation

ML20217E058
Person / Time
Site:	Beaver Valley
Issue date:	10/07/1999
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20217E034	List: IR 05000334/1999006 ML20217E030
References
50-334-99-06, 50-412-99-06, NUDOCS 9910190063
Download: ML20217E058 (27)

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. U. S. NUCLEAR REGULATORY COMMISSION

[ REGION I

' License Nos: DPR-66, NPF-73 ,

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Report Nos: 50-334/99-06, 50-412/99-06 j Docket Nos: 50-334, 50-412'

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Licensee: Duquesne Light Company Post Office Box 4 ,

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Shippingport, PA 15077 l

Facility: Beaver Valley Power Station, Units 1 and 2 Inspection' Period: August 9-13 and August 23-27,1999 Inspectors: 'J. Carrasco, Engineering Specialist G. Dentel, Resident inspector, Beaver Valley i J. Furia, Senior Radiation Specialist I R. Lorson, Senior Resident inspector, Seabrook !

'J. Noggle, Senior Radiation Specialist l J. Richmond, Resident inspector, Susquehanna D. Silk, Senior Emergency Preparedness Specialist

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- Approved by: John R. White, Chief Radiation Safety and Gafeguards Branch Division of Reactor Safety-

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9910190063 991007

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EXECUTIVE SUMMARY i Beaver Valley Power Station, Units 1 & 2 l NRC Inspection Report 50-334/99-06 & 50-412/99-06 l During the weeks of August 9-13 and August 23-27,1999,-inspectars conducted an onsite l . inspection of the licensee's corrective action program implementation using the guidance of

NRC inspection Procedure 40500, " Effectiveness of Licensee Controls m Identifying, Resolving, i

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Operations I i

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The Condition Report (CR) program is only one of several issue identification and {

l tracking systems in use at BVPS. Although it is the only site-wide tracking system, each (

of the major departments also tracks issues in their own databases. (07.1) j l

Review of the Offsite Review Committee (ORC) and Nuclear Safety Review Board (NSRB) indicated that they were effectively implementing their charters, properly reviewing and commenting on plant issues and events, and appropriately documenting their findings and recommendations. (07,1)

Audits and self-assessments of the condition report program were conducted as requireo by plant procedures. Quality Services Unit (QSU) audits were of sufficient scope and depth to properly identify programmatic deficiencies and weaknesses. Self-assessments were generally limited to compliance based program reviews. (O7.1)

Quality Services Unit's new program to evaluate self-assessments was a good initiative to improve quality and consistency. (07.1)

The Condition Report system has been effective in addressing issues placed into it, however, with the utilization of a number of altemative departmentallevelissue tracking systems, station management has u one readily available method to identify and trend

all issues identified at the station. (07.1)

The operations department has increased and improved its ability to identify problems through the CR program and self-assessments. Corrective actions for identified problems were handled appropriately, in most cases; and the licensee is aware of and addressing areas for improvement. Inspocters observed no instances of significant problem recurrence. Overall, the operations department's ability to identify, resolve and prevent problem recurrence is satisfactory. (07.2)

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The use of the condition report process for problem trending identification is improving.-

Quarterly trend analysis was performed at a very broad level. However, trend

, evaluations were not detailed. (07.2)

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Maintenance i

Material deficiencies associated with safety-related or Technical Specification equipment !

were inconsistently documented and tracked, sometimes under the Maintenance Work l Request program, by using a material deficiency tag, and sometimes under the Condition Reporting program. Several examples were identified where corrective actions were untimely and not appropriately prioritized for deficiencies identified in 1997 and 1998. (M7.1)

Condition reports were not always initiated and processed in a timely manner, in that I several condition reports took 3 to 6 days after discovery to process and review. No guidance or requirements for timeliness were provided in the Beaver Valley Condition Report procedures. This issue was entered into the corrective actions program. (M7.1)

Operations failed to monitor the correct flow indicator for the gaseous waste oxygen analyzc sample flow for a three year period, due to a failure to adequately translate a 1996 design change into operator logs and plant equipment labeling. Operation and Maintenance personnel missed several opportunities in 1999 to identify the discrepanc (NCV 50-412/99-06-01) (M7.2)

Work groups kept Measuring and Test Equipment (M&TE) instruments for extended periods of time (i.e.,30 to 90 days). One group used an informal process to ensure that all safety-related tasks affected by the M&TE were entered into the M&TE usage lo Other wok groups appeared to enter only a single work task into the M&TE usage log, during the extended M&TE usage period. The pctential exists for an incomplete review !

of the affects on equipment from M&TE which is subsequently found to be out-of- J

' calibration. This appears to be a known weakness within the M&TE program, but had not been documented in a corrective action program. (M7.3)

A review of Beaver Valley's response to three instances of non-cited violations of NRC requirements concluded that comprehensive evaluations had been performed, and that the planned or completed corrective actions appeared reasonable to prevent recurrenc However, in one case, the completed actions were untimely to address the issue. (M7.4)

The problem identification and corrective action aspects of the Maintenance Rule program were well managed, appropriately implemented by system engineering, and appeared effective in identifying system problems and improving system performanc (M7.5)

Enoineerina The licensee's Condition Report procedures lacked a clear definition of the concept of extent of condition reviews and guidance for closing condition reports. (E7)

The Quality Services Unit (QSU) has been conducting effective audits of the Nuclear Engineering Department (NED). These audits were performed in sufficient detail and with a constructive and critical attitude. Corrective actions were found effective and the details were handled in a professional manner. (E7)

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Plant Suocort The CRs generated within the radiation safety department generally did not involve issues of safety significance. Audits and self-assessments were appropriately performed and program improvements were made based upon their results. (R7.1)

The identification of problems in the chemistry area has been effective based on routine surveillances conducted by the chemistry staff and a recent self-assessment audi (R7.2)

The identification and resolution of emergency preparedness problems was effectiv (P7) {

Few secuiity issues have been identified the past three years. The security department self-identifies program refinements and improvements through an active and robust surveillance program. (S7)

Although many fire protection issuea were identified by the licensee through the CR process, the licensee has taken corrections to direct this safety significant program are (F7)

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~ TABLE OF CONTENTS Page

' EXECUTIVE SUMMARY . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . ii TABLE OF CONTE NTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . y I . OPERATI ON S * . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 07 .' Quality Assurance in Operations :. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 -

07.1 Management of the Condition Report System . . . . . . . . . . . . . . . . . . . 1 07.2 Corrective Actions Program in Operations . . . . . . . . . . . . . . . . . . . . . . 4 -

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-- I I . M aintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 M Quality Assurance in Maintenance Activities . . . . . . . . . . . . . . . . . . . . . . - 6

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M7.1. Problem Identification and the Maintenance Work Request Program . 6 M7.2 . Unit 2 Gaseous Waste Oxygen Analyzer . . . . . . . . . . . . . . . . . . . . . . . 9 M7.3 Measuring and Test Equipment Program Review. . . . . . . . . . . . . . . . 10 M7.4 Corrective Actions for NRC Non-Cited Violations . . . . . . . . . . . . . . . . 13

M7.5 Implementation of the Maintenance Rule . . . . . . . . . . . . . . . . . . . . . 15 lli . Engineering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

. E7 - Quality Assurance in Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

IV. Plant Support ' . . . . . . . . . . . . . . L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 R7 - Quality Assurance in Radiological Protection and Chemistry (RP&C)

- Activities . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 R7.1 Radiation Protection (RP) Program Problem Identification and

+ Resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 R7.2 . Chemistry Program Problem identification and Resolution ' . . . . . . . . 18

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-P7- Quality Assurance in Emergency Preparedrass Activities . . . . . . . . . . . . . . .. . . . . . . 19 S7 . Quality Assurance in Security and Safeguards Activities . . . . . . . . . . . . . . . . . . . . . . 20

'F7 Quality Assurance in Fire Protection Activities . . . . . . . . , . . . . . . . . . . . . . . . . . . . . 20 V. Management Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 X Exit Meeting Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 . . . . . 21 -

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PARTIAL LIST OF PERSONS CONTACTED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 INSPECTION PROCEDURES USED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 ITEMS OPENED, CLOSED AND DISCUSSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 LIST OF ACRONYM S USED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -. . . . . . . . . . . . . . . . . . . 23 F

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Report Details 1. OPERATIONS 07_ Quality Assurance in Operations

07.1 . Manaaement of the Condition Report System .

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l a; ;Insoection Scope (40500) I The inspectors reviewed the scope and effectiveneso of the corrective action program. A i

- representative sample of recent licensee-identified problems was reviewed to identify I

> how corrective actions were prioritized, tracked, implemented, and subsequently verified .

for effectiveness. Also, the level of management involvement, the feedback mechanisms .

for assessing corrective action effectiveness, the timeliness of corrective actions, and the effectiveness of performance trending were reviewe i

. Observations and Findings I i

Condition Reports in accordance with Nuclear Power Division Administrative Procedures (NPDAP) 5.2, initiation of Condition Reports, and NPDAP 5.6, Processing of Condition Reports, Beaver Valley Power Station (BVPS) has established a site-wide system for problem L identification (condition reports), trending, and corrective action.' Additionally, most

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. Performance Engineering (SPED), Maintenance Program Unit (MPU), Radiation

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this site-wide program. As a result, station management does not have readily available

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data base which encompasses all issue tracking systems at the station. Any plant staff member can write a condition report, which is then reviewed by the author's supervisor

, and then sent to the Operations Work Control Center (OWCC) for review. When the l OWCC is not open, condition reports are forwarded to the control room.

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. BVPS has established two committees to review, process and evaluate condition reports. The Condition Assignment Board (CAB) meets five days a week to evaluate -

submitted condition reports (CRs), classify them by significance on a scale of 1-5, and i assign due dates for proposed corrective sctions to be submitted. The Corrective Action Review Board (CARB) meets weekly to review and approve proposed corrective actions for CRs. Additionally, CRs initiated as part of the Quality Services Unit's (QSU) audit ;

and surveillance process, are tracked and controlled directly by QS l l

The inspectors noted that there are no time limits'placed for writing a CR after an issue j has been identified, nor for processing a CR to the CAB. Late in the inspection period, it was observed that the CAB was now noting CRs that had delays in being forwarded to the CAB, and that the licensee had written a CR to document this issu : ,

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One concern previously noted by the NRC (Inspection Report 50-334&412/98-11) and the licensee has been the high rejection rate of proposed corrective actions by the CARB, due to poor quality or lack of appropriate scope. A review of the rejection rate for proposed corrective actions to the CARB indicates that the rate has been steadily lowering over the past several month Condition report tracking and trending is coordinated by the Condition Report Program Administrator (CRPA) who works in the Safety and Licensing Department. Trending of CRs has generally been very limited until the past six months. This is noteworthy, since level 5 CRs are documented solely for the purpose of trending. The trending now occurririg is documented in a quarterly Condition Report Summary, which appears to adequately track and trend CR data. This system does not include data from any of the other issue tracking systems in use at BVPS, and, therefore, the data presented is only a ,

fraction of the actual tota l Special Committees BVPS has established a number of special committees to aid in ensuring that events at j the facility are properly evaluated and that corrective actions are developed and J implemented to prevent recurrence. Among these committees are the Nuclear Safety Review Board (NSRB), Onsite Safety Committee (OSC) and the Offsite Review Committee (ORC). The NSRB and ORC were reviewed as part of this inspection effor The OSC was previously reviewed by the NRC, as documented in NRC Inspection l Report 50-334&412/99-0 The NSRB was established to enhance management oversight and review of key issues to ensure thorough assessments and appropriate actions are taken. Meetings typically oc. curred on a weekly basis, or more frequently, as needed. Several NSRB meetings I were observed, and the meeting minutes for the past year were also reviewe l Discussion items observed included reviews of proposed procedure changes, Licensee Event Report (LERs) submittals and basis for continutd operation (BCO). Discussions were focused on safety issues, actions taken by the board were properly documented, and previous action items were tracked in the meeting minutes until close l The ORC functions as an independent technical advisory group to the President, Nuclear )

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Generation on all matters concerning safe performance and operation. Members are drawn from both BVPS and outside companies, with the chairman being from an outside i company. Regularly scheduled meetings were typically held every two months, with the l meeting rrinutes for the past year reviewed during this inspection. A number of.special meetings were also held to discuss specific issues, such as license amendment requests. The ORC also has five subcommittees (Audits and Inspections; Safety i Evaluation; Maintenance and Engineering; Operating Experience; and, Health Physics and Chemistry) which meet just prior to the regularly scheduled ORC meetings to i discuss, in depth, technicalissues associated with their specialty. The review of ORC l meeting minutes indicated that a broad variety of issues were discussed and reviewed, and a number of follow-up issues identified, issues classified as open items were formally tracked to conclusion, while recommendations and other issues were informally )

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As a result of these activities, committee identified programmatic issues are identified and reviewed, placed in the condition report system, and the corrective actions implemented are reviewed for completeness, accuracy and effectivenes Assessments of the Condition Report Proaram C' s audit and two self-assessments of the CR program and associated a ccuments/ records have been performed during the past year. QSU performed an audit of the Nonconformance control and corrective actions program in September 1998 (Audit BV-C-98-10), while two self-assessments, one of the CR program in June 1999 (BV-SA-99-21) and of the processing of LERs and associated CRs also in June 1999 (BV-SA-99-20) have been conducte The audit identified a number of weaknesses in the CR program, some of which have only recently been addressed. These include the lack of trending data and the lack of l self-assessments of the CR program. The self-assessments performed of this program i

have been focused on procedural compliance, with little performance-based evaluation.

l No significant changes to the CR program were attributable to self-assessment finding Recently, QSU has also begun to evaluate the quality of departmental self-assessment Although this initiative is not required by procedure, QSU has provided feedback to departmental managers, including recommendations on ways to improve the quality of self-assessment Conclusions The Condition Report (CR) program is only one of several issue identification and

tracking systems in use at BVPS. Although it is the only site-wide tracking system, each of the major departments also tracks issues in their own database Review of the Offsite Rev!ew Committee (ORC) and Nuclear Safety Review Board (NSRB) indicated that they were effectively implementing their charters, properly i reviewing and commenting on plant issues and events, and appropriately documenting -

their findings and recommendation .

Audits and self-assessments of the condition report program were conducted as required by plant procedures. Quality Services Unit (QSU) audits were of sufficient scope and

' depth to properly identify programmatic deficiencies and weaknesses. Salf-assessments were generally limited to compliance based program review Quality Services Unit's new program to evaluate self-assessments wcs a good initiative !

to improve quality and consistenc ' The Condition Report system has been effective in addressing issues placed into it, however, with the utilization of a number of alternative departmental level issue tracking systems, station management has no one readily available method to identify and trend all issues identified at the station.

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07.2 Corrective Actions Proaram in Ooerations Inspection Scope (40500)

The inspectors reviewed and assessed the Nuclear Operations Unit (NOU) and the Operations Procedure Department's (OPD) ability.to identify, resolve, and prevent recurrences of problems. The inspectors evaluated the various sources of problem l- identifcation, i reviewed corrective actions associated with those problems, and assessed l- the effectiveness of problem preventio Observations and Findinas'

l Problem Identification Methods The Operations Department has numerouw methods of identifying problems. Sources included CR's identified both within and outside of the operations department, self-assessments, and QSU audits. These sources have recently been better utilized by the l licensee, as evidenced by: (1) the number of CRs initiated by the operations department year-to-date nearly equals the total number of CRs generated in 1998 (552 and 579, l respectively); (2) the more recent self-assessments (since January 1999) have been

more detailed and self-critical than in the past indicating that corrective actions l

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associated with CR 990248, Site Self-Assessment Program is Marginally Effective, have -

produced improved self-assessments; and, (3) the quality of QSU audits has remained consistent over the past two years and QSU maintains a schedule of audits and department self-assessments to better integrate evaluation effort Interviews with nuclear operators, control room operators, nuclear shift supervisors, and work control center xW indicated that there was no knowledge of any adverse actions a taken against workw for raising concerns and that there was no hesitancy on the part of I the workers to raise concerns. Interviewees indicated that the CR process was clearly i defined as to when it was to be used. All but one of the interviewees has initiated CRs and indicated that they were mostly satisfied with the resolutions to their issue . A review of Category 5 CRs (least significant) summaries (assigned to operations) was i conducted end revealed that they were appropriately categorized except for one dealing '

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with exceeding an administrative limit for the rate of power increase for fuel conditioning

. following a refueling. The inspectors observed that Category 5 was mis-applied in this -

instance, i.e., the licensee's process would recognize this issue as more significant, and

. that the CR (990937) should be a higher category to preclude recurrence. The licensee !

agreed and initiated a CR and included its applicability to both units. This CR had been !

E originally categorized under a previous review process (i.e., prior to the creation of the )

l - Condition Assessment Board). Overall, Category 5 CRs were properly classified and given the appropriated consideratio :

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7 5 l - Recent self-assessments and QSU audits initiated CRs that identified issues that tended to be compliance-oriented, such as,' uncompleted forms or missing initials. This resulted from the assessors and auditors developing checklists based upon the applicable procedures goveming the evaluated area or department.- The self-assessments incorporated industry experience items, such as, institute of Nuclear Power Operations (INPO) good practices, into the assessments. The self-assessments also identified

" recommendations * (that did not meet the criteria of a CR) which were items noted as program enhancements which in some cases would also preclude future problems, such as, ways to reduce the caution tag backlog or modifying work control systems to provide traceability between work orders and OSTs. Self-assessment leaders stated that their finC9s were well received by department management. CRs and recommendations identified from audits and self-assessments were appropriately tracked and addressed by the operations department.

l Some of the self-assessments for NOU have been rescheduled to a later date, such as, control room administrative burden. It was also noted that the OPD has not conducted a self-assessment since 1996. Due to managerial changes in this department and the lack of documentation regarding this decision, it could not be determined why self-assessments were suspended for OPD. Accordng to NPDAP 8.29, Conducting Self-assessments, there are no requirements to conduct self-assessments except at the discretion of department managemem nor was there a time limit required to address or implement recommendations.~ The CR program has identified numerous items assigned to OPD and thus proceduralissues are being identified. Overall, self-assessments

- identified problems and provided meaningful input to the operations departmen Problem Resoj,ylig_rl Currently open corrective actions (185) from CRs do not have any immediate safety implications.. Thirty-four corrective actions are over one year old. Based upon a review of summary descriptions, the due dates for completion of the corrective actions were reasonable based upon the significance of the issues. Overdue or extended corrective actions were infrequent and of low safety significance (most originated from Category 4 CRs).

Reviews of selected CR packages (including Categories 1,2,3, and 4) that were initiated from non-cited violations, QSU audits, self-assessments, or individual initiatives I indicated that root cause evaluations, when required, and extent of c mdition reviews were acceptable to address immediate concems. Planned or completed corrective actions were appropriate, and timeliness of resolution was reasonable based upon the

. significance of the issue . Problem Prevention

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The licensee's trending capability has been evolving. it was determined that there was

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no clear guidance to define a trend. CRs are assigned Cause Codes for trending

, purposes but the codes varied in specincity Discussions with the CR coordinators for OPD and NOU indicated that the trending criteria was broad and, therefore, difficult to l

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address. A review of the CR's that resulted in the adverse trends being assigned to the OPD and NOU confirmed the coordinators' statements. The CRs dealt with varied systems, components, plant modes, and personnel making it difficult to identify a common theme to address.- Planned corrective actions for these trends was generic, such as, providing feedback to operaters, management briefings on the applicable issue, and departmental trending to identify trends earlier. Recently, each department developed Event Descriptors to assign to CRs to create more meaningful or specific l categories to trend.'

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The operations department has increased and improved its ability to identify problems i through the CR program and self-assessments. Corrective actions for identified problems were handled appropriately, in most cases; and the licensse is aware of and addressing areas for improvement. Inspectors observed no instances of significant ;

problem recurrence. Overall, the operations department's ability to identify, resolve and i t prevent problem recurrence is satisfactor The use of the condition report process for problem trending identification is improvin Quarterly trend analysis was performed at a very broad level. However, trend evaluations were not detaile . Maintenance M7 Quality Assurance in Maintenance Activities '

M7,1 Problem Identification and the Maintenance \ t '< Reauest Proaram l

a.' Jnsoection Scope (405001

During a plant walkdown, the inspectors identified 40 material deficiency tags on components that were potentially risk significant or safety-related. The inspectors reviewed each deficiency to assess the adequacy of the Corrective Actions and Maintenance Work Request programs to evaluate equipment operability, prioritize corrective actions, and resolve the identified problem ,

l l Observations and Findinas Beaver Valley maintenance personnel typically initiated corrective a::tions for material

' deficiencies and degraded components by using material deficiency tags. The inspectors reviewed 40 material deficiencies dated from April 1997 to August 1999. No i

. work order had been initiated for two identified deficiencies. Approximately eight i deficiencies, identified in 1997 and 1998, remained uncorrected. Condition reports had !

been initiated on only two of the identified deficiencies, and five deficiencies had been previously resolved, but the field tags had not been removed. Although the uncorrected deficiencies did not appear to be significant conditions adverse to quality, the planned i

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corrective actions did not appear to be appropriately prioritized and timely.

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' The iWaintenance Program Unit Condition Report Coordinator stated that considera' ole effort (!-2 person days) was required to determine which wc-k order requests had been initiated from the 40 identified deficiency tags. In several instances, the inspectors observed that the same deficiency had been identified on multiple tags or condition reports, prior to the initiation of corrective actions. Without a clear link between a

' deficiency tag number, a work order number, and a condition report, the potential existed for identified deficiencio to remain uncorrected. The licensee init:ated a CR for this issu ;

Goerability Determinations NPDAP 7,15, " Initiation of a Work Request," sections H.2 and 1.1, rt; quires an Operations '

Work Control (OWC) senior reactor operator (SRO) to evaluate each work request "to determine if the deficiency is reportable or affects the operability of the component." An OWC-3RO stated that deficiencies affecting component operability are typically identified by a work group directly to the control room Nuclear Shift Supervisor. The OWC-SRO further stated that by the time a Maintenance Work Request has been initiated from a mate 9ul deficiency tag, any required operability evaluation has already been performe The OWC-SRO stated he did not perform a discrete operability or reportability review for each work request, but would recognize an operability issue if it existed. The inspectors

observed two instances, during daily Work Control Screening Committee meetings, !

when component operability was questioned and discussed. The inspectors did not

, identify any instances where a material deficiency affected equipment operability or

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reportability and the equipment had remained in an operable statu Condition Reports NPDAP 5.2, " Initiation of Condition Reports," section IV.A.2, states all maintenance work l requests shall be reviewed in accordance with NPDAP 7.5 to determine condition report

' applicability. NPDAP 7 5 does not contain any guidance or requirements to review work i l requests for condition report appicability. However, NPDAP 7.15, section H.2, requires ,

l an OWC-SRO to evaluate each work request and, if necessary, initiate a condition !

= report. The inspectors discussed this requirement with an OWC-SRO and observed two !

daily Work Control Screening Committee meetings. The inspectors identified several l instances where the same or similar deficiency was sometimes entared into the work l

reauest process, sometimes into the condition report process, and sometime both. The inspectors concluded that the use of the condition report program, by Maintenance and Opomtions personnel, was inconsisten ,

The inspectors determined that condition repore were not always initiated and processed in a timely manner. A comparison betwo..i the discovery date, the Nuclear Shift Supervisor or Operations Work Control senior reactor operator review date. and the Conditions Assignment Board date indicated that 20% - 30% of the condition reports took 3 to 6 days after discovery to process and review. Condition report 992141 took 13 days from discovery to review. The inspectors noted that no guidance or requirements for timeliness were provided in either NPDAP 5.2, " Initiation of Condition <

Reports," or NPDAP 5.6, " Processing of Condition Reports." This issue was entered into the corrective actions program as condition report 99216 .

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Safety Iniection Gvstem Motor Ooerated Valves

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Material deficiency tags No. 3777 and 3779, dated October 1997, stated that MOV-SI-860A and MOV-SI-864B had " drifted roll pins." The roll pins connect the manual handwheel reach rod segments together. A missing or failed roll pin could prevent an operator from manually opening or closing these valves, in the event of a failed valve motor operator. There are emergency operation procedures which require manual operation of these valves. No condition report had been initiated for either valve, and the work orders to resolve this deficiency had not yet been scheduled. Operations was initially unable to provide a basis for operability for this 1997 degraded condition. . Based upon the inspectors questions, Maintenance and Operations personnel inspected the valve reach rods, and evaluated the degraded condition as not Impacting component operaoility. The inspectors noted that the issue was described insufficiently on the deficiency tag to appropriately evaluate operability and work prioritization. The inspectors concluded that the lack of a documented basis for operability, for two 1997 uncorrected degraded conditions, was a weakness in the corrective actions program, that was subsequently documented by the licensee in a C Charaina Pumo Lu AQil Cooler Discharae Pressure

. Material deficiency tag No.~ 20864, dated January 1998, identified an oil leak on the instrument line for the "A" charging pump lube oil cooler discharge pressure transmitter -

2CHS-PIT 250A. In January 1999, the plant computer system data point associated with this instrument was identified as cycling in and out of " bad data," in part, due to the oil leak at the instrument. No condition report had been initiated for this deficiency, however, a condition report had been initiated for a similar deficiency on the "B" charging pump pressure transmitter. This was an example of inconsistent use of the condition j report program. The inspectors noted that, although this did not appear to be a significant condition adverse to quality, the corrective actions did not appear to be timely, Conclusions

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Material deficiencies associated with safety-related or Technical Specification equipment i were inconsistently documented and tracked, sometimes under the Maintenance Work l Request program, by using a material deficiency tag, and sometimes under the i Condition Reporting program. Several examples were identified where corrective i actions were slow for safety-related deficiencies identified in 1997 and 199 Condition reports were not always initiated and processed in a timely manner, in that

.several condition reports took 3 to 6 days after disco'very to process and review. No guidance or requirements for timeliness were provided in the Beaver Valley condition report procedures. This issue was entered into the corrective actions progra i i

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M7.2 ' Unit 2 Gaseous Waste Oxvoen Analyzer Insoection Scope (405,QQ)

The inspectors reviewed the operability determination associated with the degraded condition identified on material deficiency tag No. 24798, to assess the adequacy of Beaver Valley's problem identification, operability determination, and corrective actions program . Observations and Findinas -

Material deficiency tag No. 24798, located at 2GWS-Fl150A, indicated that the ~"A"

Gaseous Waste Oxygen Analyzer (2GWS-OA100A) flow was less than 15 standard cubic feet per hour (scfh) on May 22,1999. Maintenance Work Order 99-207660, issued l '

to resolve this condition, was in planning and not yet scheduled for implementation. A previous condition report (CR 990364) dated February 26,1999, had identified that both

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the "A" and "B" analyzers had total sample flow below the required value of 15 scfh. This . I was an example of inconsistent use of the condition report program. The inspectors noted that the previous condition report was assigned to system engineering, and that i L the due date had been extended to September 10,1939.- The oxygen analyzers alert 1

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l operators prior to reaching potentially explosive gas mixtures in the waste gas holdup tanks. The inspectors did not identify any instances when explosive gas mixtures were j

,. 3sent in the waste gas holdup tank l Technical Specification (TS) 4.3.3.11 requires a daily channel check, when gaseous l waste tank volume is being processed. Operations stated that the daily channel check compared the percent oxygen readings between the "A" and B" analyzers, but did not compare or monitor the individual analyzer sample flows. Operations also stated that if an analyzer had less than the minimum required sample flow, the analyzer would b considered inoperable.' The inspectors identified that the operators did not clearly

document the channel check comparison between the oxygen analyzers. The inspectors identified similar issues for a source range nuclear instrumentation channel l

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check in NRC Inspection Report 50-334(412)/99-01. In March 1999, CR 990605 was l

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~ initiated to review other channel check surveillance procedures. Corrective actions were untimely and incomplete to address this issue. The Unit 2 Operations Manager acknowledged the inspector's findings and was evaluating corrective actions to address

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the concems, while initiating a condition report to document this issue, l

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!- 'In the' course of evaluating the analyzer operability with less than the minimum required

! sample flow, Operations and Maintenance subsequently determined that the flow l . indicators 2GWS-F1150A/B, in fact, did not indicate analyzer sample flow. In 1996, the original oxygen analyzers were replaced with a different model analyzer, authorized by Technical Evaluation Report (TER) 9786 as a like-in-kind replacement. The old analyzers did require 15 scTh sample flow, which was indicated by flow on 2GWS-F1150A/B.' However, the new model required only 2 scfh sample flow, which was indicated on a new flow indicator, located on the front panel of the new analyzers. The original flow indicators were left in-place, and by-pass lines were installed to divert 13 sefh around each new analyzer. The original flow indicators were not re-named, and remained labeled as " sample flow," while the new thw indicators were not labeled at all.

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l Maintenance surveillance procedures required analyzer sample flow be adjusted using i

' the new flow indicator, and identified the new indicator as the "left side flow gauge." The l

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operations procedure for analyzer startup and operation required both the original and ;

the new flow indicators to be used, to establish a by-pass flow of 13 scfh and a sample flow of 2 scfh, The original flow indicators (2GWS-Fl150A/B) remained on the PAB l operator log as " analyzer sample flow," and the new flow indicators were not added to the operator log. The inspectors concluded that Operations had not been monitoring the analyzer sample flows since the new analyzers was installed in 1996. Operation and Maintenance personnel rnissed several opportunities in 1999 to identify the discrepancy, such as during surveillance testing, and the evaluation of condition reports and deficiency tags. Since the daily channel check compared the readings from the oxygen l analyzers in both the "A" and "B" trains, not measuring the sample flow rates did not invalidate the channel chec CFR 50, Appendix B, Criterion lil, Design Control, in part, requires that measures to established to ensure that applicable regulatory requirements and the design basis are correctly translated into specifications, drawings, procedures, and instructions. The failure to adequately translate the design change, performed by TER-9786, into operator log and plant equipment labeling, in part, resulted in operation or failure to monitor analyzer s Tiple flow over a three year period. This is a violation of Appendix B Design Control rr tements. This severity Level IV violation is being treated as a Non-Cited Violation, ,nsistent with Appendix C of the NRC Enforcement Policy. This violation is !

documented in the corrective action program as condition report 992186. (NCV 50- l 412/99-06 01) J Conclusions Operations failed to monitor the correct flow indicator for the gaseous waste oxygen analyzer sample flow for a three year period, due to a failure to adequately translate a 1996 design change into operator logs and plant equipment labeling. Operation and Maintenance personnel missed several opportunities in 1999 to identify the discrepanc This is a violation of 10 CFR 50, Appendix B, Criterion Ill, Design Control requirement This severity Level IV violation is being treated as a Non-Cited Violation, consistent with Appendix C of the NRC Enforcement Poliet M7.3 Mgtgsurina and Test Eauioment Proaram Review Insoection Scope (40500)

'The inspectors reviewed the Measuring and Test Equipment (M&TE) program to assess the effectiveness of a July 1999 quality assurance audit, problem identification, and planned corrective actions.

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i 11 b. . Observations and Findinos The inspectors reviewed the following M&TE documents:

NPDAP 8.19, " Control and Use of Measuring and Test Equipment", Rev 4 i M&TE Usage Logs Retum of M&TE Delinquency Reports Delinquent M&TE Safety Review Reports j Lost or Out-of-Calibration M&TE Reports M&TE Calibration Records ]a

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M&TE Usaoe Loos and Return of M&TE Instruments i The M&TE Coordinator stated that all M&TE instruments were required to be retumed at the end of each work day. On August 25, the M&TE records indicated approximately l 40 instruments of M&TE had been checked-out and not returned for more than 30 day l .

Of those 40 instruments,18 instruments had been checked-out for longer than 90 days, 1 and 6 instruments, which were still checked-out for use, had expired calibration due dates. No condition report had been initiated to document these M&TE overdue issue The Instrument and Controls (l&C) group used an informal process to ensure that all i M&TE, checked-out for an extended period and used for multiple surveillance tests and work orders, were entered into the M&TE usage log, by having an M&TE clerk review l each completed l&C work package. However, other work groups, which checked-out )

M&TE for extended periods, appeared to enter only a single surveillance or work order number into the M&TE usage log. The inspectors concluded that, although l&C used an informal process, the control of M&TE for l&C usage was acceptable. The inspectors 4 noted that the potential existed for an incomplete review of the affects on safety-related equipment from M&TE which is subsequently found to be out-of-calibration. The inspectors concluded that this appeared to be a known weakness within the M&TE program, but had not been documented in a corrective actions program. A CR was subsequently written by the licensee do document this issu M&TE Safety Reviews for Lost or Out-of-Calibration M&TE Instrumentp M&TE Safety Reviews were performed to evaluate the affects of lost or out-of-calibration M&TE instruments on equipment. In July 1999, CR 991780, initiated as a corrective action from a quality assurance audit, identified that M&TE Safety Reviews were frequently not performed within the required 14 day time period. The M&TE Coordinator stated that the planned corrective action was to initiate a condition report for each assigned Safety Review which went overdue. The inspectors reviewed the last four

. quarterly Delinquent M&TE Safety Review Reports, and determined that 11 Safety Reviews from October to December 1998 had not been performed, and no condition report had been initiated; The inspectors concluded that the planned corrective actions from CR 991780 were too narrowly focused, because only the last quarterly delinquent report had been reviewed. The M&TE coordinator initiated a condition report to review this issue. This was an example of untimely and weak corrective actions.

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Lost or Out-of-Calibration M&TE Reoorts and M&TE Calibration Records The inspectors reviewed the M&TE usage logs, M&TE calibration records, and surveillance procedures which used the selected M&TE, for three selected M&TE ,

instruments, found out-of-calibration in October and November 1998, which had overdue '

Safety Review Mass flow meter l-D-1.421.3 was out-of-calibration on only the lower end of its range, by a small fraction of a percent of the full range. The inspectors concluded that the small calibration error would not affect equipment operabilit Mass flow meter I-D-1.421.4 was out-of-calibration at several points of the instrument range. The inspectors determined that this M&TE instrument had been used to calibrate the flow alarms for a gaseous waste radiation monitor (RM-GW106A) on surveillance procedure 1MSP-43.21-1. The inspectors reviewed the surveillance procedure and test data, and determined that the M&TE calibration error would not have adversely affected the calibration of the alarm setpoint Torque wrench l-11-2.6059 was out-of-calibration and found to apply torque values slightly higher than the indicated torque values, but within the typically allowable torque value acceptance values. The inspectors determined that this torque wrench had been checked-out for work order 1MWR069633. The maintenance technician who performed this work order stated that the torque wrench had been checked-out but had not been used during the work activit The inspectors determined that the out-of-calibration conditions, associated with the overdue M&TE Safety Reviews, for the three selected instruments, had no adverse affect on safety-related equipment. The 1998 overdue Safety Reviews were completed prior to the inspectorc' exit. No problems or equipment rework was identifie c. Conclusions i

Work groups kept Measuring and Test Equipment (M&TE) instruments for extended !

periods of time (i.e.,30 to 90 days). One group used an informal process to ensure that I all safety-related tasks affected by the M&TE were entered into the M&TE usage lo Other work groups appeared to enter only a single work task into the M&TE usage log, during the extended M&TE usage period. The potential exists for an incomplete review of the affects on safety-related equipment from M&TE which is subsequently found to be l out-of-calibration. This appears to be a known weakness within the M&TE program, but j had not been documented in a corrective actions progra !

In July 1999, CR 991780, initiated as a corrective action from a quality assurance audit, identified that M&TE Safety Reviews were frequently not performed within the required ,

14 day time period, to evaluate the affects of lost or out-of-calibration M&TE on )

equipment. The planned corrective action for this condition was to initiate a condition j taport for each assigned Safety Review which went overdue. However,11 Safety l Reviews from Octc,ber to December 1998 had not been performed, and no condition repori had been initiated. A condition report was initiated to review this issu !

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M7.4 Correctiyg Actions for NRC Non-Cited Violations

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, Insoection Screa (40500) i i

The inspectors reviewed maintenance documentation, surveillance test procedures, and interviewed system engineers to assess the effectiveness of corrective actions for selected previously identified violations of NRC requirements.

Observationg_and Findinas

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4160 Volt (4kV) Breakers I In December 1997, the 4kV system was evaluated as a Maintenance Rule category (a)

(1) system following two maintenance preventable functional failures. Beaver Valley engineers determined that the failures were caused by aged and hardened lubrication in the breaker operating mechanism. NRC Inspection Report 50-334(412)/98-09 documented that Beaver Valley had not been performing the vendor recommended breaker maintenance activities, which, in part, contributed to repetitive breaker failure The failure to identify and correct repetitive 4kV breaker failures was identified as a

. violation of NRC requirements (NCV 50-334(412)/98-09-02).

The inspectors reviewed the Maintenance Rule evaluations, associated condition reports, planned and completed corrective actions, and selected maintenance l

procedures. The plenned corrective actions included overhaul of the Unit 14kV circuit

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breakers (Unit 2 4kV circuit breakers were overhauled prior to the Unit 2 start-up) and

! preventive maintenance procedure changes. Overhaul of all Unit i safety-related 4kV breakers had been completed. The inspectors reviewed preventive maintenance L ~ procedure %-PMP-E-36-015, and determined that the revised procedure provided clear

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guidance for inspection and lubrication of the 4kV breakers'.

The inspectors concluded that the completed corrective actions appeared reasonable to

- prevent recurrenc j 480 Volt Breakers

' in September 1997, the 480 volt system was evaluated as a Maintenance Rule category ,

l (a) (1) system following two maintenance preventable functional failures. Beaver Valley ;

! determined that the failures were cause by inadequate lubrication and improper breaker set-up. Beaver Valley further determined that inadequate testing methodology (reduced l

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operating voltages) allowed degraded breaker conditions to remain undetected. NRC L Inspection Repost 50-334(412)/98-09 documented that Beaver Valley had not been i performing the vendor recommended breaker maintenance activities, which, in part, i contributed to repetitive breaker failures. The failure to identify and correct repetitive 480 volt breaker failures was identified as a violation of NRC requirements (NCV 50-334(412)/98-09-02).

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The inspectors reviewed the Maintenance Rule evaluations, associated condition reports, planned and completed corrective actions, and selected maintenance procedures. The planned corrective actions included preventive maintenance procedure

!- changes and overhaul or replacement of the existing breakers. The inspectors reviewed preventative maintenance procedure %-PMP-E-37-010, and determined that the revised I procedure provided clear guidance for measurement of the breaker trip bar force and I testing of the breaker operating mechanism at reduced operating voltages. The 480 volt (

breaker overhaul program is ongoing. The progress appeared reasonable, but was l I

} adversely affected by Beaver Valley identified vendor quality concerns; Beaver Valley F recently selected a new vendor to complete the remaining breaker overhaul The inspectors concluded that the planned or completed corrective actions appeared reasonable to prevent recurrenc {

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J Instrument Calibration Error due to incorrect Data input I In January 1998, a technician transcribed the wrong values from an engineering data I sheet into a maintenance surveillance test. This error resulted in the Unit 1 power range neutron flux instrument over-temperature / delta-temperature trip setpoint being adjusted to a wrong value. The post maintenance reviews by Maintenance and Operations Departments, prior to restoring the instrument to operation, did not detect the error. NRC Inspection Report 50-334(412)/97-11 documented that the failure to conduct the instrument calibration in accordance with the approved maintenance surveillance procedure was a violation of Technical Specification requirements (NCV 50-334/97-11-07). This violation was entered into'thecorrective actions program on condition report 980139, in January 199 The inspectors reviewed the condition report assessment, planned and completed corrective actions, and selected maintenance procedures, MPUAP 4.9, " Performance of Maintenance Procedures," was revised in December 1998 (original due date was June 1998) to clearly define the responsibilities of the Procedure Reviewer and clarify the requirements of the post performance review. A maintenance surveillance procedure review identified which procedures required data transcnption, and those procedures ,

were revised to add an independent verification (double sign-off) for the transcribed data. '

The procedure revisions were completed in February 1999 (original due date was September 1998).

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The inspectors concluded the corrective actions appeared reasonable to prevent ;

recurrenc i c. Conclusions

A review of Beaver Valley's response to three instances of non-cited violations of NRC j requirements concluded that comprehensive evaluations had been performed, and that

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the planned or completed corrective actions appeared reasonable to prevent recurrenc l j

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l- M7.5 Imolementa.fon of the Maintenance Rule l^

! Insoection Scooe (40500)

The inspectors reviewed the Maintenance Rule program to assess the effectiveness of problem identification, problem evaluation, and planned corrective actions.

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- Observations and Findinas The inspectors reviewed five Maintenance Rule Category (a)(1) Disposition reviews, and ;

concluded the category (a)(1) evaluations were well documented and complete. The 1 recommended corrective actions were broad based, and the extent of condition l considerations crossed both system and Unit boundaries. The established goals l appeared reasonable to monitor the effectiveness of the planned corrective action While only 2 Unit 1 systems and 3 Unit 2 systems had been in a category (a)(1) status -)

longer than two years, the inspectors noted that the total number of systems in a category (a)(1) stMus had increased over the past two years.

l The inspectors noted that the category (a)(1) disposition reviews and planned corrective actions were not entered into the condition report program, but v,ere documented and tracked in a System and Performance Engineering Department database (the SCARES .i program). This was an example of inconsistent use of the condition report progra j Prior to the inspectors' exit, Beaver Valley management directed that condition reports be init;ated for Maintenance Rule evaluations and planned corrective action Conclusions The problem identification and corrective action aspects of the Maintenance Rule program were well managed, appropriately implemented by system engineering, and appeared effective in identifying system problems and improving system performanc !

111. Ennineerina E7 Quality Assurance in Maintenance Inspection Scope (40500) i This inspection included an assessment of Condition Report (CR) Process and self-assessment activities as it applies'to engineering at Beaver Vallev. This inspection was accomplished through a review of applicable procedurea abw of condition reports and associated corrective actions; and, exani&g self-assessment activitie l h. -

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p 16 l Findinas and Observations j Procedures The inspectors assessed the Condition Report Process as governed by Nuclear Power

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Division Administrative Manuals Procedure (NPDAP) 5.2, Revision 10, " Initiation of Condition Reports," and NPDAP 5.6, Revision 4, " Processing of Condition Reports." ~

' The inspectors reviewed both of these procedures and found procedure NPDAP 5.2,

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adequate. However, the inspectors observed a weakness associated with NPDAP 5.6, j as it applies to engineedng, specifically extent of condition. The definition and instructions for extent of condition reviews do not appear in the body of the proc 0 dur The licensee acknowledged this observation and indicated that they will incorporate it L into the corrective actions associated with a CR that has been already initiated to address procedural deficiencie The inspectors noted that, in engineering, the process lacks trending br CRs and their l associated corrective actions. The licensee stated that this lack of trending was I i

identified prior to this NRC inspection. The inspectors also noted weaknesses on i guidance for closing condition reports, to which the licensee indicated that there is a CR I addressing this issu !

Condition Reco_lig l

L The inspectors reviewed a selected population of CRs in the engineering area and made the following specific observations:

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I CR No. 990016 addressed a lack of a formal program for the disposition of discrepancies between as-built configuration and as-designed documents. During an internal audit, the Quality Service Unit (QSU) identified a lack of a formal program to track and trend the

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disposition of discrepancies between as-built configuration and as-designed document The coirective action to address this CR, consisting of a revision of the pertinert l procedure, was completed. The inspectors verified that procedure DDP 3.5, entitled ;

l ' " Engineering Drawings and Sketches," was revised to incorporate Section 4.4.4, which

addresses identification, notification, documentation, and processing of identified H discrepancies between as built and as-designed documents. The inspectors found that this procedure revision was acceptabl <

CR No. 990017 addressed a failure to comply with procedural requirements for the updating of Type i drawings within the prescribed 14 days of Operational Acceptanc Specifically, during an intemal audit, OSU identified instances where this requirement was not met. The inspectors reviewed the corrective actions prescribed in the CR and found them acceptable.

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Self-Assessment Activities i

The inspectors reviewed several QSU audits conducted during the last two years of the Nuclear Engineering Division (NED) self-assessment program. To support these !

reviews, the inspectors conducted a number of interviews with NED personnel and noted that these audits were performed in sufficient detail and with a very constructive and critical attitude. For example, as a result of a QSU Audit performed in January 1999, a

.CR was initiated documenting that the NED self-assessment program was marginal and did not follow procedure NPDAP 8.29. The inspectors reviewed the CR and the associated corrective actions and interviewed cognizant personnel and determined that ;

the corrective action to address this deficiency was well formulate l l

The Engineering Assurance Section conducted a lessons learned discussion with NED '

personnel performing a Fire Protection self-assessment. The inspector found these and other corrective actions were effective and adequate to address conditions adverse to i quality that if not corrected may have become precursors for otner problem Conclusions The licensee's Condition Report procedures lacked a clear defiration of the concept of extent of condition reviews and guidance for closing condition report The Quality Services Unit (QSU) has been conducting effective audits of the Nuclear Engineering Department (NED). These audits were performed in sufficient detail and with a constructive and critical attitude. Corrective actions were found effective and the details were handled in a professional manne IV. Plant S sport

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R7 Quality Assurance in Radiological Protection and Chemistry (RP&C) Activities i

R Radiation Protection (RP) Proaram Problem Identification and Resolution Inspection Scope (40500)

Seventy-one condition reports assigned to the health physics department during 1998-1999 were reviewed. Also reviewed were four self-assessment reports covering various topical areas during 1997-1998, and a QSU audit dated December 11,1998 was reviewed. In addition, April, May, and June 1999 health physics department surveillances, health physics open items list and the trending of health physics l performance indicators were reviewed. Interviews were conducted with the health physics manager and health physics operations supervisors.

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18 Observations and Findinos The health physics departmrat self-assessments and QSU audit were generally comprehensive and did not .esult in significant findings or program improvements with the exception of a self-assessment of portable air filtration units, which provided significant program improvement recommendations. The requisite condition reports were developed and issues were appropriately resolved. The health physics surveillance program was active and averaged over 40 surveillances per month. The health physics open items list tracked condition report corrective action closure items -

and other business activities. Several health physics performance indicators were tracked and trended providing an effective program performance overvie Management support for the condition report program was evident in a required quarterly department report to the Senior Vice President, Nuclear Services requiring information on the corrective actions backlog and steps planned to manage the backlo Most of the health physics condition reports that were reviewed were not safety significant. An exception was condition report 991008 dated April 19,1999, that identified general dose rates in the Unit 1 ResiduM Heat Removal (RHR) platform that were four times higher than observed during the previous refueling outage. A thorough ..

investigation and cause was determined by comparing historical dose rate readings and corresponding reactor coolant radioactivity concentrations. An excellent correlation was found and the licensee determined that the four times higher dose rate would have been expected based on the reactor coolant radioactivity level and the condition report was close A non-cited violation,97-11-11, was reviewed to assess proper cause determination and resolution by the licensee.- The issue was failure of the Unit 2 control room ventilation to meet single failure criteria. The corrective actions included a letter notifying the NRC and the review of all design basis analysis calculations that use the emergency pressure fan flow rate as an input parameter. Corrective actions were sufficient to address the deficienc Conclusions ~

The CRs generated within the radiation safety department generally did not involve issues of safety significance. Audits and self-assessments were appropriately performed and program improvements were made based upon their result R7.2 Chemistry Procram Problem identification and Resolution Insoection Scope (40500)

Fifty-two condition reports were assigned to the chemistry department between 1998 and 1999, which trended down slightly from the previous two years. These CRs were reviewed along with a 1998 QSU chemistry program audit and a 1998 water chemistry self-assessment audit. Also, selected samples of chemistry surveillances, conducted by chemistry supervisors during 1999, were reviewed. Interviews with the acting Chemistry Manager and a senior Chemist were also conducte Observations and Findinas The chemistry department utilizes several mechanisms for problem identification and resolution which are appropriately funneled into the condition report program for the more significant issues. The chemistry work surveillance checklist program and the QSU

- program audit did not generate significant findings or program improvement I recommendations. For the chemistry program, the use of outside industry experts for performing a May 1998 self-assessment audit of the water management ;.,rogram was very productive.: A number of condition reports resulted from this audit and good follow through in implementing corrective actions was eviden One audit finding, noting the corrosion capability of non-treated river water utilized for the fire protection system (CR 9841526), was assigned to the system engineering organization for corrective actions. The resolution of this condition report invo".;d trending of fire protection system piping wall thickness measurements rather than addressing the cause of corrosion as ider tified oy the chemistry self-assessmen Conclusions The identification of problems in the chemistry area has been effective based on routine surveillances conducted by the chemistry staff and a recent self-assessment audit.

P7 Quality Assurance in Emergency Preparedness Activities Insoection Scone (40500)

Fourteen condition reports in 1999 were assicned to the emergency preparedness (EP)

department and were reviewed. Several 1998-1999 QSU and EP department self-assessments were reviewed. In addition, the EP department also utilizes an open item tracking cystem to capture improvement items and exedse deficiencies involving i'

outside agencies. Sixty-seven items were written in 1999 and reviewed during this inspection. An interview with an EP Supervisor was also conducte b.' Observations and Fint)ingsn No sginificant findings resulted from the various problem identification mechanisms. The EP open item tracking system did not contain any problems that may have met the criteria for a condition report. Four open items reviewed were follow-up of various emergency exercise deficiencies identifled by the Federal Emergency Management Agency (FEMA) that involved outside licensee organizations. These items did i.ot result in condition reports as the actions involved organizations outside the control of the

. licensee. This was considered acceptable since FEMA had already identified the weaknesses and the report distribution included the deficient organization Conclusions The idemification and resolution of emergency preparedness problems was effectiv l- i

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S7 ' Quality Assurance in Security and Safeguards Activities Inspection Scoce (40500)

' A total of eleven CRs were assigned to security during the previous three years which were reviewed during this inspection. Several QSU and security self-assessments were conducted during 1998-1999 and were also reviewed during this inspection. In addition, the 1999 written reports from the security observation tour program were reviewe . Observations and Findinos From 1997 through 1999, there were very few problems identified affecting the safeguards and security program. Few significant findings resulted from the QSU security program audit and security self-assessments. The security observation tour program was robust and produced a large number of program refinements and improvements. None of the observation tour reports reviewed included any condition report issues.

' Conclusiong Few security issues have been identified the past three years. The security department self-identifies program refinements and improvements through an active and robust surveillance piogra F7 Quality Assurance in Fire Protection Activities Inspection Scoce (40500)

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A sampling of condition reports, a July 1998 QSU audit, and a May 1999 nuclear engineering department fire protection self-assessment, wsre reviewed. The procedure NPDAP 3.5, Rev. 9, Fire Protection Manual, was also reviewed. Additiona!!y, samples of the system engineering fire protection engineefs monthly system surveillances and daily walkdowns of fire protection systems were reviewed. Interviews with SPED and NED personnel were also conducte Observations and Findincs A large number of condition reports have been written identifying problems in the fire protection area. The latest NRC fire protection inspection, NRC Inspection Report No (412)/98-10, concluded that inspector indicated that QSU had been effective in identifying deficiencies and that engineering support was slow in resolving the NED conducted a fire protection program engineering self-assessment to address many of these recurring issues in May 1999. As a result,22 condition reports were written to address the identified weaknesse . . . ..

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A non-cited violation,98-10-02, was reviewed to assess proper cause determination and resolution of a fire protection issue. The issue was failure to identify all cables and support equipment in a fire protection safe shutdown analysis for a Unit 2 boric acid

- valve. The licensee determined that the engineering evaluation did not include all cables needed for the valve. Corrective actions included a design change to modify the circuit so that valve 2CHS*FCV113A will fail safe open if cables are damaged by fire. All associated documents were changed to reflect the circuit design change Corrective actions were sufficient to address the deficienc Conclusion 1 Although many fire protection issues w.ere identified by the licensee through the CR process, the licensee has taken corrections to direct this safety significant prograr, are V. Management Meetings X1 Exit Meeting Summary I

The inspectors presented the inspection results to members of licensee management on August 27,1999, after the conclusion of the inspection. The licensee acknowledged the findings presented.

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22-PARTIAL LIST OF PERSONS CONTACTED

. M. Ackerman, Manager, Safety and Licensing

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R. Bisbee, Condition Report Program Administrator J. Bowden, Director, l&C Maintenance R. Brosi, Manager, Management Services T. Cosgrove, Manager, Outage Management J.- Cross, President, Generation Group J. Gallagher, Supervisor, M&TE Program, l&C Maintenance J. Giocondi, Supervisor, Quality Data Assessment K. Grada, General Manager, Planning and Scheduling E. Haley, Supervisor, FIN Inspector R. Hansen, General Manager, Maintenance Prograrns Unit R. Hecht, Director, Maintenance Support S. Jain, Senior Vice President, Nuclear Services M. Johnston, Security Manager

' W. Kline, Manager, Nuclear Engineering Department J. Kunz, Supervisor, Maintenance Support J. Macdonald, Manager, System and Performance Engineering Department M. Majeski, Senior Enginear, Engineering Assurance L. Myers, Vice President, Nuclear K. Ostrowski, Vice President - Operations and Plant Manager

M. Pearson, Manager, Quality Services Unit B. Gepelak, Licensing Engineer R. Snowden, Supervisor, Quality Control R. Vento, Manager, Health Physics R. Williams, Supervisor, Performance Engineering -

INSPECTION PROCEDURES USED

! IP 40500 Effectiveness of Licensee Process to identify, Resolve and Prevent Problems ITEMS OPENED, CLOSED AND DISCUSSED Ooened/ Closed 50-412/99-06-01 NCV Gaseous Waste Oxygen Analyzer Design Control Deficiency h

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23 LIST OF ACRONYMS USED l BCO basis for continued operation BVPS Beaver Valley Power Station CAB Condition Assignment Board CARB Corrective Action Review Board CF Code of Federal Regulations OR condition report CRPA Condition Report Program Administrato EP emergency preparedness FEMA - Federal Emergency Management Agency I&C instrument and controls LER- licensee event report M&TE measuring and test equipment MOV motor operated valve ,

MPU Maintenance Program Unit  !

MPUAP Maintenance Program Unit Administrative Procedure i'

NCV non-cited violation NED Nuclea Engineering Department

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NO Nuclear Operations Unit NPDAP Nuclear Power Division Administrative Procedure NSRB- ' Nuclear Safety Review Board OPD Operations Procedure Department ORC: Offsite Review Committee OSC' Onsite Safety Committee OWC' Operations Work Control OWCC- Operations Work Control Center PAB primary auxiliary building PM preventive maintenance i QA.- quality assurance-QSU' ~ Quality Services Unit .

RHR residual heat removal SPED System and Pe:Tormance Engineering Department SRO senior reactor operator TE technical evaluation report TS technical specification