IR 05000344/1987009

Insp Rept 50-344/87-09 on 870330-0403.Violations Noted: Failure to Comply W/Procedural Requirements for Trending

ML20214Q625
Person / Time
Site:	Trojan File:Portland General Electric icon.png
Issue date:	05/12/1987
From:	Correia R, Crews J, Jim Melfi, Richards S, Wagner W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
To:
Shared Package
ML20214Q605	List: IR 05000344/1987009 ML20214Q601 ML20214Q611
References
50-344-87-09, 50-344-87-9, NUDOCS 8706050094
Download: ML20214Q625 (17)

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U. S. NUCLEAR REGULATORY COMMISSION

REGION V

Report No: 50-344/87-09 Docket N License No. NPF-1 Licensee: Portland General Electric Company 121 S. W. Salmon Street Portland, Oregon 97204 Facility Name: Trojan Nuclear Plant Inspection at: Rai er Oregon Inspection condu : arch 30 - April 3, 1987 Inspectors: [

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Da(e Srfgned R.fCorreipT&EIns cror L74 A.F.Melfi, React 6rInspector 4/ev 0(te Signed

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W g Wagner, p ctor Inspector f~ Z f 7 Date S'igned Approved by: M MRi6h'ards Y

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Inspection During the Period of March 30 - April 3, 1987 (Report 50-344/87-09)

Areas Inspected: This unannounced inspection was conducted by four rrgional based inspectors and one inspector from the NRC Office of Inspection and Enforcement. The inspection was to assess the effectiveness of the licensee's quality verification organizations. The organizations inspected included onsite Quality Assurance, Quality Control, Performance Monitoring / Event Analysis, the Plant Review Board, Corporate Quality Assurance, and the Trojan Nuclear Operations Board. During this inspection, Inspection Procedures 30702 and 25578 were use Results: Of the areas inspected, one violation was identified for failure to comply with procedural requirements for trending (paragraph 4).

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8706050094 870512 PDR ADOCK 05000344 G PDR

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DETAILS Persons Contacted Licensee Pet 3onnel

• D. W. Cockfield, Vice President, Nuclear

• C. A. Olmstead, Trojan General Manager

• R. Jarman, Manager, Quality Assurance Department

• Yundt, Technical Functions General Manager

• Keuter, Manager, Technical Services

• Craft, Acting QC Supervisor

• J. Dunlop, QA Engineering and Support Branch Manager

• G. Zimmerman, Nuclear Regulation Branch Manager

• T. Walt, Nuclear Safety and Regulation Manager

• G. Stein, QA Engineer - PM/EA

• D. Nordstrom, Nuclear Regulation Branch Engineer

• A. Ankrum, Compliance Engineer

• J. D. Reid, Manager, Plant Services

• C. H. Brown, Operations Branch Manager, Quality Assurance B. Kershul, Engineer, Nuclear Safety and Regulation Department C. Allen, QC Inspector R. Wolford, QC Inspector J. A. Russell, QA/QC Specialist H. Goldman, HVAC System Engineer R. Budzeck, Quality Engineer - PM/EA L. Stifter, Contract Quality Engineer - PM/EA D. Swan, Manager, Maintenance R Susee, Operations Supervisor Oregon Department of Energy

• H. Moomey, Oregon Resident Inspector Other licensee employees contacted included technicians, operators, mechanics and office personne * Attended the Exit Meeting on April 3, 198 . Inspection Focus The intent of the inspection was to assess the effectiveness of various groups, within the licensee's organization, in identifying problem areas, participating in the formulation of actions to correct problems, and verifying the implementation of corrective action. In performing this assessment, the inspectors considered several factors including the qualifications of the personnel assigned, the scope and depth of the i reviews performed, the resources available, the level of sensitivity to issues, and the overall involvement of the group in the operation of the facilit _ - .. _ _ _ .-

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v 2 3. QA Auditing of Corporate Engineering and Vendors The activities of the PGE Quality Assurance Department's Engineering Branch (offsite QA) were assessed to measure the organizations effectiveness in contributing to the identification, salution, and prevention of safety significant technical problems and deficiencies in plant systems and operations. The NRC inspector's assessment was based on interviews with both management and staff of the offsite QA organization, and reviews of departmental procedures, audit and surveillance plans and reports. The NRC inspector made the following observations and comment Offsite QA is primarily responsible for performing audits of PGE's Nuclear Plant Engineering Department (NPED), the Nuclear Safety and Regulation Department (NSRD) and vendors supplying components and services to PGE for the Trojan facilit In addition to these audits, offsite QA conducts surveillances and reviews of activities where (a)

problems have been previously identified, (b) problems are suspected, or (c) the uniqueness of an activity warrants QA involvemen Offsite QA documents audit findings in two ways: nonconformance activity reports (NCAR) and recommendation NCARs require a response to address the root cause of the finding and corrective action to prevent its recurrenc Recommendations identify areas in which the QA auditors feel that a change in a method of an organization's procedural implementation would be more effectiv Offsite QA is responsible for the approval of NCAR responses, and they verify the implementation of corrective actions by reaudits, surveillances and reviews. Audit reports are distributed to the audited organization's manager and responsible supervisor, the plant general manager, the chairman of the Trojan Nuclear Operations Board (TN0B), the Vice President, Nuclear, members of the QA subcommittee of the TN08, and the Plant Review Board (PRB).

Offsite QA has also been responsible for documenting the " Annual QA Trend Analysis." The NRC inspector reviewed the 1986 analysis which consisted of data from audits conducted by onsite and offsite QA departments, as well as other departments in the PGE organizations. The summation of the audit results consisted of manhours expended, the total number of audits, surveillances and reviews performed on each organization, the number and types of deficiencies found, and the recommendations made. Trends consisted of graphic comparisons of previous year's data with those of the current yea The summary section of the analysis contained general recommendations for areas of noted weaknesses 7 " actions proposed by the QA Department to enhance their effectiveness The actions included improvements in corrective action and verification response times, more comprehensive procedure reviews and increased employee training to ensure procedural conformance. The NRC inspector concluded that the report was a comprehensive summation of audit data and that the recommendations and proposals emphasized increased attention to existing program conformanc However, it lacked in-depth and broad technical aspirations, such as an

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increased use of engineers as auditors within the QA organization, using technical staff in audits from other organizations both within PGE and from outside sources, and requiring engineering support during audits of vendors supplying technical service The NRC inspector also reviewed several recent corporate QA audits of NPED, NSRD and PGE vendors. The reviews consisted of an examination of the audit preparatica, its scope and depth, and its finding Audit preparation consisted of selection of team members, verifying that their qualifications complied with the PGE requirements for auditors, and developing the audit questionnaires and checklist The scope of each audit was to verify compliance with PGE departmental procedures and with selected 10 CFR 50 Appendix B criteria, Regulatory Guides, ANSI standards, and the Trojan Technical Specification Generally, the types of questions and checklists used in the audits for the various organizations included a review to determine if the audited organization complied with established PGE departmental procedure The audits' results reflected this type of verification. The NRC inspector asked QA offsite personnel if either audits or surveillances also included reviews of calculations, licensee event reports, license change requests, and safety evaluations, to determine their technical adequac Licensee personnel responded that as the experience and expertise of the auditor varied, the technical orientation and depth of the audit also varied. Licensee personnel also stated that the staff of corporate QA included two engineers functioning as auditors. The NRC inspector interviewed one of the engineer-auditors and reviewed a sample of his audit plans and findings. Knowledge and understanding of the technical issues, methods, and requirements used by engineering organizations were key factors in the audit conducted by engineers. Audit findings and corrective action verifications addressed not only compliance to program requirements, but also addressed in-depth technical root-cause analyses and identified problems which could have compromised the safe operation of the Trojan facility. For example, an audit of the PGE electrical engineering environmental qualification group's design change request activities resulted in an NCAR. The finding identified items subject to harsh environments which did not have an environmental qualificatio The corrective actions in this instance required an extensive re-review and verification that other such instances did not exis The NRC inspector also reviewed a PGE audit of Westinghouse's NSID organization. During this review, the NRC inspector noted that PGE QA auditors identified that PGE had specified in procurement documents that the reactor vessel head o-rings, control rod drive mechanism (CRDM) latch assembly and coil stack assembly were to be safety-related, and that the requirements of 10 CFR Part 21 applied. However, Westinghouse supplied these items as nonsafety-related and they did not invoke 10 CFR Part 2 The PGE auditors questioned Westinghouse about the matter and required detailed analyses to be performed justifying the changes. The auditor's report recommended that PGE engineers review the Westinghouse analyses to determine their validit The NRC inspector asked the responsible PGE QA auditors what had resulted from the engineering review of the Westinghouse procurement issue. Their response was that they did not know, but that they would contact the appropriate engineers. The QA

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.. 4 auditors determined that PGE engineers had at that time only concurred with the Westinghouse analyses that the CRDM coil stack assembly could be

'- classified as nonsafety-related. The NRC inspector then questioned the QA auditors why they had not pursued the issue by coordinating Westinghouse and PGE enginaering. They responded that they intended to follow-up on the matter during the next scheduled annual Westinghouse audi In this instance, the PGE offsite QA auditors had identified a significant safety concern, brought it to the attention of both the vendor and their own engineering staff for further analyses, but had not aggressively pursued and coordinated the corrective actions to ensure

, that the issue was resolved to preclude the potential installation of substandard or improperly qualified components in the Trojan plan The NRC inspector was concerned that the corporate QA auditors did not assume the lead role as the corrective action coordinators and properly prioritize the issue in relation to its relative significanc The NRC inspector also interviewed two engineering supervisors to obtain

their assessment of the effectiveness of the corporate QA audit functions. Both supervisors felt that the corporate QA organization's audit effectiveness had greatly improved during the past two years, and also that corporate QA was adequately identifying and seeking corrective actions for nonconformances which resulted from audits of their engineering organization At the conclusion of the inspection, the NRC inspector discussed with PGE onsite and offsite management the findings and conclusions reached as a ,

result of his review of the activities of the offsite QA organizatio They concurred that the effectiveness of the offsite QA organization would be enhanced by being more technically oriented. The NRC inspector

also emphasized that audit findings should be aggressively pursued and

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root cause analyses and corrective actions be detailed and in-depth with

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attention to technical issues. Emphasis was also placed on the trending of audit findings, not only to compile data on numbers and types of audit findings, but more importantly to use this information to identify potential problems in the Trojan facilit No violations or deviations were identifie . Trojan Nuclear Operations Board (TNOB)

Trojan Technical Specification 6.5.2 requires the establishment of the TNOB as an oversight committee functioning to provide independent review and audit of a broad spectrum of nuclear division activitie The Technical Specifications require the TNOB to meet at least once each six months, with a membership of at least five designated personnel meeting the qualification requirements delineated in the Technical Specifications. The TNOB reports to and advises the Vice President,

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Nuclear on those areas under review by the TN0 The licensee's Nuclear Division Procedure (NDP) No. 500-1, " Trojan Nuclear Operations Board," establishes the TNnB and provides the TN08

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charter. Previous NRC concerns during the 1984 timeframe focused on the perceived inability of the TNOB to function effectively due to the

relatively junior positions of the personnel assigned at that tim As

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stated in NDP 500-1, the licensee has strengthened the membership by assigning six top level managers to the TNOB, including the Trojan Plant General Manager, the General Manager of Technical Functions, and the Nuclear Quality Assurance Manager. In addition to the six nuclear division managers, a corporate non-nuclear manager with previous nuclear experience, and a consultant, are assigned to the TN0B. The Vice l President, Nuclear serves as an ex-officio member (non-voting).

I l The TN08 meets quarterly with each meeting lasting approximately two l days. Attendance by assigned members is mandatory, except under extremely unusual circumstances. Personnel assigned to the Nuclear Safety and Regulation Department function as the TN08 staff. They prepare reports and briefings, coordinate TNOB activities, and provide administrative suppor The inspector reviewed selected documentation associated with the TX !

including meeting minutes for the previous five TN0B meetings, audit reports by outside organizations of the QA Department, reports of TNbo subcommittees, and various miscellaneous TN08 correspondence and memorandum The inspector also discussed the TNOB with several TN08 members, including the chairman and vice-chairma The TN08 appears to focus much of its effort on review of plant events, primarily by review of Plant Review Board meeting minutes. TNOB staff personnel estimated that discussion of plant sWnts takes approximately 60% of the time of an average TN08 meeting. Discussione with TN08 personnel indicated that much of this discussion focuses on root cause determination and corrective action. A significant portion of the meeting comments recorded in the TNOB minutes relates to plant event The inspector considered the TN0B effort to follow plant events to be a strengt I Although the inspector found the TNOB to be in compliance with all requirements of the Technical Specifications to the degree TNOB activities were reviewed, the inspector made the following observations conct.rning the effectiveness of the TNOB:

As stated in NDP No. 500-1, a principal responsibility of the TNOB is to independently review the adequacy and effectiveness of the QA program, including the Nuclear QA Department (NQAD). NDP No. 500-1 requires the TN0B to audit NQAD annually. Per the Technical Specifications, audits of facility activities are performed under the cognizance of the TN0 Based on the review conducted, the inspector concluded that the TN0B is not critically assessing the effectiveness of the NQAD. For example, there was no indication in the meeting minutes reviewed by the inspector that the TNOB discussed the performance of NQAD in auditing engineering activities following the surfacing of a number of engineering problems in 198 These problems were documented in several NRC inspection reports, which were reviewed by the TN08. Additionally, the meeting minutes reviewed did not contain any indication of significant discussions concerning NQAD resources, personnel experience, or organizatio Meeting minutes do indicate that the TN08 recognized that NQAD performance prior to mid-1985 was weak, but now improving after

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reorganization under new management; however, the TN0B's role in this improvement appeared to be relatively passiv *

The last two annual TN0B audits of the NQAD were performed by organizations independent of the licensee. One was conducted by a consultant and the other by a joint utility audit grou The inspector viewed the audits as good efforts and found the results to be the type of material on which identification of weak areas concerning NQAD performance could be based, in conjunction with other performance indicators. The inspector concluded that the use of an outside organization to perform the annual NQAD audit was good, however, reports by the TN08 QA subcommittee concerning their review of the annual audit did not contain any discussion addressing the broader meaning of the findings or the overall performance of NQA The TNOB appeared satisfied that NQAQ respond only to the specific audit finding *

As discussed above, the TN0B does consider specific plant problems and events in a relatively detailed manner, however, based on the content of TNOB documentation, it appears that the TN08 discussion of broader nuclear industry topics is limited.

In summary, although the inspector concluded that the TN08 was functioning in accordance with regulatory requirements, the inspector coserved that the effectiveness of the TN08 may be increased by the TN08

taking an aggressive role in questioning the performance of NQAD and by more extensively considering the Nuclear Division's actions with regard g to the broader issues being addressed by the Nuclear Industr No violations or deviations were identifie S. Onsite QA Auditing and Surveillances l The purpose of this portion of the inspection was to assess the

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effectiveness of the licensee's onsite quality verification organizations. Specific attention was devoted to how each verification activity is planned, the qualifications of the auditors in the areas they are assigned to audit, whether the audits are technical or administrative in nature, and whether significant problems have been identified, and appropriate corrective actions taken by the license In order to accomplish this assessment, the inspecter reviewed the following audit and surveillance reports: PGE QA Audit of ISI/IST Activities This audit, conducted from October 18 through November 1, 1985,

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resulted in issuance of one NCAR and six recommendations.

QA Surveillance of Inservice Inspection

' This surveillance covered ISI of the reactor vessel and associated balance of plant equipment. No NCARs were issued. The surveillances were conducted May 7-9, 13-14, 16, 23, 27 and 29, 1985, and documented in QA Surveillance Report No, MRS-SR-024-8 .

,.* 7 c. QA Surveillance of QC Inspections by Independent ISI Contractors This surveillance, conducted May 9-10 and 13-16, 1985, resulted in one NCAR addressing lack of documentation certifying qualifications to perform and evaluate radiography. This documentation was supplied by the vendor and NCAR No. P85-18 was close The inspector reviewed the qualifications of the auditor who conducted these ISI surveillances. The auditor was a Level II in MT, PT, UT (Thickness) and RT (Film Interpretation), and Level II in Mechanical, Welding, Electrical and Receipt Inspectio The Trojan NDE qualification program is based on ASNT-TC-1 d. PGE QA Audit of Trojan Nuclear Plant Operations Department Activities This audit, conducted from January 20-24, 1986, resulted in the issuance of seven NCARs and nine recommendations. In reviewing the qualifications of the audit team members, the inspector noted that one of the auditors was a certified Shift Technical Advisor; this individual, a nuclear engineer with NSRD, served as an Technical Advisor to the audit team. The Technical Advisor's participation was particularly significant in identifying problems within the Operations Department by witnessing ongoing activities with the Control Room such as Operator performance, Shift Supervisor

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direction, and shift turnovers. Types of nonconforming activities ( identified were (1) equipment outage worksheets not reviewed by the

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Shift Supervisor or Control Operator at the beginning of their shift (NCAR No. P86-005), (2) walkdown of 90 valves revealed that P&ID M-215 incorrectly identified the positions of six valves as stated in the Incked Valve List (NCAR No. P86-007), (3) one of two A0 routine inspection and surveillance tours not completed on time (NCAR No. P86-008), and (4) an annunciator out of service in excess of one week that was not identified and controlled as a Temporary Modification (NCAR No. P86-010). The inspector also reviewed letter RES-043-86 which provided a positive response to all nine recommendations of the audit tea e. PGE QA Audit of Trojan Nuclear Plant Maintenance (Mechanical /

Welding) Department Activities This audit, conducted from March 24-28, 1986, did not identify any nonconforming conditions, however, 11 recommendations for program improvement were provided. The QA Department utilized the expertise of an outsidc consultant for this audi The consultant audit team member was a profession mechanical engineer registered in the State of Ohio with 20 years experience in the nuclear industry and quality assurance related programs. One audit team member, who is also part of the NQAD staff, has been a American Welding Society (AWS)

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i PGE QA Department Surveillance of Inservice Inspection and Reactor Coolant System Nondestructive Examination (Surveillance Report N P109)

No nonconforming conditions were reported for this surveillance conducted from April 22 through May 12, 198 PGE QA Audit of Trojan Material Control Activities This audit, conducted from July 7-15, 1986, resulted in the issuance of five NCARs, two NCRs and nine recommendations. -The outside consultant addressed in Section e. of this report was also a team member for this Trojan audit. NCAR No. P86-066 identified five nonconforming iters in the warehouse that were not identified with QC Hold Tags. NCAR No. P86-068 identified that rotating elements of stored rotating equipment were not being rotated quarterly. NCAR No.86-138 identified the use of wrong stud bolt materials used in an installation on Cooler No. V254 PGE QA Audit of Trojan Nuclear Plant Maintenance Department (Control and Electrical) Activities The audit, conducted from October 6-10 and 13-15, 1986, resulted in issuance of four NCARs and six recommendations, PGE QA Audit of Plant Modifications Activities This audit, conducted from October 20-24, 1986, resulted in five NCARs and seven recommendations. An outside consultant was utilized in this audit. The consultant's qualifications include 25 years experience in NDE, QA/QC and systems evaluation, and registration in the State of California as a Professional Engineer in Quality Engineerin PGE QA Audit of the Trojan Nuclear Plant Operations Department Activities Two NCARs and four recommendations were issued as a result of this audit conducted from January 12-16, 1987. Review of the auditor qualifications revealed that one team member is a shift supervisor and a licensed SR PGE QA Surveillance of Mechanical and Hydraulic Snubber Inspection and Testing This surveillance was conducted from April 21 through May 12, 198 The auditor possessed the necessary qualification to perform this activity as was evident by the surveillance report (SR No. P110).

The NRC inspector inquired as to whether the acceptance criteria for snubber lock-up and bleed rate compensate for the affect of temperature at which the functional test was performed. The licensee informed the inspector that the viscosity of the snubber fluid remains constant over the test temperature ranges of concern (80-110*F). However, the technical information to support this s

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statement could not be produced during this inspection. Until this information is received and reviewed by the inspector, this item will remain open (Unresolved Item No. 87-09-01). Audit of the Trojan Radiation Protection Activities This audit, dated March 24, 1986, identified two Nonconforming Activities and issued two NCARs. The NCARs were written concerning inadequate technical reviews on certain procedures, and for a leak test requirement that was not specified for a radioactive sourc Ten recommendations were also included in the audit of radiation protection. The audit was performed using QA personnel and a technical adviso Audit of Trojan Chemistry Activities This audit, dated October 10, 1986, identified two Nonconforming Activities and issued two NCARs. The NCARs were written when it was found that whiteouts had been used on QA records and a required

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space was necessary on another form. The audit was performed with a qualified consultan The report questioned procedures and the technical basis of certain sampling activities. The report also had seven recommendations for improvement of chemistry activitie Surveillance of the Trojan Leak Testing of HVAC Systems This surveillance, dated April 3, 1986, reviewed personnel qualifications, equipment calibration, and observed testing activities on the HVAC system. One NCAR was written to document a procedural deficiency which was implemented prior to its approva No other problems were identifie Surveillance of the Trojan MSIV Modification Work This surveillance, dated May, 12, 1986, reviewed personnel qualifications and contractor performance. The work area was inspected for cleanliness and scaffold safety, tool control, radiation protection and material contro One recommendation was made for Nuclear Plant Engineering to provide sufficient detail in their purchase orders to allow for a detailed receipt inspectio No other problems were identifie Surveillance of the Trojan Valve Repairing and Repacking Activities This surveillance, dated June 6, 1986, reviewed personnel qualifications, contractor performance, and observed work on valve repacking and replacement. The licensee found the workers qualified and the work adequate. No problems were identified, Surveillance of Control Room Emergency Ventilation Systems Testing This surveillance, dated September 5, 1986, included observation of inspections, tests, modifications, and maintenance activities on the ventilation system. The surveillance was more extensive than the

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previous surveillance on the HVAC system as these systems were found to be inoperable by the NRC earlier in 1986. The surveillance report states that corrective actions have been taken to restore control room habitability. One Nonconformance Report (NCR) was issued relating to traceability of documentation. There were five recommendations mentioned in this surveillance that dealt with humidistat settings, inleakage/outleakage requirements, and flow measurements. No other problems were identifie In reviewing NQAP No. 114, the inspector noted that trending information obtained from the NQAD is required to be entered onto a Trend Analysis Data Form (TADF), on an ongoing basis. The procedure also requires this form to be completed and issued at the completion of each audit or surveillance. When asked to review these data forms, the inspector was informed that the TADFs were not being completed. Four audits and one surveillance were completed since implementation of NQAP No. 11 The failure to comply with trending requirements as specified by procedure is considered an apparent violation (50-344/87-09-02).

The inspector concluded that the licensee's audits are sufficientl planned and documented to assure adequate coverage of the applicable area being inspected. The audits and surveillances cover both the programmatic and the technical aspects of the activities being inspecte The audit scheduling is dynamic in that it permits important plant activities (ISI, IST, modifications) and events to be verifie The auditors utilized during these verification activities have direct experience and expertise in the area being inspected. If the expertise is not available within the QA Departr.ent, then outside individuals with the necessary technical or operational experience are being recruite For example, specific audit areas addressed included operator watch-standing, chemistry, I&C, QC, receipt inspection, and temporary modifications; only auditors with experience in these areas were audit team members. The audited organization's response to the audit /

surveillance findings were timely. The QA Department is satisfactory evaluating each response to assure that corrective actions, including the root cuuse, is adequately addressed. All audit activity reports are brought to the attention of upper managemen . Quality Control (QC)

The purpose of this part of the inspection was to assess the effectiveness of the licensee's onsite QC organization. The scope of this review was limited in that many of the functions of QC are more rigidly defined than those of the other groups reviewe The QC organization performs observations of in process work activities at the plant and writes observation reports on these activitie Attention was given to the qualification of QC personnel, whether specific problems were identified, and to note the corrective action Also, a selected sample of observation reports was reviewed by the inspector for content and depth of revie .- -___-_ _ _ _ - ____ _ - _ _ _ _ _ - _ _ _ - _ _ _ _ _ _ _ _ _ _ .

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The personnel reviewed were qualified to ANSI 18.7-1976 for QC work. QC activities have increased over the past year, with QC becoming a separate department. The number of hold points and observation points are designated for work activities. To the extent reviewed, the inspectors found that specific problems have been identified and tracked to resolution, and the content and depth of observations was adequat One area of concern was identified. The inspector was informed by a QC inspector that QC was observing Instrumentation and Control (I&C)

technical specification surveillance The surveillances are performed under Periodic Instrumentation and Control Tests (PICTs). The inspector was informed that the work is observed every Tuesday. Several concerns were identified by the inspector subsequent to this comment. These concerns included that: (a) the observation of work is routine and might not give a true understanding of the quality of I&C work; (b) the QC inspector could be looking at the same surveillances which could inhibit QC's effectiveness; and, (c) QC might not be allowed access to observe work at other time The inspector was informed that the schedule for I&C work is known a month in advance and that different work is scheduled and observed on Tuesdays. The QC inspector can observe any work that is performed on Tuesday. The inspector was informed that the QC inspectors are not inhibited in looking at work in progres The reason why work was

! s observed only on Tuesday seems to be based on interdepartmental (I&C and QC) convenienc The remaining area of concern is that the observation schedule is too routine. Since the times when the work would be observed is known by I&C personnel, the level of work quality might be different on other days. In the inspector's opinion, to enhance QC effectiveness when observing the PICTs, the observations of work activity should occur t

randomly. The frequency of observation could still be approximately weekly, but the day when the PICTs are observed should be varied. The concern of the routine scheduling of QC observation of I&C werk will be reviewed during a future inspection (Follow-up Item 50-344/87-09-03).

7. Performance Monitoring / Events Analysis (PM/EA) Group Formulation and Staffing Following the approval of resources by licensee management, the PM/EA group was established within the Quality Assurance Departmen The initial staffing of the group commenced in September 1986, and currently numbers four, including a contract engineer, two senior

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licensee employees and a secretary. The QA Manager and former PM/EA group manager is continuing to serve as Manager PM/EA, with a senior member of the group serving as Acting Manager in his absenc It is the current practice of the QA Manager, in cooperation with other line managers within the Nuclear Division to assign senior, experienced individuals on a one to two year rotational basis to the PM/EA grou The two senior members of the group currently assigned are, (1) a former SR0 licensed senior Operations Shift Supervisor and (2) a former Mechanical Maintenance Supervisor. The contractor employee currently assigned to the group is a person with several

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l years experience, principally in the areas of instrumentation, control and test engineerin b. Functions and Activities Facility procedures and records were examined and discussions relating thereto were held with the QA Manager-PM/EA Manager and members of his staff from which the following findings resulte The responsibilities and functions of the PM/EA group are principally two in natur One principal function is in the area of events evaluation / analysis. The other principal function is that of performance monitoring. These responsibilities and functions of the PM/EA are described in Nuclear Quality Assurance Department Procedure, NQAP No. 119, issued on December 12, 1986. Other responsibilities of the PM/EA as reflected in NQAP are those of the tracking and trending of events related information as well as other QA audit and surveillance findings and related dat (1) Events Evaluation Activities With regard to the PM/EA group's involvement in events evaluation / analysis, the QA Manager described the intent of both the QA Department and other senior line managers within the Nuclear Division as that of pursuing the long range objective of a substantial improvement in the post-event evaluation / analysis process (including root cause determination) by all parts of the Nuclear Division such that it becomes "a part of the culture" of the organizatio In an attempt to accomplish this objective, the PM/EA has, according to the QA Manager and other key line managers, been assigned lead responsibility for post-event analysis on selected events, and performed an evaluation of the analysis done by the responsible (assigned) line management on all other event A review of facility records showed the pattern of PM/EA involvement in the evaluation / analysis of events at the Trojan plant since its formulation to be consistent with that described above. The records revealed that during the period October 198G through March 31, 1987, the PM/EA had been assigned lead responsibility for the post-event evaluation / analysis of seven of a total of approximately 57 events selected for formal evaluation / analysis. The records further revealed that the PM/EA group had concurred in all evaluations, in some instances after concerns identified by PM/EA (particularly in the area of root cause determination)

had been satisfactorily resolve (2) Effectiveness of Events Evaluation Discussions with the PM/EA staff and key line managers revealed the impression that the PM/EA staff's root cause determinations, both as lead and as reviewer, had resulted in measurable improvement in the discipline and effectiveness of

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.* 13 the post-event evaluation / analysis process by all departments involve A particularly impressive instance examined by the NRC inspector, and one of the first post-event evaluations undertaken by the PM/EA group with lead responsibility, was that of evaluating a generally unsuccessful Radiological Emergency Plan Annual exercise on November 19, 198 Facility records indicated that in their evaluation of this event, the PM/EA staff employed numerous analysis techniques (including Fault Tree, Change Analysis, Event / Causal Factors and MORT) and according to their estimate expended 800-1000 staff hour Twenty-five major recommendations, many multi part, resulted from the PM/EA group's evaluation in this instance. The NRC Region V staff is of the view that implementation of the PM/EA group's recommendations resulted in substantial improvements in the Trojan plant staff's performance in subsequent EP drills, particularly in the activities of the Operational and Technical Support Center Discussions with the QA Manager revealed that the licensee is currently considering adding an additional individual with a strong engineering background to the PM/EA staff. The importance of this expertise to the PM/EA-QA staff was stressed, by the NRC inspectors at the time of the exit meeting, to provide QA capability to assess the effectiveness of engineering / technical activities comparable to that currently being achieved regarding operational activitie (3) Functions and Activities-Performance Monitoring With regard to performance evaluation activities, the QA Manager described the intent of the PM/EA group's activities as those aimed principally at assessing needed improvements to increase the effectiveness of various departments and functions within the Nuclear Division. In that regard, PM/EA's performance monitoring activities are, according to the QA Manager, intended to complement (rather than duplicate) the activities of the QA Department's audit staff. Whereas QA audits are aimed at determining compliance with NRC requirements and Trojan administrative and procedural controls, the PM/EA monitoring activities are aimed at "the pursuit of excellence"--thus, a higher level of performance than mere compliance with existing requirement An examination of facility records revealed that during the period October 1986 through March 31, 1987, the PM/EA group had conducted a total of 42 " Observation" audits of activities at the Trojan site--36 of which had been conducted during the period January-March, 1987. Each had been documented in Memorandum Reports from the PM/EA Quality Engineer to the responsible first line functional supervisor of activities which were the subject of observation, after approval by the PM/EA group manage r

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The format of the Memorandum Reports included a listing of Observations, Conclusions and Recommendation In discussing the purpose and intent of the recommendations included in these Memorandum Reports, the PM/EA Manager stated that no written response to the recoinmendations was required of the functional supervisor--the intent being that they were provided for the Supervisor's consideration and action as determined appropriate. He did explain, however, that as observations audits are repeated of those activities covered in the past, and where conclusions and recommendations are similar in nature to those of past observation audits, the Memorandum Report is sent to the next higher level of supervision or managemen Thus, the PM/EA group's recommendations are escalated within the line organization in accordance with the perception of responsiveness determined by the PM/EA staf (4) Effectiveness of PM/EA Performance Activities An examination of selected observation Memorandum Reports issued by the PM/EA group revealed numerous substantive recommendations based upon the observations and conclusions contained therei The NRC inspector did, however, observe an inconsistency in the practice of identifying, within the observation Memorandum Reports, the manner of documenting discrepant conditions (such as material degradation) observed, to ensure that such conditions were followed up for corrective actions in accordance with the QA program requirement Discussions were held with key Trojan plant department managers in an effort to assass their view of the overall effectiveness of the PM/EA group's performance monitoring observation activitie Some managers expressed some initial apprehension regar,ing activities by PM/EA staff members who had been in

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respo,iible positions previously within their organization thus, " knowing where the skeletons were hung." However, such apprehensions proved not to be the case, according to the managers interviewe All managers expressed approval of the performance monitoring -

activities of PM/EA, although some managers expressed further apprehension as to how their response to recommendations might be used by higher level management in the futur In one instance, a functional manager explained that observations made by the PH/EA group of activities for which he was responsible provided him opportunities to discuss specific performance aspects with subordinates that would not have been the case otherwis The performance monitoring activities of the PM/EA group, including hou findings of a quality or safety-related nature are to be docuraented for specific corrective action, and the

o 15 informal nature in which recommendations are to be responded to, had not been described in the QA Department procedures at the time of the current inspectio Discussions with the PM/EA group Manager revealed that such a procedure was currently in preparation, and was to be finalized in the near futur The need for such a procedure was emphasized by the NRC inspector at the time of the exit meeting at the conclusion of the inspectio . Plant Review Board (PRB)

The Plant Review Board (PRB) is the on-site organization that performs an independent review of operations to ensure that the Nuclear Plant is in conformance with established procedures, license provisions, and applicable regulations. The PRB is established in Trojan Technical Specifications 6.5.1 and is chartered under Administrative Order (AO)

A0-2- The licensee has been fulfilling the technical specification requirements with respect to the composition, duties, and responsibilities of the PRB

. and to the required frequency of meetings. The PRB is also meeting the requirements as to the necessary members to establish a quorum, and has designated alternates to PRB members. The Administrative Order closely follows the technical specification and the board members are qualified to ANSI 18.7-197 As part of this inspection to verify the effectiveness of the licensee's QA organizations, a sample of recent PRB meeting minutes were reviewe The PRB reviews many activities at the plant, and the threshold for their review seems to be low. The meeting frequency is approximately once a week, versus the technical specification frequency of once a month. Most of the procedure revision reviews noted and approved in the meeting minutes are actually performed in interoffice mail routing of the procedure revisions to the PRB members prior to the meeting. The PRB appears to be asking important questions under its charter and is tracking the resolution of their questions under a commitment tracking syste The reviews of important issues by the PRB appeared extensiv The PRB is requesting cognizant personnel to attend their meetings to talk about these issues. For instance, the meeting minutes on February 11, 1987, had an extensive discussion on Limitorque actuators, and their Environmental Qualification (EQ). It was noted during this inspection that the licensee has taken Limitorque off of its approved suppliers lis Also, the meeting minutes on March 4, 1987, had an extensive discussion on the station batterie A potential problem was identified when reviewing the PRB meeting minutes concerning e proposed change in positioning of fuel assemblies in the cor Due to a past problem with core barrel baffle jetting, the licensee amended their license to allow twenty fuel assemblies to contain stainless steel rods in place of fuel pins in the corner of the fuel assembly which faces the corner of the baffl The location of these fuel assemblies is limited to the corner locations by the plant licens ,.o

The licensee desires to relocate these special assemblies to the opposite corners of the core, due to fuel burn-up consideration This movement would place the stainless steel pins facing the center of the core, instead of facing the baffl The licensee concluded, after verbal discussions with NRR, that this change could be made without NRC approval because the special assemblies would still be located in corner locations, as required by the license conditio During the inspection exit interview, the inspectors commented that while the repositioning of the fuel assemblies appears to comply with the literal license condition, the inspectc-s questioned whether the repositioning would be consistent with the technical basis for the license conditio Although this issue did not appear to have a significant impact on safety, the inspectors encouraged the licensee to communicate their intentions and considerations in writing to NR Based on the review of th6 seeting minutes, the inspector concluded that the PRB is doing an acceptable job of reviewing plant activities, and further concluded that the degree of review by PRB has significantly increased over the past two year . Unresolved Items Unresolved items are matters about which more information is required to determine whether they are acceptable or may involve violations or deviations. One new unresolved item identified during this inspection is discussed in paragraph .

10. Exit Meeting The inspectors met with licensee management representatives denoted in paragraph 1 on April 3, 1987. The scope of the inspection and the inspectors' findings as noted in this report were discussed.