IR 05000346/2002011
| ML031880844 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 07/07/2003 |
| From: | Grobe J NRC/RGN-III |
| To: | Myers L FirstEnergy Nuclear Operating Co |
| References | |
| IR-02-011, IR-03-009 | |
| Download: ML031880844 (60) | |
Text
uly 7, 2003
SUBJECT:
DAVIS-BESSE NUCLEAR POWER STATION NRC SPECIAL INSPECTIONS - ADEQUACY OF SAFETY SIGNIFICANT PROGRAMS - REPORTS NO. 50-346/02-11 and 50-346/03-09
Dear Mr. Myers:
On June 27, 2003, the NRC completed two special inspections at your Davis-Besse Nuclear Power Station. This inspections reviewed your actions to resolve Restart Checklist Item 3, associated with the adequacy of your safety significant programs. Specifically, the first inspection evaluated your process for assessing the adequacy of safety significant programs and application of the process to accomplish detailed assessments of the Corrective Actions, Quality Audits and Self Assessments, and Boric Acid Corrosion Management Programs, Restart Checklist Items 3.a., 3.c. and 3.d., respectively. The inspection included a review of a sample of activities as described in the Davis-Besse Return to Service Plan and specifically your Davis-Besse Program Technical Compliance Plan. This plan described your activities to review, evaluate, and disposition program weaknesses to ensure that programs were fulfilling required obligations and included effective interfaces. The enclosed report documents the inspection results which were discussed on June 27, 2003, with members of your staff.
Report No. 50-346/02-11 discusses our first inspection of your safety significant programs.
Based on our inspection, we have determined that your Return to Service Plan and Program Compliance Review Processes provided a reasonable method for determining if the selected programs correctly implemented regulatory and other requirements, effectively interfaced with other supporting plant programs, appropriately considered industry experience, were properly staffed by qualified individuals, and resolved identified weaknesses or deficiencies in a timely manner. We also determined that your detailed reviews of the Corrective Action, Boric Acid Corrosion Control, and Quality Assurance Audit Programs were conducted in accordance with the governing processes.
Report No. 50-346/03-09 discusses our second inspection of your safety significant programs.
Specifically, the inspection focused on your Phase 2, in-depth efforts on the Boric Acid Corrosion Control, Inservice Inspection, Plant Modification, Corrective Action, Operating Experience, and Quality Assurance Programs. Our review also included your development of an integrated Reactor Coolant System Leakage Program. Based on the results of both inspections, we have concluded that your reviews for those programs appeared thorough. Also, the corrective actions sampled were considered effective.
Restart Checklist Items No. 3.b., 3.e., 3.f., and 3.g. are closed based on the completed inspections. Item 3.a, Corrective Action Program, will remain open pending further inspection of the effectiveness of your corrective action program that will be documented in Inspection Report No. 50-346/03-010. Although the program is considered sufficient, the Corrective Action Team Inspection plans to review several specific Condition Reports to assess the implementation of your recently revised program. Item 3.c, Quality Audits and Self-Assessment of Programs, is partially complete. Further inspection of the Self-Assessment area will be conducted in the future. Item 3.d, Boric Acid Corrosion Management Program, will remain open pending resolution of corrective action program documentation of engineering evaluations as discussed in the enclosed report. The enclosed report documents the inspection results which were discussed on May 23, 2003 with members of your staff.
Based on the results of the two inspections, no findings of significance were identified.
In accordance with 10 CFR Part 2.790 of the NRC's "Rules of Practice," a copy of this letter and its enclosures will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRC's document system (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/
John A. Grobe, Chairman Davis-Besse Oversight Panel Docket No. 50-346 License No. NPF-3
Enclosures:
1. NRC Special Inspection Report No. 50-346/02-11 2. NRC Special Inspection Report No. 50-346/03-09 See Attached Distribution
DOCUMENT NAME: C:\Roger's documents\ML031880844.wpd To receive a copy of this document, indicate in the box: "C" = Copy without attachment/enclosure "E" = Copy with attachment/enclosure "N" = No copy OFFICE RIII RIII RIII RIII NAME /RA DPassehl /RA DPassehl /RA DPassehl JGrobe Acting Acting Acting for/CLipa for/KOBrien/trn for/JJacobson DATE 07/07/03 07/07/03 07/07/03 07/07/03 OFFICIAL RECORD COPY
REGION III==
Docket No: 50-346 License No: NPF-3 Report No: 50-346/02-11 Licensee: FirstEnergy Nuclear Operating Company Facility: Davis-Besse Nuclear Power Station Location: 5501 North State Route 2 Oak Harbor, OH 43449 Dates: September 9, 2002 through June 27, 2003 Inspectors: K. OBrien, Branch Chief and Team Leader L. Kozak, Project Engineer N. Shah, Resident Inspector, Braidwood Approved by: Christine Lipa, Chief Branch 4 Division of Reactor Projects
SUMMARY OF FINDINGS
IR 05000346-02-11; FirstEnergy Nuclear Operating Company; on 09/09/2002 - 06/27/2003,
Davis-Besse Nuclear Power Station. Special Inspection - Programs Part 1 This report covers a special inspection of licensee activities associated with reviewing and evaluating the adequacy of safety significant programs. This inspection was conducted by Region III based inspectors. This inspection evaluated your program assessments for the Corrective Action Program, Boric Acid Corrosion Control Program, and the Quality Assurance Oversight Program.
The inspectors determined that the licensees Return to Service Plan and Program Compliance Review Processes provided a reasonable method for determining if a plant program correctly implemented regulatory and other requirements, effectively interfaced with other supporting plant programs, appropriately considered industry experience, was properly staffed by qualified individuals, and resolved identified weaknesses or deficiencies in a timely manner. The processes also included an appropriate method for evaluating and characterizing newly identified issues.
REPORT DETAILS
Background On March 6, 2002, Davis-Besse staff notified the NRC of degradation (corrosion) of the reactor vessel head material adjacent to a control rod drive mechanism (CRDM) nozzle. This condition was caused by coolant leakage and boric acid corrosion of the head material induced by an undetected crack in the adjacent CRDM nozzle. The degraded area covered in excess of 20 square inches where the low-alloy structural steel was corroded away, leaving the thin stainless steel cladding layer. This condition represented a loss of the reactor vessels pressure retaining design function, since the cladding was not considered as pressure boundary material in the structural design of the reactor pressure vessel. While the cladding did provide a pressure retaining capability during reactor operations, the identified degradation represented an unacceptable reduction in the margin of safety of one of the three principal fission product barriers at the Davis-Besse Nuclear Power Station (reference NRC report 50-346/02-03(DRS)).
As part of the corrective actions resulting from the reactor vessel head degradation, the licensee established a Return to Service Plan to identify, monitor, and control all actions necessary for the safe and reliable return to service of Davis-Besse. The Plan consists of seven Building Blocks designed to support safe and reliable restart of the plant and to ensure sustained performance improvements. One of the Building Blocks, Program Compliance Plan, was tasked with performing reviews of selected plant programs to ensure that the programs were fulfilling required obligations, including effective interfaces and handoffs. The NRC inspectors review of these activities included an assessment of the overall process and a focused review of three licensee program reviews.
OTHER ACTIVITIES
4OA3 Event Follow-up
.1 Restart Action Plan and Program Compliance Review Processes
a. Inspection Scope
The inspectors reviewed the licensees Restart Action Plan and Program Compliance Review Processes. The inspectors also reviewed the licensee staffs implementation of the discovery phase evaluations for the Corrective Action, Boric Acid Corrosion Control, and Quality Assurance Audit Programs.
The inspectors reviewed the applicable procedures and attended licensee meetings, including the Program Review Board, Restart Station Review Board, Restart Senior Management Team, and the Management Review Board. The inspectors also conducted individual interviews.
b. Findings
The licensee documented the Restart Action Plan Process in Procedure NG-VP-00100, Restart Action Plan Process. The process included three phases of work: planning, discovery, and implementation. The planning phase consisted of approving the Building Block Plans and associated procedures. The discovery phase included an evaluation of the specific programs and an identification of issues requiring resolution.
The process included a requirement that certain types of corrective actions shall be completed prior to restart of the plant; while some corrective actions could be completed after restart of the plant. The implementation phase encompassed the development and completion of corrective actions which were to be completed prior to restart of the plant.
The licensee documented the program compliance review process in Procedure NG-EN-00385, Program Compliance Review. The procedure outlined a structured and systematic process by which to determine if the plant programs properly implemented requirements, including interfaces and obligations, necessary to support restart and operation of the plant. The process included two levels, Phase 1 and Phase 2, of program reviews. Phase 1 level reviews were a baseline screening evaluation of selected programs. Phase 2 level reviews were a detailed, systematic evaluation of those plant programs associated with the degraded reactor vessel head. Programs scheduled for a Phase 2 level review included the Boric Acid Corrosion Control (BACC),the Inservice Inspection (ISI), the Plant Modification (MOD), the Corrective Action (CAP), the Reactor Coolant Unidentified Leakage, and the Operating Experience (OE)
Programs.
The program compliance review procedure directed that Phase 1 level reviews would be completed by the program owner using a program readiness baseline assessment questionnaire. The licensee staff intended to conduct Phase 1 level reviews for approximately 50 programs.
Phase 2 level reviews were to be performed by a group of licensee and non-licensee staff. The Phase 2 level review process included:
- Identification of the program basis documents and commitments, and a determination of the programmatic elements necessary to fulfill the basis documents.
- Comparison of the basis document requirements against the program implementing procedures, including consideration of industry guidance on alternate approaches to the basis documents.
- Verification that the program goals and scope were appropriate.
- Identification of previous program issues and verification that appropriate corrective actions were implemented based upon a review of condition reports, self-assessments, quality assurance audits, peer reviews, and NRC inspections for the past 3 years.
- Identification of key program interfaces to ensure that required supporting processes and procedures are properly developed and implemented.
- Verification that program roles and responsibilities were properly identified and implemented, and that the program includes an appropriate level of management involvement.
- Determination that a sufficient number of qualified personnel existed to manage, implement, and interface with the program.
- Review of external operating experience for applicability and potential impact on the program, including effective implementation of industry lessons learned related to the program.
- Documentation in condition reports of all weaknesses and recommendations for program changes or upgrades necessary to restore compliance or correct other deficiencies.
Results from the Phase 1 and Phase 2 level reviews were presented to a Program Review Board (PRB), consisting of an independent chairman, two members of the Engineering Assessment Board, and the Program Compliance Review Owner. The PRB was chartered to evaluate the Phase 1 and Phase 2 level review-documented findings and associated corrective action recommendations. Based upon information in the Phase 1 questionnaire and the Phase 2 level review results, the Program Review Board determined the adequacy of the reviews and those actions necessary for the program to support a plant restart. The licensee staff considered the restart action plan discovery phase process complete following the PRBs review and approval of the Phase 1 and Phase 2 reports. The PRB also reviewed completed restart action items in accordance with the program review process procedure.
The inspectors reviewed the licensees process against similar program review outlines included in NRC inspection procedures and determined that the licensees process provided a reasonable outline from which to perform an overall program review.
Specifically, the inspectors determined that the outlined approach and multiple independent reviews would result in a thorough assessment. The inspectors also attended several PRB meetings to observe the review process. Both the Corrective Action Program and Boric Acid Corrosion Control Program Phase 2 review reports were initially rejected by the PRB. After revisions and a second PRB, both reports were accepted. The inspectors observed that the review board performed a very detailed review of the submitted reports and determined that the board provided a critical and thorough assessment of the program review reports.
The licensee staff documented issues, identified during the discovery phase, in condition reports. The condition reports were screened and classified by the Restart Station Review Board (RSRB) into one of four categories. The four categories included items for which corrective actions: 1) were necessary to address NRC Manual Chapter 0350 issues; 2) were necessary to address Davis-Besse Restart expectations; 3) could be implemented following plant restart (Post-Restart), and; 4) could be addressed at a time unrelated to plant restart (Not Restart). Once the licensee staff developed corrective actions to address the issues documented in the condition reports, the RSRB screened the proposed corrective actions to ensure that the underlying issues were fully addressed. The RSRB also screened maintenance work orders associated with the corrective actions.
During the inspection, the discovery phase was well underway for both the Program Compliance and the System Health Building Blocks. The inspectors observed the RSRB classification of condition reports and observed that the majority of condition reports were classified as requiring evaluation prior to restart.
The Restart Action Plan Process also described the responsibilities of the Restart Senior Management Team (RSMT). With regards to the Program Compliance Review, the RSMT was responsible for review and approval of the discovery and restart implementation action plans and for reviewing reports generated from the discovery action plan for Manual Chapter 0350 related restart items.
c. Conclusions
The inspectors determined that the licensees Restart Action Plan and Program Compliance Review Processes provided a reasonable method for determining if a plant program correctly implemented regulatory and other requirements, effectively interfaced with other supporting plant programs, appropriately considered industry experienced, was properly staffed by qualified individuals, and resolved identified weaknesses or deficiencies in a timely manner. The inspectors also concluded that the processes included an appropriate method for evaluating and characterizing newly identified issues.
.2 Corrective Action Program Compliance Review
a. Inspection Scope
The inspectors evaluated the licensees review of the Corrective Action Program (CAP),as documented in Discovery Action Plan Report PR-DAP-3-01, Revision 0, Corrective Action Program Review. Specifically, the inspectors evaluated whether the licensees program review was consistent with the licensees Program Compliance Review process as defined in procedures NG-VP-00100, Revision 1, Restart Action Plan Process, and NG-EN-00385, Revision 0, Program Compliance Review.
The inspection consisted of reviewing applicable licensee, industry and regulatory documents; interviewing those licensee personnel responsible for the CAP program reviews and implementation; observing the presentation of the Discovery Action Plan to the Restart Senior Management Team; and reviewing some of the corrective actions developed.
b. Findings
b.1 Corrective Action Program Discovery Action Plan Results The licensees Phase 2 level review of the CAP identified a number of concerns in almost every program attribute including programmatic elements, program implementation, interfaces and handoffs, roles and responsibilities, knowledge base, and external operating experience. A total of 43 CRs were issued documenting these concerns and recommendations. The majority of the CRs were classified by the RSRB as requiring evaluation prior to restart. The overall conclusion of the report was that the CAP was not consistently implemented and needed to be strengthened prior to restart of the plant.
The licensee indicated that CAP implementation (execution) problems were the most significant issues identified during the review. However, given the extent of the implementation problems identified, the licensee determined that changes to the program documents were necessary to restoring an effective CAP. Specific implementation problems documented as a result of the Phase 2 review included: 1) a recurring trend of less than adequate corrective actions; 2) less than adequate CR evaluations; 3) a hesitancy by the staff to document certain types of conditions adverse to quality; 4) management review board deficiencies; 5) a need for improvement in the trending program, and; 5) untimely supervisory and senior reactor operator reviews.
These and other findings were determined to be consistent with the Root Cause Analysis Report of the degraded pressure vessel head.
The Phase 2 level review comparison of the program documents to the applicable regulatory and other basis documents resulted in the identification of two programmatic elements that were not adequately incorporated. One element was a Quality Assurance Program Manual (QAPM) requirement for management encouragement of the staff to identify conditions that are adverse to quality. The second element was related to an Institute of Nuclear Power Operations (INPO) principle to provide prompt feedback on corrective actions to the CR initiator. The CAP Phase 2 level review team found that there was no specific program guidance for either of these elements. A number of programmatic elements, particularly those related to the implementation of the QAPM, were rated as marginal. The programmatic elements related to the requirements of 10 CFR 50, Appendix B, were determined to be either marginal or fully adequate.
b.2 Assessment Of The Corrective Action Program Compliance Review Overall, the inspectors determined that the program review team had appropriately implemented the process developed for conducting a Phase 2 level review. As discussed above, the Phase 2 level review team determined that the CAP generally met regulatory requirements and that the identified problems were primarily associated with program implementation. The inspectors independently reviewed CRs associated with the CAP that were reviewed by the Phase 2 review team and also reviewed CAP program regulatory requirements and concurred with the assessment that the identified problems were mainly with program implementation. The inspectors also determined that the recommended program infrastructure improvements could improve the overall program effectiveness.
To resolve the identified deficiencies and to improve program implementation, the licensee generated two CRs to roll up all of the issues identified during the Phase 2 level review. The program implementation problems were captured under CR 02-4884 and the program infrastructure problems were captured under CR 02-04885. The licensee chartered two separate teams to evaluate the issues associated with each CR and recommend corrective actions. The results of these efforts will be reviewed during the NRCs assessment of the licensee's implementation of corrective actions.
The CAP Phase 2 level review results did not include a required review of technical issues that had been previously closed in the corrective program to ensure that issues were appropriately evaluated and corrected. However, Corrective Action Number 51 to CR 00-0891, which was the root cause evaluation for the failure to identify the degradation of the reactor vessel head, did require a review of longstanding issues in the CAP for possible re-categorization as significant conditions adverse to quality (SCAQ). The inspectors viewed this corrective action, as an important extent of condition review of the corrective action program implementation, to ensure that no other unrecognized safety-significant equipment or technical issues existed in the plant.
However, at the time of the inspection, this corrective action had not been implemented.
A further review of this corrective action will be completed during the NRCs assessment of the licensee's implementation of the corrective actions.
c. Conclusions
The inspectors determined the licensees Phase 2 level review of the CAP was thorough and in accordance with NG-EN-00385, Program Compliance Review. The corrective actions scheduled for completion prior to restart were found to be appropriate. The CAP, prior to this review, appeared to contain the programmatic elements for a successful program; however, station personnel did not consistently identify, aggressively pursue, and effectively resolve plant issues. The inspectors determined that the reviews, conducted to evaluate the CAP issues and the associated matrix of issues and corrective actions, were considered an excellent effort. Restart Checklist Item 3.a., Corrective Action Program, remains open pending completion of the Corrective Action Team Inspection (NRC Inspection Report 50-346/03-10).
.3 Boric Acid Corrosion Control Program Compliance Review
a. Inspection Scope
The inspectors evaluated the licensees review of the BACC program, as documented in Discovery Action Plan Report PR-DAP-3-01, Revision 0, Boric Acid Program Review.
Specifically, the inspectors evaluated whether the program review was consistent with the program compliance review process as defined in procedures NG-VP-00100, Revision 1, Restart Action Plan Process and NG-EN-00385, Revision 0, Program Compliance Review.
The inspectors also compared the licensees BACC program to applicable industry guidance, primarily NRC Generic Letter 88-05, Boric Acid Corrosion of Carbon Steel Reactor Pressure Boundary Components in Pressurized Water Reactors, and Electric Power Research Institute (EPRI) Project Report 100975, Boric Acid Corrosion Guidebook, Revision 1.
This inspection consisted of a review of applicable licensee, industry and regulatory documents; interviews with licensee personnel responsible for the BACC program reviews and implementation; observation of the review teams presentation of the discovery action plan report to the RSMT; evaluation of some of the corrective actions developed in response to the BACC program review; and observation of ongoing plant inspections.
b. Findings
b.1 Boric Acid Corrosion Control Discovery Action Plan Results The licensees Phase 2 level review of the BACC program focused on the key elements included in the program compliance review procedure, described in Section
.1. b above.
Additionally, the licensee reviewed lessons learned from past boric acid control events to determine whether these related issues were properly addressed. In particular, the licensee reviewed the lessons learned from the boric acid corrosion of pressurizer spray valve RC-2 and its failure to identify the boric acid corrosion on the reactor pressure vessel head.
The licensee identified several significant weaknesses with the BACC program. These included a lack of effective program self-assessments; inconsistent oversight by the program owner; poor oversight and control of program deviations; poor identification and management of boric acid issues; program procedure deficiencies; and inadequate program interfaces with other departments and work groups. Each of these deficiencies were documented in CRs which were then coded as requiring resolution either prior to or after restart. The final Discovery Plan Phase 2 report, including the associated CRs, was reviewed and approved by the RSMT on September 11, 2002.
The inspectors verified that the program compliance review had appropriately considered past BACC events and, except as described below, had identified the significant issues affecting the BACC program. Additionally, the inspectors concluded that the corrective actions reasonably addressed the licensee-identified significant weaknesses.
However, the inspectors identified several examples where some of the above mentioned key elements of the Phase 2 level review were not met. These included:
- The review did not identify and/or clearly state the interfaces between the BACC program and the chemistry, work control, and reactor leakage monitoring groups.
- The review did not identify that the station commitments to NRC Bulletin 82-02, Degradation of Threaded Fasteners in the Reactor Coolant Pressure Boundary of PWR Plants were not met.
- The review did not evaluate why some of the past licensee technical evaluations for BACC were inadequately performed. Specifically, whether the correct information was available to and/or understood by those staff performing the evaluations.
- The review did not evaluate whether the CAP was effective in coding and trending past boric acid issues.
The inspectors noted that these issues were not identified during the RSMT review. In particular, the inspectors observed that the RSMT review was somewhat limited in that the RSMT did not effectively challenge either the scope or the conclusions of the discovery phase report.
The inspectors discussed the above observations with those staff who had conducted the BACC program Phase 2 level review. The reviewers stated that some of these issues were considered during the program review, but were either not clearly documented in the report or were assumed to be addressed by other, concurrent program reviews. For example, the reviewers were aware of past issues with the BACC program related to the CAP and QA program, but believed that these issues would be addressed by the concurrent, respective program reviews. However, the inspectors determined that this was not occurring, in part, because there was no formal communication between the various, respective program review groups. The licensee initiated CR 02-06824, 02-06825 and 02-06823 to document the inspectors concerns.
b.2 Assessment of the Boric Acid Control Program Implementation The BACC program was defined in corporate Procedure NOP-ER-2001, Revision 00, Boric Acid Control Program, and station Procedure NG-EN-00324, Revision 5, Boric Acid Corrosion Control. Each of these procedures had been recently revised to address the issues being identified through the Phase 2 level review. The inspectors noted that these procedures acceptably addressed most of the weaknesses identified during the Phase 2 level review. Specifically, the procedures:
- Defined roles and responsibilities for the BACC program owner and those personnel performing BACC inspections;
- Defined clear interfaces between the BACC program and the operations, radiation protection and engineering work groups;
- Required that a CR be implemented for any observed case of boric acid leakage on susceptible components, whether inside or outside containment;
- Defined specific actions to be performed by the BACC program owner for management oversight;
- Required that the BACC program owner perform quarterly program reviews and triennial self-assessments; and
- Contained BACC implementing guidance that was consistent with industry standards.
The inspectors also noted that the licensee had limited the use of the word should in the procedural requirements. The inspectors determined that the use of the word should was a significant weakness with the prior program procedures. The presumed procedural latitude permitted by use of the word should, led, in part, to a failure by the staff to effectively implement the program and to identify and prevent the subsequent reactor pressure vessel head corrosion.
The inspectors observed that ongoing boric acid inspections were conducted consistent with the revised BACC program procedures. Specifically, the inspectors noted that the BACC inspectors were qualified, as required, and performed the inspections as stated in the procedures. The inspectors did identify one item of concern associated with how the overall results of these inspections would be documented for future reference. At the time of this inspection, the licensee was in the process of developing a specific BACC database to track BACC inspection results. In the interim, the licensee intended to track all BACC program related issues in the CAP. While this method could be effective, the inspectors could not discern how these issues would be coded in the CAP to allow the BACC program owner to identify and track the items. The licensee staff acknowledged the inspectors concern and initiated CRs 02-06620 and 02-07344 to track resolution of the concern.
The inspectors also identified several critical areas where the revised BACC program procedural guidance was lacking. These weaknesses could permit boric acid concerns to be inappropriately resolved without the knowledge of the BACC program owner.
There was also an example where a clear interface between the BACC program and another applicable work group had not been established. Collectively, the inspectors were concerned that these issues may seriously affect the efficacy of the BACC program. Some of the issues identified by the inspectors included:
- Allowing BACC inspections to be deferred by line supervision without the approval of the BACC program owner;
- Allowing BACC-related CRs to be closed or have related commitments (such as due dates) changed without the concurrence of the BACC program owner; and
- Allowing BACC observations/evaluations regarding pressure boundary components to be resolved without being reviewed by the ISI program owner.
The inspectors also noted that in some cases, the procedural requirements for critical areas of the BACC program were unclear. For example, the inspectors could not determine if the engineering staff was required to undergo refresher training on BACC mechanisms. The inspectors identified that a concurrent licensee Phase 1 level review of the auxiliary chemistry program had identified that some engineers were not fully cognizant of corrosion water chemistry (CR 02-05552). However, this issue was not addressed in the BACC procedures. Additionally, the inspectors determined that the interface between the BACC and work control programs was not clearly defined. For example, it appeared that BACC issues could be closed to work orders without having the BACC program owner verify that the required actions were taken.
The licensee addressed some of the above issues in existing CRs. For the other issues, the licensee initiated CRs 02-06824, 02-07344, 02-06771, and 02-06619.
b3. Quality Assurance Oversight of the Boric Acid Corrosion Program Previously, the licensee identified that past quality assurance oversight of the BACC program was limited and was not effective in identifying the problems that led to the reactor vessel head corrosion. The inspectors reviewed the current BACC program quality assurance audit outline and determined that implementation of the current outline may not ensure an adequate level of future QA oversight. Specifically, the inspectors noted that the current evaluation criteria were very generic and if applied in the past, would not have identified the issues which led to the reactor vessel head corrosion. The inspectors identified the following additional concerns:
- The quality assurance auditors were not required to be qualified as BACC inspectors. The inspectors questioned whether this allowed the auditors to effectively evaluate BACC inspection activities.
- The quality assurance master assessment plan did not include a requirement to perform BACC audits during appropriate intervals, such as outages, when the majority of BACC activities occurred. This essentially allowed a program audit to consist solely of a document review with little to no observation of boric acid inspections.
The inspectors also noted that the current quality assurance program did not require a review of corrective actions for issues identified by the BACC program. In addition, the inspectors determined that the licensee had not developed controls for the site BACC implementing procedures to ensure they remained consistent with the governing corporate procedure. The licensee initiated CRs 02-06611, 02-07660, and 02-06771 to address the concerns.
c. Conclusions
The inspectors concluded that the licensees overall review of the boric acid corrosion control program was adequate and was consistent with the requirements of Procedure NG-EN-00385, Revision 0, Program Compliance Review. However, the inspectors identified several critical areas where the revised boric acid corrosion control program procedural guidance was lacking which could permit boric acid concerns to be inappropriately resolved. The licensee documented these issues in condition reports for resolution as a part of the Implementation Action Plan for the Boric Acid Corrosion Control program. Restart Checklist Item 3.d, Boric Acid Corrosion Management Program, remains open pending further inspection.
.4 Quality Assurance Program Compliance Review
a. Inspection Scope
As an independent assessment of the scope of the licensee's program compliance review process, the inspectors evaluated the licensees initial decision not to perform a program compliance review of the quality assurance (QA) oversight program. As a part of this effort, the inspectors reviewed a licensee root cause analysis report entitled, Failure in Quality Assurance Oversight to Prevent Significant Degradation of the Reactor Pressure Vessel Head, and a separate licensee evaluation of the Company Nuclear Review Board. In addition, the inspectors conducted independent reviews of the quality assurance audit program, procedures, and recent work products.
The inspectors also evaluated a subsequent licensee program compliance review of the QA audit program, as documented in Discovery Action Plan Report PR-DAP-3C-01, Revision 0, Quality Assurance (QA) Audit Program Review. Specifically, the inspectors evaluated whether the licensees program review was consistent with the program compliance review process as defined in Procedures NG-VP-00100, Revision 1, Restart Action Plan Process, and NG-EN-00385, Revision 0, Program Compliance Review.
b. Findings
b.1 Assessment of the Quality Assurance Program Related Root Cause Analyses Quality Assurance Program Root Cause Analysis Following discovery of the degraded reactor vessel head condition, the licensee conducted a number of evaluations, including a root cause analysis of the quality assurance program's failure to identify the condition (CR 2002-02578). The results of this effort were documented in a report entitled, "Failure of Quality Assurance Oversight to Prevent Significant Degradation of Reactor Pressure Vessel Head," dated September 10, 2002. Based upon this analysis, the licensee identified one root and three contributing causes for the quality assurance organizations failure to prevent the observed head degradation. The root cause was characterized as a failure of the quality assurance organization to set itself apart, in terms of expectations and performance standards, from the balance of the plant. This failure was viewed as having negatively affected quality assurance organizations ability to identify problems and effect needed positive change in station operations. The three contributing causes were associated with ineffective training for a previous boric acid corrosion event, ineffective oversight of the quality assurance function, and, for a period of time, a lack of independence of the quality assurance organization from the corrective action process.
The root cause analysis report included several corrective actions to address each of the identified causes. With few exceptions, the proposed corrective actions focused on changing the culture of the quality assurance organization.
The inspectors reviewed the root cause results and noted that the analysis was predicated on three assumptions. Of significance was the third assumption, which was that the quality assurance oversight organization had two distinct opportunities to significantly alter the degraded head condition. The first opportunity involved assuring, through proper oversight functions, that the processes used by the line organization were sufficiently robust and effective to detect and mitigate the degrading head condition. The second was the opportunity Quality Assurance had to perform direct observations of the vessel head condition. The root cause analysis investigation team also concluded that, although the quality assurance oversight program underwent substantial change during the period 1986 to 2002, no data was found to indicate that the program itself contributed to a lack of success by the oversight organization.
The inspectors reviewed information regarding the quality assurance audit process from the early 1990s, when the NRC issued numerous generic communications regarding boric acid corrosion, until 2002. The inspectors noted that the quality assurance audit process did not include, until minor changes were made associated with a 1998 boric acid corrosion event, specific inspection guidance or requirements relative to the BACC program. In addition, the inspectors noted that both the current and past inspection criteria, used by licensee auditors to assess the BACC program, were very generic.
During discussions with licensee staff, the inspectors were informed that the QA audit process did not include the BACC, in part, because the licensee staff was not aware of any specific regulatory requirement or commitment that required an audit of the BACC program. The licensee staff further indicated that the BACC program was only recently added to the audit review process based on a perceived need to conduct a review of the corrective actions developed for a 1998 event associated with packing leakage of Pressurizer Spray Valve RC-2, and based upon comparisons of the Davis-Besse QA audit program with those at other nuclear plants.
The inspectors noted that the QAPM required the program to apply to all activities associated with safety-related structures, systems, and components. The QAPM further clarified that the manual requirements, including audits, also applied to activities associated with the safety-related structures, systems, and components. Using this guidance, the inspectors concluded that the QA audit process should have included the BACC program due to the potential impacts a failure to properly define or implement this program could have on the reactor coolant system and associated systems. The licensee staff further indicated that the current QA master assessment plan was developed as a refinement to the previous program, but was not developed assuming that other programs or processes should be added. Therefore, the inspectors concluded that other activities, affecting safety-related structures, systems, and components, may not be included in the current QA audit program.
The inspectors also reviewed the quality assurance audits conducted during the previous refueling outage, RFO 12. The inspectors noted that the RFO 12 audit scope included a review of the licensee staffs implementation of Procedure NG-EN-00324, Boric Acid Corrosion Control. However, the inspectors determined that neither the audit plan, the identified method of verification, nor the narrative comments from the audit included a review of the BACC program. In addition, while the audit conclusions included a discussion of reactor vessel head cleaning, these conclusions were not supported by any information in the narrative comments. Based upon the planned audit scope and the stated methods of verification, the inspectors concluded that the quality assurance auditor, assigned to review implementation of the BACC program during RFO 12, was not likely to have personally observed or evaluated the reactor vessel head cleaning efforts or to have assessed overall adequacy of the BACC program as a part of this audit. The Quality Assurance area root cause analysis was also reviewed by the Management and Human Performance Inspection, which is documented in IR 50-346/02-18.
Therefore, while the licensees root cause analysis provided useful information and insights, the inspectors determined that root causes, in addition to those identified in the report, likely were associated with the quality assurance oversight functions failure to identify the degraded reactor vessel head.
Evaluation of the Company Nuclear Review Board Concurrent with, but separate from the previous root cause analysis, the licensee commissioned an independent evaluation of the Company Nuclear Review Boards (CNRBs) effectiveness. The evaluation was focused on the CNRBs current and past oversight role as it related to the missed opportunity for identifying the reactor vessel head degradation.
The independent evaluation determined the CNRBs charter and assigned functions based upon a review of the Updated Final Safety Analysis Report, company policies and procedures, and the NRC-approved quality assurance program. Significant among the assigned CNRB functions were requirements to provide independent review and audit of quality assurance practices and to advise the Company Vice President on those items reviewed and audited.
Based upon a review of materials routinely provided to the CNRB, past CNRB meeting minutes, discussions with CNRB members, and observation of a CNRB meeting, the independent evaluator developed several significant conclusions, including:
- The CNRB may not be meeting its charter to provide an independent safety audit function.
- The CNRB did not adequately review the health or effectiveness of the Quality Assurance Program.
- It was not apparent that the CNRB was effectively overseeing the quality assurance audits that were performed under the cognizance of the CNRB.
The independent evaluator also included recommended corrective actions to address each report conclusion. The licensee staff entered these items into its corrective action program as CR 02-07485.
The inspectors conducted an independent assessment of the performance of the CNRB over the past 2 years relative to its responsibilities for oversight of the quality assurance function. The inspectors reviewed information provided to the CNRB, and minutes of past meetings. Based upon a review of the these materials, the inspectors independently validated that the licensee finding that the CNRB provided inadequate oversight of the quality assurance function and the other significant conclusions documented in the evaluation report. The inspectors noted that the CNRB, based upon meeting minutes, seldom discussed the quality or effectiveness of quality assurance audit activities, seldom offered new or expanded areas for quality assurance auditing, or determined that the scope of quality assurance activities were appropriate to the circumstances.
Finally, the inspectors determined that the licensee identified findings of inadequate oversight of the quality assurance function, as documented in the root cause analysis and the independent CNRB evaluation, indicated that problems within the quality assurance oversight program directly contributed to the quality assurance programs failure to prevent significant degradation of the reactor pressure vessel head. The CNRB root cause assessment was also reviewed by the Management and Human Performance Inspection, which is documented in IR 50-346/02-18.
b.2 Quality Assurance Audit Program Discovery Action Plan Results Subsequent to the beginning of this inspection, the licensee performed an informal reassessment of the results of the quality assurance root cause report and the independent evaluation of the CNRB, and a review of the inspectors findings relative to the quality assurance audit process. As a result of the review and reassessment, the licensee determined that a program compliance review of the quality assurance audit program was appropriate.
As a result of the licensees Phase 2 level program compliance review of the quality assurance audit program, numerous issues were identified that required resolution, including:
- The current audit program does not fully encompass some programs or activities affecting safety-related structures, systems, and components and does not include adequate measures or tools to ensure that emergent issues, lessons learned, or program expansions are evaluated for inclusion in audit program.
- Implementing procedures do not adequately incorporate programmatic requirements or tools to ensure effective interfacing among some groups, escalation of unresolved issues, and adequate self-assessment and oversight of the audit program.
Over 90 CRs were developed to document the issues identified during the review, including four written by the quality assurance organization based upon its review of the reported results. The program review team recommended that approximately 25 percent of the CRs should be classified as items requiring the development of corrective action plans, for review and appropriate action, prior to the licensees restart of the plant.
The program review team also determined that the quality assurance program was staffed with capable individuals and that the program owner and supervisors were actively involved in the program. However, some issues with personnel qualification and training of these individuals were identified.
Upon completion of the corrective actions for the identified issues documented in the compliance plan review report, the PRB concluded that the quality assurance audit program would be ready to support restart of the plant.
b.3 Assessment Of The Quality Assurance Audit Program Compliance Review The inspectors reviewed the program compliance review results to determine if the review was conducted in accordance with the requirements outlined in Section
.1. b.1
above and was effective in identifying issues. Four areas of the review were evaluated to include: 1) identification of basis documents and comparison against program requirements; 2) program interfaces and adequate management oversight; 3) integration of operating experience, and; 4) documentation of issues in the licensees corrective action program.
The inspectors determined that the licensees identification and correlation of regulatory requirements and program guidelines, as documented in Table 3.1 of the report, was comprehensive and well annotated. The inspectors noted that several issues, developed as a result of a previous licensee root cause analysis associated with the quality assurance oversight function and an evaluation of the CNRB, were appropriately included in the table. The inspectors also identified that the licensees review had captured an inconsistency in the quality assurance organizations stop work authority, as specified in plant procedures and the governing quality assurance program manual.
The inspectors determined that the licensees assessment of program interfaces and management oversight correctly identified issues documented in the previous root cause analysis and evaluation of the CNRB. In addition, the program compliance review identified a generic quality assurance audit program weakness associated with a failure to properly integrate operating experience results, a specific example of which was the licensees failure to include the BACC program as an area requiring auditing by the quality assurance program. During a previous independent review of the quality assurance program manual requirements and plant procedures, the inspectors determined that the licensees failure to include the BACC program in the quality assurance audit process was most likely a result of this program weakness. The program compliance review resulted in the identification of 17 additional examples of safety programs that were not included in the quality assurance audit program. Similar examples of incomplete incorporation of quality assurance audit criteria for other programs were identified as a result of other Phase 2 level program compliance reviews.
Using the results of previous NRC reviews of the corrective action and BACC programs, the inspectors determined that the program review team had appropriately assessed inadequacies in the documentation of some issues developed as a result of quality assurance audits and the implementation of ineffective correction actions to some audit findings.
c. Conclusions
The inspectors determined that the licensees overall assessment of the quality assurance audit process, including the root cause analysis, the independent evaluation of the Company Nuclear Review Board, and the program compliance review were comprehensive. These efforts appropriately identified programmatic weaknesses associated with the quality assurance audit program, and the Company Nuclear Review Board oversight function of the quality assurance audit program. In addition, the root cause analysis identified management and cultural issues which could inhibit effective functioning of the quality assurance audit program. The inspectors further determined that the licensee had appropriately entered issues, identified as a result of these efforts, into its corrective action program. Restart Checklist Item 3.c, Quality Audits and Self-Assessments of Programs, remains open pending further inspection.
4OA6 Meetings
.1 Exit Meeting
The NRC inspectors presented the inspection results to Mr. J. Powers and other members of licensee management at the conclusion of the inspection on June 27, 2003.
The NRC inspectors asked the licensee whether any materials discussed as potential report material should be considered proprietary. No proprietary information was identified.
KEY POINTS OF CONTACT Licensee L. Myers, Chief Operating Officer J. Cunnings, Acting Boric Acid Program Coordinator D. Gudger, Manager, Performance Improvement B. Hennesy, Corrective Action Program Supervisor P. McCloskey, Manager Regulatory Affairs N. Morrison, Program Planner Owner C. Price, Restart Action Plan Owner R. Geiger, Program Compliance W. Pearce, Vice President Oversight S. Loehlein, Nuclear Quality Assurance Manager D. Poole, Senior Management Consultant R. Tadych, Senior Staff Engineer Nuclear Regulatory Commission C. Thomas, Senior Resident Inspector D. Simpkins, Resident Inspector LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED None LIST OF ACRONYMS USED ASME American Society of Mechanical Engineers BACC Boric Acid Corrosion Control CAP Corrective Action Program CAQ Condition Adverse To Quality CFR Code of Federal Regulations CNRB Company Nuclear Review Board CR Condition Report CRDM Control Rod Drive Mechanism INPO Institute of Nuclear Power Operations ISI Inservice Inspection MOD Modification NRC Nuclear Regulatory Commission OE Operating Experience PRB Program Review Board QA Quality Assurance QAPM Quality Assurance Program Manual RCS Reactor Coolant System RSMT Restart Management Team RSRB Restart Review Board SCAQ Significant Condition Adverse to Quality LIST OF
DOCUMENTS REVIEWED
KEY POINTS OF CONTACT
Licensee
- L. Myers, Chief Operating Officer
- D. Gudger, Manager, Performance Improvement
- B. Hennesy, Corrective Action Program Supervisor
- R. Pell, Radiation Protection Manager
- R. Greenwood, Health Physicist
- P. McCloskey, Manager Regulatory Affairs
- W. Marini, Regulatory Affairs
- M. Stevens, Director, Maintenance
- M. Roder, Manager, Operations
- N. Morrison, Program Planner Owner
- C. Price, Restart Action Plan Owner
- R. Geiger, Program Compliance
- S. Osting, Program Owner
Nuclear Regulatory Commission
- C. Thomas, Senior Resident Inspector
- D. Simpkins, Resident Inspector
LIST OF ACRONYMS USED
ASME American Society of Mechanical Engineers
BACC Boric Acid Corrosion Control
CAP Corrective Action Program
CARB Corrective Action Review Board
CFR Code of Federal Regulations
CR Condition Report
CRDM Control Rod Drive Mechanism
DAP Discovery Action Plan
DRP Division of Reactor Projects
EPRI Electric Power Research Institute
IAP Implementation Action Plan
IR Inspection Report
ISI Inservice Inspection
MAP Master Assessment Plan
MRP Material Reliability Project
NRC Nuclear Regulatory Commission
NQA Nuclear Quality Assurance
OE Operating Experience
OEAP Operating Experience Assessment Program
QA Quality Assurance
RSRB Restart Station Review Board
SDP Significance Determination Process
TMI Three Mile Island