IR 05000373/1981022
| ML20009C483 | |
| Person / Time | |
|---|---|
| Site: | LaSalle  |
| Issue date: | 07/02/1981 |
| From: | Baker K, Connaughton K, Gildner M, Holzmer M, Peschel J, Schulz R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20009C479 | List: |
| References | |
| 50-373-81-22, 50-374-81-12, NUDOCS 8107210139 | |
| Download: ML20009C483 (32) | |
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U.S. NUCLEAR REGULATORY COMMISSION OFFICE OF INSPECTION AND ENFORCEMENT
REGION III
Reports No. 50-373/81-22; 50-374/81-12 Docket Nos. 50-373; 50-374 Licenses No. CPPR-99; CPPR-100 Licensee:
Commonwealth Edison Company Post Office Box 767 Chicago, E @@0 Facili.ty Name:
LaSalle County Station, Unit 1 Inspection At:
LaSalle Site, Marseilles, IL Inspection Conducted:
April 6-10,13-17, April 27 through May 1, and May 26-29, 1981 Inspectors:
R.
. Schulz
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Connaughton
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. M. Peschel k/
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Approved By:
. Baker, Chief
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Management Programs Section
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Inspection Summary Inspection on April 6-10, 13-17, 27 through May 1, and May 26-29, 1981 l
(Reports No. 50-373/81-22; 50-374/81-12)
l Areas Inspected: The inspection at LaSalle was an announced routine inspec-l tion of the licensee's Quality Assurance Program in the following areas: QA/QC administration; qualification of personnel; design changes and modifications; i
test and measurement equipment; test and experiments; receipt, storage, and handling; records; procurements; audits; surveillance testing and calibration l
8107210139 810708 PDR ADOCK 05000373 G
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control; corrective action and non-routine reporting; inservice testing; and
maintenance. The inspection involved a total of 372 inspector-hours onsite by six NRC inspectors.
Results: Of the 13 sreas inspected, no apparent items of noncompliance or deviations were identified in 10 areas, five items of noncompliance werc identified.in three areas (failure to certify personnel to ANSI N45.2.6 -
Paragraph 7; failure to control nonconforming material - Paragraph 7; failure l
to follow record storage requirements - Paragraph d; failure to follow a quality procedure - Paragraph 14; failure to document a deficiency - Para-
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DETAILS 1.
Persons Contacted R. H. Holyoak, Station Superintendent
- R. D. Kyrouac, Lead Q.A. Engineer
- C. W. Schroeder, Technical Staff Supervisor C. C. Gaines, Computer Coordinator H. J. Hentschel, Special Test Engineer
- P. F. Manning, Quality Control Supervisor E. L. O'Connell, Modification Coordinator J. J. Coonan, Maintenance Assistant Superintendent
- R.
D. Bishop, Administrative Assistant Superintendent
- H.
L. Mulderink, Master Electrician E. E. Boyd, Master Mechanic J. W. Andrews, Central Files Supervisor S. Hedden, OAD E. Seckinger, SNED J. Atchley, Shift Foreman
- T. Quaka, Quality Assurance Superintendent
- L. Burke, Construction Project Superintendent
- W. Shewski, Managar of Quality Assurance
- B. B. Stephenson,.?roject Manager LaSalle Station
- J. Maley, Manager of Projects
- R.
Frederick, Store Supervisor
- G. J. Diederich, Station Operating Assistant Superintendent
- Roger Walker, Senior Resident Inspector
- Sam Shepley, Resident Inspector The inspectors also interviewed several other licensee employees, including operating engineers, shift engineers and foremen, reactor operators, technical staff personnel and quality control personnel.
- Denotes those present at the exit interview on June 5, 1981.
2.
QA/QC Administration Program The licensee's program for administration of the QA/QC program was inspected. This included program boundary, QA/QC procedure control, and the mechanism for evaluating the QA program.
a.
Documentation Reviewed Quality Assurance Program Topical Report CE-1-A, January 12, 1981, Revision 15.
Station Quality Assurance Manual, March 4, 1981, Revision 65.
Quality Assurance Procedures Manual, April 17, 1981, Revision 57.
Quality Assurance Program Manual, April 17, 1981, Revision 61.
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LAP 1500-1, Quality Assurance Program, Revision 00, June 1976.
LAP 1700-1, Quality Control Organization, Revision 00, December 1980.
LAP 100-1, Station Organization, Revision 05, December 1980.
b.
Findings No items of noncompliance were identified in this area.
3.
Qualification of Personnel Program The inspector reviewed the licensee's administrative controls to ascertain their conformance with the regulatory requirements and commitments made in the. Quality Assurance Program. The program was reviewed to determine that controls have established the minimum educational, experience, and qualification requirements for the plant staff and that responsibilities have been assigned to assure that these requirements will be satisfied.
a.
Documentation Reviewed Quality Assurance Program Topical Report CE-1-A, January 12, 1981, Revision 15, Section 2, Quality Assurance Program.
Quality Assurance Procedures Manual, April 17, 1981, Revision 57, Q.P. No. 2-52, Training.
Quality Assurance Program Manual, April 17, 1981, Revision 61, Q.R. No. 1.0 - Organization and Q.R. No. 2.0 - QA Frogram.
LAP-100-5, Review of Personnel Qualifications to ANSI N18.1 Requirements, Revision 06, November 1979.
b.
Findings No items of noncompliance were identified in this area.
4.
Design Changes and Modification E cogram
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The inspector reviewed the Design Change and Modification Program as implemented by the licensee to verify compliance with the Quality Assurance 'rogram, ANSI N18.7-1976, 10 CFR 50.59, and 10 CFR 50, Appendix u.
The following Quality Procedures, Directives, and Administrative Procedures were reviewed to determine that the licensee has estab-lished procedures to control design and modification requests; the designation of responsibilities for the design change and modification program; controls and responsibilities which assure that design changes and modifications are incorporated into plant procedures, operator training program and plant controlled drawings; the establishment of interface communications between the different organizations involved-4-
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in design changes and plant modifications; and that design changes and plant modification receive a safety review in accordance with 10 CFR 50.59 and timely reporting to the NRC.
a.
Documents Reviewed QA 3-2 (Revision 10), Design Change Control QA 3-51 (Revision 17), Design Control for Operations -
Plant Modifications LAP 240-3 (Revision 4), Electric Jumpers, Relay Blocks, and Lifted Electrical Leads LAP 300-5 (Revision 1), Controlling the Installation and Removal of Temporary Mechanical Maintenance Related Devices LAP 1200-10 (Revision 3),0nsite Review of Proposed Plant Modifications LAP 1300-2 (Revision 6), Plant Modifications Requiring Engineering Department Assistance LAP 1300-3 (Revision 5), Plant Modifications Not Requiring Engineering Department Assistance LTP 300-12 (Revision 0), Monthly Review of Modification $tatus LTP 800-6 (Revision 0), Modification or Repairs to ASME Coded Vessels, Pipes and Valves LTP 800-7 (Revision 1), Initial Review of Modification Work Request LTP 800-8 (Revision 0), Final Review of Modification Work Request b.
Findings No items of noncompliance were identified in this area.
c.
Discussion (1) The LaSalle instructions for handling modification packages do not address control of revisions to modification packages.
Differentiation between revisions of modification packages is important to assure proper data retrieval when required at some later date. This does not have regulatcry basis, but was offered as a suggestion to improve record control in this area. The licensee agreed to consider this matter during the next revision to applicable procedures. The inspector has no further questions at this time.
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(2)
In the area of mechanical devices used for temporary modifi-cations to facilitate maintenance, the inspector suggested that stricter controls over these devices should be exercised.
These devices are presently controlled by a caution tagging
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system.
However, it would seem more appropriate to control them in the same manner as lifted leads or jumpers to prevent inadvertently leaving them in a system that has been." restored to service," especially since the caution tag logs are not reviewed each shift. The license agreed to consider the in-spector's comments. The inspector has no further questions at this time.
(3)
Incidents of bypassing plant modification procedures at other plants operated by this licensee using similar procedures have
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been noted during previous NRC inspections.
Therefore, the
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program should be monitored closely for arte_1 modifications being accomplished through maintenance actions. The licensee acknowledged the inspector's comments, but believes the system is adequate, if used, and intends to stress its use. The in-spector has no further questions at this time since the system will work, if used.
(4) Unresolved Item (50-373/81-22-01)
10 CFR 50.59 in part requires that the licensee furnish the NRC annually or at such shorter intervals as may be specified in the license, a report containing a brief description of such changes... including a summary of the safety evaluation of each.
t LAP 1300-2 (Revision 6) states that a copy of the completed Modification Package will be given to the Office Supervisor for entry into the computer for annual reporting. At the time of the inspection, the computer program for this automated annual report was not in place and the LaSalle instruction i
for preparing the annual operating report to the NRC did not address the subject.
5.
Test and Measurement Equipment Program The program for control of test and measurement equipment was re-viewed to verify compliance with the requirements of the proposed Plant Technical Specifications and 10 CFR 50, Appendix B, Criteria XII.
The selected Quality Procedures, Instrument Procedurea, and Maintenance Procedures were reviewed to verify that controls have been established
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which set forth:
the criteria and responsibilities for identifying calibration status for each piece of equipment; a system which assures that each piece of equipment is calibrated on or before the required date; a written requirement which prohibits the use of equipment beyond its calibration period; controls preventing use of out-of-calibration equipment; and controls for evaluating the status of equipment and items previously tested or measured using the equipment found to be out-of-calibration.
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a.
Documents Reviewed QP 12-1 (Revision 8), Calibration Control of Commonwealth Edison Test and Measurement Equipment QP 12-51 (Revision 9), Control of Measuring and Test Equipment for Operations - Portable Test and Measurement Equipment LAP 300-9 (Revision 3), Control of Maintenance Test and Measuring Equipment LAP 300-10 (Revision 4), Maintenance Department Administrative Procedure to Verify Calibration and Reliability of Test and Measuring Equipment LAP 1500-3 sdevision 5), Discrepancy Records LEP-GM-106 (Revision 0), Control and Calibration of Wire Strippers LEP-GM-109 (Revision 0), Crimp Tool Calibration LIP-GM-01 (Revision 4), Instrument Data Sheets, Calibration Stickers and Definitions LIP-GM-02 (Revision 2), General Surveillance Requirements for Instrument Mechanics LIP-GM-03 (Revision 1), Calibration Check of Portable Test and Measuring Equipment LIP-GM-04 (Revision 3), On-Site Calibration of Electrical and Mechanical Maintenance Department Test and Measuring Equipment LTP 200-2 (Revision 0), Instrument Calibration b.
Findings
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No items of noncompliance were identified in this area.
c.
Discussion l
(1) Unresolved Item (50-373/81-22-01
The draft LaSalle Station Technical Specifications concern-ing the station batteries set forth requirements for specific l
gravity, voltage, connector resistance, and electrolyte temperature.
In order to show compliance with these re-quireinents, calibrated test equipment must be utilized.
No certified hydrometer floats are currently in the control l.
program.
Battery test data sheets should have places for
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recording the test equipment used for purpose of providing traceability.
(2) Unresolved Item (50-373/81-22-03)
The electrical shop's torque wrench, No. E129, did not appear on the OAD list and the inspector could not be shown an OAD input sheet showing its inclusion into the system.
(3) Unresolved Item (50-373/81-22-04)
LAP 300-10 states in part that the receipt inspection of test and measuring equipment returned from OAD shall be made by personnel from the respective maintenance shop.
In fact, receipt inspection is made by QC personnel. The procedure should be revised to reflect the actual practice used.
(4) Unresolved Item (50-373/81-22-05)
Dial indicators which are procured from an OAD approved source have initial calibration certification which are not traceable to the individual instruments.
Performing the in-plant calibration at time of receipt provides an acceptance check and provides calibration directly trace-able to each instrument.
6.
Test and Experiment Program The test and experiment program was reviewed to verify that the estab-lished administrative controls and their implementation comply with the applicable requirements specified in the proposed Plant Technical Specifications and 10 CFR 50.59.
The following Quality Procedures, Administrative Procedures, and Technical Procedures were reviewed to verify the establishment of a mechanism for handling requests or proposals for safety related test and experiments; requirements to utilize approved procedures, assignment of responsibilities for review and approval of test and experiment procedures; establishment of a system for review of pro-posed teats to determine whether they are described in the FSAR; assurance that a written safety evaluation is developed for applicable tests and experiments; and assignment of responsibility for reportfug all test and experiments conducted pursuant to 10 CFR 50.59.
a.
Documents Reviewed QP 11-51 (Revision 3), Test Control for Operations LAP 1200-5 (Revision 3), Onsite Review of Proposed Tests and Experiments-8-
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LTP 100-2 (Revision 4), Special Operation Tests LTP 200-1 (Revision 2), Nuclear Regulatory Commission Annual Report LTP 300-7 (Revision 2), N.R.C. Monthly Operating Report b.
Findings No items of noncompliance were identified in this area.
c.
Discussion (1) Review of the LaSalle procedures for Special Tests and Experiments contained no provisions for identifying re-visions to authorized test procedures.
Since revisions will be necessary from time to time, provisions for handling them should be developed in order to avoid problems in retrieval of the correct revision test package from files at a later date. There is no regulatory basis for this, but offered as a suggestion to improve Lecord control in this area.
The licensee agreed to consider this provision during the next revision to applicable procedures.
The inspector has no further questions at this time.
(2) Unresolved Item (50-373/81-22-06)
10 CFR 50.59 states that the licensee furnish the NRC annually or at such shorter intervals as may be specified in the license, a report containing a brief description of such... tests and experiments including a summary of the safety evaluation of each.
During the review of the above LaSalle procedures, the in-spector noted that the method for reporting was not included in the instructions for the monthly annual operating report or other reports. The licensee needs to ideutify the method to be used in reporting and assign reposibilities for pre-paration.
7.
Receipt, Storage and Handling of Equipment and Materials Program l
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Receipt, storage and handling of equipment and materials was reviewed to ascertain whether the licensee is implementing a QA program that is in conformance with regulatory requirements and commitments in the i
l Quality Assurance Program and implementing procedures. The inspector verified that responsibilities were assigned for receipt, acceptance, l
release, storage, and handling of items. Nonconforming items were j
reviewed for identification, segregation, control, and release.
Receipt l
inspection reports were examined for applicable signatures, justification l-9-
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for use, damage recorded, and stipulated inspection criteria.
Procedures were reviewed for levels of storage and appropriate environmental con-ditions, including shelf life.
a.
Documentation Reviewed
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Quality Assurance Program Topical Report CE-1-A, January 12, 1981, Revision 15, Sections 7, 8, 10, 13, and 15.
Q.P. No. 8-51, Identification and Control of Materials, Parts and Components for Operations - Identification, Inventory Disbursed and Use.
Q.P. No. 7-51, Control of Purchased Materials, Equipment and Services for Operations - Supplier Evaluation.
Q.P. No. 10-54, Inspection for Operations, Receiving Inspection.
Q.P. No. 13-51, Handling, Storage and Shipping for Operations -
Control of Equipment, Materials and Nuclear Fuel.
Q.P. No.15-51, Nonconforming Materials, Parts and Components for Operations - Spare Parts and Materials.
LAP 500-1, Stores Organizations, Revision 02, December 1979.
LAP 500-4, Receiving Inspection, Revision 05, April 1981.
LAP 500-5, Shipment Release, Revision 05, February 1980.
LAP 500-6, Stores Procedures, Revision 00, July 1976.
LAP 500-11, Control Of Items With Limited Shelf Life, Revision 00, March 1978.
LAP 1400-1, Control of Purchased Material, Equipment and Services, Revision 02, March 1978.
LAP 1400-2, Withdrawal and Return of ASME or Safety Related Items, Revision 06, September 1979.
I AP 1400-3, Material Request, Revision 03, November 1978.
LAP 1400-4, Tagging of ASME and Safety Related Material, Revision 02, September 1978.
LAP 1400-6, Welding Material Control, Revision 05, May 1980.
LAP 1400-8, Handling and Storage of Stainless Steel, Revision 00, December 1978.
LAP 1400-9, Receiving, Storage and Shipping of Material and Equipment, Revision 00, April 1980.
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LAP 1500-3, Discrepancy Records, Revision 05, March 1981.
LAP 1500-5, Deviation Reports, Revision 01, October 1979.
LTP 800-3, Receiving Inspection of ASME Code and Safety Related Items, Revision 04, June 1979.
LMP GM-9, LaSalle Station Safe Rigging Practices, Revision 1, November 1978.
b.
Findings (1) Noncompliance (50-373/81-22-07)
10 CFR 50, Appendix B, Criteria XV, states in part, " Measures shall be established tc control materials, parts, or components which do not conform to requirements in order to prevent their inadvertent use or installation."
Commonwealth Edison Company states in their' Quality Assurance Program Topical Report CE-1-A, Revision 15, Section 14, that controls will exist consisting of documented receipt inspec-tions and item tagging to indicate nonconforming status, with such hold and reject tags only being removed at the direction of the Quality Assurance personnel.
Contrary to the above, a dial indicator, I.D. M5069, placed on hold by Quality Control on February 25, 1981, was taken off hold and released for usage by the Mechanical Maintenance Department, without a receipt inspection being done and without the hold status being removed by Quality Assurance personnel.
An audit by Commonwealth Edison on July 16, 1980 identified similar problems concerning five instruments but did not take corrective action to preclude repetition.
Commonwealth Edison responded to this finding during the inspection and has taken corrective action to preclude repetition by notifying all
applicable personnel of the necessity of performing receipt inspections by Quality Control and of the requirement that
only Quality Assurance personnel are allowed to authorize i
removal of hold tags. Subsequent review by QA released l
the indicator for use.
No response is required.
l (2) Noncompliance (50-373/81-22-08)
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10 CFR 50, Appendix B, Criteria II, states in part, "The i
l applicant shall establish at the earliest practical time, l
consistent with the schedule for accomplishing the activities, l
a quality assurance program which complies with the require-i ments of this appendix.
This program shall be documented by l
written policies, procedures, or instructions and shall be carried out throughout plant life in accordance with these l
l policies, procedures, or instructions."
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Commonwealth Edison Company states in part in their Quality Assurance Program Topical Report CE-1-A, Revision 15, Section 2, " Certification records will be maintained by the Quality Assurance Department as well as the department where-in the employee performs his activities. Qualification and certifications will be maintained in a current status and will be established to meet the applicable requirements of ASME Code and ANSI standard N45.2.6."
Additionally, Quality Assurance Program Topical Report CE-1-A, Revision 15, Section 2, commits to ANSI N18.7-1976 which endorses ANSI N45.2.6-1973 in Paragraph 5.2.7.
Contrary to the above, Quality Control personnel, who are performing receipt inspections, do not have dovimented certifications required by ANSI N45.2.6-1973, Paragraph 2.2.4.
c.
Discussion (1) Unresolved Item (50-373/81-22-09)
Commonwealth Edison's material request process needs improve-ment, as material is requisitioned without complete information concerning the description of the items. Typical examples of information left off material requests were:
(a) Material specificaticns.
(b) Material grades.
(c) Wall thicanesscs.
(d) Classification of items - ASME B&PV Code into Classes 1, 2 or 3 which pertains to NB, NC, or ND of ASME B&PV Code,Section III, 1974.
Additionally, storeroom personnel need to be trained in the classification of items, as to safety related, non-safety related, and ASME B&PV Code,Section III material.
By being familiar with these categories, the material request process and issuance of material can be more easily controlled.
Storage of material according to Class 1, 2, 3 of the ASME B&PV Code,Section III, will also facilitate greater control, to preclude issuance of incorrect or nonconforming material for installation in the plant.
(2) Unresolved Item (53-373/81-22-10)
Serial numbers rir suges which are used for receipt
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inspection m'%v T e ntt to determine that dimensions are within all.v.a':
~ erances are not being recorded; therefore t..eir.: stration is not traceable.
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(3) Unresolved Item (50-373/81-22-11)
Quality Procedure 10-54, Inspection for Operations, Receiv-ing Inspection, ion page 5 of 7 and LTP-800-3, Receiving Inspection of ASME Code and Safety Related Items, Paragraph 8, contain statements concerning Commonwealth Edison placing a traceability number on items (purchase number plus heat or serial number) or tag if the item cannot be marked to maintain traceability to supplier's do4.Lmentation.
It was discussed with the Manager of Quality Aasurance that this statement could be interpreted to imply that Edison may place heat numbers or serial numbers on material that is lacking in re-quired markings. The Manager of Quality Assurance assured the inspector this was not the case nor the intent of the statement and that it would be clarified or deleted as appro-priate. Markings may be placed on material that requires only certificates of compliance per NA 3766.6 of the ASHI B&PV Code.
(4) Unresolved Item (50-373/81-22-12)
No surveillances or andits of receipt-handling / unloading are being done by Quality Assurance as required by Section 13 of the Quality Assurance Program Topical Report CE-1-A, January 12, 1981, Revision 15.
Additionally an inspection program for equipment and rigging has not been established as required by ANSI N45.2.2-1974, Paragraph 7.4.
8.
Records Program The records program was reviewed to ascertain that the licensee is implementing a program relating to the control of records that is in conformance with applicable regulatory requirements, Operational Quality Assurance Program, ANSI N18.7-1976 and ANSI N45.2.9-1974.
Record storage controls were reviewed including the means of trans-ferring records to the vault. Various records were reviewed for implementation and retrievability. The record index was checked against the criteria of ASNI N45.2.9-1974.
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a.
Documentation Reviewed Quality Assurance Program Manual, April 17, 1981, Revision 61, Q.R. No. 17.0 - Quality Assurance Records.
Quality Assurance Procedures Manual, April 17, 1981, Revision 57, Q.P. No. 17-51 - Quality Assurance Records for Operations - Control of Station Records.
LA? 810-1, Receipt and Distribution of Documents (Revision 3, July 1979).
LAP 810-2, Records Retention and Retrieval (R3) Operation (Revision 2, October 1978).
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LAP 810-3, Establishment, Maintenance and Transfer of Active Files to Central File Control and Records Transferred from Responsible Departments to Central File Control (Revision 4, December 1979).
LAP 810-4, Retrieving Hard Copy Materials from Central File and Satellite Files (Revision 3, September 1978).
LAP 810-5,. Drawing P.eproduction onto Hard Copy (Revision 6, February 1980).
LAP 810-8, Receipt and Distribution of Drawings (Revision 3, June 1979).
LDP 100-1, Library Orders (Revision 0, August 1977).
LDP 100-6, Storage and Preservation of Documents in the Station-Archives (Revision 1, December 1978).
LDP 100-8, Receipt and Distribution of Updates (Revision 3, February 1980).
LaSalle, FSAR, Chapter 17.0 - Quality Assusrance (AMDT 41, January 1979).
LaSalle, FSAR, Question 421.3 (AMDT 46, August 1979).
LaSalle, FSAR, Appendix B, page B.1-108, " Regulatory Guide 1.88" (AMDT 44, March 1979).
Topical Report CE-1-A.
Station Master Library Index.
LSCS Microfilming Plan.
CECO Record Type Index.
b.
Findings Noncompliance (50-373/81-22-13)
10 CFR, Appendix B, Criterion XVII, states in part, " Consistent
, with applicable regulatory requirements, the applicant shall establish requirements concerning record retention, such as duration, location, and assigned responsibility."
Commonwealth Edison Company has committed to the requirements and
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guidelines of ANSI N45.2.9-1974 through Regulatory Guide 1.88 (Revision 2) as stated in the Quality Assurance Program Topical Report CE-1-A.
Page B.1-108 of Appendix B to the LSCS FSAR states, "The station fire protection afforded the records storage area conforms to i
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NFPA 232 criteria..." and "We comply with the objectives set forth in the referenced revision of this regulatory guide."
(Regulatory Guide 1.88, Revision 2, October 1976).
ANSI N45.2.9 states " Permanent and temporary record storage facili-ties shall be constructed or located as to protect contents from possible destruction by causes such as fire..."
Contrary to the above, records were stored in a non-fire rated room in the basement of the service building. Some of the records, including strip charts and radiographs, had been stored there for periods up to six months.
In addition, the Central File Room in the service building did not conform to the fire protection criteria for file rooms specified in NFPA-232, 1975 edition.
c.
' Discussion (1) The room in which the records wcre stored is intended to be the room in which microfilming operations will take place.
Temporary storage in such a room might be allowed provided a significant backlog of work did not occur. The problem of such temporary storage could be solved by storing records to be microfilmed in two hour rated fireproof containers in the room instead of open, shelved or boxed storage.
The Central File room did not conform to the NFPA-232 (1975)
fire barrier criteria. Specifically, a fire resistive file room shall have:
Walls - non-combustible construction..., consisting of rein-forced concrete or brickwork...
- 6 inches thick for reinforced concrete
- 8 inches thick for brick
- Interior walls shall be unpierced except for protected openings.
- It is recommended that windows shall be as few and small as practicable and placed above the level of containers hcasing records.
- File room door - bearing label of Underwriters Laboratories or other nationally recognized testing laboratories.
The foregoing list is intended to be illustrative of NFPA-232
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requirements and recommendations which are not met by the LSCS Central File room.
If compliance with this code is to be reached, all NFPA-232 requirements must be adhered to.
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(2) Unresolved Item (50-373/81-22 - 14)
The storage facilities for LSCS QA records are not completely described as required by ANSI N45.2.9-1974 Paragraph 5.3.1 in that the station procedures for QA record storage do not describe the storage area for active files or for the Central File room.
In addition, the LSCS QA records storage proce-dures.do not include a method for verifying that hard copy
. records received by the Central File room are in good con-dition. These examples of LSCS QA records storage procedure deficiencies constitute an unresolved item.
(3) Unresolved Item (50-373/81-22-15)
The QA records indexing systems do not completely meet the requirements of ANSI N45.2.9-1974 Paragraph 3.2.2 in that one record type (Superseded Operating Procedures) of about 18 sampled was not listed on the index.
In addition, storage locations for records held in departments are not specified (such as Rad / Chem surveillances held by the Rad / Chem Depart-ment) The corporate Record Type-Index is inten<'ed for use for microfilmed station records during the operacions phase, and will improve the completeness of the indexing system.
It may not, however, provide sufficient identification of storage area and location within a storage area as required by Para-graph 3.2.2 of ANSI N45.2.9-1974 for unmicrofilmed records.
The records index is an unresolved item.
9.
Procurement Program The procurement program was raviewed to ascertain its conformance with regulatory requirements and commitments in the operational quality assurance program. Procurement documents were checked for technical requirements, QA program requirements, 10 CFR 21 provisions, specific identification of items, and statements concerning access to the supplier's plant or records for purposes of audit.
Procedures were reviewed to determine if responsibilities were assigned in writing for:
(a) Initiation of procurement documents, (b) review and approval of procurement documents, (c) making changes to procurement documents, and
' (d) basis for classification of procurement items. An approved vendors list was examined, along with the evaluation of suppliers after being placed on the approved suppliers list.
Procurement documents for various systems were checked, along with the supplied materials documentation, including traceability to the item.
a.
Documentation Reviewed Quality Assurance Program Manual, April 17, 1981, Revision 61, Q.R. No. 4.0 - Procurement Document Control.
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Q.P. No. 4-51, Procurement Document Control for Operation -
Processing Purchasing Documents.
Q.P. No. 7-51, Control of Purchased Materials - Equipment and Services for Operation - Supplier Evaluation.
LAP 500-2, Purchase Requisitions, Revision 06, April 1981.
LAP 500-3, Procurement Document Control, Revision 02, January 1980.
LAP 500-8, Small Purchase Order, Revision 04, July 1980.
LAP 500-7, Request for Purchase, Revision 06, May 1981.
b.
Findings No items of noncompliance were identified in this area.
10.
Audits The licensee's audit program was reviewed to ascertain whether the licensee has developed and implemented a program that is in conformance with regulatory requirements and applicable industry guides and standards.
The inspection included verification of the following:
scope of the program is consistent with the FSAR and QA Program requirements, respon-sibilities for overall management of the program have been assigned; and methods for identification and resolution of audit findings have been defined, a.
Documentation Reviewed Quality Assurance Program Topical Report CE-1-A, January 12, 1981, Revision 15, Section 16, Corrective Action.
Quality Assurance Program Topical Report CE-1-A, January 12, 1981, Revision 15, Section 18, Audits.
Quality Assurance Program Manual, April 17, 1981, Revision 61, A.R. No. 18.0, Audits and Q.R. No. 16.0, Corrective Action.
Q.P. No. 16-51, Corrective Action for Operations - Corrective Action System.
Q.P. No. 18-51, Quality Assurance Program Audits.
Q.P. No. 18-52, Audit and Surveillance of Maintenance, Spare Parts and In-Service Inspection Activities.
LAP-100-12, Trend Analysis Program, Revision 01, August 1980.
LAP-1500-4, Action Item Records, Revision 06, August 1980.
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b.
Findings No items of noncompliance were identified in this area.
11.
Surveillance Testing and Calibration Control Program The program for surveillance testing was reviewed to verify compliance with the proposed LSCS Technical Specifications. Management of periodic and non periodic surveillance testing was examined. The program for calibration of plant instrumentation and measuring and test equipment which are used in meeting technical specifications was reviewed for compliance with ANSI N18.7-1976.
Several instruments were examined to ensure that they were included in the calibration program.
a.
Documentation Reviewed LAP 100-11 LSCS General Surveillance Program (Revision 00, August 1979).
LAP 200-3 Shift Change (Revision 03, June 1980).
Quality Assurance Program Manual, April 17, 1981, Revision 61, Q.R. No. 12.0, Control of Measuring and Test Equipment.
Q.P. No. 12-51, Control of Measuring and Test Equipment for Operations - Portable Test and Measurement Equipment.
Q.P. No. 12-52, Control of Measuring and Test Equipment for Operations - Station Instrumentation.
- The following surveillances on Station Batteries:
LOS-DC-M1 LOS-DC-M2 LOS-DC-M3 LOS-DC-W1 LOS-DC-W2
- The following surveillances on Site Diesels:
LOS-DG-M1 LOS-DG-M2 LOS-DG-M3 b.
Findings No items of noncompliance were identified in this area.
c.
Discussion (1) Unresolved Item (50-373/81-22-16)
The computer generated list for periodic surveillances, and the system described by LAP-100-11 appeared satisfactory for
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the purpose of managing periodic surveillances. There was no administrative syatem for the management of non periodic surveillances, such as those required to be performed when certain limiting conditions for operations are entered.
The possibility of including the discussion of such surveillances during shift change sas discussed. A system of Equipment Outage Reports which is currently in use at the Quad-Cities Station was also uiscussed.
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(2) Unresolved Item (50-373/81-22-17)
ANSI N18.7-1976, Paragraph 5.3.7 requires that procedures be provided for assuring measurement accuracy by means of periodic calibration and testing of safety related instru-mentation and control systems and for measuring and test equipment used in activities affecting the quality of these systems, and that the calibration schedules be sufficient to keep safety related parameters within operational and safety limits. An extensive computer listing of all such plant instruments which are not already required to be calibrated by the Technical Specifications exists.
This listing also includes Balance of Plant (BOP) instrumenta-tion. There is, however, no plant instruction which governs the management of that computer program (in the same manner that LAP 100-11 manages the Surveillance program). Although all instruments examined for inclusion on the calibration printout were listed satisfactorily, there was no apparent organized effort to ensure that each instrument which is used in meeting an LC0 is periodically calibrated (except t
for tLase instruments which tests and calibrations are required by Section 4 of the Technical Specifications).
In addition, the' criteria for altering calibration fre-quency are not clearly established.
(3) Unresolved Item.(50-373/81-22-18)
l Although the measurement of battery specific gravity, cell temperature, and float voltage are required by Technical Specifications, there is no place-on any monthly or weekly surveillance data sheet for the recording of the instrument l
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number of the hydrometers, thermometers, or voltmeters used.
i There are also no instructions in the associated surveillance l
procedures to record these instrument numbers. This connent
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applies to all LOS-DC procedures.
12.
Corrective Action Program and Non-Routine Reporting Program
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l The inspector reviewed this area to verify that measures have been I
established to identify and correct conditions adverse to quality.
a.
Documentation Reviewed l
Q.P. 15-51, Nonconforming Materials, Parts, and Components for l
Operations.
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Q.P. 15-52, Nonconforming Materials, Parts and Components for Operations - Deviations and Comments (SIC).
Q.P. 16-51, Corrective Action for Operations - Corrective Action System.
Q.R. 16.0, Corrective Action.
LAP-1500-5, Deviation Report Procedure, Revision 01, October 1979.
LTP-400-3, Weekly Review of R.O. and D.V. Status.
LTP-300-8, Monthly Tend Charts.
LTP-400-1, In-Plant Inspection.
LTP-600-5, Completed Safety Related Work Requests.
LTP-600-7, Surveillance of Daily Operations.
LTP-800-1, Initial Review of Work Requests LTP-800-2, Final Review of Work Requests LTP-1500-1, Nuclear Engineers Daily Surveillance.
LAP-100-12, Trend Analysis Program, Recieved August 1980.
LAP-1500-4, Action Item Records, Revision 06, August 1980.
LAP-100-11, General Surveillance Program, Revision 00, August 1979.
LAP-850-3, Service Information Letters, Revision 07, September 1980.
LAP-850-6, Distribution and Processing of Operating Experience Information, Revision 00, March 1981.
LTP-300-7, NRC Monthly Operating Report.
Q.R. 15.0, Nonconforming Material, Parts or Components and Operations.
Q.P. 15-53, Nonconforming Materials, Parts and Components...
Inspection and Test.
b.
Findings i
No items of noncompliance were identified in this area.
c.
Discussion The licensee's system is rather narrow with a fairly high threshold for formal corrective ac; ion. The primary emphasis appears to be on identifying and revir. wing events for reporting to the NRC. The
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DVR report form does not even mention corrective action.
Corrective action is-tracked in the Action Item Record program. There is some trend analysis of DVR's required in the program.
The desirability of providing more guidance in the procedures regarding the items (work requests, etc.) to be considered in con-ducting trend analysis was discussed with the licensee.
In addition the benefits of assigning specific requirements to initiate a DVR in procedures where practical was discussed. The licensee agreed to consider the inspector's comments. The licensee initiated a change to LAP 1500-5 to require an AIR be generated in any case where cor-rective action had not been completed as the result of a DVR.
The system appears to be functional. The inspector believes the system has some inherent weaknesses such as:
(1) High threshold tends to leave problems within departments without establishing an unbiased review process.
(2) Tracking corrective action externally to the DVR makes the system somewhat cumbersome and it could break down in times of high use.
The above was discussed with the licensee. He believes the system is acceptable as it is and can support this based upon experience with basically the same system at his other operating units.
The inspector has no further questions at this time.
13.
Inservice Testing Program for Pumps and Valves a.
The inspector reviewed the licensee's inservice test program, previously submitted to the NRC for approval. The licensee has been granted interim approval to implement the program, as sub-mitted, pending a more detailed review by the NRC.
The inspector interviewed personnel concerned with program development and implementation to determine the mechanisms that will be employed to insure that the program is implemented in accordance with the requirements of the applicable edition and addenda of Section XI of the ASME Code excepting specific requirements for which interim relief has been granted. The inspector determined that the li-censee is currently cross-referencing inservice test requirements to plant procedures that will be used to conduct the tests. The licensee had not decided how the tests will be scheduled; however, he indicated that inservice test scheduling would either be covered by the general surveillance schedule or perhaps a separate computer-based tracking system used for inservice testing of pumps and valves alone. The licensee stated that records would be maintained in ac.rdance with the requirements of Section XI of the ASME Code, Articles IWP 6000 and IWV 6000.
The inspector identified one valve, (IE22 F339-High Press re Core Spray Suction Vent Stop Valve), which was required to be locked-closed which was incorrectly specified as locked-open in the inservice test program.
A review of the adminirtrative procedure governing the control of locked valves and the system operating
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procedure revealed that the locked valve verification checklists properly indicated that the valve should be locked closed. The licensee stated that a review is currently being conducted to insure correctness of, and consistency between, locked valve position requirements specified by the IST Program, plant proce-dures and plant P& ids. The inspector has no further questions at this time as it appears that controls exist to properly position the valves, b.
Findings No items of noncompliance were identified in this area.
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14.
Maintenance The inspector reviewed the licensee's Maintenance Program to ascertain whether the licensee has developed and implemented a QA program relating to maintenance activities that is in conformance with proposed Technical Specifications, 10 CFR 50, Appendix B requirements, the QA program and commitments in the QA program. The inspector also reviewed maintenance activities of safety related systems and components to ascertain whether the maintenance program is being conducted in accordance with approved procedures, regulatory guides and industry codes and standards.
The following Manuals, Quality Procedures, Administrative Procedures, Maintenance Procedures, Operating Procedures and Work Requests were reviewed to verify that: wt:tten procedures have bsen developed for the initiation, classifica5v -i and release of routine and emergency maintenance activities; criteria and responsibilities have been es-tablished for performing work inspection of maintenance activities; provision and responsibilities have been established for the inser-tion of appropriate hold points in maintenance activities; methods and responsibilities have been designated for performing testing following maintenance activities; methods and responsibilities have been established for the assembly, review, assessment and storage of completed maintenance records; administrative controls for special processes have been established; methods and responsibilities for equipment control have been established; a written preventive main-tenance program has been established; a clearly defined control system for locked open or locked closed valves has been established; and procedures have been developed for cleanliness controls and housekeeping controls.
a.
Documentation Reviewed'
Quality Assurance Program Topical Report CE-1-A, January 12, 1981, Revision 15.
Station Quality Assurance Manual, March 4, 1981, Revision 65.
QP2-53 - Qt lity Assurance Program for Operation - Classification of Structures, Systems and Components.
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QP3-3 - Classification of Systems, Componants, Parts and Materials.
QP3-52 - Design Control for Operation - Plant Maintenance.
QPS-51 - Instructions, Procedures and Drawings for Operations -
Station Pcocedures Manual.
QP8-51 - Identification and Control of Materials, Parts and Components for Operations - Identification, Inventory Control, Dispursal and Use.
QP9-1 - Control of Contractor Special Processes.
QP9-51 - Control of Special Processes for Operations - Special Processes for Maintenance and Modifications.
QP10-51 - Inspections for Operations - Maintenance.
QP10-52 - Inspections for Operations - Station Operations.
QP10-53 - Inspections for Operations - Technical Support Surveillance and Inspection.
QP10-54 - Inspections for Operations - Eeceiving Inspection.
QP11-2 - Development, Performance, Documentation and Evaluation of Preoperational and Start-up Tests.
QP12-51 - Control of Measuring and Test Equipment for Operations -
Portable Test and Measurement Equipment.
QP14-51 - Inspection, Test and Operating Status for Operations -
Tagging.
QP15-51 - Nonconforming Materials, Parts and Components for Operation - Spare Paits and Materials.
QP15-52 - Nonconforming Materials, Parts and Components for Operation - Deviation and Comments.
QP15-53 - Nonconforming Materials, Parts and Components for Operations - Inspection and Test.
QP16-51 - Corrective Action for Operations - Corrective Action System.
QP17-51 - Quality Assurance Records for Operations - Control of Station Records.
Special Processes Manual:
LAP 100-1, Revision 5, December 1980 - Station Organization.
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O LAP 100-2, Revision 2, June 1980 - Investigation of Operating /
Maintenance Errprs.
LAP 100-6, Revision 2, November 1978 - Work over Open Reactor.
LAP 100-11, Revision 0, August 1979 - LaSalle County Station.
General Surveillance Program:
LAP 100-12, Revision 1, August 1980 - Trend Analysis Program.
- LAP 200-1, Revision 6, September 1980 - Operating Department Organization.
LAP 220-1, Revision 4, August 1980 - Shift Engineer Log.
i LAP 240-1, Revision 2, August 1979 - Use of Locks on Valves.
LAP 240-3, Revision 4, December 1980 - Electric Jumpers, Relay Blocks and Lifted Electrical Leads.
LAP 240-5, Revision 1, February 1980 - Operations Equipment Key Control.
LAP 300-1, Revision 5, July 1980 - Maintenance Organization.
LAP 300-2, Revision 2, September 1978 - esntrol-of Welders Qualification and Welder Number, Letters or Symbol.
LAP 300-3, Revision 0, February 1979 - Mechanical Maintenance Vibration Monitoring Program.
LAP 300-4, Revision 4, March 1980 - Computerized Lubrication and Preventive Maintenance Program.
LAP 300-5, R..ision 1, December 1978 - Controlling the Installation and Removal of Temporary, Mechanical Maintenance Related Devices.
LAP 300-9, Revision 3, November 1979. Control of Maintenance Test
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I and Measuring Equipment.
LAP 300-10, Revision 4, February 1979 - Maintenance Department
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Administrative Procedure to Verify Calibration and Reliability of Test and Measuring Equipment.
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LAP 300-11, Revision 2, September 1978 - Computerized Maintenance
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Program.
LAP 300-14, Revision 1, July 1978 - Welders Training.
LAP 400-1, Revision 8, December 1980 - Technical Staff,rganization.
. LAP 820-1, Revision 11, September 1980 - Station Procedures.
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LAP 820-2, Revision 15, September 1980 - Station Procedure Preparation and Revision.
LAP 820-4, Revision 8, December 1980 - Temporary Procedure Changes.
LAP 820-5, Revision 3, July 1979 - Use of Station Mechanical and Electrical Checklists.
LAP 820-7, Revision 0, January 1980 - Special Procedures.
J LAP 900-4, Revision 10, January 1981 - Equipment Out of Service Procedu re.
LAP 900-10, Revision 3, June 1980 - Fire Prevention Procedure for Welding and Cutting.
LAP 900-12, Revision 4, August 1980 - Caution Card Procedure.
LAP 900-15, Revision 2, February 1981 - Housekeeping Practices.
LAP 1200-6, Revision 1, November 1979 - Onsite Review of Procedures.
I LAP 1300-1, Revision 9, October 1980 - Work Requests.
LAP 1400-1, Revision 2, rch 1978 - Control of Purchased
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Material, Equipment and Services.
LAP 1400-2, Revision 6, September 1979 - Withdrawal and Return of ASME or Safety Related Items.
LAP 1400-3, Revision 3, November 1978 - Material Request.
LAP 1400-4, Revision 2, September 1978 - Tagging of ASME and Safety Related Material.
LAP 1500-1, Revision 0, June 1976 - Quality Assurance Program.
LAP 1500-3, Revision 5, February 1980 - Discrepancy Records.
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LAP 1500-4, Revision 6, August 1980 - Action Item Records (AIR).
LAP 1500-5, Revision 1, October 1979 - Deviation Reports.
LEP GM-102, Revision 1, December 1980 - Torque Switch Setting l
and Limit Switch Setting of Motor Operated Valves (Limitorque).
LEP GM-103, Revisio:
1, July 1980 - Inspection of 4.1 KV and
6.9 KV Circuit Breakers.
LEP GM-105, Revision 2, May 1980 - Inspection of 480V (600 amp)
Circnit Breakers.
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LEP G:1-106, Revision 0, January 1980 - Control and Calibration of Wire Strippers.
LEP GM-107, Revision 0, March 1980 - Inspection of AK-2 and AK-2A Circuit Breakers.
LEP RD-101, Revision 0, March 1979 - CRD Solenoid Replacement.
LIP AR-01, Revision 0, July 1978 - Area Radiation Monitor Source Calibration.
LIP FW-02, Revisior. O, January 1979 - Fe - later Pump Discharge Flow Calibration.
LIP GM-09, Revision 0, October 1979 - Opening Process Instrument Lines.
LIP MS-01, Revision 0, October 1979 - Main Steam Isolation Valve Closure Scram Bypass Calibration.
LIP RR-08, Revision 0, November 1979 - Recirculation Flow Controller Calibration.
LIP RT-02, Revision 0, December 1978 - Reactor Bottom Head Drain Flow Indication Calibration.
LMP Gli-1, Revision 0, July 1976 - Valve Packing Procedure.
LMP GM-06, Revision 1, November 1978 - Weld Cleaning Procedure.
LMP MS-3, Revision 0, February 1979 - Main Steam Isolation Valve Disassembly and Assembly.
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LMP PC-1, Revision 1, December 1980 - Drywell Head Removal.
LMP RD-01, Revision 1, July 1980 - Control Rod Drive Inspection and Maintenance.
LMP RD-02, Revision 1, December 1980 Control Rod Drive Leak Test.
LES DC-101, Revision 2, April 1981 - 24 and 125 Volt Battery Inspection.
LES DC-103, Revision 0, April 1979 - Battery Charger Capacity Test.
LES GM-106, Revision 0, February 1979 - Inspection of General Electric MagneBlast Circuit Breakers.
LOP VQ-01E, Revision 0, May 1979 - Electrical Checklist.
LOP VQ-01M, Revision 1, January 1930 - Mechanical Checklist.
LSU 200-2, Revision 8, June 1980 - Testing Deficiencies.
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Work Requests.
L08668 - Fire Damaged Cable Repair.
LO8505 - Diesel Generator Power Assembly Replacement.
LO6107 - Scram Contactor Repair.
LO6032 - HCU 42-59 Accumulator Pressure Indicator Calibration.
LO6030 - HCU 46-27 Accumulator Pressure Indicator Calibration.
LO6015 - Diesel Generator Lockout Relay Repair.
LO5943 - Diesel Generator Soak Back Pump Vibration Check.
LO5941 - RWCU Return Isolation Transformer Repair.
LO5937 - HCU 14-15 RPS Repair.
LO5934 - Delta P Transmitter Loop Check.
LO5926 - Delta P Transmitter Loop Check.
LO5916 - Diesel Generator Governor Adjustment.
LO5899 - RCIC Vacuum Breaker Valve Adjustment.
LO5836 - HPCS Panel Terminal Block Replacement.
LO5732 - 250V Battery Charger Repair.
LO5662 - Diesel Generator Vibration Test.
L05650 - Check Valve Repair.
LO5642 - 250V Battery Charger Troubleshooting.
LO5600 - Diesel Generator Tachometer Replacement.
LO5555 - RWCU Suction Isolation Valve Trouble Shooting.
LO5449 - Delta P Transmitter Loop Check.
LO5448 - Temperature Transmitter loop Check.
WR77-34 - Modification M-1-1-77-2 N Stamp Certification.
b.
Findings (1) Noncompliance (50-373/81-22-19)
10 CFR 50, Appendix B, Criterion V states, " Activities affecting quality shall be prescribed by documented instruc-tions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings.
Instructions, procedures, or drawings shall include appropriate quantita-tive or qualitative acceptance criteria for determining that important activities have been satisfactorily accomplished."
The Station Quality Assarance Manual states in part that the Maintenance Assistant Superintehdent or the Master Mechanic shall review each Work Request and direct their staff to prepare a Maintenance / Modification Procedure, Figure 9 of the Station QA Manual, as applicable, which together with the Work Request and all other documentation constitutes the Maintenance / Modification work package.
Quality Procedure 3-52 states in part that the Maintenance Assistant Superintendent or Master Mechanic shall have prepared and approved Maintenance / Modification Procedure for safety, code and plant reliability related maintenance.
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LAP-1300-1 states in part that the Maintenance Assistant Superintendent shall sign and date the Maintenance /Modifica-tion Procedure cover sheet for maintenance procedures which have not been previously approved by onsite review.
Contrary to the above, Work Request LO8505 allowed the repair of the Unit 2 Diesel Generator A without the use of an approved procedure.
(a) The repair of the diesel was performed as a craft capa-bility operation under the direction of a Stewart and Stevenson Field Representative. The work instructions do not reference any technical manuals but do state to take actions per the service representative's direction.
(b) The work instruction has an Additional Work Requirements list attached instead of an approved Figure 9.
The in-structions provided were. inadequate in that the defective power assenbly was required to be removed, but is never reinstalled prior to a test run of the engine. Though the instructions did not require the assembly to be reinstalled it was.
(c) The work instructions and the Additional Work Require-ments fail to include any acceptance criteria or torque values.
(2) Noncompliance (50-373/81-22-20)
10 CFR 50, Appendix B, Criterion X1 states in part, "A test program shall be established to assure that all testing re-quired to demonstrate that structures, systems, and components will perform satisfactorily in service is identified and performed in accordance with written test procedures which incorporate the requirements and acceptance limits contained in applicable design documents."
10 CFR 50, Appendir. B, Criterior XVI states, " Measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and.nonconformance are promptly identified and corrected.
In the case of signi-l ficant conditions adverse to qaality, the measures shall l
assure that the cause of the condition is determined and l'
corrective action taken to preclude repetition. The identification of the significant condition adverse to
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quality, the cause of the condition, and the corrective l
action taken shall be documented and reported to appro-priate levels of management."
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QP 11-2 states that when in preoperational testing it becomes necessary to rework equipment, the action will be accomplished in accordance with controlled procedures and a table of apparent deficiencies will be documented.
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LSU 200-2 states that any deficient condition encountered prior to the completion of preoperational testing will be added.to the deficiency list and will be processed according to Step 3 and Attachment A.
Contrary to the above, during the conduct of Preoperational Test PT-DG-201A a deficiency where lockout relays 86D60, 86D61A-and 86D62A of Diesel Generators 0, lA and 2A differed in their as-built condition and also did not agree with their respective schematic diagrams IE-0-4412AH, IE-1-4009AH and IE-2.4009AH was identified on October 16, 1980 and a Deficiency Report was not written.
(a) Attachment A of LAP 300-15, Revision 0, October 10, 1979, attached to Work Request LO6015, and dated October 16, 1980, states that a diode was ordered by 0AD for relay 86D62A and must be installed. The diode is part of a suppression circuit consisting of a diode, resistor and capacitor installed across the coil of the relay.
(b) Discussions with OAD and Technical Staff personnel re-vealed that Diesel Generator IA arrived on site with the above mentioned suppression circuit while Diesel Generator 2A and 0 did not have the circuit. The schematic diagram for each diesel showed a circuit consisting of only a resistor and a diode.
Inspection of the Diesel Generators on April 29, 1980 revealed Unit 0 to have no circuit and Units 1A and 2A to have the three component circuit. Schematic diagram 1-IE-4009AH was changed by Revision H on March 16, 1981 to reflect the three component circuit while IE-0-4412AH and IE-1A-4009AH still show the two component circuit.
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(c) A discussion with Personnel at SNED revealed that on October 30, 1980 a letter had been sent to Stewar tand Stevensen describing the situation and requesting assis-tance in' obtaining the proper parts.
l (d) The Technical Staff, on April 30, 1981 after discussions
with the inspector, initiated Deficiency Reports 603 for PT-DG-101A and 209 for PT-DG-201A to correct the dis-i crepancies.
The immediate corrective action of writing deficiency reports
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l should produce the desired result of having all the diesels and schematics agree but it will not correct the cause of the problem. There appears to be a problem of equipment being turned over for preoperational testing with known, undocu-
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mented problems as indicated by a similar finding in Inspec-
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tion Report (50-373/81-20). The licensee should conduct an
extensive review to guarantee that all known equipment
problems existing at the time of turnover have been or will
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be identified by a deficicacy report.
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c.
Discussion (1) Unresolved Item (50-373/81-22-21)
The inspector observed that a formal Preventive Maintenance Program does not exist as there is no procedure to control the overall program; with respect to responsibilities, fr'equency, and type of activities to be included.
Commonwealth Edison Company has committed to ANSI N18.7-1976 through Pagulatory Guide 1.33, Revision 2, as stated in the Quality Assurance Program Topical Report CE-1-A.
ANSI N18.7-1976, Section 5.2.7.1 states in part,..."A preven-tive maintenance program including procedures as appropriate for safety-related structures, systems and components shall be established and maintained which prescribes the frequency and type of maintenance to be performed."
The Preventive Maintenance procedure, LAP 300-8, has not been issued.
The proposed program has been discussed with the Maintenance Staff but this will be an unresolved item requir-ing the review of LAP-300-8, Preventive Maintenance.
(2) Unresolved Item (50-373/81-22-22)
Commonwealth Edison Company has committed to ANSI N18.7-1976 through Regulatory Guide 1.33, Revision 2, as stated in the Quality Assurance Program Topical Report CE-1-A.
ANSI N18.7-1976, Section 5.2.10 states that ANSI N45.2.1-1973 and ANSI N45.2.3-1973 shall be applied to activities occurring during the operational phase that are comparable in nature and extent to related activities occurring during construction.
The licensee has no written Procedures to assure that the re-quirements of ANSI N45.2.1-1973 and ANSI N45.2.3-1973 are met in the applicable situations. This lack of Housekeeping and Fluid Systems Cleaning procedures is an unresolved item and will be inspected after the licensee institutes Housekeeping and Fluid System Cleaning programs.
(3) Section 4.1.1 of the Station Quality Assurance Manual requires the Operating Assistant Superintendent to review and authorize all Work Requests, while QP 3-52 assigns the same task to the Operating Engineer. This item was brought to the attention of the licensee and a change was made to the Station Quality Assurance Manual prior to the completion of the inspection.
(4)
LAP 900-10, Fire Prevention Procedure for Welding and Cutting, requires the fire watch to have first aid trainiug.
Presently only Shift Engineers and Rad / Chem technicians receive first aid training.
The licensee acknowledges that this is a typographical error and has agreed to change the procedure to eliminate the
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o first aid reference. -The inspector has no further questions at this time.
(5)
LAP 900-10, also requires the completed Welding and Cutting Permit to be filed in Central Files. The permits are presently filed in the Maintenance Office.
The licensee stated that the procedure would be changed to allow the filing of the permits in the Maintenance Office. This change would not conflict with any regulatory requirements therefore the inspector has no further questions at this time.
'(6) Selected maintenance procedures were reviewed using the Procedures Evaluation Checklist of NUREG 1369. The inspector met with the Maintenance Assistant Superintendent and discussed the checkiist and the findings. The licensee stated he had attempted to use the suggestions in the NUREG 1369 and would t
consider the inspectors comments. As there is no regulatory basis for the licensee to use NUREG 1369 the inspector has no further questions at this time.
(7) During procedure review, the inspector noted that the re-quirements of ANSI N18.7-1976, regarding procedure content, were being fulfilled. The inspector noted that if the pro-
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cedures had been written using Attachment A of' LAP 820-1,
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Station Procedures, they would not have met the requirement of ANSI N18.7-1976. Attachment A is the Standard Procedure Format and it does not provide a requirement for checklists
on involved or complex procedures and does not require accept-
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ance criteria against which to judge success or failure of test type procedures. No problems resulted from the error in the procedure. The licensee agreed to revise the procedure.
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The inspector has no further questions at this time.
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(8) Unresolved Item (50-373/81-22-23)
OP 2-53 requires che Project Engineering Manager to provide a
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complete listing of components, Piping, instruments and wiring diagrams to identify safety-related items for use in procurement, maintenance, repair, modification and for ordering spares, parts and materials.
l The Project Engineer, in a letter to C. W. Schroeder dated l
November 18, 1980, responds to AIR 1-80-133, stating in part that there is no requirement to follow QF-2-53 during construction, and that the required listing is provided by Table 3.2-1 of the FSAR, Sargent'and Lundy's Mechanical Department Equipment List, Sargent and Lundy's Instrument Index, Sargent and Lundy's Valve List, P&ID's and the GE DOINS Report.
l LaSalle County Station does not possess a set of color coded P&ID's similar to those possessed by other plants in the Commonwealth
Edison system. Discussions with Personnel gave the impression that i
the availability of such P and ID's would simplify the determination of safety-related items and reduce the possibility of error.
The
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discussions also provided differin <; opinions as to how to determine if a subassembly, component or part of a safety-related item is also safety-related, with the result of different classifications for the same item.
The approve QA program in policy 2 states that the QA Program applies to safety-related items, ASME Section III activities, and related consumables plus fire protection, security, emergency plan, meteorology and radwaste shipments.
Facilities administration pro-
cedures or other QA implementing procedures do not, except for fire protection which is included in " reliability related," describe hcw items other than safety-related and ASME Section III items will be handled or identified as being under the QA Program.
The extent of the "Q list" is an open item in SER. The licensee has not developed a list or listing covering all the activities addressed in his QA program nor has he defined how the program will be applied to the non-safety-related/ASME Section III ac-tivities.
Establishment and implementation of an effective
"Q list" is considered an unresolved item.
15.
Unresolved Items Unresolved items are matters about which more information is required in order to ascertain whether they are acceptable items or items of noncompliance.
Unresolved items disclosed durir.g the inspection are discussed in Paragraphs 4, 5, 6, 7, 8, 11 and 14.
These items will be re-inspected in the near future.
16.
Exit Interview The inspectors met with licensee representatives (denoted in Paragraph 1)
at the conclusion of the inspection on June 5, 1981. The purpose and scope of the inspection were summarized and the inspectors then discussed the enforcement findings in each area. These findings had been previously discussed with licensee representatives during the inspection.
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