IR 05000382/1993012
| ML20045A066 | |
| Person / Time | |
|---|---|
| Site: | Waterford  |
| Issue date: | 06/01/1993 |
| From: | Howell A, Wagner P NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20045A062 | List: |
| References | |
| 50-382-93-12, NUDOCS 9306090319 | |
| Download: ML20045A066 (27) | |
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APPENDIX U.S. NUCLEAR REGULATORY COMMISSION
REGION IV
Inspection Report:
50-382/93-12 Operating License:
NPF-38 Licensee: Entergy Operations, Incorporated P.O. Box B Killona, Louisiana 70066 Facility Name: Waterford Steam Electric Station, Unit 3 Inspection At: Taft, Louisiana inspection Conducted: May 3-7, 1993 Team Leader:
hO GA A 5/2 7/93 Philip C. Wagne#, Team Leader Date Division of Reactor Safety Team Members:
H. Bundy, Reactor Inspector, Plant Support Section, Division of Reactor Safety S. McCrory, Examiner, Operations Section, Division of Reactor Safety J. Whittemore, Reactor Inspector, Plant Support Section Division of Reactor Safety D. Wigginton, Senior Project Manager,- Project Directorate IV-I Office of Nucle 3 Reactor Regu ation Approved:
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Arthur T. Howell, Deputy Difector, Date Division of P/ actor Safety L-i-9306090319 930602 PDR ADOCK 05000382 G
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SUMMARY i
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A routine, announced team inspection of the corrective action, self-assessment and audit programs was conducted at the Waterford, Unit 3, facility May 3-7, 1993. The inspection also included an evaluation of the licensee's use of
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industry experience information and followup on previous inspection findings.
The team performed an integrated evaluation of these areas utilizing the guidance contained in Inspection Procedures 40500, 40702, 90700, 92701, 92702, and 92720.
The team reviewed the programmatic and organizational changes that had recently been implemented in the corrective action program processes and the products of various corrective action processes. The team determined that the changes should enhance the overall performance of the program. The changes to the program had not, however, been implemented for a sufficient time to permit
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a conclusion of the effectiveness of those changes. The team also noted that the process for handling equipment problems had not received the same level of-improvement as the other corrective action process.
The team anticipated that the changes being considered for the equipment problem process would irnrove that process.
l The team found all the reviewed corrective actions to be acceptable. The team noted some examples where the corrective actions were considered weak and several examples where the licensee had implemented strong corrective actions.
The team observed that generic implications were not always considered and that root cause analyses were not always utilized when apparently justified.
The team also observed that, in some cases, corrective action recommendations from other assessments were not being tracked and,-therefore, might not be i
properly considered.
The team noted that the disposition of some corrective action documents had become more timely and more thorough as a consequence of the organizational changes.
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The team determined that the Plant Operations Review Committee was meeting its
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license responsibility and properly using its license authority. The team
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also determined that the Safety Review Committee was providing effective self-I assessments and demonstrating a conce n for the proper application of the -
corrective action program.
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~The team concluded that the Reliability Improvement Team was an effective l
program for identifying ard correcting issues related to safety and
'eliability.
The team also concluded that the trending being performed was an
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effective self-assessment tool. However, the team determined that management could have been provided a more complete status of corrective actions within the consolidated trending program.
. l The team determined that the licensee had implemented an appropriate audit ~
program. The audit results exhibited appropriate depth and breadth and included sound findings and observations.
Suitable corrective actions for findings were usually achieved but several repeat findings and observations were identified.
The team was, therefore, concerned that sufficient emphasis
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might not have been placed in continued implementation of proposed corrective-actions.
The team was infocmed that newly implemented changes in the corrective action program and the tracking of action should improve the continued implementation of required actions.
The team determined that the licensee was effectively handling information related to industry experience. The recent procedural changes and the i
redistribution of, program responsibility should maintain the excellent program performance.
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The team also found that the licensee had taken appropriate corrective ' actions I
for some previously identified inspection findings.
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DETAILS
INTRODUCTION A team of NRC personnel conducted an integrated evaluation of the licensee's corrective action, self-assessment, and audit programs. The team also evaluated the licensee's program for the feedback of operating experience and reviewed various open items and licensee event-reports. The team used a performance-based approach in evaluating the effectiveness of the licensee's programs.
2 CORRECTIVE ACTION (92720)
2.1 Backaround The team determined that significant changes had recently been implemented in the organizational structure and the programmatic aspects of portions of the Waterford 3 corrective action program.
The team reviewed the new organizational responsibilities and the new programs to determine whether they met regulatory requirements and whether they appeared to be functional. The team also reviewed completed corrective action documentation.
2.2 Previous Proaram Discussion Prior to February 1993, the principal processes for identifying, evaluating, and proposing corrective actions for failures and nonconformances at the Waterford 3 facility were the following:
Process Acronym Lead Oraanization Quality Notice QN Quality Assurance Condition Identification CI Maintenance Department and Nonconformance NCI Condition Identification Potential Reportable Event PRE Quality Assurance Significant Occurrence Report SOR STA Department The principal differentes between the QN, PRE, and 50R were reportability and safety significance. The licensee stated that considerable time was spent in determining the proper process'for an action with little resultant benefit.
In addition, the number of required forms for any action increased the potential for an item not being adequately addressed. -The licensee,
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therefore, implemented changes to portions of the corrective action process in-early 1993.
The CI process dealt primarily with installed equipment problems.
If the equipment was not installed, the corrective action was directed to the-1-
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procurement department for resolution. The licensee determined that the CI process had been effective and, therefore, less attentien was given to its improvement.
Oversight of the corrective action program was the responsibility of the Safety Review Committee (SRC).
For the condition report portion of this program, the SRC conducted reviews of routine reports, audits and assessments.
In addition, the Quality Assurance (QA) Department conducted semi-annual corrective action audits.
2.3 Existina Proaram Discussion 2.3.1 Revised Program An employee-based quality action team developed recommendations that formed the basis for the revised Corrective Action Program.
The program was documented in Report W 2.501, " Corrective Action," Revision 1,_which became effective in February 1993.. The program combined the corrective action processes for QNs, PRES, and S0Rs and established a new program and procedure for condition reports. This new report expanded the documentation and recording requirements to include the corrective actions, the evaluations, and the verification of the completed actions. The QA department assigned the responsibility for resolving the concern and tracked the progress of the action.
For condition reports that involved a licensee event report (LER),
the responsibility was shared with the Licensing Department. The Licensing
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Department was responsible for the LER portion and QA was responsible for all other portions.
The team observed that the LER closure actions, which included the technical resolution, needed to be fully communicated to QA to ensure proper closure of the condition report.
The licensee was aware of the potential for coordination problems and close communication was taking place between the QA and licensing organizations.
The team further observed that tracking of commitments from LERs was included in the new licensing research system. This computer-based information system included search and retrieval capabilities. When fully implemented, the licensing research system should be of significant benefit to the licensee.
Since February 1993, the licensee initiated a condition report for any new problems that would have previously been documented by a QN, PRE, or an SOR.
i The superseded reports in existence were being completed under the old system.
A QN, PRE or SOR with an extended closure date may be converted to a condition report.
In the interim, several of the existing procedures-will not reference the old or, conversely, the new procedures. The team was informed that the facility staff did not consider the short-term existence of two sets of procedures to be a problem.
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2.3.2 Condition Identification When an equipment condition was discovered a CI was initiated and the deficiency was characterized. An a l documented a condition where the hardware was not in conformance with its established acceptance criteria.
For a CI to be characterized as an NCI, the condition was:
Not the result of normal wear;
Not the secondary effect resulting from failure of another
component (s); and/or
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Not identified and corrected as part of a routine work process.
- A CI or NCI on installed equipment received immediate attention for operability, reportability, and repair or replacement. Work authorization packages were prepared to correct the deficiency and could include input from design engineering. The team noted, however, that it was not possible to determine from the CI document if any design engineering input was included in the evaluation.
Licensee personnel stated that this shortcoming had been
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identified and was being evaluated.
The Manager for Technical Services was responsible for the CI process for installed equipment.
Tracking of CIs was being performed by including a list of CIs in the plan-of-the-day meeting handout once each week. The Manager for Technical Services had established a committee to review the tracking and tending of CIs to improve this area. The licensee was considering establishing a quality team to develop improvements for the CI process.
2.3.3 Operability Determinations and Root Cause Analysis The determination of equipment operability was controlled by Administrative Procedure W 4.101, "Nonconformance and Indeterminance Analysis Process,"
Revision 0.
The team was informed that some licensee-personnel considered too much emphasis was being placed on "Indeterminance" conditions and that tha determinations should establish if the component was operable or not operable.
The team was also informed that the procedure was scheduled to be revised.
The team discussed the advantages of including reference to Generic Letter 91-18 guidance in that revision.
Licensee personnel stated that root cause analysis efforts had also been identified by Entergy Operations executive management as a key process. A Key-Process Management Team had been formed to evaluate corrective action and root cause analysis processes at each Entergy Operations facility. The management team was chartered to identify the best practices at each facility. This
" Total Quality" approach was being pursued to ensure that all Entergy Operations facilities shared the benefits of the best features at each facility.
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2.4 Documentation Reviews The team reviewed numerous documents from the various corrective action processes to determine the adequacy of the licensee's actions.
During this
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portion of the inspection, three PRES and one condition report were reviewed.
The team found the licensee's actions related to those reports to be appropriate.
2.5 Conclusions The team concluded that the licensee had established and implemented a good corrective action program.
The team determined that the recently implemented changes could enhance the overall performance of the program. The team noted that the condition report process had received more attention than the CI process. The team noted that the improvements to the CI process being
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considered by the licensee should improve that process.
3 SELF-ASSESSMENT CAPABILITY (40500)
The licensee had implemented various methods and programs to identify problems and initiate corrective action. The assessment methods included those programs and organizations required by the facility license and other innovations designed to identify safety issues and improve reliability. The
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team reviewed the attributes of these programs and examined examples of the various processes for self-assessment.
3.1 Procrams and Oraanizations for Self-Assessment The team reviewed the staffing and operation of the onsite and offsite comittees required by the facility license.
3.1.1 Plant Operations Review Committee (PORC)
The PORC functioned as the onsite comittee responsible for advising the general manager of plant operations on all matters related to nuclear safety.
Technical Specification 6.5.1 established the staffing,. review responsibility, and authority for the PORC.
The Technical Specification specified seven position incumbents as comittee members and allowed either of two positions to serve as the chairperson. The responsibility, authority, and operation of the PORC was implemented by Administrative Procedure UNT-001-004, " Plant Operations Review Committee," Revision 14.
The team interviewed the PORC secretary and reviewed the PORC implementing procedure, minutes of recent meetings, and action item list. The team determined that the implementing procedure would assure that PORC responsibilities were met. The team determined that the PORC had nine permanent subcommittees. A licensee representative informed the team that the PORC did not used ad hoc subcommittees. The team noted that the Technical Specification did not address subcommittee responsibility or performance.
Procedure UNT-001-004 discussed subcommittee implementation, but did not
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provide guidance on specific subcommittee responsibilities, authority, or
performance.
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Team members did not have an opportunity to observe a PORC meeting during the inspection. The team reviewed a selection of ten recent PORC meeting minutes, starting with PORC Meeting No.92-124, held on November 12,1992.
The majority
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of these meetings (seven) were unscheduled and had been called to review one-or two " jump up" type items.
The meeting minutes indicated that the status of all action items was established during each scheduled meeting. Additional meeting minute reviews revealed that the PORC was fulfilling its review responsibilities. The PORC chairperson had assigned action item responsibility for conditions, changes, or events that were not fully understood. The team observed that the list of open action items had decreased from 12 in late 1992 to 8 at the time of this inspection.
3.1.2 Safety Review Comittee (SRC)
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The SRC functioned as the offsite comittee responsible for providing independent review and audit of safety-related activities.
The review and audit responsibility and the authority for the SRC was provided in Technical Specification 6.5.2.
The responsibility, authority, and oper ation of the SRC was implemented by Site Directive W2.203, " Safety Review Committee Charter,"
Revision 1.
To assess the recent performance of the SRC, the team reviewed the SRC charter, SRC open action items, and the minutes of the last scheduled meeting.
Technical Specification 6.5.2.9, " Authority," stated that the SRC would report to the Vice President of Operations. The SRC charter, however, stated the Vice President of 0perations would serve as SRC chairman. There was,.
therefore, an appearance that the SRC chairman was reporting to himself. The team reviewed the organization and determined the arrangement satisfied-the intent of Technical Specification 6.5.2.9.
Review of the SRC charter revealed that permanent subcommittees with identified responsibilities had been i
established.
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A review of the most recent SRC meeting minutes was conducted to assure that the committee was carrying out its license responsibilities.
The following were addressed during SRC Meeting 93-02 that was conducted April 15, 1993:
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Open SRC action items status;
Assignment and closure of SRC action items; r
Significant non-reportable events;
Reportable events (LERs);
Response to NRC violations;
Technical Specification change requests; and
SRC subcommittee reports.
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A review of the committee's dialogue and effort associated with the activities l
listed above provided indications that the SRC was properly carrying out its license review and audit responsibilities. There was also an indication that the SRC was evaluating potential generic issues, ensuring actions to preclude
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recurrence, and considering additional corrective action.
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3.1.3 Conclusions The team concluded that the PORC was meeting its license responsibility and properly using its license authority. There was, however, no charter or instructions for the PORC subcommittees.
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The team determined that the SRC was providing effective self-assessment because of an exhibited tendency to probe deeper in order to identify other causal factors and demonstrated concern for the proper application Of the corrective action program.
3.2 Consolidated Trendina and Reliability Imorovement The license had established a reliability engineering group under the Operations and Maintenance Manager. This group had responsibilities related to consolidated trending and the reliability improvement team (RIT). The team evaluated the performance in these two areas.
3.2.1 Consolidated Quarterly Trend Report
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The team reviewed the quarterly consolidated trend report for the last quarter of 1992. The team noted that the report contained trending graphs and analysis for about 45 parameters.
These parameters included the top 10 recommended by the industry and areas of personnel, equipment, plant, and maintenance performance. Organizations performed additional trending that was not included in the consolidated report. Most of the consolidated report parameters were trended against indicated goals.
TSese goals were routinely established by the organization whose activities were being trended. The executive summary of the trend report identified those trends not meeting goals and those showing continuing changes in the undesirable direction as declining or decreasing.
For adverse or declining situations, the appropriate manager was required to submit an action plan to correct the undesirable trend.
License representatives stated that the quarterly consolidated trend report was designed to provide senior management an indication of where proLisms were
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occurring. The team observed that recent reports contained about 60 pages, compared to a typical 350-page report issued in -1988. This reflected a reliability engineering group effort to provide the most meaningful information in the most concise format.
Based on the report for the last quarter of 1992, the team had two observations concerning the recent trend reports.
Maintenance Backloa Trendina The team noted that the licensee tracked and trended needed corrective maintenance that was greater than 3 months old.
The backlog had been above the goal (150) since January 1992. Additionally, the backlog had increased since June 1992 and in December 1992 was at its highest value for the year, J-6-j u
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about 235.
The' trend had steadily increased through the 1992 outage, which occurred in the October-November 1992 timeframe.
However, the trend report
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did not indicate any problem with corrective maintenance and no action plan j
was evident to correct this problem.
t Corrective Action Trendina The team noted that overdue QNs were tracked and trended, and that groups responsible for the corrective actions were identified. The licensee stated that reliability engineering intended to track overdue condition reports in the same manner.
The team determined that planned corrective action could result from sources such as corporate assessments, operational experience engineering (0EE) assessments, and NCIs. However, the status of corrective actions from these other sources were not being tracked or trended.
It appeared to the team that licensee management was not being provided a total presentation of the corrective action backlog in the consolidated trend report.
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3.2.2 Reliability Improvement Team (RIT)
The licensee created the RIT to focus on issues affecting nuclear and personnel safety, equipment availability, reliability and plant system performance. Additionally, the RIT was responsible for establishing the priority of issues and ensuring the implementation of corrective action. A team member reviewed the RIT charter and attended a scheduled n.IT meeting on May 6, 1993.
The RIT charter identified 12 specific positions as RIT members.
The RIT was to use all conceivable sources such as trending, failure reports, risk analysis, and industry contacts to accomplish this objective. After an issue was identified and its priority established, the RIT would assign an engineer to assess and make recommendations for the resolution of the issue.
Reliability engineering maintained a data base for the RIT.
A team member attended portions of the RIT meeting held on May 6,1993, and determined that the RIT was aggressively evaluating selected issues.
Examples of the issues being evaluated by the RIT at the May 6,1993, meeting included the following.
Spent Resin System The spent resin system had experienced many problems which impeded the efficient transfer of spent resin and had frequently required additional manpower to conduct simple system evolutions. During the engineer's presentation, indication was provided that there had been substantial improvement of the system hardware.
Various pumps and valves had been returned to original performance specifications. A design cnange had streamlined system operation.
Procedures had been or were being revised to enhance system performance. The noted improvement thus far had been a-7-
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decrease in the number of personnel to operate the system and a reduction in the number of events where spent resin had ended up in undesirable locations.
The RIT discussed several other potential improvements, but eventually tabled the issue until these improvements could be enluated.
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Protective Analoa Cards An industry group assessment and the licensee's trending program had identified a high failure rate of the analog logic cards used in the reactor orotection and engineered safety feature actuation systems. An early design change recommended by the RIT had installed cooling fans in some cabinets.
This modification was apparently responsible for the current failure rate.
trending down.
The licensee had determined that 400 out of 3000 installed cards had failed since the plant had been licensed. Another determination had been made to identify 22 specific cards that would directly cause a reactor trip if card failure occurred; all identified cards were replaced during an outage.
From the discussion during the meeting, it was apparent that the RIT was seeking to identify an acceptable failure rate and find ways to improve
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the system.
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Charaina Pumos The licensee had identified three specific problems associated with charging pump availability.
The areas of concern were pump block cracking, loss of lubricating oil, and short plunger packing life. Several changes had been made to enhance the performance in all areas. The most significant change had been to replace the original pump blocks with blocks of new material.
Additionally, new packing and different oil seals were being evaluated.
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Packing life and oil consumption were being measured and evaluated.
Pump operating procedures had also been revised in an effort to improve pump availability. All changes were being evaluated to determine if any increase in availability had occurred.
3.2.3 Conclusions Based on the observed RIT meeting, the team concluded that the RIT was an effective program for identifying and correcting issues related to safety and reliability. The team also determined that the trending being performed was an effective self-assessment tool. However, the team determined that management could have been provided a much clearer status of corrective actions within the consolidated trending program.
3.3 Review of Corrective Action Documentation
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The team reviewed several corrective action documents to evaluate the licensee's self-assessment efforts.
For most of the items reviewed, the documentation indicated that the operability determination had been timely and-8-
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that the proper corrective action had been implemented.
However, there was indication that generic implications of a single occurrence or condition were not always considered.
The team made some specific observations during these reviews.
Sianificant Occurrence Report (SOR)92-007 SOR 92-007 dispositioned a finding where the wiring for two pressure instrumentation channels on a safety injection tank were reversed. During an alarm setpoint verification check, the redundant control board pressure indicator responded to test pressure changes on the other pressure channel.
The condition was corrected by switching the leads on a terminal board in Control Panel-8.
The three sentence evaluation in the ciosure package stated
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that how and when the error occurred could not be determined.
The package also contained an initialed roster sheet to indicate that instrument and control shop personnel had been made aware of the error.
There was no documentation to indicate that any investigation had been performed or that personnel who may have been knowledgeable were interviewed.
Additionally,
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there was no indication that work and verification procedures had been reviewed, nor were generic implications considered. The potential for previous channel inoperability was not considered or addressed. An analysis of the root cause was not performed.
Based on the documentation in the package, the team determined that a minimum effort had been expended to assess and disposition this potentially significant finding.
Quality Notice (0N)92-004 This QN was initiated to correct a condition that had contributed to the reinstallation of an incorrectly set relief valve in the component cooling water system.
During the performance of authorized work to check and reset
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the opening setpoint, a conflict arose about the correct setpoint. Craft personnel ncted that the controlled drawing-accompanying the work package stated that the valve opening setpoint was "13/.5" psig; the valve nameplate indicated that the correct setpoint was 125 psig.
The craft personnel reasoned that the drawing was incorrect and adjusted the opening setpoint to 125 psig. During a system engineering review of the closed work package, the error was discovered.
The controlled drawing setpoint should have been 137.5 psig instead of "13/.5" psig.
The immediate corrective action was to reset the valve to the correct value and initiate a drawing rev;sion notice.
Followup corrective action was to remove the valve name plate and assign.
design engineering to collect and assemble setpoint data for all code relief valves.
The team observed that the corrective actions did.not.specify any review or removal of other valve name plates. A review of controlled documents that contained setpoints was not considered.
Root cause analysis or human performance evaluation techniques were not used in the assessment of this error.
Finally there was no review of work procedures and practices that may.
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have contributed.to the error..For example, the work authorization-contained only generic instructions and referred to other documents for detailed work instructions.
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s Potential Reportable Event (PRE)92-027 PRE 92-027 was initiated in response to an event that resulted from the incorrect installation of a design modification. On September 30, 1992, with the facility in the shutdown mode, Electrical Bus 3A3-S was lost for 59 minutes.
The loss of the safety bus occurred during the installation of new undervoltage relays with shutdown cooling being supplied by the other train.
Shutdown cooling was never lost but the non-operating train was inoperable during the bus outage.
The primary reason for initiating PRE 9? 027 was to determine reportability. A 4-hour notification was made to the ARC Operations Center. The event was eventually determined to be nonreportable, but the licensee decided to submit a voluntary LER. The licensee was using the LER as the corrective action tracking document.
The corrective actions specified in the LER to be completed prior to the next refueling outage are paraphrased below:
Revise administrative procedures to require that the outage risk
assessment team review safety-significant schedule additions and changes; Revise the design change implementation process to provide increased
interaction between the design engineer and the responsible member of the implementation organization; Counsel the engineer responsible for the design change regarding
management expectations; and Review the event with all applicable plant personnel for lessons
learned.
The team noted that the following additional assessments and evaluations of this event had been performed:
A review of the event was conducted by OEE and submitted to the plant
manager on October 6, 1992.
A recommendation was made to use an existing procedure (UNT 005-015, " Infrequently Performed Tests and Evolutions," Revision 1) when complex work packages were being implemented.
A special team from the corporate maintenance support organization
performed an assessment of the event and provided corrective action recommendations. This team recommended that critical functions be treated as protected functions. The philosophy was to perform reviews.
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beyond the protected train concept and to adopt a protected system concept.
A second recommendation was to perform a root cause analysis of the event to identify all causal factors.
OEE submitted Assessment Report 007-93 dated March 16, 1993, that served
as the final assessment of the event.
This document specified the four-corrective actions that had been noted in the LER.
The assessment
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included an additional recommendation to implement a protected train concept for those components required by the Technical Specification.
The team noted that only the LER tated corrective actions were included in the commitment tracking system.
The team expressed a concern that the additional recommended corrective actions were not included in the tracking system and might not be considered.
The team noted inconsistencies in 3 of the 14 corrective action packages that
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were reviewed.
Specifically, generic implications were not always considered and root cause analyses were not always utilized when apparently justified.
The team considered the corrective actions in some cases to be weak.
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4 AUDIT PROGRAM (40702)
4.1 Discussion The team inspected the audit program in order to:
Ascertain if the audit program was consistent with the Updated Safety
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Analysis Report (USAR) and Technical Specification requirements; Evaluate the depth of audits to determine if potential problems were
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being identified; and Evaluate the effectiveness and timeliness of implementing corrective
actions for audit findings.
4.2 Findinas The team determined that the audit schedule dated April 21, 1993, was responsive to USAR and Technical Specification commitments.
The schedule also l
included additional audits that were responsive to other internal and external commitments.
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To ascertain the effectiveness of the audit program for identifying potential problems and the suitability of the audit findings for resolving identified problems, the team reviewed the results of the following audits:
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Scheduled Audit (SA)-92-001.1,
"TS," conducted December 10,-1992,
through February 16, 1993;
SA-91-014.1, " Inspection, Test, and Operating Status," conducted
August 29 through October 24, 1991;
'SA-92-010.1, "Special Processes Control," conducted February 7 through
April 7, 1992;
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SA-92-006.1, " Station Modification / Design," conducted March 11 through
June 11, 1992; and SA-92-029.1, " Maintenance," conducted July 20 through September 1,1992.
- The audit results generally exhibited appropriate depth and breadth and some substantive issues were identified. Suitable corrective actions for audit findings were usually achieved by the issuance of QNs or, more recently, by condition reports. However, the team noted a number of repeat audit findings.
The team determined that most of the proposed corrective actions should have been effective, if properly implemented. Therefore, it appeared that sufficient emphasis was not being placed on the implementation of the proposed corrective actions and on continuing compliance.
Examples of repeat findings included the following:
Condition Report 93-021 involved an alternate PORC member not receiving
the required 2-year refresher training for 10 CFR 50.59 reviews.
This was a repeat of a finding in a previous audit where four PORC members had not received their 10 CFR 50.59 refresher training.
This issue had not, as yet, been closed by the licensee; QN QA-91-183 involved 50 of 89 clearance orders not having appropriate
descriptions entered on the clearance form. A similar finding had been issued during the previous audit; SA-92-010.1 identified numerous programmatic weaknesses that had been
previously identified in SA-90-010.1.
In addition, 17 QNs issued between January 11, 1990, and July 23, 1991, were welding related with many redundant discrepancies; and QN QA-92-096 (SA-92-029.1) Involved incomplete reviews of work
authorizations. This finding was a repeat of QN QA-90-214
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(SA-90-029.1).
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Findings documented by QNs or condition reports required a formal response i
from the audited organization and acceptance of that response by the lead auditor. Audit reports also contained observations that did not require responses. During recent audits, an observation was referred to as an opportunity for improvement (0FI). A written response to an 0FI was requested,_but not required. The audit checklists contained requirements to j
followup on previous audit observations as well as findings. The team noted i
that Audit SA-92-010.1 documented that 6 of 14 observations identified during an audit 2 years earlier (SA-90-010.1) could not be closed.
The team was informed that 0FI/QS92028/01, " Revise Modification Process," was initially considered serious enough to be documented as a condition report.
The concern involved the installation of modified charging pump cylinder blocks in accordance with the controlled work authorization process in lieu of the modification work authorization process. No problems were identified with the cylinder block installation, but the team was concerned that some of the
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requirements of the modification work authorization process might not be implemented if the work authorization process was used to implement a change.
Subsequently, the licensee established programmatic changes to use a spare parts equivalency evaluation report program for similar modifications.
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4.3 Conclusions The audit program was found to be consistent with USAR and Technical Specification requirements. The audit results generally exhibited appropriate depth and breadth.
Suitable corrective actions for identified findings were usually achieved. However, because of a substantial number of repeat findings, it appeared that sufficient emphasis was not being placed on the implementation of proposed corrective actions and continuing compliance.
Because of a significant number of repeat 0FIs, it appeared that they were only marginally successful in achieving improvements.
5 FEEDBACK OF OPERATING EXPERIENCE (90700)
The team evaluated the licensee's program to evaluate and disseminate operational experience information pertinent to plant safety.
NRC Inspection Report 50-382/92-09 had characterized the licensee's program as " exceptionally well defined and effectively implemented." The licensee had recently changed the organizational responsibility for the operational experience information program. Those changes resulted in some procedure revisions. Therefore, the
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team reviewed those revisions and assessed the effectiveness of the licensee's program.
5.1 Procram Verification
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Procedure OEEP-103, " Operational Experience Engineering," Revision 0, dated January 7,1993, provided specific details regarding the receipt, priority, tracking, and closure of NRC information notices (IN), industry group reports and notices, and in-house events. The procedure was developed as a result of recent organizational changes.
The procedure superseded Licensing
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Instruction LI-105, " Handling and Responding to NRC Information Notices,"
Revision 0, and OSAP-103, " Operations Assessment and Information Dissemination Group," Revision 8.
The Operations Assessment and Information Dissemination Group had been redesignated as OEE.
Except for the additional responsibility for NRC ins, the program implemented under OEEP-103 was virtually _ the same as that implemented using 0 ASP-103.
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The team noted that there were no specific procedural guidelines regarding
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evaluation timeliness or internal review of initial evaluations performed by OEE. The licensee established informal goals for the disposition of significant operating event reports, NRC ins,'and significant event reports.
The informal tracking information maintained by OEE-indicated that 22 of the 48 items under OEE evaluation at the time of the inspection were beyond the-informal goal of 75 days.
Further, OEE personnel indicated that the priority-of items to be evaluated was -strongly influenced by whether the items were
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subject to regular audit by an outside organization.
Finally, OEE personnel indicated that all evaluations received some amount of peer review before being submitted for approval, but the review was not required by procedure.
The team concluded that the observed practices within OEE were adequate.
Administrative Procedure UNT-006-015, " Identification, Evaluation and Reporting of Defects and Noncompliances under 10CFR21," Revision 5, provided instructions for potential defects or noncompliances that could result in a safety hazard.
It also addressed the review and evaluation of 10 CFR Part 21 reports received from external sources for applicability to Waterford 3.
Revision 5 to the procedure had been developed and approved since the-previous inspection (NRC Inspection Report 50-382/92-09) to account for recent organizational changes and revisions to 10 CFR Part 21.
The 10 CFR Part 21 evaluations were formerly the responsibility of the Event Analysis _ & Reporting group and were assigned to the Shift Technical Advisor group by the recent revision. The actual handling of 10 CFR Part 21 information and issues was essentially the same as previously reported.
5.2 Proaram Imolementation The team obtained various tracking lists, file records, and status reports regarding operational experience information from outside sources (vendors, owners' groups, industry groups, and NRC) and selected the'following packages for review:
Information Notices 92-67, 92-68, 92-78, and 93-16;
Operations & Maintenance Reminder O&MR 397;
Significant Event Report SER 92-18;
Significant Operating Event Report 50ER 92-01;
Combustion Engineering Information Bulletins CEIB 90-04 and 91-04; and
10 CFR Part 21 Evaluations CFR21-92-009,-92-011, -92-014,-92-019,
-92-021, and -92-023.
The team reviewed the packages for thoroughness and timeliness of licensee review and assessment. The team also evaluated the appropriateness, quality, and state of completion of corrective actions. All the packages ex ept one were closed with the corrective actions fully implemented or scheduled. 'The only open package (0&MR 397) was still undergoing OEE evaluation and was being tracked on the OEE Action Item List.. Evaluation packages for 10 CFR Part 21 Reports CFR-21-92-19 and CFR-21-92-21 referenced ins 92-68, and_92-67, respectively. The team reviewed those IN evaluations and found them to be mutually supportive and appropriately independent of the Part:21 evaluations.
While reviewing the evaluation of SOER 92-01, the team observed that.
Revision 1 to the original evaluation had been issued.
The recommendations in the revision had been changed to match those provided by the various responsible departments through their technical reviews.
An OEE engineer-explained that alternate recommendations were frequently provided in the technical reviews.
If found to be acceptable, OEE would issue a revised evaluation because the corrective actions had to be those endorsed by OEE.
If-OEE disagreed with the alternate recommendations, the matter would be resolved in accordance with procedural guidelines.
For the packages reviewed, the team
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determined that the licensee had adequately evaluated the information and implemented corrective actions.
The team noted that ins were being tracked more completely under the new alignment.
Formerly, the ins were only tracked up to the point when corrective action was formulated. Under the program implemented by OEE, they were being tracked through corrective action implementatica, Additionally, the number of outstanding ins had been reduced. NRC Inspction Report 50-382/92-09 identified 76 open ins at the time of that inspection.
The team identified 31 open ins during this inspection of which 12 were in the implementation phase and would not have been tracked under the previous system. The team concluded that the disposition of ins had become more timely and more thorough as a consequence of the organizational changes.
The team observed that the most recent program effectiveness review was
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performed on October 26-30, 1992.
The review was performed by an offsite team composed of individuals from Entergy's Planning and Assurance Group and Industry Events Analysts.
The team noted that the assessment was comprehensive and that it recommended several areas for improvement.
Most of the recommended improvements had been incorporated in recent procedure i
revisions and the remainder were planned for implementation in the near future.
5.3 Conclusions The team concluded that this program continued to be effectively implemented.
Recent changes to the implementing procedures and changes to organizational responsibilities appeared to improve the overall effectiveness of the program.
The team concluded that the observed practices within OEE were adequate.
The team found the procedures governing the disposition of operational experience information to be well written and to clearly describe responsibilities and required actions.
6 FOLLOWUP ON CORRECTIVE ACTIONS FOR VIOLATIONS (92702)
l 6.1 (Closed) Violation 382/9131-01:
Failure to Maintain Technically Correct Procedure j
Change 2 to Maintenance Procedure MM-007-027, "Hydramotors'- Model NH92 and U
AH92 Removal, Maintenance, Testing and Installation," Revision 0, was developed on December 20, 1990, to correct Section 8.10.
An NRC inspector
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determined on January 2,1992, that inadequate review of Change 2 failed to identify continued technical inaccuracies in Section 8.10 of the procedure.
In response to the Notice of Violation, the licensee committed to revise the procedure to correct the technical inadequacies and to further counsel the technical reviewer responsible for Change 2 to the procedure.
The team reviewed Change 3 to the procedure and verified that the previous technical inadequacy had been corrected.
In addition, guidance had been added for clarification and all' steps had been rearranged to the proper sequence.
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The team also reviewed the improving human performance record that documented counseling of the individual responsible for the technical review that had failed to identify the technical inadequacies.
6.2 (Closed) Violation 382/9201-02:
Failure to Control Field Desian Chanaes This violation involved a craftsman making a wiring change that did not agree with the latest drawing revision. The licensee's corrective actions were found to be acceptable in NRC Inspection Report 50-382/92-16, subject.to completion of the following actions:
Formalize the practice to discontinue lineouts and the requirement to
send drawing revision notices to the supervisor responsible for installing the modification; and Revise Procedure ME-007-003, " Control Circuit Testing and Maintenance,"
to require the use of the latest drawing revision for point-to-point wiring checks.
During this inspection, the team verified that the licensee had completed the above actions. The team observed that Procedure SSP-650, " Posting Controlled Documents," Revision 1, Step 5.3.1.2, required proper distribution of drawing revision notices.
The team also found that Procedure ME-007-003, Revision 5, Step 3.10, contained a statement to ensure that all point-to-point wiring checks are performed utilizing the latest control wiring diagrams or drawings revision notice.
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7 FOLLOWUP (92701)
7.1 (Closed) Insoection Followuo Item 382/9008-01:
Out-of-Tolerance
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Conditions Durina Instrumentation Calibration The lack of a requirement to perform prompt evaluations of out-of-tolerance conditions was identified during a previous inspection. That inspection also noted that the licensee had not implemented a program to review potential generic matters.
During this inspection, the team noted that the licensee had issued Administrative Procedure MD-001-028, " Writer's Guide for Maintenance Department Procedures," Revision 3.
The procedure required a standard statement be included in maintenance procedures that would direct the technician to inform both the shift supervisor and the first-line supervisor whenever an acceptance criteria was exceeded. The team also noted that the
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licensee recorded calibrations and failures of critical equipment in the instrumentation and controls trending program. The trending program
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information was reviewed quarterly. A personal computer trending program was recently placed into service to 4 low daily observation of the trending information.
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7.2 (Closed) Inspection Followup Item 382/9008-03:
Preventive Maintenance
Procram for Air Operated Valves (A0V)
An earlier inspection disclosed some maintenance program weaknesses.
One of the identified weaknesses was the lack of a formal maintenance and testing program for A0Vs.
The licensee was developing an enhanced valve testing program and committed to include A0Vs.
The team reviewed Administrative Procedure UNT-005-031, "A0V Testing, Maintenance, and Tt., ding," Revision 0, dated April 30, 1993. This procedure provided guidance tc. testing, trending, and repairing A0Vs. The team also reviewed Maintenance Procedure MI-004-298, " Guidelines for Air Operated Valve Diagnostics," Revision 0, dated December 18, 1991.
This procedure contained instructions for testing A0Vs and provided acceptance criteria.
The team found these procedures to be well written and to provide an acceptable basis for an A0V maintenance and testing program.
7.3 (Closed) Inspection Followuo Item 382/9121-02:
Failure Analysis of Pressure Switch
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While witnessing the testing of a main feedwater isolation valve, an NRC inspector observed the failure of a pressure switch on the valve actuator accumulator.
The licensee replaced the switch and initiated a root cause investigation to determine the cause of the failure.
During this inspection, the team verified that the licensee had completed the failure analysis. The licensee returned the failed switch to the vendor (IMO Industries, Inc.) for testing and failure analysis. The vendor determined that the adjusting screw had become disengaged from the nylon locking collar due to high vibration. The licensee also relocated the pressure switches away from the main feedwater isolation valves to eliminate the vibration problem (Design Change 3364).
7.4 (Closed) Inspection Followuo Item 382/9124-01: Verification of Material for Valve Seats
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While reviewing PRE 91-024, an NRC inspector identified that the seats in Check Valves SI 108A and 1088 had been replaced with seats made of EPDM (trade name). seal material using Fusor 320/322 Epoxy. Resin as a bonding agent.
Neither the seat material nor bonding agent had a documented material qualification for the specific application.
The licensee agreed to verify that the material was acceptable for use in the subject valves.
The team reviewed Report LPL-MEQ-45.09, " Environmental Qualification Assessment for TRW Hission Manufacturing Company Valves (C&S Valve Company)
used at the Waterford SES Unit No.
3," Revision 3, and Engineering Evaluation CI 278331 dated April 23, 1992.
Those documents established the acceptability of the EPDM and Fusar 320/322 materials for application in the check valves.
The EPDM seat and.Fusor 320/322 adhesive combination were determined to have a service life of 34.8 years and a ' calculated radiation
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tolerance in excess of the maximum design basis radiation exposure.
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.7.5 (Closed) Inspection Followuo Item 382/9125-05: Analysis of Diesel Enaine failure An unresolved item (382/9113-02) was initiated to further evaluate the causes and effects of a crankcase explosion in the "A" emergency diesel generator (EDG). The licensee's actions were found acceptable in NRC Inspection Report 50-382/91-25, and the unresolved item was closed. However, the licensee had not fully implemented plans to perform followup inspections of the EDGs.
The team reviewed the history of the crankcase explosion and the NRC inspection activities that had been conducted.
The team also reviewed Special
. Report SR-91-002-02 that the licensee submitted by letter dated November 27, 1991. The report, in agreement with the EDG vendor, concluded that the crankcase explosion had been initiated by a residue buildup around the piston rings in the SL cylinder. The residue had caused damage to the finish of the cylinder and overheating of the metal surface. To ensure that future residue buildup did not occur, the licensee committed to perform periodic inspections of the cylinders.
The team reviewed Surveillance Procedure MM-003-015, "18-Month Emergency Diesel Engine Inspection," Revision 8.
The procedure contained instructions to inspect the cylinders and pistons for signs of wear at 18-month intervals.
The team also reviewed the results of the EDG inspections that were conducted during the 1992 refueling outage.
The inspections were performed by the EDG vendor, Cooper Energy Services, and presented in their letter to the licensee dated October 30, 1992.
The vendor concluded that the "as-found" conditions would not have prevented the EDGs from running for " hundreds of hours without experiencing any mechanical trouble."
7.6 (Closed) Inspection Followuo Item 382/9208-03: Trainina on Determinina the Reactor Shutdown Marain The licensee had failed to maintain the Technical Specification-required shutdown margin because of the long interval between determinations of required boron concentration.
The condition occurred within 2 days of reactor shutdown and the effect of Xenon decay on shutdown margin had not been adequately considered.
The licensee committed to improve the procedural guidance and to train the reactor operators on the event.
The team reviewed Surveillance Procedure OP-903-090, " Shutdown Margin,"
Revision 6.
The procedure contained specific instructions for ensuring that an acceptable shutdown margin was available during periods when Xenon was decaying.
The team also reviewed the lesson plan and training records-for the revised reactor operator training on shutdown margin and found them to be acceptable.
8 OVERALL CONCLUSIONS The team concluded that the recently implemented changes should enhance the overall performance of the corrective action program.
The. team determined that the additional changes being considered by the licensee would further
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improve the program. The programmatic changes had not, however, been
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implemented for a sufficient period to permit a determination of the i
effectiveness of those changes.
l The team noted shortcomings with the implemented corrective actions for some problems. The team observed that generic implications were not always considered and that root cause analyses were not always utilized when apparently justified. The team also observed that, in some cases, corrective action recommendations from other assessments were not being tracked and might not be properly considered. The team concluded that the disposition of some corrective action documents had become more timely and more thorough as a consequence of the organizational changes.
The team concluded that the PORC was meeting its license responsibility and properly using its license authority. The team determined that the SRC was providing effective self-assessment and demonstrating a concern for the proper application of the corrective action program.
I The team concluded that the RIT was an effective program for identifying and correcting issues related to safety and reliability. The team also determined that the trending being performed was an effective self-assessment tool.
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However, the team determined that management could have been provided a much
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clearer status of corrective actions within the consolidated trending program.
The team concluded that the' licensee had implemented an appropriate audit program. The audit results exhibited appropriate depth and breadth and included sound findings and observations.
Suitable corrective actions for findings were usually achieved but repeat findings were observed.
The team also concluded that the licensee was effectively handling information related to industry experience, l
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i ATTACHMENT 1
1 PERSONS CONTACTED 1.1 Licensee Personnel
- R. Azzarello, Director, Design Engineering
- R. Barkhurst, Vice President, Operations
- T. Brennan, Technical Adviser
- R. Burski, Director Nuclear Safety
- G. Davie, Operations Experience Eng'neering Manager W. Day, Supervisor, Shift Technical Advisor Group
- G. Fey, Coordinator S. Ghanavati, Supervisor, Reliability Engineering J. Hoffpauir, Maintenance Superintendent M. Jackson, Secretary, Plant Operations Review Committee J. Jacques, Secretary, Operational Experience Engineering J. Johnston, Senior Engineer, Operational Experience Engineering
- G. Kohler, Quality Assurance Supervisor
- L. Laughlin, Licensing Manager
- T. Leonard, Technical Services Manager E. Linnartz, Assistant Secretary, Safety Review Committee
- A. Lockhart, Quality Assurance Manager
- D. Packer, General Manager, Plant Operations R. Pittman, Instrumentation & Controls Maintenance Superintendent J. Pollock, Supervisor, Audits and Assessments B. Proctor, Design Engineering Supervisor
- T. Smith, Manager (Acting), Plant Support and Assessment
- R. Starkey, Operations and Maintenance Manager J. Taylor, Specialist / Technician III, Operational Experience Engineering
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M. Warren, Reliability Engineer G. Wilson, Secretary, Safety Review Committee 1.2 NRC Reaion IV Personnel
- J. Dixon-Herrity, Resident Inspector
- E. Ford, Senior Resident Inspector
- T. Stetka, Chief, Project Section D In addition to.the above personnel, the inspectors contacted other personnel i
during this inspection period.
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- Denotes personnel who attended the exit meeting.
2 EXIT MEETING
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The inspection scope and findings were summarized on May 7, 1993, with the persons indicated above. The licensee acknowledged the team's findings. The licensee did not identify as proprietary any of the material provided to, or reviewed by, the inspectors during this inspection.
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ATTACHMENT 2 r
INSPECTION FINDINGS INDEX The following Violations were closed in paragraph 6:
9131-01
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9201-02 The following Inspection Followup Items were closed in paragraph 7:
9008-01 9008-03
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9121-02 9124-01 9125-05 l
9208-03
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ATTACHMENT 3 LIST OF ACRONYMS
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A0V Air Operated. Valve CI Condition Identification EDG Emergency Diesel Generator IN Information Notice
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LER Licensee Event Report NCI Nonconforming Condition Identification
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OEE Operational Experience Engineering l
OFI Opportunity for Improvement PORC Plant Operations Review Committee PRE Potential Reportable Event QA Quality Assurance QN Quality Notice RIT Reliability Improvement Team SA Scheduled Audit
SOR Significant Occurrence Report SRC Safety Review Committee STA Shift Technical Advisor USAR Updated Safety Analysis Report
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