IR 05000458/1990025

Insp Rept 50-458/90-25 on 900924-28 & 1015-19.Noncited Violation Identified.Major Areas Inspected:Quality Verification Function Including Condition Rept Program, Internal Audit Program

ML20217A359
Person / Time
Site:	River Bend
Issue date:	11/07/1990
From:	Barnes I, Ellershaw L, Stewart R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:
Shared Package
ML20217A356	List: IR 05000458/1990025 ML20217A351
References
50-458-90-25, NUDOCS 9011210019
Download: ML20217A359 (11)

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I" L, APPENDIX

.c U.S. !!UCLEAR REGULATORY COMMISSION REGI0ll IV 7 m NRC Inspection Report: 50-458/90-25 Operating License: NPF-47 +

Docket: 50-458 Licensee: Culf- States Utilities Company P.O. Box 220 St. Francisville, LA 70775 -

J' facility Nare:4: RiverBendStation(RBS)

Inspection At: RBS, St. Francisv111e, Louisians

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In'spection Conduct September 24-28 and October 15-19, 1990 j- i o

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Inspectors: . K _

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Ll/E. Ellershaw, Reactor Inspector, Materials Dage /

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I and Quality Programs Sectich, Division of Rear. tor Safety .;

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a mm // N K. C. Stewart,~ Reactor. Inspector, Materials Date '

and-Quality Programs Section, Division of

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Reactor'Satet v

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' Approved:- be // /7 b o-F. Barnes, Chief,, Materials. and Quality Date

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Programs lSection, Division of Reactor-

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q- inspection Sumary '

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11nspection Conducted September 24-28 and October 15-19, 1990 (Report 502458/90-25)

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s' iAreas Inspected: Routine, unannounced inspection.of the RBS quality' . .

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verification function including the condition report program, internal audit . '

progratigland the activities of the Independent Safety Engineering Group (ISEG). '!

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N  : Resul't s: The inspection results indicate that cin general, the quality verification function,iincludin'g the internal audit program, appears 'to be

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"cffective. The perfomance of the ISEG ~is.-considered to be a licensee strength.' However, tit was identified that_ISEG has not been at the required- -

full? staffing.of?.five engineers since february 1990. This condition was-Lidentified as a:noncited violation (paragraph 2.1). The audit and surveillance

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program has shown a decided improvement, particularly with respect to use of a performance-based approach. This is primarily at.ributed to the performance-based

. training provided to the personnel rerponsible foi performing audits and surveillances. A major revision to the condition report (CR) program is being

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finalized, with' anticipated implementation subsequent to the current refueling outage. . This should provide enhancement to the program, particularly in the

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area of ensuring thet CRs and the documents issuec to implement the CR's E disposition reference each other. An inspector ftllowup item was identified ,

with respect to verifying the implementation of tne new program (paragraph 2.2).

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DETAILS 1. : PERSONS CONTACTED sSu ,

• Ji E. Booker, Manager, Nuclear Industry Relations '

• J. W. Cook, Technical Assistant, Licensing 7

• M. E. Crowell,' Nuclear Training Coordinator

'*K. -J. Giadrosich, Supervisor, Quality Engineering i

1. *P. D. Granam,' Plant Manager i *J. R. Hamilton, Director, Design Engineering

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.* G. K. Henry. . Director, Quality Operations

• G. C.:Hockman Senior Quality Assurance (QA) Engineer

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i*T. L. Hunt, Senior Independent Safety Engineering Group Engineer

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. *G. R. Kinsell, Director, Quality Services

• J. W..Leavines, Supervisor,' Nuclear Safety Assessrient Group '(NSAG)

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• D.;N. Lorfing. Supervisor, Nuclear-Licensing

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\ *R. C. Lundholm.- Operations Engineer  ;

• 1'. M. Malik, Supervisor,;0perations QA j

*C ' L. hiller, Senior Compliance Analyst

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.*W..H." Odell, Manager,' Oversight s *J. E. -Spivey, Jr. , Senior- QA Engineer

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&.#y "*K. E.;Suhrke, General! Manager, Engineering and Administration . :CajunEElectric Power Cooperative, In :*W. L'.7 Curran,7 Site Representative-

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• E.5.Fhrd,SeniorResident. Inspector

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• Denotes. attendance at the exit interview conducted on;0ctober 19, 199 :!

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The inspectors:also: contacted other licensee personnel during this inspection. ,

b ' 2?TQUALITY VERIFICATION FUNCTION' (35702)

f RThelpurpose of this inspection wasLto assess the effectiveness of licensee

% Eqbality. verification: activities intidentifying technical issues and problems of L

)E 4 - safety significance and in following,up to ensure that the issues and problems

'e ' identified are resolved in-a timely manner._ The inspectors examined the

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d' ' programs for internal; audits and their implementation,'the' initiation and jh -

7 Oprocessingof'conditionreports(cps),andtheindependentsafetyengineering-group (ISEG) activitie W: , , i l I u

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s I ; Independent Safety Engineerina Group (ISEG) l The ISEG has been established to: (a) assure that an independent assessment and verification of overall plant nuclear safety is accomplished, and (b) to serve as the Unreviewed Safety Question Comnittee of the Nuclear Review Board. The function, composition, responsibilities, and records are delineated in Administrative Controls Section 6.2.3 of the RBS Technical Specifications (TS).

The inspectors reviewed the responsibilities and activities of this qualP; verification organization in order to assess its effectiveness.

I Procedure ISE-13-001, "lSEG Organization, Responsibilities And Training,"

Revision 6, established the organizational cuidelines and referenced the implementing ISEG procedures which were reviewed by the inspectors. Section 6. of the RBS TS requires the ISEG to be composed of at least five, dedicated, L full-time enginears located onsite with each having a bachelor's degree in

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engineering-or i elated science and at least two years professional level experience in his/her field. The inspectors reviewed ISEG's organizational structure and identified the following information. A significant reorganization i

within the Fiver Cend Nuclear Group occurred and became effective February 1, I-

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1990. One of the changes affMted ISEG. Prior to the reorganization, ISEG consisted of four engineers and a supervisor, reporting to the Manager, Oversight.

l- However, the reorganization changed the composition of ISEG by adding a fifth

, engineer's sint and eliminating the ISEG supervisor. A new group, Nucleer l' Safety Assessment Group (NSAG), with a supervisor, was created. NSAG consists of two units: ISEG and the Oversight Group. Review of a chronology of ISEG staffing-since the reorganization revealed that the required complement of five full-time, few as twodedicated engineers ISEG engineers has during not month a one been attained; period (Mayin fact,)there 199 has been It does as appear that ISEG has actively recruited through the internal placement system in order

.to reach its full complement. At the time of this inspection, the ISEG staff consisted of four engineers; however, the inspectors were presented with a memorandum dated July 2, 1990, which indicated that a qualified individual had been selected.for, and had accepted, the fifth engineer's slot. The memorandum also stated that the transfer of the individual into ISEG would not occur until l after refueling outage RF-3, which is currently in progress. The failure to have a full staff of five engineers in ISEG since February 1,1990, was identified as a noncited violation of the RBS TS. A Notice of Violation is not being issued because the criteria of Section V.A. of the iPC's Enforcement Policy have been me Procedure ISE-13-008, "lSEG Review of Condition Reports," Revision 2, established the guidelines for ISEG's review of CRs and the preparation of the Condition Report Ti end Analysis Report. While each CR is reviewed by an assigned ISEG engineer, the extent of review is based on the seriousness of the identified problem. As a minimum, the ISEG engineer is responsible for reviewing the portions of the CR which deal with investigation, analysis, corrective action, disposition details, work instructions, root causes and corrective actions to prevent recurrence, and closeout. These reviews are required to be d9cumented, with pertinent data stored in the CR data base and the hard copies stored in the CR rackage files. During the course of this inspection, tho-inspectors reviewed 72 CRs in or(*,r to verify that various

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m I-5-activities had been gerformed, one of which was review by ISEG. In addition, Procedure RBNP-052 River Bend Station Trending Program," Revision 1, requires :

ISEG to perform a trend analysis of data acquired from CRs-and 0.epare a formal

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Condition Report' Trend Analysis Report at least once every six months. The  !

itapectors reviewed the following trend reports (TRs) for the noted periods:

, TRB9-006 (November 1989); TR90-001 (December 1989); TR90-002 (January through

' April 1990); TR90-003 (May 1990); TR90-004 (June-July 1990), and TR90-005 (a semiannual reoort covering the period January through July 1990.) These TRs reflected a very comprehensive review and analysis of CRs initiated during the '

noted periods in order to identify any adverse trends. The inspectors considered this activ_ity, if continued to the same performance standards, to be !

a-very_useful management tool. It was noted that TR90-005 identified two areas

, .of-concern. The first accounted for 23 percent of the 566 CRs, and dealt with employee work practices (i.e., instances where personnel did not follow

, _ procedures properly). The second area accounted for 19 percent of the 566 CRs, and' pertained to written communications (i.e.,_a lack of sufficient information ,

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'or-documentationindrawings, procedures,orvendortechnicalmanuals). ISEG '

- Estated lin:the report that they intended to investigate the latter after T completion of the. outage. They also commented that it was apparent that "the a measuresitakenoin the; past by Management to ' improve employee job performance l has(sic)beenunsuccessful;"

l Procedure ISE-13-003 "lSEG Plant Surveillance And Special Analysis," i lRevisionL 3, requires ISEG to conduct plant surveillances and special' analyses, which ex "ine' plant operating characteristics and-personne1~ activitie ,

Paragrapt 5- and 6 oi ProceAre ISE-13-003- require ISEG engineers to perform plant- suncillances which consist of plant tours and reviews of plant: operating j

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logs and data, and!thot the frequency of such tours and the selection of the

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! areas.te be toured will be on the basis-of" interest due to unusual activities ,

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m or!problemsfor on the basis of impact on sefety and. reliability. During th ,

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week Joi; September 24.-1990,- the inspectors reviewed the surveillance reports '5Rs) j for:1990.7, 1t was noted that.the first SR (90-01) was performed in' June 199 H

• , Lwithithe last SR (90-013) being perforned in August 1990. - It appears that the g plant'surni11ancel assigned the number SR90-04 was not performed in:that there

, awas no availaole documentation. The inspectorsN r.eview revealed-that the SRs

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E'were nearly- exclus o el; devoted to;a description'of " housekeeping" conditions,

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with veryl'little ovcumentation regarding. plant operating characteristics. The a inspectors discussed this with the-NSAG supervisor who acknowledged.that the SRs -

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'l probably did not reficct everything that the ISEG engineers actually did.durin ._

their plant tours., During the week of October 15, 1990, the NSAG supervisor

presented SR90-16~ , - - - which represented a surveillance performed on October'4, e '; Y 1990. DThis SR~ documented the review and observations made with respect to

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3 safety-related ~ items '(1.e., equipment lineups., and noticeable -material conditio j

• s , suchlasoil51evelsfcomponentsupports, leaks,etc.),inadditiontoth observations regardir.g: housekeeping--conditions. The supervisor also stated in

- the SR that future SRs will " document p. ore completely the items reviewed in the ,

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Th'e' inspectors _also reviewed. Operating Experience Reports (0ERs)89-034,

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190-003, and 90-004. The OERs are primarily used to document reviews and

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analyses of unusual operating experiences at RBS and other nuclear power j plants, and reactor scram analyses. These OERs also exhibited an in-depth 6nd

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comprehensive review by the assigned ISEG engineer ;

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The inspectors identified to the NSAG supervisor that several ISEG procedures appeared to be out-of-date with respect to their addressing management positions and organizations that no longer existed. . Prior to the conclusion of lthis' inspection, the NSAG supervisor presented the inspectors with draft copies 1-of revisions to the ISEG procedures showing the planned changes, including some

.which were identified by the license !

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2.2- Condition Report program 1The CR is the mechanism used to identify and document problems and conditions

. which'are adverse to cuality and may impact the safe and reliable operation of the plant. The CR will cause evaluations and analyses to be performed in order :

to correct the problem or condition that was identified. .The responsibilities =

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and actions associated with CRs. are currently delincated in Procedure ADM-0019, i r " Initiation and Processing of Condition Reports,". Revision 9A. The-inspectors 1 were: informed that ADM-0019 will be superseded by Procedure RBNP-030, with the j same title. As noted.previously with respect to the ISEG procedures, similar conditions regarding-reference to management positions and organizations which ,

Lno_ longer existed were: identified in ADM-0019 by the licensee. Other significant

hanges were cho being made in. order to enhance the overall effectiveness of 1he program. The inspectors were:also informed that implementation of RBNP-030 u ~ would be delayed ut.til after:RF-3 had been completed.in order to allow for r extensive personnel trainin EProcedure ADM-0019 allows CRs to be closed out; prior-to' completion of corrective ,

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.actionscas long as those' actions are to be completed on Maintenance Work Orders (MW0s).ModificationRequests(MRs),DesignChangeNotices(DCNs).or nother tracking document, and the documents' cross-reference.each other. The !

11ospectors were concerned with.the potential?for a failure to reference a CR on -

Lan MW0,,MR,'or DCH, and subsequently..a revision or cancellation might be made- l to:the document which was supposed,to implement the-disposition of the CR. It n appeared that if this situation were> allowed to occur, the possibility existed

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that:the. condition which caused the-CR to be initiated.might not be correcte The' inspectors requested printouts showing closed CRs and.their associated MW0s ; ~

from-1988 through. December:1989, and closed CRsiand their associated MRs from g June"1,?1989, to present. From these lists, theiinspectors selected 14.CR/MWO' L

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! combinations ~ dnd 12 CR/MR. combinations in. order to verify that the documents j '

@  ; Jdid. cross-reference each other. The inspectors reviewed the CR/MWO. document

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combinationsiand'noted that the.CR was referenced on:the MWO if the MWO was the

7 ? result of the:CR. However, if~a CR resulted'from performing an MWO, then the l - LCRiis notLnecessarily referenced on theiMWO., It: appears thatxthe procedure ,

7does. not provide the:necessary' specificity to avoid potential problem '

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The Einspect6rs were notified that while. licensee personnel were assembling

'CR/HR document combinations, someone noticed that certain CRs were not

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referenced.on the associated'MRs which were issued to complete the CRs'

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,i corrective action. This resulted in the issuance of CR90-0940 on October 17,_ '

1990, which identified four CR/PR combinations. The CR also stated that the referenced MRs were being compared to the CRs to determine if the corret,tive action had been incorporated into the MRs disposition, and that the CR numbers would be recorded onto the MR.- In addition, the CR stated that Operations QA should investigate and determine if similar cases exist. It would appear that this problem is a result of the aforementioned lack of-procedural specificity.

J Discussions with the supervisor of.0perations QA revealed that RBNP-030 will

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clearly articulate the requirements for cross-referencing CRs and their applicable tracking documents. It should be noted that the inspectors did not

~ identify. any situations in which the condition which caused the CR to be

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initiated .had not been corrected as a' result of changes to W0s or MR '  !

Inspector-FollowupItem(458/9025-01): Review procedure RBNP-030 to verify that. the identified pregrammatic weaknesses in ADN-0019 have been correcte !

~ .3 Audit Program'and Implementation (40702 and 40704) =

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The objective of this area of the inspection was to ascertain whether the-ilicensee has developed and implemented a QA audit program that-1s-in

1. conformance with TS, regulatory requirements, comitments in the Updated Safety

Analysis Report-(USAR), and industry guides and standard The RBS'USAR, Chapter 13.4.5.7,1 states in'part, " Audits of River Bend Station -

W Activities are performed by tne Nuclear Review Board (NRB) itself, throug :their committees, through' audit teams / consultants from outside of GSU, or

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f through organizations'within GSU1 including the Quality Assurance Department."

RBS Procedure No. QAI-2.1. " Audit Performance, Reporting and Followup,"

SR evision .7,' _ indicates that the Manager, Oversight -(who also serves as Chairman M , of the1NRB) is. responsible for QA audits of RBS site activities and has Ldelegated this: responsibility to the Director, Quality Services, c ,  ;

ilr3 reviewing the programmatic aspects of the audit activities with the cognizant

", senior _QA engineer-(SQAE), the inspectors were informed that the.NRB does not, inlitself, perform site' audits,. All'_ internal site-audits are performed and !

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conducted by: the Quality Systems Group who report to the Director, Quality W Services..,However,lall.finaloaudit reports are submitted to the NRB chairman

'4 and: board members for their review. The Quality Systems Group is composed of. a Lsupervisor and nine certified auditor / lead auditor members, in addition, in ,

orden to' conduct effective performance-based:auditsF auditor assignments are

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esupplemented with consultants and/or other nuclear utility personnel with .J

,fspecialized; technical, training, education,and:expertse i in the areas being 3 iy ' auditedC An_ approved:2 year master audit schedule.was provided by the cognizant

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LSQAE which delineated the.1989-1990 scheduled *udits. The schedule included 67-auditssto be > performed within the 2 year period, _of. which 10.had been requested-

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aby: management. It was also. observed by the inspector that the approved audit-1 ? schedule identified 33 areas of activities to be audited. The : functional areasi were found W have been established in accordance with the requirements of TS H Section 6.5.3.8 and the USAR, Chapter 17.2.1 ~

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Linorder'toassesstheeffectivenessoftheauditingactivities,theinspectors ,

selectedsixcompletedinternalaudits(whicharelistedintheAttachtrentto thereport)fromthemasterauditscheduleforrevie '

, Three of.the selected audits required responses. The inspectors observed that-the audit checklists were comprehensive, relevant, and contained significant y' attributes and criteria for the activity being audited. It was also noted that

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the responses by the audited organizations to the audit findings were timely, and adequately addressed the findings and recommendations. In addition, entrance /

W exit meetings were appropriately held. In discussing the audit review with the t cognizant.SQAE, the inspectors expressed the observation that the 1989 audits appeared, in. general,.to be more_ oriented towards assessment of procedural I compliance rather than using a performance-based approach. However, it was '

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eU Y noted that Audit 89-06-I-PCON/RWMP Radwaste Management Programs u d Audit 90-05-I-CHEM Chemistry / Radiochemistry Programs, dated f/agust 11, 1989,

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and July 10, 1990, respectively, were performance-based in approach, with the-emphasis placed on the assessment of personnel performarce and th( adequacy and ,

' effectiveness of the. implementing' procedures The SQAE stated that all lead '

auditor / auditor personnel have attended a training program presenttd in July 1990, by;an.outside: contractor, entitled " Performance-Based Auditing and Surveillance." ,

' It was further indicated that:this training has increased aucitor awsreness in

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, performance-based concepts and is~being' Utilized in audit plannin '

'I'n corijunctio6 with:the audit reviews, the inspectors selected six-

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participating dJditors/ lead: auditors and a technical specialist, in order to verify!their qualifications < as. prescribed by ANSI' N45.2.23 and GSU Procedure QAP-F.3,?" Quality-Assurance. Indoctrination and Qualification of QA-

+ -Personnel," Revision 8.; The inspectors observed that each individual. file a j contained documented QA indoctrination records, training records and -

h, '; certifications,. auditor qual.ifications records, and records of work histor .i ER > It was;also, confirmed that each ofcthe individuals had. attended the-

<" Performance-Based Auditing'and Surveillance"Ltraining. program conducted in July 1990.-

4 . JThelinspectors addi d nally reviewed " Meeting Minutes for the Nuclear Review

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3 Board, Meeting:90-03, tin order to assess the NRB role in review of audit reports. cit was observed that 20:QA audits were. discussed in this meeting,

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. with each sunwarized 'by the cognizant SQAE. The minutes indicated that the audit findings and open items were; actively. discussed by the NR .

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-The inspectors-also con' ducted.a review of the surveillance activities performe ' '

by. both Operations QA (00A):and QA Engineering. In order to assess the

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-surveillance activitiesi the inspectors reviewed GSU Procedure QAl-2,3,. -

Ha, " Planning, Scheduling and Reporting QA Surveillance of-Plant' Activities." 3 tRevision 7,uin conjunction with annual:and monthly schedules, functional areas 1 and checkhst; items. Thelinspectors noted that QA Engineering currentlyL

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p; schedules.12-13 surveillances annually, with all surveillances bo %g identified 'as "Hini Safety . System Functional Inspections (MSSFIs)." : As deseibed in y Procedure QAl-2,3, the surveillances are in-depth vertical'surveillances L

.which concentrate onLa particular' item, component, subcomponent, program, or L >

activity. The surveillance focuses'on all aspects related to the particular L area, which mayl include design, installation, operational data, test data, m

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maintenance history, inspections, modifications, and training review. The inspectors selected the five MSSF1 rcports listed in the Attachment to the

. report for revier. The reports contained detailed checklists involving both technical and programmatic criteria, with the emphasis noted to be on assessment of performance. The inspectors observed that organizations being inspected were responding to surveillance findings and recommendations in a timely manner, with appropriate corrective actions being provided and root causes of problems addressed. The QA Engineering MSSFis appeared to be an

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effective tool for comprehensive assessinents of organizational performance in-specific subject area '

The OQA annual surveillance plan encompasses some 28 functionel areas that are routinely observed within the site protected area. The monthly surveillance status report indicated that 20-30 surveillences were being performed each

. month. The inspectors selected the six OQA surveillance reports listed in the :

Attachment to the report in order to assess the activities, results, and corrective actions. .It was noted that surveillances were conducted by team members having technical expertise and. training in the functional areas being observed.' The. reports reflected in-depth review and included specific observations / findings, and recommendations. The inspectors concluded that 3

findings were being responded to in a meaningful manner. It appeared that 0QA :t

surveillances we're being performed and accomplished-in accordance with applicable program requirement ,

Ho~ violations or deviations were identified in.this area of inspectio .;' EXIT INTEpVI_E_W W

n .An exit interview was conducted on.0ctober 19, 1990, with those personnel idenoted.in' paragraph'1 in which the inspection findings were summarized. No

.information was presented to the: inspectors that was identified by the licensee: ,

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[ AT_TACIPENT Mrf DOCul1ENTS REVIEWED PROCEDURES

, . Procedure RBNP-052, "Rivt. Gend 5% tion Trending Program," Revision 1

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Procedure ADM-0019 "Init16 tion and Processing of Condition Reports,"

Revision 9A

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Procedure ADM-0028, " Maintenance Work Order," Revision 10

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• Procedure.QAP-1,3,;" Quality Assurance Indoctrination and Qualification of QA Personnel," Revision 8

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Procedure QAl-2,1, " Audit, Performance, Reporting, and Followup," Revision 7 ,

Procedure QAl-2.3,:" Planning, Scheduling, and Reporting QA Surveillance of

.P1:at Activities," Revision 7 Procedure QAl-2,20. "QA Review of Condition Reports," Revision 3 T *

ProcedureilSE-13-001', "ISEG Organization, Responsibilities and Training,"

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' Procedure ISE-13 002,'".lSEC Evaluation of Procedures and Modifications,"'

Revision-3'

Procedure ISE-13-003, "ISEG Plant Surveillance and Special Ailalysis,"

Revision'3 a Proceduro ISE-13-004, "!SEG Operating Experience Review," Revisio )

L Procedure. lSE-13-005, ISEG Reconwendation Status," Revision PJ

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j Procedure'ISE-13-007, "lSEG Scram Analysis Technioues," Revision 1

Procedure ISE-13-008, "lSE0 Review of Condition Reports," Revision '2~

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lA.UDITS

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Audit.89-06-1-PCON/RWilP, Radwaste Management Programs,. dated August 11, 1989 !

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[ -Audit 90-05-I-CllEM, Chemistry / Radiochemistry Program, dated July 30, 1990 l i Audit'89-09-I-CANC, CSU QA Audit of-RBS Corrective Action and Nonconformance Control Program, dated October 26, 1989

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Audit 89-03-1-CANC, GSU Audit of RBS Corrective Action and Nonconformance Control Program, dated April 27, 1989

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m oAudit 89-02-I-STPG, GSU audit of RBS Surveillance Test Pro 9 tam, dated l

.Harch 8, 1989

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i Audit 90-03-I-STPG, RBS Surveillance Test Program, dated April 24, 1990 '

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SURVEILLANCE TEST REPORTS - OPERATIONS QA

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STP-402-4501,-STP Performances, May 8, 1990 4 '-

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5STP-207-5251,'STP. Performances, April 12, 1990 m . Surveillance Test.. Performance Program, February 18, 1990 5 ,. Maintenance Work _ Orders,-September 18,~1990  ;

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. 05-90-10-08 Effectiveness of'the Corrective Action Program, October 6,1990

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, . Surveillance Test Performance Program, August 20, 1990'

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%'  : SURVEllt ANCE REPORTS - QUALITY ENGINEERING- [

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.SSFI-Mechanical Equipment Qualification,. dated August- 21,1990(

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.[ - SSF1-MSIVL Ac6umulator System, dated October 31 1989 a

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y$>h (10CFRPart'-50AppendixRAnalysis(CRi89-1117), dated; February 7, =1990

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-MOVITestingL(IE12*MOV0241 A/B),fdatedSeptember 24,1990; N' s. % ,c

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