ML13330B181
| ML13330B181 | |
| Person / Time | |
|---|---|
| Site: | San Onofre  |
| Issue date: | 03/30/1987 |
| From: | Morgan H SOUTHERN CALIFORNIA EDISON CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 8704060370 | |
| Download: ML13330B181 (5) | |
Text
Southern California Edison Company SAN ONOFRE NUCLEAR GENERATING STATION P. 0.
BOX 128 SAN CLEMENTE, CALIFORNIA 92672 H.E.MORGAN TELEPHONE STATION MANAGER (714) 368-6241 March 30, 1987 U. S. Nuclear Regulatory Commission Document Control Desk Washington, D. C. 20555
Dear Sir:
Subject:
Docket Nos. 50-206, 50-361 and 50-362 San Onofre Nuclear Generating Station, Units 1, 2 & 3 During a recent Region V inspection, which included a review of selected Emergency Plan:Implementing Procedures (EPIPs), a discrepancy was identified in an EPIP. Specifically, the afternoon prior to the 11 am March 6, 1987, exit interview, a user controlled "pink" copy of EPIP S0123-VIII-10 was found, concurrently by the inspector and an SCE Shift Superintendent, to be missing a page. Subsequent investigation by the inspector and SCE determined that con trolled copies of the procedure at other locations were incomplete. However, both the Technical Support Center (TSC) and Control Room (CR) Controlled Files where this procedure is used, were correct.
Since this finding was discovered late in the inspection, insufficient time existed for SCE to evaluate the discrepancy and provide information to the inspector on the subject nor did the inspector have an opportunity to evaluate the repro-duction and distribution process associated with EPIPs. As subsequently dis-cussed with both the inspector and Regional Management, the enclosure to this letter provides the facts and circumstances regarding this issue, and docu-ments the programs and processes currently in place that ensures full com-pliance with regulatory requirements.
SCE has a strong commitment to achieving excellence. However, we do not be lieve that absolute perfection in the reproduction of massive volumes of docu mentation (over thirty million pages per year onsite) is achievable. SCE has an exemplary quality control program for the reproduction of procedures that minimizes the impact of random errors introduced by human error or equipment malfunction. Furthermore, since the TSC and CR copies were complete, SCE believes there is no significance to this issue.
Should you require any additional information, please so advise.
77O6550 Sincerely, PDR ADOCK 050002O6 FPDR 44 V
Enclosure:
As Stated cc:
G. Good (USNRC Region V)
R. Fish (USNRC Region V)
F. R. Huey (Senior Resident Inspector)
ENCLOSURE This enclosure provides the facts and circumstances relating to a finding presented by the NRC at the exit interview on March 6, 1987, regarding a missing page (page 22 of 26) from Emergency Plan Implementing Procedure (EPIP) S0123-VIII-10.
Background
The San Onofre Nuclear Generating Station (SONGS) Units 1, 2 and 3 are required by Technical Specification Section 6.8.1 to establish, implement and maintain procedures. There are currently 3,644 SONGS procedures being controlled by Corporate Document Management (CDM). CDM at SONGS is staffed with 75 full time employees and has a budget of over $2,000,000 per year. CDM is currently reproducing over 2,500,000 pages per month and utilizes 5 high volume mainframe copiers.
Procedures at SONGS are divided into two categories:
"White" controlled copies which are maintained by CDM personnel; and "Pink" user controlled copies available upon request. Personnel using a "Pink" copy of a procedure are aware that the "Pink" should be checked against a "White" copy by the user to assure the "Pink" is current. "White" copy files of procedures are maintained in the Unit 1 Control Room, Units 2&3 Control Room, Unit 1 Technical Support Center, Units 2&3 Technical Support Center, and several other locations (NRC Resident office, Emergency Operations Facility, Technical Library, Operation QA, etc.) for the convenience of personnel.
CDM performs reproduction and distribution, and the CDM process includes machine and personnel checks for accuracy, legibility and completeness, as follows:
- 1.
Site document revisions and Temporary Change Notices (TCN) are received from Station Procedures Group (SPG) or other field originators.
- 2.
The CDM processor verifies that all required forms accompany the original procedure and that all appropriate lines are completed.
- 3.
The original document is checked for complete and accurate pagination and legibility.
- 4.
A copy of the original is made and designated as the "Site File Copy" (SFC).
-2
- 5.
The SFC is verified against the original for completeness, accuracy, and legibility. The original is then filed in CDM files.
- 6. The processor determines distribution requirements using the current distribution matrix. The SFC is forwarded to CDM Reprographics for copying.
Note: There are normally two distribution cycles for procedures. The first is the Rush distribution to several CDM controlled locations (White copies only) including the Control Rooms and Technical Support Centers.
The second distribution cycle consists of the balance of the CDM "white" controlled distribution and the scheduled "pink", working copy, distribution. During this reproduction, several "master" copies are often made from the SFC which are in turn used on separate machines to make additional copies.
- 7. Reprographics makes all necessary.copies, per the matrix/distribution request. During the reprographic process, the photocopy machine electronically verifies source document page counts; additionally, the machine operators randomly sample copies for copy quality and pagination. The copies are returned to CDM for sorting and distribution.
- 8. CDM Field Updates retrieve controlled copies from sort bins.
The Updaters verify that all indicated distribution has been received..They then update CDM controlled field file locations.
Approximately once or twice per month, unidentified machine errors occur, which are identified by procedure users. As soon as such errors are brought to the attention of CDM, corrected copies are reproduced and redistributed, as appropriate.
History of Procedure SO123-VIII-10, Temporary Change Notice 3-8 On February 27, 1987, Emergency Plan Implementing Procedure (EPIP) SO123-VIII-10, "Emergency Coordinator Duties", Temporary Change Notice (TCN) 3-8 was approved, and transmitted to CDM for reproduction and distribution. On Monday March 2, 1987, CDM completed reproduction and distribution of the procedure, using the process described above.
On March 3, 1987, Emergency Preparedness (EP) personnel, responsible for issuance of the procedure, noted a reproduction error in their "Pink" copies of the procedure in that page 8 was cut off at the bottom. On March 4, CDM personnel examined the "White File" in the Technical Library and several "Pink" copies, none of which had the error found in the copies issued to EP. CDM promptly initiated efforts to reproduce and distribute replacement copies to EP.
-3 On March 5, 1987, the NRC inspector became aware of an error in the procedure concurrent with SCE management. Specifically, the inspector and a Shift Superintendent observed that a "Pink" copy of S0123-VIII-10 was missing page 22.
The afternoon of March 5, when the inspector informed EP personnel of the missing page, EP personnel informed the NRC inspector that there had been a repro duction error (cut off page 8) with the procedure and that corrective actions were currently underway to provide corrected copies as appropriate.
The inspector subsequently noted the "White" copy in the NRC office and another "Pink" copy was missing page 22.
EP personnel notified CDM personnel of the missing page 22 the evening of March
- 5. QA verified that the original in CDM and the SFC (from which further copies would be made) were complete.
By 11 am March 6, 1987, CDM and EP personnel completed checks of selected locations and ascertained that while some "White" and "Pink" copies had reproduction errors (including not only a missing page 22 but also a missing page 13), the "White" copies in the Unit 1 Control Room, Units 2&3 Control Room, Unit 1 Technical Support Center, and Units 2&3 Technical Support Center were complete with no errors.
Since the reproduction of the procedure was known to contain errors, a reissue of the procedure to all locations was initiated.
By the evening of March 6, 1987, CDM completed reproduction and re-distribution using the verified SFC in the CDM control file.
Subsequent investigation into the manner by which some copies of the procedure could be correct while others had errors, determined two plausible explanations:
(1) When CDM began reproduction, 2 or 3 "master" copies were promptly made from the SFC, one of which missed pages during the cycling process in the feeder (the copiers recycle the original for each copy).
Further copies were prepared on multiple machines using these "master" copies, one of which was missing page 22..All subsequent copies made from this particular "master" would also be missing any pages this "master" was missing. Apparently the checks delineated in Step 7 above failed to catch this condition.
(2) Errors noted also appear indicative of "random" machine errors in the feeding and reproduction process.
Emergency Plan Activation In accordance with the approved Emergency Plan and Emergency Plan Implementing Procedures (EPIP), in the event of an emergency, the control of SCE actions is under the cognizance of the Emergency
-4 Coordinator (EC) who will respond in conformance with procedure SO123-VIII-10. During the initial phase of an emergency, the EC is the Shift Superintendent, who will operate in the Control Room (CR).
The EC function later shifts to the TSC upon its activation. As previously stated, both the CR and TSC had correct copies of SO123-VIII-10. Therefore, in the event of an emergency requiring immediate implementation of the procedure, complete and legible copies were in place in the CR and TSC.
To support an event, EPIP callout procedures provide for CDM personnel to respond, as appropriate, to either augment site CDM personnel on days or swings or perform this function on graves, specifically to ensure that any administrative support required in the area of procedures is efficiently and expeditiously performed.
Based on the onsite and callout support from CDM, and the fact that the CR and TSC copies were correct and complete, it is not considered credible that any improper action would have resulted from the inspector's observation.
Summary In accordance with Technical Specification 6.8.1, SCE has established, implemented, and maintained an administrative program for control of all procedures, including emergency plan implementing procedures. The CDM program incorporates a comprehensive system of internal checks and quality control measures to ensure that each procedure is complete and legible. Furthermore, each user of a pro cedure has the responsibility to promptly identify undetected reproduction or distribution errors and report them to CDM. CDM has an established program for correcting reproduction and/or dis tribution errors upon notification from procedure users.
SCE believes, as demonstrated by only having one or two procedures per month identified by users as having errors - out of over 30 million pages per year, that CDM has a standard of excellence beyond that required by regulations. SCE believes that it has fully and com pletely satisfied its obligations under Technical Specification 6.8.1.
In addition, SiteQA conducted nine audits of CDM activities from November 1984 through July 1986 with only one minor finding regarding "missing" information (i.e., the "EOF" stamp was missing from procedures at the Emergency Operations Facility [SCE QA audit SCES-79-85]).
SCE believes that there are no reasonable or credible corrective actions which could be taken to significantly improve the this process.