ML17193B442
| ML17193B442 | |
| Person / Time | |
|---|---|
| Site: | Dresden, Quad Cities, Zion  |
| Issue date: | 04/30/1981 |
| From: | Baker K, Baker K, Gildner M, Grobe J, Holzmer M, Peschel J, Schulz R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML17193B440 | List: |
| References | |
| 50-237-81-06, 50-237-81-6, 50-249-81-04, 50-249-81-4, 50-254-81-03, 50-254-81-3, 50-265-81-03, 50-265-81-3, 50-295-81-05, 50-295-81-5, 50-304-81-03, 50-304-81-3, NUDOCS 8106050543 | |
| Download: ML17193B442 (29) | |
See also: IR 05000237/1981006
Text
~-.*
U.S. NUCLEAR REGULATORY COMMISSION
OFFICE OF INSPECTION AND ENFORCEMENT
REGION III
Report Nos. 50-254/81-03; 50-265/81-03;~37/81-~0-249/81-04;
50-295/81-05; 50-304/81-03
Docket Nos. 50-254; 50-265; 50-237
50-249; 50-295; 50-304
Licensee:
Commonwealth Edison Company
Post Office Box 767
Chicago, IL
60690
License Nos. DPR-29; CPR-30
Facility Name:
Quad-Cities Nuclear Power Station, Units 1 and 2
Zion Nuclear Pow.er Station, Units 1 and 2
Diesd~n Nuclear Power Station, Units 2 and 3
Inspection At:
Cordova, Illinois
Zion, Illinois
Morris, Illinois
Inspection Conducted:
February 23-27, 1981, March 9-13, 1981 (Quad-Cities)
March 17, 1981 (Zion)
Inspectors:
March 18, 1981 (Dresden)
A'
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f'-.f/* s,-;'~
R. D. Schulz
I/JI~
M. Gildner *
(Quad-Cities only)
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.. , :-rvy-...,...,._ ;-<><-
J. Peschel
(Quad-Cities only)
.-'ill rlvli,-~
M. Hot'zmer
(Quad-Cities only)
K. Baker
(Quad-Cities only)
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"*.A ./\\hr?~
/J. Grobe
(Quad-Cities only)
8118050543'
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Approved by:
-~~
~-,, ~
K. R.
aker
hief,
~~
Management
rograms Section
Inspection Swmnary
Inspection on February 23-27, March 9~13, and March 17-18, 1981 (Report Nos.
50-254/81-03; 50-265/81-03; 50-295/81-05; 50-304/81-03; 50-237/81-06;
50-249/81-04)
Areas Inspected:
The inspection at Quad-Cities was an announced routine
inspection of the licensee's implementation of the Quality Assurance
Program in the following areas:
QA/QC administration; qualification of
personnel; design changes and modifications; records control; receipt,
storage and handling; tests and exper.iments; procurement control; document
control; offsite review committee; audits; test and measurement equipment;
surveillance and calibration; maintenance; nonroutine reporting; and cor-
rective action.
The inspection at Zion and Dresden was an announced in-
spection concerning the licensee's implementation of the Quality Assurance
Program to meet the requirements of ANSI Nl8.7-1976.
The inspection at
Quad-Cities involved a total of 376 inspector-hours onsite by six NRC
inspectors including 0 inspector-hours onsite during offshifts.
The in-
spection at Zion and Dresden involved a total of four inspector-hours onsite
by one NRC inspector including 0 inspector-hours onsite during offshifts.
Results:
Of the sixteen areas at Quad-Cities inspected, no apparent items
of noncompliance or deviations were identified in nine areas, four items of
noncompliance were identified in seven areas (failure to establish design
control - Paragraph 4; faiiure to control purchased material - Paragraph 6;
failure to follow administrative procedure - paragraph 13; and failure to
implement ANSI Nl8.7-1976, paragraphs 8, 12, 14, and 16).
Dresden and Zion
were involved in the noncompliance regarding the failure to implement port-
ions of ANSI Nl8. 7-1976.
(Paragraph 2)
- 2 -
+.
DETAILS
1.
Persons Contacted - (Quad-Cities)
- N. Kalivianakis, Superintendent
- D. Bax, Assistant Superintendent Oper.ations
- L. Gerner, Training Supervisor
- F. Faley, Office *supervisor
L. Butterfield, Store Supervisor
- W. Burkamper, QC Supervisor
H. Studtman, QA Supervisor Maintenance (Corporate)
- K. Hansing, QA Engineer
- D. Thayer, Staff Assistant - Maintenance
- J. Wunderlich, Staff Assistant - Technical Staff
V; Strong, QC Supervisor - Mechanical Incorporated
T .* Tamlyn, Operating Assistant Superintendent
D. Warren, Shift Engineer
J. Kopacz, Plant Modification Coordinator
C. Smith, Assistant QC Supervisor
D. Shutte, !SI Coordinator
- Z. Rudy, Central Files Supervisor
D. Rajacvich, IM Supervisor
The inspectors also interviewed several other licensee employees, in-
cluding operating engineers, shift engineers and foremen, reactor
operators, technical staff personnel and quality control personnel.
- Denotes those present at the exit interview on March 13, 1981.
Persons Contacted - (Dresden)
R. M. Ragan, Operating Assistant Superintendent
-Persons Contacted - (Zion)
K. L. Graesser, Plant Superintendent
2.
QA/QC Administrative Program -
(Dresden and Zion)
The Quality Assurance Programs were reviewed to determine if the Dresden
and Zion stations are implementing the requirements of ANSI N18.7-1976.
The review involved a discussion with K. L. Graesser, Plant SupeFintendent
at the Zion Station and R. M. Ragan, Operating Assistant Superintendent-
at the Dresden Station.
a.
Findings.
Noncompliance (50-237/81-06-01; 50-249/81-04-01; 50-295/81-05-01;
50-304/81-03-01)
3
Dresden and Zion \\
(1)
A fluid system cleanliness program does not exist to the
extent required by Paragraph 5.2.10 of ANSI N18.7-1976
and ANSI N45.2.1-1973.
(2)
A housekeeping program does not exist to the extent required
by Paragraph 5.2.10 of ANSI N18.7-1976 and ANSI N45.2.3-1973.
(3)
Calibration procedures do not exist for safety related
instruments to the extent required by Paragraph 5.3.7 of
The areas in which Dresden and Zion are not in full compliance with
ANSI N18.7-1976 may not be limited to these discussed above.
Future
inspections will determine the scope of compliance to ANSI N18.7-1976.
-
- The remaining sections of this report concern the Quad-Cities Station only.
QA/QC Administrative Program - (Quad-Cities)
The licensee's program for administration of the QA/QC program was
inspected.
This included program boundary, QA/QC procedure control,
and the mechanism for evaluating the QA program.
a.
Documentation Reviewed
Quality Assurance Program Topical Report, CE-1-A, Revision 14
and Revision 15.
Station Quality Assurance Manual, 2/16/81, Revision 63.
Quality Assurance Manual, 2/16/81.
Technical Specification, Section 6.2, Plant Operating Procedures.
QAP-100, Rev. 3, 10/23/79, Quad-Cities Station QAP Manual
Instructions.
QAP200-2, Rev. 16, 10/27/80, Station Organization.
QAP300-0, Rev. 28, 1/27/71, Operations Department.
QAPll00-0, Rev. 26, 11/17/80, Procedure Control.
b.
Findings
Instances on noncompliance regarding the implementation of
ANSI Nl8.7-1976 were noted.
These are discussed in paragraphs
8, 12, 14 and 16 of this report.
'
- 4 -
3.
Qualification of Personnel Program
The inspector reviewed the licensee's administrative controls to
ascertain their conformance with the regulatory requirements and
commitments made in the Quality Assurance Program.
The program was
reviewed to determine that controls have been established requiring
minimum educational, experience, and qualification requirements for
the plant staff and that responsibilities have been assigned to assure
that these requirements will be satisfied.
a.
Documentation Reviewed
Quality Assurance Program Topical Report, CE-1-A, Revision 14
and Revision 15, Section 2, Quality Assurance Program.
Station QA Manual, 2/16/81, Q.P. No. 2-52, Training.
Quality Assurance Manual, 2/16/81, Q.R. No. 1.0-0rganization
and Q.R. No. 2.0-QA Program.
Technical Specification, Section 6.1, Organization, Review
Investigation, and Audit.
QAP-900-3, Rev. 2, 2/9/81, Personnel Qualification and
Certification Program for Personnel to Meet the Intent of
Memorandum No. 7, 8/13/80.
b.
Findings
No items of noncompliance or deviations were identified.
4.
Design Changes and Modification Program
The inspector review~d the Design Change and Modification Program as
implemented by the licensee to verify compliance with the Commonwealth
Edison Company Quality Assurance Program, ANSI N18.7-1976, 10 CFR 50.59,
The following Quality Procedures, Directives, and Administrative Pro-
cequres were reviewed to determine that the licensee has establishment *
procedures to control design and modification requests; the designation
of responsibilities for the design change and modification program;
controls and responsibilities which assure that design changes and
modifications are incorporated into plant procedures, operator training
program and plant controlled drawings; the establishment of interface
communications between the different organizations involved in design
changes and plant modifications; and that design changes and plant
modification receive a safety review in accordance with 10 CFR 50.59
and timely reporting to the NRC ..
- 5 -
a.
Documentation Revi'ewed
Station QA Manual, 2/16/81, QP No. 3-1, Design Control
Station QA Manual, 2/16/81, QO No. 3-2, Design Change
Station QA Manual, 2/16/81, QP No. 3-3, Classification of Systems
Component
Station QA Manual, 2/16/81) QO No. 3-51, Design Control for
Operation - Plant Modifications
Station QA Manual, 2/16/81, QP No. 6-1, Distribution of Design
Documents
QAP-300-11, Rev. 1, 9/5/75, Electric Jumpers and Relay Blocks
QAP-500-5, Rev. 5, 10/16/79, Instrument Setpoint Change
QDM-7, Drawing Control Changes and Drawing Change Request Forms
QDM-11, Drawing Control for Work Requests and Plant Modifications
b.
Findings
(1)
Noncompliance (50-254/81-03-04; 50-265/81-03-04)
10 CFR 50, Appendix B, Criterion III, Design Control states
in part that design changes shall be subject to design control
measures commensurate with those applied to the original design
and be approved by the organization that performed the original
design.
Commonwealth Edison Company states in part in their Quality
Assurance Program Topical Report, CE-1-A, Revision 14 and 15,
Section 3 - Design Control, "Design evaluations of modifications
will be' commensurate with those applied to the original design."
10 CFR 50.59 states in part, that' the licensee shall maintain
records of changes in the facility and ... these 'records
shall include a written safety evaluation which provides the
bases for the determination that the change does*not involve
an unreviewed safety question.
Contrary to the above, a nitrogen purge system to the SRM and
IRM detector connectors was installed in Unit 2 by means of a
Nuclear Work Request No. Q03507.
This activity was determined
by the licensee to be safety related but a plant modification
request had not been implemented or required by the licensee.
No records of a 50.59 review could be located for this activity.
c.
Discussion
(1)
From interviews with IM foremen, the inspecto~ determined that
the intent of the changes to the nitrogen purge system was an
attempt to reduce noise in the SRM and IRM instrumentation.
The modification was intended to be trial in nature and would
not be installed in Unit 1 if it did not improve the noise
problem.
- 6 -
Inplace plant modification procedures involve a lengthy process.
Plant special test procedures were not applicable.
The facility does not have a temporary plant modification
program.
A temporary plant modification program with all
required reviews and evaluations not unlike an expanded
special test program could be useful in cases such as these.
(2)
While the inspector was reviewing several plant modification
packages, a confusion fa~tor became apparent.
Modification
package M-4-1-79-2, entitled, "ATWS-RPT/ARI", possessed docu-
ments of the same modification number but with two different
titles. Discussions revealed that the original modification
had been revised in progress.
The file contained documents
for both the original and revised packages but made no
differentiation between them.
This situation provides the possibility of documents being
retrieved from the file which are not the latest revision.
A program should be initiated which distinguishes between
the revisions of a plant modification package.
The licensee
acknowledged the inspector's comments in this area.
5.
Test and Experiment Program
The test and experiment program was reviewed to verify that the
established administrative controls and their implementation comply
with the applicable requirements specified in the Plant Technical
Specifications and 10 CFR 50.59.
The following Quality Procedures, Administrative Procedures, and
Technical Procedures were reviewed to verify the establishment of a
mechanism for handling requests or proposals for safety related test
and experiments; requirements to utilize approved procedures, assign-
ment of responsibilities for review and approval of test and experiment
procedures; establishment of a system for review of proposed tests to
determine whether they are'described in the FSAR; assurance that a
written safety evaluation is developed for applicable tests and experi-
ments; and assignment of responsibility for reporting all test and
experiments conducted pursuant to 10 CF~ 50.59.
a.
Documents Reviewed
Station QA Manual, 2/16/81, QPll-51, Test Control For Operations -
Planned Tests
QAP 400-4, Rev. 2, 4/2~/77, Test Authorization
QTP 010-4, Preparation, Performance, and Review of Special
Operational Tests
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-*:.
b.
Findings
No items of noncompliance or deviations were identified in this area.
6.
Procurement Program
The procurement program was reviewed to ascertain its conformance with
regulatory requirements and commitments in the operational quality
assurance program.
Procurement documents were checked for technical
requirements, QA program requirements, 10 CFR 21 provisions, specific
identification of items, and statements concerning access to the
supplier's plant or records for purposes of audit.
Procedures were
reviewed to determine if responsibilities were assigned in writing for:
(a) initiation of procurement documents, (b) review and approval of
procurement documents, (c) making changes to procurement documents; and
(d) basis for classification of procurement items.
An approved vendors
list was examined, along with the evaluation of suppliers after being
placed on the approved suppliers list.
Procurement documents for various
systems were checked, along with the supplied materials documentation,
including traceability to the item.
a.
Documentation Reviewed
Quality Assurance Manual, 2/16/81, Q.R. No. 4.0 -
~rocurement
Document Control.
Station QA Manual, 2/16/81, Revision 63, Procurement Control.
Station QA Manual, 2/16/81, Q.P. No. 4-51, Procurement Document
Control for Operation - Processing Purchase Documents.
Station QA Manual, 2/16/81, Q.P. No. 7-51, Control of Purchased
Materials - Equipment and Services for Operation - Supplier
Evaluation.
Memorandum No. 6, Evaluation of Vendor Quality Assurance
Manuals, 11/27/79.
Station.Quality Assurance Manual, 2/16/81, Q.P. No. 4-1,
Request for Bid, Proposal Evaluation and Recommendation.
Station Quality Assurance Manual, 2/16/81, Q.P. No. 4-2,
Evaluation of Contractors Quality Assurance Program.
b.
Findings
Noncompliance (50-254/81-03-02; 50-265/81-03-02)
10 CFR 50, Appendix B, Criteria IV, states in part, "Measures shall
be established to assure that applicable regulatory requirements,
- 8 -
design basis, and other requirements which are necessary to assure
adequate quality are suitably included or referenced in the documents*
for procurement of material, equipment, and services, whether pur-
chased by the applicant or by its contractors or subcontractors."
10 CFR 50, Appendix B, Criteria VII, states in part, "Measures shall
be established to assure that purchased material, equipment, and
services, whether purchased directly or through contractors or sub-
contractors, conform to the procurement documents.
Documentary
evidence that material and equipment conform to the procurements
shall be available at the nuclear power plant or fuel reprocessing
plant site prior to installation or use of such material and equipment."
Commonwealth Edison Company states in part in their Quality Assurance
Program Topical Report, CE-1-A, Revision 14 and 15, Section 4 -
Procurement Document Control, "Quality Assurance Program requirements
are included as are regulatory, code, standard and design requiremepts."
Contrary to 10 CFR 50, Appendix B, Criteria IV, the following pro-
curement documents issued to Instrument Associates did not reference
a material type as required by Sargent and Lundy Design Specifications:
Purchase Order #'s
226863-
ordered 9/ 18/78, received 9/26/78,
501345-18 blanket order, received 5/12/79
501345-33 blanket order, received 1/9/80
501345-35 blanket order, received 1/9/80
501345-36 blanket order, received 1/4/80
501345-41 blanket order, received 2/15/80
501345-46 blanket order, received 3/5/80
501345-47 blanket order, received 2/12/80
501345-50 blanket order, received 5/22/80
501345-52 blanket order, received 5/22/80
501345-53 blanket order, received 3/29/80
501345-56 blanket order, received 4/10/80
501345-57 blanket order, received 4/28/80
501345-59 blanket order, received 5/16/80
501345-61 blanket order, received 5/23/80
501345-65 blanket order, received 6/17/80
501345-67 blanket order, received 9/18/80
501345-70 blanket order, received 8/18/80
501345-74 blanket order, received 10/14/80
501345-79 blanket order, received 12/19/80
501345-81 and 83 blanket order, received 12/16/80
501345-88 blanket order, received 1/5/81'
The procurement documents required the vendor to supply certifica-
tion that all stainless steel items were manufactured in accordance
- 9 -
..
with ASME SA-403 (ASTM A-276), ASME SA-182, or ASTM A-479 as applic-
able.
The type of stainless steel, type 316 or type 304, required
by design specifications for instrument tube fittings and valves was
not made a requirement of the procurement document.
The material
was ordered to the supplier's standard certification instead of to
the design requirements.
The standard certification failed to
indicate the type of stainless and therefore the specific chemical
and physical properties of the supplied material.
Contrary to 10 CFR SO, Appendix B, Criteria VII, the following
examples of noncompliance were identified:
Valves were received and accepted for installation or use on pur-
chase order numbers 226862, 501345 release No. 67, and 501345
release No. 88 without documentation conforming to ASME SA-182 as
required by the procurement document.
The certification from the
vendor stated that stainless steel valves are manufactured from
materials conforming to ASME-SA-182 excluding the heat treatment
of paragraph "SB" for forged valve bodies.
However, heat treatment
is required by the specification SA-182, for all austenetic stainless
steel.
Futthermore, the angle valves received iri pufcha~e order
No. 226863, were installed in a safety related, ATWS modificati'on,
in December of 1980 without documentation that they conformed to
the procurement requirements.
This work was accomplished under
work request No. Q00213 and work order No. 107383A.
c.
Discussion:
The licensee committed to including right of access statements in
their procurement documents in Sections 4 and 10 of the Quality
Assurance Program Topical Report, CE-1-A.
At the time of the in-
spection, right of access statements were not being included in the
In a March 10, 1981 memo from the manager of
QA to the Lead QA Engineer at Quad-Cities, Commonwealth Edison re-
committed to implementing the right of access statements in their
This fact was confirmed with the QA Manager
(Corporate) and Lead QA Engineer at Quad-Cities.
The*right of access
statements on procureinent documents is an unresolved* item and will
be reviewed during the corporate audit.
(50-254/81-03-05;
50-265/81-03-05)
d.
Licensee Action:
Since the identification of the noncompliances by the NRC inspector,
the licensee has received certification verifying the type or grade
of material furnished by Instrument Associates for all tube fittings
and valves.
This resolves only that part of the violation against
10 CFR 50, Appendix B, Criteria IV for corrective action, but a reply
'is required for corrective action to prevent recurrence.
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\\
7.
Receipt, Storage and Handling of Equipment and Materials Program
Receipt, storage and handling of equipment and materials was reviewed
to ascertain whether the licensee is implementing a QA program that is
in conformance with regulatory requirements and commitments in the
Quality Assurance Program and implementing procedures.
The inspector
verified that responsibilities were assigned for receipt, acceptance,
release, storage, and handling of items.
Nonconforming items were
reviewed for identification, segregation, control, and release.
Receipt
inspection reports were examined for applicable signatures, justification
for use, damage recorded, and stipulated inspection criteria.
Procedures
were reviewed for levels of storage and appropriate environmental condi-
tions, including shelf life.
a.
Documentation Reviewed
Quality Assurance Program Topical Report, CE-1-A, Revision 14
and Rev.is ion 15, Sections 7 ,' 8, 10, 13, and 15.
Station QA Manual, 2/16/81, Q.P. No. 7-51 - Control of Purchased
Materials, Equipment and Services for Operations - Supplier
Evaluation.
Station QA Manual, 2/16/81, Q.P. No. 8-51 - Identification and
Control of Materials, Parts and Components for Operations -
Identification, Inventory Disbursed and Use.
'Station QA Manual, 2/16/81, Q.P. No. 10-54 - Inspection for
Operations, Receiving Inspection.
Station QA Manual, 2/16/81, Q.P. No. 13-51 - Handling,
Storage and Shipping for Operations - Control of Equipment,
Materials and Nuclear Fuel.
Station QA Manual, 3/16/81, Q.P. No. 15-51 - Nonconforming
Materials, Parts and Components for Operations - Spare Parts
and Materials.
QAP-600-2, Rev. 5, 11/17/80, Withdrawing Safety-Related Items
from the Storeroom.
QAP-600-3, Rev. 4, 9/24/80, Returning Rebuilt Safety Related or
ASME Items, Parts or Components to the Storeroom.
QAP-600-6, Rev. 6, 7/16/80, Receiving, Handling and Storage of
Items and Routing of Documents.
QAP-600-7, Rev. 3, 6/6/79, Control of Items with Limited Shelf
Life.
QAP-600-8, Rev. 3, 10/23/79, Storage of Chemicals.
-
11 -
QAP-600-9, Rev. 1, 8/02/77, Storage of Resins.
QAP-600-10, Rev. 3, 6/06/79, Storage of Control Rod Drives.
QAP-600-11, Rev. 2, 6/6/79, Handling and Storage of Welding
Material.
QAP-600-12, Rev. 3, 10/23/79,.Preventive Maintenance for Items
in Storage.
- QAP-600-13, Rev. 2, 6/06/79, Levels of Storage.
QAP-600-14, Rev. 1, 12/22V80, Inter-Station/Department Transfer
of Materials, Parts and Components.
QAP-1220-1, Rev. 7, 2/04/81, Station Discrepancies.
QAP-1220-2, Rev. 2, 7/29/76, Non-Conforming Materials, Parts
and Operations.
b.
Findings
No items of noncompliance or deviations were identified.
c.
Discussion:
(1)
Mechanical Incorporated, a piping contractor for Commonwealth
Edison, was under contract for modifications to the Torus Water
Level Instrumentation as required by NUREG 0578.
It was found
that Mechanical Incorporated had some problems in the areas of
procurement, receipt inspection, and identification and control
of material.
Before this inspection was completed, Mechanical
Incorporated, under Commonwealth Edison direction, appeared to
be implementing the necessary quality assuran~e controls.
The
following areas will be re-inspected in a future inspection.
(a)
Inclusion of applicable regulatory and quality assurance
requirements in procurement documents.
(b)
Receipt inspection documentation, including heat trace-
ability, size and wall thickness verification, and
specification verification.
(c)
Control of purchased material through installation,
verifying traceability.
This is an unresolved item.
(50-254/81-03-06; 50-265/81-03-06)
(2)
Commonwealth Edison's material request process needs improvement,
as material is requisitioned and released without complete
- 12 -
information concerning the description of the items.
Typical
examples of information left off material requests were:
(a)
Material specifications.
(b)
Material grades.
(c)
Wall thicknesses.
(d)
Classification of items - ASME B & PV Code, Safety Related.
The lead QA Engineer at Quad-Cities stated that adequate
controls are in effect to prevent the use of incorrect items,.
but would implement a program to see that the mate.rial request
accurately identifies items, to preclude the possibility of
inadvertent installation of incorrect material.
The material request process is an unresolved item, and will
be re-inspected in a future inspection.
(50-254/81-03-07;
50-265/81-03-07)
8.
Records Program
The records program was reviewed to ascertain that the licensee is
implementing a program relating to the control of records that is iri
conformance with appliable regulatory requirements, Operational Quality
Assurance Program, ANSI Nl8.7-1976 and ANSI N45.2.9-1974.
Record
storage controls were reviewed including the means of-transferring
records to the vault.
Various records were reviewed for'implementation
of the program and personnel were interviewed concerning storage, access,
. and retrievability.
The record index was examined and duplicate storage
was checked against the criteria of ASNI N45.2.9.
a.
Documentation Reviewed
Quality Assurance Manual, 2/lq/81, Q.R. No. 17.0 - Quality
Assurance Records.
Station Quality Assurance Manual, 2/16/81, Q.P. No. 17-51 -
Quality Assurance Records for Operations - Control of Station
Records.
"'
QDM - Document Control Manual.
Technical Specification, Section 6.5.
QAP-1800-1, Rev. 4, 8/18/78, Station Records.
b.
Findings
Noncompliance (50-254/81-03-01; 50-265/81-03-01)
- 13 -
- ~*
/
10 CFR 50, Appendix B, Criteria II, states in part, "The applicant
~hall establish at the earliest practical time, consistent with the
schedule for accomplishing the activities, a quality assurance pro-
gram which complies with the requirements of this appendix.
This
program shall be documented by written policies, procedures, or
instructions and shall be carried out throughout plant life in
accordance with these policies, procedures, or instructions."
Commonwealth Edison Company hascomD!itted to the requirements of
ANSI Nl8.7-1976 through Regulatory Guide 1.33 (Rev. 2) as stated
in the Quality Assurance Program Topical Report, CE-1-A.
ANSI Nl8.7-1976 states in paragraph 5.2.12, "American National
Standard Requirements for Collection, Storage and Mainten~nce
of Quality Assurance Records for Nuclear Power Plants, N45.2.9-1974,
shall be used for management of plant records during the ope~ational
phas~."
ANSI N45.2.9 states "Permanent and temporary record.storage facilities
shall be constructed or located as to protect contents from possible
destruction ... "and "A satisfactory alternative to the establishing
of a record storage facility is maintenance of duplicate records stored
in a separate storage location."
Document Control Procedure QDM-1 states "To provide the safekeeping
of records, Quad-Cities station has provided dual storage facilities."
Contrary to the above, the following completed records were not
stored in two or more locations or stored so as to be protected from
possible destruction:
(1)
Completed Rad-Chem department surveillances.
(2)
Superseded Station procedures.
(3)
Special Test File.
(4)
Completed Work Requests.
. (5)
Completed Work Packages.
(6)
Completed ISI records.
(7)
Welding Forms AW-482, Welding Procedures.
Contrary to ANSI N45.2.9 Paragraph G.2, no access list to the central
file exists.
- 14 -
~.
c.
\\
Discussion:
Commonwealth Edison Quality Assurance Procedure Q.P. 17-51 states
that lifetime station generated Quality Assurance records are to be
transferred to the Office Supervisor.
QDM-6 states "Active files are purged of lifetime retainable QA .
records by the Central File Supervisor according to the QDM pro-
cedures, retention schedule, and R3 system."
The Retention Schedule had been recently updated, and Active File
indexes were being distributed to Active File Supervisors during
the inspection period.
Considerable effort was expended in order
to bring the system in conformance with requirements.
In spite of
this, the following lifetime QA records were maintained in the
active files in excess of the time period .specified in the Master
Retention Schedule:
(1)
Completed ISI Records.
(2)
Completed Work Requests.
(3)
Completed Work Packages.
(4)
Environmental Monitoring Reports.
I
This is an unresolved item which will be re-inspected in a future
insp~ction.
(50-254/81-03-08; 50-265/81-03-08)
9.
Document Control Program
The document control program was reviewed for conformance to regulatory
requirements, Quality Assurance Program requirements and applicable
industry guides and standards.
Drawings, procedures, and technical
specifications were review~d for current revisions, distribution lists,
and responsibilities assigned for implementation.
Station general
procedures, surveillance procedures and operating procedures, as-built
drawings and Technical Specifications wer~ reviewed for current revision
and distribution according to master indices.
a.
Documentation Reviewed
Station QA Manual, 2/16/81, Q.P. No. 6-51 - Document Control for
Operations - Distribution and Control of Engineering 'Documents and
Drawing Change Control.
Document Control Manual.
Technical Specifications (Unit 1 & Unit 2).
- 15 -
b.
Findings
No items of noncompliance or deviations were identified.
10.
Audits
The licensee's audit program was reviewed to ascertain whether the
licensee has developed and implemented a program that is in conformance
with regulatory requirements and applicable industry guid~s and standards.
The inspection included verification of the following:
scope of the
program is consistent with Technical Specification requirements; respons-
ibilities for overall management of the program have been assigned; and
methods for identification and resolution of audit findings have been
defined.
a.
Documentation Reviewed
Quality Assurance Program Topical Report, CE-I-A, Revision I4 and
I5, Section I6, Corrective Action.
Quality Assurance Program Topical Report, CE-I-A, Revision I4 and
I5, Section I8, Audits.
Technical Specification, Section 6.I, Organization, Review
Investigation, and Audit.
Quality Assurance Manual, 2/I6/8I, Q.R. No. I8.0 - Audits.
Quality Assurance Manual, 2/I6/8I, Q.R. No. I6.0 - Corrective Action.
Station Quality Assurance Manual, 2/I6/8I, Q.P. No. I6-5I -
Corrective Action for Operations - Corrective Action System.
Station Quality Assurance Manual, 2/I6/8I, Q.P.P No. I8-5I -
Quality Assurance Program Audits.
Station Quality Assurance Manual, 2/I6/8I, Q.P. No. I8-52 -
Audit and Surveillance of Maintenance, Spare Parts and In-Service
Inspection Activities.
Station Quality Assurance Manual, 2/I6/8I, Audit.
QAP-I220-3, Rev. I, 9/5/75, Corrective Action for Non-Conforming
Items and Operational Discrepancies.
QAP-I250-I, Rev. 2, 7/29/76, Action Item Program.
QAP-I250-2, Rev. 1, 9/05/75, Action Item Status Report.
QAP-I250-3, Rev. 6, I2/0l/79, Action Item Procedures .
- I6 -
b.
Findings
No items of noncompliance or deviations were identified.
11.
Test and Measurement Equipment Program
The program for control of test and measurement equipment was reviewed
to verify compliance with the requirements of the Quad-Cities Nuclear
Plant Technical Specifications and 10 CFR 50, Appendix B, Criteria XII.
The selected Quality Procedures, Instrument Procedures, and Maintenance
Procedures were reviewed to verify that controls have been established
which sets forth:
the criteria and responsibilities for identifying
calibration status for each piece of equipment; a system which assures
that each piece of equipment is calibrated on or before the required
date; a written requirement which prohibits the use of equipment beyond
its calibration period; control~ preventing use of out-of-calibration
equipment; and controls for evaluating the status of equipment and items
previously tested or measured using the equipment found to be out-of-
calibration.
a.
Documents Reviewed
Station QA Manual, 2/16/81, QP 12-1, Calibration Control of Test
and Measurement Equipment
Station QA Manual, 2/16/81, QP 12-51, Control of Measuring and
Test Equipment for Operations - Portable T&ME
QIP-3, Measuring and Test Equipment Calibration
QMP 100-6, Control of use and accuracy of measuring equipment
b. *
Findings
No items of noncompliance or deviations were identified in this area.
12.
Surveillance Testing and Calibration Control Program
The program for surveillance testing, calibration, and inspection of
safety related components and instrumentation was reviewed to verify
compliance with the requirements of Quad-Cities Technical Specifications
and Criteria XI of 10 CFR 50, Appendix B.
a.
Documentation Reviewed
QAP 400-2, Rev. 5, 03/08/80, Surveillance Program Responsibilities
Technical Specification 4.1 - 4.12
QOS, Operational Surveillances
QIP, Instrument Department Procedures
- 17 -
b.
Findings
Noncompliance (50-254/81-03-01; 50-265/81-03-01)
10 CFR SO, Appendix B, Criteria II, states in part, "The applicant
shall establish at the earliest practical time, consistent with.the
schedule for accomplishing the activites, a quality assurance program
which complies with the requirements of this appendix.
This program
shall be documented by written policies, procedures, or instructions
and shall be carried our throughout plant life in accordance with
these policies, procedures, or instructions."
Commonwealth Edison has committed to ANSI Nl8.7-1976 through
Regulatory Guide 1.33 (Rev. 2) ~s stated in the Quality Assurance
Program Topical Report CE-I-A.
ANSI N18.7-1976, paragraph 5.3.7 states, "Procedures shall be
provided for periodic calibration a~d testing of safety related
instrument and control systems".
Contrary to the above, adequate procedures have not been established
to provide periodic calibration of the following safety related
instruments:
(1) Diesel temperature moni,tor (multi-position thermocouple readout) .
(2)
TR-260-11; Vessel shell and flange temperatures.
(3)
TR-263-105; Recirc loop A & B temperatures.
c.
Discussion
QIP T-11 lists most of the safety related instrumentation used in
the conduct of Technical Specification surveillances and requires
them to be calibrated on a yearly basis.
The remaining safety
related instrumentation which is not specifically required to be
calibrated by the Technical Specification is calibrated with the
"Balance of Plant" (BOP) instrumentation.
BOP instrumentation is
generally calibrated on a yearly basis; however, due to the large
volume of instruments on the BOP, not all such instruments are
calibrated yearly.
Examples of safety rdlated instruments for which
the most recent calibration exceeded one year are listed above.
Inclusion of all safety related instrumentation which is required
to demonstrate compliance with the Technical Specifications and which
are currently on the BOP calibration list in a system like the one
described by QIP T-11 could provide calibration on a periodic basis.
13.
Surveillance Program
The Surveillance Program was reviewed to determine if surveillance"tests
required by Section 4 of the Technical Specifications were covered by
- 18 -
..
properly approved procedures.
These surveillance tests covered approxi-
mately 75 separate Technical Specification requirements.
Completed
surveillances were reviewed to verify that surveillances were performed
within the required peri6dicity and that the results were within the
Technical Specifications.
Work requests, operator '*s log, shift engineer's
logs, and out-of-service logs were examined for circumstances in which
non-periodic surveillances would be required.
a.
b.
Documentation Reviewed
QFP - 100-3
QOS - 202-5
QFP - 100-4
QOS - 300-6
QOS - 005-Sl
QOS - 1000-01
QOS - 005-S2
QOS - 1100-01
QOS
005-S7
QOS
1300-01
QOS - 201-01
QOS - 1400-01
QOS - 201-2
QOS - 1600-14
QOS
201-S2
QOS
1600-01
QOS - 300-2
QOS - 2300-01
QOS - 6500-01
QOS - 7500-01
Findings
NoncomEliance (50-254/81-03-03)
Technical Specification 1.7.B.l requires a monthly operability test
of the standby gas treatment system during which a 4000 cfm (+/-10%)
system flow is required.
Surveillance sheet QOS-7500-S4 records
this.flow and monthly test.
Administrative procedure QAP -400-3 requires a Deviation ~eport,
"When a safety related component or system .
. is found to vary
significantly from the system specifications."
Technical Specification 6.2.A.7 requires adherence to written
procedures covering "Surveillance and testing requirements."
Technical Specification 6.6.B.l.b requires prompt notification
with written followup for "operation of the unit or affected.
systems when any parameter or operation subject to a limiting
condition*is less conservative than the least conservative
aspect of the limiting condition for operation established in
the technical specifications."
Contrary to the above, QOS 7500-S4 documents performance of a
monthly operability test of the A train of the standby gas
treatment system on August 8, 1980 for which the system flow
was recorded as 3480 cfm.
No Deviation Report could be found
for review and no apparent notification or written followup was
provided to the NRC.
- 19 -
This is an item of noncompliance identified in Appendix A.
c.
Discussion
The demister filter of the SBGT system was replaced on August 28,
1980 in accordance with properly approved procedures.
During the
interval between August 8 and August 28, the A train was run several
times and the system flow was recorded on the daily surveillance
sheet QOS-005-Sl.
On each of these occasions, the recorded flow was
within the required margin of 4000 cfm (+/-10%) indicating system
operability.
Although the system may have been operable throughout
the period from August 8 to August 28, 1980, the licensee apparently
failed to take notice of the out-of-specification system flow during
the performance of the surveillance and during the review process.
Note is made that this is the only example of the failure of the
review process in approximately 90 completed surveillances reviewe4.
The inservice test program for pumps and valves was to be inspected.
When questioned, the licensee stated that they had not implemented
a program.
The licensee stated that NRR was aware that they were
awaiting NRR's review and approval of the program prior to implement-
ing it. Discussion with various members of the licensee's staff and
Senior Resident Inspector indicated that this was true and that it
had also been brought to NRR's attention during a meeting held at the
station in June of 1980 to discuss the program.
In addition, the
licensee had documented his position in a letter to NRR dated
September 30, 1980 which transmitted a revised program.
Most licensees
have received a letter following submittal of their programs informing
them that 10 CFR 50.SS(a)(g) required them to implement a program and
they should implement the most conservative between their submittal.
and their Technical Specifications until NRR completed a review of
.the program.
Quad-Cities has not received such a letter.
Subsequent to the inspection, the matter was discussed with NRR and
CECo Nuclear Licensing.
The licensee.has stated that he will begin
formal approval of the required procedures and will implement a
program during April 1981 for pumps and June 1981 for valves.
This
program reflects the most conservative aspects of the present
Technical Specifications and Code requirements assuming that any
exceptions requested in the revised program are to be granted.
The
licensee confirmed this is a letter to NRR dated March 31, 1981.
14.
Maintenance
The inspector reviewed the licensee's Maintenance Program to ascertain
that the QA program relating to maintenance activities is being implemented
in accordance with the QA Program, 10 CFR 50 Appendix B requirements,
and commitments in the QA Program.
The inspector also reviewed maintenance
activities of safety related systems and components to ascertain whether
the Maintenance Program is being conducted in accordance with approved
procedures, regulatory guides, industry codes or standards and in conform-
ance with Technical Specifications.
- 20 -
..
The following items were considered during this review:
written pro-
cedures have been established for initiating requests for routine and
emergency maintenance; criteria and responsibilities have been designated
for performing work inspection of maintenance activities; provisions and
responsibilities have been established for the identification of approp-
riate inspection hold points; methods and responsibilities have been
designated for performing testing following maintenance work; methods
and responsibilities for equipment control have been clearly defined;
administrative controls for special processes have been established;
limiting conditions for operation were met while components or systems
were removed from service; approvals were obtained prior to initiating
the work; activities were accomplished using approved procedures and
were inspected as applicable; functional tes.ting and/or calibrations
were performed prior to returning components or systems to service;
quality control records were maintained; activities were accomplished
by qualified personnel; parts and materials used were properly certified;
radiological controls were implemented; and, fire prevention controls
were implemented.
The inspector also reviewed the licensee's Preventive Maintenance Program
to ascertain that a written program had been established which included
responsibility for*the program, a master schedule for preventive maintenance
and documentation and review of completed preventive maintenance activities.
a,.
Documentation Reviewed
Station QA Manual, 2/16/81, QP 2-53 - Quality Assurance Program for
Operations - Classification of Structures, Systems, and Components.
Station QA Manual, 2/16/81, QP 3-52 - Design Control for
Operations - Plant Maintenance.
Station QA Manual, 2/16/81, QP 5-51 - Instructions,* Procedures
and Drawings for Operations - Station Procedures Manual.
Station QA Manual, 2/16/81, QP 7-51 - Control of Purchased
Materials, Equipment and Services for Operations - Supplier
Evaluation
Station QA Manual, 2/16/81, QP 8-51 - Identification and Control
of Materials, Parts and Components for Operations - Identification
Inventory Control, Disbursal and Use.
Station QA Manual, 2/16/81, QP 9-1 - Control* of Contractor
Special Processes.
Station QA Manual, 2/16/81, QP 9-51 - Control of Special
Processes for Operations - Special Processes for Maintenance
and Modifications.
Station QA Manual, 2/16/81, QP 10-51 - Inspections for
Operations - Maintenance.
Station QA Manual, 2/16/81, QP 10-52 - Inspections for Operations -
Station Operations.
Station QA Manual, 2/16/81, QP 10-53 - Inspection for
Operations - Technical Support Surveillance and Inspection.
Station QA Manual, 2/16/81, QP 10-54 - Inspections for
Operations - Receiving Inspection.
- 21 -
'*
Station QA Manual, 2/16/81, QP 12-51 - Control of Measuring and
Test Equipment for Operations - Portable Test and Measurement
Equipment.
Station QA Manual, 2/16/81, QP 13-51 - Handling, Storage and
Shipping for Operations - Control of Equipment, Materials
and Nuclear Fuel.
Station QA Manual, 2/16/81, QP 14-51 - Inspection, Test and
Operating Status for Operations - Tagging.
Station QA Manual, 2/16/81, QP 15-51 - Nonconforming
Materials, Parts and Components for Operations - Spare
Parts and Materials.
Station QA Manual, 2/16/81, QP 15-52 - Nonconforming Materials,
Parts and Components for Operations - Deviation and Comments.
Station QA Manual, 2/16/81, QP 15-53 - Nonconforming Materials,
Parts and Components for Operations - Inspection and Test*.*
Station QA Manual, 2/16/81, QP 16-51 - Corrective Action for
Operations - Corrective Action System.
Station QA Manual, 2/16/81, QP 17-51 - Quality Assurance
Records for Operations - Control of Station Records.
QAP 200-4, Rev. 2, 9/18/79 - Operating Engineers.
QAP 200-13, Rev. 4, 4/16/79 - Station Housekeeping Organization.
QAP 300-li, Rev. 1, 9/5/75 - Electric Jumpers and Relay Blocks.
QAP 300-12, Rev. 5, 7/31/80 - Tagging Equipment.
QAP 500-2, Rev. 2, 11/13/79 - Planning of Maintenance.
QAP 500-3, Rev. 1, 9/5/75 - Maintenance Procedures.
QAP 500-4, Rev. 1, 9/5/75 - Inspection and Test of Maintenance
Activities.
QAP 500-5, Rev. 3, 11/13/79 - Safety Related and ASHE III Work.
QAP 500-6, Rev. 1, 9/05/75 - Maint'enance Records.
QAP 600-2, Rev. 5, 11/17/80 - Withdrawing Safety Related Items
from the Store Room.
QAP 700-1, Rev. 6, 10/27/80 - Station Training Program.
QAP 1200-1, Rev. 7, 10/23/80 - Deviation Report Procedures.
QAP 1220-1, Rev. 7, 2/4/81 - Station Discrepancies.
QAP 1220-2, Rev. 2, 7/29/76 - Nonconforming Materials, Parts and
Operations.
QAP 1220-3, Rev. 1, 9/5/75 - Corrective Action for Nonconforming
Items and Operational Discrepancies.
QAP 1250-1, Rev. 2, 7/29/76 - Action Item Program.
QAP 1250-2, Rev. 1, 9/5/75 - Status Report.
QAP 1250-3, Rev. 6, 12/1/79 - Action Item Procedure.
QMP 100-3 - Fire Prevention for Welding and Cutting
Operating Instructions No. 2-2-11.- Out of Service Cards
Total Job Management Manual.
Station Quality Assurance Manual.
The facility maintenance procedures listed below were reviewed to
verify that they were technically adequate and consistent with
Technical Specifications.
- 22 -
e~
QMP 600-1
QMP 600-2
QMP 600-3
QMP .600-6
\\
QMP 600-Sl
QMP 600-S2
QMP 600-S3
QMP 600-Tl
QMP 600-T2
QMP 200-1
QMP 200-3
QMP 200-Sl
QMP 200-S6
Work Package No. 776
Work Request Q03595
Maintenance Activities Revjewed:
WR Ql0005
WR Ql0633
WR Q09483
WR Q07820
WR Q08210
WR Q08166
WR Q10471
WR Q07535
WR Q09474
WR Q00872
WR Q08819
WR Q99464
WR Ql0205
WR Q09651
.WR Q08531
WR Q08431
WR Q03595
WR Ql0158
WR Q08881
WR Q09338
WR Ql0131
WR Q052Tl
WR Ql0634
WR Q08289
WR Q08781
b.
Findings
Unit l
Unit l
Unit l
Unit l
Unit l
Unit l
Unit l
Unit l
Unit l
Unit l
Unit l
Unit l
Uni~ 1/2
Unit 2
Unit 2
Unit 2
Unit 2
Unit 2
Unit 2
Unit 2
Unit 2
Unit 2
Unit 2
Unit 2
Unit 2
24/48 Battery Charger 1B2
IA Core Spray Line
Scram Solenoid Valves 117-118
IRM Detector Cable
DW Sample Valve
Drywell Purge Valve
Suppression Chamber Test and Spray Valves LPRM 08-33D
RHR Test Return Valve
Recirc Pump Suction Valve
IRM Channel 18
Scram Pilot Valves
Valve 1001-34A
Inboard MSIV
Recirc Suction Valve
Drywell Equipment Drain Valve LPRM 48-33A
HPCI Steam Line Switch
Main Steam Tunnel Switch
Torus Vent to SBGT
Noncompliance (50-254/81-03-01; 50-265/81-03-01)
10 CFR 50, Appendix B, Criterion II, states in part, "The applicant
shall establish at the earliest practical time, consistent with the
schedule for accomplishing the activities, a quality assurance program
which complies with the requirements of this appendix.
This program
shall be documented by written policies, procedures, or instructions
and shall be carried out throughout plant life in accordance with
these policies, procedures, or instructions."
Commonwealth Edison Company has committed, to ANSI Nl8. 7-1976 through
Regulatory Guide 1.33 Revision 2, as stated in the Quality Assurance
Program Topical Report, CE-1-A.
- 23 -
ANSI Nl8.7-1976, Section 5.2.7.1 states in part ... "A preventive
maintenance program including procedures as appropriate for safety-
related structures, systems and components shall be established and
maintained which prescribes the frequency and type of maintenance to
be performed."
Contrary to the above requirement, the inspector observed that a
formal Preventive Maintenance Program does not exist . There exists
no Preventive Maintenance procedure whi~h will prescribe the frequency
and type of maintenance to be performed and no system to revise the
program based upon experience gained with the equipment.
Preventive maintenance is performed on an informal basis by individual
work sections as noted by the following examples.
(1)
Each operating crew has a lubrication program which is
administered from a card file by the Shift Foreman.
The
'
program features no written procedure, no controls _to assure
required frequencies are met, and no input to the maintenance
department concerning equipment conditions. -
(2)
The Maintenance Department's preventive maintenance program is
administered from a note book by a secretary:
This program also
features no written procedure, no controls to assure required
- frequencies are met, and no input to a trend or equipment analysis
system.
c.
Discussion
During the_ review of Nuclear Work Requests, the inspector ob~erved
that an Operating Engineer was *not checking the "Tech Spec Req."
block, and it was not being noted during QC-QA review.
Further
investigation showed that the meaning of "Tech Spec Req.", as
described in the Total Job Management Manual, was unclear to li-
censee personnel.
The licensee agreed to obtain an interpretation
from the licensee's headquarters and to assure the form is filled
out in the future.
During observation and review of work being done by a contractor,
Mechanical Incorporated, the inspector observed that the contractor
was not adequately following the licensee's Procedure QMP 100-3 Fire
Prevention for Welding and Cutting.
The QA/QC control of the con-
tractor's procedures, qualification of personnel, material storage,
- and acceptability of final product was acceptable, but during the
work process the contractor appears to require additional surveillance.
This was identified as an item of noncompliance in IE Inspection
Report No. 50-254/81-04 and 50-265/81-04.
Section 16.0 of the Quality Assurance Program Topical Report,
CE-I-A, states that for Operations, corrective action identified
from nonconformances, incidents, and deviations, trend studies
- 24 -
/
and audits are verified for satisfactory completion to preclude
repetition.
QP 15-53 assigns the responsibility to the Technical
Supervisor to be cognizant of and analyze significant trends
reported by the Discrepancy Record System.
The licensee does not
have a specific system to analyze Discrepancy Report trends.
Discrepancy Records 1382 and 1416 show that items were used "like
for like" on safety related equipment, without a Quality Assurance
Receipt Inspection, under the control of Work Requests Q08701 and
Q10471.
The relatively large number of Discrepancy Record.s of this
type (2) in a random sample of 25 Work Requests plus conversations
with personnel in the Maintenance and Technicai Departments leads
the inspector to believe that not all personnel know how to determine
if a part to be installed in a safety related system requires a
Quality Assurance Rece~pt Inspection and the accompanying red tags.
The lack of knowledge could cause a problem in the future, if key
personnel are not available, as it appears some personnel are operat-
ing from memory on a "that's the way it's always been" attitude,
rather than referring to the source document.
Dependence on personnel
rather than procedures, and the* effect on operations if key personnel
were not available or lost, due to attrition, was discussed with the
licensee.
The licensee disagreed that the plant could have a problem
if key personnel left, and stated that their plant has shown equally
efficient and safe operation after key personnel had left and the
plant h~d adequate procedures to carry on operations with turn-over
of personnel.
15.
Nonroutine Reporting Program
The inspector reviewed the licensee's program to ascertain that
responsibilities have been assigned for the review of events and
activities to assure reports of a nonroutine nature will be submitted
in conformance to the applicable regulatory requirements.
a.
Documentation Reviewed
Tecl:µiical Specification 6.3
Station QA Manual, 2/16/81, QP 10-52, Inspections for Operations -
Station Operations
Station QA Manual, 2/16/81, QP 10-53, Inspections for Operations
Technical Support Surveillance and Inspection
Station QA Manual, 2/16/81, QP-10-54, Inspections for Operations -
Receiving Inspection
Station QA Manual, 2/16/81, QP 15-51, Nonconforming Materials,
Parts and Components for Operations - Spare Parts and
Materials
Station QA Manual, 2/16/81, QP 15-52, Nonconforming Materials,
Parts and Components for Operations - Deviation and Comments
- 25 -
16.
b.
Station QA Manual, 2/16/81, QP 15-53, Nonconforming Materials,
Parts and Components for Operations - Inspection and Test
Station QA Manual, 2/16/81, QP 16-51, Corrective Action for
Operations - Corrective Action System
QAP 1200-1, Rev. 7, 10/23/80, Deviation Report Procedure
QAP 1200-2, Rev. 4, 10/23/80, 10 CFR ~art 21, Reporting of
Defects and Noncompliance
QAP 1220-1, Rev. 7, 2/4/81, Station Discrepancies
QAP 1220-2, Rev. 2, 7/29/76, Nonconforming Materials, Parts,
and Operations
QAP 1220-3, Rev. 1, 9/5/75, Corrective Action for Nonconforming
Items and Operational Discrepancies
QAP 1250-1, Rev. 2, 7/29/76, Action Item Program
QAP 1250-2, Rev. 1, 9/05/75, Station Report
QAP 1250-3, Rev. 6, 12/1/79, Action Item Procedure
QAP 1290-1, Rev. 6, 8/06/80, Reporting Requirements Procedure
Findings
No items of noncompliance were identified.
Housekeeping and Cleanliness Control
The inspector reviewed the licensee's housekeeping and cleanliness
control programs and activities to ascertain whether the licensee is
implementing adequate housekeeping and cleanliness controls to assure
that the quality of safety systems is not degraded.
a.
Documentation Reviewed
QAP 200-13, Station Housekeeping Organization
QAP 600-6, Receiving, Handling, and Storage of Items -
Routing of Documents
QIP-1, Opening Process Instrument Lines
QFP 100-6, Refueling Shift Checks
QMP 100-1, Working Over the Reactor Core
QMP 100-3, Fire Prevention for Welding and Cutting
b.
Findings
(1)
Noncompliance (50-254/81-03-01; 50-265/81-03-01)
10 CFR 50, Appendix B, Criterion II, states in part, "The
applicant shall establish at the earliest practical time,
consistent with the schedule for accomplishing the activities,
a quality assurance program which complies with the requirements
of this appendix.
This program shall be documented by written
policies, procedures, or instructions and shall be carried out
throughout plant life in accordance with these policies, pro-
cedures, or instructions."
- 26 -
I
Commonwealth Edison Company has committed to ANSI NlB.7-1976
through Regulatory Guide 1.33 Revision 2, as stated in the
Quality Assurance Program Topical Report, CE-1-A.
ANSI NlB.7-1976, Section 5.2.10 states that ANSI N45.2.l-1973
and ANSI N45.2.3-1973 shall be applied to activities occurring
d¥ring the operational phase that are comparable in nature and
extent to related activities occurring during construction.
Contrary to the above, the licensee is not implementing
ANSI NlB.7-1976 ,as shown by the following examples.
(a)
The licensee does not have a method to assure that fluid
system cleanliness is maintained in accordance with
ANSI N45.2.l-1973 as noted by the following examples:
1.
The licensee has not cla&sified it's equipment to
a cleanliness classification, planned cleanliness
control activities for cleaning and inspection
operations, and has not established procedures or
work instructions for cleanliness control practices
and inspections as required by Paragraph 2 of
ANSI N45.2.l-1973.
2.
QMO 100-1, Revision 1, July 1975 - Work Over Reactor
Core, does not reference ANSI N45.2.1-1973 and
does not mention fluid system cleanliness.
(b)
The licensee does not have a method to.assure that
housekeeping is maintained in accordance with ANSI
N45.2.3-1973.
c.
Discussion
1.
QAP 200-13, Revision 4, March 1979 does not establish
cleanliness requirements for housekeeping activities
on the basis of zone designations, as required by
Paragraph 2.1 of ANSI N45.2.3-1973.
The licensee is presently implementing it's fluid system cleanliness
and corresponding housekeeping program through the station traveler
and craft capability.
A check of the training records for mechanics
failed to produce documentation of any formal training course in fluid
system cleanliness ana the associated housekeeping requirements.
This
method does not establish a particular level of cleanliness or mention
the controls to be used to achieve it.
17.
Corrective Action Program
The inspector reviewed this area to verify that measures have been
established to identify and correct conditions adverse to quality.
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a.
Documentation Reviewed
Unit 2 Control Ro6m Log 1/18 to 2/19/81
Unit 1 Control Room Log 2/2 to 2/25/81
DVR Log 1980 - 1981 to date
QP 15-51 Nonconforming Materials, Parts, and Components for
Operations
QP 15-52 Nonconforming Materials, Parts and Components for
Operations - Deviations and Comments (SIC)
QA Policy 16.0 Corrective Action
QP 16-51 Corrective Action for Operations - Corrective Action System
QAP 1200-1 Deviation Report Procedure
QAP 1200-2 Reporting Defects and Noncompliance
QAP 1250-1 Action Item Program
QAP 1290-1 Reporting Requirements Procedure
b.
Findings
c.
No items of noncompliance or deviations were discovered as the
result of this portion of the inspection.
Paragraph 13 contains
an item of noncompliance where a deviation report (DVR) should
have been initiated.
Discussion
The licensee's system is rather narrow with a fairly high threshold .
The primary emphasis appears to be identifying and reviewing events
for reporting to the NRC.
The DVR report form does not even mention
corrective action.
Corrective action is tracked either in the Action
Item Record program or in the DVR log.
There is no specific written
assignment of responsibility to track the corrective actions in the
DVR log.
There is some trend analysis conducted for DVR's, but it is only
a review of past DVR's.
The system, based upon the lack of significant inspection findings,
appears to be *functioning.
The inspector believes the system to be
marginally acceptable for the following reasons:
(1)
High threshold tends to leave problems within departments without
establishing an unbiased review process.
(2)
Tracking corrective action externally to the DVR makes the
system somewhat cumbersome and it could break down in times of
high use.
The inspector could find no instances where the above occured, but
believes th~ system is vulnerable to these types of failures.
The
above was discussed with the licensee.
He believes the system is
acceptable as it is.
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18.
Unresolved Items
Unresolved items are matters about which more information is required
in order to ascertain whether they are acceptable items or items of
noncompliance.
Unresolved items disclosed during the inspection are
discussed in paragraphs 6c, 7c, and 8c.
19.
Exit Interview
The inspectors met with licensee representatives (denoted in paragraph 1)
at the conclusion of the inspection on March 13, 1981.
The purpose and
scope of the inspection were summarized and the inspectors then discussed
the enforcement findings in each area.
These findings had been previously
discussed with licensee representatives during meetings held throughout
the inspection .
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