ML17321A686
| ML17321A686 | |
| Person / Time | |
|---|---|
| Site: | Cook  |
| Issue date: | 06/14/1985 |
| From: | Alexich M INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG |
| To: | James Keppler NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| Shared Package | |
| ML17321A685 | List: |
| References | |
| AEP:NRC:0935, AEP:NRC:935, NUDOCS 8506270511 | |
| Download: ML17321A686 (17) | |
Text
INDIANA8 NICHIGAN ELECTRIC CONPANY P.O. BOX 16631 COLUMBUS, OHIO 43216 June 14, 1985 AEP:NRC:0935 Donald C. Cook Nuclear Plant Nos.
1 and 2
Docket Nos.
50-315 and 50-316 License Nos.
DPR-58 and DPR-74 NRC Report Nos.
50-315/85007(DRS) and 50-316/85007(DRS)
Mr. James G. Keppler U.S. Nuclear Regulatory Commission Region III 799 Roosevelt Road Glen Ellyn, IL 60137
Dear Mr. Keppler:
This letter is in response to Mr. R. L. Spessard's letter dated April 29, 1985, which forwarded the subject Inspection Reports of the special safety inspection conducted by your staff at the Donald C.
Cook Nuclear Plant and AEPSC Corporate Offices during the period February 4-7, 25-28, March 1', 4-8, 11-15, and 25-29, 1985.
The Notice of Violation attached to Mr. Spessard's letter identified two violations of 10 CFR 50, Appendix B.
An extension to June 14, 1985 for the response to these violations was granted by Mr. F. Hawkins on May 29, 1985.
The responses to these violations are addressed in the Attachment to this letter.
This document has been prepared following Corporate procedures which incorporate a reasonable set of controls to insure its accuracy and completeness prior to signature by the undersigned.
Very truly
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John E. Dolan W. G. Smith, Jr.
Bridgman R. C. Callen G. Charnoff NRC Resident Inspector - Bridgman G. Bruchmann JUil 1 g Igg
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ATTACHMENT AEP:NRC:0935 Responses to Notice 'of Violation NRC Report 50-315/85007(DRS);
50-316/85007(DRS)
ITEM NO.
1 "10 CFR 50, Appendix B, Criterion XVI, as implemented by th'e D. C.
Cook Operations Quality Assurance (QA) Program, requires that measures be established to ensure that conditions adverse to quality are promptly identified and corrected.
Contrary to the above, the inspector identified the following:
a ~
Failure to issue Action Requests where preventative or correc-tive action was necessary.
(315/85007-04A; 316/85007-04A) b.
Failure of the QA organization to perform timely follow-up of items in the Open Item Internal Staff Report.
(315/85007-04B; 316/85007-04B) c ~
Failure to ensure that deficiencies identified during audits are promptly corrected.
(315/85007-04C; 316/85007-04C) d.
Failure to ensure that items included in the Action Item Tracking System are corrected as scheduled.
(315/85007-04D; 316/85007-04D) e.
Failure to provide an effective trending program as required by ANSI N18.7-1976.
(315/85007-04E; 316/85007-04E)
This is a Severity Level IV violation (Supplement I)."
NRC Re ort Details for Item l.a "QAP No. 19, Paragraph 3.5.1.(2) of Attachment No.
2, requires that action requests (ARs) be generated for each question that resulted in a deviation or nonconformance unless either adequate corrective or preventative action was completed during the audit or the AEPSC QA Supervisor determines that corrective/preventative actions would serve no useful purpose.
The inspector noted several instances where corrective or preventative action was necessary and an AR was not issued.
For
- example, the excessive backlog of condition reports (CR) was identified in Audit Report No. QA-84-16; inappropriately, an AR was not issued.
This failure to ensure that conditions adverse to quality are promptly identified and corrected in accordance with approved procedures is in violation of 10 CFR 50, Appendix B, Criterion XVI (315/85007-04A; 316/85007-04A)."
Response
to Item l.a It is our practice not to issue an action request when corrective and/or preventive actions are agreed upon with the auditee during the course of the audit.
These commitments and scheduled completion dates (when incomplete) are documented in the audits text for future verification.
An action request is normally generated when agreement relating to either the required actions or the schedule cannot be reached during the course of the audit.
This approach is a positive aspect of the. audit program since the auditee is afforded the option to devise a mutually agreeable plan for recovery while a finding is current.
Further, this approach reduces the auditee's paper flow while not increasing that of the QA Staff (i.e., monitoring a response due date vs.
an action due date).
In the case of Audit Report No. 84-16 an action request was not issued and the audit text failed to adequately define the necessary corrective actions required for recovery.
Preventive action was described in the audit text although a scheduled completion date was not obtained and documented.
CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED Based upon a May 14, 1985 discussion with Mr. H. A. Walker (Region III), we understand that the methodology of documenting committed actions in the text of audit reports in lieu of issuing an Action Request is not a concern.
However, Audit Report No. 84-16 did not provide an adequate description of the scheduled actions and is a concern.'he QA personnel involved with Audit No. 84-16 have reviewed the audit, report and the violation described above to assure a complete understanding of the associated problem.
The backlog of condition reports identified in this audit is.discussed under item l.c below.
CORRECTIVE ACTION TAKEN TO AVOID FURTHER NONCOMPLIANCE Our review of past audit reports has identified that more detail in the description of scheduled actions would be beneficial.
Therefore, Quality Assurance Procedure (QAP) No. 18.2 (Previously numbered QAP 19) is being revised to strengthen the requirements for clearly documenting commitments in the text of audit reports.
The procedure revision was approved on May 29, 1985.
Site QA audit personnel will be trained on.the procedure revision by June 28, 1985.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance should be achieved by June 28, 1985.
NRC Report Details for Item l.b "The inspector reviewed the plant quality assurance
'Open Item Internal Staff'eport issued on March 22, 1985.
This system is used to track due dates for QA followup on action requests and open items generated as a result of either audits or surveillances.
The inspector identified that fifty-four items in this report were past the scheduled due dates with due dates from September 1,
1984 through March 15, 1985.
Additionally, two items selected from the audit records were not listed in the report.
These failures to ensure that conditions adverse to quality are promptly corrected are in violation of 10 CFR 50, Appendix B, Criterion XVI (315/85007-04B; 316/85007-04B)."
Response
to Item l.b The Open Item Listing tracks many, items in addition to the Reaudit entries.
As a point of clarification, there were 39 reaudits past due, rather than 54, at the time of the inspection.
The term "reaudits",
as defined by QA, are those follow-up verifications resulting from commitments provided by the auditee.
These commitments are documented in,the audit text or Action Request Responses.
P CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED The 39 reaudits which were noted as past due for verification during this inspection have now been completed.
CORRECTIVE ACTION TAKEN TO AVOID FURTHER NONCOMPLIANCE Additional personnel have been reassigned to support the reaudit effort in the future.
In addition, the QA administrative procedure governing the daily maintenance of the open item list has been modified to strengthen the reaudit process with emphasis on keeping the list current.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance was achieved by May 31, 1985.
NRC Report Details for Item l.c "The inspector noted that as of February 28,
- 1985, 2131 CR's were open.
These open CR's dated back several years and the large backlog appeared to be impacting their timely review by the PNSRC and NSDRC.
For example, CR12-12-83-1342 was submitted to the PNSRC for review on February 14, 1984; PNSRC review had not been completed as of March 29, 1985.
As of February 28, 1985, the PNSRC had a backlog of 1213 open CR's for review.
In another
- example, during the February 21, 1985, meeting of the NSDRC subcommittee on corporate and plant occurrences, problems-were noted with the action taken to resolve CR1-10-82-676.
This CR was sent back for additional action more than two years after it was written in October 1982.
The number of open CR's increased from 979, in July
- 1984, (as documented in QA audit report QA-84-16) to the 2131 total open at the end of February 1985.
During the inspection, the inspector noted that the number of open CR's was increasing at more than 100 a month.
In reviewing audit reports, the inspector noted that the untimely review of CR's had been documented by the licensee in audit NSDRC-95 (December 1983),
audit NSDRC-105 (April 1984),
LRC Consultants appraisal of D. C. Cook and AEPSC support activities (May 1984),
and audit QA-84-16 (July 1984).
At the time of this inspection, the licensee had not taken appropriate corrective actions to resolve the identified deficiencies.
These failures to ensure that deficiencies idehtified as a result of audits are promptly corrected are in violation of 10 CFR 50, Appendix B, Criterion 'XVI (315/85007-04C; 316/85007-04C)."
Response
to Item l.c CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED We are currently expediting the closeout of the backlogged condition reports.
We will have all Unit 1 condition reports closed or evaluated prior to the Unit 1 startup following this year's refueling outage (approximately August 10, 1985).
All Unit 2 condition reports will be closed or evaluated by the end of the Unit 2 refueling outage (approximately February 1986).
The PNSRC evaluations will assure that any safety concerns related to plant start-up and operations are appropriately addressed.-
In addition, all condition reports initiated since the latter part of 1984 have been reviewed on a daily basis by a group composed of Department Superintendents to identify items of immediate safety significance
or recurring situations.
The condition reports are subsequently reviewed within the departments for potential safety concerns and corrective action.
CORRECTIVE ACTION TAKEN TO AVOID FURTHER NONCOMPLIANCE A tracking list will be established for condition report, open items requiring resolution.
This list will be reviewed periodically by the PNSRC.
We have requested in our letter AEP:NRC:0847E dated May 31,
- 1985, NRC approval of a change to our QA program.
Specifically we propose to modify the FSAR Section 1.7.16.2.2 to allow review of the investigation and closeout actions on condition reports by management other than the PNSRC.
Should this review determine potential Technical Specification violations or adverse implications for public health and safety, the report will be forwarded to the PNSRC for their review.
Only those condition reports reviewed by the PNSRC will be forwarded to the NSDRC for an independent evaluation of the reported condition.
QA audit oversight will be applied to ensure that this difference is being correctly applied.
This change will help to ensure that those condition reports which legitimately require PNSRC and NSDRC review receive adequate attention.
The reports not reviewed by the
- PNSRC, will involve items that are controlled but do not represent significant adverse conditions.
Until now these reports have been a substantial review burden, with no perceptible safety benefit.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance is expected to be achieved for the review of backlogged condition reports and establishment of a condition report open item list by the end of the current Unit 1 refueling outage.
In accordance with 10 CFR 50.54(a)(3)(iv) we will assume that the QA program change requested in our May 31, 1985 letter is acceptable as of August 1, 1985 unless you inform us to the
'ontrary.
If acceptable the QA program change should be implemented by August 31, 1985.
NRC Re ort Details for Item 1.d "The AEPSC action item tracking (AIT) system is used to track items pertaining to D. C. Cook.
This system includes commitments made as the result of NRC inspection reports, IE bulletins, IE information
QA audit findings (CARs) are closed when response commitments are entered in the AIT system.
A bi-weekly report of overdue action items and a monthly report of open action items are sent to the action assignees.
A review of the overdue action items report dated March 14, 1985, listed 112 past
~
e
>>I
due items.
Of these 112 overdue items, 5 were assigned to the D. C. Cook plant for action.
The other 107 were assigned to AEPSC support organizations.
Thirty-eight of these items were more than 3 months overdue, with 19 of them more than 6 months overdue and 10 of them overdue more than a year.
Because of the importance of the items included in the AIT system, it is imperative that appropriate corrective actions are taken on items as they become due.
These failures to ensure that conditions adverse to quality are promptly corrected are in violation of 10 CFR 50, Appendix B, Criterion XVI (315/85007-04D; 316/85007-04D)"
Response
to Item l.d Of the 112 overdue items listed in the NRC report, 99 are internal target dates for action items not dealing with findings of conditions adverse to quality and have no significant impact on the safety of the D. C.
Cook Plant.
In addition, 80 of the 99 items have now been closed, and the remaining have revised due dates.
The 13 remaining open items deal with actual CARs or Noncompliance Reports (NCRs) of which 10 are now closed.
The 3 remaining are under review and should be closed out by July 31, 1985.
- However, since the time of the inspection additional items have appeared on the AIT syst: em as late.
These items are also being reviewed and closed where possible on the same schedule.
Many of the overdue items in the AEPSC Action Item Tracking System were attributed to a lack of clarity in the procedure that resulted in delayed submittal or a failure to submit action item closeout information to the administrators of the system.
In addition, due dates were extended without the revised dates being provided to the administrators of the system to allow updating of the action item listing.
CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED The AEPSC Vice Chairman, Engineering and Construction has issued a
memorandum to all involved AEPSC Division Managers and the D. C. Cook Plant Manager directing that specific action be taken with respect to the Action Item Tracking System overdue items. 'his directive includes a mandate to close out the open items, or where this is not, possible,.to request a new due date.
These actions should be completed by July 31, 1985.
CORRECTIVE ACTION TO BE TAKEN TO AVOID FURTHER NONCOMPLIANCES AEPSC General Procedure No. 2.2, "Action Item Tracking System,"
will be revised by June 28, 1985 to clarify those areas of the procedure which lead to a backlog of overdue items.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance should be achieved by July 31, 1985.
NRC Re ort Details for Item l.e "The inspector also reviewed other trending activities.
The trending of operating parameters is being performed by the shift technical advisors.
Also, the NSDRC subcommittee on corporate and plant occurrences prepares graphs of the total numbers of condition reports, licensee event reports and personnel error reports.
Upon requests, plant quality control will perform a search of condition reports for specific types of repetitive occurrences.
None of these activities provide trending by cause, type of failure, manufacturer, or system affected as is necessary to comply with paragraph 4.1.(4) of ANSI N18.7-1976.
These failures to provide a trending program that will promptly identify repetitive conditions adverse to quality so that the cause can be determined and appropriate action taken is in violation of 10 CFR 50, Appendix B, Criterion XVI (315/85007-04E; 316/85007-04E)
Response
to Item l.e CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED A common corrective action program for AEPSC and the D. C. Cook Plant is under development and is about to enter a test phase to ascertain its effectiveness and workability.
This program will use common, indepth cause coding which will enable us to trend appropriate management'nformation for corrective action reports.
CORRECTIVE ACTION TAKEN TO AVOID FURTHER NONCOMPLIANCE AEPSC and the D. C. Cook Plant have established a joint effort to develop a more comprehensive trending program.
Presently, our computer hardware and software at the Cook Plant have been upgraded to handle the trending of approximately 40 key operational parameters.
Companion hardware for this system has been ordered and should be installed at the AEPSC offices by August 1, 1985.
This computer system will provide a direct link b'etween AEPSC and the D. C. Cook Plant.
As discussed
- above, a common corrective action program will provide a detailed list of indepth cause codes for corrective action reports.
Cause code data extracted from these reports will then be entered into the computer system to provide trend information for management review.
The Nuclear Plant Reliability Data System coordinated by the Institute of Nuclear Power Operation will be used to perform equipment, failure trending.
8 DATE WHEN'FULL COMPLIANCE WILL BE ACHIEVED Computer hardware for this program should be installed at AEPSC by August 1, 1985.
An appropriate schedule for the remaining trending program will be developed as the computer system comes on line.
ITEM NO.
2 "10 CFR 50, Appendix B, Criterion V, as implemented by the D. C.
Cook Operations Quality Assurance
- Program, requires that activities affecting quality be performed in accordance with documented instructions and procedures of a type appropriate to the circumstances.
Contrary to the above, the inspector identified the following:
a.
Failure to issue site quality assurance audit reports within 30 days of the exit meeting as required by QAP No. 19.
(315/85007-05A; 316/85007-05A) b.
Failure to store Nuclear Safety and Design Review Committee (NSDRC) records as required by NSDRC Procedure VI.
(315/85007-05B; 316/85007-05B) c.
Failure to process Condition Reports in accordance with Plant Manager Instruction No. 7030.
(315/85007-05C; 316/85007-05C) d.
Failure to issue the annual trending and evaluation report on Condition Reports as required by procedure PMP-7030, RPT.
003.
(315/85007-05D; 316/85007-05D)
This is a Severity Level IV violation (Supplement I)."
NRC Report Details for Item 2.a "QAP No. 19, Paragraph 3.4.7 requires that site quality assurance audit reports be issued within 30 days of the exit meeting date.
Reports for Audit.
Nos. 84-14, 84-16, 84 18@
84 19'4 20@
84 22@
84-23, 85-01 and 85-02 were not issued within the 30 days
~
This failure to issue site quality assurance audit reports in accordance with procedure QAP No.
19 is in violation of 10 CFR 50, Appendix B, Criterion V (315/85007-OSA; 316/85007-05A)."
Response
to Item 2.a Because of the emphasis placed on audit report content, a
considerable amount of time was spent on the report write-up including editing and word processing.
This resulted in violation of the thirty (30) day issue requirement.
)
CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED The audits in question have been issued..
CORRECTIVE ACTION TAKEN TO AVOID FURTHER NONCOMPLIANCE In order to prevent future such occurrences, we plan to streamline the audit reporting process without sacrificing the quality of the reports or minimizing the comprehensive information contained within them.
A streamlined audit report format and corresponding procedure revision should be completed by June 28, 1985.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance has been achieved in that the audits in question have been issued.
The procedure should be revised by June 28, 1985.
NRC Report Details for Item 2.b "Paragraph E-1 of the NSDRC Procedure VI ("NSDRC Records" ), requires that two concurrent files be maintained for NSDRC records.
It further states that both files shall consist of the full inventory of NSDRC records.
The NSDRC working files are maintained by the NSDRC recording secretary and the master file is maintained at the D. C. Cook plant.
When reviewing this file at D. C. Cook, the inspector noted that 43 of the 48 regular meeting minutes were missing.
This failure to store NSDRC records in accordance with NSDRC Procedure VI is in violation of 10 CFR 50, Appendix B, Criterion V (315/85007-05B; 316/85007-05B)."
Response
to Item 2.b CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED A master index and most of the NSDRC documents have been forwarded to the Plant for inclusion into the master file. All NSDRC meeting
~ minutes are available,
- however, some earlier subcommittee records mainly from 1974, 1975 and 1976 have not yet been found.
An internal NCR has been initiated accordingly.
CORRECTIVE ACTION TAKEN TO AVOID FURTHER NONCOMPLIANCE Subsequent inventories of the Plant NSDRC file will be compared to the master index for NSDRC records supplied by AEPSC.
The Plant NSDRC master file will be subjected to future NSDRC audits.
10 DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Copies of the NSDRC records were received at the D. C. Cook Plant records center on June 12, 1985.
NRC Report Details for Item 2.c "Plant Manager Instruction No. PMI-7030 provides time limits that should be met in the investigation and processing of condition reports (CRs).
The procedure also requires that a request for extension of'ime be submitted to quality control if required action on the CR cannot be completed within the specified time.
In these
- cases, a copy of the CR is required to be submitted which specifies the estimated completion date and the reason the extension is necessary.
The inspector identified a February 28,
- 1985, memorandum which requested the extension of completion dates for 96 CRs.
The memorandum provided neither a copy of the CR which specified the estimated completion date nor the reason the extension was necessary.
These failures to process CRs in accordance with Procedure PMI-7030, are in violation of 10 CFR 50, Appendix B, Criterion V (315/85007-05C; 316/85007-05C)."
Response
to Item 2.c CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED We are currently expediting the review and closeout of all condition reports including the 96 identified in the February 28, 1985 memorandum (See
Response
to Item l.c).
CORRECTIVE ACTION TAKEN TO AVOID FURTHER NONCOMPLIANCE On May 31, 1985 we requested NRC approval of a change to our quality assurance program (See
Response
to Item l.c) that we believe will expedite and streamline the review process for all condition reports.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED Full compliance for the review of all open condition reports should be achieved by the end of the 1985 Unit 1 and Unit 2 refueling outages respectively.
NRC Reports Details for Item 2;d "Trending activities being performed in accordance with Procedure PMP-7030 RPT.003
("Review and Trending of Condition Reports by Shift Technical Advisors" ), were reviewed.
This procedure requires that a yearly analysis of CRs be performed and that a yearly report on this analysis be prepared and issued.
The analysis is performed using closed CRs.
The analysis and report for 1982 were reviewed.
No analysis or reports for 1983 and 1984 had been prepared or were in progress.
The inspector was informed that the number of CRs presently being issued prohibited the analysis and the preparation of this report.
This failure to issue the annual report on trending and evaluation of CRs as required by Procedure PMP-7030 RPT.003 is in violation of 10 CFR 50, Appendix B, Criterion V (315/85007-05D; 316/85007-05D)."
Response
to Item 2.d CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED We will continue to review all condition reports on a daily basis by a group composed of Department Superintendents.
This group identifies items of an immediate safety significance or recurring situations.
The condition reports are subsequently reviewed within the responsible department, for potential safety concerns and corrective action.
~ This daily review is helpful in identifying recurring problems that may need additional attention.
CORRECTIVE ACTION TAKEN TO AVOID FURTHER NONCOMPLIANCE Plant Manager Procedure 7030.RPT.003 will be revised by October 1, 1985, to provide quarterly trend data to the PNSRC consistent with published INPO practices on management trending.
These trends will include data to allow management to assess the corrective action program.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED PMP 7030 RPT.003 will be revised by October 1, 1985.