ML18046A514
| ML18046A514 | |
| Person / Time | |
|---|---|
| Site: | Palisades  |
| Issue date: | 02/06/1981 |
| From: | Baker K, Gildner M, Jackiw I, Schulz R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML18046A511 | List: |
| References | |
| 50-255-80-20, NUDOCS 8103190278 | |
| Download: ML18046A514 (31) | |
See also: IR 05000255/1980020
Text
U.S. NUCLEAR REGULATORY COMMISSION
OFFICE OF INSPECTION AND ENFORCEMENT
REGION III
Report No. 50-255/80-20
Docket No. 50-255
Licensee No. DPR-20
Licensee:
Consumers Power Company
212 West Michigan Avenue
Jackson, MI
49201
Facility Name:
Palisades Nuclear Generating Plant
Inspection At:
Covert, Michigan and Jackson, Michigan
Inspection Conducted:
November 3-26, December 1-5, 1980
Inspectors: ~~
- 1!7-1! ___ Jt.~t~
- >i
- Jir .... 1 Jackiw
//
~9f(_A...t1
R. D. Schulz
~--*
f M. L. Gildner
__
Approved By: ~
Nuclear Support Section 2
Inspection Summary
and January 16, 1981
-zjp;
/-S- 6!
2 -s-(f I.
- 1
- ~dd-1
I
Inspection on November 3-26, December 1-5, 1980 and January 16, 1981 (Report
No. 50-255/80-20)
Areas Inspected:
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 experiments; procurement control;
document control; offsite review committee; audits; test and measurement*
equipment; surveillance and calibration; maintenance; nonroutine reporting;
and corrective action.
The inspection involved a total of 353 inspector-hours
onsite by four NRC inspectors including 0 inspector-hours onsite during off-
shifts.
The total inspector-hours also included 50 hours5.787037e-4 days <br />0.0139 hours <br />8.267196e-5 weeks <br />1.9025e-5 months <br /> of inspection at
the licensee's corporate office by three NRC inspectors.
Results:
Of the fifteen areas inspected, no apparent items of noncompliance
or deviations were identified in six areas, ten items of noncompliance were
identified in nine areas (failure to reference applicable regulatory require-
ments in procurement documents - paragraph 7; failure to follow procedures
regarding nonconforming material reports - paragraph 8; failure to establish
measures for record control - paragraph 9; failure to provide timely review
of temporary procedure changes - paragraph 10; failure to control revisions
to drawings - paragraph 10; failure to adequately control purchased material
- paragraph 7; failure to perform required audits - paragraph 12; failure to
adhere to a technical specification requirement - paragraph 15; failure to
adhere to procedures - paragraph 6; and failure to implement corrective action
measures - paragraphs 15 and 17) .
- 2 -
DETAILS
1.
P~rsons Contact~d
R. W. Montross, Plant General Manager
H. J. Palmer, Technical Superintendent
G. G. Butler, I & C Engineer
C. H. Gilmer, Maintenance Superintendent
R. E. Mc Caleb, Quality Assurance Administrator
W. S. Skibitsky, Operation Superintendent
J. S. Rang, Operations/Maintenance Superintendent
G. C. Cheeseman, Quality Control Supervisor
M. M. Wilson, GPMD Field Representative
E. C. Huss, Material Services Supervisor
J. H. Dearth, I & C Supervisor
J. W. Roe, Calibration Supervisor
P. Wick, Document Control Center Supervisor
N. Hough, Training Supervisor
R. E. Mieras, Shift Supervisor
C. Thomas, Mechanical Maintenance Supervisor
J. F. Firlit, Director, QA-NO
J. J. Fremeau, QA Administrator - General Office
D. A. Bixel, SARE Chairman
D. P. Hoffman, Nuclear Licensing Administrator
S. R. Frost, Assistant Nuclear Licensing Administrator
P. T. Howe, Instrument and Measurement Services Supervisor
V. A. Anderson, Procurement Manager
K. W. Berry, Nuclear Activities - General Office
The inspectors also interviewed other licensee employees including
engineering and administrative personnel .
. On January 16, 1981, a management meeting was held in Consumers Power
Company corporate office in Jackson, Michigan.
The purpose of the
meeting was to discuss the findings identified during the Quality
Assurance inspection.
Attendees included the following:
NRC Region III
K. R. Baker, Chief, Nuclear Support Section 2
I. N. Jackiw,. Reactor Inspector
R. D. Schulz, Reactor Inspector
Consumers Power Company
R. B. DeWitt, Vice President, Nuclear Operations
J. G. Lewis, Director, Nuclear Services Department
J. F. Firlit, Director, Quality Assurance
D. A. Bixel, SARE Chairman
D. P. Hoffman, Licensing Administrator
- 3 -
S. R. Frost, Palisades Licensing Engineer
J. J. Fremeau, Quality Assurance Administrator
R. E. Mc Caleb, Palisades Quality Assurance Administrator
T. L. Briningstool, CPCo Testing Lab
F. S. Rettenhouse, Manager, Lab Services
J. A. Schneider, Manager,.Construction (GPMD)
2.
Licensee Action on Previous Inspection Findings
(Closed) Unresolved Item (50-255/78-30):
Reporting complet{on s~atus
of "open" items to SARE.
The inspector found that all open items are
reviewed during each quarterly SARE meeting.
(Open) Unresolved Item (50-255/78-30):
Auditing of QA Program for
adequacy as apposed to status. Refer to discussion in section 3 of
this report.
(Open) Unresolved Item (50-255/78-30):
Ballot type review process
used by SARE and PRC.
Refer to discussion in section 11 of this report.
(Closed) Unresolved Item (50-555/78-30):
Adequacy of jumper control
program vs. ANSI N18.7 requirements.
The following items were verified
by the inspector:
(1) jumpers used during non-routine operating, test
and maintenance functions are documented on a Jumper, Link and Bypass
Control Checklist.
Independent verification of jumper placement and
removal is performed at the time that tags are placed on the affected
equipment and (2) with regard to testing requirements, placement and
removal operability checks are performed.
These activities are documented on the Juinper Control Checklist.
3.
QA/QC Administrative Program
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
QAPP No. 2, Quality Assurance Program
QAPP 2-52, Classification of Safety-Related Items and Operational
Safety Actions
QADPII-3, Review of Q-List
QADPV-1, Preparation, Review and Revision of Quality Assurance
Department Procedures and Program Procedures for
Operations
b.
Findings
No items of noncompliance or deviations were identified.
- 4 -
-
c .
Discussion
During a management inspection conducted by the Performance
Appraisal Branch (Inspection Report 50-255/78-30), it was noted
by the inspection team that the licensee was not evaluating the
adequacy (effectiven~ss) of their QA Program.
The licensee had
periodically used an outside contractor to perform a corporate
audit of the implementation of its program, but these corporate
audits did not assess the adequacy of the QA Program in achieving
its objectives.
This issue has not been resolved and is still identified as an
unresolved item.
Also, during discussions with licensee personnel the inspector
was informed that the licensee is in the process of revising
the Quality Assurance Program Policy Manual.
The revision will
include many changes to the program and will require submittal
to the NRC prior to implementation.
The inspector reviewed a draft copy of Quality Assurance Policy 1
and noted that one change being considered by the licensee is to
give the QA Department authorization to stop work to achieve the
appropriate corrective action.
The current revision states that
the QA Department can only recommend stoppage of.work.
4.
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 w_as
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
b .
QAPP No. 2, Quality Assurance Program
QAPP 2-54, Training for Operations
QADP 11-1, Training and Indoctrination of Quality Assurance
Department Personnel
QADP 11-2, Quality Assurance Indoctrination and Training of
Personnel
AP 130, Master Training Plan
Findings
No items of noncompliance or deviations were identified.
- 5 -
c .
Discussion
QADP II-1, provides instructions for the indoctrination and
training of Quality Assurance - Nuclear Operations (QA-NO) De-
partment personnel.
With regard to QC personnel, this procedure
states that Quality Control personnel are trained and certified
according to applicable sections of the plant manual and that the
QC Supervisor is certified a Level III by the Director, QA~No.
The inspe_ctor noted that the QC Supervisor is certified a
Level II and not a Level III as required by the department proce-
dure.
This observation was discussed with licensee representatives
during the exit interview.
Also, during the *exit interview, the
inspector stated this is an example where requirements are imposed
on the plant without an apparent evaluation of what impact the
requirement has.
5.
Design Changes and Modification Program
The inspector reviewed the Design Change and Modification Program to
ascertain whether the licensee is implementing a QA program that is in
conformance with the Consumers Power Company Quality Assurance Program,
ANSI Nl8.7 and 10 CFR SO, Appendix B.
The review of documents, listed below, included a verification of the
following:
Procedure to control design and modification requests have been
established.
Procedures and responsibilities for design control have been
established.
Responsibilities and controls to assure that design changes and
modifications will be incorporated into plant procedures and plant
drawings have been established.
Channels of communication between design organizations and responsible
individuals have been established.
Controls requiring that** implementation of approved design changes be
in accordance with approved procedures have been established.
Methods for reporting design change/modification to the NRC in
accordance with 10 CFR 50.59 have been established.
a.
Documentation Reviewed
QAPP No. 3, Design Control
QAPP 3-51, Design Control
QAPP 3-53, Minor Modification, Specification Field Changes and
Set Point Changes
-
6 -
QAPP 6-52, Distribution and Revision Control of Design Documents
QAPP 10-51, Maintenance and Minor Modification Inspection
QCP-P-09, Facility Change Completion Review
QADP-III-1, Review of Design Change Documents
AP 9.1, Plant Modifications - Minor
AP 9.2, Equipment Specifications and Minor Field Changes
b.
Findings
No items of noncompliance or deviations were identified.
c.
Discussion
'
The inspector found that on April 28, 1980, Maintenance Order (MO)
80-EPS-053 was performed to correct a problem where the plant
diesel generators 1 and 2 failed to auto start during a turbine
trip function on CL-36.
The cause of the problem was the failure
of the 362 AST relay.
The corrective action taken during this
maintenance activity consisted of removing the failed 362 AST
relay and replacing it with two Agastat relays 362 R/AST and
362 L/AST.
This installation required that these relays be
rewired and that drawings E-121 and 950SB9 be revised.
During the review of this maintenance package, the inspector was
unable to determine that a SFC was initiated.
The SFC was not
noted on the HO located in the maintenance department files.
Prior to the conclusion of the inspection, the inspector was
informed that SFC 80-120 had been written for this MO.
No
problems were noted during the review of the SFC.
6.
Test and Experiments Program
The test and experiments program was reviewed to verify that the
established administ~ative controls and their implementation comply
with the applicable requirements specified in the Palisades Nuclear
Generating Plant Technical Specifications and 10 CFR 50.59.
a.
Documentation Reviewed
The following Quality Assurance Program Policies, Quality
Assurance Program Procedures for Operations, Palisades Nuclear
Plant Administrative Procedures, and Palisades Nucleai Plant
Engineering Manual 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; assignment of responsibilities for review
and approval of test and experiment procedures; establishment of
- 7 -
a system for review of proposed test and experiments to determine
whether they are described in the FSAR; assurance that a written
safety evaluation is developed for applicable test and experiments;
and assignment of responsibility for reporting al.l test and
experiments conducted pursuant to 10 CFR 50.59.
QAPP No. 11, Test Control
QAPP No. 20, Program Reporting
QAPP 11-51, Test Control for Nuclear Operations
AP 3.0, Review and Audit
AP 6.0, Technical Administration
AP 10-1, Appendix A-5 Working Procedures
EMP-14, Special Test Procedures
b.
Findings
Noncompliance
Palisades Nuclear Generating Plant Technical Specification para-
graph 6.8.1.C states that written procedures shall be established,
implemented and maintained covering surveillance and testing
activities of safety-related equipment.
Quality Assurance Program Procedure for Operations No. 11-51,
Test Control for Nuclear Plant Operations, Section 5.7 states
in part that special test or experiments are conducted in
accordance with written procedures.
Contrary to the above, Special Test T-131B for the Endurance Test
of Steam Driven Auxiliary Feedwater Pump P-BB was not performed in
full compliance with the approved procedure.
Step 5.5 required a
pump cooldown period of at least eight hours.
Test data was taken
after a cooldown period of seven hours and fifty five minutes.
Step 5.2 and Attachment 1, Test Equipment Data Sheet, are missing
verification signatures as required by the approved procedure.
The completed and signed off Administrative Review and Technical
Review did not note the above problems.
During discussions with plant personnel, the inspector emphasized
that the significance of this noncompliance was the lack of a
strong review process.
The completed special test procedure had
gone through three levels of review and the missing verification
signatures had not been identified as discrepancies .
- 8 -
c.
Discussion
Palisades Nuclear Plant Administrative Procedure No. 6.0, Technical
Administration, Section 5.3.1 requires that the Supervisor/Engineer,
charged with conducting a special test, will upon completion of his
review, prepare a report and forward copies to the Plant Super-
intendent, the Technical Superintendent, the Plant Review Committee
and the Special Test File.
Several tests which were performed over
six months previous to the inspection still had not had reports
written and on file.
The reports should be written within a
reasonably short period of time to preclude the loss of detail
not reflected in test data sheets.
7.
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, ~ncluding traceability to the item.
a.
Documentation Reviewed
QAPP 4-51, Procurement
QAPP 7-51, Supplier Evaluation and Selection
QAPP 7-52, Source Surveillance and Inspection
QADP IV-1, Review of Procurement Documents
QADP IV-2, Procurement of Materials and Services
QADP VII-1, Source Surveillance and Inspection
QCP~P-06, Source Inspection
CMP 13-1, Procurement Process - General
CMP 13-2, Procurement of Material
Policy No. 4, Procurement Document Control
Policy No~ 7, Control of Purchased Material, Equipment and Services
- 9 -
b.
Findings
Noncompliance
(1)
10 CFR SO, Appendix B, Criteria IV, states, "Measures shall
be established to assure that applicable regulatory require-
ments, design bases, 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 purchased by the applicant
or by its contractors or subcontractors.
To the extent
necessary, procurement documents shall require contractors
or subcontractors to provide a quality assurance program
consistent with the pertinent provisions of this appendix."
The following procurement documents did not reference a QA
program:
P. 0.
85378
30947
46324
23660
45113
1001-6797
1001-5489
1001-6960
1001-8792
1000-3215
1817913-Req. No.
1017944-Req. No.
1001-4411
1001-2796
1025786-Req. No.
1000-1463
1001-6528
UNIT
Sleeve Shaft
Motor
Motors
Shaft
Valve Discs/Disc Arm
Fittings
Fittings
Weld Rod
Valve
Impellars
Pump Shaft
0-Ring
Weld Rod
Fittings
Bevel Gear/Shaft Assy.
Dragon Valves (GPMD)
Asco Check Valve (GPMD)
USE
LPSI Pump
Diesel Engine Generator
LPSI Pump, Charging Pumps
HPSI Pump
Section III, NC, 1974
Section III, NB, 1974
Section III, NB, 1974
Steam Dump Valves
HPSI Pump *
Chemical & Volume Control
Section III, NGA
Section III, NB, 1974
Section III, NB, 1974
Control Rod Drive System
Recirc. Pump
Recirc. Pump Trip
The following procurement documents did not reference 10 CFR 21:
P.O.
ITEM
1001-6797
Fittings
1001-5489
Fittings
- 10 -
USE
Section III, NC, 1974
Section III, NB, 1974
1001-6960
Weld Rod
1001-8792
Valve
1000-3215
Impellars
Section III, NB, 1974
Steam Dump Valves
HPSI Pump
1017913 Req. No.
Pump Shaft
Chemical & Volume Control
1017944 Req. No.
0-Ring
1001-4411
Weld Rod
1001-2796
Fittings
Section III, NCA
Section III, NB, 1974
Section III, NB, 1974
(2)
Noncompliane
ITEi'l
10 CFR 50, Appendix B, Criterion VII states:
"Measures
shall be established to assure that purchased material,
equipment, and services, whether purchased directly or
through contractor and subcontractors, conform to the
These measures shall include pro-
visions, as appropriate, for source evaluation and selection,
objective evidence of quality furnished by the contractor
or subcontractor, inspection at the contractor subcontractor
source, and examination of products upon delivery.
The
effectiveness of quality by contractors and subcontractors
shall be assessed by the applicant or designee at intervals
consistent with the importance, complexity, and quantity of
the product or services.
Quali~y Assurance Program Policy No. 7 - Control of Purchased
Material, Equipment and Services states in section 3.2,
"Selection of suppliers is based on the quality assurance and
technical evaluations and the capability of t.he supplier to
provide established procurement requirements."
The following items did not meet the-procurement document
but were accepted and released for installation and use.
PURCHASE ORDER
NON CONFORMANCE
Sleeve Shaft
Plug valves
85378-Q
42604-Q
No certification to 316 S. S.
Certified to ASTMA-351 CF8M,
certification to 316 S. S.
was required.
11Nupro 11 valves
19144-Q
Certified to ASTM AS80,
certification to 316 L-Low
Carbon was required.
Two vendors, Midco Pipe & Tube and I.T.T. Harper were
placed on the approved vendors' list without the concurrence
of a quality assurance evaluation.
The quality assurance
-
11 -
evaluation on Midco Pipe & Tube, on September 8, 1978,
stated that Midco was only approved for non ASME B & PV
Code,Section III, pipe and fittings.
Midco was placed
on the approved suppliers' list for ASME B & PV Code,
Section III, pipe and fittings, and orders placed on
purchase order ~o. 's 1001-6797Q and 1001-5489Q for safety
related, code items.
Also, I.T.T. Harper was approved in
a quality assurance technical evaluation for nuts and bolts
only, but they were placed on the approved suppliers' list
for special extruded shapes and fasteners, in addition to
nuts and bolts.
In addition, Consumers Power. does not evaluate the effec-
tiveness of their suppliers quality assurance programs
either through analysis of nonconforming material reports,
for material received and inspected at the site, or through
inspections at manufacturing and supplier facilities.
c.
Discussion
Quality Assurance does not review the procurement document that
is sent to the vendor, but only reviews the initial document
for purchase.
Transposing errors that may occur concerning QA
program requirements are not checked by personnel with appropriate
training in the QA discipline.
Since the final document is sent
to the supplier, or vendor, the final document becomes the legal
document the supplier has contracted to, and is the reference
point for all subsequent communication between buyer and seller.
The final document is not checked by QA personnel until it is
received at site, and then it is checked against the initial
document by QC personnel*. for accuracy.
This may be a contributing
factor for errors in procurement documents, as the documents now
receive a single level of review by QA.
Section 5.7 of Quality Assurance Program Procedure 4-51, entitled
Procurement, discusses expedited procurement and does not estab-
lish criteria for accepting an item at site when purchased on an
expedited procurement basis.
The procedure implies that items
may be accepted for installation and used without determining
all requirements.
This concern was discussed with the Quality
Assurance Administrators at Jackson and Palisades, and they
indicated this concern would be addressed through a procedural
change indicating items would not be installed and used on a
significant risk basis without determining all requirements
beforehand.
The following procurement documents had deficiencies as noted
below:
- 12 -
Req. #1026159
Req. #1026013
Req. #1026159
Deficiency
Unapproved vendor.
Asked for certificate of compliance,
requires certified material test
report.
Penetrant Test does not
specify standard or acceptance
criteria.
No QA review.
The licensee needs to establish a uniform method for securing the
right of access with their suppliers.
8.
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 conditions, including shelf life.
a.
Documentation Reviewed
QAPP 7-53, Receiving Inspection
QAPP 8-51, Control of Materials for Operations
QAPP 13-51, Control of Handling, Storage, Shipping
QAPP 15-51, Control of Nonconforming Items
QAPP 15-52, Reporting Nonconformances During Major Modifications
QAPP 16-51, Deviation Reporting and Corrective Action
QADP XVI-1, Corrective Action Follow-up and Trend Analysis
QCP-P~04, Receipt Inspection
QCP-P-05, Processing of Nonconforming Material
CMP-13-3, Material Control
CMP-13-4, Nonconforming Material
CMP-13-5, Control of Weld Materials
- 13 -
I
. I
Policy No. 8, Identification and Contol of Materials, Parts and
Components
Policy No. 13, Handling, Storage and Shipping
Policy No. 14, Inspection, Test, and Operating Status
Policy No. 15, Nonconforming Items
Policy No. 16, Corrective Action
b.
Findings
Noncompliance
10 CFR 50, Appendix B, Criteria V states "Activities affecting
quality shall be prescribed by documented instructions, proce-
dures, or drawings, of a type appropriate to the circumstances,
and shall be accomplished in accordance with these instructions,
procedures or drawings."
Quality Control Procedure, QCP-P-05 Rev. 5, Processing of Noncon-
forming Material, states in paragraph 5.2.1: "Upon notification
from the stockman that materials which are not in an "Accept"
status have been requested for issuance, the QC Supervisor
reviews the appropriate receipt inspection file and NMR Logs
(i.e., receipt and source inspection) to verify that an NMR has
already been generated.
If no NMR exists, he initiates one in
accordance with Section 5.1.1 of this procedure, unless the
material is being issued for repair, rework, inspection or test
and is to b.e returned to the stockroom."
The following procurement documents identify items that were
released for installation on a conditional release basis, without
a nonconforming material report written concerning deficiencies
and inadequacies in documentation:
Procurement
Document
Item
Use
1001-0820
ccw Penetration
DY-150
Containment Spray Recir.
Line to SIRW Tank
DY-152
Safety Injection Tank
Drain Line
0006-0645
Gage Pressure
Subcooled Margin
Transmitters
Monitor
Plant Quality Control personnel confirmed that NMR's are not
written as required by Quality Control Procedure, QCP-P-05 .
- 14 -
9.
Records Program
The records program was reviewed to ascertain that the licensee is
implementing a program relating to the control of records that is
in conformance with regulatory requirements, Operational Quality
Assurance Program, ANSI N18.7 and ANSI N45.2.9.
Record storage
controls were reviewed along with 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.
T~e record index was examined and duplicate
storage was checked against the criteria of ANSI N45.2.9.
a.
Documentation Reviewed
Technical Specification, Section 6.10
QAPP 17-52, Collection, Storage and Maintenance of Quality
Related Records for Operations
QADP XVII-I, Collection Storage and Maintenance of Department
Records
Policy No. 17, Quality Assurance Records
QAPP 17-1, Quality Records
AP 11, Plant Records
b.
Findings
Noncompliance
10 CFR 50, Appendix B, Criteria XVII states in part " ... Consistent
with applicable regulatory requirements, the applicant shall estab-
lish requirements concerning record retention, such as duration,
location and assigned responsibilities."
Quality Assurance Program Procedure, 17-52, revision 3, Collection
Storage and Maintenance of Quality-Related Records for Operations
states "Records are stored according to ANSI N45 2.9 requirements,
as modified by QA Policy 2, for duplicate record storage locations."
Contrary to the above, the following completed records were not
duplicated:
(1)
Material Properties Records
(2)
Nonconformance Material Reports
(3)
Welding Filler Metal Material Reports
(4)
Certificates of Compliance
(5)
Maintenance Orders (1979-1980)
(6)
Personnel Training Records
(7) Facility Changes (1979-1980)
(8)
Specification Field Changes (1979-1980)
- 15 -
Duplicate records are required in lieu of fire protection vault
requirements of ANSI N45 2.9-1974.
10 CFR 50, Appendix B, Criteria XVII, state$ in_part " ... records
shall include closely-related data such as qualifications of
personnel."
Quality Assurance Program Procedure, 2-54, rev. 2, Training for
Operations states "Records of training are maintained to provide
evidence of personnel qualification, and to support certification
where such is required."
The technical superintendent was certified as a Level III,
according to ANSI N45 2.6, without records to justify or support
this qualification.
Furthermore, the technical superintendent
certified a Level II on March 5, 1980, in areas requiring specific
training, without records that maintained his own qualifications
in these disciplines.
These areas included:
(a) Receipt Inspec-
tions (b) Maintenance Inspections (c) Processing of Non-conforming
Material (d) Operations Testing Inspections (e) Source Inspections
(f) Special Activities Inspections (g) Maintenance Order Review
(h) Facility Change Completion Review and (i) New Fuel Receipt
Inspection.
c.
Discussion
Maintenance Orders, Facility Changes, and Specification Field
Change Records are kept for a two year period prior to duplicating
or microfilming.
Many of these records have been completed for
over a year, as the duplication process for 1979 records would
not occur till the end of 1980 or beginning of 1981.
Since a
permanent record storage vault has not been constructed according
to the fire code requirements of ANSI N45 2.9, duplicating or
microfilming is requ1red.
The time span for these reproducing
processes is too long to assure protection and preservation of
records.
10.
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 reviewed for current revisions, distribution lists,
and responsibilities assigned for implementation.
Quality Assurance
Program Manuals, Quality Assurance Department Procedures, Quality
Control Procedures, and as-built drawings were checked for current
revisions and distribution according to master indexes.
The control
room was additionally checked for current emergency procedures and
current P & ID's.
- 16 -
a.
Documentation Reviewed
QAPP 5-51, Development of Documents Controlling Quality Related
Activities During Operations
QAPP 6-51, Distribution and Control of Quality Related Documents
QAPP 6-52, Distribution and Revision Control of Design Documents
Policy No. 6, Document Control
QADP V-1, Preparation, Review and Revision of Quality Assurance
Department Procedures and Program Procedure for
Operations
QADP V-2, Development of Plant Quality Control Procedures
QADP VI-2, Processing and Control of Documents
AP 10-3, Document Distribution and Control
AP 10-3-1, Temporary Procedure Change
AP 10-4, Plant Drawings, Specifications and Instruction Manuals
Development
AP 10-5, Plant Drawings, Specifications and Instruction Manuals
Distribution and Control
AP 9.0, Plant Modifications - Major
b.
Findings
Noncompliance
(1)
10 CFR 50, Appendix B, Criteria VI, states in part "Measures
shall assure that documents, including changes, are reviewed
for adequacy and approved for release by authorized personnel
and are distributed to and used at the location where the
prescribed activity is performed."
Quality Assurance Program Policy No; 6, Revision 8, Document
Control, paragraph 3.1 states "A system for the preparation
of documents and revisions and their interdepartmental and
intradepartmental review, approval, and administration which
preclude the possibility of the use of outdated or inappro-
priate documents is defined by specific department procedures."
Document is defined in the QA*Program Manual as: "Instructions
procedures, drawings or other instructio-nal-type manuals or
material directly affecting a quality or safety-related
activity."
-
17 -
Contrary to the above, measures have not been established
to assure that changes to controlled drawings are distributed
and used at the location where the prescribed activity is
performed, to preclude the possibility of the use of outdated
or inappropriate documents.
The following controlled P & ID's used by the operators in
the control *room were not of the latest revision:
M-205/Rev. 28 is the latest revision.
M-208/Rev. 20 is the latest revision.
M-209/Rev. 23 is the latest revision.
M-210/Rev. 16 is the latest revision.
M-211/Rev. 28 is the latest revision.
M-213/Rev. 23 is the latest revision.
M-218/Rev. 22 is the latest revision.
M-219/Rev. 11 is the latest revision.*
M-220/Rev. 19 is the latest revision.
M...;224/Rev.
8 is the latest revision.
M-225/Rev. 11 is the latest revision.
The required red-lined changes were not on the control room
drawings.
However, all of the above drawings had red-lined
changes in the Document Control Center. It was confirmed
.with the shift supervisor that two sets of outdated drawings
were being used in the control room.
(2)
Technical Specification, Section 6.8, states in part:
" ... Temporary changes to procedures for surveillance and
testing activities of safety-related equipment may be made,
provided the change is documented, reviewed by the PRC at the
next regularly scheduled meeting and approved or disapproved
by the plant superintendent."
Contrary to the above, two test procedures, MI-2 and RI-2,
had temporary changes T-80~137 and T-80-138, respectively,
and were not reviewed by the Plant Review Committee at the
next regularly scheduled meeting.
Procedure MI-2 is
entitled Reactor Protective Trip Units, and procedure RI-2 is
entitled Thermal Margin/Low Pressurizer Pressure Channels.
These changes were reviewed in a later Plant Review Committee
meeting.
11.
Offsite Review Committee
The inspector reviewed the offsite review functions to ascertain
whether it is in accordance with Technical Specification requirements.
The inspection included a review of membership and qualifications,
subject matter, quorom requirements, safety evaluations and recom-
mendations, and frequency of meetings.
- 18 -
a.
Documentation Reviewed
QAPP No. 19, Program Review
QAPP 19-51, Safety and Audit Review Board Charter
b.
Fl.ndings
No items of noncompliance or deviations were identified.
c.
Discussion
During the management inspection conducted by the Performance
Appraisal Branch (Inspection Report 50-255/78-30), the inspectors
found that the licensee was using ballot type reviews for both
the PRC and the SARE.
The licensee was informed by letter from
Division of Operating Reactors dated July 12, 1979, that the
ballot type review does not conform with the position of NRR and
OI & E.
The licensee was also requested to review and propose a
Technical Specification change to bring the reviews by the
Palisades review committees into conformance with NRC positions.
In a letter from CPCO to D. L. Ziemann (NRR) dated September 12,
1979, the licensee stated that they are in the process of surveying
other utilities on how best to deal with the tremendous amount of
material being reviewed by ballot and that they intend to respond
more fully on this topic in about a month.
The licensee has not
yet responded.
At the exit meeting, the inspector stated that this item is being
reviewed by NRR.
The inspector also reviewed a number of SARB meeting minutes and
the following observations were made:
(1)
The Committee discussed the adequacy of "audits" and will
consider providing more guidance concerning the type of
information that needs to be contained in the audits.
(2)
Recurring problem areas at Palisades were discussed (i.e.,
problems in the training area which were identified during
audits conducted in 1976, 1977 and 1978; record storage
problems at Palisades).
(3)
The committee recommended that the audits specified by*
Technical Specifications be combined with QA audits.
And also that plants participate more in audit findings.
Based on the meeting minutes reviewed, the inspector concludes
that the SARB is adequately handling issues for which it is
responsible.
However, the inspector notes that some issues dis-
cussed by the SARB are not receiving timely attention regarding
corrective actions.
- 19 -
12.
Audits
The licensee's audit program was reviewed to ascertain whether the
licensee has developed and implemented a program that is in con-
formance with regulatory requirements and applicable industry guides
and standards.
The inspection included verification of the following:
scope of the program is consistent with Technical Specification
requirements; responsibilities for overall management of the program
have been assigned; and methods for identification and resolution of
audit findings have been defined.
a.
Documentation Reviewed
b.
c.
QAPP 18-51, Audits
QAPP XVIII-1, Audit Scheduling
Policy No. 2, Quality Assurance Program
Policy No. 18, Audits
QAPP 16-51, Deviation Reporting and Corrective Action
QAPP 16-52, Action Items
Findings
Noncompliance
10 CFR 50, Appendix B, Criteria XVIII, states, "A comprehensive
system of planned and periodic audits shall be carried out to
verify. compliance with all aspects of the quality assurance
program and to determine the effectiveness of the program: .. "
Quality Assurance Program Policy No. 18, states, "A representative
portion of the procedures and records related to each area is
audited during the scheduled period to assure a review of all
safety-related activities within a two-year period."
Contrary to the above, the audits performed for 1979 and 1980 did
not cover the entire QA Program, with the *audits scheduled for
1980 being only minimal and covering a very small portion of the
quality assurance program.
The following criteria of 10 CFR 50,
Appendix B, did not appear to be covered at all:
Criteria II, VII,
X, and XIII.
Discussion
A matter for consideration is the authority and responsibility
which is delegated to the Quality Assurance function and the
respective importance of the Quality Assurance audit group as
viewed by management.
-
20 -
The factor, communicated, was that upper management felt that many
QA findings were bothersome, insignificant, and too time consuming
at the plant level.
One of the audit reports stated, quite strongly,
that the QA auditors were worn down in trying to communicate with
management personnel and departmental supervisors at the Palisades
Plant.
Post audit conferences have been difficult to schedule by
Consumers Power QA auditors with Palisades Operational personnel,
due to a lack of interest in the audit program.
This is an area of concern and will be reinspected in future NRC
inspections.
Reference Audit Reports QP-78-10, QP-79-3, and
Nonconformance Report QG-79-1, dated 4/10/79.
13.
Test and Measurement Equipment Program
The program for control of test and measurement equipment was
reviewed to verify compliance with requirements of the Palisades
Nuclear Generating Plant Technical Specifications and Criteria XII
The inspection conducted at the corporate
office will also be applicable to the Big Rock Point plant'.
a.
Documentation Reviewed
b.
The following Quality Assurance Program Policies, Quality Assurance
Program Procedures for Operations, Palisades Nuclear Plant Admini-
strative Procedures and System Protection and Laboratory Services
Department Procedures were reviewed to verify that controls have
been established which set forth the criteria and responsibility
for assignment of calibration frequency; a formal requirement for
marking or 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; controls 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.
QAPP No. 12, Control of Measuring and Test Equipment
QAPP 12-51, Control of Portable and Laboratory Measuring and
Test Equipment
AP 17.0, Control of Measuring and Test Equipment
SPLS-07, Control of Measuring and Test Equipment
Findings
No items of noncompliance or deviations were identified .
- 21 -
the inspector.
The licensee indicated that data sheets
and procedures were also scheduled for review.
This area
will be reviewed during a subsequent NRC inspection.
15.
Maintenance
The inspector reviewed the licensee's Maintenance Program to ascertain
whether the QA Program relating to maintenance activities is being
conducted in accordance with the Quality Assurance Program, 10 CFR 50
Appendix B requirements, and commitments in the QA Program.
The_following items were considered during this review:
written
procedures 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 appropriate 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; and administrative controls for special
processes have been established.
The inspector also reviewed the licensee's Preventive Maintenance
Program and verified that a written program has been established
which includes responsibility for the program; a master schedule for
preventive maintenance; and documentation and review of completion
of preventive maintenance activities.
a.
Documentation Reviewed
QAPP No. 9, Control of Special Processes
QAPP No. 10, Inspection
QAPP 5-52, Documentation of Plant Maintenance
QAPP 9-51, Control of Special Process
QAPP 10-51, Maintenance and Minor Modification Inspection
QAPP 14-51, Operations Status Indicators - Tagging and
Documentation
AP 4.0, Operations Administration
AP 5.0, Maintenance Administration
b.
Findings
Noncompliance
10 CFR 50, Appendix B, Criterion XVI requires that in the case
of significant conditions adverse to quality, the measures shall
- 24 -
c.
Discussion
(1)
Storage of measuring and test equipment in the site I & C
shop was* cluttered and no attempt to separate controlled
calibration instruments from general test uncontrolled
equipment.
The licensee's audit program has identified
previous incidents where uncontrolled equipment was used
for calibrations.
Orderly storage of test and measuring
equipment with separation of controlled and uncontrolled
instruments could help prevent a reoccurrence of this type.
(2)
Inspection of the licensee's central instrument calibration
facilities found it to be in full compliance with both the
-requirements and intent of applicable industry standards
and regulatory requirements.
Its personnel appeared to be
qualified and dedicated to the program and its objectives.
14.
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 Palisades Nuclear Generating Plant
Technical Speci£ications and Criteria XI of 10 CFR 50, Appendix B.
a.
Documentation Reviewed
_The following Quality Assurance Program Policies, Quality
Assurance Program Procedures for Operations, Palisades Nuclear
Plant Administrative Procedures, and Palisades Nuclear Plant
Engineering Manual Procedures were reviewed to verify the estab-
lishment of a mechanism for:
scheduling of surveillance testing
and calibration of safety related components, rev1ew of completed
surveillance procedures and periodic activity procedures; and
maintaining the schedule to reflect system status.
QAPP No. 10, Inspection
QAPP No. 11, Test Control
QAPP 12-52, Control of Installed Plant Instrumentation
AP 5.0, Maintenance Administration
AP 17.0, Instrumentation Non-Conformance Action
AP 18.0, Surveillance Program Overview
AP 18.2, Procedure Scheduling and Issue
AP 18.3, Procedure Implementation
AP 18.4, Corrective Action
- 22 -
AP 18.5, Procedure Routing and Evaluation
AP 18.6, Procedure Filing and Record Storage
EM-09-01, Technical Sp~cificati6n Testing
b.
Findings
Noncompliance
Palisades Nuclear Generating Plant Technical Specification
paragraph 4.7.2.a requires that monthly the voltage of each cell
of the station batteries be measured to the nearest 0.01 volt and
recorded.
Contrary to the above, Technical Specification Surveillan*ce
Procedure ME-12, Battery Checks, has been performed since at
least May 1980 utilizing measuring instruments which did not
meet the required accuracy.
The three instruments used for this test were all Y2 controlled
instruments within their prescribed calibration interval.
All
three instruments were calibrated and certified to a user required
accuracy of +/-1.0% of reading.
With a nominal cell voltage of 2.30
volts, the instruments were only certified accurate to +/-0.023 volt.
c.
Discussion
(1)
The technical specification surveillance testing program has
recently undergone extensive revision including revised test
procedures.
Of the approximately twenty to thirty surveil-
lance tests sampled by the inspector, the above noncompiiance
was the only problem identified.
The nature of the above
noncompliance was such that it was not detectable by the
normal review process.
~
(2)
Testing, calibration, and periodic maintenance of safety
related components and systems which are not required by
the Technical Specifications are part of the Periodic
Activities Control Program.
The inspector's review of
this program found several areas of concern.
The program *
was not uniform in its implementation from one department
to another.
Instrument test and calibration data sheets
had a different acceptante criteria for "as found" values
and "final" values with no explanation.
Calibration pro-
cedures relied heavily on operator capability for proper
implementation.
The test and calibration equipment is not
always logged by the same identification numbers.
The section of the Maintenance Administration procedure
which described the Periodic Activity Control program is
under revision and a draft of the revision was reviewed by
- 23 -
assure that the cause of the condition is determined and corrective
action taken to preclude repetition.
QAPP No. 16 section 3.1 states that a failure of a safety-related
component which is significant to safety will always be evaluated.
AP 3.5, Corrective Action, defines a deviation as a nonconformance
or departure of characteristic from specified requirements.
One
example of a deviation is significant failures, malfunctions,
deficiencies and nonconformances of Q-listed materials, equipment
and structures.
Contrary to the above requirements, the inspector found that
on August 24, 1980, maintenance was performed on pressurizer
pressure indication PI-103B and no deviation report was initiated
to evaluate the nonconformance to determine if additional action
is required to prevent or reduce the possibility of recurrence.
Maintenance Order M080-PCS-lll stated that the pressurizer
pressure indicator on C-33 was reading zero and requested that
the indicator be fixed because it was needed for plant shutdown
per an EOP.
During the repair, it was discovered that the instru-
ment (PI-103B) had reversed wiring at 12-TU-4 in panel C-12.
The
immediate problem was identified and corrected.
However, the root
cause (such as personnel error; inadequate installation procedure;
or inadequate drawings) of the problem was not evaluated.
c.
Discussion
During the review of procedures relat"ing to the performance of
maintenance activities, the inspector noted that the plant
implementing procedures for inspection are not consistent with
the CPCO QA program policy.
Quality Assurance Program Policy No. 10, Inspection, section 3.3
states that inspection points are designated when deemed necessary
in the procedures and work does not proceed beyond the designated
inspection point until the inspection has been completed and
documented or written consent for bypassing the inspection has
been received from the organization responsible for performing
the inspection.
QAPP 10-51, Maintenance and Minor Modification Inspection,
states that if a representative of the inspection group cannot
be located, the work may proceed provided that the attempted
contact be documented.
The above statement in QAPP 10-51 appears to be in conflict with
the requirement of Policy 10 with regard to proceeding with the
work without the consent of the QC 'department.
Also with regard
to inspection hold points, the inspector found that criteria has
not been established for the selection of hold points for safety-
related activities. It appears that hold points are determined
- 25 -
1
based on manpower availability and not significance of the work
activity.
During discussions with licensee representatives the
inspector ~as informed. that this program deficiency had been
identified in licensee internal audits and that action has been
initiated to provide guidance for selection of inspection hold
points.
This item was discussed during the exit interview.
In addition, the following observat{ons were also made:
(1)
Controlled Material and Services Procedures Manual Proce-
dure 13-7 in section 5.2 makes reference to section 5.3.2.1
of Procedure 13-6.
This section in Procedure 13-6 does not
exist.
(2)
A new preventive maintenance procedure has been written and
is currently being routed for review and approval.
The
procedure contains instructions on how the Periodic Activity
Control Sheets (PACS) are controlled and the information
inputed into the computer.
(3)
Licensee representatives stated that a procedure is being
written to detail fire prevention requirements during welding
and cutting activities.
This is being initiated as a result
of enforcement action taken by the NRC during a previous
inspection.
16.
Nonroutine Reporting Program
The inspector reviewed the licensee'i progtam to ascertain responsi-
bilities 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
QAPP 16, Corrective Action
QAPP 15-51, Control of Nonconforming Items
QAPP 15-52, Repor~ing Nonconformance During Major Modifications
QAPP 16-51, Deviation Reporting and Corrective Action
QAPP 16-52, Action Items
QAPP 16-1, Corrective Action
AP 3.5, Corrective Action
b .
Findings
No items of noncompliance or deviations were identified.
- 26 -
17.
Corrective Action Program
The inspector reviewed this area to verify that measures have been
established to identify and correct conditions adverse to quality
- such as failures, malfunctions, deficiencies, deviations, defective
material and equipment, and nonconformance.
Corrective action taken
to preclude repetition was also examined.
The area of nonconformances
was reviewed for prompt identification and correction.
a.
Documentation Reviewed
Shift Supervisor's Log - September 25, 1980 to October 10, 1980
QA Program Monthly Status Reports - August and September 1980
QAPP 16-1, Corrective Action
QAPP 16, Corrective Action
QADP XVI-2, Action Items
QADP XVI-4, Documenting, Evaluating, Correcting and Reporting
QAPP 16-51, Deviation Reporting and Corrective Action
QAPP 16-52, Action Items
QADP XVI-1, Corrective Action Follow-*up and Trend Analysis
QADP XV-1, Nonconformance Control
QCP-P-05, Processing_of Nonconforming Material
QAPP 15-51, Control of Nonconforming Items
QAPP 15-52, Reporting Nonconfor~ances During Major Modifications
AP 3.5, Corrective Action
AP 4.0, Operations Administration
SOP 36, Reactor Protection System
.b.
Findings
Noncompliance
The following examples of items of *noncompliance were identified
in this area:
- 27 -
l
j
(1)
10 CFR SO, Appendix B, Criteria XVI, Corrective Action,
states that measures shall be established to assure that
conditions adverse to quality, such as. failures, malfunctions,
deficiencies, deviations, defective material and equipment,
and nonconformances are promptly identified and corrected.
In order to implement 10 CFR SO, Appendix B, Criteria XVI,
the licensee established completion due dates and evaluation
due dates.
Quality Assurance Program Procedure, 16-Sl,
revision 4, Deviation Reporting and Corrective Action states
in paragraphs S.1.2 and S.1.3 respectively:
Within.40 days
of the date originated, the individual who received the DR
for processing, or his alternate, assures that nonconforming
items are controlled according to QAPP lS-Sl, assigns an
individual to conduct the Evaluation and Disposition and
assigns an Evaluation due date and priority.
The reviewer
identifies the individual responsible for completion of each
corrective action, the completion due date and priority of
each corrective action.
Contrary to the above, four deviation reports were not
resolved for corrective action in accordance with established
completion dates and one deviation report did not meet the
40 day requirement concerning evaluator assignment, evaluator
due date and priority.
The deviation reports are D-QG-78-24,
D-QG-78-24A, D-QG-78-24C, D-QP-76-107, and D-QP-80-21.
Document No.
D-QG-78-24
D-QG-78-24A
D-QG-78-24C
D-QP-76-107
Document No.
D-QP-80-2,1 *
Completion Due Date
12/01/79
12/01/79
12/01/79
04/30/80
Subject
Temp proc change
involving unreviewed
safety question.
(MSLB reanalysis
concluded that the
containment pressure
would be exceeded
for a MSLB with the
Primary Coolant
System @S32F.
Cor-
rective measures
taken to reduce the
peak pressure in-
cluded filling the
headers to allow
- 28 -
Status As of 10/18/80
10% complete
SO% complete
50% complete
20% complete
Status as of 10/18/80
This document was
originated 6/24/80.
To date an evaluator
has not been assigned.
This status has not
been updated since
6/24/80.
- (Reported by QA
Consumers Power)
,
spray operation to
occur sooner dtlring
a MSLB.
On 5/22/80
with the PCS at
@532F, TC T80-96
was put into effect
to cldse both con~
tainment spray
header isolation
valves to facilitate
pump testing.
(2)
10 CFR 50, Appendix B, Criteria XVI requires that for con-
ditions adverse to quality, measures shall be established
to assure the cause of the condition be determined and that
action be taken to prevent repetition.
QAPP No. 16 states
that a failure of safety related components is an item
requiring evaluation under their corrective action system.
SOP 36, Reactor Protective System Operating Procedure
requires that "Anytime a reactor protective system input
channel becomes erratic or its output value is questionable,
a deviation report QA-16, shall be initiated.
Immediate
action should be taken to correct the problem.
If analysis
shows that the deviation causes a nonconservative trip signal
to be generated, then the channel should be either bypassed
or put into the tripped condition until corrective action is
taken."
Contrary to the above, the High Power trip, B Channel, was
bypassed on C shift September 29, 1980, due to RPCIC drift.
No corrective action system report was initi"ated as required
by the QA program and the operating procedure.
Other items
of a similar nature were noted.
See discussion below and
Findings of.section 15, Maintenance.
c.
Discussion
A number of items were noted where the formal corrective action
system was not being implemented.
The inspector perceptions of
the underlying causes are discussed below.
These perceptions
were developed through study of the licensee's systems, reviews
of records and discussions with licensee personnel.
Many personnel do not fully understand the system and the need
for it.
One of the causes of this is the tendency of the licensee
to assign the evaluation and disposition back to the initiator.
For example, in dealing with instrumentation, the I & C supervisor
who identifies that an instrument is out of tolerance initiates
the devia.tion report (DR), is then assigned the evaluation and
disposition of that DR.
Human. nature then tends to view the
process as unneeded paperwork as he has already solved the
- 29 -
problem and the DR comes back to him a few weeks later to
evaluate.
This also presents some systematic problems which
the licensee should be aware of.
One, he is not establishing
a strong first line independent review.
Two, considering
human nature, there can be a tendency to gloss over the event
when it comes back the second time.
Events such as the measured 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> unidentified primary coolant
system leakage being greater than 1 gpm on September 29, 1980
and the failure of the 1-1 diesel generator to start following
maintenance were not placed in the DR system.
They were reviewed
outside the system leaving very few records of the events or how
they were resolved.
One advantage to be gained by an effective
corrective action system is a record of the review process and
tracking of any outstanding corrective actions.
On October 6, 1980, the lic~nsee released a batch of radwaste
liquid (Batch Number 80-013-L).
Log entries indicate that the
monitor kept tripping.
The following is quoted from the "Release
Order" - "Batch tripped and reset many times."
The radiation
monitor's function is to stop the release if release limits are
being exceeded.
It appears that the problem was probably a high
background at the monitor and no release limits were exceeded.
The inspector does have concerns regarding this mode of operation.
What would happen if there was a real problem with the release
such as a wrong tank?
Would the licensee finally release it by
continuing to reset?
The licensee appears to have taken no
.corrective action regarding this event.
No Maintenance Order,
Facility Change Request or Deviation Report was initiated.
Continued operation through problems such as this can establish
the "traps" that cause a licensee to get into regulatory or
safety problems in the future.
This was discus~ed with licensee
management.
In discussion with personnel, the inspector did not find one
positive attitude toward the Corrective Action system (DR).
No one expressed an opinion that the system was effective or
provided a benefit.
The Quality Assurance Program Policy 16 states that trends observed
which are adverse to quality are considered for corrective action.
The licensee does not appear to have developed any effective trend
analysis programs.
The QA Department has one procedure, QADP XVI-1,
that does deal with trend analysis.
This analysis relates cause,
organization and activity.
The inspector reviewed one report and
it appeared superficial and did not carry on far enough.
It
concluded that Palisades has more errors during outages than Big
Rock Point. It did not question the reasons for this or propose
any corrective actions to be taken:
- 30 -
Quality Assurance has a computer system for identifying correc-
tive action items.
The shortcoming of the system appears to be
in getting timely resolution in regards to both evaluation and
corrective action.
This area appears to be out of Quality
Assurance control, and any improvement in this area seems to rest
with upper management.
All of the items stated in the item of
noncompliance were more.than adequately identified by Quality
Assurance.
A facet discussed was placing only those conditions
in the corrective action system that are of significance.
18. Exit Interview
The inspectors met with the licensee representatives (denoted in
paragraph 1) at the conclusion of the inspection on January 16,
1981.
The purpose and scope of the inspection '~as summarized and
the inspectors then discussed the enforcement findings in each
area.
These findings had been previously discussed with licensee
representat1ves during meetings held throughout the inspection .
- 31 -