ML18046A527
| ML18046A527 | |
| Person / Time | |
|---|---|
| Site: | Palisades  |
| Issue date: | 03/09/1981 |
| From: | Frost S CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.) |
| To: | James Keppler NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| Shared Package | |
| ML18046A526 | List: |
| References | |
| NUDOCS 8103250163 | |
| Download: ML18046A527 (17) | |
Text
consumers Power company Gen.. ral Offices: 212 Wetn: Michigan Avenue, Jackson, Michigan 49201 * (617) 788-0660 March 9, 1981 Mr James G Keppler Office of Inspection and Enforcement Region III US Nuclear Regulatory Commission 799 Roosevelt Road Glen Ellyn, IL 60137 DOCKET 50-255 - LICENSE DPR PALISADES PLANT - RESPONSE TO IE INSPECTION REPORT 80-20 IE Inspection Report No 50-255/80-20 dated February 11, 1981 detailed ten (10) apparent items of noncompliance.
Consumers Power has reviewed the inspection report and responses for each item are attached.
These issues and evaluation of our overall Quality Assurance Program were also discussed at our February 18, 1981 meeting with you and your staff at Glen Ellyn.
Steven R Frost Palisades Licensing Engineer CC Director, Office of Nuclear Reactor Regulation Director, Office of Inspection and Enforcement NRG Resident Inspector-Palisades Attachment (l6 pages)_
-810 3 250 /~'3
AITACHMENT Consumers Power Company Response to IE Inspection Report No 50-255/80-20 Docket 50-255 License DPR-20 Item 1 10 CFR 50, Appendix B, Criteria IV, states, "Measures shall be established to assure that applicable regulatory requirements, design bases, and other re-quirements which are necessary to assure adequate quality are suitably 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 subcoritractors to provide a quality assurance program consistent with the pertinent provisions of this appendix."
Contrary to the above, there are numerous procurement documents which do not reference applicable regulatory requirements or necessary quality assurance program requirements.
Quality Assurance program requirements have not been referenced in the procurement documents in regards to 10 CFR 50 Appendix B, ANSI N45.2, or NA-4000 of the A. S. M. E. Section III-Boiler and Pressure Vessel Code.
10 CFR 21 statements have also been omitted in procurement documents.
Examples of these omissions are purchase orders 1001-4411 and 10"01-6960 for weld rod and purchase orders 1001-6797 and 1001-5489 for fittings.
Other examples are referenced in Paragraph 7.
This is a Severity Level V violation (Supplement I).
Response to Item 1 Corrective Action Taken and Results Achieved The Requisition Engineer, QA Engineer, Administrative Supervisor and Material Supervisor have reviewed 10 CFR 21 and are aware of its contents.
The Requi-sition Engineer was instructed to incorporate the appropriate procurement statements for Purchase Orders containing Q-listed items.
Corrective Action Taken to Avoid Further Noncompliance To avoid any further noncompliance, all existing 1069 Authorization for Addition/Deletion of Redescription of Stock Items forms for Q-listed components will be reviewed to insure the inclusion of the appropriate procurement statements.
A procedure exists to assure that future buys on system-generated requisitions, for Q-listed items, contain the appropriate procurement statements.
Date of Full Compliance The actions discussed above are to be completed by June 30, 1981.
nu0381-012la-43
Item 2 10 CFR 50, Appendix B, Criteria V states in part that activities affecting quality shall be prescribed by documented instructions, procedures, 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 Nonconforming 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 be returned to the stockroom."
Contrary to the above, Nonconforming Material Reports were not being written on material lacking or deficient in documentation when rleeasing the material for installation in the plant.
The following purchase orders are examples of this practice:
Purchase Order Nos. 1001-0820, 0006-0645, DY-150, and DY-152.
(paragraph 8)
This is a Severity Level V violation (Supplement I).
Response to Item 2 Corrective Action Taken and Results Achieved The documentation associated with the Purchase Orders referenced above is now in order.
A review of all material which is currently in a "conditional release" status has been conducted.
There are no cases wherein material is in a conditional release status without an NMR having been generated.
Corrective Action Taken to Avoid Further Noncompliance The procedure (QCP-P-05) regarding processing of nonconforming material has been reviewed with all members of the QC staff.
Formal training in QC procedures will be provided to QC Department personnel.
The "conditional release tag" will be changed to address the need to issue an NMR.
Date When Full Comoliance Will Be Achieved Procedure QCP-P-05 will be revised by November 1, 1981.
nu0:381-0097b-43
Item 3 10 CFR 50 Appendix B Criteria XVII states in part..... Sufficient records shall be maintained to furnish evidence of activities affecting quality.
The records shall include at least the following:
Operating logs and results of reviews, inspections, test audits, monitoring of work performance, and material analyses.
The records shall also include closely-related data such as qualification of personnel, procedures, and equipment... Records shall be identifiable and retrievable.
Consistent with applicable regulatory requirements, the applicant shall establish requirements concerning records retention, such as duration, location, and assigned responsibility."
3 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."
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."
Contrary to the above requirements the following noncompliances were identified:
- a.
Numerous records are not stored according to ANSI N45.2.9 requirements, as modified by QA Policy 2, for duplicate record storage locations.
Examples are nonconformance material reports and personnel training records.
Other examples are referenced in paragraph 9b.
- b.
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 qualified a Level II on March 5, 1980, in specific areas requiring special training, without records that supported his own qualifications in these areas.
(paragraph 9)
This is a Severity Level VI violation (Supplement I).
Response to Item 3a Corrective Action Taken and Results Achieved All 1979-1980 "active" files will be submitted to the Document Control Center for immediate processing.
Additional personnel will be added as needed to help backfit records currently stored in the Document Control Center.
Corrective Action Taken to Avoid Further Noncompliance Chapter 11 of the Administrative Procedures will be revised to provide better guidance for the "proper" handling of our plant document storage.
Document Control Center procedures will be revised to reflect both the changes in nu0381-0097c-43
Chapter 11 of the Administrative Procedures and in the Records Management Procedures for storge and processing.
The Document Control Center will be relocated to alleviate the need of significant users to maintain "active" records.
Date When Full Compliance Will Be Achieved All 1979-1980 records are to be duplicated or microfilmed by December 15, 1981.
Response to Item 3b Corrective Action Taken and Results Achieved Level III Certification of the Technical Superintendent will be upgraded or revoked.
A review of all certifications of Levels I and II QC inspectors will be conducted by an appropriately certified Level III person.
Corrective Action to Be Taken to Avoid Further Noncompliance The N 45.2.6 requirements for written certification of qualification will be reviewed and QCP-P-08 will also be revised to provide appropriate guidance to meet these requirements.
Date When Full Compliance Will Be Achieved These procedures will be revised by April 15, 1981.
nu0381-0097c-43 4
5 Item 4 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 II 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.
(paragraph 10)
This is a Severity Level VI violation (Supplement I).
Response to Item 4 Corrective Action Taken and Results Achieved Because of the nature of the occurrence, no corrective action to correct the specific item is possible.
As noted by the inspector, the temporary changes have been reviewed by PRC.
Corrective Action Taken To Avoid Further Noncompliance The method of preparing PRC agendas has been to collect review material approximately one week in advance of the meeting and then prepare the agenda accordingly.
As a result, the temporary changes issued in the intervening one week period would not be reviewed until the following meeting.
To prevent recurrence, the PRC Secretary has been instructed to collect the temporary changes issued following preparation of the agenda, and to bring them to the meeting.
This action will be performed within approximately an hour of the PRC meeting.
The procedure which stipulates the PRC Secretary responsibili-ties has been-changed to reflect this requirement.
Date When Full Compliance Will Be Achieved The corrective actions described above have been implemented.
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Item 5 10 CFR SO, 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 inappropriate documents is defined by specific department procedures."
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 are examples of controlled drawings which are not up to date and are being used in the control room.
Other examples are referenced in paragraph lOb.
M - 220 Makeup Domestic Water and Chemical Injection M - 224 Gas Analyzing Systems M - 225 High Pressure Air Operated Valves The required red line changes had not been made on these drawings.
This is a Severity Level V violation (Supplement I).
Response to Item 5 Corrective Action Taken and Results Achieved A set of full size updated red lined prints have always been readily available in the control room area for operator use.
A set of half size prints have been ordered from our Document Control Department and are expected to be completed in a few weeks.
Corrective Action Taken To Avoid Further Noncompliance A mechanism is being established to insure that all future approved print revisions are incorporated into the controlled copy when changes to the controlled drawings are approved and issued at the plant site.
Date When Full Compliance Will Be Achieved The items discussed above will be completed by April 1, 1981.
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Item 6 10 CFR 50, Appendix B, Criteria VII states in part... "M~asures shall be established to assure that purchased material, equipment, and services, whether purchased directly or through contractors and subcontractors, conform to the procurement documents...... Measures shall include provisions as appropriate, for source evaluation and selection, objective evidence of quality furnished by the contractor or subcontractor, inspection at the contractor or subcontractor*source, and that the effectiveness of the control 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."
Quality 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 the supplier to provide established procurement requirements."
Contrary to the above requirements, the licensee failed to meet the program requirements as follows:
- a.
Three items that were purchased did not meet the procurement document but were accepted and released for installation and use.
Items purchased on Order Nos. 85378Q, 42604-Q, and 19144-Q did not meet purchase order specifications.
(paragraph 7)
- b.
Two suppliers were placed on the approved suppliers list for "Q listed" safety related items contrary to Quality Assurance Technical evaluations.
The quality assurance evaluation on Midco Pipe and Tube, on September 8, 1978, stated that Midco was only approved for non ASME B & PV Code,Section III, p_ipe and fittings.
Midco was placed on the approved suppliers list for ASME B & PV Code,Section III, pipe and fittings, and orders were placed on Purchase Order Nos. 1001-6797Q and 10015489Q for safety related, code items.
Also, ITT 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.
(paragraph 7)
- c.
Consumers Power does not evaluate the effectiveness of their suppliers quality assurance programs either thru analysis of nonconforming material reports, for material received and inspected at the site, or thru inspections at manufacturing and supplier facilities.
(paragraph 7)
This is a Severity Level V violation (Supplement I).
Response to Item 6a Corrective Action Taken and Results Achieved The referenced Purchase Orders will be reviewed and all material affected by the discrepancies noted above will be placed on hold.
NMRs will be initiated nu0381-0098c-43 7
for those materials still in stores.
Deviation Reports will be initiated for those materials used that had been found nonconforming.
The stock room will be checked for other POs covering these stock items and corrective action will be taken as needed.
This will be completed by April 1, 1981.
Corrective Action Taken To Avoid Further Noncompliance The training of QC Department personnel involved in receipt inspection will be upgraded to include formal training in the use and interpretation of the basic codes and standards (eg, ASME, ASTM, IEEE).
Date When Full Compliance Will Be Achieved All the above referenced training will be completed by November 1, 1981.
Response to Item 6b Corrective Action Taken and Results Achieved The December 1980 revision of the Approved Suppliers List indicates that Midco Pipe and Tubing Company is indeed approved, but it does not state that they can supply code material.
However, the supporting information for Midco is sketchy and no audit of Midco's QA Program has been performed.
- Likewise, Midco is not listed in the C.A.S.E. Register as a nuclear supplier.
As a result, Midco will be removed from the Approved Suppliers List until their qualifications have been demonstrated by audit.
Material supplied by Midco under POs 1001-6797Q and 1001-5489Q will be evaluated for continued ac-ceptability and appropriate corrective action taken.
The December 1980 revision of the Approved Suppliers List indicates that ITT Harper is approved to supply nuts and bolts, fasteners, extruded shapes, and spare parts.
However, the December 1980 issue of the C.A.S.E. Register lists ITT Harper as qualified to supply fasteners and associated magnetic particle and dye penetrant inspections.
The Approved Suppliers List will be revised to be consistent with the C.A.S.E. Register.
Corrective Action To Be Taken to Avoid Further Noncompliance The root cause of these deficiencies is inadequate procedures to control the evaluation of suppliers and revision of the Approved Suppliers List, and inadequate instructions to QA Department personnel regarding the specifica-tions of source surveillance and inspection requirements on procurement documents.
The Approved Suppliers List has been improved to identify the number of safety-related purchases from each supplier and nonconformances generated during receipt inspection.
The QA Department Procedures will be revised to provide adequate controls for the evaluation of suppliers and revision of the Approved Suppliers Lists.
Included will be instructions regarding the use of purchase and nonconformance information as well as information from agencies such as C.A.S.E., ASME, and LCVIP.
The procedure will establish criteria for approving suppliers by audits and other means.
In addition, provisions will be made to utilize the Approved Suppliers List as nu0381-0098c-43 8
- the vehicle to inform procurement document reviewers that source surveillance/inspection is necessary and should be specified on the procurement document.
Date When Full Compliance Will Be Achieved The above referenced department procedures will be revised by June 1, 1981.
Response to Item 6c.
Corrective Action Taken and Results Achieved The NQAPASL has been revised to provide information regarding the number of purchases and nonconforming material reports generated during receipt inspection.
This information will be utilized during periodic reevaluation of suppliers.
The NQAPASL will be revised further to provide traceability between the NMR and the procurement document with which it is associated.
This will further assist QA Department personnel in performing supplier evaluations.
The use of this information will be incorporated into QA department procedures for supplier evaluation.
Corrective Action To Be Taken To Avoid Further Noncompliance A rigorous criteria Will be developed for the application of rights of access provisions in procurement documents and for determining when surveillance/
inspections at suppliers'/manufacturers' facilities associated with specific purchases are required.
This criteria will be incorporated into QA Department procedures.
The "comments" section of the NQAPASL will be utilized to identify when source surveillance/inspection provisions should be applied to purchase documents.
The QA Department procedures will be revised to address this and QA Department personnel will be instructed accordingly.
Date When Full Compliance Will Be Achieved The criteria will be incorporated into the QA Procedures by June 1, 1981.
Discussion The discussion section of the inspection report _expresses concern over the fact that the QA Department does not review the final procurement document sent to the vendor, and identifies this as a potential contributing cause to the problem of inadequate specification of QA requirements in procurement documents.
A review of our procurement system indicates that this is simply not the case.
Our procurement system requires that the QA Department review and concur with nu0381-0098c-43 9
10 the provisions of safety-*related procurement documents.
This review is documented on a first generation form which identifies all requirements that are eventually imposed on the supplier.
The purchase requirements are transferred to a Purchase Requisition and forwarded to the Purchasing Department which transfers the information to a Purchase Order and forwards it to the supplier.
No changes to the purchase requirements are permitted after the first generation form is approved, without the con~urrence of all parties involved.
The QC organization at the plant receives a copy of the first generation form and associated PRs and POs and performs a check to assure consistency.
Rarely is a problem identified.
When an error is detected, a Memorandum of Change is generated to correct it. The MC must r-eceive the same reviews as the original first generation form.
In the unlikely event that the supplier will not accept the Memorandum of Change, the associated material is identified as nonconforming upon receipt and dispositioned ac.cordingly.
We consider this mechanism adequate to control procurement specifications.
Finally, revisions to QAPP 4-51 associated with expedited procurement will be issued by 3/31/81 to indicate that items will not be relied upon to perform their intended safety function until all QA requirements have been determined and verified through receipt inspection.
nu0381-0098c-43
11 Item 7 10 CFR 50, Appendix B, Criteria XVIII, states in part... "A comprehensive system of planned and periodic audits shall be carried out to verify com-pliance 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 all aspects of the Q.A. Program.
The following criteria of 10 CFR 50, Appendix B, did not appear to be audited at all:
Criteria II, VII, X, and XIII.
(paragraph 12).
This is a Severity Level V violation (Supplement I).
Response to Item 7 Discussion The decision not to implement a thorough QA Audit Program during 1980 was made by QA Department management solely on the basis of what was the most effective way to utilize the available QA Department resources.
Several factors con-tributed to this decision, including:
- 1.
The Biennial Corporate Audit was conducted in 1980 and examined QA Program implementation at every site.
- 2.
A significant number of deficiencies from previous audits had not been resolved and reaudits would not identify any unknowns.
- 3.
Each plant continued to implement surveillances of critical functions and audits of some activities were performed.
- 4.
The Palisades Management Review Task Force was active through May 1980 and involved significant QA Department resources.
We still feel that this effort was important enough to warrant the attention it was given.
In retrospect, had the Corporate Audit not been scheduled for 1980, the QA Department would not have been able to justify abandonment of the internal audit program.
Corrective Action Taken and Results Achieved With the exception of the mitigating factors noted above, no corrective action to correct the specific noncompliance is possible.
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12 Corrective Action To Be Taken To Avail Further Noncompliance To assure an effect1ve audit program during 1981 and beyond, the General Office QA staff has been reorganized with a single individual accountable for implementation of the audit program.
Department procedures have been revised and issued and the 1981 audit schedule has been approved and is on schedule to date.
The schedule will be updated and reissued quarterly.
To assure top management involvement, the audit program coordinator will submit a quarterly report to Vice President-Nuclear Operations.
The report will identify the audits completed to date and will suminarize the audit program status with respect to the approved schedule.
In addition, the Vice President-Nuclear Operations receives a copy of each audit report together with a memorandum identifying significant items requiring his attention.
Date When Full Compliance Will Be Achieved The corrective actions described above have been implemented.
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Item 8 Palisades Nuclear Generating Plant Technical Specification paragraph 4.7.2.a in reference to the station battery states... "every month, the voltage of each cell (to the nearest 0.01 volt)... shall be measured and recorded."
13 Contrary to the above, Tec.hnical Specification Surveillance Procedure ME-12, Battery Checks, has been performed since at least May 1980 utilizing measuring instruments which did not comply with the required accuracy.
(paragraph 15)
This is a Severity Level V violation (Supplement I).
Response to Item 8 Corrective Action Taken and Results Achieved The supervisor in charge of the subject test was notified of the requirement to use Measurement and Test Equipment (M&TE) which would produce the accuracy required by Technical Specification 4.7.2.a.
The most recent performance of this test on March 3, 1981 resulted in cell readings taken with an instrument of the required accuracy.
Corrective Action To Be Taken To Avoid Further Noncompliance Procedure ME-12 which specifies requirements related to battery*testing will be revised such that M&TE specified accuracy meets or exceeds measurement requirements of Technical Specification 4.7.2.a.
Date When Full Compliance Will Be Achieved The procedure revision described above will be implemented by May 4, 1981.
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Item 9 Technical Specification 6.8.1.0 states that... "written procedures shall be established, implemented and maintained covering surveillance and testing activites of safety-related equipment."
Contrary to the above, Special Test T-131B for the Endurance Test of Steam Driven Auxiliary Feedwater Pump P-8B was performed not adhering to the cooldown time requirement of step 5.5 and missing several required veri-fication signatures for taken data.
(paragraph 6)
This is a Severity Level V violation (Supplement I).
Response to Item 9 Corrective Action Taken and Results Achieved An audit of all special test procedures completed in 1979 and 1980 was con-ducted in January 1981.
A number of discrepancies, including uncompleted written reports of some special test activities, were identified.
The identified discrepancies are being resolved.
Corrective Action To Be Taken To Avoid Further Noncompliance 14 The procedure governing administration of the special test program has been revised such that responsibilities with respect to review of completed special tests are better defined.
Date When Full Compliance Will Be Achieved The administrative controls specified above have been implemented.
nu0381-0099c-43
Item 10 10 CFR 50, Appendix B, Criteria XVI, states in part... "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 the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition.
The identification of the significant condition adverse to quality, the cause of the condition, and the corrective action taken shall be documented and reported to appropriate levels of management."
Quality Assurance Program Policy No. 16 Section 3.1 states in part... "con-ditions which require additional action to prevent recurrence are a matter of judgement, but the following conditions are always evaluated:
... a failure of safety-related structure, system, component, or part which is significant to safety."
Quality Assurance Program Procedure 16-51 states in part... "Within 40 days of the date originated, the individual who received the DR for processing...
assures that the nonconforming items are controlled according to QAPP 15 -51... II Contrary to the above, the following examples of noncompliance were identi-fied:
- a.
On August 24, 1980, following the discovery of a wiring error, maintenance was performed on pressurizer pressure indicator PI-103B and a deviation report (DR) was not initiated as required.
(paragraph 15)
- b.
On September 29, 1980 Channel B high power reactor trip became erratic and was bypassed.
No deviation report was initiated.
(paragraph 17)
- c.
Four deviation reports were not resolved for corrective action in ac-cordance with established completion dates and one deviation report did not meet the 40 day requirement concerning evaluator assignment, evalua-tion due date and priority.
The deviation reports are D-QG-78-24, D-QG6 078-24A, D-QG-78-24C, D-QP-76-107, and D-QP-80-21.
(paragraph 17)
This is a Severity Level V violation (Supplement I).
Response to Item lOa Corrective Action Taken and Results Achieved The wiring on the pressurizer pressure indicator (PI-103B) was repaired.
The wires were apparently reversed when last connected.
nu0381-0099d-43 15
Corrective Action Taken To Avoid Further Noncompliance Criteria is being established to aid in an evaluation process as to when a deviation on event report is to be issued.
Date of Full Compliance The criteria of when to write a deviation report is to be completed by August 1, 1981.
Response to Item lOb Corrective Action Taken and Results Achieved Channel B hi-power reactor trip was repaired and is now operable.
Corrective Action Taken To Avoid Further Noncompliance Criteria is being revised to aid in an evaluation process as to when a Deviation or Event Report is to be written.
Date of Full Compliance The criteria of when to write a Deviation or Event Report is to be completed by August 1, 1981.
Response to Item lOc Corrective Action Taken and Results Achieved 16 The corrective action document which had not been assigned for evaluation has been assigned; evaluation of the deviation report is now complete.
Action for three of the overdue corrective action documents has been completed and the documents are now in the final review process.
Evaluation of the fourth overdue document identified above is being resumed.
Corrective Action To Prevent Recurrence The administrative procedure governing processing of deviation reports has been revised and now includes the requirement to assign an evaluator within 40 days.
Date When Full Compliance Will Be Achieved The procedure revision described above has been completed.
nu0381-0099d-43