ML18139B597

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Responds to NRC 810722 Ltr Re Violations Noted in IE Insp Repts 50-280/81-15 & 50-281/81-15.Corrective Actions: Computerized Tracking Sys for Commitments Developed,Dual Storage Program for QA Records Set Up & Procedures Reviewed
ML18139B597
Person / Time
Site: Surry  Dominion icon.png
Issue date: 09/01/1981
From: Oatts J
VIRGINIA POWER (VIRGINIA ELECTRIC & POWER CO.)
To: James O'Reilly
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
Shared Package
ML18139B595 List:
References
466, NUDOCS 8111050739
Download: ML18139B597 (15)
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VIRGINIA ELECTRIC AND POWER RICHMOND, VIRGINIA 23261 September 1, 1981 I'!!('\

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J. L 0ATTS SENIOR VICE PRESIDENT Mr. James P. O'Reilly, Director Serial No. 466 Office of Inspection and Enforcement NO/RMT:acm U. S. Nuclear Regulatory Commission Docket Nos. 50-280 Region II 50-281 101 Marietta Street, Suite 3100 License Nos. DPR-32 Atlanta, Georgia 30303 DPR-37

Dear Mr. O'Reilly:

I very much appreciate the time extended to us last week to meet with you and other members of your staff in Atlanta to discuss results of recent NRC inspections and other matters pertaining to the quality of operations at Surry and North Anna~ Some of the matters we discussed, especially those related to commitments and our failure in some instances to meet specified dates in a timely manner concern me greatly.

As a follow up to our meeting, I have scheduled meetings at both stations with corporate and station personnel to convey my concern to them and to personally emphasize the importance and need for strict adherance to specified require-ments.

I indicated to you that we are taking other steps to improve our program including issuance of a revised escalation procedure on quality control inspection and audit findings that will provide written notification to my office in a timely manner if appropriate corrective action is not taken in the prescribed period. We are also transferring the quality assurance audit program responsibility to the corporate office to make it more uniform and effective. Additionally, we have begun a review of our written quality assurance program to assess specified requirements. I feel these efforts will result in an improved program and certainly a more effective one.

With regard to the specific concern relative to revising procedures at the time design changes are made operational the NPSQAM will be changed to streng-then the technical review process to require the identification of all pro-cedures including maintenance and surveillance requiring changes.

We at Virginia Electric & Power are, as we have always been, dedicated to pro-ducing electricity safely and let me again assure you that philosophy will be followed by all of our employees

  • e VrnornIA ELECTRIC AND PowEH CoMPANY To James P. 0 1 Reilly
  • The attached report provides you with a detailed response to I&E Inspection Reports Nos. 50-280/81-15 and 50-281/81-15. After reviewing these reports and the detailed responses, I feel that these actions, and others will deal with the issues that were identified and result in a greatly improved operations program.

We have determined that no proprietary information is contained in the reports. Accordingly, the Virginia Electric and Power Company has no objection to these inspection reports being made a matter of public disclosure. The information contained in the attached pages is true and accurate to the best of my knowledge and belief.

yours, Attachment City of Richmond Commonwealth of Virginia ,,d- 0 -A-

  • Acknowledged before me this / day of ~ * , 19 8(

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Notary Public My Commission expires:  ;;).._...;;,-t, , 19 8 S

--'------ SEAL cc: Mr. Steven A. Varga, Chief Operating Reactors Branch No. 1 Division of Licensing

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  • VEPCO RESPONSE TO NRC NOTICE OF VIOLATION REPORT NO. 50-280/81-15, 50-281/81-15 VIOLATION A NRC COMMENT:

A. 10 CFR 50, Appendix B, Criterion XVI and the accepted QA Program, Section 17.2.16, require that measures shall be established to assure that conditions adverse to quality, such as failures 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.

Contrary to the above, measures have not been established to assure that failures and nonconformances (including NRC concerns) are promptly corrected. Although measures have been established to assure that the

  • cause of the condition is determined, corrective actions have not been effective to preclude repetition as evidenced by the number of problems identified during the previous inspection in the same functional area (Inspection Report No. 50-280/80-10 and 50-281/80-11). Specifically, Items C, D, G, and I in this Notice of Violation and Items A and Bin the Notice of Deviation, were not identified by the QA Program to assure that corrective actions designed to prevent recurrence were carried out as stated in correspondence to the NRC.

This is a Severity Level V Violation (Supplement I.E.).

RESPONSE

1. The violation is correct as stated.
2. Reason for the violation:

A loss of administrative control of commitment dates has occurred. A significant increase in items requiring response has been evident since the onset of TMI related lessons learned; moreover, this increase in required follow-up action does not yet appear to be abating. The procedure changes made to cope with the increasing volume of required action as well as increased management attention were not escalated sufficiently fast enough to adequately handle the increase in the amount of follow-up required *

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3. Corrective steps which have been taken and the results achieved:

A review of administrative practices has been made, and the need for an improved tracking system for commitments has been identified.

Additionally, the NPSQAM Section 18 has been revised to improve the escalation program. This revision provides a means for timely notification of progressively higher levels of management when corrective actions are not accomplished by a specified implementation date.

The specific corrective steps concerning violations C, D, G, and I are described under the respective headings.

4. Corrective steps which will be taken to avoid further violations:

A computerized tracking system for commitments has been developed to assist in the early identif_ication of specified action dates.

Approximately 75% of the station commitments have been entered in the new system, and reports are now being generated for proper follow-up of required actions. In addition, the improved escalation program provides a means to notify the next higher management levels of failure to respond at the specified time.

5. Date when full compliance will be achieved:

Full compliance will be achieved by October 1, 1981 *

  • VIOLATION B NRC COMMENT :

B. Technical Specification 6.4.A.2 requires that written procedures shall be provided for the calibration and testing of instruments involving nuclear safety of the station. Technical Specification 4.18.A.l requires that fire detection instruments listed in Table 3.21-1 be demonstrated operable:

1. At least once per six months by channel function test, and
2. At least once per twelve months by performance of channel calibration Heat and smoke detectors are included in Table 3.21-1.

Contrary to the above, procedures issued to implement Technical Specification 4.18.A.l do not address channel function test or channel calibration of heat detectors installed in the cable tray room, the cable tunnel and the cable vault area. In addition, the procedures do not require channel calibration of smoke detectors installed in these areas.

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RESPONSE

  • 1. The violation is correct as stated.
2. Reasons for the violations:

Existing procedures do not address channel calibration of the heat and smoke detectors since calibration of these detectors is impractical. Standard Technical Specifications do not require calibration of these instruments, and a change to the Surry Technical Specifications is necessary. Present procedures do require channel functional checks, but every channel is not tested at the required frequency.

3. Corrective action taken:

A Technical Specification change has been initiated to delete the calibration requirement, and changes to Station procedures have been initiated to insure that all channels are functionally tested at the required intervals. This type of corrective action was outlined in Audit S79-20 which identified the need for a complete review for the Periodic Test program to assure that all Technical Specifications requirements are satisfied.

4. Corrective action taken to avoid further violations:

A review of the Technical Specifications is presently underway to

  • 5.

insure that all surveillance requirements are adequately covered by approved procedures. A completion date of August 31, 1981 was established for this review and has been completed.

Date when full compliance will be achieved:

The channel test procedures will be modified by November 1, 1981, which is prior to the next scheduled performance test.

VIOLATION C.

NRC COMMENT:

C. 10 CFR 50, Appendix B, Criterion XVII and the accepted QA Program,Section 17.2.17 require that sufficient records be maintained to furnish evidence of activities affecting quality. Section 17.2.7 of the Program requires that specific records, such as copies of purchase requisitions, become a part of the station records.

Contrary to the above, copies of quality repeating purchasing requisition cards (on which each line is a separate purchase requisition) are not being maintained in station records

  • I. . ... . ,. : . : .. ' .

e e This is a Severity Level V Violation (Supplement I.E.). A similar item was brought to your attention in our letter dated July 3, 1980 .

RESPONSE

1. The violation is correct as stated.
2. Reason for violation:

The procedure changes made to cope with the increasing volume of required action as well as increased management attention were not escalated sufficiently fast enough to adequately handle the increase in the amount of follow-up required.

3. Corrective steps which have been taken and the results achieved:

Copies of repeating purchasing requisition cards are presently being maintained in Station Records.

4. Corrective steps which will be taken to avoid further violations:

An administrative procedure describing a dual storage program for certain QA records will be established. The records program will be audited periodically.

5* Date when full compliance will be achieved:

  • The storage of repeating purchasing requisition cards was completed on July 27, 1981. The dual records storage program will be established on or about November 1, 1981.

VIOLATION D:

NRC COMMENT:

D. 10 CFR 50, Append'ix B, Criterion V and the accepted QA Program, Section 17.2.5 require that activities affecting quality shall be prescribed by documented procedures and shall be accomplished in accordance with these procedures. ADM 51, Control of Procedures, dated January 1977, Section 51.3.2 and 51.3.3 requires that each supervisor who maintains an unused procedure depository shall establish procedures to ensure that;

1. Only current and approved procedures are in the unused depository.
2. Adequate supplies of unused procedures are on hand.

Contrary to the above, as of May 11, 1981, the procedures required by ADM 51 had not been established by each supervisor that maintains an unused procedure depository. Only the Operations Supervisor and Instrument and Control Supervisor had the required procedures.

This is a Severity Level V Violation (Supplement I.E.)

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e RESPONSE:

  • 1.

2.

The violation is correct as stated. A review of procedure depositories showed that only current and approved procedures in adequate supplies were being maintained in the unused procedure depositories.

Reason for violations:

As noted in Notice* of Violation A, this is an item involving a prior commitment. A loss of administrative control of commitment dates has occurred. A significant increase in items requiring response has been evident since the onset of TM! related lessons learned; moreover, this increase in required follow-up action does not yet appear to be abating.

The procedure changes made to cope with the increasing volume of required action as well as increased management attention were not escalated sufficiently fast enough to adequately handle the increase in the amount of follow-up required.

3. Corrective steps which have been taken and the results achieved:

Each supervisor who maintains an unused procedure depository has established the required written procedures.

4. Corrective steps which will be taken to avoid further violations:

Not applicable. Procedures are documented.

5* Date when full compliance will be achieved:

Full compliance has been achieved.

VIOLATION E NRC COMMENT :

E. 10 CFR 50, Appendix B, Criterion V and the accepted QA Program, Section 17.2.5 require that activities affecting quality shall be prescribed by documented procedures and shall be accomplished in accordance with these procedures.

1. The Nuclear Power Station Quality Assurance Manual, Section 12, Con-trol of Measuring and Test Equipment, Revision 8, dated September 1980, Paragraph 5.4(b) requires that if an instrument is not located for one year after having missed a required calibration date, it shall be removed from the Quality Control (QC) Program.

Contrary to the above, 19 pieces of equipment had missed their cali-bration due date by more than one year but had not been removed from the QC Program.

2. The VEPCO Development Policy Manual requires that the individual trained, the supervisor, the Nuclear Training Supervisor and the Station Manager sign the end-of-step examination and the comprehensive examination given to auxiliary operators
  • Contrary to the above, the Station Manager did not sign the end-of-step examinations for three. individuals and the immediate supervisor
  • did not sign the comprehensive examination for another individual.

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-This is a Severity Level V Violation (Supplement I.E.). A similar item was brought to your attention following a recent inspection at North

  • RESPONSE:

1.

2.

Anna (Report Nos. 50-338/81-07 and 50-339/81-07

  • The violation is correct as stated.

Reason for violation:

Personnel tasked with calibration of equipment or removal of equipment from the Surry Quality Control Program failed to comply with the NPSQAM Section 12 instructions. The task of maintaining the records accurately has been made increasingly difficult over the past two years due to the large number of Health Physics survey instruments which have been lost or otherwise unaccounted for during the Steam Generator Replacement Project.

3. Corrective steps which have been taken and the results achieved:

All Quality Control records applicable to the calibration program have been reviewed by qualified personnel, and the supervisors of equipment which is overdue for calibration have been notified and the equipment which has been lost or otherwise is unuseable has been retired.

4. Corrective steps which will be taken to avoid further violation:

Personnel involved have been reinstructed in the correct procedures for

  • 5.

maintenance of calibration records

  • Date when full compliance will be achieved:

Full compliance has been achieved.

RESPONSE: (E2)

1. The violation is denied.
2. The tests examined by the inspector were copies of the original examina-tion. The original exam cover sheet is routed to the main office in Richmond for filing in the individual's personnel record. All signature spaces are filled in on the originals, however, due to the routing procedure, the copies which are retained in the vault at Surry Training Center may be missing one or more signatures.
3. None required.

VIOLATION F NRC COMMENT:

F. 10 CFR 50, Appendix B, Criterion V and the accepted QA Program, Section 17.2.5 require that activities affecting quality shall be prescribed by procedures. The Nuclear Power Station Quality Assurance Manual (NPSQAM)

  • Section 5, Instructions, Procedures and Drawings, Revision 19, dated September 1980, Paragraph 5.1, defines 18 different types of procedures that have been established to assure safe and orderly operation of the station. The accepted QA Program, Table 17.1.0, endorses ANSI Nl8.7-1972.
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e NRC COMMENT (CONTINUED)

  • Section 5.4 of this Standard requires periodic review of procedures and states that the frequency of these reviews shall be specified.

Contrary to the above, 14 of 18 types of procedures identified in the NPSQAM are not periodically reviewed and the frequency of reviews is not specified. Examples of procedures not periodically reviewed are Quality Assurance and Periodic Test.

This is a Severity Level V Violation (Supplement I.E.).

RESPONSE

1. The violation as stated is correct.
2. Reason for violation:

While a Station ADM procedure required the periodic review of certain procedures, it was not fully understood until this IE inspection that all of the 18 procedures identified in the NPSQAM required a periodic review.

3. Corrective steps which have been taken and the results achieved:

A change to the NPSQAM is being processed which requires the periodic review of the 18 types of procedures. The check list for the Station Procedures audit has been revised to include an examination of the 18 types of procedures to verify the periodic review requirement.

4. Corrective steps which will be taken to avoid further violations:

The specific review requirement will be monitored by the Quality Control Department through the audit process to assure that all of the 18 types of procedures are reviewed periodically.

5. Date when full compliance will be achieved:

Full compliance will be achieved by December 31, 1982.

VIOLATION G NRC COMMENT:

G. 10 CFR 50, Appendix B, Criterion XII and the accepted QA Program, Sec-tion 17.2.13 require that measures be established to control the storage and preservation of material to prevent deterioration. Control of items with a limited shelf life constitute a deterioration control measure.

Contrary to the above, a program has not been developed to identify and control the receipt, storage and issuance of safety-related materials which have a limited shelf life.

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RESPONSE

1. The violation as stated is correct.
2. Reason for violation:

As noted in Notice of Violation A, this is an item involving a prior commitment. Establishment of the shelf life program was halted at the time of change in warehouse supervisors, and it was never reinstated.

The procedure changes made to cope with the increasing volume of required action as well as increased management attention were not escalated sufficiently fast enough to adequately handle the increase in the amount of follow-up required.

3. Corrective steps which have been taken and the results achieved:

Efforts to establish a shelf life program have been reinstituted.

4. Corrective steps which will be taken to avoid further violations:

The shelf life program will be formalized, and the program will be reviewed during the periodic audits of the warehousing area.

5. Date when full compliance will be achieved:

Full compliance will be achieved by June 30, 1982 *

  • VIOLATION H:

NRC COMMENT:

H. 10 CFR 50, Appendix B, Criterion XVIII and the accepted QA Program, Section 17.2.18 require that follow-up action, including reaudit of deficient areas, shall be taken where indicated. Additionally, the accepted QA Program, Table 17.2.0 endorses ANSI N45.2.12 (Draft 3, Revision 4 - 1974). Section 4.5.2 of this standard requires that followup action by the auditing organization shall be performed by the audit team leader or management of the auditing organization to confirm that corrective action is acomplished as scheduled.

Contrary to the above, for Audit S-80-13, Finding 1 was closed with-out the auditing organization confirming that corrective action was accomplished as scheduled.

This is a Severity Level V Violation (Supplement I.E.)

RESPONSE

1. The violation as stated is correct *
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2. Reason for violation:
  • 3.

An audit finding was closed without confirming the corrective action because the auditor believed that the Station Manager's explicit directive to his supervisors was sufficient.

Corrective steps which have been taken and the results achieved:

The auditor has been reinstructed in the accepted methods to close open audit findings. This action is believed to be sufficiently effective that this practice will not be repeated.

4. Corrective steps which will be taken to avoid further violations:

No further corrective action is considered necessary.

5. Date when full compliance will be achieved:

Full compliance has been achieved.

VIOLATION I NRC COMMENT:

I. 10 CFR 50, Appendix B, Criterion XVIII and the accepted QA Program, Section 17.2.18 require a system of audits shall be carried out to verify compliance with all aspects of the quality assurance program.

  • The accepted QA Program also states that provisions are established requiring that audits be performed in those areas where the require-ments of Appendix B to 10 CFR 50 are being implemented.

Contrary to the above, audits are not being conducted at the company offices in two areas, records and document control. Since a major portion of activities in each of these areas are being conducted and audited at the Surry site, a lower Severity Level has been assign~d.

This is a Severity Level VI Violation (Supplement I.F.)

RESPONSE

1. The violation as stated is correct.
2. Reason for violation:

As noted in Notice of Violation A, this is an item involving a prior commitment. The specific requirement to audit QA records in dual storage at the company offices had not been identified prior to the IE Inspection. Consequently, audits of this separate record storage program had not been performed *

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  • VIOLATION I RESPONSE (CONTINUED)
3. Corrective steps which have been taken and the results achieved:

The requirement for a dual records storage program is acknowledged, and the procedure will be documented.

4. Corrective steps which will be taken to avoid further violations:

The dual storage of QA records will be audited on a periodic basis.

5. Date when full compliance will be achieved:

Full compliance will be achieved by November 1, 1981 *

.1 e

  • VEPCO RESPONSE TO NOTICE OF DEVIATION INSPECTION REPORT 50-280/81-15, 50-281/81-15 DEVIATION A NRC COMMENT:

A. In response to Item I in the Notice of Violation transmitted by Region II letter dated July 3, 1980, VEPCO correspondence dated August 1, 1980, stated that VEPCO would prepare and issue for use, procedures which de-scribe the interface, responsibilities, lines of communications and flow of design information between VEPCO and their Architect Engineer by October 1, 1980.

Contrary to the above, procedures which describe the interface, respon-sibilities, lines of communications between VEPCO and their architect engineer were not prepared and issued for use until February 1, 1981.

RESPONSE

1. Description of corrective actions:

A review of administrative practices has been made, and the need for an improved tracking system for commitments has been identified. Addition-ally, the NPSQAM Section 18 has been revised to improve the escalation program. This revision provides a means for timely notification of progressively higher levels of management when corrective actions are not accomplished by a specified implementation date.

2. Corrective actions taken to avoid further deviation:

A computerized tracking system for commitments has been developed to assist in the early identification of specified action dates. Approxi-mately 75% of the station commitments have been entered in the new system and reports are now being generated for proper follow-up of required actions. In addition, the improved escalation program provides a means to notify the next higher management levels of failure to respond.

3. Date when corrective actions will be completed:

Full compliance will be achieved by October 1, 1981 *

.t e

  • DEVIATION B NRC COMMENT:

B. In response to Item Bin the Notice of Violation transmitted by Region II letter dated July 3, 1980, VEPCO correspondence dated August 1, 1980, listed the following corrective step to avoid further violations: A change to the Nuclear Power Station Quality Assurance Manual (NPSQAM) has been intiated to require distribution of audit responses and other pertinent documentation to the recipients of the audit report; and that the date when full compliance will be achieved for this item is January 1, 1981.

Contrary to the above, the NPSQAM change was not approved until March 5, 1981.

RESPONSE

1. Description of corrective actions:

A review of administrative practices has been made, and the need for an improved tracking system for commitments has been identified.

Additionally, the NPSQAM Section 18 has been revised to improve the escalation program. This revision provides a means for timely notifi-cation of progressively higher levels of management when corrective actions are not accomplished by a specified implementation date *

  • 2. Corrective actions taken to avoid further deviation:

A computerized tracking system for commitments has been developed to assist in the early identification of specified action dates. Approx-imately 75% of the station commitments have been entered in the new system and reports are now being generated for proper follow-up of required actions. In addition, the improved escalation program provides a means to notify the next higher*management levels of failure to respond.

3. Date when corrective actions will be completed:

Full compliance will be achieved by October 1, 1981 *

,w ,. r e e DEVIATION C NRC COMMENT:

C. In the licensee response dated December 10, 1980, to NUREG-0737, VEPCO committed the Shift Technical Advisors (STA's) to successfully complete college level training in a variety of areas.

Contrary to the above, one of the STA's assigned to the Surry Station did not attend any of the fundamentals courses. A letter dated August 13, 1980 from the professor who taught the courses for VEPCO stated that none of the STA's took the test on fluid mechanics and heat transfer.

The professor's letter also stated that attendance was down for many courses because plant need for the individuals in the program.

RESPONSE

1. Description of corrective actions:

During the summer of 1980 a professor from Old Dominion University con-ducted an engineering refresher course. The course was a mandatory re-quirement for two of the four designated Shift Technical Advisors (STA's). In addition, the course was made available for the entire engineering department, including summer student employees. Two of the four STA's were granted a waiver from attending the course due to their advanced SRO training in progress at that time. Unfortunately, this was not documented. The waivers will be documented an4 will be retained as permanent records.

2. Corrective actions taken to avoid further deviations:

Any exceptions taken to the STA Training Program, as stated in our response to NUREG-0737, will be fully documented. Training personnel will ensure that all appropriate records, including tests and attendance records, are retained as permanent records.

3. Date when corrective actions will be completed:

All corrective actions will be completed by 9/3/81 *

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