ML20005G119
| ML20005G119 | |
| Person / Time | |
|---|---|
| Site: | San Onofre  |
| Issue date: | 12/20/1989 |
| From: | Ray H SOUTHERN CALIFORNIA EDISON CO. |
| To: | Scarano R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| Shared Package | |
| ML20005G116 | List: |
| References | |
| NUDOCS 9001180150 | |
| Download: ML20005G119 (3) | |
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l Southem Ca@twnin Edlison C6mpany-n ** =ra stacet mvmc. cauroama sem
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Dacomber 20, 1989
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Mr. Ross'A..Scarano, Director L :"
U. S., Nuclear Regulatory Commission, Region'V Division of Radiation Safety and Safeguards D
1450 Maria Lane, Suite 210 M
Walnut Creek,-California 94596-5368 i
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Dear Mr. Scarano:
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Subject:
Docket Nos.- 50-306, 50-351 and 50-3'68 N
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Respiratory Protection Self Assessment san caefrg Muelear seneratinqr station u
1 Your letter dated December 8, 1989 forwarded San Onofre i
Inspection Report 89-28 and an associated ~ Notice of Violation (NOV).
We will reply to-the NOV by separate correspondence.- The purpose of this letter is to respond:to the following. comment-.in your forwarding letter:
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- (S)ubsequent to the inspection your staff provided to us an audit report of respiratory protection which concluded that
' respirators are properly cleaned,-maintained, selected and issued.*
It is clear your self assessment of this program did not present an accurate appraisal-to senior station management.
We urge you to evaluate whether this could be indicative of a more general. problem with your internal audit system."
L I appreciate you providing emphasis to this concern in your 1
. forwarding letter.
I have evaluated what' occurred in this instance in some detail and have arrived at the following 3
conclusions:
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1.
This.self assessment was not as effective as it should L
have been because it was conducted outside the provisions of our formal oversight and corrective H
action procedures.
2.
The summary conclusion that " respirators are properly l
cleaned, maintained, selected and issued" is taken from the forwarding memorandum for the audit report itself, It was an erroneous conclusion which does not p
accurately reflect the findings of the report..The report identified significant problems requiring L
k corrective action, and the conclusion was premature in that the work of the regular respiratory protection appraisal program was not yet complete.
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-Mr._Ross A. Scarano December 20,:1989 Thesel conclusions, and the action which will be-taken as a l
result,.are described in more detail below.
o names for the Audit The Nuclear Engineering, Safety &-Licensing Department (NES&L) is responsible for all oversight of licensed astivities
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.i at' san Onofre.
Most of this oversight is provided through the-formal programs.of the Nuclear. Oversight Division (NOD).
An exception has been the oversight of Her lth Physics (HP) practices a
which is conducted.by the Health Physics & Environmental (HP&E) section, reporting to the Manager of Nuclear Regulatory Affairs.
The reason for this exception is that HP&E can provide more j
expertise and insight to the-process of HP oversight than can-u
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NOD.
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However, a drawback in the performance of HP oversight by HP&E has been that the procedures for documenting the oversight l-performed,.eepecially its conclusions, and for obtaining management visibility to deficiencies and corrective actions q
- required, lack the formality and effectiveness of NOD procedures.
- Accordingly, henceforth HP&E oversight functions will conform L
with, and utilize,' NOD procedures, and HP&E reports and conclusions will'. require approval by N0D management prior to i
issuance.
This will ensure that findings are offactively-communicated and' accurately. reflected in the report summaries.
1 Findings of the Audit In addition to the erroneous. summary statement discussed above, the-forwarding memorandum for the audit report included the following other comments:
" Documentation of the respiratory protection program is less than adequate compared to industry standards and could have regulatory impact.. Discrepancies in the areas appraised were noted and are presented in the attached report."
"Although quality assurance / quality control is a later inspection module, some deficiencies were identified during this review."
The reference to "a later inspection module" was intended to
~ identify that the appraisal was as yet incomplete.
- However, quality problems had been identified already, and these were being communicated by the (interim) report provided.
As discussed in Section 2.A of the NRC inspection report,.these problems included "less than adequate" program documentation and the fact that "no formal respirator maintenance training had been conducted in over a year."
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I Mr. Ross'A. Scarano December 20,:.1989 gie K
The: numerous. discrepancies that were identified by the NRC in respiratory protection equipment which was-ready for essed qb might also have been identified by subsequent HP&E inspdction of L
maintenance quality.
However;-the. possibility that such.
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.. discrepancies existed should have.been recognized by HP&E on.the basis of-the work already. completed and more-aggressiva._ action H'
taken earlier.- It is expected that this problem will be corrected by inclusion of'the HP&E' appraisal within NOD = oversight
-procedures, as discussed above.
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If you have any questions or comments, or if you would like
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additional information, please let me know.
sincerely, h
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cc: - J. B. Martin, Regional Administrator, Region V C. W. Caldwell, NRC Senior. Resident Inspector, San Onofre t
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