ML20006C296

Responds to NRC 891121 Ltr Re Violations Noted in Insp Rept 50-461/89-32.Corrective Actions:Review Performed to Identify Surveillances Which Require Lifting of Leads in Main Control Room

ML20006C296
Person / Time
Site:	Clinton
Issue date:	12/21/1989
From:	Holtzscher D ILLINOIS POWER CO.
To:	Davis A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
References
U-601572, NUDOCS 9002070295
Download: ML20006C296 (11)

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. llLIN0/8 POWER COMPANY iP -. CuNTL'e A 4R $1AtioN. P.o. Box 678, cLINtoN. ILLINO15 01727 December 21, 1989 3.

Docket No. 50 461 1

Mr. A. B Davis Regional Administrator Region III U.S. Nuclear Regulatory Commission 799 Roosevelt Road

, Clen Ellyn, Illinois 60137

Subject:

Response to Notice of Violation in NRC Inspection L- Recort 50-461/89032 dated November 21. 1989 Daar Mr. Davis:

l This letter provides Illinois Power Company's (IP's) response to the Notice of. Violation.in NRC Inspection Report 50 461/89032. 'The Notice of Violation cites two examples where the corrective actions taken to prevent recurrence of a condition adverse to quality were not s effective. Attachn nt A discusses the failure to establish instructions L

for torquing the terminal screws on an Agastat relay after lifted leads 3 had been relanded; Attachment B discusses the failure to prevent the .

pressurization of piping above its design pressure.

Inspection Report 50 461/89032 also discusses an indicated ,

systemic weakness in the corrective action portion of the Clinton Power Station (CPS) Quality Assurance (QA) program, Attachment C discusses ,

this indicated weakness and the actions IP is, and vill be taking,' to j p' improve the ability of personnel to identify the cause, and corrective actions to prevent recurrence, of conditions adverse to quality.

IP believes that the information contained in this letter adequately responds to the Notice of Violation and the NRC concern regarding the corrective action program discussed in NRC Inspection c Report 50 461/89032.  ;

i Sincerely yours, i

D. L. Holtzscher Acting Manager -

Licensing and Safety J l

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R 4 Attachments cc: . NRC Clinton Licensing Project Manager NRC Resident Office Illinois Department of Nuclear Safety 4

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. (c , 'f =Attachm2nt A Response'to Notice of Violation in Inspection Report 50 461/89032

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The Notice'of Violation states in part:

...On' September 15, 1989, Surveillance Procedure CPS No. 9038.68, "MSIV-10 [ sic] Outboard Main Steamline Pressure Channel 056/057

, . Functional Test," did not contain any requirements to torque the terminal screws on the Agastat relay, after lifted leads had been relanded. This fact was identified before the surveillance was

, completed. Previously, on July 29, 1989, an operations monitoring observation made by members of the licensee's quality assurance department, identified that Procedure 9038.68 did not contain instructions to torque the terminal screws on the Agastat relay when the lifted leads were relanded. This fact was not identified until after

'4 the surveillance was completed and consequently entry into a Technical Specification = Limiting Condition for Operation was required. The corrective actions taken to prevent recurrence for a condition adverse to quality were not effective after the July 29, 1989, event..."

I. Background and Cause of This Violation On July 29. 1989, Quality Assurance (QA) personnel observed performance m

of surveillance procedure 9038.68, " Main Steam Isolation Valve (MSIV) -

Leakage Control (LC) Outboard Main Steam Line Pressure Channel 056/057

Functional Test". In order to perform the surveillance, leads for an Agastat .elay in the Main Control Room must be lifted and subsequently relanded. The QA' representative observing the relanding of the leads noted that the Control and Instrumentation (C&I) technician relanding

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the leads did not torque the terminal screws. Surveillance 9038.68 did t

not include instructions for torquing the terminal screws after relanding'the leads and did not require the implementation of procedure 8801.16, " Wire or Component Removal / Jumper Installation". However, when the QA representative informed the C&I technician that he was aware of a i_ requirement to torque the screws, the technician torqued the screws in e

accordance with Appendix A of procedure 8801.16.

The Shift and Line Assistant Shift Supervisor were inforned that surveillance procedure- 9038.68 did not include instructions for torquing the terminal screws after relanding the leads and that it did not require the implementation of procedure 8801.16. The QA representative documented the discrepancy in Operations Monitoring Report 89-08-010, 4 The report was subsequently forwarded to the Operations department for a resolution.

Surveillance 9038.68 allows an MSIV LC instrumentation channel to be placed in an inoperable status for up to two hours without placing the channel in a tripped condition. If the channel is required to be placed in a. tripped condition, the ACTION specified by Technical Specification 3.6.1.4 must be taken. The ACTION specifies that the inoperable channel be restored to an operable s.a'cus within thirty days or the plant be placed in a shutdown condition. Creater than two hours elapsed between the time the channel became inoperable, when the leads were lifted, and r the time the channel was restored to an operable status, when the (1)

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Attechssnt A M

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terminal screws were torqued; therefare, entry into the ACTION of Technical Specification 3.6.1.4 was required.

On September 15, 1989, the NRC Resident Inspectors observed performance

. of surveillance procedure 9038.68. The Inspectors noted that although

-the C&I technician relanding the leads was aware of the need to, and did in fact, torque the terminal screws, surveillance procedure 9038,68 did not contain information regarding torquing criteria for the Agastat relay terminal screws, The inspectors noted however that this criteria. y was included in procedure 8801,16 but that this procedure was not 1 referenced in surveillance 9038.68. In addition, they noted that step 2.1.5.0 of procedure 8801.16 states that the procedure does not cover

" wires / jumpers / components specifically contained within approved written Plant Staff proceduros in which appropriate notifications, verifications y and torquing requirements ara met," implying that surveillance 9038.68.

should either contain the torquing requirements or refer to procedure 8801.16. This, and other discrepancies noted in surveillance 9038.68, were issued as an unresolved item in NRC Inspection Report 50-461/89027.

On October 11, 1989, while reviewing the response to operations Monitoring Report 89 08 010 QA determined that the surveillance 9038.68 discrepancy was in violation of procedure 1011,02, " Implementation and Control of Surveillance Testing". In accordance with procedure 1011.02, procedure 8801,16 is-required to be implemented when a surveillance procedure which requires the lifting of leads in the Main Control Room-does not contain'the appropriate verifications and/or torquing criteria, Upon identifying the procedure violation, a corrective action document was initiated.

The cause of the failure to torque the terminal screws was a procedural inadequacy. Surveillance 9038.68 did not contain either the torquing criteria for the lifted lead terminal screws or a reference to procedure

'8801,16.

The discrepancy noted with surveillance 9038,68 recurred due to a failure to take prompt,and effective corrective action following'the July 29,1989, occurrence. The actions being taken to improve the identification of corrective actions for conditions adverse to quality are discussed in Attachment C.

II. -Corrective Actions Taken and Results Achieved A night order was issued to Operations personnel requesting that they ensure that C&I technicians torque the terminal screws for leads landed in the Main Control Room.

Surveillance 9038.68 was revised to reference procedure 8801.16.

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.', Attochment A-Response to Notice of Violation

-in-Inspection Report 50 461/89032-Appropriate Maintenance personnel have been reminded of the requirement to torque the terminal screws of leads lifted in the Main Control Room and of the need to utilize 8801.16 when torquing criteria is not included in the surveillance procedure.

III. Corrective Actions Taken to Prevent Recurrence A review is being performed to identify those surveillances which require the lifting of leads in the Main Control Room. Those surveillances will then be reviewed to verify that they' include'either the torquing criteria or a reference to procedure 8801.16. The procedure revisions are expected to be complete by June 1, 1990.

IV. Date When Full Comoliance Will Be Achieved Illinois Power will be in full compliance by June' 1,1990, 1

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a7 Attcchment B: U Response to Notice of Violation .

in Inspection Report 50 461/89032 j The' Notice of-Violation. states in part: l j

"...On September 6, 1989, the licensee identified that a section of ASME Code Class III piping, containing radioactive waste, had-been pressurized to above its design-pressure, using gaseous nitrogen, in~an a- attempt to clear a blocked line. On September 18, 1989, the' licensee conducted a critique, which identified that required approvals had not been obtained and that this methodology constituted a personnel safety hazard and was not to be used. On September 25 and 26, 1989, two different pieces of ASME Class III piping were pressurized to r.bove theirl design pressure using gaseous nitrogen in attempts to clear the blocked lines. The corrective actions taken to prevent recurrence for a condition adverse to quality were not effective after the September 6, 1989, report and September 18, 1989, critique..."

I. Background and Cause of This Violation On September 6, 1989, Plant Staff Technical personnel reviewed Maintenance Work Request (MWR) C54921 to determine if post maintenance testing was required to be performed. They noted that on May 6, 1989, a-portion of. Solid Radwaste Processing System (WX) piping had been pressurized above the line design pressure of 150 pounds per square-inch gauge (psig). On May 6, 1989, in an attempt to clear blockage from lino OWX60A, Maintenance personnel pressurized the,line to 800 psig with i water and nitrogen. . The blockage was blown out of the line and the line was then flushed clean.

'On September 6, 1989, Plant Staff Technical personnel identified that ^

the design and hydrostatic test pressure of the piping was exceeded. A corrective action document, Condition Report (CR) 1-89-09 012, was initiated.

The CR noted that Maintenance personnel had received verbal concurrence ,

from the Nuclear Station Engineering Department (NSED) to exceed the line design pressure of 150 psig; this concurrence was not noted in the MWR, A critique of-the May 6, 1989, event was held on September 18, 1989.

This cricique was attended by representatives from NSED, Industrial Safety, Plant Staff Technical, and Mechanical Maintenance.

The critique report, which discussed the cause of and the corrective actions for the May 6, 1989 event, was issued September 26, 1989.

On September 25 and 26, 1989, Maintenance Contractor Control and

. Instrumentation.(C&I) technicians were investigating the cause of instrument malfunctions in the Chemical Radwaste Reprocessing and Disposal (WZ) and WX systems. After verifying that the instruments were operating properly, an attempt was made to identify and dislodge any 4 obstruction in the lines. The lines were pressurized to 600 psig. The design pressure for the WX lines is 150 psi 6 and fifty psig for the WZ (1)

, u Att:chment'B Response to Notice of Violation '

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E, lines. .On October 6, 1989, when the MWRs under which the instrument  ;

malfunctions were being investigated were returned to Maintenance Planning to. add jobsteps to remove the obstructions from the lines, it 1 was' identified that the lines' design pressures had been exceeded. The .

maintenance planner reviewing the MWRs initiated Condition Reports  ;

documenting that the lines' design pressures had been exceeded aad-notified the Director - Outage Maintenance Support (OMS). (Maintenance -i contractor personnel report to the Director - OMS.)  !

The September 25 and 26, 1989 events were critiqued on October 12 and-13, 1989. During the critique, it was identified that on May 6, 1989, a similar event (previously discussed) had occurred and that the critique i report for that event had been issued on September 26, 1989. It was noted that neither the Director - Outage Maintenance Support nor ,

maintenance contractor personnel had attended the critique of the May 6, 1 1989 event..

The cause of the piping overpressurization was inadequate procedures and -

training. Formal training or procedures providing direction or 1 limitations for using pressure to locate or dislodge obstructions did- J not exist for maintenance, operations, or maintenance planning.

personnel. Using pressure to determine if a line is plugged /obstrueted had been accepted as a general practice in troubleshooting non.-

functioning gauges. Since troubleshooting has been classified as a s

" tool box skill" specific procedures or jobsteps were not required when s using pressure to-determine if a line is plugged / obstructed.

Exceeding piping design pressure while attempting to locate or dislodge piping obstructions recurred due to failure to take prompt and effective corrective action after identifying that the May 6, 1989 event had occurred. The actions being taken to improve the identification of .i L corrective actions for conditions adverse to quality are discussed in l Attachment C.

II. Corrective Actions Taken and Results Achieved

< Utility maintenance and maintenance contractor personnel were briefed <

t :not to pressurize a system unless specific instructions and limitations are provided in the MWR or procedure governing the work. This briefing also included information on the dangers of piping / equipment failure due l

to overpressurization. .

I-Maintenance Planning personnel were briefed on the need to include references to the maximum pressures to be used in MWR Jcbsteps '

pertaining to removing line obstructions.

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Attechnent B

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III. Corrective Actions Taken to Prevent Recurrence Procedure 1029.01, " Preparation-and Routing of Maintenance Work Requests" has been revised- to restrict the use of pressure when troubleshooting obstructed lines. Specific jobsteps or approved procedures are now required when using pressure to locate and remove-line obstructions.

A review was performed of those outstanding MWRs involving potential line obstructions to ensure that as a r.inimum, the appropriate cautions-are included in the MWRs.

.2V.  : Date When Full Como11ance Will Be Achieved Illinois Power is now in full compliance.

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L f, Atts hmentLC Response,to NRC Concern Documented lin Inspection _ Report 50 461/89032 t

- Excerot from Inanection Renort- 50-461/89032

"...Our review' indicates a significant problem with your ability to prevent recurrence of conditions adverse to quality. . The examples of" inadequate corrective actions detailed in ... this report .were

previously treated as individual problems. However, when viewed collectively, they are indicative of a systemic weakness in the corrective action portion of your (Quality Assurance) QA program. This is of significant concern to the NRC. Although your self-assessment programs are effective in the initial identification of problems, we believe that your identification, implementation,_and verification of-the efficacy.of corrective actions appears to be minimally effective.

From these examples it is also clear that this problem is not confined to a particular functional area at Clinton Power Station. The violation identified in this report is considered a further example..."

jE Illinois Power Comnany Resoonse

- Illinois Power Company (IP) has determined that the failure to effectively identify, implement and verify the corrective actions for conditions adverse to quality is attributable to.three causes: inadequate procedures and programs defining certain elements of the Corrective Action Program (i.e.,

effective immediate corrective actions, follow-up to verify implementation of corrective actions, etc.); insufficient management involvement in the prompt

- identification.. evaluation, implementation, and follow-up of timely and

- effective corrective action of conditions adverse to quality; lack of sense of i ownership and accountability for corrective- action at the supervisory and working levels.

To immediately address and correct the corrective action program inadequacies, the Vice President and the Manager - Quality Assurance (QA) conducted a management meeting to discuss the elements of, and the problems with, the-Corrective Action Program. Emphasis was placed on ensuring all CPS department Emanagers clearly understand that all CPS departments are responsible for

-implementing this program.

IP'has instituted several new initiatives to improve the ability of personnel to identify problems and to initiate, implement, and verify corrective actions at Clinton Power Station.

CPS Procedure 1016.01, " CPS Condition Reports", which provides a means for F reporting conditions adverse to quality, and QA Procedure 216.06, "QA Program Evaluation and Corrective Action Trending" are being revised to emphasize identification of the precise problem and the initiation of immediate corrective actions, and to require the immediate notification of all departments affected by the condition identified. Immediate notification will include the use of an electronic mail system for promptly notifying all managers of "significant" conditions. The procedure revisions will emphasize the need to ensure that corrective action plans (generally developed at the Supervisor and Director levels) are sufficient to preclude recurrence; that they are discussed with, and approved by, responsible managers prior to their (1)

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.Att:chment C Response to NRC Concern Documented

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being approved and submitted to Quality Assurance for review and concurrence; and that the responsible department verifies that the corrective actions havo been effectively implemented prior to closure of the corrective action document. These procedure revisions are expected to be completed by January 12, 1990, t To ensure that personnel are aware of the problems identified regardin5 the pro 6 ram and the improvements being made, managers are conducting departmental briefings to emphasize to all nuclear program employees that the Correctivo Action Program is their program, and that to be effective, all problems must be accurately identified and acted upon immediately. In these meetings, the managers explain the importance of the corrective action program, the proper method for using the program, current-problems occurring at CPS regarding corrective action, and the efforts underway to improve the program. These departmental briefings are expected to be completed by January 30, 1990.

To further increase Clinton Power Station personnel's sense of ownership and accountability regarding the Corrective Action Program, an article about the program and planned improvements was placed in the October 30, 1989 Nuclear Program News, which is distributed to all Nuclear Program personnel.

Additionally, program billboards will be posted periodically at various site locations, and a discussion of program improvements-and status will be included in the Monthly-Performance Monitoring Management Report, which is made available to all personnel.

A training program,-entitled " Root Cause Correction and Verification" is being presented to all departmental managers, directors,-supervisors, and personnel involved in developing, implementing and verifying corrective actions. This training, expected to be completed by February 15, 1990, will provide meaningful guidelines for determining, implementing and verifying the effectiveness of-corrective actions, The Corrective Action Board (CAB) is meeting on an increased fixed frequency to discuss.the most recent "significant" Condition Reports (CRs). The board will be emphasizing more timely implementation of corrective actions to preclude recurrence of the problems identified on these CRs.

The Human Performance Evaluation System (HPES) developed by the Institute of Nuclear Power Operations (INPO) will be incorporated at Clinton Power Station.

The Human Performance Evaluation System is a program developed by INPO with the-intent of improving human reliability by reducing human errors through correction of the conditions that cause the errors. A project manager has

_.been assigned to develop and begin implementation of the HPES Program at Clinton Power Station.

The Corrective Action Trend Analysis Program has been restructured based on the identification and evaluation of root causes and causal factors contained in INPO Good Practice OE 907, Root Cause Analysis. The evaluation and presentation of root cause data will be conducted on an on-going basis.

Continually evaluating and presenting this data will enhance the ability to identify and correct potential problem areas prior to an adverse trend being (2)

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-Att:chment C Response to NRC Concern Documented in Inspection Report 50 461/89032 identified.- Additionally, the root cause data will be presented in a format (e.g.,' pie charts) that will be more useable by management. This method will i '

Lbe incorporated into the Monthly Performance Monitoring. Management Report and the Quarterly Integrated Illinois Power Company Quality Assurance Program Evaluation Report.-

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To ensure that conditions adverse to quality identified in 1989 have been J aioquately addressed, a special task force has been established to verify.

effective implementation of corrective actions for a11' closed Quality ,

Significant Condition Reports, Quality Condition Reporta, Notices of -

Violation, Licensee Event Reports, Audit Findings, and Trend Analysis Program '

- Roquests for Corrective Action during the period January 1,1989 through December 1, 1989. The: task force will evaluate these items and identify those i, for which effective corrective actions have not been implemented. When the 4

task force determines that effective corrective actions have not.becu implemented either the. original corrective action documents will be reopened or new corrective action documents will be initiated. The task force is developing practices and processes to ensure that problems detected with corrective actions are dealt with at levels appropriate to the action and its priority.

This task force is comprised of top quality experienced nuclear program representatives from each CPS department. Three members of the ten member task force are supervisory level personnel. The task force is being led by an

.; experienced director level person. The task force-will report directly to the Manager - Quality Assurance. The task force review is expected to be completed by June 1,1990.

Illinois Power believes that these new initiatives will improve the ability of 3 p9rsonnel to identify problems, and to initiate, implement, and verify .i corrective- actions and therefore significantly reduce the number of recurring )

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