ML20012D491

Responds to NRC 900208 Ltr Re Violations Noted in Investigation Rept 4-89-002.Corrective Action:Proper Sequence of Insp Hold Point Placed in Procedure Under Change Implemented on 880425

ML20012D491
Person / Time
Site:	Waterford
Issue date:	03/21/1990
From:	Burski R LOUISIANA POWER & LIGHT CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
EA-89-212, W3P90-0254, W3P90-254, NUDOCS 9003270412
Download: ML20012D491 (8)

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[E' Lou 6etene Power & Light Company g 1 317 Baronne Street

,. P. O. Box 60340 New Ortsans, LA 70160-0340 Tel. $04 595 2805 c--

R. F. Surski  ;

Nuclear Saloty & Regulatory ANairs- ,

Managa 1

t. I I W3P90-0254 A4.05 '!

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'U.S. Nuclear Regulatory Commission l ATTN: Document Control Desk Washington, D.C. 20555  ;

Subject:

Waterford 3 SES. l l- Docket No. 50-382  ;

License No. NPF-38  !

h NRC Investigation Report No. 4-89-002 Reply to a Notice of Violation (EA No.89-212)  :

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Gentlemen:

'In accordance with 10 CFR 2.201, Louisiana Power & Light hereby submits in Attachment 1 the response to the Notice of Violation identified in your letter dated February 8, 1990. Note, this submittal date reflects the ten day extension _that was granted by Mr. D.D. Chamberlain of your office during a telephone conversation with Mr. L.W. Laughlin of LP&L on March 13, 1990.,

If you have any questions concerning this response, please contact l T.J. Gaudet at (504) 464-3325.

L Very truly yours, 1"

g RFB/TJG/ssf

' Attachment cci Messrs. R.D. Martin, NRC Region IV F.J. Nebdon, NRC-NRR D.L. Wigginton, NRC-NRR E.L..Blake W.M. Stevenson 1 NRC Resident Inspectors Office

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i LP&L RESPONSE TO THE NOTICE OF VIOLATION IDENTIFIED IN YOUR LETTER DATED FEBRUARY 8, 1990 ]

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VIOLATION A .;

I L Procedure Deficiency l

Technical Specification 6.8.1.a requires, in part, that written procedures' shall be maintained for quality related work as recommended in Appendix A

, of Regulatory Guide 1.33, Revision 2, February 1978. Appendix A includes' ,

gor procedures for' conduct of maintenance.

10 CFR 50 Appendix B, Criterion XVI, requires in part that conditions

" adverse to quality be promptly identified and corrected.-

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Contrary to the above, prior to April 25, 1988, Maintenance Procedure .;

ME-13-100, " Fire Barrier Installation and Rework," was deficient. An j inspection hold point was placed in Section 8.2.6 sequenced such that

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c surfaces to be inspected'were covered up with sealant, thus preventing the ,

I inspection as intended by the procedure. In addition, this deficiency in ';

the procedure, a condition adverse to quality, was recognized by LP&L '

personnel but was not promptly corrected.

This is a Severity Level IV violation, j RESPONSE r w ,

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(1) Reason for'the Violation  ;

LP&L admits this violation and has identified two root causes. The root cause for Electrical Maintenance Procedure ME-13-100 to be <!

deficient in the first place was an inadequate technical review'which allowed the incorrect placement of an inspection hold point. The-root  ;

, cause for this procedural deficiency to have existed for such an extended period of time was a lack of procedure compliance in that  :

L -although personnel performing the procedure were aware of the, deficiency (the out-of-sequence hold point), appropriate changes were not made prior to continuing performance of the repair work. As'a result, a condition' adverse to quality existed since June, 1985, the ,

date of the associated revision, but>was not corrected until April, 1988.

During. Revision 3 to the procedure, in June, 1985, it was recognized  ;

that an inspection hold' point was needed in the body of the procedure e to ensure that the removal of two inches of sealant material from ,

around the periphery of the damaged area vas being properly inspected.

Due to an inadequate technical review of the proposed procedure changes, the hold point was incorrectly sequenced in the procedure to  !

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) require inspection of the area af ter it had been reworked and new sealant had been applied. It is believed that had a proper technical review been performed the out-of-sequence hold point would have been identified and corrected and this violation would not have occurred.

LP&L also believes that the basis for this condition to have existed for such a long period of time was indicative of a weakness in the implementation of the requirements for procedure compliance. As a result, attitudes on procedure compliance at that time were such that h if an individual was familiar with the scope of the work for a

specific task, yet it differed from that of the governing procedure, P the individual could correct the situation at hand without having to

[ process a procedure change.

i In this particular instance, personnel involved with the fire L penetration repair work and its inspection were mainly contractors or personnel from organizations other than those from the Maintenance Department who were directly responsible for the procedure and changes

( thereto. Even though.many of those that were involved were aware of the deficient procedural sequence, they changed the practical sequence to meet what they believed was its intent without recommending or pursuing a procedure. change. The procedural deficiency was not at that time properly identified as a. condition that was adverse to quality. Consequently, it was left uncorrected for an extended period of tiac without proper dispositioning until a concern had been raised by an individual performing the repair work.

(2) Corrective Steps That Have Been Taken and the Results Achieved Once the procedural deficiency was brought to the attention of the Maintenance personnel in direct control of the procedure, the proper  !

sequence'of the inspection hold point was placed in the procedure ,

under a change that was immediately implemented on April 25, 1988. j It should be noted however that even though the subject hold point was out of sequence from June, 1985 to April, 1988, a subsequent hold

• point in the procedure during that time period specifically verified adhesion to the surrounding material. April, 1989 tests demonstrated excellent adhesion of the silicone _ foam installed even on top of undisturbed seal material. The fire seal inspection that was conducted between November 1988 through November 1989 identified no deficiencies regarding adhesion.

To improve the quality of reviews in the future, the current procedure for installation and rework of penetration seals, conduit seals, fire breaks and water barriers (Nuclear Operations Construction Procedure NOCP-301) requires a fire protection engineer review of changes to the procedure. Note, ME-13-100, Revision 6 had been replaced in January, 1989 by procedures, NOCP-300 for Fire Wrap Installation and Rework and NOCP-301 as described above. Subsequent to the issuance of the new A

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procedures, applicable Nuclear Operations Construction personnel were l trained on the procedures. Also, to enhance the existing training and -

qualifications for personnel involved in the installation of fire  :

seals, Nuclear Training Course Description NTC-129 and the associated Lesson Plan were revised in October and December, 1988, respectively.

L A Quality Notice (QN No. QA-89-278) and a Potential Reportable Event Report (PRE-89-138) were generated on 12/19/89 to ensure that proper i'

dispositioning of the condition adverse to quality was achieved and to properly. enter such a condition in the Waterford 3 Corrective Action Program (N0P-005). (Note: The PRE was dispositioned as not i reportable because although the_ hold points may have been conducted ,

-out ofl sequence, the final inspection was adequate to ensure fire  !

barrier cperation.) _ NOP-005 has undergone a major revision since this 1 L procedure deficiency occurred to ensure that conditions adverse'to quality and significant11ndustrial safety and plant reliability concerns are'promptly identified and corrected. (NOP-005 did not even  :

i E exist until December, 1985.)

LP&L has undertaken numerous programs and corrective action +

initiatives to upgrade procedures, enhance procedural compliance and to educate personne1'regarding management's standards and expectations. As part of LP&L's Improving Human Performance Program,  !

the Operation Zero Dtviation Program was developed to stimulate teamwork directed at compliance with plant procedures, work l

-instructions and plant expectations and standards. Although in its '

initial implementation stage, a Precursor Trending Program was recently_ established to identify, trend and ultimately provide corrective action for deficient conditions, such as procedural human factors deficiencies, which are minor if taken individually but collectively could lead to more serious problems if not addressed in a timely manner. A Plant Management Directive was issued on Procedure 't Compliance.- It specifically states that 1) if a procedure is  !

incorrect then fix it before you use it, 2) if a procedure is correct '

then comply with it and 3) if you have any comments or concerns about the adequacy of a step in a procedure, regardless of magnitude, then j contact.your supervisor for discussion and potential changes.

• Subsequent to the issuance of this violation, this directive was '

reviewed with plant and Quality Assurance personnel during one-on-one counselling sessions.

The above mentioned programs (as well as others) display the emphasis that Management has placed on procedure compliance and professionalism. The discussion of such events during plant safety meetings and the issuing of memoranda when such conditions occur have heightened personnel attention to procedural compliance and adequacy at Waterford 3 in the past year to the point in which this type of I violation should not be repeated in the future.

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o, In addition to the above, the. Senior'Vice President-Nuclear Operations 44 , issued a memorandum'on' 12/19/89-to bring this' matter.to the attention y g. , of all Nuclear Operations Employees. It addresses this incident

!d .specifically and procedure ~ compliance in general.

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(3) Corrective Steps Which Will be Taken to Avoid Further Violations

- Based on the actions described above in 1 tem (2), LP&Llis confident z

i jj that similar violations will be prevented in the future.

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.(4) Date When Full Compliance Will Be Achieved

[ .LP&L is currently in full' compliance.

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( Page 5 of 7 l VIOLATION B '

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Inaccurate Inf ormation Provided to NRC r g 10 CFR'50.9 requires, in part, that information provided to the Commission

.s :by.a licensee shall be complete and accurate in all material respects.-  !

li Contrary to the above, information provided to the Commission during a June-i '18-July 31,'1988, inspection at LP6L's Vaterford plant was not complete and

[ accurate in all material-respects. The information, provided orally in

[ response to an inspector's questions, did not accurately reflect the i i sequence of quality control inspections for fire seal repair work, and was d material in that the inspector relied upon the information to bring the /{

b matter to.a close in an inspection report issued on August _ 25, 1988.

L This is a Severity Level IV violation.  ;

b RESPONSE i: ,

-(1)' Reason for the Violation LP&L also admits this violation and believes that its root cause was personnel error. A Quality Control (QC) inspector, who was  :

responsible for perforr.ing inspections of reworked penetration seals -

prior to their being refilled with iireproof. insulation, provided inaccurate information to an NRC inspector when questioned by him. A +

contributing'cause to this violation was the procedural deficiency (the out-of-sequenced inspection hold point) that existed from June,  !

1985 to April, 1988 as'was described above in Violation A.

In August, 1988, an NRC inspector was investigating an allegation that

_had been made by an individual with' regard to the failure of a Waterford 3 QC inspector to perform inspections of reworked penetration seals prior to their being refilled with fireproof insulation material. During the NRC inspector's investigation, he g noted that the governing procedure (ME-13-100, Revision 6) had undergone a recent change (in April,1988) to correct the sequence of '

an-inspection ho13 point to verify the removal of two inches of .,

material around the penetration which had incorrectly been placed in the procedure after the area had been refilled with the insulation ,

material rather than before. Although the procedure had remained 1 deficient due to the out-of-sequence hold point for an extended period e of time, those involved with the repair work changed the sequence in practice in order to meet what they believed was its intent.

Accordingly, in practice, whenever the responsible personnel completed the removal of two inches of seal material around the periphery of the penetration, they would contact the cognizant QC inspector to perform a visual inspection of the work prior to the next step, refilling the area with insulation material.

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L The NRC resident inspector discussed this situation with the L responsible QC' inspector. When questioned by the NRC inspector as to H the actual sequence of'the hold point inspection,'the responsible QC i inspector replied that verification of removal of two inches of  ;

material was always performed prior to the refill of insulation.

material. On occasion, however, the QC inspector had performed the hold point in the sequence of the procedure after the area had been refilled. By not providing accurate information to the NRC when orally. questioned, the QC inspector violated 10CFR50.9. Although Lp6L I

L had admitted and accepted this violation, it is believed that the h, responsible.QC inspector did not make such a statement intentionally .

or maliciously.

(2) Corrective Steps That Have Been Taken and the Results Achieved l Lp6L conducted an' in depth re':ords review of procedures, inspection logs, test data and reports related to the performance of inspections  ;

of reworked penetration seals. As part of the review process, ,

interviews were held with personnel f rom Waterford 3 Quality Control 0- responsible for performing inspection hold point verifications and plant maintenance and contractors responsible for performing the i reworked seals. The results of the review indicated that this. incident was an isolated case (No other evidence of missed inspections was found regarding this individual. Other i inspection work conducted by this individual is acceptable. The '

only other inspector qualified in this particular procedure did not employ a similar. practice.); ,

- final inspection of fire seals was done as required by-the procedure and provides a high degree of confidence with regard to

-acceptability of the seal;

- fire seals are acceptable (Obvious seal adhesion problems would nave been identified.during the fire seal reinspection program conducted from November, 1988 to November, 1989. ~ Removal of seal material to facilitate adhesion was later. determined unnecessary by a special test.);-and bypassing hold points was not an accepted or common practice at Waterford 3 (There were only 13 missed inspections that were identified out of over 60,000 inspections conducted-during 1987-1989. The importance of complying with hold points is clearly recognized by QC and Maintenance personnel.)

Also, the Lp6L Quality Team (personnel assigned to receive, investigate, evaluate, resolve, and document Waterford 3 quality / nuclear safety concerns relating to the design, procurement,-

construction, maintenance, modification, or operation of Waterford 3) determined by-review of 128 concerns identified from January, 1987 to November, 1989-that no other quality team concerns relating to inspection were identified during this period.

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. a .. W3P90-0254 Page 7 of 7 ff y The responsible individual was required to meet with Quality Assurance b and Quality Control personnel to openly discuss his personal experience with this incident.- In his discussion, he specifically addressed procedural compliance, proper identification and

" documentation'of deficiencies, inspection and documentation relating to hold points and'the need for honesty, forthrightness nnd integrity.

On 12/5/89,.the. responsible individual was removed from the performance of all safety-telated work for a period of approximately.

60 days. (Notes From April, 1989 to 12/5/89, the individual had been y removed from performing safety-related QA inspections.) The individual has sin:e bcen restored to performing safety-related work

[ on a conditional basis with continued monitoring by appropriate

[ supervisory.and management personnel. After a period of approximately 6 months, the individual's. performance will be evaluated and.if found

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K ' acceptable he vill be restored to an unconditional status. The L evaluation shall be documented and made a part of the individual's permanent personnel file.

A letter was issued from the Senior Vice President-Nuclear Operations

.to bring this matter to the attention of Nuclear Operations personnel.

It outlined the actions LP&L has taken as a result of this event and-the expectations of management.

(3) Corrective Steps Which Will be Taken to Avoid'Forther Violations LBased on the actions d'escribed in Item (2), LP&L is confident that i similar violations will be prevented in the future.

(4)' Date When Full-Compliance Will Be Achieved LP&L is currently in full compliance.

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