ML20028F062
| ML20028F062 | |
| Person / Time | |
|---|---|
| Site: | Cook  |
| Issue date: | 01/24/1983 |
| From: | Hunter R INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG |
| To: | Taylor J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE) |
| References | |
| AEP:NRC:0752, AEP:NRC:752, NUDOCS 8301310081 | |
| Download: ML20028F062 (34) | |
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lNDIANA & MICHIGAN ELECTRIC COMPANY P. O. BO X 18 BOWLlHG GREEN ST ATION N EW YORK, H. Y.10004 January 24, 1983 AEP:NRC:0752 Donald C. Cook Nuclear Plant Unit Nos. 1 and 2 Docket Nos. 50-315 and 50-316 License Nos. DPR-58 and DPR-74 IE INSPECTION REP. ORT NOS. 50-315/02-17; 50-316/82-17 Mr. James M. Taylor, Director Division of Reactor Programs Office of Inspection and Enforcement U. S. Nuclear Regulatory Commission Washington, D. C. 20555
Dear Mr. Taylor:
The Attachment to this letter contains our response to IE Inspection Report Nos. 50-315/82-17; 50-316/82-17 which transmitted to us the findings of the NRC Performance Appraisal Section (PAS)
Inspection. We appreciate the comments and suggestions made by your staff during the conduct of their inspectien and contained in their report. In many cases action has been accomplished to implement the recommendations and in others we are performing the necessary reviews and planning for corrective action where appropriate, as described in the Attachment ' ' this letter.
This document has been prepared following Corporate Procedures which incorporate a reasonable set of controls to ensure its accuracy and completeness prior to signature by the undersigned.
Very truly yours, b
/os Vice President cc: John E. Dolan - Columbus I M. P. Alexich R. W. Jurgensen W. G. Smith, Jr. - Bridgman R. C. Callen G. Charnoff NRC Resident Inspector at Cook Plant - Bridgman 8301310081 830124 PDR ADOCK 05000315 PDR G
1 Attachment to AEP:NRC 0752 The Performance Appraisal Section (PAS) Inspection focused on Indiana & Michigan Electric Company (I&MECo) and American Electric Power Service Corporation (AEPSC) management controls over selected licensed activities in six areas. Each of the areas examined by the PAS is addressed below. The numbering system used below corresponds to that used in the PAS Report.
Plant Nuclear Safety Review Committee Sections 2.a.l.1 and 2.a.l.2 In response to PAS comments concerning PMI-1040 and PNSRC activities, the following actions are being taken:
(1) PMI-1040 will be modified so that it is the only procedure which delineates PNSRC duties and responsibilities. The PNSRC Charter will be cancelled.
(2) Criteria for the selection of alternate Committee members will be incorporated into PMI-1040. Generally, alternate Committee members will be those individuals who would fill the regular staff positions of the regular Committee members in their absence. Alternates to the Committee Chairman will be members of the Full Committee.
(3) Copies of PNSRC meeting minutes will be distributed to all alternate Committee members to ensure their continued cognizance of Committee activities.
(4) PMI-1040 will be modified to reflect the requirements for review of Quality Assurance (QA) and Nuclear Safety and Design Review Committee (NSDRC) audit reports as well as NEC
3 Inspection Reports (which contain citations for Technical Specification violations) and the licensee's responses thereto. The PNSRC will also review NSDRC mee.ing minutes, NSDRC reports, and reports on training programs for licensed and non-licensed personnel. In addition, the PMI will be revised to reflect the requirement to review designated operating records.
(5) A provision will be incorporated into PMI-1040 to handle dissenting opinions among Conunittee members.
(6) A thorough review of our entire safety evaluation process is being performed to ensur's compliance with the requirements of 10 CFR50.59 and the PNSRC responsibilities as defined in Technical Specifications Sections 6.5.1.6(a) through (e) .
Procedures for performing these evaluations will be prepared a
to assure an adequate and consistent approach.
(7) A training program will be established to cover the requirements of all PNSRC activities outlined in PMI-1040.
Particular emphasis will be placed on the requirement of 10 CFR50.59 safety evaluations to support changes in the plant design and/or operation. The training will be given to all PNSRC members, alternate members and Subcommittee members.
It will also be given to all replacements for the above. An annual refresher program will be conducted.
(8) A record of "Open Items" will be maintained by the PNSRC Secretary and discussions of such items will be held at regularly scheduled PNSRC meetings, as appropriate.
3 (9) PMI-1040 will be revised to address the use of specialists and consultants by the Committee.
The above described Corrective Actions will be implemented by May 31, 1983, except for Items (6) and (7) which will be completed by December 1, 1983.
Section 2.a.l.4 In response to the PAS concerns, regarding TS 6.5.1.7.b, the following Corrective Actions have been taken or will be taken:
(1) The PNSRC will review Technical Specification violations to determine whether or not unreviewed safety questions exist.
Documentation of the Committee's fi'ndings will be included in the PNSRC meeting minutes. This action has been implemented.
(2) As stated in our response to Section 2.a 1.2 above, a thorough review of our entire safety evaluation process will be performed to assure compliance with the requirements of 10 CFR50.59 and the PNSRC responsibilities as defined in Technical Specification, Sections 6.5.1.6(a) through (e) .
Procedures for performing these evaluations will be prepared to Assure an adequate and consistent approach.
[ (3) A training program will be established to cover the requirements of all PNSRC activities outlined in PMI-1040.
Particular emphasis will be placed on the requirement of 10 l
CFR50.59 safety evaluations to support changes in the plant design and/or operation. The training will be given to all PNSRC members, alternate members and Subcommittee members.
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4 It will also be given to all replacements for the above. An annual refresher program will be conducted.
Correr.tive action will be implemented by August 1, 1983.
Section 2.a.1.6 The review described in Section 2.a.1.4, above, will address the need for training of PNSRC members and alternate members regarding the structure and responsibilities of the Committee and the responsibilities of individual members and their alternates.
Section 2.a.1.7 Commencing in 1983 the American Electric Power Service Corporation Quality Assurance Department will audit the Plant Nuclear Safety Review Committee. These audits will be conducted at least once every 2 calendar years and will appear on the Quality Assurance Audit Plan Schedule.
I e
5 Nuclear Safety and Design Review Committee (NSDRC)
Section 2.a.2.1 In response to the PAS comments, the following actions have been or will be taxen:
(1) The Units 1 and 2 Technical Specifications were changed in Amendment 63 and 45, respectively to reflect the current organizational titles and NSDRC membership as reflected in the " %ctive edition of the NSDRC Charter. The above-referenced Technical Specification changes additionally made the functional reporting requirements consistent with the NSDRC Charter.
(2) The meeting minutes of the NSDRC already report the review of subjects discussed at the meetings to the Vice Chairman Engineering and Construction within 14 days. However, the NSDRC Charter will be revised to require submission'of reports of review of all items specifically listed under T.S.
6.5.2.7 to the Vice Chairman Engineering and Construction within 14 days.
(3) The NSDRC Charter, mis-quote of Technical Specification 6.5.2.8 in Section III of the NSDRC Charter "NSDRC Audit Procedure" will be corrected. The NSDRC Audit Procedures will be reviewed to incorporate the more flexible language of the T.S. specifying NSDRC audit " cognizance" rather than audit " performance", where appropriate.
(4) We will review pertinent licensee procedures to determine
6 where basic procedures should be referenced in the NSDRC Charter. For example, premedures exist which govern specific NSDRC subcommittee activities but these are not presently referenced in the NSDRC Charter.
(5) The NSDRC Charter will be revised to include guidelines on the use of alternates to include specific requirements on when an alternate can substitute for a member. As one means of keeping alternates updated on Committee activites, the minutes of each meeting will be distributed to alternates whether or not they were in attendance.
(6) The NSDRC Charter will be revised so an alternate for the Chairman is also a full Committee member.
(7) The Technical Specifications for the off-site safety review Committee do not require the review of specific " operating records". However, a requirement exists to review significant operating abnormalities. Operating records are under review to determine the means for best assuring that unusual Plant conditions are reviewed. The scope of review of the Subcommittee on Plant Occurrences is being examined to determine if additional operating records should be examined and reported to the full Committee.
(8) Several of the items listed in the finding for potential NSDRC review are currently assigned to NSDRC subcommittees.
Mechanisms will be established for Subcommittee presentations or reports to the NSDRC. The other topics listed will be considered for appropriate assignments either for full NSDRC review or Subecmmittee review and reporting.
7 (9) The membership of the NSDRC is predominantly selected from those persons whose normal duties require frequent involvement with the D. C. Cook Plant. Assignment of NSDRC memberc to perform NSDRC audits is rotated to permit Committee members to make on-site visits at periodic intervals. A program (" speakers bureau") has been developed and implemented requiring senior corporate engineering managers, the majority of whom serve on the NSDRC, to make presentations to senior staff members at the Plant on topics under their cognizance related to the operation and engineering support of the Cook Plant. Considerntion will be given to other means for improving the contact and dialogue between NSDRC members and Plant personnel.
(10) The NSDRC Charter will be revised to specifically provide for handling dissenting opinions among committee members.
(11) The NSDRC Charter will be revised to provide guidance on the definition and application of 10 CFR 50.59 as it pertains to NSDRC activities. Our target date for revision of the NSDRC Charter is August 31, 1983.
Section 2.a.2.4 The NSDRC recognizes that its responsibilities cannot be delegated to Subcommittees. Subcommittees, chartered to perform specific functions, will report the results nf their activities, findings and recommendations to the full Committee. The performance of the audit function of the NSDRC is addressed in our response to the Audit Section of the PAS Report. The compositions and responsibilities
8 of the various subcommittees will be examined during the forthcoming Charter revision to ensure their assigned tasks are comensurate with the competence of the Subcommittee membership and that the Subcommittees enjoy the ber.efit of the full Committee expertise and support, where required.
The activities of the NSDRC Subcommittee on Plant Occurrences will be expanded to include additional reviews necessary to satisfy their assigned responsibilities. For example, we have initiated a program to track significant Plant parameters and performance indices.
These will be reviewed to focus on the associated operating records which require closer scrutiny.
New procedures are being developed which will ensure the participation of all members of the NSDRC in the review process for each individual audit. Henceforth, all Audit Sunnary Reports will be forwarded to all members of the NSDRC and summaries of the individual audits will be presented at NSDRC meetings. In addition, procedures will be developed to document the review process of NSDRC Audit documents.
Section 2.a.2.5 In response to the PAS concerns, each NSDRC Subcommittee shall submit a copy of its meeting minutes to the Vice Chairman, Engineering and Construction, or shall submit a report to him every three months if no meetings were held.
9 Section 2.a.2.6 As of June, 1982, the NSDRC Subcommittee on Audits has assumed the responsibility to review AEPSC QA Audit Reports. A sununary report of the audits will be prepared by the Subcommittee on a six month basis. The first such report will cover the' period from June, 1982, to December, 1982. Subsequent to review and approval by the Audit Subcommittee, each semi-annual report will be forwarded to, and
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l reviewed by, all members of the NSDRC.
The NSDRC Subcommittee on Plant occurrences will assume the responsibility of review of significant non-reportable Condition Reports and NRC inspection findings, except those related to the Emergency Plan or the Security Plan which will be reviewed by the Subcommittee on Emergency and Security Plans,.to meet the requirements of Technical Specificiation 6.5.2.7.
The NSDRC Charter will be revised to require the NSDRC to perform or direct a semi-annual audit of the QA Department and to review written summary reports of the QA audit program.
The NSDRC Subcommittee on Plant Occurrences shall review the reports and meeting minutes of the PNSRC and make a report to the full NSDRC of all significant items, i.e. those involving nuclear safety.
The NSDRC Subcommittee on Proposed Changes shall review:
(a) Changes to pre-selected plant procedures, with potential "50.59" implications. The menbership of the Subcommittee shall include an engineer from the AEPSC Nuclear Engineering Division (or alternatively a member 4
of the NED shall be present at the meeting) who will
10 provide the Subcommittee with a safety evaluation of the change completed under the provision of 10 CFR 50.59 to verify that such actions did not constitute an unreviewed safety question. The review of procedure changes will be done after the change is effective, and a number of procedure changes may be collected periodically and then
, reviewed.
(b) Changes to equipment or systems. A review similar to that outlined in (a) above will be performed on all RFC's and on all Plant Modifications.
The findings of the Subcommittee review will be presented to th0 full NSDRC Jy meeting minutes or direct presentation at regularly scheduled NSDRC meeting.
Other changes being made in response to the PAS finding includes (1) The NSDRC members will receive a copy of all substantive changes to the AEPSC and Plant QA Policy procedures.
These distributions will be the responsibility of the AEPSC QA Manager.
(2) The NSDRC audit sched;1e will be expanded to include an audit of the activities of the NSDRC itself.
(3) A program will be developed and implemented to train, and periodically re-train (biannual refresher) , NSDRC members and alternates, and Subcommittee members, on the scope responsibilities and conduct of NSDRC activities.
This training shall include review of 10 CFR 50.59 requirements and Technical Specification reporting requirements.
11 NSDRC Audit Program section 2.a.3.2.
Under NSDP.C Audit procedures the Audit Summary Report was defined as follows: "The audit team shall summarize their findings in a formal Audit Summary Report using form QC-39. Open Action items shall be recapitulated and recommended corrective actions outlined.
The Summary Report shall contain a copy of the completed audit checklist, other audit documentation verifying compliance, and copies of all issued CARS." This report meets ANSI N45.2.12 Sec. 4.4 requirements.
The audit docket package, to be completed within 10 working days of the satisfactory disposition of all audit generated CARS,
" consisting of, but not limited to copies of the following documents;
- 1. completed Audit Checklist 2. Audit Summary Report 3. Dispositioned Corrective Action Requests 4. any other pertinient information, documents, etc." The Audit Docket Package includes all the documents previously transmitted under the Audit Summary Report Sheet plus additional information, in particular, the dispositioned corrective action requests.
The audit summary and its attachments, not just the single cover sheet, were used to meet the T/S requirement for 30 day reports.
We do not understand the source for the inspectors'. statement that only the single sheet summary form was used. The Audit Docket Package included additional information, but it was never intended that the Docket Package would be completed within 30 days.
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12 The inspectors indicated that there were contradictions between the NSDRC procedures and a form entitled " Audit Cover Sheet."
The Audit Cover Sheet was being used on a trial basis and has since been adopted by the NSDRC, now entitled " Audit Timetable", as part of the Audit Subcor.aittee Procedures. The original procedures (in effect at the time of the PAS inspection) specified the timing for some events to take place in " working" days and others in " calendar" days. To eliminate this inconsistency, the Audit Cover Sheet defines the timing only in calendar days. In preparing the cover sheet it was decided that no additional time would be allowed to complete the various parts of the audit procedure.
The procedures did not set a date for the completion of the audit docket package since specific timing was not given for the disposition of a CAR after the response had been received. The Audit Cover Sheet and Audit Procedures approved in August 1982, set specific times for the completion of all parts of the audit process. In particular, it was indicated that the CAR must be dispositioned within 5 calendar days if the audit team leader was in agreement with the disposition. If the audit team leader could not resolve the adequacy of the CAR disposition with the Plant Manager, or others involved, the dispute would be referred to the Audit Subcommittee and its Chairman l who must resolve the disposition of the CAR within 30 days.
Consequently, using the " Cover Sheet" the total time to the submission of the audit docket package would be 64 days from audit completion. Likewise, the audit docket package, with no dispute, would be due within 75 days of audit start and, if a dispute occurred, within 105 days of audit start.
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The trial cover sheet did not lengthen the allowed time as determined by the procedures and in fact set specific dates for the audit docket package which had to be met. Consequently, it tightened the process and was being used as a simplified measure for those who were handling the audits. In its reference to "Other contradictions..." (last para, p.15) the PAS fails to differentiate the time spans defined in " working" days (Procedures, in force at time of PAS inspection) and " calendar" days (Cover Sheet).
In light of the PAS concerns, the following changes are being made regarding NSDRC audits. In the future, the NSDRC audit program will be developed and administered by the AEPSC QA Department under the cognizance of the NSDRC and its Subcommittee on Audits. Qualified QA i
personnel will develop audit checklists, utilizing standard checklists and minimum checklist requirements in addition to items developed for the specific audit. Guidance will be provided on sample sizes for the specific items in checklists where appropriate. These changes will be incorporated in the audit procedures.
Section 2.a.3.3.
The following actione have been or are being taken in response to the PAS concerns regarding ANSI N45.2.12-1977 and Technical Specification 6.5.2.8:
(1) ANSI N45.2.12-1977 will be followed for T/S 6.5.2.8 requirements. Audit Summary Reports will include "an evaluation statement regarding the effectiveness of the quality assurance program elements which were audited".
Audits of procedure implementation will also evaluate procedure adequacy or effectiveness and include a statement
14 on that matter in the audit summary. This requirement will 9
be included in the audit procedures.
(2) In 1981 an additional member was added to the Audit Subcommittee to follow up on the timely submittal of audit reports. As a first step, audit procedures were proposed (and subsequently adopted at the August 1982, meeting of the NSDRC) to clarify schedule requirements and to improve performance. It evidently was not clear that CARS that required future activities for a final closecut, could be dispositioned and the audit docket package completed, without all the future work having been completed. Such corrective action requests were logged by the Subcommittee until final work was completed. As of August 1982, the NSDRC procedure place such items on the computerized commitment list maintained by AEPSC QA Department.
(3) New definitions and procedures are in place. However, further revisions and improvements will be incorporated in the procedures as the AEPSC QA Department takes over the administration of audits. The new audit program is targeted to be in operation by December 31, 1983.
i (4) NSDRC audit records will be stored in accordance with the requirements of ANSI N 45.2.9.
(5) As stated in our letter AEP:NRC:0625B dated May 13, 1982, the l
NSDRC Subcommittee on Audits has expanded its review function to include as part of its Plant audits an attempt to look for trends detrimental ta quality. The Subcommittee will concentrate its reviews on the implications of audit findings, searching for clues to problems that might exist
, 15 but are now uncovered by a single audit which by its nature is limited in scope. Subcommittee audit procedures will ensure the prompt resolution of all findings by the timely reference of problems to successively higher levels of- i management. The Subcommittee will bring significant findings to the attention of the full NSDRC for review, discussion and i
any additional necessary action.
As a result of the above, supplemental audits will be performed under the direction of the NSDRC of " deficient areas".
Qualified auditors meeting ANSI N 45.2.12 Paragraph 2.2 requirements 4
will be a part of all future NSDRC Audits. Complete implementation will be accomplished by December 31, 1983.
Section 2.a.3.4 We concede that of the 26 CARS written in 1981, four CARS generated in Audits 71, 75 and 76 were still open at the time of the +
PAS inspection. A review of Audit 79 CARS showed, however, that seven l had approved responses dated not later than March 22, 1982, and that one was closed out on July 23, 1982. The inspection report was based i
I on the Audit Status schedule, which could not reflect the Audit 79 CAR ,
disposition because the Audit Docket Package had not been approved at the time. All 1981 audit generated CARS are now closed out. As
, discussed previously, the method for the disposition of corrective l action requests has been clarified.
Open CARS were listed by the Audit Subcommittee on the Audit l
l Status sheet. When a CAR was closed out, it was so indicated but the detailed records were not on a separate listing but rather were kept f with the audit files. The new procedures, in place as of August 1982, i
track open commitments on the computerized commitment list in l
16 accordance with AEPSC General Procedure No. 2.2. This will ensure, by sign-off review, the adequacy of corrective actions. Procedures will be developed to review audit checklists to evaluate whether all necessary CARS were iscued and to initiate further action, if required.
Procedures will be strengthened to ensure that closeouts are timely, complete and proper. A special edition of the commitment list will keep the Audit Subcommittee advised of the status of NSDRC-generated commitments.
Sectica 2.a.3.5 The PAS inspectors indicated that NSDRC audits lacked adequate scope to effectively meet requirements of T/S 6.5.2.8 aad a number of examples were given. As discussed previously the audits were conducted by management personnel as members of the NSDRC. It is now planned that future NSDRC audits will be conducted in accordance with AEPSC QA Audit Procedures by AEPSC QA Department certified auditors.
Management personnel will normally participate for some period during the audit to address matters of broad concern, to participate in the decisions on the issuance of CARS,. or in the exit interview. NSDRC Audit Procedures will be prepared in time for the establishment of the new audit program which is targeted to be placed in full operation by December 31, 1983.
The new program procedures will address the scope and depth of audits and the coordination of audit plans and subjects. It will identify both on- and off-site activities subject to NSDRC audit in accordance with T/S 6.5.2.8 requirements and will assure that all appropriate criteria are addressed in a reasonable and timely manner.
17 Section 2.a.3.6.
The AEPSC QA Department will assume responsibility for planning and conducting audits under the cognizance of the NSDRC and its Audit Subcommittee. Additional time will be spent on each audit to increase the depth of coverage. Time spent on audits will vary based on the requirements of each audit; however, a guideline of about ten man days per audit for the annual and biannual T/S required audits will be set.
The number of items examined during an audit will be increased. The adequacy of selected previous CARS will be evaluated.
Sample sizes will be suggested where appropriate. Additional detail will be provided on written responses to checklist questions. Audit methods to verify program requirements will be prepared by trained AEPSC QA auditors.
Section 2.a.3.7 The statistics on the timing of completion of audit reports and CARS are summarized in our response to Section 2.a.3.3. Part of the problem in late completion was the interpretation of the audit summary report and audit docket package requirements by the PAS inspectors as previously discussed. However, additional efforts are required to improve performance. The addition of personnel to the Audit Subcommittee in 1981 and the procedures and schedules prepared in 1982 were significant steps in that direction. While the new procedures were adopted by the NSDRC at the August 1982, meeting they had been prepared well before the PAS inspection.
As previously indicated, NSDRC audits, usually conducted by
18 NSDRC members, were sent to the Vice Chairman Engineering and Construction, the Executive Vice President Construction and New York Engineering, the Chairman and the Secretary of the NSDRC, the Audit Subcommittee Chairman and the Plant Manager (all NSDRC members). The Chairman of the Audit Subcommittee and the Secretary of the Audit Subcommittee reviewed each audit report. New procedures will document the expanded review process. While each member of the NSDRC did not review each audit, an effort has been made to have each member personally involved in conducting audits at the plant or in the review of the audits or the audit program.
Reports of the Subcommittee on Audits to the NSDRC, at its regular meetings, only highlighted problem areas. A new format for reports will highlight areas of concern in each audit. Each member will now receive copies of the summary report for each audit.
The NSDRC has been keeping track of outstanding CAR commitments for many years on its audit status report. For an audit to be closed out each open CAR commitment had to be completed. The new procedures approved in August 1982, requiru this tracking to take place t
by use of the AEPSC QA Commitment List and bi-monthly reports on open and overdue items to the Chairman and Secretary of the NSDRC l Subcommittee on Audits.
To improve the overall NSDRC audit program, new procedures will define NSDRC activities that will review the status and effectiveness of the NSDRC audit program on a semi-annual basis.
Section 2.a.3.8 The NSDRC audit program will be administrated by the AEPSC QA Department under the cognizance of the NSDRC and its Audit
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l Subcommittee. A more detailed program will be instituted as previously indicated. The Audit Subcommittee will concentrate on overall reviews s
of the audit plans and schedules and on reviews of the audits.
Section 2.a.3.9 The audit status report will be issued as part of a quarterly report to the Vice Chairman of Engineering and Construction. It will continue to be a summary type report. As part of its new NSDRC audit responsibility, the AEPSC QA Department will maintain current detail j
documentation on the status of audit preparation, audit conduct, corrective action request, submission of various reports, and most 4
particularly the open corrective action request commitments requiring future actions to take place. Comments will be added, as appropriate, if delays or other problems occur.
The status of individual open CARS will be monitored by an NSDRC oriented edition of the Corporate Commitment List. This list i identifies each commitment by number, description of open items, person and department responsible for disposition, date received, date due final and date complete, and current status.
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Quality Assurance Audits In respcase to the PAS findings in the area of QA Audits, the i
- following corrective actions have been or will be taken I
l (1) Both the Corporate Procedure (QAP-19) and the Plant Quality Assurance Head Instruction (QHI-7020) are being revised to include guidance on the preparation of audit checklists, the i
preparation of audit reports, and deviation from the audit 1
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l _ _ _ . _ _ _ _ _ . . ~ _ - - - . - . - -
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checklists when conditions warrant. These procedures will be revised by February 28, 1983.
(2) Both QAP-21 and QHI-7021 have been revised to clarify the statement pertaining to waiver of lead auditor examinations.
The intent of this waiver is to allow acceptance of an examination given by an organization other than AEPSC or I&M Electric Company.
(3) PMI-2010 entitled Plant Manager and Department Head Instructions, Procedures and Associated Indexes, has been revised extensively. Revisions to this instruction address the concerns identified by PAS relative to guidance on instruction / procedure review criteria and reviewing lower tier instructions / procedures to determine if a change to a PMI has any impact on them. We plan to have this instruction approved and issued by Ma'y 31, 1983.
(4) The organizational structure, reporting lines, responsibilities, and staffing requirements, of the Plant Quality Assurance Department are currently under review to i
determine the optimum organization for fulfilling QA/QC responsibilities. Results of this management review will be used to correct weaknesses noted in the PAS report. We anticipate necessary changes will be in place prior to the end of 1983. These changes will addressed in the Regulatory Performance Improvement Program.
(5) Due to the difficulty in obtaining individuals with previous Quality Assurance auditing experience in the region around Cook Plant, we have been unable to hire experienced personnel. A decision was made to hire individuals with a
general professional background such as school teachers, security supervisors, etc., and train them to become fully -
qualified QA auditors. The Plant Auditor Qualification Program fully meets the requirements of ANSI N45.2.23 - 1978 which encompasses not only the classroom (or technical) aspects of auditing, but also the required experience. It is our position that before an individual can be qualified as a lead auditor, he must not only demonstrate comprehension of the technical knowledge required, but that he is fully capable of applying this knowledge in the actual performance of audits. The time required for an individual to reach the level where he can be qualified as a lead auditor is different in each case. We are making every effort to upgrade all of our auditors to the lead auditor level. It is to be noted that all audit activities are under the direct supervision of a full- qualified lead auditor.
(6) At the request of the AEPSC Manager of QA, the Plant Training Department is developing a program to provide auditors with a basic knowledge and understanding of Plant systems.
Tentatively, this program is envisioned as including both classroom work and in-plant walkdowns of systems, and would require about 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> per week for 14-18 weeks. The target for implementation of this program is December 31, 1983.
i (7) In a June 22, 1982 memorandum to the Plant QA Supervisor, the AEPSC Manager of QA established a program whereby he and the t
Plant QA Supervisor will review the Plant audit program during the first quarter of each year. The purpose of this program is to assess the overall audit program
22 accomplishments and effectiveness; determine if there are any trends adverse to safety or quality; and to assure that the audit program is providing feedback for continuous improvement of safety related programs and activities. In a memo, dated November 12, 1982, the AEPSC Manager of QA reviced the schedule for this review to be conducted during the first and third quarter of each year.
(8) In a memo dated June 22, 1982, the AEPSC Manager of QA directed the Plant QA Supervisor to prepare an annual summary report of the Plant Audit Program. This report will be in:luded in the Manager of QA's annual report to Senior Management.
(9) Commencing in 1983 the AEPSC QA Department will audit the Plant Nuclear Safety Review Committee. These audits will be conducted at least once every two calendar years.
(10) The AEPSC QA audit program will be reoriented to place emphasis on QA program implementation.
(11) Efforts have been initiated to research and develop
" standardized audit checklists" to be used to supplement the specific checklists developed for each audit. The AEPSC QA Department and Plant QA Department have initiated a joint effort to develop a standardized audit sampling plan and procedures for its use. The development of the " standardized l'
checklists" and sampling plan is targeted for completion by December 31, 1983.
l l (12) The AEPSC QA Department has initiated an effort to develop a trending program for audit findings. This effort is targeted for completion by December 31, 1983.
23 (13) Additional effort has been initiated to review the means of determining " effectiveness" of our QA program elements including possible " acceptance" criteria based on the audit sampling plan referenced above.
(14) Although the PAS Inspectors stated that the AEPSC (Corporate) audit reports met the program requirements, it has been recognized that additional descriptive material in support of audit findings would enhance our reports. As part of the corrective actions outlined above, the Corporate audit report format will be changed and instructions included in AEPSC audit procedures pertaining to descriptive material in audit findings.
(15) AEPSC and the Cook Plant have started the implementation of a comprehensive records program which will eventually result in audit records being microfilmed. A duplicate copy of the AEPSC audit record microfilm will be retained at the Plant, thereby meeting the ANSI N45.2.9-1974 requirements for record storage. Until this program is fully implemented, a copy of completed AEPSC QA audit reports will be sent to the Plant QA Supervisor for retention. A memo was issued by the AEPSC Manager of QA on November 15, 1982 to implement this interim measure.
DESIGN CHANGES AND MODIFICATIONS Section 4.a.1 The three Emergency Requests for Change (RFCs) identified as not having sufficient d:;ign verification documentation to meet the requirements of ANSI 45.2.11-1974 have been reviewed. These RFC's
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involved only minor changes to equipment rather than major design change. The following requirements of ANSI 45.2.11-1974 are noted:
(a) The verification shall be performed by competent individuals or groups other than those who performed the design or specified a singular design approval.
(b) The results be documented.
(c) The extent of the design verification required is a function of the item's importance to safety, the complexity of the design, the degree of standardization and the similarity with previous proven designs.
(d) Acceptable methods of verification include, but are not limited to: design review, alternate calculations and qualification testing. Design verification may vary from spot checking of calculations to actual tests in the field.
The following design verification was applicable for each RFC:
RFC 12-1803 This RFC modified the cooling water supply to the auxiliary feedpump bearing to increase their life and thus reduce maintenance outages.
A record of telephone conversations dated July 15, 1980 between the Cook Plant Manager, the Mechanical Engineering Division Lead Engineer and the Assistant Division Manager, Nuclear Engineering, which denoted engineering and safety approvals, respectively, was included in the RFC packet. .
25 This modification was relatively simple as it only involved installation of the 3/4" and 5' schedule 80 piping and associated valves and did not adversely affect the operation of the auxiliary feedwater system.
RFC 02-1823 This RFC authorized the temporary installation of a spool piece in place in the Unit 2 east motor driven auxiliary feedpump suction strainer. A record of telephone conversations between the Cook Plant Manager, a Nuclear Safety and Licensing (NS&L) Section engineer and the Assistant Division Manager of Mechanical Engineering which denoted the safety and engineering approvals, respectively, was included in the RFC packet. A subsequent transmittal of the support detail for this spocl piece included in the RFC, was made by the Mechanical Engineering Division's Piping & Valves Section. The bolt sizing was checked and verified by the Structural Design Section. This calculation and structural design approvals were indicated on the sketch included in the RFC.
RFC 02-1885 This RFC authorized the temporary installation of a plant fabricated split ring retainer for the Unit 2 steam generator stop valves until a replacement sleeve is installed. Approval to make this modification was given by the Executive Vice President - Construction &
N. Y. Engineering, on March 30, 1982 as indicated in the RFC. A proposed design of the new retainer was prepared at the plant and telecopied to the Piping & Valve Section for review. The sketch was
36 l
i reviewed and approved by both the lead engineer and the Piping &
Valves Section Manager.
A safety review was performed by a Nuclear Safety & Licensing Section engineer on March 30, 1992. Attached to the safety review memorandum was the design sketch of the new retainer. The valve was tested to insure proper operation subsequent to the modification.
Although our review of these three emergency RFC's demonstrates that there was sufficient design verification to meet the intent of ANSI 45.2.11-1974, AEPSC General Procedure No. 25 will be revised to more clearly establish the specific requirements for the initial review by AEPSC of emergency design changes, including the specific methods to be used for design verification. The target for the completion of this action is May 31, 1983.
Several concepts are presently being review at the plant to resolve the design review / verification aspects of Emergency Design Changes. Upon issuance of the revision to AEPSC General Procedure No.
25, the appropriate changes relative to the review and approval process for Em( rgency RFC's will be incorporated into PMI-5040.
Section 4.a.2 AEPSC had recognized the need to estab]ish general, overall guidance to assure uniform understanding and implementation of the design control requirements of ANSI N45.2.11-1974 as set forth in AEPSC General Procedure No. 3.0. AEPSC General Procedure No. 25 will be expanded, as required, to incorporate additional general guidance on design control. This revision is targeted for completion by August 31, 1983 after which applicable AEPSC engineering / design division
27 instructions will be revised as necessary to provide other specific guidance, as required.
Section 4.a.3 At the time of the audit there were 21 emergency RFC's listed on Design Change Status Report 1 as open. One of these RFC's had been reviewed by the NSDRC Proposed Change Subcommittee (PCS) in 1977, one was reviewed at its November 17, 1982 meeting and three at its December 17, 1982 meeting. Two other emergency RFC's are non-safety related and therefcre do not require the Subcommittee review. Eight of the fourteen remaining emergency RFC's have the field work complete and document packets submitted to AEPSC Engineering for review and normal approval routing. Six of these.eight have been approved by Engineering and forwarded to NS&L for their safety review. These are then scheduled to go for CCB approval, then review by the PCS by July 1983.
The remaining four are scheduled to be forwarded for supervisory approval, NS&L review, CCB approval, and review by the PCS by July 1983.
Five of the six remaining RFC's which have not been submitted to AEPSC for engineering and safety reviews are in various stages of documentation at the plant. The other RFC still required completion of a portion of the field work due to its interaction with another RFC.
Actions will be taken following the current Unit 2 refueling outage to expedite the processing of these RFC's.
Section 4.a.4 AEPSC General Procedure No. 25 (GP-25) is currently being revised to incorporate the Procedure Temporary Sheets and other current
28 practices. The target for completion of this action is May 31, 1983.
Several concepts are presently being reviewed to resolve the design review / verification aspects of Emergency Desigr. Changes. Subsequent to issuance of a revised GP-25, the appropriate changes relative to the reviev and approval process for Emergency RFC's will be incorporated into PMI-5040.
Section 4.a.5 AEPSC and the Cook Plant have started the implementation of a comprehensive records program which will eventually result in design calculations being microfilmed. A copy of the AEPSC design calculation microfilm will be retained at the Plant thereby meeting the ANSI N.45.2.9-1974 requirements for record storage.
Section 4.a.6 This item is concerned with an inadequacy in PMI-5040.
Revision 4, in that a hold point did not exist which assured that drawings and procedures had been revised upon the completion of an RFC.
A hold point was established in PMI-5040, Revision 5 (issued September 14, 1982) for both partial and complete RFC installations.
The training aspect of this item which concerns the l
acclimation of Plant personnel, specifically operators, to completed Design Changes is presently being reviewed.
i l Section 4.a.7 The AEPSC Change Control Board will issue, on a periodic basis, a statur report on "open" RFCs, including yearly totals and i
i
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I trends. This report will be sent to Division Management with copies to the Executive Vice President of Construction and N. Y. Engineering.
At the time of the PAS audit there were 17 emergency RFC's written prior to the end of 1979 listed on Design Change Status -
Report 1, which had not been closed out.
Eleven have the field work completed and the packet submitted to AEPSC for review and approval.
Three have the field work completed but the packet has not been submitted to AEPSC due to the need for the field to complete the verification package.
Three still require completion of some portion of the field work due to the nature of the RFC.
Of the eleven packets submitted to AEPSC where field work is complete, one has been reviewed by AEPSC and returned to the plant for final closeout. Four have been approved by the CCB and the remaining six are scheduled to be reviewed by the CCB by March 1983.
The large number of open RFC's, including the 100 normal RFC's initiated prior to 1978, results primarily from our priority system. RFC's are classified into several priority levels based upon their impact and importance to nuclear safety, preventing reoccurence of reportable events,* personnel safety, etc. The priority assigned to an RFC determines its implementation sequence. The top priority level is reserved for NRC mandated changes and those changes that AEPSC/IMECO have committed to the NRC to implement. Many of the lower tier priority RFC's propose changes that have no impact on nuclear safety, and are generally defined as " convenience" type changes to be implemented when manpower and funding permit.
30 Section 4.a.8 The Plant instruction for implementation of design changes is being reviewed and the concept of utilizing specific procedure (s) to control design modifications is being considered where applicable,.
! l The criteria established within ANST N18.7-1976 relative to inspection hold points and the criteria stated in the Plant's FSAR relative to inspection hold points ("such inspections shall be performed by qualified individuals other than those who performed or directly supervised the activity being inspected") have been re-emphasized to all responsible managers and supervisors. It is *.he Cook Plant's policy to meet the intent of this criteria. To ensure that these criteria are being achieved, the Plant Quality Assurance Department will perform periodic audits and surveillances to ensure compliance.
A review is being performed of the site QA organization and the Plant's Quality Control Implementation Coordinator functions with the intent of relieving some of the administrative functions that these I
groups are performing which would allow them to perform more random and unannounced inspections of work activities in progress. This review is scheduled for completion by February 28, 1983.
MAINTENANCE Section 5.a.1 Plant Manager Instruction PMI-2290 was recently reviewed, revised and issued (November 23, 1982) to ensure that it reflected the Plant's current mode of operation. During this review a deficiency was noted in that the requirement to obtain the Shift Supervisor's permission prior to starting work, or the requirement to notify the
31 Shift Supervisor of completion of work, for all maintenance activities was not included in the PMI. It was not the Plant's intent to have this requirement be all inclusive. The latest revision to this PMI has resolved this ambiguity.
Section 5.a.4 The need to develop a method to ensure timely revision of procedures and limited use of temporary sheets for extended periods of time was previously identified by both Plant Quality Assurance audits 4
and NRC audits at the Cook Plant, and the Plant Staff was working on a means to correct the problem. The corrective actions being considered included utilization of word processing equipment to ensure rapid changes to procedures. In addition, the Plant Manager has instructed Plant personnel to consider the following:
(1) Utilizing a temporary change only when necessary and to hold back those items deemed as convenience items until the next revision of the instruction or procedure and,
, (2) The institution of the use of a full page temporary change I
sheet concept whereby temporary changes are incorporated into the body of a procedure resulting in procedure continuity.
This concept saould eliminate the difficulty of following procedures due to the temporary changes that were placed in the front of procedures requiring an individual to go back and forth while reading or working to a procedure.
Section 5.a.5 The criteria relative to inspection hold points contained within ANSI N18.7-1976 and the FSAR has been re-emphasized io all
32 responsible Department Heads. To insure full compliance with these criteria, the Plant Manager has requested the Plant Quality Assurance Department to perform periodic surveillances of these inspection hold points.
Section 5.a.8 The Plant Manager has directed all Department Heads to include in their weekly report to him a status of the Job Orders within their department.
Section 5.a.10 The overall organization of training-related activities at the Plant will be reviewed. The objective is to have the Plant Training Section review the individual department training prograns,' provide assistance for such things as lesson plans, learning objectives and to retain all training records of Plant personnel even though the Training Section may not have conducted the training.
Section 5.a.ll Starting in January 1983 a trial program for logging C&I surveillance testing will be initiated. This program will be reviewed af ter one month by management for both the Technical and Operations Departments to assess its effectiveness. If it is deemed by management that this program is warranted, it will be incorporated into the appropriate plant procedures.
In addition, an extensive review of the controls established by Plant Manager Instruction 2140 entitled Bypass of Safety Functions:
Jumpers, Grounds, Lifted Wire and Blocked Relay Control is currently
7 33 being performed. Upon completion of this review, we will take the actions necessary to strengthen these controls. As part of this review, the weakness identified pertaining to lifting leads or installing jumpers will be considered. It is anticipated that this PMI will be issued by May 1983.
CORRECTIVE ACTION SYSTEM Section 6.a.5 The NSDRC Subcommittee on Plant Occurrences has initiated a program to track significant Plant parameters and performance indices.
These wfl1 be reviewed to focus on evaluating adverse trends or generic issues from Condition Reports, Licensee Event Reports and other pertinent documents. An attempt will be made to establish benchmarks by which per- rmance can be measured and* evaluated. Use of INPO guidelines will be used where they exist to assist in the establishment of benchmarks.
PROCUREMENT Section 7.a.7 The flange spool pieces identified in the PAS Report were wrapped as required by ANSI N45.2.2-1972. A review of this ANSI standard is being conducted to insure that its intent is followed for all applicable material covered by the standard.
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