ML20033C667

IE Performance Appraisal Insp Rept 50-293/81-20 on 810720-31 & 0810-14.No Noncompliance Noted.Major Areas Inspected:Mgt Controls in Committee Activities,Qa Audits,Design Mods, Maint,Operations,Corrective Actions Sys & Training

ML20033C667
Person / Time
Site:	Pilgrim
Issue date:	09/03/1981
From:	Ang W, Hardin A, Heishman R, Hinckley D, Oberg C, Woessner J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE)
To:
Shared Package
ML20033C664	List: ML20033C663 ML20033C667
References
50-213-81-20, 50-293-81-20, NUDOCS 8112030612
Download: ML20033C667 (44)

See also: IR 05000293/1981020

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U.S. NUCLEAR REGULATORY COMMISSION

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0FFICE OF INSPECTION AND ENFORCEMENT

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DIVISION OF PROGRAM DEVELOPMENT AND APPRAISAL

PERFORMANCE APPRAISAL SECTION (PAS)

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Report No. 50-213/81-20

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Docke'tJ E 50-293

License No. DPR-35

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Licensee:

Boston Edison Company

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800 Boylston Street

Boston, Massachusetts 02199

Facility Name:

Pilgrim, Unit 1

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Inspection at:

Pilgrim, Unit 1, Plymouth, Massachusetts

Boston Edison Company, Boston, Massachusetts

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Inspection Conducted:

July 20-31 and August 10-14, 1981

Inspectors:

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C. Oberg, Inspecgon Specialist (Team Leader)

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J. Woejsner, Inspection Specialist

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-d ALi 9lshv 'D. Hinckley, Insp! pecialist ection 'Date , (2d/~d'a 9Ab / A' Hardin, Inspection Specialist Date 'l 9 f31Q W. Ang, Inspection Specialist Date s Accompanying Personnel:

• N. Moseley, Director, Division of Program

Development and /ppraisal

• J. Partlow, Chief, Program Appraisal Branch

, C. Haughney (July 20-31) W. Holden (July 27-31)

• Present during the exit intervi

on August 14, 1981 Approved by- - - [/ / f."F. Heishman, Chief, Program Appraisal Section Dat"e v s I '8112030612 810914 PDR ADOCK 05000293 ,3 O PDR v-

.e ,. - , . . _ -. ._ . ___ _ . . . , _ - + ' ' ' ' ' 'l Og .- ~ N,1f ' ' 1 , " Inspection" Summary:. N P x. , +' ' Inspection on Ju]y F.5-31 and ' August 10-14' 1981'(Report No. 50-293/81-20 , -Areas; Inspected: .A special, announced inspection was performed of the licensee's management controls.over selected licensed activities. The- - ^.' -inspection (by five NRC Inspection Specialists) involved 528 inspector-hours onsite and at theicorporate office. 9, , .Results: The licensee's management controls in eight areasiwere-rev.iewed, '

s and conclusionD wEre drawn in each' area based on observations presented in

t this: report. 'The' conclusions are' presented as Above Average, Average, or. . ~. Below Average' as' fallo'ws: .>- ' - ' .g. \\' . Section 2',- Committee ~ ctivities - Below Average o Section 3,- Quality Assurance Audits .Below Average ~ Section 4 Design Changes and Modifications -Average- 3 ' 'Section:5, Maintenance - Below Average- Section 6, Licensed'Adtivities-(Operations) - Av eage Section 7, Corrective Action Systems - Below Average Section 8, Licensed and Nonlicensed Training - Below Average m Section 9, Procurement - Below Average Additionally, e number of' observations were presented to the Senit,r NRC- Resident Inspector as potential enforcement findings for followup as- appropriate. Thes'e' observations were also ~ discussed with the licensee durin'g + meetings on July 30 and August:14, 1981. - _ s , - . ~ ! l h . l (' ~ o , .

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. . . . -ic - . . . . . TABLE OF CONTENTS \\ < ! t l * TOPIC PAGE Inspection Scope and Objectives, Section 1 2 r3 l+ Committee Activities, Section 2 2 . Quality Assurance Audits, Section 3 '6 Design Changes and Modifications,'Section 4 17 Maintenance, Section 5 20 Licensed Activities (0perations), Section'6 22 l

Corrective Action Systems, Section 7

24 , l l Training, Section 8 28 ~ ' Procurement, Section 9 35 Management Exit-Interview 39 l Attachment A, Persons Contacted and Documents Reviewed A-1 l l l p. - l - 1 ^ . > , m k e w y

, - - g- ,. . Details L Inspection Scope and Obje'ctives The objective of the inspection was to evaluate the management control systems which have been established in support of licensed activities. The results will provide input to the NRC evaluation of licensees from a. ~ national perspective. 'The inspection effort covered licensed activities in selected functional arecs. In each of the functional. areas the inspectors reviewed written policies, procedures, and instructions; interviewed selected personnel;- and reviewed selected records and documents to determine whether: a. The licensee had written policies, procedures, or instructions to provide management controls in the subject area; b. The policies, procedures, and instructions were adequate to ensure compliance with the regulatory requirements; c. The licensee personnel who had responsibilities in the subject areas were adequately qualified, trained, and retrained to perforir, their responsibilities; d. The individuals assigned responsibilities in the subject area understood their responsibilities; and e. The requirements of the subject area had been implemented and appropriately documented in accordance with management policy. The specific findings in each area are presented as observations which are inspection findings that the inspectors believe to be of sufficient significance to be considered in the subsequent evaluation of the licensee's management performance. The observations include perceived strengths and weaknesses in the licensee's management controls that may not'have specific regulatory requirements or guidance. The observations provide the basis for drawing conclusions in each inspected functional area. The conclusions are presented as Above Average, Average, or Below Average, and represent the team's evaluation- of the licensee's management controls in each area. Some observations identified as weaknesses may be potential enforcement 4 findings. These observations were discussed with the licensee and were presented to the Senior'NRC Resident Inspector. The followup of these items will be by the IE Regional office. 2. Committee Activities The objective of this portion of the inspection was to evaluate the adequacy of,the licensee'.s_ management controls associated with the , activities. conducted by the Operations Review Committee (ORC) and the ~ Nuclear Safety Review and Audit Committee (NSRAC). - _ _ _ ~

_ -. -3- i . .. a. Observations- The following. observations, include the perceived strengths and weaknesses in the licensee's management controls that may not have specific regulatory requirments but will provide the basis for subsequent performance evaluations. Operations Review Committee (ORC). (1) The charter for the on-site committee, which at Pilgrim I was called the Operations Review Committee (0RC), listed the TS requirement for the ORC except for item 6.5.A.8, which, in part, requires written minutes for the ORC meetings be forwarded to the Nuclear Safety Review and Audit Committee (NSRAC). The charter also did not contain requirements to review the following. NRC Bulletins and Circulars . Audit Reports . Specific Operating Records . Fire Protection Plan . Surveillance Test Records . Changes to the QA Program . NRC Inspection Reports and Responses thereto . Interviews with ORC members and review of the ORC minutes revealed that the ORC did not normally review these documents.

(2) The ORC is required by TS 6.5.A.6.e. and by Nuclear Operations Department (N0D) procedure 1.2.1, Operations Review Committee, revision 10, to investigate all violations of the TS. -QA Audit 81-03 discussed a violation of TS, Section 6, by the Operations Review Committee. The ORC failed to review QA Audit Report 81-03, and this resulted in ' failure to meet NOD procedure . 1.2.1 and TS 6.5.A.6.e. This item was discussed with the licensee and was presented to the Senior NRC Resident Inspector as a potential. enforcement finding. (3) N0D procedure 1.2.1 was deficient in the following areas. (a) Thero was no time requirement specifying when meeting minutes should be_ issued following an ORC meeting. As a consequence of this deficiency, there were 11 sets of minutes undistributed as of July 26, 1981. These were for ORC meetings 81-46'on June 17, 1981 through 81-57 July 22, ~1981;

' ' , .- , < ,_ _L4 - _ , ~ .y - -. <(b) iThe membership of'.'the ORC as shown in the charter did not . agree with position titles as shown in the TS.'

Specifically, " Chief Operating Engineer"'had been' changed

to " Day. Watch Engineer / Nuclear Watch Engineer." ~~ (c) According to'the licensee's understanding, TS 6.9.B.2.e: - permitted'a change in station or. corporate organization . (described in Section 6.2 of the TS) by submitting a 30) day LER. The'PA team did 'not agree with this determination. Review of licensee procedures, includin'g , the Boston Edison Quality Assurance Manual (BEQAM) Volume ~ II, June 15, 1981, revealed that.six months following the --actual' organization change which' deleted the title of- Chief Operating Engineer,.the job responsibilities were stil1~specified in Section 1.2.7.3 of the Quality , Assurance Manual. 'It was also determined that there ~ ~ was no positive' method to assure that changes in TS or a procedure would be considered and-then factored into other procedures as applicable. ' Furthermore, the revision of a TS requirement by means of a 30 day LER allowed significant changes in the. licensee.- organization without prior NRC review. (d) The ORC charter stated that' minutes of the'0RC meetings should be forwarded to licensed operators. SRO licensed- 'individuals-received the minutes. R0 licensed individuals l were not provided these minutes. Inadequate l communications between supervisory and nonsupervisory -personnel is discussed further in Paragraph 6a(1) of this .

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(4) Other ORC weaknesses were observed as follows: (a) The members of the ORC, who were. interviewed, had not received formal training or guidance >in their review: l responsibilities'on the Committee. (b) 'In a review of ORC minutes it was observed that meeting 80-8_4, May 17, 1980, and meeting 80-96 July 26, 1980,. lacked a quorum by one individual,.as required by_the TS' requirement. -(The ORC charter would have required two additional members o's alternates for a quorum.) This was discussed with the licensee and presented to the Senior NRC Resident' Inspector as a' potential enforcement finding. L

(c)- Ihe ORC charter was' specific on the process for resolving

disagreements between an ORC member and the ORC Chairman (Section~III.C.7.1.~3). However,'none of the ORC members- interviewed were aware of the actions specified by the requi.rement. ' , . , _ . . , . ---E - - , w , ,.,-p - . y, , ,-,,,-.w-- ,.y ,y ,.,,,, ..7- ~ - -, -m ,,- + - '

v - , -5-~ l .. . (d) The ORC maintained a computerized Follow List for. problems

identified by or to the ORC.

These items.were' assigned to members of the ORC for resolution. A review'of the Follow List, issued July 21, 1981,~ revealed'that of 138 open follow items, the response due date had not been met on 50 ~ ! items. (47 were more than 3 months overdue and on 3 were more than 1 year. overdue.) '. (5) Notwithstanding the described weaknesses, the ORC was an active- committee, holding 132 meetings in 1980._ Members stated they felt free to voice dissenting opinions. They also indicated a positive attitude toward their committee membership responsibilities. Nuclear Safety Review and Audit Committee (NSRAC) (6) The NSRAC charter, revision 8, listed the requirements of_the TS. However, it did not contain the following features. Guidance on what consitutes an unreviewed safety question. . ' Requirements to periodically review facility operations . and records, including LER's and NRC inspection reports. Requirements for review of NRC Bulletins and Circulars. . (7) There was an apparent conflict in N0D procedure 1.3.4. One part of the procedure required safety evaluations for changes to Category One and Two procedures to be reviewed by NSRAC; another. part required NSRAC to review only those safety evaluations for changes to procedures listed in the FSAR, a small portion of the Catagory One and Two procedures. This caused a disagreement among the licensee staff as to the requirements for NSRAC's review of safety evaluations for changes to procedures. ~ (8) NSRAC members interviewed stated they had not received any training or instructions related to their duties as'a member of the committee. In a review of records, however, the following procedures were found that described how the NSRAC met some of the TS Charter requirements. M.1, Administrative Controls, revision 1 . M.3, Reviews, revision 0 . M.4, Open Items, revision 1 . The content of these procedures was designed to provide guidance to committee members in addition to the TS and NSRAC Charter on their duties and responsibilities. No individual committee members interviewed indicated they knew the procedures existed. .

- 6~-- .. . (8)~ An audit of the NSRAC-function was conducted by QAD'during the -period March 16 through April 6, 1981. Five deficiencies were issued to NSRAC, none of which had been responded to as of July 26; 1981. -(9) The TS 6.5.B.7.e and the NSRAC charter required the comittee to " . . . review violations of applicable statutes, codes, - regulations, orders, technical specifications, license requirementsfor internal procedures and instructions having nuclear safety significance." Meeting minutes of NSRAC for 1980 and 1981 revealed that~QA audit reports containing various of =.these violations were not reviewed by the committee. -(See observation (6)(a) in Section 3 of this report.) b. Conclusions The significant weaknesses of the ORC included an inadequate charter and failure to review internal audit reports, NRC Inspection Reports and responses thereto, NRC Bulletins and Circulars, and the Fire Protection Plan. For NSRAC, the significant weaknesses were an inadequate charter, lack of awareness of committee responsibilities by committee members, and failure to review internal audit reports. Based on these considerations, management controls associated with committee activities were considered below average. 3. Quality Assurance Audits The' objective of this portion of the inspection was to determine the adequacy of the licensee's management controls associated with quality

assurance audit activities. a. Observations The following observations include the perceived strengths and weaknesses in the licensee's management controls that may not'have specific regulatory requirements, but will provice the basis for subsequent performance evaluations. (1) All TS required audits performed at the corporate offices and the facility were performed by Quality Assurance Department (QAD) personnel under the cognizance of the Nuclear Safety Review and Audit Committee (NSRAC). As allowed by TS, the NSRAC did not participate in or perform any audits. The audit program, as established by the Boston Edison Quality Assurance Manual (BEQAM), written policy statements, and numerous implementing procedures and instructions, appeared adequate, with an exception described in observation (5)(e), to provide above average management controls in auditing. ^ Weaknesses identified in the program were not in program substance, but in its implementation and in the awareness nd -responsiveness of upper level managers acting in various oversight capacities. .

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(2)fLThere were numerous' instances of an' apparent failure by~QA'

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personnel to implement program requirements' Each of the

-. . 4 _ '.following examples ~were.' discussed with the licensee and' presented to the Senior NRC Residena Inspector as.a potential

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enforcement-finding.

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'(a)- The Unresolved Deficiency Summary, required monthly by the- 1 - -BEQAM, Section 16.3.8, had been issued only three-times ~in the.nine months preceding the-. PAS inspection. This Summary served as'the primary notification to'the Vice 2_

-President-Nuclear for " review land appropriate action" on those deficiencies that " exceed the response due.date or , .the plenned resolution date."

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' '(b). Another-principal' source of information to th'e Vice President-Nuclear-and Department Managers (Nuclear . Engineering,. Nuclear Operations,.and Nuclear Operations ' Support) was the bimonthly QA Management' Report required . ' by QAD' procedure-1.02. For 1980 and 1981, the reports , were issued only quarterly, and they failed.to contain-all the required'information, such as the identification ~by' number and subject of the audits and surveillance i inspections completed during the report period, and the . identification of the-Deficiency Reportc (DR's) issued and . closed. .p J- (c) QA personnel had failed to verify corrective action on j, audit deficiencies within 30 days of the auditee's notification-of completion as required by. the BEQAM, .! Section 16.3.4.7. The most recent status of the QAD report on DR resolution was a memorandum written August - 13, 1980, which listed 40 deficiencies requiring QA j- followup or verification. Nine of those still required . verification of corrective action. One (DR 320, issued i 2/3/78) was over three years old; several'were over two l years old. Interviews indicated that there was no schedule to complete verification. Several of the verification l' assignments had been given to the previous QA Manager who , had departed that position as of September 1, 1980, and they:had not been reassigned to someone else. The current ' QA Manager cited a lack of manpower'for failure to i: complete the verifications. ! (d) Contrary to QAD procedure 16.02, QA personnel had failed c to perform trend analyses on deficiencies and F nonconformances semiannually. The most recent report had been issued July 24, 1980, covering the first six months of 1980.' . L (e) The requirement of TS 6.5.B.8.c to audit "the results of. i' all actions required by deficiencies..." was not satisfied by the.QA audit' program. Section 16 of the BEQAM on L Corrective Action" listed several systems to effect . corrective; action, among which were " Failure and 'l p k ' "

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. . . -8- '- ,;p -. ' Malfunctions" (FMR's) and Nonconformances (NCR's). Neither of these systems were audited at six month' intervals as' required. .The' semiannual' audits on corrective action included only LER's, IE Bulletin responses, and responses.to IE Inspection Report findings. 'Section 16 also listed DR's; however, these were followed .' continuously by QAD. (f) Section 18.3.1 of the BEQAM listed all of the audits,. including the TS required audits, to be performed by QAD. Several of these' audits had not been performed in 1980 as 3 required. .-These included a semiannual audit on non-conforming material, annual audits on document control ~, records, QC inspections, and control of measuring and test equipment. Portions of these areas were audited in the course of performing other audits and surveillance inspections (mini audits). For example, the document controls for maintenance requests.(MR's) were examined in the courte of auditing both maintenance and administrative controls; however, the overall document control system was not audited as required. (g) ANSI N45.2.12 and Section 18.4.2.4 of the BEQAM require that an audit report provide "a summary of audit results, including an evaluation statement regarding the effectiveness of the quality assurance program elements which were audited." The interpretation of the ANSI requiremen~t by the licensee, as evidenced in the audit reports, was that this statement should summarize the audit findings and evaluate the effectiveness of the program implementation, not of the program itself. All audit reports examined evaluated the implementation rather than the effectiveness or adequacy of program elements, such as procedures, in the summary statements. (3) QAD suffered from a lack of management support as evidenced by a shortage of manpower resources. Prior to the PAS inspection, QAD had positions for four auditors and one supervisor, but employed only two auditors, one of whom acted as the auditing supervisor. These vacancies had been open for over a year prior to the PAS inspection. What recruiting efforts had been tried were unsuccessful. " Technical Specialists," both from within the company and from consultants had been employed to. , augment the auditing staff in tbs orformance of the majority TS required audits. One audit. <he 2 year management' audit r. of the performance of activities to meet 10 CFR 50, Appendix B criteria was performed solely by a consultant. The licensee L had plans to hire temporary auditing help from a.large L engineering consultant firm. It appeared these plans would l alleviate sonie of the burden.of the permanent staff, but the ( responsiveness of the corporate management had been slow. L , . . - - ,.

. ., , , . . . - , . g- - - - - - -- - , - . _ . _ . - _. , y ~ a- . / - - _ 9_ - _ e - : ' ..:..: , - h.~ , U In' addition? o' audits ~and corrective action. verification,= t- p. ,..- auditorstwere. required to perform surveillance inspections, f' trend' analyses ~,5 deficiency and action-item follow programs,E < F -procedure reviews and procedure. revisions, and theirJown , L- ? continuing training.- As. evidenced in observation l(2), several: , elements of the required program were not~being accomplished, ~ '

_ due in'part to lack.of manpower. y ,. , 4 - . - . E

The apparent unresponsiveness

of some. members of management.was

I ~ not due to a 1ack. of information. Although the-QA Management .

Reports were' submitted quarterlyLinstead. of bimonthly, they did ' ~ , ' ~ contain-information regarding the lack of QA resources. The: first; quarter,~1981, report stated: ~ I " Restrictions on hiring additionalLQuality' Assurance , ' ' personnel is causing deferment or_ slippage of some QA , i- activities:such as trend analysis,-~ surveillance I inspections, verification of corrective action, vendor p evaluations,.etc."

,_ Monthly reports by the audit supervisor,!the acting-QA Programs L Service Group Leader, were distributed _ only to the QA Mar.ager, F but had reported resource problems for over a year. One entry ' from July,1980, stated:

" Group-manpower shortage is crusing us to fall behind in

, L verifying Deficiency Report and Action Item corrective i" action. Should this continue, corrective action reviews. {' could become superficial." , F ,

-Much more serious concerns wera raised in'recent' monthly.

j' reports with little apparent response from management. From the; ' , ' June,1981, report: + L " Items not being accomplished as. required include QA/QC~ i training record updating, Unresolved Deficiency Summaries, corrective action verification for Deficiencies'and Action Items, QA Trend Analysis, audits,. surveillance i inspections,' procedural revisions, and maintenance of L Deficiency and Action. Item follow programs... Design t modifications to Pilgrim 1 are being performed ~without

implementation'of'our~QA management oversight function.

Similarly, internal Unit ~ 2 audits' and Unit 1: QA program audits are non-existent...It-'should~be recognized that by. . ~ , not^being able to.also be. responsive to special audit i requests as well as not meeting BEQAM audit / inspection, [ ' requirements, we are not'able to 'promptly identify ' deficient areas; thus, Nuclear; Sections could possibly; ' have several unidentified deficient areas." d _ Another- source of information on these problems was the- extensive weekly staff meetings. held by.the Vice2 4 L . President-Nuclear. .These included-the QA Manager and the- , j., iManagers of Nuclear Engineering,, Nuclear. Operations, and ' Nuclear Operations Support:(who was.also chairman'of.NSRAC). a ' n .; . , .'- , y ' . ..e.

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, - 10 - 4 . -(4) ' A source of information that reported specific problems in the audit process was the Unresolved Deficiency Summary referred to in observation (2)(a). This summary reported those deficiencies (predominantly from audit reports) on which the audited party had failed to respond to the deficiency by the 30 day due date (or a subsequent due date established by QA), or proposed corrective action exceeded the planned resolution - date.' This summary was addressed- to the -Vice President-Nuclear with copies to department managers, and others. ~ Although the current summary (7/17/81) listed only 22 deficiencies as " unresolved," there appeared to be'no adequate _ explanation for _the lack of timely resolution on many of them. For example, DR 316, issued in February, 1978, to the Nuclear Operations Support Department stated that there was' "No QA Record Index." DR 494, issued in August, 1979, to the plant site stated that " Fire Brigade (Security) members were unfamiliar with the plant." DR 496, also issued in August, 1979, against the plant site stated that " Safety-related systems.were not separated from combustible material...." All three of these had exceeded their scheduled dates for corrective action. The summary indicated that an adequate

response, including a plan for corrective action, had not been submitted by the plant staff on DR's 673 and 674. These , deficiencies, issued in October, 1980, reported that the electrical ~and mechanical preventive maintenance programs had not been implemented properly. There were numerous similar examples where both corporate and plant recipients of deficiencies had not resolved them expeditiously. This situation also reflected upper level management's lack of

participation in the resolution process. Failures to respond to audits, inadequata responses, lack of timely corrective action, and Uterviews demonstrated a non-constructive attitude between QAD auditing personnel and plant staff members. Communications had deteriorated beyond those of the-typical adversary, but usually constructive, roles found throughout the industry. (5) QAD personnel in their practices shared much of the responsibility in the communications problems and in resolving deficiencies. (a) Deficiency Reports were required to be responded to within 30 days regarding corrective action taken or planned and the date the action would be completed. Interviews with staff members and managers of both QAD and the plant site ' l revealed that although no one was certain as to when the

30 days began, all believed that it began on the date of L issuance, the date the DR was signed by the QA !!anager. The Deficiency Log and Unresolved Deficien~cy Sumiaries were written based on this assumption. The log, copies of which were sent to DR recipients, clearly listed the f . , -,

- - 11 - . . . P -due date as 30 days after the date of issuance. -By this -measure, a sample of 35 consecutive DR's issued to the plant during the past year showed.17, or nearly 50%, to be " late." An examination of the corrective action program as described-in the BEQAM revealed a different picture. Section 16.3.4.5 stated that DR's with the appropriate responses " be returned to the originator within thirty (30) days after receipt." ~ By this ceasure, few of the 17 DR's mentioned previously would have been late. Most had been " late" by only a few days, and the mail service between cuporate and site often took several days. According to a deficiency log maintained by plant - personnel since_ March 1, 1981, there had been no late responses. One extreme example of poor delivery service and failure to communicate was a recent deficiency response that took over 5 weeks to reach QAD. The deficiency report was issued May 4 with a due date of June 3. The response was dated, and presumably mailed, on May 22. This response requested an extension to July 15 for preparation of a corrective action plan. It was not received by QAD until July 1, over five weeks after it was issued. QAD responded to their extension request on July 16, the day after the requested extension was-to end. (A course of corrective action had still not been decided upon at the time of the PAS inspection.) The element in this communications problem that made it seem more significant is that both parties in the example, QAD and the recipient of the deficiency, occupied the same floor of the corporate office building. (b) When QAD personnel found an initial DR response unacceptable, they typically requested a second response within seven to. tan days without regard for time of receipt. In one case, the request was not received until one-day after the assigned due date. (c) The " Recommended Corrective Action" portian of nearly all DR's examined had not been completed by QAD. This appeared to contribute, in part, to a large number of rejected initial responses. QAD rejected responses if they failed to contain specific information; however, frequently the information omitted had not been specifically requested in the deficiency. It was not always apparent through procedures or practice that this information should obvously have been provided by the recipient. Certainly the plant staff did not appear eager to supply unsolicited information. In fact, most responses appeared intentionally brief. It is an understatement to say that communications were weak. __

7 _ _ . - _ _ _. . _ - - . . -_ . _ 7 . . E12 - - , . .. s - - L(d) QAD_ failed to label numerousxdeficiencies as t "significant," thereby preventing them from potentially- d . , ? receiving more attention and _at a higher ' level of ' ~ management. This attention,from management was only-- - - potential since the only additional -requirement fori . "significant" DR's was that the recipient. fill _in the. - ^ 1 space _on the' form labeled "Cause."' Otherwise, - determination of the cause'of the' deficiency was.not required. The' failure to identify?significant , deficiencies, and thereby determine the cause, was a ' serious' weakness-in the program. In 1980, 169 DR's were; written-and only one was'labe_ led "significant." The. -previous one had been written in October,1977. ~ A definition of "significant" was given in the.BEQAM. Thi a of six. parts to the definition were as follows: 1 "A b'eakdown in any portion of the Quality Assurance Program... "The failure or malfunction of, or use of , nonc)nforming material in, a strur:ture, system, or. component which will require extensive evaluation,. extensive redesign, or extensive repair... "The repetitive recurrence of a deficiency..." There appeared _to be numerous DR's'. meeting one or more of these criteria that were not labeled "significant,"'and as a result,_ required no investigation'into the cause of the- deficiency. , DR 665 stated that the " effectiveness of PNPS (Pilgrim Nuclear Power' Station) Training Progr'am is determined to be inadequate." DR 690 repo'ted a " failure to'use weld- r procedure specified on weld repair." This-involved the reactor pressure boundary on a two inch reactor clean-up. system drain line. DR 697 stated that the "NSRAC does not~ . review Safety Evaluations" of changes to procedures, equipment, or systems as required by TS 6.5.B.7.a. None of these three examples were labeled "significant'." ~ ' Appearing to meet the repetitive criteria of the - definition, at lcast six DRs issued during the past two years involved'a. failure to notify QC'as required in the performance of, safety-related maintenance.~ LackLof. trend analyses contributed to failure to recognize repetitive- DR's. Failure to identify significant deficiencies as -described in.10 CFR 50, Appendix B,~ Criteria.XVI, was discussed with -the licensee and-was presented to the Senior NRC Resident' Inspector as a potential' enforcement finding. s .- . .- k. - . ?~ '. a , _ .. 1- . - _,- , ..-,_,. _ ---,..,,-.,s.. , , , - , . , - - - , .

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~ -(e) The BEQAM, Section 2.2.2.2., provided the only.means'to escalate an unresolvable deficiency. The' procedure seemed ' inadequate, however, since-it required a dialog of undetermined length between the-QA Manager and the recipient department manager before the issue was referred -to the Vice President-Nuclear for arbitration.- According to records examined and interviews, only one such referral had ever been made: in July,11981, on-five DR's, the oldest one going back to October- 1979. , . BEQAM, Section'16.3.4.6., required that "Should QA find the second response not acceptable, Paragraph 2.2.2.2. ... shall be implemented." Records showed numerous DR's where a second response was either found unacceptable or-was never submitted, and no notification, per 2.2.2.2., was sent the.Vice President-Nuclear. Sharing responsibility for failure to escalate problem deficiencies appeared .to be the Vice President-Nuclear, who apparently had never requested escalation of DR's or participated in their resolution. (f) The status of many DR's was unclear. A status report on open DR's had not been issued since the August 13, 1980, memorandum on the Deficiency Follow Program. DR's written after August 13, 1980, which had not been' closed out and did not appear on the Unresolved Deficiency Summary, had no known status without investigating the individual DR file. The log entry for DR 679, for example, reporting a- deficient training program for training examiners, showed only two response due dates. There was no indication of any responses received or planned corrective action dates, and no entry on the latest Unresolved Deficiency Summary. , ' (6) Oversite of the audit program was weak. NSRAC was assigned the TS responsiblity to have ': cognizance" for the auditing program, but this committee exercised only minimum cognizance. (a) NSRAC meeting minutes of 1980 and 1981 revealed that at least three TS required audits performed by QA in 1980 had ~ not been reviewed by NSRAC. These included 80-28 on Personnel Training and Qualifications and two audits that u helped satisfy the requirement'to audit the ;onformance of l facility operations to the TS: 80-26 on Maintenance and- l 80-27 on Operations. Each of these audits reported either i violations of TS, regulations, or internal safety related procedures; and as such, were required by TS 6.5.B.7.e. to be reviewed by the NSRAC. 'This observation was discussed with the licensee and was , ' presented to the Senior NRC Resident Inspector as a potential ~ enforcement finding. _ - =*- t e

, ._ -~14 - . 4 (b) Ihe audits reviewed by NSRAC were apparently not reviewed in-session. All NSRAC members received all audit reports, and the reports were discussed at NSRAC meetings only if - someone found exception to the report or findings. This -review-by-exception method, as conducted, was considered a weakness. 'One NSRAC member claimed to have never reviewed an audit report; another stated that he only reviewed those audits that pertained-to his area of technical expertise. Both had been NSRAC members for over a year, and yet appeared very unfamiliar with the audit program. Both stated that they were not aware of the TS listed responsibilities for NSRAC, and neither had read the BEQAM, which delineated the licensee's programs to comply.with 10 CFR 50, Appendix B, including the " Criterion 18" audit requirements. Other NSRAC members appeared much better informed. (c) The audits reviewed by NSRAC received limited scrutiny. Tne reviews consisted of only the identified problems, that is, the audit reports and attached t R's. NSRAC performed no reviews of the corrective ac 'ons on audit deficiencies not on individual deficiencies, summary reports, or trend analyses. Whatever action transpired after the audit report was written was not usually reviewed by the Committee. There was no followup of reported deficiencies. NSRAC members, other than r'.partment managers, did not receive (and the minutes onfirmed no review of) the Unresolved Deficiency Summary, QA Management Reports, or related internal QAD memoranda. In addition to audit reports, NSRAC did review the annual audit schedules, the proposed team compositions, and the scopes of planned audits. Interviews with several NSRAC members indicated a general unawareness of QAD's resource problems and their demonstrated inability to complete the aeJit program requirements. (d) f,ne possible source of the lack of an informed NSRAC was that QAD was not represented in the NSRAC membership in accordance with QAD procedure 1.01. The requirement, which had not been met since September, 1980, was that the QA Manager be a NSRAC member. The QA Staff Assistant was appointed in place of the QA Manager in the reorganization i of 1980 without the procedure being changed. The Staff ~ Assistant, who was permanently located at the plant site, ! stated that he represented QA expertise on the ammittee, and not the QA Department. ! (/) The inability of QA to meet their current audit program requirements coupled with the lack.of management attention has lead to an ever-worsening condition as predicted by the audit supervisor. The 1981 audit schedule called for 39 audits,~all required by the BEQAM, 13 of which were NSRAC audits required by TS. Five of t tse had been done as of the PAS inspection,

. . - __ - _. . . . . , , . , 1 p. - ,

' m , -115 - - 1

3 ' _

'f44 - . - ' ' fleaving 34 audits remaining'to be performed in-'only four and e one-half months. s ' (8): The audit program wasinot totally marred by weaknesses and , 1 accumulating' problems. The'.individualJaudit reports were , " '

' excellent. They were thorough, contained substantial findings,- , f and vere" consistently-of excellent quality. uThe scope of most- ' audits examined, with the exception of' corrective action - ' . audits,,was broa6 enough to cover'the requirements plus- , peripherally related areas such.as document controls, training,- (and qualifications of individuals relative to the subject f , areas. + 4 . !

= Standardized check lists:were used with procedural freedom to- ^ , deviate when necessary. : Check lists were- reviewea and ipproved by the acting QA Programs. Service Group Leader; however,:this- y

was:not indicated by the supervisor's signature. One'other- potential weakness noted in the' check lists was-that there were

no sample sizes: recommended.- The audits examined, however,

used large samples in all cases. The audits'on'LER's and .. F responses to IE correspondence used a sample size of.100L 3 ! " Technical Specialists," experts from contractors or from other: . departments within the company, were frequently used as- auditors (never " lead" auditors)'to supplement the auditing- , staff.' ' 1 The substance of.the aud'it findings was'one of the program's- 7 i strongest features. DR's routinely addressed substantive , ! safety' issues. Both auditors gave a strong impression of being

aggressive in pursuing safety problems and having'a-healthy l ~ independence ~from site management. In spite of' scheduling

- pressure, there was no evidence of attempting:to meet the . schedule at the expense of quality of the individual audits. . An approximate average of ten man days per audit was ~ ~ ' maintained, based on actual-audit conduct, not including report g writing or corrective action followup. ! A program of surveillance inspections (mini-audits) was $ '. conducu ' in addition to the audit program. Five had been. ! conducted in 1981. The' subjects' included the following: ' l= surveillance testing; requirements of Amendment.42 to the TS; L control of control room drawings, followup on' Training Audit L 80-28,' vent and purge system surveillance, and TS operability- , testing. .This' program produced substantial findings that were- i handled identical to the audit deficiencies. By. design, the' l reports from the surveillance inspections were smaller'in. scope;

than the audit reports but were more-thorough than~ entire; i o p -audits.of some other nuclear' facilities. .For example, the most1 L .recent inspection, '81-12 on TS Operability Testing, = required ' l three days.by one auditor. The scope included'an in-depth p examination of four' safety related MR'si a leak on the standby- > . L liquid control pump, a RCIC valve packing leak, a core S ' o hj- , f~ . . - . . . . - - . - , .s, , n. - + . . . . - . , . - . . - . .. . , -

' ~ Am _ ' ~ _._ y 3, .. $ 1 s + . / ]

-

-f16 -

y + . J - - . . . .,9 . .g . ' " Lspray' pump breaker problem,1and an erratic HPCI controlcvalve. Three-deficiencies'resulted. ~

_ Corrective action was completed or proposed for many of:the . ~ ^' weaknesses identified by the PAS. inspectors.in this area by.the Jend of the inspection.'-Some of the actions were as follows.- - (a)/ A training' session was held for all NSRAC members. T ' (b) :The BEQAM was changed to.significantly improve the method.

of resolving deficiencies ~. "Significant" deficiencies 1 %

were assigned a higher priority with specific escalation.

requiremen.ts involving upper level corporate management.' (c) : Plans were made to hire five additional persrant 'au'ditors :

plus a permanent audit supervisor (Group-Ie .aer). -For

the

short term, plans.were made to hire six contractor- ' personnel to augment the audit staff. ~ (d)- DR's would be hand delivered to recipients to avoid ^ - , mailing delays. b. Conclusions- ! The most significant weak'nesses could be divided'into three broad-

categories: ' failure to implement the program, failure of management

< to be responsive to and support the program,'and program .. inadequacies. ' - , In-the first category, the licensee failed to meet schedule ' requirements such as issuing'various re' ports, verifying' corrective .- action on outstanding deficiencies, and performing-all the required- - j' audits. Also in the first category was the failure to-perform trend analyses, an inadequate scope on corrective action audits, Land r -failure ~of the oversite committee .NSRAC, to perform adequate i } l reviews of the program, audit' reports, and deficiencies. .

. ,. L In the second= category, management failed to respond.to.QA's need 4 for resources to complete program requirements: They failed to take action to resolve serious deficiencies,in a timely manner, tol e encourage staf_f members to be responsive to resolving deficiencies, [ and to createLa healthy,. constructive atmosphere between-QA and the-

remaining staff.- The third category included one significant weakness: an inadequate ' i method to escalate and resolve serious or~ controversial deficiencies ~. ~ The strengths of the program included-the excel. lent. depth and' ,

quality of audits and survefilance inspections, the use of-

. p " Technical Specialists" to augment the-audit staff.for their- F ' -technical; expertise on certain audit subjects, and a positive- attitude-toward correcting problems identified by the PAS , - inspections , _ I '. ' & ' ~ , , , _ . [ . ,-. . . , . , , - - , .-n, -. - -- ,..w. , , . ,

. . . . . . . - . - , , . . . . - - - . - .. , - . -+ . '

' - - ~ , , } , . , .

+ - - g

• ~

, 17.-6 ~ - ' , - x , , V , ., + , , ' ' - - .

.:

. - . . . , , ' ' Withithe corrective action =in-place'at~the. conclusion:of-the V - ' ^ Linspection and the proposed correctivelaction discussed by: thel . . licensee _ representatives, the QA' audit program should be, improved. _ Based on theJas-found conditions, hewever, management. controls in - this' area were' considered below average. - , _ I'<' 1.1-LDesion=ChangesandModifications- 4 '- o - dheobjective,ofthisportion'ofthe'inspectionwastoevaluatethe: ' ~ E

adequacy;of management controls Lassociated with design changes and

' E modifications. e i a, ' Observations- l- . ' The following observations include the perceived strengths and j weaknesses 11n the-licensee's management controls that may not'have [ -

specific: regulatory requirements but'will provide the basis for

[ ' subsequent performance evaluations.- B

(1). Procedures had been established to_ describe the:processsby

which design _ documents for changes;and modifications to safety related structures, systems, and components-were . prepared, verified, approved,'and revised. TheJdesign change ' i- and modi.'ication process ~was controlled and documented by use- j. of a Plant Design Change Request (PDCR). From conception to " i closeout of a PDCR, tlwee departments were involved: iNuclear l> Operations Department (NOD), Nuclear Operations Support' Department (NOSD), and the Nuclear: Engineering' Department- , d. (NED).~ Each department: had their own procedures;> however, none- i of the proce_dures adequately described the overall PDCR ~ - 3. ~ process. Each departmental procedure described in detail the ! responsibilities of that ' department 'and summarized the overall i _ PDCR process. Jointly, the departmental procedures adequately p.' described the PDCR process; however,'the use of three i procedures appeared to be cumbersome and difficult to follow. r (2) NED had the prime responsibility for' design change efforts, 't , including the preparation of the PDCR, narratives, safety

evaluations, and appropriate drawings. NOD reviewed and

'

approved the PDCR package for implementation and also verified. ! completeness upon closeout. PDCR implementation was' controlled - J. - by.use of a Maintenance Request (MR). 'NOSD had:the~ _ y ' responsibility for. coordinating the interface activities . . . + ' ! between the Pilgrim Station and NED.during the design-input and t,, verification stage. 'NOSD was also re~sponsible for; approving PDCR's as required by.the management process after completion t of engineering _and before: transmittal to the. site for review'

1. and approval._ Within.NOSD, PDCR's were assigned 2to; Project'

R Managers who followed the PDCR's~from conception ~through' [. implementation. The ' Project Managers were res'ponsible:for [ managing capital projects through the project life cycle. This- included _ planning,: scheduling,'and integrating. project ! ~ activities'with all departments. 'This process appeared to be

. effective. ' t ' 4 7 -.

1. .m

$<,---r w -e v ire - e w - v- + -r i e , rv-~'m

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--E- rv'wk *' e-w- w wv(r ew - e +-~ v w =*

._ - 18 - . . (3) In describing the flow of PDCR's,-the BEQAM, NED, "SD, and N0D procedures referred to a Methods, Compliance, and . aining , Group within N00. The N0D organization did not inc'ude such a group. There was a need to revise procedures to reflect the- current organizations. (4) TS 6.5.B 6.d requires the Operations Review Committee (ORC) to review all proposed changes or modifications to plant systems or equipment that affect nuclear safety, and TS 6.5.7.b requires the ORC to render determinations in writing whether or not each proposed change or modification constitutes an - unreviewed safety question. In order to make such a determination, the ORC must review all safety evaluations ass,ciated with each proposed design change or modification. ~ The DRC reviewed and approved PDCR packages. Each PDCR package was required to include the necessary safety evaluations, so that the ORC could render a determination as to whether or not an unreviewed safety question existed. By procedure, the ORC was not required to sign safety evaluations contained within a PDCR package. Their approval of the PDCR package signified review and approval of the contents of the PDCR package which included all safety evaluations. For example, PDCR 80-3, Containment Gas Control System Isolation, was approved by the ORC on March 21, 1980. This PDCR package contained ten safety evaluations; however, three of these safety evaluations (847A, 928, and 936) were dated after the ORC approval of the PDCR package, and no documentation of ORC review was evident. This observation was discussed with the licensee and presented to the Senior NRC Resident Inspector as a potential enforcement finding. (5) Interviews with NOSD personnel revealed that a written procedure describing in detail the responsibilities, activi. ties, and reporting requirements for the Project Managers had not been prepared. However, a broad scope of their functions was contained within the various departmental procedures. A Project Engineer's Manual was'being written; but had low priority and no scheduled completion (5te. (6) Implementation of PDCR's approved for construction, was under the cognizance of a Construction Management Group (CMG). This group was located at the site and was part of NOSD. CMG engineers managed the construction activities of contractor personnel. Their responsibilities included coordinating constur. tion activities with plant operations. Implementation of PDCR's was controlled by the use of MR's. At the beginning of the. PAS inspection, interviews revealed that CMG had not established a master log or tracking system that reflected the current status of PDCR 3. By the conclusion of the inspection, however, a PDCR status log had been initiated , - . -

b ' - 19 - . . -and did reflect the current ~ status of most PDCR's under the cognizance of CMG. One of'the responsibilities of CMG engineers'was to initiate the closeout phase of PDCR packages when construction activities were completed. This closeout phase included the assurance that the master PDCR package contained all the required documentation and that all applicable drawings reflected the as-built conditions. Completed PDCR packages were transmitted to the Management services Group (MSG) in N0D for closeout processing. Through interviews ~and record reviews, it was determined that the initiation of the PDCR- closeout phase by CMG was untimely in many instances. The time. frame between completion of construction activities and initiation of the closeout phase by CMG in many cases, was from three to five months and some over a year. This untimeliness caused three serious problems: the unavailability of as-built ' drawings _to N0D; the added delay in sending as-built field drawings to NED for revisions; and the delay and lack of training or operating personnel (discussed in paragraph (7) below). (7) Closecut of a PDCR package did not provide assurance that applicable procedures were revised or that operating personnel had received training on the design change or modification. There was a lack of a written program to identify affected procedures and required personnel training for PDCR's prior to implementation and to verify that procedures had been revised and training provided prior to final closeout of each PDCR package. (8) Upon receipt of a PDCR package for closeout, MSG reviewed the contents of the PDCR package for completeness, and the site Records Center processed and closed out the PDCR. As part of- the closeout process, aperture cards were made of the as-built drawings to provide a ready reference of the as-built conditions during the time that master drawings were being revised. A system had been established whereby drawings pending revisions were identified, both in the site Records Center and in the field. A significant weakness in the system, however, was the large backlog of approximately 100 drawings, pending revisions, many outstanding for over a year. b. Conclusion The licensee had established and implemented a_ program to control safety-related design changes and modifications. The NOSD appeared to be effective in managing and coordinating preparation and implementation of PDCR's. The design phase performed by NED was well' documented. Significant weaknesses identified were the untimeliness of initiation of closecut upon completion of a PDCR, the large backlog of drawings pending revisions, and the lack of a written system to ensure that operators had been trained and .

-W ~ 3 .

, - ' < , ,:,k z ! n ' +

' ' . 20 - x - y ,.. - - i - " W, I ' . y. . 2 [applicableprocedures'revisedorwrittenpriortoPDCRclosecutor: 4 . system operation. , , , - 1The= management controls associated with safety related modifications . ~andLdesign changes were considered average. - y 5! -Maintenance- . LThe: objective of this portion of the inspection was to evaluate _.the adequacy of the licensee's man'agement controls associated with corrective and preventive maintenance activities. e , a. Observations , . The following~ observations include the perceived. strengths and- , -weaknesses in the licensee's management controls that may.not have ~ , -

specific regulatory requirements but will provide the basis for subsequent performance evaluations. (1) ANSI N18.7-1976, paragraph 5.2.7.1, requires a preventive . maintenance program be established and maintained. N0D- procedure 3.M.1-1, Preventive Maintenance (PM),' addressed the PM' program. N0D procedures 3.M.1-1.1, Instrument'and Control, ' revision ~ 7, and 3.M.1-1.3, -Mechanical, revision' 3, provided a PM schedule for various categories of instrumentation and ~ equipment. 'The PM schedules were routinely. designated "as. required" or " operating cycle". . NOD procedure 3.M.1-1.2,- ' _ Electrical, revision 2, provided a component list of electrical ~ equipment with their appropriate tests but;no schedules were ' i- provided. The PM program did not include a writte'n scheduling. g~ or tracking system. Interviews revealed that even this PM i- program was fragmented. It did not address. all appropriate j. systems and components,.and, except for outage scheduled. items, i was not being accomplished. i'

This, observation was discussed with the licensee and presen'ted

to the Senior NRC Resident Inspector.as a potential enfobcement [* finding. ' (2) MOD procedure 1.5.3, Maintenance Requests, revision 13, '.- provided instructions for. performing safety-related maintenance. . or plant modifications. Maintenance was' controlled and documented by Maintenance' Request (MR) and Maintenance-Summary land Control. (MSC) Forms. The MR form provided for- ., ! identification of numerous data not normally found at other' ' ii i ,fac l ties' nspected by PAS. The MR form included'identifi ' { cation of.the equipment, identified problem, approvals n required,-TS' operability requirements,' tagging and isolation,. . operability testing, and equipment' return-to-service. The MR: '

- also addressed radiation protection, fire protection, and QC' ' regairements. 1The MSC addressed workiinstructions, drawings,. instruction = manuals, special tools and equipment, cutting and , welding,Las-found conditions, special problems ~ identified,- and

, t - - housekeeping following maintenance. 'The MR's and MSC's were . multi-copy forms with defined. distribution.' . . , , . ? r f -. ..--n - r - w-- v .v---% w - = ,% . - .. 1i- ~ .. .. w wwww-~,-r-. - - w -r -iv-*r-+-+

. . . _ m. 4 . _ . - - . . . . - _ .- _ _ . _ - . . .

'"' ' ' } _ , ' -t21'- J ' ,- . _ - . , ' s+ .1 _ j

a.,

The MR form did not provide for dates of applicable: signatures .

. ' ' including:tho' of-thejapproval to start work,,QC approval, and: - - work:completea signatures.3;MR's'provided no safety-related s designation. ' - _ (3)T A maintenance priority system had-been established. It was . '_ required that all MR's.be.given a maintenance priority by the ' ~ ~ ' -' Watch Engineer. It.was determined that'an: approximate 4000- . manhour maintenance backlog' existed, excluding outage items. Most'of these were given the lowest priority "C." 'A review of - numerous outstanding priority C MR's did not reveal.any that _ appeared to be safety-related. However,_since-there'was no - - . - safety-related designation on the form, there was no assurance ! that safety-related. maintenance would not receive a C priority.

.

Priority.C MR's apparently received little attention, and.a , licensee representative-stated that many of these. items would- 9 . probably never be accomplished.

p . l- (4)' N00 procedure 3.M.1-3, Lifted Wire:and Temporary Jumper, revision 7, addressed the administrative controls-for the.use . o of electrical jumpers'and lifted leads. The procedure.'did not 7 address the use of bypass lines or mechanical blocks. The i . procedure required verification of-installation of- electrical jumpers and lifting of wires, but did not_ require verification i t of restoration. It was not determined if any bypass lines or- mechanical blocks had been installed.

. . (5) NOD. procedure 1.3.8, Document Control, revision 25, included

• -

instructions for the control of drawings and prints. The- p procedure addressed controlled document sets maintained in the i control room, in the' electrical engineer's office, in the i, training office, and the records center. A system had been- l established to identify those drawings which were pending i revisions as a result of a design change or modification. A review ~of the control room and records center' controlled drawing sets revealed that those drawings pending revisions appeared to have been identified by an appropriate stamp,?and i the information concerning the as-built condition was available ! in the records center. Copies of marked up as-built drawings' ' pending revisions could be obtain~ed from the records center for- ' the performance of mainte' nance activities and appeared to.be provided when copies of drawings were requested. Although a !- system for the control and issuance of as-built drawings -pending-revision had been established and implemented, the [ system was not addressed by procedure. . (6) N0D procedure 1.4.6, Housekeeping, revision 5, described 1 i general housekeeping practices and responsibilities of-station / personnel. - Individual responsibilities and detailed t housekeeping requirements, however, were not-addressed.

- (7) ~A master file of vendors' manuals was maintained'in the

records center. Files were also maintained by-the Instru- , [ mentationfand Control-(I&C) Group'and by the' Maintenance Group. ,,

s - ' 4 we . s.e w- .-..-,}. , - . .- .e- e,-- .% -e-a N --w. , * . - * n 't e- v - - e o- -m - - -ec-. - e- r

, . , -- - .. , - . - . - . - ~ , , -[gg - ' . & , , . . + ^ LAn. identification number was given-to each vendor manual. The -same number was given to copies in-the various files.:0ther '<

than:the records center'being-responsible to send the I&C and

maintenance groups a: pre numbered copy of all manuals received, no other control =or! routine ' audit of the I&C and maintenanceL r files against the records center master file was..provided.

However,_at the request of the.' Chief Maintenance Engineer, the- . . - maintenance file was' audited by.the records center during June,. - , ' - '1981. 'The:I&C and maintenance groups:had'provided' file . cabinets for t_he vendor; manuals and~the files appeared to;be' well maintained. . . . ' ~ (8)- There was-not:an effective! training program for maintenance personnel. It had been the licensee's policy to hire

.

experienced crafts personnel;Lhowever, there was lack-of

' training.in-QA and administrative procedures. Additional- details of non-licensed' personnel training is. discussed.in 1 .Section-8 of this report. 1 T , b. Conclusions An-approved procedure for the control of maintenance activities had

.

been implemented. This procedure was well defined and broad in scope. -: Maintenance was performed and controlled by use of i maintenance requests. .Significant weaknesses in the overall maintenance program, however, were-identified including lack of a meaningful, integrated'PM program; lack of written administrative - r procedures-for control of as-built drawings and control ~of ver. dor manuals; lack of an effective training program for maintenance , personnel; and the large backlog of. low priority MR's. - 1 The overall. management controls associated. wit'. the maintenance.

program were considered ~below average. ~ I. 6. Licensed Activities (Operations)

The objective of this portion of the inspection was.to determine the adequacy of management controls' governing plant operations. . ,. a. Observations

The following observations include the perceived strengths:and weaknesses in the licensee's management controls that may'not have ' specific regulatory-requirements but will provide the basi 5 for subsequent performance evaluations. s

(1) .The distribution of information to operating personnel below.

the

level of Day Watch Engineer'is limited.

Some initerviewees . indicated.they may not be~ aware of antevent reported to'the NRC e ' that occurred at the. plant, since they did not receive copies .of all LER's.- Furthermore, Watch Engineers, Shift' Supervisors, , SRO's and RO's did not see many of the Bulletins, Circulars,. ~ t and'Information Notices issued by the'NRC. -A reading file was l, ' _ not maintained in:the control. room. It was noted.that the . ~ , 't Y , ' ) .t - - . - - . - - . -. - . , , , + ,....,,_,h%-.-w - , --.r v - s & . --- .

- - , -- - , , _ , ' D - "- 23~-- s , , , , , 3 AL ,. 4_ ^ " ' - stintsd purpose in'thef 0RC charter of distributing the ORC: " . - - - minutes'wasjto feedback;important-operating information to ~" , , . _ licensed operators 4 including procedure changes,-plant design: _ change ~ requests,.and assessments:of failure and malfunction - i . reports. :The ORC minutes were distributed to the watch- ' i ' ,eng neer, w oh ;had the option of providing-them to.his shift' Jpersonnel for their review. : Interviews indicated that'some' - Watch Engineers' distributed this'information,~others-did not. .- - 1The Watch Engineer was required by administrative practice to ' sign'a route slip demonstrating he had received the minutes.= The Shift Supervisors and licensed operators who' reviewed the minutes did.not record their review. , , (2) Operating Procedures were not routinely reviewed by-controlE s F room reactor operating ~ personnel. The biannual-(2-years) . review was done by the first level of management; above the

Watch Engineer. This practice omitted a prime source of input . for: procedure improvement, the' people who directly uso Lthe ' L, ' procedures. _ . (3)- There were 131t temporary procedures in effect: 29-from 1979,_81. from.1980, and 21 from 1981. Considering a total of 500 procedures, the nun 6er and age of the . temporary procedures was , considered excessive. -i t (4) The TS surveillance program was a fragmented system controlled by several'different groups. . 'For example, the ORC-Secretary , was responsible for assuring.that the reactor operationsLand

' fire protection surveillances were scheduled and performed as- . required. An I & C' supervisor did the same: type of work for.- all I&C tests. Interviews indicated that' electrical tests and I mechanical tests are nandled.in a similar manner. This ' lL' multiplicity of management controls and a lack ~of apparent ~_ - ; coordination subjected this system to a significant potential. for error. 'A. centralized _ program.to list and schedule all [ surveillance tests by means of computer,was in progress.

(5) The organizational relationships defined in the~BEQAM-were - , adequate, with one possible exception of the two positions of. q the Deputy Operations Managers. The responsibilities specified !~ in the BEQAM and plant procedures ~were assigned to-the position of Deputy Operations Manager without a division of ' ~ i responsibility between the two individuals. The ORC Follow 1 , L List assign.?d responsibility for action to each Deputy 7 - Operations Manager separately by name, and also to the ORC ^

Chairman who could be either of the Deputy Operations Managers. t. (6).-The.. hours of-work for certain licensed personnel were . - ~j. excessive; Review of overtime logs indicated one'indiv.idual had worked double shifts for six consecutive ~ days =, 96 hours in- ' one' week and were not in;accordance with the limitations- . recommended in IE Circular 80-02 of February.1', 1980. , p . m -j' - ' ' , _ _ , r - > > w + - - n x . a -. , - - + n. n..., , . . . , ,~- . , w

, - 24 - .- , l .(7) ;There were_no station procedures that required trend analyses'- of-equipment performance or operating parameters. Interviews indicated that some trending of equipment performance was done , and review of-NSRAC meeting minutes revealed that some analysis' work.had been done~ relative to RHR system and HPCI system failures. . Potential problem areas could have been observed by trending the licensee's LERs. For example, in 1980, 45% of the LER's_were reported as being caused by "other". This is about three times the national average assigned to this' category. (8) Discussions with operating personnel indicated they were not receiving timely information and training on plant modifications. For example, training on modifications that installed the ATWS panel and the shutdown panels was not given. Training which was' given on modifications was frequently delayed up to three months after completion of the work, b. Conclusions The signficant deficiencies included an inadequate' communication system between management and nonsupervisory operating personnel; the lack of performance of trend analyses on MR's and LER's; a failure to involve reactor operations and supervisors in the review and revision of plant procedures; and inadequate training of operating and maintenance personnel on plant modifications. Management controls in the area of operations were considered average. 7. Corrective Action Systems The objective of this portion of the inspection was to determine the adequacy of the licensee's management controls over'the corrective action systems, a. Observations The following observations include the perceived strengths and weaknesses in the licensee's management controls that may not have specific regulatory requirements, but will provide the basis for ~ subsequent performance evaluations. (1) The most significant weakness in this area was the apparent lack of a written corrective action system, providing documented records and adequate reviews, for use by all plant staff members. The corrective action systems in use included Maintenance Requests (MR's), Failure and Malfunction Reports (FMR's), Deficiency Reports (DR's), and Nonconformance Reports (NCR's). ,, MR's were designed to_effect corrective maintenance, and as l. ' such, were used primarily on maintenance related problems by- those involved in maintenance activities. FMR's were the principal ' corrective action system for the plant site, but were I .

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o n 25 - . , , - . _ . L

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, . . , ' .used almostLexclusively by plant supervisory personnel. Some- i - , craftspersons;had not-heard of?these reports; DR's and NCR',s were tools available only to, Quality. Assurance Department (QAD) personnel::DR's forLaudit- and surveillance inspection . findings,o , . ' JNCR's for' material; problems. i , -Neither of the two principal systems for site personnel, MR's

.and-FMR's,.were part of any training program. . Furthermore, ~ neither system appeared oriented to resolving. deficiencies < other than material' either by design 'or by practice. - MR's - 3 , ' ' were not . intended for: procedural problems- There was nothing- - .

' procedurally precluding the use of an.FMR on a software. - problem;.however, of 50'FMR'siexamined, all written in 1981, only-three-dealt with such issues:-failure to' document'a' jumper, failure to document a TS surveillance, and iraproper. operator action. ' - , (2) MR's-were used as a corre'ctive' action system to identify plant l problems for investigation and correction. They were not' adequately-designed'for:such, however; and consequently, did. , not receive the management attention warranted for such a <

system. They were intended solely to effect corrective maintenance. MR's 'were not,l therefore, ' reviewed .for , E reportability, repetitiveness, or their generic implications. { The reviews. required on MR's were limited. They were not- reviewed by the Onsite Review Committee (ORC), as FMR's were;.. . . and there was no evidence that consideration.was'given'to ' escalating the problems identified on an MR to a highe'r review

authority, such as'an-FMR that went to the ORC. MR's were not !. routinely considered'for a 10 CFR 50.59 review, nor was the need for a design change considered part of their normal review ! requirements. There were few cross-references between MR's and FMR's, although the problems identified on.FMR's frequently. ! ' resulted in MR's being issued.- Several MR's.were found, ~ ' i through investigation, to have no associated FMR's, yet ' appeared to be candidates for'a more extensive review than that ' afforded by an MR. Examples included'an inoperable breaker on e } the HPCI system (MR 81-23-7) and a HPCI MOV not seating properly.(MR 81-23-23). These individual MR's may not have

-

been significant, but .the subjects lend themselves to several questions. How-thorough was the' review?. How extensive were the problems? What level of management was made aware of the

in conditions? Usinglan MR without an adequate corrective action review process provides no assurance that these condition ~s were handled adequately. (3) FMR's had numerous-we'aknesses asla corrective action _ system. As - stated in observation (1), they were not generally-used to- report procedural problems. Interviews indicated that failure ' to follow a procedure or meet a TS surveillance requirement would'not be reported on an FMR unless someone not involved in

the failure, such as someone in the Management Services Group- ' who followed. surveillance requirements, discovered.the problem. There'wasino guidance or encouragement evident;from management ~ on plant ' staff ' members reporting their own' errors. There also' _

r- . f .. - -- l - , , nn._, , , . . . - , + - - . -.--.,,.n~ ' '

. K. ; - .' -/ - s 26 - st x . ~ - . O' '6 .,_ . appeared to be no guidance on the threshold for submitting an .' a FMR. -Those interviewed who frequently wrote FMR's indicated that the decision to submit an FMR was largely subjective. The + applicable procedure on FMR's, N0D procedure 1.3.24,-revision ~ 6, provided only general guidance on_-the application of FMR's- , and the numbers of-FMR's written-and the problems reported- -suggested that a minimum of FMR's were being submitted. i , Documentation was not' provided on, the xajority of FMR's examined in those areas of the forms-d6signated for the ORC , ' Secretary or Senior Compliance Engineer. action. These areas / were designed to include the number of the ORC meeting where

'%

the FMR.was reviewed, whether the'Eollow List (ORC) had been - f xg updated, and the disposition'of the FMR and date of ' .- , , disposition. This was contrary to the procedure. - Ty This matter was discussed with the licensee and presented.to i the Senior NRC Resident Inspector'as a potential enforcement s finding. , ' The.FMR Log was not effec'tive in several areas. It was blank for virtually all FMR's on three sections required by the log format: the ORC meeting number where theuFMR was reviewed; the associated LER, if applicable, and its'due date; and the ORC. - meeting number for the LER re iew. Six FMR's, 81-68 through 81-73, had inexplicably been erased from the: log with the next six FMR's written in their place. The log'rocorded no information regarding the missing FMR's however, the FMR's were filed as required and available for examination. e d Traceability of the details or def.ermining the status of a 'N given FMR appeared difficu1*,rfor sev'eral FMR's examined. There ~ s were no cross-references to the MR's used to effect the e corrective action for FMR identified problems. The "cause' _ description" was blank or " unknown" on a majority of the Fi4R:s. ? ' The ORC disposition, as described in the meeting minutes, was brief and poorly defined., The Follow List, ORC'.s.computerjzed action item list, contained very little descriptive,information . on the status of FMR's, ~and the Follow List item nutnber was not cross-referenced on the'FMRT - Corrective action was also inadequately defined. The typical- statement on this portion af the FMR form stated inerely "MR submitted.". There was no place on the form to identify long term corrective action to prevent recurrencei JThe FMR appeared adequate as a device to identify a problem that required further investigation, but was' ;i.nadequate for p aer followup, analysis, and reviews. , , The BEQAM, Section 16.3.7.2, requiFed' QA personnel to verify that corrective action on problems ~ identified by FMR's had been properly implemented. This had not been performed for at least ~ the two years preceeding the' PAS inspection for which records had been examined.- ..

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. , 1This: observation was~ discussed-with the licensee and presented to the Senior-NRC Resident Inspector as a potential _ enforcement' , f - fil. ding. . ,

Trend analyses on FMR'.s, requiredJsemiannually by NOS procedure

' 4 -16.02,1had not'been performed. The most recent analysis.had._ ' -

been performed on 1979 issued FMR's. :It'was written in:

October, 1980,'but was not_ reviewed by management until: August,- - 1981. This lack of response to their requirements and failure'

to make a timely _ review of> the Lanalysis of the :1979 FMR's~ restricted potential improvements to the FMR system. The trend analysis found that "60% of:the FMR's causes were unknown.in- 6; 's. . nature"~and concluded that the FMR's were "not. completed - sufficiently to. provide adequate analysis." . _ NSRAC's extent of review of FMR's was unclear. One member claimed that FMR's were not reviewed by the committee. Others ' .( stated that all FMR's were reviewed by virtue of their review - L; - of ORC' minutes, which, as stated previously, gave only the ^ - . briefest of descriptions. Due to the lack of documentation.on ' ff- the_ followup to FMR's, it appeared unlikely that NSRAC rev'iewed

the majority of FMR's and-associated corrective action to any '

- - significant extent. ' -

-

.) . .. - . - The NSRAC minutes of February 25, 1981, meeting 81-01, reported that the committee "should not be reviewing the total number of i. - F F&M's,~but should be reviewing the trend of. recurring . i' _ problems. '_' Conseqtently, the committee established an open ' j item on developing a trending method for_FMR's and LER's,. j. tabulating and evaluating these reports'for completeness'of t corrective actions, and developing a process to ensure the ~ i _ " loop is closed" on them. There had been apparently little , i , acU o_n taken on this open item at'the time of the PAS s

• -

- inspection. ' , (4) The handling of LER's appeared'to have some weakr. esses. One of < , s these was the LER Log. For several LER's that had been- ' initiated by FMR's, those FMR's were not identified as; required. - by the log. The ORC review meeting and the date~of issue for '

-

LER's/was not indicated for'any entries in the log. Most

sign'ificant was the lack.of trend analyses on LER's. Il .. L (5) The BEQAM contained in Section.2 a list of the licensee's 10 L CFR and-regulatory guide commitments. This was a partial list ' ~ of the licensee's commitments to the NRC. It did not contain all " daughter." documents-referenced by the regulatory-guides - listed or commitments _made through. correspondence with the'NRC. Furthermore, there was no cross-reference available showing .those procedures, instructions, or policy' statements that'

implemented each of their commitments. Absence of.a complete list of commitments and a cross-reference for impl.ementing. these commitments was considered a weakness. . m., ' , s L. - 2 , -

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_ _ _ _ _ _ _ _ _ - _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . - 28 - , 4 . . One step.the licensee had taken to correct this weakness was a cross-reference of all the requirements listed in TS Amendment 42 to the implementing procedures. This had proved successful, and plans were made to cross-reference all of the TS require- ments to their. implementing procedures. (6) There were positive steps planned or in the implementing stages to correct problems related to corrective action systems. One of these was a " Situation Statement Form." This was designed to be a problem or trouble identification report available for .use by all members of4the plant staff. It appeared to have all of the review requirements necessary for an adequate corrective action system. A licensee representative stated that they , intended to have this system, with corresponding training, accomplished prior to the refueling outage scheduled 'or September, 1981. b. Conclusion The weaknesses in this area involved the lack of an adequate program, failure to implement the existing program, and inadequate training on the existing program. Summarized, the most significant weaknesses included failure to have either a procedural oriented corrective action system or a system that included such items; inadequate training on existing systems; failure to perform trend analyses on reported deficiencies; failure to have adequate followup on corrective actions, including QA verification and committee reviews; and poor documentation on deficiency reports and logs. Based on these inspection findings, the management controls in this area were considered below average. 8. Tra<qing The object of this portion of the inspection was to determine the adequacy of management controls in the area of training, a. Observations The.following observations include the perceived strengths and weaknesses in the licensee's management controls that may not have specified regulatory requirements, but will provide the basis for subsequent performance evaluations. Licensed Training (1). An initial and requalification license training program for Reactor Operators (RO) and Senior Reactor Operators (SRO), had been established and described in the Pilgrim Nuclear Power Station Training Manual, revision 4. The manual was approved by ttie Pilgrim Station (Nuclear) Operations Manager. The requalification of licensed operators was also described in the " Licensed Operator Requalification Prograin," revision 4, .z; 9 . Y - _

- - _ ' - 29'- . , . submitted to the NRC on August 1, 1981, in accordance with 10 CFR 55, Appendix A. A nonlicensed training progra7 was < included in the Station Training Manual. The manual also contained a training and retraining program for Shift Technical Advisors (STA) and Fuel Handlers. The manual contained all forms and check iists used in the administration of the training programs. Corporate personnel,(including QA and QC personnel) were trained under separate program directives issued by the various departments involved. (2) The Station Training Manual was a controlled manual with copies distributed to the Vice Presicent-Nuclear, Manager of Nuclear Operations, Quality Assurance Manager, and 13 site management and training department personnel. Additional copies were distributed to the Control Room, Document Control Center, and USNRC Licensing Branch. The training manual was the primary training document on the site and established the general and specific training requirements for licensed and nonlicensed training. However, this document was not reviewed by the onsite Operations Review Committee (ORC). TS 6.5.A.6.a states that the ORC shall be responsible for review of any proposed procedure (and changes thereto) that affects nuclear safety. This observation was discussed with the licensee and presented to the Senior NRC Resident Inspector as a potential enforce men 2 finding. Review of the^ training marual identified several specific areas where' revisions and corrections were required. The training manual did not reflect the current site administrative organizations; did not contain provisions for recording changes ' and identifying effective pages; the list of reactivity and control manipulation requirements did not' agree with the requalification program submitted-to the NRC; and contained numerous errors and omissions in the text. This indicated ^ inadequate review and control of the training manual. The onsite training group was supervised by a Senior License Coordinator. The training staff included five instructors and two clerical personnel; however, this number-was not sufficient to perform the responsibilities assigned to the training group. Four additional positions had recently been authorized including a management position of Station Training Manager. [ (3) The BEQAM, paragraph 2.2.2.8, identified general training 2 ' responsibilities of the Boston Edison Company. However, there were no documents or statements issued or approved by the Vice ' President-Nuclear, or any other managerial person -that would provide policy and guidelines for an overall nuclear training . program. The licensee had issued-Policy Directives (first initiated in January 1978); however, these Policy Directives A did not include training policy. . %._ _ _ '6 .-

_ -- - 30 - . . ~(4) Position descriptions were available for most corporate and . I site personnel. However, many of the site position descriptions were out of date, not in alignment with the current organization, and did not clearly identify training responsibilities. (5) Review of the training manual and discussions with persoanel identified the following weaknesses in the licensing training program. (a) The current Initial NRC Operator License Training Program was not contained in the training manual. The program was described in memos from the Senior License Coordinator (SLC) to the Operations Manager. This new program required R0 candidates to complete three phases of instruction: Introduction (Basic Information), 4 weeks; Systems Study, 31 weeks; Formal License Preparation, 17 weeks. There were ten candiates assigned to the first class, which began training under the new plan in March 1981. (b) There was no provision in the requalification program, as described in the training manual, for ensuring that class material or lectures missed by a trainee were rescheduled and conducted in a timely manner. (c) Detailed lesson plans for the Initial Systems Training Course were not complete. For the current training class, lesson -lans were prepared and approved prior to the beginning of each individual class. " Master Lesson Plans" - a one page lesson description - had been prepared in 1975 and were used for general planning only. In addition, criteria for development of lesson plans had not been issued other than the inclusion of a lesson plan form in the training manual. (d) There is no provision in the training manual for the grading of license examinations by more than one instructor. Grading errors were identified in the review of past system examinations. However, none of these errors would have resulted in the failure of a trainee. (e) The same written examination was given to more than one group.at different times,. increasing the possibility of examinatian compros 'se. (f) System checkouts were m:de with the use of Form 07, Oral Examinatic Summary Report. There were no written criteria provided for the conduct of a system checkout =which were given by the, Senior License Coordinator. - (6) The licensee had instituted an above average program for the screening of prospective R0's. Memphis State University's- Center for. Nuclear Studies conducted a screening examination i- .1

_ _ - _ _ _ __ .____________ ______ ._ ____ _ - _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ . I - 31 - .. . and evaluation of each candidate. After initial training had been completed, a contractor administered a pre-NRC operator examination. The examination was both written and oral. Upon completion, the written recommendation of the contractor was submitted to the Operations Manager. (7) The training manual, paragraphs 3.1.1.4 and 3.1.2A.4, required the Senior License Coordinator to maintain specific individual records of operator initial and requalification training. Review of the records _for current licensed operators and discussions with management personnel revealed the following deficiencies. (a) The annual review of training records by the Operations Manager had not been accomplished (Training Manual, paragraph 3.1.2A.3.1). (b) Selected initial training records of senior R0's and SR0's were not readily available from the records center due to the lack of indexing controls. (c) System checkouts and practical factors were not signed off ' when completed. (d) Final review of the training records and certification by station management personnel, including the Nuclear Operations Manager, were not documented on Sections E through H of Form 02 as required by the training manual. The Nuclear Operations Manager confirmed that he had not reviewed license candidate's training records prior to final recommendation to take the RO examination, rather he depended upon the recommendations of the Deputy Nuclear Operations Manager, the Senior License Coordinator and the report of the training consultant. This observation was discussed with licensee and presented to the Senior NRC Resident Inspector as a potential enforcement finding. Deficiencies and noncompliance in operator training records had been previously identified by regional NRC inspectors as documented in NRC Inspection Report 50-293/8G-14. Commitments

were made by the licensee in their response to the item of noncompliance that should have resulted in the updating of all records by September 1, 1980. In addition, training record problems had been identified during BECO QA Audit #80-28, conducted September 22-26, 1980. Corrective action on training records problems (identified as an item of noncompliance as well as in a QA audit) had not been accomplished prior to the PAS inspection. These actions were completed by the end of the inspection in response to an Immediate Action Letter issued on July 31, 1981. This excessive delay in corrective action indicates a lack of management follow-through. (8) Interviews of nonsupervisory personnel and first-line supervisors (excluding training department personnel) indicated

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i

[ageneral?Iackof.knowledgeof.theltrainingmanualandtraining- ' , ~ , requirements. .One trainee, inLthe.RO training' program for four. = < - . months, had no'. knowledge;of the training manual =and the': g training 1 forms.1 '

n- ' lNonlicensed Training (9) General: Employee Training LThe : training. manual described the_ General Employee Training s(GET) for the plant staff.and other personnel requiring- , , unescorted access to the plant.' A one day trainin, session was given upon employment or. required entrance to the-plant,~ and repeated as a_retrainingLlecture.every two years thereafter. . A J > written examination was given.after all items .un a.GET. checklist were completed.- The following observations were made concerning GET training. (a) GET retraining was done every two years; however, Reg. , Guide 8.27 (March 1981), Radiation Protection Training of Personnel at Light Water Cooled Nuclear Power Plants, states that refresher training should be done annually, -as a minimum. (b) QA instru'ction contained in tne GET consisted only of brief statements of 10 CFR 50 Appendix B requirements. This indoctrination was the only . training given to . site : personnel on QA requirements, excluding QAD personnel. (c)_ The GET video tape concerning radiation protection contained errors, such as personnel not wearing'an air- ' mask in an airborne' contaminated area . (10) The training manual described a program for.the training of- maintenance, technical, and health physics personnel. The'se training programs were under the general control of the " Senior Nuclear Training Coordinator" or Senior License Coordinator - __ (SLC). Discussions ~with the SLC revealed that little of his- time was available for nonlicensed training. Specific group training was.under direction of the group _ leaders of the _ Management Services, Operations, Maintenance, Technical, and Radiological' areas._ Group training was.to consist of. initial- training..on-the-job training, and specialized training, such as_ vendor training courses. However, discussions with

site: personnel, including: supervisors, and review of specific-

~ training records revealed that:the. group training programs for . . maintenance and technical _ personnel had not been implemented. This observation was discussed with the licensee and pre sented: .to.the Senior NRC Resident _ Inspector'as a potential enforcement , 4 finding. (11).The training manual did not reflect the current practice of. ' training /and qualifying welders by the'QC Group' Leader, in . lieu - - -of the Maintenance Supervisor. 1 ,:$y g ., _ m b $ . _ . - &b-. .. ' ' .

_ '- 33 -: l >: . . ! -(12)_The training manual did not address training for the following

personnel. . Nuclear Plant Equipment Operator (Nonlicensed) . Chemical and Radiation Protection Technician . Chemical Control Operator . Radiation Protection Operator . _ Health Physics Clerk . (13) Contractors onsite received the same GET orientation training l as that provided to licensee personnel; however, an approved contractor training program had not been established for those i working in quality related areas. l (14) An approved training program for managers, supervisors,'and l 1ead personnel had not been developed. Interviews revealed j that this level of management personnel did participate in both , internal and external training activities. However, the training did not include a planned program with established goals and objectives. (15) Fire Brigade training requirements were specified in the TS_and " l in the Pilgrim Nuclear Power Station Fire Plan, approved August ! 10, 1978. Specific training weaknessess were identified during the inspection. (a) The Fire Protection Plan, paragraph 1.6, required the Pilgrim Station Manager to ". . . periodically review the training of. the Fire Brigade in order to personally assess the adequacy of the Fire Brigade." Through discussions with personnel, including the Nuclear Operations Manager it was determined that the requirement for this re'/iew and assessment was not known. This observation was discussed with the licensee and presented to the Senior NRC Resident Inspector as a

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potential enforcement finding. (b) Fire Brigaov Training Drill Records were delayed up to nine months before being submitted to the training group. i l There was no Fire Brigade team program described or referenced in the training manual. PNPS procedure 1.4.23,_ Fire Brigade Training Drill, revision 0, described the method to be used in conducting fire drills-involving the fire brigades; however, there was no provision to assure that problems identified during a drill were corrected. Individual responsibility for followup action was not assigned.

- 34 - - . . (c) Fire Brigade drills were required for each Watch Brigade- at least once every three months. Examination of training records revealed that " exercises" had been counted as drills. The definitions of " exercise" and " drill" as- contained in the fire plan were: " Exercise: A practice training session held at regular ' intervals for training and teaching purposes, including simulated fire response, which can be started and stopped at.any point during the exercise. " Drill: A practice training session held at unannounced regular intervals for evaluating effectiveness of training and performance under simulated emergency conditions. Once started, a drill should not be interrupted until completion." For example, on September 23, 1980, an indoctrination (exercise) of fire brigade members was conducted on the use of foam carts. It was counted as a " drill." This was contrary to the requirements of the Pilgrim Fire Plan, paragraph 3.f. The observation was discussed with the licensee and presented to the Senior NRC Resident Inspector as a potential enforcement finding. (16) fraining for corporate level personnel was conducted unde:- individual departmental procedures with the exception of Purchasing Department and Stores Department who had not issued procedures regarding training requirements. (17) One of the strengths of the corporate training program was t'ie establishment of a Nuclear Training Committee comprised of representatives of NED, h3S, NPD, and QA. This committee had a charter to coordinate, evaluate and provide assistance in the development and implementation of all programs utilized in the training of NED, NOS, NPD, and QA personnel. Coordination would be maintained with the BECO Training Department and with the Pilgrim Station Training organization. (18) QAD procedure 10.06, Qualification, Indoctrination, Certification, and Training of-Quality Control Personnel, revision 1, permited an oral examination to be given to . candidates for Level I and II NDE certification. This is contrary to SNT-TC-1A (1975 Edition) which specifies written examinations for qualification. Review of records, however,- determined that no QC personnel had been qualified by the use .of an oral examination. (19) QA procedure 2.02, QAD Indoctrination and. Training Program, revision 1, paragraph 5.1, required that the QA Manager shall, at least once a year, verify that all department personnel have received adequate indoctrination and training.- Paragraph 6.5

- 35 - . t -required.that the training records be authenticated by the QA Manager's initials. - Contrary to those requirements, the QA Manager.had not performed.this review as determined by review of training records. This observation was' discussed with the licensee and presented- to the Senior NRC Resident Inspector as a potential enforcement finding, b. Conclusions (1) Licensed Training Significant problems were identified in the R0 and SRO training and qualification records. Missing training record signoffs for system checkouts and practical factors caused the qualifi- cations of certain licensed personnel to be questioned during the inspection. . Training was-conducted in accordance with a training manual that had not been reviewed by the ORC. The training manual, which was the basis of the training program, was not adequately controlled, and lacked key parts.of the current training program. The license training course included the requirements of 10 CFR 55 and ANSI /ANS 3.1. While there was a shortage of instructor personnel to adequately carry out the training program, plans existed to increase the size of the training staff. Of primary importance was the lack of adequate management attention as evidenced by the lack of a definitive ~ training policy issued at the corporate level. The management controls associated with licensed operator's training were considered below average. (2) Nonlicene.ed Training Weaknesses were identified in the nonlicensed training program both onsite and at the corporate level. Although the basis for a comprehensive training program was in existance, it was lacking direction.from management and in most areas was not effectively implemented.. Some recent improvements initiated by corporate personnel had improved the quality and quantity of training provided. The primary cause of problems appeared to be the lack of mangement policy and followup. The management controls associated with nonlicensed training were considered below average. 9. PROCUREMENT The objective of this portion of the inspection was to evaluate the adequacy of management controls associated with procurement. < _ _ _

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a.;\\0bservations

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The following' observations. include

the perceived strengths and weak-

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nesses inLthe: 11censee's management controls that may not.have

. specific regulatory requirements- but will. provide' the-basis for sub- ' . > sequent performance evaluations. (1) BEQAM Volume-II, paragraphs 2.2.2.11 and 2.2.2.12,.provided the l program commitments.for. procurement, receiving inspection, and storage.:)These-paragraphs included commitments to the _ following. ~ ' ' Regulatory Guide 1.33, revision 2, 1978,_(ANSI:N18.7-1976/. , ., -ANS 3.2), QA' Program Requirements, Operations. Regulatory Guide.1.123,' revision'1, 1977, (ANSI N45.2.13), . , -QA Requirements for Control of Procurement of Equipment,; ' ' Materials,:and Services ~for Nuclear Power Plants. ~ ' Regulatory Guide 1.38, revision 2, -1977, (ANSI N45.2.~2) QA .- Requirements for Packaging,. Shipping, Receiving, Storage, ~ and Handling of Items for Nuclear Power Plants. . Regulatory Guide 1.39, revision 2,1977, (ANSI N45'.'2.3) . Housekeeping Requirements for' Nuclear' Power Plants. These commitments are implemented by the BEQAM and the. procedures of QAD NED, NOSD, N00, Purchasing Department, and Stores Department. The numerous procedures were not coordinated . and did not provide for all applicable requirements, including 'the following. (a) BEQAM'II-7, II-19, QAD procedure 7.01, and QAD instruction 7.1 did not address all ANSI N45.2.13-1976,: paragraph 10.2' requirements regarding certificates-of conformance. , NED procedure 4.01 included these requirements, but:did not include the Regulatory Guide 1.123, paragraph 6.0, requirement regarding certificates of conformance. (b) ANSI N45.2.2-1972, paragraphs 6.2 and 6.3,--storage requirements are not adequately provided for in Stores . Department procedure 13.01. (c) ANSI N45.2.2-1972,- paragraphs <6.2.1 and 6.4.1, storage - inspection ~ requirements were not contained in the QAD,~QC, 4 and Store Department procedures. 1 , . (d) ~ Regulatory Guide 1.38, revision-2, paragraph C.2.b,= '

required test weights used for rerating hoisting equipment ~

for.special~1ifts to be at.least equal to 110%-of the lift weight. .In-contrast,' Stores Department procedure.~13.01', paragraph 6.4,; allowed re-rated equipment for special-- lifts to be' tested ~to only 100% of the lift weight. s ' s, g ' - t.. m

- 37 - . . This observation was discussed with the licensee and . presented to the Senior NRC Resident Inspector as a potential enfurcement finding. (2) QAD procedure 4.06, NED procedure 4.01, N00 procedure 3.M.1-5, and Purchasing Department procedure 4.01 required identification:of 10 CFR Part 21 applicability on purchase- orders. .However, some.-purchase orders reviewed did not contain 10 CFR Part 21 applicability identification. Examples. include Purchase order 01596 3/13/78 for Limitorque motors; and Purchase' order 30310 12/16/80 for stainless' steel fittings. (3) Licensee Bulletin B-2 established the procedures and responsibilities for compliance with 10 CFR Part 21 requirements. . Interviews revealed that these were distributed only to department heads. Few on-site management personnel were aware of bulletin B-2 or its requirements. (4) The Purchasing Department and Stores Department had procedures for implementation of licensee procurement, receiving inspection and quality storage requirements. Interviews revealed, however, that neith1r the Purchasing Department nor the Stores Department had developed a training program on QA program requirements, ANSI Standard requirements and 10 CFR Part 50 and Part 21 requirements for applicable personnel. (5) QAD procedure 4.07, paragraph 8.0 provided the. audit require- ments for suppliers. The approved suppliers list (ASL) contained those suppliers considered by QAD to be acceptable for' supplying safety-related material. The ASL contained vendors who had not been audited or evaluated within the required time spans of QAD procedure 4.07. Whether or not safety-related material had been ordered from these vendors was not determined. (6) There were several QC inspection weaknesses identified during the inspection. ANSI N45.2.13-1976, establishes requirements for certificates of conformance including identification of procurement requirements met and not met, identification of purchased material, and certification by a person responsible for the QA function of the supplier. The ANSI N45.2.13 requirements are further endorsed by Regulatory Guide 1.123, / ANSI N45.2 2-1972,-requires inspection and examination of storage areas and stored items. The licensee had no QC procedures for performing the ANSI N45.2.2-1972, paragraphs 6.2 and 6.4.1, inspections. The licensee had no records'of QC inspections for these ANSI requirements. A licensee representative stated that these QC inspections were not performed. This observation was discussed with the licensee and presented to the Senior NRC Resident Inspector as potential enforcement findings. _

- 38 - .- ..- The following materialLreceiving inspection reports (MRIR) documented acceptance of certificates of conformance (C of C) that did not meet the requirements as specified. (a) MRIR 80-2157. The C of C did not specify compliance with purchase' order requirements _for stem material and for the -valves' ANSI 16.5 pressure rating. It certified compliance with unspecified " Quality Control Standards." (b) MRIR'81-31. The C of C was not signed by a QA representa tive. It was signed by the Vice President of Sales. It did not certify compliance with purchase order requirements. (c) MRIR 81-100. The C of C was not signed by a QA representative. It was signed by the Manager of Nuclear and Power Division. (d) MRIR 79-43. The C of C documented conformance to.the requirements and specifications of a drawing that was different from the drawing identified on the purchase order.- (c) MRIR 81-66. Purchase order 14167 required a C of C. Material was accepted by QC without one. These requirements were crossed out on the QC copy of the purchase order with no explanation. (7) MRIR's reviewed had recorded inspections for material identifi- cation, damage, and accompanying documentation. However, some MRIR's did not list the purchase order required documentation nor the documentation inspected during receiving inspection. (8) MRIR official copies were normally kept by QC for one year and then turned over to Document Control. An MRIR could only be obtained by requesting a specific MRIR number. No cross-references existed between purchase orders and MRIR's, or between item stock numbers and MRIR's. Document Control and QC appeared to have considerable difficulty in obtaining documentation and purchase orders for MRIR's. (9) During receiving inspection, QC identified special storage,. shelf life and preventative maintenance requirements specified by the vendor in documentation received with the material. (Stores Department procedure 13.02, paragraph 6.5). If no special requirements were provided by the. vendor, none was required by QC. "Q" category rubber "0" rings with no shelf life limitations and electric motors with no preventative maintenance requirements were observed in storage. QC did not have a means of determining the adequacy of vendor specified preventative maintenance and shelf life requirements or the acceptability of the lack of vendor requirements. _

. . _. ._ _.y_ . _ . _ _ _ ( ,i ' - .- 39 - - , ' ^

, . ..- o (10).:Several weaknes'ses were identified in the storage'of material. (a)_ ANSI'N45.2.21972,- paragraph 5.3.2 requires _ nonconforming , - -material to be; segregated or-removed from.the project when practical.; : Hundreds of items applicable to the requirement were found with "QC Hold" tags and.without "QC Hold"'or "QC Accept" . tags and were mixed in with stored - . -"QC Accept" safety-related material. P , (b) ANSI N45.2.2-1972, paragraph 6.2.1_ requires storage a'rea - access control'. During this inspection uncontrolled .' ? access of three individuals into the Grade "B" storage ' ) area was observed. ' (c) ANSI N45-2.21972, paragraph-6.3.3, requires hazardous. chemicals, paints, solvents, and other material of like ' nature:to be stored;in.a well ventilated area that'was not i in close proximity to important nuclear plant items. Contrary to this, several items marked flammable (Liquid Resin, Adhesive 847-3M and cans of Spotcheck Dye- Penetrant) were observed stored in close proximity to safetyrelated material. , i These obs'eivations were discussed with the licensee and i -~ presented to the Senior NRC Resident Inspector as a potential i enforcement-finding. . L (11) BEQAM, figures II-11 and II-16, provided an organizational chart showing a Planning, Scheduling and Cost Control Department. > This " department" was a group within Nuclear Operations Support 3'

Department. This change had not been reflected in the p applicable BEQAM sections. Interviews revealed that the.

Planning, Scheduling, and Cost Controls Manager (Manager of the Nuclear Fuels Procurement Section) had been in the. position for , i two months and was not-knowledgeable of the functions and responsibilities of the Nuclear Fuels Procurament Group. , , ( Written procedures for the group' had not~been developed. b. Conclusion 4 The written program for procurement, receiving inspection, and

,

storage program was found to be inadequate. There was a lack of i awareness, training, and implementation of the existing written " program. Numerous specific ' problems were _ identified i:; the storage l; of safety-related material, with. certificates of conformance j . documentation, and with the approved Suppliers List. I . The management controls associated with procurement, receiving q' - _ inspection, and storage were considered below average. l '10. Management Exit Interview. . An exit meeting was conducted on August 14, 1981, at the Boston Edison

, _ Company: corporate; office with;the licensee representatives identifled in . y 1 . - _ - _ _ _ _ - , -* y +- , - - , , . - m 5 g, , .r., s , e , -- f4 . - -, , 9 -.--,-7.,,

, ..c. . . - . . _- _ _ '40 -1 - ' * . , , ; - - Attachment A. (Additional meetings were held during the inspection on ' . . July 30;il981, with corporate management representatives. ! The. team leader' discussed.thelscope offthe inspection and stated that the - inspection would continue with further;in-office data' review and analysis ' by-the team' members'and that the< team would draw a conclusion'for each functional area inspected and classify the management controls of that

i. ~.an' appraisal ~ report containing observations, the conclusions for each- area as'either Above-Averaoe, Average,-or Below Average. The. issuance of .

' functional area, and an Executive Summary were discussed. The licensee was. informed that a written response would be requested for any areas ' . j. ' designated.as.Below Average and.for significant weaknesses and that some ! - of the observations' classified as a weakness are or may become " Potential. Enforcement Findings" that would be presented to the Region I Resident- = Inspector for:further disposition.- + . ^ The Limportance fof effective management and-the known programmatic-and E personnel weaknesses,'as related to the safe operation of the facility',' were: discussed. .The team members presented their observations for each ! functional. area. The. licensee'was informed that the observations 1 ~ included the perceived strengths'and weaknesses in their management control systems and that the observations would be' utilized in the evaluation.of the-licensee's programs. ! , 4 4 2- - 4 2. e 6 i , , . , < 9 .s .

• "

., - , .a .. , ~ - .=, . . . . - , , . .. . -. ,

= , .

. , . . Attachment A A. Persons Contacted .The following lists (by title) the individuals contacted during this inspection. The table to the right of the listing indicates the areas (the numbers correspond to paragraph numbers in the report) for which that individual provided significant input. Other individuals were also contacted during the inspection including technical and administra- tive personnel. Title of Individual Corporate Office S 2 S E 5 2 $ 2 President x x x

• Senior Vice_ President, Operations

& Engineering x

1. • Vice President, Nuclear

x x x x x x x x

1. • Quality Assurance Manager

x x x x x x x

• Nuclear Operations Support Manager

x x x x x Director of Stores & Services x . Superintendent, Stores Department x Manager, Nuclear Engineering Department x x x x Manager, Planning Scheduling & Cost Controls x Nuclear Fuels Procurement Group Leader x Plant Support Group Leader x x Senior Purchasing Agent x Purchasing Agent x QA Engineers & Staff Assistant x x x. Senior Licensing Engineer x

• Senic. ' Reliability Engineer

x x . Senior Compliance Engineer x x x Senior Electrical Engineer x NSRAC Members x x x Senior QA Engineer x x Staff Assistant, QAM x x Manager, Training & Development x Staff Assistant, Training x Power Systems Group Leader x Pilgrim Site

• Nuclear Operations Manager

x x x x x x x x Deputy Nuclear Operations Manager (s) x x x x x Management Services Group Leader x x x x x x x A-1- -

. . . - , .. 2 3 4 g g 2 g 2 ,

Chief, Maintenance Engineer ~ x x x x- x x x Chief, Technical Engir.eer x x -Chief, Radiological Engineer- x x Shift Technical Advisors x x Nuclear. Watch Engineers x x Day Watch Engineer x x Operations Engineer x x x x I&C Supervisor . x x x x Chemical Engineer x Craft Personnel x x x x

• QA Engineer-

x x x Maintenance Supervisor x x Nuclear Control Technician x- x Staff Assistant, Nuclear Safety x x Senior Reactor Engineer x x Senior Compliance Engineer x x x Senior Plant Engineer x Reactor Operation Supervisor x Senior Fire Protection Engineer x Senior License Coordinator- x License Instructor x Training Instructors x Staff Assistant,' Nuclear Operations x x Staff Assistant, QA x Principal Engineer QA/QC x x Senior Maintenance Engineer x -QC Engineers / Inspectors x Document Control Supervisor x x Stores Warehouse Supervisor x

1. Attended meeting on July 30, 1981

• Attended meeting on August 14, 1981

A-2 1

! ,, , -lL Cocuments Reviewed The following lists' those documents reviewed by the inspection team members to the extent necessary to satisfy the inspection objectives stated in Section 1 of the report. -Those specific procedures and instructions referenced in the report are listed.by title and revision number where they first appear. 1. Technical Specification (TS), Section 6 0, Administrative Controls 2. Final Safety Analysis Report (FSAR) 3. Selected ORC Meeting Minutes for 1980 and 1981 4. Selected NSP.AC Meeting Minutes for 1980 and 1981 5.- Quality Assurance Manual (BEQAM), Volume II 6. Position Descriptions for Various Corporate and Site Licensee Personn 1 7. Quality-A.:surance Department Procedures (QAD) 8. Quality Assurance Department Instructions (QADI) 9. Boston Edison Company Bulletins 10. Nuclear Operations Department (N00) Procedures 11. Nuclear Operations Support Department (NOSD) Procedures 12. Nuclear Engineering Department (NED) Procedures 13. Failure and Malfunction Report (F&MR) Trend Analysis, NOSD, August 6,1981 14. 'QAD Trend Analysis, July 24, 1980 15. Selected Monthly QA Program Service Group Activity Reports for 1980 and 1981 16. Various QAD Instruction Memoranda 17. Selected QA Management Reports for 1980 and 1981 18. Unresolved Deficiency Summaries for 1980 and 1981 , 19. Unresolved Deficiency Reports, July 17, 1981 A-3 - -

' . , , * -20. Failure and Malfunction Report (f&MR) Log 21. License Event Report (LER) Log 22. Maintenance Request (MR) Log 23.' I aintenance Requests (MR) M 24. Deficiency Report (DR) Log 25. Selected Maintenance Procedures (MP) for 1930 and'1981 26. -Selected F&MR's for 19R0 and 1981 27. Selected LER's for 1980 and 1981 28. Selected Deficiency Reports and Associated Correspondence for 1980 and 1981 29. Selected QA Audit Reports for.1980 and 1981 30. Pilgrim Nuclear Power Station Training Manual (Revision 4) 31. Project Quality Plans 32. Proposed Design Change Requests (PDCR's) 33. Nuclear Safety Review and Audit Committee (NSRAC) Charter, Revision 8 34. NSRAC Meeting Minutes (1980 and 1981) 35. Operations Review Committee (0RC) Minutes 36. TMI Project Progress Report, May 25, 1981 37. Pilgrim Station Watch Bill ' 38. Purchasing Department Procedures (PDP) 39. Stores Department Procedures (SDP) 40. Pilgrim Station QA Approved Suppliers List 41. Selected Production Orders for 1979, 1980, 1981 .. 42. Selected Purchase Orders for 1979, 1980, 1981 43. Selected Mater _tal Receiving Reports 1979, 1980 - ~A-4 ' a

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