ML20038C643
| ML20038C643 | |
| Person / Time | |
|---|---|
| Site: | Pilgrim |
| Issue date: | 10/16/1981 |
| From: | Corry A BOSTON EDISON CO. |
| To: | Moseley N NRC OFFICE OF INSPECTION & ENFORCEMENT (IE) |
| Shared Package | |
| ML20038C641 | List: |
| References | |
| RTR-REGGD-01.033, RTR-REGGD-1.033 81-249, NUDOCS 8112110341 | |
| Download: ML20038C643 (28) | |
Text
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e L-t EOSTON EDISON COMPANY B00 SovLsTON STREET BOSTON. MASSACHUSETTS 02199 ANDREW V. CORRY as=.co vcc eece.osat October 16, 1981 BECo Ltr. #81-249 N
Mr. Norman C. Moseley, Director Division of Program Development and Appraisal Office of Inspection and Enforcement U. S. Nuclear Regulatory Commission Washington, D. C.
20555 License No. DPR-35 Docket No. 50-293 Response to Management Appraisal Inspection 50-213/81-20 (PAB)
Dear Sir:
This is a response t'o your letter dated September 14,1981 which reported on the Performance Appraisal Inspection conducted by the Performance Appraisal Section of the NRC's Division of Program Development and Appraisal Inspection. This inspection was performed during the periods July 20-31 and August 10-14, 1981. There were eight functional areas inspected of which six were considered by the Appraisal Team to be below average. Boston Edison was requested to submit a response describing the actions that we have taken or plan to take to improve the management controls in these six areas. The inspection observations for the affected areas and Boston Edison Company's specific response and planned action for each item are provided in Attachment A.
Boston Edison Company recognizes the importance of implementing effective management controls to assure public health and safety. We have never established operational goals to be achieved at the expense of safety considerations.
To the contrary, corporate management has emphasized that safety of operation is a fundamental objective of our nuclear activities, i
In recent years, the corporation has implemented changes in management controls aimed at improving management effectiveness and at attaining above average performance in our industry. The Nuclear Organization initiated a program early in 1981 to develop an integrated work management system with the objective of achieving above average performance in the safe and reliable operation of Pilgrim Nuclear Power Station. Major changes in management systems are involved and require progressive implementation including refinement as experience is gained in startup and operation of new system elements. We are concerned that, in appraising the system, you have perceived an unbalanced approach within top management between safety and reliability.
I assure you that safety has priority for top management attention and that 4
A112110341 811123 eDR ADOCK 05000293 O
P.DR
- CO3fDN EDICON COMPANY l.
October 16,.1981 Mr. Norman C. Moseley :
1 we will devote adequate resources. to effectively implement ~ those management controls which contribute. to assuring public health and safety.
Written policies for the Nuclear Organization are being generated and will,be disseminated by December 1,1981. These policies will reaffirm Boston Edison Company's commitment to assuring safe and reliable plant operation and will delineate the Nuclear Organization's commitment to effective quality assurance and trainir.g' programs at both the corporate and site levels.
Boston Edison Company has also initiated a program to improve our
. corrective action system by identifying generic ca.uses and ensuring' effective followup through management policy and support. A review of the corrective action programs presently employed by other utilities is being initiated to determine actions that have proven effective to other utilities and 4
that can be started promptly.
In conclusion, Boston Edison reaffirms its commitment to safe operation as our highest priority. Although our corporate direction has long supported this objective, we will formalize written policies to clearly reflect the commitment. The translation of these directions and policies into action by top management in the Nuclear Organization is receiving priority attention 1
based on the results of your review.
We welcome your observations and are confident that Attachment A is responsive to your concerns, i:owever, should you have any additional comments or questions, please do not hesitate to contact us.
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Very truly yours, 4
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i ATTACHMENT A-DETAILED RESPONSES:
AREA: COMMITTEE ACTIVITIES - Operations Review Committee (0RC)
I.
General Response Boston Edison concurs with the PAB observation that the Operations Review Comittee was active, that its members. felt free to voice dissenting opinions and that its members indicated a positive attitude toward their committee membership responsibilities. Also during the course of the interviews, we were pleased to hear a PAB inspector state that the ORC meeting minutes were, in his opinion, among the best he had ever seen.
Further, the PAB report stated that its observations included perceived strengths and weaknesses that may not have specific regulatory requirements. Boston Edison agrees that there are weaknesses in some ORC activities and we will move to improve them.
II. Concerns,(Observations), Response, Actions s
NRC Concerns (Observations)
Observation #(1)
Charter for ORC does not contain requirements to review selected documents.
BECo Response The volume of information reviewed by ORC at the meetings must be kept under strict control at all times. The nature and scope of documents to be reviewed must be assessed periodically. There-fore, " summary level" information is necessary for those documents which constitute bulky information such as Audit Reports, Inspection Reports, and so forth. BECo actions should be as follows:
Immediate Action:
To measure current ORC Charter (PNPS 1.2.1) against Technical Specifications. This has been done. The ORC Charter will be measured against ANSI N18.7-1976 and Regulatory Guide 1.33 by 11/23/81 and recommended changes in the charter will be made to the Nuclear Operations Manager.
Long Term:
Develop a system whereby the following items are presented to the ORC Secretary for inclusion where appropriate on the ORC agenda.
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= 't o o NRC Bulletins.and Circulars o
Audit Reports o
Specific Operating Records o
Fire Protection Plan o
Surveillance Test Records o
Changes to the QA Program o
NRC Inspection Reports and Responses thereto
. Observation -#(2) - QA Audit #81-03 contained a Tech. Spec.
violation which was.not reviewed by ORC as required by 6.5.A.6.e BECo-Response ORC will review the methodology of how agenda items are determined.
Immediate Action:
Add Audit #81-03 to ORC Agenda and document discussion of Tech.
Spec. violation.
Long Term Action:
Assess methodology of how ORC agenda items are captured and determined.
Observation #(3) - PNPS Procedure 1.2.1 was deficient in several areas.
Further, PAB disagrees that Station or Corporate organization changes should be allowed on 30-day LER's. The ORC procedure issues deal with timeliness of issuance of minutes, membership discrepancies between procedure and Tech. Specs. and distribution of minutes to licensed personnel.
BECo Response Regarding the time frame for the issuance of ORC meeting minutes BECo will establish a goal based on actual, reasonable delivery from draft to distribution. This goal will be tentatively set at 30 days, a reasonable amount of time considering the quantity and quality of information contained in the meeting minutes plus the necessity to
" approve" the minutes at a subsequent ORC meeting.
Regarding distribution, actions are concurrently underway to enhance the effectiveness of the operating experience feedback system.
Current plans are to maintain the same methodology of providing the information to Watch Engineers (for discussion with watch sections)
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' and all non-watch senior licensed' operators.
(It is_ recognized that 100% participation is not a realistic goal. Accordingly, reasonable goals will eventually be established). Regarding the 30-day LER for organization changes, BECo does not believe that this issue is signi ficant.
In the spirit of cooperation between the licensee and the regulator, BECo intends to keep the NRC informed of significant changes in organization prior to implementation.
4 Observation #(4)(a) - Lack of formal training for ORC members.
BECo Response BECo will establish a training plan for ORC Members and alternates.
Immediate Action:
During the regularly scheduled '(Wednesday) ORC meetings, BECo will conduct an abbreviated training session for all ORC members (including alternates). A brief lesson plan is required. Documentation of completed training will be forwarded to training.
Long Term Actions:
Establish training program and retraining program for all ORC members.
Observation #(4)(b)
Regarding quorum obligations, BECo will confirm that the subject meetings had a quorum present.
Immediate Action:
Document in subsequent ORC meetings that a quorum was present at meetings questioned by PAB.
If quorum was not present, re-review material covered at that meeting.
Long Term Action:
None anticipated as BECo believes that PAB inspector may have reviewed previous ORC attendance versus present day quorum requi rements.
Observation #(4)(c)
Regarding lack of knowledge by ORC members on how to resolve disagreement with Chairman, BECo does not consider this item a problem because Procedure 1.2.1 which delineates the process steps for resolution is available for reference at any time.
Training program should address this concern adequately.
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Immediate Action:
(Per training plan specified above.)
long Term Action:
(Per training plan specified above.)
Observation #(4)(d)
Regarding the unwieldy scope of ORC follow items, it is recognized that this listing, rather typical for the industry, can no longer function as an effective management control tool. Although it worked relatively well when modifications, Tech. Spec. changes, regulatory inspections and so forth were less frequent, the follow list system in ineffective far its originally intended purpose.
Accordingly, BECo intends to shift the burden of those management control elements away from the ORC to other management personnel who will be in a position to provide summary information to the ORC thereby allowing the Committee to focus on real, safety-related matters rather than cumbersome, although essential, documentation and/or routine management control matters.
Immediate Action:
Review ORC follow list items and reduce scope to the extent practicable.
Long Term Actions:
Assess nature of follow list items and determine means to minimize the unwieldy number of items.
Start with actions required by modifications and factor those into startup test / documentation close-out program.
Ensure committee activities review the results of S.U.
Test efforts and allow ORC to capture those that are " missed" by individual reviews.
Establish similar management control methods for other items to the extent practicable.
Observation #(5)
(No negative findings.)
AREA: COMMITTEE ACTIVITIES - Continued - Nuclear Safety Review and Audit Committee (NSRAC)
I.
General Response Regarding PAB observation of NSRAC activities, Boston Edison concurs in general with the weaknesses identified.
- However, we submit that the immediate actions already taken in consort with those planned will not only improve the management controls associated with NSRAC activities but also move to improve the effectiveness of the comm; ctee itself.
Observation #(6)
The lack of the following features in the_ NSRAC Charter:
o Guidance on what constitutes an unreviewed safety question.
o Periodic reviews of facility operations and records, including LER's and NRC inspection reports, o
Requirements for review of NRC bulletins and circulars.
BECo Response Immediate Action:
(a) Guidance on what constitutes an unreviewed safety question -
The charter refers to Section 50.59, 10 CFR for the definition.
This same definition is stated in NED Procedure 3.07, Preparation and Approval of Safety Evaluations. Reviews of the NED and-N0D Safety Evaluation Procedures are being conducted to assess the need for further guidance.
If further guidance is deemed necessary, it will be incorporated into the NSRAC Charter i
and implementing procedures.
(b) Requirements to periodically review facility operations and records, including LER's and NRC inspection' reports -
The Charter has been revised (Rev. 9, August 14,1981) to require NSRAC to review (i) reports and meeting minutes of the Operations Review Committee and (j) the basis for ORC approval or disapproval of all proposed revisions to the Technical Specifications. Although the present NSRAC Charter does not require review of all LER's and the NRC inspection reports, items from any such reports which constitute violations having nuclear safety significance are required by item 1-1 (c) j of the Charter.
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NSRAC has commissioned NED's System & Safety Analysis Group to perform a systematic review of all LER's and FMR's and to report the results to NSRAC.
This is considered a pilot project for the purpose of assessing one method of further strengthening NSRAC's ability to maintain a broad-based cognizance and oversight of nuclear safety-related activities.
Long Term Actions:
I Further changes to the NSRAC Charter will be considered, as necessary, to clarify the scope of NSRAC's role as a management oversight of nuclear safety-related activities. Any further changes in NSRAC's Charter and implementary procedures will be developed in coordination with the further development of the Nuclear Organization's Integrated Work Management Systems.
The objective of this development effort will be to provide reasonable assurance, in an ongoing fashion, that the various work management and review processes related to nuclear safety at PNPS are either achieving satisfactory results or that necessary corrective actions are identified and followed up in a satisfactory 1
manner.
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Estimated completion date: December 15, 1981.
- Observation #(7) - Conflict in N0D Procedure 1.3.4.concerning requirements for safety evaluations related:to changes to
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procedures.
BECo Response Immediate Action:
N00 Procedure 1.3.4 will be revi. sed to be internally consistent.and to reflect the results of an evaluation currently in process to clarify the scope, depth, and frequency of NSRAC reviews (see 4
response to Observation #(8) below).
Estimated completion date: December 1,1981.
- Observation #(8)(a) - Training.of NSRAC Members BECo Response Immediate Action:
Training sessions were conducted for NSRAC members. relative to their NSRAC responsibilities and NSRAC Procedures on August 7 and 20,1981.
The requirement for training of new NSRAC members will be addressed in updated or additional procedures.
Estimated completion date: December 1,1981.
- Observation #(8)(b) - QAD Audit #81 NSRAC Administrative Controls l
1 BECo Response Immediate Action:
The five deficiencies issued to NSRAC were addressed at NSRAC Meeting
- 81-05 on 2/3/81 and have been responded to.
Certain action plans developed in response to the QA Audit also relate to the PAB Audit findings.
These plans are as follows:
"NSRAC to cause to be prepared a procedure to describe the scope, depth, and frequency of review to be conducted to comply with Technical Specification 6.5.B.7 to bring them all into conformance (Reference ANSI: 18,7, ANSI: 45.2.10)."
Estimated completion date:
December 1, 1981.
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AREA: QUALITY ASSURANCE AUDITS I.
General Response We concur that BECo's audit program should provide above average management controls in auditing by correcting the implementation concerns identified in the PAB inspection.
II. Concerns,(Observations), Response, Actions
= Observation #(1) - Weaknesses identified in the program were not in program substance, but in its implementation and in the awareness and responsiveness of upper level managers acting in various oversight capacities.
BECo Response Boston Edison initiated actions to implement program requirements with increased discipline and responsiveness by upper level managers during the PAB inspection.
. Observation #(2) - There were numerous instanc,es of an apparent failure by QA personnel to implement program requirements.
BECo Response An increase in the QA complement from five to fifteen engineers has been authorized by management, and an aggressive recruiting drive is currently underway.
BECo's present QA staff has been supplemented with experienced QA personnel from other firms during the interim so as to implement QA program requirements.
Immediate Action:
Specific action on each example cited is as follows:
(2a) It is anticipated that compliance with this program requirement will be achieved by 1/1/82.
It is also anticipated that the Unresolved Deficiency Summary will be computerized.
(2b) The QA Manager's Report was issued quarterly as stipulated in Paragraph 3.2.b of QAD Procedure 1.02.
Future reports will be in full compliance with the referenced procedure with the issuance of the report for the third quarter of 1981.
(2c) The BEQAf1 requirement (Section 16.3.4.7) for QA to verify corrective action within thirty days of the auditee's notification of completion was only instituted one month prior to the PAB inspection.
QAD is currently in compliance with this requirements.
The October 1981 Deficiency Report Summary Report requests each Department Manager to notify QAD of the completion status of each deficiency. A verification schedule will be determined upon receipt of notification of completion by the auditee.
The verification assignments of the previous QA Manager have been assumed by the present QA Manager.
(2d) An employment offer has been made to a suitable candidate to perform the trending required by QAD Procedure 16.02 and it is anticipated that BECo's trending program will be implemented by 11/15/81.
(2e) Failure and Malfunctions (FMR's) and Nonconformances (NCR's) will be audited by QAD during the month of November 1981.
(2f) The Document Control System will be audited by QAD Prior to 12/31/81.
(2g) All future QAD audits will provide a summary of audit results including an evaluation statement regarding the effectiveness of the quality assurance program elements which were audited.
0bservation #(3) - Lack of Management Support BECo Response Corporate management has responded to the.needs of QAD by authorizing a manpower increase.
Immediate Action Augment present staff of two BECo auditors with the temporary use of a sufficient number of consultant auditors to enable BECo to complete all program requirements.
Long Term Action:
Commence aggressive recruitment drive whereby the present staff of QA personnel will be increased to the newly authorized complement.
0bservation #(4) - The audited party failed to respond to deficiencies in a timely manner, responded inadequately, or failed to take corrective action. Communication between QAD auditing personnel and plant staff members had deteriorated.
BECo Response Nuclear Operations and Quality Assurance Managers will jointly develo.n a program to improve communications and relationships between personnel at PHPS and the QAD.
Immediate Action:
(1) The QA Manager and the Nuclear. Operations Manager. will increase their personal involvement in the audit interviews and responses to ensure improved communications between QAD personnel and plant s ta f f.
(2)
In filling QAD's authorized complement, attempts will be made to hire auditors who have had previous operating experience.
(3) The BEQAM has been changed to significantly improve the method for resolving deficiencies.
"Significant" deficiencies have been assigned a higher priority with specific escalation require-ments involving upper level corporate management.
(4) DR's are hand delivered to recipients to avoid mailing delays.
Long Term Action:
QAD will develop a Quality Assurance Indoctrination and Training Program for all personnel in the Nuclear Organization. This program will emphasize the prevention and resolution of deficiencies rather than just the detection of them. This program will be implemented by 4/1/82.
. Observation #(5) - In the opinion of the PAB, QAD personnel in their practices shared much of the responsibility in the communication problems and in resolving deficiencies.
BECo Response Action is being taken to correct the problem. Specific responses to examples (a) through (f) are as follows:
(Sa) Paragraph 16.3.4.1 of the BEQAM now states that "the time clock for time initiation, implementation, and completion of the corrective action shall be the date of the QAM's signature."
(5b) In regard to unacceptable responses to Deficiency Reports, Paragraph 16.3.4.6 of the BEQAf1 has been changed to read, "at this time, QA will establish a second response due date (no more than 30 days)."
(Sc) QAD will complete the protion of the Deficiency Report labeled " Recommended Corrective Action" in the future and the specific information required for resolution will be stipulated.
(5d) Paragraph 16.3.1 of the BEQAM has been changed to simplify the definition of a Significant Deficiency.
In addition, Paragraph 16.3.4 also requires the Lead Auditor to make "an assessment as to whether the deficiency constitutes a failure of the QA Program and is a Significant Deficiency."
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(Se) Section 2.2.2.2 has been changed whereby resolution of unresolved deficiencies is referred to the VP-Nuclear for resolution and if "a resolution acceptable to the QA Manager is not obtained, the matter shall be promptly referred to' the Executive Office of Senior Vice-President for-resolution."
(5f) Status reports have been issued for all open deficiencies; responses have been requested from Department Managers to enable QA to verify status.
Immediate Action:
Revisions have been made to the BEQAM to make it more definitive.
Some of these revisions are cited above.
Long Term Action:
The BEQAM will be reviewed and revised as necessary to delete any ambiguities and to assure that it properly reflects compliance with Appendix B.
+ Observation #(6) - Oversight of the QA Program was weak.
BECo Response The BEQAM has been revised to require distribution of Audit Reports to upper management.
In regard to items 6(a), 6(b), and 6(c), Boston Edison intends to modify the NSRAC Charter to clarify its responsibilities for oversight of all safety-related functions and activities.
Although the QAM is no longer a member of NSRAC, he is represented on this Committee by his Staff Assistance who was formerly the Quality Control Group Leader, the Maintenance Supervisor, and the Nuclear Engineering Manager.
QAD Procedure No.1.01 has been revised to reflect the change that the QAM is not a member of NSRAC, but the Department is represented to provide necessary expertise on the Committee.
Immediate Action:
Changes to the BEQAM will be made on an as-needed basis; the change to the NSRAC Charter will be made by 12/15/81.
Long Term Action:
Members of NSRAC will be included in the QA indoctrination and training program described above.
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- Observation #(7) - The inability of QA to meet their current audit program requirements coupled with the. lack of management attention has led to an ever-worsening condition.
BECo Response
,This situation has been corrected by the hiring of six temporary auditors from a consulting firm. These auditors will augment BECo's QA staff to complete all audit requirements for 1981..
Immediate Action:
Six temporary auditors have been hired from a consulting firm.
Long Term Action:
Commence an aggressive recruiting program to bring the QAD up to its authorized complement.
. Observation #(8)
(No negative findings.)
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-- AREA:
MAINTENANCE I.
General Response
. Boston Edison concurs that the procedure used to control maintenance activities is well. defined and broad in scope. -We further concur that,-
when measured against standards of excellence, the management controls associated with maintenance activities are in need of upgrading. We further wish.to point out that substantial progress in the upgrading effort had been completed with additional actions in progress or planned at the time of the PAB inspection.
II. Concerns (Observations), Response, Actions A.
NRC Concerns (Observations)
Observation #(1) - T'le lack of an integrated PM Program including a written schedule and tracking system.
BECo Response Although selected preventive maintenance is practiced at PNPS, there is not an integrated and formalized program.' This fact has been identified previously and corrective action was already in progress. The actions included the development of a plan and the subsequent authorization of fundings to establish the requisite data base.
Implementation of subsequent phases is scheduled for CY 1982.
Immediate Action:
Phase I of the action plan has been initiated with the procurement of consulting services for the development of a master equipment listing, a report of preventive maintenance requirements with a rationale for selection, and completed data forms. This activity is scheduled for completion by 4/1/82.
Long Term Action:
Phase II of the action plan will involve preparing the requisite implementing procedures and an implementation plan. The imple-mentation plan will consider revisions of the PM program based on operating experience gained through the upgraded corrective action program.
It is estimated that this phase will begin in mid Februa ry, 1982.
Phase II of the action plan involves a manual implementation initially with the concurrent development of software specifications to facilitate electronic data processing.
It is estimated that this phase will begin in May, 1982.
Observation #(2) - MR's do not contain dates for applicable signatures.
Nor does it provide for safety related designation.
BECo Response The upgraded " Work Control System" will factor these concerns into the associated _ implementing _ procedures and forms. This concern is concurrently addressed in our responses to the PAB observations on corrective action programs.
Observation #(3) - Large maintenance backlog exists without know-ledge of whether an item on the backlog involves safety-related maintenance.
BECo Response BECo has and will continue to operate PNPS in strict accordance with the Technical Specifications. When equipment failures or malfunc -
tions occur, rendering that equipment incapable of performing its intended function in its intended manner, the equipment will be considered " inoperable" and appropriate action statements per the
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Tech. Specs. will be followed. Accordingly, it is unlikely that safety-related equipment would be designated with a "C" priority.
However, to address the apparent concerns, BECo will review that backlog items at the next regularly scheduled, quarterly review to determine that no safety-related equipment which requires main-tenance has a "C" priority.
Further, PNPS Procedure 1.5.3 will be revised to prohibit the "C" priority on S-R equipment.
Action:
Review backlog for "C" priority items vs. safety-related equipment.
Revise 1.5.3 to prohibit use of "C" priority for safety-related equipment.
Observation #(4) - Lifted Lead / Jumper Procedure does not address use of bypass lines on mechanical blocks and does not require verification of restoration.
BECo Response:
BECo had previously recognized the need to expand the applicability of Procedure 3.M.1-3 to address a wider range of " temporary modif-ication" to bring the Station into conformance with ANSI N18.7-1976, Section 5.2.6.
Those actions have been planned and scheduled.
Increased attention to regulatory issues has impacted our resources to the point that we missed our original commitment date. Wcrk arounds are currently in progress.
i Action:
Complete actions previously planned.
Observation #(5) - As-built drawings pending revision are issued on request and are not procedurally addressed.
___y BECo Response:
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BECo will estabifsh a policy regarding issuance.of DCN's (as-;
builts awaiting upddting) and reflect that policy in appropriate procedures.
Action:
Determine a policy based on interviews and concensus of user groups.
Initiate revision to Procedure 1.3.8 to reflect same.
Observation #(6) - PAB determined that Procedure 1.4.6 (Housekeeping) does not address individual responsibilities'and detailed house-keeping requirements.
Action:
Establish requirements matrix from ANSI Standards; propose method-ology for implementation, obtain concurrence, initiate procedure revisions; implement.
Observation #(7) - PAB determined that vendor manuals retained by maintenance and I&C were not adequately controlled or audited.
BECo Response BECo concurs with the findings of the PAB inspector and will take appropriate corrective actions.
Action:
Revise Procedure 1.3.8 to require periodic audits of controlled vendor manuals.
Establish method to control audit.
Observation #(8) - PAB determined that maintenance personnel did not receive adequate training in QA and administrative procedures; l
effective training program for maintenance personnel did not exist.
l BECo Response l
l BECo wishes to point out that a maintenance skills instructor was assigned to the training department about 6 months ago and has already conducted selected courses on seals, packing, and rigging since assignment. A training program will be formalized early in 1982 with recommended staffing levels to allow implementation either in late 1982 or early 1983. Appropriate elements of QA and administrative procedures will be factored into the training program. (Referenced QA response 4.(2))
l Action:
i Ensure that training plans include appropriate elements of QA and I
Administrative training.
Ensure Training Manager receives appropriate levels of training in QA Program requirements.
AREA: CORRECTIVE ACTION SYSTEMS 1
I.
General Response I
Boston Edison concurs with the preceived strengths and weaknesses in the corrective action system.
Edison's objective is to improve the corrective action program to identify, evaluate and. initiate action effectively.
This program shall address information from Pilgrim Nuclear Power Station and Industry experience to enhance safety and reliability.
The key objectives of the program are to:
1.
More efficiently and effectively identify safety and reliability deviations, 2.
Strengthen the immediate and long term safety and reliability assessment of these deviations, and i
3.
Document appropriate and timely management corrective j
actions.
The safety and reliability assessment will incorporate appropriate review, management reporting escalation and trending analysis through the creation of a multi-discipline evaluation unit. The assessment process will address both hardware and software deviations.
4 A review of the corrective action programs presently employed by other utilities is being initiated to determine actions that have proven effective to other utilities and that can be started promptly.
Observation #(1) - A lack of a written corrective action system which would provide documented records and adequate reviews for use by all personnel to cover both hardware and software. problems.
Immediate Action:
The elements of the Corrective Action System are being defined and reviewed to develop an integrated organizational approach. A common deviation report is being developed which will contain essentially all of the elements of the " Situation Statement Form" as discussed in l
the PAB report. An implementation plan is being developed in order to effect an orderly transition from the current corrective maintenance system to an integrated Corrective Action Program. All the elements I
of the above defined Corrective Action Program will be identified and defined by November 15, 1981.
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long Term Program The Corrective Action Program Implementation Plan will be available l
by December 1, 1981. A preliminary effectiveness of this program will be assessed three months after the initial implementation. The program will be formally reassessed annually thereafter.
- Observation #(2) - Maintenance requests are ineffecti-2 as a corrective action system. They are not reviewed for repetitt:. mess, reportability or generic implications.
Immediate Action:
We concur with the observations concerning the M.R. as a corrective action system. The function of the M.R. in the new revised corrective action program will only be as a data source.
. Observation #(3) - Failure & Malfunction Reports are ineffective as a corrective action system. The procedure lacks guidance. The F&MR log was ineffective. The F&MR's were inadequately filled out. QA personnel have not verified corrective actions on problems identified by F&MR's.
Immediate Action:
We concur with the observation that the F&MR has weaknesses as a corrective action system.
See QA Audit Reponse (2E)
During development of the Corrective Action Program, the role of the F&MR shall be evaluated and redefined as appropriate.
Observation #(4) - The LER's were not trended. The LER log was improperly filled out.
Immediate Action:
The LER review process shall be evaluated and revised to eliminate present weaknesses.
Long Term Program:
The LER will be a data source for trending analysis within the Corrective Action Program.
+ Observation #(5) - The BEQAM contained in Section 2 a list of the licensee's 10 CFR and regulatory guide commitments to the NRC. 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, instruc-tions, or policy statements that implemented each of their commitments.
Absence of a complete list of commitments and a cross-reference for implementing these commitments was considered a weakness.
Immediate Action:
Commitments made through correspondence with the NRC are presently being tracked by utilizing a computerized system.
Long Term Program:
An integrated licensing commitment tracking system will be developed and implemented to assure timely completion of commitments made through correspondence with the NRC. The process definition and initial policy for this system is scheduled for completion by 12/1/81. The system will include an exception reporting to management.
o The list of Edison's 10 CFR and regulatory guide commitments contain in BEQAM section 2 will be cross-referenced to the procedures, instructions, and policy statements that implement each of the commitments.
0bservation #(6) - Positive steps planned or in-progress appear to include all review requirements necessary for an adequate corrective action system.
BECo Response Boston Edison concurs with the PAB observations that appropriate actions have already been planned or partially implemented. However, we wish to clarify the last statement of the observation which stated that the upgraded corrective action system was intended to be accomplished prior to the current refueling outage. Rather, Boston Edison originally intended to implement this system at or near the end of the refueling outage. The basis for that implementation schedule took into account concurrent retirement of portions of the corrective maintenance system during a transition period to optimize training and minimize confusion of subordinate members of the user groups. The new schedule will be consistent with the implementation plan specified above.
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AREA: TRAINING I.
General Response During the audit, interviews were being held for a Nuclear Training Manager who has since been selected and is scheduled to start November 9, 1981. A definitive policy statement on training will be issued.
During the previous year the training staff has doubled and plans for 1982 include not only another doubling in the training staff but an increase in the plant staff (with in-training positions) to allow for an improved program.
We have taken steps to upgrade previous missing documentation and maintain the documentation presently in place.
II. Concerns (Observations), Response, Actions NRC Concerns (Observations)
- Observation #(1) - (No negative findings.)
- Observation #(2) - Training Manual not reviewed by ORC, BECo Response BEco does not interpret the Technical Specifications as requiring ORC to review the training manual. The individual elements of the Training Manual are reviewed by respective chief engineers / group leaders and its content is established by an independent training department which is subject to audit by the QA Department.
Immediate Action:
Regarding the finding or inadequate review and control of changes to the manual, BEco will implement the changes to reflect our current training program which is more extensive than that shown in the manual.
Long Term Action:
We will review and upgrade our method for providing management control of the Training Manual and changes thereto.
- Observation #(3) - Lack of a Policy Directive at an Organization Level for Training.
BECo Response A Policy Directive will be issued by the VP-Nuclear regarding Organizational Commitments to Training.
Immediate Action:
An Organizational Policy Statment integrating on-site and off-site training will be issued by December 1,1981 l
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Observation #(4) - Lack of up-to-date position' descriptions.
BECo Response The PAB auditor was made aware that there was a corporate-wide effort in progress in this area with all position descriptions 4
scheduled to be upgraded to revised corporate standards.
Immediate Action:
This process is ongoing and will be upgraded continuously, however, we are 90% done with the initial phase and will be completed -
by March of 1982.
Observation #(5) - (a-f) General observations and weaknesses.
BEco Response Long Term Action:
Boston Edison is aware of each of the six items contained in this section and each will be considered in the reformating and revision to the Training Program and Manual.
Observation #(6) - (No negative findings.)
Observation #(7) - Non-maintenance of training records.
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BECo Response l
These items were rectified by the end of the inspection.
Long Term Action:
The actions to preclude re-occurrence are still being developed and will be implemented during the first quarter of 1982.
Observation #(9) - GET General Findings BEco Response i
Boston Edison is in general agreement with the findings and has taken the action of developing a General Employee Training Handbook which is given to each employee and contractor at the site defining all site requirements.
Immediate Action:
Site policy statements are being summarized on a posting to be located at various locations in the plant. This will be completed by November 1,1981.
Long Term Action:
General Employee Training will be the responsibility of one element of the Training Department and not a collateral duty.
- Observation #(10) - Lack of formalized Discipline Training BECo Response Boston Edison Company concurs that although requirements and programs are stipulated in the training manual, they are not presently implemented.
Specialized training has been given to Health Physics, Technical (Reactor Engineering, Chemistry, Instrumenta-tion and Control) and Maintenance personnel over the previous year, however, the courses have not been integrated into the training program or records.
Immediate Action:
A verification of each individual's qualifications has been completed by the respective Chiefs.
Long Term Action:
Resources to allow for full implementation of Discipline Training are incorporated into our plans for 1982.
. Observations #(11), (12), & (14) - Training Manual was deficient in addressing training for certain grups of individuals.
BECo Response Long Term Action:
The Training Manual will be revised by March 31, 1982 to address these concerns.
- Observation #(13) - Lack of an approved contractor training program for those working in quality related areas.
BECo Response Boston Edison Company as a Policy requires that work performed in quality related areas be accomplished in accordance with site approved procedures.
If specific training is required (CR0 removal, MSIV overhaul, seal replacement) it is provided to those performing the task.
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Long Term Action:
The Training Manual will'be revised to incorporate requirements for contractor ; training by March 31, 1982.
Observation #(15) - Specific training weaknesses in Fire Brigade Training Program.
BECo Response Long Term Action:
The Fire Protection Program _is being re-assessed and a recommended plan for improvement will be; developed by March 31,1982.
Observation #(16) - Purchasing' Department and Stores Department issued procedures regarding training requirements.
BECo Response Immediate Action:
The Purchasing Department and Stores Dbpartment will issue training procedures (refer to Procurement Area, Observation #(4).)
Observation #(17) - (No negative findings.)
Observation #(18) - QAD Procedure 10.06 Qualification, Indoctrination, Certification and Training of Quality Control Personnel does not meet requirements of SNT-TC-1A.
BECo Response immediate Action:
QAD procedure will be revised by December 1, 1981.
. Observation #(19) - QA Manager not verifying indoctrination and training of departmental personnel.
BEco Response Immediate Action:
QA Manager will conduct the required verification by November 15, 1981.
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-22 AREA: PROCUREMENT
'I.
General Response '
Boston Edison will -improve the written program for procurement, receiving inspectior, and storage program and take actions to achieve effective implementation of these programs.
'II:
Co'1cerns,(Observations), Response, Action A.
-NRC Conce'rns,(Observations)
,.., + - Observation #(1) - The numerous procedures of QAD, NED, NOSD, N00, Purchating Department, and Stores Department were not coordinated and dia <not provide for all applicable requirements.
(This may provide the basis for subsequent performance evaluations.)
BECo Response t-Our specific responses to the examples cited are as follows:
(a) The Boston Edison Quality Assurance Manual and implementing procedures will be updated to address Regulatory Guide 1.123, Paragraph,6.0 and ANSI N45.2.13-1976, Paragraph 10.2 requirements regarding certifications of compliance.
Expected completion is 12/31/81.
(b) Storage requirements are incorporated in Stores Department Procedures 13.02 and 13.05.
(c) Stores Department Procedure 13.05 will be revised to address monthly inspections that meet the requirements of ANSI N45.2.2-1972, Paragraph 6.2.1.
Quality Assurance Department Procedure 10.03 will be revised to require periodic inspections of warehouse / storage areas by QC personnel cer',1fied to the requirements of Regulatory Guide 1.58, Rev. 1.
A Quality Control Instruction (QCI) will be issued by 12/31/81, and will include a checklist that reflects the inspection l
requirements of ANSI N45.2.2-1972, Paragraphs 6.2.1 and 6.4.1.
(d) Stores Department Procedure 13.01 has been revised to require test weights used for re-rating hoisting equipment for special lists to be at least 110 percent of the lift weight.
Immediate Action:
The actions described above, with estimated completion dates, will be takt.n to rectify the problem cited.
.O Long Term Action:
A review will be performed of the various department procedures to ensure that all procedures are in compliance with the BEQAM and are appropriately coordinated.
It is anticipated that this effort
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will commence about 11/1/81; estimated completion date is 3/1/82.
Observation #(2) - Some Purchase Orders did not contain 10 CFR Part 21 applicability identification.
BECo Response Quality Assurance Department will conduct an audit of " Procurement Document Control" by 12/31/81. This audit will specifically evaluate the extent of non-compliance with the Part 21 applicability identification.
Immediate Action:
The planned audit will be conducted per the above schedule.
Long Term Action:
All procurement documents, irrespective of quality level designation, are being reviewed by QAD. Trending results will indicate the reasons for this problem; these facts will be included in the integrated Quality Assurance Indoctrination and Training Program that will be developed.
Observation #(3) - Few on-site personnel were aware of Bulletin B-2.
BECo Resonse A copy of Bulletin B-2 has been distributed to every person in the Nuclear Organization and to selected Managers in departments which interface with the Nuclear Organization.
Immediate Action:
Distribution performed as above.
Long Term Action:
A copy of Bulletin B-2 will be given to every new employee during General Employee Training.
Observation #(4) - Neither the Stores or Purchasing Departments I
had developed a Training Program or QA Program requirements.
BECo Response The Purchasing and Stores Departments ar: in the process of scoping their Training Program requirements. Once the scope of the Training Program is identified, procedures will be preparea, issued, and impl emented.
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Expected procedure completion date is 12/31,/81.
Immediate Action:
QAD to provide assistance to Stores and Purchasing Departments to develop a Training Program.
Long Term Action:
QAD will audit Stores and Purchasing Departments to ensure that training requirements are established and implemented.
. Observation #(5) - The Approved Suppliers List (ASL) contained some suppliers who had not been audited or evaluated within the required time span of QAD Procedure 4.07.
BECo Response This item dealt primarily with QA's failure to perform audits of suppliers on the Approved Suppliers List (ASL), on a triennial basis as required by QAD Procedure No. 4.07.
The triennial audits are.
currently being expedited by QA, with the assistance of qualified consultant personnel, and it is expected that compliance will be achieved by 12/31/81.
Immediate Action:
Retain temporary auditors to bring QAD up to authorized complement.
. Observation #(6) - Requirements of ANSI N45.2.13-1976 concerning Certificates of Conformance and ANSI N45.2.2 concerning inspection and examination of storage areas and stored items.
BECo Response The responses for items (a) and (c) of Observation #(1) apply here.
Immediate Action:
See Items (a) and (c) of Observation #(1).
Long Term Action:
See Items (a) and (c) of Observation #(1).
. Observation #(7) - Some Material Receipt Inspection Reports did not list the Purchase Order required documentation, nor the documentation inspection during receiving inspection.
BECo Response Quality Assurance Department Procedure 7.01, " Receipt Inspection",
provides guidance in the correct method of completing the Material Receipt Inspection Report. Personnel that are assigned the responsibility for conducting receipt inspection will receive additional training in the use of QAD Procedure-7.01.
..i O This training will be completed by 10/23/81.
Immediate Action:
As stipulated in the response, additional training will be given to QC receipt inspectors.
Long Term Action:
Periodically, provide refresher courses to personnel conducting receipt inspections.
Observation #(8) - MRIR official copies were kept by QC for one year.
BECo Response All MRIR's are now being transmitted to the Document Control Center, with appropriate documentation, on a daily basis.
The DCC is considering the use of a cross-reference system for improved retrievabili ty.
Immediate Action:
Accomplished.
Long Term Action:
Review document control procedures and revise as appropriate for improved retrievability.
. Observation #(9) - QC personnel identified special storage and preventative maintenance requirements during receipt inspections.
BECo Response Paragraph 4.3.2 of the BEQAM is currently being revised to require the cognizant engineer to list special storage, shelf life, and preventative maintenance requirements on the purchase documents.
This change will be issued by 11/15/81.
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Immediate Action:
Issue the BEQAM change described above.
Long Term Action:
Dur.ing the review of procurement documents by QA, ensure that these requirements are specified.
. Observation #(10) - Items with "QC Hold" tags were mixed in with "QC Accept" safety-related equipment.
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BECo Response (a) A QC Hold Area will be re-established within the existing warehouse and, when practical, will be utilized for QC Hold Items.
For those items that have been on QC Hold for an extended period of time and for which their pedigree is questionable, an evaluation is underway to determine whether or not they should be removed from the site.
Full compliance will ~ be achieved by 12/31/81.
(b)
In order to preclude repetition of access control violations, additional personnel barriers have been or will be installed at strategic warehouse locations. Expected completion date is 12/31/81. Additionally, access control will be observed and reported during periodic QC surveillance inspections.
(c) Hazardous material storage, as required by ANSI N45.2.2-1972, Paragraph 6.3.3, will be achieved by 12/31/81.
Immediate Action:
Complete evaluation of material with "QC Hold" tags and/or attempt to obtain proper documentation from the manufacturer.
Remove this material from the warehouse and store in a trailer alongside the warehouse.
Discard that material for which the shelf life has expired.
Long Term Action:
Continue to try to obtain documentation from manufacturers for material with "QC Hold" tags.
Observation #(11) - There is a contradiction in the organizational chart in the BEQAM.
BECo Response The BEQAM will be revised as appropriate.
Until specific procedures are in place, Nuclear Fuel Procurement personnel will use NED Procedure 4.01 to control procurement activities.
New procedures will be implemented by 12/31/81.
Immediate Action:
Complete preparation of procedures and revise BEQAM as appropriate.
Long Term Action Assure that BEQAM is revised promptly to reflect any organization changes.