ML20054H092
| ML20054H092 | |
| Person / Time | |
|---|---|
| Site: | Dresden  |
| Issue date: | 05/24/1982 |
| From: | James Heller, Knop R, Madison A, Parker M, Robinson D, Shafer W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20054H078 | List: |
| References | |
| 50-237-82-07, 50-237-82-7, 50-249-82-07, 50-249-82-7, NUDOCS 8206220563 | |
| Download: ML20054H092 (26) | |
See also: IR 05000237/1982007
Text
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U.S. NUCLEAR REGULATORY COM'!ISSION
REGION III
Report Nos. 50-237/82-07; 50-249/82-07
Docket Nos. 50-237; 50-249 License Nos. DPR-19; DPR-25
Licensee: Commonwealth Edison Company
P. O. Box 767
Chicago, IL 60690
Facility Name: Dresden Nuclear Power Station, Units 2 and 3
Dresden, IL
Inapection At: Commonwealth Edison Company Offices
Chicago, IL and the Dresden site
Inspection Conducted: April 12-16 and 19-23, 1982
d. D het ?
Inspectors: W. D. Shafer (Team Leader) 7-2./-22
(D D&kln 3
J. K. Heller - 6 ,2) - T2>
[0. U Y-rs 97 l1 t
A. L. Madison 8-M/ - 8E
0
k).o. % k o ,
M. E. Parker 6- 2. /- h2,
[ . D- t i bl
D. L. Robinson f~J /- 2 2.
Approved By: R. K p T- 2
Projects Branch 1
Accompanying Personnel
- +T. M. Tongue, NRC Senior Resident Inspector
- +M. J. Jordan, NRC Resident Inspector
- R. C. Knop, Chief, Projects Branch 1
- R. L. Spessard, Director, Division of Project and Resident Programs
+Present during the exit interview on April 19, 1982.
- Present during the exit interview on May 7, 1982.
8206220563 820607
PDR ADOCK 05000237
0 PDR
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Inspection Summary
Inspection on April 12-16 and 19-23, 1982 (Report Nos. 50-237/82-07;
50-249/82-07)
Areas Inspected: A special, announced inspection of the licensee's manage-
ment controls over selected licensed activities. The inspection involved
420 inspector-hours onsite and at the corporate office by five NRC in-
spectors including 20 inspector-hours during offshifts.
Results: The licensee's management controls for five areas were reviewed.
Of the five areas inspected, no apparent items of noncompliance were
identified in two areas, three items of noncompliance were identified in
the area of maintenance (failure to re-train maintenance personnel every
two years and failure to train maintenance personnel on station plans
and procedures - Paragraph 2.a.(7); a bypassing QA and QC personnel on
safety-related work - Paragraph 2.a.(14); failure to document on-the-job
training - Paragraph 2.a. (16));two items of noncompliance were identified
in the area of Committee Activities (failure to review Field Change Requests
- Paragraph 4.a.(1)(c)3.; failure to distribute Onsite Review Reports -
Paragraph 4.a.(3));and one item of noncompliance was identified in the area
of Quality Assurance Audits (failure to conduct adequate audits - Paragraph
5.a.(4 and 5)).
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ATTACHMENT A
1. Persons Interviewed
The following list identifies (by title) the individuals contacted during
this inspection. The columns to the right of the listing indicate the
areas for which that individual provided significant input. The number
at the top of each column refers to a specific section of the report.
Other individuals, including technical and administrative personnel, were
also contacted during the inspection.
,
Htle of Individual
Corporate Office 1 2 3 4 5
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Vice President, Nuclear Operations X i X X
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Division Vice President, Nuclear Stations i !X . lX
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- Manager, Quality Assurance lX {X
- Assistant Vice President
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X !
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Manager, Station Nuclear Engineering l' l
Department (SNED) X i X
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- Director, Nuclear Safety ;X
Production Training Manager X
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- Director, QA Operations
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X : X
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Director, QA Engineering / Construction +
, X
- 0perational Manager X
t
Maintenance Manager i X
Technical Services Manager ,X
- Director, Nuclear Licensing
- Nuclear Licensing Administrator
Supervisor, Offsite Review X
+ Senior Participant, Offsite Review (3) X
Participants, Offsite Review (3) X
Project Enaineer X
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Attachment A -2-
1 2 3 '4- 5
7___...y.__ ._; .
Nuclear Engineer i- X ! ! I
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Mechanical Engineer X i
Group Recorder L X I
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QA Training Coordinator } , X
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QA Auditor (SNED) X lX
QC Inspector (SNED) (_2) X i , i X
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Site -
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- + Station Superintendent ! X >X X >X X
+0perations, Assistant Superintendent X X ; X X
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+ Maintenance, Assistant Superintendent ,
X X X lX X
+ Administrative & Support Services,
Assistant Superintendent X ,
X X
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Operating Engineers (3) X ' X X X
+ Technical Staff Supervisor X X ; X X X
Master Mechanic X X X
Master Instrument Mechanic X X X X
Master Electrician X
Radiological / Chemistry Supervisor X X
Training Supervisor X X X X
Office Supervisor X X X
+QA Supervisor X X X X X
QC Supervisor X X X X
Shift Engineer X
Assistant Technical Staff Supervisor X X
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Attachment A -3-
1 2 3 4 5
r
Modification Coordinator X
Project Engineer X i
Procedure Coordinator X
Systems Engineer X
Nuclear Engineer f X l
Cognizant Engineer-(Mods) (2) , X I f
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0+QA Engineer, Operations '
,X X -X
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i +QA Engineer, Maintenance ! IX
< \
Mechanical Foreman (3) 'X 'X 'X
+QA Engineer Modification / Construction X ,
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X
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Station Control Room Engineers X
Licensed Operators (2) X X ,
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Non-Licensed Operators (3) lX X l
3 i
Training Instructors (2) iX ,X !X
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+QC Inspectors (2) i X jX !
lX
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Instrument Foreman (2) X
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Mechanics (8) .
X X !
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Instrument Mechanics jX i
Outage Coordinator X f
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+Present during exit interview on April 19, 1982.
- Present during exit interview on May 7,1982.
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Attachment A -4-
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2. Documents Reviewed .
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The documents listed below were reviewed by the inspection team members
to the extent necessary to satisfy the inspection objectives. The
specific procedures referenced in the report are listed by title when
they first appear.
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1. Technical Specifications, Section 6
l- 2. Quality Assurance Topical Report
j 3. Quality Assurance Manual
. Cuality Requirements-
. Quality Procedures 1
l . Station Quality Assurance Manual l
j 4. Production Training Department Organization and Administration ,
i Manual
- 5. Various Dresden Administrative Procedures (DAP's)
6. Various Dresden Personnel Procedures (DPP's)
7. Various Dresden Maintenance Procedures (DMP's)
8. Various Dresden Technical Procedures (DTP's)
- 9. Office of Nuclear Safety Organization and Administration Manual
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10. Nuclear Station Licensee Event Reports for 1981, April 20, 1982
11. Monthly Nuclear Safety Activities, January 1982
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12. Various Station Nuclear Engineering Department Procedures
j 13. Quality Assurance Memorandums 1-18
l 14. Station Position Descriptions
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15. Nuclear Stations Division Position Descriptions, April 19, 1981
16. Production Department Organization Charts, April 14, 1981
17. A Plan for Managing Commonwealth Edison Company's Operation
j of Nuclear Power Plants, April 14, 1981
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18. Professionalism Program Implementation Guide, September 1981
j 19. Total Job Management Manual
{ 20. 1981 Quality Assurance Audits
1 21. Five Station Nuclear Engineering Audits
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22. Training Records of Non-Licensed Operators, Maintenance Personnel,
and QA Auditors
23. 1981 and 82 Deviation Reports for Units 2 and 3
24. 1981 and 82 Descrepancy Report
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1. Design Changes and Modifications
a. Findings
The following findings include items of noncompliance and recognized
strengths and weaknesses in the licensee's management controls.
The strengths and weaknesses may not have a specific regulatory
bases, but do represent methods considered to be good management
practice throughout the industry.
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(1) Procedures and instructions had been issued by the licensee
to control the initiation, review, development, and imple-
mentation of design changes. These included Station Admin-
istrative Procedures, Station Engineering Procedures,
Engineering Management Procedures, Construction Department
Procedures, and Internal Department Instructions. Although
the procedures were numerous and the program somewhat complex,
the written design change program, as reviewed, was adequate.
(2) The licensee's program established measures to ensure proper
documentation of design changes and modifications. One
measure, the Modification Approval Sheet, cited in Quality
Procedure 3-51, Design Control For Operations-Modifications,
,
provided accountability for review and approval of the
- modification, but failed to provide sufficient administrative
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controls to prevent the return to service of a system prior
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to implementation of the appropriate training and procedures.
The training concern was identified by the Resident Inspector
during an earlier inspection and the required corrective
, action was initiated by the licensee (Inspection Report
j 50-010/82-04, 50-237/82-06, and 50-249/82-06). The program
! also allowed for the provisional release and return to
service of a system comprising only part of the modifica-
tion without the signoff by the Station Quality Assurance
l, Department. This piecewise approval of a modification,
while reducing scheduling difficulties associated with the
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modification and its attendant impact on plant availability,
was a program weakness as it impaired program accountability.
Reportedly, the omission of the Quality Assurance Department
in the review process was identified by the licensee and
corrective action initiated.
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(3) A concern was identified regarding the lack of documentation
l in closed out modification packages. In several instances
l these packages did not contain the specifications and draw-
ings necessary to perform the task. This weakness was
observed by the Resident and Region Inspectors prior to
this inspection (Inspection Report 50-010/82-01,
50-237/82-02, and 50-249/82-02). Although the modification
package and the supporting documentation could not be
j readily cross-referenced in some instances, the program
4 did provide a means of tracking design documents and draw-
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Ings by their modification number through the logs in-
Central Files. The modification package was controlled
by the Technical Staff while all supporting documentation
including all construction drawings were maintained by
Central Files.
It was noted that the Modification Coordinator had been
assembling the final documentation packages for submittal
to Central Files using the private correspondent files of
the cognizant engineer rather than the controlled files.
This was considered a weakness in program implementation.
(4) Design changes originating at the station made subsequent
to the initial release of design specifications and drawings
were documented by Field Change Requests (FCR's). Although
the FCR's were subject to review by the Architect Engineer
and the Station Nuclear Engineering Department, they were not
stbject to review by either the Operations or the Technical
Staff Department. No mechanism existed to require concurrence
by the Operating Engineer, Technical Staff Supervisor, and
the working department issuing the FCR. There was no direct-
feedback system to ensure site management review of FCR's.
(5) The licensee's program for implementing procedural changes
resulting in part from design changes and modifications did
not have sufficient capacity to handle the large volume of
procedures being submitted. The utilization of temporary
change forms in lieu of permanent procedural changes was
found to be extensive, with a backlog of procedures awaiting
revision and implementation numbering over 300, and increas-
ing. This was considered a significant program weakness.
(6) (Closed) Open Items (50-237/80-14-01, 50-249/80-18-02,
50-237/81-19-01, 50-249/81-13-01): Inadequate Licensed
Operator Training. Interviews and a review of training
records and procedures indicated that the licensed operator
training program associated with design changes and modi-
- fications was sufficient to ensure the operating staff's
l awareness of changes in plant systems, procedures, and
regulatory requirements. Both the required reading program
and the six week training program were being revised to
ensure proper content and prompt compliance.
(7) The licensee's program for quality control of design changes
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and modifications assigned to Station Construction was found
- to be weak. Interviews with QC Inspectors revealed that the
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QC Staff was performing its descrepancy reporting function
i through the contractor's QC Program and not its own. Non-
l comformances identified by QC Inspectors were referred
verbally to the contractor for proper documentation and
corrective action. The problems identified in the li-
censee's Station Construction Department were not trans-
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mitted to Station Management, thus preventing Station
Management's awareness.of corrective action. Delegation
of authority and responsibility for quality control to
offsite contractors, without ensuring Station Management
awareness, was considered a program weakness.
b. Conclusions
The licensee had established an effective program to control
safety related design changes and modifications. The program
appeared to be adequately-implemented with some exceptions.
The most significant weaknesses noted were the lack of site
management knowledge of major field changes, the low level'of
experience in the Technical Staff, and the large backlog of
procedures in need of revision.
2. Maintenance
a. Findings
The following findings include items of noncompliance and recognized
strengths and weaknesses in the licensee's maintenance management
controls. The strengths and weaknesses may not have a specific
regulatory bases, but do represent methods considered to be good
management practice throughout the industry.
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(1) The organization for accomplishing maintenance activities
included the Assistant Maintenance Superintendent, the
Master Mechanic, the Master. Instrument Mechanic, Master
Electrician, Staff Assistant Engineers, General Foremen,
Scheduler / Planner, Foremen, Electricians, Mechanics,
Instrument Mechanics and helpers. The Assistant M&intenance
Superintendent reported to the Station Superintendent.
(2) The Station Superintendent was responsible for the overall
station maintenance activities and reported directly to the
Division Vice President-Nuclear Stations. The maintenance
activities were controlled by onsite personnel.
(3) During outages, the licensee used CECO. maintenance workers
from other maintenance groups within the Joliet area. Main-
tenance workers at the Dresden station also routinely traveled
to fossil facilities.
(4) Review of selected personnel records and interviews revealed
that these maintenance personnel met the qualification re-
quirements of ANSI N18.1-1971. Dresden Administrative
Procedures (DAP's) described the station and maintenance
organizations.
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(5) Interviews revealed that management personnel in the main-
tenance department were being given simulator training and
assigned observation duties in the control room. Reportedly,
this had improved communications between the operations and
maintenance personnel and aided in the interface between the
two Departments.
(6) The Maintenance Department had implemented a systems train-
ing program, consisting of systems descriptions, walkthroughs,
and familiarization with plant drawings to improve maintenance
personnel knowledge of plant design and systems and to improve
equipment out of service isolation and tagging. Interviews
revealed that management personnel had completed this training
and craft personnel were being scheduled.
(7) TS 6.1.F requires retraining to be conducted at intervals not
exceeding two years. ANSI N13.1 - 1971 requires a training
program to be established which maintains the proficiency of
the operating organization.
Review of training records and interviews revealed that the
licensee had no written retraining program for Maintenance
Department personnel that maintained the proficiency of the
maintenance worker. Review of records revealed that Radio-
logical Health and Safety Training was conducted annually
and included refresher training on Security, Out of Service
Cards, and Respirator Training. Specialized training had
been performed in the Maintenance Department for some
selected personnel.
ANSI N18.1 - 1971, Section 5.4 General Employee Training,
states that all personnel regularly employed in the nuclear
power plant shall be trained in appropriate plans and
procedures.
The failure to establish a training program which maintained
the proficiency of the operating organization (which includes
the Maintenance Department) and the failure to conduct re-
training every two years was identified as an item of non-
compliance (50-237/82-07-01, 50-249/82-07-01) .
Interviews with maintenance personnel revealed that they
were unaware of their authority to initiate procedure in-
quiries and deviation reports as allowed by the written
program. Personnel interviewed stated they had not re-
ceived any training on Station Administrative Procedures.
There was no written program to train personnel on station
plans and procedures.
(8) Review of records and interviews revealed that instrument
valves manipulated by the instrument mechanics during the
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performance of all work requests and 25 percent of surveil-
lances were verified by the responsible supervisors. This
method did not provide verification, independent of the
people performing the activity, as' required by NUREG-0737,
Item I.C.6. These supervisors were directly responsible for
the personnel performing the work. The lack of independent
verification on all safety related valve manipulations,
as appropriate, was considered a significant weakness.
(9) Review of the Total Job Management (TJM) Program and inter-
views revealed that.the TJM Program was allowing the Main-
tenance Department to effectively schedule jobs from the
work request backlog. However, the TJM Program was not
updated to recognize the present organizational structure
at the Dresden Station. The TJM Program assigned responsi-
bility to the Technical Staff Supervisor to ensure the
radiation protection requirements along with Quality Control
input had been addressed. Quality Control and Rad / Chem
Supervisors were directly responsible to the Administrative
and Support Services Assistant Superintendent and not the
Technical Staff Supervisor.
(10) DAP 9-2, Procedure Preparation, required maintenance pro-
cedures to be reviewed by the Technical Staff Supervisor,
Maintenance Assistant Superintendent, Operating Engineer
or SRO, and approved by Station Superintendent. If the
Technical Staff Supervisor deemed it necessary, he could
request verification of the procedure by a verifier.
Verification of a procedure was a hands-off walk through.
The Verifier would go to each location and would simulate
the intended action. The Verifier would ensure that the
nomenclature of the procedure agreed with that of the
plant. If equipment was damaged or malfunctioning such
that the procedure could not be performed as prescribed,
the Verifier would submit work requests as necessary, or
would ensure that work requests were in progress. If
special tools were required, the Verifier would ensure
that the tools were immediately available or that a notation
was present in the procedure addressing where such tools
I could be obtained. The Verifier was free to make meaningful
comments on the procedure.
This verification if implemented for all procedures, not
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just those requested by the Technical Staff Supervisor,
should reduce the number of changes to new procedures.
Additional discussion regarding procedures and procedure
backlogs is identified in Section One, Finding Five.
l (11) Document review and interviews revealed that the licensee's
! equipment history files consisted of completed copies of
work requests, catagorized by systems. The Master Mechanic,
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Master Electrician, and Master Instrument Mechanic had the
responsibility to review their respective equipment history
- files semi-annually. These reviews resulted in judgments
as to whether a piece of equipment or an item should be
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-added to the preventative maintenance program, considering
the frequency and nature of past repairs. There did not
appear to be a review for generic consideration to ensure
that when problems with equipment were identified in one
system, that corrective action would be taken for any
system with the same equipment. A routine failure trending
program was not utilized in the Maintenance Department,
although the instrument group did maintain informal trend-
ing on specific equipment.
(12) Interviews revealed that maintenance personnel were not
necessarily the most experienced or qualified for a specific
activity. Personnel were assigned to the foremen on a
rotating basis and the foremen were not able to use the
most experienced person for the job, but were required to
select from those mechanics assigned to him. The foremen
were required to balance radiation exposure among personnel,
which posed problems when experienced personnel had high
exposures relative to others, resulting in the assignment
of work to those with lesser or no experience. In some
cases, the foremen compensated by observing the work more
l closely due to the lack of experience or familiarity of
the mechanic with the work.
Review of administrative procedures revealed that the
Radiation Protection Group was not in the review process
for work requests or maintenance procedures, but provided
input after the procedure was written. This input had to
, be requested from the Radiation Protection Group through
l either the daily management meetings, or directly from the
Maintenance Department (maintenance foremen or scheduler)
prior to performing work. The ultimate responsibility
i for radiation safety was placed upon the mechanic performing
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the work rather than Radiation Protection taking a more
i active role. There was little coordination between the
Maintenance Group performing the work and the Radiation
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Protection Group needed to provide the necessary radiation
protection measures. This method did not require direct
Radiation Protection Group involvement, thus not providing
adequate preplanning to determine or improve work methods
and ensure acceptable radiation protection.
Review of past noncompliances revealed that licensee per-
sonnel have had problems with regard to the Radiation Pro-
- tection Group not being notified prior to work being per-
l formed on radioactive equipment (Inspection Report 50-10/80-14,
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50-237/80-17 and 50-249/80-21). As a result, the licensee
committed to using a caution stamp stating " Radioactive
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Equipment-Contact Radiation Protection Prior to Disassembling
or Opening Process Line to Arrange for Survey". This stamp
was not required by written procedure. Review of work
requests revealed that this caution stamp was not being used
at all times. Fifteen of 150 work requests reviewed did
not have the stamp on the work request or the work package
folder.
The above described poor ALARA practices were considered a
significant safety weakness.
(13) Quality Cont.$1 (QC) and Quality Assurance (QA) reviewed
and approved each safety-related maintenance activity
through the review of work requests. The QC and QA review
and approval was to ensure quality requirements were
established through inspection and testing. These specific
activities were being provided on a case-by-case basis
without an appropriate inspection plan. The written program
did not include sufficient detail and guidance to ensure
adequate independent inspection activities.
lloid points were not permanently installed in the written
work procedures. The hold points were applied (hand written)
each time the written work procedure was used.
Interviews revealed that in most cases installation of
hold points on work requests were made by the same inspector
that performed the inspection of hold points. The inspectors
did not have specific criteria available to determine when
hold points were required and indicated that this was a
judgment call by the inspector. Insertion of hold points
was also influenced by the availability of inspectors
(such as whether an inspector would be onsite) and the -
amount of work load already at hand as opposed to the
actual need for hold points. Interviews also revealed
that in some cases hold points were not installed due to
the lack of inspection coverage available at the time the
work was being performed.
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(14) Quality Procedure (QP) 3-52, Design Control For Operations -
Plant Maintenance, directed that for routine type maintenance
involving safety-related and plant reliability related items
where Quality Control and Assurance personnel are not on-site
and work must be done immediately, that as long as maintenance
methods and procedures have been established and proven
through use and previously been reviewed and accepted, the .
Work Request and applicable documentation may be approved
and work assigned upon approval of the Maintenance Assistant
Superintendent, Master Instrument Mechanic, or Master
Electrician, or Master Mechanic, as appropriate, or their
designee. Under such maintenance approach, each Work Request
and associated documentation shall be reviewed promptly
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- after completion of the work by the Quality Control Inspector
and verified by the Quality Assurance Engineer or Inspector
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and their approvals shall be indicated on the completed Work
Request.
QP 3-52 defined routine as meaning work of a simple nature
that could accomplished by craft capability with guidance
stated on the work request. This procedure also stated
that work, if not performed correctly, that could have impact
on safety or plant reliability shall not be designated as
routine.
Record review and interviews revealed that maintenance work
was routinely performed during off shifts and weekends and
that as long as the work was accomplished by written pro-
cedure this was acceptable. QC was not notified prior to
the start of work in these instances. They were notified
upon completion of the work; however, this post notification
s prevented an opportunity for QC to insert hold points in
the step-by step procedures used to perform the work. A
_ review of 150 WR's revealed that 34 WR's had been completed
without review for insertion of hold points by QA or QC,
The failure to establish an acceptable program to insure
insertion of hold points on safety related work was con-
? sidered an item of noncompliance (50-237/82-07-02,
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50-249/82-07-02).
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- (15) The Quality Control (QC) Supervisor reported to the Adminis-
trative and Support Services Assistant Superintendent. There
were five QC Inspectors reporting to this position.
The CECO Topical Quality Assurance Program assigned this
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person responsibilities for Quality Control activities
, at the station such as reviewing drawings, specifications,
Maintenance / Modification procedures, and requests for
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purchases for inclusion of appliable quality requirements;
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performing receiving inspections for ASME and Safety-Related
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- incoming materials and items and inspection of fabrication
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had, installation activities; and having nondestructive
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examination and other testing performed as required.
. The Quality Control Supervisor was absent from the site
,, during the-second week of the inspection. No one had been
delegated to act in this position to ensure completion of
this organization's responsibilities. Interviews with
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/ _ QC Inspectors revealed that this was a normal practice and
j/ ; that "ev.eryone did their own thing."
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(16) Review of records and interviews revealed that on-the-job
training of maintenance personnel was not documented as
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required by Dresden Personnel Procedure, DPP-13, Training
Records, which stated that documentation of on-the-job
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training was the responsibility of each individual depart-
ment, and provided for the documentation of such training.
Two personnel folders out of 15 reviewed had on-the-job
training documented for a one week period in 1977 and none
of the 15 had on-the-job training documented since then.
Commonwealth Edison Production Training Department Organi-
zation and Administration Manual required that formal
objectives be established and chat documented records for
training be maintained. Station personnel interviewed were
unaware of these requirements and of any formal objectives
being established for on-the-job training.
The failure to document on-the-job training is considered
an item of noncompliance (50-237/82-07-03, 50-249/82-07-03),
b. Conclusions
l
The licensee's written program to control safety-related main-
l tenance activities was not adequate. Support activities for
'
maintenance program implementation was weak due to the lack of
I specific details within the program implementing procedures.
The most significant weaknesses were poor ALARA practices,
bypassing of QA and QC Involvement in routine maintenance work,
and lack.of retraining of maintenance personnel.
3. Corrective Action System and Training of Non-Licensed Operators
a. Findings
The following findings include items of noncompliance and recognized
strengths and weaknesses in the licensee management controls. The
strengths and weaknesses may not have a specific regulatory bases,
but do represent methods considered to be good management practice
throughout the industry.
Corrective Action System
(1) The licensee's corrective action system was described in
the Corporate Quality Assurance Manual, Station Quality
Assurance Manual, and the Dresden Administration procedures.
Elements of the corrective action activities reviewed and
considered to be part of the system included:
(a) Deviation Report (DVR) - used to document a departure
from accepted equipment performance or a failure to
comply with administrative controls or NRC requirements
which could result in failure of an item to perform
as required by Technical Specifications or approved
procedures.
11
_ _ _ _ _ _ _ _ _ _ _ _ .
___ - - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _
.
(b) Discrepancy Report (DR) - used to document a non-
conforming item of equipment, material, consumable,
component, part or inspection, and test procedure.
(c) Work Request (WR) - used to initiate maintenance or
modification work.
(d) Action Item Request (AIR) - used to document a task
assigned to accomplish specific results within a given
time.
(e) Licensee Event Report (LER).
(2) All plant employees were charged with the responsibility
for initiating WR's when they identified a need for cor-
rective maintenance. All employees interviewed understood
both their responsibility and how to initiate a WR but
none could state what training or retraining they had on
work requests. Review of the training records identified
that the workman received no documented training. The
,
foreman training / retraining was documented by a required
yearly reading list.
Some of the plant foremen interviewed indicated they were
not aware of the requirement in DAP 15-1, Work Request,
requiring that they must verify that procedures used in
a WR package had the latest revision. The Maintenance
Assistant Superintendent stated that this requirement was
new and until the yearly required reading list was issued,
personnel would be notified of this requirement through a
Department Memo.
(3) The plant procedures governing DVR's and DR's identified
the foreman as the person having primary responsibility to
ensure the reports were written. Interviews with mechanical
i foremen indicated a reluctance to initiate a DVR or DR.
They felt their responsibilities terminated when the problem
was identified to the Operations Department or Quality Cont.o1
Group. Interviews with the Operation Department revealed
that some supervisors were unaware that, by procedure, they
were allowed to write DR's. The reluctance to initiate DVR's
and DR's which has evolved, either through time or lack of
training was considered a weakness.
!
(4) The Technical Staff prepared supplement reports to non-
i reportable DVR's using the guidance of NUREG-0161. The
Technical Staff Supervisor stated that the supplement
reports would be used for trend analysis when computer
space was available. Trending was being performed by
the Director of Nuclear Safety for DVR's which were
elevated to LER's. There was no trending performed on
DVR's or DR's that were not reported as LER's.
i
12
- -- - ._
- _ _ _ _ _ _ _ _ . - _ _ _ _
_,. - _ . - - .--
.
One concern was identified with the closecut of corrective
action identified on DVR's. The DVR referenced the WR or
AIR initiated as a result of the DVR commitment, but the
WR did not reference the DVR. There was no requirement
to track the closed out WR back to tha DVR to ensure the
action identified on the DVR was performed. Additionally,
a DVR could be closed out, reviewed by Onsite and Offsite,
and still have the action outstanding.
(5) Two QA audit reports and a number of surveillance reports
were reviewed. These reports indicated that the auditor was
informed of, and followed the close out of open inspection
items, circulars, information notices, DVR's, DR's, and
Bulletins. As stated previously DVR's were closed out by
initiation of a WR.
(6) During interviews at corporate, the Operational Manager -
Nuclear Stations indicated that certain of his responsibili-
ties defined in paragraph 1.5.3 of the Corporate Quality
Assurance Manual had been reassigned to other departments.
The lack of Quality Assurance Manual update was discussed
with the Manager, Quality Assurance.
Training - Non-Licensed Operators
(7) DPP-3, Non-licensed Operator Training, outlined the
training typically given to individuals assigned duties
as non-licensed operators. DPP-3 stated that the program
consisted of formal classroom courses, lectures, reading
assignments, and on-the-job training for approximately a
six-month period. The course alternated between periods
onshift and in the classroom. The training consisted of
plant systems and routine operations. Qualification was
determined by an oral examination administered by an
Operating Engineer or his designee. The program described
above was approved by the Dresden On Site Review (DOSR) but
did not define the lecture material, the plants systems
or routine operations to be studied, the Dresden Administra-
tion Procedures or Quality Procedures to be covered, how
on-the-job training was documented, and what requalification
or what reexamination was necessary.
(8) A review of training documents and interviews revealed the
following program which complemented DPP-3:
(a) Prospective students were screened by a contractor
examination which was designed to eliminate the poor
performer.
(b) Students attended a course of approximately six-month
duration which alternates between two weeks of class-
room instruction and on-the-job training. The course
outline was prepared by the Training Department.
13
- _ _ __,
.__ _ _ _
_ - - - . - . - - - - --- _- . ._ . ..- - .- - - - .-.
.
..
. (c) Student progress was documented in a qualification
! book which was frequently reviewed by the instructors <
l and was written such that the student could chart ;
his own progress.
j (d) Equipment Attendant qualification was based on satis-
, factory completion of the qualification book, passing
an oral examination, and participating in a system
l walk through.
(e) Retraining was performed by having the Equipment
! Attendants attend the' sixth week training cycle along
'
with the licensed operators.
i Comparison of the Program identified in DPP-3 against
j ANSI 18.1 - 1971 and ANS 3.1 (Draft Revision), December 6,
l 1979, was not made because the formal program was not
]' sufficiently detailed. Review of the entire program showed !
that the licensee had implemented an adequate training ;
{ program but had not completely described the training in I
l DPP-3. Ilad this been accomplished, the present program and
future change would have been reviewed and approved by
appropriate site management.
!
- (9) Interviews with the Training and Operation Staff determined
'
that during the sixth shift training cycle, Equipment Atten-
dants were required to attend lectures that were geared
j more for the licensed operator. Management was aware of
, this problem and stated that the non-licensed and licensed
! operators were separated when instructors and space was
j available. Interviews with the Equipment Attendants re-
vealed this as a weakness in the program but noted some
j separation was being performed and they believed that more
Equipment Attendant specific training was planned in the
future,
l
b. Conclusions
'
Corrective Action System
, The systems to identify problems and ensure they were trans-
mitted to appropriate levels of management for resolution was
'
j effective. The licensee had established an adequate program
i
to identify, document, report, and resolve problems. The most
significant weaknesses noted were the reluctance of personnel
to initiate DVR's and DR's, the failure to ensure that WR's
were completed when used as the method for closing a DVR, and
tL9 lack of trending of DVR's and DR's.
>
4
,
!
14
l
_ _ . _ _ _ . - -__ . ..__--_. _ _ . __ _ _._.._ _ __ _ __ _ _ _. _ _ . . _ _ _ .
.
Non-Licensed Training
The licensee had an established training program that prepared
the candidate to perform as an Equipment Attendant. Weaknesses
in the program were the failure to define the program in DPP-3
and that Equipment Attendants were not always attending re-
qualification courses geared to their needs. A strength was
the screening program used to select Equipment Attendent candid-
ates.
4. Committee Activities
a. Findings
The following findings include items of noncompliance and recognized
strengths and weaknesses in the licensee's management controls.
The strengths and weaknesses may not have a specific regulatory
bases, but do represent methods considered to be good management
practice throughout the industry.
(1) The Onsite Review and Investigative Function (ORIF) responsi-
bilities and authorities are described in Section 6.1.G.2 of
the Technical Specifications (TS).
Many of the ORIF activities were not accomplished by committee
meetings, but were integrated into the administrative review
program of key supervisory personnel. For example:
(a) The ORIF is required by the TS to review facility opera-
tions to detect potential safety hazards. This review
function was accomplished by several methods as follows:
1. The Technical Staff Supervisor required that the
Unit Lead Engineer should review the unit operating
logs each working day and a' Nuclear Engineer should
review selected core parameters on a daily, weekly,
and monthly frequency (emphasis added). Also, a
review of chemical, radiochemical analysis, and
radiation surveys were conducted by the Technical
Staff Supervisor and his designee. These activi-
ties were described in Dresden Technical Procedure
(DTP) 8. Technical Staff Review Plan.
One weakness noted in this review process was that
the Systems Engineer who performed the daily review
of the unit operating logs, did not have operating
experience (SRO or R0 license) which would have
aided this review for detection of potential safety
hazards. There was no written guidance on what
this review was intended to accomplish. There
was no requirement for documenting the findings
or observations made during the review. Inter-
15
.
views revealed that any concerns identified by
this review were discussed in a daily meeting of
supervisors and group leaders.
2. A review of unit operating logs was conducted
daily by the Operations Staff. Concerns identi-
fled reportedly were discussed at the daily staff
meeting.
3. Other activities involving reviews for potential
safety hazards were accomplished by management
personnel in their daily review of the specific
department or section activities.
(b) The ORIF is required by the TS to review procedures and
changes thereto as described by TS 6.2. TS 6.2 delegates
the review responsibilities to a minimum of two supervi-
sors; one of the supervisors was the Technical Staff
Supervisor who reviewed and approved all procedures
identified in TS 6.2. The second supervisor assigned
review and approval responsibilities was the supervisor
responsible for the function described in the specific
procedure.
The Technical Staff Supervisor review and approval
provided the inter-departmental review while the
second supervisor review provided the intra-department
review. The Technical Staff Supervisor's review task
was assigned to the Procedures Manager (also a member
of the ORIF) who performed and coordinated the actual
procedure reviews.
(c) The ORIF is required by the TS to review all proposed
changes or modifications to plant systems or equipment
that affect nuclear safety. This review assignment
was accomplished in accordance with Quality Procedure
(QP) 3-51, Design Control For Operations - Plant
Modifications.
DAP 10-1, Onsite Review and Investigative Function,
required that modifications be reviewed by an established
Onsite Review Committee consisting of the Technical
Staff Supervisor, an Operating Engineer, the Maintenance
Assistant Superintendent or the Rad / Chem Supervisor, as
appropriate, and the Station Superintendent. The
following concerns were identified:
1 The personnel previously identified did not meet
as a committee to review modifications. The option
to meet as a committee was used when so requested
by any one of the members; however, the normal
review process consisted of a " ballot" type review.
16
_ _ _ . . _
_ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _
.
.
The modification under review was passed from one
member to the next and all disagreements were
resolved by member discussion or face-to-face
meetings.
2. DAP 10-1 identified the Station Superintendent as
a member of the Onsite Review Committee; however,
TS Section 6.1.G.2.a clearly states that the Station
Superintendent shall independently review and approve
the findings and recommendations developed by per-
sonnel performing the ORIF function. Interviews
revealed that *.ie actual review process was con-
ducted by the Modification Coordinator and the
Operating Engineer (or other previounty described
supervisor identified in (1)(c) aboro as appropriate).
.The Station Superintendent's review and approval,
noted by signature, was the final authorization
of the modification package.
3. There were no ORIF reviews of Field Changes.
These were changes made to the original modi-
fication that was reviewed and approved by the
ORIF. The failure to review changes to the
original modifications was identified as an
item of noncompliance (50-237/82-07-04,
50-249/82-07-04). Further observations regarding
supervisory review of Field Changes may be reviewed
in Section One of this report.
(2) As previously discussed, DAP 10-1 described the licensee's
management controls for compliance to TS 6.1.G.2. The docu-
ment also identified other procedures that described ORIF
review functions. This document, however, was inadequate
in that the functions performed by the ORIF were not properly
described as noted in (1)(c) 1., 2., and 3. above and there
was insufficent guidance in the procedure to assist the ORIF
members in their assigned task. The procedure also did not
adequately describe the content and method of submission
and presentation to various management representatives;
mechanisms for resolution of disagreement between Of fsite
and Onsite review functions; and control of records and
distribution of ORIF investigations, reviews, and reports.
The licensee apparently recognized the lack of adequate
guidance and was in the process of developing a guidance
manual for ORIF personnel. This manual was not in use at
the time of this inspection.
(3) TS 6.1.G.2.c requires that reports, reviews, investigations,
and recommendations be documer.ced with copies to the Division
Vice-President - Nuclear Stations, the Supervisor of the
,
Of fsite Review and Investigative Function, the Station Super-
intendent, and the Manager of Quality Assurance. The following
ORIF reports were not distributed as required.
.
17
__ .__
. . _ _ _ _ , - - - - -_ - _ . _ - _ . _ _ _ _ _ _ _ _ _ _ - _ _ _ _ . _ - _ . .
-. - . -. . _ .
'
,
.
.
(a) Report 81-12: This report described a modification
to the recirculation pump scoop tube travel time
(from 7 seconds to 45 seconds). The report contained
a 10 CFR 50.59 review which included justification for
the modification. The changes made to this system were
not included in the routine modification program and
the report was not distributed as required.
(b) Report 81-32: The report described a decision to stop
4
the ORIF reviews of certain Rad / Chem Department Procedures.
There was no discussion identifying the basis for this
,
decision.
!
(c) Report 81-33: This report discussed the continued
operation of Unit 3 with the inboard Main Steam Isola-
tion Valve (MSIV) (3-203-1C) DC solenoid (3-203-1C)
Icads lifted. The review concluded that continued
operation was justified because containment isolation
was accomplished with loss of AC power alone, instead
of both DC and AC power losses. This method of operation
was more conservative; however, there was no discussion
in the report regarding the less conservative operation
1 resulting from one solenoid (DC) already providing a half
i signal to the MSIV pilot valve and the potential loss
- of the other solenoid (AC) during full power operation
l without complete loss of AC power. There was no 10 CFR
50.59 evaluation conducted for this modification nor
was this report sent to the Supervisor of the Offsite
Review and Investigative Function.
A review of the Deviation Report written for this incident
revealed that the cause of the problem was personnel error.
When last worked on, the AC solenoid had been incorrectly
connected to the DC supply and likewise, the DC solenoid
was improperly connnected to the AC supply. Neither the
1
Onsite Review Report nor the Deviation Report addressed
"
the impact this personnel error might have had on the
other MSIV's.
l
The failure to distribute these reports, particularly to the
Offsite Review and Investigative Function, was considered an
item of noncompliance (50-237/82-07-05, 50-249/82-07-05).
(4) Interviews with ORIF personnel revealed a high level of
capability due to education and experience. For those
reviews requiring special reports, there were minor problems
with the thoroughness of the effort. There was no means
to evaluate the quality of reviews conducted for procedures
or modifications because only a signature or initial was
required to denote that a review was conducted.
l
18
-, - - . _ _ _ _ , _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . ._
.. .
.
.
.
There was some evidence; however, that the quality of the
initial review of procedures may need additional attention
as witnessed by the numerous revisions and changes to exist-
Ing procedures. Interviews revealed that a significant back-
log of procedure review and approval existed; the majority
of which were changes to existing procedures.
Interviews with the Procedures Coordinator revealed that a
requirement for a " walk through" had been established for
some procedures, however, there was no mandatory requirement
to " walk through" all new procedures, as appropriate.
The quality of initial review of modifications may also be
questionable as witnessed by the numerous (over 500) Field
Change Requests generated on modifications conducted during
the Unit 3 outage.
(5) ORIF records were examined to determine the completeness
of these documents. One example of incomplete records was
observed. Report 81-38, Revision 1, Review of Change to
Section 6 of the Technical Specifications, revealed that
an Onsite Review was conducted and that twenty-eight changes
to Section 6 were recommended. There was also present in
the file, an Offsite Review Report which revealed that the
Offsite Review did not agree with two of the twenty-eight
recommendations. There was no documentation that these
disagreements were resolved. Furthermore, interviews with
the Technical Staff Supervisor revealed that this recommended
Technical Specification change had been sent to NRR for
approval, when in fact, it had not. This lack of awareness
was considered a significar - program weakness.
Offsite Review and Investigative Function
(6) The Offsite Review Group functioned under the supervision of
the Director of Nuclear Safety who reported directly to the
Chairman and President of the Company. This organization
received functional direction from the Vice President of
Nuclear Operations but was independent of the organization
having operating responsibilities.
There were 46 personnel designated as participants for
Of fsite Review activities; however, the majority of these
participants did not routinely review activities unless the
Supervisor of Offsite Review selected them for a review
assignment. Interviews with several of these participants
revealed that they spent less than one percent of their time
as active members of the Offsite Review Group. Interviews
also revealed that these participants were routed copies of
Offsite Review Reports only when they functioned as members
of the group involved in the review activity. There was no
mechanism in place to provide these participants with informa-
19
.
tion of ongoing Offsite Review activities that would allow
these personnel an opportunity to determine whether they
should have been involved in a review function encompassing
their area of expertise.
(7) The majority of review work performed by the Offsite Review
Group was assigned to the Senior Participant and an Alternate
Senior Participant. These personnel had dual assignments
within the Offsite Review Group; for example, the Senior
Participant for the Dresden Station was the Alternate Par-
ticipant for the LaSalle County Station, and the Alternate
Participant for the Dresden Station was the Senior Partici-
pant for the Quad-Cities Station. This method of assignment
provided an excellent mechanism to ensure that problems
identified at one station would be communicated to other
stations for review and consideration.
Communications between site management and the Offsite
Review Group were primarily conducted by telephone and
periodic site visits by the Senior Participants. Site
visits at Dresden consisted mostly of meeting staff members
in the administrative building located outside the protected
area. Visits to the station seldom included plant tours;
reportedly because of the difficulty of complying with the
security requirements.
An interview with the Supervisor Offsite Review and Investiga-
tive Functions revealed that in order to enhance communications
he planned to conduct quarterly meetings between the Offsite
Review Group and the site staff to discuss relevant issues
face-to-face. This practice had not been initiated at the
time of this inspection.
(8) Items identified by the Offsite Review as requiring resolution
were entered into the licensee's Action Item Request (AIR)
system for tracking purposes; however, items that did not
warrant AIR consideratira were not adequately tracked to
ensure closure. The following were exampics:
(a) An Onsite Review (81-23, Rev. 1) of Section 6 to the
Technical Specifications resulted in 28 recommended
changes; two of these changes were not concurred with
by the Offsite Review Group. There was no further
documentation at the site to identify the status of
.! this disagreement or whether the TS change had been
l submitted to the NRC.
!
! (b) An Onsite Review of a TS change to the Nil Ductility
! Temperature (NDT) curves was conducted in 1979. The
report was transmitted to the Offsite Review Group
for review; however, Offsite Review was not completed
until 1982, after a site representative submitted a
l
, ,
l
20
,
- --1 m
- - . . . -
- . . . _. _
..
.
.
- Deviation Report identifying a potential violation of
the TS-reporting requirements (the issue of compliance
was reviewed by the Senior Resident Inspector).
Likewise, issues identified by the Offsite Review Group as
requiring additional Onsite Review Action, were not tracked
by the Offsite Review Group or resolved within the specified
time requested by the Offsite Review Group. Some work was
- in progress to resolve this problem; however, the lack of an
effective tracking mechanism was apparent and'was considered
.i a significant program weakness.
j (9) The Offsite Review Group relied primarily on the Onsite
'
Review and Investigative function to determine which onsite
! reports should be subject to Offsite Review. Interviews
i revealed that unless review action was specifically requested,
a review of the Onsite Report would not be made. For example,
Onsite Review Reports 81-28 and 81-31, relating to the
restoration of the HPCI steam supply lines on Units 2 and 3
respectively, were sent to the Offsite Review Group without
a review request and subsequently did not receive a formal
review. Interviews revealed that these reports could have
. been routed to the Senior Participant for consideration of
l a formal review. If the report had been routed for consid-
l eration, the Senior Participant would have signed the docu-
! ment acknowledging this consideration; however, this was
4
not accomplished on the above described reports.
'
In addition, there were some Onsite Review Reports that were
never sent to the Offsite Review Group (findings (3) of this
section discusses the content of some of these reports).
l The TS requires the Offsite Review Group to review significant
operating abnormalities or deviations from normal and expected
performance of plant equipment that affect nuclear safety
as referred to it by the Onsite Review and Investigative
i
'
Function (emphasis added). The term "as referred to" was
apparently interpreted to mean "as requested by", thus
causing the above described confusion. ANSI N18.7 - 1971,
j does not relieve the Offsite Review Group from this investi-
gative responsibility.
The Deviation Report Form was another method for the Offsite
Review Group to become aware of problems at the site. All
! non-reportable Deviation Reports were sent to the Offsite
Review Group when the reports were completed, normally
several months after the incident occurred. Some of the
above described Onsite Review Reports were referenced in
the Deviation Reports but were not included as part of
the Deviation Report Package.
The heavy reliance on the Onsite Review Group to determine
which problems should be reviewed and the lack of involvement
1
i
I
- 21
j
1
.. - - - . , - - - _ - - _ - _ - - - _ _ _ _ - . - , , . -- - .- - .- --.- -- -. O
, ._
.
.
by the Offsite Review Group to ensure review of all problems
was considered a significant program weakness.
(10) The Onsite Review and Investigative Function is required
(by TS 6.1.G.1.a.(1)) to review the safety evaluations to
equipment or systems completed under the provisions of-
10 CFR 50.59 to verify that such actions did not constitute
an unreviewed safety question.
Interviews with licensee representatives revealed that only
the safety evaluations conducted on modifications involving
safety related equipment were reviewed to verify that no
unreviewed safety questions existed. There was no Offsite
Review Group overview of 10 CFR 50.59 evaluations made for
, nonsafety-related modifications systems described in the
Safety Analysis Report. There was no assurance that non-
safety-related modifications were evaluated for their impact
on safety related-systems.
(11) A review of several Offsite Review Group Reports revealed _
,
that quality reviews had been conducted and that meaningful
recommendations had been made. Records also revealed that
monthly reports were sent to senior management by the
Director of Nuclear Safety containing summaries of the
department activities. Periodic trend reports were also
- sent to senior management and contained an annual trend of
diesel generator failures, operator errors, procedural
deficiencies, LER's, and instrument drift. Communications
between the Office of Nuclear Safety and Senior Management
,
was effective.
.
- CONCLUSIONS
There was no indication that the activities performed by the Onsite and
i Offsite Review and Investigative Functions were of any lesser quality
i
than had all the activities been performed in committee type meetings.
Communications within each group were good; however, communications
between the two groups needed strengthening. The most significant
weaknesses noted were the failure of the Offsite Review Group to review
all Onsite Review Reports and the lack of an adequate tracking mechansim
to ensure timely followup of recommendations.
5. Quality Assurance Audits
a. Findings
The following findings include items of noncompliance and recognized
strengths and weaknesses in the licensee's management controls.
The strengths and weaknesses may not have a specific regulatory
bases but do represent methods considered to be good management
practice throughout the industry.
22
. - - - - - - _ - . . - - - - - - - - - - . - - - - . - . - - . , ,
.
(1) In order to accomplish the audit program at Dresden, the QA
Department had assigned three full-time auditors and one
Supervisor to the station. Their was adequate reference
material and secretarial assistance to support the site
QA Staff.
The site QA audit program was supplemented by corporate audit
personnel and was audited by corporate and other offsite
auditors on a periodic basis. The corporate organization
was very supportive of the site QA Staff. The site QA Staff
had a good working relationship with most of the site
management.
(2) The licensee's QA Program allowed for the closure of an
audit finding when that item was addressed by an Action
Item Report (AIR). The QA Program did not require the
auditor to ensure the required corrective action was
completed. ANSI N45.2.12 - 1974, Section 4.5, requires
the auditing organization to verify the completeness and
adequacy of corrective action. The QA Staff had elected
to follow AIR's in response to audit findings and to verify
completion of corrective action. While this commendable
action has prevented any actual occurrence, the program did
not ensure this practice would be continued. This was con-
sidered a program weakness.
(3) The QA auditors were highly qualified to perform audits
in their assigned areas with one exception: Security. The
individual assigned to audit operations was licensed as an
SR0 at Dresden and also had several years of Naval opera-
tions experience. However, this same person was assigned
to audit the Security Program. There was no doc:mented
evidence that this individual had sufficient training or
expertise to audit the security area. The licensee's pro-
gram did allow for the use of outside expertise. In a
recent audit, CECO had utilized Dresden's Security Supervisor
to assist auditors at the LaSalle County Station. A similar
solution would have been appropriate. The lack of adequate
auditor expertise was considered a weakness.
(4) A lack of management attention to ensure that all 18 criteria
of 10 CFR 50, Appendix B, were addressed in QA audits as
appropriate was noted in various areas.
Five contractor audits in the first six months of 1981 did
not address all 18 criteria. This problem was also identi-
fled in a letter dated April 30, 1981, following a corporate
review. The letter suggested that an oversight function be
used in the future. Following this recommendation, the QA
Supervisor implemented a checklist to verify audit conform-
ance to the 18 criteria for use during audits of site con-
tractors. Only one contractor audit completed subsequent
23
'
l
i
,
!
to the checklist implementation did not address all 18
criteria (QAA 12-81-62). This audit was performed by the
corporate organization and did not contain an 18 criteria
checklist. A review of five vendor audits performed by
the Station Nuclear Engineering Department revealed that *
three did not address all 18 criteria of 10 CFR 50, Appendix
B, as appropriate.
The licensee had revised a management memoranda for 1982
audits (effective April 21, 1982), requiring the use of a
checklist to verify conformance to the 18 criteria. This
concern was identified by the inspector on April 20, 1982.
This resolved this item for 1982 audits; however, audits
subsequent to 1982 were not addressed and there was no QA
Program change planned that would ensure that all future
audits would include an 18 criteria checklist.
The failure to conduct audits against the 18 criteria as
appropriate was considered an item of noncompliance
(50-237/82-07-06, 50-249/82-07-06).
(5) The licensee's only method used to evaluate a program for
effectiveness was a statement in the audit report that the
adequacy of the program was acceptable. There appeared to
be no involvement by management to determine the effective-
ness of the established programs. The following were examples
of inadequate evaluations of program effectiveness.
A review of QA audits on training revealed that the
audit did not address the effectiveness of the Training
Program as required. Subsequent to this finding, the
licensee required auditors to document program effec-
tiveness following their attendance as students in a
training session. This was not an acceptable method
of compliance because an auditor receiving training
and subject to evaluation and testing by the Training
Department could not be expected to perform an inde-
pendent and objective audit.
As stated previously, security was not being audited
fully. This is partially due to the limited expertise
of the auditor assigned security. While he is perform-
ing audits to the best of his ability, he is not quali-
fled to evaluate the overall effectiveness of the
Security Program.
A final example of inadequate evaluation of program
effectiveness was the item of noncompliance described
in Section 2, Finding 14, of this report. The 11-
censee's audit of the maintenance area again contained
a statement that the program was effectively impicmented
by the station (QA) 12-81-54). There was no evaluation
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__-___ _ _ _ _ _ _ _ - _ - - - - - - _ _ - - - - - - - - --_---------- --
_,
l
l
.
of QP 3-52 to determine whether this procedure was
ef fectively impicmenting the requirements of the CECO
Topical Report 1-A. An evaluation for effectiveness
would have determined that no provisions existed in
the Topical Report for the bypassing of QA and QC
responsibility for establishing of hold points on
maintenance work.
The licensee's program of audits were accomplished to verify
compliance with all aspects of the Quality Assurance Program,
but did not determine the effectiveness of the program. The
failure to determine the effectiveness of the program was
considered an item of noncompliance (50-237/82-07-06,
50-249/82-07-06).
(6) DPP 14, Dresden Station Quality Assurance Training For
Management Personnel, required that a matrix be used to
determine who in management was to receive QA training.
During interviews with the Training Supervisor and the
instructor responsible for determining who in management
received QA program training, it was determined that the
matrix required by DPP 14 was not used in all cases. A
recent QA audit of five management personnel did not identify
any violation of the matrix.
The matrix did not ensure in all cases that personnel who
assume responsibility for a higher position receive training
required for that higher position. For example, the indivi-
dual who would assume the Station Superintendent's responsi-
bilities in his absence may not have received training when
those areas of responsibility were changed. This was con-
sidered a program weakness.
(7) Checklists used for conducting audits of contractors and
vendors were reviewed and approved by the Director of QA
(Engineering and Construction).
Interviews with auditors, revealed that they were not
encouraged to deviate from their audit checklist in the
event they identified concerns outside the original scope
of their audit. Management had placed too great an emphasis
on completion of audits within the time allotted. Four
of six auditors interviewed expressed this lack of willing-
ness to deviate and the above identified Director expressed
extreme reluctance to allow any deviation. After Senior
management was made aware of this finding several meetings
were held by QA Management to correct any misunderstandings
that auditors or managers had. Subsequent interviews did
not reveal any further concerns in this area.
(8) Various copies of QA Manuals were reviewed for proper document
control. The inspector also reviewed the availability of QA
25
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O
>
Manuals at the site. There was only one controlled copy of ,
the QA Manual assigned to 47 Technical Staff Personnel. These
were the least experienced people onsite and would have re-
quired continual reference to the QA Manual and procedures.
(9) The QA Program required reports to senior management on the
timeliness of resolution of audit findings. The QA Program
did not require trending nor were generic items required to
be addressed. However, trending data was gathered by various ;
QA personnel on request and a proposed computer trending ]
system was planned. There was no trending of QA audit find-
ings performed by site personnel. The Director of Nuclear
Safety did do some trending and distributed this data to
senior management; however, this information was not provided
to the supervisors interviewed. ,
l
(b) Conclusions j
l The licensee's written QA Program contained several programatic
weaknesses which, with the exception of QP 3-52, did not appear
to affect the quality of the work performed by the QA Staff. With
minor exceptions, the most significant strength in the area of
QA Audits was the knowledge demonstrated by the audit personnel.
The most significant weaknesses were the failure to evaluate
program effectiveness, failure of management to ensure audits
encompassed all appropriate 18 criteria, and the reluctance to
deviate from the audit checklist should the need arise.
6. Exit Interview
The inspectors met with licensee representatives denoted in Attachment
A, Section 1 of this report at the conclusion of the inspection on
May 7, 1982. The Team Leader summarized the purpose and scope of
the inspection and the inspectors presented the findings for each
section.
26
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