ML20057A496

Provides Results of Special Audit of Control Processes for Commitments That Affect Current Licensing Basis for Plant on 930517-21.Informs That Commitments Being Implemented & Maintained at Plant

ML20057A496
Person / Time
Site:	Davis Besse
Issue date:	09/01/1993
From:	Hopkins J Office of Nuclear Reactor Regulation
To:	Storz L CENTERIOR ENERGY
References
TAC-M86153, NUDOCS 9309140301
Download: ML20057A496 (16)

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ai UNITED STATES l

• 5 @'mpfL .! E NUCLEAR REGULATORY COMMISSION k..d(/...

WASHINGTON D.? 20555-0001 l September 1, 1993 Docket No. 50-346 l

Mr. Louis F. Storz Vice President, Nuclear - Davis-Berse Centerior Service Company l c/o Toledo Edison Company l 300 Madison Avenue l Toledo, Ohio 43652 l

SUBJECT:

SPECIAL AUDIT OF CONTROL PROCESSES FOR COMMITMENTS THAT AFFECT THE CURRENT LICENSING BASIS, DAVIS-BESSE NUCLEAR POWER STATION (TAC NO. M86153) l This letter provides the results of the comitment management audit conducted I

by the Office of Nuclear Reactor Regulation at the Davis-Besse Nuclear Power Station on May 17-21, 1993. As you are aware, the staff is conducting audits at a cross-section of reactor plants to assess the processes used by licensees for controlling comitments that affect the plant's current licensing basis.

The staff will use the information gathered during the audits to evaluate the regulatory process in this area. Davis-Besse was the fifth site visited by the staff. Our audit report is enclosed.

The audit team focused on three principal areas: (I) management of commitments made to the U. S. Nuclear Regulatory Comission (NRC), (2) reporting of changes to comitments made to the NRC, and (3) maintaining and updating the updated safety analysis report (USAR). In addition to reviewing the governing programs for these areas, the team reviewed the status of commitments made to

, the NRC in response to specific issues (selected generic letters, bulletins, licensee event reports, and notices of violation) in order to examine the programs in actual practice.

Overall, the team found that comitments affecting the plant's current licensing basis were being implemented and maintained at Davis-Besse. The team also found that you relied on the nuclear licensing manager to decide

when a change to a comitment needed to be reported to the NRC. Finally, the l team found that comitments that affected the plant USAR were captured by the USAR update process and were reflected in the Davis-Besse USAR. The team did not identify any items of significance in its review of comitments made in response to the specific issues selected.

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Mr. Louis F. Storz September 1, 1993 We thank the plant staff for its candor in our discussions and its cooperation in providing the team information necessary to conduct an efficient audit. If you have any questions or comments concerning this report, please contact me at (301) 504-3027 or Eric Leeds at (301) 504-II33.

Sincerely, ORIGINAL SIGNED BY:

Jon B. Hopkins, Sr. Project Manager ,

Project Directorate III-3 l Division of Reactor Projects - III/IV/V 1 Office of Nuclear Reactor Regulation

Enclosure:

As stated cc w/ enclosure:

See next page ,

DISTRIBUTION l VDocket Filer'r MRushbrook NRC & Local PDRs ACRS(IO)  :

PDIII-3 Reading E. Greenman, RIII 1 J. Roe OGC l J. Zwolinski PDIII-3 Reading ,

J. Hannon '

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l OFFICE PDIII-3:LA:DRPW PDIII-3:PM:DRPW PDIII-3:PD:DRPW NAME MhM6k JBHopkins/bj E N JHannon % l n Ii ui DATE A / 1 /93 9/ l /93 9///93 0FFICIAL RECORD DOCUMENT NAME: g:\davisbes\dbm86153.ltr

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Mr. Louis F. Storz Davis-Besse Nuclear Power Station Toledo Edison Company Unit No. I cc:

Mary E. O'Reilly Centerior Energy Corporation Ra.diological Health Program 300 Madison Avenue Ohio Department of Health Toledo, Ohio 43652 Post Office Box 118 Columbus, Ohio 43266-0149 Mr. Robert W. Schrauder Attorney General Manager, Nuclear Licensing Department of Attorney Toledo Edison Company General 300 Madison Avenue 30 East Broad Street Toledo, Ohio 43652 Columbus, Ohio 43215 I Mr. James W. Harris, Director Gerald Charnoff, Esq. Division of Power Generation  ;

Shaw, Pittman, Potts Ohio Department of Industrial Regulations i and Trowbridge P. O. Box 825  ;

2300 N Street, N.W. Columbus, Ohio 43216 Washington, D.C. 20037 l Regional Administrator, Region III Ohio Environmental Protection Agency U.S. Nuclear Regulatory Commission DERR--Compliance Unit 799 Roosevelt Road ATTN: Zack A. Clayton Glen Ellyn, Illinois 60137 P. O. Box 1049 Columbus, Ohio 43266-0149 Mr. Robert B. Borsum Babcock & Wilcox President, Board of Ottawa Nuclear Power Generation Division County Commissioners 1700 Rockville Pike, Suite 525 Port Clinton, Ohio 43452 Rockville, MD 20852 {

Resident Inspector State of Ohio U. S. Nuclear Regulatory Commission Public Utilities Commission 5503 N. State Route 2 180 East Broad Street Oak Harbor, Ohio 43449 Columbus, Ohio 43266-0573 Mr. Murray R. Edelman Mr. James R. Williams Executive Vice President - State Liaison to the NRC Power Generation Adjutant General's Department Centerior Service Company Office of Emergency Management Agency 6200 Oak Tree Boulevard 2825 West Granville Road Independence, Ohio 44101 Columbus, Ohio 43235-2712

DCIDSURE COMMITMENT MANAGEMENT AUDIT OF THE DAVIS-BESSE NUCLEAR POWER STATION MAY 17-21, 1993 -

I. Scope and Participants The purpose of the audit conducted at Davis-Besse was to assess the licensee's ,

programs for identifying and controlling commitments that affect the facil-ity's current licensing basis. The audit focused on three principal areas:

(1) management of commitments made to the U.S. Nuclear Regulatory Commission ,

(NRC), (2) reporting of changes to commitments made to the NRC, and (3) main-taining and updating the updated safety analysis report (USAR). The team reviewed the licensee's administrative procedures involving commitment j management; reporting; action tracking; control of design, configuration,. test and experiments; and others. To examine the programs in actual practice, the team reviewed the status of commitments made by the licensee to the NRC in response to specific issues. Five of these issues, generic in nature, were the following:

10 CFR 50.62 Anticipated Transient Without Scram (ATWS)

Generic Letter 89-13 Service Water System Problems Affecting Safety- '

Related Equipment Generic Letter 88-14 Instrument Air System Problems Affecting Safety-Related Equipment Bulletin 85-01 Steam Binding of Auxiliary Feedwater Pumps NUREG-0737, I.C.5 Procedures for Feedback of Operating Experience to Plant Staff The remaining issues were specific to Davis-Besse, including licensee commit-ments made in licensee event reports and responses to notices of violation.

The team also reviewed the licensee's design basis document program to determine how a commitment from the program would be captured in the commit-ment management process.

The team relied on standard NRC inspection practices in conducting the review of specific commitments. In conducting the audit, the team performed system 4 walkdowns, reviewed applicable documentation (including design change pack-ages, training records, and procedures), and interviewed plant staff. A detailed review for each issue specified above is contained in the appendix to this report.

The following NRC personnel participated in this audit:

James E. Beall, Team Leader Anthony J. D' Angelo Eric R. Duncan John P. Moulton 1

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II. Findinas and Conclusions The following are the team's findings and conclusions for the three major  ;

areas of focus: (1) commitment management, (2) reporting changes to commit-ments made to the NRC, and (3) maintaining and updating the USAR. l Commitment Manaaement: Overall, the team found that commitments affecting the l plant's current licensing basis were being implemented and maintained. In its review of licensee commitments in response to specific issues, the team found no significant deficiencies in identifyir.g, tracking, completing, and main- i taining the commitments in design, equipment, procedures, and programs. The  ;

licensee's processes for the origination and the permanent revision of plant  !

procedures provided assurance that existing commitments would be incorporated ,

in new and permanently revised procedures. Although the licensee's procedures l for plant modifications did not require a review of past commitments, the team i did not identify any examples in which a committed modification was altered or  :

deleted by a subsequent modification. The team attributed this to the .

experience level of the engineering organization and the multiple levels of  !

review and approval required by the design change process. i Reportina Chances to Commitments Made to the NRC: The team found that the '

licensee did not include in its procedures specific guidance for reporting  ;

changes to commitments to the NRC but rather relied on the judgment of the  !

nuclear licensing manager for making such decisions. The team did not  :

identify any instances in which it questioned the judgment of the licensee in i the area of reporting changes to commitments made to the NRC. The licensee's i commitment management procedure placed considerable emphasis on meeting  :

commitment dates and required that the NRC be notified of changes to commit-ment schedules by means of docketed correspondence. The licensee also 1 indicated that the NRC would be formally notified of changes that altered the intent of the original commitment.

Maintainina and Updatina the Updated Safety Analysis Report: The team found  !

that commitments that affected the plant USAR were captured by the USAR update 4

process and were reflected in the Davis-Besse USAR. The team reviewed plant modifications made to fulfill commitments regarding the addition of the diverse scram system. The design changes that affected the USAR were captured l

! in the USAR update process. In addition, the procedure that controls the USAR update process required a review of NRC docketed correspondence for potential changes to the USAR. However, the licensee did not provide guidance to its i

staff indicating specific criteria to be used to determine if a USAR change was appropriate. It appeared to the team that the licensee relied on the experience and judgment of its staff for making such decisions.

III. Discussion A. Commitment Manaaement The licensee maintained a computerized system for tracking commitment-related items. The system, the Toledo Edison Regulatory Management System (TERMS),

applied to commitments to be completed by a date or event and that, once completed, would be considered closed or ongoing. The TERMS was clearly ,

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defined and explained in Nuclear Group Procedure NG-NL-00802. The licensee ,

used Nuclear Group Procedure NG-QA-00702, " Potential Condition Adverse to l Quality Reporting," to document, evaluate, track, and close items identified as possible deficiencies. Licensee programs, such as the design basis review program, used the potential condition adverse to quality mechanism to screen and assess items for possible inclusion in the TERMS as commitments. )

l The licensee's processes for the origination and the permanent revision of plant procedures provided assurance that existing commitments would be i incorporated in new and permanently revised procedures. The team reviewed the l licensee's administrative procedure for new procedures and permanent revisions (NG-PS-00ll5). The procedure specifically required the originator to review a ,

listing of all applicable commitments and provided detailed instructions on l commitment verification and modification. All procedural commitments v .de in l response to the specific issues reviewed by the team had been incornorated in i the applicable procedures and were in effect at the time of the audit. In  ;

addition, the team identified commitments from docketed correspondence  ;

affecting three separate procedures. The commitment listings for all three '

selected procedures accurately reflected the commitments identified indepen- ,

dently by the team. The team concluded that the licensee's program for j procedure origination and permanent revision was comprehensive and effectively  !

implemented.

Plant modifications that resulted from commitments made by the licensee to the NRC, such as the diverse scram system and the anticipated transient without scram (ATWS) mitigation scram actuation circuitry (AMSAC) system,  !

were made in accordance with the plant modification procedure. Permanent l l plant modifications were controlled by procedure, NG-EN-00301, " Plant Hodifi- l cations," which implemented major plant modifications (MODS) and simple i configuration changes (SCCs). In addition, the project management for a MOD was assigned to a specific project coordinator when the MOD was the result of a regulatory commitment. The modification procedure did not require a review of past commitments to ensure a proposed modification did not alter or delete a previously implemented commitment. However, most engineers routinely conducted their own review of previously implemented commitments to ensure that the proposed modification did not adversely affect the system. The team did not identify any examples in which a committed modification was inadver-tently altered by a subsequent modification. The team attributed this to the experience level of the engineering organization and the multiple levels of review and approval required by the design change process.

In Procedure NG-NL-00802, the licensee defined a commitment as "a documented statement to or from the Nuclear Regulatory Commission (NRC) or a regulatory agency that establishes either requirements to be implemented or actions to be performed." The licensee further categorized commitments as " active," i

" negative," or " ongoing." An active commitment was one for which the licensee "had agreed to perform a specific action." A negative commitment was one

" relating to hardware issues stating that a particular action or activity will  ;

not be taken or performed.' An ongoing commitment was one "having no active '

process but requiring continuing compliance" and was " implemented by proce-dures, instructions, policies, or other implementing documents." During the audit, there were no instances of disagreement between the team and the 3

licensee involving the identification, interpretation, or intent of any commitment. The team concluded that the licensee's definition was adequate to capture the pertinent information and identify this information as commit-ments.

B. Reportino Chances to Commitments Made to the NRC The licensee's programs adequately controlled the reporting of changes to commitments made to the NRC. The licensee did not include in its procedures specific guidance for reporting changes to commitments and relied on the judgment of the nuclear licensing manager for making such decisions. The licensee's commitment management procedure (NG-NL-00802) placed considerable emphasis on meeting commitment dates and required that the NRC be notified of changes to commitment schedules by means of docketed correspondence. The licensee also indicated that the NRC would be formally notified of changes that altered the intent of the original commitment. At the audit exit meeting, the licensee stated that the commitment management procedure would be reviewed for possible formalization of guidance for reporting commitment changes.

The team noted that the licensee's modificatior program procedure required a review of cancelled modifications to ensure affe 'ed site organizations were notified and associated commitments were properly evaluated, even though its commitment management procedure did not specifically address reporting changes to commitments. Nuclear Group Procedure NG-EN-00 301 for plant modifications did require the redisposition of the document that initiated the modification.

This procedure step caused the TERMS item to be redispositioned when cancel-ling a modification. The team concluded that the licensee's program would result in notification of the NRC of the change in the commitment once the licensee completed its processing of the cancelled modification.

C. Maintainina and Updatina the Updated Safety Analysis Report Changes to the USAR at Davis-Besse were controlled in the modification control process through Procedure NG-NL-00806, " Preparation and Control of USAR Changes." The engineer preparing the modification package was required to determine if a USAR update was necessary. If so, the engineer was responsible for annotating the drawings affected, providing the text description neces-sary, and sending the package to the nuclear licensing group for inclusion in the next revision of the USAR. The procedure also required a review of all NRC docketed correspondence for potential changes to the USAR. However, the licensee did not provide guidance to its staff indicating specific criteria to be used to determine when a USAR change was appropriate. It appeared to the team that the licensee relied on the experience and judgment of its staff for making such decisions.

The team reviewed the diverse scram system (DSS) for changes made to this system and their inclusion in the USAR. Text descriptions of the DSS, a newly installed system, had been added to the USAR and adequately described the system. Of the modifications reviewed by the team, all system drawings and text descriptions of the systems affected were included in the USAR and were 4

.- accurately revised to reflect the actual plant configuration. The Davis-Besse ,

system for updating the USAR following plant modifications had effectively +

captured the sampled physical plant changes.

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APPENDIX - SPECIFIC ISSUES REVIEWED AT DAVIS-BESSE  :

To examine the implementation of the licensee's programs, the team reviewed the licensee's response to the following specific issues:

10 CFR 50.62 Anticipated Transient Without Scram  !

Generic Letter 89-13 Service Water System Problems Affecting Safety-Related Equipment Generic Letter 88-14 Instrument Air System Problems Affecting Safety-Related Equipment Bulletin 85-01 Steam Binding of Auxiliary Feedwater Pumps NUREG-0737, I.C.5 Procedures for Feedback of Operating Experience to Plant Staff Notices of Violation 50-346/87-27 (01), (02), and (03); 50-346/88-06 .

(01) and (02); 50-346/88-39 (01) and (02); and '

50-346/89-05 l Unresolved Item 50-346/89-015 i l

Licensee Event Reports 87-008-01,87-009, 87-013,88-001, 88-003, l 88-005-01, 88-007-01,89-009, 89-011, and 89-016 '

Design Basis Document Program 10 CFR 50.62 - Anticipated Transient Without Scram (ATWS)

The ATWS rule was implemented at Davis-Besse with the addition of the diverse scram system (DSS) and the ATWS mitigation system actuation circuitry (AMSAC) system. These system designs were submitted to the NRC by the licensee on February 28 and June 30, 1989. The NRC reviewed the submittals and on September 29, 1989, found that they were acceptable in accordance with the ATWS rule in 10 CFP 50.62.

The licensee's commitments to the NRC concerning ATWS had been incorporated in the physical plant. Hardware changes to the plant were in agreement with the commitments made to the NRC on separate and diverse scram system components.

In addition, the licensee had committed to perform periodic testing of the DSS. The team reviewed the licensee's periodic test procedures and results and found that the licensee's original commitments were being met. The AMSAC system had remained unchanged since it was installed.

The DSS was installed at Davis-Besse after the original plant license was issued, and the licensee had added a section to the USAR, including text and drawings, describing the DSS. The team found that the section added to the USAR described the DSS as installed in the plant. No problems or discrep-ancies were identified.

Generic letter 89-13. " Service Water System Problems Affectina Safetv-Related Eouicment" The control and implementation of commitments at Davis-Besse in response to Generic Letter (GL) 89-13 were complete and comprehensive. No discrepancies were identified. The licensee documented commitments to address GL 89-13 in letters dated January 30, 1990, and December 23, 1991. The commitments included procedure changes and periodic tests. The new procedures and periodic tests were implemented and included a Toledo Edison Regulatory Management System (TERMS) commitment identification number linking them to the GL. The service water system engineer interviewed by the team was knowl-edgeable of the plant procedures and the licensee's commitments in response to the GL. However, the TERMS showed that the ongoir.g commitment to visually inspect the intake structure had a periodicity of once every " refueling cycle" rather than once every "18 months" as indicated in the final response to ,

GL 89-13. However, this discrepancy was insignificant because the periodic test procedures contained the correct 18 month frequency and the final response to GL 89-13 was referenced in the TERMS.

Generic Letter 88-14. " Instrument Air System Problems Affectina Safety-Related >

Eouicment" The licensee responded to GL 88-14 by letter dated February 22, 1989. This response included commitments to perform system dew point checks three times weekly, filter differential pressure checks daily, and filter element inspec-tions quarterly. The team confirmed that those commitments were entered into TERMS. The system engineer for the instrument air system showed that he was knowledgeable of the plant commitment control procedures by adequately demon-strating the existence of an NRC commitment during a hypothetical instrument air procedure change. The team performed a system walkdown to verify the locations for performing dew point checks. In addition, it reviewed the completed dew point and differential pressure checks from a sample of operator logs. No deficiencies or problems were noted.

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l NRC Bulletin 85-01. " Steam Bindina of Auxiliary Feedwater pumos" The licensee's control and implementation of commitments in response to Bulletin 85-01 were complete and comprehensive. In response to the bulletin, the licensee committed to procedural changes including (1) monitoring of the auxiliary feedwater (AFW) pump's discharge piping temperature at least twice a l day and monitoring of the non-safety motor-driven feedwater pump (MDFP) casing j to ensure they are at near ambient temperature and (2) if steam binding is  !

detected, recovery of the pumps in accordance with the pump operating proce-dures.

The commitments made by the licensee involving the procedural changes were implemented and still existed in the current operating procedures even though the original procedures had been revised a number of times since the licensee's response to the bulletin on February 28, 1986. In addition to reviewing the procedures, the team reviewed the logged AFW discharge piping and MDFP casing temperatures in a sample of operator logs. No deficiencies or ,

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NUREG-0737. I.C.S. " Procedures for Feedback of Ooeratina Experience to Plant Staff" l

l The licensee's control and implementation of commitments in response to Item .

1 I.C.5 requirements were complete and the resulting program for the review l and feedback of operating experience met these requirements. The team also reviewed the licensee's actions in response to the specific issue discussed in i NRC Information Notice 92-36, "Intersystem LOCA Outside Containment," to examine the licensee's implementation of its operating experience feedback program. No deficiencies or problems were noted.

l l Desian Basis Document Proaram >

One of the licensee's improvement programs after the Davis-Besse June 9, 1985, i event involved a review of systems important to safety. The program resulted in the issuance of upgraded system descriptions in 1988. The system descrip-tions included design requirements sections including the applicable regulato-ry criteria and industry code specifications. .

The system descriptions did not include verification of design basis calcula-  ;

tions and the reconstitution or generation of analyses (where absent) to l confirm adequacy with respect to the original design bases. The licensee had >

initiated a separate program to conduct such design basis reconstitution activities. At the time of the audit, the first such system document was in a very preliminary draft form and was not reviewed by the team.

• The licensee stated that any items iJentified as potential deficiencies would -

i be reviewed within the context of Procedure NG-QA-0702, " Potential Condition l Adverse to Quality Reporting." The team noted that the procedure had accept-l able controls for evaluating items for operability and reportability and clearly specified responsibility and tracking requirements.

NOV 50-346/87-27(01)

Amendment 18 of the facility license required the licensee to complete mod-ifications identified in a safety evaluation dated July 26, 1979, including those modifications listed in Table 1 of the safety evaluation. Table 1 of the safety evaluation required that fire protection administrative controls be revised to require that qualified personnel review plant modifications, I including fire protection systems, to ensure inclusion of appropriate fire l protection requirements. These reviews were to include design reviews to verify appropriate requirements for room isolation, A notice of violation (NOV) was issued because Maintenance Procedure MP I405.07, " Fire Damper Maintenance," did not require a design review prior to modifying the fire dampers.

As part of the corrective actions, the licensee committed to modify MP 1405.07 to require a design review by facility engineering personnel before field modifications were made. The audit team verified that MP 1405.07 was modified to require this review.

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NOV 50-346/87-27(02) -

Technical Specification (TS) 3.3.3.8 required that if the number of oper-able fire detection instruments was less than the minimum number required r to be operable, the licensee restore inoperable instruments to operable  !

status within 14 days or submit a special report within the next 30 days. r On July 18, 1987, fire detection zone FDZ-A208 was declared inoperable; as  !

a result less than the required minimum number of detectors was operable. ,

An NOV was issued because the licensee had failed to restore FDZ-A208 to ,

operable status or to submit a special report as required.

f As part of the corrective actions, the licensee cor,mitted to submit the special report and to require all shift supervisors to review this incident to improve their understanding of the proper mechanism for ensuring that such incidents rere reviewed and reported appropriately. The team verified that the special report had been submitted in a timely manner and that all shift supervisors had reviewed the incident.

NOV 50-346/87-27(03)

Amendment 18 of the facility license required the licensee to complete modifications identificd in a safety evaluation dated July 26, 1979. An NOV was issued because the licensee had failed to complete the modifications committed to in the safety evaluation before the due date. One of these modifications was the replacement of deficient Kaowool wraps in the service water pump room and the component cooling water pump room.

As part of the corrective actions, the licensee committed to replace these wraps. The team verified, through records review and personal observations, including a walkdown with the licensee using plant drawings, that the Kaowool wraps in the affected rooms had been replaced.

NOV 50-346/88-06(01) l Appendix B to 10 CFR Part 50, Criterion V, requires that activities affecting quality be prescribed by documented instructions, procedures, or drawings and be accomplished in accordance with those instructions, procedures, or I drawings. An NOV was issued because the licensee had failed to use instruc-tions, procedures, or drawings for the seismic qualification evaluation and installation of a containment spray oil sightglass.

As part of the corrective actions, the licensee committed to develop a sampling program to evaluate seismic calculations performed since l January 1, 1986. The team verified that this program had been developed.

t NOV 50-346/88-06(02)

Appendix B to 10 CFR Part 50, Criterion III, requires that measures be established to ensure that applicable regulatory requirements and the design basis for applicable components are correctly translated into specifications, drawings, procedures, and instructions and that design changes, including 4

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.- field changes, were subjected to design control measures commensurate to those applied to the original design, and be approved by the organization that performed the original design. An NOV was issued because the licensee had administratively changed Specification Number 12501-E-180 to include a load profile for the station battery performance test without going through the facility change process or applying appropriate design controls.

As part of the corrective actions, the licensee committed to modify existing procedures in the design change request process to require a design review to i

ensure interfacing plant procedures are reviewed for changes. The team reviewed Engineering Department Procedure EN-DP-01021, Revision 1, and )

l verified that this commitment had been met and was still in effect.

NOV 50-346/88-39(01) )

As required by 10 CFR 50.59, the licensees are to maintain records of changes l in the facility as described in the safety analysis report. The records are ,

required to include a written safety evaluation. An NOV was issued because  !

the licensee had failed to perform a safety evaluation and to maintain that evaluation for the addition of an emergency diesel generator (EDG) protective  ;

relay to the list of protective relays not bypassed during an essential bus i under-voltage conditien or a loss-of-coolant accident. l As part of the corrective actions, the licensee committed to perform a safety evaluation for a new USAR change notice created to clarify the function of the EDG protective relay. The team verified that this safety evaluation had been performed. In addition, the licensee made a commitme r . w r= view the revision l to the USAR for which the safety evaluation in question was omit +ed to determine if other USAR changes should have had safety evaluatio.n The team noted a review had been completed that determined that no other USAF revisions had been improperly incorporated as editorial changes or without a safety evaluation. ,

NOV 50-346/88-39(02)

Technical Specification 6.8.1 required that written procedures be established, )

implemented, and maintained for the applicable procedures recommended in '

Appendix A of Regulatory Guide 1.33. Operations procedures are included in I this list.

(1) An NOV was issued because a reactor operator (RO) had failed to properly turn over an evolution in progress to another R0 as required by Opera-tions Procedure DB-0P-00000, " Conduct of Operations."

As part of the licensee's corrective actions, personnel involved in this incident were counseled with emphasis on the importance of ensuring proper communications while carrying out assignments and of maintainino l strict adherence to procedural requirements. '

(2) An NOV was issued because a condition that prevented the decay heat system from performing its function was not promptl:. reported to the l control room as required by Operations Procedure DB-0P-00000.

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As part of the licensee's corrective actions, personnel involved in l this incident were counseled with emphasis on the importance of ensuring.  !

l proper communications while carrying out assignments and of maintaining j strict adherence to procedural requirements.  !

i 1 (3) An NOV was issued because plant personnel did not perform an adequate i

walkdown of control room panels as required by Operations Procedure  !

! DG-0P-00100, " Shift Turnover." ]

2 As part of the licensee's corrective actions, personnel involved in  ;

this incident were counseled with emphasis on the importance of ensuring j proper communications while carrying out assignments and of maintaining  ;

strict adherence to procedural requirements. j (4) An NOV was issued because the status of an inoperable containment air

] cooler was not recorded as required by Operations Procedure  ;

DB-0P-00000.

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As part of the corrective actions, the licensee committed to revise  ;

Operations Procedure DB-0P-00000 to include improved methods for tracking 1 and delineating equipment that is out of service. In addition, the l licensee committed to evaluate improvements in the control room status j board to give a better indication of equipment that-is out of service or i in an abnormal lineup. The team verified that DB-0P-00000 had been '

revised and noted that, as a result of the evaluation, the control- room status board had L;en improved.

. t NOV 50-346/89-05 l 1

Technical specifications (TS) required that certain programs be established, implemented, and maintained. One of these was a program to reduce, to as low as practical levels, leakage from portions of those systems-outside the

. containment that could contain highly radioactive fluids during a serious i accident. The licensee partially implemented that program with Procedure  !

DB-SP-00001, which required that Performance Test (PT) 5164.04 be performed by August 4, 1988, and PT 5172.00 be performed by August 21, 1988. An NOV was  !

issued because the licensee had failed to complete these performance tests i i

before their respective deadlines. i As part of the corrective actions, the licensee committed to convert these i periodic tests to surveillance tests and control them under the surveillance i test program to provide adequate controls and direction for perfcrming tests t required by the TS. In addition, the licensee committed to conduct a review 1

to determiae if other critical periodic tests were used to satisfy TS testing requirements, and to convert these critical tests to surveillance tests and control them under the surveillance test program. The team verified that PT 5164.04 and PT 5172.00 had been converted to the surveillance tests and a continued to be part of the ' surveillance test program. The team also noted that three additional critical tests had been identified and converted to surveillance tests.

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] Unresolved item (URI) 50-346/89-015

) An unresolved item was opened as a result of an NRC inspector's concern that-

! the request for assistance design change request process did not provide a

program for determining design document deficiency trending, and there might '

4 not have been a program for performing root cause analyses and additional reviews of similar areas if trending showed that there was a pervasive problem j i area. l i l j In response to this URI, the licensee committed to evaluate of the inspector's concern and to consider implementing such a program. Following this evalua-tion, the licensee committed to initiate periodic trending of design document  ;

deficiencies and to take corrective actions as necessary if pervasive problems l 1 were discovered. To meet this commitment, the licensee modified Procedure

NG-QA-0702, Revision 2, to state that when a drawing differs from a-field I condition, a potential condition adverse to quality report shall be written.

The team reviewed the licensee's engineering assurance evaluation report concerning design document deficiency evaluation and trend analysis and Procedure NG-QA-0702. The team found that the. licensee had satisfied its j commitments.

Licensee Event Reports (LERs) l The audit team reviewed the commitments associated with'the corrective actions j y

contained in the following 10 LERs ,

, t 87-008-01 Inoperable Safety Features Actuation System Sequencer  !87-009 Liquid Radwaste Discharge Inoperable Due to Procedural Error  !87-013 Loss of Y2, Essential 120 VAC Bus, Due to Personnel Error During i Troubleshooting 88-001 Seismic Trigger Does Not Meet Technical . Specification Frequency Range ,

4 88-003 Fire Detection System Supervision Not Tested for Ground Fault 2

Detection Due to An Inadequate Procedure  !

88-005-01 Inoperable Fire Barrier With Inoperable Fire Detection 88-007-01 Air Operated Valve Accumulator Leakage and Subsequent Decay Heat Removal System Inoperability 89-009 Improper Operation of the High Pressure Injection System Line Isolation Valves i

89-011 Testing of Decay Heat Cooler Valves Did Not Satisfy ASME Require-ments89-016 Unplanned Release to Settling Basin During Condensate Polisher Backwash 7

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i The 10 LERs contained commitments to a wide variety of corrective actions- l including hardware modifications, technical specification and FSAR changes,  !

procedure revisions, and technical studies. The team did not identify any -

safety-significant deficiencies with respect to the licensee meeting and j maintaining the commitments made the LERs. l During the review of LER P9-016, a commitment in a response letter to  ;

NOV 50-346/89-23 concerning the same event appeared not to have been entered j into the TERMS. The commitment was to review procedures and training dealing i with the handling of radioactive effluents and was to be completed by December l 31, 1989. Although the commitment to review procedures was entered into the i TERMS, the portion of the commitment that dealt with the review of trainir.g  !

was not. However, because the procedure review portion of the commitment was met and affected licensee personnel were trained on the revised procedures, the team concluded that the intent of the commitment was satisfied. l t

During the review of LER 87-009, the team identified a commitment to conduct i an engineering review of tests that currently require the lifting of leads or '

the installation of jumpered wires to determine the feasibility of installing i permanent test switches for radiation monitors. The team reviewed the  !

documentation associated with the closecut of this commitment and was not able j to determine if the review had or had not been performed. However, the '

licensee took corrective actions to install a wiring modification, and the l team believed that this corrective action met the intent of the commitment. i r

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