ML20058C097
| ML20058C097 | |
| Person / Time | |
|---|---|
| Site: | Dresden  |
| Issue date: | 07/07/1982 |
| From: | Delgeorge L COMMONWEALTH EDISON CO. |
| To: | James Keppler NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| Shared Package | |
| ML20058C083 | List: |
| References | |
| 4481N, NUDOCS 8207260257 | |
| Download: ML20058C097 (16) | |
Text
F~
Commonwxith Edison 70" One First National Plaza, Chicago, Ilknois Q
Address Reply to: Post Office Box 767 Chicago, Illinois 60690 Jul y 7, 1982 Mr. James G. Keppler, Regional Administrator Directorate of Inspection ~and Enforcement - Region III U.S. Nuclear Regulatory Commission 799 Roosevelt Road Glen Ellyn, IL 60137
Subject:
Dresden Station Units 2 and 3 Response to I.E.
Inspec tion Report Nos. 50-237/82-07 and 50-249/82-07, dated June 7, 1982 NRC Doket Nos. 50-237 and 50-249 Reference (a):
R. L.
Spessard letter to Cordell Reed dated June 7, 1982.
Dear Mr. Keppler:
Re ference (a) transmitted the results o f a special inspection conducted by Messrs. W. D. Sha fe r, J. K. Helle r,
A.
L. Madison, M.
E.
Parker and D. L. Robinson on April 12-16 and April 19-23, 1982, of activities at Dresden Nuclear Power Station Units 2 and 3.
The Appendix to Reference (a) identified six items o f noncompliance with NRC requirements.
Our responses to those items of noncompliance are provided in At tachment A to this letter.
Also provided, in At tachment 8, are our comments concerning various subjects discussed in the Inspection Report.
As detailed in the attached responses, we believe that both noncompliance number 2, concerning the adequacy o f Quality Procedure QP 3-52 implementation o f Quality Assurance and/or Quality Control hold points, and noncompliance number 3, concerning documentation of personnel training, are not warranted and should be withdrawn.
Please direct any questions you may have concerning this matter to this o f fice.
Very truly yours,
$h= fr :1 L. O. De l Geo rg e Director o f Nuclear Licensing Im cc:
Region III Inspector - Dresden SUBSCRIBED,and SWOR to bef e m /this day o f_. t g l982 j
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No tary Public O207260257 820721 PDR ADOCK 0500023 4481N G
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COMMONWEALTH EDISON CO MP AN Y ATTACHMENT RESPONSE TO NOTICE OF VIOLATION Item af Noncompliance 1.
Technical Specification 6.1.F requires retraining to be conducted at intervals not exceeding two years.
Technical Specification 6.1.E requires retraining and replacement training of station personnel to be in accordance with ANSI N18.1
-1971Property "ANSI code" (as page type) with input value "ANSI N18.1</br></br>-1971" contains invalid characters or is incomplete and therefore can cause unexpected results during a query or annotation process., Selection and Training of Nuclear Power Plant Personnel.
ANSI N18.1-1971, Section 5.5, Retraining and Replacement Training,
requires a training program to be established which maintains the proficiency of the operating organization, through periodic training exercises, instruction periods and reviews covering items and equipment which relate to safe operation of the facility.
Contrary to the above, the licensee had no formalized retraining program for the maintenance department that maintained the proficiency of the maintenance worker, workers were not trained on appropriate plans and procedures, and retraining was not conducted every two years.
Discussion We recognize the requirements in Sections 5.4 and 5.5 of ANSI N18.1-1971 to establish a training program for all personnel includ-ing maintenance workers.
We have an established program which provides for training of personnel in " appropriate plans and procedures" as well as other categories listed in Section 5.4 o f ANSI N18.1 on an gnnual basis.
We believe that training in these plans and procedures has been commensurate with the level of responsibility o f the personnel.
For instance, although maintenance workers have the authority to initigte procedure inquiries, they are not exp'ected to perform that function in the course of their duties.
Instructions to our workers are to call to their forman's attention errors found in procedures or improved methods i
of doing a job.
The foreman will appropriately mark up a copy of the procedure and seek Maintenance Staf f assistance in making the inquiry or revision.
Further, management personnel in the Maintenance Department receive training in the area of Station Administrative Procedures via annual required reading lists.
l Corrective Actions Taken to Avoid Further Noncompliance and Date when Full Compliance Will Be Achieved In order to address your concerns in this area, we will perform a review of the initial and retraining programs to identify any areas that require further treatment or addition.
This review will be complete prior to September 1, 1982, and any changes deemed appropriate 0111 be implemented prior to the next annual retraining cycle scheduled to begin in December, 1982.
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, Item o f Noncompliance 2.
10 CFR 50, Appendix B, Criteria II, states that *.he applicant shall establish a quality assurance program whicn complies with the requirements of 10 CFR 50, Appendix B.
Topical Report, CE A was established to comply with these requirements.
Pa ragraph 10 o f the Topical Report identifies that an inspection program will be established to provide assurance that the quality control surveillance, inspection and tests defined in the specifications are performed.
Quality Assurance inspection and testing will be conducted at the station during operations, maintenance and modification activities to verify quality.
Inspection and test points will be established as required to assure quality of items and the effectiveness of the inspection program.
Contrary to the above, Quality Procedure, QP 3-52, allowed the Maintenance Department to proceed with safety-related and plant reliability-related maintenance activities without Quality Assurance and Quality Control authorization and approval, when Quality Assurance and/or Quality Control personnel were not on site and the work was routine type maintenance using approved procedures and methods.
This practice bypassed Quality Assurance and Quality Control's ability to establish and implement hold points, as hold points were not routinely written into procedures when originally approved.
Review of work request revealed tha t 34 of about 150 routine work requests were completed while Quality Assurance and/or Quality Control personnel were of fsite.
Work was allowed to proceed without the implementation o f hold points, as appropriate, to assure the quality of work being performed was 3
adequate.
)
Discussion As stated in the report, QP 3-52 provides for the Quality Assurance and Quality Control inspection requirements for maintenance activities.
This procedure not only describes overall QA/QC review of l
work request for establishing inspection hold points and witness points, but it also identifies circumstances under which QA/QC review 1
is not necessarily required prior to the start of work.
This is where the work is routine and simple and can be done as craf t capability or to a simple procedure.
The Shif t Engineer makes the decision as to the s
routine and simple nature of the work and its urgency on the basis of j
his experience and operating conditions.
The ability to respond l
quickly to repair o f routine items in o ff hours is considered important to the safe operation of the plant.
The provisions o f QP 3-52 for conducting urgent simple routine work without QA or QC review prior to the commencement of work during of f hours is judged to be a reasonable j
and safe policy and no change is deemed necessary.
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Discussion (Cont'd)
This judgement is based on the following considerations:
1.
The need for QA/QC involvement in routine work items is minimal as the work is performed on the basis o f craft capability and/or simple pre-approved procedures not requiring hold points for the routine work to be done.
Further, all such work packages are reviewed by QC and QA the next work day for adherence and compliance to requirements and acceptability.
2.
Safety-related work requests require an operability test to verify proper operation following maintenance prior to placing the item in service.
This prosines an independent check of the adequacy of the routine work performed and a verfication of the operability of the item.
j 3.
The number o f work requests initiated and completed outside normal working hours where QA/QC is not present is small compared to the total number o f safety-related work requests issued and is certainly nowhere near 20% which may be inferred from the report; and 4.
There have been no documented instances o f improper i
workmanship for these routine work requests attributable to i
the absence o f Q A/QC coverage o f routine work because approved procedures, where applicable, are required to be used and operability tests to be performed.
To the extent that appropriate judgment may not have been used in the designation o f routine nature or urgency o f the work, Quality Assurance has undertaken a special review of this type of work request covering the past two months and has identified only three (3) routine l
work requests and the Shif t Engineer's judgment appears acceptable.
Furthermore, during the past 18 months only 39 of 1250 safety-related work requests processed by Quality Assurance were completed without prior QA/QC involvement.
The Quality Procedure requires that QA/QC review such work requests as soon as possible after completion.
In the event of abuses, Q A can take steps with Station and Corporate Manage-ment to ensure uniform implementation of the provision o f QP 3-52.
For non-routine safety-related work requests, Shift Supervisors are required to call the QA/QC person on duty to provide them an opportunity to establish hold points in work packages containing procedural steps involving work which the Shif t Engineer feels should begin immediately.
In summary, we believe that our program is in full compliance with i
regulations, and that this citation should be withdrawn.
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Item o f Noncompliance 3.
10 CFR 50, Appendix B, Criteria II, states that the applicant shall establish a Quality Assurance program which complies with the requirements o f this Appendix, and that this program shall be documented in written procedures and shall be carried out.
Topical Report CE-1-A, Section 5, states:
" Generating s tation operations, procedures and instructions will be provided by the a
i Station Superintendent and will be included in the station procedures manual in a timely manner consistent with NRC license 3
requirements for administering the policies, procedures, and instructions from the time that the Operating License is issued through the life of the station; that these procedures and instructions include, Administrative Procedures."
Contrary to the above, on-the-job training was not being documented as required by Dresden Personnel Procedure, DPP-13, Training Records.
A review of training records for 15 selected personnel revealed that on-the-job training had not been documented for these personnel since 1978.
I Discussion With regard to Item 3 above, Dresden Station management believes that it is presently in compliance with appropriate regulations and that this noncompliance citation should be withdrawn.
The Dresden Station Technical Specifications, Appendix A to DPR-19 and 25,Section VI.l.E, specifies that retraining and replacement training of station personnel shall be conducted in accordance with ANSI N18.1, " Selection and Training o f Nuclear Power Plant Personnel,"
l dated March 8, 1971.
ANSI N18.1-19 71, paragraph 5.6,
" Documentation", specifies that
" records o f the qualifications, experience, training and retraining of each member o f the plant organization should be maintained" (emphasis added).
Paragraph 2.2.1 in the glossary o f terms o f ANSI N18.1-1971 i
specifies that the word "should" denotes a recommendation, and that conformance to the Standard does not necessarily require compliance with the recommendations contained within the Standard.
Dresden Administrative Procedure, DAP 8-2, Revision 4, specifies that the scope and general methods o f accomplishment for Dresden Nuclear Power Station training programs is completely detailed in the Dresden Personnel Training Procedures (DPP) series.
DPP-13, Pa ragraph B.2.d, specifies that documentation o f on-the-job training is the responsibility of each department.
The intent o f this statement in the procedure is to accomodate the fact that the Training Department does l
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. Discussion (Cont'd) not ~ conduct all on-the-job training that is accomplished at Dresden.
The individual departments are therefore responsible for ensuring that any required on-the-job training is properly documented, and that the forms are properly forwarded to the Training Department records.
However, there is no requirement within ANSI N18.1-1971, or DPP-13, to j
document all on-the-job training conducted at Dresden Station.
l DPP-13, Pa ragraph B.3, Methods, specifies that the forms for documenting training are-to be used at the discretion o f the Training Supervisor.
Although DPP-13 does not contain any forms, certain standardized forms have been established for use at' the station for documenting the training which must be documented and maintained in i
personnel records.
Paragraph B.3 states that the intent of standar-dized DPP Form 103 is that the form be used for documentation o f on-the-job training which is conducted at the station.
For those programs administered by the Training Department in which on-the-job l.
training is a specified part o f the program, documentation is main-tained on DPP Form 103 or other forms as required.
Other departments at Dresden may from time to time wish to document some specific task l
capability learned through on-the-job training, and they can do so by using DPP Form 103.
However, there is no requirement contained within this procedure or any other s tation procedure to document all on-the-l Job training or to use this specific form.
Because we believe there is no regulatory or procedural require-ment to document all on-the-job training which is conducted at-~Dresden i
Station, we believe the ' inspector's determination of noncompliance was made with an overly restrictive view of the intent of existing i
procedures.
We therefore request that this item of noncompliance be j
reconsidered and withdrawn.
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. Item o f Noncompliance 4.
Technical Specification 6.1.G.2.a.(4) requires that the Onsite Review and Irivestigative Function review all proposed changes or modifications to plant systems or equipment that affect nuclear safety.
Contrary to the above, none of the field changes generated af ter the original onsite review were reviewed by the Onsite Review and Investigative Function prior to the installation or completion of work.
Inspection Report Pa ragraph 1.a. (4 ) Discussion Design changes originating at the station made subsequent to the initial release of design specifications and drawings were documented by Field Change Requests (FCRs).
Although the FCRs were subject to review by the Architect Engineer and the Station Nuclear Engineering Department, they were not subject to review by either the Operations or the Technical Staf f Department.
No mechanism existed to require concurrence by the Operating Enginee r, Technical Staf f Supervisor, and the working department issuing the FCR.
There was no direct feedback system to ensure site management review of FCRs.
Corrective Action Taken 'and Results Achieved and Corrective Action to be Taken to Avoid Further Noncompliance To ensure appropriate onsite revew of field changes which could af fect the function or the major design criteria of an approved Modifi-cation, the " Major" category of FCRs will be deleted from use for operating stations.
If major changes are necessary, they will be i
processed as revisions to the Modification, and will require onsite review.
Revisions to the Modification are processed using the same
(
Modification Approval procedures used for initial modifications; therefore, appropriate changes to procedures and training will be l
identified and processed.
Only " Minor" FCRs will be used in connection with operating station Modifications.
These FCRs are_ associated with minor physical i
installation changes, and will be processed in accordance with established engineering / construction design control procedures to l
ensure appropriate design document revision.
In addition, when the FCR form is initiated, a copy of these minor FCR's will be distributed to the Station Technical Staf f Supervisor for information.
Since these minor FCRs do not involve functional changes or changes to the design criteria, formal review by the Technic 1 Staff Supervisor will not be l,
required.
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, Date o f Full Compliance These changes will be documented by revising QP 3-2 o f the Corporate Quality Assurance Manual.
These manual revision will be completed by October 1, 1982.
Fu rther Discussion As described in the preceding response, we are revising the Quality Assurance Manual to formally address field changes to operating station Modifications.
These revisions document the informal controls presently utilized to ensure the proper review of any changes to the design of a plant Modification.
It is our judgment that the existing controls are adequate and have precluded any non-compliance with NRC regulations, because only FCRs a f fecting minor physical changes have been processed at Dresden Station in the past three years.
The proposed changes discussed in our response will clearly formalize these review requirements for design changes for operating plants.
4481N
Item o f Noncompliance 5.
Technical Specification 6.1.G.2.c requires that reports, reviews, investigations, and recommendations be documented with copies to the Division Manager - Nuclear Stations, (Division Vice President
- Nuclear Stations), the Station Superintendent, the Supervisor o f the Off-Site Review and Investigative Function, and the Manager of Quality Assurance.
Contrary to the above, the following On-Site Review Reports were not distributed as required:
Report 82-4, 250 Volt Battery Discharge Test Report 81-83, Spill Prevention Control and Countermeasures Plan Report 81-38, Review o f Security Plan Report 81-3 4, Approval for Use o f Process Computer Program Report 81-32, Au tomated Analytical Instrumentation System Report 81-33, Operability o f Unit 3 Inboard NSIV Valve 3-203-lC with its Respective DC Solenoid 3-203-lC Lead Lifted Report 81-2, Changing o f Normal Valve Line-up o f HPCI During Stand-by Operations.
Report 81-12, Change in Recirculation Pump Scoop Tube Travel From 7 to 45 seconds.
Corrective Action Taken and Results Achieved The on-site review log was surveyed to determine which on-site reviews were not distributed as required.
Based on this survey, all on-site reviews have now been distributed to the required locations.
Corrective Action Taken to Avoid Further Noncompliance Although Dresden procedure DAP-10-1, "On-Site Review and Investi-gative Functions" already specified distribution of on-site reviews as required by the Technical Specification, a misunderstanding by Dresden l
personnel of the use of off-site review department's form that requests this review led to the above noncomliance.
Based on discussions between Dresden and the off-site review group, the requirements o f the l
Technical Specification and the use of the of f-site review request form have been clarified.
As a result of the discussions, all on-site reviews will be distributed as required and the request form will be used to indicate a specific request by Dresden to formally document the of f-site review of a particular on-site review.
Date When Full Compliance Will Be Achieved We believe that based on the above discussion that full compliance has been achieved.
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. Items o f Noncompliance 6.
10 CFR 50, Appendix B, Criterion XVIII requires a comprehensive system of audits to verify compliance with all aspects of the Quality Assurance Program and to determine the effectiveness of the program.
Contrary to the above, audits o f vendors and onsite contractors revealed the licensee did not address all 18 Criteria of 10 CFR 50, Appendix B, as appropriate.
Six 1981 audits reviewed revealed that contractors had not been audited to the applicable 18 Criteria.
Three of five audits reviewed in the vendor area did not address all 18 Criteria as appropriate.
In addition, audits of training and maintenance did not determine the effectiveness of the program.
This is a Severity Level V violation (Supplement I).
Corrective Action Taken and Results Achieved In Supplement I to the NRC report it ' stated that only one contrac-tor audit did not address the 18 Criteria.
The audit identified as Q AA 12-81-62, was performed on 11-24-81 by Dresden Quality Assurance personnel at the McCartin, McAulif fe corporate o f fice.
The audit checklist, approved by the Director o f Quality Assurance for Engineering and Construction on 11/5/81, contained seven questions which covered 6 Criteria.
The purpose of the audit was to cover all of the criteria in the McCartin, McAulif fe Q A Manual which were applicable to the corporate office.
Audit QA A 12-81-62 was the third audit conducted o f the McCartin, McAulif fe Q A Program in 1981.
The first two audits were conducted at the Dresden site earlier in the year.
Audi t QAA 12-81-10 which was conducted on 3/4/81 had 15 questions and covered 15 Criteria.
Audit QA A 12-81-41 which was conducted on 7/9/81 had 18 questions and covered 18 Criteria.
These three audits, in total, which were performed by Commonwealth Edison Quality Assurance Department site personnel, verified compliance with all aspects o f the contractor's Quality Assurance program.
In Supplement I, it also stated that three of five of f-site vendor audits did not address all 18 Criteria as appropriate.
The audits reviewed by the NRC inspector were not identified in the NRC report and, therefore, this response can only address the NRC concern in a generic way.
When performing o f f-site vendor audits, Edison auditors have documented instructions to
" examine the areas of organization, personnel qualifications, special processes, audits, equipment calibration and Quality Control Inspection.
Selected questions from other appropriate areas of the vendor's program shall also be included to assure coverage, in a broad sense, of the total QA Program".
As part of this audit approach, the Edison auditor verifies that the vendor performs audits of the total QA program on an annual basis to assure that all applicable 18 Criteria are audited by the
F Corrective Action Taken and Results Achieved ( Con t ' d )
vendor and properly implemented.
In addition, Commonwealth Edison performs witness point inspections at the vendor's f acilities during the manufacturing period.
These witness points are performed to approved checklists in the same f ashion as an audit and in many cases are done in conjunction with the Edison audit.
It is felt that this overall approach satisfies the intent of Criterion 18 to verify compliance to all aspects of the vendor's program.
Corrective Action to Prevent Recurrence In order to further emphasize that Commonwealth Edison audits of of f-site vendors specifically cover all applicable criteria, management memo dated 1/29/82 was revised on 4/21/82 to state that it is required to audit all applicable 10CFR50 Appendix B Criteria as was stated in the NRC Inspection Report.
Also, it is now required to indicate on the audit checklist which criterion are being covered by each audit question so that it is clearly identified for the NRC as to what specific Criteria are being covered.
Criteria not applicable will be documented in the audit file.
This requirement was documented in a management memo issued by the Manager o f Quality Assurance to all Q A Supervision on June 21, 1982 and has been included in the lesson plan for audit tralning.
Da te of Full Compliance Corrective action for this noncompliance is complete.
Items o f Non-Compliance, Con tinued 6.
Failure to Evaluate Training and Maintenance Program Ef fectiveness Discussion Quality Assurance '4anegement has recently emphasized the importance of an overali evaluation statement in Quality Assurance i
Audit reports.
In the ca=e o f training, an assessment statement will be made with respect to ef fective implementation of the established program.
The Production Training Department has the responsibility to evaluate the ef fectiveness of its training programs.
Such an evalua-tion is a complex time-consuming undertaking by specially trained individuals, knowledgeable in the tasks o f the trainees, and the information available to the instructors.
l For the Quality Assurance auditor who examines records of training, and monitors a f ew classes, it is possible to verify program implementation, but it is not always possible to measure the ef fective-l l
ness of training programs covering weeks or months.
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. With respect to the statement that an evaluation of QP 3-52, would have determined that no provisions existed for bypassing QA and QC responsibility for establishing hold points, Commonwealth Edison Company does not concur with this conclusion.
As discussed in Item #2, the management of the Quality Assurance is aware of the statements contained in QP 3-52.
The circumstances under which QA/QC could be bypassed for routine, yet, urgent work requests is not inconsistent with Topical Report CE l-A.
Corrective Action To Be Taken and Date of Full Compliance A statement as to the effectiveness of audited area will appear in each audit report for which the scope is adequate to make such a conclusion.
This will be e f fective July 1,1982.
l As to determining the ef fectiveness of the program (see I.R.
paragraph 5.a.(5)), the status and adequacy of the Quality Assurance Program is determined every two years by an independent management audit conducted in accordance with Chapter 2 CE 1-A.
An examination o f Attachment A of Page 4 of the NRC Inspection Report indicates that these Management Audits may not have been examined by the NRC Inspection Team.
Also, the of f-site audits conducted twice per year at the operating i
nuclear plants and construction sites provide and assessment of the program effectiveness at each site.
In total, these various audits provide the basis for evaluation of the effectiveness of the various programs and reflect the effectiveness by virtue of the assessment made as a part of each audit report.
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ATTACHMENT B COMMMENTS CONCERNING VARIOUS SUBJECTS IN THE REPORT REPORT STATEMENT 7.
The licensee's program for quality control of design changes and modifications assigned to Station Construction was found to be weak.
Interviews with QC Inspectors revealed that the QC Staf f was performing its discrepancy reporting function through the contractor's QC Program and not its own.
Nonconformances identified by QC Inspectors were referred verbally to the contractor for proper documentation and corrective action.
The problems identified in the licensee's Station Construction Department were not transmitted to Station Management, thus preventing Station Management's awareness of corrective action.
Delegation of authority and responsibility for quality control to l
offsite contractors, without ensuring Station Management awareness, was considered a program weakness.
COMMENT Quality Assurance monitors the contractors' Q A Programs and Quality Control Activities through audits, daily surveillances, and Hold Points to ensure the contractor's Quality Assurance Program is properly implemented.
Copies of all audits and surveillances are sent to the Station Superintendent to ensure station awareness o f the contractor's compliance to the Quality Assurance Program.
Utilization of the contractor Quality Control is the program used at all of Commonwealth Edison Company 's construction sites.
REPORT STATEMENT Quality Control (QC) and Quality Assurance (QA) reviewed and approved each safety-related maintenance activity through the review of work requests.
The QC and Q A 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 suf ficient detail and guidance to ensure adequate independent inspection activities.
Hold points were not permanently installed in the written work procedures.
The hold points were applied (handwritten) 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 his was a judgment call by the inspector.
Insertion o f
. 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
+he work was being performed.
COMMENT q
Hold Points are fairly consistently' established by QC for welding inspections and by QC and QA for testing where a specific procedure was made for a specified job.
The application of Hold Points is intended to be on a random basis to verify all aspects of the Maintenance Program and the Hold Points are inserted into each package as determined by the QC/QA person doing the review.
QC and QA are not intended to be in-line functions in the Maintenance Program.
Reliance is put on other aspects of the program such as training and procedures to assure quality work is being done.
REPORT STATEMENT 1
4.
The Technical Staf f prepared supplement reports to nonreportable DVR's using the guidance of NUREG-0161.
The Technical Staf f 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.
1 One concern was identified with the closecut o f corrective action identified on DVR 's.
The DVR reference 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 the 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.
COMMENT r
Paragraph 3.a.(4) identified concerns for closecut of corrective action identified on the Deviation Reports (DVR).
It was noted that a DVR could be closed by and AIR or Work Request (WR), but there was no requirement to track the WR to the deviation report.
As long as the DVR can be traced to the work request, corrective action can be l
Verified.
The work requests do not necessarily reference DVR's because this number may not be known when the WR is written.
For verification of corrective action, the trail would be from the DVR to the WR and i
A work request cannot be cancelled without permission of the cognizant Operating Engineer in accordance with QP 3-52.
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, COMMENT (Cont'd)
The paragraph also indicated there was no requirement to track the closed out WR back to the DVR to ensure the action identified was actually performed.
Quality Procedure 15-52 requires the Director of QA (Operating) to review completed Deviation Reports and to initiate special action as appropriate.
The Site QA Supervisor is also required to review completed DVR's and to verify completion of selected station commitments by audit or surveillances.
Verification of DVR's such as those discussed in the report is an important part of Corrective Action audits conducted by the site and o ff-site Q A audits.
REPORT STATEMENT 2.
The licensee's Q A Program allowed for the closure of an audit finding when that item was addressed by an Action Item Report
( AIR ).
The Q4 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 Staf f 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 considered a program weakness.
COMMENT Paragraph (2) o f the inspection report noted that the QA Program permitted audit findings to be closed on the basis of an AIR being issued.
This policy has been changed and Quality Assurance auditors will no longer be permitted to close open audit deficiencies on the basis o f AIR 's.
REPORT STATEMENT 3.
The Q A 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 SRO at Dresden and also had several years of Naval Operations experience.
Howeve r,
this same person was assigned to audit the Security Program.
There was no documented evidence that this individual had suf ficient training or expertise to audit the security area.
The licensee's program 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.
. COMMENT Paragraph (3) o f the inspection report indicated there was insufficient documented evidence that the Security auditor had suf ficient training or expertise to audit security.
In the absence of regulatory or voluntary standard for training of a security auditor, the qualifications were developed within the Quality Assurance Department.
These qualification requirements included auditor training, Nuclear General Employee training, and six months experience at a nuclear station.
In addition to this, the auditor had received both formal and informal training in the Security Program and Security Equipment since 1978.
The. formal training was documented by the Dresden Training Department, and the informal training was recapitulated in a letter of April 29, 1982 from the Security Administrator.
The qualification of the auditor and his performance in a given area continues to receive scrutiny from Quality Assurance Management a f ter his qualification.
All audit checklists are approved by the Director o f QA-Operating or the QA Supervisor-Maintenance.
Complete d audit reports in Security receive approval at this level before issue.
The results of site audits are compared to the results of NRC security, not only at Dresden, but at all stations in the Commonwealth Edison System.
These other audit reports reveal a consistent picture of the security program and the adequacy of the security audit program at Dresden, and leave absolutely no doubt as to the acceptability of his qualification to audit the Nuclear Security Area.
REPORT STATEMENT 5.
review of QA audits on training revealed that the audit did not address the ef fectiveness of the Training Program as required.
Subsequent to this finding, the licensee required auditors to document program effectiveness 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 i
expected to perform an independent and objective audit.
COMMENT l
This paragraph discussed the possibility of Quality Assurance i
determining the effectiveness of the training program while a student in the class.
This will not be done.
The Quality Assurance Department concurs that this is not an acceptable method to measure Training Program effectiveness.
i Quality Assurance Department members have provided feedback to the Training Department in the past and will continue to do so in the future, but it will be on an informal basis and not in the form of an audit report for a student in the QA Department.
i
. REPORT STATEMENT 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 Q A training.
During interviews with the Training Supervisor and the instructor responsible for determining who in management received Q A 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 individual who would assume the Station Superintendent's responsibilities in his absence may not have received training when those areas of responsibility were changed.
This was considered a program weakness.
COMMENT This paragraph described weaknesses in the QA training matrix.
The Production Training Department will issue a generic matrix for all stations in the near future to ensure appropriate training for personnel who assume responsibilities for higher positions.
l REPORT STATEMENT The Q A 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.
Ho we v e r, 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 findings 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.
COMMENT The paragraph discussed the absence of a formal requirement to trend Q A audit findings.
A Quality Assurance Memo is being developed requiring an annual trending of audit findings for the previous 12 months.
This memo will be issued by July 31, 1982.
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