ML20058L329
| ML20058L329 | |
| Person / Time | |
|---|---|
| Site: | Big Rock Point File:Consumers Energy icon.png |
| Issue date: | 12/08/1993 |
| From: | Donnelly P CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.) |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9312160267 | |
| Download: ML20058L329 (14) | |
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Consumers Patrick M Donnetty Plant Afanager MICHIGAN'S PROGRESS Big Rock Poent Nuclear Plant.10269 US 31 Nonh, Charlevom. M' 49720 December 8, 1993 Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 DOCKET 50-155 - LICENSE DPR BIG P.0CK POINT PLANT -
REPLY TO NOTICE OF VIOLATION AND PROPOSED INPOSITION OF CIVIL PENALTY -
INSPECTION REPORT 93015 NRC Inspection Report 93015 dated November 9, 1993, refers to the special inspection (by letter dated October 5, 1993) conducted August 24 through September 14, 1993, at the Big Rock Point facility. The special inspection reviewed circumstances surrounding two recent events that occurred during the recent refueling outage, and identifies several related violations. The first event was reported by Licensee Event Report (LER)93-002; Loss of Containment l
Integrity Via Feedwater System Piping. The facility was in a refueling outage and in cold shutdown at the time a minor breach occurred in the feedwater system piping following the performance of a routine local leak rate test. The facility exited the cold shutdown condition per Technical Specification definition by operating the mode selector switch from the shutdown position to the refuel position several times to accomodate additional surveillance testing. Leaving cold shutdown with the containment breached was a violation of the facilities Technical Specifications. The second event involved the inadvertent pressurization of the Primary Coolant System beyond the procedural limit in a hydrostatic test, thus lifting a steam drum safety relief valve.
On October 12, 1993, an enforcement conference was conducted in the Region III office with representative members of the NRC and Consumers Power Company to I
discuss the apparent violations, their causes, and the proposed corrective actions. The enforcement conference summary sent by letter dated October 15, 1993, was received October 19, 1993.
Pursuant to NRC Inspection Report 93015, find attached the Reply to a Notice of Violation, submitted under oath per Section 182 of the Act, 42 U.S.C. 2232.
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l BIG ROCK POINT PLANT REPLY TO CIVIL PENALTY December 8, 1993 The Corrective Actions Taken to Prevent Recurrence, although segregated by Violation in the Reply, are interrelated and should not be interpreted as
" stand alone". Taken in the aggregate, the corrective actions taken should limit any further violations of this sort.
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.d Patrick H Donnelly Plant Manager CC: Administrator, Region III, USNRC NRC Resident Inspector - Big Rock Point ATTACHMENT
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CONSUMERS POWER COMPANY
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To the best of my knowledge, information and belief, the contents of this submittal are truthful and complete.
i By o >O WYV David P Hoffman, Vice Rresident j
s Nuclear Operations l
Sworn and subscribed to before me this 8th day of December 1993.
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44 e s LeAnn Horse, Notary Public Berrien County, Michigan (Acting in Van Buren County)
My commission expires February 4, 1997.
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ATTACHMENT CONSUMERS POWER COMPANY BIG ROCK POINT PLANT DOCKET 50-155 i
REPLY TO NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY INSPECTION REPORT 93015 Dated December 8, 1993 i
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NOTICE OF VIOLATION AND PROPOSED INPOSITION OF CIVfL PENALTY -
1 INSPECTION REPORT 93015
- 1. VIOLATION A.
10 CFR Part 50, Appendix B, Criterion V, requires, in part, that activities affecting quality be prescribed in documented instructions, procedures, or drawings of a type appropriate to the circumstances, and be accomplished in accordance with these instructions, procedures, or drawings.
Technical Specification 3.6 requires, in part, that containment sphere integrity shall be maintained during shutdown, refueling, and cold shutdown, except as specified by a system of procedures or controls to be established for occasions containment must be breached during cold shutdown.
Surveillance Procedure TR-96/T7-29, " Control Rod Withdrawal Interlocks Test,"
Revision 7, Step 3.0.a. requires as a prerequisite to initiating the surveillance that plant conditions be such that the mode switch may be placed in REFUEL or RUN.
Surveillance Procedure TV-10. " Pressure Test of Nuclear Steam Supply System,"
Revision 46, Step 2.2.3.b requires in part that when flange and wall temperatures are above 130*F, hydrostatic test pressure shall not exceed 1535 psig.
1.
Contrary to the above, draining of the feedwater line, an activity affecting quality, was performed on Juna 27, 1993 using Switching and Tagging Order 93-0375. This order was an instruction not appropriate to the circumstances, in that it caused containment sphere integrity to be inadvertently breached when i
the plant was in cold shutdown, and established no controls for such a breach.
REASON FOR THE VIOLATION Consumers Power Company agrees with the violation as stated. The root cause of this event has been attributed to a less than adequate review of the switching and i
tagging order. The tagging order was written by a Control Operator and reviewed by l
at least two other licensed individuals, one being a shift supervisor who approved the order. It appears that containment integrity was never appropriately addressed.
CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED Upon discovery, VFW - 185, a one inch drain valve, was closed and caution tagged at 1850 on June 29, 1993. This action immediately restored containment integrity.
ACTIONS TAKEN TO PREVENT RECURRENCE i
containment Control
- 1. Warning labels (physical marking / visual aid) will be placed on the valves, which, if opened, could result in a direct breach of containment integrity.
- 2. Caution statements with regard to the potential for breaching containment integrity will be added to the applicable operating procedures.
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e NOTICE OF VIOLATION AND PROPOSED INPOSITION OF CIVIL PENALTY -
2 INSPECTION REPORT 93015 NOTE: ACTIONS 1. AND 2. HAVE ALREADY BEEN DISCUSSED IN LER 93-002, LOSS OF CONTAINNENT INTEGRITY VIA FEEDWATER SYSTEM PIPING. DURING THE ENFORCEMENT CONFERENCE. THE BIG ROCK POINT STAFF ADDED THE FOLLOWING ACTIONS:
- 3. Develop administrative controls to enhance operator awareness of containment integrity control issues.
- 4. Revise TR - 391, Feedwater Check Valve Leak Rate Test Attachment 1; Test Setup.
The drawing needs to be updated to include the symbol for the containment boundary. All other applicable drawings used in procedures will be reviewed to assure that containment boundaries are included where appropriate.
Mode switch control
- 5. Davelop administrative controls to enhance operator performance with regards to mode switch operation.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED The facility terminated the containment breach on June 29, 1993 at 1850 hours0.0214 days <br />0.514 hours <br />0.00306 weeks <br />7.03925e-4 months <br />.
Therefore, the facility has achieved full compliance. The additional corrective actions are expected to be completed before the 1994 Refueling Outage.
VIOLATION A.
2.
Contrary to the above, as of September 14, 1993, the licensee's surveillance for containment isolation, an activity affecting quality, was prescribed by Procedure 0-TGS-1, checklist A-9, Revision 24. This procedure was not appropriate to the circumstances, in that it failed to identify valve VFW-185 as a containment isolation valve required to be closed or capped to effect containment integrity.
REASON FOR THE VIOLATION As stated, Violation A2 suggests that 0-TGS-1, Checklist A-9, Containment Isolation Surveillance - Revision 24, was required to perform the feedwater check valve leak rate test; and since VFW-185 was omitted from the checklist, the containment breach occurred. 0-TGS-1, Master Checklist, clearly states that Checklist A-9 is referenced in the initial conditions of the TR-46, Fuel Bundle Core Loading Procedure. The completion of this checklist is therefore required prior to the reactor being refueled, and would not be required to be referenced to perfotm some other test, such as the feedwater check valve leak rate test.
As noted in the violation, the containment breach occurred June 29, 1993. TR-46, Fuel Bundle Core Loading Procedure, was completed August 10, 1993, and Checklist A-9 was completed August 4, 1993.
The Potential Violation described in the Enforcement Conference summary dated October 15, 1993, better describes the noncompliance.
W NOTICE OF VIOLATION AND PROPOSED INPOSITION OF CIVIL PENALTY -
3 INSPECTION REPORT 93015
" Criterion V: Inadequate containment isolation procedure - fails to identify the inboard feedwater line drain valve as a valve required to be closed for containment isolation".
Consumers Power Company does not deny the fact that Checklist A-9 is inadequate.
However, this inadequacy did not contribute to the containment integrity breach.
The checklist indeed failed to identify the inboard feedwater line drain valve as a valve required to be closed for containment isolation. The reason that this omission was probably never discovered is because of the fact that the component is a drain valve. If the valve had inadvertently been left open, feedwater would have escaped through the one-inch line, alerting the operating staff to its position. The position of the valve is self-disclosing during most operating conditions of the facility.
CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED Upon discovery, VFW - 185, a one inch drain valve, was closed and caution tagged at 1850 on June 29, 1993. This action immediately restored containment integrity.
ACTIONS TAKEN TO PREVENT RECURRENCE
- 1. VFW - 185 will be added to 0-TGS-1, A-9; Containment Isolation Surveillance.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED The facility terminated the containment breach on June 29, 1993 at 1850 hours0.0214 days <br />0.514 hours <br />0.00306 weeks <br />7.03925e-4 months <br />.
Therefore, the facility has achieved full compliance. The additional corrective actions are expected to be completed prior to the 1994 refueling outage.
VIOLATION A.
3.
Contrary to the above, on June 29, 1993, the control rod withdrawal interlocks test, an activity affecting quality, was not accomplished in accordance with Procedure TR-96/T7-29, in that the surveillance was initiated and performed with containment integrity breached, a plant condition that did not permit the mode switch to be placed in REFUEL.
REASON FOR THE VIOLATION Consumers Power Company agrees with the violation as stated. The prerequisites section of the control rod withdrawal interlocks test contains a shift supervisor signoff that. states " plant conditions are such that mode switch'may be placed in REFUEL or RUN". This statement is ambiguous and does not alert the shift supervisor to the fact that containment integrity is the primary plant condition that is being eluded to. This statement and the unknown containment integrity condition contributed to the mode switch being manipulated when certainly the plant conditions did not allow the repositioning of the switch.
1 NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY -
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INSPECTION REPORT 93015 CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED Upon discovery, VFW - 185, a one inch drain valve, was closed and caution tagged at 1850 on June 29, 1993. This action immediately restored containment integrity.
ACTIONS TAKEN TO PREVENT RECURRENCE Mode switch control (See Violation A1)
- 5. Develop administrative controls to enhance operator performance with regards to mode switch operation.
The following action is supplemental, and is not discussed in the LER:
TR-96/T7-29; Control Rod Withdrawal Interlocks fest, will be revised to ensure that the shift supervisor signoff addresses containment integrity as the principle plait condition that needs to be reviewed prior to manipulation of the mode switch to REFUEL or RUN.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED The facility terminated the containment breach on June 29, 1993 at 1850 hours0.0214 days <br />0.514 hours <br />0.00306 weeks <br />7.03925e-4 months <br />.
Therefore, the facility has acnieved full compliance. The additional corrective actions are expected to be completed prior to the 1994 refueling outage.
VIOLATION A.
4.
Contrary to the above, at 1:00 AM on August 24, 1993, the hydrostatic test of the primary coolant system, an activity affecting quality, was not accomplished in accordance with Procedure TV-10 in that, with the flange and wall temperature approximately 249'F throughout the test, the hydrostatic test pressure was permitted to reach 1570 psig.
REASON FOR THE VIOLATION Consumers Power Company agrees with the violation as stated. Human error has been identified as one of the root causes of this event. Instructions were inadequate.
A lack of good judgement was demonstrated by allowing the operator to leave the hydro pump. A lack of adequate planning and ensuring that the appropriate number of personnel were available to perform the inspections are also cited. In addition, less than adequate communications also contributed to the cause of the event. The volume adjustments of several public address speakers were found
" turned down" in the upper accumulator room; and no communication requirements (use of radios) had been established between the hydro pump operator and the control room.
Discussion Prior to assuming duties, the on-coming shift supervisor (SS) held a turnover with the offgoing shift. The hydro pump had been running for 3-1/2 hours with no adjustments required to the pump.
Prior to reaching hydro pressure, it was necessary to close CV-4047 (cleanup drain to radwaste) at the cleanup panel due to
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NOTICE OF VIOLATION AND PROF 0 SED IMPOSITION OF CIVIL PENALTY -
5 INSPETION REPORT 93015 i
leakage past CV-4040 and CV-4114 (cleanup high and low pressure blowdown valves).
j Hydro pressure could not be reached with CV-4047 open due to the leakage past CV-4040 and CV-4114 and relief valves downstream opening to relieve pressure.
Blowdown capability was still available but would require'a valve manipulation at the cleanup panel and in the control room.
A Total Activity Planning (TAP) meeting was held in the control room addressing the Hydro Procedure, TV-10. Duties and responsibilities were assigned at this time. Since the only personnel qualified to perform the VT-2 exams were the on-i coming and off-going SSs, the off-going SS remained to assist in performing the exams. Additional qualified personnel had been asked to stay over to help, but the overtime was refused. The outside auxiliary operator (AO) was assigned to inspect the pipe tunnel as required in TV-10. The inside A0 was assigned to be the door watch for the required high radiation area entries.
Based on the hydro pump operating properly for 3-1/2 hours with no adjustments required to the pump, a decision was made to allow the hydro pump operator to i
leave the pump to inspect for leakage in the upper and lower accumulator rooms.
The Control Room operators were directed to watch pressure and inform the pump operator if any adjustments were necessary.
Both SS's and the hydro pump operator had radios to communicate with the control room. At approximately 0030 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br /> the inspections began. One SS was performing inspections on the Emergency Condenser level and the second SS made an entry into the Control Rod Drive room. No adjustments were made during these entries. The hydro pump operator inspected the pump for r.ormal operation and then left the pump to inspect the Upper Accumulator Room for leaks. Minor leakage was found and t
corrected. Two VCRD-110 valves (control rod drive insert side vents) were leaking a few drops a second and the operator tightened these valves and reduced the leakage to less than one drop every five seconds.
Following the inspection of the j
room, the hydro pump operator returned to the hydro pump to check the pump. There were no indications of any off-normal conditions.
At approximately 0050 hours5.787037e-4 days <br />0.0139 hours <br />8.267196e-5 weeks <br />1.9025e-5 months <br />, the hydro pump operator left the pump and started to dress out in the upper accumulator room into anti-contamination clothing required i
to enter the lower accumulator room. A short time later a noise that mimicked relief valve chatter started. This noise was quite loud and sounded as if it were coming from the lower accumulator room. The pump operator noticed the pressure indicated on the control rod drive header had changed from 1500 psig indicated earlier to cycling between 1450 and 1500 psig. The pump operator returned to the pump and found that conditions had not changed. The pressure appeared unchanged or perhaps a little lower.
(The wide range and small diameter of the gauge coupled with the vibration of the hydro pump made a precise reading impossible).
At this time the pump operator returned to the upper accumulator room and finished dressing out to enter the lower accumulator room to investigate the noise and i
check for leaks. The SS that was inspecting the emergency condenser level came to the upper accumulator room and was informed that the pressure appeared to be dropping and that it sounded like a relief valve may have lifted. The control rod drive header pressure gauge was checked and pressure was fluctuating between 1450 and 1500 psig. The second SS and the inside A0 exited the control rod drive room area and also heard the noise, and entered the upper accumulator room.
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY -
6 INSPECTION REPORT 93015 At approximately 0100 hours0.00116 days <br />0.0278 hours <br />1.653439e-4 weeks <br />3.805e-5 months <br /> the control room operators observed the primary system pressure increasing roughly 1 psig every 3 seconds. After observing the pressure increase for a few moments, the control room operators attempted radio contact with the pump operator.
The pump operator had left his radio at the hydro pump. The SS's had their radios bagged in preparation for contamination entries so they did not have radios in hand at this time. The control room operators attempted to contact the pump operator via the plant paging system. No communication was returned. They then paged the SS's three times to try to relay the pressure transient information.
Neither SS heard the pages due to the loud noises in the upper accumulator room.
(It was discovered later that the volume control for the speaker in the upper accumulator room had been turned down and pages were garbled).
During the paging and after pressure had exceeded 1525 psig, the control operators attempted cleanup blowdown to lower pressure. This idea was abandoned when they remembered CV-4047 was closed; automatic control of the blowdown path was not possible from the control room. As the pump operator was descending the stairs to the lower accumulator room, he heard the paging system and what sounded like a number three. He immediately called the control room from the lower accumulator room and was informed that the pressure was increasing. He shouted up to the upper accumulator room that the pressure was increasing not decreasing as originally thought.
When the shift supervisor heard this, he immediately left for the hydro pump and attempted to reduce pressure by making an adjustment to the flow regulator. After the adjustment was made, the shift supervisor radioed the control room inquiring what the pressure indicated. The control room apprised him that pressure indicated 1568 psig and was still increasing. The shift supervisor then heard a steam drum safety relief valve lift (there are six) and was informed by the control room that alarms indicated that RV-5000 indicated first engaged and had lifted; and RV-5045 and RV-5046 low alarms (loss of input signal or faulty bias setting) were in.
Primary system pressure had decreased to approximately 1370 psig and the relief valve, RV-5000, reseated.
CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED The pump operator inspected the lower accumulator room and could find no cause for the noise that had previously sounded like relief valve chatter (not related to steam drum relief valves). The hydro pump was adjusted again and pressure was slowly increased to approximately 1490 psig. The pump eperator was then assigned to stay at the pump until the hydro was completed.
ACTIONS TAKEN TO PREVENT RECURRENCE 1.
TV 10; Pressure Test of the Nuclear Steam Supply System, will be revised.
Revisions are to include the positioning of an operator at the hydro pump at all times with communication available to the control room; communicate leakage corrections between the control room and hydro pump operators; address the use of a formal meeting to discuss procedure before use; and investigate if leakage inspections can be made earlier in the test to facilitate the procedure.
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY -
7 INSPECTION REPORT 93015 2.
Inspect the public address speakers at a regular interval to ensure that speakers are unobstructed and have adequate volume for the area the speaker services.
3.
Investigate the installation of a pressure control system on the hydro pump.
4.
Repair / Replace leaking blowdown valves, CV-4040 and CV-4114 in accordance with the Integrated Plan.
5.
Investigate moving the hydro pump to a different location to enhance command and control during the TV-10 test evolution.
6.
Review other Operations Department procedures to address if added precautions i
(i.e. communications, automatic versus manual control, system operation near safety setpoints, IPTE required), should be added based on this event.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED This event was terminated on August 24, 1993. Therefore, the facility is in full compliance. The remaining actions to avoid furthe violations will be completed by November 1, 1994.
VIOLATION B.
10 CFR Part 50, Appendix B, Criterion XVI, requires, in part, that the cause of a significant condition adverse to quality be promptly identified and corrective action taken to preclude repetition.
Contrary to the above, the licensee failed to take corrective actions to preclude repetition of a significant condition adverse to quality, in that,'after a January 10, 1992 failure caused by a shift supervisor release of work procedures without determining the resultant effect on plant conditions, and a Nay 6,1992 loss of DC power caused by implementing an inadequate switching and tagging order (together resulting in a July 22, 1992 NRC Notice of Violation), the licensee's corrective-actions failed to prevent a similar failure. Specifically, an inadequate switching and tagging order was implemented on June 27, 1993 without determining 4
the resultant effect on plant conditions.
REASON FOR THE VIOLATION Consumers Power Company agrees with the violation as stated. The corrective actions taken to prevent recurrence proved to be iraffective as they were narrow in scope. In addition, on November 2, 1993 0 0734, another example of an inadequate switching and tagging order led to the inadvertent removal of the backup core spray system from service for roughly 12 minutes before the error was identified.
CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED A Licensee Event Report has been submitted with regards to this event. Additional corrective action identified within this LER is presented below.
NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY -
8 INSPECTION 2EPORT 93015 i
ACTIONS TAKEN TO PREVENT RECURRENCE i
MANAGEMENT DIRECTION 1.
Review the Infrequently Performed Tests and Evolutions (IPTE) procedure engaging Engineering and Nuclear Performance Assessment Department personnel.
Review generic guidance in the procedure and identify where specific evolutions require mandatory implementation of the IPTE.
2.
Implement the employee self-checking and feedback (a.k.a. the STARR program):
for all other plant departments.
3.
Plant Exoectations a.
Stress requirement to personnel that one individual will be specified as the "in-charge" person and will have the primary responsibility for control of the evolution.
b.
Stress direct communication with the control room during the performance of tests 4.
Management will commit to supporting backshifts during abnormal evolutions such as refueling outages, reactivity events, IPTE's, for example.
THE FOLLOWING ACTIONS TO PREVENT RECURRENCE HAVE BEEN DOCUMENTED IN LER 93-011; IE@VERTENT REMOVAL OF A REDUNDANT CORE SPRAY VALVE AT POWER OPERATION.
I.
Develop a planning and scheduling process that will limit verbal communication with regards to tagging requests; not honor tagging requests near the end of a shift; assure Operations is allowed ample time to to i
process a tagging order in adherance with the plant tagging procedure; achieve a better interface between the Operations and Maintenance shift starting schedule; and ensure enough Operations personnel are available to support outages and other high tagging periods.
II.
Review the existing management expectations when using I&C or Engineering for tagging information.
Issue a policy statement or procedure enhancement to define expectations.
III. Instruct the Training Department to evaluate the tagging training effectiveness based on a review of this event and make appropriate enhancements.
DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED The facility is currently in full compliance. The actions taken to prevent recurrence will be completed by July 1,1994.
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9 INSPECTION REPORT 93015 1
VIOLATION C.
10 CFR Part 50, Appendix B, Criterion II, requires, in part, that training and indoctrination shall be provided as necessary to personnel performing activities t
affecting quality to assure that suitable proficiency is achieved and maintained.
Contrary to the above, on August 13, 1993, due to insufficient training and indoctrination, suitable proficiency had not been maintained by personnel performing the hydrostatic test of the primary coolant system, an activity 3
affecting quality, in that they were not aware of the rapid effects of running hydrostatic test pump en solid plant pressure.
In addition, the auxiliary operator assigned to the pump was not proficient in the ability to establish a blowdown pathway, if necessary, to reduce pressure.
REASON EOR THE VIOLATION Consumers Power Company agrees with the violation as stated. A lack of emphasis of training on solid plant operations contrib"ted to the event.
CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED The same discussion for violation A4. applies.
l ACTIONS TAKEN TO PREVENT RECURRENCE The same discussion for violation A4. applies; In addition, training will be conducted with regards to the rapid effects of running a hydrostatic test pump on solid plant pressure.
DATE WHEN full COMPLIANCE WILL BE ACHIEVED The facility is mtly in full compliance. The actions taken to prevent recurrence will t
'eted by July 1, 1994.
II. ADDITIONAL CORRECTIVE ACTIONS TO BE TAKEN WITH REGARDS TO THE ENFORCEMENT CONFERENCE 1.
Communications will be improved betwaen Palisades and Big Rock Point. Human Performance Evaluation System (HPES) efforts will be " linked" between the Consumers Power facilities. The Nuclear Performance Assessme.nt Department will be included in this program.
2.
To improve root cause evaluations; a.
INPG + raining in the area of HPES expertise was conducted November 10, 11, and 12, 1993.
i b.
Guidance will be developed as to when to use the HPES.
NOTICE OF VIOLATION AND PROPOSED INPOSITION OF CIVIL PENALTY -
10 INSPECTION REPORT 93015 c.
The Corrective Action System will be improved. Developing guidance in the selection of evaluators will be done to increase objectivity and independence.
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