ML20059C908

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Intervenor Exhibit I-MFP-110,consisting of 920519, DCO-91-MM-NO42, FMEA Controls,
ML20059C908
Person / Time
Site: Diablo Canyon  Pacific Gas & Electric icon.png
Issue date: 08/21/1993
From:
AFFILIATION NOT ASSIGNED
To:
References
OLA-2-I-MFP-110, NUDOCS 9401060202
Download: ML20059C908 (20)
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Text

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                               " MANAGEMENT

SUMMARY

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There have been a number of violations of foreign mat: rial exclusion area (FMEA) boundaries, both non-outage and outage related. This NCR has been initiated because of a violation of a FMEA at the Unit 1 reactor vessel head during 1R4 that could have resulted in foreign material entering the reactor oolant system. The scope of this NCR will not be limitea to that single event but will address the overall FMEA program. NUCLEAR REGULATCRY CCVWSSION c sru Sc ngf3_C,L* cis es ra ? ?ff-ll0 e fk'Ec l btSnxfSECIAMb 

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9a w sow w x2.;cw Page 1 of 22 9401060202 930821 PDR ADOCK 05000275 C PDR 

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c 4 4 DC0-91-MM-N042 May 19. 1992 

                                               }3I[3i UIEit.22 I.       Plant Conditions The described problem concerns discrepancies identified for both Units 1 and 2 during 2R3 and 1R4 (Refueling).                          ,

II. Description of Event A. Event: (As described in Action Request A0223568) 

 ;                                  During installation of the CETNAS (Conoseals) on the Unit 1 reactor head it was discovered that the Foreign Material Exclusion Area (FMEA) covers over the inctrument ports #74 and 75 were removed. The                        :

instaliation of the CETNAS occurred on dayshift on 3/13/91 per Work Order (WO) R0065178 Activity A08. The night before (3/12/91) on swingshift Instrumentation and Controls (I&C) performed work on instrument port #74 per WO C0082353 and #75 (WO unknown). Work package C0082353 did not have any steps to install / remove FMEA covers (it is believed that the unknown WO for #75 did not have 1 steps for FMEA covers either {may be C0083382}}. When the loss of FMEA was discovered work was stopped and the Outage Control Center (OCC) , Quality Control-(QC) was notified. The general cleanliness of the area around the CETNA ports was clean as reported by the QC inspector. Based on this evaluation and the fact that the FMEA was breached for a short period of time (approximately 12 hours) work was allowed to continue. In addition the openings were covered with lead blankets which provided protection from_ entry of , foreign objects. Due to the concerns regarding FMEA controls, the level of personnel awareness of FMEA requirements and management direction to investigate and recommend corrective actions the TRG has assigned investigative actions to provide basis for the TRG . to consider. (See investigative actions Section V.A.)

B. Inoperable Structures, Components, or Systems that Contributed to the Event

91wt e x91 mwo42.scu Page 2 of 22 4 i

i. DCO-91-MM-N042 May 19, 1992 None. C. Dates and Approximate Times for Major Occurrences: , 1. On March 12, 1991: FMEA covers removed without WO.

2. On March 13, 1991: Discovery date and work stopped.

D. Other Systems or Secondary Functions Affected:  ; None.  ; E. Method of Discovery: There have been a number of occurrences of FMEA violations detected by DCPP personnel, as noted in paragraph A., above, and reference 1. F. Operators Actions:  ; None required. G. Safety System Responses: j None required. , III. Cause of the Event A. Immediate Cause: l FMEA requirements were not specifically met for all work activities reviewed (See References, Section VI.G.3). . I B. Root Cause: Management failure to implement the FMEA program i as described in applicable administrative procedures. C. Contributory Cause:

1. There is a " lack of ownership" on specific
  • jobs for FMEA, especially when multiple disciplines work the job. There is also an overall " lack of ownership" for the program.

, i 91NCRWP\91MMN0Q.JCh Page 3 of 22 i

t DC0-91-MM-N042 May 19, 1992 i

2. There is inconsistent interpretation and implementation of FMEA requirements.
3. The FMEA procedure (C-10S4, " Foreign Materials Exclusion Program") is not " user- l friendly".
4. There is insufficient management emphasis on implementation of the FMEA program.

Management expectations are not effectively communicated.

5. There is insufficient FMEA boundary identification.

IV. Analysis of the Event A. Safety Analysis: The presence of a loose part in the primary  ! coolant system can be indicative of degraded reactor safety resulting from failure or weakening , of a safety-related component. A loose part, I whether it is from a failed or weakened component or from an item inadvertently left in the primary , system during refueling or maintenance activities can contribute to component damage and material wear by frequent impacting with other parts in the system. A loose part can pose a serious threat of partial flow blockage with attendant departure , from nucleate boiling (DNB) which in turn could result in failure of fuel cladding. In addition, , a loose part i n ceases the potential for control-rod jamming and for accumulation of increased levels of radioactive crud in the primary system. The safety analysis for any foreign material that , may be known to be unaccounted for and therefore , may be within the reactor coolant system (RCS) has been evaluated by PG&E and Westinghouse as documented in NCR DC1-91-TN-N017 (Westinghouse  : reference SECL-91-012). This NCR does not l l increase the assumed quantity of material that may  ; be within the RCS. ' 

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B. Reportability:

1. The described condition has been identified as a nonconforming plant condition under QAP-1 9wt w s91 m o42.acu Page 4 of 22

t e DCO-91-MM-N042 May 19, 1992 , i 15.B Section 2.1.8. by senior plant management direction.

2. The described condition has been reviewed in accordance with NUREG-1022 and determined not to be reportable.
3. Reviewed in accordance with NUREG 0302 and determined not to be reportable under 10 CFR 21.
4. Reviewed and determined not to be reportable j under 10 CFR 50.9 as the problem described does not involve a significant implication for public health and safety or common  ;

defense and security.

5. The described problem does not require an INPO Network entry.

V. Corrective Actions A. Investigative Actions: The immediate corrective actions for all items considered by the TRG are described in the associated AR/QE for each event. The foll: wing are investigative actions assigned by the TRG:

1. Perform interviews with personnel involved with FMEA activities both on a routine basis and during outage work. Provide a summary of the interview results that identify problem areas, problem activities and successful practices.

RESPONSIBILITY: R. Etzler (PGMC) Complete Tracking AR: A0226666, AE # 01

2. Review all AR's and QE's and last NCR's regarding FMEA. Characterize the nature of the problems into common groupings. Prepare a summary of the findings for consideration by the TRG.

RESP: McVicker/Seward (PQCI) Complete Tracking AR: A0226666, AE # 02

3. Review all reactor cavity (RXC) associated 91NCRWP\91MMW042.JCN Page 5 of 22

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1 DC0-Cl-MM-N042 May 19, 1992 FMEA ARs from item 2, determine root cause j and propose corrective actions to prevent l recurrence.

RESPONSIBILITY D. Lampert (MGMT) Complete Tracking AR: A0226666, AE # 03

4. Review all Spent Fuel Pool (SFP) associated  !

FMEA ARs from item 2, determine root cause and propose corrective actions to prevent I recurrence. RESPONSIBILITY: W. Ginter (PTEN) Complete Tracking AR: A0226666, AE # 04 S. "eview all "other" (valves and Diesel Generator) associated FMEA ARs from item 2, determine root cause and propose corrective actions to prevent recurrence. RESPONSIBILITY: T. Smith (MM) Complete Tracking AR: A0226666, AE # 05

6. Review all steam generator (S/G) associated FMEA ARs from item 2, determine root cause and propose corrective actions to prevent recurrence. t RESPONSIBILITY: 'Russ Gray (RP) Complete Tracking AR: A0226666, AE # 06
7. Quality Control will review the guidance given in the INPO Good Practice regarding FMEA controls and contact other plants to identify actions others have taken regarding '

FMEA control. QA will provide a summary of these findings at the next TRG. RESPONSIBILITY: R. McVicker (QC) Complete Tracking AR: A0226666, AE # 07

8. Review present training (GET and individual) and make recommendation. To be assisted by K. Palmer, R. McVicker/L. Opperman, D.

Haskins, W. White, J. Strahl, C. Seward, and T. Emith. RESPONSIBILITY: D. Clifton (PATT) Complete , Tracking AR: A0226666, AE # 08 , 91wcws91m042.xw Page 6 of 22

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l J DCO-91-MM-N042 May 19, 1992

9. Review accountability practices for FMEA and advise TRG.

RESPONSIBILITY: M. Burgess (PTET) Complete I Tracking AR: A0226666, AE # 09 J

10. Review and recommend corrective action (s) to  :

prevent recurrence of high risk (Anchor Darling check valve) FMEA issues (valves and  ; others). RESPONSIBILITY: K. Palmer (PGMA) Complete Tracking AR: A0226666, AE # 10 >

11. Discuss with senior plant management the TRG's recommendation that a full-time group be formed with responsibility and authority i

for monitoring FMEA. RESPONSIBILITY: T. Bennett (POUT) Return  : Tracking AR: A0226666, AE # 22

12. FMEA Coordinator to review SFP access logs and coordinate with Security to determine actions that will limit access to the SFP FMEA during nonoutage periods.

RESP: J. MacIntyre (PGMT) Return Tracking AR: A0226666, AE # 24 B. Corrective Actions to Prevent Recurrence: ,

1. Initiate a refueling outage plan and a non-outage plan for FMEA control for the spent fuel pool area. Plan outline is due by 05/10/91.

RESPONSIBILITY: T. Chitwood (PGOF) Complete  : Tracking AR: A0226666, AE # 11 Outage Related? NOUT JCO Related? No NRC Commitment? No , CMD Commitment? Yes ,

2. Initiate a refueling outage plan for FMEA  ;

control of the refueling cavity area. Plan  ! outline due by 05/10/91. This plan will be a Temporary Procedure (TP) as an attachment to AP C-1054, " Foreign Materials Exclusion Area 91NCRWP\91MMW042.JCN Page 7 of 22 i

r DC0-91-MM-N042 May 19, 1992 Controls." Mechanical Maintenance will sponsor the TP. RESPONSIBILITY: L. Neal (PGMA) Complete Tracking AR: A0226666, AE # 12 Outage Related? NOUT JCO Related? No NRC Commitment? No , CMD Commitment? Yes  !

3. A TP has been drafted for Operations FMEA.

Comments will be provided by that Department by the next TRG meeting. RESPONSIBILITY: J. Chitvood Complete Outage Related? NOUT JCO Related? No NRC Commitment? No  ; CMD Commitment? No {

4. A Temporary Procedure has been drafted for Maintenance FMEA. Comments will be provided by that Department by the next TRG meeting.

RESPONSIBILITY: C. Seward (PGMC) Complete Outage Related? NOUT  : JCO Related? No NRC Commitment? No CMD Commitment? No

5. A list of FMEA monitors will be provided to QC for training. ,

RESPONSIBILITY: R. Willis (PGMC) Complete Tracking AR: A0226666, AE # 13 Outage Related? NOUT JCO Related? No NRC Commitment? No CMD Commitment? No -

6. Provide maintenance contractor personnel FMEA training prior to 2R4 start.

RESPONSIBILITY: D. Clifton (PATT) Complete Tracking AR: A0226666, AE # 14 Outage Related? 2R4 JCO Related? No NRC Commitment? No CMD Commitment? No 91NCRWP\91MMN042.JCN Page 8 of 22 

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DCO-91-MM-N042 May 19, 1992

7. Draft a letter from J. Townsend to all personnel who may access a FMEA emphasizing the importance of eliminating uncontrolled debris, parts and tools in-FMEAs.

J RESPONSIBILITY: R. Etzler (POUT) Complete Tracking AR: A0226666, AE # 15 Outage Related? NOUT JCO Related? No NRC Commitment? No CMD Commitment? No

8. Pavise FMEA boundaries on each Unit to be consistent whether during an outage or between outages. Develop an inventory of authorized equipment, parts and tools to be controlled within each FMEA.

RESP: A. Chitwood (PGOF) Complete , Tracking AR: A0226666, AE # 16 Outage Related? NOUT JCO Related? No NRC Commitment? No - CMD Commitment? No

9. Make a stock of the fluorescent orange FMEA boundary signs available for use and revise C-10S4 to provide specific directions in the ,

use and placement of the signs. RESPONSIBILITY: R. Etzler (POUT) Complete Tracking AR: A0226666, AE # 17 Outage Related? NOUT JCO Related? No NRC Commitment? No CMD Commitment? No

10. Incorporate lessons learned from 2R4 into AP C-10S4.

RESP: J. MacIntyre (PQCI) ECD: 6/15/92 , Tracking AR: A0226666, AE # 18 Outage Related? NOUT JCO Related? No NRC Commitment? No CMD Commitment? No

11. Reconcile the inventory of the spent fuel pool FMEA area and the short and long term 91NCRWP\9D M 042.JCN Page 9 of 22

DC0-91-MM-N042 May 19, 1992 , logs. RESPONSIBILITY: A. Chitwood (PCOF) Return Tracking AR: A0226666, AE # 19 Outage Related? NOUT JCO Related? No NRC Commitment? No CMD Commitment? No ,

12. QC to provide independent verification for FMEA work performed on an off-normal basis.

That is, all expedited work not performed during normal Friday day shift plant-wide access. RESPONSIBILITY: J. MacIntyre (PQCI) Return Tracking AR: A0226666, AE # 20 Outage Related? NOUT l JCO Related? No ! NRC Commitment? No CMD Commitment? No

13. Operations to issue Shift Order and an Email
  • memorandum describing the new policy for i accessing the SFP FMEA for work. Normal access will be Friday day shift with the responsible work group providing a foreign materials monitor. Off normal access will be at any other time with authorization from the Shift Foreman and with QC independent verification.

RESPONSIBILITY: A. Chitwood (PGOF) Return Tracking AR: A0226666, AE # 21 Outage Related? NOUT JCO Related? No , NRC Commitment? No 1 CMD Commitment? No I i

14. The procedure used for control of the SFP FMEA during nonoutage periods, TP TO-9107 - l

, " Foreign Materials Exclusion Area Controls For The Spent Fuel Pool Areas During Non- l Outage Periods," will be revised to identify ' the individual responsibilities assigned by l J. Townsend on January 24, 1992. That is: R. l Powers is the responsible manager of the FMEA program, the Mechanical Maintenance department has control of the FMEA program 91wc a s91 m 042..lcw Page 10 of 22 

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l DCO-91-MM-N042 May 19, 1992 and J. MacIntyre is the Housekeeping i Coordinator matrixed to Mechanical Maintenance. This procedure will also have a comprehensive checklist detailing items to , address prior to entering the SFP FMEA added to enhance the procedure's useability. , RESP: J. MacIntyre (PGKM) Return Tracking AR: A0226666, AE # 25 Outage Related? NOUT , JCO Related? No  ! ' NRC Commitment? No j CMD Commitment? No l l 1

15. Revise C-10 S4 to:
a. convey the revised responsibilities noted in 14. above, I

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b. to incorporate lesson learned in outage 2R4 and
c. define FMEA training for initial '

qualification and regualification. Provide a revision draft for comment at the next TRG reconvene. RESP: J. MacIntyre (PGMM) Return Tracking AR: A0226666, AE # 26 Outage Related? NOUT , JCO Related? No NRC Commitment? No CMD Commitment? No

16. FMEA Coordinator to provide a recommenaation to the Training department for GET and

' requalification training for personnel  : requiring FMEA access.  ! 1 , RESP: R. Powers (PGMT) Return t Tracking AR: A0226666, AE # 27 Outage Related? NOUT l JCO Related? No NRC Commitment? No CMD Commitment? No

17. Housekeeping Coordinator to supervise a

cleanout of Unit 1 and Unit 2 SFP FMEAs.  ; 91NCRWP \91*WO42.JCW Page 11 of 22 3

DCO-91-MM-N042 May 19, 1992 RESP: J. MacIntyre (PGMM) ECD: 6/15/92 Tracking AR: A0226666, AE # 28 j Outage Related? NOUT JCO Related? No NRC Commitment? No CMD Commitment? No

18. Procedure subcommittee to determine what periodic inspection interval and cleaning interval of the SFP FMEAs are required during nonoutage periods.

RESP: J. MacIntyre (PGMM) ECD: 5/15/92 Tracking AR: A0226666, AE # 29 Outage Related? NOUT JCO Related? No NRC Commitment? No l CMD Commitment? No

19. Reactor Engineering to determine the need for SFP inspection and cleaning.

RESP: S. Chesnut (PTER) Return Tracking AR: A0226666, AE # 30 Outage Related? NOUT JCO Related? No NRC Commitment? No CMD Commitment? No

20. Housekeeping Coordinator to coordinate with Security and provide instructions on how to monitor personnel entering the SFP FMEAs.

RESP: J. MacIntyre (PGMM) Return Tracking AR: A0226666, AE # 31 Outage Related? NOUT JCO Related? No NRC Commitment? No CMD Commitment? No

21. Reactor Engineering to update CMD to commit to fuel inspection.

RESP: S. Chesnut (PTER) Return Tracking AR: A0226666, AE # 32 Outage Related? NOUT JCO Related? No NRC Commitment? No CMD Commitment? Yes (T34908, on hold) 91NCiiWP\91MHW042.JCN Page 12 of 22

DC0-91 --MM-N042 May 19, 1992

22. Develop and present training to implement AP C-10S4 for qualifying FMEA monitors.

RESP: D. Clifton (PATT) ECD: 6/30/92 > Tracking AR: A0226666, AE # 33  ; Outage Related? NOUT i JCO Related? No 3 NRC Commitment? No , CMD Commitment? No

23. Coordinate for providing procedure AP C-10S4 training for Maintenance foremen, work planners and RP foremen.

RESP: J. MacIntyre (PGMT) ECD: 6/30/92 Tracking AR: A0226666, AE # 34 Outage Related? NOUT JCO Related? No NRC Commitment? No CMD Commitment? No i C. Prudent Actions: , l

1. Radiation Protection to repair FMEA hot ,

particle boundary herculite walls in SFP area prior to the commencement of building siding refurbishment. j RESP: J. Fitzgerald (PGPR) ECD: 4/1/92 AR: A0258561 Outage Related? NOUT JCO Related? No NRC Commitment? No >- CMD Commitment? No

2. Monitor implementation of procedure AP C-10S4 during 1RS. Identify and process all ,

required revisions for this procedure  ; expediently. RESP: J. MacIntyre (PGMT) ECD: 1/15/93 AR A0265752 3 Outage Related? 1R5 JCO Related? No , NRC Commitment? No CMD Commitment? No

3. FME Coordinator to coordinate with General i 91NCRWP\91Mn 042.J0N Page 13 of 22

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l 1 DC0-91-MM-N042 May 19,1992 Employee Training (GET) to enhance FME training and make it more DCPP specific . l 1 RESP: J. MacIntyre (PGMT) ECD: 9/1/92 AR A0265753 Outage Related? NOUT JCO Related? No NRC Commitment? No l CMD Commitment? No

4. Outage management will evaluate tne need for <

pre-outage training on administrative 1 programs such as housekeeping, safety-related j materials storage, temporary attachments, compressed gas bottles, FME, etc. for DCPP personnel prior to 1R5. RESP: W. McLane (POUT) ECD: 9/1/92 AR A0265754 Outage Related? NOUT JCO Related? No NRC Commitment? No

CMD Commitment? No i

VI. Additional Information A. Failed Components: ' None. 2 B. Previous Similar Events: DC1-86-TN-N143: Tool zone not maintained around the spent fuel pool. Corrective actions included GET training, NPAP C-10 revision and permanent signs for the j SFP area. DCl-88-MM-N027: Reactor head conoseal gap and lack of timely response once discovered. Corrective actions included revision to AP , C-10, MP M-7.3 and 7.5. l DC1-88-QC-NO39: Unit 1 Reactor Head CRDM weld repair. Corrective 1 9tucews9 tnauo42.acu Page 14 of 22 y-7-- rwe r a v t-----,- *-----e r- -- - y- w- -r ,a w- - - -- -  % s.+- -+-----+~-+ms---6--r,-%-a-e+a ----c  %- 

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DC0-91-MM-N042 May 19, 1992 actions included establishing adequate-FMEA controls of the job and contractor (Westinghouse) revision of a field procedure controlling CRDM work. DC1-88-TN-N051: Generic Housekeeping NCR. Corrective actions to prevent recurrence included QC, QA, MM and other procedure revisions to define the requirements for FMEA activities. DC1-88-TN-NO34: Accountability and control of CRDM FMEA requirements was lost due to lack of training. i Corrective actions included additional FMEA barriers and training of i applicable personnel. DC1-91-TN-N017: Describes a dowel pin discovered in fuel bundle E37 during 1R4. The  ! corrective actions for this NCR have not been ' completed at this time, therefore vould not have prevented other past events. C. Operating Experience Review:

1. NPRDS:

Not applicable.

2. NRC Information Notices, Bulletins, Generic Letters:

None.

3. INPO SOERs and SERs:

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DCO-91-MM-N042 May 19, 1992 None. D. Trend Code: PG (Plant staff - general) - A1 (personnel error - ) procedure not followed), A4 (programmatic i deficiency).  ! E. Corrective Action Tracking: The tracking action request-is A0226666. l l F. Footnotes and Special Comments: None. 1 G.

References:

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1. Initiating Action Request A0223568. .
2. Administrative Procedure (AP) C-10S4,  ;
                                " Foreign Material Exclusion Area Control."
3. QC AR/QE book presented at the initial TRG and amendments.
4. Action Requests A0250677, A0251468, A0251842, A0252360 H. TRG Meeting Minutes:
1. The initial TRG met 04/09/91 and discussed the hisL;ry of FMEA considerations used to control work at DCPP.. PG&E was reminded by i the NRC at the 03/12/91 management conference -

that FMEA controls are important to the safe operation of DCPP and agreement was reached to conduct an investigation in accordance with the requirements of the NCR process.

  • The TRG assigned two investigative actions; e
1) to talk to the field personnel most ,

directly involved, and 2) review FMFA related AR/QEs and categorize the problems. A j summary of the results of these activities will be presented at the next TRG. The next  ; TRG will be held in the Outage Control Center  ; 04/19/91 at 1300.

2. An informational meeting was held 04/16/91 to ,

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DC0-91-MM-N042 May 19, 1992 provide the chairman a preliminary evaluation of the scope of AR and QE searches performed.

3. The TRG convened on 04/19/91 and additional corrective actions were assigned to the individuals most familiar with the general
                                                        ' areas' of FMEA concern (see investigative actions 3 through 7). The ' area owners' assigned will review the FMEA ARs and QEs associated with their area and provide a root cause and propose corrective actions to                                   .

prevent recurrence. The TRG will reconvene 04/30/91.

4. The TRG convened on 04/30/91 and each ' area  :

owner' presented a preliminary report of  ! problems identified in their ' area.' The TRG chairman requested each of the area owners propose a root cause and plan for corrective action at the next TRG. This TRG will reconvene on May 15, 1991.

5. The TRG convened on 05/15/91. Each area owner presented a verbal plan for improvement of FMEA control in their assigned area.

Quality Assurance presented programmatic overview of actions proposed for control of FMEA. Dale Clifton of Training presented a review of the integrated training performed  ! by PG&E at DCPP. The TRG could not concur on a root cause for the identified problem. The  ! TRG chairman requested that each assig Od area owner be prepared to present a root cause determination as previously assigned (see CAPR 3 through 6) and present a written plan for improvement of FMEA control at the  ; next TRG. This TRG will reconvene the week j 1 of June 17th, 1991. t

6. The TRG reconvened on 06/28/91. Additional
ARs identified by QC that related to FMEA 1

problem activities during 1R4 were discussed and added to the body of this NCR. QE Q0007182 was also discussed and the l corrective actions for this QE will be  ; identified and tracked by this NCR. The 

                                                        ' Area Owners' present reviewed their progress in developing a Plan of Operation for the control of FMEA work. A general discussion 91NCRWP\91 m D42.JCN                               Page 17 of 22
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DCO-91-MM-N042 May 19, 1992 regarding root cause of this NCR resulted an additional reminder by the TRG chairman that each area owner is to present and document the root cause determination for each assigned area. The results of the individual area root cause determination is to presented at the next TRG to be held the week of July 8, 1991. l

7. The TRG reconvened on July 11, 1991 at 3:00 pm PDT in Room 604 of the Administration Building to discuss contributory and root cause of FMEA problems. It was determined that the overall FMEA program is weak.

Management has not comn.unicated its expectations for FMEA management to  ; personnel, consequently the program is ' variously interpreted by various individuals and no one feels ownership for the program. Establishment and maintenance of FMEA boundaries is not consistent or effective. The governing administrative procedure is complex and vague. The TRG will reconvene on July 18, 1991 to verify corrective actions.

8. The TRG reconvened on July 18, 1991 at 3:00 pm PDT in Room 516 of the Administration Building to discuss progress on corrective actions. The status has been updated as shown in this draft of the TRG minutes. QC agreed to draft a TP for the reactor cav'"f FMEA control plan, Mechanical Maintenance volunteered to sponsor the TP through the  !

PSRC. This TP will be effective during 2R4 l and if the results are good it will be permanently incorporated into AP C-10S4. The TRG will reconvene on August 1, 1991 at 3:00 pm PDT to ensure corrective actions are completed and to discuss " ownership" of the FMEA program.

9. On October 29, 1991, the TRG reconvened in Room 516 of the Administration Building to discuss the Stop Work Order (SWO) imposed on the Spent Fuel Pool (SFP) FMEA. The SWO was imposed as a result of an audit which identified numerous discrepancies between the FMEA logs and the articles in the SFP FMEA.

91NCRWP\91MMw042.JCN Page 18 of 22

I DCO-91-MM-N042 , l May 19, 1992 During non-outage Operations controls the SFP _ FMEA and during outages Mechanical ' Maintenance controls the SFP FMEA. It was decided that a policy of opening the SFP FMEA one day a week for miscellaneous, normal access with those departments working in the area providing an individual designated as the FMEA monitor for their work will be implemented on a trail basis. For , off-normal, necessary access to the SFP FMEA, ' the department desiring access must request approval from the Shift Foreman (who will control the key to the area) and must request QC to provide independent verification during l their access. Friday, day shift will be the l designated normal access period for the SFP FMEA. . The TRG plans on reconvening on November 26, 1991 to evaluate the short term results of the new SFP FMEA access policy.

10. On November 26, 1991, the TRG reconvened and '

considered the following: The TRG determined that the corrective actions from the last TRG (which dealt with a stop work order in the FHBs) do not appear to  ! be working. Out of the four weekly SFP entries since the last TRG, four ARs were written (A025067~, A0251468, A0251842, A0252360). The TRG discussed that personnel are trained on FMEA requirements, but the i requirements are so stringent that it appears  ; to be impossible for personnel to remember them 100% of the time and also do their jobs.

In addition, it will become increasingly j difficult to have only one entry per week as the next outage approaches.

t i a i e 91NCRWPN91*mh042.JCN Page 19 of 22

1 9 DCO-91-MM-N042 l May 19, 1992 1 The TRG discussed root causes: PROBLEM - why? - CAUSE BARRIERS FMEA program not 1. Tracking 1. Frequent  ! maintained forms not audits properly around filled out 2. Constant { SFP (properly) surveillanc

2. Personnel e j not 3. Restricted l following entry times requirement s i
                    ----_-_ ----__-------_-----_------------------_ _-                            1
1. Tracking Workers do not 1. Checklist '

forms not know how to fill 2. Dedicated filled out out forms FMEA (properly) monitor Program may be group ,

2. Personnel too complicated 3. Highly _

not trained l following FMEA l requirement monitors s for each l group 

                    --------------------------------------------------                            1 Workers do not                                 Human error -           1. Universal know how to fill                               knowledge                   FMEA out forms                                      exceeded                    training
2. Training prerequisit es prior to  ;

entry The TRG discussed potential corrective actions (" barriers" above). Monitors / constant surveillance will not prevent problems -BUT- can fix them immediately and increase awareness. Currently, each department provides a monitor, but the biggest problem is that no department takes overall FMEA responsibility for multi-discipline jobs. For this and manpower reasons, we cannot use one or two highly trained people in each department, and no one department (e.g. Ops, MM) has the resources to take on all FMEA (at all times) in addition to their normal work. The 91NCRWD\91MMN042.x N Page 20 of 22

l DCO-91-MM-N042 i May 19, 1992 questions that need to be answered are: (1) l Who will monitor FMEA? (2) Who owns FMEA  ; areas? (3) How much training will monitors need? The TRG recommended that a full-time group be formed with full responsibility and authority for monitoring the FMEA program. An investigative action item was assigned to discuss this recommendation with senior plant , management. This TRG will reconvene to discuss the results.

11. On January 29, 1992, in room 516 of the administration building at 1:00 pm PST, the TRG reconvened to discuss the progress of the -

FMEA program and managements direction regarding the future of the FMEA program. Management has expressed concern that the secondary side of the plant is at much at risk as the primary side regarding FMEA as far as generating capacity is concerned. Mechanical Maintenance has been assigned the lead for FMEA (ownership). A Housekeeping Coordinator position has been created (rotational basis) matrixed to the Mechanical Maintenance. Initially J. MacIntyre will assume this position. , Additional investigative, corrective and prudent actions have been assigned as noted-above by the change bars in the right uand margin. The TRG will reconvene on February 28, 1992 at 2:00 pm PST to discuss progress in the newly assigned actions.

12. On March 4, 1992, the TRG reconvened at 1:00 pm PST in room 533 of the administration building to discuss the results and conclusions that have occurred in the last month or so.

A draft revision proposal for AP C-10S4 was presented for comment to the TRG. The TRG will reconvene following task force , 9wtps91mwo42.;cu Page 21 of 22 v - -- m . --- . - _ _ - - - _ _ _ _ - _ - _ - - - - _ _ - -

DC0-91-MM-N042 Mry 19, 1992 review of the proposed revision of C-10S4 to f determine if conflicts can be resolved at a working level before proposing the revision to plant management. This reconvene is to be on March 18, 1992. The proposed revisions to AP C-10S4 are  ; attached.

13. On May 7, 1992, at 10.00 am PDT in room 533 of the administration building, the TRG reconvened to discuss a draft revision to administrative procedure AP C-10S4, " Foreign Materials Exclusion Program." This procedure will be put on the PSRC agenda for May 27, 1992.
,                            Additional discussion was conducted on

! closure of this NCR. " Proposed" was removed  : j from the root cause section. Actions tracked ' by AEs were reviewed and statused as shown above. Additional AEs were drafted, as l 3 noted. 1 The estimated closure date for this NCR is August 3, 1992. I. Remarks: , None. J. Attachments:

1. DRAFT PROPOSAL FOR AP C-10S4 REVISION i J

l t a 91NCRWP\91MN042.J CN Page 22 of 22 1 1}}

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