ML20062N768

Responds to Violation Noted in Insp Rept 50-346/93-19. Corrective Actions:Emergency battery-operated Lights (EBL) Corrected & Procedure DB-ME-04100 Being Revised to Address Only EBLs Required by 10CFR50,App R

ML20062N768
Person / Time
Site:	Davis Besse
Issue date:	01/10/1994
From:	Storz L CENTERIOR ENERGY
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
2196, NUDOCS 9401210076
Download: ML20062N768 (4)

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j CENTERROR ENERGY 300 Mod: son Avenue Louis E Storr.

Toleda OH 43052-OOO1 Vice President-Nuckeor 419 249-2300 Daws-Desse Docket Number 50-346 License Number NPF-3 Serial Number 2196 January 10, 1994 United States Nuclear Regulatory Commission Document Control Desk Vashington, D. C.

20555

Subject:

Response to Inspection Report Number 50-346/93019 Gentlemen:

Toledo Edison has received Inspection Report 93019 (Log Number 1-2949) and provides the following response.

Violation:

10 CFR Part 50, Appendix B, Criterion XVI, " Corrective Action,"

requires, in part, that measures be established to assure that conditions adverse to quality are promptly identified and corrected.

In the case of significant conditions adverse to-quality, the measures shall assure that the cause of the condition is determined and corrective actions taken to preclude repetition.

Contrary to the above, since October 1, 1991, quality assurance activities, surveillance testing and personnel observations identified on multiple occasions that Appendix R required emergency lighting battery packs were in an unsatisfactory condition (a significant condition adverse to quality) and-adequate actions were not taken to identify the root causes and preclude repetition.

Response

Acceptance or Denial of the Alleged Violation

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Toledo Edison acknowledges the alleged violation.

Reason for the Violation s.~g7 g

Periodic Testing of' Emergency Battery-operated Lights (EBL) is I

performed in accordance with procedure DB-ME-04100, Emergency jggggggmqqp Lighting System Test.

In June-1989, the periodicity of.this test was changed from monthly to quarterly.

At that time, the Ope @mg Componies.

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=d Page 2 frequency of deficiencies observed on a monthly basis for.

battery electrolyte level was perceived as being lov enough to j

justify a quarterly periodicity for testing. The battery i

manufacturer ccncurred with a quarterly frequency as long as monthly test data demonstrated that electrolyte level observed for a three-month period did not' decrease to an unacceptable

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level.

Subsequent to the revision to a quarterly frequency, a Ouulity Assurance (QA) audit performed in 1991 concluded that control of maintenance and testing of emergency. lighting was the area most in need of improvement. As a result of this audit, enhancements were made to DB-ME-04100 to more adequately track EBL maintenance. A fire protection audit conducted in 1992 identified only one EBL deficiency out of a sample of 54 EBLs.

Based on these results, the corrective. action taken as a result of the 1991 audit was judged as adequate.

An audit completed in September of 1993 identified anomalies in 9 out of a sample of 80 EBLs. The 9 EBLs were corrected expeditiously under a Maintenance Work Order. No further corrective actions were t

deemed necessary at that time.

j Hany of the EBL deficiencies identified during routine testing vere as a result of expected degradation. This was not considered unreasonable because some EBLs'are installed-in higher temperature areas and discussions with the EBL vendor indicated that EBLs which are installed in a higher temperature environment have a shorter life expectancy. However, after' i

further reviewing data from the audit, test and maintenance records, it is apparent that Toledo Edison established an inappropriate threshold for initiating corrective action for recurring EBL deficiencies.

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i Corrective Actions Taken and Results Achieved The EBLs noted by the NRC Resident Inspector on October 9, 1993, vere corrected as noted in Inspection Report 93019.

Site personnel met on November 11, 1993 to develop"an' action.

plan to comprehensively address EBL test deficiencies and to propose programmatic changes.

A thorough' review of EPRI j

guidelines on EBL maintenance and vendor recommendations was

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completed on November 12, 1993 to support proposed improvements to the EBL test and maintenance program.

Modifications to EBLs 1

were proposed and are currently under evaluation to enhance

'l" testing and maintenance.

Several Potential Condition Adverse to Quality (PCAQ) Reports have been initiated which have prompted further analysis and walkdowns of EBLs.

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l Docket Number 50-346 l

License Number NPF-3 Serial Number 2196 Page 3 A test procedure revision was initiated and is in progress to return to a monthly frequency and upgrade data collection.

Discussions were held with the Electrical Maintenance Unit to instill a heightened awareness of PCAQs and to stress management's expectations.

j Toledo Edison recognizes that the threshold for identification of PCAQs and the evaluation of implemented corrective actions as a result of Quality Assurance audits has not been completely consistent with management expectations. As a result,.

Management Corrective Action Report (MCAR)93-003 has been initiated to address these issues. An HCAR is the highest level of document used to initiate corrective actions for i

significant conditions adverse to quality.

Corrective Actions to Prevent Recurrence Procedure DB-ME-04100 is being revised to address only those EBLs required by 10CFR Part 50 Appendix R, and to change the testing frequency for these EBLs from quarterly to monthly.

The procedure vill require more detailed data collection for electrolyte level and battery voltage to aid in the trending.

program and to ensure the Shift Supervisor.is notified when.a-unit does not function as required. The revised. procedure vill direct evaluation of EBL failures in accordance with NG-0A-00702, Potential Condition Adverse to Quality Reporting.

t This will ensure proper attention to EBLs required by Appendix.

l R.

The procedure revision to DB-ME-04100 vill be completed by.

January 31, 1994.

Plant Engineering vill assume the responsibility as Designated Reviewer for completed EBL Tests and trending EBL~ test results.

Trending vill provide a firm basis for evaluation of EBL testing frequencies and maintenance intervals.

The MCAR (93-003) on inadequate corrective action vill provide evaluation of root cause and corrective action to prevent recurrence for the broader issue identified above.

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1 Docket Number 50-346 License Number NPF-3 Serial Number 2196 Page 4 Date When Full Compliance vill be Achieved Full compliance vill be achieved for the issue of the EBL' testing and maintenance program when the revision to DB-ME-04100 is implemented and the first month's testing'is completed. The procedure vill be implemented by February 1, 1994. The first month's testing vill be completed l

by March 1, 1994.

The date for resolution of issues identified on MCAR 93-003 vill be provided in Toledo Edison's future response to'the apparent violations discussed at the December 17, 1993 Enforcement Conference.

Should you have any questions or require additional information, please contact Mr. V. T. O'Connor, Manager - Regulatory Affairs, at (419) 249-2366.

Very truly yours,

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cc:

J. B. Martin, Regional Administrator, NRC Region III I

S. Stasek, DB-1 NRC Senior Resident Inspector a

R. J. Stransky, NRC Project Manager Utility Radiological Safety Board 2

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