ML20064L789

Responds to NRC Ltr Re Violations Noted in IE Investigation Rept 50-261/82-33.Corrective Actions:Corporate QA Mgt Will Review Audit Schedule Monthly & Dedicated Fire Protection Organization Will Ensure Triannual Fire Insp

ML20064L789
Person / Time
Site:	Robinson
Issue date:	12/02/1982
From:	Utley E CAROLINA POWER & LIGHT CO.
To:	James O'Reilly NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
References
NUDOCS 8302150374
Download: ML20064L789 (7)

Text

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CD&L Carolina Power & Light Company *

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DEC 021982

-, m c G MB DI Mr. James P. O'Reilly, Regional Administrator United States Nuclear Regulatory Commission Region 11 101 Marietta Street, N.W., Suite 3100 Atlanta, GA 30303 H. B. ROBINSON STEAM ELECTRIC PLANT, UNIT NO. 2 DOCKET NO. 50-261 LICENSE NO. DPR-23 RESPONSE TO INSPECTION REPORT IER-82-33

Dear Mr. O'Reilly:

Carolina Power & Light Company has received and reviewed the subject Inspection Report and provides the following response:

A. Severity Level IV Violation (IER-82-33-01-SL4)

Technical Specification 6.5.3.1 requires that the Performance Evaluation Unit of the Corporate Quality Assurance Department perform audits of plant activities. Specific audit subjects are defined in Specification 6.5.3.2.d.

1. Technical Specification 6.5.3.2.d(5) requires an audit of the Emergency Plan and implementing procedures at least once per 24 months.

Contrary to the above, this audit requirement was not performed at  !

least once per 24 months. Audit QAA/20-19 conducted October 15-19, 1979, and Audit QAA/20-29 conducted July 12-16, 1982, performed this function. These audits were conducted 34 months apart.

2. Technical Specification 6.5.3.2.d(7) requires an audit of the Facility Fire Protection Program and implementing procedures at least once per 24 months.

Contrary to the above, this audit requirement was not performed at least once per 24 months. Audit QAA/20-18 conducted June 18-22, 1979, and Audit QAA/20-24/25 conducted August 24 - September 2, 1981, performed this function. These audits were conducted 26 months apart.

8302150374 821202 '

l PDR ADOCK 05000261 0 PDR 411 Fayetteville Street

• P. O. Box 1551

• Raleigh, N. C. 2760 '

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Response

1. Admission or Denial of the Alleged Violation Carolina Pbwer & Light Company acknowledges both examples in the violation.

2. Reason for the Violation The schedule that tracked the Emergency Plan and Fire Protection Program audits was not properly maintained.

3. Corrective Steps Which Have Been Taken to Prevent Further Violation Those responsible for maintaining the audit schedule have been counseled on the necessity to ensure schedules are kept up to date and the audits are performed on time. Corporate QA (CQA) Management will review the schedule monthly.

4. Corrective Steps Which Will be Taken to Prevent Further Violation The counseling and review described above will prevent further violation.

5. Date When Full Compliance Will be Achieved Full compliance has been achieved.

B. Severity Level IV Violation (IER-82-33-02-SL4)

Techilcal Specification 6.5.4.2 requires that an inspection and audit of the fire protection and loss prevention program be performed by an outside qualified fire consultant at intervals no greater than three years.

Contrary to the above, this audit and inspection was not performed at intervals no greater than three years. An audit and inspection was conducted September 16-17, 1981. This requirement has been in effect since February 28, 1978 (Amendment 31). This audit was conducted 43 months af ter implementation.

Response

1. Admission or Denial of the Alleged Violation Carolina Pbwer & Light Company acknowledges the violation.

- 2. Reason for the Violation The + 25 percent adjustment to test intervals allowed by Technical Spec'ification (T.S.) 4.0 was erroneously applied to T. S. - 6.5.4.2

(125% of 36 = 45 months). Therefore, delays in receiving and reviewing bids and providing purchase requisitions for an outside qualified fire consultant to perform the tri-annual inspection was not given the proper priority prior to the 36-month cutoff date.

3. Corrective Steps That Have Been Taken and Results Achieved A dedicated Fire Protection Organization was established on site in July, 1981. This Organization scheduled the September 16-17, 1981 inspection and will ensure that the tri-annual fire inspection is i performed in the future as required by Technical Specifications.

4. Corrective Steps the Will be Taken to Avoid Fuither Violation Scheduling of the tri-annual Fire Protection Inspection on a rigid three (3) year interval by the dedicated onsite Fire Protection Organization should prevent further violation.

5. Date When Full Compliance Will be Achieved Full compliance has been achieved.

C. Severity Level IV Violation (IER-82-33-03-SL4) 10 CFR 50, Appendix B, Criterion V and the accepted QA Program (Letter dated March 18, 1981, Serial No. 0QA-81-026) require that activities t affecting quality shall be prescribed by documented procedures and shall i be accomplished in accordance with these procedures. The accepted QA j Program endorses ANSI N45.2.12-1977 for performance of audits.

Section 4.5.1 of this standard requires the audited organization to respond as requested by the audit report. CQAD 80-1, Procedure for Corporate QA Audits, Revision 2, paragraph 6.6.1, requires that the audited organization respond to audits within 30 days.

l l Contrary to the above, two audit responses were not submitted within 30 days. Audit QAA/20-23 was issued on February 5, 1981, and responded to March 16, 1981. Audit QAA/20-27 was issued on June 15, 1982, and responded to August 6, 1982.

Response

1. Admission or Denial of Alleged Violation Carolina Power & Light Company acknowledges the violation.

2. Reason for the Violation The responsibility for responding to Inspection Report QAA/20-23 in February, 1981, was not centralized and resulted in an overdue response. In July, 1981, a Regulatory Compliance Subunit was formed

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on site which is responsible for providing management with complete responses to the various audits on a schedule such that they are submitted on time. The response to QAA/20-27 was deliberately delayed three weeks as agreed to by a telephone conversation between the Regulatory Compliance Subunit on site and the Performance Evaluation Unit, which issued Audit Report QAA/20-27. This was documented in an August 9, 1982 memorandum,82-435 which personnel in both the Regulatory Compliance Subunit and the Performance Evaluation Unit 7

described the need for additional time to adequately review all the plant responses. -

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3. Corrective Steps Which Have Been Taken and Results Achieved It is now the position of CP&L that a written response describing the '

1 Plant's position on all nonconformances will be provided to Corporate I

QA Group within the requested time frame. This position-is described in Corporate QA Procedure 80-1. Should additional time be needed, telephone conversations will not be used to request additional time for responses.

4. Corrective Steps Which Will be Taken to Prevent Further Violation The above action should prevent recurrences.

1 1 5. Date When Full Compliance Will be Achieved 1

I Full compliance has been achieved with the understanding that telephone conversations cannot extend Corporate QA due dates for initial responses.

D. Severity Level V Violation (IER-82-33-04-SL5)

Technical Specification 6.5.3.4 requires that results of plant audits are 3 approved by the Principal QA Specialist and transmitted to management

! within 30 days af ter completion of the audit.

i Contrary to the above, sudits QAA/20-27 and 20-28 were not transmitted to i management within 30 days. Audit QAA/20-27 conducted April 26-30, 1982,

, was transmitted June 15, 1982, and Audit QAA/20-28 conducted May 11-14,

! 1982, was transmitted June 15, 1982.

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Response

1. Admission or Denial of the Alleged Violation i

Carolina Pbwer & Light Company acknowledges the violation.

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2. Reason for the Violation

! Too many activities were included within the scope of the audit to allow for a proper review and. evaluation of each item within the allowed time frame. Corporate QA Auditors were allowed to begin their next audit prior to submitting the reports on their previous audits.

This resulted in an inordinate administrative burden which prevented all audit reports from being approved and transmitted within the 30-days required by Technical Specification 6.5.3.4.

3. Corrective Steps Which Have Been Taken and Results Achieved The frequency of plant audits has been increased in order to reduce

, the scope of each audit. Corporate QA Auditors are now required to t

submit their audit reports within five (5) working days of an audit 4

and prior to starting their next audit. This will insure that adequate time is allotted to review and initial the reports within the 30 days.

4. Corrective Steps That Will be Taken to Prevent Further Violation The work load of Corporate QA Auditors is being reviewed to ensure it

is consistent with the above policy of submitting audit reports prior to initiating another audit. Additional personnel will be involved as necessary to meet the 30-day report requirement.

5. Date k' hen Full Compliance Will be Achieved Full compliance was achieved-with the requirement for auditors to submit reports within five (5) working days of the completion of an

audit and prior to involvement with another audit.

E. Severity Level V Violation (IER-82-33-05-SL5) 10 CFR 50, Appendix B Criterion V and the accepted QA Program (Letter dated March 18, 1981, Serial No. OQA-026) require that activities

- affecting quality shall be prescribed by documented procedures and shall.

be accomplished in accordance with these procedures. CQAD 80-1, Procedure j for Corporate- QA Audits, Revision 2, defines a nonconformance as "A r deficiency in characteristic, documentation, or procedure which renders ,

i the quality of an item unacceptable or indeterminate." This procedure also defines a concern as "A questionable practice which has the potenital of causing a nonconformance or-where additional information is required for evaluation of acceptability."

4 Contrary to the above, a finding (nonconformance) was incorrectly

identified as a concern in Audit QAA/20-28 Concern 3. This concern 4

identified that Emergency Instructions did not meet the requirements of ANSI N18.7-1976 Section 5.3.9.1.

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Response

1. Admission or Denial of the Alleged Violation Carolina Power & Light Company denies the alleged violation.

2. Reason for the Denial

, The auditors identified that although the Emergency Instructions included: A. Discussion, B. Symptoms, C. Automatic Actions, and D.

Manual Actions, they did not specifically provide a separate list for "Immediate Operator Actions" and " Subsequent Operator Action" as 4

suggested in ANSI-18.7-1976. Immediate and Subsequent Operator Actions are included in the list of Manual Actions; therefore, a nonconformance, "A deficiency in characteristic, documentation, or

, procedure which renders the quality of an item unacceptable or where additional information is required for evaluation of acceptability" did not exist. It was ' the auditor's opinion that the definition for a concern "A questionable practice which has the potential of causing a nonconformance or where additional information is required for evaluation of acceptability" was more appropriate because there was a possibility that revisions to EI-17 could inadvertently delete an

, Immediate or Subsequent Action without the reviewer realizing that these specific Manual Actions were required to be in the procedure.

The plant was required to respond in writing to this concern.

Revision 4 to Corporate QA Procedure 80-1 redefines Nonconformance, Findings, Concerns, and Comments. Generally, Findings and Concerns are both nonconformances which require a written response. Comments do not require a written response.

F. Severity Level V Violation (IER-82-33-06-SL5) 10 CFR 50, Appendix B Criterion XVII and the accepted QA Program (March 18, 1981 Letter, Serial No. OQA-81-026) require. that sufficient records be maintained to furnish evidence of activities affecting quality. The accepted 1A Program endorses ANSI N45.2.9-1974, Collection ,

Storage, and Maintenance of QA Records. Paragraph 5.4.2 of this standard requires that records be stored on shelving.

Contrary to the above, boxes containing radiographs were not being stored on shelving in the vault during an inspection of the vault on September 21-22, 1982.

Response

1. Admission or Denial of the Alleged Violation Carolina Power & Light Company acknowledges the violation.

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2. Reason for the Violttion A Purchase Requisition No. 437 was initiated on January 13, 1982 to purchase file cabinets to store large forms and radiographs. Until the cabinet arrived, the radiographs were stored on the floor in the vault. The radiographs were on the vault floor during the inspection.

3. Corrective Steps That Have Been Taken and Results Achieved The large file cabinet arrived September 23, 1982. The radiographs have been properly stored in the file cabinet.

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4. Corrective Steps Which Will be Taken to Prevent Further Violation The storage of the radiographs in the file cabinets will prevent further violation.

5. Date When Full Compliance Will be Achieved Full compliance has Lten achieved.

If you have any questions concerning this response, please contact me.

Yours very truly,

[ /7 E.' E. Utley Executive Vice President Power Supply and Engineering & Construction AWS/cfr (5795C6T2) cc: Mr. J. P. O'Reilly (NRC-RII)

Mr. G. Requa (NRC)

Mr. Steve Weise (NRC-HBR)