ML20087J427

Forwards Complete Responses to Tracked Info Items 058,059 & Tracked Recommendation Item 060 Re Site Auditing

ML20087J427
Person / Time
Site:	Midland
Issue date:	03/14/1984
From:	CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.)
To:	STONE & WEBSTER, INC.
References
CSC-7458, NUDOCS 8403220202
Download: ML20087J427 (11)

Text

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,p CONSUMERS POWER' COMPANY

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Transmittal No:

CSC-7458 Date: Marct. 14, 1984 To:

Stone & Webster P O Box 1963

(_. )Q n a PRINGIPAL STAFF Midland, MI 48640 V

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Description:==

Tracked Information Item 058 Tracked Information Item 059 Tracked Recommendation Item 060.

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- JCKehpler,; NRC Region III; w/a -

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JJHarrison, NRC Region III w/a RJCook, NRC Site w/a RAWells, MPQAD w/a gg y g D BHPeck, MEC w/a NIReichel, MEC w/a DDJohnson, MEC w/a NR ! D. g 8403220202 840314 PDR ADOCK 05000329 b)\\ \\

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Sheet 1 of 1 STONE & WEBSTER

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CONSTRUCTION IMPLEMENTATION

' O TRACKED ACTION ITEM OVERVIEW D TRACKED INFORMATION ITEM MIDLAND NUCLEAR PldNT J.0. NO,14509 O TRACKED RECOuuENDATION ITEM REFERENCE (S)

O UtJTR ACKED ITEM CIO Evaluati6n No. MP-MIS-072-0001

O HOLD POINT NOTIFICATION COtJDITION DETAILS.

Volumes I and II of the Consumers Power Company Quality Assurance Program Manual commits to annual construction audits and a Q.A. program complying with 10CFR50, Appendix B.

A review of site audits and audit schedules concluded that it was not apparent that applicable criteria from 10CFR50, Appendix B, has been addressed during annual audits.

CPCo should review past audits to assure applicable criterion were addressed and provide evidence of the results~.

Please advise CIO of action to be taken.

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SP JDEt T TITLE DATE COMPLETION DATE RcSember t 4/gg Audit Branch Head 3/13/84

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RESPOtJSE ACCEPTED DATE RESPONSE VERIFIED / CLOSED DATE

'Respon:o to'CIO Itca #058 This item states that it is not apparent from a review of past audits and Audit Schedules that all applicable criteria from 10CFR50, Appendix B are addressed.

It is the C10 recommendation that all past audits be reviewed to assure that all appli~ cable criteria are covered during annual audits.

The A&MS and MPQAD Audit Schedules and the newly developed Master Audit Plan do provide evidence that a comprehensive Quality Assurance Audit Program for the Midland Project.has been established.

Programmatic quality audits are performed

'by A&MS, engineering design' audits performed by DQAE and implementation (specific task) audits are performed by Site Audit Branch. The Site Audit Branch therefore concluded that essential elements of the Quality Assurance Program and applicable criteria have been addressed during annual audits and there is no need to review past Audit Reports. The audit program for B&W, CP Co end Bechtel uses as its basis the requirements of their Topical Reports which have been reviewed by the NRC and accepted as appropriate methods to implement 10CFR50, Appendix B Criteria.

Using these docments as a basis ensures that Midland Project audits provide full coverage of the accepted QA Program.

In addition, MPQAD Site Audit Branch and A&MS will look at past third party audits.

This review will determine if the third party raised concerns which addressed a lack of the applicable criteria being covered during annual audits.

The results of the evaluation will be forwarded to the CIO Program Manager.

It should be noted that the Site Audit Branch is developing a computerized procedural matrix, which aligns all construction and quality assurance procedures used on the site with the applicable 18 Criteria.

This system will also indicate the procedural coverage of the Site Audit Branch programs, t

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Sheet 1 of 1

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'"T" UMBER STONE & WEBSTER

EUsg**ERlH CONSTRUCTION IMPLEMENTATION

, C TRACKED ACTION ITEM i

@ TR ACKED ltJFORMATION ITEM MIDLAND NUCLEAR PldNT J.0 NO.14509 D TRACKED RECOMMsNDATloN ITEu REFERENCE (S) l O UtlTRACKEDITEM CIO Evaluation No. MP-MIS-072-0001 10 HOLD POINT !iOTIFICATION COtJDITION DETAILS 10CFR50, Appendix B, Criterion-No. XVI corrective action requires, in part, that conditions adverse to quality be promptly identified and e.orrected. The January 1984 Status Report'(MPQAD Site Audits) indicated that 37 audit reports were open, of which 22 had been open for six months or longer, some dating back to 1981.

15 of the 37 audit reports had findings overdue.

Records revealed a failure to maintain audit reports and related corrective actions (memo L.J. Barbieri to R.A. Wells 2/7/84).

A review of audits (open and closed) prior to June 1983 should be conducted to assure adequacy of auditing, proper close out of findings, compliance to 10CFR50, Appendix B, and objective evidence as to adequacy 'of past audits.

(PAGE Please advise CIO of actions to be taken.

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March 19,-1984

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' RESPONSE See Attached (P AGE X

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NO ATTACHMENTS EST. CORRECTIVE ACTION RESPot4 DENT TITLE DATE COMPLETION DATE RCSeraber J/f:r/ [A/

Audit Branch Head 3/13/84 i

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RESPOt2SE ACCEPTED DATE RESPOtiSE VERIFIED / CLOSED DATE

o Rasp;nsa to CIO Itan 6059 The first paragraph riports there may exist a condition adverse to quality due to overdue and lack of attention to tracking Audit Findings.

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The following is a summary and status of open Audit Reports which was developed from a status report which the Audit Branch issues monthly to Consumers Power Company and Bechtel management.

status of Actich Items l.

' Audit Reports _with open Action Items = 33 2.

Audit Reports from #1 above, open 6 months or longer = 21

-3.

Of #2.above, 11 Audit Repc ts are indefinitely ext' ended.

4.

Of #1 above, open 6 months or less = 12 Audit Reports 5.

5fd2above,only7ofthecumulative33 Audit Findings issued with 21 reports-are beyond commitment date and all 7 have had reminders issued.

'6.

Of #5 above, the remaining 26 Findin'gs are not beyond the required commitment response date.

7.

From #3 above, the 11 Audit Reports involve a total of 45 Findings which were indefinitely extended as a result of no construction activities on Q work since 2/12/82.

I-8.

.Thereforei the Status Su= mary indicates there are 21 Audit Reports (#2 above) open with action items 6 months or longer and of those 21,11 have been indefinitely extended because of no. construction activity. Therefore, there are 10 Audit Reports open'6 =onths or longer.

Of those 10 Audit Reports,

.there is a total of 33 open AFR/URIs.

Seven of the 33 are open beyond co==itment date, with action item reminders issued and the remaining 25 are withi.n com:1.tment dates. Therefore, a review is n,ot warranted at this time because all open action ite=s are being tracked and are not judged to be creating' conditions adverse to quality.

The second paragraph states that Audit Reports and related corrective actions were not being. maintained.

In fact,_the Audit Reports and related action items (AFRs,

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URIs) were being maintained according to MPQAD Procedure F-12M, Rev 4.

'The requirement as stated in Rev 4 was for the auditor to maintain the original Report and Findings until closure of all outstanding action items and at that time, 7he Audit Report became a Quality Record and was to be controlled as a Quality Record.

It should.be understood that this was the practice prior to a singular dedicated audit activity being established on the Midland Project ar.d audits were previously conducted by individual disciplines. The Site Audit Branch, with management' agreement, made a decision to centralize and control (and proceduralize this control') all'past and related corr'ective actions. The memo from LJBarbieri i o RAWells documented this activity and did not indicate in any way some previous t

~ failure to maintain Audit Reports.

-It should be noted that all Audit Reports with their respective action items have been accounted for as evidenced by Audit Log entries.

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7 R2sponsa'to CIO Item #059=

P gg(2 Paragraph ~ three recommends.a review of all audits (opened and closed) prior to i June,.1983,- to assure adequacy of auditing proper close-out of Findings,

- compliance to 10CFR50, Appendix B. and objective evidence as to adequacy of past audits. ' There ' is no indication that the audits themselves, close-out of findings or compliance to 10CFR50, Appendix-B are suspect.- To confirm the adequacy of

- audits. performed prior.'to' June, 1983, a nonstatistical sample will he reviewed

- and.an evaluation made over the.next 12 months. This will also include a review of any third pa'rty concerns. _, Corrective action will be taken.if required. The Site ' Audit-. Branch is scheduling future audits which will provide a new look at the same' activities and current' status will be determined.

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Sheet 1 of 3 STONE & WEBSTER

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CONSTRUCTION IMPLEMENTATION O TRACKED ACTION ITEM OVERVIEW

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O TRACKED INFORMATION ITEM

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Np nuclear PldNT./,0. NO. /4509 O TRACKED RECOMMENDATION ITEM REFERENCE (S) Recommendations "MPQAD-Site Auditing"

' O UNTRACKEDITEM CIO Evaluation No. MP-MIS-072-0001

' O HOLD POINT NOTIFICATION CONDITION DETAILS The following recommendations and. beneficial results are divided into three categories:

(1) Management involvement, (2) Tracking of audits / audit findings (corrective action),

-and (3) Training records and certification of audit personnel.

1.

Management Involvement a.

Revise Volume No. II Procedure 18-1 and F-IM to reflect more accurately duties and responsibilities of site audit branch.

Advantage

1) To reflect the process currently in use.

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Continued on Sheet 2 of 3 ATTACHMENTS

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RESPONSE

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NO ATTACHMENTS EST. CORRECTIVE ACTION FFSP NDENT TITLE DATE COMPLETION DATE RCSeciber gj.f/pq/

Audit Branch llead 3/13/84

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• CONDITION DETAILS (continu;d)'

Sheet 2 of 3 1.-

(con,tinued)

b. Revise Procedure No. F-IM to improve management involvement in evaluating audit results and reoccuring delinquent or inadequate responses, and establish time frame for audit responses / evaluation cycles.

Advantage

1).To improve adequacy and timeliness of audit responses.

2.

Tracking' Audits / Audit Findings (Corrective Action) a.

Revise procedures to prov % instructions for both auditing and audited organizations' rt tibilities.

Advantage 1)

Clear and complete instructions facilitate timely and adequate closure.

2)' Define responsibilities.

b.

Develop a mechanism to assure that all' app'licable criterion of

,10CFR50, Appendix B, have been audited annually.

Advantage 1)

Enhances tracking, trending and planning.

2)

Provides objective evidence that auditing program addresses pertinent criterion from 10CFR50, Appendix B, and is ongoing.

3) Aids in auditing / evaluating adequacy of program.

c. -Revise Procedure No. F-IM to clarify the use of an indefinite (hold) status for tracking of audit reports.

Advantage 1)

Define criteria for use of.(hold) status.

2)

Provide instructions for auditing personnel.

3)

Reflect current operations.

d.- Copies of all project related audit reports (on or off site) should ce retained to closure for information by a site organization.

Advantage

1) Provides overview of complete audit program status for the project.

2) Provides hard copy for details of open findings.

3) Aid to be used.in conjunction with Quail.

4)

Improve tracking and trending.

n CONDITION DETAILS (continued)

Sheet 3 of 3

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3.

Training Records and Certification of Auditors a.

Auditors should be included in the ccmputer tracking program for training already in use for other MPQAD personnel.

Advantage

1) Provide computerized tracking.

2) Provides instant statusfr.g.

3) Provides evidence of traini,ng.

4) Establishes matrix 6f quality affecting procedures commensurate with job assignment.

b.

Copies of auditors / lead auditors' certifications should be main-talried on site for personnel assigned to the project.

Advantage

1) Provides objective evidence of audit personnel qualification and certification.

c.

Personnel assigned to the auditing branch should be certified as auditors in accordance with Procedure No. B-6 (auditors) while-in training for lead auditor certification.

Advantage

1) Provide objective evidence that personnel participating-as audit team members are qualified and trained.

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Rigpensa to CIO Itsa #060 la.

Volume II, Procedure 18-1, is currently being revised and the responsibilities i

of the Site Audit Branch will be defined.

lb.

The Audit Branch has full access to management and it is inherent in the respon'sibilities of the Audit Branch Head to advise management when higher

< level management involvement is required.. Managenent is also aware of the status of open action items throu.gh the " Audit Su= mary Status" issued monthly.

The F-1M Procedure, Audits, establishes the time frame for corrective action commitments.

2a.

Volume II, Pro'cedure 18-1 does address CP Co responsibilities of CP Co audited organizations. The instructions for both auditing and audited organization's responsibilities are accomplished through the entrance and exit meetings.

MPQAD Procedure F-lM, Audits, is presently being revised and it will be reviewed to ensure the appropriate instructions are clear.

2b.

The Site Audit Branch recognizes the potential net benefit for such a matrix and had started this effort prior to CIO evaluation. This is not considered a' program requirement.

2c.

Items so identified, IDE, indicate a hold due to project constraints.

F-lM will be reviewed to see whether this is needed 'in the next revision.

2d.

Site Audit Branch is on distribution for A&MS and DQAE audits so that their Audit Reports can be reviewed for information purposeg and they are generally retained.

-The Site Audit Branch does retain all information pertinent to open Findings for which responsibility is assigned to the Branch, therefore, the Site Audit Branch' is aware of status of reports issued to and by the Audit Branch.

DQAE and A&MS are responsible for maintaining their respective audits.

3a.

The training and certification of CP Co Project Engineering and Construction Audit Team Leaders is performed by A&MS and the periodic status report A&MS provides to the Site Audit Branch for the 9 certified Branch auditors is adequate. The training of Audit Branch personnel is incorporated into the Site Training Matrix.

The Audit Branch will discuss with A&MS the possibility of entering certification data for Audit Team Leaders into the computerized tracking system.

3b.

As ststed above,-the training and certification is performed by A&MS and the certification records are availabe in A&MS files in Jackson.

3c.

The celection of personnel to be assigned to the Audit Branch is based upon a number of criteria, one of which is their past audit experience.

The hiring policy-for the Audit Branch has been for the candidates to have the required education and audit experience to become Audit Team Leaders and only require CP Co specific training and experience under the CP Co Audit Program

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prior to certification. Therefore, the qualifications for certification as an Auditor in accordance with CP Co E&QA Procedure B-6 have already been met or exceeded, making the Audit Branch's policy of Audit Team Leaders-in-Training participating in audits more restrictive than certifying the same personnel as Auditors.

(continued.)

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3c. (continued)

- The time period between their date of hire and certification is usually limited, to the time needed to participate in the required number of CP Co

audits.(usually.less than three months).

Additionally, CP Co commits to Re3. Guide 1.46 which endorses ANSI N45.2.23, 1978. This Standard only addresses the qualification.and certification for Audit Team Leaders, not

' Auditors.

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