ML20090J212
| ML20090J212 | |
| Person / Time | |
|---|---|
| Site: | Point Beach  |
| Issue date: | 04/02/1984 |
| From: | Burstein S WISCONSIN ELECTRIC POWER CO. |
| To: | Spessard R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| Shared Package | |
| ML20090J201 | List: |
| References | |
| NUDOCS 8405220374 | |
| Download: ML20090J212 (78) | |
Text
{{#Wiki_filter:. L' n Msconsin Electnc mcome 231 W. LO9 MAN, P.O. BOX 2c46. MllWAUKEE, WI 53201 i l April 2, 1984 l Mr. R. L. Spessard, Director Division of Engineering U. S. NUCLEAR REGULATORY COMMISSION, REGION III 799 Roosevelt Road Glen Ellyn, Illinois 60137
Dear Mr. Spessard:
DOCKETS 50-266 and 50-301 INSPECTION REPORT 50-266/83-21 and 50-301/83-20 SPECIAL INSPECTION OF QUALITY ASSURANCE PROGRAM POINT BEACH NUCLEAR PLANT, UNITS 1 and 2 This is in response to your Special Inspection Report transmitted with your letter of February 21, 1984 in respect to quality assurance program activities at Point Beach Nuclear Plant. We appreciate your having extended the time of response from March 23 to this date in our telephone conversation of March 21. This has enabled us to make our response more complete, with appropriate review by senior management. b Our response to each of the items of your report is
, contained in four attachments to this letter as follows:
A. -Alleged Violations B. Open Items C. Unresolved Items D. Alleged Program Weaknesses In.each of these attachments, we have transcribed the (tem identified in your report with the specific examples noted. Following each example, we have inserted the supporting paragraph taken from Appendix A of your report. Based on the exit interview of November 16, 1983, we had, prior to receipt of your February 21 transmittal, developed a responsive action / tracking system and 8405220374 840517
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.i i Mr. R . L. Spessard April 2, 1984 i-had:designa.*ed each observation, as we understood at that time, a "QA finding". The paragraph following each specific item, such as each alleged violation, and identified as 83/NRC-XX is
[ NRC "QA finding" cotresponding to this specific item denominator. i Following these identified "QA findings" is our specific response i to your findings, including our proposed or completed corrective t- action and our schedule for implementing or completing that action. In a few cases dealing primarily with items of Sections B, C, and D
- on open items or alleged program weaknesses, we have had insufficient time to complete our analysis and response.
In response to the tabulation of twenty-two alleged violations, including subparts in Attachment A, you will note that i l we believe ourselves already to be in compliance with thirteen of these items. In Attachment C we believe we can resolve, or have ! resolved, seven of the thirteen unresolved items identified in your l- report. We believe the details we covered in the November 16, 1983 exit interview and the discussions in our management meeting of January 4, 1984 have been most helpful in our analysis and response in respect to each item. As we advised you at that latter meeting, we have been actively pursuing appropriate action or response to your special QA investigation since~the' exit interview of November 16. We also advised you at the January 4 meeting that our responses to i your special investigation are not being limited to only those items identified in your report. We have additionally initiated the p following activities:
- 1. We have contacted other utilities to' obtain information on the functioning of their. Off-Site Review Committee, particularly on how they perform audits. _
- 2. Our Corporate Quality Assurance Committee functions.
are being revised. Mr. J. W. Boston, Senior Vice President of Wisconsin Electric, has been_ appointed chairman of this committee. i e'
- 3. A Modification - Request Task Force has been formed to
_ review our procedures for processing modification requests. ! 4. A separate Maintenance Request Task Force has -been formed to review procedures for processing maintenance , _ requests.. i
- 5. A group has been formed to review the control of component technical' manuals and to' implement appropriate procedures to improve-the control. Their consideration will include: Generic Letter 83-28. In order to complete this process as expeditiously as possible, the. group t
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- Mr. R..L. Spessard April 2, 1984
- will have no other higher priority assignments. A member of the Point Beach supervisory staff has been designated to lead the implementation of this activity.
- 6. We are proceeding to install a Maintenance Management System to enhance the control of documentation of our maintenance activities.
- 7. An Inter-Section Review Group has been established
[ to evaluate Nuclear Power Department interfaces and procedures. i ' Some administrative activities currently being 8. performed at . Point Beach are being transferred to our Corporate headquarters to allow the plant staff to devote more time to procedural aspects related to on-site quality assurance matters.
- 9. Attention to the status of--drawing change notices is being emphasized and included.in_ performance indicators reviewed each month by,the Vice President-Nuclear Power.
We are pleased to note that your inspection of_QA matters
-related to the steam generatorfreplacement: work revealed no items of concern. With respect to the overall quality assurance activities at Point Beach, we believe that much of your listing of findings concerns relates to differences in interpretation and perhaps even philosophy related to the implementatio_n of our QA program. For example, our commitment to perform " audits", particularly relating to activities of our Off-Site Review Committee, was made many years ago before the adoption of- Appendix B requirements. The word " audit" as we-intended it then, and as we believed was understood by the NRC when it gave its approval of our-QA. program, was intended to cover either random or special Lsampling of specific items by. competent members of our Off-Site Review-Committee. , We did not intend to provide a complete line-by-line examination of'every technical specification requirement,-for example.- Nor did we' intend to' qualify recognized professional and expert members of our Off-Site Review Committee as " lead auditors", as this term was-later: defined. !We
'believe_it isLimpossible_to compel-the non-employe experts on_our Off-Site Review Committee c to qualify for. and' maintain " lead auditor"
- status.- To perform a line-by-line audit of operational . procedures -
by lead auditors, as would be-required by your analysis-(See
, Appendix A,' Item 31 [11]), would be a substantial clerical chore and would-deprive us of'the review by highly qualified specialists deliberately selected to serve on our committee-because of their special. expertise. ' Surely 1such an interpretation.and adherence-to literal-language, as'you propose,.would result in a lesser level'of quality. assurance.and would be counterproductive.
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Mr. R. L. Spessard April 2, 1984 We very much appreciate your candid observation that your designation of programmatic deficiencies did not manifest themselves in operations and equipment problems. We again call your attention to the fact that our QA program received previous NRC review and approval. I refer you to a letter from George Lear, Chief, Operating Reactors, Branch 3,-dated July 20, 1977, finding our QA program contained within the FFSDAR as being acceptable. We recognize, of course, by this very response that
, our QA program, as well as any such activity, can be improved.
Your audit, as well as the one we had undertaken earlier in 1983, has identified several such areas where improvement should be made. We are being guided by these audits and our own best engineering and quality assuranco judgments to continue to assure that the Point Beach Nuclear Plant is operated in a safe and reliable manner. Very truly yours,
/~ m Executive Vice President Sol Burstein Attachments Copy to Resident Inspector
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i ; 1 ATTACHMENT A , 1 VIOLATION NO. 1 (Level IV) 10 CFR 50, Appendix B, Criterion VI, as implemented by the Point Beach Quality Assurance Program, FSAR Section 1.8.6, including a commitment to ANSI N18.7-1976, requires measures be established to control the issuance of documents, such as instruct, ions, procedures, and drawings, including changes thereto, and that the measures assure that the documents and changes are reviewed for adequacy and approved for release and used at the location where the prescribed activity is performed. Contrary to the above, the following examples of failure to comply with these requirements were identified:
- a. The Instrument and Controls Department did not annotate or update drawings in the shop when DCN's were issued, as required by Section 5.2.15 of ANSI N18.7-1976 and Procedure PBNP 2.2.4.
3k(ii) The Instrument and Control Department did not update the drawing in the shop when a DCN was issued. The DCN's were filed in a 3-ring binder as they were received and the drawings were not annotated as to the existing change. This is contrary to 10 CFR 50, Appendix B, Criterion VI; ANSI U18.7-1976; and Administrative Procedure PBNP 2.2.4. This is an example of an item of noncompliance with 10 CFR 50, Appendix B, Criterion V (266/83-21-22E; 301/83-20-22E). PBNP 83/NRC-79 I&C neither incorporates any DCN's onto drawings nor indicates a revision in progress on the drawing.
Response
This finding is technically correct. It is acknowledged that the subject condition did exist as a violation of PBNP procedures However, these drawings were under such administrative controls that the requirements of 10 CFR 50 and the FSAR were not violated. It has been the practice of I&C to treat all drawings under their control "for information only." Before any of these drawings are used for maintenance or for modification work, a verification step of checking controlled drawings and "as-built conditions" is performed. While this practice is efficient and has resulted in no difficulties, it is agreed that there is a small possibility that crrcrs could occur. The following actions will therefore be taken:
- 1. The administrative procedure for DCN's will be reviewed and ch,anged to describe how controlled copies of drawings will be maintained, including DCN incorporation. This will be accomplished by September 30, 1984.
- 2. Only drawings controlled under the referenced administrative procedure will be utilized by I&C for maintenance and modification work. Drawings that are to be controlled will be verified and under administrative control by ,
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Violation No. 1-2
- b. DCN's 83-43 and 83-78 were not incorporated into controlled drawings M-201 and M-207 in the control rom, auxiliary feedwater purup rom, and auxiliary building, as required by Section 5.2.15 of ANSI N18.7-1976 and PBNP 2.2.4.
3k(ii) PBNP 2.2.4, Paragraph 3.5, requires that a DCN be attached to the drawing or the drawing marked up to agree with the DCN and noted on the drawing that the DCN was incorporated.
%e following DCN's were found not incorporated into the drawings located in the control rom, auxiliary feedwater purrp rom, and auxiliary building (i.e., locations where Operations personnel would expect to find up-to-date documents):
DCN 83-43 to Drawing M-201, Sheet 1, was not incorporated. DCN 83-78 to Drawing M-207, Sheet 1, was not incorporated.
'Ihis is an exarrple of an item of nonempliance with 10 CFR 50, Appendix B, Criterion VI (266/83-21-22B; 301/83-20-22B) .
PBNP 83/NRC-78 It was noted that drawing changes were not appropriately entered on the Operations controlled drawings, as required, in two instances checked at the Auxiliary Operator's station in the turbine hall and PAB and in the control rom. Despcme: m e cbservation'is accepted.- A check has been made to ensure all DCN's were entered en the appropriate drawings by January 31,1984. .We are now in empliance. To further assure emplian , we will incorporate DCN's as-part of the CR audit program for EQRS. 1 y
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Violation No. 1-3 4
- c. Maintenance Procedure PT-M-1 was performed on Batteries DOS and D06 from July 31 through October 31, 1975, and on Battery D06 on September 30, 1983, with out-of-date revisions of the procedure.
3k (ii) The QA program commits the licensee to ANSI N18.7-1976.
- ANSI N18.7-1976, Section 5.2.15, states, in part.
" Participating organization shall have procedures for control of the documents and changes thereto to preclude
- the possibility of use of outdated or inappropriate documents. Document control measures shall provide for
...(4) Ascertaining that proper documents are being used... (5) Establishing current and updated distribution lists." The following are examplies where this did not occur:
PT-M-1 (Maintenance Surveillance) was performed on Batteries DOS and D06 7/31/75 through 10/31/75 to Revision 0, in lieu of Revision 1 which was issued 7/9/75. PT-M-1 (Maintenance Surveillance) was performed i Lon Battery D06 on 9/30/83 to Revision 1, in lieu of Revision 3 which was issued 9/23/83. This is contrary to 10 CFR Part 50, Appendix B Criterion.VI. This is an example of an item of non-compliance (266/83-21-22A; 301/83-20-22A). , 1 PBNP 83/NRC-84 i An outdated revison of the station battery test was used.
- Subsequently, a data sheet marked "Revison 1" was used with Revision 3 of the procedure.- -
Response
The finding is accepted. The specific. instance occurred when Maintenance attached a form to a periodic test procedure. The form.itself was never actually revised, although the procedural guidance was revised. In i this instance, the document error was the retention of the' form (which had been revision numbered and dated) and discarding of the procedure after use. J
-All Maintenance procedures have been audited to verify correct revision status. Discrepancy logs were generated to correct and complete the formal record. Procedural history records are also being developed.
The Maintenance. procedural f history was completed by February 29, 1984. p
< Maintenance procedures'(as'others).have gone through several different methods of. review, approval, and routing over the years.- They are now being processed as.the proceldures of other groups, which has proved to be a successful technique of document control. This'should preclude similar violations in the future, e J We arelnow in compliance.-
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Violation No. 1 - 4
- d. The Maintenance Department did not maintain indices or another system to indicate revision status of Maintenance procedures, as required by Section 5.2.15 of ANST N18.7-1976.
3k(ii) The Maintenant. Separtment did not maintain indices for its procedures, or have any other document control measures to assure that proper documents were being used, as required by ANSI N18.7-1976 and 10 CFR 50, Appendix B, Criterion VI. The method the inspector used to acquire the latest Maintenance procedure was to n1k Staff Services for the latest procedure. If it had been changed in the last few years, Staff Services would have the. latest procedure. If Staff Services did not have the procedure, the inspector returned to the Maintenance office and by searching in the master file obtained the latest revision to a procedure. The shop assumed that the last revision in the master file was not out of date due to actually misfiling or renoval from the file. This was the case for procedures which had not been changed in the last few years and which Staff Services had control of. This is an example of an item of noncompliance
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with 10 CFR 50, Appendix B, Criterion VI (266/83-21-22D; 3ol/83-21-22D). PBNP 83/NRC-80 There are no procedure indices for Maintenance procedures to provide verification that the procedure being used is the current and up-to-date revision of the document. Response: w Procedure indices were developed and procedure history files updated
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- e. -Controlled copies.of Procedures ICP 2.3 ICP 2.15, and ICP 10.2 in the control room and available for use were not the latest' revision.
3k(ii) The following procedures were found in the control room in accordance with Procedure PBNP 6.1.2.c; however, they were not the latest revision: Procedure Revision in Control Room Latest Revision ICP 2.3 Rev 3, dated 12/22/82* Rev 9, 6/29/83 ICP 2.15 Rev 6,. dated 12/17/82 Unit 1 Rev 9 8/16/83 Unit 2, Rev 0 8/16/83 i ICP 10.2 Rev 6, dated 1/29/82 Rev 7, 10/19/83 This is an example of an item of noncompliance with 10 CFR 50,
' Appendix B, Criterion VI (266/83-21-22C; 301/83-20-22C).
PBNP 83/NRC-82 There is no defined responsibility for maintaining ICP's in the control room up to date.- -
Response
t This finding is. technically correct.- Although we accept the observation as factual, we believe this would be more appropriately identified as an open item.' As your inspector will recall, he had conversations with the Superintendent'- I&C which involved the fact that he was actively pursuing- > corrective action to bring the procedures into compliance with PBNP 6.1.2.c. . PBNP 6.1.2.c. requires Staff Services-to distribute changes to certain I&C procedures to control room file and. Reactor Engineering office files, but does not define who is responsible to place'the new procedure-revisions in the file and remove the superseded procedure revisions. -Also, no copy of the. current. procedure revision. index is maintained in the procedure files in these locations,. so that the user can verify that a current copy of the
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procedure is being utilized. It is agreed that this situation-can result in the wrong revision being utilized. The following-actions will therefore be taken:
- 1. 'I&C.will. evaluate the necessity for maintaining each of ;
the procedures currently in there locations.and eliminate .{ any unnecessary procedure distribution.. This will be-completed.by June 1, 1984. I i
*InLNRC letter of 2/21/84, Section;3k(ii), you refer to ICP 2.3, Rev. 3, i
dated 12/22/82. 'Please note Revision 6, not Revision 3, was dated 12/22/82. To further clarify the record, ICP 2.3 is not issued to the control room by
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- 2. For these procedures which must be distributed to these
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locations, I&C will assume' responsibility for placing new procedure revisions in the files and removing I superseded procedure revisions. I&C will also be responsible for maintaining a copy of the current t 3 - procedure revision index in the files. This uill be implemented by June.l. 1984. Changes to PBNP 6.1.2.c will be made by June 1, 1984,
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o VIOLATION NO. 2. (Level IV) 10 CFR 50, Appendix B, Criterion V, as implemented by the Point Beach Quality Assurance Program, FSAR Section 1.8.5, including a commitment to ANSI N18.7-1976, requires that activities affecting quality be prescribed by documented instructions and procedures which include appropriate quantitative and qualitative acceptance criteria for determining that important activities have been satisfactorily accomplished. Contrary to the above, the following examples of failure to have or follow appropriate procedures or instructions were identified:
- a. No procedure or requirement existed for performing the documented evaluation required by Section 5.2.16 of ANSI N18.7-1976 when measuring and test equipment was found out of calibration. An example was identified by the inspectors in which a documented evaluation was not made when three torque wrenches were found out of calibration.
3f(ii) Three 0-600 ft-lb torque wrenches; #H57167, #E57167, and
#E45984 were found to be out of calibration at their last calibration in the M&C Department. No documented evaluation was required by PBNP 5.5, nor was one made, concerning the validity of work completed with these devices since the previous calibration The lack of a procedural requirement to perform an evaluation on M&TE found to be out of calibration is contrary to Section
.5.2.16 of ANSI N18.7-1976 and is an example of a noncompliance with 10 CFR 50, Appendix B, Criterion V (266/83-21-08E; 301/83-20-08E).
PENP 83/NRC-06 There is no tracking system to ensure proper calibration of mechsnical MTE (torque wrenches, micrometers, etc.). Furthem, when an out-of-calibration condition did arise, it was difficult to determine what measurements had been performed with that equipment.
Response
Although we recognize this as a violation of the ANSI standard, we believe this example should more appropriately be an open item. This item is similar to the Quality Assurance Section Deficiency _ Report A-153-83 dated September 15, 1983. By May 31, 1984, a review will be conducted of these practices. As Step 2.5 of PENP~5.5 states, those maintenance activities which require calibrated MTE will be logged, so-that if out-of-calibration MTE is found, the use of that. equipment can be tracked. PBNP 5.5 will be changed as a result of review to require documented evaluation of~ out-of-tolerance-MTE.
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Violation No. 2 - 2
- b. No procedure or requirement existed for independent verification of jumpers and lifted leads, as required by Section 5.2.6 of ANSI N18.7-1976.
3e(ii) Review of the jumper and lif ted lead log revealed that the following had been performed without independent verification: 28, Unit 1 component cooling system slides opened on 10/11/83 29, Unit 1 safety injection system, lif ted wires in cabinet 1324F-B on 10/11/83 37, Unit 2 -radiation monitoring system, jumpered out flow switch on 10/20/83 The following was installed and removed without independent verification: 13, Unit 2 safety injection valves 2MOV 841 A/B lif ted control motor leads ANSI N18.7-1976, Section 5.2.6, requires that these types of temporary modifications be independently verified. As discussed in Paragraph 3.d(ii), there were no procedural requirements for independent verification of jumpers and lifted leads. Failure to have procedural requirements and failure to perform independent verifications of temporary modifications is an example of an item of noncompliance pursuant to 10 CFR 50, Appendix B, Criterion V, the Quality Assurance program, as described in Section 1.8 and 1.8.5 of the FSAR'and ANSI N18.7 (266/83-21-08D; 305/83-20-08D (sic)). PBNP 83/NRC-48 There is no periodic and documented review of existing jumpers and no independent verification of jumper instal-lation, per requirements of ANSI N18.7, Step 5.2.6.
Response
We acknowledge this' fir. ding, in that.there was no independent verification of jumper installation. The procedure has been' reviewed to incorporate independent verification appropriately and was changed by March 1, 1984. EQRS does periodically audit the " Lifted Lead and Jumper," and this audit is documented. Revison 5 of PBNP 4.17 includes the requirement for appropriate independent verification of the removal of jumpers,- bypasses, and lifted leads, in accordance with plant policy. We are now in compliance. 'We note that this item was also identified as the third example of Open Item No. 8. l' (
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- Violation No. 2 - 3
.c.- The disassembly, repair, and reassembly of Unit 2 2P15A safety injection i pump were accomplished in June, 1983, (an activity beyond normal craft 4
skills) without the use of approved maintenar.:e procedures,, as required by Section 5.2.7 of ANSI N18.7-1976. l 3c(ii) Review of MR's 34916, 36643, and 38068 and interviews revealed i that the Unit 2 2P15A safety injection pump was disassembled, repaired, and reassembled to correct deficiencies described on these MR's in June, 1983. These repairs were made without the use of an approved special or routine maintenance procedure, based on interviews with personnel and the fact that there were - no instructions or reference to maintenance procedures or technical manual for performing these repairs listed on the MR's. ' Licensee representatives stated that technical manuals were used; however, these were not approved or controlled. ANSI N18.7-1976, Section 5.2.7, requires maintenance to be preplanned and performed in accordance with written procedures appropriate to the circum-stance. Disassembly, repair, and reassembly of a safety injection pump was beyond the normal skill of the crafts.- Failure to specify and utilize the appropriate approved maintenance procedures,'which include the= appropriate qualitative and quantitative acceptance criteria for repair of the 2P15A safety injection pump, is an item of noncompliance pursuant to 10 CFR 50, Appendix B, Criterion V, the Quality Assurance Program, as described in Section 1.8 and 1.8.5 of the FSAR and ANSI N18.7 _ (301/83-20-08A).. PBNP 83/NRC-70
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Three MR's were written to repair a safety injection pump.
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(34916,'36643, and 38068). There were no specific documented instructions concerning disassembly and repair of the pump; no reference to routine maintenance procedures-(RMP's), SMP's, or technical manuals; nor were hold points exhibited. Since this is a rather frequent evolution, it was suggested an RMP be prepared to perform the task.
-Response:
The fact that a maintenance procedure was not referenced on ttt MR's is accepted. An RMP has existed-for repair work done on safety injection pumps since-ll/19/73. This approved procedure, used while.the unit'is on line, addresses operational-requirements for removing ~ pump from service; references! the technical manual-'for apecific repair instructions; and' addresses testing requirements,for' returning;the pump to service. 'This. RNP was not used in the~above-referencediinstance, due to. supervisory oversight, because the unit was in a refueling . , outage. Although not documented, repairs were performed'
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using the technical manual as-a reference,land post-maintenance testing was performed as indicated'on'the maintenance requests.- To address 1this. the maintenance. request procedure will be-reviewed.by M'y.31, a 1984,.to determine'the types of instructions which should-be included on the MR.- m.
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Violation No. 2 - 4
- d. No independent technical review was performed for Modification 82-114, as required by Procedure PBNP 3.1.2, Rev. 13.
3e(ii) Review of Modification Request 82-114 showed that there was no documented independent technical review performed for the replacement and interchange of Unit 1 pressurizer sample valves for the modification. Section 4.4.1 of Procedure PBNP 3.1.2, Revision 13, requires that " independent technical review (s) of the design change is obtained..." Section ll.a of the modifi-cation request form requires the technical review to be documented in Section 11.a of the form. The independent review was not documented in Section ll.a of the modification form for Modifi-cation Request 82-114. Failure to perform and document this review is an example of an item of noncompliance pursuant to 10 CFR 50, Appendix B, Criterion V, and the Point Beach Quality Assurance Program as described in the FSAR, Section 1.8.5, and PBNP 3.1.2 (266/83-21-08C). PBNP 83/NRC-29 For Modification Request 82-114 (sampling system valve replacement), there was no documentation of an independent technical review having been performed, as specified in ANSI N45.2.ll.
Response
An independent technical review had been performed, but proper signoff of the review on the modification request form was not done. Required signatures have been obtained and involved personnel reminded of the need to follow established design control requirements. We are now in compliance. 4
Violation No. 2 - 5 l
- e. No procedurc existed for the setting of torque switches on Limitorque
. valves, an activity beyond normal craft skills, as required by Section 5.2.7 of ANSI N18.7-1976.
3c(ii) Interviews revealed that no written procedure existed for the setting of torque switches on Limitorque valves, and there was no requirement to record the amperage used to set the torque switches. Verbal instructions were used to set torque switches. On June 10, 1983, the torque switch for component cooling water valve 2MOV-738B was adjusted per MR 38030 without a written procedure. As described above, ANSI N18.7 requires written procedures appropriate to the circumstance. It is the inspector's ex-perience that the industry considers setting of torque switches to be beyond the normal skill of the crafts; however, the licensee disagrees with this position. Failure to have a written procedure which includes the appropriate qualitative and-quantitative acceptance criteria and setting 2MOV-738B without a procedure is an item of noncompliance pursuant to 10 CFR 50, Appendix B, Criterion V, the Quality Assurance Program,.as described in Section 1.8 and 1.8.5 of the FSAR and ANSI N18.7-1976 (266/83-21-08A; 301/83-20-08B). PBNP 83/NRC-71 There is no Maintenance procedure for testing Limitorque valve motor current.
Response
We disagree with the broad statement that " setting of torque switches is beyond the normal skill of the crafts." " Normal skill" is a product of natural ability, training, and experience. We agree there is no written instruction and up to now no such procedure was found nec-essary. I An administrative procedure will be developed prior to August 31, 1984. Individual " maintenance instructions" for appropriate maintenance activities will be developed on an appropriate schedule. l l v w-
Violation No. 2 - 6
- f. A review of four completed maintenance requests (MR's) revealed that they had not been processed in accordance with the MR form, in that the required Maintenance procedure titles or numbers were not recorded on the MR by Maintenance supervision.
3c(ii) The MR form requires Maintenance supervision to reference SMP's j drawings, procedures, etc. , on the MR form. Review of completed MR's 36617, 36761, 36764, and 38005 revealed that Maintenance supervision had not listed the SMP or RMP numbers or titles on the MR form. Failure to list the appropriate SMP or RMP on the MR forms is an item of noncompliance pursuant to 10 CFR 50, Appendix B, Criterion V, and the Quality Assurance Program, as described in Section 1.8.5 of the FSAR (266/83-21-08B; 301/83-20-08C). PBNP 83/NRC-54 There is no indication on some MR's of the specific SMP/RMP used.
Response
This observation is accepted as correct. Generically, the MR form (MT-19, 4/83) has a specific place for referencing SMP, RMP, procedures, etc. As part of an MR procedure review under the criterion and guideline of ANSI N18.7, we will review this portion of the MR form for appropriate human engineering aspects in an attempt to eliminate any examples to the contrary. This review will be done by May 31, 1984. It should be emphasized that the form is not the controlling document, but rather the procedure, PBNP 3.1.3. The MR form does not require a reference to SMP's, drawings, procedure, etc. There is a place to list numbers, but there is no procedural requirement to do so. This example of a violation is more appropriately classified as a weakness. h
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r ... - . VIOLATION NO. 3 l (Level IV) 10 CFR 50.59 requires that a written safety evaluation be prepared and 4 maintained for changes-in the facility, as described in the Safety Analysis Report, documenting the basis for the determination that the change does not ir.volve an unreviewed safety question.
. Contrary to the above, the following design changes were implemented or
- approved for implementation without the preparation of the required safety
; evaluation:
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- a. 82 Relocation of fuel oil line between the emergency diesel generators and the emergency fuel oil tank.
! b. 82 Improvement of shielding wall around the reactor plant , j demineralizers. '
- j. c. 83 Installation of shield wall close to reactor coolant filters.
- d. 83 Provide electrical power for steam generator outage utilizing reactor coolant pump power leads.
3e(ii) Review of Modification Requests 82-51, relocation of the fuel
- oil line between the emergency diesel generators and the 12,000-gallon emergency tank; 82-73, improve shielding around
- l the reactor plant demineralizers by. adding to an existing
- shield wall; 83-66, installation of shield wall close to reactor coolant. filters; and 83-97, provide' temporary electrical power for steam generator outage utilizing reactor coolant pump
! power leads, showed these were classified as non-nuclear-related and no 10 CFR 50.59 safety evaluations were required consistent , with the licensee's past practice. These systems are described j in the FSAR'and 10 CFR 50.59 requires a written safety evaluation-
- for changes in the facility as described in the safety analysis report. ' Failure to perform and document safety evaluations for.
, the above modifications is an item of noncompliance pursuant to j- 10 CFR 50.59 (266/83-21-14; 301/83-20-14).-
l Response: } This notice.of violation cited four examples of modifications for which no documented safety evaluation pursuant to 10 CFR 50.59 was prepared
, - prior to the implementation or approval ~for implementation of these j plant modifications. Since the initial publication of 10 CFR 50.59 in' August of 1973,*it has been our understanding that the scope of 10 CFR 50.59 required reviews for proposed changes to the safety analysis report. Further, it is our belief that the. intent of both 10 CFR 50.59 and the supporting sta;ements of consideration reference ; the-safety analysis report, which we differentiate'from the entire:
Final Safety Analysis ReportL(FSAR). - It should also be noted that, until~quite recently, our.FSAR was known as the Final Facility Descriptionfand Safety Analysis Report (FFDSAR), clearly indicating-1 4 a s o -v--a w M n- *-e 4 4 ,w. g +g w 4 4--*---r-- ~ - - -wvm-~s -pp - w e-r +-,m --p w%q gy=.e s. r,y-wy-~vg
. , - , .- _. .. . . - = _ _ _ ._ _ _ - . .
- rc Violation-No. 3 - 2 i the scope of the documents. Thus, plant practice was to review i proposed facility changes against our safety analysis report (FFDSAR, Chapter 14), rather than against the entire FFDSAR.
This practice was further confirmed by the Inspection and Enforcement position paco on 50.59 issued June 1, 1976, which states that the
- intent is limited to those changes, "which could impact the safety
- of operations." Therefore, it was our belief and practice that 10 CFR 50.59 applied to the safety analysis report, not the entire i Final Safety Analysis Report.
~ In reviewing the specific examples cited, it is noted that three of the 3 modifications did, in fact _ receive a level of review comparable to i that which would have been given to a modification requiring a 10 CFR 50.59 l review. In all cases, compensatory engineering measures, as evaluated by the engineering and safety reviews performed, were taken, as necessary. These measures assured a greater protection to public health and safety than normally expected through a 10 CFR 50.59 documented review. Therefore, the major basis for this violation is not the lack of review, but the lack of a documented. review. j In the several discussions following the discovery of this violation.
- it became clear that our interpretation was not that favored by the l NRC. .Thus, on January 17, 1984, a memorandum was issued which expanded
;. our scope of 10 CFR 50.59 reviews to encompass the entire FSAR, ; including the five volumes and associated appendices. This memorandum constitutes corrective action taken, action taken to prevent further noncompliance, and January 17, 1984, is the date when full compliance was achieved. However, during the' aforementioned discussions with
- Region-III representatives, it was acknowledged that cequiring 10 CFR 50.59 i
reviews for alll changes to FSAR-mentioned systems and components would expand 50.59 reviews beyond their intended scope. For example, as
~
i described in the Inspection and Enforcement position' paper, a simple
, change in the engineering office layout is now required to have- -
a documented 10 CFR 50.50 review, since this layout is shown in an
- FSAR drawing.. Clearly, this is not what is required by 10 CFR 50.59.
l Therefore, although the above action has achieved full compliance, we intend to define.the intended scope of 10 CFR 50.59 to eliminate these nonproductive reviews. It is our intent to provide more detailed guidance and criteria in our plant administrative procedures. , This will allow the fulfillment'of the stated objectives of 10 CFR'50.59 without diluting the importance of 50.59 reviews through trivial
- exercises.
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.. - - . _. .. -. - - . - - . -- . ~ . -
+ . l l l VIOLATION NO. 4 (Level IV)
- j. 10 CFR 50, Appendix B, criterion II, as implemented by the. Point Beach
- _ -Quality Assurance Program, FSAR Section 1.8.2, requires that personnel l
- performing activities affecting quality be trained as necessary to assure -'
that suitable proficiency is. achieved and maintained. Contrary to the above, inspection training was not provided to personnel performing inspections in the Instrument and Control and Maintenance and Construction Departments. While the technical qualifications of these personnel is not in question, they had received no training in the inspection process, inspector responsibilities, etc. I 3a(ii) Criterion II of 10 CFR 50, Appendix.B. states, in part:
"The program shall provide for indoctrination and training of personnel performing' activities affecting quality...."
Section 1.8.2 of the FSAR states that the program provides
- such training and that training procedures are established.
A review of the G/C audit revealed several potential i
, noncompliances or program deficiencies in this area. The j findings and finding numbers are listed below
. 83-039 - Maintenance supervisors sign off for inspect. ions performed without evidence of inspection training on file.
! . 83-042 - All inspections performed by I&C personnel are done I without inspection training (including receiving inspection), i )
- An evaluation of the corrective action responses to these findings revealed the
] following shortcomings: i . 83-039 - The response did not address the specific issue j presented in the finding. The response addressed the i craft skill training but did not address inspection training. i
. 042 - The response addressed receiving inspection j training only.
i !- .The inspectors examined the inspection' training of Maintenance and I&C personnel .(G/C findings 83-039 and 83-042) relative to the requirements of Generic Letter 81-01, the WEPCO response to that letter, and the conditions of the NRC acceptance of the.
~
WEPCO response. The WEPCO response basically stated'the inspection program described in FSAR Section 1.8.10 as an 1 alternative to the requirements of Generic Letter 81-01. The NRC accepted the WEPCO alternative contingent, in part , i upon WEPCO maintaining adequate records to provide objectivs 4 evidence of the following activities:
. The use'of " peer" type, independent inspection for final ' -
acceptance of work.
. l Initial evaluation and periodic reevaluation of personnel who perform these inspections.
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Violation No. 4 - 2
. .Necessary training to assure acceptable proficiency of these personnel.
. Requirement for demonstrated proficiency of these personnel.
The PBNP FSAR Section 1.8.10 states that, with few exceptions, Point Beach personnel meet the requirements of ANSI 18.1-1971 (as required by Section-3.4.2 of ANSI 18.7-1976) and are therefore qualified to perform plant inspection, examination, and testing activities. ANSI 18.1-1971 does not directly address the qualifications for inspection personnel. It does require that training and retraining programs be established to develop fully qualified personnel and to maintain proficiency (Section 5.1). FSAR Section 1.8.2 states that personnel performing quality-related activities are trained and qualified in the principles and techniques of the activity being performed and that appropriate training procedures are established. The failure to provide inspection training for Maintenance-and I&C personnel performing inspections is considered a violation of 10 CFR 50, Appendix B, Criterion II (266/83-21-02;. 301/83-20-02).
Response
PBNP has long recognized that the only adequate' inspection for quality. ! characteristics of craft work is that performed by personnel familiar with the craft under inspection. Deficiencies, when identified, were i addressed to increasing levels of authority until a mutually-satisfactory resolution was obtained. However, it is acknowledged that the training heretofore provided did not provide documentation in the areas covered within this citation. Accordingly, the Nuclear Power Department-(NPD) has established an Inter-Section Review Group (ISRG) and'an associated working group to evaluate a number of issues,-including training of personnel. One of the objectives of the working group will be to establish and recommend appropriate training of personnel performing inspections in the-I&C and Maintenance.& Construction Divisions. We expect that a' scope-of-training-document will-be proposed by the group by May 1, 1984, with program development and training initiated.by October 1, 1984.
-As an interim action until the complete establishment of_a formal, training program, a memorandum will be prepared by April 15s 1984, reminding all supervisory personnel of their responsibilities in the inspection process.~ Full compliance is expected to be achieved on or.
'about April 1. 1985, with the initial completion of the formal: training program; however, the corrective action taken as above should' prevent' further noncompliance in the interim.-
;We would emphasize that at the time of the NRC_ audit, the'QA Committee had not~ accepted the' proposed corrective action related to WE QA Com-mittee Audit Finding 83-039.
L
VIOL /. TION No. 5 (Level V) Technical Specification 15.6.5.3.8 requires that audits be performed under i the cognizance of the Off-Site Review Committee (OSRC) encompassing conformance of facility operation to provisions contained in the Technical Specifications and applicable license conditions at least once per year, and the results of actions taken to correct deficiencies occurring in facility equipment, structures, systems or method of operation that affect nuclear safety at least twice per year. , Contrary to the above, during the period November, 1980, through May, 1983:
- a. No audits were performed under the cognizance of the OSRC of Technical Specifications contained in Sections 15.6 (Administrative Controls),
15.2 (Limiting Safety System Settings), 15.5 (Design Features). 31(11) Technical Specification 15.6.5.3.8(a) requires that audits be performed under the cognizance of the OSRC encompassing the conformance of facility operation to provisions contained within the Technical Specifications and applicable license conditions at least once per year. It has been the custom for the OSRC members to perform these audits during the semi-annual meetings. A review of the OSRC minutes from November, 1980, through May, 1983, revealed that not all provisions of the Technical Specifications were being audited. Specifically, no audits have been performed on the requirements of Section 15.6, " Administrative Controls," Section 15.2 Safety Limits and Limiting Safety System Settings," Section 15.5,
" Design Features." Audits of Section 15.3 " Limiting Conditions for Operations," have been limited to Subsections 15.3.1,
" Reactor Coolant System," and 15.3.10. " Control Rod and Power Distribution Limits." Further, the OSRC Review and Audit Plan dated October 4, 1983, covering the period of Fall, 1983, through Spring, 1986, specifically noted that Sections 15.6 and 15.3 were not included (although three subsections of Section 15.3 were included in the attached tabulation). The plan suggested that significant violations in those areas would be reviewed as part of the OSRC normal review function.
This does not constitute an audit. The failure of the OSRC to audit all provisions of the Technical Specifications is considered an example'of a violation of the Technical Specification 15.6.5.3.8 (266/83-21-24A; 301/83-20-24A). PBNP 83/NRC-04 The Off-Site Review Committee does not perform a line-by-line audit of the total Technical Specifications as required. About 80 man-hours of auditing per year is probably insufficient time.
Response
We wish to point out that the OSRC PBNP was formed prior to Appendix B and many of the standards presently being applied to Quality Assurance-type activities. The E
Violation No. 5-2 types of reviews and audits which have been carried out are in accordance with what we intended to do in committing to carry out our Technical Specifications. Nonetheless, we recognize that definitions and interpretations have changed over the years and that the NRC does not consider the audits f to meet current standards. We also wish to comment on the concern over the areas audited. We do not consider that a 100%, line-by-line investigation is the intent of any auditing activity. Auditing, financial or otherwise, is a spot check to give reasonable assurance that necessary activities have been carried out. As part of our redirection of OSRC audits, we will prepare a plan which we consider will, over a period of time, appropriately audit activities in each of the sections of the Tech Specs referred to in your findings. It should be noted a review of the last six meeting minutes of the OSRC shows that the OSRC discussed more than 65 items contained in Sections 15.2, 15.5, although such sections were not always identified in the minutes.
~
l 1 i I l l L
Violation No. 5 - 3 ) I
- b. Only limited audits were performed of Technical Specifications contained in Sections 15.3 (Limiting Conditions for Operation).
See Violation No. Sa, 31(11) .
- c. No audits were performed of the results of actions taken to correct deficiencies.
31(11) Technical Specification 15.6.5.3.8(c) requires audits to be performed under the cognizance of the OSRC of actions taken to correct deficiencies occurring in facility equipment, structures, systems, or method of operation that affect nuclear safety at least twice per year. A review of the OSRC meeting minutes from November, 1980, through May, 1983, indicated that no audits had been performed in this area. The OSRC Review and Audit Plan for Fall, 1983, through Spring, 1986, noted that audits in this area could be accomplished by means of discussions with responsible staff members. This does not constitute an audit. The failure to perform audits in this area is considered an example of a violation of the Technical Specification 15.6.5.3.8 (266/83-21-24B; 301/83-20-24B). PBNP 83/NRC-26 Formal audit checklists are not used: 1) By the Off-Site Review Committee 2) By PBNP in all its audits, in particular, in the quarterly audits of Operations logs.
Response
It is acknowledged that neither the Off-Site Review Committee nor PBNP has a complete file of audit checklists. To correct the Point Beach aspects of this report, PBNP 3.3.2,
" Administration of Quality Assurance Audits and Surveillances,"
has been revised to require an audit plan or checklist for QA review activities. This procedure was issued December 9, 1983. Checklists were implemented by December 9, 1983, and will continue through the future. See response to item 6a for OSRC corrective action. I i
Violation No. 5 - 4 The following excerpt from 31(11) is not applicable to Sa, 5b, or Sc, and is to be viewed as background information: It is the NRC position that an organized written plan or matrix should exist which identifies all applicable Technical Specification line items to be audited. During each 12-month period, a selected sample of line items in each of the 5 major sections of the Technical Specifications are to be audited and audits scheduled such that all applicable line items in the Technical Specification will be examined by the auditing organizations within a specified period of time. The time period is to be determined by the licensee and will be subject to NRC review. The period should be based on the history of Technical Specification compliance and the audit. frequency should be increased or decreased accordingly. The plan or matrix should be routinely updated to accurately reflect the status of the audit program.
i VIOLATION NO. 6 (Level V) 10 CFR 50, Appendix B, Criterion XVIII, as implemented by Point Beach Quality Assurance Program, FSAR Section 1.8.18, including a commitment to ANSI N45.2.12, ANSI N45.2.23, and ANSI N18.7-1976, requires that a comprehensive system of planned and periodic audits be carried out in accordance with written procedures or checklists by appropriately trained personnel and the results documented and reviewed by management having responsibility in the area audited. Contrary to the above, the following examples of failure to meet these requirements were identified:
- a. Audits were performed by Point Beach site personnel and OSRC members not having appropriate audit training, as required by ANSI N45.2.23-1978.
While these personnel had appropriate technical qualifications, they lacked training in audit techniques and requirements. 31(11) Section 1.8 (Quality Assurance Program) of the FSAR states that the PBNP QA Program commits to the guidance provided in ANSI 18.7-1976, which includes commitment (with exceptions noted) to ANSI 45.2.12 (Draft 4, Rev. 2), " Requirements for Auditing of Qur.lity Assurance Programs for Nuclear Power Plants." The OSRC audits are not conducted in accordance with this standard in that there is no documented audit training of OSRC members, as required by Sections 2.3 and 5.3 of the standard. However, there was no question relative to the technical competence of the auditors. 3h(ii) A review of qualification of audit personnel, audit training, and maintenance of proficiency revealed the following:
- A member of the Nuclear Engineering Section (NES) audited QAD in 1981 and 1982 without having received documented audit training which was included as a finding in the G/C audit.
In-plant auditors of the Point Beach Engineering, Quality and Regulatory Services (EQRS) have no documented evidence of audit training. They did appear competent to perform those audits they completed. There was no appropriately trained lead auditor in the EQRS organization. The failure of the EQRS to conduct audits with appropriately trained auditors under the direction of a designated lead auditor is contrary to ANSI 45.2.23, Section 1.8 of the FSAR, and is an example of a noncompliance with 10 CFR 50,
' Appendix B, Criterion XVIII (266/83-21-17A; 301/83-20-17A).
t
' l Violation No. 6'- 2 PBNP 83/NRC-27 Item: Formal auditor qualifications are not documented.
- l. NES conducts technical audits of QAD without documented audit training.
- 2. There is no documented QA audit training for EQRS
- personnel.
1
- 3. There is no lead auditor at PBNP.
Response
This is accepted as an appropriate observation. The QA program description at Pages 1.8-22 and 1.8-23 acknowledges l that technical audits are not performed under ANSI N45.2.12 requirements. QAD has established lead auditor training program. This program is available to provide general audit training, although some modifications may be necessary. This modified program was implemented in January, 1984.
. 1. Training for qualification as a lead auditor should l not be required for NES personnel. As a response to j the Corporate QA Committee audit NES has requested in
{ a memorandum to Mr. D. M. Stevens, dated November 29, 1983, QA auditor training for seven people from NES
~
i staff. This training has been completed.
- 2. PBNP sent two individuals to the above-mentioned audit
. training program in January, 1984.
- 3. Since PBNP conducts technical audits subject to further 3 audit by qualified lead auditors, no requirement exists for PBNP to possess lead auditors.
1 As stated in the. forwarding letter, we are discussing =
- the subject. of 0ff-Site review committee audits with other utilities and find that such auditing' activities have been delegated to others by the OSRC, a practice l which apparently satisfies the NRC.- While.we believe
. .such delegation is less effective than~ personal in-volvement of the senior individuals serving on our 0SRC.-
- ve also believe it is impractical to provide them the training necessary to qualify individuals as QA auditors in accordance with QA standards and to
. maintain such qualifications. We, therefore, may be 4 required to respond to this finding, as'have others, by delegating the audit activities and having the OSRC review the audit reports. Such audits would.
utilize appropriate audit check lists and be conducted' by trained auditors. JWe are.now in compliance. .-
,,si' .-*
Violation No. 6-3 b.- Audit reports by the Quality Assurance Division did not always contain an evaluation statement of the effectiveness of the quality assurance program elements audited, as required by Section 4.4.4 of ANSI N45.12-1976. 3h(ii) Section 4.4.4 of ANSI 45.2.12-1976 requires that audit reports contain a summary of audit results, including an evaluation statement regarding the effectiveness of the quality assurance program elements audited. The audit reports issued by the QAD did not consistently contain this evaluation. The audit reports issued by EQRS, in general..contain no evaluation statements. FSAR Section 1.8.18 states that " Technical Audits" are not performed under the requirements of ANSI 45.2.12. To the extent that EQRS audits are considered technical audits, the specific requirement for an evaluation statement does not apply, although it is good practice. These statements provide one resource for management and independent review organizations in assessing the adequacy of the program.- The failure of the QAD to consistently include evaluation statements in its audit reports is contrary to the requirements of ANSI N45.2.12 and is an example of a noncompliance with 10 CFR 50, Appendix B, Criterion XVIII (266/83-21-17B; 301/83-20-17B). PBNP 83/NRC-11 There is no periodic assessment of the effectiveness of the QA program, either as a statement in the individual audit reports or in a combined statement.
Response
QAD has revised QAI 6 to require such an assessment in audit reports. This revision was implemented by December 30,- 1983. We are now in compliance.
-i
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Violation No. 6 - 4
- c. ' Audit responses were not always submitted within the 30-day time period. For example, of a sample of ten audits performed by QAD within the last two years, six responses were late. Of the responses to the 55 findings of the audit led by a Gilbert / Commonwealth representative for the Quality Assurance Committee, 23 were late by 27 to 56 days.
3h(ii) A review of audit follow-up indicated that out of ten QAD audits reviewed, five responses were late and one audit per-formed on July 21, 1983, had received no response. Of the responses to the 55 findings of the G/C audit, 23 were late by 27 to 56 days. The failure to respond to audit findings within the 30 days required by ANSI N45.2.12 is an example of a noncompliance with 10 CFR 50, Appendix B, Criterion XVIII (266/83-21-17C; 301/83-20-17C). PBNP 83/NRC-16 Many times appropriate corrective action is not taken in a timely fashion. This is not in accordance with ANSI N45.2.12.
Response
Revision 3 to PBNP 3.3.2, " Administration of Quality Assurance Audits and Surveillances," requires a 30-day response to in-plant audit ftndings, as well as providing for notifying the Manager - PBNP and then the Vice President should audit findings not be responded to within 30 and 60 days, respectively. This procedure was issued December 9, 1983. QA section procedure QAI PB-7.1 has been issued, which also establishes an escalation process when responses are not responsive or timely. We are now in compliance. 1 4 k
l Violation No. 6 - 5
- d. The OSRC issued no reports of its audits, as required by Section 4.4 of ANSI N45.2.12-1976, nor does it maintain records of audit procedures or checklists..as required by Section 5.2 of the standard. Audit results were summarized in OSRC meeting minutes.
31(11) Records of audits performed are not generated or maintained in accordance with Sections 4.4 and 5.2. No audit reports are issued (results of audits are summarized in the meeting minutes). Audit records (checklists, procedures, etc.) were not maintained. The failure of the OSRC to conduct its audits in accordance with ANSI N45.2.12, as committed in Section 1.8 of the FSAR, is an example of a violation of 10 CFR 50, Appendix B, '_ Criterion XVIII (266/83-21-17D; 301/83-20-17D). PBNP 83/NRC-03 There are no formal specific audit reports, the audit documentation being contained within the OSRC minutes.
Response
As mentioned in response to Violation 6a, the OSRC members themselves may no longer conduct audits. As noted earlier, we would like to reiterate that the definition of audit.in ANSI N45.2.12 was made after the initial requirement for the OSRC to' conduct audits. In view of this and the fact that ANSI N45.2.12 exists.as guidance only, no actua1' violation should be inferred. This is more of a good practice than an actual violation of requirements.- We consider that we are now in compliance. F.
.S v {s b
, .s ..
VIOLATION NO. 7 (Level V) 10 CFR 50, Appendix B, Criterion XV, as implemented by the Point Beach Quality Assurance Program, FSAR Section 1.8.15, including a commitment to ANSI N18.7-1976, requires that procedures and practices be established and documented to control materials, parts, or components which do not conform to requirements in order to prevent their inadvertent use or installation. Contrary to the above, no documented program existed to prevent the use of material from " Ready Stores" that had exceeded its shelf life. Par. 2: (Closed) Open Item (266/81-07-01; 301/81-06-01): Failure to control items with shelf-life limits. The licensee has failed to implement a program to control items in ready stores having limited shelf life. This has been made an item of noncompliance (266/83-21-26; 301/83-20-26) (see Paragraph 3m(ii)). 3m(ii): The licensee has no established program for shelf-life control for items in the PBNP Ready Stores. This is in noncompliance with 10 CFR 50, Appendix B, Criterion XV (266/83-21-26; 301/83-20-26). The licensee stated that a program had been drafted and was in the review process. However, considering that the item was originally identified in April, 1981, during a previous NRC inspection, corrective action has not been timely. PBNP 83/NRC-02 ' There has been no shelf-life control program established.
Response
This observation is accepted as correct, in part. We believe that we fully met the intent of the provisions of 10 CFR 50, Appendix B, Criterion XV, as it relates to the control of nonconforming materials. It is acknowledged that a formal shelf-life program was not fully implemented; however, a program is now in place. A shelf-life control program would better be stated as a program improvement rather than a violation for not providing such a program. Initial expansion of a shelf-life program occurred on March'1, 1984. We are now in compliance.
- ~ , . -
VIOLATION NO. 8 (Level V) 10 CFR 50, Appendix B, Criterion XVII, as implemented by the Point Beach Quality Assurance Program FSAR Section 1.8.17, requires that sufficient records be maintained to furnish evidence of activities affecting quality and that these records be stored to prevent destruction by fire, flooding, theft, or deterioration by environmental conditions. Procedure PBNP 2.2.1 requires that these records be stored in the vault or microfilmed for duplicate record storage Contrary to the above, the only copies of MR's dating from 1978 and records of surveillance tests PT-M-1 (1971-83), PT-S-2 (1976-83), PT-A-1 (1971-83) were stored on open shelves in the Maintenance office and in non-fire rated cabinets in the I& office. 3c(ii) During an inspector's review of Maintenance, the inspector noted that MR's which had been prepared and completed since 1978, starting with No. 20006 through approximately 38000, were stored on open shelves in the Maintenance office and in non-fire rated cabinets in the I&C office. These MR's included many which were safety related. Also, technical specification tests completed by Maintenance were stored in non-fire rated file cabinets in the Maintenance office. Some of the test records stored and the date of the tests were PT-M-1, Station Battery (1971-1983); PT-S-2, Emergency Diesel Annual Inspection (1976-1983); and PT-A-1, , 3A Emergency Diesel Annual Inspection (1971-1983). Technical Specification 15.6.10 requires records of principal maintenance activities and periodic checks to be retained. Regulatory Guide 1.88 and ANSI N45.2.9, Section 5.6, require these records to be . stored in fire rated vaults or duplicate records stored in a remote location. The licensee procedure, PBNP 2.2.1, requires these records to be stored in the vault or microfilmed for duplicate records storage. Tnese records were not stored in a fire rated vault nor was a duplicate record established. This is an item of noncompliance pursuant to 10 CFR 50, Appendix B, Criterion XVII, the Quality Assurance Program, as described'in Sections 1.8 and 1.8.17 of the FSAR, Regulatory Guide 1.88, ANSI N45.2.9, and PBNP 2.2.1 (266/83-21-09; 301/83-20-09). PBNP 83/NRC-76 Records stored in the Maintenance office have not been duplicated or stored in accordance with ANSI N45.2.9 guidance. These records. include, but are not limited to, surveillance tests, procedures, and maintenance requests.
Response
The finding is' accepted as correct. Maintenance records have been microfilmed in accordance with existing procedures.
.We are now in compliance.
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VIOLATION NO. 9 (Level V) 10 CFR 50, Appendix B, Criterion II, as implemented by the Point Beach Quality Assurance Program, FSAR Section 1.8.2, requires that activities affecting quality be conducted under suitably controlled conditions, including cleanliness. Contrary to the above, the following examples of failure to maintain 4 cleanliness were identified during a walk-through inspection on October 11, 1983: Loose items (tools, lens caps, paper) on the refueling bridge crane while people were working over the refueling pool. Gum wrappers and candy wrappers in the residual heat removal pump room (posted as no smoking or chewing area). 3j(ii) The inspector found while performing a walk-through of the plants on October 11, 1983, that a general housekeeping problem existed throughout both plants, as evidenced by:
. Several loose items were noticed on the refueling bridge (tools, lens caps, paper) while people were working over the refueling pool.
. Gum wrappers and candy wrappers were found in an area that was posted as no chewing or smoking for radiological purposes (i.e., residual heat removal RHR pump room).
This is an item of noncompliance with 10 CFR 50, Appendix B, Criterion II, which requires suitable cleanliness conditions for accomplishing activities affecting quality (266/83-21-20; 301/83-20-20). The inspector also noted cigarette butts laying on the floor of the El. 6.5' of the f acade (both units) and around the "A" main steam isolation valve for Unit 2. These areas were posted as no chewing or smoking areas for radiological purposes. The basement of the facade areas were in a general unclean condition with dirt, tape, radiological control swipes, and a respirator laying around. The licensee was informed of the inspector's findings on October 11, 1983, and took action to clean up the areas. A subsequent walk-through of the plants on October 28, 1983, showed an improvement and no major problems were identified in the housekeeping and cleanliness areas of the plant at that time. , PBNP 83/NRC-89 On 10/11, a cleanliness / housekeeping inspection was conducted, and a potential item of noncompliance was identified in that cigarette butts, candy wrappers and other refuse were observed in controlled side areas not designated for such purposes (the Unit 2 facade).
c -
. g- ~ .
Violation No. 9 - 2
Response
-The finding is accepted as correct. Adherence to work rules has had much emphasis at Point Beach. To reinforce the seriousness of violations to smoking and eating policies and housekeeping in general, the Manager - Point Beach Nuclear Plant sent a memo to each Point Beach employee and contractor supervisor by January 1, 1984. As noted in the NRC exit, a followup inspection on October 27, 1983, indicated a significant improvement.in the areas checked. We are now in compliance.
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.:n, 'b.
ATTACHMENT B OPEN ITEMS Attached are the paragraphs identifying 11 open items with 59 specific examples. Following each example is the deficiency /QA finding, as identified by Wisconsin Electric as a result of the exit interview of November 16, 1983. Also included is the p corrective action. The included dates should be recognized as targets and not as commitments. l We will note that we could find no open item identifiable in Paragraph 3k(ii) as you listed in Inspection Reports No. 50-266/83-21(DE); 50-301/83-20(DE), Section 4. 'e 4 m r
1 l 1 OPEN ITEMS Open Item No. 1 (3a(ii)) The following e::cerpt from 3a(ii) is not applicable to Open Item No.1 and is to be viewed a background information. Section 1.8.16 of the FSAR, " Corrective Action," states: " Procedures and practices are established and documented to assure that conditions adverse to quality, such as deviations, are promptly identified and l corrected. In the case of significant conditions adverse to quality. these measures include assurance that the cause of the condition is determined and corrective action taken to preclude repetition. These include provisions for identification of the significant condition adverse to quality, the cause of the condition, and the
- corrective action taken to be documented and reported to appropriate l levels of management. Provisions are included for followup reviews to verify proper implementation of corrective actions and to close out the corrective action documentation." There are several weaknesses in the corrective action system currently in place at PBNP.
Example I :While reviewing IST records for valves, the inspector noted a comment in the margin on the data record made by the person performing the test that Valves 850A&B were not fully closed when the indicating lights indicated the full closed position. The inspector asked the engineer who had reviewed and approved the data record if this condition had been corrected; the engineer did not know. He stated l that the operator should have initiated an MR to repair the valve. ! The inspector asked if there was a tracking system to assure that j the repair was accomplished; he stated that there was not. The i engineer informed the inspector the following day that the operator had initiated an MR and provided the MR number. Apparently, this system places almost total reliance on the operator to have done the "right" thing with no formal verification or tracking on the part of supervision, such as the noting of the MR number initiated in the l procedure margin by the operator. PBNP 83/NRC-19 i There is no apparent comprehensive corrective action system, i.e., inservice test deficiencies are noted but there is no reference to the maintenance request icaued to correct the deficiency, nor is any tracking of repair completion in a tracking / deficiency log. Although it was ccknowledged that there is an administrative system for nonconformance identification and reporting, the NCR's are ! closed out quickly; there is no long-term corrective action; there is no review to identify possible generic issues; nor are NCR's periodically reviewed and open NCR's tracked on the administrative punchlist or similar document.
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Response
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\ The observation is accepted. Neither PBNP 4.5.7, " Technical Specification Test", nor PBNP 4.5.8, " Inservice Inspection Tests
nor PBNP 4.5.9 " Periodic Callups", nor PBNP 4.5.10. " Operations Refueling Tests",: givabggdance on how to take corrective action l when a deficiency is'found"in the testing. Further, there is no , method for tracking th $ completion of these maintenance requests.
. Specific methods for> improving this tracking are under evaluation.
The process of NCR iisauance, review, and closure will undergo an ! intensive isluation, with the necessary improvements identified i and proceduralized by May 31, 1984. The procedures will be reviewed to give guidance on deficiency
- followup by May 31, 1984.
s , ! The following excerpt from 3a(ii) is not\api icable l to Open Iten No. 1 and is l to be viewed as ba?k ground information. ,, i e5 Tracking weaknessds extended.*M other corrective action situations, > cm well. Itwasnote'dbycdgOSRCinminutesofMeetingNo.29that ! the Administrative Punch 11st:-(AIL) was ineffective in serving as a tracking document for SOER's. It! was noted that, while the completion of' required reviews were tracked and documented, required actions or f their completion were not tracked. Example II: The corrective action documents used by the licensee include the I maintenance request (MR), SOE's, LER's, NCR's, QDR's, and ADR's. The MR covers hardware problems. The NCR's, SOE's, and.LER's cover significant conditions. The QDR's and ADR's cover specific areas. There was no formal system for reporting or review of those items that do not fall within the criteria for these documents, such- - , ' as a deviation report which would cover any or all deviations or nonconforming conditions adverse to quality and could be written or initiated at any organisational hvel. While many such items were covered in the Manager's Supervisory Staff meetings and tracked as open items in the mesting'ainutes (and sometimes the'APL),'there is s no system for assuringsall items were documented in a systematic
" manner. Thisecould preclude these items from being considered in 3 assessments of,,Q'A program status.gidequacy and effectiveness.
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Thyre is' essentially no formal tracking of followup corrective. actions,ta, y. ken'to corr,ect deficient areas. I l
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s The lack of formality.in some areas is accepted as a correct observation.'} Deficiencies.identifiedandreportedbyQADare l, ' tracked and followed up per QAI-PB-7. A functional corrective ! action system is in place at Point Beach in that deficiency , l reports on one audit.are followed up in a subsequent audit.- j !a This system will be proceduralised by May 31, 1984. ' L , m ._._.__...______.__.___..________m.__
Further, an inter-section committee will be formed which will evaluate a corrective action tracking system departmentwide. This committee should have its recommendations to the Vice President by May 31, 1984. Open Items - 3 Example III: As noted in Paragraphs 3.1 and 3.h, the OSRC does not perform audits of corrective action effectiveness, as required by the Technical (NR)* Specifications, nor has the QAD performed any audits of the overall corrective action system in the last two years (audits of some corrective action systems, such as the maintenance request system, have been performed). These items collectively indicate weaknesses in the corrective action program. This weakness is considered an open item and will be reviewed further in a future inspection (266/83-21-04; 301/83-20-04).**
*(NR) denotes there is no PBNP response at this time.
**This represents three specific examples.
L
Open Items - 4 Open Item No. 2 (3b(ii)) Example I: The licensee's procedure for the control of Maintenance activities was PBNP 3.1.3. PBNP 6.1.3 contained supplemental instructions for
! the I&C group regarding maintenance requests. PBNP 5.1.4 contained instructions which were almost the same as PBNP 3.1.3 and apparently i was not used any longer, based on interviews with M;.intenance super-vision. The inspector's review of the current Revision 7 of PBNP 3.1.3 and the associated maintenance request (MR) form revealed the following:
As noted above, there were three procedures which described the processing of MR's. It appeared that these three could be combined into one and eliminate possible confusion. PBNP 83/NRC-56 There are currently three procedures governing maintenance requests (3.1.7, a general, overall procedure; 6.1.3, used by I&C; and 5.1.4, utilized by Maintenance, however, not currently in use). These procedures should be reviewed with consideration given to integrating them into one comprehensive procedure.
Response
We acknowledge this observation. Three separate procedures can be confusing when changes to one are not appropriately factored into each of the others. The intent of the thrce separate procedures, which collectively form one procedure, was to provide for the group specialization which exists. The three procedures will be combined into one overall procedure following the MR procedure review under the criterion and guideline of ANSI N18.7. This will be done by May 31, 1984. , Example II: The purpose of 3.1.3 is, in part, "to provide a means for all personnel to report. deficiencies that require maintenance work which does not (NR) involve a substantial modification." Normal maintenance does not involve modification and the phrase "which does not involve a substantial modification" is not appropriate. Example III: There was no requirement in the procedure or on the MR form for shift supervision to document approval for work to commence. Interviews revealed the approval was verbally obtained and, if a tagout was required, approval was documented on the tagout form. Also, shift supervision did not get a copy of the MR at the time work commenced, which should be used to keep the control' room informed on what work was in progress for plant status and shift turnover purposes. With this informal system, it was possible for work to.be performed on the plant without shift supervision's knowledge. This matter is consideret to be a significant weakness, and was discussed at length with license < representatives. The licensee took some prompt corrective action, which included issuing a memorandum to all personnel to require notification of shift supervision and the~ maintenance of "in-process"
'MR's by the shift supervisor.
l Open Items - 5 PBNP 83/NRC-65 There is no provision on the MR form for DSS approval to commence work.
Response
PBNP acknowledges this observation. Approval required to commence work is accomplished through the same vehicle which is used to complete the loop of removing system from operational service; specifically, the red tag series. This observation cannot be implemented without an in-depth review of the MR process so that the Shift Superintendent is not unduly burdened with administrative duties needlessly. This aspect will be evaluated during an MR procedure review under the criterion and guideline of ANSI N18.7, and a method of documentation of this activity will be evaluated and implemented by May 31, 1984. Example IV: There was no requirement for shift supervision to document on the MR that the maintenance had been satisfactorily completed and followup (NR) requirements had been completed. Example V: The procedure and the MR form did not address requirements to reference the associated radiation work permit (RWP) and equipment tagout on the MR form. PBNP 83/NRC-57 There is no requirement to record an RWP number on the MR.
Response
We accept the observation as correct. There has been no historically-demonstrated need for this cross-reference. PBNP ALARA philosophy is predicated on cleanliness and job planning, rather than statistical compilation. The MR serves to close the equipment loop and the RWP serves to close the personnel exposure loop. Cross-referencing for subsequent similar tasks is accomplished through equipment numbers and/or job description which appear on both the ER and RWP. Although no problem is perceived at this time, this aspect will be evaluated during an MR procedure review under the criterion and guideline of ANSI N18.7 by May 31, 1984. PBNP 83/NRC-59 There is no re'quirement to document a red tag series on the maintenance request. l l q
Open Items - 6
Response
We accept the observation. The red tag procedure is intended to open, control, and close the loop associated with the removal and return of equipment, primarily to provide adequate personnel safety. Consequently, it becomes important to reference the work request number (s) on the red tag series to ensure total inclusion as the PBNP red tag procedure does. The MR procedure, on the other hand, is intended to open, control, close, and document the loop associated with equipment deficiencies. While the specifics of the maintenance request process are germane to the red tag documentation, the reverse is not true. However, this will be further evaluated during an MR procedure review under the criterion and guideline of ANSI N18.7. This review will be done by May 31, 1984. Example VI: Review of completed MR's showed that Operations stamps the MR form for required return-to-service testing. Procedure PBNP 3.1.3 does not describe this activity. The MR form and the tagout form also have equipment testing requirements. It appeared that the testing requirements could be combined into one requirement to avoid confusion. PBNP 83/NRC-87 A review of the use of the Operations " inservice test required" stamp should be conducted on the best document to place this on to ensure proper testing is conducted following MR completion and eliminate possible duplication.
Response
This observation is accepted. The use of this stamp will be reviewed along with revision to maintenance request procedure. It is felt that the use of the stamp should be either described in that procedure, or the intent of the stamp be included on the maintenance request form. This will be evaluated during an MR procedure review under the criterion and guideline of ANSI N18.7 by May 31, 1984. Example VII: Cognizant Maintenance supervision was not required to approve MR's and had limited involvement in the preparation of the MR. As discussed in Paragraph 3c(ii), there was a lack of adequate work (NR) instructions on most completed MR's. Not having cognizant Maintenance supervision in the preparation-and-approval chain may have cont-ibuted to this lack of. instruction. Example VIII: The MR form did not have a space allotted specifically for work instructions to the Maintenance worker. When work instructions were provided, it was usually in the paragraph entitled " Defect (Describe the problem /Kequest) (When defect does not exist,-but
,a request for service is made)." Neither the procedure nor the form emphasized.the need for adequate work instruction'in the preparation of the MR, nor specifically required'the cognizant Maintenance supervisor to determine the need for work instructions.
Open Items - 7 PBNP 83/NRC-66 There is no provision on the MR form for documenting references or instructions to workers.
Response
? PBNP acknowledges this observation. It will be evaluated during an overall MR procedure review under the criterion and guideline set forth in ANSI N18.7. This will be done by May 31, 1984. Example IX: If the requirements of a Maintenance activity exceeded the scope spec'.fied on the MR, there was no written guidance in the procedure to terminate the work and revise the MR or initiate a new MR. Continuing to work outside the original scope of the MR would result in an unapproved work activity. PBNP 83/NRC-60 There is no procedural guidance on what actions to take if the repair work necessary exceeds the scope of the originally approved MR.
Response
This observation is accepted as correct. The Superintendent - M&C or I&C is charged with the responsibility of correcting equipment deficiencies in accordance with the administrative controls established. Further guidance in this regard will be evaluated for inclusion during an MR procedure review under the criterion'and guideline of ANSI N18.7. We have relied on close on-the-job supervision and good communications between the worker and the supervisor to assure l that if the scope of the " repair" changes, the supervisor is aware and concurs. Because we are reevaluating the approval for beginning of work, we will also review this observation. This review will be done by May 31, 1984. Example X: There was no requirement to identify test and measuring equipment used on an MR. (This was also identified in the recent Gilbert / Commonwealth Associates audit.) PBNP 83/NRG-67 There is no provision for logging the serial number of MTE on the MR form.
Response
PBNP acknowledges this observation. This will be evaluated during an MR procedure review under the criterion and guideline of ANSI N18.7. This review will be done by May 31. 1984.
i Open Items - 8 Example XI: There was no requirement for cognizant Maintenance supervision to evaluate if the MR was a design change and document this decision on the MR form. PBNP 83/NRC-68 There is no guidance in PBNP 3.1.3 to direct evaluation of an MR as a modification requeet, and there is no place to document that such review was completed on the MR. There should be procedural guidance for the review, even if it is not documented on the MR form.
Response
PBNP acknowledges this observation for the procedural guidance and will evaluate both the guidance and the documentation during an overall MR procedure review under the criterion and guideline set forth in ANSI N18.7. This review will be done by May 31, 1984. Example XII: There was no requirement for cognizant Maintenznce supervision to review the completed MR and assure that the root cause was determined and documented. PBNP 83/NRC-64 There is no requirement to review the MR to ensure the root cuase of the failure or discrepancy has been docu-mented. This is contrary to the requirements of ANSI i N18.7.
Response
PBNP acknowledges this finding. This will be evaluated as part of an overall MR procedure review under the criterion and guideline set forth in ANSI N18.7. THis review will be done by May 31, 1984. Example XIII: Maintenance supervision was not required to' insert " hold points," nor was QA required to review and approve MR's and
' insert " hold points," if required' prior.to issuance of the
~
MR's. PBNP 83/NRC-55 There is no documentation of independent QC inspection maintenance activities, whether this function is performed , by the foreman acting as QC inspector or other independent in-process inspection. QA inspections of' maintenance activ-ities should include real-time, in-process audits.
Response
We acknowledge this finding-that the documentation of the above activities is-insufficient to demonstrate ~ total compliance with WE response and NRC acceptance,of this response to Generic Letter 81-01. . This aspect will be evaluated 'during an MR procedure: re-Eview under the. criterion and guideline:of ANSI N18.7, and a method. of documentation of this activity.will be evaluated and implemented. '~ _ , by .May_ 31 .'.1984.
1 i l , Open Items - 9 I- Example IVX: There was no guidance in the procedure related to work within craft capabilities or when a Maintenance procedure should be prepared, based on the complexity of the work. l PBNP 83/NRC-58 i
-There is no procedure or policy on determining an individual worker's scope of responsibility, i.e., no checkoff that the assigned worker has been qualified to do the task.
Response: j 4 We acknowledge that minimal documentation exists for
" craftsmanship" level of qualification for many PBNP employees.
F We are developing _ training programs and qualification documentation which are being utilized by recently hired employees. Progression i' through the craftsmen ranks is contingent on the completion of time, experience, and training within classifications. A PBNP employee's scope of responsibility is defined by his immediate supervisor and/or group head. This aspect will be evaluated during an MR procedure review under the' criterion and guideline of ANSI N18.7, and a method of documentation of this activity will be evaluated by May 31, 1984, and implettented, if appropriate. Example XV: The procedure did not address the reportability of the failure or malfunction which was identified by the MR, nor was there a y requirement to reference on the MR form any reports which were generated. PBNP 83/NRC _6_2 2 There is no requirement or guidance tol evaluate a maintenance request for LER, NPRDS, or 10 CFR Part 21~reportability.
Response
This observation is acknowledged and will be evaluated as part of an overall MR procedura review under the criterion and guideline set forth.in ANSI N18.7. The evaluations are being performed presently, but in an informal manner not represented in the present procedure.under control of the'QA Coordinator and Quality Engineer. Final complete review'and revision of the-MR procedure can be' accomplished by May 31, 1984. Example XVI:- The MR form required documenting whether an ignition permit'was required.-~There was no guidance in the procedure as to when an ' ignition permit was required or reference to the: ignition permit
. procedure which contained such guidanca. ~
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l i i PBNP 83/NRC-63 There is no guidance or reference to the ignition control permit procedure in the maintenance request procedure.
Response
PBNP acknowledges this observation. This will be evaluated during an overall MR procedure review under the criterion and guidance of ANSI N18.7. This review will be done by May 31, 1984. l 4
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Open Items - 10 Example XVII: The procedure required documenting information on the MR to identify traceability of any parts used. However, there was no , (NR) discussion or reference to another procedure on how to initially - obtain the part. Example XVIII: The procedure did not provide any guidance on the temporary (NR) and permanent storage of MR's. Example XIX: There was no requirement to put the date the work activity was (NR) initiated on the MR form. This could be useful when reviewing an event. Example XX: Interviews revealed that QA reviewed all completed work requests; (NR) however, there was no requirement in the procedure for QA to review all MR's. The above items were discussed with the licensee. The licensee stated that these items would be included as items to be addressed in a planned upgrade in their Maintenance program. This is considered to be an open item pending further review of the licensee's action during a subsequent inspection (266/83-21-05; 301/83-20-05).*
*This represents 20 specific examples.
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Open Items - 11 Open Item No. 3 (3n(ii)) Example I: The inspector reviewed the licensee's program for control of technical manuals. A program was in place. Procedure 2.2.3, Revision 6, provided the guidance and requirements. The pro-cedure required technical manuals to be updated as changes were received from the vendors; however, it did not specify who was responsible for compiling the c'..tnges and assuring that the changes were distributed and accomplished. PBNP 83/NRC-77 The procedure for the control of technical manuals should be upgraded to designate responsibility for issuing up-dates and revisions to manual holders with documentation.
Response
The observation is accepted. A propsed revision to PBNP 2.2.3,
" Component Instruction Manuals," is being routed for review. QSRO assigned work item of July, 1983, previously identified problems with manual control and, specifically, updating manual drawings.
It is expected that approximately 80 weeks (3200 man-hours) will be required to perform the job. Inventory of manual storage locations is in progress and continues as personnel tvailability permits. A status memo will be forwarded to the Manager - Point Beach Nuclear Plant quarterly, starting in January, 1984, until all manuals at Point Beach are controlled appropriately. Example II: Review of the licensee's preventive maintenance (PM) program showed that the program had been established _and implemented. The program included a schedule and PM procedures in the form of callup cards which included instructions or referenced procedures for performing the PM. Description. and responsibilities for the PM program were described in PBNP 5.1.3. Review of Revision 1 of this procedure re-vealed that there were no instructions specifying the following for the PM program: Responsibility for establishing the frequency for performing preventive maintenance. 3 Responsibility and requirement of upgrading the PM program, based on system failures. PBNP 83/NRC-73 PBNP 5.1.3, " Preventive Maintenance," does'not specify . ., responsibility for establishing the frequency of such main-tenance, upgrading or increasing of frequency, etc. e
1
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Open Items - 12 1 l
Response
This observation is accepted as correct. Responsibility for implementing the preventive maintenance program is addressed in PBNP 1.3.3 and PBNP 5.0.1. PBNP 5.1.3 has been changed to more clearly assign responsibility as of February 29, 1984. Example III: The licensee had established machinery histories for operating equipment. Review of the machinery history procedure, PBNP 5.7, Revision 0, revealed it did not contain a requirement to periodically review the machinery history cards for repetitive failures or other problems. PBNP 83/NRC-72 PBNP 5.7, " Machinery History," does not include provisions for periodic review of such records to determine if a problem is repetitive in nature.
Response
This observation is accepted as correct. Although it is felt that knowledge of repetitive problems is best obtained by the involvement of Maintenance supervision in the daily activities of the work group, and the machine history file serves as a source of information which can be reviewed to further evaluate equipment reliability, the procedure will be reviewed by May 31, 1984. Example IV: The licensee had developed an ignition control permit procedure, PBNP 3.4.1, which specified the requirements'for ignition permits and fire watches. A weakness was noted in Revision 5 of the procedure, in that it did not require the fire watch to be. capable of communicating with the control room when a fire hazard activity was performed in the proximity of flammable material, cable trays, or vital equipment. PBNP 83/NRC-90 The ignition control procedure should be revised to require personnel to know where communications devices (telephone or Gai-tronics) are located and to contact " Control" when a fire-watch is established in a flammable materials or cable tray area. Rosponse: This observation is accepted. This additional instruction-has been included in the procedure. Example V: Review of the procedures for. preparation of special and routine Maintenance procedures (PBNP. 5.1.1 and 5.1.2) showed there was no requirement to insert " hold points" ':ba these procedures, when applicable.
j PBNP 83/NRC-20 1 There is no requirement or guidance for insertion of " hold points" on the MR, RMP, or SMP; i.e., when inspection should occur, etc. Open Items - 13
Response
This observation is accepted as correct. For evaluations covered solely under a maintenance request, hold points .if used, are best left to the supervisor to determine and document, if necessary, on his instructions to workers. Guidance for the supervisors will be included as part of a broader review of the PBNP administrative and management control policies and practices related to the conduct of maintenance and documentation of quality control inspections. This will be done by May 31, 1984 Criteria for hold points in all SMP's, RMP's, as well as periodic tests for both I&C, as well as Maintenance, will have to be defined. The aforementioned groups will then be required to implement these criteria. -This will be a continuing process with initial results prior to September 3, 1984. These items are considered to be an open item pending further review of the licensee's actions during a subsequent inspection (266/83-21-06; 301/83-20-06) .* i l l l
*This includes five specific examples.
Open Items - 14 Open Item No. 4 (3b(ii)) ] 1 Example I: Review of the index for routine maintenance procedures (RMP's) showed that only 22 procedures had been prepared. This is a small (NR) number considering the number of maintenance tasks performed and the length of time the plant has operated. Example II: Interviews revealed the licensee was performing independent position verifications of instrument isolation and bypass valves that were manipulated for calibrations during refueling outages. Calibrations are not normally performed du:ing plant operation, except if maintenance was required. The licensee identified during the interview with the inspector that independent position verificatior during maintenance had not been addressed and agreed to address the matter. This is considered to be an open item pending further review-of the licensee's action during a subsequent inspection (266/83-21-07; 301/83-20-07).* PBNP 83/NRC-88 Independent verification of. valves under I&C control should be formally addressed.
Response
This finding is technically correct. ICP 10.12 requires I&C to perform independent valve position verification on all instrumentation calibrated and maintained inside containment and safety-related instrumentation outside containment prior to initial criticality following refueling operations. There are circumstances which could develop during operations subsequent to initial criticality following refueling that would require instrument calibration or maintenance. In such circumstances, there is no formal requirement to perform independent valve position verification. It should be noted that such maintenance and calibration is rare, and that there is only a very small percentage of safety-related or important-to-safety instruments that would have normal indications if an improper valve lineup existed. Because the possibility exists (even though cemote) for valfe lineup errors of this nature to go undetected, the following actions will be taken:
- 1. I&C will establish a criterion which can be utilized to -
determine whether a specific instrument requires independent valve position. verification. This criterion will follow l guidelines _already' established by Operations. This criterion
- f will be established by June 1,-1984.
- 2. .I&C will modify existing procedures and write any new procedures necessaryLto formally document them and require
- independent valve position verification for the instruments l
' meeting the criteria. established above. These procedures j will be implemented by December 31, 1984._ '
L .. l *This includes two specific examples. , l l
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Open Items - 15 l 4 Open Item No. 5 (3c(ii))
' Example I: Review of completed MR's listed in Paragraph 3.c(ii) revealed they usually only contained documentation of the problem and the corrective (NR) action. There was rarely any instructions provided on the MR form for Maintenance personnel performing the work. Very seldom was an
, SMP, RMP, technical manual, or drawing referenced on the MR form. There was very little written evidence of any preplanning of a - maintenance activity. This is considered to be a significant weakness. Example II: Interviews revealed there were no independent QC inspections of maintenance work in progress. The licensee had no plant personnel ! (NR) dedicated to performing independent QC inspections. Any in-process . inspections performed were by Maintenance supervision who were not independent nor did they have any documented inspection training. This is discussed further in Paragraph 3.a(ii) < Example III: Review of Procedure RMP-25, " Repair of Waste Gas Compressor KIA (KIB)," Revision 0, revealed that the instruction provided for repair (NR) of the compressor was inadequate. Section 3.3 of the procedure' states, ! " Disassemble and repair KIA (KIB) waste gas compressor as required." -; There was no reference to a technical manual, drawing, or instruction , on how to perform the disassembly and repair. This is considered to
- be an open item pending further review of the licensee's action during
' a subsequent inspection (266;83/21-10; 301/83-20-10).* 1 l 4 1 i i
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*This' includes three specific examples.
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Open Items - 16 Open Item No. 6 (3d(ii)) The licensee's main procedure for control of design changes was PBNP 3.1.2, " Modification Request," Revision 13. The corporate Nuclear Engineering Section procedure for control of design changes was NES 4.3, " Modification Request," dated 6/1/81, and referenced PBNP 3.1.2 for preparation and implementation of design changes. Several other procedures supported design change activities. Review of the design change program given in these procedures revealed that the program does not fully meet the requirements of ANSI N45.2.11, 1974, " Quality Assurance Requirements for the Design of Nuclear Power Plants." Some of the areas of the standard not addressed are listed ' as follows: Example I: All of design input listed in Section 3.2 of the standard are not addressed. (See PBNP 83/NRC-33 in Example II below.) Example II: Design analysis instructions required by Section 4.2 have not been (NR) prepared. Example III: Interface control requirements of Section 5 were only partially identified. The interfaces between the site and NES and different site organizations were not well described. NES did not have internal or external interface procedures. The lack of NES internal interface procedures was also identified in the Gilbert / Commonwealth Associates audit. PBNP 83/NRC-35 PBNP 3.1.2 does not specify interfacing between the plant and NES.
Response
The purpose of NES Procedure 4.3 is to define the function-of NES in processing proposed modification requests for PBNP. . It provides some interface requirements between NES and PBNP regarding modification requests. PBNP 3.1.3 addressas PBNP/NES interface six times. PBNP 3.1.2 will be reviewed with NES 4.3 to assure compatibility and appropriate guidance by May 31, 1984. Example IV: The current procedures did-not fully describe design verification and who can perform it, as described in Section 6.1. PBNP 83/NRC-33 PBNP 3.1.2 does not meet N45.2.ll (1974), which contains 19 criteria to be evaluated; i.e., design inputs, analysis, specifications, design verification, etc.
Open Items - 17
Response
This finding is accepted as a suggestion. A design control procedure is in preparation to provide more specific guidance than contained in PBNP 3.1.2. FSAR, Section 1.8.3, specifies that we are committed to perform modification design activities to Section 8 of ANSI N45.2.11 (1974). We comply with Section 8, but the 19 criteria mentioned above are in Section 6 of ANSI N45.2.11. During the design control procedure review, the inclusion of the 19 criteria will be evaluated. This procedure should be issued by May 31, 1984. The licensee had identified that an additional procedure was requried to meet the requirements of ANSI N45.2.11 and was in the process of preparing this procedure. This is considered to be an open item pending further review of the licensee's action during a subsequent inspection (266/83-21-11; 301/83-20-11) .* t 4
*This includes four specific examples.
Open Items - 18 Open Item No. 7 (3d(ii)) Review of Procedure PBNP 3.1.2, Revision 13 revealed the following: . Example I: Section 4.9 required that "a new or modified system should not be placed in operation until appropriate changes are made to the P&ID's and the logic diagrams in the control room." This is a necessary requirement; however, there was no re-quirement to document, prior to acceptance of the system ! for operation, that the required drawings had been marked up. PBNP 83/NRC-34 PBNP 3.1.2, Step 4.9, discusses markup (bubble) drawings in the control room. There is no requirement, however, to document the markup or to identify the individual DCN's or to document DCN receipt.
Response
This observation is accepted as correct. Although this has not been a significant problem, it could be rectified by requiring signed acknowledgement cards, as is now the case with some procedures. Each group would incorporate DCN's as they determine 4 proper, with receipt signatures returned to the Supervisor - Staff Services. This process could be surveilled periodically. This process will be evaluated by April 15, 1984. Example II: Also, there was no requirement to document which specific (NR) drawings were required to be marked up. Example III: There was no requirement to establish training requirements for a modification prior to and/or after releasing for operation. There was no discussion on how information on the modifi-cation is given to the Training Department. Interviews with the Training Department revealed that training on modifi-cations was being accomplished, but the program had not-been formalized, and the licensee recognized that improvaments were needed. PBNP 83/NRC-36 The subject of training that is conducted as a result of modifications is not addressed within'the procedure nor is implementation specified. The procedure and modification form should be expanded to be utilized as a training tool.
Response
Although not included in the procedural guidance .there is - a checkoff and signoff cnt the modification request orm f to ensure required training is performed. Additionally, Training is now routed all modifications.when' initiated to determine if training
- may be required. Procedural changes will be made to better address training' requirements by May 31, 1984.-
i Open Items - 19 t Example IV: Section 4.1.7 of the procedure required that documents requiring changes are . indicated on Page 15 of the modification request farm by the Modification Engineer. Identification of document changes was indicated by a check mark by the applicable documents listed , on Page 6 such as drawings and procedures. There was no requirement to identify the specific documents to be changed or to document this in the modification package. When the responsible person initialed I that the document identified on Page 6 had been changed, there was no record of the specific documents that had been changed. PBNP 83/NRC-31 There is no listing within the modification request package delineating procedures which were reviewed or changed by the modification, new drawings which were issued, technical manuals issued or updated, etc.
Response
< This observation is' accepted. Although the, final design section of the Lodification request form. clearly states that new drawings, specifications, etc. , should be listed, existing - documents which require changes are not required to be listed. i'.though listing all such documents may hamper the timely closeout of modification requests, a review of the practice will be done by IJay 31, 1984. l Example V: The procedure described the methods by which a modification could
- be installed, such as a special maintenance procedure (SMP) or maintenance request (MR). However, there was no guidance on when an SMP was required, such as for complicated modifications, or an MR for very simple modifications. There was no guidance on what should-be in an installation procedure, such as reference to drawings, 1
weld procedures, and construction proceduras. PBNP 83/NRC-39 ! No procedural guidance is provided on the installation procedures, i.e., a checklist-type system which specifies an SMP, or at least an MR or other document. to perform the work.
' Response:
This observation is accepted, although a checklist on the modification request form specifies whether an SHT or MR~is required. Procedural: guidance will be evaluated by May 31, 1984 Example VI: There was no requirement to identify or attach a copy.of the SMP,- MR, or other implementing procedures as part of the modification 1 . history package.
~PBNP 83/NRC-32 There'is no docuuentation or' identification on how the modification.
has been implemented / installed; i.e., via RMP,jSMP MR. y s,,,,g ,we - -- - m - p n -e- - wr- w- gya ,e ,w qymn
Open Items - 20
Response
Although PBNP 3.1.2 does not clearly delineate the requirements for SMP or MR or RMP, it is included in Section ll.b of the modification request form, EQR-23 (10/83). Step 4.5.2 of the procedure does say, " Installation documentation....is also verified and referenced or attached...." Although we feel this is adequate, the procedure will be rereviewed by May 31, 1984. Example VII: There was no guidance in the precedure which addressed what documents should be included in the final modification history package. PBNP 83/NRC-38 PBNP 3.1.2 does not describe what the contents of the entire i modification package should include.
Response
This observation is accepted. Some additional guidance will be provided in PBNP 3.1.2 to describe what the contents of a modification package should include by May 31, 1984. Example VIII: Section 4.3.1 of the procedure indicates that a safety eval-uation, as required by 10 CFR 50.59, was required for only safety-related modifications. It did not address changes to the facil-ity, as described in the FSAR, as required by 10 CFR 50.59.
Response
The response to Violation 3 is applicable to this item. Example IX: There was no guidance provided on the procurement of safety-related equipment for a modification request,such as referencing the procurement procedure. PBNP 83/NRC-40 l No guidance is provided in PBNP 3.1.2 concerning the procurement l of safety-related equipment.
Response
The guidance for procurement of safety-related equipment is contained within PBNP 3.3.1, " Administration of Hardware Quality Assurance." In order to maintain consistency between PBNP procedures, the guidance contained within one is not duplicated in another. In view of the number of interfacing procedures,
~
it i.s not reasonable to provide references to those procedures within the modification request procedure.- Therefore, no action is taken in response to this observation.
Open Items'- 21 Example X: There was no discussion related to sending 10 CFR 50.59 safety evaluation to the Off-Site Committee for approval when the modification involved an unreviewed safety question. PBNP 83/NRC-41 PBNP 3.1.2 does not state the 50.59 discussions are transmitted to the OSRC in accordance with Technical Specification 15.6.5.2.7(c) and 15.6.5.3.7(a) and (b). i
Response
50.59 reviews are included in Manager's Supervisory Staff meeting minutes, which, per PBNP 1.7.1, Section 5.4, are copied to the Chairman of the OSRC. Although this satisfies the Technical Specification requirement, a procedural review will be done by May 31, 1984. Example XI: Section 4.2.2.0 required that fire hazard associated with the installation of the modification be evaluated. There was no requirement to identify design requirements for fire protection associated with a modification. l PBNP 83/NRC-42
- PBNP 3.1.2 does not include the requirement to conduct a fire hazards review, both in the design and during the implementation of a modification.
Response
Fire hazards, both during and after implementation, are required to be identified per PBNP 3.1.2, Step 4.2.2.0, as part of the engineering evaluation. This requirement is clearly listed on the engineering evaluation form. Some minor changes to PBNP 3.1.2 will be made te ensure a review for fire hazards is also performed for modifications i for which an engineering evaluation is not required by May 31,-1984. Example XII: There was no requirement for Quality Assurance to review the- , modification request package, after preparation but prior to ) implementation, to assure QA requirements-were included. Also, there was no requirement for QA to review the modification. package after the modification had been completed to assure that all the
- necessary documentation was included and proptrly completed.
PBNP 83/NRC Presently, the QA program provides for QA reviews of modification requests only at the initiation and at modification completion. I Provide a method for in-process QA coverage. 1 1
Open Items - 22
Response
This observation is accepted. PBNP 3.1.2 will be revised to add guidance and specificity for additional QA review between the design and construction phases of modification requests. The revision will be included in a broader review of the modification request routine by May 31, 1984, f 7.he licensee agreed to consider the inspector's comments for incorporation into the design change. program. This is considered an opet. item pending further review of the liceasee's action during a subsequent inspection (266/83-21-12; 301/83-20-12) * [
. *This includes 12 specific examples.
Open Items 23 Open Item No. 8 (3d(ii)) Examrle I: Procedure PBNP 4.17, " Lifted Wire, Jumpers, and Bypasses," Revision 4, specified the means of controlling jumpers on plant systems. Review of this procedure showed there was no requirement to perform a 10 CFR 50.59 review for the installation of bypasses or jumpers not covered by procedures which could affect plant safety. PBNP 83/NRC-47 The plant program for jumpers, bypasses and lif ted leads is inadequate in that these are in fact temporary modifications and, as such, should require a 50.59 review and appropriate management approval prior to installation, including backshift.
Response
We acknowledge this observation. PBMP has issued Revision 5 of this procedure to more accurately reflect the fact "that these are, in fact,' temporary modifications." As such, they will undergo more appropriate review and approval. This revision was completed by February 29, 1984. We are now ia compliance. , Example II: The procedure did not address the use of mechanical devices, such as dutchmen, temporary strainers, blind flanges, and piping bypasses. PBNP 83/NRC-49 4 Mechanical jumpers should be included in the scope of lif ted leads, bypasses, and jumpers.
Response
We accept the observation with the caveat that although not clear, mechanical jumpers are included within the scope of this procedure. This observation may have resulted from the fact that very few - mechanical jumpers are ever installed. The " Lifted Lead and Jumper" form (OPS-13,-11/81) has a block to be checked for " Mechanical." During the recently-completed review and revision to this procedure, we more clearly delineated this aspect in the procedure since it did not appear to be. clearly stated. This procedure review and change was done on February 29, 1984. Example III: Also, the procedure did not require independent verification of the installation and removal of jumpers and bypasses, as required by ANSI N18.7-1976. PBNP 83/NRC-48 There is no periodic and documented review of existing jumpers and no independent-verification of jumper installation per requirements in ANSI N18.7, Step 5.2.6.
Open Items - 24 l l l
Response
We partially agree with this finding in that there is now no independent verification of jumper installation. The procedure has been reviewed to incorporate independent verification appropriately and changed by March 1, 1984. EQRS does periodically (quarterly) audit the " Lifted Lead and Jumper," and this audit is documented. This audit function will be reviewed for adequacy by June 30, 1984. Revision 5 of PBNP 4.17 includes the requirement for appropriate independent verification of the removal of jumpers, bypasses, and lifted leads, in accordance with plant policy. The comments relating to independent verification and periodic review of the log were addressed in PBNP 83/NRC-48. This is in the response to Violation 2, Example b. The inspector discussed revising the procedure with the licensee to include 10 CFR 50.59 review requirements; approval of jumpers and bypasses by the Manager's Supervisory Staff (MSS) prior to installation, except for backshift emergencies where MSS approval can be after the installation; independent review of installation and removal of jumpers and bypasses; a periodic review of the jumper and bypass log; and control of mechanical jumper devices. The licensee representatives stated they were aware of most of the above items and were writing a temporary modification procedure to control jumpers and bypasses which would include these items. This matter is considered to be an open item pending further review of the licensee's actions during a subsequent inspection (266/83-21-13; 301/83-20-13).* l l
*This includes three specific examples.- !
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e 0 o t Open Items - 25 Open Item No. 9 (3h(ii)) The inspector could find no clearly-documented delineation of authority or~ responsibility between the QAD and EQRS in the area of audits. The licensee stated that this would be addressed in the revision to QA Volume II currently in progress. This is considered an open item pending completion of the revision to QA Volume II (266/83-21-18; 301/83-20-18). P3NP 83/NRC-14 There is no interfacing procedure between EQRS and QAD which defines responsibility and authority in the two organizations. This procedure should specify how the 18 criteria of Appendix B are fulfilled.
Response
This observation is accepted. An inter-section committee will evaluate existing procedures and make appropriate recommendations to the Vice President by May 31, 1984. d s
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1 Open Item No. 10 (3h(ii)) Example I: EQRS technical auditors have no documentation to support their (NR) qualifications to audit technical areas ! Example II: Since EQRS auditors have no formally-documented audit training, (NR) the audit procedure, PBNP 3.3.2, Revision 2, is not detailed enough. I Example III: When audit responses were overdue or continue to be unacceptable, there was no automatic escalation to higher levels of management i to assure corrective action.
- PBNP 83/NRC-17 There is no automatic escalation to upper management of inadequate i
audit responses to assure timely corrective action is being taken. i i
Response
i Revision 3 to PBNP 3.3.2, " Administration of Quality Assurance ! Audits and Surveillances," requires a 30-day response to in-plant i audit findings, as well as providing for notifying the Manager -
- PBNP and then the.Vice President should audit findings not be
] responded to within 30 and 60 days, respectively. This procedure ! was issued December 30, 1983. 1 Example IV: Audits by QAD were not consistent in reporting of persons contacted ] (NR) and pre-audit and post-audit attendees. ] Example V: Comprehensive audits of the overall corrective action system and j organization (Criteria II and XVI of 10 CFR 50, Appendix B).have not been performed in the last two years. Such~ audits are of value in assessing system effectiveness and adequacy in contrast j to individual program elements. t PBNP 83/NRC-12 , I It is not apparent how management assesses the effectiveness of j the QA program. 1
- Response
- l. Management assessment is provided through a wide variety of methods,.
including periodic meetings between the Superintendent-QADs and: the Executive Vice President and Vice President-Nuclear Power QA
- Committee meetings, QSRO meetings, as well as copy to routing of NCR's, g LER's and other appropriate correspondence. .As an aid to the determin-
,_ ation of the effectiveness of the QA program, audits will reflect a i statement of effectiveness'of the program portion audited. -Further,- i by ' fay 1,1984, our Inter-Section Committee will recommend to the Vice - President appropriate management assessment techniques. l l , These items will be pursued further during a subsequent inspection 'l and are collectively . considered an open item (266/83-21-19; 301/83-20-19). l l
~
. o; a Open Items - 27 Open~ Item No. 11 (31(11)) There were several weaknesses noted in the conduct of OSRC activities: Example I: The audits required by the TS to be conducted under the cognizance of the OSRC were conducted' exclusively by the members. . While the participation of OSRC members in these audits was a i significant strength, the exclusive use of OSRC members precludes reasonably _ comprehensive coverage of all Technical Specifications and other required audits in a reasonable period of time. - The i OSRC is staffed by senior-level personnel and provides a good I (NR) overview of plant activities. Cognizance of these activities is maintained, in part, by the review of the minutes of the Manager's Supervisory Staff meetings and on-site reviews during the OSRC t- semiannual meetings. However, as discussed above, the OSRC is not conducting the total audit program. required by the Technical Speci-fications. The use of the QAD, EQRS, and, perhaps, subcommittees i to perform these audits under the cognizance of the OSRC would 4 permit the audit program to be implemented in a comprehensive i j manner without diluting other OSRC activities, including parti- l l cipation in audit activities during.the on-site meetings. Example II: Open items (tracked via meeting mintues) were occasionally closed
~
{ prior to completion and evaluation of corrective actions. For l 2 example Item 20 of the minutes.of the meeting held on May 15-17,
- (NR) 1983, was closed on.the basis that a modification had been submitted.
- . - This removed any tracking mechanism for followup on the adequacy of the corrective action.
}_ Example III: The 0SRC had no charter.(other than the TS) or procedures'for
! the conduct of its activities (e.g., conduct of audits, audit i program planning, provisions for-providing minority reports, etc.).-
A draft charter was in the review process, which did provide some pro:edural guidance. j-
; PBNP 83/NRC-05 i
j - A~ charter of the OSRC should be prepared which outlines how business is conducted and_ include an expanded section which
- identifies the qualifications required and how the present -,
OSRC. meets these requirements. j Response: i A-charter.was discussed at the December OSRC meeting and will be-a approved prior to the first 1984 OSRC meeting..<It will not duplicate Technical Specification items regarding OSRC composition or operation. Resumes of OSRC will be updated by_the first meeting in 1984, but not'
~
included in charter. These weaknesses are considered an open item and will be reviewed further in a future inspection (266;83/21-25; 301/83-20-25).*
*This includes three specific examples..
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e ATTACHMENT C UNRESOLVED ITEMS Unresolved Item No. 1 (3a(ii)) The licensee's QA program is described,in Section 1.8 of the FSAR. Implementing procedures are included in QA Volume I, " Point Beach i Nuclear Plant Administrative Control Policies and Procedures Manual" (PBNP's), and various deparment procedures. QA Volume II, " Quality ] Assurance and Reliability Manual for Materials, Repairs, and Modifications," defines the quality assurance program to be imposed i for materials, repairs, and modifications for PBNP, along with program objectives and responsible company organizations and personnel. It also defines those systems and components to which the program applies. Section 1.8.2 of the FSAR states that management review of the status and adequacy of the QA program is accomplished, in part, by at least semiannual review by the WEPC0 QA Committee (QAC). This committee is compesed of management representatives from participating departments within WEPCO (nuclear and non-nuclear) and a consultant. A review of the QAC meeting minutes from March, 1982, through June, 1983, showed that the first effort to assess the QA program during this period, in a ecmprehensive manner, occurred in May, 1983. During May, 1983, a consultant from Gilbert / Commonwealth Associates (G/C), at the request of the QAC, conducted an audit of the WEPCO QA program and implementation for compliance with Section 1.8 of the FSAR. One of the findings of this audit was that the QAC had been ineffective in its review of the status and adequacy of the QA program (Finding 83-024). The QAC had conducted only one audit of the nuclear QA program in 1981 and one in 1982. Neither audit was sufficiently comprehensive to assess the program. The licensee had recognized this problem and initiated the G/C audit as a first step in taking corrective action. Actions have also been initiated to provide long-term corrective action. The failure of the QAC to review the status and adequacy of the QA program on a semiannual basis, as committed in the FSAR, is considered a violation of 10 CFR 50, Appendix B, Criterion II. However, since this item was also identified by the licensee,. in accordance with NRC enforcement policy, it will not be pursued as an item of noncompliance unless the licensee fails to take timely and effective corrective action. This is considered an unresolved item pending review of the completed corrective action (266/83-21-01; 301/83-20-01). PBNP 83/NRC-10 There is no documentation that the QA Committee will review the j effectiveness of the QA program every six months, in accordance
- with the FSAR 1.8 (Page 1.8-7).
[ Response: The finding is accepted. The Chairman of the QA Committee requested the~ Superintendent of QAD to include an assessment of the QA program be made an agenda item at each meeting of'the QA Committee. This will be done starting in 1984. Concurrently..a restructuring of the QA Committee is contemplated, which may cause FSAR 1.8 changes. l
l l i i Unresolved Items - 2 Unresolved Item No. 2 (3f(ii)) An inspection of equipment inventory and traceability revealed the following: Example I: The Maintenance and Construction Department has no formal equipment (NR) inventory list, although a handwritten draft of the torque wrench inventory was produced during the inspection. Example II: Maintenance and Construction Department micrometers are not marked with a unique identifying number and no traceability is maintained to NBS standards. (The lack of traceability was also identified by the May, 1983, audit by Gilbert / Commonwealth as Finding No. 83-041.: PBNP 83/NRC-07 For micrometers, there is no identification or status of calibration on the equipment and no traceability to National Bureau of Standards. Response: The observation is accepted as correct. As noted in the response to the 1983 QA Committee audit (83-041), PBNP 5.5, " Control of Measuring and Test Equipment," was issued June 23, 1983, and revised August 5, 1983. Although a very literal interpretation of ANSI N18.7-1976 would allow checking of micrometers in accordance with " normal commercial practices," PBNP will uniquely identify micrometers and have traceability to NBS. This will be done by July 1, 1984. Pending the M&C Department implementation and NRC review of the l corrective action response to the QA Committee audit and formalization of an inventory control system, these items will remain as an unresolved item (266/83-21-15; 301/83-20-15).*
*This includes two specific examples.
Unresolved Items - 3
-e Unresolved Item No. 3 (3f(ii))
A review of calibration status marking revealed the following: Micrometers used by the Maintenance group have no status marking (calibration stickers). The lack of statuc marking onmicrometers is a further example of lack of calibration control and will be tracked as an unresolved item pending implementation of the corrective action response to the Gilber/ Commonwealth Audit Finding 83-041 (266/83-21-16; 301/83-20-16). Response: See the reference and response to unresolved item No. 2. 4 i e I
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l Unresolved Items 4 Unresolved Item No. 4 (3j (ii)) The inspector talked to Maintenance personnel to determine the ) criteria or guidelines for conducting the "... final internal , inspections of pressure vessels, tanks, etc....," as stated in the QA program. The inspector could find no program or any procedures requiring such inspections. Maintenance personnel felt that cleanliness and internal inspections were part of good shop practices. The licensee had no documentation of performing such inspections. A program identifying the guidelines or criteria for these inspections needs to be established, which, as a minimum, requires these inspections to be accomplished prior to reinstalling the reactor vessel head, sealing safety-related systems af ter opening them, etc. The results of this inspection should also be documented, identifying such things as (1) conditions encountered which were not anticipated, including nonconformances, (2) identity of inspector or tester and (3) completion date of the test. The licensee has taken exception to this documentation in the QA program. This is an unresolved item pending further review by the inspector (266/83-21-21; 301/83-20-21). PBNP 83/NRC-21 Cleanliness inspections on equipment closeouts need to be documented. Response: We acknowledge this observation. PBNP policy has been to require closeout cleanliness inspections by the responsible work group, and we hold them responsible accordingly. The degree of documentation of this activity will be upgraded. This will be included in an overall MR procedure review under the criterion and guideline set forth in ANSI N18.7 to be done by May 31, 1984.
.s Unresolved Items - 5 Unresolved Item No. 5 (3k(ii))
The inspector also identified that the biennial review of procedures required by ANSI N18.7-1976 and implemented by PBNP 2.1.2 was not being accomplished or documented. All departments lacked this review, including Operations, Maintenance, I&C, Nuclear Engineering Section, etc. This noncompliance was identified in the Gilbert / Commonwealth audit. The licensee is taking action based on that audit finding. Because this was identified by the licensee and the licensee was taking corrective action, this item is considered unresolved pending completion of corrective action (266/83-21-23; 301/83-20-23). PBNP 83/NRC-81 Biennial procedure reviews are not being appropriately documented. Response: PBNP acknowledges this finding. An evaluation will be made of current methods of control and documentation of this function by May 31, 1984. NE procedures will be changed by May 31, 1984, to provide the requirement for periodic review. QAS has committed in a respose to the QA Committee audit to also assure appropriate review. d I 4 l _ _ _ _ _ . - - _m
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d Unresolved Items - 6 Unresolved Item No. 6 (3m(ii)) Other items of potential noncompliance and procurement program deficiencies were included as findings in the G/C audit (see Paragraph 3a(ii)). These findings and finding numbers are listed below. Example I: 83-003 - Failure to route all purchase requests initiated by the (NR) Nuclear Engineering Section through the Quality Assurance Division for review, as required by FSAR, Section 1.8.7. Example II: 83-009 - Failure to post 10 CFR 21 requirements and procedures for reporting in the Purchasing Department. PBNP 83/NRC-86 The posting of 10 CFR 21 in the plant and in the corporate office is not adequate. Paraphrased, the regulation states that each corporation shall post current copies of 10 CFR 21, Section 206 of the Energy Reorganization Act of 1974, and procedures adopted pursuant to the above where the activities subject to this part are conducted (10 CFR 21.6(a)). Response: This posting within the plant was evaluated as a result of the QA Committee audit. Revised postings were placed June 28, 1983. It is believed that these postings are adequate in content. By April 15, 1984, an evaluation of posting adequacy in each area will be reviewed. Example III: 83-011 - Lack of Procurement Department procedures concerning the generation.and maintenance of quality-related records, as required by FSAR, Section 1.8.17. PBNP 83/NRC-08 QAD does not follow up on Purchasing Department to assure proper transfer of QA-status information to purchase orders. Response: There appears to be some misunderstanding on the part of the NRC concerning this issue. QAD receives copies of all QA-scope purchase orders, at which time a review is performed, as stated in QAI PB-4, Section 3.14. Further, random checks of this function are performed during-QAD audits of the Purchasing Department. l As a footnote, it should also be noted that the Purchasing Department performs such review internally prior to issuance of QA-scope P.O.'s (effective September 1, 1983). This observation is not appropriate, in that controls are in place.
1
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i Unresolved items - 7 Example IV: 83-012 - Inability to assure that adequate quality requirements (NR) are included, referenced, or attached to procurement documents (especially 10 CFR 21 requirements). Example V: 83-026 - Lack of QAD receipt inspection procedures or instructions, (NR) as required by FSAR, Section 1.8.7. Example VI: 83-046 - Lack of receiving inspection procedures for receipt of i (NR) QA-scope items at PBNP Ready Stores. Example VII: 83-050 - Receiving inspection documentation of I&C equipment (NR) is not documented, as required by FSAR, Section 1.8.10. 1-An evaluation of the corrective action responses to these findings revealed the following shortcomings: 3 83-012 - Preventing future problems was addressed. However, the response did not address assuring that currently open purchase orders contain adequate quality requirements or that items currently in stock were procured with adequate quality requirements. 83-026 - No date was committed for completion of the training program or issuance of procedures / instructions. 83-046 - No date was committed for completion of corrective
- action implementation.
The lack of commitment dates in the 83-046 and 83-050 responses
- are derivative, at'least in part, to the lack of a completion date for 83-026.
In accordance with NRC enforcement policy, those procurement program findings identified by the G/C audit will not be pursued as items of noncompliance at this tile, but will- be. considered an unresolved item pending complete and timely corrective action by. the licensee (266/83-21-27; 301/83-20-27).*
*This includes seven specific examples.
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ATTACHMENT D PROGRAM WEAKNESSES l Program Weaknesses (3d(ii)) Example I: Review of the drawing change notice (DCN) status list of November 1 1983, showed there was significant backlog of drawings l requiring revision. Approximately 160 drawing revisions were outstanding for DCN's originated between January and October, 1983. l Interviews revealed that the backlog had been larger and the l licensee was taking steps to reduce it. l PBNP 83/NRC-75 There is a backlog of aporoximately 160 DCN's which have not been incorporated into plant drawings. Response: The observation is accepted as correct. To streamline the DCN process, DCN's are sent directly to the Engineering and Construction Department (which is responsible for drawing changes by Point Beach on a monthly basis, in accordance with Step 3.4.9 of PBNP 2.2.4, " Drawing Change Procedure," which was recently revised. Example II: Interviews revealed that NES engineers were generally not familiar with ANSI N45.2.ll-1974. PBNP 83/NRC-44 NES personnel are generally not aware of ANSI N45.2.11 guidance. Response: It is technically correct, but part of problem may be how the NES personnel interviewed were questioned. However, since FSAR 1.8 commits us to at least the provisions of Section 8 of ANSI N45.2.11 (1974), corrective act:on will be to work with QAD to develop and present a specific training lesson on ANSI N45.2.11 by April 1, 1984. Example III,: The drawing control program did not require informing the central drawing control person that a modification request was in progress which changed certain drawings until the modification was completed. This created the possibility that two or more persons could be making changes to the same drawing without other(s) knowing it. PBNP 83/NRC-74 There is no notification made to Staff Services so drawings can be annotated that a design change is being considered or made to alert other individuals to check with each cognizant engineer assigned to a modification that DCN's are in process which might affect other projects. Response: This observation is accepted as correct. Since all modifications are controlled by the Modification Engineer, multiple changes to a single system would be caught in his review process. Few problems have been observed in this area, but the process will be reevaluated by May 31, 1984.
I Program Weaknesses - 2 Example IV: Also, there was no description of how drawing revisions are handled (NR) between initiation and completion of the modification. Example V: The system that one of the contractors went through to revise a (NR) drawing was described to the inspector by an NES engineer and it was quite complicated. This was not described in any procedure. The procedure for drawing control, PBNP 2.2.4, described the iniriation of a DCN, starting with the "as-built" condition or when an error was noted on a drawing.
Program Weaknesses - 3 Program Weaknesses (3d(ii)) Review of completed modification packages listed in Paragraph 3.e(i) showed it to be difficult to track how the modifications were implemented and what documents were revised as a result of the modifications for the following reasons: Example I:The modification package normally did not identify how the modification was implemented. It did not reference special maintenance procedures (SMP) or maintenance requests which may have been used, nor were these documents included in the modification history package. PBNP 83/NRC-28 As a general rule, the documentation in final design packages is not well organized. Applicable and affected drawings are not documented on the modification request, nor are they annotated to reference the modification. Response: This observation is accepted. Additional procedural controls will be provided to establish minimum standards of acceptability for design packages by Ma 31, 1984. PBNP 83/NRC-32 There is no documentation or identification on how the modification has been implemented / installed; 1.e., via RMP, SMP, MR. Response: Although PBNP 3.1.1 does not clearly delineate the requirements for SMP or MR or RMP, it is included in Section ll.b of the modification request form, EQR-23 (10/83). Step 4.5.2 of the procedure does say, " Installation documentation....is also verified and referenced or attached...." Although we feel this is adequate, the procedure will be rereviewed by May 31, 1984. Exa=ple II: Section 11 of the modification form required a " Final Design (NR) Description" to be included on the form prior to implementation of the modification. In some cases, the description was very short, did not reference drawings, or give a good description of the modification. For Modification Request 83-5, the description merely stated " Installed 3/8" Valck (sic)* Mark 11 Valve." Example III: There was no identification in the modification package of the procedures that were revised, the drawings that were revised, or the training that was accomplished as a result of the modification. PBNP 83/NRC-31 1 There is no listing within the modification request package j delineating procedures which were reviewed or changed by the l modification, new drawings which were issued, technical manuals i issued or updated, etc. !
- Valek Mark II Valve.
I Program Weaknesses - 4 1 Response: This observation is accepted. Although the final design of the modification request form clearly states that new drawings, specific 4tions, etc., should be listed, existing documents which requi:s cha..si.a are not required to be listed. Although listing all such documents may hamper the timely closeout of modification requests, a review of the practice will be done by May 31, 1984. Example IV: Drawing and sketches included in the modification packages were (NR) not always positively identified to the appropriate modification request. In regard to the first and third items, the concerns of Paragraph 3.d(ii) identified a weakness that there was no requirement for these items. Other matters identified during the review of modification history packages were as follows: Example VI: SMP's used to implement modification requests did not always provide adequate instruction to do the job. The following are examples: Section 3.6 of SMP 425 used to implement Modification Recuest 82-13 stated " Weld flanges lA, install plates and torque studs." There was no reference to an applicable drawing or veld procedure. PBNP 83/NRC-50 When SMP's are issued, the instructions are vague. For example, SMP 425 required a weld, but no procedure for a weld was required. Response: The detailed observation is accepted as correct. The exte.t of detailed instructions provided in Section 3 (Maintenance and Contractor section) of an SMP is dependent on many factors, inclu-ding complexity, uniqueness, other procedures and documents, experience of personnel, involvement of other groups or agencies, authorized inspector hold points, etc. In this case, SMP 425 served to coordinate the activities associated with the installation of a modification request which included a specific welding procedure. While SMP 425 may be seen as having vague instructions, SMP 426 contains 7 pages of instructions pertaining to Section 3. PBNP 5.1.2, "Special Maintenance Procedure," will be reviewed and changed appropriately by May 31, 1984. Example VII: Section 3.4 of SMP 427 for Modification Request M661 stated
" Tie-in reactor coolant 995 vent to downstream side of RC-535 (NR) valve per approved drawing using approved weld procedure." The actual drawing and weld procedure were not identified.
l i Program Weaknesses - 5 Example VIII: Section 3.6 of SMP 428 for Modification Request M661 stated
" Connect reactor coolant gas vent to pressurize (sic) relief tank (NR) per approved drawing using approved welding procedure." The actual drawing and weld procedure were not identified. Also, the SMP's did not always reference the modification package they were written to implement.
Example IX: Safety evaluations for modifications were brief and sometimes without much documented basis. For example, the summary of the safety evaluation for Modification Request 82-114 stated, in part,
" Manual valves will meet or exceed primary sample system specification."
The basis for the statement was not provided, in that the specification for the primary sample system and valve specification were not given. PBNP 83/NRC-30 The written safety evaluation summacies for modification requests are often too brief and should be expanded to be more meaningful, stating specific bases for the decisions made. Response: This observation will be considered. Performance of safety evaluations is addressed in both PBNP 3.1.2 and PBNP 3.1.1. Procedural guidance exists, so PBNP is in compliance with 10 CFR 50.59. Although the observation is subjective in nature, the procedure will be reevaluated by May 31, 1984. Example X:The licensee safety evaluation form was written in such a way it did not address all the requirements of 10 CFR 50.59(a)(2). It (NR) consisted of a checklist of review items and a summary. The Off-Site Review Committee stated in the minutes of Meeting No. 27 (June, 1982) that the documented safety evaluations for modifications is merely a checklist of items to be addressed and represented conclusions rather than a basis for conclusions of the safety evaluations. The Committee recommended that the process be revised to identify those safety-related aspects that could be potentially affected by the modification and then address the basis of why the modification was acceptable, with respect to this potential. The above items were discussed with licensee representatives and they agreed to take these items under consideration.*
*This includes 10 specific examples.
i l l Program Weaknesses - 6 , 1 Program Weaknesses (3h(ii)) 1 Example I: Verification of corrective action is not .always accomplished in a timely manner by QAD. To date, 8 findings from the April 15, 1982, l audit of NES; one finding from the July 13-14, 1982, audit of Point l Beach; four findings from the January 20-21, 1983, audit of Point ; each; and three findings from the February 24-25, 1983, audit of I the Point Beach Emergency Plan remain open. PBNP 83/NRC-16 Many times appropriate corrective action is not taken in a timely fashion. This is not in accordance with ANSI 45.2.12. Response: Revision 3 to PBNP 3.3.2, " Administration of Quality Assurance Audits and Surveillances," requires a 30-day response to in-plant audit findings, as well as providing for notifying i the Manager - PBNP and then the Vice President should audit j findings not be responded to within 30 and 60 days, respectively. This procedure was issued December 30, 1983. Example II: A review of audit scheduling indicated that QAD is implementing its schedule, although some audits were performed late. The audit schedule of EQRS was not completed in 1981 or 1982, but appears to to on schedule since April, 1983. PBNP 83/NRC-23 PBNP did not meet audit schedule commitments during 1981 and 1982. Response: The finding is accepted as correct. A revised audit schedule was prepared on October 10, 1983, and audits since that date have complied with that schedule. Also, additional personnel will be trained in the performance of surveillance. As experienced staff is developed, better compliance will be achieved in 1984. Example III: A review of audit performance and reports revealed the following: Audits by EQRS vere accomplished in accordance with written checklists and objective evidence was documented; however, the quarterly audits of Operational Logs were not accomplished with written checklists, but did reference procedures used. As of the October audits, deficiencies were identified and corrective action was being requested , in writing using a new audit deficiency report (ADR). l PBNP 83/NRC-26 i Formal audit checklists are not used: 1) by the Off-Site Review Committee 2) by PBNP in all its audits, in particular in the quarterly audits of Operations logs. > Response: The response to this item was discussed under the topic of violation 5.c. l
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l Program Weaknesses - 7 Program Weaknesses (3k(ii)) Example I:The licensee's practice of using the "in-use" method of reviewing procedures does not meet all of the intent for this biennial review. "In-use" review criteria according to PBNF 2.1.2 would be by "means of including actual performance of the procedure or a substantial portion of the procedure, review for training or requalification purposes." This type of review would not identify a need for a procedure change due to such reasons as regulatory changes (i.e., 10 CFR, FSAR, TS, etc.), changes to codes, standards, etc., experiences at the facility, or changes at the facility (i.e., management position, responsibilities, reportability, etc.). PENP 83/NRC-81 Biennial procedure reviews are not being appropriately documented. Response: PBNP acknowledges this finding. An evaluation will be made of current methods of control and documentation of this function by May 31, 1984. NES Procedure 1.1 will be changed by May 31, 1984, to provide the requirement for periodic review. QAD had committed in the 1983 audit for the QA Committee to also assure appropriate review. Exmnple II*The inspector was also concerned that the first page of the procedures is the only page that identifies the revision number, and the issue date of the procedure. The accompanying pages of the procedure only list the page number and document number without any reference to revision or issuc date. Should the cover sheet become detached from the document, there is no method for determining if the latest pages of the procedure or the accompanying data sheets are in use without the issue date or the revision number on the accompanying pages. The licenace stated that its position was that no procedure was to be used unless all pages were included. The inspector had no further questions and the item is considered closed. PBNP 83/NRC-83 The revision number is not put on each page of a procedure. Response: This observation is accepted as correct. Since PBNP does not issue page changes, but instead completely reissues documents, it is not felt necessary at this time to change methodology to indicating revision number and date on each page. The process of complete document revision, rather than page changes, was initiated because of document integrity problems associated with the latter practice. A reevaluation will be conducted by QSRO by April 30, 1984.}}