ML20098B851

Responds to NRC Re Violations Noted in Insp Rept 50-346/84-09.Corrective Actions:Ad 1803 Revised to Incorporate Independent Verifications for Removal & Return to Svc of Plant Equipment for Sys Affecting Plant Safety

ML20098B851
Person / Time
Site:	Davis Besse
Issue date:	08/17/1984
From:	Crouse R TOLEDO EDISON CO.
To:	Norelius C NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
Shared Package
ML20098B837	List: ML20098B851
References
1-459, NUDOCS 8409260314
Download: ML20098B851 (10)

Text

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Docket No. 50-346 TOLEDO

!!E)l!$()lU License No. NPF-3 R'CHARO P. CAOUSE Serial No. 1-459 vaemumm Nwww aim ass-saas August 17, 1984 Mr. C. E. Norelius, Director Division of Reactor Projects United States Nuclear Regulatory Commission Region III 799 Roosevelt Road Glen Ellyn, Illinois 60137

Dear Mr. Norelius:

Toledo Edison acknowledges receipt of your July 11, 1984 letter (Log No.

1-992) and enclosures; Appendix A, Notice of Violation; and Inspection Report No. 50-346/84-09 (DRS).

Following an examination of the items of concern, Toledo Edison herein offers information regarding these items:

1.

Violation:

10 CFR 50, Appendix B, Criterion V, as implemented by Toledo Edison Quality Assurance Program as de-scribed in Section 17.2.5, including a commitment to ANSI N18.7-1972, requires that activities af-fecting quality be prescribed by documented instruc-tions and procedures. Section 5.1.5 of ANSI 18.7-1972, and Section 1.C.6 of NUREG-0737, require in-dependent verification of tagging activities rela-tive to removal from and return to service of plant equipment.

Contrary ro the above, no procedure or requirement existed for independent verification of tagging plant equipment out or service.

This is a Severity Level IV violation (Supplement I).

Response: (1) Corrective action taken and results achieved.

A February 11, 1982 letter (Log No. 902), from Nuclear Reactor Regulation (NRR) concluded that Toled 2dison had met the requirements of NUREG-0737, Item 1.C.6 for guidance on procedures for verifying correct perform-ance of operating activities.

8409260314 840907 PDR ADOCK 05000346 G

PDR THE TOLEDO EDISON COMPANY EDISON PLAZA 300 MAD 3DN AVENUE TOLEDO, OHIO 43652 MG 241984

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[f Since:knitialoperation'ofDavia-Besse,To'edoEdison i

l (has used maintenance; personnel for independent verifi-Leation for placement of~tagsifor removal of equipment

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from service. The extent of' verification.has been s

Lgoverned by Administrative Procedure'AD 1803, " Safety-Tagging". It is our' understanding ' hat our method?

t of independent verification as practiced in the procedure does not satisfy the Region ~III interpreta-

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. tion of. independent. verification for all circumotances.

(2) - Corrective action to be taken. to avoid further noncom -

.pliance.

i A modification will' be made to ' Administrative Procedure LAD 1803," Safety Tagging", which will incorporate inde-pendent verifications for removal and return to service of plant equipment by knowledgeable Operations Department personnel for systems affecting plant safety. This modi-fication to the procedure will speelfy the applicable-4 systems.

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(3) Date when full compliance will be achieved.

Procedure modifications to AD 1803, " Safety Tagging",

will be implemented by September 3,1984.

2.

Violation:

Technical Specification, Sections 6.5.1.6.d and-p 6.5.1.7.a. require the Station Review Board to j;

review all proposed changes or modifications to plant systems or equipment that affect nuclear a

safety and recommend written approval or disap-i proval of changes or modifications to the Station Superintendent.

Contrary to the above, temporary modifications _

associated wf:h nonconformance reports NCR-232-81, I

(Limitorque Valve Modification),'NCR 392-81 (Ser-vice Water Valve Modification), and NCR 83-01 i.

(Auxiliary'Feedwater Pump Steam Line Modification) were rot reviewed by the Station Review Board and I

a recommendation concerning the modification's acceptability was not made to the Station Super-intendent.

i This is a Severity Level V violation (Supplement I)'.

Response: : (1) Corrective action taken atJ results achieved.

The Station Revier Board (SRB) : reviewed the item of

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noncompliance in a meeting which included the Quality Assurance Director and the Facility Engineering F

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General Supervisor. -Per. Section 8.1', Step 4 of ANSI N45.2.11-1974, " Quality Assurance Requirements for

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Design.of Nuclear Power Plants", the disposition of a

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noncomforming item.can-possibly result.in.a design-

. change,-and therefore,~ the finding as stated _is

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- correct. By Administrative: Procedure AD 1845.00,-

" Changes, Tests, and Experiments", Section 2.3, only

. dispositions for repairs which do not affect the fundamental. design of the affected'part are excluded

- from the Facility Change Request-(FCR)' administrative O

controls. 'The FCR process-involves the SRB reviews-necessary-to satisfy the requirements of Technical

- Specification, Section 6.5.1.6.d.

However, in order to assure the acceptability of the disposition of Non-comformancel Reports (NCR's), and satisfy the-require-ments of Technical. Specification, Section 6.f.1.7.a.

SRB will review NCR's which are not dispositioned as rework, or reject. Other permitted dispositions may

- involve facility modifications, and as such, contain safety evaluations supporting the disposition._ The SRB meeting discussions also confirmed'that Supplier Devia-i tion. Reoorts (SDR's) must -be similarly ' reviewed. It is recognized that these reviews will constitute a consider-able increase in the SRB workload and, therefore, will-be accomplished by subcommittee activities, the results of which will be presented to the SRB.

(2) Corrective action taken to avoid further noncompliance.-

The SRB Charter is being revised to include in Sub-committee Instructions the requirements to review oispositioned nonconformances (NCR's and SDR's), which ate dispositioned use-as-is, use-as-is temporarily, or.

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repair, i-(3) Date when full compliance will be achieved.

Full compliance will be achieved by September 14, 1984.

3.

Violation:

~ 10 CFR 50, Appendix B, Criterion XVII, as implemented by-the Toledo Edison Operating QA Program and the

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FSAR Section 17.2, require-that the applicant shall provide record storage consistent with applicable regulatory requirements. - The Toledo Edison QA Program.

commits to.*WSI N45.2.9-1974 and Regulatory Guide l.88, Revision 2, October, 1976, with an exception 1

specifying a two hour fire-protection rating for'

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record storage facilities.

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' Dohkit s N:>. : 50-346 ILic;nsiN$.;NPF-3 tSerial No. 1-459-sAugust 17.~1984 Page14 Contrary'to the above, records'of audits, auditor

.and QC inspector qualification / certification and

, calibrations were not provided the required protec-

' tion.

This is a Severity Level V violation (Supplement I).

Response

Toledo Edison tak'es exception to.this finding. ANSI N45.29-1974 contains the following. definition of Quality Assurance Records.

" Quality Assurance Records -- Those records which.

furnish documentary evidence of the quality of-items and of activities affecting._ quality. For the purposes of this-standard a document is considered a Quality Assurance Record when the document has been completed."

The Toledo Edison Nuclear Quality Assurance Manual and Chapter 17.2 of the Updated Safety Analysis Report further defines a completed Quality Assurance Record as follows:

" Quality Assurance Records - A document is considered completed when all applicable inform--

ation has been recorded and the record has been reviewed and approved by the applicable indivi-duals."

Furthermore, the scope of ANSI N45.2.9-1974 states:

"It (this standard) is not' intended to cover the preparation of the records, nor to include working documents not yet designated as Quality -

Assurance Records."

The audit records stored in the Davis-Besse Administ-ration Building (DBAB) are working records in which there are open audit findings. These documents are 2

periedically updated to reflect actions taken to re-solve the audit findings. Therefore, Toledo Edison considers'these audit documents as working documents and subsequently not within the scope of the ANSI t-N45.2.9.

Auditor qualification / certification records stored in the DBAB and Quality Control Inspector qualification /

certification records stored in the QC trailer are for those individuals presently on the QA/QC staff. As required by' ANSI N45.2.6 and ANSI N45.2.2.23,.these l'

-documents att periodically updated to renew and evaluate the individual's certification. Therefore, t

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Toledo Edison considers these documents to also be

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' working documents ~and subse'quently not'within the scope of ANSI N45.2.9.-

Calibration records for test and' measuring equipment.

are maintained in' individual folders for each piece of equipment.under the calibration program.. These

. folders provide an equipment history file for each piece of equipment and are' periodically updated as i-c'alibration ' occurs. : Therefore, Toledo Edison considers these documents.to be working documents and not within.

the, cope of ANSI N45.2.9.

Furthermore, even if under ANSI N45.2.9, these documents would only need to be

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maingained until recalibrated. Therefore, if the-cali'> ration record were destroyed, the performance of a neir calibration and the: generation of the calibration 2

-reco.d would meet the record retention requirements of l

ANSI N45.2.9.

Based upon LSe above response. Toledo Edison is in compliance witi 10 CFR 50, Appendix B, Criterion XVII, and requests that your office retract this item of noncompliance, f-4.

' Violation:

10 CFR 50, Appendix B, Criterion-XVI, as implemented by the Toledo Edison's Operational Quality Assurance Program, requires that measures be established to as-sure that conditions adverse to quality are promptly j

identified and corrected.

Contrary to the above, five open Nonconformance Re-portr> were noted with temporary-fixes or dispositions for short term use. These temporary conditions had-existed for a period of one to five years. Addition-1-

ally, two Corrective Action Requests, written in 1982 with 1983 scheduled completion dates, were still open j.

at the time of this inspection.

This is a Severity Level V violation (Supplement I).

Response: (1) Corrective action taken and the results achieved.

4 Two of the four Nonconformance Reports (NCRs) refer-enced'in the Inspection Report-have been closed. The work necessary to close the remaining.two NCR,is scheduled to'be performed during the next Refueling Outage. Toledo Edison is reviewing the outstanding

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NCRs to' determine those NCRs' requiring an= outage to

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correct, those which may be worked during non-outage conditions and those which the requested work has been L

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. work closeouts.

-The two Correction Action 1 Requests (CARS) referenced in theiInspection Report remain'open. The completion-of the corrective action associated with those CARS ~ is presently scheduled for September 30,' 1984.- The Corrective Action completion dates for these CARS have extended beyond their original; completion date;as'the action-necessary to complete the Corrective Action.was-

'.significantly greater than originally anticipsccd.

(2) ' Corrective: Action to be taken to avoid further noncom-pliance.

- The track'ing of NCRs has been added t.o the' Davis-Besse-Maintenance Management System-(DBMMS). A recent1 enhancement has-been added to the DBMMS which readily allows the identification and sorting of those NCRs requiring an outage to complete..This information.

will in turn enable the NCRs to be scheduled for completion during appropriate outage conditions.

In addition, Toledo Edison is making a conscientious effort to reduce the number of open NCRs. As compared to the same period in 1983, Toledo Edison has redMed the number of open NCRs by approximately 20 percent.

It should be further noted that Toledo Edis'on also-utilizes the Nonconformance Report system to document nonconformances on Non-Nuclear Safety Related Equipment.

Like NCRs,-Toledo Edison will continue to apply.a conscientious effort to resolve open CARS to ensure that appropriate corrective measures are taken to thoroughly resolve the issue in a timely manner.

(3) Date when full compliance will be achieved.

The NCRs referenced by this Inspection Report will be closed at the completion of the 1984 Refueling Outage.

l The CARS referenced by the Inspection Report will be closed upon acceptance of their~ corrective action by F

Toledo Edison Quality' Assurance.

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'5.

Violation:

10 CFR 50, Appendix B, Criterion XII, as implemented by the Toledo Edison Operational Quality Assurance Program, requires that measures be established to assure that tools, gages, instruments and other mea-suring and testing devices used in activities

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affecting quality are properly controlled, calibrated and adjusted at specified periods to maintain accur-acy within necessary limits.

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.Page;7 Contrary to the above, test and measuring equipment-available for use by the Quality Control Department; was not controlled and calibrated as required.

))3sisaSeverityLevelVviola'tida(SupplementI).

1 Response: (1) Corrective action taken and the results achieved.

In response to thefspecific findings described in the Inspection Report, Toledo Edison has taken the follow-

' ing actions.-

~1.

Quality Control Instruction.3120 has-been revised to include the requirement'that the instrument used on an. inspection or test be identified on the appropriate data sheet.

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~ Calibration-labels which indicate the calibration E

due date have been affixed in instruments QCT-5 and QCT-6.

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. 3. - - Instrument QC-3 has been calibrated and the

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appropriate calibration label affixed.

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Action cards as required by Quality Control i

Instruction 3120 have been completed for instru-

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ments QCT-5 and QCT-6.

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Quality Control has verified that calibration records for all measurement and test equipment utilized by Quality Control personnel are avail-able. All measurement and test equipment not available for use by Quality Control personnel have been removed from the Quality Control Measurement and Test equipment storage area.

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(2) Corrective action to be taken to avoid further noncom-

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pliance..

All measuring and test equipment available for use by Quality Control personnal has been reviewed to ensure that proper 1 calibration labels are affixed, action-cards tracking calibration due date are in plats,'and that calibration records are'available. All defici-~

encies noted have been corrected.

In addition, the deficiencies addressed in the NRC Inspection Report have been reviewed with the Quality Control personnel.

(3) Date when full compliance will be. achieved.

Full compliance has been achieved.

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Violation:

-Davis-Besse Nuclear Power Station Technical Specifi-cation for Reactor Coolant System Chemistry,-Section 3.4.7, requires that-the reactor ecolant system chem-

.istry shall be maineained within the steady state limit for chlorides of 0.15 ppm.

Contrary to the'above, the chloride concentration in-the-reactor coolant system exceeded the limit: to a maximum of 0.26 ppm, for a total of 22 hours2.546296e-4 days <br />0.00611 hours <br />3.637566e-5 weeks <br />8.371e-6 months <br />. The underlying cause was determined to be the premature breakdown of recently installed resin in the purifi-cation demineralizers as a result of the following:

a.

Purchase of'the resin was uncontrolled as a non-Q item with no receipt inspection or testing, allowing an unacceptable type of resin to be installed in the demineralizers.

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Failure to follow procedure LI 4782 which speci-

'fied the resin chemical and physical requirements.

This is a Severity Level-IV violation (Supplement-1).

Response: (1) Corrective action taken and results achieved.

The' resin in purification demineralizer 1-1 was replaced with Rohm & Haas resin IRN-150LC. Addition-ally, to ensure the purchase of the proper resin, personnel selecting resin have been instructed by the l

Chemist & Health Physicist to ensure it mee:s the i

criteria given in Procedure LI 4782.00, Laboratories j

Instrument and Reagent Calibration.

l (2) Corrective action taken to avoid further noncompliance.

The Reactor Coolant System (RCS) purification demin-eralizer resin will be purchased, receipt inspected, and stored in accordance with the Toledo Edison

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Nuclear Quality Assurance Manual.

L (3) Date when full compliance will be achieved.

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l The RCS chloride concentration was within the limit of 0.15 ppa on December 11. 1983. Full compliance has been achieved since.further purchase of the RCS puri-fication demineralizer resins will fall under the guide-

-lines of the Toledo Edison Nuclear Quality Amaurance Program.

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Violation:

10 CFR' 50, Appendix B, Criterion II states in part, "The program shall provide for indoctrination and training of personnel performing activities affecting quality as necessary to assure that suitable pro-ficiency is achieved and maintained.

The Davis-Besse Updated Saf'ety Analysis Report (USAR) in Section 13.2.1 states that the training program is described and administered by the AD 1828 series of procedures. Section 13.2.2.2 of the USAR includes commitments that Chemistry and Health Physics (C&HP) personnel are properly trained and maintain profi-ciency in their required job skills through continued training. Section 13.2.2.3 of the USAR includes com-mitments that maintenance personnel are properly trained to perform their jobs and that they remain proficient 'in the required job skills.

Administrative Procedure AD 1828.00 (Personnel Training Program) requires initial training and con-tinuing training for C&HP personnel per AD 1828.12 and for all maintenance personnel per AD 1828.11.

Contrary to the above, the Master Training Schedule for lo84-did not identify that any initial or con-tinuing training had been scheduled in 1984 for C&HP personnel or for Electrical Maintenance personnel.

This is a Severity Level V violation (Supplement 1).

Response: (1) Corrective action taken and results achieved.

The 1984 Master Training Schedule (April 18, 1984),

was in error in that it did not identify training for C&HP and Electrical Maintenance personnel required by Administrative Procedure AD 1828.00. This schedule was updated on July 31,.1984 to include all training that had been previously conducted for C&HP and Electrical Maintenance personnel during 1984, as well as training scheduled for completion during the remainder of 1984.

A Training Needs Analysis for both C&RP and Electrical Maintenance personnel was completed on July 31, 1984.-

The results of this analysis will be used to improve both initial and continuing training programs.

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Corrective action to be taken to: avoid further noncom-(2) pliance.

The' Training-System Development'(TSD) Action Plan currently being implemented by the Training Depart-ment, iis designed to achieve and maintain INPO accred-itation of Davis-Besse. training programs. The TSD process will' be used to further modify and improve the

-existing C&HP and Electrical Maintenance training pro-grams. As a result of_the training needs analysis, a-

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comprehensive training program is being outlined for O

C&HP personnel'together with a two_ phased. program designed.for Electrical Maintenance personnel. _The-first' phase will meet immediate-training needs and the second phase will' provide a: comprehensive training-program.-

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.A previously identified' Training Department procedure-

'will be developed to provide administrative controls for the development and approval-of the Master Training Schedule. The 1985 Master Training Schedule will be developed and revised using this procedure.

(3) Date when full compliance will-be achieved.

The Training Department procedure to provide' admin-istrative control for the development and approval of.

i the Master Training Schedule will be issued by Sept-ember 30, 1984. Accreditation of the Davis-Besse training programs will be accomplished on the schedule provided to INPO.

i Very1truly yours,

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