ML20116D177
| ML20116D177 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 03/04/1985 |
| From: | Crouse R TOLEDO EDISON CO. |
| To: | James Keppler NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| Shared Package | |
| ML20116D145 | List: |
| References | |
| NUDOCS 8504290313 | |
| Download: ML20116D177 (31) | |
Text
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g-Docket No. 50-346 7otsoo License No. NPF-3 Serial No. 1-502 INCm Nucler
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March 4, 1985 Mr. James G. Keppler Regional Administrator, Region III United States Nuclear Regulatory Commission 799 Roosevelt Road Glen Ellyn, IL _60137
Dear Mr. Keppler:
In accordance with Toledo Edison's commitment to provide supplemental information to the Davis-Besse Systematic Assessment of Licensee Performance (SALP) report response (Serial No. 1-497) submitted on February 4, 1985, I am pleased to submit this letter and its associated attachments.
This supplemental information was requested by Messrs. W. D. Shafer and W. Rogers of your staff during a telephone conference call with Toledo Edison (TED) representatives on February 19, 1985. The enclosure lists the NRC Staff's requests and TEDS responses. These responses have been incorporated into Attachments I, II and III of TEDS February 4, 1985, submittal. Attachments I, II and III are enclosed and the responses incorporated are identified by margin revision bars. Attachment IV is new and lists the Performance Enhancement Program Action Plans in response to NRC Request No. 12.
I am looking forward to meeting with you on March 6, 1985 to further discuss these and other TED activities which support our commitment to improved regulatory performance.
Very truly yours,
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I THE TOLEDO EDISON COMPANY EDISON PLAZA 300 MADISON AVENUE TOLEDO, OHIO 43652 k
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ENCLOSURE TOLEDO EDISON SUPPLEMENT TO SALP RESPONSE NRC REQUEST /TED RESPONSE NRC Request No. 1:
During the January 4, 1985, SALP presentation, TED committed to having its senior management visit the plant on an increased basis:
A.
This includes which specific TED senior management individuals?
B.
At what frequency will these individuals visit the plant?
C.
How will visit findings identified by these individuals be documented?
D.
What mechanism will TED use to ensure that these findings are tracked and resolved?
TED Response No. 1:
See Attachment I for TEDS response.
NRC Request No. 2:
Regarding TEDS response under Serial No. 1-497, Attachment II, Section 1.B.1, Plant Operations -- Adherence to Procedures, and TEDS increased efforts to ensure attention to detail by the control room operations staff through:
(1) Discouraging the access and limiting the visit duration of non-essential personnel in the control room.
(2) Encouraging professionalism by the operators.
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(3) Reducing nuisance alarms.
A.
Please discuss the measures you have taken or will take to ensure that above items (1), (2) and (3) are accomplished and continue to be complied with.
B.
For above item (3), please identify the number of nuisance alarms that exist, the priority for removal and the proposed milestones for l
completion.
C.
In addition, please identify the mechanism for handling future l
nuisance alarms, l
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s TED Response No. 2:
See Attachment II,Section I.B.1, for TEDS response.
NRC Request No. 3:
Please address personnel accountability for procedure adherence under SALP response Section I.B Adherence to Procedures.
TED Response No. 3:
See Attachment II,Section I.B.1 for TEDS response.
NRC Request No. 4:
Regarding TEDS response under Serial No. 1-497, Attachment II,Section I.B.3, Plant Operations -- Recognition of Design Basis Requirements, please discuss the following items under the USAR review:
A.
How the review really will be performed.
B.
How results will be disseminated to the rest of the Nuclear Mission, C.
What chapters will be covered by review.
D.
What are TEDS plans for Chapter 15, "Accielent Analysis".
NOTE: At a minimum, please state that these are things that TED will do in the fututs. TED can discuss it in the broadest of terms, i.e.,
it is not necessary to go into considerable detail.
TED Response No. 4:
See Attachment II, Section.I.B.3 for TEDS response.
i NRC Request No. 5:
Your SALP response did not discuss the problem of jumper and lif ted wire
' log entries. Please address how TED plans to reduce the number of jumper and lifted wire log entries.
TED Response No. 5:
See Attachment II,Section I.B.4 for TEDS response.
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NRC Request No. 6:
Regarding TEDS response under Serial No. 1-497, Attachment I,Section II.B. Maintenance -- TED Corrective Actions does not describe the known backlog of Maintenance Work Orders (MW0s). Please identify:
A.
The number of outstanding MW0s.
B.
Your proposal for reducing this number.
C.
The method to ensure the MWO backlog will be monitored by management.
Please include milestones as appropriate.
l TED Response No. 6:
See Attachment II,Section II.B.1 for TEDS response.
NRC Request No. 7:
t Please identify when TED plans to complete construction of the Personnel Shop Facility.
TED Response No. 7:
See Attachment II,Section II.B.1 for TEDS response.
NRC Request No. 8:
Regarding TEDS response under Serial No. 1-497, Attachment II,Section III.B, Emergency Preparedness -- TED Corrective Actions:
A.
Section III.B.1 -- Emergency Preparedness QA Audit Requirements:
TEDS Corrective Action, regarding the checklist for QA audits, may be L
a violation of regulations on QA independence. If QA lacks technical l
understanding of the program, it should have an outside consultant i
perform a review or contact another utility or INPO. Emergency l
Planning should not be involved with the audit checklist prior to the audit.
B.
Section III.B.2 -- Tracking Emergency Preparednese Activities.
l Please provide more specificity, include specificity on the commit-ment for scheduling routine activities on the following items:
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1.
General items described in the Activity Tracking System.
2.
How will TED handle future commitments.
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3.
How will this system interface with the Licensing Commitment Tracking System.
4.
What type of items will be included as commitments and routine activities.
5.
How will TED ensure coordination between groups.
C.
Section III.B.3 -- Preparation for and Performance of 1985 Emergency Preparedness Exercise: Discuss who is on the Scenario Development Team.
NOTE: TEDS responses to Request No. 8 A, B, and C, should address:
completion of corrective actions for NRC concerns, audit findings, drill or exercise identified weaknesses and disposition of audit observations or recommendations, procedure revision requiring assist-ance from other departments, disposition of training feedback recommend-ations, and drill or inventory requirements.
D.
Section III.B.4 -- Emergency Preparedness Training How will TED management assure an understanding of the material?
TED Response No. 8:
A.
See Attachment II,Section III.B.1 for TEDS response.
B.
See Attachment II,Section III.B.2 for TEDS response.
C.
See Attachment II,Section III.B.3 for TEDS response.
D.
See Attachment II,Section III.B.4 for TEDS response.
NRC Request No. 9:
Regarding TEDS response under Serial No. 1-497, Attachment II, Section l
IV.B.3, Quality programs and Administrative Controls -- Manageme"t overview, l
please discuss the following:
A.
How will TED supervisors know when they are suppose to ctend QA exit i
interviews.
B.
How does TED let senior management know if they should attend?
l TED Response No. 9:
See Attachment II,Section IV.B.3 for TEDS response.
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e NRC Request No. 10:
Please discuss how will TED formally control the interchange of spare parts between similar components.
TED Response No. 10:
See Attachment II,Section IV.B.4 for TEDS response.
NRC Request No. 11:
Please provide a commitment to accomplish the Action Plan items developed from your training diagnostic of April, 1984.
Include milestones as appropriate.
TED Response No. 11:
See Attachment II,Section V.B.4 for TEDS response.
NRC Request No. 12:
Certain Performance Enhancement Program (PEP) Action Plans are in place, which will assist TED in improving regulatory performance. We would like to see TED list these in Attachment IV to the SALP response in order to give recognition to this ongoing work which has appropriate milestones, etc. in place.
The titles and identification number of these action plans are as follows:
A-2 Integrated Approach to Goals, Objectives and Strategic Plan A-3 Management Training B-5 Personnel Division Resources C/CM-1 Configuration Management D/FP-1 Development of Fire Protection Program D/L-1 Commitment Management D/QA-1 QA Awareness Program D/QA-2 QA Procedures Review Group D/QA-3 QA Auditor Commensurate Training Program D/SM-1 Safety Evaluations D/SM-2 SRB Performar.ce Criteria D/SM-3 CNRB Meeting with Corporate Management D/SM-4 CNRB Training D/SM-5 Appointment of CNRB Sub-Committees for Review / Screening of Routine and Periodic Documents D/SM-6 Improve Preparation of CNRB Members Prior to CNRB Meeting D/SM-7 Submit Appropriate Information to the CNRB for their review D/SM-8 Provide Procedures to Control Nuclear Safety Related Activities D/SM-9 Nuclear Industry Operating Experience Program D/SM-10 SRB Training s
D/SM-11 Evaluate the Current Program for Safety Management Improvements E/SP-2 STA Assume Interim EDO Function E/SP-3 Non-outage Work Prioritization E/SP-4 Develop a Failure Analysis Program l
E/SP-5 Station Procedure Error Reduction Plan E/SP-6 Generic Guidance thraugh Standing Orders, Special Orders and Administrative Memos E/SP-8 STA Program Improvementa E/SP-9 Maintenance MBO Program E/SP-10 Determine _the type of permanent, non-outage backshift coverage, if any for I&C and Electrical Shops E/SP-11 Determine the type of permanent, non-outage backshift coverage, if any, for mechanical maintenance and station services E/SP-12 Select a method for updating the stock system F/TS-1
-Improve the FCR process F/TS-2 Improve TED/Bechtel Communications F/TS-3 Establish Realistic Schedules and Clear Priorities F/TS-5 Improve the Engineers Performance TED Response No. 12:
These Action Plans have been listed in Attachment IV, Improving Regulatory Performance -- Performance Enhancement Program Action Plans.
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ATTACHMENT I TOLEDO EDISON 4
RESPONSE TO SALP 4 IMPROVING REGULATORf PERFORMANCE IN PLANT OPERATIONS, MAINTENANCE, EMERGENCY N PAREDNESS, QUALITY PROGRAMS AND ADMINISTRATIVE CONTROLS, AND TRAINING Toledo Edison (TED) Corporate and Nuclear Mission Management are committed to achieving significant improvements in regulatory performance at the Davis-Besse Nuclear Power Station Unit No. 1.
Actions completed, in progress and planned to improve our regulatory performance in the functional areas of Plant Operations, Maintenance, Emergency Preparedness, Quality Programs and Administrative Controls, and Training are described in Attachment II. Attachment III lists, in tabular format, the SALPs cate-gorized concerns, TEDS specific corrective actions and their associated milestone dates.
In addition to the specific planned corrective actions in each of the five areas discussed in Attachment II and III, Toledo Edison is providing a broader case of actions to further improve its nuclear program through additional managament involvement and critical self evaluation.
A task force is being formed to review and advise senior management on the scope and depth of the company's actions. The members will be experienced in utility management, regulatory relations and communications skills.
The members are being selected from the industry as wall as from Toledo Edison personnel. Headed by Richard Crouse, Vice President, Nuclear, this group will revieu and evaluate the individual corrective actions of the company to be sure they are sufficient to significantly improve the current conditions. Through Mr. Crouse this group will report regularly to the Chief Executive Officer their findings and actions.
Plant visits by Senior Management have been initiated to provide overview and feedback to the canagement staff. The Chief Executive Officer of TED is making regular visits to the plant, including visits at offshif t times.
The Vice President-Nuclear visits the plant or meets with plant employees at tne Davis-Besse Administration Building on at least a weekly basis.
The Assistant Vice President-Nuclear's office is located at the Davis-Besse Administration Building and he visits the plant on at least a weekly basis.
The Nuclear Division Directors having Davis-Besse responsibilities are visiting the plant, if their office is not located there, on at least a weekly basis.
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Notes should be completed by each Senior Management member documenting his visit. Visit findings are written up identifying any unusual conditions or situations and are tracked to resolution by established corrective action systems, such as Surveillance Reports or Station Work Requests.
To underline our commitment to the operations and training programs these visits will include Plant and Traintug Center visits.
The Performance Enhancement Program is initiating two key programs to improve the overall quality of Toledo Edison management.
These include use of performance measures in conjunction with an expanded Management By Objective program (PEP Implementation Plan A-2(1)) and a Quality Assurance Awareness Program (PEP Implementation Plan D/QA-1). The details of these programs will be discussed with your staff at the planned February 7-8, 1985 PEP review meetings.
The expanded Management by Objectives program is the means by which we can properly assign responsibility for needed corrective actions to achieve excellence. This program also allows us to assign accountability. The expanded Performance Measures program is the management tool by which we will measure our performance toward achieving our objectives and goals.
Additionally, focused management attention is being placed on Toledo Edison's commitment tracking and training schedule compliance. This will improve the direct management support in the commitment and training areas. Through use of these tools, management will hold individuals responsible to ensure that commitments are met.
o ATTACHMENT II r
IMPROVING REGULATORY PERFORMANCE AT THE DAVIS-BESSE NUCLEAR POWER STATION UNIT NO. 1 i
I.
PLANT OPERATIONS A.
Areas of SALP Concerns 1.
Adherence to procedures.
2.
Review of equipment status changet..
-3.
Recognition of Design Bases requirements.
4.
~ Jumper and lifted wire log reductions.
l B.
TED Corrective Actions i
1.
Adherence to procedures:
I Administrative Procedure AD 1839.00, Station Operations, 4
has been revised concerning the generation and documenta-tion of valve lineup (s). Specifically, this revision provides increased guidance concerning_the valve lineup of i
a system or component being removed from or returned to Checklist, was modified to impose increased requirements se rvice.
In addition, Plant Procedure PP 1102.01, Pre-start i
for valve lineup verifications being conducted following.an extended outage.
Implementation of these steps will ensure that the system is properly returned to service and is in its correct lineup for operatioa.
j.
Administrative Procedure AD 1839.00 has been revised to l'
reinforce control and accountability of procedure sign-off by requiring the use of initials rather than a check mark.
Also, the determination that a specific operations procedural step is not applicable must now be made by a Senior Reactor Operator (SRO). license holder.
All operations personnel have been made aware of the i
serious need for strict adherence to plant procedures.
Personnel violating procedures will receive appropriate i
management reprimand based on the specific circumstances.
i-TED has increased its efforts to ensure attention to detail by the control room operations staff through:
(1) discour-aging the access and limiting the visit duration of non-essential personnel in the control room; (2) encouraging professionalism by the operators; and (3) reducing nuisance alarms. The intent of these actions is to improve attitudes about quality of the work performed and to reduce errors.
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To discourage access to the control room and limit the visit duration of non-essential personnel, the Operations Engineer has issued a memorandum (dated January 9, 1985) to all operations personnel explaining the rules for control room access. This memorandum was explicitly discussed with ic each shift. Major items included to accomplish limited i
control room access and visit duration were:
1.
Moved the control room's " Restricted Zone"'to prevent access to the panel area. This limits unnecessary traffic into the control room area.
2.
Barred equipment operators from the restricted zone except when requested to be present by the reactor operators.
3.
Removed all the chairs from the control room except for the ones necessary for the licensed operators.
L 4.
Removed hat racks and replaced with wardrobe lockers.
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Placed specific rules on access and use of the kitchen area by non-licensed operators.
6.
Ordered a new office for the testing shift to be i
installed in the turbine building adjacent to the lunchroom. This will keep testing shift operators out of the control room.
7.
Moved the procedure files to the shift administrative assistant's office (the procedures, of course, remain in the control room).
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Restricted tours of the control room.
In addition all other station personnel were issued a memorandum from the plant manager explaining these new rules along with a copy of Standing Order No. 27 concerning i'
control room access.
Shift Supervisors, Assistant Shift Supervisors, and Reactor Operators have been told to 4
enforce the guidelines under Standing Order No. 27.
Since the implementation of this new program, the traffic j -
in the control room has been significantly reduced and the operators are not distracted by unnecessary personnel in the area.
To encourage professionalism the Operations Engineer has been meeting with each shift discussing the many items included in the Davis-Besse regulatory improvement programs.
In addition several hardware items have been ordered for installation to assist the operators in their duties and to l
foster a professional environment. The following identifies l'
specific actions taken:
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1.
A new testing shift office has been ordered.
2.
A new equipment operator study room and office has been ordered for replacement of the cramped quarters occupied previously.
3.
A committee, including operators, engineering, Shift Supervisor and administrative assistants, has been formed to rework the Shift Supervisor's office and administrative assistant's office to make these areas more efficient and professional.
4.
All operators will receive new working uniforms to promote a more professional appearance.
5.
A salary review is underway to make the management positions of Shift Supervisor and Assistant Shift Supervisor more appealing to union members.
6.
Implementation of the Nuclear Mission MBO process will give the management personnel more pride of ownership to the goals and objectives of not only operations but the entire mission.
In order to accomplish a reduction in the number of nuisance alarms in the control room and to maintain the number at a minimum, TED has established an alarm reduction program.
This program strives to achieve the desired operating philosophy for the control room alarms, that being a
" Blackboard Concept," minimizing the number of annunciator alarms in the alarmed state during normal operation.
The program is supported by a quarterly review of the control room annunciator panels to moniilr annunciator alarms in the " alarmed" condition. The annunciator alarms in the " alarmed" state are reviewed and assessed on an individual basis to determine the nature /cause of the alarm. When.au alarm is classified as a nuisance alarm, corrective action is then undertaken to eliminate the distraction to the control room operator. Corrective action typically utilizes appropriate station adminis-trative procedures to extinguish the nuisance alarm.
Corrective actions may also be undertaken for alarms which are not necessarily assessed as nuisance alarms to assist in achieving the " Blackboard Concept." An example of this would be when an alarm is assessed to be caused by an equipment failure / malfunction and the repair of the failure is known to be delayed for a significant period of time.
Since the alarm would be expected to be a distraction if left in the alarmed state for a significant period, corrective action would be undertaken to extinguish the alarm.
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The nuisance alarm reduction program has already provided positive actions in the_ reduction of nuisance alarms.
Within the last six months, nine nuisance alarms have been extinguished. Also, numerous." alarmed" annunciator alarms have been extinguished as a result of completion of related maintenance activities.
As of February 25, 1985, there are currently 13 control room annunciator alarms (out of a total of 527 alarms) in the alarmed state. Of these 13 alarms, 3 alarms are considered to be nuisance alarms.
The resolution of the 3 nuisance alarms is expected to be as follows:
- One of the 3 alarms is currently expected to be resolved (extinguished) within the next 30 days.
- The remaining 2 nuisance alarms are planned to be resolved through the implementation of Facility Change Requests. The completion of the related FCRs will be dependent upon the Davis-Besse scheduling priorities developed by the Integrated Living Schedule Program.
The remaining 10 alarms should be eliminated through the completion of maintenance work activities.
If it is determined that these alarms may remain in the alarmed state for a significant period of time, actions will be taken to temporarily extinguish the alarm (s), using appropriate administrative procedures, to alleviate the distraction to the control room operators.
The nuisance alarm reduction program will continue to assess and assist in the resolution of future nuisance alarms as they develop.
An increase in the training of the operations staff has
.been scheduled for 1985. This training (including admini-l strative procedures training) is reflected on the 1985 i.
Master Training Schedule. Further discussion of operations
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staff training is discussed under Section V, Training, of this attachment. This action will enable the staff to be l
more technically knowledgeable and thus improve their support of the operators.
i 2.
Review of equipment status changes:
TED has revised procedure AD 1844.00, Maintenance, to require that an experienced non-shift SRO review all Maintenance Work Orders (MW0s). The SR0 reviews the proposed work for potential system operability impacts.
Guidance has been provided so that any proposed change in plant configuration is carefully reviewed for its impact, i 4
This will provide a much improved ability to recognize system operability problems.
3.
Recognition of Design Bases requirements:
In addition to the short term measures discussed in Section 2 above, TED will institute a program to perform a system-by-system review of Design Bases contained in the Davis-Besse USAR. This review, a major undertaking, will be performed by experienced individuals familiar with Davis-Besse design, operations or regulatory requirements and utilize external technical support (B&W, Bechtel, etc.) as appro-priate. A task force has been assigned the responsibility for developing a specific action plan for the USAR review.
The schedule for developing the plan, including specific milestone dates, is listed in Attachment III,Section I.3.
This plan, including the system review schedule, will be submitted to the NRC by May 1, 1985. TED's review of the USAR is to be performed on a system-by-system basis and will include all safety related systems and major non-safety related systems. The review is to be performed by a committee composed of highly experienced members of the TED Nuclear Facility Engineering and Davis-Besse Station organizations. The primary purpose of this review is to extract from the USAR information on system and component functional and operational requirements. Each system review should include an examination of all portions of the SAR pertaining to that system, including sections of Chapter 15 where appropriate. The operational and functional requirements for systems and components identified during this review are to be made available to the appropriate Engineering and Operations divisions of the Nuclear Mission, although the format for the presentation of this information and the method of its distribution has not yet been identified.
Through a mechanism to be established by TED, operational restrictions identified for the systems and components are to be factored into appropriate system operating procedures and training.
4.
Jumper and lifted wire log reductions:
TED plans to reduce the number of outstanding jumper and lifted wire log entries. Operations has generated a list identifying FCRs with jumper and lifted wires. Nuclear Facility Engineering (NFE) will review this list for work prioritizing and scheduling by April 15, 1985.
By April 15, 1985, NFE will also establish a goal to significantly reduce the number of jumpers installed and lifted wires by the end of 1985. k
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n II.
MAINTENANCE A.
Areas of SALP Concerns 1.
Managenent overview.
2.
Strengthening of and adherence to procedures.
B.
TED Corrective Actions 1.
Management overview:
The key Maintenance Department Head position, Maintenance Engineer, has been filied with an individual who has the leadership and experience to provide increased management control of maintenance activities.
TED has authorized an increase in 1985 of four (4) additional Maintenance Foremen to provide increased overview of maintenance activities and provide more field supervision which will lead to improved performance. These positions will be filled by July 5, 1985.
In addition, a Corporate Recruiting Task Force has been established to recruit key personnel, one of which is the identified critical position of Lead Instrument and Control engineer.
A Management by Objectives program to improve account-ability of job responsibilities and defined objectives has been initiated within the Maintenance Department. The HBO program will provide employees with a clear understanding of desired actions and results (i.e., define responsiblities and accountability).
TED has developed a system for the prioritization of non-outage maintenance activities to improve management planning and control. The process is designed to provide for completion of the most important work first and is based on a weighted rating system.
In January, 1985, 420 more corrective Maintenance Work Orders (MW0s) were closed out than were written, illustrating that TED has made recent progress on reducing the MWO backlog. As of February 25, 1985, 1,250 corrective NW0s were open. To continue reducing the MWO backlog, TED will use its system for prioritization of non-outage maintenance activities which includes the prioritization of MW0s, i.e.,
the most important MW0s are scheduled first.
In addition, TED will review under its prioritization program, MW0s which uave been open for some time to determine both the reason and the appropriate disposition. The system for prioritization (PEP Implementation Plan E/SP-3) will be implemented by June 1, 1985. Monthly tracking of the number of MW0s written versus those closed out is reviewed by TED management to ensure that an acceptable level of progress is maintained in reducing the MWO backlog..-
Maintenance has two shifts per day coverage in effect (except for weekends and holidays) and the backshift will be expanded in 1985 to increase the tag-outs being performed to support day shift corrective maintenance and increase backshift surveillance testing.
Construction of the Personnel Shop Facility, which will provide improved facilities for maintenance activities, is,,fe scheduled for completion in the first quarter of 1987.
A quality circle program has been implemented in one of the maintenance areas with favorable results, and has been expanded into five other skill areas. This program provides valuable information about problems and ways to solve those problems from the employees, who may have a better perspective on a problem than management.
2.
Strengthening of and adherence to procedures:
TED has modified procedures AD 1844.00, Maintenance, AD 1845.00, Changes, Tests and Experiments, and IC 2001.00 Instrument Calibration, to better control nuclear safety-related work. The maintenance procedures have been modified to require use of controlled drawings and vendor manuals in the field. Compliance with these procedures will ensure that field maintenance activities are using the most current and accurate information available.
"Information only" vendor manuals may now only be used to assist in the planning, inspection, and monitoring of conditions for informational purposes.
Procedure AD 1845.00 will be modified to ensure all required work is complete for a specific Facility Change Request (FCR) prior to conducting the related testing.
III. EMERGENCY PREPAREDNESS A.
Areas of SALP Concerns 1.
Emergency Preparedness (EP) QA audit requirements.
2.
Tracking Emergency Preparedness activities.
3.
Preparation for and performance of 1985 EP exercise.
4.
Emergency Preparedness training.
B.
TED Corrective Actions 1.
Emergency Preparedness QA audit requirements:
This SALP concern has been addressed by the development of a process whereby both Emergency Planning (EP) and Quality Assurance (QA) review the checklist for QA audit requirements prior to audit initiation. QA (with or without a consultant) prepares the audit checklist. EP reviews this list during the QA entrance interview for completeness, clarity and
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o understanding. EP is not allowed to remove any items from the list at any time. EP may request QA to add items if EP feels such items are needed for completeness of detail for the 10CFR50.54(q) review. This review will be documented in the entrance interview notes.
2.
Tracking Emergency Preparedness activities:
The Activity Scheduling System is currently under development which will be used to identify, schedule and track required activities, both commitments and routine activities. The Activity Scheduling System will include NRC and INPO commitments, QA Audit Finding Report (AFR) commitments, all EP required activities (NUREG-0654), periodic tests, drill and exercise critique items, training requirements, procedure and plan revision due dates, recommendations from training sessions as appropriate, and audit observation items. All commitments will be entered into the system per a specific proceduralized method and will show required due dates.
The procedure will utilize forms to enter commitments. The commitment portion of the Activity Scheduling System will duplicate pertinent information on the Licensing Commitment Tracking System and EP will be responsible to both systems.
Commitments for inclusion into the Activity Scheduling System are commitments to the NRC from Inspection Report responses, commitments to INPO from the annual review and assistance visit, and QA AFR response commitments. Routine activities for inclusion are monthly communication tests, semi-annual shift augmentation drills, periodic tests, inventories, complete training requirements from Chapter 8 of the Davis-Besse Emergency Plan Manual, and procedure revision items. The Activity Scheduling System will be used as a tool fcr coordinating EP activities between TED departments. The Activity Scheduling System will utilize a form, similar to that of the Licensing Commitment Tracking System, for assigning other departments' responsible individuals. Division directors will receive monthly commitment reports. The Vice President-Nuclear or Assistant Vice President-Nuclear will receive an overdue commitment report.
Through appropriate use of this system, management can assure all required activities will be completed on time.
Use of the system and its procedures on a trial basis will be done prior to formal implementation. This system will be formally implemented for all future commitments by September 30, 1985.
3.
Preparation for and performance of 1985 Emergency Preparedness exercise:
A schedule for the next annual EP exercise has been established with the State of Ohio and Ottawa County. Under TED manage-ment endorsement, an internal-TED Scenario Development Committee was established in January, 1985 which includes members with technical expertise. The Scenario Development Committee includes the Operations Engineer, Emergency.
Preparedness Coordinator, Facility Modification Manager, Nuclear Support Training Supervisor, Environmental Monitoring Supervisor, Chemical and Radiological Supervisor, Computer Systems Technical Programmer, Electrical & Control Systems Engineer, Nuclear Energy Information Administrator, Security Supervisor, two NUTECH engineers (consultants), and two Reed Products and Services consultants. These items will improve the timely establishment of exercise objectives and ensure technical accuracy of the exercise scenario. The EDO program is being modified to establish.a full-time Emergency Planning Supervisor / Emergency Duty Officer (EDO) position. This will significantly upgrade the technical experience of the EDO position and will result in improved perfo rmance.
4.
Emergency Preparedness training:
The Emergency Preparedness training format has been improved by including more hands-on training and the 1985 Training Schedule has been prepared for all Emergency Response Programs, both Corporate and Station. This schedule was developed in conjunction with the Nuclear Training Department.
The station schedule has been issued as part of the Nuclear Training Department's Master Training Schedule. Also, controller training classes will be provided for the 1985 annual exercise controllers. Understanding of the material is verified through satisfactory completion of examinations, table top exercises and the annual exercise.
IV.
QUALITY PROGRAMS AND ADMINISTRATIVE CONTROLS A.
Areas of SALP Concerns 1.
Review of nuclear safdty-related temporary facility changes.
2.
Consistency of design documents with as-built conditions.
3.
Management overview.
4.
Quality Assurance effectiveness.
B.
TED Corrective Actions 1.
Review of nuclear safety-related temporary facility changes:
The Station Review Board's (SRB) charter has been modified to require review of Nonconformance Reports (NCR) which constitute nuclear safety-related (NSR) temporary facility e
f changes. The NCR procedure has also been modified so that now all NSR NCRs that are dispositioned "use-as-is", "use-as-is-temporarily", or " repair" require a written Safety Evaluation.
Additionally, the Jumper and Lifted Wire (J&LW) Control procedure, AD 1823.00, has been modified to require a written Safety Evaluation for any J&LW that is not removed from a NSR system when maintenance has been completed.
Compliance with these procedures will provide the required review for changes made to the plant in the cases which didn't fall under the provisions of procedure AD 1845.00, Changes, Tests and Experiments.
2.
Consistency of design documents with as-built conditions:
An extensive effort was employed during 1983-1984 to assess work completed on all modification work packages released for implementation. Design documents were updated to reflect all work completed. Currently TED is updating design documents as work orders are closed so that the documents properly reflect the as-built status of the plant.
3.
Management overview:
Standing Order 39 has been issued directing the Shift Supervisor to carefully review any changes to equipment status for any potential effects on operability.
If a clear determination cannot be made the Shif t Supervisor is required to consult Station management for a determination.
Station management personnel can be contacted using a paging system, if necessary.
A Surveillance Report system has been implemented to identify potential quality concerns.
QA Audit Finding Reports and Nonconformance Reports authoriz-ing temporary changes are sent to the Station Review Board for their review. The rate of resolution of Audit Finding Reports and Nonconformance Reports are monitored by performance measures to encourage prompt resolution.
Attendance by the immediate supervisor of the audited area is required at QA exit interviews to ensure adequate management participation.
In addition to the direct supervisor of the activity being audited, his supervisor may also be requested by the audit team leader to attend the exit interview. Furthermore, when the results of the audit warrant, the audit team leader also requests higher level management attendance at the exit interview.
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i
'V 4.
Quality Assurance effectiveness:
The effectiveness of-Quality Assurance is being enhanced th' rough increased technical training of auditors (PEP r
Implementation Plan D/QA-3), the implementation of area-specific QA training for Station and appropriate support 3
personnel, and supplementing audit teams with individuals possessing area-specific technical expertise.
Consistent with INPO recommendations, the expansion of QA coverage into the non-nuclear portions of the plant (Balance of Plant) is being developed. TED will determine an initial list of those Balance of Plant systems and/or components to which a Quality Program should be applied.
The initial list will be completed by August 29, 1985. The requirements of the quality program to be applied to the Balance of Plant systems and/or components will be developed by July 31, 1985.
=
QAawarenbsswillbeintegratedintotraining. The QA segmentaof General Employee Training (GET) will be revised to meet INPO guidelines by February 28, 1985. This GET segment will be expanded into a QA indoctrination and training package by May 1, 1985. Also, schedules will be initiated by June 1, 1985 for development of individual training plans covering QA requirements appropriate to each
,3 tNuclear Program Division and/or Department.
To control the cannibalization of spare parts between identical items, A'ministrative. Procedure AD 1847.00, Station Materials Control,'is being revised to require Quality Control to be ~ contacted to perform an inspection when a portion of a cannibalized item or component will be used as a spare part.-
V.
TRAINING A.
Area of SALP Concerns 1.
QA program requirements within Nuclear Training.
2.
Non-operator and operator training and retraining areas.
3.
Management overview.
B.
TED Corrective Action 1.
QA program requirements within Nuclear Training:
Nuclear Training procedures, the last of which was approved in December, 1984, have been generated which address QA requirements. A training schedule has been developed and implemented consistent with the 1985 Master Training
~
a Schedule. These procedures provide instructions for the L
accomplishment of the various training functions.
I.. _ -
r 2.
Non-operator and operator training and retraining areas:
The training staff has been doubled since the summer of 1984. At the end of January, 1985, the Training staff numbered thirty people. This increase in the Training staff has significantly reduced self-study requirements.
For this remaining self-study, guidance for a systematic program is being provided by Nuclear Training based on each individuals needs.
Measures will be implemented by May 31, 1985 for the improvement of Reactor Operator (RO) and Senior Reactor Operator (SRO) requalification exams. Non-operator training program improvements are being implemented through the use of the Action Status List within Nuclear Training. This list provides milestones for accomplishing program improve-ments as they are identified. This list was developed as a management tool for implementing and tracking training program improvements.
Two Nuclear Training procedures, NSP/NT-007, Training Program Implementation, and NSP/NT-008, Training Program Evaluation, have been implemented which proceduralize the analysis of examinations and provide feedback of that analysis into the training programs. The 1985 Requalifi-cation Training Schedule has been developed based on knowledge weaknesses in a particular examination subject area identified through the analysis of the 1984 requalifi-cation erams.
3.
Management overview:
Nuclear Training procedures will require that vendor lesson plans be reviewed and approved by the Nuclear Training Department prior to their use. Following completion of each Nuclear Training class provided by a vendor, the class is evaluated by both the students and vendor for the appropriateness of scope and presentation.
A procedure will be developed by April 15, 1985 to provide for an evaluation by the Nuclear Training staff (on a random sampling basis) of contractor-delivered training, i.e. by sitting in on the class and evaluating the training.
The Training Diagnostic conducted by a third party in late 1983 identified problems in the areas of Management, Organization, l'eeds Analysis, Program Design, Program Development, Program Implementation, Program Evaluation, Staff Qualification and Development, and Facility. Some identified problems required specific short term actions to resolve. These types of items were incorporated into the Performance Enhancement Program (PEP) as Interim Actions.
4 The majority of the problems identified and the recommended actions were broad training process-related items that necessitated being incorporated into a long-term, more encompassing plan with a single objective. That single objective is provided by the industry (including TED) commitment to the establishment of performance based training programs meeting the criteria necessary to be awarded INPO accreditation. Accreditation not only incorporates the identified diagnostic items, but includes other training elements not addressed by the diagnostic and provides an iterative process of evaluation and feedback that insures uodating and continued improvement.
Utilizing TED's accreditation plan, all aforementioned criteria are individually addressed and incorporated into the training programs for INPO Accreditation Board review.
TED's accreditation plan will prepare all INP0-identified training programs for accreditation. The first milestone is to have the Non-Licensed Operator, Licensed Operator, and Requalification Training Programs ready for INPO Board review by December 31, 1985.
ATTACHMENT III ACTIONS AND MILESTONE DATES FOR IMPROVING REGULATORY PERFORMANCE
.SALP FUNCTIONAL AREA:
I. PLANT OPERATIONS Area of Milestone SALP Concern TED Corrective Action Date 1.
- Adherence to A.
Revise Station procedure AD 1839.00 Completed procedures.
to govern generation and documenta-tion of valve lir.eup(s).
B.
Modify Plant procedure PP 1102.01 Completed-to impose increased requirements for valve lineup verifications following an extended outage.
C.
Revise Station procedure AD 1839.00 Completed to reinforce control of operations procedure signoff by requiring use of initials rather than check marks.
D.
Determination that a specific Completed procedural step is not applicable, must be made by a SRO license holder.
E.
Schedule increased training of Completed Station staff in 1985.
F.
Provide more explicit direction Completed concerning limited control room access and visit duration.
G.
Eliminate one of three remaining 4/1/85 nuisance alarms.
2.
Review of equip-A.
Require review of all Maintenance Completed ment status Work Orders (MW0s) by SR0 qualified changes.
individuals.
3. -- 1 Recognition of A.
Develop plan for system-by-system 4/15/85 Design Bases review of the USAR.
-Requirements.
1.
Draft plan.
3/22/85 2.
Management approval of plan.
4/15/85 B.
Submit plan and system review 5/1/85 schedule to NRC.
a SALP FUNCTIONAL AREA:
I. PLANT OPERATIONS (Continued)
Area of Milestone SALP Concern TED Corrective Action Date 4.
Jumper and Lif ted A.
Generate a list identifying FCRs Completed Wire Log Reductions with jumpers and lifted wires.
B.
Prioritize, schedule work, and 4/15/85 establish goals for significantly reducing number of jumper and lifted wires by end of 1985.
l l
4 j
i,
SALP FUNCTIONAL-AREA:
II. MAINTENANCE Area of Milestone SALP Concern TED Corrective Action Date 1.
Management A.
Fill Maintenance Engineer position.
Completed Overview.
B.
Fill four additional Maintenance 7/01/85 foremen positions.
C.
Maintenance Supervisor Management 7/01/85 By Objectives (MBO) program in place (PEP Implementation Plan E/SP-9).
D.'
Develop a system for prioritization Completed of non-outage maintenance activities (PEP Implementation Plan E/SP-3).
E.
Implement the system for 6/01/85 prioritization of non-outage maintenance activities (PEP Imple-mentation Plan E/SP-3).
F.
Implement a quality circle program.
Completed G.
Complete Personnel Shop Facility 3/31/87 construction.
2.
Strengthening A.
Modify procedures AD 1844.00, Completed of and AD 1845.00 and IC 2001.00 to better adherence to control nuclear safety-related work.
procedures.
B.
Modify maintenance procedures to Completed require use of controlled drawings in the field.
C.
Modify procedure AE 1845.00 to 3/15/85 ensure that all required work is complete for a specific Facility Change Request prior to conducting the related testing.
SALP FUNCTIONAL AREA:
III. EMERGENCY PREPAREDNESS Area of Milestone SALP Concern TED Corrective Action Date 1.
Emergency A.
Develop 1984 audit checklist.
Completed Preparedness (EP)
QA audit B.
Develop 1985 audit checklist.
10/01/85 requirements.
2.
Tracking Emergency A.
Develop Activity Scheduling System.
3/01/85 Preparedness activities.
B.
Formally implement EP Activity 9/30/85 Scheduling System for future commitments.
3.
Preparation for A.
Establish EP exercise schedule with Completed and performance State of Ohio and Ottawa County, of 1985 Emergency Preparedness B.
Establish Scenario Development Completed Exercise.
Committee, with technical expertise.
C.
Establish permanent Emergency Duty 3/15/85 Officer position.
4.
Emergency A.
Improve training format.
Completed Preparedness training.
B.
Establish training schedule Completed on 1985 Master Training Schedule.
C.
Implement controller training 7/01/85 classes.
a.
SALP FUNCTIONAL AREA:
IV. QUALITY PROGRAMS AND ADMINISTRATIVE CONTROLS Area of Milestone l
SALP Concern TED Corrective Action Date 1.
Review of nuclear A.
Modify Station Review Board (SRB)
Completed safety-related Charter to require review of NSR temporary facility Nonconformance Reports (NCRs).
changes.
B.
Modify NCR procedure to require Completed Safety Evaluation for all NSR NCRs dispositioned "use-as-is", "use-as-is-temporarily", or " repair".
C.
Modify procedure AD 1823.00 to Completed require a Safety Evaluation for any J&LW not removed from a NSR system when maintenance is completed.
2.
Consistency A.
Require the updating of design Completed of design documents as work orders are closed.
documents with as-built conditions.
3.
Management A.
Issue Standing Order 39 directing Completed Overview.
Shift Supervisor to review any changes to equipment status for any potential effects on operability and if necessary, consult with Station management.
B.
Implement a Surveillance Report Completed system to identify potential quality Concerns.
C.
Implement requirement for performance Completed l
performance monitoring of NCR resolution.
I D.
Require sending QA Audit Finding Completed Reports and NCRs authorizing temporary facility changes to SRB for review.
E.
Implement requirement for performance Completed monitoring of the rate of resolution of audit finding reports.
F.
Require immediate supervisor Completed attendance at QA audit exit inter-views.
9 SALP FUNCTIONAL AREA:
IV. QUALITY PROGRAMS AND ADMINISTRATIVE CONTROLS (Continued)
Area of Milestone SALP Concern TED Corrective Action Date 4.
Quality A.
Require increased technical train-Completed Assurance ing for auditors (PEP Implementation effectiveness.
Plan D/QA-3).
B.
Require supplementing of audit teams Completed with area-specific technical expertise.
C.
Balance of Plant Quality Program:
1.
Determine an initial list of 8/29/85 those Balance of Plant systems and/or components to which a Quality Program should be applied.
2.
Develop the Quality Program 7/31/85 requirements to be applied to the Balance of Plant systems and/or components.
3.
Commence implementation of a 8/29/85 Balance of Plant Quality Program.
D.
QA Awareness Training 1.
Revise the QA segment of General 2/28/85 Employee Training to meet INPO guidelines.
2.
Expand the General Employee 5/01/85 Training segment on Quality Assurance into a Quality Awareness indoctrination and training package (PEP Imple-mentation Plan D/QA-1).
3.
Initiate schedules for develop-6/01/85 ment of individual training plans covering the Quality Assurance requirements appropriate to each Nuclear Program Division and/or Department.
. <. o SALP FUNCTIONAL AREA:
V. TRAINING Area of Milestone SALP Concern TED Corrective Action Date 1.
QA program A.
Generate Nuclear Training procedures Completed requirements which address QA requirements.
within Nuclear Training.
B.
Develop and implement a training.
Completed schedule.
2.
Non-operator A.
Reduce significantly self-study Completed and operator requirements.
training and retraining B.
Provide self-study guidance.
Completed areas.
C.
Implement measures for the improve-5/31/85 ment of R0 and SRO requalification examinations.
D.
Implement an Action Status List for Completed non-operator training programs.
E.
Develop procedure to identify Completed deficiencies in licensed operator knowledge and address in requalification training.
3.
Management A.
Develop procedure to provide an 4/15/85 Overview.
evaluation on a random sampling basis of contractor delivered training.
B.
Have ready Non-Licensed Operator, 12/31/85 Licensed Operator and Requalifi-cation Training Programs for INPO Board review.
1 c
ATTACHMENT IV IMPROVING REGULATORY PERFORMANCE PERFORMANCE ENHANCEMENT PROGRAM ACTION PLANS In addition to the specific items discussed in Attachments 1, 2 and 3, certain Performance Enhancement Program Action Plans are in place which will assist TED in improving regulatory performance. The identification and titles of these action plans are as follows:
A-2 Integrated Approach to Goals, Objectives and Strategic Plan A-3 Management Training B-5 Personnel Division Resources C/CM-1 Configuration Management D/FP-1 Development of Fire Protection Program D/L-1 Commitment Management D/0A-1 QA Awareness Program D/QA-2 QA Procedures Review Group D/QA-3 QA Auditor Commensurate Training Program D/SM-1 Safety Evaluations D/SM-2 SRB Performance Criteria D/SM-3 CNRB Meeting with Corporate Management D/SM-4 CNRB Training D/SM-5 Appointment of CNRB Sub-Committees for Review / Screening of Routine and Periodic Documents D/SM-6 Improve Preparation of CNRB Members Prior to CNRL Meeting D/SM-7 Submit Appropriate Information to the CNRB for Their Review D/SM-8 Provide Procedures to Control Nuclear Safety Related Activities D/SM-9 Nuclear Industry Operating Experience Program D/SM-10 SRB Training D/SM-11 Evaluate the Current Program for Safety Management Improvements,
o r
P a
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n:,o E/SP-2 STA Assume Interim EDO Function
-E/SP-3 Non-Outage Work Prioritization E/SP-4 Develop a Failure Analysis Program E/SP-5 Station Procedure Error Reduction Plan E/SP-6
' Generic Guidance through Standing Orders, Special Orders and Administrative Memos E/SP-8 STA Program Improvements E/SP-9 Maintenance HBO Program E/SP-10 Determine the Type of Permanent, Non-outage Backshift Coverage, if any, for I&C and Electrical Shops E/SP-11 Determine the Type of Permanent, Non-outage Backshift Coverage, if any, for Mechanical Maintenance and Station Services E/SP-12 Select a Method for Updating the Stock System F/TS-1 Improve the FCR process F/TS-2 Improve TED/Bechtel Communications F/TS-3 Establish Realistic Schedules and Clear Priorities F/TS-5 Improve the Engineer's Performance Further information on the specifics and milestone dates of each action plan are contained within the respective plan.
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