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1 REPORT OF '
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QUALITY ASSURANCE i
AUDIT i
Audit No:
OAS-JPN-92-3
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j Location of Audit:
Juno Beach Date of j
Alugt:
October 27,1992. - February 4,1993 i
Audit i
Seone:
To assess the adequacy and evaluate the implementation of the FPL OA Manual and 1
Departmental Ols by Nuclear Engineering (JPN).
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Audit Summarv:
This audit assessed various programmatic areas and activities implemented by Nuclear j
Engineering at Juno Beach. Those activities included Organization, Procedures &
Instructions, Training, ASME Section XI, PTN PEG (Safety Classifications, Safety Evaluations, Design inputs, Design Bases, Cesign Analysis, and Minnr Engineering Packages), Special Processes & Welding, OA Records, Document Control and Intemal Commitments. As a result of the audit, three findings are being issued.
Although deficiencies were identified,it does not appear that any significant imput upon the performance of safety / quality related activities resulted.
A significant effort on the part of Document Control and OA Records personnel to perform quality work wAs observed. It was apparent that most individuals directly -
involved in performing a function (s) were knowledgeable in their duties. In select areas, however, some individuals were not always aware of procedural requirements.
It is recognized that the organization now performing the Document Control and QA Records activities is a relatively new organization. As such, these groups have undergone personnel turnover at both the worker and management levels. Alarge effort to put into place procedures and conduct personnel training is ongoing. The organization currently has several plans and schedules awaiting completion and implementation it is anticipated that once completed, these two groups will more
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efficiently and effectively implement their activities.
Engineering activities associated with the PTN Production Engineering Group (PEG)'
were also audited. It was determined that Plant Change / Modifications (PC/Ms) were properly classified, safety evaluations adequately addressed. the respective change (s), and Minor Engineering Packages (MEPs) were utilized appropriately j
relative to the change (s). It was also verified that the design inputs were reasonable and sufficient for the change, and properly translated to the output document (s).
Furthermore, it was determined that the design analysis supported and sufficiently sucstantiated the modification (s).
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REPORT OF QUALITY ASSURANCE AUDIT Audit No:
CAS-JPN-92-3 The JPN OA program was reviewed to verify implementation and programmatic compliance to the FPL QA Manual. Of those areas reviewed as identified above, three findings were identified. These were in the areas / categories of procedures and training.
By reviewing procedures and conducting interviews,it was identified that the Juno Document Control Center does not have Quality instructions that address all OP requirements.
l The JPN program was also reviewed to verify implementation of procedures and instructions. Of those areas reviewed, four implementation weaknesses were identified. These were in the areas / categories of training, document control, and OA records indexing.
Through procedure and document reviews, and personnel interviews, it was determined that currently there are no specific training plans / schedules for the Document Control /OA Records section. Furthermore, a continuing training program for the Document Control /QA Records section has not been developed. It should be noted, however, that these plans are in the process of being developed.
When reviewing departmental training records, it was identified that only a few individuals working in Document Control /OA Records have had training on applicable j
JPN Ols. It was also determined by personnelinterviews and record reviews, that as is currently required, on-the-job training has not been documented.
Through interviews and a review of documents, it was identified that JPN has not issued a OA Records Index to the OA Records Center. There is a list of OA Records in j
a 01, however, the O! is sent to Document Control for distribution and not to OA Records.
Through interviews and observation, itwas determined that the Records Centers OA Records Indexing systemis comprised of two elements. Some records received are entered into the PASSPORT Document Management System. This portion of the Records Centers Index constitutes a valid"Index". This system does not, however, specify record retention requirements. The second element of the Records Centers Indexing system is the PC software that is being tested. Since it is in test, credit for the sof tware cannot be taken. The only method to retrieve the records being entered into this system is to manually go through al the input forms. Finally,there is no method being employed to identify records that are " logged out" for microfilming. It was noted that in all cases, the records requested were retrieved.
The items discussed above are addressed in Finding No.1.
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AUDIT Audit No:
OAS-JPN-92-3 During procedural reviews, a was also identified that certain NDE training procedures were not in agreement with the corresponding Engineering O! in that the training procedures required less training than stated in the 01. It was noted during training record reviews that the NDE tpilning being completed did meet the applicable qualification requirements. This is addressed in Finding No. 2.
I Through discussions with document control personnel and document reviews,it was identified that a follow-up is not always being performed for copyholders that have not returned their receipt acknowledgement following the issuance of a second request.
i This Mem is addressed in Finding No. 3.
I As an cdditional item, the control of the Nuclear Policy Manual was audited as required, by Nuuear Policy (NP 100), Nine of the twenty-six manuals located at Juno Beach were reviewed. None of those reviewed were found to be totally accurate. The discrepancies were of a variety in nature. Some of the discrepancies identified consisted of a missing purpose statement, incorrect revisions, missing policies, manuals containing policies that had been canceled, and several revisions of the same policy in a manual. Management was informed of the observations noted and steps are currently underway to correct this issue.
Based on the activities and objective evidence audited,it was determined that the requirements of the OA Programwere adequately addressed by procedures and the implementation of those procedures was effective. The findings in this report identify areas where improvements in procedures and implementation are needed.
Satisfactory Areas:
1.
Organization 2.
Safety Classification and Safety Evaluations 4.
Technical Specifications 5.
Design inputs / Design Basis 6.
Design Analysif 7.
Minor Engineering Packages 8.
Welding 9.
Intemal Commitments Findinos:
1.
Procedures, Training and Document Control 2.
Conflicting Procedures 3.
Document Control Receipt Acknowledgement Follow-up 3 of 14
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AUDIT Audit No:
OAS-JPN-92 3
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Detalls:
Finding No.1 - Procedures, training and implementation supporting the QA Records and Document Control Centers are not always in compliance with QA Manual Requirements
- Criteria:
A.
OP 17.1, " Quality Assurgnce Records", Rev.17, contains the following requirements for written instructions:
Paragraph 5.6.1 1
" Written storage instructions shall designate a custodian with the authority and the responsibility for the implementation of the instructions. The written instructions shallinclude the following as a minimur,n: 1) a description of the storage area; 2) the type of filing system to be used...", etc.
Paragraph 5.1 1
- Each organization shallestablish alist of Quality Assurance Records generated by the organization and their retention times. This list shall be maintained current and sent to the records storage facility (s) that receive the Quality Assurance Record (s)."
Paragraph 5.4.4 "The organization responsible for the receipt, storage and retrieval of Quality Assurance Records shall establish an index of Ouality Assurance Records. The index shall indicate the location of the Quality Assurance Records within the records system and designate the records' retention times."
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OP 2.5, " Quality Assurance Indoctrination and Departmental Training", Rev.10, contains the following requirements regarding departmental training:
Paragraph 5.2 "The objective of each department's training program is to provide each individual with the technical and quality assurance program training needed for the i
individual's position. To attain this objective, the training program for each department or plant shall have the following characteristics:
1.
A wntten training plan and/or schedule.
2.
Training shall consist of:
a.
Activities affecting quality for which the individual is responsible; 4 of 14 w
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Requirements. procedures, or instructions to be followed in t
performance of those activities...;
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A continuing program with provisions to train present personnel and replacement personnel,r."
e-Findina:
The procedures, training and iraplementation supporting the QA Records and Document Control Centers are not always in compliance with OA Manual requirements. Specifically, the following have not been accomplished:
i 1.
The establishment of written instructions for the storage f Leility; 2.
The transmittal of a complete list of Engineering department OA Records to the storage facility; I
3.
The creation and maintenance of a list /index of OA records maintained by the OA Records group; 4.
Training on the requirements, procedures, and instructions for personnel performing activities affecting quality in the Document Control and QA Records sections.
Discussion:
1.
The operations of the.OA Records Center are ongoing without complete written instructions as required by OP 17.1. While some of the requirements are met by existing JPN Ol's, not all of the requirements are addressed it.erein. Specifically,
'l there are no written instructions which describe the storage area, describe the i
type of filing system used, describe rules governing access to and control of the j
files, describe the method used for accounting for records removed from the storage area or which describe the method for destruction of records. Also, there I
are activities being performc; which are not adequately described in existing
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procedures. An example of this is the use of form JDC-092,
- Document index Sheet
- for the indexing of OA records. This form is in use but is not described procedurally.
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2.
JPN-Ol-6.8 contains a master list of OA Records which is supposed to serve'as the list of QA records for Nuclear Engineering. This list has not been sent (other than as a superseded procedure) to the OA Records section. Note: The Equipment,' Support and Inspection group (ESl) has submitted a list of OA records to the OA Records section. Without lists of records, OA Records j
personnel cannot develop an index of records to f acilitate the correct classification of incoming records.
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REPORT OF QUALITY ASSURANCE AUDIT Audit No:
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Partially as a result of the situation discussed in paragraph two above, an index of
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OA records has not been developed in the OA Records section. The absence of a records index may lead to jmproper classification and/or retention of incoming records. An example of this was observed when a batch of welding procedure qualification reports was submitted to the records center without adequate identification of the record type or retention period. The technician was attempting to index them as " procedures" for lack of a specific document type (for l
POR's) when this was brought into question by the auditor.
l A document was produced titled "OA Records Index" which was intended as a locator for the records in house, but was observed to be inaccurate. This index was an attempt to control the incoming records that were backlogging prior to full implementation of the microfilming operation. Records that are sent out of the records area for microfilming are not logged out.
Furthermore, the OA records technician explained that the index system consists of two computer data bases. Records incoming on form 81 are entered into PASSPORT, however, no retention time is entered because none is provided on the form and this detail is not provided by Oi 6.8. Records incoming on form 92 (which is not procedurally defined) are not identified as OA records. They will apparently be entered into PC DMS once the software is approved for use (it is currently in the software test phase). It was also observed that those records incoming on form 92 are a mix of OA and non-OA records.
Discussions with Document Control /OA Records management indicated that an official Records Retention Schedule does exist. This schedule is documented at the Corporate level and provides a listing of records and their respective retention periods. However, this listing does not accurately reflect the current records being generated by Nuclear Division and is one of the items currently under review by the Document Control /OA Records organization.
4 During interviews with Document Control and QA Records personnel it was observed that some individuals were not aware of all the requirements of the JPN Ol's that apply to their activities. A review of the Nuclear Engineering departmental training records for Document Control and QA Records related Ol's, especiatty O16.1 " Document Control," 016.3," Drawing Controt," Ol 6.4, " Control I
of Vendor Manuals" and O! 6.8," Quality Assurance Records." revealed that only
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three of twenty-two document control /OA records personnel appeared on the j
attendance sheets and these persons were only exposed to two of these Ol's.
Likewise, available documentation does not indicate that a training schedule is in place for personnel currently performing the document control and QA record control functions. At the time of the audit the Senior Staff Analyst in Document i
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REPORT OF QUALITY ASSURANCE AUDIT Audit No:
OAS-JPN-92-3
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Control was assembling data on the job knowledge of all such personnel to provide a baseline from which an in depth departmental training program could be built. There is also no objective evidence indicating that a continuing training program plan is currently in place for the Document Control and QA Records t
groups. The plan for the coptinuing training program for these groups is stillin development.
Recommendation:
4 Your response must address the flading identified above.
The following recommendations are offered for your consideration.
1.
Review the current existing Ol and determine those requirements not addressed.
Incorporate necessary guidance into the 01. Also determine any other activities being performed by the OA Records Centerthat should be described in the Ols and incorporate as appropriate.
2.
Determine if the development of the JPN OA Records list is to be performed at the departmentalor group /section level. Place the appropriate guidance for the development, submittal and maintenance of the JPN OA Records list into the appropriate instructions. Develop the lists and forward them to OA Records.
~. Establish an implementation date for the QA Records software that is currently in testing. During the interim, establish a system to index the incoming records.
Place the appropriate guidance for performing this activity, to include updating of the OA Records index, into instructions. Review allindexing systems that willbe used and ensure that all programmatic requirements (e.g., retention times, log out, etc.) will be satisfied and any additional procedural guidance is provided.
4.
Conduct training on applicable Ol's for Document Control and QA Records personnel. If necessary, document a " qualification" for personnel based on on-the job training. Continue development of* a baseline training plan and continuing training program with an established due date. Describe these activities (program development and maintenance) in appropriate instructions.
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DEPARTMENT AUDIT Audit No:
OAS-JPN-92-3 Detalls:
Finding No. 2 - Inconsistency in NDE Training Procedures Criterla:
JPN-O!-9.3, " Nondestructive Examination (NDE) Personnel Qualification and Certification *, Rev. 0, Table 2 identifies the minimum acceptable hourly training requirements to qualify for certification in a given method.
Findina:
NDE training procedures conflict with JPN-Ol-9.3.
.I Discussion:
Contradictions in training requirements between JPN-Ol 9.3 and the NDE training procedures were identified. Specifically, JPN OI 9.3 requires that for ET certification, 40 hours4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br /> training is required for Level I while TR ET, " Eddy Current Training Procedure" states that 13 hours1.50463e-4 days <br />0.00361 hours <br />2.149471e-5 weeks <br />4.9465e-6 months <br /> is required. Also, the 01 states that 40 hours4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br /> training is required for Level 11 while TR ET requires 81/2 hours. Furthermore, the 01 states that for UT Level 11 certification, 40 hours4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br /> classroom and 40 hours4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br /> lab is required while TR UT, " Ultrasonics Levels I,11, and 111" requires 38 hours4.398148e-4 days <br />0.0106 hours <br />6.283069e-5 weeks <br />1.4459e-5 months <br /> classroom and 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br /> lab.
1 11 should be noted that personnel performing inspection activities did meet the necessary training requirements. This discrepancy is sinply a procedural dispanty.
Recommendation:
Your response must address the finding identified above.
The following recommendation is offered for your consideration.
Correct the procedural discrepancies described above and clarity / revise any training documentation to indicate completed training as appropriate. Ensure procedural controls are in place to describe how documentation of training is to be performed and that continuity exists between all training procedures used by NDE.
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DEPARTMENT AUDIT l
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Audit No:
OAS-JPN-92-3 w
i Detalls:
Finding No. 3 - Follow-up by Document Control of receipt acknowledgements after 30 days is not always performed.
Criteria:
JPN-Ol 6.1," Document Control *, Rev. 4 contains the following requirements:
a Paragraph 8.3.1
" Thirty days after distribution, JPN Document Control will contact holders who have not retumed a signed receipt acknowledgement. A follow up letter will be sent two weeks later."
Paragraph 8.3.2
"!! the follow up letter is not retumed within 7 days, the controlled copyholder may be deleted from the distribution list. The holder will be notified of the deletion and the status of their document (i.e. uncontrolled). Furthermore, the holder will be asked to retum the document to JPN Document Control."
Findinn; A review of the available documentation indicates that there is not always a follow up of receipt acknowledgements that are not returned after thirty days.
Discussion:
A review of the 4-29-92 distribution of Revision 22 of the PSL Radio'ogical Emergency Plan revealed that fourteen transmittals to copyholders did not result in the return of their receipt acknowledgements even after a second request was issued.
In addition, there is no further evidence of follow up after the issuance of second requests and the copyholders neither appear on the " Nuclear Division Recall Report" nor were they removed from the distribution list. Other documents with missing receipt acknowledgements and no apparent follow up include certain JPN Quality Instructions, Nuclear Materials Management Quality. instructions, the Quality Assurance Manual and Nuclear Policies. JPN-Cl 6.1, paragraph 8.3.2 requires that copyholders be notified that unreturned follow up of document distribution will result in de control of the document for that copyholder.
During verification of distribution follow up,it was noted that the Document Control Reference Center was in possession of a copy of the PSL Radiological Emergency Plan, Rev. 22 stamped with the red " Controlled Document" stamp. However, the distribution list for this document did not show the reference center as being a copyholder and the document should have been at revision 23.
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REPORT OF QUALITY ASSURANCE DEPARTMENT AUDIT l
Audit No:
CAS-JPN-92-3 I
Recommendation:
Your response must addres; the finding identified above.
The following recommendation is offered for your consideration.
Perform a review of the documentation indicating transmittals not returned. Notify f
these copyholders that their current documents are now uncontrolled and perform a recall of the documents. Take the appropriate action to inventory the document (s) to determine the acceptability of the documents and the reissuance as controlled copies where needed.
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QUALITY ASSURANCE DEPARTMENT AUDIT Audit No:
OAS-JPN-92-3 Audit Particinants:
Name Denartment A_
g, Q,
P. R. Croom JNA X
X R. L. Simpson JNA.
X X
J. B. Perkins JNA X
X D. L. Smith JPN X
R. S. Custis JPN X
L.F.Pabm JPN X
L. Elford JPN X
X X
D. A. Brown JPN X
X X
H. R. Gavankar JPN X
J.T. Luke JPN X
T. F. Skiba JPN X
X E. L. Anderson JPN X
X C. G. O'Farrill JPN X
X R.A.Symes JPN X
J. P. Brannin JNA X
L. Richardson JDC X
X R. Renuart JDC X
X J. B. Hosmer JPN X
X M. L. Moorer JDC X
S. Kozlin JDC X
T. D. James JDC X
D. C. Baker JPN X
A. Castaldi JPN X
D. C. Peteralski JPN X
A. Boaz JDC X
L. E. Rudicel JPN X
Kev:
A Attended Pre-Audit Conference B - Interviewed or Contacted Dunng Audit C - Attended Post-Audit Conference 11 of 14
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QUALITY ASSURANCE DEPARTMENT AUDIT l
Audit No-CAS-JPN 92-3
References:
10 CFR 50, Appendix B TOR 1.0, Rev. 23 e
OP 2.4, Rev. 7 QP 2.5, P.ev.10 OP 2.14, Rev. 2 OP 3.2, Rev. 8 OP 3.4, Rev.10 OP 6.1, Rev. 3 OP 6.2, Rev. 8 OP 6.6, Rev. 4 OP 6.7, Rev. 2 OP 9.1, Rev. 4 OP 9.4, Rev. 2 I
OP 17.1, Rev.16 Nuclear Policy Manual Departmental Quality instructions Departmental Procedures
~ Discipline Standards Departmental Training Records NDE Oualifications/ Certifications Engineering Packages 92102, Rev.0,91-088, Rev. O Minor Engineering Packages92-031, Rev. O,92107, Rev. O,91-197, Rev. O PTN and PSL ISI Programs and Plans NRC/ Licensing Correspondence PTN and PSL Outage Reports Reactor Vessel Material Surveillance Program For Turkey Point Unit 3 Analysis of Capsule V, dated 8/86 Analysis Report of Capsule S for PTN 3 and PTN-4, dated 5/79 and Capsule T for PTN-4, dated 7/76 Procedure Qualification Reports Welding Standards
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Welding Filler Material Procurement Soecifications Welding Procedure Specifications Welding Control Manual JPN OAl Records Nuclear Engineering Drawing index NIS Computer Software Index Nuclear Document Center Controlled Document Distribution List Change Request Document Control Procedure Distribution Receipt Log Docum'ent Control Nuclear Division Recall Report 12 of 14
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.T OF, DEPARTMENT AUDIT Audit NE OAS-JPN-92-3 Nuclear Drawing Records files Nuclear DivisionTransmittalLog Nuclear Engineering Document Control Procedure Schedule and Status Log Nuclear Engineering Document Control Records Marsgement Program Manual Calculation PSL-2FJi-92-005, Rev. 2 OA approvalletters for Nuclear Engineering OAl/New Employee Orientation Program
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Pre Audit Conference:
Post Audit Conference:
Location:
Juno Beach Location:
Juno Beach Date:
October 27,1992 Date:
February 4,1993 Summary of Post Audit Conference:
The results of the audit were presented to the auditee. Some discussions were held relative to the 4
circumstances potentially leading to the audit findings and also current "self-initiated" corrective actions.
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The audited organization agreed with the findings presented and was thanked for their cooperation during the course of the audit.
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l DEPARTMENT AUDIT Audit No:
OAS-JPN-92-3 Principal Auditor:
N 4firA M, 2 f' 3
'R. L. Simpsori Date
' Performance Assessment QuaRy Assurance - Juno kW 2-26-93 J. B. Perkins Date Performance A'sessment Quality Assura ce - Juno Reviewed By:
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O P R. Croom Date Supervisor Periormance Assessment Quality Assurance Juno Acoroved Bv:
20!9 %
R. A. Symes
'Date '
Ouality Manag r Juno Beach
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FPL JQQ-96-078 l
To:
J. Scarola Date:
June 11,1996 From:
L. W. Bladow Department:
JNA/PSL
Subject:
Quality Assurance Audit OSL-PCM-96-11 Attached is an audit conducted to review the St. Lucie plant program for review and implementation of Plant Change / Modification Packages and stand alone Engineering Safety Evaluations. Three QA Findings were identified during the audit. The overall conclucion resulting from this audit is that the pre-implementation review of design changes and safety evaluations by the plant organization is poorly defimed and does not provide adequate assurance that the requirements of these engineering documents will be captured and satisfied prior to implementation. Management attention and inter-1 departmental corrective action, as discussed at the audit exit meeting, will be required to improve performance in this area.
The following findings are documented in this report and have been discussed with appropriate personnel and exited with PSL Plant Management.
Findine 1:
Plant procedures and instructions do not adequately define the review and comment process by plant departments impacted by PC/M packages or the resolution of those comrnents during the PC/M preparation stage. (Before issuance to the plant)
Findine 2:
Plant procedures and instructions do not adequately address the review and resolution of comments by plant departments or the identification of plant procedures impacted by PC/M packages during the final review stage of the PC/M packages to be implemented. (After issuance to the Plant)
Findine 3:
Plant procedures and instructions do not adequately address the review of Safety Evaluations for impact on plant procedures and instructions. No procedure exists which specifies how St. Lucie Plant reviews and implements Safety Evaluation requirements.
Conditi'on Reports have been generated for the above findings. In accordance with the FPL Quality Assurance Program, please ensure that the Condition Reports which address these findings are responded to within 30 days of origination. As noted in QI 16 PR/PSL-2 response to Condition Reports resulting from QA audit findings must include the following:
1.
The results of review and investigation of the findings including identification of the probable root cause/ causal factors.
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Results of your examination of potential weaknesses in departmental self-assessment programs which may have impeded self-identification of the problem.
3.
A determination of the generic impact of the finding, i.e., whether it extends to other
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areas, systems, drawings, procedures, etc., or whether it is isolated to those examples cited in the audited report.
4.
Actions taken or planned to correct the findings identified and to prevent recurrence of the j
deficiency. Corrective actions should address the causal factors and enhancements to the audited department's self-assessment program.
5.
Date when full corrective action was or will be achieved.
4 6.
Identification of the individual (s) responsible for the corrective action.
For those corrective actions which cannot be completed within 90 days from the audit report j
transmittal, the response shall (1) include an explanation why the action cannot be completed within 1
90 days and (2) include both the cognizant Vice President (or Director where the Director is a direct i
j report of the President - Nuclear Division) and the Director - Nuclear Assurance on distribution.
N An evaluation should be made of the findings identified in this audit to determine reportability.
We sincerely appreciate the cooperation we received from your staff during the course of the audit.
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Please contact me at extension 7111 or the respective QA contact if you have any questions.
4 h
.i L. W. Bladow
[
- Quality Manager-PSL LWB/JTV/ sir -
Attachment Copies to:
Dist. Attached
AUDIT REPORT QSL.PCM-96-11 Page 2 of 19 Executive Summary:
A quality assurance audit of St. Lucie Unit 1 Cycle 14 refueling activities identified process deficiencies related to the implementation of specific criteria contained in PC/M 054-196" St. Lucie Unit 1 Cycle 14 Reload." Specifically, at the time of the initiation of fuel movement, prerequisites for spent fuel pool cooling contained in the fuel reload Plant Change /Modificadon (PC/M) package had not been satisfied.
Condition Report 96-786 was generated on May 12,1996 to document and address these deficiencies. Fuel movement was stopped until the prerequisites were satisfied.
The PSL Quality Assurance Department performed an additional audit to review the generic implications of this issue. An additional review of PC/Ms being implemented during the PSL-1 refueling outage was conducted to provide assurance that engineering requirements contained in PC/Ms being implemented have been satisfied.
No additional PC/Ms being implemented during the PSL-1 outage were i
identified for which prerequisite requirements had not been met.
This audit also reviewed the broader topics of the PC/M review process and the stand alone Safety Evaluation review process.
l The audit identified deficiencies in the areas of PC/M review.
implementation, and completion as well as deficiencies in the area of Engineering Safety Evaluation implementation.
The overall evaluation of this program is that the pre-implementation review of design changes and safety evaluations by the plant organization at PSL is poorly defined and does not provide adequate assurance that requirements of these engineering documents will be captured and satisfied prior to implementation.
Prompt corrective action. as discussed with the St. Lucie Information Services Supervisor and initiated in part during this audit. is necessary to correct the identified deficiencies. A number of corrective actions have already been implemented as recommended by the Event Response Team formed to address CR 96-786.
Findings - Three QA Audit Findings are contained in this report:
Plant procedures and instructions do not adequately define the review and comment process by plant departments impacted by PC/M packages or the 4
AUDIT REPORT nsL.PCM-%11__
PN Page 3 of 19 resolution of those comments during the PC/M preparation stage. (Before issuance to the plant)(Gee Pg.10)
Plant procedures and instructions do not adequately address the review and resolution of comments by plant departments or the identification of plant procedures impacted by PC/hf packages duri.g the final review stage of the PC/M packages to be implemented. (After issuance to the Plant) (See Pg.13)
Plant procedur:s and instructions do not adequately address the review of Engineering Safety Evaluations for impact on plant procedures and instructions. No procedure exists which specifies how St. Lucie Plant reviews and implements Safety Evaluation requirements. (See Pg.16) l
AUDIT REPORT QSL-PCM-96 --
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Location of Audit St. Lucie Plant Da(s of Audit May,1996 Audit Scope a
This audit was conducted to evaluate the procedural processes utilized for the review and implementation ofdesign changes via PC/M packages, and the review and implementation of Safety Evaluations.
Audit Details On May 12,1996 St. Lucie Plant Unit I was conducting a full core off-load to the Spent Fuel Pool for Cycle 14 refueling. A QA auditor reviewing refueling activities identified that the applicable plant refueling procedures did not encompass criteria that was specified in PC/M 054-196 "St. Lucie Unit 1 Cycle 14 Reload."
PSL 1/14 refueling activities nivolve a full core off-load of cycle 13 fuel to suppon reactor vessel and core barrel inspections. Operational requirements to properly control cycle 14 refueling activities are specified by PC/M 054-196. This PC/M authorizes transferring all cycle 13 fuel ttssemblies to the Spent Fuel Pool (SFP). The PC/M contains a 10CFR50.59 safety evaluation which presumes that operational requirements are satisfied to remain within the Unit i FSAR licensing basis for the SFP. The operational requirements (i.e., prerequisites) were derived from engineering input assumptions in a cycle specific SFP cooling analysis completed to justify a full core off-load.
Prerequisites to core alterations are established by performance of OP l-1600023. " Refueling Sequencing Guidelines." Revision 59 and subsequent procedure changes.
QA reviewed refueling activities and configuration controls for the full core off-load to verify compliance to PC/M 054-196 requirements. PC/M prerequisites for spent fuel pool cooling were not met prior to the transfer of fuel to the spent fuel pool. Core off-load was commenced with only one SFP pump in operation, instead of two as specified by the PC/M. Prerequisites to check and monitor SFP temperature had not been performed. In addition the PC/M requirement to have SFP temperature less than 106 F and monitored by an operable control room annunciator, were not verifiable due to instrument calibration issues. After transferring seven fuel assemblies to the SFP.
core o1T-load was stopped by Operations to correct the prereq lsite procedural and calibration deficiencies identified by QA. Other PC/M prerequisites, not added to procedures, specified that the reactor be at least 168 hours0.00194 days <br />0.0467 hours <br />2.777778e-4 weeks <br />6.3924e-5 months <br /> suberitical prior to core off-load and that operation of two SFP pumps continue for at least 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> after core off-load.
C
AUDIT REPORT QSL-PCM-96 Page 5 of 19 The prerequisites for fuel movement were not clearly identified in the PC/M document. Section 6.0 Plant Restrictions of the PC/M (page 20 of 32), identifies plant resuictions associated with removal of cycle 13 nuclear fuel assemblies and installation and operation of the cycle 14 reload core. For example,Iten I of Section 6.0, highlights completion of the engineering package as a Mode 2 hold point. In contrast, prerequisites for SFP cooling are not highlighted, but are presented in an ambiguous manner, requiring tracing through the pacilage and culling them from multiple paragraphs within an attachment. For example. Section 6.0 refers to Section V Implementation (pages 28 to 32 of 32), for additional requirements.Section V identifies a complete listing ofimplementation requirements, except that at step 1.7, it refers to Attachment 8 for Operational Requirements related to S.P. cooling. These operational requirements are actually prerequisites for SFP cooling to establish the initial SFP water and cooling system conditions prior to commencing core off-load.
The PC/M also specified that core alterations be suspended if one SFP pump became inoperable.
This requirement appears more restrictive than TS 3.8.1.2. It is not clear in the PC/M what conditions were intended to constitute operability for the spent fuel pumps. During core off-load, the A SFP pump was effectively inoperable, due to Train A emergency diesel generator unavailability.
JPN engineering was notified by QA on 5/15/96, of the reload PC/M requirement Section 6.0, Item
- 3. to perform an additional evaluation due to not meeting SFP cooling prerequisites. This is also consistent with TQR 3.0, whereupon changes from the approved quality-requirements specified in design output shall be approved and documented by the design organization.
On May 13.1996 an Event Response Team was formed by the plant. and meetings were held to identify and determine the ioot cause of the failure to address PC/M pre-implementation criteria in plant procedures. A list of potential causes and corrective actions was generated as a result of these meetings. These corrective actions are being further developed and finalized under the plant's corrective action tracking system.
1 In response to this event, the Quality Assurance Department initiated this audit to evaluate the plant's compliance with QI 3-PR/PSL-1 " Design Control" as well as other related upper and lower J
tier documents addressing the design change prdcess. The audit scope was expanded to also include the process for implementing Safety Evaluations including ' Stand Alone' 10 CFR 50.59 Safety Evaluations generated outside of the PCM process. These evaluations are performed per ENG-QI 2.0 " Engineering Evaluations" and AP 0005769 "10 CFR 50.59 Safety Evaluation Guidelines."
3 This audit was performed by reviewing the following; existing plant and Engineering procedures j
and instructions related to design control and Safety Evaluations. ten PC'M packages awaiting t
implementation during the current Unit 1 Cycle 14 refueling outage. and ten Safety Evaluations.1.i 1
AUDIT REPORT
_ _ __ QstypcM.96 -
Page 6 of 19 addition, interviews were held with members of the Information Services Department and the Site Engineering Department.
4 The preparation and review of Engineering Packages and Minor Engineering Packages at St. Lucie is controlled by Site Engineering. Specific details of the preparation process are delineated in Engineering Quality Instructions.
Deficiencies were found to exist in the procedural methods used to identify, specify, initiate, document, and control PC/M activities in the following areas (Specifics are contained in the applicable Findings ):
~
s Preparation Finding 1 Review and Implementation Finding 2 A lack of procedural guidance exists for the review and implementation of Engineering Safety Evaluations (Specifics are contained in Finding 3).
)
In addition to the deficiencies documented in the Findings, an overall observation gained from this audit is that the plant procedures governino the responsibilities and process methods for important activities such as design and plant modifications are for the most part general in nature. These procedures do not contain sufficiently detailed criteria and instructions to provide a smooth and comprehensive, documented process for the performance of plant modifications or the implementation of other Engineering developed evaluations. Quality Instructions are being utilized to provide the specifics of the design control process. TQR 5.0 states in part:
" Quality Instructions provide directionfor activities affecting quality. Quality Instructions shall require that instructions. procedures, and drawings affecting quality include adequate quantitative and qualitative acceptance criteria. as appropriate for determining satisfactory work performance and quality compliance. These acceptance criteria requirements apply to important activities such as design. operations, test control. inspection, and plant modifications. Activities affecting quality ofnuclear safety-related structures, systems, and components shall be prescribed by documented inspections. procedures. or drawings ofa t.mc avorovriate to the circumstances and shall be accomplished in accordance with these instructions. procedures. or drawings. These documents shall include appropriate quantitative criteria such as din asions tolerances and operating limits, and qualitative criteria such as comparative workmanship samples. to assure that the quality assurance activity has been satisfactorily accomplished.
- Quality Instructions alone may be utilized to provide the specifics of a process, but it may be in the plant's interest to encompass the specific implementing criteria and process details in a lower tier
AUDIT REPORT QSL-PCMA641 Page 7 of 19 9
document such as an administrative procedure, instruction, or guideline. Otherwise, the appropriate Quality Instmetion must be sufficiently detailed to provide sufficient guidance for all of those departments involved or affected by the process.
QI 3-PR/PSL-1 Section 5.2 specifies the procedural methods and criteria to be utilized for PC/M package closeout. Included in this secticn are the dotuments known as the Implementor Turnover Package (ITOP), Attachment 3, and the System Acceptance Turnover Sheet (SATS), Attachment
- 4. These attachments are utilized to identify documentary evidence of PC/M completion and release systems and components back to plant control upon completion of the modification, or portion of the modification.
The ITOP format being utilized is very sparse in nature. There is no unique number identification for tracking and recall purposes, which is important when multiple ITOPs are generated on any one PC/M. The ITOP does not pro ~ide for documentation of all the specific individual documents such as NPWOs, procedures, drawings, inspections, tests, instructions, parts traceability, etc. which compris: the objective evidence of completion of the design change to the PC/M requirements.
System walkdown signatures and punch lists for partial or incomplete turnovers are also not addressed by this Attachment.
Likewise, the SATS format being utilized does not provide sufficient detail to document satisfactory evidence of the completion of important activities prior to the acceptance of the system or components by the plant organization and Operations Department. The Attachment does not identify or provide for signatory evidence that procedures, drawings, labels, tags, operating documents, logs, system lineups, etc. have been completed or updated to a sufficient level to support the system or components return to service.
Deficiencies identified within the PC/M review process were discussed with the St. Lucie Information Services Supervisor. The following actions developed as part of the plant's self assessment in response to Condition Report 96-786 and previously issued PMAI 96-03 311 had been taken or were in progress at the time that this report was prepared:
1.
A change t, QI 3-PR/PSL-1 was mace to include a specific check by Configuration Management for Pre-implementation requirements.
2.
OPS /OST was added to Document Control Distribution List for all PC/Ms.
3.
Reactor Engineering interfaced with PTN on FSAR violation concerning core off-load.
4.
FRG expectations regarding PC/M implementation requirements were revised.
AUDIT REPORT QSL-PCM-96 __
Page 8 of 19 i
I 5.
JPN performed a look back on all Unit 1 Cycle 14 Refueling Oucage-related PC/Ms to ensure j
that no other pre-implementation steps were missed. (Completed 05/21/96) 6.
Future corrective actions are being pursued which include the evaluation of the Turkey Point Nuclear Plant's PC/M front-end review process for implementation. The PTN process has
'~
elements which will formalize the front-end' review of PCMs. This process includes the i
following elements:
The Implementor is designated by the Plant when a PC/M is originated.
a.
b.
The Implementation Review (IR) process to include disposition of comments and an IR Quorum requirement which should include Operations, Configuration Management, and the Implementor.
j The PC/M Review Form ( Attachment 2 ) should require sign-off prior a FRG.
c.
7.
Adoption of the PTN ITOPs /SATS process for system tumover and acceptance.
These coractive actions are based on the plant's self assessment for Condition Report 96-786 and PMAI 96-03-311 and should be effective in providing procedural visibility regarding PC/M pre-iinplementation requirements. The inclusion of OPS /OST to the distribution list for all PC/Ms should enhance the plant's determination of PC/M effects on operations. The proposed revisions to the PC/M front-end review process would be effective in providing an opportunity for affected depanments to determine the impact of the PC/M on their respective functions and obtain comment resolution.
Satisfactory Areas Engineering adherence to activities specified within existing Engineering Quality Instructions Findines 1.
Plant procedures and instructions do not adequately address the review and comment by plant departments impacted by PC/M packages or resolution of those comments in the PC/M preparation stage. (Before issuance to the plant) 2.
Plant procedures and instructions do not adequately address the review and resolution of comments by plant departments or the identification of plant procedures impacted by PC/M packages during the final review stage of the PC/M packages to be implemented. (After issuance to the Plant)
.. =..
2.
1 AUDIT REPORT QSL-PCM-96-11.._
3.
Plant procedures and instructions do not adequately address the review of Engineering Safety Evaluations for impact on plant procedures and instructions. No procedure exists for specifying the St. Lucie plant's implementation of Safety Evaluations.
a
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4 d
l l
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AUDIT REPORT
- QSL-PCM-96-11 Page 11 of 19 For Engineering Packages, two formal mandatory meetings are stipulated prior to fmal EP approval and transmittal to the plant for FRG approval. These two meetings are the Conceptual /Upfront Design Review Meeting and the Implementation Review Meeting. Both meetings are coordinated and chaired by Engineering.
The Conceptual /Upfront Design Md'eting is intended to identify and address issues involving design, construction, procurement. maintenance, safety, openbility, health physics, cost, schedule, and startup. The Implementation Review Meeting is intended to review the Engineering Package for constructability, operability, maintainability, and plant procedural impact. The comments, requirements, and other criteria identified in the review are required shall be resolved and/or incorporated into the Engineering Package.
For Minor Engineering Packages. no meetings as specified previously are required.
No proceduralized method exists for the implementing or other affected depamnents to provide comments or obtain comment resolution prior to the MEP being issued by Engineering.
Discussions were held with representatives of Site Engineering and Configuration Management conceming details of the Implementing Review meeting process. It was leamed that meetings are scheduled and that departments specified by Engineering are notified of the scheduled date, time, and location. There is no criteria for the minimum quomm required for the meetings and attendance is not mandatory for the notified groups. Formal meeting minutes are not maintained as a record. In addition.
comments from participating groups are not formalized and maintained as a record with the Engineering Package nor are the comments and comment resolutions transmitted with the package.
A review of the ten PC/M packages performed during the audit revealed that nine of the packages each impacted at least one plant procedure. Only two of the PC/Ms designated that updates or changes were required to specific procedures. None of the procedures identified dming the PC/M review were determined to require changes to incorporate PC/M pre-implementation criteria as in the case specified in CR 96-786.
AUDIT REPORT QSL.PCM-9641-- - -- _ _
Page 13 of 19 Finding No. 2 PCM Review Process - Final Stage Finding:
Plant procedures and instructions do not adequately address the resiew and resolution of comments by plant depanments or the identification of plaat procedures impacted by PC/M packages during the final review stage of the PC/M packages to be implemented. (After issuance to theTlant)
Criteria:
TQR 3.0 - Topical Quality Assurance Report, Design Control Paracraoh 3.2.2
" Design changes shall be reviewed to ensure that implementation of the design change is coordinated with any necessary changes to operating procedures and practices, and required Nuclear Assurance activities, such as inspections and surveillances."
SQM 3.0 - St. Lucie Plant Site Quality Manual, Design Control Ao_oendix A States that "The minimum information required for PC/Ms at Nuclear Plants is to include the effects of the PC/M on plant procedures. Additional information may be required by individual plant procedures."
Discussion:
QI 3-PR/PSL-1 provides responsibilities and guidelines for PC/M package processing. Section 5.0 states ia part that:
"JPN shall forward the original PC/M to Configuration Management who shall provide distribution to applicable departments. Configuration Management shall:
1.
Notify the appropriate plant Maintenance Departments that the PC/M is ready for review and processing.
2.
Prepare PC/M packages for review and approval using Attachment 2 or its equivalent. This preparation involves the assembly and review of applicable documents required to complete the PC/M. Attachment 2 or its equivalent shall be used to document screening to determine if FRG review and approval is required. The attachment shall remain with the original PC/M for closure or cancellation documentation." designates various " Areas Affected by the PC/M" with a designation ofeither YES or NO. and an area for description. No designated area is available to
AUDIT REPORT "N
QSL-PCM-96-lL Page 14 of 19 signify review and approval by the implementing department or other departments affected by the PC/M. In addition, there is no formalized process specified for the implementing department or other affected departments to provide comments or obtain comment resolution prior to the PC/M being sent to the FRG, if required, for val. There is no process specified for the implementing or affected departments z-tc. J.
'ify procedures or instructionfraffected by the PC/M. There is no minimum quorum review specified for plant departments prior to FRG approval and issue of the package by CM for implementation.
QI 3-PR/PSL-1 establishes the responsibilities for only a limited listing of plant departments involved with the PC/M process. Specific PC/M review guidelines broken down by each potential group or department in the review chain are not encompassed within procedures. Guidelines specifying particular areas of review such as maintainability, impact on procedures, training, spare parts, Environmental Qualification, Vendor Manuals, scheduling, etc. are not provided.
QI 3-PR/PSL-1 states in part that "CM is responsible for Notification of Training, procedure review ( for upgrade ) and spare parts, as identified on Attachment 2. The implementing Department is responsible for updating plant procedures that are affected by PCMs and Drawing Change Requests (DCRs) upon notification by CM."
Current plant procedures and PC/M processes do not stipulate methods for identifying v.nd completing plant procedure changes that may be necessary to implement specific steps or criteria specified within the PC/M document. These changes may be required prior to, during, or immediately at the completion of the PC/M in whole or part as with systems with multiple independent trains or common components. These procedure changes may be necessary to perform the safe operation of equipment, subsystems, or systems when retumed to service. Condition Report 96-786 documents a case where specific criteria contained within a PC/M were not incorporated into plant procedures resulting in the temporary suspension of fuel movement until the specific criteria was proceduralized and met.
Specific procedures that require update to incorporate changes based on PC/M design scope are not formally identified and documented in any procedure or instruction including Attachment 2. Attachment 2 designates types of procedures affected. but not specific procedures. There is neither a department responsibility nor, more appropriately, an individual responsibility assigned to initiate and track procedure changes to completion.
AUDIT REPORT QSL-PCM-96-11 Page 16 of 19 Finding No. 3 Safety Evaluation Review and Implementation Finding:
Plant procedures and instructions do not adequately address the review of Safety Evaluations for impact on plant procedures and instructions. No procedure exists which specifies how St. Lucie Plant reviews and implements Safety Evaluation requirements.
Criteria:
TQR 5.0 - Topical Quality Assurance Report, Instructions, Procedures and Drawings Paracraoh 5.1
" Activities affecting quality of nuclear safety-related structures, systems, and compenents shall be prescribed by documented instructions, procedures, or drawings of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings."
Discussion:
This audit addressed safety evaluations issued as " stand alone" evaluations. There is no proceduralized process in place which specifies the required reviews by the plant organization for the impact and implementation of requirements contained in these Safety Evaluations. A review of the St. Lucie Plant controlled procedure index identified that no plant procedure exists for the implementation of Safety Evaluations conducted by Engineering. This process would include the identification, documentation, and tracking of required procedure changes, plant actions or administrative controls needed to satisfy Safety Evaluation criteria.
A sample review of ten previously identified Safety Evaluations was conducted.
Many of these safety evaluations were issued on a contingency basis to address potential issues. Of the ten reviewed, nine of the evaluations were determined to require some form of procedure change to satisfy the evaluation criteria if the safety evaluation was to be relied upon. This QA review did not identify any safety evaluations being currently relied upon for which ommitance of procedure changes adversely impacts plant operation. It is recommended in Finding 3 that a more comprehensive review be performed by the plant and Engineering. Current procedure revisions and outstanding procedure change requests were reviewed for the ten specified safety evaluations. Several of the procedures reviewed had not incorporated the evaluation requirements nor had procedure changes been submitted for approval at the time of this report.
Two procedures which had encompassed a Safety Evaluation were I&C procedures 1-1400182 ' Refueling Machine Load Cell Calibration' and 1-1400183 " Spent Fuel
AUDIT REPORT
__ _ QSL.PCM-96 -
Page 17 of 19 i
Machine Load Cell Calibration." Both procedures had incorporated criteria from JPN-PSL-SEFJ-96-020 R/0 " Refueling Equipment Underload and Overload Settings." The current revision to this Safety Evaluation at the time of this report was Rev. 2. A review of both revisions determined that the later revision had no impact on the criteria contained within the procedures. In addition, procedure NOP 2-0030123 " Reactor Operating Guide' lines During Steady State and Scheduled Load Changes" and Rev.1 dated 5/21/96 had encompassed tl e requirements of JPN-PSL-SENP-96-007.
Recommendation:
Your response must address the rhove finding in the manner described in the cover letter. The following recomm~ acons are offered for your consideration:
1.
Develop a procedure to ensure that all applicable departments review Safety Evaluations for impa'ct on their programs and procedures. This procedure should provide a means to document, track, and assign responsibility for changes to programmatic elements. Turkey Point Plant Administrative Procedure 0-ADM-507. " Processing Safety Evaluations" may be helpful as a model to be tailored to meet St. Lucie Plant requirements.
2.
He plant organization and Engineering should perform a "lookback" review of open Safety Evaluations to determine which safety evaluations are currently being relied upon and revise required procedures immediately.
AUDIT REPORT QSL-PCM-96-11 Page 18 of 19 j
Audit
Participants:
Name Department / Group A
R D.
Denver Engineering '
X C.
Wasik Engineering X
X J.
Holt Information Services X
X J.
Harmon Information Services X
J.
Walls Quality Assurance X
X P.
Roach Quality Assurance X
X M.
Dixon Information Services X
D.
Huey Quality Assurance X
Key:
A - Attended Pre-Audit Conference / Notified of Audit B - Interviewed or Contacted During Audit
References:
FPL TQR 3.0 Design Control Rev.I1 FPL TQR 5.0 Instructions. Procedures and Drawings Rev.10 SQM 3.0 Design Control Rev.1 QI 3-PR/PSL-1 Design Control Rev.39 ENG-QI 1.0 Design Control Rev.3 ENG-Q1 1.1 Engineering Packages Rev.0 ENG-QI 1.2 Minor Engineering Packages Rev.0 ENG-QI 2.0 Engineering Evaluations Rev.1 AP 0005769 10 CFR 50.59 Safety Evaluation Guidelines Rev.2
\\
AUDIT REPORT QSL-PCM-96-11 Page 19 of 19 Pre-Audit Conference:
i Location:
St. Lucie Plant
)
Date:
May 17,1996
'~
Post-Audit Conference:
1 Location:
St. Lucie Plant Date:
June 11,1996 i
Summary of Post-Audit Conference:
The audit results were discussed with personnel in attendance. Plant and engineering personnel agreed that the Findings were valid and that corrective action would be taken to correct the noted deficiencies. There was a valuable discussion of the issues identified in the Findings and cooperative ideas regarding process improvements.
Personnel in attendance were: J. Scarola. W. Bladow, R. Keane, J. Voorhees, J. Porter, D. Denver, D. Wolf, C. Burton. E. Weinkam. H. Johnson, J. Holt, M. Miller (USNRCY, C. O'Farrill, S. Valdes Location of Audit:
St. Lucie Plar.t
'f Accomnanvine Auditor:
I b // 9h Rober[Ke Date '
e Quali,
ssurance Lead A'uditor/ Reviewed hv:
N J.
. Voorhees Date
, A Supenisor - PSL
~
6
- ~ ~~ ~~ AUDIT PLAN'
~
QSL-PC/M-96-11 Activity /Locr. tion To Be Audited:
Design Control and Engineering Safety Evaluation implementation at St. Lucie Plant Audit Purpose /
3 Scope:
a This audit will evaluate the program adequacy and assess the implementation of the activities associated with PC/M packages and Engineering Safety Evaluations for compliance with requirements. The scope of the audit encompasses the following areas:
1
~
1.
The review and, approval process for PC/Ms in the preparation stages prior to issue to Plant.
2.
He review and approval process for PC/Ms by the Plant Organization upon issue by Engineering.
3.
The implementation of PC/M criteria by plant procedures and instructions.
4.
The turnover and system acceptance process for PC/Ms.
5.
The review and implementation of Engineering Safety Evaluations including governing procedures.
a 6.
Overall review of audit area effectiveness.
Organization (s)
To Be Notified:
1 PSL Document Control Engineering PSL Information Services Checlist Or Procedures To Be Employed: Checklist to be prepared by the lead auditor.
. Applicable Documents:
The following documents and procedures are subject to audit ( this list may not be all inclusive) :
FPL Topical Quality Assurance Report FSL Site Quality Manual PSL Site Quality Instructions Engineering Quality Instructions Plant Procedures, Instructions and Guidelines
)
Lead Au ' or:
Approved By:
f wwh %
Re'b M eane J.
othees V
Inter-Office Correspondence FPL JQQ-96-123 To:
'. Scarola Date:
September 9,1996 From:
L. W. Bladow Department:
JNA/PSL
Subject:
Quality Assurance Audit OSL-PM-96-17 Attached is a summary report for QA Performance Monitoring activities completed during July / August,1996 to assess the implementation of the Quality Assurance Program at St. Lucie. The following findings are documented in this report and have been discussed with appropriate personnel and exited with PSL Plant Management.
Findine 1:
Several instances were observed in which Radiation Workers did not follow approved plant health physics procedures.
Findinc 2:
Nine instances ofimproper configuration control of plant valves were identified in connection with PCM 153-194.
Findine 3:
Modification of the Unit 1 Excore Nuclear Instrumentation was allowed to proceed to completion despite multiple indications of design process breakdown.
Findinc 4:
In two cases. Condition Report dispositions provided corrective action of unsatisfactory depth.
Findinc 5:
In three cases inadequate inter-departmental coordination has caused Quality Assurance audit finding responses to have unsatisfactory content.
Condition Reports have been generated for the above findings. In accordance with the FPL Quality Assurance Program, please ensure that the Condition Reports which address these findings are responded to within 30 days of origination. As noted in SQM 16.0 responses to QA audit findings must include the following:
1.
The results of review and investigation of the findings including identification of the probable root cat w/ causal factors.
2.
Results of your examination of potential weaknesses in departmental self-assessment programs which may have impeded self-identification of the problem.
3.
A detennination of the generic impact of the finding. i.e. whether it extends to other areas, systems drawings, procedures. etc., or whether it is isolated to those examples ci'te in the audited report.
hVf
r s
O Inter-Office Correspondence I
1 -.... -. - -.
FPL.
l l
JQQ-96-123 l
To:
J. Scarola Date:
September 9,1996
(
From:
L. W. Bladow Depanment:
JNA/PSL
Subject:
Quality Assurance Audit OSL-PM-96-17 Attached is a summary report for QA Performance Monitoring activities completed during July / August,1996 to assess the implementation of the Quality Assurance Program at St. Lucie. The following findings are documented in this repon and have been discussed with appropriate personnel and exited with PSL Plant Management.
Findine 1:
Several instances were observed in which Radiation Workers did not follow approved plant health physics procedures.
l I
Findine 2:
Nine instances ofimproper configuration control of plant valves were identified in t
connection with PCM 153-194.
l l
Findine 3:
Modification of the Unit 1 Excore Nuclear instrumentation was allowed to proceed to comple: ion despite multiple indications of design process breakdown.
l Findine 4:
In two cases. Condition Report dispositions provided corrective action of l
unsatisfactory depth.
Findine 5:
In three cases inadequate inter-departmental coordination has caused Quality Assurance audit finding responses to have unsatisfactory content.
J l
l Condition Reports have been generated for the above findings. In accordance with the FPL Quality i
Assurance Program, please ensure that the Condition Reports which cddress these findings are responded to wit!:in 30 days of origination. As noted in SQM 16.0 responses to QA audit findings must include the following:
1.
The results of review and investigation of the findings including identification of the probable root cause/ causal factors.
2.
Results of your examination of potential weaknesses in departmental self-assessment programs which may have impeded self-identification of the problem.
3.
A determination of the generic impact of the finding, i.e., whether it extends to other
[
areas, systems, drawings, procedures. etc.. or whether it is isolated to those examples cite g in the audited report.
V
s
.o
'~
~ ~ ~ JQQ-96-123 September 9,1996 Pagetwo i
4.
Actions taken or planned to correct the findings identified and to prevent recurrence of the l
deficiency. Corrective actions should address the causal factors and enhancements to the 1
audited department's self-assessment program.
5.
Date when full corrective action was or will be achieved.
6.
Identification of the individual (s) responsible for the corrective action.
For those corrective actions which cannot be completed within 90 days from the audit report transmittal, the response shall (1) include an explanation why the action cannot be completed within 90 days and (2) include both the cognizant Vice President (or Director where the Director is a direct report of the President - Nuclear Division) and the Director - Nuclear Assurance on distribution.
i Please note that the audit finding response must be signed by the Vice President - PSL in order to j-be accepted by Quality Assurance.
An evaluation should be made of the findings identified in this audit to determine reportability.
We sincerely appreciate the cooperation we received from your staff during the course of the audit.
Please contact me at extension 7111 or the respective QA contact if you have any questions.
Ao -
L. W. Bladow Quality Manager - PSL LWB/DCL/mkl Attachment Copies to:
Dist. Attached
.