ML20141C994
| ML20141C994 | |
| Person / Time | |
|---|---|
| Site: | Browns Ferry, Sequoyah, 05000000 |
| Issue date: | 03/17/1986 |
| From: | Croes J, Hornstra D, Stevens W TENNESSEE VALLEY AUTHORITY |
| To: | |
| Shared Package | |
| ML082340290 | List: |
| References | |
| I-85-165-SQN, NUDOCS 8604070367 | |
| Download: ML20141C994 (10) | |
Text
v.
TENNCSSEE VALLEY AUTHORITY NUCLEAR SAFETY REVIEW STAFF NSRS REPORT No:
I-86-165-SQN EMPLOYEE CONCERN NO:
SQP-5-004-004 SQP-5-004-006
SUBJECT:
CRAFTSMEN DIRECTED TO VIOLATE PROCEDURES, USE TOOLS OTHER THAN THOSE SPECIFIED, AND USE QUESTIONABLE QA MATERIAL DATES OF INVESTIGATION:
FEBRUARY 13 - FEBRUARY 24, 1986
.7 /7 E STIGATOR:
t A-( HORNSTRA DATE /
3[/7!R6 MM INVESTIGATOR:
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}WhM 2 //7 /VC REVIEWED BY:
1 M. A. KOLTOWICH DAT,E
/
APPROVED BY:
I W. D. STEVENS DATE G
l R604070367 060328 PDR ADOCK 05000259 P
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I.
BACKGROUND A Nuclear Safety Review Staff (NSRS) investigation was conducted to determine the validity of expressed employee concerns received by Quality Technology Company (QTC)/ Employee Response Team (ERT) and the NSRS Site Representative at Sequoyah Nuclear Plant (SQN). The concerns of record, as summarized on the Employee Concern Assignment Request Form from QTC and identified as SQP-5-004-004 and SQP-5-004-006, stated:
-004 Sequoyah: CI is frequently directed by Supervisor to violate procedures.
Supervisor argues with CI when CI refuses to violate procedures. Names / details known to QTC and withheld to maintain confidentiality. No furt<2r information may be released. Nuclear Power Concern. CI has no further information.,
-006 Procedure MI-10.37 requires a 0-30 in. Ib. torque wrench be used yet craft are told to use a 0-24 in. Ib. torque wrench. CI feels that craft should not be asked to violate a procedure.
Nuclear Power Concern. CI has no further information.
The NSRS investigators contacted QTC for additional information on SQP-5-004-004 to determine the particular organization at SQN from which this concern was expressed. QTC stated that concern SQP-5-004-004 involved the Electrical Maintenance Section and that one of the general foremen had been identified as the supervisor who had directed the concerned individual (CI) to violate the procedures.
During preparation for this investigation, the investigators learned that the NSRS SQN Site Representative had been approached with a similar concern and was provided with examples of direction to use material of ques.tionable material traceability.
II.
SCOPE A.
The scope of this investigation was determined from the concern of
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record to be four issues reqJiring investigation:
1.
Electrical maintenance personnel have been directed to violate Procedures by performing steps contrary to those in the procedures.
2.
Electrical maintenance personnel have been directed to violate procedures by using tools different from those specified in procedures.
I
3.
During the performance of MI-10.37, a craftsman was directed to use a torque device or item of measuring and-test equipment (M&TE) other than that specified in the procedure.
4.
Electrical maintenance personnel have been provided or have been directed to use material on Critical Structures Systems, and Components (CSSC) equipment which was either non-QA or had questionable traceability.
B.
This investigation was conducted by interviewing 22 electrical maintenance craftsmen and reviewing selected surveillance instruc-tions (sis), maintenance instructions (mis), maintenance requests (MRs), work requests (WRs), and associated Power Storeroom Requisitions (TVA 575D (FD-5-70)).
III.
SUMMARY
OF FINDINGS A.
Requirements and Convaitments 1.
SQN Technical Specification (TS) 6.8.1 (Ref. 1) specifies that written procedures shall be established, implemented, and maintained covering activities as recommended in Appendix A of Regulatory Guide (RG) 1.33. R2 (Ref. 2), plus other activities identified in TS 6.8.1.
2.
SQN Technical Specifications 6.8.2 and 6.8.3 specify requirements for procedures, and changes thereto, by the plant Operations Review Committee (PORC) and requirements for temporary changes.
3.
RG 1.33, Appendix A, identifies procedures for performing i
maintenance and states that, " Procedures for the repair or j
replacement of equipment should be prepared prior to beginning work."
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4.
SQN Administrative Instruction AI-30 (Ref. 3) states that:
Written procedures shall be established, l
j implemented and maintained in accordance with the requirements of Technical Specification
[.
l 6.8.1.
All activities affecting CSSC systems or their i
structures or components.(reference SQA-134 list i
of CSSC equipment) shall be perfomed in accord-l ance with written instructions....
The execution of an instruction requires the exercise of judgement on the part of plant personnel in determining applicability of inst ructions. An instruction should never be bitudly followed by personnel.... When a condition exists that could adversely affect 2
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4 to provide comments on procedure improvement and craftsman signoff on (or review of) procedure revisions.
Some instances were noted where the general foreman had signed in the space for the craftsman to comment on recent procedure revisions.
Recently, forms have been included with work packages which ask the craftsmen to provide feedback on procedure improvement.
4.
Nine (50 percent) of 18 craftsmen stated that they had been directed to use tools different from those called out in the procedure. One of the problems cited by eight craftsmen was that the procedures are too restrictive. A frequently cited example was that procedures specified the length of a screw-driver. These craftsmen felt that it should be acceptable to substitute an 8-inch shaft common screwdriver for a 6-inch shaft screwdriver if the blade dimensions were the same.
However, if they did make this substitution, they were concerned that NRC would say they had violated the procedure.
5.
On December 31, 1985, MI-10.37 (Ref. 6) was performed on' MR A593499 on a steam generator blowdown isolation valve replacement limit switch. MI-10.37 specified the use of a torque screwdriver with a range of 0-30 in-lb.
The 0-30 in-lb screwdriver was not available for the performance of the MI since it had been sent out for calibration. A 0-24 in-lb torque screwdriver was substituted which was considered technically adequate to torque screws to a maximum of 20 in-lbs.
The substituted torque screwdriver was used without processing a temporary or nonintent change to the procedure. Based upon discussions with electrical maintenance management, several persons in electrical maintenance engineering and management were involved in the decision to use the torque screwdriver different from the one called for and were not aware that a nonintent change was necessary. This violation was identified during an NRC inspection conducted on December 8, 1985, through January 5, 1986. A severity level V violation was issued by the NRC.which the Electrical Maintenance Supervisor has responded to with an admission that the violation occurred.
I 6.
During the investigation, a review of SI-238 Diesel Generator (DG) Battery System Inspection data packages was made. The following observations'were noted:
i (a) Several unusual trends were noted in the intercell connector resistance readings fo,r DC 1A-A.
One example was the connection to cell No. 10, which was tested on June 4, 1985, had a resistance of.117 milliohms (a resistance greater than.150 milliohms is unacceptable),
On August 31, 1985, the intercell connector resistance j
recording for cell No. 10 was.038 milliohms. Given the l
deterioration found on the bolt for this terminal on October 25, 1985, during performance of HR A518211 this l
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recorded figure is unlikely. The investigators observed that the record entry on the SI data sheet appeared altered. It was impossible to determine the original entry from the microfilm copy since the original data sheet was destroyed.
(This is standard practice af ter microfilming has been verified.) The person who signed the data sheet does not remember altering the figure and knows how to properly change a quality record if necessary.
The person who recorded the resistance readings also stated that they did not make the change.
On-October 25, 1985, the SI was conducted again, but this time the resistance reading was.180 milliohms.
(b) MR A518211 was written to correct the excessive connection resistances on DG 1A-A, cell No. 10.
An inspection of the connection on cell No. 10 on February 18, 1986, by the investigators revealed the bolt used on cell No.10 was of a different material (plated carbon steel) from the stain-less steel bolts on the other terminals.' The stainless steel bolts have 316 stamped on the bolt head; the bolt on cell No. 10 had trade and class markings on its head. The vendor manual (C&D Installation and Maintenance Manual) specifies stainless steel or brass fasteners be used on C&D batteries. MR A518211 did not specify the bolt material required for the intercell connectors.
(c) The TVA 6436 F Report of Failure attached to MR A518211 stated in the action section that the bolt, nut, and washer were replaced, and the connections were cleaned and coated with a nonoxidizing agent. The DG Batteries are
.CSSC equipment and require QA replacement parts. Only one 575 was recorded on the MR and only covered a replacement nut which was specified to be non-QA. No issuing paper-work (575) was noted for the bolt, washer, and nonoxidizing agent.
(d) Tha bolt that was incorrect on the DG 1A-A battery cell No. 10 was replaced on WR B116001 dated February 23, 1986.
During the investigation, additional work was performed on 4
intercell connectors on DG 1A-A battery.
The documentation was reviewed by the investigators with the following observations:
i o WR B108283 removed intercell Z bars and fastenors from the spare battery, and WR B103376 reinstalled the Z bars where intercell cables had been installed in DG 1A-A.
o The WR made no mention of fasteners being changed on the DG 1A-A battery, o During the performance of the work, fastences were transferred from the spare to the DG 1A-A battery without traceability.
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7.
A review of the Electric Maintenance tool room receiving, issuing, and storage practices for small parts drawn from Power Stores for general plant use was conducted.
Some practices which indicate a breakdown of the QA Program (traceability) are as follows:
(a) Bins for small parts are not identified as QA or non-QA
- parts, (b) the 575 is not kept with the parts to ensure that a part withdrawal is recorded against the proper 575, (c) new parts received by the stockroom with a different 575 number are being dumped into the same bin with the remaining stock, and (d) the 575s are kept in a stack, separate from the parts.
When a part such as a bolt is needed, the stock room attendant (or the evening / midnight general foremen or foreman) gets the bolt and looks in the stack of 575s for a matching description.
This 575 number bec6mes the number for the bolt that has been withdrawn.
8.
Many personnel problems in the Electric Maintenance Shop were noted but were outside the scope of this investigation. These problems included employee morale, favoritism, poor communi-cations, and lack of trust in management. Details of these issues were discussed with the supervisor of the Electrical Maintenance Section on February 24, 1986, and are not included as a part of this report.
IV.
CONCLUSIONS AND RECOMMENDATIONS A.
Concern SQP-5-004-004 was substantiated in that numerous craftsmen had stated that they had been directed to violate the procedure, when procedural problems existed, rather than wait for the appropriate changes to be made to the procedures. There was no evidence found that the type of procedural violations identified in this investigation resulted in plant hardware being left in a degraded or indeterminate condition.
(Also see section IV.F.)
B.
Concern SQP-5-004-006 was substantiated in that SQN Electrical Maintenance personnel acknowledged the use of an improper M&TE device (torque screwdriver) in response to the associated NRC violation notification.
C.
Improper material (a plated bolt) was found installed on an intercell connector of the DG 1A-A battery. Upon notification of this deficiency, SQN Electrical Maintenance personnel promptly replaced the bolt with a fastener in accordance with vendor i
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requirements. One of the contributing causes of the installation of improper material was the failure of the work instructions to identify the required material to be used and the QA level to be observed.
Recommendation I-86-165-SQN-01, Identification of Proper Material and QA Level Designation on MRs and WRs Those responsible for preparing MRs/WRs should be directed to specify correct material and QA level required for replacement parts.
[P2]
D.
The Electrical Maintenance Tool Shop practice of reissuing parts, issued for general plant use, resulted in a loss of traceability.
Parts were maintained in ummarked bins in the tool room and mixed with remaining parts acquired on previous 575s. Associated 575s were filed elsewhere in the tool room. No Electrical Maintenance Section instructions or higher-level instructions were found which prescribed requirements and/or acceptable practices for reissuing small standard parts from section tool rooms.
Recommendations I-85-165-SQN-02, Montraceable Parts in Electrical Maintenance Shop All QA parts in electrical maintenance which have not had traces-bility maintained should be handled as nonconforming material as required by the Topical Report.
[P1]
I-86-165-SQN-03, CA Review of Handline of Parts for General Purpose Use on CSSC Equipment The SQN Plant QA Staff should review the practices of other SQN sections to determine if their handling of parts for general purpose use for CSSC equipment also causes a loss of traceability.
The Plant QA Staff should also perfom an evaluation of the adequacy of material traceability on the MRs, WRs, and WPs in electrical maintenance and all other sections at SQN. Corrective Action Requests / Deviation Reports,(CARS /DRs) should be initiated as required.
(P1]
s I-85-165-SQN-04, Procedures for Handlinn' Parts for General Purpose Use on CSSC Equipment SQN Standard Practico (SQA 45) should be revised to address detailed requirements for handling QA material under the users control when performing MRs.
Section instruction letters should be prepared / revised as necessary to provide guidance to craf tsmen or other plant personnel involved in the handling of material once it has been drawn from Powar Stores for general plant use.
(P2]
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I-86-165-SQN-05, Impact of Use of Montraceable Material on CSSC Equipment An evaluation should be conducted to determine the impact en the plant caused by the use of nontraceable material (non-QA material and material which cannot be linked to a unique 575) reissued for use on CSSC equipment from any of the tool rooms.
[P1]
E.
Based upon MRs and WRs reviewed on DC 1A-A battery, insufficient attention to detail has been directed to traceability of documentation for replacement / repair parts. Deficiencies included not having the appropriate 575s for all the parts / lubricants replaced, the use of a 575 for non-QA material when QA material was required, and work performed beyond that described in the WR (transfer of fasteners from the " spare" DG battery to the DC 1A-A battery) without material traceability.
Recommendations I-86-165-SQN-06, Electrical Maintenance Training on Traceability of CSSC Parts The need to properly document the traceability of replacement parts and lubricants should be emphasized to all Electrical Maintenance Section personnel.
[P1]
I-86-165-SQN-07, Responsibility for Increasinz Scope of MRs Steps to document additional work required in an MR/WR beyond that initially prescribed should be specified in appropriate cection instructions. The responsibility for revising the ccope of the MR should be clearly defined.
(P2]
l F.
The listing of required tools in Electrical Maintenance Section mis was overly restrictive.
Specification of the length of a common screwdriver. although helpful in selecting tools for the typical application of the MI, may delay or prevent the completion of work or may develop an attitude that the craf tsman and/or his supervisor may interpret the " intent" of procedures.
I-86-165-SQN-08 Identify Mandatory Versus Nonmandatory Tools and Equipment s.
mis should be reviewed to determine which, tools and equipment identified in the mis are mandatory.
For those toclo/ equipment considered mandatory, the stop(s) where required chould be identified.
Other tools which are considered only a recommendation should be placed in a separate licting.
[P3]
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DOCUMENTS REVIEWED IN INVESTICATION I-86-165-SQN AND REFERENCES 1.
SQN Technical Specifications 6.8 2.
NRC Regulatory Guide 1.33 R2, " Quality Assurance Requirements (Operation)," dated February 1978 3.
SQN Administrative Instruction AI-30, R7, " Nuclear Plant Method of Operation," dated July 18, 1984 4.
Topical Report TVA-TR75-1, R8, " Quality Assurance Program Description for Design, Construction, and Operation " Section 17.2.8,
" Identification and Control of Katerials, Parts and Components" 5.
SQN Standard Practice SQA-45, R18. " Quality Control of Material and Facts and Services," dated November 21, 1985 6.
SQN Naintenance Instruction MI 10.37, "NAMCO Limit Switches," RS, dated
' December 13, 1985 O
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iva 63(OS-9 65)(OP WP-5 SS)
L*NITED STATES GOVERNMENT Memorandum TENNESSEE VALLEY AUTHORITY TO: H. L. Abercrombie, Site Director. Sequoyah Nuclear Plant FROM: K. W. Whitt, Director of Nuclear Safety Review Staff E3A8 C-K MAR 171986 DATE:
SUBJECT:
NUCLEAR SAFETY REVIEW STAFF INVESTIGATION REPORT TRANSMITTAL Transmitted herein is NJRS Report No.
I-86-206-SON Subject CONDUIT REMOVAL AND REPLACEMENT WITHOUT PROPER DOCUMENTATION Concern No.
SOP-6-003-003 and associated prioritized recomendations for your acti~on/ disposition.
This report contains two Priority 1 [P1) recommendations which must be addressed before startup. Should you have any questions, please contact
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W. D. Stevens at telephone 6231-K Recommend Reportability Determination: Yes X
No.
warts naa
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Sfft oursorrics.
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e irector, NSRS/ Designee 9m 19'B6 WDS:GDM l
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Cottle. WB9*wn i James P. Darling. M R. P. Denise, LI4-A.C G. B. Kirk, SQN'"'**-
D. R. Nichols, Elb? ' m-x QTC/ERT, Watts Bc S cie..
i i..w Eric S11ger, LP6P; 4-L J. H. Sullivan, Sya'.
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