ML20147H182
| ML20147H182 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 02/29/1988 |
| From: | Shelton D TOLEDO EDISON CO. |
| To: | NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM) |
| References | |
| 1-782, NUDOCS 8803080409 | |
| Download: ML20147H182 (4) | |
Text
_ _ - _ _ - _ _ _ __
a TOLEDO
%s EDISON s cena twe cm Docket No. 50-346 DONALD C SHEUON
- w. e m o 4 e*,-
License No. NPF-3 l' ) * * * *
- Serial No. 1-782 February 29, 1988 Document Control Desk United States Nuclear Regulatory Commission k'ashington, D. C.
20555
Subject:
Response to Inspection Report 88004 Centlemen:
Toledo Edison has received Inspection Report 88004 (Log No. 1-1738 dated January 28, 1988) and provides the following response Violation 88004-01:
10 CFR 50, Appendix B, Criterion V, "Instructions, Procedures, and Draw-ings," requires in part that activities affecting quality be accomplished in accordance with appropriate procedures. This requirement is imple-mented by the Toledo Edison Company Nuclear Quality Assurance Manual, Section 5, and Nuclear Group Procedure NG-AV-115, which require that the Quality Assurance Director approve procedures and changes thereto which implement requirements of the Nuclear Quality Assurance Manual.
l Contrary to the above, on May 19, 1987, Revision 27 to site procedure l
AD 1805, "Procedure Preparation and Maintenance," a procedure affecting p
quality, was issued without the Quality Assurance Director's approval.
I mb
, @A Acceptance or Denial of the A11eeed Violation 88 mJ Toledo Edison acknowledges the alleged violation.
S5 Reason for the violation:
38 The subject procedure, AD 1805, is an internal administrative process established by Toledo Edison to ensure that all station procedures are prepared, reviewed, and approved uniformly and consistently. Although it WLD controls the internal preparation of nuclear safety-related procedures, AD 1805, standing alone, has no direct impact on plant safety.
The condition identified in this violation resulted from difficulties encountered during the review and comment period for Revision 27 to AD 1805. Not all of the Quality Assurance Department (QAD) comments were resolved during this period and, as a result, were referred to the Station Revieu Board (SRB) for resolution.
THE TOLEDO EDtSON COMPANY EDSON F'LAZA 300 MADISON AVENUE TOLEDO OHIO 43652 up
Dockat No. 50-346 License No. NPF-3 Serial No. 1-782 Page 2 The SRB (which includes a QA representative) eet on May 8,1987, to review and evaluate unresolved QA comments concerning draft procedure AD 1805.00, Revision 27.
The SRB concluded that the procedure did not meet the requirements of its controlling procedure (NG-AV-II5, Revision 1, Preparation and Control of Nuclear Group Division / Department Procedures),
but approved the procedure with the requirement to revise the controlling procedure prior to issuance of AD 1805.00, Revision 27.
The procedure was then forwarded to the Plant Manager for review and approval. On May 13, 1987, responsible station personnel signed the procedure cover sheet based on the understanding that the SRB had resolved QA comments and forwarded the procedure to the Information Management Department for administrative processing. At the time, they were unavare that the revision to NG-AV-115 had to be implemented prior to implementing AD 1805.00, Revision 27.
Administrative processing of AD 1805.00, Revision 27, was completed and the procedure was issued without the QA Director's signature on the Procedure Development Form (PDF). Under the procedures in effect at the time, it was not the responsibility of the Information Management Department to determine the appropriateness of the approval process but to complete processing through distribution.
Revision 27 to AD 1805 retained QA review and concurrence but removed the formal QA approval signature requirement. The Quality Assurance Department was involved in the review and comment cycle of station procedures during the period of concern. OA verified that of the 703 procedures issued between May 19, 1987, (date AD 1805, Revision 27, was issued) and January 8, 1988, those that required QA review were reviewed. This verification could not be made for one procedure revision but a subsequent review indicated that the revision in question was administrative and would have elicited no comments from QA. Therefore, this review demonstrates that 0A was appropriately involved in the review and comment cycle for station procedures.
Corrective Action Taken and Results Achieved The need to revise NC-AV-115. Revision 1 had previously been identified prior to issuance of AD 1805.00, Revision 27.
QA personnel issued additional comments to AD 1805.00 on May 20, 1987 after they discovered Revision 27 had been issued without the QA Director's approval. When QA concerns were not resolved in a timely manner, Potential Condition Adverse to Quality (PCAQ) Report 87-0322 was issued on June 26, 1987. This report documented the circumstances which led to AD 1805 being issued without Quality Assurance Director's approval. To resolve the PCAQ concerns, Nuclear Group Procedure NG-AV-115 was revised to include specific criteria relative to the method to be used to signify Nuclear Group review and comment resolution. Specifically, NG-IM-IIS now requires validation of review and comment resolution.
This criterion was established to prevent a recutrence of the activities which resulted in the release of AD 1805 without the QA Director's approval. NG-IM-00ll5, Revision 0 (equivalent to NG-AV-115, Revision 3) includes all the information required to resolve the PCAQ finding and should preclude recurrence.
Docket N3. 50-346 License No. NPF-3 Serial No. 1-782 Page 3 Date When Full Compliance Will Be Achieved:
Full compliance was achieved on February 16, 1988 when NG-IM-00115 Revision 0 and DB-0P-00003, Revision 0 became effective.
Violation 88004-02:
10 CFR 50, Appendix B, Criterion XVI, "Corrective Action," requires that conditions adverse to quality shall be promptly identified and corrected.
This requirement is implemented by the Toledo Edison Company Nuclear Quality Assurance Manual, Section 14, which requires that procedure deviations be promptly identified, documented and corrected.
Contrary to the above, the NRC inspection determined that as of January 8, 1988, a failure to obtain Quality Assurance Director approval of Revision 27 to procedure AD 1805, a condition adverse to quality documented on Poten-tial Condition Adverse to Quality Report No.87-032 on June 26, 1987, had not been resolved.
Acceptance or Denial of the Alleged Violation Toledo Edison acknowledges the alleged violation.
Reason for Violationt Quality Assurance Department personnel discovered that AD 1805.00, Revision 27, had been approved by the Plant Manger and issued for training and implementation on May 19, 1987 without the QA Director's approval.
This was the same day that Revision 27 was issued. QA attempts to resolve concerns related to the procedure were unsuccessful and subsequently on June 26, 1987, the QA Director issued a Potential Condition Adverse to Quality Repert (PCAQR) identifying programmatic implementation deficiencies concerning the approval and issuance of AD 1805.00, Revision 27.
Attempts to resolve the PCAQ findings were unsuccessful and the QA Director proposed escalating the PCAQ to a Management Corrective Action (MCA). However, the Plant Manager and the QA Director agreed on required corrective action to resolve the PCAQ on September 2, 1987 and no further escalation was necessary. Plans were to revise NG-AV-115. Rev. 1, revise AD 1805, Rev. 27 and to establish a Nuclear Group Procedure Index which delineated those procedures which required Nuclear Group review and comment resolution. On October 21, 1987, NG-AV-115. Rev. 2, was approved by the Vice President Nuclear and scheduled to become effective on December 21, 1987.
Implementation of NC-AV-115. Rev. 2 was delayed on November 30, 1987, due to problems with several key elements of NC-AV-115. Rev. 2 not associated with the conflict between NG-AV-115. Rev. I and AD 1805.00, Revision 27.
Dockot Noa 50-346 License No. NPF-3 Serial No. 1-782 Page 4 These unrelated problems were identified as the individual Divisional Department Procedure Specifications were~being developed.
Revision 3 to NG-AV-115 was initiated to correct these problems and was considered necessary to preclude forcing divisions to write two new procedure specifications, one for Revision 2 and one for Revision 3.
Also, the revision would result in procedures that are functional and program-atically uniform.
The condition was p omptly identified, and documented. Corrective action was identified and agreed upon but implementation took longer than expected due to unrelated factors.
Corrective Action Taken and Results Achieved The appropriate procedures have been revised and implemented. The desired results have been achieved.
Date When Full Compliance Will Be Achieved:
Full Compliance was achieved on February 16, 1988 when NC-IM-00115, Revision 0 and the Nuclear Division / Department implementing procedures became effective.
Very tr
- yours, EBS:bab
~
cc: DB-1 Resident Inspector A. B. Davis, Regional Administrator R. B. Landsman, NRC Region III A. W. DeAgazio, NRR Project Manager