SNRC-1454, Forwards Description of Actions Taken to Prevent Recurrence of Untimely,Incomplete or Inadequate Corrective Action Responses to Nuclear QA Dept Audit Findings,Per NRC

Forwards Description of Actions Taken to Prevent Recurrence of Untimely,Incomplete or Inadequate Corrective Action Responses to Nuclear QA Dept Audit Findings,Per NRC

ML20151V722
Person / Time
Site:	Shoreham File:Long Island Lighting Company icon.png
Issue date:	04/27/1988
From:	Leonard J LONG ISLAND LIGHTING CO.
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
SNRC-1454, NUDOCS 8805030165
Download: ML20151V722 (20)

Text

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e e ggg LONG ISLAND LIGHTING COMPANY SHOREHAM NUCLEAR POWER STATION f

P.O. BOX 618, NORTH COUNTRY ROAD e WADING RIVER. N.Y.11792 JOHN 0. LEON ARD, JR.

wc enisioinn meAn oesn'"

SNRC 1454 APh 27 988 U.S. Nuclear hegulatory Commission ATTN: Document Control Desk Washington, DC 20555 Peply to Notice of Violation Shoreham Nuclear Power Station - Unit 1 '

Docket No. 50-322

Reference:

NRC letter (W. T. Russell) to LILCO (J. D. Leonard, Jr. ) , dated March 28, 1988, Notice of Violation Gentlemen:

Attachment 1 describes, as requested by your letter, specific actions that were taken to (1) prevent recurrence of untimely, incomplete or inadequate corrective action responses to Nuclear Quality Assurance Department audit findings or other identified deficiencies, and (2) inform SNPS personnel that falsification of records is a serious offense that cannot and will not be tolerated. Attachment 2 is a memo recently issued which reiterates LILCO's position on accurate data and records. I Attachment 3 is forwarded in response to the Notice of Violation enclosed in the referenced letter and was prepared in accordance with your instructions.

NRC acceptance of LILCO's responses to correct the identified deficiencies is documented in Section 5 of NRC Inspection Report 50-322/86-07; Section 6 of NRC Inspection Report 50-322/86-08; Section 8 of NRC Inspection Report 50-322/86-10; Section 12 of NRC Inspection Report 50-322/86-14; Section 5 of NRC Inspection i j

Report 87-14 and Special Safety Inspection 50-322/86-11. l Additionally, the NRC Systematic Assessment of Licensee l Performance (SALP) Report, Number 50-322/86-99, states that LILCO '

... implemented an effective radiation protection program and 8805030165 880427  !

PDR ADOCK 05000322 \

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. s SNRC-1454 Page 2 l 1

I substantially corrected previous concerns for the past 4 deficiencies in their chemistry program." Please be assured that )

our management is mindful of the need to continue the aggressive implementation of the corrective actions described in this letter and shall continue to maintain our high level of performance.  !

Very truly yours, 1

e

.mc sw Jo n . Leonard, Jr.

Vice P esident - Nuclear pera ions D JO/ s Attachments cc S. Brown W. T . Russell F. Crescenzo 4

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'Attrchmont 1 SNRC-1454 Page 1 Resolution of Deficiencies at Shoreham A. The Vice President - Nuclear Operations and the Plant Manager held several mretings. One meeting was held with station Foremen and 1st Line Supervisors for the purpose of encouraging and stressing the absolute necessity for open communications on matters affecting quality or safety. The concept of individual responsibility and accountability was also discussed. On April 2, 1986, a meeting was held with Local 1049 IBEW Union Stewards and a Union Business Representative in order to impress upon them both their role and the importance the company places on the concept of individual responsibility and accountability. Plant staff Section Heads were also interviewed by the Vice President -

Nuclear Operations and the Plant Manager to emphasize the need for open conmunications about quality or safety concerns, and the need for aggressive management involvement in station activities.

B. The Plant Manager issued several directives to plant Division Managers and Section Heads which were aimed at increasing management attention and responsiveness to nuclear quality assurance audit findings; improving administrative control over personnel training and qualification programs; establishing a personnel resources report to readily appraise upper management of current vacancies and personnel transfers; and improving personal observations by Division Managers and Section Heads for work being performed in the plant under their area of responsibility.

To improve the responsiveness and awareness of Plant Staff Division Managers to quality assurance activities within their specific areas of responsibility, the Plant Manager has directed that they attend quality assurance audit entrance and exit meetings and that corrective action responses and corrective actions be completed within thirty days from issuance of an audit report. Where completion of corrective

, actions is not readily achievable within thirty (30) days, the Plant Manager is to be informed by the respective Division Manager of the specific reasons for not complying with his directive. Additionally, Division Managers will review and approve corrective action responses to audit findings and provide the Plant Manager with a copy of their approval.

C. The Nuclear Quality Assurance (NOA) Department conducted a systematic review of the causes and contributors that led to the conditions which ultimately resulted in the March 20, 1986 enforcement conference. This systematic review culminated in development of a comprehensive action plan within the NQA Department to identify and eliminate root causes and implement corrective and preventive actions. This

Attachment 1 ,

SNRC-1454 Page 2 action plan is described in LILCO letter SNRC-1249,. dated April 18, 1986.

Although the quality assurance audit process successfully identified findings of significance in the radiochemistry-area, the resolution of those findings was not performed in a timely manner. Therefore, a number of actions have been and continue to be implemented to improve management attention and follow-up to audit findings and to ensure that the overall Nuclear Quality Assurance Program is more aggressive in ensuring timely resolution of quality concerns. To start, the Nuclear Quality Assurance Manager met with Department Managers in the Office of Nuclear Operations, the Nuclear Quality Assurance Department Division Managers and the lead ,

auditors to emphasize the importance of notifying upper management of potentially serious quality er safety problems. ,

Also, at the direction of the Nuclear Quality Assurance Manager, the format of the quality assurance audit open items status listing was revised to more clearly present finding data and its distribution was expanded to ensure Office of Nuclear Operations Division Managers receive a copy. This management tool continues to assist management in keeping abreast of outstanding quality assurance open items, timeliness of response, response acceptability and potential for adverse trend. Further, the lead auditors and the appropriate NQA Division Manager meet with the NQA Department Manager to summarize the results of each audit conducted by the NQA Department. This serves two functions: a) to assure UQA Manager oversight of the results and conclusions of the '

audits, and b) to provide, through the NQA Manager, prompt notification to upper management of significant findings or conclusions Audit reports are now distributed to Office of Nuclear 1 Operations Department Managers regardless of the audited area. This is intended to assure that issues affecting departmental interfaces receive appropriate interdepartmental attention and consideration.

Two quarterly activities were described at the March 20, 1986 enforcement conference; the quarterly trend analysis report and the quarterly audit finding summaries. The quarterly trend analysis report analyzes LILCO deficiency reports, audit findings and audit observations. The quarterly audit finding report categorizes findings of audits and has established training as a separate category. These reports  !

are sent to the Vice President - Nuclear Operations.

The NQA Department has developed, promoted and encouraged the l use of the Quality Hotline Program which is used by station and support personnel. LILCO's highest level of management i has endorsed the Quality Hotline Program and encourages its r

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Attechnant 1 SNRC-1454-Page 3 '

Quality Hotline Program provides employees with a confidential means to have quality issues addressed by LILCO management. The promotion of the Quality Hotline Program was accomplished by placing notices on department bulletin boards, an article in the company paper and a video tape shown to employees during General Employee Training (GET) and.

GET requalification training. The Vice President - Nuclear Operations and the Plant Manager addressed plant personnel with regard to the desired use of this program.

Other Nuclear Quality Assurance Department actions in the areas of audits and auditor training are described in detail in the previously identified LILCO letter on this subject.

Falsification of Records During the course of the previously described meetings, LILCO employees and contractors employed at SNPS were made aware that our company considers falsification of documents to be a serious offense that cannot and will not be tolerated. Furthermore, memorandum VPNO 88-68 (Attachment 2) reaffi.rms this fact.

Employees and contractors working at SNPS are aware and mindful of the disciplinary action that was and will be imposed on anyone participating in this kind of wrongdoing.

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Attachment 2 SNRC-1454 +

Pago l' April 25, 1988 VPNO88-68 All Site Employees and Contractors Falsification of Documents As many of you well remember, about two years ago we met to l discuss and emphasize the importance your management places on the concept of individual responsibility.and accountability.  !

Today, that concept is just as important as it was then. This  !

concept works and results in excellence of performance. Our most i recent NRC Systematic Assessment of Licensee Performance (SALP)

Report verifies this fact and your continued commitment to these standards will ensure that Shoreham will be the safest and most '

I effective operating nuclear power plant in the country.

1 Embodied in the concept of responsibility and accountability is I

the absolute need to be completely truthful about our achievements and our mistakes. It is well known that the validity of SNPS documentation and records is uncompromisingly l essential. Thus, falsification of records is considered a serious offense against your fellow workers who are striving for excellence and it can not and will not be tolerated.

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( v'- l l QD.j' l341% Q eona.de Jr.

,s'dVi e President, ,

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Nuclear Operations i

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Attachment 3 SNRC-1454 Page 1 RESPONSE TO NOTICE OF VIOLATION Since the deficiencies which led to the Notice of Violations were identified, actions have been taken in order to establish an effective and well managed Radiochemistry Program. Several corrective and preventive actions address other identified deficiencies within the Radiochemistry Program as well as the noted violations. A brief discussion of the general program established to implement the required corrective actions within the Radiochemistry Program is provided.

During the enforcement conference with the NRC on March 20, 1986, and later in LILCO letter SNRC-1245, dated April 3, 1986, the elements of the LILCO Radiochemistry Improvement Program (RIP) were outlined. This program was established to correct deficien-cies which existed within the Radiochemistry Program with parti-cular emphasis on the areas of Radiochemistry section management, training, qualification, maintenance of qualification, laboratory quality assurance, and section communication. The program provided both short term and long term corrective actions and consisted of three main elements. First, changes were made in existing section management. Second, a LILCO managed Radio-chemistry Improvement Task Force was created to work with the Radiochemistry section on remedial program development. Third, periodic assessments of program progress were provided by our Nuclear Quality Assurance Department and Hydro Nuclear Services, '

Inc., a LILCO consultant.

MANAGEMENT CHANGES 4

Immediate, Short Term A LILCO Manager within the Radiological Controls Division was temporarily assigned to fill the Radiochenistry Engineer's position until a qualified Section Head could be hired to fill the position. The Acting Radiochemistry Engineer was returned to

his regular position of Radiochemistry Support Supervisor pending reassignment. Additionally, the Radiochemistry Supervisor j position within the Section was eliminated to permit direct reporting responsibility between the Radiochemistry Engineer and the Radiochemistry Foreman.

Long Term 1

LILCO increased the recruitment efforts to fill positions within

- the Radiochemistry Section with experienced and capable company employees. To allow for an orderly transition to this long term 4

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Attachmsnt 3 i SNRC-1454 Page 2

. to fill vacancies. The following is a summary of the management changes within the Radiological Controls Division completed under this long term effort:

1. The incumbent Radiological Controls Division Manager was '

transferred to the newly established Operational Assessment.

Group, and the position filled by internal promotion of the Health Physics Engineer in March 1987.

2. The Radiochemistry Engineer position was, filled by a qualified individual hired from outside the company in April 1987.

3. The incumbent Radiochemistry Support, Supervisor,was reassigned after a qualified individual'was hired from outside the Company in February 1987.

4. The two Foreman vacancies have been filled internally by i promotion of LILCO Radiochemistry Section Technicians. I

5. Other vacancies within the Radiochemistry Section are now staffed with LILCO employees.

RADIOCHEMISTRY IMPROVEMENT TASK FORCE The Radiochemistry Improvement Task Force supplemented the Radio-chrmistry a staff with temporary personneleto improve the on the ,

job training and qualification process, to' improve laboratory quality assurance, and to assist with other programs requiring improvement. Because of its independence, these efforts were not subordinate to day-to-day section activities, nor were improve-ment efforts distracted by necessary attention to routine chemistry activities. This Task Force reported directly to the Plant Manager.

PERIODIC ASSESSMENT OF IMPROVEMENT ,

At the Plant Manager's request, the NQA Department conducted an ,

internal self assessment of the Radiochemistry program. Results i of this self assessment were provided directly to the Plant 3 l

Manager. Additionally, Hydro Nuclear Services, Inc., a consul-tant organization, conducted an independent verification of the f self assessment. These assessments and independent verifications ,

were continued at six month intervals until the section was "

considered by the Plant Manager to be functioning satisfactorily.

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' Attachment 3 SNRC-1454 "

Page 3 VIOLATION A DESCRIPTION OF VIOLATION:

Technical Specification 6.4, "Training", requires, in part, a i retraining and replacement program for the station staff be maintained under the Training Supervisor that meets or exceeds the requirements of Section 5 of ANSI N18.1 - 1971. ANSI N18.1 -

1971, Section 5, establishes requirements for training radio-chemistry technicians.

Procedure SP No. 71.006.01, written pursuant to the requirements of Technical Specification 6.4, requires that individual tech-  :

nicians demonstrate practical abilities by either following procedure checkout guidelines or through technician task evaluation guides.

Contrary to the above, ac of February 1986, the practical abilities of chemistry technicians were demonstrated by open book exams rather than by the use of procedure checkout guidelines or through the use of task evaluation guidelines.

1) REASON FOR VIOLATION 1 As stated in the Description of Violation above, station procedures in place at the time were adequate to implement a  :

training and qualification program required by applicable ,

Technical Specifications. This violation occurred as a ,

result of failure on the part of the then section management and supervisors to ensure activities were conducted in ,

accordance with established procedures. It is evident that those individuals were not sufficiently sensitive to the rigorous standards which must be maintained to assure training and qualification activities provide the highest level of confidence that section personnel are capable of performing their required duties.

2) CORRECTIVE STEPS TAKEN AND RESULTS ACHIEVED:

The corrective steps taken were separated into short term and long term actions.

SHORT TERM ACTIONS:

During the conference between LILCO and the NRC held on March 20, 1986, the NRC was informed of our commitment to not I resume low power operations until requalification of an adequate number of our Radiochemistry technician staff was i

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' Attich23nt 3 SNRC-1454 Page 4 complete. Until a Radiochemistry technicians' qualifications t could be appropriately performed, supervisory ccverage was provided on the technician's shift. The requalification activities that were conducted in accordance with SP 71.

006.01 and Padiochemistry Improvement Program short term action plan are as follows:

a) Technician candidates for requalification were selected from those whose basic training records had been reexamined to encure the prequalification requirements of the Qualification Procedure SP 71.006.01 had been met.

b) For each task of the Backshift Qualification Task Listing in SP 71.006.01, the technician demonstrated, through actual task performance, that he was capable of performing the task. That performance was demonstrated to and documented by a member of the Radiochemistry Section or Task Force professional staff, who employed a previously prepared task-specific Evaluation Guide in accordance with SP 71.006.01 to ensure objective evaluation of that performance. On-the-spot remedial advice to the technician was allowed provided a notation of weaknesses and satisfactory correction of those weaknesses was made in the qualification record. If warranted, retraining was conducted to reinforce areas of identified weakness. The Nuclear Quality Assurance Department significantly increased its surveillances of the requalification effort to ensure adherence to Qualification Procedure during the technicians <

performance.

The technician co-signed his qualification record as an indication of his agreement with his capability to perform each pertinent task unsupervised.

c) On-the-job training by the Radiochemistry Improvement Task Force was conducted for specific technical areas identified as needing reinforcement. This included the proper use of Chemistry Control Charts, correlation between p!! and conductivity, and chloride stress corrosion. On-the-job training by other members of the radiochemistry staff addressed utilization of the stations chemistry Technical Specification, general good laboratory practice, and utilization of only calibrated equipment.

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Atttchment 3 SNRC-1454 Page 5 The results of these short term actions were reviewed by .

members of the NRC staff during a Special Safety Inspection (Inspection 86-11) conducted on July 28, 1986 through August 1, 1986. As a result of this follow-up inspection, the deficiency was closed.

LONG TERM ACTIONS:

The effort to verify and upgrade Radiochemistry technician qualifications in required backshift activities was followed by a continued effort on the part of the Radiochemistry Improvement Task Force to upgrade the level of training of Radiochemistry technicians in areas of their responsibility.

Ten new technicians were hired during June and July of 1986.

These newly hired employees were provided 6 months of formal classroom training. The training was prepared and conducted by staff professionals of the NUS Corporation and included instruction in the following areas: basic water chemistry fundamentals, radiochemistry and radiochemical analysis, BWR systems familiarization, analytical techniques and analysis methods. This training provided the basic structure and content of the current initial training requirements for Radiochemistry technicians as outlined in the Shoreham Nuclear Power Station Radiochemistry Technician Program Description dated February 19, 1988.

During the training period for new technicians, Task Force personnel reviewed and revised station procedures used by the Radiochemistry section to conduct routine activities. Along with these procedure revisions, an evaluation check list was prepared to be utilized in the qualification of technicians on section procedures. Upon completion of the initial training period, the ten newly hired technicians were allowed to perform routine Radiochemistry section functions under the supervision of qualified technicians or Task Force personnel.

Once a technician was sufficiently familiar with a task, the Task Force conducted a performance evaluation and qual-l ification on required station procedures for each new technician, A similar process was performed to qualify incumbent technicians in required procedures which were not part of the backshift qualification list. As of Octoher 31, 1987, the qualification of Radiochemistry technicians was  !

sufficiently complete to allow the release of consultant j personnel augmenting the Section's activities. 1 l

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Attcchm:nt 3 ,

SNRC-1454 Page 6

3) CORRECTIVE STEPS THAT WILL BE TAKEN:

Simultaneous with the above qualification effort was an effort to develop a new training and qualification program for Radiochemistry technicians which would meet the Institute of Nuclear Power Operations (INPO) accreditation standards.

This effort was begun in early 1987 under contract to the 4

Nuclear Utility Services (NUS) Corporation and was completed by members of LILCO Office of Training and the Radiochemistry Section. The elements of the Radiochemistry Technician Training Program which were developed, include: 1) initial classroom training of new technicians, 2) on-the-job training, task evaluation and qualification based upon a task analysis of technician duties and, 3) continuing and refresher training for qualified technicians to ensure proficiency and provide review of industry practices, problem .

areas and procedure changes. The new Radiochemistry t Technician Training and Qualification Program will ensure that future technicians receive training appropriate to their job function and that qualifications are conducted using appropriate task evaluation vehicles. This new Program was accredited in April 1988 by the National Academy for Nuclear Training. Receipt of this accreditation should provide every confidence that future training and qualification efforts will be conducted so as to provide fully capable staff technicianc.

Additionally, the Office of Training has completed and implemented a new "OJT Trainer / Evaluator Training Program",

which provides adequate knowledge and skills to perform OJT and task evaluation for qualification. Successful completion of this program is required prior to designated personnel performing OJT and task evaluation for qualification. This training will prevent a repeat of occurrences which resulted in this violation.

4) DATE OF FULL COMPLIANCE:

Through the efforts of the Radiochemistry Inprovement Task Force, and Radiochemistry Section personnel current Radio-chemistry technicians are fully qualified to perform the tasks which they are currently assigned. These qualifi-cations were performed in accordance with requiremunts of station procedure SP 71.006.01, and Technical Specifications, Section 6.4. Full compliance has therefore been achieved.

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2 Attschment 3 SNRC-1454  !

Pago 7 VIOLATION B DESCRIPTION OF VIOLATION: ,l Technical Specification 6.3.1, "Unit Staff Qualification", ('

requires, in part, that each member of the unit staff shall meet or exceed the minimum qualifications of ANSI N18.1 - 1971.for  :

comparable positions. ANSI N18.1 - 1971 requires that repairmen in responsible positions shall have a minimum of three years'in ,

one or more crafts. 6 i

Contrary to the above, as of February 1986, radiochemistry technicians, repairmen in responsible positions, routinely

performed electrical repair maintenance on electronic equipment of the Radiation Monitoring System, including safety related

equipment, without any training or previous background in the electronice craft. ,

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1) REASON FOR VIOLATION: ,

, i i This violation occurred as a result of the failure on the  ;

j part of the then section management to ensure that

) radiochemistry technicians met the requirements of ANSI ,

N18.1, 1971. However, we believe that we failed to meet the i requirements of Section 4.5.2, "Technicians" vs Section

! 4.5.3, "Repairmen". The specifics of this violation are an 1 j example of the lack of attention to detail which existed l within the Radiochemistry section at the time the deficiency i

was noted.

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2) CORRECTIVE STEPS TAKEN AND RESULTS ACHIEVED: i i As stated above, the reason for this violation rests with i I

section management, therefore this discussion of corrective measures will not repeat the discussion of section management changes previously provided. Rather, specific additional  !

steps taken will be described.

1 At the time the deficiency was noted, the Radiochemistry j technicians did not meet the requirements of ANSI N18.1-1971, i Section 4.5.2. Although the Radiochemistry technicians had sufficient training and experience in chemistry, they were not sufficiently trained nor had sufficient work experience l to perform repairs on the electronic equipment associated j with the Radiation Monitoring System (RMS).

l To correct this deficiency, the responsibility for electronic j equipment repair of selected portions of the Radiation i

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' Attcchm:nt 3 SNRC-1454 Page 8 Monitoring System (RMS) was transferred to the Computer Engineering Section. The technicians within the computer section meet the requirements of ANSI N18.1-1971, Section 4.5.2, by having sufficient training and experience in electronic troubleshooting and repair to effectively perform these duties. Radiochemistry technicians retain responsi-bility for operation of sampling apparatus associated with the RMS. The necessary qualifications of the Radiochemistry technicians who perform these required samples were included in the qualification verification effort previously described.

3) CORRECTIVE STEPS TO BE TAKEN:

The Computer Engineering section has assumed full responsi-bility for calibration, maintenance and repairs on selected portions of the RMS. Since the transfer of responsibility was established, routine calibrations, functional tasks and other required electronics repair activities have been performed by the Computer Engineering Section. As each required calibration or functional test has been performed, the Computer Engineering section has also assumed respon-sibility for the maintenance of required station procedures necessary to accomplish these activities.

4) DATE OF FULL COMPLIANCE:

The Computer Engineering technicians who now perform required electronic equipment repair on the RMS are fully qualified in accordance with station procedure SP C1.011.01 and meet requirements of Technical Specifications, Section 6.3.1 and ANSI 18.1-1971, Section 4.5.2. Full compliance has now been achieved.

VIOLATION C DESCRIPTION OF VIOLATION Technical Specification 6.8.1.a, "Procedures and Program",

requires that written procedures be established, implemented and maintained covering the activities of Appendix "A" of Regulatory Guide 1.33, Revision 2, February, 1978. Appendix "A" of i Regulatory Guide 1.33 requires chemistry and radiochemistry procedures.

Chemistry Procedure SP 78.011.38, "Chloride Analysis, Specific Ion Electrode Method", written pursuant to the requirements of i Technical Specification 6.3.1.a, requires the use of control '

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' Attachm2nt 3 SNRC-1454 Page 9 charts for. plotting results of control standards for chloride analysis which is required by the Technical Specifications.

Cont *cary to the above, between November, 1985 through February, 1986, control charts for plotting results of control standards for chloride analysis which were required by the Technical Specification were not used.

1) REASON FOR VIOLATION:

This deficiency resulted from failure of the then section management and supervisors to pursue on aggressive laboratory QA/QC program. Such a program would have included routine use of control charts for control of analysis results and periodic inspections by supervisory personnel to-ensure the validity of analytical results was maintained as well as compliance with written analysis procedures. _This lack of attention to detail on the part of section management resulted in the deficiency noted.

2) CORRECTIVE STEPS TAKEN AND RESULTS ACHIEVED:

Two actions taken which impact this deficiency have been l discussed previously. First, as part of the initial '

Radiochemistry technician qualification reverification,  :

on-the-job training in the proper use of Chemistry Control i Charts was provided to technicians. Radiochemistry staff members provided the on-the-job training covering general i good laboratory practices. Secondly, a member of the Radiochemistry Improvement Task Force revised procedures to implement an effective laboratory QA/QC program. These i procedures provided for periodic monitoring by section j supervisors as well as day-to-day analysis control. i In LILCO's letter SNRC-1245 dated April 3, 1986, the following actions were committed to in response to this j violation:

a) Short Term Action: Improved methods including proper control chart preparation have been-incorporated in a  !

procedure change. The procedure change, and sufficient l data to accurately prepare the chart, will be in place l prior to plant startup.

b) Long Term Action: Purchase of an ion chromatograph is being considered for performance of Technical J Specification Chloride analysis, j i

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• Attachtsnt 3  :

SNRC-1454 Page 10 The procedure revisions referred to above were. completed and implemented prior to plant startup. The ion chromatograph was purchased and installed in the laboratory as the primary ,

method for performance of routine chloride analysis, including _those required by Technical Specifications. Daily standard checks of the applicable calibration curves associated with this instrument are performed, along with  !

documented routine supervisory review of both analysis and control standard results in accordance with staBion 1 i procedures.

The overall' improvement in laboratory QA/QC practices described above were reviewed by members of the NRC Staff i during a Special Safety Inspection --(Inspection 86-11)  ;

conducted July 28, 1986 through August 1, 1986. As result of '

q the actions described above the deficiency was closed during this follow-up inspection.

3) CORRECTIVE STEPS TO BE TAKEN:

The actions necessary to establish an effective and  :

comprehensive laboratory QA/QC program were in place as of August 1, 1986. Since that date the actions taken have been '

intended to ensure personnel responsible for performing and i

) supervising analyses are knowledgeable of program )

j requirements.

J The Radiochemistry Technician Training and Qualification j.

Program described earlier, provides Radiochemistry tech-nicians with knowledge of the fundamental principles by which i  !

l analysis results are controlled and assures qualification in '

1 the mechanics of the analysis and control process. A LILCO supervisor within the current Radiochemistry section staff is 4

responsible for review of routine analysis results and control charts. This individual, the Plant Chemist, is 4 thoroughly knowledgeable of program requirements and has received additional training in Analytical Quality Control

, methods provided by the NUS Corporation. Routine inspection of laboratory quality control practices are performed as part l~ of the Radiochemistry section preventive maintenance program to ensure compliance with procedural requirements and 1 maintain adequate control limits for established analytical  ;

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j In addition, the LILCO Nuclear Quality Assurance Department l 1 has placed special emphasis on review of this area during the

, conduct of audits and surveillances of the Radiochemistry

section.

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Attcchm;nt 3 SNRC-1454 Page 11

4) DATE OF FULL COMPLIANCE:

Current station procedures establish an organized and manageable laboratory QA/QC program and our Radiochemistry section management is cognizant of its requiremente.

Assurance of highly reliable analytical results is and will continue to be of highest priority with section supervisors.

Full compliance has been achieved.

VIOLATION D DESCRIPTION OF VIOLATIONS:

Technical Specification 6.8.1.d requires that written procedures be established, implemented, and maintained covering surveillance and test activities of safety related equipment.

Station Procedure SP No. 74.631.17, "RBSVS Normal Range Radiation Monitor Functional Test" written pursuant to the requirements of Technical Specification 6.8.1.d, requires that procedural steps on the surveillance of certain safety related equipment be initialed off as they are performed.

Contrary to the above, on November 21, 1985, surveillance testing of Panel 21 of the safety related Reactor Building Standby Ventilation System was initiated, and

1) The procedure was signed off as complete, by a Nuclear Chemistry Technician, even though he had not completed and initialed all the procedural steps; and

2) the procedural steps were subsequently initialed by a 1 Radiochemistry Foreman using the initials of the Nuclear !

Chemistry Technici;' and these procedural steps had not l been performed.

1) REASON FOR VIOLATION:

This violation was caused by the inappropriate actions of one j individual, the Radiochemistry Foreman responsible for review ,

and contral of the specific surveillance test performed on j November 21, 1985. Two specific errors in judgement were i evidenced from the investigation conducted. The foreman incorrectly "acsumed" the unsigned steps had been performed and then took completely inappropriate actions to correct the situation by inserting the technicians initials on the ,

record. 1 i

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2) CORRECTIVE STEPS TAKEN AND RESULTS ACHIEVED:

} On December 17, 1985, the surveillance test of the Reactor [

] Building Standby Vontilation System radiation monitoring  :

i panel, 1D11*PNL-021, was reperformed using station procedure l j SP 74.631.17. This test indicated the panel-was functioning }

] correctly. l 4

!. In February 1986, the foreman responsible for the violation

] was suspended pending completion of investigations. LILCO  !

f permanently terminated the foreman's employment on May 12,  !

j. 1986. l i

3) CORRECTIVE STEPS TO BE TAKEN

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I No further actions beyond those described in Attachment 1 are 1 planned or considered necessary in response to this  :

.; violation. The actions described in Attachment 1,-  :

i termination of the responsible foreman, together with the i management changes within the Radiochemistry section t j previously described are sufficient to ensure such violation j are not repeated. 1 i  !

i 4) DATE OF FULL COMPLIANCE: I

} i Full compliance has been achieved. i 1

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VIOLATION E f l <

l DESCRIPTION OF VIOLATION  !

) Appendix "B" to License NPF-36 incorporates New York State 3 Discharge Permit No. 0026344. The New York State Discharge i j Permit No. 0026344 requires that water samples from Outfalls 002 ,

and 003 must be collected during the middle and end of each month  !

for analysis. Section 5.2 of Appendix "B" requires that records  :

i and logs relative to environmental acpects of facility operation j

, shall be mado and retained in a manner convenient for review and '

l inspection.  ;

i j Co.v:rary to the above '

! 1) Water samples were not collected for Outfalls No. 002 l and 003 in mid-December, 1985, and 1 2) when it was discovered in January, 1986 that no ,

I mid-December, 1985 sample was available for analysis, a sample from a different collection was analyzed and its i

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Attechm:nt 3 SNRC-1434 Page 13 results were recorded in a discharge log as results of water samples from mid-December, 1985.

1) REASON FOR VIOLATIO,tjl As with the previous violation, this deficiency resulted in part from the inappropriate actions of a single individual, the Radiochemistry foreman. It is also evident that deficiencies existed with the Radiochemistry section program that allowed the required sample to be missed. Such omissions illustrate the inappropriately low level of attention which the then section management and supervisors afforded routine section activities at the time of the deficiency.

2) CORRECTIVE STEPS TAKEN AND RESULTS ACHIEVED:

As reported in the NRC OI Investigation Report No. 1-86-008, LILCO disclosed the missed sample and resulting noncompliance condition to New York State in March 1986. Prior to this, the foreman responsible for directing that the December 1985 SPDES recorde be falsified was suspended pending completion of investigations. The foreman's employment was terminated on May 12, 1986 because of his actions related to this violation.

Station procedures by which SPDES samples are obtained have been revised to ensure requirements are clearly stated Tnd appropriate supervisory reviews are provided. Additionally, the management of the Radiochemistry section and the reporting structure of the section was changed, as has been

previously discussed. These actions have established a section structure which allows managers to closely monitor routine section activities and has placed personnel within  !

the section who understand and are sensitive to the degree of 3 detail which supervisors must impart to their review of 4

section activities.

3) CORRECTIVE ACTIONS TO BE TAKEN:

No further actions beyond those described in Attachment 1 are planned or considered necessary in response to this violation. The actions described in Attachment 1, termination of the responsible foreman, together with the management changes within the Radiochemistry section previously dencribed are sufficient to ensure such violation are not repeated.

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Attechment 3 SNRC-1454 Page 14

4) DATE OF FULL COMPLIANCE Full compliance has been achieved.

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