ML20153G907
| ML20153G907 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 08/26/1988 |
| From: | Shelton D TOLEDO EDISON CO. |
| To: | Davis A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| References | |
| 1-829, NUDOCS 8809090031 | |
| Download: ML20153G907 (3) | |
Text
.
~.
PR10R11Y ROUTIM
""d km]!h-Iqirst TOLEco EDISON 08 h
}
acm.we wc m Ma _q, f It E N.d'~~
DONALD C. SHELTON
- w. w ew,
{419)N9 2300 Docket No. 50-346 License No. NPF-3 Serial No. 1-829 August 26, 1988 Hr. A. B. Davis, Regional Administrator Region III 799 Roosevelt Road Glen Ellyn, IL 60137 subject: Toledo Edison's Action Plan on Procedures Dear Mr. Pavis On August 18, 1988, a meeting was held at the NRC Regica III office between Toledo Edison (TE) and members of your staff. The purpose of the meeting was to discuss the ongoing NRC Region III inspection in the Davis-Besse Quality Assurance / Quality control areas.
Subsequent to the meeting, Hr. Robert V. DeFayette of your staff discussed the following NRC concerns by telephone with Toledo Edison representatives on August 23, 1988:
1)
Quality Control Instructions (OCIs) are not being adequately controlled:
2)
QC inspectors are not promptly initiating the process to resolve identified procedural deficiencies; 3)
Procedural compliance has not been thoroughly assessed for the entire Nuclear Group j
4)
Adherence to the procedure change process has not been evaluated for to o the entire Nuclear Group; OO l
Mo 5)
The root cause of the procedural compliance encern has not been g
evaluated.
oo 0@
As discussed with your staff, TE vill take the following actions.
o
$g 1.
The remaining Quality Control Instructions (0CIs) vill be superseded by gg Quality Assurance Division Procedures (OADPs).
Concurrently with superseding the OCIs, all QADPs vill be reviewed and identified THE TOLEDO ED: SON COMPANY EDISON PLAZA 300 MN.GON AVENUE TOLEDO, OHtO 43652
\\g Al)G 31195 /[8
(
Dock 3t Ns. 50-346 Lic nsa Ns. NPP-3 S3riol Ns. 1-829 Page 2 deficiencieJ vill be corrected.
QADPs that are revised or which supersede OCIs vill be approved by September 1, 1988 and become effective by September 8, 1988, following required training.
2.
In conjunction with the change from QCIs to QADPs and the revision of identified QADP deficiencies, the QA Division vill conduct retraining on the PCR process. This retraining vill re-emphasize the need to promptly initiate actions to correct identified procedural deficiencies.
Retraining vill be completed by September 16, 1988.
Additionally, if the results of the audit indicate other divisions are having similar problems, retre.ining vill be conducted for those divisions as well.
3.
Toledo Edison vill conduct an interdisciplinary audit to assess procedural compliance and the everall administration of the procedure program. The audit vill analyze a representative sample of procedures to determine if the procedures are functionally adequate (capable of being followed), and whether identified procedural deficiencies have had corrective actions initiated (i.e., via Procedure Change Requests or Potential Condition Adverse to Quality Reports).
If it is determined that a corrective action has not been initiated, the necessary corrective action vill be taken and the cause of the failure to take this action vill be determined.
A minimum sample of 125 procedures (4% of the population) vill be selected for the audit.
Procedures vill be selected from each Nuclear Group Division. The sample vill include recently revised procedures, older working level procedures and administrative procedures. The audit vill be conducted by a team of individuals knowledgeable in the procedure program and audit practices.
This audit is scheduled to begin on September 6, 1988 and vill be completed by October 14, 1988.
An audit report vill be issued by October 28, 1988.
4.
The current procedure change process at Davis-Besse requires individuals from all departments, including QA, to stop vork and notify their supervisor whenever a technical deficiency is discovered in a procedure that they are following.
Procedures found to contain such deficiencies are required to be corrected prior to continuing vork.
The individual discovering a deficiency is required to submit a Procedure Change Request (PCR) form.
Processing time for accepted PCRs is a function of the number of change requests currently in the system.
However, each department and division has the ability to expedite the change process for any procedure deemed to require immediate attention.
Procedure changes and revisions can, and have been. trocessed in as little as one day.
If the audit results indicate that the time required to change or revise a procedure, using the current procedure change process, is a contributor to procedural noncompliance, TE vill revise the change process such that the processing time is reduced.
l 3
b Docket No. 50-346
- License No. NPF-3 Serial No. 1-829 Page 3 5.
A root cause evaluation vill be conducted to determine the reason for the increase in procedural noncompliance, which has been identified by TE's Trend Report.
Much of the information necessary to perform this evaluation vill be obtained during the audit process described above.
Evaluation of this information vill begin upon completion of the audit (October 14, 1988) and vill be completed by November 10, 1988.
Your q
staff vill then be notified of the results.
e T
Please contact Mr. R. V. Schrauder, Nuclear Licensing Manager, at (419) 249-2366 if there are any questions.
Sincerely yours, C
[
GH/CFH/ tit cc: DB-1 Resident Inspector f
A. V. DeAgazio, Project Manager Document Control Desk 5
.. y
=
aW 6
y
=
.j r
1 g
'