ML20207N036

Ack Receipt of Re Violations Noted in Insp Rept 50-267/86-23.Violations 1 & 4 Withdrawn.Implementation of Corrective Actions for Violations 2 & 3 Will Be Reviewed During Future Insp

ML20207N036
Person / Time
Site:	Fort Saint Vrain
Issue date:	01/06/1987
From:	Gagliardo J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:	Robert Williams PUBLIC SERVICE CO. OF COLORADO
References
NUDOCS 8701130411
Download: ML20207N036 (2)

See also: IR 05000267/1986023

Text

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JAN 61987

In Reply Refer To:

Docket: 50-267/86-23

Public Service Company of Colorado

ATTN: Robert O. Williams, Jr.

Vice President, Nuclear Operations

P. O. Box 840

Denver, Colorado 80201-0840

Gentlemen:

Thank you for your letter of November 26, 1986, in response to our letter and

Notice of Violation dated October 28, 1986. We have reviewed your reply and

find the following:

Violation 1: Since our inspector did not review the audits cited in your

response, we withdraw this violation and will carry it as an unresolved

item, pending our review of these cited audits during a future

inspection.

Violations 2 and 3: We find your reply responsive to the concerns raised

in the Notice of Violation. We will review the implementation of your

corrective actions during a future inspection to determine that full

compliance has been achieved and will be maintained.

Violation 4: We understand that the violation, as stated, is correct

with regard to the paragraph of Procedure QAAP-1 used in the violation;

we also understand that in the context of Procedure QAAP-1, taken as a

whole, no violation exists. Therefore, we conclude that Procedure QAAP-1

requires clarification. Since you have connitted to revise

Procedure QAAP-1 (per telecon between your Mr. Tomlinson and our

Mr. Jaudon on January 5,1987), the violation is withdrawn,-and the

revised Procedure QAAP-1 will be reviewed during a future inspection.

Sincerely,

ognM sMned By

J. E. GcLliardo

J. E. Gagliardo, Chief

Reactor Projects Branch

cc:

J. W. Gahm, Manager, Nuclear

Production Division

Fort St. Vrain Nuclear Station

16805 WCR 191

Platteville, Colorado 80651

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16805 WCR 19 1/2, Platteville, Colorado 80651

November'26, 1986

Fort St. Vrain

Unit No. 1

P-86646

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Regional Administrator -

Region IV

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U. S. Nuclear Regulatory Commission I{

611 Ryan Plaza Drive, Suite 1000 DEC 3 -M

- Arlington, Texas 76011 1 { _

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Attention: Mr. J. E. Gagliardo, Chief

Reactcr Projects Branch

Docket No. 50-267

SUBJECT: I&E Inspection Report 86-23

REFERENCE: NRC Letter, Gagliardo to Williams,

dated 10-28-86 (G-86565)

Dear Mr. Gagliardo:

This letter is in response to the Notice of Violations received as a

result of inspections conducted at Fort St. Vrain during the period

August 11 - 15, 1986. The following response to the items contained

- in the Notice of Violations is hereby submitted:

1. Failure to perform periodic review of the Fort St. Vrain

Generating Station audit program:

10CFR Part 50, Appendix B, Criterion XVIII, requires a

comprehensive system of audits to be performed. As part of this

audit program, the approved Fort St. Vrain Quality Assurance

Program, Updated Final Safety Analysis Report (UFSAR),

Revision 3, Section B.5.19.15, contains the licensee commitment

to ANSI Standard N18.7-1972. This standard, in Section 4.1,

requires periodic reviews by the owner organization of the

licensee audit program.

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-P-86646 -2- November 26, 1986

Contrary to this, the licensee failed to perform such reviews,

which was confirmed by a licensee Quality Assurance audit person.

This is a Severity Level IV violation. (Supplement I)(50-

267/8623-01)

(1) The reason for the violation if admitted:

This violation is not admitted. A review of the

Fort St. Vrain QA Audit Program is conducted biennially

during the performance of the Nuclear Facility Safety

Committee (NFSC) Audit of the FSV QA Program. The audits

were reviewed by QA and the following excerpts from the

audits are provided:

__

• (NFSC D-81-01) "FSV has an audit program which

is committed to auditing all areas and

activities once every two (2) years. A schedule

has been developed to implement this commitment.

The audits currently being conducted do not

address the systemic (sic) requirements for the

criterion being audited. Rather, the audits are

addressing only specific activities wit.in that

criterion for procedure compliance . . ."

• (NFSC D-83-01) " Reviewed the Audit Report file

to verify that an audit report is prepared for

each audit, that it assesses the effectiveness

of the audit program . . . "

" Reviewed the audit schedule to verify all

elements of the QA Program are being audited."

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(NFSC D-85-01) "A review of the implementation

of the audit program was performed to verify

compliance with the FSAR, the QA Program, and

the implementing procedures. The review

encompassed the planning, scheduling, conduct,

reporting, and follow-up activities relating to

auditing and monitoring."

These reviews by the NFSC meet the intent of

ANSI N18.7 - 1972, Section 4.1, for periodic review of the

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audit program which, as stated in the updated FSAR,

Section B.S.19.15, the FSV QA Program is responsive to for

guidance.

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P-86646 -3- November 26, 1986

We recognized from discussions with the staff during this

inspection, that the audit program review process needs to

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. -be strengthened and have initiated measures to do so. These

measures include implementation of e new audit to review the

. Nuclear Facility Safety Committee (NFSC) activities and a

commitment to provide an in-depth review of the QA Audit

Program in NFSC D-87-01, QA Program Audit. This commitment

was made in response to NRC open item 8619-02 in

September, 1986. The QA Audit of NFSC activities is

currently in progress. These audits, conducted alternately,

will provide a formal review of the audit functions on an

annual basis.

,

A question also arose during this inspection as to the

interpretation of Technical Specification AC 7.1.3. PSC has

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interpreted this section as regarding the collective

competence of the NFSC membership required to review

problems in certain areas. We recognize the Technical

Specification as written is subject to mis-interpretation

and have submitted a change to AC 7.1.3 which more

accurately reflects the ANSI N18.7 - 1972 requirement. This

change is currently in for Plant Operations Review

Committee and NFSC reviews prior to NRC submittal.

Fort St. Vrain is in compliance with 10CFR50, Appendix B,

Criterion XVIII and ANSI N18.7 - 1972, Section 4.1, as they

relate to owner organization review of the Licensee Audit

program.

(2) The corrective steps which have been taken and the results

achieved:

. , Not applicable.

(3) Corrective steps which will be taken to avoid further

violations:

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Not applicable.

(4) The date when full compliance will be achieved:

Not applicable.

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P-86646 -4- November 26, 1986

2. Failure to have and to review examinations for lead auditors:

10CFR Part 50, Appendix B, Criterion XVIII, requires an audit

program performed by appropriately trained personnel. To assure

appropriate training, licensee UFSAR Section 85.18.2 states that

auditors and lead auditors are selected and qualified- in

_accordance with ANSI Standard N45.2.23-1978. ANSI N45.2.23-1978,

Section 4.2, requires that copies of the objective evidence of

the types and content of examinations used for qualification of

lead auditors shall be retained, and that the employer shall be

responsible for the conformance of the examination to

N45.2.23-1978.

Contrary to the above, the licensee had utilized outside

contractors for qualification training of Public Service Company

_, of Colorado (PSC) employees as lead auditors at Fort St. Vrain,

and licensee did not have copies of examinations for lead

auditors, nor documentation of review of examinations used for

conformance to ANSI N45.2.23-1978.

This is a Severity Level IV violation. (Supplement I) (50-

267/8623-02)

(1) The reason for the violation if admitted:

Fort St. Vrain has used two outside contractors to perform

lead auditor training - GA Technologies, Inc. and

Stat-A-Matrix Institute. Fort St. Vrain interpreted the

requirement for " objective evidence of type and content of

examinations" to be satisfied by the course outline and

certificates of completion provided by these two companies.

. . (2) The corrective steps which have been taken and the results

achieved:

On August 26, 1986, QA requested and has received from

GA Tec56niagic , Inc. and Stat-A-Matrix Institute additional

inforna,,t1 - the type and content of examinations given to

PSC Auditors. The informatio.n provided substantiated the

validity of utilizing these two organizations for lead

auditor training.

,

(3) Corrective steps which will be taken to avoid further

violations:

A commitment has been entered in the QA Commitment System to

require that during the annual review of lead auditor

qualifications, verification that " objective evidence of the

type and content of examinations" is on file for the

calendar year involved.

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P-86646 -5- November 26, 1986

(4) The date when full compliance will be achieved:

Full compliance will be achieved by December 31, 1986.

3. Failure to have records checklist for designating required

records:

10CFR Part 50, Appendix B, Criterion XVII requires retention of

records for activities affecting quality. In the accomplishment

of this requirement, licensee UFSAR Section B5.19.9 contains the

licensee commitment to ANSI Standard N45.2.9-1974 and Regulatory

Guide 1.88. Section 4.2 of ANSI N45.2.9-1974 specifies that, as

a minimum, records receipt control shall include a records

checklist designating the required records.

__ Contrary to the above, the licensee was not using a records

checklist.

This is a Severity Level IV violation. (Supplement'I)(50-

267/8623-03)

(1) The reason for the violation if admitted:

Fort St. Vrain has been using a records transmittal form to

satisfy the ANSI N45.2.9-1974 requirements for a records

" checklist" designating the required records. During a

review of transmittal practices in response to this

violation, it was determined that the transmittal form, as

currently used, did not verify that records packages

submitted to the Records Center were complete.

(2) The corrective steps which have been taken and the results

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achieved:

None

(3) Corrective steps which will be taken to avoid further

violations:

Administrative Procedure Q-17, Quality Records, will be

revised to require that the total number of pages submitted

to the Records Center be entered on the transmittal form.

Records Center Procedure RCM-2, Receipt, Review, and Control

of Records, will be revised to require that the records be

checked to verify the number of pages listed on the

transmittal form has been received by the Records Center

prior to filing the records.

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P-86646 -6- November 26, 1986

(4) The date when full compliance will be achieved:

Administrative Procedure Q-17 and RCM-2 will be .'evised by

January 31, 1987.

4. Failure to provide notices for audits:

10CFR Part 50, Appendix B, Criterion V, requires that activities

affecting quality shall be prescribed and accomplished in

accordance with documented procedures. Licensee UFSAR

Section B.5.5.1 contains the licensee commitment to ANSI

Standard N18.7-1972, which in Section 5.1.2, ' requires the

licensee to have and to follow procedures.

Licensee procedure QAAP-1, Issue 3, " Guidelines for Quality

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Assurance and Nuclear Facility Safety Committee Audits," states

in Section 4.2.2 that a matrix which defines the applicability of

the 18 criteria of 10CFR50, Appendix B, to each of the QA Audits

is contained in Attachment QAAP-10 and is to be a major element

in the development of audit plans and checklists.

Contrary to the above, based on a list of audits provided by the

licensee audit group, the following audits did not have matrices

in Attachment QAAP-10:

QAA-502 QA Program for Radioactive Waste Packages

QAA-503 Spent Fuel and Radioactive Waste Shipping

QAA-1003 Procurement

QAA-1004 Maintenance QC & QA/QC

QAA-1301 Results

QAA-1402 Environmental Qualification

QAA-1404 Nuclear Licensing and Fuels

. . QAA-1703 Unescorted Access Qualifications

QAA-1802 Commitment Review

QAA-3000 Miscellaneous

NFSC-C Corrective Action

NFSC-D QA Program

This is a Severity Level V violation. (Supplement I)(50-

267/8623-04)

(1) The reason for the violation if admitted:

This violation is not admitted. Attachment ID to QAAP-1 is

a matrix used to provide assistance to audit ' teams in the

preparation of audit plans and checklists. This matrix does

nothing more than list the pertinent 10CFR50, Appendix B

criteria for regularly scheduled QA audits.

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P-86646 -7- November 26, 1986

The list of audits given in the violation contains two types

of audits, QA audits and NFSC audits. The QA audits listed

were performed for the first time within the last two years

with the exception of the QAA-3000 miscellaneous audit,

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which does not have a defined scope. Contained within the

scope of each audit plan and report was a listing of the

applicable Appendix B criteria. There is no requirement in

QAAP-1 for the development of an Attachment ID matrix for

all QAA audits prior to the audit, nor are restrictions

imposed on the addition of audits to the program prior to

initiation or performance of such audits.

NFSC audits are performed under the direction of the Nuclear

Facility Safety Committee (NFSC) by NFSC members. Although

QA supports the NFSC in the performance of these audits by

developing schedules and providing clerical support, NFSC

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lead auditors are responsible for the conduct of the audits.

NFSC audits are prepared using the same format as the QAA

audits, including the listing of applicable 10CFR50,

Appendix B criteria in the scope of the audits.

QA will revise QAAP-1 to clarify the requirements for

10CFR50, Appendix B criteria in the audit scopes.

Fort St. Vrain is in compliance with 10CFR50, Appendix B,

Criterion V and ANSI N18.7-1972, Section 5.1.2 as they

relate to the auditing program.

(2) The corrective steps which have been taken and the results

achieved:

Not applicable.

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(3) Corrective steps which will be taken to avoid further

violations:

Not applicable.

(4) The date when full compliance will be achieved:

Not applicable.

Should you have any further questions, please contact

Mr. M. H. Holmes at (303) 480-6960.

Sincerely,

P.

. .h.

. Tomlinson

Manager, Quality Assurance Division

PFT/clk