ML20209D213

Nuclear Safety Review Staff Investigation Rept, Drawing Control Master Index Sys

ML20209D213
Person / Time
Site:	Sequoyah
Issue date:	12/26/1985
From:	Mcclure R, Sauer R, Simonds W TENNESSEE VALLEY AUTHORITY
To:
Shared Package
ML20209B481	List: ML20209B478 ML20209D185 ML20209D213 ML20209D369 ML20209D399 ML20209D487 ML20209D608 ML20209D651 ML20209D725 ML20209D776 ML20209D846 ML20209D901 ML20209D944 ML20209D976 ML20209E026 ML20209E079 ML20209E115 ML20209E150 ML20209E229 ML20209E290
References
I-85-472-NPS, NUDOCS 8702040436
Download: ML20209D213 (9)

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ATTACHMENT B p g,1 og g y:

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'8 TENNESSEE VALLEY AUTHORITY l *.1, ; ilta.-. g. '.*,' :)

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NUCLEAR SAFETY REVIEW STAFF f ';. -...,.

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.NSRS INVESTIGATION REPORT NO.

I-85-472-NPS i slr.,

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lU EMPLOYEE CONCERN N05: IN-86-108-002 (WBN) i i!' l i

11-85-062-002 (BFN) t' X1-85-062-002 (BLN)

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SUBJECT:

DRAWING CONTROL MASTER INDEX SYSTEM

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.. <!. DATES OF

$*'INVESTICATION:

OCTOBER 2-30. 1985

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W. R. SIMONDS DATE

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1-R. E. MCCLURE.

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R. C. SAUER

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,i ATTACHMENT B Page 2 of 8

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BACKCROUND

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.r *I 'p* * " ' - p A Nuclear Safety Review Staff (NSRS) investigation was conducted to d '.1 determine'the validity of two. expressed employee concerns as received by

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'i The y:J'g !."* - Quality Technology company (QTC)/ Employee Response Team (ERT).

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• ';,i,;jRequestFormsfromQTCandidentifiedasIK-85-062-002andIN.

• :;j,'[@7,",,,'..i 108-002, stated:

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The current TVA system of using a master' card

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Concern:

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. file of drawings (this system in place at Sequoyah) is

' l f, ; t; inadequate and should not be implemented (if not already)

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at Watts Bar, Browns Fetry, and Bellefonte. This system

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allows for instant disarray, distruction, or loss of ref-

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. ' erence cards if a drawer is dropped or the system sabo-iH taged. The data from the cards should be input to the

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From this stated concern, NSRS made the following assumptions:

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e' Reference 1 states that the Drawing Control Center'(DCC) was estab-7,' ; fl; lished at each nuclear plant site for handling configuration control

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drawings. Configuration control (CC) is defined as the system h[.f,. "

whereby drawings are as-constructed prior to transfer and upon com-pletion of each workplan. The only drawings not under CC are those

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1hiM.4 Therefore, it is assumed by the investigator that " drawings" as used

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b "D ' M in the above concern means "CC drawings."

i T,A.*?.?rM/. e.'A master index card file system (master index) was generally

... :, y.t accepted for use prior to 1983 within NUC PR to maintain as-con-

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structed status and distribution information for CC drawings on file in the DpC. However, references 1, 2, 7, and 14 indicate that the

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Drawing' Management System (DMS) has replaced the master index, in

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addition to other systems, and is currently intended to be the single CC drawing management system for'the Office of Power and

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Engineerkng(P&E) (Nuclear). Therefore, it is assumed by the

'O-investigator that the above concern inadvertently refers to the

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SCOPE,

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The scope of the investigation is defined by the concerns of record A.

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to be two specific issues requiring investigation as follows:

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The master index used by the Sequoyah (SQN) DCC for CC drawings

. l }p i is inadequate and should not be implemented at TVA's other

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nuclear plants.

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Information contained in the SQN master index should be estab-

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lished as a computerized data base which is accessible to all fl applicable TVA offices.

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"IN$nkify comitment/Idh8 Afd@t find-f 4#L j

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NSRS, reviewed corresponde Yel

'...,.f,,[*' ;,;S ings applicable to the drawing control program for TVA's nuclear

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, ; power plants. Quality assurance program procedures and plant f@U.j.M }E 1;I,;' instruct *1ons were also reviewed to identify programatic controls., g

. Interviews were conducted with nine DCC employees and CC Task Force

.t.O 8f;i. !,i members to obtain details of current CC drawing control practices s.'

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and requirements.

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SUMMARY

OF FINDINCS

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Requirements and Comitments NUC PR NQAM, Part III, Section 1.1, dated March 21, 1985.,"Docu-1 1.

.I ment Control."

" Y.f.b NUC PR NQAM, Part V, Section 6.1 (ID-QAP-6.1), dated i,

2.

December 31, 1984, " Configuration Drawing Control."

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Memorandum from H. J. Green to A. W. Crevasse, " Joint Quality

.,1 3.

Assurance Audit Report No. JA8100-06 (A24 820128 001)," dated

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• March 8, 1982 (L16 820305 876),. comits TVA to develop the DMS Gi in accordance with the CC Task Force recomendationis (ref.14).

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k Memorandum from J. A. Coffey to Manual Holders, "BFN Regulatory S

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Performance Improvement Plan (RPIP) Oversight Croup Meeting

. !j5.1.. 'i Minutes No. 84-12," dated Ju'ly 19, 1984 (L24 840719 800).

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Memorandum from J. A. Coffey to R. J. Mullin, "BFN Deviation

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^ ^!, h'.(. ' '.l JA8100-06-A05 As-Constructed Drawings," dated February 2, 1985

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(R25 850212 952), provides status and updated progress in imple-j,$,','

menting CC Task Force recostunendations.

- TVATopicalReportTVA-TR75-1A, Revision 8. Table 17D-3comdts Jhi%, a

• TVAff.o US NRC Regulatory Cuide 1.33, (Revision 2), dated 6.

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Febnsary 1978, " Quality Assurance Program Requirements (Opera-

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' tions)." which endorses use of ANSI N18.7-1976.

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7.* ANSI N18.7-1976, " Administrative Controls and Quality Assurance

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j for the Operational Phase of Nuclear Power Plants."

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Findings

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SQN Master.Index

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L The master index was implemented through reference 19 for CC

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drawings on July 11, 1979. It contains an index card for The -cards are intended e,ach CC drawing on file'in the DCC.to contain the as-constructe

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't mation applicable to the corresponding drawings. SQN DCC i 8,';. d,

personnel stated that they continue to mai: stain the master r. r MEjl jj,

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index in accordance with reference 19 and that they

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• ATTACHMENT B Page 4 of 8

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' ji-;.I rely upon the index cards as a source of information to t

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and distribution.

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As a result of SQN DCC personnel interviews, it was deter-l' r;,.......'

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mined that access to the master,index is not controlled, nor I.h f

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,.;,h.. I is it periodically audited to verify the integrity of the information on the cards.

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References 1 and 2 do not identify the master index as an I..

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I' approved CC drawing control system.

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Drawing Management System (DMS)

References 1, 6, and 7 collectively identify the DMS as the

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'i single system to be used within P&E (Nuclear) to store,

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update, and retrieve construction status and other informa-

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D, tion for TVA and vendor drawings. The DMS data base is a

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protected by security features.-

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Reference 23 states that the DMS replaces several systems controlled document which is periodically audited and is l

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that previously contained drawing information which were not og E.J. 4. ',,;h f j ; $! [,.

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generally accessible to all TVA organizations needing the

.*ic As-constructed status, revision level,.and information.

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'N; distribution information can be retrieved by any authorized f i.;h,k;';;,

N DMS user through online access to TVA's mainframe computer.

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Browns Ferry converted its CC drawing control system to the

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DMS effective December 21, 1983. BFN DCC personnel update e.-

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the DMS for BFN CC drawings in accordance with upper-tier

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requirements and utilize the DMS exclusively to obtain dis-

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tribution and construction status information. *

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7, SQN has placed all of its CC drawing information onto the

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DMS but has not fully divorced its use of the Master Index

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card system. As a result, SQN has on occasion used the c

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index as its official drawing record control system for L...' :3.,'.".',. ':II f

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distribution and construction status information.

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Watts Bar DCC personnel use the DMS for CC drawing control y

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according to the WBN DCC Supervisor.

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Bellefonte DCC personnel use the DMS for CC drawing control

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according to the BLN DCC Acting Supervisor.

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ATTACHMENT B r

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,aIV.jCONCLUSIONSANDRECOMMENDATIONS,f:,

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1. 'The employee concern is substantiated not on the specifics of

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'follows:

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., a. The " current TVA system" for configuration control is

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jp* intended to be the DMS not the master card index system as

'8; alleged. However, upper-tier instructions do not preclude

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the use of the master card file and, therefore, though SQN t

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DCC personnel are complying with the updating of DMS for SQN

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.. % 2) requirements, they are not meeting the literal intent of

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CC drawings in accordance with upper-tier (reference 1 and

• / c.pyyh,21 the requirements to use DMS exclusively, since SQN DCC

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personnel continue to maintain and utilize the master index.

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The SQN master index system is not a reliable CC drawing f.; y j ' "

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p control system since it is not controlled nor is it an approved QA program method.

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,. c. The master index is inadequate for TVA use 'becaUse it is a j." k {y - [...!;-

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localized system which does not provide accessibility to E

other TVA organizations having a need to obtain the proper y p*, ' 8 ']

as-constructed status of SQN equipment.

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Accordingly, P&E (Nuclear) decided to replace,all the systems

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such as the master index with the DMS as the single CC drawing t.-

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j.! :; 'gI f, management system for P&E (Nuclear). Browns Ferry, Watts Bar,

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and Bellefonte do not use a master index system for CC drawing control but do use DMS.

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Recommeridations l

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I-85-472-NPS-01, Configuration Drawing Control Requirements t 1 l,.

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• The upperatier requirements contained in references 1 and 2 do

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not preclude the continued use of master index systems for con-struction status and other information retrieval for CC draw-

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ings. NSRS recommends:

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That references 1 and 2 be revised to require DMS utili-a.

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ration exclusively by site DCC organizations for CC drawing

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information retrieval, and

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that the master index be placed under the QA program as a

• !.87 backup system, if desired, or until total conversion to DMS

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occurs. [P2]

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. 2. ;,.I-85-472-NPS-02, SoliTw'- - Itation of DMS

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Page 6 of 8

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's,.,SQN DCC has not implemented the DMS as the single CC drawing

.' management system. NSRS reconsnends that SQN revise reference 19 4:E:,M, F,-

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:to require exclusive utilization of DMS for CC drawing informa-ije This action should establish the DMS as the 1, ![* l.Nlp'h. ';.

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jition retrieval.

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l single CC drawing management system and discontinue DCC utiliza-

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3..II-85-472-NPS-03, Need to Perform Audit / Survey Master Index

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System o

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Because SQN DCC is using the non-QA approved Master Card Index s

system on occasion as its official drawing control system for

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. distribution and consti-uction status infomation, DQA is

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' requested to audit / survey the adequacy of this area in the near

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future and on a periodic basis until total conversion to DMS j i.,

. occurs.

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No response to this issue is required. NSRS will moniter the

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progress of this issue based on the responses made and actions

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.taken to 1 and 2 above.

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. i ; I.N ATTACHMENT B Page 7 of 8

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DOCUMENTS REVIEWED IN INVESTIGATION NO. I-85-472-NPS e

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AND REFERENCES

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1.

NUC PR NQAM, Part III, Section 1.1, dated March 21, 1985, " Document

' ' ' 'l..%

Control" I

jsi 2. ) NUC PR NQAM, Part V, Section 6.1 (ID-QAP-6.1), dated December 31, 1984,

" Configuration Drawini; Control"

'9

'! 3.

Drawing Management System (DMS) Users Manual, Revision 0 (B42 850606 509)'

..i 4.

Memorandum from H. L. Abercrombie to Those listed, dated August 24, 1983, '

" Document Control and Drawing Management Meeting Notes" i sNh,i (L68 830817 801) f 984

.[* 5. a; Memorandum f rom M. M. McGuire to R. D. Guthrie, dated August 14,1 14 "DMS Subtask Group of the Configuration Centrol Task Force" 9,i:

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(L99,841023 003) f I8 I8d! 6..

Memorandum from R. D. Guthrie to Joe W. Anderson, dated May 3, 1985,

" Request for Drawing Management System (DMS) Qualit,y' Control and

.i ' {

Information Systems Analysis Services" (R25 850501 910),N f.

,. l.{; 7. ', BFN - Regulatory Per orinance Improvement Plant - Oversight Group Meeting f

5

• 9.j !;l, f;.te:..i ! i ' i !.

Minutes - No. 84-12 4-3[,

': 'fhl{,8.j,f Memorandum from R. M. Wright to PWR Project Files', dated April 17, 1984, i.,'ij!![.,".I;';.,:'

"SQN - As-Constructed Drawing Heating Notes" (BWP 840417 004)

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Memorandum from R. M. Wright to PWR Project Files, dated May 30, 1984,,

l.' '.;. * :}'.L.:

"SQN - As-Constructed Drawing Task Force" (BWP 840530 001)

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' '. '. n,R.. :".. ;,..'. T.10.1 : Memorandum fifom R. H. Wright to PWR Pr i

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16, 1984, I, 7; jf[$ -

"SQN - As-Constructed Drawing Task Force" (BWP 840816 006)

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f,f.11. ;; Memorandum from R. H. Wright to PWR Project Flies, dated March 21, 1984,

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"BFN - As-Constructed Drawing Task Force - Meeting Notes"

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(BWP 840321 004)

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@h.12.j,I'MemorandumfromH.J.GreentoA.W. Crevasse,datedMarch8,198

" Joint Quality Assurance Audit Report No. JA8100-06"

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-(A24 820128 001) (L16 820305 876) -

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.::y 13. ! Memorandum from h. A. Coffey to R. J. Mullin, dated Febntary 12, 1985, "BFN - Deviations JA8100-06-A05 - As-Constructed Drawings" 1;; '

"(R25 850212 952)

• i 14.

Task Force Report, dated June 3, 1983, " Report of Recommendations from i

the As-Constructed Drawing Task Force" (A43 830711 005)

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..c ATTACHMENT B Page 8 of 8 j'

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• L 215 f.3"/i#: OEDC and QA&AS Joint Quality Assurance Audit Report No. JA8100 j

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4 January 28, 1982 (A24 820128 001)

g. 'k $16..' ANSI N18.7-1976, "Administr.ative Controls and Quality Assurance for the I

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9:je' jir.';, li d i.! a i

r.. Operational Phase of Nuclear Power Plants"

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@ ii'17.(.~10 CFR Tart 50, Appendix B, Criterion VI, " Document Con f.

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h'18 3 SQN M&AI-3, Revs. 4 and 5. " Revision of As-Constructed Drawings" I, g t 9 I.

19.

SQN AI-25. Revisions O and 10. " Receipt. Filing, and Distribution of

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Drawings" i;.i. i f;,.

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'f9. 2'O.. WBN AI-4.10, Revision 3. " Drawing Control Cent'er for a Licensed Unit"

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BLN BLA5.9, Revision 17, " Drawing Control Before Receipt of an Operating License"

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.[.iji' 22. i BFE DCU-IMH-X.1, dated September 22, 1985,'*,' Drawing Control"

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[,. {il 23. f,Hemorandum from R. D. Cuthrie to James P. Darling, dated Oc(ober 5,1984,

. * ; jllE!.NI;.,' i "BFN - Drawing Management System (DMS) Budet Request!' N i ' ;j jif e},vi h,;!

b (R25 841002 864) l y[24.,]HemorandumfromMichaelL.ScalftoR.D.Cuthrie,datedJuly 15, 1985

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ATTACIDiENT C NSRS INVESTIGATION REPORT NO. I-85-460-NPS O

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.g ATTACHMENT C Page 1 of 6 v y

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TENNESSEE VALLEY AUTHORITY

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NUCLEAR SAFETY REVIEW STAFF I*

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NSRS INVESTIGATION REPORT No. I-85-460-NPS

'i EMPLOYEE CONCERN:

XX-85-062-001

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SUBJECT:

DRAWING CONTROL AT OFFSITE LOCATIONS AND DRAWING MANAGEMENT i'

SYSTEM ACCURACY 1

.N:. DATES OF

',;,;.. INVESTIGATION:

OCTOBER 2-20, 1985

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R. E. MCCLURE DATE

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INVESTIGATOR:

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. REVIEWED BY

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W. D. STEVENS DATE

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.o ATTACHMENT C Pcgs 2 of 6 i[:g.3 ' N.'

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'.,'. ' j"... " I..BA.CKGROUND

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'{.,'.A Nuclear. Safety Review Staff (NSRS) investigation was conducted to

I,i]., ', ' detemine the validity of an expressed employee concern as re

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the Quality Technology Company (QTC)/ Employee Response Team (ERT). The

~ l..i. ;- ~j concern of record as summarized on Employee Concern Assignment Request stated:

p.g.4*,13,. fom from QTC and identified as IK-85-062-001

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Browns Ferry, Bellefonte, Sequoyah - CI has been unoffi-

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cially informed that the latest drawings on all TVA j

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nuclear power plant si~tes are not, in the majority of instances, the latest drawings at offsite TVA administra-i 3

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tive offices / departments, including a computer printout that does not reflect the current drawing revision.

This can, and does, cause design, modification, and/or

-d repair problems.

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SCOPE The scope of this investigation is defined by the concern of record

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which entails determining the validity of this concern, management A.

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recognition of the problem, and corrective actions being avsluated.

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The NSRS reviewed documents and interviewed. cognizant personnel to g

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determine'if offsite locations did have the current drawing revision and if the Drawing Management System (DMS) reflected the current i

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information.

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.i3' III.

SUMMARY

OF FINDINGS

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A.

Requirements and Commitments f;g..,

1.) 10 CFR Part 50, Appendix B, Criterion V, " Instructions,

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• Procedures, and Drawings"; Crite ion VI, " Document Control" l' ' i l

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2.j EN DES-EP 4.19 " Drawing Management System Users Manual"

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3.'!NuclearQualityAssuranceManual(NQAM),PartV,Section2.4

!i (ID-QAP 2.4), " Control of Modifications," dated July 10, 1985 I

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and Section 6.1 (ID-QAP 6.1), " Configuration Drawing Control "

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, dated' December 31, 1984 i

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NQAM, Part III, Section 1.1, " Document Control," dated March 21,

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1985

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B.

Findings

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There have been frequent cases over the years of offsite J-document control centers not having the latest drawings and the

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drawing information system in plac,e at the time not reflecting

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the latest revision at the site. This has been true both for

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i* "as-constructed" and "as-designed" drawings and for both TVA and

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.. vendors. The DMS was implemented in December 1983 to provid.s W.

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online access for drawing infomation and is now the sole 5

i drawing infomation system used by P&E (Nuclear). However,

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i documentation (Ref. 9) was reviewed stating that all the

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!drawingsusedindesign, operation,andmaintenancearenotin

'.I the DMS.

The DMS data base is being expanded throughout P&E to eij'd' enhance data integrity.

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2.

Review of DCC logs, workplan generated changes to drawings, and

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the DMS show that several months are often required for a

~I typical drawing change to be processed.

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f*L 3.* Significant Condition Report (SCR)' SCR GENIMS8501-was initiated

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'on August 20, 1985, concerning data entry into-the DMS not

' taking place in a timely manner. This SCR do'cisments a large

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9j scale, corporate-wide problem that has been addressed with L. 'l-resources, goals, and reporting.

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I !N 4.!TVAhasrecognizedthisproblemandhastakenactionas

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', evidenced by the following:

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A configuration management program was established June 13 j

1985, by J. A. Coffey, Site Director, Browns Ferry Nuclear i

I Plant (BFN), as part of the P&E Configuration Control Task

' he.

Force (CCTF).

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b.

"DMS Overview II" memorandum dated July 15, 1985, from Michael L. Scalf, Chairman, DMS Subtask Group to R. D.

3 @.:.

Guthrey, Chairman, P&E Configuration Control Task Force, 5M summarizes current activities and reflects that each nuclear

,'I.i plant has at least one representative on the group.

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,h Communication between the CCTF and the DCC in Chattanooga c.

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has taken place to detemine possible improvements.

'd.

Quality Notice NQAM Part V. Section 2.4, entitled " Design

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Change Control System Using Design Change Supplements," was issued on September 9,1985, to implement a pilot design N'

change control system at BEN.

. e' Regulatory Performanc,e Improvement Plan (RPIP) action item e.

No. 11.25 to " correct weaknesses in document control system" l,.

has been identified, and corrective action is being taken.

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ATTACHMENT C Pag 2 4 ef 6 8, '* r. 'i.i g.

5.'. After reviewing several workplan drawing changes and interview-

!.';,;if,ffEilY)h if.ingresponsibleemployees,itwasevidentthatthereisnota

'l,$}h.'h.d' l'. universal understanding of how TVA is maintaining configuration I

control via the DMS.

Many employees do not recognize the need

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'. for a DMS (and timely update to it) or the need to maintain I current drawings at offsite locations.

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. {i ;d,',",k(. 6.,. Management appears to be unaware of general configuration

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management systems, such as described in reference 15.

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CONCLUSIONS.AND RECOMMENDATIONS

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A, Conclusions i

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The employee concern is substantiated for the following reasons:

I 1.. The DMS has been less effective than it should be because:

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a.

The DMS base has never been fully defined and loaded.

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Neither management nor employees have a universal

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understanding of what configuration control means and how it

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is to be implemented via the DMS.'

c.

Management failed to put in place audit end feedback 4

mechanisms on the sites to evaluate the DMS.

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A large time cycle in the drawing update process at the

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• sites has resulted in eut-of-configuration drawings in offsite document control centers.

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2., TVA has recognized that the existing DMS is in need of g

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improvement.. A task force has been established to address and 9 [,

N resolve these problems, and.significant progress has been

, documented (Refs. 9 and 13).

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Recommendations

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1.,I-85-460-NPS-01, prevent Recurrence

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1mplement the' corrective action and the actions required to G[l'[es.1

,! prevent, recurrence of significant condition report SCR

yg.

CENIMS8501 as outlined below:

't p a.

Establish appropriate instructions within OE to:

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T (1) Define specifically which documents are to be entered

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j-into DMS.

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,j, Establish all mandatory data elements to be entered.

(2)

(3) Standardize exact procedure of data entry.

(4) Provide schedule guidelines.

Classify all drawings in DMS into three categories, each b.

with the following percent initial allowable date entry I

~

error rate:

(1) critical 0%

-(2) primary 1%

(3) other 5%

jd Nuclear projects ensure that appropriate management c.

emphasis, procedures, resources, and training are in place

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to maintain the data performance identified above.

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3

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t, I-85-460-NPS-02, SON. BFN. WBN. and BLN Site Management Action 2.,

Establish an expedited process and distribution system to handle

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i drawing changes and updating of the DMS.

Delei;ste' to the site

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, QA unit the responsibility of auditing DMS site changes, tracking results, trending performance, and reporting on these parameters.

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ATTACHMENT C

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Pego 6 of 6

> h* ^ 2 DOCUMENTS REVIEWED IN INVESTICATION I-85-460-NPS 3

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AND REFERENCES

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' i N . I 1.

TVA memorandum from T. Chapman to N. Beasley, " Documentation Problems

• /$ h *.,l Identified in Configuration Cor. trol Task Force Meeting Notes of

. ; :.., hi,3.:,j March 6, 1985" (B45 850603 200)

'j. a., ",

py*i.2.I.TVAmemorandumfromR.CuthreytoJ.AndersondatedMay3,1985," Request

'l iI for.DMS QC and Information Systems Analysis Service" (LOO 850507 513)

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.,s' " 3. TVA memorandum from M. Scalf to C. O' Dell dated October 18, 1985, 1:.

• 7:!I.

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" Request for DMS Adjunct Support" (no RIMS /MEDS number)

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4.

Operational Quality Assurance Manual - Drawing Control dated November 2, O. r.,.' ; -

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8.

1984

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.!*.] t l i ID-QAP 2.4, " Control of Modifications," Rev. 7/10/85

' 3 :rg., 5

,] ',h' 6. NQAM Part V, Section 2.4, " Design Change Supplements," Rev. 7/10/85

..: q.

6.'t. 7 SCRGENIMS 8501 dated August 20, 1985 (B04 850820 001).-

N 4.'

. 2 i.).,

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• Regulatory Perfornance Improvement Plan - Action Item 11.25

.!fj!.'

f-Giti.

9.

TVA memorandum from M. Scalf to R Cuthrey dated March 12, 1985, "DMS g'jP Overview" (B04 850312 400)

. b1A TVA memorandum from R. Cuthrey to Those listed dated October 9, 1984, j'&.10.

?!

" Configuration Control Task Force - Subtask Groups" (OEN 841011 011)

... e.

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TVA memorandum from R. Wright to Design Services Files date,d January 31, r

1985, "BFN - Office of Power Engineering Configuration Control Task 1

Force" (QMS 850225'202)

" 12.

TVA memorandum from R. Cantrell to D. Bowen dated November 21, 1984, "DMS - Engineering Projects Responsibilities" (IMS 841121 002)

. '.j ' 13.

NSRS draft report R-85-11-NPS l 1

'[ 14.

TVA memorandum from M. Scalf to R. Cuthrey dated September 30, 1985 "DMS Activities Report" (no RIMS /MEDS number)

, 15.

DOE Directive 4700-Draft dated 2-20-85, Chapter 3, Section C "Configura-tion Management" t

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ATTACHMENT D NSRS Investigation Report No. I-83-13-NPS S

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