ML20214V803
| ML20214V803 | |
| Person / Time | |
|---|---|
| Site: | Comanche Peak  |
| Issue date: | 05/13/1987 |
| From: | Beck J, Boydston D, Hansel J TEXAS UTILITIES ELECTRIC CO. (TU ELECTRIC) |
| To: | |
| Shared Package | |
| ML20214V785 | List: |
| References | |
| NUDOCS 8706120302 | |
| Download: ML20214V803 (137) | |
Text
,
n COMANCHE PEAK RESPONSE TEAM RESULTS REPORT ISAP: VII.a.2
Title:
Nonconformance and Corrective Action System REVISION 1 O
cha tLJ D-sAAr Issue Coordinator f Date
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iew Team Leader Date' l
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T 3 El Johng. Beck,ChairmanCPRT-SRT Date
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9 Revision:
1 Page 1 of 95 RESULTS REPORT i-ISAP VII.a.2 Nonconformance and Corrective Action Systems l'
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1.0 DESCRIPTION
OF ISSUE IDENTIFIED BY NRC 1.1 Nonconformance Issues Identified by the NRC (USNRC Letter January 8, 1985, Pg. 25)
"There were several weaknesses in the NCR and deficiency identification reporting systems. The TRT found that:
The TUEC procedure for preparation and processing of l
i NCRs did not'contain explicit instructions for handling
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voided NCRs.
NCRs were used as a tracking document to record removal of a part from equipment on a permanent equipment 1'
transfer rather than for reporting a nonconforming condition; such usage of the NCR was not defined in procedures, t
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There was an inconsistency between paragraphs 2.1 and 3.2.1 in procedure CP-QP-16.0.
Paragraph 2.1 required all site employees to report nonconformances to their supervisor or to the site QA supervisor, while paragraph 3.2.1 required persons other than QA or QC l
personnel to submit a draf t NCR to the Paper Flow j
Group.
The NCR form had no form number or revision date to indicate that the form was being adequately contrclied.
l There were two versions of the TUEC NCR form, one with and one without a space for the Authorized Nuclear Inspection (ANI) review.
The NCR form had no space to identify the cause of the nonconformance and the steps taken to prevent its recurrence.
The NCR form had no provision for quality assurance review.
The TRT found approximately 40 different forms (other than NCRs) for recording deficiencies. Many of these O
forms and reports were not considered in trending i
nonconforming conditions.
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RESULTS REPORT ISAP VII.a.2 (Cont'd)
1.0 DESCRIPTION
OF ISSUE IDENTIFIED BY NRC (Cont'd)
The TRT notes that TUEC did not initiate an NCR identifying the widespread problem of missing locknuts; only a Request for Field Information was generated.
Deficiency reporting procedure CP-EP-16.3 appeared to relate only to Craft and Engineering personnel and was not directed to noncraft and nonengineering personnel who may have had knowledge of reportable items.
Procedure CP-EP-16.3 indicated that the applicable manager was responsible for documenting and reporting Deficiency and Disposition Reports (DDRs); but there were no checks or balances to ensure that a manager or a designated substitute would process a DDR."
Other external source issue documents such as the Construction Adequacy Team (CAT) report, the Management Analysis Company
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(MAC) report, NRC Region IV Reports (RIVIR), and allegations as reported in Safety Evaluation Report Supplements (SSERs) elaborate on weaknesses in the NCR system. These other external source documents are not directly addressed in the report but are discussed in Reference 9.1.
1.2 Corrective Action Issues Identified by the NRC (Enclosure to USNRC Letter dated January 8, 1985)
" Repetitive NCRs were issued that identified the need to retrain construction personnel in the requirements and contents of QA procedures. One corrective action request (CAR) dealing with inadequate construction training and records remained open for one year. The identical problem' was identified in a subsequent CAR, which still had not been closed at the time of the TRT onsite review. [The subject of craft training is addressed in Action Plan I.d.3.]
The Brown & Root corrective action system was generally ineffective and was bypassed by the Brown & Root QA Manager, as exemplified in the following instances:
There were no definitive instructions to describe the types of problems that required corrective action.
Minimal procedural instructions resulted in corrective action decisions frequently being left to the judgment of the QA Manager.
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RESULTS REPORT j
ISAP VII.a.2 (Cont'd) l 1.0 DESCRITTION OF ISSUE IDENTIFIED BY NRC (Cont'd) 51nceJune1983, Brown &RoothadissuednoCorrective Action Requests (CARS), and was substituting memos and letters of concern for this function. This shortcut had become a regular method of operation and appeared to bypass the CAR system.
The TUEC corrective action system was poorly structured and ineffective in that:
Controlling procedures were brief and general.
There was no translation of FSAR requirements on trending and no details on how trend analyses were to c
be accomplished.
Quarterly reports were not issued in a timely manner.
j The method of categorizing problems by building did not assure meaningful trend analysis.
A 1984 CAR report identified three items requiring 5
action; however, none had been taken.
4.
CAR 029 was used as a vehicle for a specific e
disposition rather than for generic action, as intended l
by the CAR system."
j Other external source issue documents such as the CAT report, the MAC report, RIVIRs, and allegations as reported in SSERs elaborate on weaknesses in the Corrective Action system.
These other external source documents are not directly
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addressed in this report but are discussed in Reference 9.1.
1 1.3 10CFR50.55(e) Reportability Issues Identified by the NRC (Enclosure to USNRC Letter dated January 8, 1985)
"There. were potential weaknesses in the TUEC 10CFR50.55(e) deficiency reporting system. Applicable procedures did not identify what types of deficiencies constituted significant breakdowns in the QA program, nor how they should be evaluated l
for reportability to the NRC. Evaluation guidelines for reporting hardware deficiencies lacked clarity and definitive instructions and the threshold for reporting deficiencies was jN too high. Specific past and present construction deficiencies that were not reported by TUEC are listed in Sections 4, 5 and l
11 [NRC January 8 letter].
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'RESULTS REPORT j 3
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[k ISAP VII.a.2 I
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,1. 0 DESCRIPTION OF ISSUE' IDENTIFIED BY NikC (Cont'd)
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The TRT found examples in Unit I where deficiencies existed so that TUEC was in potential violation of the, codes, procedures, guidelines, and commitments concerning loir.ing devices f.or i
threaded fasteners.
In spite of the requirements pt %us.cf to 10CFR50.55(e)(1), TUEC did not repart to the NRC the !dmission of thread-locking devices in the Unit I nuclear safety systems
.t FT4 and did not attempt corrective action until May 1984, when I
%v TUEC tested previously applied paint for thread-lock
' _f i capability. That test was inconciraive, since it did not f
establish th,at the paint, an epoxy process, would reliably I ',
perform as an effective locking device under all service L..
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conditionsiand throughout the expected lifetime of the plant.
Further, TUEC could not identify to the TRT which paint was the subject of testing.
.I TUEC did not consider the Cygna audit findings regarding the DCC as appropriate for formal reporting to the NRC pursuant to
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- 10CFR50.55(e), as required by procedure CP-EP-16.3, " Control
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) of Reportable Deficiencies."
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- TURC failed to maintain material traceability for safety-related material and numerous hardware components. This QA 3
breakdown was identified in an ASME Code survey in October, 1981 yet was not reported to the NRC in accordance with the requirements of VJCFR50.55(e)."
other external source issue documents such as the CAT report, v
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-the MAC report, RIVIRs, and allegations as reported in SSERs g
elaborate on weaknesses in the 10CFR50.55 (e) Reportability system. These other external source documents are not directly addressed in this report but are discussed in Reference 9.1.
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2.0 ACTION IDENTIFIED BY NRC l
Evaluate the TRT findings and consider the implications of these findings on construction quality. "... examination of the potential 1
safety implications should include, but not be limited to the areas l
or activities selected by the TRT."
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" Address the root cause of each finding and its generic
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implications..."
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1 RESULTS REPORT I
ISAP VII.a.2 (Cont'd) 2.0 ACTION IDENTIFIED BY NRC (Cont'd)
" Address the collective significance of these deficiencies..."
" Propose an action plan...that will ensure that such problems do not occur in the future."
3.0 BACKGROUND
Because of the close interrelationship of TRT concerns involving the nonconformance systems, the corrective action systems, and the 10CFR50.55(e) reportability system, all TRT issues have been addressed under this Issue-Specific Action Plan (ISAP)
ISAP VII.a.2, and by a self-initiated review by TUGC0 described later in this section. The TRT concerns that have been addressed by this action plan are as follows:
Did the large number of methods utilized to document and O
report non-conformances cnsure appropriate processing and dispositioning of all non-conformances?
Is there and has there been an adequate trending program in place as committed to in the FSAR?
Have the TUEC and Brown & Root corrective action systems been properly implementod?
Are the procedures and-prattices presently and previously utilized for the evaluation of the 10CFR50.55(e) reportable items adequate to ensure all conditions required to be reported were reported?
This action plan was written to answer these questions. The evaluations conducted under this action plan using the methodology described herein, addresses the TRT issues listed under 1.1,1.2, l
and 1.3 above, as identified in the January 8, 1985 NRC TRT letter.
Additionally, other issues listed in SSERs 7, 8, 9, 10, 11, 12, 13 and other External Source Issues (ESI) documents such as Management Analysis Company (MAC) reports, Construction Assessment Team (CAT) reports, and NRC Region IV Inspection Reports were addressed.
In addition to actions performed by the Review Team, TUGC0 is performing a self-initiated determination of the technical adequacy
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of all construction NCRs that have been voided or dispositioned "use-as-is" or " repair" (see TUGC0 CAR-062). TUGCO is also performing a self-initiated review of all TUGC0 Design Deficiency Reports (TDDRs) for technical adequacy of dispositions of the TDDRs.
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RESULTS REPORT ISAP VII.a.2 (Cont'd)
3.0 BACKGROUND
(Cont'd)
An overview of the two TUGCO self-initiated reviews of NCRs and TDDRs is being performed by third-party engineers.
The results of the TUGC0 reviews and the third-party overviews will be reported in a supplement to the VII.a.2 Results Report.
The Testing Program (TP) Review Team will determine, among other things, whether the Test Deficiency Reports (TDRs) were prepared when they should have been and whether the TDRs were properly processed and closed. The results of the review will be reported in the ISAP III.a.1, Hot Functional Testing, Results Report.
4.0 CPRT ACTION PLAN 4.1 Scope and Methodology The objectives of this action plan were to assess the adequacy of the CPSES nonconformance/ corrective action /reportability systems and evaluate effectiveness of implementation. The handling of design deficiencies or nonconformances covered by the TDDR system was also examined and assessed as a related, but separate management system. The Trend Analysis system was also evaluated.
The external source issues concerned with these four programs were included in the evaluation. Earlier revisions of these programs were reviewed to identify any programmatic problems that could lead to undetected or uncorrected hardware problems. The current programs were evaluated against current requirements and commitments and recommendations were made as appropriate.
The scope of the' evaluation of each of the four systems is summarized below:
Nonconformance System:
The methods used by Brown and Root and TUGC0 during construction were evaluated. The methods were treated in two general groups for the evaluation. The first group used the Nonconformance Report (NCR) for documenting and processing nonconforming conditions that require input from design O-engineering. This includes dispositions to "use-as-is" or perform non-standard repairs.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
The second group uses proceduralized forms other than NCRs for processing nonconforming conditions that provide for rework or standard repair. The nonconforming conditions are documented on "Other Forms" (Attachment 1) such as: Multiple Weld Data Cards (MWDCs), Weld Data Cards (WDCs), Repair Process Sheets (RPSs), Inspection Reports (irs) and Field Deficiency Reports (FDRs).
These methods were reviewed to determine if reported nonconforming conditions were properly processed and l
resolved.
In addition, the procedures defining reporting and processing requirements were reviewed for compliance with FSAR commitments and 10CFR50 Appendix B requirements.
Corrective Action System: Applicable-procedures and program implementation were revicwed for adequacy. The Trend Analysis Program was included in this review.
10CFR50.55(e) Reportability System:
Applicable procedures and program implementation were reviewed for adequacy.
TUGC0 Design Deficiency Report (TDDR) System: The adequacy of procedures and process implementation were evaluated, including the initiation and closeout of TDDRs.
The technical adequacy of TDDR dispositions is being evaluated by TUGC0 in a separate effort, whic,h is being overviewed by the DAP Review Team.
Results of the Nonconformance System evaluation were used as appropriate in evaluation of the 10CFR50.55(e) Reportability system. The spec'ific evaluation tasks for each of the four systems are outlined in the following sections.
4.1.1 Nonconformance System The following tasks have been implemented:
Methods for processing nonconformances were identified.
Processing of nonconformances was reviewed.
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N-RESULTS REPORT ISAP VII.a.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
External source issues were evaluated.
RTLs were notified of hardware concerns as applicable.
Identification of Methods of Processing Nonconformances A review of construction and QC procedures was conducted to identify the forms and methods used by TUGC0 and Brown & Root for documenting and processing nonconforming conditions during construction. The search identified the Nonconformance Reports as well as the "Other Forms" used for processing nonconforming conditions. Nonconformance Report (NCR) logs that indicate each TUGC0 and each Brown & Root NCR produced from the inception of construction to mid-1985 were (G
obtained from the Project. The NRC was contacted to
)
obtain a listing of forms they observed for recording deficiencies.
Review of Processing of Nonconforming Conditions The systems used for controlling nonconforming conditions were evaluated to determine that:
Proper dispositioning of nonconformances and reworkable items occurred.
Nonconformance reporting systems in use conformed to FSAR and QA Program requirements.
Samples were selected from identified populations. An engineering evaluation of the data resulting from the review of the sample items was performed.
"Other Forms" used for documenting and processing reworkable items were also grouped into appropriate populations.
For the populations of Multiple Weld Data Cards (MWDCs) used for pipe supports, Weld Data Cards (WDCs) used for pipe welds, and Field Deficiency O
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
Reports (FDRs), samples were randomly selected. An evaluation of data from these samples was performed.
For the non-ASME population of Inspection Reports an engineered sample
- was selected. The selection was done so as to obtain items from different hardware groups and across the entire period of construction.
The evaluation of these selected items provided the data necessary for determining whether the control system has been and is presently functioning properly and effectively.
Each selected historical NCR was initially evaluated using a prepared checklist that included a number of attributes as follows:
The nonconforming item was properly i
identified.
The nonconforming condition was properly described.
l The disposition was identified as use-as-is, rework, repair, or scrap.
The Nonconformance Report contained signature approval by appropriate personnel.
l Reworked, repaired, and replacement items were inspected and tested in accordance with original requirements or acceptable alternates.
An independent review was conducted of the nonconformance, including disposition and closeout by appropriately qualified personnel.
The nonconformance was included in the trend analysis process and reviewed for corrective action.
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The use of judgment to select f rom a population those items that are likely to be the most critical.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
The nonconformance was reviewed to determine
. necessity for conducting further evaluation i
for 10CFR50.55(e) reportability.
The attributes listed were applied in a manner that allowed for effective data collection and analyses.
From this initial evaluation, all selected NCRs were then examined and assessed on the basis of the following criteria considered essential to an effective nonconformance control system:
Nonconforming conditions are documented and processed on the basis of approved nonconformance control procedures.
Nonconforming conditions recommended for use cm a "use-as-is" or repair basis are subject to review
'L and approval by qualified and authorized design engineering personnel, i-Nonconforming conditions to be reworked or repaired (using preapproved repair procedure) are properly controlled, reworked (or repaired) and reinspected in accordance with approved procedures and/or design documents.
l The procedures related to the selected NCRs and those related to the selected nonconforming conditions processed on "Other Forms" were reviewed. The review was conducted to determine whether the procedures adequately specified the methods for processing and dispositioning of NCRs and of the "Other Forms" selected for evaluation. The criteria for review of the NCR and "Other Forms" procedures were taken from the eight attributes previously identified and applied judiciously to allow for data collection, which data are used in making a determination of procedure acceptability, The current NCR system (May 1986 to August 1986) was i
evaluated to determine the degree of compliance with Regulatory and FSAR requirements. Data collection sheets were prepared for use while reviewing NCRs and i
i for checking other portions of the system, such as NCR I
tracking, accountability, tagging, and reportability screening.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
Approximately 100 NCRs each from TUGC0 and Brown and Root were selected. The selection was from those current NCRs that were produced under procedural controls in effect from May 1986 to August 1986. The current NCR procedures were reviewed to essentially the same criteria.
The current methods using "Other Forms" for processing nonconformances were evaluated to determine the degree of compliance with regulatory and FSAR requirements.
The evaluation consisted of reviewing the current procedures for the "Other Forms." The evaluation included a check of approximately 20 of the "Other Forms." The check evaluated the definition, implementation and satisfactory closeout of reworked items.
OU Evaluate External Source Issues Each of the External Source Issues specifically related to nonconformance systems was evaluated to determine the impact of the issue, if any, upon the nonconformance control systems. When an impact was indicated the specific issue was investigated.
Hardware Concerns Applicable Review Team 5eaders were notified of any potential hardware concerns which required further evaluation.
4.1.2 Corrective Action System I
The following tasks were implemented in the corrective action systems evaluation.
Procedures were reviewed for compliance with licensing and regulatory commitments.
Implementation of the site corrective action system was reviewed.
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Trend analysis activity was reviewed.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
TRT and SSER findings were evaluated.
Review Team Leaders were notified of hardware concerns, as applicable.
Review of Procedures TUGC0 and Brown & Root site corrective action procedures were reviewed. A detailed checklist was developed that addressed precedure coverage for the following:
Conditions adverse to quality including nonconformances, failures, malfunctions, deficiencies, deviations, and defective material and equipment are evaluated by qualified personnel and appropriate
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corrective action is taken to prevent recurrence.
l Follow-up action is taken to verify proper implementation of corrective ar ton in a timely fashion.
Significant conditions adverse to quality, including identification of the cause and action to prevent recurrence, are documented and reported to appropriate levels of management for review and assessment.
Where procedural discrepancies were identified, discrepancy documents were initiated to enable action to be taken to correct the current systems in effect for Unit 2.
Implementation of Corrective Action System Implementation of site corrective action systems was reviewed for conformance to procedural and program requirements. The Corrective Action Request (CAR) population was identified (approximately 48 closed TUGC0 CARS and 57 closed Brown & Root CARS existed as t ()
of March 1,1986). Each of the closed CARS was reviewed using a checklist developed from FSAR commitments. Potential specific or generic concerns relating to hardware were reported to the appropriate RTL.
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3 RESULTS REPORT ISAP VII.a.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
Trend Analysis System i
Implementation of the trend analysis system was reviewed in comparison to FSAR commitments.
Evaluation of External Source Issues Each of the External Source Issues specifically relating to the corrective action and trend analysis i
systems was evaluated to determine the impact of the issue, if any, upon the corrective action systems.
When an impact was indicated, the specific issue was examined.
Hardware Concerns Applicable Review Team Leaders were notified of any s
potential hardware concerns which required further evaluation.
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4.1.3 10CFR50.55(e) Reportability System The following tasks were implemented in the 10CFR50.55(e) reportability system evaluation.
Reportability procedures were evaluated for compliance with requirements.
Implementation of the reportability system was reviewed to determine effectiveness of the system.
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Evaluation of Reportability Procedures l
Site procedures that specified the method of evaluating deficiencies for reportability per 10CFR50.55(e)
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requirements were identified and reviewed. Each l
procedure that formed a part of the reportabilit-l system was reviewed to determine whether the t!.;4. hold of reportability was properly specified and that the following elements were covered.
(Reference 9.15)
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1 Page 14 of 95 e~'s RESULTS REPORT l
ISAP VII.a.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
Provision is made for evaluating each nonconformance condition for reportability.
Checklist is used for determining reportability.
Reportability checklist addresses at a minimum, determinations on:
Significant breakdown in the QA Program.
Significant deficiency in design documents as released for construction.
O Design documents released for construction do not meet the requirements of the FSAR or construction permit.
Nonconformance involves a deficiency in construction.
Nonconformance involves a deviation from performance specifications.
Provision is made for documenting each evaluation.
Provision is made for reporting each significant deficiency to the Nuclear Regulatory Commission (NRC) Inspection and Enforcement Regional Office within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> after determination of the significant deficiency.
Provision is made for submitting a written report on the reportable deficiency within 30 days to the NRC Regional Office with copies sent to the Director of Inspection and g-w Enforcement, U.S. NRC. The report shall
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include a description of the deficiency, an analysis of the safety implications and the corrective action taken, and sufficient
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) information to permit analysis and evaluation of the deficiency and of the corrective action.
If sufficient information is not available for a definitive report to be submitted within 30 days, an interim report containing all available information shall be filed, together with a statement as to when a complete report will be filed.
Provision is made for remedial action of the significant deficiency.
Review of Implementation The implementation of the 10CFR50.55(e) reportability system was reviewed for compliance with program O-procedures and commitments. Approximately sixty (60)
Significant Deficiency Analysis Reports (SDARs) were selected (lists of SDARs and an SDAR index indicated that approximately 214 existed as of May 1, 1986 Reference 9.16). The SDARs were sorted into three (3) categories and quantities were selected as follows:
10 - Closed by NRC Inspection Report 15 to 20 - Reported but not yet closed 30 to 40 - Determined not reportable or being evaluated and listed as potentially reportable.
The selection was made to provide a representative distribution of time frame and procedural applicability. The quantity of 60 SDARs represented approximately 50% of SDARs open as of May 9, 1986.
These formal reportability evaluations are not to be confused with the initial screening of nonconformances for potential reportability.
Initial screening was addressed under the nonconformance system evaluation.
Information developed during the evaluation of the i
nonconformance system was utilized in this evaluation.
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1 Pags-16 of 95 RESULTS REPORT ISAP VII.a.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
The external source issues along with any additional
~SSER findings which involve 50.55(e) reportability were evaluated to determine their impact, if any, upon the reportability system. When such an impact was indicated the specific issue was addressed.
Actions to correct generic deviations in the current program were identified and reported to TUGC0 for action.
4.1.4 TDDR System The evaluation of the adequacy of the TDDR process was conducted to address the following issues:
Design deficiencies and errors are processed in an adequately controlled manner.
Identified design deficiencies and errors are promptly corrected.
Where appropriate, corrective action to preclude repetition has been taken and verified adequate for those design deficiencies and errors considered significant or recurring.
Significant design deficiencies and errors are evaluated for reportability.
The evaluation consisted of the following steps:
f i
Applicable Regulatory Guides were reviewed to prepare a checklist of attributes for the TDDR procedure review and a data sheet for j
evaluation of the TDDR sample items.
l The procedures (including all revisions) applicable to the TDDR process (TNE-AD-5)
. were reviewed using the checklist.
Key personnel were interviewed and applicable j
records reviewed to determine whether TDDRs
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were initiated when required. The records reviewed included TUGC0 QA audit files for l
procedure TNE-AD-5 and TNE QA surveillance files on the TDDR process.
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1 RESULTS REPORT ISAP VII.a.2 (Cont'd)
. l 4.0 CPRT ACTION PLAN (Cont'd)
TDDR logs were obtained and used to select a sample of 60 closed TDDRs (exclusive of thoae resulting from DAP Discrepancy / Issue Resolution Reports).
4.2 Participants Roles and Responsibilities 4.2.1 QA/QC Review Team 4.2.1.1 Scope The QA/QC Review Team was charged with the overall responsibility for the conduct of the evaluation and preparation of the report.
4.2.1.2 Personnel O
Mr. J. L. Hansel Review Team Leader Mr. D. L. Boydston Issue Coordinator 4.2.2 TUGC0 - CPSES Project 4.2.2.1 Scope TUGC0 provided support to the QA/QC Review Team to obtain documentation and information relative to the QA/QC Review Team's evaluations.
4.2.2.2 Personnel Mr. D. W. Snow QA/QC Coordinator 4.3 Qualifications of Personnel All personnel associated with analysis and evaluation of the systems and findings covered by this action plan were qualified in accordance with the requirements of the CPRT Program Plan.
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1 Page 18 of 95 (ql RESULTS REPORT ISAP VII.a.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.4 Procedures Checklists that addressed as a minimum the items in Section 4.1 were developed as an integral part of this evaluation.
These checklists were retained to support the justification of conclusions.
4.5 Standards / Acceptance Criteria Applicable standards and acceptance criteria for tnis evaluation were derived from 10CFR50, Appendix B, Criteria KV, XVI, 10CFR50.55(e), and the FSAR.
5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS
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This Action Plan addresses separately, four related subjects, each of which must be addressed for the historical and the current periods. Because of this comp 1.xity, an outline and a flow chart are provided below to indicate how the evaluation reJults are presented.
OUTLINE 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS General 5.1 Nonconformance System Evaluation 5.1.1 NCR System Evaluation - Historical 5.1.2 FCR System Evaluation - Current 5.1.3 "Other Forms" System Evaluation - Historical 5.1.4 "Other Forms" System Evaluation - Current 5.1.5 Nonconformance System Trend Analysis 5.1.6 Nonconformance System Conclusions O)
(m, 5.1.7 Nonconformance System Recommended Corrective Action
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RESULTS REPORT s
ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.2 Corrective Action (CA) System Evaluation (Includes Trending) 5.2.1 Introduction 5.2.2 Adequacy of CA System Procedures 5.2.3 CA Trend Analysis Program Implementation 5.2.4
'CA System Implementation 5.2.5 CA System Trend Analysis 5.2.6 CA System Conclusions 5.2.7 CA System Recommended Corrective Action O)
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5.3 10CFR50.55(e) Reportability System Evaluation 5.3.1 Adequacy of Reportability System Procedures 5.3.2 Reportability System Implementation 5.3.3 Reportability System Trend Analysis 5.3.4 Reportability System Conclusions 5.3.5 Recommendations for the Improvement of the Reportability System 5.4 TUGCO Nuclear Engineering Design Deficiency Report (TDDR) System Evaluation 5.4.1
-Introduction 5.4.2 TDDR System Implementation and Evaluation 5.4.3 TDDR System Trend Analysis s
5.4.4 TDDR System Conclusions 5.4.5 TDDR System Recommended Corrective Action 5.5 External Source Issues 5.6 Issues Referred from Other ISAPs
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RESULTS REPORT ISAP VII.a.2 (Cont'd)
ISAP Vll.a.2 IMPLEMENTATION FLOW CHART ISAP Vll.a.2 Evaluation Nonconformance Corrective Action 10CFR50.55 (e )
TODR Reportability I
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1 1
Identify methods for Identify CARS identify SDARs documenting & processing
& procedures.
/ TDDRs nonconforming conditions.
& procedures to be reviewed.
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1 Method Method
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Nonconformance "other forms
- Reports (NCR 's)
MWDC 5WLD WDC~ l:PWLD.l FDR IR Used for Used for conditions conditions dispositioned :
dispositioned:
Use asis
. Rework Non-standard Standard Repair Repair C'
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l Select documents for review.
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l Prepare data collection checklists.
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l Review documents and collect data.
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l Evaluate data.
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Identify corrective action if necessary.
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General This results report documents the CPRT evaluation of the CPSES Ncnconformance, Corrective Action, Reportability and TDDR systems. This review was designed to address two concerns for each system:
Were the historical systems adequately developed and implemented?
Are the current systems satisfactorily designed to meet applicable requirements and are they being properly and effectively implemented?
The requirements for the four systems are:
10CFR50 Appendix B for the Nonconformance system, O
Corrective Action system, and the TDDR system.
10CFR 50.55 (e) for the Reportability system.
To present an overall perspective of the four programs, the Review Team developed the following set of objectives based on the content of the requirement documents. The specific requirements utilized for the evaluation of each of the systems are identified within the applicable sections of this Results Report.
The objectives of the Nonconformance system are:
to control items, services, or activities that do not conform to design requirements; to assure that the nonconforming conditions are properly evaluated and dispositioned by responsible and qualified authorities; to provide documentation and verification of the acceptability of l
nonconforming conditions that have been reworked, repaired or I
accepted-as-is; and to provide data to the Corrective Action system for purposes of identifying significant conditions adverse to quality and adverse trends or patterns.
The objectives of the Corrective Action system are:
to assure that conditions adverse to quality such as failures, malfunctions, deficiencies, deviations, defective material or equipment, and nonconformances are promptly identified and corrected; to determine the cause of significant conditions adverse to quality; to take O
corrective action to preclude recurrence of significant conditions adverse to quality; and to document and report to management, significant conditions adverse to quality, the cause of each and the corrective action taken.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
The objectives of the 10CFR50.55(e) Reportability system are:
to provide the NRC staff with prompt and timely notification of safety significant deficiencies; to provide a basis for evaluation of the potential safety. consequences of such deficiencies; to provide the NRC with a report of each significant deficiency identified that includes an analysis of safety implications, corrective action taken, and sufficient information to permit analysis and evaluation of the deficiency and of the corrective action.
The TDDR system is defined in THE-AD-5 as a system that was used by TUGC0 engineering for recording design deficiencies and errors and for taking corrective action and action to prevent recurrence when required. The system was used as a supplement to the design verification program for designs produced by TUGC0 engineering but not for designs produced by other organizations.
O The objectives of the TDDR system are:
to assure that design deficiencies and errors have been identified and resolved; to assure that corrective action to preclude repetition of such errors has been taken and verified to be adequate for those design deficiencies and errors considered significant or recurring; and to assure that significant design deficiencies or errors are evaluated for reportability.
The implementation of this ISAP was accomplished in four separate systems evaluations.
Nonconformance system evaluation.
Corrective action system evaluation.
10CFR50.55(e) Reportability system evaluation.
TDDR system evaluation The combined objective of these control systems is to assure that conditions adverse to quality are identified, documented and properly controlled; that the causes of the significant or recurring conditions are determined, and that corrective actions are taken, and reported, as required, to management and the NRC.
For purposes of this report, however, each of the systems will be treated as a distinct control system.
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ISAP VII.a.2 (Cont'd) l i
5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.1 Nonconformance System Evaluation The Nonconformance system, as described in Section 4.0, consists of two individual systems. One uses Nonconformance Report (NCR) documents to control items reconstended for disposition on a "use-as-is" or non-standard repair basis.
The second uses "Other Forms" to control nonconforming items
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to be dispositioned by standard repair or rework. These two j
systems have been evaluated separately to determine the degree of compliance of each with the following principle criteria cited in Section 4.0 of the Action Plan.
Nonconforming conditions are documented and processed j
on the basis of approved nonconformance control procedures.
Nonconforming conditions recommended for use on a use-as-is or non-standard repair basis are subjected to I
proper review and approval by qualified and authorized design engirieering personnel.
Nonconforming conditions that were dispositioned rework or repair, ara properly controlled, reworked (or repaired) and reinspected in accordance with approved procedures and/or design documents.
4 Prior to beginning the evaluation of the NCR and the "Other 4
g Forms" systems, the Review Team determined which documents were to be reviewed and prepared checklists for recording the data resulting from the reviews. The first step in the review
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process was to identify the various methods used to document, process, control and disposition nonconforming conditions.
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The Review Team s,earched through the FSAR Section 17.1.15 and i
the Brown & Root and TUCCO construction, inspection and quality procedures utilized from the start of the project.
i The search of procedures revealed that the project had j
committed in the FSAR to document deficient conditions on:
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Inspection Reports 1
Deficiency Reports i
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Nonconformance Reports The FSAR through Amendment 50 (July 13, 1984) further described the intended use of each of these documents.
An Inspection Report (IR) is used to document field inspections performed by Quality Control (QC). Each attribute on the IR is verified to be satisfactory or-unsatisfactory.
A Deficiency Report (DR) is an in-process document used
'I to document discrepancies.
(These forms were used for documenting nonhardware discrepancies and therefore were not includsd in the review).
A Nonconformance Report (NCR) is used to document deficiencies when:
The-deficiency is not listed in the attributes on the IR; The deficiency effects an item previously accepted by final inspection; The disposition of a deficiency identified on an IR or DR is "Use-as-Is" or " Repair" (except routine proc =duralized in-process repairs); or Another method of documenting the deficiency is not prescribed.
The search of procedures identified "Other Forms", i.e. other than NCRs, that were also used to document or record deficient or nonconforming conditions. The Review Team grouped the "Other Forms" into categories that are listed in Attachment 1.
Several of these "Other Forms" were also used to process / disposition nonconforming conditions.
The following categories of documents, used to document as well as process and disposition nonconforming conditions, were selected for review:
Field Deficiency Reports (FDRs)
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Inspection Reports (irs)
Weld Data Cards (WDCs)
Multiple Weld Data Cards (MWDCs)
The remainder of the "Other Forms" categories were used simply to document inspection results, not to process or disposition nonconforming conditions; consequently, they were not subjected to further Review Team consideration.
In these instances the identified nonconformance was to be transferred to an NCR'and processed accordingly.
The evaluation results for the nonconformance system appear ir.
section 5.1.1 through 5.1.4 beler.
In each of the discussions the procedures are addressed first, followed by a discussion O
of system implementation. The results are presented for both historical systems and the current systems. Nonconformance Reports (NCR) system evaluation is presented first, followed by an evaluation of the "Other Forms" system. As indicated in Section 4.0, samples were selected from the populations, with exception of the non-ASME populations of Inspection Reports and the current NCRs. Engineering evaluation of data from these samples was performed.
For the non-ASME Inspection Reports and the current NCRs, engineered samples were selected to confirm adequacy of the specific nonconformance system under examination.
5.1.1 NCR System Evaluation - Historical (Prior to mid-1985)
Procedural Controls The Review Team reviewed the historical NCR procedures, CP-QP-16.0*(TUGCO) and CP-QAP-15.1 and CP-QAP-16.1 (Brown & Root) for compliance with the applicable attributes specified in Section 4.0.
In summary, the Review Team concluded that the NCR procedures used by Brown & Root and TUGCO, notwithstanding certain weaknesses, were sufficiently detailed and clear to satisfy the objectives of the program. Details supporting this conclusion are provided in Attachment 3.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
NCR Program Implementation 4
To evaluate implementation of the NCR systems.. the Review Team obtained the TUGC0 and the Brown & Root NCR logs and, from these, selected a total of 370 closed, I
valid NCRs covering the period from early 1975 to mid-1985. The total included 127 TUGC0 and 243 Brown &
Root-generated NCRs. Each NCR was initially examined j
for compliance with specified attributes; the results j
are summarized in Attachment 3.
During the process of selecting NCRs for examination, the Review Team identified 21 NCRs that had been voided I
by'TUGC0 and Brown & Root.
Since voiding was not adequately described in the procedures, these 21 NCRs were individually evaluated to understand the basis for O,
their being voided.
In each case the Review Team determined that an adequate basis existed for each voided NCR. Data supporting this conclusion are 4
available in Reference 9.2.
On the basis of the above and the findings and observations noted in Attachment 3, the Review Team
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concludes that, with the exception discussed below the historical NCR systems used to control nonconforming 4
j conditions has, since project inception, been j
implemented in a satisfactory and effective manner.
i This is based on observation that nonconforming j
conditions were properly identified and documented.
l tracked and controlled, and in most instances satisfactorily dispositioned and closed out. The i
principal exception to this conclusion results from the
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fact that NCRs were frequently dispositioned by personne1'from organizations not authorized by i
procedure to provide disposition. This finding raises questions regarding the technical validity of these 4
dispositions. QA/QC Program Deviation Report (PDR)
PDR 74 was prepared to document this deviation, including incorrect processing of deviations discussed in more detail below. Independent of these findings, i
actions have been initiated by TUGC0 to re-examine the technical validity of all use-as-is/ repair / void dispositions. This action should adequately address
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the concerns raised in this Results Report regarding I
the validity of NCR dispositions.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
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5.1.2 NCR System Evaluation - Current (as of 9/86)
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The Review Team performed an evaluation of the current NCR systems in use by TUGC0 and Brown & Root for the construction phase of CPSES and concludes that the present systems are generally satisfactory and in compliance with FSAR/ Regulatory Guide commitments. One area requiring improvement concerns consistency in reviewing NCRs for reportability (See PDR 069). This conclusion of general acceptability was arrived at as a result of the two studies listed below, details of I
which are contained in Attachment 4.
Adequacy of NCR Procedures The current NCR procedures, CP-QP-16.0 Rev 23, May 19, 4
1986, "Nonconformances, (TUGCO) and CP-QAP-16.1 Rev 26, Feb. 18, 1986, and DCN 1, April 4, 1986, " Control of Nonconforming Items," (Brown & Root) were reviewed and evaluated for their degree of compliance with the FSAR and Regulatory Guide commitments using the criteria indicated in Section 4.0.
The procedures were l
found to be acceptable and in compliance with regulatory standards and licensing commitments.
NCR Program Implementation The Review Team evaluated the implementation of the two CPSES NCR systems covering TUGC0 and Brown & Root to determine the degree of compliance with the NCR system procedures and to assess the effectiveness of these systems.
The implem'entation evaluation was conducted by reviewing NCRs and related documentation, and performing field evaluations. These evaluations are detailed in Reference 9.2 and summarized below.
The Review Team selected 229 closed NCRs from approximately 4,500 NCRs (119 from approximately 2,200 TUGC0 NCRs and 110 from approximately 2,300 Brown &
Root NCRs) that had been generated during the time l
frame of the most recent NCR procedures (May 1986 to August 1986). The NCRs were selected from the various engineering discipline, e.g., Mechanical. I&C,
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Civil / Structural, etc., responsible for dispositioning NCRs. The Review Team determined that these NCRs had been prepared and dispositioned properly and generally in accordance with the nonconformance procedures. The attributes for which the NCRs were evaluated and the results of the evaluations are shown in Attachment 4.
On the basis of this review, the Review Team concludes that the current NCR systems established to control nonconforming conditions are, with one exception, satisfactory. The exception involves inconsistencies in the evaluation of NCRs for 10CFR50.55e reportability.
In the area of reportability evaluations, current implementation was not completely satisfactory in that some NCRs were not evaluated for reportability. These generic deviations are described in more detail in Attachment 4 and recorded on PDR 69.
5.1.3 "Other Forms" System Evaluation - Historical (Prior to.
September 1985)
Ceneral "Other Forms", as indicated in 5.1 above, were used at CPSES for documenting and processing nonconforming items that were to be reworked, or repaired in accordance with standard preapproved repair proudures.
For evaluation of the "Other Foras" the. Review Team selected samples of documented nonconformances from the forms listed below. The details of selection and population descriptions are contained in Reference 9.3.
Weld Data Cards (WDCs) - These forms are work process travelers used to document ASME Section III pipe welds. The Review Team identified a population of 66,500 WDCs, which provided the quality records of the fabrication and installation of safety-related, large bore and small bore pipe welds. All of these hardware items had been completed prior to June 12, 1985.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Multiple Wald Data Cards (MWDCs) - These forms are work process travelers used to document ASME Section III pipe support welds.
The Review Team. identified a population of 17,884 MWDCs, which provided quality records of the fabrication and installation of safety-related, large bore and small bore, rigid and non-rigid pipe supports, restraints and hangers. All of these hardware items had been completed prior to September 25, 1985.
Field Deficiency Reports (FDRs) - These forms were in-process documents used by both Brown
& Root and TUGC0 to document nonconformances.
The log of FDRs obtained from TUGC0 included 5,000 FDR numbers; many, however, were iO unused.
The FDRs were used from mid-1978 to late 1982.
Inspection Reports (irs) - These forms are used for documenting the results of inspections performed by Quality Control.
These forms also serve as travelers for construction of supports not covered by MWDCs. The IR has been used throughout the construction period.
Adequacy of "Other Forms" Procedures The Review Team determined which procedures and revisions were to be reviewed by identifying those applicable to the sample items. From this the Review Team identified and reviewed 175 procedure documents (initial procedures plus revisions) specifically related to the sample items in the "Other Forms" populations.
The review was based on the evaluation attributes listed in Section 4.0 applicable to each procedure and procedure revision. The details of the procedures review are located in Reference 9.4.
The Review Team evaluated the data resulting from the reviews O
of the procedures / revisions applicable to these "Other Forms" and concluded that these documents have not provided sufficient specificity to assure that nonconforming items
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) processed pursuant to the "Other Forms" procedures result in documented and traceable resolution of the nonconforming item.
The Review Team considered this lack of procedural guidance to represent a Program Deviation.
PDR 59 was prepared to document absence of adequate procedural controls applicable to the use of "Other Forms" in documenting, processing and dispositioning nonconformances on a rework or standard repair basis.
Examples are listed in the PDR.
"Other-Fores" Program Implementation For the Other Forms" system, the Review Team selected samples from the MWDC, WDC, and FDR populations and performed an engineering evaluation on the resulting data.
In order to evaluate non-ASME irs outside of the MWDC and WDC O
populations (ASME Section III), an engineered sample of approximately 64 irs was selected. The sample was selected'on the basis that each IR contain at least one instance of an unsatisfactory condition and that some of the irs come from the mechanical, civil and electrical disciplines within the populations as established in the VII.c ISAP.
Attributes for the review of the ASME Section III Support Wald (MWDC) and Pipe Wald (WDC) populations were selected from Section 4.0.
The attribute for FDRs was to determine whether the FDR had been used only for documenting in-process nonconforming conditions that were reworkable.
The items selected were reviewed and the data recorded for evaluation. When deviations were identified they were recorded on Deviation Reports (DRs) for hardware-related deviations or PDRs for programmatic deviations. The details of the review are' located in Reference 9.5.
The Review Team generated 20 DRs to record deviations identified in 130 items sampled from the populations.
In some instance there was insufficient objective evidence to conclude that the nonconforming item had been satisfactorily reworked and accepted by QC. In other instances there was a lack of sufficient evidence to demonstrate required inspections had been performed and that weld repairs were limited to two cycles as required per specifications (see Attachment 6, two Pages).
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RESULTS REPORT
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ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Each DR was subjected to an evaluation to determine whether the deviation was safety-significant. During the evaluation process,.some documentation was located in other files and, in other instances, inspections and field evaluations were performed to permit a satisfactory close-out of the nonconforming condition.
It was determined that none of the deviations was safety-significcat. Nevertheless, the absence of available and retrievable documentation to support rework, reinspection, and closeout of nonconforming conditions identified on "Other Forms" is considered a weakness in the Nonconformance system. Accordingly, PDR 59 was used to
'h-identify this generic deviation and to obtain corrective action. Specific deviations supporting this generic concern are referenced in the PDR.
The FDR system was put into use in May 1978 and was O
discontinued in~1ste 1982. During this period approximately 2,000 FDRs were prepared. The FDR los book contains numbers from 1 to 5,000. Approximately 3,000 of the FDR numbers were not used.
The Review Team found that the nrocedure for Field Deficiency Reports did not provide adequate controls for the use of the FDR. This is confirmed by the problems noted during the review of the sample of FDRs.
Since the use of the FDR was discontinued in late 1982, no recommendation or comments are
.c offered with respect to procedural changes. The nature and the significance of the problems discovered during the review of the FDRs are discussed below.
In the FDR population the Review Team found that 12 of the 60 FDRs did not contain sufficient information to allow the
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Review Team to determine whether the FDRs had been used correctly.
Information was ultimately obtained from documentation packages and files that allowed determination of whether usage was correct, i.e., FDRs were used for rework only and not for dispositions requiring design engineering approval such as those required for "use-as-is" or non-standard repair.
In 8 of the 12 instances the usage of the FDR was considered to be incorrect.
In the other four instances, the FDRs were used correctly. In three of the instances the item was accepted on a "use-as-is" basis; in one
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instance the item was repaired.
In three of the four remaining FDRs the condition was not fully addressed in the
" action taken" portion of the FDRs yet the FDR was closed by s.N,
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
QC thereby accepting the condition.
In the eighth instance the FDR cited an incorrect DCA which did not address the subject of the FDR, namely that of an " unqualified welder" yet the FDR was closed. The condition reported in each of the FDRs,should have been processed and resolved via the NCR t
i.
system; consequently the Review Team prepared PDR 64 to
, document this program deviation.
(Reference 9.6) 5.1.4 "Other Forms" System Evaluation - Current (September 1, 1986 - December 31, 1986)
Procedure Review In July 1986, the Review Team identified procedures governing the other forms (Reference 9.7).
Several of i
the procedures were reviewed to determine whether the fp) historical procedure weaknesses were still present. In
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general, essentially the same results were obtained from the review of the current procedures as were g
obtained from the review of the historical procedures; that is, the current "Other Forms" procedures do not I
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provide sufficient guidance or detail with respect to the rework reinspection and closecut resolution of nonconforming conditions documented on these "Other Forms".
This was also recorded on PDR 59.
The details of the review are located in Reference 9.7.
Program Implementation i
a To evaluate the current other forms and either confirm or refute the conditions found by the Review Team in the historical "Other Forms" review, a group of current "Other Forms" documents was selected.
The group was selected on the basis that the "Other Forms" document contain at least one incidence of an unsatisfactory condition identified in 1986. The Review Team selected approximately 25 items. The list of items and the details of the review are in Reference 9.8.
From the group of documents reviewed, it was determined that the nonconformances, all of which involved ASMI Section III activities, were being processed on NCRs.
(~'l The other nonconformances represented in-process
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\\m-reworks and were processed on irs.
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RESULTS REPORT ISAP VII.a.2 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS The Review Team found it necessary to search for documentation that would allow a determination to be made as to whether the nonconformances were being properly processed. The Review Team ultimately concluded that the current (1986) "Other Forms" are being properly processed and provide a documented trail of rework, reinspection and satisfactory closeout resolution. The details of the review are contained in Reference 9.9.
5.1.5 Nonconformance System Trend Analysis A description of each valid DR prepared during the review of the Nonconformance system is listed in The groups of DRs that exhibited similarities, as shown by the categorization table in
', were analyzed and all of the DRs were
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also subjected to a combined evaluation in accordance with Appendix E of the CPRT Program Plan.
Deviation Reports Five of the deviations (DRs 1, 2, 3, 10 and 14) represented single occurrences. They were evaluated and found to be not safety-significant.
DRs 4 and 6 both covered incomplete descriptions of the deviation in documents used for processing nonconformances. These deviations were evaluated and found to be not safety-significant.
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DRs 5 and 12 both identified a condition where there was a difference between the drawing and the as-built l
condition identified on an IR.
In each case the differences between the as-built conditions and drawings were resolved by taking measurements of the affected attributes and comparing them, in one case with the engineering analysis dimensions, and in the other case, to the latest revision of the drawing.
Both hardware items were found to be capable of performing their safety-related function and the deviations were considered to be not safety-significant.
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DRs 7 and 19 describe 14 ASME pipe welds where the g
documentation packages indicated that the welds were rejected by radiographic examination (RT); however, no evidence was available in the documentation packages that the welds were accepted by RT after repair.
During the safety significance evaluations, evidence of l
the RT examinations of the repaired welds was located.
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These documentation deviations had no impact on the quality of the hardware and were determined to be not safety-significant.
1 DRs 8 and 23 identified seven ASME welds that were 4
repaired without evidence in the weld documentation package of magnetic particle (MT) or liquid penetrant (PT) examination having been performed af ter excavation and prior to weld repair. During the safety-O significance evaluation, documentation was located that indicated that, in one case, the MT/PT examination had been performed; in the other six cases a change to the i
l ASME Code allowed omission of surface examination of repair areas on inaccessible interior surfaces. In each of the six cases, documentation was provided i
indicating that the surface of each weld was inaccessible for MT/PT. The deviations were evaluated and found to be not safety-significant.
DRs 9 and 21 represent two cases where there was no apparent evidence in the weld documentation packages of 1
approval for performing more than two weld repairs.
During the safety-significant evaluation it was determined in one case only three repairs (instead of seven indicated on the DR) had been performed in one location such that multiple weld repair effects would be experienced.
In that case an approval by the owner for the third repair was located.
For the other DR evidence of owner approval was located. The two deviations (on two deviation reports) were found to be not safety-significant and were considered to have no impact on hardware quality.
DRs 11, 16, 18, 20 and 22 identify five cases where there was no evidence in the documentation packages
>O that unacceptable inspection results had been resolved.
During the safety-significance evaluation documentation supporting resolution of the rejected attributes was located. The conditions reported on the aforementioned DRs were found to be not safety-significant.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
DRs 13, 28 and 29 describe the lack of documented evidence of inspection / reinspection of attributes.
During safety-significance evaluation, documented evidence of inspection was located for one DR.
The item identified on the second DR was reinspected and found to be acceptable. The third DR relates to inspection of a rework of bent rebar. This third DR has been evaluated. The three deviations were found to be not safety-significant.
DRs 24, 25, 26 and 27 describe four cases where FDRs were used in place of NCRs for use-as-is and repair dispositions. Two of the four DRs were evaluated and determined to be not safety-significant. The safety-significance of DR 25 and DR 26 was indeterminate. DR 25 and DR 26 have both been included in PDR 64.
The hardware quality was not adversely impacted by the other two DRs.
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The individual deviations addressed above, except for DRs 25 and 26, were evaluated as a set in accordance with Appendix E.
These deviations involve either incomplete or missing documentatien of rework inspection or failure to perform / document the results of rework inspection.
In each instance, the specific deviation was satisfactorily resolved on the basis of later documentation searches which turned up required inspection data or else by means of reinspection / field verification activity.
In all instances, sufficient data were provided to confirm that the item of j
nonconformance had been properly reworked and is in compliance with applicable design requirements. These deviations,are of a nature such that additional deviations of this type, while likely to exist elsewhere in the populations, would be satisfactorily resolved in the same manner as those identified by the Review Team. On the basis of such satisfactory resolution and the absence of any adverse hardware implications, the set of deviations was considered not to be an adverse trend.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION,OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
QA/QC Program Deviation Reports A description of each valid PDR prepared during the evaluation of the Nonconformance system is listed in.
The valid PDRs prepared during the evaluation of the other systems are also listed in.
The Nonconformance system PDRs are discussed below.
PDR 64 was prepared to document a program deviation wherein FDRs had been used in place of NCRs for dispositions of hardware nonconformances on a use-as-is and repair basis. The use of FDRs was dircontinued in late 1982.
Substantive modification of the program will therefore not be required. This PDR will not require extensive evaluation since the procedure is no
-"g longer in use and the effort required for validation of g,)
FDRs dispositioned "use-as-is"/ repair is not extensive.
In view of the absence of any need to substantially change the QA/QC program and the absence of extensive efforts to evaluate the program deviation, this condition was determined not to be a QA/QC Program Deficiency.
PDR 59 was prepared to document a generic program deviation wherein evidence of rework, reinspection and resolution closeout of certain nonconforming items was not available. It is the Review Team's determination that this deviation results from inadequate procedures and work practices used to document and rework in-process nonconformances. Improved procedural controls that emphasize the need for documentation of rework is considered to be appropriate corrective action. This generic deviation is of a type that substantive work will not be required to modify the QA/QC Program and extensive effort will not be required to evaluate the impact of this deviation on construction quality. Further, the needed procedural improvements are not considered substantive.
It was therefore determined that this deviation does not constitute a QA/QC Program Deficiency.
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PDR 69 was prepared to document the lack of review of
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10 of 119 TUGC0 NCRs for reportability. Resolution of this program deviation requires a review for
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) reportability of NCRs issued between June 30, 1985 and October 31, 1986. NCRs issued prior to the earlier date were properly evaluated for reportability.
Consequently no re-review was necessary. The effort can be accomplished without extensive effort on the part of TUGCO.
Substantive revision of the QA/QC Program will not be required to correct the generic deviation and bring it into compliance with the regulatory requirements, FSAR commitments or other licensing commitments. Neither will extensive evaluation be required to determine the effect of this deviation on the quality of construction. On the basis of the above it was concluded by the Review Team that PDR 69 is not a QA/QC Program Deficiency.
PDR 74 was prepared to document the incorrect O
processing of NCRs to personnel and organizations other than those authorized by procedures CP-QAP-15.1, CP-QAP-16.1, and CP-QP-16.0 as applicable from the start of the project until mid-1985. The NCRs incorrectly processed were for the reasons noted below.
Quantity (out of 370 NCRs)
Total B&R TUGC0 Incorrectly processed for:
112 69 43 Review of nonconformance 190 141 49 Disposition preparation a
183 127 56 Disposition review 92 82 10 Disposition closeout Through a separate action TUGC0 identified questionable dispositions of NCRs and recorded the concern on CAR-062. The resulting corrective action was to identify a quantity of NCRs that had been dispositioned use-as-is, repair or void and review them for technical adequacy. That review resulted in a decision by TUGC0 to perform an independent review of the technical adequacy of all NCRs dispositioned use-as-is, repair or void. The DAP Review Team will perform a third-party overview of the TUGC0 review. This condition of improper NCR processing is considered a trend.
In view of the self-initiated NCR review, the other actions being taken by TUGC0 in response to CAR-062, and actions that will be required in response to PDR 74 the Review Team will defer any further action on this matter to Collective Evaluation.
=
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Root Cause and Generic Implication Analysis No adverse trends or QA/QC Program Deficiencies were identified during this review of the Nonconformance system. Therefore, root cause and generic implication analyses were not conducted.
5.1.6 Nonconformance System Conclusions The Nonconformance system in place at CPSES is, with some exceptions, considered to be satisfae:ory a ni compliance with regulatory standards and FSAR commitments. The several systems that comprise the ij Nonconformance system have provided (and continue to provide) a mechanism for identifying, tracking and controlling nonconforming items, and in most instances, i'
have provided for closeout resolution of such items on
-()
a sound and satisfactory basis. These systems have also provided input data for trend analysis and for use in identifying significant quality deficiencies, as indicated in Section 5.2.3.
Several areas were identified that are considered to be in need of improvement; these are summarized as follows:
Improvements are required in procedures and implementing practices to assure a satisfactory basis is provided for closeout resolution of nonconforming items identified on "Other Forms" and dispositioned on a rework basis.
(PDR 59) i Improvements are required to assure all of j
the NCRs are evaluated for reportability.
(PDR 69)
Some areas were identified that do not require improvement but do need correction of the identified condition; they are summarized as follows:
Improvements are not required in NCR processing because the review of current NCRs indicates they are being properly processed.
Action is required however, to resolve NCRs w----,--ww--,.,,-..
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Page 39 of 95 RESULTS REPORT ISAP VII.a.2 i
(Cont'd) l 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) which were routed to and acted upon by organizations and individuals that were not authorized to do so.
(PDR 74)
Improvements are not required for the use of FDRs because the FDR process has been discontinued. Action is however, required to identify all FDRs that were incorrectly used to disposition nonconforming conditions on a use-as-is or repair basis. The Review Team recommends a re-examination of previously dispositioned FDRs.
(PDR 64)
In addition to the PDRs and self-initiated action committed to by TUGCO, 27 valid Deviation Reports were prepared, 25 of which were found to be not i
safety-significant or to not represent an adverse j.
trend.
The safety-significance of DRs 25 and 26 was indeterminate and the DRs have been included in PDR 64 5.1.7 Nonconformance System Recommended Corrective Action The Review Team identified the following items that require corrective action.
NCR disposition approvals:
The Review Team's concerns regarding the technical adequacy of NCR dispositions relating from disposition actions taken by unauthorized organization / individuals is addressed by the TUGC0 self-initiated review of technical adequacy of NCRs dispositioned void, repair or use-as-is. Action to preclude repetition is being addressed in a generic TUGC0 nonconformance control procedure, NEO 3.05.
This generic prccedure will cause a closer control to be placed on the development and approval of NCR dispositions.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Reportability review of nonconformances:
In response to the concerns identified in PDR 69, TUGC0 committed to review all NCRs that were prepared subsequent to 6/30/86 up to the point of issuance of NEO 3.05, i.e.,
12/22/86. TUGC0 procedure NEO 3.05 requires a discrete process step for the reportability review to be conducted by TUGC0 Engineering.
Implementation of NEO-3.05 should preclude repetition of this condition.
FDRs used for use-as-is or repair dispositions and de facto acceptance of the hardware:
[ >')
As a result of the concerns identified in N-PDR 64 regarding the inappropriate use of Field Deficiency Reports, the Review Team recommends that each of the FDRs be reviewed by TUGC0 to assure that each use-as-is or repair (other than standard repair) disposition and those FDRs where de facto acceptance has taken place has been subjected to design engineering evaluation and to the independent reviews required.
"Other Forms" procedures and practices inadequate for rework dispositions:
In response to the concerns identified in PDR 59 regarding the use of "Other Forms" to disposition rework conditions, it is recommended that actions be taken to ensure that all in-process rework is performed on the basis of procedural controls that require clear evidence of rework and subsequent reinspection / closeout resolutien. TUGC0 should consider incorporating the necessary controls in a single, top-level procedure as opposed to the current practice of employing tO a multiplicity of procedures.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.2 Corrective Action System Evaluation 5.2.1 Introduction The purpose of a Corrective Action system is to provide an orderly mechanism for assuring that conditions adverse to quality such as failures, deviations, deficiencies and nonconformances are promptly identified and corrected. Data associated with adverse conditions are to be collected and analyzed for adverse trends or patterns.
In instances where significant conditions adverse to quality are identified, measures-are to be taken such that the cause of the condition is determined and corrective action (s) taken to prevent recurrence.
O-The Corrective Action systems addressed in this ISAP are focused on conditions adverse to quality that have been identified within the Construction organizations at CPSES. Adverse conditions identified by the Engineering and Procurement organizations are managed and controlled by means of programs and procedures internal to each respective organization. These programs / procedures were not evaluated as part of this ISAP.
The Review Team prepared data sheets and checklists based upon criteria specified in Section 4.0; 10CFR50 Appendix B and FSAR commitments made by TUGCO. Copies of these data sheets and checklists are located in Reference 9.10.
These data sheets and checklists were developed to enable the Review Team to focus its I
evaluation,on the following criteria:
Conditions adverse to quality are accurately
[
documented and collectively evaluated for l
adverse trends and patterns.
l Corrective Action Requests (CARS) are initiated in a timely manner for purposes of identifying and addressing significant
~'s conditions adverse to quality, (d
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Corrective actions are proposed and initiated in a. reasonable and timely manner sufficient to resolve the problem and preclude recurrence.
Actions taken are verified as effective to preclude a repetition of significant conditions adverse to quality.
The CPSES Corrective Action system is actually comprised of two systems:
the TUGC0 CA system and the Brown & Root CA system.
In order to evaluate the effectiveness of the CPSES Corrective Action systems, the Review Team completed the folldwing tasks:
().
Reviewed and evaluated the Corrective Action system's procedures for compliance with regulatory requirements and TUGC0 licensing commitments.
This review encompassed procedures developed by both Brown & Root and TUCCO.
Reviewed and evaluated implementation of Brown & Root and TUGC0 Corrective Action systems for compliance with regulatory requirements, licensing commitments and procedural controls.
Examined and assessed External Source issues identified in Reference 9.1.
5.2.2 Adequacy of CA System's Procedures The initial action taken by the Review Team was to
-l identify Brown & Root and TUGC0 procedures used to 1) i identify adverse trends and 2) initiate corrective l
action (s). Specific Brown & Root /TUGC0 procedures identified in the course of the Review Team's evaluation (through December, 1986) were as follows:
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Organization Title Procedure No Brown & Root Correctivs Action CP-QAP-16.1, Rev. A,B,0&l, from 7/75 to 2/85 Brown & Root Corrective Action CP-QAP-17.1, Rev. O thru 8, from 12/79 to 4/85 TUGC0 Corrective Action CP-QP-17.0, Rev. O thru 8, from 5/80 s
to 2/86
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TUGCO Preparation and QI-QP-17.0 Distributioa of
-1, Rev. O Trend Reports thru Rev. 2, from 12/85 to 2/86 The Review Team determined that the procedures issued by Brown & Root and TUGC0 to control their respective Corrective Action systems contained provisions for performing both the trend analysis and the corrective action functions.
The Brown & Root procedures extended from mid-1975 to the present time. TUGCO procedures were first issued in 1980 and also extend to the present time period.
(Note:
Prior to 1980, TUGCO utilized Brown & Root procedures for addressing corrective action concerns.) The early Brown & Root i
procedures" addressed overall regulatory requirements and licensing / regulatory commitments; however, these procedures were lacking in instructional detail, particularly with respect to (1) determination of the cause of adverse conditions, (2) timeliness of corrective actions and (3) documentation requirements.
The procedures were also lacking in detail with respect to trend analysis. Initial TUGC0 procedures had similar shortcomings.
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-1 5.0 IMPLEMENTATION OF' ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
A TRT finding stated that "The Brown & Root corrective action system was generally ineffective and was bypassed by the Brown & Root QA Manager" (Section 1.2).
The QA/QC Review Team review of Brown & Root procedures revealed the following:
The Brown & Root QA manual (Section 17.0 -
Corrective Action) was revised on February 14, 1984 to allow the use of menos, letters or CARS to report the need for corrective action. Follow-up to determine effectiveness in correcting and preventing recurrence of problems identified was required.
Brown & Root Procedure CP-QAP-17.1 (Rev. 6) dated March 1, 1984 implemented the above f
change in the QA manual allowing the use of T
memos and letters to report the need for corrective action. Corrective action
),
follow-up was required. Revision 7 (October 15, 1984) to CP-QAP-17.1 spelled out requirements for logging, tracking and i
follow-up for corrective actions. A requirement to initiate a CAR, if the corrective action response to a me.
or letter was incomplete, was added January 25, j
1985 (Change Notice No. I to Rev. 7).
Based on the above discussion, the TRT finding that menos and letters were used to bypass the CAR system was not substantiated.
Implementation of the combined letter, memo, CAR system is discussed in Section 5.2.4.
Later Brown & Root and TUGC0 Corrective Action system procedures werr improvements over earlier versions.
1 However, as ineicated in Sections 5.2.3 and 5.2.4, procedural weaknesses did not preclude or inhibit implementation of a reasonably effective Corrective Action program during the course of construction at CPSES.
The current TUGC0 trend analysis procedure.
QI-QP-17.0-1, Revision 2, 02/25/86 is basically sound and represents a considerable improvement from earlier procedural guidance used by TUGCO.
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~T RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.2.3 CA System Trend Analysis Program Implementation Trend analysis activity was initiated by Brown & Root in 1975 without benefit of adequate procedural guidance. Results of trending from 1975 through 1981 are reflected in Brown & Root Monthly QA/QC Reports.
-Quarterly trend analyses were initiated by TUGC0 in 1979 (also without procedural guidance) utilizing, as input, results of the Brown & Root efforts.
The TUGC0 and Brown & Root trend analysis program improved with time and resulted in identifying conditions adverse to quality and in need of corrective action.
CARS were initiated as a result of both formal and informal trending (Reference 9.14).
Current trend analysis activity in effect over the past 1 - 1 1/2
/'~%
years is considered to be comprehensive and provides h
utility management with appropriate data concerning adverse trends and patterns.
In summary, the trend analysis programs in place at CPSES have been, and continue to be, in compliance with FSAR licensing commitments. Data concerning the Review Team's analysis are provided in Reference 9.11.
5.2.4 CA System Implementation To assess the effectiveness of implementation of Brown
& Root and TUGC0 Corrective Action systems, the Review Team examined all (105 closed) Corrective Action Requests (CARS) issued by both organizations from inception of the program in 1975 through January, 1986.
Of these, 57 CARS were issued by Brown & Root; 48 by TUGCO.
[ Note that in addition to the CAR process, significant conditions adverse to quality, are also reported on NCRs, Significant Deficiency Analysis Reports (SDARs), audit and inspection reports and startup test reports. CARS are used in instances where an adverse (or potentially adverse) trend or pattern is believed to exist. Thus, a single CAR may reflect the results of analyzing several hundred individual discrepancies or noncompliances]. Brown & Root also O
used letters and memos to report the need for corrective action. All 13 of the letters and memos logged on the Corrective Action Memo / Letter Log were examined by the Review Team.
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1 Page 46 of 95 RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Data Sheet Checklists were prepared and used by the Review Team to examine and assess each CAR and letter / memo issued by Brown & Root and TUGCO. These Data Sheet Checklists are available in Reference 9.12.
CARS and letter / memos examined covered a wide spectrum of conditions adverse to quality as illustrated below:
repetitive violations of minimum pipe wall at counterbore (CAR S-16) violations of QC and ANI (Authorized Nuclear Insper.cion) inspection hold points.(CAR S-43) modifications of equipment, building structures without engineering approved documentation (CAR-025) repetitive electrical termination failures
~-
and deficiencies (CAR-042).
A number of the CARS and letter / memos examined, particularly those in the post-1982 time frame, apparently resulted from both formal and informal trend analyses performed by the project.
Examination and assessment of all 105 closed CARS and the B&R memos and letters of concern against the criteria listed in 5.2.1 indicate the following:
Input to the Corrective Action systems was initially on the basis of NCR input and trend analysis.
Input was expanded in 1979 i
to include irs, FDRs, CMCs as well as NCRs.
'Notwithstanding procedural shortcomings, the trend analysis programs improved with time and are presently considered satisfactory.
CARS and letter / memos were prepared and issued for conditions that, in the Review Team's judgment, were significant to quality, or indicative of generic
(%
programmatic deficiencies having potential i
for adverse quality implications. As an example of the latter, CAR S-3 (issued by Brown & Root in 1975) described programmatic
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) deficiencies involving failure to issue design specification changes to equipment and material suppliers. A number of CARS were initially issued to describe non-recurring events or problems that could have better been handled via individual NCRs. However, these instances were relatively few in number and were essentially eliminated with time.
The Review Team found corrective actions initiated in response to specific problems and conditions adverse to quality to be reasonable and appropriate.
The Review Team further concluded that the corrective actions proposed were implemented in a timely and satisfactory manner, and were generally sufficient to resolve the specific problem or
(/)
condition.
In a few instances, the x,
thoroughness of these actions was s
questionable. These are discussed below.
Timeliness of implementation was frequently dependent on the scope and complexity of the issues being addressed. This complexity factor was taken into account in the Review Team's determination of timeliness of corrective actions.
The effectiveness of CAR and letter / memo resolutions was generally considered adequate.
Some exceptions were found early in both Brown & Root and TUGC0 programs in which short-term solutions were proposed (and accepted).
These usually proved ineffective and resulted in incomplete or nonpermanent fixes.
Subsequent CARS resulted in more effective long-term actions that were generally sufficient to resolve the initial problem or concern.
An engineering evaluation of the data from the review of the 105 closed CARS and letter / memos was performed. Because of the complexity of 22 of the CARS a further O'
evaluation was performed to better assess the follow-up corrective actions, including actions to identify and correct the underlying causes of the conditions. The
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RESULTS REPORT ISAP VII.a.2 (Cont'd) l 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) documentation for these aspects was satisfactory for 16 of these 22 CARS. Six of the 22 CARS have only limited documentation supporting the follow-up and identification of action to correct the underlying causes of the conditions. Although the documentation is marginally acceptable the Review Team judges the documentation to be sufficient to indicate that acceptable actions were taken and therefore concludes the CARS and letter / memos to be acceptable.
Monitoring of corrective actions to verify long-term acceptability and to assure non-recurrence of problems and significant f-s quality conditions previously addressed has
(,
improved over the past year. This improvement of monitoring will strengthen and upgrade the Corrective Action systems.
i The Review Team concludes that, in practice, decisions to issue or not to issue CARS were made on the basis of reasonable technical judgment. This conclusion is based on discussions with current and prior Brown &
Root and TUGC0 QA management and supplemented by data obtained through further research.
QA Managers interviewed were judged to be knowledgeable and well versed in requirements regarding data trend analysis and deficiency reporting. The decision making process, as evidenced by review of CARS and letter / memos issued by the two organizations, is evidence of a reasonable screening process.
In summary the Review Team concludes that the Corrective Action systems in place at CPSES have functioned adequately and, in most instances, have been effective in resolving significant quality problems and/or generic deficiencies.
O i
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1 Page 49 of 95 RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.2.5 CA System Trend Analysis There were no deviations identified within the CA systems, including their respective Trend Analysis programs. A trend analysis was therefore not required.
5.2,6 CA System Conclusions The Corrective Action systems, including the Trend Analysis programs contained within them, in place at CPSES are effective and generally in compliance with applicable regulatory standards and licensing commitments. The Corrective Action systems were used by Brown & Root and TUGC0 to identify recurrent or significant conditions adverse to quality and to cause corrective and preventive actions to be initiated.' The programs improved throughout the course of construction and are in compliance with applicable regulations and licensing commitments.
5.2.7 Recommended Corrective Actions for the CA System No recommended corrective actions for the CA systems are required.
5.3 10CFR50.55(e) Reportability System Evaluation Evaluation of the Reportability system included the following tasks:
Evaluation of Reportability procedures for compliance with requirements.
Review of implementation of the Reportability system.
The review of the Reportability system addresses the process by which a nonconforming condition is evaluated for reporting to NRC under 10CFR50.55(e). The process of screening nonconforming conditions to determine which items should be identified to the reportability system for evaluation is addressed in Section 5.1.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Conc'd) 5.3.1 Adequacy of Reportability System Procedures l
The first step accomplished was the identification of the reportability procedures. For any given period there was a primary procedure governing the identification and reporting of significant deficiencies to the NRC in accordance with 10CFR50.55 (e). These procedures (all revisions) were evaluated using the attributes listed in Section 4.0, Project Inception to November 1978 From project inception until November 1978, the
" procedure" used for the Reportability system was the "TUGC0/TUSI CPSES Quality Assurance Plan", Section 2.9, initially titled " Quality Assurance Deviation O
Administration" and later titled " Quality Assurance Nonconformance Administration". Although this document was a section of the QA Plan, it was used as a procedure. This document contained specific responsibilities and adequate procedural steps to provide a framework for meeting the regulatory requirements for items identified to TUGC0 for reportability evaluation.
November 1978 to October 1979 On November 28, 1978, TUGC0 issued a new procedure for reportability, CP-QP-16.1, Significant Construction l
Deficiencies. This procedure initiated use of a new form, Design / Construction Significant Deficiencies Analysis Report (SDAR) for reportability evaluation and documentation.
The initial issue of the procedure was in effect until October 1979. This procedure designated responsibility "for evaluating and determining the reportability of significant design and construction deficiencies...".
The procedure covered all regulatory requirements for determining reportability and making the required notifications once an item has been introduced into the O
process with the exception that there is no requirement to indicate, in instances where interim reports were issued, when the final report would be complete.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
October 1979 to November 1985 Procedure CP-QP-16.1 was revised on October 25, 1979 (Revision 1).
Revision 1 to CP-QP-16.1 added no new material and deleted several items. Of concern was deletion of the section on " Formal Notification and Reporting". This deletion left the procedure silent on the subject of written (interim or final) reports except through reference to 10CFR50.55(e).
Additionally, an appendix was deleted from the previous revision that contained an excerpt from an NRC manual providing guidance relative to 10CFR50.55(e) deficiency.
reperting. With this deletion, the guidance for determination of reportability was considerably reduced in detail.
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The effect of Revision I was to weaken a generally
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adequate procedure to the point that it no longer adequately described procedural methods for assuring that reportability requirements would be met.
This does not mean that the reportability requirements were not met.
TUGCO's practices, over and above procedure requirements, were adequate as described later in this report. This indicates that proper guidance, over and above the procedure itself, was available to responsible personnel.
Subsequent revisions to CP-QP-16.1, Revision 1 did not correct the inadequacies of Revision 1.
In summary, during the period of time from October 1979 through November 1985, the governing reportability procedure CP-QP-16.1, Revisions 1 through 6, was not adequate in identifying formal significant deficiency l
reporting requirements.
An assessment of the ramifications of these procedural inadequacies on the actual reportability process is provided in the evaluation of Reportability system implementation.
November 1985 to Present In November 1985, a new procedure governing the
/"'
Reportsbility system was issued, replacing CP-QP-16.1.
(s,T
)
This procedure shifted the primary responsibility for l
the Reportability system from TUGC0 Quality Assurance to TUGCO Engineering. The procedure, NEO CS-1, l
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RESULTS REPORT ISAP VII.a.2 (Cont'd)
^
5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
" Evaluation of and Report of Items / Events Under 10CFR21 and 10CFR50.55(e)," Revision 0, was in effect as of the Review Team's cut-off date for this evaluation, i.e.,
May 1, 1986.
Procedure NEO CS-1 is a considerable improvement over the superseded CP-QP-16.1.
Responsibilities and required actions are well-defined. Upper level TUGC0 management is involved in the process (e.g., final determination on reportable items is made by the-TUGC0 Executive Vice President, Nuclear Engineering and Operations). Additionally, all TUGC0 organizations responsible to the Executive Vice President are required to " define in their procedures who is responsible for screening all reports / forms used to document deficiencies within five working days to O
determine if the items should be considered potentially significant".
Once an item / event is considered potentially reportable, it is identified to the Site Coordinator, who initiates action to determine reportability._ A maximum of 30 days is allowed by NEO CS-1 to determine j
if the item is reportable with NRC notification (verbal) required within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of completing this determination, or 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> af ter expiration of the 30-day period. Although this 30-day period for reportability determination reflects current i
understandings between TUGC0 and NRC, it is the Review Team's belief that consideration should be given toward i
reducing the allotted time to better coincide with more I
stringent evaluation and reporting requirements that l
will be in,effect during the operations phase.
(
In summary, since November 1985, the Reportability system has operated under adequate procedural controls.
5.3.2 Reportability System Implementation i
To accomplich the evaluation of the Reportability system implev.entation, the Review Team selectively reviewed the record files for items that had been O
evaluated for adherence to project procedures and regulatory requirements. The Review Team made
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLIEENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) judgments, based on these records, as to the appropriateness of decisions on reportable versus nonreportable. The selection of files reviewed was as described below.
Significant Deficiency Analysis Reports were divided into 3 categories. The first category included SDARs issued by TUGC0 concerning both reportable and nonreportable items and identified (by TUGCO) as closed by NRC Inspection Reports. The second category included SDARs determined to be reportable, but not as yet closed by the NRC. The third category involved SDARs determined to be either not reportable, or characterized as "under evaluation" and designated as potentially reportable.
O-The Review Team selected SDARs from each category covering periods of time when the previously referenced procedures were in effect. The Review Team selected SDARs to provide a range of items of varying complexity. The number of SDARs in each category examined by the Review Team was as follows:
Closed by NRC - 10 Reportable but still open - 16 Not reportable and still open - 35 Note that the review emphasized "not reportable" items to ensure that appropriate evaluation judgements were made and, further, that items / events with true safety-significant implications were, in fact, l
reported. The review also placed a greater emphasis on current TUGC0 practices (i.e., most of the open items are relatively recent).
i The findings of the Reportability system implements on evaluation are as follows:
Regulatory time constraints were generally 1
met once an item was classified as l
potentially reportable. There were only a few cases where interim reports were not O
issued within the prescribed 30-day period.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 4 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
The analyses in the SDAR packages were summary in nature. In general they adequately described the conclusions of the analysis performed. Summaries were signed by the engineering manager responsible for the analysis, indicating that the appropriate engineering tasks were satisfactorily completed.
The Review Team concluded that all prior TUGCO determinations relative to the reportability or non-reportability of an 4
item / event were reasonable.
The TRT noted that most of the reports did not identify the cause of the deficiency.
O' The QA/QC Review Team concurs with this finding and notes that, without identifying the cause of the deficiency, it is difficult to make an accurate determination of action to preclude recurrence.
4 The Review Team noted some difficulties on the part of TUGC0 in meeting its own schedules for completion of corrective actions.
In several instances the schedule for corrective action was missed by several months; in some cases by years. No formal notification was made to the NRC or to TUGC0 management when significant schedule slippage occurred. However, final closeout inspections by the NRC were conducted when the corrective action was actually completed, l
Indicating that there was at least informal communication regarding the closeout status of SDAR items.
An assessment of adherence to procedures was made. Most of the team's findings from this assessment concern minor administrative errors such as incompleteness in filling out the SDAR forms. For example, several forms did not have the " structure" block filled out or indicate the name of the individual identifying the problem.
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1 Page 55 of 95 RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
It is understood that in January 1986 TUGC0 assembled a task force to establish a baseline status of all reportable items and to upgrade reportability files. Emphasis is being placed on completing corrective actions and closing out open SDARs.
An area of concern with the Reportability system involves the SDAR documentation files system. The " official" site files for the Reportability system are located in three different areas. The QA reportability files for items identified prior to 1982 are located in the Permanent Plant Record Vault (PPRV).
These files are not considered part of the PPRV but are merely stored there in O,
custody of the QA Supervisor. The QA files from 1982 until November 1985 are located in the QA Supervisor's office. The official files for items identified after November, 1985 are kept by the Site Coordinator responsible for reportability. The Coordinator retains files for items prior to November 1985 as well but these files are not
" official" and there is no assurance that they are complete. Actions are recommended to consolidate all SDAR files within a central location.
In addition to the files not being consolidated, they are not maintained as
" Quality Records" as required per NEO CS-1.
Files do not include an index; further, storage facilities are inconsistent with those required for QA records that are to be maintained for the life of the plant. This failure to follow appropriate practices for i
storage, indexing, and consolidation of SDAR j
record files was determined to be a QA/QC program deviation (PDR 52).
In summary, the Review Team found that TUGCO's
()
implementation of the Reportability system has been adequate and in compliance with applicable regulatory requirements. The Review Team found that TUGC0
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEU S TATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) generally applied sound judgment in performing evaluations and making determinations of reportability.
In a few instances the time requirements for written reports were not met, but these generally involved delays of only a day or two.
Most of the problems found were in the nature of minor administrative errors. The program appears to have improved steadily since November 1985. A major effort to resolve the status of open items began in January 1986 and emphasizes increased management attention to this subject.
Improvements are recommended involving cause determinations of significant deficiencies and in the quality of QA record files.
5.3.3 Reportability System Trend Analysis
(h A single QA/QC program deviation was identified
%,,/
involving weaknesses in the storage and control of SDAR record files. The items that comprise the QA/QC program deviation had no effect on the quality of construction and are not safety-significant. The QA/QC program deviations for record keeping practices has been analyzed and is judged not to represent a QA/QC Program Deficiency requiring substantive modification to the reportability program.
5.3.4 Reportability System Conclusions The procedures governing the Reportability system are considered adequate from project inception to October 1979. From that date through November 1985, changes l
in procedure reduced the effectiveness of the i
procedural controls at CPSES. The issue of a new procedure 'in November 1985 corrected most procedural i
i shortcomings and provides an adequate framework for the Reportability system. However, the 30-day period allowed by NEO CS-1, Revision 0, from identification of the potentially significant condition until initial notification to NRC, should be reexamined with a view towards reducing the time allotted to reflect more closely reporting requirements that will be in effect i
j during plant operations.
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1 Page 57 of 95 j
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
As to implementation of the Reportability system, it was found that decisions on reportability/
non-reportability were generally sound and that the program, in general, has been and is currently adequate and in compliance with regulatory requirements. An item of concern is that final reports on items / events reported to the NRC often fail to contain identification of probable cause of the deficiency.
10CFR50.55(e) requires, in part, that the final report contain " sufficient information to permit analysis and evaluation of the deficiency and of the corrective action". Cause identification is considered necessary to determine the appropriateness of corrective action.
A second item of concern involves the quality of the QA record files maintained for the reportability system.
O The record files are dispersed in several locations, h
inadequately stored and not properly indexed. This generic deviation is described in PDR 52.
5.3.5 Recommendations for Improvement of the Reportability System The following recommendations are made to strengthen and improve the current Reportability system in place at CPSES:
Consideration should be given to reducing the 30-day reportability evaluation period permitted in NEO CS-1 to coincide more closely with the shorter reportability l
evaluation periods mandated during plant operation. Gradual reduction of the 30-day
' allowance will enable personnel to become accustomed to these more stringent time constraints.
l Completed SDAR reports should include a determination of root cause or probable root cause sufficient to permit action to be taken to avoid recurrence of the deficiency.
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Page 58 of 95 RESULTS REPORT
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ISAP VII.a.2
'Y (Cont'd)
't 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) l-The current process of evaluating status, follow-ups on corrective actions, and emphasis on timely closure of items should be proceduralized and the emphasis in this area continued.
QA record file deviations identified in' PDR 52 should be corrected and the records system brought into compliance with ANSI
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N45.2.9.
g 5.4 TDDR System Evaluations i
5.4.1 Introduction 1
s The Review Team performed an in-depth study of the TDDR s
system, focusing on the identification, control, handling and resolution of design deficiencies and The TDDR system has, contrary to the governing errors.
procedure, concentrated on the handling of design deficiencies or errors identified subsequent to completion of individual design documents / packages as i
opposed to error / deficiencies identified in the course of design development.
(Note:
This appears inconsistent with the intent of the TDDR procedure, j
TNE-AD-5, Revision 8, which indicates that the procedure is applicable to deficiencies / errors identified during either performance or review of' design activities. This inconsistency is addressed in 5.4.2).
,. 9. d i
The TDDR system is considered by the Review Team to be a non-mandatory program that exceeds the design,
review / design control provisions of Appendix B and associated regulatory standards. Notwithstanding the non-mandatory aspects of the program, the Review Team's examination was performed on the basis that design errors and defects that have been identified by TUGC0 g
under this program must be subject to specified management controls, including controls to limit processing or implementation of deficient or erroneous design products and that provide for prompt and O
effective resolution of all identified deficiencies and errors. Consequently, effective implementation of this
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program was viewed as a TUGC0 commitment with J
safety-related implications.
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RESULTS REPORT
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s ISAP V}1.a.21' (Cont'd)
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5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) d The evaluation consisted of a review of the FSAR and applicable regulatory and industry standards for purposes of identifying appropriate attributes for use n
't in evaluating perfctmance; examination of procedures i
g T
' applicable to the TDDR. process (specifically, TNE-AD-5,-
Revisions 0 through 8); review of TDDR logs, which were used by the Review Team to delect, s sample of 60 closed TDDRs (excluding those resulting from DAP Discrepancy Issue Resolution Reports);.end examination of the TDDR population sample. Examination of actual TDDR documents was performed Nn the basis of document M
package review, personal interviews with cognizant TUGC0 representatives'and supplemented where approprjate by field inspections.
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As irNicated in Section 4.0, this evaluation was 3
performed specifically to answer the following I
questions:
Have' the design deficiencies and errors been q' s
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identified a'nd processed in an adequately s., controlled system?
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Where appropriate, has corrective action to,.
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errors considered,significant or recurring?
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are they' evaluated for reportability?
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This effort consisted of an evaluation of sixty (60) l, completed TDDRs and TNCRs.-(the TNCR was the predecessor t
of the TDDR). As a result of the evaluation, the findings and observations described below were 6
developed with respect to the effectiveness of the TDDR system.
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RESULTS REPORT-ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Use of the TDDR System Few actual design deficiencies (or errors) have been identified and documented using the TDDR system. This is primarily because no planned review process has been established that could be used to identify design problems. The TDDR system has been used primarily to identify minor documentation and clerical-type errors.
-Approxisately 70% of the TDDRs reviewed for this Action i
Plan involve clerical or minor documentation errors that would not have an adverse impact on design-related activities.
There has been relatively little effort to date to,
establish technical-type surveillances, audits, or other reviews appropriate for identifying design problems and deficiencies.
The processing and control of the deficiencies (or errors) that have been identified to date has been ineffective. This is due, in part, to the lack of-satisfactory procedural controls involving 1) hardware impact assessments and 2) closecut verification and, further, is the result of ineffective implementation of existing procedural requirements. Specific findings and concerns that form the basis for this conclusion are detailed below.
TNE-AD-5, the governing TUGC0 procedure applicable to the TDDR system, does not require independent L
verification of corrective / preventive action completion. The verification that was performed was often incomplete and inadequate. A description of the required verification and examples of incomplete verifications are included in Attachment 8 under
" Verification of Corrective / Preventive Action".
The lack of an effective verification process has been addressed on PDR 66.
i The TDDR system does not provide for assessing the impact of design deficiencies or errors on completed l
design, fabrication, installation, testing or operation
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activities.
In one case, when existing hardware was noted as having been affected by the reported
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deficiency, no indication could be found that any
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Page 61 of 95 RESULTS REPORT l
ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) l notification had been made to the appropriate personnel nor was there indication of other action taken to assure that the hardware is corrected. Attachment 8 under " Notification of Possible Hardware Deficiency" l
contains additional details and examples.
This deviation has been addressed on PDR 67.
The TDDR process also failed to provide for control of hardware (or design) impacted by the identified deficiency (or error). There are no procedural requirements for such controls specified in TNE-AD-5.
Therefore a design document identified as deficient-could continue to be used without restriction for further design or for construction, installatior or for other safety-related activities. This finding has also been addressed on PDR 67.
TNE-AD-5, Revision 9, Section 2.8, Management Review (concerning approval of corrective / preventive action) states, " Concurrence shall serve as authorization to proceed with its implementation". Contrary to this requirement, approximately 70% of the TDDRs reviewed had their respective corrective and/or preventive action implemented, and sometimes completed, prior to the required approval. Also noted was that one TDDR 5
and one TNCR had been initiated after the reported deficiency had been identified by other means and the corrective / preventive action already implemented. In these instances all of the procedural reviews were performed after the fact. Examples of these deviations
- re contained in Attachment 8 under " Management Approval of Corrective / Preventive Action". Theaa discrepancies are addressed on PDR 72.
TDDR ME-86-013 involves failure of a vendor to test supplied equipment adequately per specification.
This TDDR, which was dispositioned "use-as-is", should have been transferred to an NCR. As a result of the Review Team's discussion with TUGCO, action was taken to identify this failure on NCRs CM87167, CM87168, CM87169, and CM87170. No further action is required regarding the specific findings; however, PDR 71 has l
been prepared to address the failure to utilize NCRs for "use-as-is" dispositions.
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1 Page 62 of 95 Od-RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
TDDR Closure The Review Team's evaluation indicates that most of the deficiencies and errors identified on TDDRs/TNCRs had, in fact, been corrected. Two exceptior.s were noted as described in Attachment 9.
Although the majority of the deficiencies identified through the TDDR process had been corrected, the timeliness of the action taken in relation to the scope of the problem and action required, was of ten judged to be unsatisfactory. It also should be noted that this review has been directed to closed TDDRs. From the beginning of the TDDR process (6/83) thru the end of 1985, a total of 109 TDDRs/TNCRs had been written. As of Dec. 17, 1986, only 97 have been closed. The remainder, totalling 48.7 percent of all deficiencies identified in this
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time frame, remain uncorrected. All have been open for
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at least one year.
In the Review Team's judgment, many of the unresolved deficiencies could have been resolved in considerably less time. The lack of timely TDDR resolution has been addressed as a generic deviation on PDR 66.
Action to Prevent Recurrence Action to prevent recurrence for those deficiencies and errors considered significant or recurring has not been performed. Section 3.0 of TNE-AD-5 requires that a quarterly report be prepared that would " include an.
evaluation for identification of significant or recurring deficiencies (or errors)".
In the seven quarterly reports issued to date (thru the 1st quarter of 1986), no discussion was made of significant or recurring deficiencies (or errors). The indivfdual quarterly reports have been used for trending of the reported deficiencies.
Significant deficiencies, as defined by TNE-AD-5 Sections 1.4.3.a are deficiencies reportable under 10CFR50.55(e).
Some of the deficiencies identified in the TDDR system fit this definition of significant.
f"'s Item one on Attachment 10 lists deficiencies considered
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significant based upon the TNE-AD-5 definition.
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1 Page 63 of ?S RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Recurring deficiencies were also noted by the Review Team when an analysis of all (seven) quarterly reports was made collectively. Although TUGC0 did use the quarterly reports for trending..it failed to collectively evaluate the results of the individual quarterly reports to identify recurring deficiencies.
Item 2 on Attachment 10 identifies four categories of recurring deficiencies not. identified by TUGCO.
+
As a result of TUGCO's failure to identify significant and recurring design deficiencies or errors, the cause for these deficiencies has not been determined, 1
appropriate corrective action has not been taken to preclude recurrence and management has not been informed. These deviations in the trending of. design
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deficiencies and errors has been addressed on PDR 68.
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Review of TDDRs for Reportability All deficiencies (or errors) noted on TDDRs require a review for reportability. The samples reviewed by the Review Team were all reviewed for reportability by TUGCO,'with two exceptions. The TDDRs that failed to indicate a review for reportability are EE-84-024 and SP-85-054.
This condition had previously been identified on-TNE Surveillance Report TSR 86-20 and is being tracked through an existing TUGC0 control system;
)
therefore, no further corrective action is required.
5.4.3 TDDR System Trend Analysis A total of five QA/QC program deviations were identified in the TUGCO Design Deficiency Reporting i
(TDDR) system. Each PDR was evaluated per Appendix E 1
to determine whether any of these deviations constituted a QA/QC Program Deficiency.
4 PDR 66 identifies generic deviations involving inadequate or incomplete verifications of corrective actions taken to resolve specific design deficiencies
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or errors. The absence of timely corrective actions is also addressed in this PDR. The correction of this
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deviation will not require substantive revision of the TDDR program or extensive evaluations to assess impact i
on quality of construction.
In each instance the
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-design deficiency or error was either satisfactorily resolved or is in process of resolution.
It is therefore concluded that PDR 66 is not a QA/QC Program Deficiency.
PDR 67 identifies a program deviation resulting from failure on the part of TUGC0 to assess the impact of design deficiencies or errors on ongoing or completed activities such as fabrication, installation or testing. Further, in one instance where an adverse impact determination was made, there was no indication of follow-on corrective action to control ~the item impacted. The correction of this deviation will not require _ substantive program revision or an extensive evaluation effort. None of these deviations have an adverse impact on hardware or construction quality and, O
consequently, are determined to be not safety-significant. In view of the foregoing, PDR 67 is not a QA/QC Program Deficiency.
PDR 68 describes failures on the part of TUGC0 to identify significant or recurring design deficiencies such that appropriate preventive actions could be taken.
Significant or recurring design deficiencies could have and should have been identified via trend analysis of quarterly TDDR status reports. PDR 68 was evaluated per Appendix E and determined not to constitute a QA/QC Program Deficiency. The lack of effective TDDR trend analysis inhibited determination j
of the root cause of significant or recurring problems.
However, it did not preclude resolution of each 1
TDDR-identified design problem on an individual basis.
PDR 71 involved failures to use NCRs to disposition nonconforming items identified in a TDDR. These failures represent deviations regarding the itse of appropriate procedures for dispositioning discrepant items and have no hardware impact. PDR 71 does not constitute a QA/QC Program Deficiency as defined in Appendix E of the CPRT Program Plan.
In addition, the basis for each "use-as-is" disposition is considered 1-O_,/
reasonable and was made by appropriate engineering authority, albeit on the basis of an incorrect form, s
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
PDR 72 describes failures to comply with procedures requiring prior review and approval of corrective actions to resolve design deficiencies and errors.
PDR 72 does not constitute a QA/QC Program Deficiency requiring substantial program modification or extensive evaluation to assess impact. In each instance, the corrective action taken was reasonable and appropriate even though initiated without prerequisite approvals.
On the basis that none of the TDDR-related QA/QC Program Deviations, individually or collectively, represents a QA/QC Program Deficiency as defined in Appendix E, a root cause/ generic implications analysis is not required.
5.4.4 TDDR System Conclusions In summary, the TDDR system, both in procedure and in practice, does not adequately address all of TUGCO's procedural commitments and has not been properly and effeetively implemented.
For the individual TDDRs evaluated, most of the reported deficiencies (or errors) had been' resolved, although the timeliness of resolution is of concern.
4 Most were also examined for reportability. However, the program is not fully effective due to 1).the absence of planned design review or surveillance process to identify design problems, 2) inadequate procedural requirements concerning corrective action verification and design deficiency impact assessment;
- 3) lack of proper implementation of the existing procedural requirements, particularly in addressing i
recurring problems and 4) lack of timely corrective actions. Consequently the effectiveness of the TDDR system has been diminished from what it might be and presently appears less than satisfactory. Given the fact that the TDDR process extends beyond existing design control requirements of Appendix B, the program i
can be eliminated based on the understanding that design deficiencies and errors of the type identified
- O under this program can be and will be processed under other Appendix B design control and corrective action j.
programsuin place at TUGCO.
The Review Team recommends that, unless the TDDR can be made to function effectively, it be eliminated.
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1 Page 66 of 95 RESULTS REPORT ISAP VII.a.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.4.5 TDDR System Corrective Action All previously initiated TNCRs and TDDRs (including those previously closed) should be reevaluated against the criteria listed below and appropriate corrective action taken as needed. Additionally, these criteria should be incorporated into the TDDR procedure, TNE-AD-5, and should be considered mandatory requirements for processing design deficiencies and errors under the TDDR system, assuming this system is retained by TUGCO.
4 The impact of design deficiencies errors on i
previously completed design, fabrication, d
installation and testing activities shopld be ascertained and documented.
Cognizant supervision should be promptly appraised of design deficiencies / errors that, upon evaluation, are found to impact the quality or acceptability of items or activities under their cognizance.
Measures should be taken to preclude further processing or application of design found to l
be defective or in error until such time that an engineering assessment is made of the impact of further processing. This applies to all items and activities (construction, testing operations, etc.) impacted or potentially impacted by the design defect.
The appropriate corrective / preventive action should be established, thoroughly describing the specified actions, and approved prior to implementation.
Verification of the completed corrective / preventive action should be performed by individuals independent of the implementation of the corrective / preventive action (i.e., QA or EA).
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A system should be developed to identify all significant and recurring deficiencies (or errors).
The cause must be determined for these identified deficiencies (or errors) and the appropriate action taken to preclude recurrence. Also management should be kept informed of the identified deficiencies.
Measures should be established to follow up action assure timely completion and implementation of the opecified i -
corrective / preventive action.
1 TDDRs should not be used, in lieu of an NCR, to disposition hardware nonconformances.
5.5 External Source Issues Each of the external source issues identified for consideration by the Review Team has been evaluated. These external source issues consist of issues identified by:
the i
NRC's Technical Review Team in their January 8, letter; the Construction Adequacy Team in their report; the Management Analysis Company in their report; allegations expressed in Safety Evaluation Report Supplements. The Review Team did not attempt to verify or validate the specifics of each External l
Source Issue ~or TRT finding,~nor did it attempt to determine whether each issue or finding was an isolated incident. The Review Team did, however, examine each issue or finding frpm the viewpoint of its impact on the individual systems covered in VII.a.2, When such impacts were indicated,~the specific issue or finding was considered in the Review Team's investigations an,,d assessments. The results of these assessments are contained in Reference 9.1.
In general, the Review Team concurs with many of the findings of the TRT.. In some instances the Review Team's conclusions do not precisely agree with the TRT findings. In those instances the Review Team found the differences to be based primarily on differences that were detailed in procedures for 4
different time frames. These differences are described in Reference 9.1.
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v RESULTS REPORT ISAP VII.a.2 (Cont'd) i 1
5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.6 Issues from Other ISAPs When issues from other ISAPs were referred to ISAP VII.a.2, or when ISAP VII.a.2 was referenced in other ISAPs, the Review Team considered the applicable issues and found them to not result in substantive change to the conclusions, ongoing activities or corrective action for the applicable systems (Reference 9.13).
All items as of the date of the report have been considered. Other issues that may arise after this report will be considered in collective evaluation.
a
6.0 CONCLUSION
S Nonconformance System Conclusions The Nonconformance system in place at CPSES, with noted exceptions, is considered satisfactory and in compliance with applicable 1
regulatory requirements and FSAR licensing commitments. This l
system, in the aggregate, has provided an effective mechanism for the identification, tagging, documentation, tracking and control of discrepant or nonconforming conditions and, further, have provided l
for the closeout resolution of such conditions on a reasonably sound basis.
In addition, the NCR systems have provided input data for trending analysis and have been used for identification of significant safety conditions reportable to NRC per.10CFR50.55(e).
The Nonconformance system currently in place at CPSES is, with the j
exceptions listed below, considered to be comprehensive and effective.
Improvements in procedural controls and implementing practices are needed to provide a satisfactory (and documented) basis for closeout resciution of nonconforming items identified on "Other Forms" and'dispositioned on a rework basis.
(See PDR 59)
Improvements are needed in NCR processing to assure that all NCRs and NCR-type documents are processed to the appropriately-designated organization (and individual within the organization) for review and disposition.
(See PDR 74)
Actions are required to assure all NCRs are systematically
. ( -s considered for reportability evaluation.
(See PDR 69) j l
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6.0 CONCLUSION
S (Cont'd)
In addition to the program deviations described above, a generic deviation was identified involving misuse of Field Deficiency Reports (FDRs) to disposition nonconformances on a "use-as-is" or repair basis. Since the FDR process has been discontinued, no future actions are recommended; however, a re-examination of previously dispositioned FDRs is recommended to confirm the technical validity of such dispositions.
(See PDR 64)
In addition to the program deviations cited above, 27 valid Deviation Reports (DRs) were prepared, none of which was found to be safety-significant or representative of an adverse trend.
Corrective Action System Conclusions The Corrective Action systems in place at CPSES are considered I}.
effective and generally in compliance with applicable regulatory
'N-standards and licensing commitments. The Corrective Action systems were effectively used by Brown & Root and TUGC0 to identify recurrent or significant conditions adverse to quality and to cause corrective and preventive actions to be initiated. The programs improved through the course of construction and are considered to be acceptable.
Reportability System Conclusions Implementation of the Reportability system was found to be adequate and in compliance with applicable regulatory requirements. The Review Team found that TUGC0 generally applied sound judgment in performing safety-significance evaluations and in making determinations of reportability.
In a few instances the time requirements for written reports were not met, but these occurrences usually involved delays of only.a day or two. Most of the concerns identified by the Review Team were in the nature of minor administrative errors or procedural noncompliance rather than violation of regulatory requirements. The system appears to have steadily improved particularly during the latter phases of construction. A major effort to resolve all open significant deficiency items began in January 1986, emphasizing this increased attention. Deviations in record keeping were indicated and are detailed in PDR 52.
In addition, there is a need for improvement
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in root cause determinations and in the timeliness of corrective actions.
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RESULTS REPORT ISAP VII.a.2 (Cont'd)
6.0 CONCLUSION
S (Cont'd)
TDDR System Conclusions The TDDR system, both in procedure and in practice, does not adequately address all of the required FSAR and Regulatory Guide commitments and has not, in the Review Team's judgment, been properly and effectively implemented.
For the TDDRs evaluated, most of the reported deficiencies (or errors) had been resolved, although the timeliness of resolution is of concern. Most were also properly examined for reportability.
However, the system is not considered satisfactory due to 1) the absence of planned design review or surveillance activities to identify design problems, 2) inadequate procedural requirements involving corrective action verification and provisions for assessing the impact of identified design deficiencies or errors and 3) lack of proper implementation of the existing procedural O_-
requirements. Consequently, the effectiveness of the TDDR system
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has been diminished from what it might be and presently appears less than satisfactory. Since the TDDR system is essentially a self-initiated program extending beyond the traditional design control, functions imposed by Appendix B, the program can be eliminated without adverse consequence.
In the event the TDDR system is retained, it is essential that the deviations identified in this ISAP be resolved and appropriate improvements in performances defined and implemented. The Review Team recommends that, unless the program can be made to function effectively and in accordance with performances criteria indicated in this ISAP, it be eliminated. Specific programmatic weaknesses and recommended improvements are identified on PDRs 66, 67, 68, 71, and 72.
It is understood that TUGC0 is implementing an Engineering Assurance system to perform surveillance for the purpose of identifying design deficiencies and errors, and taking applicable corrective action (see' Engineering Procedures ECE-5.01-13, Rev. 0),
" Design Change Authorization", and ECE-2.11 Rev. O, " Design Change Trending"). This should include the functions of the TDDR system and eliminate tha need for the TDDR system.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 7.0 ONGOING ACTIVITIES 7.1 Nonconformance System As indicated in Section 5.1.1, NCRs were sent to personnel and organizations other than those t.uthorized by procedure for disposition. This incorrect processing of NCRs raises questions regarding the technical adequacy of NCR di sasitions. This finding, coupled with TRT and TUGCO's concerns involving questionable dispositions, is being addressed by the self-initiated TUGC0 review to determine the technical adequacy o. all NCRs dispositioned on a use-as-is, repair and void basis. The Review Team's conclusions of generally satisfactory compliance with applicable regulatory and licensing commitments is contingent upon satisfactory completion of this self-initiated review effort. This TUGC0 review is being performed in accordance with corrective action cited in CAR-062. The self-initiated review is being overviewed by the Design Adequacy Program (DAP) Review Team in
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accordance with DAP Instruction DI-M003. The results of the review and the overview will be reported by the respective organizations separately from this report.
7.2 Corrective Action System There are no ongoing activities.
7.3 Reportability System There are no ongoing activities.
7.4 TUGC0 Design Deficiency Report (TDDR) System There are no ongoing activities.
8.0 ACTION TO PRECLUDE OCCURRENCE IN THE FUTURE Implementation of the recommended corrective actions and continuous monitoring of these systems through audits, surveillance and management reviews will be sufficient to prevent recurrence of the program deviations identified in this ISAP.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) l
9.0 REFERENCES
AND ATTACHMENTS References 9.1 Working File VII.a.2-3A 9.2 Working File VII.a.2-4B l
9.3 Working File VII.a.2-5A, 6A 7A, 10A 9.4 Working File VII.a.2-SC, 6C, 7C, IOC 9.5 Working File VII.a.2-3C 9.6 Working File VII.a.2-7B 9.7 Working File VII.a.2-10C
( }
9.8 Working File VII.a.2-10 9.9 Working File VII.a.2-10B 9.10 Working File VII.a.2-8B, 8C 9.11 Working File VII.a.2-8B 9.12 Working File VII.a.2-8B 9.13 Working File VII.a.2-3B 9.14 Working File VII.a.2-8B 9.15 Working File VII.a.2-9C 9.16 Working File VII.a.2-9A.002 through 006 Attachments 1.
"Other Forms" Categories 2.
Historical NCR Procedure Weaknesses 3.
Historical NCR Review Results sO
(,,)
4.
Current NCR Review Results
Revision:
1 Page 73 of 95 RESULTS REPORT ISAP VII.a.2 (Cont'd)
9.0 REFERENCES
AND ATTACHMENTS (Cont'd) 5.
Nonconformance System DRs 6.
Categorization of Nonconformance System DRs 7.
VII.a.2 QA/QC Program Deviation Reports i
8.
TDDR Processing and Control of Design Deficiencies 9.
Uncorrected Reported Design Deficiencies 10.
Significant or Recurring Design Deficiencies
- O i.
I 4
- O
. - ~... -..... -.., -. -., -.. -.. - -. - -. - - -..
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1 Page 74 of 95 O
RESULTS REPORT ISAP VII.a.2 (Cont'd)
Attachment i "Other Forms" C ta egories Test Reports Civil / Structural Test Reports Construction Surveillance Reports Design Field Changes Evaluation Reports Field Deficiency Reports (FDRs)
Inspection Reports (irs)
Item / System Test Reports Receiving Inspection Reports (RIRs)
Weld Data Cards (WDCs)
Multiple Weld Data Cards (MWDCs) i i
- O
+
1
,-......________.._,.___,_.-_,_....__,..-,-..-,..-_-.,_____.,-..-,..._,_..__,,...__.,,m._
__m,._._,.
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1 Page 75 of 95 O
RESULTS REPORT ISAP VII.a.2 (Cont'd)
Historical NCR Procedure Weaknesses The results of this review indicates the following areas where procedural guidance did not fully specify requirements.
Voiding NCRs Some procedure revisions addressed voiding NCRs, others did not.
When
" voiding of NCRs" was addressed the requirement for stating the reason was not included in all revisions.
NCR Logs The TUGC0 procedure did not contain provision for an NCR log until Revision 7.
Trend Code The requirement for a trend code was not included in the TUGC0 procedure.
s__
The B&R procedure addressed a Trend code, but did not provide adequate details to assure uniform application.
Corrective Action This subject is discussed under the Corrective Action System portion of this report.
Reportability Not all of the Brown & Root NCRs procedurally required a reportability evaluation. TUCCO procedures after mid 1985 incorporate requirements for reportability evaluations.
6 i
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Rcvision:
1 Page 76 of 95 RESULTS REPORT ISAP VII.a.2 (Cont'd)
Historical NCR Review Results Attribute Results Nonconforming condition The Review Team found in each instance the description NCR included enough information for the proper description of the nonconforming conditions.
NCR logs used to track The Review Team obtained copies of NCR and status NCRs logs for review.
Information was present in the logs that allowed for accountability and tracking from inception through disposition and closeout. The NCR logging activity is considered satisfactory.
/~'s Proper processing of NCRs The Review Team found in many instances
()
to cognizant / appropriate that the NCRs had not been sent to the organizations correct organization, in that personnel from organizations other than those authorized by procedure were providing disposition and closeout action. These conditions are discussed in more detail below.
(See PDR 74)
Disposition of The Review Team found that in 183 (56 of 127 nonconforming items on a TUGC0 and 127 of 243 Brown & Root) of 370 use-as-is basis or NCRs the disposition approval had been non-standard repair basis performed by personnel other than those by cognizant and authorized by the procedure. This finding authorized engineering raises questions regarding the technical personnel validity of these dispositions.
(It should be noted that during the review of current NCRs the Review Team found that the NCRs were being sent to the correct organizations and individuals for disposition and closeout.)
Nonconforming conditions The Review Team identified vue NCR where the dispositioned for rework / disposition had been marked " Rework" yet a repair are properly repair weld to the base metal was conducted reworked / repaired and without stating a repair procedure.
reinspected per This was reported on a Deviation Report.
applicable / approved The deviation was subsequently evaluated
()
documents and found to be not safety significant.
Revision:
1 Page 77 of 95 O
RESULTS REPCRT ISAP VII.a.2 (Cont'd)
Historical NCR Review Results (Cont'd)
_ Attribute Results The Review Team found two instances in the 370 NCRs where the reinspection of the rework was not indicated to have been satisfactorily completed. These findings have been forwarded to TUGC0 and have been addressed on TUGC0 NCRs. The Review Team concludes these two instances of inadequate rework closecut to be isolated incidents not impacting this attribute.
In all other instances satisfactory evidence of reinspection was available.
(DR 28, 29)
NCRs satisfactorily NCRs were satisfactorily closed out in all closed out cases with the exception of the two N
instances cited above where there was no indication of closeout or reinspection.
NCRs evaluated for The Review Team found that there was no reportability per indication on the NCRs that the evaluation 10CFR50.55(e) for 10 CFR 50.55(e) reportability evaluations had been performed for 298 NCRs (127 TUGC0 and 171 Brown & Root) out of 370. The time frames encompassed by these 298 NCRs are:
October 1960, to July 1985, for TUGC0 and October 1978, to July 1985, for Brown & Root.
Subsequent investigation of this apparent lack of screening of NCRs disclosed that reviews were conducted by the TUGC0 QA Supervisor, and later the Brown & Root site QA manager, on copies of NCRs that were sent to them on a daily basis. The Review Team found both the TUGC0 and the Brown & Root current NCR procedures to require the action addressee to decide whether the nonconforming condition should have further evaluation and record the results of their decision on the NCR. This was determined to be a minor O
procedural departure that requires no further action.
.. - ~
Revision:
1 Page 78 of 95 O
RESULTS REPORT ISAP VII.a.2 i
(Cont'd)
Historical NCR Review Results (Cont'd)
Attribute Results The cause of the In some cases the NCRs had provision for nonconformance and the stating the cause of the nonconformance and steps taken to prevent the action taken to prevent recurrence but in i
recurrence is stated.
most cases they did not. This is not considered to be a fault with the system because action to prevent recurrence of a nonconformance is not required unless the nonconformance is a significant condition adverse to quality. The Corrective Action system exists to identify and obtain action to prevent recurrence of significant nonconformances which are adverse to quality.
The Corrective Action System is discussed in
()
Section 5.2.
The nonconformance is The NCRs did not always have a space and included in the trend instructions for entering a trend code on the analysis process and face of the NCR. Trending analysis was reviewed for corrective performed however, and reports were
- action, generated. The corrective action and trend analysis processes are discussed in Section 5.2 of the Results Report.
O
Revision:
1 Page 79 of 95 t
1 l\\
RESULTS REPORT ISAP VII.a.2 (Cont'd) i 1
Current NCR Review Results 1
Attribute Results The nonconforming condition is fully Confirmed by review of 110 and clearly described. The item is Brown & Root and 119 TUGC0 uniquely identified and thcre is NCRs. -All were judged to be sufficient information to identify /
acceptable in that the locate the item.
description of the nonconforming condition contained sufficient information to identify, locate and understand the nonconforming item.
Nonconforming items are tagged to Confirmed by visual field
}
identify status and, where practical, verification of tags on l
are segregated.
nonconforming material including nonconformances applicable to Unit 1, Unit 2, 1
and common areas.
1 Control of continued work on a Confirmed by assessment'of i
nonconforming part is accomplished procedures CP-QP-16.0 and i
through proper request and review CP-QAP-16.1.
There were process by applicable disciplines.
no nonconforming items observed being worked in the field so actual implementation could not be independently verified.
NCR logs (B&R and TUGCO) provide Confirmed by spot checking identity and status of each NCR.
copies of the NCR Data Action organization and status is Base and Master Data Base indicated for.each NCR.
l l
Disposition of each unsatisfactory, This was judged to be unacceptable, or indeterminate acceptable as confirmed by condition recommended for disposition examination of NCRs to "use-as-is" or perform dispositioned "use as-is" or l
non-standard-repair is provided by
" repair / rework." The appropriate engineering personnel.
dispositions stated on the i
NCRs examined were judged to
!O
~
Revision:
1 Page 80 of 95
'Q.
RESULTS REPORT ISAP VII.a.2 (Cont'd)
Current NCR Review Results (Cont'd)
Attribute Results be appropriate for the l
conditions stated. The technical adequacy of dispositions to use-as-is and repair are assured by Design Engineering in accordance with ECE-AD-5-2.
Documentation indicates that NCRs This was confirmed by dispositioned for " rework" or examination of NCR closeout,
" repair" have been properly repaired by reviewing recently and inspected in accordance with completed NCR packages specified engineering requirements.
packages (including supporting O
documentation). The packages were complete and indicated satisfactory completion of the authorized rework, repair, and reinspection.
NCRs dispositioned as " voided",
This item was judged to be
" duplicate", "not an NCR", (or acceptable after reviewing the similar terms) should state the 229 NCRs in this evaluation.
reason that it will not be evaluated Forty-seven of the NCRs in this as a unione NCR.
evaluation could be categorized as " voided". All but one NCR contained justification for not being evaluated as a unique NCR.
The single NCR in question did, however, reference another NCR which provided an adequate explanation for the voiding action.
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1
)
Page 81 of 95
(~~)
RESULTS REPORT ISAP VII.a.2 (Cont'd)
Current NCR Review Results (Cont'd)
Attribute Results TUGC0 evaluates nonconformances This item is reported under the for determination of trends. Trend corrective action (5.2) reports are issued, reviewed and section of this report.
used to take appropriate corrective action where required.
Significant conditions reportable During this evaluation it was to NRC per 10CFR 50.55(e) are noted that ten TUGC0 NCRs had identified, reported, and Corrective been closed without the 10 CFR Actions taken to preclude repetition.
50.55(e) evaluation being noted on the NCR. These NCRs were evaluated, and it is concluded that, although the
/'l NCR procedure was violated,
\\~ /
these omissions do not violate any FSAR or licensing commitments. The NCRs in question were issued to correct documentation problems.
Conclusions were drawn that the present system for evaluating NCRs for potential reportability per 10 CFR 50.55 (e) is not functioning satisfactorily.
In response to this finding TUGC0 committed, in NCR E-86-202249, to a review of NCRs for reportability evaluation. This review will cover all hCRs dispositioned since the revision of the NCR procedure which incorporated this requirement on 6/30/85.
NCRs prior to 6/30/85 are discussed in the " Historical NCR System" and considered acceptable. This action is satisfactory.
p Revision:
1 Page 82 of 95 RESULTS REPORT ISAP VII.a.2 (Cont'd)
Current NCR Review Results 5
(Cont'd)
Attribute R,esults 1
i Component Modification Cards (CMCs)
This element was verified by and Design Change Authorizations spot checking DCA computer (DCAs) are not being used to-logs and CMC computer logs circumvent the NCR system.
and by review of 100 DCA and CMC documents. The DCAs and CMCs are used by Engineering r
to initiate changes to design documents and either form can be selected for this purpose.
Of the 100 DCAs and CMCs eu. mined only one DCA indicated a potential for a change being made to-
- O accommodate an as-built, i.e.,
nonconforming coadition.
Further examination indicated
!~
appropriate resolution.
It is concluded that the CMC and DCA system is not being i
employed to circumvent the NCR process. On the contrary, j
many CMCs referenced an NCR among the referenced documents indicating that when a nonconforming condition exists it was properly documented and processed on an NCR. The CMC was subsequently prepared to resolve / disposition the nonconforming condition.
i NCRs are approved / reviewed /
Two hundred twenty-nine (229) dispositioned/ verified by NCRs were examined for proper personnel authorized to perform authorisations to provide these functions, dispositions to NCRs. In the j
NCRs examined, authorization j
documentation was provided 4!O l
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w n
,n n-,
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Revision:
1 Page 83 of 95 O)
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RESULTS REPORT ISAP VII.a.2 (Cont'd)
Current NCR Review Results (Cont'd)
Attribute Results showing disposition authority.
Proper organizational responsibilities were verified on the NCRs examined. These lists are revised periodically with changes of personnel.
- l During the evaluation of the TUGC0 NCRs, it was noted that 12 NCRs had been assigned to Quality Engineering as the
" action addressee". Action addressees on the NCR form
()
currently do not include Quality Engineering. On the basis that these NCRs were issued to correct documentation nonconformances.
Quality Engineering is considered an appropriate addressee to disposition the f
NCR. TUCCO will modify the NCR procedure to allow for Quality Engineering to be the addressee when appropriate.
This is considered j
satisfactory resolution of this minor procedural inconsistency.
l O
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,.---.ae,,,y--,-.,,,,.m.m.,,,
-,,.,n--,,.,-,-.n.-,
---_-,,,,,--_,.~.-,n,,...
..,,,n-.n.,,.-,,,~-.n
Revision:
1 Page 84 of 95 OV RESULTS REPORT ISAP VII.a.2 (Cont'd)
Nonconformance System DRs DR/PDR NUMBER DESCRIPTION OF DEVIATION R-VII.a.2-DR-1 Weld metal build up of lip of containment liner base segment done without procedure for base metal repair. Disposition not approved by engineering.
(Containment liner)
R-VII.a.2-DR-2 Unsat IR MI-920 "A-490 bolts not torqued due to inaccessibility".
IR not closed. (Pipe Support / restraint)
R-VII.a.2-DR-3 IRN states A-490 bolts to be loosened and retightened. A-490 bolts cannot be reused per AISC Code. Disposition is questionable.
(Pipe support / restraint)
O R-VII.a.2-DR-4 Bolts scored. Extent of scoring is questionable. Use-as-is disposition is questionable.
(Pipe support / restraint)
R-VII.a.2-DR-5 Anchor bolt location dimensions differ between dwg. and as-built IR.
No corrective action taken.
Inspection report closed in error.
(Pipe support)
R-VII.a.2-DR-6 In a group of Richmond inserts, some were nonconforming. Notation of which inserts were affected was not documented. Deviation description not complete. Disposition questionable. Closecut indeterminate.
(Pipe support)
R-VII.a.2-DR-7 ASME weld rejected by RT and was not reexamined by RT after repair. Less stringent NDE was used and would have been OK if used originally. Closecut indeterminate.
(Diesel Oil pipe)
R-VII.a.2-DR-8 ASME requires MT/PT of weld excavation or UT of completed weld. No evidence of examination of ASME weld excavation.
\\,
(Reactor Coolant Pipe) 4
-,_n-,
-. ~..
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RESULTS REPORT i
ISAP VII.a.2 (Cont'd)
Nonconformance System DRs (Cont'd)
DR/PDR NUMBER DESCRIPTION OF DEVIATION R-VII.a.2-DR-9 No evidence of approval of more than 2 weld repair cycles of stainless steel weld.
Closeout indeterminate.
(Reactor coolant pipe)
R-VII.a.2-DR-10 Four clearance deviations. Disposition for all deviations not provided. Disposition questionable. Closeout indeterminate.
(Pipe support) i R-VII.a.2-DR-11 Clearance and grouting deviations noted on QCCSC were signed " SAT".
No disposition of deviations. No evidence of resolution.
()
Closeout indeterminate.
(Pipe support)
R-VII.a.2-DR-12 Base plate dimensions on dwg. differ from i
"as-built" IR.
No evidence of resolution.
I Hardware condition indeterminate.
(Pipe
)
support)
R-VII.a.2-DR-13 Pipe support removed from base plate. No i
evidence that removal area of base' metal was visually inspected. No evidence of inspection.
(Pipe support)
R-VII.a.2-DR-14 No documentation in records vault for two field welds. No documentation for work done.
(Pipe welds)
R-VII.a.2-DR-15 R-VII.a.2-DR-16 IR indicates base plate dimensions out of tolerance. No evidence of resolution.
Closeout marked SAT but closeout is e
indeterminate. (Pipe support)
R-VII.a.2-DR-17
-1 R-VII.a.2-DR-18 QCCSC notes undersize cotter pins. No 3
evidence of how resolved. QCCSC signed off "UNSAT".
(Pipe support)
Invalidated - documentation located.
. ~ _, _ _ _ _, _ _ _ _ _ ~ _ _. _ ~.
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1 Page 86 of 95 I)
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RESULTS REPORT ISAP VII.a.2 (Cont'd)
Nonconformance System DRs (Cont'd)
DR/PDR NUMBER DESCRIPTION OF DEVIATION R-VII.a.2-DR-19 Thirteen welds rejected by RT were not (13 deviations) reexamined by RT as required for these ASME welds. Less stringent NDE was used and would have been OK if used initially.
(Various piping systems)
R-VII.a.2-DR-20 Area to be repaired is stated on Repair Process Sheet (RPS). No evidence of resolution.
(Containment Spray Pipe)
R-VII.a.2-DR-21 No evidence of approval of more than 2 weld repair cycles of stainless steel weld.
Closeout indeterminate.
(Containment Spray Pipe)
R-VII.a.2-DR-22 Check list indicates that a clamp spacer is loose and that the washer may be too large.
No evidence of resolution.
(Pipe support)
R-VII.a.2-DR-23 ASME requires MT-PT of weld repair excavation (6 deviations) or UT of repaired weld. No evidence that either was done. No evidence of examination of ASME weld excavation.
(Various piping systems)
R-VII.a.2-DR-24 Evidence that concrete pour was different than required by engineering.
FDR used instead of NCR for use-as-is disposition.
(Containment, Unit 1)
R-VII.a.2-DR-25 Cable storage deviation reported and dispositioned on FDR instead of NCR as required.
FDR used instead of NCR for use-as-is disposition.
(Cable in storage)
R-VII.a.2-DR-26 Partial penetration welds instead of full penetration welds were used on a support for conduit and recorded and accepted for use-as-is (per DCA) on an FDR instead of an I)
NCR.
FDR instead of an NCR was used for a
\\--
use-as-is disposition.
(Conduit support)
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1 Page 87 of 95 RESULTS REPORT ISAP VII.a.2 (Cont'd)
Nonconformance System DRs (Cont'd)
DR/PDR NUMBER DESCRIPTION OF DEVIATION R-VII.a.2-DR-27 Containment spray fan coil unit was damaged from overhead construction. The deviation was recorded and dispositioned for use-as-is on an FDR instead of an NCR as required.
(Containment spray fan coil unit)
R-VII.a.2-DR-28 NCR E-84-100659S was closed out without documented evidence that retermination of the cable had been inspected. No evidence of closeout.
(Cable termination)
R-VII.a.2-DR-29 DDR C-214 (DDRs were used prior to NCRs by Brown & Root) was closed out without evidence O
of reinspection acceptance of some reworked bent rebar. No evidence of closeout.
(Safeguard #1)
R-VII.a.2-DR-30 Invalidated - Requirements clarified - Deviation does not exist.
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v RESULTS REPORT ISAP VII.a.2 (Cont'd)
Categorization of Nonconformance System DRs (Category definitions are on the second page of this attachment.)
R Vil.a.2 REF OTY CATEGORY POPULATIONS DR#
PDR# OF ITEMS A B
C, D E
F G
H I
J K L M SWLDPWLD FDR NCR I
I l
1 l
X 2
1 1'
l X
f 3
1 1
X 4
1 1
l y
5 1
1 X
1 i
X 8
59 1
l 1
l lX 9
1 i
1 l
i i
i x.
10 1
l 1
X r
11 59 1
1 X
12 59 1
1 l
l X l
{
13 1
1 xj I4 I
I 1
I lX i 16 59 1
1 1
x 18 59 1
1 1
X 19 13 13 1 X l 20 1
1 X
l 21 1
1 xi 22 59 1
1 X
23 59 6
6 X
24 64 1
1 X
25 64 1
1 X
26 64 1
1 X
27 M
1 1
X 28 59 1
O 1
X 29 59 1
1 X
Totals 27 2
44 1
1 2
2 14 7
2 1
5 3
1 4
1 12 8
4 3
Revision:
1 Page 89 of 95
's /
FESULTS REPORT ISAP VII.a.2 (Conc'd)
(Cont'd)
Categorization of Nonconformance System DRs CATEGORY DEFINITIONS A.
Inspection documentation not closed, i
B.
Disposition is questionable.
C.
Deviation description not complete.
D.
Dimensions differ between dwg. and as-built IR.
E.
No evidence that reworked ASME welds rejected by RT were g
reexamined by RT.
/
F.
No evidence of ASME weld excavation examination.
G.
No evidence of approval for more than 2 weld repairs.
H.
Disposition indeterminate.
I.
No evidence of resolution.
1 J.
No evidence of inspection / reinspection.
K.
No documentation for work done.
L.
FDRs used in place of NCRs for use-as-is and repair dispositions.
M.
Base metal weld repair performed without approved procedures.
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1 Page 90 of 95 1
v RESULTS REPORT ISAP VII.a.2 (Cont'd)
VII.a.2 QA/QC Program Deviation Reports Ten valid PDRs were prepared and are listed below:
Nonconformance System PDR 64 FDRs used in place of NCRs for disposition of use-as-is or repair PDR 59 Rework, reinspection and resolution closecut not evident PDR 69 NCRs closed without evaluation for reportability.
PDR 74 Incorrect processing of NCRs to personnel and organizations other than those authorized by procedure.
10CFR50.55(e) Reportability System PDR 52 Reportability files not maintained as quality records TUGC0 Design Deficiency Report (TDDR) System PDR 66 Verification of TDDR corrective / preventive action often incomplete and not timely PDR 67 TDDRs do not assess impact of design deficiency on previous hardware / design.
PDR 68 Action to preclude repetition of significant/ recurring deficiencies in TDDR process is often not taken.
PDR 71 TDDR used in place of NCR for use-as-is disposition of hardware..
PDR 72 TDDR corrective action taken prior to authorization.
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RESULTS REPORT ISAP VII.a.2 (Cont'd)
TDDR Processing and Control of Design Deficiencies
" Verification of Corrective / Preventive Action" During the review of the TDDR system, several instances were identified where the completion of the corrective / preventive action could not be completely verified. This was determined to have been caused by a lack of procedural requirement for an appropriate independent review and verification of the completed corrective / preventive action. Examples of how the corrective / preventive action was performed is as follows:
1.
All TNCRs (issued per TNE-AD-5 Rev. 0 & 1) were required to be verified by the individual responsible for implementing the corrective / preventive action (the TNE Supervising Engineer).
No independent review was performed at all. Two examples of the result of this are:
~s k)
TNCR-014: no indication of preventive action being s-verified.
TNCR-017: the attendance sheets for those individuals requiring additional training for the preventive action are incomplete.
2.
Presently the TNE Director of Engineering is responsible for the verification on TDDRs. This level of management review has not produced an adequate method for the described verification required.
Examples of TDDRs in this category are:
ME-84-029: no statement of any verification for the C/A.
IC-84-005:' statement of verification incomplete.
ME-84-011: corrective action was not completed or verified for Unit 2.
IC-85-018: the attendance sheet for the preventive action is for the wrong procedure.
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RESULTS REPORT ISAP VII.a.2 (Cont'd)
TDDR Processing and Control of Design Deficiencies (Cont'd) 3.
In a few cases where training was specified, the prescribed preventive action did not address the individuals or organizations designated to receive this training; consequently completion of training can not be completely verified. Examples of these TDDRs are: CS-85-012, ME-84-021 EE-84-002, EE-85-019, SP-85-054, TNCR-006, and TNCR-016.
" Notification of Possible Hardware Deficiency" 1.
Several TDDRs reviewed identified design errors that would have required a hardware modification (assuming the equipment was already installed); these TDDRs did not identify the status of the affected hardware. Therefore it is uncertain if the appropriate personnel had been notified or made aware of design corrections which could impact equipment or hardware O.
installation.
Examples of TDDRs with this problem are identified below:
EE-84-024: the inadequate control of valves in the event of a power failure.
FP-86-376: an electrical conduit that should have a fire seal.
FP-85-024: an improper connection into the plant l
underground water main.
i l
2.
On TDDR EE-85-019, no indication of notification to the appropriate personnel of the identified hardware deficiency.
i l
Note:
Similar procedure deviations had been noted on TUGC0 QA j
Audit TCP-85-37 (Dec. 85).
^
" Management Approval of Corrective / Preventive Action" l
1.
The following listed TDDRs are a few of those identified as I
having their respective corrective / preventive action being implemented prior to authorization by management as required by procedures i
I CS-85-012 i
CS-85-010 l
SR-86-005 l
l IC-85-009 l
EE-84-001 w
Revisiont 1
Page 93 of 95 O
RESULTS REPORT ISAP VII.a.2 (Cont'd)
TDDR Processing and Control of Design Deficiencies (Cont'd) 2.
One TDDR and one TNCR that were reviewed had been initiated after the reported deficiencies (or errors) were previously identified by other means and the corrective / preventive action was already completed.
TNCR-017 was initiated 1/12/84 and the preventive action had been completed on 1/4/84.
TDDR FP-85-104 was initiated 11/11/85 and the corrective action was completed on 10/31/85.
O A
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Page 94 of 95 O
RESULTS REPORT ISAP VII.a.2 (Cont'd)
Uncorrected Reported Design Deficiencies 1.
On TNCR-006 the prescribed corrective action did not address the specific design deficiency identified, where a vendor's concurrence was not received prior to revising the vendor's drawing. Therefore there is no indication of the deficiency having been corrected. This deviation has recently been identified by TUCCO by TDDR C-87-297.
2.
On TDDR ME-84-011 no indication of verification of the corrective action for Unit 2 has been provided.
Further investigation by the Review Team could not provide any evidence of corrective action being implemented for Unit 2.
This deviation has recently been identified by TUCCO on TDDR C-87-298.
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RESULTS REPORT ISAP VII.a.2 (Cont'd) 0 Significant or Recurring Design Deficiencies 1.
The following listed TDDRs have been determined to be reportable under 10CFR50.55(e):
ME-84-013*
ME-85-004*
SY-85-030*
IC-86-133*
PS-86-184*
ME-84-007 These items are not sample items selected specifically for this ISAP review but vere noted during the review.
g-s 2.
The four areas of concern that have been repeatedly identified
( )
on the quarterly reports are as follows:
" Design documents are verified and numbered correctly and as per the applicable procedural requirements" has been identified as an area of concern in six out of seven quarterly reports.
" Proper inclusion of design changes into drawings, to avoid incorporation errors" has been identified as an area of concern in five out of seven quarterly reports.
"All pertinent design criteria are taken into consideration" has been identified as an area of concern in five out of seven quarterly reports.
"Conformance with governing technical and procedural requirements to avoid design and documentation errors" has been identified as an area of concern in five out of seven quarterly reports.
Ix- >
o O
COMANCHE PEAK RESPONSE TEAM RESULTS REPORT ISAP VII,b.1 Titlet Onsite Fabrication REVISION 1 O
Sk &
A-Lt By Issue Coordinator Date
~
b/FI7 m
==e Ra w Team Leader A Dat#
/
V/b 2.//t/iv JohnW. Beck, Chaira.an CPRT-SRT Date O4 cpl [-
O
<t,1 gS
Revisient 1
Page 1 of 40 RESULTS REPORT ISAP V11.b.1 Onsite Fabrication
1.0 DESCRIPTION
OF ISSUE IDENTIFIED BY NRC 1.1 USNRC-TRT Letter January 8. 1985, Issue 8. Onsite Fabrication "The TRT findings regarding onsite fabrication shop activities indicated that A.
The scrap and salvage pile in the fabrication (fab) shop lafdown yard was not identified and did not have restricted access.
B.
Material requisitions prepared in the fab shop did not comply with the applicable procedure.
C.
The fab shop foremen were not familiar with procedures that controlled the work under their responsibility.
D.
Fabrication and installation procedures did not include O
information to ensure that Brown & Root fabricated threads conformed to design specifications or to an applicable standard.
E.
Indeterminate bulk materials that accumulated as a result of site cleanup operations were singled with controlled safety and non-safety asterial in the fab shop laydown yard.
F.
Site surveillance of asterial storage was not documented.
G.
Work in the fab shop was performed in response to memos and sketches instead of hanger packages, travelers, and controlled drawings."
2.0 ACTIONIDENTIFIEbBYNRC Evaluate the TRT findings and consider the implications of these findings on construction quality. "... examination of the potential safety implications should include, but not be limited to the areas or activities selected by the TRT."
" Address the root cause of each finding and its generic implications..."
" Address the collective significance of these deficiencies..."
" Propose an action plan...that will ensure that such problems do not occur in the future."
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1 Page 2 of 40 4
RESULTS REPORT ISAP VII.b.1 (Cont'd)
3.0 BACKGROUND
This Action Plan provided for an assessment of onsite fabrication activities, in general, whether performed in the fabrication shop or other plant areas.
CPSES Safety Evaluation Report Supplement No. 11 (SSER 11), May 1985. Appendix 0, Allegation AQ-138 (pages 0-145 to 0-153) discussed fabrication shop activities under QA/QC Category 55, Onsite Fabrication. Specifically, Allegation AQ-138 consists of twelve (12) elements:
- 1. Personnel asked to perform work without knowledge of paperwork.
(Substantiated)
- 2. Paperwork illegal due to post dating.
(Unable to substantiate)
- 3. Non-safety material mixed with safety-related material.
(Not t
substantiated) i
- 4. Personnel directed not to mark indeterminate material as scrap.
(Not substantiated)
- 5. Electrical and iron fab shop asterial consolidated and mixed.
(Not substantiated)
- 6. Electrical personnel used undocumented material.
(Unable to substantiate)
{
(Not substantiated) i
- 8. Undocumented weld repairs made on base metal.
(Unable to substantiate)
- 9. Threaded rod cut.without QC verification of heat numbers.
(Not substantiated) 1
- 10. Arc cut done too close to cut line.
(Unable to substantiate)
- 11. Beam clips may have been cracked during bending.
(Not substantiated)
- 12. Chain and triple hook fabricated without regard to procedures.
l j
(Unable to substantiate)
NOTE: The statements shown in parentheses above are NRC l
conclusions.
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1 Page 3 of 40 REStfLTS REPORT ISAP VII.b.1 i
(Cont'd) 3.0 BACKGR0tlND (Cont'd) 1 SSER 11, Appendix P (Page P-14) lists seven (7) concerns relative to Allegation AQ-138. Four (4) of these concerns are a reiteration of ones stated in AQ-138. The remaining three (3), listed below, are the result of the TRT investigation of AQ-138.
i
- 1. Material requisitions did not comply with procedures.
j
- 2. Randon QC surveillance of storage areas not performed.
- 3. Unused material not returned to warehouse.
J l
A preliminary investigation by the QA/QC Review Team indicated that except for the fuel pool liner fabrication effort, only a small amount of safety-related work was performed in the onsite fabrication shop prior to January 1980. The work activities performed at the onsite fabrication shop ranged from simple cutting of asterial through the fabrication or modification of complex i
items that involved fit-up, welding, and machining operations.
{
Because of modifications, the fabrication of components of ten occurs periodically throughout the installation and checkout phases of an ites. r'onsequently, a documentation package for a completed j
assembly some<imes includes inspection data entries covering a time j
span of five gS) years or more. The program of procedural controls for onsite fabrication activities has evolved with time as a result of corrective actions to probless identified by both internal and i
)
external sources.
t Fabrication and inspection records for work performed are not maintained on file in the fabrication shop. Locating the trail of work performed in the shop required utilisation of the shop's hanger request and assoranda files. These files provided a trail for evaluating the records of the work performed (drawing, procedure, inspection, installation and acceptance) as recorded in the ites documentation packages. The documentation packages identified through the*use of the shop's files include records of j
fabrication activities performed in the shop and within the plant during installation. These packages are maintained and available for review either in the TUCCO records vault or the Brown & Root permanent plant recorde vault (PPRV) for completed items and in the interia records vault (IRV) for items in-process.
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1 Page 4 of 40 C]/
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RESUI.TS REPORT ISAP VII.b.1 (Cont'd) 3.0 BACKCROUND (Cont'd)
Based upon the preliminary investigation, it was determined that a directed approach for selecting sample items for review would provide a more effective means to assess a representative cross-section of activities over time than would a random sample selection process. The use of a directed approach ensured that the selection of items that involved significant iron shop fa'srication activities included items fabricated during the time period involved with the TRT investigations, i.e., July - September 1984.
Coupled with an indepth survey of current fabrication shop activities, the directed approach also enabled assessment of the evolving program of procedural controls with time and an evaluation of the of factiveness of corrective actions taken for the problems identified by internal and external sources.
4.0 CPRT ACTION Pl.AN 3
4.1 Scope and Methodology
)
This Issue-Specific Action Plan assessed the adequacy of the procedural control of onsite fabrication activities at CPSES.
These activities include fabrication in the onsite fabrication shop as well as fabrication-type activities performed within the plant during installation. Action Plan VII.a.8, "Tuel Pool Liner Documentation", identified a large number of documentation discrepancies resulting from failure to implement procedures and the lack of definitive procedural direction. Due to the potential for the existence of similar discrepancies in other areas / work activities, the scope of Action Plan VII.b.1 was expanded to encompass onsite fabrication activities in general. The evaluation considered the evolution of procedural controls with time and includes an assessment of the current program.
This action plan' consisted of two separate areas of evaluation a) Concerns that were evaluated by review of safety-related fabrication document packages:
Material requisitions not properly completed.
O
R;vicient 1
Page 5 of 40 RESULTS RE20RT ISAP VII.b.1 (Cont'd) 4.0 CPRT ACTION Pt.AN (Cont'd)
Fabricated thread conformance.
Fabrication / inspection accomplished without full knowledge / utilization of correct paperwork e.g., drawings, travelers and procedures.
Fabrication using undocumented material.
Fabrication 1ivolving unauthorized / improperly documented repairs.
b) Concerns that were evaluated by physical survey and by review of procedures, survey, surveillance and audit records to identify trends and corrective action effectiveness Shop Foresen familiarity with procedures.
Control of nonconforming hardware, indeterminate material and scrap and salvage areas.
Segregation of safety, non-safety and bulk material.
Surveillance of material storage.
The specific methodology is described below.
Applicable material storage, fabrication, and inspection l
procedures in effect for both ASME and non-ASME safety-related work in onsite fabrication areas were identified and reviewed.
The procedural adequacy with respect to controls for material traceability, fabrication processes and ites acceptability was evaluated for compliance with the applicable requirements of 10CTR50 Appendix B and the FSAR.
Categories of both ASME and non-ASME safety-related fabricated items were selected for review in a manner that provided for an evaluation of a reasonable cross-section of onsite fabrication shop activities for the time period 1980 through December 1985. Three (3) ASME Code and six (6) non-ASME Code n
sample items were also selected from the 1978 and 1979 time U
period.
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1 Page 6 of 40 RESULTS REPORT ISAP VII.b.1 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
ASME Ites Selection locause fabrication and inspection records are not esintained in the fabrication shop, the shop's hanger request and memoranda files were reviewed to select the ASME Code itees for evaluation. The files contained information for identifying itees that represented significant fabrication activities, both in the shop and within the plant, during selected time periods, e.g., the time of the TRT's investigations, July - September 1984 Fabrication shop activities consist of the following groups of work activities:
a) Cutting of asterial and material identification transfer.
b) Fitup and welding.
c) Machining, threading, bending, and other forming activities.
The fabricated /sodified itees under the jurisdiction of ASME Code requirements that were selected for review represented at least two (2) of the above groups of work activities. Where practical, based upon the above groups of work activities, three (3) semple items per calendar quarter were selected over the 1980 through 1985 time period. Three (3) sample itees i
were also drawn from the 1978 and 1979 time period for a total
[
of seventy-three (73) items.
t Non-ASME Itee Selection l
The documentatiot)irements (cable tray hangers) were alsopack{
to ASME Code requ evaluated. The non-ASME semple itees were selected by reviewing a data base printout that contained a listing of
(
cable tray hangers and their fabrication completion dates.
Fabrication activities associated with cable tray hangers and structural steel comprise essentially all of the safety-related work performed by the fabrication shop. The only structural steel itees evaluated were those fabricated or O
modified as a task operation incidental to completion of a component support assembly. Other structural steel itees were l
not evaluated independently because of their lack of ccapienity, i.e., review team inability to identify individual
R:visient 1
Page 7 of 40 RESULTS REPORT ISAP VII.b.1 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) structural steel itene that involved a significant number of fabrication shop processing operations. The QA/QC Review Tean concluded that a review of structural steel items would not provide information, relative to the fabrication shop.
difforent than the ASME and non-ASME sample items. The structural steel population within Action Plan VII.c evaluated the fabrication / installation of structural steel since these activities took place primarily within the plant.
Review Activities The completed documentation packages for the selected sample itees were reviewed for adequacy of material identification, applicable drawings and procedures usel, and fabrication and inspection sign-offs. Deviations identified during the review were documented and processed in accordance with CFRT procedures. When necessary to confirm or resolve the 4 O
hardware was eussined in place.
deviation and aid in the safety significance evaluation, the An indepth survey of current fabrication shop activities was also performed. This three-part survey was implemented to determine the adequacy and implementation of present procedural controle and to resolve or confirm the NRC-TRT investigation concerns that could not be assessed by review of documentation alone, e.g., shop forenen familiarity with procedures and singling of controlled safety and non-safety material.
Storage and surveillance procedures and records were reviewed, under Action Plan VII.a.7. " Housekeeping and Systee Clean 11nese", for adequacy of requirements, identification of trends, and offactiveness of corrective action.
Inforestion from the V11,s.7 evaluation was evaluated for applicability to the issues addressed in this Action Plan.
A detailed analysis on the data from the above reviews was conducted to determine the adequacy of onsite fabrication activities in meeting the applicable requirements of 10CFR$0 Appendia 5 and the F8AA.
Deviations identified were documented on either a Construction Deviation Report (DR) or on a QA/QC Program Deviation Report O
(FDR) and evaluated in accordance with CFRT progree requirements.
Revisient 1
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Page 8 of 40 RESULTS REPO$T ISAP VII.b.1 (Cont'd) l 4.0 CPRT ACTION PLAN (Cont'd)
Deviations related to material traceability were documented on Deviation Reports and were transmitted to the Action Plan VII.a.1 Issue Coordinator for evaluation and action as appropriate.
l 4.2 Participant's Roles and Responsibilities t
The organisations and personnel that participated in this effort are described below with their respective scopes of work.
r i
4.2.1 TUCCO CPSES Project 4.2.1.1 Scope Assisted the QA/QC Review Team in the identification and provision of O
specifications, drawings. procedures i
and other documentation necessary for the esecution of this action i
plan.
r Assisted in determining the type of items fabricated or modified onsite in the fabrication shop and/or other plant areas.
Processed NCRs that were generated due to this action plan.
1 4.2.1.2 Personnel l
Mr. C. R. Hooton Project Coordinator
(
(TWR) i t
Mr. D. W. Snow TUCCO QC f
Coordinator L
4.2.2 CPRT QA/QC Review Tees 4.2.2.1 Scope O
The QA/QC Review Team was responsible for evaluating the adequacy of completed inspection records (docuesntation packages) l for the selected sample itese.
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1 Page 9 of 40 1
RESULTS REPORT ISAP VII,b.1 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.2.2.2 Personnel (prior to March 1. 1986)
Mr. John Hansel QA/QC Review Team Leader Mr. S. L. Crawford Issue Coordinator 1
4.2.2.3 Personnel (starting March 1. 1986) 1 Mr. J. L. Hansel QA/QC Review Team Leader Mr. G. W. Ross Issue Coordinator 4.3 Qualifications of Personnel There were no tests or inspections required during the f
implementation of this action plang therefore, inspection personnel certified in accordance with ANSI N45.2.6 were not i
]
required.
Participants were qualified to the requirements of the CPRT Program Plan.
l 4.4 Procedures i
Matrices, checklists and data sheets were developed as an i
integral part of the evaluation. No formal procedures were prepared because no reinspections were performed.
4 4.5 Standards / Acceptance criteria i
L Acceptance criteria were based on the requirements of 10CFR50 q
Appendia 5. FSAR commitments, applicable codes and standards and a review of shop fabrication procedures, QC inspection l
y j
procedures, drawings and sketches.
Fabrication work activities were considered acceptable if all 4
required documents:
a) were present and correctly identified the drawings and process procedures used.
I b) identified the inspection criteria and j
c) provided authorized inspection sign-offs attesting to i
j the adequacy of the items and documentation.
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1 Page 10 of 40 RESULTS REPORT V
ISAP VII b.1 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESITLTS 5.1 Population Identification The types of activities performed in the fabrication shop were reviewed to identify populations of work for which the documentation could be evaluated for implementation of this Action Plan. The documentation for safety-related component support assemblies was determined to be the most applicable for evaluation because these assemblies typically require a considerable amount of onsite fabrication / modification of piece parts and represent a major portion of the work performed in the onsite fabrication shop, i.e., ficup, welding, assembly, and inspection.
Documentation packages related to pipe hanger assemblies were identified to represent ASME Code fabrication activities and packages related to cable tray hangers were identified to represent the non-ASME safety-related activities.
5.2 Sample selection A sample of seventy-three (73) assemblies, subject to ASME Code, was selected primarily by reviewing the hanger request and memoranda files located in the CFSES onsite fabrication shop.
Each of the selected items represented fabrication / modification effort involving at least two (2) of the following groups of work activities:
a) Cutting of material and material identification
- transfer, b)
Tit-up and welding.
c) Machining, threading, bending, and other forming activities.
Of the seventy-three (73) ASME sample itema reviewed, the selection included approximately three (3) per calendar quarter over the period January 1981 through December 1985.
Fifteen (15) samples were selected for 1981.
Because of the liatted pipe hanger installation effort prior to 1981, only two (2) samples were reviewed for 1978, one (1) for 1979 and seven (7) for 1980. The easples for 1978 and 1979 were selected from the Action Plan V11.c populations because of the O
limited hanger request and memoranda files maintained by the i
fabrication shop for the 1978 and 1980 time-frame. The samples for 1980 were selected by reviewing a number of
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1 Page 11 of 40 ts RESULTS REPORT U
ISAP VII.b.1 (Cont'd) i.
5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) documentation packages in the Permanent Plant Records Vault (PPRV) and selecting those that represented a significant number of fabrication activities during that year.
The non-ASME sample items were selected by review of a data base printout maintained in the PPRV. The printout contained a listing of the cable tray hangers in numerical order and also identified the inspection records, including their dates of sign-off, that were included in the documentation packages.
Based upon the inspection sign-off dates, a total of eighteen (18) non-Code, safety-related cable tray hanger documentation packages was selected (three (3) per year from 1978 through 1983].
i 5.3 Procedure Requirements O
The historical files for the construction and inspection procedures used for the work activities being evaluated were initially subjected to a general "overall requirements" i
review based upon the requirements of 10CFR50, Appendix B and j
FSAR commitments.
j The review of inspection procedures included an evaluation of t
the evolution / maturation of procedural controls with time.
The criteria listed below were utilised for evaluating the procedurest j
Title with issue or effective date.
Listing of all applicable references.
t j
Complete purpose and scope.
i 6
Responsibility for implementation.
Identification of personnel qualification requirements.
Instructions (detailed instructions including delineation of required inspection points).
J Acceptance criteria for all inspected attributes.
[
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Processing of nonconforming attributes.
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1 Page 12 of 40 RESULTS REPORT ISAP VII.b.1
'(Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Documentation requirements.
(i.e.
How to fill out documents or otherwise record data or document the acceptance of an actribute inspected.)
Review and processing of records.
Referenced, and clearly defined use of attachments.
The results of the review are documented on checklists that are included in the Action Plan working file.
(Reference 9.11 A listing of the procedures reviewed is presented in to this report. Brown & Root construction procedures provided the criteria used by craft for fabrication and installation activities both in the fabrication shop and within the plant.
Inspection activities associated with component supports subject to ASME Code requirements were also governed by B&R procedures. TUGC0 procedures governed the O
inspection activities associated with non-ASME code sample items.
Following review of the historical procedures, a separate indepth evaluation was performed relative to the adequacy of the current construction and inspection procedures for the ASME Code (pipe hanger) and non-ASME Code (cable tray hanger) component supports. This evaluation was performed as a part of the indepth survey of current fabrication shop activities i
(discussed in Section 5.5 of this report) and utilized checklist criteria prepared specifically for that survey (Reference 9.2).
j Procedures Evaluation Results As reflected in Attachment 1, inspection requirements and I
accept /rejecg criteria for component supports were provided in a large number an'd variety of procedures. Many of these provided overlapping and differently stated requirements and criterial most underwent many modifications during the 1978 to 1985' time period. For example QI-qAP-11.1-20, (issue date i
January 3, 1980) was revised seven (7) times in 1980. As indicated in Attachment 2. QI-QAF-11.1-28. (issue date September 8, 1980) has been revised thirty-four (34) times and currently references twenty-one (21) different forms / documents with applicability to component support documentation i
packages, compared to only seven (7) required by earlier versions. Subsidiary procedures have similarly undergone i
numerous revisions.
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1 Page 13 of 40 RESULTS REPORT i
ISAP VII.b.1 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
In evaluating the results of the procedure reviews, the relative significance of the above criteria was considered.
Although inadequacies were identified in both the historical and current construction procedures, they were judged to be minor and would not adversely impact the performance of activities governed by the procedure.
l Inadequacies were also identified in both the historical and current inspection procedures. Most of the inadequacies were i
ainor and would not adversely impact the performance of inspection activities. However, many of the inspection procedures failed to provide adequate instructions for documenting the results of inspections. As a result, the i
documentation packages for component supports may not contain objective evidence that all required inspections have been performed and accepted. The documentation package review i
discussed in Section 5.4 confirms that this is the case.
The following are examples of the inadequacies identified in the primary governing inspection procedure employed by Brown &
j Root for the ASME Code sample items (QI-QAP 11.1-28).
}
Paragraph 3.4.3, Note 2 requires inspection verification of welder qualification and verification i
of weld filler material data between the WFML and the i
WDC, (Weld filler material los and Wald Data Card). No j
inspection instructions or provisions are included, however, for recording the inspection results.
The procedure does not address inspection nor does it provide criteria for the inspection of onsite fabricated U-bolts.
(Although TUGC0 inspection instruction QI-QP-11.14-1 addresses such inspection for their,non-ASME hardware, Brown & Root has no comparable l
procedures). The documentation packages assembled by Brown & Root contain no objective evidence for the inspection of U-bolts fabricated onsite.
l Paragraph 3.7.3 provides criteria for use by inspectors j
for verification of concrete anchor bolts length j
identification and die stamping. However, no instructions or provisions are included relative to j
documenting these inspections.
a Paragraph 3.4.4.7 addresses inspection requirements relative to " weep hole" verification; however, no j
instructions or provisions have been included for l
documenting the results of this inspection.
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1 Page 14 of 40 RESULTS REPORT ISAP VII,b.1 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
In addition, both the Brown & Root and TUGC0 procedures reflect inadequate compliance with the applicable B&R and TUGC0 internal requirements for the preparation, content and structure of procedures.
(Reference B&R CP-QAP-6.1 and CP-CPM-6.1; TUGC0 CP-QP-6.0)
For example, CP-QAP-6.1 requires that the reference section shall list the codes, standards, procedures, etc., that are referenced in the text.
Procedure QI-QAP-11.1-28. Revision 34 does not list the supporting procedures that are referenced in the text.
An evaluation conclusion is that the historical individual procedures lack procedural integration, i.e., the precedence / hierarchy of procedures is not clearly delineated within the procedures or by a " hierarchy of procedures" document. Many of the individual procedures lack full references to other applicable procedures, attachments and inspection forms.
Such references are necessary for ensuring O
the recording and compilation of consistently adequate inspection documentation.
The identified inadequacies described in the paragraphs above have been transmitted to the QA/QC Collective Evaluation Group for use in conjunction with their overview of the TUGC0 program for updating specifications, procedures and drawings as discussed in Section 7.0 of this report.
It should be understood that the procedure review did not evaluate the technical adequacy to ascertain the completeness of the overall inspection program or to determine the adequacy of the stated acceptance criteria or construction requirements. Such a detailed technical adequacy review is not within the scope of this Action Plan. The results of the Action Plan VII.c evaluation of the quality of construction indicate that technically inadequate construction and inspection procedures are the root cause or a contributing cause of some of the construction deficiencies and adverse trends identified by the VII.c reinspections/ documentation reviews.. See the Action Plan VII.c Results Report for the details of these findings.
l 5.4 Documentation Packase Review l
The inspection requirements information resulting from the review of Brown & Root and TUGC0 inspection procedures was used in developing a checklist for evaluating the onsite fabrication activities. This information, in conjunction with r
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1 Page 15 of 40 RESULTS REPORT 1
i ISAP VII.b.1 1
(Cont'd) i 5.0 IMPLEMENTATION.0F ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) i information from the applicable requirements of 10CFR50, i
Appendix B, ANSI N45.2; ASME Section III; Gibbs & Hill specifications 2323-MS-46A, ES-100 SS-16B and SS-17; and the j
commitments in Chapter 17 of the FSAR, provided criteria for j
assessing the adequacy of the documentation.
The documentation packages fcr the sample items were reviewed in accordance with the checklist. Where the package included j
references to other documentation such as receiving inspection records (RIR), inspection reports (IR) and nonconformance
+
reports (NCR) filed elsewhere, that documentation was also j
reviewed.
To perform the assessment of Brown & Root and TUGC0 compliance i
to procedural controls, it was necessary to review, extract l
and record information from a large number of forms and
)
inspection record sheets such as Material Identification Loss (MIL), Hanger Inspection Reports (HIR), Weld Filler Material Loss (WFML), Component Modification Cards (CMC),
Vendor-Supplied Component Modification Records (VSCMR), and Nondestructive Examination Reports (NDE). The types of review i
data extracted from these inspection forms and records are reflected on the individual checklists and data sheets i
l compiled for each of the documentation packages evaluated.
The individual checklists and data sheets have been retained and are included in the Action Plan working file.
(Reference 4
j 9.3]
Review of the documentation packages identified numerous deviations that'can be placed into either of two (2) categories - general or specific. General deviations are
- those that were prevalent-in a substantial number of sample items and reflect deviations of a procedural or QA prograa nature. General deviations were documented on Program l
Deviation Reportar (PDRs).
Specific deviations are those i
associated with specific component support assemblies or items and concern missing data, undocumented traceability of l
asterial, indeterminate inspector certifications or welder qualifications, etc..
The specific deviations were documented on Construction Deviation Reports (DRs). Descriptions of both the general and specific deviations identified during the implementation of this Action Plan are. included in Attachments 1
3 and 4 to this report. Summaries of these deviations are l
provided later in this section.
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1 Page 16 of 40 RESULTS REPORT ISAP VII.b.1 (Cont'd) 5.0 IMPLEMENTATION 0F ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
The matrix in Attachment 5 to this report presents a summary of the numbers and types of deviations found in each of the sample items.
The deviations are tabulated by attributes that correlate to the more detailed attribute criteria provide 1 in the Action Plan checklist developed specifically for review of the sample items.
During the records review, no attempt was made to evaluate the significance of the individual deviations, i.e., obvious transposition errors were documented and counted as heavily as were errors of omission. Following the Action Plan documentation review, however, each of the specific deviations was evaluated and classified as to its potential effect on the hardware. A listing of the specific deviations and definitions of the assigned classifications of
" insignificant", " notable", and "significant" are given in.
It should be noted that the definitions and usage of these classifications are unique to the deviations O
identified by this Action Plan.
The number of discrepant / questionable data points varied from none in six (6) of the sample packages to as many as twelve (12) in one sample package.
In general, about two (2) discrepant / questionable data point entries were found in typical sample items.
The number of inspection points varies from sample item to sample ites depending on hardware complexity, procedural maturity and hardware rework. Also, because of the sample selection criteria employed, the Action Plan sample items likely involved "above average" amounts of onsite fabrication
~
and fabrication-related activities.
In order to provide a perspective of the number of errors versus the number of opportunities for error, a review of a typical sample documentation package from each of four (4) time periods was made. This review, while not comprehensive, indicates that the number of opportunities for error varied from forty-nine (49) in the earlier time period to four hundred thirty-four (434) in the later tima period, while the number of errors remained relatively constant at about two per package.
O The ratio of the number of data point deviations versus the number of opportunities for error found in the documentation packages declined, in general, for the ASME Code assemblies fabricated / modified during the latter years covered by this
Revision:
1 Page 17 of 40
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RESULTS REPORT ISAP VII.b.1 (Cont' d) 5.0 IMPLEMENTATION 0F ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) evaluation. The decline in deviations (despite the increasing number of opportunities for making data entry errors because of added requirements), is most likely attributable to experience gained with applicable hardware items and procedures.
Review of Related Records Welder Qualification The qualification status of all welders who performed the onsite welding recorded in the sample item documentation packages was reviewed to verify qualification in applicable weld processes on the dates identified for the welding activities. The review was limited to verifying that the correct qualification codes for the applicable weld processes were recorded O
on the weekly Walder Qualification Matrix (WQM) for the dates identified. The use of the Welder Qualification Matrix was considered acceptable based on the ISAP VII.a.8 Issue Coordinator's evaluation of its accuracy.
t No discrepancies related to welder qualification were identified during the evaluation of the seventy-three (73) sample items subject to ASME Code requirements.
However, appropriate welder qualification records could not be located for several of the welders of record who performed welding activities on eight (8) of the non-ASME Code cable tray hanger sample items. A Construction Deviation Report (DR) was written to document the questionable welder qualification status relative to the identified sample items.
[ Reference DR No. R-VII.b.1-EGEN-DR31.]
Inspectors and NDE Personnel Certification The certification status of all QC inspectors who had performed or signed off inspections on the sampled records (repair records, hanger inspection reports, material identification logs, NDE reports, etc.) was reviewed by reference to personnel certification files.
A comparison was made to determine if the personnel had been certified in appropriate disciplines / procedures prior to performing inspections or examination activities.
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1 Page 18 of 40
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RESULTS REPORT ISAP VII.b.1 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
As reflected in Attachment 5 to this report, a total of forty-four (44) of the documentation packages contained records of inspections performed / recorded by individuals for whom evidence of proper certification could not be located.
Construction Deviation Reports were initiated to document the questionable certification status of the inspectors for whom evidence of appropriate certification could not be located. These DRs have been reviewed and validated by the ISAP I.d.1 Issue Coordinator, in accordance with QA/QC Review Team procedures.
The I.d.1 evaluation of the inspectors identified on these DRs has indicated that the qualifications of five (5) inspectors were questionable. Four (4) of these
()
five (5) had previously been identified as requiring Phase III evaluation through ISAP I.d.1.
Their work has been evaluated under Phase III of the I.d.1 Action Plan and was found to be acceptable. The work of the remaining individual will also be evaluated under Phase III of ISAP I.d.1.
The results will be reported through'the Collective Evaluation of the Construction QA/QC Program.
Summary of General Deviations The general deviations identified during evaluation of the documentation packages involved a lack of thorough procedural definition of the inspections required and/or inadequate documentation of the inspections performed. These general deviations were documented on QA/QC Program Deviation Report No. 38 for the ASME Code sample items (B&R responsibility) and on QA/QC Program Deviation Report No. 39 for the non-ASME sample items (TUGC0 responsibility). The general deviations identified during this evaluation are described in Attachment 3 to this report. The most important general deviation concerns the lack of objective evidence relative to inspection of threading and bending operations. Such operations were performed during onsite fabrication of U-bolts used for component supports subject to ASME Code requirements.
The O
remaining general deviations identified in the documentation packages and described in Attachment 3, while not acceptable from a QA record standpoint, have a low potential to adversely impact the adequacy of the hardware. A summary of these general deviations is provided below:
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1 Page 19 of 40 RESULTS REPORT ISAP VII.b.1 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULT 3 (Cont'd)
No. of Packages Exhibiting Description of Deviation the Deviation a.
No evidence that inspections were 78 performed, e.g., site threading /
bending, Hilti bolt die stamping.
b.
Inadequate / inconsistent information, 14 e.g., references, material identifi-cation data.
c.
Insufficient data / missing records, 84 e.g., missing data entries, lack of information relative to inspector identification, type of observations, results.
d.
Illegible records, improper data 20 corrections, incomplete identification of records to items.
Summary of Specific Deviations The specific deviations are listed in Attachment 4 to this report and are classified as " insignificant", " notable" or "significant" relative to their potential effect on the hardware. Definition of these classifications is given in.
It should be noted that several of the sample ites documentation packages contained multiple deviations that fall into separate classifications or levels of significance. The specific deviations were documented on a total of thirty-two (32) Construction Deviation Reports, which were processed iti accordance with CPRT procedures. When necessary to confirm or resolve the deviation and aid in the safety significance evaluation, the hardware tras examined in place. The following is a summary of the data presented in :
O
Revision:
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RESULTS REPORT ISAP VII.b.1 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
NOTE:
Some DRs identify problems with multiple sample items, therefore, there is not a direct correlation between the number of DRs and number of deviating sample items.
Category Number of Number of Number of Number of of Deviating Insignificant Notable Significant Deviation Sample Items Deviations Deviations Deviations
- Traceability 31 10 20 5
Questionable Inspector Certifications 44 0
44 0
Walder Qualification 8
0 0
8 Missing Documentation i
1 0
0 1
Documentation Conflict 2
1 1
0 In view of the number of deviations identified during this Action Plan evaluation, an evaluation was performed relative to the adequacy of the procedures and practices employed i
during the current QA review of inspection records prior to placing them in the vault as permanent plant quality records.
Although excellent procedures have been established for this
- effort, e.g., CP-QAP-12.1, it was noted that the procedures i
were not being consistently implemented. Attachment 3 to l
CP-QAP-12.1 provides a comprehensive checklist for assuring consistency and completeness of documentation packages. The evaluation revealed, however, that not all of the reviewers utilized the checklist. Although the reviewers have been provided with training in the procedure, it was found that the i
reviewers were not consistent in its interpretation nor in the utilization of ancillary review tools, e.g., heat number logs.
i The material traceability deviations have been provided to the Action Plan VII.a.1 Issue Coordinator for evaluation and action as iO appropriate.
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RESULTS REPORT l
4 ISAP VII.b.1 (Cont'd) 5.0 IMPLEMENTATION'0F ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
The results of this particular evaluation and the substance of j
the findings were discussed thoroughly in meetings with cognizant Brown & Root supervisory representatives.
Commitments were made that additional training and supervisory overview would be provided for the documentation package review activities.
Implementation of these commitments will preclude recurrence of the substantial number and types of documentation deviations identified during the Action Plan evaluations.
Two out-of-scope observation reports were initiated during this review. The first report concerns the probability that some of the hanger saddles installed on safety-related pipe were processed by a vendor who was not on the Approved Suppliers List during the timeframe in which this processing occurred. This item was documented as an out-of-scope observation because the information was found during review of O
a Receiving Inspection Report (RIR) not applicable to hardware in the sample documentation package undergoing review. The i.
second out-of-scope observation concerns the lack of inspection criteria for component support snubber and low friction bearing plate installations, which was noted in early revisions of QI-QAP-11.1-28.
Evaluation indicates that the present procedure provides adequate instructions relative to these installations.
Inspection criteria were added by Revision 4 of the procedure (12/8/80).
Snubber installation appears to have started in early 1981. This out-of-scope report was initiated to determine the significance, if any, of this omission in the inspection procedure during the early timeframe of component support installations.
Both of these out-of-scope observations have been forwarded to the QA/QC Review Team Hardware Collective Evaluation Engineer for processing in accordance with CPRT procedures.
In addition, the first report was also transmitted to the Issue Coordinator for Action Plan VII.a.9, Receipt and Storage of Purchased Material and Equipment, for information and actiipn as appropriate.
5.5 Results of Indepth Survey of Currently Ongoing Fabrication Shop Activities O
In order to evaluate the issues / concerns identified by NRC letter January 8,1985, Issue 8. Onsite Fabrication and CPSES Safety Evaluation Report Supplement No. 11, an indepth survey of present fabrication shop activities at CPSES was performed.
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RESULTS REPORT ISAP VII.b.1 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
The survey of current fabrication shop activities consisted of three (3) parts:
- Evaluation of current shop and inspection procedures versus applicable 10CFR50 Appendix B criteria, Verification of the implementation of defined i
procedural controls, and Evaluation of current fabrication shop activities relative to the specific elements of the External Issues identified in the USNRC Letter, January 8, 1985, Issue 8 and SSER 11, Appendices 0 and P (see Sections 1.0 and 3.0 above).
The checklist developed for the survey defines the specific criteria and elements evaluated / verified.
[ Reference 9.2]
The overall results of the survey indicated that the Brown &
Root implementation of the defined procedural controls currentlyappjicabletofabricationshopactivitieswasvery good. The applicable construction procedures were posted on a large display >oard in the fabrication shop. Supervision and craft personndt were knowledgeable of these procedures.
No procedural imptlementation deficiencies or documentation discrepancies were identified during the survey of current fabrication shop activities and the review of in-process documentation in the shop.
An indepth evaluation of the current Brown & Root and TUGC0 procedures for controlling the onsite fabrication and inspection activities revealed only minor inadequacies.
Except for a lack of sufficient detail for inspection and documentation of onsite threading and bending activities, the composite of these procedures meets the requirements of 10CFR50, Appendix B and FSAR commitments. As previously discussed in Section 5.3 of this report, however, several of s
the procedures are not in full compliance with the Brown &
4 Root and TUGC0 internal requirements for the structure and content of procedures.
The evaluation of current activities relative to the 0,
identified external issues revealed that the currently implemented controls effectively address these issues. There were no discrepancies noted relative to any of the identified external issues / concerns.
Rsvision:
1 Page 23 of 40 RESULTS REPORT ISAP VII.b.1 (Cont'd) 5.0 IMPLEMENTATION 0F ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.6 Compliance With 10CFR50, Appendix B and FSAR Conunitments The discrepancies identified through implementation of this Action Plan reflect a number of failures to comply fully with the applicable criteria of 10CFR50, Appendix B, and FSAR Commitments. Basec' on the reviewr Performed, the historical documentation of onsite fabrication activities fails to consistently provide:
Details necessary to permit complete confirmation of a.
acceptable inspection activities, i
l b.
Documented acceptance of item or activity by authorized personnel.
c.
Completely legible, accurate records of work accomplished.
d.
Identification of the person (s) recording the data and approving the inspection results.
Materials traceability information.
e.
The PDRs identify discrepancies in documentation packages that represent activities performed in the past. With the exception of the procedural inadequacies discussed in Section 5.3 of this report, the current program provides adequate l
control of onsite fabrication activities.
Althcush the PDRs document a number of past failures to
(
implement FSVL commitments consistently, it is concluded that i
corrective action can be accomplished without the need for a substantive revision of the current program. The evaluation effort recommended in Paragraph 5.9 is not considered to be extensive.
l The QA/QC Program Deviations were evaluated to determine if l
the PDRs should be classified as QA/QC Program Deficiencies.
In accordance with the CPRT Program Plan, Appendix E, a QA/QC Program Deficiency is defined as a deviation meeting one or more of the following criteria:
Inadequacy of a QA/QC program element such that
' g substantive revision of the program or other corrective action is required to bring it into compliance with the regulatory requirements, FSAR coimaitments or other licensing commitments; or L
Revision:
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RESULTS REPORT
~
ISAP VII.b.1 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Extensive evaluation would be required to determine the effect on the quality of construction.
Based on the above definition, the deviations documented on the PDRs do not meet the criteria for classification as QA/QC Program Deficiency. Therefore, the deviations described in the Program Deviation Reports are not considered to be QA/QC Program Deficiencies.
5.7 Trend Analysis Documentation deviations were found to be present in sixty-seven (67) of the seventy-three (73) "ASME Code" documentation packages and in each of the eighteen (18) non-ASME item documentation packages reviewed during implementation of this Action Plan. This was determined to constitute a trend and an analysis was performed in accordance
()
with Appendix E of the CPRT Program Plan.
[ Reference 9.4]
The deviations identified during this evaluation involved three types of errors:
- 1) clerical errors and omissions such as dates, drawing and procedure revision numbers, etc.; 2) questionable inspector certifications and welder qualifications (non-ASME); and 3) inadequate data / documentation to establish material traceability and no evidence of inspection of site fabrication of U-bolts or marking of Hilti bolts (ASME only).
i The number of deviations in each of these three categories (see Attachment 5) make it likely that similar deviations exist in the remainder of the component support documentation packages. Consequently, an evaluation of the potential for safety significance was made.
In the first category (Attributes 1-5.. Attachment 5), the deviations are not acceptable from a QA records standpoint, but are insignificant with regard to potential for adverse impact on the hardware.
Similar deviations in the remainder of the population would also be insignificant with respect to hardware impact.
In the second category (Attributes 6 & 7, Attachment 5),
instances of questionable inspector certifications have been referred to the Action Plan I.d.1 Issue Coordinator for evaluation. The results of this evaluation and corrective action if required, will be reported in the Collective Evaluation report. The deviations for welder qualification in the non-ASME sample items have all been evaluated to be
Revision:
1 1
4 Page 25 of 40 1
I
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RESULTS REPORT ISAP VII.b.1 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) insignificant with respect to impact'on hardware.
In each case, alternate documentation was available to verify qualification. Action Plan VII.c also identified instances of questionable welder qualifications that were resolved through the use of alternate documentation. Therefore, it is probable that alternate documentation for welder qualification would exist for similar deviations in the remainder of the population.
In the third category (Attributes 8, 9, & 10, Attachment 5),
each deviation was considered to be either notable or significant relative to a potential adverse impact on the hardware. However, each was subsequently determined to have no safety-significant effect on the hardware.
In the case of i
site-fabricated U-bolts, the acceptability of U-bolts was said i
by B&R QC to be verified as part of the final installation
]
inspection. However, this is not stated in the procedure nor separately documented. Observation of bending and threading i
operations in the fabrication shop indicates that craft applied controls provide a high degree of confidence that U-bolts are acceptable. Additionally, there were no deviations involving site-fabricated U-bolts identified by the Action Plan VII.c reinspections. Consequently, it is considered that the lack of specific inspection / documentation for site-fabricated U-bolts is unlikely to have a safety-significant effect on the hardware.
In the case of Hilti bolts, the procedure requires verification of " star stamp" marking of Super Kwik type Hilti bolts; but no provision is made for documenting this verification. As a result of an NRC inspection, TUGC0 has initiated Corrective Action Requests (CARS) 58 and 74 to verify the correct marking and usage of Hilti Super Kwik i
bolts. The QA/QC Review Team considers this ites to be adequately addressed by these CARS.
In the cases of asterial traceability problems, field i
observation or the location of missing / alternative documentation confirmed that acceptable material was used.
In each case the deviation was determined to have no safety-significant hardware effect on the sample items. This indicates that similar deviations in the remainder of the population would also have no safety-significant hardware effect. However, insufficient data is available to allow a final conclusion. Therefore, the deviations and information i
regarding asterial traceability problems have been referred to I,
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l Revision:
1 Page 26 of 40 RESUI.TS REPORT ISAP VII,b.1 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) the Issue Coordinator of Action Plan VII.a.1, " Material Traceability", for information and action as appropriate. An evaluation of the potet?.ial for safety-significant hardware impact of material traceability deviations will be made by that Action Plan.
Based on the above, the QA/QC Review Team concluded that the deviations identified in onsite fabrication records do not constitute an " adverse trend" as defined by Section 5 of Appendix E of the CPRT Program Plan. Therefore, root cause and generic implication analyses were not performed.
5.8 Root Cause and Generic Implications In accordance with the CPRT Program Plan, root cause and generic implications evaluations are not required since no deficiencies or adverse trends were identified.
Conclusions relative to the deviations identified by this Action Plan and the findings of Action Plan VII.c will be made through the Collective Evaluation of the Construction QA/QC Program and the Collective Evaluation of the Quality of Construction.
5.9 Recommended Corrective Action I
The Engineer should perform an analysis to confirm the acceptability of the safety-related component support installations.
Based on the substantial number of deviations identified, the status of the documentation is indicative of a deviation from specification requirements. The analysis j
should be made with specific emphasis on the effect of inadequate inspection and material traceability documentation.
The deviations identified during the implementation of this Action Plan were determined to have no safety-significant hardware effect. However, Action Plan VII.c identified several deviations within component support sample items that were determined to be construction deficiencies. Accordingly, the Engineer should consider the deviations identified by both of these Action Plans in performing the above analysis to confirm the acceptability of safety-related component supports.
Ravision:
1 Page 27 of 40 RESULTS REPORT ISAP VII.b.1 (Cont'd)
6.0 CONCLUSION
S The implementation of this Action Plan evaluated each of the NRC-TRT findings regarding past onsite fabrication shop activities and the NRC conclusions thereto. An indepth survey and evaluation of present activities relative to the identified issues / concerns revealed no discrepancies. Although inadequacies relatable to the NRC-TRT findings and other external source issues were identified in the historical procedures and the QC records evaluated, it was concluded that currently implemented controls in the fabrication shop ef fectively address these issues and concerns.
Because Action Plan VII.a.8, Fuel Pool Liner Documentation, identified a large number of documentation deviations resulting-from failure to implement procedures and the lack of definitive procedural direction, this Action Plan was expanded to evaluate onsite fabrication activities, in general, whether performed in the fabrication shop or other plant areas. Although deviations similar to those identified by Action Plan VII.a.8 were identified in the sample packages that were evaluated, determinations were made that O
none of the deviations resulted in a safety-significant effect on the hardware represented by these documentation packages.
The fabrication shop is under the direction of Brown & Root.
Construction and inspection activities in the fabrication shop and other plant areas are governed by Brown & Root and TUGC0 procedures which have evolved over the seven year time period encompassed by this review. The review of procedures, forms and documentation packages indicates that the construction methodology and details were understood. However, the applicable inspection requirements were conveyed in numerous procedures that provide overlapping and differently stated requirements and criteria.
These procedures were frequently changed, and implementation of the procedures was inadequately supervised.
The above factors 4 coupled with a lack of detailed guidance within individual procedures'(relative to data entries, cross-references to other applicable procedures, etc.), contributed to inconsistency and gaps in the documentation of inspection results.
In turn, the lack of appropriate supervisory overview and timely QA monitoring of the inspection records resulted in the placement of unsatisfactory QA documentation in the permanent plant records.
Thirty-two (32) Deviation Reports and two (2) QA/QC Program Deviation Reports were issued to document the deviations identified O
through implementation of this Action Plan. Most of these deviations were identified in the historical documentation packages. These deviations confirm the NRC-TRT findings concerning
~ _ _ _
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RESULTS REPORT ISAP VII.b.1 (Cont'd) j
6.0 CONCLUSION
S (Cont'd) past procedural inadequacies and implementation problems relative to management and inspection controls of onsite f abrication 4
activities. The deviations described in these reports have been j
evaluated and determined to have no safety-significant hardware effect on the component support systems.
As described above under the summary of general deviations. Brown &
Root and TUGC0 procedures have been established for ensuring the l
adequacy of inspection records in completed documentation packages, t
Effective implementation of these procedures will assure that complete and acceptable documentation packages are maintained for safety-related component supports.
i l
7.0 ONGOING ACTIVITIES 4
TUGC0 is presently implementing a Hardware Validation Program for
'O pipe supports and a Field Verification / Design Adequacy Verification Program for cable tray supports.
These prograss are applicable to Unit 1 and Common areas; and appear to be adequate to demonstrate the acceptability of the hardware. The documentation resulting from these programs will resolve the documentation deviations, with j
the exception of material traceability deviations.
The material traceability deviations identified during this evaluation have been l
referred to the Action Plan VII.a.1 Issue Coordinator for information and evaluation. TUGC0 is presently developing a Specification, Procedure, and Drawing Update Program that should, i
when effectively implemented, resolve the identified procedural i
inadequacies. The deviations and corrective action recommendations relative to the procedural inadequacies identified during this evaluation have been coordinated with the Collective Evaluation Group for integration into their overview of this update task effort.
8.0 ACTION TO PRECLUDE OCCURRENCE IN THE FUTURE Fabrication, installation and inspection of the component support and other safety-related systess is still in process. Brown & Root and TUGC0 implementation of documentation review procedures, as previously discussed under " Summary of Specific Deviations", will preclude recurrence of the number and types of documentation O
deviations identified during the Action Plan evaluation, l
\\
l _ _ _ - - - _ -.. _ _ _, _ _ _ _ _. _. _.. ~. _ -
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1 Page 29 of 40 RESULTS REPORT ISAP VII.b.1 i
(Cont'd) r
9.0 REFERENCES
I 9.1 ISAP VII.b.1, File #3 Procedures Review
(
9.2 ISAP VII.b.1, File #4E Survey Checklist i
l 9.3 ISAP VII.b.1, File #4b Record Review 1
9.4 ISAP VII.b.1, File #6B Trend Analysis I
I I
4 l
i i
i 4
II i
i I
i l
l l
l l
l 1
l
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Revision:
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RESULTS REPORT ISAP VII.b.1 (Cont'd)
Procedures Reviewed During the Implementation of ISAP VII.b.1 CP-CPM-6.9 General Piping Procedure i
Appendix 6.9B Welding Filler Material Control 1
Appendix 6.9C Material Identification Appendix 6.9D Welding and Related Processes Appendix 6.9E Pipe Fabrication and Installation Appendix 6.9G Documentation for ASME Welding, Fabrication and Installation Activities Appendix 6.9H Cleanliness Control
()
Appendix 6.91 Pressure Testing CP-CPM-7.3 General Fabrication Procedure CP-CPM-7.3B Fabrication of ASME Component Supports CP-CPM-7.3D Welding and Related Processes J
CP-CPM-9.10 Component Support Installation 1
CEI-20 Installation of Hilti Drilled-In Bolts 1
CP-NDEP-200 Visual Inspection Structural Weldsents s
CP-QAP-8.1 Receiving Inspection CP-QAP-8,5 Reclassification of Code Material CP-QAP-12.1 Mech. Component Installation Verification, N-5 Certification CP-QAP-16.1 Control of Nonconforming Items I
j QI-QAP-10.1-20 Component Support Inspection Criteria
. ~.,
. _ _ _ _ = - _.
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RESULTS REPORT ISAP VII.b.1 (Cont'd)
(Cont'd)
QI-QAP-10.2-4B Ultrasonic Examination of Hilti Bolts QI-QAP-11.1-5 ASME Section III Traceability Requirements i
QI-QAP-11.1-20 Component Support Inspection Criteria QI-QAP-11.1-26 Pipe Fabrication and Equipment Installation Inspections QI-QAP-11.1-28 Installation Inspections of ASME Component Supports, Class 1, 2, & 3 i
QI-QAP-11.1-28A Installation Inspections of ASME Class 1, 2, and 3 Snubbers QI-QAP-11.2-28 Fabrication and Installation Inspection of Safety Class Component 1
Supports QI-QP-11.0-15 Verification of Base Plates for Grouting QI-QP-11.3-2 Cable Tray and Conduit Ranger Inspection QI-QP-11.10-2 Cable Tray Hanger Inspection QI-QP-11.14-4 Control of Material Traceability for j
Site Fabricated Structural / Miscellaneous Steel i
QI-QP-11.21-1 Requirements for Visual Weld Inspection i
l QI-QP-16.0-5 Reporting of Base Metal Defects CP-QP-15.0 Tagging System CP-QP-16.0 Nonconformances
()
CP-QP-18.0 Inspection Report l
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RESULTS REPORT ISAP VII.b.1 (Cont'd)
QI-QAP-11.1-28 Revision History Ql-QAP.11.1 28 I
A B
C D
E F
G H
I J
K L
M N O P Q S
T U
REVISION & lSSUE DATE Rev.34 11 20-85 e
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e Rev. 33 08 29-85 e
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e Rev.30 0415 85 e
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e Rev.29 01-25-85 e
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Rev. 28 12-06-84 e
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Rev. 27 11-15-84 e
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Rev. 26 10-18-84 e
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e Rev. 25 06-11-84 e
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e Rev. 24 0418-84 e
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e Rev. 23 10-24-83 5
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e Rev. 22 08-04-83 e
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Rev. 21 06-29 83 e
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Rev. 20 0516-83 e
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Rev.19 0412 83 e
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Rev.18 03-31-83 e
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Rev.17 02-02-83 e
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Rev.16 12-15-82 e
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e Rev.15 10-29-82 e
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Rev.13 09-21-82 e
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Rev.12 09-03-82 e
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Rev.11 07-21-82 e
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l Rev.10 06-12-82 e
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Rev.09 03-1182 e
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Rev.08 01-15-82 e
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Rev.07 05-28-81 e
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e Rev. 06 06-18-81 e
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e Rev. 05 01-07-81 e
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e Rev. 04 12-08-80 e
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e Rev. 03 10-03-80 e
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g Rev.02 09-15-80 e
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j Rev. 01 09-11-80 e
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l Rev.00 09-08-80 e
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(Cont'd) t l
I Document code for table on previous page.
A. - Material Identification Log.
B. - Hanger Inspection Report.
C. - Weld Filler Material Log.
D. - Weld Data Card.
E. - Multiple Weld Data Card.
F. - Component Modification Card.
G. - Nondestructive Examination Reports.
H. - NF-1/NF-2 Forms.
I. - Material Requests.
J. - Vendor Supplied Component Modification Record.
K. - Inspected Item Removal Notice.
L. - Structural Assembly Verification Card.
M. - Manufactures Record Sheet.
N. - Construction Operations Traveler.
O. - Repair Process Sheet.
P. - Vendor Certified Drawing / Design Reviewed Drawing.
Q. - Component Support Drawings.
R. - Typical Inspection Drawings.
S. - Vendor Supplied Code Date Report.
T. - Vendor Supplied Material Report.
U. - Certified Material Test Report / Certificate of Conformance.
- ~. - - -
5 Revision:
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Page 34 of 40 RESULTS REPORT
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ISAP VII.b.1 (Cont'd) i i
1
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General Deviations 5
PDRs 38 and 39 address deviations of a procedural or QA Program nature that were common to a substantial number of the QA records of the ASME Code and non-ASME safety-related sample items. PDR 38 documents the general deviations of this nature identified in the ASME Code QA records (Brown & Root responsibility) and PDR 39 addresses those identified in 4
the non-ASME sample records (TUGC0 responsibility).
j The PDRs both provide examples, as summarized below, of identified i
deviations from the requirements of: a) 10CFR50 Appendix B, Criterion XVII, Quality Assurance Records
" Sufficient Records shall be maintained to furnish evidence of activities affecting quality," and b)
ANSI N45.2.9-1974, Paragraph 2.3.1 "...such quality assurance records shall be legible, completely filled out and identifiable to the ites...".
- O Of the ninety-one (91) documentation packages evaluated, seventy-eight (78) lacked objective (verifiable) evidence that l
certain detailed fabrication operations were independently l
inspected by QC as required by applicable code, specification, or procedure. Although inspection requirements had been established I
for most of the operations in question, provisions / instructions for documenting the results of these inspections were either inadequate or lacking.
Fourteen (14) of the sample iten documentation packages contained inspection records with inadequate / inconsistent information, e.g.,
inspection records referenced by a data entry or necessary to j
amplify information relative to a data entry were not available in j
the permanent plant records, data necessary for establishing or re-establishing materials traceability were available only in records maintained in personally held employee files, etc..
Eighty-four (84) documentation packages were found to have missing records; improperly completed data entries; inspection records that lacked sufficient information to establish inspector or data i
recorder identification, type of observation, applicable procedure l
l and/or revision level; and/or lacked sufficient information to l
identify the inspection results clearly.
i Twenty (20) of the inspection record packages contained illegible inspection records or data point entries, records that did not list
{
l the date of inspection, reflected improper corrections or lacked sufficient information to identify the action taken for nonconformances.
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Revision:
1 Page 35 of 40
()
RESULTS REPORT ISAP VII.b.1 (Cont'd)
Specific Deviations Potential Effect DR Number Description of Deviation On Hardware R-VII.b.1-16-DR-01 Traceability of a BOM (Bill Insignificant 3
of Material) item is in question due to documentation inconsistencies.
R-VII.b.1-01-DR-02 Traceability for itema listed Notable on a Manufacturing Record Sheet is listed as "N/A", (with a cross-reference to an inspection report).
R-VII.b.1-04-DR-03 Traceability of a BOM item to a Insignificant specific heat number is in question.
(Three possible heat numbers, all traceable, are a
identified).
1 R-VII.b.1-05-DR-04 Traceability to a specific heat Insignificant j
number is not possible. Two heat numbers, both traceable, are identified.
j R-VII.b.1-05-DR-05 No traceability for BOM item 10.
Significant l
R-VII.b.1-12-DR-06 Heat number discrepancy between Insignificant two documents.
R-VII.b.1-14-DR-07 No traceability to the MIC number Notable listed for the snubber barrel installed on this assembly.
R-VII.b.1-17-DR-08 No traceability to the heat Insignificant number listed for tube steel installed on this assembly.
R-VII.b.1-18-DR-09 No traceability to the MIC Notable number listed for BOM item Number 7 for this assembly.
O
__.--_._._--_--.-_.,,,-.,.-,*,y
,.m,c, p,,,
y y
u.__9m.p.
y-.,
,_.p y-,,_m..,,
,sy,
- ,_.pp,
-m,
-w9,,
y-,
e.p
4 I
t Revision:
1 Page 36 of 40 l
RESULTS REPORT ISAP VII,b.1 (Cont'd) i (Cont'd)
Potential Effect DR Number Description of Deviation on Hardware R-VII.b.1-19-DR-10 Traceability for BOM items Notable in question due to documentation i
inconsistencies.
i R-VII.b.1-19-DR-11 Traceability for eye rod in Notable question due to documentation j
inconsistencies.
R-VII.b.1-24-DR-12 No traceability for U bolt Insignificant installed on this assembly.
R-VII.b.1-32-DR-13 No traceability for BOM itea significant 24 (eye rod).
R-VII.b.1-40-DR-14 fraceability for BOM ites 17 Notable in question due to documentation inconsistencies.
R-VII.b.1-42-DR-15 No traceability for BOM items Significant 17 and 12.
i i
R-VII-b.1-43-DR-16 No traceability for B0M item 10.
Significant i
R-VII.b.1-45-DR-17 No traceability for BOM ites 7.
Notable L
1 R-VII.b.1-48-DR-18 Traceability for BOM ites 1 is Insignificant in question.
R-VII.b.1-53-DR-19 Traceability for BOM items 19, 22 Insignificant and 28 in question due to
' documentation inconsistencias.
j R-VII.b.1-61-DR-21 No traceability for BOM item 3.
Insignificant i
R-VII.b.1-73-DR-23 Certifications do not reference Insignificant the code class of asterial for BOM ites 1.
(Heat number is available and traceable),
i!O i
1
-, - - - - - - > ~ -., - - -. ~, -.. -.. - -.
,,,_n-.--_-,- - -
r.,,v-m,,-mm,an,,--e
--.-.n m
e g a,-- g n---,,m.-,n,s-~m--,----nn,-
,.w,.w,,.
~ _ _ -. _ - -
~ _...
= _ _. = -.
Revision:
1 Page 37 of 40 RESULTS REPORT ISAP VII.b.1 (Cont'd)
(Cont'd)
Potr.tial Effect DR Number Description of Deviation Un Hardware R-VII.b.1-02-DR-24 Design documents conflict *:ith Notable "as-built" shia sizes; irspection documents which accepted these shias are also in conflict.
j n-VII.b.1-15-DR-25 No traceability for BOM ites 27.
Significant R-VII.b.1-45-DR-26 Traceability for BOM item 16 is Insignificant in question due to identification 4
of two heat numbers (both traceable).
R-VII.b.1-41-DR-28 No traceability for BOM item 19 Notable due to failure to record data.
1 3
R-VII.b.1-45-DR-29 Traceability for BOM ites 7 is Notable
{
in question.
R-VII.b.1-EGEN-DR-30 Material traceability information Notable l
is inadequate for eleven (11) cable tray hatser assemblies.
R-VII.b.1-EGEN-DR-31 Felder qualification records not Significant available for welders of record for eight (8) cable tray hanger assemblies, l
R-VII.b.1-EGEN-DR-32 Inspector certification records Notable j
not avail.able for dates certain inspections were performed on j
' cable tray hanger assemblies.
R-VII.b.1-GEN-DR-33 Inspector certification records Notable l
and not available for dates certain R-VII.b.1-48-DR-34 inspections performed on ASME Code pipe hanger assemblies.
R-VII.b.1-30-DR-01 Missing records in pipe hanger Insignificant documentation package.
Records do not reflect that hanger has been voided and is no longer installed.
Revision:
1 Page 38 of 40 0
RESULTS REPORT ISAP VII.b.1 (Cont'd)
(Cont'd) 1 Definition of Classifications:
Insignificant: Deviations that are primarily obvious documentation O
errors with a negligible potential to adversely affect the acceptability of the hardware. Example: Material not traceable to a specific heat number but is traceable to one of three heat numbers, all of which are acceptable material.
Notable:
Deviations that have a moderate potential to adversely affect the acceptability of the hardware. Example:
Lack of traceability of components salvaged from previously accepted vendor-supplied supports.
Significant:
Deviations that make the acceptability of the hardware indeterminate without additional evaluation.
Example:
Lack of traceability of bulk materials such as plate, tube steel, etc..
(These classifications are unique to the deviations identified by this Action Plan.)
O
l I
Revision:
1 Page 39 of 40 RESULTS REPORT ISAP VII b.1 (Cont'd)
Attribute Deviation Matrices ISAP VII,b.1. Results Report - Attachment #5 Sheet 1 of 2 Attribute deviation frequency per year for ASME Code samples 1
2A 28 2C 20 3A 38 3C 30 3E 3F 3G 4
5 6
7 8
9 10 Total 1978 -1980 3
0 0
0 1
0 1
1 2
2 0
10 2
0 4
0 4
0 5
35 1981 6
0 1
0 2
0 1
1 1
1 1
11 4
1 7
0 9
10 9
64 1982 2
0 0
0 0
0 0
0 0
0 0
4 2
0 9
0 1
8 5
31 1983 3
0 3
0 1
0 1
0 1
1 1
3 1
0 5
0 8
6 7
41 1984 1
1 1
0 0
0 1
0 0
1 0
3 1
0 1
0 1
2 8
21 1985 1
0 0
0 0
0 0
0 0
1 1
3 0
2 3
0 1
5 6
23 Total 16 1
5 0
4 0
4 2
4 6
3 34 10 2
29 0
24 31 40 215 Attributes :
1 -1s the procedurally required documentation for operations performed present ?
2A - Are all required entries legible ?
28 - Are all entries completed appropriately ?
2C - Are all operations signed off in correct sequence 7 20 - Are all corrections / changes properly performed and annotated ?
- 3. -Do allinspection recordsidentify ?
A -ltemsinspected.
8 -Date ofinspection.
l C -inspector.
l 0 -Type of observation.
E -Resultsoracceptabil,ity.
1 F - Actions for nonconformatices.
l G - Drawing, Specification, Procedures and revision levels.
4.
- Are all entries on related documents consistent ?
- 5. - Are all required inspections complete and acceptable ?
- 6. -Inspector Certifications.
- 7. -Welder Qualifications.
- 8. -MaterialTraceability.
- 9. -Site fabrication of threads and bending operations.
- 10. -Marking of Hilti's.
1
s Revision:
1 Page 40 of 40 0
RESULTS REPORT ISAP VII.b.1 (Cont'd)
(Cont'd)
ISAP VII.b.1 Results Report - Attachment #5 Sheet 2 of 2 Attribute deviation frequency per year for non ASME samples Sample years 1
2A 28 2C 2D 3A 38 3C 30 3E 3F 3G 4
5 6
7 8
Total 1978 0
0 1
0 0
0 0
0 0
1 0
3 2
1 3
2 2
15 1979 1
0 0
0 0
0 0
0 0
0 0
3 2
0 3
1 2
12 1980 0
0 0
0 0
0 0
0 0
1 0
3 1
1 3
0 0
9 1981 0
0 0
0 0
0 0
0 0
0 0
3 0
0 3
2 1
9 1982 1
0 0
0 1
0 0
0 0
0 0
3 0
2 1
0 3
11 1983 0
0 0
0 0
0 1
0 0
0 0
3 0
1 2
3 3
13 Total 2
0 1
0 1
0 1
0 0
2 0
18 5
5 15 8
11 69 Attributes :
1 1 -is the procedurally required documentation for operations performed present ?
2A - Are all required entries legible 7 28 - Are all entries completed appropriately ?
2C - Are all operations signed off in correct sequence ?
2D - Are all corrections / changes properly performed and annotated ?
- 3. -Do allinspection recordsidentify ?
A -ltemsinspected.
8 -Date ofinspection.
C -inspector.
D -Type of observation.
E -Resultsoracceptability.
F - Actions for noncohformances.
G - Drswing, Specification, Procedures and revision levels.
- 4. - Are all entries on related documents consistent ?
I
- 5. - Are all required inspections complete and acceptable ?
- 6. -InspectorCertifications.
- 7. -WelderQualifications.
- 8. -MaterialTraceability, i O
_.. _ _,, _ _ _ _. _. _ _ _ _ _ _ _ _ _ _ _. _ _ _ _ _ _ _ _ _ _.. _, _ _ _ _ _ _ _ _ _, _ _ _ _ _ _ _ _. _ _ _. _ _ _ _ -.