ML20215B955
| ML20215B955 | |
| Person / Time | |
|---|---|
| Issue date: | 10/02/1986 |
| From: | Merschoff E, Trottier E NRC OFFICE OF INSPECTION & ENFORCEMENT (IE) |
| To: | |
| Shared Package | |
| ML20215B944 | List: |
| References | |
| REF-PT21-86, REF-QA-99900317 NUDOCS 8610100007 | |
| Download: ML20215B955 (15) | |
Text
.
ORGANIZATION:
COOPER ENERGY SERVICES GROVE CITY, PENNSYLVANIA REPORT INSPECTION INSPECTION N0.: 99900317/86-01 DATES: 07/28-08/01/86 ON-SITE HOURS: 84 CORRESPONDENCE ADDRESS:
Cooper Industries Cooper Energy Services ATTN: Mr. F. B. Stolba, Vice President and General Manager 150 Lincoln Avenue Grove City, Pennsylvania 16127 ORGANIZATIONAL CONTACT:
W. H. Allen Lambert, Manager of QA TELEPHONE NUMBER:
(412) 458-8000 NUCLEAR INDUSTRY ACTIVITY: Original equipment manufacturer of standby diesel generators for nuclear service. Current salas in parts, repair and service only. No nuclear orders for engines.
ASSIGNED INSPECTOR:
k d [fb E. H. Trottier, Reactive Inspection Section (RIS)
Date OTHER INSPECTOR (S):
W. P. Haass, Program Coordination Section E. Yachir~ k, RIS
/c((st, APPROVED BY:
Date E. W. Merschoff, Chief //IS, Vendor P ogram Branch INSPECTION BASES AND SCOPE:
A.
BASES:
10 CFR Part 21 and 10 CFR Parc 50, Appendix B.
B.
SCOPE: This inspection was performed in response to two recent and significant Part 21 reports involving Cooper stendby diesel generators.
In addition, this inspection sought to verify corrective and preventive actions taken in response to findings of the previous NRC inspection (84-01, March 12-16, 1984).
PLANT SITE APPLICABILITY: Eyron 1/2 (50-454, 455); Braidwood 1/2 (50-45E/457);
Cooper (50-298); Nine Mile Point 2 (50-410); Palo Verde 1/2/3 (50-528, 529, 530);
(continued on next page) 8610100007 861002 PDR GA999 EMVCOIN 99905317 PDR
ORGANIZATION:
COOPER ENERGY SERVICES GROVE CITY, PENNSYLVANIA REPORT INSPECTION NO.: 99900317/86-01 RESULTS:
PAGE 2 of 12 PLANT SITE APPLICABILITY (continued) South Texas 1/2 (50-498, 499); Susquehanna 1/2 (50-387, 388); Waterford 3 (50-382); Zion 1/2 (50-295, 304).
A.
VIOLATIONS:
There were no violatiens identified as a result of this inspection.
B.
NONCONFORMANCES:
Contrary to Standards Numbering and Handling Procedure SA-1, out of date procedures (old revisions) and an out of date procedure index were found in the heat treatment area shop office procedures manual (86-01-01).
C.
UNRESOLVED ITEMS:
There were no unresolved items resulting from this inspection.
D.
STATUS OF PREVIOUS INSPECTION FINDINGS:
1.
Inspection 84-01 (March 12-16, 1984) a.
Nonconformance 1 (0 pen): Heat treatment procedures available in the fabrication area were not current revisions. Specifically, procedures HT-17N and HT-18AN were cited as being out of date according to the Standards Manual for Engineering Material Specifications.
The inspector reviewed implementation of the corrective and preventive actions that Cooper submitteo in their response to this finding. Neither the corrective action nor the action taken to prevent recurrence has been effective.
In reviewing the revision status of the same two heat treat procedures (HT-17N and HT-18AN) available in the heat treat area shop office, out of date revisions were found and the procedures index did not reflect the current revision to the procedures.
The heat treatment area shop office was found to contain two sets of the subject heat treat procedures. One set was found in the Standards Manual for Engineering Material Specifications, while another set was found in a separate binder containir.g only the Standards Manual Chapter for heat treating (Chapter 13).
Both the Manual and separate Chapter 13 binder had separate
ORGANIZATION: COOPER ENERGY SERVICES GR0VE CITY, PENNSYLVANIA REPORT INSPECTION NO.: 99900317/86-01 RESULTS:
FAGE 3 of 12 procedure revision indexes.
In the Standards Manual, procedure HT-17N was current (11/84) in both the index and as found, while procedure HT-18AN showed a revision date of "7/81" in the index and "9/5/75" as found.
In the separate binder of heat treatment procedures, HT-17N showed a revision date of "11/84" in the index and "2/17/82" as found, while HT-18AN showed a revision date of "2/85" in the index and "7/28/81" as found.
In summary, an out of date revision to HT-17N was found in the shop binder; only the index of the shop binder showed the current revision of HT-18AN.
Nonconformance 86-01-01 was identified in this area of the inspection.
The preventive action taken by Cooper Energy Services (CES) to prevent recurrence of this nonconformance was found to be imple-mented, but its effectiveness was inadequate, as evidenced by Nonconformance 86-01-01 identified above. The inspector reviewed the standard document distribution list that showed position titles (rather than just names) for the intended distribution of documents such as procedure revisions. This change was made by CES to help ensure that as personnel changes occur in the company, standard documents would reach the required functional area, rather than be sent to a perscr. who may not still be servina in the intended area of responsibility.
b.
Nonconformance 2 (Closed): Quality Control Inspection Plans (QCIP) for 11 components on 7 diesel generator units were not signed / stamped or dated by the inspector to indicate various inspection activities had been conducted.
Corrective action and preventive measures for this nonconformance were found to be adequately implemented. Specifically, the subject QCIPs were reviewed and corrected, where possible. A training class was conducted on or about June 15, 1984, to review the requirements of the governing Quality Centrol Procedure l
l (QCP-10-1).
l l
c.
Nonconformance 3 (Closed): Purchase orders were missing for l
lube oil lines on four nuclear standby diesel engines and conrecting rod bearing shells on one engine. These itens are cla:.sified as critical components.
1 1
ORGANIZATION: COOPER ENERGY SERVICES GR0VE CITY, PENNSYLVANIA REPORT INSPECTION NO.: 99900317/86-01 RESULTS:
PAGE 4 cf 12 All documents related to this finding were reviewed. The purchase orders for the subject components were found with their respective documentation packages (material test reports).
Further, it was determined that purchase orders for critical components are being maintained by CES Quality Assurance personnel.
d.
Nonconformance 4 (Closed): Three quality control inspectors were found to have performed nondestructive testing for which they were not qualified; one inspector could not be verified as being qualified to perform such testing (no record of qualification).
The qualification history for these four persons was reviewed.
The three inspectors identified above as not being qualified at the time of performing the nondestructive testing were, in fact, properly and currently qualified to perform such examina-tions. The fourth inspector left the company on July 22, 1977.
His official records (including NDE qualification history) were disposed of in 1979, in accordance with the requirements of QCP-10-12, " Quality Program Requirements for Qualification and Certification of NDE Personnel."
e.
Nonconformance 5 (Closed): Calibration services were performed by seven companies with no evidence that their calibration program had ever been reviewed and approved by CES. One of these seven companies did not appear on the Approved Vendors List.
The inspector reviewed records associated with these seven Calibration service companies. Each has now been approved by either a review of their Quality Assurance Program, or by demonstrated performance history. All seven companies were found on the current Approved Vendors List.
f.
Nonconformance 6 (Closed): Various pieces of measuring and test equipment in use at shop work stations were found overdue for calibration, or their calibration stickers were inadequate or nonexistent.
In addition, CES does not investigate the accept-ability of items previously tested or inspected by a piece of M&TE found to be out of calibration.
The inspector checked several pieces of test equipment in manufacturing areas of the shop. All stickers were legible and all equipment was current in calibration status. An internal memorandum issued August 20, 1986 requires the tool room calibration technician to inform the quality control area
ORGANIZATION: COOPER ENERGY SERVICES GROVE CITY, PENNSYLVANIA REPORT INSPECTION N0.: 99900317/86-01 RESULTS:
PAGE 5 of 12 supervisor (responsible for M&TE tool room) when any piece of test equipment is found out of calibration. The supervisor is responsible for reviewing and investigating all relevant aspects of the out of calibration incident (with particular emphasis on the margin of calibration error and its impact on previous production) and documenting this review in a written report.
The report is submitted to CES Quality Assurance for potential corrective action.
g.
Nonconformance 7 (Closed): Some purchase orders for critical components were not signed and dated by QA personnel, while others did not require the supplier to have a QA program.
In discussions with CES personnel, the inspector was advised that purchase requirements are of ten satisfied by a document that augments the original purchase order. This document is an Engineering Control Specification, having special purchasing requirements for nuclear application and is designated "SGN."
All purchase orders associated with this nonconformance were reviewed and found to have referenced SGNs that require appro-priate vendor quality assurance / quality control conditions.
Purchase orders cited by this nonconformance were reviewed and found to have been signed by CES QA representatives as required.
h.
Nonconformance 8 (Closed): No evidence was found of documented instructions or procedures that addressed procurement document content and control.
The inspector reviewed Section 5 of the CES Quality Assurance Manual (QAM), Par graph 5.2 and fcund that it specifies all requirements for procurement document control, including a l
review by Quality Assurance for the original procurement docu-ments and any changes thereto.
i.
Nonconformance 9 (Closed):
No evidence was presented to show that three vendors of critical components (jacket water pumps and crankshaf ts) submitted a copy of their QAM, or of a OAM evaluation checklist.
The inspector reviewed the CES quality control procedure governing the requirements for vendor selection. The procedure (QCP-10-8) has been revised to allow a vendor's past performance history to be a basis for selection as an i
ORGANIZATION: COOPER ENERGY SERVICES GR0VE CITY, PENNSYLVANIA REPORT INSPECTION NO.: 99900317/86-01 RESULTS:
PAGE 6 of 12 approved vendor. This method of approval has been applied to the three vendors who were the subject of this noncon-formance.
J.
Nonconformance 10 (Closed): CES had not established measures to preclude the requisition of M&TE calibration nonconformance identified in previous customer audits.
The inspector reviewed the corrective and preventive. measures taken to preclude recurrence of this nonconformance and found them adequate. The computerized tool recall and inventory program is in effect and the listing was found to include the personal calibration equipment of manufacturing personnel.
Tools selected at random by the inspector were found to be within the calibration frequency specified in the master calibration list.
k.
Nonconformance 11 (0 pen): The written 10 CFR Part 21 response documenting evaluation of the circumstances surrounding damaced resistance temperature detector wires on a standby diesel engine was not provided within the time specified in QCP-10-14.
In reviewing the status of corrective and preventive measures for this nonconformance, the inspector noted that in at least one instance, no evidence was found to show that CES had implemented their stated preventive action.
(Advise engineer-ing of the 30 day response requirement; followup with engineer-ing if their input is not received in 20 days.) Discussions with CES personnel revealed that in this instance, investigation and determination of the root cause of an engir.e malfunction took several months. Thus, the efficacy 6f the 30 day response requirement was questioned, except to satisfy the requirement of the subject CES procedure (QCP-10-14). CES has therefore committed to revise QCP-10-14 and delete the 30 day requirement for a 10 CFR Part 21 report that of ten is not technically possible.
1.
Nonconformance 12 (Closed): Design changes on several Request for Draf ting Action (RFDA) forms were not verified or checked by an individual other than the person who performed the origital design.
ORGANIZATION: COOPER ENERGY SERVICES GR0VE CITY, PENNSYLVANIA REPORT INSPECTION NO.: 99900317/86-01 RESULTS:
PAGE 7 of 12 Corrective action for this nonconformance was accomplished by a re-review of each of the subject RFDAs. The inspector verified that the re-reviews were conducted and documented. Preventive action was accomplished by a revision to the procedure that controls RFDAs (CES Procedure SA-4).
This procedure revision was reviewed by the inspector and found to be adequate.
m.
Nanconformance 13 (Closed): The " Order Affected" block on several RFDAs was not completed as required; several RFDAs that had been approved and implemented, were not signed as being approved.
The inspector reviewed the subject RFDAs and found them to be properly signed off. A review of an additional 10 RFDAs did not yield any deficiencies.
n.
Nonconformance 14 (Closed): Several nonconforming items /
deviations / failures in CES equipment shipped to nuclear facilities were not evaluated by CES as required by 10 CFR Part 21.
The inspector reviewed all correspondence related to deficiencies in CES-supplied equipment at commercial nuclear pcwer plants.
No evidence was found to show that CES ever failed to conduct a technical evaluation, followed by a 10 CFR Part 21 notifica-tion when appropriate, of any deficiency about which CES had knowledge.
It appears that the subject nonconforming items /
deviations / failures were never brought to the attention of CES by the licensee, o.
Nonconformance 15 (Closed): The CES procedure identified as controlling the progress of potential 10 CFR Part 21 noncon-formances did not specifically provide for the review and I
escalation into the 10 CFR Part 21 review systen of identified problems.
The inspector reviewed the CES QA procedure that governs complience to the requirements of 10 CFR Part 21. Paragraph 4.2.1 of the subject procedure was found to contain a require-ment that a Material Review Request (MRR) be issued for defi-ciencies that are potential 10 CFR Part 21 items. The MRR is identified as being a Part 21 item by the words " Reported per
ORGANIZATION: COOPER ENERGY SERVICES GROVE CITY, PENNSYLVANIA REPORT INSPECTION N0.: 99900317/86-01 RESULTS:
PAGE 8 of 12 QCP-10-14" written on it. This alerts all CES employees to the purpose of the MRR. The inspector noted some inconsistencies in how these MRRs are actually being identified by CES.
Some were found to have " Critical" written on them. When brought to the attentien of the CES QA staff, it was learned that an internal memorandum was being prepared to correct this, as well as other related 10 CFR Part 21 findings.
(see item k above.)
p.
Nanconformance 16 (Closed): CES procedures do not require, and records were not prepared to assure compliance with the 2-day reporting requirement found in 10 CFR Part 21.
The inspector examined reccrds (letters to the Nuclear Regulatory Commission (NRC)) that indicated the Vice President and General Manager of CES consistently notified the NRC of a defect / failure within 2 days of learning that the defect / failure is known to have an impact on safety. This 2-day notification is subsequent to the evaluation that establishes the existence of a defect /
failure. Section 4.2.4 of the CES procedure on Part 21 notifi-cation appears to address this matter adequately.
E.
OTHER FINDINGS AND COMMENTS:
1.
Part 21 Program The major purpose for conducting this inspection was to review CES' program for complying with 10 CFR Part 21. Two recent and signifi-cant engine failures at commercial nuclear power plants were reported to the NRC as being under evaluation by CES. The evaluation process for each failure was reviewed by the inspector. The CES evaluation of each appears to be adequate, as follows:
a.
Rocker Arm Failures Two of four KSV-20 diesel engir,es manufactured by Cooper-Bessemer and installed at Commonwealth Edison Company's Byron Station experienced rocker arm failures in November 1985 and February 1986. As a result of the ensuing evaluation, it was initially concluded that the broken rocker arms were a secondary failure that occurred as a result of the seizure of the valve train crosshead bushing.
ORGANIZATION: COOPER ENERGY SERVICES GR0VE CITY,. PENNSYLVANIA REPORT INSPECTION NO.: 99900317/86-01 RESULTS:
PAGE 9 of 12 The latter was thot ght to be the direct result of some radial misalignment of cylinder liners, which in turn caused cylinder head misalignment. The liner misalignment was corrected, the broken rocker arms were replaced, and the engines were successfully tested.
On March 11, 1986, CES issued a Part 21 report describing the problem, the investigation conducted, and the recommended corrective action. The vendor also issued Service News Bulletin No. 698, " Power Head Assembly," dated March 11, 1986 to identify the problem and present what was thought to be the solution.
On May 5,1986, another rocker arm failure occurred. Alignment of the cylinder line was rechecked and found to be within toler-In reviewing the entire maintenance history of the engine, ance.
a seemingly insignificant fact was uncovered:
the utility had a history of ordering an excessive number of push rod retaining rings. Since these retaining rings were also bent in the recent failures, the CES investigation focused on the connection between these two apparently unrelated items. The result was the sclution to the history of seized crosshead bushings and rocker arm failures at Byron Station.
The root cause of the rocker arm failures was a misinterpretation of the venoor's instructions for setting valve tappet to lifter clearance.
In setting the tappet clearance, the dial indicator probe was placed on an incorrect surface, giving an improper measurement. More significantly, adjustment must be performed on cylinder pairs, rather than on all cylinders with a cormion engine position.
Performing the clearance check incorrectly resulted in improper location of the push rods, effectively increasing their length, and causing excessive force on the rocker arms. Although the vendor concluded that the problem was not generic, an instruction manual supplement (#72486) has been i
prepared for distribution to all affected customers. This is to l
help assure ccmplete clarity of the valve clearance procedure.
The necessary corrective action has been performed on the diesels at Byron Station. The diesels have been successfully tested, reinspected, and declared operational. They continue to run satisfactorily.
w
ORGANIZATION: COOPER ENERGY SERVICES GR0VE CITY, PENNSYLVANIA REPORT INSPECTION N0.: 99900317/86-01 RESULTS:
PAGE 10 of 12 b.
Loose Air Start Valve Seat Inserts On May 5,1986, an attempt to start an engine at Nine Mile-2 was unsuccessful. The engine would not " roll" with starting air. Subsequent investigation revealed that the air start valve seat insert in one cylinder was loose. The loose insert was free to fall out as its air start valve opened, effectively preventing starting air from entering the engine cylinder. The vendor determined that the loose insert was caused by improper correction of the head over-bore for the valve seat insert. The correction involved copper plating the insert, which then deformed as a result of thermal cycling. A second insert was also found to be loose.
It appears that the second loose insert was caused by an error in the selection of the insert part number during the manufacturing process.
Inserts are specifically matched to the insert bore to assure a proper shrink fit. Selecting an incorrect part did not allow a proper interference fit.
The utility proposed to check the adequacy of all starting air valve inserts on both engines (32 cylinder heads). The check was performed using a specially designed tool and precalculated force to determine insert tightness.
No other inserts were found to be loose. Other types of inserts (inlet and exhaust valves) were checked for tightness and found to be acceptable.
The utility performed an audit of CES records regarding air valve inserts and whether or not copper plating was used elsewhere as a corrective measure to assure a proper interference fit.
Lo further errors or copper plating locations were found.
The corrective actions have been completed, the engine tested and declared operational.
CES performed an audit of the records of diesel engines for their other nuclear utility customers. Nine other inserts located in six engines owned by three licensees were identified as having copper plated insert bores. Two of the licensees (Commonwealth Edison Company and Pennsylvania Power and Light Company) have been notified. The third utility (Arizona Public Service) is in the process of being notified, c.
Part 21 Activities CES's Part 21 files were reviewed to determine the adequacy of problem evaluation, reportability evaluation, corrective action, notification of affected customers, and adherence to their procedure. All files appeared to be adequately complete.
ORGANIZATION: COOPER ENERGY SERVICES GROVE CITY, PENNSYLVANIA REPORT INSPECTION N0.: 99900317/86-01 RESULTS:
PAGE 11 of 12 The inspector also reviewed a file of engine problems that were deemed by the vendor to not warrant reporting to the NRC. All items appeared to be adequately categorized in that they were not generic, or not safety related.
The CES's Part 21 file was compared to the listing of Part 21 reports received by the NRC from all sources during the 1985-1986 period. Discrepancies were found in three areas:
Failure of turbocharger bolts at Palo Verde in September 1985 due to the lack of proper pre-stress to preclude fatigue by vibration was determined to be non-sdfety related.
Slipping of the fuel rack linkage arm on the governor shaf t was determined to require no corrective action because insufficient assembly torque was used by the maintenance staff.
However, CES will use a larger bolt on future engines.
Failure of two Cooper diesel engines to sustain an adequate fuel oil prime at Braidwood station was attributed to an architect-engineering installation problem.
Other than the above, which were judged to be ac e ptable differences, there was ccmplete consistency with NRC records.
The vendor's Part 21 precedure requires all problem identifi-cation and evaluations, potentially reportabla under Part 21, to be reported to the QA Manager for purposes of central filing.
Contrary to this requirement, not all nonreportable evaluations were included in the QA Manager's file. Missing from the file are reports or requests from utilities made to other groups within CES (e.g., Engineering Service Group and Field Office).
To remedy this situation, an interoffice memorandum was prepared that requires "...any such communication received by anycne in the C.B. (ESG) organization be copied to the CA Manager regardless of the ultimate disposition." The stated intent cf the memo is to ensure CA has a copy of all relevant dccuments regarding pctential 10 CFR Part 21 items. This memo was prepared on July 31, 1986 and sent tc all CES's Division Managers.
ORGANIZATION:
COOPER ENERGY SERVICES GR0VE CITY, PENNSYLVANIA REPORT INSPECTION N0.: 99900317/86-01 RESULTS:
PAGE 12 of 12 2.
Peasuring and Test Equipment Control In reviewing the CES program for calibration of measuring and test equipment, the inspector noted some confusion between required calibration frequency, required calibration date and due date marked on calibration stickers attached to individual pieces of test equipment.
In discussions with CES personnel and a review of the governing Quality Control Procedure (QCP-10-15, Section 4.7), it appears that unnecessary confusion is being created by the choice of the date format used to establish when a piece of test equipment is due for calibration, and when it should be next recalled. The QCP specifies, and the master calibration schedule printout calls for, a " year-week" format. For example, a date identified as 86/21 indicates calibration due the twenty-first week of 1986. The difficulty, of course, is that few people can convert that information into a commonly understandable date (i.e., week of May 18). The stated reason for using such a system is that the CES accounting system is based on calendar weeks and the charges for calibration services are billed internally using that format.
The inspector noted that a vernier caliper was marked " Cal Due 7-18-86," but in reviewing the calibration schedule printout, it was last calibrated the 20th week of 1986.
Using a quarterly calibration frequency, as required,17 weeks after the 20th week yields calibration due the 33rd week of 1986 (i.e., week of August 11). When the calibration technician was asked about the oisparity, he produced a conversion card for weeks to dates. When asked why the piece of test equipment was incorrectly dated if a conversion chart was available, the inspector was told the dates are usually estimated by adding 13 weeks to the current date and approxi-mating when that would occur in the usual day / month / year format.
The present system of scheduling calibration cue dates for measuring and test equipment at CES is not well controlled. The inspector received a verbal commitment from the QA staff that a review and probable change would be forthcoming.
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