ML20215N771
| ML20215N771 | |
| Person / Time | |
|---|---|
| Site: | Fort Saint Vrain  |
| Issue date: | 10/27/1986 |
| From: | Tomlinson P PUBLIC SERVICE CO. OF COLORADO |
| To: | Gagliardo J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| References | |
| P-86578, NUDOCS 8611070252 | |
| Download: ML20215N771 (5) | |
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16805 WCR 19 1/2, Platteville, Colorado 80651 October 27, 1986 Fort St. Vrain Unit No. 1 P-86578 r<
Regional Administrator f _ % (6j dI OskY/j,,
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Region IV r
U. S. Nuclear Regulatory Commission i
((i,a 611 Ryan Plaza Drive, Suite 1000 L ! OCT 311986 Arlington, Texas 76011 i
Attention:
Mr. J. E. Gagliardo, Chief
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Reactor Projects Branch Docket No. 50-267
SUBJECT:
I&E Inspection Report 86-19
REFERENCE:
NRC Letter, Gagliardo to Williams, dated 9-11-86 (G-86506)
Dear Mr. Gagliardo:
This letter is in response to the Notice of Violation received as a result of inspections conducted at Fort St. Vrain during the period June 23 to 27, 1986. The following response to the items contained in the Notice of Violation is hereby submitted:
Prompt and Effective Corrective Action Criterion XVI of Appendix B of 10CFR Part 50 and the licensee's approved Quality Assurance Program require that conditions adverse to quality be promptly identified and corrected.
Contrary to the above, certain conditions, adverse to quality, which had been identified, had not been corrected.
Examples are:
Nonconformance Reports 37, 38, and 40, issued as a result of the 1983 biennial review of Quality Assurance, were not documented as being resolved.
Corrective action report (CAR)81-204, dated June 28, 1981, remained unresolved and unclosed.
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P-86578 October 27, 1986
- CAR-83-082 was closed without the response addressing the deficiency stated therein.
This is a Severity Level IV violation. (Supplement I.D.) (8619-03)
(1) The reason for the violation if admitted:
The root cause of these examples-was a general avoidance by upper management to address particularly difficult problems coupled with the fact that executive management was not exclusively dedicated to nuclear production concerns.
The first example is the result of inadequate quality controls to ensure documentation was in place or referenced to document resolution of Nonconformance Reports 37, 38, and 40.
The second example is the result of the inability to achieve corrective action in a timely manner due to the complexity of the problem, divisional interfaces, and discovery of additional problems during the course of resolution.
The third example is not symptomatic of the stated violation.
(2) The corrective steps which have been taken and the results achieved:
The corrective action system is being upgraded to include specific requirements relative to time frames for completion of corrective actions, elaboration on CAR disposition requirements for programmatic applicability, root cause evaluation, "look back" review process, and programmatic analysis.
In addition, an NFSC Audit of the corrective action program originally scheduled to begin in September, 1986, was deferred and'rescoped to conduct an in-depth, self-appraisal of corrective action progress.
This audit began October 9, 1986, and includes a review of the corrective action program as a whole to determine the existence of any other areas symptomatic of this problem.
Due to the early stage of development of the corrective steps taken, it is too soon to quantify the results achieved.
In order to provide senior management with frequent assessments of corrective _ action program performance and progress, a status update is regularly given at the Senior Planning Team Meetings which are directed by the Vice President, Nuclear Operations.
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P-86578 October 27, 1986 Example #1 NCR's 35, 36, 37, and 38 were grouped as examples for Torrey Pines Audit Finding #3; however, the PSC Corrective Action Request (CAR). for this finding specifically referenced only NCR 35. The corrective action for Torrey Pines Audit Finding #3-consisted of a revision to APM Q-16, Corrective Action System, which specifically. addressed NCR's 35 and '36 and included measures regarding changing scheduled CAR completion dates, which is the subject of NCR 38.
The subject of NCR 37, timeliness of corrective action, was not addressed as it was felt to be a senior management issue.
NCR 40, concerning deficiencies in the Master Calibration Schedule, documented in Torrey Pines Audit Finding #1, was not addressed in a CAR.
No documentation can be found to indicate why this was not addressed.
It is believed a new CAR was not issued due to a virtually identical CAR (CAR-81-219) which was open at the same time; however, this was not documented on that CAR or in the Torrey Pines-Audit historical file.
CAR-81-219 was subsequently closed July 21, 1983, based upon revision of the Master Calibration Schedule and development of.a new data base by tha Results Department.
Example #2 CAR-81-204 was initiated in June of 1981 as a result of deficiencies identified in QA Audit 2201-80-01.
The CAR identified that there were significant discrepancies and apparent inconsistencies between the Technical Specifications, Master Setpoint List, Master Instrument Calibration Schedule, and the Safety Related Lists.
After much correspondence, QA received in February and March of 1984, a two part response which identified the corrective actions taken by Nuclear Production Division (NPD) to resolve the CAR. After evaluation by QA and completion of additional corrective actions requested by QA, Nuclear Production responsibilities, which constituted the majority of this CAR, were judged as complete.
However, additional discrepancies were uncovered during this time which were the responsibility of the Nuclear Engineering Division (NED).
Subsequently, following the completion of NPD responsibilities, the CAR was transferred to NED in July, 1984.
Five action items were required to be completed by NED, all of which were assigned ~to Change Notices (CN).
Four of these Change Notices are completed, and the last, CN-2188, has been completed and approved in NED and is presently J
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P-86578 October 27, 1986 in Technical Services for review and approval. QA is currently evaluating CN-2188 in regard to CAR-81-204 closure.
Example #3 In evaluating CAR-83-082, the Training Unit'was unable to obtain any information relative to deficiencies in the Fire Brigade Training Program other than that presented by the "for example" of Nonconformance Report 13, which, in fact, is a requirement of the overall Fire Brigade Program, not the training program. The response to the CAR specifically addressed that deficiency.
The FSV Fire Brigade Training Program was revised in March, 1981, to conform to Appendix R to 10CFR50, which is much more detailed than the requirements o f-Section 27 of NFPA Code-1975.
(3) Corrective steps which will be taken to avoid further violations:
Quality Assurance has initiated a program to upgrade the corrective action system and other quality issues. The program includes:
1.
Revise Administrative Procedure (APM) Q-16, Corrective Action System to include:
a) Specific requirements for actions. relative to time frames for completion of required actions.
CAR's open in excess of 180 days will be evaluated by management to improve resolution time.
b) Elaboration on CAR disposition requirements for programmatic applicability, root cause evaluation, "look back" review process, and programmatic analysis, c) Establishment of a
corrective action performance tracking system for review by the Fort St. Vrain Senior Planning Team and senior management.
2.
Complete the NFSC Audit of the corrective action program and develop an action plan to address identified problem areas.
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It is recognized. that procedural controls alone will not resolve the corrective action problems. To this end, the Vice President, Nuclear Operations is personally involved to provide the management direction and support needed for the improvement of quality programs and administrative controls affecting quality.
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P-86578 October 27, 1986 (4) The date when full compliance will be achieved:
1.
Review of open' Corrective Action Requests by the Senior Planning Team has been in progress since September, 1986.
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Administrative Procedure Q-16 will be revised by December 31, 1986.
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The NFSC Audit of the corrective action program will be completed by December 31, 1986.
4.
Based on results of the NFSC Audit, an action plan will be formulated to address specifics identified by January 30, 1987.
Compliance with the Corrective Action System is'an ongoing process.
This process is examined regularly in audits of the Corrective Action System and, to a lesser extent in each audit performed, the results of which are reported to management.
Should you have any further questions, please contact Mr. M. H. Holmes at (303) 480-6960.
Sincerely, 4
P. F. Tomlinson Manager, Quality-Assurance Division PFT/c1k i
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