ML20217K675
| ML20217K675 | |
| Person / Time | |
|---|---|
| Site: | Paducah Gaseous Diffusion Plant |
| Issue date: | 10/24/1997 |
| From: | Polston S UNITED STATES ENRICHMENT CORP. (USEC) |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| 70-7001-97-07, 70-7001-97-7, GDP-97-1040, NUDOCS 9710280371 | |
| Download: ML20217K675 (17) | |
Text
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Un.ted States Entwhoent GwpsGm e
Paducah Lie Offwe P O, thin 1410 Paducah. KY 42001 Tel-502 4415803 ias: 502 4415801 October 24,1997 United States Nuclear Regulatory Commission SERIAL: GDP 97-1040 Attention: Document Control Desk Washington, D.C. 20555 Paducah Gascous Diffusion Plant (PGDP)
Docket No. 70-7001 l
Response to Inspection Report (IR) 70-7001/97007 Notices of Violations (NOVs)
The Nuclear Regulatory Commission (NRC) letter dated September 24,1997, transmitted the subject IR which contained five NOVs. The United States Enrichment Corporation's (USEC) response to these violations is provided in Enclosures 1-5, Enclosure 6 lists the commitments made in this report. Unless specifically noted, the corrective actions specified in each enclosure apply solely to PGDP.
If you have any questions regarding this submittal, please contact Bill Sykes at (502) 441-6796.
Sincerely, s1AA.4.
Steve Polston General Manager Paducah Gaseous Diffusion Plant SP:SRC: mig y
Enclosures (6) p 7{
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NRC Rep 5n Ill NRC Senior Resident Inspector, PGDP 9710280371 971024 i
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ENCLOSURE 1 UNITED STATES ENRICllMENT CORPORAT!ON (USEC)
REPLY TO NOTICE OF VIOLATION (NOV) 70-7001/97007-02 d
The regulations ir 10 CFR 76.93 require,in part, that the certificatee shall establish, maintain, and execute a quality assurance program satisfying each of the applicable requirements of ASME NQA-1-1989.
l l
Section 3.15 of the Safety Analysis Repon,"Q AND AQ STRUCTURES, SYSTE.MS, AND COMPONENTS," dermed, in part, tk systems or components used in the plant that have a "Q" or "AQ" function, i.e., a significant safety function requiring the system or component to be covered by the Quality Assurance Program (QAP).
Section 3.15.1.3.13 of the Safety A aalysis Report identified uranium hexafluoride cylinders, except 2S and 1-kilogram cylinders, as having a "Q" function for " safe containment of uranium hexafluoride during transport, sampling, feeding, filling, and storage and to prevent a release of L
_ liquid uranium hexafluoride "
Section 2.6.1 of the Quality Assurance Program stated, in part, that: "A document control system is established for Q items and related activities and services...This system ensures that documents defining the performance of quality-related activities are controlled so only current and correct information is available at the location where the activity is performed prior to commencing work."
Violation Cited Contrary to the above, from March 3 through August 25,1997, uranium hexafluoride cylinder tare weight listings used in Building C-310 were not maintained in the document control system to ensure that only current and correct information was available in the Building C-310 withdrawal room, a location where uranium hexafluoride cylinders were filled, a quality-related activity.
I.
Reason for Violation The Root Cause of this violation was that personnel were unfamiliar with the requirements for recognizing a controlled document as described in the Document Control (DC) procedure UE2-TO RM103' " Document Control Program." Two years have elapsed since the last training class, the DC Program was conducted at PGDP.
Consequently, plant personnel failed to recognize that when CP4-CO-CN2010 and CP4-CO-CN2012 were changed to designate the Tare Weight Books as containing " official" tare weights, the use of the information contained in the Tare Weight Books (generated by CP4-SS-NM1111) should be controlled under the DC program.
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II.
Corrective Actions Taken and Results Achieved 1.
Tare Weight Book NMC&A 01 was upgraded to a controlled document on August 25,- 1997.
Nuclear Material Control and Accountability (NMC&A) reviewed other reports generated by their department to determine if others needed to be included in the DC program and none were found.
3.
A Lessons Learned memorandum was issued to all organizational managers on October 22,1997, providing guidance on the recognition of docunients which
- should be submitted for control through the Document Control Program.
Ill.
Corrective Actions to be Taken 1.
Change Step 6.2.2 of Procedure CP4-SS-NM1111 by November 26,1997, to require future revisions of Tare Weight Book NMC&A-01 to be submitted to DC.
2.
Complete DC Program retraining for PGDP Group Managers by December 5, 1997.
i IV.
DEg_of.Eull Comnliance USEC achieved full compliance with the requirements cited in this violation on August 27, 1997, when the Tare Weight book was submitted to DC and field copies were replaced with the controlled copy. - Subsequent actions to prevent similar violations will be completed by December 5,1997.
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ENCLOSURE 2 UNITED STATES ENRICliMENT CORPORATION (USEC)
REPLY TO NOTICE OF VIOLATION (NOV) 70-7001/97007-05 The regulations in 10 CFR 76.93 require, in part, that the certificatee shall establish, maintain, and execute a quality assurance program satisfying each of the applicable requirements of ASME
- NQA 1-1989.
Section 3.15 of the Safety Analysis Report,"Q AND AQ STRUCTURES, SYSTEMS, AND COMPONENTS," defined, in part, the systems or components used in the plant that have a "Q" or"AQ" function, i.e., a significant safety function requiring the system or component to be covered by the Quality Assurance Program (QAP).
Sections 3.15 and 5.2 of the Safety Analysis Report identified the high pressure fire water system, the criticality accident alarm system, and nuclear criticality safety controls, as systems, components, or controls having a "Q","AQ" or a significant safety function.
The Quality Assurance Program, Section 2.5 and Appendix A, Section 1, Element 1.5, required, in part, that activities affecting saft ty or quality are prescribed and performed in accordance with
. documented procedures appropriat: to the circumstances.
Violations Cited Contrary to the above, maintenance activities affecting safety or quality were not performed in accordance with documented procedures appropriate to the circumstances in the following examples:
On August 5,1997, maintenance and work control activities associated with a.
replacement of high-pressure fire water sectional Valve HP-0-16-S-3 (Work Order Task R 9600735-01), were not prescribed or performed in accordance with procedures appropriate to the circumstances in that Technical Safety Requirement (TSR) 2.3.4.9 compensatory measures were not identified in the procedures or implemented within eight hours after the sectional valve for the Building C-315 high-pressure fire protection system was closed.
b.
On July 30,1997, maintenance and work control activities associated with replacement and post maintenance testing of the Building C-335 "C" criticality accident alarm system cluster (Work Order Task R 9705259-01) were not prescribed or performed in accordance with procedures appropriate to the circumstances in that proper system alignment and operability, following completion of the work, was not assured. As a result, on August 5,1997, the system nitrogen bottle valve was discovered closed, isolating the safety-related pressure source to the system homs.
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u On August I and 2,1997, maintenance staffdid not perform criticality controls c.
for system filters installed in a Building C-400 negative air machine (NAM) in accordance with Procedure CP2 GP MS2033," Operation of 1000 and 2000CFM Negative Air Machines." Specifically, the staff failed to remove the negative air machine from service and request an evaluation of the fihers due to changes in the pressure drop across the filters in excess of the procedure specified acceptance criteria.
Example n 1.
Reason for Violation The reason for the violation was that personnel responsible for the implementation of the LCO required actions failed to follow the procedural steps included in CP4 SS-FS6117,
" Fire Protection impairment Permit (FPIP)," CP2-CO-CN1031," Tracking ofinoperable TSR Structures, Systems, and Components," and CP2-GP-GP1032," Work Control Pocess." The involved individuals collectively failed to recognize that a required action (providing a temporary water supply for C-315) had been missed and that verification of all the necessary actions had been completed.
Corrective Actions Taken and Results Achieved 1.
The temporary water supply was connected to C-315 on August 6,1997.
2.
A memorandum was issued on August 6,1997, to all Fire Services (FS)
Supervisors on the implementation of the procedural requirements in CP4-SS-FS6117," Fire Protection Impairment Permit," to remind them to:
- a. Document all required compensatory measures on all FPIP.
- b. Fax a copy of FPIP's for TSR required systems to PSS for review,
- c. Personally verify that TSR required actions performed by FS are complete,
- d. Record all TSR required LCO actions performed by FS in the shift log and fax a copy of the log entries to the PSS.
3.
Procedure CP2-CO-CN1031 was changed to include a requirement that the PSS discuss the specific required TSR actions with the affected front line manager prior to declaring a TSR required system inoperable for planned work or upon discovering a system is inoperable due to emergent conditions.
111.
Corrective Actions to be Taken 1.
Issue a new Fire Services abnormal operating procedure to address TSR and non-TSR compensatory measures to be taken for inoperable fire protection systems and E2-2
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,m components and train FS personnel on the procedure by December 5,1997. This L action will incorporate the information contained in the memorandum issued to FS Supervisors on August 6,1997 (Action 1 in part II (Corrective Actions Taken and Results Achieved)).
- 2.
An action has been developed to address the failure of Maintenance, Operations, and Fire Services to follow procedure with regard to the signature for " Permission to Start Work" and use of the Appendix in CP4 SS-FS6117. This action is included in the Summary following Example c of this violation.
IV..
Date of Full Comoliance.
USEC achieved full compliance when the tc..iporary water supply was connected to C-315 on August 6,1997 Actions to prevent recurrence will be completed by December 11,1997.
Example b 11,.
Reason for Violation The apparent reason for this example of the violation was that Instrument Maintenance
. failed to follow the steps as described in the work package and procedure used to perform the work. Though the investigation was not conclusive, it appears that Instrument Maintenance performed an action to close the valve to conserve nitrogen during the testing of the horns, even though this action was not described in the procedure or work package as an accepted practice, A contributing cause of the violation would be the failure of maintenance to recognize the need to verify that the bottle was opened after testing.
i II.
Corrective Actions Taken and Results Achieved 1, _. The nitrogen cylinder valves on the other 28 clusters were verified to be open as required.
2.
. CP4-GP-lM6209," Criticality Accident Alarm System FunctionalTests," revision 3
- was issued on August 8,1997, to initially close the nitrogen cylinder then open the valve after the testing is performed. Opening the nitrogen cylinder valve is documented on an in-hand data sheet in the procedure.
.III.
i Corrective Actions to be Taken 1.1 Revise affected plant procedures to incorporate opening / closing nitrogen cylinder valve and documenting on the data sheet that the nitrogen cylinder valve is in the open position following maintenance / testing by October 31,19,97.
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2.
An action has been developed to address the failure of maintenance personnel to verify that actions donc during maintenance are returned to original status following the work. This action is included in the Summary following Example c of this violation.
IV.
Date of Full Comp.Luigg USEC achieved full compliance with the requirements as stated in this violation when the nitrogen cylinder valve was opened on August 5,1997. Actions to prevent recurrence will be completed by December 11,1997.
F.xnmnlec I.
11ackuround On August 1,1997, NAM unit 2000-9 was moved from the expansion joint cut down area to the G-17 valve disassembly area in C-400. When the unit was started the filter readings were out-of-tolerance. The HEPA hiechanical group was contacted and a new j
baseline was set as required. After the baseline was set the unit was left running. On shutdown of the unit a 0.6 Differential Pressure (D/P) drop (procedure limit is 0.4 D/P) in the HEPA filter was observed by the mechanic operating the unit. The hiechanical Supervisor was informed of the readings and HEPA Mechanical group was again notified.
On August 2,1997, the NAM unit 2000-9 was restarted without establishing a new baseline as required by procedure. The unit was shutdown on August 2 after completing the work and was not used again before it was tagged out on August 6.
II.
Reason for Violation The root cause for this example of this violation was that prompt action was not taken by Maintenance to remove t' NAM unit from service following notification of an out-of-tolerance reading. A conuc,;uting cause was that the procedure did not provide clear guidance concerning the actions to take when a NAM unit is observed to be out-of-tolerance.
III.
Cortcetive Actions Taken and Results Achieved I.
Upon discovery of this event on August 6,1997, the NAM unit was tagged out and the Supervisor initiated a protlem report to document the failure.
7.
On September 17,1997, the Maintenance Organizational Manager issued a Maintenance Functional Directive (No,97-027) to Operations, Work Control, Engineering, Production Support, and Site and Facility Services as an interim compensatory measure to provide additional guidance to NAM users until procedure changes can be made.
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IV.
Corrective Actions to be Taken 1.
Procedure CP2-GP-MS2033," Operation of 1000 and 2000 CFM Negative Air Machines," will be changed by November 14,1997, to incorporate the guidance from Maintenance Functional Directive No.97-027.
2.
An action has been developed to address the failure of Maintenance to ensure equipment is removed from service when found out of operating parameters. This action is included in the Summary following Example c of this violation.
IV.
Date of Full Comnliance USEC achieved full compliance with the requirements of this violation on August 6, 1997, when the NAM unit in C-400 was shut down. Actions to prevent recurrence will be completed by December 11,1997.
Summan*_
USEC has evaluated each of the examples as cited in the violation and recognizes that they represent weaknesses in the areas of procedural adherence, communication between functional organizations, shift turnover, and post-maintenance validation.
To specifically address the weaknesses as described in the examples of this violation, Maintenance, Operations, and Site and Facility Services will prepare a lessons learned summary {
of each example and have their Front-Line Managers present the summary to their work groups by December 11,1997. As a minimum, this summary will include a brief description of the event and a description of the causes (e.g., failure to follow procedure, ineffective coordination between work groups, ineffective post-maintenance activity, inadequate shift tumover, etc.),
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ENCLOSURE 3 UNITED STATES ENRICHMENT CORPORATION (USEC)
- REPLY TO NOTICE OF VIOLATION (NOV) 70 7001/97007 06 -
The regulations in 10 CFR 76.68 provide in part, that the certificatec may make changes to the plant' operations, as described in the Safety Analysis Report, without prior Commission approval provided that a safety evaluation is performed that demonstrates that the change does not pose an undue risk to the public safety.
The Safety Analysis Report, Section 3, Section 3.2.4," Piping and Valves," stated, in part, that all autoclave piping, out to the outside containment valve, was (sic) installed to national standards and i
1 engineering piping specifications.
Engineering Specification 15137HP,"UF. Gas and Liquid Piping Systems " required,in part, the performance of a vacuum test at 0.5 pounds force per square inch absolute (psla), held for two hours with no noticeable rise in pressure.
t Violation Cited L
Contrary to the above, on July 7,1997, the certificatee authorized the performance of an acceptance vacuum test on uranium hexafiouride piping, modified by the instrument upgrade project, which was less stringent than that specified in Engineering Specification 15137HP without performing a safety evaluation of the change in the acceptance criteria. Specifically, Temporary Procedures CP2-EG.
EG6031.tmp through CP2-EG EG6033.tmp required the vacuum test to be performed at a pressure of less than 5.0 pounds per square inch absolute for 10 minutes with a pressure rise of not more that (sic) 0.25 pounds force per square inch absolute.
' l.
Reasons for Violation The events that led to this violation were initially identified in NOV 97004-09 for PGDP. A chronology of activities associated with this violation (i.e.,97007-06) and NOV 97-004-09 is attached to this response.
The reason for the violation was failure of responsible individuals to comply with the existing procedural requirements (C.P3 EG EG1074," Design Document Change Process"). As previously stated in the response to NOV 97004-09, this occurred because of a failure of training to address this element of the modification process. The nonconforming condition had not been identified or corrected at the time the new temporary procedures were issued. The responsible individuals did not yet understand that the deviation from engineering specifications had not been appropriately reconciled. Temporary procedures (i.e. CP2-EG-EG6032.tmp and CP2-EG-EG6033.tmp) were created and PORC approved on July 10 to implement design output documents that were thought to have ahady received an appropriate level of review and approval. The individuals responsible for ti. development of these procedures were not aware that the deviation from the engineering specification had not been appropriately reconciled.
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A 10 CFR 76.68 review was performed when temporary procedures CP2 EG-EG6032.tmp and CP2 EG EG6033.tmp were created. The PCR evaluators did not address specific details of the design output specifications in the PCR because they believed that the design process that produced the specifications had already provided the required level of review and approval. Once the nonconforming condition was identified, an engineering evaluation and a 10 CFR 76.68 review was performed and approved by the Plant Operations Review Committee.
USEC desires to clarify one detail cited in this NOV:
The statement of violation incorrectly depicts that procedure CP2-EG-EG6031.tmp contains vacuum test acceptance criteria. This procedure tests instrument piping at pressures ranging from 25 pounds per square inch gauge (psig) to 220 psig. There is no vacuum test performed in the referenced procedure, 11.
Corrective Actions Taken and Results Achieved 1.
As stated in the response to NOV 97004-09, the revised vacuum test criteria for ESO Z90830 have been reviewed in an engineering evaluation in accordance with plant l
l-procedures. The evaluation provides a documented engineering basis for changes made to acceptance criteria. A Plant Change Review has been performed to address requirements of 10 CFR 76.68. The revised test procedures and associated updated review documentation have been satisfactorily reviewed and approved by the Plant Operations 1
Review Committee. This action was complete on August 12,1997, 2.
A recall of modification work packages from construction and maintenance crafts has ensured that similar problems do not exist with cther modifications. Newly created modification packages continue to be evaluated to ensure test plans are controlled as design output documents in accordance with plant procedures.
3.
As stated in the response to NOV 97004-09, requirements for the handling of changes to modification test plans were communicated (by Required Reading / Crew Briefing) to Design Engineering personnel. The specific lessons teamed from this event were discussed in the briefing, including the need to perform a 10 CFR 76.68 review of deviations from design specifications. Management expectations for rigorous compliance to procedure were also identified. This action was ccmplete on August 12,1997.
III.
Correclive Stens to be Taken The above steps are belirved adequate to prevent recurrence, such that no additional corrective action is required.
IV.
Date of Full Comnliance Full compliance was achieved when the engineering evaluation was peiformed to address the difference in acceptance criteria on August 12,1997.
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r CllRONOLOGY 07 ACTIVITIES Date Activity Nov. 5,1996 Initial PORC approval of Modification Package, including Test Plans.,
Modification Work Instructions, and associated 10CFR76.68 review May 29,1997 Modification Test Plan revised to add vacuum test (rev.1). The test criteria took exception to values specified in Engineering Specification 15137HP for pressure and duration.
June 19 Modification Test Plan revised to expand test boundary (rev.2)
June 26 NRC inspector initiates investigation of potential nonconforraance to requirements for control of procedures in regards to Test Plans.
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July 7 Test Plans were incorporated into draft Temporary Procedures and initial 10CFR76.68 review completed July 10 PORC approved Revision 0 of Temporary Procedures July 11 Revision 0 of Temporary Procedures distributed July 14 NRC exit debrief citer. failure to provide adequate review and approval of changes to original Test Plans and identifies addition of vacuum test as example of change.
August 4 NRC resident identifies potential nonconformance in documentation provided to support exception to vacuum test criteria identified in Engineering Specification 15137HP (exception was taken in the May 29 revision to Modification Test Plan). An Engineering evaluation was initiated to upgrade documentation.
August 5 NRC Inspection 70-7001/97004 issued, identifying the failure to perform an adequate review of the revised acceptance criteria.
Augua ;>
Instrument Maintenance initiates unsuccessful attempt to perform test procedure.
8 August 8 Engineering Management issues Stop Work and recalls all active modification packages to verify adequate work instructions and test plans.
August 12 PORC approval received for temporary procedures, updated PCRs and engineering evaluation.
August 25 NRC exit debriefidentifies issue with inadequate reviews for changes to acceptance criteria E3-3
ENCLOSURE 4 L
UNITED STATES ENRICliMENT CORPORATION (USEC)
REPLY TO NOTICE OF VIOLATION (NOV) 70 7001/97007-07 Technical Safety Reginrement 3.9, requires, in part, that written procedures shall be implemented for activities describcd in the Safety Analysis Report, Section 6.11, Appendix A.
Safety Analysis Report, Sec' ion 6.11.- Appendix A, describes, in part, procedure control as an activity for which procedures.< hall be implemented.
Procedure CP2-PS-PS1031; " Processing New Procedures and Deletions, " Revision 0, def'med, in part, the' process for developing, approval, and maintenance of new procedures for activities in the Appendix D.
Appendix D of Procedure CP2-PS-PS1031 identified, changes in equipment and facilities as activities requiring procedures.
Liolation Cited
_ Contrary to the above, between March 3 and July 15,1997, plant staff performed changes to the Building C-337A autoclaves using engineering instructions that were not developed, approved, and maintained in accordance with Procedure CP2 PS PS1031. Specifically, the procedures were not
- cross-discipline reviewed, defined as either regulatory or non-regulatory, designated as in hand,-
general intent, or administrative, or' otherwise processed in accordance with the procedure.
1.
Backmound The initial failure to properly review and control modification work instructions was cited as-part of Notice of Violation'97004-09, dated' August 5,1997 As discussed in IR 97007-07, the response to the earlier violation was directed toward controlling changes to approved -
engineering instructions as a part of the associated modification package ad did not address the use of these same engineering instructions vice approved procedures in their implementing documentation.
'II.
Reasons for Violation-Responsible individuals failed to implement procedural type controls for modification of
-work instructions because they were not aware that the documents incorporating modification work instructions must receive the same review, approval, control and 10 CFR E76.68 evaluation as provided for modification packages or procedures.. Additionally, the=
ins'. ructions / guidance provided by work control procedures were unclear regarding use of modification work instructions.
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- III, Corrective Actions Taken and Results Achieved 1.
Engineering management stopped all modification work certified for construction and reviewed modification field installation instructions (engin ering instructions), work packages and test plans. This stop work and review effort was addressed by Corrective Action Taken 11.2 of the response to NOV 97004-09.
Modification work packages were developed, reviewed, and approved as needed to bring the documents into compliance with plant requirements. For each modification, including the bulloing C-337A autoclave instrument upgrade, complete modification work packages were assembled to ensure necessary details were provided, including precautions, prerequisites, and step sequencing. Each modification work package received cross-discipline reviews, and evaluations were performed to assure they received the same review and approvals as modification packages including a 10 CFR 76.68 screening. Newly created moditication packagu continue to be evaluated and 1
controlled as described in this Modification Installation Recovery Plan identified in the response to NOV 97004-09. This was accomplished on August 14,1997 for the work packages for the autoclave instrument upgrade noted.
2, The procedure for development of maintenance packages, CP2-GP GP1032, Rev. 2, change B, " Work Control Process," was revised August i1,1997, to more clearly define requirements associated with the use of modification work instructions, " skill of the craft," and required reviews. Complementary changes svere also made to CP2-PS-PS1031, " Procedure Control Process." These actions address the broader issue of the need to clarify requirements associated with review, approval, control and 10 CFR 76.68 evaluation of maintenance or modification work instructions implemented in the work control process.
3.
Training, briefings, or required reading for work planners and Maintenance Front Line Managers on the subject changes to CP2-GP-GP1032 were completed October 17, 1997.
111.
Corrective Stens to be Taken The above actions are believed adequate to preclude further violation.
IV.
Date of Full Compliance Full compliance with this violation was achieved ot August 14,1997 when engineering instructions cited and associated maintenance work packages were reviewed and approved in accordance with the Modification Installation Recovery Plan.
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ENCLOSURES i
UNITED STATES ENRIClih1ENT CORPORATION (USEC)
RESPONSE TO NOTICE OF VIOLATION (NOV) 70-7001/97007-20 Technical Safety Requirement 3.9 requires,in part, that written procedures shall be prepared and
, implemented for the environmental protection program as specified in Technical Safety Requirement 3.16.
Procedure CP4-EW EVi 100," Environmental hionitoring Notebooks " Section 6.2.5 required, in part, that if calculations were recorded in a notebook, at least ten percent of the calculations were to be reviewed by the supervisor or another technician, and the signature of the reviewer and review date were also to be logged in 'he notebook.-
Xiolation Cited _
Contrary to the above, for the period hiarch 3 to August 12,1997, the environmental nn -
ring group maintained two notebooks in which calculations were recorded that were not check (ed) in accordan with Procedure CP4 EW-EV1110. Specifically, notebooks which included American-Sigma refrigerated composite sampler and flowmeter data and calculations were maintained but were not reviewed as required by CP4-EW EV1110, Rev. O.
1.
Backcround Information The intent of Procedure CP4 EW EV1110 was to perform calculation checks / reviews for critical or diflicult calculations, or for calculations prone to errors, such as repetitive
. calculations; whereas, the subject American Sigma composite sampler and flowmeter calculations are simple, straight-forward tasks. In one case, sampling tubing length is divided by the time required for water to flow from the tubing inlet to a fixed / measured mark, to give flow velocity in feet per second. The other :alculation involves dividing a flowmeter display reading by water flow determined from a flume reading, multiplied by 100, to determine percent agreement.
Ili Reasons for Violation The reason for this violation was that responsible management was not rigorous in either fully implementing the procedure or properly communicating the intention of the procedure by defining, listing or marking those activities that were intended to require calculational checking.
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III.
Corrective Actions Taken and Results Achievgl Responsible management took the following corr ctive actions to assure that the intent of Procedure CP4 EW-EV1100 was understood and that the requirements thereof were being fully implemented:
1.
At least ten percent of the calculations in the logbooks cited in NOV 97007-20 (Calibration Logbook staning Febmary 18,1997, and American Sigma Flowmeter Logbook starting December 1995) were reviewed pursuant to Procedure CP4-EW-EV1110 on August 12,1997. No calculational errors were found.
2.
All other current environmental monitoring / sampling logbooks were also reviewed to confirm that at least ten percent of the calculations were being checked in accordance with Procedure CP4-EW-EV1110.
3.
On October 3,1997, it was determined that, contrary to the literal requirements of Procedure CP4-EW-EV1110, some calculational checks had been documented via the initials versus signature of the reviewer. This discrepancy was corrected.
4.
Management continues to implement the calculation check and signature verification requirements of Procedure CP4-EW-EVi 100 as written. (However, at some future date, Procedure CP4-EW-EV1110 may be revised: (1) to specify where initials are acceptable and where a signature is necessary; and/or (2) to define criteria for determining when calculation checks are required and to specify those that currently require such checking.)
IV.
Corrective Actions to be Taken No further corrective actions are planned; the above actions are considered adequate to correct and preclude recurrence of the cited deficiency.
- V.
Date of Full Comnliance Full compliance was achieved when the above mentioned corrective actions were completed on October 3,1997.
ENCLOSURE 6 LIST OF COhihilThiENTS Endonati l
- 1. Change Step 6.2.2 of Procedure CP4.SS Nhillll by November 26,1997, to require Riture revisions of Tate Weight Book NhiC&A 01 to be submitted to DC.
- 2. Cornplete DC Program renalning for PGDP Group hianagers by December 5,1997.
EndasttL2 Example a I
- l. Issue a new Fire Services abnormal operating procedure to addass TSR and non TSR compensatory measures to be taken for inoperable fire protection systems and components and train FS personnel on the procedure by December 5,1997. This action will incoq orate the informatlun contained in the memorandum issue to FS Supervisors on August 6,1997 (Action 1 in part 11 (Corrective Aq1[ons TaktD. add SCElts Achleved]).
- 2. An actior been developed to address the failure ofhiaintenance, Operations, and Fire Services to follow,
edure with regard to the signature for " Permission to Start Work" and use of the Appendix i.
P4 S3 FS6117. This action is included in the Summary following Example c of this violation.
Example b
- 1. Revise affected plant procedures to incorporate opening / closing nitrogen cylinder valve and documenting on the data sheet that the nitroEen cylinder valve is in the open position following maintenancehesting by October 31,1997.
- 2. An action has been developed to address the failure of maintenance personnel to verify that actions donc during maintenance are returned to original status following the wmk. This action is included in the Summary following Example c nf this violation.
Example c
changed by November 14,1997, to incorporate the guidance from hiaintenance Functional Directive No. 97 027.
2, An action has been developed ta address the failure of hfaintenance to ensure equipment is removed from service when found out of operating parameters. This action is included in the Summary E61
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l Summary 4
- l. -To specifically address the weaknesses as described in the examples of this violation. Maintenance, Opeintions, and Site and Facility Services will prepare a lessons learned summary of each example I and have their Front l.ine Managers present the summary to theit work groups by December 11, 1997. As a minimum, this summary willinclude a briefdescription of the event and a description of the causes (e.g., failure to follow procedure, ineffective coordination between work groups, T
ineffective post. maintenance activity, inadequate shin tumover, etc.).
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linclosure 4 None None r
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