ML20235F657
| ML20235F657 | |
| Person / Time | |
|---|---|
| Site: | Summer  |
| Issue date: | 09/18/1987 |
| From: | Belisle A, Moore R, Runyan M, Shannon M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | |
| Shared Package | |
| ML20235F629 | List: |
| References | |
| 50-395-87-20, NUDOCS 8709290266 | |
| Download: ML20235F657 (23) | |
See also: IR 05000395/1987020
Text
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UNITED STATES
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NUCLEAR REGULATORY COMMISSION
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101 MARIETTA STREET, N.W.
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ATL ANTA, GEORG! A 30323
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Report No.:
50-395/87-20
Licensee:
South Carolina Electric and Gas Company
Columbia, SC 29218
Docket No.:
50-395
License No.:
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Facility Name:
Summer
Inspection Conducted:
July 13-24, 1987
Inspectors:
(b/ .hn /b m
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R. M6 ore
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Date Signed
1kwe%
9l18l87
M. Runy n
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Date Signed
IBh2
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M. Shannon
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Date Signed
Accompanying Personnel:
K. Jur
Approved by:
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A. Belisle, Chief
D&te Signed
Quality Assurance Programs section
' Division of Reactor Safety
SUMMARY
Scope:
This routine, announced inspection was conducted in the areas of design
changes, operations / surveillance testing, ability to identify and then resolve
maintuance, and qua'lity assurance
and was intended to verify the licensee s
plant deficiencies.
Results:
Four violations were identified:
failure to provide design input
for modifications, failure to perform an adequate design analysis for
modifications, failure to follow an operating procedure and an
inadequate operating procedure, and inadequate review of previous
audit findings for adequacy of corrective action implementation.
8709290266 870922
ADOCK 05000395
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REPORT DETAILS
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1.
Persons Contacted
Licensee Employees
D. Arthur, Security Administrative Supervisor
- L. Blue, Manager, Support Services
- M. Browne, Group Manager, Technical & Support Services
- R. Campbell, Independent Safety Engineering Group
R. Clary, Manager, Nuclear Engineering
R. Clay, Manager,' Nuclear Engineering Group
- M. Clonts, Manager, Modification and Control Services
R. Cox, Supervisor, Mechanical
L. Cunningham, Surveillance Specialist II
T. Curtain, Supervisor, Project Engineering.I&C
R. Davis, Surveillance Specialist I
8. Estes, Senior Engineer, Mechanical
D. Fleming, Apprentice Technician
- W. Frady, Associate Manager, Quality Assurance
T. Franchuk, Surveillance Specialist II
- M. Ganett, QA Supervisor, Maintenance
- D. Gentry, Associate Manager, Nuclear Security
J. Gordan, Procurement Engineering
M.' Hazel, Mechanical Engineer, Project Engineering
- S. Hunt, Manager, Nuclear Quality Control
- A. Koon, Manager, Technical Support
H. Kunkle, Surveillance Specialist II
- F. Leach, Manager, Quality Assurance
T. Lovett, Technician
E. Lynch, Surveillance Specialist II
G. Moffat, Associate Manager, Project Engineering
- A. Monroe, Regulatory Compliance
- D. Moore, Director, Quality and Procurement Services
G. Mundy, Senior Technician
- D. Nauman, Vice President, Nuclear Operations
- K. Nettles, Group Manager, Technical Services
L. New, Surveillance Specialist III
C. Osier, Associate Manager, Maintenance Engineering
- A. Paglia, Manager, Nuclear Licensing
J. Proper, QA Supervisor, Operations
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- G. Putt, Manager, Scheduling
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- M. Quinton, Manager, Maintenance Services
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R. Rusaw, I&C Engineer
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- J. Skolds, Deputy Director, Operations and Maintenance
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- G. Soult, Manager, Operations
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R. Sweet, Surveillance Specialist II
C. Tyler, Surveillance Specialist II
- D. Warner, Manager, Nuclear Fuel Management
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R. Waselus, Electrical Supervisor, Project Engineering
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- M. Williams, Group Manager, Nuclear Regulatory & Developmental Service
- W. Williams, Specialist Assistant, Nuclear Operations - Santee Cooper
Other licensee employees contacted included engineers, technicians,
operators, mechanics, security force members, and office personnel.
NRC Resident Inspectors
- R. Prevatte, Senior Resident Inspector
- Attended exit interview
Acronyms and Abbreviations
AI
Administrative Instruction
Corrective Action Request
Engineered Safety Feature
Final Safety Analysis Report
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Health Physics
~ Instrumentation and Control
' Inservice Inspection
JC0
Justification for Continued Operation
MCN
Modification Change Notice
Management Directive
MRF
Modification Request Form
NCN
Nonconformance Notice
NOD
Nuclear Operations Department
Nuclear Steam System Supplier
PSRC
Plant Safety Review Committee
Quality Assurance
Q-List
Quality List (Safety Related Items)
QPS
Quality and Procurement Services Procedure
Reactor Coolant Pump
Safety Injection
SPP
Security Procedure
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TS
Technical Specifications
TWR
Technical Work Record
VAC
Volts-Alternating Current
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Exit-Interview
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The-inspection scope and findings were summarized on July 24, 1987, with
those persons indicated in-paragraph I above.
The inspector described the
areasLinspected and discussed in detail the inspection findings.
No
dissenting comments.were received from the licensee.
Violation:
Failure to Provide Design _ Input for Modifications,_
paragrah 6.
Violation:
Failure to Preform an Adequate Analysis Before Making a
Design Change,-paragraph 7.
Violation:
Failure to Follow an Operating-Procedure and an
Inadequate Operating Procedure, paragraph 7.
-Violation:
Inadequate Review of Previous Audit Findings for Adequacy
of Corrective Action Implementation, paragraph 9.
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The licensee did not identify as proprietary any of.the materials provided
to or reviewed by the. inspectors during this inspection.
3.
. Licensee Action on Previous Enforcement Matters
Thissubjectwasnotaddressedintheinspection.
- 4.
Unresolved Items
Unresolved items were not identified during this inspection.
5.
General Background
The intent of this inspection was to assess South Carolina Electric and
Gas' '(SCE&G) quality assurance effectiveness.
For the purposes of this
inspection, quality assurance effectiveness is being defined as the
ability of the licensee to identify and correct their own problems.
The
term quality assurance effectiveness is used in this application, but it
is not meant to be limited to the licensee's Quality Assurance Department
or the Quality Assurance Program.
Those elements are part of a broader
focus'on the licensee's commitment to quality.
Other elements include all
. personnel, procedures, polices, training, attitudes, etc.
The premise of this inspection was that the overall intent of quality
assurance is to ensure safe and reliable operations and that the ultimate
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effectiveness of the licensee's program to ensure quality can be measured
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objectively by examining various operational performance indicators.
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increase in the number or severity of licensee event reports (LER), a'
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decline in the' availability of safety systems, or- an increase in. the
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-number of reactor trips, for example, indicate a problem in the. licensee's
program to ensure quality.
It-indicates, irrespective of compliance to
regulatory requirements, an area where quality assurance is ineffective.
'This: inspection, therefore, was performance - based rather than compliance
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- based.
In the past, the " bottom line" during inspections was whether
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regulatory requirements were being met.
The " bottom ifne" during this
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inspection was whether the intent of the requirements is being achieved.
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6.
Design Changes
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The licensee's quality assuranca effectiveness in the area of design
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changes was assessed by reviewing' 7 recent design changes, 16
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non permanent design changes, quality assurance audits performed in this
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area, and nonconformance notices for the last 18 months for which design
error was determined the chief case.
The intent of the inspection was to
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. conduct a broad assessment of the effectiveness of the licensee's program
to implement changes to existing plant configurations.
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The licensee's program provides two methods for documenting a design
change:
an MRF and an NCN.
The MRF is the normal scheduled method to
implement a change.
Design changes may also proceed from NCNs when action
to correct the nonconformance results in a change to the plant
configuration.
If this change is major, an MRF is generated which then
supersedes the NCN as the design change implementing mechanism.
Design work is performed primarily by the licensee's nuclear engineering
group and their design consultant.
Generally, extensive projects are
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handled by the design consultant as well as certain elements, such as
design calculations and seismic analyses, of less extensive projects for
which the licensee's engineering group has primary responsibility.
The inspector reviewed the last two QA audits performed in the area of
design control.
Audit II-3-87-G, Station Design Control, was performed
from February 4 to March 26, 1987, and issued April 22, 1987.
The major
audit finding was that one in five 10 CFR 50.59 evaluation analyses were
determined to be deficient.
These deficiencies included a lack of
justification to support answers to the unreviewed safety question
determination, that the justification given was merely a restatement of
the unreviewed safety question phraseology or didn't sup3 ort the answer
given.
Other findings involved minor administrative
ssues.
The
inspector's followup on the major finding of this audit is documented
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later in this section.
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Audit II-2-86-G, Station Design Activities, was conducted February 10 to
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February 26, 1986, and issued March 27, 1986.
Findings involved failure
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- to document 1certain reviews, out-of-date- drawings, inadequat'e' handling of
training . records, inadequate distinction between seismic _ qualified and
seismic mounted equipment, Q-List anomalies, and other administrative
discrepancies.
Corrective action for these items appeared complete and
expeditious.
The inspector reviewed the'following design change packages:
MRF
10659
Move Hilti-801t Location
~MRF
20801
RC Wide Range T-Hot and T-Cold
MRF.
20995'
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- MRF
21008
Diesel Generator Emergency Cooling
MRF
~21215
Relocation of Regulator and Relief Valves
MRF
21225
Invertor Capacitor Mounts
- MRF
31968
NI-33 Separation
The asterisked MRFs were generated by the licensee's design consultant.
All others were performed by the site engineering group with perhaps some
assistance from the design consultant.
During this review problems were identified with MRF 10659, 20801, 20995,
21215, and 21225.
This problem is further discussed in another section of
this report.
The ins)ector . concentrated on the adecuacy of the 10 CFR 50.59 safety
evaluat ons performed for the above design changes in light of the 1987 QA
audit finding.
In contrast to the audit findings, there were no instances
where there appeared to be a lack of reasonable justification for answers
given to the standard safety evaluation questions.
In addition, each MCN
or change to the original MRF package was adequately addressed as to its
. impact on the base 10 CFR 50.59 evaluation.
The inspector's sample of MRF
packages was totally separate from the sample taken in the QA audit.
The
corrective action taken for the QA audit finding ' appears to be adequate
and the inspector concluded that the licensee's requirements to document
10 CFR 50.59 evaluations were being met.
A weakness inherent in each design package reviewed was a lack of order
- and coordination in the structure of the package.
The TWR and associated
design documents often appeared to be more a random collection of field
notes than a finished design product.
This situation created much
uncertainty in the inspector s _ package review and often necessitated
interviewing the lead engineer for clarification.
In each case the lead
engineer provided adequate clarification; however, the fact that the
packages are not formally structured and clearly presented has the
potential to cause problems for the design verifier, especially if the
lead engineer for some reason is not readily available for consultation.
The inspector did not find any specific problems directly attributable to
this issue, but the licensee needs to be aware that the degree of
informality present in the finished design packages may eventually lead to
quality compromises.
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The design package reviews appeared to be commendably complete and in-
depth.
This includes both the official design verification and the QA
review.
The design verification review was well documented and included
some rather substantial comments which were thoroughly addressed and
corrected or clarified.
Each design package received a thorough QA
review, which is a very good practice.
Every QA review raised some
interesting questions from both an administrative and technical
perspective and each issue was conscientiously addressed and documented.
The licensee's program for updating essential drawings affected by a
modification requires the formation of interim drawings for such time as
the modification is in progress and the completion of final as-built
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drawings once the change is complete.
The inspector reviewed drawing
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changes made for MRF 20995 and verified that all changes where made as
documented in the design package.
Bwed on interviews with licensee
personnel, it appeared that a drawing update backlog, in the sense of a
growing number of unfinished drawings, did not exist.
The system for ensuring that training is provided to personnel affected by
a design change and that necessary procedures are revised appeared to be
excellent.
The process is handled administrative 1y by an interface review
form which is sent from the lead engineer to various group heads.
The
responses are collected by the lead en
ultimately approved by his supervisor. gineer and the entire process is
A spot check of procedures cited
for revision did not reveal any discrepancies.
The licensee relies heavily on its design consultant for complicated
technical work such as design calculations and seismic analyses.
Apparently, much of this work is not reviewed by the site engineering
group in that the design verification is also performed by the consultant.
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In light of this situation, the inspector requested the most recent QA
audits performed at the consultant's office to verify that requirements to
ensure the adequacy of procured services were being met.
The audits
(dated October 11, 1985, and September 25, 1986) of the consultant's QA
program and activities were quite extensive and appeared to encompass the
total service range provided to the licensee.
Identifying findings,
formulating corrective action, and subsequent followup in response to
these audits provided reasonable assurance that the licensee had taken
adequate measures to assure the quality of work provided by the
consultant.
Guidance for post-modification testing was somewhat lacking in the MRF
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packages, but this was partly the result of the design program previous to
August 1986 when functional tests and electrical check-outs were
identified and performed by groups other than the engineering department.
As of the August 1986 revision to the Technical Services procedures, the
Nuclear Engineering group is responsible for specifying functional tests,
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if required.
These tests must be performed.to ensure that the design
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intent was. met by the modification.
The inspector verified that design
packages originated after the procedural change, included the
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specification of functional tests when needed.
The. inspector selected several design calculations at random to spot ~ check
computational accuracy, methodologies used, and resultant determinations
as to the acceptance of the design.
This review did not reveal any
errors.
The following additional. aspects of design packages were reviewed and
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appeared adequate:
Specification of materials and parts
Appendix R reviews
Documentation of PSRC review
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Determination of effect on TS operability
10 CFR 21 evaluations
FSAR revisions
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The inspector reviewed the following non permanent (temporary)
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modifications:
MRF Number
Description
20944
Unserviceable U.V. Relay
20984
Auxiliary Building Operator Watch Station
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21074
Temporary Replacement of the Liquid Waste
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Monitor Tank Pump "A"
21098
Hard Pipe for Vent Valve XVT-11091
21146
Temporary
Replacement of the Waste
Evaporator Feed Pump
21166
Temporary Pump Replacement for RCDT
21186
Temporary Penetration Sealing Apparatus
21191
Torsional Testing on Turbine Generator
21196
Temporary Modification of FW Piping for
Vibration Analysis
21206
Temporary Demin Feedwater to Auxiliary
Boiler Transfer Pumps
21222
Motor Driven Emergency Feedwater Test
21227
Temporary C Chiller "SI" By-Pass
21232
Reactor Building Purge Supply Valve Repair
21240
Condensate Polishers Kidney Loop Blanks
31738
Speed Switch Temporary Modification
31952
Removal Inverter CSR Relay
This list comprised most of the non permanent modifications in effect
since January 1986.
This list included both safety-related and
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non-nuclear safety systems, and both open and closed modifications.
The
licensee administers temporary modifications with the same administrative
procedures used for permanent modifications. This eliminates some of the
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typical deficiencies found in temporary modifications which result from
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less formal and less stringent requirements. No examples were found where
a temporary modification was retained for an inordinate amount of time.
Management has a clear policy of limiting the backlog of temporary
modifications, reevaluating existing oras, and converting them to
permanent modifications as the situations dictates.
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paragraphs, specific issues involving the review of non-permanent
modifications are discussed.
MRF 21232 involved the removal of actuators and the installation of
locking devices on 36 inch containment purge supply and exhaust isolation
valves.
The- inspector questioned the licensee's compliance to TS 3.6.1.7
which states that these valves must be operable during modes 1, 2, 3, and
4 and how TS 4.6.1.7.1.b is satisfied to verify that the valves are sealed
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closed at least once per 31 days. Discussions with-the resident inspector
identified that the NRC had previously reviewed this temporary modifica-
tion.
Since these valves must remain closed in modes 1, 2, 3, and 4,
they are considered operable in the closed position and the fact that
they are locked closed provides reasonable assurance that they will remain
sealed after they are verified.
MRF 21227 involved rearranging the control circuitry to allow the
C-Chilled Water Pump and C-Chiller to be run prior to being declared
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operable (to remove impurities) without violating TS 4.8.1.1.2.e.5.c which
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requires (by design documents) that no more than one chilled water pump
and one chiller be connected to an ESF bus and be capable of starting at
any one time.
The statement was made in the MRF package that this system
will be returned to the original design condition by July 1,1987, or
earlier.
This deadline was not met and it was not administratively
extended, but the inspector verified that the existing configuration was
not a safety concern and that this administrative oversight was an
isolated example.
MRF 20944 involved a failed undervoltage relay input to the RPS system on
one of the three phases of the A .RCP motor.
The modification inserted a
pennanent undervoltage signal which had the effect of creating a two out
of two logic instead of the normal three out of three logic input to RPS.
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This change was in the conservative direction.
The inspector investigated
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reasons for not having replacement relays in stock and the lengthy
procurement delay for a replacement, but concluded that neither case was
unusual.
MRF 31952 involved removing the overcurrent sensing relays for 120 VAC
vital power systems.
Although the relays do not perform an accident
mitigating function nor are involved in any accident analysis,
the NSSS
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supplier consistently recommended that they be replaced.
The licensee
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desired to _ remove them permanently because of a high failure rate,
but
the licensee and the supplier could not agree on this point.
The licensee
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documented an engineering justification with the concurrence of the design
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consultant that the output breaker invertors are self-limiting and that
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bus components and connecting cabling are adequately sized to handle the
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maximum fault current on a continuing basis, concluding that the temporary
modification could be extended indefinitely.
Although neither the
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inspector nor the licensee understood the supplier's position on this
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issue, it appeared that the licensee had adequately justified the
modification at least from a nuclear safety standpoint.
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MRF 31738 involved locking the Component Cooling pumps in low speed and
Service Water pumps in high speed due to repeated failures of the
operating mechanisms on the associated speed changing switches.
The
inspector reviewed the vital FSAR references given in the 10 CFR 50.59
safety evaluation and concurred that this pump speed configuration
satisfied the accident analyses for plant operations.
A concern was
expressed about the statement (in the MRF package) that since the system
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will be running in high speed, ' inservice' testing of the high speed mode
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will not be required as long as this MRF is in effect.
The inspector
verified that high speed ISI testing of the Service Water pumps was still
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being _ accomplished and that the intended comment was that low speed
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testing would not be required.
This temporary modification was made
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permanent by MCN "G".
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In ' general, the temporary modifications review revealed that safety
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evaluations,
testing
requirements,
interface reviews,
training,
procedures, procurement, and other issues were being addressed with the
same degree of attention afforded permanent modifications.
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The inspector reviewed the temporary bypass, jumper, and lifted lead log
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maintained in the control room.
None of the six bypasses, jumpers, or
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lifted leads were applied on safety-related equipment nor were any of them
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maintained for an excessive period of time.
Licensee personnel were
complying with their procedure to review the status of ex h item once each
month to justify its continuation.
A good indicator of the overall performance achieved by a design
organization is the frequency and severity of nonconforming conditions
which are caused by design errors.
The inspector reviewed the following
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NCNs issued since January 1986, for which design error was determined the
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chief cause:
NCN No.
Description
2340
Lack of Supports for Spent Fuel Pit Bridge Crane
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Loose Set Screw and Switch Misalignment for the
Diesel Generator
2356
Power for the
"C" Chiller Anti-Recycle Bypass
Circuit Timers not Provided from Uninterruptable
Source
2357
JC0 for Circuit Breaker Deviation with FSAR
2370
Test Cubes for Grouting Fails to Reach Required
Strength
2374
Documentary Contradiction of Fire Damper
Locations
2416
Damaged Fire Wall
2461
Timing Relay not in Conformance with Design
Drawing
2567
Wallplate Not Installed Per Design Specifications
2606
Welding not Conducted per Drawing
2716
Rosemount Transmitters Electrical Connections not
Sealed
The inspector's review of this material did not disclose any instances
where it appeared that a design error transmitted through a design change
had caused the nonconformance.
It appeared that the licensee had
adequately addressed each _ nonconformance area and achieved a reasonable
solution.
Within this area, one violation was identified.
The licensee is committed
to Regulatory Guide 1.64, Revision 2, which endorses ANSI N45.2.11-1974
Quality Assurance Requirements for the Design of Nuclear Power Plants.
Section 3.1 of this standard states the following:
Applicable design inputs, such as design bases, regulatory
requirements, codes and standards, shall be identified, documented
and their selection reviewed and approved.
Changes from specified
design inputs including the reasons for the changes shall be
identified, approved, documented and controlled.
The design input shall be specified on a timely basis and to the
level of detail necessary to permit the design activity to be carried
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out in a correct manner and to provide a consistent basis for making
design decisions, accomplishing design verification measures, and
evaluating design changes.
The intent of this standard had not been met for any site-generated design
change packages reviewed by the inspector (MRF Nos. 10659, 20801, 20995,
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21215, and 21225).
Specifically, design inputs for these design changes
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were not formally identified, specifically approved, nor presented in
necessary detail to meet the intent of the standard.
Nowhere in the TWR
was any information formally identified as design input.
The TWR
contained a collection of statements and information but did not offer a
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formal distinction between design inputs, assumptions, speculations,
useful information, etc.
The intent of the ANSI standard is that the
design input be officially identified as such.
The requirement that the
design input selection be reviewed and approved was not met.
The only
review afforded the design input selection was the design verification,
which is' an overall design package review, but not the specific, focused
design input review and approval called for by the ANSI standard.
The
design inputs included in the TWR were not presented in necessary detail
to meet the standard's intent, especially for providing a consistent basis
for accomplishing design verification measures.
In all cases, a complete
reference was not provided concerning design bases, regulatory require-
ments, codes, and standards used in formulating the finished design
product.
Any changes made to the design inputs were also not formally
documented.
In general, the licensee failed to positively control the use
of design inputs for site generated designs.
Design changes assigned to
the design consultant appeared to meet the requirements of the ANSI
standard for design input control.
This issue is identified as Violation
395/87-20-01, Failure to Provide Design Input for Modifications.
The overall assessment of the design control area is that quality
assurance effectiveness is average to good in comparison to other
licensees.
Good attitudes toward quality, high knowledge levels, and an
improving trend are evident.
7.
Operations / Surveillance Testing
The licensee's quality assurance effectiveness in operations and surveil-
lance testing was assessed by reviewing various surveillance, procedures,
and calibrations and by performing system walkdowns and equipment
inspections.
The quarterly pump surveillance
for the SW pumps, SW booster pumps and
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the component cooling water pumps were reviewed.
The surveillance
appeared to be satisfactory.
It was noted that total SW flow cannot be
accurately obtained at the detector location in the SW Pump House.
The
inaccuracy is due to the detector location being too close to the pump.
The licensee is now assessing possible modifications to resolve this item.
It was noted during the review of the SW pump surveillance that flow to
various components was being throttled to help the SW booster pumps meet
their acceptance criteria.
Due to the throttling in the system various
relief valve setpoints had to be increased.
The QA group addressed the
throttling and relief valve problems in an audit finding.
Engineering
addressed both issues and was able to provide supporting evidence for the
flow limits and relief valve setpoints.
Conservative administrative
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limits were set for the various throttled flows.
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.The monthly SW system valve l'ineup verification surveillance, STP-123.001,
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was ' reviewed and the SW system was walked down to verify valve positions._
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It was- noted that the valves that supply cooling water to the SW pump oil
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. coolers and gland ' seals were not included in the surveillance.
These
valves supply SW' cooling to safety-related components and need to be
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Also, it was found.that the SW pump
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lube oil coclers did not have the required cooling flow.
There was: a
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discrepancy between the SW pump operating procedure and the daily logsheet-
taken by the auxiliary operator.
Procedure 50P 117, SW System Operating
Procedure, lists the required flow for the upper bearing as 10.to 12
gallons per minute' and the flow for the lower bearing as 3 to 4 gallons
per minute.
The lower bearing flows on both SW pumps were found to be 2.2
gallons. per minute and for the upper bearing on the "B"_ SW pump, flow was
found to be-8.0-gallons per minute.
The licensee stated that the minimum
flows were based on a maximum SW pump discharge pressure decrease during
accident conditions while still maintaining adequate-cooling flow to the
bearing lube oil heat exchangers.
Flows were increased to the correct
values and the licensee' indicated that the logsheet would be revised to
show the correct limits.
.The concern with this item is that the operating procedure and the daily.
'logsheet did not reflect'the same requirements.
This can be an indication
that the procedure may not be used by the operator during pump startup'or
that sufficient attention has not been placed on ensuring that procedure
and logsheet criteria are identical.
'The inspector also noted that the precaution section of the SW motor
operating procedure did not list the motor restart requirements as listed
on the motor data plate.
Basically, the manufacturer requires that the
operator wait five minutes after the first start and then for third start
to wait _20 minutes if the motor was not running and 45 minutes if the
motor was running.
This. requirement is for protecting the motor windings
from over heating and causing winding damage.
The licensee indicated that
the operating procedure would be revised to include the applicable restart
requirements.
The issues of not following an operating procedure and
inadequate operating procedure are identified as violation 395/87-20-03.
During a walkdown in the SW pump house it was noted that the temperature
in the room appeared high.
One of the fan units was being repai red and
outside temperature was 94 F.
The control room indication for the SW pump
room was 94 F.
A thermometer was taken out to the SW pump room and
temperatures were measured by the licensee at various points in the room
and at the motor ventilation inlets.
Room temperatures varied between
103 F and 106 F and the motor inlets read 104 F.
Technical Specification 3/4.7.11 lists the maximum SW pump room tempera-
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ture as 102 F for entering the action statement.
The action statement
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requires that a special report be sent to the Commission if the room
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temperature is above the TS limit for more that eight hours.
The TS limit
is based on the environmental qualification (EQ) requirements of the
equipment 'in the room.
The Westinghouse Evaluation of Motor Insulation
document and the V.
C. Summer Summary Sheet for the Environmental
Qualification of Electrical Equipment in Mild Environment Areas for the SW
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motors were obtained from the licensee.
The documents show that the SW
motors are rated for 40-year continuous life at 104*F.
The 102 F TS limit is based on the EQ requirements of the service water
pump motors.
The air temperature entering the motors is the limiting
parameter. for ensuring that the TS limit is not exceeded.
This also
ensures that the EQ requirements are not exceeded.
>
The licensee had previously addressed the SW pump room temperature problem
and had considered the problem resolved.
Larger air coolers had been
installed and the room temperature detectors had been moved. The modifica-
tion that moved the detectors appeared to have been inadequately analyzed.
The licensee had taken various room temperature readings and had
determined that the original detector location was not representative of
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actual room temperature.
With this data the licensee justified changing
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the detector location to its present position in the pump room ceiling.
During the temperature data taking, the licensee failed to take moter
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ventilation inlet temperatures or to take temperature readings at the
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proposed detector sites. .The detectors were then moved to a location that
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had not been analyzed to verify that it would be representative of actual
room temperature.
Another room temperature test was performed on July 21, 1987.
The results
indicated that the room temperature detectors were placed in a
non-conservative location because they indicated 3-4 degrees below the
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observed room thermometer readings and 6 degrees below the motor inlet
reading on the "A" SW pump motor.
It appears that the ventilation system
is affecting the temperature detectors.
Cooler air enters at the ceiling
level and exits at the ceiling level.
This effects the temperature
detectors which are now located on the ceiling since they now detect the
cooler ventilation system air temperature.
A modification is needed to
force the inlet air down to the floor level for better room air mixing.
During the course of the inspection the licensee indicated that louvers
would be placed on the ventilation inlets to force the cooled air to the
floor area.
The licensee also indicated that a TS change to increase the
SW pump room temperature would be pursued.
The licensee indicated that TS limit of 102 F was not exceeded because the
room temperature detectors did not exceed 102 F.
The inspector has
indicated that the equipment is surrounded by air that exceeds the 102 TS
limit and this violates the intent of the room temperature TS.
This issue
is identified as Violation 395/87-20-02, Failure to Perform an Adequate
Design Analysis.
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During a walkdown of the SW system it was noted that the "A" SW screen
wash pump had been tagged out of service for 18 months.
MRF 20992 had
been generated to remove the old pump because it needed to be repaired.
The QA review, dated March 3, 1986, for MRF 20992, step 2, stated "suggest
a clarifying note be added to the essential drawing' note include in the
removal" and step 2 of the acknowledgement stated, , showing the motor
flow diagram." A working copy of D-302-221, Rev.14, which shows the "A"
SW screen wash pump, does not indicate that the pump has been removed as
stated by the QA request.
This drawing discrepancy appears to be an
,
isolated example; consequently, a violation is not warranted.
This
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discrepancy was brought to management's attention for resolution. The
screen wash pumps are not required when the SW pumps are run in fast
speed, as they are currently.
MRF 21073 is now being processed to remove
all of the SW screen wash pumps during the five-year plan to be submitted
in 1989.
The ' Spent Fuel Pool Ixhaust system radiation monitor, RMA6, was inspected
for TS compliance and for compliance to the manufacturer's maintenance
calibration requirements.
The monthly and 18-month surveillance were
reviewed.
Twenty-four monthly surveillance
were reviewed and the
following discrepancies were observed:
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a.
The "TS allowable value" was improperly calculated higher than
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allowable in two instances.
The adjusted setpoint was in the
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allowable range.
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b.
Five of 24 as found settings were above the previous TS allowable
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value.
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c.
The 18-month calibration performed on December 21, 1985, may have been
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inadequate in that after the calibration the background reading
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increased from about 125 cpm to about 350 cpm.
After the 18-month
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calibration performed on July 28, 1986, the background reading
returned to approximately 100 cpm.
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Due to seven off normal occurrences identified in 1985, the licensee took
corrective action to eliminate the problem with the various radiation
monitor hi-alarm setpoints.
The setpoints were found to be set above the
previous TS value.
Changes to the hi-alarm setpoint were apparently made
due to changing background radiation.
Procedure requirements were changed
and responsibilities were shifted from I&C to HP.
The changes appear to
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have been effective because discrepancies have not been identified since
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June 1986.
The fluctuations in background readings, following the 18-
month calibration, may require further management attention.
The quarterly surveillance STP 501.002, for the vital batteries was
reviewed for TS compliance.
The last four quarterly surveillance for 1A
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and the IB batteries were reviewed.
It was noted that two individual cell
voltages were recorded out of tolerance low at 2.13 VDC and 2.14 VDC.
The
administrative limit for cell voltage is >2.15 VDC and the TS limit for
cell voltage in >2.13 VDC. -These items were not noted in the remarks as
required by procedure nor noted as out of tolerance by the reviewer.
A
random sample of about 20 weekly battery surveillance, STP 503.001, were
reviewed and they were satisfactory.
This discrepancy appeared to be an
isolated example; consequently, a violation is not warranted.
The
discrepancy was brought to management's attention for resolution.
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Instrument calibration packages were reviewed to ensure that instruments,
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used for TS surveillance data, were proper:y calibrated.
The calibration
program appears to be excellent.
A total of 28 different instrument
packages were reviewed.
A few minor administrative discrepancies were
noted such as completion of "Date" section following the " Performed By"
section.
It was also noted that in one instance the test results were not
reviewed within seven days as required.
The overall assessment of the
surevillance program and plant operations is that these areas are above
average.
In the areas of calibration and maintenance, the licensee appears to be
excellent.
Various inspections throughout the plant revealed that the
plant is maintained in a excellent condition.
A high degree of
cleanliness was observed thoughout the plant, not just on the normal tour
routes.
Interviews indicate high knowledge levels and a professional
attitude.
The licensee appears to be identifying deficiencies and taking
adequate corrective action.
8.
Maintenance
The licensee's quality assurance effectiveness in the area of maintenance
was assessed by reviewing maintenance work requests and reviewing various
maintenance activities.
The Quarterly Plant Performance Indicator Report data for maintenance
trended the volume of corrective and preventive maintenance completed and
opened during the quarter .
Additional programs which identify problems
are the Equipment Aging Report, ISI Program for Pump and Valves and the
Nuclear Plant Reliability Data System (NPRDS).
All Maintenance Work
Requests (MWR) are trended via a post-maintenance review.
Adverse trends
can be identified by the maintenance engineers performing this review.
The inspector reviewed the evaluation and correction of a problem
identified with the solenoids on the feed system isolation valves.
The
problem was identified during a routine replacement of solenoid coils for
the isolation valves.
As a result of the process to qualify the
replacement parts it was discovered that AC coils had been installed on
the valves rather than DC coils as required.
The incorrect solenoids were
installed in 1984.
An evaluation performed indicated that the failure
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resulting from the AC coil would result in valve failure as a closure of
the isolation valve and therefore represented no plant safety problems.
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The evaluation required a verification of solenoids in all the isolation
valves to verify proper coil installation.
Some additional AC coils were
located in passive installations - i.e.,
acting as installed spares with
no function - and these were replaced.
The root cause determination was
that the coils were incorrectly labeled by the vendor and not discovered
at receipt inspection since the receipt inspection practice did not
require an ohmic resistance verification.
Evaluation and corrective
action for this item appeared adequate.
The inspector reviewed the three previous maintenance activity
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surveillance
performed by the site QA organization.
A comprehensive
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surveillance was performed September 15 to October 6, 1986.
This surveil-
lance, II-18-86-0 addressed major Maintenance group activities and
resulted in two findings regarding failure to adequately apply procedures.
Surveillance II-26-86-H performed in December 1986 reviewed maintenance
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and craft training and resulted in 4 non-safety significant findings.
The
most recent audit was performed in June 1987 and addressed. control of
purchased material, special processes and QA records.
Three findings were
identified related to QA record storage, use of unapproved vendor manuals
and traceability 'of materials used in the plant.
The surveillance
reviewed appeared adequate in providing reasonable assurance of the
quality of maintenance activities.
The inspector reviewed approximately 60 completed maintenance work
packages.
The purpose of this review was to verify completeness of the
maintenance documentation, traceability and qualification of replacement
parts and materials and qualification and control of measuring and test
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equipment (M&TE).
No major problems were identified in this review, and
it appeared that the maintenance activities were well documented.
Overall
performance in the maintenance area appeared to be above average.
9.
Quality Assurance
The following procedures were reviewed and evaluated during the assessment
of the licensee's QA department:
Quality Assurance Procedure (QPS) - 101, Internal SCE&G/QA Audits,
Revision 0.
Quality and Procurement Services Procedure (QPS) - 102, Surveillance
of Site Activities, Revision 0.
Quality and Procurement Services Administrative Instruction (AI) -
301, Site Surveillance, Revision 0.
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Quality and Procurement Services Procedure (QPS) 10, SCE&G Quality
Assurance Audit / Surveillance Report Preparation, Rev. 0.
Quality and Procurement Services Procedure (QPS) - 103, Quality
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Assurance Trend Analysis, Revision 0.
Management Directive (MD) - 16, Response and Escalation of
Surveillance / Audit Findings, Revision 5.
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Security Procedure (SPP) - 007, Protection of Safeguards Information,
Revisions 0, 1, 2, and 3.
In order to assess the QA organization's effectiveness, the following
corrective action program aspects were evaluated; deficiency
identification and trend analysis, corrective action timeliness,
escalation / elevation of surveillance findings, and corrective action
closure adequacy.
The inspector determined that the overall effectiveness
of the QA department appeared to be average; however, several weaknesses
were identified.
The bases for this evaluation are explained in the
following paragraphs.
There are two types of audits / surveillance conducted by the licensee.
Per QPS-102, Type I surveillance
consist of:
"The observation of the
performance of a safety / quality related task, activity or system or review
of documentation to assure that it is or has been accomplished or is being
performed in accordance with previously reviewed and approved criteria and
that the activity is achieving the desired results."
PER QPS-101, Type II surveillance
consist of:
"A documented activity
performed in accordance with written procedures or checklists to verify,
by examination and evaluation of objective evidence, that applicable
elements of the Quality Assurance Program have been developed, documented
and effectively implemented in accordance with specified requirements."
One area of concern exists in the fact that the licensee does not utilize
audit plans in the performance of audits.
An audit plan usually contains
written procedures or checklists as part of the plan itself.
However, the
licensee places full credit in the surveillance report and the
notification letter as being a fully compretansive detail of what is to be
evaluated during a surveillance and what was actually surveilled.
This
can lend itself to concerns that if the specific detail is not delineated
in the report, then no other documentation can be used as objective
evidence for the surveillance.
Additionally, by not utilizing an audit
plan, the audited organization may not be able to adequately prepare for
an audit nor be prepared to adequately support an audit.
In the utiliza-
tion of checklists, the licensee takes no credit for surveillance
checklists as being records.
The inspector reviewed Type II surveillance
(e.g. Surveillance
II-6-87-T, II-20-86-T, II-6-86-T) where checklist
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questions were often left blank or ' referenced notes that were also not -
records (some notes were not available.for review by the inspector). This
can result'in problems if concerns arise as to the depth certain items or
areas were evaluated during the course of the : surveillance, with the
surveillance report and findings as sole documentation.
The inspector reviewed the licensee's surveillance schedule for 1986 and
1987, and it appeared that almost all surveillance were accomplished as
scheduled, with few exceptions.
Approximately 60 percent of all type I
inspections are scheduled. activities with the remaining 40 percent
determined by the surveillance specialists with supervisory approval.
This practice allows flexibility in determining areas to be surveilled and
provides for QA responsiveness.
However, there existed no formalized
criteria to determine when this type of surveillance was to be performed
on a specific area or department. After reviewing approximately 35 type I
surveillance
and 15 type II surveillance, it appeared the licensee's
surveillance program utilized procedure compliance verification as the key
indicator in assessing department performance during an audit.
The
licensee acknowledged this . concern and indicated they realized the need .
for more technically oriented. surveillance.
Some surveillance have
resulted in technical deficiencies being identified (e.g. surveillance
II-21-86-D, ISI), but it appeared many audits as well as findings were
still oriented toward procedural compliance.
To assess the effectiveness of the licensee's trending program, the
inspector reviewed the QA Trend Analysis procedure (QPS-103) and the four
QA Finding Trend Analysis reports that have been written since the
program's inception in February 1986.
Trending is performed on a
semi-annual frequency and is based on the following:
Total findings issued to N0D by deficiency code.
Total findings issued to N0D by group / manager codes.
Total findings issued to the supervisors of each group by deficiency
code.
Total surveillance by manager code with and without findings.
This data is then interpreted as to; the number of findings issued to each
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group manager, changes in the number of total findings within each group,
and changes in the number of findings within each area.
,
It appeared that this type of analysis, based on the number of findings
and to whom they were issued, appeared to be ineffective in identifying
significant adverse trends.
This conclusion is based on the fact that QA
has identified repeat findings written against the same group.
However,
these report findings have only been identified in surveillance reports;
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the Trend Analysis program was not utilized in preventing repeat findings
in a specific subject area.
The deficiency codes assigned to findings
were trended, but it appeared that these codes were not specific enough to
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prevent recurring problems .and subsequent negative trends.
The licensee
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stated that QA personnel would receive root cause analysis training in the
future,- and this. should expedite trending effectiveness.
The trend
analysis program can _ be utilized as an effective tool to help schedule-
audits and to help establish certain areas within 'an audit' needing
-specific attention.
6
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LQA trending:fdentified a recurring problem.with the number of findings
with procedure violation being the main cause by deficiency codes (2/13/87
and 7/7/87 Trend Analysis reports).
QA identified the number of findings
with this deficiency code and sorted them by group and manager.
It was
stated in' these reports that this indicated a significant adverse trend,
with increased management attention being necessary, yet there was no
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. justification in the report on why or why not an adverse- trend was
apparent.
In this case, on February 25, 1987, the Plant Manager wrote a
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memo to the Deputy Director, Operations and Maintenance, and the Group
Manager, Technical and Support Services, requesting identification of what
action was taken to' reduce the number of procedure violations.
A response.
dated March 24, 1987, identified that the procedure violation deficiency
code is applied " liberally" to classify findings and no significant
adverse trends were actually present.
It appeared that the trending as
performed' was ineffective in establishing actual root cause and
identifying significant trerds.
In addition, with trending based on
finding numbers as compared to finding content, the QA organization has no
vehicle to identify adverse trends based on finding content.
The~QA
organization had. identified where the number of findings by deficiency
code or group warranted. increased management attention; but QA -did not
have a mechanism to elicit a. response from a group' or department to
justify or explain an apparent adverse trend;
The inspector did not find
instances where QA trending of surveillance findings had resulted in
significant positive corrective action due to reversal of an adverse
trend.
More importantly, there have been instances where effective
trending could have initiated adequate corrective action for a recurring
problem area (NRC Inspection Report No. 50-395/87-20, Item 87-20-04).
Additionally, if the subject of findings were more closely evaluated for
trends, CAR 87-07 concerning meteorological tower functional tests,
possibly could have been prevented.
The licensee had identified this as a
recurring problem area, but had no vehicle to generate responsiveness and
steps to preclude recurrence from the responsible group. . Only after QA
identified the failure to perform these functionals for the third time was
a CAR initiated.
More effective trend analysis coupled with a mechanism
for initiating corrective action after a trend was identified, could
possibly have precluded the issuance of this CAR.
Further program
improvements are needed in this area.
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In order to ensure effective corrective action by the licensee, timeliness
for surveillance finding closure was evaluated.
The inspector reviewed
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the following during his evaluation of this area:
Management Directive -
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16, Response and Escalation of Surveillance / Audit Findings; the April 2,
1987, and the July 2,1987 (draft) of the licensee's Elevated / Escalated
Items reports (spanning the first two quarters of 1987); finding
initiation to closure time frames and the computer tracking program
(CHAMPS); 3 NSSS surveillance findings that were open for more than 9
months (findings 3-HMK-86-0-03, II-26-85-M-01, II-21-86-D-01) and their
associated documentation; and approximately 30 escalation letters.
The ifcensee calculated average time frame for closure of surveillance
findings calculated from the date of the audit reports was 66.5 days.
This number does not include time lengths of findings that were still
open, nor the approximately four weeks from finding acknowledgement to
audit report issuance; however, it does include data from findings that
were issued closed.
The inspector determined these factors would change
the time frame. from initiation to closure to approximately 100 days; this
did not appear to be excessive.
To verify that findings were being closed
expeditiously, the three findings identified above were evaluated for
corrective action timeliness.
Finding 03-HMK-86-0-03 was initiated on February 19, 1986, and concerned
switch setting values for limitorque operators.
Resolution of this
finding involved receiving design information from the Architect Engineer
due to difficulties with obtaining this information from the vendor.
During the time this finding has remained open, the QA department has
verified interim corrective action.
Action taken by QA appeared adequate
with closure scheduled for July 1987.
Finding II-21-86-D-01 was initiated on August 27, 1987, and concerns
containment valves being leak tested with the pressure differential
applied in the opposite direction from how the valve performs its intended
function.
Resolution of this technical finding has involved various
management meetings, transfer of certain departmental responsibilities,
and extensive technical research.
It appeared QA was responsive in their
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attempt to resolve this issue.
Verification was scheduled for July 24.
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1987.
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Finding II-26-85-M-01 was initiated on November 14, 1985, and concerns
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certain records not being transmitted to the DRS per established
{
requirements.
It appeared that the major delay in closing this finding
)
was the involvement of a third party in resolution.
The finding's
scheduled closure date had been changed an excessive number of times
(eight) compared to the relative insignificance of the finding.
The
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licensee acknowledged this, and it appeared that this incident was
isolated; consequently, a violation in not warranted.
Corrective action
completion is scheduled for September 30, 1987.
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The inspector had a concern that QA was allowing responsible organizations
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an inordinate amount of time for corrective action resolution.
This
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- concern a)peared to be ~ unfounded with o'nly one~ exception (identified
above).-
iowever, findings that involved- corrective action from third
parties were the deficiencies that dictated longer resolution time frames.
The escalation / elevation procedure provided no mechanism for eliciting
responsiveness from these third parties.
If such a mechanism existed,
findings that are ' involved or require third' party action, could be more
expeditiously resolved.
Overall, the QA effectiveness in this area
appeared adequate.
In' order to assess the overall adequacy of the licensee's corrective
action program, the inspector assessed performance of deficiency
identification', trending, corrective action timeliness, and the
effectiveness of the escalation / elevation procedure.
The inspector also
reviewed numerous Type I and II surveillance
and their associated
findings to assess the adequacy of corrective action closures.
The QA' department identified findings commensurate with the audit program
depth and scope.
However, trending of these findings has area for
improvement.
The weaknesses identified with the trending program, cou)1ed
with inadequate _ attention to previous audit findings have .resulted in'
inadequate corrective action implementation.
The licensee's QA
organization appeared to be able to obtain resolution of findings without
major delays,
However, complex technical issues with crossing
responsibility lines appeared to lengthen closure time frames for
findings.
This can. partially be attributed to the fact that there was no
formalized mechanism used to elicit responsiveness from . third parties
involved in audit findings.
The licensee .did not present objective evidence that, during the 1987
audit on Security and Maintenance of Security Equipment (II-10-87-I),
. specific attention was given to verification of corrective action
implementation for findings 02, 07, 08, and 09, which were identified in
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the 1986 Security audit (11-14-86-I).
Three of these findings were
initially closed based partially on procedure revisions, with no evidence
of procedure implementation verification in the original closure, nor by
re-audit in the 1987 Security Surveillance.
Additionally, the 1985
Security Surveillance (II-10-85-1) identified a. deficiency (finding 05)
where four controllers were not on distribution for Security Procedure
SPP-007, Protection of Safeguards Information, and were working to
outdated copies.-
The 1985 audit also identified a need for general
controller training (finding 12).
In 1986, the Security Surveillance
identified that each controller had a copy of the last revision of SPP-007
(which. was identified in 1985), yet two additional findings (02 and 06)
documented deficiencies in the controlled distribution of security
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procedures and revisions.
The 1986 Security Surveillance also identified
security . training deficiencies (finding 09).
The 1987 Security
Surveillance report (II 10-87-1) noted that:
"Each Controller has a
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controlled -copy of SPP-007." and "Each Controller has been instructed to
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.the' requ rements of SPP-007 after the revision 'date of the procedure "
However, the inspector identified that one of the controllers identified
in the. report, in fact, .did not have a current revision as of the date of
the surveillance; therefore, this _ individual could not have been
instructed to the requirements of the latest revision of SPP-007., as the
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surveillance report. stated.
It was identified that this controller had
worked to_ the wrong revision level for a year.
These' discrepancies are
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identified as violation 395/87-20-04, Inadequate Review of Previous Adult
Findings for Adequacy of Corrective Action Implementation.
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If the licensee had identified through the trending of findings that these
areas were repetitively deficient, more' complete and effective corrective
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action.could have been taken to prevent the deficiencies identified by the
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~ inspector.
Although the findings from the 1985 and 1986 security
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surveillance
are not exact repetitions, the fact the QA identified the
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security program (in the areas of procedure control and training) as not
being adequate, coupled with the repetitive nature of the findings, more
in-depth cause analysis should have propagated, with the result being more
effective initial corrective action.
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The licensee's QA organization appeared to adequately identify issues
commensurate with the depth of the surveillance performed.
However, the
licensee's' surveillance prog' ram mainly consisted' of. procedure compliance
verifications.
The licensee s QA department escalated issues as required.
The licensee's policy for resolving issues at the lowest management level
appeared to be implemented effectively.
In the area of individual audit
planning,'the licensee could have been more effective, as evidenced by the
failure to adequately address specific previous audit findings in the
performance of audits.
The trend analysis program has been implemented
for two years, but did not appear to be an effective tool in preventing-
recurring problems or identifying root causes as related to the nature of
findings.
Based on evidence that some findings were closed based on
procedure revisions, the adequacy of verification of procedure revision
3
implementation was an area of concern.
As a result of the above
deficiencies, the effectiveness of the QA department appeared to be
average to below average.
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