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U.S. NUCLE AF. rlEGULATORY COMMISSION Cf hee of Inspector and Auditor o.i. o, mnic,,,,, o o jbvci er 26, I986 Report of Interview James G. PARTLOW, Director, Division of Inspection Programs, Office of Inspection and Enforcement'(IE), was interviewed concerning the appropriate-i ness of the NRC accepting input from a utility relating to proposed violations during the period the draft NRC inspection report is being processed. PARTLOW stated normally inspection reports are issued ',tithin 30 days of the exit briefing with the utility. Although PARTLOW knew of no specific guidance in IE Manuals addressing the issue of accepting input from a utility after the conclusion of an inspection, PARTLOW believed there are instances where it would be appropriate to accept the additional information and delete the proposed violation from the inspection report. Generally these instances would depend on how soon after completion of the inspection the information was provided, as well as the nature of the proposed violation and the nature of the new information. As an example, PARTLOW stated that shortly after completion of an inspection, if the utility provided the NRC with a record that was difficult to locate and which resolved an issue, then it would be proper to delete the pecposed violation from the report. However, if the proposed violation was an indication of a possible wi.despread problem, then it would be appropriate to document the finding in the final report. PARTLOW further explained that if the information provided by the utility was created subsequent to the inspection in response to a proposed violation, then it would not be proper for the NRC to use this input to delete a proposed viola-tion from an inspection report.
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't=x m S #T N o. J In P.eply Refer To:
Dockets: 50-445/84-32 FEg 15 IES .
50-446/84-11 Texas Utilities Electric Company ATTN: M. D, Spence, President, TUGC0
- Skyway Tower 400 North Olive Street Lock Box 81 Dallas, Texas 75201 Gentlemen:
This refers to the inspection conducted under the Resident Inspection Program by Mr. H. S. Phillips of this office and NRC contract personnel durino the period August 20, 1984, tnrough September 20, 1984, of activi..e., eutnerized by NRC Construction Permits CPPR-126 and CPPR-127 for the Comanche Peak facility, Units 1 and 2, and to the discussion of our findings with Mr. D. Chapman and other memDers of your staff at the conclusion of the inspection.
Areas examined during the inspection included a review and evaluation of how effectively Texas Util' ties Electric Company management has implemented the l' corporate quality assurance (QA) program for design, procurement, and construction activities. Special emphasis was placed on evaluating the management of the audit program; manegement's action to regularly review the status and adequacy of the QA program; and followup on findings pertinent to !
program management identified by previous NRC and consultant inspection teams.
Within these areas, the inspection consisted of selective examination nf procedures and representative records, interviews with personnel, and observations by the inspectors. These findings are documented in the enclosed inspection report.
During this inspection, it was found that certain of your activities were. in violation of NRC requirements. Consequently, you are required to respond to this violation, in writing, in accordance with the provisions of Section 2.201 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations. Your response should be based on the specifics contained in the Notice of Violation enclosed with this letter.
These violations may be related to findings identified by the NRC Technical )
Review Team (TRT). If the issues are considereo to be similar, you may respond to the items separately or as part of the Comanche Peak Response Team Action Plan.
RRI PM' TL/TFd D/d5&S CR 2 D/D NRRg28h SPhillips/1t DHunnicutt RBingart DHunter RDenise Noonan d l' *- /8 C' /j, /SE / /84 L /;~, /85 '), f /84 I: /2.0/84 g6' 5 1
Texas Utilities Electric Company Should.you have any questions concerning this inspection, we will be ple'ased to discuss them with you.
Sincerely, "oefsinat sisned by:
r.i M . H U N N t'af.
D. R. Hunter, Chief Reactor Project Branch 2
Enclosure:
- 1. Appendix A - Notice of Violation
- 2. Appendix B - NRC Inspection Report 50-445/84-32 50-446/84-11 cc w/ enclosure:
Texas Utilities Electric Company Texas Utilities Electric Ccmpany ATTN: B. R. Clements, Vice ATTN: J. W. Beck, Manager President, Nuclear Nuclear Services Skyway Tower Skyway Tower i 400 North Olive Street 400 North Olive Street I
Lock Box 81 Lock Box 81-Dallas, Texas 75201 Dallas, Texas 75201 +
bec to DMB (IE01) bec distrib. by RIV:
RPB1 RRI-0PS TX State Dept. Health RPB2 RRI-CONST. Juanita Ellis EP&RPB R. Bangart Renea Hicks R. Martin, RA J. Gagliardo Billie Pirner Garde C. Wisner, PA0 D. Hunnicutt S. Phillips R. Denise, DRSP TRT (CPSES) (2)
RIV File S. Treby, ELD MIS System D. Eisenhut, NRR
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APPENDIX A NOTICE OF VIOLATION Texas Utilities Electric Company Dockets: 50-445/84-32 )
Comanche Peak Steam Electric Station, Units 1 and 2 50-446/84-11 (
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Construction Permits: CPPR-126 l CPPR-127 i 8ased on the results of an NRC inspection conducted during the period of August 20, 1984, through September 20, 1984, and in accordance with the NRC Enforcement Policy (10 CFR Part 2, Appendix C), 49 FR 8583, dated March 8, 1984, the following violations were identified:
- 1. Failure to Regularly Review the Status and Adeauacy of the OA D-naram Criterion II of Appendix 8 to 10 CFR 50, as implemented by the Preliminary Safety Analysis Report (PSAR) and the Final Safety Analysis Report (FSAR),
Section 17.1, " Quality Assurance Program," and ANSI N45.2-1971, requires that the quality assurance program shall provide for the regular review Ly the management participating in the program, of the status and adequacy of the part of the quality assurance program for which they have designated responsibility.
Contrary to the above, the applicant did not establish quality assurance procedures to regularly review the status and adequacy of the construction quality assurance program; nor did the applicant appear to have reviewed the status and adequacy of the construction quality assurance program.
This is a Severity Level IV Violation. (Supplement II) (445/8432-02; 446/8411-02)
- 2. Failure to Establish and Implement a Comprehensive System of_ Planned and Periodic Audits l
Criterion XVIII of Appendix B to 10 CFR 50, states, in pact, "A l comprehensive system of planned and periodic audits shali be carried out to verify compliance with all aspects of the quality assurance program and to determine the effectiveness of the program." The requirements are 3 addressed in the PSAR and FSAR, Section 17.1, " Quality Assurance Program," ;
which references Regulatory Guide 1.28 (ANSI N45.2) and ANSI N45.2.12 (Draft 3, Re,ision 4). Those commitments require that a comprehensive system of planned audits be performed on an annual frequency.
Contrary to the above, the following examples were identified which l l demonstrate the failure to establish and implement a comprehensive system f l of planned and periodic audits of safety-r. elated activities as required, l as noted below. i I
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i Notice of Violation ,
- a. Annual audits were not adequately addressed by the audit i
implementation procedures.
- TUGC0 Procedure DQP-CS-4, Revision 0, dated August 9, 1978, only required two audits of vendors fabricating reactor coolant pressure boundary components, parts, and equipment; o_n_e audit of vendors fabricating engineered safeguards components, parts', and equipment; and audits of balance of plant (safety-related) as required by the quality assurance Iranager.
- TUGC0 Procedure DQP-CS-4, Revision 2, dated April 16, 1981, required only that organizations will be audited on a regularly scheduled basis.
- TUGC0 Procedure DQP-CS-4, Revisions 2 and "), dM .ot specify auditing frequer.cies for design, procurement, construction, and operations activities.
- TUGC0 Procedure DQP-CS-4, Revision 10, based audit requirements on Regulatory Guide 1.33, Revision 2, February 1978. This commitment did not fully address the requirements.of the construction quality assurance program.
The above procedure and subsequent revisions failed te describe and require annual audits in accordance with commitments and requirements. Earlier audit procedures were not available to determine if they met requirements.
- b. Planning and staffing to perform 1983 audits was inadequate to assure that a comprehensive system of audits was established and implemented to verify compliance with all aspects of the quality assurance program, in that, of 656 safety-related procedures (which control safety-related activities) the NRC review revealed that the_ applicant sampled only 165, or 25 percent, during the 1983 audit program.
Consequently, significant aspects of the safety-related activities were not adequately audited.
- c. The Westinghouse site organization, established in 1977 to perform Nuclear Steam System Supply (NSSS) engineering services, was not audited by TUGC0 during the years of 1977, 1978, 1979, 1980, and 1981.
- d. Audits of_ vendors that manufacture or fabricate parts, components, and equipment for reactor coolant pressure boundary and engineered safeguards systems have not been conducted annually dating back to August 9, 1978.
This is a Severity Level IV Viciation'. (5upplement II) (445/8432-03; 446/8411-03)
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i Notice of Violation 3. Failure to Properly Certify a Vendor Compliance Inspector Criterion V of 10 CFR 50, Appendix B, states, in part, " Activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and .i shall be accomplished in accordance with these instructions, procedures, or drawings."
TUGC0 Procedure DQP-VC-4, Revision 6, dated January 5, 1984, requires that Level II inspectors (Corporate QA) shall attend and satisfactorily q j
complete nondestructive testing courses including eddy current testing. 1 i
Contrary to the above, one of six inspector's files had no documentation to show that the inspector had attended and completed an eddy current testing course. Subsequent, discussions revealed thh riu .v. been certified without meeting this requirement. The vendor compliance supervisor stated that this inspection skill is not needed since there is ,
no present vendor work activity which would require this skill; therefore:
this procedure was revised and the requirement omitted during this inspection.
This is a Severity Level V Violation. (Supplement II) (445/8432-05; 446/8411-05)
Pursuant to the provisions of 10 CFR 2.201, Texas Utilities Electric Company is hereby required to submit to this office, within 30 days of the date of this Notice, a written statement or explanation in reply, including: (1) the corrective steps which have been taken and the results achieved; (2) corrective steps which will be taken to avoid further violations; and (3) the date when full compliance will be achieved.
response time for good cause shown. Consideration may be given to extending your Dated:
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l APPENDIX B I
l U. S. NUCLEAR REGULATORY COMMISSION REGION IV 1
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' NRC Inspection Report: 50-445/84-32 Construction Permit: CPPR-126 50-446/84-11 Dockets: 50-445 CPPR-127 50-446 Category: A2 Licensee: Texas Utilities Electric Company i
Skyway Tower 400 North Olive Street Lock Box 81 Dallas, Texas 75201 Facility Name:
Comanche Peak Steam Electric Station (CPSE5), Units 1 and 2 i
i Inspection At:
Dallas Corporate Office, Dallas, Texas Inspection Conducted:
August 20, 1984 through September 20, 1984 Inspector: /
/////78 H. S. Phi' lips, Senior Resident Reactor Inspector Construction Date NRC Contract Personnel:
B. Freed, Senior Project Engineer, EG&G Idaho, Inc.
G. Thomas, Quality Engineer, EG&G Idaho, Inc. i Approved: / 2' ,2/[, ,,, g p D. M. Hurini c utt , Team Leader bN Region IV Task Force 06te <
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Xnspection Summary 2nspection Conducted August 20 through September 50-446/84-11) 20. 1984 (Report 50-445/84-32:
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2 1 Areas Inspected: Routine, announced inspection to determine how effectively corporate management has implemented the QA program for controlling design, procurement, and construction activities; and to determine how site management interfaces with corporate management. The inspection involved 74 inspector-hours by one NRC inspector and 176 inspector-hours by two NRC contract personnel at the corporate office and the site.
Results: Within the two areas inspected, three violations were identified (f ailure to regularly review the status and adequacy of the QA program -
paragraph 2b.; failure to establish / implement a comprehensive system of. planned i and periodic audits paragraphs 2c.(1) and 2d.(3)(a);.and failure to properly certify a Level II vendor compliance inspector, paragraph 2d.(3)(f).
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t DETAILS
- 1. Persons Contacted W. Clements, Vice President Nuclear Operations, Texas Utilities Generating Company (TUGCO) !
"D. M. Chapman, Manager, Quality Assurance (QA), TUGC0
- R. G. Spangler, Supervisor, QA Services, TUGC0 l
- D. L. Anderson, Supervisor, QA' Audits, TUGC0 A. H. Boren, Supervisor, Vendot- Compliance, TUGC0
- S. L. Spencer, QA Auditor, TUGC0 D. 2. Hathcock, QA Auditor, TUGC0 H. R. Napper, QA Auditor, TUGC0 A. Vega, Site QA Manager, TUGC0 L. M. Bielfeldt, Supervisor, Quality Engineering, TUGM C. Welch, Supervisor, QA, TUGC0 J. H. Roberts, Supervisor, Construction /Startup, TUGC0 :
J. T. Merritt, Assistant Manager, Engineering and Construction, TUGC0 R. Gentry. Manager, Project Support Services, TUGC0 F. Peyton, Supervisor, Purchasing, TUGC0 M. Strange, Supervisor, Engineering Support, TUGC0 R. Baker, Staff Engineer, TUGC0 ;
H. Harrison, Supervisor, Technical Services, TUGC0 ;
G. Krishnan, Supervisor Stress Analysis Group, TUGC0 i R. Williams, Draf ting Supervisor, TUGC0 G. Purdy, Site QA Manager, Brown & Root Inc. (B&R)
R. L. Moller, Site Manager, Westinghouse
- Denotes these attending one or more exit interviews.
- 2. Texas Utilities Manacement of OA Activities
- a. Introduction The objective of this inspection was to determine the status of the .j construction QA program and the effectiveness of implementation of j the corporate QA program for ongoing design, procurement, and j construction activities. {
i The NRC inspectors reviewed the QA commitments described in Section 17.1, " Quality Assurance During Design and Construction."
Texas Utilities Electric Company (TVEC), as the applicant, has delegated to Texas Utilities Generating Company (TUGCO) the responsibility and authority for engineering, design, procurement, construction, operation, and QA activities at Comanche Peak Steam Electrical Station (CPSES). Gibbs & Hill Inc. (G&H), is the Architect-Engineer (AE) and provides TUGC0 with design, engineering, ,
and procurement services as requested. Westinghouse (W) is-the J Nuclear Steam Supply System (NS$$) supplier and provides TUGC0 with l the design, engineering, procurement and f abrication services for the NSSS and the initial supply of nuclear fuel. Brown and Root, Inc.
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L (B&R) is the Construction Manager / Constructor and provides l
construction services at tne site, including the QA program for ASME Division 1 Code work.
- b. Organization The TUGC0 corporate management structure and responsibilities were described in the Final Safety Analysis Report (FSAR); and the various TUGC0 QA manuals and procedures described how FSAR requirements were implement <d to control design, procurement, and construction activities. Recent organizational changes pertaining to the QA program were described in FSAR figures 17.1-1, 17.1-2, 17.1-3, 17.1-4, and 17.1-5 which were included in Amendment 50 dated July 13, 1984.
Recently, there have Deen three important QA personnei cnanges. A new site QA manager reported in March 1984, a new site quality engineering supervisor reported in August 1984, and a new vendor compliance supervisor was recently selected. These organizational changes were made to replace individuals who were reassigned or promoted to other positions, and these changes were reported to the NRC. The independence and effectiveness of the QA effort do not appear to be adversely affected by these changes.
The assistant project general (APG) manager reports to both the VP of engineering and construction and to the TUGC0 Executive VP of l operations. Discussions with the APG manager confirmed this and that he was supervised by both. This management practice is questionable.
The CPSES QA Plan Section 1.2, paragraph 1.2.1, does not describe the APG maneger's interface with or the responsibility to the VP nuclear operations. Subsequent discussions with TUGC0 QA personnel revealed that this position was discussed in the startup QA manual. This item is considered unresolved pending clarification of the QA plan and further review during a subsequent inspection. (445/8432-01; 446/8411-01)
- c. QA Program TUGC0 QA Program Plan and subtier procedures for design, construction, engineering, and procurement described the centrol of all related project and quality activities. A sample of these procedures were reviewed and documented in NRC Inspection Report No.
50-445/84-22; 50-446/84-07.
The Quality Assurance Program (described in the FSAR) provided the delegation of design, engineering, construction, and procurement functions to prime contractors, subcontractors, and vendors. It stated that the TUGC0 audit program assured tnat these organizations had adequate QA programs and verified implementation of the overall QA program within TUGCO. ,
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The inspectors reviewed the QA program procedures and any objective evidence to determine if the applicant-regularly reviewed the status and adequacy of the QA program as required by Criterion II of Appendix B to 10 CFR 50, the PSAR and FSAR, and ANSI N45.2-1971. _
Reviews end discussions revealed no documented requirements or :
evidence that the QA program status and adequacy had been reviewed by the applicant. In order to determine if the QA program had been assessed, the inspectors reviewed additional information. In late 1981 and 1982 audits were performed by a consultant (Fred Lobbin), by Sargent and Lundy (using INPO criteria), and by TUGC0 (using INPO criteria). Each of these audits evaluated limited aspects of the QA program. In 1983 Cygna evaluated the design program.
The Lobbin Report (February 4, 1982) R-82-01, contained four major findings:
- level of experience within the TUGC0 QA organization is low; i.e., commercial nuclear plant design and construction QA experience;
! - staffing for the audit and surveillance functions is inadequate;
- the number and scope of design and construction audits conducted by TUGC0 QA to date has been limited; and QA management has not defined clearly the objectives for the surveillance program resulting in a program which, in the author's (Lobbin) opinion "is presantly ineffective."
The TUGC0 QA manager responded to these findings in an office memorandum (QBC-18), dated February 23, 1982. This response basically concurred with these findings.
The response committed to recruit nuclear experienced individuals, to increase the number and scope of site audits, and to more effectively use the. surveillance program. Two program reports (QBC-25 and 29) regarding these matters were issued from the QA manager to the VP ,
nuclear operations on May 21 and August 31, 1982, respectively, i Following the Lobbin Report, the NRC performed a CAT inspection (IR 445/83-18; 446/83-12 dated April 11, 1983) and included a review of the TUGC0 audit program at the corporate offices. The inspection included a review of 18 audits (conducted between 1978 and early 1983), auditor qualifications, audit planning and scheduling, audit reporting and followup, and audit program effectiveness. The report concluded that weaknesses existed in the established QA audit program and included the scheduling and frequiency of audits, the lack of effective monitoring of the construction program, and the lack of effective resolution of certain audit findings. The inspection also indicated that the QA program should have been more effective.
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I Based on the findings in the Lobbin report, and the findings in the NRC CAT report, the QA program continues to exhibit weaknesses. The continuing weaknesses in the QA program over a significant period of ,
time reinforce the need for the applicant ~to routinely assess the status and adequacy of the QA program routinely.to ensure'that the areas are identified and adequate and_ timely corrective action is I
taken to correct the QA program weaknesses.
The failure to regularly review the status and adequacy of the QA ~'
l program as required is a violation of Criterion II of Appendix B to 10 CFR 50. (445/8432-02; 446/8411-02)
- d. Management of the TUGC0 Audit Program (1) Program Requirements FSAR Subsections 17.1.2, "QA Program," and 17.1.18 " Audits," require internal audits of (TUGC0 corporate and site activities) and external ;
l audits (prime contractors, subcontractors and vendors) to evaluate l the effectiveness of the QA program by verifying conformance with design requirements; compliance with established requirements, methods and procedures; and implementation of corrective action.
These commitments require the establishment and implementation of a comprehensive system of planned and periodic audits of all aspects of the QA program.
The TUGC0 cudit program consisted of internal and external audits of i design, construction, engineering, and procurement activities. TUGCD also retained responsibility for the external audits that were usually delegated to the AE and NSSS organizations; i.e.,-audit of vendors. In addition to construction and vendor audits, the TUGC0 ,
audit group was also responsible for performing )
preoperational/startup and plant operation audits. !
TUGC0 committed to the audit requirements of ANSI N45.2.12-1973, Draft 3, Revision 0, Section 3, " Audit System," and these program management' objectives are:
- to determine that a-QA program has been developed and documented in accordance with applicable requirements; -
to verify that the program has been implemented, )
to assess program effectiveness;
- to identify program nonconformance; and
- to verify program correction where appropriate.
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This section also stated that to achieve these ANSI standard objectives full management backing, manpower, funding, and facilities shall be available to implement the system of audits.
(2) NRC Evaluation of Planning / Implementation of Program 1
The NRC inspector reviewed and evaluated the applicant's plans, j procedures, and number of audits performed (see paragraph 2e below) j and determined that planning was inadequate. _This audit effort was 1 too large for the'four available TUGC0 auditors in 1981, even though I additional specialists were utilized to assist with the audit activities.
(a) The inspector reviewed and evaluated planning documents (formal and informal) used by the TUGC0 QA manager. surerv'cor QA services, and supervisor QA audits. The review and discussions with these individuals revealed that annual audit plans were based'on the audit of organizations rather than activities.
TUGC0 Audit Procedure DQP-CS-4, Revision 0, dated August 9, 1978 required:
- semiannual internal audits, semiannual construction audits, annual AE audits, annual NSSS audits, and annual plant operation audits.
However, for vendor audits the procedure required:
first audit at 15 percent; and second audit at 60 percent ,
" item completion" by reactor coolant pressure boundary vendors; one audit of engineered safeguards vendors at 25 percent item completion; and audit of balance of plant (other safety-related) vendors as determined by the manager QA.
This does not meet the requirements of paragraphs 3.4.1 and 3.4.2 " Scheduling," of ANSI N45.2.12 which requires, " Auditing be initiated as early in the life of the activity as ;
practicable . . . applicable elepents of the QA program shall te audited at least annually or at least once within the life of the activity whichever is shorter." 1 i
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i Furthermore, Audit Procedure DQP-CS-4, Revision 2, April 16, 1981, and Revision 10, June 4, 1984, htve further reduced the I (scheduling) frequency of audits. Revision 10 now states, in {
part, "3.2.1, The following organizations will be audited on a regularly scheduled basis but in accordance with Regulatory Guide (RG) 1.33, Revision 2, January 1978, Regulatory' ;
Position 4: a. AE; b. N555; c. constructor; d. TUGC0 Internal;
- e. Preoperational/Startup; f. Plant Operations;
- g. Subcontractor. . . 3.2.1 In lieu of regularly scheduled audits of vendors TUGC0 QA will perform the following:
- a. Monitor the individual vendor ratings which are based on vendor performance . . . b. for those venders who cannot be eva?cated based on vendor ratings . . . regularly scheduled auditu d11 be performed based on level of activity."
i The NRC inspector discussed with TUGC0 management tha f+c+ + hat RG : 33 i is for operations and does not fully address tne requirements of j the construction QA program.
This failure to develop audit program procedures which adequately address and describe QA program requirements and commitments is a violation of Appendix B, 10 CFR Part 50, Criterion Xi/III (445/8432-03a; 446/8411-03a).
(b) In addition to evaluating to determine if annual audits were planned, the NRC inspector requested objective evidence which would demonstrate that planning for audits for calendar years 1983 and 1984 included a method to verify compliance with all aspects of the QA program and to determine the effectiveness of the QA program. The review of the objectivet0vidence revealed that the planning was not adequate, particularly regarding the audit basis, status, and tracking. The only' objective evidence available consisted of a listing of planned audits of internal organizations and contractors each year and a summary of 1983 audit results and criteria audited; however, this data in many cases did not list the criteria audited and whiles reviewing older audits it was noted that an "after the fact" review '
resulted in identifying the applicable criteria covered \1er various organizations. .
The inspector requested a listing of selected site procedures which were in effect in 1983 that were representative of site safety-related activities and subject to audit by TUGC0 corporate QA. The review of the listings provided and the 1983 audits revealed the following information:
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Audits of Total Procedures % Audited Procedures Procedures Audited / Referenced in 1983 l TUGC0 Quality Documents Index (December 20, 1983) 295 71 24 TUSI Engineering Instruction Index (December 2, 1983) 65 16 25 TUSI Nuclear Engineering Procedures / Instructions Index (September 26, 1983) 26 le V TUSI Engineering Procedures Index (November 4, 1983) 30 12 40 B&R Quality Document Index (November 22, 1983) 51 20 39 B&R Construction Procedures Index (June 20, 1983) 189 28 15 1
Total 656 165 25 Only 25 percent of the procedures (specific safety-related activities) were audited in 1983. Although audits on a sampling basis are acceptable, there was no evidence that all safety-related areas were audited. The audits did not encompass all aspects of the QA program in order to determine effectiveness.
The failure to properly plan or produce evidence of adequate planning for a comprehensive audit program to verify compliance with all aspects of the QA program resulted in the failure to audit significant parts of the QA program is a violation of Criterion XVIII of Appendix 8 to 10 CFR 50 (445/8432-03b; 446/8411-03b). ;
The NRC inspector contacted the Westinghouse {WJ site manager to review the procedure listing for safety-related activities which TUGC0 had audited. As indicated below, no audits of NSSS site j activities were performed in 1983. Discussions with the {W}
site manager revealed that no audits had been performed by TUGC0 QA in 1977, 1978, 1979, 1980, or 1981. This was discussed with the TUGC0 audit staff and QA manager who did not disagree with )
the stated audit frequency.
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{W1 Site Organization External' Total Procedures % Audited {
Procedures -
Procedures Audited / Referenced in 1983 l Westinghouse (W) Site Applicable Procedure, QA Manual, May 1983 LIE 0- <
PPD Procedures 14 ', ,
Installation Procedures 29 / .
The failure to audit (W) procedures (safety-related activities) annually as required by ANSI N45.2.12, Draf t 3, Revision 0, of .
e the QA program is a violation of Criterion XVIII of Aopandix 8 to 10 CFR Part 50, (445/8432-03c; 44618411 u m .
(c) The NRC inspector discussed The staffir of the Audit Program with'TUGC0 QA managerant the findings of the Lobtin Peport and -
the NRC CAT Team Report regarding the staffing of.-the audit
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functions. The discussions revealed that the TUGC0 audit staff had been increased from 4 to the present nutber of 12 between 1982 and 1984, and TUGC0 management has been looking for 3 or 4 additional nuclear experienced auditors to further increase.the audit staff. However,itwtlsalsorevealedthatmanagementhad not determined the total auditi required nor the manpower nerded to accomplish the audits. >
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This matter is an unresolved item pending the" determination of the number of audits and auditors that will be Aeeded to t effectively implement the audit ptogram (445/8432 '04; -
446/8411-04). ]
(d) The NRC inspector determined through review of charts'and
- l procedures that current organization provided organizational freedom from cost and schedule.
(e) The NRC inspector evaluated audit personnel qualifications by reviewing 14 personnel files of lead auditors and auditors.
This included presently employed and formerly employed auditors. 1 These personnel were qualified as required by TUGC0 i Procedure DQI-QA-2.1, Revision 7, and ANSI N45.2.23-1978,
" Qualification of Quality Program Audit Personnel for Nuclear Power Plants." .
(f) The NRC inspectors reviewed TUGC0 Audit Procedures DQP-CS-4, Revision 10 (June 4, 1984), and pQI-CS-4.6, Revision 7 (April 13, 1984). As previously discussed in paragraph 2.C(1),
DQP-CS-4 does not include adequate commitments to perform annual.
audits and failed to address both design'and construction ana '
plant operations audit requirements.
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- e. Implementation of the TUGC0 Audit procram The NP.C inspectors selected three areas of the audit program to l
review asd evaluate implementation. Results of this evaluation are discussed in tne folicwing paragraphs.
l 4 I (1) Internal Audits of Site Activities - The NRC inspector reviewee j l the index which showed all site audits and found that 1 l
s Audits TCP-1 through TCP-112 had been performed between March 1978 and August 1984. The number per year are:
(1) 4 in 1978; (2) 3 in 1979; (3) 10 in 1980; (4) 11 in 1981; (5) 30 in 1982; (6) 29 in 1983; and (7) 22 during the first 8 months of 1984. After the audit program was found inadequate in the consultant's report (Lobbin), the number of audits increased from les5 than 1.0 per month in 3082 +n ? 5 per mentr in 1982., After the NRC CAT inspection report in 1963 this number incEeased to 2.7 per month for the first 8 months of 1984 This indica +es that positive action concerning these j reported weaknesses was taken; however, as previously discussed i objectiveievidence was not available that the. required number of audits anc auditors has been identified. This item was previously identified above as unresolved.
l The 1983 and 1984 audit schedule included each audit scheduled, i cancelled, and any additional audits planned or performed.
- l. Whece audits were cancelled, tney were rescheduled and other i audits were added and performed. This effort was well documented. .
In 1083 tne TUGC0 audit group performed 158 audits. Sixty-five intereal audits of site activities are as follows: J construction /QC/ engineering - 33 audits; l n startup - 5 audits; and i
operations - 27 audits. j l
Tbe NRC inspector selected and reviewed 31 TCP 1983 audits of ]
site activities. The audit files included notification to the j organization audited, an audit plan, checklists, an audit report, audit response, and evaluation / closeout of findings.
Audit reports reflected good preparation and execution.
Substantial findings generally resulted and were resolved.
Several lead auditors were interviewed concerning the management of the TUGC0 audit program. They stated that the audit program l had weaknesses or deficiencies in 1978 but they had witnessed !
dramatic improvements and were confider.t that the audit program was currently working well. .
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(2) Assurance of Design Control - TUGC0 management verified that i design was controlled in accordance with the QA program i requirements and procedures through administering an effective ;
audit program. The design control functions were delegated to j the AE and (W); however, TUGC0 was designated the engineering ;
organization responsibility for plant design. j l
The NRC inspector reviewed and evaluated the results documented {
in 15 TUGC0 internal and external audit reports which i specifically relate to Criterion III of 10 CFR Part 50, i I
Appendix B, design and applicable procedures. These represent all audits design and consisted of 8 audits of TUGCO, 3 of 0Q, and 4 of G&H, engineering organizations. All audit findings, '!
- concerns, and deficiencies were closed through correspondence l and were later verified through subsequent audits. Manacement involvement was evident as the VP nuclear opera 6.us was on concurrence and was furnished status reports by the QA manager.
In October 1982, TUGC0 initiated a special audit effort to review design using the Institute of Nuclear Power Operations (INPD) performance objectives and criteria. Sargent & Lundy personnel were used to perform this audit. This audit identified 13 findings and TUGC0 audit No. TNO-2, dated June 1983, verified corrective action.
(3) Assurance Control of Procurement Activities - TUGC0 management elected to retain procurement responsibilities except for I certain functions delegated to the AE and NS55. The NRC '
inspector selected several functions retained by TUGC0 to l determine if their audit program effectively monitored or l verified that procurement activities were accomplished in j accordance with the QA program and applicable procurement Management involvement with procurement documents, procedures.
I bid / source evaluation, and specific QA inputs were reviewed by the inspector. The vendor audits and evaluation of vendors were l a large work effort. The following are the results of this review and evaluation.
l The NRC Comanche Peak Special Review Team Report dated July 13, t
1984, at the site identified a potential violation, i.e.,
failure to perform annual audits of vendors. The report '
documented an inspection of the procurement effort at site and part of this inspection included determining the frequency of vendor audits. As a result of the special inspection, the TUGC0 QA manager approved an FSAR change request, dated August 3, 1984, which asked that TUGC0 be allowed to adopt NRC RG 1.144 ;
audit requirements in lieu of ANSI N45.2.12. Oraft 3, l Revision 0, for construction and ANSI N45.2.12, Draft 4, Revision 2 for operations. This requested change would not change the requirement to perform internal audits annually but l
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would reduce the requirement to perform annual audits of suppliers. Considering this requested QA program chenge which had not been approved by the NRC, the following are the inspection results:
(a) The NRC inspector reviewed the TUGC0 vendor audit program f for 1983 to determine compliance with commitments (FSAR Section 17, paragraph 17.1.18), ANSI N45.2.12 and TUGC0 procedures DQP-CS-4 and 0QI-CS-4.5.
The annual audit schedule revealed that 60 vendor audits were scheduled during 1983. Audit TCLC-2 was cancelled (lack of activity with Purchase Order CPC-307) and audit TBS-3 was rescheduled (delayed by 1 week) as a result of NRC CAT Team inspection findings. %e "Dr inspector' selected 3 vendor audit files, TVO-1. TMM-3, and TBF-2, for review to determine the extent of the audits as applicable to the audit plan checklist, noted deficiencies, concerns, and comments. Also included in this review were the corrective actions and/or preventive action documented in writing by the vendor in response to the applicable audit findings. Documents in file closed the audit findings and r
indicated that followup on corrective action would be
' verified during the next audit.
The NRC inspector reviewed the vendor audit frequency to determine if TUGC0 established a schedule to cnnually audit vendors. The licensee commitment to ANSI N45.2.12, Draft 3, Revision 0, requires annual audits or at least once within the life of the activity. Neither procedural requirements were established, nor were vendors audited annually.
The failure to establish procedural requirements and to perform annual vendor audits is a violation of Criterion XVIII of 10 CFR Part 50, Appendix B and ANSI N45.2.12, Draft 3, Revision 0 (445/8432-03d; 446/8411-03d).
(b) The NRC inspector reviewed the approved vendors list (AVL) program for 1983 to verify that methods used by TUGC0 to qualify vendors to supply safety-related materials, parts, and services were consistent with the QA plan, procedural !
requirements, and commitments described in-ANSI N45.2.13-1976, A review of supplemental memos and i preaward survey files and revisions 9 through 12 of the AVL verified that the' AVL was current. This review showed i 33 additions, 40 status changes, and 1 deletion to the AVL for the period January 24, 1983, through December 20, 1983.
The preaward survey files reviewed were consistent with A __ - _-- _ - _ __ _ _ _ _ _ - - _ _ _ - _ _ _ _ _ - _
i Procedures DQP-CS-4, Revision 10, and DQI-CS-4.2, !
Revision 3, December 1, 1982. During the review of 1 preaward survey files, the inspector confirmed that formal i identification letters, the survey date, and the scope of the survey (checklist) were consistent with the vendor QA program. Also, the corrective action responses by the l supplier concerning noted deficiencies,' concerns, and comments were reviewed, and followup action verified in a subsequent audit. ,
(c) The NRC inspector reviewed the vendor performance {
evaluation (VPE) system to determine compliance with i commitment and procedural requirements. TUGC0 Procedure !
0QP-CS-4.3, paragraph 1.1 stated that the purpose of the evaluation was to establish a compreherciva 'r + had cf identifying system weaknesses in vencor QA programs tnrough acceptable / unacceptable hardware information generated as a result of vendor release inspections. The VPE files included release inspection trip report cover sheets, vendor rating sheets, releases, and the inspection checklists as requirea by TUGC0 Precedure DQI-CS-4.3, Revision 4, paragraph 3.1.
The NRC inspector reviewed 3 VPE packages to determine that the quality assurance services (QAS) group's review was consistent with procedural requirements. One vendor file (Paul Monroe Hydraulic) was still active pending engineering review and evaluation on the 0-ring discrepancy l identified during release inspection at Remo Hydraulics l (Purchase Order CPF-11436-5 issued to Paul Mnnroe l Hydraulics) for 20 hydraulic snubber assemblies. As
- required by DQP-VC-3, one vendor package (Meddco Metals) was being held on a yellow flag sheet to alert TUGC0 l auditors of next request for release so that TUGCC auditors could accompany the TUGC0 vendor compliance inspector to j resurvey the vendor. One other vendor (Volumetrics) l performance evaluation record was reviewed and it showed a j
! vendor rating of greater than 90. The NRC inspector interviewed the QA audit supervisor to determine what objective evidence (as required by referenced TUGC0 l Procedure 0Q1-C5-4.3, paragraph 3.2) was used to perform l l the vendor evaluation and support vendor ratings. Preaward l surveys, previous audits, and receiving inspection reports were used as objective evidence to give the rating.
l l The NRC inspector reviewed the receiving inspection
! activity for previous release inspection shipments relative l
[ to the aforementioned vendors. Receipt inspection 1 l consisted of shipping damage inspection, receipt of documentation, identification, and quality assurance release, i
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(d) The NRC inspector reviewed the method by which the licensee performed source selection to determine that procedural i requirements were met. QA plan Section 4.0, Revision 4, July 31, 1984, required that a purchase order for safety-related items not be issued to a vendor unless TUGC0 QA had reviewed and accepted the purchase order; i.e. , QA determines whether QA provisions are adequate and determines that a preaward evaluation recommends selection of the vendor.
When procurement solicited bids outside the AVL, TUGC0 QA requested that an uncontrolled copy of the vendors quality assurance manual be sent with the bid response. In the event of a positive bid response from the unapproved supplier, the TUGC0 procurement grcup N W ')t.M er.d a request for QA program evaluation, Form QA-VE, to the TUGC0 QA audit group supervisor to initiate a preaward survey per QA Procedure DQT-CS-4.4, paragraph 3.1.
However, until the preaward survey is completed and a ;
supplemental memo has been issued by the audit group supervisor, no further procurement action was taken.
The NRC inspector reviewed the actions taken when an acceptable bidder takes exceptions to thi purchase order or subcontract. Upon receipt of the exception, procurement filled out an expediting request, assigns a procurement log number, and forwarded this request to the field requisition originator for engineering review and evaluation. Shoulc the engineering group allow the ' exception, the necessary )
actions; i.e., design changes, were initiated. The expediting request was returned to procurement accompanied by a field requisition documenting the change with the approval signatures of engineering and QA.
(e) The NRC inspector reviewed the method by which TUGC0 performed vendor item acceptance of safety-related materials, parts, and components. TUGC0 Procedure DQP-VC-1, Revision 8, June 4, 1984, paragraph 1.1, specified that the purpose was to establish guidelines for performing final inspection and release of i TUGC0 purchased equipment and applies to both safety-related and nonsafety-related equipment. This procedure allowed for a waiver, in which case the inspection checklist applicable to the procurement specification became the responsibility of CPSES receiving inspection as described in B&R CPSES Procedure CP-QAP-8.1, Revision 8, June 11, 1984/ paragraph 3.4.1 (f) The NRC inspector reviewed six vendor compliance inspector's files to determine if training / certification )
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records met the requirements of RNSI N45.2.6-1978 and TUGC0 Procedure DQP-VC-4, " Guidelines for Certifying Vendor Compliance Personnel." Section 3.2.2 states that a Level II inspector shall attend and satisfactorily complete the nondestructive examination (NDE) courses. One inspector had not completed all of the NDE courses but had been certified. This finding was discussed with the vendor compliance supervisor who stated that there is no real need for certification in eddy current testing since inspectors do not utilize this NDE technique and the requirements would therefore be deleted from the procedure. The NRC inspector verified the deletion of this requirement and procedural revision during this inspection.
The failure to certify the inspecter : n. . c( ith tne !
procedure is a violation of Criterion V of Appendix B to 10 CFR 50 (445/8432-05; 446/8411-05).
No other violations or deviations were identified.
- 3. TUGC0 Corporate OA - Site QA Activities Interface Appendix B to 10 CFR Part 50 requires TUGC0 to establish proper organizational and management interfaces, and procedures must describe how various organizations coordinate and communicate design, procurement, engineering, construction, and QA/ control activities and information. The following paragraphs describe inspection of this requirement,
- a. Site Organization t
TUGC0 Procedure CP-QP-3.0, Revision 15, July 30, 1984, described the site QA organization for design and construction. This organization l consisted of a site QA manager, QA supervisor, and a QC supervisor.
The site group performed no audit function, however, they did perform QA surveillance. The site group consisted of 13 QA/QC managers and more than 150 lead /QC inspectors and quality engineers. These personnel inspected non-ASME work.
l B&R QA manual and implementing Procedure CP-QAP-03.01, Revision 6, described their responsibilities for QA/QC and construction activities pertaining to ASME work. This organization consisted of a QA manager, QE supervisor, and a QC supervisor.
The total QA/QC work force involved with design / construction activities was approximately 100.
Several other site subcontractors such as Bahnson, Brand Industrial Services, Inc. , and Chicago Bridge and Iron, have small QA groups on site and, as is the case with B&R, these organizations were audited by their respective corporate offices.
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-i The NRC inspector interviewed the TUGC0 site QA manager to determine how the site QA group interfaced with the corporate QA office. He stated that daily conversations occur between managers of these-organizations, however, he did not make_ written summary reports.
Quarterly trending reports which analyze reported nonconformances and deficiencies are sent to the corporate QA manager,
- b. Site Surveillance f The NRC inspector noted that surveillance were briefly mentioned in TUGC0 Procedure DQP-CS-4, Revision 10; however, there was no mention of how or if the surveillance would be.used to complement the audit program. During discussions with.the QA manager and other personnel, it was revealed that procedures were not tracked to' assure that all were audited. The present audit staff could no+ su."+ al cite procedures. annually. The NRC inspector pointed out that the surveillance function may complement and be used to (1) check that all procedures are implemented; (2) identify nonconforming trends; and (3) to feed potentially deficient or weak areas to the audit group which could, in turn, factor,this information into the audit i
program. Audit priorities could then be established and the' audit personnel could be more effectively used.
I TUGC0 Surveillance Procedures CP-QP-11.2, 19.3, 19.4, 19.5, 19.6, i 19.7, 20.0, and 27.0 described the surveillance of specific activities; however, no general procedure which describes the overall surveillance program was provided. The present program did not appear to have sufficient purpose, direction, coordination, and feedback in relationship with the overall QA program. Furthermore, the inspection revealed that the surveillance staff had been reduced from a supervisor and eight technical personnel to four technical personnel. Considering the Lobbin Report this reduction of surveillance effort may not be a' prudent action.
l As noted in the findings in the Lobbin Report; i.e., QA management had not clearly defined the objectives and scope of the surveillance program, it appeared that TUGC0 r.eeded to strengthen the surveillance program. The TUGC0 management decision to commit to a sutueillance program was a strength, but this lack of purpose and direction and support was a program weakness.
l' Additionally,'the surveillance group was no longer observing work in l
Unit 1 but will now place most of their effort on Unit 2 construction j activities.
This matter is consicated unresolved pending clarification of the audit and surveillance program effort,and further review during a-l subsequentinspection(445/8432-0q;446/8411-06).
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The NRC inspector randomly selected and reviewed 28 surveillance performed in 1982, 1983, and 1984. Findings and resolutions of these !
findings were reviewed and in each case, written responses and corrective action were adequate.
- c. Site Design Activities The NRC inspector reviewed and evaluated selected site activities pertaining to design verifications, design changes, design inputs, and control of vendor drawings as follows: .
1 (1) Design Verification - The NRC inspector interviewed the TUGC0 l supervisor of engineering, support, and other engineering {
personnel to determine how design verifications were performed, l and examined the related procedures, logs, e d M ice verification packages. Authorized desigr veiitie n ere maintained on lists and an automated tracking system was in j place.to assure that'all design changes, i.e., design change i t *horizations/ component modification cards (DCA/ CMC) were {
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'ified. Three design verification reports were reviewed to (
assure that the design verifier was on the authorized list.
Design verifiers were not to be involved in the original design review to assure an independence. It was noted that each DCA/ CMC was being reviewed for verification. If there was no authorized signoff, then the design was verified.
Audit TGH-23, conducted during August 1984, concentrated on Unit 1 quality related activities for which onsite G&H design review team had responsibility. The audit involved evaluation of the program established and implemented for site review and processing of changes (CMA and DCC) associated calculations and l 287 design review packages were reviewed. No major technical l
problems were identified during this audit. l (2) Design Changes - The NRC inspector interviewed engineers and <
draftsmen in TUGC0 engineering to determine how design changes l were processed and examined the related procedures, files, (
reports, and tracking systems. A master list was maintained .
identifying those individuals who were authorized to approve !
design changes and G&H updates this list by memo. The NRC review of three design review files verified that the reviewers j were on the authorized list. 1 The NRC inspector also reviewed the method used to incorporate j field changes (CCA/ CMC) into related drawings and the subsequent {
review, approval, and incorporation of changes into as-built drawings. One observation requi, red additional discussions. The drafting supervisor's (piping support) authority to incorporate 1 a change into a drawing was transmitted and' signed by a clerk, j This was clarified as being acceptable by management because it i
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was in accordance with established procedure (CP-EI 4.6-8, paragraph 3.3) and also, as a final control, the as-built l
drawing was reviewed and approved by an authorized project
- enginear prior to release.
l The NRC inspector examined how the TUGC0 administrative services group handled NRC IE Bulletins, Circulars, and Information Notices. These documents were coordinated by the operations support department and were distributed to the appropriate TUGC0 engineering group for action. Design changes resulting from these inputs were processed in accordance with established
! design control procedures. Responses from personnel receiving these reports were reviewed to verify that the reports were adequately addressed. Summary reports and log sheets are used to keep management current as to the status of +ha enT9anset, i
An INPO audit of the operating experience review program in 1982 l noted the following good practice, "The procedures for handling industry experience are excellent and are expected to provide a firm base for developing an effective industry experience !
program."
TUGC0 QA audit Report TUG-41 was conducted in December 1983 to review implementation of the operations support program for evaluating and responding to NRC IE Bulletins, IE Notices, IE Circulars, and generic letters. The auditors found the program in compliance witn procedural requirements and the overall effectiveness of the program appeared to be adequate.
(3) Design Documcnt Control - Two packages were reviewed and these contained evidence of vendor data checklists, indexes, approval letters, and the vendor stamp on drawings wat observed,
- d. Site Procurement Activities The NRC inspector determined that the TUGC0 procurement function was delegated to the TUGC0 site organization. The major procurement occurred several years ago; however, present procurement activities associated with items procured offsite for installation were performeo by TUGC0 or were contracted to G&H, (W), or B&R who were evaluated and qualified by TUGC0 QA, Procurement documents were reviewed, approved, and controlled; and receipt inspection of safety-related j items on site was performed in accordance with written procedures and checklists.
The NRC inspector selected two procurement actions for review:
- P.O. CPF-1233-S issued to Combustion-Engineering for the procurement of a heated junction thermocouple system.
- CPF-10469-5 issued to Paul Monroe H,ydraulics to refurbish four Rockwell International actuators. 3 I,
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Both the procurement actions were reviewed to determine that technical requirements were commensurate with the scope of the procurement and was authenticated by engineering review in accordance with TUGC0 engineering division Procedure CP-EP-3.0, Section'2.0(d).
Both procurement actions reflected the necessary QA review signatures, as required tar TUGC0 engineering division Procedure CP-EP-5.0, paragraph 3.1.2; QA Procedure DQP-CS-2, paragraph 3.1.8; and instruction QI-QP 5.0.1. All field requisitions !
initiated to generate a supplement to the aforementioned purchase orders were reviewed and documented as required by Procedure CP-EP-5.0. Reporting requirements set forth by 10 CFR Part 21 were included in the purchase order. The NRC inspector reviewed and verified that both purchase orders specified that the supplier shall establish provisions for imposing similar QA requirements'on epolicable subtier vendors, No violations or deviations were identified.
- 4. Unresolved Items Unresolved items are matters about which more information is required in order to determine whether they are acceptable items, items of noncompliance, or deviations. Unresolved items are identified in this report in paragraphs 2.a. 2.c.(2) and 3.b.
- 5. Exit Interview ,
! The NRC inspector met with members of tne TUGC0 staff (denoted in l l paragraph 1) at various times during the course of the inspection. The j l scope and findings of the inspection were discussed. ,
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