TXX-4779, Responds to NRC Re Violations Noted in Insp Repts 50-445/85-14 & 50-446/85-11.Corrective Actions:Chemistry Section Forms Evaluated & Listed Improvements Will Be Incorporated
| ML20211G044 | |
| Person / Time | |
|---|---|
| Site: | Comanche Peak  |
| Issue date: | 05/16/1986 |
| From: | Counsil W TEXAS UTILITIES ELECTRIC CO. (TU ELECTRIC) |
| To: | Johnson E NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| Shared Package | |
| ML20211G035 | List: |
| References | |
| TXX-4779, NUDOCS 8606190270 | |
| Download: ML20211G044 (25) | |
Text
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- Leg i TXX-4779 File # 10130 IR 85-14 TEXAS UTILITIES GENERATING COMPANY 85-11 NKYWAY TOWER . 400 NORTH OtJVE NTHEET, I.M. A1 e DAILAN, TEXAN 75301 May 16, 1986 $bbb
.20ASifn'.h ] b NAY 211986 1 0 t JL
~
p Mr. Eric H. Johnson, Director Division of Reactor Safety and Projects U. S. Nuclear Regulatory Commission 611 Ryan Plaza Drive, Suite 1000 Arlington, Texas 76012 l
SUBJECT:
COMANCHE PEAK STEAM ELECTRIC STATION (CPSES)
DOCKET NOS. 50-445 AND 50-446 RESPONSE TO NRC NOTICE OF VIOLATION !
INSPECTION REPORT N0.: 50-445/85-14 AND 50-446/85-11
Dear Mr. Johnson:
We have reviewed your letter of March 6, 1986, concerning the inspection by ;
Mr. T. F. Westerman and others of the Region IV Comanche Peak Group during i the period September 30 through October 31, 1985. This inspection covered activities authorized by NRC Construction Permits CPPR-126 and CPPR-127 for Comanche Peak Steam Electric Station Units 1 and 2.
We requested and received a four week extension in providing our response during a telephone discussion on April 7, 1986. We requested and received an additional two week extension during a telephone discussion on May 2, 1986. We have provided our response to the Notice of Violation and the Notice of Deviation in the attachments to this letter. To aid in understanding our response, we have repeated the Notice followed by our response.
Very truly yours, W. G. Counsil JWA/arh c- Region IV (Original + 1 copy)
Director, Inspection and Enforcement (15 copies)
U. S. Nuclear Regulatory Commission Washington, D.C. 20555 Mr. V. S. Noonan Mr. D. L. Kelley 8606190270 860616 PDR ADOCK 05000445 G PDR A DIVENION OF TEXAR UT112 TEEN ELECTRIC (X)MPANY It.-095 I 84 l
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, , ' , NRC Notice of Violation Item A (445/8514-V-01)
Criterion XVII of Appendix B to 10CFR Part 50, as implemented by Section 3.8, Revision 4, of the Operations Administrative Control and Quality Assurance Plan, requires that (1) sufficient records shall be maintained to furnish evidence of activities affecting quality, and (2) that the records shall include the results and acceptability of tests and analyses, and the action taken in connection with any deficiencies noted.
Contrary to the above:
- 1. A significant number of instances of missing data entries was noted in water chemistry records covering the period March 1983 through September 1985, with respect to the chemistry sampling frequency requirements of Procedures CHM-501, " Chemistry Control of the Primary Cooling Water Systems." No annotations were made in the records to explain why the samples were not taken.
- 2. Review of the water chemistry records showed instances of failure to make required entries to indicate when the Shift Supervisor was notified in regard to out-of-specificiation chemistry results.
- 3. The records did not identify what corrective actions were taken after entry of out-of-specification results.
- 4. Inadequate reviews were performed of the acceptability of water chemistry data, as evidenced by the presence of review and approval signatures on forms containing discrepant data results.
Response to Item A Notice of Violation 445/8514-V-01 is written in four parts, each of which is addressed separately.
Part 1
- 1. Reason for Violation:
An investigation by the Chemistry and Environmental Engineer confirms instances of missing entries on Chemistry data sheets, with no explanation in some cases. In many cases there are explanations on data sheets preceding the ones with missing data; explanations such as system drained, not in service, or problem with analytical equipment. Chemistry personnel failed to document the continuing situation on subsequent data sheets when data was unavailable.
CHM-501 and CHM-508, the governing procedures cited in this part of the Violation, require the recording of data on appropriate data j sheets. However, no guidance is provided concerning documentation :
of samples not taken, or there is no requirement to document the I reason samples are not taken in the comments section of the data sheet.
\
. NRC Notice of Violation I Item A (445/8514-V-01) !
(Continued) l
- 2. Corrective Action Taken:
A. Chemistry section forms have been evaluated. The following improvements were identified and will be incorporated:
All data sheets associated with the CHM-500 series proce-dures will have the same general lay-out; Parameter limits will be highlighted in red ink; Sample data and time columns will be clearly delineated; Where applicable, a chemical addition column will be included; and Each form will include the following note; " Circle out-of-specification parameters."
The following corrective actions are in progress or will be completed pending approval of CHM-500 series procedures.
B. Chemistry data sheets (forms) associated with the following procedures are being revised:
Procedure No. Revision No. Procedure Title CHM-501 1 Chemistry Control of the Steam Generators CHM-502 1 Chemistry Control of the Water Treatment System CHM-503 1 Chemistry Control of the Condensate System CHM-504 1 Chemistry Control of the Feedwater System CHM-505 1 Chemistry Control of the Secondary Support System CHM-506 1 Chemistry Control of the Primary System CHM-507 1 Chemistry Control of the Residual Heat Removal System CHM-508 1 Chemistry Control of the Primary Support System
NRC Notice of Violation Item A (445/8514-V-01)
(Continued)
CHM-509 1 Chemistry Control of the Primary Makeup System CHM-510 1 Chemistry Control of the Boron Recovery System CHM-511 1 Chemistry Control of the Safeguards System CHM-517 1 Sampling and Analysis of Liquid Waste Systems CHM-519 1 Chemistry Control of the Refueling Water
- 3. Corrective Steps to Avoid Recurrence:
A. The Chemistry section attended a training session on January 9, 1986, which addressed the following topics:
Procedure compliance; Problems associated with existing data sheets; Pending revisions to existing data sheets; Consequences of missing surveillance item; Consequences of not reporting an out-of-specification parameter; Proper routing of data sheets; Corrective action recommendations; and Proper or key points to consider when filling out a data sheet. The following items were addressed:
- 1. Ensure all data entries are clearly written;
- 2. Circle all out-of-specification parameters;
- 3. Ensure that data is reviewed against specified limits;
- 4. Ensure that all footnotes are used correctly;
- 5. Fill in blanks;
- 6. Document systems that are not in service;
. NRC Notice of Violation Item A (445/8514-V-01)
(Continued)
- 7. Document reason for taking sample if not routine;
- 8. Utilize standard nomenclature.
Additionally, Chemistry directive 86-001 was issued to address these Concerns.
B. Upon approval of the above referenced procedures, implementation training will be provided to familiarize all Chemistry section personnel with the new data sheets (forms).
- 4. Date of Full Compliance:
A. Chemistry data sheets (forms) associated with the referenced CHM-500 series procedures will be revised by June 1, 1986.
B. Chemistry section personnel will receive additional training on the revised data sheet forms by June 1, 1986.
Part 2
- 1. Reason for Violation:
There have been instances of failure to make required entries to indicate that the Shift Supervisor was notified in regard to out-of-specification Chemistry results. Some of these instances are failure to notify the Shift Supervisor for each sample for a continuing condition, specifically the pH depression.
These deficiencies are procedurally related because CHM-508, Revision 0, required the notification of the Shift Supervisor but did not require documentation of this notification on the data sheet. Also data sheet CHM-508-1 did not require identification of out-of-specification conditions or notification of the Shift Supervisor. CHM-501, Revision 0, did not require immediate notification of the Shift Supervisor upon verification of an out-of-specification condition and the time of notification be recorded on the appropriate data sheet. This problem is aggravated by the listing of Mode 1 limits on data sheet CHM-501-1 for steam generators so it is not readily apparent which values are out-of-specification. This is a contributing factor to personnel errors during shutdown conditions.
- 2. Corrective Action Taken:
The data sheets are being revised to show the appropriate limits for the applicable condition.
. , . NRC Notics of Violation Item A (445/8514-V-01)
(Continued)-
CHM-508 has been revised to include the requirement to immediately notify the Shift Supervisor in the event of an out-of-specification condition and to document this notification on the data sheets.
- 3. Corrective Steps to Avoid Recurrence:
The corrective action, with Chemistry section personnel training, should prevert this part of the Violation from reoccuring.
- 4. Date of Full Compliance:
CHM-508 was revised October 15, 1984. Chemistry data sheets (forms) will be revised by June 1, 1986.
Part 3
- 1. Reason for Violation:
Investigation confirms that the Chemistry data sheets do not typically indicate the corrective actions taken for out-of-specification chemistry.
This deficiency is procedurally related because CHM-501 and CHM-508 indicate that the Chemistry Supervisor will investigate out-of-specification chemistry and determine the corrective action to be taken. There is no guidance to document corrective actions in other administrative procedures or on the data sheets.
This deficiency was also identified in TUGC0 Corporate QA Audit TUG-76 as Deficiency No. 1.
- 2. Corrective Action Taken:
Guidance provided by the revised procedure CHM-104 provides necessary corrective action. This corrective action was the result of TUGC0 QA Audit TUG-76.
- 3. Corrective Steps to Avoid Recurrence:
The training provided under the Part 1 Preventive Action should prevent this deficiency from reoccurring.
- 4. Date of Full Compliance:
Procedure CHM-104 was revised on May 24,, 1985. Personnel training was completed on January 9, 1986.
NRC Notice of Violation Item A (445/8514-V-01)
(Continued)
Part 4
- 1. Reason for Violation:
CHM-101, Revision 1 (5-12-82), " Chemistry / Radiochemistry Administrative Control," states that records produced by technicians shall be independently reviewed by a qualified person and forwarded to the Chemistry and Environmental Engineer or his designee for approval.
CHM-101, Revision 2 (12-8-83), states that Chemistry and Environmental Supervisors are responsible for reviewing data sheets and that Staff Chemists are responsible for approving data sheets.
- 2. Corrective Action Taken:
A qualified person will review all past CHM-501-1 and CHM-508-1 data sheets. This review will be performed to determine if there is any significant chemistry concern indicated which has not been identified and resolved. Also, a representative selection based on the number of records generated from other procedures utilized during the January 1983 to September 1985 time period will be reviewed. If similar problems are found to exist in the selected records, then a full review will be conducted. Deficient or nonconforming conditions discovered during these reviews will be documented in accordance with station procedures.
- 3. Corrective Steps to Avoid Recurrence:
All Chemistry and Environmental Supervisors and Staff Chemists have been reminded of their administrative responsibilities.
- 4. Date of Full Compliance:
All required document reitews will be complete by August 1, 1986.
e s Notice of Violation Item f(~446/8511-V-01)
Criterion V of Appendix B to 10 CFR Part 50, as implemented by TUGC0 Quality Assurance Plan (QAP), Section 5.0, Revision 3, dated July 31, 1984, requires that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings.
Paragraphs 2.3 and 3.1.1.1 of Brown & Root (B&R) Procedure CQ-QAP-16.2, Revision 25, require that nonconformances be identified, documented by completing the NCR form, and dispositioned. Paragraph 3.19.5.2 of B&R Procedure CP-CPM 6.90, Revision 6, states, in part, with respect to NCRs for minimum wall violations, ". . . Welding engineering shall review the conditions stated on the NCR . . . ."
Contrary to the above, repair of a minimum wall violation associated with weld 21-2 in component CC-2-RB-053 was noted on October 9, 1985, from record review to have been performed without documenting the condition on an NCR form.
Response to Item B
- 1. Reason for Violation:
A QC Inspector failed to follow QI-QAP-11.1-26 which requires the initiation of a Nonconformance Report (NRC) for minimum wall violation (MWV).
- 2. Corrective Action Taken:
A review was conducted to determine the method used to identify and correct the MWV and concluded that the repair process used was technically adequate and would not have been altered regardless of the document used to record the MWV (i.e., Unsatisfactory IR attribute vs NCR). While we believe that the violation is a iso-lated occurence we are confident that any other similar minimum wall violation would have been likewise adequately dispositioned.
- 3. Corrective Steps to Avoid Recurrence:
All applicable QE's and QC Inspectors were retrained in the speci-fic QI-QAP-11.1-26 program requirements relative to welded repairs associated with MWV's. Additionally, construction proce-dure CP-CPM-6.9D will be revised to clarify the requirement that an NCR must be generated whenever a MWV is identified. Appropriate Weld Engineering personnel will be trained to the revised CP-CPM-6.9D requirements.
- 4. Date of Full Compliance:
May 16, 1986.
Notice of Violation Item C (446/8511-V-02)
Criterion V of Appendix B to 10 CFR Part 50, as implemented by TUGC0 QAP, Section 5.0, Revision 3, dated July 31, 1984, requires that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings.
Paragraphs 3.1.1.1 of B&R Procedure DCP-3, Revision 18, states, in part,
" . . Issuance and receipt of controlled desien changes are documented on the Document Distribution Log . . . by signature or initial of the file custodian and dated." Paragraph 3.2.2.5 of this procedure additionally requires that the face of a retained superseded document
- nust be stamped "V0ID."
Contrary to the above:
- 1. Satellite document control center 307 was noted on October 14, 1985, to be in possession of a controlled copy of Component Modification Card 96181 for which receipt had not been signed for and dated on the Document Distribution Log.
- 2. A copy of superseded Design Change Authorization (DCA) 21446, Revision 0, was noted on the same date to be present in two packages for Drawings 2323-El-1702, Sheet 002, Revision 2. Both copies of DCA 21446, Revision 0, were not startped "V0ID" on the face of the document.
Response to Item C - No. I
- 1. Reason for Violation:
Failure to properly implement procedure.
- 2. Corrective Action Taken:
The Document Distribution Log was corrected by the inclusion of proper initial and date. The Document Distribution Log was reviewed and there were no other violations of this nature l identified. l
- 3. Corrective Steps to Avoid Recurrence: j Appropriate DCC personnal were reinstructed in the proper receipt acknowledgement of design changes. DCP-3 rev. 19 paragraph 3.1.1.1 includes verification responsibilities by DCC personnel to :
ensure acknowledgment of design changes is documented. ;
- 4. Date of Full Compliance:
March 31, 1986.
- - +
Notice of Violation '
Item C (446/8511-V-02)
(Continued)
Response to Item C - No. 2
- 1. Reason for Violation:
Failure to properly implement procedure.
- 2. Corrective Action Taken:
The drawing package contents were immediately corrected. It was determined that the drawing was not used in the performance of plant work. Monitoring a sample of drawing package contents revealed that no drawings or design changes were found to be out of revision.
- 3. Corrective Steps to Avoid Recurrence:
Personnel were reinstructed in the need to assure up-to-date contents in drawing packages, including the marking of superseded drawings as " void".
- 4. Date of Full Compliance:
April 1, 1986.
. Notice of Violation Item D__(446/8511-V-03)
Criterion V of Appendix B to 10 CFR Part 50, as implemented by TUGC0 QAP, Section 5.0, Revision 3, dated July 31, 1984, requires that activities affecting quality shall be prescribed by dccumented instructions, procedures, or drawings of a type appropr: ate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings.
Section 17.1.17 of the Final Safety Analysis Report, Volume XIV, Amendment 50, dated July 13, 1984, commits to procedures requiring that records be controlled and accounted for during transfer between organizations.
Contrary to the above, original sole copy design records were ascertained on October 16, 1985, to have been shipped to Stone and Webster Engineering Corporation, New York, without the establishment and implementation of procedures that address required control and inventory measures.
Response to Item D
- 1. Reason for Violation:
Conditions noted in the violation are the result of a failure to follow established procedures for control of engineering documents.
TUGC0 Nuclear Engineering (TNE) Procedure TNE-AD-4 specifies that duplicate copies of engineering documents prepared or processed by TNE shall be maintained at the site or Gibbs & Hill /New York, as applicable.
In 1985, Stone & Webster Engineering Corporation (SWEC) assumed design responsibility for pipe supports. In order to consider and
! incorporate, where possible, existing information into SWEC designs, TUGC0 initiated shipment of pipe support design records offsite, t
- 2. Corrective Action Taken:
Measures to establish compliance with TNE procedure TNE-AD-4 and 4
subordinate TNE instruction TNE-AD-4-6 (issued specifically for transmittal and duplicate retention of pipe support calculations) have been implemented for pipe support records previously forwarded to SWEC. These efforts, involving the return of copies and I complete accountability, were completed in February 1986.
- 3. Corrective Steps to Avoid Recurrence:
TNE-AD-4-6 was issued November 25, 1985, establishing a program for transmittal requirements for pipe support design records. In addition, TNE-AD-4 will be reviewed and revised, if required, to assure the adequacy of measures prescribing the offsite transmittal of engineering documents.
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Notico of Violati@n i Item D (446/8511-V-02)
(Continued) ,
- 4. Date of Full Compliance:
As noted in items 2 and 3, all measures have been completed with the exception of the review / revision of Procedure TNE-AD-4. These measures will be accomplished no later than May 22, 1986.
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Notice of Violation Item E (446/8514-V-03)
Criterion VI of Appendix 8 to 10 CFR Part 50, as implemented by Section 3.8, Revision 4, of the Operations Administrative and Quality Assurance Plan, requires that (1) measures shall be established to control the issuance of documents such as drawings, including changes thereto; and (2) the measures shall assure that documents, including changes,_are reviewed for adequacy and approved for release by authorized personnel.
Paragraphs 2 and 4 in Revisions 7 and 8 of Station Administration Manual Procedure No.~ STA-405 require that all documented nonconformances, in which "use-as-is" dispositions are recommended, be forwarded to TUGC0 Operations Results Engineering group for review to determine if as-built
- documentation changes are needed.
Paragraph 4.0 in Revision 0 of Nuclear Operations Engineering Manual Instruction No. N0E-201-5 requires that proposed drawing changes be submitted to the Operations Superintendent for review, approval, and
, authorization to distribute the revised drawings.
Contrary to the above, nine-as-built drawings were revised and distributed by TUGC0 Nuclear Engineering to reflect NCR identified undersize welds, without receiving TUGC0 Operations review, approval, and authorization to distribute the revised drawings.
Response to Item E
- 1. Reason for Violation:
The condition noted in the violation is the result of the issue of i pipe support drawings by TNE documenting acceptance of "Use-As-Is" conditions prior to the proper disposition of several TUGC0 Operations' NCR's.
Prior approval of drawings which document the "Use-As-Is" disposition of NCR's by TUGC0 Operations is a requirement of Station Administration Manual Procedure STA-405.
Please note the following in regards to Appendix "A", item E, third l paragraph of the subject NRC Inspection Report. Procedure N0E-201-5 does not require "non-vital" drawings, such as BRH (pipe support) drawings be submitted to the TUGC0 Operations Superintendent prior to issue by PSE (Pipe Support Engineering).
However, the generic issue of whether such drawings should be classified as " vital" and therefore be submitted to the TUGC0 Operations Superintendent is being processed by TUGC0 Deficiency Report (DR-86-007) whose disposition is yet outstanding.
- 2. Corrective Action Taken:
The pipe support drawings noted in the finding were subsequently reviewed by TUGC0 Operations. Approval has been documented by j closure of the corresponding TUGC0 Operations' NCR's, completed
- December 19, 1985.
_ .- ~ . _ _ _ _ _ _ _ - _ _ - - _ _ - . . _ . . _ _ _ _ _ _ _ _ _
o . '. Notice of Violation Item E (446/8511-V-02)
(Continued)
- 3. Corrective Steps to Avoid Recurrence:
i As a result of this specific finding, TNE Procedure TNE-AD-4-5 Revision I was issued November 11, 1985. Procedures which describe TNE and TUGC0 Operations interface arrangements applicable to pipe supports were reviewed to assure consistency. No additional conflicts were noted. Adherence to these interface requirements should preclude further violations of this nature.
- 4. Date of Full Compliance:
As noted above, full compliance has been achieved. .
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Notice of Violation Item F (446/8514-V-04)
Criterion V of Appendix B to 10 CFR Part 50, as implemented by TUGC0 QAP, Section 5.0, Revision 3, dated July 31, 1984, requires that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings.
Paragraph 3.0 of Procedure CP-QP-2.1, Revision 14, dated October 17, 1983, states in part, ". . . inspection personnel . . . shall have experience in and shall have completed a technical training course and examination in the area of inspection responsibilities." Paragraph 3.7 of this procedure states, in part, ". . . Inspection personnel shall be certified by the TUGC0 site QA supervisor as being qualified to perform their assigned tasks."
Contrary to the above, it was noted on October 21, 1985, during review of documentation for Class 1E lighting system conduit EAB1-1 that the electrical-inspector, who had signed inspection reports E-1-0024951 and E-1-0027419, had not been certified to the applicable Procedure QI-QP-11.2-25, Revision 17, dated February 13, 1984, " Inspection of New 1 Installations for Class 1E Lighting Systems." 1 Response to Item F
- 1. Reason for Violation:
Oversight by QC Supervision which allowed the inspector in question to inspect to QI-QP-11.3-25 prior to final sign-off of his certification.
- 2. Corrective Action Taken:
NCR E-85-101639 was initiated to address this violation. In addition, 800 Inspection Reports completed by 163 QC Inspectors
, during the past six months were reviewed to determine if further l
violations of this nature had occured. All of the reports reviewed I were completed by QC Inspectors certified to the activity 1 inspected. l l 3. Corrective Steps to Avoid Recurrence:
QC Supervision is issued a weekly list which identifies the certification capabilities and status of their personnel, for use in inspection assignments. Based upon the above review results this action is sufficient to avoid recurrence of this violation.
Inspections performed prior to June 1985 are subject to CPRT action item VII.c.
- 4. Date of Full Compliance:
May 5, 1986.
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Notice of Deviation Item A (445/8514-D-01)
Section 4.1.6 of ERC Comanche Peak Project Procedure (CPP) CPP-012, "QA/QC Interface with Construction /TUGC0" states, "The QA/QC Records Administrator controls requests for equipment / services and distributes and controls requests for technical information."
Contrary to the above, the QA/QC Records Administrator does not receive copies of requests to provide for control of these documents (445/8514-D-01).
With respect to item A in the Notice of Deviation, the NRC has ascertained subsequent to this report period that ERC logs for tracking of equipment / service requests have not been utilizing procedurally required unique numbers for individual requests. Accordingly, please address this as part of your response to item A in the Notice of Deviation.
Response to Item A
- 1. Reason for Deviation:
As the NRC identified, the QA/QC Records Administrator does not control requests for equipment / services from the Constructor /TUGCO.
Due to a misunderstanding of the NRC's concern at the time of the finding, it was not explained that such requests are tracked by a computerized log maintained by the Inspection Supervisor or his designee.
Subsequent NRC investigation confirmed the presence of this tracking mechanism. Consequently, the original NRC concern was resolved. However, the NRC inspector subsequently identified a related concern: the log did not show a unique number for each equipment / services request as required by CPP-012.
The function of the equipment / services tracking mechanism is to ensure that all necessary equipment / services (i.e. scaffolding, painting or lagging removal, etc.) are installed or performed oefore inspection takes place and are maintained until inspection is completed. All open equipment / services requests (ESRs) are maintained in a folder associated with the verification package with which they are identified. The computer tracking mechanism tracks the status of tha most recently opened ESR. This function is served satisfactorily by the mechanism currently in place (the same mechanism in place at the time of the NRC inspection).
Changes to the mechanism used to track open ESRs are not required since no failures to perform the intended function exist. However procedure CPP-012 must reflect current practice.
- . . Nstice of Deviation Item A (445/8514-D-01)
(Continued)
- 2. Corrective Action Taken:
ERC Comanche Peak Project Procedure CPP-012 was revised March 11, 1986, to remove reference to the ESR log.
- 3. Corrective Steps to Avoid Recurrence:
The action to correct the reported condition serves as action to prevent recurrence.
- 4. Date of Full Compliance:
March 11, 1986.
N3tice of D:viation Item B (445/8!if4 D 62)
Section 4.1 of CPRT Issue-Specific Action Plan (ISAP) No. VII.c Revision 0, dated June 21, 1985, states, in part,
. . . Where required, documentation reviews will be utilized to supplement the reinspections for attributes which are nonrecreatable or inaccessible. . . ."
Section 4.1.3 of the ISAP states, in part,
. . . The inspection procedure will provide detailed instructions to the inspectors and/or documentation reviewers for performing the reinspections and/or documentation reviews. . ."
Contrary to the above, the following examples were noted of inadequate procedural guidance and document reviewer performance in regard to nonrecreatable and inaccessible attributes:
- 1. Quality Instruction (QI) QI-013 Revision 4, lists no specific attributes, but instead specifies that the inspector verify installations in accordance with one or more of a listing of TUGC0 procedures; i.e., QI-QP-11.8.1, -5, -6, and -8. The list of appropriate procedures does not, however, indicate the applicable revision number of each procedure. In that the number of nonrecreatable or inaccessible inspection attributes can vary from revision to revision of a procedure (e.g. Revisions 0 and 1 of TUGC0 Procedure QI-QP-ll.8-8), the absence of guidance on applicable procedure revision numbers does not constitute detailed instructions.
- 2. During the documentation review of Verification Package No.
R-E-CDUT-064, in accordance with QI-009, Revision 0, there was no evidence that a documentation check was made of inaccessible attributes for conduit C13016037 that were caused by the installation of separation barrier material (445/8514-D-02).
Response to Item B
- 1. Investigation:
QI-013 " Documentation Review for Instrumentation Equipment /R-E-ININ" does not, in fact, list specific attributes for the inspector to verify. The purpose of the documentation review governed by 01-013 is to provide inspector qualification information as input to ISAP I.d.1. The intent of QI-013 is to verify the inspector who signed the inspection report (IR) being reviewed was certified to the appropriate revision of the Quality Instruction (QI) that was in place at the time of the inspection.
To do this the document reviewer records the inspector's name, the QI number, and the revision of the procedure noted on the IR. Then the inspector certifications are reviewed to determine if the inspector was certified to the appropriate revision at the time of signing the IR.
V Notice of D:viation Item B (445/8514-D-01)
(Continued)
This is an appropriate way to verify inspector certifications.
Consequently, no deviating condition is believed to exist.
Regarding use of document reviews to supplement reinspections for inaccessible attributes, the NRC finding is correct, based on Revision 2 of the CPRT Program Plan. However, in the ensuing time period, Revision 3 of the CPRT Program Plan, including a revised ISAP VII.c was issued. ISAP VII.c as now written dictates that, after the sixty inspections have been concluded for the population sample, any attributes.which were found to be inaccessible will cause additional samples to be selected from the population and inspected only for those attributes which were inaccessible in preceding inspections. Document review will only be used for non-recreatable attributes unless sixty occurrences of the attribute are not accessible from the population as a whole. Consequently, the programmatic change in Revision 3 resolved this finding.
- 2. Corrective Action Taken:
No corrective action for items 1 and 2 are planned.
- 3. Corrective Steps to Avoid Recurrence:
No corrective steps for items 1 and 2 are applicable
- 4. Date of Full Compliance:
February 24, 1986.
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Notice of D2viation Item C (445/8514-D-03)
QI-009, Revision 0, " Document Review of Conduit /R-E-CDUT", requires the ERC inspector to:
- verify that inspection reports signed by electrical inspectors were dated after their date of certification and prior to their date of expiration, and,
- document the SBM inspection report (IR) and/or latest construction operation traveler number at the bottom of the checklist.
Contrary to the above:
Review of ERC accepted documentation for conduit C14R13047 showed that the ERC inspector failed to identify that the certification to the applicable Procedure QI-QP-11.3-23 had lapsed for the TUGC0 electrical inspector signing IR-E-46087.
- The ERC completed inspection record checklist for conduit C13016037 in Verification Package No. R-E-CDUT-064 did not contain documentation of the SBM IR or latest construction operation traveler number (445/8514-D-03).
Response to Item C
- 1. Reason for Deviation:
A review of verification Package No. R-E-CDUT-064 and R-E-CDUT-070 confirmed the NRC findings. This was determined to be an inspection error.
- 2. Corrective Action Taken:
- (DR) Deviation Report R-E-CDUT-070-DR1 was written by the inspector.
- The number for the latest construction operation traveler was added to the applicable checklist on 11/21/85.
- The inspector was given additional training on 11/8/85.
Reinspection of 25% of this inspector's work involved 28 verification packages and was completed before 11/21/85. The results of the 25% reir.spection has been evaluated and based upon the minor nature 7f the discrepancies identified, no further actions was deemed necessary on the Inspector's past performance.
- 3. Corrective Steps to Avoid Recurrence:
An overview Inspection Program has been' implemented to reinspect a sample of each Inspector's work on a continuing basis. Action is ongoing to analyze results of the Overview Inspection program, gather pertinent inspector error data from other sources (NRC reinspections, etc.), and to effect required additional formal training of inspectors.
Notice of Deviation Item C (445/8514-D-01)-
(Cont ~Inued)
- 4. Date of Full Compliance:
Corrective action was completed by November 21, 1985. Preventive action involves an ongoing program.
e
Notice of Deviation ;
Item D (445/8514-D-01) i l
l Section 4 of CPP-009, Revision 3, states, in part, with respect to ISAP l No. VII.c, " Qualified QA/QC Review Team personnel perform field ;
reinspections of specific hardware items and reviews of appropriate '
documents in accordance with approved instructions . . . ."
Contrary to the above, the following examples were noted where field reinspections of hardware items were not performed in accordance with approved instructions:
- 1. Attribute 4.5 in Section 5.0 of QI-055, Revision 0, ste.es with respect to spring nuts, " Verify that the serrated grooves align with the channel clamping ridge." Checklists for support No. 007D (Verification Package No. I-S-INSP-007) and support No. 028 (Verification Package No. I-S-INSP-028) were signed by two separate ERC inspectors that this attribute was acceptable. NRC inspectors showed, however, that the spring nut serrated grooves did not align with the channel clamping ridge on both of these supports.
- 2. Section 5.3.4.C in QI-027 states with respect to dimensional tolerances not shown on design drawings, " Component member length
+/-1/2 inch."
The bill of material on Revision 2 of drawing No. CT-1-097-402-C52R in Verification Package No. I-S-LBSR-023 shows item No. 4 (2 pieces) to be 7 3/4 inches long. The applicable inspection checklist used during the ERC reinspection of this pipe support shows the installed configuration to be acceptable. NRC inspect-tion determined, however, the actual length dimensions of the two pieces to be 6 5/8 inches and 6 1/2 inches, respectively, both of which are under the indicated minimum dimension of 7 1/4 inches.
- 3. Section 5.0 in QI-012 states, in part, " Verify that the piping / tubing and components . . . material agree with the Bill of Materials shown on the Instrument Installation Detail drawing.
Tubing is marked with longitudinal color coded marks for traceability. Use applicable drawing to identify tubing . . .
Verify that the installed tubing has the proper slope. The required slope for process wetted lines is one (1) inch per foot minimum. This slope requirement may be reduced to 1/4 inch per foot when physical layout is a problem. Verify that there is a proper air gap. The minimum gap spacing shall always be 1/8 inch to allow each instrument sensing line to expand independently at all bends without striking adjacent sensing lines, other equipment, concrete or steel building memberc."
The applicable inspection checklist used during the ERC reinspection of instrumentation installation Verification Paccage No. 1-E-ININ-026 showed that the above attributes were inspected and accepted, as evidenced by the inspector's sigaoff (initials).
- .~ Notice of Deviation Item D (445/8514-D l (Continued)
However, NRC inspection of the instrumentation installation revealed:
(a) Six sections of tubing had no color coding for traceability; (b) Ten sections of tubings, in which physical layout was not a problem, had slopes of 7/16 inch to less than 1/4_ inch per foot and one section had reverse slope; and (c) Two tubing sections had zero gap spacing between the high pressure and low pressure legs and the concrete penetration.
- 4. Section 1.7 in QI-012 requires that: (a) tubing bend be verified to have a minimum radius of four times the normal tube size by using either a template, or by direct measurement calculations; and (b) the measured and calculated values be entered into the Minimum Bend Radius Record, with date and inspector's initials.
During NRC inspection of Verification Package No. I-E-ININ-04, equipment tag No. 1-FT-156, it was noted that the inspection 4
checklist was dated and initialed, attesting to the fact that the
, tubing bends had been verified as having a minimum radius of four j times the nominal tube size. However,' review of the applicable
- Minimum Bend Radius Record showed that the ERC inspector.had l neither measured and calculated, nor-used a template to verify 4
minimum bend radius. In addition, the following notes had been entered by the ERC inspector: " Ist 90' bend from instrument (hi &
lo side) . . . cannot be measured with existing tools. Four (4) other bends visually more than 90' to accommodate slope" (445/8514-D-04).
Response to Item D
- 1. Reason for Deviation:
- Reinspection confirmed the NRC findings.
Item 1 an_d_2 Inspector error.
Item 3_
- 1 Inspector Error. Ongoing adjacent construction and housekeeping '
. activities (i.e., wiping down, climbing, ongoing work in e
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- 4
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- Notice of Deviation Item D (4T578514-D-01 (Continued) surrounding areas, etc.) prevent a firm determination as to whether or not the NRC identified findings existed at the time of the ERC inspection but, enough indication exists to justify retraining of the inspectors as a step to assure recertification of those items which may well have been inspector error.
Item 4 Inspector error. QI requires clarification to allow inspector to indicate inaccessible bends.
- 2. Corrective Action Taken:
Item 1
~ Deviation Reports I-S-INSP-007-DR2 and DR3 dated November 18, 1985, and I-S-INSP-028-DR2 dated November 8, 1985, were written to document the misaligned spring nuts.
Twenty five percent of the work of both inspectors was reinspected.
The results of the reinspection were documented and evaluated by inspection supervision. A decision was made to reinspect 100% of the spring nuts previously inspected by the first-inspector. The results of the reinspection indicated a high error rate. This inspector's services were discontinued and 100% of his work was reinspected. The retained inspector was retrained on November 12, 1985. All necessary reinspections were completed by December 5, 1985. Deviating conditions identified by the reinspections have -
been documented in the applicable Verification Packages and DRs initiated.
A general training session on Spring Nut inspection was given to all non-affected inspectors involved in the reinspection of this attribute. This retraining has been documented.
Item 2 Deviation Report I-S-LBSR-023-DR2 dated November 13, 1985, was written to document the dimensional deviations. The responsible inspector was the same one vhose services were discontinued as indicated above.
Item 3 and 4 The Verification Package documentation for ININ-026 has been reinspected, I-E-ININ-004 was corrected, and DRs I-E-ININ-026-DR-2,
- # '. Notice of Dsviation Item D (445/8514-D-01 (Continued)
-4,-and -5 were issued. In addition, revision 1 of QI-012 was issued January 30, 1986, and now provides a basis for the inspectors to indicate inaccessible bends. Due to problems noted by ERC and ti:ose identified herein by the NRC, all ININ Verification Packages issued prior to January 14, 1986, will be reissued for reinspection.
- 3. Corrective Steps to Avoid Recurrence:
An Overview Inspection program has been implemented to reinspect a sample of each Inspector's work on a continuing basis. Action is ongoing to analyze results of the Overview Inspection program, gather pertinent inspector error data from other sources (NRC reinspections, etc.) and to effect required additional formal training of inspectors.
- 4. Date of Full Compliance:
Corrective action is complete with the exception of the total reinspection.of the ININ packages.
Preventive action involves an ongoing program.
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