TXX-6082, Forwards Response to Violations Noted in Insp Repts 50-445/86-17 & 50-446/86-14.Corrective Actions:Maint of QA Corrective Action & Design Assurance Program General & Discipline Files Improved

Forwards Response to Violations Noted in Insp Repts 50-445/86-17 & 50-446/86-14.Corrective Actions:Maint of QA Corrective Action & Design Assurance Program General & Discipline Files Improved

ML20214T787
Person / Time
Site:	Comanche Peak
Issue date:	11/12/1986
From:	Counsil W TEXAS UTILITIES ELECTRIC CO. (TU ELECTRIC)
To:	Grimes B NRC OFFICE OF INSPECTION & ENFORCEMENT (IE)
References
TXX-6082, NUDOCS 8612090005
Download: ML20214T787 (21)

Text

._

Log # TXX-6082 File # 10130 IR 86-17 TEXAS UTILITIES GENERATING COMPANY IR 86-14 SKYWAY TOWER . 400 NORTH OfJVE STREET.1.B. 81. DALLAS, TEXAS 75381 WILLIAM G. COUNSIL EEcertvt vict PatssoENT r-

*M@MDMM N Mr. Brian K. Grimes, Director Division of Quality Assurance, Vendor, glgg and Technical Training Center Programs Office of Inspection and Enforcement J

<eo l

M U.S. Nuclear Regulatory Commission Washington, D.C. 20555

SUBJECT:

COMANCHE PEAK STEAM ELECTRIC STATION (CPSES)

DOCKET NOS. 50-445 AND 50-446 RESPONSE TO CONCERNS IN INSPECTION REPORT N0. 50-445/86-17 AND 50-446/86-14

Dear Mr. Grimes:

We have reviewed report numbers 50-445/86-17,50-446/86-14, concerning the inspection conducted by Mr. D. P. Norkin (Inspection Team Leader from the U.S.

Nuclear Regulatory Commission Office of Inspection and Enforcement), J. W.

Gilray, J. G. Spraul, R. P. McIntyre, and V. L. Wenczel at the following dates:

Location Date TERA Corporation, Bethesda, Maryland June 16-18, 1986 TERA Corporation, CPSES Site June 24, 1986 TERA Corporation, Berkeley and July 7-17,1986 San Jose, California This inspection covered TERA's Quality Assurance Program for the Comanche Peak Design Adequacy Program for Comanche Peak Steam Electric Station Units 1 and 2.

8612090005 PDR 861112 l O ADOCK 05000445 PDR go {

\

f&1 $ < vnuw, or aus enu mrs arenic cmunn

TXX-6082 November 12, 1986 Page 2 Several concerns were identified during the inspection and were designated as open items in the inspection report. Our responses to these open items are attached to this letter.

Very truly your'

- W. G. Counsil JDS/mlh Attachments ,

c - NRC Office of Inspection and Enforcement (Original + 15 copies)

NRC Region IV (2 copies)

Mr. V. S. Noonan Mr. D. L. Kelley l

Mr. E. H. Johnson I

I l

Attachment to TXX-6082 November 12, 1986 '

7 Page_1 of 19 l Onen Item _Q-1  ;

Procedure DAP-14, " Records," indicates that the CPRT Central Files will_

document CPRT activities. ' Contrary to this, three completed records in the DAP QA manager's file were not in the CPRT Central File nor did there appear to be a documented, routine, systematic method to get such records into the CPRT Central File. These records include two completed observation reports (DAP-08-QA-002 dated March 1, 1986, and DAP-08-QA-004 dated March 1, 1986) and one completed CAR (DAP-CA-QA-003 dated March 21,1986).

l

Response

Specific Issue - A review of the DAP General File 13.4, Corrective Action

-Reports, and the two subfiles, CAR Working File (13.4-002) and Observation-Working File (13.4-003) was performed by the DAP QA Manager on June 26, 1986.

1 The review compared the DAP General File contents to the DAP QA Manager's i files. In addition to the items listed above in Open Item Q-1, several t additional correspondences were missing from the DAP General File. These included the closed out forms for Observations DAP-08-QA-04, 05 and 07, copies-of issued Observations DAP-0B-QA-09 and 10, and several interim correspondences associated with CARS. Copies of all identified missing records were added to the.DAP General File.

Generic Implications - The problem of improper.and erroneous filing practices L was previously documented via a QA Observation, DAP-0B-QA-002 dated 12/10/85.

These problems have affccted several DAP files; however, not systematically in any single area or discipline. On occasions where items were not immediately

. retrievable, efforts have been successful in securing the document elsewhere >

-in the DAP filing system, either at that location or other locations. Upon closure of the DAP program, DAP working files for all locations will be merged into a single file to be turned over to the CPRT-Central File. With duplication of most files at various locations, the process of merging will assure obtaining a complete central file. Notwithstanding, the following actions have been taken to improve the DAP filing system.

Action to Prevent Recurrence - With regard to QA Corrective Action records

specifically, the QA Manager began separating corrective action correspondence into separate, distinct records with appropriate file index numbers assigned.

Each evolution of a CAR or Observation, consisting of issuance, reissuance if necessary, and close out notification, is documented under a separate cover memo with appropriate file codes assigned. This should reduce the probability -

of error for misfiling these records in other QA record files.

I With regard to the overall DAP General Files and Discipline Files, the DAP Manager has taken significant corrective actions. Following a meeting of key administrative personnel to discuss the problems associated with DAP files, a memo entitled "DAP File Maintenance Guide", dated August 6, 1986, was issued 1

l

_ __ _ . - ~ - _ - _ , , , _ - , , _ _ , _ . ~ . . _ . _ _ _ _ _ - _ _ _ _ . _ _, __ _ _ _ _ . . - _ _ . _ . _ -_..

1 Attachment to TXX-6082 November 12, 1986 Page 2 of 19 by the DAP Manager. This memo, among other things, delineates explicit personnel assignments for DAP file maintenance at each of the four main DAP work locations. All DAP-originated documents are routed to one central location (Berkeley) for assignment of a controlled file log number and for proper distribution to appropriate file locations. An updated copy of the file contents log sheets is sent weekly with the DAP files from the primary (Berkeley) file to the backup file (site). In addition, the guidelines '

provide additional administrative controls to ensure that DAP-related documents receive proper file coding, distribution, filing, and meet QA records requirements in accordance with DAP-14.

It should also be noted that the DAP files located at the TERA offices in Berkeley have been designated for eventual turnover to the CPRT Central Files.

Activities are underway to ensure that, with a few exceptions (such as Training and Qualifications Records and DIR and Trending records maintained in t Bethesda), the CPSES-located files are being completed as a duplicate of the Berkeley-located DAP files.

Open Item Q-2 Section 4.4.2 of DAP-17 requires that a new CAR be issued if follow-up is not completed within two months from the date of issue of the CAR. The new CAR is to show the reason for the delay in the close out. Contrary to this, four CARS listed below did not have the follow-up completed within two months from the date of issue, and a new CAR was not issued:

(a) DAP-CA-QA-003, issued 11-22-85, follow-up completed 3-21-86 (b) DAP-CA-QA-004, issued 11-22-85, follow-up completed 5-14-86 (c) DAP-CA-QA-005, issued 1-30-86, follow-up completed 5-5-86 (d) DAP-CA-QA-006, issued 1-30-86, still open

Response

Specific Issue - A review of all CARS issued through June 30, 1986, was conducted by the DAP QA Manager to assess the need for reissuance. In addition to the four CARS listed above, CAR number DAP-CA-QA-001 had been open

for longer than 60 days although it had been closed out prior to the review.

Also, DAP-CA-QA-006 was closed on 6/27/86, following the NRC Inspection in early June. A memo was written to the Review Team Leader by the QA Manager on July 2, 1986, documenting this review and also documenting explanations for the open time duration of the five CARS which had been open for a total time greater than 60 days. None of these CARS were reissued since they were already closed and reissuance would serve no purpose. A copy of this memo was routed to the DAP Corrective Action Report file for documentation.

3 4

Attachment to'TXX-6082 o November 12, 1986-Page 3 of 19 l

Generic' Implications - There are no generic implications since.this is a unique requirement of DAP-17 on the CARS only, all CARS were reviewed and the '

results documented,' and overall' corrective action was sufficient to warrant closure in each case.

Action to Prevent Recurrence - The DAP QA Manager is now tracking potential reissuance dates on the DAP CAR Log. The log is routinely reviewed by him and

is transmitted to the DAP Review Team Leader on a quarterly basis for his

review. This should ensure that CARS will be reissued if necessary in the 1- future.

Open Item Q-3 i Section 4.1 of DAP-17 requires the originator of a CAR to designate whether the observation is a nonconformance or a systematic deficiency when the CAR is

first issued. Contrary to this, five CARS (DAP-CA-QA-2 through 6) were not so designated when.they were first issued. The proper designation was shown on i later issues of these CARS.

Response:-

l Specific Issue - A-review of CARS, both in the QA Manager's files and in the

- DAP General File, was performed on 6/26/86 by the QA Manager to verify that each CAR was properly designated as either a nonconformance or a systematic deficiency on the CAR form.. Changes were made, initialed and dated to add the designation where missing. Since the CARS involved were appropriately closed, addressing either the specific or generic aspects of the CAR as appropriate, no further action was required. The results of the review were documented via a memo to the Review Team Leader, dated July 2, 1986, with a documentation copy routed to the DAP CAR file.

Generic Implications - This requirement is unique to DAP CARS which were all reviewed. There are no generic implications.

Action to Prevent Recurrence - This situation was basically an oversight on the part of the DAP QA Manager. The proper designation was being made on the handwritten CAR forms, but the typing process was not consistently marking the designation box on the form on the typed version. The reviewer, prior to l signing the CAR for issuance by the DAP QA Manager, did not notice the omission. The raised level of awareness on the part of the DAP QA Manager and DAP auditor (s) should preclude this omission from recurring.

P Attachment to TXX-6082 November 12, 1986 Page 4 of 19 i

Ooen Item Q-4 The training and qualifications of DAP personnel were evaluated for compliance with Procedure DAP-15, Rev.1, " Training and Quallfications". This procedure defines the required training and qualifications of personnel assigned to the

~ CPRT DAP and the resolution of Technical Review Team (TRT) issues in the Civil / Structural, Mechanical and Miscellaneous areas. The team reviewed the documentation required by DAP-15 for 12 personnel listed as approved and active on the June 10, 1986 print-out of the Personnel Data Base. These personnel represented a sample of Design Reviewers, Group Leaders and Discipline Coordinators. The documentation reviewed included resumes, approval of DAP personnel memorandums, training records, CPRT objectivity forms, and DAP personnel qualification memorandums from the Discipline -

Coordinators.

All'DAP personnel documentation reviewed was complete, except for the memorandums from the Discipline Coordinators to DAP personnel. The memorandum is required by DAP-15, Section 4.7 and advises reviewers that, for design

, ateas unique to nuclear power plants, they shall only review work which they have personally performed previously on a commercial nuclear power plant. For all other areas, reviewers shall only review design areas where they have had applicable experience (not necessarily at commercial nuclear power plants).

If reviewers are assigned work in an area in which they feel they don't meet ,

i the above requirements, they are required to immediately notify their

, supervisor or Discipline Coordinator. This memorandum is required to be ,

signed by the reviewer (and returned to the Discipline Coordinator) to acknowledge having been advised of the requirements and provided with a list of design areas unique to nuclear power plants.

f Approximately 50% of the 12 personnel surveyed had received this memorandum.

An interview with the DAP Training Coordinator indicated that this figure 4

approximates the percentage for the entira DAP roster of personnel. TERA  !

stated that they are presently in the process of completing the implementation

< of this requirement of Section 4.7 of DAP-15. TERA should evaluate the extent to which reviews were completed by personnel who did not have direct experience, as stated above.

Response

I Specific Issue - The requirement for DAP personnel qualification memoranda

! from the Discipline Coordinators was added to the DAP program via Revision 1 to procedure DAP-15, which was issued on 2/28/86. In order to better control documentation of accomplishment of this requirement, Revision 2 to DAP-15,

issued 8/14/86, explicitly assigned to the DAP Training Coordinator the responsibility for maintaining and tracking documentation of accomplishment of l the DAP-15, Section 4.7 requirement and clarified that this documentation would be maintained at the Bethesda, MD work location. At the time of the NRC f

. - _ . . _ _ . . . _ _ . _ . . _ _ . . ~ _ _ _ _ _ . , . _ _ _ _ _ _ _ _ - . - , - _ _ - . _ - . _ , , - . - . - _ -

Attachment to TXX-6082 November 12, 1986 Page 5 of 19 inspection at the TERA Bethesda location, June 16 to 18,1986, the documentation in possession of the DAP Training Coordinator was incomplete The DAP Training Coordinator was asked by DAP management to expedite completion of this activity and secure the additional signed memoranda__? That has now been accomplished. A recent follow-up by the Overview Quality Team on 1 September 9, sampled 31 personnel from the personnel roster and concluded that the qualification memoranda were complete, or otherwise accounted for, as appropriate.

The memoranda that were provided by the Discipline Coordinators were adequate l in defining the qualifications requirements, in providing listings of design <

areas considered specific-to nuclear power plants, and in providing instructions to personnel regarding their proper course of action if assigned

, work in an area for which they consider themselves unqualified 1.e., unable to meet the experience requirements. Though implied, the memoranda did not i explicitly address work which may have been performed prior to their receipt '

of the memoranda. Consequently, to provide added assurance a second memorandum has been issued to all affected DAP personnel requesting their i specific assessment of any work previously performed with regard to their

, experience qualifications. In the event that work is identified which was performed by personnel not meeting the experience requirements, DAP management will reassess the work for adequacy by appropriate, qualified personnel and correct it if necessary. The above activities are expected to be completed by November 30, 1986.

Generic Implications - Based upon completion of the initial qualification memoranda, there appear to be no generic implications. Nevertheless, the on-going effort will verify that reviews were completed by personnel with the requisite qualifications and experience. There should be no generic implications of this issue beyond the scope of the planned activity.

< Action to Prevent Recurrence - The revised procedure, DAP-15, Rev. 2, supplies adequate administrative controls to ensure that new project personnel will meet qualifications requirements. It is unlikely that additional personnel qualifications beyond those currently specified by Rev. 3 of the CPRT Program Plan will be imposed on DAP personnel. No further corrective actions beyond

( those described above appear to be warranted.

Open Item Q-5 The TERA internal audit program was evaluated to determine compliance with procedure DAP-16, Revision 1, " Audits" with respect to the audit schedules, the completed audit reports, the checklist worksheets used in the audits and the findings. The qualification of the lead auditor was examined along with the process used by TERA for qualifying him.

4

• - -g, --,-,,-,e,m-n-mn, ,-w- .y ,-.m, w .eww-,e u- --wa ..-em.,gv,g,

.= . - .-.

4 Attachment to TXX-6082 November 12, 1986 Pa; 6 of 19 1

Five audits have been conducted by TERA from November 1985 through May 1986, consisting of 47 man days of auditing. All engineering disciplines were audited at each of the four offices (Berkeley, Bethesda, Comanche Peak site, and San Jose). The audits were conducted using checklist worksheets which, when completed, describe audit objectives, documents reviewed, results and findings of the audit and recommendations.

I The team found the audit process and resultant reports to be acceptable for verifyina compliance with TERA's commitments in the CPRT program plan. The frequency and depth of the audits appear to be adequate to assure all engineering disciplines are reviewed in a timely and effective manner. The findings were valid, adequately documented, and were properly resolved (as indicated in Section 3.3 above). However, TERA needs to assess whether its failure to identify issues identified by the NRC team indicates any programmatic shortcomings in the internal audit program.

I

Response

Specific Issue - In order to assess whether or not the failure of the DAP audit program to identify the issues identified by the NRC team indicates programmatic shortcomings in the internal audit program, the following analysis of the Open Items identified was performed:

Open Item Q-1: This item represents a noncompliance with DAP procedures.

Open Item Q-2: This item represents a noncompliance with DAP procedures.

! Open Item Q-3: This item represents a noncompliance with DAP procedures.

Open Item Q-4 This item does not represent a noncompliance with DAP

. procedures. DAP QA has been cognizant of and involved in 4

the issue of documentation of' qualifications requirements since November of 1985, with the issuance of CAR DAP-CA-

, QA-004. The DAP program incorporated the new requirement

] for previous experience qualifications via Revision 1 to DAP-15, issued 2/28/86. DAP-15, Rev. 1, requires that personnel shall not be assigned work for which they are unqualified, and that the implementation of the commitment

be documented as specified via the signature of reviewers on specific memoranda provided by the Discipline Coordinators. The DAP management, including the Discipline Coordinators and Group Leads, who make work assignments, were aware of this commitment at the time of issuance of Rev. I to DAP-15. There is no evidence to j indicate that work assignments have been made to l

1 i

. Attachment to TXX-6082 I

November 12, 1986 Page 7 of 19 unqualified personnel. The documentation aspect of the commitment was ongoing at the time of the NRC inspection.

A documentation tracking system was developed via the DAP Personnel Roster and data base by the DAP Training

, . Coordinator to be able to track DAP personnel required to be qualified and to flag missing documentation. DAP-15 was subsequently revised again, Rev. 2 dated 8/14/86, to specifically state that the Training Coordinator was to-receive and maintain the qualifications requirements documentation. Prior to this, the qualifications files were maintained by the Discipline Coordinators in the Discipline Files. Even though it has taken an excessive amount of time for the qualifications documentation to be

collected at the Bethesda location and accounted for by the Training Coordinator, there is no basic time requirement for the existence of the documentation until the DSAP Results Reports are approved by the DAP management for turnover to the CPRT Central Files. In 1

~

reality, the memos ~from the Discipline Coordinators to the various reviewers were issued in late April and early May, 4

so that the reviewers were made aware of the requirements and the listings of design areas specific to nuclear power 4

plants. Again, the status of the documentation in terms of the reviewer acknowledgement should not imply that i

personnel are violating DAP-15 commitments. It is evident that the risk of incurring rework, if for some reason a reviewer disregarded the requirements and ultimately could not acknowledge his compliance, increases with the time delay in securing the documentation of compliance. DAP management concurred with NRC during their inspection that the collection of the documentation should be expedited; i and it was. Additional corrective action is being taken to ensure that any previous work performed by DAP personnel fits within the qualifications commitments as discussed under the response to Open Item Q-4.

Open Item Q-5: This item does not in itself represent a noncompliance

! with DAP procedures.

Open Item Q-6: This item does not represent a nonconformance with DAP procedures or CPRT program plan commitments. The Review

Team Leader reviews and approves DAP personnel education and qualifications for the assigned DAP function, including the DAP QA Manager, who is required to be a Lead i

4 1

4

-+-~..-e ,- , - - - . . - - ,, , , , . . . , , - - - , , , , , , - , - - , , . - - ,,-,--.nm-,.c.--.--...-_an,,-- ---,-,,---w--.,--_a- -. - - - - -

..= _- - . .

t Attachment to TXX-6082 November 12, 1986 Page 8 of 19 Auditor. He documents his approval by signature and his approval is maintained as part of the DAP records. DAP management agreed with NRC at the time of the inspection that it would be preferable to consolidate audit personnel qualifications under a single DAP procedure. This was accomplished with the issuance of procedure DAP-23 on 7/18/86, and the DAP QA Manager certification as a Lead Auditor under DAP-23 on 7/30/86.

Open Item Q-7: This item did not represent a procedural or program noncompliance, but was a reconrnendation which DAP accepted and has since acted on.

' Open Item Q-8: This item represents a procedural noncompliance, although of a minor nature at this time. DAP-QA had previously issued an observation on filing problems in December, o 1985, and was aware of ongoing difficulties in this area.

Continuing efforts were ongoing to improve the filing i system and status.

Open Item Q-9: This item represents a procedural noncompliance but had been previously identified by DAP QA. Corrective actions were and are ongoing.

Open Item Q-10: It should be noted that the intent of the procedures are to assure that accomplishment of a given activity, e.g.,

reviewing and checking, is documented by the person performing the activity. In the cases referenced, personnel had indicated completion of the review and check activities by printing their names on the form rather than signing in script. DAP management agreed with NRC recommendations to modify this practice and to i

procedurally organize records quality practices.

Additionally, the generic issue of records quality had been previously addressed by DAP QA.

Open Item Q-11: This item did not represent a procedural noncompliance but

is a poor practice and had been previously identified by DAP QA. In response, DAP management issued a memorandum to reviewers advising them of good record practices. DAP management agreed with the NRC recommendation to proceduralize record quality practices.

Open Item Q-12: This item did not represent a procedural noncompliance.

l DAP management agreed with NRC recommendations to strengthen the procedural requirements in this area, t

i I

Attachment to TXX-6082 November 12, 1986 Page 9 of 19 Open Item Q-13: This item did not represent a procedural noncompliance and was an isolated issue.

Based on the above, it appears that of the thirteen Open Items identified, six could be classified as DAP procedural noncompliances with the balance being recommendations and mutually agreed upon upgrade activities. Of the six which could be classified as procedural noncompliances (Q-1, Q-2, Q-3, Q-8, Q-9 end Q-10), two (Q-8 and Q-9) had been previously identified by DAP QA audits. The other four (Q-1, Q-2, Q-3 and Q-10) were of a minor nature, had no impact on completed work, and were easily corrected. It is concluded that the issues identified by the NRC Team do not indicate any programmatic shortcomings in the internal audit program. It should be noted that independent of NRC inspection results, the DAP management, at a meeting with the Senior Review Team on May 22, 1986, committed to upgrade the DAP audit program commencing in June,1986, to include an audit of each DAP work location (Bethesda, MD; CPSES

, site; San Jose, CA; and Berkeley, CA) once per month. This has been accomplished to date, although this frequency may be relaxed as DAP review activities are completed. The results of this increased level of auditing would not yet have been fully apparent at the time of the NRC inspection in June and July, 1986.

Additional confidence is provided in the DAP audit program by the overview activities of the CPRT Overview Quality Team (0QT). This group has directly observed DAP audits, has reviewed audit reports, has reviewed personnel qualifications, and remains cognizant of the DAP QA activities in general. To date, while the 0QT has made valuable recommendations, they have endorsed the overall DAP audit program's effectiveness.

Generic Implications - TM above discussion does not imply any generic implicatiens of this issue.

Action to Prevent Recurrence - TERA will continue with an effective internal DAP audit program and with DAP management philosophy to comply with all commitments.

Open Item Q-6 The qualifications of the TERA lead auditor were reviewed based on a certification of his qualifications, which was prepared by a nuclear utility where he was recently employed. While this certification meets the requirements of ANSI /ASME N45.2.23-1978, " Qualification of Quality Assurance Program Audit Personnel for Nuclear Power Plants," TERA in accordance with Section 12.31. " Education and Experience," and 5.2 " Certification of Qualification," is obligated to verify that the lead auditor's education and experience meet the qualification requirements of ANSI /ASME N45.2.23 and separately certify his qualification. Based on NRC/ TERA discussions, TERA has agreed to separately qualify and certify its lead auditor to this degree.

Attachment to TXX-6082 November 12, 1986 Page 10 of 19

Response

Specific Issue - DAP procedure DAP-23, Rev. O, DAP Quality Assurance Auditor Qualifications, was issued on July 18, 1986. This procedure provides a mechanism for qualifications and certification of lead auditors within the DAP program. The DAP lead auditor was certified as such under DAP-23 on July 30, 1986. It should be noted that the DAP Review Team Leader had already specifically reviewed and formally approved on January 22, 1986, the previous lead auditor certification of the DAP QA Manager, including his education and experience credentials.

Generic Implications - DAP-23 was also used to certify an additional lead auditor on July 30, 1986, who is performing audits of the Civil / Structural and Mechanical Issue Specific Action Plans. It is intended that an additional DAP lead auditor will be certified under DAP-23 in the near future.

Action to Prevent Recurrence - None required beyond the issuance of DAP-23 which applies to all future DAP lead auditors.

Open Item Q-7 DAP-14, Revision 0, " Design Adequacy Program Records," establishes requirements for establishment, maintenance, and disposition of DAP records.

The official files for DAP records of completed work are at Berkeley. In other DAP locations, temporary storage of records is used for work in-process. i Upon completion of a review activity, the evaluation results and supportive i documentation are transferred to the Berkeley official file. The team was limited to the review of temporary records for Bethesda's electrical / civil / mechanical work in progress and DAP's administrative records which contain personnel training and qualification files. Subsequent NRC inspections will assess records control at other TERA locations to determine each facility's compliance with DAP-14. Records reviewed at Bethesda included l design review checklists, drawings, calculations, evaluations, logs, personnel '

training and qualification files, correspondence, audit reports, and j discrepancy reports (DIRs). These records were found to be maintained in accordance with DAP-14. However, Section 3.3 indicates that CARS were not filed in accordance with DAP-14.

Some checklist changes were lined out :nd initialed, but not dated.

Initialing and dating record changes is not a DAP requirement. However, based on NRC/ TERA discussion, DAP procedures will be revised to include a requirement to initial and date changes to DAP records.

l

4 i

Attachment to TXX-6082

• November 12, 1986 Page 11 of 19 Resoonse:

Specific Issue - Revision 2 to DAP-14, Design Adequacy Program Records, was issued on August 15, 1986. This revision included a new Attachment E, Record Quality Requirements, effective August 1, 1986. Attachment E includes the requirement that correcticns be properly annotated, initialed, and dated.

Additionally, a Corrective Action Report, DAP-CA-QA-016, was issued on August ,

13, 1986, by DAP QA, requesting that previously approved design review checklists be reviewed for compliance with DAP procedures DAP-4, 5 and 6.

This review effort has been expanded to include compliance with DAP-14, Rev.

2, requirements. Furthermore, DAP file personnel are now using Attachment E to DAP-14 as a basis for evaluating whether to accept documents sent to the files, i

. Generic Implications - The . issue of changes to design review evaluation checklists which were lined out and initialed, but not dated, could have L generic implications with regard to other types of DAP records. The Revision 2 to DAP-14 consequently was made applicable to DAP records in general, rather than being restricted to design review checklists.

i Action to Prevent Recurrence - The application of DAP-14, Rev. 2, should be

! sufficient to prevent recurrence. DAP QA audits include record quality attributes on checklists. Past audits have focused on this important area.

i Future audits will also focus on this area to verify compliance with DAP-14.

Open Item Q-8' In reviewing the Berkeley files, the team could not locate a DAP-1 design criteria list associated with the radiation checklist (DAP-CLA-M-007). TERA located this design criteria list (DAP-CR-M-007/Rev.1) in the 7.4 file (item 094) although the DAP file index indicates that the list should have been filed in the X.C.1 file. The list itself was so marked, but apparently misfiled. Similarly, the team was unable to locate a Type A

checklist for the welding criteria list (DAP-CR-M-11). TERA obtained this

! checklist (DAP-CLA-M-011) from the TERA site office. The DAP file index indicates the checklist should have been filed in the Berkeley X.B.2 file.

TERA should review these circumstances and determine whether they indicate a generic problem.

Response

Specific Issue - The specific documents referenced above were correctly filed following NRC inspection.

i l

\

\

i i

1

• I t

Attachment to TXX-6082 l November 12, 1986 Page 12 of 19 i

Generic Implications - As indicated in the response to Open Item Q-1, the problem with misfiling of documents has been recognized and dealt with by DAP management. This was previously identified by an Observation, DAP-08-QA-002, issued December 10, 1985, which documented additional examples of improper filing practices. At that time, corrective actions were accomplished consisting of review of the files at Berkeley and Bethesda the weeks of December 16 and 30 respectively, discussions with administrative personnel in both offices, additional training, and issuance of a memorandum with additional guidance on the filing system, dated December 24, 1985. Additional corrective actions have since been accomplished (described below) which are generic to the DAP files.

Action to Prevent Recurrence - Following a meeting with key administrative personnel and QA in Bethesda, MD on July 22-24, 1986, the DAP Manager. issued a "DAP File Maintenance Guide," via internal DAP memorandum dated Augu:t 6, L 1986. This guide strengthens the administrative controls over DAP files.

Among other aspects, the guide clearly delineates primary and secondary personnel respcnsibility for file maintenance at each file location, establishes a central distribution point in Berkeley, standardizes file content log sheets for each file location, emphasizes responsibility for assigning file code numbers, and provides, with a few exceptions, for duplication of the Berkeley files at the CPSES TERA location. These increased administrative controls should prevent recurrence of significant future problems in this area.

Open Item Q-9 The DIR (i.e. Discrepancy / Issue Resolution Report) number assigned to each unsatisfactory item is required to be listed in the " comments" column of the Type C checklists (Section 4.5). The team reviewed Type C checklists and found that 3 of 3 C/S and 2 of 3 electrical Type C checklists that should have identified DIRs did not have the assigned DIR number listed in the " Comments" column, as shown in Table 1. The DIRs had been issued, but they were not cross-referenced in the checklists. TERA audits previously identified this type of problem (See CAR No. DAP-CA-QA-09).

Resoonse:

I Specific Issue - The specific issue discussed above is considered part of a generic issue as discussed below.

!- Generic Implications - The issue of listing of DIR numbers for unsatisfactory items on Type C checklists has been documented on CAR number DAP-CA-QA-09, issued May 20, 1986, as discussed in the open item description above.

i Additional instances of checklists not conforming to DAP procadural requirements were documented in CARS DAP-CA-QA-010, DAP-CA-QA-Oll, and DAP-CA-QA-016. The latter CAR summarized the need to systematically review pre-viously approved checklists for compliance to DAP procedures.

Attachment to TXX-6082 November 12, 1986 Page 13 of 19 Such a plan is currently being implemented. The review plan developed in response to DAP-CA-QA-016 ensures, among other things, that DIR numbers are explicitly listed in the checklists as appropriate, or specifically cross-referenced for traceability between the DIRs and the affected checklist ,

attributes.

' Action to Prevent Recurrence - The DAP Manager has issued, via memorandum dated September 29, 1986, a reminder to project personnel of the DAP policy on procedural compliance. The memorandum included as an attachment the checklist being used to review previously approved Type C checklists to focus on those aspects that have proved to be inadequately complied with in the past. This increased level of awareness and management direction should be sufficient to prevent recurrence.

Ooen Item Q-10 Each completed Type C checklist is required to be signed by the reviewer, the '

checker, and the Discipline Coordinator (Section 4.6). The checker is required to verify the accuracy of at least 10% of the checklist items. The team reviewed the checklists shown in Table 1. As shown in Table 1, 5 of 5 C/S Type C checklists sampled were not signed by the reviewer and 4 of 5 were not signed by the checker. Mechanical (2) and EIC (6) checklists were properly signed in all cases. Action needs to be taken to determine the extent of this problem and to ensure that the checklists have been properly accomplished and verified.

Resoonse:

Specific Issue - The checklists involved in this open item listed in Table I with "No" indicated in the various " Signed" columns did, in fact, contain the name of the reviewer and checker involved. However, the names were printed rather than signed in script. The Type C checklist review being performed in response to DAP CAR Number DAP-CA-QA-016 will verify proper approvals and I signatures on all previously completed checklists, including the specific ones l listed in Table 1. Any discrepancies identified as a result of the review will be corrected. In the case of reviewers, checkers, or Discipline Coordinators who printed rather than signed their name, the document will 1 either be signed or the person involved will sign an attestation that he l actually did perform the function as indicated by his printed name on the document (s) in question. The attestation, in this case, will be filed within the DAP files and maintained and will specifically identify the documents to which the attestation applies.

Attachment to TXX-6082 November 12, 1986 Page 14 of 19 Generic Implications -'The evidence involved C/S Type C Checklists only; however, remedial action is being taken for the Type C Checklists for all disciplines. Accordingly, the following actions have been taken.

Action.to Prevent Recurrence - Revision 2 to DAP-14 was issued on August 15, 1986. This revision included a new Att:chment E, Record Quality Requirements, which indicates the requirement that signatures be present as required on all records. This additional administrative control should prevent recurrence of t

this problem. . Additionally, the DAP Manager issued, via memorandum dated

, September 29, 1986, a reminder to project personnel regarding required compliance of DAP documents and records with DAP procedures, and emphasizing those types of problems previously encountered. This also should contribute to prevention of recurrence.

Open Item Q-11 4 <

Contrary to good practice, the C/S checklists shown in Table I were completed in pencil. It is understood that TERA plans to convert these checklists to a more permanent records retention format and to revise DAP procedures to

! preclude the use of pencil in other records.

l Response:

Specific Issue - Revision 2 to DAP-14, Design Adequacy Program Records, was issued on August 15, 1986. This revision included a new Attachment E, Record Quality Requirements, which precludes future use of pencil for record copies of documents. With regard to the specific C/S checklists, electrostatic copies of the pencil versions will be made and retained as the record copies.

Generic Implications - The revision to DAP-14 applies to all DAP records and was not limited to C/S checklists. A review of checklists is being performed in response to DAP CAR Number DAP-CA-QA-016 which includes review for compliance with DAP-14, Rev. 2 requirements. Discrepancies identified will be i

corrected.

Action to Prevent Recurrence - Application of DAP-14, Rev. 2 should prevent recurrence of this problem.

Ooen Item Q-12 The team reviewed the Type A checklists and the HDA description and validation '

, checklists in Tables 2 and 3, and found they were properly signed.

i i

l

Attachment to TXX-6082 November 12, 1986 Page 15 of 19 4

Table 1. Type C, " Design Review Evaluation," Checklist Reviewed By Team Sioned

• Disci- DIRs Disc.

oline Checklist No Title Listed Revie4et- Checker Coord.

M DAP-CLC-M-072 Drip Pot for MS to AF Turbine Y Y Y Y M DAP-CLC-M-006 V.E. Welding Eng.

QA Requirements Y Y Y Y C/S DAP-CLS-CS-030 Tornado Missiles NA N N Y DAP-CLC-CS-042 RB Eqpt Hatch C/S Analysis & Design NA N N Y C/S DAP-CLC-CS-001 Aux Building Platform N N N Y

.C/S DAP-CLC-CS-038 Cable Spreading Room N N N Y C/S DAP-CLC-CS-029 RB#1 Polar Crane i Support Details N N Y Y

< EIC DAP-CL-I-002 Standby Electrical

, AC System (D/G) Y Y Y Y EIC DAP-CL-I-011 AFW-Class 1E 480V Alarms Y Y Y Y EIC DAP-CL-I-019 Transmitter Func-tional Requirements Y Y Y Y EIC DAP-CLC-E-007 Batteries / Chargers Capacity Y Y Y Y EIC DAP-CLC-E-037 Fire Protection i

Review N Y Y Y EIC DAP-CLC-E-055 Diesel Generator Neutral Grounding N Y Y Y 4

4 l *M - Mechanical

, C/S = Civil / Structural

! EIC - Electrical / Instrumentation and Controls f

, , , - . . . - _ . _ . _ _ _ . . . - , _ . _ . . . - . _ _ . _ ,, , - . , . , _ , , _ . . -_,,.,.r.y_,._,-__,,w,-_, .._,,,.,_,_,,_,____,..m._,, .,,,,,,---.,,_,,,-cy.__. ____.._m_,.v__

Attachment to TXX-6082 November 12, 1986 Page 16 of 19 The reviewer or assigned personnel is required to examine all items on the checklist form and indicate whether each item was found to be satisfactory, unsatisfactory, not checked, or not applicable. "Not Checked" or "NC" may be

. used when a standard checklist form is used to perform a limited review of a given subject such that an applicable area was excluded from the review scope (Section 4.3).

The team reviewed the Type C checklists in Table 1 and found that some checklists show a reason in the comments column when "NC" is used; others do not. Although DAP procedures do not require this documentation, the team s considers that TERA should revise DAP-5 to require justification when a criterion is marked "NC," or otherwise indicated to be not applicable. This 4 action would be consistent with DAP-5 requirements for indicating the basis for determining verification conclusions. Documenting the thought process behind the not checked /not applicable determination provides assurance that all checklist items were considered.

Response

Specific Issue - Revision 3 to DAP-5 was approved September 12, 1986, and Revision 3 to DAP-6 was also approved September 12, 1986. These revisions incorporate additional guidance for providing explanations when "NC" or "NA .

are used in a Type C checklist and the basis is not already apparent to a qualified reviewer.

! The adequacy of the basis for "NC" or "NA" used in previously approved Type C checklists is being assessed as part of the generic review being conducted in response to DAP CAR Number DAP-CA-QA-016. Those found to be inadequate will be corrected.

Generic Implications - This concern is specific to Type C checklists only and has no generic implications beyond them. The response to DAP CAR Number DAP-CA-QA-016 will address all Type C checklists.

Action to Prevent Recurrence - The administrative controls and guidance i provided by DAP-5, Rev. 3, and DAP-6, Rev. 3, and the DAP Manager's memorandum

! issued to project personnel, dated September 29, 1986, reminding them of' procedural requirements on Type C checklists should be sufficient to prevent j

recurrence, i

i t

4 i

.____._._.,._.____,,,.._.,__.__,_._,__.-___.,.,.._____..______..__...___.,__,,.__,_.-_m., _ _ - . . - . . _ . . .

Attachment to TXX-6082 November 12, 1986 Page 17 of 19 Table 2. Type A, " Design Criteria Review," Checklists and DAP-1,

" Design Criteria lists," Reviewed by Team

• Disci-oline Checklist Desian Criteria List Title M DAP-CLA-M-002 DAP-CR-M-002/Rev. 1 Overpressure Protection M DAP-CLA-M-001 DAP-CR-M-001 Auxiliary Feedwater System M DAP-CLA-M-003 DAP-CR-M-003 HVAC/ Control Room M DAP-CLA-M-011 DAP-CR-M-011 Welding Engineering M DAP-CLA-M-007 DAP-CR-M-007/Rev. 1 Radiation Protection C/S DAP-CLA-C/S-001 **DAP-CR-CS-001/ Draft Load Determinations Rev. 1 C/S DAP-CLA-C/S-004 Same as above Foundations EIC DAP-CLA-EIC-006 DAP-CR-EIC-007/Rev. 1 Control EIC DAP-CLA-EIC-004 DAP-CR-EIC-005/Rev.1 Electrical Load Capacity EIC DAP-CLA-EIC-003 DAP-CR-EIC-004/Rev. 1 Electrical Characteristics EIC DAP-CLA-EIC-010 DAP-CR-EIC-011/Rev. 1 Support System - D/G

• M - Mechanical C/S - Civil / Structural EIC = Electrical / Instrumentation and Controls

• • Civil / Structural has only I criteria list.

m . _

Attachment to TXX-6082 November 12, 1986 Page 18 of 19 Table 3. DAP-21 Attachment B, "HDA Description and Validation," Checklists Reviewed by Team

• No. Title M004.0A System Pressure Drop - Gas Systems M034.0 Temp. and Humidity Range - Normal and Accident M085.0 Flooding - Internal - Critical Crack and Break Locations E002 600V Power Cable - Selection / Sizing / Spec E044.1 Raceway, Cable Trays - Equipment Installation Design E075.0 Protective Devices Settings - Calculations / Analysis l 1007.0 Microprocessor Based Monitoring Systems (Class IE) -

Component Spec.

1016.0 Transmitters - Component Specification 1037.1 Instrument Panel / Rack Design - Panel Location C139.2 Safe Shutdown Inpoundment Dam C136 Tornado Dampers and Blowout Panels C136A Hand cales for Tornado Dampers Cl368 Hand calcs for Blowout Panels C136C Computer cales for Blowout Panels C191.083 Miscellaneous Category Steel

• M - Mechanical E - Electrical I - Instrumentation and Controls C - Civil / Structural

r

. r ,

s .

Attachment to .T'XX-6082 November 12, 1986 - q Page 19 of 19 l l

Open Item Q-13.

DAP-21 Attachment B, " Homogeneous Design Activity (HOA) Description and Validation Checklist," has space for signature of both the preparer (reviewer) and the Discipline Coordinator (approver). The procedure is silent on actions to be taken'when the Discipline Coordinator is also the reviewer. The team reviewed Attachment B HDA checklists'shown in Table 3. Checklists reviewed were signed and dated, ~but numerous EIC checklists have the same signature on the " Prepared by" line and the " Approved by" line. In each of these cases, a

" checked by" line has been added, signed, and dated by a second individual.

Discussion with TERA personnel indicsite the checking was a technical overview of the reviewer's work which was requested by TERA management when the reviewer and approver are the same individual. The team considers that DAP procedures should address the above situation, so that the meaning of the checker's signature is clear in cases such as the EIC HDA checklists.

Resoonse:

Specific Issue - The HDA checklists involved were limited to the I&C Discipline. The I&C Group Leader and Deputy Group Leader have been. advised that, although DAP-21 does not require so, it is preferred that the preparer and approver be different-individuals. It is believed that there is no value

~

in revising DAP-21 at this time since the work involving the DAP-21 HDA checklists is complete, no future activity is expected in this area, and the issue is limited to one group. With regard to the referenced checklists themselves, there is no reason to doubt their current validity. The individuals involved are both qualified; these same individuals would have been the individuals involved no matter what the evolutionary sequences of the '

documents.

Generic Implications - This issue is limited to the DAP-21, Attachment-B, HDA ,

checklists, and further limited to the I&C Discipline. DAPs 5 and 6 adequately address review and approval of Design Review checklists. DAP-8

• adequately addresses review and approval of Engineering Evaluations; DAP-9 adequately addresses review and approval of Results Reports.

Action to Prevent Recurrence - No action to prevent recurrence is appropriate beyond the reminder to the group involved. No further work is anticipated involving DAP-21 HDA checklists, as that work is considered complete.

i

• w<,-+.,,,<----,-3, - - ,r_. m,,.._-,__.,e-. . - . - - - , , . , .--#m.w.,m-..-.o_-___m% , , . , , . . - _ , . _ , - , . _ .

,,e ,, . .m.,,,,,,,,,,_m-,,w,-,----we,w