TXX-6895, Forwards Addl Info to 870715 Response to Violations Noted in Insp Repts 50-445/84-32 & 50-446/84-11,based on 870715 Meeting W/Nrc.Lack of Procedures to Review Status of Const QA Program Addressed in Issue Specific Action Plan VII.a.5

Forwards Addl Info to 870715 Response to Violations Noted in Insp Repts 50-445/84-32 & 50-446/84-11,based on 870715 Meeting W/Nrc.Lack of Procedures to Review Status of Const QA Program Addressed in Issue Specific Action Plan VII.a.5

ML20236N217
Person / Time
Site:	Comanche Peak
Issue date:	11/06/1987
From:	Counsil W, Woodlan D TEXAS UTILITIES ELECTRIC CO. (TU ELECTRIC)
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
TXX-6895, NUDOCS 8711160067
Download: ML20236N217 (11)

Text

_-.

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') l M Log #:TXX-6895.

== File # 10130 L . -~

IR 84-32 l

-Z _ IR 84-11

• ' # * I RIELECTRIC November 6, 1987

, William G. Counsil Executive Vice Presuknt j U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555

SUBJECT:

COMANCHE PEAK STEAM ELECTRIC STATION (CPSES)

DOCKET NOS. 50-445 AND 50-446 REQUEST FOR ADDITIONAL INFORMATION REGARDING INSPECTION REPORT: 50-445/84-32 AND 50-446/84-11

Reference:

1. Letter from D. R. Hunter (NRC) to M. D. Spence (TUGCo) dated February 15, 1985

2. .TXX-6144 from W. G. Counsil (TVEC) to R. D. Martin (NRC),

dated February 2, 1987 Gentlemen:

On' July 15, 1987, TV Electric representatives met with your R. F. Warnick and

. members of his staff to discuss the subject inspection report (Reference 1) and our response to the attached Notice of Violation , Item 1 and 2 (Reference  ;

2). As .a result of that meeting, the following additional information '

relative.to our response to these items is provided.

For convenience, the alleged violation from the subject report and our initial response has been provided, followed by the additional information.

Very truly yours, G. G. Q W. G. Counsil By:D D. R. Woodlan Supervisor, Docket ,

Licensing l RDD:tgj j c- Mr. R. D. Martin, Region IV Resident Inspectors, CPSES (3) 8711160067 871106  !

PDR ADOCK 05000445 l G PDR p

400 Noah Olive Street LB 81 Dallas, Texas 73201 (

Attachment lto TXX-6895

. November 6, 1987

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Page 1 of 10 Alleaed Violation

1. Failure to Reaularly Review the Status a1d Adecuacy of the 0A Procram Criterion II of Appendix B to 10CFR50, 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 by the management participating in the pragram, 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.

(445/8432-02;446/8411-02)

TUGC0 RESPONSE TUGC0 acknowledges that procedures were not established for the regular review of the status and adequacy <af the construction quality assurance (QA) program. Notwithstanding this lack of procedures, it is TUGCO's view that managers and corporate offict:rs by virtue of their day to day involvement were aware of the status and adequacy of the construction QA program. That awareness was based on various practices employed by TUGC0 managers and officers during the history of CPSES to evaluate the QA program. Those practices includttd the use of quality committees, documented management review, and independent evaluations. In addition, these managers and officers routinely received a variety of reports  ;

concerning the adequacy of the construction QA program such as TUGC0 QA internal audit reports and reports produced by independent personnel from outside of the TUGC0 organization.

1. Corrective Action and Results Achieved TUGC0 recognizes that regularly scheduled QA program assessments and reviews serve to focus management's attention on program adequacy and effectiveness. Accordingly, the Quality Assurance Overview Committee was l formed and has met regularly since September 1985. The original charter for this committee was contained in Procedure DQP-CQ-5. The duties and responsibilities of this committee are currently described in the following policies and procedures:

o NE0 Policy Statement Number 2, " Quality Assurance Program" (Revision 0 dated June 23,1986): Requires the NE0 Vice Presidents to meet periodically to assess the status and adequacy of the QA program and at least annually to provide a written assessment of the overall effectiveness of the program to the Executive Vice President, NE0. The Executive Vice President, NE0 will assure that an annual {

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Attachment.to TXX-6895.

. November 6, 1987 ~

Page 2 of 10 independent assessment of the TUGCO audit program is' performed and the results reflected in the Vice Presidents' annual assessment.

o NE0 Procedure 2.20, " Senior Management QA Overview  ;

Program" (Revision 2, dated October 13,1986): Defines '

the methodology employed by the NE0 Vice Presidents in meeting their responsibilities as-defined in HE0 Policy l Statement No. 2. This procedure establishes a committee  !

which meets at least quarterly to evaluate the status and i adequacy of the TUGC0 QA program.

o NE0 Procedure 2.08, " Joint Utility Management Audit Program" (Revision 0 dated June 23,1986): Provides'a method which the Executive Vice President, NE0 may utilize to perform the independent assessment of the TUGC0 audit

. program as delineated in NE0 Policy Statement No. 2.

2. Corrective Steps to Avoid Recurrence The corrective acticns described above are considered sufficient to  !

prevent further violations.

3. Date When in Full Compliance Full compliance was achieved June 23, 1986.

ADDITIONALINF03 MAT 10N The lack of procedures resulted in a lack of documented reviews of the status and adequacy of ttie construction quality assurance program. This condition represented a weakness in the construction quality assurance program.

Based on the NRC finding, it was determined that specific formal controls to address this area were recuired. This, in part, resulted in the issuance of a j memorandum from the Presicent of Texas Utilities which called for development l of policies and procedures to ensure that the "Overall effectiveness of the l quality assurance program. . .be regularly reported to Corporate Management. . .". j Subsequently, Nuclear Engineering and Operations (NE0) Policy Statement Number '

2 was issued, detailing this policy and causing the development of (

implementing NE0 procedures 2.20, " Senior Management QA Overview Program," and i 2.08, " Joint Utility Management Audit Program".

The lack of established procedures to regularly review the status and adequacy  !

of the construction quality assurance program concern was addressed in issue Specific Action Plan (If;AP) VII.a.5. " Periodic Review of QA Program." The ISAP evaluated the new procedural controls implemented based on the i requirements of ANSI N45.2-1971 and 10CFR50 Appendix B, as well as applicable criteria from the Institute for Nuclear Power Operations and the applicable sections of the NRC Standard Review Plan, NUREG-0800. Because of the similarity of the criteria in these documents, the ISAP criteria were developeu to closely reflect and expand upon the criteria contained in the .

Standard Review Plan. The ISAP review reached the following conclusions:

I

. Attachment to TXX-6895 1 November 6, 1987

. Page 3 of 10' ' J

..n o The program now provides for a regular assessment of the status ,

and adequacy of the QA program, o The program defines the management positions responsible for the

' periodic review of the QA Program.

o The program describes the methodology for performing the program assessments and their frequency.

o The program describes the methodology for reporting, tracking and follow-up of the results of the periodic review of the QA Program.

o Regular program review meetings are being held in conformance with the new procedures.

o Meetings are focusing effectively on identified problems in the QA program, o Refinements are being made to improve the implementation and documentation of the procedural controls which govern the review.

Based on the above described actions, we believe that the concerns identified in the violation have been thoroughly addressed. These actions will assure that the QA Program remains in compliance with the specified requirements.

Alleged Violation

2. Failure to Establish and Implement a Comprehensive System of Planned and Periodic Audits Criterion XVill of Appendix B to 10CFR50, states, in 3 art, "A comprehensive system of planned and periodic audits siall 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 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, Revision 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 demonstrate the failure to establish and implement a comprehensive system of planned and periodic audits of safety-related activities as required, as noted below:

a. Annual audits were not adequately addressed by the audit implementation procedures.

o 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

Attachment to TXX-6895

• November 6, 1987 /

!- Page 4 of 10 i i

l- equipment; one audit of vendors fabricating engineered l safeguards components, parts, and equipment; and audits of balance of plant (safety-related) as required by the quality assurance manager.

o TUGC0 Procedure 00P-CS-4, Revision 2, dated April 16, i 1981, required only that organizations will be audited on '

a regularly scheduled basis.

o TUGC0 Procedure 00P-CS-4, Revisions 2 and 10, did not specify auditing frequencies for design, procurement, construction, and operations activities, o 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 to 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 3 that the applicant sampled only 165, or 25 percent, during the l 1983 audit program. Consequently, significant aspects of the i safety-related activities were not adequately audited.

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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. Audit 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. (445/8432-03; 446/8411-03)

TUGC0 RESPONSE The number and scope of audits conducted each year by TUGC0 over the history of the CPSES project reflect the evolution of the TUGC0 audit program from an initial overview function to the present role in which TUGC0 has assumed primary audit responsibility. The TUGC0 audit program was initially described in the CPSES QA Plan and beginning in 1978 in Procedure CQP-CS-4. (The procedure identification was changed to DQP-CS-4 in 1982.) The TUGC0 QA Department audit responsibilities described in the

Attachment to TXX-6895 L

t November 6, 1987 Page 5 of 10 SAR were formalized in Revision 0 (dated August 29,1978) of this procedure which established an audit plan. Consistent with TUGC0's initial overview role as outlined in PSAR Table 17.1-1, a minimum number of audits were planned and conducted for those organizations whose QA programs were described in the SAR. As TUGC0 assumed direct responsibility for site construction and engineering activities, the audit responsibilities of the QA Department expanded commensurately.

Accordingly, procedure CQP-CS-4 was revised to address these responsibilities by providing for regularly scheduled audits of these i activities and organizations and for the generation of an annual audit plan.

TUGC0 believes that the audit planning and scheduling practices employed by TUGC0 and its principal contractors over the history of the project collectively provided adequate audit coverage of the construction QA program. The conclusions of the CPRT independent review regarding audit planning and scheduling, as described in the Results Report for ISAP VII.a.4, was that " Audit planning and scheduling, though in the past not in compliance regarding frequency and not formally systemized until recently, did appear to be well thought out in the centext of the TUGC0 concept of the audit program requirements at any particular time".

Our response to each of the examples is set forth below.

ADDITIONAL INFORMATION To address the concerns of this violation, Issue Specific Action Plan (ISAP)

VII.a.4 was developed. This plan had the specific task of evaluating and considering the implications of these concerns on construction quality, determining the root cause of the findings and any generic implications, addressing the collective significance of the deficiencies, and proposing an action plan which would ensure that such problems do not recur. Input to the ISAP included the NRC Notice of Violation,10CFR50 Appendix B, SSER 11, the applicable portions of NUREG 0800, and various regulatory guides and standards.

l The ISAP VII.a.4 Results Report states: "The overall effectiveness of the audit program has been less than fully adequate. Specific examples are: it has failed to identify and cause corrective action of inadequacies in such areas as QC inspector training, qualification, and certification; and control of non-conforming items and corrective action. It is concluded, from the evidence observed that the failure to identify and cause corrective action in these two areas was due primarily to the practice of auditing to existing procedures while not performing verification of the adequacy of existing procedures to implement program requirements. It is further concluded that the cause of the deviations and weaknesses in the QA audit program which have been identified in this report are the result of inadequate procedures."

The ISAP Results Report also states: "Although audit program deviations and weaknesses related to construction activities were identified, it has been determined that no action is required beyond that specified in ISAP VII.c,

Attachment to TXX-6895 November 6, 1987 I

. Page 6 of 10 which addresses all areas of safety-related hardware and is intended to provide confidence that any currently unidentified concerns related to the quality of construction of the CPSES hardware will have been identified, evaluated and resolved."

TUGC0 RESPONSE TO EXAMPLE 2.a j l

TUGC0 has committed to meet the provisions of ANSI N45.2.12, " Requirements for Auditing of Quality Assurance Programs for Nuclear Power Plants,"

Draft 3, Revision 0 (vice Revision 4 as stated in the Notice of l Violation), dated May 2, 1973. We acknowledge that the TUGC0 audit '

implementation procedures did not explicitly establish an annual audit frequency for all organizations or activities. However, the preplanned audits conducted each year by TUGC0 and its principal contractors provided audit coverage of the involved organizations and the activities of design, construction, procurement and others, as applicable.

1. Corrective Action and Results Achieved Procedure DQP-CS-4, " Procedure to Establish and Apply a System of Preaward Evaluations, Audit and Surveillance", was revised in November 1984 to specifically require that applicable elements of the construction QA program be audited by TUGC0 annually or at least once within the life of .

an activity, whichever is shorter. Procedure DQP-CS-4 has subsequently '

been re-identified as DQP-QA-15.

2. Corrective Steos to Avoid Recurrence The corrective actions described above are considered sufficient to avoid further violations.

3. Date When in Full Comoliance Full compliance was achieved in November 1984.

ADDITIONAL INFORMATION ITEM 2.a ISAP VII.a.4 evaluated the audit program performance based on records of the audits performed. The evaluation concluded that the failure to perform vendor audits on an annual frequency resulted in no adverse affect on the audit

, program because of the additional activities implemented by the QA organization to supplement the audits which did occur. These additional activities included joint inspection / audits during which auditors would accompany inspectors on release inspection trips to investigate specific problems, and requests for corrective action sent to vendors for specific, identified problems that did not warrant an audit investigation or did not appear to indicate an adverse trend.

1 As stated in the response to a recent NRC request for additional information regarding this ISAP (Reference TXX-6656, dated August 14, 1987), "when the ISAP VII.a.4 Results Report was prepared...there were no 'known problems with

Attachment to TXX-6895 November 6, 1987 Page 7 of 10 vendor supplied material' which were attributed to the failure to perform I

' vendor audits on an annual basis. In other words, no procurred hardware problems were known that could have been identified and corrected through audits or other vendor compliance activities. Subsequent to issuance of the ISAP VII.a.4 Results Report, the scope and methodology of ISAP VII.a.9 has been revised to include hardware inspections which may identify problems which might have been identified in an audit program. Information pertinent to the adequacy of the audit program that is gathered during implementation of ISAP VII.a.9 and other ISAPs will be evaluated during the collective evaluation process and described in the Collective Evaluation Report."

TUCC0 RESPONSE TO EXAMPLE 2.h TUGC0 denies the allegation of a violation for the reasons that follow.

With respect to staffing levels, a designated audit group staff was established in 1979 which increased in strength each year through 1983; however, the number of qualified personnel who actually performed audits during those years also included members of the QA organization other than those assigned to the audit group. It is TUGC0's view that the total number of QA personnel who performed audits during 1983 represented an adequate staffing level. The CPRT independent review resulted in the same conclusion as documented in the Results Report for ISAP VII.a.4.

With respect to audit planning, TUGC0 has reviewed the 1983 audit plan against those safety-related procedurm for activities which were being more than minimally performed during 1983. Those procedures were grouped by activity groups which were then compared to the scopes of the audits conducted during 1983. All but three of the sixty activity groups identified were subject to audit during 1983. Of the three activity groups not subjected to a specifically scoped audit during 1983, two received ancillary coverage as a result of the 1983 auditing activities and one (Protective Coatings QC Inspection) was excluded from the 1983 audit program due to the extensive review by the NRC of that area which was ongoing during 1983.

TUGC0 believes that the 1983 audit program coverage of the design and construction phase of CPSES was adequate. This conclusion was also reached by the CPRT independent review as described in the Results Report for 1 SAP VII.a.4. However, TUGC0 concluded that some of its administrative practices in scheduling audits should be formalized in a procedure or instruction. Accordingly, Instruction DQI-AG-1.7, "CPSES Construction Phase Audit Program", was issued June 27, 1985. (This instruction has since been re-identified as Procedure DQP-AG-4.) A similar procedure for the scheduling of operations phase audits has been issued as DQP-AG-3, "CPSES Operation Phase Audit Program."

ADDITIONAL INFORMATION ITEM 2.b No additional information was requested.

Attachment to TXX-6895 l: ' Novemb r 6, IF87

, Page 8 of 10

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1 TUGC0 RESPONSE TO EXAMPLE 2.c TUGC0 denies the allegation of a violation for the reasons that follow.

TUGC0 did not perform audits of the Westinghouse site organization because this organization is not and has never been responsible for the performance of safety-related activities. This was verified by TUGC0 during Westinghouse audits TWH-23 and TWH-24 conducted in 1982. However, subsequent to the NRC inspection TUGC0 performed an audit in November 1984 (audit number TWH-30) of the Westinghouse site activities which confirmed that the Westinghouse site organization was not responsible for the performance of safety-related work activities. Therefore, there is and was no requirement to audit this organization. The CPRT independent ,

review resulted in the same conclusion as documented in the Results Report l for ISAP VII.a.4.

To assure that we remain cognizant of the scope of work for the i Westinghouse site organization, the Westinghouse Division responsible for the Westinghouse site organization has been identified on the vendor audit i schedule and the TUGC0 Approved Vendors List (AVL). This assures that an '

annual evaluation of that Division's activities will be performed.

ADDITIONAL INFORMATION ITEM 2.c The CPRT review of this issue examined the scope of activities for which Westinghouse was responsible during the period in question. This review determined that between 1977 and 1981, the Westinghouse site organization provided support to the Westinghouse home office through involvement in the transmittal of Field Change Notices (FCNs) and engineering dispositions of Field Deficiency Reports (FDR) to TU Electric. Based on this, it was determined that the Westinghouse site organization did perform activities subject to 10CFR50 Appendix B Criterion VI, ' Document Control."

This activity was performed by Westinghouse personnel in accordance with procedures OPR 210-2 for FDRs and OPR 305-4 for FCNs. These procedures are in turn implemented in accordance with the requirements of the Westinghouse '

Nuclear Service Division Quality Assurance Program Plan WCAP 9245. As a result of this, the site organization was subject to audit by Westinghouse per WCAP 9245, and was audited six times in the period from January 1978 to October 1986.

For this activity, the requirements of ANSI 45.2.12 were met by TV Electric's audits of the Westinghouse parent organization for compliance with 10CFR50 Appendix B Criterion XVIII.

TUGC0 RESPONSE TO EXAMPLE 2.d 2

TUGC0 assumed responsibility for the vendor audit program from Gibbs &

Hill beginning in January 1978. To assure the most effective utilization of audit resources, TUGC0 QA management scheduled vendor audits based on the following:

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' Attachment to TXX-6895' -)

November 6, 1987 l l 3 Page 9 'of.10. l l.

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o Vendor Activity; I o Evaluation ratings determined from reviews of source o release inspection trip reports; o Receipt, installation or test problems communicated to the audit group from the site; o The last audit date.

This practice assured the application of audit resources to a vendor during active fabrication or when source or receipt inspections or other information indicated potential quality problems.

There were occasions when vendors were not audited annually due to satisfactory vendor ratings or lack of activity at the vendor facility.

However, it is our view that our practices resulted in an adequate vendor audit program and were equivalent to the practices endorsed by the NRC in Regulatory Guide 1.144, Revision 1. The CPRT independent review of this violation concluded in the Results Report for ISAP VII.a.4 that the failure to perform audits of all TUGC0 vendors on an annual frequency did not result in any adverse effects on the audit program because of the ,!

additional activities implemented by the QA organization to supplement the audit activity.

1. Corrective Action and Results Achieved Following the NRC Special Review Team inspection conducted in early 1984, TUGC0 determined that the FSAR description of its external audit program i needed clarification. Consequently, in August 1984 TUGC0 revised FSAR l Table 1A(B) to adopt a commitment to paragraph C.3(b), " External Audits",

of Regulatory Guide 1.144, Revision 1. This commitment requires the performance of annual evaluations and triennial audits of active vendors.

TUGC0 Procedure DQP-CS-4, " Procedure to Establish and Apply a System of Pre-award Evaluations, Audits and Surveillance," was revised in November 1984 to incorporate this commitment. (This procedure has since been re-identified as DQP-QA-15, "TUGC0 QA Audit Program.") Evaluations for all active vendors on the AVL which were last audited during or before 1983 were completed in the first quarter of 1985. As of January 1,1986 all active vendors on the AVL were within their annual evaluation and triennial audit frequency.

2. Corrective Ste.ps to Avoid Recurrence The corrective actions described above are considered sufficient to prevent recurrence of this violation.

Attachment to TXX-6895

,a November 6, 1987"

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3. Date When in Full Compliance Full compliance was achieved 'as of January 1,1986.

ADDITIONAL INFORMATION IT[M 2.d A CPRT review was performed based on the audit index for the period, which determined that the audits were not performed in accordance with the  ;

applicable requirements for timeliness or frequency. The review determined j that a number of mitigating activities were performed during this period. '

These included:

o A vendor rating program was used to adjust the scheduling of inspections and audits. Some of the audits which were reviewed by the CPRT were noted to have been performed in response to  !

unsatisfactory inspection results.

o In mid-1979, a joint inspection / audit program was instituted l whereby auditors would accompany inspectors on release inspection trips to investigate specific program areas based on problems identified during previous source inspections.

o TV Electric QA used " Request (s) for Corrective Action" which were correspondence with the vendors requesting corrective action for i specific, identified problems when it was concluded that the problems did not warrant an audit investigation or did not appear to indicate an adverse trend.

o Internal documents known as " Yellow Flag Sheets" were also utilized by the TV Electric QA Staff to ensure that applicable QA personnel were aware of status and/or problems with particular i vendors (e.g., a hold placed on shipments from a vendor until after an audit was performed).

While source inspections and limited scope audits were not intended to serve  ;

as substitutes for a regularly scheduled program of audits, they did provide data which was used by TV Electric to evaluate the effectiveness of vendor QA programs.

As discussed in the response to NRC's request for additional information  !

related to this ISAP (TXX-6656 dated August 14, 1987), " Subsequent to the issue of the ISAP VII.a.4 Results Report, the scope and methodology of ISAP VII.a.9 has been revised to include hardware inspections which may identify ,

l problems which might have been identified in an audit program. Information pertinent to the adequacy of the audit program...will be evaluated during the collective evaluation process and described in the Collective Evaluation Report."

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