View source for BECO-LTR-93-013, Responds to NRC Re Violations Noted in Insp Rept 50-293/92-27.Corrective Actions:Fire Protection Group Now Repts Under Mechanical Sys Engineering Div to Enable Fire Protection Personnel to Be Trained as Sys Engineers

{{Adams
| number = ML20128H753
| issue date = 02/10/1993
| title = Responds to NRC Re Violations Noted in Insp Rept 50-293/92-27.Corrective Actions:Fire Protection Group Now Repts Under Mechanical Sys Engineering Div to Enable Fire Protection Personnel to Be Trained as Sys Engineers
| author name = Boulette E
| author affiliation = BOSTON EDISON CO.
| addressee name = 
| addressee affiliation = NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
| docket = 05000293
| license number = 
| contact person = 
| document report number = BECO-LTR-93-013, BECO-LTR-93-13, NUDOCS 9302170151
| title reference date = 01-25-1993
| document type = CORRESPONDENCE-LETTERS, INCOMING CORRESPONDENCE
| page count = 7
}}

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             ,                                   ~ BOSTON EDISON Pdgren Nuclear Power Station Hacky Hd! Road 10 CFR 2.201                    .-
Plymouth, Massa:busetts 02360 February 10, 1993 E. T. Boulette, PhD                                                            BEco Ltr. 93-013 Senior Vee Presdent-- Nuclear U.S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D.C. 20555 Docket No. 50-293 License No. OPR-35

==Subject:==
REPLY TO NOTICE OF VIOLATION (REFERENCE NRC REGION I INSPECTION REPORT NO. 50-293/92-27)

==Dear Sir:==

Enclosed is Boston Edison Company's reply to the Notice of Violation contained in the subject inspection report.              As indicated in BEco Letter No. 93-009, dated January 25, 1993, this reply is being submitted within 30 days of receipt of the report.
Please do not hesitate to contact me if there are any questions regarding the enclosed reply.
dd./bt    ',
E. T. Bou tt /      )
Senior Vice President Nuclear GJB/bal

==Enclosure:==
Reply to Notice of Violation 50-293/92-27-01 1
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                      - cci     Mr.--Thomasfi. Martini                                                           .
lRegionaliAdministrator, Region-I.                                             '+
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                               . King of-Prussia, PA'19406l                                          .. . .
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!                               Div. of Reactor Projects-1/II Office of NRR - USNRC                                                           "
One White flint North - Mail Stop 1401 11555 Rockville Pike                                           -                 .
Rockville, ND 20852                                                              .
Sr. NRC Resident inspector - Pilgrim Station 3
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                                                                                        .                                                              ENCLOSURE REPLY TO NOTICE OF VIOLATION 50-293/92-27-01 Boston-Edison Company                                                                                                    Docket No. 50-293
)                                                 Pilgrim Nuclear Power Station                                                                                           License No. DPR-35 During an NRC inspection conducted from November 16-20, 1992, violations of NRC requirements were identified. In accordance with the, " General Statement of Policy and Procedures for NRC Enforcement Actions", 10 CFR Part 2, Appendix C (1990), the violations are listed below:
10 CFR 50, Appendix B, Criterion XVI, requires that measures shall be established to assure that conditions adverse to quality, such as failures, deficiencies, defective material and equipment, are promptly identified and corrected. Boston Edison Company (BEco) Fire Protection Program, N0P83FP1, requires that the fire protection program be periodically audited. The BEco Quality Assurance Program Sections 2.5.6, 16 and 16.2.4 require that audit deficiencies be reported to responsible management.
Conditions adverse to quality shall be corrected and such corrective action shall be timely.
Contrary to the above, actions were not taken in a timely manner to correct audit findings and other conditions adverse to quality as evioenced by the following examples:
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* A lack of required fireproofing material on structural steel in ;ome areas of the Reactor Building was identified by Quality Assurance Deficiency 1306, October 24, 1984. The same deficiency was also identified in Audits No. 90-30, December 5, 1990, and 91-45, January 9, 1992. Corrective action was not taken to repair this deficiency until November 19, 1992, after it was again brought to your attention during our inspection.
* In June 1988, an engineering service request (ESR 88-407) was issued identifying a broken sight glass on the diesel fire pump fuel oil day tank which was also identified in Maintenance Requests Sd-33-51 and 88-33-161.
Audit No. 90-30, December 5, 1990, further identi~ied ' hat the design of the day tank sight glass was not in accordance with the design requirements of the National Fire Protection Code No. 20. To date, no corrective action has been taken to bring the tank volume measurement system into NFPA code design.
This is a Severity Level IV Violation (Supplement 1).
REASON FOR VIOLATION Structural steel fire proofing material was removed / damaged in some areas of the Reactor Building, Vital MG Set and Switchgear Rooms during the implementation of various plant modifications in early 1984. Upon completion of the modifications, the fire proofing material was not re-applied tc ill of the steel beams.                                                         The application of the fire coating was a commitment in the 1978 fire protection Safety Evaluation Report (SER).
Quality Assurance Audit No. 84-27 identified this issue as a concern and documented it on Deficiency Report (DR) No.1306 in October of 1984. The DR was subsequently closed during 1985 based upou completion of a portion of ae corrective action. The fire proofing had been reapplied to the steel in the Vital MG Set and Switchgear Rooms but not in the Reactor Building. The DR was inappropriately closed; some of the steel in the Reactor Building remained uncoated.
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                                    ,in1588,aManagementCorrectiveActionRequest(MCAR)wasgeneratedtodocumentsomeof the steel in the Reactor Building was still in need of repair.                                                                                                                                            It was initially believed by the Appendix R Project that Engineering could perform an evaluation to demonstrate that the steel in the uncoated condition was acceptable as is. The barriers supported by the steel in question are not required for Appendix R fire area separation and do not separate redundant trains of safe shutdown equipment. During development of the draft engineering tvaluation, it was recognized that the steel protection was an SER commitment; consequently, the draft evaluation was never issued. It was subsequently determined the appropriate course of action was to reapply the fire proofing to the steel. This conclusien was not effectively communicated to BECo management and, consequently, the repair work was not planned, funded or implemented in a timely manner.
Although this issue was discussed in subsequent QA Audit Reports Nos. 90-30 and 91-45, additional Deficiency Reports were not issued by the Quality Assurance Department since MCAR 88-001 remained open. The MCAR, however, was also inappropriately closed in 1991 prior to completion of the required work.
Tne concern with the glass tube sight gage on the diesel fire pump fuel oil storage tr.ni                                                                                                                                           _
was also a case of miscommunication and ineffective corrective action tracking. Alti.ough the problem was documented as an observation in various QA Audit Reports, it was not effectively communicated to management that the design of the gage was contrary to NFPA guidelines. In addition, although the problem was documented on an Engineering Service Request (ESR), the condition did not receive appropriate attention.
NFPA Code No. 20 states that means other than sight glass tubes be provided for determining the amount of fuel in a storage tank. Since the initial finding in QA Audit Report No. 88-42, tne sic,ht glass which is susceptible to damage had been broken several times and, therefore, was unable to provide oil level indication.                                                                                                                                       ESR No. 88-407 was written to Engineering requesting a resolution of the concern.                                                                                                                                       Although the ESR was answered indicating an alternative design was being prsued, the issue was not properly prioritized and the sight glass was not replaced. Although the existing installation was contrary to NFPA Code requirements, the condition posed no safety concern to plant operations. The sight glass can be valved out of service to eliminate concerns for breakage, leakage or rupture during a fire. Tank level can be verified operationally via Procedure 8.B.1, " Fire Pump Test", by running the diesel oil transfer pump until the tank                                                                                                                                       a high level alarm is received in the Control Room. Although this means to verify tank level is cumbersome, system operability was never in question. The low safety significance combined with no operability impact also contributed to the delays in resolviag this concern.
In summary, both concerns were the result of ineffective implementation of the corrective action process. Although the Quality Assurance audit reports initially identified the issues, the DR and MCAR processes did not ensure timely corrective action was taken.                                                                                                                                  In addition, the other plant corrective action process that existed at the time, Failure and Malfunction Reports (F&MR), was not appropriately used. Initiation of an F&MR in conjunction with the other documents would have helped to ensure a more timely resolution.
The miscommunication of fira protection requirements also contributed to the delays in correcting these two issues.
CORRECTIVE ACTION TAKEN AND RESULTS ACHIEVED The fire proofing was reapplied to the structural steel in the Reactor Building during December of 1992.                                                                                                The work was done by an approved supplier in accordance with Engineering Specification No. M505, " Structural Steel Fire Proofing". Repair work was inspected by the Station Fire Protection and Prevention Officer (FPPO) with satisfactory results. The SER commitment to coat structural steel in the Reactor Building with a fire proof retardant is now satisfied.
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            <AP  h ant Design Change (PDC), initiated in August of 1992, to replace the sight glass on                        '
the diesel . fire _ pump day tank was issued 'on _ December 18, 1992. The new design is a float type level indicator that meets the NFPA requirement that sight tubes not be used. The -                         ;
PDC is scheduledefor implemcntation-when the diesel fire pump-is taken outff service for                         '
            -maintenance and will- be completed by March 31, 1993,                                                            i CORRECTIVE ACTION TAKEN TO PRECLUDE RECURRENCE f
The fire protection group now reports under the Mechanical Systems Engineering Division (MSED) that is part of the Plant Department. Prior to this change, the group was a separate division in the Plant Support Department. The reorganization will enable fire protection personnel to be trained as systems engineers in addition to maintaining-their
,            proficiency in fire protection. This should enhance the overall fire protection program at Pilgrim Station as the systems engineering expertise will be more readily available to-the fire protection personnel.           It is also believed this integration between the fire.
protection and technical divisions will improve the overall communication process with-management in ensuring fire protection commitments and code requirements are satisfied.
The reorganization will also help ensure the existing internal corrective action process is used more effectively.        This process has undergone significant improvement at Pilgrim Station. The improved process called the Problem Report (PR) Program consolidated several existing coi rective action tracking systems including Failure and Malfunction Reports,_
Potential Conditions Adverse to Quality, and Recommendations for Improvement into one program. This program is a closed loop tracking system and was implemented in March of 1992. Some of the highlights of the new PR Program that will help address thesa fire protection issues include the following:
* All Problem Reports undergo a formal structured screening process which assigns a graded significance level. A Screening Coordinator _ males the initial assignment of significance level that is then validated by a- Problem Assessment Committee (PAC).                   PAC currently consists of the day-shift Watch Engineer, SR0 licensed as Chairman, and senior representatives from the QA, Regulatory Affairs, Radiological and Engineering Departments
* The new Problem Report process ensures significant problems are brought to_ the attention of the Nuclear Watch Engineer (NWE). The NWE is required to-review significant problems and formally determine system operability and provide the basis for that determination. Compensatory measures including fire watches are also determined.
* Each action item assignment is required to detail the action necessary to respond to the assignment and the documentation necessary to support closure.
All assigned actions are made by the PR Coordinators and validated by the-Technical Programs Division Manager prior to assignment distribution. Closure L
documentation is validated by the PR coordinators to ensure adequacy.
* The Problem Report Nuclear Organization Procedure (N0P) places _ time limit requirements on evaluation completion and allows shortening of evaluacion time limits to meet regulatory requirements.
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* The Problem Report Process provides several checks and balances to ensure i-action completion, The most effective is the " Notice" process.                    This process, similar to the Master Surveillance Tracking Program (MSTP) Notice _ process, l-                           provides automatic notification to Coordinators and action owners when certain milestones are reached. The " ALERT NOTICE" is issued one day after the action's due date. The " FAILURE-TO-COMPLY NOTICE" is issued every day after an action has passed its dead date.
P7p: 3
* All change requests that revise due dates, assigned work scope, or ownership   ,
                    . must be approved by the owner's section manager. These section manager         ;
approved change requests are validated via a formal file review for           1 acceptability by the PR Coordinator.
* Other checks and balances include issuing a monthly PR status report that includes the number of open and past due items. The report is distributed to   -
senior management and is part of an on going effort to reduce the number of open items and to minimize the time taken to implement corrective actions.
Outstanding fire protection issues were reviewed to ensure they were properly captured on the appropriate corrective action docun,e-t, Several prs were initiated as a result of this review,      future fire protection problems including hardware deficiencies, failure to fulfill regulatory commitments and other system abnormalities will be documented and processed using the PR Program. This will bettu ensure work is properly prioritized, planned and implemented in a timely manner.
The Quality Assurance Department's DR process has also undergone significant revision since the subject deficiency was identified. In early 1992, the DR process was revised to assign deficiency " levels" to help focus appropriate management attention to more significant deficiencies based on safety significance, regulatory compliance, etc.
Concurrent with this change, documentation requirements were strengthened to require more thorough documentation for the basis of DR closure by the QA Engineer. These changes were recently reviewed with applicable department personnel . The MCAR process is also being.
revised to strengthen the closecut requirements and increase the level of management attention required for each MCAR. A Problem Report was written (PR 93.0069) to document that MCAR 88-001 closeout was inappropriate.
In addition to these programmatic changes, QA audits of the corrective action program have included reviews of closed DRs and MCARs to verify that closecut was appropriate. The review of closed DRs has indicated the inappropriate closecut of the subject DR (1305) was an isolated occurrence. This conclusion is further supported by the results of QA Surveillances and DR process reviews conducted during the annual Combined Utility Assessment Team (CUAT) audits. Also, as a result of deficiencies identified during the 1989 Corrective Action Audit, a review was conducted of all closed MCARs existing at that time. This review resulted in the reopening of several closed MCARs. MCARs that were closed between 1989 and present were also reviewed with no other inappropriate. closeouts identified. We are confident the ongoing internal reviews in conjunction with the programmatic changes discussed above will further enhance the effectiveness of the existing QA corrective action processes.
     -We recognize recent findings may suggest existing corrective' action processes are not always ensuring timely corrective action. Ongoing enhancements to the Problem Report Program as well as recent changes to existing QA processes will improve the timel' ness of corrective action implementation at Pilgrim Station. Although considerable progress has been made with the implementation of the new PR Program, additional efforts are still warranted. Management has a heightened awareness and increased sensitivity to the ticeliness issue and we are continuing to monitor progress in this area.
One recent improvement includes establishing goals for the average age of open Problem Report evaluations and corrective action items to be more consistent with INP0 Good Practices. These goals are being incorporated into the Goals and Objectives of applicable Departments and should help to maintain the proper focus on closing out issues. Also, the average age _of open issues has been steadily declining over the past six months. Average age of open issues is included in'the PR status report which is distributed to senior management on a monthly basis.
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O Senk'ormanagementisalsorequestingeachDepartmentreviewoutstandingissuestoensure they are captured on the appropriate corrective action document. A review of outstanding prs is also planned, This review will focus on open significance level I . prs and those I
corrective action documents that were converted into prs when the new Problem Report Program was implemented in March of 1992. The review will include the following:
* Open significance level I prs will be reviewed to ensure action plans are commensurate with safety significance. This review will be completed by May 31, 1993.
* Corrective action documents converted into prs will be reviewed to ensure appropriate assignment of significance level and to ensure action plans are commensurate with safety significance. These documents are being selected for review because they may not have been subjected to the same level of screening as prs written under the new system. This review will be done in two phases with those greater than 2 years in age expected to be completed by May 31, 1993, and remaining prs by August 31, 1993.
We are also establishing a task force chartered to make additional recommendations to                                                                                              ~
senior management to address the timeliness of corrective action ssue. The task force                                                                                        4 will meet periodically with management, and a final report containing recommendations is expected before restarting from refueling outage No. 9, scheduled to begin in April of 1993.
DATE WHEN Full COMPLI ANCE WILL BE ACHIEVED The structural steel fire proofing was reapplied on December 31, 1992.                                                                                                              The new diesel fire pump day tank level indicator will be installed during the diesel fire pump system outage and will be completed by March 31, 1993.
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