View source for W3P88-1270, Responds to NRC Ltr Re Violations Noted in Insp Rept 50-382/88-13.Corrective Actions Taken:Maint Directive 28, Troubleshooting, Developed & Training Session on Attention to Details Presented to Inspectors

{{Adams
| number = ML20207G594
| issue date = 08/17/1988
| title = Responds to NRC Ltr Re Violations Noted in Insp Rept 50-382/88-13.Corrective Actions Taken:Maint Directive 28, Troubleshooting, Developed & Training Session on Attention to Details Presented to Inspectors
| author name = Burski R
| author affiliation = LOUISIANA POWER &amp; LIGHT CO.
| addressee name = 
| addressee affiliation = NRC OFFICE OF ADMINISTRATION &amp; RESOURCES MANAGEMENT (ARM)
| docket = 05000382
| license number = 
| contact person = 
| document report number = W3P88-1270, NUDOCS 8808240171
| document type = CORRESPONDENCE-LETTERS, INCOMING CORRESPONDENCE, UTILITY TO NRC
| page count = 8
}}

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* a P. O. BOX 00340 LOUISI POWER &ANA LIGHT/ 317NEW                      BAHONNESTREET
* ORLEANS, LOUISIANA 70160 * (504)595 3100
   $iTONEvsNU August 17, 1988               W3P88-1270 A4.05 QA U.S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, D.C. 20555

==Subject:==
Waterford 3 SES Docket No. 50-382 License No. NPF-38 NRC Inspection Report 88-13 In accordance with 10CFR Part 2.201, Louisiana Power & Light hereby submits in Attachment 1 the cesponses to the Violations identified in Appendix A of the subject Inspection Report.
If you have any questions concerning these responses, please contact L.W. Laughlin, Site Licensing Support, at (504) 464-3499.
Very truly yours, R.F.        ski Manager Nuclear Safety & Regulatory Affairs RFB:TJG:ssf Attachment cc:    R.D. Martin, NRC Region IV J.A. Calvo, NRC-NRR D.L. kigginten, NRC-NRR NRC Resident Inspectors Office E.L. Blake W.M. Stevenson 8800240171 880817 2 PDR ADOCK 0500 O
l "AN EQUAL OPPORTUNITY EMPLOYER"                                                     ZEol     1 l

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Attachment to W3P88-1270 Page 1 of 7
                                             -ATTACHMENT 1 LP&L Responses to Violations Identified in Appendix A
                                      ,of Inspection Report 88-13 A. VIOLATION NO. 8813-01
                 , Inadequate Maintenance Work Instructions Technical Specification 6.8.1.a requires written procedures to be esta-blished, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978.
Regulacory Guide 1.33 requires procedures appropriate to the circumstances for performing maintenance on safety-related equipment.
Procedure UNT-7-005, Revision 2, "Cleanliness Control," is an approved procedure that requires cleanliness control requirements to be established when opening emergency diesel generator air systems.
Contrary to the above, on May 11, 1988, control air valves were manipu-lated, the starter system disconnected, and the start air system actuated using work instructions that were not appropriate in that they did not include these tasks and they did not require the implementation of clean-    ,
liness controls.
This is a Severicy Level IV violation.

===RESPONSE===
LP&L acknowledges that this incident was a Violation of the guidelines of Regulatory Guide 1.33 in that the work instructions for replacing control air interface check valve EGA-421B were not detailed enough relative to the circumstances.
(1) Heason For The Violation The requirements for dispositioning a condition as "Troubleshoot" when the failure mechanism or the reason for a degraded condition cannot be detected easily are provided in Plant Operations Admini-strative Procedure UNT-05-015, "Work Authorization Preparation and Implementation". Since specific guidance for determining where to
,-                     differentiate between troubleshooting and rework is not provided in the procedure, a conscientious decisior has to be made by maintenance personnel when in the field performing routine maintenance under a specific work authorization. Because troubleshooting involves a logical sequence of evente which is determined by the outcome of a NS90035D

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Attachment to W3P88-1270                                 i Page 2 of 7 previous step or action, specific troubleshooting instructions are difficult to write in the planning process.               In this incident, the extent of work after valve replacement was not known or defined at the time, so a statement to troubleshoot was included on the work authorization in accordance with UNT-05-015.
The responsibilities and criteria for cleaning fluid systems and associated components are provided in Plant Administrative Procedure UNT-07-005, "Cleanliness Control". This procedure, which is based on the guidance provideu in Regulatory Guide 1.37 (Quality Assurance Requirements for Cleaning of Fluid Systems and Associated Components of Water-Cooled Nuclear Power Plants) and ANSI N45.2.1-1973 (Cleaning of Fluid Systems and Associated Components for Nuclear Power Plants) is written primarily to address fluid systems. Although the diesel generator air system is listed as a Class "C" cleanliness system in the attachment of UNT-07-005, the procedure does not realistically address maintaining cleanliness in such an instrument and control system. The inspection criteria detailed in the procedure are not adequate for an instrument systems of such a small size. Therefore, maintenance personnel had the impression that the procedure did not apply, as was the case cited in this inspection.
(2) Corrective Actions That Have Been Taken Since the occurrence of this incident, a Maintenance Directive (No.
: 28) entitled, "Troubleshooting" was developed to provide guidance on writing troubleshoot instructions and establishing limitations on what can and cannot be done in the field on work authorizations dispositioned as "Troubleshoot". The directive instructs ibintenance personnel to contact their supervisor for clarification if it becomes questionable as to whether or not a certain activity is allowed under troubleshoot authority. The directive also pointe out that trouble-shooting does not allow deviation from procedural requirements and that complete and accurate documentation of all steps and actions taken as well as observations noted is imperative.
I With regard to cleanliness control during maintenance on instrument and control tubing and air lines, Instrument and Control Planners have been trained and instructed to include Cleanliness Control Forms (Attachment 6.1 of UNT-07-005) into the work authorization packages whenever breaking a system boundary.
(3) Corrective Actions To Be Taken UNT-07-005 will be revised to include responsibilities for establi-shing and maintaining adequate cleanliness controls when performing maintenance activities on instrument and control tubing.
Although not specifically part of the corrective actions for this violation, it is worthwhile to note that beginning in September, NS90035D
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Attachment to W3P88-1270 Page 3 of 7 1988, a pilot program entitled "Operation ZERO Deviations" will be implemented at Waterford 3 in the areas of Operations, Mainte-nance, Security, Health Physics and Chemistry. The intent of this program is to emphasize procedure and work instruction compliance and to instill in employees the importance of stopping work when neces-sary as opposed to deviating from a procedure or. instruction. This program emphasizes management concern and efforts toward reducing unauthorized procedure and work instruction deficiencies.
(4) Date When Full Compliance Will Be Achieved UNT-07-005 will be revised by September 30, 1988.
B. VIOLATION 8813-02 Failure To Implement Quality Assurance Procedures Criterion II of Appendix B to 10 CFR Part 50 states, in part, that a quality assurance program shall be documented in procedures and carried out in accordance with those procedures.
Quality Assurance Program Procedure QAP-012, Revision 6, "Corrective                       '
Action," requires initiation of a Quality Notice when conditions adverse to quality are identified.
Contrary to the above, Quality Assurance Inspection Report 88-012, dated April 21, 1988, noted that several wires of hydrogen analyzer       "A" had 5een landed at the wrong terminal points and accepted by quality assurance inspectors during the replacement of the hydrogen analyzer. No Quality Notice had been initiated on this condition which is adverse to quality as of June 15, 1988, when the NRC inspector reviewed the work documentation.
This is a Severity Level IV violation.

===RESPONSE===
LP&L acknowledges that this incident was a violation of criterion II of Appendix B to 10CFR50 in that a Quality Notice (QN) should have been issued in accordance with Quality Assurance Procedure QAP-012, "Corrective Action" since a condition adverse to quality (incorrect wire terminations that damaged equipment) existed.
(1) Reason For The Violation Prior to April 20, 1988, terminations were made and verified by QA Inspection to the Hydrogen Analyzer Sequencer Module. On April 20, 1988, during the performance of functional testing, damage to a NS90035D

Attachment to W3P88-1270 Page 4 of 7 transistor on a different module occurred. Upon troubleshooting, an I&C technician found wires on the Hydrogen Analyzer Sequencer Module to be incorrectly terminated.      Subsequently, on April 21, 1988, the following sequence of events took place: the work instructions were revised to correctly terminate the Sequencer Module, the work was completed per the revised work instructions and Quality Assurance verified the rework and reterminations.
On April 22, 1988, the QA inspector learned from a cognizant member of the Nuclear Operations Engineering Department that a design construction package change (DCPC) was going to be issued to address the wiring error. Based on the premise that the work instruction was revised, the errors w;*e +.orrected, a DCPC was to be issued and the overall concerns were documented in Inspection / Observation Report 88-012, which was dated April 21, 1988 but signed off by the inspec-tor on April 22, 1988, the inspector believed that no further actions were warranted. Consequently, a QN was not issued by Quality Assurance.
(2) Corrective Actions That Have Been Taken Two QNs were issued on June 17, 1988 to document the errors made during the implementation of SM 983. QN QA-88-075 was issued to Operations QA for the inspection error and QN QA-88-080 was issued to Nuclear Operations Engineering and Construction for the incorrect wiring of the hydrogen analyzers. Corrective action taken by QA has resulted in an emphasis by the Quality Inspection organization on attention to detail involving inspections.
A training session on attention to details was presented to inspec-tors on August 8, 1988.      Inspectors were cautioned as to the importance of recognizing, reviewing and understanding the inspection requirements imposed on the work document. Inspectors were also reminded to complete all the necessary . steps when performing an inspection. In addition, the use of inspection obt,ervation reports has been discontinued as a means of problem identification.
(3) Corrective Actions To Be Taken Quality Assurance personnel will undergo Lessons Learned Training.
Emphasis will be placed on the importance of paying attention to detail and utilizing the corrective action systems that are currently in place.
(4) Date When Full Compliance Will Be Achieved Lessons Learned Training will be completed by September 30, 1988.
NS90035D

Attachment to W3P88-1270 Page 5 of 7 C. VIOLATION 8813-03 Failure To Identify And Correct Deficiencies Criterion XVI of Appendix B to 10 CFR Part 50 states, in part, that measures shall be established to assure that conditions adverse to quality, such as deficiencies, are promptly identified and corrected, and that the causes be determined and corrective action taken to preclude repetition.
Contrary to the above, N3 inspectors identified deficiencies in safety system operating procedures and/or component identification labeling during ten inspections performed from February 1,1986, through May 31, 1988. Again, on June 7, 1988, the NRC inspector identified procedural and component identification labeling deficiencies with the hydrogen analyzer system. Licensee management has failed to establish adequate measures to independently identify, correct, and preclude repeated deficiencies with safety system procedures and component identification labeling.
This is a Severity Level IV violation.
RESP 3NSE LP&L 4.eknowledges that this incident was a violation of Criterion XVI of 10CFR Part 50, Appendix B in that adequate corrective actions have not been taken to preclude repeated deficiencies with safety system procedures and component identification labeling.
(1) Reason For The Violation Plant Administrative Procedure OP-100-004, "UNID/EQ Tagging of Plant Components", delineates the method for replacement of Unique Identification (UNID)/ Environmentally Qualified (EQ) equipment tags and also provides the administrative requirements for installation of new UNID/EQ tags. UNID tags which are hung as part of a design change are the responsibility of the decartment or group that implements the changc. Since there are no requirements to verify that tags are hung correctly or to use controlled drawings for ensuring proper placement of tags, inconsistencies in the hanging of UNID tags have resulted.
(NOTE: The failure to implement the above requirements has resulted in the incorrect hanging of various tags on the Hydrogen Analyzer as was stipulated in this inspection report.)
NS90035D

Attachment to W3P88-1270 Page 6 of 7-Additionally, for components which are identified as not having UNID numbers, the method in place for assigning a UNID to a compo-nent, ensuring the UNID tag is hung properly and notifying .he cognizant work groups of this type of situation is not sufficiently integrated to ensure the elimination of the tfpe of problem described in the violation. The current approach for addressing these items, which involves the use of several procedures by several different groups, has proven to be unreliable. This condition coupled with the lack of a formal program to identify, correct and preclude deficien-cies with safety system precedures and cor ponent identification labeling is the basis for the violation.
(2) Corrective Actions That Have Been Taken In early 1988, the responsibility for trending was transferred from the QA department to the Event Analysis, Reporting and Response (EAR &R) organization, which reports directly to the Plant Manager.
                           !n May,1988, using the QA Trending Program as a baseline, the EAR &R organization established the Nuclear Operations Trending Program.
This program, which broadens the scope of that which was previously trended, provides a method for co11ceting, correlating and analyzing corrective action reports in efforts to identify potentially signifi-cant trends. The Program is utilized for the review and analysis of Licensee Event Reports (LERs), NRC Reports, Quality. Notices, Noncon-forming Condition Identifications, Discrepancy Notices and other reports which identify incidents or occurrences to determine apparent and/or root cause.
Plant Adninistrative Procedure UNT-6-014, "Root Cause Determination and Trending", was approved in August, 1988. The specific purposes of this procedure are to establish the requirements for the evalu-ation and investigation of an event or condition for root cause determination and to provide a method for the categorization of root causes and their trending criteria. An adverse trend will be identi-fled for recurring deficiencies.              By the use of an Adverse Trend Report, an adverse trend, which will include a summary of the defi-ciency, root causes and any recommendations, will be submitted to the appropriate Department Head, Group Head and Assistatit Plant Manager.
The Department Head, with approval by the Assistant Plant Manager, will be responsible for determining the necessary corrective actions.
After completica of the corrective actions, the item will be trans-mitted to EAR &R for closure.             Implementation of this procedure will provide a significant enhancement to the existing trending program.
i NS90035D

Attachment to W3P88-1270 Page 7 of 7 (3) Corrective Actions To Be Taken OP-100-004 is being revised to specifically address the repeated tagging concerns regarding improper installation of UNID tags.
To alleviate inconsistencies that currently exist on two forms, the forms will be consolidated into one. This form, the UNID Tag Replacement Form, will be used to request, hang and verify proper placement of UNID tags. This procedure will also be revised to require an individual, when hanging or verifying a UNID tag, to refer to the primary source document for ensuring that the tag is correctly placed. A procedural requirement will be implemented to ensure that labeling and/or tagging deficiencies found during lineups will be appropriately documented so that the necessary corrective actions will be performed. To ensure that separate procedures are not utilized by various departments, a Plant procedure will be developed to cover all aspects of UNID tagging.
Additionally, to ensure completeness of lineups in safety systems, the existing Procedure Review Checklist in Administrative Procedure OP-100-013, "Writer's Guide For Operating Procedures", will be revised to require that valve / breaker lineups be verified with appropriate documentation.
Implementation of these actions coupled with the performance of ongoing detailed system walkdowns in accordance with Administrative Procedure OP-10-001, "Duties and Responsibilities of Operators on Duty", will provide assurance that the procedures for safety related systems reflect the actual plant configuration to the maximum extent possible.
The above actions will address the present violation. However, to provide additional assurance tbst repeated deficiencies with safety system procedures and component identification labeling are mini-mized, Management has set an objective, which is scheduled for completion by December 31, 1989, to have applicable system engineers perform walkdowns of the accessible portions of safety systems using design documentation.
(4) Date When Full Compliance Will Be Achieved Procedures OP-100-004 and OP-100-013 will be revised by September 30, 1988.
Development of the new procedure for UNID tagging is scheduled for completion by December 31, 1988.
NS90035D
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