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{{#Wiki_filter:SOUTHERN CALIFORNIA EDISONDouglas R.BauderSiteVice President&Station ManagerSanOnofre Nuclear Generating Station An EDISON INTERNATIONAL CompanyAugust30, 2010 u.s.Nuclear Regulatory Commission Attn: DocumentControlDesk Washington,DC20555-0001
{{#Wiki_filter:SOUTHERN CALIFORNIA                                                   Douglas R. Bauder EDISON                                                                Site Vice President & Station Manager San Onofre Nuclear Generating Station An EDISON INTERNATIONAL Company 10 CFR 2.201 August 30, 2010 u.s. Nuclear Regulatory Commission Attn: Document Control Desk Washington, DC 20555-0001


==Subject:==
==Subject:==
DocketNos.50-361,50-362ReplytoNoticeofViolationEA-10-12510CFR2.201
Docket Nos. 50-361, 50-362 Reply to Notice of Violation EA-10-125


==Reference:==
==Reference:==
Letter,Mr.MichaelC.Hay(NRC)toMr.Ross T.Ridenoure(SCE),datedJuly30,2010
Letter, Mr. Michael C. Hay (NRC) to Mr. Ross T. Ridenoure (SCE), dated July 30, 2010


==DearSirorMadam:==
==Dear Sir or Madam:==


The reference letter transmittedNRCInspectionReportNo.
The reference letter transmitted NRC Inspection Report No. 05000361/2010006 and 05000362/2010006 to Southern California Edison Company (SCE). The inspection report provided the results of the NRC Problem Identification and Resolution Inspection at San Onofre Nuclear Generatirig Station (SONGS), Units 2 and 3 that was completed on June 17, 2010. The referenced report also transmitted a Notice of Violation (EA          125). The Enclosure to this letter provides the required response to the Notice of Violation. The new commitments that SCE has made in this letter are listed at the end of Enclosure 1.
05000361/2010006 and 05000362/2010006 to SouthernCaliforniaEdison Company(SCE).The inspectionreportprovidedtheresultsoftheNRCProblem IdentificationandResolutionInspectionatSanOnofre Nuclear GeneratirigStation(SONGS),Units2and3thatwascompletedonJune17,2010.Thereferencedreportalso transmittedaNoticeof Violation125).TheEnclosuretothisletterprovidestherequiredresponsetotheNoticeof Violation.Thenew commitmentsthatSCEhasmadeinthisletterarelistedattheend of Enclosure 1.SCEremainscommittedto addressingandresolvingtheissueofproblem identificationandresolutionatSONGS.Ifyouhaveany questionsorrequire further information, please contactmeorMr.RichardSt.Ongeat(949)368-6240.
SCE remains committed to addressing and resolving the issue of problem identification and resolution at SONGS. If you have any questions or require further information, please contact me or Mr. Richard St. Onge at (949) 368-6240.
Sincerely,
Sincerely,


==Enclosure:==
==Enclosure:==
Asstatedcc:E.E.Collins,Regional Administrator,NRCRegionIVG.G.Warnick,NRC Senior ResidentInspector,SanOnofreUnits2and3P.O.Box128SanClemente,CA 92672 (949)368-9275 PAX 89275.Fax:(949)368-9881 Doug.Bauder@sce.com Enclosure Page 1 of 5 ENCLOSURE Reply to Notice of Violation EA-10-125 Docket Nos. 50-361, 50-362 VIOLATION EA-10-125 The NRC Notice of Violation (NOV) states:
As stated cc:       E. E. Collins, Regional Administrator, NRC Region IV G. G. Warnick, NRC Senior Resident Inspector, San Onofre Units 2 and 3 P.O. Box 128 San Clemente, CA 92672 (949) 368-9275 PAX 89275 .
Technical Specification 5.
Fax: (949) 368-9881 Doug.Bauder@sce.com
5.1.1a requires, in part, that written procedures be established, implemented, and maintained covering the applicable procedures recommended in Regulatory Guide 1.33, Revi sion 2, Appendix A, February 1978.
Regulatory Guide 1.33, "Quality Assurance Program Requirements (Operations)," Appendix A, recommends procedures for the operation of certain plant systems.


Contrary to the above, prior to Apr il 23, 2010, Southern California Edison Company failed to maintain written pr ocedures as recommended in Regulatory Guide 1.33, Revision 2, Appendix A, February 1978. Specifically, the licensee failed to ensure that following modifications made to the instrument air system the affected system procedures [were] either suspended, put on administrative hold, or otherwise restricted from use until the required changes were implemented. As a result, several procedures with known technical deficiencies were inappropriately available for use following plant modifications.  
Enclosure Page 1 of 5 ENCLOSURE Reply to Notice of Violation EA-10-125 Docket Nos. 50-361, 50-362 VIOLATION EA-10-125 The NRC Notice of Violation (NOV) states:
Technical Specification 5.5.1.1a requires, in part, that written procedures be established, implemented, and maintained covering the applicable procedures recommended in Regulatory Guide 1.33, Revision 2, Appendix A, February 1978.
Regulatory Guide 1.33, Quality Assurance Program Requirements (Operations), Appendix A, recommends procedures for the operation of certain plant systems.
Contrary to the above, prior to April 23, 2010, Southern California Edison Company failed to maintain written procedures as recommended in Regulatory Guide 1.33, Revision 2, Appendix A, February 1978. Specifically, the licensee failed to ensure that following modifications made to the instrument air system the affected system procedures [were] either suspended, put on administrative hold, or otherwise restricted from use until the required changes were implemented. As a result, several procedures with known technical deficiencies were inappropriately available for use following plant modifications.
This violation is associated with a Green Significance Determination Finding (very low safety significance).
SCE RESPONSE BACKGROUND On April 23, 2010, the Nuclear Regulatory Commission (NRC) Problem Identification and Resolution (PI&R) inspection team identified eight plant procedures that inappropriately remained available for use following modifications to the instrument air system. The NRC had identified similar Non-Cited Violations (NCVs) in prior inspections (NRC Inspection Reports 05000361; 05000362/2009003-02 and 05000361; 05000362/2009009-02), involving the failure to identify and correct similar procedure deficiencies. Because compliance was not restored following these prior violations, the NRC issued EA-10-125.
As discussed with the NRC during the PI&R inspection exit meeting on June 17, 2010, Southern California Edison (SCE) does not contest the violation or the NRCs determination of its significance.


This violation is associated with a Green Si gnificance Determination Finding (very low safety significance).
Enclosure Page 2 of 5 I. REASON FOR THE VIOLATION SCE performed a Root Cause Evaluation (RCE) to determine why the eight procedures remained available for use after modifications to the instrument air system. [Ref. 1]
SCE RESPONSE BACKGROUND On April 23, 2010, the Nuclear Regulatory Commission (NRC) Probl em Identification and Resolution (PI&R) inspection team i dentified eight plant procedures that inappropriately remained available for use follo wing modifications to the instrument air system. The NRC had identifi ed similar Non-Cited Violat ions (NCVs) in prior inspections (NRC Inspection Reports 05000361; 05000362/2009003-02 and 05000361;  
The RCE determined that the root cause of this violation was that plant procedure SO123-XV-51, Site Program Impact Assessment and Resolution, did not clearly define the requirements to maintain accurate procedures. Consequently, personnel were making decisions about return to service without procedures being accurately revised and maintained. Without clearly defined criteria in SO123-XV-51, plant personnel improperly allowed inaccurate procedures to remain in use.
SCE also identified contributing causes for the violation [Ref. 1, p. 13]:
: 1. Some SONGS organizations did not perform the Site Program Impact (SPI) assessment of modifications in a timely manner. The SPI assessment is intended to evaluate site programs, including procedures, instructions, and training, that might be affected as a result of changes to plant design configuration or work process.
: 2. The Engineering Change Package (ECP) procedures did not require the engineer responsible for installing the design change to notify the SPI owner of a field change, thereby resulting in a failure to determine if procedures were affected.
: 3. In the SAP business process software system used at SONGS, the Reqd for Return to Service assignment block to indicate whether revisions to procedures are required defaulted as unchecked, thereby increasing the chances of human error in the reporting of required changes.
: 4. SONGS organization personnel did not understand the process and reason to suspend procedures that had been rendered inaccurate through plant modifications.
II. CORRECTIVE STEPS THAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED SCE took the following interim corrective actions:
* The Site Procedures group reviewed the list of all 260 pending modification-related procedure change requests, and if the procedure was not changed to reflect an installed plant modification, then the procedure was suspended or revised. This included the eight (8) procedures that the NRC had identified as being rendered inaccurate by modifications to the instrument air system, and eleven (11) additional procedures. This action was completed on May 7, 2010.
[Ref. 2, Task 0010; Ref. 1, Attachment 7]
* The Site Procedures group reviewed outstanding SPI assignments not completed for which modifications to plant equipment had already been installed.


05000362/2009009-02), involving t he failure to identify and correct similar procedure deficiencies. Because compliance was not restored following these prior violations, the NRC issued EA-10-125.  
Enclosure Page 3 of 5 If a technically inaccurate procedure was identified, then the procedure was suspended or revised. This action was completed on May 21, 2010. [Ref. 2, Task 0011]
* The Manager, Site Procedures issued immediately effective direction to all procedure authors not to approve the turnover of any modifications to any plant equipment where the modification has caused an existing procedure to be inaccurate in any fashion. If it is not possible to change procedures prior to turnover and suspension of the procedure is appropriate, then the procedure may be suspended and turnover can proceed. This action was completed on May 7, 2010. [Ref. 2, Task 0009; Ref. 1, Attachment 6]
* On May 20, 2010, the Supervisor, Maintenance and Construction Services (M&CS) Engineering Support directed responsible work organization engineers not to process any turnovers on modifications where procedure SPIs have not been evaluated. The direction stated that engineering change package turnovers shall not be processed if the modification results in any procedure being technically inaccurate in any fashion. [Ref. 2, Task 0012 & Attachment to Task 0012] The review of this direction by the appropriate personnel is being tracked through the SONGS corrective action program. [Ref. 3]
SCE also took the following corrective actions to prevent recurrence. First:
Procedure SO123-XV-51 has two objectives: (1) to provide a method for identifying and assessing impact to site programs, procedures or instructions as a result of changes in plant design, configuration or work process; and (2) to provide a process for tracking and managing Site Program Impact (SPI) review through the use of SAP. [Ref. 4] To satisfy these two objectives and the requirement of Technical Specification 5.5.1.1a to maintain accurate procedures, the following changes were made to SO123-XV-51 to clarify the SPI scoping responsibilities or organizations that implement changes to plant design:
* Provide specific criteria that if a procedure is identified as being made inaccurate to any extent by the modification to plant equipment, then it must be revised or suspended before the system is returned to service.
* Describe the process in SAP for tracking procedures which will be modified or suspended as a result of SPI. This change will explain how the individual responsible for the ECP turnover will identify procedures which must be modified before a system is returned to service and those which must be suspended.
* Require the individual responsible for the SPI to identify those procedures which must be modified or suspended before system or partial system return to service.
These actions to prevent recurrence were completed on August 20, 2010. The revision to SO123-XV-51 also included revisions to correct contributing cause number 1 in Section I, above. [Ref. 4]


As discussed with the NRC during the PI&R inspection exit meeting on June 17, 2010, Southern California Edison (SCE) does not contest the viol ation or the NRC's determination of its significance.
Enclosure Page 4 of 5 Second, to address contributing cause number 3 identified in Section I, above, SCE also modified the SAP assignment block to default to check the block titled Reqd for Return to Service for new SPI assignments. This action was taken on May 14, 2010.
 
Enclosure Page 2 of 5 I. REASON FOR THE VIOLATION SCE performed a Root Cause Evaluation (RCE) to determine why the eight procedures remained available for use after modifications to the instrum ent air system.
[Ref. 1]
The RCE determined that the root cause of this violation was t hat plant procedure SO123-XV-51, Site Program Impact Assessment and Resolution, did not clearly define the requirements to maintain accurate procedures. Consequently, personnel were making decisions about return to service without procedures being accurately revised and maintained. Without clearly defined criteria in SO123-XV-51, plant personnel improperly allowed inaccurate pr ocedures to remain in use. SCE also identified contributing causes for the violation [R ef. 1, p. 13]:  1. Some SONGS organizations did not per form the Site Program Impact (SPI) assessment of modifications in a timely manner. The SPI assessment is intended to evaluate site programs, in cluding procedures, instructions, and training, that might be affected as a result of changes to plant design configuration or work process. 2. The Engineering Change Package (E CP) procedures did not require the engineer responsible for installing the des ign change to notify the SPI owner of a field change, thereby resulting in a fa ilure to determine if procedures were affected. 3. In the "SAP" business process software system used at SONGS, the "Req'd for Return to Service" assignment block to indicate whether revisions to procedures are required defaulted as unchecked, ther eby increasing the chances of human error in the reporting of required changes. 4. SONGS organization personnel did not understand t he process and reason to suspend procedures that had been rendered inaccurate through plant
 
modifications. II. CORRECTIVE STEPS THAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED SCE took the following interim corrective actions:  The Site Procedures group reviewed the list of all 260 pending modification-related procedure change requests, and if the procedure was not changed to reflect an installed plant modification, then the procedure was suspended or revised. This included the eight (8) procedures that the NRC had identified as being rendered inaccurate by modifications to the instrument air system, and eleven (11) additional procedures. This action was completed on May 7, 2010.
[Ref. 2, Task 0010; Ref. 1, Attachment 7]  The Site Procedures group reviewed outstanding SPI assignments not completed for which modifications to plant equipment had already been installed.
Enclosure Page 3 of 5 If a technically inaccurate procedure was identified, then the procedure was suspended or revised. This action was completed on May 21, 2010.  [Ref. 2, Task 0011]  The Manager, Site Procedures issued i mmediately effective direction to all procedure authors not to approve the turnover of any modifications to any plant equipment where the modification has caused an existing procedure to be inaccurate in any fashion. If it is not possible to change procedures prior to turnover and suspension of the procedur e is appropriate, t hen the procedure may be suspended and turnover can proceed. This action was completed on May 7, 2010.  [Ref. 2, Task 0009; Re
: f. 1, Attachment 6]  On May 20, 2010, the Supervisor, Ma intenance and Construction Services (M&CS) Engineering Support directed res ponsible work organization engineers not to process any turnovers on modi fications where procedure SPIs have not been evaluated. The direction stated t hat engineering ch ange package turnovers shall not be processed if the modification resu lts in any procedure being technically inaccurate in any fashion.
[Ref. 2, Task 0012 & Attachment to Task 0012]  The review of this direction by the appropriate personnel is being tracked through the SONGS corrective action program.  [Ref. 3] SCE also took the following corrective actions to prevent recurrence. First:
Procedure SO123-XV-51 has two objec tives: (1) to provide a method for identifying and assessing impact to site programs, procedures or instructions as a result of changes in plant design, configuration or work process; and (2) to provide a process for tracking and managing Site Program Impact (SPI) review through the use of SAP.  [Ref. 4]  To satisfy these two objectives and the requirement of Technical Specification 5.5.1.1a to maintain accurate procedures, the following changes were made to SO123-XV-51 to clarify the SPI scoping responsibilities or organizations that implement changes to plant design:  Provide specific criteria that if a procedure is identified as being made inaccurate to any extent by the modifi cation to plant equipment, then it must be revised or suspended before the system is returned to service. Describe the process in SAP for tracking procedures which will be modified or suspended as a result of SPI. This change will explain how the individual responsible for the ECP turnover will identify procedures which must be modified before a system is returned to service and those which must be suspended. Require the individual responsible for the SPI to identify those procedures which must be modified or suspended before system or partial system return to service.
These actions to prevent recurrence were co mpleted on August 20, 2010. The revision to SO123-XV-51 also included revisions to correct contributing cause number 1 in Section I, above.  [Ref. 4]
Enclosure Page 4 of 5 Second, to address contributing cause numbe r 3 identified in Section I, above, SCE also modified the SAP assignment block to de fault to check the bl ock titled "Req'd for Return to Service" for new SPI assignments.
This action was taken on May 14, 2010.
[Ref. 1, Attachments 2 & 8]
[Ref. 1, Attachments 2 & 8]
Third, to address contributing cause number 4, i.e, the organizati onal understanding of the procedural change process, SCE identified t he relevant site population and issued required reading as a one-time action. Co mpletion of the required reading is being tracked through the SONGS correcti ve action program. [Ref. 5] III. CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS In addition to the actions already taken to prevent recurrence and identified in Section II, above, SCE will also take action to addr ess the remaining contributing cause (contributing cause number 2). Specifica lly, SCE will modify the ECP procedure (SO123-XXIV-10.1, Attachment 12) to provide the engineer responsible for installing the design change with guidance as to when SPI ow ner must be notified of a field change.
Third, to address contributing cause number 4, i.e, the organizational understanding of the procedural change process, SCE identified the relevant site population and issued required reading as a one-time action. Completion of the required reading is being tracked through the SONGS corrective action program. [Ref. 5]
[Ref. 1, Attachment 2] This action wil l be completed by September 30, 2010. IV. DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED SCE returned to full compliance on May 7, 2010 by suspending the use of the eight procedures that were rendered inaccurate due to changes to the instrument air system.
III. CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS In addition to the actions already taken to prevent recurrence and identified in Section II, above, SCE will also take action to address the remaining contributing cause (contributing cause number 2). Specifically, SCE will modify the ECP procedure (SO123-XXIV-10.1, Attachment 12) to provide the engineer responsible for installing the design change with guidance as to when SPI owner must be notified of a field change.
As noted above, SCE's extent of condition review identified eleven additional procedures that should have been suspended or changed before the return of relevant equipment to service following plant modifications. Each of these procedures were appropriately changed or placed on hold, on or before May 7, 2010. V. REFERENCES 1. Root Cause Evaluation, Failure to Properly Control Changes to Procedures, NN # 200888919 (June 9, 2010). 2. SONGS Nuclear Noti fication, NN 200888919. 3. SONGS Nuclear Noti fication, NN 201078691. 4. SONGS Procedure SO 123-XV-51, Rev. 14. 5. SONGS Nuclear Noti fication, NN 201078968. VI. LIST OF REGULATORY COMMITMENTS The following table identifies those actions committed to by SCE in this document. Any other statements in this s ubmittal are provided for in formation purposes and are not considered to be regul atory commitments.
[Ref. 1, Attachment 2] This action will be completed by September 30, 2010.
Enclosure Page 5 of 5 Regulatory Commitment Due Date On May 20, 2010, the Super visor, Maintenance and Construction Services (M&CS) Engineering Support directed responsible work organization engineers not to process any turnovers on modifications where procedure
IV. DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED SCE returned to full compliance on May 7, 2010 by suspending the use of the eight procedures that were rendered inaccurate due to changes to the instrument air system.
 
As noted above, SCEs extent of condition review identified eleven additional procedures that should have been suspended or changed before the return of relevant equipment to service following plant modifications. Each of these procedures were appropriately changed or placed on hold, on or before May 7, 2010.
SPIs have not been evaluated.
V.     REFERENCES
The direction stated that engineering change package tu rnovers shall not be processed if the modification results in any procedure being technically inaccurate in any fa shion. The review of this direction by the appropriate personnel is being tracked through the SONGS corrective action program.  [Success criterion is 95% attainment.]
: 1. Root Cause Evaluation, Failure to Properly Control Changes to Procedures, NN # 200888919 (June 9, 2010).
September 30, 2010
: 2. SONGS Nuclear Notification, NN 200888919.
[T]o address contributing cause number 4, i.e, the organizational understanding of the procedural change
: 3. SONGS Nuclear Notification, NN 201078691.
 
: 4. SONGS Procedure SO123-XV-51, Rev. 14.
process, SCE identified the relevant site population and issued required reading as a one-time action. Completion
: 5. SONGS Nuclear Notification, NN 201078968.
 
VI. LIST OF REGULATORY COMMITMENTS The following table identifies those actions committed to by SCE in this document. Any other statements in this submittal are provided for information purposes and are not considered to be regulatory commitments.
of the required reading is being tracked through the SONGS corrective action program.  [Success criterion is 95% attainment.]
September 30, 2010 Modify the ECP procedure (S O123-XXIV-10.1, Attachment 12) to provide the engineer responsible for installing the design change with guidance as to when SPI owner must


be notified of a field change.
Enclosure Page 5 of 5 Regulatory Commitment                          Due Date On May 20, 2010, the Supervisor, Maintenance and            September 30, 2010 Construction Services (M&CS) Engineering Support directed responsible work organization engineers not to process any turnovers on modifications where procedure SPIs have not been evaluated. The direction stated that engineering change package turnovers shall not be processed if the modification results in any procedure being technically inaccurate in any fashion. The review of this direction by the appropriate personnel is being tracked through the SONGS corrective action program. [Success criterion is 95% attainment.]
September 30, 2010}}
[T]o address contributing cause number 4, i.e, the          September 30, 2010 organizational understanding of the procedural change process, SCE identified the relevant site population and issued required reading as a one-time action. Completion of the required reading is being tracked through the SONGS corrective action program. [Success criterion is 95% attainment.]
Modify the ECP procedure (SO123-XXIV-10.1, Attachment        September 30, 2010
: 12) to provide the engineer responsible for installing the design change with guidance as to when SPI owner must be notified of a field change.}}

Latest revision as of 13:58, 13 November 2019

Reply to Notice of Violation EA-10-125
ML102430113
Person / Time
Site: San Onofre  Southern California Edison icon.png
Issue date: 08/30/2010
From: Bauder D
Southern California Edison Co
To:
Document Control Desk, Office of Nuclear Reactor Regulation
References
EA-10-125
Download: ML102430113 (6)


Text

SOUTHERN CALIFORNIA Douglas R. Bauder EDISON Site Vice President & Station Manager San Onofre Nuclear Generating Station An EDISON INTERNATIONAL Company 10 CFR 2.201 August 30, 2010 u.s. Nuclear Regulatory Commission Attn: Document Control Desk Washington, DC 20555-0001

Subject:

Docket Nos. 50-361, 50-362 Reply to Notice of Violation EA-10-125

Reference:

Letter, Mr. Michael C. Hay (NRC) to Mr. Ross T. Ridenoure (SCE), dated July 30, 2010

Dear Sir or Madam:

The reference letter transmitted NRC Inspection Report No. 05000361/2010006 and 05000362/2010006 to Southern California Edison Company (SCE). The inspection report provided the results of the NRC Problem Identification and Resolution Inspection at San Onofre Nuclear Generatirig Station (SONGS), Units 2 and 3 that was completed on June 17, 2010. The referenced report also transmitted a Notice of Violation (EA 125). The Enclosure to this letter provides the required response to the Notice of Violation. The new commitments that SCE has made in this letter are listed at the end of Enclosure 1.

SCE remains committed to addressing and resolving the issue of problem identification and resolution at SONGS. If you have any questions or require further information, please contact me or Mr. Richard St. Onge at (949) 368-6240.

Sincerely,

Enclosure:

As stated cc: E. E. Collins, Regional Administrator, NRC Region IV G. G. Warnick, NRC Senior Resident Inspector, San Onofre Units 2 and 3 P.O. Box 128 San Clemente, CA 92672 (949) 368-9275 PAX 89275 .

Fax: (949) 368-9881 Doug.Bauder@sce.com

Enclosure Page 1 of 5 ENCLOSURE Reply to Notice of Violation EA-10-125 Docket Nos. 50-361, 50-362 VIOLATION EA-10-125 The NRC Notice of Violation (NOV) states:

Technical Specification 5.5.1.1a requires, in part, that written procedures be established, implemented, and maintained covering the applicable procedures recommended in Regulatory Guide 1.33, Revision 2, Appendix A, February 1978.

Regulatory Guide 1.33, Quality Assurance Program Requirements (Operations), Appendix A, recommends procedures for the operation of certain plant systems.

Contrary to the above, prior to April 23, 2010, Southern California Edison Company failed to maintain written procedures as recommended in Regulatory Guide 1.33, Revision 2, Appendix A, February 1978. Specifically, the licensee failed to ensure that following modifications made to the instrument air system the affected system procedures [were] either suspended, put on administrative hold, or otherwise restricted from use until the required changes were implemented. As a result, several procedures with known technical deficiencies were inappropriately available for use following plant modifications.

This violation is associated with a Green Significance Determination Finding (very low safety significance).

SCE RESPONSE BACKGROUND On April 23, 2010, the Nuclear Regulatory Commission (NRC) Problem Identification and Resolution (PI&R) inspection team identified eight plant procedures that inappropriately remained available for use following modifications to the instrument air system. The NRC had identified similar Non-Cited Violations (NCVs) in prior inspections (NRC Inspection Reports 05000361;05000362/2009003-02 and 05000361;05000362/2009009-02), involving the failure to identify and correct similar procedure deficiencies. Because compliance was not restored following these prior violations, the NRC issued EA-10-125.

As discussed with the NRC during the PI&R inspection exit meeting on June 17, 2010, Southern California Edison (SCE) does not contest the violation or the NRCs determination of its significance.

Enclosure Page 2 of 5 I. REASON FOR THE VIOLATION SCE performed a Root Cause Evaluation (RCE) to determine why the eight procedures remained available for use after modifications to the instrument air system. [Ref. 1]

The RCE determined that the root cause of this violation was that plant procedure SO123-XV-51, Site Program Impact Assessment and Resolution, did not clearly define the requirements to maintain accurate procedures. Consequently, personnel were making decisions about return to service without procedures being accurately revised and maintained. Without clearly defined criteria in SO123-XV-51, plant personnel improperly allowed inaccurate procedures to remain in use.

SCE also identified contributing causes for the violation [Ref. 1, p. 13]:

1. Some SONGS organizations did not perform the Site Program Impact (SPI) assessment of modifications in a timely manner. The SPI assessment is intended to evaluate site programs, including procedures, instructions, and training, that might be affected as a result of changes to plant design configuration or work process.
2. The Engineering Change Package (ECP) procedures did not require the engineer responsible for installing the design change to notify the SPI owner of a field change, thereby resulting in a failure to determine if procedures were affected.
3. In the SAP business process software system used at SONGS, the Reqd for Return to Service assignment block to indicate whether revisions to procedures are required defaulted as unchecked, thereby increasing the chances of human error in the reporting of required changes.
4. SONGS organization personnel did not understand the process and reason to suspend procedures that had been rendered inaccurate through plant modifications.

II. CORRECTIVE STEPS THAT HAVE BEEN TAKEN AND THE RESULTS ACHIEVED SCE took the following interim corrective actions:

  • The Site Procedures group reviewed the list of all 260 pending modification-related procedure change requests, and if the procedure was not changed to reflect an installed plant modification, then the procedure was suspended or revised. This included the eight (8) procedures that the NRC had identified as being rendered inaccurate by modifications to the instrument air system, and eleven (11) additional procedures. This action was completed on May 7, 2010.

[Ref. 2, Task 0010; Ref. 1, Attachment 7]

  • The Site Procedures group reviewed outstanding SPI assignments not completed for which modifications to plant equipment had already been installed.

Enclosure Page 3 of 5 If a technically inaccurate procedure was identified, then the procedure was suspended or revised. This action was completed on May 21, 2010. [Ref. 2, Task 0011]

  • The Manager, Site Procedures issued immediately effective direction to all procedure authors not to approve the turnover of any modifications to any plant equipment where the modification has caused an existing procedure to be inaccurate in any fashion. If it is not possible to change procedures prior to turnover and suspension of the procedure is appropriate, then the procedure may be suspended and turnover can proceed. This action was completed on May 7, 2010. [Ref. 2, Task 0009; Ref. 1, Attachment 6]
  • On May 20, 2010, the Supervisor, Maintenance and Construction Services (M&CS) Engineering Support directed responsible work organization engineers not to process any turnovers on modifications where procedure SPIs have not been evaluated. The direction stated that engineering change package turnovers shall not be processed if the modification results in any procedure being technically inaccurate in any fashion. [Ref. 2, Task 0012 & Attachment to Task 0012] The review of this direction by the appropriate personnel is being tracked through the SONGS corrective action program. [Ref. 3]

SCE also took the following corrective actions to prevent recurrence. First:

Procedure SO123-XV-51 has two objectives: (1) to provide a method for identifying and assessing impact to site programs, procedures or instructions as a result of changes in plant design, configuration or work process; and (2) to provide a process for tracking and managing Site Program Impact (SPI) review through the use of SAP. [Ref. 4] To satisfy these two objectives and the requirement of Technical Specification 5.5.1.1a to maintain accurate procedures, the following changes were made to SO123-XV-51 to clarify the SPI scoping responsibilities or organizations that implement changes to plant design:

  • Provide specific criteria that if a procedure is identified as being made inaccurate to any extent by the modification to plant equipment, then it must be revised or suspended before the system is returned to service.
  • Describe the process in SAP for tracking procedures which will be modified or suspended as a result of SPI. This change will explain how the individual responsible for the ECP turnover will identify procedures which must be modified before a system is returned to service and those which must be suspended.
  • Require the individual responsible for the SPI to identify those procedures which must be modified or suspended before system or partial system return to service.

These actions to prevent recurrence were completed on August 20, 2010. The revision to SO123-XV-51 also included revisions to correct contributing cause number 1 in Section I, above. [Ref. 4]

Enclosure Page 4 of 5 Second, to address contributing cause number 3 identified in Section I, above, SCE also modified the SAP assignment block to default to check the block titled Reqd for Return to Service for new SPI assignments. This action was taken on May 14, 2010.

[Ref. 1, Attachments 2 & 8]

Third, to address contributing cause number 4, i.e, the organizational understanding of the procedural change process, SCE identified the relevant site population and issued required reading as a one-time action. Completion of the required reading is being tracked through the SONGS corrective action program. [Ref. 5]

III. CORRECTIVE STEPS THAT WILL BE TAKEN TO AVOID FURTHER VIOLATIONS In addition to the actions already taken to prevent recurrence and identified in Section II, above, SCE will also take action to address the remaining contributing cause (contributing cause number 2). Specifically, SCE will modify the ECP procedure (SO123-XXIV-10.1, Attachment 12) to provide the engineer responsible for installing the design change with guidance as to when SPI owner must be notified of a field change.

[Ref. 1, Attachment 2] This action will be completed by September 30, 2010.

IV. DATE WHEN FULL COMPLIANCE WILL BE ACHIEVED SCE returned to full compliance on May 7, 2010 by suspending the use of the eight procedures that were rendered inaccurate due to changes to the instrument air system.

As noted above, SCEs extent of condition review identified eleven additional procedures that should have been suspended or changed before the return of relevant equipment to service following plant modifications. Each of these procedures were appropriately changed or placed on hold, on or before May 7, 2010.

V. REFERENCES

1. Root Cause Evaluation, Failure to Properly Control Changes to Procedures, NN # 200888919 (June 9, 2010).
2. SONGS Nuclear Notification, NN 200888919.
3. SONGS Nuclear Notification, NN 201078691.
4. SONGS Procedure SO123-XV-51, Rev. 14.
5. SONGS Nuclear Notification, NN 201078968.

VI. LIST OF REGULATORY COMMITMENTS The following table identifies those actions committed to by SCE in this document. Any other statements in this submittal are provided for information purposes and are not considered to be regulatory commitments.

Enclosure Page 5 of 5 Regulatory Commitment Due Date On May 20, 2010, the Supervisor, Maintenance and September 30, 2010 Construction Services (M&CS) Engineering Support directed responsible work organization engineers not to process any turnovers on modifications where procedure SPIs have not been evaluated. The direction stated that engineering change package turnovers shall not be processed if the modification results in any procedure being technically inaccurate in any fashion. The review of this direction by the appropriate personnel is being tracked through the SONGS corrective action program. [Success criterion is 95% attainment.]

[T]o address contributing cause number 4, i.e, the September 30, 2010 organizational understanding of the procedural change process, SCE identified the relevant site population and issued required reading as a one-time action. Completion of the required reading is being tracked through the SONGS corrective action program. [Success criterion is 95% attainment.]

Modify the ECP procedure (SO123-XXIV-10.1, Attachment September 30, 2010

12) to provide the engineer responsible for installing the design change with guidance as to when SPI owner must be notified of a field change.