ML18089A266

Assessment of Pse&G Operations QA Program for Salem Generating Stations,Units 1 & 2.

ML18089A266
Person / Time
Site:	Salem
Issue date:	07/27/1983
From:	MANAGEMENT ANALYSIS CO.
To:
Shared Package
ML18089A265	List: ML18089A264 ML18089A266
References
NUDOCS 8308030008
Download: ML18089A266 (32)

Text

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ASSESSMENT OF THE PUBLIC SERVICE ELECTRIC & GAS COMPANY OPERATIONS QUALITY ASSURANCE PROGRAM FOR SALEM GENERATING ST ATIONS UNITS l AND 2 Prepared For PUBLIC SERVICE ELECTRIC & GAS COMPANY 80 Park Place Newark, New Jersey 07101 r

July 27, 1983 Management Analysis Company Project Number: MAC-83-F 113 Public Service Electric & Gas Company Puchase Order Number: 885292

--8308080008830729 PDR ADOCK 05000272 P PDR

l I

I EXECUTIVE

SUMMARY

At the request of the Public Service Electric and Gas Company (PSE&G), Management Analysis Company (MAC) performed an assessment of the Operations Quality Assurance (QA) program for the Salem Nuclear Power Station. This assessment evaluated the Operations QA program against good practice and did not generate "findings" normally done in a QA audit.

The. QA Department (QAD) was in a state of transition at the time of the assessment, having reorganized on January 3, 1983. Not only were they recently reorganized internally as a department but they were also reporting to a different level of manage-ment. In addition, QAD was in the process of relocating its personnel in Newark to the site. This organizational and locational transition was an important factor in the condition of the QA program during the assessment.

The Executive Summary is presented in five sections:

• Program Definition

• Program Organization

• Program Management

• Program Implementation

• Program Measurement PROGRAM DEFINITION The Final Safety Analysis Report (FSAR) Section 17.2 was basically found satisfactory.

However, it does require revision to reflect the latest organization and responsibilities within the Nuclear Department. At the time of the next revision to the FSAR, it is suggested the Salem FSAR Section 17.2 commitments be analyzed to determine if any exceptions or clarifications should be taken to better describe the methods employed to comply with the QA requirements.

The Quality Assurance Policies and Procedures Manual does not reflect the current organization and should be updated. In addition, the current QAD procedures should be revised as appropriate to meet current practice.

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PROGRAM ORGANIZATION The organizational structure for the Nuclear Department and the reporting level of the QAO were found acceptable in meeting the requirements of *IOCFR50 Appendix B and good QA practice. The internal organizational structure of the QAD was also reviewed and determined to be acceptable in its present form. However, it is MAC's opinion that the present assignment of certain QAD responsibilities and personnel should be reexamined. For example, it is suggested that the station QA group be given greater involvement in the performance of plant-related audits. Station QA should also place greater emphasis on the performance of surveillances of activities in progress and should have responsibility for all inspections performed for the acceptance of work or material.

The present staff of the QAD generally have acceptable educational qualifications and QA/QC training. However, more experience in and knowl~dge of activities associated with plant maintenance, modification and operation would be beneficial.

There also appeared to be a reasonable number of positions allocated to QAD ('::::.' 65). A number of these positions were open at the time of this assessment and this impacted on the QAD's ability to fully implement their responsibilities. In addition, MAC felt that the allocation of manpower between the station QA group and the QA support groups should be reexamined with the thought of assigning more people to the station group.

The responsibilities and interfaces between QAD and the other Nuclear Department groups relative to the implementation of QA criteria were reviewed and found to be in need of further definition. This is true in areas such as document control, inspection, procurement control and QA records management where the major portions of the responsibility for implementation lie outside the QAD.

PROGRAM MANAGEMENT Based upon extensive interviews with QAD personnel and on MAC team member observa-tions, it was concluded that additional direction is needed from QAD management to the first level supervisors within the QAD. These first level supervisors expressed concern relative to the amount of direction and guidance provided them by supervision.

The communication of information relative to QA plans, goals, schedules, policies, activities, etc., need to be improved both vertically and horizontally.

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PROGRAM IMPLEMENTATION MAC performed an assessment of the overall adequacy of the QA program implemen-tation with special attention given to those areas addressed in the scope of this report.

The QAD, along with other departments within the Nuclear Department, was evaluated.

The documents and activities evaluated during the assessment reflected mainly the implementation of the QA program established by the previous QA organization.

The basis for the implementation assessment was regulatory requirements from the Salem FSAR Section 17.2, those commitments identified in the PSE&G Corporate Quality Assurance Policies and Procedures Manual and other implementing procedures and instructions.

The conclusion of this assessment was that the program could have been implemented more rigorously. The major issues which contribute to this condition include:

1. The organizational transition and personnel relocation have temporarily hindered the overall effectiveness in implementation of the program.

2. The procedures required to execute the QA program should be integrated throughout the Nuclear Department to establish a consistent approach.

• 3. Interfaces within QAO and between QAD and other Nuclear Department groups need improvement to enhance the resolution of problems and establish a team effort towards QA.

PROGRAM MEASUREMENT The measurement by QAO of the QA program implementation can be improved. The scope of the audit and surveillance programs should be expanded and personnel need more experience in plant operations. Improvement is needed in the timely identification and resolution of significant audit and surveillance findings. Analysis of data should be performed to identify trends earlier and effect escalation where necessary.

OVERALL QA PROGRAM ASSESSMENT During the past several years there have been a number of changes in the organizational structure and responsibility assignments within QAD and with other organizations having a significant involvement in the Salem Nuclear Power Station QA program. Updating

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policies and procedures, developing ,new practices and establishing necessary interfaces between participating organizations have lagged the dynamics of the organizational structure. As a result, action is necessary throughout the Nuclear Department to further assure compliance with regulatory commitments, to meet the goals and expectations of PSE&G and maintain the high standards expected of the nuclear power industry.

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TABLE OF CONTENTS Section EXECUTIVE

SUMMARY

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1.0 INTRODUCTION

1-1 1.1 Background ......................................... 1-1 1.2 Process and Scope .................................... 1-1 2.0 ISSUES AND RECOMMENDATIONS ............................ 2-1 2.1 Identification and Control of Materials, Parts and Components .............................. . 2-1 2.2 Quality Assurance Records 2-1 2.3 Document Control ................................... 2-2 2.4 Commitment Management 2-3 2.5 Training and Certification ............................. 2-4 2.6 Procurement Control 2-5 2.7 Corrective Action ................................... ~ 2-6 2.8 Housekeeping 2-7 2.9 Audits .............................................. 2-8 2.10 Control of Nonconformance 2-9 2.11 Calibration and Control of Measuring and Test Equipment 2-10 2.12 Receiving and Storage ................................ 2-12 2.13 Test Control ...............* ........................ . 2-14 2.14 Inspection Test and Operating Status .................... 2-14 2.15 Control of Special Processes ............................ 2-14 2.16 QAD Surveillance .................................... 2-15 2.17 Inspection 2-16 2.18 Instructions and Procedures ........................... 2-20 2.19 Contractor Activities 2-20

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'5046-3 1-1 LO INTRODUCTION I.I BACKGROUND Management Analysis Company (MAC) was employed by Public Service Electric and Gas Company (PSE&G) to perform an assessment of their operations quality assurance (QA) program for the Salem Nuclear Power Station.

At the time of the assessment both Salem units were shut down. Unit 2 was in an outage. Unit l was down because of the trip breaker problem. These circum-stances obviously affected plant conditions at the time of the assessment.

The Quality Assurance Department (QAD) was in an organizational transition due to recent restructuring of the QA function in PSE&G. In addition, the Nuclear Department was in the process of moving from Newark to the site. These factors also affected the overall situation at Salem during the assessment which was based upon conditions existing in April and May 1983.

L2 PROCESS AND SCOPE The processes utilized in the performance of the assessment included a combina-tion of investigative and diagnostic approaches. These processes included a review of applicable program documents, evaluation of program implementation and a series of interviews with key QA and interfacing organization personnel.

The assessment addressed the following areas:

l. Identification and Control of Materials, Parts and Components

2. QA Records Management

3. Document Control

4. Commitment Management

5. Training and Certification of QAD Personnel

6. Procurement Control

7. Corrective Action

8. Plant Housekeeping

.. 5046-3 1-2

9. Audits

10. Control of Nonconforming Materials, Parts and Components

11. Calibration and Control of Measuring and Test Equipment

12. Receiving and Storage

13. Test Control

14. Inspection, Test and Operating Status

15. Control of Special Processes

16. QAD Surveillance

17. Inspection

18. Instructions and Procedures

19. Contractor Activities Identification of the MAC evaluators and all PSE&G and contractor personnel contacted during the assessment are included in Attachment l of this report.

2.0 ISSUES AND RECOMMENDATIONS 2.1 IDENTIFICATION AND CONTROL OF MATERIALS, PARTS AND COMPONENTS This part of the QA program appeared satisfactory, except maintenance work orders presently do not provide identification and traceability of safety-related commercial catalog items (CCI) utilized as spare parts.

Issue Maintenance work orders do not provide identification and traceability of safety-related CCls utilized as spare parts. Presently, the responsible supervisor only writes the words "commercial catalog item" on most work orders.

Recommendation Greater emphasis should be placed on entering identification numbers such as purchase order, QC or folio numbers on work orders requiring safety-related CCis.

2.2 QUALITY ASSURANCE RECORDS Record classification, storage, indexing and control should be improved. The responsibilities for QA records management are fragmented and different systems for controlling, indexing and storing are used by different departments. Some records are stored manually and some. are stored in a computerized system (CARMS). Interfaces between the two systems should be improved.

Issue

• The system and facilities for storing QA records needs improvement to assure adequate protection and timely filing.

• The responsibilities for QA records management is presently fragmented between several organizations. Interfaces between groups and systems are not well defined.

• The effectiveness of the Technical Document Room (TOR) station indexing system could be improved. TOR procedure number 5, "Indexing of Station Records", provides indexing by record type. Investigation of design change package-related installation records found they were also filed by work order number. Retrievability of any specific records within the package can only be acc~mplished by means of search and elimination.

5046-3 2-2

• Although the Operations Department TOR has access to the Construction Department's computer assisted records management system (CARMS) equipment and cartridges in their facility, the TOR personnel cannot access data due to lack of training on the equipment.

• The ability to reproduce clear copies of records from film from .the TOR system or CARMS is limited.

• CARMS allows for a more specific retrievability factor; however, due to the erratic indexing input from the inception of the program retrievability was somewhat difficult for early documents.

RecommendatiOn It is recommended that an overall assessment be accomplished, taking into consid-eration all of the past and present systems employed for records management.

This assessment should include a review of regulatory requirements, ability to retrieve data already in the system, compatibility and interfaces and consideration of centralizing all records management for the Nuclear Department under a single organization and system.

2.3 DOCUMENT CONTRO..

Improvements can be made which will assure the latest drawings are available in the control room and other work locations. A review of the control room drawing files found instances where drawings were out of revision or did not reflect the as-built condition of the plant.

The Nuclear Department needs procedures to govern document control which provides centralized and consistent guidelines for the development, review/

approval, control and issuance of manuals, procedures and instructions.

Issue There is not a Nuclear Department procedure which establishes a consistent system for document control. This can cause or contribute to problems in areas such as the following:

f Understanding the responsibilities of Engineering and Operations in the control of the station as-built documents.

• Assuring correct drawing revisions in station files.

• Maintaining appropriate mechanisms to verify that controlled documents are received by using organizations.

• Assuring current maintenance procedure revisions in controlled manuals.

• Ensuring that all groups in the Nuclear Department have consistent procedures governing document control.

Recommendation A detailed assessment of document control at the Salem station should be performed. A Nuclear Department system for document control should be established. The system should cover format, preparation, review/approval, issue, change, distribution and verification of receipt at the point of use.

Responsibilities and interfaces of all involved organizations should be clearly stated.

2.4 COMMITMENT MANAGEMENT Procedures governing commitment management were in draft form. Verification of compliance with regulatory commitments should be improved.

Issue Procedures for commitment management have not been approved. Draft procedures for "Nuclear Licensing and Regulation", and "Response to Regulatory and Licensing Documents", were available. However, discussion with interfacing organizations, such as QAD, indicate they were not aware of these draft procedures.

Recommendation The draft procedures should be coordinated with affected organizations and issued as approved documents.

Issue

• QAD is not systematically providing corrective action verification of LERs and NRC noncompliances as required by Quality Assurance Instructions (QAI).

.. 5046:..3 2-4

• At the present time there is no systematic documented verification that all commitments have been met. The Nuclear Licensing and Regulations Depart-ment relies on receiving a memo or verbal notification by the responsible department manager.

Recommendation

• The Nuclear Licensing and Regulations Department or assigned interfacing group be specifically responsible for verification of status and completion of all commitment items.

• QAD provide regularly scheduled audits to assure that the verification program is working effectively.

2.5 TRAINING AND CERTIFICATION Inspector qualification/certifications records do not include identification of specific disciplines. Present records could be interpreted to give an open certification to inspect any discipline.

Issue QAD inspector certifications are not discipline oriented. Currently, certification as a level II inspector or verifer gives the individual an open qualification/

certification to inspect any discipline (i.e., civil, structural, mechanical, electrical and I&C) at the discretion of his supervisor. This could result in inspection by unqualified personnel.

Recommendation Procedures for certifying inspectors should be revised to identify specific disciplines of qualification.

Issue The PSE&G QAD training and cerification manual has not yet been approved.

Recommendation Update and approve QAD training and certification manual.

. ' 5046-3 2-5 2.6 PROCUREMENT CONTRa...

Revie~ of procurement-related documents and procedures found Engineering and QAD have not always properly utilized existing procedures, instructions and forms to perform procurement document reviews, associated quality engineering and inspection planning.

Review of the maintenance and betterment contractor's (Catalytic) QA program determined performance of numerous procurements classified by Catalytic Engineering as non-safety related (NSR) in the past. These procurements should be reviewed by PSE&G to verify correct classification.

PSE&G receiving inspection sampling plans for items procured in quantity should be reevaluated in terms o.f allowable rejections for lot size on safety-related (SR) items~ The current allowable rejection percentage appears somewhat liberal for SR items.

Issue Requirements imposed in procurement documents to assure the quality of pro-cured materials and services can be improved. Review of procurement documents by QA engineers to assure appropriate and adequate specification of requirements should be more consistent in preventing unnecessary or unrealistic requirements and providing meaningful acceptance criteria and storage requirements.

Recommendation The activities of procurement document review, associated quality engineering and inspection planning should be assessed in detail by PSE&G QAD with the following emphasis:

• Proper utilization of QAD procedures, instructions and forms which provide a reasonable basis for an effective program.

• Assuring that engineering is providing adequate quality criteria, such as storage and maintenance requirements.

'5046:.3 2-6 Issue PSE&G QA and Engineering personnel reviewed many of their procurements classified as non-safety related to determine if the classification was correct.

However, the maintenance and betterment contractor (Catalytic) has made non-safety-related procurements in the past and these have not been reviewed for correct classification. PSE&G personnel stated that Catalytic could no longer procure items other than support items (i.e., office supplies, etc.).

Recommendation PSE&G should assess the need for a review of Catalytic non-safety-related purchase- orders similar to the one accomplished for PSE&G.

Issue Storeroom procedures provide for sampling inspection of items procured in quantity. The plan is not limited to non-safety-related material. The plan permits acceptance of large lot size~ without screening when some rejects are found.

Recommendation PSE&G QAD should reexamine the sampling plans acceptance limits for safety-related items. Revise applicable procedures as necessary.

2. 7 CORRECTIVE ACTION Issue Action Requests (ARs) are not always resolved in a timely manner. Review of open ARs reveal ARs dating back to 1980. QAD has adopted a policy allowing the closing of ARs without verifying the corrective action has been satisfactorily implemented. Items which QA consider minor are also being closed out without any commitment from the action organization.

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-1 2-7 Recommendation All AR responses should be evaluated and verified within a specific time. It is suggested that verifications be assigned by the audits group to cognizant QAD personnel to expedite closeouts.

Issue The process of escalating unresolved problems should be clearly defined. Quality Assurance Procedures (QAPs) provide direction for the specification of response due dates but gives little guidance on what happens if a response is inadequate or late. This can result in unresolved problems not being escalated in a timely manner.

Recommendation Revise QAPs to better define responsibilities, interfaces, limits and required escalations. It is also recommended the QA policies and procedures manual reflect a parallel requirement.

Issue There is no formalized trend analysis program in effect to identify unfavorable quality assurance trends. Repetitive type conditions could go unde.tected by the QAD and PSE&G management.

Recommendation It is recommended that a formal *trend analysis program be established which includes ARs, deficiency requests and LERs. Other factors may also be input into the program.

2.8 HOUSEKEEPING PSE&G has provisions for regular inspections of the Salem site for housekeeping.

These inspections have not always been performed regularly as required by procedures. Based on observations, MAC concluded that housekeeping at Salem should be improved.

.. 5046:..3 2-8 Issue Housekeeping procedures provide for housekeeping zones II, IV and V, which are

• roughly equivalent to zones with the same designation in ANSI standard N45.2.3.

This standard, which is endorsed in Chapter 17.2 of the Salem FSAR, has zones I through V. There is no exception taken to the standard.

Zone I housekeeping is the highest level and would be appropriate where work was being performed - on equipment highly sensitive to environmental factors or required unusual cleanliness.

Recommendation Revise FSAR Chapter 17 to eliminate or clarify the use of zone I cleanliness.

Revise procedures to include all cleanliness zone requirements or take exception to ANSI N45.2.3.

Issue Procedures require a weekly housekeeping inspection by a team made up of representatives from six departments. No inspections were performed in March 1983. Two were accomplished during the month of April.

As* an overall observation, housekeeping was marginal. The PSE&G personnel contacted indicated conditions were worse than normal due to the high level of activity as a result of the outage.

Recommendation Greater emphasis should be placed on housekeeping during outage periods. The performance of the regularly scheduled inspections should be improved.

2.9 ALDITS The QA audit program procedures, schedules and audit reports were reviewed. It was found that the scope of the audit program should be expanded .to provide additional coverage of subjects such as operation of the station technical documents room, document control as it exists at the department level and Site Quality Assurance Engineer (SQAE) activities.

. '5046:.3 2-9 Auditor personnel need additional experience in plant operation activities.

Issue Based upon interviews and review of past and present audit reports and schedules, it appears that audits of the following areas should be expanded:

• Operations of the station technical document room (QA Records Management).

• Document control as it exists at the department and group level.

• SQAE-related activities.

Recommendation Review audit overall program for Salem with input from all groups within the QAD to assure the audit program covers all required areas.

Issue While the present auditing staff has good academic and QA experience backgrounds, exposure to operating activities should be enhanced.

Recommendation

• Consider using station QA personnel familiar with plant operations on future audit teams.

• Consider placement of personnel with greater operational experience within the audit group.

• Train existing auditors in plant systems and plant operating practices.

2.10 CONTROL OF NONCONFORMANCE The present system used by all departments of maintaining their own deficiency report (DR) does not provide for complete, accurate and up-to-date status of nonconforming conditions of the plant at a single place. This area would be of particular concern at times when plant operating modes are being changed.

.. 5046'-3 2-10 Issue Procedures require that controls be maintained for the initiation and control of DRs. However, each department has its own system for meeting this require-ment. This fragmentation of control systems creates difficulty when attempting to ascertain the status of all current DRs. A review of the logs maintained by QAD indicates incomplete information for several DRs issued by other depart-ments. The incomplete information_ was due to DRs being voided or, in some cases, not being distributed to QAD as required by procedures.

Recommendation Procedures should be revised to require QAD to control issuance, distribution, tracking and statusing of all DRs issued at the station. This would provide a central control point for DRs and allow a single organization to easily determine the status of all station nonconformances prior to changes in operating modes.

2.11 CALIBRATION AND CONTROL OF MEASURING AND TEST EQUIPMENT This program element was evaluated in the maintenance, l&C and operations areas, as applicable. The Maintenance Department has regularly made informal changes to the equipment list, relative to the ID numbers and required calibration frequencies. It could not be ascertained during the assessment who or whether the changes were authorized. Review of Maintenance Department test equipment sign out logs determined that better controls are needed to assure traceability to the specific work orders. Improved controls should be used for instrument information folders containing items such as technical manuals, calibration curves, etc.

Issue The instrument list required to identify each piece of equipment by name, M number, serial number, location and required calibration frequency is not being maintained in a controlled manner. It is not clear who is responsible to authorize such changes to this list or if existing changes were authorized.

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. '5046'-3 2-11 Recommendation Responsibility for maintenance of the program for control of portable test equipment should be assigned to a specific department.

Issue Some procedural requirements are not being met. Some examples are:

• The Maintenance Department test equipment sign out log is required to identify information about use of test equipment, including work order numbers. However, a review of this log indicated several uses of test equipment to perform a maintenance task where traceability to a specific work order number was not maintained.

• It is required that individual folders be maintained for each piece of test equipment. These folders are to contain pertinent information about the instrument (i.e., technical manuals, calibration curves, etc.). However, observation of the Maintenance Department files showed that for some instruments, such as gauges, individual folders are not being maintained *as required.

• Administrative Procedure (AP) SR-9 "Calibration Program - Mechanical" requires calibration certificates and mechanical test equipment sign out logs be maintained per enclosures one and two of the program. A review of records for mechanical test equipment indicated that some required logs are not available and others have been revised and no longer satisfy the requirements.

Recommendation It is recommended that departments strictly adhere to established procedures and requirements or revise the procedure if appropriate.

Issue Based on the inspection tour of the storeroom areas and interviews with storeroom supervisory personnel, it was learned that mechanical test equipment overdue for calibration and equipment received from calibration facilities but not yet inspected is placed on a table in the storeroom with no provision for locking the area. Although access to the entire storeroom is controlled during normal working hours, access may be achieved by station personnel after normal working hours if accompanied by a security guard. Since the calibrated tool storage is locked and not accessible to station personnel after normal working hours, it is possible that tools in the unlocked area could be taken from the storeroom and used.

.. 5046:...3 2-12 Recommendation Provisions should be made for a quarantined area in the storeroom so positive access control can be maintained during and after normal working hours.

Issue Procedures were reviewed to determine compliance to applicable codes and standards referenced by the FSAR. It was found that QAI 12-1 generally addressed requirements for calibration and control of measuring and test equipment during fabrication, construction, test and start-up but contained few requirements specified for commercial operations.

Recommendation

• QAP 12 should be revised to provide greater detail regarding calibration and control of measuring and test equipment requirements during commercial operation.

• QAI 12-1 should be revised to address the requirements of applicable codes and standards for calibration and control of measuring and test equipment during commercial operation.

2.12 RECEIVING AND STORAGE Problems related to receiving and storage of materials, equipment and components were observed. Items received at different warehouses are being received, inspected and identified differently.

There needs to be a program for maintenance (i.e., shaft rotation, lubrication and check of dessicants) in warehouses.

Storage and housekeeping practices need improvement in the warehouse.

Inspection of warehouses revealed the presence of damaged end caps, unprotected threads, and a need for improvement in the general housekeeping.

Issue There needs to be more consistency in the way materials are received, inspected and identified. For example, in warehouse 1 and 5 a white stick-on quality release

'5046'...3 2-13 label is used to identify safety-related items which have been found acceptable by QC inspection. Items found not acceptable or questionable are identified with a red stick-on hold label for a hardware problem and a purple stick-on hold label for a documentation problem. Procedures for this system need improvement.

In warehouse 2 inspection is done by the stockhandlers except for verification of proper documentation by QC. Acceptable material is identified by a green tie-on tag. Unacceptable material is identified by a white tie-on reject tag.

Recammendation A single program for receiving inspection and identification of materials, parts and components should be developed and implemented.

Issue A system for maintaining items stored in warehouses (i.e., shaft rotation, lubrica-tion, check of dessicants) needs to be established. One warehouse storekeeper stated he has not received specific direction or guidance in this regard and had no program in effect.

Recommendation It is recommended that adequate requirements and controls be specified in procurement-related documents by engineering and QA. Secondly, a controlled and verifiable common program be implemented in all Nuclear Department ware-houses.

Issue Storeroom procedures require a monthly inspection of safety-related storage areas. Reports were on file attesting to the performance of these inspections.

However, conditions in the warehouses were marginal.

Recommendations An increased effort should be made in the warehouses to ensure proper storage ar:id housekeeping practices are understood and followed.

' 5046-3 . 2-14 2.13 TEST CONTROL This area was found generally satisfactory.

• 2.14 INSPECTION TEST AND OPERATING ST ATUS This area was found generally satisfactory except for the lack of identification of inspection status of CCls as required by procedures.

Issue Procedures were found to address status identification during design, construction and test phases but did not always include commercial operations.

Recommendation Procedures should be revised to address status identification required during commercial operation in greater detail.

Issue Based on a tour of warehouse 2 and the storeroom area and discussions with warehouse personnel, it was found that there is a need for identification of the inspection status of CCis. Specifically, identification measures for the status of each CCI subjected to receiving inspection in accordance with procedures are needed.

Recommendation It is recommended inspection, AP and QA instructions be revised as required for identifying inspection status of CCis in warehouse 2 and the storeroom.

2.15 CONTROL CF SPECIAL PROCESSES Controls involving special processes were found satisfactory, except that some procedures need revision in the assignment of responsibilities to personnel involved in ctintrolling these processes in order to be consistent.

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. '5046'-3 2-15 Issue QAD, administrative and various maintenance procedures were reviewed. This review indicated that assignment of responsibilities to personnel involved in control of special processes was not always consistent throughout these procedures.

Recommendation Procedures should be reviewed and revised, as necessary, to reflect a consistent assignment of responsibilities throughout all procedures addressing control of special processes.

2.16 QAD SURVEILLANCE The surveillance program needs to be strengthened for activities of the maintenance and betterment contractor. QAPs require, as a minimum, QAD to perform surveillance activities biweekly. This commitment is not always met.

The scope of the surveillance program should also include PSE&G quality control activities.

Issue Procedures require a surveillance program be applied to activities affecting quality and safety as identified on the Salem "Q" List. The procedure further defines the areas subject to surveillance, the frequency at which surveillance will be performed, surveillance planning and documentation of results. An assessment of the implementation of the surveillance program indicated the following problems:

• Procedures require biweekly surveillance of contractor activities. However, surveillance of maintenance and betterment contractors to date has not been implemented on a biweekly basis.

• Procedures require that surveillance activities not occurring within specified frequencies be recorded in the surveillance log. The use of this log has not been fully implemented. As a result, no record is maintained for surveillance activities which were not performed on schedule.

.. 5046'...3 2-16 Recommendation

• QAD personnel should review the scope of the surveillance program and make changes as appropriate.

2.17 INSPECTION Some problems were cited in this area. Receiving inspection activities should be improved to assure that proper procedures are being

• utilized by qualified personnel.

QAD quality control personnel should be involved in final inspection of welding and providing input for inspection points when a general troubleshooting procedure is utilized for maintenance activities.

Issue It is required that inspections of safety-related activities be performed in accordance with approved written procedures which set forth inspection requirements and acceptance limits. Although procedures require receiving inspection be performed in accordance with applicable procedures or checklists, procedures or checklists for verifying physical characteristics of items are not in use.

It is also required that records of inspections be kept in sufficient detail to permit adequate confirmation of the inspection program. Although procedures make provisions for detailing the results of inspections and identifying persons performing these inspections on checklists, the checklists are not being utilized to document results of receiving inspection.

Recommendation

• Procedures should be revised to address the use of all forms and checklists required during receiving inspection planning and performance.

• General inspection procedures addressing the requirements for performing receiving inspections for compliance to specified acceptance criteria should be issued.

. ' 5046-3 2-17

• After issuance/revision of the procedures identified above, rece1vmg inspection practices should be modified to comply with these procedures at all warehouses and storerooms where safety-related materials are received.

Issue QAPs governing "Receiving Inspection" require that rece1vmg inspection of material procured by the Electric Production Department (EPD) be performed in accordance with applicable station administrative procedures. These procedures allow stockhandlers to perform the physical receiving inspection of items with QAD personnel involved only in documentation review. It is required that inspections necessary to assure quality be performed by qualified individuals other than those who performed or directly supervised the activity being inspected. The utilization of stockhandlers to perform receiving inspection in warehouse 2 and the storeroom does not satisfy requirements for inspector qualification.

Recommendation Nuclear Department procedures should be revised to require receiving inspection activities be performed by QAD or other certified personnel.

Issue The "Material Procurement, Receiving, Storage, Issue, Transfer, Shipping and Services Program" allows the procurement of safety-related CCls with no require-ments for supplier documentation. Considering the inspection personnel qualifi-cation and procedural deficiencies identified in issues above, routine receipt of safety-related CCis may occur without QAD involvement.

Recommendation Procedures should be revised to require all safety-related items, including CCis, to be subject to receiving inspection activities performed by QAD or other certified personnel.

Issue Procedures governing "Control of Station Maintenance" describe the Maintenance Department's control of station work orders including the use of maintenance

2-18 procedures, specification of inspection hold points and interfaces with the QAD.

However, no QAD procedures are in effect to describe how QA personnel are to interface with the Maintenance Department to control specification of inspection hold points, hold point notification, performance and documentation.

Recommendation Interfaces between the QAD and other station organizations and actions required by QAD personnel during these interfaces should be defined in procedures.

Issue There is significant involvement by the QAD in review and acceptance of contractor construction work packages (CWPs). This involvement includes initial and final CWP review and a final walk down of completed work for acceptance.

However, QAD procedures do not adequately describe the applicable interfaces and responsibilities of QAD personnel.

Recommendation

• The QAD should issue instructions to detail interfaces between the QAD and contractor organizations and identify actions required by QAD personnel during these interfaces.

Issue QAPs governing the "Inspection Program" were reviewed. It is required that inspections necessary to assure quality be performed by qualified individuals other than those who performed or directly supervised the activity being inspected. A review of maintenance work orders and associated maintenance procedures involving welding included only inspection hold points for fit up before welding.

These procedures did not include an inspection hold point for final visual inspection of welding by QAD personnel. A review of weld history records for completed welds indicated that final visual inspection is being performed by maintenance supervisory personnel. The inspection program should be upgraded to require inspections by independent and certified personnel.

. '5046-3 2-19 It is also required that inspections of safety-related activities be performed in accordance with approved written procedures which set forth the requirements and acceptance limits. It was found that approved procedures for performance of final visual inspection of welds by maintenance personnel are not in effect.

Recommendation Maintenance Department procedures for performance of welding should be revised to include inspection hold points to be performed by QAD or other certified independent personnel for final visual inspection of welds. Procedures should be revised to include inspection criteria and acceptance limits for the final visual inspection of welds.

Issue A review of completed work orders in the Maintenance Department indicated that the majority of work requested was approached utilizing a general troubleshooting maintenance procedure attached to the work order. In these cases the cause of the item or system problem was identified and corrective action was effected by maintenance personnel without QAD being presented the opportunity to specify inspection hold points.

Recommendation QAD personnel should specify inspection hold points for activities controlled by general troubleshooting procedures attached to safety-related work orders.

Issue The maintenance and betterment contractor (Catalytic) presently may utilize Catalytic working sketches which are not approved by PSE&G to perform final inspection and acceptance of items. Discussion with PSE&G QA/QC site personnel found they also use such sketches for the final system walkdowns and acceptance.

• . '5046-3 2-20 Recommendation Obtain PSE&G engineering approval of the sketches or utilize engineering approved drawings as supplied by PSE&G.

2.18 INSTRUCTIONS AND PROCEDURES There is a need to upgrade the instructions and procedures in the Nuclear Department to provide a consistent and integrated set of policies and practices for the QA program. This need impacts on most of the elements of the QA program.

Issue There is not a Nuclear Department set of instructions and procedures which provides a clear definition of. the QA policies, assignment of responsibilities, description of interfaces and acceptable practices for implementing the program. The recent organizational restructuring has resulted in many of the existing procedures being obsolete.

Recommendation The QAD should take steps to update the QA program definition documents (FSAR and QA manual). They should then work closely with other Nuclear Department groups to develop a consistent set of provisions for the QA program in the QAD procedures that complement and support the procedures of the other groups.

l..19 CONTRACTOR ACTIVITIES The maintenance and betterment contractor (Catalytic) was assessed to determine compliance with PSE&G QA requirements. The contractor's QA program was generally fat.ind to be acceptable. However, one problem exists w~th the use of PSE&G unapproved Catalytic work sketches to perform final inspections. The contractor's engineering group on site develops work sketches of the PSE&G design change package when PSE&G drawings are not adequate for field applica-tion. Although these sketches may contain new or additional data, they are not approved by PSE&G Engineering.

.. 5046..:3 2-21 Issue The issues associated with contractor activities are contained earlier in this section under the specialized topical areas.

Recommendation The recommendations associated with contractor activities are contained earlier in this section under the specialized topical areas.

ATTACHMENT 1 PERSONS CONTACTED

5046-3 A-1 ATTACHMENT l PERSONS CONTACTED Name Position E. Barradale Manager, Nuclear Construction Support H. Fistel QA Receiving Control J. Fisher QA Engineer J. Hagan Maintenance Engineer

• I R. Vanderdecker Senior Supervisor Planning, I&C I I

M. Platt Energy, Inc.

K. Whitcomb Energy, Inc.

J. Hart Warehouse Supervisor L. Sutton Storekeeper A. Nassman QA Manager W. Schultz QA Engineer M. Rosenzweig QA Engineer E. Witkin QA Engineer L. Fry Operations Manager D. Tauber QC Supervisor B. Leap QA Supervisor D. Thomas Senior Maintenance Supervisor D.,Perkins Site QA Engineer C. Perez Site QA Manager, Catalytic D. Shibinski QA Engineer L.Lake MIET R. Brandt MIET A. Ortecelle I&C Supervisor

-i 5046-3 A-2 Name Position V. Glad Maintenance Department P. Vandy Storeroom Supervisor J. Barnes Maintenance Department J. Cortez Engineering R. D*e Sanctis Manager, Procedures and Materials R. Patnell Engineering T. Taylor Manager, Engineering and Control N. Petrella Engineering and Control D. McLaughlin Nuclear Construction Support J. Jackson Technical Engineer E. Meyer QA Engineer D. Lyons On-Site Test Group R. Mitt! General Manager, Nuclear Assurance and Regulations F. Omohundro Manager, Corporate QA

~

W. Nevins QA Engineer MAC PERSONNEL Name Position A. Crevasse Project Manager J. Orlando Consultant C. Warren Consultant i