IR 05000324/1987031

Insp Repts 50-324/87-31 & 50-325/87-32 on 870914-18 & 0928-1002.Violations Noted.Major Areas Inspected:Qa Effectiveness

ML20237D206
Person / Time
Site:	Brunswick
Issue date:	11/18/1987
From:	Belisle G, Breslau B, Russell Gibbs, Moore L, Shannon M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:
Shared Package
ML20237D181	List: IR 05000324/1987031 ML20237D179 ML20237D197
References
50-324-87-31, 50-325-87-32, NUDOCS 8712230109
Download: ML20237D206 (27)

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jeNog'D UMITED STATES o NUCLEAR REGULATORY COMMISSION j n REGION 11

'g j 101 MARIETTA STREET, * t ATLANTA, GEORGI A 30323 4.,...../.

Report Nos.:. 50-324/87-31 and 50-325/87-32

Licensee: Carolina Power and Light Company P. O. Box 1551 i Raleigh, NC 27602 Dock'et Nos.: 50-324 and 50-325 License Nos.: DPR-71 and DPR-62 Facility Name- Brunswick 1 and 2 Inspection Conducted: September 14-18, 1987 and September.28 - October 2, 1987 Inspectors: / -

/ !!97 D'. Gibbs Date Signed 8.~A. Breslau 1? Y e~

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Date' Signed ll 18 D M. C. Shannon D6te Figned N, ll l9 W]

L. R. Moore Date Signed Accompanying Personnel; G. A. Belisle, September 28 - October 2, 1987'

Approved by:

G. A. BH isle, Chief "

[7 o//X ////8 Date'51gned

Quality Assurance. Programs Section Division of Reactor Safety SUMMARY

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Scope: This routine, announced inspection was conducted in the area of quality l assurance effectiveness.

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Results: Four violations were identified: failure to take prompt and adequate corrective action to resolve Engineering Work Requests (EWRs), failure to document the results of reviews of EWRs, failure to properly maintain the Core

. Spray system in accordance with USAS requirements, and failure to conduct adequate audit I 8712230109 871211 PDR ADOCK 05000324 0 f*Mr phg ec

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I REPORT DETAILS 1 Persons Contacted i

Licensee Employees 1 D. Anderson, Project Engineer

• H. Banks, Corporate Quality Assurance (QA) Manager A. Bentsen, Instrumentation and Control (I&C) Technician

• E. Bishop, Operations Manager S. Boice, Project Engineer, Emergency Core Cooling System (ECCS)

E. Cathey, Project Engineer, Procurement D. Cerasuolo, Senior Radwaste Engineer

• C. Dietz, General Manager W. Dorman, QA Supervisor

• E. Eckstein, Manager of Technical Support

• K. Enzor, Director of Regulatory Compliance E. Harrelson, Technical Support Engineer

• R. Helme, Director of On-site Nuclear Safety

• J. Henderson, Supervisor, Environmental and Radiation Control (E&RC)

M. Hogle, Engineering Supervisor, Systems C. Johnson, Technical Support Engineer

• L. Jones, Director. QA/ Quality Control (QC)

W. Mauney, Senior Specialist, I&C

• C, Mosley, Corporate QA J. Nikitas, Project Engineer, Electrical J. O' Conner, Environmental Qualification (EQ) Engineer, Technical Support

• J. O'Sullivan, Maintenance Manager B. Porterfield, Senior Fire Protection Engineer

• R. Poulk, Senior Specialist, Regulatory Compliance D. Ramsey, Engineering Technician A. Richards, Principal QA Engineer

• C. Schaecher, Project Engineer

• J. Smith, Director, Administrative Support G. Thompson, Project Engineer, Electrical

• J. Titrington, Principal Engineer, Operations

• M. Turkel, Site Licensing, Harris Nuclear Plant D. Whitehead, Principal Engineer, Performance Evaluation Unit (PEU)

B. Wilson, Project Engineer L. Wright, Senior QA Specialist

• T. Wyllie, Manager of Engineering and Construction Other licensee employees contacted included engineers, technicians, operators, mechanics, and office personne NRC Resident Inspectors

• Ruland, Senior Resident Inspector L. Garner, Resident Inspector

• Attended exit interview

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1 List of Abbreviations AMMS - Automated Maintenance Management System A0 -

Auxiliary Operator BBC -

Brown Boveri Corporation BCU -

Brunswick Construction Unit BESU - Brunswick Engineering Support Unit BWR -

Boiling Water Reactor CRD - Control Rod Drive DRE -

Direct Replacement Evaluation EER -

Engineering Evaluation Report E0P - Emergency Operating Procedure FR -

Field Report GE -

General Electric HCU - Hydraulic Control Unit ISI -

Inservice Inspection LER -

Licensee Event Report MCC - Motor Control Center MI -

Maintenance Instruction MIP - Maintenance Improvement Program MMM - Maintenance Management Manual MP -

Maintenance Procedure MSIV - Main Steam Isolation Valve MST -

Maintenance Surveillance Test M&TE - Measuring and Test Equipment i NBS -

National Bureau of Standards i NCR - Nonconformance Report NFR - Nonconforming Field Report NPSH - Net Positive Suction Head NRR - Nuclear Reactor Regulation ODCM - Off-site Dose Calculation Manual OI -

Operation Instruction PAM - Procedure Administrative Manual PM -

Plant Modification PNSC - Plant Nuclear Safety Committee PSIG - Pounds Per Square Inch Gauge PT -

Performance Test RB -

Reactor Building RHR - Residual Heat Removal RPS - Reactor Protection System RWCU - Reactor Water Cleanup System i

SER - Safety Evaluation Report l

SGTS - Standby Gas Treatment System SIL - Service Information Letter TM -

Technical Manual 1 TS -

Technical Specifications UE&C - United Engineering and Construction USAS - United States of America Standard WR/J0- Work Request / Job Order

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3 Exit Interview The inspection scope and findings were summarized on October 2, 1987, with those persons indicated in paragraph 1 above. The inspector described the areas inspected and discussed in detail the inspection findings listed belo No dissenting comments were received from the license Failure to take prompt and adequate corrective action to resolve Engineering Work Requests, paragraph Failure to document the results of reviews of Engineering Work Requests, paragraph Failure to properly maintain the Core Spray system in accordance with 10 CFR 50.55a and USAS requirements, paragraph Failure to conduct adequate audits, paragraph Potential inadequacy relative to maintaining an adequate supply of water for fire protection, paragraph The licensee did not identify as proprietary any of the materials provided to or reviewed by the inspector during this inspectio . Licensee Action on Previous Enforcement Matters This subject was not addressed in the inspectio . Unresolved Items Unresolved items are matters about which more information is required to determine whether they are acceptable or may involve violations or deviations. One new unresolved item was identified during this inspection and is discussed in paragraph . Quality Assurance Effectiveness The objective of this inspection was to assess quality assurance l effectiveness. For this report, quality assurance effectiveness is defined as the ability of the licensee to identify, correct, and prevent problem The term quality assurance effectiveness is used in this application, but it is not meant to be limited to the licensee's Quality Assurance Departmen It is the total sum of all efforts to achieve quality result l l

This was a performance-based rather than compliance-based inspectio l Instead of verifying compliance to programmatic requirements, the i principal effort was to determine whether the results that the Quality Assurance program was designed to accomplish were actually achieve I l

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The inspection effort was divided into the following areas:

Design Control Maintenance Operations and Surveillance Testing Quality Assurance / Quality Control Measurement and Test Equipment ,

Each area is addressed separately in this repor Due to problems encountered in the early stages of this inspection which involved the Brunswick site EWR process, a significant amount of the inspection team's effort was devoted toward a full investigation of this are Conclusions reached concerning the EWR process are as follows (for additional details see Paragraph 6.0):

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The site has a very large backlog of unresolved EWRs (i.e. , over 1900) which makes proper management of the area very difficul The backlog includes a large number of safety-related items which have not received prompt nor adequate management attention and corrective actio The backlog includes deficient plant equipment, as well as, plant improvement item Some EWRs could be closed with a written evaluation which specifies the engineering justification as to why the item is " acceptable as is", without any additional corrective actio At least one item violated licensee commitments and/or regulatory requirements (see paragraph 6.a).

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Many items have not been worked due to manpower and/or budget restraints as stated by the license . Design Control The licensee's Quality Assurance Effectiveness in the area of Design Control was assessed by reviewing an extensive modification package, reviewing various EWRs, performing system walkdowns and interviewing plant personne The inspector performed a detailed review of plant modification 85-063 and the associated 42 revision It appeared that design inputs, analyses, reviews, and approvals were adequately detailed and modification require-ments such as procurement, material, welding, torque value, procedural,

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and post-maintenance testing were acceptable.

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l One mechanism which is used to initiate design changes is the EWR progra The inspector reviewed the EWR program and noted that over 1900 EWRs were presently outstanding. Information concerning approximately eighty EWRs was requested from the license The following thirty-four EWRs were discussed in detail with members of the licensee's engineering staf EWR EWR EWR 84-1024 02151 02573 84-564 79-406 82-189

'83-1550 84-428 83-070 84-685 83-650 03373 84-496 83-417 82-015 83-083 84-391 02355 84-362 00-922 84-809A 82-294 01438A 03374 84-390 84-719 83-1380 83-1210 83-769 83-272 83-463 01434 83-366 84-472 Within this area, four violations and one unresolved item were identified and are discussed in the following paragraph a, Failure to Maintain the Core Spray System in accordance with 10 CFR 50.55a and USAS B3 EWR 83-083 Dated February 21, 1983 The "B" core spray suction relief valve 1-E21-F032B, was found missing in November 1979. An EWR written on February 21,1983 by engineering personnel stated that it was an ISI relief valve and that the relief valve needed to be reinstalled prior to the end of the 1983 outag Work order 1-M-85-342 removed the "A" core spray suction relief valve 1-E21-F032A on September 8,1985; repairs could not be made due to lack of replacement parts. Neither relief valve has been replaced nor parts ordered for repair EER 1-M-2243, dated November 21, 1979, stated that the suction piping is designed to 150 pound class and that the suction relief valve is required to declare the system operabl It also stated that the discharge piping high pressure alarms are 450 psig and l discharge relief valve is set at 500 psig and neither of these j are adequate to prevent over pressurization of the suction pipin EER 85-256 stated that' the UE&C pipe rating is 125 psig and that the discharge relief valve 1-E21-F012A (500 psig) would provide i

adequate over pressure protection.

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Administrative controls (caution tags) were put in place in 1979 for the "B" trai The tags were found missing in 1985 and were replaced when caution tags were also placed on the "A" train. The tags cautioned against closure of all of the suction valves, which could lead to system over pressurization. The licensee has kept either the suction valves from the suppression chamber (torus) or the suction valves from the condensate storage tank (F001A, F002A, F001B, and F002B) open to meet the operability requirements of the Technical Specifications.

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10 CFR 50.55a(g)(4) states that components which are classified as Code Class 1, 2, or 3 shall meet American Society of Mechanical Engineers (ASME)Section XI requirements. The FSAR, Section 3.2.2.7, l list the core spray system as being designed in accordance with USAS B31.1. USAS B31.1, 1967, Section 102, design criteria, requires that pump suction lines have relief valves unless the system is designed for the maximum pressure to which it may accidentally be subjected, or unless there is a suitable alarm to warn the operato The system was designed with 125 psig suction relief valves and could be subjected to primary system pressure up to 1100 psig due to valve seat leakage. The suction piping does not have an alarm to warn the operato The caution tags placed on the system in 1979 were found to be missing in 1985. The engineering evaluations did not agree, in that, the 1985 EER said the discharge relief would protect the system and the 1979 EER said the discharge relief would not protect the syste The reason for not repairing the deficiency was that a replacement valve or parts could not be purchase An EER provides a means to deviate from certain requirements for reasonable periods of time. Failure to replace a 3/4-inch, 125 pound relief for eight years is not reasonable. Due to the various dis-crepancies, extended periods of time, and the failure to comply with 10 CFR 50.55a and USAS requirements, this item is identified as Violation 50-324/87-31-03 and 50-325/87-32-0 b. Failure to take Prompt and Adequate Corrective Action to Resolve EWRs The following EWRs are combined as they exhibit untimely or  ;

inadequate corrective action by the license EWR 84-1024 Dated January 6, 1984 This EWR addresses a deficiency, identified by the manufacturer, found i to exist on the Brunswick 4160 volt breaker BBC notified the NRC I on April 28, 1983, that a potential deficiency existed in the SHK j switchgear breakers supplied to the nuclear industry. The defect  ;

could cause the 4160 volt breakers to reclose after being reener-gized, resulting in the potential to overload the emergency diesel generator BBC also stated that due to the infrequency of this l

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condition it may go unnoticed by the users. BBC notified the users to make repairs at the next regularly scheduled maintenance inspec-tion. Brunswick personnel stated that about 160 man-hours would be needed and that the expected completion date for this item is around 199 Due to the adverse effect that could result from this condition, minimum resources required, and length of time that management has been aware of this problem, this item is considered an example of untimely corrective actio EWR 83-417 Dated July 14, 1983 In 1977 RHR pressure transmitter 2E11-PT-N026A, which was a model GE 551, was replaced with a model GE 556. The new transmitter coul not be verified as a "Q" item as required. The transmitter was considered a "Q" item because of pressure boundary requirements and it was used by the control room during the steam condensing mode of RHR. A documented review was not performed at this time to verify transmitter accuracy and reliability to insure continued system operabilit A draft DRE,86-175, was written on November 5,1986, which stated that the GE 556 purchase specification was unknown and that the transmitter was obtained from on-hand stock with no purchase order number. The DRE compared the critical characteristics of the GE-556 with a Rosemount 1151 and determined that the Rosemount would be an acceptable replacement. A GE 551 was the original transmitter and its critical characteristics should have been compared to the Rosemount 1151 for the direct replacemen This item was deferred in 1984 until 1985 due to budgeting and then again to 1986. It was removed from the budget in 1986. During January 1987 this transmitter was downgraded to a non "Q" item due to a plant modification that removed the steam condensing mod Due to the length of time this deficiency was known by the licensee, this item is considered an example of inadequate and untimely corrective actio EWR 83-1100 Dated April 27, 1983 This EWR tracks a previously identified problem with the seismic qualification of relays in the diesel generator control circuit An LER written on April 1,1982, stated that a mechanical shock to this relay could cause it to actuate, thus causing a lockout of the affected diesel generator. The first of four extensions lists higher priority work as the reason for not resolving this item. The seismi-cally qualified relays were finally installed and the modification declared operable in April 198 _ - _ _ - _ - _ _ _ _ _ _ - _ _ _ _ _ _ . _ _ _

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8 l Due to the safety significance of this item for common mode failure and four years to resolve the deficiency, this item is considered an example of untimely corrective actio EWR 84-809A Dated June 25, 1984 This EWR addresses inadequate core spray initiations due to deener-gizing electrical circuits associated with newly installed analog equipmen This event was previously noted as occurring twice and was noted in NRC Inspection Report Nos. 50-325/324 81-20 and 50-325/324 81-2 In November 1981, this event occurred again but was attributed to personnel error. Prior to November 1981, the licensee separated the power supplies such that one inverter was supplied by one circuit and a redundant circuit supplied the other inverter. Additionally, the licensee made administrative changes to the ground hunting and battery maintenance procedures to reduce the probability of recurrence of this event (noted in NRC Inspection Report Nos. 50-325/324-81-31). Associated PMs85-020 and 85-021 are still in the preparation phase. Discussions with the system engineer indicate that these PMs add additional circuit redundancy but do not correct the problem with the circuit board. These PMs are scheduled for implementation in 1988. This problem has been identified since 198 The plant modifications have been continually deferred due to budget constraints. The original plant modification that installed the analog equipment was unsatisfactory. Due to the length of time this deficiency has been known and the determination by engineering that the proposed plant modification will not resolve the deficiency, this item is considered an example of inadequate and untimely corrective actio EWR 83-463 Date July 28, 1983 The offgas systems for coth units were modified approximately four years ago to provide for holdup time and exhaust cleanup prior to environmental release. The new system was designed with bypass valves that fail open on loss of control air which could release untreated exhaust to the plant stack. This EWR was initiated by an operations engineer and he stated that the open valves were adverse to the system fail safe design.

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A documented review was not performed to address the significance of

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this item. It is known that on high steam line radiation the reactor would be shutdown and the steam lines would be isolated in accordance i with the E0Ps. This w'ould mitigate an off-site release from the offgas system.

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Another identified problem is that there is no alarm to warn the control room operator of improper valve position and the operator must rely on identifying incorrect valve position indicatio An investigation of this problem has not been performed since it was identified four years ag The potential exist for an off-site releas Due to the extended period of time that this potential problem has been known, this is considered an example of inadequate and untimely corrective actio EWR 83-168 Dated March 28, 1983 This EWR identified a problem with the accuracy of the flow instru-ments for ventilation exhaust from the turbine building, reactor building, and main stac Exhaust flows from these buildings are used to estimate off-site doses in accordance with the ODC An engineering evaluation of this problem was performed in 1985 (two years later), and stated that the mounting of the flow sent. ors was in a turbulent area of the ductwork which affects the accuracy, that a plant modification would be needed, and this item needed budgeting to remount the sensor Due to conservatism in calculating off-site releases, operability is not a concern for these instruments; however, the length of time this deficiency has remained open, is considered an example of inadequate ,

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EWR 80-272 Dated October 28, 1980 This EWR identified a problem with the valve position indication used by the control room for MSIVs. Due to heat from the main steam system, the MSIV indicators were failing and would not deenergize, thus providing unreliable control room indicatio Original plant modifications were implemented in 1981 and 1982, but failed to correct the heating problem. Other plant modifications were written to address this problem again, in 1984 for Unit 1, and in 1985 for Unit 2. Both modifications have now been implemented; 1985 for Unit 1 and 1986 for Unit 2. Part of the delay in correcting this item was caused by budgeting restraint Due to the length of time to adequately resolve this item, this is considered an example of untimely corrective actio J l

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l l EWR 84-170 Dated February 8,1984 This EWR identified a fire detector that was hanging from the ceiling in the south west corner of the Unit 2 cable spreading room. Resolu-tion of this deficiency has been delayed because it has not been budgete This is an example of inadequate and untimely corrective actio EWR 84-719 Dated April 27, 1984 This EWR identified a problem in the procurement of fire protection

, equipment, in that the procurement documents are not reviewed to l ensure that appropriate fire protection requirements are being me The Brunswick SER requires that procurement documents include appropriate fire protection requirement Discussions with licensee personnel indicated that a procedure has sti11 not been approved that assigns responsibility for revie Due to the length of time that this item has remained open, this item is considered an example of inadequate and untimely corrective actio EWR 02151 Dated January 2, 1985 This EWR identifies a problem with a control room annunciator, in that the fuel pool cooling alarm is constantly in the alarm condition. This annunciator was in alarm on both units. This annunciator is not considered to be safety-related but would indicate an inadequate spent fuel pool cooling condition. Discussions with licensee personnel indicated that a recent investigation of this problem identified improper spent fuel cooling system operation as the root cause of the alarm problem. System operations were changed and the alarm cleared in Unit 2. Unit I had previously lifted one of five leads in the alarm circuitry and this had cleared the alar The input for the lif ted lead was unknown at the time of this discussion and the lead needed to be reconnected. It is not a good practice to lift leads in order to clear alarms. Operations, with the assistance of maintenance, should have the expertise to identify operational deficiencies that lead to alarms and take corrective action. It appears that these annunciators were in the alarmed state for extended periods of time and should have been resolved prior to initiation of the EWR. This is considered another example of inadequate corrective actio Other examples of untimely or inadequate corrective action include:

84-685 83-083 84-362 82-294 84-472

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10 CFR 50 Appendix B, Criteria XVI states that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and correcte Contrary to the above criteria, it appears that the licensee has not taken timely, or in some cases, adequate corrective action to resolve identified deficiencies. Seventeen of the thirty-six EWRs reviewed in detail were found to fit this situation. This indicates an EWR weakness problem that will require intensive management attention to resolve. In ganeral, the licensee is not ensuring that identified deficiencies are promptly and adequately corrected. This issue is identified as violation 324/87-31-01 and 325/87-32-0 Failure to Document the Results of Reviews of Engineering Work Requests The following EWRs are combined as they exhibit failure to document engineering reviews of identified deficiencie EWR 84-685 Date May 9, 1984 In April 1984, a problem with the skid mounted supply breaker for the SGTS was identified. Schematic prints identify the breakers as being 60 amp, whereas the manufacturer supplied 50 amp breakers. A letter from the manufacturer, Farr Company, was received by the license on May 1,1984, and it confirmed the telcon of April 19, 1984, in that the 50 amp circuit breaker is not adequate for the load ano should be replaced with a 60 amp circuit breake An engineering evaluation was not performed to justify continued operability of the four SGTS. These are TS systems and are required for plant operatio Discussions with the licensee indicated that because the four systems were able to pass their monthly surveil-l lances they could be considered operable even though a defect existed.

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The NRC contacted the Farr Company on October 8,1987, to obtain information concerning the bases for the Farr Company letter to the licensee. A Farr Company representative indicated that the wrong breakers were originally supplied with the SGTS skid and needed to be replaced with 60 amp breakers. The manufacturer based the breaker size on a full load rating of 43.6 amps at 460v. Using a 480v rating would further increase the heater amperage f rom 22.6 amps to 2 amps, thereby increasing full load amps to 44.2 amp By using GE publication GET2779F, the selection of circuit breaker rating can be obtained. Various calculations indicate that a 60 amp breaker is

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required. The publication also references the national electrical code which requires a minimum breaker size equal to or greater than the continuous load current x 1.2 This calculation also requires that a 60 amp breaker be installe The manufacturer indicated that the 50 amp breaker would be marginal at bes The licensee provided graphs showing that the 50 amp breaker was satisfactory, however, they did not supply supporting calculations or code requirements. The graphs were generated during September 1987, and addressed the proposed Westinghouse replacement breakers, not the ITE breaker supplied by the manufacturer. During the 1987 outage the SGTS motors were changed to smaller motor Calculations still indicate that a larger breaker is neede During a telephone conversation with licensee personnel on October 28, 1987, the inspectors were informed that the SGTS were operable based on additional information received from the vendo The licensee's failure to review this item and thereby ensuring acceptable continued operability, is considered to be an example of failure to document review EWR 84-496 Dated April 19, 1984 EWR 01334 Dated July 17, 1984 EWR 84-496 reported that an unauthorized jumper (2-3676) was found in Panel XU-42, Diesel Generator Controls and Indication, which was not listed in the control room jumper log and not shown on the electrical schematics. The tag was hung on August 21, 1978. EWR 01334 identified that three months later jumpers were also found in the other three diesel generator panel The first EWR extension request stated that, " investigation not started due to higher priority work." An evaluation was not docu-mented to show that these jumpers did not impact system operabilit Per discussions with plant engineering personnel it was found that an evaluation was perf ormed in late 1986; two years late The jumpers are in a non-safety circuit that only provides DG wattage to the control room operato It was then found that another EWR had been written on July 17, 1978, to address an unauthorized plant modification, which installed jumpers and resistors in the DG wattmeter circuit. This EWR had been voided even though the circuits had been modifie The licensee did not take adequate corrective acticn, in that jumpers in the other three DG panels were not identified for three month Jumper tags were installed in four panels and were not identified by I operations / maintenance' personnel for over six years. An unauthorized modification was addressed by a 1978 EWR, however, and the EWR was voided even though the modification was performed.

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l This deficiency was not evaluated to indicate justified continued operation. This item is another example of failure to document the results of a review or analysi EWR 84-472 Dated April- 27, 1984 This EWR identifies a problem with area radiation monitors' high alarm setpoint dri f It identifies that the frequency of this problem is increasing, and the supervisor was in concurrence that

"there is a setpoint problem."

This EWR was sent to engineering to investigate and determine the source of the problem. A documented review was not performed to justify continued system operatio Thirteen months later an extension for the investigation was requested due to higher priority work and system engineering qualification; it also stated that this item had not been evaluate Discussions with the licensee indicated that no action was taken on this item; however, and at this time there does not appear to be a setpoint drift problem, therefore this EWR is being closed by the licensee. This item is considered to be another example of failure to document the results of a review or analysi EWR 84-391 Dated November 7, 1983 This EWR identifies a problem raised by a technical support engineer concerning possible RWCU system inadvertent isolation. Due to the system configuration when RHR is in the shutdown cooling mode, adequate NPSH may not be available to the RWCU system pumps with the reactor at 0 psig pressure and 212 F temperatur Discussions with the licensee identified that preliminary calcula-tions snow that this may not be a problem; however the licensee did not perform a review of this item which probably could have been used to close this concer This item is considered to be another example of failure to document the results of a review or analysi Other examples of failure to document the results of a review or analysis include:

84-1024 83-463 83-168 79-399 84-809A 84-362 82-294 i

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1 10 CFR 50 Appendix B Criteria XVII and the licensee's Quality Assurance Program collectively require that records shall be maintained to provide documentary evidence of activities affecting quality and these records shall include results of review Results of reviews of EWRs are not documented as require Twelve of l thirty-six EWRs reviewed in detail exhibited this proble In general the licensee is not adequately reviewing EWRs or docu-menting the results of their reviews until work on the EWR is

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budgeted. In some cases reviews or evaluations are never performed.

I A potential deficiency must be reviewed and the results of the review must be documented in order to justify continued operability. This issue is identified as violation 324/87-31-02 and 325/87-32-02.

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d. Potential Inadequacy Relative to Maintaining An Adequate Water Supply to Meet Fire Protection Requirements EWR 84-362 Dated March 14, 1984 EWR 82-294 Dated August 24, 1982 EWR 84-362 identifies a problem with the fire protection syste A number of sprinkler systems were found to draw more water than could be supplied for a duration of two hours as required by the SE Discussions with plant personnel indicated that calculations confirmed a 240,000 gallon capacity is needed versus the original design of 200,000 gallons to meet the two hour rating requiremen The licensee did not perform an evaluation to justify continued system operability, submit a variance or TS change to the NRC, or administratively control the fire tank level above the new 240,000 gallon limi EWR 82-294 identifies a problem with the fire protection tank low level alarm being set below the TS minimum level of 200,000 gallon A plant modification,84-269, to correct the level problem was written on April 5,1984; yet no work has been performed on this item due to budgeting restraint The fire prote</ tion Safety Evaluation Report (SER) by NRR assumes that the design of the fire protection primary water tank is large enough to provide over two hours of fire flow for the largest expected demand and its water level is electrically supervised. A TS minimum level of 200,000 gallons is based on meeting the maximum two hour deman EWR 84-362 documents that the maximum demand exceeds the original design and the TS minimum value. The licensee was aware of this problem and failed to take corrective actio As a result of this

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known deficiency, the licensee could not meet the fire protection two hour supply requirement. Upon notification, the licensee revised 01-03.3, A0 Daily - Surveillance Report, te maintain the fire tank level greater than 240,000 gallon EWR 82-294 Documents that the low level alarm is alarming below the TS value and therefore the water level is not electrically supervised as require The licensee did not perform an evaluation to justify continued system operability, submit a variance or TS change to the NRC nor administratively control the fire tank level above the new 240,000 gallon limi These issues are identified as unresolved item 324/87-31-05 and 325/87-32-0 Management Weaknesses The following items are grouped together because they appear to exhibit management weaknesses in resolving issues and inadequate management attentio EWR 82-189 Dated May 11, 1982 This EWR implements SIL Number 373, where the vendor recommends new CRD hydraulic control system scram valve opening air pressure settings. This item has not been adequately addressed by managemen EWR 83-070 Dated February 31, 1983 This EWR also implements SIL Number 373, which recommends changing HCU inlet and outlet scram valves start-to-open setpoints. This is a

. change to the original manufacturer specification per FP 50890-GE T.M. (HCU) page 5-4. This change will require an engineering evalua-tion and plant modificatio Discussions with the system engineer indicated that this item needs to be incorporated in the technical manual and in the maintenance procedures, but was not accomplished due to a lack of " ownership" for {

q accomplishment. The actions were not specifically assigned and no y action was take EWR 82-015 Dated January 18, 1982 l

BESU identified possible errors in the TS regarding RHR shutdown cooling isolation logi Twelve items were identified; three items l

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remain open which are addressed in a proposed draft TS change. The TS change, 85-12, contains a significant number of required change Management has not pro'vided adequate attention to finalize the pro-posed TS change; TS change 85-12 has been in draft form in excess of two year _ _ _ _ _ _ _ - _ _ . >

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EWR 83-1380 Dated June 4, 1983 The licensee's QA organization issued NCR S-82-039, for failure to have an adequate Q-list. The required due date for response to this NCR was August 25, 198 This deficiency was first noted in 1979 (ref. 0QAI-79-28 and 00AI-79-35) and EWR 80-001 was written to develop this lis Delays in issuing a contract for completing the project caused a request for an extension to December 31, 198 Resources were diverted from this project and coupled with other management decisiens, prompted an additional extension to complete this project; the last extension was granted to March 1988. Discussions with the project engineer indicate this date will probably slip several more month This issue has been ongoing for over eight year EWR 83-366 Dated June 23, 1983 The fuel pools frequently overflow to the reactor cavity with over-flow leakage to the reactor building ventilatio This was noted as a continuing equipment contamination and corrosion problem. It was also noted as a serious personnel contamination problem. Review of the EWR package indicate no action was taken concerning this problem until a serious overflow occurred; 25,000 gallons in a 1985 due to inadvertent ECCS initiation during a refueling outag The licensee revised outage control procedures and the maintenance procedures, MP-7, 8, and 9. These revised procedures and the 1985 LER corrective actions, appear to provide adequate controls to prevent recurrence of this even This EWR is still open, with a note attached stating this item is an enhancement item and will be left open and investigated at a future date. This EWR appears to have been corrected in 1985 as a result of the corrective actions from the 1985 LER. Management does not appear to have a mechanism to relate corrective actions initiater from other problems back to a related EW EWR 80-184 Dated July 18, 1980 This EWR addresses the in-vessel capsule removal schedul A TS evision was requested on January 17, 1985, but has not been ieceive The items identified in this section indicate a general lack of i management attention. Overall the EWR program appears to be a dumping ground for problems and concerns, some of which should be

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handled by other site disciplines.

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17 Management Overview and Summary I' The licensee provided an overview of the EWR program after the i inspectors raised concerns with size of backlog and corrective action l

item CP&L management expressed the following concerns:

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Size of backlog precludes effective managemen Backlog contained old items which appeared to no longer be vali Response times and adequacy are difficult to determine and asses The licensee also provided a list of EWR process improvement actions that were to be pursued which included forming an EWR Engineering Review Board, developing a work management system and providing an independent review of backlogged EWRs for safety and operability concerns. Actions taken to date have not resulted in any significant reduction in the EWR backlo Management has started an initiative to reassign items ir, order to clear up the large backlog of EWR In some instances items that have been idle for years, have now become problems for the new responsible organizations. The Technical Support Engineering Group, which includes the system engineers, appears to have so many other responsibilities that they are unable to adequately perform their system engineering functio The budgeting process used by the licensee may have an adverse effect on their ability to resolve issues. Those items that do not directly affect continued plant operation are placed in the budgeting process and may wait years for budgetin Items that are not budgeted may not be worked, this also includes the preliminary evaluations that in some cases could eliminate an item or escalate an item to a higher priorit The system causes frustration, as individuals identify items that they feel are important but do not receive feedback for extended periods of tim Additional management attention and more resources will be required to resolve the large backlog of issues now in the EWR progra . Maintenance This QA assessment included a review of the maintenance area. This review was to determine maintenance program status, re'iew initiatives being taken to improve the program, and determine the ibility of the licensee to identify their own problems and take adequate corrective action in resolving those problems. The inspection was conducted through interviews

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with personnel, observation of a maintenance activity in progress, and a review of completed maintenance work orders and their associated mainte-nance procedures. The detailed scope of this part of the assessment and conclusions reached are as follows:

! Management Initiatives and Program Controls

Use of AMMS Computer Planning System, although a relat<vely new system, is rapidly becoming a valuable management tool for planning and controlling maintenance activitie The system is currently being used to generate automated maintenance work orders. The system has the capability of sorting an entire maintenance work package in many different ways, providing management practically any information r they may require concerning a particular packag During this assessment, a brief review of the MIP was conducted by the inspector. The program has a large scope and the initiatives being undertaken should result in significant improvements in the maintenance area. The MIP was started in January 1983, and initial efforts focused on reorganizing and staffing the maintenance engineering organization and rewriting maintenance instruction The engineering reorganization, for the most part, was completed in l 1985 and Phase I of the instructions rewrite (pts to the new MST

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format), was completed in January 198 This effort included the l l issuance of approximately 450 documents. Phase II of the rewrite program (rewrite of mis in the new PAM format), involving approxi- -4 mately 1800 documents, began in March 1986 and is well underwa Phase III (rewrite of Administrative MPs into the MMM) has just begun. Other initiatives of MIP include the AMMS Corporate Planning System discussed above, as well as, the following maintenance j trending / improvement initiatives as follows: 1

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Oil analysis including physicals, spectrographic analysis, and i ferrography l

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Vibration analysis of rotating equipment

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Motor operator valve testing I l

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Equipment repetitive failure analysis and;

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Post-maintenance work inspections / audit Observation of Maintenance in Progress The inspector observed a maintenance activity in progress and conducted a walk-through inspection of the service water and diesel l

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generator buildings. The activity observed was reinstallation of the regulator in the cooling line to the 2B service water pump. Attri-butes observed included: proper use of a calibrated instrument l

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(torque wrench), observation of a QA hold point inspection for system l cleanliness prior to final closure, proper traceability of materials,

and adherence to procedures by maintenance personnel. As a result of

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observing this activity, conclusions reached were that the instruc-tions for the performance of work were clear and personnel performing the work were knowledgeable of procedure requirements and equipment.

A walk-through inspection of the diesel building determined that the area was clean and orderly. A walk-through inspection of the service water building determined that a significant amount of general main-tenance was being performed in the area resulting in a general lack of' cleanliness. Specific concerns nc .ed by the walk-through were discussed with the Maintenance Manager immediately after the walk-throug Review of Completed Maintenance Work Packages The inspection included a detailed review of five completed work order packages. The review was conducted to verify that maintenance of safety-related equipment is being performed in accordance with technical requirements for the equipment, and to ensure that mainte-nance activities are being completed and properly documented. This review did not reveal any discrepancies in the work / documentation process. All concerns raised by the inspector were satisfactorily resolve The following are the work packages that were reviewed:

WR/JO 85-ADWC1 -

Replacement of valve 1-SW-V20 WR/JO 85-AAGZ1 - Trouble shooting of valve actuator for valve 1-E11-F052 WR/JO 85-AHZJ1 - Replacement of instrument isolation valve 1-B32-N0188- WR/JO 85-AAAG2 - Troubleshooting of valve actuator for valve 1-E11-F017 WR/JO 85-AHJC1 - Correction of packing leak on valve 1-B21-F011 Within this area no violations or deviations were identifie . Operations / Surveillance Testing The licensee's quality assurance effectiveness in the area of operations and surveillance testing was assessed by a review of various surveil-lances, procedures, and calibrations. The intent of the inspection was to assess the effectiveness of the licensee's program to identify deficien-cies and to take adequate and timely corrective actio The data for the quarterly service water pump and discharge valve operability surveillance te'sts and the Reactor Core Isolation Cooling system operability surveillance test were reviewe The results of this review indicate the tests were in conformance with their respective test procedures and each met the requirements specified in the FSAR and the T ..

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A review of Operations Action Item Tracking system procedure, 01-25 Revision 002, indicates that this procedure provides a method for tracking and ensuring the timely completion of commitment and action items assigned to operation The Operations Action Item list contained approximately 450 items. Of these, 8 had exceeded their required action due date, and 40 were due action during the week of October 28, 1987. The inspector determined from his review of the overdue items that each was in the process of being dispositioned by the responsible individual, and safety or operability issues were not involve Additionally, a review of Operations Internal Audits procedure, 01-29, Revision 012, was conducte This procedure appears to be comprehensive and addresses the methodology for performing internal audits of the Operations department instructions, procedures, and applicable record This procedure requires that audit findings which require further correc-tive action, to be entered into the Operation Action Item tracking syste Attachment I of 01-29 lists the areas to be audited; this list does not contain 01-25. Line management involvement is ensuring that an internal monitoring or audit of the action item tracking systems could identify significant trends and prevent similar problems from occurring.

, Within this area, no violations or deviations were identifie . Quality Assurance / Quality Control The licensee's quality assurance function at Brunswick is performed by a corporate group, PEU, which conducts audits, and an onsite QA/QC group which performs surveillance, quality control functions, and receipt inspection Audits by the PEU tended to be large scope programmatic reviews of site functional areas which fulfilled, via TS required audits, the licensee's commitment for site audits. Surveillance by the site QA group were more in-depth specialized reviews of plant activitie Assessment of the quality assurance area consisted of: a review of audits and audit findings from 1985 to present, review of onsite problem identification programs, (i.e., nonconformances and operating event '

reports), and trend reports generated from those finding The inspector reviewed a selection of audits from 1986 and 1987, audit findings for this two year period and the audit schedule for 1987. The following audit reports and associated audit check lists were reviewed:

Audit Number Activity Audited l

Operations, Environmental and

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QAA 21-86-06 l Radiation Control QAA 21-86-07 Operations and Emergency Activities QAA 21-86-08 Operations i QAA 21-91-86-01 Construction QAA 21-91-86-02 Construction l i

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QAA 103-86-02 Engineering Support Unit (BESU)

QAA 21-87-01 Security QAA 21-87-01x Radwaste Program QAA 21-87-03 Fire Protection and Loss Protection QAA 21-87-04 Maintenance QAA 21-87-05 Inservice Inspection Program

! QAA 91-87-01 Construction QAA 103-87-01 BESU i

The audit scopes appeared to be adequate for the activity audited, (with i an exception to be discussed later) and the check-list items appeared to

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reflect the stated audit scope The responses by the auditor to the individual check-list items were often brief such that reconstruction of the audit data would be difficult or inhibited. For example Audit QAA-21-86-06, item 4.6.1, stated, " verify that areas designated radiation areas do not exceed 5 mr/hr at the posted bounda ry. " The comment by the auditor was " verified by sight." This comment did not indicate what radiation areas were observed nor how verification by " sight" was made. Occasionally portions of the audit check list comments were difficult to read or completely illegible Audits 21-86-08, 91-86-02 and 21-87-01. Brief and illegible comments inhibit reconstruction of audit activity. Although the audits reviewed by the inspector appeared to adequately review an activity with respect to check list items, auditor comments were inconsistent in their ability to provide an indication of item application depth to the activit Discus-sion with QA management indicated an awareness of this weakness and an attempt to strengthen this area has been mad Some success was noted in the more recent 1987 audits as the auditors comments were substantially more aetailed. Of particular merit in the licensee's audit practice was the use of technical and experienced personnel from other plants or departments. Each audit included personnel able to provide expertise in an area. Documentation demonstrating the individual's qualifications in the area of audit activity was included in the audit report packag QA management was in the process of standardizing a method to improve the audit skills of the technical auditors. Additionally, it was noted that audits included previous open audit items in the audit scope and either closed the item or provided a status update. Review of audit findings for 1986 and 1987 demonstrated that findings were adequately followed up and closed in subsequent audit Only five relatively minor audit findings were open at the close of this inspectio The inspector reviewed the audit schedule for 1987 to verify that audits required by TS were scheduled and performe The licensee has met or exceeded the listed audit requirements. Due to problems identified in engineering activities with respect to EWRs, the inspector reviewed audits to determine if QA attention had been applied to this area. The audits of the BESU, QAA 103-86-02 and 103-87-01, did not include a review of EWR Engineering Procedure ENP-20, Engineering Work Request, Revision 5, i

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purpose section states that EWRs provide a methodology for identifying engineering problems. Review of corrective action audits since 1985 indicated that EWRs were not included in the corrective action audits'

scope Discussion with corporate QA management indicated that EWRs were not regarded as a corrective action mechanism but as an input to the engineering review process. The audits of BESU (which included corrective action), reviewed nonconformance reports which were assigned BESU responsibilit Although the audit schedule fulfilled licensee audit requirements, the scope of the audits, with respect to BESU and/or

, corrective actions, failed to adequately cover this aspect of engineering l responsibility. A violation was identified in this area and is discussed I

in a later paragrap The onsite QA/QC group performs the following functions:

Procedure / program review Surveillance of plant activities QA engineering review - compliance to design basis, FSAR, et Receipt inspection Nonconformances identified from these functions were reported as NCRs (significant items) or NFRs (less significant items). The inspector's attention focused on the backlog of NCRs and those NCRs closed since September 1986. Approximately 84 NCRs were open as of September 24, 1987, and 154 items had been closed in that one year perio Of the closed items, 25 percent were granted one or more extensions and 15 percent were late greater than 30 days from commitment date. A sample of closed items indicated that although corrective action completions were often truant and therefore, extended or late, items with operability implications were resolved in a timely manner. Open NCRs ranged from initiation in 1979 to the present. A sample of these backlogged, items and long term resolution closed items was reviewed and discussed with responsible plant personnel to determine if the items were in process for resolution and that long term open items were not caused by inattention by plant management. The following NCRs were reviewed: ,

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S-79-534 50 Feet Elevation RB Number 2 l Ceiling Leak l S-81-005 Training Record Storage S-82-024 Storage of QA Records (Construction)

S-82-027 TS Require Certain Surveillance Requirements to be Implemented S-82-039 Failure to have an Adequate Q-list S-83-065 Primary Coolant Specific Activity and Analysis Program S-83-094 RPS Manual Bypass Inadequacies

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S-83-157 Installation of Non qualified Breakers into MCCs and AC/DC Distribution Panels R-84-051 Unit 1 Piping Installed in Unit 2 S-85-070 E&RC M&TE Out-of-Tolerance Evaluations S-86-004 Non-Q Material Installed When Q-list Required S-86-005 Incorrect Wire Installed on Category 1 Limitorque Actuators S-86-006 Non Q-list Wire Installed on Q-list Equipment R-86-007 Document Review Sampling Program Deficiencies S-86-008 Inadequate Maintenance Instruction S-86-012 Nitrogen Backup System Not Operated in Accordance With System Design S-86-013 Public Address System S-86-041 Plant Testing and Calibration Procedures Do Not Meet FSAR Commitments S-86-050 Document Sampling Review Program S-86-053 Document Sampling Review Program S-86-056 Inadequate Procedure Review S-87-027 Valve Testing Deficiencies 5-87-034 Equipment Clearance Procedure Review of nonconformances indicated a generous management policy of granting extensions for corrective actions. Extensions were not logged or 1

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trended which prevented accurate appraisal of the volume or justification for extension Long term open items were to be addressed by current programs or projected modifications so that no operability or environmental problems were identifie Response tn NCRs have improved within the last yea The onsite QA group performed a surveillance of EWRs, (Surveillance Report No. 86-18), dated March 13, 1986. This surveillance issued nine concerns which identified problems with the administration and management of EWR Concerns are the lowest mechanism of identifying problems in the hierarchy of nonconformances, i.e. below NCRS and FRs. The concerns with the EWR system and backlog were not considered a significant plant proble The backlog at that time was 1702 outstanding EWRs. After 18 months there appeared to be no significant corrective action. This is indicative of QA l failure to adequately assess the scope of the problem or to communicate l the importance of this problem to managemen l l

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The inspector reviewed Plant Nuclear Safety Committee trend reports for 1987 and quarterly 1987 nonconformance trend reports by the QA grou Nonconformances appeared to be extensively trended for those mechanisms recognized as problem identification programs. Overall the corporate and site QA programs appear to meet regulatory requirement Within this area, one violation was identifie The licensee corrective action audits did not review the engineering work request program which engineering procedure, ENP 20, Revision 5, describes as a problem identification / corrective action system. ANSI N45.2.12 requires audits of selected elements of the QA program to be performed to the depth necessary to determine if they are being implemented effectively. As discussed in paragraph 6 multiple problems were identified with the EWR program. This program was not audited even though the EWR program i s by procedure def nition a problem identification / corrective action procra This failure of the QA program to perform adequate audits of the corrective action systems is identified as violation 324/87-31-04, 325/87-32-0 . Measuring and Test Equipment (M&TE)

The inspector reviewed the implementation of the licensee's M&TE program as defined by the licensee's commitments to applicable regulatory guides and standards, the quality assurance corporate manual, and site proce-dure This review consisted of a documentation review, observation of equipment calibration, and tours of calibration and equipment storage facilitie The result of this review was that the implementation of the licensee M&TE program appeared to comply with plant commitments and site procedure The inspector reviewed documentation to verify M&TE calibration frequen-cies were met, calibration documentation was complete and provided traceability to the NBS, and timely and adequate evaluation of out-of-tolerance M&TE was performe The following equipment documentation was reviewed to verify adequate historical information and NBS traceability:

AC-2 HG-22 BMT-1 HG-35 C-15 PG-506 CR-180 PY-2A DC-13 R-15 FM-6 RC-15 G-115 RT-4 G-147 S-8 G-69 T/C-016 HG-10 TH-8 l

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l The following items were due or near due for calibratio These items were located and verified calibrated or separated from equipment available for check out to plant personne G-10 G-183 G-6 G-129 G-184 G-61A G-16 G-185 G-75A G-166 G-186 G-99A G-171 G-27A HG-15 G-172 G-31 HG-2 G-173 G-36A HG-7 G-174 G-38 HYD-17 G-178 G-43A HYD-20B G-179 G-51A HYD-21B G-180 G-52 HYD-22A G-181A G-55A PC-15 G-182 G-56A PC-17 The licensee maintained a log of equipment out-of-tolerance reports which listed the out-of-tolerance range, the date a request for evaluation was initiated, and the date the evaluation was received. Plant procedures require evaluation response within 15 working day Review of the log indicated that this time requirement was consistently met. The inspector reviewed the out-of-tolerance evaluations for the following instruments:

Instrument Initiation Date G-174 04/17/87 G-173 04/17/87 G-133 04/21/87 G-60 04/21/87 G-132 04/21/87 HG-21 05/06/87 G-132 06/10/87 G-179 06/10/87 G-145 06/23/87 G-103 07/14/87 G-14 07/16/87 FM-34 07/23/87 A-10 07/23/87 G-141 07/23/87 HG-41 08/10/87 G-143 08/11/87 HG-1 08/12/87 G-139 09/09/87 G-176 09/09/87 G-117 09/10/87 G-83A 09/10/87 G-13A 09/11/87

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The usage of instruments appeared to be adequately evaluated with respect

to application of the equipment and the range of the out-of-tolerance I condition. Maintenance of M&lE documentation es QA records appeared to meet the guidelines of ANSI N45.2.9 - 1974, and requirements of the corporate QA manua The inspector observed the performance of a gauge calibration by a

technician in the calibration laboratory. The appropriate calibration

! instruction was open and referenced and shop standards were in calibration

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and traceable to the NB Discussion with the technician demonstrated a thorough background knowledge of calibration technique and familiarity ,

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with the calibration instruction and applicable administrative procedure The inspector toured the M&TE calibration and storage facilities to observe methods of storage, environmental controls, equipment issue procedures, inventory control, and to verify adherence to requirements for calibration stickers and segregation of equipment out-of- calibration.

l Equipment stored in the mechanical tool room and the I&C tool issue room l appeared to be adequately stored to preclude damage during storag Environmental controls in both calibration laboratories appeared adequate for those calibrations performed onsit Equipment issue procedures ensured adequate information on activity cards to identify previous use of i

equipment, and the requirements for equipment turn-in at the end of each

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shift provided good inventory control by M&TE personnel . The inspector verified calibration stickers were attached to equipment in the tool issue l areas and that this information adequately reflected information on the

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associated equipment calibration documentation. Broken or uncalibrated equipment was removed from the equipment issue area Overall the licensee control of measuring and test equipment was good and documenta-

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tion of equipment and out-of-tolerance evaluations appeared adequate.

l Within this area, no violations or deviations were identifie II

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