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{{Adams | |||
| number = ML20214M877 | |||
| issue date = 08/13/1986 | |||
| title = Insp Repts 50-327/86-41 & 50-328/86-41 on 860707-11. Violation Noted:Failure to Process Corrective Action Request in Accordance W/Established Procedures | |||
| author name = Belisle G, Moore L, Runyan M | |||
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) | |||
| addressee name = | |||
| addressee affiliation = | |||
| docket = 05000327, 05000328 | |||
| license number = | |||
| contact person = | |||
| document report number = 50-327-86-41, 50-328-86-41, NUDOCS 8609110361 | |||
| package number = ML20214M862 | |||
| document type = INSPECTION REPORT, NRC-GENERATED, INSPECTION REPORT, UTILITY, TEXT-INSPECTION & AUDIT & I&E CIRCULARS | |||
| page count = 14 | |||
}} | |||
See also: [[see also::IR 05000327/1986041]] | |||
=Text= | |||
{{#Wiki_filter:p (fru UNITE 3 STA TES | |||
' | |||
. | |||
' | |||
. o' NUCLEAR REGULATORY COMMISSION | |||
^ | |||
-['' p REGION 11 | |||
g j 101 MARIETTA STREET.N.W. | |||
* * ATLANTA. GEORGI A 30323 | |||
\...../ | |||
' | |||
Report Nos.: 50-327/86-41 and 50-328/86-41 | |||
' | |||
. Licensee: Tennessee Valley Authority | |||
6N38 A Lookout Place | |||
1101 Market Street | |||
Chattanooga, TN 37402-2801 | |||
Docket Nos.: 50-327 and 50-328 License Nos.: DPR-77 and DPR-79 | |||
Facility Name: Sequoyah 1 and 2 | |||
Inspection Conducted: July 7-11, 1986 | |||
Inspectors: 1 %w 8 -33- 8 6 | |||
M. F. R ~ an 1 Date Signed | |||
.\ M - 8/ 8b | |||
L. R. Moore ' | |||
' Date Signed | |||
Accompanying Personnel: G. A. Belisle, RII | |||
C. Wallenga, IE | |||
' | |||
Approved by: ./ n 7 / I | |||
G. A. Belisle, Acting Section Chief / Date Signed | |||
Quality Assurance Programs Section | |||
Division of Reactor Safety | |||
SUMMARY | |||
Scope: This routine, special unannounced inspection was conducted at the | |||
corporate offices and on site in the areas of QA audit effectiveness, QA record | |||
storage practices, and licensee actions on previously identified inspection | |||
findings. | |||
Results: One violation was identified. | |||
n | |||
8609110361 860829 | |||
PDR ADOCK 05000327 | |||
G PDR | |||
< | |||
* | |||
. | |||
REPORT DETAILS | |||
1. Persons Contacted | |||
Licensee Employees | |||
*H. Abercrombie, Site Director | |||
*W. Andrews, Site Quality Manager | |||
*J. Anthony, Operations Supervisor | |||
*W. Baker, Fire Protection Engineer | |||
*R. Birchell, Licensing Engineer | |||
*T. Blankenship, Manager, Information Services | |||
R. Bruce, Section Supervisor, QA Branch | |||
*R. Buchholz, Site Representative, Office of Nuclear Power (0NP) | |||
*M. Cooper, Mechanical Engineer | |||
*E. Craig, Mechanical Modifications | |||
*E. Craigge, Independent Safety Staff | |||
M. Crane, Materials Unit Supervisor | |||
**J. Crittenden, Assistant Branch Chief, Nuclear Quality Assurance (NQA) | |||
*H. Elkins, Instrument Maintenance Group Supervisor | |||
K. Faulkner, Supervisor, Instrument Shop | |||
*R. Fortenberry, Technical Support Supervisor | |||
J. Green, Measuring and Test Equipment (M&TE) Foreman | |||
**J. Huston, Deputy Director, NQA | |||
D. Jackson, Safety Specialist | |||
*D. Jeralds, Instrument Craft Supervisor | |||
*J. Kelly, Engineer | |||
*G. Kirk, Compliance Licensing Supervisor | |||
M. Koss, Welder and Metallurgical Specialist | |||
*C. LaFever, Instrument Engineer | |||
*D. Lambert, Manager, Nuclear Safety and Licensing | |||
R. Mullin, Chief, Nuclear Quality Audit & Evaluation Branch | |||
*L. Nobles, Superintendent, Operations | |||
*M. Parcell, Compliance Licensing | |||
G. Petty, Materials Officer, Specifications Materials Unit | |||
G. Poe, Hazardous Materials Control Specialist | |||
*R. Pierce, Material Maintenance Supervisor | |||
L. Reardon, QA Specialist | |||
R. Rogers, Compliance Specialist | |||
*M. Sedlacik, Modification Section A Supervisor | |||
*J. Steigelman, Unit Supervisor, Radiation Control | |||
J. Stitt, Corrective Action Coordinator | |||
**F. Szczepanski, Chief, Nuclear Safety Staff | |||
*R. Thompson, Assistant Branch Chief, ONP | |||
*D. Tullis, Maintenance, Special Projects | |||
*P. Wallace, Plant Manager | |||
*K. Weller, Systems Engineer | |||
G. Wilbourn, Technical Reports Specialist | |||
.__ - . _ _ _ _ _ . ._ -_ | |||
- | |||
. | |||
2 | |||
Other licensee employees contacted included technicians and office | |||
personnel. | |||
NRC Resident Inspectors | |||
*P. Harmon | |||
*D. Loveless | |||
*K. Jennison | |||
* Attended exit interview at Sequoyah Plant site. | |||
** Attended exit interview at TVA Corporate Office. | |||
2. Exit Interview | |||
The inapection scope and findings were summarized on July 11, 1986, wit.h | |||
those persons indicated in the paragraph above. Two exits were performed on | |||
this date, one exit at the Sequoyah plant site and a second at the TVA | |||
corporate office. The inspector described the areas inspected and discussed | |||
in detail the inspection findings. No dissenting comments were receised | |||
from the licensee. | |||
Violation, Failure to Process a Corrective Action Request in Accordance | |||
With Established Procedures, paragraph 5. | |||
1 Inspector Followup Item, Storage and Control of QA Records During Review, | |||
paragraph 7. | |||
At the exit interview, the issue regarding QA records was presented as | |||
an unresonable item. TVA personnel stated that TVA would submit a | |||
formal response to the NRC, Region II, resolving this issue. | |||
Upon NRC Region II management review of this issue, it was decided | |||
than an inspector followup item was more appropriate. This change in | |||
item classification discussed with the Chief, Nuclear Quality Audit | |||
and Evaluation Branch during a telephone conversation conducted on | |||
August 20, 1986. | |||
The licensee did not identify as proprietary any of the materials provided | |||
to or reviewed by the inspectors during this inspection. | |||
3. Licensee Action on Previous Enforcement Matters (92702) | |||
a. (Closed) Severity Level IV violation (327, 328/85-05-01): Failure To | |||
Evaluate Out-0f-Calibration Measuring And Test Equipment In A Timely | |||
Manner. | |||
The licensee response dated May 10, 1985, was considered acceptable by | |||
Region II. | |||
. -- _ | |||
. | |||
3 | |||
Closure was based on Revision 5 to Procedure IA-31, Control of | |||
Measuring and Test Equipment and Verification of Timely Evaluations of | |||
Out-of-Calibration M&TE. This revision required a safety evaluation of | |||
equipment usage if an out-of-tolerance evaluation was not completed in | |||
ten days. The inspector verified implementation of this revision. A | |||
present total of 12 evaluations were outstanding, which was a | |||
considerable improvement over the backlog of evaluations existing at | |||
the initiation of this violation. | |||
The inspector concluded that the licensee had corrected the previous | |||
problem and developed corrective actions to preclude recurrence of | |||
similar problems. Corrective actions stated in the licensee response | |||
have been implemented. | |||
b. (Closed) Severity Level V violation (327, 328/86-12-01): Inadequate | |||
Document Controls | |||
The licensee response dated May 27, 1986, was considered acceptable by | |||
Region II. | |||
The inspector reviewed a records transmittal form which transferred the | |||
19 preoperational test records in question to the Document Control | |||
Center on February 14, 1986. Three records (W-10.5 (Unit 1), W-9.1 and | |||
W-10.1 (Unit 2)) were selected at random and were verified to be | |||
located in the vault. The inspectors were assured by licensee | |||
personnel that no other preoperational test records were outstanding | |||
and that all such records are being handled as permanent plant QA | |||
records. The inspector concluded that the licensee had corrected the | |||
previous problem and developed corrective action to preclude recurrence | |||
of similar problems. Corrective actions stated in the licensee response | |||
have been implemented. | |||
4. Unresolved Items | |||
Unresolved items were not identified during this inspection. | |||
5. Corrective Action (92720) | |||
The inspectors reviewed computer tracking system (VIAS) printouts that | |||
provided status for audit findings. Two printouts were available. One | |||
contained a listing for all outstanding audit findings and the other | |||
contained a listing for audit findings in escalation. Currently, at | |||
Sequoyah, the following audit findings were in escalation as of the July 10, | |||
1986, VIAS printout: | |||
_ _ . - _ | |||
_ - . _ . _ .. . _ _ _ | |||
.- _ _. | |||
* | |||
. | |||
4 | |||
QSQ-A-84-0014-02 (SQ-8400-14), which deals with inadequate, | |||
inconsistent, and not properly implemented chemical control procedures. | |||
QSQ-A-86-001-01, which deals with various document control problems. | |||
QSQ-A-86-0001-02, which deals with improper storage of documents. | |||
QSS-A-84-0011-02 (CH-8400-11), which deals with not providing annual | |||
training of section and unit supervisors. | |||
QSS-A-85-0006-03, which deals with safeguards information | |||
QSS-A-85-0010-03, which deals with inadequacies in the records | |||
management program for health physics QA records. | |||
During an inspection conducted February 10-14, 1986 (NRC Inspection Report | |||
Nos. 50-327/86-12 and 50-328/86-12, paragraph 6.f), the inspectors | |||
identified that the VIAS data base could not be relied upon to provide all | |||
information relevant to deficiencies that were found in the deficiency | |||
document packages. The inspectors also identified that VIAS did not provide | |||
an adequate picture of the chronological events leading up to the deficiency | |||
cl.osure for many of the deficiencies. | |||
The VIAS printouts reviewed during this inspection show considerable | |||
improvement in that information is now available to determine audit finding | |||
status. | |||
The February inspection (paragraph 6.h) also identified weaknesses in the | |||
. effectiveness of the escalation program. During this inspection, the | |||
inspectors identified that once items are escalated, TVA management has been | |||
effective in seeking active item resolution. A weakness still exists, | |||
however, in that there is a time delay from when items are ready to be | |||
escalated until they are actually escalated. This area was discussed in | |||
depth with licensee QA management personnel at the exit interview. | |||
The inspectors reviewed NC0-CAR-86-003 dated 2/5/86. This corrective action | |||
i report (CAR) was written due to several audit findings not being escalated | |||
l | |||
in accordance with established procedures. Procedure DQAI-204 Handling of | |||
Central Of fice Corrective Action Reports and Discrepancy Reports, | |||
Revision 0, administratively delineates the processing of CARS. This CAR | |||
i was judged to be significant by licensee personnel. Significant conditions | |||
! adverse to quality are defined in the Nuclear Quality Assurance Manual | |||
' | |||
(NQAM), Part III, Section 7.2, Corrective Action, as: | |||
Any condition which is reportable to NRC within 24 hours or within 30 | |||
days in accordance with the technical specifications of the affected | |||
! | |||
plant or under 10 CFR Part 21; any gross or widespread noncompliance | |||
with procedural requirements which negates the effectiveness of quality | |||
assurance controls imposed by this quality assurance manual; or any | |||
, | |||
condition which has recurred with such frequency that it indicates past | |||
corrective action (if any) has been ineffective. | |||
. _ . . . .- - - - .. .- | |||
~ | |||
* | |||
. | |||
5 | |||
This CAR was not reportable to the NRC in accordance with Technical | |||
Specifications or under 10 CFR Part 21. | |||
Within this area one violation was identified. DQAI-204 requires that for | |||
significant CARS the responsible supervisor provides recommended corrective | |||
action, both remedial and recurrence control with estimated completion dates | |||
for each. The procedure also requires returning the CAR to the Program | |||
Development Group (PDG) within 14 working days. Any exception requiring | |||
more than 14 working days for significant CARS shall be documented by the | |||
responsible supervisor, concurred with the Chief, Quality Systems Branch | |||
(QSB) and approved by the appropriate division director. | |||
NC0-CAR-86-003 was judged to be significant by appropriate supervision and | |||
root cause analysis was also required to be performed. The CAR was | |||
identified on 2/5/86, but the corrective action response due date was | |||
3/3/86, which exceeds the required response date for significant CARS. | |||
Discussions with appropriate supervision identified that this may have been | |||
an administrative oversight. This administrative oversight contributed to | |||
an extension greater than 14 working days not being documented, concurred, | |||
and approved by appropriate management. DQAI-204 also requires that | |||
estimated corrective action due dates be provided for both remedial and | |||
recarrence corrective action. The corrective action due dates were not | |||
provided for all remedial corrective actions. These examples of failure to | |||
follow established measures for correcting identified problems is identified | |||
as violation 327,328/86-41-01. | |||
Additional CARS were also reviewed and these appeared to have been handled | |||
crrrectly. | |||
In addition to the violation previously discussed, the inspectors review of | |||
DQAI-204-identified the following poor practices and problems: | |||
a. DQAl-204, does not reflect current TVA organizational responsibilities | |||
and has not been revised since its issuance in September 1984. | |||
i | |||
b. Since DQAI-204 is somewhat out-of-date, TVA employees are apparently | |||
only referencing the NQAM for questions regarding the handling of CARS. | |||
This was apparent from the facts that when individuals were queried as | |||
to the requirements for handling CARS, the NQAM was the document each | |||
individual addressed for the proper requirement. Responsible TVA | |||
employees identified the NQAM as the most current document for use for | |||
CAR handling. Also, the Nuclear Control Office (NC0) - CAR Routing | |||
Sheet states " Expedite per NQAM, Part III, Section 7.2." | |||
l | |||
l | |||
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* | |||
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6 | |||
c. While the CAR Coordinator met the specific DQAI-204 procedural | |||
requirements to provide a monthly corrective action summary report | |||
which included NC0-CAR-86-003, only four entries as to the status of | |||
the CAR were made between the issuance on February 5,1986, and the | |||
July 8, 1986 Central Office CAR and DR Monthly Report date. Only one | |||
entry was made after March 23, 1986. The summary report failed to | |||
provide information on the status of the CAR and in fact, with what | |||
information was provided, presented information that was misleading. | |||
Additional information relating to this is discussed in paragraph 5.e. | |||
d. The CAR Coordinator's NC0-CAR-86-003 file contained little information | |||
about the actual status of the CAR. Several penciled comments without | |||
dates or initials were found on the copy of the CAR in the file. | |||
Follow-up activities were not apparently documented to any standard | |||
and, while problems with the resolution of the remedial corrective | |||
action activities were on-going, the documentation of an initial | |||
problem was just recently noted by licensee personnel on the status | |||
sheet in the CAR file. | |||
e. The last Quarterly Division of Nuclear Quality Assurance (DNQA) | |||
Corrective Action Meeting held May l',1986, and documented in meeting | |||
minutes dated May 14, 1986, appears to have superficially addressed | |||
NC0-CAR-86-003 in that the meeting minutes states that following a | |||
group discussion, the status of the CARS was established to be: | |||
...E NC0-CAR-86-003, the action to correct and prevent recurrence | |||
of the cited condition has been corrected with the release of | |||
Revision 1 to DQAI-104. Quality System Branch (QSB) closure of | |||
the CAR is pending their review of the document. | |||
The significant fact that the remedial actions identified in the CAR to | |||
correct the problems that led to the CAR were still incomplete and | |||
still did not have estimated completion dates appears to have been | |||
missed. From the write-up of the report, it appears that closure of | |||
the CAR is dependent only on QSB approving the procedural revision. | |||
f. The verification activities being conducted for the effectiveness of | |||
the corrective action implementation were weak. No formal verification | |||
plan was developed and only recent documentation of the status of some | |||
on-going efforts since the verification effort started over a month ago | |||
were presented. Current verification activities for NC0-CAR-86-003, | |||
that were identified by the CAR Coordinator as being in progress, | |||
appeared to lack completeness and depth. | |||
I | |||
J | |||
. | |||
7 | |||
g. The NC0-CAR routing sheet provides incorrect information in Block 2 for | |||
the, " Response due by item." The routing sheet states (30 calendar | |||
days). As previously noted, the 30 calendar days is correct only for | |||
non-significant CARS. | |||
6. QA Audit Effectiveness | |||
Significant problems have recently been identified by the NRC and the | |||
licensee QA staff with the Technical Specification (TS) surveillance testing | |||
program. These findings were both licensee and NRC identified. The | |||
licensee's pattern of identifying deficiencies in Quality Assurance (QA) | |||
audits was inconsistent in that findings were not identified in 1984 or | |||
1985, but numerous problems were identified in 1986. The 1986 audit | |||
findings were of a programmatic nature and therefore probably existed | |||
previously. The quality of the audits conducted in 1984 and 1985 was | |||
questionable. This inspection was conducted to identify the reason for this | |||
inconsistent performance of the QA audit function. | |||
The following licensee QA audits were reviewed: | |||
SQ-83TS-07, Technical Specification, April 21-28, 1983 | |||
Number of Auditors: 3 | |||
Length of Inspection: I week | |||
Deviations | |||
a. Discrepancies exist within the SQN technical specifications | |||
b. Discrepancies exist within the SQN surveillance instructions | |||
c. SQN Standard Practice SQA-41 contains discrepancies | |||
d. Conditional surveillance instruction packages are not properly | |||
controlled as required in SQN Administrative Instruction AI-4 | |||
e. The minutes of Plant Operations Review Committee meetings are not | |||
, | |||
being authenticated as required by SQN Standard Practice SQA-21 | |||
, SQA-8400-08, Compliance with Technical Specifications, May 11, 1984 | |||
Number of Auditors: 2 | |||
Length of Inspection: I week | |||
Deviations: None | |||
.-. _ _ _ | |||
. - , -- | |||
* | |||
. | |||
.d | |||
8 | |||
QSQ-A-85-0003, Test Control and Housekeeping, March 22, 1985 | |||
Number of auditors: 2 | |||
Length of Inspection 1 week | |||
Deviations: None | |||
QSQ-A-85-0006, Compliance with Plant Technical Specifications, May 3, 1985 | |||
Number of Auditors: 2 | |||
Length of Inspection: I week | |||
Deviations: None | |||
QSQ-A-86-0005, Compliance with Plant Technical Specifications, April 16, | |||
1986 | |||
Number of Auditors: 5 | |||
Length of Inspection: 2 weeks | |||
Deviations: | |||
a. The appendices of Sequoyah (SQN) Surveillance Instruction (SI)-1, | |||
Surveillance Test Program, procedure title inadequately and/or | |||
incorrectly cross-references Technical Specification surveillance | |||
requirements to site implementing instructions. | |||
b. Contrary to Technical Specification 6.5.1.6.e, the SQN Plant | |||
Operations Review Committee (PORC) is not investigating and | |||
reporting on all Technical Specification violations. | |||
c. The SQN Independent Safety Engineering Group (ISEG) is not | |||
reporting its activities as required by Technical Specification | |||
6.2.3, Area Plan Procedure 0604.05, and .SQN Standard Practice | |||
SQA117. | |||
d. Plant Operations Review Committee (PORC) meeting minutes are not | |||
being maintained and distributed as required by SQN Standard | |||
Practice SQA 21. | |||
e. SQN is not organizationally structured in accordance with the | |||
Technical Specifications. | |||
f. SQN is not processing changes to the Technical Specifications in | |||
accordance with Area Plan Procedure 0602.03 and SQN Standard | |||
Practice SQA 30. | |||
* | |||
. | |||
9 | |||
g. SQN has no site instruction to accomplish surveillance requirement | |||
4.3.3.9.C.5.a | |||
h. Testing of penetration overcurrent protective devices does not | |||
appear to be adequately controlled to ensure that surveillance | |||
requirements will be met. | |||
It is evident from the data presented above that the quality of TS | |||
compliance audits fell from the 1983 audit to those conducted in 1984 and | |||
1985 and was restored in 1986. The most obvious correlation is | |||
inspector-weeks allotted: | |||
Inspector-Weeks # Deviations | |||
1983 3 5 | |||
1984 2 0 | |||
1985 2 0 | |||
2 0 | |||
1986 10 8 | |||
Though the number of deviations identified is not, in itself, a measure of | |||
the quality of an audit, it does provide some indication of the depth and | |||
scope. The correlation between increased inspector-weeks and increased | |||
number of deviations in 1986 is unmistakable. The inspectors discussed the | |||
issue of personnel allotted for inspections with two auditors and two | |||
managers. The only reason that 5 inspectors were committed for 2 weeks to | |||
perform the 1986 audit was that the resources were (unexpectedly) available. | |||
Three of the five were in a training status, but two of these were highly | |||
qualified, technically oriented inspectors with line experience. Despite | |||
the increased output from the 1986 audit, the licensee stated that the | |||
increased manpower for this inspection will most likely not be continued in | |||
1987 or beyond primarily because the resources would not be available. | |||
, | |||
The inspectors were provided an organizational chart of the Nuclear Quality | |||
Audit and Evaluation Division and discussed various details of tha | |||
> | |||
organization with the Division Head. The chart, as updated by the Division | |||
Head, showed approximately 13 current vacancies for auditors. Several | |||
! existing auditors had been loaned out to other licensee activities. The net | |||
result was a severe depletion of manpower resources such that it will be | |||
difficult for the licensee to cover their basic inspection commitments. | |||
Even with all vacancies filled and loanees returned, the licensee stated | |||
that the manpower allotment of the 1986 audits would still be unattainable | |||
on a consistent basis. | |||
._ -. | |||
_ . -. _ - _ _ ._ _ _ _ __ _ .. _ __ - _ ._. | |||
4 | |||
- | |||
. | |||
! 10 | |||
: | |||
: | |||
}. The inspectors explored other possible reasons for the sudden increase in | |||
audit quality. One appears to be a new policy of hiring individuals with | |||
j more technical and operational backgrounds. This policy had an apparent | |||
direct effect-on the 1986 audit in that two of the auditors, in a training | |||
status, had technical backgrounds and made significant contributions to the | |||
audit findings despite their inexperience as auditors. The continued | |||
commitment to fill vacancies with individuals with operational and technical | |||
1 | |||
backgrounds is perceived by NRC as highly positive. | |||
i | |||
Another factor involved in the improved 1986 audit appeared to be an | |||
upscaled and broadened audit checklist. The checklist used for the 1986 | |||
audit was much more detailed and covered more areas than the checklists used | |||
in 1984 and 1985. The inspectors review of audit checklists confirmed a ; | |||
statement by a former auditor that audits conducted in 1985 and before were | |||
: more or less of a non-technical nature concerned more with form than | |||
l substance i.e., literal compliance, whereas the 1986 audit became more | |||
, | |||
involved with functional compliance. | |||
! | |||
In conclusion, it appeared that three major factors contributed to the | |||
difference in performance between the 1986 audit and those conducted in 1984 i | |||
' | |||
and 1985: more manpower, more technically-oriented auditors, and an | |||
; -improved audit checklist. The last two of these elements should be | |||
; available in future audits, but the manpower issue, as discussed previously, | |||
j 'is highly uncertain. | |||
7. QA Record Storage Practices | |||
, | |||
QA audit QSQ-A-85-0006, May 3,1985, identified the following observation | |||
i concerning the handling of surveillance instruction (SI) data packages while | |||
awaiting QA review: | |||
4 | |||
The QA Staff has a collection area where sis are kept while awaiting QA | |||
i review. This collection area is an unattended, open shelf area in the | |||
office building that does not afford the SI data packages any | |||
. | |||
protection from damage or loss. During the audit, in excess of 500 sis | |||
l were observed in this area which were less than one month old, although | |||
' | |||
two observed were in excess of 7 months old. The procedure controlling | |||
-the collection, storage, and maintenance of QA records (NQAM, Part III, | |||
Section 4.1) lists these SI data sheets as "QA records with lifetime | |||
retention period." The data sheets are not defined as QA records until | |||
: they have been completed. However, information necessary to verify- | |||
; compliance to the technical specifications should be properly protected l | |||
2 | |||
especially if the information and/or data is irretrievable. | |||
i | |||
. | |||
I | |||
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t | |||
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. - - _ , . . - _ . . - - - , _ - - . . - - . . - - . _ - - - . - . - - - - - - . . . - . ~ . . - - | |||
* | |||
. | |||
" | |||
11 | |||
Area of Concern | |||
QAB recommends that sis and other CSSC-related inprocess documentation | |||
be collected, stored, and maintained in a manner commensurate with | |||
their importance. QAB will list this as an area of concern and inspect | |||
the storage of SI data packages in future audits. | |||
Evidently, action was not taken on this matter and the licensee's 1986.QA | |||
audit did not address it. NRC Inspection Report Nos. 50-327, 328/86-32, | |||
identified the same problem with approximately 300 sis observed to be in the | |||
same condition. The inspectors interviewed the QA supervisor responsible | |||
for QA SI reviews. He asserted that sis in this limbo state, awaiting QA | |||
review, were not considered QA records as defined by ANSI N45.2.9-1974, | |||
Section 1.4, in that the sis were not completed records until the final QA | |||
review. The inspectors observed that the sis had been moved to a metal file | |||
cabinet which was not fire-resistant. The sis were filed randomly without | |||
an administrative tracking mechanism. QA personnel, when time is available, | |||
select records from the cabinet for review, supposedly concentrating on sis | |||
of the greatest age. The inspectors determined by random sample that | |||
approximately 10 percent of the sis were older than two months with a | |||
maximum age of approximately 4 months. The total number of outstanding sis | |||
was approximately 200. The cabinet is supposedly locked when not in use | |||
although the inspectors found it unlocked on one random trial. | |||
The licensee stated that SI's awaiting QA review are not official QA | |||
records. The licensee is committed to Regulatory Guide 1.88 which endorses | |||
ANSI N45.2.9-1974, Requirements for Collection, Storage, and Maintenance of | |||
Quality Assurance Records for Nuclear Power Plants. This standard defines a | |||
QA record as a specified document that has been completed. The licensee's | |||
procedure, Administrative Instruction (AI)-7, Section 3.1, defines document | |||
completion at the time of entry of the final signature and date, unless | |||
otherwise specified. This is consistent with the licensee's argument that | |||
the sis are not QA records until the QA review is completed. However, | |||
SI-1, Section 9.2.3.8, states that when an SI data package is finished, it | |||
is to be immediately reviewed by the section supervisor or cognizant | |||
reviewer to determine, among other things, if the package is complete as a | |||
QA record. The wording of this procedure implies that the data package | |||
becomes a QA record immediately af ter the data is completely entered and | |||
immediate reviews are performed. Thus, the licensee's procedures conflict | |||
on this issue. | |||
NRC concerns include the possible loss of irreplaceable information on sis | |||
due to fire or mishandling and the lengthy delay in completing the official | |||
review of test results which are satisfying immediate operability | |||
determinations as defined by Technical Specifications. The licensee's | |||
interpretation of the definition of a QA record in this instance appears to | |||
lead to an uncontrolled and unregulated compromise of safety-related | |||
- .- .. .. . . _ , - . = . = . | |||
- | |||
. | |||
12 | |||
information. NRC will track this as Inspector Followup Item 327, | |||
328/86-41-02, Storage and Control of QA Records During Review. The | |||
licensee was requested to submit a formal response to this issue. | |||
8. Licensee Action on Previously Identified Inspection Findings (92701) | |||
a. (Closed) Inspector Followup Item 327,328/84-01-04: Lack of Aerosol | |||
Control | |||
Closure was based on a Power Stores Section Instruction Letter No. 33, | |||
Control of Aerosol Spray, Revision 0. This instruction requires | |||
procurement of approved aerosol sprays as listed in Standard Practice | |||
SQA-160. Aerosol sprays not on this list will be affixed with a label | |||
which states; "Not approved for use on materials which may come in | |||
contact with reactor coolant - guard against overspray". | |||
b. (Closed) Inspector Followup Item 327,328/85-05-03: Control and | |||
Accountability of Measuring and Test Equipment (M&TE) | |||
Closure was based on an inspector's sample of randomly selected M&TE | |||
items and a review of the M&TE inventory list. All equipment in the | |||
sample was verified to be at the location indicated on master inventory | |||
list. The M&TE selected also had accurate calibration and calibration | |||
due dates on equipment labels, | |||
c. (0 pen) Inspector Followup Item 327,328/85-21-03: Development of | |||
Procedure STI-1 to Provide Positive Control of STEAR Activities | |||
This item remains open due to the active status of procedure SQA-100 | |||
which previously provided controls for STEAR activities. Presently two | |||
procedures are approved, STI-1 approved July 31, 1986, and SQA-100. | |||
This item can be closed when SQA-100 is cancelled. Cancellation was | |||
delayed due to active instructions which reference this procedure. | |||
These STEAR instructions are as follows: 83-18, 83-20, 84-04, 84-06, | |||
and 84-07. | |||
. | |||
l d. (Closed) Inspector Followup Item 327,328/86-12-02: Verify that | |||
Licensee Closes All Pre-Operational Packages Prior to Startup | |||
The inspector reviewed a computer listing of all pre-operational tests | |||
. | |||
which listed dates for Westinghouse and Plant-Manager approval. All 19 | |||
l preoperational test records in question were indicated as having | |||
! | |||
Westinghouse and Plant Manager approval. The inspector reviewed a | |||
letter from Westinghouse to TVA dated June 6,1986, which closed out | |||
Westinghouse approval of all outstanding tests. The inspector verified | |||
by sampling three test packages that review signatures matched the | |||
dates on the computer printout. The licensee stated that all | |||
pre-operational test packages have been fully approved and are being | |||
l | |||
stored as permanent plant QA records in the Document Control Center | |||
vault. | |||
1 | |||
. _ . _ - . _ . _ . . _ _ _ _ _. | |||
. . | |||
, | |||
13 | |||
e. (Closed) Inspector Followup Item 327, 328/85-21-02: Development of | |||
Staff Guidance for Preparation of USQD Form | |||
SQA-119 was revised on September 25, 1985, to upgrade Unresolved Safety | |||
l Question Determination (USQD) procedures. The USQD is the mechanism | |||
for processing unreviewed environmental issues. | |||
, | |||
I | |||
I | |||
i | |||
i | |||
,. - , - - - . . . , , , - , - _ - - . - . . - . . _ . . _ , . - . ,,..,_,,, ,._,,e,.,,...- w,--.,. ,.--- -- ,.,..-, , y y ., -. . _ . , . , , - - - - , | |||
}} |
Latest revision as of 13:54, 4 May 2021
ML20214M877 | |
Person / Time | |
---|---|
Site: | Sequoyah |
Issue date: | 08/13/1986 |
From: | Belisle G, Moore L, Runyan M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
To: | |
Shared Package | |
ML20214M862 | List: |
References | |
50-327-86-41, 50-328-86-41, NUDOCS 8609110361 | |
Download: ML20214M877 (14) | |
See also: IR 05000327/1986041
Text
p (fru UNITE 3 STA TES
'
.
'
. o' NUCLEAR REGULATORY COMMISSION
^
-[ p REGION 11
g j 101 MARIETTA STREET.N.W.
- * ATLANTA. GEORGI A 30323
\...../
'
Report Nos.: 50-327/86-41 and 50-328/86-41
'
. Licensee: Tennessee Valley Authority
6N38 A Lookout Place
1101 Market Street
Chattanooga, TN 37402-2801
Docket Nos.: 50-327 and 50-328 License Nos.: DPR-77 and DPR-79
Facility Name: Sequoyah 1 and 2
Inspection Conducted: July 7-11, 1986
Inspectors: 1 %w 8 -33- 8 6
M. F. R ~ an 1 Date Signed
.\ M - 8/ 8b
L. R. Moore '
' Date Signed
Accompanying Personnel: G. A. Belisle, RII
C. Wallenga, IE
'
Approved by: ./ n 7 / I
G. A. Belisle, Acting Section Chief / Date Signed
Quality Assurance Programs Section
Division of Reactor Safety
SUMMARY
Scope: This routine, special unannounced inspection was conducted at the
corporate offices and on site in the areas of QA audit effectiveness, QA record
storage practices, and licensee actions on previously identified inspection
findings.
Results: One violation was identified.
n
8609110361 860829
PDR ADOCK 05000327
G PDR
<
.
REPORT DETAILS
1. Persons Contacted
Licensee Employees
- H. Abercrombie, Site Director
- W. Andrews, Site Quality Manager
- J. Anthony, Operations Supervisor
- W. Baker, Fire Protection Engineer
- R. Birchell, Licensing Engineer
- T. Blankenship, Manager, Information Services
R. Bruce, Section Supervisor, QA Branch
- R. Buchholz, Site Representative, Office of Nuclear Power (0NP)
- M. Cooper, Mechanical Engineer
- E. Craig, Mechanical Modifications
- E. Craigge, Independent Safety Staff
M. Crane, Materials Unit Supervisor
- J. Crittenden, Assistant Branch Chief, Nuclear Quality Assurance (NQA)
- H. Elkins, Instrument Maintenance Group Supervisor
K. Faulkner, Supervisor, Instrument Shop
- R. Fortenberry, Technical Support Supervisor
J. Green, Measuring and Test Equipment (M&TE) Foreman
- J. Huston, Deputy Director, NQA
D. Jackson, Safety Specialist
- D. Jeralds, Instrument Craft Supervisor
- J. Kelly, Engineer
- G. Kirk, Compliance Licensing Supervisor
M. Koss, Welder and Metallurgical Specialist
- C. LaFever, Instrument Engineer
- D. Lambert, Manager, Nuclear Safety and Licensing
R. Mullin, Chief, Nuclear Quality Audit & Evaluation Branch
- L. Nobles, Superintendent, Operations
- M. Parcell, Compliance Licensing
G. Petty, Materials Officer, Specifications Materials Unit
G. Poe, Hazardous Materials Control Specialist
- R. Pierce, Material Maintenance Supervisor
L. Reardon, QA Specialist
R. Rogers, Compliance Specialist
- M. Sedlacik, Modification Section A Supervisor
- J. Steigelman, Unit Supervisor, Radiation Control
J. Stitt, Corrective Action Coordinator
- F. Szczepanski, Chief, Nuclear Safety Staff
- R. Thompson, Assistant Branch Chief, ONP
- D. Tullis, Maintenance, Special Projects
- P. Wallace, Plant Manager
- K. Weller, Systems Engineer
G. Wilbourn, Technical Reports Specialist
.__ - . _ _ _ _ _ . ._ -_
-
.
2
Other licensee employees contacted included technicians and office
personnel.
NRC Resident Inspectors
- P. Harmon
- D. Loveless
- K. Jennison
- Attended exit interview at Sequoyah Plant site.
- Attended exit interview at TVA Corporate Office.
2. Exit Interview
The inapection scope and findings were summarized on July 11, 1986, wit.h
those persons indicated in the paragraph above. Two exits were performed on
this date, one exit at the Sequoyah plant site and a second at the TVA
corporate office. The inspector described the areas inspected and discussed
in detail the inspection findings. No dissenting comments were receised
from the licensee.
Violation, Failure to Process a Corrective Action Request in Accordance
With Established Procedures, paragraph 5.
1 Inspector Followup Item, Storage and Control of QA Records During Review,
paragraph 7.
At the exit interview, the issue regarding QA records was presented as
an unresonable item. TVA personnel stated that TVA would submit a
formal response to the NRC, Region II, resolving this issue.
Upon NRC Region II management review of this issue, it was decided
than an inspector followup item was more appropriate. This change in
item classification discussed with the Chief, Nuclear Quality Audit
and Evaluation Branch during a telephone conversation conducted on
August 20, 1986.
The licensee did not identify as proprietary any of the materials provided
to or reviewed by the inspectors during this inspection.
3. Licensee Action on Previous Enforcement Matters (92702)
a. (Closed) Severity Level IV violation (327, 328/85-05-01): Failure To
Evaluate Out-0f-Calibration Measuring And Test Equipment In A Timely
Manner.
The licensee response dated May 10, 1985, was considered acceptable by
Region II.
. -- _
.
3
Closure was based on Revision 5 to Procedure IA-31, Control of
Measuring and Test Equipment and Verification of Timely Evaluations of
Out-of-Calibration M&TE. This revision required a safety evaluation of
equipment usage if an out-of-tolerance evaluation was not completed in
ten days. The inspector verified implementation of this revision. A
present total of 12 evaluations were outstanding, which was a
considerable improvement over the backlog of evaluations existing at
the initiation of this violation.
The inspector concluded that the licensee had corrected the previous
problem and developed corrective actions to preclude recurrence of
similar problems. Corrective actions stated in the licensee response
have been implemented.
b. (Closed) Severity Level V violation (327, 328/86-12-01): Inadequate
Document Controls
The licensee response dated May 27, 1986, was considered acceptable by
Region II.
The inspector reviewed a records transmittal form which transferred the
19 preoperational test records in question to the Document Control
Center on February 14, 1986. Three records (W-10.5 (Unit 1), W-9.1 and
W-10.1 (Unit 2)) were selected at random and were verified to be
located in the vault. The inspectors were assured by licensee
personnel that no other preoperational test records were outstanding
and that all such records are being handled as permanent plant QA
records. The inspector concluded that the licensee had corrected the
previous problem and developed corrective action to preclude recurrence
of similar problems. Corrective actions stated in the licensee response
have been implemented.
4. Unresolved Items
Unresolved items were not identified during this inspection.
5. Corrective Action (92720)
The inspectors reviewed computer tracking system (VIAS) printouts that
provided status for audit findings. Two printouts were available. One
contained a listing for all outstanding audit findings and the other
contained a listing for audit findings in escalation. Currently, at
Sequoyah, the following audit findings were in escalation as of the July 10,
1986, VIAS printout:
_ _ . - _
_ - . _ . _ .. . _ _ _
.- _ _.
.
4
QSQ-A-84-0014-02 (SQ-8400-14), which deals with inadequate,
inconsistent, and not properly implemented chemical control procedures.
QSQ-A-86-001-01, which deals with various document control problems.
QSQ-A-86-0001-02, which deals with improper storage of documents.
QSS-A-84-0011-02 (CH-8400-11), which deals with not providing annual
training of section and unit supervisors.
QSS-A-85-0006-03, which deals with safeguards information
QSS-A-85-0010-03, which deals with inadequacies in the records
management program for health physics QA records.
During an inspection conducted February 10-14, 1986 (NRC Inspection Report
Nos. 50-327/86-12 and 50-328/86-12, paragraph 6.f), the inspectors
identified that the VIAS data base could not be relied upon to provide all
information relevant to deficiencies that were found in the deficiency
document packages. The inspectors also identified that VIAS did not provide
an adequate picture of the chronological events leading up to the deficiency
cl.osure for many of the deficiencies.
The VIAS printouts reviewed during this inspection show considerable
improvement in that information is now available to determine audit finding
status.
The February inspection (paragraph 6.h) also identified weaknesses in the
. effectiveness of the escalation program. During this inspection, the
inspectors identified that once items are escalated, TVA management has been
effective in seeking active item resolution. A weakness still exists,
however, in that there is a time delay from when items are ready to be
escalated until they are actually escalated. This area was discussed in
depth with licensee QA management personnel at the exit interview.
The inspectors reviewed NC0-CAR-86-003 dated 2/5/86. This corrective action
i report (CAR) was written due to several audit findings not being escalated
l
in accordance with established procedures. Procedure DQAI-204 Handling of
Central Of fice Corrective Action Reports and Discrepancy Reports,
Revision 0, administratively delineates the processing of CARS. This CAR
i was judged to be significant by licensee personnel. Significant conditions
! adverse to quality are defined in the Nuclear Quality Assurance Manual
'
(NQAM), Part III, Section 7.2, Corrective Action, as:
Any condition which is reportable to NRC within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> or within 30
days in accordance with the technical specifications of the affected
!
plant or under 10 CFR Part 21; any gross or widespread noncompliance
with procedural requirements which negates the effectiveness of quality
assurance controls imposed by this quality assurance manual; or any
,
condition which has recurred with such frequency that it indicates past
corrective action (if any) has been ineffective.
. _ . . . .- - - - .. .-
~
.
5
This CAR was not reportable to the NRC in accordance with Technical
Specifications or under 10 CFR Part 21.
Within this area one violation was identified. DQAI-204 requires that for
significant CARS the responsible supervisor provides recommended corrective
action, both remedial and recurrence control with estimated completion dates
for each. The procedure also requires returning the CAR to the Program
Development Group (PDG) within 14 working days. Any exception requiring
more than 14 working days for significant CARS shall be documented by the
responsible supervisor, concurred with the Chief, Quality Systems Branch
(QSB) and approved by the appropriate division director.
NC0-CAR-86-003 was judged to be significant by appropriate supervision and
root cause analysis was also required to be performed. The CAR was
identified on 2/5/86, but the corrective action response due date was
3/3/86, which exceeds the required response date for significant CARS.
Discussions with appropriate supervision identified that this may have been
an administrative oversight. This administrative oversight contributed to
an extension greater than 14 working days not being documented, concurred,
and approved by appropriate management. DQAI-204 also requires that
estimated corrective action due dates be provided for both remedial and
recarrence corrective action. The corrective action due dates were not
provided for all remedial corrective actions. These examples of failure to
follow established measures for correcting identified problems is identified
as violation 327,328/86-41-01.
Additional CARS were also reviewed and these appeared to have been handled
crrrectly.
In addition to the violation previously discussed, the inspectors review of
DQAI-204-identified the following poor practices and problems:
a. DQAl-204, does not reflect current TVA organizational responsibilities
and has not been revised since its issuance in September 1984.
i
b. Since DQAI-204 is somewhat out-of-date, TVA employees are apparently
only referencing the NQAM for questions regarding the handling of CARS.
This was apparent from the facts that when individuals were queried as
to the requirements for handling CARS, the NQAM was the document each
individual addressed for the proper requirement. Responsible TVA
employees identified the NQAM as the most current document for use for
CAR handling. Also, the Nuclear Control Office (NC0) - CAR Routing
Sheet states " Expedite per NQAM, Part III, Section 7.2."
l
l
!
.
6
c. While the CAR Coordinator met the specific DQAI-204 procedural
requirements to provide a monthly corrective action summary report
which included NC0-CAR-86-003, only four entries as to the status of
the CAR were made between the issuance on February 5,1986, and the
July 8, 1986 Central Office CAR and DR Monthly Report date. Only one
entry was made after March 23, 1986. The summary report failed to
provide information on the status of the CAR and in fact, with what
information was provided, presented information that was misleading.
Additional information relating to this is discussed in paragraph 5.e.
d. The CAR Coordinator's NC0-CAR-86-003 file contained little information
about the actual status of the CAR. Several penciled comments without
dates or initials were found on the copy of the CAR in the file.
Follow-up activities were not apparently documented to any standard
and, while problems with the resolution of the remedial corrective
action activities were on-going, the documentation of an initial
problem was just recently noted by licensee personnel on the status
sheet in the CAR file.
e. The last Quarterly Division of Nuclear Quality Assurance (DNQA)
Corrective Action Meeting held May l',1986, and documented in meeting
minutes dated May 14, 1986, appears to have superficially addressed
NC0-CAR-86-003 in that the meeting minutes states that following a
group discussion, the status of the CARS was established to be:
...E NC0-CAR-86-003, the action to correct and prevent recurrence
of the cited condition has been corrected with the release of
Revision 1 to DQAI-104. Quality System Branch (QSB) closure of
the CAR is pending their review of the document.
The significant fact that the remedial actions identified in the CAR to
correct the problems that led to the CAR were still incomplete and
still did not have estimated completion dates appears to have been
missed. From the write-up of the report, it appears that closure of
the CAR is dependent only on QSB approving the procedural revision.
f. The verification activities being conducted for the effectiveness of
the corrective action implementation were weak. No formal verification
plan was developed and only recent documentation of the status of some
on-going efforts since the verification effort started over a month ago
were presented. Current verification activities for NC0-CAR-86-003,
that were identified by the CAR Coordinator as being in progress,
appeared to lack completeness and depth.
I
J
.
7
g. The NC0-CAR routing sheet provides incorrect information in Block 2 for
the, " Response due by item." The routing sheet states (30 calendar
days). As previously noted, the 30 calendar days is correct only for
non-significant CARS.
6. QA Audit Effectiveness
Significant problems have recently been identified by the NRC and the
licensee QA staff with the Technical Specification (TS) surveillance testing
program. These findings were both licensee and NRC identified. The
licensee's pattern of identifying deficiencies in Quality Assurance (QA)
audits was inconsistent in that findings were not identified in 1984 or
1985, but numerous problems were identified in 1986. The 1986 audit
findings were of a programmatic nature and therefore probably existed
previously. The quality of the audits conducted in 1984 and 1985 was
questionable. This inspection was conducted to identify the reason for this
inconsistent performance of the QA audit function.
The following licensee QA audits were reviewed:
SQ-83TS-07, Technical Specification, April 21-28, 1983
Number of Auditors: 3
Length of Inspection: I week
Deviations
a. Discrepancies exist within the SQN technical specifications
b. Discrepancies exist within the SQN surveillance instructions
c. SQN Standard Practice SQA-41 contains discrepancies
d. Conditional surveillance instruction packages are not properly
controlled as required in SQN Administrative Instruction AI-4
e. The minutes of Plant Operations Review Committee meetings are not
,
being authenticated as required by SQN Standard Practice SQA-21
, SQA-8400-08, Compliance with Technical Specifications, May 11, 1984
Number of Auditors: 2
Length of Inspection: I week
Deviations: None
.-. _ _ _
. - , --
.
.d
8
QSQ-A-85-0003, Test Control and Housekeeping, March 22, 1985
Number of auditors: 2
Length of Inspection 1 week
Deviations: None
QSQ-A-85-0006, Compliance with Plant Technical Specifications, May 3, 1985
Number of Auditors: 2
Length of Inspection: I week
Deviations: None
QSQ-A-86-0005, Compliance with Plant Technical Specifications, April 16,
1986
Number of Auditors: 5
Length of Inspection: 2 weeks
Deviations:
a. The appendices of Sequoyah (SQN) Surveillance Instruction (SI)-1,
Surveillance Test Program, procedure title inadequately and/or
incorrectly cross-references Technical Specification surveillance
requirements to site implementing instructions.
b. Contrary to Technical Specification 6.5.1.6.e, the SQN Plant
Operations Review Committee (PORC) is not investigating and
reporting on all Technical Specification violations.
c. The SQN Independent Safety Engineering Group (ISEG) is not
reporting its activities as required by Technical Specification 6.2.3, Area Plan Procedure 0604.05, and .SQN Standard Practice
SQA117.
d. Plant Operations Review Committee (PORC) meeting minutes are not
being maintained and distributed as required by SQN Standard
Practice SQA 21.
e. SQN is not organizationally structured in accordance with the
Technical Specifications.
f. SQN is not processing changes to the Technical Specifications in
accordance with Area Plan Procedure 0602.03 and SQN Standard
Practice SQA 30.
.
9
g. SQN has no site instruction to accomplish surveillance requirement 4.3.3.9.C.5.a
h. Testing of penetration overcurrent protective devices does not
appear to be adequately controlled to ensure that surveillance
requirements will be met.
It is evident from the data presented above that the quality of TS
compliance audits fell from the 1983 audit to those conducted in 1984 and
1985 and was restored in 1986. The most obvious correlation is
inspector-weeks allotted:
Inspector-Weeks # Deviations
1983 3 5
1984 2 0
1985 2 0
2 0
1986 10 8
Though the number of deviations identified is not, in itself, a measure of
the quality of an audit, it does provide some indication of the depth and
scope. The correlation between increased inspector-weeks and increased
number of deviations in 1986 is unmistakable. The inspectors discussed the
issue of personnel allotted for inspections with two auditors and two
managers. The only reason that 5 inspectors were committed for 2 weeks to
perform the 1986 audit was that the resources were (unexpectedly) available.
Three of the five were in a training status, but two of these were highly
qualified, technically oriented inspectors with line experience. Despite
the increased output from the 1986 audit, the licensee stated that the
increased manpower for this inspection will most likely not be continued in
1987 or beyond primarily because the resources would not be available.
,
The inspectors were provided an organizational chart of the Nuclear Quality
Audit and Evaluation Division and discussed various details of tha
>
organization with the Division Head. The chart, as updated by the Division
Head, showed approximately 13 current vacancies for auditors. Several
! existing auditors had been loaned out to other licensee activities. The net
result was a severe depletion of manpower resources such that it will be
difficult for the licensee to cover their basic inspection commitments.
Even with all vacancies filled and loanees returned, the licensee stated
that the manpower allotment of the 1986 audits would still be unattainable
on a consistent basis.
._ -.
_ . -. _ - _ _ ._ _ _ _ __ _ .. _ __ - _ ._.
4
-
.
! 10
}. The inspectors explored other possible reasons for the sudden increase in
audit quality. One appears to be a new policy of hiring individuals with
j more technical and operational backgrounds. This policy had an apparent
direct effect-on the 1986 audit in that two of the auditors, in a training
status, had technical backgrounds and made significant contributions to the
audit findings despite their inexperience as auditors. The continued
commitment to fill vacancies with individuals with operational and technical
1
backgrounds is perceived by NRC as highly positive.
i
Another factor involved in the improved 1986 audit appeared to be an
upscaled and broadened audit checklist. The checklist used for the 1986
audit was much more detailed and covered more areas than the checklists used
in 1984 and 1985. The inspectors review of audit checklists confirmed a ;
statement by a former auditor that audits conducted in 1985 and before were
- more or less of a non-technical nature concerned more with form than
l substance i.e., literal compliance, whereas the 1986 audit became more
,
involved with functional compliance.
!
In conclusion, it appeared that three major factors contributed to the
difference in performance between the 1986 audit and those conducted in 1984 i
'
and 1985: more manpower, more technically-oriented auditors, and an
- -improved audit checklist. The last two of these elements should be
- available in future audits, but the manpower issue, as discussed previously,
j 'is highly uncertain.
7. QA Record Storage Practices
,
QA audit QSQ-A-85-0006, May 3,1985, identified the following observation
i concerning the handling of surveillance instruction (SI) data packages while
awaiting QA review:
4
The QA Staff has a collection area where sis are kept while awaiting QA
i review. This collection area is an unattended, open shelf area in the
office building that does not afford the SI data packages any
.
protection from damage or loss. During the audit, in excess of 500 sis
l were observed in this area which were less than one month old, although
'
two observed were in excess of 7 months old. The procedure controlling
-the collection, storage, and maintenance of QA records (NQAM, Part III,
Section 4.1) lists these SI data sheets as "QA records with lifetime
retention period." The data sheets are not defined as QA records until
- they have been completed. However, information necessary to verify-
- compliance to the technical specifications should be properly protected l
2
especially if the information and/or data is irretrievable.
i
.
I
I
t
l
. - - _ , . . - _ . . - - - , _ - - . . - - . . - - . _ - - - . - . - - - - - - . . . - . ~ . . - -
.
"
11
Area of Concern
QAB recommends that sis and other CSSC-related inprocess documentation
be collected, stored, and maintained in a manner commensurate with
their importance. QAB will list this as an area of concern and inspect
the storage of SI data packages in future audits.
Evidently, action was not taken on this matter and the licensee's 1986.QA
audit did not address it. NRC Inspection Report Nos. 50-327, 328/86-32,
identified the same problem with approximately 300 sis observed to be in the
same condition. The inspectors interviewed the QA supervisor responsible
for QA SI reviews. He asserted that sis in this limbo state, awaiting QA
review, were not considered QA records as defined by ANSI N45.2.9-1974,
Section 1.4, in that the sis were not completed records until the final QA
review. The inspectors observed that the sis had been moved to a metal file
cabinet which was not fire-resistant. The sis were filed randomly without
an administrative tracking mechanism. QA personnel, when time is available,
select records from the cabinet for review, supposedly concentrating on sis
of the greatest age. The inspectors determined by random sample that
approximately 10 percent of the sis were older than two months with a
maximum age of approximately 4 months. The total number of outstanding sis
was approximately 200. The cabinet is supposedly locked when not in use
although the inspectors found it unlocked on one random trial.
The licensee stated that SI's awaiting QA review are not official QA
records. The licensee is committed to Regulatory Guide 1.88 which endorses
ANSI N45.2.9-1974, Requirements for Collection, Storage, and Maintenance of
Quality Assurance Records for Nuclear Power Plants. This standard defines a
QA record as a specified document that has been completed. The licensee's
procedure, Administrative Instruction (AI)-7, Section 3.1, defines document
completion at the time of entry of the final signature and date, unless
otherwise specified. This is consistent with the licensee's argument that
the sis are not QA records until the QA review is completed. However,
SI-1, Section 9.2.3.8, states that when an SI data package is finished, it
is to be immediately reviewed by the section supervisor or cognizant
reviewer to determine, among other things, if the package is complete as a
QA record. The wording of this procedure implies that the data package
becomes a QA record immediately af ter the data is completely entered and
immediate reviews are performed. Thus, the licensee's procedures conflict
on this issue.
NRC concerns include the possible loss of irreplaceable information on sis
due to fire or mishandling and the lengthy delay in completing the official
review of test results which are satisfying immediate operability
determinations as defined by Technical Specifications. The licensee's
interpretation of the definition of a QA record in this instance appears to
lead to an uncontrolled and unregulated compromise of safety-related
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information. NRC will track this as Inspector Followup Item 327,
328/86-41-02, Storage and Control of QA Records During Review. The
licensee was requested to submit a formal response to this issue.
8. Licensee Action on Previously Identified Inspection Findings (92701)
a. (Closed) Inspector Followup Item 327,328/84-01-04: Lack of Aerosol
Control
Closure was based on a Power Stores Section Instruction Letter No. 33,
Control of Aerosol Spray, Revision 0. This instruction requires
procurement of approved aerosol sprays as listed in Standard Practice
SQA-160. Aerosol sprays not on this list will be affixed with a label
which states; "Not approved for use on materials which may come in
contact with reactor coolant - guard against overspray".
b. (Closed) Inspector Followup Item 327,328/85-05-03: Control and
Accountability of Measuring and Test Equipment (M&TE)
Closure was based on an inspector's sample of randomly selected M&TE
items and a review of the M&TE inventory list. All equipment in the
sample was verified to be at the location indicated on master inventory
list. The M&TE selected also had accurate calibration and calibration
due dates on equipment labels,
c. (0 pen) Inspector Followup Item 327,328/85-21-03: Development of
Procedure STI-1 to Provide Positive Control of STEAR Activities
This item remains open due to the active status of procedure SQA-100
which previously provided controls for STEAR activities. Presently two
procedures are approved, STI-1 approved July 31, 1986, and SQA-100.
This item can be closed when SQA-100 is cancelled. Cancellation was
delayed due to active instructions which reference this procedure.
These STEAR instructions are as follows: 83-18, 83-20, 84-04, 84-06,
and 84-07.
.
l d. (Closed) Inspector Followup Item 327,328/86-12-02: Verify that
Licensee Closes All Pre-Operational Packages Prior to Startup
The inspector reviewed a computer listing of all pre-operational tests
.
which listed dates for Westinghouse and Plant-Manager approval. All 19
l preoperational test records in question were indicated as having
!
Westinghouse and Plant Manager approval. The inspector reviewed a
letter from Westinghouse to TVA dated June 6,1986, which closed out
Westinghouse approval of all outstanding tests. The inspector verified
by sampling three test packages that review signatures matched the
dates on the computer printout. The licensee stated that all
pre-operational test packages have been fully approved and are being
l
stored as permanent plant QA records in the Document Control Center
vault.
1
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e. (Closed) Inspector Followup Item 327, 328/85-21-02: Development of
Staff Guidance for Preparation of USQD Form
SQA-119 was revised on September 25, 1985, to upgrade Unresolved Safety
l Question Determination (USQD) procedures. The USQD is the mechanism
for processing unreviewed environmental issues.
,
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