ML20214M877: Difference between revisions

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#REDIRECT [[IR 05000327/1986041]]
{{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
!
 
*
  .
                                        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
                  -          .-                              .. ..    .    . _ ,  - . = . = .
 
  -
      .
                                            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

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
ML20214M877
Person / Time
Site: Sequoyah  Tennessee Valley Authority icon.png
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.

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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

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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.

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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.

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}. 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.

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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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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.

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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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