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        /LLIN0/S POWER COMPANY IP     CLINTON POWER STATION, P.O. BOX 399, CLINTON, ILLINOIS 61727 Q37-81(06-ll)-L U-0244 June 11, 1981 Mr. James G. Keppler Director U. S. Nuclear Regulatory Commission Office of Inspection and Enforcement Region III 799 Roosevelt Road Glen Ellyn, Illinois         61037
/LLIN0/S POWER COMPANY IP CLINTON POWER STATION, P.O. BOX 399, CLINTON, ILLINOIS 61727 Q37-81(06-ll)-L U-0244 June 11, 1981 Mr. James G. Keppler Director U. S. Nuclear Regulatory Commission Office of Inspection and Enforcement Region III 799 Roosevelt Road Glen Ellyn, Illinois 61037


==Dear Mr. Keppler:==
==Dear Mr. Keppler:==
This is in response to your Notice of Violation and Inspection Report Number 50-461/81-05 on the NRC special team inspection of the Clinton Power Station conducted during the period February 9 -
This is in response to your Notice of Violation and Inspection Report Number 50-461/81-05 on the NRC special team inspection of the Clinton Power Station conducted during the period February 9 -
March 5, 1981.         Illinois Power Company's response to the items discussed during the March 12, 1981 meeting and summarized in the
March 5, 1981.
        " Inspection Results" section of your report is included as Appendix A. In addition, Appendix B provides the additional information requested in your letter dated April 21, 1981 related to the unresolved matter discussed in Paragraphs C.2.b and D.4.b(4) of your report.
Illinois Power Company's response to the items discussed during the March 12, 1981 meeting and summarized in the
" Inspection Results" section of your report is included as Appendix A.
In addition, Appendix B provides the additional information requested in your {{letter dated|date=April 21, 1981|text=letter dated April 21, 1981}} related to the unresolved matter discussed in Paragraphs C.2.b and D.4.b(4) of your report.
Illinois Power Company's response for the eleven (11) items of noncompliance cited in the Notice of Violation is: as follows:
Illinois Power Company's response for the eleven (11) items of noncompliance cited in the Notice of Violation is: as follows:
: 1. Criterion V, Instructions, Procedures and Drawings -
1.
Criterion V, Instructions, Procedures and Drawings -
The Notice of Violation states in part:
The Notice of Violation states in part:
                    " Contrary to the above (10CFR50 Appendix B, Criterion V and Illinois Power Company, Clinton Power Station PSAR Section 17.1.5.1):
" Contrary to the above (10CFR50 Appendix B, Criterion V and Illinois Power Company, Clinton Power Station PSAR Section 17.1.5.1):
: a. The hanger installation / inspection tolerance procedure was incomplete in that it did not cover all areas necessary to ensure proper installation and QC acceptance inspection.
a.
: b. Specific instructions for installing mechanical snubbers was lacking.
The hanger installation / inspection tolerance procedure was incomplete in that it did not cover all areas necessary to ensure proper installation and QC acceptance inspection.
: c. The procedure for installing the penetration seismic guides was not adequately detailed to control weld distortion."
b.
8107280415 810720 PDR ADOCK 05000461 N
Specific instructions for installing mechanical snubbers was lacking.
G                  PDR
c.
The procedure for installing the penetration seismic guides was not adequately detailed to control weld distortion."
8107280415 810720 N
PDR ADOCK 05000461 G
PDR


e J J. G. Kcppler                                     June 11, 1981 NRC                                               Page 2
e J
    ,          A new procedure, BAP 3.2.5, " Piping Component Supports", covering the installation and inspection of piping component supports /
J. G. Kcppler June 11, 1981 NRC Page 2 A new procedure, BAP 3.2.5, " Piping Component Supports", covering the installation and inspection of piping component supports /
hangers has been written, reviewed, approved, and issued for implementation. This procedure provides specific installation and inspection instructions and criteria, including: dimensional tolerances, base plate bolt hole location / bolt pattern, support pin-to-pin dimensions, locations, angularity clearances, centers of gravity and other related criteria. Quality Control instructions, including checklists were revised to reflect the new installation and inspection procedure requirements.
hangers has been written, reviewed, approved, and issued for implementation.
This procedure provides specific installation and inspection instructions and criteria, including:
dimensional tolerances, base plate bolt hole location / bolt pattern, support pin-to-pin dimensions, locations, angularity clearances, centers of gravity and other related criteria.
Quality Control instructions, including checklists were revised to reflect the new installation and inspection procedure requirements.
Specific installation and inspection instructions for Pacific Scientific mechanical snubbers are also included in BAP 3.2.5.
Specific installation and inspection instructions for Pacific Scientific mechanical snubbers are also included in BAP 3.2.5.
Certain handling, storage, and preventative maintenance precautions or requirements are being included in the existing Storage and Maintenance program.
Certain handling, storage, and preventative maintenance precautions or requirements are being included in the existing Storage and Maintenance program.
A trial program for installation and inspection of piping component supports / hangers to rSe new procedures has been completed and results reviewed oy the NRC during an inspection visit on June 5-6, 1981.
A trial program for installation and inspection of piping component supports / hangers to rSe new procedures has been completed and results reviewed oy the NRC during an inspection visit on June 5-6, 1981.
A nonconformance report (NCR) was issued to document conditions noted on the Reactor Water Cleanup pipe seismic guides inside the guard pipe for engineering review and disposition. Work was terminated until the NCR was dispositioned and appropriate installation procedures / guidance were issued.
A nonconformance report (NCR) was issued to document conditions noted on the Reactor Water Cleanup pipe seismic guides inside the guard pipe for engineering review and disposition.
The S&L drawing (M06-1000, Sheet 6) has been revised to indicate that the " cold gap position" is the thickness of shim stock to be used during fabrication / installation welding of seismic guides. The installation traveler for the remaining seismic guide work is being revised to incorporate additional detail and steps to control weld distortion within acceptable limits.
Work was terminated until the NCR was dispositioned and appropriate installation procedures / guidance were issued.
: 2. Criterion V, Instructions, Procedures, and Drawings -
The S&L drawing (M06-1000, Sheet 6) has been revised to indicate that the " cold gap position" is the thickness of shim stock to be used during fabrication / installation welding of seismic guides.
The installation traveler for the remaining seismic guide work is being revised to incorporate additional detail and steps to control weld distortion within acceptable limits.
2.
Criterion V, Instructions, Procedures, and Drawings -
The Notice of Violation states in part:
The Notice of Violation states in part:
                    " Contrary to the above (10CFR50 Appendix B, Criterion V and Illinois Power Company, Clinton Power Station PSAR, Section 17.1.5.1) in the area of pipe supports and restraints:                                                   ,
" Contrary to the above (10CFR50 Appendix B, Criterion V and Illinois Power Company, Clinton Power Station PSAR, Section 17.1.5.1) in the area of pipe supports and restraints:
: a. Eight out of the nine safety-related and installed hangers, struts and snubbers observed by the inspector did not conform to the construction drawing requirements.
a.
: b. The Reactor. Water Cleanup pipe penetration seismic guide inside the guard pipe did not conform to the design drawing clearance requirement."
Eight out of the nine safety-related and installed hangers, struts and snubbers observed by the inspector did not conform to the construction drawing requirements.
b.
The Reactor. Water Cleanup pipe penetration seismic guide inside the guard pipe did not conform to the design drawing clearance requirement."
l
l


        . J. G. Keppler                                                                 June 11, 1981 Page 3 A new procedure, BAP 3.2.5, " Piping Component Supports",
J. G. Keppler June 11, 1981 Page 3 A new procedure, BAP 3.2.5, " Piping Component Supports",
which provides specific and generic instructions for the fabrication, installation, and inspection of pipe supports, has been issued. Training classes were held for craft, supervisory, quality control, and technical services personnel. All previously installed hangers will be reinspected and reevaluated to the criteria included in the new procedure.
which provides specific and generic instructions for the fabrication, installation, and inspection of pipe supports, has been issued.
A trial program was conducted to ensure that the new procedures were adequate for controlling hanger installations and inspections. The results of the program were reviewed by the NRC during an inspection visit on June 5-6, 1981.
Training classes were held for craft, supervisory, quality control, and technical services personnel.
A nonconformance report (NCR) was issued to document conditions noted on the Reactor Water Cleanup (RWCU) pipe seismic guides inside the guard pipe for engineering review and disposition. Work on further installation of such seismic guides was suspended until the NCR was dispositioned and appropriate installation / guidance were issued.-                         The A-E determined that even a zero clearance condition would not result in unacceptable stresses for any of the assemblies. Further investigation in the field substantiated that the installed condition is bounded by the A-E's calculations. As a result of this investigation, the NCR was dispositioned " accept-as-is".                           Since the fabrication procedure followed for the other installed seismic guides was the same (except that main steam guides were shop assembled with some additional welding controls) and no repairs were required for the RWCU guide assembly, no further action will be needed on the others. The S&L drawing (M06-1000, Sheet 6) has been revised to indicate that the " cold gap position" is the thickness of shim stock to be used during fabrication / installation welding of the seismic guides. The installation traveler for the remaining seismic guide work is being revised to incorporate additional detail and steps to minimize weld distortion.
All previously installed hangers will be reinspected and reevaluated to the criteria included in the new procedure.
A trial program was conducted to ensure that the new procedures were adequate for controlling hanger installations and inspections.
The results of the program were reviewed by the NRC during an inspection visit on June 5-6, 1981.
A nonconformance report (NCR) was issued to document conditions noted on the Reactor Water Cleanup (RWCU) pipe seismic guides inside the guard pipe for engineering review and disposition.
Work on further installation of such seismic guides was suspended until the NCR was dispositioned and appropriate installation / guidance were issued.-
The A-E determined that even a zero clearance condition would not result in unacceptable stresses for any of the assemblies.
Further investigation in the field substantiated that the installed condition is bounded by the A-E's calculations.
As a result of this investigation, the NCR was dispositioned " accept-as-is".
Since the fabrication procedure followed for the other installed seismic guides was the same (except that main steam guides were shop assembled with some additional welding controls) and no repairs were required for the RWCU guide assembly, no further action will be needed on the others.
The S&L drawing (M06-1000, Sheet 6) has been revised to indicate that the " cold gap position" is the thickness of shim stock to be used during fabrication / installation welding of the seismic guides.
The installation traveler for the remaining seismic guide work is being revised to incorporate additional detail and steps to minimize weld distortion.
Installation of all seismic guides is expected to be completed by July 31, 1981.
Installation of all seismic guides is expected to be completed by July 31, 1981.
: 3. Criterion X, Inspection The Notice of Violation states in part:
3.
                      " Contrary to the above (10CFR50 Appendix B, Criterion X and the CPS PSAR Section 17.1.10.1).
Criterion X, Inspection The Notice of Violation states in part:
: a.                       The existing hanger inspection program was inadequate in that it did not provide for timely inspections to identify deficiencies and to initiate corrective actions to prevent recurrance and it did not distinguish the inspection requirements for each phase of hanger installation.
" Contrary to the above (10CFR50 Appendix B, Criterion X and the CPS PSAR Section 17.1.10.1).
a.
The existing hanger inspection program was inadequate in that it did not provide for timely inspections to identify deficiencies and to initiate corrective actions to prevent recurrance and it did not distinguish the inspection requirements for each phase of hanger installation.


        -    .    . - . - =       - .    =   . _ - . - .-.    - . -    -    .__ - _        - ._  . . - -
. -. - =
          .. J . G. Keppler                                                             June 11, 1981         ,
=
j NRC                                                                     Page 4
.. J. G. Keppler June 11, 1981 j
: b.     The traveler QC acceptance provision for the pipe 4
NRC Page 4 b.
penetration seismic guide was inadequate in that i                                       it. did not provide for inspection measurement after component installation."
The traveler QC acceptance provision for the pipe penetration seismic guide was inadequate in that 4
A three phase program for installation and inspection of piping component supports / hangers has been developed and instituted through a new procedure, BAP 3.2.5, " Piping .
i it. did not provide for inspection measurement after component installation."
Component Supports" and all new safety-related pipe hangers will be installed and inspected to its provisions. The three phases of this program are:
A three phase program for installation and inspection of piping component supports / hangers has been developed and instituted through a new procedure, BAP 3.2.5, " Piping.
Phase       I:   Installation and inspection of. the hanger /.
Component Supports" and all new safety-related pipe hangers will be installed and inspected to its provisions.
i support's primary attachment to the building i                                             or structure.
The three phases of this program are:
I Phase       II:   Installation and inspection of the hanger / -
Phase I:
                                                                              ~
Installation and inspection of. the hanger /.
i support's primary attachment to the building i
or structure.
I Phase II:
Installation and inspection of the hanger / -
~
support's construction from the anchor point to the pipe.
support's construction from the anchor point to the pipe.
Phase III:         This phase occurs just prior, to system func-l tional testing and encompasses final cold                       '
l Phase III:
,                                            s etting . adj us tments , removal of travel stops,   '
This phase occurs just prior, to system func-tional testing and encompasses final cold s etting. adj us tments, removal of travel stops,
{
{
and other final setting adjustments.
and other final setting adjustments.
i As the craft completes installation activities of each phase, the hanger will. be inspected.                 A copy of each inspection checklist, for each-of the three phases, is forwarded to Baldwin Associates
i As the craft completes installation activities of each phase, the hanger will. be inspected.
              . Quality Assurance for trend analysis.                   In this-way, generic or repetitive problems can be identified and' corrective action initiated to prevent recurrence.
A copy of each inspection checklist, for each-of the three phases, is forwarded to Baldwin Associates
A trial program for installation and inspection of piping component supports / hangers to the new procedure has been completed i               and resultu reviewed by the NRC during an inspection visit on j               June 5-6, 1981.
. Quality Assurance for trend analysis.
As noted in the previous two items of noncompliance, relative to the~ Reactor Water Cleanup pipe seismic guides insideL the guard-pipe, a nonconformance report (NCR) was issued to document condi-tions noted and. to obtain engineering review and disposition.                       -
In this-way, generic or repetitive problems can be identified and' corrective action initiated to prevent recurrence.
l               Work on further installation of such seismic guides was suspended j           . until the NCR was dispositioned and appropriate installation and l
A trial program for installation and inspection of piping component supports / hangers to the new procedure has been completed i
inspection: procedures / guidance was issued. The S&L drawing (M06-1000, Sheet 6) was revised to indicate that the " cold gap                               i position" is the thickness af shim stock:to be used during fabrication / installation welding of the seismic guides.                   The L               installation traveler for the remaining seismic guides work-is being revised to incorporate additional detail and : steps to j               minimize weld distortion and to ensure -design requirements are I               met.           This will -include appropriate QC inspection signoffs .
and resultu reviewed by the NRC during an inspection visit on j
L                           Installation of all seismic. guides is expected to be l'               completed by; July.31, 1981.
June 5-6, 1981.
As noted in the previous two items of noncompliance, relative to the~ Reactor Water Cleanup pipe seismic guides insideL the guard-pipe, a nonconformance report (NCR) was issued to document condi-tions noted and. to obtain engineering review and disposition.
l Work on further installation of such seismic guides was suspended j
. until the NCR was dispositioned and appropriate installation and inspection: procedures / guidance was issued.
The S&L drawing l
i (M06-1000, Sheet 6) was revised to indicate that the " cold gap position" is the thickness af shim stock:to be used during fabrication / installation welding of the seismic guides.
The L
installation traveler for the remaining seismic guides work-is being revised to incorporate additional detail and : steps to j
minimize weld distortion and to ensure -design requirements are I
met.
This will -include appropriate QC inspection signoffs.
L Installation of all seismic. guides is expected to be l'
completed by; July.31, 1981.
I k'
I k'


r l     . .- J. G. Keppler                                         Juno 11, 1981 NRC                                                   Page 5
r l
: 4. Criterion XVIII, Audits The Notice of Violation states in part:
J. G. Keppler Juno 11, 1981 NRC Page 5 4.
                      " Contrary to the above (10CFR50 Appendix B, Criterion XVIII and CPS PSAR Section 17.1.18.1), relative to pipe hanger design and installation activities, the licensee audit of the A-E, the licensee audit and surveillance of contractor site performance, and the contractor's internal audits were considered inadequate in that detailed hanger audit requirements were absence, problems were not prevented from recurring, and programatic audit planning, scheduling, and implementation was absent for on-going safety-related hanger installation and QC inspection activities."
Criterion XVIII, Audits The Notice of Violation states in part:
A plan for coordinated licensee and contractor audits and surveillances was developed and implemented in conjunction with the trial program for pipe hanger installation and inspection activities. In addition, a detailed plan of licensee and contractor audits and surveillances to periodically assess the adequacy and effectiveness of programs for design, fabrication, installation and inspection of seismic Category I piping and component supports and hangers has been issued. This plan includes a series of audits, which were already part of previously established audit plans and schedules, and a series of surveillances of on-going activities. The plan also describes the time / period of the planned audit or surveillance, the overall scope of activities, the items or components, and the applicable 10CFR50 Appendix B criteria to be covered.
" Contrary to the above (10CFR50 Appendix B, Criterion XVIII and CPS PSAR Section 17.1.18.1), relative to pipe hanger design and installation activities, the licensee audit of the A-E, the licensee audit and surveillance of contractor site performance, and the contractor's internal audits were considered inadequate in that detailed hanger audit requirements were absence, problems were not prevented from recurring, and programatic audit planning, scheduling, and implementation was absent for on-going safety-related hanger installation and QC inspection activities."
A plan for coordinated licensee and contractor audits and surveillances was developed and implemented in conjunction with the trial program for pipe hanger installation and inspection activities.
In addition, a detailed plan of licensee and contractor audits and surveillances to periodically assess the adequacy and effectiveness of programs for design, fabrication, installation and inspection of seismic Category I piping and component supports and hangers has been issued.
This plan includes a series of audits, which were already part of previously established audit plans and schedules, and a series of surveillances of on-going activities.
The plan also describes the time / period of the planned audit or surveillance, the overall scope of activities, the items or components, and the applicable 10CFR50 Appendix B criteria to be covered.
IP Construction QA has developed a detailed surveillance checklist to be used during surveillance of hanger installation /
IP Construction QA has developed a detailed surveillance checklist to be used during surveillance of hanger installation /
inspection activities in the field. Detailed checklists for audits are prepared by the audit team after formal assignment and the scope of the audit is determined. This occurs prior to the scheduled audit and complies to IP's commitment to Regulatory Guide 1.144 (Jan. 1979) and ANSI N45.2.12 (1977) " Requirements for Auditing of Quality Assurance Programs-for Nuclear Power Plants."
inspection activities in the field.
Detailed checklists for audits are prepared by the audit team after formal assignment and the scope of the audit is determined.
This occurs prior to the scheduled audit and complies to IP's commitment to Regulatory Guide 1.144 (Jan. 1979) and ANSI N45.2.12 (1977) " Requirements for Auditing of Quality Assurance Programs-for Nuclear Power Plants."
IP Construction QA surveillance program has been upgraded to include a plan and pre-prepared checklist-s for certain activities.
IP Construction QA surveillance program has been upgraded to include a plan and pre-prepared checklist-s for certain activities.
Surveillances are scheduled dependent on the nature of activities and performance trends.
Surveillances are scheduled dependent on the nature of activities and performance trends.
The contractor and licensee audit programs and plans are being reviewed to determine what changes or improvement, if any, are needed to ensure comprehensive and sufficient coverage of activities. This review is expected to be completed by July 31, 1981 and any changes should be implemented throughout the remainder of 1981.
The contractor and licensee audit programs and plans are being reviewed to determine what changes or improvement, if any, are needed to ensure comprehensive and sufficient coverage of activities.
This review is expected to be completed by July 31, 1981 and any changes should be implemented throughout the remainder of 1981.


        ,      ..      J. G. Koppler                                                                 June 11, 1981 NRC                                                                           Page 6
J. G. Koppler June 11, 1981 NRC Page 6 5.
: 5.       Criterion IX - Control of Special Processes -
Criterion IX - Control of Special Processes -
The Notice of Violation states in part:
The Notice of Violation states in part:
                                      " Contrary to the above (10CFR50 Appendix B, Criterion IX; CPS PSAR. Section 17.1.9.3; and ASME B&PV Code, NA-4411) ,
" Contrary to the above (10CFR50 Appendix B, Criterion IX; CPS PSAR. Section 17.1.9.3; and ASME B&PV Code, NA-4411),
welding was not being accomplished in accordance with applicable codes, in that, controlled welding procedure specifications with the associated welding parameters sheets were not located at the prescribed activity (welding) . "
welding was not being accomplished in accordance with applicable codes, in that, controlled welding procedure specifications with the associated welding parameters sheets were not located at the prescribed activity (welding). "
The Welding Procedure Specification Information Handbooks
The Welding Procedure Specification Information Handbooks
(" Blue Books") which contain a listing of welding parameters have been recalled and will be reissued to Discipline Super-intendents for distribution to welders as controlled documents and will be kept current per BA Project Procedures.                             This will be accomplished by July 15, 1981 and we will.be in full ccmpliance.
(" Blue Books") which contain a listing of welding parameters have been recalled and will be reissued to Discipline Super-intendents for distribution to welders as controlled documents and will be kept current per BA Project Procedures.
This will be accomplished by July 15, 1981 and we will.be in full ccmpliance.
In addition, welding procedure specifications and the associated welding parameter sheets are available in controlled Technical Services Manuals at various Document Control centers within the plant.
In addition, welding procedure specifications and the associated welding parameter sheets are available in controlled Technical Services Manuals at various Document Control centers within the plant.
: 6.       Criterion XVII, Quality Assurance Records The Notice of Violation states in part:
6.
                                      " Contrary to the above (10CFR50 Appendix B, Criteria XVII and CPS PSAR Section 17.1.17.1), reviews of nonconformance reports, audits, and surveillances, for reportability-pursuant to 10CFR50.55 e( ) are not bein enable-verification of proper review."g documented to The nonconformance report (NCR) form has been revised to include a block for the contractor's project engineering group to indicate review for 10CFR50.55(e) reportability. Additionally, the contractor's QA organization has revised their procedures for reviewing NCR's to include documentation, via -a log entry and a stamp on the NCR, that their review for reportability has-been accomplished. IP QA conducts a quarterly trend review of NCR's.
Criterion XVII, Quality Assurance Records The Notice of Violation states in part:
" Contrary to the above (10CFR50 Appendix B, Criteria XVII and CPS PSAR Section 17.1.17.1), reviews of nonconformance reports, audits, and surveillances, for reportability-enable-verification of proper review."g documented to pursuant to 10CFR50.55 e( ) are not bein The nonconformance report (NCR) form has been revised to include a block for the contractor's project engineering group to indicate review for 10CFR50.55(e) reportability.
Additionally, the contractor's QA organization has revised their procedures for reviewing NCR's to include documentation, via -a log entry and a stamp on the NCR, that their review for reportability has-been accomplished.
IP QA conducts a quarterly trend review of NCR's.
The form which documents the results of their review is being modified to include documentedLevidence of IP QA's review for.
The form which documents the results of their review is being modified to include documentedLevidence of IP QA's review for.
reportability at that time.
reportability at that time.
The contractor has also revised their QA procedures regarding reviews of audit and surveillance reports to include a requirement for the Manager of QA to stamp, sign and date the affected documents;
The contractor has also revised their QA procedures regarding reviews of audit and surveillance reports to include a requirement for the Manager of QA to stamp, sign and date the affected documents; indicating a review for potentially reportable 10CFR50.55(e) conditions has been made.
:                      indicating a review for potentially reportable 10CFR50.55(e)
IP has modified their audit report title page fonn to include a definite signed statement that indicates a review of the report including the-audit findings
'                      conditions has been made.                       IP has modified their audit report title page fonn to include a definite signed statement that indicates a review of the report including the-audit findings for.potentially reportable items by the team leader has been completed.         Further changes / modifications to the IP QA surveillance finding form are being made to provide documented evidence' that the QA Supervisor's review includes a review for reportability.
- for.potentially reportable items by the team leader has been completed.
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Further changes / modifications to the IP QA surveillance finding form are being made to provide documented evidence' that the QA Supervisor's review includes a review for reportability.
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i J. G. Keppler                                       June 11, 1981 NRC                                                 Page 7 All the above documentation of reviews will show the results of these reviews as either "yes" or "no". The actual reporting process of the potential reportable item will be in accordance with formal procedures issued by the contractor and licensee.
i J. G. Keppler June 11, 1981 NRC Page 7 All the above documentation of reviews will show the results of these reviews as either "yes" or "no".
The actual reporting process of the potential reportable item will be in accordance with formal procedures issued by the contractor and licensee.
The above noted actions should ensure appropriate documentation of reviews in the future.
The above noted actions should ensure appropriate documentation of reviews in the future.
We expect to have appropriate changes / modifications in procedures and forms and necessary training associated completed such that full compliance is achieved by July 1, 1981.
We expect to have appropriate changes / modifications in procedures and forms and necessary training associated completed such that full compliance is achieved by July 1, 1981.
: 7. Criterion XVI, Corrective Action The Notice of Violation states in part:
7.
                " Contrary to the above (10CFR50 Appendix B, Criterion XVI and IPC Quality Assurance Manual, Chapter 16)-
Criterion XVI, Corrective Action The Notice of Violation states in part:
: a. Neither prompt nor effective corrective action to preclude repetition was taken in response to the following audits and other documents concerning electrical hanger installation activities.
" Contrary to the above (10CFR50 Appendix B, Criterion XVI and IPC Quality Assurance Manual, Chapter 16)-
(1) Baldwin Associates (BA) Internal Audit Report I-134, dated January 22, 1980.
a.
(2) BA Internal Audit Report I-137, dated February 19, 1980.
Neither prompt nor effective corrective action to preclude repetition was taken in response to the following audits and other documents concerning electrical hanger installation activities.
(3) Corrective Action Request (CAR) number 049 dated March 3, 1980.
(1)
(4) BA Internal Audit Report I-150, dated June 24, 1980.
Baldwin Associates (BA) Internal Audit Report I-134, dated January 22, 1980.
(5) Site Surveillance Report No. S-313 dated August 18, 1980.
(2)
: b. The licensee failed to take prompt corrective action in response to a special QA Review of IEEE Environmental and Seismic Qualifications, dated 9-17-80, which identified the current practice of granting unconditional acceptance status to components lacking quality documentation."
BA Internal Audit Report I-137, dated February 19, 1980.
: a. This item involves the recognition of an overall problem during an early phase when subproblems arise which are not recognized as being related. Problem recognition is not unique to nuclear power plant construction; it is common to most complex, multi-activity functions.
(3)
Corrective Action Request (CAR) number 049 dated March 3, 1980.
(4)
BA Internal Audit Report I-150, dated June 24, 1980.
(5)
Site Surveillance Report No. S-313 dated August 18, 1980.
b.
The licensee failed to take prompt corrective action in response to a special QA Review of IEEE Environmental and Seismic Qualifications, dated 9-17-80, which identified the current practice of granting unconditional acceptance status to components lacking quality documentation."
a.
This item involves the recognition of an overall problem during an early phase when subproblems arise which are not recognized as being related.
Problem recognition is not unique to nuclear power plant construction; it is common to most complex, multi-activity functions.
Electrical hanger installation is a complex activity.
Electrical hanger installation is a complex activity.
Initial corrective actions (audit findings and CARS) were directed toward correcting specific deficiencies within the established electrical hanger installation system. It was not obvious at that time that the individual specific problems were
Initial corrective actions (audit findings and CARS) were directed toward correcting specific deficiencies within the established electrical hanger installation system.
It was not obvious at that time that the individual specific problems were


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J. G. Keppler                                                                                                     June 11, 1981 NRC                                                                                                               Page 8
2\\
    ~
J 2
indicative of a broader general problem. The full extent and need
>4e n-
.                  for substantial revision of the entire system were not l                 realized until it was determined to be reportable under 10CFR50.55(e) in September 1980.
--,-a
In retrospect, it can be concluded that an earlier decision to revise the entire system could have been made. This, however was not apparent as each successive level of corrective action was taken. Based on evaluations made at the time, and the value judgments rendered by those involved, the corrective action proposed at each step was considered sufficient. This experience emphasizes the difficult when working on individual trees." yWeinbelieve                                        "seeingthat            the forest this form of problem recognition can be Dnproved by better communications between the parties involved.
_a_m Ax a
i It has been Illinois Power Company's philosophy that the responsibility for quality lies with the organizations responsible for doing the work. The quality assurance organizations (IP and BA) monitor this effort through audits and surveillances, including the identification of the development and/or evaluation of resolutions which will ensure compliance with established program and commitments. These deficiencies are normally resolved without top management invaivement; however, the lines of communication are maintained and j                 problems which warrant such attention are reported to upper 3                  management.
J. G. Keppler June 11, 1981
To improve communications between the parties involved in evaluating and correcting findings and to enhance management participation, a system of periodic quality review meetings has been established. These meetings will bring together quality, engineering, and construction management and supervision from Illinois Power,                         Baldwin Associates and others such as Sargent and Lundy and General                                   Electric, as necesasry, to evaluate and coordinate quality activities :bi the work areas involved.             Concurrence with evaluation of quality problems and plans of action will be documented. These periodic assessments will be in addition to reporting ind resolution methods currently employed, and will be conducted specifically.
+
NRC Page 8 indicative of a broader general problem.
The full extent and need
~
for substantial revision of the entire system were not l
realized until it was determined to be reportable under 10CFR50.55(e) in September 1980.
In retrospect, it can be concluded that an earlier decision to revise the entire system could have been made.
: This, however was not apparent as each successive level of corrective action was taken.
Based on evaluations made at the time, and the value judgments rendered by those involved, the corrective action proposed at each step was considered sufficient.
This when working on individual trees." y in "seeing the forest experience emphasizes the difficult We believe that this form of problem recognition can be Dnproved by better communications between the parties involved.
i It has been Illinois Power Company's philosophy that the responsibility for quality lies with the organizations responsible for doing the work.
The quality assurance organizations (IP and BA) monitor this effort through audits and surveillances, including the identification of the development and/or evaluation of resolutions which will ensure compliance with established program and commitments.
These deficiencies are normally resolved without top management invaivement; however, the lines of communication are maintained and j
problems which warrant such attention are reported to upper management.
3 To improve communications between the parties involved in evaluating and correcting findings and to enhance management participation, a system of periodic quality review meetings has been established.
These meetings will bring together quality, engineering, and construction management and supervision from Illinois Power, Baldwin Associates and others such as Sargent and Lundy and General Electric, as necesasry, to evaluate and coordinate quality activities :bi the work areas involved.
Concurrence with evaluation of quality problems and plans of action will be documented.
These periodic assessments will be in addition to reporting ind resolution methods currently employed, and will be conducted specifically.
to avoid escalation of lower-level problems, or lack of prompt execution of previously approved action plans.
to avoid escalation of lower-level problems, or lack of prompt execution of previously approved action plans.
We believe that this interchange will improve communication and coordination of quality activities and will enhance our capability to identify trends or other signals which indicate that broad corrective action is needed.
We believe that this interchange will improve communication and coordination of quality activities and will enhance our capability to identify trends or other signals which indicate that broad corrective action is needed.
: b.           Corrective action was taken to resolve this issue.
b.
The Baldwin Associates Quality Assurance Manual and associated procedures were revised subsequent to and as a result of the i                Special QA Review to better distinguish types of documentation and conditions to be met for conditional acceptance and final acceptance of safety-related equipment. Based on the revisions to the program for obtaining documentation, we consider this an adequate approach to satisfying-the intent of our regulatory commitments.
Corrective action was taken to resolve this issue.
          , - , _ . . - ,                  , , - - - - -            . _ ~ .        - - - - . -            - _ - - , . . . , , - -            , , -,.- ,, ---_.- ..._.
The Baldwin Associates Quality Assurance Manual and associated procedures were revised subsequent to and as a result of the Special QA Review to better distinguish types of documentation i
and conditions to be met for conditional acceptance and final acceptance of safety-related equipment.
Based on the revisions to the program for obtaining documentation, we consider this an adequate approach to satisfying-the intent of our regulatory commitments.
~.


J. G. Keppler                                       Juns 11, 1981 NRC                                                 Page 9
J. G. Keppler Juns 11, 1981 NRC Page 9 8.
: 8. Criterion III, Design Contro_1 The Notice of Violation states in part:
Criterion III, Design Contro_1 The Notice of Violation states in part:
                                                                    " Contrary to the above (10CFR50 A pendix B, Criterion III and CPS PSAR Section 17.1.3.3 :
" Contrary to the above (10CFR50 A pendix B, Criterion III and CPS PSAR Section 17.1.3.3 :
: a. The pipe suspension system components were fabricated and installed prior to formal calculations (design verification) being performed and documented including review and approval by authorized personnel.
a.
: b. Management failed to act to prevent further fabrication end installation of seismic supports when the apparent problem concerning lack of formal approval of calculations had been identified."
The pipe suspension system components were fabricated and installed prior to formal calculations (design verification) being performed and documented including review and approval by authorized personnel.
: a. As of March 1, 1981, formal design calculations for pipe suspension system component drawings which were reissued based on verification to new dynamic loads data have been reviewed and approved by authorized personnel.
b.
Management failed to act to prevent further fabrication end installation of seismic supports when the apparent problem concerning lack of formal approval of calculations had been identified."
a.
As of March 1, 1981, formal design calculations for pipe suspension system component drawings which were reissued based on verification to new dynamic loads data have been reviewed and approved by authorized personnel.
Design calculations for pipe suspension system component drawings which have not yet been verified to new dynamic loads data, will be reviewed and approved in conjunction with the final load verification program now scheduled for completion in July 1981.
Design calculations for pipe suspension system component drawings which have not yet been verified to new dynamic loads data, will be reviewed and approved in conjunction with the final load verification program now scheduled for completion in July 1981.
Therefore all pipe suspension system component drawings are expected to be reissued and based upon approved design calculations by August 1, 1981.
Therefore all pipe suspension system component drawings are expected to be reissued and based upon approved design calculations by August 1, 1981.
: b. The inspector notes that Sargent and Lundy's management did not place a hold on the Clinton dynamic hanger /-
b.
The inspector notes that Sargent and Lundy's management did not place a hold on the Clinton dynamic hanger /-
seismic supports released for fabrication and installation without reviewed and approved calculations as a result of a similar finding in 1979 on another S&L project.
seismic supports released for fabrication and installation without reviewed and approved calculations as a result of a similar finding in 1979 on another S&L project.
However, in late 1978, all the unfabricated dynamic hangers for the Containment, Fuel, and Auxiliary Buildings were put on hold by ECN's 844 and 908.
However, in late 1978, all the unfabricated dynamic hangers for the Containment, Fuel, and Auxiliary Buildings were put on hold by ECN's 844 and 908.
Sargent and Lundy and Illinois Power Ccupany determined that the installation of dynamic hangers of the Control i                                                                   and Diesel Generator Buildings would continue because the dynamic response spectra changes were judged to have minimal effects in these buildings. During the NRC inspection, Sargent and-Lundy issued ECN 2071 which.
Sargent and Lundy and Illinois Power Ccupany determined that the installation of dynamic hangers of the Control i
put the remaining uninstalled (but previously fabricated) non-verified dynamic hangers on hold until the load verification.is completed. As of June 3, 1981, the following status existed, (doesn't include May releases):
and Diesel Generator Buildings would continue because the dynamic response spectra changes were judged to have minimal effects in these buildings.
(1) 1556 dynamic supports released with verified loads (2)   22 dyna-ic supports installed without verified loads (3)   94 dynamic supports supports on " hold'.'
During the NRC inspection, Sargent and-Lundy issued ECN 2071 which.
put the remaining uninstalled (but previously fabricated) non-verified dynamic hangers on hold until the load verification.is completed.
As of June 3, 1981, the following status existed, (doesn't include May releases):
(1) 1556 dynamic supports released with verified loads (2) 22 dyna-ic supports installed without verified loads (3) 94 dynamic supports supports on " hold'.'


J. G. Keppler                                         June 11, 1981 NRC                                                   Page 10 It is expected that drawings for those dynamic supports installed without verification to new loads data and those on hold will be reissued based on new loads verification by August 1, 1981.
J. G. Keppler June 11, 1981 NRC Page 10 It is expected that drawings for those dynamic supports installed without verification to new loads data and those on hold will be reissued based on new loads verification by August 1, 1981.
9     Criterion II, Quality Assurance Program The Notice of Violation states in part:
9 Criterion II, Quality Assurance Program The Notice of Violation states in part:
                    " Contrary to the above (10CFR50 Appendix B, Criterion II and IFC Quality Assurance Manual Chapter 2) the licensee failed to provide quality assurance conn als over the preparation, review, and approval of "As-built" electrical hanger drawings prepared by iPC engineers.
" Contrary to the above (10CFR50 Appendix B, Criterion II and IFC Quality Assurance Manual Chapter 2) the licensee failed to provide quality assurance conn als over the preparation, review, and approval of "As-built" electrical hanger drawings prepared by iPC engineers.
          -        Furthermore, the licensee failed to establish which Quality Assurance Organizatic.i would have functional control over the "As-built" electrical hanger program.
Furthermore, the licensee failed to establish which Quality Assurance Organizatic.i would have functional control over the "As-built" electrical hanger program.
As a result, activities affecting the quality of safety related hangers were performed without approved procedures. For example:
As a result, activities affecting the quality of safety related hangers were performed without approved procedures.
: a. The actual "As-Built" hanger installation could not be determined on six "As-built" electrical hanger drawings reviewed and approved for use by Sargent and Lundy (S&L), the Architect Engineer, due to conflict in drawing dimensions and indeterminate dimension orientation.
For example:
: b. No program was established to ensure that approved "As-Built" design parameters would be implemented into the base design documents. As a result, the use of an alternate hanger detail contrary to that specified in the base design criteria was approved.
a.
These "As-Built" drawings had been prepared and reviewed by IP and submitted to S&L by BA for review and statusing in accordance with a program documented in a letter. However, formal procedures had not been adequately prepared for performing these activities at Clinton. Sargent and Lundy did hnve a procedure Proj ect Instruction PI-CP-023, Rev. O, " Review of Baldwin l      Associates Prepared Seismic Category I Cable Tray Hanger and Conduit Hanger Assembly Drawings", which was originally intended to cover
The actual "As-Built" hanger installation could not be determined on six "As-built" electrical hanger drawings reviewed and approved for use by Sargent and Lundy (S&L), the Architect Engineer, due to conflict in drawing dimensions and indeterminate dimension orientation.
!      " shop drawings." However, this procedure appeared to be written in terms general enough to cover "As-built" drawings also. After S&L had received and reviewed some of the "Arbuilt" drawings it was determined that although most of the same requirements apply, more specific delineation regarding review of "As-builts" and revision of pertinent Sargent and Lundy design documents was required.       Prior to the NRC inspection, Project Instruction PI-CP-023 had been revised to incorporate the needed changes and l     was in comment and approval circuit. The drawings reviewed by the NRC inspector were the first ones returned by S&L to the site.
b.
No program was established to ensure that approved "As-Built" design parameters would be implemented into the base design documents.
As a result, the use of an alternate hanger detail contrary to that specified in the base design criteria was approved.
These "As-Built" drawings had been prepared and reviewed by IP and submitted to S&L by BA for review and statusing in accordance with a program documented in a letter.
However, formal procedures had not been adequately prepared for performing these activities at Clinton.
Sargent and Lundy did hnve a procedure l
Proj ect Instruction PI-CP-023, Rev. O, " Review of Baldwin Associates Prepared Seismic Category I Cable Tray Hanger and Conduit Hanger Assembly Drawings", which was originally intended to cover
" shop drawings."
However, this procedure appeared to be written in terms general enough to cover "As-built" drawings also.
After S&L had received and reviewed some of the "Arbuilt" drawings it was determined that although most of the same requirements apply, more specific delineation regarding review of "As-builts" and revision of pertinent Sargent and Lundy design documents was required.
Prior to the NRC inspection, Project Instruction PI-CP-023 had been revised to incorporate the needed changes and l
was in comment and approval circuit.
The drawings reviewed by the NRC inspector were the first ones returned by S&L to the site.
l
l
[           Although several errors were noted in the "As-built" electrical l     hanger drawings, none of them would have compromised the structural integrity of the supports, nor prevented the QC inspector-t
[
Although several errors were noted in the "As-built" electrical l
hanger drawings, none of them would have compromised the structural integrity of the supports, nor prevented the QC inspector-t


  . .J..G.       Keppler                                                     June 11, 1981 NRC                                                                 Page 11 from performing his inspection (i.e. the inspector would have issued an NCR if the hanger did not agree with the drawing.)
.J..G. Keppler June 11, 1981 NRC Page 11 from performing his inspection (i.e. the inspector would have issued an NCR if the hanger did not agree with the drawing.)
However, Illinois Power was concerned with the number of errors and has taken, or is taking the following actions .
However, Illinois Power was concerned with the number of errors and has taken, or is taking the following actions.
(a)   The responsibility for preparing, reviewing, appraving and submitting "As-Built" electrical hanger drawings to S&L for review and statusing was transfered from IP to BA.
(a)
(b)   Baldwin Associates has developed, approved, and issued a procedure, BAP 3.3.8 " Electrical Hanger As-Built Drawings" to cover the activities of (a).
The responsibility for preparing, reviewing, appraving and submitting "As-Built" electrical hanger drawings to S&L for review and statusing was transfered from IP to BA.
(c)   "As-Built" drawings completed under IP direction, but not yet transmitted to S&L prior to shifting responsi .
(b)
bilities to BA, have been or are being reviewed, corrected and processed in accordance with BAP 3.3.8.                                   ;
Baldwin Associates has developed, approved, and issued a procedure, BAP 3.3.8 " Electrical Hanger As-Built Drawings" to cover the activities of (a).
(d)   Sargent & Lundy has revised, approved, and issued Project Instruction PI-CP-023 Revision 1 to include specific requirements regarding the review and statusing of "As-Built" hanger drawings. The procedure requires                                     '
(c)
verification of the adequacy of a hanger which deviares from the S&L design document.
"As-Built" drawings completed under IP direction, but not yet transmitted to S&L prior to shifting responsi.
(e)   "As-Built" drawings completed and submitted to S&L have been or are being reevaluated- to the require-ments of PI-CP-023, Rev. 1.
bilities to BA, have been or are being reviewed, corrected and processed in accordance with BAP 3.3.8.
(f)   "As-Built" drawings completed by IP, statused by S&L,-
(d)
Sargent & Lundy has revised, approved, and issued Project Instruction PI-CP-023 Revision 1 to include specific requirements regarding the review and statusing of "As-Built" hanger drawings.
The procedure requires verification of the adequacy of a hanger which deviares from the S&L design document.
(e)
"As-Built" drawings completed and submitted to S&L have been or are being reevaluated-to the require-ments of PI-CP-023, Rev. 1.
(f)
"As-Built" drawings completed by IP, statused by S&L,-
and transmitted back to CPS prior to issuance of BAP 3.3.8 and PI-CP-023, Rev. 1, have been or are being reviewed, corrected as necessary and processed in accordance with these procedures / instructions.
and transmitted back to CPS prior to issuance of BAP 3.3.8 and PI-CP-023, Rev. 1, have been or are being reviewed, corrected as necessary and processed in accordance with these procedures / instructions.
Although not all "As-Built" drawings have been prepared,                               -
Although not all "As-Built" drawings have been prepared, reviewed, approved, and statused to date, corrective action has been'taken to ensure that1the final product,
reviewed, approved, and statused to date, corrective action has been'taken to ensure that1the final product,
" installed hangers", meets all design and quality requirements.
                        " installed hangers", meets all design and quality requirements.
10.
: 10. Criterion VI - Document Control The Notice of Violation states in part:
Criterion VI - Document Control The Notice of Violation states in part:
                      '' Contrary to the above (10CFR50 Appendix B, Criterion VI-
'' Contrary to the above (10CFR50 Appendix B, Criterion VI-
                      . and IPC Quality Assurance Manual) changes and current revision to electrical drawings were not being used as follows...."
. and IPC Quality Assurance Manual) changes and current revision to electrical drawings were not being used as follows...."
Field Change Requests (FCR) noted in the noncompliance have
Field Change Requests (FCR) noted in the noncompliance have
    -been listed on the fieldicopy of the- drawings.                 The latest drawing revisions noted:in the item of . noncompliance are now in use . in the field and the superseded -drawings have been . removed.               It should be recognized that the two (2) noted later-drawing revisions either had not been or were being _ processed by Document Control /-
-been listed on the fieldicopy of the-drawings.
e,,   ,, ,  w-,-n-,   -rn,,~-m-,,,-m-c~-,-~~r-n-ma--
The latest drawing revisions noted:in the item of. noncompliance are now in use. in the field and the superseded -drawings have been. removed.
It should be recognized that the two (2) noted later-drawing revisions either had not been or were being _ processed by Document Control /-
e,,
w-,-n-,
-rn,,~-m-,,,-m-c~-,-~~r-n-ma--


                          -          -          -  -      _ -_    .        _ ~ . -                   - . = . - - -     - - __ - -                            - . -  .
_ ~. -
                                                                                                                                                                            ^
-. =. - - -
..
^
                  ..    .J. G. Keppler                                                                               June 11, 1981 NRC                                                                                           Page 12 1
.J.
Reproduction group at time of the NRC inspection.                                             An undocu-mented check of approximately 50 FCR's/ drawings we~ made to i                       determine extent of problem and no other cases / deficiencies were                                                                                 ,
G. Keppler June 11, 1981 F
i                        noted.
NRC Page 12 1
One additional person, the Drawing Inventory Coordinator, l                       is being assigned to full time . document control inventory and                                                                                     :
Reproduction group at time of the NRC inspection.
i                      survey responsibilities, effective June 15, 1981. This position l
An undocu-mented check of approximately 50 FCR's/ drawings we~ made to i
had been vacant since January 1981. A formal routine and ongoing -
determine extent of problem and no other cases / deficiencies were i
inventory which is the prime responsibility of this position,                                                                                       4
noted.
:                        will be accomplished commencing June 15, 1981. Four people                                                                                           .
One additional person, the Drawing Inventory Coordinator, l
j                        and a new blue print machine have been added' to our operation in                                                                                 1
is being assigned to full time. document control inventory and i
;                        an effort to improve drawing turn around time and keep pace with                                                                                   ,
survey responsibilities, effective June 15, 1981.
4                        the ever increasing influx of new/ revised drawings. These actions should minimize recurrence of - these and- similiar problems.
This position l
1 i                               11.       Criterion V, Instructions, Procedures and' Drawings The Notice of Violation states in part:
had been vacant since January 1981.
                                          " Contrary to the above (10CFR50 Appendix B, Criterion V                                                                           '
A formal routine and ongoing -
and IP-Quality Assurance Manual, Chapter V), equipment i                                        receipt inspection activities affecting quality were not accomplished in accordance with written procedures
inventory which is the prime responsibility of this position, 4
!                                        as follows:
will be accomplished commencing June 15, 1981.
j                                        a.    -Paragraph 6.9.1.3 of Baldwin AssociatesLProcedure-(BAP) 2.3 stetes, in part , " Quality - Control shall i                                               revise documentation related to'the receipt of
Four people j
:                                              the items / materials, e.g. RIR, logs, etc., to reflect-the return." Contrary to this, RIR S-ll630, dated i                                                September 29, 1980, which documented;the receipt of the electrical penetration primary header plate
and a new blue print machine have been added' to our operation in 1
:                                                bolts was not revised to reflect the return of these bolts to Conax for rethreading.
an effort to improve drawing turn around time and keep pace with the ever increasing influx of new/ revised drawings.
l                                       b.     Paragraphs 112.11 and ll2.lla of Sargent and Lundy Specification K-2978, states "In -special cases, where l
These actions 4
should minimize recurrence of - these and-similiar problems.
1 i
11.
Criterion V, Instructions, Procedures and' Drawings The Notice of Violation states in part:
" Contrary to the above (10CFR50 Appendix B, Criterion V and IP-Quality Assurance Manual, Chapter V), equipment receipt inspection activities affecting quality were i
not accomplished in accordance with written procedures as follows:
-Paragraph 6.9.1.3 of Baldwin AssociatesLProcedure-j a.
(BAP) 2.3 stetes, in part, " Quality - Control shall i
revise documentation related to'the receipt of the items / materials, e.g. RIR, logs, etc., to reflect-the return."
Contrary to this, RIR S-ll630, dated September 29, 1980, which documented;the receipt i
of the electrical penetration primary header plate bolts was not revised to reflect the return of these bolts to Conax for rethreading.
l b.
Paragraphs 112.11 and ll2.lla of Sargent and Lundy Specification K-2978, states "In -special cases, where l
all of the documentation may not be available at
all of the documentation may not be available at
{
{
the time the equipment is ready for shipment,; shipment.
the time the equipment is ready for shipment,; shipment.
to the site will be permitted under the-following l                                                conditions: upon written approval of the Purchaser, a Certificate -of Compliance shall be transmitted with the shipment. Approval for use of Certificate of L
to the site will be permitted under the-following conditions:
Compliance shall be obtained prior to shipment."
upon written approval of the Purchaser, l
l
a Certificate -of Compliance shall be transmitted with L
:                                                Paragraph - 5.2. 3 of BAP 2.20 states , in part:                                         "The
the shipment.
!                                                authorization shall be in letter form signed by-
Approval for use of Certificate of Compliance shall be obtained prior to shipment."
;                                                the Manager of_ Quality Control and.....shall form a part of the procurement documents." ' Contrary to these
l Paragraph - 5.2. 3 of BAP 2.20 states, in part:
                                                -requirements, Conax Corporation electrical. penetrations were shipped-to the. licensee and a Certificate of j.
"The authorization shall be in letter form signed by-the Manager of_ Quality Control and.....shall form a part of the procurement documents." ' Contrary to these
Compliance was transmitted in~ lieu of . complete documentation without prior written authorization.                                                           ,
-requirements, Conax Corporation electrical. penetrations j.
were shipped-to the. licensee and a Certificate of Compliance was transmitted in~ lieu of. complete documentation without prior written authorization.
f 1
f 1
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  ,, J. G. Kappler                                       June 11,1981 NRC                                                 Pago 13
J. G. Kappler June 11,1981 NRC Pago 13 c.
: c. Paragraph 5.2.4 of BAP 2.20 states "Upon receipt
Paragraph 5.2.4 of BAP 2.20 states "Upon receipt of the authorized letter of compliance, items shall be placed on " Conditional Accept" status in accordance with BAP 2.3, for documentation requirements."
-                  of the authorized letter of compliance, items shall be placed on " Conditional Accept" status in accordance with BAP 2.3, for documentation requirements." Contrary to this electrical penetrations IEE21E, IEE01E, and 4160V electrical switchgear IAP07E were not placed on " Conditional Accept" status nor were conditional accept tags attached as required by BAP 2.3."
Contrary to this electrical penetrations IEE21E, IEE01E, and 4160V electrical switchgear IAP07E were not placed on " Conditional Accept" status nor were conditional accept tags attached as required by BAP 2.3."
: a. Baldwin Associates Procedure (BAP 2.3) has been revised to delete the requirement to revise the original RIR when items are returned to the vendor. The documentation of items being returned is accomplished using a Material Return Transmittal, Form JV-418, which is and has been a requirement of BAP 2.3. Therefore, the revision of the original RIR is not considered necessary.
a.
b&c. The requirement to obtain prior written authorization to ship equipment on a Certificate of Compliance in special cases where all documentation may not be available at time of shipment was not construed to be applicable to missing engineering or design docu-mentation. All manufacturing documentation was available and was shipped with the equipment. Seismic and enrionmental qualification data reports were not available, in that tests had not been accomplished yet. However, these documents are considered design /
Baldwin Associates Procedure (BAP 2.3) has been revised to delete the requirement to revise the original RIR when items are returned to the vendor.
engineering documentation and are required to be submitted directly to Sargent and Lundy. A Field Change Request (FCR-9071) has been initiated to revise Sargent and Lundy Specification K-2978, and other specifications, to clarify that shipmentoof equipment to the site will be allowed in cases where design /
The documentation of items being returned is accomplished using a Material Return Transmittal, Form JV-418, which is and has been a requirement of BAP 2.3.
engineering documentation is not available. However, a Certificate of Compliance will be required for manufacturing documentation that is lacking.
Therefore, the revision of the original RIR is not considered necessary.
b&c.
The requirement to obtain prior written authorization to ship equipment on a Certificate of Compliance in special cases where all documentation may not be available at time of shipment was not construed to be applicable to missing engineering or design docu-mentation.
All manufacturing documentation was available and was shipped with the equipment.
Seismic and enrionmental qualification data reports were not available, in that tests had not been accomplished yet.
However, these documents are considered design /
engineering documentation and are required to be submitted directly to Sargent and Lundy.
A Field Change Request (FCR-9071) has been initiated to revise Sargent and Lundy Specification K-2978, and other specifications, to clarify that shipmentoof equipment to the site will be allowed in cases where design /
engineering documentation is not available.
: However, a Certificate of Compliance will be required for manufacturing documentation that is lacking.
The requirements of BAP 2.20, paragraph 5.2.4 and BAP 2.3 apply to manufacturing data / documentation received from the vendor and not the engineering /
The requirements of BAP 2.20, paragraph 5.2.4 and BAP 2.3 apply to manufacturing data / documentation received from the vendor and not the engineering /
design data. The electrical penetrations and switchgear referred to in the item of noncom-pliance were received with all the appropriate manufacturing data / documentation. The engineering /
design data.
The electrical penetrations and switchgear referred to in the item of noncom-pliance were received with all the appropriate manufacturing data / documentation.
The engineering /
design documentation is being tracked through appropriate checklists and computer file system to ensure that the documentation is obtained.
design documentation is being tracked through appropriate checklists and computer file system to ensure that the documentation is obtained.


J. G. Keppler                                     June 11, 1981 NRC                                               Page 14 I trust that our response is satisfactory to allow closecut of these items when all actions are complete. I hereby affirm that the information contained in this letter is correct to the best of my knowledge.
J. G. Keppler June 11, 1981 NRC Page 14 I trust that our response is satisfactory to allow closecut of these items when all actions are complete.
Sincerely, M
I hereby affirm that the information contained in this letter is correct to the best of my knowledge.
W$
Sincerely,MW$
L. J. Koch Vice-President Attachments:
L. J. Koch Vice-President Attachments:
Appendix A   - IPC Response to Concerns Expressed in Paragraph C.2 of the NRC Special Team Inspection Report, 50-461/81-05.
Appendix A
Appendix B   - Additional Information on Items Regarding Unresolved Matter cc: H. H. Livermore, NRC Resident Inspector Director, Quality Assurance CPS /DRC t
- IPC Response to Concerns Expressed in Paragraph C.2 of the NRC Special Team Inspection Report, 50-461/81-05.
l 1
Appendix B
- Additional Information on Items Regarding Unresolved Matter cc:
H. H. Livermore, NRC Resident Inspector Director, Quality Assurance CPS /DRC t
1


-                              Appendix A >
Appendix A >
IPC Response to Concerns Expressed in Paragraph C.2 of the NRC Special Team inspection Report, 50-461/81-05 Section C.2 " Conclusion" of the Inspection Report describes five (5) concerns or " specific weaknesse's" preceived by the NRC inspection team based on the inspection findings and consists of impressions or opinions formed by the team in five areas. These opinions are generally very broad and difficult to address in detail. They may have been formed from a particular perspective and do not necessarily reflect all the pertinent considerations at the time. Some are based on incomplete information. These concerns were discussed during a meeting at NRC Region III office in Glen Ellyn,_ Illinois on March 12, 1981.
IPC Response to Concerns Expressed in Paragraph C.2 of the NRC Special Team inspection Report, 50-461/81-05 Section C.2 " Conclusion" of the Inspection Report describes five (5) concerns or " specific weaknesse's" preceived by the NRC inspection team based on the inspection findings and consists of impressions or opinions formed by the team in five areas.
These opinions are generally very broad and difficult to address in detail.
They may have been formed from a particular perspective and do not necessarily reflect all the pertinent considerations at the time.
Some are based on incomplete information.
These concerns were discussed during a meeting at NRC Region III office in Glen Ellyn,_ Illinois on March 12, 1981.
Illinois Power Company's response to each of these concerns is included in the following sections. Where we differ with the position taken by the inspection team, we have attempted to explain the basis for the difference.
Illinois Power Company's response to each of these concerns is included in the following sections. Where we differ with the position taken by the inspection team, we have attempted to explain the basis for the difference.


    . J. G. K:ppler                                         App:ndix A Page 2
J. G. K:ppler App:ndix A Page 2 a.
: a. " Weakness in the identification of root causes and the initiation of prompt and effective corrective action."
" Weakness in the identification of root causes and the initiation of prompt and effective corrective action."
Summary (by NRC of their findings)
Summary (by NRC of their findings)
          " Deficient Class lE electrical raceway hanger installation activities continued over a nine-month period with in-effective construction and engineering controls and inadequate QA involvement and enforcement of quality pro-gram requirements to bring timely co~rrective action. "
" Deficient Class lE electrical raceway hanger installation activities continued over a nine-month period with in-effective construction and engineering controls and inadequate QA involvement and enforcement of quality pro-gram requirements to bring timely co~rrective action. "
This finding involves the recognition of an overall problem during an early phase when subproblems arise which are not recognized as being relaced. Problem recognition is not unique to nuclear power plant con-struction; it is common to most complex, multi-activity functions.
This finding involves the recognition of an overall problem during an early phase when subproblems arise which are not recognized as being relaced.
The example given on electrical hanger installation involves a complex activity. Initial corrective actions (audit findings and CARS) were directed toward correcting specific deficiencies within the established electrical hanger installation system. It was not obvious that the individual specific problems were indicative of a broader general problem. The full extent and need for substantial revision of the entire system was not realized until it was determined to be reportable under 50.55(e).
Problem recognition is not unique to nuclear power plant con-struction; it is common to most complex, multi-activity functions.
The example given on electrical hanger installation involves a complex activity.
Initial corrective actions (audit findings and CARS) were directed toward correcting specific deficiencies within the established electrical hanger installation system.
It was not obvious that the individual specific problems were indicative of a broader general problem.
The full extent and need for substantial revision of the entire system was not realized until it was determined to be reportable under 50.55(e).
In retrospect, it can be concluded that an earlier decision to revise the entire system could have been made.
In retrospect, it can be concluded that an earlier decision to revise the entire system could have been made.
This however, was not apparent as each successive level of corrective action was taken. Based on evaluations made at this time, and the value judgements rendered by those involved, the corrective action proposed at each step was considered sufficient. This experience emphasizes the difficulty in "seeing the forest when working on individual trees."   We believe that this form of problem recognition can be improved by better communications between the parties involved.
This however, was not apparent as each successive level of corrective action was taken.
It has been Illinois Power Company's philosophy that the responsibility for quality lies with the organizations responsible for doing the work. The quality assurance organizations (IP and BA) monitor this effort through audit and surveillance, including the identification of the development and/or evaluation of resolutions which will ensure compliance with established program and commitments. These deficiencies are normally resolved without top management involvement; however, the lines of communication are maintained and problems which warrant such attention are reported to upper management.
Based on evaluations made at this time, and the value judgements rendered by those involved, the corrective action proposed at each step was considered sufficient.
This experience emphasizes the difficulty in "seeing the forest when working on individual trees."
We believe that this form of problem recognition can be improved by better communications between the parties involved.
It has been Illinois Power Company's philosophy that the responsibility for quality lies with the organizations responsible for doing the work.
The quality assurance organizations (IP and BA) monitor this effort through audit and surveillance, including the identification of the development and/or evaluation of resolutions which will ensure compliance with established program and commitments.
These deficiencies are normally resolved without top management involvement; however, the lines of communication are maintained and problems which warrant such attention are reported to upper management.
To improve communications between the parties involved in evaluating and correcting findings and to enhance management participation, a system of periodic
To improve communications between the parties involved in evaluating and correcting findings and to enhance management participation, a system of periodic


        --- . --            _            -- -                  - -          -            .            .          -            .= .        .  -            .-  .
.=.
                .. J. G. Kcppler                                                                                                           App:ndix A Page 3 1   .
J. G. Kcppler App:ndix A Page 3 1
quality review meetings has been established.                                                                         These meetings will bring together quality, engineering and construction management and supervision from IP, BA and others such as S&L.and GE, as necessary, to>
quality review meetings has been established.
evaluate and. coordinate quality activities in the work areas involved. Concurrence with evaluation of quality i                                 problems and plans of action will be documented. These periodic assessments will be supplemental to reporting and resolution methods currently employed, and will be conducted specifically to provide for early detection of lower-level problems, and prompt execution of pre-i                                viously approved action plans.
These meetings will bring together quality, engineering and construction management and supervision from IP, BA and others such as S&L.and GE, as necessary, to>
This interchange should improve communication and coordination of quality activities and enhance our capability to identify trends or other signals which indicate that broad corrective action is needed.                                                                                                              .
evaluate and. coordinate quality activities in the work areas involved.
: b. "No controlled - and documented system has been fully and effectively implemented as'of February 27, 1981, to identify-the status of items as to their acceptability to procurement i
Concurrence with evaluation of quality i
specification requirements.
problems and plans of action will be documented.
Summary (by NRC of their findings)
These periodic assessments will be supplemental to reporting and resolution methods currently employed, and will be conducted specifically to provide for early detection of lower-level problems, and prompt execution of pre-viously approved action plans.
                        "Significant amounts of equipment has been accepted in violation of procurement specification documentation re-quirements, and released for installation without full knowledge of the status of required documentation or identification of the equipment as to its acceptability.
i This interchange should improve communication and coordination of quality activities and enhance our capability to identify trends or other signals which indicate that broad corrective action is needed.
The Clinton plant quality. control and quality. assurance                                                                                                               ,
b.
organizations and project management has allowed this situation to continue for two years and only recently had steps been taken to bring it under control."
"No controlled - and documented system has been fully and effectively implemented as'of February 27, 1981, to identify-the status of items as to their acceptability to procurement specification requirements.
Actions to improve the documentation receipt and accounting system have been in progress since inadequacies                             -
i Summary (by NRC of their findings)
were first identified in 1978.
"Significant amounts of equipment has been accepted in violation of procurement specification documentation re-quirements, and released for installation without full knowledge of the status of required documentation or identification of the equipment as to its acceptability.
The first initiative was to develop new, more com-prehensive checklists, and verify status against documentation received. This was a detailed, time-consuming effort and uncovered problems not originally foreseen. Results of this effort indicated that engineering reports to support compliance to codes and standards imposed by equipment specifications could not be assessed adequately by the contractor.
The Clinton plant quality. control and quality. assurance organizations and project management has allowed this situation to continue for two years and only recently had steps been taken to bring it under control."
These engineering. reports required extensive review by 1                                 the design engineer, and protrccted time for resolution of. comments and deficiencies. At that time the decision was made to account for these engineering documents                                 -
Actions to improve the documentation receipt and accounting system have been in progress since inadequacies were first identified in 1978.
separately. As described in detail in the response to the unresolved item on documentation (Appendix B to this letter), this appeared .to be consistent with NRC guidance on " documents which cannot be readily obs ined in a timely _ fashion."
The first initiative was to develop new, more com-prehensive checklists, and verify status against documentation received.
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This was a detailed, time-consuming effort and uncovered problems not originally foreseen.
Results of this effort indicated that engineering reports to support compliance to codes and standards imposed by equipment specifications could not be assessed adequately by the contractor.
These engineering. reports required extensive review by 1
the design engineer, and protrccted time for resolution of. comments and deficiencies.
At that time the decision was made to account for these engineering documents separately.
As described in detail in the response to the unresolved item on documentation (Appendix B to this letter), this appeared.to be consistent with NRC guidance on " documents which cannot be readily obs ined in a timely _ fashion."
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              . . - J. G. Keppler;                                                                                                                     ' Appendix A Page 4 Proper accounting for this documentation was always intended.                 While the process of developing complete checklists for the engineering documents was time consuming, and some equipment was installed prior to receipt of engineering documentation, procedural controls to prevent use of any equipment lacking ade-quate documentation were instituted. These included a requirement for the contractor to verify completion of both checklists (manufacturing and engineering) prior to turnover, and prior to final contract payment.
- J. G. Keppler;
With these controls in effect, it was known that accurate documentation accountability 'could be achieved prior to any equipment being turned over for pre-operational testing. Any documentation missing at the time of turnover will be contralled as part of the turnover control system.
' Appendix A Page 4 Proper accounting for this documentation was always intended.
Most of the engineering documents listed on the engineering document checklists are ASME Code related reports, environmental qualification reports, or seismic qualification reports.                                                 Receipt of'ASME code related                                                                         !
While the process of developing complete checklists for the engineering documents was time consuming, and some equipment was installed prior to receipt of engineering documentation, procedural controls to prevent use of any equipment lacking ade-quate documentation were instituted.
reports is proceeding satisfactorily. Environmental qualification reports are all bein~g re-evaluated (and                                                                                                                       i many being held by suppliers) due to the ramifications of NUREG-0588.                           Many seismic qualification reports                                                                                                 ;
These included a requirement for the contractor to verify completion of both checklists (manufacturing and engineering) prior to turnover, and prior to final contract payment.
are being re-evaluated and some retesting performed                                                                                                                         j due to MARK III containment new-loads effects.                                                                                                                               '
With these controls in effect, it was known that accurate documentation accountability 'could be achieved prior to any equipment being turned over for pre-operational testing.
Any documentation missing at the time of turnover will be contralled as part of the turnover control system.
Most of the engineering documents listed on the engineering document checklists are ASME Code related reports, environmental qualification reports, or seismic qualification reports.
Receipt of'ASME code related reports is proceeding satisfactorily.
Environmental qualification reports are all bein~g re-evaluated (and i
many being held by suppliers) due to the ramifications of NUREG-0588.
Many seismic qualification reports are being re-evaluated and some retesting performed j
due to MARK III containment new-loads effects.
Accordingly, the actual receipt of some documentation may be late, but will. be maintained under controlled ~
Accordingly, the actual receipt of some documentation may be late, but will. be maintained under controlled ~
conditions.
conditions.
: c.      " Weakness in the development of installation /QC inspection plan and criteria and in the tLaeliness of effectiveness of QC inspections."
" Weakness in the development of installation /QC inspection c.
plan and criteria and in the tLaeliness of effectiveness of QC inspections."
Summary (by NRC of their findings)
Summary (by NRC of their findings)
                            " Weaknesses in the " travelers" which detail installation and inspection requirement, have freq'tently been identified in QA audits and surveillances. Improvements have resulted-from recent changes but further attention is needed as evidenced by thc team inepection~ findings. Included should-be: (a) strong action by QA/QC when hold points are bypassed, (b) assuring current requirements are. reflected in the travelers, if QCf (as recently requested by the manager) is removed from the review cycle for Field Change Requests (FCR's)
" Weaknesses in the " travelers" which detail installation and inspection requirement, have freq'tently been identified in QA audits and surveillances.
                            . and (c) closer review for establishing: inspection points so L                           they occur in the proper sequence to assure design requirements are met."
Improvements have resulted-from recent changes but further attention is needed as evidenced by thc team inepection~ findings.
lr Installation plans and .the associated QC inspection criteria are embodied in the installation travelers.and-the procedures which govern their. development and use.
Included should-be:
;                                      Weaknesses noted during this inspection focused primarily i                                     'on the piping and component: support; traveler system.
(a) strong action by QA/QC when hold points are bypassed, (b) assuring current requirements are. reflected in the travelers, if QCf (as recently requested by the manager) is removed from the review cycle for Field Change Requests (FCR's)
. and (c) closer review for establishing: inspection points so L
they occur in the proper sequence to assure design requirements lr are met."
Installation plans and.the associated QC inspection criteria are embodied in the installation travelers.and-the procedures which govern their. development and use.
Weaknesses noted during this inspection focused primarily i
'on the piping and component: support; traveler system.
4 i
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  . J. G. Koppler                                                 App:ndix A Page 5 Improvements to this system are currently in progress in response to noncompliance items 81-05-01, 81-05-02, and 81-05-03. Details of these improvements are contained in the response to these items.
J. G. Koppler App:ndix A Page 5 Improvements to this system are currently in progress in response to noncompliance items 81-05-01, 81-05-02, and 81-05-03.
Other traveler systems such as welding, equipment installation, electrical hanger and raceway installation, concrete placement, earthwork, electrical cable pulling and cable termination are also being reviewed for possible improvement. Except for the latter two, which have not yet
Details of these improvements are contained in the response to these items.
              'oeen fully implemented, most of these traveler systems are considered adequate at this time.
Other traveler systems such as welding, equipment installation, electrical hanger and raceway installation, concrete placement, earthwork, electrical cable pulling and cable termination are also being reviewed for possible improvement.
Except for the latter two, which have not yet
'oeen fully implemented, most of these traveler systems are considered adequate at this time.
For all traveler systems, and especially pipe hanger /-
For all traveler systems, and especially pipe hanger /-
component support, a critical assessment is being made of work package scope, and the integration of proper levels of QC inspection at appropriate intervals.             In come cases, scope of individual travelers will be reduced to permit inspection as discrete work elements are completed; while others will require in-progress inspection.             In all cases, the processing of each traveler and traveler modification (required for each FCR) will include QC review for establishment of inspection points. Through QA surveillance or audit of these travelers, the completeness and detail of the inspection plans will be assessed against design criteria. Both 6A and IP management have emphasized the importance of adhering to established HOLD points,
component support, a critical assessment is being made of work package scope, and the integration of proper levels of QC inspection at appropriate intervals.
: d. " Weakness in adherence to procedures, design requirement and PSAR commitments."
In come cases, scope of individual travelers will be reduced to permit inspection as discrete work elements are completed; while others will require in-progress inspection.
In all cases, the processing of each traveler and traveler modification (required for each FCR) will include QC review for establishment of inspection points.
Through QA surveillance or audit of these travelers, the completeness and detail of the inspection plans will be assessed against design criteria.
Both 6A and IP management have emphasized the importance of adhering to established HOLD points, d.
" Weakness in adherence to procedures, design requirement and PSAR commitments."
Summary (by NRC of their findings)
Summary (by NRC of their findings)
        " Quality organization could be more effective with strenger emphasis and support by top management.             Throughout the inter-views and discussions, the prevailing attitude was getting the job done with inadequate concer' for QA/QC 'and job details.
" Quality organization could be more effective with strenger emphasis and support by top management.
QA/QC in their enforcement of p. cedures and other requirements must not be unduly swayed by arguments based on cost and schedule considerations. Recent changes have resulted in improvements but further improvements are needed."
Throughout the inter-views and discussions, the prevailing attitude was getting the job done with inadequate concer' for QA/QC 'and job details.
(1)       We believe that all information available was not re-viewed by the NRC inspection team. An extensive PSAR Commitment Control Program is maintained in the NSED offices located in Decatur.           The computer program used to track CPS PSAR commitments was established in 1976.
QA/QC in their enforcement of p. cedures and other requirements must not be unduly swayed by arguments based on cost and schedule considerations.
The program lists all PSAR commitments, including Regulatory Guides, industry codes, and standards. It is continuously used as a. management tool to provide respon-sible IP managers and supervisors guidance for reviewing CPS-related specifications and procedures. Other docu-ments, such as a PSAR index to commitments and various special commitment summaries are also used.
Recent changes have resulted in improvements but further improvements are needed."
(1)
We believe that all information available was not re-viewed by the NRC inspection team.
An extensive PSAR Commitment Control Program is maintained in the NSED offices located in Decatur.
The computer program used to track CPS PSAR commitments was established in 1976.
The program lists all PSAR commitments, including Regulatory Guides, industry codes, and standards.
It is continuously used as a. management tool to provide respon-sible IP managers and supervisors guidance for reviewing CPS-related specifications and procedures.
Other docu-ments, such as a PSAR index to commitments and various special commitment summaries are also used.


    .., .. J. G. Kepp'er                                                                     Appcndix A Pege 6 3     .
.. J. G. Kepp'er Appcndix A Pege 6 3
The program description was revised and strengthened i                                 on June 23, 1978, to require positive feedback from
The program description was revised and strengthened i
;                                internal IP organizations assigned responsibility for
on June 23, 1978, to require positive feedback from internal IP organizations assigned responsibility for verifying that PSAR commitments were being implemented.
,                                verifying that PSAR commitments were being implemented.
1 This program was again revised on February 23, 1980, j'
1
to require written verification from organizations out-side :IP that PSAR commitments were being met.
:                                    This program was again revised on February 23, 1980, j'                               to require written verification from organizations out-
These verification letters are maintained on file, and in many cases, outline the detailed methods of compliance.
!                                side :IP that PSAR commitments were being met. These verification letters are maintained on file, and in many cases, outline the detailed methods of compliance. Status i                                 of this compliance program is reported monthly to IP's top management.     A condensed version of the program out-
Status i
:                                put is also reported monthly by the Company to the Illinois Commerce Commission.                                                   -    '
of this compliance program is reported monthly to IP's top management.
!                                    The formal program description was net reviewed during the inspection.     We believe that the IP Commitment Control
A condensed version of the program out-put is also reported monthly by the Company to the Illinois Commerce Commission.
!-                                Program for CPS has been, and is currently, an effective management tool for monitoring PSAR commitments.
The formal program description was net reviewed during the inspection.
!                      (2)           The requirement for vendors to have prior written j                                 authorization to ship with- Certificate of Compliances in                           .
We believe that the IP Commitment Control Program for CPS has been, and is currently, an effective management tool for monitoring PSAR commitments.
i                                lieu of all documentation, is contained in most CPS pro-                           '
(2)
l i                                 curement specifications.                 This has proved to be an un-
The requirement for vendors to have prior written j
!                                realistic requirement. We have successfully demonstrated
authorization to ship with-Certificate of Compliances in i
;                                a new system of document accountability and. control .which I                                 assures that regulatory requirements are met for issuance j                                 of materials and equipment for installation or use at the site.
lieu of all documentation, is contained in most CPS pro-i curement specifications.
(3)           We disagree with the inspector's interpretation of                               ,
This has proved to be an un-realistic requirement.
Procedures BAP 2.20 and 2.3.                   Equipment with missing               I
We have successfully demonstrated a new system of document accountability and. control.which I
                                  " engineering documents" is not placed in a conditional accept status, nor is this required by those procedures.
assures that regulatory requirements are met for issuance j
of materials and equipment for installation or use at the site.
(3)
We disagree with the inspector's interpretation of Procedures BAP 2.20 and 2.3.
Equipment with missing
" engineering documents" is not placed in a conditional accept status, nor is this required by those procedures.
Consequently, we feel.that we are following these procedures to meet the purpose for which they were written.
Consequently, we feel.that we are following these procedures to meet the purpose for which they were written.
1
e.
: e.     "Other Items" i
"Other Items" i
l                     Summary (by NRC of their findings)
l Summary (by NRC of their findings)
                      " Management is not sufficiently involved in plant quality problems and has not fully utilized-QA as a management tool."
" Management is not sufficiently involved in plant quality problems and has not fully utilized-QA as a management tool."
[                                     This topic deals with the authority and involvement of the quality organizations within Illinois Power Company                             )
[
l                                 and Baldwin Associates.               Particular emphasis was placed on discussion of identification and resolution of QA/QC problems. A related subject involved the discussion of                             ;
This topic deals with the authority and involvement of the quality organizations within Illinois Power Company
interaction between the quality organizations and the                               l management of IP and BA.
)
i There was considerable discussion of the involvement of.IP QA in the development of departmental procedures in the Company. . Existing practices involve a QA review.
l and Baldwin Associates.
Particular emphasis was placed on discussion of identification and resolution of QA/QC problems.
A related subject involved the discussion of interaction between the quality organizations and the management of IP and BA.
i There was considerable discussion of the involvement of.IP QA in the development of departmental procedures in the Company.. Existing practices involve a QA review.
of these departmental procedures, but.does not require
of these departmental procedures, but.does not require


t
t
                    ...J. G..Kappler                                                                 Appendix A i                                                                                                     Page 7 I                                     QA approval. This does not in any way diminish the
...J.
G..Kappler Appendix A i
Page 7 I
QA approval.
This does not in any way diminish the
[
[
authority of QA since through their auditing programs, i                                     they review all departmental documents that relate ito s control of work and also audit conformance to those                                   -
authority of QA since through their auditing programs, i
l                                      documents. Therefore, Quality Assurance has the ability and authority to ensure that departmental procedures and
they review all departmental documents that relate ito s control of work and also audit conformance to those l
{                                     instructions conform to all applicable requirements as
documents.
:                                      established by regulations, codes, standards, etc.                           and to ensure that they are properly implemented.                           Upon further evaluation, however, we have determined that
Therefore, Quality Assurance has the ability and authority to ensure that departmental procedures and
!                                      this philosophy and practice would be better understood
{
;                                      if IP departmental procedures were approved by IP QA and i                                     we will revise our procedures to include such documented review and concurrence.         Although this action will not change the principle or intent of our e::isting practices, i                                     it will make them clearer and more obvious to all parti-cipants.
instructions conform to all applicable requirements as established by regulations, codes, standards, etc.
The discussions relating to responsiveness of the total organizational structure to the findings of quality
and to ensure that they are properly implemented.
,                                      organizations reveal that this is a very complex process l                                     and that effective communications are necessary to ensure j                                     thorough understanding of the process. We found, for example, that some corrective actions taken in response
Upon further evaluation, however, we have determined that this philosophy and practice would be better understood if IP departmental procedures were approved by IP QA and i
'                                      to a finding by a quality organization were not effectively communicated through the records system relating it to j                                     the finding. In some instances, similar findings were
we will revise our procedures to include such documented review and concurrence.
,                                      reported several times in a series of audit reports                                   7
Although this action will not change the principle or intent of our e::isting practices, i
:                                      without reflecting the actions which had been taken to
it will make them clearer and more obvious to all parti-cipants.
;                                      correct the reported conditions. This quite logically creates the impression of unresponsiveness to the findings, even though very significant efforts had been made to attempt to correct the condition.                       In some instances,
The discussions relating to responsiveness of the total organizational structure to the findings of quality organizations reveal that this is a very complex process l
(                                     corrective actions were taken, but they were unsuccessful i                                     and, therefore, a similar problem was found in a subsequent audit. The audit reports and related documents, however, do not adequately describea the actual sequence of events.
and that effective communications are necessary to ensure j
We believe that this situation can be improved by revising our communications to more clearly tie the corrective action to the audit findings. We are evaluating various record and document control systems which will relate these communications in such a manner that the " entire story" will be available in one place.                       This should make the quality audits more effective and should assist management in evaluating the responsiveness of all segments of the organization to the quality program.                         These improve-ments should also simplify the task of the NRC in conducting their audits of the Clinton Proj ect.
thorough understanding of the process.
Another item of discussion involved the role of Illinois Power Company upper management and their support of quality activities. This is a difficult subject to place in per-spective because many of the activities of top management are not documented or recorded. The influence of top management is,primarily exercised through discussion and
We found, for example, that some corrective actions taken in response to a finding by a quality organization were not effectively communicated through the records system relating it to j
                                            ~
the finding.
verbal direction. In fact, it is generally expected-that
In some instances, similar findings were reported several times in a series of audit reports 7
without reflecting the actions which had been taken to correct the reported conditions.
This quite logically creates the impression of unresponsiveness to the findings, even though very significant efforts had been made to attempt to correct the condition.
In some instances,
(
corrective actions were taken, but they were unsuccessful i
and, therefore, a similar problem was found in a subsequent audit.
The audit reports and related documents, however, do not adequately describea the actual sequence of events.
We believe that this situation can be improved by revising our communications to more clearly tie the corrective action to the audit findings.
We are evaluating various record and document control systems which will relate these communications in such a manner that the " entire story" will be available in one place.
This should make the quality audits more effective and should assist management in evaluating the responsiveness of all segments of the organization to the quality program.
These improve-ments should also simplify the task of the NRC in conducting their audits of the Clinton Proj ect.
Another item of discussion involved the role of Illinois Power Company upper management and their support of quality activities.
This is a difficult subject to place in per-spective because many of the activities of top management are not documented or recorded.
The influence of top management is,primarily exercised through discussion and
~
verbal direction.
In fact, it is generally expected-that
(
(


J. G. Koppler                                         Appendix A Page 8
J. G. Koppler Appendix A Page 8 top management will work in this manner rather than writing letters of communications to people in the organization.
.              top management will work in this manner rather than writing
A determination of the interest and involvement of top management should include some measurement of accessibility of top management to the quality organization management and supervision.
!                letters of communications to people in the organization.
Illinois Power Company top management has always had an "open-door" policy to QA/QC personnel.
A determination of the interest and involvement of top management should include some measurement of accessibility of top management to the quality organization management and supervision.     Illinois Power Company top management has always had an "open-door" policy to QA/QC personnel.
This includes not only direct communication in accordance i
This includes not only direct communication in accordance i               with the line organizational structure, but also across organizational lines. For example, the Director - QA is in direct contact with the Executive Vice-President and Vice-Presidents as well as managers and supervisors in the total Clinton project organization. Both the IP and BA quality organizations independently establish their audit programs and schedule, and do not require prior approval of a specific audit activity. In other words, they are free to conduct formal audits or informal surveillances at any time to report the results directly to appropriate management levels without going through a line organization. This independence of action and communication provides a very effective method of communication and exercise of authority.     Unfortunately, it does not always leave convenient " tracks" which lend themselves to audit or review.     To overcome this inherent deficiency, Illinois Power Company has relied heavily on j               independent reviews and audits by outside parties. These audits are scheduled at the option and direction of top management. They tend to focus on communication flow of information, management direction, and responsiveness to the quality objectives of the Company. We believe that this combination of informal availability of top manage-ment to the quality organizations and the independent review of the effectiveness of the total quality enter-prise provides a good balance.
with the line organizational structure, but also across organizational lines.
,                    Another area which. generated considerable discussion
For example, the Director - QA is in direct contact with the Executive Vice-President and Vice-Presidents as well as managers and supervisors in the total Clinton project organization.
!                involved the management role of the quality organizations.
Both the IP and BA quality organizations independently establish their audit programs and schedule, and do not require prior approval of a specific audit activity.
As stated earlier, some problems in resolving quality l
In other words, they are free to conduct formal audits or informal surveillances at any time to report the results directly to appropriate management levels without going through a line organization.
findings were interpreted erroneously as a lack of responsiveness.     In addition, some lack of involvement l               by quality organization personnel was interpreted as i               lack of management involvement by QA and lack of manage-
This independence of action and communication provides a very effective method of communication and exercise of authority.
!                ment recognition of the role of QA.     We wish to emphasize
Unfortunately, it does not always leave convenient " tracks" which lend themselves to audit or review.
:                that we consider QA an arm of management with the very specific responsibility of monitoring and verifying the i               quality aspects of the overall job.     We expect our quality organization to be aware of construction needs and to be responsive to those needs within the contraints of their primary responsibility.     This means that the quality organization should be aware of scheduling requirements 1
To overcome this inherent deficiency, Illinois Power Company has relied heavily on j
to ensure that QA does not unnecessarily delay construction work, but they must not permit scheduling considerations to affect the quality or completeness of their work.       A question was raised as to why the IP Supervisor of
independent reviews and audits by outside parties.
These audits are scheduled at the option and direction of top management.
They tend to focus on communication flow of information, management direction, and responsiveness to the quality objectives of the Company.
We believe that this combination of informal availability of top manage-ment to the quality organizations and the independent review of the effectiveness of the total quality enter-prise provides a good balance.
Another area which. generated considerable discussion involved the management role of the quality organizations.
As stated earlier, some problems in resolving quality findings were interpreted erroneously as a lack of l
responsiveness.
In addition, some lack of involvement l
by quality organization personnel was interpreted as i
lack of management involvement by QA and lack of manage-ment recognition of the role of QA.
We wish to emphasize that we consider QA an arm of management with the very specific responsibility of monitoring and verifying the i
quality aspects of the overall job.
We expect our quality organization to be aware of construction needs and to be responsive to those needs within the contraints of their primary responsibility.
This means that the quality organization should be aware of scheduling requirements 1
to ensure that QA does not unnecessarily delay construction work, but they must not permit scheduling considerations to affect the quality or completeness of their work.
A question was raised as to why the IP Supervisor of


                                                            .      .                .                                    =   _ _                        _
=
s                            .. J. G. Keppler                                                                                                                 Ascendix A Page 9 Construction Quality-Assurance did not participate in the weekly construction scheduling meetings. As we indicated, he is permitted to participate in these meetings, but he is not required to do so. He is aware o;                                                                                               l the information to be discussed at the meeting and he is free to participate if he wishes. On the other! hand, if he judges that the material is not of direct interest or importance to the quality organization, he is free to not                                                                                             .
J. G. Keppler Ascendix A s
attend. We believe that this approach permits the quality organization to maintain the flexibility and freedom which is necessary to effectively carry out its responsibilities.
Page 9 Construction Quality-Assurance did not participate in the weekly construction scheduling meetings.
To require participation in construction and scheduling activities may generate undue concern about construction problems and to influence the planning and effectiveness of the quality organization.                                   We have tried to maintain maximum fr eedom of operation of our quality . organization; to permit freedom of choice by the organization as to where and what to audit and to conduct surveillances they see fit. We do, of course, expect our quality organization to do their work in a timely fashion and to not unnecessarily delay construction work.
As we indicated, he is permitted to participate in these meetings, but he is not required to do so.
Finally, there was considerable discussion of timeliness
He is aware o; the information to be discussed at the meeting and he is free to participate if he wishes.
'                                                                      of inspection and other quality-related activities on the Clinton proj ect.                                 In particular, the timeliness of inspec-tions relative to construction progress was emphasized.
On the other! hand, if he judges that the material is not of direct interest or importance to the quality organization, he is free to not attend.
!                                                                      Our evaluation of our current practices indicates that this matter interacts with many activities. We expect to modify some of our procedures and practices to reduce the time span between the. performance of work and its inspection and acceptance. This will require some modi-fication in the philosophy in developing travelers for the work and in " packaging" the work to permit interim inspection as well as final inspection of smaller work packages. We believe that we can improve our overall system to reduce some of the timing intervals involved 4-                                                                     and view this as an overall planning and scheduling-activity rather than simply a quality activity.                                                                                             We expect to be making changes in both the construction and quality practices which will' reduce the tLme interval and reduce the volume of work which has not yet been accepted.
We believe that this approach permits the quality organization to maintain the flexibility and freedom which is necessary to effectively carry out its responsibilities.
We will try to be realistic in making-these changes and to take into account the status of the work involved. For example, approximately 80% of the large bore pipe has been erected and to backfit a different system at this time would undoubtedly be counterproductive.                                                                     In most cases, we will make modifications to the existing system, but not depart significantly from present practices.                                                                                             In instances where little work is now in place, we may make more signi-ficant changes.                                   In addition, we expect to achie.a general improvement in this area by the simple mechanism of making the people in all organizations aware of the importance of
To require participation in construction and scheduling activities may generate undue concern about construction problems and to influence the planning and effectiveness of the quality organization.
                                                                      . performing inspections and establishing acceptance of work as soon as practicable after the work has been performed.
We have tried to maintain maximum fr eedom of operation of our quality. organization; to permit freedom of choice by the organization as to where and what to audit and to conduct surveillances they see fit.
We do, of course, expect our quality organization to do their work in a timely fashion and to not unnecessarily delay construction work.
Finally, there was considerable discussion of timeliness of inspection and other quality-related activities on the Clinton proj ect.
In particular, the timeliness of inspec-tions relative to construction progress was emphasized.
Our evaluation of our current practices indicates that this matter interacts with many activities.
We expect to modify some of our procedures and practices to reduce the time span between the. performance of work and its inspection and acceptance.
This will require some modi-fication in the philosophy in developing travelers for the work and in " packaging" the work to permit interim inspection as well as final inspection of smaller work packages.
We believe that we can improve our overall system to reduce some of the timing intervals involved 4 -
and view this as an overall planning and scheduling-activity rather than simply a quality activity.
We expect to be making changes in both the construction and quality practices which will' reduce the tLme interval and reduce the volume of work which has not yet been accepted.
We will try to be realistic in making-these changes and to take into account the status of the work involved.
For example, approximately 80% of the large bore pipe has been erected and to backfit a different system at this time would undoubtedly be counterproductive.
In most cases, we will make modifications to the existing system, but not depart significantly from present practices.
In instances where little work is now in place, we may make more signi-ficant changes.
In addition, we expect to achie.a general improvement in this area by the simple mechanism of making the people in all organizations aware of the importance of
. performing inspections and establishing acceptance of work as soon as practicable after the work has been performed.


e Appendix B Additional Information on Items Regarding Unresolved Matter The following additional information is provided relative to the unresolved matter on the control of documentation and release of safety-related equipment for installation.
e Appendix B Additional Information on Items Regarding Unresolved Matter The following additional information is provided relative to the unresolved matter on the control of documentation and release of safety-related equipment for installation.
: 1. Question:         "When will it be required to write an NCR for either insufficient or deficient docu-i                                  mentation prior to conditional release of hardware at the site? The response should address both quality-related and engineering documentation required to satisfy procure-ment and specification requirements."
1.
Answer:           Per BA's existing procedures, NCR's are required to be generated for items conditionally released to the field without acceptance of all manufacturing related documentation.
Question:
Engineering documentation is accepted through BA s documentation               Per the requirements of BA' procedures.
"When will it be required to write an NCR for either insufficient or deficient docu-mentation prior to conditional release of i
hardware at the site?
The response should address both quality-related and engineering documentation required to satisfy procure-ment and specification requirements."
Answer:
Per BA's existing procedures, NCR's are required to be generated for items conditionally released to the field without acceptance of all manufacturing related documentation.
Engineering documentation is accepted through BA s documentation Per the requirements of BA' procedures.
s QA Manual an item is not final accepted until all documentation is received and acceptable.
s QA Manual an item is not final accepted until all documentation is received and acceptable.
: 2. Question:         " Describe the criteria used to determine how one differentiates between quality-related documentation and engineering documentation.
2.
Question:
" Describe the criteria used to determine how one differentiates between quality-related documentation and engineering documentation.
Provide a representative list of engineering-type documentation."
Provide a representative list of engineering-type documentation."
Answer-           The term " engineering documentation" as used 4
Answer-The term " engineering documentation" as used at CPS is a general category of documentation 4
at CPS is a general category of documentation which is included in the generic term " quality-related documentation."   Engineering documentation typically includes design calculations, design criteria, drawings, specifications, stress reports, etc.
which is included in the generic term " quality-related documentation."
  -                                This usage is consistent with ANSI N45.2.9, Appendix A, which - in a general way - lists various types of quality assu*ance records or documents. Section A.1 addresses design (engineering) recorus and includes - as examples -
Engineering documentation typically includes design calculations, design criteria, drawings, specifications, stress reports, etc.
This usage is consistent with ANSI N45.2.9, Appendix A, which - in a general way - lists various types of quality assu*ance records or documents.
Section A.1 addresses design (engineering) recorus and includes - as examples -
calculations, design reports, stress reports, etc.
calculations, design reports, stress reports, etc.


J.G. Keppler                                           Appendix B
J.G. Keppler Appendix B Page 2 3.
  .                                                              Page 2
Question:
: 3. Question:     " Describe in detail when and how S&L determines the required engineering documentation that must be received at the site and found accep-table by BA. Pescribe the extent of an independent review and verification of the BA prepared engineering documentation lists prior to release. Include in your description the extent the list is signed, dated and controlled to assure it can be properly tracked to maintain it current with hardware configuration and/or purchase order."
" Describe in detail when and how S&L determines the required engineering documentation that must be received at the site and found accep-table by BA.
Answer:       Sargent & Lundy determines the_ documentation submittal requirements during the review of the draft copy of the specification. These requirements are included in the specifications, in the S&L standard forms which are part of the specification (Examples :   S&L Forms 350, 1922, etc.) and in the Quality Assurance requirements section of the specification. The Quality Assurance requirements section of the specification provides a generic preliminary list of documentation submittal requirements.
Pescribe the extent of an independent review and verification of the BA prepared engineering documentation lists prior to release.
Include in your description the extent the list is signed, dated and controlled to assure it can be properly tracked to maintain it current with hardware configuration and/or purchase order."
Answer:
Sargent & Lundy determines the_ documentation submittal requirements during the review of the draft copy of the specification.
These requirements are included in the specifications, in the S&L standard forms which are part of the specification (Examples :
S&L Forms 350, 1922, etc.) and in the Quality Assurance requirements section of the specification.
The Quality Assurance requirements section of the specification provides a generic preliminary list of documentation submittal requirements.
This list is reviewed by the Contractor during contract negotiations and is finalized as part of the contract.
This list is reviewed by the Contractor during contract negotiations and is finalized as part of the contract.
After award of the contract, and in accordance with Sargent & Lundy's Project Instruction PI-CP-019 the specification responsible engineers prepare and forward to the Quality Control Division (QCD) a list of engineering documents expected to be submitted by the Contractor for each specification. This list is entered into the." Engineering Documents List." The list is updated and issued monthly.
After award of the contract, and in accordance with Sargent & Lundy's Project Instruction PI-CP-019 the specification responsible engineers prepare and forward to the Quality Control Division (QCD) a list of engineering documents expected to be submitted by the Contractor for each specification.
This list is entered into the." Engineering Documents List."
The list is updated and issued monthly.
The specification responsible engineers notify QCD of any corrections, additions or deletions to be made to the issued document.
The specification responsible engineers notify QCD of any corrections, additions or deletions to be made to the issued document.
The BA " Engineering Documentation Checklist" is prepared by the BA QA Procurement Engineer-and is reviewed against the S&L " Engineering Documents List." .Any conflicts are resolved and the checklist is dated, signed and forwarded with the original requisition for fu-ther review.
The BA " Engineering Documentation Checklist" is prepared by the BA QA Procurement Engineer-and is reviewed against the S&L " Engineering Documents List.".Any conflicts are resolved and the checklist is dated, signed and forwarded with the original requisition for fu-ther review.
The checklist is returned to BA QA with typed purchase order for review and distribution for use in accounting for documentation received.
The checklist is returned to BA QA with typed purchase order for review and distribution for use in accounting for documentation received.
c                           Any modifications / changes to the checklist, including that resulting from change / amendments
c Any modifications / changes to the checklist, including that resulting from change / amendments


J.G. Keppler                                       Amendment B
J.G. Keppler Amendment B Page 3 to the purchase order after original pre-paration. dating and signing results in a revision being prepared in the same manner as the original.
  .                                                          Page 3 to the purchase order after original pre-paration. dating and signing results in a revision being prepared in the same manner as the original.
4.
: 4. Question: " Describe the involvement of the S&L QA or QC organization in the preparation of the engineering documentation list."
Question:
Answer:   Sargent & Lundy Quclity Control Division (QCD) organization's involvement in the preparation of the Engineering Documents List is described in Sargent & Lundy's Project Instruction PI-CP-019. This involvement can be summarized as follows:
" Describe the involvement of the S&L QA or QC organization in the preparation of the engineering documentation list."
: 1. QCD receives a list of the expected documents from the engineers ar m includes them in the list.
Answer:
: 2. QCD issues the list on a monthly basis.
Sargent & Lundy Quclity Control Division (QCD) organization's involvement in the preparation of the Engineering Documents List is described in Sargent & Lundy's Project Instruction PI-CP-019.
: 3. Any corrections / deletions / additions to the issued list are received from the engineers and incorporated in the next issued list.
This involvement can be summarized as follows:
: 4. When documents are received at S&L from the contractor, they cre transmitted to QCD for distribution within S&L for review. At this time, the list is revised to note receipt of the documents.
1.
: 5. QCD resolves with the engineer all comments     '
QCD receives a list of the expected documents from the engineers ar m includes them in the list.
generated during the review; then returns the results of the review to the contractor.
2.
QCD issues the list on a monthly basis.
3.
Any corrections / deletions / additions to the issued list are received from the engineers and incorporated in the next issued list.
4.
When documents are received at S&L from the contractor, they cre transmitted to QCD for distribution within S&L for review.
At this time, the list is revised to note receipt of the documents.
5.
QCD resolves with the engineer all comments generated during the review; then returns the results of the review to the contractor.
The list is then revised to note the data returned and the status.
The list is then revised to note the data returned and the status.
: 6. QCD is responsible for followup on any open comments until they are resolved.
6.
: 5. Question: " Describe the extent the engineering documentation list delineates the specific engineering, technical, cnr. specification requirements which must be met and which must be substantiated by documentation at the site. Describe the detail in which the received documentation must record engineering results in order to be found acceptable."
QCD is responsible for followup on any open comments until they are resolved.
5.
Question:
" Describe the extent the engineering documentation list delineates the specific engineering, technical, cnr. specification requirements which must be met and which must be substantiated by documentation at the site.
Describe the detail in which the received documentation must record engineering results in order to be found acceptable."


J.G. Keppler                                                                       Appendix B Page 4 Answer:                                     Sargent & Lundy's Engineering Documents List is a tracking log which lists all specific engineering, technical and specification documents required. The documents are iden-tified by tag numbers for each specification.
J.G. Keppler Appendix B Page 4 Answer:
Sargent & Lundy's Engineering Documents List is a tracking log which lists all specific engineering, technical and specification documents required.
The documents are iden-tified by tag numbers for each specification.
The specific requirements to be met and documented by the listed documents are not a part of the Engineering Documents List.
The specific requirements to be met and documented by the listed documents are not a part of the Engineering Documents List.
Determination of the adequacy of this documen-tation is the responsibility of the cognizant Sargent & Lundy design engir er.
Determination of the adequacy of this documen-tation is the responsibility of the cognizant Sargent & Lundy design engir er.
: 6. Question:                                   " Describe the controls which assure the engineering document list is properly prepared and released prior to conditional release of the hardware."
6.
Answer:                                     The " Engineering Documentation Checklist" is prepared by BA QA upon the issuance of a requisition to purchase equipment to a specification. The Engineering' Documentation Checklist is reviewed and finalized when the Purchase Order la issued to the vendor. This BA procedures BAP 2.20, action is controlled
Question:
                                                      " Documentation      by' BQA 122, " Review of Review; Requisitions and Purchase Orders;" and BQAI-120-1, " Instructions for Preparing and Processing Documentation Checklists" and occurs prior to the hardware arriving on-site.
" Describe the controls which assure the engineering document list is properly prepared and released prior to conditional release of the hardware."
: 7. Question:                                   " Describe the procedural controls for main-taining control and acccuntability (punch list /
Answer:
computer list) for incomplete or deficient documentation. Include in your description the specific information the punch list and/or computer program contains. Must the punch list and/or computer program identify incomplete or deficient engineering documentation prior to conditionc1 release of hardware? Provide your rationale if it does not. Describe tha controls to close out open items on the punch list and/or computer program in a timely manner."
The " Engineering Documentation Checklist" is prepared by BA QA upon the issuance of a requisition to purchase equipment to a specification.
Answer:                                     Basically, our system for maintaining control and accountability for incomplete or deficient documentation consists of two major parts:
The Engineering' Documentation Checklist is reviewed and finalized when the Purchase Order la issued to the vendor.
This action is controlled by' BQA 122, " Review of BA procedures BAP 2.20,
" Documentation Review; Requisitions and Purchase Orders;" and BQAI-120-1, " Instructions for Preparing and Processing Documentation Checklists" and occurs prior to the hardware arriving on-site.
7.
Question:
" Describe the procedural controls for main-taining control and acccuntability (punch list /
computer list) for incomplete or deficient documentation.
Include in your description the specific information the punch list and/or computer program contains.
Must the punch list and/or computer program identify incomplete or deficient engineering documentation prior to conditionc1 release of hardware?
Provide your rationale if it does not.
Describe tha controls to close out open items on the punch list and/or computer program in a timely manner."
Answer:
Basically, our system for maintaining control and accountability for incomplete or deficient documentation consists of two major parts:
(1) Manufacturing 6ocumentation, and (2) Design / engineering documentation.
(1) Manufacturing 6ocumentation, and (2) Design / engineering documentation.


Appendix B J. G. Keppler Page 5
J. G. Keppler Appendix B Page 5 1.
: 1. Manufacturing documentation.             Items received-on site with missing, incomplete, deficient or otherwise unacceptable manufacturing documentation can only be released to the field for installation under controlled and documented measures. The items                             '
Manufacturing documentation.
will be tagged with a " Conditional Accept" tag and the Receiving Inspection Report (RIR) will remain open until the required documentation is received and found acceptable. Except for those cases where an Authorized Interim Letter of Compliat.ce is provided as temporary evidence of compliance (i.e., required documentation not available yet and as agreed upon in the procurement.
Items received-on site with missing, incomplete, deficient or otherwise unacceptable manufacturing documentation can only be released to the field for installation under controlled and documented measures.
document) , a nonconformance report (NCR) is generated to provide for engineering and
The items will be tagged with a " Conditional Accept" tag and the Receiving Inspection Report (RIR) will remain open until the required documentation is received and found acceptable.
                                      -quality review and authorization to release.
Except for those cases where an Authorized Interim Letter of Compliat.ce is provided as temporary evidence of compliance (i.e., required documentation not available yet and as agreed upon in the procurement.
document), a nonconformance report (NCR) is generated to provide for engineering and
-quality review and authorization to release.
The BA QA generated manufacturing' Documenta _
The BA QA generated manufacturing' Documenta _
tion Checklist, the RIR, and the NCR are all used to maintain control and accountability of this type documentation.
tion Checklist, the RIR, and the NCR are all used to maintain control and accountability of this type documentation.
: 2. Design / engineering documentation.             Design /
2.
engineering documentation is not sent to the site by the supplier at the time'of shipment. This documentation is sent directly to Sargent & Lundy - (S&L) for their. review and acceptance and may be accomplished prior to or after delivery.
Design / engineering documentation.
of the item toLthe site. Subsequent to S&L's review a copy of the accepted documen-tation is sent by S&L to the, site.
Design /
engineering documentation is not sent to the site by the supplier at the time'of shipment.
This documentation is sent directly to Sargent & Lundy - (S&L) for their. review and acceptance and may be accomplished prior to or after delivery.
of the item toLthe site.
Subsequent to S&L's review a copy of the accepted documen-tation is sent by S&L to the, site.
The BA QA generated Engineering Documentation Checklist is used to maintain control and accountability-of this type of documentation.
The BA QA generated Engineering Documentation Checklist is used to maintain control and accountability-of this type of documentation.
In addition, a computer file is generated from the documentation checklists. As-the design / engineering documentation is- received onisite, the Engineering Documentation Checklist _and the computer file are updated.
In addition, a computer file is generated from the documentation checklists.
Design / engineering documentation' is not required to be on ' site prior to releasing the item for installation. Therefore,                     ,.
As-the design / engineering documentation is-received onisite, the Engineering Documentation Checklist _and the computer file are updated.
                                        " Conditional Accept" tags are not attached
Design / engineering documentation' is not required to be on ' site prior to releasing the item for installation.
                                      .for this situation.                           ,
Therefore,
" Conditional Accept" tags are not attached
.for this situation.
s'
s'


J. G. Kcppler                                                     Appcndix B
J. G. Kcppler Appcndix B Page 6 This computer file provides an indispensable tool for fast reference on documentation status.
.                                                                      Page 6
It can be sorted in any number of ways; equipment number, specification, i
,                                              This computer file provides an indispensable tool for fast reference on documentation status. It can be sorted in any number of ways; equipment number, specification,                 i all complete documentation, turnover package, system, area, etc.
all complete documentation, turnover package, system, area, etc.
The computer file is used to assist the engineers in preparing the Turnover Exception List.Baldwin Associates Procedure BAP 2.17, " System /Sub-system Turnover," outlines steps required in the preparation of turnover packages.
The computer file is used to assist the engineers in preparing the Turnover Exception List.Baldwin Associates Procedure BAP 2.17, " System /Sub-system Turnover," outlines steps required in the preparation of turnover packages.
Included in it are provisions for listing missing documentation as exception items at the time of turnover. Exception items are tracked on the Turnover Exception List, and are finally dispositioned upon evaluation of Illinois Power Company, Baldwin Associates, and Sargent and Lundy.
Included in it are provisions for listing missing documentation as exception items at the time of turnover.
Exception items are tracked on the Turnover Exception List, and are finally dispositioned upon evaluation of Illinois Power Company, Baldwin Associates, and Sargent and Lundy.
Missing items, hardware or software, when received on site after a system has been turned over to Illinois Power Company Startup, are identified by Baldwin Associates on a Construction Work Request.
Missing items, hardware or software, when received on site after a system has been turned over to Illinois Power Company Startup, are identified by Baldwin Associates on a Construction Work Request.
This is forwarded to Illinois Power Startup Group who in turn issues the Construction Work Request to Baldwin Associates for action. Once action is-complete, whether it involves installation of an item or update of checklists and computer files and transmittal of a documentation to the Document Records Center-(DRC), Baldwin Associates Quality Control will verify and document appropriate action to the Illinois Power Startup Group.
This is forwarded to Illinois Power Startup Group who in turn issues the Construction Work Request to Baldwin Associates for action.
Once action is-complete, whether it involves installation of an item or update of checklists and computer files and transmittal of a documentation to the Document Records Center-(DRC), Baldwin Associates Quality Control will verify and document appropriate action to the Illinois Power Startup Group.
Illinois Power Startup Group then closes the item on the exception list.
Illinois Power Startup Group then closes the item on the exception list.
The computer file is a tracking tool, a log of documents required and documents received. Items listed as required, but not complete, are closed only upon receipt of acceptable documentation and subsequent notification by Baldwin Associate engineering that the documentation has been sent to the Document Records Center.
The computer file is a tracking tool, a log of documents required and documents received.
Items listed as required, but not complete, are closed only upon receipt of acceptable documentation and subsequent notification by Baldwin Associate engineering that the documentation has been sent to the Document Records Center.
t
t
______m________ ..____ . _ .
______m________


J. G. Keppler                               Apptndix B
J. G. Keppler Apptndix B Page 7 8.
    .                                                  Page 7
Question:
: 8. Question: " Describe in detail the specific responsibilities of the BA QA organization when it receives the completed quality and engineering checklists. Does BA QA evaluate the results of both lists to verify all required objectives have been met, and is BA QA required to sign and date the lists attesting to such?"
" Describe in detail the specific responsibilities of the BA QA organization when it receives the completed quality and engineering checklists.
Answer:   BA QA reviews both checklists for accuracy and completeness. This review assures the documentation requirements of the contract have been met. BA QA stamps, initials, and dates each checklist and forwards them to the Document RecordssCenter.
Does BA QA evaluate the results of both lists to verify all required objectives have been met, and is BA QA required to sign and date the lists attesting to such?"
: 9. Question: " Describe the planning for requiring BA and IPC to audit and survey this overall program on~ a regalarly scheduled basis."
Answer:
Answer:   BA audits this activity, as other activities, in accordance with the BA QA Manual and BA QA Procedures. This program is subject to IP QA audit as a part of the regularly scheduled audits of BA.
BA QA reviews both checklists for accuracy and completeness.
: 10. Question: " Describe the extent Mr. Ennen will evaluate the total program and conduct special surveillance i
This review assures the documentation requirements of the contract have been met.
BA QA stamps, initials, and dates each checklist and forwards them to the Document RecordssCenter.
9.
Question:
" Describe the planning for requiring BA and IPC to audit and survey this overall program on~ a regalarly scheduled basis."
Answer:
BA audits this activity, as other activities, in accordance with the BA QA Manual and BA QA Procedures.
This program is subject to IP QA audit as a part of the regularly scheduled audits of BA.
10.
Question:
" Describe the extent Mr. Ennen will evaluate the total program and conduct special surveillance i
to provide additional professional QA overview and input as to the workability and control-1 ability of this program."
to provide additional professional QA overview and input as to the workability and control-1 ability of this program."
Answer:   .The Quality Assurance department assigns personnel to various work assignments and surveillance activities based upon experience and the nature of activity. This
Answer:
,                          practice will continue. Concerning surveillances regarding the documentation efforts, Quality Assurance will continue to review both the program and practices to ensure adequacy with regulatory requirements. Various. personnel assignmen:s will be made to accomplish this objective in the future.
.The Quality Assurance department assigns personnel to various work assignments and surveillance activities based upon experience and the nature of activity.
: 11. Question: " Describe the role of IPC top management in overseeing this overall effort to assure it is properly managed and effective. How much will top management rely on QA in this regard."
This practice will continue.
Answer:   Quality Assurance will provide periodic reports to upper management regarding the progress and status of the documentation efforts. These reports may be in the form of surveillance reports, audit reports, monthly QA reports, or-Quality Review meeting notes. These reports will be reviewed by management and form a basis for keeping management advised as to the adequacy of company efforts in
Concerning surveillances regarding the documentation efforts, Quality Assurance will continue to review both the program and practices to ensure adequacy with regulatory requirements.
Various. personnel assignmen:s will be made to accomplish this objective in the future.
11.
Question:
" Describe the role of IPC top management in overseeing this overall effort to assure it is properly managed and effective.
How much will top management rely on QA in this regard."
Answer:
Quality Assurance will provide periodic reports to upper management regarding the progress and status of the documentation efforts.
These reports may be in the form of surveillance reports, audit reports, monthly QA reports, or-Quality Review meeting notes.
These reports will be reviewed by management and form a basis for keeping management advised as to the adequacy of company efforts in


J. G. Koppler                               Appendix B
J. G. Koppler Appendix B Pagn 8 meeting regulatory efforts.
.                                                  Pagn 8 meeting regulatory efforts. Since IP upper management is dedicated to ensuring compliance with regulations and committed to codes and standards, action will be taken by appropriate levels of management for those identified issues which do not comply with our commitments.
Since IP upper management is dedicated to ensuring compliance with regulations and committed to codes and standards, action will be taken by appropriate levels of management for those identified issues which do not comply with our commitments.
: 12. Question: "Does S&L intend to revise their specification requirement for the use of a " Certificate of Compliance" in lieu of missing documertation?
12.
Question:
"Does S&L intend to revise their specification requirement for the use of a " Certificate of Compliance" in lieu of missing documertation?
If not, how will you comply with Paragraph 5.2.4 of BAP 2.20?"
If not, how will you comply with Paragraph 5.2.4 of BAP 2.20?"
Answer:   A field change request (FCR 9071) has been initiated to revise various Sargent and Lundy Specifications to clarify that shipment of equipment to the site will be allowed in cases where design /ecagineering documentation is not   >
Answer:
available. However, a Certificate of Compliance will be required for manufacturing documentation that is lacking. The requirements of Paragraph 5.2.4 of BAP 2.20 apply'to manufacturing / quality documentation only.
A field change request (FCR 9071) has been initiated to revise various Sargent and Lundy Specifications to clarify that shipment of equipment to the site will be allowed in cases where design /ecagineering documentation is not available.
: 13. Question: "Will Paragraph 17.1.17.1 of the CPS PSAR be       j tevised? If not, will Paragraph 17.1 of the       i CPS FSAR which states that Paragraph 17.'l of the PSAR was fully implemented be revised?"
However, a Certificate of Compliance will be required for manufacturing documentation that is lacking.
Answer:   Illinois Power will ensure that the FSAR accurately reflects the QA program and practices. If, after reviewing the PSAR Chapter 17.1.17.1, we consider that further clarification of interpretation is necesasry, we will amend the FSAR to better describe the essential points of our documentation efforts.
The requirements of Paragraph 5.2.4 of BAP 2.20 apply'to manufacturing / quality documentation only.
13.
Question:
"Will Paragraph 17.1.17.1 of the CPS PSAR be j
tevised?
If not, will Paragraph 17.1 of the i
CPS FSAR which states that Paragraph 17.'l of the PSAR was fully implemented be revised?"
Answer:
Illinois Power will ensure that the FSAR accurately reflects the QA program and practices.
If, after reviewing the PSAR Chapter 17.1.17.1, we consider that further clarification of interpretation is necesasry, we will amend the FSAR to better describe the essential points of our documentation efforts.
_ _ _ _ - _ _}}
_ _ _ _ - _ _}}

Latest revision as of 08:30, 21 December 2024

Responds to NRC 810312 Meeting Re Violations Noted in IE Insp Rept 50-461/81-05.Corrective Actions:Trial Program for Installation & Insp of Piping Component Supports/Hangers to New Procedures Completed
ML20009E752
Person / Time
Site: Clinton Constellation icon.png
Issue date: 07/20/1981
From: Koch L
ILLINOIS POWER CO.
To: James Keppler
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
Shared Package
ML20009E745 List:
References
Q37-81(06-11)-1, U-0244, NUDOCS 8107280415
Download: ML20009E752 (31)


Text

.

/LLIN0/S POWER COMPANY IP CLINTON POWER STATION, P.O. BOX 399, CLINTON, ILLINOIS 61727 Q37-81(06-ll)-L U-0244 June 11, 1981 Mr. James G. Keppler Director U. S. Nuclear Regulatory Commission Office of Inspection and Enforcement Region III 799 Roosevelt Road Glen Ellyn, Illinois 61037

Dear Mr. Keppler:

This is in response to your Notice of Violation and Inspection Report Number 50-461/81-05 on the NRC special team inspection of the Clinton Power Station conducted during the period February 9 -

March 5, 1981.

Illinois Power Company's response to the items discussed during the March 12, 1981 meeting and summarized in the

" Inspection Results" section of your report is included as Appendix A.

In addition, Appendix B provides the additional information requested in your letter dated April 21, 1981 related to the unresolved matter discussed in Paragraphs C.2.b and D.4.b(4) of your report.

Illinois Power Company's response for the eleven (11) items of noncompliance cited in the Notice of Violation is: as follows:

1.

Criterion V, Instructions, Procedures and Drawings -

The Notice of Violation states in part:

" Contrary to the above (10CFR50 Appendix B, Criterion V and Illinois Power Company, Clinton Power Station PSAR Section 17.1.5.1):

a.

The hanger installation / inspection tolerance procedure was incomplete in that it did not cover all areas necessary to ensure proper installation and QC acceptance inspection.

b.

Specific instructions for installing mechanical snubbers was lacking.

c.

The procedure for installing the penetration seismic guides was not adequately detailed to control weld distortion."

8107280415 810720 N

PDR ADOCK 05000461 G

PDR

e J

J. G. Kcppler June 11, 1981 NRC Page 2 A new procedure, BAP 3.2.5, " Piping Component Supports", covering the installation and inspection of piping component supports /

hangers has been written, reviewed, approved, and issued for implementation.

This procedure provides specific installation and inspection instructions and criteria, including:

dimensional tolerances, base plate bolt hole location / bolt pattern, support pin-to-pin dimensions, locations, angularity clearances, centers of gravity and other related criteria.

Quality Control instructions, including checklists were revised to reflect the new installation and inspection procedure requirements.

Specific installation and inspection instructions for Pacific Scientific mechanical snubbers are also included in BAP 3.2.5.

Certain handling, storage, and preventative maintenance precautions or requirements are being included in the existing Storage and Maintenance program.

A trial program for installation and inspection of piping component supports / hangers to rSe new procedures has been completed and results reviewed oy the NRC during an inspection visit on June 5-6, 1981.

A nonconformance report (NCR) was issued to document conditions noted on the Reactor Water Cleanup pipe seismic guides inside the guard pipe for engineering review and disposition.

Work was terminated until the NCR was dispositioned and appropriate installation procedures / guidance were issued.

The S&L drawing (M06-1000, Sheet 6) has been revised to indicate that the " cold gap position" is the thickness of shim stock to be used during fabrication / installation welding of seismic guides.

The installation traveler for the remaining seismic guide work is being revised to incorporate additional detail and steps to control weld distortion within acceptable limits.

2.

Criterion V, Instructions, Procedures, and Drawings -

The Notice of Violation states in part:

" Contrary to the above (10CFR50 Appendix B, Criterion V and Illinois Power Company, Clinton Power Station PSAR, Section 17.1.5.1) in the area of pipe supports and restraints:

a.

Eight out of the nine safety-related and installed hangers, struts and snubbers observed by the inspector did not conform to the construction drawing requirements.

b.

The Reactor. Water Cleanup pipe penetration seismic guide inside the guard pipe did not conform to the design drawing clearance requirement."

l

J. G. Keppler June 11, 1981 Page 3 A new procedure, BAP 3.2.5, " Piping Component Supports",

which provides specific and generic instructions for the fabrication, installation, and inspection of pipe supports, has been issued.

Training classes were held for craft, supervisory, quality control, and technical services personnel.

All previously installed hangers will be reinspected and reevaluated to the criteria included in the new procedure.

A trial program was conducted to ensure that the new procedures were adequate for controlling hanger installations and inspections.

The results of the program were reviewed by the NRC during an inspection visit on June 5-6, 1981.

A nonconformance report (NCR) was issued to document conditions noted on the Reactor Water Cleanup (RWCU) pipe seismic guides inside the guard pipe for engineering review and disposition.

Work on further installation of such seismic guides was suspended until the NCR was dispositioned and appropriate installation / guidance were issued.-

The A-E determined that even a zero clearance condition would not result in unacceptable stresses for any of the assemblies.

Further investigation in the field substantiated that the installed condition is bounded by the A-E's calculations.

As a result of this investigation, the NCR was dispositioned " accept-as-is".

Since the fabrication procedure followed for the other installed seismic guides was the same (except that main steam guides were shop assembled with some additional welding controls) and no repairs were required for the RWCU guide assembly, no further action will be needed on the others.

The S&L drawing (M06-1000, Sheet 6) has been revised to indicate that the " cold gap position" is the thickness of shim stock to be used during fabrication / installation welding of the seismic guides.

The installation traveler for the remaining seismic guide work is being revised to incorporate additional detail and steps to minimize weld distortion.

Installation of all seismic guides is expected to be completed by July 31, 1981.

3.

Criterion X, Inspection The Notice of Violation states in part:

" Contrary to the above (10CFR50 Appendix B, Criterion X and the CPS PSAR Section 17.1.10.1).

a.

The existing hanger inspection program was inadequate in that it did not provide for timely inspections to identify deficiencies and to initiate corrective actions to prevent recurrance and it did not distinguish the inspection requirements for each phase of hanger installation.

. -. - =

=

.. J. G. Keppler June 11, 1981 j

NRC Page 4 b.

The traveler QC acceptance provision for the pipe penetration seismic guide was inadequate in that 4

i it. did not provide for inspection measurement after component installation."

A three phase program for installation and inspection of piping component supports / hangers has been developed and instituted through a new procedure, BAP 3.2.5, " Piping.

Component Supports" and all new safety-related pipe hangers will be installed and inspected to its provisions.

The three phases of this program are:

Phase I:

Installation and inspection of. the hanger /.

i support's primary attachment to the building i

or structure.

I Phase II:

Installation and inspection of the hanger / -

~

support's construction from the anchor point to the pipe.

l Phase III:

This phase occurs just prior, to system func-tional testing and encompasses final cold s etting. adj us tments, removal of travel stops,

{

and other final setting adjustments.

i As the craft completes installation activities of each phase, the hanger will. be inspected.

A copy of each inspection checklist, for each-of the three phases, is forwarded to Baldwin Associates

. Quality Assurance for trend analysis.

In this-way, generic or repetitive problems can be identified and' corrective action initiated to prevent recurrence.

A trial program for installation and inspection of piping component supports / hangers to the new procedure has been completed i

and resultu reviewed by the NRC during an inspection visit on j

June 5-6, 1981.

As noted in the previous two items of noncompliance, relative to the~ Reactor Water Cleanup pipe seismic guides insideL the guard-pipe, a nonconformance report (NCR) was issued to document condi-tions noted and. to obtain engineering review and disposition.

l Work on further installation of such seismic guides was suspended j

. until the NCR was dispositioned and appropriate installation and inspection: procedures / guidance was issued.

The S&L drawing l

i (M06-1000, Sheet 6) was revised to indicate that the " cold gap position" is the thickness af shim stock:to be used during fabrication / installation welding of the seismic guides.

The L

installation traveler for the remaining seismic guides work-is being revised to incorporate additional detail and : steps to j

minimize weld distortion and to ensure -design requirements are I

met.

This will -include appropriate QC inspection signoffs.

L Installation of all seismic. guides is expected to be l'

completed by; July.31, 1981.

I k'

r l

J. G. Keppler Juno 11, 1981 NRC Page 5 4.

Criterion XVIII, Audits The Notice of Violation states in part:

" Contrary to the above (10CFR50 Appendix B, Criterion XVIII and CPS PSAR Section 17.1.18.1), relative to pipe hanger design and installation activities, the licensee audit of the A-E, the licensee audit and surveillance of contractor site performance, and the contractor's internal audits were considered inadequate in that detailed hanger audit requirements were absence, problems were not prevented from recurring, and programatic audit planning, scheduling, and implementation was absent for on-going safety-related hanger installation and QC inspection activities."

A plan for coordinated licensee and contractor audits and surveillances was developed and implemented in conjunction with the trial program for pipe hanger installation and inspection activities.

In addition, a detailed plan of licensee and contractor audits and surveillances to periodically assess the adequacy and effectiveness of programs for design, fabrication, installation and inspection of seismic Category I piping and component supports and hangers has been issued.

This plan includes a series of audits, which were already part of previously established audit plans and schedules, and a series of surveillances of on-going activities.

The plan also describes the time / period of the planned audit or surveillance, the overall scope of activities, the items or components, and the applicable 10CFR50 Appendix B criteria to be covered.

IP Construction QA has developed a detailed surveillance checklist to be used during surveillance of hanger installation /

inspection activities in the field.

Detailed checklists for audits are prepared by the audit team after formal assignment and the scope of the audit is determined.

This occurs prior to the scheduled audit and complies to IP's commitment to Regulatory Guide 1.144 (Jan. 1979) and ANSI N45.2.12 (1977) " Requirements for Auditing of Quality Assurance Programs-for Nuclear Power Plants."

IP Construction QA surveillance program has been upgraded to include a plan and pre-prepared checklist-s for certain activities.

Surveillances are scheduled dependent on the nature of activities and performance trends.

The contractor and licensee audit programs and plans are being reviewed to determine what changes or improvement, if any, are needed to ensure comprehensive and sufficient coverage of activities.

This review is expected to be completed by July 31, 1981 and any changes should be implemented throughout the remainder of 1981.

J. G. Koppler June 11, 1981 NRC Page 6 5.

Criterion IX - Control of Special Processes -

The Notice of Violation states in part:

" Contrary to the above (10CFR50 Appendix B, Criterion IX; CPS PSAR. Section 17.1.9.3; and ASME B&PV Code, NA-4411),

welding was not being accomplished in accordance with applicable codes, in that, controlled welding procedure specifications with the associated welding parameters sheets were not located at the prescribed activity (welding). "

The Welding Procedure Specification Information Handbooks

(" Blue Books") which contain a listing of welding parameters have been recalled and will be reissued to Discipline Super-intendents for distribution to welders as controlled documents and will be kept current per BA Project Procedures.

This will be accomplished by July 15, 1981 and we will.be in full ccmpliance.

In addition, welding procedure specifications and the associated welding parameter sheets are available in controlled Technical Services Manuals at various Document Control centers within the plant.

6.

Criterion XVII, Quality Assurance Records The Notice of Violation states in part:

" Contrary to the above (10CFR50 Appendix B, Criteria XVII and CPS PSAR Section 17.1.17.1), reviews of nonconformance reports, audits, and surveillances, for reportability-enable-verification of proper review."g documented to pursuant to 10CFR50.55 e( ) are not bein The nonconformance report (NCR) form has been revised to include a block for the contractor's project engineering group to indicate review for 10CFR50.55(e) reportability.

Additionally, the contractor's QA organization has revised their procedures for reviewing NCR's to include documentation, via -a log entry and a stamp on the NCR, that their review for reportability has-been accomplished.

IP QA conducts a quarterly trend review of NCR's.

The form which documents the results of their review is being modified to include documentedLevidence of IP QA's review for.

reportability at that time.

The contractor has also revised their QA procedures regarding reviews of audit and surveillance reports to include a requirement for the Manager of QA to stamp, sign and date the affected documents; indicating a review for potentially reportable 10CFR50.55(e) conditions has been made.

IP has modified their audit report title page fonn to include a definite signed statement that indicates a review of the report including the-audit findings

- for.potentially reportable items by the team leader has been completed.

Further changes / modifications to the IP QA surveillance finding form are being made to provide documented evidence' that the QA Supervisor's review includes a review for reportability.

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i J. G. Keppler June 11, 1981 NRC Page 7 All the above documentation of reviews will show the results of these reviews as either "yes" or "no".

The actual reporting process of the potential reportable item will be in accordance with formal procedures issued by the contractor and licensee.

The above noted actions should ensure appropriate documentation of reviews in the future.

We expect to have appropriate changes / modifications in procedures and forms and necessary training associated completed such that full compliance is achieved by July 1, 1981.

7.

Criterion XVI, Corrective Action The Notice of Violation states in part:

" Contrary to the above (10CFR50 Appendix B, Criterion XVI and IPC Quality Assurance Manual, Chapter 16)-

a.

Neither prompt nor effective corrective action to preclude repetition was taken in response to the following audits and other documents concerning electrical hanger installation activities.

(1)

Baldwin Associates (BA) Internal Audit Report I-134, dated January 22, 1980.

(2)

BA Internal Audit Report I-137, dated February 19, 1980.

(3)

Corrective Action Request (CAR) number 049 dated March 3, 1980.

(4)

BA Internal Audit Report I-150, dated June 24, 1980.

(5)

Site Surveillance Report No. S-313 dated August 18, 1980.

b.

The licensee failed to take prompt corrective action in response to a special QA Review of IEEE Environmental and Seismic Qualifications, dated 9-17-80, which identified the current practice of granting unconditional acceptance status to components lacking quality documentation."

a.

This item involves the recognition of an overall problem during an early phase when subproblems arise which are not recognized as being related.

Problem recognition is not unique to nuclear power plant construction; it is common to most complex, multi-activity functions.

Electrical hanger installation is a complex activity.

Initial corrective actions (audit findings and CARS) were directed toward correcting specific deficiencies within the established electrical hanger installation system.

It was not obvious at that time that the individual specific problems were


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NRC Page 8 indicative of a broader general problem.

The full extent and need

~

for substantial revision of the entire system were not l

realized until it was determined to be reportable under 10CFR50.55(e) in September 1980.

In retrospect, it can be concluded that an earlier decision to revise the entire system could have been made.

This, however was not apparent as each successive level of corrective action was taken.

Based on evaluations made at the time, and the value judgments rendered by those involved, the corrective action proposed at each step was considered sufficient.

This when working on individual trees." y in "seeing the forest experience emphasizes the difficult We believe that this form of problem recognition can be Dnproved by better communications between the parties involved.

i It has been Illinois Power Company's philosophy that the responsibility for quality lies with the organizations responsible for doing the work.

The quality assurance organizations (IP and BA) monitor this effort through audits and surveillances, including the identification of the development and/or evaluation of resolutions which will ensure compliance with established program and commitments.

These deficiencies are normally resolved without top management invaivement; however, the lines of communication are maintained and j

problems which warrant such attention are reported to upper management.

3 To improve communications between the parties involved in evaluating and correcting findings and to enhance management participation, a system of periodic quality review meetings has been established.

These meetings will bring together quality, engineering, and construction management and supervision from Illinois Power, Baldwin Associates and others such as Sargent and Lundy and General Electric, as necesasry, to evaluate and coordinate quality activities :bi the work areas involved.

Concurrence with evaluation of quality problems and plans of action will be documented.

These periodic assessments will be in addition to reporting ind resolution methods currently employed, and will be conducted specifically.

to avoid escalation of lower-level problems, or lack of prompt execution of previously approved action plans.

We believe that this interchange will improve communication and coordination of quality activities and will enhance our capability to identify trends or other signals which indicate that broad corrective action is needed.

b.

Corrective action was taken to resolve this issue.

The Baldwin Associates Quality Assurance Manual and associated procedures were revised subsequent to and as a result of the Special QA Review to better distinguish types of documentation i

and conditions to be met for conditional acceptance and final acceptance of safety-related equipment.

Based on the revisions to the program for obtaining documentation, we consider this an adequate approach to satisfying-the intent of our regulatory commitments.

~.

J. G. Keppler Juns 11, 1981 NRC Page 9 8.

Criterion III, Design Contro_1 The Notice of Violation states in part:

" Contrary to the above (10CFR50 A pendix B, Criterion III and CPS PSAR Section 17.1.3.3 :

a.

The pipe suspension system components were fabricated and installed prior to formal calculations (design verification) being performed and documented including review and approval by authorized personnel.

b.

Management failed to act to prevent further fabrication end installation of seismic supports when the apparent problem concerning lack of formal approval of calculations had been identified."

a.

As of March 1, 1981, formal design calculations for pipe suspension system component drawings which were reissued based on verification to new dynamic loads data have been reviewed and approved by authorized personnel.

Design calculations for pipe suspension system component drawings which have not yet been verified to new dynamic loads data, will be reviewed and approved in conjunction with the final load verification program now scheduled for completion in July 1981.

Therefore all pipe suspension system component drawings are expected to be reissued and based upon approved design calculations by August 1, 1981.

b.

The inspector notes that Sargent and Lundy's management did not place a hold on the Clinton dynamic hanger /-

seismic supports released for fabrication and installation without reviewed and approved calculations as a result of a similar finding in 1979 on another S&L project.

However, in late 1978, all the unfabricated dynamic hangers for the Containment, Fuel, and Auxiliary Buildings were put on hold by ECN's 844 and 908.

Sargent and Lundy and Illinois Power Ccupany determined that the installation of dynamic hangers of the Control i

and Diesel Generator Buildings would continue because the dynamic response spectra changes were judged to have minimal effects in these buildings.

During the NRC inspection, Sargent and-Lundy issued ECN 2071 which.

put the remaining uninstalled (but previously fabricated) non-verified dynamic hangers on hold until the load verification.is completed.

As of June 3, 1981, the following status existed, (doesn't include May releases):

(1) 1556 dynamic supports released with verified loads (2) 22 dyna-ic supports installed without verified loads (3) 94 dynamic supports supports on " hold'.'

J. G. Keppler June 11, 1981 NRC Page 10 It is expected that drawings for those dynamic supports installed without verification to new loads data and those on hold will be reissued based on new loads verification by August 1, 1981.

9 Criterion II, Quality Assurance Program The Notice of Violation states in part:

" Contrary to the above (10CFR50 Appendix B, Criterion II and IFC Quality Assurance Manual Chapter 2) the licensee failed to provide quality assurance conn als over the preparation, review, and approval of "As-built" electrical hanger drawings prepared by iPC engineers.

Furthermore, the licensee failed to establish which Quality Assurance Organizatic.i would have functional control over the "As-built" electrical hanger program.

As a result, activities affecting the quality of safety related hangers were performed without approved procedures.

For example:

a.

The actual "As-Built" hanger installation could not be determined on six "As-built" electrical hanger drawings reviewed and approved for use by Sargent and Lundy (S&L), the Architect Engineer, due to conflict in drawing dimensions and indeterminate dimension orientation.

b.

No program was established to ensure that approved "As-Built" design parameters would be implemented into the base design documents.

As a result, the use of an alternate hanger detail contrary to that specified in the base design criteria was approved.

These "As-Built" drawings had been prepared and reviewed by IP and submitted to S&L by BA for review and statusing in accordance with a program documented in a letter.

However, formal procedures had not been adequately prepared for performing these activities at Clinton.

Sargent and Lundy did hnve a procedure l

Proj ect Instruction PI-CP-023, Rev. O, " Review of Baldwin Associates Prepared Seismic Category I Cable Tray Hanger and Conduit Hanger Assembly Drawings", which was originally intended to cover

" shop drawings."

However, this procedure appeared to be written in terms general enough to cover "As-built" drawings also.

After S&L had received and reviewed some of the "Arbuilt" drawings it was determined that although most of the same requirements apply, more specific delineation regarding review of "As-builts" and revision of pertinent Sargent and Lundy design documents was required.

Prior to the NRC inspection, Project Instruction PI-CP-023 had been revised to incorporate the needed changes and l

was in comment and approval circuit.

The drawings reviewed by the NRC inspector were the first ones returned by S&L to the site.

l

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Although several errors were noted in the "As-built" electrical l

hanger drawings, none of them would have compromised the structural integrity of the supports, nor prevented the QC inspector-t

.J..G. Keppler June 11, 1981 NRC Page 11 from performing his inspection (i.e. the inspector would have issued an NCR if the hanger did not agree with the drawing.)

However, Illinois Power was concerned with the number of errors and has taken, or is taking the following actions.

(a)

The responsibility for preparing, reviewing, appraving and submitting "As-Built" electrical hanger drawings to S&L for review and statusing was transfered from IP to BA.

(b)

Baldwin Associates has developed, approved, and issued a procedure, BAP 3.3.8 " Electrical Hanger As-Built Drawings" to cover the activities of (a).

(c)

"As-Built" drawings completed under IP direction, but not yet transmitted to S&L prior to shifting responsi.

bilities to BA, have been or are being reviewed, corrected and processed in accordance with BAP 3.3.8.

(d)

Sargent & Lundy has revised, approved, and issued Project Instruction PI-CP-023 Revision 1 to include specific requirements regarding the review and statusing of "As-Built" hanger drawings.

The procedure requires verification of the adequacy of a hanger which deviares from the S&L design document.

(e)

"As-Built" drawings completed and submitted to S&L have been or are being reevaluated-to the require-ments of PI-CP-023, Rev. 1.

(f)

"As-Built" drawings completed by IP, statused by S&L,-

and transmitted back to CPS prior to issuance of BAP 3.3.8 and PI-CP-023, Rev. 1, have been or are being reviewed, corrected as necessary and processed in accordance with these procedures / instructions.

Although not all "As-Built" drawings have been prepared, reviewed, approved, and statused to date, corrective action has been'taken to ensure that1the final product,

" installed hangers", meets all design and quality requirements.

10.

Criterion VI - Document Control The Notice of Violation states in part:

Contrary to the above (10CFR50 Appendix B, Criterion VI-

. and IPC Quality Assurance Manual) changes and current revision to electrical drawings were not being used as follows...."

Field Change Requests (FCR) noted in the noncompliance have

-been listed on the fieldicopy of the-drawings.

The latest drawing revisions noted:in the item of. noncompliance are now in use. in the field and the superseded -drawings have been. removed.

It should be recognized that the two (2) noted later-drawing revisions either had not been or were being _ processed by Document Control /-

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G. Keppler June 11, 1981 F

NRC Page 12 1

Reproduction group at time of the NRC inspection.

An undocu-mented check of approximately 50 FCR's/ drawings we~ made to i

determine extent of problem and no other cases / deficiencies were i

noted.

One additional person, the Drawing Inventory Coordinator, l

is being assigned to full time. document control inventory and i

survey responsibilities, effective June 15, 1981.

This position l

had been vacant since January 1981.

A formal routine and ongoing -

inventory which is the prime responsibility of this position, 4

will be accomplished commencing June 15, 1981.

Four people j

and a new blue print machine have been added' to our operation in 1

an effort to improve drawing turn around time and keep pace with the ever increasing influx of new/ revised drawings.

These actions 4

should minimize recurrence of - these and-similiar problems.

1 i

11.

Criterion V, Instructions, Procedures and' Drawings The Notice of Violation states in part:

" Contrary to the above (10CFR50 Appendix B, Criterion V and IP-Quality Assurance Manual, Chapter V), equipment receipt inspection activities affecting quality were i

not accomplished in accordance with written procedures as follows:

-Paragraph 6.9.1.3 of Baldwin AssociatesLProcedure-j a.

(BAP) 2.3 stetes, in part, " Quality - Control shall i

revise documentation related to'the receipt of the items / materials, e.g. RIR, logs, etc., to reflect-the return."

Contrary to this, RIR S-ll630, dated September 29, 1980, which documented;the receipt i

of the electrical penetration primary header plate bolts was not revised to reflect the return of these bolts to Conax for rethreading.

l b.

Paragraphs 112.11 and ll2.lla of Sargent and Lundy Specification K-2978, states "In -special cases, where l

all of the documentation may not be available at

{

the time the equipment is ready for shipment,; shipment.

to the site will be permitted under the-following conditions:

upon written approval of the Purchaser, l

a Certificate -of Compliance shall be transmitted with L

the shipment.

Approval for use of Certificate of Compliance shall be obtained prior to shipment."

l Paragraph - 5.2. 3 of BAP 2.20 states, in part:

"The authorization shall be in letter form signed by-the Manager of_ Quality Control and.....shall form a part of the procurement documents." ' Contrary to these

-requirements, Conax Corporation electrical. penetrations j.

were shipped-to the. licensee and a Certificate of Compliance was transmitted in~ lieu of. complete documentation without prior written authorization.

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Paragraph 5.2.4 of BAP 2.20 states "Upon receipt of the authorized letter of compliance, items shall be placed on " Conditional Accept" status in accordance with BAP 2.3, for documentation requirements."

Contrary to this electrical penetrations IEE21E, IEE01E, and 4160V electrical switchgear IAP07E were not placed on " Conditional Accept" status nor were conditional accept tags attached as required by BAP 2.3."

a.

Baldwin Associates Procedure (BAP 2.3) has been revised to delete the requirement to revise the original RIR when items are returned to the vendor.

The documentation of items being returned is accomplished using a Material Return Transmittal, Form JV-418, which is and has been a requirement of BAP 2.3.

Therefore, the revision of the original RIR is not considered necessary.

b&c.

The requirement to obtain prior written authorization to ship equipment on a Certificate of Compliance in special cases where all documentation may not be available at time of shipment was not construed to be applicable to missing engineering or design docu-mentation.

All manufacturing documentation was available and was shipped with the equipment.

Seismic and enrionmental qualification data reports were not available, in that tests had not been accomplished yet.

However, these documents are considered design /

engineering documentation and are required to be submitted directly to Sargent and Lundy.

A Field Change Request (FCR-9071) has been initiated to revise Sargent and Lundy Specification K-2978, and other specifications, to clarify that shipmentoof equipment to the site will be allowed in cases where design /

engineering documentation is not available.

However, a Certificate of Compliance will be required for manufacturing documentation that is lacking.

The requirements of BAP 2.20, paragraph 5.2.4 and BAP 2.3 apply to manufacturing data / documentation received from the vendor and not the engineering /

design data.

The electrical penetrations and switchgear referred to in the item of noncom-pliance were received with all the appropriate manufacturing data / documentation.

The engineering /

design documentation is being tracked through appropriate checklists and computer file system to ensure that the documentation is obtained.

J. G. Keppler June 11, 1981 NRC Page 14 I trust that our response is satisfactory to allow closecut of these items when all actions are complete.

I hereby affirm that the information contained in this letter is correct to the best of my knowledge.

Sincerely,MW$

L. J. Koch Vice-President Attachments:

Appendix A

- IPC Response to Concerns Expressed in Paragraph C.2 of the NRC Special Team Inspection Report, 50-461/81-05.

Appendix B

- Additional Information on Items Regarding Unresolved Matter cc:

H. H. Livermore, NRC Resident Inspector Director, Quality Assurance CPS /DRC t

1

Appendix A >

IPC Response to Concerns Expressed in Paragraph C.2 of the NRC Special Team inspection Report, 50-461/81-05 Section C.2 " Conclusion" of the Inspection Report describes five (5) concerns or " specific weaknesse's" preceived by the NRC inspection team based on the inspection findings and consists of impressions or opinions formed by the team in five areas.

These opinions are generally very broad and difficult to address in detail.

They may have been formed from a particular perspective and do not necessarily reflect all the pertinent considerations at the time.

Some are based on incomplete information.

These concerns were discussed during a meeting at NRC Region III office in Glen Ellyn,_ Illinois on March 12, 1981.

Illinois Power Company's response to each of these concerns is included in the following sections. Where we differ with the position taken by the inspection team, we have attempted to explain the basis for the difference.

J. G. K:ppler App:ndix A Page 2 a.

" Weakness in the identification of root causes and the initiation of prompt and effective corrective action."

Summary (by NRC of their findings)

" Deficient Class lE electrical raceway hanger installation activities continued over a nine-month period with in-effective construction and engineering controls and inadequate QA involvement and enforcement of quality pro-gram requirements to bring timely co~rrective action. "

This finding involves the recognition of an overall problem during an early phase when subproblems arise which are not recognized as being relaced.

Problem recognition is not unique to nuclear power plant con-struction; it is common to most complex, multi-activity functions.

The example given on electrical hanger installation involves a complex activity.

Initial corrective actions (audit findings and CARS) were directed toward correcting specific deficiencies within the established electrical hanger installation system.

It was not obvious that the individual specific problems were indicative of a broader general problem.

The full extent and need for substantial revision of the entire system was not realized until it was determined to be reportable under 50.55(e).

In retrospect, it can be concluded that an earlier decision to revise the entire system could have been made.

This however, was not apparent as each successive level of corrective action was taken.

Based on evaluations made at this time, and the value judgements rendered by those involved, the corrective action proposed at each step was considered sufficient.

This experience emphasizes the difficulty in "seeing the forest when working on individual trees."

We believe that this form of problem recognition can be improved by better communications between the parties involved.

It has been Illinois Power Company's philosophy that the responsibility for quality lies with the organizations responsible for doing the work.

The quality assurance organizations (IP and BA) monitor this effort through audit and surveillance, including the identification of the development and/or evaluation of resolutions which will ensure compliance with established program and commitments.

These deficiencies are normally resolved without top management involvement; however, the lines of communication are maintained and problems which warrant such attention are reported to upper management.

To improve communications between the parties involved in evaluating and correcting findings and to enhance management participation, a system of periodic

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J. G. Kcppler App:ndix A Page 3 1

quality review meetings has been established.

These meetings will bring together quality, engineering and construction management and supervision from IP, BA and others such as S&L.and GE, as necessary, to>

evaluate and. coordinate quality activities in the work areas involved.

Concurrence with evaluation of quality i

problems and plans of action will be documented.

These periodic assessments will be supplemental to reporting and resolution methods currently employed, and will be conducted specifically to provide for early detection of lower-level problems, and prompt execution of pre-viously approved action plans.

i This interchange should improve communication and coordination of quality activities and enhance our capability to identify trends or other signals which indicate that broad corrective action is needed.

b.

"No controlled - and documented system has been fully and effectively implemented as'of February 27, 1981, to identify-the status of items as to their acceptability to procurement specification requirements.

i Summary (by NRC of their findings)

"Significant amounts of equipment has been accepted in violation of procurement specification documentation re-quirements, and released for installation without full knowledge of the status of required documentation or identification of the equipment as to its acceptability.

The Clinton plant quality. control and quality. assurance organizations and project management has allowed this situation to continue for two years and only recently had steps been taken to bring it under control."

Actions to improve the documentation receipt and accounting system have been in progress since inadequacies were first identified in 1978.

The first initiative was to develop new, more com-prehensive checklists, and verify status against documentation received.

This was a detailed, time-consuming effort and uncovered problems not originally foreseen.

Results of this effort indicated that engineering reports to support compliance to codes and standards imposed by equipment specifications could not be assessed adequately by the contractor.

These engineering. reports required extensive review by 1

the design engineer, and protrccted time for resolution of. comments and deficiencies.

At that time the decision was made to account for these engineering documents separately.

As described in detail in the response to the unresolved item on documentation (Appendix B to this letter), this appeared.to be consistent with NRC guidance on " documents which cannot be readily obs ined in a timely _ fashion."

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' Appendix A Page 4 Proper accounting for this documentation was always intended.

While the process of developing complete checklists for the engineering documents was time consuming, and some equipment was installed prior to receipt of engineering documentation, procedural controls to prevent use of any equipment lacking ade-quate documentation were instituted.

These included a requirement for the contractor to verify completion of both checklists (manufacturing and engineering) prior to turnover, and prior to final contract payment.

With these controls in effect, it was known that accurate documentation accountability 'could be achieved prior to any equipment being turned over for pre-operational testing.

Any documentation missing at the time of turnover will be contralled as part of the turnover control system.

Most of the engineering documents listed on the engineering document checklists are ASME Code related reports, environmental qualification reports, or seismic qualification reports.

Receipt of'ASME code related reports is proceeding satisfactorily.

Environmental qualification reports are all bein~g re-evaluated (and i

many being held by suppliers) due to the ramifications of NUREG-0588.

Many seismic qualification reports are being re-evaluated and some retesting performed j

due to MARK III containment new-loads effects.

Accordingly, the actual receipt of some documentation may be late, but will. be maintained under controlled ~

conditions.

" Weakness in the development of installation /QC inspection c.

plan and criteria and in the tLaeliness of effectiveness of QC inspections."

Summary (by NRC of their findings)

" Weaknesses in the " travelers" which detail installation and inspection requirement, have freq'tently been identified in QA audits and surveillances.

Improvements have resulted-from recent changes but further attention is needed as evidenced by thc team inepection~ findings.

Included should-be:

(a) strong action by QA/QC when hold points are bypassed, (b) assuring current requirements are. reflected in the travelers, if QCf (as recently requested by the manager) is removed from the review cycle for Field Change Requests (FCR's)

. and (c) closer review for establishing: inspection points so L

they occur in the proper sequence to assure design requirements lr are met."

Installation plans and.the associated QC inspection criteria are embodied in the installation travelers.and-the procedures which govern their. development and use.

Weaknesses noted during this inspection focused primarily i

'on the piping and component: support; traveler system.

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J. G. Koppler App:ndix A Page 5 Improvements to this system are currently in progress in response to noncompliance items 81-05-01, 81-05-02, and 81-05-03.

Details of these improvements are contained in the response to these items.

Other traveler systems such as welding, equipment installation, electrical hanger and raceway installation, concrete placement, earthwork, electrical cable pulling and cable termination are also being reviewed for possible improvement.

Except for the latter two, which have not yet

'oeen fully implemented, most of these traveler systems are considered adequate at this time.

For all traveler systems, and especially pipe hanger /-

component support, a critical assessment is being made of work package scope, and the integration of proper levels of QC inspection at appropriate intervals.

In come cases, scope of individual travelers will be reduced to permit inspection as discrete work elements are completed; while others will require in-progress inspection.

In all cases, the processing of each traveler and traveler modification (required for each FCR) will include QC review for establishment of inspection points.

Through QA surveillance or audit of these travelers, the completeness and detail of the inspection plans will be assessed against design criteria.

Both 6A and IP management have emphasized the importance of adhering to established HOLD points, d.

" Weakness in adherence to procedures, design requirement and PSAR commitments."

Summary (by NRC of their findings)

" Quality organization could be more effective with strenger emphasis and support by top management.

Throughout the inter-views and discussions, the prevailing attitude was getting the job done with inadequate concer' for QA/QC 'and job details.

QA/QC in their enforcement of p. cedures and other requirements must not be unduly swayed by arguments based on cost and schedule considerations.

Recent changes have resulted in improvements but further improvements are needed."

(1)

We believe that all information available was not re-viewed by the NRC inspection team.

An extensive PSAR Commitment Control Program is maintained in the NSED offices located in Decatur.

The computer program used to track CPS PSAR commitments was established in 1976.

The program lists all PSAR commitments, including Regulatory Guides, industry codes, and standards.

It is continuously used as a. management tool to provide respon-sible IP managers and supervisors guidance for reviewing CPS-related specifications and procedures.

Other docu-ments, such as a PSAR index to commitments and various special commitment summaries are also used.

.. J. G. Kepp'er Appcndix A Pege 6 3

The program description was revised and strengthened i

on June 23, 1978, to require positive feedback from internal IP organizations assigned responsibility for verifying that PSAR commitments were being implemented.

1 This program was again revised on February 23, 1980, j'

to require written verification from organizations out-side :IP that PSAR commitments were being met.

These verification letters are maintained on file, and in many cases, outline the detailed methods of compliance.

Status i

of this compliance program is reported monthly to IP's top management.

A condensed version of the program out-put is also reported monthly by the Company to the Illinois Commerce Commission.

The formal program description was net reviewed during the inspection.

We believe that the IP Commitment Control Program for CPS has been, and is currently, an effective management tool for monitoring PSAR commitments.

(2)

The requirement for vendors to have prior written j

authorization to ship with-Certificate of Compliances in i

lieu of all documentation, is contained in most CPS pro-i curement specifications.

This has proved to be an un-realistic requirement.

We have successfully demonstrated a new system of document accountability and. control.which I

assures that regulatory requirements are met for issuance j

of materials and equipment for installation or use at the site.

(3)

We disagree with the inspector's interpretation of Procedures BAP 2.20 and 2.3.

Equipment with missing

" engineering documents" is not placed in a conditional accept status, nor is this required by those procedures.

Consequently, we feel.that we are following these procedures to meet the purpose for which they were written.

e.

"Other Items" i

l Summary (by NRC of their findings)

" Management is not sufficiently involved in plant quality problems and has not fully utilized-QA as a management tool."

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This topic deals with the authority and involvement of the quality organizations within Illinois Power Company

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l and Baldwin Associates.

Particular emphasis was placed on discussion of identification and resolution of QA/QC problems.

A related subject involved the discussion of interaction between the quality organizations and the management of IP and BA.

i There was considerable discussion of the involvement of.IP QA in the development of departmental procedures in the Company.. Existing practices involve a QA review.

of these departmental procedures, but.does not require

t

...J.

G..Kappler Appendix A i

Page 7 I

QA approval.

This does not in any way diminish the

[

authority of QA since through their auditing programs, i

they review all departmental documents that relate ito s control of work and also audit conformance to those l

documents.

Therefore, Quality Assurance has the ability and authority to ensure that departmental procedures and

{

instructions conform to all applicable requirements as established by regulations, codes, standards, etc.

and to ensure that they are properly implemented.

Upon further evaluation, however, we have determined that this philosophy and practice would be better understood if IP departmental procedures were approved by IP QA and i

we will revise our procedures to include such documented review and concurrence.

Although this action will not change the principle or intent of our e::isting practices, i

it will make them clearer and more obvious to all parti-cipants.

The discussions relating to responsiveness of the total organizational structure to the findings of quality organizations reveal that this is a very complex process l

and that effective communications are necessary to ensure j

thorough understanding of the process.

We found, for example, that some corrective actions taken in response to a finding by a quality organization were not effectively communicated through the records system relating it to j

the finding.

In some instances, similar findings were reported several times in a series of audit reports 7

without reflecting the actions which had been taken to correct the reported conditions.

This quite logically creates the impression of unresponsiveness to the findings, even though very significant efforts had been made to attempt to correct the condition.

In some instances,

(

corrective actions were taken, but they were unsuccessful i

and, therefore, a similar problem was found in a subsequent audit.

The audit reports and related documents, however, do not adequately describea the actual sequence of events.

We believe that this situation can be improved by revising our communications to more clearly tie the corrective action to the audit findings.

We are evaluating various record and document control systems which will relate these communications in such a manner that the " entire story" will be available in one place.

This should make the quality audits more effective and should assist management in evaluating the responsiveness of all segments of the organization to the quality program.

These improve-ments should also simplify the task of the NRC in conducting their audits of the Clinton Proj ect.

Another item of discussion involved the role of Illinois Power Company upper management and their support of quality activities.

This is a difficult subject to place in per-spective because many of the activities of top management are not documented or recorded.

The influence of top management is,primarily exercised through discussion and

~

verbal direction.

In fact, it is generally expected-that

(

J. G. Koppler Appendix A Page 8 top management will work in this manner rather than writing letters of communications to people in the organization.

A determination of the interest and involvement of top management should include some measurement of accessibility of top management to the quality organization management and supervision.

Illinois Power Company top management has always had an "open-door" policy to QA/QC personnel.

This includes not only direct communication in accordance i

with the line organizational structure, but also across organizational lines.

For example, the Director - QA is in direct contact with the Executive Vice-President and Vice-Presidents as well as managers and supervisors in the total Clinton project organization.

Both the IP and BA quality organizations independently establish their audit programs and schedule, and do not require prior approval of a specific audit activity.

In other words, they are free to conduct formal audits or informal surveillances at any time to report the results directly to appropriate management levels without going through a line organization.

This independence of action and communication provides a very effective method of communication and exercise of authority.

Unfortunately, it does not always leave convenient " tracks" which lend themselves to audit or review.

To overcome this inherent deficiency, Illinois Power Company has relied heavily on j

independent reviews and audits by outside parties.

These audits are scheduled at the option and direction of top management.

They tend to focus on communication flow of information, management direction, and responsiveness to the quality objectives of the Company.

We believe that this combination of informal availability of top manage-ment to the quality organizations and the independent review of the effectiveness of the total quality enter-prise provides a good balance.

Another area which. generated considerable discussion involved the management role of the quality organizations.

As stated earlier, some problems in resolving quality findings were interpreted erroneously as a lack of l

responsiveness.

In addition, some lack of involvement l

by quality organization personnel was interpreted as i

lack of management involvement by QA and lack of manage-ment recognition of the role of QA.

We wish to emphasize that we consider QA an arm of management with the very specific responsibility of monitoring and verifying the i

quality aspects of the overall job.

We expect our quality organization to be aware of construction needs and to be responsive to those needs within the contraints of their primary responsibility.

This means that the quality organization should be aware of scheduling requirements 1

to ensure that QA does not unnecessarily delay construction work, but they must not permit scheduling considerations to affect the quality or completeness of their work.

A question was raised as to why the IP Supervisor of

=

J. G. Keppler Ascendix A s

Page 9 Construction Quality-Assurance did not participate in the weekly construction scheduling meetings.

As we indicated, he is permitted to participate in these meetings, but he is not required to do so.

He is aware o; the information to be discussed at the meeting and he is free to participate if he wishes.

On the other! hand, if he judges that the material is not of direct interest or importance to the quality organization, he is free to not attend.

We believe that this approach permits the quality organization to maintain the flexibility and freedom which is necessary to effectively carry out its responsibilities.

To require participation in construction and scheduling activities may generate undue concern about construction problems and to influence the planning and effectiveness of the quality organization.

We have tried to maintain maximum fr eedom of operation of our quality. organization; to permit freedom of choice by the organization as to where and what to audit and to conduct surveillances they see fit.

We do, of course, expect our quality organization to do their work in a timely fashion and to not unnecessarily delay construction work.

Finally, there was considerable discussion of timeliness of inspection and other quality-related activities on the Clinton proj ect.

In particular, the timeliness of inspec-tions relative to construction progress was emphasized.

Our evaluation of our current practices indicates that this matter interacts with many activities.

We expect to modify some of our procedures and practices to reduce the time span between the. performance of work and its inspection and acceptance.

This will require some modi-fication in the philosophy in developing travelers for the work and in " packaging" the work to permit interim inspection as well as final inspection of smaller work packages.

We believe that we can improve our overall system to reduce some of the timing intervals involved 4 -

and view this as an overall planning and scheduling-activity rather than simply a quality activity.

We expect to be making changes in both the construction and quality practices which will' reduce the tLme interval and reduce the volume of work which has not yet been accepted.

We will try to be realistic in making-these changes and to take into account the status of the work involved.

For example, approximately 80% of the large bore pipe has been erected and to backfit a different system at this time would undoubtedly be counterproductive.

In most cases, we will make modifications to the existing system, but not depart significantly from present practices.

In instances where little work is now in place, we may make more signi-ficant changes.

In addition, we expect to achie.a general improvement in this area by the simple mechanism of making the people in all organizations aware of the importance of

. performing inspections and establishing acceptance of work as soon as practicable after the work has been performed.

e Appendix B Additional Information on Items Regarding Unresolved Matter The following additional information is provided relative to the unresolved matter on the control of documentation and release of safety-related equipment for installation.

1.

Question:

"When will it be required to write an NCR for either insufficient or deficient docu-mentation prior to conditional release of i

hardware at the site?

The response should address both quality-related and engineering documentation required to satisfy procure-ment and specification requirements."

Answer:

Per BA's existing procedures, NCR's are required to be generated for items conditionally released to the field without acceptance of all manufacturing related documentation.

Engineering documentation is accepted through BA s documentation Per the requirements of BA' procedures.

s QA Manual an item is not final accepted until all documentation is received and acceptable.

2.

Question:

" Describe the criteria used to determine how one differentiates between quality-related documentation and engineering documentation.

Provide a representative list of engineering-type documentation."

Answer-The term " engineering documentation" as used at CPS is a general category of documentation 4

which is included in the generic term " quality-related documentation."

Engineering documentation typically includes design calculations, design criteria, drawings, specifications, stress reports, etc.

This usage is consistent with ANSI N45.2.9, Appendix A, which - in a general way - lists various types of quality assu*ance records or documents.

Section A.1 addresses design (engineering) recorus and includes - as examples -

calculations, design reports, stress reports, etc.

J.G. Keppler Appendix B Page 2 3.

Question:

" Describe in detail when and how S&L determines the required engineering documentation that must be received at the site and found accep-table by BA.

Pescribe the extent of an independent review and verification of the BA prepared engineering documentation lists prior to release.

Include in your description the extent the list is signed, dated and controlled to assure it can be properly tracked to maintain it current with hardware configuration and/or purchase order."

Answer:

Sargent & Lundy determines the_ documentation submittal requirements during the review of the draft copy of the specification.

These requirements are included in the specifications, in the S&L standard forms which are part of the specification (Examples :

S&L Forms 350, 1922, etc.) and in the Quality Assurance requirements section of the specification.

The Quality Assurance requirements section of the specification provides a generic preliminary list of documentation submittal requirements.

This list is reviewed by the Contractor during contract negotiations and is finalized as part of the contract.

After award of the contract, and in accordance with Sargent & Lundy's Project Instruction PI-CP-019 the specification responsible engineers prepare and forward to the Quality Control Division (QCD) a list of engineering documents expected to be submitted by the Contractor for each specification.

This list is entered into the." Engineering Documents List."

The list is updated and issued monthly.

The specification responsible engineers notify QCD of any corrections, additions or deletions to be made to the issued document.

The BA " Engineering Documentation Checklist" is prepared by the BA QA Procurement Engineer-and is reviewed against the S&L " Engineering Documents List.".Any conflicts are resolved and the checklist is dated, signed and forwarded with the original requisition for fu-ther review.

The checklist is returned to BA QA with typed purchase order for review and distribution for use in accounting for documentation received.

c Any modifications / changes to the checklist, including that resulting from change / amendments

J.G. Keppler Amendment B Page 3 to the purchase order after original pre-paration. dating and signing results in a revision being prepared in the same manner as the original.

4.

Question:

" Describe the involvement of the S&L QA or QC organization in the preparation of the engineering documentation list."

Answer:

Sargent & Lundy Quclity Control Division (QCD) organization's involvement in the preparation of the Engineering Documents List is described in Sargent & Lundy's Project Instruction PI-CP-019.

This involvement can be summarized as follows:

1.

QCD receives a list of the expected documents from the engineers ar m includes them in the list.

2.

QCD issues the list on a monthly basis.

3.

Any corrections / deletions / additions to the issued list are received from the engineers and incorporated in the next issued list.

4.

When documents are received at S&L from the contractor, they cre transmitted to QCD for distribution within S&L for review.

At this time, the list is revised to note receipt of the documents.

5.

QCD resolves with the engineer all comments generated during the review; then returns the results of the review to the contractor.

The list is then revised to note the data returned and the status.

6.

QCD is responsible for followup on any open comments until they are resolved.

5.

Question:

" Describe the extent the engineering documentation list delineates the specific engineering, technical, cnr. specification requirements which must be met and which must be substantiated by documentation at the site.

Describe the detail in which the received documentation must record engineering results in order to be found acceptable."

J.G. Keppler Appendix B Page 4 Answer:

Sargent & Lundy's Engineering Documents List is a tracking log which lists all specific engineering, technical and specification documents required.

The documents are iden-tified by tag numbers for each specification.

The specific requirements to be met and documented by the listed documents are not a part of the Engineering Documents List.

Determination of the adequacy of this documen-tation is the responsibility of the cognizant Sargent & Lundy design engir er.

6.

Question:

" Describe the controls which assure the engineering document list is properly prepared and released prior to conditional release of the hardware."

Answer:

The " Engineering Documentation Checklist" is prepared by BA QA upon the issuance of a requisition to purchase equipment to a specification.

The Engineering' Documentation Checklist is reviewed and finalized when the Purchase Order la issued to the vendor.

This action is controlled by' BQA 122, " Review of BA procedures BAP 2.20,

" Documentation Review; Requisitions and Purchase Orders;" and BQAI-120-1, " Instructions for Preparing and Processing Documentation Checklists" and occurs prior to the hardware arriving on-site.

7.

Question:

" Describe the procedural controls for main-taining control and acccuntability (punch list /

computer list) for incomplete or deficient documentation.

Include in your description the specific information the punch list and/or computer program contains.

Must the punch list and/or computer program identify incomplete or deficient engineering documentation prior to conditionc1 release of hardware?

Provide your rationale if it does not.

Describe tha controls to close out open items on the punch list and/or computer program in a timely manner."

Answer:

Basically, our system for maintaining control and accountability for incomplete or deficient documentation consists of two major parts:

(1) Manufacturing 6ocumentation, and (2) Design / engineering documentation.

J. G. Keppler Appendix B Page 5 1.

Manufacturing documentation.

Items received-on site with missing, incomplete, deficient or otherwise unacceptable manufacturing documentation can only be released to the field for installation under controlled and documented measures.

The items will be tagged with a " Conditional Accept" tag and the Receiving Inspection Report (RIR) will remain open until the required documentation is received and found acceptable.

Except for those cases where an Authorized Interim Letter of Compliat.ce is provided as temporary evidence of compliance (i.e., required documentation not available yet and as agreed upon in the procurement.

document), a nonconformance report (NCR) is generated to provide for engineering and

-quality review and authorization to release.

The BA QA generated manufacturing' Documenta _

tion Checklist, the RIR, and the NCR are all used to maintain control and accountability of this type documentation.

2.

Design / engineering documentation.

Design /

engineering documentation is not sent to the site by the supplier at the time'of shipment.

This documentation is sent directly to Sargent & Lundy - (S&L) for their. review and acceptance and may be accomplished prior to or after delivery.

of the item toLthe site.

Subsequent to S&L's review a copy of the accepted documen-tation is sent by S&L to the, site.

The BA QA generated Engineering Documentation Checklist is used to maintain control and accountability-of this type of documentation.

In addition, a computer file is generated from the documentation checklists.

As-the design / engineering documentation is-received onisite, the Engineering Documentation Checklist _and the computer file are updated.

Design / engineering documentation' is not required to be on ' site prior to releasing the item for installation.

Therefore,

" Conditional Accept" tags are not attached

.for this situation.

s'

J. G. Kcppler Appcndix B Page 6 This computer file provides an indispensable tool for fast reference on documentation status.

It can be sorted in any number of ways; equipment number, specification, i

all complete documentation, turnover package, system, area, etc.

The computer file is used to assist the engineers in preparing the Turnover Exception List.Baldwin Associates Procedure BAP 2.17, " System /Sub-system Turnover," outlines steps required in the preparation of turnover packages.

Included in it are provisions for listing missing documentation as exception items at the time of turnover.

Exception items are tracked on the Turnover Exception List, and are finally dispositioned upon evaluation of Illinois Power Company, Baldwin Associates, and Sargent and Lundy.

Missing items, hardware or software, when received on site after a system has been turned over to Illinois Power Company Startup, are identified by Baldwin Associates on a Construction Work Request.

This is forwarded to Illinois Power Startup Group who in turn issues the Construction Work Request to Baldwin Associates for action.

Once action is-complete, whether it involves installation of an item or update of checklists and computer files and transmittal of a documentation to the Document Records Center-(DRC), Baldwin Associates Quality Control will verify and document appropriate action to the Illinois Power Startup Group.

Illinois Power Startup Group then closes the item on the exception list.

The computer file is a tracking tool, a log of documents required and documents received.

Items listed as required, but not complete, are closed only upon receipt of acceptable documentation and subsequent notification by Baldwin Associate engineering that the documentation has been sent to the Document Records Center.

t

______m________

J. G. Keppler Apptndix B Page 7 8.

Question:

" Describe in detail the specific responsibilities of the BA QA organization when it receives the completed quality and engineering checklists.

Does BA QA evaluate the results of both lists to verify all required objectives have been met, and is BA QA required to sign and date the lists attesting to such?"

Answer:

BA QA reviews both checklists for accuracy and completeness.

This review assures the documentation requirements of the contract have been met.

BA QA stamps, initials, and dates each checklist and forwards them to the Document RecordssCenter.

9.

Question:

" Describe the planning for requiring BA and IPC to audit and survey this overall program on~ a regalarly scheduled basis."

Answer:

BA audits this activity, as other activities, in accordance with the BA QA Manual and BA QA Procedures.

This program is subject to IP QA audit as a part of the regularly scheduled audits of BA.

10.

Question:

" Describe the extent Mr. Ennen will evaluate the total program and conduct special surveillance i

to provide additional professional QA overview and input as to the workability and control-1 ability of this program."

Answer:

.The Quality Assurance department assigns personnel to various work assignments and surveillance activities based upon experience and the nature of activity.

This practice will continue.

Concerning surveillances regarding the documentation efforts, Quality Assurance will continue to review both the program and practices to ensure adequacy with regulatory requirements.

Various. personnel assignmen:s will be made to accomplish this objective in the future.

11.

Question:

" Describe the role of IPC top management in overseeing this overall effort to assure it is properly managed and effective.

How much will top management rely on QA in this regard."

Answer:

Quality Assurance will provide periodic reports to upper management regarding the progress and status of the documentation efforts.

These reports may be in the form of surveillance reports, audit reports, monthly QA reports, or-Quality Review meeting notes.

These reports will be reviewed by management and form a basis for keeping management advised as to the adequacy of company efforts in

J. G. Koppler Appendix B Pagn 8 meeting regulatory efforts.

Since IP upper management is dedicated to ensuring compliance with regulations and committed to codes and standards, action will be taken by appropriate levels of management for those identified issues which do not comply with our commitments.

12.

Question:

"Does S&L intend to revise their specification requirement for the use of a " Certificate of Compliance" in lieu of missing documertation?

If not, how will you comply with Paragraph 5.2.4 of BAP 2.20?"

Answer:

A field change request (FCR 9071) has been initiated to revise various Sargent and Lundy Specifications to clarify that shipment of equipment to the site will be allowed in cases where design /ecagineering documentation is not available.

However, a Certificate of Compliance will be required for manufacturing documentation that is lacking.

The requirements of Paragraph 5.2.4 of BAP 2.20 apply'to manufacturing / quality documentation only.

13.

Question:

"Will Paragraph 17.1.17.1 of the CPS PSAR be j

tevised?

If not, will Paragraph 17.1 of the i

CPS FSAR which states that Paragraph 17.'l of the PSAR was fully implemented be revised?"

Answer:

Illinois Power will ensure that the FSAR accurately reflects the QA program and practices.

If, after reviewing the PSAR Chapter 17.1.17.1, we consider that further clarification of interpretation is necesasry, we will amend the FSAR to better describe the essential points of our documentation efforts.

_ _ _ _ - _ _