ML20077N266

Responds to NRC Re Violations Noted in IE Insp Rept 50-341/83-07.Corrective Actions:Each Recipient of Controlled Design Documents Audited Periodically to Verify Currency of Latest Document

ML20077N266
Person / Time
Site:	Fermi
Issue date:	08/28/1983
From:	Wells D DETROIT EDISON CO.
To:	Spessard R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
Shared Package
ML20077N249	List: ML20077N266
References
EF2-64314, NUDOCS 8309130008
Download: ML20077N266 (12)

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Donald A. Wells ManagenOuath Assuance (313) 237'% 57 Edison in?n '22e August 28, 1983 EF2-64314 Mr. R.L. Spessard, Director Division of Engineering U.S. Nuclear Regulatory Ccmnission Region III 799 Roosevelt Road Glen Ellyn, Illinois 60137

Subject:

Nonccxrpliance at Enrico Fenni Unit 2 - IE Report 50-341/83-07

Dear Mr. Spessard:

This letter responds to the items of nonccrupliance described in your IE Report No. 50-341/83-07. This inspection of Enrico Fenni Unit 2

- construction site activities was perfonned by Messrs. P.A. Barrett, K.R. Naidu, R. Mendez, I. Ahned and B.H. Little on March 15-17, 24,

April 11-14, 18, 19 end May 3, 1983.

The itans of nonccxrpliance are discussed in this reply as required by Section 2.201 of the NRC's " Rules of Practice", Part 2, Title 10, Code of Federal Regulations.

The enclosed response is arranged to correspond to the sequence of items cited in the body.of your report. The number for the item of nonccxnpliance and the applicable criterion is referenced.

We trust this letter satisfactorily answers the concern raised in your report. If you have questions, please contact Mr. G.M. Trahey, Aesjstant Director - Project Quality Assurance.

Very truly yours, m ,

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DAW /WEM/pn cc: Mr. Richard DeYoung, Director Office of Inspection and Enforcement U.S. Nuclear Regulatory Ccmnission Washington, D.C. 20555 Mr. Paul Byron, Senior Resident Insptctor U.S. Nuclear Regulatory Ccmnission 6450 North Dixie Highway Newport, Michigan 48166 gCf3 k@

B309130008 830908 -

PDR ADOCK 05000341 G PDR

'Mr. R.L. Spessard, Director August 12, 1983 EF2-64314 Page Two bec: F.E. Agosti T.A. Alessi A. Alexiou C.R. Bacon W.F. Colbert W.M. Everett i W.J. Fahrner D. Ferencz E.P. Griffing

. C.M. Heidel W.R. Holland Institute of Nuclear Power Operations (INPO)

W.H. Jens R.S. Lenart E. Lusis P.A. Marquardt/ Docket File (2)

W.E. Miller, Jr.

E.H. Newton S.H. Noetzel 1J.W. Nunley R.A. Rateick W.L. Reid J.D. Ryan L.E. Schuerman D. Spiers G.M. Trahey R.A. Vance/L.E. Eix A.E. Wegele Site Document Control NRC Follow-Up Book /NRC File Chron File

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THE DEIROIT EDISON CatPANY PROJECT QUALITY ASSURANCE ENRICO FERMI 2 PROJECT Response to NRC Report No. 50-341/83-07 Docket No. 50-341 License No. CPPR-87 Inspection at: Fermi 2 Site, Newport, Michigan Inspection Conducted: March 15-17, 24, April 11-14, 18, 19 and May 3, 1983 APPROVED DATE 26 b Director - Project Quality Ashurande J

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Response to NRC Inspection Report No. 50-341/83-07 (83-07-01)

Statment of Noncmpliance, 83-07-01 10CFR50, Appendix B, Criterion XVIII states, in part, "A c mprehen-sive system of planned and periodic audits shall be carried out...to determine the effectiveness of the OA program. Followup action, including re-audit of deficient areas, shall be taken where indi-cated".

The Enrico Fenni Power Plant Unit 2 Quality Assurance Manual, Proce-dures Nos. 19.3.8 and 19.3.9, Revision 6 state, in part, " Audit results shall include, where appropriate, analysis of quality data to measure OA program effectiveness and indicate quality trends...

Cmpliance with corrective action requirments should be verified by re-audit if necessary".

Contrary to the above, as of January, 1983, Detroit Edison failed to take adequate followup action, including re-audit and/or significant surveillance of deficient areas within the design change distribu-tion program to determine the effectiveness of that program. Speci-fically, a June 1981, Detroit Edison audit identified that several contractors were not adequately distributing design changes, and significant followup action was not taken to determine if the pro-gram was effectively corrected.

Corrective Action Taken and Results Achieved Detroit Edison's Information Systems Organization has formed a group titled " Internal Quality Control Group of Information Systcas".

This group has instituted a program whereby each recipient of con-trolled design documents is audited on a periodic basis to verify the recipient has the latest design document, as well as, design change documents.

Project Quality Assurance's Construction Quality Assurance organiza-tion has undergone reorganization whereby an actual Corrective Action group has been formed. This group has primary responsibility for assuring that adequate followup actions are instituted to adverse audit findings.

Corrective Action Taken to Avoid Further Noncmpliance The Corrective Action group will initiate programs to assure that significant audit findings are closed satisfactorily. These signi-ficant audit findings will stay open until programs are in place, and it has been verified that corrective action is emplete.

The Date When Full Compliance will be Achieved The Corrective Action program will be in place by August 31, 1983.

Response to NRC Inspection Report No. 50-341/83-07 (83-07-03)

Statment of Noncanpliance, 83-07-03 10 Cat 50, Appendix B, Criterion V states, in part, " Activities affecting quality shall be prescribed by documented instructions, procedures or drawings...and shall be acccmplished in accordance with these instructions, procedures, or drawings".

Enrico Fermi, Unit 2, Project Procedures Manual, Part II, Proce-dures 3.20, Revision 4, Paragraph 5.6 and 3.21, Revision 4, Para-graph 5.7 require that the number of outstanding change papers (DCR, DCN, FMR, etc.) against any document do not exceed five.

Contrary to the above, as of February 5, 1983, the number of unin-corporated design changes were as follows:

. Specification 3071-31 had 60

. Specification 3071-33 had 23

. Specification 3071-128 had 18

. Drawing SE721N-0061A had 30

. Drawing SE721N-0061C had 28 Corrective Action Taken and Results Achieved The corrective action taken on those five (5) documents was to incorporate the outstanding (open) change documents identified in the NRC Report. However, issuing and incorporating change docu-ments is a dynamic activity and the number of change documents open against design documents fluctuates. Below is the status (as of August 4,1983) of each design A t v wnt identified in the NRC Inspection Report and the number of open change documents against them.

Document Revision Open Change Docurrents 3071-031 G 2 3071-033 0 $

• 3071-128-EA AE D 3071-128-EB AE 2 3071-128-ED AE 2 3071-128-EQ AE 1 3071-128-Er AE $

SE721N-0061A J $

SE721N-0061C J 3 4

2 As of August 4,1983, the number of OA Invel 1 design documents with five (5) or more open change documents has been reduced to forty-two (42) .

• Note: Refer to Corrective Action Taken to Avoid Further Nonccmpli-ance regarding specification 3071-128.

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Response to NRC Inspection Report No. 50-341/83-07

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_( 83-07-03) c Corrective Action Taken to Avoid Further Nonccupliance Project Engineering has made the following comnitment 'to control -i the number of unincorporated change <h'=nts against design docu-

- ments:

The number of M Ievel 1 design documents with five (5) or more change rh =nts open against then shall be one hundred fifty (150) or less.. The objective is that no design docu-ment shall have more than a total of five (5) change docu-ments open against it.

To meet the stated cmmitment, the following actions have been

taken:

. Change rh' = nt incorporation into design documents will be initiated when any drawing or specification accumulates

three (3) change papers against it.

I . Should any @ Level 1' design rh'=nt attain eight (8) or more outstanding - (open) changet <1 vm-nts against it, the design document shall be identified and the incorporation of all change documents shall be expedited. The director of project design will take appropriate action concerning  ;

4 design <h' = nts, including such action as issuing "Stop Work" directives,~until the change rh' = nts have been incorporated into the affected design document.

I- To implement these actions, two organizations have been formed to control and monitor the issuance and incorporation of change docu-

~ments into design th' _nts. These organizations are the Change

' Control Board and the Change Control Group.

The Change Control Board (CCB) is charged with the responsibility >

- to assure that all necessary measures are taken to control changes

! on the Fermi'2 Project. The OCB functions in the review and approval stage of the change document process prior to issuance of the change rh'=nt. -

Change documents are screened and released

- for engineering ar.d construction by the OCB. The Assistant Project l-

' > Manager - Engineering,-is' designated as chairman of the OCB, with i members from the various organizations assigned to the CCB. Pro-i ject Procedure 3.26 delineates the responsibilities and duties of ,

the CrB.

The Change Control Group (COG) is responsible for control of all changes starting with the issuance of the change document through the' incorporation of the change document into design documents.

'Ihe COG is responsible for identifying and monitoring all design

+ <h'=nts having outstanding (open) change documents. Further, the COG provides scheduling, expediting and documentation of status at all stages of the change process.

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Response to NRC Inspection Report No. 50-341/83-07 (83-07-03)

Corrective Action Taken to Avoid Further Noncompliance (cont'd)

In addition to the newly-fonned organizations, project specifica-tion 3071-128 has been divided into fifteen (15) major sections for ease of identifying and incorporating change ch'=nts. Change At v'=nts, when issued against this specification, must now iden-tify the particular section of the specification it was issued against. Further, the specification is now revised according to each section. This process allows construction and engineering to readily identify the change thm e nts of concern when utilizing the specification, allows more frequent revisions, and reduced the cost of revising the specification.

The Date When Full Canpliance will be Achieved Full canpliance has been achieved.

4 Response to NRC Inspection Report No. 50-341/83-07. (83-07-05a) ,

Statement of Noncompliance, 83-07-05a 10CFR50, Am=ndhe B, Criterion VI states, in part, " Measures shall

'be established to control the. issuance of documents, such as... draw-ings, including changes thereto, which prescribe all activities affecting quality. These measures shall assure that documents, including changes...are distributed to and used at the location where the prescribed activity is performed".

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The Enrico Fermi Power Plant, Unit 2,-Quality Assurance Manual, Pro-cedure No. 5, Revision 4 states, in part, " Written procedures siall ic . be implemented for receiving, identifying, filing...and reporting the. status of project <*v,=nts to assure such cbcuments are ade-quately controlled and to assure atv'ents, including changes, i thereto, prescribing activities affecting quality have.been... dis-l tributed and used at the work place where these activities are per-formed".

Contrary to the above:

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( a. As of April 13, 1983, appropriate instructions or procedures had

not been developed to assure that design changes muld be con-trolled and that such control would result in proper and timely updating of drawing copies at the location where the prescribed

{ activity is performed. Consequently, at Detroit Edison Start-Up l .and L.K.' Ccustock distribution points, lack of instructions

- resulted in twenty-four (24) and eighteen (18) design changes, respectively, which had not been marked (posted) on Drawing 6E721N-0010. Additionally, Field Modification Requests (FMRs)

S5552 and S5554' issued on March 4, 1983; Design Change Notice

(DCN) 8819 and Design Change Request (DCR) P12404 both issued en -

!- March 7, 1983, had not been posted on their respective drawings.

Further, numerous errors, discrepancies, and inconsistencies

. between the ARMS-PM04 listing, the master drawing copy in Docu-i ment Control, and with drawings . issued for construction in the

, field were noted (see Paragraph 4, of Inspection Report 50-341/

! 83-07).

i Corrective Action Taken and Results Achieved

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Each of the specific errors identified by the inspectors has been

! investigated and appropriately resolved.

Corrective Action Taken to Avoid Further Nonccupliance

1. Functional Modifications i

t An internal quality control function was implemented in early 1983. This group reviews the currency of design documents .

l-affected by change since the previous review, in each of the l several document control satellites on a monthly basis, and the

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Response to NRC Inspection Report No. 50-341/83-07 (83-07-05b)

Statement of Nonccrnpliance, 83-07-05b 10CFR50, Appendix B, Criterion VI states, in part, " Measures shall

'be established to control the issuance of documents, such as... draw-ings, including changes thereto, which prescribe all activities affecting quality. These measures shall assure that documents, including changes...are distributed to and used at the location where the prescribed activity is performed".

The Enrico Fermi Power Plant, Unit 2, Quality Assurance Manual, Pro-cedure No. 5, Revision 4 states, in part, " Written procedures shall be implemented for receiving, identifying, filing...and reporting the status of project documents to assure such <hm-nts are ade-quately controlled and to assure documents, including changes thereto, prescribing activities affecting quality have been... dis-tributed and used at the work place where these activities are per-formed".

Contrary to the above:

b. As of April 14, 1983, the licensee's th,wnt control measures failed to provide for incorporating design changes into control documents used in the performance of preoperational testing.

The control documents did not reflect the changes made, and the responsibility for incorporating changes was not defined for systems undergoing preoperational testing.

Corrective Action Taken and Results Achieved Paragraph Sa of the subject Inspection Report states that a hard-ware change, Design Change Request (DCR) .No. SB2336 Revision A, was implemented during preoperational testing of the Standby Liquid Control Systan (SICS), but that the change was not reflected in the Preoperational Test Procedure (C4100.001) or the Preoperational Reference Documents. The PREr.C4100.01 was not revised since the DCR No. SB2336 Revision A is for a test connection to support LIRT which is not a part of this PRET. The Startup Test Engineer requested that SOP 23.139 be revised to include the hardware changes implemented by Design Change Request (DCR) No. SB2336, Revision A.

As of April 14, 1983, all of the applicable design changes noted in deficiency finding Sa above have been incorporated into the System Operating Procedure (SOP) 23.139, " Standby Liquid Control System" with Tanporary Change Request No. T0149.

The nonconformance cited in 5b states, "No deficiencies were identi-fled with Reactor Recirculatica Systen. Design Change Notice (DCN)

No. 8200, issued Novenber 23, 1982, added ik inch " keep full" pip-ing, valves, and spool pieces to the Reactor Water Cleanup System (RWCS). The hardware change was ccxrpleted in March 1983, during preoperational testing of the RNCS. This DCN was noted on PRET

Response to NRC Inspection Report No. 50-341/83-07 (83-07-05a)

Corrective Action Taken to Avoid Further Nonempliance (cont'd) currency of "For Construction" design documents of all recipi-ents on a bi-monthly basis. As a result of this NRC inspection, this function has been modified to include a 100% review of all design documents in the satellites on a rotating (one per month) basis. Errors detected in any case are corrected as found.

2. Procedural and Training Modifications Plant Operations Manual 12.000.09, Revision 1, "Managment of Records", was issued April-5, 1983. The procedure defines the functions and responsibilities for the management of Fermi 2 records by the Records Center, Plant Technical Library, and Information Centers as defined in ANSI N45.2.9-1974, and ANSI N45.2.ll-1974, Sections 7 and 8.

Plant Operations Manual 12.000.40 " Management of Controlled Documents", was issued April 5, 1983. The procedure defines the functions and responsibilities for the management of controlled Fermi 2 documentation as defined in ANSI N45.2.9-1974, and ANSI N45.2.ll-1974, Sections 7 and 8, by Document Control.

These two procedures present a cmprehensive overview of the functions and responsibilities of Nuclear Administration -

Information Systes. They identify requirements, responsibili-ties, interfaces and guidelines for the activities described between Nuclear Administration - Information Systems, Document Control and other Nuclear Operations organizational units and Construction (when used with PPM Section 2 procedures) .

Information Syste s supervisors and work leaders have received classrom instruction on the procedures. The session was video taped and all personnel have viewed it. Further, all new per-sonnel cming into the Information Systes department and appli-cable contractor personnel will be trained on the application of these two procedures.

Lastly, Infcmation Systems Work Instruction ISWI 00.40.23,

" Document Control Satellites", issued June 27, 1983, describes the methods used to effectively process drawings and other related documents in the Document Control Satellites. All involved personnel will have been trained on this instruction by Septcaber 1,1983.

The Date When Full Cmpliance will be Achieved

,i Full c pliance will be achieved by Septaber 1, 1983.

Response to NRC Inspection Report No. 50-341/83-07 (83-07-05b)

Corrective Action Taken and Results Achieved (cont'd)

Reference Diagram 6M721-2046, but not in the referenced SOP 23.707 which is the document used for making system valve lineups." The valves in question are assigned to the Condensate Systen (P1100) and not the Reactor Water Cleanup System (G3300) .

As of July 5, 1983, all of the applicable design changes and any outstanding Tsuporary Change Requests have been incorporated into the Major Modification of SOP 23.707, " Reactor Water Cleanup".

Corrective Action Taken to Avoid Further Noncompliance The Startup Test Engineer is responsible for reviewing change docu-ments to assess their impact and assure incorporation into the pre-operational test, and for requesting that the change documents be incorporated in the SOP. This responsibility is documented in Startup Instructica 8.1.0.01, (Testing Progress Checklist, Revision 7), dated July 9,1983, and Startup Ietter 10,872, dated March 24, 1983.

The responsibility for revising SOPS lies with Nuclear Operations Department, however, Startup does subnit information and recamenda-ticas for revision.

Upon notification frun the responsible Startup Test Engineer, Nuclear Operations ensures that any reccmnendations for improvement and/or corrections to SOPS are given full consideration. Recan-mendations, if being offered on systems not yet undergoing pre-operational testing, can be forwarded to the Operations Engineer for processing. Any recarmendation, detailing a design change or equip-ment modification, directly impacting an SOP shall be incorporated in a timely manner. Procedural changes necessary to support a pre-operational test in progress will be handled prmptly by the on-duty Nuclear Shift Supervisor and the Startup Test Engineer per Plant Operating Manual, General Administrative Procedure 12.000.07. This procedure clearly defines Nuclear Operations responsibilities during preoperational testing prior to initial fuel loading. This proce-dure has been revised to cmply with NP-83-1073 and has been imple-men'md by Nuclear Product. ion personnel.

Nuclear Production matorandum NP-83-1073 dated July 1, 1983, states in part: "During the course of the field verification, if a change is required,in the Nuclear Production procedure used during preoper-ational test, the change can be made by pen and ink, noted and dated 1

by the Startup 'lbst Engineer, the Nuclear Shift Supervisor and, if safety related, by the Quality Assurance organization's representa-tive. The test may then continue".

"Upon canpletion of the preoperational test...the marked up master Nuclear Production procedure shall be subnitted as a Major Change

Response to NRC Inspection Report No. 50-341/83-07 (83-07-05b)

Corrective Action Taken to Avoid Further Nonccanpliance (cont'd) i request. The field copy used in preoperational test is maintained with the preoperational test package as a record of the testing activities."

The Date When Full Compliance will be Achieved The procedures discussed above are approved and in place. Full ccm-liance has been achieved.

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