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{{Adams
{{Adams
| number = ML20154R374
| number = ML20207C002
| issue date = 09/21/1988
| issue date = 07/25/1988
| title = Ack Receipt of 880727 Ltr Informing NRC of Steps Taken to Correct Violations Noted in Insp Rept 50-285/88-21
| title = Insp Rept 50-285/88-21 on 880627-0701.Violations Noted. Major Areas Inspected:Corrective Action Program
| author name = Callan L
| author name = Barnes I, Mcneill W
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
| addressee name = Morris K
| addressee name =  
| addressee affiliation = OMAHA PUBLIC POWER DISTRICT
| addressee affiliation =  
| docket = 05000285
| docket = 05000285
| license number =  
| license number =  
| contact person =  
| contact person =  
| document report number = NUDOCS 8810040237
| document report number = 50-285-88-21, NUDOCS 8808040385
| document type = CORRESPONDENCE-LETTERS, NRC TO UTILITY, OUTGOING CORRESPONDENCE
| package number = ML20207B993
| page count = 2
| document type = INSPECTION REPORT, NRC-GENERATED, INSPECTION REPORT, UTILITY, TEXT-INSPECTION & AUDIT & I&E CIRCULARS
| page count = 6
}}
}}


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=Text=
=Text=
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I APPENDIX B
. SEP 2 l 1988 In Reply Refer To:
  :U.S. NUCLEAR REGULATORY COMMISSION Region IV NRC-Inspection Report: _50-285/88-21 Operating License: DPR-40 Docket: 50-285 Licensee: Omaha Public-Power District (0 PPD)
Docket: 50-285/88-21 Omaha Public Power District ATTN: Kenneth J. Morris, Division Manager Nuclear Operations 1623 Harney Street Omaha, Nebraska 68102 Gentlemen:
1623 Harney Street Omaha, Nebraska 68102 Facility Name: Fort Calhoun Station (FCS)
Thank you for your letter numbered LIC-88-760, in response ~ to our letter and Notice of Violation dated July 27, 198 We have reviewed your reply and find it responsive to the concerns raised in our Notice of Violation. We will review the implementation of your corrective actions during a ^;ture inspection to determine that full compliance has been achieved and will be maintaine
Inspection At: FCS, Blair, Nebraska Inspection Conducted: June 27 through July 1, 1988 Inspector: 8<e    7- 2f-6'r
  /h W. M. McNeill, Reactor Engineer, Materials and Date Quality Programs Section, Division of Reactor Safety Approved: 8%    7-25-PP I. Barnes, Chief, Materials and Quality Programs Date Section, Division of Reactor Safety Inspection Summary Inspectior. Conducted June 27 through July 1, 1988 (50-285/88-21)
Areas Inspected: Routine, unannounced inspection of the corrective action progra Results: Within the area inspected, one violation was identified (failure to establish procedural controls in regard to conditional release of nonconforming items, paragraph 2).


Sincerely,
8808040385 880727 PDR ADOCK 050002G5 Q  PDC
'rigual ,
    , ,,
    .
a D. IQ L. J. Callan, Director Division of Reactor Projects CC:
Fort Calhoun Station ATTN: W. G. Gates, Manager P.O. Box 399 Fort Calhoun, Nebraska 68023 Harry H. Voigt. Es LeBoeuf. Lamb Leiby & MacRae 1333 New Hampshire Avenue, NW Washington, D. Nebraska Radiation Control Program Director RIV:MQPS M C:MQPS M S fd 0:DRP4 Ejl WMcNeill/cjg IBarnes JLN hoan LJCalltn 9/$ 4/88 7/w/88 9/J.0/88 i / 21 / 8 8 LO 8G10040237 880921    h \\
gaa noccxosoopgg5
      ,


_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .
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  (haha Public Power District -2-bec to DMB (IE01)
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bec distrib. by RIV:
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R.D. Martin, RA RPB-DRSS Section Chief (DRP/P) MIS System RIV File  DRP RSTS Operator  Project Engineer DRP/B Lisa Shea, RM/ALF P. Milano, NRR Project Manager W. McNeill I. Barnes DRS
 
          .
DETAILS Persons Contacted
b
  *C. Brunnert, Operations Quality Assurance (QA) Supervisor M. Butt, Human Performance Evaluation System Coordinator S. Clayton, Shift Technical Advisor
*J. Fisicaro, Nuclear Licensing and Regulatory Affairs Manager
*R. Jaworski, Station Engineering Manager
*J. Kecy, Reactor Engineer K. Miller, Maintenance Supervisor
*K. Morris, Nuclear Operations Division Manager
  *A. Richards, QA & Quality Control (QC) Manager B. Shubert, Shift Technical Advisor
  *C. Simmons, Onsite Licensing Engineer
  * Denotes personnel attending exit meetin The NRC inspector also contacted other personnel including administrative and clerical personne . Corrective Action (92720)
The objective of this inspection was to detennine whether the licensee has developed a comprehensive corrective action program to identify, follow, and correct safety-related problems. In this regard, the NRC inspector reviewed: (a) the QA program description found in Appendix A of the Updated Safety Analysis Report, Revision 4, dated July 1987; (b) QA Plan for Fort Calhoun Station, Unit No.1, Revision 12; and (c) the implementing procedures contained in the Attachment to this repor Operating Events The NRC inspector found that a program for reporting operational events was documented in station standing orders. Events are documented and prioritized; initial corrective actions are established, followed and reported as necessary to the NRC via the Licensee Event Reports (LERs). However, the program had been subject to significant changes, namely computerization of the infortnation, since the beginning of the yea The new computerized program was not yet described in procedure Based on a sample review of recent "Incident Reports," it was found that the computer coding of the reports was not consistent. It was difficult to relate reports of a similar characte For example, two recent reports on the inservice inspection (880107 and 880031) were found to be coded differently. The consideration of root cause analysis was not yet addressed in practice or procedures, but the licensee reportedly will do so at some time in the futur *
l .


i P
b. Internally Identified Problems The NRC inspector found that internally identified problems requiring corrective maintenance were identified and trended with other i
  --w . - - - _ . _ , , . -_ --, _ - , _ __ , _ . _ _- _ , _ _ ._ ____ __ ,_,
maintenance activities as part of the station performance indicator Yet this was recent, within the past several months, and was not defined in a program and procedures. The licensee in this area has identified in his planning documents that a comprehensive approach such as correlating corrective maintenance with LERs, QA surveillance findings, and other information will be undertaken. Generic consideration and root cause analysis has yet to be undertaken in this are The NRC inspector found that quality documents such as nonconfomance reports (NRs), deficiency reports (DRs), surveillance items (sis), and quality reports (QRs) were addressed in QA department procedures. Based on a review of recent quality trend reports, it was found by the NRC inspector that the licensee was using items which were identified on open or unresolved NRs. A total of six such NRs (i.e., NRs 86-01, 86-03, 86-54, 87-40, 87-67, and 87-75) were identifie The NRC inspector noted that the QA plan provided a
      -
"conditional release basis," but this process was not defined in QA department procedures. The absence of procedures in this area appears to have resulted in the following:
Technical justifications for use of nonconforming items were documented for each of the above NRs, but the justifications did not address that the releases were conditiona The lack of defined authority resulted in technical justifications originating from a variety of station staff (e.g., maintenance, station engineering, station manager, and nuclear production engineering).


.
Conflicting information was contained in the technical justifications such as the status of the engineering evaluation of the upper guide structure lift rig on NR 86-03 and the material composition of replacement Limitorque declutch shafts on NR 87-4 *
.'.
The status of equipment was not clear because the scope of hrs was changed to include additional items such as Valcor valve springs on NR 86-01 and charging pump gaskets on NR 87-7 The lack of procedural controls in regard to "conditional release" of nonconforming items was identified as an apparent violation (285/8821-01).
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  . . . _ . . . - _ _ . _. . _ . _ _ _ _ _
Om;ha Public Power District 1623 Harney Omaha. Nebraska 68102 2247 3[lKC)[h[lW/D 1 402/536 4000  - ,!


        '
Another observation of the NRC inspector was that, although quality problenis are trended in monthly reports to upper management, the effectiveness of these trend reports may be questionable. It was noted that the quality trend reports for the past year have consistently identified a problem with implementation of maintenance procedure =
          '
*
i SEP I ? te
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        . -- t LIC-88-760        - _ _
l U. S. Nuclear Regulatory Commission Attn: Document Control Desk      i Mail Station PI-137      l Washington, DC 20555      ;
i References: Docket No. 50-285 Letter from NRC (L. J. Callan) to OPPD (K. J. Morris) dated July 27, 1988 Gentlemen:
t SUBJECT: Response to Notice of Violation - NRC Inspection Report 50-285/88-21      l


Omaha Public Power District (OPPD) received the subject inspection report on corrective action programs. The report identified one violation on failure to
This was.also identified as a problem in a recent management review of FCS by Stone & Webster. The Stone & Webster report also cited the same sort of problem in the health physics area. The quality trend reports address this area but did not identify a similar proble c.- Externally Identified Problems NRC inspection findings were tracked in'the quality trending reports but this was not procedurally required to be performed. NRC reports such as Information Notices, Bulletins, Generic Letters, were addressed in corporate office procedures. The implementation of these procedures will have to be addressed in a corporate office' inspectio INP0 reports such as Significant Operating Experience Reports, and Significant Event Reports were addressed in site procedures. Based on a review of a sample of such reports, the identification and review of problems was found to be in conformance with procedure One observation by the NRC inspector was that the NRC and INP0 reports often cover the same subject and it was difficult to see how, when both NRC and INP0 addressed the same subject, the review activities would be coordinated between site and corporat Human Performance Evaluation System FCS has established a Human Performance Evaluation System program, but this has not been formalized in procedures. The program is based on INP0's "near miss" event concept. The only case addressed to date was reviewed. The NRC inspector noted that the program as drafted does not include subjects such as allegations or employee concern Summary This inspection identified that a basis for a comprehensive corrective action program was present at FCS; however, significant elements of the program were found to be in development (as part of a general improvement program) and were neither formalized in procedures nor fully implemented. Additional review of the program and its implementation will be performed during a subsequent inspectio . Exit Meeting The NRC inspector conducted an exit meeting on July 1,1988, with the licensee personnel denoted in paragraph 1. The NRC resident inspector also attended. At this meeting, the scope and findings of the inspection were summarize The licensee did not identify any of the information discussed at the exit as proprietary.
, establish procedural controls in regard to conditional release of nonconforming
; items. Please find attached OPPD's response to the Notice of Violation in
! accordance with 10 CFR Part 2.201. The submittal date of September 6, 1988 was
!
discussed between Mr. R. Mullikin of Region IV and Mr. J. J. Fisicaro of my    !
l staf l
          .
1 If you have any questions concerning this matter, please contact u I
          '
!
(


Sincerely,
b_
,
  /n .-
  // . /f N'
I k.J. Morris        !
l Division Manager l
Nuclear Operations      l
          !
KJM/mc        l Attachment        j c: LeBoeuf, Lamb, Leiby & MacRae      !
R. D. Martin, NRC Regional Administrator P. D. Milano, NRC Project Manager P. H. Harrell. NRC Senior Resident inspector TCh 'lb)
~ 2807/3 o f,
---  -_
    ~~g:mym
    - _ - _ _ - - -    --
t


  ---__  --_ _ _ - ___ __ ____ - - _ -_________ - _. ______
  ,~ .,. '
  .
  .
  *
ATTACHMENT
  .       ;
  ' Control of Nonconforming Items, QAM 7.4, Revision 0, dated September 1, 198 . Deficiency Control and Corrective Action, QAM 10.4, Revision 0, dated September 1, 198 . 10 CFR 21 Reporting of Defects and Noncompliance, QAM 10.5, Revision 2, dated January 12, 198 . Nonconformance Control, SO G-18, Revision 11, dated December 29, 198 . Re:eiving,. Shipping, Stores Control and Storage of Critical Element and Radioactive Material Packaging, Fire Protection Materials and Limited CQE, S0 G-22, Revision 27, dated March 14, 198 . Reporting of Defects and Non-Compliance to the Nuclear Regulatory Conunission, S0 G-42, Revision 7, dated December 22, 198 . Operating Experience Review, SO G-55, Revision 3, dated January 25, 198 . Procedures for Feedback of Operating Experience to Plant Staff, S0 0-39, Revision 4, dated September 24, 198 . Reportable Occurrences, S0 R-3, Revision 9, dated March 18, 1987, 1 Station Incident Reports, S0 R-4, Revision 14, dated November 6, 198 . Notification of Significant Events, S0 R-11, Revision 9, dated December 17, 198 . Control of Nonconforming Items and Materials, QADP-13, Revision 4, dated January 14, 198 . Deficiency Tracking and Trending, QADP-14, Revision 4, dated March 31, 198 .- Control of Deficiencies and Corrective Action, QADP-17, Revision 4, dated February 3, 198 . 10 CFR 21, Reporting of Defects and Noncompliance, QADP-19, Revision 4, dated May 2, 1988.
* -O' '
  .
r i
  ,   ATTACHMENT
        !
        '
!  During an NRC inspection conducted on June 27 through July 1,1988, a violation of NRC requirements was identified. The violation involved failure to estab-
, lish procedural controls in regard to conditional release of nonconforming  ,
!  items. In accordance with the "General Statement of Policy and Procedure for  '
i  NRC Enforcement Actions", 10 CFR Part 2, Appendix C (1988), the violation is  i
'
listed below:      l


l l  Criterion XV of Appendix B to 10 CFR Part 50 and the licensee's approved  j f  quality assurance program description requires that measures be established  '
; 16. Control of Deficiencies and Corrective Action, GSEP A-8, Revision , dated l February 198 . Regulatory Requirements Log, NPD G-2, Revision 1, dated December 31, 198 . Nuclear Production Division Action Log, NPD G-3, Revision 0, dated August 1, 198 . . ._ _ _ . _ _ _ _ ..- . _ . . _ . . . _ _ _ _ . _ . . . . _ . - _ - .
)  to control materials, parts, or components which do not conform to require-  l ments, in order to prevent their inadvertent use or installation. The Qual- l ity Assurance Plan for Fort Calhoun Station, Unit No. 1. Section 7.4, parat graph 4.2.3 provides for a "conditional release basis", for use of noncon- ;
  <
.1  forming items which can be corrected if a statement documenting the author-  [
y[,, _ . ,
 
  <-_
ity and technical justification is prepared. Paragraph 4.3.1 of the same  !
  -
        '
.
I plan also requires that procedures for the control of nonconforming items
    '2
;  shall be contained in the Quality Assurance Department Manua [
;  Contrary to the above, the Quality Assurance Department Manual procedures  !
: for control of nonconforming items did not address a "conditional release  '
j  basis" although the process was being implemented,    f i
 
j  This is a Severity Level IV Violation (Supplement I.D.) (285/8821-21)  l
.
.
 
:
        !
4- '19. ' Reporting and Corrective Action of Conditions Adverse to Quality, NPD QA-11, Revision 2, dated February 26, 1988, i-
OPPD RESPONSE      j l
  '2 Reporting of Defects and Noncompliance to the Nuclear Regulatory
I i
The Reason for the Violation if Admitted    l t
OPPD admits the violation as stated. As described in Section 7.4 of the Qual- !
l  ity Assurance Plan for Fort Calhoun Station, OPPD has the ability to provide a  !
;  "Conditional Release Basis" for nonconforming material. The procedures that  !
,
implement this provision center on nonconforming material at the point of re-  ,
1  ceipt inspection. Items that were in operation and then found to be nonconform-  !
ing are not addressed in the implementation procedures in sufficient detail,  i The corrective Steos Which Have Been Taken and the Results Achieved  ,
OPPD has admitted that this method is a procedurally inadequate control mechan-  i i  ism. Therefore, OPPD has retained a consultant to restructure the Fort Calhoun  !
Nonconformance Progra This project was initiated in July 1988. The major  ;
j)  elements of this program include revisions to Quality Assurance Department Pro- ;
, cedure QADP 13, Standing Orders G 18 and G-22, along with revisions to the QA  !
j  Plan,       j
        :
i
  '
Technical justifications for use of nonconforming items were documented to en-  !
!  sure safe plant operation. Although the justiff:ations are adequate, the cited  {
4  NRs are still open, pending long term follow up on these itens. This will en-  l sure proper corrective actions on the root causes are accomplished, and will  !
. ensure tracking until the revised procedure is in place and in use. QA Plan,  ;
;  Section 7.4, Rev. 1. now provides clear authority concerning who may perform  j
;  technical justifications,      j
!  Any new NRs initiated for items already in operation (e.g., not receipt inspec-  f j  tion identified) will remain open until the revised procedures are in plac }        l
 
1        !
        --
 
_ _ _ _ _ _ _ _ _ ____ _
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. *
, ,
. s .
  '
'
  ,
  ,
Aktachment(Continued)
Comission, NPD QA-12, Revision 1, dated May 5,198 i-f-1 s
'
The Corrective Stoos Which Will Be Taken I  Each of the six cited NRs will be closed as expeditiously as possible over the
,
next 90 days, i
!  OPPD is undertaking a general programmatic upgrade of procurement and storage practices for safety related material and services to bring them into compli-ance with currently accepted NRC and INPO criteria, and to maintain the prac-i tices and procedures at the required quality level on a continuing basis to
. support safe operation at Fort Calhoun Station. The improvement program will incorporate the following major elements of the restructured NR program: Revise Standing Order G-18 to include a separate dedicated section for pro-
,  cessing nonconformances for operational "Conditional Release Basis" mater-
;  tal.
 
l Ensure Standing Order G 18 still clearly addresses the control of noncon-


forming material discovered during receipt inspection.
F
: Establish a new vehicle for the resolution of minor or questionable receipt inspection discrepancie . Provide proper "flagging" that the NR is a "Conditional Release Basis" NR on both the revised form and in the technical justification used for re-leas . Provide administrative controls to limit the scope of an NR such that if additional concerns are identified at a later date, they will become the subject of a separate N . Provide clear authority as to who shall authorize the release of the mater-tal for us . Revise QADP 13 and Standing Order G 22 to include provisions for engineer-ing revie Date of Full Comoliance OPPD will be in full compilance by December 1. 198 .
        ,
        ;
}}
}}

Latest revision as of 16:17, 27 December 2020

Insp Rept 50-285/88-21 on 880627-0701.Violations Noted. Major Areas Inspected:Corrective Action Program
ML20207C002
Person / Time
Site: Fort Calhoun Omaha Public Power District icon.png
Issue date: 07/25/1988
From: Barnes I, Mcneill W
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:
Shared Package
ML20207B993 List:
References
50-285-88-21, NUDOCS 8808040385
Download: ML20207C002 (6)


Text

o s

  • *

. . .

l l

I APPENDIX B

U.S. NUCLEAR REGULATORY COMMISSION Region IV NRC-Inspection Report: _50-285/88-21 Operating License: DPR-40 Docket: 50-285 Licensee: Omaha Public-Power District (0 PPD)

1623 Harney Street Omaha, Nebraska 68102 Facility Name: Fort Calhoun Station (FCS)

Inspection At: FCS, Blair, Nebraska Inspection Conducted: June 27 through July 1, 1988 Inspector: 8<e 7- 2f-6'r

/h W. M. McNeill, Reactor Engineer, Materials and Date Quality Programs Section, Division of Reactor Safety Approved: 8% 7-25-PP I. Barnes, Chief, Materials and Quality Programs Date Section, Division of Reactor Safety Inspection Summary Inspectior. Conducted June 27 through July 1, 1988 (50-285/88-21)

Areas Inspected: Routine, unannounced inspection of the corrective action progra Results: Within the area inspected, one violation was identified (failure to establish procedural controls in regard to conditional release of nonconforming items, paragraph 2).

8808040385 880727 PDR ADOCK 050002G5 Q PDC

._

__m .

'

-

. .

.. .

DETAILS Persons Contacted

  • C. Brunnert, Operations Quality Assurance (QA) Supervisor M. Butt, Human Performance Evaluation System Coordinator S. Clayton, Shift Technical Advisor
  • J. Fisicaro, Nuclear Licensing and Regulatory Affairs Manager
  • R. Jaworski, Station Engineering Manager
  • J. Kecy, Reactor Engineer K. Miller, Maintenance Supervisor
  • K. Morris, Nuclear Operations Division Manager
  • A. Richards, QA & Quality Control (QC) Manager B. Shubert, Shift Technical Advisor
  • C. Simmons, Onsite Licensing Engineer
  • Denotes personnel attending exit meetin The NRC inspector also contacted other personnel including administrative and clerical personne . Corrective Action (92720)

The objective of this inspection was to detennine whether the licensee has developed a comprehensive corrective action program to identify, follow, and correct safety-related problems. In this regard, the NRC inspector reviewed: (a) the QA program description found in Appendix A of the Updated Safety Analysis Report, Revision 4, dated July 1987; (b) QA Plan for Fort Calhoun Station, Unit No.1, Revision 12; and (c) the implementing procedures contained in the Attachment to this repor Operating Events The NRC inspector found that a program for reporting operational events was documented in station standing orders. Events are documented and prioritized; initial corrective actions are established, followed and reported as necessary to the NRC via the Licensee Event Reports (LERs). However, the program had been subject to significant changes, namely computerization of the infortnation, since the beginning of the yea The new computerized program was not yet described in procedure Based on a sample review of recent "Incident Reports," it was found that the computer coding of the reports was not consistent. It was difficult to relate reports of a similar characte For example, two recent reports on the inservice inspection (880107 and 880031) were found to be coded differently. The consideration of root cause analysis was not yet addressed in practice or procedures, but the licensee reportedly will do so at some time in the futur *

l .

b. Internally Identified Problems The NRC inspector found that internally identified problems requiring corrective maintenance were identified and trended with other i

maintenance activities as part of the station performance indicator Yet this was recent, within the past several months, and was not defined in a program and procedures. The licensee in this area has identified in his planning documents that a comprehensive approach such as correlating corrective maintenance with LERs, QA surveillance findings, and other information will be undertaken. Generic consideration and root cause analysis has yet to be undertaken in this are The NRC inspector found that quality documents such as nonconfomance reports (NRs), deficiency reports (DRs), surveillance items (sis), and quality reports (QRs) were addressed in QA department procedures. Based on a review of recent quality trend reports, it was found by the NRC inspector that the licensee was using items which were identified on open or unresolved NRs. A total of six such NRs (i.e., NRs 86-01, 86-03, 86-54, 87-40, 87-67, and 87-75) were identifie The NRC inspector noted that the QA plan provided a

"conditional release basis," but this process was not defined in QA department procedures. The absence of procedures in this area appears to have resulted in the following:

Technical justifications for use of nonconforming items were documented for each of the above NRs, but the justifications did not address that the releases were conditiona The lack of defined authority resulted in technical justifications originating from a variety of station staff (e.g., maintenance, station engineering, station manager, and nuclear production engineering).

Conflicting information was contained in the technical justifications such as the status of the engineering evaluation of the upper guide structure lift rig on NR 86-03 and the material composition of replacement Limitorque declutch shafts on NR 87-4 *

The status of equipment was not clear because the scope of hrs was changed to include additional items such as Valcor valve springs on NR 86-01 and charging pump gaskets on NR 87-7 The lack of procedural controls in regard to "conditional release" of nonconforming items was identified as an apparent violation (285/8821-01).

Another observation of the NRC inspector was that, although quality problenis are trended in monthly reports to upper management, the effectiveness of these trend reports may be questionable. It was noted that the quality trend reports for the past year have consistently identified a problem with implementation of maintenance procedure =

,.y , .

This was.also identified as a problem in a recent management review of FCS by Stone & Webster. The Stone & Webster report also cited the same sort of problem in the health physics area. The quality trend reports address this area but did not identify a similar proble c.- Externally Identified Problems NRC inspection findings were tracked in'the quality trending reports but this was not procedurally required to be performed. NRC reports such as Information Notices, Bulletins, Generic Letters, were addressed in corporate office procedures. The implementation of these procedures will have to be addressed in a corporate office' inspectio INP0 reports such as Significant Operating Experience Reports, and Significant Event Reports were addressed in site procedures. Based on a review of a sample of such reports, the identification and review of problems was found to be in conformance with procedure One observation by the NRC inspector was that the NRC and INP0 reports often cover the same subject and it was difficult to see how, when both NRC and INP0 addressed the same subject, the review activities would be coordinated between site and corporat Human Performance Evaluation System FCS has established a Human Performance Evaluation System program, but this has not been formalized in procedures. The program is based on INP0's "near miss" event concept. The only case addressed to date was reviewed. The NRC inspector noted that the program as drafted does not include subjects such as allegations or employee concern Summary This inspection identified that a basis for a comprehensive corrective action program was present at FCS; however, significant elements of the program were found to be in development (as part of a general improvement program) and were neither formalized in procedures nor fully implemented. Additional review of the program and its implementation will be performed during a subsequent inspectio . Exit Meeting The NRC inspector conducted an exit meeting on July 1,1988, with the licensee personnel denoted in paragraph 1. The NRC resident inspector also attended. At this meeting, the scope and findings of the inspection were summarize The licensee did not identify any of the information discussed at the exit as proprietary.

b_

,~ .,. '

.

ATTACHMENT

' Control of Nonconforming Items, QAM 7.4, Revision 0, dated September 1, 198 . Deficiency Control and Corrective Action, QAM 10.4, Revision 0, dated September 1, 198 . 10 CFR 21 Reporting of Defects and Noncompliance, QAM 10.5, Revision 2, dated January 12, 198 . Nonconformance Control, SO G-18, Revision 11, dated December 29, 198 . Re:eiving,. Shipping, Stores Control and Storage of Critical Element and Radioactive Material Packaging, Fire Protection Materials and Limited CQE, S0 G-22, Revision 27, dated March 14, 198 . Reporting of Defects and Non-Compliance to the Nuclear Regulatory Conunission, S0 G-42, Revision 7, dated December 22, 198 . Operating Experience Review, SO G-55, Revision 3, dated January 25, 198 . Procedures for Feedback of Operating Experience to Plant Staff, S0 0-39, Revision 4, dated September 24, 198 . Reportable Occurrences, S0 R-3, Revision 9, dated March 18, 1987, 1 Station Incident Reports, S0 R-4, Revision 14, dated November 6, 198 . Notification of Significant Events, S0 R-11, Revision 9, dated December 17, 198 . Control of Nonconforming Items and Materials, QADP-13, Revision 4, dated January 14, 198 . Deficiency Tracking and Trending, QADP-14, Revision 4, dated March 31, 198 .- Control of Deficiencies and Corrective Action, QADP-17, Revision 4, dated February 3, 198 . 10 CFR 21, Reporting of Defects and Noncompliance, QADP-19, Revision 4, dated May 2, 1988.

16. Control of Deficiencies and Corrective Action, GSEP A-8, Revision , dated l February 198 . Regulatory Requirements Log, NPD G-2, Revision 1, dated December 31, 198 . Nuclear Production Division Action Log, NPD G-3, Revision 0, dated August 1, 198 . . ._ _ _ . _ _ _ _ ..- . _ . . _ . . . _ _ _ _ . _ . . . . _ . - _ - .

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<-_

-

.

'2

.

4- '19. ' Reporting and Corrective Action of Conditions Adverse to Quality, NPD QA-11, Revision 2, dated February 26, 1988, i-

'2 Reporting of Defects and Noncompliance to the Nuclear Regulatory

,

Comission, NPD QA-12, Revision 1, dated May 5,198 i-f-1 s

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