ML20141J956
ML20141J956 | |
Person / Time | |
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Site: | Wolf Creek |
Issue date: | 08/17/1997 |
From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
To: | |
Shared Package | |
ML20141J953 | List: |
References | |
50-482-97-13, NUDOCS 9708210435 | |
Download: ML20141J956 (16) | |
See also: IR 05000482/1997013
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EfLQ_1.OSURE
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U.S. NUCLEAR REGULATORY COMMISSION
REGION IV
Docket No.: 50-482
1.19ense No,: it?F 42
Hoport No.: 50 4812,97 13
Licentce; W'alf Creek Nuclear Operatine Corporation-
Facility: Wolf-Creek Generating S.ation
Location: 1550 Oxen Lane, NE
Burlington, Kansas '
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Detew: June 24 27, with in-office inspection continuing until July 8,1997-
Inspector: Lawrence E. Ellershaw, Reactor inspector, Maintenance Branch
Approved By: Dr. Dale A. Powers, Chief, Maintenance Branch
I '- !/ision of Reactor Safety
ATTACHMENT: Supplemental information
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9708210435 470317
PDR ADOCK 05000482
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EXECUTIVE SUMMARY
Wolf Creek Generating Station
NRC Inspection Report 50-482/97-13
This inspection consiste of a followup on licensee identified welding work control issues
by observation of welding and welding material control activities, and review of corre tive i
actions for adequacy and completeness.
Maintenanen
- Licensee personnel identified an apparent falsification of a field welding material
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requisition form (Section MB.1).
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Licensee personnel identified four examples of undocumented and unauthorized
work performed by the mechanical maintenance organization (Section M8.1.b).
Licensee personnel identified a lack of control over welding materials
(Section M8.1.b).
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The licensee's actions in response to each of the welding work control failures were
appropriate (Section M8.1.b).
The licensee implemented a thorough training plan to assure that the identified
welding work control f ailures would not recur (Section M8.1.b).
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REPORT DETAlLE
- Eymmarv of Plant Status
The plant operated at 100 percent power throughout the inspection period.
11. Maintenance !
M8 Miscellaneous Maintenance issues
M8.1 Followuo on Weldina lesues (55050)
During December 1996, the licensee terminated a mechanical maintenance welder 4
for apparently falsifying a field welding material requisition slip. On December 13,
,_ 1996, licensee personnel Initiated Performance improvement Request 96 3277 to
[ document, evaluate, and implement corrective actions to minimize the potential for
recurrence. Licensee personnel also notified the NRC of the incident.
-The licensee's investigation determined that uron completion of his assigned work, >
the welder attempted to return unused weld filler material to the weld rod room
attendant. The welder, however, had apparently lost his copy of the field welding
material requisition slip. He obtained and completed a new weld filler material
requisition form, and apparontly signed the welding engineer's name to the approval
block on the form, He then used the falsified requisition form to return the unused
weld filler material to the weld rod room attendant. The attendant noted that the
welding engineer's approval signature was different from the way it was normally
signed. The attendant contacted a welding engineering department supervisor, who
took the slip to the welding engineer who had purportedly signed it.- The welding
engineer determined that the signature was not his. Subsequently, the welder's
ernployment at the Wolf Creek Generating Station was terminated.
The inspector noted during review of Section 4.2 in Procedure FMC 1, " Filler
Material Control," Revision 6, that the welding engineer is responsible for verifying
that the welder is qualified to weld to the welding procedure specification listed on
- the field welding material requisition and the applicable weld data sheet prior to
authorizing issuance of weld filler material. Section 5.5 states that a welder shall
return unused weld filler materials, containers, and the welder's copy of the field
- welding material requisition form to the point of issue.
This licensee-identified issue of an apparently falsified field welding material
requisition form, and the welder's failure to return his copy of the requisition to the
point of issue, is an unresolved item pending further NRC review (50-482/9713-01).
As part of the Performance impronment Request 96 3277 evaluation, a review of
field welding material requisition slip's for the previous 2 years was undertaken to
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determine if other improprieties had occurred. The reviewers de' ermined that this l
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was an isolated case, and that there was no evidence to suggest that the welding
l material control program was not effective. Thus, Performance improvement
Request 96 3277 was closed on January 2,1997, i
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However, during the licensee's investigation, additional welding program / work
control concerns were identified, including:
- Failure to control welding filler material
Performance of unauthorized and undocumented work activities
Conduct of non licensee work in the mechanical maintenance welding shop
These concerns prompted the licensea to initiate a self assessment effort to further
evaluate the adequacy of the implementation of the welding program and associated
work activities. A self assessment team was created and on January 28,1997,
Self Assessment Plan SEL 97-003, " Welding and Associated Work Controls," was
approved for their activities. On February 13,1997, during the self assessment
team interviews with welding personnel, it was learned that unauthorized and
undocumented work had been performed on safety related equipment (i.e., weld
repair to a normal charging pump room pipe support base plate, and grinding of
vendor supplied welds on essential service water piping). The self assessment team
identified a total of eight issues of concern.
At that time, the plant manager instituted an iremediate stop of alllicensee
employee welding activities. Additionally, alllicensee issued welder
certifications were revoked. This included licensee employed welders and
contractor welders. Based on the new information, the licensee formed incident
Investigation Team 97-01 to investigate the welding issues developed by the self-
assessment team. The incident investigation team was chartered to investigate,
determine the root cause, and recommend corrective actions. During the incident
investigation team's effort, an additional three issues of concern were identified.
Therefore, the licensee's investigative efforts developed a total of 11 issues of
concern from all sources. The licensee initiated performance improvement requests
to investigate and evaluate all of the identified issues for technical and safety
concerns. The licensee's investigation and evaluation effort determined that there
was some degree of validity for 8 of the 11 issues of concern,
a. insocction Scone
The scope of this inspection was to evaluate each of the issues of concern to
assure that technical or safety concerns did not exist, and to determine whether
licensee corrective actions were comprehensive and appropriate.
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Further, tne inspector reviewed the following procedures:
- AP 29F 002, " Control of Welding Operations," Revision 2
- CWD 1, " Control of Welding Documentation," Revision 6
- AP 16-001, " Control of Maintenance," Revision 1
, The inspector also reviewed all of the applicable performance improvement requests
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l In addition, the inspector observed shielded metal arc welding. The welding l
l was performad on the third stage extraction to heater piping (Group PSA
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material, Line AC-005 GAD 16) that was being fabricated under Work
Package WPT 118876 1. The alloy piping was being fabricated to replace
carbon steel piping that had been degraded by flow accelerated erosion.
Tha inspector also observed and evaluated welding filler material control (i.e.,
storage, identification, issuance, welder's control, and return to storage).
b. Observations and Findinns
Each of the licensee validated eight issues of concern documented in the
performance improvement requests is discussed below. The inspector determined
that the licensee's actions in followup to these issues of concern were appropriate.
b.1 Performance Imorovement Reauest 97-0453: Initiated on February 13,1997, to
address a welding issue in which a welder may have performed a weld fitup and
seat weld while water was weeping from a valve's weld joint. This activity was
scheduled to have been performed on March 23,1996, during Refueling Outage
Vill.
During the licensee's investigation of this matter, no definitive substantiation could
be reached. However, the licensee investigators were able to determine that the
weld had not been made under the described conditions that resulted in the
initiation of the performance improvement request. Documentation existed which
showed that a task had been developed to disassemble the valve, evacuate the
water, and clean it to f acilitate making the seal weld, and records showed that the
seal weld was made on March 24,1996, and was accepted by a quality control
inspector.
Subsequent to completion of the weld, the valve was tested and it was found that
the valve would not seat. The valve was cut out of the line and replaced with a
new valve that was tested and accepted.
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b.2 Performance Imorovement Reouest 97-0454: Initiated on February 13,1997, to
address an issue where a nonsafety related conduit support in the turbine building
had been shortened with a band saw without appropriate work authorization. This
activity occurred during October 1995.
The support had been shortened to facilitate freeing a suspended rigging load that
had become hung up on the support. The workers considered this to be a
personnel safety threat and they acted on their own initiative to eliminate the threat.
Later, the workers notified their supervisor. The supervisor requested that the
j support be inspected and evaluated against the design specification. It was
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determined that !be support was acceptable and met design specification criteria.
Neither the workers nor the supervisor initiated a performance improvement request.
While this work was nonsafety related, it was an example of personnel working
outside the scope of their authorized work activity,
b.3 Performance Imnrovement Reauest 97-0469: Initiated on February 13,1997, to
address vendor installed welds that had been altered (ground) without authorization
or documentation. These welds were on a safety related essential service water
J system elbow on the Train A component cooling water room cooler, it was
identified that a welder had been instructed to grind the weld crowns to avoid
interference with an existing box support. This incident occurred on March 28,
1996, during Refueling Outage Vill.
The interference resulted from implementing a design change package. The
package required the f abrication of a new spool piece, removal of the existing pipe,
and installation of the new pipe spool piece. The large weld crowns created an
interference (i.e., the pipe would not pass through the support) with the box
support.
Licensee personnel, upon learning of this issue, immediately initiated actions to
identify the specific welds that had been altered. The shift supervisor declared
Train A of the component cooling water system inoperable and entered the 72-hour
limiting condition for operation. Licensee personnel located and identified the
specific wolds, and performed magnetic particle and ultrasonic examinations on
them. The examined welds were accepted (there were no surface indications and
the design-specified minimum wall thicknesses had not been violated). The limiting
condition for operation was exited and the Train A component cooling water system
was declared operable,
Section 5.7 in Procedere AP 16C-002, states,in part, that work group supervisors
are responsible for:
Ensuring the shop / field work is performed in accordance with the
requirements of the work package task and applicable procedures.
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Section 5.9 states, in part, that workers are responsible for:
- Ensuring the work is performed in accordance with the requirements of the
work package task and applicable procedures.
- Notifying the supervisor if work cannot be performed in accordance with the
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which change the scope of the work to be performed.
- Documenting in the work completion / history sections c the task package:
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i Summary of work performed (as found condition, corrective action, as left
j condition, parts used, man-hours, etc.).
The licensee's investigation revealed that there was no documentation showing that
grinding of the welds was authorized or performed.
This issue of unauthorized and undocumented work is an .nr tolved item pending
further NRC review (50 482/9713-02).
b.4 Performance Imorovement Reauest 97-0470: Initiated on February 13,1997,to
address an anauthorized base metal weld repair (plug weld). The repair had been
made on a safety related normal charging pump pipe support baseplate. The
support was identified as one of six within the normal charging pump suction and
discharge isolation boundaries.
Licensee personnel determined that an unauthorized and undocumented plug weld
had been performed around August 29,1996, to repair a mis-drilled baseplate hole.
The hole had been drilled during a modification to the normal charging pump.
Licensee personnel learned that a welder had made a series of mistakes with the
support baseplate, and that he performed weld repairs to the baseplate without
revising or creating new documentation to reflect the weld repair.
Licensee personnel remcved paint and examined each of the six support baseplates
within the normal charging pump suction and discharge isolation boundaries using
an acid etch. They identified weld filler material on one of the support baseplates
(BG01-H012/112(Q)) located on the discharge side of the pump. Examination of
the repair showed that it was structurally sound and exhibited good workmanship.
On March 14,1997, design engineering provided a "use-as-is" disposition for the
unauthorized and undocumented condition.
This issue of unauthorized and undocumented work is a secor.d example of an
unresol'ed item pending further NRC review (50-482/9713-02).
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b.5 brformance Imorovement Reauest 97-0481: Initiated on February 14,1997, to
address the concern that field welding material requisitions had been pre signed by I
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During the licensee investigators' interviews, it was learned that a welding
supervisor may have improperly pre-signed approximately 10 field welding material
requisitions for use on a day that the supervisor was not going to be at work. The
j pre signing was apparently done to facilitate welding activities scheduled to be
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performed on nonsafety related chiller equipment.
Licensee personnel investigated this issue and identified 5 field welding material
requisitions, dated May 28,1996, that were signed by the welding supervisor,
f They appeared to have been dated by the lead welder (determined by apparent
differences in handwriting and date writing style). Licenseo security records
showed that the welding supervisor passed through security at 6:05 a.m. on
May 28,1996. This was just 3 minutes before the first apparently presigned
requisition was used.
The licensee's investigation established that the welding supervisor denied signing
blank field welding material requisitions. The licensee's investigation confirmed that
the supervisor and lead welder were both at work on the date of the subject work
performance, and the style of the written date on the five requisition forms was
different from that normally used by the supervisor.
Licenseo personnel evaluated the five field welding material requisitions and verified
that the specified welding material was appropriate for the job description annotated
on each requisition. No adverse conditions to plant systems or components were
ic'intified. Additional ly, licensee personnel found no similar anomalies with respect
to field welding material requisitions.
Procedure FMC 1, Section 5.4.1, Revision 6, states that the welding engineer (or
authorized designee) shall authorire the issue of filler material only to qualified
welders, by approving the field welding material requisition form. While the
procedure does not specifically prohibit pre signing a requisition form, signing a
blank requisition form would not provide the level of control intended by the
procedure. Such advance signing would preclude assuring that appropriate filler
material would be issued only to a qualified welder for a specified job,
b.6 brformance Imorovement Reouest 97 0481: Initiated on February 14,1997, to
address unauthorized and undocumented work (cutting, moving, and rewelding a
welded beam attachment) during modification to the nonsafety related auxiliary
boiler system piping.
During the initial self assessment team interviews, licensee personnel learned that a
welder had cut, moved, and rewelded a welded beam attachment. The welded
beam attachment was identified as being part of a pipe support for a 2-inch drain
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line on the auxiliary boiler. The incident Investigation Team conducted a field
verification and confirmed that the welded beam attachrr.ent had been cut, moved,
and rewelded. The licensee's engineering organization performed an evaluation and
determined that the new welds and location of the attachment were within design
limits and were subsequently dispositioned acceptable.
While this work was nonsafety related, it was another example of personnel
working outside the scope of their authorized work activity.
h.7 Performance Improvement Renuest 97 0652: Initiated on February 28,1997, to
, address the discovery of unattended weld filler material found in the weld shop
area.
The licensee's investigation determined that the material may have besn
inadvertently left on a welder's work table upon completion of a welding job in
which the same weld filler material had been used. The welder's stub bucket,
containing used weld rod, had been returned to the weld materialissue room. It
appeared however, that two pieces of ER 309L weld rod did not get placed in the
stub bucket.
Licensee personnel conducted a search on the next day of the weld shop area. The
search located several pieces of filler material, most of which were minor pieces,
some of which had been fashioned into various simple tools or shop aids (i.e.,
hooks, spacers, etc.). Licensee personnel considered this to be insignificant even
though it was characterized as improper use of weld filler material. Additional
information traelved by the welding supervisor prompted a more thorough search on
March 3,1997. This search located 3 pieces of stainless weld rod and 10 pieces of
E7018 covered electrodes.
Section 4.4 in Procedure FMC-1 states that the welder is responsible for controlling
the materials issued, and for returning unused materials, containers, and the field
welding material requisition form to the point of issue. Section 5.4.11 states that
filler material stubs and damaged filler material shall be placed in stub buckets by
the welder. The stub buckets shall be returned daily to the rod room where the
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filler material was issued. Any coated electrodes that the welder removes from
portable rod warmers or exposes to the atmosphere in excess of the maximum
allowed times shall be returned in the stub bucket and scrapped.
This issue of not returning weld filler material upon completion of the welding
activity is an unresolved item pending further NRC review (50-482/9713-03),
b.8 Performance Imorovement Reauest 97 0739: Initiated on March 7,1997, to
address the identification of an undocuenented weld repair (plug welds) to a
nonsafety related plate of the stator water cooling system that had been mis-orilled.
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This occurred during a modification (Design Change Package 07091) to the stator
water cooling system, in which a 16-inch x 16 inch x 3/8-inch plate _was required to
be drilled for attachment to an existing support. _ The plate was used for supporting
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a pressure regulator and - flow meter.- Apparently during fabrication in the weld
shop, the holes were incorrectly drilled.
Licensee personnel confirmed that two plue welds had been made in the plate
without proper authorization and documentation. Tne licensee's engineering
organization evaluated the plate and determined that the stator water cooling
system was operable, but the' plate should be replaced at a later date to be
scheduled by the integrated Planning and Scheduling group.
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While this work was nonsafety-related, it was another example of personnel
working outside the scope of their authorized work activity,
b.9 Licensee Identified Root Causes
Licensee personnel used change and STORM (Stimulus Team Operation Response
and Management) analyses as the_ major techniques to identify the root cause and
contributing causes of the welding problems. These analyses, and the corrective
actions, were addressed in Performance Improvement Request 97-0481. The
licensee also used a consultant from Performance improvement International to-
assist in developing the causes using the Performance improvement International
process.
l Briefly, the contributing causes were identified as follows:
- Ineffective changing work scope management, (i.e., there had been an
elimination of contractor welding personnel during 1995, without providing ;
appropriate training to licensee welders who were now tasked to perform
work previousiv performed by contractors)-
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- Pressures brought on by greatly emphasized adherence to schedule that
caused workers to take short cuts
- Less than adequate communications _and reporting of problems within the
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mechanical maintenance organization
- Work processes were determined to be burdensome and cumbersome
- - Supervision of maintenance welding field activities was less than adequate
The root cause was determined to be a willingness on the part of the welding
personnel to perform work outside the scope of the work control process. The
reasons for this attitude were not conclusively established; however, less than
adequate supervision was considered a key element.
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I b.10 Corrective Actions '
Besides making immediate evaluations for each of the identified failures, licensee
personnel reviewed all performance improvement requests for the preceding
2 years. Additionally, they evaluated quality engineering audits, surveillances, plant
evaluations, and self assessments, and determined that these conditions (i.e.,
performance of unauthorized and undocumented work, and a failure to follow
established program / procedure requirements), were limited to the mechanical
maintenance organization.
Licensee personnel also performed a sample inspection of safety and nonsafety-
related equipment that the welding group had worked on between January 1995
and February 1997. A plant walk down was conducted on March 18,1997, during
which a sample of 110 work package tasks (i.e., component installation or
modifications) performed by welding personnel were inspected and compared with
the actual documentation packages. The walkdown teams found no evidence of -
undocumented or unauthorized work activities.
The licensee established three action items specifically related to the welding / work
control failures. Action item 1 pertained to disciplinary action and was not
reviewed by the inspector. Action item 2 pertained to whether proper training had
been provided to the mechanical maintenance organization for installation and
modification work that had previously been performed by contractor personnel.
Action item 3 pertained to the work philosophy and dealt with reinforcement of
management expectations regarding procedural complia. ice, problem identification
and solving, quality and production performance of day-to-day work activities,
communications regarding problems or concerns, and safety priorities.
Action items 2 and 3 were addressed by the establishment of a weld recovery plan.
The plan was a comprehensive training program designed to assure that all i
personnel associated with welding activities (contractor and licensee) received
appropriate technical and general work-related training. This included welding
engineers, planners, fitters, firewatch personnel, and welders. With the exception
of welder qualifications, most of the training was designed to be follow-on or
enhancement to existing training. Nearly all of the scheduled training had been
completed by the end of the onsite portion of this inspection.
In addition, field welding oversight was being performed on a daily basis and was
intended to be continued through Refueling Outage IX (near the end of 1997).
This was being accomplished with the use of a comprehensive document called a
" Welding Oversight Checklist," Revision 1. Further, a self assessment of the weld
program was scheduled to be performed and completed by November 8,1997, with
a report issued by November 15,1997.
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Additional actions were established under Performence improvement
Requests 97-1385, -1386, -1387, and -1388. Each of these dealt with evaluation
- and possible improvement to programs / processes; work control process; welding
engineering dispositions; process indicators and problem reporting reinforcement;
and work schedule process. Performance Improvement Request 97-1388, " Work
Scheduling Process," was completed on June 10,1997; however, the other three
were not scheduled for completion untillater during 1997 and 1998.
b.11 Observation of Weldino and Tour of Storaae Area
The inspector observed shielded metal arc welding performed by two licensee
welders, both of whom were documented in the current welder qualification log as
qualified to perform the shielded metal arc welding process. The welding was
performed on chrome-molybdenum alloy replacement piping for third-stage
extraction to Heaters 7A and 78 piping under Work Package WPT 118876-1. The
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package designated use of Welding Procedure Specification 1-0105T02, Revision 0, i
The inspector verified that the welders used the welding procedure specification and
that electrical characteristics, preheat maintenance, and travel speed were complied
with. The inspector also verified that each welder had a copy of the field welding
, material requisition slips for the issued welding material. The inspector also noted
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that the E901883 welding electrodes were properly maintained in a portable,
heated, caddy.
The inspector also toured the welding material storage and issue room. All holding
ovens were appropriately identified and maintained at the proper temperature range.
The inspector verified that the weld rods inside each oven corresponded to the weld
rod identification noted on the ovens. The tool room attendants had current copies '
of the filler material control procedure, a list of qualified welders, and the authorized
signature list, which identified those personnel who could authorize the issuance of
welding material. The inspector also verified that the field welding material
requisition slips were properly completed, and that those associated with the two
welders previously observed, matched those in the welders' possession.
c. Conclusions
The licensee had taken the appropriate steps to reconcile and correct the identified
welding work control failures.
Observation of in-process welding and the control of welding materials revealed that
the observed personnel were properly performing their assigned work activities (i.e.,
welding was performed by qualified welders in accordance with the welding
procedure specification, and welding material was properly controlled).
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V. Manaaement Meetinas
X1 - Exit Meeting Summary
,The inspector presented the inspection results to members of licensee management
at the_ conclusion of the onsite portion of the inspection on June 27,1997. The
licensee personnel' acknowledged the findings presented.
On July 8 and August'12,1997, supplemental exits were held via telephone with
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Mr. C. Reekie and Ms. C. Redding, respectively. l The purpose of the first followup -
was to inform the licensee of a change to information provided at the onsite exit.
At the onsite exit, two of the findings were characterized as potential violations.
After in office review of additio al information, these items were reclassified as -
unresolved items pending further NRC review. The purpose of the second followup
was to inform the licensee of the identification of a third unresolved item pending
further NRC review.
The inspector asked the licensee personnel whether any materials examined during~
the inspection should be considered proprietary. No proprietary information was--
identified.
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ATTACHMENT
SUPPLEMENTAL INFORMATION
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. PARTIAL LIST OF PERSONS CONTACTED '
Licensee
B. Bergstrom, Supervisor, Maintenance
-- G. Boyer, Chief Administrative _ Officer
. B. Dale, Supervisor,- Maintenance-
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R. Denton, Quality Assurance Specialist
C. Fowler, Manager, Integrated Plant Scheduling
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D. Gillespie, Supervisor, Modifications
l .K. Hughes, Supervisor, Training Development
!- 'J. Johnson,-Superintendent, Security
G. Lawson, Superintendent,- Maintenance Planning
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l - W. Lindsay, Manager, Hot License
R. Miller, Superintendent, Mechanical Maintenance
D. Moore, Manager, Maintenance -
T. Morrill, Assistant to the Vice President, Engineering
W. Norton, Manager, Performance Improvement and Assessments
_ C. Redding, Engineering Specialist, Licensing
C. Reekie, Engineering Specialist, Licensing
R. Sims, Manager, System Engineering
S. Sprague, Maintenance Welding Engineer
J. Weeks, Manager, Emergency Planning
S. Wideman, Engineering Specialist, Licensing
C. Younie, Manager, Operations J
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F. Ringwald, Senior Resident inspector
INSPECTION PROCEDURES USED -
IP 55050. Nuclear Welding GeneralInspection Procedure
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ITEMS OPENED
Qpened
50-482/9713-01 URI welder failed to return copy of field welding
material requisition, and a field welding
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material requisition was apparently falsified
(Section M8.1)
50-482/9713-02, URI unauthorized and undocumented work was
two examples performed (Section M8.1.b.3 and M8.1.b.4)
50-482/9713-03 URI welding material was not returned to the point
- of issuance (Section M8.1.b 7)
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DOCUMENTS REVIEWED
Procedurqa
Number Revision Title
FMC-1 6 Filler Material Control
CWD-1 6 Control Of Welding Documentation
AP 29F-002 2 Control Of Welding Operations
AP 1 BC-002 8 Procedure Use and Adherence
AP 16-001 1 Control of Maintenance
Other Documents
Self Assessment Plan SEL 97-003, January 28,1997
incident Investigation Team Report 97-01, May 29,1997
Weld Recovery Plan, April 28,1997
Welding Procedure Specification 1-0105TO2, Revision 1
Performance Imorovement Reauests
96-3277, December 13,1996 97-0652, February 28,1997
97-0453, February 13,1997 97-0739, March 7,1997
97-0454, February 13,1997 97-1385, May 12, .1997
97-0469, February 13,1997 97-1386, May 12,1997
97-0470, February 13,1997 9~/-1387, May 12,1997
97-0481, February 14,1997 97-1388, May 12,1997