IR 05000327/1986053

Insp Repts 50-327/86-53 & 50-328/86-53 on 860929-1003. Violation Noted:Failure to Promptly Correct Conditions Adverse to Quality

ML20214Q336
Person / Time
Site:	Sequoyah
Issue date:	11/03/1986
From:	Belisle G, Runyan M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:
Shared Package
ML20214Q311	List: IR 05000327/1986053 ML20214Q306
References
50-327-86-53, 50-328-86-53, NUDOCS 8612050109
Download: ML20214Q336 (13)

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>2 0f 0 UNITED STAT'ES

! [ 'o NUCLEAR REGULATORY COMMISSION

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l Report Nos.: 50-327/86-53 and 50-329/86-53

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l Licensee: Tennessee Valley Authority 6N 38A Lookout Place j 1101 Market Street Chattanooga, TN 37402-2801 Docket Nos.: 50-327 and 50-328 License Nos.: DPR-77 and DPR-79 Facility Name: Sequoyah 1 and 2 Inspection Conducted: September 29 - October 3, 1986 Inspector: [-wu mlv //!j'M M. F. Runyan / Date Signed Accompanying Personnel: G. A. Belisle Approved by: h =w 4 // d2 G. A. Belisle,"Section Chief Date Signed Division of Reactor Safety SUMMARY Scope: -This routine, announced inspection was conducted at TVA corporate offices in Chattanooga and at Sequoyah to assess the adequacy of corrective action taken on escalated quality assurance (QA) audit deviations.

I Results: One violation was identified - Failure to promptly correct conditions l adverse to qualit *

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8612050109 861124 '

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., 6 DETAILS Persons Contacted Licensee Employees

• H. Abercrombie, Sequoyah Site Director

• Andrews, Site Quality Manager .

• Birchell, Licensing Engineer

• W. Cottle, Assistant Manager, Office of Nuclear Power D. Craven, Supervisor, Site QA Staff

• J. Crittenden, Assistant Branch Chief,' Nuclear Quality Audit and Evaluation Branch (NQA&EB)

• Gridley, Director, Nuclear Safety and Licensing

• P. Hammons, Nuclear Safety and Licensing

• J. Huston, Director, Nuclear QA *

' *J. Kearney, Performance Assessment Engineer

• • G. Killian, Assistant Branch Chief, NQA&EB

• J. Wills, Project Manager, Licensing C. Wilson, Technical Secretary, Nuclear Safety Review Board (NSRB)

Other licensee employees contacted included engineers and office personne NRC Resident Inspector K. Jennison, Senior Resident Inspector

• Attended exit interview Exit Interview The inspection scope and findings were summarized on October 3, 1986, with those persons indicated in paragraph 1 above. The inspector described the areas inspected and discussed in detail the inspection findir.gs listed below. No dissenting comments were received from the license Violation - Failure to prompt!1y correct conditions adverse to quality, paragraph The licensee did not identify as proprietary any of the material provided to or reviewed by the inspector during this inspectio . Licensee Action on Previous Enforcement Matters Previous Severity Level IV Violations 50-327, 328/82-16-01, 83-27-01, "

83-27-04, and 85-04-01, were the primary focus of the inspection. Due to their similar nature, these items are not addressed individually in this paragraph, but are referenced generically in paragraph 6 under the broad topic of corrective action. All of these items will remain ope ,

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Unresolved Items Unresolved items were not identified during the inspection. ,

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5, General This inspection was performed to review TVA's corrective actions on previously identified audit findings. The inspection was limited to only

those findings (deviations) currently under escalation that were identified

! by audits conducted relative to Sequoyah plant activitie ,

, Escalation responsibilities are delineated in DQAI-104. Corrective action requests (CARS) or audit findings (deviations) can be escalated for a variety of reasons involving any of the following:

L Item significance Late response Inadequate responses '

Repeated requests for extensions Failure to complete corrective actions within required timeframes When direct action by responsible personnel fails to achieve the results require ,

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NRC violations and Institute of Nuclear Power Operations findings also have conditions for escalation.

, If any of these conditions ~ exist, then the finding is escalated to the next management level (Director, Division of Quality Assurance and the Site *

Director). The finding resolution can then be immediate.(depending on '

significance) or it can be delayed until the' next regularly scheduled corrective action meetings, which for. nuclear plant sites, occur,at .

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approximately quarterly intervals. At this time, discussions are conducted that result in a definitive course of action.to disposition the finding

, satisfactorily. -If management is unable to achieve acceptable disposition

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at this time or if previous commitments are not met, then the' finding is l,

promptly brought to the Manager of Nuclear Power for. resolutio ,

i From this sequence of events, it can be seen that finding-resolution usually occurs at appropriate management levels. When a finding reaches. escalation,

, attempts to resolve it at lower supervisory levels have failed and the

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solution is'left to upper management. If attempts at this level do not resolve the finding, then upper management has failed and the finding must

', then be resolved by the Manager of Nuclear Powe On some-findings that involve problems-of large magnitude or general policy, then reasonably, the

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Manager of' Nuclear Power must exercise the ultimate authorit The-inspectors received a copy of the September 26, 1986, TVA-Verification i and Improvement Administration System (VIAS) which contained the status o open active escalated deviations. At Sequoyah,.there are currently six i findings-in escalatio The following .is a:brief description of. these findings: a

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QSQ-A-84-0014 (SQ-A-84-11), Finding 02, which involved, generally, problems with the plant chemical control procedures. The specific finding remaining outstanding delineates that chemistry personnel are not sufficiently trained and indoctrinated in the specific requirements affecting quality related activities associated with the chemical control program. This is 1 of. 17 details that constitute the generic findin QSS-A-84-0011 (CH-8400-11), Finding 02, which involved annual training for selected plant personnel relative to the Radiological Emergency Plan assembly and accountability requirement QSS-A-85-0006, Finding 03, which involved plant safeguards informatio No direct inspection was performed on this ite QSS-A-85-0010, Finding 03, which involved inadequacies in the storage, handling, and retrievability (some records could not be located) of health physics record QSS-A-86-0001, Finding 01, which involved not accomplishing document control activities in accordance with procedural requirement Specifically, the finding involved previously identified commitments that were not being tracked in site instruction QSS-A-86-0001, Finding 02, which involved a failure ~ to provide proper storage of QA records in accordance with regulatory requirements and procedural controls. The specific finding concerned temperature, humidity, and drainage requirements in the vaul These findings were reviewed by the inspectors, with the exception of QSS-A-85-0006 as discussed previously, to determine corrective action resolutio . Corrective Action The following information was determined by the inspectors from VIAS, corporate QA records, and discussions with QA personnel:

Audit Number QSQ-A-84-0014 (SQ-8400-14)

Audit Subject Sequoyah Chemistry Program Audit Issue Date November 2, 1984 Finding Escalation Date October 9, 1985 Total Number of Findings 6

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Audit Number QSS-A-84-0011 (CH-8400-11)

AuditSubject Radiological Planning Audit Issue Date August 9, 1984

Finding Escalation Date March 28, 1986

Total Number of Findings 4 Audit Number QSS-A-85-0006 AuditSubject Physical Security Plan, Safcguards Contingency Plan, Security Personnel Training and Qualification

A;dit Issue Date March 22, 1985 Finding Escalation Date January 17, 1986 Total Number of Findings 3

Audit Number QSS-A-85-0010 ,

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' !. ? 6 AuditSubject Internal Radiation Controf .

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Audit Issue Date , _

May 10, 1985 Finding Escalation Date March 10, 1986 Total Number of findings 6 Audit Number QSS-A-86-0001 AuditSubject Document Control, Records Control Audit Issue Date December 6, 1985 i

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Finding Escalation Dat June 20, 1986 Total Number of Findings 5 l

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It is not unusual that one finding may have multiple parts. However; prior to closure, all parts of the finding have to be closei The following is the current (September 26,1986) status of these items as delineated on VIAS:

QSQ-A-84-0014 (02); date escalated October 9, 1985; Chemistry audit at SQN revealed the status of this deviation is not correct. SQN states that this is tied to training deviation mentioned but that corrective action completion date had been establishe .

QSS-A-84-0011 (02); date escalated March 28, 1986; W. A. D. should verify that committed corrective action (L38 860613 875) is complete and advise J. E. Huston immediately of any unresolved aspects of the corrective action plan. This item will either be closed based upon satisfactory verification action or will be escalated to the Office of Nuclear Power (0NP) Manager for resolution if corrective action is not complet QSS-A-85-0006 (03); date escalated January 17, 1986; this deviation report should be escalated to ONP Manager for resolution of details 4 and 5 of the original audit findin QSS-A-8500-0010 (03); date escalated March 10, 1986; this deviation report is being escalated to ONP Manager for resolution. SQN has not established an adequate records management program for control of health physics record QSS-A-86-0001 (01); date escalated June 20, 1986; T. A. Flippo should evaluate SQN's response which is' required by October 1, 1986, and

" advise J. E. Huston immediately of the results so that the escalation form can be completed with respect to the escalated corrective action plan and schedul QSS-A-86-0001 (02); date escalated June 20, 1986; this deviation report should be escalated to the ONP Manager for resolution. SQN should ascertain the status of resolution of this corrective action, especially the scheduled completion date for the design change request (DCR) concerning the drain valve. The status of corrective action for details 2 and 3 must be completed as committe The inspectors selected two findings and performed an indepth review of those findings. Their resolution is typical of all the findings under escalatio Audit QSQ-A-84-0014 (SQ-A-84-11), Finding 02, concerned Sequoyah (SQN)

chemical control procedure deficiencies. In correspondence L17 841102 801, dated November 2, 1984, this audit was forwarded to the Sequoyah (SQN) Site Directo The audit also requested that a formal response be forwarded to

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QA within 30 days. In correspondence S53 841203 837, dated December 3, 1984, the SQN Site Director requested a 30 day extention to complete the responses to the findings in this audi In correspondence S53 850104 970, dated January 9, 1985, the SQN Site Director provided responses to the audit findings. In correspondence L17 850314 802, dated March 14,1985,QA provided an evaluation of the SQN response. The evaluation stated the following:

(Finding) - Deviation 1, Acceptable Deviation 2, Acceptable, inform QA when actions are complete so they can be reviewed l Deviation 3, Some details acceptable, some details require clarification Deviation 4, Needs clarification Deviation 5, Clarify within 30 days Deviation 6, Clarify within 30 days

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In correspondence S53 850412 832, dated April 16, 1985, the SQN Site I Director provided clarified responses to QA. In correspondence '

L17 850524 800, dated May 24, 1985, QA notified the SQN Site Director that their (SQN) clarified responses were acceptabl In correspondence L17 851009 801, dated October 9, 1985, QA evaluated the corrective action relating to findings 2, 3, and 4 of this audit. This corrective action was to have been done by September 1, 198 Relative to finding 02, 13 of 17 details of the finding had not been performe Similar problems existed with finding 03; finding 04 was close In correspondence L17 851009 802, dated October 9, 1985, the Chief, Quality Assurance Branch Notified the Director of Quality Assurance that finding 02 and 03 were being brought to his attention with the recommendation that i;hese findings be escalated. In correspondence L20 851010 974, dated Octob*ei- 10, 1985, the Director of Quality Assurance notified the SQN Site Director that based on the quarterly corrective action meeting (L17 851011 803) conducted at SQN on September 19, 1985, mutual agreement was reached to escalate these finding In summary up to this time frame:

Audit issued 11/02/84 Request to delay response 12/03/84 Response sent 01/09/85 Response evaluated inadequate 03/14/85 Additional response sent 04/16/85 Response evaluated 05/24/85 Reinspection & evaluation 10/09/85 Escalation 10/10/85 <

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In correspondence S53 851029 966, dated October 30, 1985, the SQN Site Director states in part (for finding 03) that due to the escalation process,

"A revised response would serve no useful purpose until after we have reviewed the escalation package. After identifying any additional correc-tive actions required, we will contact the Director of Quality Assurance, per DQA escalation procedures, to discuss actions to be taken and a schedule for completion of these actions."

In correspondence L17 851113 800, dated November 5, 1985, site QA identified that during surveillance 10C-85-P-004 deficiencies were identified with the chemistry section instructions and use of measuring and test equipment. Site QA generated Corrective Action Request (CAR) 84-06/01 The initial audit finding identified in 11/84 and the inability to correct this problem has now, in part, directly led to the identification of another redundant proble In correspondence L17 860204 802, dated February 4, 1986, a meeting was proposed to be held before February 9, 1986, and that if a quality notice was prepared, it would be issued before February 28, 198 In correspondence L17 860321 803, dated March 19, 1986, the results of the Quarterly Corrective Action Meeting betweer. DQA and SQN were documente This meeting was conducted January 28, 1986. The status for finding 03 was basically a repeat from correspondence L17 860204 802 about the proposed meeting being held prior to February 9, 198 The status for finding 02 references comments made in conjunction with CAR-84-06/014. The status for CAR-84-06/014 states that it was agreed that this CAR would not be combined with the audit item and that it (the CAR; would remain open and escalated. Interested parties would meet with SQN Chemistry personnel no later than February 5, 1986, to verify corrective action completio In correspondence L17 860425 800, dated April 25, 1986, QA notified the SQN Site Director that finding 03 was closed based on a review of the corrective actio In correspondence LO3 860520 851, dated May 20, 1986, tiie results of the Quarterly Corrective Action Meeting between DQA and SQN were documente This meeting was conducted April 30, 1986. The status for finding 02 was that this issue was similar to a generic training deviation cited during the February training audit but would be tracked separately. It was agreed that the commitment date for correcting this item would be the same as that for correcting the generic deviation (QSQ-A-86-0004-007) which had not as yet been determined.

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Since the findings (02 and 03) went into escalation on October 10, 1985, one (03) was resolved on April 25, 1986, and the other is still pendin The results of Quarterly Corrective Action Meetings on January 28 and April 30, 1986, apparently were of little value in resolving finding 0 Since finding 03 was resolved after the January 28 meeting, the inspector assumes that this item's resolution was helped by that meetin In reviewing correspondence related to audit QSQ-A-86-0004, the inspector reviewed the following:

AuditSubject Plant Staff Performance, Training, and Qualification Audi'. Issue Dat March 12, 1986 Total Number of Findings 11 In correspondence S53 860410 945, dated April 10, 1986, the SQN site responded to the 11 audit findings generated during this audit. In corre-spondence L47 860410 802, dated April 10, 1986, a response to one finding was sent from the training center. In correspondence L01 860512 830, dated May 12, 1986, corporate DQA accepted the response for correspondence L47 860410 802. In correspondence L19 860630 901, dated June 30, 1986, corporate QA responded to 553 860410 945 and requested additional informa-tion for ten findings or parts of findings. A request was made to respond to this letter within 30 days. In correspondence S10 860728 801 dated August 6, 1986, the SQN Site Director notified corporate QA that he received the June 30, 1986, correspondence and that his staff was reviewing the evaluation to determine if any additional corrective action was necessar Upon completion of this review, a revised response will be issued by August 29, 198 In correspondence S10 860811 825, dated August 5, 1986, the SQN Site Director requested to extend the completion date for finding 008 to September 1, 198 In correspondence S10 860829 855, dated August 29, 1986, the SQN Site Director submitted revised responses to the remaining audit findings request 3d by the June 30, 1986, correspondenc In summary up to this time frame:

Original escalation for findings 02, 03 10/10/85 Similar audit finding 02 surveillance finding 11/05/85 Quarterly corrective action meeting 01/28/86 Similar audit finding (QSQ-A-86-0004) 03/12/86 SQN response to audit QSQ-A-86-0004 04/10/86 Original finding 03 closed 04/25/86 Quarterly corrective action meeting 04/30/86 QA reviews SQN response, requests additional response within 3fi, days 06/30/86 SQN reviewing QA 06430/86 request 08/06/86

SQNrespondstoQArgquestforadditional

information g 08/29/86

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Up to the date of this inspection, audit QSQ-A-86-0014 (SQ-A-84-11), finding 02, which identified that chemistry personnel are not sufficiently trained and indoctrinated in the specific requirements affecting quality related activities associated with the chemical control program, had been unresolved since November 198 The final resolution for this finding is still questionable since the 08/29/86 SQN response to QA states that SQN is still evaluating the issue of indoctrination and training programs for various engineers to determine if additional corrective action is require It also states that a supplemental response will be provided to QA by October 31, 198 The inspectors, in addition to the audits and documents previously mentioned, also reviewed another audit and findings associated with that audi Audit QSQ-A-86-0001 was conducted'in the area of document control at Sequoyah (SQN) from October 23 to November 8, 1985, and issued December 6, 1985. Deviation number one (001) of this report was summarized as follows:

Sequoyah Nuclear Plant (SQN) is not accomplishing document control activities in accordance with the Nuclear Quality Assurance Manual (NQAM), Technical Specification, ANSI N18.7, and Administrative Instruction AI-4 with respect to commitment control, periodic review, temporary changes, current revision control, procedure format, revision history, and procedure approva This deviation comprised nine details, each of which were addressed independently in correspondence between QAB and the site. Due to the site's failure to meet repeated corrective action extension requests and previous unacceptable responses, NQA&EB recommended by memorandum (L19 860620 904)

dated June 20, 1986, to the Director, Nuclear QA, that details No. 1 and No. 7 of this deviation be escalated in accordance with DQAI-10 Detail No. 1 involved nine commitments identified by SQN Commitment Action Tracking System (CATS) that were not being tracked as long-term commitments in site instruction This allows a situation where a revision to a procedure could inadvertently delete one of these commitments. Detail No. 7 involved instruction manual revision receipt transmittal acknowledgements not being received within ten days as required by AI- A meeting was held on site June 20, 1986, between NQA&EB and site personnel during which a mutually acceptable course of corrective action was agreed upon. However, when a formal response from the site dated July 29, 1986, (500 860728 801) was received, corrective action for detail No. 1 was again ,

found unacceptable by NQA&EB. The heart of the disagreement surrounded the i site commitment date of January 1, 1990, to complete an exhaustive search of l all plant instructions to identify and protect all embedded commitment NQA&EB demanded the establishment of " interim controls" for which the site ;

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In correspondence L17 860910 801, dated September 10, 1986, from the Director, NQA, to the SQN Site Director, a request was made that the site resubmit a response for each of the nine details of the original deviation. The reason for this request was that SQN had failed to notify NQA&EB of completion of corrective action for the details for which corrective action had been approved. The most crucial unresolved issue remained the establishment of interim measures to prevent inadvertent removal of commitments from plant instructions. The memorandum stated that unless a corrective action plan could be agreed upon by October 1, 1986, the issue would be escalated to the Manager of Nuclear Power for resolutio SQN failed to respond by October 1, 1986, and a draft memorandum to the Manager of Nuclear Power for escalation was prepared. SQN stated that a response was in typing, but, according to NQA&EB personnel, it would again not be acceptable with respect to detail No. Therefore, from the date this item was escalated, June 20, 1986, to October 3, 1986, the date of the NRC exit meeting, little progress was made in the resolution of this matte i These two specific examples, as well as the general overview of other items that have been escalated to upper management for resolution, constitute a violation in that corrective action has not led to prompt resolution of identified problems that were adverse to quality. This is identified as violation 327, 328/86-53-0 In addition to reviewing the audits previously outlined, the inspector also discussed finding corrective action with a member of SQN's NSRB. The NSRB has been aware of corrective action inadequacies; however, they +ad adopted a " wait-and-see" attitude pending programmatic refinement ,

' Documents Reviewed

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The following documentation was reviewed during this inspection: -

DQAI-103, Responding to and Correction of_ Deficiencies Within DNQA, Revision 2

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DQAI-104, Escalation of Responsibility For Deviation Corrective Action, Revision 2 DQAI-204, Handling of Central Office Corrective Action Reports and Discrepancy Reports, Revision 1

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TVA Verification and Improvement Administration System Open Active Escalated Deviations dated 9/26/86 (VIAS)

Audit SQ-8400-14, issued 11/2/84 Audit CH-8400-11, issued 8/9/84 Audit QSS-A-85-0006, issued 3/22/85 Audit QSS-A-85-0010, issued 5/10/85 Audit QSS-A-86-0001, issued 12/6/85 In addition to the previously mentioned documentation, the following documents were reviewed relative to each audit:

Audit TVA Document Document Date SQ-8400-14 L17 840911 805 09/11/84 L17 841102 801 11/02/84 553 841203 837 12/03/84 S53 850104 970 01/09/85 L17 850314 802 03/14/85 S53 850412 832 04/16/85 L17 850524 800 05/24/85 L19 850722 802 07/22/85 L17 850816 804 08/16/85 L29 850826 802 08/26/85 L17 851003 800 10/03/85 L17 851009 801 10/09/85 L17 851009 802 10/09/85 L20 851010 974 10/10/85 L17 851011 803 10/11/85 553 851029.966 10/30/85 L17 851113 800 11/05/85 L17 860204 802 02/04/86 L29 860203 893 02/04/86 L17 860321 803 03/19/86 L17 860425 800 04/25/86 LO3 860520 851 05/20/86 Audit TVA Document Document Date CH-8400-11 0QA 840809 701 08/09/84 L17 840917 802 09/10/84 L44 840912 803 09/17/84 L17 841012 810 10/12/84 L17 841012 805 10/12/84 L17 841012 800 10/12/84 S01 841120 894 11/26/84 L17 850208 800 02/05/85 L17 850522 801 05/22/85 L17 850402 801 04/02/85 L17 850613 805 06/13/85 L17 850426 801 04/26/85 L17 850606 803 06/06/85

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S01 850801 895 08/28/85 L17 850903 800 09/03/85 L17 851018 803 10/18/85 R42 850529 801 05/31/85 L17 851115 804 11/15/85 S53 851115 840 11/19/85 L17 851129 807 11/29/85 R42 850529 891 05/31/85 L17 860321 803 03/19/86 L17 860328 800 03/28/86 L17 841214 800 12/04/84 LO3 860613 875 06/12/86 Audit TVA Document Document Date QSS-A-85-0006 L17 850322 803 03/22/85 (Srfeguards Information)

Audit TVA Document Document Date QSS-A-85-0010 L17 850510 801 05/10/85 R42 850611 901 06/12/85 L17 850618 803 06/18/85 L17 850618 804 06/18/85 553 850619 884 06/24/85 553 850610 838 06/10/85 L17 850724 809 07/03/85 L17 850809 800 08/09/85 L17 850808 800 08/08/85 553 850906 960 09/10/85 L17 850920 801 09/20/85 553 851009 866 10/15/86 L17 851230 800 12/30/86 LO3 860512 826 05/12/86 L20 860401 835 04/01/86 LO3 860520 851 05/20/86 L17 860310 803 03/10/86 Audit TVA Document Document Date QSQ-A-86-0001 L17 851206 803 12/06/85 553 860106 812 01/07/86 553 860207 984 02/11/86 553 860319 829 03/25/86 L17 860331 800 03/31/86 553 860429 853 05/05/86 LO3 860512 828 05/12/86 L19 860620 904 06/20/86 510 860722 801 07/29/86 S00 860728 801 07/29/86 L17 860910 807 09/10/86 L19 860620 903 09/26/86