ML20137Z312
| ML20137Z312 | |
| Person / Time | |
|---|---|
| Site: | Comanche Peak  |
| Issue date: | 03/19/1985 |
| From: | Clements B TEXAS UTILITIES ELECTRIC CO. (TU ELECTRIC) |
| To: | Hunter D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| Shared Package | |
| ML20137Z299 | List: |
| References | |
| TXX-#4439, NUDOCS 8510080216 | |
| Download: ML20137Z312 (18) | |
Text
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! TEXAS UTILITIES GENERATING COMPANY 9.sL V W AV to nW E st . 4 tHe N e s te T H t il.8 % k t. 8 pe E FT, l..H, es t . 04 8.1.4 es, T F 4 4 m T Sito g March 19, 1985
.... .niu.
.. v..n.m. cL.a..w.e s.t..e..... TXX #4439 Docket No. 50-445 i -
1
( Mr. Dorwin R. Hunter y( g g p'"r (( t I Chlef, Reactor Project Branch 2 --- ,
! U.S. Nuc! car Regulatory Commission, ,
l Region IV Office of Inspection and Enforctment W22m '
l Parkway Central Plaza Building . _,// j 611 Ryan Plaza Drive, Suite 1000 ,
Arlington, TX 76011
Dear Mr. Hunter:
3
SUBJECT:
COMANCIIE PEAK STEAM El.ECTRIC STATION l RESPONSE TO NRC NOTICE OF VIOI.ATION t INSPECTION REPORT No: 50-445/84-11 [
Wo have reviewed your letter dated February 12, 1985 portaining to the l t inspection conducted by Messrn. D t.. Kelley, W. F. Smith and NRC contract ;
personnel of activitics authorized by NRC Construction Permit CPPR-126 for l Comanche Peak, Unit 1. We are herchy responding to the Notice of Violation ;
listed in Appendix A of that letter.
- l In our letter of March 14, 1985 on the above subject, we advised you that i wo anticipated completing our response by March 20, 1985. As indicated 9
abovel we have completed our response and it la forwarded for your review. !
i To aid in the understanding of our responso, we have repeated the Notice of i Violation followed by our responso. We feel the enclosed Information to be responsivo to the Inspoetor's findings, if you have any quantions, pleano !
advino. !
Yours truly, i 4s ;
- m. atant I =
,%ye&n_s. o BRCtkh i
Enclosure ;
et NRC Region IV - (0 + 1 copy) j Director, inspcetion and Enforcement (15 copten) :
U.S. Nuclear Regulatory Commisalon -
Washington, D.C. 20555 :
Mr. V. fl. Noonan
,e eeen.sesv eer enzie renerea.n=cenec oewe 4n :
f.....
NOTICE OF VIOLATION 445/8431-05 10CFR Part 50 Appendix B, Criterion V and FSAR Section 17.2.5, state in part.
" Activities affecting quality shall . . . accomplished in accordance with these instructions, procedures, or drawings."
Contrary to the above, the applicant 05 (a) failed to make changes to ELM-302, Revision 0, "480V Circuit Breaker Inspection and Testing," Section 6.0 in accordance with STA-205 Revision 2. " Temporary Changes to Procedures "
05 (b) failed to properly perform a review of Attachment 2 to ELM-302; 05 (c) failed to make changes to Section 8.2 of "CpSES Protective Relay Settings (480V Safeguards Buses)" in accordance with STA-205; 05 (d) failed to make the entries in the " Safety-Related OSD Log", as required by WilS-001, Revision 9. " Receiving and Inspection of Material, Parts and Components":
05 (e) failed to eng items in the level A storage arens as required by WilS-002, Revinfon 5. "llandling and Storage"; and 05 (f) failed to include "Q" material handling equipment on the plant's l periodic maintenance and inspection program as required by WilS-002, Revision 5. "llandling and Storage."
! RESP 0NSE!
l Dincunninn:
Thin Violation contains six examples of noncompliance with 10CFR50 Appendix R. Criterion V. Each han been reviewed by CpSE!! Plant Operations personnel to l determine its effect on safety related activitics, performed te date, no that appropriate corrective and preventive action may be taken. Specifics of the deficiency addronned in the body of the Innpection Report ato addressed as follows:
8411-05(n) _
Contrary to the above (10CFR50), Appendix n. Critorion V), the appifennts o fatted to innko changen to ELM-302 Revision 0, 480V Circuit Bronker Inspection and Tenting," Section 6.0 in necordance with STA-205.
Revision 2. " Temporary Changen to Procedures,"
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NOTICE OF VIOLATION l 445/8431-05 (cont.)
8431-05(n) (cont.)
During the performance of work, the Electrieni Supervisor recognized that the minimum clone and trip voltagen listed in Section 6.0, " Acceptance Criteria",
of E!.M-302, "480V Air Circuit areaker Inspection" was not correct. After investigating the problem, the Supervisor determined that the voltagen listed in Attachment 2 of E!.M-302 were the correct valuen per the manufacturer's recommendationn; therefore, the voltage valuen in Section 6.0 were changed.
The temporary chango was handled in accordance with MDA-201, "Electrieni and Mechantent Maintenance Procedures and Instructions", paragraph 4.7.2.2, which doncribes how to change "Inntructions". Paragraph 4.7.2.2 of MDA-201 staten,
" Temporary changen shall be reviewed and approved by a Maintenance Supervisor and concurrenco-indiented by initiating and dating the change (s)." The temporary change nhould have been handled in accordance with MDA-201, Paragraph 4.6.1 which ntaten, " Temporary changes to safety related maintenance procedurns shall be accomplished in accordance with STA-205, " Temporary Changen to Proceduren."
It in important to note that n!! Mechanical Maintenance Procedures (MEM'n) and Electrient Maintenanco Proceduren (E!M's) were in the procons of boing changed and designnted as Mechanical Maintenanen Proceduren (tutP'n), Mechanieni Maintenance Instructionn (MMI's). Electrient Maintenanco Proceduren (EMP's) and Electrical Maintenance inntructions (EMI'n). MDA-201 containn criterin for determining proceduren and instructionn. All the Mi# n and E!.M's which fit the guidelinen of MDA-201 Parngraph 4.2.1, were changed to letP'n and EMP'n while all HEM'n nnd El.M's which fit the guidelines of MDA-201, Paragraph 4.2.2, were change to MMI'm and EMI's. Thin proccan involven retiring npproved MEM'n and El.M's and innuing tetP'n, MMt'n, EMP's and EMI's.
Corrective Action Deficiency Report (DR)84-067 wnm written an a renuit of thin innpection to cover the generic problem where MEM's and El.M's were incorrectly changed. The recommended corrective action on DR 84-067 van rovined nfter thin inspection to include the following:
MFtt's and El.M'n that wore (and are) Technical Specification Surveillanco Tenen were being rectannified an MMP'n and TMP'n an outlined in HDA-201 Paragrnph 4.2.1.1.
All other HEM's and Cl.M's that worn incorrectly changed moot the definition of an " Instruction" nn outlined in MDA-201, Paragraph 4.2.2 and baned upon that definition, would not have affected operntions.
All the changen hnd been handled as changen to "Inntructions" and had the proper review upccified for instructionn, including Quality Control review.
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NOTICE OF VIOLATION i
i 445/8431-05 (cont.)
) 8431-05(n) (cont.)
i procedure ELM-302 was innued na EMI-302 on December 12. 1984 with the minimum
!- clone and trip voltagen listed in Section 6.0 connintent with the valuen i linted in the Signoff/ Data Sheet.
j !
I Preventive Actions !
3 Currently all ELM's have been retired and all but eleven (11) MEM'n have been !
i retired. In the interim, the Electrient and Mechanient Hnintenance !
1 Supervinary pornonnel were retrained on the requirements of MDA-201, paragraph l 4.6.1, which states that if any changen are made to MEM'n or ELM's, they will ,
- be handled in accordance with STA-205.
j Date of Corrective and Preventive Action impicmentations ;
I i j proceduro ELM-302 wan changed to EMi-302 on December 12, 1984. ,
i
{ Electrient and Mechanient Maintenance Supervisory pornonnel were retrained on l
] the requirements of HDA-201 on December 11-18, 1984.
l H 411 -O'l(b) 1 !
j Contrary to the above (100FR50 Appendix B, Criterion V) the appliennt:
1 i o failed to proporly perform n rnview of Attachment 2 of EI.H-302.
I I
j Corrective Action: '
I The minimum clone coil voltago and maximum trip coil voltage on Attachment 2 !
of ELM-302 were inadvertently reverned when the olcetrician recorded tho l r valuen. This inconnintency wan not detected by the Electrient Supervinor '
during hin review of the work package or by Maintenanco Engineering pornonnel l l during the pont-work review procena. It should be noted that the Resultn '
- Engineering ncetion in not involved in the pont-work review of Haintonnnco i Action Requents (HAR'n). When the deficiency was brought to the attention of [
j the renponnible Electrical Supervinor, by the NRC innpcetor, the data van
. corrected on the Maintennnce Action Requent (HAR 84-1401 on 8/29/84). The deficiency wan an isolated cano of a mintake being mndo during the recording t
- of dntn that went undetected in the pont-work review procenn. Stntion j
- proceduren adoquately descrlho the responsibility of supervinory pornonnot and r I
Haintennnec Fngineering pornonnel in the pont-work review procenn. [
prevent Ivo A_ct lon_: ;
i
- The Electrical Supervinor and Hafntennnce Engineering pornonnel romponsible !
j for the pont-work review of thin MAR woro cautioned of their ronponsibilition and admonished to enrefully perform post-work reviewn.
j Date of correctivo and preventive Action implementations
! Data van corrected on the Halntenance Action Requent (HAR 84-1403) on i l Augunt 29, 1984. ,
l !
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NOTICE OF VIOLATION 445/8431-05 (cont.)
8431-05(c)
Contrary to the above (10CFR50, Appendix B Criterion V) the applicants o failed to make changen to Section 8.2 of "CPSES Protective Relay (480V Safeguards Busen)" in accordance with STA-205.
Corrective Actiont ,
During the planning stages of thin Maintenance Action Requent (MAR), the Electrient Supervisor responsible for the work, identified that equipment required to supply 3600 nmps primary and 90 amps secondary was not availabic.
The nupervisor contacted Resulta Engineering who decided that a 3200 nmps primary and 80 nmps accondary would be adequate to tent the breaker. Resulta Engineering committed to supply a memorandum detailing the interim revision which in in accordance with EDA-305, " Control of Protective Reiny Settings."
The supervisor, knowing the revision van forthcoming, changed a copy of the CPSES Protective Relay Settings attached to the MAR; this was incorrect. The test point ampernge nhould not be changed unless the memorandum in attached or referenced by nn interoffice memorandum number. The memorandum describing the interim revision van never received by the Maintenance Department nor attached to the MAR. Therefore, the results of the tent on the bronker nre indeterminate beenune no documentation in availablo that substantiaten the trip tent at 3200 ampa/80 amps. Another MAR will be written to perform the trip tent on the breaker.
Preventive Action:
These circumstances were discussed with the supervisor involved and he van reminded of the correct procedure for relay settings. In addition, other Electrient Maintenance and Resultn Engineering nupervisory pornonnel will be retrained on the provintonn of F.DA-305.
Date of corrnctive and Preventive Action Implementation:
All training and the new MAR will be conpleted by March 22, 1985.
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NOTICE OF VIOLATION 445/8431-05 (cont.) l g431-05(d) f Contrary to the above (10CFR50 Appendix B, criterion V) the applicant l o failed to make the entrien in the " Safety-Related OSD Log," na required by WilS-001, Revision 9. " Receiving and Inspection of -
Materini, Parts and Components."
Correctivo Action:
The OSD Log wan initinted by Procedure No. WilS-001, Revision 8. The purpose. ,
of the log was to have an available listing at the warehouse showing the i ntatus of open items pending renolution such as part number discrepancien and documentation deficiencien. The OSD Log was not required nor was it intended to become n Quality Record. The banin for thin was that the completed OSD itucif wan attached to the RIR pnekage when the receipt inspection van completed and forwarded to the Records Vault. Although Procedure No. Wits-001 has never required the completed OSD to be attached to the RIR package, this han always been the policy. ,
Since tho OSD Log van not n Quality Record there were no requirements for strikcovern, ominnions, and whitenuta in regard to initinin, dates, or final dinposition. ;
Procedure No. WilS-001. Revision 9 states, "The log _phould include the initials i of the innpoctor who innued the OS&D, date of issue P.O. line item no., RIR I no. and Date Cloned." Although the intent of the procedure was to list all of l the above attributen, the procedure did not enke it mandatory by stating :
"nhn11". l Procedure No. WilS-001 will be rovined to require the completed OASD to be l ntenched to the RIR packago and to state, "the 088D tog nhall include the i l above noted attributen." l i
Preventivo Action ;
Havinton to Procedurn No. WilS-001 will require the completed 0580 to become !
part of the RIR package and annure n!! required attributen are linted on the '
OSAD I.og. !
_Date of Correctivo and Preventive Action Inplementation Procedure No. Wils-001 will he revined by April 15, 1985. l l
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1 l i NOTICE OF VIOLATION 445/8431-05 (cont.) [
i 8431-05(e) !
Contrary to the above (10CFR50, Appendix B, Criterion V) the applicant l o failed to tag items in the Level A storage areas as required by WHS-002. Revision 5. "llandling and Storage"; and ,
corrective Action:
TUCCo operations has requested and received a designated space in the environmentally controlled area for warehousing items requiring Level A '
storage. Because the construction procedure controls the temperature.
humidity, dust, etc.. TUCCo Operations felt that it was not neconsary to l reference the Level A temperature and humidity limits in the Warehousing (
Hanual until TUCCo Operations has complete control of the area. l l
j The environmentally controlled storage area is controlled by TUCCo l
Construction and supervised by Brown & Root contract personnel. Brown & Root l Construction Procedure No. 35-il95-ICP-5 entablinhen the specific limits for temperature and humidity. '
l This resulted in no adverne affect on plant operations beenuso the applicable l construction procedure establishes a temperature range for Level A storage at I 60'-90*F and the humidity shall be less than 60%. All TUCCo operationn material stored in Level A nrea was controlled under the temperature and ,
humidity limits of the construction procedure.
procedure No. WilS-002 will be revined to interface with the construction temperature and humidity limits.
! pnragraph 4.3.1.1 of procedure No. W11S-002 staton in part " . . . The Receiving Innpoetion Instruction shall contain all special stornge and handling requirements for I.cyc1 A itemn. A specint lonpaction/ifandling
~
Required Tag shall be attached to the item until innued from the :
Warehouse . . ."
i Many Level B itemn have been located in the Level A storage area to provide a l hetter atorage environment. Thene itemn have no special temperature and !
humidity storage requirements which would require a Specint !
! Innpoetion/llandling Required Tag. The npplienble Receipt innpcetion ;
Inntruction did not delinento any speelal storage or handling requirements for .
thene Level !! items. Ilowever, procedure Hon. W118-001 and Wils-002 will be f revined to addronn items other than level A stored in the Lovel A nren.
This part of the deficiency renulted in no adverne affeet on plant operations, beenune items found in Levnt A ntorage without Specint Innpoetion/Ilandling l Required Tagn were actually Level 11 items whf eh had no special stornge I requirementn doncrlhed in the Recolpt inopection Instructions. I I
i
NOTICE OF VIOLATION i 445/8431-05 (cont.)
8431-05(e) (cont.)
Preventive Action Revision to Procedure Nos. WHS-001 and WilS-002 will clarify the storage requirements for Level B items in the Level A storage area.
Date of Corrective and Preventivo Action implementation:
Procedure Non. W11S-001 and WilS-002 will be revised by April 15, 1985.
8431-05(f)
Contrary to the above (10CFR50, Appendix B Critorion V) the applicants o failed to include "Q" materint handling equipment on the plant's periodic maintenance and inspection program as required by WilS-002 Revision 5. "llandling and Storage."
Corrective Action:
This deficiency will be corrected by including the material hoisting equipment uned at the warehoune in the plant's periodic inspection and maintenance program. WilS-002 will be revised to provido a periodic inspection and maintonnnec program for the fork lift.
Slings are now controlled by and issued to the warehouse by the Maintenance Department. Thone niings are returned to the Maintenance Department for portodic inspection and new alings issued. The worn nylon niing observed during the innpaction han been disponed of.
Preventivo Action:
Hnintenance Department control of niings will annura periodic innpection and thn frequent innue of new niings will prevent abnormal wear and tent.
Inclusion of hotating equipment in the maintenance program and development of an inspection and maintennnec program for the fork lift will annure that requiremonta of ANSI N45.2.2 nre met.
hto of Correctivo and Prevenrive Action implomontationt Wils-002 will be revised by April 15, 1985.
NOTICE OF VIOLATION 445/8431-07 10 CFR Part 50, Appendix B, Criterion VIII states, in part, that measures shall be established for the identification and control of materials, parts, and components, including partially fabricated assemblies and as identified in FSAR, Section 17.2.8, " Identification and Control of Haterials, Parts, and Components," which states, in part, ". . . materials, parts, and components be identified and controlled to prevent the use of incorrect . . . items."
Contrary to the above, the applicant stored quality and non quality material together in a "Q" materint-hold nrea of the maintenance building.
RESPONSE
Corrective Actiont Purnuant to the directiven of FSAR, Section 17.2.8 and of 10CFR50, Appendix B, Criterion VIII Maintenance Department Administrative Procedures were establinhed to identify and control materials, parts and components to prevent the une of incorrect or defective items. Procedure MDA-404, " Control of Hatorials, Parts and Components," addressen, in part, the identification and control of materinin, parts and components during maintenance and requires that auch items be identified by name or number prior to removal from the work location and, an applicabic, prior to relocation to the staging aren.
Additionally, the procedure requires separation of nnfety related items from non-nafety reinted itema no long an the itema are not adequately identified.
Therefore, the procedure does not preclude the integration of safety related and non-safety related items within a staging area so long as the nnfety reinted itema are adequately identified.
The arenn noted by the NRC worn identified with "Q Haterial" or "Q Material Stornge Aren" nigns and, by inference, non-Q material appenrod out of place in such nrenn. Thenn arenn are not intended to be "Q Materint iloid Arcan" an found in warehousing activitten. Instond they are used an work arcan
" temporary storage areas while work in in progress and these signs serve an additional identification that there in some "0" material in thin aren.
Therefore, non-Q items such as tooln, rags, etc. that are related to the work activitica may be found in theno aronn. Maintenance has, however, had succenn at using thene denignationn an a good practico and will provide additionni training to maintenanco pornonnel to annure they recognise the dissimilaritten between Q materin! "llold" aroan and Q Material "Storngo" or " Staging" areas.
Preventive Action:
The requirements of HDA-404 procedurally annuro that materials, parts and components are adequately controlled. Training, as noted above, will be provided.
Date of corroetiva and Proventive Action implementation:
Training will be provided to maintenance pornonnet by May 1, 1985.
NOTICE OF VIOLATION 445/8431-08 10 CFR Part 50 Appendix B, Criterion V and FSAR Section 17.2.5, state in part, " Activities affecting quality shall be prescribed by documented instructions, procedures or drawings . .."
Contrary to the above 08 (a) procedure STA-602, Revision 0, " Temporary Modifications and Bypassing of Safety Functions," did not require adequate control for temporary modifications; 08 (b) Design control procedure NDE-201 did not adequately addrens the performance of emergency modifications; and 08 (c) Record retention requirements had not been adequately established in station procedure STA-302, Revision 4, in that four Technical Specification record types were not identified for retention.
RESP 0NSE:
Dincunninn Deficiencies identified in these procedures have been evaluated and are in the process of being corrected. Each part of the Violation is separately addrenned by its unique identifier used in the body of the Inspection Report.
8411-08(n)
Deficiency:
STA-606, Revision 3, " Maintenance Action Requesta" and HDA-103, Revision 4
" MAR Procensing - Maintenance Department" did not require the name IcVel of supervisory review for a change to the MAR nn was required for the original MAR.
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NOTICE OF VIOLATION 445/8431-08 (cont.)
Corrective Action:
Procedure STA-606. " Maintenance Action Request" and MDA-103, " MAR Processing -
Maintenance Department" will be revised to require a Supervisor in the responsible organization to review revisions to a MAR. As part of his review, the Supervisor will be required to consider the impact of the revision on the original scope of work. In addition, he will be required to obtain a review by the Quality Control Section in accordance with the new revision. If the revision impacts the scope of work, the Supervisor will be required to notify the Shift Supervisor of the revision. The Shift Supervisor will then revise any applicable clearance permits when requested in accordance with STA-605, to cover the revised scope of the work. The Supervisor will also be required to consider the impact of the revision on any other permits which have been issued. If the revision to the work requires a revision to existing permits or additional permits not required in the original scope, the Supervisor will be required to notify the appropriate organization. The organization responsible for issuing the permit will then revise / initiate the appropriate permit as neccesary to cover the revised scope of work.
Preventive Action:
Revisions to Procedure STA-606 and MDA-103 will ensure that revisions to the Maintenance Action Requests receive the same level of supervisory review as required for the original MAR.
Date of Corrective and Preventive Action implementation:
Procedure STA-606, Revision 4 has been submitted for station review. The target date for issuance of STA-606, Revision 4, in April 1, 1985.
Procedure MDA-103 Revision 5, is being revised to submit for station review.
The target date for issuance of MDA-103, Revision 5, in April 8, 1985.
Deficiency:
Troublenhooting guidance contained in MDA-103, Revinton 4, acetion 3.12 and 4.4, wan inadequate.
Corrective Action:
Procedure STA-606, " Maintenance Action Requents" and MDA-103, " MAR Proccasing
- Maintenance Department" will be revised to more cicarly define the neope of troublenhooting. When work must be performed that exceeds thin neope, exinting proceduren or inntructions will be utilized or adequate work instructions will be written in a MAR.
NOTICE OF VIOLATION 445/8431-08 (cont.)
RESPONSE: (cont.)
Preventive Action:
Revisions to Procedure STA-606 and MDA-103 will ensure that adequate procedures and work instructions are available for repair of safety related equipment.
Date of Corrective and Preventive Action Implementation: j Procedure STA-606, Revision 4, has been submitted for station review. The target date for issuance of STA-606, Revision 4, is April 1, 1985.
Procedure HDA-103, Revision 5, is being revised to submit for station review.
The target date for issuance of MDA-103, Revision 5, is April 8, 1985.
Deficiency:
Procedure STA-602, Revision 0, " Temporary Modifications and Bypassing of Safety Functions," did not require that temporary modifications to; . . .
Corrective Action:
CPSES Operations Administrative Control and Quality Assurance Plan (OAC/QAP).
Section 5.3 requires that temporary modifications to safety related equipment be controlled by approved procedures. Procedure STA-602, is the station procedure for control of temporary modifications. STA-602 is presently being revised to implement the applicabic requirements of 10CFR50.59.
All present temporary modifications remaining in effect until receipt of plant license will have received a review for applicability of an unreviewed safety question as outlined in Revision 1 of STA-602. The revision to STA-602 will require that a more thorough analysis of the effect of the modification on the plant be documented and provided to operations personnel.
Preventive Action:
Revisions to STA-602 will provido procedural control for temporary ,
modifications to safety related equipment.
Date of Correctivo and Proventive Action impicmentation:
STA-602 will be revised and issued by June 1, 1985.
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NOTICE OF VIOLATION 445/8431-08 (cont.)
RESPONSE: (cont.)
8431-08(b) i Deficiency:
Design control procedure N0E-201 did not adequately address the performance of emergency modifications; and Corrective Action:
Procedure N0E-201, Design Modification Control addressed the processing of emergency modifications by Technical Support Engineering and referred to the
" Limited Final Design Package." Procedure N0E-201 is the basic control procedure for all modifications and its requirements are further defined by supporting instructions utilized by Technical Support and Operations personnel.
Instruction N0E-201-14 Revision 0. Emergency Modifications, not listed as a document reviewed in Inspection Report 8431 (Page 21), was issued December 1, 1983. This instruction describes the make-up of an Emergency Modification Package which includes a Safety Evaluation plus other documents necessary to 4
define or describe the modification.
N0E-201, Revision 2, states that the Emergency Modification Package must be approved by SORC prior to implementation. N0E-201-14, Revision 1, issued October 29, 1984, further clarifies the requirement for SORC approval prior to the implementation of emergency modifications.
Emergency Modifications have not been addressed in the Station (STA's) and Engineering (EDA's) procedures. Procedure STA-701, Station Modification Control and EDA-205, Design Modification Implementation are presently being revised to reflect requirements of N0E-201 and N0E-201-14.
The existence of procedural deficiencies in STA-701 and EDA-205 has had no safety implications where Emergency Modifications are concerned. No safety related Emergency Modifications have been processed to date - all have been normal modifications. ,
Preventive Action:
Revisions to STA-701 and EDA-205, now in progress will ensure that emergency modifications receive all of the necessary reviews and approvals required by N0E-201 and its implementing instructions. In addition, until procedure revisions are complete, any emergency modification will be processed through station engineering as a normal modification.
Date of Corrective Action Implementation:
l Revision to STA-701 and EDA-205 will be complete by May 1, 1985.
NOTICE OF VIOLATION 445/8431-08 (cont.)
RESPONSE: (cont.)
8431-08(c)
Deficiency:
Record retention requirements had not been adequately established in station procedure STA-302, Revision 4, in that four Technical Specification record types were not identified for retention.
Appendix A to ANSI N45.2.9 is utilized in STA-302, " Station Records", as a general guideline for types of records to be retained and their retention periods. As stated in Appendix A, this list is not "all inclusive" and therefore has never been used as the sole document for making record retention determination decisions. To provide adequate procedural guidance to station personnel concerning record retention, additional action is necessary.
Corrective Action:
Station procedure STA-302 will be revised deleting attachment seven (7),
referred to as attachment five (5) in the NRC inspection report. STA-302 will be further revised to state:
" Retention periods for all records relating to quality related items and activities shall be in accordance with the requirements of Section 6.10 of the Technical Specifications, the FSAR, the requirements contained in ANSI N45.2.9-1974 as endorsed by NRC Regulatory Guide 1.88 (10/76)."
Preventive Action:
The proposed revision to STA-302 will provide additional guidance to station personnel for meeting Technical Specification and FSAR requirements for record retention.
Date of Corrective and Preventive Action Implementation:
STA-302 will be revised by April 1, 1985.
NOTICE OF VIOLATION 445/8431-14 10 CFR Part 50, Appendix B, Criterion XII, states, in part, that measures shall be established to assure that tools, gages, instruments, and other measuring and testing devices used in activities affecting quality are properly controlled, calibrated, and adjusted at specified periods to maintain accuracy within necessary limits.
CPSES FSAR. Section 17.2.12 " Control of Measuring and Test Equipment," states in part, ". . . Control for measuring and test equipment include the transportation, storage, and protection of equipment.
The Operations Administrative /QA Plan established the responsibilities for developing and implementing procedures for control of measuring and testing equipment.
Contrary to the above, control and calibration of measuring and testing equipment was not adequately established, including assignments of responsibility for equipment checkout and transportation.
RESPONSE
Discussion:
The Violation identifies the absence of six elements in Procedure STA-608 Revision 5, Control of Measuring and Test Equipment, considered necessary to be in station procedures for adequate control and calibration of measuring and test equipment (M&TE). Each element is separately addressed showing corrective measures taken, or to be taken, which will ensure that the procedural deficiency has no impact on safety related M&TE activities.
Training will be conducted to make responsible personnel aware of proposed corrective and preventive actions.
Element No. 1:
o The organization, departments, or section responsible for station M&TE.
STA-608 does not uniquely identify each group, by name, which has responsibility for station M&TE. Under the CPSES program, it is possible for any station group to procure measuring and test equipment (M&TE) for which they become responsible.
S'2A-608, " Control of Measuring and Test Equipment" is a Station Administration Manual procedure, developed under the joint direction of the Engineering and Maintenance Department Superintendents as tasked by paragraph 1.0 of Section 6.5 of the Operations Administrative Control and Quality Assurance Plan (OAC/QAP). STA-608 delineates the requirements for the control and calibration of all M&TE used by station personnel. STA-608, Revision 5, stated in part, "This procedure applies to measuring and test equipment that is used in quality related activities . .. The intent of of this statement was to make STA-608 applicable to all M&TE owned or used by plant personnel regardless of which department (Administration, Engineering, Maintenance, or Operations) owned or used the M&TE. Revision 6 to STA-608 which was issued 8/8/84 and Revision 7, which was issued 1/7/85, applies to all (M&TE) unless an exception is specifically authorized In those cases, procedures will be written to cover the specific M&TE.
NOTICE OF VIOLATION 445/8431-14 (cont.)
RESPONSE (cont.):
Corrective Action:
STA-608, Revisions 6 and 7, issued subsequent to the audit clarify that STA-608 is applicable to all station M&TE except for radiation protection equipment and chemistry equipment which are specifically exempted under the applicability statement of STA-608, Revision 7.
Preventive Action:
The corrective action taken will ensure that organizations, departments or sections responsible for station M&TE are identified.
Date of Corrective and Preventive Action Implementation:
STA-608, Revision 6 was issued August 8, 1984. STA-608, Revision 7 was issued January 7, 1985.
Element No. 2:
o Responsibility for promulgation and distribution of the supervisory schedules used for M&TE calibration.
STA-608 does not specify who is responsible for the promulgation and distribution of the supervisory schedules used for M&TE calibration. The MODS system is designed to track date of last calibration, compute the date of next calibration and, when requested, print out the MODS Supervisory Summary indicating those calibrations due the next month. It has been the responsibility of the supervisor owning the M&TE to request the Supervisory Schedule and the work sheets.
Corrective Action:
STA-608 will be revised to clarify this issue.
Preventive Action:
The corrective action will ensure that responsibility for development and distribution of supervisory schedules used for M&TE calibration is identified.
Date of Corrective and Preventive Action Implementation
- STA-608 will be revised by K1y 1, 1985.
NOTICE OF VIOLATION 445/8431-14 (cont.)
RESPONSE (cont.):
Element No. 3 o Equipment Checkout STA-608, Revision 5, did not adequately address equipment checkout. As a minimum, the following information is required to control the checkout of M&TE:
o Description of M&TE o Model Number .
o Tag Number o Identify of individual checking M&TE out o Time /Date of Checkout o Identity of activities that M&TE is to be used on (component or procedure) o Time /Date of check in Corrective Action:
STA-608 will be revised to require that M&TE issue will be controlled by a checkout form and log containing the above information.
Preventive Action:
Proposed revision stated in the Corrective Action will ensure the control of M&TE checkout.
Date of Corrective and Preventive Action Implementation:
STA-608 will be revised by May 1, 1985.
Element No. 4:
o Cross department procedure for sharing or use of M&TE Corrective Action:
Subsequent to the NRC inspection, STA-608 was revised to include requirements limiting access to M&TE by personnel outside the owning department, and requires checkout when access is granted. (Reference STA-608, Revision 7, Paragraph 4.7.2)
Preventive Action:
The added procedural requirement to STA-608, Revision 7 will adequately address departmental sharing of M&TE.
Date of Corrective and Preventive Action Implementation:
STA-608 Revision 7 was issued January 7, 1985.
NOTICE OF VIOLATION 445/8431-14 (cont.)
RESPONSE (cont.):
Element No. 5:
o Procedures to ensure M&TE is used by only qualified personnel.
STA-608 does not address the qualifications of personnel who checkout M&TE.
All CPSES training programs address the qualifications of personnel and discuss the training needed to carry out their respective tasks. The knowledge of how to use M&TE for the assigned task is only one aspect of an individual's qualifications; consequently, an individual checking out M&TE for an assigned task is required to have the necessary qualifications for that task. It is the work group supervisor's responsibility to ensure that their personnel are qualified to perform a task, not the M&TE checkout program.
However, procedures do exist which identify training and qualification requirements necessary for an individual to perform a task.
Element No. 6:
o Procedures to ensure safety during use and transportation.
Corrective Action:
Subsequent to the NRC inspection, STA-608 was revised to include the requirements for handling M&TE in a manner which precludes any adverse effect on equipment calibration (reference STA-608, Revision 6 and 7, paragraph 4.7.4) and the requirements for transporting M&TE in accordance with WHS-004,
" Packing and Shipping.of Materials, Parts, and Components". (Reference STA-608, Revision 6 end 7, paragraph 4.4.2.5.)
Preventive Action:
Revisions 6 and 7 of STA-608 will ensure the adequate safety of M&TE during use and transportation.
Date of Corrective and Preventive Action Implementation:
STA-608, Revision 6 was issued August 8, 1984. STA-608, Revision 7 was issued January 7, 1985.
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