ML20091K399

Responds to NRC Re Violations Noted in IE Insp Rept 50-346/84-01.Corrective Actions:Station Review Board Subcommittee Received Closed Internal Audit Finding Repts by Direct Distribution from QA

ML20091K399
Person / Time
Site:	Davis Besse
Issue date:	05/22/1984
From:	Crouse R TOLEDO EDISON CO.
To:	Norelius C NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
Shared Package
ML20091K394	List: ML20091K399
References
1-431, NUDOCS 8406070047
Download: ML20091K399 (7)

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l Docket No. 50-346 TotEDO

!i(}!kICIPN License No. NPF-3 ncomo p cmau Serial No. 1-431  %.~ ,

s. . .,

May 22, 1984 mam Mr. C. E. Norelius, Director .

Division of Project and Resident Programs j United States Nuc1 car Regulatory Commission Region III 799 Roosevelt Road Glen Ellyn, Illinois 60137

Dear Mr. Norelius:

l Toledo Edison acknowledges receipt of your April 18, 1984 letter (Log No.

1-946) and enclosures; Appendix, Notice of Viointion; and report 50-346/

84-01 (DPRP), referencing five apparent violations.

In your inspection report cover letter, you requested Toledo Edison to describe the steps we plan to take to strengthen our interim actions prior to the impicmentatio- of the Performance Enhancement Program. Subsequent to issuance of Inspection Report 84-01, on April 27, 1984, Toledo Edison met with representatives from Region III and provided a comprehensive up-date of the interim measures being taken. Based upon the discussions that ensued at that meeting and the comprehensive material presented.

Toledo Edison believes the request contained in Inspection Report 84-01 was satisfied.

Following an examination of the items of concern, Toledo Edison herein offers information regarding these items:

1. Violation: Technient Specification 6.3.1.6.e atatent The Station Review Board shall be responnihte for inventigation of all violations of the Technical Specifications in-cluding preparation and forwarding of reports covering evaluation and recommendations to prevent recurrence to the Vice-President-Nuclent and to the Company Nuclear Review Board.

Contrary to the above, completed Audit Finding Reports 1051-1, 977-2, 959-7, 959-8, 1001-1, 1001-4, 1001-5, 1001-6, 1072-1, 842-1, 906-1, 1069-1, and 1069-2 were not reviewed by the Station Review Board. Thin in a repent item of noncompliance.

This in a Severity 1.evel IV violation (Suppicment 1).

THE TOLEOO EDISON COMPANY EDISON PLAZA 300 MADIGON AVENUE TOLLDO OHIO 43052 9406070047 840601 1 PDR ADOCK 05000346 l G PDN MAY 2 41984

Docket No. 50-346 License No. NPF-3 [

Serial No.1-431 May 22, 1984 Page 2 Responset (1) Corrective action taken and the results achieved.

. A review of the completed Audit Finding Reports (AFR's) listed above indicated that two (2) were from internal <

audits and eleven (11) were from external audits. In-ternal audits are conducted within Toledo Edison organi-zations and external audits are conducted at the vendor's facilities.

Toledo Edison's review process requires the Station ,

Review Board (SRB) Subcommittee to review all internal audits for Technical Specification violations. The SRB Subcommittee submits their findings to the full SRB for appropriato action.

The SRB Subcommittee reviewed AFR 959-7 and 959-8 on March 8, 1984, and their findings were reviewed by the full SRB on March 14, 1984. No Technical Specification violations were identified. Therefore, with regard to the two internal AFR's, Toledo Edison complied with the Technical Specification requirements and AFR review practices.

With regard to the external AFR's (1051-1, 977-2, 1001-1, 1001-4, 1001-5, 1001-6, 1072-1, 842-1, 906-1, 1069-1, and 1069-2), Toledo Edison's position is that i they do not require r6 view by the SRB Subcommittee or the full SRB. External AFR's generally identify pro- i grammatic deficiencien with the vendor's implementation of his quality Assurance program.

(2) Corrective action taken to avoid further noncompliance.

The SRB Subcommitteu now receives closed internal AFR's by direct distribution f rom Quality Assurance.

Additionally, as a second check, the SRB Subcommittee will review the closed AFR Honthly Report on the Davis-Besse Maintenance Management System (DBMHS)

4onthly Report.

(3) 1 ate when full compliance will be achioved. l Full compliance was achieved March 14, 1984, when the SRB reviewed the SRB Subcommittee findings on AFR  ;

959-7 and 959-8.  !

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Docket Noo 50-346 License No. NPF-3 Scrial No. 1-431 .

May 22. 1984 Page 0 l

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2. Violation: 10 CFR 50, Armendix H. Criterion V stateu in part:

"Activitien affecting quality _shn11 he prescribed by documented instructions, procedurou or drawinga, et n type approprinto to the circumstances and shall be accomplished in accordance with these instructions, proceduren, or drawings..."

Contrary to the above, on February 9, 1984 instrument and control technicians woro using an uncontrolled drawing in the repair of core finod tank level indi-i cator 3Al.

This is a Severity 1ovel IV violation (Supplemont 1).

Responses (1) Corrective action taken and results achieved.

The use of information-only drawings in the Instrument

& Control (18C) Shop is a holdover from the situation which existed prior to the drawing control program.

The shops' developed their own marked-up drawings and have, out of familiarity, been reluctant to dispose of them. The drawings in question have boon removed from the 18C Shop.

(2) Correctivo action taken to avoid further noncomplianco.

Toledo Edison is pronently taking several measures to improve the control over information-only and uncon-trolled drawings. Davis-Basse Special Order No. 32 will be expanded to provido additional guidance over the use of information-only and uncontrolled drawings.

Outdated, marked-up, information-only drawings used in the field will be removed f rom all shop' s. reviewed by the staff, and compared with the existing drawinge, as a cross check, if necessary, and then disposed of.

Nuclear Safety Related information-only drawings may only be used for referenco purposes and, as a practico, will be discarded when no lonpar needed. The Special Order will specifically prohibit the use of such drawings for maintenance purposes in the field.

The une of uncontrolled Nuclent Gnfaty Related drawings for field maintenance purposos in the pinnt is prohibited.

Guidance will be provided in the Special Order to state that the drawings in instruction manunts should not be used and that corresponding controlled Station drawings should be utilir.ed for maintenanco purposes.

l .

t Docket N3. 50-346 1.icense No. NPF-3 Serini No. 1-431 May 22, 1981 Page 4 l

If a Nuclear Safety Related drawing in uncontrolled and is needed for maintenance purponen, Nuclear Facility Engineering will validate the drawing to the as-built condition prior to use.

(3) Date when full compliance will be achieved.

Full compliance will be achieved by July 30, 1984.

3. Violation: Technical Specit1 cation 6._8.1.a staten that written i proceduran shall be omtablished, implemented and '

maintaired covering the appitcable proceduren recom- _

mended in Appendix "A"_of Regulatory Guido L 3 3,  ;

November, 1972. Appendix "A" of Regislatory Guide  ;

1.33. November.1972 itata under Hection I, Admin- i

,tatrative Procedurse, item h entitled "I.og Entrien, Record Rotontion, and Review Proceduren." Administra-tive Procedura AD lH1H.02, " Performance of Survo11- i lance and Portodic Tentn," 8ection 4.2 staten once _a malfunctton han been idontifted to the shift super-vinor. . ."The tent may he niinpunded _ by tho 8ht f t Super-vinor unt11 the malfunct tonn _ are cleared, or it u.ay be, _

co,nteted m with the tent parnonnel making the adjunt=,

ment. The Shift Supervinor shall__ indicate the mittia=

tion in his log and on the_ tent _dattelency lint, if the_ Shift supervinor determinen that the dofteteney 1,n_ minor _nnd doen not aff6ct the operahtitty of equip; ment, the doficiency__nh_nll be noted on the tcat deitetency list and the tent continued to complotton." ,

AD lH lH29, Moction h.12 staten t hat af ter tbo Hhtt t. '

Hupervinor reviewn the te_nt resultn, he niiill nign the data cover sheet trdicating Technical Spectitentionn, ,

requirement a hava havn inet . . . "At thin point unicnolved ,

te_at dottciencien may extet an long as they_do not affect techntent_nportiten_ tion requiremonta or eqig ,

ment operahtitty." AD lH1H.02 Hortion $ and Fncinnure I requiron tent complotton hafore wohmittal to the phtft nopervinor for review.

i pontrary to the abryve g n Ifebrun L6. 19H4 dur,ing the_ _

l perf or_mance of tir 4011.01, the nh t t e _nuyervisor en-countcred a datletency nffeeting_aquip_m_cnt opor7iTt ty (the linf aty Fonturen Actient_ ton _.haque_nre) but_ didyt, muttpund _the t ent__or_ malto adju_nt men _t n al lowing _tlio_ t on_t t o cont inuel MT *>011.01 wan mu_b_m_it_to_d to t he aliif t_

mispe rv i no r p r i o r t o__t o_u t _r emp l e t i on ( t_he a r r ep t n_n c e j rttraria hn_d not hoon nigiled by_ tlie den _tannted tuviewar){ l and the ahlf t nupervisor nignud _t he _ dnta_ cover alicot, I i

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l Docket No. 50-346 1,1 cense No. NPF-3 Serial No. 1-431 Itay 22, 1984 Page 5 I

i with an unresolved tent deficiency that affected out-

, st9nding Technical Specification requirements. ,,,

l This is a Scvority 1.evel IV violation (Supplement 1).

Responnet (1) Corrective action taken and results achieved.

On February 6, 1984, whila performing ST 5031.01, Safety Features Actuation System (SFAS) Hontily Test.

l the computer was inoperable. At thin timo, :he Shift 1 Supervinor should have, but did not, suspend the test to reacheduto it when the computer was operable to meet the surveillance requirements of the Safety Fea-turen Actuation Sequencer. The acceptanco critoria was not signed of f when the Shitt Supervisor signed the tent. This was due to this test requiring the Donignated Reviewer to sign the acceptance critoria.

l llowever, the test la routed to the Donignated Reviewer l after the Shift Supervisor signs the test an por AD 1 1838.02, Performance of Surveillance and Periodit.

! Tests. On February 14, 1984 the test was rotun with l the computer verifying the Safety Featuren Actuation Sequencor surveillance requirements. Thin test was run prior to exceeding the Technical Specifica: Lou

, ocheduling requirements of February 17, 1984, 0840.

The Safety Features Actuation tioquencer was never inoperable.

(2) Corrective action taken to avoid further norcompliance.

To prevent the Bhift Supervinor from signing an incomplete test, a modification was writtei, to AD 1838.02, Performance of Surveillance and Psriodic Tents, instructing the Shift Supervisor t., either hold or suspend if the tent is unable to be completed.

A memo was written to the Shif t Supervisors to help clarify this matter.

The Bafety Featuren Actuation Surveillan:o Test van modified to have thu acceptance critorir nigned prior to submittal to the tihift Hupervisor. It van also modified to require the computer operahto prior to running the surveillance tent.

l (3) Data when full romp 11ance will be achieved.

Full comptinnee was achieved Hay 18, itH4, when the modification to AD 1838.02 and ST $031 01 were ap-proved.

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._ s.;

DockstrN5. 50-346 License No. NPF-3 Serial No. 1-431 May 22, 1984 Page-6 t-

~4. Violation: 10 CFR 50 Appendix B Criterion III states in part:

" Measures shall be established to assure that ap-plicable regulatory requirements and the design Y..

basis, as defined in 10 CFR 50.2 and as specified in the license application, for those structures, systems and components to which this appendix ap--

plies are correctly translated into specifications, drawings, procedures, and instructions."

Contrary to the above, the original installation of the control room emergency ventilation system was not properly translated into drawing M-027A.

Drawing M-027A is Figure 9.4-1 in-the USAR and FSAR.

Specifically, the ductwork associated with isolation dampers HV-5301 F and HV-5311 F is shown geing to the turbine building lavatory when this ductwork really goes to the control room lavatory. Also, the duct-work associated with isolation dampers HV-5301 G and HV-5311 G is shown going to the control room lavatory when this ductwork really goes-to the turbine building c

lavatory.

This is'a' Severity Level IV violation (Supplement 1).

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Response: (1) Corrective action taken and results achieved.

A review was performed of the control room emergency ventilation system design drawings, FSAR, and USAR.

This. review has concluded that dampers HV 5301G and HV 5311G are associated with ductwork going to the j; control room lavatory and dampers HV 5301F and HV

, 5311F are associated.with'the ductwork going to the di turbine building lavatory. Additional reviews of n  ; equipment lists indicates these dampers are identical.

Based upon the reviews performed, Maintenance Work Order (MWO) 1-84-1490-00 was issued.to change the damper identification tags to reflect the correct configuration as shown in drawing M-027A, Revision 23.

(2) Corrective action taken to avoid further noncompliance.

The damper identification tags have been changed to reflect the current configuration as depicted in the design drawing.

- Docket No. 50-346'

' License No. NPF-3 Serial No. 1-431 May 22, 1984 Page 7 (3) Date when full compliance will be achieved.

Under MWO 1-84-1490-00, the damper identification tags were changed as shown in drawing M-027A, Rev. 23, and walked down in a field inspection on May 10. 1984.

Very truly'yours, ffk  : "

RPC:SGW:nif

, cc: DB-1 NRC Resident Inspector A

F 1

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