ML20058N959

Forwards Revised Response to Violations Noted in Insp Repts 50-352/90-13 & 50-353/90-13.Corrective Actions:Ltr Issued to All Plant Personnel Providing Instructions on Proper Use & Handling of Controlled Documents in Controlled Locations

ML20058N959
Person / Time
Site:	Limerick
Issue date:	08/13/1990
From:	Leitch G PECO ENERGY CO., (FORMERLY PHILADELPHIA ELECTRIC
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
NUDOCS 9008150267
Download: ML20058N959 (8)

Text

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i PHILADELPHIA ELiiCTRIC1 COMPANY kiMERICK GE'NER ATING ST ATION-P. O. BOX A y l S AN ATOG A, PENNSYLV ANI A 19464 F- - (2:s) 327.i200, ext, sooo August 13, 1990 G M AH AM M. LEITCH .,

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LU.S. Nuclear Regulatory Commission '

~E . ATTN:L Document Control Desk i

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SUBJECT:

Limerick Generating Station, Unit 1 ',

Revised Reply to a Notice of Violation NRC Inspection Report Nos. 50-352/90-13 ,

4 and 50-353/90-12 '

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Dear Sirs:

Attached is a revised. Philadelphia Electric Company reply

'to a-Notico of-Violation for Limerick Generating Station (LGS)-

Unit'1, which was contained in NRC Inspection Report Nos.  ;

50-352/90-13 and;50-353/90-12 for-LGS, Units 1 and 2, dated May 7, 1990.- .This Notice of-Violation pertains to the failure to  ;

iproperly control documents affecting quality and was identified i

during . art NRC inspection conducted between March 6 and '

April 9', 1990,r'at LGS Units 1 and 2., -;

' . _ . .The attachment to this letter;provides.a restatement of the violation.followed by our~ revised response. During the performance of-the second audit of procedures.as committed to.in. .

the original response, discrepancies in other; controlled books wererldentified. We then. recognized the need to-revise this j

violation responce to identify that the initial audit completed  ;

on May 10,~1990,. was not sufficient to identify and correct 4

-deficiencies in the controlled copy procedure books.

Furthermore, during review of the-document. control program by the i new DAC-Supervisor, additional deficiencies in other controlled -

documents (e.g. drawings) were identified. Therefore, this i responseLis also,being. revised to. include all of the corrective  ;

actions directed at these additional deficiencies. The changes  !

are' indicated by revision bar markers in the right hand margins.  :

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, .. -lIf you have any questions,~or require additional I 1

intormation please contact us.

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Very truly yours, j

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aGraham'M. Leitch b .

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's Vice President, LGS.

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DMS/JLPacah Attachment ,f.; -

c e t -. T. T. Martin ~, Administrator, Region I USNRC -(

T.-Ji' Kenny, USNRC Senior Resident' Inspector,. LGS '

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Attachment' ,

. Page-1 of 6

., Inspection No. 50-352/90 Reply to a Notice of: Violation Restatement-of'the Violation-  ;

1 As a-result of an inspection: conducted on March 6 - April 9, i 1990,.and'in accordance-with NRC Enforcement Policy (10 CPR 2, j Appendix C), the following violation was identified: i 10.CFR 50, Appendix B, Criterion VI, " Document C0ntrol,"

requires that measures be' established to control the issuance of procedures, including changes, which prescribe alltactivities affecting quality, and that these procedures, including changes, are distributed to the location where the prescribed activity is-performed. These requirements are implemented by Administrative Procedure A-2, " Control of Procedures and Certain Documents." l Contrary to the above, on March 30, 1990, the Construction  !

Building-controlled procedures were'found to not be maintained per A-2 in that there were obsolete procedure revisions, missing-procedures, misfiled procedures'and a missing volume of procedures, i

This is a Severity' Level V violation. (Supplement I)

RESPONSE  ;

Admission of Alleged Violation  !

i' Philadelphia Electric Company (PECo) acknowledges the violation.

Background

From March 6, 1990, to April 9,.1990, the Limerick Generat! rig Staticn (LGS) NRC Resident Inspectors conducted an inspection of the Document Control ~and Records Re:ention Programs for LGS. During their inspection, they issued one triolation related to the Document Control Program. This violation concerned missing and misfiled controlled procedures, incorrect revisions of controlled procedures, and missing controlled procedure books identified in the Controlled Document Locations (CDL). Additionally, the Inspectors identified discrepancies

-with the. Records Retention Program in that boxes of completed procedures were improperly stored, inspection of the PECo storage vault was not being. properly performed, and periodic testing of the Bechtel storage vault fire protection system was not being performed at the established frequency.

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Attachmsnt

_Pagt 2 of'6

. Inspection No. 50-352/90-17 i 4

,  ; Reason forithe-Violation The cause of this violation as well as the identified discrepancies is the result of two principa1 factors. The first principal' factor was insufficient management oversight to_ ensure

'that comprehensive programs existed.in the areas of Document Control and Record Retention. The second principal factor was. ,

that the. administrative controls were inadequate-to ensure an  !

effective controlled document usage and handling process.  ;

Corrective Actions Taken and Results Achieved After Plant Management was notified on March 30, 1990, by j the NRC Resident Inspectors of the violation and discrepancies

-for the Document Control and Records Retention Programs, the- i following immediate corrective actions were implemented. j o On March 31, 1990, a review of six of the largest CDLs at LGS was initiated.- Approximately one-third of the procedures in-these CDLs were reviewed to determine the extent of_the problem. Discrepancies similar to those cited l-in the violation were identified in each CDL. Therefore, on April 2,.1990, an audit of procedures issued and controlled by LGS Document Administration Center (DAC) was initiated.

L The audit was completed by May 10, 1990,~but discrepancies e L were identified in the master listing indicating that  ;

l several CDLs were not audited. _A second' comprehensive audit was initiated and completed by July 31, 1990, to provide the.  !

assurance that all procedures controlled by LGS-DAC and the master distribution list are being adequately maintained.

L All discrepancies. identified during the second audit-were ,

b corrected by July 31, 1990.  ;

) o .On April 12, 1990,- a letter was issued from the LGS Support Manager, responsible for Document Control, to all LGS personnel providing instructions on_the proper use and j handling of the controlled documents in the CDLs.

o On AprilR23, l'90, a letter was issued from the Support  !

Manager to Site Management requesting their assistance to ensure the proper use of all controlled documents within their departments at LGS.

o The boxes of completed procedures which were improperly i stored were shipped to the PECo storage vault by April 6, 1990.

o A complete audit of controlled copies of Technical Specifications (TS) books on site was completed by July 31, 1990. Prior to the audit we reevaluated the number

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'Attachm3nt;

$s hf . Pagt 3 of 6 Inspectibn1No. 50-352/90 'j h '.

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of_ controlled copies of TS-books, significantlyLreduced the-i e distribution and removed the deleted books.- Obsolete'pages,

missing pages, and misfiled;pages were discovered and

-immediately corrected. ,

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o A 100% audit of Technical Specification PORC Positions, a controlled document, is in progress and' expected to be sT complete by~ August 15,.1990.

T'" . o. .A 100% audit of all as-built drawings is in. progress and 7(g expected to be complete:by August 17, 1990.

/mib 1o The distribution of Nuclear Group Administrative Procedures

'at LGS will be reviewed and a 100% audit of all locations 11s si+ expected to be-complete by September 25, 1990..

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o The Final Safety Analysis Report (FSAR) books at LGS have not been audited; however, distribution of the-initial

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issuance ~of;the Updated Final Safety Analysis! Report is currently _-being performed- . The distribution'has been significantly; reduced and the DAC will assume responsibility 3 for all future updatss. This eliminates'the need-to audit the FSAR books.  ;

o- Review and evaluation of documents including but not.llmited' j to Root Cause Analysis Manual, Industrial Safety and Health Manual, Testing and Laboratories Procedures, and Evaluated

' Chemicals / Materials List is being performed to. determine the  ;

required leveliof control and the groups responsible.for.

i maintaining this information. This is expected-to be- t complete by December 31, 1990.

o Administrative Procedure A-6.1, " Control of Vendor Manuals," ,

was issued on July 24, 1990 to define the Vendor Manual Program.

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Corrective Actions to Prevent Recurrence L

To assure adequate oversight of all controlled documents at 1

! LGS, the following administrative controls and corrective actions will be implemented and completed. These corrective actions will prevent _ recurrence of the violation as well.as the discrepancies addressed in Section 10 of this Inspection Report.

o .A random sampling methodology is being developed using L~ Military Standard 105, " SAMPLING PROCEDURES AND TABLES FOR INSPECTION BY ATTRIBUTES." This periodic random sampling methodology will be performed on all the CDLs and will l

identify specific deficiencies, potential problem areas, and

adverse trends in a timely manner. Follow up actions will

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Attachment' Pago 4 of'6 Inspection.No. 50-352/90 be developed for errors identified during/the: periodic L

. random samplingx based on the number and-the severity of-the.

errors. A procedure will be written to ensure this periodic.

+ random sampling methodology is performedLon-an established frequency. An " Administrative Guideline" (AG)'will be written to' describe how to perform the-periodic random sampling methodology. The AG will be implemented through the above procedure. This random sampling-methodology'will be implemented by October 1, 1990; In the' interim, a.

complete' audit of procedures issued and controlled by LGS

- DAC was completed on July- 31,.1990. This audit was initiated.to provide additional assurance that all procedures controlled by LGS DAC~are being adequately maintained. Another 100% audit-to provide additional-assurance that distribution schedules are correct and all-procedures are accurate is expected to be completed by September 25, 1990.

This random sampling would identify discrepancies of the type identified in a previous Violation, 50-353/89-81-01.

However, the corrective _ actions taken in response to;that violation would not have prevented the discrepancies identified in this violation from occurring.

o On April'2, 1990, the Document Administration Center (DAC) supervisor was reassigned to a staff function outside of the

', Document Control and-Records Retention Program areas. The DAC supervisor was-replaced on an interim basis by the Superintendent-Administration until a permanent-replacement could be established. On May121, 1990, a new DAC supervisor was appointed.to assume the DAC' responsibility. The new DAC' supervisor-previously worked at LGS-as the Bechtel Document Control supervisor and has eleven years experience in2this-field. This individual will provide enhanced management oversight'of the Document Control Program needed to ensure that these discrepancies will not recur.

o General Employee Training (GET) will be revised to include a segment which emphasizes-the responsibilities of all LGS personnel for proper use and handling of controlled procedures.. The administrative guidance provided in the April 12 and April 23, 1990 letters, described previously, will also be addressed in this training. This item will be implemented by August 31, 1990.

o A review of the current Document Control and Record Retention Programs is presently being performed by the new DAC supervisor. After this review is completed, a reference manual describing the DAC functions, responsibilities, and training requirements will be developed and reviewed with all current and future DAC personnel. This manual will be controlled and neriodically reviewed by the DAC supervisor.

ja - t Attachmnnt s vn Pag 3'S ofL6

' Inspection No.150-352/90-13 w,

.This item will be completed and implemented by. December 131,

'1990..

o A revision to. Administrative (A) Procedure!A-46,

" Maintenance of Plant Quality Assurance Records," and a_new

. procedure A-46.1, " Nuclear Records-Management,".was issued

.on June 29,.1990. These procedures provide additional l clarification on the Record Retention Program processes and q defineLthe responsibilities of the DAC personnel and of the personnel-who interface with the DAC personnel regarding the storage of controlled documents.- ,

S o Quarterly inspection of the PECo storage vault was a responsibility of the previous DAC supervisor who was reassigned on April 2, 1990, as a result-of the previous document control problems. This function is now the responsibility of a clerk under the direction of the new DAC E stoervisor. .The issue regarding this Inspection Report-was reviewed and discussed with the new supervisor and' clerk to stress the importance of-performing inspections in accoedance with'all-procedures.

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.o Control of the Bechtel storage vault-fire protectiou system has been fully assumed by the LGS Fire Protection group.

Procedures RT-2-022-601-0.and RT-7-022-344-0 sere issued on  !

July 31, 1990 to assure that the fire protection system for this vault is properly. tested. Functional testing of the  ;

detectors is performed on a'six month frequency.

]1 o .The' existing method of distributing information from and to l Nuclear Group Headquarters and Peach-Bottom Atomic Power Station is being revised. . A111 controlled documents will be j distributed to a single point.of accountability at each a location. For LGS, this will be.the DAC supervisor. Direct i distribution to individuals from any of the-three. locations will be discontinued, providing better control and j l

accountability for all documents. We expect this new .

process to be completely in place by December 31, 1990. )

i Previous Violations 50-352/87-05-01, and 50-352/87-19-01, and Section=2.2.of Inspection Report 50-352/90-02, discuss ,

discrepancies with Category I red-lined (as-built) drawings. i

.This sub-group of' drawings is controlled by the Modification

' Coordination Section with procedure A-6, "Contrcl and

, ' Distribution of Drawings, Manuals, and Drawing Logs," rather than the DAC personnel with procedure A-2. Because of this, the L corrective actionsLidentified for these items would not have precluded this violation-from occurring.

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.Attcchm2nt Pag 3 6 of 6

. -Inspection No. 50-352/90-13

=Date When Full Compliance Was Achieved, Full' compliance with procedures controlled by. LGS DAC was achieved: by July 31, 1990. Full compliance with onsite r controlled copies of Technical Specifications books was achieved

, lby-July- 31,-1990. ' Full compliance with Technical Specifications ,

PORC, Positions and as-built drawings will be achieved at the [

completion of ongoing audits that are expected to be complete by_

- August- 17, 1990. Full compliance with Nuclear. Group l

-Administrative Procedures at LGS is expected by September 25, ,

1990. Full compliance for other controlled documents will be i k achieved-after determining the required level of. control, the .[

L group responsible for maintaining such documents, and performing audits of these documents. This is expected to be complete by

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December'31, 1990.  ;

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