IR 05000293/1981036
| ML20041D372 | |
| Person / Time | |
|---|---|
| Site: | Pilgrim |
| Issue date: | 02/05/1982 |
| From: | Blumberg N, Caphton D, Meyer G, Napuda G, Naquda G, Shaub E NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20041D355 | List: |
| References | |
| 50-293-81-36, NUDOCS 8203050268 | |
| Download: ML20041D372 (26) | |
Text
-
.
.
U.S. NUCLEAR REGULATORY COMMISSION OFFICE OF INSPECTION AND ENFORCEMENT Region I Report No. 50-293/81-E Docket No. 50-293 License No. DPR-35 Priority
-
Category C
Licensee: Boston Edison Company M/C Nuclear 800 Boylston Street Boston, Massachusetts Facility Name: Pilgrim Nuclear Power Station, Unit 1 Inspection at: Boston and Plymouth, Massachusetts Inspection conducted: November 30 - December 4, 1981 Inspectors: h d"9 O
G. Napudd, Reactgr[1spector date signed A
%,-
TfS f E S N. Blumberg, Reactor Inspector date signed W
b 2 82. -
.
Meyer, Reactor ispector dath signed
?$
$.h "
2/ ~ b'2-E. T. Shaub, Reactor Inspector date signed Approved by:
- 1i @ I A
D. L. Caphtcrf, Chief, Management date signed Programs Section, DE&TI
8203050268 820216 PDR ADOCK 05000293 (D PDR
-
.
.
-
..
.
.
,
i
,
i
!
i j
Inspection Summary:
Inspection on November 30 - December 4, 1981 (Inspection Report No. 50-293/
81-36)
Areas Inspected:
Routine announced inspection by four Region based inspectors of licensee action on previously identified inspection findings including those of Performance Appraisal Branch Inspection No. 50-293/81-20 and
,
i inspection of surveillance test scheduling.
The inspection involved 120 inspector-hours onsite by four Region based inspectors and 24 inspector-hours at the corporate office by three Region based inspectors.
Results: Non compliances: Three in the two areas inspected (Violation -
T.S. amendments not properly posted, paragraph 2); (Violation - Master surveillance schedule not established, paragraph 9); (Violation - Program
<
and procedures not established for station housekeeping, system protection
and system cleaning, paragraph 8.b).
.
.
.
i
!
!
.
<
!
l
'
l
I r
.
,.-
-..-
-
-
..
-
-, - - - -
.
-
.
.
Details 1.
Persons Contacted a.
Boston Edison Company W. Anderson, Information Resources Management Group Leader W. Armstrong, Deputy Nuclear Operations Manager R. Atkin:, Senior Electrical Engineer H. Brannan, Manager, Quality Assurance
F. Famulari, Group Leader, Operations Quality Assurance J. Frasu, Supervisor, Document Control Group J. Fulton, Licensing Group Leader F. Giardiello, Senior Compliance Engineer E. Graham, Senior Plant Engineer
R. Kennedy, Senior Quality Assurance Engineer
J. Lepore, Superintendent Store
R. Machon, Manager, Nuclear Operations
A. Morisi, Manager, Nuclear Operation Support Department
J. Nicholson, Staff Assistant K. Roberts, Chief Maintenance Engineer R. Silva, Senior Maintenance Engineer E. Ziemianski, Management Services Group Leader b.
Consultants / Contractors F. Kruse, Supervisor, Technical Information Operations, i
Raytheon Service Co.
N. McCarthy, Technical Information Operation, Raytheon Service Co.
C. Rice, Consultant, LRS
R. Staker, Consultant, LRS
c.
NRC H. Eichenholz, Resident Inspector
J. Johnson, Senter Resident Inspector
- denotes those present at exit interview conducted on December 4, 1981.
The inspectors also interview other licensee and contractor personnel including staff engineers, administrative support personnel, reactor operators
.and technicians.
2.
Licensee Action on Previously Identified Items (Closed) Unresolved Item (293/78-06-06): Review adequacy and timeliness of corrective action for QAD Audit 78-5.
The inspector reviewed documentation associated with corrective action and resolutions of identified deficiencies.
Based upon the actions taken by the licensee, this' item is closed.
,
.;..
.
.
i (Closed) Unresolved Item (293/78-26-02): Review corrective action for audit 78-17 to assure its acceptability and adequacy. The inspector reviewed documentation associated with the acceptance of corrective
,
'
action by the Quality Assurance Department (QAD).
Based upon the corrective action taken, this item is closed.
(Closed) Unresolved Item (80-11-01). The inspector verified that the
-
QA related procedures of the Testing and Standards Section, and the Nuclear Organization were incorporated into the index required by the QA Manual. Based upon the corrective action taken, this item is closed.
(Closed) Unresolved Item (80-11-02).
The inspector verified that paragraph 6.2.2.7 of Nuclear Operations Support Procedure 6.02-7, i
Issuance and Control of Facility Operating License / Tech Specifications i
and Revisions Thereto, Rev. 2 (draft), provided a method for alerting /
notifying operations personnel that a modification had been completed
,
'
in that interim prior to a drawing change notice being issued. The J
inspector noted that work instructions were being developed that would address the step by step details of this method. A licensee represent-ative stated those instructions are scheduled to be issued by February, 1982. Based upon the above, this item is closed.
(Closed) Unresolved Item (293/80-11-03).
The inspector verified that the clerical error on Drawing M-241 had been corrected. This item is
,
'
closed.
I (Closed) Unresolved Item (293/80-11-04).
The inspector verified that the subject aperture cards had been annotated with applicable PDCR numbers from the current master index. This item is closed.
(Closed) Unresolved Item (293/80-11-05): Review Corrective Action
System in detail for adequacy and timeliness. Based on the discussions in paragraphs 3 and 4 of this report this item is closed for record purposes.
(Closed) Inspector Follow Item (293/81-01-04):
(a) Station procedure 1.3.18, " Relief Personnel" should be revised to ensure that the oncoming shift signs the shift turnover sheet before assuming the watch.
The inspector determined that procedure 1.3.18 has been revised to require this.
(b) Station procedure E.M.1-19A, " Reactor Level Calibration", should be revised so that data sheet setpoints and acceptable water level ranges are consistent with those specified in the basic procedure. The inspector determined that procedure 8.M.1-19A has been revised to make basic procedure and data sheet setpoints consistent with each other.
.
.
_
'
.
.
(c) Although already in compliance with ANSI N18.7 - 1976, procedure 1.3.4 should be revised to clarify administrative instructions for retiring temporary changes or incorporating them into permanent procedures.
The inspector determined that procedure had not yet been revised. However, during this inspection, the licensee issued an office instruction for disposition of temporary procedures approaching their expiration date.
Based on the above actions for each item, this item is closed.
(Closed) Inspector Follow Item (293/79-21-05):
Amendment 38 to the Technical Specifications had been received by corporate officer, but had not been sent to Pilgrim Station for posting.
The inspector determined that Amendment 38 has now been posted to the Station Technical Specifications.
Based on the above, this item is closed.
However, the inspector noted that in one instance a " basis" page in the Control Room Technical Specification had not been removed when Amendment 38 had been posted.
This page was immediately removed by the Shift Supervisor.
The inspector conducted a review of the posting of later amendments to the Control Room Technical Specifications (T.S.).
During this review, the inspector determined that Amendment 49, received by the Station during October,1981 had not been posted to the Control Room copy as of December 3, 1981, and that Amendment 50 had been placed in the front of the Control Room copy without performing a page for page posting as required by the T.S. Amendment.
The inspector observed that by December 4,1981 the posting deficiencies noted above had been corrected.
Failure to properly post amendments to the Technical Specifications is contrary to Technical Specification 6.8.A and station procedure 1.3.6.
This is a violation (293/81-36-08).
(Closed) Unresolved Item (293/79-21-02): Temporary change 79-2 posted to Procedure 2.2.85, " Fuel Pool Cooling and Filte ing System", had not been documented by a Procedure Change Notice nor received by the ORC.
During this inspection, the licensee provided, documentation of ORC review of this change.
Based on this documentation, this item is closed.
_
_
______ __.
.
.
'
(0 pen) Violation Severity Level 5 (293/81-01-01):
Standby Gas Treatment System (SGTS) Fire Deluge System operability tests not performed as required by the Technical Specifications.
The I
licensee stated that this test had not been performed because an operability test would damage the SGTS charcoal filters. A design change is in progress which would allow an operability test of the sprinkler system.
The above modification had been scheduled to be completed prior to startup from the current refueling outage. However, the licensee has determined that they will not be able to complete the modification by plant startup. The inspector observed the draft of a letter to the NRC which will request an extension.until January 25, 1982.
In the interim, af ter startup, the licensee stated that fire patrols would be posted as required by the Technical Specification Limiting Conditions for Operation.
Until completion of final corrective actions, this item remains open.
3.
General The primary purpose of this inspection was to determine the adequacy and status of corrective actions described in the licensee's October 16, 1981, response (BECo letter # 81-249) to Management Appraisal Inspection Report 50-293/ 81-20 (PAS).
Those PAS identified deficiencies considered to be violations are identified as such and discussed in paragraphs four through seven.
The paragraph identification from the PAS report, and the page number and identifier from tne licensee's response is provided with each.
During the review of a PAS item, a more encompassing area of concern was identified and is discussed in paragraph eight. Deficiencies identified during this inspection are discussed in paragraphs two and nine.
An evaluation of the status of immediate and long term actions described in the licensee's response was communicated to NRC management for dis-cussion with the licensee in an upcoming management meeting.
This evaluation is summarized in the following table.
PAS Area and Concern Licensee Response / Commitment Findings / Status CORRECTIVE ACTIONS
1. Inadequate program.
Review of ot.her utilities No objective corrective action programs.
evidence of review.
.
...
.
..
-.
. _ _ _ _ _ _
_ _ _ _ _ _ _ - _ _ _ _ _
--
_
.
.
Elements of corrective Committee has action will be uefined and been formed to reviewed to develop an define elements.
integrated organizational approach by November 15, 1981.
A plan will be developed for Plan not yet the transition from the implemented nor current to the integrated a target date corrective action system and established, implemented by December 1, 1981 and implemented thereafter.
Evaluate and redefine the role To be included of Maintenance Requests (MRs)
in the develop-and Failure and Malfunction ment of the Reports (FMRs) in the correct-integrated ive action program.
Establish corrective the Situation Statement Form.
action system.
Target date for implementation not established.
2. Failure to implement Evaluate present LER review Interim completion program.
process.
Establish LERs as December 2, data source for trend analysis.
1981.
LER analysis in draft form.
3. Inadequate training Not addressed.
The new training for personnel in use program should of system.
incorporate this aspect.
QA AUDITS-
1. Lack of management Initiated acti.ons to implement Boston Edison support and program requirements; increased Quality Assur-responsiveness, discipline and responsiveness ance Manual by senior management.
(BEQAM) revised to require increased escalation of items to manage-ment.
-
-
-___________ ___ _
.
-
-
.
.
.
4 Increase staff by ten QA Positions Engineers.
Commence authorized by J
'
aggressive recruiting effort.
management.
,
Currently using contracted consultants (auditors).
(N00) and QA Managers increase No ob.iective personal involvement evidence-of participation in audit interviews.
yet.
Establish a program to improve Implement a QA communications and relations indoctrination between N00 and QA Departments, and training program for NOD and NSRAC by April 1, 1982.
2. Program BEQAM revisions to better BEQAM and proc-
,
!
inadequacies, define Significant Deficiencies; edure revisions and, escalate them to senior 1981.
level management.
3. Failure to Modify NSRAC charter to clarify Initial NSRAC implement oversight responsibilities for charter revision program.
safety related activities, by December 15, 1981.
Further major changes anticipated.
No target date established.
Establish verification DR Log being schedule for Deficiency expanded.
To Reports (DR) to ensure comple-establish a tion of corrective action and Follow-Items 30 day verification by QA.
Coordinator for corrective actions.
Employment offer to individual Employment to perform trend analysis.
offer made.
Trending now being done by consulting firm.
I
.
.--.-.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_-
l
.
,
QA audits to include summary Summary included evaluating effectiveness of in recent QA QA program elements audited, audits.
COMMITTEE ACTIVITIES l
Operations Review Committee (dRC)
1. Inadequate Charter.
Review charter against Review and T.S., R.G. 1.33, and recommendations ANSI 18.7.
Recommend completed
--
changes by November 23, 1981.
November 23, 1981.
2. Failure to perform Assess for preferred method-Management required review.
ology and develop a system to reviewing method-assure capture of items for ology. Target ORC agenda.
date for complet-ion not established.
Review the ORC " follow Backlog of items list" and reduce its scope.
being reduced. A subcommittee to be established approximately January.1982 to perform detailed review of items.
3. Committee Training plan to be developed.
Plan to be Responsibilities, developed and first training session presented by January,1982.
Nuclear Safety Review and Audit Committee (NSRAC)
1. Inadequate Charter.
Change Charter and develop Charter revised
-
additional implementing December 15, 1981.
procedures.
Further major changes / revisions planned.
_
_
_____ _ _ _-- __
.
_[.
.
.-
,
.
2. Committee Train members and include Training given Responsibilities.
training into implementing August 7 and procedure.
~
20, 1981.
Training
-
Manual issued and procedure is in draft.
,
Review Nuclear Engineering Formal handouts Department (NED) and N00 distributed to procedures that address safety members.
Draft issues, procedure address-
,frg safety evaluations in comment cycle.
3. Failure to perform Charter requires review of NED to perform required reviews.
only safety related items and systematic violations.
reviews of LERs and FMRs, and report results to NSRAC.
Identify review requirements.
Anticipated major charter revisions will address.
- PROCUREMENT 1. Written program Review of department procedures Review being was inadequate to ensure compliance with BEQAM performed by for procurement, and other requirements, and contracted storage and coordination of those procedures services.
receipt inspections. ' by March 1,1982.
Revise BEQAM to reflect organ-BEQAM has been izational changes and complete revised and preparation of procurement procedures
'
proceduresa being revised.
QA Department'to conduct audit of Audit in process.
Procurement Document Control to evaluate Part 21 applicability I
by December 31, 1981.
l
)
. f"
,,. -
_ _ _ _ _ _ _. _ _ _ _ _ _. _ _ _ _ _ _. _ _. _ _ _ _ _ _ _
_
_
_
.
_
l
.
.
BEQAM revised to request that BEQAM has been cognizant engineer list special revised.
- storage,- shelf life, and preveut-ive maintenance requirements by November 15, 1981.
f Revise procedures to include ANSI Procedures N45.2.2 requirements by December revised.
31, 1981.
i Revise BEQAM and procedures to In process.
,
include ANSI N45.2.13 require-ments by December 31, 1981.
<
2. Lack of Training.
Scoping of training program Consultant requirements in process; prepare performing this and issue procedures by December task.
Completici 31, 1981, and implement.
expected by March, 1982.
'
Provide additional training on Training receipt inspection by October presented
.
23, 1981 with periodic refresher November 6, 1981, training.
3. Inadequate QA will expedite required audits Supplier audits Implementation of suppliers on the Approved being conducted Supplier List to -complete them by contracted
' -
by December 31, 1981.
services so as to meet target
'
date.
,
QC Hold Area to be established.
Established.
Hazardous material storage to Material removed comply with ANSI N45.2.2 by from warehouse December 31, 1981.
and stored in trailers.
Evaluation underway to remove Consultant has items with questionable-two engineers traceability from the site by doing evaluation.
December 31, 1981.
.c
,
-
- --
--
,
.
.
MAINTENANCE
i 1. Lack of Integrated Consulting firm developing a In process.
Preventive Mainten-Master Equipment List and a
,
ance (PM) Program, report on PM requirements (Phase I).
Develop an Implementing Plan Expect to
,
and procedures between February proceed as
'
and April, 1982.
Develop soft-scheduled.
EDP ware for EDP.
and software to start May, 1982.
2. Lack of Control of Establish policy regarding.issu-To be incorporated
"As Builts" and ing Design Change Notices (DCN)
into work vendor manuals.
and revise procedures as system. Change necessary.
to procedure
,
initiated.
'
Manuals audited by Document Procedure not
Control group.
Procedure to be yet revised.
revised to require periodic Licensee estimates audit of manuals.
six to twelve months needed to establish method of control.
,
3. Large Backlog of Review backlog of Priority C vs.
Review done Low Priority (C)
safety related items.
Revise twice.
Procedure Maintenance procedure to prohibit use of not yet revised.
Requests (MR).
category C for safety related items.
4. Inadequate Training.
Maintenance instructor hired.
Veri fied.
Formalize training program by Action in early 1982; increase staffing progress as to allow late 1982 implement part of a three ation; ensure QA elements are year commitment included in program.
to training.
i I
.
,
.
.
5. Inadequate Establish matrix of requirements Little action Housekeeping.
from ANSI standards and propose accomplished methodology. Develop procedure and target date and implement.
for completion not established.
TRAINING
Licensed 1.
Inadequate Manage-Issue policy directive by VP Draft has been ment Concern.
on commitment to training.
on VP's desk several days as of December 4,1981.
Organization policy statement by Draft on VP's December 1, 1981 to integrate desk for signa-onsite/offsite training.
ture.
Update corporate and site-Completed, personnel position descriptions except for one by March 1, 1982.
onsite technical support group.
2. Inadequate Program.
Reformating and revision to the No action or Training Program and Manual.
date targeted for completion.
Training manual deficiencies for Draft completed, certain groups of individuals, approval antici-to be corrected by March 31, 1982. pated by December 15, 1981.
3.
Failure to Actions to prevent recurrence to Procedure yet Implement Program.
be developed by first quarter to be developed 1982.
with completion date not targeted.
'
Training Manager to audit train-Records audited
'
ing records quarterly.
August 11, 198 _
.
_
.
.
.
.
.
.
.
.
Non-Licensed 1. Lack of Corporate General Employee Training (GET)
Position to be Policy and Inade-will be the responsibility of one filled by quate Program, element of the Training Department. April, 1982.
Site policy statement to be Posting Completed.
summarized and posted by November 11, 1981.
Revise Training Manual to include Manual revision specific discipline training by targeted for 1982, and contractor training by Ap ril, 1982.
March 31, 1982.
Health Physics training started
September, 1981.
i Issue training procedures for Being developed Purchasing and Stores Department.
by contracted
!
services.
Completion targeted for Apri l, 1982.
5. Inadequate QA Manager will verify each QA Completed.
Implementation.
individual's qualifications.
Respective chiefs to verify each Station Manager plant individual's qualifications stated this has been done.
Add necessary resources to Training Manager incorporate full implementation stated training i
of discipline training for 1982.
to be implemented at least one module per discipline by December 31, 1982,'and four new training positions have been authorized.
4.
Corrective Action Systems a.
Documentation was not provided on the majority of the Failure and Malfunction Reports (FMR) examined in those areas of the form designated as the responsibility of the ORC secretary or Senior i
-, ~ -
.
,
Compliance Engineer.
Specific examples include FMR's 81-59, 81-62 and 81-79 (PAB paragraph 7.a(3)).
The above is contrary to 10 CFR 50, Appendix B, Criterion V, Instruction, procedures, and Drawings; which states in part,
" Activities affecting quality shall be prescribed by documented instructions, precedures or drawings... and shall be accomplished in accordance with these instructions, procedures or drawings."
The Boston Edison Quality Assurance Manual, Section 16.3.7.3 requires corrective actiota resulting from failures and malfunctions be documented and records thereof be maintained in the Station File.
Further, Nuclear Operations Dept. procedure 1.3.24 Failure and function Reports, paragraph C4 also requires the Senior Compliance Engineer to indicate final disposition of the event on the FMR form.
The QA Department conducted Audit 81-25 during November, 1981, and the corrective action associated with identified FMR deficiencies is to be monitored by the Audit Followup System.
The inspector determined these actions to be consistent with the licensee's response (page 16, Observation #(3)).
No further response to this violation required.
The licensee response did not provide a time frame for the full establishment of the Corrective Action Program. This will be discussed with the licensee by NRC management during an upcoming meeting. Any committment the licensee may make as a result of this meeting and the progress in establishing the Corrective Action Program will be reviewed during a subsequent inspection (IFI 293/81-36-01).
b.
Quality Assurance personnel did not provide verification of the implementation of corrective action on " Failure and Malfunctions" during the two years for which Failure and Malfunction Reports were examined (PAS paragraph 3.1(2)(c)).
The above is contrary to 10 CFR 50, Appendix B, Criterion V, Instruction, Procedures and Drawings, which states in part,
" Activities affecting quality shall be prescribed in documented instructions procedures or drawings... and shall be accomplished in accordance with these instructions procedures or drawings.
]
Further, Boston Edison Quality Assurance Manual Section 16.3.7.2
!
requires Quality Assurance personnel to verify that the corrective action has been properly implemented.
j The inspector verified that the QA Department is verifying correct-ive action within 30 days of its completion with respect to current audits. Additionally, Audit 81-25 (November, 1981) was conducted to determine the status of outstanding corrective
. actions from previous audits. This corrective action is consistent L
l
_ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _. _
d
.
.
with the licensee's response (page 8, item (2c)).
No further response to this noncompliance is required.
However, the inspector stated that the adequacy and timeliness of corrective actions associated with Audit 81-25 will be reviewed during a subsequent inspection (IFI 293/81-36-02).
The licensee acknolwedged the inspector's statement.
5.
Quality Assurance Audits a.
The Unresolved Deficiency Summary had been issued only three times (Jan., April, and July) in the nine months preceding the August, 1981 PAS inspection.
This Summary served as the primary notification to the Vice President-Nuclear for " review and appropriate action" on those deficiencies that " exceed the response due date or the planned resolution date." (PAB paragraph 3.a(2)(a)).
The above is contrary to 10 CFR 50 Appendix B, Criterion V, Instruction Procedures and Drawings, which states in part " Activities affecting quality shall be prescribed by documented instructions, procedures, or drawings... and shall be accomplished in accord-ance with these instructions, procedures or drawings.
Further, the Boston Edison Quality Assurance Manual (BEQAM) Section 16.3.8 requires that, " Unresolved deficiencies, those which exceed the-response due date or the planned resolution date, are submitted for review and appropriate action to the Vice President-Nuclear
on the monthly Unresolved Deficiency Summary."
The licensee is presently issuing the Unresolved Deficiency Summaries monthly to the Vice President-Nuclear and concurrently developing the computer software to incorporate the Unresolved Deficiency Summary into their computerized Licensing Tracking System. The inspector determined that these actions were consistent with the licensee's response (page 7, item (2a)).
This violation is considered closed, and no further licensee response is required.
b.
Trend Analyses have not been performed on Deficiencies, Nonconform-ances, and Stop Work Orders since July 24, 1980.
(PAS paragraph 3.a (2)(d)).
The above is contrary to 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures and Drawings whdch states in part,
" Activities effecting quality shall be prescribed by documented instructions,-procedures, or drawings and shall be accomplished in accordance with these instructions, procedures, or drawings.
'Further, the Quality Assurance Department (QAD) Procedure 16.02, Revision 5, Section 6.1, requires that documents relating to Deficiencies, Nonconformances, and Stop Work Orders be reviewed
_
routinely to determine any adverse trends and a Trend Analysis Report be submitted to the Quality Assurance Manager at least every six month.
.
The licensee is currently employing a consultant to perfccm trend analysis. Draf t copies of the LER & Fire Protection Trend Analysis have been forwarded to the QA Manager with a subsequent report to be issued to Boston Edison Management by December 15, 1981.
The inspector reviewed the drafts and determined ne above date, specified in the licensee's response (page 8, item (2d)), should be met. No further response to this violation is required.
c.
Audits of the results of all actions required by deficiencies have not been performed semi-annually.
The scope of the semi-annual corrective action audits have included only those actions taken on IE Bulletins, 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> LER's and NRC inspection reports l
(PAS paragraph 3.a(2)(e).
The audits did not include "Nonconformances" and " Failure and Malfunctions," both j f which are required to be audited by Section 16, Corrective Act'on Systems, of the BECo Quality Assurance Manual (BEQAM).
The above is contrary to Technical Specification 6.5.9.8.C which l
requires that audits of facility activities shall be performed under the cognizance of NSRAC.
These audits are to encompass the
!
results of all action required by deficiencies occurring in facility equipment structures... that affect nuclear safety at least once per six months.
I The inspector verified that licensee audit 81-28, completed l
October 30, 1981, addressed the Corrective Action System and l
included Nonconformances and " Failure and Malfunctions".
The l
inspector also verified that it was conducted in accordance with j
BEco QAM requirements, and this action was consistent with the
!
licensee's response (page 8, item (2e)). No further response to this violation is required.
d.
A semi-annual cudit on nonconforming material and annual audits
,
i of document control, records, QC inspections, and control of
!
measuring and test equiprent scheduled for completion during 1980 were not performed.
(PAS 3a(2)(f)).
The above is contrary to 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures e d Drawings which states in part,.
" Activities effecting quality shall be prescribed by documented
instructions, procedures or drawings... and shall be accomplished
in accordance with these instructions, procedures, or drawings."
Further, the Boston Edison Quality Assurance Manual (BEQAM),
<
Section 18.3.1 states in part, " Quality Assurance personnel are to perform internal audits... in accordance with the frequency intervals specified... in order to verify implementation of the BEQAM."
As of December 2, 1981, twenty-two of the required 30 areas for 1981 had been audited or were in the process of being audited.
l
.
l
.
.
The licensee stetmi that the remaining eight areas to be audited in 1981 are scheduled for completion by the end of the calendar year. The inspector reviewed selected audit checklists, time and manpower planning for the 1981 audits in progress and planned, and the certification / qualifications of the contracted auditors.
The inspector determined that the quality of these audits was being maintained to previously established levels. This was consistent with the licensee's response (page 8, item (2f) and Observation #(3)). No further response to this violation is required.
e.
Quality Assurance audit reports contained no statement evaluating
"the effectiveness of the quality assurance program elements which were audited". All the report summaries examined contained statements regarding the implementation of the program elements, not their effectiveness (PAS paragraph 3a(2)(9)).
The above is contrary to the Boston Edison Quality Assurance Manual (BEQAM), Section 18.4.2.4, which requires a summary of audit results including an evaluation statement regarding the effectiveness of the QA program elements which were audited.
The inspectors reviewed QA audit 81-21, Quality Control, and verified the audit summary included a statement on the effectiveness of the QA program elements audited.
The inclusion of this statement in the audit summary was consistent with the licensee's response (page 8, item (2g)).
This violation is considered closed, and no further licensee response is required.
f.
The Quality Assurance Manager was not a member of the Nuclear Safety Review and Audit Committee (NSRAC) at the time of the August 1981, PAS inspection and had not been since the current QA manager assumed the position in September 1980 (PAS paragraph 3.a(6)(d)).
The above is contrary to 10 CFR 50, Appendix B, Criterion V Instructions, Procedures and Drawings, which states in part,
" Activities affecting quality shall be prescribed by documented instructions, procedures, or drawings... and shall be accomplished in accordance with these instructions, procedures, or drawings".
And, The Boston Edison Quality Assurance Department Procedure, and 1.01, Organization, Revision 7, requires that, "the QA manager reporting to the Vice President-Nuclear shall have responsibilities which include... serving as a member of the Quality Assurance Review and Nuclear Safety Review and Audit Committee".
The licensee has revised QAD Procedure 1.01, Organization, Rev.
8, October 14, 1981, to allow a senior member of the Quality Assurance Department to represent the Quality Assurance Manager / Department on the Nuclear Safety Review and Audit Committee. This corrective
.
.
.
action is consistent with the licensee's response (page 10, Observation
- (6)). This violation is considered closed, and no further licensee response is required.
6.
Committee Activities a.
Certain Quality Assurance Department audits conducted in 1980 were not reviewed by Nuclear Safety Review and Audit Committee (NSRAC). These audits were 80-20, Personnel Training and Qualification; 80-27, Operations; and 80-26 Maintenance, all of which contained noncompliance with Technical Specifications (PAS paragraphs 2.a(9) and 3.a(6)(a)).
The above is contrary to Technical Specification 6.5.B.7.e. which requires that NSRAC shall review violations of applicable statutes codes, regulations, orders, Technical Specifications, license requirements, or of internal procedures or instructions having, nuclear safety significance.
The inspectors reviewed the revision to BEQAM Section 18.4.1.1 which now requires distribution of all audit reports to upper management including Operational Review Committee and NSRAC.
This corrective action is consistent with the licensee's response
~(page 10, Observation #(6)), and the violation is considered closed with no further licensee response required.
,
b.
The Operational Review Committee (ORC) did not investigate all violations of the Technical Specifications (TS), specifically, QA audit 81-03 which discussed a violation of Technical Specifications Section 6.5.B.10 (PAB paragraph 2.a(2)).
The above is contrary to Technical Specification 6.5.A.6.e which requires ORC to be responsible for, " Investigation of all violations of Technical Specifications and-shall prepare and forward a report covering evaluation and recommendations to prevent recurrence
"
....
'
The licensee is in the process of reviewing the ORC charter and the methodology for determining agenda items for ORC. Audit 81-03 was reviewed by ORC in the meeting (#10) of December 2, 1981.
These actions are consistent with the licensee's response (page 2, Observation #(2)). This violation is considered closed, and no further licensee response is required.
The subsequent ORC charter changes ard the plan developed to determine agenda items will be revicyed during a subsequent inspection (IFI 293/81-36-03).
__
=
- -.
.
.
.
7.
Procurement a.
The following deficiencies were identified in the QAD, QC and Store Department procedures (PAB paragraph 9a(1)).
(1) BEQAM Sections 7 and 19, QAD Procedure 7.01 and QAD instruction 7.1 didn't address all ANSI N45.2.13-1976, paragraph 10.2, requirements regarding certificates of conformance.
Nuclear Engineering Department procedure 4.01 did not include the Regulatory Guide 1.123 paragraph 6.0 requirement regarding certificate of compliance.
(2) ANSI N45.".2-1972, paragraph 6.2 and 6.3, storage requirements are not adequately provided for in Stores Department Procedure 13.01.
(3) ANSI N45.2.2-1972, paragraph 6.2.1 and 6.3 storage inspection requirements were not contained in the QAD, QC, or Stores Department Procedures.
(4) Regulatory Guide 1.38, Revision 2, paragraph C.2.b requires test weights used for rerating hoisting equipment for special lifts to be at least equal to 110% of the lift weight.
Store Department Procedure 13.01 paragraph 6.4, allowed rerated equipment for special lifts t9 be tested to 100% of the lift weight.
This is contrary to 10 CFR 50, Appendix B, Criterion V that states in part, " Activities affecting quality shall be prescribed by documented instructions, procedures... of a type apprr.priate to the circumstances....
Instructions, procedures..
shall include appropriate quantitative or qualitative acceptance
"
criteria.
...
The inspectors verified that the following licensee's corrective action was consistent with their response (page 22, Observation #
(1)).
No further response is required for this item of noncompl-iance.
(1) BEQAM Sections 4 and 19 are currently being revised to address Regulatory. Guide 1.123, paragraph 6 and ANSI N45.2.13-1976.
(2) Storage requirements of ANSI N45.2.2.-1972 are incorporated in Stores Department Procedures 13.02 and 13.05.
(3) Stores Department Procedure 13.05, QAD Procedure 10.03 have been revised to incorporate the storage inspection require-ments of ANSI N45.2.2-1972 and Regulatory Guide 1.58, Rev.
1.
In addition, a check list has been generated and incorporated
-
_
. _ _.
-
.
..
.
into QAD Procedure 10.03 that list the inspection requirements of ANSI N45.2.2.
,
(4) Stores Department Procedure 13.01 has been revised to require rerating of hoisting equipment for special lifts to be at least 110% of lift weight.
The adequacy and timeliness of revisions to Sections 4 and 19 of the BEQAM and the licensee committment to perform a review of the various department procedures to ensure coordination and compliance with the BEQAM by March 1, 1982, will be reviewed during a subsequent inspection (IFI 293/81-36-07).
b.
Quality Control (QC) inspection deficiencies were identified in that the following material receiving inspection reports (MRIR)
documented acceptance of certificates of conformance (C of C)
that did not meet the requirements as specified (PAB paragraph 9a(6)).
(1) MRIR 80-2157. The C of C did not specify compliance with purchase order requirements for stem material and for the valves' ANSI 16.5 pressure rating.
It certified compliance with unspecified " Quality Control Standards."
(2) MRIR 81-31. The C of C was not signed by a QA representative.
It was signed by the Vice President of Sales.
It did not certify compliance with purchase order requirements.
(3) MRIR 81-100.
The C of C was not signed by a QA representative.
It was signed by the Manager of Nuclear and Power Division.
(4) MRIR 79-43. The C of C documented conformance to the require-ments anu specifications of a drawing that was diff; rent from the drawing identified on the purchase order.
(5) MRIR 81-66.
Purchase order 14167 required a C of C.
Material was accepted by QC without one.
These requirements were crossed out on the QC copy of the purchase order with no explanation.
The above is contrary to 10 CFR 50, Appendix B, Criterion V, Instruction, Procedures, or Drawings which states in part, " Activities affecting quality shall be prescribed by documented instructions, procedures, or drawings... and shall be accomplished in accordance with these procedures, instructions, or drawings". The Boston Edison Quality Assurance Manual (BEQAM), Section 2 commits to ANSI N45.2.2-1972 (Regulatory Guide 1.38, Rev. 2) and ANSI N45.2.13 (Regulatory Guide 1.123, Revision 1). ANSI N45.2.13-1976, establishes requirements for certificates of conformance including identification of procurement requirements met and not met, identification of l
.
.
_.
_
-
.
.
purchased material, and certification by a person responsible for the QA function of the supplier.
The ANSI N45.2.13 requirements are further endorsed by Regulatory Guide 1.123; ANSI N45.2.2-1972, requires inspection and examination of storage areas and stored items.
.i The inspector verified that the licensee's corrective action is consistent with their response (page 14, Observation #(6)).
The licensee is currently revising and updating Sections 4, 7, and 19 of the BEQAM and implementing procedures to address Reg. Guide 1.123, Paragraph 6.0 and ANSI N45.2.13-1976, Paragraph 10.2
'
requirements regarding certificates of conformance.
No further response to this violation is required.
The adequacy and timeliness of the licensee's actions will be reviewed in conjunction with IFI 192/81-36-07 discussed in para-graph a. above,
,
c.
The following deficiencies were identified in the storage of materials (PAB paragraph 9a.(6)).
(1) Hundreds of relatively small materials with "QC Hold" tags and some without "QC Hold" or "QC Accepted"-tags were mixed in with stored "QC Accepted" safety-related materials.
(2) On August 12, 1981 uncontrolled access of three individuals in-the Grade "B" storage area was observed.
(3) Several items marked flammable (liquid resin, adhesive 847-3M, anu spotcheck dye penetrant) were observed stored in i
close proximity to safety-related material.
The above is contrary to 10 CFR 50, Appendix B, Criterion V Instruction, Procedures, and Drawings, which states in part,
" Activities affecting quality be prescribed by documented instructions, procedures, or drawings... and shall be accomplished in accordance
'.
with these instructions, procedures, or drawings". The Boston Edison Quality Assurance Manual commits to ANSI N45.2.2-1972.
(Regulatory Guide 1.38, Revision 2) that establishes the following specific requirements:
(1) Paragraph 5.3.2 requires nonconforming materials to be segregated when practical or removed from the project site when practical.
(2) Paragraph 6.2.1 requires storage area access control.
(3) Paragraph 6.3.3 requires hazardous chemicals, paints, solvents, and other materials of like name to be stored in well vent-ilated areas which'are not in close proximity to important nuclear plant item.
.
The inspectors toured the licensee's controlled Grade "B" storage area to verify the corrective action as described in the licensee's response (page 26, Observation #(10)).
(1) A caged QC Hold Area has been established within the storage area.
Segregation is now being maintained where practicable.
In addition, the licensee is using consultants to perform an evaluation of the items with questionable quality traceability.
(2) The licensee has established warehouse access control by limiting non-Stores personnel to one controlled ingress / egress point.
(3) A controlled storage facility has been established to store hazardous chemicals. The licensee has refurbished a trailer to use as this storage facility.
This violation is considered closed, and no further licensee response is required.
8.
Maintenance a.
Preventive Maintenance ANSI N18.7-1976, paragraph 5.2.7.1, requires a preventive mainten-ance program be established and maintained. NOD procedure 3.M.1-1, Preventive Maintenance (PM), addressed the-PM program. N0D procedures 3.M.1-1.1, Instrument and Control, revision 7, and 3.M.1-1.3, Mechanical, revision 3, provided a PM schedule for-various categories of instrumentation and equipment. The PM schedules were routinely designated "as required" or " operating cycle".
N00 procedure 3.M.1-1.2, Electrical, revision 2, provided a component list of electrical equipment with their appropriate tests, but no schedules were provided. The PM program did not include a written scheduling or tracking system.
Interviews revealed that even this PM program was fragmented.
It did not address all appropriate systems and components, and, except for outage scheduled items, was not being accomplished.
(PAS paragraph 5.a(1)).
Paragraph 5.2.7.1 of ANSI N18.7-1976 states, in part, the following:
"... A preventive maintenance program including procedures as appropriate for safety-related structures, systems and components shall be established and maintained which prescribes
the frequeticy and type of maintenance to be performed. A preliminary program based on service conditions and experience with comparable equipment should be developed prior to fuel loading.
The program should be revised and updated as experience.is gained with the equipment.
"
...
._.
-
-
-
.
.
In their response to this finding (page 12, paragraph I), the licensee concurred that their preventive maintenance program required substantial improvement and stated the actions that were being taken to improve the program. During this inspection, a licensee representative stated that, although the PM program required substantial improvement, it still complied with the minimum requirements of ANSI 18.7.
The inspector reviewed licensee's compliance to existing Station P.M. procedures 3.M.1-1.2, " Electrical", and 3.M.1-1.3, " Mechanical".
- Based on this review, the inspector determined that, although the records and P.M. scheduling were disorganized, electrical P.M.'s were being performed as specified by procedure 3.M.1-1.2.
However, mechanical inspections of pumps, air compressors, and fans required by procedure 3.M.1-1.3 were not being accomplished.
Based on the above observations and other program inadequacies, the inspector determined that the P.M. program, as currently implemented, does not meet requirements of ANSI 18.7-1976, paragraph 5.2.7.1, and constitutes a violation.
The inspector reviewed BECo's response (page 12, Observation
- (1)) and determined that the stated corrective actions to improve the P.M. program, when implemented, would be adequate. The inspector also determined that the stated corrective actions were in progress with an anticipated completion date of May, 1982.
No further response from the licensee concerning this violation is required at this time.
The adequacy and timeliness of the licensee's correc'tive actions, as stated in the licensee's response, will be reviewed during a subsequent NRC:RI inspection (Inspector Follow Item (IFI) 293/81-36-04).
b.
Housekeeping Nuclear Operations Department (N00) procedure 1.4.6, Housekeeping, revision 5, described general housekeeping practices and responsibilities of station personnel.
Individual responsibilities and detailed
'
housekeeping requirements, however, were not addressed (PAS paragraph 5.a.(6)).
The licensee response (page 14, Observation #(6)) to the above item was inadequate in that no dates for completion of corrective action were established, nor was the degree of compliance to ANSI N45.2.3 clearly defined in the response. Additionally, based on discussions with licensee rpresentatives, as of the date of this inspection, adequate corrective actions had not been taken, nor were they in progress.
l
,
i
.
..
.
During this inspection, the inspector conducted a further review of Procedure 1.4.6 and determined that it did not reflect the requirements of ANSI N45.2.3, " Housekeeping During the Construction Phase of Nuclear Power Plants" as applicable to the operational phase, in that the procedure did not establish housekeeping zones, maintenance of housekeeping records and inspections, or training and qualification of personnel.
Further, the licensee had identified inadequacies in their own program concerning general plant housekeeping in January, 1981.
As partial corrective action to this inadequacy, office memorandums were issued concerning plant housekeeping, waste reduction, and radwaste volume reduction.
However, none of these memorandoms have been issued as approved procedures as required by Regulat ry Guide 1.33 and ANSI N18.7.
Further, ANSI N18.7-1976 requires compliance to ANSI N45.2.1,
" Cleaning of Fluid Systems and Associated Components...". The inspector determined that no procedures or program existed at the station for implementing this ANSI standard.
Failure to establish programs and procedures for housekeeping, protection of open systems, and cleaning of systems and syrtem components to comply with the requirements of ANSI N18.7-1976, ANSI N45.2.3-1973, and ANSI N45.2.1-1973 is contrary to these standards and constitutes a violation (293/81-36-05).
9.
Surveillance Scheduling The inspector also reviused implementation of the QA Program with respect to plant survaillances.
This was in addition to the primary purpose of this inspection as described in paragraphs 3 - 8.
ANSI N18.7 requires the establishment of a master surveillance schedule reflecting the status of all planned inplant surveillance tests and inspections. Currently, surveillance tests are scheduled by each Station department. The licensee, in early 1981, decided to establish a master schedule and status.
Through discussions with licensee representatives, the inspector determined that, as of December, 1981, a master surveillance schedule and status had neither been established nor implemented. A licensee representative stated that work toward this goal _was in progress, and provided to the inspector a preliminary master surveillance schedule.
However, the accuracy of this schedule had not yet been verified, nor had an. implementing procedure been written.
Failure to establish a master surveillance test schedule and status is contrary to Technical Specification 6.8.A and ANSI N18.7-1972, paragraph 5.1.7, and is a violation (293/81-36-06).
J
f
.
.
10. Management Meetings Licensee nanagement was informed of the scope and purpose of the inspection at entrance interviews conducted at the Pilgrim Nuclear Plant on November 30, 1981 and the Boston Edison Corporate offices on December 2, 1981. The findings of the inspection were discussed with licensee representatives periodically during the inspection.
An exit interview was conducted at the Pilgrim Nuclear Plant on December 4,1981, at which time the findings of the inspection were presented to the licensee management (see paragraph 1 for attendees).
,
I