ML20237L159
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COMANCHE PEAK RESPONSE TEAM RESULTS REPORTS A
1 EXAS UTILITIES GENERATING COMPANY A DIVISION OF TEXAS UTILITIES ELECTRIC COMPANY SEAS 28s8R8588sLs a "" --
~c C0riANCHE PEAK RESPONSE TEAM .
l ACTION PLAN ISAP .I.d.2 l TITLE: Guidelines for. Administration of QC Inspector Test Revision No. 0 1 2 Revised to Reflec1 Reflect Comment Description Original Issue NRC Coments On Plan M. 4/~o i k 0 7^
SVE/W Re nd by: '
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Review Team Leader Date l0f ff (s t 'g3~ lf2 ff'il
/3ec4,,:sr n/sk e i u Team V & Q, fk (Op _ w\, {j Date ic/[/g y ' ,j2., jg (
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Revision: 2 Paga 2 of 7 4
ISAP I.d.2 (Cont'd)
3.0 BACKGROUND
(Cont'd)
The TRT concluded that the certification review process should provide more detailed information concerning administrative guidelines, procedural requirements, and test flexibility.
The availability of such information would reduce the possibility of not properly verifying the capabilities of the inspectors being tested.
4.0 CPRT ACTION PLAN 4.1 Scope and Methodology The objective of this action plan is to ensure that the CPSES .
training and certification program complies with ANSI Standard N45.2.6 - 1978 and Regulatory Guide 1.58, Revision 1.
The specific TRT issue primarily addresses the training and certification program for Electrical Inspectors. In light of the potential generic implication for other QC inspector training and certification, this plan addresses the training and certification program for all CPSES inspectors.
The following tasks will be implemented to achieve the above objective:
Review procedures and recommend improvements.
Evaluate recommendations and revised instructions.
Evaluate effectiveness of changes.
4.1.1 Procedural Review A Special Evaluation Team (SET) compr. sed of individuals with no responsibility f<r administering the CPSES inspector / certification program,will be used
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, Pcgs 3 of 7 ISAP I.d.2 L (Cont'd) 1 4.0 CPRT ACTION PLAN (Cont'd) to conduct an independent review of procedures CP-QP-2.1, " Training of Inspection Personnel", and CP-QP-2.3, " Documentation within QA/QC Personnel Qualification File". The qualifications of SET members are described in paragraph 4.3. SET will be required to make recommendations for improvement to TUEC and the QA/QC Review Team Leader.
In addition to verifying compliance with the FSAR commitments the following items will be considered during the SET review of the procedures:
Method of verifying education and work experience.
Methods of~ determining levels of capability. l Method of establishing, controlling, and updating questions to be used in examinations.
Methods of justifying performance for decertification.
Methods to ensure inspectors being examined do not have prior ir. formation on the specific examination questions to be used, i.e. that each examination is a valid measure of the inspector's knowledge of the test subject.
Methods on how tests are monitored and for determining test scores. ,
i Methods for handling ratesting of inspectors j who have previously failed examinations.
Methods for ensuring inspectors who have been i previously tested and certified are retested l or requalified when significant changes are {
made to inspection procedures.
Method of administering training in each specific discipline.
Methods for determining waivers for OJT. l Recommendations for improvement will be forwarded to j TUEC with copies transmitted to the QA/QC Review Team Leader for reecncilation and concurrence. )
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i ISAP I.d.2 )
(Cont'd) -.
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'4.0 CPRT ACTION PLA'1 (Cont'd).
4.1.2 Evaluate Recommendations and Revise Instructions l 1 1
TUEC will review the recommendations submitted by SET l and revise the instructions as necessary. The QA/QC. !
Review Team Leader shall document'his agreement with the adequacy of the revised instructions.
Additionally, the following subtasks will be performed!
If revised procedures are issued l- incorporating the recommendations, an l- evaluation to determine if the comments apply and are reflected in the daughter instructions (qualifications of specific inspection personnel) will be conducted by .
TUEC and be overviewed by the QA/QC RTL.
All inspector certification exams currently in use will be reviewed by TUEC and revised as needed to ensure that they reflect the -
current requirements'.
Future. examinations will be administered in accordance with these revised procedures.
In addition to the revision of the procedures as requested by the NRC, SET, and the QA/QC RTL, a review will be conducted to determine whether other improvements should be made to the' program to enhance training of inspection personnel. This review will be accomplished in conjunction with the qualifications records system review described in ISAP I.d.1.
4.1.3 Evaluate Effectiveness l The effectiveness of procedure charges will be evaluated by monitoring the Phase II reviews of ISAP I.d.1. Should'any major concerns emerge during the Phase II reviews of ISAP I.d.1, recommended changes to the procedures will be forwarded to TUGC0 at this point of this action plan.
4.1.4 Use of Results The results of this evaluation will be factored into the overall collective evaluations (Quality of Construction and adequacy of QA/QC Program) te be conducted during the. final stages of the CPRT Program.
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".i ISAP I.d.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.2 Participants Roles and Responsibility 1es 4.2.1 Special Evaluation Team (SET) 4.2.1.1 Review the p'rocedures for " Training of j Inspection Personnel", and the " Documentation within QA/QC Personnel Qualification File" for compliance with standards.
4.2.1.2 Recommend improvements to TUGC0 and QA/QC Review Team Leader.
4.2.1.3 Evaluate the effectiveness of procedure changes.
4.2.1.4 Personnel Dr. D. G. Anderson, Third-party Advisor Mr. J. W. Sutton, Third-party Advisor Mr. M. L. Curland, Third-party Advisor 4.2.2 TUEC 4.2.2.1 Review SET recommendations and revise instructions.
4.2.2.2 Determine if recommendations apply to daughter instructions.
4.2.2.3 Review and revise all current certification ,
exams to reflect current requirements. ]
4.2.2.4 Personnel P. E. Halstead, Manager of Quality Control 4.2.3 QA/QC Review Team ,
4.2.3.1 Review SET recommendations and document agreement.
Rsvision: 2 Psge 6 of 7 ISAP I.d.2 '
(Cont'd) 1 4.0 CPRT ACTION PLAN (Cont'd) 4.2.3.2 Review TUEC instruction revisions and I document agreement.
4.2.3.3 Overview TUEC's consideration of daughter i 1
instructions.
4.2.3.4 Personnel Mr. J. L. Hansel, QA/QC Review Team Leader Mr. J. E. Young, Issue Coordinator 4.3 Qualifications of Personnel SET and ERC personnel will have, as a minimum, five (5) years of management / supervisory level experience in QA/QC.
Each person will ha,ve experience in some aspect of training, either inspection of training programs or actual experience in the conduct of training and will meet the qualification requirements specified in the CPRT of Program Plan and appropriate Issue-Specific Action Plans.
4.4 Procedures This action plan will be conducted in accordance with the CPRT Program Plan and Issue-Specific Action Plans.
4.5 Standards / Acceptance Criteria The principal criteria and basis for this review will be the TUEC commitment in the FSAR to comply with the ANSI Standard N45.2.6-1978 as endorsed by Regulatory Guide 1.58, Revision 1. ;
4.6 Decision Criteria There are three primary decision points in the action plan. I Criteria are established to assure that action will be taken on questionable items until an adequate basis exists for ;
disposition.
4.6.1 Initial Review Conducted Unless the procedures CP-QP-2.1 and CP-QP-2.3, clearly meet the requirements, recommendations will be forwarded to TCEC for reconciliation.
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Revision: 2 Pass 7 of 7 3
ISAP I.d.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.6.2 Review and Reconciliation by TUEC Recommendations will be evaluated and procedures revised as necessary with concurrence from the QA/QC Review Team Leader that FSAR commitments have been satisfied.
4.6.3 Evaluation of Results Evaluate implementation of revised procedures during the conduct of ISAP's I.d.1 and VII.c to determine if !
the revisions are adequate and prove to be effective. -l If found to be inadequate, additional recommendations will be provided to TUGCO.
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t COMANCHE PEAK RESPONSE TEAM RESULTS REPORT ISAP: I.d.2
Title:
Guidelines for Administration of QC Inspector Test REVISION 1 V,
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Y b Iss(e Coordinjrtor Date ' '
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R 11 b ew Team Leader ddu Date' '
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1%a. L' Job:# W. Beck, Chairman CPRT-SRT Date g/n/x.
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,.,3 Paga 1 of 40 l ,. RESUITS REPORT ISAP I.d.2 Guidelines for Administration of QC Inspector Tests
1.0 DESCRIPTION
OF ISSUE IDENTIFIED BY NRC (NUREG-0797, Supplement Number 7, Page J-111)
"The TRT found a iack of guidelines and procedural requirements for the testing and certifying of Electrical QC Inspectors.
Specifically, it was found that:
No time limit or additional training requirements existed between a failed test and retest.
No controls existed to assure that the same test would not be given if an individual previously failed test.
No consistency existed in test scoring.
No guidelines or procedures were available to control the disqualification of questions from the test.
No program was available for establishing new tests (except when procedures changed). The same tests had been utilized for the last 2 years."
2.0 ACTION IDENTIFIED BY NRC (NUREG-0797, Supplement Number 7, Page J-111)
"Accordingly, TUEC shall develop a testing program for Electrical .
QC Inspectors which provides adequate administrative guidelines, !
procedural requirements and test flexibility to assure that suitable proficiency is achieved and maintained.
The deficiencies identified with the Electrical QC Inspections have le~nefic implications to other construction disciplines. The .
implications of these findings will be further assessed as part of l t h Sverall programmatic review of QC inspector training and qualification and the results of this review will be reported under the QA/QC category on ' Training and Qualification'." l
3.0 BACKGROUND
Prior to 1978, Brown & Root, as part of their overall responsibility as constructor, maintained a QC inspector certification program covering both ASME and non-ASME site inspection activities. TUCCO QA initially established a QC
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,- RESULTS REPORT ISAP I.d.2 '
(Cont'd) l
3.0 BACKGROUND
(Cont'd) inspector certification program in 1978 when TUGC0 assumed responsibility for the non-ASME QA program. Brown & Root retained responsibility for the ASME QA program and maintained their own separate QC inspector certification program to support the ASME QA program.
Since its inception in May 1978, the TUGC0 QC inspector certification program has been base,d on certifying personnel id a given inspection function / activity rather than a general certification of an individual in a discipline. The TUCCO approach is consistent with the practice of some other members of the nuclear industry. The more common approach in the nuclear industry is to issue general discipline certifications for inspectors. If properly implemented, the TUGC0 approach is conservative in that it would require additional training and examinations beyond what is normally required by programs in which general discipline certifications are issued. However, because of the increased number of certifications and attendant certification requirements, the TUGC0 approach is more difficult to administer than the -
alternate approach. Both approaches are satisfactory. ,
TUGC0 was not initially committed to address the requirements of Regulatory Guide 1.58. Ravision 1, " Qualification of Nuclear Power Plant Inspection, Examination, and Testing Personnel" and ANSI N45.2.6-1978, " Qualifications of Inspection, Examination and Testing Personnel for Nuclear Power Plants". However. Amendment
- 14 to the FSAR dated January 30,4181, stated that "CPSES QA Personnel are in compliance with Revision 1 (9/80) of the Regulatory Guide." This commitment was subsequently revised by knendment #15 to the FSAR dated February 20, 1981, which stated the following:
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~ For inspection activities within the scope of the ASME Code, inspectors are qualified in compliance with the
' y. ; requirements of Regulatory Guide 1.58, Revision 1.
- 2. For inspection activities outside the scope of the ASME Code, inspection personnel are qualified in general compliance with the requirement of Regulatory Guide 1.58, Revision 1 except as follows:
(A) Some inspection personnel qualifications are documented on a TUGC0 form and not on the Constructor's form.
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4 4 RESULTS REPORT ISAP I.d.2 (Cont'd) i 4
3.0 BACKGROUND
(Cont'd)
(B) Some of the qualification forms are signed by a TUGC0 representative and not by a i constructor representative.
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(C) Some Level III personnel are not formally designated by their employer. Rather, these persons performing corresponding activities are qualified, based on demonstrated experience by the' applicant. .
- 3. Qualification records are collected, stored and controlled in compliance with ANSI N45.2.9 Draft 11.-
Revision 0, dated January 17, 1973 as included in the
' Gray Book'."
Amendment #18 to the FSAR dated April 21, 1981 made the following two changes:
Item C ebove was deleted to prevent possible confusion based on comments from the NRC Staff.
A second paragraph was added to item 3. above which stated "For operational phase activities, CPSES-TUGC0 Operations will comply with the provisions of Reg. Guide 1.58 Rev. 1, for the qualification of quality control inspection personnel."
TUGC0 subsequently issued CP-QP-2.1, Revision 8, " Training of Inspection Personnel" dated August 4, 1981, in which substantial changes were included which appear related to the requirements of the FSAR commitment to Regulatory Guide 1.58, Revision 1 and ANSI N45.2.6 - 1978.
Afsu5stantial number of revisions were made to CP-QP-2.1 between Augus't 4, 1981, and October 30, 1984, when Revision 17 to CP-QP-2.1 watr fasued. Revision 17, along with CP-QP-2.3, Revision 5 i "D' documentation Within QA/QC Personnel Qualification File," was the '
revision which was reviewed during the implementation of this ISAP.
The initial specific issue raised by the NRC TRT was the lack of guidelines and procedural requirements for testing and certifying electrical QC inspectors. Subsequent issues presented in Supplements 7 and 11 of the Safety Evaluation Report were an expansion of this initial issue in terms of specific examples. l i
Attachment A of this Results Report summarizes these issues from Supplements'7 and 11.
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- c. RESULTS REPORT ISAP I.d.2' (Cont'd)
3.0 BACKGROUND
(Cont'd)
As reflected in this ISAP, a decision was made by the Review Tean Leader with concurrence from the Senior Review Team to focus the review of procedures on the TUGC0 QC inspector certification program and to not review the related Brown & Root procedures which cover certification of inspectors under the Brown & Root ASME program. This decision was based on the following:
The NRC concerns were primarily aimed at the TUGC0 certification program. In addition, SSER-11 stated that the Brown & Root procedures met or exceeded the requirements of ANSI N45.2.6 and Regulatory Guide 1.58.
ASME Code Requirements introduce additional rigor into the Brown & Root certification program as evidenced by periodic ASME Code Surveys and overview and participation in the certification process by the Authorized Nuclear Inspector.
The adequacy of implementation of the current Brown & Root certification program is being verified during the implementation of ISAP I.d.1, "QC Iespector Qualifications."
ISAP I.d.1 addresses NRC concerns regarding the qualifications of all historical electrical QC inspectors and also requires an assessment of the adequacy of the qualifications of all current TUGC0 and Brown & Root inspectors in all disciplines. The I.d.1 work is being conducted in three phases. During Phase I, the training, qualification and certification files for each applicable inspector are reviewed against project requirements and FSAR commitments by independent third-party personnel (QA/QC Review Team or Special Evaluation Team personnel). If concerns are identified for specific inspectors, they are further evaluated during Phase II by the same independent third-party personnel taking into (6hsideration other appropriate factors including further information provided by TUCCO. Finally, if the qualifications of 1'nfitidual inspectors are still questionable at the completion of th's Phase II evaluation, they are placed into Phase III. In Phase III a reinspection of at least a portion of the individuals' work will be conducted to finally determine the adequacy of their qualifications.
4.0 CPRT ACTION PLAN 4.1 The objective of this action plan was to ensure that the TUGC0 CPSES training and certification program for QC Inspectors complies with ANSI Standard N45.2.6 - 1978 and Regulatory Guide 1.58, Revision 1.
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Revision: 1 Pago 5 of 40 l
l RESULTS REPORT
, e ISAP I.d.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
The initial specific TRT issue primarily addressed the training and certification program for electrical inspectors.
In light of the generic implication for other TUGC0 QC -
inspector training and certification, this plan addressed the training and certification program for all TUGC0 CPSES inspectors.
The following tasks were imple,mented to achieve the above objective:
Reviewed procedures, identified deviations from requirements and recommended improvements; Evaluated recommendations and revised instructions; and Evaluated adequacy and effectiveness of changes.
4.1.1. Procedural Review A Special Evaluation Team (SET) comprised of individuals with no responsibility for administering the TUGC0 CPSES inspector certification program conducted an independent review of procedures CP-QP-2.1, Revision 17 dated October 30, 1984,
" Training of Inspection Personnel," and CP-QP-2.3, Revision 5 dated October 30, 1984, " Documentation Within QA/QC Personnel Qualification File." SET made recommendations for improvement to TUGCO and the QA/QC Review Team Leader. The qualifications of SET members are described in paragraph 4.3.
The following items were considered during the SET review of the procedures:
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Method of verifying education and work experience;
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Methods of determining levels of capability; Kathod of establishing, controlling and updating questions to be used in examinations; Methods of justifying performance for decertification; a
Revision: 1 Page 6 of 40 RESULTS REPORT ISAP 1.d.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
Methods to ensure inspectors being examined do not have prior information on the specific examination questions to be used, i.e. that each examination is a valid measure of the inspector's knowledge of the test subject; Methods on how tests are monitored and for l determining t,est scores; !
Methods for handling ratesting of inspectors who have previously failed examinations; Methods for ensuring ins actors who have been previously tested and cactified are retested or requalified when significant changes are made to inspection procedures; 1 Method of administering training in each specific discipline; and Methods for determining waivers for OJT; Recomme'2datiene for improvement were forwarded to TUGC0 and esp.es transmitted to the QA/QC Review Team Leader for reconciliation and concurrence.
i CP-QP-2.1, Revision 17 and CP-QP-2.3, Revision 5 were reviewed by the QA/QC Review Team to identify specific deviations from FSAR commitments. This review was conducted to comply with the latest documentation requirements of QA/QC Review Team procedures issued subsequent to the procedure review conducted by
-: SET.
I .-c. -4.1.2 Evaluate Recommendations and Revise Instructions TUGCO reviewed the recommendations submitted by SET and the QA/QC Review Team Leader and revised the instructions as necessary. The QA/QC Review Team Leader documented his agreement with the adequacy of the revised instructions.
Revision: 1
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, RESULTS REPORT ISAP I.d.2 (Cont'd) ,
4.0 CPRT ACTION PLAN (Cont'd)
Additionally, the following subtasks were performed:
All inspector certification exams were reviewed and revised by TUCCO to reflect current requirements. Examinations are now administered using these tevised procedures.
A review was conducted to determine whether other improvements should be made to the program to enhance training of inspection personnel. This review was accomplished in conjunction with the QA/QC Review Team evaluation of the effectiveness of the procedure changes. The results of this review are addressed in Section 5.2.3 of this results report.
4.1.3 Evaluate Effectiveness The effectiveness of procedure changes was evaluated by the QA/QC Review Team by reviewing the Qualification Files for a number of QC inspectors who have been certified and/or re-certified since the issuance of :
CP-QP-21, Revision 18 dated August 19, 1985. The l results of this evaluation are addressed in Section 5.2.3 of this Results Report.
4.1.4 Use of Results '
The results of this evaluation will be factored into the overall collective evaluations (Quality of Construction and QA/QC Program Adequacy) to be
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,_ conducted during the final stages of the CPRT Program.
4;2. -Participant's Roles and Responsibilities 4.2.1 Special Evaluation Team (SET) 4.2.1.1 Reviewed ths procedures for " Training of Inspection Personnel," anc the " Documentation Within QA/QC Personnel Qualification File" and recommended improvements to TUGC0 and the I QA/QC Raview Team Leader.
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,, RESULTS REPORT ISAP I.d.2 i (Cont'd) l 1 4.0 CPRT ACTION PLAN (Cont'd) l i
4.2.1.2 Provided comments to the QA/QC Review Team Leader on the adequacy of revised procedures.
4.2.1.3 Personnel Mr. J. W. Sutton Third-party Advisor Mr. M. L. Cur, land Third-party Advisor 4.2.2 TUGC0 QA 4.2.2.1 Reviewed SET recommendations and revised instructions.
4.2.2.2 Determined if recommendations apply to daughter instructions.
4.2.2.3 Reviewed and revised all current certification exams to reflect current requirements.
4.2.2.4 Personnel P. E. Halstead Quality Control Manager, Site A. M. Contino Quality Training Supervisor 4.2.3 QA/QC Review Team 4.2.3.1 Reviewed SET recommendations and documented
~~-[ agreement.
~y; -, 4.2.3.2 Reviewed procedures for compliance with FSAR commitments and documented agreement with revisions.
4.2.3.3 Overviewed TUCCO's consideration of daughter instructions.
4.2.3.4 Personnel Mr. J. L. Hansel QA/QC Review Team Leader i
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Revision: 1 Pago 9 of 40 RESULTS REPORT ISAP I.d.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
Mr. J. D. Christensen QA/QC Deputy Review Team Leader Mr. J. E. Young Issue Coordinator 4.3 Qualifications of Personnel SET and ERC personnel had as a minimum,'five (5) years of management / supervisory level experience in QA/QC. Each person had experience in some aspect of training, either inspection of training programs or actual experience in the conduct of training and met the qualification requirements specified in the CPRT Program Plan.
4.4 Procedures This action plan was conducted in accordance with the CPRT Program Plan. No specific procedures were developed for use in this ISAP.
4.5 Standards / Acceptance Criteria The Standards used for this review were ANSI N45.2.6-1978 as endorsed by Regulatory Guide 1.58 Revision 1. Acceptance criteria were these specified in these Standards.
4.6 Decision Criteria There were three primary decision points in the action plan.
4.6.1 Initial Review Coor.rcted
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f' Unless the procedures, CP-QP-2.1 and CP-QP-2.3, clearly met the requirements, recommendations were forwarded to l
y, ~, TUGC0 for reconciliation.
4.6<2 Review and Reconciliation by TUGC0 Recommendations were evaluated and procedures revised as necessary with concurrence from the QA/QC Review Team Leader that FSAR commitments vare satisfied. j l
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RESULTS REPORT I ISAP I.d.2 i (Cont'd) j l
4.0 CPRT ACTION PLAN (Cont'd) 4.6.3 Evaluation of Results j
l Implementation of revised procedures were evaluated '
during the implementation of this ISAP to determine if the revisions and their implementation were in j compliance with ANSI N45.2.6 and Regulatory Guide 1.58, l Revision 1 and to determine whether other improvements '
should be made to the p,rogram to enhance training of inspection personnel.
5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS i
5.1 Introduction '
The objective of this action plan was to ensure that TUGC0 had implemented a training and certification program for QC inspectors which was effective and which complied with ANSI N45.2.6-1978 and Regulatory Guide 1.58, Revision *1.
Specifically, the f ollowing tasks were accomplished to achieve the objective:
SET and the QA/QC Review Team reviewed procedures which were in effect on October 30, 1984, identified deviations from requirements and recommended improvements to the procedures.
. TUGC0 evaluated the SET recommendations and revised the procedures, effective August 19, 1985.
SET and the QA/QC Review Team evaluated the revised procedures for adequacy, and the QA/QC Review Team
_' f, verified that they had been satisf actorily imple=ented.
- u 'S ec tions 5.2.1, 5.2.2, and 5.2.3 which follow describe in
' detail the yesults of the three tasks listed above.
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(Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont 5.2 Implementation of Tasks 5.2.1 Procedure Review The procedures which were initially reviewed by SET and i the QA/QC Review Team were CP-QP-2.1, Revision 17 dated October 30, 1984, " Training of Inspection Personnel" and CP-QP-2,3, Revision 5 dated October 30,1984, "File." A Documentation Within Q'/QC Personnel Qualification CP-QP-2.1, Revision 17, addressed the following:
Responsibilities of the TUGC0 QA personnel for implementing the training and certification program; ,
Recommendations for education and experience for inspection personnel; Required capabilities of inspection personnel; Physical requirements for inspection i personnel; Requirements for indoctrination and training of inspection personnel; and Requirements for examination and certification of personnel.
CP-QP-2.3 supplemented the requirements of CP-QP-2.1 by defining the typical concent of an individual '
inspector's personnel training file and by defining how and by whom these training files would be maintained.
A series of TUGC0 QA Instructions (OI-QPs) commonly }
ref erred to as " daughter instructions" also supplemented CP-QP-2.1, Revision 17 (nd CP-QP-2.3, Revision 5. Attachment B contains the listing of these daughter instructions that were in effect at the cine of the review. These instructions defined specific inspection functions and capabilities for inspection personnel. They also defined specific requirements for documenting training activities and the qualification i
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.. RESULTS REPORT
, ISAP I.d.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) of these personnel, including on-the-job training, demonstration of proficiency and completion of examination requirements. These " daughter instructions" were subsequently deleted and applicable requirements incorporated into the revised CP-QP-2.1.
Further details are contained in Section 5.2.2.
As previously indicated,, two. reviews were conductec of CP-QP-2,1, Revision 17 and CP-QP-2.3, Revision 5. The first review was conducted by SET and resulted in the submittal to TUGC0 of recommendations for improvement of the procedures. These recommendations, which are summarized in Attachment C, were provided to TUGC0 by
" marked up" copies of procedures, listings of comments and discussions with TUGC0 personnel.
Significant changes were made to QA/QC Review Team procedural requirements for documentation after the initial review conducted by SET. Because of this, a second review was conducted by the QA/QC Review Team for the purpose of documenting the procedural review in accordance with the latest QA/QC Review Team procedural requirements. This review consisted of a detailed evaluation of the adequacy of CP-QP-2.1, Revision 17 and CP-QP-2.3, Revision 5 in addressing the requirements of ANSI N45.2.6-1978 and Regulatory Guide 1.56, Revision 1 as committed to by the CPSES FSAR.
This review concluded that the subject procedures did not adequately address the requirements of ANSI N45.2.6 and Regulatory Guide 1.58. It was further concluded that the procedures had violated the requirements of
' Criterion V. " Instructions, Procedures, and Drawings" of 10CTR50, Appendix B. As a result, the following
'QA/QC Program Deviation was issued:
QA/QC-PDR-35: The procedures violate the requirements of ANSI N45.2.6 and Regulatory Guide 1.58 requirements as follows: j
- 1) The procedures did not specifically address the requirements that persons be removed from an activity if it is determined that their capabilities are not in accordance with the job qualifications.
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RESULTS REPORT ISAP I.d.2 (Cont'd) 1 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
- 2) The procedures did not adequately address the requirement that a person who has not performed inspection, examination, or testing activities for a period of one year be re-evaluated by a redetermination of required capability.
- 3) The ' procedures did not adequately require certification records to contain the information specified by ANSI N45.2.6.
- 4) The procedures did not address the requirement to conduct examinations of special physical characteristic 9 (in this case, color visfon casts) on an annual basis. The e testing requirements were allowed to be waived but no guidance was provided regarding limitations on waivers.
- 5) The procedure did not address the Regulatory Guide requirements which state thet Level III personnel should be capable of reviewing and approving inspection, examination and testing procedures and of evaluating the adequacy of such procedures to accomplish the inspection, examination and test objectives.
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- 6) The procedures did not specify that
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a candidate should be a high school graduate or have a GED equivalent of a high school diploma. Also, there was no comatitment that the specified education and experience reccamendations of the standard be followed nor was an alternate to the recommendations provided as is 1 required by the Regulatory Guide. '
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ISAP I.d.2 l
(Cont'd) !
l 5.0 IMPLDiENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
In addition, the procedures violate the requirements of Criterion V of 10CFR50, Appendix B. Criterion V states
" Instructions, procedures, or drawings shall l include appropriate quantitative or ]
qualitative acceptance criteria for i determining that important activities have I been satisfactorily accomplished."
Specifically,'the procedures omitted definitive acceptance criteria for inspector certification and only provided guidance in most important areas of the certification process. The procedures allowed many (if not all) procedural requirements to be waived without adequate guidance to define, limit or control the use of waivers. As an illustration of this, Attachment D contains verbatim extracts of paragraphs and sentences from the two procedures which provide only general guidance or allow waiver of requirements.
The end result of the procedural discrepancies describec above in the deviation was that compliance with the procedures would not have assured compliance with TUGC0 licensing commitments, nor would necessarily have resulted in the certification of qualified inspectors. The purpose of CP-QP-2.1, Revision 17 was "to establish the minimum requirements for training, qualification, and certification of personnel performing inspection (s) and to provide assurance that these personnel have, and maintain, the appropriate
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knowledge and skill to properly perform their assigned responsibilities,...." Because no base set of minimum
- e. - requirements was specified, the stated purpose of
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CP-QP-2.1 was not achieved. The vagueness and general tone of the procedures made it unlikely that any consistent application of standards or guidelines regarding training, examination or certification of inspectors would have occurred during implementation of the procedures.
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I 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.2.2 TUGC0 Evaluation of SET Recommendations and Revision of Procedures The SET recommendations for improvements were initially i provided to TUCCO in November 1984, and formally discussed with TUGC0 in a meeting during March 1985.
In the same general time frene, TUCCO was in the process of making pers,onnel changes within the QA organization. Most of the personnel responsible for development and implementation of procedures CP-QP-2.1 and CP-QP'2.3 were changed. The newly-assigned TUGC0 personnel also identified the need for improvements and the procedures were significantly upgraded and modified.
CP-QP-2.1, Revision 18 was issued on August 19, 1985.
Attachment C describes how the SET recommendations were addressed in this revision. Effective at the issuance of Revision 18, the " daughter instructions" were deleted and the appropriate requirements incorporated into Revision 18. Specifically, personnel capabilities for the various Level I and Level II inspection functions were extracted from the daughter instructions, revised and included in Attach =ents to CP-QP-2.1, Revision 18. Also Revision 18 defined the method of certifying Level II inspectors to a discipline series of inspection instructions (providing training and examination requirements for each instruction within the series have been satisfied) and defined each discipline series. It also added requirements for technical training outlines, on the job training and proficiency demonstrations which had
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previously been primarily covered in the daughter instructions. At the same time, CP-QP-2.3 was deleted
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and QI-QP-2,1-23 Revision 0 was issued August 19, 1985, to govern " Training / Certification Records Processing."
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,,' RESULTS REPORT ISAP I.d.2 (Cont'd) 5.0 IMPLEMENTATION-0F ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Separate from but closely related to the procedural upgrades described above, TUCCO undertook to computerize and upgrade their bank of examination questions used to test candidates for inspector certification. A computer program was developed and existing test questions were input into the system.
This work was completed in March 1985. TUGC0 personnel then spent an additiona.1 two months evaluating, editing, deleting and adding to the bank of test questions. The QA/0C Review Team conducted an evaluation of this updated computerized test question bank and found the questions and the related application and control measures to be satisfactory.
The work conducted by TUGCO resulted in a significant upgrade both in test question adequacy and the method in which examinations comprised of randomly selected questions could be utilized. These two improvements significantly increased the effectiveness of the inspector testing program.
5.2.3 Adequacy of Revised Procedures and Verification of Implementation SET reviewed CP-QP-2.1, Revision 18 and QI-QP-2.1-23, Revision 0 to determine how their recommendations had been addressed. The results of this review, along with supplementary information subsequently identified by the QA/QC Review Team, are contained in Attachment C.
In addition, SET also verified that the appropriate portions of the " daughter instructions" had been adequately incorporated into CP-QP-2.1.
~f - 3' The QA/QC Review Team. reviewed the revised procedures to verify compliance with Regulatory Guide 1.58 and I e. - ANSI N45.2.6 as committed to by the CPSES TSAR and to
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determine if the revised procedures adequately resolved the previously-identified QA/QC Program Deviation.
This review verified that the deviation had been resolved. The revised procedures were much more definitive and were judged to be in cempliance with TSAR requirements.
Revision: 1 Pago 17 of 40
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ISAP I.d.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Only one area of possible concern remained as a result of this review. Revision 18 of CP-QP-2.1 as well as subsequent revisions (current is Revision 22) allow specific requirements of the procedure, with the exception of education and experience, to be reduced or waived. The procedure does clarify the intent of waivers by stating that assurance is to be provided that "the individual does have ' comparable' or. -
' equivalent' competence'to that which would have been gained from the iten being waived." A discussion was held with TUGC0 regarding this possible concern. A recommendation was made by the QA/QC Review Team that TUCCO consider adding proficiency demonstrations and written examinations as items which cannot be waived for the initial certification of a Level I or Level II inspector to an inspection instruction. As a result of this recommendation, Revision 22 to CP-QP-2.1 was issued in which the section 3.8 on waivers was replaced as follows:
"3.8 SUBSTITUTION OF TRAINING REQUIREMENTS Specific training, OJT and written examination requirements as delineated in paragraphs 3.5.lc, 3.5.1d, and 3.6.1 respectively, may be substituted for existing certified personnel who are candidates for Level I and Level II certification in comparable inspection activities. Such substitutions must be approved by the Administrative Level III (or General Level III) and documanced on Attachment 14. These substitutions must be fully supported by CPSES site-substituted experience or training
- c. -
or examination which provides assurance that the individual does have ' comparable' or
' equivalent' knowledge to that which would have been gained for the item being !
substituted."
)
This revision clarified TUGCO's intent and adequately {
addressed the QA/QC Review Team recommendation.
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, RESULTS REPORT ISAP I.d.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
The QA/QC Review Team conducted a verification of the
, implementation of CP-QP-2.1 since the issuance of Revision 18. The scope of this verification included the review of documentation for seventeen (17) inspectors and inspector candidates certified by TUGC0 from August 19, 1985 until April 16, 1986. Although some minor documentation errors and one concern regarding alternate col,or vision tests were identified, the overall compliance was satisfactory and provided assurance that inspectors are currently being certified in accordance with FSAR commitments. Further discussion with TUGC0 QA personnel resolved the QA/QC Review Team concern regarding alternate color vision tests.
The practice of utilizing Level I personnel to plan and set up inspections, supervise or maintain surveillance over inspections, supervise and certify lower level personnel, report inspection results and evaluate the validity and acceptability of inspections had been identified in a Notice of. Violation (EA 86-09) by the NBC. As noted during the reviews and verification of implementation, use of Level I personnel by TUGC0 to function as Level II personnel is not permitted by.
procedure or allowed in practice. TUGC0 is not currently making it a practice to conduct inspections using Level I personnel, even with appropriate supervision of the inspections by Level II personnel as is allowed by Regulatory Guide 1.58, N45.2.6 and TUGC0 procedures.
During the implementation verification, the concern
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' expressed above regarding waivers was evaluated. Seven waivers were identified and all involved reduction of
- e. - on-the-job training. The waivers all provided adequate justification for reducing on-the-job training, and in all cases proficienc/ to conduct the required inspection tacks was satisfactorily demonstrated. It was concluded that the application of the waivers.as allowed by CP-QP-2.1, Revisions 18 through 21, was satisfactory.
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ISAP I.d.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.3 Compliance with 10CFR50, Appendix B and the FSAR As discussed in Section 5.2.1, a QA/QC Program Deviation (QA/QC-PDR-35) applicable to CP-QP-2,1, Revision 17 and supplementary procedure CP-QP-2.3, Revision 5 was identified.
It can be concluded that the TUGC0 inspector certification program was not in compliance with FSAR commitments nor in compliance with 10CFR50, Appendix B requirements from the time of the TUGC0 commitment to Regulatory Guide 1.58 Revision 1 on January 30, 1981, until the issuance of Revision la of CP-QP-2.1 on August 19, 1985.
The deviation was evaluated to determine if it should be classified as a QA/QC Program Deficiency. A QA/QC Program Deficiency is defined as a deviation satisfying one or more of the following criteria:
Inadequacy of a QA/QC program element such that substantive revision cf the program or other corrective action is required to bring it into compliance with the regulatory requirements, FSAR commitments or other licensing commitments; or Extensive evaluation would be required to determine the '
effect on the quality of construction.
Based on this definition QA/QC-PDR-35, which involves both the failure to comply with the requirements of Criterion V of 10CTR50, Appendix B and failure to comply with FSAR commitments (Regulatory Guide 1.58 and ANSI N45.2.6), has been classified as a QA/QC Program Deficiency. The changes which
__ , vere made to the QC inspector certification program concurrent
'Cwith the issuance of Revision 18 of CP-QP-2.1 are substantive in terms of the first criterion of the definition of QA/QC
'S ,frogram Deficiencies above. In terns of the second criterion of the definition, the major procedural inadequacies which were in existence prior to R2 vision 18 of CP-QP-2.1 can be directly linked to the inspector certification problems identified by the NRC. These problems in turn resulted in the establishment of this ISAP, ISAP I.d.1, "QC Inspector Qualifications" and contributed to the decision to establish ISAP VII.c, Construction Reinspection / Documentation Review Plan." Thus, extensive evaluations were required to be conducted to determine the effect of this deviation on the quality of construction.
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(Cont'd) 5.0 IMPLDfENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.4 Trend Analysis The scope of this action plan was essentially limited to identifying problems with one activity (certification of inspectors), correcting these problems and verifying the current activity is being conducted satisfactorily. Therefore no trend analysis was required.
5.5 Root Cause and Generic Implica'tions 5.5.1 Root Cause The NRC-TRT, as documented in SSER-il, page 0-111, found in the TUGC0 QC training and certification program "a lack of programmatic controls to ensure that the program achieves and maintains requirements as set forth in 10CFR50, Appendix B. Problem areas were:
(1) in the documentation for qualification, including verification of education and experience;-(2) in the training and certification program; (3) in the racertification program; and (4) in the certification testing progran. The TRT concludes that these deficiencies in procedural requirements and guidelines in the training and certification programs are of major concern." QA/QC-PDR-35, which, as discussed in Section 5.3 above, is classified as a QA/QC Program Deficiency, confirms the NRC-TRT conclusion quoted above. As a result, a root cause analysis was conducted in accordance with CPRT Program Plan requirements. A description of that analysis follows. It should be kept in mind that the QA/QC Program Deficiency is not applicable to the TUGC0 certification program after
-: August 19, 1985, when procedures were issued by TUGC0 5
which fully complied with FSAR commitments.
- e. -
' - A detailed review of procedural revisions in effect prior to Revision 17 of CP-qP-2.1 and Revision 5 of CP-QP-2.3 was not within the scope of this action plan and was not conducted. However, a limited review of these procedures indicated that many of the same discrepancies noted during the review of CP-QP-2.1, Revision 17 and CP-QP-2,3, Revision 5 existed in earlier revisions. As further support to this s
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.- Pega 21 of 40 RESULTS REPORT ISAP I.d.2 ',
(Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) conclusion, it is the understanding of the QA/QC Review Team (based on discussions with TUCCO personnel) that Revisions 17 and 5 were made in an attempt to address NRC-TRT concerns rhich had been verbally presented to '
TUGC0 during the course of the NRC-TRT evaluations.
The fact that inadequate procedures remained undetected in this area at least since the TUGCC commitment to ANSI N45.2.6 and Regulatory Guide 1.58 in 1981, can likely be attributed to weaknesses in the TUGC0 Audit Program and the Management Assessment Program, both of which are being addressed in separate ISAPs.
The direct causes for the procedural weaknesses identified potentially can be attributed to one or more of the following three factors. The first is that the FSAR requirements, including the referenced codes and standards, were unclear. The second potential factor is that there were inadequate requirements for procedure preparation. The last potential factor is personnel failure. The following paraEraphs discuss each of these potential factors.
Clarity of FSAR Requirements The FSAR clearly applies the requirements of ANSI N45.2.6 and Regulatory Guide 1.58 to the TUGC0 inspector certification program. It also, of course, very clearly applies the Criteria of 10CFR50, Appendix B to the work.
Although the nuclear industry struggled somewhat to addrese properly the intent of N45.2.6 and Regulatory Guide 1.58 after they
~~f' were issued.(Regulatory Guide 1.58, Revision I was issued in September 1980), by the time k' of the TRT evaluation and the issuance of
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Revision 17 of CP-QP-2.1 in October 1984, sufficient knowledge and experience had been gained within the nuclear industry to result in broad agreement that the requirements contained within these documents were intended to be applied as written. It is conclude:I that the clarity of the TSAR requirements was not a major factor in causing an inadequate procedure to be written.
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. Inadequate Requirements for Procedure Preparation .
A copy of TUGC0 procedure CP-QP-6.0, Revision 6, " Preparation of Quality Procedures and Instructions" dated October 25, 1984, was-examined. This procedure governed the preparation a.nd review of CP-QP-2.1 Revision 17 and CP-QP-2.3 Revision 5. This examination noted that the following requirements or guidelines were contained in CP-QP-6.0:
(1) Individuals preparing or revising documents were required to research the FSAR, regulatory requirements, and related industry codes and standards to assure adequate incorporation of requirements.
(2) Authors were to consult other personnel knowledgeable in the document's subject for experienced input to assure that the document requirements were practical and efficient.
(3) The procedure indicated authors should normally submit prepared documents to " cognizant individual (s)" for review and comment.
(4) Procedures were to be prepared under I ', ', the direction of the QE supervisor and approved by the TUGCO site QA Manager or designee.
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It is concluded that CP-QP-6.0, Revision 6 was weak in its requirements for review of procedural revisions. While not considered a primary cause of the problem, the weakness may be a contributing factor. It was noted that the individuals responsible for the preparation and approval of CP-QP-6.0, Revision 6 were the same individuals responsible f'or the preparation and approval of CP-QP-2.1, Revision 17 and CP-QP-2.3, Revision 5.
Personnel Failure Based on the previous analysis it appears that personnel failure was the likely direct cause for the inadequacies noted in the discrepant procedure. Personnel failure could be caused by a lack of capability, a lack of experience, an isolated or infrequent error en the part of personnel conducting the work or improper supervision of the persons .
conducting the work.
Capability of personnel (for this purpose defined as a person's inherent intelligence and ability to carry out ressonable tasks) is difficult to determine in an analysis such as this. However, a review of the resumes of the persons who prepared and approved the procedure provides some information from which some judgements regarding capability
~p- can be made. The resumes for both persons indicated steady performance with reasonable
- e. - advancement in responsibilities and did not reflect a pattern indicative of inability to conduct assigned work. The person who approved the procedure had a B.S. degree in engineering and had been a TUGC0 employee for eleven years. Lack of capability is not' considered a liksly cause for personnel f ailure in this case.
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- n ISAP I.d.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
A review of the resumes to determine the experience of the individuals who prepared and reviewed the procedures was also conducted. The procedure preparer had a substantial number of years of experience in the nuclear industry but primarily in field engineering organizations. He had less than one year of QA experience (not QC) prior to being assigned to the IUGC0 QA organization.
He had been assigned to the TUGC0 QA organization as a Senior QA Specialist for about one and a half years prior to issuance of the subject procedures and had been certified discipline Level III in the areas of Instrumentation, Mechanical and Receiving.
The individual who approved the procedures had been with the TUGC0 Dallas QA organization for about 11 years and had only been recently assigned to the construction site. Although he had extensive QA experience and was a degreed engineer, he had no direct construction QC experience. His QA experience was limited to the Comanche Peak Project and he had no substantial exposure to other nuclear industry construction QC programs. It is concluded that lack of experience of involved individuals likely contributed to the preparation of inadequate procedure revisions.
The scope of the problems identified in the precedure make it difficult to conclude that
~~
this was an isolated error. However, it should be noted that CP-QP-6.0 required that
- m - Regulatory Guide 1.58 and ANSI N45.2.6 be
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researched for procedural revisions to ensure their requirements were addressed. This apparently did not occur or was not properly accomplished. On the other hand, the procedure was being revised and the preparer may have been given specific direction by supervision on what changes were to be made. 1 In fact, TUGC0 memorandum TUQ-2363 dated l September 24, 1984, directs the incorporation l
)
Revision: 1 Page 25 of 40 RESULTS REPORT ISAP I.d.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) of certain requirements into Revision 17 of CP-QP-2.1. Failure of the precedure preparer to adequately review applicable regulatory requirements and industry codes and standards may have contributed to the problem but this is not considered to be the likely primary cause of the problem.
In regard to ' improper supervision of the work, CP-QP-6.0 requires revisions of procedures to be prepared under the direction of the QE Supervisor. It is difficult to clearly determine what impact supervision may have had on the revision of the subject procedures. It can only be noted that the revisions were not adequate and, as discussed above, specific direction may have been given to the procedura preparer on how the procedures were to be revised. 'On the more positive side, it is clear that an attempt was made in the revisions to address the specific problems identified by the NRC-TRT.
However, given the nature of the NRC concerns, it can be argued that a complete review and analysis of the procedures versus the requirements was in order. This j apparently was not conducted or was not properly conducted. It is concluded that improper supervision of the work may have contributed to the problem.
Based on the discussions abcve it is concluded that the
~~f~ likely root cause of the deficiency is inexperience on the part of the personnel who had the responsibility b; ',
for the revision and approval of the deficient procedures. Other factors which may have contributed to the problem are as follows:
- 1) CP-QP-6.0, Revision 6 was weak in specifying requirements for review of procedures an~d procedure revisions. (Note - The fact that this procedure was also prepared and l
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( Revision: 1
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' Pese 26 of 40
{
1 1
, RESULTS REPORT ISAP I.d.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) approved by the same individuals who prepared and approved the deficient procedures possibly strengthens the conclusion regarding inexperience being the likely root cause.)
- 2) There was an apparent failure to adequately review applicable regulatory and industry codes and sea,ndards as required by CP-QP-6.0.
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- 3) There was possible inadequate supervision of the work as required by CP-QP-6.0.
Although the likely root cause of the procedural inadequacies has been identified as inexperienced personnel, the broader question of whether senior management was remiss in assigning inexperienced personnel to this activity requires further investigation. This question is beyond the scope of this ISAP and will.be addressed during the collective evaluation process.
5.5.2 Generic Implications There are three areas which must be considered in regard to the generic implications of the identified QA/QC Deficiency. The first involves the possible certification of unqualified inspectors which in turn could result in serious nonconforming hardware conditions remaining undetected. ISAP I.d.1 and ISAP VII.c are adequate in scope to address this area. The results of the implementation of ISAP I.d.1 and ISAP VII.c vill be reviewed by the QA/QC Review Team during
' the collective evaluation process to verify that the generic implications of any past program problems have
- e. '
been fully identified, evaluated, and any required
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corrective actions identified.
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,. RESULTS REPORT ~
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ISAP I.d.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
The second area which must be considered is the potential for other inadequate QA/QC procedures to 'have existed. As part of the collective evaluation process, all of the procedures and procedure. revisions prepared and/or approved by the persons who prepared and reviewed CP-QP-2.1, Revision 17, CP-QP-2.3, Revision 5 and CP-QP-6.0, Revision 6 will be reviewed for adequacy. The results ,of these reviews will be
- evaluated and any additional required action, including further evaluations, will be identified. In addition, the results of other ISAPs which also require the-
. review of additional QA/QC procedures and instruction will provide additional data on whether this is a legitimate area of concern. Examples of other ISAPs which require these reviews include VII.a.2, "Non-Conformance and Corrective Action System",
VII.a.4, " Audit Program and Auditor Qualification",
VII.a.5, " Periodic Review of QA Program", VII.a.6, "Exic Interviews", VII.a.7, " Housekeeping and System Cleanliness" and VII.a.8, " Fuel Pool Liner Documentation." The resolution of this area vill be addressed during the collective evaluation process and additional procedures will be evaluated if the results so dictate.
The third area is the possibility of the continued assignment of inexperienced personnel to make and approve procedural changes in the area of inspector training and certification. As mentioned in Section 5.2.2, most of the personnel responsible for the development and implementation of the inspector
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certification program were changed. The new personnel 2
' are experienced personnel and the adequacy of their work has been confirmed during the course of the
- t- ] implementation of this ISAP.
No additional actions beyond those already identified by the CPRT arn necessary at this time to address the generic implications of the identified QA/QC Program Deficiency.
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,' RESULTS REPORT ISAP I.d.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.6 Recommended Corrective Action TUGCO has already corrected the procedural problems identified in this results report and, as indicated in Section 5.2.3 above, has implemented satisfactorily an effective QC inspector certification program which meets the requirements of Regulatory Guide 1.58. Revision 1 and ANSI N45.2.6-1978.
In a/c':Lon, TUGC0 has incorpo. rated QA/QC Review Team recoL7andations for improvement into Revision 22'of CP-QP-2.1.
No further action is required.
6.0 CONCLUSION
S TUGC0 has implemented an effective training and certification progran in compliance with FSAR requirements since the issuance of CP-QP-2.1, Revision 18 on August 19, 1985.
The NRC TRT concerns related to the TUGC0 certification procedures contained in SSER's 7 and 11 have been satisfactorily addressed as documented in Attachment A. Final conclusions on the overall impact of past inadequacies in the TUGC0 inspector certification program will be addressed in the I.d.1 Results Report and QA/QC Review Team collective evaluation reports.
7.0 ONGOING ACTIVITIES The SRT considers the implementation of this ISAP to be complete.
The final conclusions regarding root cause and generic implications of the 4A/QC Program Deficiency identified during implementation of this.:ISAP will be handled as described in Section 5.5.
L 8.0 A'CTION TO PRECLUDE OCCURRENCE IN THE FUTURE Continued management involvement in regularly evaluating the adequacy of the inspector certification program and promptly correcting any identified discrepancies should avoid further problems in the TUGC0 inspector certification progran, i
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RESULTS REPORT ISAP I.d.2 l (Cont'd)
Attachment A TRT/NRC Concerns The following is a summary of the concerns reported in SSER's 7 and 11 by the TRT and NRC. They form the basis from which the SET focused l attention on the programmatic aspects of the QC inspector qualification / certification process. Corrective actions by TUCCO are also identified.
(1) No time limit or additional training requirements existed
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between a failed test and retest.
CP-QP-2.1, Revision 18, Section 3.6.1 required that any individual who fails a written exam be retrained and that ratesting cannot occur less chan two (2) days nor more chan two (2) weeks following the failed exam. Revision 21 also required retraining but stated recasting will begin no sooner than one (1) week following the failed exam. Both revisions state that an individual who fails two (2) written exams is ineligible for re-test or certification in that specific activity.
(2) No controls existed to assure that the same test would not be given if an individual previously failed that test.
CP-QP-2.1 Revision 18, Section 3.6.1 required that examination questions be selected randomly from a computerized bank of current questions to ensure the same test is not given consecutively.
(3) No consistency existed in test scoring.
Section 3.6.1 of CP-QP-2.1, Revision 18 provided adequate T~'fguidelines to ensure consistency in the scoring of
' examinations. Revision 21 provided some additional guidelines t- on how questions which may be disqualified are handled in regard to test scoring.
(4) No guidelines or procedures were available to control the disqualification of questions frem the test.
CP-QP-2.1, Revision 18, Section 3.6.1 provided guidelines for the disqualification of axam questions.
- Rovision: 1 Pags 30 of 40 RESULTS REPORT ISAP I.d.2 (Cont'd)
Attachment A (Cont'd)
(5) No program was available for establishing new tests (except when procedures changed). The same tests had been utilized for the last 2 years.
CP-QP-2.1, Revision 18 required that each time an exam is given that it be generated by randomly selecting questions from a computerized bank of cu,rrent questions. Thus new exams are produced each time.
(6) No specific details on how tests should be monitored.
CP-QP-2.1, Revision 18, Section 3.6.1 established naasures to assure the security and confidentiality of exam questions and answers and required proctoring of exams during testing periods.
(7) No procedures for establishing, controlling, and updating questions to be used in examinations.
- Section 3.7.2 of QI-QP-2.1-23, Revision 0 and Section 3.6.1 of CP-QP-2.1, Revision 18 adequately addressed the requirements for establishing, controlling, and updating exau questions.
(B) No procedures to ensure inspectors being examined do not have prior information on the specific examination questions to be us ed, i.e . that each examination is a valid measure of the inspector's knowledge of the test subject.
CP-QF-2.1, Revision 18 required each exam to be developed using randomly selected questions from a computerized bank of
,, questions. Also see answers to items (5) and (6) above.
.(9)~No procedures for determining test scores.
'Section 3.6.1 of CP-QP-2.1, Revision 18 adequately addressed this concern. Additional dettil and direction were included in the same section of Revision 21 of CP-QP-2.1.
(10) No procedures for handling recasting of inspectors who ha've previously f ailed examinations.
See response to item (1) above.
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Attachment A (Cont'd)
)
(11) No procedures for ensuring inspectors who have been previously tested and certified are ratested or requalified when i significant changes are made to inspection procedures. I CP-QP-2.1, Revision 19 adequately addressed this concern in Section 3.5.2 by requiring retraining whenever procedures are revised. ,
(12) There were no requirements for verification of education and
-work experience.
Section 3.2.4 of CP-QP-2.1, Revision 18 required verification of education and work experience to be complaced prior to certification.
(13) Personnel capabilities were not specifically defined by levels (I, II, III).
Personnel capabilities were defined by Levels in Section 3.3 and Attachments lA through IL in CP-QP-2.1, Revision 18.
d4) T% specific inspection disciplines were addressed,in separate quality instructions and were administered by a cognizant quality engineer in that discipline. There was no one individual who controlled the training programs. As a result, the overall quality training program lacked cohesion.
With the issuance of CP-QP-2.1, Revision 18, applicable requirements from the separate quality instructions were incorporated into CP-QP-2.1 and the instructions deleted. In addition, Section 2.3 of CP-QP-2.1, Revision 18 and Section 22.2 of QI-QP-2.1-23, Revision 0 clearly defined
" responsibilities for the training program. The evaluation of
', 'the adequacy of implementation conducted by the QA/QC Review Team during the course of implementation of this ISAP has confirmed that a cohesive training, examination and certification program is in place.
(15) Racertification could be accomplished by a simple "yes" from an inspector's supervisor.
Section 3.7.2 of CP-QP-2.1, Revision 18 provided adequate guidance for r certification of inspectors. An annual perfontance evaluation is conducted and documented on a form which requires the QC Supervisor to state whether the individual has perfor=ed satisfactorily in the applicable
Revision: 1 Page 32 of 40 I RESULTS REPORT t
ISAP I.d.2 (Cont'd)
Attachment A (Cont'd)
I inspection area during the last twelve (12) months, whether maintenance of the certification is required, and whether he/she recommends retaining the current level of certification, upgrading the certification, or removing the certification. There is a space for documenting comments and for identifying who performed a field evaluation if required.
Section 3.5.2 of QI-QP-2.1-23, Revision 0 also requires edat in the event a returned annual performance evaluation indicates that an inspector has been inactive, the applicable Level III shall be contacted for evaluation and determination of racertification requirements prior to further processing.
Revision 21 of CP-QP-2.1 further strengthened this area by the addition of a requirement in Section 3.7.2 that any individual who has not demonstrated activity in the discipline / area certified for a period of one year shall be re-evaluated by a demonstration of proficiency.
(16) There were no guidelines for using vaivers for OJT, even though waivers were frequently used.
Section 3.8 of CP-QP-2.1, Revision 18 stated that waivers shall be documented to provide assurance that the individual has " comparable" or " equivalent" competence to that which would have been gained from the item being waived. A form was required to be completed in which justification for the waiver must be documented. This practice is considered to be satisfactory.
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'Rovision: 1 Pago 33 of 40 i
RESULTS REPORT ISAP I.d.2 !
(Cont'd)
Attachment B List Of " Daughter Instructions" The following is the Itst of " daughter instructions" in effect on October 30, 1984, the date of issuance of CP-QP-2.1, Revision 17:
QI-QP-2.1-1 Qualification of Civil Inspection Personnel, !
Revision 5, dated July 28, 1983.
QI-QP-2.1-2 Qualification of Soils and Concrete Test Personnel, Revision 3 dated December 17, 1983.
QI-QP-2.1-3 Qualification of Electrical Inspection and Test Personnel, Revision 9 dated September 13, 1984 QI-QP-2.1-4 Qualification of Protective Coating Inspection Personnel, Revision 6 dated July 28, 1983.
QI-QP-2.1-6 Qualification of Receiving Inspection Personnel, Revision 5 dated July 28, 1983.
QI-QP-2.1-8 Qualification of Instrumentation and Radwaste Mechanical Inspection Personnel, Revision 9 dated September 13, 1984 QI-QP-2.1-9 ' Qualification of Non-ASME Pipe Support Inspection Personnel, Reviaion 5 dated September 13, 1984 QI-QP-2.1-11 Qualification of Concrete Expansion Anchor Support Inspection Personnel, Revision 3 dated July 29, 1983.
QI-QP-2.1-14 Qualification of Electrical Racewey/ Support Inspection
__ Personnel, Reviaion 6 dated September 18, 1984 QI-QP-2)1-15 Qualification of Structural Steel Inspection Personnel,
' t '. Revision 5 dated September 13, 1984 QI-QP-2.1-18 Qualification of Fire Protection Inspection Personnel.
Revision 4 dated September 13, 1984 QI-QP-2.1-19 Qualification of Weld Inspection Personnel, Revision 1 dated July 29, 1983.
QI-QP-2.1-21 Qualification of Baseplates for Grouting Verification Personnel, Res.sion 2 dated February 27, 1984 QI-QP-2.1-22 Training and Certification of Receiving Inspection Personnel for ASMI Section XI Items, Revision 0 dated April 17, 1984
__ _ ________m_ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ . _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - . . . _ _ _ _ __.__-______.__..___._._._m
~ Revision: 1 Pego 34 of 40 RESULTS REPORT ISAP I.d.2 (Cont'd)
Attachment C SET Recommendations !
The following SET recommendations were provided to TUGC0 QC Supervision initially on November 30, 1984 and formally discussed on March 26, 1985.
In that same time frame, TUCCO QC made a number of personnel changes.
This resulted in the SET recommendations not always being addressed directly, but rather indirectly as a result of TUGC0 QC self-initicted changes. The TUGC0 improvements are also indicated along with each initial SET recommendation.
(1) Develop and use a check list of the data / documentation that should be included in each training and certification file.
The checklist can be printed or secured to the inside cover of the file and used to check off the items needed as they are deposited therein. Reason: To help ensure that each fils does in fact contain what is required and to maintain consistency.
QI-QP-2.1-23 addresses this recommendation in Section 3.4.2.
(2) Consider modification of the TUGC0 Procedure (esp CP-QP-2.1) where specified requirements are unnecessarily restrictive and beyond the guidelines of N45.2.6, e.3 It is not apparent that there is a need for the Ishisara color vision test. A ,
color chart test may be adequate and can be made "Memoryproof" by scrambling the order of the colors displayed. Reason: To be more consistent, to avoid unnecessary requirements and to establish so, no-go criteria.
The Ishisara color vision test remains the primary color vision test. The method of conducting alternate color vision test as prescribed by CP-QP-2.1 Revision 22 is considered to
~['peadequately"memoryproof". The current TUGC0 practices in
,. . :. -this area are satisfactory.
(i) Consider establishing guidelines for qualification and certification as a General Inspector, Kaason: The skill, knowledge, experience, etc. should be appropriate for personnel expected to be capable over a broader spectrum of activities. After several specific certifications, documenting the justification for waiving OJT on remaining procedures when giving General Certifications would minimize questions on the judg=ent calls.
Revision: 1
". Pcg2 33 of 40
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RESULTS REPO'RT
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ISAP I.d.2 (Cont'd)
Attachment C (Cont'd)
CP-QF-2.1, Revision 18, Section 3.3.2 addressed this concern by stating Level II taspectors are authorized to perform inspections in a disdipline procedural series (a " general inspector" certification in context of the SET reco==endation) provided training and certification requirements for each instruction within that series have been satisfied.
(4) Oral and or written examinatio'ns are currently permitted by the IUCCO Procedure. Consider inclusion of a more detailed description for 'each method. For Example: Establish a bank of crza questions, (for each subject or discipline).
Establish a means for randomly drasing questions to be used (could be by group) .
Sectica 3.6.1 of CP-QP-2.1 Revision 18 specified that written exaufn tion questions are to be selected on a random basis from a computerized bank of questions. Oral examinations are no longer given or addressed by procedure. Revision 18 reqaires candidates to take a written examination and demonstrate their proficiency in the field.
(5) Consider using only written examinations.
As stated above, only written examinations are used in conjunction with the proficiency demonstration.
(6) Consider administering open book examinations with ti=e limdza. This will promote utilization of procedures. This wsm a suggestion and not a requirement.
TUGC3 currently allows the use of both open or closed beek
.: examinations. The criteria for a passing score is ten (10)
'poista higher for an open book examination (90 versus 80%)
- g_ -than for a closed book examination.
(7) Scramble the order of multiple choice ansvers for individual questions to further protect the integrity acd security of exams.
CP+q?-2.1, Revision 18 required that examinations be rande=1y selected from a back of questions to ensure the same test is not 1ven consecutively (different test each time) . Security mesurres havu been established to limit access to the exa=1tation back. These practices adequately address the ori;;inal SET recommendation.
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Page 36 of 40
' RESULTS REPORT
)
ISAP I.d.2 (Cont'd)
Attachment C (Cont'd)
(8) File completed exams separate from certification file eor further security and limit access to both exam banks and completed exams.
C?-QP=2.1, Revision 18, paragraph 3.6.lh. adequately addressed this concern. Copies of complaced examinations are not maintained in certification files. Only score sheets are currently placed in the certification files.
(9) Document results of avaluation of missed exam questions in terms of why the question was failed and va e is to be done about it..
CP-QP-2.1, Revision 18, Sectica 3.6.1 requires individuals who fail an exam to be retrained and ratested. In addition, this section requires questions which have, for example, incorrect technical content or poor sentence structure to be disqualified and removed from the computer bank. These requirements adequately address the SET concern. Current TUGC0 practice is to document the reason for any disqualification.
(10) Train examiners so as to obtain consistency in administration of exams.
This recommendation applied to oral exams and is no longer applicable because only written exams are now allowed.
(11) Consider acceptance of certification granted elsew'aere on the basis of a knowledge and adequacy of the other certification
~'
process and its implementation. Include a minimum
_ ' probationary period (e.g. 90 days), and examination and
' performance demonstration for proof of capability. This was a
% ' suggestion and not a requirement.
TUGC0 elected not to accept this recommendation. The QA/QC Review Team encorses the TUGC0 position on this recommendation.
(12) Provide explanation for apparent inconsistencies between data sources, such as; between resumes and verifications, or why training is given subsequent to waiver of training for certification.
Sections 2.4.1 and 3.4.2 of QI-QP-2.1-23 adequately address this SET concern.
s
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Revision: 1;
- Pago 37 of 40
,.. RESULTS REPORT ISAP I.d.2 (Cont'd)
Attachment C (Cont'd)
(13) The term "QC Technician" and the term "QC Inspector" are defined as Level I and II Inspectors in only one place ' Para.
3.1.1 & 3.2.1 of CP-QP-2.1). Consider a'more specific statement that wherever che term is used it means Level I and II respectively. Reasco: To avoid misunderstand 1ng when giving credit for prior experience as a certified Inspector.
~
Revision 18 of CP-QP-2.1 clarified these terms throughout the procedure.
(14) Suggest that procedure include actions to be taken whtn a candidate fails an examination, i.e. waiting period before retaking exam, retraining required, etc.
Section 3.6.1 of CP-QP-2,1, Revision 18 addressed this recommendation. Revision 21 of CP-QP-2.1 stated that ratesting cannot begin sooner than one (1) week following the failed examination. If an individual fails two (2) exams he/she is ineligible for re-test or certification in that activity.
(15) Consider specifying that if the vision acuity test is passed with corrective lenses, che certification form should so
, state. Specified in CP-QP-2.1 Revision 18 (Draft). This is included on the Visual Acuity Examination Form only.
TUGC0 did not incorporate this recommendation. The Visual Acuity Examination Form indicates whether corrective lenses were used to pass the test. This form is included in the certification file, along with the certification form, and this practice is considered satisfactory.
.e
('16)'Co11eges normally require satisfactory completion of High L:. -School (or G.E.D.). Consider obtaining college attendance and
' ~ curriculum verification only when college level work is indicated on resumes.
C?-QP-2.1, Revision 18 requires verification of education sufficient to support certification. If credit is taken for a G.E.D. in supporting the certification, only the G.E.D. is normally verified by TUGCO. If an associate degree or B.S.
degree is used to support certification, only the applicable degree is normally verified by TUCCO. The procedures are adequate to resolve this SET recommendation.
s
Rovision: 1
"[ s Pege 38 of I.0 y
- p. RESUI.TS REPORT ISAP I'd.2 .
(Cont'd)
Attachment C (Cont'd)
(17) Consider specifying that an Armed Services record in not a suitable substitute for verification of High School diploma.
The TUGC0 procedures do not specifically address this recommendation. The TUCCO procedures are considered satisfactory in that they require checks verifying that education is sufficient to support certification. It is not TUCCO's current practice to utilize an Armed Services record as verification of educacion.
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, h RESULTS REPORT ISAP I.d.2 3 (Cont'd) i i
Attachment D Extracts From CP-QP-2.1, Revision 17 and CP-QP-2.3, Revision 5 l Note - Underlined portions were added by. reviewer to identify areas of concern.
"The following is the recommended personnel education and experience for each level." (CP-QP-2.1, Section 3.1)
"Related experience considerations for initial certification is as
- follows
- " (CP-QP-2.1, Section 3.1)
"Other color vision test may be implemented with approval by the QE Supervisor and documented as appropriate." (CP-QP-2.1 Section 3.3) j " Waivers may be granted on a case-by-case basis by the TUCCO Site
- Quality Assurance Manager, per paragraph 3.8." (CP-QP-7,1 Section 3.3)
'I
" Indoctrination requirements shall normally be satisfied within the first 60 days of employment." (CP-QP-2.1 Section 3)
"Waivering of OJT training requirements., may be granted if an inspector has at least 6 months experience as a Level I, and it is determined that the OJT activity being waived if sufficiently similar to other procedures in which hs is already certifisd. OJT can be waived with eg approval of the site QA Manager or his designee, per paragraph 3.8."
(CP-QP-2.1, Paragraph 3.4.4)
" Waivers for any examinations must be approved by the Site QA Manager."
(CP-QP-2.1 Section 3.5)
"All subsequent pages of the test shall be similar to those in Attachaien( 9A." (CP-QP-2.1, Paragraph 3.5.4) i "There thall be a significant number of test questions to adequately indicate proficiency and knowledge in the inspection activity."
(CP-QP-2.1, Paragraph 3.5.6)
"An inspector designated " Level II" shall be authorized to perform inspections in accordance with all instructions in that procedural series in which he is so designated. Waivers to this shall be considered based y he following:" (CP-QP-2.1 Paragraph 3.5.6)
"When proiset requirements dict &te, an individual may be certified to a limited scope of an inspection activity. The limited scope certification shall be documented on the Inspection Certification Form (Attachment 6) and shall clearl delineate the inspection authority given the inspector." (CP-QP-2 I section 3.6)
L Revision: 1
'et, Pcge 40 of 40 L :.
F RESULTS REPORT l
- ISAP I.d.2 (Cont'd)
Attachment D (Cont'd)
"All waivers pertaining to this procedure shall have approval of the Sita QA Manager or his designee. These waivers shall have documentation, per Attachment 11, providing assurance that the basis for the waiver is consistent with the applicable waiver guidelines, properly assessed, reviewed, approved and documented." (CP-QP-2.1 Section 3.8) l "The purpose of this Instruction is to supplement the technical training requirements of Reference 1-A by:
- a. Defining typical content of a CPSES QA/QC individual's personnel training file;" (CP-QP-2.3 Section 2.0)
" Personnel considered for certification should meet recommended education, training and expreience to ensure understanding of the principles and procedures of those areas of inspection in which they are being considered for certification, consistant with Reference 1-A."
(CP-QP-2.3, Paragraph 3.1.1)
" Documented evidence of such education, training and experience should be made part of the individuals training file before he/the is certified. " (3.1.1) (CP-QP-2.3, Paragraph 3.1.1)
"Thus, for example, each QC Technician or Inspector will have in a personnel file or certification file at least the following:" (CP-QP-2,1 Section 3.2)
" form referenetd herein and identified as " TYPICAL" may be substituted
~
for by similar forms which serve the same purpose (s) a'nd which may pre-date this Instruction." (CP-QP-2.3, Section 3.5) s
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COMANCHE PEAK RESPONSE TEAM ACTION PLAN ISAP I.d.3
Title:
Craft Personnel Training Revision No. O Description Original Issue Prepared and Recommended by: [ /
Review Team .h
< M Leader If Date 2V kb Approved by:
Senior Review Team ( , hw Date /lL+/rc 1
Rsvision: 0 Page- 1 of 6 i
4 ISAP I.d.3 Craft Personnel Training
1.0 DESCRIPTION
OF ISSUES IDETTIFIED BY NRC (NUREG-0797, Supplement No.
- 7. Page J-34 and Supplement Number 8, Page K-147)
It was alleged that, in general, there were problems with the adequacy of training of personnel installing conduit supports.
"The TRT interviewed personnel.. craft supervisors, and training personnel to determine the availability and effectiveness of the training program, and found that there was a training program for newly hired personnel or transfers into the installation. This training program included periodic briefings on procedure changes.
The interviews revealed that the training program was not effective because 7 of the 11 crew members interviewed were not cognizant of Manual 2323-5-0910. " Conduit and Junction Box Supports", which is the primary reference manual'for installation of supports. '
Although these seven crew members indicated that they had no need to use this manual in their job assignments, the TRT could not ;
substantiate this assertion. Hence, the lack of awareness of this i
procedure by craft personnel may be indicative of poor training in '
the area of procedural requirements."
"An NRC Region IV Resident Inspector identified a violation as a )
result of a discussion with a craft person who stated that he had not received instructions about how to rig and handle a large motor-operated valve."
"The NRC Technical Review Team (TRT) found no need to contact the alleger to further clarify the allegation. The TRT reviewed NRC Inspecticn Report 50-445/79-27, 50-446/79-26 and its corresponding Notice of Violation (NOV). The TRT also reviewed the Texas Utilities Electric Company (TUEC) response to these documents (TXX-3080, dated December 18, 1979), which stated that the subject valve was not mishandled, nor was it damaged. The engineering organization had not, however, reviewed specific vendor rigging or handling reco=mendations or noted the procedures for loads exceeding 2000 pounds. An NRC follow up inspection verified that Brown & Root (B&R) Procedures CP-CPM-6.3, 35-1195-CCP-24, 35-1195-ACP-3, and QI-QAP-13.1-1 were reviewed by TUEC and revised appropriately. NRC Inspection Report 50-445/80-18, 50-446/80-18 (dated September 19, 1980) documented corrective action during the follow up inspection."
2.0 ACTION IDENTIFIEL BY NRC (NUREG-0797, Supplement No. 7, Page J-35 and Supplement Number 8, Page K-147)
" Prior to fuel load TUEC shall accomplish the following action:
Evaluate the adecuacy of craft personnel training it the use of installation manuals to attablish root causes and appropriate L _ _ _ _ - _ _ _ _ - _ - _ _ _ _
Revision: 0 Page 2 of 6 s
ISAP I.d.3 (Cont'd) 2.0 ACTION IDENTIFIED BY NRC (Cont'd) corrective actions. This action shall be integrated with other actions concerning craf t personnel training addressed under QA/QC Category 8, 'As-Built'."
The TRT determined that Region IV (RIV) confirmed that the craft person's stated need for better instructions was correct and confirmed follow up inspection by the RIV inspector to verify that corrective action was accomplished in accordance with TUEC letter TXX-3080 (December 18, 1979). The TRT concludes that the failure to provide proper instructions for rigging and handling heavy loads is safety-significant and has ceneric implications; however, I corrective action was taken. oc evidence of further inadequacies in this area was found; consequently the allegation requires no further action.
3.0 BACKGROUND
3.1 Information Supplementing NRC Description of Issue A preliminary investigation f rom the CPRT revealed that Manual 2323-S-0910, " Conduit and Junction Box Supports", is an engineering document. As such, it was required that only structurcl engineers and craft supervisors be familiar with l the use of the document. When craft personnel began installing junction box or conduit supports they were given specific directions by their supervisor concerning the type of support which was required to be installed. Thus there was no need for the craft to be aware of this document.
~
"The TRT interviewed TUEC's Rigging Craft Superintendent, Assistant Mechanical Superintendent, and Senior Staff Engineer. They stated that the revised procedures (specifically, CCP-2A, Revision 4, " Rigging"; CP-CPM-6.3, Revision 10. " Preparation, Approval, and Control of Operation Travelers"; and, CP-CPM-6.9, Revision 2. " General Piping Procedure") adequately controlled heavy lifts of equipment and components. Non-conformance Report (NCR) M-2128 documented the problem which was identified as a violation, and the appropriate site personnel reviewed the NRC Inspection Report and concurred with the corrective acticr. In addition, the TRT independently reviewed the revised procedures for the control of hecay lifts of equipment and found the control of rigging and handling to be acceptable for loads less than or exceeding 2000 pounds." (NUREG-0797, Supplement No. 8, Page K-147)
, _ , , . _ , _ _ , _ _ _ a______ _ _ _ _ _ _ . _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____ _ _ _ _ _ _ _ _ - - - - - _ _ _ _ _ _ - - - - - _ _ - - - - - - - -- - - - - - - - - -
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. Paga ISAP I.d.3 (Cont'd) l l
l l
4.0 CPRT ACTION PLAN 4.1 Scope and Methodology The objective of this action is to evaluate the Craft Training Program to determine if it was adequate in the past, and also evaluate the current program.
To achieve this objective, the following tasks will be implemented:
Resolve specific NRC concerns.
Review procedures anc interview personnel.
4.1.1 Specific NRC Concerns To address the specific concerns regarding Manual 2323-S-0910 (NUREG-0737 Supplement Number 7, Page J-34), the installation procedure for conduit and junction box supports, ECP-19, " Exposed Conduit /
Junction Box and Hanger Fabrication and Installations" will be further investigated to determine if craft personnel should have been cognizant of the manual. If required, the existing procedures will be reviewed and recommendations for improvement made to TUCCO as required.
To address the NRC concern involving instructions for rigging and handling heavy loads (NUREG-0737 Supplement Number 8, Page K-147), the procedure or method used to retrain craft to revised procedures will be reviewed.
+
Revision: 0 Page 4 of 6 ISAP I.d.3-(Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.1.2 Special Evaluation Team A Special Evaluation Team (SET) comprised of individuals with no direct responsibility to CPSES will
. perform the evaluation of the Craft Training Program including the craft personnel selection, training, assignment and retraining. The following, items will be considered during the SET review:
How requirements for craft skill levels are established.
- How craft personnel (when selected and while on assignment) are determined to meet the skill and performance requirements.
l
- How craft personnel classifications are estab)4.shed for crew loading.
How craft personnel become aware of changes
, in design and construction requirements and-how retraining occurs.
l
- How craft personnel are informed and become knowledgeable of QA/QC requirements / criteria and changes to those requirements / criteria.
I l -
How management is assured that the craft l personnel selection, training, assignment and retraining program complies with project requirements.
How supervisory personnel are selected and trained.
- How background of education and experience of craft personnel is verified and documented.
The SET evaluation will be accomplished through l reviewing those craft procedures that were in l
existence, interviewing craft personnel, and observing training and field activities.
4.1.2.1 Review Procedures The Craft Training Procedure (CP-CPM-2.2) will be reviewed to determine if it supports the activities as described during interviews and field observations.
l.
1
R0 vision: 0 Pego 6 of 6 ISAP I.d.3 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.2.2 Evaluation Research Corporation (ERC) 4.2.2.1 ERC will be responsible for evaluating recommendations and reconciliation of comments with TUEC.
4.2.2.2 Personnel:
Mr. J. L. Hansel, QA/QC Review Team Leader Mr. J. E. Young, Issue Coordinator 4.3 qualifications of Personnel SET and ERC personnel will have, as a minimum, 5 years of management / supervisory level experience in QA/QC, Each person will have experience in some aspect of training, either review of training programs or actual experience in the conduct of training and will meet the qualification requirements specified in the CPRT Program Plan.
4.4 Procedures This action plan will be conducted in accordance with the CPRT Program Plan.
4.5 Standards / Acceptance Criteria The requirements of ANSI N45.2-1971, set forth in part that personnel performing activities affecting quality are trained and indoctrinated to assure the suitable proficiency is achieved and maintained, will be met.
4.6 Decision Criteria The results of inspections conducted during ISAP VII.c will provide an indication of the adequacy of hardware construction. This information will be categorized by major discipline i.e., civil, mechanical, electrical, and structural. This information can then be compared to the results of this ISAP during the collective evaluation phase.
If craf t training was determined to be a root cause, l
recommendation will be provided to TL'GCO.
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1 L--_-_--__---__----
- g. .
COMANCHE PEAK RESPONSE TEAM RESULTS REPORT ISAP: I.d.3
Title:
Craft Personnel Training REVISION 1 l
Nf4~ -
Issue C6ordinator r/.1r/rd Date M - b @[3M!86
- Red ew Team Leader [J Dac4 /
Gr a % -
J p W. Beck, Chairman CPRT-SRT
<Ai/n.
Date 8
e e
____________.__m___ __.
Revision: 1 Pege 1 of 21:
REStJLTS REPORT ;
ISAP I.d.3 Craft Personnel Training
1.0 DESCRIPTION
OP ISSUES IDENTITIED BT NRC The NRC identified two specific concerns about the adequacy of craft personnel craining. Those concerns, which are described below, involved the training of personnel installing conduit supports.and those handling heavy loads.
1.1 Conduit Supports It was alleged that, in general, there were problems with the adequacy of training of personnel installing conduit supports.
"The TRT interviewed personnel, craft supervisors, and training personcel to determine the availability and ef festiveness of the training program, and found that there was a training program for newly hired personnel or transfers into the installation. This 0 :ining program included periodic briefings on prc edure changes. The interviews revealed that the trainintt progras' was not effective because 7 of the.11 crew members interviewed were not cognizant of Manual 2323-5-0910. " Conduit and Junction Box Supports", which is the primary reference manual for inavallation of supports.
Although these seven crew members indicated that they had no need to use this manual in their job assignments, the TRT could not substantiate this assertion. Hence, the lack of awareness of this procedure by craft personnel may be indicative of poor training in the area of procedural
{
requirements." (NUREG-0797, Supplement Number 7, Page J-34) J l
1.2 Heavy Loads "An NBC Region IV Resident Inspector ident*.!ied a violation as a result of a discussion with a craf t person who stated that he had not received instructions about how to rig and handle a large motor-operated volve."
"The TRT reviewed NRC Inspection Raport 50-445/79-27, 50-446/79-26 and its corresponding Notice of Violation (NOV).
The TRT also reviewed the Texas Utilities Electric Company (TUIC) response to these docuannes (T F-3080, dated December 18, 1979), which stated that the subjcco valve was not ,
mishandled, nor was it damaged. The sustneering organization had not, however, reviewed specific vendor rigging or handling recommendations or noted the procedures for loads exceeding
Revision: 1 Pege 2 of 21
. ,RESULTS REPORT ISAP I.d.3 (Cont'd) !
1.0 DESCRIPTION
OF ISSUES IDENTIFIED BY NRC (Cont'd) 2000 pounds. An NRC follow up inspection verified that Brown
& Root (B&R) Procedures CP-CPM-6.3, 35-1195-CCP-24, 35-1195-ACP-3, and QI-QAP-13.1-1 were reviewed by TUEC'and revised appropriately. .NRC Inspection Report 50-445/80-18, 50-446/80-18 (dated September 19, 1980) documented corrective action during the follow-up inspection." (NUREG-0797, Supplement Number 8, Page K-147) 2.0 ACTION IDENTIFIED BT NRC Actions identified by NRC to resolve concerns about craft personnel training are provided below.
2.1 Conduit Supports
" Prior to fuel load TUEC shall accomplish the following action: Evaluate the adequacy of craft personnel training in the use of installation manuals to establish root causes and appropriate corrective actions. This action shall be integrated with other actions concerning craf t personnel training addressed under QA/QC Category 8, ' As-Built'."
(NUREG-0797 Supplement Number 7. Page J-35) The installation manual associated with conduit supports is Manual 2323-S-0910.
2.2 Heavy Loads "The TRT determined that Region IV (RIV) confirmed that the craft person's stated need for better instructions was correct and confirmed follow up inspection by the RIY inspector to verify that corrective action was accomplished in accordance with TUEC letter TII-3080 (December 18, 1979). The TRT concludes that the failure to provide proper instructions for rigging and bandling heavy loads is safety-significant and has generic implications; however, corrective action was takan.
No evidence of further inadequacies in this ares was found; consequently the allegation requires no further action."
(NUREG-0797, Supplement Number 8 Page K-147)
\
- Revisien
- 1
. Page 3 of 21 i
RESULTS REPORT ISAP I.d.3 (Cont'd) 3.0 BACKCROUND The following information supplements the NRC description of issues provided in Section 1.0.
3.1 conduit Supports Manual 2323-5-0910 is an engineering document containing detailed drawings for installation of conduit / junction box supports. These detailed drawings are referred to as S-910/S2-910 drawings. Prior to the use of work packages, craft personnel obtained the S-910/52-910 drawings needed to install supports from Manual 2323-5-0910. Guidance for selecting the appropriate supports was provided by engineering. After work packages were instituted, craft personnel received S-910/S2-910 drawings in those packages.
Cognizant engineers designated the type of supports to be used, and package processors provided appropriate drawings from Manual 2323-S-0910. Contact of craf t personnel with' Manual 2323-5-0910 was through the S-910/S2-910 drawings.
3.2 Heavy Loads "The TRT interviewed TUIC's Rigging Craft Superintendent.
Assistant Mechanical Superintendent, and Senior Staff Engineer. They stated that the revised procedures (specifically, CCP-2A, Revision 4. " Rigging"; CP-CPM-6.3, Revision 10. " Preparation, Approval, and Control of Operation Travelers"; and, CP-CPM-6.9, Revision 2, " General Piping Procedure") adequately controlled heavy lif ts of equipment and components. Non-conformance Report (NCR) M-2128 documented the problem which was identified as a violation, and the appropriate site personnel reviewed the NRC Inspection Report and concurred with the corrective action. In addition, the TRT independently reviewed the revised procedures for the control of heavy lifts of equipment and found the control of rigging and handling to be acceptable for loads less than or exceeding 2000 pounds." (NUREG-0797, Supplement Number 8 Page K-147) 4.0 CPRT ACTION PLAN 4.1 Scope and Methodology The objective of this action plan was o evaluate craft training programs to determina if they were adequate in the past, and also to evaluate current programs.
l Revision: 1 i
Pege 4 of 21 RESULTS REPORT ISAP I.d,3 (Cont'd) l 4.0 CPRT ACTION PLAN (Cont'd)
To achieve this objective, the following taska were l implemented:
Resolution of the two specific NRC concerns.
Assessment of craf t personnel training programs.
4.1.1 Specific NRC Concerns 4.1.1.1 Conduit Supports l
Conduit installation procedures were reviewed, electrical craft personnel were interviewed, and the installation of a conduit support was observed to determine if craf t personnel should have been cognizant of Manual 2323-S-0910.
4.1.1.2 Heavy Loads No further action on handling heavy loads was specifica by NRC. Nevertheless, procedural retraining practices were checked to ensure that corrective actions were being properly implemented by craft personnel. These checks included a review of Brown & Root procedure CP-CPM-2.2, Training of Personnel in Procedural Requirements; interviews of riggers; and an observation of a rigging activity. '
4.1.2 Craf t Personnel Training Programs The assessment of craf t personnel training programs was accomplished by reviewing craft training procedures, interviewing craf t personnel, and observing training and field activities. The following items were considered during this assessment:
- How skill requirements for craft classification levels are established.
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(Cont'd) 1.0 CPRT ACTION PLAN (Cont'd)
How background of education and experience of craft personnel is verified and documented.
How craft personnel are determined to meet skill and performance requirements.
t How craft personnel classifications are established for crew loading.
How craft personnel become aware of changes to construction requirements and how retraining occurs.
How craft personnel become aware of QA/0C requirements / criteria and changes to those requirements / criteria.
How management is assured that craft personnel selection, training, assignment and retraining comply with project' requirements.
How craft personnel are trained.
How supervisory personnel are selected and trained.
4.1.2.1 Review Training Procedures Craf t training procedures (Brown & Root CP-CPM-2.2 and Bahnson QCI-CPSES-013) were l reviewed to determine if they supported the activities described during interviews and field observations.
4.1.2.2 Interview Personnel Craft personnel, from the general superintendent / building manager level to the helper level, were ints:rviewed to determine how craft personnel were selected and trained.
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- . - . - - - _ = _ - - _ _ _ - _ - - - - , _ _ - _ _ - - a
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. Pcg3 6 of 21 RESULTS REPORT ISAP I.d.3 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.1.2.3 Observe Training and Field Activities Training and field activities were observed to determine if adequate training was provided and to evaluate how well craft personnel performed in the field.
4.1.3 Use of Results The QA/QC Review Team used results of their activities to draw conclusions about the adequacy of past and current craf t personnel training practices. These conclusions may be modified if shortcomings in the training of craf t personnel are determined to be the root cause of any construction deficiencies or adverse trends identified by other ISAPs. A review of the root causes of any construction deficiencies and adverse trends and, if appropriate,' a reassessment of the adequacy of past training will be conducted by the Collective Evaluation Group after the results reports of other ISAPs are issued.
4.2 Participants Roles and Responsibilities 4.2.1 Special Evaluation Team (Prior to April 24, 1986) 4.2.1.1 The Special Evaluation Team interviewed personnel and' observed training activities for scoping purposes.
i 4.2.1.2 Personnel i Mr. M. L. Curland Consultant Mr. J. W. Sutton Consultant 4.2.2 Evaluation Research Corporation 4.2.2.1 The Evaluation Rasearch Corporation was responsible for evaluating' the adequacy pf the craft training progress at CPSES by reviewing procedures, interviewing personnel, and observing trgining and field activities. !
On April 24, 1986, the QA/QC' Review Tess I replac,ed the Spacial Evalhation Tees.
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Paga 7 of 21 RESULTS RE? ORT ISAP I.d.3 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.2.2.2 Personnel Mr. J. L. Ransel QA/QC Review Team Leader Mt. A. P. Amoruso Issue Coordinates Mr. W. M. Sides Senior QA Engineer 4.'3 Qualifications of Personnel All personnel associated with the evaluation of the adequacy of craf t personnel training programs were qualified in accordance with the requirements of the CPRT Program Plan.
4.4 Procedures This action plan was conducted in accordance with the CPRT Program Plan.
4.5 Standards / Acceptance Criteria The requirements of ANSI N45.2-1971 state that personnel performing activities af f ecting quality shall' be trained and indoctrinated to assure that suitable proficiency is achieved and maintained.
4.6 Decision Criteria This action plan will be closed if craft personnel training is found to meet the requirements of ANSI N45.2-1971.
5Property "ANSI code" (as page type) with input value "ANSI N45.2-1971.</br></br>5" contains invalid characters or is incomplete and therefore can cause unexpected results during a query or annotation process..0 IMPLDENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS 5.1 NRC Concerne 5.1.1 Conduit and Junction Box Supports To determine if craft personnel should have been cognizant of Manual 2323-5-0910 " Conduit and Junction Box Supports", two procedures were reviewed, four people were interviewed, and a field activity was observed. ,
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. Page 8 of 21 RESULTS REPORT ISAP I.d.3 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Brown & Root procedures. ECP-19 and ECP-19A address the installation of safety-related conduit and associated junction box supports. These two procedures were reviewed to determine if craft personnel were required to use Manual 2323-5-0910. ECP-19 states that safety-related conduit / junction box supports are to be installed in accordance with typical 5-910/$2-910 drawings. These drawings sake up Manual 2323-5-0910.
ECP-19A states that typical support drawings for safety-related' conduit will be taken from Manual t
2323-5-0910. Therefore, the crafts were required to
{
use S-910/S2-910 drawings.
Four electricians, i.e., general superintendent, foreman, and two journeynen, were interviewed concerning their knowledge of 5-910/52-910 drawings.
They were familiar with the use of 5-910 and $2-910 drawings for installing conduit supports. However, three of the four could not readily associate " Manual 2323-5-0910" as the binder for S-910/$2-910 drawings.
Since S-910/52-910' drawings are the engineering documents used in the field by craf t personnel to install conduit / junction box supports, the inability to readily recall the name of the manual that binds these drawings does not affect worlananship.
The installation of a conduit support in Unit 2 was observed. The work package contained an isometric drawing, a construction operation traveler and detailed conduit support drawings. Craf t personnel used the detailed drawing spe:ified on the isometric to install the support and were aware that this drawing was an
$2-910 drawing.
The action identified by NRC for this concern, as stated in Section 2.0, was to evaluate the adequacy of craft personnel training in the use of installation manuals and in performing tasks addressed as examples of faulty construction under QA/QC Category 83 As-Built, in NUREG-0797, Supplement Number 11. In the case of installation annuals, engineering is responsible for assuring that pertinent construction requireaants in those manuals are listed on appropriate operation travelers or provided separately for work not requiring travelers. Craft personnel must be ,
l
1 Revision: 1
. Pago 9 og 21 RESULTS REPORT ISAP I.d.3 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) proficient in using drawings, tolerances and instructions that are provided by engineering but do not have to be thoroughly familiar with the manuals from which information is extracted. As discussed above, craft personnel could not readily recall how Manual 2323-S-0910 related to their work, but their training in the use of drawings taken from that manual was determined to be adequate based on interviews and a field observation. The adequacy of craft personnel training in the use of travelers containing instructions from other assuals is discussed and assessed under the general topic of craft personnel training programs in Section 5.2.
In the case of the faulty construction addressed under QA/QC Category 8, As-Built, the examples presented address hardware discrepancies and differences between installed hardware and as-built drawings. The causes of these problems could be shortcomings in the training of craft personnel or could be inadequate design information, procedures, nanagement direction, or training of non-craf t perso' nel n conducting walkdowns.
In the case of craft personnel, the adequacy of their training to support the installation of hardware in accordance with' instructions provided by engineering is discussed and assessed under the general topic of craft personnel training programs in Section 5.2.
5.1.2 Rigging and Handling Heavy Loads As discussed in Sections 1.0 and 2.0, corrective action taken by TUCCO to resolve NRC concerns about instructions for rigging and handling heavy loads included revising procedures that addressed the subject. These revisions were reviewed and found acceptable by the TRT. No further action was requirsd.
However, to assure that craft personnel are being trained on the content of procedures that address rigging and handling of heavy loads. Brown & Root procedure CP-CPM-2.2, Training of Personnel in Procedural Requirements, was reviewed. This procedure adequately addresses (1) the requirement for craf t personnel to be made aware of procedures and changes applicable to th,eir work and (2) the process for accomplishing and documenting that training.
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. Pags 10 of 21 RESULTS REPORT ISAP I.d.3 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Interviews, record checks and a fi-eld observation were conducted to monitor the implementation of procedure CP-CPM-2.2. Five riggers, i.e., a general superintendent, a foreman, two journeyman and a helper, were interviewed. The interviews established that riggers read new procedures that pertain to their work and discuss changes to those procedures with ti. air supervisors. They are knowledgeable of the following procedures as appropriate to their job classifications:
CCP-24, Rigging; CPM-6.3. Preparation, Approval, and l
Control of Operation Travelers; CPM-7.1A, Documentation Package Preparation; CPM-14.1, Guideline for Protection of Plant Equipment; and CPM-15.1, observation of Hold Points.
Training records for two of those interviewed, a journeyman and the helper, were checked to assure that
- training applicable to their work had been accomplished and recorded. No discrepancies were noted.
A rigging and lifting operation was observed to check the effectiveness of procedural training in covering revised procedures. No itses on the critical equipment list that is attached to CCP-24 were scheduled for lif ting because of the completion status of the plants.
Therefore, the rigging and lifting of a condenser tube bundle was observed. -The pre-lift briefing, inspection of handling equipment, rigging, and lifting complied with the requirements of CCP-24 for the handling of permanent plant equipment not on the critical equipment list. No discrepancies were noted.
I The training checks, interviews, and rigging operation demonstrated that training related to rigging and handling operations has been effective.
5.2 Craf t Personnel Trainina 5.2.1 Introduction This evaluation covers ths Brown & Root and Bahnson' craft training programs. Those two training programs vers used because Brown & Root and Bahnson were the major construction contractors involved with safety-related work remaining on site at the time of the evaluation.
- Craf t personnel employed by Brown &
Root and Behnson comprised more than 99% of the work force involved with safety-related work.
. I
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i ISAP I.d.3 -
l (Cont'd) l 5.0 I.TLiWATION OF ACTION PLAN AND DISCUSSION OF ROiUI.TS (Cont'd)
The first step in the evaluation of ): aft training was to cover the selection and assignment process for craft personnel by interviewing management representatives and general superintendents. This established the basic entry skills of craft personnel.
Next, the evaluation covered the training provided to craf t personnel as determined by interviewing craf t supervisory and non-supervisory personnel and by reviewing procedural, on-the-job (0JT), classroom and mockup training. This established craft capability levels.
Finally, the evaluation covered workmanship by interviewing craf t personnel, observing field activities and reviewing corrective action requests related to craft performance. Workmanship resulting from the training that was conducted provided the basis for an assessment of the adequacy of craft personnel training.
Thirty-seven interviews were conducted during this evaluation. A matrix listing those interviewed by classification and craft group is included as Attachment L.
5.2.2 Selection and Assignment Craft personnel are selected by a process which commences in contractor employment offices where preliminary screening actions take place. These screening actions are intended to ensure that only those individuals with applicable construction skills or capabilities are considered for employment. All hiring activity is contingent upon existing manpower needs as established by project management.
Employment forms are completed by applicants and reviewed by employment office personnel and craft management. After these reviews, applicants are I
l interviewed by craf t supervisors, usually general l f oremen. These interviews provide a first-hand i assessment regarding an applicant's capabilities and experience through in-depth questioning of craft
( -_ -___________-
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" Pego 12 of 21 RESULTS REPORT ISAP I.d.3 (Cont'd) 5, J IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) techniques.- Routine work histories are spot checked to verify the skills and knowledge professed by the applicant. These spot checks include obtaining backgrounds of applicants from associates at other work sites, information about work habits and skills from former employers and educational achievements from schools. Brown & Root uses a polygraph during pre-employment questioning.
People are assigned to grade classifications and craf t groups accceding to skills, experience and manpower needs. Specific skill requirements for entry level positions in a craft are determined by the experience and judgment of craf t supervisors. The interview process, including communications between esployment personnel and craf t supervisors, is used to place an individual in the appropriate craft group and grade classification.
A crew is asse up of eight to fourteen people assigned to a foreman. The classifications that make up a crew depend upon the work to be accomplished and are determined by general superintendents. Most new hires are started in a helper classification until their on-the-job performance has been observed and evaluated by their foremen and the required procedural training has been completed. The least experienced new hires are assigned to the lowest helper level. Transfers within the work force to craft groups and crews are ,
made by general superintendents based on the performance, skills and potential of craf t personnel and manpower needs of the project.
An exception to the general approach discussed above for selecting and assigning craft personnel applies to welders. Brown & Root craf t supervisors requiring welders submit a requisition to the Welding Engineer. i The Welding Engineer interviews and selects personnel j according to requirements specified on the requisition.
The velders are qualified and receive special training, i
as needed, before being assigned. Therefore, only' qualified welders are turned over to the electrical, mechanical, and structural craft organizations.
Bahnson welders are qualified as a part of the hiring process and are ,then assigned to hanger crews.
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. Pago 13 of 21 RESULTS REPORT ISAP I.d.3 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PI.AN AND DISCUSSION OF RESULTS (Cont'd)
On-the-job performance is evaluated every three months by Brown & Root and annually by Bahnson using standardized forms that address knowledge, skills, productivity and leadership. These evaluations are used to counsel employees, determiue compliance with project requirements and select supervisory personnel.
If a craft worker's performance is determined to be inconsistent or less than expected on the basis of the original selection and assignment process, the cognizant foresan has recourse to recommending termination, transfer or retraining of the employee.
The overall craft selection and assignment process comprises a practical approach which contains responsible checks and balances.
5.2.3 Training Programs Brown & Root and Bahnson craft personnel training programs are made up of four elements: procedural training, on-the-job training (0JT), classroom training, and mockup training. These programs are administered by project managers through craft supervisors using training coordinators.
Procedural training is governed by the folleving procedures Brown & Root, CP-CPM-2.2, Revision 4 -
Training of Personnel in Procedural Requirements Bahnson, QCI-CPSES-013 Revision 4 -
Indoctrination and Training of Personnel These Brown & Root and Bahnson training procedures were reviewed and found to contain guidance for conducting procedural training for craft personnel.
Implementation of these procedures was evaluated by I checking administrative controls and training records.
Administrative controls were found to have provisiens l
l for assuring that craft personnel complete required procedural training as procedures are revised and personnel are assigned to naw crews or grade classifications., Craf t supervisors are involved in
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, Pegs la of 21 RESULTS REPORT ISAP I.d.3 (Cont'd) 5.0 IMPLEMENTATION OT ACTION PLAN AND DISCUSSION OT RESULTS (Cont'd) authenticating procedural training requirements for crews and grade classifications and are provided the training status of assigned parsonnel. The training recoeds chosen for review included those for craft personnel previously interviewed and those observed in the field performing work. The records were checked to assure that procedures pertinent to each crew and grade classification were listed as r? uirements and that people assigned to those crews and classifications had completed the training that was prescribed. No discrepancies were noted.
Interviews with Brown & Root and Bahnson craft personnel established that procedural training had always been a part of training programs. This training was provided by reading assignments or classroom sessions followed by discussions with forsman.
Brown & koot issued TCP-1, Project Training, on October 3, 1975. The format and means of storing training information improved when CP-CPM-2.2 was issued on December 18, 1981. Information is available prior to 1981 but retrieval is more difficult. Bahnson proceduralized their training program on July 21, 1983 with the issuance of QCI-CPSES-013. Training records exist before the issuance of QCI-CPSES-013, extending back into 1982.
On-the-job training (0JT) is an important part of Brown
& Root and Bahnson training programs for both craf t personnel and supervisors. During interviews, craf t personnel stressed the significant role this type of training has played since the beginning of work at the site. New hires for all craf ts receive OJT before being allowed to work under reduced supervision. Newly j hired helpers are under close scrutiny of journeymen j until they demonstrate their ability to handle I supporting taska. Newly hired journsynen work with site-experienced journeymen and are under the close supervisieu of forenen until they demonstrate proficiency in their crafts. iLi process for new journsynen takes from two weeks to saves.2 months depending on the complexity of the work and the
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, RESULTS REPORT ISAP I.d.3 I (Cont'd) l 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) experience and learning ab111ty of the journeyman involved. OJT is also usei to prepara supervisors for higher grade levels, sygrade craf t skills. . correct problem areas, and clarify information obtained in procedural and classroom : raining. The effectiveness of OJT is monitored by craft supervisors using productivity, work rejec'; rates, nonconformances, and personnel performance e'ta!uations. This monitoring is part of the periodic asse/sment of progress made by supervisors and is not s;cumented. Supervisors feed back areas requiring additional training into OJT or classroom training through the craft organization and the project training coordinator respectively.
Since documentation of OJT is not required by either construction contractor, interviews and field observations were used to assess this training.
Interviews established that craf t personnel believe that OJT has been and continues to be effective. Field observations established that foremen control work i activities by assigning work, briefing personnel on the details of work, answering questions, checking procedural compliance and inspecting work. Journeyman openly discuss problems with foremen in a professional manner.
Classroom training has been an inherent part of contractor programs since work began at the site.
- Brown & Root has used classroom training to upgrade skill levels and improve the understanding of construction requirements that are contained in procedures. Bahnson has used classroom training to orient new hires, cover procedures with craft personnel, and discuss problem areas with cognizant groups.
Classroom training that was conducted by Brown & Root between 1975 and 1984 to upgrade skills was generally scheduled af ter normal working hours on a voluntary basis without monetary compensation. Craft personnel sought these courses to improve their skills and promotion potential. Their interest is shown by a l cumulative enrollment in these courses of over 25,000.
j Courses taught included welding, concrete placement, concrete patching, conduit bending, electrical terminations, pipefitting, component supports and f
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. Pege 16 of 21 RESULTS REPORT ISAP I.d.3 (Cont'd) 5.0 IMPLEMENTATION OT ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) hangers, rebar, cadwelding, instrumentation, sillwright maintenance, blueprint reading, material control, and document control. Classroom training for upgrading skills has also been conducted by Brown & Roos during normal working hours. The purpose of this training was to develop skills in short supply for upcoming work.
These courses covered welding and pipefitting to support peak demand periods for those skills and has shifted to conduit supports, conduit bending, and electrical terminations to support peak demand periods for those skills. Supervisors select personnel for the courses conducted during norma 3 wccrking hours based on the performance and potential of each individual.
Bahnson has used OJT and the hiring process to obtain skills needed to accomplish their scope of work.
Classroom training has been used by both Brewn & Root and Bahnson to improve the ' understanding by craf t personnel of construction requirements contained in procedures. For Brown & Root, craft supervisors decide when this type of training will be used and what procedures or changes will be covered. These decisions are based on the needs of craft personnel and the complexity of procedures. All mechanical craft personnel are being sent through classroca refresher training on procedures to reinforce their knowledge of construction requirements applicable to their work assignments. All electrical craf t personnel are being recycled through classroom refresher training every six months to reinforce their knowledge of pertinent J 7rocedures. For Bahnson, classroom training is I scheduled by project management and is used to review l procedures with newly hired personnel during indoctrination and with all craf t personnel when .
sigt2ficant changes to procedures are presulgated.
Mockup training has been used by Brown & Root to augment OJT and classroos training. Mockup training develops hands-on skills for craf t personnel using components similar to those installed in the plant.
This training has been used for coatings, conduit, cable trays, pipefitting, component hangers / supports, Hilti bolts, electrical terminations, rigging and l
welding. Bahnson uses mockup training for velding and correcting field problems that are suited to this type of training.
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(Cont'd) 5.0 IMPI.DENTATION OF ACTION PLAN AND DISCUSSION OF RESUI.TS (Cont'd)
Two classes and one mockup session conducted by Brown &
Root were observed to assess classroom and mockup training. The classes covered the installation of conduit supports and the content of welding procedures.
The mockup session involved high voltage cable terminations. These observations established that lesson plans are being used, instructors are well prepared, students have the opportunity to ask questions, training aids clarify concepts, and quizzes and performance tests are given to assess the effectiveness of this training and the knowledge and skills of attendees. The training sessions met the objectives of lesson plans. Also, interviews with Brown & Root and Bahnson craf t personnel established that classroom and mockup training in the past has been beneficial in upgrading skills.
5.2.4 Training Effectiveness The adequacy of current training was assessed by observing work and training activities and interviewing craft personnel. The adequacy of past training was assessed by reviewing Corrective Action Requests (CARS), considering training that was conducted as discussed f.n Section 5.2.3, and interviewing craf t i personnel . CA?s were selected for use in the assessment of the adequacy of past training because any shortcomings in the training of craft personnel should have shown up as recurring hardware and documentation nonconformances, and noteworthy recurring hardware and documentation conconformances were to be addressed by CARS. The effectiveness of CARS in addressing the causes and corrective actions for recurring hardware and documentation problems will be verified by reinspection covered by other ISAPs.
Eleven work activities, two classes, and one mockup session were observed and twenty-six interviews were conducted to assess the adequacy of current training by Brown & Root and Bahnson. The work activities covered electrical, mechanical, rigging, and EVAC (heating,'
l ventilation, and air conditioning) areas. Obse rvations
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- Page 12 of 21 RESULTS REPORT ISAP I.d.3 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) of the work activities determined that work packages containing travelers, drawings and other appropriate instructions are used; that forenen closely supervise work; that foresen and journeynen discuss procedural questions; that procedures are available at craft field stations and are used; that work is accomplished in accordance with travelers and procedures; and that hold points are honored. The working environment is professional, i.e., craft personnel are attentive to work, ask questions freely, are respectful to supervisors, and are knowledgeable of their work.
Discussions with craft personnel during these field observations found them knowledgeable not only about what they were doing but also why they were doing it.
They credited OJT as an important aspect of their development. Results of the observations of classroom and mockup training are summarised in Section 5.2.3.
The interviews determined that craft personnel are informed about changes in construction and quality control requirements through the procedural training system and through changes on travelers, and that training programs are adequate for craft personnel to achieve proficiency in accomplishing ongoing work.
Based en the work activities, classroom training and mockup session that were observed and the interviews that were conducted, current training by Brown & Root and Bahnson was assessed as adequate.
Ninety-seven Cias issued since 1977 were reviewed, training conducted since 1975 was considered, and seventeen interviews of craft personnel with more than two years of on site experience were conducted to assess the adequacy of past training by Brown & Root and Bahnson. Twenty-seven of the ninety-seven CARS that were reviewed related to craf t performance.
Twelve of the twenty-seven were issued by TUGCO, fourteen were issued by Brown & Root, and one was issued by Bahnson. Fif teen of the twenty-seven CARS were recurring. Of those fifteen, three desit with errors on veld data cards and weld material ~
requisitions, eight dealt with failures to notify QC and/or che Authorized Nuclear Inspector (ANI) at predetermined hold points, and four dealt with failures
. Ravision: 1 Page 19 of 21 RESULTS REPORT ISAP I.d.3 (Cont'd) 5.0 IMPLDENTATION OF ACTION PLAN !)ND DISCUSSION OF RESULTS (Cont'd) to generate Inspected Item Removal Notices (IRNs).
These issues were administrative in nature and were resolved by clarifyiss procedures followed by additional training. After these issues were fed back into training programs and corrective measures were implemented, no additional CARS on these subjects were issued.
Training conducted since 1975 that was considered in the assessment of past training is summarized in Section 5.2.3. Seventean craft personnel with more than evo years of on siti experience were interviewed -
to determine how training was conducted. Information obtained from these interviews supported the conclusion that past training by Brown & Root and Bahnson was adequate to achieve proficiency in accomplishing assigned work. Based on CARS, training conducted, and intarviews, past training by Brown & Root and Bahnson was assessed as adequate.
This assessment of past training does not include results of hardware and documentation reinspection conducted by the Comanche Peak Response Team. These reinspection are covered by other ISAPs. Therefore, the adequacy of past training will be reassessed if the results of other ISAPs identify shortcomings in the training of craf t personnel as the root cause of any construction deficiencies or adverse trends. Such a reassessment will be conducted, if appropriate, by the Collective Evaluation Group af ter the results reports of other ISAPs are issued.
5.3 Root Cause and Generic Implication Evaluation Sines no program deviations or deficiencies were identified, root cause and generic implication analyses are not applicable.
6.0 CONCLUSION
S Craf t personnel were cognizant of detailed drawings for conduit and junction box supports contained in Manual 2323-S-0910. Craft personnel could not readily. recall the name of the manual from which the drawings were extracted but that information does not affect workmanship because craft personnel use the drawings, and not the manual, to accomplish their work.
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6.0 CONCLUSION
S (Cont'd)
Brown & Root procedure CP-CPM-2.2 provides for the retraining of craft personnel on revised procedures. Craft personnel are knowledgeable of the procedural requirements for rigging. Training conducted on rigging has been effective.
Past and current practices used for craft selection and training were found to be in compliance with ANSI N45.2-1971 and, therefore, were determined to be adequate. The craft selection and assignment process is a practical approach with responsible checks and balances. Procedural, on-the-job, classroca and mockup tra.ning programs have been effective.
No program deviations or deficiencies were identified.
7.0 ONGOING ACTIVITIES No ongoing activities have resulted from implementation of this '
action plan.
8.0 ACTION TO PRECLUDE OCCURRENCE IN THE FUTURE Since no program devtstions or deficiencies were identified, action to preclude occurrence in the future is not applicable.
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COMANCHE PEAK RESPONSE TEAM ACTION PLAN ISAP VII.a.4
Title:
Audit Program and Auditor Qualification i
Revision No. 0 1 Description Original Issue O! 10 Prepared and .
J Recommended by:
Review Team Leader /
Date N Z,/ 'ff~ / 2 sf afG l.
Approved by:
d L Q, k L h y,y Senior Review Team v
vate vlailtr lv /unci i e
1 R2 vision: 1 Page 1 of 9 ISAP VII.a.4 Audit Program and Auditor Qualification i
1.0 DESCRIPTION
OF ISSUE IDENTIFIED BY NRC l
The Comanche Peak SSER 11, Appendix P, Section 4.7, pages P-31 I through P-34, describes the NRC concerns in the areas of audit and I reporting. The concerns pertaining to the audit program and audit personnel qualification have been extracted and are presented here: l l ,
i
" Region IV found that TUEC's audit procedures did not comply with NRC requirements, and that the program was not implemented in accordance with procedures. The lack of an established audit program was also substantiated by Region IV.
For example, Region IV Report No. 50-445/84-32 cited TUEC for failure to establish and implement a comprehensive system of planned and periodic audits. Non-compliances identified were:
annual audits were not adequately addressed by audit implementation procedures; planning and staffing to perform 1983 audits were inadequate; The Westinghouse site organization performing Nuclear Steam Supply System (NSSS) engineering services was not audited by TUEC from 1977 through 1981; and audits of vendors that manufacture or fabricate parts, components, and equipment for safety related systems l
were not conducted in compliance with annual or other applicable requirements dating back to August 1978.
l Assessments by the Miscellaneous and Mechanical and Piping Groups concurred with the QA/QC Group that the audit frequency of vendors did not comply with ANSI N45.2.12 requirements.
Review of past administration of the audit program disclosed that during 1981 and 1982, the height of construction, the audit staff consisted of four auditors. From 1982 to 1984, the audit staff has increased from 4 to 12. Also, on occasions, individuals participating on the audit teams were not QA auditors. As such, a potential existed to compromise their independence. The TRT reviewed the technical background, experience, and training of auditors, as well as the quality of audit reports. The TRT determined auditor staffing and qualifications to be questionable, which rendered the audit results for 1981 through 1983 potentially ineffective.
The TRT and Region IV reviewed the scope of the QA Program audited during 1983. Of approximately 650 safety related procedures, 165 (25% overall) were audited. In looking at quality precedures, TUEC audited 24" of TUCCO's implementing procedures and 39" of Brown & Root procedures for a composite 32" audit rate. Although audits en a sampling basis are acceptable, there was no evidence that all safety related areas were audited. The audits did not encompass all aspects of the QA Program in order to determine effectiveness.
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Rsvisient I l Page 2 of 9 ISAP VII.a.4 (Cont'd)
1.0 DESCRIPTION
OF ISSUE (Cont'd)
With respect to audit corrective action follow up, it was learned that TUEC QA had not been verifying that corrective 1 action on previous audit findings was accomplished. For example, audit TCP-111, initiated to verify corrective actions on previous audit findings, was started prior to the TRT's review. TUEC emphasized that TCP-111 be considered a " Punch List of Completion Tasks" to verify that corrective action had been implemented and not an attempt to rewrite or change previous audit findings. Another specific example of ineffective follow up action was found that pertained to a deficiency identified in audit TCP-23, performed in September, ,
1981. Audit TCP-68, conducted in March, 1983, attempted to !
verify corrective action of TCP-23's audit finding, but logs that would document the corrective action had been destroyed.
A new deficiency was written at that time and the response was accepted, but the corrective action implementation is still '
unverified. '
Following the Lobbin Report, the NRC performed a CAT inspection (IR 445/83-18;446/83-12, dated April 11,1983) and I included a review of the TUCCO audit program at the corporate I offices. The inspection included a review of 18 audits (conducted between 1978 and early 1983), auditor qualifications, audit planning and scheduling, audit reporting and follow up, and audit program effectiveness. The report concluded that weaknesses existed in the established QA audit program which included the scheduling and frequency of audits, the lack of effective monitoring of the construction program, and the lack of effective resolution of certain audit findings. The inspection also indicated that the QA Program, should have been more effective.
i During the TRT's evaluation of allegations and concerns, it l
I was observed that the audit function did not always identify ' l QA Program breakdowns, or if reported, effective corrective action was not instituted to prevent recurrence . ..
Based on its findir.gs and observations, the TRT concludes that '
the QA audit . . . program has had and continues to exhibit deficiencies. Over a significant period of time, recurring i
deficiencies include: inadequate staffing during peak periods; '
. procedural and implementation inadequacies; questionable qualifications and capabilities; incomplete assessment of the ,
QA program on an annual basis . . . In su=mation, the QA/0C l <
Group finds the past audit . . . system less than adequate, I and the audit . . . program at the time of the TRT review was i questionable."
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ISAP VII.a.4 (Cont'd) 2.0 ACTION IDENTIFIED BY NRC Evaluate the TRT findings and consider the implications of these findings on construction quality. "... examination of the potential safety implications should include, but not be limited to the areas or activities selected by the TRT."
" Address the root cause of each finding and its generic implications..."
" Address the collective significance of these deficiencies..."
" Propose an action plan... that will ensure that such problems do not occur in the- future."
3.0 BACKGROUND
In addition to the TRT issue and SSER 11, the NRC issued a notice of violation (445/8432-03; 446/8411-03):
- Contrary to requirements, the following examples were identified which demonstrate the failure to establish and implement a comprehensive system of planned and periodic audits of safety related activities as required, as noted below
Annual audits were not adequately addressed by the audit implementation procedures.
TUCCO Procedure DQP-CS-4, Revision 0, dated August 9, 1978, only required two audits of vendors fabricating reactor coolant pressure boundary components, parts, and equipment; one audit of vendors fabricating engineered safeguards components, parts, and equipment; and audits of balance of plant (safety related) as required by the quality assurance manager.
TUGC0 Procedure DQP-CS-4, Revision 2, dated April 16, 1981, required only that organizations will be audited on a regularly scheduled basis.
TUCCO Procedure DQP-CS-4, Revisions 2 and 10, did not specify auditing frequencies for design, procurement, construction, and operations activities.
1 Ravision: 1 Page 4 of 9
. 1 ISAP VII.a.4 (Cont'd)
3.0 BACKGROUND
. (Cont ' d)
TUGC0 Procedure DQP-CS-4, Revision 10, based audit requirements on Regulatory Guide 1.33, Revision 2, Feb ruary, 1978. This commitment did not fully address i the requirements of the Construction Quality Assuranca Program.
The above procedure and subsequent revisions failed to deceribe and require annual audits in accordance with commitments and requirements. Earlier audit procedures were not available to determine if they met requirements.
Planning and staffing to perform 1983 audits was inadequate to assure that a comprehensive system of audits was established and implemented to verify compliance with all aspects of the Quality Assurance Program, in that, of 656 safety related procedures (which control safety related activities) the NRC review revealed that the applicant sampled only 165, or 25 percent, during the 1983 audit program. Consequently, significant aspects of the safety related activities were not adequately audited.
~
The Westingho'use site organization, established in 1977 to perform Nuclear Steam System Supply (NSSS) engineering services, was not audited by TUGC0 during the yea 23 of 1977, 1978, 1979, 1980, and 1981.
Audits of vendors that manufacture or fabricate part/,
components, and equipment for reactor coolant pressure boundary and engineered safeguards systems have not been conducted annually dating back to August 9,1978.
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, Rsvision: 1 Page 5 of 9 1 -s ISAP VII.a.4 (Cont'd) 4.0 CPRT ACTION PLAN 4.1 Scope and Methodology 4.1.1 .The scope of this action plan is to evaluate the adequacy of the TUGC0 QA Audit Program f rom its inception to the present, determine the effect of any !
identified inadequacies on the Quality Assurance Program and/or the physical plant..and to recommend appropriate corrections and/or improvements to the current program. This evaluation will be accomplished thr~agh a review which will address audit planning and scheduling, preparation, performance, reporting, follow up and closecut, and audit personnel qualification.
4.1.2 The specific methodology is described below.
4.1.2.1 All revisions of the program and procedures.
pertaining to the QA Audit Program that have ,
been in effect at CPSES will be evaluated to 1 identify commitments and the degree to which- ;
the written program conformed to these i commitments. Included in this evaluation will be the CPSES PSAR/FSAR (Appendices lA(N) and 1A(B), Chapter 17.1, and QA branch questions and answers); TUGC0 Corporate Quality Assurance Program; CPSES Project -
Quality Assurance Plan (Design and l Construction); Dallas Quality Procedures / '
Instructions manual. I 4.1.2.2 Reports, documentation, and data generated ;
during the implementation of the program will be reviewed on a selective basis to evaluate the effectiveness of implementation. The selection of specific iters to be reviewed will be based on concerns identified by the NRC; significant revisions to commitments, program description, and/or organization; and to pursue questionable areas identified during the review. Specific topics to be l addressed include the following:
Audit Planning Criteria Published and As-run Schedules
A
, R2 vision: .1 Page- 6 of 9 ISAP VII.a.4 (Cont'd) q 4.0 CPRT ACTION PLAN (Cont'd)
- j. Audit Plans and Checklists Audit Reports i
Audit Deficiency Follow up Audit Team Members, Including Qualifications and Staffing Levels Organizations Performing Audit Activities Application of Audit Activities to Hardware vs Program / Procedures i
The-object of this evaluation is to develop a conclusion concerning the adequacy of program assessment provided by the Audit Program.- i This information will be used as an input for
- recommendations for revision of the current program, as appropriate. !
4.1.2.3 Should audit program deficiencies or weaknesses related to construction activities be identified, they will be evaluated to determine whether action beyond that specified in ISAP VII.c is required to identify. potential areas of concern regarding construction quality. Should such actions be g required, a detailed plan will be developed !
and this ISAP revised to describe the methodology. In addition, should any identified audit program deficiencies apply also to off-site TUGC0 suppliers, a program will be developed to determine the acceptability of the suppliers' quality assurance programs for the applicable equipment and services during the period in question. This program, if required, will utilize external sources of information such as other utility or architect-engineer audits, the Coordinated Agency for Supplier Evaluation, and the NRC " White Book". If suppliers are identified for which the l
i R; vision: 1 Page 7 of 9 i ISAP VII.a.4 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) adequacy of the QA program cannot be I determined, a detailed plan will be developed I to resolve the concern and this ISAP revised i to describe the methodology. I 4.1.2.4 The current audit program, including auditor I qualification requirements, will be evaluated against licensing commitments contained in the FSAR.
A determination will be made concerning the i adequacy of the TUGC0 written program and the qualifications of the audit staff and I staffing levels for the remaining j construction phase of Unit 2 and for the operations phase.
4.1.2.5 The Results Report will provide l recommendations for corrective action and/or !
program improvements as appropriate.
4.1.2.6 Copies of the Results Report for this ISAP l vill be provided to TUGC0 for their ;
consideration in responding to the NRC Notice I of Violation (445/8432-03; 446/8411-03).
l 4.2 Participant's Roles and Responsibilities 4.2.1 TUGC0 4.2.1.1 Scope TUGC0 will assist in identifying and locating applicable information and documentation to support the Review Team activities.
4.2.1.2 Personnel Mr. D. McAfee, Dallas QA Manager, will ensure effective coordination between the Review Team and TUGCO.
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kovision: '1 Page- 8 of 9
.ISAP VII.a.4 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.2.2 ERC 4.2.2.1 Scope ERC will be responsible for reviewing applicable TUGC0 documentation to determine the adaquacy of'the program.
4 2.2.2 Personnel Mr. J. Hansel Review Team Leader Mr. J. Gelzer Issue Coordinator I 4.3 Qualifications of Personnel 4.3.1 Participants will be qualified to the requirements of the CPSES Quality Assurance Program or to the specific requirements of the CPRT Program Plan.
4.4 Procedures Program Plan and Issue-Specific Action Plans.
4.5 Standards / Acceptance Criteria Audit activities shall be in compliance with 10CFR50, Appendix B, Criterion XVIII and the applicable codes and standards i relating to CPSES FSAR paragraph 17.1.18. Specifically such activities are acceptable if:
4.5.1 Audits to assure that procedures and activitics comply with the overall QA program are performed by:
4.5.1.1 The QA organization to provide a comprehensive independent verification and i evaluation of quality-related procedures and l activities.
4.5.1.2 The applicant to verify and evaluate the.QA programs procedures, and activities of suppliers.
4.5.2 An audit plan is prepared identifying audits to be performed, their f requencies, and schedules. Audits should be regularly scheduled based upon the status and j l
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ISAP VII.a.4 a (Cont'd) !
4.0 CPRT ACTION PLAN-(Cont'd) safety importance of the activities being performed and are initiated early enough to assure effective QA during design, procurement, manufacturing, construction, installation, inspection, and testing.
4.5.3 Audits include an objective evaluation of quality-related practices, procedures, instructions; activities and items; and review of documents and records to 1 ensure that the QA program is effective and properly implemented.
4.5.4 Provisions are established requiring that audits be performed in all areas where the requirements of 1 Appendix B.to 10C7R Part 50 are applicable. Areas which are often neglected but should be included are activities associated with:
4.5.4.1 Indoctrination and training programs.
4.5.4.2 Interface control among the applicant and the principal contractors.
4.5.4.3 Corrective action, calibration, and non-conformance control systems.
4.5.4.4 SAR commitments.
4.5.5 Audit data are analyzed and the resulting reports indicating any quality problems and the effectiveness of the QA program, including che need for reaudit of deficient areas, are reported to management for review and assessment.
4.5.6 Audits are performed in accordance with pre-established written procedures or checklists and conducted by trained personnel having no direct respot.aibilities in the areas being audited.
4.6 Decision Criteria l
Decisions concerning the number of individual reports, i i
records, files, etc., to be reviewed, and the level of detail to which they will be reviewed, will be determined by the i quantity and quality of data obtained as implementation of the ISAP proceeds.
This item will be censidered closed when sufficient data has been evaluated to support a firm conclusion as to the I
acceptability of the program against the acceptance criteria contained in Paragraph 4.5. I i
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COMANCHE PEAK RESPCNSE TEAM RESULTS REPORT 4.
ISAP: VII.a.4
Title:
Audit Program and Auditor Qualification REVISION 1 I
_k , W 11 fb e Coordinator / Date Revi MM Team Leader' 4 n Date/ /
Pl, uO Jonn . Beck, Chairman CPRT-SRT
+//rhc.
Date
,, p.
4
" ^
Revision: 1 Page 1 of 53 i
RESUI.TS REPORT d ISAP V!I.a.4 Audit Program and Auditor Qualification
1.0 DESCRIPTION
OF ISSUE The Comanche Peak SSER 11 Appendix P, Section 4.7, pages P-31 through P-34, describes the NRC concerns in the areas of Quality Assurance auditing and audit reporting. The concerns pertaining to the audit program and audit personnel qualification have been I e.ctracted and are presented here:
" Region IV found that TUEC's audit procedures did not comply with NRC requirements, and that the program was not implemented in accordance with procedures. The lack of an -
established audit program was also substantiated by Region IV.
For example, Region IV Report No. 50-445/84-32 cited TUIC for failure to establish and implement a comprehensive system of' planned and periodic audits. Non-compliances identified were:
annual audits were not adequately addressed by audit implementation procedures; planning and staffing to perform 1983 audits were inadequate; the Westinghouse eita organization performing Nuclear Steam Supply System (NSSS) engineering services was not audited by TUEC from 1977 through 1981; and audits of venders that manufacture or fabricate parts, components, and equipment for safety-related. systems were not conducted in compliance with annual or other applicable requirements dating back to August 1978. 1 Assessments by the Miscellaneous and Mechanical and Piping Groups concurred with the QA/QC Group that the audit frequency of vendors did not comply with ANSI N45.2.12 requirements.
Review of past ad= ministration of the audit program disclosed that during 1981 and 1982, the height of construction, the audit staff consisted of four auditors. Frem 1982 to 1984,
' the audit staff has increased from 4 to 12. Also, on occasions, individuals participating on the audit teams were not QA auditors. As such, a potential existed to compromise j their ladependence. The TRT reviewed the technical background, experience, and training of auditors, as well at the quality of audit reports. The TRT determined auditor staffing and qualifications to be questionable, which re'ndered the audit results for 1981 through 1983 potentially
- ineffective.
The TRT and Region IV reviewed the scope of the QA Program audited during 1983. Of approx 1=ately 650 safety-related procedures, 165 (25% overall) were audited. In looking at quality procedures, TUIC audited T4: of !!GCO's implementing procedures and 39% of Brevn' 6 Root procecures for a cemposite 32: audit rate. Although audits on a sa=pling basis are
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p l Revision: 1 Pcga 2 of 53 RISULTS REPORT i l
ISAP VII.a.4 (Cont'd)
\
)
1.0 DESCRIPTION
OF ISSUE (Cont'd) I i
acceptable, there was no evidence that all safety-related areas were audited. The audits did not encompass all aspects !
of the QA Program in order to determine effectiveness.
With respect to audit corrective action follow-up, it was j learned that TUIC QA had net been verifying that corrective )
a4 tion on previous audit findings was accomplished. For I example, audit TCP-111, initiated to verify corrective actions on previous audit findings, was started prior to the TRT's review. TUEC emphasired that TCP-111 be considered a "Pucch
- List of Completion Tasks" to verify that corra.cive action had ,
been implemented and not an attempt to rewrite or change previous audit findings. Another specific example of *
{
j ineffective follev-up action was found that pertained to a 4 deficiency identified in audit TCP-23, performed in September, l 1981. Audit TCP-68, conducted in March,1983', attempted to '
verify corrective action of TCP-23's audit finding, but logs that would decument the corrective action had been destroyed.
A new deficiency was vricten at that time and the response was accepted, but the corrective action implementation is still unverified.
Following the Lobbin Report, the NRC perfor=ed a CAT inspection (IR 445/83-18;446/83-12, dated April 11, 1983) and included a review of the TUGC0 audit program at the cerporate offices. The inspection included a review of 18 audits (conducted between 1978 and early 1983), auditor qualifications, audit planning and scheduling, audit reporting and follow-up, and audit program effectiveness. The report concluded that weaknesses existed in the established QA audit
~ program which included the scheduling and frequency of audits, the lack of effective monitoring of the construction progran, and the lack of effective resolution of certain audit !
findings. The inspection also indicated that the QA Prcgra: l should have been more effective.
During the TRT's evaluation of allegations and concerns, it was observed that the audit function did not always identify QA Program breakdowns, or if reported, effective corrective action was not instituted to prevent recurrence . . . {
Based on its findings and observations, the TRT concludes that the QA audit . . . progra= has had and continues to exhibit ;
l deficiencies. Over a significant period of' time, recurring j deficiencies include: inadequate staffing during peak periods; pre:edural and i:ple=en:stien inadequacies; questicnaMe
l a o
- s Revision: 1 Page 3 of $3 RESUI.TS REPORT ISAP VII.a.4 (Cont'd)
1.0 DESCRIPTION
OF ISSUE (Cont'd) qualifications and capabilities; incomplete assessment of the QA Program on an annual basis; . . . In summation, the QA/QC Group finds the past audit . . . system less than adequate, and the audit .
. . program at the time of the TRT review was questionable."
9 2.0 ACTION IDENTIFIED Evaluate'the TRT findings and consider the implications of these findings on construction quality. ". .. examination of the potential safety implications should include, but not be 1
limited to the areas or activities selected by the TRT." "
" Address the root cause of each finding and its generic '
implications..."
" Address the collective significance of these deficiencies..."
" Propose an action plan... that will ensure that such problems do not occur in the future."
3.0 BACKGROUND
In addition to the TRT issue and SSER ll, the NRC issued the following notice of violation (445/8432-03; 446/8411-03) on Feb ruary 15, 1985:
" Contrary to requirements, the following examples were identified
~~ which demonstrate the failure to establish and implement a comprehensive system of planned and periodic audits of safety-related activities as required, as noted below:
Annual audits were not adequately addressed by the audit implementation procedures.
TUCCO Procedure DQP-CS-4, Revision 0, dated August 9, 1978, only required two audits of vendors fabricating reactor coolant pressure boundary components, parts, and equipment; ene auditlof venders fabricating engineered safeguards components, parts, and equipment; and audits of balance of plant (safety-related) as required by the quality assurance manager.
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Rovision: 1 l Page 4 of 53 RESULTS REPORT .
ISAP VII.a.4 (Cont'd) l
3.0 BACKGROUND
(Cont'd)
TUGC0 Procedure DQP-CS-4, Revision 2, dated April 16, 1981, required only that organizations will be audited on a regularly scheduled basis.
TUGC0 Procedure DQP-CS-4, Revisions 2 and 10, did not specify auditing fr'equencies for design, procurement, construction, and operations activities.
TUGC0 Procedure DQ'P*-CS-4, Revision 10, based audit requirements on Regulatory Guide 1.33. Revision 2, Feb ruary, 1978. This commitmant did not fully address the requirements of the Construction Quality Assurance Program.
The above procedure and subsequent revisions failed to describe and require annual audits in accordance with co=nicments and requirements. Earlier audit procedures were not available to determine if they met requirements.
Planning and staffing to perform 1983 audits was inadequate to assure that a comprehensive system of audits was established and implemented to verify compliance with all aspects of the Quality Assurance Program, in that, of 656 safety-related procedures (which control safety-related activities) the KRC review revealed that the applicant sampled only 165, or 25 percent, during the 1983 audit program. Consequently, significant aspects of the safety-related activities were not adequately audited.
The Westinghouse site organization, established in 1977 to
~~ perform Nuclear Steam System Supply (NSSS) engineering services, was not audited by TUGC0 during the years of 1977, 1978, 1979, 1980, and 1981.
Audits of vendors that manufacture or fabricate parts, components, and equipment for reactor coolant pressure boundary and engineered safeguards systems have not been conducted annually dating back to August 9, 1978."
1
-i R3 vision: 1
, Pese 5 of 53 RESULTS RIPORT ISAP VII.a.4 (Cont'd)
)
4.0 CPRT ACTION PLAN f
4.1 Scope and Methodology 4.1.1 The scope of this action plan was to evaluate the adequacy of the TUGCO QA Audit Program from its inception to the present, determine the effect of any identified inadequacies on the Quality Assurance Program and/or the physical plant and to recommend appropriate corrections &nd/or improvements to the current program. This evaluation was accomplished through a review which addressed audit planning and scheduling, preparation, performance, reporting, follow-up and closecut and audit personnel qualification. ~
4.1.2 The specific methodology is described below.
i 4.1.2.1 Available revisions of the program and I
procedures pertaining to the QA Audit Progra=
for CPSES vere reviewed to identify licensing ;
commitments and the degree of conformance to J these commitments in the written program. '
Included in this review were the CPSES PSAR/ TSAR (Appendixes 1A(N) and 1A(b),
Chapter 17.1, and QA Branch questions and anrvers), TUGC0 Corporate Quality Assurance Program, CPSES Project Quality Assurance Plan (Dasign and Construction) and Dallas Quality Procedures / Instructions Manus 1. 1 4.1.2.2 Reports, docu=entation and data generated
' during the i=plementation of the QA audit program vore selected for review on the basis of concerns identified by the NRC; significant revisions to ce==ittents, progra:
description and/or organization; and to pursue questionable areas identified during the review. Specific topics addressed include the following:
Audit Planning Criteria, Published and As-run Schedules, Audit Plans and Checklists.
Revision: 1 Page 6 of 53 RESULTS RIPCRT ISAP VII.a.4 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
Audit Reports.
Audit Deficiency Follow-up, Audit Team Members. Including Qualifications and Staffing Levels.
Organizations Performing Audit Activities and
- Application of Audit Activities to Eardware vs Program / Procedures.
From this evaluation, conclusions were drawn concerning the adequacy of program assessment provided by the audit program. This information was used as input for the recommendations for revisions to the current l program.
4.1.2.3 Should audit program deficiencies or weaknesses related to construction activities be identified, they will be evaluated to determine whether action beyond that specified in ISAP VII.c is required to identify potential areas of concern regarding construction quality. Should such actions be
' required, a detailed plan will be developed and this ISAP revised to describe the methodology. (This conditional step was
' determined to be not required and therefore was not perforned. See Section 6.0 for discussion.) In addition, should any identified audit program deficiencies apply also to off-site TUGC0 suppliers, a program will be developed to determine the acceptability of the suppliers' quality-assurance programs for the applicable equipnent and services during the period in question. This program, if required, will utilize external sources of information such as other utility or architect-engineer audits, the Coordinated Agency for Supplier Evaluation and the NRC " White Sock." !!
suppliers are identified for which the v _ _ _ _ _ _ _ _ _ - - _ . - - .- -
4 l R3 vision: 1 Page 7 of $3 RESULTS RI? ORT ISAP VII.a.4 (Cont'd) 1 4.0 CPRT ACTION PLAN (Cont'd) 1 l
adequacy of the QA program cannot be determined, a detailed plan will be developed to resolve the concern and this ISAP revised to describe the methodology. .
(This conditional step was determ1ntd to be not required and therefore was not performed. See Section 6.0 for discussion.)
4.1.2.4 The current audit program, including auditor
, qualification requirements, was evaluated against licensing commitments contained in the FSAR. '
The qualifications of the current audit staff were evaluated.- A determination was made concerning the adequacy of the TUGC0 written program and the' qualifications of the audit staff for the remaining construction phase of Unic 2 and for the operations phase.
4.1.2.5 QA/QC Program deviations were identified for correction and suggested program improvements are presented.
4.1.2.6 Copies of the results report for this ISAP will be provided to TUGC0 for their consideration in responding to the NRC Notice of Violation (445/8432-03; 446/8411-03).
4.2 Participants Roles and Resoonsib111 ties 4.2.1 TUGCO 4.2.1.1 Scope TUCCO assisted in identifying and locating applicable information and documentation to support the Review Team activities.
4.2.1.2 Personnel Mr. D. McAfee. Dallas QA M.anager, provided coordination between the Review Team and ;
TOCCO QA staff persennel.
F.svision: 1 Page 8 of $3 RESULTS REPORT ISAP VII.a.4 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.2.2 ERC 4.2.2.1 Scope ERC was responsible for reviewing applicable TUCCO documentation to determine the adequacy of the program.
4.2.2.2 Personnel Mr.'J. Hansel Review Team Leader
(
Mr. J. Celzer Issus Coordinator 4.3 Qualifications of Personnel Participants were qualified to the specific requirements of the CPRT Program Plan.
4.4 Standards /Acceotance Criteria Audit activities shall be in ecepliance with 10CTR50 Appendix B, Criterion XVIII and the applicable codes and standards relating to the CPSES PSAR/ TSAR sections pertaining to the QA audit program as interpreted in Section 7.1 of the NRC Standard Review Plan (NURIG 0800). Specifically such activities are in compliance if (quoting from NUREG 0800):
" Audits to assure that procedures and activities co= ply with the overall QA program are performed by:
The QA organization to provide a comprehensive independent verification and evaluation of quality-related procedures and activities.
The applicant to verify and evaluate the QA programs, procedures, and activities of suppliers.
An audit plan is prepared identifying audits to be perior:ed, their frequencies, and schedules. Audits should be regularly scheduled based upon the status and safety 1:pertance of the activities being performed and are initiated early enough to assure effective QA during design, procurement, manufacturing, construction, installation, inspection, and testing.
Revision: 1 Pcge 9 ef 53 I
RESULTS REPORT ISAP VII.a.4 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
Audits include an objective evaluation of quality-I
' related practices, procedures, instructions; activities and items; and review of documents and records to ensure that the QA program is effective and properly implemented.
Provisions are established requiring that audits be performed in all armas where the requirements of Appendix B to 10CPR Part 50 are applicable. Areas which are often neglecced but should be included are activities associated with: '
Indoctrination and training programs. "
Interface control among the applicant and the principal contractors.
1 Corrective action, calibration, and non-conformance control systems.
SAR commitments.
Audit data are analyzed and the resulting reports indicating any quality problems and the effectiveness i
of the QA program, including the need for reaudit of I
deficient areas, are reported to managenent for review and assessment.
Audits are perfor=ed in acccrdance with pre-established written procedures or checklists and conducted by
' trained personnel having no direct responsibilities in the areas being audited."
4.5 Decisien Criteria Decisions concerning the number of individual reports, records and files to be reviewed, and the level of detail te which they were reviewed, were based on the quantity and quality of data obtained as inplenentatien of the ISAP proceeded. Sufficient data were evaluated to support the conclusions reached as to the acceptability of the pregram against the acceptance criteria contained in Paragraph 4.4
-____.n_-_._--- - - - - - - - - -- --- - -
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R vision:
1 Page 10 of 53
\
RESULTS REPORT {
ISAP VII.a.4 (Cont'd) l 5.0 IMPLEMENTATION OF ACTIM PLAN AND DISCUSSION OF RESULTS The TUGC0 QA Audit Program adequacy.was evaluated from its inception to the present. The specific TRT findings in the SSER 11 and the February 15, 1983, Notice of Violation are addressed in 1 this section.
The implementation of this action plan was accomplished in two p' nase s : Audit Program (Section 5.1) and Audit Personnel Qualification (Section 5.2). These sections are sub-divided as follove to address the various elements of the Audit Program and the Audit Personnel Qualification Program:
Section 5.1 Audit Program 5.1.1 Organization 5.1.2 Staffing 5.1.3 Audit Planning and Scheduling 5.1.4 Audit Preparation 5.1.5 Audit Performance i
5.1.6 Audit Reporting 5.1.7 Tollow-up and Closecut Section 5.2 Audit Personnel Qualification 5.2.1 Qualification Require =ents 5.2.2 Training / Qualification Records Implementation consisted of a review of program definition and implementation documents, a review of records and other related documents and interviews with personnel involved in the progra=.
The historical PSAR/FSAR was reviewed to identify the standar'ds and regulatory guidance to which TUGC0 was committed, pertaining to the audit progra= and qualification of audit personnel. This review determined that:
The basis for the audit program from Dece=ber 1973 (A=end=ent
- 2 of the PSAR) threugh the present is ANSI N45.2.12-1973 (Draft 3, Revision 0. May 2, 1973) as contained in " Guidance on Quality Assurance Requirements During Design and
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RE5L],7S REPORT W
ISAP VII.c.4 (Cont'd) 5.0 IMPLD.3TATION OF ACTION PLAN AND DISCUSSION OF RISULTS (Cont'd)
Procurement Phase of Nuclear P=wer Plants" (Gray Book), dated l June 7, 1973, and as amplified by the " Regulatory Staff Comments and Supplementary Guidance on N45.2 Standards" contained in Section D.2.b of the Gray Book.
The only exception to this commitment is that since August 1984 (Amendment #52 of the FSAR) TUGC0 elected to adopt, as an alternative for scheduling external audits, the guidance provided by Regulatory Guide 1.144, Revision 1. September 1980, Paragraph C.3(b).
The basis for audit personnel qualifications vas ANSI N45.2.12-1973 until June 1, 1983, which was the effective date of TUGC0 commitment to Regulatory Guide 1.146 August 1980, which endorses ANSI N45.2.23-1978.
The documents and record files reviewed included the following:
- CPSES PSAR, CPSES TSAR, TUGC0 Corporate Quality Assurance Program.
CPSES Project Quality Assurance Plan for Design and Construction.
Dallas Quality Procedures / Instructions Manual.
Audit Report Files, Audit Report Notes Files.
Equipnent Release Files (Vendor Cc=pliance Release Inspections).
Vendor Correspondence Files.
Vender Reevaluation Files.
Vendor Performance Evaluatien Files and Audit Personnel Training / Qualification Files.
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Findings pertinent to each topic will be discussed within the appropriate sub-section. At the end of each sub-section a statement regarding possible adverse effects of the findings on the audit program will be made. There is no direct connection between the audit program and the quality of Luatalled hardware; therefore, no conclusions regarding the st' acus of the physical plant have been made.
Recommended cerrective action for QA/QC Program Deviations identified in'the body of this report are summarized in section 5.3, " Evaluation of Fir: dings".
5.1 Audit Program Documents and files were reviewed to evaluate the adequacy and effectiveness of the TUGCO audit' program including organization, staffing, planning and scheduling, preparation, performance, reporting and deficiency follow-up and closecut.
Initially, 69 audit files were reviewed to assist in reaching a conclusion pertaining to the performance of the TUGCO QA audit personnel. Internal audits were selected to provide data from the in:eption of the program to the present, as well as a sampling of the various disciplines and major topics of interest such as document control and nonconformance/ corrective action systems. Vender audits were selected primarily to review TUGC0 activities pertaining to pr1=e contractors (B&R, H. G&B) as well as on-site contractors. This review was not intended to be a comprehensive evaluation of ti.e scope, content, conclusions,
etc., of the audit; rather, it was intended to deter =ine if the required steps in the audit process had been properly 1 p e rf o r=e d . The review addressed the following items: j s
Audit Preparation - To determine if the audit scope was docu=ented, if an audit team leader had been designated, if checklists had been prepared and if they appeared to contain an appropriate level of detail.
Audit Perfor ance - To identify the audit tea =, to deter =1ne if pre-audit and post-audit conf erences were conducted, if it appeared that objective evidence had been examined and if audit personnel appeared to evaluate progra ele =ents to sece depth. j l
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Audit Reporting - To determine if audit reports had {
been prepared that would provide appropriate management I with sufficient information concerning the adequacy and effectiveness of the audited QA program elements.
Audit Deficiency Follow-up and Closecut - To deter =ine if responses to audit deficiencies were evaluated, if an acceptable course and schedule for corrective action had been agreed on and if implementation of corrective action was verified.
Later, as the result of input received from other QA/QC Review Team Issue coordinators, nine (9) audit files were reviewed in depth in an attempt to reach a conclusion as to why particular programmatic problem areas (e.g., non-conformance control and corrective action systems, inspector training, qualification, and certification programs), which were identified by External Sources had not been identified and corrected through i=plementation of the TUGCO QA audit program. The review of these nine (9) files included a re-review of four (4) of the sixty-nine (69) previously reviewed and were selected on the basis of their titles in the audit index as being the total available that addressed these subjects. This review included the following activities:
A detailed review of the audit checklist for centent l and to attempt to determine if th. checklist was developed from requirements documents or fro: the i existing vritten program, A review of auditor field notes to attempt to e t e r=ine f the depth of examination, sa=ple size (when applicable), type of objective evidence evaluated, whether program documents were evaluated against requirements, and if apparent deviations had been flagged to be included in the audit report, l
A review of the audit report to determine if rhe findings docu=ented in the auditor field notes were ,
accurately reflected in the report and A review of documentation subsequent to the audit report in an atte=pt to determine the adequacy of auditor evaluation of respenses to audit deficiencies, dialogue leading to agree =ent on proposed corrective action and verification of ce=pletion of corrective action.
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RESULTS REPORT ISAP VII.a.4 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
In response to the NRC Notice of Violation (445/8432;-
446/8411), the audit files representing the 29 internal audits of the design / construction phase performed during 1983 were reviewed to identify the major activities, organizations, and Appendix 5 criteria which were addressed, to enable an evaluation of the audit program coverage for tha year. These 29 files included five whi'ch had been previously reviewed.
The Design' Adequacy Review Team provided a list of design specifications.which they plan to evaluate for design adequacy and Architect-Engineer / Vendor interface. From the vendors identified, twelve were selected for this review based on considerations such as frequency of audits performed.. -
awareness of problems with a particular vendor, apparent time frame of vendor activity and type of product. Additional rationale for selection is contained in the working files for this ISAP.
A review was performed of TUGC0 QA Audit and Vendor Compliance files (audit reports, audit notes, equipment releases, vendor correspondence, vendor performance evaluation and vender reevaluation files) for these twelve vendors to evaluate the degree of awareness by TUGC0 QA of the adequacy, effectiveness and status of the QA programs of their vendors despite the fact that annual vendor audies vers not scheduled. '
The results of these reviews are summarized in the following ;
paragraphs.
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5.1.1 Organization )
ANET N45.2.12-1973 Section 1.4, " Organization",
l states, "The organizational structure, functional i responsibilities, levels of authority, and lines of I internal and external communication for management direction of audits of the quality assuranca pregra: l shall be docu=ented". .
Although Section 17.1.18 (Audits) of the CPSES TSAR states that TUCCO will perform audits, nowhere in Section 17.1.1 (Organization) is the responsibility for the audit program delineated.
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Within section 17.1.1.1 the list of principal duties I and responsibilities of the Director, Quality Assurance includes " monitoring and surveillance of the quality assurance activities conducted by TUGCO, prime contractors, sub-contractors and vendors." However there is no specific mention (nor has there been since the original. docketing of the PSAR) of responsibility for the audit program.
During the review of the QA program and records, it was determined that the QA organization was in fact responsible for the audit program and that TUGC0 management recognized and supported this '
responsibility..
It was noted that on December 30, 1985 TUCCO QA initiated a request for an FSAR revision to include the audit program among the principal ducias and responsibilities of the Director, Quality Assurance.
The TUGC0 (A Audit Program is administered and implemented by the Dallas-based Quality Assurance organization. The implementing procedures for the audit program are contained la the Dallas Quality Procedures / Instructions Manual. Since 1982, procedures in this manual have assigned responsibilities for execution of portions of the QA audit program to the position of Supervisor, QA Audits. This positien was not officially recognized in published organi:stional descriptions and organization charts until the issue of procedure DQP-QA-16. " Dallas Quality Assurance Organization" in September 1985. During the review of the audit pr^ gram procedures,and records, it was deter =ined that the position was filled during this period and was recognized and supported by QA management.
Although ANSI N45.2.12-1973 and the accompanying staff ce==ents and guidance pertain primarily to the auditing organi:ation. the require =ents of the ANSI standard and the associated supplementary guidance listed belov s apply as well to the audited organi:ation as an l
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' integral part of the overall audit program. Therefore.
these requirements should be included in QA program documents applicable to the audited organization as well as the auditing organization (e.g. , Corporate QA Program, Project QA Plan) to ensure compliance by all responsible organizations.
An effective audit system shall include-provisions for reasonable and timely access of audit personnel to facilities, documents, and personnel necessary in the planning and performance of the audits.
At the. post audit conference an effort shall be made to astablish a tentative course and schedule of corrective action for non--
conformances. Where it is not possible to provide such information at the post audit conference, the managemert of the audited organization should commt.c to a specific date for the determination of the course of corrective action and the schedule for implementation.
Management of the audited organization or activity shall review and investigate the audit findings to determine and schedule appropriate corractive action. They shall respond to the report 1- writing, vichin 30 days after receipt. j The review of these files indicated that these requirements had been met in that: l 0
There was no evidence to indicate that audit
. persennel had been denied reasonable and {
timely access as required to perform their duties.
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There was no evidence to indicate that P l problems had been encountered pertaining to I f *
. the establishment of the tentative course and I '
schedule of corrective actions and schedule
[ fer i=ple=entation.
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There was evidence that management-of the audited organization reviewed and investigated audit findings and determined and scheduled corrective action. Written responses were received by the auditing organization within a reasonable time of the reque;ted date (on time, or within one week) in approximately eighty (80) percent of the files reviewed. This ratio is not unusual in the experience of the RTL.
The first two of these requirements listed above are not addressed in the TUGC0 QA program documents. The' third is addressed to the audited organization only through the transmittal of the audit report.
Conclusions It is concluded that the failure to formally document the responsibility for the audit program in the PSAR/ TSAR resulted in no adverse effect on the audit program because sus" tier program documents were written and management accad as if the responsibility had been formally documented.
It is concluded that the failure to formally describe the position and responsibilities of the Supervisor, QA Audits, in organization descriptions resulted in no adverse effect on the audit program because audit program documents were written and QA manage =ent acted as if the position had been formally documented.
It is concluded that the failure to include the responsibilities of the audited organization in appropriate program documents resulted in no adverse effect on the audit program because review of the audit files revealed that the require =ents had been =et by the audited organization.
5.1.2 Staffing The adequacy of the TUCCO audit staff (number and qualifications) has been questioned by the NRC. When i considering the adequacy of an audit staff, one =ust include not only personnel assigned full ti=e to the audit function, but also the qualified personnel l available en call to tne audit organization.
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5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
The applicable standards and regulations contain no requirement for an audit staff, per se; only that management shall establish an audit system that includes manpower, funding and facilities to implement the system. This allows management maximum flexibility to allocate resources, even to the extreme of assigning a full-time audirtadministrator responsible for planning and scheduling of audits and tracking open items, who has free access to qualified audit personnel as required for individual audit preparation, conduct, reporting and follow-up, but who has no permanently assigned audit staff.
Therefore, judgement on the adequacy of the size of an audit staff must be based on factors such as assigned duties and responsibilities, outside resources available on a timely basis and the ability to accomplish the scheduled audit activities (providing schedules are not dictated by manpower availability).
The years 1981 - 1982 were cited by the TRT as a period when the numbers and qualifications of the TUGC0 audit staff were questionable. In addition, Region IV Inspection Report 445/84-32 cited 1983 as a period when the audit staff was inadequate. A review was performed of training and qualification files for TUCCO Quality Assurance personnel (designated audit staff and others) who participated in the audit program as Lead Auditors or auditors during these periods. The following tabulatien su==arizes the characteristics of these l personnel. I
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Rsvision: 1 Page 19 of 33 RESULTS RIPORT ISAP VII.a.4 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 1981 1982 1983 Designated Audit Staff $ 11 14 (Including Supervisor)
Total Participants 13 20 25 Qualified Lead Auditors 10 16 18 l Education
- Masters Degree 0 1 1 Bachelors (Engineering) 7 6 8 Bachelors (Other) 2 2 5 Associates (Technical) 0 1 2-Associates (Other) 0 1 1 Some College 1 2 3 NOTE: Tour of the engineers were registered Professional Engineers, and one was a certified Quality Engineer. One holder of an Industrial Management degree was also a certified Quality Engineer.
Since the formation of.a designated audit staff in 1979, through the present. it has been the practice to supplement the staff as needed with other qualified members of the QA organization to function as auditors and lead auditors. It is therefore concluded that, based on the evaluation of the years 1981 through 1983 and the other files reviewed, the for= ally designated audit staff could be considered deficient in nu=bers and technical qualifications, but that the effective audit staff of Quality Assurance personnel was, and continues to be, adequate in both nu=ber and qualifications.
Conclusions Based on the reviews performed, it is cencluded that individuals did not audit activities which they were responsible for perfor=ing.
It is cencluded that audit staffing was adequate to i=ple:ent the audit progra= anc schedules during tne periods of 1starast.
Personnel nolding =ultiple degrees are listed only once, in the highest applicable categcry.
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R0 vision: 1 Page 20 of 53 RESULTS REPORT ISAP VII.a.4 (Cont'd) 5.0 IMPLEMENTATION OP ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.1.3 Audit Planning and Scheduling This section addresses the following topics:
Scheduling requirements.
Vendor audit scheduling and performance, NRC Notice of Violation pertaining to Westinghouse site organization, Planning and scheduling process for internal audits and
- NRC Notice of Violation pertaining to 1983 audit program coverage.
The requirements of ANSI N45.2.12-1973 pertaining to audit planning and scheduling can be paraphrased by sayinE that audits are performed by or for an organization participating in activities affecting quality and that elements of the Quality Assurance program affecting these activities shall be audiced at least annus11y or at least once within the life of the activity, whichever is shorter. Within this context, the following terms are defined:
Organization - Plant owner, contractor, etc.,
Activities - As listed in the last sentence of ANSI N45.2.12-1973, Paragraph 1.2, and Elements - The 18 criteria of 10CPR50, Appendix B.
The TUGC0 vritten program (i.e., PSAR/PSAR, QA Progra=,
QA Plan and i=plementing procedures) reflected the require =ent for scheduling internal audits on an annual basis only from August 1973 through April 1981. The annual requirement was not reintroduced until Nove:bar 1984 Additionally, the progra: never has required that vendors be audiced on an annual basis.
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RESULTS REPORT l i
ISAP VII.a.4 (Cont'd) 5.0 IMPLDENTATION OF ACTION PLAN AND DISCUSSION OF RESULTd (Cont'd)
Not until the issuance of DQP-CS-4, Revisier 11, in November 1984, was the TUGC0 written program in full compliance with applicable planning and scheduling commitments. This revision reflected the options permitted by Regulatory Guide 1.144 to audis ' vendors on a triennial basis, provided annual assessments are performed. This revision also contained tL4 requirement to audit other applicable organ 12ations (e.g., TUCCO, site contractors) at least annually.
This lack of requirements in the written pre. gram for scheduling annual internal audit and suppliar audits constituted a noncompliance with licensin3 commitments.
Vendor Audit Program In evaluating the effect of this noncompliance on the vendor audit program, the following evolution of TUGC0 QA audit program responsibilities was identified:
From 1973 to 1977, TUGC0 was responsible for auditing only the major contractors: Gibbs &
Hill (C&H), Brown & Root (B&R), and Westinghouse (W). During this same ti=e period G&B, B&R, and W had pri=e responsibility for vendor preaward surveys, audits, and source inspections. However, TUCCO did participate in these activities.
Early in 1978, although V retained its original role concerning NSSS vendors and B&R retained full responsibility for its ASME suppliers. TUGC0 assumed more direct control in the other vender preaward survey, audit, and source inspection activities previously delegated to G6H and B&R. This included balance of plant vendors (safety-related and non-safety-related), on-site contractors and non-ASME material suppliers. Additional control was exercised through increased involvement in the scheduling process and the conduct of ore joint audits.
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Early in 1981, TUGC0 began performing vendor-related activities without G4H involvement. Also during 1981, TUGCO assumed full responsibility for non-ASME material suppliers from B&R. This level of responsibility has continued to the present.
Based on the review *of the audit index, it was determined that TUGC0 QA performed audits of the major contractors during the period from 1973 to 1977 as follows:
1973 1974 1975 1976 1977 G&H N/A 4 1 1 2 W 1 'O 1 6 4 B&R (Houston) N/A 1 0 2 1 B&R (Site) N/A N/A 2 1 1 The PSAA was docketed in 1973 and the Construction Per=1t was issued in December 1974 The tabulation indicates that with two exceptions, required audits were perfor=ed during this period in accordance with the annual requirements of ANSI N45.2.12-1973.
From 1978 (when TUCCO became more involved in the administration of the audit program) through 1984, the perfor=ance of contractor / vender audits was not in accordance with applicable require =ents for tice11 ness or frequency. For example, for five of the twelve vendors reviewed, the initial audit was perfor=ed after the first release inspection (in three cases more than a year afterward) which was not in co=pliance with the l ANSI requirement that auditing be initiated as early in the life of the activity as practicable to assure timely i=ple entation of quality assurance requirement. It was also noted that anywhere fre=
four =enths - six years elapsed between aucits of these vendors. No sing 1e vendor was audited on an annual basis throughout this ti=e period which constituted a violatien of the ANSI requirement for annual audits. 1 l
The foregoing raises a concern that the TUCCC QA organization was not cognizant of the effectiveness of the vendor's QA programs. In assessing this concern, the ic11owing was disclosed:
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In October 1978, TUCCO QA instituted a Vender Rating program whereby numerical ratings were assigned to vendors based on type, severity, )
and quantity of defects identified during j source inspections. . These ratings were I utilized to adjust the scheduling of inspections and audits. In January 1981, a Vendor Performance Evaluation system was instituted which enhanced the Vendor Rating system by also considering the number of items submitted for inspection in calculating the rating. It was noted during the review that various audic notifications and/or ~
reports documented that some of these audits had been initiated as a result of unsatisfactory source inspection reports.
In May 1979, a Joint Inspection / Audit progra=
vas instituted whereby auditors vould accompany inspectors on release inspection trips to investigate specific program areas based on problems identified during previous source inspections.
TUCCO QA also utilized " Requests for Corrective Action" which were correspondence with the vendors requesting corrective action for specific, identified problems when it was concluded that the problems did not warrant an audit investigation or did not appear to indicate an adverse trend.
Internal documents known as " Yellow Flag Sheets" were also utilized by the TUCCO CA staff to ensure that applicable QA personnel were aware of status and/or proble=s with particular vendors, e.g., a hold placed on ship =ents from a vendor until after an audit was perf or=ed.
While 1: is recognized that source inspections and 11=1ted-scope audits performed in response to identified problems might not be considered adequate substientas for regularly scheduled program audits, they did provide data which were utilized to so=e extent by TUCCO to evaluate the effectiveness of vender QA programs.
Revision:
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Procure =ent Phase of Nuclear Power Plants" (Gray Book), dated June 7, 1973, and as amplified by the " Regulatory Staff Com=ents and Supplementary Guidance on N45.2 Standards" contained in Section D.2.b of the Gray Book.
The only exception to this commitment is that since August 1984 (Amendaent #52 of the FSAR) TUGC0 elected to adopt, as an alternative for scheduling external audits, the guidance provided by Regalatory Guide 1.144 Revision 1, September 1980, Paragraph C.3(b).
The basis for audit personnel qualifications was ANSI N45.2.12-1973 until June 1, 1983, which was the effective date of TUGC0 ce==itment to Regulatory Guide 1.146, August 1980, which endorses ANSI N45,2.23-1978.
The docu=ents and record files reviewed included the following:
- CPSES FSAE, TUGC0 Corporate Quality Assurance Program, '
CPSES Project Quality Assurance Plan for Design and Construction, Dallas Quality Procedures / Instructions Manual, Audit Report Files, Audit Report Notes Files, Equip =ent Release Files (Vender Co=pliance Release Inspections).
Vender Correspondence Files, i
Vender Reevaluation Files.
Vendor Perf or=ance Evaluation Files and Audit Personnel Training / Qualification Files.
Rsvicion: 1 Page 10 of 53 RESULTS REPORT ISAP VII.a.4 (Cont'd) 5.0 IMPLDENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS The TUCCO QA Audit Pro;; ram edequacy was evaluated from its inception to the present. The specific TRT findings in the SSER 11
.nd the February 15, 1963, Notice of Violation are addressed in this section.
The implementation of this action plan was accomplished in two phases: Audit Program (Section 5.1) and Audit Personnel Qualification (Section 5.2). These sections are sub-divided as follows to address the various elements of the Audit Program and the Audit Personnel Qualification Program:
Section 5.1 Audit Program 5.1.1 Organization 5.1.2 Staffing 5.1.3 Audit Planning and Scheduling 5.1.4 Audit Preparation 5.1.5 Audit Performance 5.1.6 Audit Reporting 5.1.7 Follow-up and Closecut j
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Section 5.2 Audit Personnel Qualification 5.2.1 Qualification Require:ents 5.2.2 Training / Qualification Records Implementation consistad of a review of pregra= definition and i=plementation docu=ents, a review of records and other related docu=ents and interviews with personnel involved in the program.
The historical PSAR/PSAR was reviewed to identify the standar'ds and regulatory guidance to which TUGC0 was ce==1tted, pertaining to the '
audit progra= and qualification of audit personnel. This review deter =ined that:
The basis for the audit program fro: Dece=ber 1973 (A=end:ent f/2 of the PSAR) threugh the present is ANSI N45.2.12-1973 i (Draft 3. Revision 0, May 2, 1973) as contained in " Guidance on Quality Assurance Requirtsents During Design and
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RESITLTS REPORT l l
1 ISAP VII.a.4 '
(Cont'd)
I 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OT RESULTS (Cont'd)
Findings pertinent to each topic will be discussed within the i appropriate sub-section. At the end of each sub-section a ,
statement regarding possible adverse effects of the findings on the audit program vill be made. There is no direct connection between the audit program and the quality of installed hardware; therefore.
no conclusions regarding the st'atus of the physical plant have been made.
Recom= ended cerrective action for Q/lQC Program Deviations identified in'the body of this report are sunnarized in section 5.3, " Evaluation of Findings".
5.1 Audit Program ~
Documents and files were reviewed to evaluate the adequacy and effectiveness of the TUGC0 audit' program including organization, staffing, planning and scheduling, preparation, performance, reperting and deficiency follow-up and closeout.
Initially, 69 audit files were reviewed to assist in reaching a conclusion pertaining to the performance'of the TUCCO QA j audit personnel. Internal audits were selected to provide data from the inception of the program to the present, as well as a sampling of the various disciplines and major topics of interest such as document control and nonconformance/ corrective action systems. Vander audits were selected primarily to review TUGC0 activities pertaining to prime contractors (B&R. E, G&H) as well as on-site contractors. This review was not intended to be a comprehensive evaluation of the scope, content, conclusions,
etc., of the audit; rather, it was intended to determine if the required steps in the audit process had been properly p e rf o r=e d . The review addressed the following items:
Audit Preparation - To determine if the audit scope was documented, if an audit team leader had been designated if checklists had been prepared and if they ,
appsared to contain an appropriate level of detail.
}2 Audit Performance - To identify the audit team, to de te r=ine if pre-audit and post-audit conferences vere conducted if it appeared that objective evidence had been exa=1ned and if audit personnel appeared to evaluate progra= ele =ents to some depth.
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.$.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)'
Audit Reporting - To determine if audit reports had been prepared that would provide appropriate management with sufficient information concerning the adequacy and effectiveness of the audited QA program elements.
Audit Deficiency Follow-up and Closecut - To deter =ine if responses to audit deficiencies were evaluated, if an. acceptable course and schedule for corrective action had been agreed on and if implementation of corrective action was verified.
Later, as the result of input received from other QA/QC Review Team Issue Coordinators, nine (9) audit files were reviewed in depth in an attempc to reach a conclusion as to why particular programmatic problem areas (e.g., non-conformance control and corrective action systems, inspector training, qualification, and certification programs), which were identified by External Sources had not been identified and corrected through-implementation of the TUGC0 QA audit program. The review of these nine (9) files included a re-review of four (4) of the sixty-nine (69) previously reviewed and were selected on the basis of their titles in the audit index as being the total available that addressed these subjects. This review included the following activities:
A detailed review of the audit checklist for content and to attempt to determine if the checklist was developed from requirements documents or from the -
existing written program, A review of auditor field notes to attempt to determine the depth of examination, sample si:e (when applicable), type of objective evidence evaluated, whether program documents were evaluated against requirements, and if apparent deviations had been flagged to be included in the audit report, A review of the audit report to determine if the findings documented in the auditor field notes were accurately reflected in the report and A review of documentation subsequent to the audit report in an attempt to detarmine the adequacy of auditor evaluation of responses to audit deficiencies, dialogue Laading to agree =ent on proposed corrective action and verification of completion of corrective action.
Revision: 1 Page 14 of $3 RESULTS REPORT ISAP VII.a.4 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS-(Cont'd)
In response to the NRC Notice of Violation (445/8432; i 446/8411), the audit files representing the 29 internal audits of the design / construction phase performed during 1983 were.
reviewed to identify the major activities, organizations, and Appendix 5 criteria which were addressed, to enable an evaluation of the audit program coverage for the year. .These 29 files included five which had been previously reviewed.
The Design' Adequacy Review Team provided a list of design.
specifications.which they plan to evaluate for design adequacy and Architect-Engineer / Vendor interface.
From the vendors identified, twelve were selected for this review based on considerations such se frequency of audits performed.
- awareness of problems with a particular vendor, apparent time frame of vendor activity and type of product. Additional rationale for selection is contained in the working files for this ISAP.
A review was performed of TUGC0 QA Audit and Vendor Compliance files (audit reports, audit notes, equipment releases, vendor correspondence.. vender perfor=ance evaluation and vendor reevaluation files) for these twelve vendors to evaluate the degree of awareness by TUGC0 QA of the adequacy, effectiveness and status of the QA programs of their vendors despite the fact that annual vendor audits were not scheduled.
The results of these reviews are summarized in the following paragraphs.
5.1.1 Organization ANST N45.2.12-1973, Section 1.4, " Organization",
states, "The organizational structure, functional responsibilities, levels of authority, and lines of intsrnal and external communication for =an$gement direction of audits of the quality assuranca program shall be documented".
Although Section 17.1.18 (Audits) of the C?SES FSAR states that TUGC0 vill perfor= audits, nowhere in Section 17.1.1 (Organization) is the responsibility for the audit program delineated.
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There was evidence that man 4gement of the audited organization reviewed and investigated audit findings and determined and scheduled corrective action. Written responses were received by the auditing organization within a reasonable time of the requested date (on time, or within one week) in approximately eighty (80) percent of the files reviewed. This ratio is not unusual in the experience of the RTL.
The first two of these requirements listed above are f
not addressed in the TUGCO QA program documents. The' third is addressed to the audited organization only through the transmittal of the audit report.
Conclusions It is concluded that the failure to formally docu=ent the responsibility for the audit program in the PSAR/FSAR resulted in no adverse effect on the audit program because sub-tier program documents were written and management acted as if the responsibility had been formally documented.
It is concluded that the failure to formally describe the position and responsibilities of the Supurvisor. QA Audits, in organization descriptions resulted in no adverse effect on the audit program because audit program documents were written and QA =anage=ent acted as if the position had been formally documented.
It is concluded that the failure to include the responsibilities of the audited organization in appropriate program documents resulted in no adverse effect on the audit program because review of the audit files revealed that the require ents had been =et by the audited organization.
5.1.2 Staffing The adequacy of the TUCCO audit staff (nu=ber and qualifications) has been questioned by the NRC. When considering the adequacy of an audit staff, one cust include not only personnel assigned full ti=e to the audit function, but also the qualified personnel avat.able en call to tne audit organization.
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The applicable standards and regulations contain no requirement for an audit staff, per se; only that management shall establish an audit systsm that includes aanpower, funding and facilities to implement the system. Thir allows management maximum flexibility to allocate resources, even to the extreme of assigning a full-time audie administrator responsible for planning and scheduling of audits and tracking open items, who has free access to qualified audit personnel as required for individual audit preparation, conduct, reporting and follow-up, but who has no permanently assigned audit staff.
Therefore, judgement on the adequacy of the size of an audit staff must be based on factors such as assigned duties and responsibilities, outside resources available on a timely basis and the ability to acco=plish the scheduled audit activities (providing schedules are not dictated by manpower availability).
The years 1981 - 1982 were cited by the TRT as a peried when the nu=bers and qualifications of the TUCCO audic staff were questionable. In addition, Region IV b Inspection Report 445/84-32 cited 1983 as a period when the audit staff was inadequate. A review was perfor=ed of training and qualification files for TUCCO Quality Assurance personnel (designated audit staff and others) who participated in the audit program as Lead Auditors or auditors during these periods. The following tabulation su==arizes the characteristics of these personnel.
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1981 1982' 1983 Designated Audit Staff 5 11 14 (Including Supervisor)
Total Participants 13 20 25 Qualified Lead Auditors 10 16 18 Education
- Masters Degree 0 1 1 Bachelors (Engineering) 7 6 8 Bachelors (Other) 2 2 5 Associates (Technical) 0 1 2*
Associates (Other) 'O 1 1 Some College 1 2 '3 NOTE: Four of the engineers were registered Professional Engineers, and'one was a certified Quality Engineer. One holder of an Industrial Management degree was also a certified Quality Engineer.
Since the formatirn of a designated audit staff in 1979, through the present, it has been the practice to supplement the staff as needed with other qualified-members of the QA organization to function as auditors and lead auditors. It is therefore concluded that, based on the evaluation of the years 1981 through 1983 and the other files reviewed, the for= ally designated audit staff could be considered deficient in nu=bers and technical qualifications, but that the effective i audit staff of Quality Assurance personnel was, and continues to be, adequate in both number and qualifications.
Conclustens Based on the reviews performed, it is cencluded that individuals did not audit activities which they were '
responsible for perfor=1ng.
It is concluded that audit staffing was adecuate to imple:ent the audit program and schedules during the periods of incarast.
Personnel nolding nultiple degrees are listed only once, in the highest applicable category.
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Page 20 of 53 RESULTS REPORT ISAP VII.a.4 (Cont'd) 1 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.1.3 Audit Planning and Scheduling This section addresses the following topics:
Scheduling requirements, ,
1 Vendor audit scheduling and performance, NRC Notice of Violation pertaining to Westinghouse site organization, Planning and scheduling process for internal audits Lud
-' NRC Notice of Violation pertaining to 1983 audit program coverage.
The requirements of ANSI N45.2.12-1973 pertaining to audit planning and scheduling can be paraphrased by saying that audits are performed by or for an organization participating in activities affecting quality and that elements of the Quality Assurance program affecting these activities shall be audited at least annually or at least once within the life of the activity, whichever is shorter. Within this context, the following terms are defined:
Organization - Plant owner, contractor, etc.,
Activities - As listed in tne last sentence of ANSI Na5.2.12-1973, Paragraph 1.2, and Elements - The 18 criteria of 10CPR50, Appendix B.
The TUGC0 vritten program (i.e., PSAR/PSAR, QA Progra=,
QA Plan and 1:ple=enting procedures) reflected the require ent for scheduling internal audits on an annual basis only from August 1973 through April 1981. The annual require:ent was not reintroduced until Nove:ber 1984 Additionally, the program never has required that vendors be audited on an annual basis. 3 I
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Not until the issuance of DQP-CS-4, Revision 11, in November 1984, was the TUGC0 vritten program in full compliance with applicable planning and scheduling commitments. This revision reflected the options permitted by Regulatory Guide 1.144 to audit vendors on-a triennial basis, provided annual assessments are performed. This revision also contained the requirement to audit other applicable organizations (e.g., TUGCO, site contractors) at least annually.
This lack of requirements in the vricten program for scheduling annual internal audit and supplier audits constituted a noncompliance with licensing commitments.
Vendor Audit Program In evaluating the effect of this noncompliance on the vendor audit program, the following evolution of TUCCO QA audit program responsibilities was identified:
From 1973 to 1977 TUGC0 was responsible for auditing only the major contractors: Gibbs &
Hill (G6H), Brown & Root (B&R), and k' westinghouse (E). During this same ti=e period G&H, B&R, and E had pri=e responsibility for vendor preaward surveys, audits, and source inspections. However.
TUCCO did participate in these activities.
Early in 1978, although E retained its original role concerning NSSS vendors and B&R retained full responsibility for its ASME suppliers. TUGC0 assumed more direct control in the other vender preavard survey, audit.
and source inspection activities previously delegated to C&H and B&R. This included balance of plant vendors (safety-related and non-safety-related), on-site contractors and non-ASME material suppliers. Additional control was exercised through increased involvement in the scheduling process and the conduct of note joint audits. '
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Early in 1981. TUGC0 began performing vendor-related activities without G&H involvement. Also during 1981, TUCCO assu=ed full responsibility for non-ASMI material suppliers from B&R. This level of responsibility has continued to the present.
Based on che reviev'of the audit index it was determined that TUGC0 QA performed audits of the major contractors during the period from 1973 to 1977 as follova:
1973 1974 1975 1976 1977
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C&H N/A 4 1 1 2 W 1 'O 1 6 4 B&R (Houston)' N/A 1 0 2 1 B&R (Site) N/A N/A 2 1 1 The PSAR was docketed in 1973 and the Construction Permit was issued in December 1974 The tabulatien indicates that with two exceptions, required audies I
vare perfor=ed during this period in accordance with the annual requirements of ANSI N45.2.12-1973.
Frem 1978 (when TUGC0 became more involved in the administration of the audit program) through 1984, the perfor=ance of contractor / vendor audits was not in accordance with applicable require =ents for ti=eliness or frequency. For example, for five of the twelve vendors reviewed, the initial audit was perfor=ed after the first release inspection (in three cases = ore chan a year af terward) which was not in ec=pliance with the ANSI requirement that auditing be initiated as early in the life of the activity as practicable to assure t1=ely implementation of quality assurance require =ents. It was also noted that anywhere fre=
four =enths to six years elapsed between audits of these vendors. No single vendor was audited on an annual basis throughout this time period, which constituted a violation of the ANSI require =ent for annual audits.
The feregeing raises a concern that the TUCCC QA organization was not cognizant of the effectiveness of the vendor's QA progra=s. In assessing this concern, the fe;;cweng was disclosed:
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In October 1978. TUGC0 QA instituted a Vander Rating program whereby numerical ratings were assigned to vendors based on type, severity, and quantity of defects identified during source inspections. These ratings were utilized to adjust the scheduling of inspections and audits. In January 1981, a Vendor Performance Evaluation system was instituted which enhanced the Vendor Racing system by also considering the number of items submitted for inspection in calculating the rating. It was noted during the review that various audit notifications and/or ~
reports documented that some of these audits had been initiated as a result of unsatisfactory source inspection reports.
In May 1979, a Joint Inspection / Audit progra=
vas instituted whereby auditors would accompany inspectors on release inspection trips to investigate specific program areas based on problems identified during previous source inspections.
TUCCO QA also utilized " Requests for Corrective Action" which were correspondence with the vendors requesting correceive action for specific, identified problems when it was concluded that the proble=s did not warrant an audit investigation or did not appear to indicate an adverse trend.
Internal documents known as "Yellev Tiag Sheets" were also utilized by the TUCCO OA staff to ensure that applicable QA personnel vere aware of status and/or proble=s with particular vendors, e.g. , a hold placed on shipments from a vender until after an' audit was perfor:ed.
While it is recognized that source inspections and 11:1ted-scope audits perfor:ed in response to identified proble=s might not be considered adequate substituras for regularly scheduled progra: audits, they did provide data which were utilized to so=e extent by TUCCO to evaluate the effectiveness of vender QA progrs=s.
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RESULTS REPORT ISAP VII.a.4 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) l It is concluded that during the period prior to 1978, the frequency of performance of contractor / vender audits, with the exception of the two cases noted, was satisfactory, but for the period from 1978 through November 1984 the frequency was not satisfactory.
However, it is further concluded that as a result of the source inspection activities, the limited audit activity, vendor ratings, corrective action requests and internal QA communications, that sufficient information was available to, and used to some extent by, the QA organization to evaluate the effectiveness of vendor QA programs even though audits of the vendors were not performed on an annual basis. "
The NRC notice of violation (445/8432-03; 446/8411-03) identified that the Westinghouse site organization had not been audited from its inception in 1977 through 1981. To provide background, the description of the Westinghouse site organization in the NSSS contract between TUGC0 and Westinghouse includes the following in Section 5.0 (paragraphs A and B are not applicable to this discussion):
"C. Construction Site Services - Beginning 21 months prior to the arrival of the first of Vendor's equipment at the job site (er such later date as may be mutually agreed upon),
Vender shall establish an organization with representation at the job site to the excent necessary in the judgenent of Purchaser to coordinate construction site activities for Vendor's equipnent. This organization vill be retained with representation at the job site until fuel loading of the second NSSS is conpleted.
D. Field Testing and Startup Services - Vender shall establish an organization to provide advice and consultation on testing and startup. Special startup and testing equipnent (or its then current equivalent) identified in Exhibit A shall be provided at the job site by Vendor on a cost-free loan basis. Testing and startup precedure l preparation assistance shall also be provided."
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Further, the safety-related activities relating to !
erecting, installing, inspecting, testing, etc., of the NSSS vere the responsibility of TUGC0 and were performed by TUCCO or Brown & Root organizational elements. The activities performud by the Westinghouse site organization were primarily liaison and did not include the categories of safety-related activities requirint, periodic audits as listed in Section 1.2 of ANSI N45.2.12-1973.
This understanding of the involvement of the Westinghouse site organization in the site safety- ,
related activities was confirmed by TUGC0 QA during the performance of an audit of Westinghouse site activities pertaining to work on the reactor internals (audit TVH-23) in March 1982. This audit confirmed that the development of work travelers was performed by Texas Utilities Services Inc. engineering and that construction and inspection activities were perfor:ed by Brown & Root. The audit also revealed that Westinghouse-Pensacola supplied drawings and perfor=ed overview surveillance of TUGC0 and Brown & Root activities related to the reactor internals. After concerns were expressed by the NRC, an audit of Westinghouse site activities was scheduled and perforned in November 1984 (audit TWH-30). This audit confir=ed the TUGC0 understanding of the Westinghouse 1 site organization scope of work.
It was determined that the V site organization scepe of l vork did not include the categories of safety-related J activities requiring periodic audits per ANSI l N45.2.12-1973. This position was confirmed by TUCCD l through the performance of the above-mentiened audits.
It is therefore concluded that there was no requirement to audit the Westinghouse site organization. )
Internal Audit Program I As previously discussed ANSI N45.2.12-1973 recuires that applicable progra= ele =ents affecting an activity be audited annually. This means that the activities c:
be audited must be identified along with the progra:
ele:ents af fecting these activities. Audits of these
Revision: 1 Page 26 of 53 RESULTS REPORT ISAP VII.a.4 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) activities are to be scheduled on the basis of their status and safety importance and performed to evaluate the adequacy and effectiveness of the program as developed and implemented by the participating organizations.
Evaluating the adequacy of the TUGC0 QA internal audit program at the construction site is complex. Prior to 1978, site audits were scheduled and conducted as vendor audits. Since that time, except for contractors operating under their own QA programs, site audits have been scheduled and conducted as internal audits.
The following paragraphs describe the evolution of the i audit planning process during the Design / Construction phase of CPSES.
When the TUGC0 internal audit program was first
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implemented at the construction site in 1978, audit planning and scheduling appeared to be primarily activity-orientud. However, by 1982 audit planning appeared to have become primarily organization-oriented. During the review of the audit files, observations related to the structure of checklists, task assignments of team members during the audit, structure and content of audit reports, as well as audit titles indicates that audit planning and scheduling continued to be organization-oriented.
This approach to audit planning evolved to accc =edate the organizational structure and procedure syste=s that ,
developed as TUGC0 assumed additional responsibility j for site activities. j l
The written program has always required that audit I planning and scheduling activities be performed, and the reviews of the files revealed that audit schedules had been prepared. However, it was deter =1ned that until the issuance of procedure DQP-AG-4, "CPSES Construction Phase Audit Prograc," Revision 0, en September 4, 1985, there was no procedure that detailed the audit planning and scheduling process. A review of q this procedure revealed that althcugh audits were to be j
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R3 vision: 1 Page 27 of 53 RESULTS REPORT ISAP VII.a.4 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) performed annually, activities to be audited would be determined from existing programs and procedures, rather than from an analysis of site activities affecting quality and their importance to safety. The I procedure also implied that audit planning was organization-oriented.
However, as a result of discussions with TUGCO QA i management and a review of audit schedules, it is concluded that the audit planning and scheduling process has generally considered project activities as an input. Procedure DQP-AG-4 has since been revised (Revision 1, dated January 27, 1986), and now describes an adequate audit planning and scheduling process.
Procedure DQP-AG-4 also provides for the development of an annual audit schedule which is subject to periodic review and adjustment based on project status, program changes, outside reviews, etc. As-run schedules f or past years have been prepared to document audits scheduled but not performed (and the reasons why they were not performed), and additional audits which had been added to the schedule.
It was noted that the proposed 1986 audit schedule includes a short scoping statement for each scheduled audit. This enhancement to the schedule provides a more complete description of the planned audit program coverage.
Also related to audit planning, the NRC Notice of l Violation (445/8432-03; 446/8411-03) stated that TUCCO audit planning for 1983 was inadequate because only 25 percent of the safety-related procedures were audited.
This use of procedures as an audit planning baseline is appropriate only when the procedures are pre-defined as ;
the program elements. Accountability for audit I coverage vould then be s1=plified because a procedure listing is very specific as opposed to developing a list of activities, applicable criteria, and participating organizations. Attractive as it may appear, this =ethod of audit planning contains weaknesses and is not recc= mended because auditing strictly by the procedures could result in overlooking an activity for which a procedure was required but had not been developed.
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By calculating the percentage of ptocedures addressed by the audit program, an inference could be drawn as to the adequacy of audit program coverage. However, unless this information is correlated with actual project activity, previous audit and/or surveillance results, importance of ths activities represented by procedures not audited, etc., ne judgement should be
=ade of the adequacy of audit program coverage based solely on percentage of procedures audited.
A review of the 1983 Audit Program revealed that TUGC0 perfor=ed twenty-nine (29) internal audits of i design / construction phase activities as well as eight - i onsite audits of construction contractors.
From data gathered during the review of the twenty-nine (29) internal audit files, a matrix was developed to evaluate the activities audited, the program elements (Appendix B criteria) addressed, and the organizations through which they were addressed. In addition, the list of activities audited (contractor and internal) was compared to the major site activities in process during the year as identified by project control personnel. These evaluations revealed that the 1983 audit program addresses the major on-going site activities, that all site organizations were audited, and that all program elements (Appendix B criteria) were addressed. Therefore, it is concluded that the audit program coverage of the Design / Construction Phase of CPS S during 1983 was adequate. It was also noted that the audit schedule was adjusted throughout the year in response to organizational and progra: changes, to address proble=s identified by outside organizations and to reflect changes in the project schedules.
Cenclusiens It is concluded that the failure to perform vendor audits on an annual frequency resulted in no adverse effect on the audit program because of the additienal activities imple=ented by the QA organization to supplenent the audit activity.
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Page 29 of 53 RESULTS REPORT ISAP VII.a.4 (Cont'd) 5.0 IMPLDENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) l It is concluded that there was no requirement to audit ;
the Westinghouse site organization. '
It is concluded that the lack of a formalized methodology for internal audit planning and scheduling resulted in no adverse effect on the audit program because it nas established that audit planning was accomplished and audit schedules were prepared to implement the audit program. .
5.1.4 Audit Preparation The audit preparation phase consists primarily of -
accumulating pertinent documents and data from internal and external sources from which the Audit Team Leaders would develop the final detailed audit scopes and audit chec klis t s.
The reviews of the audit files revealed that while checklists had been prepared for the conduct of the audits and that sources such as TUGC0 site surveillance, INPO evaluations, CAT reports, etc., had been utilized to address topics of special interest, the majority of the checklists reviewed in detail appeared to have been developed from existing procedures rather than from governing requirements. As discussed previously, utilizing procedures as the baseline could preclude verification that the procedures, individually or collectively, adequately implement the requirements.
It can be an acceptabic practice to perfor= only compliance audits for those portiens of a progra: which remain basically unchanged. However, there was no evidence in the .TUCCO QA audit '.'iles reviewed to indicate that a comprehensive assessment of the written program had previously been performed in the areas of Non-conf or=ance Control / Corrective Action or QC Training / Qualification / Certification to verify that the program procedures were in compliance with governing requirements.
In addition, the checklists reviewed did net provide for verification that procedures in different CPSES procedure systems that address the sa=e or similar activities were consistent in approach, level of detail or control of the activity.
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During 1985, the QA Audit Group initiated the use of an
" Appendix 3 Checklist." Applicable portions of this standard caecklist are now utilized by the audit team to verify that the procedures within the scope of the audit are in compliance with the applicable criteria of 10CTR50 Appendix B.
Conclusions It is' concluded that the audit preparation activities l vere not adequate. This resulted in an adverse effect ,
on the audit program, in that most audits reviewed did i not evaluate the adequacy of the written program to implement the governing requirements.
5.1.5 Audit Performance ANSI N45.2.12-1973, to which TUGC0 was ce=mitted through May 1983, contains no specific criteria for an Audit Team Leader.
From February 1982 through February 1985, as a portion l cf on-the-job training, the TUCCO program contained provisions for a lead auditor candidate to be designated as the acting Audic Team Leader, to perform under the direct supervision of a qualified Lead Auditet.
This practice did not constitute a noncompliance prior to the June 1983 comm1tment to ANSI N45.2.23-1978.
However, from that time until the issue of procedure DQP-CS-3, TUCCO QA Audit Program " Revision 12, dated February 15, 1985, the practica did constitute a technical noncompliance with the requirements of ASSI S45.2.23-1978.
It is not uncommon for an audit team leader to delegn:e functions to team members during the course of an audit, for training or other reasons, while retaining ultimate responsibility therefore. However, in the TCGC0 program, full responsibility for an audit was assigned to other than a qualified Lead Auditor, which was contrary to the requirements of ANSI S45.2.23-197S.
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ANSI N45.2.12-1973 requires that auditors be independent of any direct responsibility for the activities they will audit. The reporting level for the Director, Quality Assurance provides adequate independence of the QA staff from the design and construction activities.
The NRC raised a question in SSER 11 concerning the objectivity of surveillance personnel performing audAts of activities over which they had surveillance responsibility. This practice is not uncommen in the industry and, in fact, can be beneficial to the audit program in that the knowledge and experience gained by ;
personnel from surveillance activities can be utilized as input to the audit planning process and through participation on the audit team. The only time this situation might constitute a conflict would be the case where the purpose of the audit was to evaluate the adequacy and ef f ectiveness of the surveillance program itself. No audits of this nature were identified during this review.
It was determined that pre-audit and post-audit conferences were conducted by the audit team and that appropriate personnel were in attendance.
The review of the audit files revealed that objective evidence had been examined when appropriate to support the audit activity as defined by the audit checklists.
It appears that the auditors evaluated program ele =ents to an appropriate depth to support the audit checklists.
Conclusions l
1 It is concluded that the practice of designating a lead )
auditor candidate as an acting team leader resulted in j no adverse effect on the audit program because the
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direct supervision of a qualified lead auditor who was l a cember of the audit team.
It is concluded that the practice of utili:ing site surveillance personnel as audit team members had to adverse effect en the audit program because these persernel did not perform audits of activities which they were responsible for performing.
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5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.1.6 Audit Reporting The review of audit files revealed that audit <t srting l
i has not always complied with the requirements 01 43SI j N45.2.12-1973. Early in the program, audit reports did not consistently include items such as a description of the audit scope, persons contacted, a summary of audit results and an evaluation statement regarding the effectiveness of the QA Program elements which were audited. However, the information not included in the reports, with the exception of the summary and the evaluation statement, can be found in the audit files.
The content and quality of audit reports have gradually improved over time. Currently, the audit reports provide the reader with an adequate understanding of the scope and results of the audit. The current procedures adequately reflect the requirements of ANSI N45.2.12-1973.
During the detailed revicv of the nine (9) audit files in the training and nonconformance control areas (see Page 12), several deviations were observed that indicate weaknesses in the implementation of the audit program related to audit reporting:
- There were approximately twenty instances where the published audit reports did not appear to accurately reflect the auditors' field notes and/or checklists. For example, items in the notes that appeared to be deficiencies were reported as concerns or comments, and in one case, an item identified as "unsat" on the audit checklist was not reflected in the audit report at all. The items identified did not pertain directly to any items of hardware. (It is recognized by the RTL that additional data could have been i obtained which could have altered the I conclusions and was not reflected in the notes / checklist).
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Revision: 1 Page 33 of 53 RESLTTS REPORT ISAP VII.a.4 (Cont'd) 5.0 IMPLDfENTATION OF ACTION Pt.AN AND DISCUSSION OF RESULTS (Cont'd) 1 In many of these cases, the accompanying notes seemed to indicate that the auditor either judged the "importance" of the finding in the decision to document, or may have had additional information which was not included in the audit files. There was no discernible pattern for not documenting identified unsatisfactory conditions.
It was noted that the category of " concern" was deleted from audit reports in April 1984 with the issue of revision 7 of DQI-CS-4.6.
All discrepancies are now categorized as deficiencies in the TUGC0 audit program.
It is the responsibility of the Audit Team Leader to ensure that the audit report accurately reflects the audit findings as documanced by the audit team, and that pertinent backup data is included in the audit files.
There were occasions when major sections of checklists were not completed which, in effset, altered the scope of the audit. This l was not documented in the audit report. This could have provided an inaccurate view of audit program coverage.
In some cases, the reason for the o=issien l vas noted on the checklist (e.g., "c1:e I constraints", " covered by another checklist",
l "would have required verification of other procedures", etc.), but in some cases was l not. There was no discernible pattern in the stated reasons for not completing checklists.
In March 1985, the QA Audit Supervisor instituted a " Checklist Review Verification l Form" (not procedurally defined) which is l used by the Audit Team Leader to document the excett of completion of the audit checklist.
This form is now utili:ed in the audit planning process to ensure that ince:plete itees are rescheduled as required.
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It was noted that the TUCC0 audit reports do not include a formal Recommended Corrective Action for identified deficiencies. The language of ANSI N45.2.12-1973 can be interpreted either way as to whether or not this is a requirement. The RTL supports the TUGC0 position, although it is contrary to experience, because the responsible organization is better able to determine the proper course of corrective action and is ultimately responsible for the final determination and implementation. The QA organization remains responsible for -
evaluation and approval of the course of corrective action as well as verification of ef f ective implementation.
Audit report distribution did not appear to be consistent in that the reports in some cases were addressed to the supervisor responsible for the activity requiring corrective action rather than to project management, although project management did receive copies. Although this is technically not a violation of requirements, it can cause project management to be omitted from direct i participation in the reporting, investigation, and corrective action activities of the audit process. In addition, original recipients did not always receive subsequent correspondence related to follow-up and closecut.
Conclusions It is concluded that the lack of information in early audit reports (e.g., audit scope, sum =ary of audit results, evaluation statement) could have resulted in an adverse effect on the audit program in that it would have contributed to a lack of full understanding by the reader of the adequacy and effectiveness of the QA program as evaluated by the QA organization.
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It is concluded that the failure to properly document
! audit deficiencies could have resulted in an adverse effect on the adequacy of the audit program in that appropriate management may not be made aware of all items requiring corrective action or of their importance.
l It is concluded that the failure to document deviations from the audit checklists could have resultsd in an adverse effect on the audit program in that appropriate management might not be made aware of program activities / elements which were not evaluated.
l It is concluded that the failure of the auditor to recommend effective corrective action for audit deficiencies resulted in no adverse effect on the audit program because the organization responsible for the activity has the ultimate responsibility for determination of corrective action.
It is concluded that the lack of consistent ,
distribution of audit reports and subsequent !
correspondence could have resulted in an adverse effect en the adequacy of the audit program in that project l management would not be involved in the activities pertaining to investigation, corrective action and ,
closecut of audit deficiencies. '
5.1.7 Follow-up and Closecut The final major stop in the audit process is timely follow-up, by both the audited organization and the auditing organirstion.
The review of the audit report files indicated that, throughout the program, the early steps of the follow-up process appeared to have been completed in a timely manner by both the audited organization and the auditing organization. This included deter =ination ef, and schedule for ce=pletion of corrective action by the audited organi:ation, evaluation of the propesed corrective action by the auditing organization and additional correspondence between the two, as required, until resolution was reached.
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The timeliness of implementation of corrective action by the audited organization cannot be ascertained from the audit files for reasons that are discussed below.
Interviews with the Assistant QA Manager indicate that the general feeling within the auditing organization was that implementation of corrective action was t imely. However, the timeliness of verification of implementation of correctiva action by the auditing organization, as well as closecut of the audit l
deficiencies and audit reports was eften unsatisfactory.
This situation was eventually recognized and addressed 3 by TUCCO QA through the performance of audit TCP-lll, "Closecut of Open Construction Audit Findings" in August 1984 This audit was performed to verify implementation of corrective action for 83 deficiencies and 22 concerns, some of which had been open for over six years. During the audit, all but four (4) items (2 deficiencies and 2 concerns) were found to have been completed. These four items were reissued as three deficiencies against audit TCP-lli, which were then closed in a fbilow-up two months later.
The NRC addressed the inability of TUGC0 QA to close an audit finding from TCP-23 during the conduct of audit TCP-68. The deficiency in question was subsequently identified as audit TCP-40, Deficiency 2. It was determined that this deficiency was closed during the conduct of audit TCP-99 in March 1984 Contributing causes to the lack of ti:ely follow-up were a combination of (1) the practice of each lead auditor being responsible for scheduling applicable follow-ups during subsequent audits, (2) related audits being scheduled up to a year later, and (3) lack of a formal tracking and status system for audit deficiencies. The apparent lack of urgency for follow-up may have been influenced in part by the general feeling that implementation was indeed ti:ely, and therefore additional action was not required to expedite imple=entation.
Procedure DQI-AO-1.B. " Internal Audit Deficiency Follow-up/Closecut" issued in June 1955, addressed these problems by instituting a tracking system for internal audit deficiencies. The tracking system described in the procedure is adequate.
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RESULTS REPORT h ISAP VII.a.4 '
i (Cont'd) 1' 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Conclusions It is concluded that the failure to perform timely verification of implementation of corrective action for audit deficiencies could have resulted in an adverse effect on the adequacy of the audit program in that one of the major goals of an audit program is to identify and ensure corrective action for program deficiencies.
1 5.2 Audit Personnel Qualification Program documents and audit personnel training / qualification filas were reviewed co evaluate the adequacy and effectiveness of the TUCCO program for qualification and certification of audit personnel. The results of.these reviews are summarized in the succeeding paragraphs.
5.2.1 Qualification Requirements Prior to June 1983, TUGC0 was committed to the requirements of ANSI N45.2.12-1973 for audit personnel training and qualification. Th.e TUGC0 written program for this period was in compliance with the ANSI requirements.
It was noted from reviewing the training and qualification files for this period that, beginning in 1977, a form similar to the form contained in ANSI N45.2.23 was being used to document certifications for lead auditor. The use of the modified form was proceduralized in 1980. It was noted that in the use l of this for= (for which there was yet no commitment) '
TUGC0 was awarding qualification credits for attributes in addition to those specified in ANSI S45.2.23 and was not requiring the saae number of qualification credits as was the ANSI.
1 Revision 5 of CQI-QS-2.1, " Qualification of Audit l Personnel," issued June 1, 1983, resulted in the :
written program being in co=pliance with ANSI ;
S45.2.23-1978. At this time, audit persennel who had been qualified and certified under the previous procedure revision were reevaluated and new !
certifications issued. This procedure has since been ;
cancelled and the appropriate material incorporated into DQP-QA-2, Revision 11. The current procedures are in compliance with governing requirements.
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Conclusions It is concluded that ette audit personnel qualification program adequately reflacted the requirements of the appropriate governing standards and regulatory guidance and therefore resulted'in no' adverse effect on the audit program.
5.2.2 Training / Qualification Records of approximately fifty (50) personnel identified as having performed as auditors or lead auditors since 1978, the personnel qualification files of 41 of these individuals were reviewed for evidence of education, training and experience used as a basis for qualification and/or certification. The personnel reviewed were all members of the TUGC0 QA organization,'
though not necessarily assigned to the audit staff.
Included in this total are all who performed as auditors or lead auditors since 1981, as well as some who had participated earlier.
All files, except.as discussed below, contained adequate documentation (e.g., resume, training records, reading lists, certifications, etc.)
appropriate to the time of certification, including evaluation and t certification of personnel on-board on June 1, 1983 (Date of Commitment to ANSI N45.2.23-1978).
Files for six personnel contained no resume or other independent supporting documentation for lead auditor certifications issued in 1977, 1978, and 1981. None of these personnel have ptreicipated in the program since 1982. Although no judgement of competency of these i
personnel can be made from the records reviewed, others certified during this period were determined to be-l adequately qualified,' based on their records.
1 Review of Lead Auditor qualification files indicates that all personnel currently certified as Lead Auditor, except as neced below, have satisfied the require:en:s of ANSI N45.2.23-1978.
Although there is no regulatory require =ent to verify the education, experience, etc., for audit personnel, it was noted that TUGC0 OA is in the process of performing these verifications for the current staff and has incorporated such a requirement in DQP-QA-2.
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ISAP VII.a.4 (Cont'd) 1 5.0 UTPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) l ANSI N45.2.23-1978, Section 4.2 states that the development and administration of the examination for lead auditor is the responsibility of the employer. It f
also states that this activity may be delegated to an independent certifying agency but that the employer shall retain responsibility for confor:ance of the examination and its administration to the standard.
The applicable TUGC0 procedure does not specifically reflect this requirement, although it could be interpreted to do so.
During the review of qualification files of current staff members, it was observed that at least three personnel had been granted certification as lead auditor who had no record of being administered an examination by or for TUGCO. They had been given credit for examinations administered by previous employers. It is believed that this action has not resulted in the certification of unqualified personnel, but it constitutes a violation of the requirements of j ANSI N45.2.23-1978.
Based on the review of audit personnel training and qualification files, it was concluded that with the exception pertaining to the examination of Lead Auditors, the TUGC0 program for qualification and certification of audit personnel was satisfactorily imple=ented.
Conclusions It is concluded that independent backup infor:atien not being in the files for auditors in the past resulted in no adverse effect on the audit program in that the files did contain evidence that QA management had perfor:ed an evaluation of the personnel and found the:
to be qualified.
It is cencluded that the failure of TUCCO to ad=inister lead auditor exa=inations to particular individuals resulted in no adverse effect on the audit progra: in that the persennel are otherwise cualified and are believed capable of satisfactorily performing as lead auditors.
Revision: 1 Page 40 of $3 RESULTS REPORT ISAP VII.a.4 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'O 5.3 Evaluation of Findings This section summarizes the deviations and weaknesses identified throughout this report. Each item includes the determination of whether or not it was considered to be a QA/QC program deviation, states a recommended corrective action if appropriate, or describes correctivo action which has already been taken.
The corrective actions describe below are intended to preclude recurrence of the identified deviations. It has been determined that remedial corrective action would previde no additional benefit to the QA Audit Program.
Audit Program 10CTR50, Appendix B, Criterion I, states in part,
". . . the authority and duties of persons and organizations performing activities affecting the safety-related functions of structures, systems, and components shall be clearly established and delineated in writing . . ." Criterion XVIII states in part, "A comprehensive system.of planned and periodic audits shall be carried out. . ."
Contrary to the above, the CPSES FSAR does not address the organizational responsibility for the definition and implementation of the audit program.
This is a QA/QC Progra= Deviatiet..
Therefore, it is recommended that the CPSES FSAR be revised to define the responsibilities for the audit program. A proposed change to the FSAR has been submitced to TUCCO licensing, has been reviewed by the RTL and found to be acceptable, i 10CFR50, Appendix B, Criterien I, states in part,'
". . . the authority and duties of personc and organizations performing activities affecting the safety-related functions of structures, tystems, and ce=ponents shall be clearly established and delineated in writing . . ." Criterion XVIII states in part, "A comprehensive system of planned and periodic audits shall be carried out. . 1 Contrary to the above, the QA program documents did not delineate responsibilities for the Supervisor, CA Audits.
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RESLTLTS REPORT
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ISAP VII.a.4 (Cont'd) a 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RISULTS (Cont'd)
This is a QA/QC Program Deviation.
Corrective action was taken in DQP-QA-16, Revision 0, I issued in September 1985. This has been reviewed and found acceptable.
10CTR50, Appendix B, Criterion V, states in part,
" Activities affecting quality shall be prescribed by !
documented instructions, procedures . . . of a type appropriate to the circumstances. . ."
ANSI N45.2.12-1973, paragraph 3.2, states in part, "An effective audit system . . .shall include . . .
provisions for reasonable and timely access of audit personnel to facilities, documents, and personnel necessary in the planning and performance of the audits. . . ."
ANSI N45.2.12-1973, paragraph 4.5.1, states in part,
". . . management of the audited organization or activity shall review and investigate the audit findings to determine and sch9dule appropriate corrective action. They shall respond to the report in writing, within 30 days after receipt."
The " Gray Book", paragraph D.2.b. states in part,
". . .during the [ post-audit] conference an effort shall be made to establish a tentative course and schedule of corrective action for non-confor=ances.
Where it is not possible to provide such inf or=ation at the post-audit conference, the canagement of the audited organization should co==it to a specific date for determination of the course of corrective action and the schedule for i=ple=entation."
Contrary to the above, neither the TUCCO QA Progra= nor the CPSES QA Plan, the documents in the written pregra:
which veuld provide direction to the manage =ent of the audited organizations, addresses the require =ents. 1 This is a QA/QC Program Deviation.
It is reco== ended that appropriate OA program docu=ents (e.g., Corporate QA Program, Site QA Plan) be revised to include these require =ents.
The TRT concluded that the QA audit progra: had inadequate staff 1ng during peak periods.
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This NRC finding was evaluated by considering both the designated audic staff and other members of the QA organization who performed as auditors. The total number of participants in audits shows that the audit staff was adequate in numbers and qualifications.
Accordingly, this NRC Finding was not substantiated.
ANSI N45.2.12-1973, paragraph 3.4.2, states in part,
" Applicable elements of the Quality Assurance Program shall be audited at least annually or at least once within the life of the activity, whichever is shorter."
Contrary to the above, internal annual. audits were not specified in procedure from 1981 to 1984 This is a QA/QC Program Deviation. The NRC finding in this area was substantiated.
Corrective action was taken in DQP-CS-4, Revision 11 issued in November, 1984 This has been reviewed and found acceptable.
ANSI N45.2.12-1973, paragraph 3.4.2, states in part,
" Applicable elements of the Quality Assurance Progra shall be audited at least annually or at least once within the life of the activity, whichever is shorter."
Contrary to the above vender annual audits were not specified in procedures.
This is a QA/QC Program Deviation. The NRC finding in this area was substantiated.
Corrective action was taken in FSAR Amendment #52 issued in August 1984 and DQP-CS-4, Revision 11 issued in Nove=ber 1984 This has been reviewed and found acceptable.
ANSI N45.2.12-1973, paragraph 3.4.2, states in part.
" Applicable elenents of the Quality Assurance Progra:
shall be audited at least annually or at least once within the life of the activity, whichever is shorter."
Contrary to the above, annual audits were not perfer.ed l for contractor organization in two (2) instances out of I
sixteen (16) required audits fre= 1973 to 1977.
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This is a QA/QC program deviation. The NRC finding in this area was substantiated.
Corrective action was taken by QA management in that for the remainder of that phase of the !UGC0 audit program, audits of major contractors were performed at least annually.
ANSI N45.2.12-1973, paragraph 3.4.2, states in part,
" Applicable elements of the Quality Assurance Progra:
shall be audited at least annually or at least once within the life of the activity, whichever is shorter."
Contrary to the above, annual vendor audits were not perfor=ed in that initiation was not timely and/or intervals were too large in all evelve (12) organizations examined between 1976 and l'984 This is a QA/QC program deviation. The NRC finding in this area was substantiated.
Corrective action was taken in DAP-CS-4, Revision 11, issued in November 1984 This has been reviewed and found acceptable.
NRC Notice of Violation (445/8432-03, 446/8411-03) stated that the E site organization was not audited between 1971 and 1981.
It was deter =ined that the nature of the work activities for the 3 site organization did not involve control of safety-related activities and therefore is not required to be included in the audic schedule.
Accordingly, this NRC Finding was not substantiated.
ANSI Na5.2.12-1973, paragraph 5.3, states in part,
" Planning of the audit system shall be conducted to assure coverage of the applicable quality assurance progra: . . . and in paragraph 3.4.2, " Audits shall ,
. assure confor=ance with the develeped and 1:ple:ented progra=."
Contrary to the above, audit checklists were developed ft:= existing procedures rather than governing require:ents for the majority of audits reviewed. For i
exa ple, no assessment of the written progra= adequacy wa s pe r f o r:e d 1- areas of non-cenfor=ance or corrective action or QC Tr..ining/ Qualification / Certification.
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RESULTS REPORT ISAP VII.a.4 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) l This is a QA/QC Program Deviation.
Corrective action consists of use of an " Appendix B checklist". This has been reviewed and found acceptable. However, for program enhancement. DQP-AG-2 should be revised to reflect use of this checklist.
Checklists did not provide verification that procedures in different systems were consistent for the same activities performed by different organizations.
This is not a QA/QC Program Deviation.
ANSI N45.2.12-1973, paragraph 1.5.1, states in part,
"[An) Audit [is) a formal documented activity performed in accordance with written procedures or checklists to verify, by evaluatica of objective evidence that a quality assurance program has been . . . implemented in accordance with applicable requirements of ANSI N45.2.
Contrary to the above, the audit preparation phase was less than adequate because audits did not provide sufficient checking of program adequacy for the activities being audited and resulted in incomplete evaluation of the adequacy of the overall QA/QC program.
This is a QA/QC Program Deviation.
Corrective action censists of the use of an " Appendix 3 Checklist." This has been reviewed and found acceptable. However, for program enhancement, it is recommended that procedure DQP-AG-2 be revised to !
reflect the use of this checklist.
ANSI N45.2.12-1973, paragraph 4.2.2, states in part. I responsibilities (of the audit team leader) include I orientation of the team, .. ., assuring co==unications within the team and with the organization being audited, participation in the audit performance, and coordinating the preparation and issuance of reports."
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ISAP VII.a.4 (Cont'd) l 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
ANSIN45.2.23i$478, paragraph 1.1,statesinpart
" requirements . . . for the qualification of audit team j leaders, henceforth identified as a " Lead Auditors", who organizes and directs audits, report audit findings, and evaluates corrective action."
Contrary to the above, Lead Auditcr candidates were designated as acting team leaders (with signature j authority). i This is a QA/QC Program Deviation.
Corrective action was taken in DQP-CS-3, Revision 12, j issued in February 1985. This has been reviewed and found acceptable.
ANSI N45.2.12-1973, paragraph 4.4, states in part "An !
audit report shall be written and signed by the audit !
ceam leader which provides: :
Description of the audit scope A su==ary of audit results including an evaluation statement regarding the effectiveness of the QA program elements which were audited." j Contrary to the above, audit reporte did not include scope description and evaluation statements.
This is a QA/QC Program Deviation.
Corrective action was taken in CQI-CS-4.6, Revisien 0, issued in July 1981. This has been reviewed and found acceptable.
Audit files contain instances of:
Field notes on identified conditions that are not properly addressed in the final report.
Checklists that are not completed. ,
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' 1 RESULTS REPORT ISAP VII.a.4 (Cont'd) 5.0' IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
This is not a QA/QC Program deviation, but indicates implementation weaknesses in that the documented record does not reflect all actions of the audit team.
ANSI N45.2.12-1973, paragraph 4.4, states in part.
" Distribution of the [ audit] report shall include responsible management."
1 Contrary to the above, original recipients did not always receive subsequent correspondence related to follow-up and closecut of audit reports.
This is a QA/QC Program Deviation.
- Corrective action was taken in DQP-AG-5, Revision 0, dated September 9, 1985. This has been reviewed and
-found acceptable. However, for program enhancement, i
applicable procedures should be revised to define the f' addressecs and minimum distribution for audit reports.
. ANSI N45.2.12-1973, paragraph 4.5, states in part,
" Follow-up action shall be performed by the audit team leader or management of the auditing organization to:
. . . confirm that corrective action is accomplished as scheduled."
Contrary to the above. QA verification of c1=eliness of closecut was unsatisfactory although audit personnel believed that actual i=plementation of correct 1're action was timely.
This is a QA/QC Program Deviation. The NRC finding in this area was substantiated.
1 Corrective action was taken in DQI-AG-1.8 Revision 0, issued in June 1985. This has been reviewed and found I acceptable.
1 Audit Personnel Qualifications The procedure for qualification of audit personnel contained weaknesses in that, for example.
OJT could be performed under qualified auditors in addition to Lead Auditors.
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The required reading list was incomplete. 1 There was no stated requirement to retain information pertaining to examinations.
This is not a QA/QC Program Deviation.
When procedure DQP-QA-2, Revision 11 was issued in December 1985, the weaknesses were eliminated.
Six (6) audit personnel qua31fication files in the period prior to June 1983 are incomplete.
This is not a QA/QC Program Deviation.
ANSI N45.2.23-1978, Piragraph 4.2, states in part, "The development and administration of the examination for lead auditor . . . is the responsibility of the employer.. . ."
Contrary to the above, at least three members of the current audit staff have been certified as Lead Auditors by TUGCO, but have not been ad=inistered an examination by, or for, TUGCO.
This is a QA/QC Program Deviation.
It is recommended that these personnel, and any others currently certified who did not meet the requirements, be administered an examination in accordance with the requirements of the standard.
5.4 Trend Analysis l
A total of fourteen (14) QA/QC Program Deviations were identified. These findings are characterized as failures to fully translate audit program requirements into the procedures used to implement the program. This can also be characterized ,
as a lack of specificity in the CPSES implementing j procedures. This therefore resulted in a failure to preperly 1 implement the audit program. '
Because each of the deviations can be traced to inadequacy of procedures, this has been determined to constitute a trend.
Therefore a trend analysis has been perfor:ed in accerdance with Appendix E of the CPRT Program Plan.
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None of the deviations described in Section 5.3. taken individually, is believed to represent a significant breakdown in the audit program. However, taken collectively, there.vas a potential for breakdown in the audit program. Therefore this is considered to be a trend adverse to the audit program.
As noted previously, there is no direct connection between an
' audit program and the quality of installed hardware. For this reason, it cannot be concluded that this' trend is an " adverse trend." as defined by Section 5 of Appendix E of the CPRT Program Plan. However, an inadequate audit program can fail to identify weaknesses in'the prescribed QA/QC programs that in turn could allow hardware problems to go undetected. For' this reason the RTL has determined that a root cause and generic implications analysis should be performed.
5.5 Root Cause and Generic Implication Evaluation '
The NRC findings led to two hypothesized root causes which were: 1) TUEC's audit procedures did not comply with NRC requirements and 2) the program was not implemented in accordance with procedures. The CPRT. evaluation also found instances of failure to implement governing requirements properly, but in~each case this was traced to a lack of specificity in the implementing procedures for the CPSES Quality Assurance Audit Program. Therefore, all substantiated findings can be traced to the first of NRC's hypothesized root causes. As discussed below, CPRT investigation has shown that the lack of procedural compliance with NRC requirements was caused by lack of a management system which would previde for overall coordination and control of project activities and provide a consistent mechanism for translation of governing requirements into ispir.menting procedures and by f ailure to periodically check program procedures against progra:
requirements and commitments. This lack of procedural j compliance remained uncorrected because of the apparent lack !
of full appreciation by previous TUIC manage =ent of the role of an effective QA Audit Program in ensuring the overall effectiveness of the CPSES QA Program and therefore is considered to be the root cause.
The generic implications of this root cause will be evaluated during the conduct of other ISAPs and will be considered ;
during the collective evaluation phase of the QA/QC Prcgram.
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1 RESULTS REPORT ISAP VII.a.4 (Cont'd) j 1
l 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) [
i A substantive contributing causr for the lack of a full assessment of the completeness of QA Audit Program s implementing procedures is determined to be the lack of a procedural hierarchy for CPSES. A procedural hierarchy would provide for at least one additional tier of procedures which would provide a bridge from the requirements documents to the implementing procedures, and in addition would provide a vehicle for management to describe the overall coordination and control of project activities and organizations for topi s such as the following:
Interpretation and application of commit.:ents to codes, standards and regulations, '
Definition and application of self-imposed requirements.
Standardization of terminology and definitions.
Delineation of responsibilities.
Description and responsibility of organizational interfaces and Structure and content of sub-tier procedures.
A potential generic implication is that the types of procedural inadequacies identified in the audit program may exist in other procedure systems at CPSES. The lack of an upper tier of procedures covering the topics identified above leads to procedura development by each organization without for=al corporate guidance or formal coordination between organizations. Further investigation is required to deter =ine if this lack of standardization contributed to similar procedure inadequacies in other areas or organizations.
Further investigation is beyond the scope of this action plan and will be addressed as part of Collective Evaluation of the l
Construction QA/QC Program using information from this and !
other ISAPs.
Corrective actions related to the adequacy of the c.urrent CPSES QA Audit Progra= have been identified. Additional '
actions to prevent future occurrence of sim11ar deviations or 1
r.ogra==atic veaknesses are discussed in Section 8.0 belev.
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6.0 CONCLUSION
S Section 4.1.2.3 of ISAP VII.a.4 describes conditional steps that were to be performed depending on the results of reviews and evaluations. Although audit program deviations and weaknesses related to construction activities were identified it has been determined that no action is required beyond that specified in ISAP VII.c, which addresses all areas of safety-related hardware and is intended to provide confidence that any currently unidentified concerns related to the quality of construction of the CPSES hardware vill have been identified, evaluated and resolved.
Therefore, no additional programs or plana were developed to address this area. Audit program deviations applicable to off-site TUCCO suppliers were also identified. During the investigation and evaluation of the impact of these deviations, sufficient
- information was obtained to-provide confidence that the acceptability of the suppliers' quality assurance programs for the applicable equipment and services could be, and was, evaluated by TUGC0 during the periods in question. Therefore, no additional l programs or plans were developed to determine the acceptability of I the suppliers' quality assurance programs based on the efforts of others, t As a result of this review of the TUCCO QA audit program, it has been determined that at no time has the vricten program been in full compliance with governing standards and regulatory guidance, and in addition has exhibited other weaknesses as described in this report. This determination substantiated the TRT finding that
". . . TUEC's audit procedures did not comply with NRC requirements."
The overall effectiveness of the audit program has been less than f ully adequate. Specific examples are: it has failed to identify and cause corrective action of inadequacies in such areas as QC inspector training, qualification, and certification; and control of non-conforming items and corrective action. It is concluded, from the evidence observed, that the failure to identify and cause corrective action in these two areas was due pri=arily to the practice of auditing to existing procedures while not performing verification of the adequacy of existing procedures to i=ple=ent program requirements. It is further concluded that the cause of the deviations and weaknesses in the QA audit program which have been identified in thia report are the result of inadequate procedures. This resulted from the lack of a procedure hierarchy which would have provided for overall coordination and control of project activities and organizations by senior management for topics such as the following:
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" l RESULTS REPORT ISAP VII.a.4 (Cont'd)'
- 6. 0. CONCLUSIONS (Cont'd)
Interpretation and application of commitments to codes, standards and regulations, Definition and application of self-imposed requirements.
Standardization of terminology and definitions, Delineation of responsibilities, L
Description and responsibility of organizational interfaces and Structure and content of sub-tier procedures. -
Essed on the written record the overall competency of the audit f personnel appears to be adequate to perform the required audits for 1 the design, construction, and operation phases of CPSES. Except as previously noted, the program for qualification of audit personnel 1 is considered to have been adequate, although TUCCO was slow to !
recognize and incorporate applicable standards and guidance available to the nuclear industry.
The NRC TRT and Region' IV findings concerning auditor staffing and qualifications during 1981, 1982, and 1983 could be considered valid if the program had been totally. dependent on the personnel assigned to the permanent audit staf f. However, in-light of the total number and qualifications of personnel available to, and utilized in, the audit program, the. audit staff is. considered both ;
adequate and qualified.
Audit planning and scheduling, though in the past not in ce=pliance regarding frequency and not formally systematized until recently, did appear to be well thought out in the context of the TUCCO concept of the' audit program requirements at any particular ti=e.
However, due to the lack of a procedure hierarchy which would provide a firm basis for the development of implementing procedures, the ef festiveness of the audit program to deter =ine the adequacy of the construction QA program was less than desir2ble.
There is evidence that appropriate consideration has been given to
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input f rom sources such as NRC inspections, previous audits, and surveillance.
Except as noted, the findings pertaining to scheduling of audit frequency are valid. Appropriate procedures have been revised, which now properly address scheduling of audit frequency.
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6.0 CONCLUSION
S (Cont'd) l The current written program for auditing and audit personnel )
qualification is in compliance with applicable requirements except '
in the following areas Definition of responsibility for the audit program in the FSAR Definition of responsibilities of the audited organization In addition, at least three currently certified lead auditors have not been administered an examination by or for TUCCO.
Appropriate corrective action should be taken in these areas.
7.0 ONGOING ACTIVITIES The Audit Program and procedures discussed in this report are applicable to the remaining construction phase on Unit 2 and for the operating phase of the plant.
8.0 ACTION TO PRECLUDE OCCURRENCE IN THE FUTURE To prevent future occurrence of the same or similar deviations and weaknesses in the QA audit program (or other portions of the CPSES program) management, particularly senior management (Vice President and above), must actively participate in the program and be kept 4 appraised of audit program results.
This may be accomplished through development of a hierarchy of procedures as described in Section 6.0 of this report. This would provide the necessary standards and management controls under which the overall program can be effectively defined and implemented. In addition, the procedures should provide for direct senior management participation in the audit program in areas such as audit planning and scheduling, and resolution of programmatic problems.
Management at all levels must utilize the output of the audit program (audit reports, su=maries, trend analyses, etc.) to evaluate the adequacy and effectiveness of their portion of the QA progra=. This should be acco=plished by developing requirements for appropriate participation in the development of corrective action for identified deficiencies, and follev-up to ensure that the corrective action has been effectively implemented.
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6.0 CONCLUSION
S (Cont'd)
In addition, an independent, periodic assessment of the audit program is essential to provide Senior management with timely identification and corrective action of deficiencies or weaknesses in the audit program. Such a program will be defined in ISAP VII.a.5.
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l Revision No. 0 1 Reflects Corrnents Description Original Issue On Plan l %. ,
'Prepai d and.:
Recommended by:
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Approved by: r l Senior Review Tec<,n edd /(d h _
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Revision: 1 ;
Page 1 of 5 l ISAP VII.a.5 Periodic Review of QA Program l
1.0 DESCRIPTION
OF ISSUE IDENTIFIED BY NRC The Comanche Peak SSER 11, Appendix P, Section 4.7, pages P-31 l through P-34, describes the NRC concerns in the areas of audit and I reporting. The concerns pertaining to the Periodic Review of QA f program have been extracted and are presented here:
"The TRT found that TUEC management had failed to periodically l review the status and adequacy of their QA program. This was confirmed by Region IV (IR 50-445/84-32). TUEC representatives stated that there had been no regular assessments or reviews of the adequacy of the total QA program by upper management, as required in Criterion II of 10CFR50, Appendix B, and as committed in the FSAR.
With respect to follow-up corrective action for previous findings cited against the audit program by NRC and TUEC i
consultant audit / inspection teams, the TRT found TUEC's corrective action follow-up to be not fully effective. The Fred Lobbin Report (a TUEC consultant), dated February,1982, identified four major findings: (1) level of experience within the TUGC0 QA organization is low; i.e., commercial nuclear plant design and construction QA experience; (2) staf fing for the audit and surveillance functions is inadequate; (3) the number and scope of design and construction audits conducted by TUGC0 QA to date has been limited; and (4) QA management has not defined clearly the objectives for the surveillance program resulting in a program which, in the author's opinion "is presently ineffective." To date, findings (2), (3) and (4) have not been adequately addressed by TUEC. (Region IV Report No. 50-445/84-32.)
Based on its findings and observations, the TRT concludes that the QA audit and reporting program has had and continues to exhibit deficiencies. Over a significant period of time, recurring deficiencies include:.... failure by management to review the QA program for effectiveness; procedural and implementation inadequacies;....and insufficient management direction and understanding. In summation, the QA/QC group finds the past audit and reporting system less than adequate, and the audit and reporting program at the time of the TRT- I review was questionable."
2.0 ACTION IDENTIFIED BY NRC Evaluate the TRT findings and consider the i=plications of these findings en construction quality. "... examination of the potential safety implications should include, but not be li=ited to the areas or activities selected by the TRT."
Revision: 1 Page 2 of 5 ISAP VII.a.5 "
(Cont'd) 2.0 ACTICN IDENTIFIED BY NRC (Cont'd)
" Address the root cause of each finding and its generic implications..."
" Address the collective significance of these deficiencies..."
" Propose an action plan...that will ensure that such problems do not occur in the future."
3.0 BACKGROUND
The intent of this Issue-Specific Action Plan (ISAP) is to ensure that, for the remaining construction phase for Unit 2 and for operations, a Periodic Review of QA Program is developed which will provide corporate management with data concerning the adequacy and effectiveness of the overall QA Program and which provides for the evaluation, by management, of adverse findings and subsequent corrective action follow up.
1 This ISAP is not intended to perform evaluations which would result in conclusions regarding the installed hardware. The quality of hardware and any potential safety i=plications will be assessed from other hardware and programmatic ISAPs and the self-initiated Reverification Program, ISAP VII.e.
In addition to the TRT issue, the NRC issued a notice of violation (445/8432-02; 446/8411-02):
Contrary to the requirements, the applicant did not establish quality assurance procedures to regularly review the status and adequacy of the construction quality assurance program; nor did the applicant appear to have reviewed the status and adequacy of the construction quality assurance program.
4.0 CPRT ACTION PLAN 4.1 Scope and Methodolocv 4.1.1 The purpose of this action plan is to assess the adequacy of the current CPSES Periodic Review of QA Program against criteria to be developed as part of this plan. The Review Team will review in-place Periodic Review of QA Programs in other organizations and will censult with INFO to define criteria for an adequate and effective Periodic Review of QA Program.
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Rsvision: 1 Page 3 of 5 ISAP VII.a.$
(Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
The Review Team will then evaluate the current CPSES Periodic Review of QA Program against the criteria l developed above and recommend appropriate revisions to the CPSES Program.
4.1.2 The specific methodology is described below.
L 4.1.2.1 The Review Team will obtain from other utilities, and INPO, information and procedures governing in-place Periodic Review i of QA Programs for both construction and i operations phases.
4.1.2.2 The Review Team will review the current TUCCO vritten program and practices implementing the Periodic Review of QA Program.
4.1.2.3 Utilizing the information gathered, a set of !
criteria vill be developed to define an !
effective Periodic Review of QA Program for '
CPSES which addresses, among others, the following:
Scheduling and performance of !
reviews at least annually 1 Reports directed to, and responses received from, a sufficiently high level of management to ensure effective correction action Ongoing contact by management with program status Identification of corrective action Tracking and follow up 4.1.2.4 The current TUGC0 program will be evaltsted against the criteria developed above and,1f appropriate, revisions to the TUGC0 written program will be proposed to assure that an effective Periodic Review of QA Program is in I effect for the remaining construction phase of Unit 2 and for the operations phase.
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Rsvision: 1 Page 4 of 5 ISAP VII.a.5 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.1.2.5 Copies of the Results Report for this ISAP will be provided to TUGC0 for their consideration in responding to the NRC Notice of Violation (445/8432-02; 446/8411-02). i 4.2 Participants Roles and Responsibilities 4.2.1 TUCCO 4.2.1.1 Scope TUGC0 will assist in identifying and locating applicable information and documentation to support the Review Team activities, and will provide contact with other utilities and INFO.
4.2.1.2 Personnel Mr. David McAfee, Dallas QA Manager, will ensure effective coordination between the Review Team and TUGCO.
4.2.2 ERC 4.2.2.1 Scope ERC will be responsible to communicate with outside organizations and TUGC0 Management; provide review of data and make recommendations.
4.2.2.2 Personnel Mr. J. Esnsel Review Team Leader Mr. J. Gelzer Issue Coordinator I
Quality Engineers as required.
4.3 Qualifications of Persennel Participants will be qualified to the requirements of the CPSES quality assurance program or to the specific I.
requirements of the CPRT Progra: Tian.
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Page 5 of 5 i ISAP VII.a.5 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.4 Procedures 4.4.1 Program Plan and Issue-Specific Action Plans.
4.5 Standards / Acceptance Criteria Periodic Review of QA activities shall be in compliance with 10CTR50, Appendix B, Criterion II and ANSI N45.2-1971, Section 2. Specifically, such activities are acceptchle if a description is provided of how management (above or outside the QA organization) regularly assesses the scope, status, adequacy, and compliance of the QA Program to 10CTR50, ,
Appendix B. These measures should include-4.5.1 Frequent contact with program status through reports, meetings, and/or audits.
4.5.2 Performance of an annual review preplanned and .
i documented. Corrective action is identified and tracked.
4.6 Decision Criteria This item will be considered complete when the following have been accomplished:
4.6.1 A set of criteria for an effective Periodic Review of '
QA Program has been developed.
i 4.6.2 The TUCCO. Program has been evaluated against the ,
criteria.
l 4.6.3 The results of the evaluation have been transmitted to
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l TUCCO for consideration in their program.
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! , i COMANCHE PEAK RESPONSE TEAM RESULTS REPORT ISAP: VII.a.$ j
Title:
Periodic Review of QA Program REVISION 1 9 l3ll$1e Coord;Lnator / ,// Date
$ ' ' ' Lh ] 31 SN Date /
Rev w Team Leader /
L &. 14] -
- 1/A l!$$n Jc(ps W. Beck, Chairman CPRT-SRT Date
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l i Revision: 1 Page 1 of 11 )
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RESULTS REPORT ISAP VII.a.5 Periodic Review of QA Program A.0 DESCRIPTION OF ISSUE 3 l
The Comanche Peak SSER 11, Appendix P. Section 4.7. pages P-31
.through P-34, describes the NRC concerns in the areas of audit and reporting. The concerns pertaining to the Periodic Review of QA l
program have been extracted and are presented here:
"The TRT found that TUEC management had failed to periodically I review the status and adequacy of their QA program. This was confirmed by Region IV (IR 50-445/84-32). TUEC representatives stated that there had been no reguist assessments or reviews of the adequacy of the total QA program by upper management, as required in Criterion II of 10CFR50, Appendix B, and as committed in the FSAR.
With respect to follow-up corrective action for previous findings cited against the tudit program by NRC and TUEC consultant audit / inspection teams, the TRT found TUEC's corrective action follow-up to be not fully effective. The Fred Lobbin Report (a TUEC consultant), dated February,1982, identified four major findings: (1) level of experience within
! the TUGC0 QA organization is low; i.e., commercial nuclear plant design and construction QA experience; (2) staffing for the audit and surveillance functions is inadequate; (3) the number and scope of design and construction audits cor: ducted by TUGCO QA to date has been limited; and (4) QA management has not defined clearly the objectives for the surveillance program resulting in a program which, in the author's opinion "is presently ineffective." To date, findings (2), (3) and (4) have not been adequately addressed by TUEC. (Region IV Report No. 50-445/84-32.)
Based on its findings and observations, the TRT concludes that the QA audit and reporting program has had and continues to exhibit deficiencies. Over a significant period of time, recurring deficiencies include:.... failure by management to review the QA program for effectiveness; procedural and implementation inadequacies;....and insufficient management direction and understanding. In summation, the QA/QC group finds the past audit and reporting system less than adequate, ,
and the audit and reporting program at the time of the TRT f review was questionable." -
I I Rsvision:
1 Pege 2 of 11
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l RESULTS REPORT ISAP VII.a.5 (Cont'd) i 2.0 ACTION IDENTIFIED l
Evaluate the TRT findings and consider the implications of these {
findings on construction quality. "... examination of the potential safety implications should include, but not be limited to the areas or activities selected by the TRT."
" Address the root cause of each finding and its generic implications..."
" Address the collective significance of these deficiencies..."
" Propose an action plan...that will ensure that such problems do not occur in the future."
3.0 BACKGROUND
The intent of this Issue-Specific Action Plan (ISAP) was to ensure that, for any remaining construction or modification activities for Unit 1, the remaining construction phase for Unit 2 and for operations, a Periodic Review of QA Program has been developed which will provide corporate management with data concerning the adequacy and effectiveness of the overall QA Program and which will provide for the evaluation, by management, of adverse findings and subsequent corrective action follow up.
This ISAP was not intended to perform evaluations which would ;
result in conclusions regarding the installed hardware. The quality of hardware and any potential safety implications will be i assessed from other hardware and programmatic ISAPs and the self-initiated Construction Reinspection / Documentation Review Plan, ISAP VII.c.
Any past effects of an inadequate management review of the QA Program would be addressed through the implementation of other CPRT ISAPs. One example is ISAP VII.e.4, " Audit Pregram and Auditor Qualification," which identified inadequacies in the TUGC0 QA Audit Program which continued uncorrected for long periods of time. In addition, the topic of overall assessment of the QA Program will be addressed during the collective evaluation of QA/QC Program adequacy. Therefore, the first three items in Section 2.0 of this report, which pertain to consideration of the implications of the4 TRT findings on construction quality, their root cause and generic implications, and their collective significance, will be addressed elsewhere.
'* Revision: 1
. Page 3 of 11 RESULTS REPORT ISAP VII.a.5 (Cont'd)
3.0 BACKGROUND
(Cont'd)
In addition to the TRT issue, the NRC issued a notice of violation (445/8432-02; 446/8411-02):
" Contrary to the requirements, the applicant did not establish !
quality assurance procedures to regularly review the status and adequacy of the construction quality assurance program; nor did the applicant appear to have reviewed the status and adequacy of the construction quality assurance program."
4.0 CPRT ACTION PLAN 4.1 Scope and Methodology 4.1.1 The purpose of this action plan was to assess the adequacy of the current CPSES Periodic Review of QA Program against criteria to be developed as part of this plan. The Review Team was to consult with INPO to define criteria for an adequate and effective Periodic Review of QA Program.
The Review Team then evaluated the current CPSES Periodic Review of QA Program against the criteria developed.
4.1.2 ,The specific methodology is described below.
4.1.2.1 The Review Team obtained information from INPO governing Periodic Review of QA Programs for both construction and operations phases.
4.1.2.2 The Review Team reviewed the current TUGC0 written program and practices implementing the Periodic Review of QA Program.
1 4.1.2.3 Utilizing the information gathered, a set of criteria was developed to define an effective Periodie Review of QA Program for CPSES which addresses, among others, the following:
- Scheduling and performance of J reviews at least annually, 1
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a Revision: 1 Page 4 of 11 RESULTS REPORT ISAP VII.a.$
(Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
- Reports directed to, and respcuses received from, a sufficiently high level of management to ensure effective corrective action,
- Ongoing contact by management with program status.
Identification of corrective action.
- Tracking and follow-up.
4.1.2.4 The current TUGC0 program was evaluated against the criteria developed to assure that an adequate Periodic Review of QA Program is in effect for any, remaining construction or modification activities for Unit 1, the remaining construction phase of Unit 2 and for the operations phase.
4.1.2.5 Copies of the Results Report for this ISAP will be provided to TUGC0 for their consideration in responding to the NRC Notice of Violation (445/8432-02; 446/8411-02).
4.2 Participants Roles and Responsibilities J.P-4.2.1 TUGC0 4.2.1.1 Scope TUGC0 assisted in identifying and locating applicable information and documentation to support the Review Team activities, and provided contact with INPO.
4.2.1.2 Personnel Mr. John Streeter. Director, Quality Assurance, provided coordination between the Review Team and TUGCO. -
r Revision: 1 Page 5 of 11 RESULTS REPORT ISAP VII.a.5 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.2.2 ERC 4.2.2.1 Scope -
ERC communicated with outside organizations and TUGC0 Manegement, reviewed data, developed criteria and evaluated the current program.
4.2.2.2 Personnel Mr. J. Hansel Review Team Leader Mr. J. Gelzer Issue Coordinator Quality Engineers as required.
4.3 Qualifications of Personnel Participants were qualified to the specific requirements of the CPRT Program Plan.
4.4 Standards / Acceptance Criteria Periodic Review of QA activities shall be in compliance with 10CTR50 Appendix B, Criterion II and ANSI N45.2-1971, Section 2. Specifically, such activities are acceptable if a description is provided of how management (above or outside the QA organization) regularly assesses the scope, statur,,
adequacy, and compliance of the QA Program tc 10CFR50, Appendix B. These measures should include:
4.4.1 Frequent contact with program status through reports, meetings, and/or audits.
4.4.2 Performance of an annual review preplanned and documented. Corrective action is identified and tracked.
4.5 Decision Criteria a 1
I This item will be considered complete when the following have been accomplished:
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Page 6 of 11 RESULTS REPORT ISAP VII.a.5 (Cont'd) ;
4.0 CPRT ACTION PLAN (Cont'd) 4.5.1 A set of criteria for an effective Periodic Review of QA Program has been developed.
4.5.2 The TUCCD Program has been evaluated against the criteria.
4.5.3 The results of the evaluation have been transmitted to TUGC0 for consideration in their program.
5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS The following sections address the development of criteria for a Periodic Review of QA Program and the evaluation of the current TUCCO program.
l l 5.1 Developeene of Criteria The TUGC0 licensing commitment for the Periodic Review of the QA Program is contained in 10CTR50, Appendix B, Criterion II, which states in part, " . . . The applicant shall regularly review the status and adequacy of the quality assurance program. . . ." In addition, ANSI N45.2-1971, to which TUGC0 is committed, states in Section 2. ". . . The program shall provide for the ragular review, by management of organizations participating in the program, of the status and adequacy of that part of the quality assurance program for which they have designated responsibility."
In addition to these regulatory commitments made by TUCCO, the NRC Standard Review Plan, NUREG-0800, contains acceptance criteria for the review of QA programs. In Section 17.1, the criteria pertaining to Periodic Review of QA Program is as follows:
" Activities related to quality assurance program (17.1.2) are acceptable ift . ..
2.C.1 A description is provided of how management (above or outside the QA organization) ,
regularly assesses the scope, status 6 adequacy, and coupliance of the QA program to I 10CFR Part 50, Appendix B. These measures should include:
. Revision: 1 Page 7 of 11
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RESULTS REPORT I
ISAP VII.a.5 l (Cont'd) ]
i 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) ]
- a. Frequent contact with program status 1 through reports, meetings, and/or i audits. -
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- b. Performance of an annual assessment i preplanned and documented.
Corrective action is identified and tracked."
INPO was considered as an additional source for input to the development of criteria. INPO identified three criteria documents to the RTL which they felt might be applicable, and copies were obtained from TUGCO.
After review and consideration of the information available, and because the applicable INPO information was similar, it was decided that the criteria to be developed in this ISAP j
should closely reflect and expand upon the criteria contained in the Standard Review Plan. As a result, the following set of criteria for periodic review of QA program has been developed:
5.1.1 The program shall require the regular assessment of the scope, status, adequacy, and compliance of the QA program to 10CTR50, Appendix B.
5.1.2 The program shall define the management positions responsible for the Periodic Review of QA Program.
These positions shall be above or outside the QA organization and the line managers directly responsible for activities affecting quality.
5.1.3 The program shall describe the methodology for performing the QA program assessments and their frequency. As a minimum, the methods described shall include the following:
- Frequent contact, by personnel responsible for the reviews, with program status through reports, meetings, and/or audits. ,
- Performance of preplanned and documented assessments to be performed at least annually.
Revision: 1 Page 8 of 11 )
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RESULTS REPORT ISAP VII.a.5 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.1.4 The program shall describe the methodology for reporting, tracking and follow-up of the results of the Periodic Review of QA Program. -
5.2 Review of Current Program The written program for periodic review of the QA progras is contained in the TUGC0 Nuclear Engineering and Operations (NED) Policies and Procedures Manual and consists.of the 1 following documents that collectively define and implement the program:
- A memorandum dated August 30, 1985, from the President i
of TUGC0 that transmitted policy statements that identified TUGC0 corporate goals and objectives to the Executive Vice President, NEO with a request to initiate NEO policies and procedures to ensure implementation of the policy statements. Policy Statement Number 5 states in part, "Overall effectiveness of the quality assurance program shall be regularly reported to Corporate Management..."
- NEO Policy Statement Number 2. " Quality Assurance Program," Revision 0, dated June 23, 1986.
- . Procedure NEO 2.20. " Senior Management QA Overview Program," Revision 1, dated June 23, 1986.
j
- Procedure NEO 2.08, " Joint Utility Management Audit j Program." Revision 0, dated June 23, 1986.
l A review of these documents was performed utilizing the l ,
criteria in Sections 5.1.1 through 5.1.4 above. Based on this review, a review of the minutes of previous Senior Management QA Overview Committee (Committee) meetings and observation of l two Committee meetings, the following has been determined:
5.2.1 The program provides for a regular assessment of the status and adequacy of the QA Program.
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l Revision: 1 Page 9 of 11 RESULTS REPORT ;
i ISAP VII a.5 '
(Cont'd) 1 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) '
1 5.2.2 The program defines the management positions responsible for the periodic review of QA Program as the Executive Vice President, NEO and the Vice Presidents reporting to him. These positions are above and outside the QA organization and the line managers directly responsible for activities affecting quality.
5.2.3 The program describes the methodology for performing the program assessments and their frequency.
- Frequent contact with program status is accomplished by personnel responsible for the reviews through reports and meetings.
- Provision has been made for preplanned and scheduled annual assessments to be performed by senior management and also for an outside, independent audit of the TUGC0 QA Audit Program.
5.2.4 The program describes the methodology for reporting, tracking and follow-up of the results of the periodic review of QA Program.
5.2.5 Revision 1 of Procedure NEO 2.20 states that the
. committee shall meet at least quarterly. Since the inception of the committee in September 1985, through July 1986, there have been five committee meetings.
This is in excess of the minimum number established.
5.2.6 The Committee meetings have focused on identified problems in the QA program such as the control of non-conformances; consolidated reporting of open item ;
status; trend analysis system; development of, and the !
setting of priorities for, the NEO Policies and Procedures; interface requirements; and transition to j operating status.
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5.2.7 The minutes of the first three committee asetings, prepared prior to procedure revision, lack details for some items addressed, responsibilities assigned and J actions taken. This was due, et least in part, to the f act that the Executive 71ce President, NEO, and all i committee members were present at, and participated in-. j the meetings and were therefore cognizant of the j actions which transpired.
Revision: 1 Page 10 of 11
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RESULTS REPORT ISAP VII.a.5 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Revision 1 of Procedure NEO 2.20 contains specific requirements for the content of committee meeting minutts, including a method to track all items requiring committee action. The minutes of subsequent meetings (May 8,1986 and July 8,1986) are much improved in this respect and provide additional detail and a more descriptive record of the committee activities.
5.3 Evcluation of Findings Based on the evaluation described in Section 5.2 above, it is concluded that the TUCCO written program for the Periodic Review of QA Program is acceptable. The RIL has no further recommendations.
6.0 CONCLUSION
S With the issue of the TUGC0 Corporate Nuclear Policy in August 1985, and the subsequent development of the NEO Policies and Procedures Manual fable of Contents, and the subsequent development of individual policies and procedures, TUGC0 management has taken positive steps to define an effective system to provide the necessary controls and guidance to ensure the adequate and effective implementation and review of the QA program.
It is further concluded that, based on discussions with the Executive Vice President, NEO, his vice presidents and review of Committee activities, current management at this level understands the importance of an effective QA program and also the need for regular review of the program to measure its adequacy and effectiveness. ,
Recent activities at this level have consisted of assembling the upper management team, identifying and implementing the data gathering and reporting methodology to enhance management review capabilities, and identifying priorities for development of the individual NEO Policies and Procedures.
Finally, it is concluded that continued implementation of the l Periodic Review of the QA Program as recently demonstrated, and in j accordance with the program as presently defined, will result in an ]
adequate and effective Periodie Review of the QA Program. j i
Revision: 1 Page 11 of-11 RESULTS REPORT ISAP VII.a.5 (Cont'd) 7.0 ONGOING ACTIVITIES The program for the periodic review of the QA Program will be applicable to any remaining construction or modification activities for Unit 1, the remaining construction phase on Unit 2 and for the operating phase of the plant.
8.0 ACTION TO PRECLUDE OCCURRENCE IN THE FUTURE TUGC0 Management implementation of the program as outlined in the NEO Policies and Procedures Manual vill ensure a continuing acceptable program for the Periodic Review of the QA Program.
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I COMANCHE PEAK RESPONSE TEAM ACTION PLAN ISAP VII.a.6
Title:
Exit Interviews Revision No. l 0 1 Reflects Comments Description Original Issue On Plan Prepared and (L t.M Recommended by:
Review Team Leader Date N El W ' A 9 'Il Approved by: f.
Senior Review Teatr. R d, /M hC _j. >--
Date (,/s//rf / /2./ /n.
Revision: 1
, Page 1 of 6 ISAP VII.a.6 Exit Interviews
1.0 DESCRIPTION
OF ISSUE IDENTIFIED BY NRC l "The TUEC exit interview system for departing employees appeared to i be neither well structured vor effective, as evidenced by the lack of employee confidence, limited implementation, failure to document explanations and rationale, a d failure to complete corrective actions and to determine root causes." (NRC letter, January 8, 1985) l l I
k'ith the issue of NRC (NUREG-0797, Supplement No. 11) the TRT elaborated upon their findings as part of their investigation of l Allegation No. AQ-133, which alleged the " Personnel Exit Interview Program is inadequate and ....not effective." Upon completion of its investigation the TRT substantiated the concern regarding the program's adequacy and effectiveness, additionally stating that its implementation by exit interview and follow up did not appear to meet the objective of the program.
2.0 ACTION IDENTIFIED BY NRC Evaluate the TRT findings and consider the implications of these findings on construction quality. "... examination of the potential safety implications should include, but not be limited to the areas or activities selected by the TRT."
" Address the root cause of each finding and its generic implications..."
" Address the collective significance of these deficiencies..."
" Propose an action plan...that will ensure that such problems do not occur in the future."
3.0 BACKGROUND
I In response to the NRC Enforcement Action, EA 83-64, TUGC0 l procedurally defined programs which required all personnel departing from QA/QC to complete a questionnaire and all Brown &
Root construction employees terminating employ =ent to be int e rviewed. One of :he purposes of the questionnaires and interviews was to identify " quality concerns". TUEC in turn vas committed to evaluate and disposition these concerns.
- In April of 1984 TUEC initiated a " Quality Awareness Program" which ,
included a " Hotline" for employees to call in quality concerns. I I
Revision: 1 Page 2 of 6 ISAP VII.a.6 (Cont'd) ]
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3.0 BACKGROUND
(Cont'd)
An.0mbudsman from an outside organization (Gilbert / Commonwealth) was assigned to the site in November 1983, and personnel released :
from QA/QC since October 3, 1983 who had not filled out a questionnaire were located. if possible, and given the opportunity to fill out the questionnaire.
On January 14, 1985, TUEC established an independent group called .
SAFETEAM utilizing personnel from Utility Technical Services, Inc. l This group has assumed the responsibility for interviewing personnel and investigating concerns.
l 4.0 CPRT ACTION PLAN 4.1 Scope and Methodology 4.1.1 The purpose of this action plan is to determine if TUGC0 management has now established an effective program which encourages employees to voice concerns regarding safety and seriously evaluates these concerns. This determination will be made by evaluation of the adequacy of the policies, procedures and activities of the CPSES Ombudsman and the CPSES SAFETEAM in identifying and resolving site personnel concerns which have potential safety implications. The scope includes the evaluation of the Ombudsman's activities associated with employee concerns brought before him, including those uncompleted actions transferred by him to TUGCO. However, due to the time frame within which this plan will be conducted related to the time of transfer of responsibilities from Ombudsman, the majority of review and evaluation will center upon the activities and program of the SAFETEAM as implemented through December 1985.
The following general activities will be implemented during the process of evaluating the Ombudsman and SAFETEAM activities:
4.1.1.1 Develop evalus. tion attributes from TUGC0 commitments and industry guidelines.
1 4.1.1.2 Evaluate procedural compliance to commitments !
made.
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Page 3 of 6 l
ISAP VII.a.6 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.1.1.3 Evaluate procedural implementation. ,
I 4.1.1.4 Determine adequacy of existing program.
4.1.2 Implementation Methodology 4.1.2.1 A set of attributes shall be developed to be i
employed during the teview of procedures'as well as procedure implementation. Attributes development will consider:
Commitments made by TUGC0 in response to NRC enforcement action EA-83-64.
Appropriate requirements of 10CFR50, Appendix B, Criterion I.
Applicable industry criteria as available, i
During attribute development stage the following areas are to be considered:
Identification, investigation and evaluation of concerns.
Resolution of concern with employee.
Notification given to TUGC0 management of those concerns of potential safety implications. i Employee anonymity and protection from harassment and/or intimidation. '
Ombudsman /SAFETEAM/TUGC0 coordination.
Interviewer / Investigator independence.
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i ISAP VII.a.6 (Cont'd)
L 4.0 CPRT ACTION PLAN (Cont'd) 4.1.2.2 Develop chncklist(s) with attributes from the above. Attributes may be separated into two sections as regards mandatory and non-mandatory based upon the source of the i criteria being either TUGC0 commitment or industry example. These checklists will be used during both the policy / procedure review and the implementation review.
4.1.2.3 Review established policies / procedures in place governing the activities of the Ombudsman /SAFETEAM interviews tc the checklist attributes.
4.1.2.4 Using checklist (s) developed, evaluate the implementation of the policies / procedures being utilized by the Ombudsman and SAFETEAM to determine compliance with same and the effectiveness of their implementation.
Implementation will, in the case of SAFETEAM, be limited to examination of records which, in the judgment of SAFETEAM, will not compromise the independence and effectiveness of their operation, but more importantly will not cause adverse effect upon the protection of the anonymity of past or future employee participants of the program. The Issue Coordinator will abide by the SAFETEAM's advisenent in these instances.
4.1.2.5 Reviews and evaluations shall be conducted of and limited to past items of concern brought before the Ombudsman or identified through erpioyee interviews with the SAFETEAM.
Evaluations will then be made as to the ,
effectiveness of the Ombudsman /SAFETEAM's handling of the concerns including the evaluation for potential safety implications.
^
Any specific technical issues or concerns found during this review shall be coordinated with QA/QC RTL and other cognizant RTLs to determine additional evaluation as required. ,
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. Revision: 1 Page 5 of 6 ISAP VII.a.6 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.1.2.6 The results of reviews and evaluations j conducted in paragraphs 4.1.2.3, 4.1.2.4 and 4.1.2.5 will provide a basis for determining whether the Ombudsmans interview program and implementation was adequate and effective in identified employee concerns, as well as determining whether the existing SAFETEAM program as implemented is effective in identifying and evaluating e.mployee concerns regarding potential safety implications. The results of this action plan will provide input for the overall evaluation of the adequacy of the QA program being conducted by the QA/QC Review Team as well as providing recommendations for improvement for future program implementation as required.
]
4.2 Participants Roles and Responsibilities l I
4.2.1 Evaluation Research Corporation l 1
This action plan will be developed and implemented by Evaluation Research Corporation (ERC).
4.2.1.1 Scope The entire scope of this action plan will be implemented by ERC. j 1
4.2.1.2 Persennel Mr. J. L. Hansel QA/QC Review Team Leader Mr. P. E. Ortstadt Issue Coordinator 4.3 Qualifications of Personnel
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Personnel participating in the implementatice of this action plan shall be qualified in accordance with the requirements of the TUGCOs " Program Plan and Issue-Specific Action Plans".
4.4 Procedures Development and implementation of this action plan shall be in accordance with TUCCOs Program Plan and Issue-Specific Action Plans. Checklists will be developed by the Issue Coordinator for use in cenducting reviews of policies and procedures and
Revision: 1 Page 6 of 6 ISAP VII.a.6 (Cont'd) I i
4.0 CPRT ACTION PLAN (Cont'd) program implementation. Procedures to implement this action.
plan will be developed only as required by Issue Coordinator /
Review Team Leader decision. ,
4.5 Standards / Acceptance Criteria There are no published industry standards addressing exit _
interviews nor criteria for acceptable programs. For this action plan, acceptance criteria will be developed from TUGC0 commitments made in response to the NRC Enforcement Actions and available industry " Guidelines". The criteria to be developed at the beginning of this plan will consider the-following areas:
-1 4.5.1 Concern identification 4.5.2 Concern investigation 4.5.3 Concern identification as to potential safety implications 4.5.4 Concern notification to responsible TUGC0 management 4.5.5 Concern resolution '
4.5.6 Feedback to employee 4.5.7 Employee anonymity 4.5.8 Interviewer independence 4.6 Decision Criteria l
This plan will be closed when:
4.6.1 Evaluation of the current program against the developed f criteria has been completed and recommendations for J l program improvement concerning any areas of weaknesses l which may be identified have been transmitted to TUCCO. !
4.6.2 Any specific technical issues or cencerns identified are assigned to cognizant RTL(s) for resolution.
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l COMANCHE PEAK RESPONSE TEAM ~
RESULTS REPORT i
ISAP: VII.a.6
Title:
Exit Interviews REVISION 1 l
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IssYe Coordinator Date /
i o h, /rt, 4'Al /0 ZY h Rev Team Leader Date I /
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t.J . /o/2 9 /fL JohnWpeck,ChairmanCPRT-SRT Date l
'~ Revision: 1
, Pago 1 of 12 RESULTS REPORT ISAP VII.a.6 Exit Interviews
1.0 DESCRIPTION
OF ISSUE IDENTIFIED BY THE NRC (US NRC-TRT Letter January 8, 1985) l "The TUEC exit interview system for departing employees appeared to be neither well structured nor effective, as evidenced by the lack of employee confidence, limited implementation, failure to document explanations and rationale, and failure to complete corrective actions and to determine root causes."
With the issue of NUREG-0797, Supplement No. 11 the TRT elaborated upon its findings as part of their investigation of Allegation AQ-133, which alleged the " Personnel Exit Interview Program is inadequate and ....not effective." Upon completion of its investigation, the TRT concluded "the concern regarding the adequacy and effectiveness of the exit interview program was substantiated. Although still in its infancy, the exit interviev questionnaire and followup which were reviewed by TRT, do not appear :o meet the program objective."
2.0 ACTION IDENTIFIED BY STC 1
Evaluate the TRT findings and consider the implications of these 1 j
findings on construction quality. "... examination of the potential safety i=p11 cations should include, but not be ILnited to the areas or activities selected by the TRT." )
" Address the root cause of each finding and its generic implications . . . " '
" Address the collective significance of these deficiencies..."
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" Propose an action plan...that will ensure that such problems do not occur in the future."
3.0 BACKGROUND
i In response to the NRC Notice of Violation EA 83-64, dated i August 29, 1983. TUCCO initiated several actions to reaffirm its com=itment to an effective, independent QA/QC program. The eight actions included a program "to ensure that all OA/QC e=ployees be given the opportunity to state concerns regarding quality prior to s
_ _ _ _ _ _ _ _ _ . _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ . _ _ _ _ - - - . - - -- - - - - ~ - - - - -
- Rsvision: 1-Paga 2 of 42
- RESULTS REPORT s.
' ISAP VII.a.6
{ (Cont'd) r
3.0 BACKGROUND
(Cont'd) j dissociation with the QA/QC department" (TUGC0 letter to NRC dated 1
September 28, 1983). An exit interview program was formally initiated in November 1983, whose purpose was identification, evaluation and disposition of employee concerns. This program was for QA/QC employees leaving the QA/QC department.
No formal industry criteria or NRC requirements were available when the exit intervfew program was established. The TUGC0 program was formulated with a limited scope. This initial program was carried i out through 1984 and eventaally replaced by SATETEAM in 1985.
In November 1983, TUGC0 contracted the professional services of an Ombudsman to streng,then efforts to solicit and respond to employee concerns. The Ombudsman was present through May 1985. His principal functien was to assist utility management with the implementation of the exit interview program.
l Brown & Root (B&R) also had an exit interview process to cover l terminating B&R personnel, with interviews conducted by the B&R personnel offit.e or by the B&R assistant project manager.
QA/QC-related concerns or comments identified by B&R personnel were sent to TUGC0 QA for review and resolution.
In the summer of 1984, the NRC TRT examined TUGCO's personnel exit
'. interview program and concluded that it was neither adequate nor effective and that "although in its infancy, the exit interviev questionnaire and follow-up.... do not appear to meet the program objective". (NUREG-0797, Supplement No. 11, May 1985) l In an effort to impreve communication on potential quality concerns
' between employee and management, TUGC0 contracted the services of SAFETEAM from Utility Technical Services (now SYNDECO Inc.), in December 1984. Established on site January 14, 1985, SATETEAM's-purpose is to provide a program that will identify and investigate concerns of all CPSES employees. This action provided an interview program that covers all employees.
Attaciment A provides a chronology of events associated with the C?SES exit interview programs.
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M 3 MSUt.T{ REPORT ,-
ISAP VII.a.6 M c, , (Cont'd) g l M }. %
4.0 CPRT ACTIO3 PLAN .
4.1 Scope and Methodetogy \ l The purecse of this Action Plan was to determine if RTGC0 i
management has estattished an offectiset . employes exit 9 intetview progrib. which encouraQs unployees to voice concerns 4
' 1l g regarding qualify" sad properly eval d tes those having g _ % potential. quality implications. E'.s termination was made L by evaluatint the adequacy of the policies, procedures and j ,' ,.E
, activities e( Qbe CPSES Exit Interview Program /0mbudsman and
, .s the CPSES SAFETEAM in identifying and resolving site personnel concerns which have potential quality implications. The scope ,
included the evaluation of the Ombudsman's activitiesp asssciated with employee concerns brought before him. The
" Ombddsman's activities were evaluated for the duration of his assignment on site. De pcriod 'of SAFETEAM evaluation was
+ ,,
selectet as the year 1985. These time periods, as defined.
[ ! provided sufficient data for evaluation.
, , ..u The follfping general activities were Orplemented during the process.uf evaluating the 5xit Interview Program /0mbudsman and
' SAFE *.74h' programs:
>, a
- Developed evaluatio-n attributes from TUGC0 commitments and industry prac.tices.
Evaluated compliance of the writ.cen program to 1 commitments made.
Evaluated program implementation.
4 Determined adequacy of' existing program.
4.1.1 Attribute Development A set of attributes was developed and employed during the review of procedures as well as procedure implementation. Attribute development considered the criteria of Section 4.5, which were drawn from the i following sources: l Commitments made by TUCCO in response to NRC enforcement action EA-63-64 and appropriate requirements of 10CFPJO, Appendix B, Criterien 1.
Applicable industry practices as available.
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RESULTS REPORT l
I ISAP VII.a.6 1 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.1,2 Checklist Development Checklists vt.re developed based on the above attributes. These checklists were used during both the policy / procedure review and the implementation review.
4.1.3 Poliev/ Procedure Review Policies / procedures governing the activities of the Ombudsman /SAFETEAM interviews were reviewed to the checklist attributes.
4.1.4 Exit Interview Program /0=budsman and SAFETEAM Evaluation The implementation of the Exit Interview Program / Ombudsman and SAFETEAM policies / procedures was evaluated to determine compliance with the attributes and the effectiveness of their implementation.
Access to the Exit Interview Program /0mbudsman records was unrestricted to the QA/QC Review Team. In the case of the SAFETEAM record review, all records were made available with the exception of the report com=ents from the legal member of the Steering Cc=mittee. These were classified as " Attorney-Client Confidential". The QA/QC Review Team is satisfied that this action did not inhibit satisfactory evaluation of the program.
4.1.5 Review of Previously Identified Itecs of Concern Reviews and evaluations were conducted of past items of concern identified during the time period of the Ombudsman or identified through employee interviews with the S AFETEAM.
Evaluations were made of the effectiveness of the 0=budsman/SAFETEAM's handling of the concerns, including the evaluation for potential quality implications .
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1 Pess 5 of 42 RESULTS REPORT l
ISAP VII.a.6 i (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 1 I
Any specific technical issues or concerns found during this review were discussed with the QA/QC RTL, TUGC0 or other cognizant RTLs as required to determine if 1 additional evaluation was required. I 4.1.6 Concluding Activities The results of reviews and evaluations described in Sections 4.1.3, 4.1.4 and 4.1.5 provided a basis f or determining the following:
k'hether the Exit Interview Program and use of the Ombudsman was adequately implemented and ef f ective in identifying employee concerns.
k'hether the existing SAFETEAM program as implemented is presently effective in identifying and evaluating employee concerns regarding potential quality implications.
This Action Plan also provided recommended actions for improvement for the current program.
4.2 Participants Roles and Responsibilities 4.2.1 QA/QC Review Team 4.2.1.1 Scope All activities in this Action Plan were carried cut by the QA/QC Review Team.
4.2.1.2 Personnel:
Mr. J. L. Hansel QA/QC Review Team i Leader Mr. P. E. Ortstadt Issue Coordinator I
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, Page 6 of I' RESULTS REPORT
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ISAP VII.a.6 (Cont'd) i 4.0 CPRT ACTION PLAN (Cont'd) j 4.3 Qualifications of Personnel l 1
Personnel participating in the implementation of this Action 71an were qualified in accordance with the requirements of the CPRT Program Plan. i l'
4.4 Procedures e
Checklists were developed by the Issue Coordinator for use in conducting reviews of policies and procedures and program implementation. No procedures were developed during the implementation of this Action Plan.
4.5 Standards / Acceptance Criteria There are no published industry standards addressing exit interviews nor criteria for acceptable programs. For this Action Plan, acceptance criteria were developed from TUGC0 commitmen?.s made in response to the NRC Enforcement Action, applicable TUGC0 licensing commitments and available industry practices.
The acceptance criteria developed for ths; plan addressed the following areas:
Program Definition / Independence: Ehereisa comprehensive description of purpcse, policy, implementing requirements, and personnel authority, duties and independence.
Concern Identification: There are means to make known, log and track to closure each concern.
Concern Investigation: Concerns investigated by knowledgeable personnel and investigations are complete and fully documented.
Identify Potential Quality Implications: There is recognition, classification, and assigned priority.
Upper Management Involvement: There is awareness of concern patterns and program effectiveness, and potential need for corrective measures and root cause identification. 1 D
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RESULTS REPORT 1
ISAP VII.a.6 (Cont'd)
.4.0 CPRT ACTION PLAN (Cont'd)
Concern Resolution: Resolution addresses all aspects of the concern, and provides supporting rationale, corrective action and complete documentation.
Employee Feedback: There is timely and complete feedback that notes actions taken and further options available. ,
Employee Protection From Reprisal: Confidentiality and employee anonymity are provided.
5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS The primary objective of this Action Plan was the evaluation of the effectiveness of the current employee interview program, SATETEAM.
This program is available to all personnel on site. The portion of the earlier exit interview program involving the Ombudsman's activities was also evaluated to determine the effectiveness of-identification, investigation and closure of concerns. The Ombudsman's scope included interviews of departing QA/QC personnel and~1 investigation of concerns raised by-QA/QC and craft personnel.
This section is organized as follows: Program Requirements Identification (Section 5.1), Exit Interview Program /0mbudsman (Section 5.2) and SAFETEAM Program (Section 5.3).
There is no TSAR requirement for an exit interview program at CPSES, nor do published industry standards exist for such programs.
Therefore, the criteria for evaluation of the CPSES personnel exit interview programs were developed from commitments to NRC and elements of existing industry programs considered instrumental to program success. From these commitments and elements of existing programs a set of attributes was established which formed the basis for developing program content and implementation checklists.
5.1 Program Requirements Identification TUGC0 made commitments to the NRC in response to NRC licensing actions regarding CPSES QA program effectiveness. These were examined for requirements that could be applied to the evaluation of the exit interview programs. In addition, two industry programs were also examined to identify practices that appeared to play an important role in the success of these programs.
Revision: 1 Pago 8 of 42 RESL*LTS REPORT . i i
15AP VII.a.6 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Commitments to NRC
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1 In responding to the NRC Notice of Violation (NRC-NOV l EA-83-64), TUGC0 committed to eight actions. These actions, in part, appeared to: 1) emphasize the commitment to quality at CPSES; 2) identify management's desire for employees to
, express concerns regarding quality without fear of reprisal;
- 3) provide all QA/QC employees the opportunity to state concerns regarding quality prior to disassociation with the QA/QC department, and further to provide for such concerns to be evaluated and dispositioned by TUGC0 and 4) counsel selected QA/QC personnel on employee relations and on considerations of both labor law and atomic energy law.
The NOV cited TUGC0 against criterion 1 of 10CFR50 Appendix B
- Organizational Freedom for QA/QC Personnel. The exit interview program was established in response to this citation and was intended to enhance organizational freedom by providing a separate avenue for personnel to express quality concerns. This commitment is the basis for including the current employee interview program as part of the QA/QC Review Team evaluation.
Industrv Practices Two examples of existing exit interview programs in use by industry were obtained. One of these was a patented program employed by several utilities over a number of years. Program manuals / procedures for these progrrms were examined for identification of program practices, which in the QA/QC Review Team's judgment, could be instrumental to the success of the program.
Attributem/Chechlists The examinations described above identified one commitment to the NRC associated with the exit interview program, that is, item seven of the eight actions proposed by TUGC0 in response to the NRC NOV EA 83-64, which reads as follows:
" Seventh Licensees will initiate a program to ensure that all QA/QC employees are given the opportunity to state concerns regarding quality prior to disassociation with the QA/QC department. Stated concerns will be evaluated and dispositioned by Licensees."
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RESULTS REPORT ISAP VII.a.6 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Since this commitment was made in response to the NOV citing TUGC0 against Criterion 1 - Organizational Freedom for QA/QC Personnel, this aspect of Criterion 1 was taken as a second )
TUGC0 commitment for the employee interview program for purposes of the QA/QC Review Team evaluation. These two items, the seventh item of TUCCO's response and organizational freedom for QA/QC personnel, were considered to be mandatory attributes during checklist development.
Ten industry practices were identified as elements of an effective exit interview program. Since there was no TUGC0 commitment to these elements, they were considered as non-mandatory attributes. The tetribute list is shown in Attachment B.
Checklists for evaluation of the Policies / Procedures of the Exit Interview Program /0mbudsman and SAFETEAM programs and their implementation were developed from the attributes.
Checklists for program implementation also included requirements identified during program evaluation.
5.2 Exit Interview Program / Ombudsman The purpose of this phase of the Action Plan implementation was to determine the validity of allegation AQ-133 and its subsequent substantiation by the NRC TRT. An additional element of this evaluation was to determine the potential for the presence of hardware deficiencies resulting from the alleged ineffectiveness of the program.
The Ombudrman was employed from November 1983 to mid-May 1985 and was contracted to provide outside expertise for the investigation of employee concerns. He was hired to strengthen the utility's efforts to solicit and respond to employee quality-related concerns, especially those personnel leaving the QA/QC organization. The Ombudsman had extensive management and technical experience with nuclear reactor plant inspection programs and appeared to be properly qualified to perform evaluations and investigations of expressed concerns.
Fevf.sien : 1 Pega 10 of 42 RESULTS REPORT ISAP VII.a.6 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.2.1 Program Definition This. portion of the QA/QC Review Team evaluation covered the adequacy of the documented TUCCO program.
The program was initially defined by a series of TUGC0 memoranda issued by corporate and site QA management I over a period of eight months. These memoranda defined elements of the exit interview program and the process for investigating employee concerns and assigned responsibilities to personnel implementing the program.
Initial interviews began October 6, 1983. However, the 1
requirement to use the questionnaire form did not exist until November 16, 1983. The program procedures were .
first issued on October 29, 1984, in DQP-QA-6, !
Revision 0, entitled " Quality Assurance Investigations".
The initial exit interview program using the Ombudsman was not set up to meet predefined criteria similar to those developed for this action plan. Nevertheless, ]
the QA/QC Review Team performed its evaluation against i the Action Plan acceptance criteria in order to judge '
overall effectiveness.
The program as defined did meet its primary objective ;
of providing an opportunity for QA/QC employees to express concerns regarding quality prior to dissociation with the QA/QC department. However, the program was not sufficiently well-defined to achieve ;
fully its potential effectiveness. Review of the I program definition against the criteria revealed the following program weaknesses: 1 Threshold criteria for initiating investigations were not established but were ,
rather lef t to the individual QA superviser's !
discretion. 4 The program did not provide for employee anonymity.
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1 Revision: 1 Pags 11 of 42 RESULTS REPORT ISAP VII.a.6 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS _ (Cont'd)
Successive memoranda raised conflicting instructions as to the Ombudsman's scope of responsibilities and the distribution of investigation documentation.
Formal introduction, by memorandum, of the Quality Assurance Investigation (QAI) form occurred over a month af ter its required use.
The program procedures were issued more than a year after initial implementation. While the memoranda directives were consolidated in the procedures, the weaknesses cited above were still not addressed.
5.2.2 Ombudsman organizational Position and Availability The Ombudsman's relationship to the utility, his availability for contact by employee and the ease with which employees could make concerns ~known to him were evaluated.
The Ombudsman was 1) to report directly to the Supervisor, Construction Quality Assurance, 2) have direct access to all levels of Texas Utilities management and 3) was to function as an independent representative of TUGC0 management. He was to be located in the construction administration building and generally be available Monday afternoon through Friday morning for employee contact, by phone or in person.
Investigation revealed that during his tenure, the Ombudsman reported to the Senior TUGC0 Site QA/QC official and functioned as a member of the site QA organization. His office was established in the administration area in close proximity to his supervisor. Memoranda gave notification of the Ombudsman's presence onsite, his location and phone' number and encouraged all CPSES QA/QC employees to !
identify concerns to TUGC0 supervisors, management or the Ombudsman without fear of retribution.
Rsvision: 1 ,
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{
t 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
The Ombudsman's affiliation with the site QA/QC organization was emphasized by the location of his office. Although it was not TUGCO's intent for him to be independent of the QA/QC organization, in at least one instance, his initial office location caused an employee to be concerned about anonymity. This resulted in relocation of the Ombudsman away from the administration area. This apparent lack of independence could have created a potential for limiting the level of employee confidence in the p rogram.
The initial memoranda notifying employees of the Ombudsman's presence onsite appeared satisfactory and adequately identified the means to contact him in person or by phone. This provided an alternate route, other than their supervisor, for an employee to report a quality concern. However, after March 1984 there is no evidence that there was a formal on-going effort to make new hires aware of, and to remind existing employees of, the Ombudsman's availability.
5.2.3 Concern Identification and Investigation The exit interview program consisted of two main functions to be performed by QA supervision and the Ombudsman: 1) provide the employee with the means to voice concerns (the QA/QC Questionnaire Interview) and
- 2) investigate and resolve those concerns where f warranted (Quality Assurance Investigation, QAI) . The I details of these functions as required by the program are provided below:
QA/QC Questionnaire Interview I
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This activity was evaluated to determine if all l departing QA/QC employees were given the opportunity to complete the QA/QC Questionnaire.
Use of the QA/QC questionnaire was defined on November 16 and 17, 1983. QA supervisors both in Dallas (memorandum QTQ-503) and at the site (memoranda l QTQ-504 and 508) were to assure that personnel under their supervision were afforded the opportunity to complete the questionnaire prior to departing the QA/QC 4 organization. The QA manager was to receive copies of all questionnaires which identified employee concerns (memorandum QTQ-504).
Revision: 1 Page-13 of 42 RESULTS REPORT ISAP VII.a.6 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
In April 1984 QA supervisors were reminded to insure that employees received questionnaire interviews by the Ombudsman or, in his absence, the employee's supervisor (memorandum TUQ-2012). This allowed exit interviews and concern investigations to proceed when the Ombudsman was not on site.
In May 1984 QC management determined that forty-two (42) QA/QC employees who. departed after October 3, 1983, were not given an exit interview. These individuals were to be located and given the opportunity.to complete the questionnaire. This responsibility was first assigned to corporate security (memorandum TUQ-2012) and then to the Ombudsman (memorandum TUQ-2108).
The requirement to contact forty-two (42) departed employees and afford them the opportunity to complete questionnaires was found to be completed. Memorandum CQA-015, dated June 29, 1984, verified that contact had been made for all but eight (8) persons. Corporate Security was assigned the responsibility to contact the remaining eight. During review of the questionnaire forms it was noted that all but two of the eight persons had returned completed forms. The remaining two persons included one employee who refused to respond and one case where TUGC0 legal department advised against further contact because of potential involvement in ASLB hearings.
The QA/QC Review Team obtained a list of employees who departed the QA/QC organization between October 3, 1983, and May 17, 1985. This time period corresponded to the time from program initiation to the end of the l Ombudsman's activity onsite. A total of two hundred ninety-one (291) persons were identified. A review of QA/QC Questionnaire files. at both corporate and CPSES QA offices revealed forms (and/or documented attempts to contact the employee) for two hundred and fifty-eight (258) employees. Comparison of names on the list to those on questionnaires showed that it was not possible to determine whether all departing QA/QC ,
personnel were afforded the opportunity to receive an I interview. This resulted from the lack of specificity i
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RESULTS REPORT -
ISAP VII.a.6 l (Cont'd) '
l 3.0 IMPLEMENTATION OF ACTION PLAN AND D*.SCUSSION OF RESULTS (Cont'd) because of the use of nicknames, married names, and initials, misspelling and duplication of interviews when employees were employed by more than one QA organization at CPSES. It also was evident that in some instances questionnaire forms were used for walk-in/ phone-in employee contacts. The QA/QC Review Team was able to determine that at least two hundred and twenty-eight (228) of the two hundred and ninety-one (291) individuals completed or were requested to complete an exit interview questionnaire.
Brown & Root (B&R) also used a termination exit interview form. Those B&R forms that identified '
quality concerns were forwarded to TUGC0 for evaluation. This activity included all B&R personnel and exceeded the TUGC0 commitment reflected in the response to the NOV.
It appeared that an extensive effort was made by TUGC0 and B&R to afford both departing QA/QC and craft personnel the opportunity to complete a questionnaire and voice their concerns. This effort was considered adequate.
The following additional observations were noted:
The Ombudsman was interviewer-of-record on only 12% of the total interviews conducted.
The fact that QA/QC supervisors conducted the i majority of the interviews could have created a potential to limit employee confidence in ;
the exit interview program, especially among '
QA/QC employees.
l Distribution, to Corporate QA management and l Security., of QA/QC questionnaires with noted concert as required by memorandum QTQ-504, was not always evident.
It appeared that employees did not receive results of preliminary investigations that did not result in the initiation of a QAI.
Rsvision: 1 Page 15 of 42 RESULTS REPORT ISAP VII.a.6 (Cont'd) 1 5.0 IMP 1.EMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Concern Investigation. Evaluation and Disposition Evaluation of this activity was to determine 1) if employee-identified concerns were evaluated and dispositioned properly and 2) if, concern evaluation and/or disposition improprieties were identified, did they represent a potential to affect the quality of the I installed hardware.
The concern investigation, evaluation and disposition program was defined by memoranda and one procedure.
The concern investigation function was first defined in writing by memorandum QTQ-548, issued in January 1984, which introduced the QAI form. This form was to be initiated in response to an employee concern when, -in the opinion of supervision, an in-depth investigation was warranted. The memorandum also required Quality.
Engineering (QE) to control the numbering of QAIs and to track each QAI through resolution. It required that the employee be notified of the results of the concern investigation and the options that were available to him if he was not satisfied with the results.
In April 1984, a memorandum (TUQ-2012) further required that completed QAIs be sent to the corporate QA manager. QAIs were to remain open until the communication of results to the employee had been accomplished.
In October 1984, a procedure, DQP-QA-6, Revision 0 was issued to document the methods to initiate, investigate, document and close QAIs. It required that the site QA manager evaluate craft Termination Exit Forms sent to him from craft supervision for potential initiation of QAIs. Monthly reporting of open QAls and submittal of the status of the investigations and copies of the completed QAI files to Dallas and CPSES QA managers and the Vice President, Nuclear Operations were also required. The procedure also specified that the Dallas QA manager provide QAI closure authorization with QE issuing the closeout letter which was sent to the Vice President, Nuclear Operations. QAIs, both those completed and in process, were to be kept in locked files.
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RESULTS REPORT I
ISAP VII.a.6 )
(Cont'd) '
5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
I The Ombudsman's investigative responsibilities were {
defined by memoranda QTQ-496, QTQ-540, TUQ-1887 and subsequently by DQP-QA-6, Revision O. These memoranda
)
progressively reduced his duties from investigating all concerns to assisting TUGC0 management in investigations. This was a change from the initial l policy of having the Ombudsman conduct all exit i interviews and provided for interview coverage at all times.
The QAI log revealed that during the Ombudsman's tenure, a total of fifty-three (53) QAIs were initiated and processed, thirty-five (35) being assigned to the Ombudsman for investigation. The remaining eighteen-(18) were assigned to either corporate security or other QA department personnel. All QAI files were reviewed by the QA/QC Review Team.
The review revealed the following areas that were in conformance with or exceeded program requirements:
Concern investigation was not limited to just ;
QA/QC personnel as originally intended, but '
rather included other CPSES employees as well.
QE properly logged all QAIs by ID number, noted key personnel involved in investigations, concern subject and open and closed dates.
Personnel who were involved in investigations in all cases appeared to be knowledgeable in the area associated with the concern. Although the program did not require concerns to be classified by subject, it appeared that the majority of quality-related concerns were investigated by the Ombudsman or the Dallas / Site QA l department personnel. j l
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There was no program policy for the maintenance of confidentiality. However, some documents' generated during investigations were marked confidential and/or had " controlled" distribution.
Corporate QE satisfactorily maintained the security requirements of the QAI files.
CPSES concern investigations appeared to receive at least two levels of review prior to closure: the site QA manager level review (with recommendation for closure) and the corporate QA manager level review (with i authorization for closure).
The observations below reflect less than adequate investigation program implementation.
In the majority of instances, evidence was not available to confirm that concern resolutions were communicated to the employee by the supervisor initiating the investigation as required. .For example, the file for QAI-004 documented a commitment te make employee contact, but not its accomplishment. It is recognized that the employees may have been no longer onsite. i' Any attempts to contact the employee should have been documented.
Concerns often triggered review of associated issues in order to determine whether or not an in-depth investigation by QAI was required. For the most part these reviews followed a logical path. However, in some cases, the documented logic to close a concern without benefit of further investigation was incomplete. This may have resulted from the lack of program definition of a threshold level for QAI initiation. For example:
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RESULTS REPORT
- l. ISAP VII.a.6 l
(Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
- 1) QAI-005 and QAI-008 were initiated by corporate QA for concerns which l could have been initiated sooner by site QA. QAI-005 had no hardware quality implications, however QAI-008 had a potential for hardware quality implications and is addressed further below.
l 2) Files supporting the investigation of one mail-in concern regarding the employee's certification indicated that four (4) CPSES persons were contacted for input. However, no input was received. The investigation was not completed, nor was a QAI initiated. This concern, however had no hardware quality implications.
- 3) In response to a testing violation concern, memorandum TUQ-1894 documented the reasons for not initiating a QAI. From the memorandum, it was not clear to the QA/QC Review Team that the alleged viciation had not occurred. TUGC0 was requested to provide further evidence that 'the hardware integrity had not been compromised. TUCCO's 1 response to this request was !
accepted by the QA/QC Review Team as adequate.
- 4) An employee concern regarding high vibrations and humidity effects upon equipment was not investigated by QAI and the justification for not investigating the concern was not i evident in the files. TUGC0 was requested, by the QA/QC Review Team, l
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Page 19 og e RESULTS REPORT ISAP VII.a.6 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS'(Cont'd) i to investigate the concern and report their. findings. The TUGC0 response received by the QA/QC Review Team was satisfactory.
Supporting material generated during the course of investigations and upon which.
resolutions were based was not always present or referenced in the files (QAI-016, 018, and 030).. These had no hardware quality implications.
Rationale to support responses to concerns which initiated QAls was not considered complete in some cases (QAIs 008, 019, 026, 048, and 001). Only QAI-001 represented a potential for hardware quality implications and is addressed further below.
Some investigations appeared not to address the concern (s) completely (QAIs 005, 008, 009, 017, 029, 039, 041 and 046). Only QAI-008 had a potential for. hardware quality implications and is addressed further below.
The QA/QC Review Team required more information to support the closure of QAI-001 and QAI-008. TUGC0 !
investigated these QAIs further and reported the results to the QA/QC Review Team. These TUGC0 actions, and those described above, resulted in satisf actory closure of all QA/QC Review Team concerns that represented potential quality implications upon installed hardware.
TUGC0 superseded DQP-QA-6, Revision 0 with DQP-CQ-2, Revision 0 (June 3, 1985) and Revision 1 (September 9, 1985). The former maintained the same program, adding the responsibilities of the Director QA and deleting those of the Ombudsman as well as giving QA supervisors an option to use the SAFETEAM rather than the existing exit interview program. The latter revision made minor changes and is still considered to be an active procedure. It appears, however, that the SAFETEAM has conducted all exit interviews subsequent to its initiation; consequently, no further QAIs have been issued.
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ISAP VII.a.6 .
(Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.3 SAFETEAM Program The purpose of this phase of Action Plan implementation was to determine if TUGC0 management presently has established an effective erployee interview program which encourages employees to voice concerns and properly evaluates those having potential nuclear quality implications.
TUGC0 contracted the services of SATETEAM from Utility Technical Services (UTS is now SYNDECO Inc.) in mid-December 1984. SATETEAM is a trademark originating from the program used at the Ferud 2 Nuclear Plant, owned by Detroit Edison Company.
The purpose of SAFETEAM is to provide a program that will help identify and investigate quality concerns of all CPSES employees.
5.3.1 Program Definition The CPSES SATETEAM program was developed from the UTS Program Manual, UTS Handbook program descriptions and the UTS/TUGC0 service agreement. The manual and handbook are generic documents describing such activities for a standard program.
The program is implemented in accordance with the above guidelines with few variances. All variances are considered by the QA/QC Review Team to be minor, except those addressing reportable concerns and the Steering Committee membership, both of which will be discussed later. As no subtier procedures exist which describe the CPSES-specific SAFETEAM implementing practices, these variances were originally documented by infor=al notes to applicable sections of the manual. Prior to completion of this Action Plan the SATETEAM Director ,
formally documented all substantive variances by I memorandum.
5.3.2 Organizational Structure / Independence The organizational structure for the SAFE J is delineated in the SATETEAM Program Manual and consists ,
of a SAFETEAM Director, (a TUGC0 employee, who reports j to the Executive Vice President , Nuclear Engineering I and Operations), an Interview Coordinator, j
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Interviewers, an Investigator Coordinator and i Investigators. The manual also calls for a Steering l Committee to review the resolution of concerns and i the reports made to the individual expressing the concern.
i The SAFETEAM organization is being implemented as described above and is adequately separated from QA/QC f and other organizational elements involved in the design and construction of CPSES. Therefore SAFETEAM i is acceptably located within the TUGC0 Organization to assure independence and to minimize the potential for conflicts of interest.
5.3.3 Personnel Qualifications The Program Manual provides no SAFETEAM personnel qualification guidelines. It describes personnel capabilities under descriptions of " work relationships" and " duties". However, the manual provides no such capability requirements for Interviewers. The manual describes the Interviewer as "one of the most critical elements of the program....the only point of contact between SAFETEAM and the employee." Interviewers and Investigators are provided by the subcontractor.
Discussions with the Interview Coordinator revealed that Interviewers are part-time employees with non-technical backgrounds who are chosen on the basis of good " people skills". This choice of personnel is f intended to provide an interview atmosphere conducive j to obtaining complete information from the concerned employee. Training of. Interviewers at CPSES was given by the subcontractor initially in January 1985 with additional instruction in February 1986.
The contractor's plan for the development and training of Interviewers was examined. The plan appeared to be comprehensive. A portion of instruction outline entitled " Familiarity With Nuclear Power Site",
includes a facility tour. While interpersonal skills are recognized as desirable, it is also important that the Interviewer has a basic familiarity with technical terminology and with the CPSES structures and systems.
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. RESULTS REPORT ISAP VII.a.6 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) ;
The QA/QC Review Team found no formal documentation of' the initial CPSES-specific training given nor identification of those trained. The current Interviewers' capabilities vera determined to be adequate based on observation of the characterization of specific concerns identified and discussion with the j Interview Coordinator. Future training given to- .,
personnel should be supported by records which clearly a document the specifics of instruction and the identification of the recipients. ,
Investigators are full-time employees with technical backgrounds. SAFETEAM has developed and documented CPSES specific guidelines for investigator qualifications which, in essence, require nuclear quality control inspector or quality assurance j engineer / auditor experience. In lieu of these qualifications the SAFITEAM director has the option to assess individual education, expertise and demonstrated capability or training.
The guidelines for Investigator qualifications were !
considered complete and appropriate for the selection of personnel. A review of five (5) resumes indicated that the Investigators appear to be adequately qualified to conduct investigations and perform evaluations of repo.rted concerns.
5.3.4 Program Implementation To determine the effectiveness of the SAFETEAM program implementation, the QA/QC Review Team reviews and evaluations focused upon the concerns investigated by SAFETEAM for the period of January through December '
1985. This corresponds to the period from program initiation through the start of the QA/QC Review Team evaluation. This was considered adequate to assess the effectiveness of the current program. It was determined that during this time, SAFETEAM received 948 concerns from 741 interviews.
Selection was made of a cross section of these 1985 conc e rns . The interview files selected for review were those with investigations completed and considered closed; that is, the response letter had been sent to the employee. During the latter part of the year, files considered for review were chosen from those that had the draft of the employee response letter in the l
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RESULTS REPORT ISAP VII.a.6 i (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Steering Committee final review stage. The list of file titles was reviewed to include a11'those readily identified concerns associated with employee access to and participation in the SAFETEAM program. The remaining files-reviewed were selected to cover the time span considered. The sixty-seven (67) interview files selected included one hundred end one (101) employee concerns. Within this total, fifty-one (51) were associated with plant safety (Class'1) and nineteen (19) were associated with SAFETEAM access. !
(Classification of concerns is discussed below). See Attachment C for concerns selected and reviewed. I The following paragraphs describe the evaluation of the SAFETEAM program implementation. Departures from the Program Manual are described with the QA/QC Review Team evaluation of their potential impact on the program.
Program implementation is addressed in the areas-of 1)
Concern Identification; 2) Investigation and Resolution of Concerns; and 3) Reporting and Feedback of Concerns and' Investigations.
i Concern Identification The evaluation of the process of concern identification included both the employee's'avareness of his obligation to make his concerns known and appropriate avenues available to him to do so. New B&R' employees are shown a video tape presentation of the President of TUGC0 emphasizing CPSES's commitment to quality and encouraging employee participation in maintaining this ceneitment. As stated earlier, memoranda were issued to all CPSES employees in December 1983 by the President of TUGC0 that described CPSES's policy regarding the reporting and investigating of quality matters and policy regarding intimidation. Memoranda from Brown & Root and TUGC0 senior management in July 1985 to all supervisors and CPSES employees clearly .
established the policy regarding the options, including SAFETEAM, for the reporting of concerns. The SAFETEAM I program is also introduced to employees through small l group presentations, pay check inserts and posters.
located throughout the plant site. Further publicity J
is obtained through company literature, bumper stickers !
and coffee cups. The SAFETEAM building is conspicuously located on the plant site and is readily accessible, 9
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I 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
It is clear that the SAFETEAM program was adequately publicized by both TUCCO and B&R.
A review of SAFETEAM files, which specifically included those with concerns regardinr employee access to SAFETEAM, revealed no intent or action to curtail employee utilization of the program.
The SAFETEAM program provides employees with various ways to vcice concerns, namely by scheduled interviews, employee initiated walk-in, phone-in or mail-in contacts. Prior to departing the site, employees are given the opportunity to visit the SAFETEAM and to view a videotape presentation given by the President of TUGCO. The presentation discusses CPSES quality of construction, and thanks the employee for his/her efforts. It also informs the employee that concerns will be investigated and corrected and the employee is assured that confidentiality will be mainta,ined. After the presentation the employees are invited to request an interview if they have any concerns they wish to express. If not, they are given a report form upon which to report any concerns and a postage-paid envelope together with a toll free telephone number prior to leaving.
All employee concerns, no matter how initiated, are handled in the same manner once the interviewer /
employee contact is made. The SAFETEAM process begins when an employee voices a concern during an interview session with a SAFETEAM interviewer. The details of the interview are tape-recorded if the employee agrees and documented on an interview form.
The top of this form is separable from the rest of the form and contains the employee's name together with an interview serial number. After separation it is maintained by the SAFETEAM Interview Coordinator in a locked file. The remaining portion of the form containing the interview details is identified only by the serial n .ber and is kept in the concern folder.
All concern records from this point forward are controlled only by the number to provide employee anonymity. The concern folder is then sent to the SAFETEAM Director.
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(Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Confidentiality and employee anonymity were found to be satisfactory as evidenced by the "Name-Control Numbers" method employed.- In four cases, however, the names of employees were inadvertently. disclosed in the files due to the nature of the investigation and inclusion of supporting documentation. Due to the_ security '
maintained over the files, it is felt that the employee's anonymity had not been compromised.
Notification.to the SAFETEAM Director caused the names to be obliterated in these cases.(concerns 10261A/10500B/10556A/10584A).
The QA/QC Review Team concludes that all employees had ample opportunity to voice concerns and that'all concerns were treated seriously throughout the SAFETEAM' I interview process.
Investigation and Resolution of Concern '
All concerns are reviewed and classified by the SAFETEAM Director into categories for follow-up investigations. The categories include Class 1, Plant Safety concerns; Class 2, Security concerns; Class 3, Site Practice. concerns; Class 4. Industrial Safety 1 concerns; and Class 5, Miscellaneous concerns.- These categories are used to assign concerns for investigation to SAFETEAM, Security, Management, Safety and others as required.
The SAFETEAM Program Manual designates Class 1 as Nuclear Safety rather than Plant Safety as used at CPSES. This variance is considered unimportant as the significance of the class is maintained.
In some cases concerns that are classified other than Class 1 (Plant Safety), based upon the main thrust of the stated concern, contained potential quality implications. This is discussed below in detail.
SAFETEAM is not assigned the responsibility for {
resolving concerns nor for verifying that actions j required by the resolution are in fact completed. l SAFETEAM must rely upon proper and correct input from the CPSES organizations called upon for assistance in investigations. SAFETEAM assigns the concern to an Investigator. After beceming familiar with the
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RESULTS REPORT ?
ISAP VII.a.6 (Cont'd) 5.0- IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) r concern, the Investigator requests the appropriate asnagement group to investigate and resolve those classified as Class 2 through 5, with results to be returned to SAFETEAM. For. Class I concerns, the SAFETEAM Investigator performs the investigation, with assistance f rom cognizant CPSES organizations.
For-example, if the investigation of a concern requires-an inspection or engineering evaluation, SAFETEAM requests that QC perform the inspections and Engineering perform the evaluations. When investigation activities are conducted by the project as' stated above, any problems found are corrected through normal site processes and are evaluated and reported under existing CPSES procedures and controls.
SAFETEAM is then informed of the results of these inspections and evaluations. . When SAFETIAM receives all of the investigation and evaluation results, the Investigator assembles the information for preparation =
of an investigation report.
The.QA/QC Review Team found that the overall j investigation and resolution process meets the i requirement of the program by properly evaluating and documenting those identified concerns related to quality. The' Review Team has the following observations regarding the investigation and resolution process:
SAFETEAM investigates the concern as
" bounded" by the employees' statements.
During the performance of the investigation, it may become apparent that a concern not initially classified as plant safety-related may, in fact, point toward other matters that have plant safety-related implications (10151A). These quality problem indications may not be included in the investigative process. The recognition and follow-up of, these indications then should be the responsibility of the QA representative on !
the Steering Committee. There was little evidence that the QA representative was identifying or causing action to be taken on such quality-related indications. When the employee's concerns are directed, by his/her i
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Revision: 1 Page 27 of 42 RESULTS REPORT ISAP VII.a.6 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) statements, toward non-plant safety classification (10021A/10045A/10279A and C) but include potential for QA ramifications, the Class 1 aspect of the concern should be identified and documented by the QA representative of the Steering Committee. As a result of discussions with the QA/QC Review Team Leader, the Director of QA has re-emphasized these as QA representative function responsibilities.
In some instances responses are general in nature. This is an acceptable response when the employee's concern lacks specific details to warrant complete investigation. General responses are not adequate when responding to r i
concerns which state specific details. This type of response states only why the condition should not exist rather than recognizing that the condition does exist and describing the action taken to correct it (10045A). Use of such responses was discussed with the SAFETEAM Director. The QA/QC Review Team has adequate confidence that general responses will not be employed inappropriately.
Reporting and Feedback The QA/QC Review Team evaluated the reports on SAFETEAM activities to TUCCO management and feedback of concern )
resolution to the employee. Reporting to TUGC0 j management is accomplished by semi-monthly written i
' reports from SAFETEAM and the Steering Committee reviev of the concern and investigation files and reports. ,
Employee feedback is accomplished by letter from the SAFETEAM when the concern investigation has been completed.
The SAFETEAM Director provides the Executive Vice President. Nuclear Engineering and Operations with a semi-monthly report which apprises him of statistics ;
i such as:
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The number of personnel exiting through the SAFETEAM, The number of reports prepared, identified by the five classifications, The number of open and completed actions regarding concerns, and The number of responses sent to employees.
These reports, which contain program statistics, do not convey infor1 nation such as details of investigations, trends of concerns, potential trouble areas, etc..
Interviews revealed that occasional telephone communication between the SAFETEAM Director and TUGC0 senior management did convey information of this type when considered necessary even though no periodic, formal status meetings took place.
The QA/QC Review Team felt that this method of reporting coupled with the absence of periodic status meetings limited upper management awareness of,SAFETEAM activity details. Prior to completion of this Action Plan the Executive Vice President, NEO, had established bi-veekly meetings with the SAFETEAM Director and key personnel for the purpose of informing TUGC0 management of the details of SAFETEAM activities.
The Steering Committee receives copies of the investigation reports and of the response to be sent to the employee. This committee reviews these for accuracy and adequacy. The SAFETEAM Program Manual requires the membership of the Steering Committee to be comprised of the Executive in charge of corporate QA, a legal representative and a representative of corporate public relations. In practice at CPSES, the site QC Manager, rather than the Corporate QA Director, is a ,
member. Additionally it was observed that his }
committee functions were almost entirely delegated to his QA/QC supervisors.
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The QA/QC Review Team initially found that the QA membership on the Steering Committee as practiced, was z less than adequate because 1) its repetitive delegation of responsibilities was inappropriate, 2) it did not comply with the SAFETEAM manual requirements and was not documented as an implementation variance, and 3) it afforded a potential to limit the QA Director's awareness of QA-related employee concerns.
Discussions with TUGC0 resulted in the documentation of
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the variance to the manual requirement by the SAFETEAM Director. In addition, the corporate QA Director's memorandum documents the delegation of his committee I membership to the CPSES QC Manager and in the latter's absence, to the CPSES QA Manager. Further delegation. _
for any reason, requires the QA Director's approval.
Through discussion with the QA Director, it was learned that he is apprised of quality-related concerns through communications with upper management and the Steering Committee members, in addition the SAFETEAM requires the QA Director's action on those concerns which could represent a conflict of interest, should site QA/QC management become a subject of the employee concern.
Upon completion of the Steering Committee review an original copy of the letter signed by the SAFETEAM Director is sent to the employee. The letter includes
- 1) an introductory statement thanking the employee for making his concern known through the SAFETEAM Program;
- 2) a description of the employee's concern; 3) a description of investigative actions taken to resolve the concern; and 4) instructions for further contact should the e=ployee desire further communication regarding the subject or additional concerns.
The QA/QC Review Team finds that a SAFETEAM response to the e=ployee was made in all cases and contained suf ficient information (i.e., appropriate details of the action taken, or planned and the CPSES organization responsible) to explain fully the investigative activities undertaken as a result of the employees concern. The fact that the letter restates the employee's concern (as SAFETEAM understood it) affords l the employee the opportunity to follow-up on any
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, ISAP VII.a.6 (Cont'd) 5.0 I!TLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) misunderocandings should they have occurred. An example of the above and the adequacy of the SATETEAM i follow-up saa identified during the evaluation (10488A
& B). In this caso, the corrective action reported as complete to the empicyee was found by the employee not to have been completed. The employee recentacted SATETEAM who in turn took further action to have the responsible organization conplete the required action.
This action was completed to the satisfaction of both the employee and the SAFETEAM. The QA/QC Review Team found that the average time frem identification of a concern to notification of the employee by letter was five months. Of the files reviewed, time for notification varied from one month to ten months (10500B/10138A, B, and C). Recognizing that an employee's perception of SAFETEAM creditability could be influenced by the time it takes to receive a response.to his/her concern', efforts should be made where practical to reduce the response time to a minimum. The SAFETEl.M Director has initiated measures to reduce the time involved in Steering Committee review while still maintaining a complete review.
The SAFETEAM manual requires that when an investigation reveals that the concern stated in the interview is reportable (based on the requirements of 10CTR50.55(e) and 10CTR21), a transmittal of the facts involved should be prepared and sent to the Director / Manager of Quality Assurance. At CPSES, SATETEAM does mot make determinations as to whether concerns are reportable. SAFETEAM does not perform engineering or quality assurance functions but rather i
engages such actions through the solicitation of CPSES l organizational involvement in the resolution of conce rns. Deportability functions, therefore, are addreuand through CPSES established programs. The QA/QC Review Team finds this practice acceptable.
With the initiation of bi-weekly status meetings between the SAFETEAM Director and the Executive Vice President, NEO and other key personnel, the QA/QC Revir.' Team feels that reporting of SATETEAM activities to upper management and the feedback of concern resolution to the employee is satisfactory.
R2 vision: 1 Page 31 of 42 RESULTS REPORT ISAP VII.a.6 (Cont'd) 5.0 IMPLEMENTATION OF ACTION .LAN AND DISCUSSION OF RESULTS (Cont'd) 5.3.5 Employee Protection The SAFETEAM program provides anonymity to the employee. Methods include the separation of the employee's name from the balance of the interview form and maintenance of locked files which relate the employee to the interview form. Investigation and resolution of the concern, preparation and review of the letter of response (except for final dispatch to the employee) and periodic reporting to management is perfor=ed without reference to the employee's name or position.
Except for the inadvertent disclosure of four names, discussed previously in Section 5.3.4, confidentiality and anonymity were found to be satisfactory.
5.4 Summarv of Results 5.4.1 Exit Interview Program / Ombudsman The exit interview program and use of the Ombudsman did provide adequate opportunity for individuals to express concerns and provided a =echanism for investigation and resolution of these concerns. These were the primary objectives of the program. Some improvements were incorporated as the program evolved. Exit interviews were extended to cover craft personnel. Eevever, the program did not meet all the criteria that might have been set for a broader program. A comparison of the Exit Interview Program against the criteria of Section 4.5 is made in the following paragraphs:
Program Definition / Independence: The com=itment to the exit interview program was sufficiently important to merit implementation by procedure rather than a series of memoranda. Further, these memoranda lacked continuity, specificity and implementing detail. A procedure was issued two-thirds of the way into implementation. While this procedure consolidated program requirements, it still lacked important details.
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ISAP VII.a.6 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
The program was not intended to be conducted independent of the QA organization. The Ombudsman functioned as a member of the QA/QC organization rather than being independent of it. The majority of interviews were conducted by QA/1C supervisors. Even though management made its policy against intimidation / harassment clear and encouraged employees to voice concerns, the lack of program independence from the QA/QC organization could have created a potential for limiting the level of employee confidence in the program.
Concern Identification: TUGC0 provided and initially made employees aware of sufficient avenues to make their concerns known and all avenuer seem to have been employed. QAIs were logged by QE from initiation to closure and appear complete. QA/QC Questionnaire interviews were not logged, therefore making it impossible to relate interviews given to a listing of employees to whom the opportunity should have been offered. However, it appeared that both TUGC0 and B&R made sufficient efforts to afford all departing QA/QC and craft employees the opportunity to complete an exit interview questionnaire.
Concern Investigation: QAIs were initiated for both ,
QA/QC and craft personnel. During the evaluation of {
the concern investigation process, several program and {
implementation weaknesses were identified. Typical problems identified were:
Investigation results not communicated to employee, lack of definition of threshold level for QAI initiation, lack of supporting documentation, i l
failure to comple.ely r address concern, and failure to provido complete rationale to fully support QAI closure decision.
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RESULTS REPORT i
ISAP VII.a.6 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSS 7.ON OF RESULTS (Cont'd)
However none of these identified problems, with the exception of those associated with the four concerns !
noted in Section 5.2.3, were felt to be indicative of or relate to actual quality implications to hardware.
These exceptions, two QA/QC Questionnaire concerns and two QAI resolutions (QAI-001 and 008), along with the Review Team's observations, were referred to TUGC0 QA for re-evaluation. Upon examination of the results of TUGCO's investigations, the QA/QC Review Team concluded that these issues were satisfactorily resolved and no potential hardware problems associated with those concerns exist.
Identify Potential Quality Implications: Even though the program did not require priority classification of concerns relating to quality, those with potential QA implicacit.s were treated appropriately.
Upper Management Involvement: Corporate QA and Security mansgement received QAI packages for review.
Cicsure authorization was made by corporate QA. In many cases it could not be determined if reports of QAI content were made above these management levels other than notice of closure of QAIs. The required reports to upper management provided open/ closed status only.
Concern Resolution: Rationale to support resolutions was not always clear and/or relevant and in some cases were not documented completely.
Employee Feedback: Response of resolution to the employee was not in evidence in most cases even though this was a program requirement for closure of QAIs.
Employee Protection frem Reprisal: Interview confidentiality and employee anonymity were not program requirements. All QAI files are properly secured.
1 5.4.2 SAFETEAM Program f
SAFETEAM provides a well-defined and well-structured program for all employees to voice concerns and has appropriate mechanisms to resolve those concerns.
Progra= implementation was found to be satisfactory.
Several progra= reco=mendations were made to TUGC0 and implemented by them during the course of the evaluation.
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The following is a summary of the QA/QC Review Team evaluation of observations. They are discussed in the order of the acceptance criteria of Section 4.5:
Program Definition / Independence: The program requirements are properly defined by the SAFETEAM Program Manual'and Handbook. Implementation is in accordance with program requirements, with all substantive variances now documented by memorandum.
The organization is entirely independent from the CPSES QA/QC organization as well as Construction and Engineering. The existence of this independence is a significant improvement over the previous exit interview program. The SAFETEAM is staffed by capable personnel. The CPSES QC Manager functions as the QA representative on the Steering Committee with further delegation of responsibility controlled by the QA Director.
Concern Identification: The program and its availability to employees is publicized widely and continually by a variety of means. The employees have
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ample avenues available to =ake concerns known. All concerns are satisfactorily logged and tracked to closure. Interviews are conducted and treated in a sincere and professional manner.
Concern Investigation: Investigations of concerns appear to be thorough and they effectively address the concern as stated by the employee. They are conducted i by organizations / personnel cognizant in the area of the l concern. Documentation of investigations and I resolutions is satisfactory and with few exceptions is complete and properly filed. !
Identify Potential Quality Implications: The SAFETEAM method of classifying concerns assures that those with potential quality implications are distinguished ,
from the others and SAFETEAM " directs" the .
investigation process of these. Potential quality i implications which may arise during the course of resolving non-Class 1 concerns will be recognized and addressed through the review responsibility of the QA representative on the Steering Committee.
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Revision: 1 Page 35 of 42 RESULTS REPORT ISAP VII.a.6 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Upper Management Involvement: Upper management awareness of the program status and details ef concerns was lessened by the lack of formal meetings.wlch the
.SAFETEAM Director and the statistical format of semi-monthly reports. TUGC0 has initiated scheduled.
meetings between the Executive Vice President, NEO, his Vice Presidents and key CPSES personnel and the.
SAFETEAM. Director to enhance reporting of program results to upper management. .This action provides the potential for improved management awareness.
Concern Resolution: The resolutions of concerns were satisfactory and appeared to be based on sufficient investigative information. In a fe*r cases, resolutions of concerns other than Class 1 appeared to be based on general responses. Although not found to be a common practice (and indeed someti,mes necessary where concern details are not givan by the employee), such responses should be closely evaluated for adequacy. Corrective actions resulting from resolution are effected through proper CPSES programa.
Employee Feedback: Feedback of concern resolution to the employee is satisfactorily accomplished and documented. The response to the employee additionally informs him of his options and means to communicate further if he so desires. Efforts to reduce the time required to close the concern and provide notification to the employee have been initiated by the SAFETEAM Director.
i Employee Protection From Reprisal: The program j requirement for employee confidentiality was another a notable improvement over the previous program. The .I SATETEAM processes for maintaining employee anonymity .
and security of the files are satisfactory and are -
capable of providing employee protection. "
5.5 Root Cause and Generic Implications No deficiencies were identified. Therefore, no root cause evaluation and generic implications analysis were conducted.
1
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Ravision: '.
Pega 36 of 4 RESULTS REPORT ISAP VII.a.6 (Cont'd)
6.0 CONCLUSION
S I 6.1 Exit Interview Program /0mbudsman Based on the review of the Exit Interview Program in effect between December 1983 and May 1985, it is concluded that the program (which included the QA/QC Questionnaire and QAI programs) met the intent of item seven (7) of TUCCOs response to the NRC NOV in that it afforded QA/QC employees the opportunity to state concerns regarding quality prior to dissociation from the QA/QC department and provided a mechanism for evaluating and dispositioning such concerns.
However, the. program did not fully meet the criteria of Section 4.5.
6.2 SAFETEAM Program The SAFETEAM Program and its implementation represents a significant improvement over the previous exit interview
~
program. The program as structured, defined and implemented effectively encourages employees to voice concerns and provides adequate means to do so. Resolution of the employee's specific concern as stated appears satisfactory,-
however related issues, some of which may have had quality implications, which arose during the investigation were not in all cases addressed. With the recognition of these implications now a directed responsibility-of the QA member of the Steering Committee, effective response to all QA ramifications of employees concerns can be achieved.
7.0 CNGOING ACTIVITIES The SAFETEAM Program in existence at this time will be applicable to the remaining construction phase on Unit 2 and for the initial operating phase of the plant.
8.0 ACTION TO PRECLUDE OCCURRENCE IN THE TUTURE None are required.
_ _ _ _ - _ _ - _ _ . a
i Revision: 1 Pege 37 of 42 RESULTS REPORT-ISAP VII.a.6 (Cont'd)
Attachment A Chronology DATE EVENT / DOCUMENT SUBJECT 08/29/83 NOV EA-83-64 Issued.
09/28/83 TUGC0 responde,.to NOV EA-83-64 10/03/83 TUEC initiated Exit Interview Program.
11/08/83 Assignment of Ombudsman - QTQ-496.
11/16/83 QA/QC Questionnaires for personnel leaving QA Department - QTQ-503.
11/16/83 Routing of QA/QC Questionnaires - QTQ-504 11/17/83 Continuation of QA/QC Questionnaires -
QTQ-508.
12/14/83 Availability of Dmbudsman - TUQ-1887.
12/16/83 Meeting - Investigating A11egatior.s and Concerns at CPSES - QTQ-540.
12/20/83 M. D. Spence letter to all CPSES personnel on investiga-ing and reporting quality matters to nuclear safety.
01/03/84 Policy for investigating QA/QC Concerns -
QTQ-548.
03/22/84 QA Policy - TUQ-1982.
04/11/84 Quality Assurance Allegations / Concerns -
TUQ-2012.
05/15/84 Personnel no longer in QA/QC - TUQ-2108.
06/15/84 Exit interviews - TUQ-2180.
06/29/84 Interview of personnel no longer in QA/QC -
CQA-015.
10/29/84 DQP-QA-6 Revision 0 issued " Quality Assurance Investigations".
.____ -____ _ __ D
Rsvision: 1 Pegs 38 of 42 RESULTS REPORT -
ISAP VII.a.6 (Cont'd)
Attachment A (Cont'd)
DATE EVENT / DOCUMENT SUBJECT 01/08/85 TRT letter identified deficient Exit Interview. Program.
01/14/85 SAFETEAM arrived on site.
02/09/85 SAFETEAM to conduct exit interviews in lieu of DQP-QA-6, (B&R QA memo).
05/17/85 Ombudsman's QAI Status Report - CQA-0110.
05/17/85 Ombudsman leaves site.
06/03/85 DQP-QA-6 changed to DQP-CQ-2 Revision 0
" Quality Assurance Investigations".
09/09/85 DQP-CQ-2, Revision 1 issued " Quality Assurance Investigations".
l 1
Revision: 1 Pege 39 of 42 RESULTS REPORT ISAP VII.a.6 (Cont'd)
Attachment B Attributes List ATTRIBUTES / SOURCE RESP. ATTRIBUTE / SOURCE RESP.
Mandatory' Attributes Non-Mandatory Attributes NRC NOV EA-83-64 Responses Industry Examples QA/QC Questionnaires for 0 Adequate program O/S departing QA/QC personnel. exposure to employee. ;
Concern reporting O/S
" avenues" easily available.
10CFR50 Appendix B Criterion 1 Authority 6 duties of O/S Concern identification 0/S persons & organizations.. and classification shall be clearly established as to importance, and delineated in writing, organization, etc.
".... Persons performing O/S Concern validation. 0/S functions shall have sufficient organizational Investigation and 0/5 freedom. resolution by cognizant organization, etc.
Resolution feedback O/S to employee.
Complete activity 0/S documentation.
Comprehensive reports 0/5 to management.
Independent reviev 0/5
& comment on investigation reports of noted concerns.
Confidentiality / O/S Employee Anonymity
} Legend: 0 = Ombudsman Responsibility l S = SAFETEAM Responsibility 1
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'1 Rsvision: 1
. Page 40 of 42 RESUI.TS REPORT ISAP VII.a.6 (Cont'd)
Attachment C SAFETEAM Concerns Reviewed CONCERN NO. CLASS DATE CONCERN NO. CLASS- DATE 10013 A 3 01/29/85 10138 A 3 03/15/85 10021 A 3 02/04/85 B 3 03/15/85 10039 A 1 02/08/85 C 1 03/15/85 B 1 02/08/85 10151 A 3 03/18/85
~
10045 A 4 02/11/85 10158 A 5 03/19/85 B 4 02/11/85 10164 A 3 03/20/85 c 4 02/11/85 10180 A 3 03/26/85 D 3 '02/11/85 10203 A 1 04/02/85 10050 A 1 02/18/85 10209 A 3 04/03/85 B 1 02/18/85 B 2 04/03/85 C 1 02/18/85 C 4 04/03/85 D 3 02/18/85 D 3 04/03/85 10066 A 3 02/20/85 10226 A 4 04/10/85 B 2 02/20/85 B 3 04/10/85 c 3 02/20/85 c 3 04/10/85 10073 A 1 02/21/85 10261 A 3 04/19/85 10090 A 1 02/28/85 10267 A 3 04/23/85 B 1 02/28/85 10268 c 3 04/24/85 10099 A 4 02/28/85 10279 A 3 04/25/85 10105 A 1 03/04/85 B 3 04/25/85 B 1 03/04/85 c 3 04/25/85 ,
c 3 03/04/85 10298 A- 3 05/02/85 i
Revision: 1 Pago 41-of 42 RESULTS REPORT ISAP VII.a.6 (Cont'd)
Attachment C (Cont'd)
CONCERN NO. CLASS DATE CONCERN NO. CLASS DATE 10314 A 1 05/06/85 10488 A 1 07/26/85 B 3 05/06/85 B 1 07/26/85 C 1 05/06/85 C 1 07/26/85 D 3 05/06/85 10497 A 1 08/05/85 E 3 05/06/85 10500 B 1 08/06/85 10326 A 3 05/09/85 10513 B 1 08/16/85 10328 G 3 05/09/85 10517 A 3 08/19/85 10396 A 3 05/31/85 10532 A 1 08/29/85 B- 1 05/31/85 10540 A 1 09/05/85 10406 A 1 06/03/85 10545 B 1 09/10/85 10411 A 1 06/05/85 10556 A 1 09/19/85 10420 C 3 06/10/85 10568 A 1 09/27/85 10432 A 3 06/13/85 10570 A 1 09/30/85 10434 A 1 06/13/85 10571 A 1 10/02/85 B 1 06/13/85 10572 A 1 10/02/85 10464 B 1 07/03/85 10576 A i 10/07/85 10465 A 1 07/08/85 10576 B 1 10/07/85 10475 A 1 07/17/85 C 1 10/07/85 10478 A 3 07/19/85 10584 C 3 10/11/85 B 1 07/19/85 10599 A 3 10/23/85 10484 A 1 07/25/85 10628 A 3 10/85 l
l
Revision: 1 Pege 42 of 42 I RESULTS REPORT ISAP VII.a.6 (Cont'd) ,
Attachment C (Cont'd).
CONCERN NO. CLASS DATE CONCERN NO. CLASS DATE 10678 A 5 10/85 10748 A 1 12/10/85 B -5 10/85 10749 A 1 12/10/85 10715 A 3 11/06/85 10757 A i 12/19/85 10731 B 1 11/19/85 10760 A 1 12/20/85 10738 B 1 '11/22/85 B 1 12/20/85 10739 D 1 11/85 10764 A 1 12/28/85 L 10743 B 3' 11/27/85 B 1 12/28/85.
l 10745 A 4 12/05/85 1
I l
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4.
COMANCHE PEAK RESPONSE TEAM ACTION PLAN i ISAP VII.a.8
Title:
Fuel Pool Liner Documentation Revision No. 0 1 Reflects Coments Description Original Issue On Plan Prepared and // ,, ,,{
Recomended by: r'-
Review Team Leader Date U lV I ZY '.84* a
- e. ev v Tean N.) k L), /$1_
v /
Date Go lk/ l[$ /f2-4l8L ,
i
_ - . . . . . - - - . . _ _ __ - _ _-_--___---...__...---_-_____--_---_2.--
i ; A.
i Revision: 1
)
Page 1 of 6 j ISAP VII.a.8 i i
Fuel Pool Liner Documentation l
1.0 DESCRIPTION
OF ISSUE IDENTIFIED BY NRC (USNRC Letter of January 8, 1985, Pg. 3)
" Based on the TRT review of about 200 fuel pool travelers, TUEC was unable to maintain an effective and controlled QC program for fuel pool liner fabrication, installation, and inspection. Typical fuel pool traveler irregularities were:
There was apparently a routine practice during construction of the fuel pool that allowed Craft personnel to complete a portion of the inspection report forms prior to the actual inspection. Craft personnel entered the word " SAT," dated the entry, and left blank only the space for the QC inspector's signature. It appeared that the Craf t personnel were judging the inspection results prior to inspections.
The date accompanying the signature for visual examination of an inside weld was changed to a date that appeared to precede the examination.
Entries by the same inspector for two different inspections did not appear to match in that one entry appeared to be written by another person.
The procedure number for a dye penetrant inspection was changed by an inspector different from the one who conducted the inspection.
The date for a dye penetrant inspection was changed by an inspector other than the one who performed the inspection.
Fuel pool travelers were found with missing QC sign offs for fitup and cleanliness. No proof could be found that some of the required weld fitup .and cleanliness inspections were ever perf ormed.
The TRT review disclosed the following irregularities with traveler entries in addition to those listed above:
Date changes after the fact Sign offs for functions out of sequence Corrections after the fact Changes to first party inspector date sign offs Missing signatures"
-_____.__-__-__-______-_A
o W ,
Revision: 1 Page 2 of 6
> :A.
~
ISAP VII.a.8 (Cont'd) 2.0 ACTION IDENTIFIED BY NRC
- Evaluate.the TRT findings and consider the implications of these findings on construction quality. "... examination of.
the potential safety implications should include, but not be limited to the areas or activities selected by the 'TRT." ',
" Address the root cause of each finding and its generic implications..." ,
- " Address the collective significance of these deficiencies..."
" Propose an action plan...that will ensure.that such problems do not occur in the future."
3.0 BACKGROUND
}
'CPSES Safety Evaluation Report, Supplement 10 (SSER #10), April 1985, provides additional information related to the technical adequacy of fuel pool liner (and transfer canal and reactor refueling cavity liner) welds. The following observations were made by SSER #10:
The fuel pool liners are not required by FSAR to meet 10CTR50 or ASME B&PV Code requirements (although G&H Specification 2323-55-18 does impose 10CTR50 Appendix B QA Program requirements). The fuel pool liners also are not required to be designed and erected to meet Seismic Category I criteria.
The Brown & Root construction and inspection procedures used for fuel pool liner erection and welding are consistent with C&H Specification 2323-SS-18.
The TRT observed approximately 20" of the seam welds in the spent fuel pools. The leak chase system and imbeds are inaccessible and were not checked.
Five (5) allegations were reviewed by the.TRT related to fuel pool liner ficup and welding; none of the allegations were found to have safety significance.
The observations of SSER #10 notwithstanding, Gibbs & Hill Specification 2323-SS-18, Revision April 15, 1985, Paragraph 1.1 does identify the stainless steel liner systems (except the Unit 1 and Unit 2 Reacter Suilding Refueling Cavities) as Nuclear Safety Related. This includes the spent fuel storage pools, transfer canals, and cash loading pits.
f a .
Tcovision: 1 Page 3 of 6 4
ISAP VII.a.8 (Cont'd)
3.0 BACKGROUND
(Cont'd)
QA/QC aspects of the fuel pool liner erection and welding are not included in SSER #10,-but have been published in SSER #11, May 1985.
I The reinspection of fuel pool liner welds will be performed under !
ISAP VII~c, " Construction Reinspection / Documentation Review Plan",
population FPLR. : }1 I
~4.0 CPRT ACTION PLAN 4.1 Scope and Methodology 4.1.1 The objective of this action plan is to evaluate irregularities in the fuel pool liner travelers and related documentation.
To achieve this objective the following tasks will be implemented:
Review of liner specification, drawings and procedures to determine requirements.
Review of liner travelers for irregularities. ,
4.1.2 The specific methodology is described below:
4.1.2.1 Review the fuel pool liner specification, I drawings, and fabrication and inspection procedures. Identify the erection, inspection and testing requirements.
4.1.2.2 Select a sample of the liner welds for traveler review. The sample will be trandomly selected from a list of all the spent fuel pool, transfer canal, and cask loading pit ,
travelers used during erection of the liner ,
and associated components. The sample will ,
be selected to provide ut least 95/5 screen. '
A minimum randem saeple si:e of 60 is required to meet this condition in accordance with CPRT Program Plan Appendix D. Table 1. I A sample review is considered a reasonable l l approach for the following reasons:
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Rovision: 1 Page 4 of 6 i'
ISAP VII.a.8 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
No programmatic deficiencies have been identified in this population to date.
I The population.of travelers is homogeneous in that all the work was accomplished by the same crafts and used the same procedures.
4.1.2.3 Obtain fuel pool travelers associated with the liner veld sample selected. Review these travelers to determine if all the required inspections were performed to the applicable design and procedure requirements and that the travelers were properly completed. The review will be conducted using a documentation data sheet and vill include, but is not limited to, verification of date entries and authorized inspection sign offs.
4.2 Participant's Roles and Responsibilities The organizations and personnel that will par,ticipate in this effort are described below with their respective scopes of work.
4.2.1 TUGC0 4.2.1.1 Scope Assist the QA/QC Review Team in the identification and provision of all necessary specifications, drawings, procedures and other documentation necessary for the execution of this j action plan, j Process NCRs that may be generated due to this action plan.
4.2.1.2 Personnel Mr. C. R. Hooton - Project Coordinator (CPPE) l l
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J; Rsvision: 1 Page. 5 of 6 4
l ISAP VII.a.8 (Cont'd) 4.0 CPRT -ACTION PLAN (Cont'd)
Mr. D. Snow - TUGC0 QA/QC Coordinator
- l. 4.2.2 CPRT QA/QC Review Team l 4.2.2.1 Scope The QA/QC Review Team will be responsible to l evaluate the adequacy of completed inspection records (travelers) for fuel pool liner fabrication.
4.2.2.2 Personnel Mr. J. L. Hansel - QA/QC Review Team Leader Mr. M. P. Obert - Issue Coordinator j 4.3 Qualifications of Personnel Where tests or inspections require the use of certified inspectors, qualification will be t'o the requirements of ANSI N45.2.6 at the appropriate level. Third-party inspectors will l be certified ' the requirements of the third-party employer's
! Quality Assurance Program and specifically trained to the I requirements of thefquality procedures developed under this action plan.
Other participants will be qualified to the requirements of the CPSES Quality Assurance Program, or to the specific requirements of the CPRT Program Plan.
4.4 Procedures Matrices, checklists, and data sheets may be developed as an integral part of the evaluation. These will be retained to support justification of conclusions. ,
l 4.5 Standards / Acceptance Criteria Fuel pool liner inspection records shall be in compliance with the inspection record requirements of 10CFR50 Appendix.B. .
Criterion X - " Inspection", and Criterion XVII " Quality Assurance Records" and the associated commitments of CPSES/ TSAR paragraphs 17.1.10 and 17.1.17 respectively.
Specifically, such records are acceptable if they provide, as a minimum.
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[ . Page 6 of 6 i . .g ISAP VII.a.8 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.5.1 Sufficient detail to permit adequate confirmation of inspection activities.
4.5.2 Identification of the person (s) recording the data and approving the' Inspection Results.
4.5.3 Acceptance of the item or activity documented and approved by authorized personnel.
4.5.4 Type of observation and results.
4.5.5 Action taken in connection with any deficiencies noted.
4.5.6' Legible, accurate record of work accomplished.
4.6 Decision Criteria If the compilation of information resulting from the l implementation of paragraphs 4.1.2.1 through 4.1.2.4 contains 1 any safety-significant deficiencies or adverse trends whose '
root causes are attributable to inspection inadequacies, ,
corrective action will be included in the ISAP Results Report ,
and the ISAP closed. Otherwise, document the results of the evaluation in the ISAP Results Report and close the ISAP.
t l
r I u..,_.___, - - _ -- - - - - _ _ - - _
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y 1 .I 4
l COMANCHE PEAK RESPONSE TEAM RESULTS REPORT l
l-l ISAP: VII.a.8 l
Title:
Fuel Pool Liner Documentation REVISION 1 l
l dh. J Issue Coordinator u- + ch Date C J e ieT Team Leade'r nk/x Date/ I M o. k Ja2rn W. Beck, Chairman CPRT-SRT nMn Date i
l i
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l i
t
.____-a
, i I 4 Rovision: I f Pcgo 1 of 39 l 1
- RESULTS REPORT I l
ISAP VII.a.8 Fuel Pool Liner Documentation
1.0 DESCRIPTION
OF ISSUE IDENTIFIED BY NRC The following issue was identified by the NRC fn the USNRC-TRT letter January 8, 1985, Enclosure Item 2.A. Quality Control Inspection:
" Based on the TRT review of about 200 fuel pool travelers, TUEC was unable to maintain an effective and controlled QC program for fuel pool liner fabrication, installation, and inspection. Typical fuel pool traveler irregularities were:
There was apparently a routine practice during construction of the fuel pool that allowed Craft personnel to complete a portion of the inspection report forms prior to the actual inspection. Craft personnel entered the word " SAT," dated the entry, and left blank only the space for the QC inspector's signature. It appeared that the Craft personnel were judging the inspection results prior to inspections.
The date accompanying the signature for visual examination of an inside weld was changed to a date that appeared to precede the examination.
Entries by the same inspector for two different inspections did not appear to match in that one entry appeared to be writcen by another person.
The procedure number for a dye penetrant inspection was changed by an inspector different from the one who conducted the inspection. l The date for a dye penetrant inspection was changed by an inspector other than the one who performed the inspection.
Fuel pool travelers were found with missing QC sign offs for ficup and cleanliness. No proof could be found that some of the required weld fitup and cleanliness inspections were ever performed.
The TRT review disclosed the following irregularities with above:
traveler entries in addition to those listed Date changes after the fact T
Sign offs for functions out of sequence l
- t. .-________u
l l Revision: 1 Page 2 of 39 RESULTS REPORT ISAP VII.a.8 (Conc'd)
1.0 DESCRIPTION
OF. ISSUE IDENTIFIED BY NRC (Cont'd)
Corrections after the fact Changes to first party inspector date sign offs Missing signatures."
2.0 ACTION IDENTIFIED BY NRC Evaluate the TRT findings and consider the implications of these findings on construction quality. "... examination of the potential safety implications of the TRT findings should include, but not be limited to the areas or activities selected by the TRT."
" Address the root cause of each finding and its generic implications..."
" Address the collective significance of these deficiencies..."
" Propose an action plan...that will ensure that such problems do not occur in the future."
3.0 BACKGROUND
The fuel pool stainless steel liner system consists of the refueling cavity, transfer canals, epent fuel storage pools and cask loading pits within Unit 1 and 2 Reactor Buildings and the Fuel Building. These liner systems were site-fabricated and erected by Brown & Root. Other liner systems, such as the containment liner (carbon steel) and the condensate storage tank liner (stainless steel), were fabricated and erected by Chicago Bridge & Iron (CB&I).
CPSES Safety Evaluation Report. Supplement 10 (SSER Number 10),
April 1985, provides additional information related to the technical adequacy of fuel pool liner (and transfer canal and reactor refueling cavity liner) welds. The following observations were made in SSER Number 10:
s
.' )
- Revision: 1 l Page 3 of 39 RESULTS REPORT ISAP VII.a.8 (Cont'd)
3.0 BACKGROUND
(Cont'd)
The fuel pool liners are not required by FSAR to meet 10CFR50 Appendix B or ASME B&PV Code requirements (although Gibbs &
Hill Specification 2323-SS-18 does impose 10CFR50 Appendix B
'QA Program requirements). The fuel pool liners also are not required to be designed to meet Seismic Category I criteria.
[SSER 10, M&P Category 43, paragraph 4.1(b), 4.1(c). Page N-272)
The Brown & Root construction and inspection procedures used for fuel pool liner erection and welding are consistent with G&H Specification 2323-SS-18. [SSER 10, M&P Category 43, paragraph 4.1(e), Page N-273]
The TRT observed approximately 20% of the seam welds in the spent fuel pools. The leak chase system and imbeds are inaccessible and were not checked. [SSER 10, M&P Category 43, paragraph 4.4, Page N-275)
Six (6) allegations were reviewed by the TRT related to fuel pool liner ficup and welding; none of the allegations were found to have safety significance. (SSER 10, M&P Category 43, paragraph 5, Page N-282)
The observations of SSER Number 10 notwithstanding, Gibbs & Hill Specification 2323-SS-18, Revision 4 April 5, 1985, Paragraph 1.1 identifies the stainless steel liner systems (except the Unit I and Unit 2 Reactor Building Refueling Cavities) as Nuclear Safety-Related. Previous revisions, while less explicit, were labeled "This Specification covers Nuclear Safety Related Equipment".
QA/QC aspects of the fuel pool liner erection and welding were not included in SSER Number 10, but were published in SSER Number 11 May 1985. Under QA/QC Category 6, QC Inspection, SSER Number 1 identifies allegations AQ-55 and AQ-78. These allegations are paraphrased in SSER Number 11 as follows:
"It is alleged that fuel transfer canal liner documentation was falsified, that required weld radiography was not complaced, and that hold points on inspection travelers for the fuel building were signed off improperly."
The TRT investigation found that "the allegation that required radiography was not completed is not substantiated, since the TRT found records showing the results of radiography of those velds for which radiography was required. The primary subject of this s
,' Rsvision: 1
-. Page 4 of 39 RESULTS REPORT ISAP VII.a.8 (Cont'd)
3.0 BACKGROUND
(Cont'd) allegation was the falsification or improper sign-off of records i.e., inspection travelers. The TRT could not conclude that the irregularities noted constituted falsification, per se.
Apparently, these irregularities occurred because of poor practices and inadequate inspection forms. Some travelers also appeared to have been signed off improperly.". However, they concluded "that there are record anomalies apparent in the liner plate travelers which are not adequately explained on the face of the traveler (e.g., dates changed), which violate procedures (e.g., failure to transfer sign-off from chits to traveler daily), and which employ inadequate procedures (i.e., confusion over the use of the five-line traveler)."
This Action Plan addresses fuel pool liner documentation problems.
The physical reinspection of fuel pool liner welds was performed under ISAP VII.c. " Construction Reinspection / Documentation Review Plan", population FPLR (Fuel Pool Liner).
4.0 CPRT ACTION PLAN 4.1 Scope and Methodology The fuel pool liner systems are not defined as nuclear safety-related in the CPSES FSAR. However, they are classified as safety-related in Gibbs & Hill specification 2323-S5-18. For the purposes of this action plan, the fuel pool liner systems were considered to be safety-related. This action plan was developed to evaluate compliance with the internally-i= posed requirements of 10CTR50, Appendix B.
The objective of this action plan was to evaluate irregularities in the fuel pool liner travelers and related documentation and to identify progra:matic implications.
To achieve this objective the following tasks were !
implemented:
Review of liner specification, drawings and procedures I to determine requirements.
Review of liner travelers for irregularities.
l
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Revision:
i.' 1 Page 5 of 39 j
i( - RESULTS REPORT Y~ ~ E
~ .
ISAP VII.a,8 -- *-
(Cont'd) *"-
4.0 CPRT ACTION PLAN (Cont'd) - M 2' The specific methodology is dascri M C '#~
4.1.1 a tion ,C. dfavingt ,
The fuel pooland and fabrication liner sp'ec insp W [ffin proieh EFes were reviewed and the erection, inspection and testing requirements were identified.
. .- ..m 4.1.2 A sample of the liner veldq for traveler and related documents review was rand dly selected from a list of safety-related spent fuel pool, transfer canal and cask loading pit velds prepared during e'rectitftr of the liner and associated components. Although the' reactor building refueling cavity liners were downgraded to non-nuclear saf ety-related (NNS) by Gibbli'& Hill specification 2323-SS-18, Revision 4, they had been fabricated under the same control program as the remainder of the fuel pool liner system. Inspection travelers for the reactor building refueling cavity liners were not included, however, because there was no reason to believe that different information would be gained by their review. A minimum random sample size of sixty (60) was selected.
A sample review was considered to be a reasonable approach since the population of travelers is i
homogeneous in that all the work was accomplished by the same craft and inspection personnel using similar procedures.
.s -
4.1.3 Fuel pool liner inspection travelers associated with the selected liner welds were obtained. These travelers were reviewed to determine if all the required inspections were performed to the a'pplicable design and procedure requirements and that the travelers were properly completed. The review included, but was not limited to, verification of date entries, inspection sign,o(fs by certified personnel and irregularities of tht* types identified by the NRC-TRT. The information obtained was summarized on a documentation data sheet to aid in the evaluation.
_. C: ..
s
y Rsvision: L1 Pese 6 of 39 RESULTS REPORT ISAP VII.a.8 (Cont'd) 4.0 CPRT ACTION. PLAN (Cont'd) 4.2 Participant's Roles and Responsibilities The organizations and personnel that participated in this effort are described below with their respective scopes of work.
4.2.1 TUGC0 CPSES Project 4.2.1.1 Scope Assisted the QA/QC Review Team in !
the identification and provision of '
all necessary specifications, drawings,' procedures and other documentation necessary for the execution of'this action. plan.
i I Processed DRs/NCRa that were generated due to this action plan.
4.2.1.2 Personnel Mr. C. R. Hooton Project Coordinator (TNE)
Mr. D. W. Snow TUGC0 QC s Coordinator "
4.2.2 CPRT QA/QC Review Team 4.2.2.1 Scope The QA/QC Review Team was responsible for evaluating the adequacy of completed inspection records.(travelers) for fuel pool liner fabrication.
{
4.2.2.2 Personnel (Prior to March 1, 1986)
Mr..J. L. Hansel QA/QC Review Team Leader Mr. S. L. Crawford Issue Coordinator I
1 4
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.* Revision: 1 i Pcgs 7 of 39
, RESULTS REPORT ISAP VII.a.8 (Cont'd) l l 4.0 CPRT ACTION PLAN (Cont'd) 4.2.2.3 Personnel (Starting March 1, 1986)
Mr. J. L. Hansel QA/QC Review Team
. Leader l
Mr. G. W. Ross Issue Coordinator u
' NOTE: Although shown as Issue Coordinator in Revision 1 of the Action Plan, M. P. Obert performed no work on this Action Plan.
4.3 Qualifications of Personnel No inspections were required during the implementation of this action plan; therefore, inspection personnel certified in accordance with ANSI N45.2.6 were not required.
Participants were qualified to the requirements of the CPRT Program Plan. l 4.4 Procedures Matrices and data sheets were developed as an integral part of the evaluation. No formal procedures were prepared since no reinspection were performed.
4.5 Standards / Acceptance Criteria Fuel pool liner inspection records shall be in compliance with the inspection record requirements of 10CTR50 Appendix B, Criterion X , " Inspection", and Criterion XVII " Quality Assurance Records" and the associated commitments of CPSES/FSAR paragraphs 17.1.10 and 17.1.17 respectively.
Minimum acceptance criteria abstracted from these documents are:
4.5.1 Records shall provide sufficient detail to permit adequate confirmation of acceptable inspection activities.
4.5.2 Records shall provide identification of the person (s) recording the data and approving the Inspection l Results. I 4.5.3 {
Records shall show acceptance of the item or activity !
documented and approved by authorized personnel.
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Revision: 1 Page 8 of 39 RESULTS REPORT ISAP VII.a.B i (Cont'd)
/
4.0 CPRT ACTION PLAN (Cont'd) l i i' 4.5.4 Records shall identify the type of observation and ,
results. '
4.5.5 Records shall identify the action taken in connection with any deficiencies noted.
4.5.6 Records shall provide a legible, accurate record of work accomplished.
5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS 5.1 Population Identification A compilation of Brown & Root Stainless Steel Liner Inspection Travelers for the Unit 1 and Unit 2 Spent Fuel Pools Transfer
' Canals and Spent Fuel Cask Pits was obtained by conducting an inventory of the travelers in the Permanent Plant Records Vault (PPRV). These also include travelers for the removal of temporary attachment velds which were included in the same files. Two thousand six hundred and ten (2610) travelers were identified. This list of travelers was validated by comparison with fuel pool liner system weld map drawing.
5.2 Sample Selection A random sample of sixty (60) inspection travelers was entracted from the population list using random number tables provided by the CPRT statistical consultant. (Reference 9.1) 5.3 Specification and Procedure Requirements All revisions of the Gibbs & Hill Specification 2323-SS-18,
" Stainless Steel Liners" and Brown & Root and TUGC0 construction and inspection procedures were reviewed to identify requirements for the fabrication, installation, inspection and testing of the stainless steel fuel pool liner systems. A list of the procedures reviewed and their revision dates is included as Attachment 1 to this report.
Construction (site fabrication, erection and installation) of the fuel pool liners was governed by Brown & Root procedure 35-1195-CCP-38 (now generally identified ae CCP-38). In addition to erection and installation sequences, CCP-38 also identified the QC Hold Points (since Revision 1, October 21, 1977) to be observed for the ficup and welding of floor and wall plate liner sections.
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.' Pege 9 of 39 RESULTS REPORT ISAP VII.a.8 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
The historical files for the inspection' procedures used by Brown & Root and TUGC0 for ficup and welding inspection of stainless steel liners were reviewed to ide.ntify the required QC hold points and inspection documentation to be used for the inspection of liner welds. Brown & Root and TUGC0 procedure historical files were also reviewed for effective dates art any special requirements for materials or techniques to be followed by Nondestructive Examination (NDE) personnel. The NDE procedures were standard NDE procedures used for site NDE and were not specifically written for the fuel pool liner.
The information gathered through these reviews was utilized to develop a Fuel Pool Liner Documentation Data Sheet. This Data Sheet was used to summarize the information contained in the inspection traveler packages and related documentation to aid in the evaluation.
5.4 Review of Travelers and Related Records Traveler Evolution The Brown & Root Stainless Steel Liner Inspection Traveler is the form used to document completed inspection hold points.
This form underwent several modifications during the period of
?uel pool liner installation. Six different inspection travelers (plus several minor versions) were promulgated by construction and inspection procedures during the time of erection and installation of the fuel pool liners:
j' November 1977 5 QC hold points, 1 page August 1978 5 QC hold points 2 pages April 1979 8 QC hold points, 2 pages t
June 1982 7 QC hold points, 2 pages September 1982 8 QC hold points 2 pages January 1984 8 QC hold points, 2 pages (add hear # for repair)
' Additionally, a " Nondestructive Test Inspection Request" form s was used to iocument those inspections or tests that were not t' shown as hold points on the inspection traveler. Liquid ;
, , s penetrant examination after removal of temporary attachments is an example. This form, as defined in CCP-38, was primarily used as the mettis by which tne craf t notified QC that an item
- o. y !y was ready for inspection.
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RESULTS REPORT 4
ISAP VII.a.8 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
The changes to the inspection travelers do not appear to be in response to specification revisions and were apparently intended to document inspection points more clearly, consistent with fabrication / installation work sequence.
In some cases, the traveler applicable at the time was l
partially completed; some completed inspection hold points l
were documented on the traveler, others were documented on l
supplemental travelers, inspection reports and nondestructive test inspection request tickets.
Neither the construction procedures nor the inspection procedures provide explicit guidelines for the completion of the inspection travelete. As a consequence of the number of different travelers and lack of procedural guidance, there was inconsistency in the documentation and recording of fuel pool liner inspections.
Inspection Traveler Package Review Inspection traveler packages were obtained and reviewed as described in paragraph 4.1.3 above. Where the traveler packages included other documentation such as Nondestructive Test Inspection Request tickets, weld repair records, NDE reports (including radiographic (RT) examination), inspection reports (IR) and nonconformance reports (NCR), that documentation was also reviewed. In order to perform an assessment of welder qualifications, it was necessary to review all Wald Material Requests and Wald Filler Material Logs (WMR/WFML) (approximately 250) listed on the travelers.
The information extracted from the travelers, WMR/WFMLs and related documentation was recorded on Fuel Fool Liner Documentation Data Sheets prepared for this action plan.
(Reference 9.2)
The review of the travelets and associated documents identified numerous deviations which fall into two categories
- general and specific. General deviations are those of a l
I programmatic nature which were orevalent in all samples and concern procedural requirements, traveler content, related.
documentation, data recording and recordkeeping. General l
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(
RESULTS REPORT ISAP VII.a.8 '
(Cont'd) '
5.0 i IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Con deviations are described in Attachment 2. These general deviations are collectively addressed in QA/QC Program Deviation Reports QA/QC-PDR-1 and QA/QC-PDR-2. The most significant general deviation. relates to the inconsistency in documenting hold point 1, verification of cleanliness and weld joint fit-up. The remaining general deviations described in Attachment 2, while certainly not acceptable from a QA record standpoint, are relatively insignificant in regard to their impact on the adequacy of the hardware.
Specific deviations are described in Attachment 3 to this report and are coded as " insignificant", " notable" or "significant" relative to their potential effect on the hardware. Definition of these codes is given in Attachment 3.
Of the sixty (60) weld documentation packages reviewed, thirteen (13) contained significant documentation deviations, twenty-four (24) contained notable documentation deviations and eleven (11) contained insignificant deviations. It should be noted that some documentation packages contained multiple deviations which fall into separate " codes" or levels of significance.
Review of Related Records Welding Procedures The review of the fuel pool liner inspection travelers identified five (5) Brown & Root welding procedures which had been used for fabrication welding of the liners:
WPS 88023 - Manual GTAW* (January 19, 1977 -
September 7, 1984)
WPS 88025 - Manual GTAW (March 13, 1978 -
present)
WPS 88031 - SMAW** (June 18, 1976 -
April 3, 1978)
Gas Tungsten Arc Welding Shielded Metal Arc Welding s
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.. RESULTS REPORT ISAP VII.a.8 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
WPS 88032 - SMAW (May 18, 1977 - present) 1 WPS 99020 - Auto GTAW (February 9,1977 - March 14, 1 1980) l The weld procedure history files were reviewed to identify the effective date and revision, the qualified base and filler materials and the referenced procedure qualifications.
Walder Qualification The qualification status of the fifty (50) welders who performed the welding recorded cn the sampled travelers was reviewed to verify qualification in applicable weld processes on the dates identified by weld material issue records. The review was limited to verifying that the correct qualification codes for the applicable weld processes were recorded on the weekly Walder Qualification Matrix (WQM) during the dates identified.
The use of the Walder Qual,1fication Matrix was considered acceptable since discussions with the Authorized Nuclear Inspector (Independent third-party) indicated no discrepancies had been identified with regard to welder qualification. Additionally, a spoccheck of the accuracy of the WQM was made by tracing through the supporting documentation to the veld filler material issue records. No discrepancies were noted.
Approximately one hundred sixty (160) weekly WQMs were reviewed with thirteen (13) noted as missing. Although a few weekly WQMs were missing, the continuity of maintenance of qualification could be established through those remaining. No discrepancies related to welder qualification were noted. (Reference 9.2)
Note: The WQM is an administrative tool and is not a permanent plant record.
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Inspectors and NDE Personnel Certification A list of the twenty-five (25) QC inspectors who had performed or signed off inspections on the sampled travelers (or related repair records, NDE reports and inspection reports) was compared to personnel certification files to determine if the personnel had been certified in appropriate disciplines / procedures prior to performing inspection or examination activities.
Thirteen (13) deviations involving eight (8) persons were identified by the review. These included:
- a. No certification to the appropriate procedure found
- b. No TUGC0 certification to TUGC0 procedures (but Brown & Root certification present)
- c. Certification signed by Level III on date later than performance of inspection.
See Deviation Report R-VII.a.8-DR2. Inspector
. certification deviations are not shown in Attach =ents 2 and 3.
In addition, an evaluation was performed of the documentation supporting the certifications of all twenty-five (25) QC inspectors. This evaluation was performed by ISAP I.d.1 personnel in accordance with the I.d.1 guidelines. [Ref. ISAP 1.d.1, QC Inspector Qualifications)
The resu3ts of the I.d.1 evaluation, which included
.UGCO/B&R verification of experience and education, are summarized as follows:
Of the twenty-five (25) inspectors l identified, six (6) had been considered to be satisfactory during a previous I.d.1 Review.
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Sixteen (16) are considered to be adequate, from a qualification standpoint, to perform the activity for which they were certified.
Three (3) are considered to be not qualified.
A Phase III evaluation of the non-fuel pool liner inspections performed by these individuals will be required. This evaluation will be conducted in accordance with ISAP I.d.1 guidelines. The results will be reported through the Collective Evaluation of the Construction QA/QC Program.
During the course of fuel pool liner records review, the QA/QC Review Team noted that B&R became aware in June 1979, that one of the three (3) inspectors, placed in Phase III above, may not have been qualified to perform fuel pool liner inspections. Investigative action was taken which included a reinspection of all recreatable inspection hold points previously inspected by this individual. This reinspection was documented on an Inspection Report dated August 1, 1979. All reinspected hold points were found to be acceptable.
This action is considered to be adequate to resolve the concern with regard to this inspector's work on the fuel pool liner.
5.5 Close-out of Related External Issue This item deals with the Unit 2 Reactor Building cavity liners which were not included in the population for this Action Plan.
During the course of the investigation of allegations AQ-55 and AQ-78, the TRT reviewed Nonconformance Report (NCR)
M-83-00795 concerning the welding of stainless steel liners.
This NCR had been revised twice to change the description of the nonconforming condition.
SSER Number 11 states "It appeared to the TRT that this revision was issued to avoid the investigation that the original NCR would have required.". SSER Number 11 further states that the TRT "... does not accept TUEC's explanation that the revision was simply a matter of word changes.". (Reference SSER No. 11. Appendix 0. Page 0-202] {
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Subsequent to the TRT review, NCR M-83-00795 was revised a third time to change the justification for the disposition based upon the declassifiestion of the reactor cavity liner to non-safety-related by Revision 4 of Specification 1.323-S5-18.
A CPRT review of NCR M-83-00795 through Revision 3 revealed the following:
a) NCR M-83-00795 (March 18, 1983) was generated to document nonconformances identified during a review of documentation for " randomly" selected welds. (The sample selected was a " grab sample" and not a statistically random sample.) The NCR was dispositioned "use-as-is" with the justification given as " Subject welds are seam welds utilized to provide leak tightness of the liner. Acceptability of welds shall be based on vacuum box and hydrostatic tests."
(It is the opinion of the QA/QC Review Team that, based upon the random selection, appropriate disposition of the NCR would require investigation of all fuel pool liner welds to determine the extent of the problem.]
b) Revision 1 (March 28, 1983) deleted reference to the random selection, leading to the inference that only the listed welds were affected. Therefore an investigation would not be required. The disposition and justification remained unchanged.
c) Revision 2 (August 8, 1984) deleted weld 1225 from the listing of welds affected. Weld 1225 is a plate-to-embed weld. No explanation of the deletion was provided.
d) Revision 3 (April 30, 1985) changed the justification of the disposition based upon the declassification of the Reactor Cavity liner by revision 4 of the specification.
Based upon the NCR review and discussions with TUGC0 personnel, the TRT position stated in SSER Number 11 could not be supported in that the revision to delete the word " random" did not change the original disposition of the NCR. However, the disposition of the NCR does not address appropriate action to investigate other fuel pool liner welds to determine the extent of the problem. Implementation of the corrective action recommended in Section 5.10 will resolve the hardware concerns relative to this NCR.
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\
ISAP VII.a.8 I (Cont'd) f l
5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
NCR M-83-00795 has been referred to the Issue Coordinator for q ISAP VII.a.2, "Nonconformance and Corrective Action System," )
for information and evaluation. ,
1 5.6 Summary of Results of Review of Inspection Traveler Packages and Related Records The inspection travelers and related records selected for review covered a time span from January 1978 through April 1983. This time span coincides with the major fabrication and installation activities associated with the fuel pool liners.
The occurrence of document deviations does not appear to be concentrated in any time period within this time span.
Attachment 3 presents the specific deviations'found and lists the applicable inspection traveler package. There are eleven (11) types of specific deviations listed. As previously noted, thirteen (13) documentation packages contained significant documentation deviations, twenty-four (24) contained notable documentation deviations and eleven (11) contained insignificant documentation deviations. The most significant deviations were the failure to maintain weld filler material traceability (5 welds) and failure to provide any evidence that required liquid penetrant and/or leak test (vacuum box) examin tions had been performed (8 welds).
Although required inspections and examinations are not verifiable for a number of welds, there is substantial evidence to indicate that sound welds were made. The general deviations noted in Section 5.4 above are not shown in the matrix since they are prevalent in all sample items.
The following is a summary of the data presented in Attachment 3. The deviations are categorized by irregularity codes which correspond to the acceptance criteria given in Section 4.5 above.
Number of Deviating Sample Items One or more deviations: 33 Deviationa under two or more codes: 6 Multiple deviations under one code: 2 3
Revision:
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(Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Number of Deviating
[ ample Items Code ISAP Acceptance Criteria A: Records shall provide sufficient detail to 14 permit adequate confirmation of acceptable inspection activities.
B: Records shall provide identification of the O person (s) recording the data and approving the inspection results.
C: Records shall show acceptance of the item or 0 activity documented and approved by authorized personnel.
D: Records shall identify the type of 0 observation and results.
E: Records shall identify the' action taken in 0 connection with any deficiencies noted.
F: Records shall provide a legible, accurate 25 record of work accomplished.
The review of fuel pool liner inspection travelers and associated documentation resulted in the issuance of seven (7) Construction Deviation Reports (DRs). These DRs document deviations from defined fuel pool liner procedural and/or specification requirements and are listed below. (Reference 9.4)
R-VII.a.8 - DR1 : Invalidated per CPRT procedures
- R-VII.a.8 - DR2 : Inspector certification discrepancies R-VII.a.8 - DR3 : Inspection travelers record different veld procedure than I that on the applicable WMR !
R-VII.a.8 - DR4 : Missing Weld Filler Metal Logs (WFML)
DRs invalidated as a result of additional information obtained after issuance of the DR and of further in-depth investigation.
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R-VII.a.8 - DR5 : WMRs listed on inspection traveler have the applicable weld
" lined oat" R-VII.a.8 - DR6 : Penetrant materials batch number not recorded R-VII.a.8 - DR7 : Brand name and number of leak test fluid not recorded R-VII.a.8 - DR8 : Liquid penetrant and/or leak test (vacuum box) not performed R-VII.a.8 - DR9 : Invalidated per CPRT Project procedures
- R-VII.a.8 - DR10: Invalidated per CPRT Project procedures
- R-VII.a.8 - DR11: Invalidated per CPRT Project procedures.
- Evaluation of these Construction Deviation Reports for safety significance by the CPRT Safety Significance Evaluation Group indicates that none of the deviations have a hardware safety significance. This evaluation is consistent with the TRT technical evaluation stated in SSER Number 10 and Number 11 and is based on the conclusion that the liner will perform its intended function of providing a leak tight membrane which is backed by a monitored leak collection and detection system. A synopsis of the safety significance evaluation is presented in Attachment 4 (Reference 9.5) 5.7 Compliance with 10CFR50, Appendix B and FSAR Commitments The deviations identified through implementation of this action plan, as discussed above, together with those identified by the ISAP VII.c Fuel Pool Liner documentation review, reflect inadequate implementation of the requirements of 10CTR50, Appendix B, Criteria V " Instructions, Procedures and Drawings", Criteria X " Inspection" and Criteria XVII -
" Quality Assurance Records". Based on the number and type of deviations identified, the fuel pool liner documentation fails to provide:
DRs it;"elidated as a result of additional information obtained after insuance of the DR sad of further in-depth investigation.
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- a. Sufficient detail to permit adequate confirmation of acceptable inspection activities.
- b. Legible, accurate record of work accomplished.
.Two (2) QA/QC Program Deviation Reports (PDRs) were written to document the breakdown in the documentation portion of the QA/QC program applicable to the fuel pool liners. (Reference 9.4)
QA/QC-PDR-1: Fuel pool liner records are not sufficient to provide evidence of the acceptability of activities af f ecting quality.
QA/QC-PDR-2: Inspection planning did not provide for 1) predesignation of applicable hold points and 2) consistency in completing data entries.
Each of the above QA/QC Program Deviations was evaluated to determine if it should be classified as a QA/QC Program Deficiency. In accordance with the CPRT Program Plan, Appendix E, a QA/QC Program Deficiency is defined as a deviation meeting one or more of the folleving criteria:
Inadequacy of a QA/QC program element such that substantive revision of the program or other corrective action is required to bring it into compliance with the regulatory requirements FSAR commitments or other licensing commitments; or Extensive evaluation would be required to determine the effect on the quality of construction.
The deviations described in reports QA/QC-PDR-1 and 2 invo".ve the program which was applied to the fuel pool liner systems.
Since these systems are now complete, revision to the program or other similar corrective actions would be inappropriate with respect to the fuel pool liner systems. The evaluacion recommended in paragraph 5.10 of this report is not con 91dered to be extensive. Therefore the deviations described it. these PDRs are considered not to be QA/QC Program Deficiencies, i
,- Revision: 1 Page 20 of 39 RESULTS REPORT ISAP VII.a.8 (Cont'd) )
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5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.8 Trend Anal'ysis Documentation deviations were found to be present in each of the Fuel Pool Liner Inspection Traveler packages reviewed during implementation of this Action Plan. This was determined to constitute a trend and an evaluation was performed in accordance with Appendix E of the CPRT Program Plan. (Reference 9.6)
Because a substantial number of deviations were identified affecting essentially all of the sample items reviewed, the trend is considered to be adverse to the quality of the fuel pool liner QA records.
The deviations were evaluated both individually and collectively to be not safety-significant. They are of such a nature that the presence of additional similar deviations would not result in a safety-significant deficiency occurring within the Fuel Pool Liner System. Therefore it is concluded that this trend is not an " adverse trend" as defined by Section 5.0 of Appendix E of the CPRT Program Plan.
l The established TUGCO AWS or the B&R ASME control programs were not implemented for the construction of the fuel pool liners since the liners were not governed by these established codes. The program implemented for the liner construction contained some elements of each of these programs, but was unique. Therefore, it is not obvious that similar deviations would likely occur in the documentation of other areas of the plant. However, due to the nature of the deviations, and the QA/QC organizations and procedural system involved, a i
conservative view indicates a small potential for the existence of similar deviations in other areas / work activities. Therefore, a further investigation of this potential will be made as part of the implementation of ISAP VII.b.1 which will perform a retrospective review of onsite fabrication / installation activities. ISAP VII.b.1 is considered to be the appropriate vehicle for this further investigation since this Action Plan will review documentation resulting from onsite f abrication and installation activities covered by both the B&R ASHI and the TUGC0 AWS control programs. ISAP VII.b.1 has been revised to address this additional investigation.
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.' Page 21 of 39 RESULTS REPORT ISAP VII.a.8 (Cont'd) l 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) 5.9 Root Cause and Generic Implications In accordance with the CPRT Program Plan, root cause and generic implications evaluations are not required relative to fuel pool liner documentation since no deficiencies or adverse trends were identified. However, the subject of documentation inadequacies will be addressed as a result of the broader evaluations made through Action Plan VII.b.1 and QA/QC Collective Evaluation activities.
5.10 Recommended Corrective Action The following recommend'ation is not required for the QA/QC Review Team to reach a final conclusion. However, in order to fully resolve this issue, the Engineer should provide final approval of the fuel pool liner systca.
The Engineer should conduct an evaluation to establish the acceptability of the fuel pool liner in view of the number of documentation gaps and inconsistencies in the fabrication records. The gaps and inconsistencies identified in the sample, the most serious of'which involve failure to conduct and/or document required inspections or examinations and lack of weld filler material traceability, are indicative of a substantial lack of documentation which should be available to substantiate compliance with specification requirements.
Because of the classification status of the liner system, this ;
analysis should be directed primarily at the consideration of 1 the functional aspects of the liner system rather than at nuclear safety considerations.
The Engineer should request that the fuel pool liner Inspection Traveler packages and related records be reviewed further by the TUGC0 Quality group to the extent necessary to provide the Engineer with sufficient information to permit an evaluation of the acceptability of the fuel pool liner system.
NOTE: The Engineer has concurred with this recommended corrective action.
6,0 CONCLUSIONS A substantial number of documentation problems exist in the fuel pool liner documentation packages, some of which raise concerns of the adequacy of the liner hardware. The significant problems identified in the sixty (60) weld traveler packages reviewed are as follows:
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Pega 22 of 39 j RESULTS REPORT i ISAP VII.a.8 (Cont'd)
6.0 CONCLUSION
S (Cont'd) !
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Traceability of weld filler material was not maintained for five (5) welds. ]
Evidence of performance of required liquid penetrant and/or leak testing (vacuum box) was not available in eight (8) weld traveler packages.
In addition to these significant problems, there were twenty-four (24) weld traveler packages with lesser but notable problems and one (1) general problem involving the adequacy of cleanliness and weld joint fit-up records. Although not considered to be significant problems, they are serious enough to cast an element of doubt regarding the adequacy of certain activities / items. There were eleven (11) weld traveler packages in which insignificant problems were identified. There were an additional four (4) general items documented in QA/QC Program Deviation Reports which were also relatively insignificant problems. Although the procedures and forms relating to work,' inspection and documentation requirements contained some weaknesses, most of the problems identified more probably relate to lack of attention on the part of the QA/QC supervision responsible for the task of inspection and documentation thereof.
Because of the substantial number of documentation deviations identified during implementation of this Action Plan, the TRT finding that TUEC did not maintain an effective and controlled QC program for fuel pool liner fabrication, installation, and inspection is confirmed.
The deviations noted confirm the " irregularities" identified by the US NRC as a part of the TRT letter, and of SSER Number 11. The results of the ISAP VII.c Fuel Pool Liner document review identified similar documentation deviations. [Ref. 9.3]
The primary subject of allegations AQ-55 and AQ-78 was the falsification or improper sign-off of records. As a result of their investigation, the TRT stated in SSER Number 11: "...the TRT concludes that these travelers were signed off improperly, i.e.,
without substantiation or personal inspection of the inside weld.
The TRT does not consider this improper sign-off to be falsification, as stated by the alleger, because of an apparent absence of an intent to deceive.". The CPRT concurs with this conclusion as no evidence was noted during the CPRT review of sixty (60) fuel pool inspection traveler packages to indicate that entries had been fraudulently made or that inspection conclusions, i.e., acceptability of hardware, had been altered.
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ISAP VII.a.8 7 (Cont'd)
6.0 CONCLUSION
S (Cont'd)
Despite the documentation problems, there is a substantial amount of information available to indicate that it is likely that the fuel pool liner system was generally fabricated and installed utilizing qualified weld procedures and welders and that appropriate inspections and tests were actually conducted.
Nonetheless, the QA/QC Review Team considers that the Engineering evaluation recommended in Section 5.10 is appropriate.
Because the QA/QC program implemented for liner construction was unique to the fuel pool liner systems (dif ferent from the TUGC0 AWS or the B&R ASME control programs) it is not obvious that similar discrepancies would necessarily occur in the documentation for ether areas of the plant. Nevertheless, ISAP VII,b.1, which will perform a retrospective review of onsite fabrication activities, has been expanded to investigate this possibility. ISAP VII.b.1 is considered to be the appropriate vehicle for the further investigation since this Action Plan will review documentation resulting from activities covered by both the B&R ASME and the TUGC0 AWS control programs.
Seven (7) Construction Deviation Reports and two (2) QA/QC Program Deviation Reports were issued to document the discrepancies
- j. identified through implementation of the Action Plan. The deviations described in these reports have been evaluated and determined to have no safety-significant hardware effect on-the fuel pool stainless steel liner systems. For purposes of the safety significance evaluation, indeterminate conditions were treated as unacceptable conditions.
i 7.0 ONGOING ACTIVITIES The SRT considers the implementation of ISAP VII.a.8 to be complete. The action recommended in paragraph 5.10 is not mandatory; therefore CPRT overview of action taken by the Engineer is not required.
The effect of inspector qualifications will be evaluated and reported through Phase 3 implementation of ISAP I.d.1, QC Inspector Qualifications.
NCR M-83-00795 has been referred to the ISAP VII.a.2 Issue Coordinator for information and evaluation, s
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., Pegs 24 of 39 RESULTS REPORT ISAP VII.a.8 (Cont'd) 8.0 ACTION TO PRECLUDE OCCURRENCE IN THE FUTURE Fabrication and erection of the fuel pool liner system is complete; therefore no action is required to preclude recurrence.
9.0 REFERENCES
9.1 ISAP VII.a.B Working File, File #5 (Sample Items List).
9.2 ISAP VII.a.8 Working File, File #7B (Review Results Documentation) 9.3 ISAP VII.a.8 Working File, Fila #7A (Documents Reviewed) 9.4 ISAP VII.a.8 Working File, File #8A (Deviation Reports) 9.5 ISAP VII.a.8 Working File, File #8B (Safety Significance Evaluations) 9.6 ISAP VII.a.8 Working File, File #8C (Trend Analysis) 1 l
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Attachment 1 Specification and Procedure Revision Histories Gibbs & Fill Specification
" Stainless Steel Liners" Specification No. 2323-55-18 Revision 1 04/16/75 Revision 2 10/16/75 Revision 3 04/06/79 Revision 4 04/05/85 Procedure Revision History Construction Procedure Revision Date.
B&R:
35-1195-CCP-38 Revision 0 07/19/77
" Stainless Steel Liner Erection" Revision 1 10/21/77 ICN#1 11/03/77 Revision 2 12/08/77 ICN#1 01/06/78 (dated 1977)
ICN#2 08/04/78 ICN#3 04/18/79 fevision 3 05/23/79 ICN#1 07/26/79 ICN#2 06/22/82 ICN#3 09/07/82 ICN#4 12/17/82 Revision 4 01/05/84 ICN#1 07/02/84 ;
ICN#2 04/22/85 '
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Attachment 1 (Cont'd) '
Procedure Revision History Welding Procedure Process Revision Date Change' Notice B&R:88023 Manual (GTAW) 0 01/19/77 ------
- Gas Tungsten Arc Welding 1 02/24/77 ------
2 06/09/77 ------
3 03/09/78 ICN#1 (Not in file).
ICN#2 (Not in file)
ICN#3 09/05/78 ICN#4 09/06/78 ICN#5 09/08/78 ICN#6 09/09/78 ICN#7 10/06/78* .
4 09/20/78 ICN#1 10/12/78 ICN#2 10/17/78 ICN#3 11/08/78 ICN#4 11/10/78 ICN#5 11/14/78 ICN#6 11/15/78 ICN#7 12/07/78 ICN#8 03/01/79 5 04/03/79 ICN#1 04/09/79 ICN#2 04/09/79 ICN#3 04/10/79 6 04/13/79 ICN#1 04/30/79 ICN#2 05/02/79 ICN#3 04/30/79 ICN#4 05/07/79 ICN#5 05/10/79 ICN#6 06/12/79 7 06/18/79 ICN#1 07/02/79 8 10/15/79 ICN#1 10/29/79 ICN#2 01/30/80 ICN#7 to Revision issued after Revision 4 because the engineer (G&H) did not accept Revision 4 until October 6, 1978, and Revision 4 was not available I
for use before that date.
s
I Revision:
1
. Pego 27 of 39 RESULTS REPORT
~
ISAP VII.a.8
{
(Cont'd)
Attachment 1 i (Cont'd) 1 Procedure Revision History Welding (Cont'd)
Procedurs Process Revision Date Change Notice B&R:88023 Manual-GTAW 9 03/20/80 ICN#1 04/03/80 ICN#2 04/03/80 ICN#3 04/15/80 ICN#4 10/01/80 10 04/18/82 -----
Deleted 09/07/84 (Incorp. in 88025)
B&R:88025 Manual GTAW 0 03/13/78 ICN#1 08/08/78 ICN#2 09/05/78 ICN#3 09/06/78 1 09/20/78 ICN#1 11/10/78 L
ICN#2 11/15/78 2 04/03/79 ICN#1 04/10/79 ICN#2 05/08/79 ICN#3 05/10/79
~
3 10/15/79 -----
4 03/19/80 ICN#1 04/09/80 ICN#2 08/13/8D ICH#3 12/16/81 5 03/16/82 ICN#1 04/22/82 ICN#2 12/10/82 i 6 09/14/84 ICN#1 07/20/84 7 10/22/84 ICN#1 01/21/85 l
l l
t
Ravision: I Pags 28 of 39 4 RESULTS REPORT a l ISAP VII.a.8 (Cont'd)
Attachment 1 (Cont'd)
{
Procedure Revision History-Welding (Cont'd)
Procedure Process Revision Date Change Notice B&R:88031 (SMAW) 0 06/18/76 ICN #1 12-6-77*
Shielded Metal Arc Welding 1 01/23/78 -----
Deleted 04/03/78 (Incorp. in 88032)
- ICN #1 to Revision 0 not incorporated in Revision 1.
Procedure Process Revision Date Change Notice B&R:88032 SMAW 0 05/18/77 -----
1 03/09/78 -----
2 04/03/78 -----
3 05/31/78 ICN#1 09/06/78 ICN#2 09/13/78 4 10/30/78 -----
5 04/03/79 ICN#1 04/10/79 ICN#2 05/07/79 ICN#3 05/10/79 ICN#4 06/12/79 6 08/23/79 -----
7 03/19/80 ICN#1 04/09/80 ICN#2 05/27/80 ICN#3 07/15/80 8 01/02/82 -----
9 10/22/84 -----
2
. Revision: 1 Pego 29 of 39 RESULTS REPORT ISAP VII.a.8 '
(Cont'd)
Attachment 1 (Cont'd)
Procedure Revision History Walding (Cont'd)-
Procedure Process Revision Date Change Notice B&R:99020 Automatic Gas 0 02/09/77 -----
Tungsten Arc l Welding 1 09/23/77 -----
2 08/23/78 -----
3 09/01/78 ICN#1 11/06/78 4 04/03/79 ICN#1 04/10/79 ICN#2 05/08/79 ICN#3 11/05/79 l
ICN#4 11/07/79 5 03/21/80 :CN#1 04/03/80 ICN#2 04/03/80 ICN#3 04/03/80 ICN#4 04/15/80 6 05/19/80 ICN#1 06/10/80 Deleted 03/14/80 (Not needed)
\
1
% i
Rcvision: 1
. Page 30 of 39 4
RESULTS REPORT ISAP VII.a.B (Cont'd)
Attachment 1 (Cont'd)
Procedure Revision History Inspection Procedure Revision Date B&R: CP-QCP-2.11 (0) 09/28/77
" Inspection of (1) 01/10/78 Stainless Steel deleted 01/10/79 (Incorp. in Pool Liner QI-QAP-10.1-4)
Systems" B&R: CP-QCI-2.11 0 11/29/72
" Welding Inspection , 1 12/01/77 and Fit-up of !
2 01/09/78 Stainless deleted 01/10/79 (Incorp. in Steel Liners" QI-QAP-10.1-4)
B&R: QI-QAP-10.1-4 0 01/05/79* l
" Welding Inspection deleted 12/28/79 (Renu =bered as
)
I and Fit-up of QI-QAP-11.1-4)
Stainlass Steel Liners" l
B&R:QI-QAP-11.1-4 0 12/26/79
" Weld Inspection deleted Inspection of 01/15/82 (deleted in error) reissued 01/26/82 (no change)
Stainless deleted Steel Liners" 04/05/82 (TUGC0 QI-QP-11.14-6)
TUGCO:
I QI-QP-11.14-6 0 03/26/82
" Inspection of Site 1 09/08/82 Fabrication and 2 03/09/83 Installation of 3 03/25/83 Stainless Steel 4 06/17/83 Liners" 5 08/23/83 6 01/10/84 deleted 11/18/85
- QI-QAP-10.1-4 van also issued as Revision 0, August 24, 1978, titled " Request for Requalification of Welders by ANI".
! 5 l
__ _ _ . _ - _ _ - - - - - - - ~ - -
Revision: 1 Page 31 of 39-RESULTS REPORT ISAP VII.a.8 (Cont'd)
Attachment 1 (Cont'd)
Procedure Revision History NDE Procedures B&R: CP-NDEP-200-Visual Examination Weldments Issued: 06/18/75 (revised 04/20/76, 04/23/76, 01/05/79, 03/13/79, 09/27/79)
Deleted: 02/13/81 B&R: QI-QAP-10.2-7-Visual Examination Weldments
- Rev 0 02/13/81 Rev 1 05/27/81 Rev 2 11/10/81 Rev 3 12/08/81 Rev 4 12/16/81 Rev 5 01/11/82 Rev 6 01/14/82 Deleted. 03/12/82 Replaced by: QI-QAP-11.1-26, R7 l QI-QAP-11.1-28, R9 QI-QAP-11.1-38, RO
- 1. Revision 0 did not require personnel to be "crained, qualified, and certified", merely " familiar with methods"; Revision 1 required certifications.
- 2. This is a general procedure; the "B&R Stainless Steel Liner Inspection Report" was not a part of the procedure.
B&R: CP-KDEP-300-Liquid Penetrant Examination Issued: 10/15/75 (revised 09/14/78, 01/05/79, 03/13/79, 09/27/79)
Deleted: 02/13/81 s
. * ^ .
Revision: 1
^
Page 32 of 39 4
RESULTS REPORT ISAP VII.a.8 (Cont'd)-
Attachment 1 (Cont'd)
Procedure Revision History NDE Procedures (Cont'd)
B&R: QI-QAP-10.2-1-Liquid Penetrant Examination Rev 0 02/13/81 Rev 1 01/11/82
- Rev 2 07/15/82 TUGCO: QI-QP-11.18-1-Liquid Penetrant Examination Rev 0 07/01/82 i Rev i 07/28/82 -
Rev 2 12/30/82 Rev 3 07/24/84
- 1. Requirement to record penetrant material batch numbers was not added to QI-QAP-10.2-1, Paragraph 4.10 until Revision 1, January 11, 1982; B&R: CP-NDEP-600-Leak Detection (Vacuum Box)
- Issued: 12/10/75 (revised 04/28/76, 09/13/78, 10/22/79) ,
Deleted: 02/13/81 B&R: QI-QAP-10.2-6-Leak Detection (Vacuum Box)
- i Rev 0 02/13/81 Rev 1 01/11/82 TUGCO: QI-QP-11.18-6-Leak Detection (Vacuum Box)
- Rev 0 02/04/83 Rev 1 03/08/83
- 1. Leak detection fluid is required to be certified to meet limits of 500 ppm sulphur and 500 ppm halogen; QI-QP-11.18-6, Revision 1, 1
March 9 1983 Nupro "$noop"in changed lieu ofParagraph 2.3.2 to provide for the use of certifications, l
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Revision:
Page 33 of 39 1
)
I RESULTS REPORT
-. j ISAP VII.a.8 i (Cont'd) '
l Attachment 1 i (Cont'd) l Procedure Revision History NDE Procedures-(Cont'd)
B&R:CP-NDEP-101-Radiographic Examination Issued: 11/14/75 (revised 09/11/78, 01/05/79, 03/13/79, 09/27/79)
Deleted: 02/13/81 l
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. Revision: 1- a
. Pega 34 of 39 RESULTS REPORT ISAP VII.a.8 (Cont'd)
Attachment 2 i Fuel Pool Liner Documentation - General Discrepancies Drawing number RFB 00831 is universally entered on the travelers, but the entries do not reference the applicable drawing sheet and/or revision used for installation or inspection. Additionally, the revision level of the NDE procedures used is not consistently recorded. [ Reference QA/QC-PDR-1]
" Metal _ Type" ~1s universally entered as " stainless steel" or "S/S", but the traveler does not identify the specific type i and grade of material (e.g., ASTM A240. Ty 304L, ERA). This information can be identified on receiving records related to liner place piece numbers; but it is not established for miscellaneous material such as angles, channel, attachments, and bolting. For miscellaneous material, the travelers do not reflect the specific location (except by weld number) nor the specific identification by part number or bill of material number. The major pieces - liner plate, etc., - are identified by piece numbers. A review of receiving records indicates that all stainless steel miscellaneous material received onsite during the period of fuel pool liner fabrication and erection met specification requirements and was purchased as "Q" material. (Reference QA/QC-PDR-1]
There is no consistency whether or not Nondestructive Test Inspection Request tickets are included in the inspection traveler packages. Although the tickets are required to be generated, the procedure does not address retention.
1 The ticket was also used, in accordance with the procedure, to document inspection hold points not included on the traveler such as liquid penetrant inspection after removal of temporary attachments. [ Reference QA/QC-PDR-1)
There was no consistency in how hold point 1 (verify ficup and cleanliness) was recorded on five -hold-point travelers (CCP-38, Revision 2, ICN #2) or eight -hold-point travelers (QI-QP-11.14-6) when the inspection was actually performed and recorded on the original 1-page traveler (CP-QCI-2.11-1).
Some travelers mark hold point 1 as N/A, while others were signed (with either the original date or a new date) based on the signoff on the CP-QCI-2.11-1 traveler. (Reference QA/QC-PDR-2) s
,' i Revision:
. 1 i Pegs 35 of 39 RESULTS REPORT
+
ISAP VII.a.8 (Cont'd)
Attachment 2 (Cont'd)
Since November 1977, the inspection traveler weld inspection sheet has continuously had provisions for recording "Magnaflux Spotcheck" (sic) (should be "Spotchek") penetrant, cleaner, and developer batch numbers, (on CP-QCI-2.11-1, 35-1195-CCP-38, and QI-QP-11.14-6 forms); but only one (1) of sixty- (60) travelers reviewed (weld 1825) recorded that data.
Furthermore, procedures QI-QAP-10.2-1 and QI-QP-11.18-1 require recording penetrant material batch numbers.
Specification 2323-SS-18. Revision 4, added the requirement that liquid penetrant tests be performed in accordance with Section V of the ASHI Code.Section V requires certification of the halogen and sulfur content of penetrant materials used on stainless steel surfaces.
The NDE procedures also require halogen and sulfur certifications (500 ppm maximum each) when used for examination of stainless, steel. surfaces, and for the certification to be retained. Since the batch numbers were not recorded, the traveler review.provided no evidence that acceptable liquid penetrant materials were used. See Deviation Report R-VII.a.8-DR6. [ Reference QA/QC-PDR-1)
Note: Corrective actions in response to Stop Work Order No.
28, 11-23-82, and NCR No. H-4484 R1, closed 12-20-82 have verified that all batches of penetrant material received onsite were acceptable.
Leak detection procedures NDEP-600. QI-QAP-10.2-6, and QI-QP-11.18-6 require the leak detection liquid used on stainless steel surfaces to be certified to 500 ppm maximum halogen and sulfur content, and also require leak test reports to document the manufacturer's brand name and number. The entries on the travelers only identify a trade name " Snoop",
but do not identify a batch or trace number to relate to chemical certifications. As a result, the traveler review provided no evidence that acceptable leak detection liquids were used. See Deviation Report R-VII.a.8-DR7. [ Reference QA/QC-PDR-1)
Note: QI-QP-11.18-6 was revised by Revision 1, March 8 I 1983, to provide for the use of Nupro Company " Snoop" Icak detection liquid in lieu of halogen and sulfur certifications.
s
.g ,'4- e Rovision: 1 Paga 36'of 39 RESULTS REPORT ISAP VII.a.8 (Cont'd)
Attachment 3 Specific Deviations Potential Effect on Hardware
- 1. Liquid penetrant and vacuum box performed prior to visual examination
.for surface preparation (prerequisite for
, psnecrant examination). (Weld 31)
- 7. significant
- 2. Incorrect procedure typed on traveler form.
lined out by different inspector than person performing inspection / examination. (Weld 310) Insignificant
- 3. WMR/WTMLs listed against incorrect hold points.
(Welds $11, 603, 626, 638, 3444, 3445, 3478, 3512, 3582, 3620) Notable 4 Procedurer lined thru sud changed on traveler one (1) month af ter performance of inspection (erpmination). (Welds 537A, 603, 638, 639, 664)
Insignificant t
- 5. No veld filler material issued after ficup inspection for seam weld. (Wald 736) Notable
- i. 6. Backing plate ficup recorded for plate to angle weld; that joint configuration is an overlap. fillet veld and should have no backing strip.'(Weld 998) insignificant
- 7. Traveler for Wald 1225 reflects " Cask Pit";
CP-QCI-2,11-1 traveler (original ficup) reflects " Fuel' Building Canal". Location and Unit cumber no;; recorded on Traveler.
(Weld 3569, 1225) Insignificant
- 8. Weld date entered on traveler in lieu of welder symbol. Walder was identified on WTML.
(Weld 1407) Insignificant
- 9. Final LT (VB) signed " satisfactory" by L. Wilkitson, but remaining portion of VB is "X'd" out. Therefore performance of Final LT is indeterminate. (Weld 2007) Notable
{
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D
- l. ,g .} " Revision:
1 b1
.,. j *,y g,4 i' ,
Page 37 of 39
- y. L ,
, 4 .
1$ o *
'y 9 q u
' y /,
")
3 i; \
. RESULTS REPORT , r+ ' 7 ( k' i}
.. . + ft* s
% / "
- h. }y. 3
%cTf*'
ISAP VII.a.8 (Cont'd) i)
4 t
-(, 4 "i $ ,
k tO Attoihddae 3 4 g 9., s \nf '$
' ># '\ . s i n (Cont'd) f >
+
9 , '
I'- 4
,4 _
- - [I ? ~ <
!4t Potential Effect
,a( , ... -
.epa't
.f 7r on Hardware 4
x
.o , s gg
- f. E W 10. . Multiple irregular ties were not.th during / t Q ^
review of WMRs/ VIES auch as: '3 6 j .
(
n3 4
- a. Welds lined out on the WMR although the *
, ys3 WMR is shown nn the applicable B&R
- Stainless Stet.1 Liner Inspection Traveler.
7.y g ')
r\C -
~
(Welds 865, 886, 969, 1180, 1188,-1203, 2007) Notable t
i -[+
W 3, "l Wcid E I Filler hiter141 Logs.(VFML) which were d'
? ,
4
+
- i. ;"
flisted on V.01 travelers were not located in 4
'[,3 the record files turned over to the TUGC0 Operat;lons Vault.. (Velds 173 310, 886, T!44/s. !
\ .
3512) l3 i My Signiffeant j y s '\ . t. a=
r
% v t. . Veld procedures recornd ca? thesBk1 traveletsi -
/ g, '
- dE not match those recdeded on~the listed, j
\
' /'
(
WMR/wTN . (Welds 736, 886.j225, 1503, r
$ \ ,3129) ) Notable
('
fs t1 -
p 4 i*
' 11. ,The hd d, point for ligaid penetrant and/or leak i
" ' tesf.(Vacuum box) was,'not signed off. Therefore ci. performando as required by Specification 2323-55-18 ,s ,
rf cannot be determined. (Welds 310, 1605, 1795, #
2007, 3444, 3445, 3512b3672) Significant sg -
t)
I' ,
( \, - >
n
\ % %
% Definition of, Codes: 9 * '
4 , i T*
t I
Insigniff.cgt$'; Leviations that are primarily ah'vious doc:bentation l* $
8 errors with a negligible potential to adversely affect g the acceptability /6f the hardware. I
- Ic <
't '
Notable: Deviutions that have a moderate potential to adversely., #
i a*fect tha actiptability of the hardware.
t p A s
Signif1Sanr:
g' l (
Devia_tions tha': make the acceptability of chv' specific '.j' 1 '. .-
/a l
kf 7 item to specification requirements indecerninate s f,3 l t i
l without
,N c.
additional evaluation.
.")
'd
, l'.
(These codes are uniqua -to tr.e deviations identified by this Action \
l !
Plan.) 3
, 5 N 1
g \
1 t '
a I
j }- ,
v,s s
)-
3 I
A
p ** e Ravision: 1 Pcg3 38 of 39
. RESULTS REPORT ISAP VII.a 8 (Cont'd)
Attachment 4 Synopsis of Safety Significance Evaluation of Fuel Pool Liner Construction Deviations Function of Fuel Pool Liner System:
The fuel pool liners are intended to provide a leak tight barrier over the reinforced concrete structural walls and floor. The liner l
!. seam welds provide membrane continuity across the joints of the plates. An integral part of the liner system is a network of leak collection channels designed to carry any water which could leak through the seams to specified, monitored collection points.
l
Reference:
- 2) G6H Specification 2323-S5-18, Section 7.0 The liners are not required to be seismic Category I because damage or loss of the plate would not result in a significant loss of water since the concrete cavity structure would withstand an SSE without significant damage. The stresses induced in the fuel pool liner plate welds due to a Safe Shutdown Earthquake (SSE) will usually be well below the maximum allowable stress levels and therefore liner failure is not considered a likely event. Even in the event of a liner plate failure, it would not likely block the spent fuel coolant outlets completely and cooling of spent fuel would be maintained. The liners do not provide any structural integrity to the concrete structure. Their primary purpose is to provide a smooth, easily decontaminated surf ace.
Reference:
- 2) NUREG-0797, Supplement 10 (SSER-10), page N-282 Objective of the Evaluation:
To confirm that adequate evidence exists to demonstrate that the liner velds can perform their intended function.
Evaluation:
Specification 2323-SS-18 required a 48 hour5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> leakage test to be performed prior to acceptance of the liner system. A review of the test reports indicates successful test and acceptance of all sections of the liner system. TUGC0 Operations Department Instruction, OWI-104 Revision 3, indicates that operations personnel monitor fuel pool liner leakage twice per shift, s
a .- .
,, Rsvision:. 1
, . Pass 39 of 39 y .,
y*. RESULTS REPORT ISAP VII.a.8 (Cont'd)
Attachment 4 (Cont'd)
Conclusion:
Based upon the above, it is concluded that the reported deviations do siot affect the ability of-the liner system to perform its intended function.
36 4
COMANCHE PEAK RESPONSE TEAM ACTION PLAN ISAP VII.b.2 TitJe: Yahe Ideasserbly Eevicier No.
~~ ~
0 ~~~
1 Reffects CoITinints Description Original Issue On Plan Prepared and Recon = ended by: / '
Feview Team Leader 72t= .._
2 Ib ,,
Approved by: ,,
Senior Review Team .j d A ./k L gi - -
04 p
J / a Date h/L/[f /!D!80
- i
' i
~
, . Revision: 1 Page 1 of 7 ISAP VII.b.2 Valve Disassembly
1.0 DESCRIPTION
OF ISSUE IDENTIFIED BY NRC (USNRC letter of January 8, 1985, Pg. 23)
"The TRT found that installation of certain butt-welded valves in three systems required removal of the valve bonnets and internals prior to welding to protect temperature-sensitive parts. The three systems involved were the spent fuel cooling and cleaning system, the boron recycle system, and the chemical and volume control system. This installation process was poorly controlled in that disassembled parts were piled in uncontrolled areas, resulting in lost, damaged, or interchanged parts. This practice created the potential for interchanging valve bonnets and internal parts having different pressure and temperature ratings."
2.0 ACTION IDENTIFIED BY NRC Evaluate the TRT findings and consider the implications of these findings on construction quality. " ... examination of the potential safety implications should include, but not be limited to the areas or activities selected by the TRT."
" Address the root cause of each finding and its generic implications..."
" Address the collective significance of these deficiencies..."
" Propose an action plan...that will ensure that such problems do not occur in the future."
3.0 BACKGROUND
Other possible reasons for valve disassembly include hydrotest, flushing, purging and repair, and therefore many different valve types are potentially affected.
Additional background information such as valve manuf acturers, types, sizes, ratings, installation dates, etc. will be obtained as a part of the implementation of this Issue-Specific Action Plan.
l l
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',' , Revision: 1 Pcge 2 of 7 ISAP VII.b.2 (Cont'd) 4.0 CPRT ACTION PLAN 4.1 Scope and Methodology The objective of this action plan is two fold. Firstly, to evaluate if procedures are adequate to control the valve disassembly / reassembly process. Secondly, to evaluate if valves that required disassembly were properly reassembled; and, if not, whether an improperly reassembled valve could result in a code violation or have a safety consequence.
The following tasks will be implemented to achieve these objectives:
Identify all valves which have been disassembled and reassembled.
A procedure review to determine adequacy of control of valve components curing disassembly and reassembly.
A safety consequence analysis to determine if valve component parts from one valve are physically capable of fitting up to another valve of the same type but having a lower pressure /t'emperature rating or code class and identify potential risks if such reassembly occurred.
A reinspection of valves which have been disassembled and reassembled to establish confidence that valves were properly reasse.mbled.
The first three of the above tasks shall be considered Phase I of this action plan. Phase II of this plan will be the fourth task. .
The specific methodology is described below:
4.1.1 The first step in this investigation will be to j
identify the population of valves which have been i disassembled. All valve disassembly and reassembly was accomplished under operation travelers. A log of all operation travelers will be reviewed and those pertinent to valve disassembly will be utilized to develop a list of all valves which have been disassembled.
i l
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i
, Rsvision: 1 Page 3 of 7 ISAP VII.b.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) !
From this list another list will be developed of those valves in the population identified in the TRT issue (diaphragm valves in the spent fuel cooling and cleaning. system, the boron recycle system, and the chemical and volume control system).
4.1.2 Review applicable procedures, for both construction and QC, to determine if they provided adequate controls'of materials during valve disassembly and reassembly. In addition to proper matching of components, the procedures will be reviewed for their adequacy to identify and replace parts damaged during the disassembly, storage and reassembly process.
If procedures have changed during the course of construction the historical file of procedures will be reviewed to determine if improper reassembly were more likely to occur during a particular time frame. If the procedures for Units 1, 2 and Common are different.
they will each be evaluated.
In terms of valve installation processes present procedures will be viewed as adequate or not based on their clarity, completeness and on the practicality of their use.
4.1.3 In parallel with the procedure review, an analysis will be made to determine ehe safety consequences of improperly assembled valves. The analysis will include potential failure modes resulting from improper reassembly of the generic valves in question. Generic valves are those which required disassembly of all valves of that type. This analysis will be performed on a case basis for non generic valve types pending the results of reinspection.
In addition, an evaluation will be made to define potential code violations which could result from improperly assembled valves.
4.1.4 A reinspection of valves which have been disassembled will be performed to provide assurance that the valves were reassembled using the correct components. A sample of valves from the population of all valves which have been disassembled will be reinspected and an additional sample of valves from the population cocprised of the valves identified in the TRT issue t _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ - _ -
Revicion: 1 Page 4 of 7 ISAP VII.b.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) i' vill be reinspected. Both samples will be in accordance with the sampling criteria guidelines of Appendix D. Sample reinspection is considered to be reasonable approach for the following reasons:
No programmatic deficiencies have been identified in this population to date.
The population of valves which have been disassembled is homogeneous. Specifically, all the valves were disassembled by the same craft under the same procedures. Therefore, sampling in accordance with Appendix D will detect, with a high level of accuracy, programmatic errors associated with the process of disassembling and reassembling valves.
4.1.5 Manufacturers drawings and disassembly procedures will be reviewed and documentation packages will be assembled for those valves selected in the random sample. Inspection procedure will be predicated on the results of this review. If review of the documentation for a specific valve indicates probable improper reassembly, reinspection will include a verification of internal parts. Probable improper reassembly will be indicated by an inconsistency in internal ecmponent serial nos from one Operation Traveler to another for a particular valve.
1 4.2 Procedures Operations, construction and/or OC procedures now in effect will be reviewed and if found satisfactory, will be used for disassembly, inspection, reassembly and test as required.
4.3 Participants Roles and Responsib111 ties The organizations and personnel that will participate in this effort are described below with their respective scopes of work.
0
- Rsvision: 1 Page 5 of 7 ISAP VII.b.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.3.1 TUGC0' Comanche Peak Project Engineering CPPE 4.3.1.1 Scope.
Assist the QA/QC Review Team in the identification and provision of all necessary specifications, drawings, procedures and other documentation necessary for the execution of this action plan.
Assist in determining the physical location of the valves selected for inspection.-
Process NCRs that may be generated due to this action plan.
4.3.1.2 Personnel Mr. C. Moehlman TUGC0 Coordinator 4.3.2 Brown & Root M111 wright Shop 4.3.2.1 Scope Disassemble and reassemble valves, as required, for inspection.
4.3.2.2 Personnel Mr. C. Moehlman TUGC0 Coordinator '
4.3.3 CPRT-QA/QC Review Team I
4.3.3.1 Personnel All activities not identified in 4.3.1. and 4.3.2 above will be the responsibility of the QA/QC Review Team.
4.3.3.2 Personnel Mr. M. Obert Issue Coordinator Mr. C. Spinks Inspection Supervisor l
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, , R3vicion: 1 I Page 6 of 7 ISAP VII.b.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
Mr. J. Adam Safety Significance Evaluation Supervisor Mr. J. L. Hansel QA/QC Review Team Leader j 4.4 Qualifications of Personnel Where inspections require the use of certified inspectors, qualification will be to the requirements of ANSI N45.2.6 at the appropriate level. CPS 2S personnel vill be qualified in accordance with applicable project requirements. Third-party inspectors will be certified to the requirements of the third-party employer's Quality Assurance Program and 1
specifically trained to the requirements of the CPSES quality procedures.
Other participants will be qualified to the requirements of the CPSES Quality Assurance Program or to the specific requirements of the Program Plan.
4.5 Sampling Plan The sampling plan will be designed in accordance with the guidelines of Appendix D, and will result in reasonable assurance that programmatic deficiencies do not exist in the population.
The minimum sample size according to Appendix D is 60, with a detection number of zero (i.e., the critical region is one or more deficiencies found in the sample). If one (1) deficiency is found, the sample vill be expanded to 95, and the root cause of the deficiency will be evaluated. If no further deficiencies are found, and the deficiency from the first sample is determined to be non-programmatic, it will be concluded that the population passes the requirements of Appendix D. If the number of deficiencies discovered is large (i.e., two or more), or a potential root cause is identified as program =atic, a 100" reinspection and record review of the population will be performed.
4.6 Acceptance Criteria A valve vill be accepted if the body markings and bonnet markings found in the field are traceable to the Manufacturer's Data Report (Form h*PV-1) in the Receipt Inspection Report for that valve. Valves which have Permanent Equipment Transfers documenting replacement of valve
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ISAP VII.b.2 (Cont'd)
'4.0 CPRT ACTION PLAN (Cont'd) components and for which the new component is traceable'to a form NPV-1 of a valve of identical make, pressure rating, temperature rating, metallurgical type and code class'are acceptable.
4.7 Decision Criteria 4.7.1 The action plan will be closed if the valves which have been disassembled and reassembled can perform.their intended safety function. Otherwise necessary corrective action will be recommended to meet the design requirements.
4.7.2 If a safety-significant deficiency is found the sample will be expanded and a root cause and generic implication analysis will be done. .If deviations are found, trend analysis will be done and for any adverse trend identified a root cause and generic implication analysis will be performed. Any QA/QC Program L deficiencies found will be identified to the QA/QC 1
Programmatic Issue Supervisor for analysis.
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COMANCHE PEAK RESPONSE TEAM ,
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RESITLTS REPORT. J t
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ISAP: VII,b.2 1
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Title:
Valve Disassembly REVISION 1 4 I
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issue Coordinator
,/w h D&te /
Revi WO Team Leader 3 18 '&d Dat4 '
j f1 &,/ C 3 2 0 / f fe Johrp. Beck, Chair =an CPR -5KT Date l
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Revision: .1 Page 1 of 20 1 RESULTS REPORT ISAP VII.b.2 f
Valve Disassembly
1.0 DESCRIPTION
OF ISSUE (USNRC Letter of January 8, 1985, Page. 23)
"The TRT found that installation of certain butt-velded valves in three systems required removal of the valve bonnets and internals prior to velding to protect temperature-sensitive parts. The three systems involved were the spent fuel cooling and cleaning syste=,
the boren recycle system. and the chemical and volume control system. This installation process was poorly controlled in that
' disassembled parts were piled in. uncontrolled areas, resulting in lost, da: aged, or interchanged parts. This practice created the potential for interchanging valve bonnets and internal parts having different pressure and temperature ratings."
2.0 ACTION IDENTIFIED Evaluate the TRT findings and consider the i=plications of these findings on construction quality. "... examination of the pacential safety i=plications should include, but not be li=ited to the areas or activities selected by the TRT."
" Address the root cause of each finding and' its generic i:p11 cations..."
" Address the collective significance of these deficiencies..."
" Propose an action ple.n...that vill ensure that such proble=s do not occur in the future."
3.0 BACKCROUND The valves identified by the NRC staff are of a particular type which required disassembly for installation. Other possible reasons for valve disassembly include hydrotest, flushing, purging, and repair, and therefore many different valve types could be affected if the concern is substantiated. Accordingly, all valves which'had been disasse bled under the Construction QA program, regardless of valve type or reason for disassembly, were included in this action plan.
The loss of or dar. age to valve parts is not a concern if the parts are replaced with acceptable spare parts and properly documented.
The program for valve testing provides assurance that valve damage that would hinder preper operation of the valve is detected and corrected. As the issue as stated in SER-ll did not allege any
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.. PaSe 2 of 20 RESULTS RIPORT ISAP VII.b.2 (Cont'd) l 3.0 BACKCROUS*D (Cont'd) -k improper handling of lost or damaged valve parts this action plan focused on the " potential for interchanging valve bonnets and internal parts having different pressure and temperature ratings".
SER-11 states it. part that:
"The TRT interviewed QC inspectors who knew of recent incidents involving lost, misplaced or interchanged valve bonnets. The QC inspectors stated that when these valves were disassembled for system flush under the direction of startup test engineers, one bonnet was lost and a mismatch between
-valve body and bonnet occurred. Although these incidents were '
documented in nonconformance reports, see e.g., NCR M-11645 (May 8, 1984), the problems associated with maintaining control of valve parts during installation, system flush, and startup indicated to the TRT that in spite of the issuance of the revised traveler and CP-CPM-9.18 in June 1983, loss, damage, and interchange of valve parts continued to occur.
The TRT did not find any evidence that B&R addressed the problem en a progra=matic basis, e.g., by use of a formal corrective action request (CAR)...
The TRT concludes that the allegation concerning interchanged valve parts (AQ-52) was substantiated. The TRT also concludes that this condition has potential quality significance due to the generic implications. The generic implications are based on documented evidence that the interchange of valve parts did occur and effective progra=matic corrective action was not implemented to identify the problem and to prevent the loss, damage, and interchange of valve parts."
An assessment of TUCCO's handling of programmatic corrective action '
vill be included in ISAP VII.a.2, "Nonconformance and Corrective Action Systems". This action plan (Valve Disassembly) was l structured to evaluate the adequacy of current procedures to centrol the valve disassembly / reassembly process and to evaluate the physical status of valves which are itstalled in the plant and have been disassembled and reassembled.
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'- RISULTS REPORT e
ISAP VII.b.2 (Cont'd) 4.0 CPRT ACTION PLAN 4.1 Scope and Methodology The objective of this action plan was two fold: 1) to
! evaluate if procedures are adequate to control the valve l disassembly / reassembly process; 2) to evaluate if valves that i required disassembly were properly reassembled and, if not, l vhether an improperly reassembled valve could result in a ecde l violation or have a safety consequence.
l The following tasks were i=ple=ented to achieve these objectives:
l Identification of all valves which have been disasse: bled and reassembled under the Constructica QA progra=.
A procedure review to determine adequacy of control of valve ce=ponents during disassembly and reassembly.
A gefety consequence analysis to deter =ine if valve eccponent parts fre= one valve are physically capable of fitting up to another valve of the same type but having a lever pressure /te=perature rating or Code class and identification of potential risks if such reatsembly occurred.
- A reinspection of valves which have been disassembled and reasse= bled to establish confidence that valves were properly reassembled.
The first three of the above tasks were considered Phase I of this action plan. Phase II of this plan was the fourth task.
The specific methodology is described below:
4.1.1 The first step in this investigation was to identify the population of valves which have been disasse: bled.
All valve disassembly and reassembly was acco=plished under operation travelers or Item Removal Nctices (IRNs). A log of all operation travelers was reviewed and those pertinent to valve disassembly were utilized to develop a list of all valves which have been disassembled. The log includes QC Checklists for valves (QCVs) which acco=pany IRNs applicable to valve ,
disasse=bly. )
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.. RESL*LTS rep 0RT ISAP VII,b.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd)
Fro = this list another list was developed of those valves in the population identified in the TRT issue (diaphrag= valves in the spent fuel cooling and cleaning syste=, the boren recycle syste=, and the che:ical and volu=e control systa=).
4.1.2 Applicable procedures were reviewed, for both construction and QC, to deter =ine if they provided adequate controls of =aterials during valve disasse=bly and reasse=bly. In addition to proper =acching of co=penents, the procedures were reviewed for their adequacy to identify and replace parts da: aged during the disasse=bly, storage and reasse=bly process.
For procedures which changed during the course of construction, the historical file of procedures was reviewed to deter =ine if 1= proper reasse=bly was =cre likely to occur during a particular ci=e fra e. Uni:s 1, 2 and Co==en used the same procedures.
In ter=s of valva installation processes, present procedures were viewed as adequate or not, based on their clarity, co=pleteness and on the practicality of their use.
4.1.3 In parallel with the procedure review, an analysis was
=ade to deter =ine the safety consequences of i= properly asse= bled valves. The analysis included potential failure = odes resulting fro = i= proper reasse=bly of the generic valves in question. Generic valves are those which required disasse=bly of all valves of that type.
This analysis was to be perfor=ed on a case basis fer non generic valve types pending the results of )
reinspection. (As discussed in Section 5, this was net l required.) I In additien, an evaluation was =ade to define potential code violations which could result fro: i= properly asse= bled valves.
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., RESULTS REPORT l'
ISAP VII,b.2 (Cont'd) 4.0 C?RT ACTION PLAN (Cont'd) 4.1.4 A reinspectier. of valves which were disassembled was performed to provide assurance that the valves were reasse= bled using the correct components. A sa:ple of valves from the population of all valves which were-disasse= bled was reinspected, and an additienal sa:ple of valves from the population comprised of the valves identified in the TRT issue was reinspected. Both saeples were in accordance with the sampling criteria guidelines of Appendix D. Sample reinspection was considered to be a reasonable approach for the following reasons:
- No prograc=atic deficiencies were identified in Phase I of this ISAP.
- The population of valves which have been
, disassembled is homogeneous. Specifically.
I all the valves were disasseebied by the sa=e craft under the same procedures.
4.1.5 Manufacturers drawings and disasse=bly procedures were reviewed and documentation packages were asse: bled for those valves selected in the random steples. The inspection procedure was predicated on the results of this review. If review of the docu=entation for a specific valve indicated probable improper reasse:bly, reinspection was to include a verification of interr.a1 parts. Probable impreper reassembly would have been indicated by an inconsistency in internal component serial nu=bers from one Operation Travelt- to another for a particular valve. (As discussed ir Sectien 5.
internal verification was not found to 'se necessary.)
l 4.2 Procedures Construction and QC procedures now in effect were reviewed for use if disasse=bly, inspection, reasse=bly and test of any valves had been necessary as a result of the implementation of this ISAP.
4.3 Participants Roles and Responsibilities The organizations and personnel that participated in this effort are described belov vith their respective scepes of work.
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. RESULTS REPORT ISAP VII.b.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.3.1 TUGC0 Comanche Peak Project Engineering CPPE 4.3.1.1 Scope Assisted the QA/QC Review Tea: in the identification and provision of all necessary specifications, drawings, procedures and other documentation necessary for the execution of this action plan.
- Assisted in determining the physical location of the valves selected for inspection.
Process NCRs that were generated due to this action plan.
4.3.1.2 Personnel Mr. C. Meehlman TUGC0 Coordinator Mr. D. Snow QA/QC Coordinator 4.3.2 Brown & Rect M111vright Shop 4.3.0.1 Scope Disasse:ble and reassemble valves, as required, for inspection. (As discussed in Section 5, this was not required.)
4.3.2.2 Personnel Mr. C. Moehlman TUCCO Coordinator 4.3.3 CPRT-QA/QC Review Team 4.3.3.1 Personnel All activities not identified in 4.3.1 and 4.3.2 above were the responsibility of the QA/QC Review Team.
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Page 7 of 20 RESL*LTS REPORT ISAP VII.b.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.3.3.2 Personnel Mr. M. Obert Issue Coordinator Mr. C. Spinks Inspection Supervisor Mr. J. Adam Safety Significance Evaluation Supervisor Mr. J. L. Hansel QA/QC Review Team Leader 4.4 Qualifications of Personnel W7ere inspections required the use of certified inspecters, qualification was to the requirements of ANSI N45.2.6 at the appropriate level. CPSES personnel were qualified in accordance with applicable project require =ents. Third-party inspectors were certified to the requirements of the third-party employer's Quality Assurance Progra= and <
specifically trained to the require =ents of the CPSES quality '
procedures.
Other partic,ipants were qualified to the require =ents of the CPSES Quality Assurance Progra: cr to the specific requirements of the CPRT Progra: Plan.
4.5 Sa:eling Plan The sampling plan was designed in accordance with the guidelines of Appendix D. to result in reasonable assurance that progra==atic deficiencies do not exist in the populatien.
The minimum sample size according to Appendix D is 60, with a detection nu bar of zero (i.e., the critical regien is one or more deficiencies found in the sample).
4.6 Acceptance Criteria-A valve was accepted if the body markings and bonnet markings found in the field were traceable to the Manufacturer's Data Report (For= NPV-1) in the Receipt Inspection Report for that valve. Valves which have Per:anent Equipment Transfers docu=enting replace =ent of valve components and for which the new component was traceable to a for: NPV-1 of a valve of identical make, pressure rating, te=perature rating, metallurgical type and Code class are acceptable.
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. RESULTS REPORT ISAP VII.b.2 (Cont'd) 4.0 CPRT ACTION PLAN (Cont'd) 4.7 Decision Criteria 4.7.1 The action plan will be closed if the valves which were disassembled and reassembled can perform their intended safety function. Otherwise necessary corrective action will be recommended to meet the design requirements.
4.7.2 If a safety-significant deficiency is found the sa=ple vill be expanded and a root cause and generic implication analysis will be done. If deviations are found, trend analysis will be done and for any adverse trend identified a root cause and generic implication analysis will be performed. Any QA/QC Program deficiencies found will be identified to the QA/QC Progra==atic Issue Supervisor f or analysis.
5.0 1F.PLEF.ENTATION OT ACTION PLAN AND DISCUSSION OF RESULTS 3.1 Su==ary ef Action Plan I=plementation The first step of imple enting this action plan was identification of the subject valves in the populatten. This was acec:plished in two ways.
First, the generic valves (i.e., those valves which required disassembly by nature of their type) were identified by reviewing installation procedures. It was concluded that ITT-Grinnell supplied diaphragm valves were those addressed in the TRT issue which " required removal of the vsive bonnets and internals prior to welding to protect temperature sensitive parts". Additionally, it was found that Borg 'n'arner supplied check valves were disassembled after receipt on site to perform a modification identified by the manufacturer. These l
two generic valve types were included in the population using a listing of valve tag numbers (unique numbers given_to an installed valve) by purchase order. The listing groups the valves according to their manufacturer and type. For these valves an analysis was performed to determine if physical reinspection was required. This analysis lists the possible effects of interchanging those parts of the generic valves where parts of one rating or class valve are physically capable of fitting up with a valve of another rating or class.
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RESULTS REPORT ISAP VII,b.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RISULTS (Cont'd)
In addition to the generic valve types requiring disasse:bly, other specific valves were disasse= bled for various reasons j such as repair, maintenance, or testing. To identify these I valves, operation traveler logs were researched. Due to the large number of valve types / sizes in this category and the
, relatively small number of valves of any given type / size actually disassembled, an analysis such as was perforced fer the generic valves was not performed unless it was deter =ined l
during the reinspection program that a deviation was found fcr a specific valve type. No such cases were found.
A population of one thousand three hundred forty-five (1345) valves that were disassechled and reassembled was identified. l Approximately seven hundred (700) of these valves were ITT-Grinnell diaphragm valves. Tro= within this overall i population a second set of three hundred thirty-four (33')
valves was identified consisting of those valves addressed in the TRT issue (i.e.. ITT-Grinnell diaphrag= valves in the spent fuel cooling and cleaning system, the boron recycle syste=, and the che:ical and volu=e control syste:). The j populations were censidered to be homogeneous for tne felleving reasons: ,
- 1. The valves were disasse: bled by = embers of the ,sare craft 1.e., Brown & Root =111vrights.
- 2. All valves were disasse: bled using the sa=e construction and QA/QC procedures.
- 3. All valves in the samples could be and vere reinspected to the sa:e checklist and attributes and used the sa:e acceptance criteria.
A random sa:ple was chosen fro: both the general population and the TRT issue valves. The samples were rande:1y selected to obtain at least sixty (60) items froc each group in erder to achieve the cenfidence level prescribed in Appendix D of the CPRT Progra: Plan. During random selection of the sixty (60) valves for the general population some sa:ple overla r occurred. Valves which satisfied the criteria of the TRT issue sa:ple were selected in the general population sa:ple. ,
This required selection of only a sufficient number of '
additional valves in the TRT issue saeple to have sixty (60) valves frem each population. Thus, the total nu:ber of valves reinspected was one-hundred six (106).
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1 RESUITS REPORT l
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ISAP VII.b.2 (Cent'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RISULTS (Cont'd)
For each valve selected in the sample an inspection package was assembled containing the manufacturers drawing, piping isometric, and operational travelers associated with that valve. These documents were reviewed for any indications of incorrect valve reassembly which might require disasse:bly of the valve for inspection of internal components. To make this determination the travelers were checked for variances in internal component serial numbers. No such cases were found.
The valves in the sample were then physically inspected in accordance with QI-018. Reinspection of Previously Disasse: bled Valves. The purpose of the inspection was to verify that the body and bonnet it. stalled in the field could be traced back to proper docu=entation showing that they were received fro = the manufacturer as part of the same valve assembly or that plant documentation showed replace =ent of the valve ce:penent.
Valves which had their body and/or bonnet markings obscured by insulation, paint, etc., were classified as inaccessible and were replaced by the next rande:1y selected valve. Forty-two (42) valves were found to be inaccessible. Ne bias was introduced as insulation or paint does not effect the cetheds l- used for the control of the disassembly /reasse=bly of the valve.
5.2 Evaluation and Categorization of Inseection Findings No safety-significant deficiencies were found during the course of the reinspection progra= for this issue.
Description of Deviatiens There were four (4) valid deviations. These were all on ITT-Grinnell diaphrag: valves. The deviations consisted of the bonnet assemblies installed on the four (4) valves being different fre= the bonnet asse:bly that the Manufacturer's Data Report For= (NPV-1) indicated belonged on the valve.
The total of ene-hundred six (106) valves reinspected !
consisted of seventy-nine (79) ITT-Grinnell diaphrag= valves and twenty-seven (27) valves frc: eight (8) manufacturers. I i
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C RESULTS REPORT ISAP VII.b.2 ;
(Cont'd) (
5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Review of the documents assembled for the reinspection packages revealed one case where the bonnet of a diaphragm s valve had been lost and one case where the bonnet had been !
damaged. These were not considered deviations as they were I properly identified by TUCCO using the NCR system and traceability of the installed components was maintained using Petuanent Equipment Transfers.
The ITT-Grinnell diaphragm valves required. disassembly for installation to protect the non-metallic diaphrag=
from heat damage during velding of the body into the pipe line. The disassembly of the valve is accomplished by unbolting the valve bonnet and lifting the bonnet off the body. The diaphragm and other internals remain attached to the bonnet so that the valve is essentially in two pieces, the body and the bonnet. Further disassembly of the bonnet is not required for installation.
The reason for the deviations being limited to the ITT-Grinnell diaphragm valves is judged to be due to the much
- greater opportunity for the switching of parts. This opportunity arose from there being a relatively large nu=ber of this type valve, all of which had to be disassembled to be installed. This resulted in many valve bonnets of the same size and-type in storage avaiting reassembly at the same time.
The only noticeable difference in the valves would be the marking of the valve tag number on the bag in which the bonnet was kept. Thus the opportunity existed to retrieve the wrong storage bag. No other kind of valve was disassembled in such large numbers at a given time.
Two types of ITT-Grinnell diaphragm valves were supplied. The first type is a standard Class 150 valve per ANSI B16.5. This class is commonly referred to as the 150 lb. class valves but in fact are good for pressures higher than 150 psi depending upon the temperature. The design pressure and ce=perature of the ITT-Grinnell standard Class 150 valve is 255 psi at 150' F.
For seme applications valves rated fer 300 psi at 150' F vere specified. The valves provided for these applications are slightly modified versions of the standard Class 150 valve. These modifications are only made to valve sizes 2".
3", and 4". Other valve sizes are identical irrespective of pressure / temperature rating.
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5.0 IMPLEMENTATION OT ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd) l There are two modifications. The most significant modification I is the additicn.of a support sheet behind the diaphrag= to increase diaphragm life by reducing abrasion to the back of the diaphrag= operating at the higher pressure. The support sheet is not required for safe operation of the valve.
Additionally, the manually operated valves rated at a design pressure of 300 psi have a brass spindle instead of stainless steel. This is to reduce galling at higher operating pressures. Valves with air operators have stainless steel spindles for both pressure / temperature ratings. The change in spindle material does not affect safe operation of the valve.
Both modifications described are made only to improve valve lifetice and do not affect the safety performance of the valve. The valves with design pressure of 255 psi and the valves with design pressure of 300 psi have bonnets and bodies of identical material type and metal thickness and identical
'diaphrag:s.
Both of the valve types (255 psi and 300 psi design pressure) were supplied to CPSES in ASME Code class 2 and 3. The ASME valves of a given pressure racing are manufactured the sa:e regardless of desired Code class. After manufacturing they are certified to the desired Code class through different post manufacturing testing, with the more stringent testing being performed on Code class 2. The difference in testing involves only the body of the valve. There is no dif ference in the certification of the bonnets of class 2 and class 3 valves.
Therefore, there is no substantive effect of interchanging class 2 and class 3 bennets on ITT-Grinnell diaphrag: valves.
Additionally, some non-ASME class diaphrag: valves were supplied. The difference in non-ASME and ASME manufacturing processes for the bonnets and these valves are all in the
' level of QA requirements and documentation. The chemical and physical properties identified in the material specifications of the non-ASME and ASME Code class valve bonnets are the same. Also the post manufacturing testing perfor:ed on the ncn-ASME valve bonnets is the same as that for the ASME bonnets, and therefore, the likelihood of an undetected valve I bonnat defect is the same for both ASME and non-ASME valves.
It is concluded that there is no substantive effect of interchanging a non-ASME bonnet with an ASME bonnet on ITT-Grinnell diaphragm valves.
Revision: 1 Page 13 of :o FESULTS REPORT ISAP VII b.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
The valve bonnet of a given ITT-Grinnell diaphrag: valve. size vill physically fit up with any valve body of the same size, regardless of their respective pressure / temperature rating or Code class. Any undocumented interchange of one valve bonnet for another discovered during the reinspection was censidered a deviation.
For two of the bonnets found to be deviations (valve tag no.
2-8422 and 2-7131B), documentation was found in the TUCCO vault substantiating that the valve bonnets installed are identical in pressure / temperature rating and Code class to those which were supposed to be installed.
Of the re=aining two deviations, one of the valves (valve tag no. XSF-179) is a standard (255 psi at 150*F) rated valve, ASME Code class 3. Documentation was not found to identify the pressure / te=perature rating and Code class of the installed bonnet. However, the bonnet was verified through markings stamped on the bonnet to be an ASME Code class ce=ponent so it cust be equal to or better than Code class 3.
Likewise since only two valve types were supplied to CPSES the installed bonnet must be equal to or better in pressure /te=perature rating.
The recaining valve deviation (valve tag no.1-7046) was en a Code class 3 valve rated at 300 psi and 150*F. No documentation was found identifying the installed bonnet but it was verified through markings sta: ped on the bonnet as an ASME Code class component so it cust be equal to or better than required. The reasoning used to classify the deviatien as non-safety significant is as.follows. Making a worst case assumption, the. installed bonnet is assumed to be a standard bonnet. This is a three inch valve. The required bonnet would, at most, have the modification of adding the plastic support sheet. This valve is air operated, so the spindle is stainless steel regardless of the bonnet type. Per ITT-Grinnell, use of a standard valve in a 300 psi system is not recommended; however, lack of the support sheet would reduce diaphragm life but would not prevent proper valve operation. This, coupled with the fact that the valve pressure containing boundary (body and bonnet valls) for both valve types are identical, led to the conclusion of non-safety significance of the deviation. No credit was taken for this valve's expected operating pressure and te=perature being substantially lower than even the standard valve's capabilities. 4
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. RESULTS REPORT ISAP VII.b.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF REStJLIS (Cont'd)
The valves found to have deviations were installed between early 1979 and late 1981. This was a period of high activity for diaphrag= valve installation. It should be noted that the installation travelers for two of the valves. Tag No. 1-7046 disassembled in December, 1980 and Tag No. 2-8422 disassembled in January, 1981, included requirements to record the markings on the bonnets and to verify the numbers at reassembly. This j was done and indicates that the valves as originally issued '
for installation and as currently installed in the plant are the same. This means that the switching of the bonnets occurred prior to their issue for installation. No documentation has been found indicating disassembly prior to installation issue, nor any reason found for disassembly prior i
to issue. '
The travelers for the other two valves with deviations were written prior to the practice of recording bonnet markings so it is unknown when the switching of the bonnets occurred.
Procedure Review Procedures pertaining to valve disasse=bly/reasse:bly are designed to:
- 1. Provide instructions to craft for proper precess co:pletion.
- 2. Provide control for tracking of ce=ponents (valve bonnets) to ensure re=oved parts are returned to proper locations or to ensure interchanged parts are properly recorded (on PETS).
- 3. Provide control for identification and proper replace =ent of lost or da: aged parts. 4 The valve installation process was performed under Construction Procedure CP-CPM-6.9, General Piping Procedure including Appendix E Pipe Fabrication and Installation initially issued in October 1978.
From the initial issue of this procedure in October, 1978, through toe present time the requirement has existed to perfor valve disassembly /reasse=bly using Construction i
Operation Traveler's prepared using Construction Procedure '
CP-CPM-6.3, " Preparation. Approval, and Control of Operation
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. RESULTS REPORT ISAP VII.b.2 (Cont'd) 5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESULTS (Cont'd)
Travelers". The operation traveler " serves as a fabrication /
installation / inspection checklist of operations necessary to achieve a quality end product". Both CP-CPM-6.9 and CP-CPM-6.3 provide for Quality Assurance participation in beth the preparation of the traveler, to ensure proper inspection hold points were included, and during the actual disassembly / reassembly. Procedure CP-CPM-6.9 has also always contained a provision that the parts fro: disasse: bled valves be placed in a bag or box which was marked with the valve nu=ber. The bag / box was required to be stored in the valve ,
vicinity for large valves or in a secure storage area for smaller valves (ITT-Grinnell diaphragm valves can all be censidered scall).
The early procedures in use did not specifically call for recorcing on the travelers the marking stamped on the valve pieces stored nor for QC verification that the same co:penents were being reassembled as were removed. They were adequate, ;
however, if properly followed, to accomplish the' disassembly /
reassembly of valves with correct ec=ponents. This cenclusien follows frc= the requirements to mark the bag containing the disassembled cecponents and to store the= in specified areas.
The valve storage area at the millvright shop was inspected and it was found that valves are currently being carked and stored correctly. The millvright shop personnel are knowledgeable in require =ents for equipment cocponent traceability and have i=ple=ented an effective progra: to reet these require =ents. These personnel have been in charge since early 1983. Sufficient information for evaluating valve stcrage prior to this time is not available.
The issue related to docu=entation of interchanging bonnets on l the diaphrag valves was recognized by TUCCO and as early as i 1980 travelers began to be written requiring that the body and bonnst identification nu=bers (nu=bers that are marked on the individual ec=ponent and are different free the valve asse:bly serial nu=ber) be recorded at the time of valve disasse:bly.
In June, 1953 the procedures were revised and a new procedure, CP-CPM-9.18 Valve Disasse=bly/ Reassembly was issued. This procedure covers valve types including the ITT-Grinnell diaphrag: valves. At the same time Quality Assurance issued i
p Revision: 1 Pag 2 16 et 20 l RESULTS RIPORT ISAP VII.b.2 (Cont'd) 5.0 IMPI.EMENTATION OF ACTION PLAN Ab*D DISCUSSION OF RESUI.TS (Cont'd) procedure QI-QAP-11.1-39A Valve Disasse bly/Reasse bly correspondit to CP-CPM-9.18. This QA procedure specified use of aQCV" checklist which requires the recording of body and bonnet ider.tification nu=bers upon disasse:bly and a verifttation :f the proper nu=bers at the ti=e of reasse:bly.
This ensures snat the proper bonnet is returned to the valve.
The require ents of Procedure QI-QAP-11.1-39A have now been incorporated into QI-QAP-11.1-26, ASHI Pipe Fabrication and Installation Inspections.
CP-CPM-9.18 allows valve disasse:bly to be initiated through use of an operations traveler (CP-CPM-6.3) or an IRN (CP-CPM-6.10). The IRN is used if valves are only disassembled /reasse= bled without addition of spare parts and disassembly /reasse bly procedures are included in CP-CPM-9.18.
Otherwise the operations traveler is used. In both cases QC is involved as specified in Q1-QAP-11.1-26. The QC checklist used with both the operations traveler and the IRN requires recording of the bonnet identification numbers.
s Ad=17.istrative actions were takeh in =id-1985 to ensure the above require n.nts were fully i=ple ented in the startup test 7 7 e rt a= .
The current pregra provides the controls necessary to ensure:
- 1. Proper installation of valve co=penents and
- 2. That non-cenfor:ances (lost or damaged parts or interchanges,affecting performance characteristics) vill be identified and corrected.
The example ci a lost valve cited by TRT in SSER-11 is net unexpected in a large project. The procedures are structured to detect such proble=s. The particular instance =entioned was detected by the project and documented on a Nonconfor:ance Repert, thereby de=enstrating that the procedure syste: is working as designed to identify and correct any lost or da: aged parts.
5.3 Trend Analysis A trend analysis was performed for the four (4) valid deviations found.
All deviatiens were found in ITT-Crinnell diaphrar: valves.
It is significantly less likely that similar deviations exist in valves other than IT*-Grinnell valves for the following reasons:
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RESL1TS REPORT 4 ' hp y't V y a
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.ISAP VII.b.2 s l 9 .y -'
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(Cont'd) ,
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' 5.0 IMPLDIENTATION OT ACTION Pl.AN AND ITISCt$$ ION OF RESL1TS (Co;.t'd) ;J
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s 1. These valves (non-diaphragr) were rot disassembled such
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9 that large numbers of compatible va've . parts were 4 '
I5 " l g available for' interchange sA was the; case with the ,
1 ITT-Grinnell diaphragm valves. Even though all the (
( valses were disassembled by the same craft and under 3
the same procedural control, the valves other than
. . !- s i ITT-Grinnell diaphragm valves were less likely to be 4
( '
interchangedfas there was less potential. \ , ,
- 2. 0(thevalvesotherthanITT-Grinnell,diaphrarmvalvh ,
reinspected, no valid deviations were found.
For the ITT-Grinnell diaphragm valves, it was dete hined that '
the effect of using a valve bonnet rated at 255 psi.on a valve ^
body rated for 300 psi vould not cause a safety-significant deviation in any instance. This comes from the fact ~ tha :,"the pressure boundaries of the valve and the diaphrag= are identical for both ratings. The only differences (diaphrage support sheet and brass spindle in higher rated bonnet) are for increased life / reduced maintenance and are rot re gt.ir e d for the safe operation of the valve.
No deviations in code class were found so no trend for code class violations exists.
The ron-ASMI and ASME Code class valve bonnets are manufactured by the same physical process and use the same materials. Additionally, the post manufacturing testing of the non-ASMI bonnets is the same as for the ASME bonnets.
While the potential for switching non-ASME and ASME Code class bonnets did exist, there is no implication that switching of non-ASME and ASMI valve bonnets could be safety-significant.
Therefore, the four deviations were not judged to be an adverse trend.
5.4 Root Cause and Generie Implication Evaluation The reinspection program found no construction deficiencies.
No adverse trend exists. Therefore, no root cause or generic implication analyses were required.
Revisien: t Page 18 ef :o RESULTS REPORT ISAP VII.b.2 (Cont'd)
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5.0 IMPLEMENTATION OF ACTION PLAN AND DISCUSSION OF RESL*LTS (Cont'd) l 1
The NRC hypothesized root cause that the process for valve $
disassembly / reassembly was not controlled was partially substantiated. The lack of adequate control was limited to ITT-Grinnell valves that were disassembled in large nu=bers at the same time. Although the procedures at that time appeared adequate to accomplish the disassembly / reassembly of valves correctly, they did not contain requirements to record and verify valve bonnet identification numbers, and undocumented interchanges occurred as large numbers of asse=bly/ disassembly operations were performed with similar valves. The procedures were strengthened in June, 1983.
The preble= does not extend to the general population because large r. umbers of other types of valves were not disassembled at the sa e time. The results of our investigation support this.
5.5 Evaluatien of Results Aeainst Actien Plan Decisten Criteria No construction deficiencies were found. The valves found with deviations were determined to be able to perfor their l
intended functions under the design conditions. Therefore, the '
action plan is to be considered closed.
This action plan required expansion of the sample upon finding one or more construction deficiencies. Since none was found, the sample was not expanded.
5.6 Identification and Discussion of Corrective Actien The prograc=atic requirements to preclude switching valve bonnets at the time of reassembly have already been addressed by TUGCO. The change of personnel and revamp of the 3111vright valve storage area in February, 1983, should act to minimize loss, damage or inadvertent interchange of valve bonnets. The procedures in place since mid-1983 requiring the l verification during reassembly that the body and bonnet l identification numbers match those when the valve was l disassembled preclude an inadvertent and undetected switching {
of the valve bonnets. 1 The specific valves found with deviations have been identified to TUCCO and have been entered into the TUGC0 Non-conf ormance l Report (NCR) system.
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- RESULTS REPORT
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l ISAP VII.b.2 (Cont'd)
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I 5.0 IMPLEMENTATION OP ACTION PLAN AND DISCUSSION OT RISULTS (Con 5.7 Out of Scope Observations During the course of reinspection, thirteen (13) valves were found to have the required code data tag missing. This tag lists the manuf acturer's name and serial number. Code class, pressure / temperature rating, and year built. These valves were identified to TUCCO and NCRs written covering this observation. TUCCO had already identified a problem with missing code data tags and has in place acceptable procedures for handling missing data tags. The absence of these tags has no effect on the perfor=ance or safety of the valves.
i No other out-of-scope observations were noted during icplacentation of this action plan.
6.0 COSCLU5iCSS Two valid deviations were found in the sa=ple from the general population of valves disasse= bled and reassembled, one of which was aise part of the TRT issue population. Two more valid deviations were found in the additional sa:ples selected just fro: the TRT population.
No construction deficiencies and no code-class deviations were found in the samples.
A safety significance evaluation has shown that no construction deficiencies can occur on the ITT-Grinnell valves due to interchanged parts occurring during reasse=bly of disassembled valves.
Based on the results of the reinspection program the follosing conclusions are dravn:
There is a 95 percent confidence that at least 95 percent of the general population of valves that were disassembled were reassembled in a functionally correct manner and have no pode class deviations (i.e., zero construction deficiencies or code class deviations found in a sample of sixty).
There is a 95 percent confidence that at least 95 percent of the TRT issue valves (i.e.. ITT-Crinnell valves in the spent fuel cooling and cleaning system, the boren recycle syste=,
and the che:ical and volume control system) that were i
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Pcge 20 of 10 RESULTS REPORT ISAP VII.b.2 (Cont'd)
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7.0 ONGOING ACTIVITIES (Cont'd) I disassembled were reassembled in a functionally correct manner and have no code class deviation (i.e., zero construction .
deficiencies or code class deviations found in a saeple of sixty).
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The procedures for valve disassembly / reassembly were reviewed and f determined to provide adequate control requirements except in cases '
where large numbers of similar valves were simultaneously disassembled. Furthermore, no instances were found that the control process broke down except in the case of the ITT-Grinnell valves. The improvements made to the control process since 1983 provide reasonable assurance that an adequate control process is in place.
The four deviations occurred on ITT-Grinnell diaphrag= valves in a time frame when relatively large numbers of valves were disasse= bled at the same tice. This fact, along with confidence in the process for the control of valve disassembly / reassembly, indicates that uncontrolled switching of valve bonnets does not extend to the general pcpulation. .
7.0 ONGOING ACTIVITIES The SRT considers the i=plementation of VII.b.2 to be ec=plete.
The disposition of the NCRs for the four deviations vill correct the "as installed" documentation for the valves.
The assessment of TUCCO's handling of progra==atic corrective action regarding control of valve disasse=bly/ reassembly will be l addressed in ISAP VII.a.2.
8.0 ACTION TO pKECEUDE OCCURRENCE IN THE FUTURE As previously discussed the control process currently in effect is adequate to ensure proper valve disassembly / reassembly.
Additionally, discussions with millvright supervision and the supervisor of the valve storage area in the millwright shop revealed an appreciation for the need to maintain proper material traceability.
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