21st Annual Report, July 1, 2010—June 30, 2011
Preface | Executive Summary | Memoriam for William Conway
Volume I TOC | Volume II TOC | PG&E Response | Contact | DCISC Home Page
21st Annual Report, Volume I, Section 4.11, Quality Programs
4.11.1 Overview and Previous Activities
The DCISC has followed PG&E’s quality programs continuously since 1990. The DCISC looked at the following aspects of the quality programs in Fact-finding meetings and public meetings in the previous period (2009–2010):
- Missed Hold Points During 1R15
- Quality Verification’s Assessment of Station Performance
- Overview of the Quality Verification Organization
In the last reporting period DCISC concluded that QV continued to identify items that need correction, and two of these, Electrical Safety (Personnel Safety) and Preventive Maintenance (PM) Program Implementation Deficiencies need management attention. The Quality Control (QC) section of Quality Verification (QV) is taking corrective action to improve the problem they had in the past on missed QC hold points. The most recent Quality Performance Assessment Report (QPAR), covering the period from July through November 2009, appears to be an informative and helpful management report. The Key Gaps that are listed are clear and well supported. The process of highlighting continuing Key Gaps and escalating issues as deemed necessary appears sound and effective.
4.11.2 Current Period Activities
During the current period, the DCISC has reviewed the following quality-related matters at two Fact-finding meetings and two DCISC public meetings:
- Quality Verification (QV) DCPP Site Status Report & QV Activities
- QV Perspective on Plant Performance
- Software QA Program
Quality Verification (QV) DCPP Site Status Report & QV Activities (Volume II, Exhibit D.2, Section 3.10)
The DCPP Site Status Report, issued monthly basis, contains all of the issues that QV has identified and is currently following. The report listed the following:
QV Director Concerns (Concerns, insights, order of significance status)
- CORRECTIVE ACTION PROGRAM (CAP) PERFORMANCE HAS FALTERED–A QV audit finding revealed an adverse trend in ineffective correction actions both in station and QV identified problem areas.
- SIGNIFICANT CROSS-CUTTING ISSUE (SCCI)—Site Leadership actions failed to avert SCCI. The RCE has determined that Leadership did not provide adequate standards in several programmatic areas, nor did they ensure sustainable programs in the areas of evaluations. Contributors include a poorly documented and maintained licensing basis, Corrective Action Program (CAP) weakness, and loss of proficiency in performing proper evaluations.
- SECURITY PERFORMANCE–This area falls outside the DCISC scope.
QV Issues in Elevation/Escalation
- 04/07/10–1st.Level Escalation–Open–Maintenance–Seismically Induced System Interaction (SISI) Program Timelines and Effectiveness–During the past 12 months, QV audits and assessments have indicated that SISI area owner inspections and area manager housekeeping walkdowns have not been consistently performed. Additionally, quality records of area owner inspections have not been adequately generated and maintained, and some SISI area owners and managers have not received adequate training. SISI Program weaknesses, including failure to implement plant procedures and failure to generate and maintain quality records for SISI inspections, were identified during the 2008 NRC PI&R inspection. Corrective actions to address this escalation are complete, but the extent of condition and extent of cause have not been completed. Inspections and documentation have been properly completed since escalation of this issue.
- 03/30/10–1st. Level Escalation–Open–Site Services–Quality Records Management–A failure to monitor and enforce records management requirements has resulted in a continuing lack of station compliance with quality records requirements. This presents a risk of a loss of quality records and a potential for regulatory action. ACE corrective actions include clarification of the timeliness clock for maintenance records, and establishment of suitable metrics to monitor performance in this area. The extent of condition and extent of cause were not completed as part of the ACE and are being tracked on separate SAPNs. Records management issues continue to occur, and are being evaluated in light of the recent ACE corrective actions.
QV Issues & Trends (Including indications of line sensitivity or defensiveness to issues, isolation, arrogance or complacency).
- Engineering–Design and licensing basis deficiencies continue to be identified in areas such as: the new reactor vessel heads and control-rod drive mechanism designs, emergency diesel generator air system design classification, in core thimble eddy current evaluations, the in-service inspection of the Unit 1 containment structure, and 230 kV system interaction with the 4 kV FLUR/SLUR (First Level Undervoltage Relay/Second Level Undervoltage Relay) set-points. Weaknesses exist where Engineering Programs cross-organizational boundaries, potentially as a result of an overly-narrow focus towards Engineering in procedures and guidance.
- Fire Protection Programs–The Fire Protection programs audit revealed that the FSAR and administrative procedures are not being properly maintained with respect to the Fire Brigade and Fire Protection Programs. An audit finding was identified with respect to fire door maintenance and/or modification leaving door gaps greater than tolerance.
- Supplemental Personnel Oversight–Weaknesses in supplemental personnel oversight have led to a string of errors during the ISFSI campaign and pre-outage work, including missed QC hold points, an incorrectly installed adapter ring, an incorrectly installed MPC lid, untimely CAP documentation, and a Raychem splice installation by unqualified personnel. A contributing factor may be that this is the first time that a major portion of the cask loading team consists of Holtec personnel.
- Electrical Safety–The adverse trend in electrical safety practices was escalated to the Station Director on 11/05/10. The resulting action plan was incorporated into the DCPP 2010 Operating Plan and continues to be effectively implemented. A few actions in the focus area action plan are overdue and need updating or re-forecasted due dates.
- Maintenance–Supplemental workers performed Equipment Qualified (EQ) splices without having the required qualification. An ACE is in process to address this issue. A stop work was issued to Maintenance and Strategic Projects to ensure Raychem is installed in accordance with the site-specific qualification requirements until it is proven that the past practices are acceptable and fall within the established training and qualifications requirements. Maintenance has taken steps to ensure appropriately qualified site personnel for EQ splice installations.
- Radiation Protection (RP)–RP has experienced a significant loss of personnel and may be vulnerable to human error and programmatic breakdowns depending upon how well it manages its knowledge transfer and turnover. QV has identified weak RAM (Radioactive Material Program) storage practices, including outdoor storage vulnerable to container corrosion and decay. The lack of appropriate RAM program oversight may be a contributor to this problem. RP needs a documented plan to ensure success in its plan to bring its procedures up to station standards, as weak procedures coupled with high personnel turnover may lead to serious operational errors. Radiological postings have been moved without the consent of RP, potentially representing a programmatic weakness in behaviors related to radiation posting.
- Learning Services–A recent ACE failed to evaluate the impact on instruction provided by an unqualified instructor. Recent HU (Human Performance) errors and other challenges related to the newly installed Human-Machine Interface (HMI) screens at the Aux. Board may indicate that training was inadequate to properly prepare operators for design change implementation. A root cause team has been formed to address weaknesses in training aspects related to newly installed designs.