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):

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 (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)

  1. 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.
  2. 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.
  3. SECURITY PERFORMANCE–This area falls outside the DCISC scope.

QV Issues in Elevation/Escalation

  1. 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.
  2. 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).

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.

Regarding staffing in the QV Department, there are 25 approved positions in the QV Department with 2 positions vacant. QV continues to try to fill the positions with personnel from other departments to capitalize on their experience at DCPP. There are possibly 2 QV individuals who might retire in the next 5 years.

Quality Verification (QV) continues to do a good job of identifying problems and areas for improvement at DCPP. The DCPP Site Status Report identifies all QV problems at DCPP and provides DCPP Management with information about the various Departments. DCISC should continue reviewing this report at future Fact Finding Meetings.

Quality Verification Organization’s Perspective on Plant Performance; the Quality Performance Assessment Report; and Quality Verification’s Top Concerns (Volume II, Exhibit B.6)

Quality Verification (QV) identified two new station gaps to excellence regarding weaknesses in the Foreign Materials Exclusion (FME) Program; and inadequate Owner Acceptance Reviews of vendor design work identified during the recent cycle 16 refueling outages. DCPP has addressed the identified gaps in its FME Program through the use of human error prevention tools, training and monitoring. QV did not find the FME Program to be ineffective but rather QV identified weaknesses in the Program sufficient to justify monitoring station performance and worker practices in the field. QV reviewed the results of the self-assessment by the FME Program and identified key corrective actions associated with communication of standards and expectations and the monitoring of performance. There appeared to be inadequate follow up concerning those issues entering into the cycle 16 refueling outages and the resulting monitoring of the FME team’s performance during the cycle 16 outages did not show the desired improvement over that from prior outages.

A gap to inadequate Owner Acceptance Review of vendor design work was addressed through re analysis, further review of operability issues, and hardware modification. PG&E retains the responsibility to validate that its vendors’ designs are correct, and QV’s statistical sampling of owner acceptance reviews was based upon risk significance, complexity, and impact of the specific design. The inadequately reviewed designs were installed in the field–an example was a design which resulted in a temperature error in connection with a control rod drive mechanism which, while having no impact on safety, was found to have resulted from an inadequate review by the vendor.

New department gaps included those associated with: deficient Maintenance department work practices caused by inconsistent tailboards, incomplete work packages, inadequate use of operating experience in work packages, and insufficient oversight of supplemental workers; as well as problems being screened out of the Corrective Action Program (CAP) thereby resulting in untimely and ineffective corrective actions. QV now includes personnel with licensed reactor operator and security supervisory experience necessary to review the safety-security interface, a principal focus of the DCISC’s review of security-related issues.

The CAP implementation shortfalls at DCPP included the NRC’s area of Problem Evaluation during the period of the Quality Performance Assessment Report (QPAR) for the third period of 2010, during which the highest volume and most significant CAP-related problems identified by QV were those related to the area of Problem Evaluation including: a failure to evaluate a nonconforming condition; problems screened out of the CAP; and repeated occurrences of untimely NRC Maintenance Rule determinations. A weakness in CAP trending was identified as a mid-cycle review Area For Improvement, and the CAP is increasingly reliant on the robustness of its trending process. The areas of key component weakness identified in the CAP should be addressed and resolved by the second quarter of 2011. The processes employed by the Corrective Action Review Board (CARB) are improving and that CARB reviews drive improved performance and quality of apparent cause evaluations (ACE) and identify and correct inadequately closed SAP Notifications. Trending program weakness represents an ongoing area of vulnerability, and QV has recommended a line performance analysis to try to identify staff knowledge gaps and associated training needs.

DCPP site leadership’s actions related to the significant Cross-Cutting Issue of Evaluation of Thoroughness by the NRC were inclusion of Thoroughness Evaluation as a focus area of the 2011-2015 Operating Plan; development of an action plan; and completion of the pilot review of the License Basis Verification Project (LBVP). DCPP is following up on the NRC’s inspection and the proposed violation resulting from the 2008 CAP audit when and where these problems should have been reported. An ACE has identified key corrective actions including: the use of the Quality Assurance (QA) training program to ensure proficiency in key functions; revision and improvement of audit checklists to include review of operating experience and NRC trends; establishment of recurring QA training for specific high level, risk significant ‘evaluative’ areas; and ensuring all QV work functions are appropriately represented within the QV Curriculum Review Committee (CRC) The NRC’s resident inspector has also suggested revising RCEs to provide for and include a role for QA. RCE measures will be made more clear and quantifiable and the RCE process will be institutionalized to review missed opportunities for QV’s insight. Contributing factors and insights include governance and metrics needing more run time and he stated that appropriate actions are being taken regarding this gap in station performance.

4.11.3 Conclusions and Recommendations

QV continues to identify items that need correction, in particular gaps in the DCPP Corrective Action Program evaluation thoroughness, which was also identified by the NRC as a substantive cross-cutting issue. 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. Because of the number and significance of QV-escalated items and Top Concerns, the DCISC will increase its monitoring and review in the QV area.

For more information contact:

Diablo Canyon Independent Safety Committee
Office of the Legal Counsel
857 Cass Street, Suite D, Monterey, California 93940
Telephone: in California call 800-439-4688; outside of California call 831-647-1044
Send E-mail to: dcsafety@dcisc.org.