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EMPLOYEE CONCERNS

SPECIAL PROGRAM

VOLUME 8 QUALITY ASSURANCE CATEGORY

SUMMARY AND CONCLUSIONS

TVA

NUCLEAR POWER

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EMPLOYEE CONCERNS

SPECIAL PROGRAM

VOLUME 8 QUALITY ASSURANCE CATEGORY

SUMMARY AND CONCLUSIONS

TVA

NUCLEAR POWER

EMPLOYEE CONCENS SPECIAL PROGRAM

EQUAfIV E SUMMARY

is report was prepared by Se A Welbter Eineering COIpontioa (SWEC) to dcribe the resmis of tbhe eaaEtin of 539 eqidoes m v smiged to the QuaIy An.m Category of tbe Esploye Caer Task Group (ECO) It sommaries the speAic doeficiencies found and the arrective actions that reand, aseaes the cumulative resuls of the eIaluation, describes the root cases of nmanci P identified from a uis of the caamanative fings and the root cause corrective actions taken by TVA, ad ases the effeiveaes of the corrective acdon to preent reurrence

The TVA Ndlear Qality Asurance Propa.m described in a Topical Repor on Quality Amoianc (TVA-T75-1A), which was fist ined in 19751 Ti Topical Report describs the TVA orpnirgmin for quality aIiraen and defines the TVA requirements and mmia * for aaring the quality of safety-related activities in the design, cotrction,

and operatio of its alear ftclides Each revision of the Topical Report h been iaims d and accepted by the Nuclear Rapegatory Comnmon and is refereed in Safety Analpi Reports which are the basic lirng docmaueut for clear facaliti

The current revio of the Topical Report (Reviiou 9) reflecs the comolidated nuclear power opuahtion created by TVA in January of 1986 to improve management e&sctivenM in its mnclear aivities, including thos related to quality iaranre. This mriion of the Topical Report was accepted by the Nuclear Regulatory Comnsiron in

January of 197.

The 539 individual concerm evaluated in th category represaented 183 separe ius u alla pNIbles with the TVA Quality Aurance Propan and dwt impineration

IteRf prior to January 1966 (principally during the 1980 to 1965 taimefra ) and with the qaaladoi- of quality Iurance and quality control personel during this same period. Th evaluation of thes imsse was performed between February, 1966 and February, 1968. Each las was investigated at applicable TVA locations and, when necessary, corrective acton was initiated by TVA.

Became the role of the ECSP was to identify and resolve problems, the Quality Auurance Caegory evaluation concentrated on problem ar; therefore, the conclusions emphasize

egpthive fndiap and problem. Even with this negative bias, it is noted that approximately one-half of the iuses were either not factual or identified factual conditions that were not

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problem. Moeov, of the 86 isues that did identify probles, over half (45) had already been ir.mdfied by TVA and corective action had been initiated by TVA prior to the evahisnda by the Quality A race Caagory Evaluatioan Group (QACEG). These 45 were iti evuatd ina ecomictio with the root c analysis and amesed a to the adequacy of cueaie acon. The 41 rmain isu resulted in the initiatinn of 139 actions to correct the isfleadFd Aal aIess the siificance determine the exatent and assi corrective and preadiv action. (SiB additioml co arscie acooS were initiated to address ddieres. dentified daring the evalatian that were not part of the original ames raised

-hroME 1mploye cocrnS.) -|^»^ -- ---- M^M^\ To date, noe of the filingsm from the 41 isr's in this category that had not already been identified by TVA has -esmtituted a condition that could hwe adversely affected the health or safety of the public. Corrective action for some of the findings requires further evaluatior of plant hardware and/or the implementation of control programs. These evaluations, which ae outside of the scope of the Employee Concerns Special Program (ECSP), could result in a determination that the conditions adversely affect safety-related hardware or control program for safety-related activities. If this is the case, the safety isnue will be identified jnd corrected in accordance with TVA's corrective action program. Becae of the many hardware and programmatic initiatives and evaluations completed or currently underway, it a cosidered unlikely that significant new safety problems will be identified

Findings resuting from fthe Quality Assurance Category evaluation are described in six "Subcapgory Reports". The more significant findings at the subcategory level Pre identified as "major" and those that tended to be of less significanwe or were isolated problems are identified as "Netive Findings." These findings were documented in Corrective Action Tracking Documents (CATDs) by the Quality Assurance Category Evaluation Group (QACEG) and Corrective Action Plans (CAPs) have been developed by TVA line management The Corrective Action Plans were reviewed by the QACEG and were found to contain adequate provisions to resolve identified problems.

Review of the subcategory findings in the context of the overall category indicates that although the quality assurance program described in the TVA Topical Report was responsive to regulatory requirements there were implementation problems during the timeframe of the concerns (principally 1980-1985), particularly in the areas of (1) procedure adequacy and adherence, (2) procurement and use of material and replacement parts, and (3) document control/quality assurance records. Corrective action for each of these three areas is discussed below under "Corrective Actions."

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arther anmmentm of the coleetie uyiifR- of ala Aibaieapry repour in the QA C y revealed tht weakness in the area of correctie action hd been a significnt

robleim As umed here, correctie action refe to acities to ientify Aideia ies** and pIoblem remsol tiem M n tinlZ y me mer ad present their recurrence. Fidmlip in this campry liutde thrt

* Ftentiml problem a or geerdc e asm idenied iaternally to TVA and by merd suaca s o&u as tda Nodlear Replabmy OCnnmisim or the ImHtur for

Nudclear Power Operati were not alanys aequely evaluated, treaded, or reviewed for geeral or plant ipecife ppliabilty.

* The several quality assurance audit program did not always result in the identification and resolutio. of problem and action to prevent their recurrence.

* Nonconfrnmance control methods were cumbersome and complex; multiple reporting and resolution methods were in use and there were no inter-divisional procedues goerning interfaces; corrective action did not always address root causes and the potential for recurrene; correctie action did not always seek out and address the Ail etent of identified problems; action to prevent the recurrence of problems was not coisatently developed which, in some cases, allowed problem. or perceived problems to recur and mnumlar the asignmemt of resposibility and nacountabilaty was ambiguous; criteria for timelinss were not consistently applied.

* The he inspection program did not include all of the inspection requirements of qpocable specifiatio, codes and standards; did not assure that all identified defidcenries were documented and resolved; and was not consistently executed and enforced.

Because corrective action was a significant problenm finding in this area were reviewed to determine the principal or root causes and an asse.sment was made to determine whether the action initiated by TVA Adequately addressed the root causes as well as the specific problems identified The results of this review and assessment are discussed below under "Causes" and "Corrective Actions," spectively.

C-m

The principal causes for weakness in corrective action were lack of sufficient emphasis on the development and disciplined implementation of effective practices and procedures to fulfill program commitments and failure to maintain the pecessary degree of active participation in and positive control over the corrective action process. Some of the weakness also resulted from differences and disagreements between organizations that were not effectively resolved. These factors resulted in the following:

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*Atheae 1M,1 lpoeqa pe NsO W po.m=M ma r pma c fir e ea ua de& fm be& homel and a somws uwm mM how bhlped Mius y ad Morrnat jobeao ik was I sMd. end some Mo an d pmeblem we C mr p.11mse vftd Ins miel -h - p -9

* ndido -sr aadewd ts IhmI y o am iiy -bya

either ais sIa n or the qIalay m i m am d orreacti ton or idMaaf. d probes was not aIyS effcive or timy. Corrective actioa omadamna waoe imnepI y pinumed to emnre tdht correcte action piam aes coplteted ao time ·an onam iud2 the desired relMI

* TIm wa an iminf method toidentfy problen, aign grpmibility far their ago l -in, and t the SrOtaaa procm to R aPpei TIe umethod and pmoedrm i me were deaeam a addreaiq root cam analis ad geenec

IPaicl9 y deenMiao. ald wee xot l hfoowed.

Mll rgiew procas fr design otpo t dome diM d not coMrmely amore " they adoded A0 of the requi*emeans and mimmea eoataa in aqplicable codes, ftadk repBlatio, and TVA liiceing domo.e Smlarly, the review proce for

mpcdama pocdres and imrndeat did not -o tht they iondlded an otf o iWplctMi 9 slliruea of deip outpot do ameaa or of progam levl peamaing domuas whd an tb Topical Report or the Nder Quity AAiuane Mism

TVA hIs oaaitted to adequate correcsiv actio for each of the speoc aptive adi in thi catery. Co.plestio of these acd in mcojMnctio wit othe cd hr aih as d aumaed in the TVA Corporate Nudcar Perfaamaee Plan (NPP) and the TVA Topical Report, tit TVA has taken or is taki, w resolve the inip idumified in the QA Campry. Wh tdwm wa not adequae information to bound idenified problem, propaa hae been identified ft rther siew ad evalaiao to determine the atmr of pob en, or poIeaal problen and the actions nece y to reli them

Aio lidatd by TVA to addre the three prculr impemp from above noted review of the QA bcategory reports are

* Desip Basis Verification Program and specifcation improvement progana were indamed to ensmr that design output documents contain applicable requirements of reguladios, codes, and standards. The endre procedure system is being restructuread procedures are being reviewed to camure tht tey include the requiments of design output documents the Topical Report and the Nuclear

eS

Qulity Assurance Ma=aL Proceadme comliac is being stressed by upper aqnm and training programs nphai the need for procedures and the

requirement to follow them. These actions should resole problems with the poeduIe adeIqucy iad adhmerece

* The RepbamentItem Program was deveoped by TVA to address problem with the procirement and se of naterial and replaem purts. This program was nhasitted tothe NRC on April 1, 1967, ad has received their concrrmence.

* Correctie action for problems with document control and quality amrance reIords was initiated by TVA in 1983. Thbcse problems that remain are principally in the area of vendor information, offsite document control centers, and the quality asurance records for the Watts Bar facility. Corrective action for each of these areas has been developed and imnpleentaion is in progress.

Regarding the corrective action process itself TVA has initiated a number of actions that will strengthen the overall process and corect the root causs of the problem. In early 1986, TVA reconstructed its dear power organiio in order to provide more effective managemea of its uclear operations. Presently, the whole of the TVA Nudear Power Orguaniaon is operating under a strong central managment system. This organisatioaal strcture provides a ramework for establishing a conistent management system that is supported by integrated policics and procedures with controlled inimnatio by line organizatons. The strengthened Quality Assurance organization, and the newly created Engineering Assurance oranization both have the visibility to enasure that problems can be identified early and avoided or xpeditiously resoled. In addition, a program was initiated to assure that lines of authority and responsibility were dear and that personnel understood their duti and responsibilitis, that they had required resources, and that they Imnew they were accountble for the quality and timelinss a their work. These actions should correct the principal uses of problems in corrective ac ion and the overreliance on the quality assurance organiatioan

Corrective action has also been initiated for the other cause factors associated with the corrective action process.

* The TVA Nuclear Operating Experience Review Program was initiated for both internally and eaternally identified problems or events. Additionally, TVA initiated acdon to evaluate and improve the trend ai alysis program concurrent with this evaluation.

* iVA has restructured and strengthened the QA Audit Program. Staffing is being increased to levels which should alleviate prralems with accomplishing required audits. Technical audits are being conducted of engineering activities to assess product adequacy. The program now includes mandatory requirements for root cause analysis, recurrence prevention actions, and escalation of unresolved audit fNdings to higher levels of management.

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T VA'-* - ýsm now pop hr cmurd ot inikm adm to qf am

Adsm to Q@Isy RqMg (CAmR) PM uMn k W" -d tic smlil .----f-I n i -4 * A modb& m poodes a =00 nekn Mth ,couscev aiim, is dm Win *a ?Fed= Qoft Amomo TheLMil

* Dantcomoep a idea desibe sed nook* ywmoswookm m mL

pm a m demip 1" i - imp Wo - iweio In dto iwcdm p IIP01mm - = o gim wish fthR wIvn i am~ i~wmm dsairbed Am& Cah..q kinsB bpcii ahuuh. wil tr~it ftnm a -~bznda othe P&w 0 o UuAmt fopectio pi -P& is and moomeumf 'tca to ef

iA - to * r ummmm win * thet Ammrvm dan M andd indeque actionwa dewyt

- thm *=ad -luo* thecome

The TVA CoruAsmf msoNner Pr, tomm Pian (CQV) was effec-e in idendtfiq and .. frnlqfth rm vs mi of fth dddrnie idmndftedv.thoq omplog e ,m l mu in fth

In --- I.b-o the ~finidwisgi do wloped to iqhiemphmu th CW4P, th prapm in ph=c to 0uol1 the 9oalty inmuctin mm 9--- -l~nmdum pabkms nosed in fth rep=%, and

ft speific senrscdivc atids tolom or to be take by TVA wo addrrnso .ne.uptive &fini -go worea the anudfca root -o diecideuuclon detfied in this coupry.

Senor emi in TVA headquutr, arpuuizedin and at acut plotauined to wudane thk ei dra to lmknplme the orap 11ino ito their effcdvme mod adjau them a spm=)m to Abtain aeuired ramals

F."

MPQZYEE CONCERNS SPECIAL PROGRAM VOLUME S

QUALrffl ASURANC CITAOIY SUMMARY AND CONCLUSIONS

TAIL" WO mVOZrS

EXr1VE SUMMARY ES-1

PREFACE i

1.0 iNTRODUCION 1-1

2.0 SUBCATEGORY DESCRIPTIONS 2-1

3.0 CATEGORY ASSESSMENT 3-1

4.0 CATEGORY FINDINGS 4-1

5.0 CONCLUSION 5-1

APPENDIX A -QUALTY ASSURANCE CATEGORY TABLE A-I OF REPORTS

APPENDIX B - QUALITY ASSURANCE CATEGORY B-1 EVALUATION GROUP PERSONNEL

APPENDIX C - SUBCATEGORY REPORT OVERVIEWS C-1

PREFACE

This report is e of a series prepared nder the Eployee Cocerns Special Program (ECSP) of the Tennessee Valley Authority (VA). The ECSP and the organization which arried out the progam, the Employee Concerns Task Group (EC ), were established by TVA's Manager of Nuclear Powar to eale and respond to those Office of Nuclear Power (ONP) employe concers filed before Februay 1, 1986 that related to TVA's uar power program. Concerns led after that date ae handled by the ongoing ONP

Employee Concerns Program (ECP).

The ECSP addressed more than 5,800 employee concerns. Each of the concerns was a formal, written description of a circmance or circumstances that an employee cited as inappropriate, ineffcient, unjust, or unsafe. The scope of the ECSP was to thoroughly evaluate all alleged problems (issues) presented in the concerns and to report the results of those evaluations in a form accessible to ONP employees, the Nudear Regulatory Commission (NRC), and the general public.

This preface contaim background information on how the ECSP was initiated, descriptions of the categories to which coce were assigned for evaluation, profiles of the Senior Review Panel members who provided independent oversight of the program, and information on feedback of program reult to employs

A HOSONRY OF THE NMPIV CONCERNS SPMAIA PROGRAM

In early 1985, a gap in eninunieains between management and non-management employees at Watts Bar Nuclear Plant was recopized. After consultation with the NRC about this situation, the TVA Board of Directors directed that a far-reaching employee concerns program be implemented at Watts Bar. The Employee Concerns Special Program was established to thoroughly review employee concerns. To ensure that employees felt free to express their concerns without fear of retaliation, an independent contractor was selected to interview employees then assigned to Watts Bar.

Precautions were taken throughout the program to protect the identities of those who expressed cocerns. The original records of the interviews remain in the custody of the interviewing contractor; the only other copies of these records are held by the NRC Only the contractor and the NRC have had access to these files. The information provided to TVA was screened to maintain employee confidentiality.

Upon completion of the interview phase on February 1, 1966, 5,876 employees had been interviewed. Approximately one third of the employees (1,850) had expressed one or more concerns, resulting in ipproximately 5,000 individual employee concerns. Although TVA extended the program to employees at all Office of Nuclear Power sites through the use of mailers and a toll free telephone number, most of the concerns were from Watts Bar employees.

As EuI plole C1 cua Tack GOuqp w asU id to cuy out the pro n Tbe Task Groufps nm.lm d of qal l *perasm id a Rs qmapproach to problem

enbdosnialmo *ms i s the - - .-- to mens* eo ainilem pia hre from usgeral hrs sm.r Thieo m , ta Tack Grv ualp .qainIuD In ed the fomowizng

* C-i eapime shardog thre n rammrsm h viem

* Cc-u gnpsmred by erin r aplops nein propm

* Addtid l o o m nider ttitd ftom the finenrw fils by the contractor and the NRC

* Addtional itre identified by Task Group evaluator.

* Concern received by the NRC before February 1, 1986, and referred to TVA.

* Comcern identified by TVA's fomer Nuclear Saety Review SMtaf

* Open itea Ideanfied fm reviews of TVA icomingcorrespondece.

CATEGORIZATION OF CONCMNS

The concern wre Frouped inso ine cateri to provide for conistent evaluaion of related ooaer m is alsbo aided in identifyig and developing corrective actions that addremed identified dienci especifiuly and programmticallyb to prevent recurrence. The repoibihy fr each category wa aigned to a de=igtWed Category Evaluation Group. This repoibil included idendficadon of the iue raised by the concerns, thorough invedpgion, determinaion of pearic applicability and root causes of defideanc, evaluation of Corrective Acdon Plans (CAh) developed by the line orpnitinam, and preparando of the prupam reporm. In addition, the line organizations evaluated idendfied defiiencie for potential reportability to the NRC under Title 10 to the Code of Federal Repladaom Pas 5055(), 5072,50.73 and 2L

The cocern were ooped into the folowing artenries

* Cangrtesle - Concern about the adequacy of construction practices, the quality of -coatructed facilities (adcluding welding and as-designed features), in-storage and

installed maenanmce prior to turnover to operaions, measuring and test equipment and handling of equipment used during construction, and construction testing activities. TVA personnel evaluated the concrmr in this category.

* - Cur. about the adequcy of the desipa iPocas and the dipBaBd -r urues b'ITh desDpI proc. I m is of the techical and

· proeIIM that omm .a . wih th tiMmuik m- o deigp ipus aud ledto mil Ib ds te aSmmss o desip mutpt documlO These coClr wereo

_md byB echadW WIestPern eCupOldOs .

* Op.m. - a-CMO ; aboutr pmaou m ir - aelitlus Incihing operor tpatiainM., =moma * or einNt msek urkty, health phyui, and ALARA ( low as ms hlY ai;v;ablte) WrNliemeta a Md aBaw a rneopet ratonal and mrillas 6 tasdg Pannumi fiear TVA uad firtom yeR Corporation performed the Osnhatioms f this Fcary.

* Maral Crnasl - Concer about the adequacy of material, incuding its procurenaet recsipt, lmdlin, storag, and in aiaton, and the adequacy of procedures goerin material controL TVA personnd evaluated the concerns in this a gory.

* Wl -Coancerns about ay apea ot weldDing, inditn welder or weld procedure q.nie.rtsiE , a .__mid_ mea traOnetm , weld

ay filer maerial quaihty, and weid dooinauon The welding o r were wealuetd by persomnel fro TVA and tb EGAG Idaho Corporadon.

* Ia.uld., Binau.ar ,m Wued r uMI«mindd - Coacerus about personnel cuct thbat iaerfees with the abflty of eaoiloees to ffili their asigned

pon.btlldas ua nmthori ed acios taao -s eiplnoyes for fitfiling their maOiped rpaibfithds, ad lepal acidaes or voaidriw. of TVA policies nd replaiom. Concem in this cateapy were trartted by tbe Task Group to the Offim of the Iapector General for evaluadon.

* Mar maa aud P srsnamd Conmrm. about tb ademiquacy of poucies, manager nt attitude and ectiveness,r in structures personn manaement, and pesonel training and qalifEiction, acept training and qualification covered by the Quality AauanceiQaly Control Category. These concerns were evaluated by TVA penoa eland contracted rcouaftn

* Quality A r oneW Qalty Came l - Coceras about the adequacy of Quality AssuranceQuality Control progams and procedures (e., auditing; document control reords; defciency rrortn and corrective action; and inspection, except nondesructive amination and welding insp n) anddi i) ad the training qualification, and certfication of Quality AMurance/Quality Control personnel. The concerns in this category were evaluated by Stone A Webster Engineering Corporation.

* MdteW So - Cooce about the worm l eamlo et and controls which protct the ealth nd saft of e layes In the workplrae (excdding health physics and ALARA). TVA pameam ad the DPont Company - Safety Management saON - al-ated e2em Pome .

CaOmM that rbcd mLre W th s a y wre anmsi d to matiple categories. In such cae each catpay edalad the omas n hm ts specie point of view.

Emh Caepo y Elmaoton Group sorted it srndpd c m nto subcategories, aordin to subj atter o tthe sbcot cra then tfti elemeas. An element is a group of related concers tht raise the same or smla iSRMa An isnet is a alleged problem cited or implied as interpreted by an evalutor, in one or more coner. Concenr were evaluated according to the issues they raised A compehensive explanation of the evaluation and reporting process is motaned in the introducion section of each category report and in the program summ report.

PtOORAMn OVERCTCr

The ECSP ha been reviwed, muted and ilapected by the NRC the TVA Office of the Iupector General, and the TVA Nuclear Qualty Assurance Division. To provide additional independent and objective oenight, the TVA Manager of Nuclear Power established a Senior Review Panel of recognized epemrt witn the muclear power industry. Those selected had extensive backgrounds with experience in the design, cnstuction, operation, quality assurance and safey evaluation of mdear power plants.

The Senior Review Panel provided overight to enmre that (1) the scope ad depth of the evaluation effort was adequate, (2) the evaluation findl and conclusions were logically derived from the evidence, (3) the proposed CAPs adequately addressed identified deficiies, and (4) the reports adequately described the evaluation effort, the evaluation finding and concusions and the measures taken to resolve the identified deficiencies.

Prnfile at the Senio Ravicw PanBliia

Myer BnmAer

Queryec Associates Inc, Knovill, Tennessee. Consultant on engineering practices for nuclear and advanced technology pogra. More than 40 years of experience with complex technological activities including the Manhattan Project, and advanced nuclear fuel processing and wate management intallations Former Director of Engineering at the Oak Ridge National Laboratory and, for ten years, a Member of the NRC Advisory Committee on Reactor Safeguards (Chairman in 1977). Known for his work in standards, quality assurance, and tem failure assessment.

Famer startup readine co ltant for Three Mile Island Former manager in the Naval Reactor Program. Farmer Vice President for Naval Rear Plant Construction for New York Shipbuilding Corprationd. Farmer Profeor of Mechanical Engineering at the University of Penmyhlaa. Nearly 50 years of eperience in engineering management,

aseral prorme quality control, radiological control coarcton, and training related to auclear fdides.

Former Vice President for Quality and Technoloy, Babcock and Wilcox Company. Former manager in the Naval Reactor Program. Former Assitant Director (Plant Engineering) for the Atomic Energy Commission Forty years of experience in the design, manufacturing research and development, testing, operation, and maintenance of nuclear plants.

JIuagh C lsVall* Jr.

Former Nuclear Project Manager for Sargent and Lundy. Twenty-five years experience in project management liceing construction, design, and operation of nuclear power facilities.

naniel nL Garlnds

Former Manager, Nuclear Quality Assurance Program Offic for Westingbouse Hanford Company. While at Wesinghouse, aisted Department of Energy in developing Quality Asurance standards and programs. Thirty years of experience in the quality assurance of nuclear plan, cludin preparation of plans, procedures, and manuals; indoctrination and training of personnel; and participation in more than 400 quality assurance audits, frequently as audit team leader.

JanusIL McMsfS9 (Deceased)

Over 40 yeas experience in ASME Code fabrication work, specialty welding practices, materials technology., and quality assurance methodology. Former Director of Quality Assurance and Inspection for the Oak Ridge National Laboratory.

These members served on the panel for part of the duration of the program.

Ha tn FInd I rnmnn

These cteory reportms d their appendices re nteanded to inform the cocerned i l a to how his or her concerns wereddred. These reportsm mmmarize the

np oyee Comem Task Grop's inwestiptio bdiin, and Hi mmpent idenified correctve ados. In most casesm the caorned individual should be able to identify the ranhinetioa the a soeoieaed with hbier cocern using the folowlb nstep

1. Determne which caeory would cotain the mcocen A list of the categories begins on pae i of this reface.

2. Review the ategory report identified in step 1, above. In particular, review the Categoy Asessment" and "Condusions" sections and the appendix titled

"Subtegory Report Overviews."

A proens ha been developed which will permit employees to obtain additional information coceram io their specic concern. As has been the ca throughout this program, this will be done in a manner that ensures the conidentiality of the individuaL Details of this proas will be made available coincident with the release of these category reports.

What tn Do If Yu Rlme Your Coierne Has Not Been Adequ.ely Addrsd

The Employee CAocerns Task Group has made an intensive effort to thoroughly evaluate and report on all the issues raised by the concerns. In some cases, adequate information may not have been available to properly evaluate your concern or the concern may have been misinterpreted by the Task Group. Any employee who believes that his/her concern has not been adequately addressed by the ECSP is requested to bring this to TVA's attention by taking the question to the Employee Concerns Program site representative.

QUEiSONS ABO1r CONCRNS

Li INTRODUCTION

Tis report daa n the remul of dthe aluatiedo of quality -ma related employe conar that were received by the Tennaesse Valley Authority (TVA) priarly undwr the Ealopes Coaera Special Phe (ECSP), prior to February 1, 96l bt Qualeyi AmrPn Ctegory Eabrionup (QACEO) was rpoadbie

for the evaluadtion of those cocers related to quality anIrnce prora and procaedure aI to the traint q.nlidamti , and cerdti tio of Quality A race and QnlitCowrol(QAQC) perone

Tlb TVA Nuclear Quality Assurance Proa is described in a Topical Report on quality auane (TVA-TR75-A), which wa first imued in 1975. This Topical Report describes the TVA orpazatiom for quality aourance and defines the TVA requirements for auring the quality of safety-related activities in the design, coautrndon, and operation of its nudear facilities. Each revision of the Topical Report has been raiewed and accepted by the Nuclear Regulatory Commnu.o and is referenced in Safety Analysis Reports which are the basic licesita donments for deair hfalde

The curnt revision of the Topical Report (Revision 9) reflec the conolidated nclea power orguizadon created by TVA In Januay of 1966 to improve nmgm-nt cAfcdvenimas in its nuclear activities, including thos related to quality assuran. Thi revision of the Topical Report was accepted by the Nuclear Repulatory Comission i January of 1967.

The issues or alleged problems withe TVA quality assurance program and its implementation that were evaluated by the QACEG had to do with conditions that esisted, or were perceived to hab existed, prior to the consolidation of the muclear power orgnization that took place in January 1966 (principally during the 1960 to 1985 time frame) and wit the qualifications of quality assurance and quality control personnel durig this same period.

Beaies February 1966 and February 1966, the Quality Assurance Category Evaluatidon Group invoWesdd 39 employee concerns that raised 183 issues, primarily regarding six aspects of the TVA Oualty Assurance Proram. These aspects were: (1) propgram maneatme (2) inspection; (3) corrective action; (4) recorda management and document control; (5) the procedures system; and (6) the qualifications of OA/QC personnel.

Grouping the 183 issues based on similarities resulted in 38 elements to be reviewed and evaluated. These elements were assigned to one of six subcategories based on their content. The ubcategories are described in Section 2.0 of this report.

Results of dtho is doa him bus pulM d Ia sk -Aba y report, supplmdrp b by i5 Se1qY NPlea VI elrmm ledie r porm which were pupad to upport sirup of tt ilbly. The A 1 ubea griel and 15 Sia8Rh istelesl m sa MMiaedby m r dt isdd tinAppeed<MA.

Sader as ples tl@ sppar i pealie iI t is iloerit oaomiadmm tim p-a ng thbeo mm i sisMch tw delopsLd

FiSt, dh moidy it &s actld work t ib qri d to ialenmmt a quaty -gm popm is porimd by thI eni comtid and pd operautod 0- - -aero them ts qualy I s I-. Ihpuiio etl Comqundy, in th Employs Coemr Tuk Groupo Mr nprdil th quity of work performed by other then th quality -muraefqua ty control orEpianion were pri rily iprd to teEa-ismorI CaustrucdoB, or Operatio caIteories or to th topial atg es of Welding or Maerial CooL The coocern u iwed to te Quality Anrmor Category wero prinpaly related to the ma ement and performri- of he quality uirnt/q Hy cotrol aorpaitna or to

mdom paersised to be of a "qualiRy ' ameure. Although they did raie Ir thadt re*td on dr puromm of the eQlarfsria , comtrcdoa, and

aopdorI orgpnVh di , thue wre typically propmnac, procedural or doo related raher thn bu related so thl quay of work products, or plant hdw-re. Within the Quality Amurnce cateory ielf the issue deried fom the eaplaojy coce m co rd a wid range of topic, but were fomd in the isk re adeimed abome

Seoad, the objec f the ECSF w not to coduc a omprnbeaiv rview of a mpeas of the TVA maclW powr proepm. Is prpal purpose was to raliw pecml employes nr iM deaOliy the ium they raied, evaluate dm iuer *.fflceady to determine their validity, and whbea ecen ry. identiiy the need for and wriy cnp of correctd actio to eas re tbhat plant safety w

oI coupioJMs d. Therefore, the condao that result fom the ECSP, iM dig thoe contained is tL sc ry report, were derived from the employ comenr asd mre bounded by their mope.

Thrd, the aeployee ram , by their arBe, focmed ttention on the naepve aspect ot qPualty eince -mM-----manMd practdes within TVA. Became the role of the ECSP w to idealFy d rMole problenm, the Qualty Asurance category evaluatdor comsatrated on proble areas Therefore, tbe audusloo emphrlie aegative Iadlp and problerm ra. Even with this aoepive bia it is noted that pproiately half o the issue were ultimately determined to be unfonded Moreover, of thoe issues that did represent problems, half were coodidoa that had already been idetadfied by TVA and corrective action had been inidatd.

I2 badems Tem

The Ievlratioa d qalty nramr relahed employee concern was performed by Stone A Webter Engineering Corporadon (SWEC) which wa respoible for amnag the evalation activity, and for reporting the results to TVA in moardace with the propam and procedures of the Employee Concern Task Group. A ss nt of thi thi sk to SWEC ws to mure a degree of objectivity and inempeeace for the -evandoam. Team members were selected with a wide vurety exaperience, primcipy qualiy assurane but aio ihdin personnel with bnckrouds in comtruction, project iuanment and neeri. The bi team was supplemented, a necesry, with SWEC penonnel having expertise in specific areas such as nmdestructive mninatioUn Management oversigbt was also provided by the SWEC headquarters Quality Assurance Department Managemet Resumes of key personnel and a listing of other personnel are in Appendix B.

1.3 Eivaldan sPrmese

The Employee Conceran Special Proram had its primary objective, the evahudoan, timely diposidon, correcdon and do iut of safety-related employee concerans. A secondary objective was the evaluation, timely disposidon, correction and closeout of those employe concerns which were not safety-related. Both objectives were pursued concrrently by the Enployee Concern Task Group.

To this nd, the entire program was governed by the ECTG program manual and procedures which provided a riorous framework for determination of concern applicability and the subsequent invuptations and evaluations, resolutions for identified deiciencies, results reportin and tradlng of the cloeout of corrective

13.1 General

The evaluation of quality assurance related employee concern was performed at three levels. At the lowest level, employee concerns were grouped into 38 '"eements" based on the issues contained in the concern descriptios An issue is deined as an alleged problem cited by one or more concerns. Because many of the issue identified by the concerns affected more than one location, over 300 individual investigations of issues were conducted. The inesigations covered each nuclear plant site as wel as TVA corporate offcr. ' 4 the second level, completed "element" evaluations were grow ped into six "subcategories" based on general content. The elem in each subcategory were reviewed collectively to determine whether there were larger issues, common

mom s~d m% pr oin te~ lb edhas doi~nm -A w"e wamd sqd Mil ens al ues ulic woud su be apperen bou a

voilnasWM*dh dhsgadodme mbu

H 1. h ab u~iy p~m 3 p s wene i ed sed achiatd usalesly to dommos ubsib On wen e ambi wchk could be & aourn lb .om~ufiw hm nl*d - lb - ath ol- Anne d dip. bumes connud Is eqi~m muem Te ranks at ilk fiel

M~~Ww=@sriýlb mbe~sedes l doidetoefb

buhud qs the buees seach Widefied. Wkbu ecut Hibs lpor , rebud buss were -rue into elemmea for wagaa

'The buses idde subk damwne lbs fospled, followift a j pgsqued esmbd - h ainode io acquire reime kufrmdnua -~d lb m ad buses ihms and the reptsway

At do WlmeAu lasS l mb shdo p H PI ioduded reviews of ~e~bupmmlbss *ep. respo by do N3Cj INFO ad -6 endpualm mum dp fr rmpom. Fid cecks ofa nt rado

ad darmni vets pm 4 nuen Inniecdus wene conchwe and ~uidwon lolsu to oie0seuemy to dowsurak lbe vm~da of

m a dm to v.* amehum. Arvsý ruspulti aersusi mcsh. weon ddened sed Consisiu Acdw Tkocdqn Doasem (CAlMs) wone Wood and reviewed wish IVA Lne Mumqhl TVA Haesmeuuu 00 metl ed.. I In wer e misie ha- whe eex*W aminud wi

Iubusepuy rais amo lb reeds of lb eldeizivups (ledmfin- mrCoke acdams manew and ulpffimcnc for mbetadadms buss)Pm Each e mmii u tpeso lbe Quaity Amnurm Cue1..7 Wet adlbued skier imdWdelor ar per o at s ismm

roblims Wadeusfied through lbe elemmn nagd were V "smmdm- y suulyzed at lb mibaiss WWve to determine the inimediaew awss ad to doetec qmupsm of underlIng foot cmuse Probj isadsfWlg d5hrnh dl root m~w snalysi wor referred to tlb mu~ouble maqe. using Cawecslv Acala Trackbig Doumens

(CATDI) for peprad of orrece m acdon pim. TVA lin -- wM coDlec acnd I on ipo wer revirewd andm when

LIA Caslpeyr hahil f...

At thda aoPy Ieovl, the nmpdv fBodiip or was s ideHnified at the ub--lpry leel wn a- yd for iapo t puar- tbdt might not

m been ppren wheO tb aurbawhedesd was aumined idvhbI* that wMod hundem uspicmat or pOuy - ic Im If this

inal4y " Idmatfd sipicaua or dprop tc wea me I-firher evaluadon was performed to determine the perceied root aues of the weaklnmm The TVA Corporte Nudear Performance Plan (CNPP), the TVA Topical Report on Quality Auace (TVA-TR-1-75A), and donuxmen daeloped to iunplenent their -a--nin-e-a were then reviewed to deterin wbhether mnframidet edon had been inidated to correc the root cusek of the weakneo s and to prevent their recurrece. Fialy, the QA Caesagry Report was prepred to nnmmadin renults and mcohieoe and to provide an overall met dof their sficnce.

is MCAUTGRCOI Y

Tb coeamer in the Quality Asurano Categry were divided into six subcategories bsed a broad tpical subject. Each of tbhe bcalagories is described briefly below wis the types fImes each coammied.

Appaadeb C to this report, Subcategoy Report Overview, contaains summry desripi of the subcagory issues and evaluaio resuals and brief descriptions of the spgtive findhg and corresponding corrective actions in each subcategoy.

Within this aubctsepory tldre.were 106 concern which were grouped into 42 issues generally related to mnmesi-lr I topics wi the QA organization. The issues wer grouped into seven eeament Noaonafeormsanc; QA Procedure Revisions; Procurement; Audi; QA Proram (Authority, Independence and Program Issues); QA Eectiedao De ceaunioa; and QA Management and Policy.

Twenty e me were ot verified a fiactual or wre actually accurate but not a problem Eleven ises were factualy accurase and identifled problems but corrective action for the problems wa fnhiated before the employee concerns evaluation was undertaken. Six ies were actual and identified problem for which corrective action ha been or will be taken as a result of the employee concerns evaluation. Two isues did not identify problems but as reIt of the evaluation, a problem was discovered for which correch a action was initiated.

The 121 concerns in this subcatgory were grouped into 44 issues related to inspection procedures and inpecti actividties by OC personnel. These issues were evaluated under the following four lements: Receipt Inpection; Procedures/Inspection Criteri; Incoplete/Inadequate Inspection; and Inspection Responsiveness.

Eighteen issues were not verified a factual or were factually accurate but not a problem. Fourteen issues were factual and identified a problem, but corrective action was nitiated before the employee concern evaluatidon of the issue was undertaken and 12 isuems were factual and identified problems for which corrective action was initiated a ti e result of an employee concern evaluation.

The 73 employee concerns in this subcategory were grouped into 23 issues related to the capabilities of QA (which included OC) personnel. The issues were evaluated under the following four elements: Oualificadon of Personnel, Training of Personnel, Certification of Personnel; and Testing of Personnel.

aaararaon

Twelve issues we not verified as factual or were factuay accurate but not a problem. Four ises were factual and identified problems for which corrective action had been take prior to employe coner evaluation. Five issues were factual and identified problem. for which correcive action has tLn or will be taken a result of the Employee Coocernmm evaluaton. Two issues did not identify problems but a result of doe vatfo, a problem was dicoered for which corrective tiowa nitited.

The 69 employee cocr in this subategory were grouped anto 29 issues which focus attention oa the adequacy of the TVA systems employed for the control of oonardming ltetm and the prompt correction of nonoorming conditions. The

issues we evaluhated under the following fifteen elements: Discrepancies not being Domented; Timely Issuance of Discrpancy Doncumentation Processing of Dcepc ReporDesi Changes Disposition Assignment/Corrective Action; Asignment of Root Cause; Disposition by Sampling; Consistency of Resolution; Discpancy StatusFracking; Corrective Action for NDE Program; Discrepancy Review for Reportablity FolowigMeeng Nonconformance Procedure; Procedure Adequacy Corrective Action Compleomplementation; QOCIR's superseded by IRN's; and Program Adequacy of the Corrective Action Program.

Fourteen issues were not verified a factual or were factually accurate but not a problem. Five issues were factually accurate and described problems but corrective acoon for the problems was initiated befor the employee concerns evaluation was undertaken. Nine issues were factual and identified proble for which corrective acdon has been or wilbe taken a a result of the evaluation. One issue did not identify a problem, but a a rsult of the employee concerns evaluation a problem was identified for which corrective action was initiated.

The 134 employee concerns in this subcategory were grouped into 25 issues related to Quality Assurance Records and to the control of documents. They were evaluated under tio following four elements Falsification of Records; Inadequate Docmuentado Drawing Control; and Records Management

Since the issues involving possible falsification of records were addressed in another ECFG Category, the concerns within the Falsification of Records" element were investigated strictly from a OA/QC standpoint.

Nine issues were not verified as factual. Eight issues were factual and identified a problem for which corrective action had.been taken prior to evaluation. Eight issues were factual amd identified a problem for which corrective action has been or will be taken as a result of the employee concerns evaluation.

Thib Mubeltpoy ddreM 21 Waues deried from 37 eployee cocerm eerally related to mtnR eterami to the QA rpto that could ave imnpcted the efdcvei at ae overn QA prAorm. The oceM were broad in Mature and dealt woisat aid poli rather than hardwa. 'The iese contaiea d within thbse anB ru wre Fwaluated under the followh five eb.lemn ManageHmeIt of Cne Action d Mal m t Directed Dviatdo; Control of Cra; Manageumet Awareas oQuaty M raWNce FiacdoM ad Panire to FWrw Procdures

Thiren of tbhe ue wre not verld a facua or wre factually ur but not a problem. Sen sue were factual and dentified a problem but corrective action for the problem wa initeited before the employee concur evaluation. One issue did not identif.a problem but a a result of the employee concern evaluation a problem was dicovered for which corrective action was initiated.

3i CATBGORY A -M---r4T

FMdibp re-mUing fsm the Qualty Awrainmo egory ealh.rianM are ...mm..ia d in the "Suboneoary Report Overview (see Appendix . This secton decribes the remt orf - u inat of these fadin tat ws perf&oed to determine whetbr, in thas ea0 t of the overall catIony there were propagrdc weak s and, if so, whether sch ekim m had been recogained ad adeqtely addressed by TVA ti rougabt pCoaporte Nudcler Poi .. m nPlan insor odter etashA correcive action prmpIn. TIrhe oohedl doth u mant are

U1 ' r quality ma mrane proprm decribed in the TVA Topical Report was rponsive to reglatory requirements. Only on negative finding in this category affected the Topical Report and this was a minor clarificadon regarding the requirements for certifying spervisory personnel to perform inspections. The requiresment for this had been misinterpreted and required clarification, but as noted n SubcategryReport 8030 the Impct of the misinterpretation was not

32 Revirw of theu wbcategoy ndina In thecotetm of th onerll aregory indica that although the quality ainrm progrm described a the TVA Topical Report was responsiw to reglatory requrements, tere were implementation proble durhg the tmeframe of the concers (principally 19601985).

Indivdualy, most of the negatie fdin were not siglcant, but there were the areas where the negative findp were considered serious because of their prevalec or because of the potenial impact they had on plant licensing. These three areas are (1) procedure adequacy and adherence, (2) procurement and use of material and replacemrou part, and (3) document control/quality assurance record. Therefore, discussion of these three areas at the category report level was considered warranted and is incuded in secdos 4.1, 4.2 and 4 below, respectively. In each of these discussions the finding in this category are presented first The corrective acions taken to address negative finding are then described, followed by a summary of the significance of the findin and an massment of the adequacy of the correctve actios to correct known deficiencies

and prevent their recurreanc. Addidonally, during the preparation of this report, the category reports prepared by other ategories were reviewed "ud, where appropriate, are referenced in the discusnsions.

e~TFlp-~nr-· - ;.

33 FPade ammentnu b atM bal,. uipmn of an-I P 1 tp- mpw in the QAm-P -, Wemimith~weommsin the urnat uneal mrbad bum.a - I~bkm. TM k dbind In isls 44 belo . Intkdhd.la.,lbs &-b - pueuedft. Namt, d~wat m w iss b u eddm o bosbums a - muM.. noank pig -hue dwvothe am Mod"~ Cweabs adhs I* cone bulk do- NO ams d tdo aeci f - thu ddunkemd4kk ý,I hem ) pwqpq~ rn uuuw hued. afttiskelfre m mnincuesdq mdpre sofreemmmu~s atMWems

3A4 Tlombout the wbulax p mm., u~at hepmovkd t teTvA Tapim Report on, Qumlis Aimmsm wen smewe oo demu.es whethe they wen reIPOs.- to repINatmy sph eMM As mooed Amos the reqinruhmeaw and

u~tinmmdescribed In ths Tapimi Report wem repowms to replatm reqiremm EKweve, sin.poorg In --mminmsthe ebfedve

oftl th qni ne~lemmutwa obnmmmd istheames noted Amow IreMtbeing in them arem was wimidered w ermed. Thmnm&M, a corrpahlbm as wan ade ba ete thear @rmvW rshof the Topics[ Report (Ravislos 9), and the previou to hida (Rwv~io A) whkch was the revisom In afect at the due emupbyne ?im P ws rehmld, lbresuls ofthdis upuhe v arefInSmedas n4Abelow.

4 CAIOYtIMaNNmWGS

41 hmeIdueAdupqm" d Amhsem

4.1 Nlhp

A. BvhLdo identified sae procedus defidn aes in all QA ubas ries and in vrtmasfy ar=a reviewed. Procedure

ddidn f iacinderd fiames whbm the procedum did not dearly addres ll of the requiremaut of replatioa, codmes smtaeri, or dep output edomn s or did noth imlntiue tbhe inPn-imiea of the qualty umae pronr. The directio provided in procedures sometimes were e or conofting or in conflict with each other or with the provisio of higher-dter doumaent EPnrples of procedurs where some deficie es were observed indude: prourAment and use of material and spare part; receipt inmwion of warnty parts (prts supplied ee of chdme to TVA); certification mad diiw-nr of calfbrionM standard and calibration of 4q1pm% uea d durfig rucipt i-pdoan; aine - procedures for nsomennt to Aite in-aIn. pacon procedures in areas such

* compreuion fittinp, site irpecion of vendor equlpment, conduit and condut supports able, itrume , lunenrs, anchor bolts, wrdia, coting, electrical coect dedc cy ideanMtidon and ruedsobat; vendor domn control; .. d.tu e of controDed doannent in oflite document control center; dmely distribtion of document and change thereto; verifiadoa of document status quality uranac record; training and he Ado umentatia of training; trend analyi and nonconformance controL

B. Many of the procedure deficendes described in this report bad been prously identified and corrected by TVA. However, in the past, corrective actions were often implemented only for fture work. There were no prviWons to evaluate the impact of identified procedure deficiendes on previous work or installed hardware to determine whether the specific corrective action for the procdure deicincy needed to be retroactiw (beckit).

C. Procedure deficiencies were also identified in other category reports. The Cotruction Category Report 10000, the Engineering Category Report 20000, the Operations Category Report 30000, the Material Control Category Report 40000, and the Welding Category Report 50000 each discuss deficiencies related to procedures with corrponding corrective actions.

-~p~il-·- · ?-- -- --

D. To oopw to ; pr tbm wis pen~. m ýUn-ram wMi the PrO.WNe dthw.. k -b usag adw. Lu In m topioei by

- W* i ns ofa wof d ugmd (L& vim wmU bmm). Roiw of =p TV A Am& Ri ua C -W Repo ad Mao £eWM 60We

*Aft lb19 to M135 fts Sineas that thus poo ish kk.atzfed pin o~m auqdhmpobkmd diq lts p d odii..

IL ploufu. acdrmeepolinw F Me ntia~sd bby othe atgo POLb. Kq~murl Campy Rsput 2000 and dm Operadam

Camwq Rqost 30 dea pubws. wish -m~ awuil a~d - adgc -v sedu cd

4= Camudf Ad

DBM of fte 4ec5 punwshe dudkoedm isaotmi ptor to or a a rmkoti o gn Us q weaadwa. ha bee.dearneusd smd ho bee or bs bede cm em & Wher c ummy., pleudge prop hr -df howlduli hmr been x wE be amq bbd I w e suh quaal1

- i *hrvet~vth aupsi ofpirm wicksm. Ia nowslsm In to -a o dmildoulca a thy - idmid. Cain e saedm for the -oh of oth aer x c mpu inutuud1 ther reapmedi. =Mps

Ib a aseu u, pubis.on wishte 6@TA p oidn *umn wan reoooind and am addrWInsdi the Cporas ?%dlew P it nce Han. Is thisPh TVimA ha ommswd so a Wq tea ;ropum ft ~upaftodad e mnlg the nuclearopolbims *asm lb.procedur Wan. bslq delape Is a -a finm b des Wmam wh"c bIncde F a M01 -~ podl% f ves sd WMuIW* sd &dlvii leve pracedW smd haruales lb Nuclea Propsuedo Beec in TVA co Fn he-iqmieA ha ee tub ed uW wbtsh Us-" aupmlh d Iqisstaa Is In pupo.-. Eah WVA Nuclea Diviii. is "Pautlq doe ebn Deveoumn of fthi qstm pl=e emaphe mb e= nla pm; pubis.. throug deliv pucedure reffvie Intr- ad isamdlvwslna Poorn doei uwa invofremenk and kedbac& IlM~sei proceures will be reviewed ad revised on a sheby-sht b"si to ammr their coubA-mnanwith the requiremeint I she ; wrpiaepeeldirociesadm

prceurs.In the shon tarm, th Nuclea QUality Assuanc Mainua ha benrevised to provide mmoreffeetiv corporat contro of OA & tactvtis

Mhe tNo volume o~fth manua we ONP corporat QA re-iemn-

and the I- a--afos oa paper at pl us sepocd . TMi ilterim uumtedse ON? a m m tsin mo to ter iyhuido la mals

fLBt th ho m pepm i8s Pi obt. Deoip B3ab Verm.ios PIn he besa nbud to ern tdh thuns a ade g s duu bubd to(h a dams pq u. re nnofi trs bPuki cods and ** * DeaiDarn us being prepued rhaMaAe igraeme. p um a In pe) aRm t ro Me d npb dames aoen pIter Rson pnia (3 reiw edte ap dommasp i &de proar esk boriokam t oer r nenl o min a de ate

they om d qpie iab r esimei boh ,ep mode aeond dab nd tham d ttheyue ar mi-av' m N

RprIdanW ptsedure compnlu there are our boe cas why poedures were ot B owed: (1) either the p dur could not be Slo ed bcam of le r, ooauiting or missing fnormateon (2) the pammad taoled akeda the proper tra g (3) there isted a poor atttudle or lack of s tion to quality, or (4) there wr edequt or

SProcedure adequay s addressed bo; the other three ase ar addresed below.

o* Taiing (Iael 2)

A m re ag lim traih pream w cindesor clams on p oedure wopliaorlu which hae beew anraded by eappoidme ely 95 perC tof

ated ONP pnoonael, nclding epymaors aJ n=wmr. Is additio, ONP ha lancreed t-a ft ve of traini ad certicatdo requiremens for Qualh Conro pmonel

* Attitude and -forema (Item3 and 4)

Poor attude or lack of ention to qualty can only be Improd through maprial and mpurvisoy st acdon. Tlay at iabibit a quality colous atdad and reach workers and iampectors on a personal basis to incras their sne of pride ia workmoau hp and their understanding of nclear ainduty requ ars The issue qa managmen and supeWvsor trainin along th line is addraed In the Nuclear Performance Plan. ForP the cra, weekly "tool b meetings are held for this purpo. These meetapgs allow workers to becom more Involved with solving and avoid g problen through teamworlk. For OC a progam which evaluates each inspectors peformance has be estabiahd Inspectors who replarly do not folow promdures will be identled to QC Unit Supervisors for appropriate action. TVA's new poucy of making both craft and OC unit supervIso uldmtely resp lble for QA violations

; ___ ___

-wo ff abfr ui*p go -u bw*m a -~ dmps of OWNb~ Meow mw 7ks waf -wq umando o ame

or of do~e awasK - oef at cd Iumi delkmmqor WsA.mshd lbs d6d MqM bd~ dwis day# Wsft mnee Iiebdm Is dim imost Isimes dKlbyc ust TWWbR EOWMa

peussof bod huelshoYQqpusma u degiau or inmmm~oadW 11 witonb s umiW imwkr; p -- An adikduw 33* wo J*Wu to bo a possoM l r sm budmi~.mpoa w admhosI 36* b.. or

mM es Q~U dmmemum. Mbin~a bw of dos

ai*Msd by TVA. *as uoift wm wt rnsk la Is a of plau

Nuiutbem Ik k amid dos vb ismdu reidaf Aulql III amdon mk umigmyo %wars dot. lbehd bes IodmeWu mkuugb eqispu minu lba dmbie warn or wanlas dmt o be dikadm 1%~ Wade t w Wm me. an bowspolm a mula mb su

me~~rum ~ ti. smb emobio at m" adke - wbwes pikrinwmpodarwmuuqmegjmdns

lbs am at the del~deale iwdeste fs sh ad adbe caqulW woomolbs ms Isal ml ardin phOMWd hiudsi bubt an presidiu adequWady mi mp wfs p go@-an usiir- s.o

Mlbqk woe I rsmesm to eslbdh promsea lsON wore a

inkmrmd whkhc redsuhd in Imfebedis in a umbsor Of grow

IThe gmr l a ed a ed s coendk aes iom ta re in proes -m orre o t lu Me tdeidmlhs e malae is els cate y pea kied ha the peas

ml eIn!udionrmlas, in- d a" i me w da ft -m m a t e ` u gmont a 1respim m a is iss n4

42Phi tsF

A. Problem ba beemn idendled wih the procamret ad use of "coammrcial pads. maW eal and rmplnament parts at each TVA

iclar po;r7 plt Spedfiarny, commerdal au d V maoerials and repmment parts were procured without having appropriate QA prpamoadei r equirement s ivoked in proae enet doMncmns. 2 These hrms ha -uenrey been used in safet related applicatiof widot approprie actiom to uppa as ithe kmnd vri their

L Iapementa g pronderes at the time of promrment did not require that procueisemn docmnis. (pitch.. orders and conau s) coauin QA Propam requiemre l for suppliers or sabmmppliers of safety-related aosrrials prts, or a ern.

C. Whea QA requireaAnts were lnoked, principmal suppliers were not required to pm these on to aub pplHers in the coau t chain. Thre re, som item were procured without anrce that a quality arnos prapm was applied either at the supplier or eb-uppIer

D. Cormercial pad material and replacment it can be used in safty relatied applidou Tbis proae is referred to a uppadiag"

Propam w mts or without performing ther conirmatory tasda to vri material owelficaan requirements were met.

* For American Society of Mechnia Engineers (ASME) Code itsh , the TVA review performed in supprt of the material uppnde did not ombstetly verify material compliance with Code requirements reprding vendor A programs (including TVA approval of the OA program) md onfirmator tstirngt

- - to -urt nd me di n w"s -A ~rof NOUN go bmbqitM ad - red ne -d th Sao mu

I. b a havra da M1de Rqmy mimq ihdpif IO 179 TVA uuopkid doe puIi wish anomdi qM Pam n

wrVAPI Nind1w SAWi Rvadwf Staf (HERS) Repom Nor. W-M17NPS 1U413-NP- t R-U@7..NS idsrnlid dsfdsd.in TVA's rand.. for the Inmu - O - lme uepleceset hsm CM Impcdoa Rsport Nor.

S&Wq %M@&U died dml dddu.1u.L w~I, W

lo be dipuin by Iu pmmnmimn d pms u umid pudis wihmm -unuidn ofIs ~~udn 'd wii aeubm iih of 1M 1mm by W.We IVA look awMR -de cdto improve do pu~~ V-mTVA had w---p~nc ~rmr

hbr to diuMudim of auuny*sh 1mmi band d to addum do ibfm dtha pw ;I I mis p.mhr mW hwe bed. ankd

-u~~ of imsequd msna

ki np-'n cf1kdwud panmom is dalbsiranud do mad

lums Propme (REP) in NovelubmsM k6 is ha mpu da to wii thu do qmMatm~a sw of satyiai se has

ma nd wE M be du9u t 0g doe an of mumpmlhd uupu inm hm MIDe SON he~umr ms P,~ ka

lum~do 1 REP a dbut bflty ani wil ama n a model hor 1k alber7Anmdiv plM.!

7. At Waa Ow ad Dhlhhas, do Ausrims Soisqt hor Maehamela Liaoser (MM!E) Dole, md Pim=, Vumel Code. Seedos UfL

wM qbn o mdea pow pm k Haing- -- -1- 1 r3 laIsp---- in pracdme Ax pr.cca im i ad up~adi of MOteia rwuttd In 6 Inuisiuum of lhun AMM Codsr qisqumfeNowm Simo fth AMM code does not Wow dsvladm fran its rrnqui smsauu eizer the materiel In prdmm wMl boo to be Idswified and Wo4rumai no

Qal a r dulofim t ue dombs m a wiB hue to he pueped y WA ad Npoaed by the Nerw Repdolry

Ga ni.iiw. hI thinsOwrebo f.dend by oter cmegopxqup. Ma Opr o repua y Report 3M0 pd the MduMiai Comrl CRnP y Report 4M - c d Ud M in.h ths t with

In th Muiwr of Nucear Power's earuda of Noembser 24, 19s6 Mad Febrmry 104 1M7, specific direcdio w wsa for the cotrol of

p nemnst tem For ewmidte, the procuuiment of Qumlf Awraoce l nI (noaa-saqfe bMeaed) iloma will be per.aled only with a

saed ptable proces to aIlow omuinerd*aBy proured itbem to be "dedic"r r me on u-mq ed applpictoe Any bean for wrhich aa o epI "dediad ron pro camn b. defind at the de of pubm q-i dmpli pirraionn is rue oquind to be procred a QPy Asramr (QA) Level I f(ar ed). The Febrr.y 10, IM, umunmad g *Oach c uino for td e1vdoiion and awsm deAd corrective

dmoa oprusyr.ly hmld dQA kLel nU (In. .re-. ld) it .whten the is a lack aof Ae dea to pereit Prals addediain.

TIe Rapluinsm Ite Pmauma (RIP) wa uldaed by TVA prdally a a rMt dat 35 NR nport R44-17-NPS and NRC I spectl o Reports 50327 and 32W641 wicL cited pIcumreisit problem. The scope of the propam, inudingq list of eom ee'ms relted to this We, wa addrssed in a letter from A to NRC dated April 1,1 7. This plan inchad. pruni-lm for aevshdo of commercial pade isoms currenty imaled in esrelted equipment. QA rview of procurement do nan d chd thermIo for afety relaed mweral and sevimce is to inaclude verfiation of proper QA level eCignmean specification of wtedmial rquirnsenis proper QA requireMsna. 10CMR21 appliability, ampales ad Maccurse em descriptios, ideaidamant of amh coapoanr andoar sstem which wll cotain the itea, nd oamre ad receipt impcduon reqiiamniO.

AddilaUmlly, The Division of Nudclear En earing ha committed to a periftin improvement proprm to uppade TA macla pdeficatiom to require material identcation and traceability coient

with the requirements of 10 CFR 50 Appendix B, Criterion MIE, and code requirmns a aMpplicable to each site.

423 2 my

Cods~~~ -W~s " ~ ~ ~Wok

p ~I dik a* fth ulum GAM wus at bmb UebioW ON" Conl~ep at 3C1U -m~bt m - n sem at doe bmh ulmd =po at doe -- -

Ahtun, o -s em~ md mu~ uwdr po C mp , donr - mu m-mpn at I i tpdo bern.. the -m

- d=W PH I~ a~-l comd Mcmmom hooneshd Gn.b As a remit, a uetfrsd ~hm beeindfle~d by both thia

wep d dot Mddw Camtr Cbmiy.

13m conduiamm at "~i aoq .. the Materia Cnrolu CAmqWx ladicms that the Wdatibed deldmlun an prindpel related to

A- - -- todo wish - js umil for *-14--m defidneuci limits w dm do t imfi dwe p 4m sday ho bm adueily Wbod by

beufkdim at omote k"*vwL Ho m a ovitlor at oi domm. -ralmd ., i qg wish ; F mmt and wa~mpulsn. mot seimhE Doie and Ptum@.VameCode ~sbees iudtBBumd abeI dWvwtIRw.

lbs Pe mnuwaids.idatd by TVA o Mealy douen nd ml -daiipie ism*~lu p co-rafd awd the c mm Iswi

Om for pi. ad - at inauris and rehuemhm WEl amrste do di and pumta pblemnrelatod so minm ad ur at h1M and pmm th*f ,mm==

U. DeeuW Cain"aud QinIfy Ainne Bear&d

Them wo subjea m aftiemd a AUi~ topi sii both wlms the hMdAWS of oftpis remddieeti bein ame m trol at tpuha ram mrekin is lfuinmd by d&=men cul etodlae

43J 11 N p

A. bs the are at Documen Caonrol dsikrbelma dekay ahead belore March 190 which amd smu work to be pertormed to outdoed

reprsm~u~In adddton, at some sit ass* inmaal m~trn and laiq etowdm wor inable to deterudm the smns of druwmelp and Pocudore W huntl . MU. Cuepadsom=bdo

coirdposdq eri, wor mode and It wam no e, A p osibl to desaumin the sttuow d dmip docwmnt and chinsgs thereto

L -is-- d Mar lMe.id paadhm* a d-to - in Ate Do rmna MmqOu S I- wON& d i me aelect d omthe refledt I amead to *a1 qa ams wa S amS e maed

C t. F e s i Nmad wased m on a Cue atd

C edmSI eem ent ime - 11 wit da DammstCod~o

con ComaintMn in posift Dribewew n oodetenw wadlr d is wen awid i ad tp asr n d a mtatuau r on

icdrl Sesa e syMann ad S3y d. Als, -mi coalaied oi vdiCeeid wador mas did no accuraey rea

E. For raes whr aeteded weendor l'iaaatn had been used to polrm mping emoL no iaon iealadbed bea roume tued to determie whether aM adsse iamp on hoadame bad reulotd.f AiN, te. pIn lo t NRC Geners InaMer 8a- upres the 2 ido awm

ncmpemes or amer warder iuixtoa bed meo been bey iaie.. d. Mtaqb o amst of tha acdow to iqiame* te paieofm a tletter had beren ibid eudntl teea to quire inf ton and inrupora it in work instions I d not been

F. Sperfc probe with QA cok s faicincded retriabiity, control, and ditraibdam prtudrliy in the reas of construedon records and engoerng aI d vaedor aumr s. nt i11 o 9legible,

i**pk* W los dortroed, or misplecd rIcors beve been do -n-ted in te paS and corrective action intended to resolve thes problemS had beea take on soral occasiom

* The rtrievability o OA racords for coumdrctm was ncomidaed slow wad unprediabe. Reods were sattered throughout difnrart opnlzo and retriav was difZRh and in som cam iamoiiibe ibout Gfidig t person wa bad id the r cond.

* In Ei`neerirk recordi such as sendal aic sjm ln wre naot atma.amly mlbradnsd waome record were blst and in one ca

vendor alnationa were irdvrtently destroyed. As a result, substantil work ai been required to retrieve, regenerate or uprade quality aranm c reords to support the adequaqcy the

4AS Cboft~

wim~i um m Moo -oof k .M o d 1m b m 1mb to ~ md so".

npft=o&s bww rnm d d ~ - nst in

Far t:ucdimk id Opmod@WM~ amK q for -mm a 1 b t~w Dm~ SOMM (DMM)

Won d.ds qvmuat do ou uo mkw i IM isba rn~.b.n a*= anqwr ma for um by the Dhdm of

N.dm Euomboaf mI Nutdm m~ au ' d the Nodmo Sim Dbaseor so omm .pdo, ud ustdsum A, b.dom (bchiq aspiammd sco hi-"-i. ---- -- 1d to WA aug qippn m vudar

-mi DIE wil ma bm udibd by di. Domomm CAmro ~awi. h C.poda Gmm *dq mdfln -oie O.

OAm pmm ab bm mii qmin =0 adkm so ftD inw mL IMw Db.m of Nolew (OIiy Aum u bm.. iip -u m do

in do*za. WA dh bM Ind* li tbus dm o

palma lauqw hitm domalommi awm w msroha h .uh edaiNO"A mmii uv ibmwTA Dsm Mampam

Is.. so* IM 1dU Off sodmd a =Wl of dom Ruamim Rsuismis MM~ (331 PR rnu Q-am 4u enAsuO

=WWsdo bmW uuu-am OR dddsWi A to*k hgrm w .iIhu domlp . 'i M&k bdWid a owm hr

iyuk do iMM IlL uuu, ibm Dlvha of Nocdm arSmice DomW Cuei au Rwdbun Flm~a Dinm WA

inpam haip ism r qupohl. hr umIhblq sadud mdis~ mi u~ua dotk pmuaia Wainpom rwifida,

.d -OW SIA 3ROM& Mua PO - ?N.

As ommi *in. sma dt do domsoa P c - puoblm ib dw u -wb ib dmha.m at dom = ham bm enmocii. Hbomwr

mo-mcds um amlmh dommoi amur dafiemade ou fonad oo bm lmaqummor m' bmdmd 1 inmw Dlviii of Nuudua Eqonmrq hr

wsnde doaomemat 5@n~ Smqamd hr cousrucdos OA recodoat ismWr 3arumd Soipaa

4.10

snt dik ne 0e ads on, mbmi bm no bee defsed ml TVA is lo pm.da I as appropri aer- a e to les tbe pgeeral

Cmoucd e sins forI DNE Eamd Poject -pmm was A- -- n - b pedp y DIEM Poject mReS o bk M' -i mi

hImpt.ma aI PiofftRu PbaC ovmr Dthe Ca sno yal kEmES. I adiudo bm wonbmmq Remed and a rm on Sysitem (ERIS) Ffopm D We -me Group is po- M for writing or mwriind prodinrm and l-rmdosm to eisur cnrolm as in plae for DNE drip. the S Prop.u Control Group will conduct propI svmilawe dt oubout DNE to 'Ilady deficiencies and Cnue thy are

comected is a timely eaer.

At SON, a propmn hr beesn uHAblI to acquire ad ootrol current eador inb.n-dsn ami hnde--e bqer su e ns will be performed

to a ei ILth be lpty ot sIUB t iselaBd HIw e wau jeoprdized * a tr l oIt --in --- t mhat performed afq ousdated madO Moelsmn msOdr mad der Any dirapeai's noted will be evauated and approprially domu ed Caoletino. of the rerienal, indeuit , ad e irMOla of comarrumdma QA aord is scheduiled for

At Wle Ba, a warifhlom propm in a plan to mpare record amuanHsshy prpaum (lidq and Iadi1) wfth tb records acmually realaned. Thi wl identifady uay o8id, lost or inacuratey stuatsed eoede. Corrnecti acon to present mrecurI ce ao included training

d-mes for QA nreco peoael and a requirkmeat for verification of rteaton periods before be dicods e dmtroyed.

Is order to inpio oenral perforame, the Document Control and Records Mmame Dranch be been eahkhed ia the ONP hieqarners. Thi branch b fspoaitble for emblihbiqY a corporae Ieon I magmemeu wish TVA. RU is nk -a- - methods

w8I be decaed in a eries o dirol, and standds whi will be ia soerdems wYA the polcies maimed in tbhe anclaw procedures stem. Until tbs wnear procedmr. tm requWsremea re awailable, Project M ear-B Procudees (Imser vuionaI proceres that are part of the praae TVA procdure ytse) will be utilized to lefine requiremenws. There action wil provide for coiet identifation of tbho records whic an to be maismaind sad the metods for their collection, identifmatin, towrae, and retrieval. Records anarment personnel are

4.11

433

cm es Odin fo m" th do u om ent mom Qan reaPH puhim - imidwd ad c buosd -do a dis sahms Ptanolems did alo eaf do .tin.ft uubmm by ths cnm but for the

Smam pulb'se-moIno uo t deamomm wm mooed stplm us. but they m mat dp form W TA prinperd docminamL 13e sipiflam prob oW c F mi offn-do04 docomm astalmmou and prblmwas Vendor nmu.Each of d ths. u is am beiq

pm lbfknr -m

Varou I -- how bms bddd to Wosst* Nihssm or mopommo ~ ~ s, - egi. hu.zuinli

lubiumaef but aphduim wil rommW iode.ed Gdhliindies IMe membldimnhu and ofs.ia at aqw wsvp -m mas& pnro vii purewmtwvimmo In pmtutei lbcme onaus a I andw mpg 6 ie. Aid - Wea to a onumsim dth they reprmesed ssrtas sauby problem. Their uipmfirn.m is - lt lbn mra of ipaltyum r Bomingdmmtu whiedm ourso 9spi elty mand ausam to quMy respulrnmý timum do objective evidesm aoued in dosmmentm Is ksmseslL Weaknes In dbs - how esie and will autism to require .ubinaula gmsfo to

4A lbw omu@m Ae mdn hesmaer paiyasra.poaeci wo

am a &uesei actiity. Radhe, Ik is a pracm. aumistdq of a wmube of acti Wtes du~d to d4uPit and resolv dokeldeadh an.I h Irblm and prava their

.enuc.= 'Thes activities include, but wre no niabed tor

" Fisu Un. Impection to deWiy mand resolv defikdeudh in work prothacs a ealy u poaudh in lbm productio poom.

" Pnmeah ubmom. aral mand resolution .newtho o resolve dekicenadh ideatifled shrooib impection and othe actviie thw uinow be corected w Ithi lbscope ssofteim q reurmeaeither becam. thei srlswk mem

4-12

bmm day -qlm dediom and udain kms adONEm=. oher thn the lMif urlmn At TVA them referred to oam diom advene

to s ab the ; ma e snsm and to ml sime. The WA deuadnim da *'ColrMo Ad t OQaie is broader thi the rupoolry ddliddan o aL - eaoidome but daom bohk Iare conOHlbd by t*b e s Wsm theys a aimei d a e hanrk ai report.

* Qaulme -m R ani d oi In a sh e ldveias of pr5p5I prO Odmrme and paiudm (Iacdiol inspcio and -n-mu s.Irm aco ol) ina obtnaiig deired rmes and to vermiy conm e wih th re6quirsels of poies,

* Feedback from both aternal and external sources tht provide either overchecim of tbe q alty a-ce propam or information that can ast in improvinq it. Inseral fedMek ca be iformal, such as tht resultiq from tbe actie pUrticdipo of imnaSer and supervisors in the actiities they we rmpondOis for. It an also be form, such as the us of formald tread alysis

mchiqoe or the actidies of internal rwieisevuatim poupS such a the Nuclder Mamps Reviow Group and the Plunt Operats Rview Cn..i . at WTVA. Zisermal feedback sours induds she Nuder Replaint y ori.dna iustry pomp uc ash thla titute for Nudear Power Operations ad the Edison Electri Iiest* oter odear utilities and i o aio o tiq orndo OGraphicaly tis layered approach to

orrPedie action ud look IMa Fipre 1, below.

ktand---

Feedbaeck

oQA Audia

' Noacoflib occ Control

First LiUn Inspecoi

Figure 1 Layered Corrective Action

4.13

k der po be etid"es the mo maoies pres msies ormnaed to

ua*ual.. * *m*m at slw -oi aiosped of rspkedh. 6aume M coinc for PH *d to nion a1111M

.d.... C rumW amd aCi i A- me d a in prsel ad

m* a. coleis reas in this caepsy iia thm sh ui . did t uilr prdcipt in ad pIromo tdhe or ec maa rca e to

a mfides. d&epef 'bo s 1edaM tf do doe=m= and -Pnder dWBdnda em poor -prodre a*ma e slow mad weak

nrcdo* d i maddamrf adieor to a qfly, mad ianndscia In the qrpdY *r A a-d ni r ipm indiaes tat ao srrds aris ed that tmi m eo R t de a ired a i onm a they aoald th bee. If h bed bee advely n m inoked is ad ;pems.ey pal nd on eaed sd. for o ee N.lhd defsomi. aP d PObP em, dknea hdbck p-de qualy r awold bkm bees awdbl ad amald hm. bee aed o solaorlh eo e tdsc arb tmo acrsI problelm ad prinw their enmreins

CAarmoab Ataia Finding A

TVA hm aidrhad isa or t admop which wll sareogthe tbhes orrcads samle praa

Is early M6, TVA isouatrced is ulearpr pw orgaido In order so provide mon derais manae-m of its maclear operadoo. Nuclear

aki idd we udsd I tbh Offia of Nuclear Poer, reporide to a ige ummrerr. NTh Corporaes Nuciar PoerfmaniN Ple (CNW) wu Iapripd ad imr in Msrch on 196 to durcrib thoae aom being tabas or oso be s so m&rom perfora ad is pecik maclear pedomnmes Vim imn bee or wIl be prepared to apaem tib CNFP. Each &dMl witbhi. the Offi of Nuclear Powr haJ lidaed podice proUa proder. ad ardoan to Implemeu htb mama si mde Ia s aclear perfarms plam Reviews of the CNPP and the initiaides

which upport is implmoerdo verfied tha they enuompams the priipel cau=o for weakums a thi arreaida acdon prom.L

Preisuy, the whole of the TVA Nuclear Power Orpnizaiad is operatindg under a utronag trl mOmiema y syem. This orpaiztioal structure provid a hfamework for stablshing q coaieaat mAnageumI syaStm

414

toi is ppaned by b aeped poli. p' rd Idfin with cob roaed Ien....m by Hash 'Ith stratheed QualOty

Am s -,.. and the wly ce*emed BE I sw g Amuraoce booh has td vbWiry to ms tha pdbo m cm be

WM.e d sa a avoided or Ienl dmIy uled. IK addio, a p1pm w- -asied mto - thm besd Boo su y l 1 yday -wn dew d dt.- - .A.e-s d their Aid _nd rq n .i . ot aLy hid -rqmu l I- II and dMt ty kmew tay were

a -u'Ble -r the qwOy ad tdimikes of tsheir wok. TMis pnoapm In AlId wris peo dese Ad.fgd for eac oaTVA's nlear direaerM , mmi - sia to form dnI d defi ia. a.d m.pnadineu

Tlm provide for am ability and form a bois pinat which performce is Imerad. The posidti decripdon were reviewed to Ideni*y an waknesms Aipicatdu of eorb, or moinfg fnctions in the posidtion decripdoos and to mre that key interface upan.ilitiea betee p were proper defaind. ut poucie have been lued and ad dus hbse beean take to reinforce the aed for quality

amOulhry Ind e l elfe l dmel rokdOlm ofprobieas.

Corunw ade hal a lso bmeen lidased Ir tl specfit Iptl n flodip related so corrective acoa. Wherm fiadifroam other ECIG cateprie a died a this report their rupece arse y repoM i deibe conrrwectI acdoa for the abdip In their reqpecde cateories.

* Work cotrol methods did not Lme adequae provisio to manure peream.1 - ad provide edbak idomadoa to mqean and peio. In tbe Quality Amrans Caegory it wa noted tha Wa

Br had ind iuned a procedue for overchecds of ilpector performam in 1986 but that this procedure w not being followed. At Beefoers, me aluornal proPin did exist amd was being ulid to aimse nd impro inpector perf-orm-e-. Overall, the

pIDrrmacese walumIon of quality aurance and quality crarol peronnl raed aon t TVA miirl perfonmae review process wich did not mearily requie drect obervaon of work.

Correedm Aedin Pr FindngJ B

* The Division of Nucar Quality urance ha implemented a procedure to monitor penomaae performance and report feedback idormation to ana esaat, supervision, and inspection penonnei Both pod and poor performance is to be identided and appropriate acuid taken for ach.

415

* WVik od has bem addmmd l aher ooy am"epaOm Mw .-bruss QcM Iert wap S rS I a uni c y

AIsp »i Lb mOpuiaolrMsp B|lp,,t each 3 s Jim dibl tabi n sled I woik com wih eamgiladb aOnfotde

* Tied mi. cm be a Mt tool fr -ei1nig ad scopf qmay publems md d-eloupl imemelds alam sad TVA sed treed -msk f#r dm lb pumpoe tC* a deps ic sw, i abOht bt1m f"o. b apMedon Rjec"i Nodoe nd tb d&mu meodi d rportud dMimadoe ad te aeRct ato redoq the mIhft s l of tread ari Os cur r proebm ws mosed i tAet stob d prmiem trad rmyR prodlnm reqirem ta a

Comidom AdrM 0a Qury riporn be iemd fasor adsm t r, Bo plxrqm dinedos is provided to wAt comaimes an i *e useand do peaia wo mmcl how to iapsPm Lb

* TVA ilemd mdas io r lmhes d tr h rbe aned aby*is puom anuserrat wth dL6 sahls.i. A domdfidq o r ariMd waih add Ltb pom usd pArndi"q

uumindea f or up me., lysI Lb delidea of ad...e tvah TMiW port of t L abrt nw head ubeIpeea so tbi

haludom MIis report indedes tdb db present md repon ahim sor me ll uhdmtionm ad - bdiq wed by m-Memsn

.It .m.hdes . ... dL pre samus mod "-r * 0Ms"kdemR of dL ppmi me&di uiM 'N u p m.. when empaered to popmthe d aadr wdis Lb doelary." Ares for iIQaom imbdis L teporpd of pIohis a wUE a M-pds wd -EM del imua md oaup, deAmdo of made mash, - problem ri= mm ad slmuiom of dLa buem Ts aerso wsa implemead, wll iuiy eabams tbe marotioam thas tread anlyuis a kn sk to tb corrective acton

* ProMba wriain TVA seem to hr bepua I the early 190r., after MTh liem Mle Island iaddent and the signimi t iadusywide clws iardused a reumt of Lthat ddena. Technial probema and

4-16

.. I

proalas in the IM p of fh t b q mflby -e maHd. dtat a s and w i 4laved p-reio by othadr alr atdlid. sas Cm ui- to dhu s plM r col q WcmA. TVA did o01 0ae6sds of ry epasm in m k oina thMs. pbleAm a tbsy

@= I. s - pc os umla whrie limanrby apaea mcold hol barn baer udiled hhds the famnd attiIoa tIht s paid to pI rsaI acqilMem - I pmmn i tamb IqtcsmammS In aend M eaidp amd re d I magmo aasthok techaical midql of the saaiq plracs,- ad radr lidorardon onaL Albbom m our pAoM wam wird d on mhidple omios. by TVA, tde Nudar Replaroy C*dlan, the Iauda-e for Nucearf Pwer Operdtio ad ahr, aba tidmas they ware aowed to remain uisucected or, is -m mass, eeeiid prevmadi action was not tab and probleam emacc a d to te point w e the quality of the TVA mcMdr program was hiuly cidded.

Ihe TVA Nuclear Opading Eqmime Review proapm ha been iidaid fr bot latemly and ameruy Wiasiid problem or swems. UndrW tks *amst- ulnpimt probl-em or msoms idelMtid at other mdir pleas by t NR NSAIS NU a vuados, and obrws, and agum problems (wmse) idatled at TVAs modIl pmaIts w1 be made th rbjeta of arqiaaon review reports. Operating Iperince

tdormoau ( rmal and arM nal to TVA) wll be smrmad to deeradnie qplility to TVA. If it deeraa d that the probea is appliab to TVA, thia a analyi* w0l be perftrmed to dewelop oorecd artion raimum eBa Da or posidoas to be providdo to sits, eanieerb and tralig parnomel to take im dle awracdwv actio if necmary. A corpwrae md operatinag periean data be is beii deseloped to interboa wits a fuace of the TVA uclear ocpQnirtio.- b data bes will provide WTVAwids sMI and provide the Mdcmy managI en tool to track all periso review iteas. A feedback merhmi a bas beaen esablshd to emur that the mylud operadin superimen review rwranndtiaor are factond into the proam of operatdoe, deisp, oouMtcrdon, and trailf,

* Other cateory group has also noted weakneses in the use of Iadmtry aeperiena e dbacr The Eniaeerin Category Report 20000 the Operatidons Category Report 30MO, and the Material Control Category Report 40000 each discuss deticiencies related to the use of industry experience feedback and orresponding corrective acda.a

4.17

442 Qmft ýýMOM

At a"& mowl's 'mes. ofin amt -ý insmihq u~m - Ms~sd u dm by wdindkm ow p 36y by

IWOk ad byw fth MC -d is fth audm m iwn ~mbd i thTVAod Fhs NIhum bf's

Adty Am* MitOip wereod gmduuml' sU~dlffrsnqdmd modaiie wo mt smid.4 ud the =ope t .of ao the aids wu de.isma Ddcl-in weo Wo iodmuibd rdoed to the dueiine of

snu edw am's. =eoemd domme don, md twhe ais to p iem

b~aIw n ds~ can") hoWd fth riew ofam GesIhete A mit mporm. Mwb beim ia Omu rpors mud the .yomu reui& 6m. k dotm soim thut ' ues dmahaftsmu~ dooly -gd delelemaleso abmm ein undwiftl -ý or meulqg

wWn b*m'sm -W -W -m doe amftom spedlaiy moled

authmw* or pý euuvri to abe. effeedve md aoxlWk ruohado. for -llllp - frm Ife=~e was iow and sourmedm so&bi &.h wmroqd wai meal d wItw oabat eddacihoq insind withos hwing asmb bae maimdo to uppe -atimm by do GA widoua

As wmue In Nuds Sbt~y Revie Scoff Rsport 14$4-$WBN mud durft QACEO ovahmlom. aiw W of the e~ugineelg pro... appow to bars

ooumraedon 2"dVNmilsrid .maen ad weo wek in addrusagq sehiiUPewOf eqineerlag Produ qaualty.

4.18

*Asi at he IM en VoI pma ly- s thaRIl had -dea depth for *the a- mird, atd iw04d soe bad mwede - as pert dthe adis ambieaLd. No dm m, al =PqAd a-es wo e miti me so-I ame soht ae i om Iid thea wn

Amai repar rfe m to ised i-molgi booh Jmkred ad Irogandoa that ideied pmb Me1 in tbh se, but wch roWted In no reques for ooede aedon. Ina other cw, amdit dwiasioan reports wm iueed but

-oieped inas respases did not resut in .rlcdl ,crrecvs ado.. EixIpe of these two codit inlsded saee of tbhe sipificat probeMa tht aa now being adremd by TVA such a ewiroaearal

uamaMo. Ri% protecdon, Siuruemrdos mppara, curtian aupe of the coeedise aid. povm, ad n of aendor iDoreidoIm.

TVA hs resmeimed ad mr ted tbhe QA Audit Propam. Sft i i be inmei d oa whi wich shoad deverw probeism wilh aisr q eIquireW d md.l Technical stHe so belg

of fcMt adtio ad deerm ato quality, reft urnean prewado acnimo and escaladion of umokld audit izaiy to hgher No w& of

e--- -- ns W k rnlaM d to iideufdos and adequate clars of ideasfled problems can oly be resolved through a mobimans of efbrt by both auditlg and andised pemiasi. In this reprd TVA is imphiusin the value of and is purad an efectives QA Audit propae through both thn QA orpaisdon and line

445J NPaei ermaaee CNeul (Cm Ig of CrmiMes Advese o QuMaty)

* WA utilied a number of .iferf an methods to document and resolve anonAirnnldag conditk. l eI included Noncafonning Conditon Report, Defcidency Reports Sip ant Condition Reports, Corrective Action Requests, Work Requess, and Maintenance Reque, among othe.

* Ur d thes mBipl mdethoai dm wish INm a ---1--irn hr hiHrm rthbsii ~ rntiiiiii d bHe al TVA oanr loa idosd 6001l a sd d -u- rd thon Mf dor A ..M .yd hedsion The2a diam TVA uob a

-i Dbat) a&u had hek ow peonars ad * i--MIal prov ei to dabs 4suind e abrad huhea. wone We. Thes Ws a1; id 1 ish ama st. for emuyft co.Ulk trau , -d reolkiq

-de leaP--s, 9for aog LrI the rasi d bthe arIon problem rep aU b method in plaw peroadg overall tread al or for rMso l d a dn dmednni problem. - Sirnm a collecade

iBdrlbo h tbh vwriour method u ed wud acquWisd to supprt ths aivitidas, idendfed proem ascontued to exist without -pp rs .. mem vbitaitye ad ameusand

o* The aduk . probem rMportiq eshoh did not I1isde eed Us psetio for dtmey or adespot pa3ssic0 pMclcbly vatf ado-m, law - -e dsermia o ad abseqem a orrsdeperede aUdom. Spei drs- omld be ad madly wae ud@umed ad

WnUrued, but hader a-aliB m a deuest r foot -as ad p-eric i llr ad ato proaMs aed e action a ptevm probem

* Whe aornedse acdton wa-amuuk wI ideadud, p oeus is agI d1hIM thim was slow is mniy cowes Ewaluad.m Is this aaspy oated omssr where aees mkadvey mdior d- -rpI med amuncorrected for avsemlsa perli at due without adequae

* NWom ionussns asral del*dumads ware aso nosed by other ais puueopL lTb Coanstcdton Caeory Report IaM ad the Operada Category Report 3OW each diasu deldmas in namudnrm u contrl and crrumpoadiag acrrscdve aIdom.

4I2

TVA aam II Nw po r m ed at tmmem aims t q f MaI1 31, 1W9, u ummubmd to kithe Node t f-L It Comdom Adl- on w thf Report (CQR) Iupa, ubis umoudI tb m Memhsm iechanka m prmues a afItl eeiq qvmfo hr nao oedo =dok, is dumeud ia ts Plder GeQo Ammie Mem h-oe abo bene ms bdmt solhM mp d hfor ima- Ibths( qmue , for -o mbeads -r igfemds mod noomes - - , amd hr tbe timly emBnln and rusOlem d of pObMal. A crporso prtam for problem trFddq ad reohldos has been asblished to provide a -mcl Mo for blproved ------ R vBisHltC d comi trol

ZEMA

hem ** ad -a r ol weorate t lq owrly colaK, or aunained oiudlq lorma . DM NepLiessf or bldequsades in

d»rmus E w Mu m o C R sqpohp and eulmimMaep "mpi'r p heqmr; vional weldl hepeclepo ad co4lp Most of thL deide nd muoed ln this caepIy were wu otlt However, tho related ao (1) elctra itca llaom (2) laer---cUai (3) pipe

utmad (4) w-d comrbted t ooms of tbhe mr leass ow ti addrened withbin TVA. The aodY in this categmy s otisem with thos of other caerless 11. Caumemlosaon Caseoy Raport 1iOO the E.arqimg Casory Report 20MKO tbs Operadam Catgory Report 3=0 and bs Materiel Comrol Case Report 400 each disusa dal udes in the abone ea m ad correpa edbi orrcive actios.

Deelg output domn mrs belg imparoved throbh a pocifcadon iproomment propam and deuip bms verficatdon propam. These we -al .aumy..d. to ensure that appropriate repglatory, code and smdas requirements and TVA comaitmenw e amrtained in Desip O-pu An MeuM

19 - .- - -- T77 '.1 '3 w '7 "'T I ý - Vo

.ola PMOI&Mu IN -eow bonee ad wt hnd an ofd dps dudo co A.- . r-- - d own pudar

001-01 WO -#S -W 401lf or SOM

~~i~ a-b hbmA t.b- ~m

PruM@9=-r wso.im h m sead nb.4.1, tdepo

At 3eIlshwiw, IVA med Quaft ComwroI hmudpdive Repors (QC~Ra) In '3MMM Mdolum mooed by ISuIS '3rlq PIMm cmmunucdn.. QKM& m~eed, kirn mWio ad nwhidc% polisd iqmp hr

.~inskg mhlvei aid Mlmhls w of ~ ,l anmidarn whim MqpkAd Sdel WW100bd IS 911ft SmMIMO 110 III IM Bdubi -OW QOM with toe bipsud diddmm Mpaudq UnSA" In M at Wow lUý lnvesdm RA0uida Naodos (Rtfe). a" rndwarndahilbvmdas enatjm M -mdidwasuiirdwlmebsewd -w veded as on* whiev bmau QOhdd muI Twafnthi aduorn - mnk ýasw!ý. dol not awntkdo reif of Mw T Am. .ilb

* Whimdaliedieds zPi Roed vissd mwhdm isber Mild cheap requn GorMMS--km vnwm wer Midmed, but no rupkem wm weIN place to sam* Oft to ther idmu m sahdas.

Thu~M% =doud be domed aid dnuwayed upon the idadam of serredv autism. M& mak kib Ait o difin f w mm sl~ble, to

.AMfdad hid bm MeesifdW aid w"c debedesd wer cwecWe - a Inik of "m EMw lmpea9'n.

" At Wts Ear, pIar to Ift Impecdla Rajedam Nod..s (R.M) were Mm requed to be kwed If difidleades mated by leupector could bes

sarued behre. do mpca left the area. MNs war descrbed Ina procethwa - cuaadm d vveadin toolk ad could have Me.ed dwm purpaiaL Howeve, sfm scety wer no ahesp required to be Wooed, aH noed Mdeiades wo wt Wadeeifed Mwe emailtdu lick of klantirao., Would M Nippon M effsetiv trend aualp"i

* lBsh aslt l PDdmo prpUs was aO 0wqs comu bea l Ul md or eObi d, o a w eam do is Mst to Cthie, i maHlhed hoa ages or codlk i sp Is ds oute doimemos or

prosv iortt o o he dbt a" s ds deloped m am Iesaihon pam-idor with lub -- aos or hedbsk betw s *ita

BI oames Im tha t w Ms probl em a is " wbs p W M

wolm at be tld s - a each ss. hoblem -a - ad mooed that had bus m, ked a os sim se ablt iadesT ad temrIu, hither indie of poor amnim.d..t Somis codmi wes also moed that maied ho 1... . actiaos machw a (1) iunimMar eder m eaot o pocdrs requkmens. (2) thd poiy at Weas orf to not eport dutalines. Id adified by flid inspctOn i wi dor suppoed -q OMs, (3) cn-m 0o ilesedtio procedures that rveim d and, Moqa-uly, reaisated required inupecdans or (4) the failur to Meioatl IRN is aiccordn with procedures. A law imances resultd ha I-dQatse tralag of permonmoL

* Mr of aBs imas wahueed in s cte-opry warn related to tbs qu^md.m" or apablUad of bio*pds penuawl Fladhl 1- this

oriy ladhta tht imost of ts dlrdeM-a realaeod t ts trining, quIM-deml ad cerdimiado of impection p;eromni were lI rmideaplq aseatlon to detai i d keepin was Iiequams ai B -Ms and at A locatki n l somis imua-- impectorns were

adequately traied or did not flow proudere, but thds smdldm wer et -pm^mdit. Overl impector per&trinmeB is comidered to he been adeq MIlt.

Th Impaction Rejection Notice (IRN) param at coastructio sites bas beeas traebhed IRNs ans ow amed for each deficiency ideAed dar t l UImp iapdon . The aotrl o IRN procesin ha also bes re ed to provids UamM oa proper resoluioan

I addIo, IRNs a mow desrari d ad d retained a "'tfe-t-Plan qualky reorde which should ehamce the ability to rtracs and analyze impctios multe, aM problem, ad dmotrate1 hardware

Coasency in site impacdon activities will result from combination of tb eforts to standardize inspection procedures and management action to comistemay enforce requirements. Each of these are described in Secdon 4.12 of this report.

The ~ G- me far fht wemWS k imnd aid. m was t U m DBlk CM Won .m ^U B Opf Imin ed OPiM

A.mmpa* i nhost piors fis p s s mdpo mtm ah

p bamnd didaa u us'- oft h -anmde a -e

Som t ls ek as aas ruiied a du aereuss a & .sm. bares dot were not U An*di rs oled. Thus hosI nabedisth ls hlowl:

* ANsabn heelk in,.doa wai d aMbIs hao book latrnl and moo -sao ih w cohld bevs helped en*ify aInd .orre pbles. it wa lesebdwevly ums and som. idaMd probles wsr not adueed deq-uumy or i a d sty mansr.

* Crdvab i imdo. rlWih too heaMly n bs pqulift a urame e" -e-m zupoMbNi n d a-la wNL

* Om.Idm reqvirk erreaks Pistods wIs not omseuady -oed ad ieadmled by sither Uns -n or ds qufeIt - mpess - - d nseidi sa@Wm hr ideaded p abl-m

as Wo aU e-ibe or desI. Coredves aois co=rns.* -r badmquately permed n ams tha ncorse' -iim plaus won

Soew and -uwml fsd lbs desred realts.

* Thems w as saM iora maIbd o ideA lt problwem, gi

SguollMey for their sohudom, ad ack the resoludo, pIos to * IteM. T amthod at d proodero isa us r aumnaid-u- n oml were deaest n root cause -ameIs d gunerik aplbillty

d1-im-v m and wonhuussy armed

* The reiew pas- fohr deap on" domes did aom comlassidy lLmes s lsy itshded aa l of tls ra peqamsar aid .aiull

conlceis applicabl cods, saderd repladoes. and TVA Mmin docuassm. SlIrly. tlbs reew proV s for work Ingri prosadwrs and Wauudom did not cousiseady aure thb they luaded all of ts reqiremme of desip output doausou or of ;pp l, pim sul -Idoaris^ w mach As lbs Topical Report or th

adsaer ouswBy Mu.mrao Miunm

4.24

444 bmmy

The - Iaew wa mdia a pnolic. paenr. m ld reqidremntI in plasc -a fut I i pr em ur p a pdo ad n coarrect both the

st pd*bloHm m bs roos miEs dtha rmesbad in a weak correctie dce pames i pLrb - s pm , -bor thedr ecmm d-epean

as thd -bIf wm al s of Ine Iamr to puma their kinylatalm a u . Over l, lS s o kn taken bo lucre.

i smsgmt suppaort for nd p6 i tbh correctie adon praos m- acmared in th NucleNa mrP tRl .D

4.5 TVA Tplal aeprt (TVA.TTIA)

Slae the aluation in this ctory idicated that although tbs TVA Topical Report on Quality Assamos w repomhe to regulatory reqolrunmas, there wa poor pFerirmuo in ianplemertin som of its requirments and om and Stri hlei of the buic equireM s at the Topical Rport

evel cO -rd wramd a order o determin wha er this had been a*maiished subequem 10 the 196 riorpilnmdl of the TVA Office of Nuelsa Powr, the cunant nr (ReviW 9) of the Topical Report wan

-um-ed wih the peiou rneviion (Rlio 8). Tis remas of this compurisoM

45 As wold sbeupmd, thas ity of t ins in tbh Topcal Report were orpdlloo RPeMio Io of tb Topical Report wa mWd in 1984 ma hd mat bees updated to nfeimC or.n oaf duco clms san that dtm. AboMough th Nuclear Replaory Comuins had ben notifd of td cho s I" a lrid, the Topdal Report bad not been updated. Obseunrvios rprding the b orgadMi chaea described in the Topial Report ar

A. Rision 8 of tbh Topial Report refecs thTVA orpoiation and phIosophy during th tima euaploe - w ere bein reived. 'is r ision depicin tbh frn eated orpnaoonaIl qgiproach to

flky armos that was ected In my of tbh proc res and prdo that were used to ileames th d quality msurIce proram. The TVA oups with fuhataal r-epouablitisn for quality maurmo wr loosely ded topther and dtermninl the rapomlrblanl ofa tha various oups ad the authority they had to acute these reprioililes was dificuAlt Ther were at lau t oaven OA orpadonuso. ad these, like the line orpaniao., w 00n centrally cotroled. Olves this stsaurn, it would have required a high level of overarl or izatonal commtment to quality amuranc, a substanial effort on the part of uaaaere, and a high level of commnination

uer~m. NO-1SWA8 10ip o I~m gos wr~ Iupei lb abofd Aw-de kdwl.i pq~l~ms lbwshd qmftw

mdw bmtw. wAMfsm pi omwohhm.

a. Rmw mm d as I*" lbplnd Iqi iuaes TVi A wdam Ow ande pir km at f th l mw

~~uhinil ruepsub we hr m a au o abos

* the ~A biq Dkhhnws inns.hu@debu~d. Mdldý

o Mws DM"oi of Nude. Qualt Amrne (DKIQA) ism bee soklhhed Al Qualty AMum ad Qmalty Cbmsrr

& ~mme repMr a IN iNaqs. An Eog~milq Amwrin MIA) houmisb bm amatd *in &oe DiM"o ot Ndew

Esmsr~.TUe A oriwml 11upormo to h Doiecor otf N-ea~mek ~s Dkoecor of Node.

Q Alit wu ms itm Mwsu Rh A wzuds k reulbls hrwshe mm ad pouesare doa

dou h qfty -s ij upmfr eqlaeuq and daap wftdm o' dhet qouedIq -ocom isesh .baowpy wish othe m1pWdor. -mu ~dlnedw aiq of -wn= - - - p opm mie and

teihalm mte o inn axqilan wish qmaksy inu reqdrme.addwhe ec~uiuie~cy afew4Wdw~wok

*CooUullmdoe ot-mansmemrnpulblida An ab ~s r~ced In she WA soupore. hei mmis ul In she Dulou of Nudeer

Eqleelq ad Nwd. asw atm (DNI and DNC), and at -lrt* =der *ash SmeDco,

" mw eeobill of o o wih Bndum.I reaoullliaer qmflty innan more dowly defined

Soim of tis duwuslo reule Wderns from the .ooldueot she ONE. The mea ýine frmIprm In

doe deflideet - If rpublis and inseuou wihnd betwee I o r-11ti

" An importus loprao-enet Is fte hxbdud of seli ;eurmu un~dig" the rol of Mhe D"Ivio of Nuclm

3I~U.~'I.neuu an* d dos*p ac~tiva d&W" plan aperslM& "We Whoul ftrin sh"bty of TVA to mda~nfta~

desipb" ofoperaslagms Infthlhhaneeprdftbrokeof ft Plan Opeadio eview Co=Wmmitten review ad apprWa of

pooprma srnl ladm w diCfd Iad treqtdhed wisdh haMd sumiB t overeIght Of thbee chaesm to plant

4.U . I addan lo th rersWiiton the aomh mlrli decripom, a nm er of Aanaeslod were asroei d a sabadb iadd Ia Riio 9. ThMes

A. RaPlresa a ir tbe asral a procurme mmt d nt were strghened lnd the procurmnt ofa co ercial n." or '"off-hes4l bem is now qi fiaily addrsemd.

B Vendor ucotr by WA bas been ehaed through improved ddatid of the require nts mad rspornibltires that apply to the activities of WA orpntdoam purchaing iterm, and of the VA ProcIreneat Quality Amsurnc orpnidoo.

C Requiren lor mrenip lapetio na iclude spei drections for oumsercalar ade - a m D. Mterial control requimrems won upaded to eahance traceabiiy

of materials f receipt throuh istadoa.

. Documena control requira were refined and stangaewed, pardcularly In the mes dt tb carlot of drvwla. In a related marea tie corpaorsewide sya btrig implmeatd to hadle qualty euror rword Is now re renaed rather tdha tbh pvious system

that wa under dthe ontrol of the eansering orpanlatla

F. Canrmn related to th procdumres used to impleam t the quaity mranos pn e were upraded and requiren s for the review of

nd oaacurrec with t procedures by tihe Division of Nuclear Quality Amerance ,u -mphulue

0. Reuiemeas for adg of personal ad she doW n rion of ts -utifi wer upe aded

. Corrcdve action requitaan w signt ifcanty upgraded in th w of the coantrl of oodidon adverse to quaity and udit by the

Division of Nuclear Ouality Amurance organisaon. In additon rauinmran have ba iaposed regarding the teation of problenm through tre a mag m chain to he Manger of Nuclear Power (if they ca be resolved u*sdhorfly at lower levels).

4-27

-s pw~d md o mm by a ids up~at qs bu

alb. mdd*q - s d -s~bi~mkiu Ob taps's wim 1m.1 - - d q ummis prop=

upbum iissdd api oWsm Ash. bus sui .hdwhsrsIs dis Wups'Vo - p4- d -- wKI mt u soh* hs Mhe

*L pmoleS.a do 7u*Wuim Nswu.~ thu I mh~uW .Ifp~ 11 pIM mul -O 'M SO Ofu MW~ O '-AN RW 1w idm th a 0 1 sthft VA indlw pnws gema is a MM mum esi mid wil mphir mouui nd dotIq igutslm di. Topirn Ropen m oralsud Rumeoisstl with thu aVMW&6=ofsa GMPWaIN owmm in d* a-ympi-d isis uusofq m mdw tTVA--------- buduruW

vussud w -aibuudq usA t tusilwmuphoftudhw~

4-X

SA CONCLUSON

5. AT TVA, plans for quality mrans ere seianlly In place from the early 197t. T'esb plans w desrbed In the TVA Topical Report on Quality Auranoem (VA-TR75-A). Athough the quality saras e program described in the Topical Report was reponi to regulatory lrequireomen weakees dvloped in Implemeg ts reqnr mntls during the 1960 to 19i5 ti me. So of these weak aessa relected in thd euploye cancerm evanhud in the

uality Assurance cau ry.

52 The one sidicant probe ideified through collective analysis of the fldin in this categoy was in the corrective action process. Th principal or root cause of this weake was attributed to a hailure by managemnt to develop l Aly efficdve methods for the corrective action process This faure is at leasut partially attributable to the evolution of tbhe TVA nuclear power proram which expanded rapidly in the late 1970s and early 1980's and then contracted. The experience be of available nuclear manage was diluted during the expansion period, a tide when acresed maagemet attentio was required. In a closelyknt orpladon, some of the eft s of this could have bhn overcome through close

i *ur*ni coord cindtion, and control by upper m gm t However, the TVA ormdmaa n.i with mcaonl pOnreb.liue for corrective action acted Indepndently with little eatraiid control. OGiven this, it would have required a high level of experieoe, mitme and cooperation throughout the orpaniatio in order for this proces to nmtion effctively. Tse actors existed in vryi degree, but the overall level required were not achieved.

.3 Beginnig in 196, TVA ainitiated maor actions to improve the management of its mclear operations. Ths aclear power orpanition was reconstructed under a single manager n the Ofic of Nuclear Power. Corporate and site-specific nuclear performance plans were issued to describe the actions TVA initiated to improve performance throughout its nuclear power organiation. These nuclear performance plans effectively identified the root causes of the deficiencies dentified through emplo concerns in tinhe Quality Assurance Category and the

actions to be taken to correct them. Implementatin of the commitments they contain has been inrated.

M5641- du is sohpud W Iuip~isibttsos iwuilkmu maph=n(vlie iaedsd ~aiqd u~ lb WA ,ph Ropon) anp muse tho opsaft

k W bjipwaspwimm ad ata mku no uubue dk ft w to~eu ls~ m In fts madmo -pui-m- - ipo mubw, thei

UJA A abd is Vqaly mumasg pmm b msdi lo "h muim esOMM ebn. Coellqf P" clflillsku.~lliul a" ebois mcdi.lk sedan I R au win hel us""ls cmfddema In TW~A=%qiml to imluemet the ov~uml

APPENDIX A

QUALIT ASSURANCE CATEGORY TABLE OF REPOTS

Rpuem i the Qimy^ A.mmc- Cmegoy aomprim Vohm 8 of the Employee Comerm Igcd A uFpmo Report dFiI and rC-ndo Tabe AB A bloBw ikmu eac&h od

_the - -*U- o the propm by umber am tiLe T blA 2 iIdrent s' the report mbe m tide fo the 15 element leveld epm pmroeread to spead y addre the

Tae A.1

QA Catqry - Subcatepry Reports

I=LE

QA CATEGORY REPORT

QA MANAGEMENT AND POLICY SUBCATEGORY

INSPECTION SUBCATEGORY

QUAUTY ASSURANCE PERSONNEL SUBCATEGORY

NONCONFORMANCE CONTROL AND CORRECTIVE ACTION SUBCATECORY

DOCUMENT CONTROL AND RECORDS SUBCATEGORY

GENERAL MANAGEMENT AND POLICY SUBCATEGORY

a

o

a

snm

800-So

snow4

MR4M

QUhJZTYASUU3ANC1 CAOfTAKE OF EOI

TaWk.2

IngeAin - osecto Psovepelm u udx

Kbwcdn-IPko copemhu

IKiomflu P*.Saiofmps

WI Minqemeuz 0 5Iuu PrCuin Dewiuim Reponiug

WI E~uudDocument Oosity

WI Docment Dbribudoo Cmsoul

W~ Qualiay Awwanice Records

AFFKNEI 3

U ~d SW. Coa Gind Aadm - Badminorof inp EqImer 1gn

W Kmr Joined Slow A Welumr in IM7. Me is mmmly qm the QA Caftegy Ph wins Group mipsd to the Temmet Valley Mtkdriiy (WVA) Hit is Siam a moon muims is the , N .udpoin. i icv .u mW Iho of qoe

ommrebmd to TVA's ipdaq ammm pepum md the -pd~mm of QA=Q Peumi dPd At@Bo(WlAs Nudewow FR F-did..

As ftopu M- qir of the quaity ,moey prup a the Diusi pma Coqumays Ciffo Pbdma &mad* he -id md nu pd the dwa~etu SOCMMh "PmIi o wr*pI- qU~y.

Wr. &L.~ ado u m da Psuec Qualty Amosma~ MqInrI wbet he .map mud w~mPTW the overal Siom A Webmr Coudit Amuuu prop= Cwuic*q Am & Wekto's rqu Imiluilti OR the IKWES Oinch Rive Breeder Float pOjeciL He Also mupd md ait m prct quality amm huefimdoms on Same & Wduter's Nite bfe FbimUi 2 projcz.

As Qwlky Awmum Endumer Mr. Kmr perfurmued qualty muomm sremu relate to =dew ; Ric t Hkmiug deveopet of QA Topica Report for sobmn~oo to the NRC, qualty on -hol Prmmm deeo~nat a aumiructon mud qualty ummoe mumeu He

mEdmd- s urg itid. in deelpngaekom.nqualtymom progp ad; prcedihu for Imm-hcdi.9 mperudin mud mhuckwfesfor thewr mdew plma Mr. Urr evauaed ~abf inilsy Waukr mN pCa andor M developed utiliy pordoum of safet uml~yus

IFU IL He glo developed smnm and proupde. for CenraWa oqualityrelat edatvities hlr ainmcda. of idrph=in mud served an the crpartme ammuineme tuked with

~iL-AmblmtyGCAI@mp Bud

SI& UmbUl* -~ Mmm h Admfghtdm - 134 No -1 1 Thiwzalty

ML bm bm hem no m d In huJMc 001% Aý for - tim 25 ym W ~~wamchi l shra Q m Y~MANK fink uw mdamacal

As Askit. D&Wiim I IuVP of Sto= a Webuu'psm F Pmoaree Q)ualiy Amzarmm (PQA) D&Wwai, W. Mem I Pected the ofla aD al miids a policies in five eGlionalPCV~ efi= Hleso -*P jwd ipdiiNRC-inmhad iatboecdmmata~msrucna

shme u the Sonm A Woimi's Qualiy Aým Reproeomtior

A& Mmmois y emc apedimmomn lach.Qty Amrm -Frdi Wekdqbaz theb Umatd Stswd Cum& c. lb a dowlaped it~ po~i. ad I p m and Fwmm f -0d desi mur-m malmn "o~ 8 1 aPe BiQ A P op u OA pwIhmuu m 1", aiv jwu-m it10C101O the OA aectiom of Silty Anulsis Report to be in auuqpliui wit NRC (1OOFRAO Appenfi B) =boy on d. uuimud.kds. andlient

Ptig -10--m BUoiWedty- hieloSrtdm - do~o-1384

Wr. ftay bmw Ovr1 yew~ apu 1 in (uf Amxum and CcntroL

Wr. h"y joined SWEC in IMma~e 131 m Eq-i Vrlu Awem~c Analyst in fth

p 10 P Awg vsh -0 cmdwf NRC uqIreiep I n 137 bk. fty 6ruuerrI to the Quf Ainý 1emm m a Qwf ai Spcmf amnibe: for wrh Fiedd Qwmt yw CrOnIE ][au LM 1b3 e WU 10.~t Soupvinr Of PR F 0 dm .minmbk for ofpm dolb Capou QOliy Amrin Peepuu Other dudes

bm W66d NtffAmm to the (set Eno QinaytS1m !)iuiia, iqmuamIb for mI I I n smw.m ofOt Q mmmy ftxofd smu; and Land

On~dk -ym Mimi^. .ep e for the Symmm Do slapume Secdon and A Iiuomut kef a hma, wM. ubuied t viewq andI p -- iq GA pmrosiin

In 197h Mr. ay mupued mSquyvw, Sm Suu~msam, reqimnible fo In~u~g md gai dbm hor -sm d c to 11 Nq , imhdlq inqf repons to ~inmfor actio.. In 1NZ Wr Nazy wa inmed so fti auth.. Pkue to sowt

dhe diem in pmpuadan of IheuIq- fsmomy md gook 0 Wmation ruort. In 1983, Mr. Nay vu od a the OA D1-tepumnwm cuud Rprinod c and the Senior SOPU4b1 Of(QA Iud Swatu

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