IR 05000341/1986011

Insp Rept 50-341/86-11 on 860407-11 & 21-25.Violation Noted: Failure to Perform Channel Functional Tests & Calibr & Failure to Take Prompt & Timely Corrective Action on 25 Audit Findings

ML20199C760
Person / Time
Site:	Fermi
Issue date:	06/13/1986
From:	Choules N, Hawkins F, Rogers W, Sutphin R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20199C748	List: IR 05000341/1986011 ML20199C745 ML20199C757
References
50-341-86-11, NUDOCS 8606180242
Download: ML20199C760 (13)

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U.S. NUCLEAR REGULATORY COMMISSION

REGION III

Report No. 50-341/86011(DRS)

Docket No. 50-341 License No. NPF-33 Licensee: Detroit Edison Company 2000 Second Avenue Detroit, MI 48224 Facility Name: Enrico Fermi Nuclear Power Plant, Unit 2 Inspection At: Enrico Fermi 2 Site, Monroe, MI Inspection Conducted: April 7-11 and 21-25, 1986 Enforcement Conference Conducted: May 30, 1986

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Inspectors:

hN. C.0'Choules [!/3hb Date

. G. ' g h b13f}&

Date R. N. Sutphin '

0[13 / f(a Date

Approved By: F. C. Hawkins, Chief 6/l3/B(,

Quality Assurance Programs Section Date '

Inspection Summary

.nspection on April 7-11 and 21-25,1986 (Report No. 50-341/86011(DRS))

Areas Inspected: Routine, announced inspection by two regional inspectors and the Senior Resident Inspector of the licensee's actions on previous inspection findings; audit program, and surveillance testing and calibration control program; program implementation for calibration, surveillance, audits, and receipt, storage and handling of equipment; and the annual quality assurance program review. The inspection was conducted in accordance with IE Inspection

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Procedure Nos. 35701, 38702, 40702, 40704, 56700, 61700, 61725 and 9270 Results: Three violations were identified (failure to perform channel functional tests and calibrations (two occurrences)-Paragraph 4, and failure to complete timely corrective action-Paragraph 7).

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8606180242 860613 PDR ADOCK 05000341 G PDR

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DETAILS 1. Persons Contacted Inspection at Fermi 2 on .4cril 7-11 and 21-25,1986 Detroit Edison Company

• M. Champley, Director, Fiscal and Materials Management

, *J. Cohen, Licensing Engineer

• D. Eloff, Surveillance Coordinator

• R. Filipek, Instrument and Control Engineer

• S. Fox, Lead Quality Assurance Engineer, Audits

• R. Lenart, Plant Manager

~* Miller, Supervisor, Operational Assurance

• G. Overbeck, Superintendent, Operations

• F. Reimann, Radiological Assessor

• F. Schwartz, Superintendent, Staff QA

• J. Sutka, General Supervisor, Materials

, *G. Trahey, Director, Nuclear QA Other personnel were contacted as a matter of routine during the inspectio * Denotes those attending the exit interview on April 25, 1986, Enforcement Conference at the Region III office on May 30, 1986 Detroit Edison Company R. Lenart, Plant Manager G. Overbeck, Superintendent, Operations J. Plona, Technical Engineer J. Cohen, Licensing Engineer USNRC C. Paperiello, Director, Division of Reactor Safety J. Harrison, Chief, Engineering Branch F. Hawkins, Chief, Quality Assurance Programs Section N. Choules, Reactor Inspector W. Rogers, Senior Resident Inspector R. DeFayette, Project Manager J. Bauer, Reactor Inspector

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2. Licensee Action on Previous Inspection Findings (Closed) Unresolved Item (341/85026-01): Late responses to audit findings. The licensee continues to have several audit findings that are 6 to 18 months old which have not been addresse This unresolved item is closed and upgraded to a violatio See Paragraph 8.b. of this repor (0 pen) Unresolved Item (341/85026-02): Low completion rate of preventive maintenance (PM) tasks. The licensee has reviewed the PM program and made changes to improve completion of PMs. A PM task force was organized in March 1986. The task force reviewed the backlog, prioritized the work, and in April 1986, implemented a new program for scheduling and monitoring the completion of PMs. This item will remain open until the effectiveness of the new program is assesse (0 pen) Unresolved Item (341/85026-03): PM program did not ensure higher prior.ity tasks were performed. As part of the licensee's program to improve the completion rate of PMs, the status of PMs are reviewed. If a PM is not accomplished on schedule, management is informed and they must approve the delay. PMs which are not completed as scheduled during the month will be given priority for completion during the following month. The licensee is formalizing

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this practice in procedure No. AD 12.000.17. This item will remain open pending NRC review of the procedure after it is issue (Closed) Open Item (341/85026-04): Adequacy of calibration frequency for instruments which are not specified by the Technical Specification In response to the inspector's concern, the licensee documented earlier evaluations that were made regarding calibration frequencie As a result of these evaluations, three calibration intervals were established: 18 months, one year, and as needed, (0 pen) Open Item (341/85026-05): No procedure to implement the Technical Specification requirement for leak rate testing. The licensee is collecting data to write the procedure and has committed to complete it by the time the plant is in commercial operatio This item will remain open pending preparation of the procedur . Surveillance Testing and Calibration Control

The inspector reviewed the program for the control and evaluation of surveillance testing, calibration, and inspection as required by Section 4 of the Technical Specifications and Inservice Inspection of i Pumps and Valves as described in 10 CFR 50.55a(g). The calibration of l safety-related instrumentation which is not specifically controlled by I

the Technical Specification was also reviewed. The following items l regarding the surveillance testing program and the calibration of safety-related instrumentation were considered during this review: master schedules for surveillance testing, calibration, and inservice testing i

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had been established; responsibility had been assigned for the maintenance of the master surveillance schedule; formal requirements for the conduct of surveillance tests, calibrations, and inspections in accordance with approved procedures had been established; responsibilities and definition of methods for the review and evaluation of surveillance test and calibration data had been established; responsibility to ensure that required schedules were satisfied had been established; and calibration requirements for non-Technical Specification safety-related instruments had been establishe Documents Reviewed (1) Administrative Procedure' 12.000.18, " Surveillance Program,"

Revision 1 (2) Administrative Procedure 12.000.17, " Preventive Maintenance Program," Revision .

(3) Computer printouts of surveillance and calibration schedule Inspection Results Procedure No. 12.000.18 controls surveillance testing required by the Technical Specifications. Surveillance testing is scheduled on a master computer schedule and surveillance performance forms are issued for required surveillance Calibrations of safety-related components, not identified in the Technical Specifications, are controlled by PM program procedure No. 12.000.17. A master computer schedule has been developed for the PM program. The inspector reviewed the schedule and identified that the components and the frequency of calibration are . properly indicated on the computer printout. However, the desired PM completion dates had not been entered for several of the component As indicated in Section 2 of this report, the licensee is working on the prioritization of PMs. This includes component calibration The inspector also identified concerns with the non-Technical Specification calibration program. Those issues are discussed in Paragraph . Calibration The inspector reviewed the licensee's implementation of the program for calibration of equipment associated with safety-related systems to verify conformance with the Technical Specification and other regulatory requirement .

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a. Documents Reviewed (1) Administrative procedures for the control of calibration (2) Selected instrument calibration record (3) Selected calibrations procedure b. Inspection Results The inspector reviewed records for approximately 40 calibrations and functional tests required by the Technical Specifications. With two exceptions, he verified that the instruments were calibrated and functional tests performed at the specified frequencie To meet the Limiting Condition for Operations, Technical S;.ecification Sections 3.4.2.2 and 4.4.2.2 require that the low-low set function pressure actuation instrumentation for safety relief valves F013A and F013G be functionally tested once every 31 days and calibrated once every 18 months when the reactor is in Operational Conditions 1, 2 and 3. Records indicated that the reactor had achieved criticality (Operational Condition 2) on June 21, 1985, without the low-low set instrumentation Leing functionally tested during the 31 days prior to that time. Technical Specification Section 4.0.4 requires performance of applicable surveillances (functional tests and calibrations) prior to entry into an Operational Condition associated with the Limiting Condition for Operatio On July 3, 1985, technicians performed the 18 month calibration required by Technical Specification Section 4.2. It was

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conducted in accordance with Procedure 44.040.06, "ATWS/SP.V Low-Low Set Reactor Vessel Pressure Division II." At that time, a master trip unit, required to actuate the low-low set for valve F013G was found inoperable and replaced. As a result, the low-low set instrumentation and function for F013G was inoperable during initial criticality and subsequent low power operation (June 21 - July 3, 1985).

Additionally, two of the four 18 month calibrations were not performed within the 18 month plus 25% time period specified by the Technical Specifications. Specifically, calibrations conducted according to procedure Nos. 44.040.05 and .07 were due on June 29 and 27, 1985, respectively. They were performed on July 1 and July 11, 1985, and the instruments were determined to be in calibration. The records also indicate that channel functional tests were performed on July 11 and 12, 1985, and the instrumentation was found to comply with the Technical Specifications at that time, some 20 days after they were required to be performe These failures to perform the specified functional tests and calibrations and the inoperable low-low set instrumentation for valve F013G are in violation of Technical Specification Sections 3.4.2.2, 4.4.2.2 and 4.0.4. (341/86011-01)

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Contributing to this violation was the fact that licensee personnel had incorrectly identified the functional tests and calibrations as being required for Operational Condition 1. Although the calibrations and functional tests were performed prior to Operational Condition 1, this error led to them not being performed prior to Operational Conditions 2 and 3. Review of records indicated that the functional tests have been performed as required since July 1985. The licensee submitted Licensee Event Report (LER) No.86-010 for this inciden Another example when functional tests and calibrations were not performed as required by the Technical Specifications was reported by the licensee on April 30, 1986. On that date, the licensee identified in LER 86-008 that some of the required reactor coolant system leakage detection surveillances had not been accomplished since original startup of the unit. The licensee discovered the surveillance inadequacies while trying to identify the appropriate acceptance tests for replacement floor drain and equipment drain sump level indicators under an engineering design change that was performed during the current outage. Specifically, the drywell equipment drain

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sump level monthly functional test, the drywell floor drain sump level monthly functional test, the drywell equipment pump-run-time system monthly functional test and 18, month calibration, and the drywell floor drain pump-run-time system monthly functional test and 18 month calibration had not been incorporated into the surveillance test progra These tests are required by Technical Specification Surveillance Requirement 4.4.3.1.b. The pump-run-time systems and the drywell equipment drain sump level comprise a portion of the primary containment sump flow monitoring system and are required to be operable during Operational Conditions 1, 2 and 3 as stated in Technical Specification Section 3.4.3. During the time period from initial startup of the unit until discovery of the inadequate surveillance program, the licensee ascended from Operational Condition 4 to either Operational Conditions 2 or 3 on five occasions (June 21, 1985; June 29, 1985; August 10, 1985; September 5, 1985; and September 13,1985).

The failures to perform the surveillances under the required surveillance program prior to crossing into Operational Conditions 2 and 3 is in violation of Technical Specification Section 4. (341/86011-02).

The inspector performed a followup on the information provided in the LER and determined it to be accurate. The inspector concurs with the licensee's analysis of the root cause as that of a misinterpretation of the reactor coolant system leakage detection system surveillance requirements when the surveillance procedures were originally writte .

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l The -inspector also reviewed the qualifications of selected personnel performing surveillance test calibrations. They were found to be acceptable. Personnel were observed during the functional testing of two components, and no concerns were identified. The technical content of 16 functional and calibration procedures were also reviewed. The inspector identified that for procedure No. 44-220-202 (" Suppression Pool Water Temperature Instrumentation Channel Calibration", Revision 1), the test resistance was not specified t be set on the decade resistance box and test equipment was not required to be removed. The licensee-agreed with the inspector's comments and will revise the procedure accordingl Using drawings, the inspector selected ten components which were associated with safety-related systems or functions, but were no specified in the Technical Specifications as requiring calibratio The inspector verified, from a review of records, that these components had been calibrated as required. Because the licensee had not completed the schedule of PMs, as discussed in Section 3, the inspector could not determine the extent of the calibration backlo During the review of records for calibrations not specifically required by the Technical Specification, but required to verify compliance with the Technical Specification,.the-inspector noted that the. licensee does-not use individual specific procedures for loop and component calibrations. The licensee has a series of generic procedures for performing loop and component calibration Specifically, there are generic procedures for removing and returning equipment to service, for loop calibrations, and for calibration of general types of instruments. The procedures are not generally .

written for a specific system or instrument model. ,For example, i Procedure 46.000.02 (" Flow and Level Sensing Instrument") is written to calibrate general types of' flow and level instruments, but no l specific vendor models of instruments were addresse The manner in which these loop and component calibrations are handled increases the potential for error, especially during removal and return of instruments to service. The inspector discussed the use of generic procedures with the licensee at the exit meeting and in a phone conversation with the Operations Superintendent on May 1, ,

1986. The licensee committed to evaluate their program for non-Technical Specification required calibrations, also assess the need to use more specific procedures, and develop a plan to improve '

the present program. The licensee committed to-discuss this plan with the Region after they complete their evaluation. This is considered an unresolved item pending NRC review of the licensee's plan (341/86011-03).

5. Surveillance The inspector reviewed the implementation of the licensee's surveillance program to verify that the licensee was performing surveillances of safety-related systems and components according to approved procedure .

. Documents Reviewed (1) Selected surveillance procedure (2) Selected surveillance record Inspection Results The inspector verified that surveillance procedures had been prepared for 14 selected Technical Specification requirements. The inspector verified from a review of the records that the surveillances had been performed. Six completed surveillance tests were reviewed to verify that the acceptance criteria was met. The procedures for these surveillances were reviewed for technical content, and no concerns were identifie . Quality Assurance Program Annual Review The inspector reviewed quality assurance program activities to verify that changes made in the quality program commitments, since fuel load and startup, had been properly incorporated into the appropriate work instructions and procedure Documents Reviewed (1) Nuclear Operations Directive (2) Operational Quality Assurance Program Requirement (3) Nuclear Operations Interfacing Procedure (4) Nuclear Quality Assurance Procedure .

(5) Final Safety Analysis Repor (6) Final Safety Analysis Report Change Notice Inspection Results The inspector identified the implementing documents which addressed each of the changes of significance in the March 1985 Quality Assurance Program for Plant Operation. The inspector reviewed a sample of these implementing documents and determined that appropriate changes had been made and that related working level instructions also conformed to the Quality Assurance Program Plan for Operation ,s

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7. Audit Program The inspector reviewed the audit program to verify that the licensee had developed and implemented a quality assurance (QA) program relating to audits of safety-related activities that complied with regulatory requirements and commitment Documents Reviewed (1) Operational Quality Assurance Policie (2) Operational Quality Assurance Program Requirement (3) Nuclear Quality Assurance Procedure (4) Nuclear Operations Interfacing Procedure (5) Final Safety Analysis Report, (FSAR).

(6) NQA Combined Open Item Status Report.

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(7) List of Ope,n items Initiated by Staf (8) Open Item Followup Sheet (9) Technical Specification, (TS). Inspection Results The inspector determined that the scope of the audit program had been defined and that it was consistent with the FSAR and Technical Specification. The licensee had developed policies, program requirements, and procedures that provided for qualifications, training, special expertise, and independence of audit personne Audit program plans included provisions for schedules, periodic reviews of status, reports to management, reaudits when required,

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and followup on audit findings and corrective actions. Specific audit plans and checklists were prepared for each audit.

The inspector reviewed the licensee's audit program planning guideline documents to determine the policy and requirements for the time frame in which all line items in the Technical Specification would be audited. Section 6.3.1 of the QAPR-18 (Internal Audits),

states that at least once per twelve months, auditing will be accomplished in the area of Technical Specification and license conditions; however, it does not address the time involved for a

100% coverage of the Technical Specification line items. It is the NRC's expectation that the 100% audit coverage in this area would be accomplished in soMe preset time: preferably three to five year The licensee has initiated auditing in these areas on a selected basis, but does not have a documented policy for the time frame in which to

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complete the 100% coverag Pending establishment of a firm policy for this aspect of the auditing program, this matter is considered open (341/86011-04). '

8. Audit Implementation The inspector reviewed the implementation of the audit program to verify that qualified personnel are conducting routine audits to ensure that licensee activities conform with regulatory requirements and commitment Documents Reviewed (1) Nuclear Quality Assurance Procedures (2) Audit Plans (3) Audit Checklists (4) Audit Schedules (5) Auditor Certifications (6) Audit Reports , Inspection Results During the followup of Unresolved Item No. 341/85026-01, the inspector reviewed the licensee's performance regarding timeliness of responses to audit findings and related requests for corrective actions. The inspector reviewed 25 items and, as of April 9, 1986, found their status to be as follows: -

(1) Three items were still open after 17-18 month (2) Three items were still open after 12-13 month (3) Eleven items were still open after eight month (4) Six items were still open after seven month (5) Two items were still open after six month The inspector selected a sample of the 25 items for a detailed review of significance and to determine if prompt remedial and corrective action was feasible. The review indicated that timely corrective actions had not been achieved. Typical examples included audit finding Nos. A-QS-84-27-01 (open 18 months - items in storage level B area have specified maximum storage temperature less than allowed in level B storage), A-QS-84-34-01 (open 17 months - no implementing procedures address QAPR-4 requirements), A-QS-84-34-02 (open 17 months procurement forms are referenced by procedures but are not attached to procedures), A-QS-85-10 (open 12 months - NRC Form 5's have not been completed for last quarter 1984), A-QS-85-35-01 (open 6 months - failure to certify personnel per ANSI N45.2.6).

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These failures to take timely corrective action in response to the audit findings are in violation of 10 CFR 50, Appendix B, Criterion XVI(341/86011-05). (Unresolved Item No. 341/85026-01 is considered closed and upgraded to this violation).

The inspector reviewed the current audit activities and verified that the audits were being conducted by qualified personnel, in accordance with approved audit plans and checklists, and according to current audit schedules. Two sets of new audit plans and checklists were reviewed by the inspector and found to be in accordance with requirements and commitments. Seven qualification record files were reviewed and were found to meet requirement Reports of recent audits were reviewed and were found to be acceptabl The licensee's more recent responses to audit findings were improving from an overall timeliness standpoin . Receipt, Storage, and Handling of Equipment and Materials The inspector reviewed the licensee's program for the receipt, storage, and handling of equipment and materials to verify that program commitments were being properly implemente Documents Reviewe_d (1) Nuclear Operations Program Description (2) Operational Quality Assurance Program Requirement (3) Nuclear Operations Interfacing Procedure (4) Nuclear Quality Assurance Procedure (5) Power Plant Maintenance Instruction (6) Approved Suppliers Lis Inspection Results The inspector verified that the licensee had implemented programs in the areas of receipt, storage, and handling to meet their commitments to ANSI N18.7 - 1976, Section 5.2.1 In the area of shelf life control, the inspector observed one situation in which a material's shelf life had expired. The situation involved several drums of EPICOR Bead Resin, EP-11, which had a manufacturer's 2/86 expiration date printed on the side of the drum. Before the end of this inspection, licensee personnel had begun the required review and evaluation, but it had not been completed. Since this item had not been completely reviewed and a disposition established, it is considered an open item (341/86011-06).

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i During the inspector's review of level "A" storage, a commercial '

quality (CQ) item was selected to verify its receipt, inspection, and dedication records. The item was a control room printed circuit boar The licensee was unable to provide all of the review and dedication l information on this item that is required by 10 CFR, Part 21. The status of this item is considered open pending a review of the pertinent records (341/86011-07).

The inspector reviewed the storage of level "A" and "B" safety-related items in warehouse The following observations were made:

(1) The licensee has not segregated safety-related items from the nonsafety-related items in warehouse (2) Most of the safety-related items are marked; however, the nonsafety-related items are not marke (3) There is generally no storage level (A, B, C, D) requirement marked on the items (less than 1% are so marked).

(4) There is a lack of strict access control: doors are usually not locked and doors are frequently left open exposing the warehouse and the items in storage to visiting personnel, wind, dirt, dust, humidity, and the weathe The inspector did not identify any instance where safety-related items were compromised due to these conditions and observations; however, the overall warehouse operation is considered to be weak. The licensee indicated that they would initiate a review and reconsideration of the above practices. This is considered to be an open item (341/86011-08).

10. Unresolved Items Unresolved items are matters about which more information is required in order to ascertain whether they are acceptable items, violations, or deviations. One unresolved item was disclosed during this inspection, i

11. Open Items j Open items are matters which have been discussed with the licensee, which will be reviewed further by the inspector, and which involve some action on the part of the NRC or licensee or bot Four open items were l disclosed during the inspection. D 12. Exit Interview The inspectors met with licensee representatives listed in Paragraph on April 25, 1986, and summarized the purpose, scope, and findings of the inspection. The inspector discussed the likely informational content of the inspection report with regard to documents or processes reviewed by the inspector. The licensee did not identify any such documents or processes as proprietar _

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13. Enforcement Conference An enforcement conference was held with the licensee in the Region III office on May 30, 1986, as a result of the violations identified in Paragraph Both the violations involved the failure to perform functional tests and calibrations as required by the Technical Specifications. The purpose of the conference was to discuss the violations, their significance and cause, and the licensee's corrective action Mr. Carl J. Paperiello, Director, Division of Reactor Safety, opened the meeting by describing its purpose and scope. Mr. Paperiello expressed a concern that the two violations, along with other missed surveillances, indicate that not enough attention is paid to detail when surveillance procedures are prepared. Mr. N. C. Choules, Reactor Inspector, presented the Region's understanding of the two violation In addressing the violations, the licensee acknowledged them and presented what they considered to be the strengths and weaknesses of their present program. They also presented corrective actions to prevent recurrence of instances similar to those which have been identified. Corrective actions included improving the method for implementation of Technical Specification changes, improving the technical review process of surveillances, and review of surveillance procedures and scheduling by the Independent Safety Evaluation Group (ISEG).

Regional personnel acknowledged the licensee's proposed corrective actions. Both parties agreed that planned improvements were conceptually sound and that future performance will determine their appropriateness.

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