IR 05000341/1987027

Insp Rept 50-341/87-27 on 870701-10.Violations Noted.Major Areas Inspected:Events Surrounding Unplanned Mode Change (Cold Shutdown to Hot Shutdown) of 870626

ML20237L018
Person / Time
Site:	Fermi
Issue date:	08/12/1987
From:	Dave Hills, Hopkins J, Mcgregor L, Wright G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20237K994	List: IR 05000341/1987027 ML20237K992 ML20237L011
References
50-341-87-27, NUDOCS 8708200047
Download: ML20237L018 (10)

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I l U.S. NUCLEAR REGULATORY COMMISSION L REGION III

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Report No. 50-341/87027(DR$)

l Docket No. 50-341 Licensee: Detroit Edison Company , Second Avenue j

' Detroit, MI 48226 '

j Facility Name: Fermi 2 Nuclear Power Plant j l

j Inspection At: Fermi 2 Facility, Newport Michigan j Inspection Conducted: July 1-10, 1987 j Inspectors: re o f k[2 Date l

i .H k s { f1 Date 1

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U*te (/ , 1, Approved By: Geo'f . Ir Test Programs Section ef kl N

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Inspection Summary Inspection during the period of July 1-10, 1987 (Report No. 50-341/87027(DRS))' {

Areas Inspec.ted: Special inspection of the events surrounding the unplanned l'

mode change (cold shut down to hot shut down) of June 26, 198 Results: Three (3) violations of Technical Specifications were identified ;

during the review of the unplanned reactor mode chang i

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i 8708200047 870813 '1 PDR ADOCK 05000341 a G PDR- ,1

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DETAILS

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1. P3 rsons Contacted Detesit Edison Company L

l *#B. Ralph Sylvia, Group Vice President, Nuclear l *F. Agosti, Vice President Operations

• 1. S.' G. Catola, Chairman, NSRG

, "R. Lenart, Plant Manager, Nuclear Production

! *T. Randazzo, Director, Regulatory Affairs

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• G. Trahey, Director Nuclear Quality Assurance

• 1. G. Overbeck, Director Operator Training f *#E, Preston, Director Plant Safety

• 1. S. Frost, Licensing

^$. Cashell, Licensing Engineer

• 1. W. Tucker, Superintendent Operations J. Clark, Nuclear Shift Supervisor R. Trimai, Nuclear Assistant Shift Supervisor M. Koralewski, Control Room Nuclear Supervising Operator R. Valdeze, Nuclear Supervising Operator in Training

[ J. Louis, Shift Technical Advisor R. Jolley, Shift Operations Advisor T. Given, Control Room Nuclear Supervising Operator

1. M. L. Bufalini, II, Supervisor, Media Relations

• 1. P. A. Marquardt, General Attorney USNRC Personnel

1. A. Bert Davis, Regional Administrator i

1. E. G. Greenman, Deputy Director, Division of Reactor Projects

1. C. W. Hehl, Chief, Operations Branch

• 1. G. C. Wright, Chief, Test Programs Section

1. B. Berson, Regional Counsel

• 1. W. Rogers, SRI

• Parker, RI

• 1. D. Hills, Reactor Inspector

• 1. J. Hopkins, Reactor Inspecter

• 1. L. G. McGregor, Reactor Inspector

1. W. H. Schultz, Enforcement Coordinator

1. P. R. Pelke, Project Inspector

1. J. J. Stefano, Project Manager (NRR)

• Denotes those at the July 2, 1987 exit intervie ADenotes those at the July 7,1987 management meeting.

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2. Sequence of Events  !

l DATE TIME -DESCRIPTION 6/25/87 0120 Reactor is manually scrammed from low power due to Recirculation Pump LC l 6/25/87 1436 ESF signal received /Several systems !

fail to respond as expected including j both LPCI divisions and EDG No. 1 /25/87 2106 Entered OSL 87-0465 on EDG No. 13, i l

6/25/87 2206 Entered OSL 87-0466 on Divisions 1  !

and 2 RHR Syste /26/87 0330 Placed RHR System in shutdown coolin !

6/26/87 0400 RECIRC LOOP 'A' TEMPERATURE 240 )

'1 6/26/87 0455 -l Reactor in Cola Shutdown (Mode 4)

at <200 degrees /26/87 0500 RECIRC LOOP 'A' TEMPERATURE 190 ,

6/26/87 0600 RECIRC LOOP 'A' TEMPERATURE 160 )

6/26/87 0700 RECIRC LOOP 'A' TEMPERATURE 140 /26/87 0700-0800 Shift Turnover / Recirculation loop temperature approximately 145 degrees RHR HX Outlet Valve was closed by l previous shift to prevent further  ;

cooldown below 140 degrees Oncoming i shift awire of this except NSS who I does not'specifically remember / Relief shift is present during morning hours only/CRNSO assigns trainec to control reactor water temperatur Understanding of trainee is that he is only responsible '

for logging temperatur /26/8'i 0800 RECIRC LOOP 'A' TEMPERATURE 150 /26/87 0800-1160 Temperature increases from 150 degrras F to 186 degrees F. During this time the shift is involved in surveillance, procedure change request review and maintenance activities in preparation

'for subsequent plant startup planned for the following day. Attempts to restore RWCU system in progress.

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I DATE TIME DESCRIPTION

1 6/26/87 0900 RECIRC LOOP 'A' TEMPERATURE 165 /26/87 1000 RECIRC LOOP 'A' TEMPERATURE 178 l 6/26/87 1100 RECIRC LOOP 'A' TEMPERATURE 186 !

l 6/26/87 1135-1205 CRNSO relieved for lunch by relief NSO. 1 l

6/26/87 1200 RECIRC LOOP 'A' TEMPERATURE 195 /26/87 1200-1225 NSS relieves NASS for lunc !

6/26/87 1300 RECIRC LOOP 'A' TEMPERATURE 205 F !

(Mode 3 was entered at > 200 F).

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6/26/87 1400 Recirculation loop temperature log reading is not recorde j i

6/26/87 1500 RECIRC LOOP 'A' TEMPERATURE 220 F l l

Trainee informs CRNSO/CRNS0 immediately !

l takes actions to reduce reactor water l temperature and informs NASS and NS l 6/26/87 1525 Recirculation loop temperature reduced l to below 200 degrees F (Enter Mode 4). l 6/26/87 1600 RECIRC LOOP 'A' TEMPERATURE 168 /26/87 1700 RECIRC LOOP 'A' TEMPERATURE 158 /27/87 0433 Cleared OSL 87-0466'on Divisions 1 j and 2 RHR Syste )

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6/27/87 0705 Cleared OSL 87-0465 on EDG No. 1 l 6/27/87 1600 Licensee notifies Reg n III Duty j Officer of the heat up even ,

6/28/87 1133 Commenced reactor startu /28/87 1344 Reactor critica l 6/29/87 1858 Licensee notifies NRC Operations Center cf the heat up even . Event Description

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The following is a description of the June 26, 1987 mode change event derived primarily from interviews with the individuals involved and !

supplemental by logs and computer data retrieva j i

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0n June 25, 1987,~the-reactor plant.was in Hot Shutdown (Mode 3), H after having shutdown.due to a failure'of the Recirculation Pump "B" _

Motor-Generato At approximately 1500 hours0.0174 days <br />0.417 hours <br />0.00248 weeks <br />5.7075e-4 months <br /> an Engineered Safet Feature (ESF) signal was received during.(I&C) testing. SeveralLsystems failed to respond as' expected to the_ESF signal including both divisions of the Low-Pressure Coolant Injection (LPCI):which failed-to start an Emergency Diesel Generator-13 (EDG-13) which experienced voltage regulator problems during its automatic start sequenc The LPCI mode of Residual Heat. Removal (RHR) and EDG-13 were declared inoperable. . Unrelated to 1

, the ESF signal,.the Reactor Water Cleanup ~ System.(RWCU)-isolated on high

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demineralized filter inlet temperature at approximately 2100 hour0.0243 days <br />0.583 hours <br />0.00347 weeks <br />7.9905e-4 months <br /> Based onLthe amount of. inoperable' equipment'and the time frames in which' /

they had to be returned to service, plant' management decided-to placeithe unit in Cold. Shutdown (Mode 4). A cool.down.was started'a_t approximately1 j midnight on June 26 and.the reactor was in Mode 4-(less than 200 degrees F) .l at 0445 hours0.00515 days <br />0.124 hours <br />7.357804e-4 weeks <br />1.693225e-4 months <br /> that.same day. Reactor water temperature had been reduced using the shutdown co,;ing mode'of RHR in accordance with P0M 23.205,-

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" Residual Heat Removal System."

f The shift complement consisted of the' Nuclear Shift Supervisor (NSS),- !

Nuclear Assistant Shift Supervisor'(NASS), Control Room Nuclear Supervising- 'j i Operator (CRNS0) and a trainee assigned to the CRNS Additionally, ther ;

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were three Nuclear Station Operators (NS0) from the relief cr d to assist j in the work load, a Shift Operations Advisor (SOA) and a Shift Technical i Advisor (STA). The STA also served as the General Electric Start-up Tests i Operation observer (STO). The shift planned to be involved in normal surveillance for Mode 4 in. addition to surveillance and maintenance l l activities in preparation for. a planned start-up'the following day.

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Shift turnover was conducted at approximately 0700 hourt Jn' June ~26,1987, at which time the plant was in Mode 4 with reactor. water temperature at i 145 degrees F, recirculation loop 'A' had full shutdown cooling flow and -

loop IB' had 5% flow,'RHR pump 'C' was operating for. shutdown cooling and 1 the RHR Heat Exchanger (RHR HX) Outlet Valve E11-F048A was shut to' prevent reactor cooldown below 140 degrees F. Interviews with shift personnel !

indicated that with the exception of the NSS, the entire control room shift including the trainee understood that the RHR Heat Exchanger

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(HX) Outlet Valve was shut.

l Immediately following the shift turnover an apparent misunderstandin between the CRNSO and trainee resulted in.the CRNS0 believing that the l trainee understood'he had been assigned the responsibility of logging and controlling reactor water temperature. Whereas the trainee believed he was only to log the temperature Shift routine hat both the CRNSO and trainee involved in surveillance required for Mode 4 and the planned start up. The NASS was involved in procedure change requests (PCR), reviewing surveillance for Mode 4 and

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l maintenance activities. The CRNSO was also assisting in restoring the RWCU system to service as reactor water level 'was increasing with no i means of rejecting wate From 0800 to 1200 hours0.0139 days <br />0.333 hours <br />0.00198 weeks <br />4.566e-4 months <br />, the trainee logged recirculation loop temperatures hourly from 150 to 195 degrees F (approximately 10 degrees per hour heat up rate). At approximately 1130 hours0.0131 days <br />0.314 hours <br />0.00187 weeks <br />4.29965e-4 months <br /> the CRNSO was relieved for a 30 minute lunch break by an NSO from the relief crew. At approximately noon the NASS was relieved by the NSS for a 25 minute break. The trainee logged the recirculation loop temperature of 205 degrees F at 1300 hours0.015 days <br />0.361 hours <br />0.00215 weeks <br />4.9465e-4 months <br />. The 1400 hour0.0162 days <br />0.389 hours <br />0.00231 weeks <br />5.327e-4 months <br /> log readings were not taken. At approximately 1500 hours0.0174 days <br />0.417 hours <br />0.00248 weeks <br />5.7075e-4 months <br /> the i trainee noticed the recirculation loop temperature was 220 degrees F and l informed the CRNSO. The CRNSO immediately started to cool the primary l systom and notifled.the NASS and NSS. The reactor 'A' recirculation .

j loop temperature was logged at 170 degrees F at 1600 hour0.0185 days <br />0.444 hours <br />0.00265 weeks <br />6.088e-4 months <br /> l On Saturday, June 27,1987 at 1600 bours, the licensee notified I the Region III Duty Officer of the even At 1900 hours0.022 days <br />0.528 hours <br />0.00314 weeks <br />7.2295e-4 months <br /> on Monday, l June 29, 1987, the licensee notified the NRC Operations Center of l the even . Results of Special Inspection I l

Region III inspectors conducted a special inspection of the event on July 1 and 2, 1987. The inspection consisted of interviews with pertinent l shift personnel involved in the inadvertent heatup of June 26, 1987 and other licensee staff personnel. In addition, the inspectors reviewed shift logs, strip chart recordings, procedures, Emergency Response

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l Information System (ERIS) data, and other pertinent documentatio It was determined that a number of contributing factors were evident in the event. The first and most serious is the lack of attention to an essential plant parameter (reactor water temperature) by the on-shift personnel. Review of the data showed an easily identifiable upward trend in reactor water temperature. This lack of attention and identification occurred even though the increasing trend was expected when the Residual Heat Removal System Heat Exchanger Outlet Valve is closed during shutdown cooling. Interviews with shift personnel indicate that they were aware of these expectations. Licensed personnel available in the control room included the CRNS0 and the NASS. At different times the NSS relieved the NASS and another NS0 relieved the CRNS During the morning hours, the routine shift was augmented by three NS0s from the relief crew who were in the control room assisting in various activitie The Shift Operations Advisor (SOA), licensed as a Senior Reactor Operator, and the Shift Technical Advisor (STA), who is not licensed, were also in the control room at various times. The STA and the SOA are not required to be present in Mode 4. These personnel had been assigned other duties by the NASS including procedure changes,

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maintenance activities and surveillance such that they were not in a [

position nor were they responsible for monitoring reactor water l temperature, j As a result of the normal shift personnels failure to monitor a critical plant parameter, reactor water temperature was allowed to exceed the -l 200 degree F Technical Specification limit and the reactor entered Mode 3 i for a period of approximately two hours. Entry into Mode 3 represented a j violation of Technical Specification 3.0.4 in that equipment required to !

be operable prior to entry into this operational condition was inoperable l (341/87027-01(DRS)). The inoperable equipment included Emergency Diesel- j Generator No. 13 for inspection of the voltage regulator, Divisions I and II of the Low Pressure Coolant Injection (LPCI) mode of RHR which was

" administratively". inoperable to investigate its apparent failure to f automatically start on an ESF signal (the system was never functionally j inoperable), and Division II of-the Main Steam Isolation Valve Leakage j

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Control Syste The inspectors determined that various procedural inadequacies also contributed to this event. A review of procedures Plant Operations Manual (POM) 22.000.10 " Shutdown From Rated Power To Cold Shutdown," !

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Revision 5,-POM 22.000.12 " Reactor Heatup, Cooldown and Temperature j

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Vs. Pressure Monitoring" Revision 6, and P0M 23.205 " Residual Heat i Removal System" Revision 15, identified a lack of guidance for proper i maintenance of a cold shutdown condition. In particular, no direction ?

was given as to the proper temperature band to maintain reactor water l temperature within or what action (s) to take to restore reactor water 1 temperature. Failure to provide this type of guidance resulted in a I lack of definitive and consistent methods to maintain cold shutdow i

A review of P0M 21.000.01 " Conduct of Shift Operations" Revision 33 h identified a lack of specific guidance concerning allowable usage and !

control of nonlicensed operators in training for a Reactor Operator (RO) ;

or Senior Reactor Operator (SRO) license. Step 6.3.5 of the procedure indicated that " manipulations of reactor controls must be under the l direction of a licensed operator and with the cognizance of the control ]

toom NSO." However, this statement is considered vague in that it i neither defines what controls would fall under this requirement nor j the method of supervision that constitutes "under the direction of." i Interviews with various licensee personnel showed that plant management had not provided specific guidance in this regards and therefore the l :

philosophy of these individuals on training varied considerably. As  !

a result, the NSO improperly turned over complete responsibility for l maintaining a cold shutdown condition to the trainee.in that he did  ;

not ensure or remain cognizant of the activity. Due to miscommunication !

between the trainee and the NSO, the trainee was.only logging and not j actually controlling reactor water temperature. Further the NASS indicated -

during the interviews that he relied upon the NSO to inform him of changing l plant conditions during routine operation Neither philosophy is '

consistent with what the NRC expects as a proper method for the NSO or NASS to monitor and remain cognizant of plant conditions. This is

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in part due to a failure of plant' management to' adequately define methods of, accomplishing this responsibility in either procedures or other directives and is a failure on tne part of the individuals to execute to provisions of their license The procedural inadequacies are considered examples of a violation of 10 CFR 50, Appendix 8, Criterion V (341/87027-02(DRS)).

A review was conducted to determine whether personnel actions on June 26, 1987, were in accordance with existing plant administrative procedure P0M 12.000.057 " Nuclear Production Organization" Revision 3 described the following responsibilities: The NSO has shared responsibility with the NSS to maintain proficient and current knowledge of plant and system statu > The NSO shall remain continuously cognizant of the reactor ,

power level and plant statu l

'l The NASS assists ;he NSS in the operation of the plant and control room under cll conditions, ensuring compliance with all applicable procedures and regulation P0M 21.000.01 indicated that in conjunction with short on-shift relief for the NSS, NASS or control room NSO, the oncoming operator is to be fully cognizant of existing plant conditions and evnlutions in progres During the 7:00 a.m. to 4:00 p.m. shift on June 26, 1987, various individuals filled these positions. It is clear that the normal shift crew failed to properly discharge their responsibilities. Furthermore two individuals who provided short-term relief during the event did not become fully cognizant of existing plant conditions as evidenced by their lack of action to suspend the heatu These items are considered a violation of Technical Specification 6.8. in that the personnel did not properly implement established procedures governed by Regulatory Guide 1.33, Revision 2, Febr n ry 1978 in regards to these administrative requirements (341/87027-03(DRS)).

The inspectors reviewed deportability requirements to ensure satisfactory conformance of licensee reports associated with the event with applicable regulations. It was determined that the event did not correspond to an Emergency Classification in the licensee's approved Emergency Plan and thus did not require immediate notification of the NRC Operations Center in accordance with that provision of 10 CFR 50.72. Review of 10 CFR 50.36 and 10 CFR 50.72 did not identify any requirements to notify the NRC within one or four hours. A determination on the effect that specific statements in the facility operating licensee and technical specifications have upon deportability remains to be completed. The deportability aspect of the event is considered an Unresolved Item pending further NRC review (341/87027-04(DRS)).

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l The event, from a plant status / transient aspect,.is considered to be of i l

minor safety significance from the technical aspect. However, a managerial j breakdown is' clearly evident which represents a more serious reflection on the ability to properly control activities and safely operate the plan Indicative of this breakdown was plant management's tolerance or .

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unawareness bf an attitude which would allow numerous on-shift' licensed !

personnel to neglect their responsibility of remaining cognizant'of plant l l status in favor of performing other activities in preparation for a l subsequent plant startu <

Actions taken during the event-and interviews with personnel clearly i indicate a lack of appropriate management direction and emphasis given ;

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to the plant' licensed operators regarding operational conduct including: !

!- proper controls and methods of supervision for trainees, appreoriate short-term relief turnover responsibilities, appropriate definitions and methods to adequately fulfill responsibilities of remaining cognizant of plant status, and adequate direction as to maintaining cold shutdown.

i Management Meeting On July 7, 1987, a management meeting, at Detroit Edison Company's request, l was held at the Region III office in Glen Ellyn, Illinoi Detroit Edison !

Company presented the Region III staff with the results of the DECO ,

investigation into the unplanned heatup of June 26, 1987. Detroit Edison !

then discussed actions being taken to correct the identified deficiencies j including: - Examination of all control room shift personnel on their prescribed duties and responsibilities, Define relationship between the control room NS0 and trainees, i Clarify procedure (s) for short-term relief turnovers of control ,

room NS0s and NASS'.  !

! Augmentation of shifts during periods of high work activity, Reduce to the minimum the administrative activities of the shift l personne l i Emphasize to all shift personnel the importance of remaining ?

cognizant of plant condition !

1 Interim Exit Interview The inspectors met with licensee representatives (denoted in Paragraph 1)

on July 2,1987, and summarized the scope and findings of the inspection activities to the date including: Lack of guidance to operations personnel on the relationship of trainee's to the shif I

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.1 4 Procedural. inadequacy ~ Short term relief turnovers- '

d Relationships between shift members as'to the conduct offoperations

.Li M., assignment of activities which distract from an individual's 1

ability.to stay. abreast of.the overall. plant statu j

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. Deportability of the June 26,1987.ievent

..,. > inconsistencies between-individuals recollections of controlc room workloa :;

' ' Inconsistencies's between the trainee's-account of.'his activitiesi around 12iO0f(noon), on July'26, 1987; and.the relief.NS0'.s-description.of that: tim l The inspectors also discussed;the likely. informational content of.the J inspection report with regard to' documents or processes' reviewed by the-inspectors during~the inspection. The licensoe did not Lidentify' any= su ;q

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documents / processes as proprietary. 'The licensee acknowledged.the findings-of the inspectio _

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