IR 05000341/1993011
| ML20045G256 | |
| Person / Time | |
|---|---|
| Site: | Fermi  |
| Issue date: | 06/25/1993 |
| From: | Phillips M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20045G250 | List: |
| References | |
| 50-341-93-11, NUDOCS 9307130099 | |
| Preceding documents: |
|
| Download: ML20045G256 (21) | |
Text
{{#Wiki_filter:- . -. 'i , U. S. NUCLEAR REGULATORY COMMISSION
REGION III
. . Report No. 50-341/930ll(DRP)
Docket No. 50-341 License No. NPF-43
, . Licensee: Detroit Edison Company
2000 Second Avenue i Detroit, MI 48226 { Facility Name: Fermi 2 Inspection At: Fermi Site, Newport, MI ! Inspection Conducted: May 4 through June 3, and June 24, 1993 Inspectors: W. Stearns, Lead Inspector
K. Riemer R. Twigg , }gy h i Approved By: M. Phil ps, Chief 2f . Reactor Projects Section 2B Date ' i ) Insoection from May 4 through June 3.1993 (Report No. 50-341/9301h(DRP)) , Inspection Summary: The purpose of this unannounced,.special inspection was- ! to assess self-checking, verification, and independent verification activities
at the Fermi 2 Nuclear Facility. ' The inspection consisted of a review of al'
LERs and Inspection Reports dated 1991 and later.
The inspection also included a review of DERs which met specific sorting criteria (see Attachment 2). In addition, selected QA audits /surveillances were reviewed.
Completed maintenance and surveillance packages were also reviewed. The inspection also consisted of a review of administrative procedures to assess the effectiveness in controlling and complying with applicable codes and standards. The inspectors also observed selected surveillance and maintenance activities in progress.
Inspection modules utilized were 35702 and 40500.
Results: Two violations were identified, one with multiple examples. One violation involved the failure to meet TS requirements concerning shift turnovers (paragraph 6.a).
The other violation involved multiple examples of inadequate procedures. (paragraphs 3, 5, and-6.a).
The absence of independe-verification requirements in multiple Instrumentation & Controls (l&C) procedures had been identified to the licensee in a DER issued in June 1992; however, since immediate corrective actions had not been specified and the 0* organization had failed to identify the scope of the problem during two audi 5 in August and Septen.ber 1992, enforcement discretion was not exercised (paragraph 5).
In addition to the violations, an unresolved item was identified concerning whether the Independent Safety Engineering Group (ISEG, was meeting its Technical Specification requirements to assure personnel 9307130099 930702 I PDR ADOCK 05000341
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errors are reduced as much as practical-(paragraph 11).
In addition,-the j inspection revealed a high incidence of personnel errors associated with ! verification activities (paragraph 9 and also Attachment 1). These personnel ! errors have occurred at a relatively constant rate for the past 2 -% years; have not been confined to any particular group or_ organization; and the safety .j significance of the related events has increased in recent months.. j . ' Specific strengths and weaknesses were as follows: i Plant Operations j T Operations personnel exhibited insufficient attention to detail during two
shift turnovers that resulted in failure to detect an inoperable recorder ' while stamping the associated strip charts during each turnover. The recorder
indicated zero when the actual pressure was approximately 1,000 psig.
l Interdepartmental communications with the I&C personnel performing work on!the - l reactor vessel pressure recorder appeared to be weak.
.f Maintenance and Surveillance Since 1989, I&C surveillance procedures were modified to. remove independent j verification requirements-and utilize verification, contrary to Fermi ! Management Directives. The deficiency had been identified to the licensee in- ! June 1992, but immediate corrective actions'had not been implemented:as of the .:" date of this inspection.
No other examples were found where the Fermi Management Directives were
- l misinterpreted regarding the incorporation of independent verification
{ requirements in procedures.
t
Management expectations were not understood by the workforce. During l interviews with personnel, it became apparent that various terms relating to - verification had different meanings depending on whether management or workers
were asked to define them.
l , There were a number of procedures that specified the requirements for the performance of various verification activities.
There was an example where , i the operations procedure required independent verification while the
associated I&C procedure for the same equipment valving operation did not.
! , ' i The licensee had undertaken the development of long-term corrective actions to ' revise the associated FMDs such that independent verification requirements
were specified in only one FMD, and then to revise the appropriate I&C , I procedures during their 2-year review cycle. A draft of the revised FMD was ' undergoing onsite review at the end of the inspection.
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i i Safety Assessment /Ouality Verification .
A weakness was noted with the licensee's inability to correct long-standing ! problems with personnel errors.
Corrective actions to reduce the personnel i error rate had been initiated at the conclusion of the last refueling outage; i however, the rate noted over the past 2 % years had remained essentially . constant. Since the ISEG is responsible to assure that human errors are ! reduced as much as practical, it did not appear that their efforts' had been i effective.
j i The August and September 1992 audits failed to identify that the July 1992 response provided by the Maintenance Department to DER-0296 was in error.
The
audits took note of the response without verifying its accuracy.
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DETAILS 1.
Persons Contacted Detroit Edison
- D. Gipson, Senior Vice President, Nuclear Generation
+*R. McKeon, Plant Manager, Nuclear Production
- R. Stafford, Nuclear Assurance Manager-
+*P. Fessler, Director, Technical Manager R. Eberhardt, Superintendent, Radiation Protection +*J. Plona, Superintendent,' Operations
- A. Kowalczuk, Plant Support Superintendent
- G. Pierce,. Work Control Supervisor
+T. Bradish, Superintendent, Audits
+R. Szkotnicki, Supervisor, Inspection & Surveillance
J. Walker, Director, Plant Engineering ! +*B. Tucker, Superintendent, Technical Engineering
G. Smith, Nuclear Fuel i
- J. Malaric, Supervisor, Modifications L. Fron, Technical
- R. Newkirk, Supervisor, Licensing / Risk Analysis
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- J. Korte, Director, Nuclear Security
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- L. Goodman, Director, Nuclear Quality Assurance l
L. Biehle, Modifications l +*E.
Nicholite, Maintenance ' S. Kremer, Plant Support +R. Matthews, Operations r M. Casey, Nuclear Training J. Sweeney, Quality Assurance ! +*J. Conen, Senior Engineer, Licensing
+*W. Miller, Nuclear Licensing
- R. DeLong, Radiation Protection
' +*J. Nolloth, Maintenance Superintendent
- H. Cawell, Quality Assurance, I&S
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- R. Gummaraju, Quality Assurance, Audits Group i
+
- M. Rhodes, HPES Coordinator 4*J. Nyquist, ISEG Supervisor
+*J. Tibai, Compliance', Engineering NRC Personnel [ !
- E. Greenman, Director, Division of Reactor Projects l
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- W. Dean, Acting Project Director, PD-III-1, NRR
- M. Phillips, Chief, Projects Section 2B
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- W. Kropp, Senior Resident Inspector, Fermi
- T. Colburn, Project Manager, NRR
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- W. Stearns, Resident Inspector, Monticello
- K. Riemer, Resident Inspector, Fermi i
- R. Twigg, Reactor Inspector, Region III
- Denotes those attending the exit meeting on June 3,-1993.
, + Denotes those participating in telephone exit on - June 24, 1993.
. The inspectors also contacted other licensee employees including members
of the technical and engineering staffs, and the reactor and auxiliary i operators.
! 2.
Inspection Summarv j I In areas where verification activities were reviewed by the inspectors, a relatively high incidence of personnel errors was identified.
These~
personnel errors have occurred at a relatively constant rate for the ' past 2 % years; have not been confined to any particular group.or ' organization; and the safety significance of the related events has l increased in recent months. Although the personnel error problem was , known to management, corrective actions have not been effective to date.
Management expectations as they relate to verification requirements were !' not clearly understood by workers. This was highlighted throughout the inspectors' interviews of maintenance personnel.
! Procedures for the performance of independent verification activities i were not clear, in some cases failed to accomplish their intended function, and conflicted between departments. An example. was identified , where Operations Department and I&C Department procedures that perform j the same evolution conflicted in how verification was to be performed.
.j Control room staff displayed a lack of attention to detail during two- ' consecutive shift turnovers when a recorder was inoperable and reading 0 psig while the plant was operating with a pressure of approximately
' 1,000 psig.
3.
Action on Previous Inspection Findinas (92701) . (Closed) Unresolved Item (341/93004-01(DRP)): Independent Verification ! was not performed in a timely fashion. During the inspectors' initial investigation of the February 10, 1993, event, a review of the Abnormal ' Lineup Sheet (ALS) used for the evolution determined that the
independent verification (IV) was performed almost four hours after the ! performance of the evolution that required the ALS to be initiated.
During this followup, the inspector noted that Fermi 2 administrative , procedure Section 5.2.6 of NPP-0P1-12, " Tagging and Protective Barrier , System," specified that independent verification shall be required when
isolating components and upon restoration of components to service.
Independent verification of component position shall be performed in
accordance with NPP-0PI-08, " Control of Equipment." Section 5.3 of NPP-
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h ! h t l ! ' OP1-08 stated that independent verification should be done in a timely manner.
10 CFR Part 50, Appendix B Criterion V requires, in part, that , activities affecting quality be prescribed by documented instructions, t procedures, or drawings of a _ type appropriate to the circumstances, and be accomplished in accordance with these instructions, procedures, or i drawings.
In this instance, these procedures were not appropriate to the circumstances in that they failed to ensure that the independent
verification for the ALS implemented on February 10, 1993, was performed ' prior to the evolution being performed.
If the lineup had been incorrect, the event would have already occurred prior to the performance of the verification.
The associated unresolved item is . closed as it has been ennverted to a violation of Criterion V to 10 CFR
Part 50, Appendix is (341/930ll-Ola).
! One violation was identified in this area.
t 4.
Reauirements - Indeoendent Verification [ t The requirements for independent verification at Fermi 2 were based on i commitments to Reg Guide 1 33 (Feb 1978), which endorses ANSI N18.7-
1976/ANS-3.2.
In addition, Appendix H of the FSAR committed Fermi to [ the NRC position stated in item I.C 6 of NUREG-0737, which includes the following: - ' a.
Extends the requirements of ANSI N18.7(ANS 3.2) to cover surveillance testing in addition to maintenance activities.
b.
For the return-to-service of equipment important to safety, a second qualified operator should verify proper systems alignment . unless functional testing can be performed without compromising i plant safety, and can prove that all equipment, valves, and ' switches involved in the activity are correctly aligned.
The Fermi Management Directives (FMDs) identify the requirements for i controlling all activities related to the safe operation of Fermi 2 and i define specific individual and organizational res)onsibility and authority for implementing those requirements.
T1e directives for I Independent Verification (IV) are located in many different FMDs and are j difficult to follow.
Examples of the requirements for IV contained in
the current FMDs are provided as follows:
! c.
FMD-PRI " Procedures, Manuals & Orders" step 4.11.2 states: ! Procedures involving the alignment of systems and components
identified in the Technical Specifications, or otherwise important j to safety, shall provide for independent verification that the i correct system or component was removed from service, and that ! systems and components returned to service are properly aligned [ before the system is declared operational.
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FMD-OPl " Operations" step 4.9.6 states: When a system important to ! safety is removed from service, independent verification shall be provided to the extent necessary to ensure that the correct system
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was removed from service. The. independent verification shall include all components that are placed in an abnormal position or condition.
e.
FMD-0P1 " Operations" step 4.10.3 states: Independent ' veri ficat ion' shall be performed by one of the following methods: -(l)- performance of a functional test that proves conclusively that all components are in the correct position; (2) observing and documenting the existence or absence of alarms or other indications that prove conclusively that all components are in the correct position; and (3) direct determination that affected equipment is in the correct position by a second individual who is qualified to perform the tasks being verified, and who possesses operating knowledge of the system and its relationship to plant safety.
The inspectors noted that Criterion e.2 above would not be sufficient to provide independent verification that a plant task had been performed properly.
The absence of alarms may be due to burned out light bulbs, failed alarm circuit boards, or other conditions that had no bearing on the work performed for which verification had been required.
Similarly, the presence of an alarm could be spurious or.due to a faulty component not associated with the work that had been performed.
Therefore, the existence or absence of an alarm would not be sufficient in and of itself to constitute performance of an independent verification.
In an effort to minimize confusion regarding independent verification the licensee drafted an FMD specifically addressing IV in March-1993, This FMD was still in the review and approval process at the conclusion of the inspection.
The review and evaluation of this procedure for adequacy is an inspection followup item (341/93011-02).
No violations or deviations were identified in this area.
5.
Administrative Issues The initial review of Electrical, Operations, and Instrumentation and Control (I&C) procedures along with Deviation Event Report 92-0296 " Independent Verification of Maintenance Surveillance Procedures" identified concerns with I&C surveillance procedures. The DER noted that the verification being performed in I&C surveillance procedures in lieu of independent verification was not in accordance with the Fermi FMDs.
The DER included the FMD-CTl step 4.5.5 for Calibration, Testing, and Surveillance. This FMD required independent verification of the installation and removal of jumpers and lifted leads and the return of systems to normal configuration following calibration or test. The licensee's activities to address this DER were as follows: July 1992 Maintenance stated that all IVs for I&C surveillance were accomplished through conclusive functional testing or other indications such as a
- . . .-- .= ~.- = .. -. - .-.- . l;j - . .l l t I lack of alarms. The statement "NONE" in the IV section of the -! procedures meant that no separate instructional steps were needed to i accomplish _the IV.
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December 1992
A proposed revision to the FMD-PRI for procedures, orders, and manuals l was put on hold by the executive vice-president. This would have
modified the requirements such that IV would no longer be necessary in. ! lieu of verification.
. ! February 1993
i A revision to the FMD-CTI for Calibration, Testing, and Surveillance was proposed. The Fermi Writer's Guide Appendix C for I&C surveillance-was I revised to include verification, "where appropriate" as an alternative
to Independent Verification.
, f Of the 15 current I&C surveillance procedures reviewed by the-
inspectors, all were found to have no independent verification steps in-l the IV section of the procedure.
In addition, discussions with I&C i craft personnel revealed that they were of the understanding that if
there were no steps in the IV section of the procedure, no IV was required.
This was contrary to the position expressed by the i maintenaate management and that stated in the above July 1992 entry.
l Examples were p.
- edures failed to specify anything in the IV section i
included i PROCEDURE # TITLE t i 44.020.212 NSSS-HPCI STEAM LINE PRESSURE, DIV. II CHANNEL B j CALIBRATION / FUNCTIONAL 44.020.203 NSSS-HPCI STEAM LINE FLOW, DIV. I CAL
44.220.403 MAIN STEAM ISOLATION VALVE LEAKAGE CONTROL SYSTEM DIV.
-i II CONTROL AIR PRESSURE, CHANNEL CALIBRATION / J FUNCTIONAL i f ! 44.020.262 NSSS-HPCI STEAM LINE FLOW DIV. II, RESPONSE TIME TEST i 44.030.257 REACTOR VESSEL WATER LEVEL DIV. I, CHANNEL C . , CALIBRATION / FUNCTIONAL
44.030.218 ECCS-RHR PUMP B DISCHARGE PRESSURE (ADS PERMISSIVE) ! CALIBRATION / FUNCTIONAL I A review of old revisions for these procedures found that all had IV steps included in 1989, but these were replaced with the statement
"NONE" over the following 2 years. Verification of some steps within
the procedures were added as a "second check" during performance of the j
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i ! ! ! procedures. The "second check" verification was a good work practice intended to reduce personnel errors.
However, "second check" i verification did not meet the IV requirements of the FMDs because it j could be performed by the same work team. Three of these procedures . ! were identified in response to DER 92-0296 and had IV steps reinserted
in March 1993. The licensee's internal investigation of this issue
determined that there were approximately 500 I&C procedures that lacked
independent verification specifications. These procedures did not t conform to the Fermi FMD requirements and as a result were a violation ! of 10 CFR Part 50, Appendix B, Criterion V, which requires that i activities affecting quality be accomplished in accordance with ! procedures that are appropriate to the circumstances.
Although the ! significance and breadth of.the discrepancy between I&C procedures and l the FMDs was identified by your staff in June of 1992, corrective ! actions were not developed until shortly before the start of this ! inspection.
In addition, an audit performed by your QA organization in i September 1992 did not delve into the specifics of the response provided i by the maintenance department that independent verifications were being l performed per your Fermi Management Directives. Had the QA organization
focused on that response, they would have discovered then that this ! assertion was in error. Therefore, given the earlier opportunities to ! take corrective action and the failure of your QA organization to
identify the error in the maintenance department's assertion, the j exercise of enforcement discretion was not deemed to be warranted.
The i licensee recently initiated corrective actions to reinstate'the ! independent verification in these procedures.
In addition, verification activities were being performed in lieu of independent verification.
< The failure of these I&C procedures to comply with Fermi FMDs is an ! example of a violation of Criterion V of Appendix B to 10 CFR Part 50 ! (341/93011-01b).
-{ t One violation was identified in this area.
6.
Performance-Related Independent Verification Issues , i a.
Surveillance 44.120.001 ! '! During the performance of the surveillance on the Division 1, ! Post-Accident Monitoring Pressure Recorder B21-R623A, a fuse was i blown that caused the recorder to read downscale with the plant at i power and the actual pressure at approximately 1,000-psig.
The
fuse blew apparently as a result of the final step in the l procedure involving the landing of a lead. The landed lead was l " verified" by one of the two technicians performing the , surveillance.
However, no independent verification of the return ! to service of the recorder was required by the procedure, so none ! was performed.
Consequently, the equipment remained inoperable ! after the I&C technicians notified operations that they were ! finished and left the control room.
Criterion V of Appendix B to i 10 CFR Part 50 requires, in part,'that work be accomplished in ! accordance with procedures that are adequate for the circumstances i and that they shall contain appropriate quantitative or -
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qualitative acceptance criteria for determining that activities have been satisfactorily accomplished. The failure of the procedure to contain any requirement or acceptance criteria to determine that the recorder had been satisfactorily returned to service is a violation of Criterion V (341/930ll-Olc).
Operations personnel did not verify that the recorder was reading correctly.
Per interviews, I&C personnel understood that the operators were responsible for determining that the recorder was operable since it was their equipment and the operators knew what the recorder should read.
Better communication and teamwork. between the technicians and the operators may have prevented the equipment from remaining inoperable.
With this in mind, later that day followino two shift turnovers, the failed recorder was finally discovered.
The strip chart recorder paper had been stamped by the operators during each turnover; however, the operators had apparently not taken note of the plant conditions shown, since the recorder indicated reactor pressure as O psig when it was actually approximately 1,000 psig.
Fermi Administrative Procedure NPP-0Pl-05, " Shift Turnover," required the control room operators to perform shift turnovers, walkdown the control boards, and be aware of any off-normal conditions.
Fermi Technical Specification 6.8.1.a requires that written procedures shall be established, implemented, and maintained covering the applicable procedures recommended in Appendix A of' Regulatory Guide 1.33, Revision 2, February 1978.
Section 1.g of Appendix A to this regulatory guide revision requires, in part, that shift and relief turnover be covered by written procedures.
Fermi Administrative Procedure NPP-OPl-05, " Shift Turnover," requires the control room operators to perform shift turnovers, walkdown the control boards, and be aware of the status of any off-normal conditions.
The failure to be aware of the abnormal conditions of the recorder over two shift turnovers on April 29, 1993, is a violation of Criterion V (341/93011-03), and indicates insufficient attention to detail by control room personnel in the panel walkdown activity.
b.
I&C Procedure 44.010.075(76)(77)(78) Prior to this inspection, operations identified that these I&C procedures did not require a lock seal to be placed after manipulation of associated scram discharge volume transmitter source valves.
The operators noted, during a pre-startup walkdown, that these valves were not lockwired as required by the operations procedure. The valves were lockwired prior to being declared operable for startup.
The lack of a lock seal to detect valve tampering conflicted with the requirements of operations procedure 27.000.01. An additional conflict was that the operations procedure required independent verification and the I&C procedures did not.
The I&C procedures were subsequently revised
- - . $ -i i i 'I to incorporate the lock seal requirement, although verification
remained in lieu of independent verification.
The inspectors did j not identify examples where work performed under the old ! surveillance procedures was completed without the ultimate j placement of the lock seals prior to declaring the associated HCU r operable.
I i Two violations were identified.
! i 7.
Manaaement Expectations - Independent Verification i
Training on independent verification for Maintenance personnel was [ assessed through interviews with the Fermi training staff. Specific IV , training occurred in 1988 with some followup included in quarterly
training. The training staff stated that all IV training had been based j on the FMDs.
l t Interviews with I&C technicians revealed that the technicians did not [ have a good understanding of independent verification requirements or i methods by which it could be accomplished. The technicians stated: ! ! o They would follow the procedures as written; j o The statement "NONE" for IV in the surveillance procedures meant ! that no IV was required; and ! o All methods of IV were required to be performed by an individual f not associated with the job, including functional testing.
l ! These positions were in conflict with the expectations expressed by the t maintenance supervisors. Namely, { . o Technicians were expected to follow " good work practices" when j returning equipment to service, i.e. " ensure it works even if the procedure does not specifically require it";
o The statement "NONE" in the procedures means that IV is
accomplished within the steps of the procedure by functional test
or other indications i.e. alarms; and j o No individual, independent of the job, is required by I&C ! surveillance procedures to perform IV.
! ! Based on the above statements, there appears to be confusion regarding
management expectations and the adequacy of training concerning what verification / independent verification means.
No violations or deviations were identified in this area.
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Quality Assurance Audits l ! The inspectors reviewed the following quality assurance audits: ! a Audit # Audit Date Audit Subject- 'i ! 92-0109 August 5, 1992 TS Surveillance Program i ! 92-0114 September 3, 1992 Inservice Testing Program- 'i - ! 92-0097 September 17, 1992 Corrective Maintenance Program ! [ 92-0125 November 12, 1992 Inservice Inspection and
Special Process Programs- + Both the August 5th and September 17th audits discussed the DER l concerning " Independent Verification of Maintenance Surveillance .. .) ! Procedures." This DER was generated on June 19, 1992, and-identified concerns with the lack of independent verification in certain j procedures. As of August 5, 1992, maintenance's response was being i evaluated by Plant Safety, with timely resolution identified as a ! concern to be evaluated in the next TS surveillance program audit..The ! audit also stated that per maintenance, independent verifications were
being performed in accordance with FMD-0Pl.
These conclusions were ! essentially repeated again in the September-17,-1992, audit report.
! However, the audit team did not investigate the maintenance l organization's claim that independent verification was in fact being
accomplished by the various methods described in FMD-0Pl. This was not i true, as was eventually determined in the DER that is discussed above in-
paragraph 5 of this report.
In this case the audits did not delve into i the issue in sufficient scope to identify the finding.
i No violations or deviations were identified in this area.
, 9.
Personnel Errors During the review of LERs and DERs for issues regarding independent l verification it became apparent that there were a large number of l personnel errors being experienced at fermi 2.
As this inspection
progressed, a partial list of personnel errors was developed based on a -! review of a small subset of the total population of DERs that had been j obtained on a sort of items related to verification activities. -The keywords used in the sort are identified in Attachment 2 to this report.
, This list of activities where personnel errors had occurred at Fermi 2 ' since January 1991 is attached to this report (see Attachment 1).
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A review of the events indicated that the errors were happening at a l relatively constant rate over the time frame under review.
In addition, j they were spread among all departments, with no particular department j ' standing out from the others. The personnel errors presented on the . !
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! list represent a large spectrum with regards to _ safety significance.
! The most severe being three isolated and independent events that j ' resulted in reactor scrams.
j ! Since the purpose of this inspection was to evaluate independent j verification issues, it did not analyze the errors to determine which i barriers may have broken down or to identify the root causes.
However, j the team noted that during the course of interviews with personnel, , morale was low. This may have been due, in part, to recent reductions l " in the work force and a lack of a positive incentive program for a " job j
well done." Some of the workers interviewed also expressed a reluctance
to discuss or bring up problems or issues to management's attention.
The licensee had been aware of problems with personnel errors given the i significant events that had cccurred subsequent to the last refueling ! outage and findings that had been previously-presented by the QA l organization.
However, this inspection indicated that the underlying
problems have been present for at least the 2 % years worth of data j examined and are not indicative of a recent slump.
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No violations or deviations were identified in this area.
l ! 10.
Personnel Error Reduction l } Efforts had been initiated to reduce personnel errors over the last l year, but have not been effective to date. These efforts included the j initiation of self-checking programs and the recent implementation of
the Personnel Error Reduction Program.
! ! Self checking practices utilized at Fermi 2 included " STAR" (Stop Think Act Review) and SLTVAMO (Stop Locate Touch Verify Anticipate Manipulate , ' Observe).
Both, if used properly, should enhance an individual's
, attention to detail during the performance of his duties. The STAR
program had been in existence for over a year, with no significant
change in personnel error rate.
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The Personnel Error Reduction Program, which was initiated following the ! l 1992 refueling outage, was developed based on a memo dated November 25, l
1992 from D. Gipson, Senior Vice President, Nuclear Generation, to R.
! McKeon. Plant Manager and staff. The plant responded by preparing course i
material starting in January 1993. The first training classes were i i presented to Fermi management in April 1993.
Training for the worker l level employee began the week of May 10, 1993.
The benefits of this
' training have not been realized to date.
l ! a 11.
Independent Safety EnQineerina Group (ISEG) i ! Section 6.2.3.3 of the TS requires the ISEG to be responsible for ! maintaining surveillance of unit activities to provide independent !
f verification that these activities are performed correctly and that l l human errors are reduced as much as practical.
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-- - The inspectors questioned the ISEG supervisor with respect to how ISEG was meeting the intent of this requirement. The inspectors were informed that the generic issue' of personnel errors is a task that has been assigned'to'ISEG but that the investigation hasn't commenced yet. A review of ISEG's task list of work indicated their focus had predominately been reactive in nature responding to events as they occur.
Based on the results of this inspection, specifically the constant rate of personnel errors, the inspectors were-concerr.ed with ISEG's effectiveness in reducing human errors as much as practical.
During the exit meeting, the ISEG supervisor stated that there were several activities that ISEG had implemented to meet-the TS requirement to reduce human errors as much as practical.
Given the late timing of this information, this is an Unresolved Item'pending receipt of information showing how ISEG has complied with TS 6.2.3.3 (341/93011-04).
12.
Star Lua In LER 87-054, the licensee committed to install star lugs on terminal connections used for surveillance testing.
The purpose of the star lugs was to provide an improved test connection in order to reduce the number of inadvertent actuations of safety related equipment.
During the course of this inspection, panel HllP628 was inspected and found to have a number of star lugs installed. A review of procedure 46.000.199, rev. 22, " Star Lug Installation and Removal" determined that panel HilP628 was not included in this procedure.
The inspectors requested the licensee to provide information showing the method used to control the installation of these lugs. The licensee provided a copy of the engineering design package (EDP 11249) and work request (WR 000Z913529) used to install star lugs in various locations, including panel HllP628.
The inspectors have no further concerns in this area.
13.
Interim Alteration Checklists During the course of this inspection, the inspectors reviewed approximately 15 completed worked packages which had been submitted to document control to be microfilmed for archiving.
Of these 15 packages, four required and had Interim Alteration Checklists included (see below). The inspectors did not find any examples where the checklists had been removed from the packages submitted to document control for archiving.
a.
Procedure 42.306.01 Vaulted 5/15/91 b.
Work Package 000Z913548 Completed 1/17/93 c.
Work Package 000Z923690 Vaulted 2/18/93 d.
Work Package 000Z925901 Completed 3/2/93
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... ____ _ . _-, ~_ . _. _ ._ .. _ i 14.
Unresolved items i Unresolved items are matters about which more information is required in order to ascertain whether'they are acceptable items, violations, or j deviations. An unresolved item disclosed during the inspection is discussed in paragraph 11.
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15.
Inspector Followup Items - Inspection Followup items are matters which have been discussed with the .l licensee, which will be reviewed by the-inspector and which involve some ' action on the part of the NRC or licensee or.both. An Inspection Followup Item disclosed during the inspection is -discussed in- . paragraph 4.
16.
Exit Interview . The inspectors met with the licensee representatives _ denoted in j paragraph 1 at the conclusion of the inspection on June 3,-1993.
The ' inspectors summarized the purpose and scope of the inspection and the i findings.
The inspectors also discussed the likely ' informational ., content of the inspection report, with regard to documents or processes
reviewed by the inspectors during the inspection.
The licensee did not l identify any such documents or processes as proprietary.
At the end of " the exit interview, the licensee commented on how ISEG was meeting its TS requirements to reduce personnel-errors as noted in Section 11 of the i report.
i , , Attachments:
1.
Personnel Errors 2.
Sorting Criteria ,
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t Attachment 1 , , Personnel Errors.
- = ESF/RPS Actuation, LER, or Technical Specification item
. Document Event Date Descriotion . 1.
DER 91-090 4/04/91 Fuel bundle was not seated properly in the spent fuel pool.
. 2.
DER 91-214 4/12/91 DC breaker inadvertently opened while restoring battery charger.
3.
- LER 91-007 4/14/91 Error During Performance of Radiation
Monitor Calibration Resulted in Actuation - of ESF. An RP technician did not reset all activated trips upon completion of the , procedure. CCHVAC shifted from normal to i the recirculation mode and Div. I RBHVAC ! tripped.
4.
- LER 91-008 4/24/91 ESF Actuation During Performance of i
Reactor Pressure Vessel Level Transmitter . ' Calibration (RBHVAC isolated, SGTS auto started, CCHVAC shifted to recirculation).
. Occurred during performance of a
surveillance when the output logic' switch was inadvertently mispositioned during j rework of the circuit board.
5.
- LER 91009 4/29/91 Loss of Power to Bus 65F_Causes ESF'
Actuations. During performance of a surveillance test Bus 65F lost power and ' the following ESF actuations occurred: , RBHVAC isolated, SGTS autostarted, and CCHVAC received an. isolation signal. A
knife switch was not in the correct . position prior to performing a. step in the i procedure due to personnel error.
, 6.
IR 91009 5/03/91 Loss of UPS occurred when a jumper was not i removed prior to charging the bus.
i 7.
DER 91-349 5/12/91 EDG No. 13 loaded to 2500 Kw @ higher rate than specified by procedure.
)
! I
, -. . .-- -- - _ -. .. .- -- - ! ! i ! 8.
- IR 91009 5/25/91 ESF/RPS actuation due to improperly I
installed IRM supply fuse cap. A full l ' scram signal was received -(all rods were already inserted in the core) during a-test of one channel of the IRMs.
' 9.
IR 91015 6/21/91-Control room operators' did not realize a recorder was missing its reference scale.
10.
- LER 91-016 7/01/91 Inadvertent Closure of HPCI Isolation
! Valve During Performance of a Surveillance i Test. Although the rotary switch at an ! MCC was turned to the "0FF" position, the ~ MCC did not deenergize and the condition ' was not recognized by operations or I&C , personnel conducting the test.
j i 11.
- LER 91-017 8/13/91 Valve E51-F062 Closed Due to Personnel l
Error During Surveillance. The unplanned j ESF actuation occurred when the I&C~ r repairman moved a test lead and caused the - containment isolation logic for the valve i to be satisfied
i 12.
- DER 91-774 9/29/91 Reactor recirc limiter set 0 48% and not at the post MEOD (Maximum Extended l
Operating Domain) value of 37%. j i 13.
- LER 91-018 10/02/91 APRM Weekly Calibration. Requirement Not l
Performed per Technical Specification. An-i error was made during implementation.of a i TS Amendment. The error resulted in the i failure to complete two weekly channel ! ' calibration requirements:for the APRMs.
l 14.
DER 91-793 10/07/91 Fire protection valve found mispositioned
during valve lineup verification.
15.
- LER 91-019 11/20/91 RWCU Isolated twice due to High Pump Room Differential Temperature and Personnel
! . Error During System Restoration.
The { first isolation occurred due to a high-
differential room temperature. The second .j isolation occurred when an operator ! grounded a jumper during its removal which ! caused a fuse to blow in the isolation ! logic.
] 3.
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_ _ - -_ _ _ _ 'l 16.
- DER 91-900 12/04/91 Combustion Turbine Generator Switch mispositioned and CTG 11-1 was not available for auto-start.
The mispositioning occurred approximately one-shift earlier during a return to standby evolution.
17.
DER 91-912 12/12/91 RWCU pumps tripped due to inboard isolation valve (G33 F001) closure while attempting to backseat for packing leak control (incorrect contacts were made up).
18.
IR 91024 12/16/91 Mobile crane contacts 120 KV line. While ~ moving a mobile 40 ton crane outside the plant's protected area, personnel inadvertently contacted an overhead 120 KV line with the crane.
19.
DER 92-010 1/01/92 Hitrogen steam vaporizer found not in its proper freeze protection lineup.
20.
DER 92-044 1/31/92 Sample left purging after sampling complete.
21.
IR 92004 3/17/92 A half scram occurred when an operator improperly ranged' the IRMs.
22.
IR 92037 4/92 Two of the three containment isolation valves were-listed on an ALS as required to be chain locked closed.
The third valve should have also been chain locked closed. Additionally, an~IV was performed after the chain and lock had been installed without the problem being recognized.
23.
DER 92-220 5/16/92 Eight abnormal lineup sheets found with discrepancies during QA audit.
24.
- LER 92-005 6/03/92 Standby Gas Treatment System Div I and II inoperable due' to operator placing PE relays in tripped condition.
25.
DER 92-324 6/29/92 T48-F435B Nitrogen Supply to Reactor Building Found Closed.
26.
- DER 92-457 9/12/92 Missed 4-hour TS Surveillance during Rx-
-Cooldown.
-.. - - .. - . . - . _
i I 27.
IR 92012 9/12/92 Personnel detensioned the South ! Suppression Chamber Access-Hatch Bolts I with plant conditions still requiring.
, primary containment' integrity.
l r 28.
- LER 92008 9/19/92 65F Bus Deenergized During Surveillance.
An electrician missed a step in the
procedure resulting in a loss of shutdown ! cooling and ESF actuations of RBHVAC, .i CCHVAC, SGTS, EECW, and Containment Isolation valves.
. ' 29.
DER 92-502 9/26/92 Sample purge valve for TBCCW l. eft open results in TOC going high (recurring r problem). ! 30.
DER 92-503 9/26/92 Core Spray mechanical seal. leak due to missed step'in procedure, contaminates floor.
l 31.
- LER 92012 11/18/92 Manual Scram Due to Loss of Feedwater i
After Heater Feed Pumps Tripped when NPPO
opens wrong valve on demineralizer.
i ! 32.
DER 92-678 12/08/92 New fuel vault radiation monitor cable
found disconnected (RP tech did not ! reconnect during calibration procedures).
33.
DER 92-702 12/14/92 Overflow of RWCU phase separator "A" i 34.
- LER 93-003 9/25/92 TS Required Recorder Discovered Not to-be Qualified. Technicians installed wrong i
recorder in control room.
35.
IR 93004 2/10/93 Improper Implementation of Abnormal Lineup j i Sheet (IV completed four hours after the event occurred).
-1 36.
IR 93004 2/17/93 Leads improperly lifted on EPA breaker
repl acement.
! 37.
- LER 93-004 2/19/93 Automatic Rx Trip / Turbine Trip'on toss of l
Condenser Vacuum. Vacuum loss due to loss l of Bus 69J caused by electrician. ! connecting test equipment to incorrect . relay.
l 38.
DER 93-141 3/11/93 Computer room above floor Halon main bank hose was found disconnected.
39.
DER 93-150 3/15/93 Drain Cooler LCVs (H22F004A/B/C)- found l isolated due to mispositioned valves.
I . .- - . - ,- - .- - . ..
,. - . .. = -. ... - - - -. -. ... .. . L-4 0. DER 93-231 '4/26/93 Wrong recorder (fuel pool radiation monitor) was removed from the control room. , panel.
41.
DER 93-238 4/28/93 Incorrect instrument removed from service
during corrective maintenance both. ' electrically and physically (TBCCW heat- ' exchanger, Inlet / outlet temperature ! recorder).
42.
- LER 93-007 4/20/93 Reactor Trip on IRM Upscale'During Reactor
- Pressure and Feedwater' Transient Due to l Personnel Error.
.; l 43.
- LER 93-TBD 11/??/92 Control Room Recorder Found Powered From Unauthorized source.
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$ $ i .i , ! , a
20 , -, . ~. - . _.
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. - - ..- ! I Attachment 2 ! Sortina Criteria ) l
The below listed sorting criteria were used to obtain DERs dated January 1991
and later for evaluation during this inspection.
l t i Sort by Keyword ,
1.
(XE) Independent Verification 2.
(AF) Lifted Lead & Jumper Control 3.
(Lineup) Device Lineups , 4.
(AN) Valve Lineups l 5.
(AG) Locked Valve Control
6.
(CB) Control of In-Plant Instrumentation i ! . Sort by Causal Factors j ! -
- 1.
(D457) TRNG/ QUAL " Verification & Self Check" 2.
(D360) Self Check'not Applied , 3.
(D361) System Align not Verified l 4.
(D363)(4&5) Self checking
' 5.
(D366&D368) Other verifications 6.
(367) Documentation not followed correctly
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