IR 05000341/1993014
| ML20045G507 | |
| Person / Time | |
|---|---|
| Site: | Fermi  |
| Issue date: | 07/07/1993 |
| From: | Phillips M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20045G501 | List: |
| References | |
| 50-341-93-14, NUDOCS 9307140054 | |
| Download: ML20045G507 (43) | |
Text
{{#Wiki_filter:.. -. . i , ., , < ] U.S. NUCLEAR REGULATORY COMMISSION REG 1014 III l Report No. 50-341/93014(DRP) l Docket No. 50-341 License Nos. NPF-43 Enforcement Action No.-93-154 l -! ' Licensee: Detroit Edison Company 2000 Second Avenue Detroit, MI 48226
i Facility Name: Fermi 2 , Meeting Conducted: July 1, 1993
fleeting Location: Region III Office i 799 Roosevelt Road
Glen Ellyn, Illinois j Inspectors: K. Riemer _; R. Twigg l M Approved By: M. P. Phillips, Chief 7 7/ PS ! ' ~ Reactor Projects Section 2B Dat'e , r f Meetina Summary Enforcement Conference on July 1.1993 (Report No. 50-341/93014 (DRP) ! Areas Discussed: An apparent violation identified during the inspection was .i discussed, along with corrective actions taken or planned by the licensee.
f' The apparent violation concerned the technical inoperability of both divisions of the Post Accident Monitoring for wide range drywell pressure, and was the result of multiple potential violations associated with the modification and ! installation process for this engineering design package.
, [
i i l !
f I , 9307140054 930708 l PDR ADDCK 05000341 G PDR l
_ _ - _ _ _ _ _ ._.
- __ m. _ f I DETAILS !j I.
Persons Contacted l Detroit Edison Company-P. Fessler, Director, Technical Manager D. Gipson, Senior Vice President, Nuclear Generation L. Goodman, Director, NQA , H. Higgins, Supervisor, Operations Support i L. Layton, Supervisor, Nuclear Communications ! J. Malaric, Supervisor, Modifications
W. Miller, Director, Nuclear Licensing J. Nolloth, Superintendent, Maintenance . M. Quint, Quality Assurance
R. Stafford, Manager, Nuclear Assurance . J. Walker, Director, Plant Engineering . J. Tibai, Principle Compliance Engineer ! S. Williams, Modifications Field Engineer Atlas Consultina l ! J. Crews, Executive Consultant j UE&C - Catalytic ' . A. Anderson, Site Manager . J. Lewis, Manager, Power Projects ! U. S. Nuclear Reaulatory Commission f i J. Martin, Regional Administrator, RIII l E. Greenman, Director, DRP l R. DeFayett<t, Director, Enforcement and Investigations Staff, RIII i P. Pelke, Er.forcement Specialist, RIII ' . D. Hoefling, Regional Counsel, RIII ! J. Segella, Office of Enforcement ! L. Schafer, Chief, Branch 2 ! M. Phillips, Chief, Section 2B i T. Colburn, Project Manager, NRR r W. Kropp, Senior Resident Inspector, Fermi j K. Riemer, Resident Inspector, fermi
R. Twigg, Reactor Engineer, RIII All of the above personnel attended the meeting conducted on July I, { 1993.
2.
Enforcement Conference j The conference was conducted as a result of the preliminary findings of
the inspection conducted from May 24 to June 8, 1993, in which an i ,
l -
! i i .- .- - . - _ _ .
i a . I apparent violation of NRC regulations was identified.
Inspection.
findings were' documented in Inspection Report 50-341/93012(DRP), transmitted to the licensee by letter' dated June 18, 1993.
_ The purpose of this conference was to (1) discuss the apparent .! violation, the cause, and the _ licensee's corrective actions; I (2) determine if there were any escalating or mitigating circumstances; l and (3) obtain any information that would help determine the appropriate j enforcement action. The' conference was open to the public with one j member of the public attending.
, Following an introduction by the Regional Administrator, the apparent I violation was presented. The licensee's representatives provided additional information concerning the apparent violations. _The i licensee's representatives described the events which' led to the
apparent violation, including root causes and corrective actions taken.
? At the conclusion of the meeting, the licensee-was informed that'they l would be notified in the near future of the final enforcement action.
! .i Attachments: , ., 1.
NRC Presentation Slides
2.
Deco Presentation Slides l ! l
i , l ! I i h-lq ! !
I
!
f
i .i b ! t ,
f i t i i a-l ! ' .._.- _ - _, , . . _ . .
. . n . . . , U.S NUCLEAR REGULATORY COMMISSION
REGION III
. ! ENFORCEMENT CONFERENCE
DETROIT EDISON FERMI 2 . P JULY 1,1993 11:00 A.M. (CDT) a , REPORT NUMBER 50-341/93012 EA NUMBER 93-154 , ' . REGION III OFFICE 799 ROOSEVELT ROAP, BUILDING 4 GLEN ELLYN, ILLINOIS , .
r .. . . . FERMI 2 l ENFORCEMENT CON ~FERENCE AGENDA JULY 1,1993
INTRODUCTION AND OP:3NING R:3 MARKS
Edward G. Greenman, Director, Division of Reactor Projects i DISCUSSION OF ENFORCEMENT POLICY i R. DeFayatte, Director, Enforcement and Investigation
Coordination Staff XRC OVERVIEW ' Edward G. Greenman, Director, Division of Reactor Projects , APPARENT VIOLATIONS SUMMARY Wayne Kropp, Senior Resident Inspector, Fermi 2
LICENSEE PRESENTATION NRC FOLLOWUP QUESTIONS-CONCLUSION O? CONFERENCE Jack B. Martin, Region Ill Administrator
P_UBLIC QU_ES_TJONS l . .
. , , i j . . NRC 3VALUA'ION - 1.
INADEQUATE ENGINEERIN~G SUPPORT 2.
INADEQUATE QA/QC VERIFICATION 3.
INADEQUATE OPERATIONS SUPPORT FOR ASSESSING IMPACT ON EOP.
4.
INADEQUATE VERIFICATION OF SIGNOFFS BY
MODIFICATION GROUP
5.
INADEQUATE SUPERVISION OF CONTRACTOR CRAFT ~
i 6.
INADEQUATE CONTR~OL OF SAFETY RELATED MATERIAL
._ , . . ' SUMYARY .
i o CONCERN WITH MODIFICATION PROCESS AT ' FERMI 2 BASED ON: i - 1.
MULTIPLE BREAKDOWNS DURING INSTALLATION OF POST ACCIDENT INSTRUMENTATION MODIFICATION 2.
RECENT DEFICIENCY IDENTIFIED WITH POST MODIFICATION TESTING 3.
FAILURE TO INCORPORATE RELAYS ADDED t VIA MODIFICATIONS TO PM PROGRAM ' o CONCERN WITH QA/QC'S FAILURE TO IDENTIFY , THE PRO.B.LEMS WITH THE POST MODIFICATION TESTING AND THE POST ACCIDENT INSTR'UMENTATION MODIFICATION
- . .
POST ACCIDEN"INSTRUYENTATION WID 3 RANGE DRYWELL PRESSURE.
- , F CONSISTS OF TWO DIVISIONS. EACH DIVISION HAS A RECORDER USED TO MONITOR DRYWELL AND SUPPRESSION CHAMBER PRESSURES WHEN IMPLEMENTING EMERGENCY OPER.ATING PROCEDURES.
THERE ARE NO AUTOMATIC FUNCTIONS INITIATED BY THESE RECORDERS.
. ' -- - - - -
- - . . . . . TECHNICAL SPECIFICATION (TS) . , i TS 3.3.7.5 - REQUIIES BOTH DIVISIONS OF THE POST ' ACCIDENT MONITORING - WIDE RANGE DRYWELL PRESSURE INSTRUMENTS TO BE OPERABLE IN MODES 1 AND 2.
THE TS FURTHER STATES: . o WITH LESS THAN THE MINIMUM CHANNELS OPERABLE (ONE), THE INOPERABLE CHANNEL (S)
BE IESTORED TO OPERABLE WITHIN 48 HOURS OR BE IN AT LEAST HOT SHUTDOWN WITHIN THE NEXT 12 HOURS.
I WITH LESS THAN THE REQUIRED NUMBER OF o CHANNEL-S OPERABLE (TWO), THE INOPERABLE-i CHANNEL BE RESTORED TO OPERABILITY WITHIN 7 DAYS OR BE IN AT LEAST HOT SHUTDOWN WITHIN THE NEXT 12 HOURS.
\\
- ._ . . APPARENT VIOLATION . CONTRARY TO TECHNICAL SPECIFICATIONS, BOTH DIVISIONS OF POST ACCIDENT MONITORING - WIDE RANGE DRYWELL RECORDERS WERE INOPERABLE FROM NOVEMBER 4,1992 UNTIL JANUARY 7,1993 DUE TO:
o T.HE DIVISION 11 RECORDER NOT.BEING SEISMICALLY Q~UALIFIED, AND o THE DIVISION I RECORDER NOT BEING POWERED FROM A DEDICATED POWER SOURCE
CONTRARY TO TECHNICAL SPECIFICATIONS, ONE DIVISION OF POST ACCIDENT MONITORING - WIDE RANGE DRYWELL RECORDERS WAS INOPERABLE FROM JANUARY 7,1992 UNTIL MAY 19,1993 DUE TO THE DIVISION I RECORDER NOT BEING POWERED FROM A DEDICATED POWER SOURCE.
i , d .- !
T - - ~ - ^ -- - - . . . . CHRONOLOGY OF EVENTS . , . ! May 1991 Work on modification stopped with only a small portion of the work accomplished.
. . June 1992 Modification re-activated , September 1992 Division II non-seismic recorder installed.
October 1992 Division I recorder installed with incorrect power source.
' ' November 4.1992 Fermi 2 enters Mode 2.
January 6.1993 Division II recorder discovered to be non-seismic.
May 18.1993 Division I recorder discovered powered from a non-dedicated sourc. . NRC CONCERNS o BARRIERS THAT FAILED 1.
INADEQUATE "YELLOWLINING" BY QC. (CRITERION V - INADEQUATE PROCEDURE) 2.
INADEQUATE VERIFICATION BY MODIFICATION ENGINEER OF POWER SOURCE. (CRITERION V - NOT USING PROCEDURE) 3.
WORK PACKAGE DID NOT REQUIRE VERIFICATION OF , SERIAL NUMBERS. (CRITERION VIII) 4.
NO INDEPENDENT VERIFICATION TO ASSURE MATERIALS INSTALLED MEET DESIGN.
(CRITERION X) 5.
RECORDER MODIFIED WITHOUT ENGINEERING , CHANGE REQUEST.
(CRITERION III) ' 6.
EVALUATION WAS OF INSUFFICIENT SCOPE TO IDENTIFY PROBLEMS WITH DIVISION I.
! - (CRITERION XVI)
7.
EOP NOT REVISED TO ACCOUNT FOR RELOCATION OF DRYWELL PRESSURE TRANSMITTERS. (CRITERION III)
8.
CALCULATION USED IN DESIGN WAS NOT ACCURATE . FOR TRANSMITTER LOCATION. (CRITERION III) . I
POST ACCIDENT MONITORING DRYWELL AND TORUS PRESSURE RECORDER EVENT immediate Actions (Remedial, Investigative, and Corrective) (continued) Improved labeling of electrical outlets: . - Initiated a practice of labeling power cords to match their corresponding electrical outlet.
Completed a comprehensive independent engineering assessment. . of Engineering Design Package 11264. Initiated review of other Operations Procedures and Emergency Operating Procedure calculations. Strengthened review of modifications for impact on operating procedures.
Examined other "at risk" modifications for problems: . - Nuclear Quality Assurance completed an assessment of post modification testing of 1992 "at risk" modifications for safety systems.
- Completed a broader assessment to ensure iiistallation conforms with final design.
- Completed a Human Performance Enhancement System barrier analysis to determine cause.
. ' DETROIT EDISON - FERMI 2 m
. POST ACCIDENT MONITORING DRYWELL AND TORUS PRESSURE RECORDER EVENT immediate Actions (Remedial, investigative, and Corrective) (continued) Completed a comprehensive review of the preventative maintenance
program for modifications issued the previous 12 months.
Improved identification and control of material: . - Procurement and storage practices.
- Revisions to inspection, modification, and work control procedures.
Improved yellow-line verification: . - Clarified expectations.
- For safety related material, required verification that material installed is in conformance with the Engineering Design Package.
Improved work packages: . - Ensure removal of shipping plugs, devices, etc.
- Clearly defined transfer of responsibilities for work between work groups.
l DETROIT EDISON l - FERMI 2 i - - - - - . - - - - - .. - - - . - ,_ - . . . - -
POST ACCIDENT MONITORING DRYWELL AND TORUS PRESSURE RECORDER EVENT Immediate Actions (Remedial, investigative, and Corrective) (continued) Communicated this event and its significance to site employees: . - Conducted accountability meetings.
- Communicated individually to site employees the impact of personnel errors.
- Communicated individually to site employees the importance of properly performing and documenting work.
. DETROIT EDISON - FERMI 2 - - - .
- , POST ACCIDENT MONITORING , DRYWELL AND TORUS PRESSURE RECORDER EVENT e , Conclusions ' . . Extensive reviews and walkdowns performed to ensure a complete understanding of the scope and breadth: - Some additional Agastat relays found not in the Preventative Maintenance Program. No other instances found where the Preventative Maintenance Program wasn't updated to reflect plant modifications.
- - Three additional discrepancies found with post modification testing for "at risk" modifications. No other problems found with "at risk" modifications.
' - Eleven transmitters found with loose covers.
, - Several other minor problems found with Engineering Design Package 11264.
- None of the additional problems found impacted System Operability.
l Deficiencies identified (both individually and collectively) do not represent a . . Quality Assurance program breakdown. Further reinforced through: - Previous Quality Assurance assessments.
. l - Other assessments.
- Our years of experience with the current modification program.
Weaknesses identified have provided valuable insights regarding improvements-
. necessary to our modification program.
l , DETROIT EDISON . FERMI 2' .. .- . .. - . .. . -. . -. -.. - - =
N2 OI SM r T e R I p DE N o EF r E p T r V d e I a o im O n p E e R ) t r R n d p h T t E e n f E m a o o D G D t t s s n n R s r N e e io i r O t e s d a d s I n R C A c r u i t i o f OE n o t c T R e t n e d d e r I d e N E n e i h e il R O o a e t f v U e i d MS d o i e r t so g n
t S s a p g I T n E y u r N R b io e e lp p . t r E P d a o sd la u D e c ne d
el i n s l u S m id f I s a d CU r o a p.
t t R n i e i i v f os i C m r, h n nin d o es k A O C ( n ae e idg in l a . t l r T t n din dly S D e lap inw w e
ep T s s s r u f r, ic eb o izp o s r r ON o ee u u t r r o r a ad e s e h P A C ip nis gc merd le u e r t h L o s s e mco n aw ir t oc ex a n no r L o e De r e o Up P r E R n g s r W w o re r Y O P P - - - R D . . . e s
POST ACCIDENT MONITORING ' DRYWELL AND TORUS. PRESSURE RECORDER EVENT
Modification Process Corrective Actions Ownership . Process improvements . Training . Additional Self-Assessments . l ! . . ! . - , r - DETROIT EDISON l FERMI:2 ! .. -.... - -... -... - - ' . - .. -..... ..... - .. -..... . -.. -. - ... .......,.. . -,.. .... . - ,. -
POST ACCIDENT MONITORING DRYWELL AND TORUS PRESSURE RECORDER EVENT , Ownershio Joint Engineering / Implementing Organization / Operations walkdown . of field completed modifications: , - Enhances Ownership.
- Improves interface with Operations.
- Reduces potential oversights.
Turnover to Operations: . Enhances accountability and ownership.
- Actively involves Operations.
+ - - Will utilize Turnover Checklist.
. t > b . DETROIT EDISON FERMI 2 i . ,. -. _ -~ ,_m... .. -.-,. - - *.. -. -, - - ~ ~ -.. - -
---. - -,* w 4----. --we.. , -u -- - . -- - --. -....-- - - -., - - - --.o- - - - - - - - - - - - - - - - -
---
& --
.. POST ACCIDENT MONITORING DRYWELL AND TORUS PRESSURE RECORDER EVENT y Ownershio (continued) ! Assignment of engineers to Modification Organization for implemen- . . tation of major design changes during outages: - Enhances ownership by Engineering.
- Provides field experience.
. Plant Modification Review Group process (PMRG): . Series of meetings chaired by Engineering.
- - Effective when implemented properly.
- Additional Management emphasis.
Specific Point of Contact in functional organizations.
- - Fewer field changes and better communications.
. - DETROIT. EDISON.
. FERMI 2 . -. - . .. - - - - - - - -. -. -. - -.. . . .
- _.
. . . POST ACCIDENT MONITORING DRYWELL AND TORUS PRESSURE RECORDER EVENT Process imorovements Modification Process Redesign: . - Procedures were complex / confusing / burdensome.
- Redesigned process to make it efficient and streamlined.
- Fewer opportunities for mistakes.
- Eliminates unnecessary duplication.
.
- Improve prioritization.
- More responsive to Plant problems.
- Integrated information system (long term).
! i i . DETROIT EDISON . FERMI 2 - -. - - . . -. - - - . -. - - - -. -... - - .. - - - . .
POST ACCIDENT MONITORING.
DRYWELL AND TORUS PRESSURE RECORDER EVENT Process improvements (continued) Configuration Control and testing of modifications "at risk": - - Test requirements not reflected in work packages.
- Root Cause: Procedure deficiencies and inattention to detail.
- Reconcile Engineering Design Package / work package / field installation.
Improvements in the process by which design changes are . incorporated in Programs and Procedures: - Current process adequate but fragmented.
- Simplified procedure.
- Comprehensive Turnover Checklist.
- Reduced potential for error and omissions.
DETROIT EDISON - FERMI 2 . - - - -- . . - . .. .- - . .. - -..
ZN O-u> 2 s.
-m Z .. Ow
wm w e r
> - c o W ~5) p e s a c .c - W E o O .
w l +
E c O
- g a
D 5> ) $ m.
E O -
- D & G e E ' c - O m o a E a" O O - OW O -- --- V o) o >-
0
0
6 & E E f - m O -
9 ~E o E o) Z W O O E"
22 G
c O V C D O u c -- u j { , $, O M O_ M o a o > 'O ' Ec g, .- O'_ -g o e_ w c c Z m '5
O O c a _] ,E g $ W CL, A 0) e {O - Q E C o
- O
+- u) & O O J ' E e " o e a U O C D & O o-O.
x .G --cw C a m O o O =
g g ,G g - m < O o,e c
$ $ 3 0 # 9 "e.c
- V $o $D.0 E' rd 3 & 15 2 ac m cm e o OZ o o m~ c m - c a - $ ~5. 8 e *3 O.
a. < 6 ~5 E
RO E o J o aB
a gC O O
o w e002wE cg O ' c O
a
- O
a oE y cn , , , , __; , , W O . . . .
POST ACCIDENT MONITORING DRYWELL AND TORUS PRESSURE RECORDER EVENT Training (continued) Personnel Error Reduction training: . - Emphasizes self-checking.
- Utilizes Fermi case studies.
Management meetings to discuss problems, Lessons Learned, and . corrective actions with individuals associated with the modifications process: - Meetings with mixed groups.
- Convey management expectations.
- Review Lessons Learned.
- Review modification process enhancements.
- Re-emphasize ownership principles.
-
l . DETROIT EDISON FERMI 2 l - .- . . -.
POST ACCIDENT MONITORING DRYWELL AND TORUS PR. ESSURE RECORDER EVENT AdditionalSelf Assessments Review of modifications implemented during more than one outage: . - Five modifications identified.
' - Involves additional interfaces, loss of continuity, people changes.
- Review for same type problems identified with Drywell and Torus Pressure Recorder modification.
Review of "Off-the-Shelf" design packages prior to implementation: . - Design packages "On-the-Shelf" for more than one operating cycle on Administrative Hold.
- Engineering and Modification will review prior to start of field work.
- Improves communications.
l - Re-establishes ownership.
i . l . DETROIT EDISON FERMI 2
. .
POST ACCIDENT MONITORING DRYWELL AND TORUS PRESSURE RECORDER EVENT Additional Self Assessments (continued) Review of modifications since Second Refuel Outage for . incorporation of changes in Operating Procedures and Preventative Maintenance program: - One Operating Procedure and several Preventative Maintenance items missed.
- Review will identify and correct any other problem.
- Process being improved.
Comprehensive Independent Review (ISEG) of selected complete . modifications: - Completed modifications reviewed on selective on-going basis.
! - Check on process improvement effectiveness.
l . ! DETROIT EDISON ! FERMI 2 - . - - .
. . - - l POST ACCIDENT MONITORING DRYWELL AND TORUS PRESSURE RECORDER EVENT l imorovements in Quality Assurance Caoabilities Yellow-lining verifications . Improvements in technical capability . . l . ( t
9 . DETROIT EDISON . . FERMI 2 -..-... -.- - -. - - - - - -. - - - - - . -. ...... . -. -... - -
POST ACCIDENT MONITORING DRYWELL AND TORUS PRESSURE RECORDER EVENT Causes of Quality Assurance Yellow-linina Verification Problems Expectations not clearly understood: . - Verbatim yellow-lining per Engineering Design Package yellow-lining instructions.
Procedure containe' +tle directions on yellow-lining.
- - Training: Yellow-linil,o '.>t covered as part of established training.
Perceived schedule pressure.
. Personnel error.
. . DETROIT EDISON . FERMI 2 - , - - . . .. .
- - _ - _ - - . POST ACCIDENT MONITORING DRYWELL AND TORUS PRESSURE RECORDER EVENT Approach: . - Developing ongoing engineering surveillance that will sample output from Technical Organization on a monthly basis.
, - Commencing to use engineers in audit group to lend technical depth to selected audits, as well as perform special surveillances, e.g., Operations audit, Measuring and Test Equipment audit, Instrument and Control surveillance testing surveillance.
. l l - Will be developing work control process surveillance to monitor i quality of work packages in the field.
- During modification installation, engineers within Nuclear Quality Assurance will be able to assist inspectors when questions arise.
- Will measure effectiveness of corrective action by coordinated monitoring of selected Engineering Design Packages including design, installation, and testing.
. DETROIT EDISON - FERMI 2
E_ _ -
a POST ACCIDENT MONITORING DRYWELL AND TORUS PRESSURE RECORDER EVENT Approach (continued): . - Evaluation performed of Quality Assurance program level documents (Fermi Management Directives) against potential Appendix B violations listed in inspection report to identify any other weaknesses. Prograrn is sufficient to prevent these potential violations.
- Increar'd follow-up will be conducted on audited areas rated less than satisfactory in addition to follow-up on corrective actions for all identified problems.
Revision being made to Guide to Risk Based Applications for - Fermi 2 to make it more user-friendly for Nuclear Quality Assurance personnel. This guide is based on Fermi specific Probabilistic Risk Assessment results.
'l
l l
DETROIT EDISON . . FERMI 2 -. -... . - -. -.. - - - -. -. - . -. -. - - - - - - -. -.- .-. . -..
. . . ! POST ACCIDENT MONITORING DRYWELL AND TORUS PRESSURE RECORDER EVENT Effectiveness Concern identified with implementation of a modification during Compliance Based Inspection.
Conclusions . Changes in communication of expectations, training, procedures, personnel, and approach will strengthen Nuclear Quality Assurance's ability to monitor the quality of engineering work and implementation of modifications.
!
l DETROIT EDISON l ~ i FERMI 2 !
. . POST ACCIDENT MONITORING DRYWELL AND TORUS PRESSURE RECORDER EVENT Common Cause Analysis Using Organizational and , Programmatic Diagnostic Chart Methodology ' (Failure Prevention, Inc.)
Evaluated / identified causes of the following: . - . Licensing Event Report 93-003 Wrong recorder.
- Licensing Event Report 93-008 Wrong outlet.
- Engineering Design Package "At risk" testing / inspection differences.
, Agastat Relays not in Preventative Maintenance program (recent - performance issues).
i f .h
DETROIT EDISON . FERMI 2- - - . - - --.- . -.. -- .-....... - -
. POST ACCIDENT MONITORING ' DRYWELL AND TORUS PRESSURE RECORDER EVENT Maior common causes Organizational breakdowns: . - Inadequate job skills, work practice, or decision making.
- Inadequate prioritization of work.
Programmatic deficiencies: . Insufficient detallness.
- Organization-to-Program interface deficiencies: . - Lack of Organizational Authority for program implementation.
. .. . . DETROIT EDISON-FERMI 2! .-. .. -. - - . . . -. .. - -.. - - -.
- POST ACCIDENT MONITORING i DRYWELL AND TORUS PRESSURE RECORDER EVENT Corrective Action Process Weaknesses and improvements ' Lack of breadth: .
- Feedback of Lessons Learned.
- Increased Management involvement.
- New coordinating organization.
Inadequate documentation: . - Feedback of Lessons Learned.
- Increased. Management involvement.
- Flyer mailed to all site personnel.
Added to Personnel Error Reduction training.
- - -- Site television advisory.
Personnel Error Reduction: . - Training.
- Supervisor Observation program.
. - Elimination of distractions.
DETROIT EDISON- . FERMI 2 . - . . -. -.. . .. -. .. . . -. -.. -.... . . -. - -.. -.- - - -. .
. - POST ACCIDENT MONITORING ' DRYWELL AND TORUS PRESSURE RECORDER EVENT Corrective Actions (continued) Weaknesses and Irnprovements (continued) Inadequate follow-up: . , - Management controls being revised.
- Feedback of Lessons Learned.
- Increased Management involvement.
Narrow definition of what requires Root Cause: . - Redefinition.
- Training.
Failure to detect trends: .- - Trending of all Deviation Event Reports.
. - Integration of Work Requests into trending.
Qualitative Performance Measures: . -- Current measures - - Average. age of open Deviation Event Reports.
Number of open Deviation Event Reports.
- L - New measures -
- Repeat problems and/or rejected responses.
' DETROIT EDISON . FERMI 2 -.- --- - -.-......-.- . -. -. .- . - - -. - . - -. - - -. - . -. -.. .. =. -..
i POST ACCIDENT MONITordlNG , DrdYWELL AND TordUS I)rdE55UrdE rdEcordDErd 9/ENT _ _ Potential Violation Matrix App B Criteria Fermi Management Potential Violation * Corrective Action Presentor Directive
7Q1 Step 5.4.7 Reviewer of EDP, for impact.
-Initial screening by SRO/tt0 Fessler i Quality was not qualified.
-Coordinate reviews with job ! Assurance
- skills.
, Program _ -Create a review checklist.
_ _ _ _. _ _. _ _ _ _ _ _ _ _ _. _ _ - ill CM1 Step 4.9 Design Change interface with l Improvements will be made Walker i Design Control procedures revision process l in the process by which ' resulting in EOP procedure not i design changes are
accurate.
i! ncorporated into Programs l l and Procedures.
! Ill CM1 Step 4.9 Design Change interface with ! Improvements will be made Wolker l Design Control procedures revision process ! in the process by which ! ' resulting in ERIS and EOP l design changes are i i procedures not accurate.
l incorporated into Programs ' , ! and Procedures.
w a ! lll l CM1 Step 4.10 Failure to initiate on Engineering l -Improved ownership.
Walker ! ! Design Control j Change Request l -Reduced personnel errors.
! . ! , V ! PR1 Steps 4.6.1,4.6.2, No procedure for doing yellow-i Existing procedures Goodman l , ! i4.7.3 lining.
l been revised. governing yellow-lining have Instructions, Fessler 1 Procedures and ! . - -__ Drawings ' -- -- i - Ucensee requires further clarification to%nde) stand some of these potential violations.
.
POST ACCIDEnff MONITOR 11N9 DidYtNELL AND fordUS PidEEUUrlE rdEcordDErd !EVEfff Potential Violation Matrix ! App B Criteria Fermi Managemen Potential Violation' Correctbe Action Presentor Directives V PRI Steps 4.6.1. 4.6.2, Failed to torque transmitter Future work packages will Fessler 4.7.3 covers and install operating describe specific required Instructions Procedures and plugs. Onadequate ! activities in detail.
, Drawings pr cedures) V mal Step 4.4.2 Modification Engineer failed to. -Conducted Accountability Fessler Instructions, f Ilow work instruction to verify i Moetings.
Stafford Procedures and proper power source
- -Will issue Lessons Learned.
Walker Drawings
- _ Improved ownership.
- ' -Reduced personnel errors.
-Formal turnover to
- Operations.
Vill MA1 Step 4.8 Failed to separate Q/Non O ' Procedures and practice for Fessler Identification and ' PM2 Steps 4.2. 4.3 m teri I On storage).
l storage, identification, ' control, verification PM3 Steps 4.5.8,4.7.5 j improved.
M a er P and Components j X !N1 Steps 4.6.3,4.7.1 Failed to specify a means to l NPP-mal-01 and FIP-CMl-18 Fessler inspection
- yerify appropriate parts j revised to specifically require' Goodman installed.
verification / documentation __ of nameplate data.
__ y XVI CA1 Step 4.5 _ Corrective Actions for LER 93-Feedback through Lessons Stafford Corrective Action
- 003 focused on material control Learned.
- issue: evaluation of event failed Walker to identify Division I problems.
, men: Oth;
- - Licensee requires further clarification to'4;nderstand some of these potential violations.
.
_a,s .aA
eam ,- - eem -. -. .a -. .a m a > l s k p
r i - ' e $ , l
l l ' , ' I i .~,. j - '# , 8., 'E l.b '. , i.
..?.
. ..
- %*
. , - q h ..' ' k , , - - ,f ' { ' .
- .s..}
'.} .,, t ' 7 ' . , ~ ' j . - , . - - ". .I , a ' t ....., :...; ' -
! .
',, j'f " , ;... } ', -
, .. a ?W']: .
- _
- -yb n
._ ,
, . ,
a
.. - - ,.. m , m m .- - < m m
, ._ m m ' . t
? gmEm e I a '
- .
x4-u)W$A a a.
- 3
% J t - :. - ' l , - n
- h
- g[ $' D f '$q 9' 1 cr D > 3 4.? . ;. , e } %' , . O % % >- % . - . . utlS;?)', W O O x n '. l g O O O lb , H t .y' - .- " , I; '%, - - c . }g:m gogo s.
,3.y % , Z Z n
y'# . ;. '. . .
4 g%3% r s s cq . , f.l.?, ' '4 . r r; . M '
- "
Om O {} l i w ak %aga q m [4 , . y.. g < j != -{ b. - } z $ $ Nz fyg$pf-Mi,/ 9hl !
- .Ii i
ihi[itg, y_ . 9 d9 - o - j - -
wM.
?ng&.4{O:Iy'f ' ~ " 5$' ~ .
9; ' I a".b nw n - . . l puptq%~v,. 9.
.. ,.;a; f n ' r . .. r Ndh",fff[,f $ i m - - . , ,, M . ! Ae;L.. -. -.... - - -. "j M' . e.. - - . fI., . - / m.s . .. . ..
i ) i i ! ! l ! i i $ i i
5, i I . .
I i
J . , ,- -
. . _.. _ _ __ _ _ _ _ t l l d:.!,wif M
. remm ca6 ' m Q f >* ",; W ~ 'ODERATOR ' y m ~.4g.73.._7.e.. g g yg g g. y m p.:* v n w w m m m h 9F w m m r.w.m ney l l June 28, 1993 . IF YOU THINK ERROR REDUCTION ' DOESN'T MATTER... . I ... Read the attached page-one lead article from the Saturday, l June 26 edition of the Monroe Evening News.
To give you an idea i how significant the placement of this story was, the lead story in Sunday's edition of the Monroe Evening News was: "Clinton Bombs Baghdad."
i Help reduce personnel errors.
If you've had error-reduction ' training, apply what you learned. If you haven't yet scheduled , , the training, sign-up through your supervisor.
As the posters now appearing around the site say " Don't work 'around problems, work tbrough them."
You can make a difference.
i Douglas R.
Gipson Senior Vice President, Nuclear Generation . E t i
i -
. . . , . - . - - - . ---. - -- - -- . -- _,e - , - - - - ,,-/
- - - . . . . < i , _ _ __ __ _ _ _ . , ' t';g' 85 Socked Court stiffens jsb bias rules - ne s/s.
Tiger losing streak - Y Ds*'""' 64 hits four in Boston
Weather /2A Sports /1B ^ - g' HUD waste is a disgrace .
Editorial /4A -
1 ma Evening Ct993MONROEPU MONROE, MICH, S ATURDAY, JUNE 26.1993 35 CENTS 18TN YEAR - NO.176(USPS 359-400) ! l t llNTHE NEWS Edison COuld be fined fOr Fermi goof ~ iI etterman CIOSOS a Federal authorities want to talk to The unhty didn't discover the blunders until early Janu-Edison officials said the problems have been corrected ary, after the plant had been operating at least two and procedures hate been changed so it won t happen ' Out tenure at NBC Detroit Edison Co. about a problem. monihs.
again. "While it is a senous matter and involves the technical specifications of the lant. it would have taken plagued system for post-accident mom-De snafu could have affected plant safety if a serious
- By The Associated Press toring at 1 crmi 2.
accident had occurred at the P ant during that period, three than s to hapyn simu taneously for this to be l nmenta i s fety. sa Edism spAesman kw W David I.etternun closed out an dius.
accordmg to the federal Nuclear Regulatory Comimssion.
+ i inous 18 % > cars Enday night De gap-By CHART.ES SLAT De NRC has an enforcement conference set with the lie said the plant would have had to have a loss-of- '
- toothed maestro of postmodern Evenmg News sta8f wnte'
off,lity on Thursday at the federal agency's regional uti coolant accident, a loss of off-site wer and a seismic t 'ces in Glen Ellyn. lil. to discuss the apparent viold-event, such as an earthquake, for t problems to have ka)e ia i citt a his sur.
Detsm Edison Co. may face federal fines for pmily tm o its ru es- ~ pnse guesi Bnwe Spnngsteen.
inualhng gauges meant to provide cruual data to opera.
affected safety.
tms en e event a sen acWent at hs Fernu 2 "We are taNng about potential fines, but that decision But ao NRC inspection report notes that gisen the num-Springsteen thus became the last of nuclear p ant.
wouldn t be made at the enforcement conference, said her of problems involved in the gauge design and instal-t ' an estimated 6.000 guests.
A series of mix-ups led workets to improperly install Pam Alloway, an NRC spokeswoman. She said such a lation."it appears that the (utihty) was fortuitous in that ConFratulatinE,imself for finally the wrtmg post-accident pessure-measunng devices and decision typically es made two to four weeks after such , h i nfh h plug them mio the wrong electrical outlets at the plant, a conference.
See FEFIMI. Page 1OA a a t r.
tacr.
- pirate parent General Elettric, saying.
"If GE had a sense of humor, they'd
The iceman waiteth Accused send a guy in here right now to lire ~' GE didn t Letterman, promising I " surprises and free balkmns for the ,l $ gyg ! a l kids? went seven minutes over his ' ' O EE uEE usual hour w nh high spints and nos- .
, t. sign - all the nwire renurkable since y - e . y m n.
of niot made ' h most of th,e 1.ette_rman camp will be r h. u* l;, sM rg q4 t.
, n.
_ - r.., _ _r e., _ _, ier 88' ,s;t M?%
E-at new CBS of fnesjuq a few blotks '
g* m s away.
, 4 3..., L,( g~ N;. ; w ,
ME OS licsc r. L.ctientun's Iinal Top 10 list ..e.
_ how on NBC.
on his is,i,lue Nicht y% r.. s Top to Ilygs i liase To Do Before i I'f { '., , .J .** NEW YORK f AP)- De accused mas-h[p b "" ' H& T
.ethertn e e 'a w*' dr4 v.:W n m f elI a n I art stu ,
- O 9 va *.um t on tanne*umn thits %emicit (-b. {.[ 7
, ~' dent who apparently forgot one of the
nJ unic down hn milcare.
g,.. .,, " first rules of war.1. nose hps sank ships.
+ ft i Siddag Ibrahim Saddsg Als. 32. and eat final om voor head and oivrtF
%...dh e seven other men were being held without
.. ...e .,,a.- hail Friday in a vaq bombing and asm "' .. - - . - .. .-. . -... .. . - - - - -
_ _ _. _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ __ . _. _. . __- _ _ g Court stiffens job bias rules =~ '
Partly wnny Q . Tocay s ngh U , News focus /5A - Tiger losing streak ~ n 64C hits four.m Boston - n* 0 HUD waste is a disgrace Partly cloudy
Tongni s, Weather /2A Sports /1B ' >
Editorial /4A -
J Evening c1993MONROEPU . MONROE. MtCH. SATURD AY. JUNC 26.1993 35 CENTS iSTH YE AR NO.176(USPS 35M00) .. . , I Edison could be fined for Fermi goof IN THE NEWS letterinan CIOSOS a Federal authorities want to talk to The utihty didn't dncover the blunders until early Janu-Edison officials said the problems have been corrected - ary, af ter the plant had been operating at least two and procedures have been changed so it won t happet Out tenure at NBC Detroit Edison Co. about a problem. months.
again. "While it is a serious matter and involves the iaat 't*a"id haveta'ea plagued 5J5 tem for post-accident mom- ,,,,,,,,,,,,o,,,,,,,,,,ed piant sarety ir a serious
- c=5 5eedcaa"a$ of the rtaneously for this to be three thin s to happen simu By The Aw.cated Press IOT1ng at l*CrEi 2.
accident had occurred at the plant dunng that period.
inienta t safety, said Edison spokesman 14w Lay-
Das ed Lx-temun closed out an illus.
accord ng to the federal Nuclear Regulatory Comnussion.
trmu-It' years Friday night.The gar-By CHARLES SLAT The NRC has an enforcement conference set with the lie said the plant would have had to have a loss-of-F ' 4 tm shed metro of oostremder, u Evenmg Nc=s staft -nttar utihty on Thursday at the federal agency's regional coolant accident, a loss of off site ser and a seismic Detroit Edison Co may f a e federal fines for poorly offices m Glen Ellyn. Ill..to discuss the apparent viola-event. such as an earthquak e, for problems to have
- $e eN as b sur a
I'"ns og tts tu es-affected safety.
, pnse cust Brute Spnngsteen.
mstalhng gauges meant to prmide crucul data to opera- -We are talking about poiential fines. but that deci Hut ao NRC inspection report notes that given the num-t 1 ts in the event of a senous accident at its Iermi 2 wouldn't be made at the enforcement conference,, sion Spn'neen thus became the last of nu(lear plant- ' said ber of problems involved m the gauge design and instal-an esumami Mil 10 puests.
A senes f mix-ups led workers to improperly mstall Pam Alloway, an NRC spokeswoman She said such a jai,on. "it appears that the (utshiy) was fortuitous in that ' Congratalaung him cif for fina11y the wnw pomident prmre-measunng devices and decision typically is made two to four weeks after such a a t ng s ac - plug thetii mto the wrong cledrical outlets at the plant. a (onference.
See FERMt. Page 10A nfh h ! p.ne psent General Electnc. uying.
"If GE h4 a sen e of humor.thev'd send a gey in here nght now to fire Accused The iceman waiteth "" GL dida i Letterman. promning a wrprnes and free balkmns for the kids." weat sesen mmutes mer his - m usual hour = tth high spirits and nos-p talcia - all the more renurkabne smcc y O DlOt ma e ' mat of t5e Letterman camp aill be tepenmg for work Nlonda mormng ' 7 -. > ' - I.T ' . y.
ai ne * C B% othses tust a !cu blosks; h.
k-M,, - . u
- -
f re 88"* 4 -,' m DP $ u rg' s.e,M5 a away ' sy&,f " it.. ', Me m OS a t lloc is l<nennani hnal 1"r to hst '- , g,, - y .. - on hes lap ' Laic Night show m NBC-y..3.A Top Iti n.mgs i llo e To (b Behwe i I.!'?
_
- .
j
- -
. ' I .
NEW YORK I api--The suused mas-t coe NM, 'l.p q s - -
termind of a plot to make New Yor k an , (y p]- - T.
ciplodmg mme ficid n a martul arts stu-l o p. I w.y. rt k,.,rp.n e e seu.nu n .-.g g' dent who apparently fosgor one or the l , 0 * h .m eue c ananum er thu. w e.=ae tt ,- first rules of war. tamse bps unk ships 6. M end =mr ha tus nuncage-47 e{g.
- ' -
N.
, j Siddig Ibrahim Seddig Ah.12. and ' < e e one hea tem yove head ans o.orh~ q seven other men were beine hcid without i a2V ' * - + m. MC nonc . Sail Fnday in a vast immbing and asm o. - e -.. --w
- - -. "
es .. _ . . ._, - - .. . . _, _ - .- -
_ - P" ]g Monroe EvNig News Sat. June 26. t993 l GOP seething over ' inaccurate' commercial DEATHS JACKSON. Mnh ( AP)- Mn higan Repub hued hne tonneused a penny to the I c Tane hn reveus to pull the iommer;iah htans are tryme to forte campaign wmmer t ampayn " vid Jas ison County Sherif f llank - i tials f er Democ ra Janet C Rm befois etl the C /mslak. co t hauman of Leiarte's tam-The law suit see k s to stop the stations f rom frederick Toburen Sarafina Marie Northern broadcastme the vimmertials because they air, caNng them " an num;ht he paicn 4tgg p4p g - g.reder st k Saraf ma Mane Northern, mfant are k now,dy i Ae or m retkico t nregard of i Toburen. 7N of Allen Park, w ho dauthier of Mit hael Northern arid Rot Nfort n running for a state lh>use seat "I am inid Amt ihn." uid Ma hvan GOP the truth has relatives in Monroe County.
Aenes Rice of Monroe. died at .wama i<epubin an ( lyde E Le Tarte m Iueo spokesman Bry an i lomi "We are at tbc point WLAJ TV rencial ules manacer Jon Harpst died Ihursday in hn home under 146 a m Thurulay in the Tole-day's cual general elet wn DntrKt 65 mv.
in the t.ampaign w here Janei think s she t an und uations U an't tudre dnputes mer anura-the case of Arbr llospice.
do Hmpiral, the day af ter her ~ ers parb of Jas kwn and I ason counttes uy anything and get aw ay w nh cy "The 1 CC Wederai Communrt anons Com-I riends may call from 4 to 9 birth iI R s beforI w ens. Democrats aill hase a R ot he f or I N t ampaign director. Mary nusuoni des not allow us in tensor m any w ay p m Sunday and Monday in the Gr.neude sen n es were held at % u eanuge m the 110 scar state House.
Matthews. said the t ommercul is at turare or edit m any w ay any pohtical spot." he said ban Funeral t h eme. 23#0 61-I p m i nday in Roselawn Memo-R ot b efmt 's t onuoc r u als say I.e lar te bet ause it says donations were gnen "for" reun cd campaign (unitibutions of at least t e larte, ret to hm1 The RepublKan Pvty has spent more than dard Rd. Tayh Sersnes w dl be rial Park.12Salle lhe Rev. 'lerry $1 M Dho to help i eTaise. but it's illegal for at 10 a m Tuesday m the funeral Sm:th of Monroe Chrntian Mn- $10 & H Irom three people w ho ewett f avors Ilmi said at least one of the people hsied en pople to earnurk dmatmns to any candidate.
hnme and at 10.30 a m. in St.
sionary Albance Church of fidat- , l m tetum the ad. John Rakolta of Bloomfield lldls, t kol said I-r antes Cabrmi Cathohc Churc h ed Allore funeral llome was in Repdhtan, say the three people named in doesn't even know w ho Ir I.ute is- - he are rerular. staunch suppor1ers of the H' AHen Park. Bunal wiU follow charge of urangements, the ad donated the memey to the Michigan Rakolta s la*>er. Kenneth T Brooks. fded a Repubbt an Pany ~Ihey would make donations 'n Michigan Memorial Park. Flat Survivors are her parents.
' G )p. ra Rot helort la nun agamst Rabehist's campaign and four w hether er not Clyde I eTarte was running.
R ot k.
Charles and Sandra Penrod of "Iti m ouunght he. None of the mdisiduah Lansmg aiea telesnmn stanons who refused be sa.id Born July 19.1916, inIda,he Monroe, and grandparents. Robert w as the son of Elmer and Matilda and Phylin N,rthern of Iktroit.
Toburen. He was rnarried to Arvella Cousino.
FROM PAGE 1 A P,7fJe","s"I'" *N "'u"E'M FU N ERA LS and the Allen Park Kroghts of l Columbus.
He is survived by his wife;Iwo KEITH E. SPENCE 3 l Fermitcono sons. Robert and William; two PETERSIRIRG - Scruces daughters. Mrs. Lermard (Gad) have been set for Keith E l the af!ested system did not play a role in prm for use on the control room simulator at the Altogether, the NRC identified at least 10 12 Butte and Mrs. Jay (Jacquelyn) Spenter. 56 the former superin-udme mpus to etiher the reattor prote(Inm or plant, even to the point of fahng the vintrol potentral vmlanons involving the installation Gilks; two brothers. Clyde and tendent of Consumers Power , ! cmrinnt y viety features attuanon spiems. In room niountmg bratket to make it ht.
and connguranon of the momtormg system.
Erwin; two saters. Lila Sortor and I those t.nes. ihe violation would have been co s J R Whitme riant, whodied ugmtont hom a ufety perspet five? ^""Scr reuwdn wa, pluged mto an electrj-NRC inspectors contluded that the j. b was Ahee Rehberg; 10 randt hddren "I h "" "I F ' o t al outlet that was not hnked to the plant s bostbed due to tauses suth as meffectne con.
and 10 great grandt uldren.
day mormng.
T he problemi, in volved the installation of emergenc generators if of fsite elettrical muruments to record pressure m the reat tor power to tfic plant f ailed. it also would have trol and storate of etpn iment. lat k of supers,.fle was preteded in death bY Witaoun n from 2 to 4 m. ;md 7 to 9 p m Sunday and k)tonday soon of contrattors. m quate engmeermg and two brothers. Charles and James.
drvwell - or primary tonramn.cnt system - i.uled to operate.
operatmns support hw the job, and inadequate Memorials may be made to ai the Wetherby Chapel..m2 Wdtf-af ter a -enoin rextor accident The reuwders would momfor preswre and allow operators to Transnnnus for the instruments aim were quainy assurance and quahiy control prote.
Arbor llospice. 7445 Allen Rd, wmj As e. Jat hson. Mah, w here dure 3 Sune 210. Allen Park. Mi. 4M101.
serm es are sei for il a m. Tues-determne whether to vent it instaHed five feet above Ihr level m the dry-well on the first floor of the teattor budding The enforcement conferente Thursday will dav Bunal n m Alaska Cemetery, Alaska. Mn h lint ske mstallatum durmg the plant's third instead of at floor level as designed it alw be oprn to the pbbc as past of a two-year NRC Emma T. Crenshaw norn in Jxkson. he was ihe son st tucims last fall was plagued by miudven-was distovered that shippinc plugs were t-f t Inal program that will allow the pubhc mio sures Among them, workers installed m the in the transmitters and their uhers were about 25 pert er.t of wt h umferentes. Previ.
CLAREMORE.Okla -Emma of Robert M and Maree 1 Miller) seal ress tor Jontrol room a recorder designed mytoperly t ghiened ously. all such uinierentes were closed T. Crenshaw.96 who had made Npenter and husband of Donna h CD' C' her home w ith a great-niece. Wdla P T (cond ' R. Moore e,f Claremore, died at He graduated wnh an eintrical ' 30P m Tue'd'y * C'e m "'e f"r'""*"h d '"s"*v*'e*I n n emt y in 1959 and Regnmalllospital Mrs Crenshaw Ean e , a lo uom c.n esdroppmg hy law Siddir alm allecedly talked of All ihn ret alh, the scemmr lie was an c uellent employee.
wai humerly of Monnie.
worL ed with Hendu Cor and e n f oru *.. but his idea el sub.
ha partiupatmn in tests to pre-nancte and inepotude of the Trade When he'd tome by the olhte he Prnate travewle servites will I,""unonpeahh Auouates ef ore h that she i B1 und, w as to ref er pare for the Trade Center bomb-Cenier s.uspn is. who used ibeir w as pohte. Lican iut. well4pA-k held Juiv h a' Roselawn Memo-f """ " F ( "" * "" ' ' I" * C ' '" U S to the tWed Nanons as '"The Fhit mg. boasted of "tonnn tions" that real names and had apparently ken The t hent where he worked r eal Park. 'LaSalle. Rite Funer al Ja(kson headquaners m 19ft floose" and the lederal budd ng would rei a tar bomb under the ont riminating evidente in their raved about him. When they had to Sermes is m tharge of arrange.
lie held a series cf other posts as me cenic, - Umted Nanons.and uncred words homes, who hved, worshiped and lav him off,they made us promne ments, with the tompany untd being apt to catth the car of a juror or protested together.
wid find mmeihing else for him " Horn Aur i 3.
1896 in asstened as Whomg plant superm-j lin rians for the latter? Siddig sentenemg judge "We can get Reatteon to his arrest by those Charleston.'Mo. she w as the 'emkna m N 4 Liber the. year.
I Ned. auordmg to the usm-you anytmv - % sn s.,. s;,u.
.a o,, m,. ,v... Born in the Sudan in IW1 Sid-a,,a,n., a w,n,,,,, w r,,hersne he stepped dow n as wperinice
- ,R_E Y, PLEASE READ THIS!!!! thorough - 1. carried through to completion. 2.
a) marked by full detail b) careful about detail c) complete in all respects.
We recently underwent significant scrutiny as a result of the "T50 Recorder" event and the issues related to it.
Our own investigation into this issue, along with other information afforded us from DER reviews and NRC inspections, reinforces the need for us to focus more attention on the thorouch implementation of each task we perform.
Thorough task implementation has 3 primary steps: 1.
Spend the time to plan each task.
2.
Spend the time to work the plan correctly.
3.
Spend the time to verify that each task was implemented correctly, in accordance with the plan.
DOCUMENTATION of each task must be treated with the same level of importance as the task itself.
An accurate description of WHAT was done and HOW it was done makes traceability much easier.
Spend the time to provide thorouch documentation regarding each task.
This becomes more critical if alternate steps (where permitted) are used during task implementation.
(It may result.
in a more effective / efficient plan in the future!!) In the times ahead of us, we must all maintain an , attitude toward insisting on DOING THINGS RIGHT THE FIRST TIME, EVERY TIME! ! ! . .. P }}