IR 05000341/1993022
| ML20058H346 | |
| Person / Time | |
|---|---|
| Site: | Fermi  |
| Issue date: | 12/02/1993 |
| From: | Phillips M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20058H336 | List: |
| References | |
| 50-341-93-22, EA-93-294, NUDOCS 9312130053 | |
| Download: ML20058H346 (13) | |
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U.S. NUCLEAR REGULATORY COMMISSION REGION III i
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Report No. 50-341/93022(DRP) , (
Docket No. 50-341 License Nos. NPF-43 .
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Enforcement Action No.93-294 Licensee: Detroit Edison Company 2000 Second Avenue Detroit, MI 48226
Facility Name: Fermi 2 !
Inspection At: Fermi Site, Newport, Michigan Inspection Conducted: October 12, 1993, through November 10, 1993 !
Inspectors: R. Twigg i'
W. Kropp K. Riemer !
Approved By: dI C T). elcoh 4 Da;g I
llips, Chief W & _3 ;
Reactor Projects Section 2B i
inspection Summary
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Inspection from October 12. 1993, through November 10. 1993 -
IReport No. 50-341/93022(DRP)) :
Areas inspected: A special, unannounced safety inspection by the reactor ;
engineer, senior resident, and resident inspector. . The inspection was :
initiated in response to the event of Sept 17, 1993, where three maintenance . I workers received first and second~ degree burns after a valve stem was ejected during work on a pressurized non-safety related system. Although the system was non-safety related, there was regulatory concern because the event _
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resulted from failure to correct previously identified work control and work performance deficiencies. As a result, the focus of the irispection was on the i corrective action proces i Results: Of the areas inspected, one apparent violation with four examples'. I was. identified (paragraph 3). The apparent viola. tion regarded a breakdown of the corrective action program that was based on repetitive conditions advers to quality identified by the Fermi organization, but not correcte l PD O ADOCK 05000341 PDR
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DETAILS Persons Contacted Detroit Edison Company j
R. Bragg, Group Lead, NQA :
'J. Conen, Senior Engineer, Plant Safety . !
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R. DeLong, RPM .
P. Fessler, Director, Technical Manager !
L. Goodman, Director, NQA 1 J. Green, Superintendent, I&C i R. Gummaraju, Audits, GP 1 P. Hudson, Turbine, Group Lead, ,
J. Malaric, Supervisor, Modifications :
R. McKeon, Plant Manager, Nuclear Production l W. Miller, Director, Nuclear Licensing i R. Newkirk, Supervisor, Licensing i J. Nolloth, Superintendent, Maintenance l J. Nyquist, Supervisor, Safety Engineering :
D. Ockerman, Nuclear Training
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r J. Pendergast, Engineer, Compliance :
, G. Pierce, Work Control 7 J. Plona, Superintendent, Operations l B. Sheffel, Technical Engineering .j R. Szkotnicki, Supervisor, Production Quality Assurance :
K. Tageson, Licensing l J Walker, Director, Plant Engineering j U. S. Nuclear Reaulatory Commission f
W. Kropp, Senior Resident Inspector, Fermi'
K. Riemer, Resident Inspector, Fermi r
. R. Twigg, Reactor Engineer, RIII ;
All of the above personnel attended the exit interview conducted on November 10, 199 !
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The inspectors also talked with and interviewed several other licensee employees, including members of the technical and engineering staffs; ,
reactor operators; shift supervisors; mechanical, and instrument i maintenance management personnel; plant safety, safety engineering, and i quality assurance personne :
-! Event Description l
On September 17, 1993, a well-planned shutdown and outage at the Fermi l Nuclear Station had been developed to troubleshoot a' problem with the :
N22F415A Heater Drain valve, whose stem was thought to.have separated l from the disk. However, the work was initiated contrary to the pla l This resulted in three General Maintenance Journeymen (GMJ) receiving !
first and second degree burns to their hands, arms, and torso, and the ,
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manual scramming of the plant from approximately 17 percent power to ~!
isolate the feedwater system leak. The burns resulted from a water and !
steam spray through the vacant-packing gland of the valve when the GMJs !
remov'ed the valve's actuator with the system pressurized and the valve !
stem ejected becoming a missile, which could have caused much more ;
serious injur i
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The overriding concern in developing the work package and planning the outage had been that the system be depressurized prior to starting work given the inherent danger posed by a suspected uncoupled valve ste The removal of the valve actuator with the. feedwater system still :
pressurized was caused by the decision of the Nuclear Shift Supervisor l (NSS) to release the work package prior to establishing the required !
plant conditions for the work. The NSS had released the package for 1 work with his understanding that the package would only be worked up~ to 1 the point of removing the air supply to the actuato The intent was to ;
complete all work, such as tagging out the actuator air lines, that could be completed without actually removing the actuator. .This !
decision had been openly discussed at the plan-of-the-day meeting
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without objection. When the package was subsequently released to the -
Maintenance Department by the tagging center supervisor, this !
information was not communicate Interviews with SR0s made it apparent- i that releasing work packages prior to establishing required plant ;
conditions for the purpose of completing preliminary steps was a common .i practice. Senior management indicated they were unaware that 3 authorizing work packages without proper plant conditions continued l after an event in September 1992, which is discussed later in this 'l repor ,
3. Conclusions - '
The performance trend at fermi over the past year, as noted during recent senior management visits and as described in this report, ha i been in the negative direction, culminating in the September 17 event in ;
which it was only fortuitous that personnel were not severely injure The event was the result of recurring deficiencies in the.ALS process, ,
work authorization, and personnel performance. These deficiencies had been identified by the Fermi organization repetitively with ineffective !
corrective actions. In addition, the Fermi organization had ,
repetitively identified significant weaknesses'in the corrective action program over the last two years. Given the continued inability of th .'
corrective action program to effectively prevent recurrence of similar ;
conditions adverse to quality, the inspectors concluded that there was a breakdown in this program. Corrective actions are required by 10 CFR Part 50, Appendix B, Criterion XVI. The failure to implement an !
effective corrective action program is an apparent violation of.this ;
criterion (341/93022-01). -
4. Insoector Review
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Although the injuries to personnel during this event were significant in themselves, the regulatory significance of the event was with the
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previously-identified conditions that allowed this event. to occur, .
namely, inadequate work controls, Abnormal Lineup Sheet (ALS) process- ,
problems, and personnel errors. Therefore, an exhaustive analysis of - ;
the September 17, 1993, event was not conducted, rather, the inspectors i focused on why these conditions continued to recu l f Repetitive Problems with Abnormal Lineuo Sheets (ALS1 .j
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In May 1992, a licensee audit concluded Abnormal Lineup' Sheet !
(ALS) discrepancies had been a recurring problem and were .!
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significant due to the potential impact on personnel safety and plant availability / reliability. The excessive number of- !
discrepancies indicated that "a performance problem existed in the ;
' Tagging and Protective Barrier' process..." A review of
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Deviation Event Reports (DERs), audit reports, and previous NRC ,
inspections found that the licensee failed to establish corrective actions after May 1992 to ensure an effective ALS process was in-place prior to the September 17, 1993, event. The following is a history of the ALS DERs, audits, and NRC findings subsequent to i that repor l 5/92 AUDIT 92-084 - Discrepancies were identified in eight ALSs ,
during a Quality Program Assurance audit of operations. DER 92-220 documented that.ALS discrepancies had been identified :
as a recurring problem and was "significant due to the l potential impact on personnel safety and plant - :
availability / reliability. The excessive-number of c discrepancies indicates that a performance problem exists in the ' Tagging and Protective Barrier' process..."
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2/93 NRC Violation - procedure for conducting an ALS was not appropriate to the circumstances to ensure that-an independent verification for an abnormal valve lineup required for a plant evolution was' accomplished prior to the ;
evolutio !
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3/93 SURVEILLANCE 93-0302 - Documented eight discrepancies-between marked-up plant drawings (Mylars) and cleared ALS i 4/93 DER 93-198 - Valve B2103F020 was found closed. Normal l position was ope l 5/93 AUDIT 93-0119 - Documented recurring Mylar /ALS 9 discrepancies.
L 6/93 NRC Unresolved item - identified a concern with !
discrepancies between the ALS and the work request / temporary modification for work on Standby Liquid Controi pump .
This item is still unresolve /93 The performance problems with the ALS process first identified in May 1992 continued and resulted in the work ,
package for the job associated with the September 17, 1993 i event being released with only part of the' pre-planned ALS :
complete DER 93-545 was issued for a capped instrument .
line that had not been included on the system ALS for the ,
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9/93 DER 93-541 -- An ALS Independent Verification was not j
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i-Given the repetitive nature of inadequate ALS's since the May-1992 l audit identified the problem, the inspectors concluded that the !
corrective action program had failed to ensure that problems with l the ALS system had been corrected to prevent recurrence as ;
required by Criterion XVI of Appendix B to 10 CFR Part 50. This -
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is an example where the corrective action program had failed ;
(341/93022-Ola). l
! Work Authorization On September 12, 1992, the licensee. removed twenty-four out of j twenty-eight bolts on the South Suppression Chamber (Torus) Hatch ;
without proper plant conditions being available. The-licensee j issued DER 92-0435, which identified a number of failed or I nonexistent barriers, including deficiencies within the work l control process. The corrective actions identified at that time ,
included reviewing the methods and requirements for releasing. work ;
packages and developing appropriate actions to ensure work- ]
activities were adequately controlled in the futur Subsequently- 1 in February 1993, NRC inspection report No. 50-341/93-004 :
identified another inadequate release of a work package for work .l on an EPA breaker. The package was released with a step added by _ .!
the Nuclear Shift Supervisor requiring maintenance to contact th NSS prior to replacing the breaker. .This method of maintaining j control of the work activity was not defined in the station's j administrative procedures. As such, the validity of the method ;
was not established and was not uniformly applied as evidenced by -
the lack of any similar statement in the work package on September -;
17, 199 ,
Other examples of work packages released inappropriately for work .!
occurred on January 31, 1993, March 4, 1993,.and June 15,.199 j In the first case, the LC0 for the standby feedwater system'was'
entered and work commenced when the replacement valve was )
inappropriate for the installation; and in the second case the LCO 1 for the non-interruptable air supply was entered without having !
the ccrrect parts available for the work; and in the thir;d case i steps in a work package were recorded as completed for work on the !
Standby Gas Treatment system room cooler that had actually been :j completed under a different work packag On September 3,.1993, the licensee's Quality Assurance (QA)
organization performed an assessment of the corrective actions in DER 92-0435 and concluded that. adequate tools and barriers were.in j place, if~ properly applied, to prevent similar occurrence However, this was-not the case, as exemplified in the September
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17, 1993, event described in paragraph 2 above. This work package was released for implementation prior to plant conditions being acceptable as called for in.the work package. The following. is a
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brief. history of DER 92-0435 issued for the torus hatch event and !
relevant NRC findings:
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September 12. 1992 - DER 92-0435 issued for the torus hatch even October 1. 1992 - Root cause and corrective actions delineated in !
June 2. 1993 - DER 92-0435 submitted for closure by Operation [
i September 3.1993 - The licensee's Quality Assurance (QA) i organization performed an assessment of the corrective actions :
described in DER 92-0435. The assessment concluded that adequate !
tools and barriers were in place, if properly applied, to prevent +
similar occurrence ,
September 13. 1993 - Safety Engineering reviewed DER 92-0435 for j closure and had three coments. The comments pertained to-training that was no longer applicable; the lack of the :
responsibilities of the new work planning organization in l procedures; and the lack of a DER review checklis .
October 8. 1993 - After the September 17, 1993, event, the QA .'
organization performed additional reviews _ of current work- control practices and concluded that not all the corrective actions in DER l 92-435 had been either fully or effectively implemented. The- ;
reviews also concluded that the original QA conclusions.of d September 3, 1993, were primarily based-on a paperwork review :
versus a performance based approac '
October 14. 1993 - Also, after the September 17, 1993, event, the j licensee's Safety Engineering organization evaluated the- '
corrective actions identified in DER 92-0435 and concluded the .l following:
- The attention and follow-up_of key corrective actions diminished between January and September 199 . The subject of how to change the work control process was discussed several times in the period of January-September 1993. However, the discussions lacked the formality.of trackable conclusions with assigned responsibilities for action items. As a result, progress was not being effectively monitored for performance.against expectation The failure to implement effective corrective actions for DER 92-0435, given more than a year from its initiation, is an example of untimely corrective actions and is another example of a violation of Criterion XVI of Appendix B to 10 CFR Part 50 (341/93022-Olb).
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C. Becurrina personnel Errors With Same Causal Factors Fermi has had a significant history of events.resulting from I multiple personnel errors over the past year, including five ;
reactor scram events. The inspectors conducted a review of the i history behind personnel errors at fermi and identified an Human l Performance Evaluation System (HPES) assessment that was completed .j in September 1991. This HPES was requested by the Plant Manager :
to evaluate Fermi's personnel errors relating to " inattention to l detail" up to that tim Interviews of approximately 100 plant .l employees were performed. The HPES identified verbal and written i communications, work organization and planning, and supervisory !
and managerial methods as common causal factors for the events up l to that time. Inadequate communications, both written and oral, t appeared to be the dominant factor. Specifically, communications ;
within departments and between departments throughout the station j organizations were inadequate. As a result, management's !
expectations were not communicated to the worker, and worker l concerns and recommendations for improvement were not communicated ,
to managemen Communications were also identified as the primary !
causal factor for inappropriate attitude among the worker I
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Specifically, a significant number of workers did not--feel that station management respected their recommendations (e.g. procedure i changes), needs, or desires, and several mangers did not feel that l station workers had any respect for the plant, their job, or . '
managements need Employees identified several cases during RF02 where pressure to "get the job done" caused personnel to skim the )
work procedure / package, do the work, and signoff the work j package / procedure steps late '
These causal factors have continued as identified in several .
recent NRC inspections. Inspection report No. 50-341/93007 noted ]
several examples of inadequate communications between system i engineering and design engineering and between system engineering j and maintenanc It also noted communication deficiencies within a the system engineering organization. Inspection report No. 50- 1 341/93011 noted that the relatively high incidence of personnel errors in the independent verification area were partially due to failure of management to make its expectations clear' to plant workers, confusion between various. plant procedures, and j inattention to detai Inspection report No. 50-341/93013 noted a "
concern with non-licensed operator rounds that indicated "an ;
example where management expectations for NPP0 tours have not been effectively promulgated to the plant staff." Inspection report No. 50-341/93016 noted that the conduct of required fire watches did not meet management expectation The causal factors (verbal and written communications, work .
i organization and planning, and supervisory and managerial methods)
for personnel errors due to " inattention to detail" identified by the HPES of September 1991 have continued to date, as evidenced by
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the following examples of multiple personnel error events with- i
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similar causes since that tim i April 1992 - DER 92-0168 - A lock wire for a Hydraulic Control .
Unit (HCU) valve was found missing during a routine. inspection by i QA. The identified root cause was " failure to follow procedure." i The corrective actions were limited to a review, by the on-shift 'l crew, of their responsibilities when preparing ALS's. No !
programmatic concerns were identified despite the fact that eight ;
different people were involved in this event, any one of which ;
could have identified the error had they followed the ALS tagging 1 procedure j June 1992 - LER 92-005 - Both trains of Standby Gas Treatment System were inoperable due to an operator placing each division's ,
PE relay in the tripped condition. The primary root cause was :l inadequate communications betw"en the operator in the field and -
the control room personnel. Contributing causes were inadequate !
work practices (the operator failed to use the procedure in 1 resetting the relay), inadequate self-checking, and unfamiliarity i with the PE relay by the rounds operato !
September 1992 - DER 92-0435 - Partial removal of a torus hatch occurred while the plant was in an operating condition requiring .
containment integrity (see Section 4.B above). Contributing causes to this event included inadequate communications between operations and maintenance, management expectations not.being -)*
understood by the workers, and lack of outage management oversigh ,
i November 1992 - LERs 93003 and 93008 - Both trains of Post J Accident Monitoring of drywell pressure were inoperable due to improper installation. This event was the subject of escalated enforcement in inspection report No. 50-341/93012 for failure to adequately implement an engineering plant modification that resulted in a Technical Specification violatio Contributing causes to this event were poor communications within the'
workgroup, failure to use the procedure in verifying installation, perceived. schedular pressure, and inadequate work practices. The long-term corrective actions submitted for this violation focused on improvements to the modification and Quality Control processes without specifying a date for completion. The response indicated that full compliance with the violation had been achieved as of May 19, 199 December 1992 - DER 92-702 - A phase separator tank for radwrte overflowed. Causal factors for the event were inadequate verbal communications, schedular pressure to "get the job done" (evolution performed at turnover with distractions due to repeat
- work on other equipment resulting in other alarms), failure to fully implement corrective actions for previous overflows
- (telephone jacks were installed for better communications but were
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i not incorporated into training and were never used), inadequate work practices, and inadequate trainin Aoril 1993 - DER 93-231 - The wrong recorder was removed from .
control room panel. Contributing causes identified included !
inadequate verbal / written communications, interface design, i perceived schedular pressure, and inadequate work practice ;
July 1993 - LER 93009 - Emergency Equipment Cooling Water _
l initiated to maintain drywell pressere when the valve ' connecting !
the service water intake to the circulating water pond was opened l The principle cause for this event was inadequate communications !
between departments. A painter saw a switch on the wall and ;
thinking it was an electrical outlet switch, pushed the open lever l
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without communicating with anyone to verify he was correc August 1993 - LER 93010 - Reactor scram due to false high water .
level tri The scram was caused by an NPPO attempting to remove 1 some tape from a valve handle on the instrument manifol .j However, after the trip, control room personnel failed to respond ,
to annunciators associated with the Gland Seal-steam system, l eventually resulting in closure of the MSIVs. A violation for :
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this event was-issued in inspection report No. 50-341/93018. The :
response for this violation was u, der development at the time of l this inspection. A contributing cause to the violation was !
inadequate communications within the control room, when an extra -
licensed operator came into the control room and began acting j without informing the shift superviso ]
Sentember 1993 - LER 93013 - Three'worksrs injured and plant i manually scrammed due to maintenance breach of reactor feedwater i system at power. A contributing cause was inadequate work i instructions. The shift supervisor understood that work would -l cease upon removal of air from the valve actuator; however, this 1 was not understood by the maintenance workers performing the jo !
Given this history of recurrent personnel errors for common causes, the most significant being inadequate communication of work instructions, the inspectors concluded that the corrective action program had failed to ensure that corrective actions had been implemented to prevent the ,
recurrence of significant conditions adverse to quality as required by i Criterion XVI of Appendix B to 10 CFR Part 50. This is an example where the corrective action program had failed (341/93022-Olc). History of Licensee Assessments of the Corrective Action Proaram Weaknesses in the corrective action program were identified by'the 'j licensee's own audits over the last two years, culminating in "less than )
satisfactory" ratings for the corrective action program in the audits of April 1993 and September 1993. In May 1992 a. third party (an outside consultant) audit and internal audits emphasized the need to heighten awareness of Deviation Event Reports (DERs) exhibiting the following: j g l l
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- Untimely or ineffective corrective action, '
- Lack of coordination between organizations to resolve problems, or
- Instances displaying a lack of teamwor The licensee's Plant Safety organization responded with a corrective action program continuous improvement plan (CAPCIP) dated May 199 '
The CAPCIP actions were found by the Quality Program Assurance to have >
addre ed the audit team's recommendations with followup to assess the effectiveness of the actions scheduled for October 1992. However,-the audit in October 1992 concluded that the effectiveness of the CAPCIP for the observation-of ineffective coordination between site organizations could not be assessed given the limited time. The audit did verify 1 continued implementation of the CAPCI '
Based on continuing problems noted in subsequent internal audits, the conclusion must be that the CAPCIP was not effective in improving the ,
DER process. Audits conducted in March 1992, May 1992, April 1993, and September 1993 identified " lack of coordination between organizations to resolve problems" as causes of ineffective corrective action ;
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Deficiencies were identified in the October 1992 audit, April 1993 audit, June 1993 NRC inspection, and September 1993 audit, where DER reports had been closed prior to completion of the corrective action After the April 1993 audit concluded that the corrective action program was "less than satisfactory," the licensee initiated another CAPCI In September 1993, internal audits again concluded that the corrective action program was "less than satisfactory." The following is a '
synopsis of the self assessment results and pertinent NRC report October 1991 - Audit 91-0192 identified a concern with the average age of open DERs, in that, the solving of problems was not in as timely a manner as targeted. The concern was identified in the audit as an observation with no response required. The audit identified what !
appeared to be three primary factors that caused the increase in age of open DERs. These factors were: (1) working on DERs becomes a priority when the assigned due date approaches; (2) nobody wants to be on the DER ;
delinquent list; and (3) nobody wants to pursue a justification for an '
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March 1992 - Audit 92-0070 identified the three following observations: Ineffective coordination between site organizations was leading to ineffective corrective action . DER trend data base was not being well utilized by plant personnel for investigation of root causes or identification of trend . "As found" failed conditions had not always been preserved when there was equipment failure May 1991 - Based on assessments by a third party (an outside consultant)
and internal audits, the-licensee's Plant Safety organization initiated
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l a CAPCIP in May 199 The CAPCIP's urpose was to heighten the station awareness of DERs exhibiting 1) untimely or ineffective corrective ,
actions, 2) lack of coordination between organizations to resolve I problems, and 3) instances displaying a lack of team wor !
'1 June 1991 - NRC inspection report No. 92010 identified that th'e licensee '
had no working definition of "Significant Condition Adverse to Quality". j
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0_ctober 1992 - Audit 92-0129 resulted in the following two DERs. DER !92-605 was issued to identify inappropriate closure of DERs with outstanding corrective actions to prevent recurrence, and DER 92-602.was ;
issued to identify a failure to complete all corrective actions t identified in DER 88-1616. This audit concluded that the effectiveness of CAPCIP implemented in response to the observation in Audit 92-070 of ineffective coordination between site organizations could not be :
assessed given the limited time. However, the audit did verify continued implementation of the CAPCI '
March 1993 - NRC inspection report No. 93004 identified an Unresolved Item (341/93004-06(DRP)) based on a concern that the licensee was taking [
a narrow approach to reviews of Information Notices for applicability to :
Fermi j
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April 1993 - Audit 93-0115 identified problems with 1) failure to timely document a repeat equipment problem in the DER process, 2) assignment of :
unqualified evaluators for DERs classified as "significant condition i adverse to quality," 3) management's review of DERs, 4) submittal of !
DERs for closure prior to having completed corrective actions, 5) ;
closure of DERs with outstanding corrective actions. -In addition, the !
audit identified a concern with the practice of dispositioning NRC i Information Notices as "not applicable" without documenting !
justificatio The QA organization identified the Corrective Action l Program as "less than satisfactory" and concluded that additional !
followup on the observation from Audit 92-070 pertaining to ineffective ;
coordination between site organizations was needed_during the next j corrective action audit because the problem had not been sufficiently i resolved to allow closure of the finding. This was based on the !
identification, during this audit, of ineffective corrective actions due :
to poor communications (DER 93-240). As a result of the "less than !
satisfactory" rating, another CAPCIP was initiate j June 1993 - NRC inspection report No. 93007 identified the lack of- j timely completion of corrective action for a significant condition l adverse to quality (SCAQ) associated with water hammer in the HPCI ;
system and issued a violation of 10 CFR 50, Appendix B, Criterion XVI l
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(341/93007-Ola). Also, failure to document the cause and_ corrective actions for a SCAQ for leakage past the HPCI F001 injection valve was t identifie i
NRC inspection report No. 93010 identified concerns with the disposition of DER 92-0560 for water found in a drywell pressure transmitter. .The i concerns included an inaccurate root cause determination, an inadequate l i
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review by the Independent Safety Engineering Group (ISEG), and a lack of j an assessment by Plant Safety of the affect of water in the 1
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transmitter Auaust 1993 - NRC inspection report No. 93016 documented a concern with the licensee's inadequate assessment of possible water hammer in the ,
RHR/LPCI system as described in IN 87-1 I
Seotember 1993 - NRC inspection report No. 93016 identified a " lack of-timely follow up" in resolving the periodic high RCIC suction pressure ]
by engineering as an Inspection followup Item (341/93016-05). i
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Sep_tymber 1993 - Audit 93-0136 identified problems in the following j areas: 1) failure to perform re-reviews of Operating Experience Reports i for continued adequacy of corrective actions and 2) the closure of DERs- l before completion of corrective actions. The QA organization again i identified the corrective action program as "less than satisfactory."
The followup on the observation from Audit 92-070 pertaining to ineffective coordination between site organizations again identified i instances where DER commitments were not adequately communicated to !
other work groups resulting in DERs being closed prior to completion of :
all corrective action '
The licensee did an excellent job of identifying the problems that :
existed for correction by site management. However, once identified for i correction, management was ineffective in ensuring that effective I corrective action was implemented in a timely manner as evidenced by the
, repeat audit findings. Examples of-repeat findings included continued i l closure of DERs before completion of corrective actions, ineffective :l l coordination between site organizations, and the items discussed in I i Section 4 above. Based on the recurrence of similar conditions adverse j
to quality and the repeat audit findings for the same DER program deficiencies, the inspectors concluded that the corrective action program had failed to ensure that corrective actions had been implemented to prevent the recurrence of significant conditions adverse to quality as required by Criterion XVI of Appendix B to 10 CFR Part 5 This is an example where the corrective action program had failed (341/93022-Old). Inspectors' Evaluation of Root Causes The inspectors concluded that the lack of coordination between departments within the Fermi organization was the primary root cause of the inadequate corrective action program and the recurring conditions-adverse to quality in the areas of the Abnormal Lineup Sheet (ALS) I process, work authorization, and personnel errors due to common causes.
! Safety Sionificance l
A breakdown of the corrective action program is significant in that it has allowed conditions to exist for over a year that can have a
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q significant impact on the plant. In the area of personnel errors, there Y have been five reactor scrams during this period. Similarly, there have l been several instances of trains of safety-related equipment made ~!
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inoperable, and in two cases,- standby gas. treatment in June.1992 and drywell pressure recorder from November 1992 to January 1993, this was .i true for both of the available trains. fianagement was made aware of the ll root causes of these problems in an HPES performed in September 1991; -l however, corrective actions have been ineffective to preclude repetitive '!
problems due to these same causes. Although the QA organization, i through its audits, has consistently identified the problems and, in
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i many cases, their causes, for the deficiencies in the corrective action !
program, efforts to correct these problems have'been ineffective. As }
noted throughout this report, there have been significant weaknesses in -!
the corrective action program, almost all of v.hich have been identified !
by the licensee as early as 199 j Licensee Actions The latest corrective action program continuous improvement plan initiated in May 1993 contains action items for corrective action i improvement, personnel error reduction, equipment improvements, and !
procedure re-engineering. Some of these action items have been !
completed while others are ongoing. The licensee's corrective actions !
for improvement of the corrective action program will be further i reviewed at the enforcement conference scheduled on December 14, 199 :
'l Exit Interview i i
The inspectors met with the licensee representatives denoted in !
paragraph I during the inspection period and at the conclusion of the !
inspection on November 10, 199 The inspectors summarized the scope :
and results of the inspection and discussed the likely content of this ;
inspection report. The licensee acknowledged the information and did !
not indicate that any of the information disclosed during the inspection !
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could be considered proprietary in natur i l
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