ML20056E152
| ML20056E152 | |
| Person / Time | |
|---|---|
| Site: | Fermi  |
| Issue date: | 08/13/1993 |
| From: | Martin J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | Gipson D DETROIT EDISON CO. |
| Shared Package | |
| ML20056E153 | List: |
| References | |
| EA-93-154, NUDOCS 9308200125 | |
| Download: ML20056E152 (5) | |
See also: IR 05000341/1993012
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UNITED STATES
NUCLEAR REGULATORY COMMISSION
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GLEN El1YN, ILLINOIS 6o137-5927
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August 13, 1993
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Docket No.
50-341
License No.
NPF- 43
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EA 93-154
The Detroit Edison Company
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ATTN: Mr. D. R. Gipson
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Senior Vice President
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Nuclear Generation
6400 North Dixie Highway
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Newport, Michigan 48166
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Dear Mr. Gipson:
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SUBJECT:
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(NRC INSPECTION REPORT 50-341/93012(DRP))
This refers to the inspection conducted during the period of May 24 through
June 8,1993, at your fermi 2 facility, to review the circumstances
surrounding your determination that both divisions of the Post Accident
Monitoring System for wide range drywell pressure had been inoperable.
During this inspection a violation of NRC requirements was identified, and
on July 1,1993, an open enforcement conference was held in the Region III
office.
The report documenting the inspection was sent to you by letter dated
June 18, 1993. The report summarizing the conference was sent to you by
letter dated July 8, 1993.
You identified a problem with the Division 2 Post Accident Monitoring System
recorders for wide range drywell pressure on January 19, 1993, and submitted
a written licensee event report (LER) on February 18, 1993.
On May 15, 1993,
after finding installation errors associated with the transmitters that
provide signals to these recorders, you initiated a review of the engineering
design package (EDP) for the installation of the recorders and transmitters.
On May 19, 1993, your review determined that the Division 1 recorder also had
some problems associated with its installation.
Additionally, the review
found that the emergency operating procedures (EOP) had not been properly
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revised to reflect the implementation of the EDP, and were inadequate.
On
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June 18, 1993, you submitted a second LER describing the findings of your full
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review of the installation problems with the wide range drywell pressure
recorders.
CERTIFIED MAIL
RETURN RECEIPT RE_ QUESTED
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9308200125 930813
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ADOCK 05000341
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The Detroit Edison Company
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August 13, 1993
The root cause for the problems discussed above was a breakdown in the
modification process associated with the EDP covering installation of the
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transmitters and recorders for the wide range drywell pressure channels. This
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breakdown was reflected in numerous instances where procedures were inadequate
or personnel failed to correctly implement them, material controls were
insufficient, the independent verification process was insufficient, and
design changes were not properly reflected in procedures. Additionally, your
initial corrective actions upon the discovery of the first division being
inoperable were insufficient.
Some of the errors, deviations from proper procedures, or inadequacies in the
process were so obvious and fundamental that they clearly should have been
avoided.
For example, craft personnel, with the approval from Plant
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Engineering, assumed the EDP to be in error and modified the simulator
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recorder mounting bracket to make it fit in the control room panel.
This
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modification was performed without issuing an Engineering Change Request as
required. Another example involved the Quality Control inspector's verifying
that the Division I control room recorder was plugged into a receptacle when
in fact it was not. Similarly, the failure of the EDP to include instructions
to change the water level versus drywell pressure curve in the E0P in
accordance with the change in location of the transmitters is significant.
Even if the hardware change had been implemented correctly, the failure to
update the curves could have rendered the whole design change meaningless.
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The f4RC recognizes that, through your followup and corrective actions, you
have confirmed that this apparent breakdown in the modification process for
the Post Accident Monitoring System drywell pressure monitors does not appear
to extend to other engineering design packages and/or modifications.
flevertheless, the f4RC considers the problems in the implementation of this
particular design change package / modification to be of significant regulatory
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concern because of the number of failures and the numerous organizations and
personnel involved in these modification process errors. This breakdown
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ultimately resulted in the violation, which is described in the enclosed
140tice of Violation (f40tice), concerning the inoperability of both divisions
of the post accident monitoring system from 140vember 4,1992, when the plant
entered operational Mode 2, until January 7, 1993.
We acknowledge your immediate corrective actions, which included installation
of a seismically-qualified recorder for Division 2 in January 1993 and
connection of the Division 1 recorder to vital power in May 1993; correction
of the associated E0P curve calculations and updating the E0Ps and Emergency
Response Information System; tightening of the transmitter caps and
replacement of the shipping plugs; verification that other control room
instruments were appropriately qualified and connected to vital power;
checking other transmitters for loose covers and performing an analysis that
confirmed the operability of those transmitters found with loose covers; and
improving work packages and identification and control of material.
Additional corrective actions included walkdowns of similar modifications;
improving labeling of electrical outlets; a comprehensive engineering
assessment of this modification for other potential errors; and communication
of this event to site employees.
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The Detroit Edison Company
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August 13, 1993
We also acknowledge your long-term corrective actions, which included a
comprehensive review of the modification process to ensure that proper post-
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modification testing was specified and that components were included in the
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preventive maintenance system; development of a formal turnover process to
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operations; initiation of the joint engineering, operations, construction
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walkdown of field completed modifications; identification of a specific point
of contact for each modification; a redesign of the modification process to
reduce opportunities for mistakes; improvement of configuration control and
the process by which design changes are inccrporated in programs and
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procedures; improvement in the self-assessment capabilities of the quality
assurance organization when it comes to evaluating modifications; and
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improvement in the verification process for modifications.
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Nevertheless, in order to emphasize the importance of a questioning attitude,
careful attention to the development of adequate design modification
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procedures, and strict adherence to proper procedures throughout the
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modification process, I have been authorized, after consultation with the
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Deputy Executive Director for Nuclear Reactor Regulation, Regional Operations
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and Research and the Director, Office of Enforcement, to issue this Notice of
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Violation which, in accordance with the " General Statement of Policy and
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Procedure for NRC Enforcement Actions,.(Enforcement Policy) 10 CFR Part 2,
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Appendix C, has been categorized at Severity Level III.
In accordance with
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the Enforcement Policy, a civil penalty is considered for a Severity Level 111
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violation.
However, we have decided not to propose a civil penalty in this
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case after considering the adjustment factors in the NRC Enforcement Policy.
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Specifically, we determined that full mitigation of the base civil penalty was
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appropriate due to your identification of the inoperable recorders and-your
comprehensive corrective actions. The remaining factors in the Enforcement
Policy were considered and no further adjustment to the base civil penalty was
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considered appropriate.
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You are required to respond to this letter and should follow the instructions
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specified in the enclosed Notice of Violation (Notice) when preparing your
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response.
In your response, you should document the specific actions taken
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and any additional actions you pla.1 to prevent recurrence. Your response
should focus.on corrective actions planned or taken to address the breakdown
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during the implementation of the EDP described above and describe how those
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corrective actions will ensure that a similar breakdown in your modification
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process will be prevented.
After reviewing your response to this Notice,
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including your proposed corrective actions and the results of future
inspections, the NRC will determine whether further NRC enforcement action is
necessary to ensure compliance with NRC regulatory requirements.
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In accordance with 10 CFR 2.790 of the NRC's " Rules of Practice," a copy of
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this letter and its enclosure will be placed in the NRC Public Document Room.
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The Detroit Edison Company
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August 13, 1993
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The responses directed by this letter and the enclosed Notice are not subject
to the clearance procedures of the Office of Management and Budget as required
by the Paperwork Reduction Act of 1980, Pub. L. No.96-511.
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Sincerely,
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S hat h Y . ban L L
ffrN-JohnB. Martin
Regional Administrator
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Enclosure:
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cc w/ enclosure:
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John A. Tibai, Supervisor
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of Compliance
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P. A. Marquardt, Corporate
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Legal Department
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OC/LFDCB
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Resident Inspector, RIII
James R. Padgett, Michigan Public
Service Commission
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Michigan Department of
Public Health
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Monroe County Office of
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Civil Preparedness
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T. Colburn, LPM, NRR
H. Miller, RIII
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T. Martin, RIII
B. Jorgensen, RIII
W. Dean, PDIII-1, NRR
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The Detroit Edison Company
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August 13, 1993
DISTRIBUT10f4:
SECY
CA
JTaylor, EDO
HThompson, DEDS
JSniezek, DEDR
JGray, OE
WTroskoski, OE
LChandler, OGC
JGoldberg, OGC
TMurley, f4RR
JPartlow, f4RR
Enforcement Coordinators
RI, Ril, RIV, RV
Fingram, GPA/PA
DWilliams, OlG
BHayes, 01
EJordan, AEOD
JSegala, OE
JLuehman, OE
Day File
,EA F,ile (2)
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