ML20137A454
| ML20137A454 | |
| Person / Time | |
|---|---|
| Site: | Fermi  |
| Issue date: | 01/03/1986 |
| From: | Dupont S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | Wright G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| Shared Package | |
| ML20137A446 | List: |
| References | |
| NUDOCS 8601140386 | |
| Download: ML20137A454 (4) | |
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l JAN 3 1986 EMORANDUM FOR: -Geoffrey C. Wright, Chief, Projects Section 20 Reactor Projects Branch 2, Division of Reactor Projects THRU:
Mark A. Ring, Chief, Test Programs Section. Engineering Branch, Division of Reactor Safety FROM:
Stevie G. DuPont, Reactor Inspector, Test Programs Section, Engineering Branch, Division of Reactor Safety
SUBJECT:
LER REVIEW OF 1985 FERMI 2 LERS As previously discussed with you, I have reviewed the LERs issued by Femi 2 beginning with LER 85001 dated March 1985 through LER 85077 dated December 1985.
This review was not conducted to determine if the LERs were issued administratively in accordance with requirements or to determine the frequency of component or system failure. The purpose of the review was to detennine whether the licensee adequately evaluated the events for root causes and properly corrected for these root causes.
Three areas of concern were identified during the review:
1.
Knowledge or status of equipment and systems 2.
Control of operations and evolutions j
3.
Failure to follow procedures In addition to the above three areas, the area of missed surveillances was initially considered; however, of the seven LERs related to missed surveillances (85002, 85018, 85020, 85037, 85038, 85062, 85070) the ;aajority had lack of equipment status as the root cause and as such, resulted an missed surveillances.
It should be noted that as late as September,1985, the licensee was still missing surveillances indicating previous corrective actions were inadequate. LER 85070 identified several problems not corrected by the previous LERs. The root causes are:
Rad / Chem was not informed that the Division I PCAMS was isolated Rad / Chem does not routinely attend shift turnovers 4
and as such, is not aware of out-of-service equipment.
Fermi does not have an Equisnent Status Board available to verify the operability o" the equipment.
8601140386 860109 PDR ADOCK 05000341 S
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l Geoffrey C. Wright 2
g3 The identified root cause by the licensee was Mrsonnel error by failing to follow the procedure for verifying the sample lineup. As indicated above, this is an inadequate determination of and correction for the root cause.
A.
Equipment Status. There were nine LERs (excluding the seven missed surveillances) in this area (85003, 85006, 85020, 85027, 85029, 85043, 85044, 85069 and 85070). The first four LERs occurred prior to Full Power License.
In all cases, the LERs were the result of the control room not being aware of what component was being tested / calibrated, out of service or in service.
In July, the licensee implemented a LCO Status Board to inform the operator of LCO requirements. However, as late as October (LERs 85069 and 85070), LCOs have been entered or violated without knowledge by the operations staff. This indicates that the LC0 Status Board is not effective without an Equipment Status Board (ESB). The ESB is needed to flag when a LC0 is entered.
B.
Control of Operations. There were nine LERs in this area (85004, 85013, 83522, 85035, 85056, 85053, 85060, 85072, and 85075). The larger portion of these LERs occurred during September and October, indicating an increasing trend.
These LERs occurred because:
System lineups are not verified when returning equipment to service, LER 85075 Operations is not adequately controlling equipment and testing (i.e., non-licensee operator using the wrong key to unlock the wrong panel to pull the wrong fuses). LERs 85072, 85022, 85013 and 85004.
l Operations not ensuring post maintenance / modification testing completed prior to returning to service. LERs 85060 and 85956.
Inadequate understandnic of duties such that the Operations Staff failed to perform required functions. LERs 85057 and 85035.
i C.
Failure to Follow Procedures. There were 12 LERs in this area. With the exception of two (85012 and 85016), they were the results of I&C personnel. Six(85005,85014,85015,85021,85030,and85067)were i
the results of valving errors during surveillance or returning to l
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.O J A;. i 1536 Geoffrey C. Wright 3
1 service after surveillance.
In all six cases the corrective actions were the same:
Training of I&C personnel using mockup Revising procedures Even though the corrective actions began after the April 8, 1985 (LER 85005) event, another event similar to all of the previous occurred on September 28,1985 (LER 85067) in that the I&C personnel was not aware that the instrument had a comon sensing line with several other instruments.
In this case the licensee's corrective actions were not effective after five months.
In addition, there were four LERs (85053. 85054, 85061 and 85077) where I&C personnel lifted the wrong leads or perfomed procedure steps out i
of sequence.
I&C personnel appear to be extremely weak in training and general knowledge of their job and functions.
One additional area which is of interest but was not included in the review is RWCU isolations. There were 14 LERs identifying isolations from High Differential Flow. LaSalle had a similar problem. Perhaps LaSalle and Fenni should be encouraged to comunicate with each other.
J In sumary, none of the LERs had an effective date for completion of the corrective actions. This is an apparent weakness when coupled with the failure to correct repetitive I&C personnel error's in valving instruments in and out of service as described in (C.) above and the licensee should be encouraged to provide completion dates. Additional recomendations resulting from this review include:
Establishment of an Equipment Status Board More effective training of I&C personnel j
Emphasis on a clear understanding of responsibilities to Operations, equipment to and from service)phasizing removal and restoration of Rad / Chem and I&C personnel (em
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.3 Geoffrey C. Wright 4
JAN 3 1986 I
Since this review was not solicited on your part 'out, rather, perfonned as a result of my own persor.a1 concerns with the quality of Fenni's LERs. the results are hereby previded to you to utilize in whatever manner you deem most effective.
Stevie G. DuPont Reactor Inspector 1
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D nt/jk Rir.g 01 03/86 01/ /86 4
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