ML20140D696

Responds to NRC Re Violations Noted in Insp Rept 50-341/84-20.Corrective actions:200 Alarm Response Procedures Reviewed to Determine Generic Problem Re Incorrect Setpoints or Initiating Devices

ML20140D696
Person / Time
Site:	Fermi
Issue date:	11/29/1984
From:	Jens W DETROIT EDISON CO.
To:	James Keppler NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
Shared Package
ML20140D682	List: IR 05000341/1984020 ML20140D696
References
EF2-70041, NUDOCS 8412180615
Download: ML20140D696 (7)

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, Wafne H. Jen) '

Vics Presdent Nuclear Operatu>ns Forme 2 Ed*s' i on 'd $$7,n"Ny November 29, 1984

,,,,,se.4,se EP2-20041 Mr. James G. Keppler <

Regional Administrator Region III U.S. Nuclear Regulatory Commission

~799 Roosevelt Road Glen Ellyn, Illinoin 60137

Reference:

Fermi 2 NRC Docket No. 50-341

Subject:

Detroit Edison Response NRC Inspection Report No. 50-341/84-20 This letter responds to the items of noncompliance described in your Inspection Report No. 50-341/84-20. This inspection was conducted by Messrs. P. M. Byron and M. E. Parker of NRC Region III between August 1 and September 30, 1984.

The items of noncompliance are discussed in this reply as required by Section 2.201 of the NRC's " Rules of Practices",

Part 2, Title 10, Code of Federal Regulations.

The enclosed response is arranged to correspond to the sequence of items cited in the body of the inspection report.

The appropriate criterion and the numbers identifying the items are referenced.

We trust this letter satisfactorily responds to the noncom-pliances cited in the inspection report. If you have questions regarding this matter, please contact Mr. Lewis Bregni, (313) 586-5083.

Sincerely, cc: P. M. Byron R. C. Knop USNRC, Document Control Desk

)(7hNb- l Washington D.C. 20555 l o!$dhjj, PDR DEC 5 $$4

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THE DETROIT EDISON COMPANY.

FERMI 2 NUCLEAR OPERATIONS ORGANIZATION RESPONSE TO NRC REPORT NO. 50-341/84-20 DOCKET NO. 50-341 LICENSE NO. CPPR-87 INSPECTION AT: FERMI 2, NEWPORT, MICHIGAN INSPECTION CONDUCTED: August 1, through September 30, 1984 i

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RESPONSE TC NRC' INSPECTION' REPORT NO. 50-341/84-20 Statement of Noncompliance 84-20-11 10 CFR-50, Appendix-'B,' Criterion VI, as implemented by DECO Operational Quality Assurance Policies, OQAP-6, requires that measures-be established to control the preparation, revision, issuance, and use of documents which. prescribe activities affecting quality to assure that they are reviewed forLadequacy.

Contrary to the above, the licensee failed to adequately review Alarm Response Procedures. These procedures-included incorrect units,. incorrect values, and incorrect initiating devices.

Corrective Action Taken and Results Achieved The specific deficiencies identified by the NRC inspector have been corrected. This included deactivation of Project Procedures Manual, Appendix B, " Abbreviations and Acronyms" which incorrectly identified the abbreviation for micrombo per centimeter as "mho/cm".

Except for the omission of the symbol for micro which occur-red in all nine procedures, all of the errors identified resulted from the-transposition of two instrument desig-nation numbers. To determine if incorrect setpoints or initiating devices is a generic problem, more than 200 of the 1500 Alarm Response Procedures are being reviewed by che Nuclear Production Department. This review will concentrate on identifying incorrect instrument designations an3 alarm setpoints. Based on the results of this review, Detroit Edison will determine if a re-review of all 1500 procedures is warranted.

Corrective Action Taken to Avoid Further Noncompliance On October 11, 1984, a detailed surveillance of the Plant Operating Manual (POM) procedures preparation and review process was conducted by Nuclear Quality Assurance. The surveillance, No. S-OA-P-84-722, was designed to determine whether or not the review process as specified in POM Procedure 12.000.07, " Plant Operations Manual Procedures" and Power Plant Order (PPO) EFP-1053 " Responsibilities for Reviewing Plant Operations Manual Procedures" is effective.

These procedures governed the review of all POM procedures including the Alarm Response Procedures.

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RESPONSE TO NRC INSPECTION REPORT NO.- 50-341/84-20 l

. Corrective Action Taken to Avoid'Further Noncompliance (Cont'd)

As a result of this surveillance,' Detroit' Edison has placed special emphasis on improving the' development and review of-

-plant procedures. 'This effort is being. focused by a thorough review and revision.to POM 12.000.07, " Plant Operations _ Manual Procedures"~, which governs the development and approval of plant procedures. Specific improvements _

which address preventing the types of errors identified by_

the NRC inspector 'nclude:

Each safety related procedure.or change as identified in the approval column of_the.POM Index (i.e. SR) will be assigned to'a special technical reviewer who is not the author. This reviewer will review for the techni-cal adequacy and correctness of the procedure. The reviewer will sign the coversheet showing approval prior to submission of the procedure to the On-Site Review Organization.(OSRO).

~ Checklists are being developed to ensure that reviews

are comprehensive. These checklists will include the requirement that setpoints and other numerical data are-verified for correct value and units.

Power Plant Order (PPO).EFP-1053 is being revised to incorporate practical guidelines for procedure prepara-tion and review. These guidelines will be consistent with and supplement the requirements of POM 12.000.07.

This program for the review of procedures will commence fol-lowing the revision and approval of POM 12.000.07 and EFP-1053. These procedures will be approved by December 15, 1984.

l Date When Full Compliance Will Be Achieved Full compliance will be achieved by December 15, 1984.

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RESPONSE TO NRC INSPECTION REPORT NO. 50-341/84-20 Statement of Noncompliance 84-20-14 10 CFRt50, Appendix B, Criterion V, as implemented by DECO Operational Quality Assurance Policy 5, requires that activities affecting quality shall be prescribed by appropriately documented instructions or procedures and shall be accomplished in accordance with these documents.

a. DECO Startup Instruction 7.5.7.4.5.01, Revision 7, dated January 31, 1982, Section 4.5.4 states that the shift test engineers are. responsible for determining if the work falls within the definitions of a minor deficiency.

Contrary to the above, the shif t test engineer inade-quately reviewed Minor Deficiency Logs (MDL) by allow-ing work to be performed using the MDL which did not fall within the category of a minor deficiency.

b. Procedure 12.000.52T, Revision 0, dated August 24, 1982, Section 6.1.3 required that generic equipment defects must be reported by a nonconformance report (NCR).

Contrary to the above, the licensee documented on March 1, 1983, that 332 Emergency Diesel Generator control wire terminations were discrepant on an MDL rather than an NCR.

c. Project Procedure 7.13, Section 4.2 requires any site personnel observing a deviation shall bring it to the attention of QA and document it on a Design Deviation Report (DDR).

Contrary to the above, the licensee documented three discrepant conditions on Quality Surveillance Summary (sic) FC/M-4789 dated November 4, 1983, rather than on a DDR or NCR.

Corrective Action Taken and Results Achieved Items a and b in the NRC inspection report concern the use of the Minor Deficiency Log (MDL) to document and correct a hardware deficiency which was determined to be a nonconform-ing condition. Specifically, the review of the MDL failed to identify that the number of minor deficiencies involving EDG termination lugs required that a nonconformance report be issued. And, a nonconforming condition, i.e. the number of deficient termination lugs, could not be documented and corrected using the MDL.

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RESPONSE TO NRC INSPECTION REPORT NO. 50-341/84-20 Corrective Action Taken and Results Achieved (Cont'd)

Subsequent to this occurence, NQA recommended that pro-cedures 12.000.15, "PN-21 (Work Order) Processing" and 12.000.45T, "PN-21 (Work Order) Processing for Systems Under the System Completion Organization" be used as a replacement for the MDL procedure (Startup Instruction S.I. 4.5.4.04).

Based on that recommendation, S.I. 4.5.4.04 was cancelled effective April 17, 1984. Work previously performed under the MDL system is now controlled by Nuclear Operations using procedure 12.000.15.

PN-21's are reviewed by the section head or a designee to determine if the initiation of a Deviation / Event Report (DER) in accordance with procedure 12.000.32 is warranted.

Procedure 12.000.32, " Deviation and Corrective Action Reporting" includes guidelines fo.r initiating DER's. Guide-lines include repetitive equipment failures (identical fail-ures on like equipment) and hardware problems requiring cor-rective action to prevent recurrence. As required by Procedure 12.000.15, Nuclear Quality Assurance (NQA) reviews safety related PN-21 Attachment A's in accordance with Nuclear Quality Assurance Procedure (NQAP) 0503, " Review of Work Order (PN-21) Packages." This procedure has been revised to require a review for adverse trends including cases where the corrective maintenance will not correct the cause of the problem. If the NQA review of a PN-21 indicates that a DER is required but has not been issued, the NQA reviewer is required to notify the appropriate supervisor or section head to resolve the issue and/or initiate a DER.

Item C in the NRC inspection report involves the use of a Quality Surveillance Finding (QSF) (FC/M-4789) rather than a nonconformance report to document a nonconforming condition.

Nonconformance Reports NCR 84-0024 and 84-0190 were initi-ated as a result of two of the discrepant conditions identi-fled on QSF FC/M-4789. The third discrepant item, indented surfaces on crimps not facing outward, was determined not to be a nonconformance by Field Engineering. The " outward facing" condition was preferred to facilitate inspection, and was not intended to be an acceptance criterion.

NQAP 1803T, the procedure under which QSF FC/M-4789 was issued, has been discontinued effective October 1, 1984, and replaced with NQAP 1802. NQAP 1802 more clearly requires that if a hardware deficiency exists or could 4

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RESPONSE TO NRC INSPECTION REPORT NO. 50-341/84-20 Corrective Action Taken and Results Achieved (Cont'd) exist, a nonconformance document or PN-21 form will be initiated, as appropriate, according to the requirements of Procedure- 12.000.32, " Deviation and Corrective Action Reporting" and 12.000.15, "PN-21 (Work Order) Processing"; a QSF will not be initiated for these deficiencies.

Corrective Action Taken to Avoid Further Noncompliance Nonconformance reporting and corrective action systems at Fermi 2 are being consolidated into a single program for site personnel including the Startup Test Engineers who are now under the Technical Engineer Section Head._ Training in the new procedure 11.000.52, " Deviation and Corrective Act-ion Reporting" is being conducted for site personnel. To address the specific concerns identified by the NRC inspec-tor, the following actions were taken:

NQA personnel responsible for reviewing PN-21's were indoctrinated in the procedural requirements and their individual responsibilities for the identification of adverse trends or problems NQA personnel were indoctrinated in the requirements of NQAP 1802 including actions to be taken when hardware deviations are identified. Additionally, this proce-dure requires that all surveillance findings' receive a QA review for adverse trends.

Date When Full Compliance Will be Achieved Full compliance has been achieved.

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