ML20199G081
| ML20199G081 | |
| Person / Time | |
|---|---|
| Site: | Fermi  |
| Issue date: | 11/20/1997 |
| From: | Grant G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | Gipson D DETROIT EDISON CO. |
| References | |
| 50-341-97-02, 50-341-97-03, 50-341-97-2, 50-341-97-3, EA-97-201, NUDOCS 9711250090 | |
| Download: ML20199G081 (45) | |
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UNITED STATES k
NUCL. EAR RE20LATORY COMMISSION Q
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Bo1 WARRENVILLE ROAD
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USLE. tLLINots 60532-4351 November 20, 1997 EA 97-201 Mr. D. R, Gipson Senior Vice President Nuclear Generation The Detroit Edison Company 6400 North Dixie Highway Newport, MI 48166
SUBJECT:
SUMMARY
OF AUGUST 6,1997, PREDECISIONAL ENFORCEMENT CONFERENCE TO DISCUSS THREE APPARENT CORRECTIVE ACTION VIOLATIONS
Dear Mr. Gipson:
This refers to a Predecisional Enforcement Conference conducted by Mr. A. Bill Beach, Regional Administrator, and other mes,ibers of the Region ill and Headquarters staff on August 6,1997, at the NRC Region ill office in Lisle, Illinois. The purpose of this conference was to discuss three apparent violations of 10 CFR Part 50, Appendix B, Criterion XVI. We have enclosed a copy of the draft proposed violations provided to you at the conference (Enclosure 1), a copy of the handout you provided at the meeting (Enclosure 2), and a partiallist of conference attendees (Enclosure 3).
Inspection Reports No. 50-341/97002 and 50-341/97003, dated June 2,1037, and July 1,1997, respectively, discussed the background associated with three apparent violations for inadequate corrective actions.
Your staff opened the conference with an outline discussing each of the proposed violations, how they occurred, and their perspective on the safety significance for each issue. When asked if they agreed with the violations, your staff strongly indicated that they did not agree with the level of the violations being characterized as severity level 111 in accordance with NUREG-1600, "Getieral Statement of Policy and Procedures for NRC Enforcement Actions." During the conference, a..d subsequent intemal discussion among NRC management, your concems were thoroughly reviewed.
You were notified by separate correspondence (Inspection Report No. 50-344/97013 and letter dated September 23,1997) of our decision regarding the enforcement action, based on the information presented and discussed at the Predecisional Enforcement Conference. No response is required to this correspondence.
In accordance with 10 CFR Part 2.790 of the NRC's " Rules of Practice," a copy of this letter and I
(
its enclosures, will be placed in the NRC Public Document Room.
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PDR ADOCK 05000341 h.lh.h.h l
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PDR t
s D. Gipson.
2-We will g!adly discuss any questions you have concerning this Predecisinnal Enforcement Conference.
Sincerely, fl V
fWf Geoffrey E. Grant, Director Division of Reactor Projects Docket No. 50-341 License No. NPF-43
Enclosures:
As Stated cc w/encis:
N. Peterson, Supervisor of Compliance P, A. Marquardt, Corporate Legal Department James R. Padgett, Michigan Public Service Commission Michigan Department of Environmental Quality Monroe County, Emergency Management Division
D. Gipson We will gladly discuss any questions you have concerning this Predecisional Enforcement Conference.
Sincerely, Geoffrey E. Grant, Director Division of Reactor Projects Docket No. 50 341 License No. NPF-43
Enclosures:
As Stated cc w/ encl:
N. Peterson, Si.pervisor of Compliance P. A. Marquardt, Corporate Legal Department James R. Padgett, Michigan Public Service Commission Michigan Department of Environmental Quality Monroe County, Emergency Management Division Docket File w/enct Project Manager, NRR w/enci PUBLIC IE-01 w/ encl DRP w/enci OC/LFDCB wlenct Rill PRR w/ encl SRI Fermi w/encI A. B. Beach w/enci Rill Enf Coordinator wienci Deputy RA w/enct TSS wlenct DRS w/enci (2)
J. Goldborg, OGC J. Lieberman, OE R. Zimmerman, NRR DOCUMENT NAME: G:\\ferm\\fer97enf.ltr To receive a copy of tide docunwnt. Indicate in the boa "C' = Copy without attachnunt/ enclosure "E" = Copy with attachment! enclosure
- N' = No enpy f
Rlli Rlli Rlll OFFICE Rlil Jordan:dp h Grant NAME DATE 11/I 97 11/ /97
~
OFFICIAL RECORD COPY
1 D. Gipson S We will gladly discuss any questions you have concerning this Predecisional Enforcement Conference.
Sincerely, 1
/s/ Marc L. Dapas for Geoffrey E. Grant, Director C vision of Reactor Projects Docket No. 50-341 License No. NPF-43
Enclosures:
As Stated cc w/encis:
N. Peterson, Gopervisor of Compliance P. A. Marquardt, Corporate Legal Department Jari.as R. Padgett, Michigan Public Service Commission Michigan Department of Environmental Quality Monroe County, Emergency Management Division Docket File w/enct Project Manager, NRR w/ encl PUBLIC IE-01 w/enct DRP w/enci OC/LFDCB w/enci Rill PRR w/enct SRI Fermi w/enct A. B. Beach w/enct Rlli Enf Coordinator w/enct Deputy RA w/enct TSS w/enct DRS w/enct (2)
J. Goldberg, OGC J. Lieberman, OE R. Zimmerman, NRR See attached concurrence DOCUMENT NAME: G:\\ferm\\fer97enf.ltr To receive a copy of this document. Indicate in the box "C* = cas y without attachnm.itlenetosure *E' = Copy with attachment! enclosure
'N' = No copy Rlli Rlll Rlll I
f, I
OFFICE Rlli Jordan:dphh Grant /////[
NAME DATE 11697 I
11PJ97 OFFICIAL RECORD COPY
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The apparent violations disct.ssed in the predecisional enforcement conference are subjet.t to further review and are subject to change prior to any resulting enforcement action A,
10 CFR 50, Appendix B, Criterion XVI, " Corrective Actions,"
requires that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected.
In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined ar.1 corrective action taken to prelude repetition.
The identification of the signifi,. nt condition adverse to quality, the cause of the condition, and the corrective action taken shall be documented and reported to appropriate levels of management.
Contrary to the above:
e of December 26, 1996, following the licensee's identification ci August 22, 1996 of a significant condition adverse to quality containment-oxygen monitoring instrumentation calibration procedures introduced a non conservative error -
corrective actions were not taken to preclude recurrence as demonstrated by the duration of the out of-calibration oxygen monitoring instruments.
B.
10 CFR 50, Appendix B, Criterion XVI, " Corrective Actions,"
requires that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected.
In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition.
The identification of the significant condition adverse to quality, the cause of the condition, and the corrective action taken shall be documented and reported to appropriate levels of management.
Contrary to the above:
From 1989 until 1997 the licensee had not established measures to assure that the cause of a significant condition adverse to cuality
- a potential motor pinion gear problem that was cocumented in Limitorque Maintenance Update 89 01 -
was determined and corrective action taken to preclude recurrence.
Consequently, a motor pinion gear problem recurred and was identified when High Pressure Coolant Injection Valve E4150 F006 failed to perform during the conduct of a surveillance test on February 16, 1997.
The apparent violations discussed in the predecisional enforcement conference are subject to further review and are subject to change prior to any resulting enforcement action
a e
lhe apparent violations discussed in the precktisional enforcewnt conference are subjact to further review and are subject to change prior to any resulting 09forcement action C.
10 CFR 50, Appendix B, Criterion XVI. " Corrective Actions."
requires that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected.
In the case of significant conditions adverse to quality, the measures shall assure tiit the cause of the condition is determined and corrective action taken to preclude repetition.
The identification of the significant condition adverse to quality, the cause of the condition, and the corrective action taken shall be documented and reported to appropriate levels of management.
Contrary to the above:
As of April 1997, following the licensee's identification of a condition adverse to quality -- a Motor Control Center (MCC) fuse disconnect switch in a safety system failed to remain closed on October 26, 1995
- measure were not established to determine the cause of the fuse disconnect switch failure and corrective actions were not taken to prevent the failure of multiple switches in safety related applications.
Consequently, several safety related MCC fused disconnect switches failed to remain closed in March and April 1997.
The apparent violations discussed in the predecisional enforcement conference are subject to further review and are subject to change prior to any resulting enforcement action 0
DETROHEDISON t
i f
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PRE-DECISIONAL ENFORCEMENT CONFERENCE e
August 6,1997-l l
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E i
m Page1 l
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AGENDA / SPEAKERS Opening Remarks -
D. Gipson Primary Containment O2 Analyzer Calibration -
J. Plona/P. Fessler 1
MOV Motor Shaft Set Screw -
P. Fessler 480V MCC Fused Disconnect Switch Maintenance -
J. Green '
Page 2 r
G-m+
+
. AGENDA / SPEAKERS (contv)
Preventive Maintenance-Program Enhancements -
P. Fessler Corrective Action Program Enhancements -
J. Moyers Concluding Statement -
D. Gipson/P. Fessler, Page 3
~
Analyzer Calibration BACKGROLEND
+ April 1996 startup from forced outage l
- System Engineer questioned O analyzer readings of 2
L 0%
- Consistent with grab samples Page 4 t-
~ Primary Containment O 2
Analyzer Calibration BACKGROUh D (cont'd)
+ May 1996 calibration
- System Engineer questioned differences in readings when one O analyzer calibrated in inerted environment 2
- Differences were within acceptance criteria (+/-1.1%)
+ System Engineer continued data collection and monitoring of system performance L
Page5
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~
2 Analyzer Calibration BACKGROLND (cont'd)
+ July 1996 - System Engineer confirmed zero shift from olant investigation Zero Shift" anomaly is a non-conservative shift of the monitor scale when the O analyzer is calibrated.while 2
Primary Containment is de-inerted and then used when the Primary Containment is inerted.
- Both O analyzers had been calibrated in an inerted 2
environment Page 6 a
~
' Primary Containment O 2
Analyzer Calibration BACKGROCND (cont'd?
+ August 1996 - System Engineer notified Operations and Maintenance of calibration anomalies in inerted environment
+ September 1996 - 0 analyzers calibrated prior to 2
upcoming refueling outage October 1996 - Procedures revised to require O analyzer 2
calibration in an inerted environment s
Page 7
^
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2 Analyzer Calibration BACKGROCSD (cont'd)
+ December 1996 - System Engineer notifies Operations of expiration of O analyzer calibration interval and provides j
2 recommendation concerning calibration before startup i
- Recommendation is incorporated into night orders l
- Recommendation by System Engineer questioned by resident inspector (DER 96-1885 issued)
{
- Drywell inerted in Mode 4 and analyzers calibrated l
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Page8 l
~ Primary Containment Og Analyzer Calibration 1
BACKGROEND (cont'd)
+ December 1996 to March 1997 - Ongoing discussions with t
vendor and other utilities i
- Fermi-2 and vendor laboratory tests conducted
+ March 1997 - LER 97-004 issued for miscalibration of analyzers i
Page 9
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2 Analyzer Calibration BACKGROLXD (cont'd)
+ July 1997 - Fermi-2 confirmed TS 3.6.6.2 limits (4%.0 )
2 were never exceeded
- Confirmation provided by comparison of O Analyzer 2
readings to grab sample results and other correctly calibrated. analyzers l
- August 1997 - LER 97-004, Supplement 1 issued to report results of TS 3.6.6.2 confirmation Page 10
l
~ ' Primary Containment O 2
Analyzer Calibration 1
CAUSES
+ Lack of anderstanding by the vendor and Fermi-2 7
personnel of the zero-shift anomaly caused by differing calibration conditions
+ Several missed opportunities to initiate Corrective' Action l
Program
+ Operators did not question implications of night order actions associated with calibrating O analyzers in 2
de-inerted environment Page II
' ' Primary Containment O2 Analyzer Calibration CORRECTIVE ACTIONS i
l
+ Procedures were revised as issue was further defined and l
understood
+ TS changes will be processed to allow calibration to be delayed until an inerted environment is achieved
+ CARD Process
+ Operational Excellence Plan
- ODIs
- Operator liaison to System Engineering '
Page 12 i
~ ' Primary Containment 0 1
Analyzer ~ Calibration 1
SAFETY SIGNIFICANCE
+ Safety significance minimal since O limit was not 2
exceeded
+ H analyzers operable 2
i 6
[
1 Page 13
MOVMotor Shaft Set Screw BACKGROCSD
+ April 1988 - November 1989 - MOV Operator rebuild procedures revised to incorporate a number ofindustry identified issues (Including pinion gear set screw)
- Limitorque issues Maintenance Update 89-1 Page 14
s MOVMotor Shaft Set Screw l
BACKGRODD (cont'd?
+ Corrective maintenance for set screw established on an "as-available" versus " risk significant" basis
- Failure rate did not warrant a higher priority
- Intrusiveness and one time nature of work required CM rather than PM
- Limitorque did not provide recommendation regarding timeliness ofimplementation
- Formal PRA insights not available in this time period
- GL 89-10 program in its infancy (lots of evolutions, l
PMs, what should be done)
Page 15
l 1
MOVMotor Shaft Set Screw l
BACKGROLND (cont'd)
+ 1993 and 1994 (DERs 93-0338 and 94-0319)- Valve failures documented due to set screw issues
- Valve failures not outside of expected site valve failure rate
+ February 1997 - E4150F006 Failure (L.ER 97-002)
- Set screw installed and lockwired.
- Key staked
- Set screw not countersunk to shaft (dimpled)
- Set screw overtorqued Page 16
/
l MOVMotor Shaft Set Screw CAUSE
+ Did not properly prioritize implementation of vendor guidance
+ Did not track implementation to completion s
i Page 17
1 MOVMotor Shaft Set Screw CORRECTIVE ACTION
+ Evaluated MOVs for risk significance
+ Corrected 67 most risk significant MOVs in 1997 prior to startup from Forced Outage
+ Set screw countersinking of remaining risk significant and maintenance rule MOVs to be completed by end of RFO6 t
+ Expectations on Work Package documentation (Operations Excellence Plan Item III.1.C.3)
h MOVMotor Shaft Set Screw h
SAFETY SIGNIFICANCE
+ Safety significance minimal due to availability of the remaining ECCS systems, RCIC, and SBFW t
t
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l i
1 s
i Page 19 i
~ 480 VMCCFusedDisconnect Switches BACKGROD D
+ 1995 - Investigation (DER 95-0846) begun on sticking and difficulty in closing fused disconnect switches
- Identified pre-1995 unexpected openings in DER search and occasional undocumented instances of sluggish switch operation
- Cause identified as inadequate lubrication
- No vendor manual guidance on lubrication
- No approved lubricant for Fermi for a time
- Investigation concluded unexpected openings to be random with low frequency Page 20
480 VMCCFusedDisconnect
~
~
Switches i
BACKGROLND (cont'd)
+ Corrective Action for DER 95-0846
- PMs revised to require lubrication
- Identified approved lubricant in 1996
- Prioritization and implementation established based on Low frequency.ampared to industry data for PRA Normal PM schedule System outage. schedule Page 21
g 480 VMCCFusedDisconnect
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Switches BACKGROUND (cont'd)
+ Vendor-recommended cycling interval was changed from 18 months
+ Investigation did not analyze unexpected opening in combination with an external event (seismic)
+ Investigation did not evaluate lubricant mixing effects
+ Approx. 70 of 300 safety-related fused disconnect switches had PM completed prior to forced outage Page 22 e __ __
~
480 VMCCFusedDisconnect Switches
+ Corrective Actions to clean, lubricate and cycle fused disconnects were shown to be effective based on no repeat events for over one year
+ LER 97-008 issued May 1997 to document identified cases of unexpected opening of fused disconnect switches i
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t Page 2.1 i
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' 480 VMCCFusedDisconnect Switches CAUSE i
i
+ Lack of adequate implementation of vendor guidance for i
periodic cycling of fused disconnect switches i
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Page 24 o
480 VMCCFusedDisconnect Switches I
CORRECTIVE ACTIONS
+ Cleaned, lubricated and cycled fused disconnect switches connected to safety related and balance of plant loads prior j
to startup from forced outage
- PM program for the disconnect switches rebaselined
- MCC PM events created for lubrication and cycling of fused disconnect switches at 18 months
- Control group of disconnects identified
- Monitoring of Safety Tagging Re,ords for successes No unexpected openings since this has begun Page 25
480 VMCCFusedDisconnect
~
~
Switches CORRECTIVE ACTIONS (cont'd)
+ Evaluation of mixing lubricants found compatible with each other and 'MCC components
+ Documentation of MCC fused disconnect problems
+ Trained personnel on proper latching indications prior to startup from forced outage
+ Evaluating replacement of MCC equipment
+ Enhancement of PM Program Page 26
]
480 VMCC FusedDisconnect
^
^
Switches SAFETY SIGNIFICANCE
+ Analysis ofidentified unexpected opening of fused disconnect switches supports the conclusion that they are within the random frequency for this type of switch, and therefore do not rep esent a significant increase in risk
- 4 documented cases of unexpected opening of safety l
related fused disconnect switches since 1993 l
i
- 7 documented cases of unexpected opening of non-safety related fused disconnect switches to fully latch since 1993 l
Page 27 l
h l
1 PMProgram Enhancements
+ PMs completed for restart
- MCC Fused Disconnect Switches
- Most Risk Significant MOVs
+ Increased System Engineering involvement e
l s
[
Page 28
PMProgram Enhancements
+ Self Assessment of three pilot s: stems (Switchyard, HPCI, GSW)
- Using outside technical experts (Duke Engineering)
- Comparing vendor guidance to existing PMs
- Providing technical changejustifications
- Incorporating Maintenance Rule insights
- Planned benchmarking with USA /EPRI i
s Page 29
l'
, Corrective Action Program Enhancements BACKGROL3D January 1997 - Team Formed
- Multidisciplined group, all functional areas, contractors, union and management l
- 2 6-ys of facilitated team building
- Reviewed historical problems with process i
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i Page 30 i
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Corrective Action Program Enhancements 3ACKGROLND (cont'd)
+ February - August 1997 - Process Development
- Benchmarked other utilities /INPO
- Employee Feedback
- Drafted Procedures Corrective Action
>> Cause Analysis
- Dry Runs
- Met with Union management i
Page 3I I
,]
~ ^ Corrective Action Program Enhancements BACKGROUND (econt'd;
- Peer Review
- Training of Site Personnel i
i l
Page 32 I
' Corrective Action Program
~
Enhancements CARD PROCESS
+ New Name
- Condition Assessment Resolution Document
+ Simplified initiation process
+ Up front Operability /Reportability Determination by Operations and Licensing
+ Ownership Committee
- Review significance level
- A.ssign Responsible Organization for
~
assessment / resolution Page 33
?
/
.}
Corrective Action Program Enhancements CARD PROCESS (cont'd)
+ CARD Review Board
+ Effectiveness review
+ Team approach
+ Enhanced trending
+ Root Cause procedure Page 34
. Corrective Action Program Enhancements CARD PROCESS (cont'd)
+ Training
- Learning Maps to discuss "Why"
- CARD procedure to discuss "How"
- Cause Analysis for small group
- Goal - Increase ownership, accountability, teamwork
- Think preventive versus reactive O{C
~ Corrective Action Program Enhancements CARD PROCESS (cont'd)
+ Implementation
- Organization Unit Heads to collectively agree on implementation - August 1997
- INPO Review - September 1997
- Effectiveness reviews scheduled after implementation for course correction s
i i
i Page 36
Closing Comments L
+ Actively pursuing personnel issues
- New personnel in key management positions
- Goals are to instill:
l Involvement, Ownership, Accountability, Teamwork l
Questioning Attitude 1
>> Low Tolerance for Problems
- Performing Benchmarking and Assessments t
I f
[
Page 37 h
2 Closing Comments (cont'd)
- Emphasizing Conservative Decision Making Expectations
>> Reinforcement Demonstration
- Resolution being addressed is for old versus new j
problems e
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s
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Page 33 i
3*o ENCLOSURE 3 PARTIAL LIST OF CONFERENCE ATTENDEES ON AUGUST 6: 1997 Qtjroit Edison Company (DECO) i P. Borer, Vice President, Nuclear Generation P. Fessler, Plant Manager D, Gipsort, Senior Vice President, Nuclear Generation J. Green, Superintendent, Maintenance Support J. Moyers, Director, Nuclear Quality Assurance W. O'Connor, Director, Nuclear Assessment i
N. Peterson, Director, Licensing J. Plona Technical Director
- U S. Nuclear Reaulatory Commission -
A. Seach, Regional Administrator, Region lll G, 3 rant, Director, Division of Reactor Projects, Region til i
.J. Grobe, Director, Division of Reactor Safety, Region 111 M. Jordan, Chief, Reactor Projects Branch 5, Region ill A. Kugler, Project Manager, NRR G. Harris, SRI, Fermi N O'Keefe, Rl, Fermi J. Gavula, Chief Engineernig Specialist 1, Division of Reactor Safety, Region til H. Walker, Reactor inspector, Division of Reactor Safety, Region ll1 4
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