ML20210U028
| ML20210U028 | |
| Person / Time | |
|---|---|
| Site: | Fermi  |
| Issue date: | 07/07/1997 |
| From: | Chapman N BECHTEL POWER CORP. |
| To: | Grimsley D NRC OFFICE OF ADMINISTRATION (ADM) |
| Shared Package | |
| ML20210U024 | List: |
| References | |
| FOIA-97-264 NUDOCS 9709170062 | |
| Download: ML20210U028 (42) | |
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[/'d SERVICE FOR EVALUATING REGULATORY CHANGES e
F0WPA REQUEST Caso No:
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July 7,1997 RotatadCC:
Mr. D.11. Grimsley, Director Division of Freedom of Information & Publication Services Office of Administration U. S. Nuclear Regulatory Commission Washington, DC 20555 P - Mr. Grimsley:
Pursuant to the Freedom of Information Act, and the implementing regulations in Title 10 of the Code of Federal Regulations, I am requesting that the Plant issues Matrix for Fermi 2 be placed in the Public Document Room.
Very truly yours,
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Nancy G. Chapman SERCil Manager BECHTEL POWEP CORPORATION 9801 Washingtonian Blvd.. Gaithersburg, Maryland 20878 5356 Fax: (301) 926-7036 Phone: (301) 417-3771 9709170062 970912 PDR FOIA CHAPMAN 97-264 PDR 1
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PLANT ISSUES MATRIX.
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CAUSE- :ij REF ID BY DESCRIPTION -
5/6/1997
" " * * " * " ~
"* GENERATOR LOADED ONTO GRID "" I'irst time since..
- shutdown for refueling outage on 9/27/96.
5/2/1997 Licensee plant Support - ne audits of RERP activities satisfied the requirements of 10 CFR Self-Critical IR 97006 150.54(t) and were excellent in scope and detail.
'5/2/1997 Plant Support ne overall efTectiveness of the licensee's emergency preparedness IR 97006
' facilities, equipment, training, and organization was very good. -
5/2/1997 :
Plant Support Licensee personnel appropriately declared two Unusual Events during Teamwork / Skill IR 97006 -
actual activations of the RERP Plan. Emergency classifications had been Level made correctly and offsite notifications had been made in a timely manner.
5/2/1997 NRC Plant Support ne emergency response facilities were well maintained and in very
, invohed IR 97006"
. good material condition.
Management 5/2/1997 NRC Plant Suppon -- Management support for the RERP program was identified as a strength Involved IR 97006 by the RERP Supervisor. The RERP stafTwas proactive in maintaining Management and improving the program and responsive to identified issues.
5/2/1997
.NRC Plant Suppon rne RERP program was effective in maintaining the operational involved IR 97006 readiness of your emergency response facilities, equipment, and Management personnel. Emergency response facilities, equipment, and supplies were in a very good state ofoperational readiness. Interviews with emergency response organization personnel demonstrated very good knowledge of emergency implementing procedures and responsibilities. Management suppon was strong.
5/2/1997 NRC Plant Support - ne inspector completed Temporary Instruction 2515/134 "Onshift Dose IR 97006 Assessment Capabilities" and verified that the licensee's capabilities met requirements.
5/2/1997
- " Reactor Startup after forced outage (1/17/97) ""
5!2/1997 NRC Plant Support Interviews with key emergency response organization personnel Teamwork / Skill IR 97006 demonstrated very good knowledge of the emergency implementing Level procedures and their responsibilities.
Page I of 41 b
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PLANT ISSUES MATRIX 28->al-97 Fermi DATE ID HY SALP DESCRIPTION CAUSE REF 4/15/1997
"" SMM SCREENING MEETING ""
4/10/1997 Licensee Engineering Discovered that ITE model 5600 480 VAC - 250 VDC breakers may not Engineering'De ENS 32127 fully latch. Latter expanded to ALL 1129 breakers (339 Safety Related).
sign Deficiency Licensee did not perform preventive maintenance for about 18 months.
Inspectors found corrective actions (4/17/87) to be inadequate. Possible escalated enforcement.
4/2/1997 Licensee Engineering Discovered that pow er and contrc i cables to emergency equipment Engineering'De ENS 32073 cooling w ater (EECW) Division I & 11 primary containment inboard sign Deficiency return isolation salves would be afTected by high energy line break (IIELB)during DBA LOCA. "* RETRACTED ON 4/17/97 *"
3/19/1997 NRC Plant Support inspectors assessed selected ponions of the February Emergency Other/NA IR 97002 Preparedness Drill, which included partial state and local participar.
Overall performance was acceptable.
3/19/1997 Plant Support Excellent radiological protection support w as ebsen ed during Teamwork / Skill IR 97002 calibration work in a contaminated sump. Workers identified a good Level way to perform work from outside the contaminated area, minimizing i exposure.
3/19/1997 NRC Maintenance (FME): The inspectors identified weaknesses in foreign material Inadequate IR 97002/UR11ER 97002 exclusion during the conduct of maintenance the high pressure coolant Procedure / Instr injection valve.
uction 3/19/1997 NRC Plant Support inspectors identified improper control of a visitor inside the protected Personne!
IR 97002 area by a guard performing escort duties.
Performance Deficiency 3/19/1997 Licensee Plant Support The licensee identified poor administrative control of designated vehicles.
Other/NA IR 97002 l' age 2 of 41 L __ _____
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I PLANT ISSUES MhTRIX 2W-97 Fermi DATE ID BY SALP DESCRIPTION CAUSE REF 3/19/1997 NRC Maintenance ne inspectors identified weaknesses in the control of troubleshooting Teamwork' Skill IR 97002 performed before initiating a work request. Troubleshooting was Level performed by operators that did not has e had the appropriate skills to do the checks. Also, an annunciator card was removed from an operable i
Emergency Diesel Generate-(EDG) to troubleshoot a problem in another EIXi. Since the root cause of the original failure had not been determined, operability of both EDC was put intojeopardy. (M1.2) 3/19,97 3/19/1997 NRC Plant Support inspectors identified a security door card reader that was fully functional Other/NA IR 97002 and being used, but w hich was labelled as inactive and for emergency I
use. His was considered a weak practice.
3/IS!!997 NRC Operations The inspectcr noted continued impros ement in operator control room involved IR 97002 formality, operator shift briefings, and communication ofissues to site Management management.
3/18/1997 NRC Operations Review of unresolved item 50-341/96016-03 identified failure of Personnel IR 97002 operators to document a problem with calibration of the oggen Performance monitor. This is an apparent violation.
Deficiency 3/l8/1997 Maintenance Two equipment functional failures occurred in EDG I4. Licensee Teamwork / Skill IR 97002 operability determinations and repair efforts showed good coordination Level and communication between Operations, Maintenance, and System Engine ering.
3/18/1997 Licensee Engineering The licensee identified an error in the computer calculation of reactor Engineering'De IR 97002 power. This was reported because at times during three previous sign Deficiency operating cycles, the maximum licensed power limit was exceeded by 0.6 NWth.
3/18/1997 NRC Engineering He inspectors identified that the licensee operated uith less than the inadequate IR 97002 required number of primary containment oxygen monitors during nine Oversight periods in the past. He monitors wcre rendered inoperable unknowingly because the calibration method induced a non-conservative error. He inaccuracy was identified in mid-1996 by System Engineering and Operations was notified; howes er, the operability implications were not recognized and investigated. His is an apparent violation.
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PLANT ISSUES MATRIX Wal-9' Fermi Y
IDIlY SALP DESCRIPTION CAUSE REF DATE 2/25/1997 Self-Revealed Maintenance Bree Un-related isolated failures caused 2 engine trips and stopping Equipment surveillance testing on the Emergency Diesel Generator (EDG) 14. (1)
Malfunction On 2/26S7 during fast start surveillance testing, overspeed alarms were received during two test attempts. An alarm and overspeed trip was received during the third attempt. He system engineer and maintenance personnel found the overspeed microswitch, w hich was bolted to the engine, was loose. This allowed the switch to intermittently touch the fuel rack lever, falsely indicating an overspeed condition. The switch was replaced and secured properly. The same switch had been replaced during RFOS a few months previously. This was considered a Maintenance Rule functional failure, and was being imestigated as a maintenance presentable failure _ ne system engineer inspected the remaining EDGs for possible common mode fai!ures, and found the other switches properly secured. (2) On 2/27/97 follow ing repairs. EDG 14 was again fast started for post-maintenance testing. Forty-fise minutes into its run, operators smelled an acrid odor, received permission to open the local control panel, and found thin smoke coming from the Low Speed Auxiliaries Relay. Before they could get permission to unload and shutdown the diesel. it tripped on reverse power. (3) On 2/28/97 following replacement of die failed relay, the engine was successfully tested on February 28, but the KW meter on the local panel stuck while unloading. At i800KW, the meter stuck and then freed itself and indicated 800KW. De EDG was shutdown. De system engineer determined that the safety function was not affected by the meter sticking, but Operations decided to repair the meter before returning the EDG to operable status.
2/16/1997 Licensee Maintenance llPCI discharge vahe failed to open during surveillance. Failure was Equipmtnt ENS 31796 due to pinon gear dis-engaging with shaft Other MOVs may also be Malfunction afTected Licensee on 3/3/97 made a committement to inspected and modify as needed 72 safety related MOVs before startup.
2/6/1997 Licensee Engineering nermal power limit exceeded for operating cycles I-3 due to error in EngineeringDe ENS 31743 density compensating computer algorithm used to comert difTrantial sign Deficiency pressures into mass flow rates.
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j PLANT ISSUES MATRIX Fermi DATE
=I ID BY SALP DESCRIPTION CAUSE REF 2/3/1997 Licensee Operations A non-licensed cperator improperly operated a knife switch without Personnel IR 97002/NOV properly identifying it tripping both generator output breakers when the Performance generator w as shutdow n. Lack of supervision, system knowledge, rnd Deficiency procedural guidance did not stop the operator from taking an inappropriate action.
2!!/1997 NRC Plant Support Background investigation information was receis ed in some cases 's fore Personnel IR 96015 written consent was obtained to do the insestigation.
Performance Deficiency 2/1/1997 Main Generator Rotor shipped off-site for balancing. Rotor bowing caused by gernerator motorizing event. Forced outage of 6 or mor-weeks 2/1/1997 Licensee Plant Support Several measurement standards for the Escellence Pian have not been inadequate IR 96015 developed.
Osersight 2/1/1997 NRC Plant Support Compensation was not provided for some cable trays containing safety Personnel IR 96015 related cables located outside of a vital area Performance Deficiency 2/1/1997 NRC Plant Support Required element of security force physical examination was not Inadequate IR 96015 completed in some cases.
Oversight 2/1/1997 NRC Plant Support (STRENGTil): Security department participation in the Deviation Event Self-Critical IR 96015 Report program has improved significantly within the last six months of 1996.
2/1/1997 NRC Plant Support (STRENGTII): Quality Assurance has continued to be effective in Self-Critical IR 96015 identifying decline of effectiveness in some aspects of the security organization.
2/1/1997 NRC Plant Support Procedures were not prepared for control and use of w eapons, and for Personnel IR 96015 processing Mutual Assistance Forces if needed.
Performance Deficiency 2/3/1997 NRC Plant Support Number of security force errors has not decreased for the last half of Personnel IR 96015 1996.
Performance Deficiency Page 6 cf 41 l
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CAUSE REF j;
DATE ID BY SALP..
- DESCRIPTION l/10/1997
- " * " " " * - *"" SilUTDOWN DUE TO OFFGAS VALVE PROBLEM -
(INADEQUATE MAINTENANCE)& TURBINE VIBRATION *""
,1/1/1997 '.
- """"" ' *"" STARTUP FROM REACTOR TRIP (12/28S6) *""
1/1/1997 Self-Revealed.. Maintenance Developed a turbine rub that resulted in a high vibration turbine trip Equipment IR 96016.
before it could be seuled. With turbine offline, developed an offgas Malfunction problem with drain tank operation for the SJAE suction path; lost suction.
a few times briefly, so shut down. Caused by sludge in instrument lines and improperly adjusted AOVs not shuning completely.
12/28/1996 Self-Revealed
- Multiple
. During attempted to place reference leg backfill system in service, got a Engineering'De IR 96016cNOV/ ENS 31518 pressure spike in the instrument line which caused a very brieflevel 8 sign Deficiency level 2 indication spike that caused a scram. Three days investigating because some ESF actuations did not occur (due to 56 msec duration).
12/28/1996-
""* REACTOR TRIP (see REF LEG BACKFILL)""*
12/26/1996 NRC
. Maintenance. Inspectors identified that an inadequate review of TS surveillance and Inadequate IR 96016 mode change restraint requirements for Primary Containment Oversight '
Monitoring System resulted in a late starnip scheduling change to avoid
' exceeding surveillance interval. Near Miss presented by NRC intervention.
12/26/1996
- "" STARTUP FROM FORCED SilUTDOWN (12/24/96) *"**
12/24/1996 Self-Revealed Maintenance Technical Specification required shutdown due to a failure of a Drywell Inade.yste IR 96016/NOV/ ENS 31507 Vacuum Breaker to close during surveillance testing. The failure was due. Procedurdinstr '
to an inadequate procedure that did not ensure the magnet assembly w as uction secured.
12/24/1996
""* FORCED SilUTDOWN (VACUUM BKR FAILED)"*"
12/23/1996
"*** STARTUP FROM FORCED OUTAGE (12/22/96) *""
Self-Critical 12/22/1996
"*" FORCED OUTAGE (SRV "D" FAILED) ""*
m W 996
- * * *
- STA RTUP FROM FORCED OUTAGE (12/8/96) ""
- Page 3 of 41
i PLANT ISSUES MATRIX 28-Ad-97 Fermi DATE ID IW SALP DESCRIPTION CAUSE REF 1
12/21/1996 Self-Res ealed Maintenance SRV "D* stuck open. Closed itselfjust before operators inserted a Equipment manual scram. Investigation found bent solenoid sahe stem.
Malfunction 12/19/1996 Self-Res caled Maintenance The licensee replaced a new Intermediate Range Monitor detector that OtherSA IR 96016 was damaged by mishandling while attempting to free the detector drive.
An investigation revealed that the drive malfunctioned due to undetected material from a presious bearing failure in the gearbox.
12!!6/1996 NRC Engineering The 10 CFR 50.59 program was generally adequate. Ilowever, a safety inadequate IR 46013 evaluation for the impact of using the Emergency Equipment Cooling Osersight Water (EECW) System to supplement drywell cooling during extended hot weather did not consider all applicable scenarios.
12/16/1996 NRC Engineering The inspectors identified informal and untimely correct.e actions for a inadequate IR 96013/NOV problem uith the EDG 12 mullier. The issue w as improperly assigned a Oversight low significance and closed. Corrective actions were rescheduled without reassessing the operability determinatic>n.
12/16/1996 Licensee Maintenance Wrong Reactor Water Cleanup (RWCU) system vahes were worked Personnel I!t96013 during the outage. During startup, control indication showed a 4 5 gpm Perfomiance leak out of the RWCU. 'Ihe correct valves were repaired following plant Deficiency
' shutdown.
12/16/1996 Self-Revealed Maintenance ' Two surveillances were started without meeting the plat conditions to Inadequate IR 96013 complete the tests. Reviews by schedulers and operators were Oversight inadequate.
12/16/1996 NRC Operations Performance of operations activities during plant startup, shutdown, and Teamwork / Skill IR 96013 refueling activities were well-controlled. Communications and Level coordination were good. In contrast, a number of routine evolutions were not properly controlled and errors were made w hich resulte(in one scram and overflowing the spent fuel pel. A non-cited violation was issued tar the performance related to the scram.
l' age 9 of 41
3 o
PLANT ISSUES MATRIX 2W#
Fermi SALP b
DESCRIPTION CAUSE REF DATE ID llY t
12/16/1996 Licensee Maintenance ne licensee idemified two cases oflifled leads that were not relanded inadequate IR 96013/NOV Ilowing maintenance. Both cases were found by workers but not Procedure / Instr
.. ported or corrected until post maintenance checks. Fn one case, the uction investigation did not identify the cause. The inspectors determined the surs eillance procedure was inadequate to 5 erify propec system restoration.
12/16/1996 Self-Rescaled Maintenance De control center emergency makeup ai-fiher overheated due to Personnel IR 96013/NCY improper / inadequate maintenance. De investigahn was unable to Performance determine how the heater came to be set 100F too high. Responw to the Deficiency event was proper, but the filter had to be replaced. Valves needed to deluge the filter were found incorrectly labelled.
12/I6/1996 NRC Engineering he inspectors idemified that a technical specification (TS) change was Inskquare IR 96013/NOV required as a result of the core reload analysis. Existing rod block Osersight monitor (RBM) operability requirements w ere not adequate to prevent exceeding fuel mechanical ovepower limits during a rod withdrawal error event, but the 50.59 evaluation did not determine a TS change was necessary.
12/12/1996 Self-Rescaled Engineering Battery charger would not work when 2 of 3 circuit boards were replaced Persennel IR 96012
, with updated boards. He oesign change package evaluated the change Performance to have no effect.
Deficiency 12/12/1996 Licensee Engineering De stem (arm) to disk (bucket) connection for the turbine control vah es Engineering'De IR 90012 were considerably out of tolerance due to improperly heat treated collars sign Deficiency holding the disk to the stem.
12/12/1996 NRC Maintenance Rust was found underneath snubber N30-3259-G68 on the 52 inch main inadequate IR 9er012 steam manifold pipe. Although the snubber tested satisfactorily, and the Oversight rust was only on the outer sleeve, the thrust ring showed extensive wear caused by vibration.
12/12/1996 NRC Engineering Numerous problems were encountered during testing and startup of the Engineering /De IR 90012 station blackout combustion turbine generator (CTG) I!.1. The turbine sign Deficiency generator vibration exceeded the licensee's specifications. A ground was discoverd in the generator field during testing that appeared to contribute to excessive vibration in the unit.
Page 10 of 41 l
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PLANT ISSUES MATRIX Wal-97 Fermi i
DATE ID BY.
SALP DESCRIPTION CAUSE REF 12/3/1996 Self-Rescaled LOSS OF SliUTDOWN COOLING DUE TO UNEXPLAINED Other.WA IR 96013/LER 960201NS CLOSURE OF Tile SUCTION PATil ISOLATION VALVE: The "C" 31398 RilR pump tripped w hile in the shutdown cooling mode. The pump tripped when the suction path valve (El I F009) closed for no apoarent reason. This is the only suction line for shutdown cooling, so even though other RilR pumps were asailable, shutdown cooling was lost for 25 minutes. Vessel temperature increased 2 degrees before the vahe could be reopened and shutdown cooling restored. CAUSE WAS DETERMINED BY LICENSEE TO BE A SPURIOUS INVALID REACTOR PRESSURE SIGNAL 12/2/1996
"*" SilUTDOWN (see SRV "A" entry dated Il'29 96) ***"
II/29/1996
- "** STARUP FROM 5th REFUELING OUTAGE ""*
l1/29/1996 Self-Revealed Engineering SRV "A" did not indicate open when vahe was open. Indication Engineering /De required for accident monitoring.
sign Deficiency iI/22/1996 Licensee Operations Licensee controls to resise the licensed operator requalification training invoked IR 96014 program were satisfactory Management i1/22/1996 NRC Operations He Licensed Operator Requalification training program was not Inadequate IR 96014 efTective in all areas. A pattern of poor operator performance existed Procedure!!nstr that was attributable to inadequate and incorrect procedures, operator uction usage of procedures, and operators failing to control uork activities.
I1/22/1990 Licensee Operations ne requalification dynamic simulator scenarios contained all the Teamwork / Skill IR 96014 quantitative and qualitative attributes necessary to pros ide an efTecthe Lesel evaluation of operator skills. The job performance measures (JPMs) satisfied the quality checklist and were considered good. The facility did not administer a written examination. Minor weaknesses existed in the operators' usage of procedures and in three-way communications during the dynamic simulator scenarios.
l' age 12 of 41
-=- - - - - - -
--~-
~ ' ^
t PLANT ISSUES MATRIX mum Fermi i
DATE ID !!Y SALP DESCRIPTION CAUSE REF 4
4 i!/22/1996 NRC Operations (STRENGTil): The feedback process was correctly implemented.
Self-Critical IR 96014 Operator and crew weaknesses as well as operator training requests were used to select training requirements for the upcoming training cycle.
There was a satisfactory tracking program to incorporate changes to the examination bank material when procedure changes or modifications were implemented. The program was current and up to date.
1i/22/1996 NRC Operations One concem involving the operation of the Rod Worth Minimizer on the Engineering'De IR 96014 simulator was identiGed.
sign Deficiency i1/22/1996 NRC Operations
' (STRENGTil): The facility evaluators adequately identi6ed operator Self-Critical IR 96014 performance errors during the operating examinations.
I1/22/1996 Self-Resealed Operations One entire crew failed their requaliGcation examination because they Teamwork / Skill IR 96014 failed to properly execute plant emergency operating procedures.
Level Control room communications were a contributing muse to the failures.
I1/20!!996 SMM Screening Meeting - FERMI full Discussion l1/I5/1996 Licensee Engineering inadequate water supply to the standby feedwater system for Appendix R Engineering'De LER 96019 requirements.
sign Deficiency i1/14/1996 Self-Revealed Maintenance RCIC Valve Failed Logic Test due to Wiring Error. While conducting Personnel IR 96013/NOV post maintenance test. I&C identiGed that the RCIC steam inlet valve Performance had two wires w hich were not connected.
Deficiency 11/14/1996 Licensee Maintenance Reactor Recirculation Pump trip coil not connected. One of four trip Personnel IR 96013/NOV coils were found to be disconnected. Maintenance and post maintenance Performance testing had been performed before the fault was found.
Deficiency 11/13/1996 Self-Revealed Maintenance Loads tripped during diesel testing: During the LOOP & LOCA test of Equipment the EDG, the "A" core spray pump and the "A" Ri1R pumps sequenced Malfunction onto the emergency bus but tripped on over current. The cause was due to a faulty card in the under voltage circuit. 'the system was worked on during the outage but pass several tests before the failure.
11/7/1996 PPR end (3/96-9/96) - PPR Meeting Page 13 of 41 l
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PLANT ISSUES MATRIX N497 Fermi DESCRIPTION CAUSE REF
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DATE ID BY SALP i
10'25/1996 Self-Revealed Engineering During a routine safety bus undervoltage surveillance, operators were inadequate IR 96010<NOV unable to start a residual heat removal sersice water pump. His pump Procedure!1nstr was not previously identified as being rendered inoperable during uction performance of these surveillances, and thus TS action statements u ere not entered. A violation was cited for this event (NOV). (E3.2) 10/25/1996 Self-Revealed Operations Plant configuration control problems resulted in two minor Personnel IR 96010NCV contamination spills and various tagout problems.
Performance Deficiency 10/22/1996 NRC Engineering Special Test was not stopped as required: A test for natural circulation in Personnel IR 96010 NOV the core was performed to a!!ow work on the RIIR shutdown cooling Performance suction valves. He licensee had set up several temperature detectors in Deficiency the core to monitor the temperature of the coolant to verify that natural circulation was occurring. He procedure gave specific instructions to terminate the test if temperature monitoring was lost. He test engineer pushed the wrong button and lost indication. He engineer made seseral attempts to regain indication and left the area twice to seek assistance.
The control room was not informed of this condition until the inspectors identified it to them. He control room stopped the test and restored shutdown cooling.
10!!7/1996 Licensee Engineering Fuel Rack Design Deficency: The licensee identified in 1983 that seven Personnel IR 96010 fuel storage rack panels were manufactured upside down. He analysis Performance determined that the racks were acceptable. In 1991, the licensee Deficiency responded to an industry concem with Boraflex gapping and determined that they were not susceptible. Hey failed to evaluate the preuous design issue of racks being manufactured upside down. In 1996, they discovered this error and removed all spent fuel from the afTected racks.
10!!6/1996 Self-Revealed Maintenance ESF: While preparing for a safety battery test discharge, the fuses for a inadequate IR 96010 NOV test battery were not installed when it was connected to the bus. As a Procedure / Instr result, the bus was unintentionally deenergized w hen attempting to uction restore from the test, resulting in ESF actuations. The cause was similar to a battery charger testing problem a year earlier.
l' age 16 of 41
i PLANT ISSUES MATRIX N=W Fermi DATE ID IlY j
SALP DESCRIPTION CAUSE REF 10/14/1996 Self-Revealed Maintenance Vacuum breaker "J" stuck open, necessitating shutdown per TS. Found Equipment IR 46016/NOV magnet assembly improperly installed during the refueling outage.
Malfunction 10!!I/1996 Licensee Plant Support Lessons learned compiled from RFO4 ALARA postjob reviews were TeamworL5 kill IR 96011 etTectively implemented for RFOS and resulted in a net dose savings Lesel during the outage.
10!!l/1996 Licensee Plant Support Excellent control of potentially contaminated materials existed All Teamwork / Skill IR 96011 potentially contaminated items were either w ithin the designated areas or Level were bagged and labeled appropriately.
10/11/1996 Licensee '
Plant Support RP coverage for specificjobs and routine rounds was evident. RP techs Teamwork / Skill IR 9601I at the control points adequately briefed workers and exercised Lesel appropriate control of various tasks.
10/11/1996 NRC Plant Support 10/11/96,NRC. Plant Support,NRC identification of chewed gum in the Personnel IR 9601I reactor building indicated a continuing problem. He licensee had Performance identified evidence of eating and drinking on August 19 in the Radwaste Deficiency Building and on August 26 around the turbine oflice, 10/11/1996 Licensee Plant Support The ALARA Co.nmittee planning for dose reduction and ALARA Involved IR 9601I activities for RFO5 was of sufficient scope and depth to contribute to Management
' dose savings achieved. The ALARA committee was efTective in communicating high expectations to both the radiation protection staff and Task Managers.
10!!I/1996 NRC Plant Support Planning for the control rod position indicating probe modification task Personnel IR 9601I significantly underestimated the work scope and the dose expenditure for Performance the scaffolding and cable installation phases.
Deficiency 10/8/1996 NRC Engineering Inspectors identified that an inade.guate safety evaluation was performed inadequate IR 96010?NOV prior to taking the General Service Water System out of senice for Oversight maintenance. As a result, Engineering failed to evaluate the need to provide an alternate source of makeup to the Ultimate IIcat Sink to '
compensate for evaporative losses w hile in shutdow n cooling.
Page 17 of 41
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p PLANT ISSUES MATRIX 2W'7 Fermi DATE ID BY SALP h
DESCRIPTION CAUSE REF 10/2/1996 Self-Revealed Operations While attempting to use the Core Spray Keep Fill System to fill the Personnel IR 96010 reactor vessel, the throttle va!>e overloads tripped. De inspectors Performance questioned the use of a safety system as a matter orconvenience to fill Deficiency the reactor, when non-safety systems uere available.
9/2811996 Self-Revealed Operations ESF ACTUATION: Torus-Drywell vacuum breaker opened. Operations inadequate IR 96010/LER 96-1I did not account for energy added to the torus from RilR while purging Oversight the drywell.
9/28/1996 Self-Revealed Operations ESF ACTUATION: During fill and senting of EECW system, auto start Inadequate IR 96010/NOV/LER 96-15 of pump occurred. Operations w as filling two portions of the system Oversight simultaneously when low pressure conditions occurred.
9/27/1996 PLANT SilUTDOWN FOR REFUEL OUTAGE 9'27/1996 Operations Plant shutdown for the refueling outage was controlled and deliberate.
Teamwork / Skill IR 96010 Level 9'25/1996 station held a day-long stand down. nieetings were conducted to IR 96010 emphasis reactor safety, adherence to procedures, and u ork control.
9/23/1996 Licensee Maintenance Licensee personnel found and stopped unauthorised maintenance Personnel IR 96010 NCV activities on the refueling bridge by sptem engineer and contract Performance personnel.
Deficiency 9/18/1996 Self-Revealed Maintenance Technician connected portable test instrumentation across wrong Personnel IR 96010NCV terminals on 24'48 V battery. Damaged only test instrumentation.
Performance Deficiency 9/13/1996 NRC Operations here were significant weaknesses regarding the failure oflicensee inadequate IR 9620I corrective actions to prevent recurrence of problems. For example, in Osersight the operations area, deficiencies were identified in procedure preparation and upgrade during 1994 and part of 1995 in deviation report. De repetitive nature of the problem was noted in a recently issued adverse trend report. Also in the operations area, the lack of effectiveness of correctise action initiatives were evidenced by recurrent improper component manipulations, and by repetitive failures to enter Technical Specification action statements.
l' age 19 of 41
PLANT ISSUES MATRIX' 2 W 97 Fermi DATE ID ilY SALP DESCRIPTION CAL'SE REF i.
9/13/1996 NRC Engineering One calculation had to be created to serify that existing instrumentation EngineeringT)e IR %201 would detect a pressure transient in the IIPCI system steam exhaust line sign Deficiency and fwlate the system as required. Other calculations. such as one for fuse selection, and one for motor operated vahe (MOV) pickup voltage, required ccrrections in order to s erify sy stem operability.
9/13/1996 NRC Engineering 11PCI system and the NI AS w ere capable of performing their intended Engineering /De IR %201 safety functions; however, numerous inconsistencies in the UFSAR and sign Deficiency design basis documents were identified.
9/I3/1996 NRC Maintenance In the biannual audits of the corrective action program, NQA did not Inadequate IR %201 follow the requirements of the QA manual for generating DERs and for Oversight escalating repetitive issues to management attention.
9/13/1996 NRC Maintenance Nuclear quality assurance (NQA) audits and surveillances did not reflect Inadequate IR 96201 the adverse trends apparent from the DERs in the areas of work control Oversight and operations.
9/13/1996 NRC Maintenance There was some resistance by craft personnel to participate in the DER Personnel IR 96201 initiation.
Performance Deficiency 9/13/1996 Licensee Plant Support Failure to follow radiological administrative procedures: Licensee persormel IR 96007/NCV identified several instances of eating and drinking in the radiologically Performance restricted area. Prompt corrective measures were taken.
Deficiency 9/13/1996 NRC Maintenance Weaknesses in initial characterization of problems, assignment of Inadequate IR 96201 probable cause, and root cause analysis contributed to the inadequate Oversight corrective actions. For example, a substantial number of the work control related DERs had the same probable cauw " inattention to detail." The corresponding correctise actions were generally limited to counseling and retraining of employees. The lack of specific requirements to bring recurring issues to the attention of upper les els of management also contributed to the chronic nature of the problems.
Page 20 cf 41
e PLANT ISSUES MATRIX 2 W -97 Fermi DATE ID BY U
SALP h
DESCRIPTION CAUSE REF
!i 9/13/1996 Self-Revealed Maintenance Equipment material condition: A series of existing equipment Other/NA 1R 96007 deficiencies in a reactor building equipment drain sump went unidentified until a new equipment leak began increasing the input to the sump.
9/13/1996 NRC Engineering Surveillance test acceptance criteria disagreed with supporting Engineering'De IR 96201 calculations. Maximum leakage rates allowed by surseillance could sign Deficiency exceed NI AS system capacity. Also minimum pickup voltage for an MOV exceeded the voltage available at the valve.
9/13/1996 NRC Operations Weaknesses in the corrective action and quality assurance programs inadequate IR %20I contributed te weak performance in the area of operations.
Osersight 9/l3/1996 NRC Operations Corrective actions repeatedly failed to prevent recurrent personnel Inadequate IR 96201 performance problems.
Oversight 9/I3/1996 NRC Operations The site-wide problem identification and corrective action process using Self-Critical IR 9620I Deviation Event Reports (DERs) was comprehensise and continued to gain acceptance by site personnel. The tracking and trending of the DERs within the corrective action program identified adverse trends in the areas of operations, maintenance and engineering.
9/13/1996 NRC Operations Root cause analyses were not probing enough to determine the inadequate IR 96201 appropriate causal factors, and there was no escalation process to bring Procedure / Instr management attention to longstanding issues, uction 9/13/1996 NRC Opera mns Guidance needed to properly classify DERs according to the significance Inadequate IR %20I of the problem or event was not provided. The procedure also lacked, Procedure / Instr specific requirements to escalate lonF standing repetitive issues to the uction attention of upper management.
9/13/1996 NRC Operations Licensee self-assements of OPERATIONS continued to be wcak:
Other/NA IR 96201 Assessments routinely do not find problems in operations area.
Frequency and rigor has not changed even though OPERATIONS was rated Category 3 for last two SALPS. Confirmed by Special inspections Branch (FOSI) inspection.
Page 21 of 41
PLANT ISSUES MATRIX 2N Fermi DATE ID B.
SALP DESCRIPTION CAUSE REF 9/13/1996 Self-Revealed Maintenance inadequate surveillance procedure resuhed b the residual heat removal Inadequate IR 96010.NOV service water pump beining inoperable without operations knowledge.
Proceduselnstr uction 9/10/1996 NRC Maintenance Work activity w as performed outside the 10CFR5039 safety esaluation:
Inadegr.are IR 90007/NOV inspectors identi6cd that safety system service water modification was Osersight performed in manner contrary to the applicable 10 CFR 5039 safety evaluation.
9.9/1996 Self-Revealed Operations Reactor Core Isolation Cooling system rendered inopenible and required inade,r2 ate IR 96007/NOV an entry into Technical SpeciScation LCO actions: Operators failed to Oversight adequately evaluate the consequences of removing the Reactor Core isolation Cooling Barometric Condenser Coraiensate Pump from sersice, which subsequently rendered the Reactor Core Isolation Cooling syster-moperabic and required an entry into Technical SpeciGcation LCO
=
actions.
9:6/1996 Licensee Operations Ventilation damper not rcstored after maintenance due to inadequate inadequate IR 96007AOV restoration procedure-Licensee identified inadequate restoration from Procedure / Instr emergency diesel generator su itchgear room mainter -nce resuhed in a action damper being left in the wrong configuration. This was an additional example of a continuing concern w ith inadequate configuration control on restoration from maintenance activities. INEFFECTIVE COMMUNICATIONS BETWEEN DEPARTMENTS 9'6/1996 Maintenance implementation of F1RST reduced backky (STRENGT1I): Fermi Self-Critical IR 96007' Integrated Resource Support Team (FIRST) implemered cr simple / minor maintenance, initiafly worked oser one-third of new w ork requests. May alkm Maintenance to focus more on signifiant work.
9/1/1996
"** END OF PPR (3% - 9 96)"**
&21/1996 NRC Maintenance Two examples of failure to follow pMmo (8'3N & &21/96): On Personnel IR 06007/NOV A'sgust 21,1996. four scafTolds crected in the Ausiliary Buikling wcre Performance not inspected by a senior reactor operator or reactor operator. On Deficiency August 3,1996, a general supersisor f.miled to initial and date a change in step sequence. a minor revision to Work Instruction.
IMge::vf 41
i 2W#
PLANT ISSUES MATRIX Fermi CAUSE REF DATE ID IW SALP DESCRIPTION 8/15/1996 Self-Revealed Maintenance Response to diesel trip (STRENGT11). Maint nar 2. Engmeermg. an*
Teamwork / Skill IR 96007 Operations respmse to mi emc gency diesel generator trip was pronpt Level and well coordinated. He potential for common mode failure was effectively addressed.
Engineerhig Timeiy and through root cause dt.crmination (STRENGTil): The root Teamworukill IR %006 8/2/1996 cause investigatioa. of the fire in the Reactor Water Clearmy -'ilter Loci Demineralizer control panel was timely aad thorougin. and supported a prompt rcpair and return to service w i;hout ads enely impacting reactor water chemistry.
8/2/1996 Liesnsee Maintenance Coordination prof
- cms during service water outag - A series of general Inadequate IR 96006 sers ice water pump problems resulted in hasing one pump ur.available Oversight or in reduced statas, during most of the inspection period _ Lack of coordination within maintenance and among supporting groups contributed to the extended period this important system was at a reduced capability.
82/1996 Self-Revealed Operations Status of plant equipment was not maintained: Control room operators inadequate IR 96006 and a chemistry technician uere smaware of the abnormal Post Accident Oversight Sampling System lineup when they attempted to draw a sample for the emergency exercise. When flow ould not be established, operaters discos cred that the flow path had been tagged shut for almost 2 months. OPERATOR KNOWLEDGE DEFICIENCY 8C/1996 Operations Use of procedures and good coerdination during sinalator training Teamwork / Ski!!
IR 96006 (STRENGTH): Inspectors observed proper use ofprocedures and Loei emergency declarations, and good coordination and teamwork in the simulator during a training session and the Fermi Emergency Nredness Exercise.
8 2/1996 Self-Revealed Operations Near-miss on entry into required technical specification action Ir: adequate IR 96006 iquament: A near miss occurred en Technical Specification action Osersight statement entry during an Emergency Diesel Generator 12 surveillance.
Lack of attentics to detail and the absence of a pre-job brief contributed to the event. OPERATOR KNOWLEDGE DEFICENCY Page 23 <f 41
PLANT ISSUES MATRIX 2"
Fermi DATE ID BY o
SALP DESCRIPTION CAUSE REF it ET1996 NRC Engineering Overa!1 followup of SWSOP1 %as adequate: NRC followup inspection of Other'NA IR 96006 the licensee-perfo.med Senice Water Sptem Operational Performance inspection found some areas uhich wcre not covered by the licensee team. Iloweser, the NRC identified no additional concems and concluded thr.: the licensee self assessment was adequate.
E'2/1996 Licensee Plant Support Work performed under wrong radiological uork permit Instrumentation Persornel IR 960063CV and Controls workers performed surveillance activities co the scram Performance discharge solume instruments under the wrong Radiation Work Permit.
Defksency and a radiation protection supen isor missed an opportunity to catch the error.
&Tl996 Licensee Plant Support Violation of radiological controls: Two imtances were identified where Personnel IR,0006%CV personnel ner. to the site violated site radiological controls. While the Performance consequences of the events w ere minor, the adequacy of radiation Deficiency worker training was of concern.
8/2/1990 Plant Support Emergency preparedness exercise sery good (STRENGT11): Osera!.I Teamwcrk.3 kill IR 96006 performance durmg the 1996 emergency preparedness exercise was serv Loei good and as indicated by the following obsenations. Emergency classifications and notifications to ofTsite authorities were made in a timely manner. Technical Support Center sta!Trapidly oaluated plant conditions and made appropriate emergency classifications. Command and control and ofTsite communications were sery good in the Emergency Operations Facility.
8/2/19o6 NRC Maintenance Preparation and execution of work during maintenance outages declinett Inadequate IR 96006 Problems wcre identified in timely assignment of outage managers, parts Oversight availability, and coordination between organizations. As and example, restoration from liigh Pressure Coolant Injection (IIPCI) motor operated valve testing resulted in a delay in retuming IIPCI back to senice. Two bolts =cre not installed on the vahe actuator coser housing. This j
required the valve actuator to be disassembled to check for damage and to restore the actuator to a normal operation.
(
l' age 24 of 41
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- N PLANT ISSUES MATRIX T
Fermi ph t
11 ATE ID BY SALP DESCRIPTION CAUSE REF S'I/1996 Pint Suppert OtherNA
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S'I!!996 NRC Maintenance Failure to follow precedure: A Temporary Plant Space Request was not Perwe nel IR 46006%OV ini:iated for equipment w hich w ere not scismica!!y restrained in the Perfemance Divhion 11 Battery Room. located in the Ausiliary fluildmg.
Deficiency 7,29/1996 NRC Engineering Inadequate correctise actions: A drain line fm the Dhiskm I safety inadequate IR 9%%KOV related service w ater common return !me to the mechanical draft cocimg Osersight towers was found by the inspectors to be partially plugged fa the second time in four months. Correcthe actiens for Viobtnm 34I Wol-03 failed to identify this repeat occurrence.
7/19'1996 Self-Rescaled Maintenance llPCI suction sahes su itched frorn Condensate Storage Tank to Torus -
Personnel IR 96006' ENS 30767/
ESF Actuation: Technicians inadsertent!) caused actuathm ahile Pe-formance LER 96010 performing unrelated surs eillance in cabinet.
Deficiency 7/II/1996 NRC Operatiers inadequate operating procedure: Inspectors identified an esample of an inadequate IR 96006%OV inadequate system operating procedure for Residual IIcat Remosal Procedure. Instr Service Water in that a!! system sahes were not included in the system uction lineup.
f>CS?! 996 NRC Engineering Weak plant engineering surport contributed to management deciskm.
Inadequate IR 96005 making without all the necessary infirmat;on: This resulted in control Os ersight room operators and operatkms management not being aware of the efTect of filter clogging in the reactor water lesel instrument reference Icg backfill system. NRC identification of this situation resulted in prompt correcth e action.
628!!996 Engineering Site engineers and licensing staff demonstrated a good questioning Teamwork,3 kill IR 96005 attitude in identifying an existing dhishmal separation Appendh R issue Level (STR2NGT11): This issue identified a postulated fire that could affect both disiskms of safety-related air systems.
l' age 25 of 41 E_
a PLANT ISSUES MATRIX Na#
Fermi 2
DATE ID BY SALP DESCRIPTION CAUSE REF t
6 28/1996 NRC Engineering inadequate engineermg support of teming: Lack of system engineenng Inadequate IR 96005 experience and an inadequate procedure complicated testing of the Osersight CCliVAC Emergency Makeup Filter folkming filter sampling. This resulted in the plant being within 12 minutes of a Technical Specification required shutdown.
6/28/1996 Licensee Engineering Missed surseillance due to document control: The document changes Inadequate IR 96005 and temporary modification necessary to permit performance of an 18 Osersight month inspection of the diesel fire pump with the plant at power were uncoordinated. This resulted in exceeding the periodicity of the sun ei!!ance. The end product of the temporary modification was good following correction ofinitial inadequacies.
6/28/1996 Engineering System startup testing for the flydrogen Water Chemistry System was Other/NA IR 96005 performed in a coordinated. deliberate manner (STRENGTil):
6.28'1996 Plant Support Radiation protection (RP) and chemistry support for IIWC wstem Teamwork / Skill IR 96005 testing. and RP support of maintenance on a contam' ated pump were Level m
obsen ed to be very efTectise (STRENGT11):
628/1996 NRC Operatiens inadequate procedure resiews failed to identify that the al wrmal Inadequate IR 96005
., operating procedure for restoration ofControl Center lleating.
Procedure / Instr Ventilation and Air Conditioning (CCl!VAC) on a loss of air could not action be performed. Once deficiencies were identified. operations 3 as slow to a
communicate the problems to management This procedure was being relied upon to mitigate the effects of a licensee identified Appendix R issue.
6?I4/1996 NRC Maintenance Improvements in material conditior:: Plant material condition, which Teamwork / Skill IR 96006 w as previously an operator distraction, i= prosed during the force outage Level in March. Control Rod position IndicatLm Prope issue was one of the major problems that were eliminated.
Page 26 of M
o t
PLANT ISSUES MATRIX 28*'-'7 Fermi DATE ID BY SALP DESCRIPTION CAUSE REF 6/12!I996 NRC
, Operations RCIC pump was inadvertently operated without a discharge flow prJr Personnel IR 96004'NCV This was due to operators not promptly recogninn; the failure of the Performance system minimum flow valve to open. Operators allowed the RCIC pump Defriency to run against dead-head for about 9 minutes. The minimum flow vahe did not open because of a failed opening coil. OPERATOR KNOWLEDGE DEFICENCY 6'10/1996 Licensee Operations West Circulating Water Reservoir Decanting (C%RD) Pump Run Personnel IR 96004'IR 96005 Without Discharge Flow Path: A non-licensed opera:or identified that the Performance West CWRD Pump was running with the Defeiency discharge valve closed. The West CWRD Pump was started by another non-licensed operator in accordance with procedures but did not open the pump discharge sahe. The pump was left running at shut-o:f head for approximately two hours. Though the potential for pump damage existed, no pump damage was noted. OPERATOR KNOWLEDGE DEFICENCY 6/7/1996 NRC Maintenance Diesel Fire Pur p (Di P) Work Performed Without Meeting Required Inadequate IR 96005SCV Plant Conditions: On June 7. maintenance personnel signed on to Job Oversight FP87960412 to perform an 18-Month sunciliance inspection of the Fermi 2 DFP. Thejob paperwork had a note that stated "This test should be performed ahile the plant is shutdown - per UFSAR (Updated Final Safety Analysis Report)." The copy of the surveillance procedure used to start work, 34.501.002, " Fire Pump (Diesel) Inspection,' Revision 27, listed required plant conditions as " Plant cold (Mode 4 or S L" The inspectors reviewed the requirements of the UFSAR and found that Section 9A.6 ' 7 ' c required that the inspection be perfonned during a plant shutdown.The mspectors further determined that Licensing Change Request (LCR) 95-0-99-UFS had been approved to permit erformance on line, and that Res ision 28 to the surveillance procedure was issued on
~
June 3 to support on line performance. Operating shift personnel had reviewed the revised procedure and concluded the nerk was permitted w hi!e operating. but did not notice the copy actually signed on was the previous revision (Ret.ision 27). that required the plant to be shutdown.
Page27of 41
o PLANT ISSUES MATRIX 2N Fermi DATE ID BY SALP DESCRIPTION CAUSE REF 5/28/1996 NRC Maintenance Problems with scheduling and work control during maintenance outage Inadequate IR 96001%CV on CCilVAC: Preparations for this system outage dx! not adequately Oversight prepare for contingencies. Despite a recer t history of damper boot seal failures and scheduled work on a number of the damper actuators, no spare seals were available. System engineers imohed in the test had no experience with the emergency makeup filta test. DifTwulties =ith that test due to an ' adequate procedure nearly resulted in a plant sc.am to m
comply with required TS actions because the procedure w as inadequate.
The major equipment problems experienced in this outage were probably caused by a combination of the maintenance personnel performing the work and the age of the inflatable seal, which were not replaced penodically and uere likely original equipment.
5/25/1996 Licensee Maintenance ESF Actuation due to personnel error and maintenance-A Technician Personnel IR 46004' LER 96009' inadvertently cracked the indicating lamp socket dunng maintenance.
Performance ENS 30545 Later an auxiliry operator disemered the power ready light for Dnision Deficiency 2 Torus Water Management System (TWMS) local panel uas broken.
While attempting to imestigate the broken socket, an auxiliary operator caused a short circuit that resulted in an ESF actuation of the TWMS isolation vahes.
$!!6/1996 NRC Operations inspector identified deficiencies =ith abnormal operating procedure:
Inadequate IR 96004%CV Several ventilation dampers were found in configurations that did not Procedure 1nstr agree with AOP 20.413.01 Rev 12 fix uction CCIIVAC.
5/15/1996 Operations Operators demonstrated good command and control during performance Teamwork / Skill IR 96044 of a plant shutdown and startup (STRENGT!!): During startup on 422.
Lesel operator performance in conducting activities uas gad esen though the operators were challenged by equipment problems.
Page 28 ef 41 a
PLANT ISSUES MATRIX 28J"'#
Fermi DATE ID BY SALP DESCRIPTION CAUSE REF Sil5/1996 NRC Maintenance Four exampics ofinadequate Foreign Material Exclusion: licensee OtherHA IR 96004 discosered a piece of n ire lodged near the disc and seat of Safety Relief Valve Vacuum Breaker (305) durmg Disision 2 EECW lleat Exchanger cleaning. the licensee identified a w ad of fibrous material stuck to the tube sheet on the emergency equipment service water side of the heat exchanger (4/1) during disassembly of the North Feedwater IIcater Drain Valve, the licensee identified that foreign material (a 2-1/2" long threaded stud and a 1/2" pin) acre found inside the valve h4 (4'2) during NRC walkdown of the RllR complex. a plastic bottle and a piece of wood were found floating in the Division 2 Ultimate flest Sink Reservoir. In addition, numerous grating clamps were found missing or broken. Some of the missing clamps most likely had fallen into the resersoir. Inside the pump rooms,tu o floor penetrations were not cos cred, allow ing the possibility for debris to fa!! into the resenoir (5/2) 5/15/1996 NRC Operations Four examp!es of inadequate operator performance invohing inadequate Personnel IR 9600430V procedure compliance-This is a continuing concern. During per'ormance Performance of Emergency Diesel Generator (EDG) 14 surveillance testing, an Deficiency operator opened a disconnect and electncians installed aje:r per on the wrong metercontrol center cabinet position (3GO) while cross-t>ing divisions of the non-interruptible instrument air system (NIAS),
operators failed to open the NIAS Division I and Division 2 Cross Tm Isolation Valve (4G) during the Division i EECW surveinance test, the EECW pump did not start and received a tripped indication. Licensee investigation rescaled that the breaker charging spring toggle switch was in "off,* which prevented the charging spring from being recharged following the presious operation (4/11) w hile performing a licensed operator walkdown of the Control Rod Drive (CRD)11 draulic Control 3
Units (IICUs) following maintenance activities. the Charging Water Isolation Valve (C11-FI 13) for IICU 38-51 w as found closed w hen required to be opert Page 29 of 41
PLANT ISSUES MATRIX 23J=I#
Fermi DATE ID IW SALP DESCRIPTION CAUSE REF 5/I3/1996 Engineering Site engineers and licensing stafIdemonstrated a good questioning Consenative IR 960041.ER 96001TNS attitude in identifying an existing divisional separation Appendix R issue Decision 3G161 (STRENGTII): A condition was identified where inadequate separation of Division I and 2 NIAS control circuits existed. As a result, the potential existed for both disisions of NIAS to be afTected by a fire near the Dis ision 2 compressor. The licensee took prompt corrective actions.
5/2/1996 NRC Engineering Failure to identify cause: On February 23.1995. a flow reduction inadequate IR 96004NOV occurred in the Division 11 Residual llear Remm al Senice Water.
Osersight Emergency Equipment Sersice Water. and Emergency Diesel Generator 93 Senice Water systems, w hich was a significant condition adverse to
- 1uality, and as of May 2.1996. the licensee failed to identify the cause for the condition.
4/19/1996 NRC Operations Problems during Startup: Seseral personnel errors occurred during the uartup from the force outage due to the service watermakeup tank design problem. these included Residual heat remmal sesice water system waterhammer (4115), and mispositioned hydrualic contol unit charging water isolation valve (4'16) 4/19/1996 NRC Engineering Problenis during Startup: Ses eral personnel errors occurred during the nartup from the force outage due to the senice watermakeup tank design problem. these included Residual heat removal sesice water system waterhammer(4/15), seismic monitoring system suneillance testing requirements not being verified (4 17) reactor water cleanup sy stem anple sink gauge glass rupture that resulte din contamination (4fl8).
5 and the general approach to performing the makeup tank modification 6 developed as the outage proressed without adequare pre-planning).
4/19/1996 NRC Maintenance Problems during Startup: Sescral personnel errors occurred during the startup from the force outage due to the service watermakeup tank design problem. these included near miss on perfrorming post maintenance testing (friction testing) on control rod dris es (4/16). seismic monitoring sprem sunei!!ance testing recuirements not being serified (4e 17). and the general approach to performing the makeup tank modification (developed as the outage proressed without adequate pre-planning) l' age 30 of 41
PLANT ISSUES MATRIX W"'#
Fermi DATE ID HY SALP DESCRIITION CAUSE REF 4/18/1996 Self-Revealed Engineering Repeated Failure of Pnmary Coolant Sample Flow Gage Glass: During a Engineering 1)e IR 96004 tlant pressure increase as part of plant startup on April 18, the flow gage sign Deficiency glass associated w ith Reactor Recirculation Loop B ruptured and caused a spill w hile the sample point was in service. The same flow glass had
^
-: racked and leaked on August 1,1995.as documented in Inspection Report 95009. That failure occurred while placing the sample point in mersice, and had been attributed to age or material defect.
4/10!!996 Self-Revea! d Operations Water llammer Occurred in the Emigg Equipment Cooling Water Inadequate IR 96004 System (EECW): On April 10, following modifications to Division I of Procedurcilnstr die EECW system and heat exchanger cleaning. the system was started uction ibr testing. A water hammer esent u as witnessed by operators and engineers p esent. Engineering w afled down the portion of the system and found no problems. The licensee determined that no fill and vent of 1he system was performed, contributing to the occurrence of this water hammer event. No previous occurrence of water hammer in this system was identified by the licensee.
4/4/1996 Plant Support Low collective dose and good rad worker practices.
Invohed IR 46002 IR96006 Stanagement 4!4/I996 NRC Plant Support Decreased Dryw ell dose rates. Radiation detection instrumentation Invohed IR 96002 IR 96006 maintained in exceelent condition and cahbrated. Personnel proficient hianagement m use of detection instrumentation. Atanagement osersight of radioactive material was effective as demonstrated by lack of errers in shipments.
4/3/1996 SALP 15 ENDS u.....n..
4/2/1996 Licensee Alaintenance Bolts Looced during Niaintenance on Wrong Control Rod Dris e Personnel IR 96004SCV P.techanism (CRDAT): contract worLers u ere under the reactor vessel Performance preparing CRDSt 30-51 for removal w hen they identified that they had Deficiency loosened 6 of the 8 bolts on the wrong CRDNt (34-51).
l' age 31 of 4i
PLANT ISSUES MATRIX W=I-97 Fermi DE5 CRIPTION CAUSE REF DATE ID BY SALP 3
4C/1996 Licensee Engineering The licensee also identified a crack on the No. 211igh Pressure Control EngineeringDe IR 96003 Valve spring-can housing: The crack was due to =ibration between the sign Deficiency
! turbine stop and control valves. Presious reports (IR 9(402 and 95012)
- identified other cracks due to turbine stop & control vahe s ibration. The crack did not impact the operability of the spring-can support. The i occurrence of this and the previous failures continue to be of concern.
4/2/1996 NRC Operations
! Blocked Drain Lines to Mechanical Draft Cooling towers (MDCT): drain IR 06003 Ines for the combined Residual IIcat Removal service water return to the
- MDCT were found to be blocked by corrosion and debris buildup. This Ihas a impact on the MDCTs to function during extreme w inter conditins land may have been frozen w hen the diesel renerator service water Ipumps were inoperable due to frozen intakes (see entry on 2 '696) 3f28'1996
!SMM SCREENING MEETING 3 0 7/1996 Licensee Engineering iLicensee identified that the emergency equipment cooling water system Engineering De 50.72 0 0179) imakeup tanks wou'd not meet their design criteria during either an sign Deficiency saccident or seismic event. Licensee entered TS 3.0.3 and shutdown to icold shutdow n.
3/27/1996 Licensee Operations Torus sample w as missed: The torus w as vented before the required Inadequate IR 96003 isample was taken.
Oversight 3/27<!996 Operations 60perators performed a plant shutdown following identification of EECW Teamwork / Ski!!
IR9U03 Klesign deficiencies without problems (STRENGTil): The operators Level tperformed the shutdown methodically and per plant procedures. AI!
- activities were well-coordinated and expected plant response to equipment manipulation was properly anticipated. The nuclear shift isrepervisor and nuclear assistant shift supenisor provided excellent oversight of the evolution.
3/l8/1996 Licensee Mamtenance iTesting of the 12 Emergency Diesel Generator resulted in a plant LER 9c003 rondition outside of design basis.
3/IS/1996 Licensee Engineering fresting of the 12 Emergency Diesel Generator resulted in a plant LER 96003 condition outside of design basis.
l l' age 32 of Al
O
'Wul-9
PLANT ISSUES MATRIX Fermi y '
.~,1 ~;
DESCRIPTION CAUSE REF DATE ID BY SALP 6WN
(
identified. Inappropriate Certification of Quahty inadequate IR 96001'NOV 3/10'19 %
NRC Plant Suppon IN R(.
!Controi(QC) Inspecter-On June 29.1944. Detroit Edisen certified as a Oversight
! Level Ill QC Inspector, an indis idual w ith an aswciate degree who had liess than sesen years of related experience in the areas of polymer.
- metal, and electrical testing. The licenwe's initial investigatism of an iinternal concern w as inadequate.
3/10/1996 NRC Maintenance
! Material condition of balance of plant continues to distract onwators:
Equipment IR 96002 Several systems are distractions to the operators. rod position Malfunction iindications (rod drift alarms) turbine building s entilation (fans -
repeated failures) main steam line vibration (supports and subsystems llines cracking and fatigue).
3!I0!!996 1.icensee Engineering IUFSAR Disagreement tSTRENGT1I): Table 9.2-3 and section 9.2.2.2 of Other'NA IR 96001'IR 95009 the UFSAR. listed the maximum flow rate through the shell side of the IEESW/EECW heat exchanger as 1450 gpm As documented in linspection Report 34iN5009. routine surseillance runs used a flow rate of 1670 gpm. The licensee w as in the process of determining correctis e actions.
3/9/1996 License Engineering UFSAR Disagreement (STRENGTII) Section 1L3.1.5.1 of the UFSAR.
Other/NA IR 96002 istated that safety equipment cabling was color coded orange for Disision 11 and blue for Division 2, w hile BOP cabling was black, or magenta in a few cases Iloweser. during ronstructior, extra dis isional color coded cabling was used to complete BOP electrical distributi(m.
1%ge 33 of tI
PLANT ISSUES MATRIX N"I#
Fermi f
DATE ID BY SALP DESCRIPTION CAUSE
!i REI' 3/9/1996 1.icensee Engineering IUFSAR Disagreement (STRENGTil): Section I 1.5 of the UFSAR, Other/NA IR 96002 estated that the " heart of the permanent Fermi 2 solid radwaste system is Ithe radwaste volume reduction and solidification system," and that a tvendor system is to be used when the asphalt system (above) is not sworking or at plant management discretien. Section 11.5 documented Ithe various elements of that system including the asphalt system, esaporator, etc. Iloweser, the permanent system was not the primary tsystem and has not been used for several years. The sendw sy stem, rwhich was also described in this section, had been used exclusively. De IUFSAR also stated that two freon dry-cleaning units are used for cleaning contaminated laundry. lionever, the license used an offsite wendor facility for this purpose.
I 3/3/lo96 NRC Maintenance
!Two events occurred due to equipment being unexpectedly alTected by Personnel IR 960i12 anaintenance activities: On March 4, uork on a local switch enclosure Performance Ifor the EDG 1 I starting air compressor caused a short. De sheet Deficiency j
resulted in a blown control power fuse and an EDG 1I starting air receiver tank low pressure alarm. Foilowing the alarm, the air start header was cross-tied to EDG 12 air header. He blown fuse was identified and replaced. He starting air receisers were promptly restored to normal. On March 8, inspectors identified that the drain salve for the EDG 11 Engine Drisen Air Coolant Pump was open. De valve should have been shut to prevent draining of thejacket water expansion tank. As previously documented in Inspection Report (IR) 96002. a similar valve on EDG 14 was found out of position open on February 26, 5996. He licensee determined that the vahe was most likely inadvertently bumped opened due to unrelated maintenance near the valve.
3/7/1996 Licensee Operations Emergency Diesel Generator i I was inoperable due to degraded fuel oil.
Other/NA IR 960031ER An extension of technical specifications was granted (NOED) to a!!ow 96004/IOCFR 50.72 continued operations while fuel oil was replaced.
3rl'1996 Self-Revealed Engineering Rod Positica Indication Continue to be Problem: Excessive control rod Equipment IR 96002 IR 95012 IR drive drift alarms and loss of notch position indication. Caused by Malfunction 95009 IR 95004 control rod position indication probe cable' connector problems.
Page 34 of 41
_.c
-PLANT ISSUES MATRIX N=I-97 Fermi DATE ID IW SALP DESCRII' TION CAUSE REF 3/7/1996 Licensee Operations ilnadvertent actuation of Drywell-to-Torus vacuum breaker due to PersonncI LER 96002 operator error.
Performance Deficiency 3/1/1996
~"a"**
.a u.*****
....... ~..
....... ~..
END OF PPR (935 - 3S6) 2/23/1996 Self-Revealed Operations EDG 14 retumed to stand-by without the starting air being lined up.
Personnel IR 96002 Performance Deficiency 2/16/1996 Self-Revealed Engineering Continued problems with reactor building VAC. Fr quent trips and EngineermgDe IR 96002 temperature control problems.
sign Deficiency 2/I4/1996 NRC Operations
<fnadequate Procedures: Operating procedures afTecting the Residaal Inadequate IR 96002/NOV ileat Removal system wcre found to contain incorrect serpoints.
Procedure / instr Utanges due to system modifications were not incorporated into uction operating procedures.
2/12/1996 NRC Maintenance inadequate Work Control: Work Request was inadequate in that it failed Personnel IR 96002%OV so ensure that the Combustion Turbine Generator Unit I l-I was returned Performance ao service with its battery in an Deficiency acceptable state of charge.
2/12/1996 Licensee Engineering Survei!!ance Test'ng was Outside of Design Basis (STRENGTU):
EngineeringDe IR 96002/LEP 06003 Licensee determine that during past performance of Bus 64C sign Deficiency tandervoltage protection sursei!!ances, that the plant was outside the design basis. While in " test," the automatic transfer af swing bus 72CF would not occur. This affected i ow Pressure Core hnjection vahes. Engineering performed a prompt and thorough review of this condition.
2/7/1996 Self-Revealed Operations Personnel Error Cause Vacuum Breaker Actuation: An operator failed to Personnel IR 96002/NOV implement System Ope ating Procedure 23109 Section 5.0, Ready Performance Mode, Note (2), in that the division I thermal recombiner suction was Deficiency lined up to the drywcil and torus simultaneously in a non-cmergency situation. This resulted in the actuation of the Containment Vacuum Ilreaker.
l' axe 35 of 41
'.L PLANT ISSUES MATRIX -
2
- 97 Fermi DATE ID BY SALP DESCRIPTION CAUSE REF
'2/6/1996 Self-Revealed Operations ad Division I & II Emergency Diesel Generator Serde Water systems Enginecrmg'De IR 9600Zt$0.7?l.ER
,potentially inoperable due te icing of pumps "B" & "C" discharges.
sign Deficiency 9600I
! Licensee did not recognize the poter :ial for common mode failure.
2/6/1996 NRC Operations Both Di.ision I & !! Emergency Diesel Generator Sersice Water systems EngineeringDe IR 9600230.72 LER potenti2!!y inoperable due to icing of pumps "B" & "C" discharges.
sign Deficiency 96001 Licensee did not recognire the potential for common mode failure.
I/31/1996 Self-Revested Ataintenance Repeat Work-Repeat gasket failure on waste :ohection filter resulted in Personnel IR 96002/lR 95014 spills of 2000 and 6000 gals.
Performance Deficiency I/23/1996 Licensee Alaintenance inadequate surve21ance procedure resulted in the Ultima:e ifeat Sink Inadequate IR 96002 being isolated fer a brief period. Inadequate sys:em knowledge Procedure 1nstr contribated.
uction I/10/1996 NRC Plant Support Post accident sampling sy stem was poorly maintained.
Inadequate IR 95014 Oversight I!!0/1996 NRC Plant Support Chemistry department's correctise actions to QA findings w ere narrowly inadequate IR 95014 focussed and did not resolve identified problems.
Oversight 1/9/1996 Self-Revealed Staintenance Alaintenance personnel worked on Div I & 11 mechanical draft coolmg Personnel IR 96002 towers at same time without authorization.
Performance Deficiency I/l/1996 Self-Revealed Alaintenance Repeated cooling tower desce sprem failures. Failures resulted in Engineering'De IR 96002 operator distractions.
sign Deficiency 12/29/1995 Self-Revealed Operations Wrong lube oil was added to RCIC pump during presentive maintenance.
PersorncI IR 95014 Performance Deficiency 12/29/1995 NRC hiaintenance Wrong tube oil was added to RCIC pump during presentive maint nance.
Personnel IR 950!4 Performance Deficiency hrge 36 of 41
1
.o i
e PLANT ISSUES MATRIX Wal-97 Fermi 4
I
- j SALP DESCRIPTION CAUSE REF l
DATE ID BY 12/2I/1995 Self-Rescaled Operations initiation of CO2 in Battery Charger room. Operators bagged CO2 Personnel IR 95014'60.72 detectors. (Turbine and Aux BLDGs wcre evacuated and the residents Performance j
w ere not informed).
Deficiency 12/21/1995 Self-Revealed Maintenance initiation of CO2 in Battery Charger room. Operators begged CO2 Personnel IR 95014i30.72 detectors. (Turbine and Aus BLDGs v ere evacuated and the residents Performance were not informed).
Deficiency 12/13/1995 Licensee Engineering STRENGTil:
Teamwork / Skill LER 95008 Engineering discovered a nonconserva4ise ommission in the heat balance Level calulations for core thermal power. Control rod drive flow was not included. Error created about i MWt. Licensefs resicw of power histroy indicated that limits wcre not exceeded during current cycle _
llowever, licensed limit could has e been exceed on one or more occassions during previous 3 cy cles.
12/13/1995 NRC Plant Support Radiation postings uere inadequate to indicate actual conditions in the Inadequate IR 95014 heater rooms (si ns and ropes not rehung).
Procedure 1nstr g
uction a
12/12/1995 Licensee Operations STRENGTil:
TeamworL/ Skill IR 96002tlR 95012 Good control of work activities involving reactce m ater cleanup sstem Lesel repairs.
12/12/1995 Licensee Maintenance STRENGTil:
Teammork/ Skill IR 9600211R 95012 Good control of work actis ities involving reactor water cleanup sstem Level repairs.
12/12/1995 NRC Operations QA and ISEG osersight of operations was w eait Exarr:ples included the Inadequate IR 95012 improper testing that rendered the battery inoperable and the failure to Osersight recognin the emergency desel generator inoperability.
12/11/1995' Self-Rescaled Operations South East Generator 11 drogen cooler leak. General setsice wate was Equipment IR 95014 3
isolated and Generator returned in degraded condition. Work Malfunction coordination was good and repairs uere prornpt l' age 37 of 41
~
PLANT ISSUES MATRIX 23Ja*
Fermi DATE ID BY SALP DESCRIPTION CAUSE REF 12/1I/1995 Self-Revealed Maintenance South East Generator flydrogen cooler leak. General sersice water was Equipment IR 95014 isolated and Generator returned in degraded condition. Work Malfunction coordination was good and repairs were prompt.
12/10/1995 NRC Maintenance Main steam line hanger found broken and not supporting pipe run.
Equipment IR 950I4 Malfunction 12/5/1995 Self-Revealed Operations Unexpected auto start of Div I control air compressor due to incorrect PersonncI 1R 95014 tagout lineup being performed. (repeat problem)
Performance Deficiency 12/1/1995 Licensee Engineering Several temporary modification implementation errors during installation Persormel IR 95014 of alternate air system.
Performance Defic ency 12/I/1995 Licensee Engineering Inadequate coordination between departments resu.%f in problems and inadequa*e iR 46002 delays during Circulating Water Pmp No. 5 modificadoru (This is an Osersight example oflack of coordination between dywL~d, impacting implementation of modificatens, this is a long standing Engineering support problem.)
12/l!!995 NRC Engineering Several temporary modification implementation errors during instaffation PersonncI IR 95014 of attemate air system Performance Deficiency 12/1/1995 NRC Maintenance Inadequate coordmation between den =nments resulted in problems and Inadequate IR 96002 delays during Circulating Water iamp No. 5 modification. (This is an Osersight example oflack ofcoordination betw een departments impacting implementation of modifications. this is a long standing Engineering support problem.)
12/1/1995 NRC Engineering Degraded material condition of station blackout turbine generator (CTG-Inadequate IR 95012'JR 950II Il-1). Licensee to refurbish unit in 4S6 Osersight II/26/1995 Seif-Rescaled Maintenance Repeat gasket failure on waste collection filter resulted in spills of 2000 Inadequate IR 96002'IR 95014 and 6000 gals.
Oversight Page 38 cf 41 s
f
.~.
PLANT ISSUES MATRIX M"'-'7 Fermi DATE ID BY SALI' DESCRIPTION CAUSE REF i1/!6/1995 NRC Maintenance Safety related station battery had excessive corrosion. One cell required Inadequate IR 95012'NOV removal and cleaning of a terminal post. Battery seismic storap racks Oversight wcre also degrading.
I1/16/1995 NRC Engineering Safety related station battery had excessise corrosion. One cell required Inadequate IR 95012WOV removal and cleaning of a terminal post. Battery seismic storage racks Oversight were also degrading.
10'23/1995 Self-Rescaled Maintenance During presentive maintenance to the Disision 2 control room IIVAC Personnel IR 95032 system, an electrician improperly connected the test leads resuhing in Performance damage to the ground fault circuit.
Deficiency 10/20/1995 Self-Revealed Operations Small reactor fuel leak identified and prompt actions were taken Equipment IR 95012 including reducing power. Testing confirmed a leak on the core Malfunction periphery. Dree control rods were inserted to suppress pow er and limit release rate from the leak.
10/20/1995 Selt-Revealed Engineering Small reactor fuel leak identified and prompt actions were taken Equipment IR 95012 including reducing power. Testing cenfirmed a leak on the core Malfunction periphery. Hree control rods wcre inserted to suppress power and limit release rate from the leak.
10/19/1995 NRC Operations Argon was used to fill hydraulic contol unit accumulators for 10 weeks Personnel IR 950121NOV i7 stead of Nitrogen required by procedure.
Performance Deficiency 10/11/1995 NRC Plant Support Be need for increased security followup and oversight of securny Inadequate IR 9501I contingency training because of training delays caused by the extended Oversight outage for turbine repair. His is a long term issue that has not been resolved.
10'4/1995 Self-Revealed Engineering Supply line to number 8 turbine bearing desekred a crack at a weld for Equipment IR 95012 a suppon lug. He cauw of the crack related to turbine sibration. A Malfunction series of repairs were made to reduce vibration of the pipe.
10/3/1995 NRC Maintenance Battery & Charger unintentionally made inoperable due to installation of Personnel IR 95012'SL lli test load.
Performance Deficiency Page 39 of 41
. ~
PLANT ISSUES MATRIX N"I#
Fermi DATE ID BY SALP DESCRIITION CAljSE REF 7,
10/3/1995 NRC Operations Battery & Charger unintentiona!!y made inoperable due to installation of Persor*nel IR 95012tSL 111 test load.
Performance Deficency 9 75/1995 Self-Revealed Plant Support Two occurrences ofinadequate compensatory actions. On 9/2195. a Personnel IR 9501373.71 vital area door failed to alarm w hen thumblocked open. Compensatory Perfonnance action was taken but later removed and the associated security card Deficiency reader w as disabled. Upon review by security supenision, it w<s determined that disabling the card reader was not a proper compensatory measure. Appropriate compensatory measures wcre restored. On 929/95, a similar esent occurred.
9 02/1995 Self-Revealed Mainte ance Operators failed to recognize that Core Spray was inoperable during a Personnel IR 95012 surveillance resulting in not entering the TS LCO. TS Requirements Performance were not violated.
Deficiency 9.22/1995 Self-Revealed Operations Operators failed to recognize that Core Spray was inoperable during a Personnel IR 95012 surveillance resulting in not entering the TS LCO. TS Requirements Perfamance were not violated.
Deficiency 9/20!!995 NRC Engineering EDG I I was made ineperable by a worker accidentally bumping a Personnel IR 95012 switch. Operations did not recognize inop condition due to inadequate Perfonnance procedures and ineffective communications between departments.
Deficiency 9 7 0/1995 Self-Revealed Operations EDG I I w as made inoperable by a worker accidentally bumping a Personnel IR 95012 switch. Operations did not recognize inop condition due to inadequate Performance procedures and ineffective communications betw een departments.
Deficiency 9/19/1995 NRC Plant Support liigh failure rate of emergency lights.
Inadequate IR 95009' NOV Oversight 9/19/1995 NRC Maintenance fligh failure rate of emergency lights.
Inadequate IR 95009;NOV Oversight 9/7/1995 NRC Operations Degrading material condition of General Sen ice Water System. Ses eral Equipment IR 95012'IR 9501 tilR cracks and through-wall holes found in General Sen ice Water piping.
Malfunction 95009 9/7/1995 NRC Engineering Degrading material condition of General Sen ice Water System. Several Equipment IR 95012ilR 9501l'IR cracks and through-wall holes found in General Sen ice Water piping.
Malfunction 95009 l' age 40 <f 41
,s.
PLANT ISSUES MATRIX 28~'"'-9 7 Fermi DATE IDIlY SALF DESCRIPTION CAUSE REF 6!!/1995 Self-Revealed Engineering from 635 to present excessise control rod drhe drift alarms and loss of EngineeringDe IR 96002ilR 95012'IR notch position indication. Caused by control rod position indication sign Deficiency 95009 !R 95004 probe cable' connector problems.
6/1/1995 Self-Revealed Maintenance From 685 to present, excesshe control rod drise drift alarms and loss of EngineeringDe IR 96002'.IR 95012'IR notch position indication. Caused by control rod position indication sign Deficiency 95009 IR 95004 probe cable' connecter problems.
l' age 41qf41