ML20213G179
| ML20213G179 | |
| Person / Time | |
|---|---|
| Site: | Fermi  |
| Issue date: | 11/01/1986 |
| From: | Sylvia B DETROIT EDISON CO. |
| To: | James Keppler NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| References | |
| GP-86-0008, GP-86-8, NUDOCS 8611170359 | |
| Download: ML20213G179 (2) | |
Text
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WM Nonh Dwe Higtnay ale n se.non. u.cnigan 48 tes November 1, 1986 I I p oise6-4ts GP-86-0008 FRIORITY E00TI M frit ipCIJL Lic Mr. James G. Keppler 6 -t
[,3 Regional Administrator Region III g((
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U.
S. Nuclear Regulatory Commission D
799 Roosevelt Road FILE,geg Glen Ellyn, Illinois 60137
Dear Mr. Keppler:
Reference:
Fermi 2 NRC Docket No. 50-341 Facility Operating License No. NPF-43
Subject:
Control Rod Manipulation Errors Since the plant startup in August 1986, we have experienced three instances of control rod manipulation errors.
While none of these individual instances have posed any threat to reactor safety, we appreciate the significance of such events. and have treated them as though they were reportable.
These events indicate that errors are being repeated and that enhancements to our earlier corrective actions are needed.
Although the errors were not significant from a technical perspective, we are nevertheless seriously concerned with the human performance considerations involved.
In each case the manipulation error was immediately recognized and corrected, and the shift supervisor notified.
Before proceeding, concurrence was received from Reactor Engineering that there was neither a reactor safety nor a technical concern as a result of the manipulation errors.
The corrective actions put in place by the Reactor Operations Improvement Program (ROIP) have been effective and we plan to continue this program.
In addition, we are taking the following immediate corrective actions to minimize the opportunity for these types of errors to reoccur:
1.
Starting with the evening shift on October 31, 1986, a verification process was initiated for each control rod moved in which the selected rod is verified to conform to the rod pull sheet by two separate individuals.
Confirmation of correct control rod selection is based on observation of the select matrix display, full core display, or process computer CRT display.
Only after confirmation by the two individuals will the reactor operator move the control rod, except in " emergency" conditions.
8611170359 861101 g
gDR ADOCK 05000341 NOV 6 m l
Mr. Jcans G. K0ppler November 1, 1986 GP-86-0008 Page 2 e
2.
A formalized routine will be developed to execute rod movements.
This routine will incorporate a formal format for reading the rod sequence sheet, selecting a rod, confirming rod selection, moving the rod, confirming proper rod motion and documenting rod position.
Each reactor operator will be trained to use this routine as a pattern for all subsequent rod manipulations.
Furthermore, the rod pull sheets will again be revised to incorporate modifications that make the sheets easier for the operator to read, verify and document rod movement.
These improvements will be implemented within two weeks to allow time for observations to be made on the simulator relative to these changes.
At my request INPO has agreed to send a team to Fermi 2 during the week of November 10 to evaluate these events using their Human Performance Evaluation Process.
In addition, the Plant Manager has directed that a parallel evalaation be conducted using internal resources.
The results of these reviews will be closely coordinated by the Director, Operator Training so that the recommendations can be incorporated Into the appropriate plant procedures and training programs.
These actions were discussed with Messrs. Greenman and Guldemond of your staff on October 31, 1986.
This letter confirms the results of that discussion.
We want to make it clear that we take any failure to follow procedures very seriously, even when they pose no threat to the health and safety of the public or employees.
That is why we have vigorously and quickly implemented the above corrective actions.
We will continue to observe Control Room operations and implement improvements, as appropriate.
While any human endeavor is susceptible to error, our goal is to minimize the opportunity for such errors to occur.
Sincerely, cc:
J. J. Stefano W. G.
Rogers G. C. Wright USNRC Document Control Desk Washington, D. C. 20555