ML20214V718
| ML20214V718 | |
| Person / Time | |
|---|---|
| Site: | Fermi  |
| Issue date: | 11/28/1986 |
| From: | Wright G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20214V695 | List: |
| References | |
| 50-341-86-33, NUDOCS 8612090801 | |
| Download: ML20214V718 (8) | |
See also: IR 05000341/1986033
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U. S. NUCLEAR REGULATORY COMMISSION
REGION III
Report No. 50-341/86033
Docket No. 50-341
License No. NPF-33
Licensee: Detroit Edison Company
2000 Second Avenue
Detroit, MI 48224
Facility Name:
Fermi 2
Inspection At: Fermi Site, Newport, MI
Inspection Conducted: September 30 through November 10, 1986
Inspectors:
M. J. Farber
D. J. Sullivan
T. S. Rotella
M. R. Johnson
J. A. Isom
W. F. Burton
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L. E. W it
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Approved By:
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Reactor Projects Section 2C
Date
Inspection Summary
Inspection on September 30 through November 10, 1986 (Report
No. 50-342/86033(DRP))
Areas Inspected: Announced special safety inspection by the Augmented Restart
Inspection Team of routine control room operations, shift turnovers, operator
response to plant transients, operator control of maintenance and surveillance,
startup testing, plant maintenance, and followup to the October 5th and 6th
ECCS actuations.
Results:
No violations or deviations were identified.
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DETAILS
1.
Persons Contacted
- F. E. Agosti, Vice President, Nuclear Operations
- L. P. Bregni, Compliance Engineer, Licensing
- L. B. Collins, System Engineer, Nuclear Engineering
- R. S. Lenart, Plant Manager
R. A. May, Maintenance Engineer
- G. D. Ohlenmacher, Assistant Maintenance Engineer
G. R. Overbeck, Director, Operator Training
C. V. Phillips, Staff, Maintenance
- E. Preston, Operations Engineer
- F. H. Sondgeroth, Region Ill Engineer, Licensing
- B. R. Sylvia, Group Vice President
- G. M. Trahey, Director, Quality Assurance
- W. M. Tucker, Acting Superintendent, Operations
- Denotes those who attended the exit meeting on November 4,1986.
The inspectors also contacted other licensee administrative and technical
personnel during the course of the inspection.
2.
Routine Control Room Operations
The inspectors monitored routine control operation on a three shift basis
for the majority of plant operating time during the inspection period.
While monitoring control room operations the team focused on communications
among shift personnel, adherence to procedures, recognition or and
response to annunciators, involvement of shift supervisors in plant
operations, and congestion in the control room. Among the evolutions
observed by the team were reactor / plant startups, reactor / plant
shutdowns, turbine / generator operation, and equipment out-of-service and
restoration. The inspectors had comments with respect to the following
evolutions:
a.
Reactor / plant startups
On October 31st, with the reactor at 17% power and pulling control
rods to support operation of the main turbine, a reactor operator
made two control rod manipulation errors, each approximately two
hours apart. The first error resulted from the operator inadvertently
skipping a step in the sequence on his pull sheet. He moved one
control rod one notch out of sequence. He immediately recognized
his error and reported it to his supervisors. With the concurrence
of Reactor Engineering and his supervisors the rod was reinserted
to its proper position and the correct sequence restored.
Approximately two hours later the operator had completed pulling
each of the four rods in the selected group one notch. At this time
an indication problem arose and the operator stopped rod movement
to resolve it. When he started to pull rods again, he failed to
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select the next rod in the sequence and pulled the rod which had
dust previously been moved. The operator, once again, immediately
recognized his error and notified his supervisors. .The shift
supervisor ordered all rod movements stopped and the operator.was
. replaced. With the concurrence of Reactor Engineering,' after a
technical and. safety evaluation, the rod was reinserted to its
proper position. While there was little technical or safety
significance to,these errors, the failure of management programs
to prevent the recurrence of rod manipulation errors was of concern
to the inspectors. Following discussions with the inspectors-and
regional management the licensee implemented a program of double
verification for all rod movements. This program was contained in
a standing. order for all operators. The inspector reviewed the
order,to assess its adequacy, noted that operators were required
to sign for having read it, and attended shift turnover meetings.
where the double verification program was explained to the operators.
Additional actions taken by the licensee include revision of the
rod pull sheets to make them easier to follow and a request to INP0
for a two day Human Performance Evaluation Study (to be conducted
November 10-11,1986).
Review of the revised rod pull sheets and
the INP0 evaluation results is an Open Item (341/86083-01(DRP)).
No further errors were reported or observed during subsequent rod
manipulations; however, the inspectors will continue to monitor this
situation to determine if the program is effective.
b.
Equipment out-of-service and restoration
On October 28th, with the plant in cold shutdown, control room
operators were returning the "A" Reactor Recirculation Pump to
service. When they attempted to start the Motor Generator (MG) set
which provides power to the pump, the operator attending the MG set
heard unusual noises and the sound of electrical arcing. Before
the operators in the control room could shut down the machine, it
tripped.
Inspection revealed that the carbon brushes, used for
transmitting excitation power from the stationary part of the
machine to the rotating element, had been removed from the brush-
holders and were not properly seated on their slip rings. The
attempted start with the brushes removed resulted in damage to
the slip rings, some brushes, and some brushholders. The licensee
determined that after the reactor shutdown on October 23rd, the
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operators lifted the brushes from their holders in order to measure
their length and determine if replacement was in order.
Following
these measurements, the brushes were left out of the holders. When
the operating crew attempted to start the MG set, they were unaware
that the brushes were not installed as required.
The licensee's review of the incident revealed that the operator
who removed the brushes informed the control room that he had not
reinstalled them. He was directed to place a Control Room
Information System (CRIS) Jot on the MG set controls on the panel
as a reminder that the brushes were lifted. He failed to do this.
Review of the control room operator's log showed that an entry,
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stating that the MG set brushes.were lifted, had been made and that
other operators had reviewed the log. ' Fourteen shifts later the
entry was not remembered when the MG set was being' returned to
service.
The key element in this incident appears to be the failure of the
operator to place a CRIS dot on the MG set controls as directed.
Licensee management determined that the administrative controls
in place at the time of the incident were adequate to have prevented
it if they had been followed and an Urgent Required Reading was
issued for all operators which stressed the importance of careful
log reviews and adequate identification of off-normal equipment
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conditions. The inspector reviewed the required reading and
determined that it properly stressed the necessity for adhering
to in-place controls. The inspector reviewed the administrative
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controls discussed in the required reading and agreed that they
were adequate to have prevented the incident, had they been followed.
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Shift Turnover Meetings
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The team monitored shift relief and turnover meetings to assess log
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reviews, panel walkdowns, problem identification, equipment statusing,
proper communications, crew attentiveness, and supervisor effectiveness.
The. team noted that shift turnovers were generally efficient and
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well-run. There were two areas were noted by the-team as needing some
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improvement:
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Some of the individuals providing information at the shift briefings
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spoke so softly that it was nearly impossible to hear them.- This
was not limited to operators; it also included Startup, Reactor
Engineering, Health Physics, and Chemistry personnel.
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During the briefings, it appeared that operators were paying very
little attention to their panels and concentrating on the briefing.
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The shift supervisors were positioning themselves in such a manner
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as to force the operators to turn away from their panels.
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The licensee acknowledged these comments. The inspector noted at the
next shift briefing following the exit meeting that people with
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information spoke up and that the shift supervisor positioned himself
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in the' control room such that his operators could periodically monitor
their panels while he gave his briefing.
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4.
. Operator Response to Plant Transients
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The team monitored operator response during plant transients and abnormal
situations to evaluate operator understanding of plant behavior, operator
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understanding of system interaction, communications under stress, use of
procedures, and integrated shift performance.
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The following transients and abnormal situations were observed:
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Frequent level transients caused by Startup Level Control Valve
problems
120VAC balance of plant instrument power supply transferring from
primary to alternate power feeds
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Intentional scram and plant cooldown caused by continuing problems
with the 120VAC balance of plant instrument power supply
a.
Balance of plant instrument power supply (MPU-3) transfer.
The transfer of MPU-3 between the primary and alternate power feeds
is essentially a dead bus transfer and resulted in the loss of a
considerable amount of equipment and instrumentation. More detailed
information on the equipment lost and the reason for the transfer is
contained in Inspection Report 50-341/86032(DRP). As a result of
this event the operators were faced with a loss of feedwater (loss
of control air to the Startup Level Control Valve), a main turbine
trip, loss of offgas, Division II Standby Gas Treatment actuation,
and shifting of Control Center HVAC to recirculation on loss of
Reactor Building HVAC. After a moment of initial confusion caused
by the number of annunciators which alarmed, the operators
identified their problems, rapidly prioritized them, and then began
addressing these problems. Reactor vessel level control was rapidly
restored using the Standby Feedwater system and then the operators
began to systematically restore the lost equipment. The event was
handled in an exceptionally business-like and professional manner.
The operators were knowledgeable with respect to what had happened
to their plant and what would be necessary to restore it.
b.
Intentional reactor scram and plant cooldown.
Further problems, on the same day, with MPU-3 led the licensee to
decide that the plant should be shut down. Failure of the power
supply appeared imminent and such a failure would result in a plant
trip.
It was decided that a scram, rather than a shutdown, was
warranted due to the potential impact if MPU-3 failed during the
evolution (MPU-3 supplied power for the Rod Sequence Control System
and the Rod Worth Minimizer).
The operators carefully reviewed
their plant status, planned for the expected rapid cooldown due to
lack of decay heat, and developed contingency plans for use in the
event of other possible equipment failures during the evolution.
As a direct result of the planning by the operators the plant was
scrammed and the cooldown completed in a safe, controlled, efficient
manner.
5.
Control of Maintenance and Turveillance
The team monitored operation's control of maintenance and surveillance
activities to assess adherence to procedures, understanding of plant
status, and adherence to technical specifications.
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The team monitored the following maintenance:
Startup Level Control Valve
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Reactor Core Isolation Cooling turbine oil leaks
Traversing Incore Probe ball valve
Source Range Monitor "B" cable problem-
Gland Seal Regulator
The team monitored the following surveillances:
Main Steam Isolation Valve Closure
Core Spray Pump and Valve Operability
Main Steam Line "D" Rad Monitor
Drywell Pressure Instrument C71-N050C
Reactor Recirculation Pump Valve Operability Checks
Control Rod Scram Time Testing
The team participated in followup inspections after the licensee reported
that during the performance of HPCI Condensate Storage Tank Level
Calibrations, HPCI and RCIC were both inoperable for two periods of two
hours. Review of.the event revealed that no action had been taken within
one hour to proceed to STARTUP as required by Technical Specification 3.0.3.
This matter is subject to potential escalated enforcement and is
discussed in detail in Inspection Report 50-341/86032(DRP).
The team noted that with the exception of the HPCI/RCIC/ CST event,
operators appeared to be aware of the impacts of maintenance and
surveillances by other departments on plant status.and equipment
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operability.
6.
'Startup Testing
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The team monitored operator involvement in startup testing to evaluate
pre-test briefings, understanding of test conditions, impact of testing
on operability, understanding of-the test procedure, control of the test
evolution, adherence to test procedures, and communications between
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operators and test engineers.
The team monitored the following startup tests:
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STUT.010.022, Pressure Regulator
STUT.01A.023, Startup Level Control Valve
STUT.018.013, Traversing Incore Probe - Process Computer Interface
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Checks
STUT.01G.014, RCIC Vessel Injection
STUT.01A.028, Remote Shutdown Demonstration
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STUT.HUC.014 RCIC System - 150 psig Hot CST Injection
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STUT.HUD.014, RCIC System - 150 psig Vessel Injection
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.The team noted that briefings before tests were generally thorough and
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-impact of the testing on the plant, that procedural adherence was
enforced, and that the shift supervisor always remained in control of
the the plant. The operators and test personnel were especially
well-prepared for.the Remote Shutdown Demonstration. A separate shutdown
crew was identified and they spent ~approximately one week preparing for
the test. Equipment locations were reviewed, the procedure was walked
through several times, test engineers and operators met to discuss the
procedure and its intent, the RCIC pump was operated from the Remote
Shutdown Panel for practice, and contingency plans were developed in case
of abnormal occurrences. The intensive preparation resulted in a test
that was performed exceptionally well. On-shift operators, the shutdown
crew, and the test engineers knew their duties and how to carry them out
with little or no confusion or questions. Excellent communications were
maintained between all involved personnel throughout the test and the
Control Room shift supervisor remained in charge of the plant at all
times.
7.
Plant Maintenance
During the inspection period, the team and the resident inspectors became
concerned with the material condition of the plant as evidenced by the
number of CRIS dots on the panels, the backlog of work requests, the
number of leaking valves and_ flanges, and the apparent inability of the
maintenance department to resolve some recurrent equipment problems.
Team members and the residents inspected the plant and reviewed logs to
identify maintenance concerns and then met with licensee management to
discuss them. The licensee has developed a comprehensive program to
restore and improve plant material conditions. Additional information
on this subject is contained in Inspection Report 50-341/86032(DRP).
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ECCS Actuation Followup
On October 5,1986, an I&C technician improperly operated a valve on a
differential pressure transmitter during a Reactor Vessel' Level Channel
Calibration causing a full ECCS actuation. On October 6th, improper
restoration of the transmitter after the event caused an RPS Full Scram
signal to be generated when the calibration was attempted again.
Details
of this event and the licensee's corrective action are contained in
Inspection Report 50-341/86032(DRP). Since the event the Restart Team
Leader has periodically met with I&C supervision to review the
implementation of the corrective action. The licensee appears to be
proceeding adequately, although somewhat slowly. The team will observe
future surveillances involving differential pressure transmitters to
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assess the effectiveness of the licensee's cor?ective actions.
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9.
Open Item
Open items are matters which have been discussed with the licensee, which
will be reviewed further by the inspector, and which involve some action
on the part of the NRC or licensee or both. An open item disclosed
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during the inspection is discussed in Paragraph 2.a.
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10. Exit Interview
The inspectors met with licensee representatives.(denoted in Paragraph 1)
on Novenber 4,1986 and informally throughout the inpsection period and
summarized the scope and findings of the inspection activities. The
inspectors also discussed the likely informational content of the
inspection report with regard to documents or processes reviewed by the
inspectors during the inspection. The licensee did not identify any such
documents / processes as proprietary. The licensee acknowledged the
findings of the inspection.
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