ML20245H749
| ML20245H749 | |
| Person / Time | |
|---|---|
| Site: | Fermi |
| Issue date: | 04/17/1989 |
| From: | Ring M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20245H740 | List: |
| References | |
| 50-341-89-07, 50-341-89-7, NUDOCS 8905030503 | |
| Download: ML20245H749 (12) | |
See also: IR 05000341/1989007
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U.~ S. NUCLEAR REGULATORY. COMMISSION'
REGION III
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Report'No.'50-341/89007(DRP)
Docket No. 50-341
License No. NPF-43-
Licensee: -Detroit' Edison Company
2000 Second Avenue
Detroit, MI 48226
Facility Name: ' Fermi 2
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Inspection At: Fermi Site, Newport, MI
Inspection Conducted: January 18 through March 23, 1989
knspectors:
. W. G. Rogers
'S. Stasek
h.
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Approved By: Mark. A. ' Ring, Chief
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Reactor Projects Secti n 3B
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Inspection - Suninary.
Inspection on January-18 through March 23, 1989 (Report No. 50-341/89007(DRp))
Area Inspected:
Followup of a January 18, 1989 event where.the High Pressure
Coolant Injection System (HPCI) Division II steamline flow differential
.. pressure transmitter was found calibrated to a value greater than the Technical
Specification allowable value (93702).
Results: One violation was identified for failure to take proper and timely
corrective action which resulted in a violation of Technical Specification 3.3.2
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(Paragraph 6).
In addition, one open item was identified relating to the.'
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proceduralization of Nuclear Engineering notifications to nuclear production
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organizations (Paragraph 4).
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DETAILS
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1.
Persons Contacted
a.
Detroit Edison Company
- P. Anthony, Compliance, Engineering
- S. Catola, Vice President, Nuclear Engineering
W. Colonnello, Plant Safety
- G. Cranston, General Director, Nuclear Engineering
D. Fallon, System Engineer .
- P. Fessler, Director, Plant Safety
- W. Gilbert, Supervisor, Engineering Research
- D. Gipson, Plant Manager
- L. Goodman, Director, Licensing
- R. McKuen, Superintendent, Operations
- D. Odland, Superintendent, Maintenance
- A. Settles, Technical Superintendent
- R. Stafford, Director, Quality Assurance
- J. Tibai, NSRG Staff Engineer
- J. Walker, General Supervisor, Engineering
b.
U. S. Nuclear Regulatory Commission
- W. Rogers, Senior Resident Inspector
- S. Stasek, Resident Inspector
- J. McCormick-Barger, Reactor Inspector
- Denotes those attending the exit meeting on March 23, 1989.
The inspectors also contacted other members of the licensee's staff during
the course of the inspection.
2.
Event Synopsis
On January 18, 1989, the licensee identified that the High Pressure
Coolant Injection (HPCI) steamline flow differential pressure (dp)
isolation instrumentation had failed the routine channel check. This
instrumentation provides for an isolation of the HPCI system upon
detection of a leak in the steam piping and is required to be operable
by the plant's Technical Specifications while in Modes 1, 2, and 3.
Upon discovery, operations personnel declared HPCI inoperable and took
the required actions per Technical Specifications.
Investigation into
the cause of the channel check failure revealed that Division I
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isolation circuii+ v i,ad a shuck indicator and would not affect the
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proper functioni4 or the Wolation logic. However, during
troubleshooting activities related to the failed channel check, the
licensee determined that HPCI Division II differential pressure isolation
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transmitter E41-N0578 had been calibrated using an erroneous static head
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correction. This resulted in the transmitter being calibrated to a value
greater than the Technical Specification allowable value. The correct
head correction was subsequently calculated, E41-N0578 recalibrates, and
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3.
Root Cause Determination
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The licensee performed a review to determine root cause of the discrepant
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condition and found numerous' personnel errors had occurred which
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contributed to the problem condition.
The review was performed and
documented under Deviation Event Report (DER) 89-0092 and Human
Performance Evaluation System (HPES) Report 89-001. The following
sequence of events outlines the specifics:
a.
On October 31, 1985, a design change (EDP 4459) was issued to
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relocate the instrument sensing lines for E41-N0578.
In response,
the I&C department appropriately calculated a static head correction
factor of 41.9 inches WC and calibrated the instrument following
completion of installation per EDP 4459.
(At this time, E41-N057B
was correctly calibrated.)
b.
On July 13, 1987, Nuclear Engineering issued, as part of a new
program to develop design calculations for instrumentation in the
plant, design calculation DC 4572, Revision 0, which included the
subject instrument.
However, the DC was prepared using EDP 4459
which had not been as-built verified at the time. This was in error
in that DC 4572 should have been issued using the pre-EDP instrument
configuration and EDP 4459 should have referenced the design
calculation as a document requiring revision upon EDP completion.
(Although an administrative error occurred at this time, no effect
on actual instrument calibration resulted.)
c.
On December 22, 1987, DC 4572, Revision A, was issued by Nuclear
Engineering in recognition that the design calculation had been
inappropriately prepared using EDP 4459. However, during preparation
of DC 4572, Revision A, the static head correction factor was
incorrectly calculated and incorporated into the DC. This
promulgated a revision to surveillance procedure 44.020.204,
"NSSSS-HPCI Steamline Flow, Division II, Calibration," and resulted
in the head correction being changed from a 41.9 inches WC to an
erroneous 83.8 inches WC in the procedure.
(Again, although a
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problem with the surveillance procedure had occurred, no change in
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the actual, correct calibration of the in-plant instrument had
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occurred to date.)
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d.
By June 17, 1988, Nuclear Engineering had identified the erroneous
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head correction existed in DC 4572, Revision A, and issued DC 4572,
Revision B, incorporating a corrected value of 42 inches WC. On that
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day, a speed memo was transmitted to the maintenance department
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(I&C procedures group) identifying the discrepancy and specifying
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that procedure 44.020.204 required revision to reflect the true head
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correction factor.
The speed memo, as written, indicated that the in-plant instrument
was adequately calibrated, that only the procedure itself was
affected, and that the next scheduled update of the procedure was
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January 31, 1989. From discussion with the author of the memo, the
' spector ascertained that the date given was provided for
,oformation only, not to be used by the I&C department for
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scheduling purposes. However, the recipient of the speed memo
interpreted the scheduled update information to mean that the
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procedure revision may occur no later than that and, therefore,
scheduled the change consistent with the date provided.
In the
interim, no restriction on usage of 44.020.204 was provided.
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e.
In July 1988, E41-N0578 began experiencing operational problems
whereby short duration high trip signals were periodically
generated. Work Request (WR) 0108880725 was initiated and
subsequently, work completed in November 1988. To correct the
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operational problems identified, the transmitter was determined to
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need replacement and under the WR, a new transmitter was installed
and subsequently calibrated on November 22, 1988.
f.
Procedure 44.020.204 was used to perform the instrument
calibration on November 22, 1988.
However, the current procedure
revision at the time used the static head correction factor of
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83.8 inches WC which resulted in the transmitter being miscalibrated
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to greater than the Technical Specification allowable value. The TS
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allowable value was less than or equal to 410.0 inches WC and the
actual calibrated value was 441.4 inches WC.
g.
After E41-N057B was placed into service, operations determined an
apparent discrepancy existed in steamflow indication and initiated
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WR 0128881201. The WR was worked on December 29, 1988 by I&C
personnel and included a partial calibration using procedure
44.020.20.. Since the procedure still had the wrong head correction
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included, the partial calibration reinforced the earlier
miscalibration. When no problem could be found with the instrument,
the I&C technician indicated in the package that engineering neeced
to perform further review of the problem. This note was not
identified during the review cycle on the work package and the WR
was closed without action by engineering being initiated.
h.
Operations continued to note a steamflow discrepancy and initiated
a second work request (WR) 016C890117 on January 17, 1989. The
next day, E41-N0578 failed its channel check.
(Until this time,
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although discrepancies were noted, no failure to meet surveillance
acceptance criteria had occurred.)
1.
WR 016C890117 was immediately worked following the surveillance
failure. Another partial calibration was performed (again using
'he deficient procedure) with no problems identified. This time,
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urther troubleshooting was conducted and the erroneous head
correction was identified.
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The is.nector performed an independent review of inprocess Deviation
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Event deport (DER) 89-0092, HPES Report 89-001, Licensee Event Report
(LER) J9-004-00, Design Calculations (DC) 4572, Revision 0, and 4572,
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Revis On A, as well as related DERs 88-0835, 88-1029, and 87-180 and
ascertained the licensee's evaluation of root cause was substantially
accurate.
In addition, review of the electrical schematic and system
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logic diagrams was conducted and interviews.of involved plant personnel
performed.
4.
Corrective Actions
Upon the failure of E41-N0578 to pass its required channel check, the
licensee took the actions required by Technical Specification
Table 3.3.2-1, Item 4.a.1.
That line item references Action Statement 23
which required that the affected system isolation valves be closed within
one hour and the affected system declared inoperable. Subsequently, it
was determined that the instrument had been calibrated using a, deficient
procedure. The procedure,was then corrected, the instrument recalibrates,
and HPCI returned to an operable status.
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To prevent recurrence:
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The licensee initiaied a recheck for accuracy of all design
calculations associated with EDPs. That recheck was subsequently
completed with one additional minor discrepancy identified.
A requirement to perform as-found calibration checks when replacing
instruments was established.
To ensure that discrepancies identified in work packages would be
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adequately addressed in the future, a required review of the work
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package review checklist by Quality Assurance was initiated.
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The licensee is currently developing a system whereby communication
from Nuclear Engineering to Production organizations concerning
changes to design related documents would be proceduralized.
Disposition of this action will be tracked via DER 88-0835. Pursuant
to completion of development / implementation of this formalized system
and further inspector review, this will remain an open item
(341/89007-01(DRP)).
5.
Safety Significance of E41-N0578 Being Miscalibrated
E41-N057B is one of four instruments installed to provide for a HPCI
isolation upon a break in the steamline to the HPCI turbine.
E41-N0578
is designated Division II and provides the input to close HPCI steamline
valves E41-F003 and E41-F600 (bypass around E41-F003), and pump supply
valve E41-F041 upon receipt of a high differential pressure in the
steamline. When the isolation logic is completed, a HPCI turbine trip is
also then automatically initiated.
Likewise, Division I is initiated from
E41-N057A which provides input to close steamline valve E41-F002 and pump
supply valve E41-F042 upon receipt of a high differential pressure in the
steamline. Because of the designed redundancy, closing either of the
steamline valves (plus in one case the bypass valve) and either of the
pump supply valves would provide the required isolation / turbine trip
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functions.
In addition, two HPCI equipment room temperature monitors
which also provide inputs to the isolation logic to these same valves
were operable during November 1988-January 1989 timeframe.
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Summarizing, although E41-N0578 was calibrated such that it would not
provide an isolation of the HPCI system within the allowable limits of
Technical Specifications, E41-N0578 is but one of four instruments that
provide that safety function.
If a HPCI steamline break had occurred
during the time that E41-N0578 was miscalibrated, three other instruments
were available to initiate the isolation within the Technical
Specification allowable value. Also, E41-N0578 could.have provided a
signal to the isolation logic, albeit at a somewhat higher steamflow
setpoint than required by the Technical Specifications.
6.
Conclusions
A weakness in implementation of the design control program was identified
during the inspection. The inspector noted that although the engineer'
who prepared DC 4572, Revision A, had made a calculational error, the error
went undetected during an independent verification, and was subsequently
approved and issued by Nuclear Engineering in December 1987 (reference
Paragraph 3.c).
When the inspector questioned Nuclear Engineering
personnel as to the reason for this, the response was that the DC was
prepared by General Electric Co. personnel under contract to DECO. The
engineer who had prepared the DC apparently lacked familiarity with
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Fermi's administrative / design control system. The verifier was also a
GE engineer with the same lack of familiarity and therefore was unable to
recognize the error. DECO management of the GE contract only required
sampling of the calculations per specific criteria prior to final approval
and issuance.
In addition, a weakness in.the maintenance work process was also noted.
The length of time that E41-N057B operated while miscalibrated was
possibly extended due to the inadequate closeout review cf the work
package for WR 0128881201 (reference Paragraph 3.g).
Had engineering
review been initiated per the notation made by the technician in the work
package, the steamflow discrepancy and the associated head correction
problem could possibly have been addressed and resolved earlier.
The inspector confirmed the lie.ensee's determination that a violation
of the Limiting Conditions for Operation (LC0) for Technical Specification 3.3.2 occurred in that the trip setpoint for HPCI steamflow
transmitter E41-N0578 was set at a value which exceeded the allowable
value in Technical Specification Table 3.3.2-2, Item 4.a.1, without the
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. licensee taking the required actions of TS Table 3.3.2-1, Action 23, in
the required timeframe. This condition existed from November 22, 1988
when the transmitter was installed and calibrated until the time of
discovery on January 18, 1989. During that time, the reactor was at power
for approximately 46 days.
This violation was caused by the licensee's failure to take prcper and
timely corrective action in that:
a.
Upon identification by Nuclear Engineering that a discrepancy
existed between an as-built condition in the plant (and
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associated calibration procedure), and the information shown in the
governing design calculation DC 4572 was corrected and notification
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of the discrepancy made to the I&C department via a speed memo
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(reference Paragraph 3.d), a Deviation Event Report (DER) was not
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initiated. This was in direct conflict with Fermi Interfacing
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Procedure FIP-CM1-04, " Lead Design Document Index," which required
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that a DER be initiated to ensure proper disposition.
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Upon notification of the deficiency in procedure 44.020.204, I&C
personnel scheduled the procedure for revision approximately six
months in advance with no restrictions established for its use in
the interim. This allowed the deficient procedure to be used to
calibrate an instrument required by Technical Specifications and
directly resulted in nonconservative instrument operation for an
extended period of time (reference Paragraph 3.d).
This was due
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to the unprecise language used in the speed memo.
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This is considered to be a violation of 10 CFR 50, Appendix B,
Criterion XVI, " Corrective Action" (341/89007-02(DRP)).
7.
Exit Interview
The inspectors met with licensee representatives (denoted in Paragraph 1)
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on March 23, 1989, and informally throughout the inspection 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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REPORT / LETTER TRAVELER
RIII REPORT / LETTER TRAVELLER
TOTAL DAYS TO ISSUE
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- Licensee:
- Draft Completion Date:
- ReportNo(s):
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- Detroit Edison
- 50-341/89007(DRP)
- Initial Typing:
- Facility (s):
- Inspection End Date:
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- Received Start
End
- 03-23-89
- Fermi 2
- * Inspector Review:
- Start
End
- Inspector (s):
- Date Mailed:
- License No(s):
- W. Rogers
- Cate Trans. (PC) 4/05/89 ~~~ : S. Stasek
- Date' Received:
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$
REVIEW ~PRDCESS
$
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Data
- Doc
- Insp/PM :
S.C.
B.C.
D.D.
Mgmt. Unit
- Format : In :-Out: In : Out: In : Out: In : Out: In : Out:
In : Out
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- Issue Date:
- Note :
- Licensee
HQ(DMB)
- No.
- COMMENT
- Proprietary Review Notif.
- Telephone
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DUE
RECEIVED :
- Written
DUE
RECEIVED :
- Licensee Response:
- DUE
~TYYUEU
RECEIVED :
- Thank You Letter:
DUE ~~
ISSUED
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NRC 766 FORM
U.S. NUCLEAR REGULATORY COMMISSION
- PRINCIPAL INSPECTOR
(6-83)
- S. Stasek
INSPECTOR'S REPORT
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0FFICE OF INSPECTION AND ENFORCEMENT
- REVIEWER
'
&\\.1L) AC<
INSI)ltCTORS
~ ~~'
S. Stasek,
W. Rodgers
SITE NAME
- TRANSACTION:
DOCKET N0
- REPORT (15-19):NEXT INSPEC.
Fermi 2
- TYPE (1)
- (2-14) 8-DIGITS: N0.
- SEQ. -: M0.
- YR.
~~~
- XI-INSERT :-05000341
- 89007: A X:
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- D-DELETE :
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- U***********w********************M'*'H********************
PERIOD OF INSPECTION.
- INSPECTION PERFORMED BY'(33)
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FROM: (21-26)
- TO :(27-32)
1-REGIONAL OFFICE STAFF : 0THER:
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ORGANIZATION CODE OF REGION /HQ CONDUCTING ACTIVITY:
REGIONAL ACTION (37)
REGION (34) : DIVISION (35)
BRANCE'f36)
1-NRC FORl4 591
--~lI' 2- REGIONAL OFFICE
3
2
3
LETTER
- A*********T*********FT'***wTTA**********
TYPE OF ACTIVITY CONDUCTED (38-39)-
~02-SAFETY
06-MGMT. VISIT
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~-03-INCIDENT
X 07-SPECIAL
~~10-PLANT SEC.
14-INQUIRY
11-IhVENT.VER.
~~15-INVESTI-
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~~12-SHIPMENT / EXPORT-~
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05-MGMT. AUDIT
13-IMPORT
- 1***KTTT***********************************m**i17111***********
INSPECTION / INVESTIGATION
- TOTAL NO 0F
- ENFORCEMENT
- REPORT CONTAIN
FINDINGS-(40)
- VIOLATIONS &
- CONFERENCE
- 2.790 INF0.
A: B: C: D:
- DEVIATIONS
- HELD
- 1-CLEAR
- (41-42)
- 1-YES (43)
(44)
X:
- 2-VIOLATION
- 3-DEVIATION :~A : B: C: D: A: B: C: D: A: 8: C: D:
- 4-VIOLATION & : 1:
DEVIATION :
- TETTER DIFkl70RT~ TRANSMITTAL DATE :
- REPORT SENT
- OR REG.
- TO HQ. FOR
- LETTER ISSUED : ACTION
(45-50)
(51-56)
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~VI@OLATION SEVERTTV~ ~~i3T
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- DOCKET NUMBER
N0
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________
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VIOLATION OR DEVIATION (ENTER UP TO 2400 CHARACTERS FOR EACH ITEM)
1 Nuclear Engineering failed to initiate a Deviation Event Report-(DER) upon 2
identification that the High Pressure Coolant Injection (HPCI) steamline 3
flow differential pressure transmitter E41-N0578 as-built condition was not 4
consistent with its associated calibration procedure 44.020.204 and Design 5
.
Calculation 4572, but instead internally corrected the DC and notified the 6
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I&C department of the need to revise 44.020.204 via a speed memo on
7 June 17, 1988.
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