Text

Insp Rept 50-341/89-07 on 890118-0323.Violations Noted. Major Areas Inspected:Followup of 890118 Event Where HPCI Div II Steam Line Flow Differential Pressure Transmitter Was Found Calibr to Value Greater than Tech Spec Limit
	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: ML20245H736; ML20245H745; ML20245H749;
References
	50-341-89-07, 50-341-89-7, NUDOCS 8905030503
	Download: ML20245H749 (12)
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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

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Facility Name: ' Fermi 2

Inspection At: Fermi Site, Newport, MI

Inspection Conducted: January 18 through March 23, 1989

knspectors: . W. G. Rogers

'S. Stasek

Approved By: Mark. A. ' Ring, Chief

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).

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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

(Paragraph 6). In addition, one open item was identified relating to the.'

l. proceduralization of Nuclear Engineering notifications to nuclear production

l organizations (Paragraph 4).

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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 ,

isolation circuii+ v i,ad a shuck indicator and would not affect the I

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 l

transmitter E41-N0578 had been calibrated using an erroneous static head l

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

HPCI declared operable.

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3. Root Cause Determination l

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The licensee performed a review to determine root cause of the discrepant i

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:

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a. On October 31, 1985, a design change (EDP 4459) was issued to

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 {

problem with the surveillance procedure had occurred, no change in !

the actual, correct calibration of the in-plant instrument had j

occurred to date.) i

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d. By June 17, 1988, Nuclear Engineering had identified the erroneous

head correction existed in DC 4572, Revision A, and issued DC 4572, l

Revision B, incorporating a corrected value of 42 inches WC. On that {

day, a speed memo was transmitted to the maintenance department l

(I&C procedures group) identifying the discrepancy and specifying l

that procedure 44.020.204 required revision to reflect the true head i

correction factor.

The speed memo, as written, indicated that the in-plant instrument

was adequately calibrated, that only the procedure itself 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 l

interpreted the scheduled update information to mean that the 1

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. f

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 !

operational problems identified, the transmitter was determined to !

need replacement and under the WR, a new transmitter was installed

and subsequently calibrated on November 22, 1988. l

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 ,

83.8 inches WC which resulted in the transmitter being miscalibrated l

to greater than the Technical Specification allowable value. The TS "

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 i

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 ,

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,

although discrepancies were noted, no failure to meet surveillance

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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 I

correction was identified. !

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The is.nector performed an independent review of inprocess Deviation i

Event deport (DER) 89-0092, HPES Report 89-001, Licensee Event Report

(LER) J9-004-00, Design Calculations (DC) 4572, Revision 0, and 4572, 1

Revis On A, as well as related DERs 88-0835, 88-1029, and 87-180 and l

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 ,

adequately addressed in the future, a required review of the work l

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

f 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 ,

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

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value in Technical Specification Table 3.3.2-2, Item 4.a.1, without the

. 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 !

of the discrepancy made to the I&C department via a speed memo l

(reference Paragraph 3.d), a Deviation Event Report (DER) was not j

initiated. This was in direct conflict with Fermi Interfacing ~!

Procedure FIP-CM1-04, " Lead Design Document Index," which required j

that a DER be initiated to ensure proper disposition. j

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 l

to the unprecise language used in the speed memo. l

This is considered to be a violation of 10 CFR 50, Appendix B,

Criterion XVI, " Corrective Action" (341/89007-02(DRP)).

7. Exit Interview

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The inspectors met with licensee representatives (denoted in Paragraph 1)

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): : J

Detroit Edison : :50-341/89007(DRP) :

: Initial Typing: : :

Facility (s): : : Inspection End Date: j

: 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 :

NPF-43 ::Date' Received: : :

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Data :

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NRC 766 FORM

NRC FORM 766 U.S. NUCLEAR REGULATORY COMMISSION : PRINCIPAL INSPECTOR

(6-83) : S. Stasek

IE MC 0535 INSPECTOR'S REPORT ,

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INSPECTION / INVESTIGATION : TOTAL NO 0F : ENFORCEMENT : REPORT CONTAIN

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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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