NRC-91-0094, Responds to NRC Re Violations Noted in Insp Rept 50-341/91-02.Corrective Actions:Writers Guide Revised to Define Acceptance Criteria in Technical Surveillance Procedures & Onsite Radiation Protection Meetings Held

Responds to NRC Re Violations Noted in Insp Rept 50-341/91-02.Corrective Actions:Writers Guide Revised to Define Acceptance Criteria in Technical Surveillance Procedures & Onsite Radiation Protection Meetings Held

ML20082F912
Person / Time
Site:	Fermi
Issue date:	08/12/1991
From:	Orser W DETROIT EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
CON-NRC-91-0094, CON-NRC-91-94 NUDOCS 9108160113
Download: ML20082F912 (10)

Text

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'99' Edison !EEF## ^usuet '2 NRC-91-0094

% ~opere,ms e U. S. Nuclear Regulatory Commission Attention: Document Control Desk Washington, D. C. 20555

Reference:

1) Fermi 2 NRC Docket No. 50-341 NRC License No. NPF-43

2) Notice of Violation, NRC Inspection Report No. 50-341/91002, dated July 11, 1991

Subject:

Response to the Notice of Violation 91-002 Attached is the response to the Nctice of Violation 91-002 contained in Reference 2. These violations occurred or were discovered during a special-NRC team inspection of the Fermi 2 modification implementation process.

Detroit Edison is pleased the inspection cor.cluded that the modification process at Fermi was adequate and that individual aspects of the process were good. However, the detracting minor documentation errors, the occasional performance of work steps nonsequentially and the instances of failing to follow proper radiological controls are of concern to Detroit Edison and are areas that company personnel concur need increased attention. The feedback provided by the inspection will provide a basis for continued improvement at Fermi 2.

If there are any questions relating to this response, please contact Terry Riley, Supervisor, Compliance and Special Projects, at (313) l' t

586-1684 or Patricia Anthony, Senior Compliance Engineer, at (313)

! 586-1617.

1 i Sincerely, V IkY cc: A. B. Davis R. W. DeFayette J. F. Stang S. Stasek Region III

~8 wn n8 n PDR ADOCK 03000341

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Attachment to' August 12, 1991 NRC-91-0094 Page 1 Statement of Violation 91-002-01 In the Notice of Violation contained in Reference 2, it states:

"10 CFR 50, Appendix B, Criterion V, requires that activities affecting quality be prescribed by documented instructions, procedures, and drawings, and those activities be accomplished in accordance with those instructions, procedures, and drawings.

Instructions, procedures, or drawings shall include appropriate quantitative or qualitative acceptance criteria for determining that important activities have been satisfacterily accomplished.

Fermi Management Directive. FHD CT1, Revision 1, " Calibration, Testing, and Surveillance," Section 4.5 312, an instruction requires, in part, that the calibration, test or surveillance procedure provide a sequence of operations, including inspections, functional checks, and measurements, as applicable, and the acceptance criteria and the means by which the response is to be observed for each.

Under " Definitions" of Appendix A. Revision 3, to the Fermi Management Policy and Directives Manual, acceptance criteria is defined as a limit or limits placed on the variation permitted in the characteristics of an item expressed in definitive engineering terms such as dimensional tolerances, chemical composition limits, density and size of defects, temperature ranges, item limits, operating parameters, and other similar characteristics.

Contrary to the above, surveillance procedures for the reactor protection system electrical protection assembly calibration / functional tests, 42.610.02 (Division 1) and 42.610.04 (Division II) did not include appropriate quantitative or qualitative acceptance criteria for the EPA breakers in that the undervoltage time delay limits were not acceptance criteria."

Reason for the Violation:

Procedures are developed using the Fermi 2 Writers Guide. The

-existing definition of acceptance criteria at that time in this

-document did not cover all values / settings required to support component and/or system operability, only values / settings specifically listed as line items in the Technical Specifications.

Since the undervoltage time delay limits were not line items in the Technical Specifications, they were designated as " acceptable limits" which did not have to be met in order for the EPA breakers to be considered operable. This was consistent with the guidance provided in the Fermi 2 Writers Guide at that time.

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i Attachment to August 12, 1991 NRC-91-0094 Page 2 Corrective Actions Being Taken and Results Achieved:

Procedures 42.610.02 and 42.610.04 have been placed in suspense so they cannot be used. Revisions to these procedures are being prepared to properly identify the time delay limits as acceptance criteria.

The precedure revisions will be approved by August. 16, 1991.

All procedures which use the term " acceptable limits" have been identified. These procedures are being reviewed to determine if any of these acceptable limits should actually be acceptance criteria.

The review is expected to be complete by the cr.d cf Septc.eber,1991, Appropriate procedure revisions, if any are needed, will be generated. Initial reviews indicate that the problem with the EPA undervoltage relay time delays was an isolated incident.

Corrective Actions to be Taken to Prevent Recurrence:

The Fermi 2 Writers Guide is being revised to define acceptance criteria in plant technical surveillance procedures as the performance limits necessary to meet the Technical Specification requirements.

This revision will be completed by August 16, 1991. Once this is completed, the guide will be issued as required reading to personnel responsible for developing procedures.

The NRC's notice of violation and Detroit Edison's response will be distributed to Maintenance, Operations, Technical Engineering and Nuclear. Engineering personnel for required reading in August 1991.

Date When Full Coggliance Will Be Achieved:

Detroit Edison is presently in full compliance and the corrective actions will ensure that Fermi 2 remains in compliance.

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Attachaent to August 12, 1991 NRC-91-0094 Page 3 Statement of Violation 91-002-02 In the Notice of Violation contained in Reference 2, it states:

" Technical Specification 6.8.1 requires that written procedures shall be established, implemented and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1 33, Revision 2, February 1978.

Appendix A of Regulatory Guide 1.33, Revision 2, February 1978, Scction 9, recommends proce* men for performing maintenance.

Procedure NPP-MA1-04 , Revision 7, " Conduct of Haintenance",

Section 5,2 3 requires that actual work instructions be included on the work request planning form. Instructions are to be followed sequentially unless as indicated within the body of the instructions.

Contrary to the above, on numerous occasions (work requests 0030900322, 010c890814, 011c890814, 005C890814, 020D900724, 0090901129, 010D901129, 008D901129, 007D901129, 010D901112) maintenance work instructions were not followed sequentially and this was not indicated in the body of work instructions."

Reason for the Violation:

A review of this issue has . led to the conclusion that this violation is attributable to personnel error. Several factors which contributed to this violation were identified.

First, procedure NPP-MA1-04 was determined to be overly restrictive as it relates to the performance sequence of steps in work packages.

This allowed no flexibility for the supervisors and craft who are capable of informed and responsible decisions in this area. Second, there was a lack of personnel attention to detail in regards to the requirements of NPP-MA1-04. Finally, there was a lack of '

comprehension / full understanding of the significance of proper documentation of work performed.

As was confirmed in Reference 2, there was no safety significance or impact on component operability as a result of these-decisions. -

Therefore, this level of performance was inappropriately accepted.

Corrective Actions Being Taken and Results Achieved:

A comprehensive review of the work packages completed in the month of April, 1991 has been performed by the Maintenance Department. The purpose of this review was to identify and correct any discrepancies in the documentation. The Quality Assurance organization is performing a surveillance of this review and it is expected to be completed at the end of August 1991.

Attachment to August 12, 1991 NRC-91-0094 Page 4 After the concern with attention to detail in work package documentation was identified during the outage, the subject was discussed in meetings with senior management. The appropriato expectations were conveyed down the line organization to the craftsmen and first line supervisors in a variety of meetings.

Corrective Actions Taken to Prevent Recurrence:

Detroit Edison's Quality Assurance organization is implementing increased inspections to provide specific feedback to the nuclear organization regarding work package performance and documentation.

This information is used in continuing briefings to improve the standards of performance in this area. Inspections will continue to monitor site performance in this area for work performed after April, 1991. This is an ongoing activity !n which the frequency and depth of review will be modified based upon the inspection results and trends. '

Maintenance management is providing formal presentations to personnel to communicate expectations in the areas of work package documentation, procedural compliance and related topics. These meetings will be held by August 15, 1991.

Procedure NPP-MA1-04 is being revised to provide supervisory discretion in the performance sequence of steps within work packages.

This revision is expected to be approved by the end of August 1991.

In the interim, th? planning and work groups have been instructed to include a statement allowing non-sequential performance of steps in the work packages, if appropriate.

The NRC's violation and this response will be in the required reading issued to Operations, Maintenance and Technical Engineering personnel in August, 1991.

Date When Full Compliance Will Be Achieved:

Detroit Edison is presently in full compliance. The actions described previously in this section will ensure that full compliance is maintained.

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Attachment to August 12, 1991 NRC-91-0094 Page 5 Statement of Violation 91-002-03 In the Notice of Violation contained in Reference 2, it states:

" Technical Specification 6.8.1 requires that written procedures shall be established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, February 1978.

Appendix A of Regulatory Guide 133, Revision 2, February 1978, Sectior, 7 recommended proccJures for control of radioactivity (for limiting materials released to the environment and limiting personnel exposure),

a. Procedure F1P-RC1-01, Revision 2, Accessing and Working in Radiologically Controlled Areas", Section 5.1.1 required written instructions on appropriate radiation work permits (RWP) always be followed.

RWP No. 91-1155. Special Instruction 2.A. required on May 1, 1991, that coveralls be worn for entry into the contaminated work area for EDP 08321, on the second floor of the Turbine Building.

Contrary to the above, on May 1, 1991, a contractor wolder, while working inside a contaminated area controlled by RWP 91-1155, improperly wore radiation protection coveralls in that the coveralls were unzipped while in the contaminated area to use a pen. This is an example of a violation.

b. Procedure FIP-RC1-01, Revision 2, " Accessing and Working In Radiologically Controlled Areas", Section 5.1.1 required that written instructions on appropriate RWPs always be followed. J RWP 91-1155, Special Instruction 7, required that a whole body frisk be performed at the nearest frisker location immediately upon exiting the contaminated work area for EDP 08321.

Contrary to the_above, on May 1, 1991, a contractor carpenter failed to perform a whole body frisk at the nearest frisker location immediately upon exiting the contaminated area for EDP 08321. This is an example or a violation.

c. Procedure FIP-RC1-01, Revision 2, " Accessing and Working In Radiologically Controlled Areas", Section 5.1.1 required that radiological postings never be-violated.

Contrary to the above, on May 2, 1991, a contractor violated a

• radiological costing by climbing above a contamination boundary area posting affixed to a ladder on the south side of the drywell, in the Reactor Building. This is an example of a violation.

Attachsent to August 12, 1991 NRC-91-0094 Page 6

d. Procedure F1P-RCI-01, Revision 2, " Accessing and Working In Radiologically Controlled Areas", Section 5.1.1 required that written instructions on appropriate RWPs always be followed.

RWP 91-1151, Special instruction 4, required that workers bag all tools and equipment or have radiation protection personnel survey items prior to removal from the contaminated work areas for EDP 11300.

Contrary to the above, on May 6, 1991, contractor Vers passed tools and equipment through piping penetrat on P-17171 on the first floor of the Turbine Building steam tunnel (a contaminated work area for EDP 11300) to the second floor of the steam tunnel (a radiologically clean area) without bagging ot performing surveys of the tools and equipment. This is ar.

example of a violation."

Reason for the Violation:

The four violation examples noted by the NRC have similar causes. The primary reason for these violations 13 personnel error. Several factors contributed to these errors, as follows: (1) lack of personnel accountability for and personal ownership of Radiation Protection responsibilities; (2) ineffective implementation of administrative and procedural controla; (3) lack of attention to detail in implementing existing and adequate Radiation Protection policies and practices and (4) inade:guate contractor controls .

The four examples noted all involved personnel errors committed by contractors. Decru't WimWs review of the current rhdiation protection program requirements at F6ral 2 indicates that current l

policies, practices and procedures are sufficient to have precluded i

the occurrence of these events., Tnis is based on the following:

(1) Violation 91-002-03a: As noted in tne vlolation stat ment, EIP-RC1-01 requires that written instructions on appropriate RWPs

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always be followed. RWP oi-1155 required that coveralls be worn

! inside the affected contaminated area for EDP 8321. All radiation workers are trained in proper techniques for donning and wearing anti-contamination clott g, A practical demonstration is required to qualify. The contract individual involved showed a disregard for these requirements.

(2) Violat. ion 91-002-03b: As noted in the violation statement, FIP-RC1-01 requires that written instructions on appropriate RWPs i

always be followed. RWP 91-1155 required whole body frisks at the nearest frisker upon exiting the contaminated area. All radiation workers are trained on RWP compliance and frisking requirements.

A practical demonstration of frisking techniques is required to qualify as a radiation worker. The contract individual involved showed a disregard for these requirements.

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August 12, 1991 NRC-91-0094 Page 7 (3) Violation 91-002-03c: As noted in the violation statement, FIP-RC1-01 requires that radiological postings never be violated.

All site personnel are trained on the requirements of radiological postings. Discussion with the area Radiatico Protection Technician assigned indicated the worker was directed not to cross the boundary during a pre-job briefing. The contract worker involved demonstrated a disregard for these requirements.

(4) Violation 91-002-03d: As noted in the violation statement, FIP-RC1-01 rc eu M that written instructions on appropriate RWPs always'be followed. RWP 91-1151 required that personnel involved bag tools / equipment or perform radiation surveys prior to removal from the contaminated areas for EDP 11300. All radiation workers are instructed and tested on the correct method for removal of tools / equipment from contaminated areas. The contract workers involved demonstrated a general failure to observe the appropriate radiological requirements.

Ultimately, the responsibility and accountability for inplementation of appropriate radiological controls rests with the individual (s) involved in the work activity. Initiatives are underway to improve Fermi 2 performance in this area as described below.

Corrective Actions Taken and Results Achieved:

For each exarnle violation noted by the NRC, the following remedial actions werr 2 ken:

(1) Violation 91-002-03a - The contractor involved was released from Employment at fermi 2.

(2) Violation 91-002-03b - The contract worker involved was not immediately identified due to the time lag prior to notification of site Radiation Protection personnel and the Modifications Supervisor. Later, the contractor was identified and released by the Modifications Supervisor. Radiation Protection technicians were briefed on the concern and the contract ALARA Coordinator discussed the incident witn other contract persor.nel.

. (3) Violation 91-002-03c - Although a Radiation Protection technician was notified of the NRC inspector's concern, the technician stated that the contract worker did not violate the posting while he observed the work and it was not clear to him that a previous violation had occurred. No further remedial action was taken for this instance.

(4) Violation 91-002-03d - Site Radiation Protection personnel were notified of this-incident and proceeded to survey the area and the tools placed.in the area. A posted area was established by Radiation Protection. Radiation Protection technicians were briefed on this event and instructed to be alert to similar circumstances which could develop on other jobs. The contract

g Attachment to August 12, 1991 NRC-91-0094 Page 8 ALARA Coordinator briefed modifications personnel on this event.

'the contract workers involved were released from employment at Fermi 2. No recurrence of this problem was identified during the outage. RadWorker training has been reviewed and determined to  ;

adequately cover passing material in/out of contaminated areas.

Corrective Action to be Taken to Prevent Recurrence:

Deviation Event Report (DER) , .,617 was written to address these violations. This DER addr; es further corrective actions being taken to prever.t recurrence of tht.a violations of radiation protection program requirements and procedures.

Current radiation protection requirements are adequate to preclude these violations. All personnel who work at Fermi 2 are, however, individually responsible for their actions in this regard. Attention )

to detail during the performance of all jobs involving radiological conditions is essential to successful implementation of these  !

requirements.

The following actions are being/will be taken to address the root causes of these violations:

o Contracts for off-site assistance will more clearly emphasize that Fermi 2 radiological protect, ion program, policies and procedures must be followed at all times by contract personnel during the performance of their contract duties. Appropriate disciplinary actions, up to and including personnel release from the job site, will be taken in the event these requirements are violated.

During contract negotiations, continued emphasis will be placed on individual ownership, responsibility and accountability during the performance of required tasks. Pre-job briefings will also continue to focus on these and other matters specific to radiological controls, o Onsite meetings will be held between Radiation Protection management, department heads and other key supervisory personnel to discuss the importance of proper implementation of radiological controls. These meetings will emphasice previous problems experienced, individual job responsibilities, accountability for personnel actions and supervisory controls. This action will be-completed by the end of 1991.

o When radiation protection implementation problems are encountered, accountability meetings will be held with the individual (s) involved, their supervision, the Plant Manager and the Radiation Protection manager (RPM). Actions will be critiqued and appropriate lessons learned will be disseminated, as needed.

o A special radiological assessment will be conducted regarding the understanding of individual responsibility to up-hold and follow radiological practices, assess implementation problems experienced by site workers and to determine the effectiveness of corrective

Attach ent to August 12, 1991 NRC-91-0094 Page 9 actions taken or underway to improve performance. A report on this assessment will be issued onsite by March 31, 1992. This will allow sufficient time to review results of meetings with supervision and identify any additional corrective actions to be implemented.

o A discussion of the above incidents, the NRC Notice of Violatior, and this response will be included in site radiation worker training. Training for site radiation workers will be completed during the current requalification cycle, which is scheduled to end in SeptemLer, 1992, contractors will be trained when hired, o Managemenu initiatives are underway to rely less on the use of contractors for futu,e outages.

Date When Full Compliance Will S3 Achieved:

The requireuents of Technical Specification 6.8.1, our commitment to Appendix A of Regulatory Guide 133, Revision 2, and existing site radiat19n protection programs, practices ano procedures are already fully complied with by Fermi 2. The incidents identified in this violecien involved personnel errors and/or failures to implement these receirements. The corrective actions identified above should result in improvements in effective implementation of these controls.

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