IR 05000341/2007007

IR 05000341-07-007; 08/27/2007-09/14/2007; Fermi Power Plant, Unit 2; Biennial Problem Identification and Resolution

ML072990395
Person / Time
Site:	Fermi
Issue date:	10/26/2007
From:	Christine Lipa NRC/RGN-III/DRP/RPB4
To:	Jennifer Davis Detroit Edison
References
IR-07-007
Download: ML072990395 (22)

Text

October 26, 2007Mr. Jack M. DavisSenior Vice President and Chief Nuclear Officer Detroit Edison Company Fermi 2 - 210 NOC 6400 North Dixie Highway Newport, MI 48166SUBJECT:FERMI POWER PLANT, UNIT 2, NRC PROBLEM IDENTIFICATION ANDRESOLUTION INSPECTION REPORT 05000341/2007007

Dear Mr. Davis:

On September 14, 2007, the U.S. Nuclear Regulatory Commission (NRC) completed ateam inspection of problem identification and resolution at your Fermi Power Plant, Unit 2.

The enclosed report documents the inspection findings which were discussed on September 14, 2007, with members of your staff.The inspection examined activities conducted under your license as they relate to safety and tocompliance with the Commission's rules and regulations and with the conditions of your license.

The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel.On the basis of the sample selected for review, the team concluded that, in general, problemswere properly identified, evaluated, and corrected. However, the inspectors identified one finding of very low safety significance (Green). In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letterand its enclosure will be made available electronically for public inspection in the NRC J. Davis-2-Public Document Room or from the Publicly Available Records (PARS) component ofNRC's document system (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).

Sincerely,

/RA/Christine A. Lipa, ChiefBranch 4 Division of Reactor ProjectsDocket No. 50-341License No. NPF-43Enclosure:Inspection Report 05000341/2007007 w/Attachment: Supplemental Informationcc w/encl:J. Plona, Vice President, Nuclear Generation K. Hlavaty, Plant Manager R. Gaston, Manager, Nuclear Licensing D. Pettinari, Legal Department Michigan Department of Environmental Quality Waste and Hazardous Materials Division M. Yudasz, Jr., Director, Monroe County Emergency Management Division Supervisor - Electric Operators State Liaison Officer, State of Michigan Wayne County Emergency Management Division

SUMMARY OF FINDINGS

IR 05000341/2007007; 08/27/2007-09/14/2007; Fermi Power Plant, Unit 2; Biennial ProblemIdentification and Resolution.The inspection was conducted by three Region III inspectors and the resident inspector. OneGreen finding of very low safety significance was identified during this inspection. The significance of most findings is indicated by their color (Green, White, Yellow, Red) using Inspection Manual Chapter 0609, "Significance Determination Process (SDP)." The finding was assessed using the SDP process. The NRC's program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, "Reactor Oversight Process," Revision 4, dated December 2006.Identification and Resolution of ProblemsIn summary, the inspectors concluded that the corrective action process was generally effectiveat identifying and resolving issues as indicated by the conditions observed in the plant, process meetings observed, and the issues that had been entered in the process that inspectors reviewed. The licensee had program managers monitoring performance of the program and pursuing improved implementation. Operating experience was reviewed for plant applicability and also used in issue evaluations. The audit and self-assessment programs were functioning adequately, but had not identified some broad trends such as an NRC substantive crosscutting issue. The licensee periodically monitored the safety conscious work environment and results were acceptable and consistent with input to the corrective action process and employee concerns program. Two areas of concern were identified by inspectors based on issues in corrective action documents. Licensee staff had previously identified that there was acceptance of inadequate procedures and work instructions that inspectors concluded was continuing based on recent issues. Also, inspectors observed that some activities that required interfacing with off site organizations had problems due to lack of ownership by station personnel.A.

NRC-Identified

and Self-Revealed Findings

Cornerstone: Initiating Events

Green.

A finding involving the failure to maintain adequate maintenance procedures toclean the '2B' Main Unit Transformer was self-revealed during an event. The procedure did not contain adequate controls over the removal of the cooling fans from service with the transformer energized. As a result, the licensee removed too many coolers which caused localized overheating subsequently resulting in the transformer failure, turbine trip, and reactor scram. The licensee entered the issue into their corrective action program as CARD 06-24046 and created procedures for cleaning the transformers.

The inspectors determined that the finding was associated with cross-cutting aspect H.2(c), Human Performance - Resources.This finding was determined to be more than minor because the improper transformercleaning resulted in a reactor scram. This finding was determined to be of very low safety significance because it did not contribute to the likelihood that mitigation 3equipment or functions would not be available. No violation of regulatory requirementswas identified. (Section 4OA2a.(2))

B.Licensee-Identified Violations

None

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REPORT DETAILS

4.

OTHER ACTIVITIES (OA)

4OA2Problem Identification and Resolution (PI&R) a.Assessment of the Corrective Action Program (CAP) (1)Inspection ScopeThe inspectors reviewed items selected across the NRC's cornerstones of safetyto determine if problems were being properly identified, characterized, and entered into the corrective action program for timely and complete evaluation and resolution.

Specifically, the inspectors selected and reviewed condition assessment resolution documents (CARDs) generated since November 2005, when the previous NRC problem identification and resolution team inspection was conducted (Inspection Report (IR) 05000341/2005020). These documents included CARDs, apparent cause evaluations (ACEs) and root cause evaluations (RCEs).The inspectors evaluated CARDs to determine the licensee's threshold for identifyingproblems and entering them into the corrective action program. The inspectors also conducted walkdowns, observed Ownership Screening Committee and CARD Review Board meetings, and interviewed plant personnel to review processes where problems and findings could be identified. The process was also reviewed for requiring prompt evaluation of issues for operability and reportability.The inspectors also reviewed a sample of previous Non-Cited Violations to verify thatthe issues were adequately prioritized and evaluated and appropriate corrective actions were taken. A review of the diesel fire pump was expanded to include CARDs initiated during the past five years. In addition, the inspectors interviewed the diesel fire pump system engineer to evaluate system performance over the past five years.Documents substantially reviewed by the inspectors are listed in the Attachmentto this report. Completion of these interviews, observations, and record reviews constituted one inspection sample.

(2)AssessmentIdentification of IssuesThe inspectors concluded that, overall, the licensee was effective at identifyingproblems and entering them into the corrective action program. This was evidenced by the relatively few deficiencies identified that did not have CARDs written, the high number of CARDs generated and the broad distribution between departments. The inspectors did, however, identify one minor case during this inspection where CARDs were not written when deficiencies were identified during a self-assessment. For 5example, Operations Self-Assessment NPOP-06-0047 identified areas for improvementin the areas of log and record-keeping as well as shift turnovers but the issues were not entered into the corrective action program.Prioritization and Evaluation of IssuesOne finding of very low safety significance (Green) was identified as self-revealed whenthe '2B' Main Unit Transformer (MUT) suffered a fatal internal fault on June 15, 2006.

See the "Main Unit Transformer Trip" discussion below.Issues in the CAP were properly prioritized. The inspectors concluded that theOwnership Screening Committee and CARD Review Board were generally effective in assuring the proper significance levels were assigned. The licensee was monitoring the backlog of open CARDs and attempting to reduce the number to a target level.For the ACEs and RCEs reviewed by the inspectors, the inspectors concluded thatthey were performed using systematic methods. The licensee had made numerous improvements in the evaluation processes to improve uniformity and quality of analysis and documentation. Training had also been provided to staff members who perform and review issue evaluations. The thoroughness of evaluation and level of detail in the ACEs and RCEs was improved over the two year period, however, the evaluation of issues remained an area of concern for the inspectors. One example was shown in reviewing the root cause evaluation associated with CARD 06-24046, "Main Unit Transformer 2B Sudden Pressure Trip", the inspectors identified the licensee's failure to either develop corrective actions or explain why none were needed for a contributing cause of the event. On March 25, 2006, switchyard disconnect DO arced for approximately 14 minutes which was later determined to have contributed to the subsequent MUT 2B failure. The licensee discovered that CARD 04-20108 was initiated on January 10, 2004, to investigate the 'DO' disconnect for proper configuration; however, the CARD was closed on December 13, 2004, with no corrective actions taken. Therefore, the inspectors concluded that in 2006 the licensee failed to properly evaluate why the 2004 CARD was closed without corrective actions. The licensee later determined that if the configuration was corrected, the arcing event would not have occurred and thus considered the closure of the CARD with no actions taken to be a contributing cause of the MUT 2B failure. Although the licensee reviewed potential damage to other equipment as a result of the arcing event, the licensee failed to review the events and circumstances of the contributing cause in order to identify any corrective actions. Once identified, the licensee entered this issue into their corrective action program as CARD 07-25091 to perform the necessary review.A second example was revealed when the inspectors reviewed CARD 05-24619which was initiated on August 6, 2005, to review an abnormal condition associated with the Division I Control Center Heating, Ventilation, and Air Conditioning Return Air Fan. During the extent of condition review, the licensee discovered that approximately 22 percent of the work requests sampled did not clearly reflect the correct installation instructions. Therefore, the recommendation was made to have a second planner verify work package instructions to clearly reflect the correct installation or modification instructions for equivalent parts. The licensee concluded that the recommendation was addressed under another action item in the CARD; however, the referenced action item 6did not address the recommendation. Consequently, the inspectors identified that therecommendation for a second planner review was never implemented. Once identified, the licensee entered this issue into their corrective action program as CARD 07-25136 to review the inspectors' concerns.Main Unit Transformer Trip

a. Inspection Scope

The inspectors selected CARD 06-24046, "Main Unit Transformer 2B SuddenPressure Trip, " because the issue was associated with a level 1 root cause evaluation completed within the past two years of this inspection. The inspectors verified the following attributes during their review of the licensee's corrective actions for the above action requests and other related action requests:complete and accurate identification of the problem in a timelymanner commensurate with its safety significance and ease of discovery;consideration of the extent of condition, generic implications, commoncause and previous occurrences;evaluation and disposition of operability/reportability issues;classification and prioritization of the resolution of the problem,commensurate with safety significance;identification of the root and contributing causes of the problem; andidentification of corrective actions which were appropriately focused tocorrect the problem.The inspectors discussed the corrective actions and associated action requestevaluations with licensee personnel.

b. Findings

Introduction:

A finding of very low safety significance (Green) was self-revealedon June 15, 2006, when the '2B' Main Unit Transformer (MUT) suffered a fatal internal fault on the Z phase high voltage windings because of localized overheating. The maintenance instructions that the licensee utilized to clean the MUT were insufficient to ensure that the MUT remained adequately cooled.Description: On June 15, 2006, the licensee began activities to clean MUT 2Bbecause the heat exchanger cooling fins were becoming clogged with insects and cottonwood common for that time of year. The work instructions that were to used to clean the transformer did not contain any guidance on the proper method to remove the oil coolers from service. Consequently, the licensee removed two adjacent coolers on the transformer Z phase approximately six hours before cleaning of the coolers commenced. This extended time period allowed temperature stratification of the oil in the Z phase and localized overheating of the windings.

7The licensee then started to clean the transformer by spraying cool water on thecooling fins. Twenty-three minutes after the cleaning began, MUT 2B suffered a fatal internal fault on the Z phase high voltage winding. The failure caused the MUT sudden pressure relay to actuate causing a main generator trip and subsequent reactor scram. All plant equipment operated as designed as a result of the scram and no fires resulted from the failure.The licensee entered this issue into their corrective action program asCARD 06-24046 and performed a root cause evaluation of the issue. The licensee determined that the root cause of the failure was the failure to use a formalized work control process to control the MUT cleaning which thereby failed to prevent two adjacent coolers to be taken out of service together for an extended period of time. The licensee postulated that the overheating from the two coolers being removed from service coupled with the relatively rapid cooling of the oil from the water spray caused moisture to propagate from the cellulose insulation to the oil. The increased moisture in the oil decreased the dielectric strength of the oil which caused the internal fault.As a result of this event, the licensee developed a detailed procedure to cleanboth MUTs, reviewed and modified other similar jobs on other equipment, and disseminated lessons learned to from this event to Operations, Maintenance, and Engineering.Analysis: The inspectors determined that the failure to maintain adequatemaintenance procedures to clean the '2B' Main Unit Transformer was a performance deficiency. This finding was determined to be more than minor in accordance with Manual Chapter (MC) 0612, "Power Reactor Inspection Reports," Appendix B. Specifically, the inspectors reviewed the examples of minor and more than minor issues in MC 0612, Appendix E, and determined that there was one example related to this issue. Example 4b states that the a procedural deficiency is more than minor if the error caused a reactor trip or other transient. The inspectors assessed the finding using the Phase 1 SDP and determined that the finding was associated with the Initiating Events Cornerstone. The finding did not contribute to the likelihood that mitigation equipment or functions would not be available; therefore, this finding screened as Green. Once identified, the licensee entered this issue into their corrective action program as CARD 06-24046, performed a root cause evaluation, and created procedures for cleaning the transformers. The inspectors determined that the finding is associated with a cross-cutting aspect in the area of Human Performance, Resources because the licensee did not maintain complete and accurate procedures or work packages for cleaning the MUTs (H.2(c)).Enforcement: Because the MUTs are not safety-related components, neitherthe requirements of 10 CFR 50, Appendix B, nor Regulatory Guide 1.33 apply to this issue. Therefore, no violation of regulatory requirements occurred and this failure is being treated as a finding and is identified as FIN 05000341/2007007-01: Inadequate Main Unit Transformer Cleaning Procedures.

8Effectiveness of Corrective ActionsThe inspectors concluded that, overall, corrective action effectiveness had improvedfrom 2005 to 2007, but observed that on a broad basis, the licensee had not effectively addressed issues with work instruction quality and ownership of issues involving off site organizations.The inspectors noted several examples of workers accepting less than adequateprocedures or work instructions during this inspection. The licensee performed a common cause analysis last year of several significant operational events and documented the review in CARD 06-25246. The licensee identified, among other issues, the staff's acceptance of poor procedures as a contributing cause. Corrective actions were completed including stand downs and training. However, about a month later, engineering reviewed the preventative maintenance (PM) packages for the inspection and testing of both MUTs and determined that they were adequate despite deficiencies in the level of detail of the work instructions. Specifically, replacement of cooling fan motors was directed as a single line in the work instructions with no steps to perform a post maintenance test. Further, the work instructions contained a step to test the MUT alarms but included no guidance on how to test them, exactly what alarms to test, or the standards with which to measure success or failure such as with the use of acceptance criteria. Once identified, the licensee entered this issue into their corrective action program as CARD 07-25107 to review the inspectors' concerns.The inspectors were concerned that standards for improved procedure quality had notbeen internalized within the licensee's organization. The inspectors determined that a lack of effective prioritization for improving the work instructions for the MUT PM packages had continued. For example, on September 13, 2007, an event with the station air system was caused, in part, because several departments accepted inadequate work instructions. In addition, when the inspectors initially inquired about the adequacy of the MUT PM packages, as discussed above, the licensee staff's position was that the PMs contained adequate work instructions. The inspectors also reviewed CARD 03-18293, written on June 5, 2003, that identified deficiencies with the work instructions for the MUTs and other switchyard-related equipment. That CARD was still open at the close of this inspection. The inspectors determined that several recent NRC findings, events, and otherissues were related to a lack of licensee ownership of issues related to equipment maintained by outside organizations, such as switchyard equipment or the MUTs.

For example, FIN 05000341/2007004-01 identified transient combustibles in a switchyard relay house, which was not monitored adequately because the licensee stated that they did not consider themselves responsible for the switchyard relay house. FIN 05000341/2007002-02 identified deficiencies with the Alternate Emergency Operations Facility due to the licensee's reliance on an unofficial agreement with Warren Service Center management to maintain the facility. Lastly, the cleaning instructions for MUT 2B were inadequate partly because of the licensee's reliance on the Distribution Operations personnel, who routinely cleaned the MUTs andhave knowledge and experience in performing the task. Once identified, the licensee entered this trend into their corrective action program as CARD 07-25174 to review the inspectors' concerns.

9 b.Assessment of the Use of Operating Experience (1)Inspection ScopeThe inspectors reviewed completed licensee evaluations of industry operatingexperience from the past two years to determine if industry experience was being promptly reviewed by appropriately qualified individuals at Fermi and actions, either CARDs or program enhancements, were being taken to address those issues that were applicable to Fermi. In addition, the inspectors interviewed the operating experience program coordinator to determine how the process worked.

(2)AssessmentNo findings of significance were identified. The licensee was using appropriatelyqualified individuals to promptly evaluate industry experience. Corrective actions and program enhancements were entered into the corrective action program, as necessary, to address those items applicable to Fermi. The inspectors noted that the licensee had increased the use of operating experience during reviews of CARDs.

c.Assessment of Self-Assessments and Audits (1)Inspection ScopeInspectors reviewed the audit plans and the self-assessment plans and discussed theprograms with the responsible managers for the programs. Inspectors also reviewed a sample of self-assessment and audits in different departments including recent reviews of the CAP.

(2)AssessmentNo findings of significance were identified. The audits and self-assessments were appropriately planned and conducted for the identification, evaluation, and correction of issues and demonstrated the ability of the licensee to be effective in these areas.

Self-assessments of the CAP were critical and had identified program improvements.

The results did not identify any substantial issues differing with inspector observations.

Reorganizations by the licensee had simplified and clarified responsibilities for the programs. However, while self-assessments were generally effective at identifying lower-level areas for improvement, the inspectors identified inconsistencies in the breadth and depth of the self-assessments as well as documentation and distribution of the assessment results. The licensee explained that the lack of a formalized self-assessment procedure was the reason for such a wide disparity between assessments.

The inspectors noted that the lack of a formalized procedure for performing assessments was an impediment to the licensee identifying more significant trends before being identified by either an outside organization or an event. For example, despite two NRC substantive cross-cutting issues issued during the two-year inspection period, the licensee failed to identify the issues prior to the NRC. Additionally, a self-assessment performed on April 30, 2007, on Operations Human Performance identified errors in the area of planning review, specifically inadequate review of procedures or surveillances; however, the licensee failed to identify planning review as an area for 10improvement. Consequently, the licensee failed to initiate a CARD identifying planningreview as an area for improvement. On September 13, 2007, an event occurred with the station air system which was due to inadequate planning and review of the work instructions. The licensee entered the inspectors' concerns with the self-assessment program into the corrective action program as CARD 07-24971. d.Assessment of Safety-Conscious Work Environment (1)Inspection ScopeThe inspectors assessed the station's safety conscious work environment throughreviews of the employee concern program implementing procedures, discussions with the ombudsman responsible for administration of the employee concern program, a review of the issues brought to the program, interviews with personnel from various station departments, and reviews of issue reports. The inspectors also reviewed the results from Safety Culture Assessments conducted by the Utilities Service Alliance (USA) in 2003 and 2006 and a contractor evaluation and a subsequent follow up evaluation.

(2)AssessmentNo findings of significance were identified. Based on the external safety conscious workenvironment reviews that affirmed an adequate safety culture, the lack of negative feedback to the inspectors during interactions and interviews with licensee staff, and lack of safety culture issues brought to the CAP and ECP, inspectors concluded that the plant safety conscious work environment was adequate to support safe plant operations.

The inspectors did note however that the methods adopted by the USA for SCWE evaluation no longer included an anonymous survey of plant worker attitudes. The last anonymous survey had been conducted at the plant in 2005 with adequate results.4OA6Meetings

.1 Exit MeetingOn September 14, 2007, the inspectors presented the preliminary inspection results toJoe Plona, Site Vice President, and other Fermi personnel.

The inspectors stated that they had reviewed proprietary and confidential information during the inspection but that that information would not included in the inspection report. ATTACHMENT:

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

LicenseeBill Axelson, ConsultantLinda Bugoci, Manager Corrective Action

Terry Brown, Manager Radiation Protection

Matt Caragher, Director Nuclear Engineering

Dale Chupurdy, Maintenance Specialist

Wayne Colonnello, Director Nuclear Support

Tom Dong, Manager Nuclear Performance Engineering & Fuels

Sam Hassoun, Licensing Principal Engineer

Beth Hare, Supervisor Component Engineering

Kevin Hlavaty, Director Nuclear Production

Ken Howard, Manager Nuclear Plant Support Engineering (PSE)

Joe Janssen, Manager Nuclear Maintenance

Rod Johnson, Supervisor Compliance

Dave Keskitalo, Supervisor Radiological Engineering

Ed Kokosky, Manager Nuclear Training

Kendra Hullum-Lawson, PSE-Mechanical/Civil Senior Engineer

John Louwers, Supervisor QA

Mark McDonough, Fire Protection Engineer

John Moyers, Manager Nuclear Quality Assurance (QA)

Dwi Murray, Licensing Engineer

Dan Noetzel, Manager Engineering 1st Team

Peg Offerle, Supervisor Corrective Action

Joe Plona, Site Vice President

Mike Philippon, Director Nuclear Assessment

Kent Scott, Manager Nuclear OperationsKirk Snyder, Manager Nuclear System Engineering

Tom Stack, Manager Nuclear Security

Stan Stasek, Director Nuclear Projects

Greg Strobel, Operations Engineer

Tom Thomas, Ombudsman

Sue Uema, Supervisor PSE-DesignNuclear Regulatory Commission

C. Lipa, Chief, Reactor Projects Branch 4

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ITEMS OPENED, CLOSED, AND DISCUSSED

Opened and

Closed

05000341/2007007-01 FINInadequate Main Unit Transformer Cleaning Procedures

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LIST OF DOCUMENTS REVIEWED

The following is a list of licensee documents reviewed during the inspection, includingdocuments prepared by others for the licensee.

Inclusion of a document on this list does not