IR 05000341/2009007

IR 05000341-09-007 on 09/21/2009 - 10/5/2009 for Fermi Power Plant, Unit 2, Biennial Problem Identification

ML093140550
Person / Time
Site:	Fermi
Issue date:	11/10/2009
From:	Jack Giessner Reactor Projects Region 3 Branch 4
To:	Jennifer Davis Detroit Edison
References
IR-09-007
Download: ML093140550 (27)

Text

UNITED STATES ber 10, 2009

SUBJECT:

FERMI POWER PLANT, UNIT 2, NRC BIENNIAL PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000341/2009007

Dear Mr. Davis:

On October 5, 2009, the U.S. Nuclear Regulatory Commission (NRC) completed a biennial team inspection of problem identification and resolution at your Fermi Power Plant, Unit 2.

The enclosed inspection report documents the inspection findings which were discussed on October 5, 2009, with Mr. J. Plona and other members of your staff.

This inspection was an examination of activities conducted under your license as they relate to the identification and resolution of problems, compliance with the Commission=s rules and regulations, and with the conditions of your operating license. Within these areas, the inspection involved selected examination of procedures and representative records, observations of activities, and interviews with personnel.

Based on the results of this inspection, no findings of significance were identified. The inspection team concluded that on the basis of the sample selected for review, in general, problems were properly identified, evaluated, and corrected. The team noted that the licensee reviewed operating experience for applicability to station activities. Audits and self-assessments were determined to be performed at an appropriate level to identify deficiencies. During interviews conducted during the inspection, workers at the site expressed freedom to raise nuclear safety concerns.

In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and its enclosure will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRC's document system (ADAMS), accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).

Sincerely,

/RA/

John B. Giessner, Chief Branch 4 Division of Reactor Projects Docket No. 50-341 License No. NPF-43

Enclosure:

Inspection Report 05000341/2009007 w/Attachment: Supplemental Information

REGION III==

Docket No: 50-341 License No: NPF-43 Report No: 05000341/2009007 Licensee: Detroit Edison Company Facility: Fermi Power Plant, Unit 2 Location: Newport, MI Dates: September 21 through October 5, 2009 Team Lead: J. Rutkowski, Senior Resident Inspector, Davis-Besse Inspectors: J. Gilliam, Reactor Inspector R. Jones, Resident Inspector T. Steadham, Resident Inspector G. Wright, Project Engineer Approved by: J. Giessner, Chief Branch 4 Division of Reactor Projects Enclosure

TABLE OF CONTENTS 4. OTHER ACTIVITIES ......................................................................................................2 4OA2 Problem Identification and Resolution (71152B)..................................................2 4OA6 Management Meetings - Exit Meeting Summary ...............................................10 SUPPLEMENTAL INFORMATION ...............................................................................................1 KEY POINTS OF CONTACT.....................................................................................................1 LIST OF ITEMS OPENED, CLOSED AND DISCUSSED .........................................................1 LIST OF DOCUMENTS REVIEWED.........................................................................................2 Enclosure

SUMMARY OF FINDINGS

IR 05000341/2009007; 09/21/2009 - 10/5/2009; Fermi Power Plant, Unit 2; Routine Biennial

Problem Identification and Resolution Inspection.

This inspection was performed by three NRC regional inspectors and two resident inspectors.

The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process, Revision 4, dated December 2006.

Problem Identification and Resolution On the basis of the sample selected for review, the team concluded that implementation of the corrective action program (CAP) at Fermi was generally good. The licensee had a low threshold for identifying problems and entering them in the CAP, however there was less than licensee-expected use of the system by site employees in some departments. Items entered into the CAP were screened and prioritized in a timely manner using established criteria and were properly evaluated commensurate with their safety significance. In general, causes for issues were adequately determined and corrective actions were generally implemented in a timely manner, commensurate with the safety significance. Some issues required reanalysis due to recurrence of the issues, in part, because of less than desired thoroughness of the original analysis and less than desired effectiveness of original corrective actions. The team noted that the licensee reviewed operating experience for applicability to station activities.

Audits and self-assessments were determined to be performed at an appropriate level to identify deficiencies. On the basis of interviews conducted during the inspection, workers at the site expressed freedom to raise safety concerns through their supervisors, through the employee concerns program, or by use of the CAP. Some interviewees stated that the CAP was less than effective for resolving issues of low significance.

NRC-Identified

and Self-Revealed Findings No items of significance were identified.

Licensee-Identified Violations

No violations of significance were identified.

REPORT DETAILS

4OA2 Problem Identification and Resolution

The activities documented in Sections

.1 through .4 constituted one biennial sample of

problem identification and resolution as defined in IP 71152.

.1 Assessment of the Corrective Action Program Effectiveness

a. Inspection Scope

The inspector reviewed the licensees corrective action program (CAP) implementing procedures and attended CAP meetings to assess the implementation of the CAP by site personnel.

The inspectors reviewed risk and safety significant issues in the licensees CAP since the last NRC biennial Problem Identification and Resolution (PI&R) inspection in September 2007. The selection of issues ensured an adequate review of issues across NRC cornerstones. The inspectors used issues identified through NRC generic communications, department self-assessments, licensee audits, operating experience reports, and NRC documented findings, including NRC observations from the last biennial PI&R, as sources to select issues. Additionally, the inspectors reviewed condition assessment resolution documents (CARDs) generated as a result of facility personnels performance in daily plant activities. The inspectors reviewed a selection of completed investigations from the licensees various investigation methods, which included root cause, apparent cause, equipment apparent cause, and quick human performance investigations.

The inspectors selected three high-risk systems, which included feedwater check valves, division 2 emergency diesel generators, and residual heat removal service water to review in detail. The inspectors review was to determine whether the licensee staff were properly monitoring and evaluating the performance of these systems through effective implementation of station monitoring programs. A 5 year review on the licensee's check valve testing program was also undertaken to assess the licensee staff efforts in monitoring for system degradation due to aging aspects. The inspectors also performed partial system walkdowns of division 2 emergency diesel generators and division 2 residual heat removal service water system.

During the reviews, the inspectors determined whether the licensee staffs actions were in compliance with the facilitys CAP and 10 CFR Part 50, Appendix B requirements.

Specifically, the inspectors determined if licensee personnel were identifying plant issues at the proper threshold, entering the plant issues into the stations CAP in a timely manner, and assigning the appropriate prioritization for resolution of the issues. The inspectors also determined whether the licensee staff assigned the appropriate investigation method to ensure the proper determination of root, apparent, and contributing causes. The inspectors also evaluated the timeliness and effectiveness of corrective actions for selected issue reports, completed investigations, and NRC findings, including non-cited violations.

b. Assessment

(1) Effectiveness of Problem Identification The inspectors concluded that, generally, concerns were being appropriately identified and captured in the CAP by the use of the CARD process. During the time period sampled, the station initiated approximately eight thousand to nine thousand CARDs per year with the majority of the documents classified as a level 3 (an adverse condition that has or would have minimal affect on the safe or reliable operation of the plant or personnel safety) or a level 4 (a condition that is not adverse to quality or a concern, suggestion, or a question that does not represent a condition adverse to quality, nonconformance, or program deficiency). The inspectors did not identify any concerns with identification of level 1 issues (a significant concern adverse to quality) or level 2 issues (an adverse condition that has potential or actual effect on safe or reliable operation of the plant or personnel safety). The inspectors did find, although it was a station expectation to document all concerns, a reluctance to document some concerns that were perceived by the organization as low-level concerns.

The inspectors determined that the station was generally effective at trending low-level issues to prevent larger issues from developing. The licensee also used the CAP to document instances where previous corrective actions were ineffective or were inappropriately closed.

Observations General Requirements Procedure MQA11, "Condition Assessment Resolution Document," stated that it applies to all personnel performing work at Fermi Energy Center. It also defined "condition" as a potential or real situation that may require further review, evaluation, or action for resolution. The situation may be adverse to quality, may not meet Fermi expectations, or may provide opportunities for improvement. Once a "condition" is identified, the condition was to be documented on a CARD. This did not always happen.

Reluctance to Initiate CARDs The Operations Department identified in self-assessment SA-08-0013 that there were gaps in the tagging process. One of the reasons identified for the gaps was that plant personnel were hesitant to report process flaws; CARD 08-22699 was initiated. CARD investigations concluded that the expectation for when to write CARDs was unclear and that there were some organizational and individual factors. The factors included concerns with getting others in trouble, lack of confidence in the CARD process to resolve issues, and CARD initiation causing strained working relationships between working groups.

Security Department apparent cause evaluations (ACEs) reviewed by the inspectors documented that prior opportunities to address some concerns were not entered into the CAP. For example, a weapons handling issue on February 6, 2008, was documented in CARD 08-20866. The resulting ACE determined that the event would not have happened if, among other reasons, the stiffener plate in the officers holster was not broken. As part of the ACE investigation, the licensee identified additional holsters with broken stiffener plates. Because some of the officers used velcro straps to help compensate for the broken stiffener plates, the inspectors concluded that the officers either knew or should have known that their holster was damaged; however, the inspectors could find no CARDs related to damaged holsters other than CARD 08-20866. This issue did not affect the sites ability to implement the security plan.

In September 2008 the licensee completed an ACE for a quality assurance audit finding on a maintenance work order (WO) not being vaulted in a timely manner (CARD 08-26117). The ACE stated the maintenance department self-identified problems with the information and with the WO tracking and close-out process but had not written a CARD.

Inspection Team Examples The inspectors conducted a field walkdown of two systems within the residual heat removal complex. The inspectors identified three low-significance conditions that were not previously identified by CARDs. The licensee subsequently wrote CARDs 09-27814, 09-27815, and 09-27862 to document the low-significance conditions.

During interviews with station personnel, the inspectors were told that due to some low-level issues not getting fixed, or not getting fixed in a timely manner, and due to the cumbersome nature of the CARD and work management processes (making it difficult to determine issue status), some individuals felt discouraged from identifying low-level issues in the CAP. If a CARD needs a WO to direct work to correct the identified condition, the CARD may be closed to the WO, however, the condition documented in the CARD may not have been corrected. Interviewees said this makes tracking the actual completion of a particular issue/condition difficult. The licensee initiated CARD 09-28028 to address the concern.

The inspectors also identified that immediate action documentation did not become part of the CARD documents in cases where the immediate actions were to provide "coaching." This was based on some individuals perception that coaching is the first level of discipline and disciplinary actions are not documented in CARDs. The licensee documented the identified condition in CARD 09-28027.

Findings No findings of significance were identified.

(2) Effectiveness of Prioritization and Evaluation of Issues The inspectors concluded that the station was generally effective at prioritizing and evaluating issues commensurate with the safety significance of the identified problem.

The inspectors determined that the Corrective Action Review Board and Ownership Screening Committee meetings were generally thorough and maintained a high standard for approving and reviewing CARDs. The timeliness of initial classifications and the level of classification appeared consistent with the licensees procedures. The inspectors determined that the licensee was generally effective at evaluating equipment functionality requirements after a degraded or non-conforming issue was identified.

While most evaluations were good, some evaluation weaknesses observed by inspectors could be characterized as addressing the symptoms rather than the causes.

Several conditions in the inspection period occurred which had been identified earlier, but were not corrected in time to prevent a recurrence of the condition. These included conditions with scaffolding and with feedwater check valves.

Observations Comprehensiveness of Evaluations CARD 08-25796 was issued to document a violation of high radiation area (HRA) entry requirements by two workers. The workers had signed onto the radiological work permit (RWP) under the incorrect task and subsequently entered a HRA without authority. The ACE identified inadequate self-checking as the apparent cause; however, the information provided in the CARD file indicated that the workers were confused and uncertain about the task requirements. A subsequent common cause analysis identified additional causes which better supported the evidence documented.

The inspectors concluded that the licensee missed opportunities to identify and correct underlying human performance issues that contributed to additional events within the Security Department because an initial evaluation of a condition was narrowly focused.

The licensee discovered a weapon in an unsafe configuration on August 8, 2008, documented the issue in CARD 08-25081, and performed an ACE. The licensee concluded the apparent cause was an inadequate use of human performance tools to ensure the weapon was configured properly. Over the next 4 months, four additional weapons-related human performance errors occurred. The licensee identified an emerging trend, initiated CARD 08-28155, and performed a common cause analysis.

The licensee concluded that an inadequate use of human performance tools contributed to each of those events and developed corrective actions to address the trend. The licensee missed the opportunity to evaluate why corrective actions from the prior ACE were not effective in improving the use of human performance tools. CARDs 09-27693 and 09-27695 were issued to document the NRC observations. This issue did not affect the sites ability to implement the security plan.

During refueling outage 13 in April 2009, the inboard isolation check valve for the B feedwater line, B2100F010B, failed its as-found local leak rate test (LLRT). The licensee documented the failure in CARD 09-22205 and performed a root cause evaluation (RCE). The root cause charter included the requirement to review the effectiveness of prior corrective actions. The inspectors concluded that the licensees efforts in completing this charter item were less than adequate. Specifically, the section of the RCE that discussed prior evaluations only provided a list of deficiencies but offered no conclusions as to why two previous RCEs and 11 CARDs failed to identify and correct the cause of repeated LLRT failures. Additionally the action to review effectiveness of prior actions, which was captured in the CARD as action item number 11, was assigned a due date of November 13, 2009. The inspectors concluded that the licensee could not have adequately addressed the charter item to review the effectiveness of prior corrective actions as part of the RCE since the RCE was completed prior to the action item scheduled date. The licensee initiated CARD 09-27863 to document the NRC observation.

Extent of Condition CARD 09-25098 documented an adverse trend associated with the storage of scaffolding. The licensee's scaffolding review identified 22 scaffold CARDs issued from January 2008 through July 2009. Of these, 17 were identified by outside agencies; NRC identified 16 of the documented conditions. One deficiency identified as part of the investigation was that there was a lack of understanding of and questioning attitudes for the requirement to maintain plant configuration control.

CARDs 08-20866, 08-20866, and 08-26117 previously discussed in this report each identified concerns with identification of low-significance items. Additionally CARD 08-25436 documented a safety culture assessment team concern with identification of low-level issues. The inspectors did not identify a document for determining the extent of each condition and if there were any common factors.

CARDs 09-28027, 09-28032, and 09-28028 were written during this inspection to address identified concerns with documenting low-level concerns.

Findings No findings of significance were identified.

(3) Effectiveness of Corrective Actions The inspectors concluded that corrective actions for identified deficiencies were generally timely and adequately implemented, commensurate with their safety significance. Problems identified using root or apparent cause methodologies were resolved in accordance with licensee program and NRC requirements. The inspectors also sampled corrective actions assignments for selected NRC documented violations and findings and determined that the actions were generally effective and timely.

However the inspectors did notice a number of untimely and ineffective corrective actions as described below. The inspectors concluded that identified untimely and particularly ineffective corrective actions were, in part, due to lack of effective evaluation of the original issues.

Observations During refueling outage 13 (RF13) in April 2009, the inboard isolation check valve for the B feedwater line, B2100F010B, failed its as-found LLRT. CARD 09-22205 documented the failure and the licensee performed a root cause evaluation (RCE).

The RCE identified deficiencies with prior evaluations on feedwater check valve LLRT failures dating back to the late 1980s. The licensee determined that corrective actions from two previous RCEs were not effective in preventing the LLRT failure in RF13.

Because of the long history of LLRT failures on these valves and inadequate root cause evaluations, the inspectors documented a Non-Cited Violation (NCV) of Criterion XVI in inspection report 05000341/2007004 for the failure to identify the cause and take appropriate corrective actions. The inspectors concluded that the B2100F010B LLRT failure in RF13 did not constitute a violation of regulatory requirements because the corrective actions taken in RF12 to improve LLRT performance were effective in preventing a repeat penetration failure. Specifically, the outboard isolation check valve for the B feedwater line, B2100F076B, passed its as-found LLRT thereby preserving the integrity of the penetration within Technical Specification limits.

Operator distraction 2006-050 for waste collector tank (WCT) sample line being plugged was a long-standing issue. Multiple CARDs and WOs were initiated to resolve the distraction; however, initial efforts to correct this distraction failed and subsequent additional troubleshooting and investigations were required. Following several internal meetings, a comprehensive WO was planned to consolidate the corrective action implementation activities. The implementation plan did not address all operational and technical specification requirements, and was not performed. The work was later restructured to be performed in two major portions; all work outside the WCT was scheduled for November 2009 and all work inside the tank was scheduled for the next refueling outage.

CARD 09-25098, discussed in the previous section of this report, documented an adverse trend associated with the storage of scaffolding. The licensees review of the trend identified 22 scaffold CARDs issued from January 2008 through July 2009. The adverse trend investigation documented that ineffective corrective actions in the response to identified scaffold concerns led to nine repeat scaffold storage CARDs.

CARD 08-25436 documented that the Nuclear Safety Culture Assessment team found the reluctance of personnel to document low-level concerns. An action plan to address the concern was formulated and documented as complete on February 20, 2009. The inspectors determined the original concern still exists. CARDs 09-28027, 09-28032, and 09-28028 were written during this inspection to address NRC-identified issues with documenting low-level concerns.

Findings No findings of significance were identified.

.2 Assessment of the Use of Operating Experience

a. Inspection Scope

The inspectors reviewed the licensees implementation of the facilitys Operating Experience (OE) program. Specifically, the inspectors reviewed implementing OE program procedures, attended CAP meetings to observe the use of OE information, completed evaluations of OE issues and events, and selected monthly assessments of the OE composite performance indicators. The inspectors review was to determine whether the licensee was effectively integrating OE experience into the performance of daily activities, whether evaluations of issues were proper and conducted by qualified personnel, whether the licensees program was sufficient to prevent future occurrences of previous industry events, and whether the licensee effectively used the information in developing departmental assessments and facility audits. The inspectors also assessed if corrective actions, as a result of OE experience, were identified and effectively and timely implemented.

b. Assessment Operating experience was reviewed by the licensee and evaluated for applicability to Fermi. Necessary corrective actions and program enhancements from the licensee OE evaluations were placed into the CAP.

Observations The inspectors reviewed root cause evaluations (RCEs) associated with two local leak rate testing (LLRT) failures as documented in CARDs 07-25836 and 09-22205. The inspectors noted that each RCE included detailed discussions of both external and internal OE. Notably, the OE discussion contained in both was a significant improvement when compared to the RCE completed as a result of the April 1, 2006, LLRT failure as documented in CARD 06-21751. Specifically, the 06-21751 RCE failed to review the licensees own internal operating experience which showed that the proposed corrective actions were not consistent with the operating experience of the feedwater check valves. In the 09-22205 RCE, the licensee sought to understand the relevant internal and external operating experience and how that information affected the proposed corrective actions.

Findings No findings of significance were identified.

.3 Assessment of Self-Assessments and Audits

a. Inspection Scope

The inspectors assessed the licensee staffs ability to identify and enter issues into the corrective action program, prioritize and evaluate issues, and implement effective corrective actions, through efforts from departmental assessments and audits.

b. Assessment The inspectors concluded that self-assessments and audits were typically accurate, thorough, and effective at identifying issues and enhancement opportunities at an appropriate threshold level. The inspectors concluded that these audits and self-assessments were completed by personnel knowledgeable in the subject area. In many cases, these self-assessments and audits had identified concerns that were not previously recognized by the station in formal documents. Those concerns were entered in the CAP. The inspectors found that identified concerns were further evaluated as required by the CAP.

Findings No findings of significance were identified.

.4 Assessment of Safety Conscious Work Environment

a. Inspection Scope

The inspectors assessed the licensees safety conscious work environment through the reviews of the facilitys employee concern program implementing procedures, discussions with coordinators of the employee concern program, interviews with personnel from various departments, and reviews of issue reports. The inspectors also reviewed the results from a safety culture assessment which included survey results.

b. Assessment The licensee had a safety culture assessment performed by Utilities Service Alliance (USA) in July of 2008. The USA team was comprised of 12 individuals with 7 being from sites other than Fermi. The methodology included a site survey, documentation reviews, site observations, and interviews. While the assessment had a number of observations/recommendations, the inspectors identified a number of issues with the report. From the data provided, the inspectors were not able to determine if the overall conclusion in the report was appropriate. Additionally, by design, the documented assessment was not able to show if certain groups in the station were outside the established and expected norm. Also, the report did not provide the licensee information on how their culture compared to industry norms.

The inspectors interviews with licensee personnel indicated that personnel were free to raise issues either directly with their supervisors, by use of the CAP, or through the Employee Concerns Program. However, some of the interviewed personnel felt the CAP was ineffective in addressing low-level issues.

Observations Safety Culture Assessment The report indicated that approximately 49 percent of the 1000+ individuals available to take the survey responded. The report, however, did not address whether this was a sufficient number of individuals upon which to draw reasonable conclusions. By design, the survey did not collect demographic information from the individuals answering the survey. Without this information, the inspectors were not able to determine whether specific organizations were under-represented in the survey, whether there were significant differences between organizations, or if the survey results were being skewed by high participation organizations.

The licensee's assessment team interviewed approximately 60 individuals, out of a population of 1000+, from across the site organizations. Without the demographic information, the selection of individuals might not be an informed selection and the ability of the NRC inspection team to confirm/validate the surveys results was hampered. At the conclusion of the inspection, the licensee did provide a list of individuals interviewed and their respective departments but this listing did not correlate departments to interview responses.

The assessment concluded that Fermi 2 nuclear station has a strong Nuclear Safety Culture... However, there was no discussion on how this conclusion was reached, especially compared to the survey results. For example, the survey results indicated that only 55 percent of the respondents agreed with Principle 1 Everyone is personally responsible for nuclear safety, only 48 percent of the respondents agreed with Principle 2 Leaders demonstrate commitment to safety, and only 51 percent of the respondents agreed with Principle 3 Trust permeates the organization. While the inspectors did not disagree with the conclusion, it was not obvious how it was reached given the lack of positive survey results.

The results from the interviews and observations, as seen in the survey, were not broken down by functional organization and therefore it was not possible to identify specific issues within organizations. In the case of the interviews, the USA team would have been aware of the interviewees organizational affiliation; however, that information was not presented in the report. In addition, the number of individuals from each organization was not provided in the report and no discussion regarding whether the sample size was representative was provided. The assessment team did identify some concerns that were documented in CARDs 08-25422, 08-25424, 08-25434, and 08-25436. Those concerns were not identified as specific to any organization, although some examples within the CARDs did list specific departments.

Safety Culture Work Environment Interviews The inspectors interviewed personnel from across the station organization. Most of the people interviewed were first line supervision or below in the organizational structure.

Interviewees were Detroit Edison employees and long-term contractors. All but one of the interviewed personnel stated that they felt free to raise issues either with their supervisor, through the CAP, or through the Employee Concerns Program and that there were no adverse personal consequences from raising concerns.

Some Detroit Edison craft personnel stated that the CAP was effective for significant concerns but not for resolving issues that were perceived as low-significance. Thus they expressed reluctance to document low-level issues in the CAP. It was viewed that low-significance items would not be resolved, or not resolved to their satisfaction, and/or would take an inordinate period of time to resolve. Several of the interviewees said they seldom, if ever, wrote CARDS.

Most interviewees stated they were comfortable in bringing concerns to the attention of their supervisors. Several interviewees stated, however, that their supervisors also expressed the belief that conditions associated with low-level concerns would either not be addressed or not addressed in a timely manner.

The licensee initiated CARD 09-28028 to document the inspectors' observations.

Findings No findings of significance were identified.

4OA6 Management Meetings - Exit Meeting Summary

On October 9, 2009, the inspectors presented the inspection results to Mr. J. Plona, Site Vice President, and other members of the licensee staff. The licensee acknowledged the issues presented. The inspectors confirmed that none of the potential report input discussed was considered proprietary.

ATTACHMENT:

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee

M. Clements, Trending Coordinator-Corrective Action Program

R. Eberhardt, Performance Improvement Manager

R. Johnson, Licensing Manager

J. Pendergast, Principal Engineer-Licensing

D. Sadowyj, Senior Engineer-Corrective Action Program

T. Thomas, Ombudsman-Employee Concerns Program

Nuclear Regulatory Commission

R. Morris, Senior Resident Inspector

LIST OF ITEMS

OPENED, CLOSED AND DISCUSSED

None Attachment