IR 05000341/1985040

Forwards Order Modifying License & Notice of Violation & Proposed Imposition of Civil Penalties in Amount of $300,000 Based on Violations Noted in Insp Rept 50-341/85-40 on 850701-1014 Re Rod Pull Errors & Premature Criticality

ML20209E806
Person / Time
Site:	Fermi
Issue date:	07/03/1986
From:	Taylor J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE)
To:	Mccarthy W DETROIT EDISON CO.
Shared Package
ML20209E709	List: IR 05000341/1985040 IR 05000701/2010015 ML20209E702 ML20209E725 ML20209E744 ML20209E759 ML20209E779 ML20209E832
References
EA-86-061, EA-86-61, NUDOCS 8609110359
Download: ML20209E806 (4)

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Attachment 11 GNNTBD AT5s NUCLEAR REGULATORY COMbfl8SMm WaSetMS 7081, D. C. M

\c-) . at o un Docket No. 50-341 License No. NPF-43 EA 86-61 The Detroit Edison Company

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ATTN: Walter J. McCarthy, J Chairman of the Board and Chief Executive Officer 2000 Second Avenue Detroit, MI 48226 -

Gentlemen:

SUBJECT: ORDER MODIFYING THE LICENSE EFFECTIVE D94EDIATELY AND NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES (NR; INSPECTION REPORT N /85040(DRP))

This refers to the inspection conducted by the NRC during the period. July 1 -

October 14, 1965, of activities authorized by NRC License Nc. hPF-43 for Ferr.i-2 and interviews conducted by the Office of Investigations with employees involved in the control rod pull error on July 1-2, 1985. While this inspection also identified additional violations that will be addressed in separate correspondence, the ma.jor emphasis was to review the circumstances associated with the control rod pull errors, premature criticality, and subsequent reconsnencement of rod pulling which o: curred July 1-2, 1985. The inspection report (50-341/85040 (DRP))

identified violations of NRC requirements associated with this incident and was provided to you on January 7,1985. On May 9, 1986 an enforcement conference was held with you and menbers of your staff to discuss the incident, the relatec violations, their causes, and your proposed corrective action.

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On July 3,1985, members of your staff provided information to the resident inspector on a rod pull error, acknowledging that company procedures had been violated and that there may have been a premature criticality. On July 4, 1985, the Shift Reactor Engineer made a detemination that the reactor had been critical with a 114 second perio It was not until after meetings on July 4 and 5,1985 that Detroit Edison Company (Deco) mana9ement initiated an investigation into the cause of the premature criticality. After Region !!!

was notified of the criticality on July 15, 1985, the licensee's corrective actions were confirmed in a Confimatory Action Letter dated July 16, 198 The inspection and investigations into the events that preceded and followed the premature criticality revealed a major breakdown in the perfomance of control room personnel, in the management of control room activities, and in the evaluation of the incident 1smediately following the rod pull error. This l breakdown wes illustrated in part by the lack of ex serienced shift personnel, !

the disregard for established procedures exhibited ny the Nuclear Supervising Operator (N50) and Nuclear shift Supervisor (NS$), the failure of key shift CERT!FIED MAIL-RETuRK RECEly1 RE0uESTED e6ov11oas9 e60e27 RES E PDR '

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l The Detroit Edison Campasy -2- i l

personnel to fully understand their responsibilities and exercise supervisory oversight, failure to properly use the Shift Operations Advisor (504) and a lack of sensitivity to onpoing processes, incidents, and events demonstrated by shift personnel. The 'ack of involvement and awareness by the NSS, a senior licensed operator, to the evolutions in process and their potential consequences was particularly egregiou The premature criticality occurred when the inexperienced N50 who was in

' control of the reactor startup failed to follow the rod pull sheet and pulled eleven control rods to the Yull-out position (48) rather than position M and mistakenly verified the position as 04 for each rod. The MSO had never taken the reactor critical before and received only casual observation from an unlicensed Shift Technical Advisor in Training. Other members of the shift -

crew were preoccupied with other tasks and at some time during the event were absent from the control room. The MSS who was responsible for managing the shift and overseeing startup activities, and the 50A who was to provide the experience factor for the shift and guidance to inexperienced operators, did not directly observe the rod pulls or respond to the five short period alar annunciations. Wher, the NSO did recognize his rod pull error, he proceeded to reinsert the rods and had the M55 notified. The M55's review of the incident was shallow and he pervitted the N50 to start withdrawing control rods again without adequately analyzing the causal factors that led to the inciden Iter. I described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalties involves the error by a reactor operator (the Nuclear Supervising Operator) in pulling eleven control rods to the full-out position.

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The reactor operator did not follow the specified rod pull procedure and, in additior., improperly verified and documented the position of the cor. trol rod Contributing to this error were the relative inexperience of the reactor operator and the fact that his training on a simulator had used a rod pull sequence different fron. that used in the actual plan Itee II involves violations associated with the lack of the overall oversight of the control roce during rod pulling which was especially important in view of the lack of operator experience of the NSS and NSO. This was compounded by the failure to use the shift advisors who were there, in part, to compensate for the lack of reactor experience on shift. The July 1-2 event demonstrated the significant failure to properly supervise control room activities and a lack of coordinated efforts in the control roor during a significant plant evolutio Item III involves the failure of the MSS to recognize the significance of the rod pull error and his direction that startup be resumed shortly after the mispositioned rods were returned to their proper position. This violation illustrates a lack of understanding of the need to pro of the rod pull error, a significant procedural error,perly assess startup, before resuming the causes to evaluate the consequences of the svent, and to fuplement effective corrective

actions. The decision by the MS$ to resume rod pulling was based on minimal l

review and evaluation contrary to quality assurance requirements and a management directive to suspend safety-related activities after an event until the problem tes been identified, its cause determined, and a solution formulated and implemente .

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The Detroit Edison Compavy -3-To emphasias the need for you to ensure that there is proper oversight of control room activities and that control room personnel and supervisors responsibly and professionally discharge their licensed and procedural dutie I have determined, after consultation with the Commission, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalties in the amount of Three Hundred Thousand Dollars (5300,000) for the violations set forth in the enclosed Notice. In accordance with the " General $tatement of Policy and procedures for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1985)

(Enforcement Policy), the violations described in the enclosed Notice have been categorized as three separate Severity Level III problems. Each of the problems represents a serious breakdown in the management controls and discipline in the control room and, therefore, the base civil penalty was escalated to

$100,000 for the violations associated with each probles area for a total of

$300,000. ,Given the seriousness of this matter, mitigation was not considered -

cppropriat The enclosed order Modifying the License (Ismediately Effective) is based in part on the supervisory weaknesses of the Nuclear Shift Supervisor exhibited during the July 1-2, 1985 rod pull error and subsequent events. As the most responsible representative of licensee management in the control room at the time of the incident and as a senior licensed operator, he is individually )

responsible for the activities in the control roan. The July 1-2 incident 1 reflects a failure by this individual to perform at the level expected of licensed supervisory personnel. Therefore, the Order requires that the licensee demonstrate that 'the Nuclear Shift Supervisor has been retrained and reexamined before he is allowed to resume licensed or supervisory responsibilities in the control room. The July 1-2 incident also reflects inadequate procedures and actions of other control root personnel (Nuclear Assistant Shift Supervisor, Nuclear Supervising Operator, shift Reactor Engineer, and Shift Operations Advisor). Thus, the enclosed Order also requires the implementation of a control room audit prograr. to further ensure activities in the control roar are conscientiously carried out. Letters will also be sent to the shift personnel in the control room during the rod pull incident to emphasize their individual responsibilities for safe operation of the facilit An additional matter of considerable concern to me is the lack of forthrightness i exhibited by DECO management in effectively communicating to the NRC in a timely

! manner all of the information concerning the rod pull error known to Deco. We recognize that while this was not a reportable event, you provided some information te the Resident Inspector about the event on July 3,1985. However, even though the decision on full power licensing was imminent, you did not inform the Resident Inspector, the Region III Office, or NRR that you had determined on July 5,1985 that Femi had, in fact, gone critical on July 1, 1985. More importantly, notwithstanding that this event represented a gross error caused by inexperienced personnel with insufficient management control, neither Mr. Lenart. Assistant Manager, Nuclear production Dr. Jens Vice president, Nuclear Operations, nor anyone else employed by Deco prior to the issuance of full power license on July 15,1985 corrected the impression left by the staff at the July 10, 1985 Cosuission meeting that DECO was en outstanding perfomer in the area of control room operation Deco should have recognized that the performance of personnel and management had significance beyond the technical issues associated with the rod pull error ,

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The Detroit Edison Caspary -4-itself and, therefore, corrected the erroneous impression which the staff had at the time'of licensing. Without addressing whether this failure constitutes a legal violation, it clearly represents a departure from the highest standards of cossanication and candor that we expect from licensees at all times and especially at sensitive times in the regulatory process such as at the time of licensing. I espect that in the future Deco will fully emot these standard You are required to respond to this letter and should follow the instructions specified in the enclosed Notice and Order when preparing your msponse. Your response should specifically document the corrective actions taken or any additional actions to increase management attention and direction over the operation of the Fermi-2 facility. After reviewing your response to this  :

Notice and Order, including your proposed corrective actions, the NRC will l determine whether further enforcement action is necessary to ensure compliance !

with regulatory requirement I In accordance with 2.790 of the NRC's " Rules of Practice," Part 2, Title 10 Code of Federal Regulations, a copy of this letter and its enclosure will be placed in the NR; Public Document Roc The responses directed by this letter and the enclosed Notice and Order are not subject to the clearance procedure of the Office of Managemsnt and Budget, as required by the Paperwork Reduction Act of 1980, PF 96-51

Sincerely,

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. JamesM. Taylor / rector

.fice of Inspe: tion and Enforcene Enclosures:

1. Order Modifying License 2. Notice of Violation and Proposed Imposition of Civil Penalty cc w/ enclosure:

L. P. gregni Licensing Engineer P. A. Marquardt, Corporate Legal Department Licensing Fee Management Branch Resident Inspector. RIII Ronald Callen, Michigan Pubite service Cosmission *

Harry H. Voigt. Es Nuclear Facilities and Environmental Monitoring Section Monroe County Office of Civil Preparedness

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