ML20140D352
| ML20140D352 | |
| Person / Time | |
|---|---|
| Site: | Fermi  |
| Issue date: | 06/02/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20140D327 | List: |
| References | |
| 50-341-97-02, 50-341-97-2, NUDOCS 9706100356 | |
| Download: ML20140D352 (75) | |
See also: IR 05000341/1997002
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U.S. NUCLEAR REGULATORY COMMISSION
REGION 3
Docket No: 50-341
License No: NPF-43
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Report No: 50-341/97-02
Licensee: Detroit Edison Company (DECO)
Facility: Enrico Fermi, Unit 2
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Location: 6400 N. Dixie Hwy. I
Newport, MI 48166 l
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Dates: February 1 through March 19,1997
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inspectors: G. Harris, Senior Resident inspector ,
C. O'Keefe, Resident inspector !
Approved by: Mike Jordan, Chief, Branch 5 i
Division of Reactor Projects
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9706100356 970602 N
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EXECUTIVE SUMMARY
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Enrico Fermi, Unit 2
NRC Inspection Report 50-341/97002
This inspection included aspects of licensee operations, engineering, maintenance, and i
plant support. The report covers a 6-week period of resident inspection.
Operations
e A non-licensed operator improperly operated a knife switch without properly
identifying it, tripping both' generator output breakers when the generator was
shutdown. Lack of supervision, system knowledge, and procedural guidance
contributed to the operator taking the inappropriate action. (04.1)
I e' The inspector noted continued improvement in operator control room formality,
. operator shift briefings, and communication of issues to site management. (01.1)
e Review of unresolved item 50-341/96016-03 identified failure of operators to
document a problem with calibration of the oxygen monitor. This is an apparent
l violation. (E8.1)
Maintenan.ca
e The inspectors identified weaknesses in the control of troubleshooting performed ,
before initiating a work request. Troubleshooting was performed by operators that !
did not have the appropriate skills to do the checks. Also, an annunciator card was ;
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removed from an operable Emergency Diesel Generator (EDG) to troubleshoot a ;
l- - problem in another EDG. Since the root cause of the original failure had not been l
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determined, operability of both EDGs was put into jeopardy. (Mt.2)
e The inspectors identified weaknesses in foreign material exclusion during the
- conduct of maintenance for the high pressure coolant injection valve. (M2.1) l
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e Two equipment functional failures occurred in EDG 14. Licensee operability
determinations and repair efforts showed good coordination and communication
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between Operations, Maintenance, and System Engineering. (M2.2)
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l Enaineerina
e The licensee identified an error in the computer calculation of reactor power. This
l was reported because at times during three previous operating cycles, the
maximum licensed power limit was exceeded by 0.6 MWth. (E3.1)
e The licensee identified several design issues that potentially placed the Emergency
l Equipment Cooling Water System outside its design basis. Modification and
i analytical work was in progress to resolve the issues at the end of the inspection.
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(E3.2)
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The inspectors identified that the licensee operated with less than the required
number of primary containment oxygen monitors during nine periods in the past.
The monitors were rendered inoperable unknowingly because the calibration method
induced a non-conservative error. The inaccuracy was identified in mid-1996 by
System Engineering and Operations was notified; however, the operability
implications were not recognized and investigated. This is an apparent violation.
(E8.1)
Plant Suonort
e Excellent radiological protection support was observed during calibration work in a
contaminated sump. Workers identified a good way to perform work from outside
the contaminated area, minimizing exposure. (R1.1)
e inspectors assessed selected portions of the February Emergency Preparedness
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Drill, which included partial state and local participation. Overall performance was l
acceptable. (P1.1) !
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e Inspectors identified improper control of a visitor inside the protected area by a ;
guard performing escort duties. This will be further reviewed by a regional security
l specialist inspector. (S1.1)
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e The licensee identified poor administrative control of designated vehicles. This will
be further reviewed by a regional security specialist inspector. -(S1.2)
e Inspectors identified a security door card reader that was fully functional and being
used, but which was labelled as inactive and for emergency use. This was
considered a weak practice. (S1.3)
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Report Details
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[ Summary of Plant Status
- Unit 2 spent this inspection period shutdown to conduct repairs to the main generator i
j required as the result of a switchyard breaker failure which led to motorizing the generator.
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During this forced outage, engineering identified several design issues with the Emergency
] Equipment Cooling Water (EECW) System. These issues will have to be addressed prior to
i startup, and willinvolve some modifications to the plant. Also, a motor operated valve
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(MOV) failure in the High Pressure Coolant injection (HPCI) System occurred; licensee
- corrective actions included inspection and possible modification of over 70 other safety- -
- significant MOVs to ensure similar problems do not exist. These inspections continued at
i the close of this inspection period.
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1 1. Operations '
l 01 Conduct of Operations
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01.1 General Comments (71707)
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Using Inspection Procedure 71707, the inspectors conducted frequent reviews of
j plant operations. Inspectors routinely attended Operations shift turnovers to assess
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the quality of the briefings on plant status and problems encountered. Operator
response to alarms was observed and compared to alarm response procedures. ]
- Procedure use and procedure quality was assessed. Operator control of work .l
- activities was observed. Operator support of work and test activities was also
observed.
t - The inspectors observed that improvements noted in inspection Report 96016 in
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the areas of control room formality and improved operator radio and face to face )
i communications continued during this inspection period. Operator shift briefings l
l were improved by having each watchstander report the status of equipment and i
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operations in progress in the area of his responsibility. Also, plant status and
i Operations concerns were reported to management at the morning meeting by the 3
Nuclear Shift Supervisor (NSS), improving communications with the site. l
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, The inspectors reviewed control room and NSS logs daily. The inspectors noted
i' that recent licensee efforts to improve tho quality of operator logs was evident.
Log entries were beginning to include more detail, particularly in explaining why
< actions were taken or the basis for important decisions.
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! The inspector noted that, while plant operations have been somewhat limited during
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this inspection, operator errors were low. A significant exception to this is j
discussed in Section 04.1. 1
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! 02 Operational Status of Facilities ar.d Eaulpment t
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l 02.1 - Enaineered Safety Feature System Walkdowns (71707)
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} The inspectors used inspection Procedure 71707 to walk down accessible portions
- of the following safety significant systems:
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! * Division 1. Emergency Equipment Cooling Water System (EECW)
l * Standby Liquid Control System (SBLC)
i e Reactor Core Isolation Cooling System (RCIC)
- e Standby Feedwater System
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o- Division 1 Standby Gas Treatment System
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- Fuel Pool Cooling
- e Emergency Diesel Generator (EDG) 12
l. Equipment operability, material condition, and housekeeping were determined to be
j acceptable. Several discrepancies were brought to the licensee's attention and j
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were corrected. l
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The inspectors identified that the Fuel Pool Cooling Trouble Alarm was marked as
j being defeated for work that was already completed and tags had been removed.
Operators had failed to remove the " alarm defeated" placard when clearing tags.
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j The inspectors identified several strip heater junction boxes used to heat SBLC
l piping were not properly secured. Also, the inspectors identified seven carts in the j
i reactor building which were not adequately restrained to avoid damaging safety .)
j related equipment during a seismic event. These included heavy carts secured to i
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non-seismic conduit and a cart loaded with portable lead shielding tied to a
temporary boundary rope post. This was a minor violation, and will not be cited
because the requirements of Section IV of NUAEG-1600, " Gen'o ral Statement of :
Policy and Procedures for NRC Enforcement Actions" were met. l
(NCV)(50-341/97002-01)
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The inspectors identified a vertical channel used as a pipe support in the EDG 12 I
Fuel Oil Storage Room which was full of fuel oil. The licensee was unable to
determine how it got there, but removed the fuel from the stanchion. The
inspectors discussed this issue with fire protection personnel and determined that it
did not constitute a fire loading beyond the design of the room, but it was
considered a poor practice.
The inspectors identified that Heat Trace Control Panel P34-P400, Circuit #1 had
power on and heater on indications, but the current meter indicated no current.
This provided heat tracing to Post Accidsnt Sampling System piping and
components. Operations confirmed the meter was not working properly and wrote i
a work request.
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- 04 Operator Knowledge and Performance
04.1 Switchina Error Canand Generator Outout Breaker Trios
a. Insoection Scone (71707)
The inspectors interviewed operators involved in the switching error to determine
the sequence of events. The controls used in switching operations for both
switchyards on site were reviewed. Discussions were held with Operations
management to determine management expectations for switchyard operations.
Corrective actions for the January 17,1996 CM breaker failure event were also
reviewed.
b.- Observations and Findinas
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On February 3, a switching order was received from the Central System Supervisor
(CSS) for the restoration of bus 302, which forms part of the 345KV Switchyard.
The switching order was given verbally by phone to the Fermi control room. This
order ir.cluded the instruction to "Put Pot [entiall Throwovers to normal."
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l The inspectors determined that Detroit Edison CSS substation switching orders
were given in general terms. The CSS was not expected to be familiar with the
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detailed steps necessary to accomplish the switch alignments. A detailed operating
I procedure did not exist. Fermi operators relied on two lists that showed normal and
alternate potential throwover switch positions. The inspectors identified that the
sheets were not verified or controlled. Operations policy required that two qualified
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! operators perform the switching evolutions.
For restoration c,f Bus 302, the manipulations should have only involved potential
throwover switches in the relay house at the 345KV switchyard. Those switches
were placed in the correct position (i.e., normalized) by a non-licensed operator
(NLO) supervised by a licensed operator. Without direction, the NLO then
proceeded to the control room relay room with the intent at normalizing additional
switches. However, there were no Bus 302 controls in ti+ nelay room. On the
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it panel for Bus 301, the NLO found a knife switch open and but it, believing he was
returning the switch to its normal position.
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The switch operated was a knife switch (different appearance and desion than a
potentiel throwover switch), which was opened during generator shutdown to
disable the main generator reverse power trip of the two generator output breakers,
designated CM and CF. When the knife switch was shut, CM and CF breakers
tripped because the reverse power logic was satisfied by the existing lineup. The
breaker trips did not interrupt offeita power.
The inspectors determined that the causes of this event included that the NLO had
never performed a Bus 302 restoration and was not adequately supervised. The
operator did not verify the function of the knife switch or self-check that it was the
right type of switch. Contributing to the knowledge deficiency, Detroit Edison had
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' no operating procedures for its substations. The CSS provided switching orders
that were not always detailed, relying heavily on operator knowledge of the local
substation design.
Operator knowledge deficiencies in the area of switchyard operations were
identified by the licensee in late 1996. Trair.ing on switchyard design, operations
and inspections were in progress at the time of the event, but the operator had not
yet received the training.
As a result of this event, the licensee took prompt corrective action to prevent
further switching errors; all switching operations were stopped pending operator
- training on switching operations and management expectations, which had been
completed by the and of this inspection. Written procedures to cover switching
operations were being created in cooperation with the CSS group at the conclusion
of this inspection, with the first procedures for the 120KV switchyard having been
approved. The non-licensed operator was removed from shift and completed
upgrading on performance and knowledge deficiencies. Additionally, the knife
switch that was improperly operated was tagged to indicate that it was to remain
open during generator shutdown periods.
c. Conclusions
This event closely followed the CM breaker failure event, which led to motorizing
the main generator when operators responded inappropriately. Both events -
involved operator knowledge weaknesses and lack of adequate instructions for
switching operations as primary causes. Licensee corrective actions for the
generator reverse power event initially concentrated on equipment inspections, but
did not promptly address the lack of procedures and training for operating
switchyard equipment. The equipment inspections resulted in a substantial increase
in the number of switching operations and increased the chances of another
operator error.
The inspectors were concerned that the operator's performance was contrary to
several principles of safe opertations; he operated equipment which he had no
specific order to operate, with'which he was not familiar, for which there was no
procedure, without supervision present or aware of the intended action, without
properly identifying that it was the correct switch, or even the correct type of
switch.
Failure to have written procedures for operating equipment in the offsite power
supply system was con'sidered a violation of Technical Specification 6.8.1.
(VIO)(50-341/97002-02)
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l1. Maintenance
M1 Conduct of Maintenance
M1.1 General Comments
a. Insoection Scone (62703)
The inspectors observed the performance of maintenance activities. This included
preparation, briefings, scheduling meetings, and tagouts in addition to actual work
performance. All or portions of the following specific work activities were
observed:
e Emergency Diesel Generator (EDG) 11,14 Fast Start Surveillances
e Sump D076 Level Switch Calibration
- Main Generator Disassembly and Inspection Activities
e RCIC Valve E51-F045 Replacement Activities
- Local Leak Rate Testing of Division 1 EECW Makeup Tank
- Sequence of Events Test 97-02, Division 1 EESW Makeup to EECW
Validation Test
e High Pressure Turbine Balancing and Reinstallation Activities
- Main Generator inspection and Disassembly
- Division 1 SBGT Filter Sampling
- Division 1 SBGT Post Maintenance Surveillance Testing
- VOTES Testing of High Pressure Coolant injection (HPCl) Valve E4150-F042
e Thermographic Inspection of Bus 11EA
e Troubleshooting of EDG 14 failures
- Troubleshooting of HPCI Valve E41-F006
- Control Rod Position Indication Probe Receipt inspections
b. Observations and Findinas
The inspectors observed disassembly of the HPCI Injection Valve (E4150-F006),
inspectors identified a concern regarding foreign material exclusion practices during
maintenance when workers left the work area for a break. The inspectors observed
that no measures were taken to exclude foreign material from entering the MOV
gearbox after the motor was removed. In response to the inspectors' concerns, the
liceneee replaced the gearbox grease to ensure no foreign material was
inadvertently introduced. The valve was successfully retested and observed to
operate normally. The inspector considers this an isolated case and will continue to
monitor the licensee's action.
The inspectors observed thermographic inspection of several electrical cabinets.
The electricians performing the inspections had been trained and were
knowledgeable on the infrared inspection equipment and how to perform the l
inspections. However, the results of the inspections were determined by the I
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judgement of the electrician. The procedure did not retain the inspection results for
later comparison, and no baseline data was available. Also, the procedure did not
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require that equipment powered thiough the cabinet be checked to determine which ;
loads were running to help identify components which would be expected to be )
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hotter. Sirnilarly, the work package brought to the work site did not include a load :
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, . list or internal sketches to aid in identification of any problems. No problems were
identified by the thermographic inspections.
The inspectors observed calibration of a new level switch installed in Sump D076
by instrumentation and Control (l&C) personnel. The inspectors observed that 2 of .
the 3 workers, each in different locations, did not have copies of the work package; *
instead, they were in communication with the work leader who had the package. l
l The inspectors noted the communications to be informal and lacked repeat-backs. i
- . The inspectors found the work instructions being used to be minimal, but pre-job
l preparation and work execution were excellent. : As discussed in Section R1.1, the
[ workers found an innovative way to stay outside the contaminated area and limit ,
exposure. The inspectors discussed the minimal procedure and the lack of work
package at each of the work sites with an I&C supervisor, who stated that these
practices met l&C supervision expectations.
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- c. Conclusions
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l The conduct of maintenance was generally acceptable. However, the inspectors t
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- were concemed by the handling of E4150-F006 during maintenance. This valve
had a high safety significance, but was not properly protected from foreign !
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material. The minimal sump level instrument calibration procedure and informal
communications did not prevent successful work completion; however, the
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inspectors were concerned that the workers were forced to rely on craft skill and
detailed preparation in order to work around the lack of procedures at each of the j
job sites. .Oue to the simplicity of the system, this did not present a significant ,
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problem. l
These examples reflected the continuance of past inspection concerns. The
i inspectors considered that the expectations from maintenance supervision remained
low for quality of work procedures and referring to procedures during work.
M1.2 Control of Troubleshootina Activities
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a. Insoection Scone (62703,71707)
The inspectors investigated several instances where initial troubleshooting was
performed in accordance with MOPO4, " Conduct of Operations." The guidance and
actual practices for performing such troubleshooting was discussed with several
NSSs and several members of Operations Management. These practices were
compared with troubleshooting performed under a work request by maintenance
personnel, and were discussed with NSSs and maintenance planners and a
maintenance engineer.
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- . b. Findanas and Observations i
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i. MOPO4 directs the NSS to perform troubleshooting to identify the cause of j
equipment problems in order that a proper work request may be written. It then ;
j listed guidelines on how to control the troubleshooting. i
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I The inspectors found a variety of practices with respect to implementation of f
i MOPO4 troubleshooting. Some shifts used mostly operators to perform
{ troubleshooting, while others used a mix of craft and operations personnel. In one !
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case, a licensed operator was assigned to take electrical measurements while i
! troubleshooting the failure of the "B" Reactor Protection System Motor Generator !
j to start, despite initially not knowing how to take the measurements. )
1 Despite guidelines in MOPO4 to write down the problem, possible causes, and plans I
i to identify the exact cause, this was not done in the cases reviewed. This was- j
- considered a weakness because information which could have been a useful part of ;
j the maintenance history of the equipment was not recorded. -
l The inspectors noted that MOPO4 required NSSs to perform troubleshooting which
- in some cases might have been more appropriately planned and performed by
? qualified craft personnel. This placed additional burden on shift personnel.
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However, Operations personnel interviewed felt that using MOPO4 had the -
advantage of allowing prompt troubleshooting with those individuals most familiar i
with the aspects of the component failure. !
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i Of the several examples of MOPO4 troubleshooting ' reviewed, only one example !
!- raised a concern for potentially inappropriate actions. On February 28, the NSS '
[ directed troubleshooting of what appeared to be a bad alarm card that caused an ;
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EDG 14 slarm to continuously alarm. An operator removed the suspect annunciator
card from EDG 14 control panel and replaced it with the corresponding card from -
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EDG 13 control panel. The alarm cleared, and the EDG 14 card was determined to :
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have failed. A work request was written to replace the failed card and the EDG 13 l
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alarm card was replaced in its original position. -
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, The inspectors interviewed several personnel and determined this to be a common
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troubleshooting practice for EDG annunciator problems. Moreover, operators stated
that removing EDG annunciator cards did not affect the safety function. As a
result, in this case, operators did not check system schematics, verify that the !
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cards swapped were in fact identical, or test the replacement card for proper ;
operation. This practice was considered to be poor because configuration control l
- was not assured, and the possibility of unrecognized damage to the working part l
could be introduced. l
The inspectors reviewed planning and execution of troubleshooting conducted
under a work request per MWCO2, " Work Control Conduct Manual," for ;
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comparison. The inspector noted that troubleshooting under a work request l
provide additional control such as planning, spare parts, qualified and experienced !
workers, and additional reviews. ;
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i The inspectors discussed the above findings with the Operations Superintendent, :
l who agreed with the findings. . Operations management planned to review the
- controls in place and actual practices for troubleshooting. s
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c. Conclusions l
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, The inspectors considered that troubleshooting controls in MOPO4 and MWCO2
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, were weak. MOPO4 had better guidelines, but were not closely followed, and i
MWCO2 had few controls but appeared to be more controlled in practice. l
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Additionally, the practice of using personnel without the appropriate craft
knowledge to perform even limited troubleshooting was considered to be weak.
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The practice of removing components from operable safety equipment to conduct I
troubleshooting could potentially result in configuration control problems and - I
unknowingly cause damage to good components. In the specific cases discussed l
above, the inspectors were satisfied that equipment operability was not affected )
and no damage resulted.
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This will be an inspection Followup ltem pending additional inspections of l
troubleshooting activities and the controls used. The inspectors will also review 1
any changes made as a result of the licensee's reviews of troubleshooting controls )
and practices. (IFI)(50-341/97002-03)
M2 Maintenance and Material Condition of Facilities and Equipment !
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M2.1 Hioh Pressure Coolant Iniection Svstem (HPCI) inlection Valve Failure Durina l
Surveillance i
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a. Insoection Scone (62703) i
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The inspectors reviewed surveillance procedure 24.202.05, "HPCI System Cold :
Shutdown Valve Operability Test." The inspectors witnessed disassembly of the ,
valve for evaluation following the failure of the valve to open when demanded. The ;
inspectors reviewed control room logs and interviewed system engineering and ,
maintenance personnel. :
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b. Observations and Findinos !
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The inspectors reviewed the licensee's surveillance procedure and noted that step
5.1.24 required opening E4150-F006 and measuring stroke time. The inspectors
noted that the valve failed to open as demanded. Troubleshooting identified that ;
there was no problem with control or logic of the valve, and an operator verified !
locally that the valve atem did not move.
The inspectors observed maintenance workers remove the motor from the motor !
gear housing. The inspectors observed that the pinion gear had slipped axially
along the motor shaf:, and the set screw appeared to have been originally secured ,
due to the presence of some slight deformation in the motor shaft. Earlier ;
modifications had installed lockwire such that the screw could not back out. The
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inspectors examined the set screw face and noted some signs of wear. The !
inspector examined the grease in the gear box and noted some areas were ' :
l. darkened. The licensee reexamined the grease and confirmed the inspector's .l
I observation. The licensee stated that the grosso was of good quality, but was ;
replaced for other reasons.
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The inspectors examined other parts including the key and gear teeth. No [
!. significant deformation of the parts were observed at the time. The inspector noted j
l during valve disassembly that the motor gear cavity was left uncovered during a j
break, potentially allowing foreign material entry into the cavity. This observation
was discussed with management who agreed that this was not the correct -
practice. - ,
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L A review of maintenance history by the inspector showed that the motor had been
! replaced in 1988, but no maintenance had been performed since that time. Pinion
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l gear slippage had been identified as an industry problem shortly after the last
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maintenance work on this MOV. The licensee proposed corrective action at the l
time of the industry report included drilling a hole in the motor shaft for proper
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seating of the set screw, install the set screw with the pinion gear in the hole, and ,
i secure the set screw with lockwire or thread compound. However, no corrective
l actions had yet been implemented in this valve.
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l The licensee decided to implement modifications to selected affected valves as a l
l result of the HPCI failure. The valves were ranked according to safety significance ;
l using the maintenance rule, and other risk insights.' The inspector reviewed j
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probable risk assessment data and noted that the loss of HPCI injection was a
l significant contributor to core damage frequency. A list of over 70 valves was
generated as a result of this effort. The valves were scheduled to be completed ,
prior to startup. In addition to the modifications for the pinion gear, the licensee
implemented changes to the auxiliary contacts and torque switches. Several
l discussions were held with Region 111 and NRR concerning the problem. The NRC
planned to conduct a special inspection to address these issues.
c. Conclusions
The inspectors considered that the licensee took prompt and appropriate corrective
L 1 actions to determine the cause of the valve failure. Maintenance practices in
l foreign material exclusion were observed to be weak. The inspectors considered
that the decision to promptly address MOVs with safety and maintenance rule
significance was appropriate.
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This issue will be treated as an Unresolved item pending additional NRC specialist
inspections into MOV maintenance and review of operability issues raised as a
result of licensee findings during their MOV inspections. ~ (URI)(50-341/97002-04)
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Correct!ve actions will be reviewed under LER 97-002.
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l M2.2 EDG'14 Functional Failures :
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I a. Insoection Scone (62703,61726)-
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L The inspectors observed troubleshooting following two EDG 14 equipment 1
problems. Operations' response to the failures were obsec<ed and verified to be in j
accordance with technical specifications. The failures were discussed with the
system engineer and a maintenance rule engineer. Final post maintenance testing
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b. Rndmgs and Observations
l On February 26 during a Fast Start Surveillance Test per Surveillance Procedure
l 24.307.17, operators received overspeed alarms twice. After verifying proper
l frequency of the generator and contacting the control room, the alarms were reset
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and promptly received again two additional times. On the third alarm, the ergine
tripped. EDG 14 was appropriately declared inoperable pending inspections and
repairs.
The system engineer and maintenance personnel found that the overspeed
l microswitch, which was bolted to the engine, was not properly secured. This <
L pilowed the switch to intermittently touch the fuel rack lever. The falso overspeed '
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l condition did not last long enough to trip the fuel racks the first two times. The
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switch was replaced and secured tightly.
The inspectors noted that the switch had been replaced during the refueling outage 'l
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a few months previously due to slow actuation during testing. The licensee -
determined this to be a Maintenance Rule functional failure, but was still evaluating
j whether it was a maintenance preventable failure. The system engineer inspected
the remaining EDGs for possible common mode failures, and found the other
switches were properly secured.
Following repairs, EDG.14 was again fast started for post mainten.ance testing. l
Forty-five minutes into its run, operators smelled an acrid odor. The condition was
reported to the control room, and permission was granted to open the local control
panel cover. Thin smoke was then observed coming from the Low Speed
Auxiliaries (LSA) Relay. Before they could get permission to unload and shutdown !
the EDG, it tripped on reverse power. l
1
The. system engineer noticed, that when the relay failed, it caused the governor to
reset, lowering load until it tripped on reverse power. The licensee determined this
to be a Maintenance Rule functional failure, but was still evaluating whether it was
a maintenance preventable failure. The licensee replaced the failed relay,
inspections revealed no damage as a result of the event. The engine was
!
was sent to a laboratory for failure analysis.
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The inspectors reviewed EDG 14 electrical schematics with the system engineer l
and confirmed that the licensee's conclusions on the causes of the failures were l
consistent with the indications. .
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c. Conclusions 1
The inspectors considered that Operations personnel responded appropriately to the
(.' EDG 14 failures. The potential for common mode failures were appropriately -;
considered. System engineering and maintenance personnel coordinated well to j
promptly identify and correct the problems. System engineesing and Operations l
performed appropriate operability assessments, and communicated well in i
determining potential indications and failure modes.
Ill. Enginsedng
\
- E3 Engineering Procedures and Documentation
L 1
1 1
l' E3.1 Fermi Report for Exceedina Maximum Core Thermal Power
a. Irnoection Scone (92700) l
i
The inspectors investigated the circumstances leading up to the licensee's finding l
that deficiencies in a portion of a computer code introduced a non-conservative
.
-!
error into the calculation of reactor thermal power. Computer configuration control l
was reviewed. Past findings of problems with the calculation were reviewed to *
determine if problems were of a similar nature.
b. Findinas and Observations ;
On February 6 during a review of Reactor Water Cleanup System (RWCU) inputs to ,
the reactor heat balance calculation, engineering identified that the computer l
algorithm used to calculate core thermal power contained an equation error. Using :
plant data, the licensee calculated that the equation could result in a 0.6 MWth l
non-conservative error. This was reported as a 4-hour notification per 10 CFR "
50.72, and by LER 97-001 because the licensed maximum core thermal power was i
exceeded at times during Cycles 1,2, and 3. During Cycles 4 and 5, the licensee
was not able to reach the new maximum licensed thermal power following power
uprate due to steam flow problems. :
.
The problem was diMovered while engineering was investigating a problem with a j
i computer input for HWCU flow (DER 97-0015L which provided input for the
reactor heat balance calculation. The investigation revealed that a flow calculation J
subroutine used a density ratio (calibration referenced to 126F, corrected to actual
value typically near 500F) that did not apply a square-root correction. The error
j was not readily apparent because it was in machine language driver code.
$ The licensee discussed the issue with the vendor, who agreed that the code was in
{ error. The problem was believed to have been introduced when the calibratiort
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reference temperature was changed in response to General Electric Service
information Letter No. 451; because the calibration was originally performed near
operating temperature, the density correction ratio was 1, which would not change
if the square root was taken.
The inspectors noted that this'was the third time in recent history that Fermi i
reported exceeding the maximum licensed core thermal power limit. The first was
to report that the heat balance calculation did not account for seal tiow to the
reactor recirculation pumps, which was a 0.7 MWth non-conservative error. This
was an industry problem reported by many boiling water reactors because General
Electric had considered the impact of this flow to be insignificant during design, and
therefore had not included this in the heat balance calculation. The second
notification was to report that a computer input calibration scaling error resulting in
a 3.0 MWth non-conservative error existed because the conversion from millivolts '
to power units was not properly matched for reactor recirculation pump speed. The
licensee identified this problem as a result of increased questioning of the heat
balance calculation .by engineering personnel following the first issus. The
corrective actions for these two problems included varifying that all heat balance
inputs were accounted for and that the calibration procedures for the instruments
providing those inputs were correct. The latter effort was still in progress.
The licensee planned to correct the current problem with the software code
modification prior to the next startup. The licensee aise commissioned a detailed
review of heat balance calculational method, assumptions, and inputs. This review
l
was to be performed by the vendor, with a third party review to be i ompleted later i
this year. '
c. Conclusiong
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The safety significance of this issue was low because the error amounted to a small I
fraction (0.015 percent) of the licensed power limit. Moreover, a subsequent I
analysis to support power uprate indicated that maximum power could be safely i
raised above that which was actually repcrted as having been exceeded. Long term l
corrective actions will be reviewed during followup for LER 97 001.
{
This issue will be reviewed and resolved with a previous non-conservative scaling
error (October 4,1996). The previous issue is an unresolved inspection item
(URI) (50-341/96010-10).
l E3.2 Licensee ReoorteLEmeroency Eauioment Coolina Water (EECW) Desian
Qeficiencies
l
a. Insoection Scone (375.511
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The inspectors reviewed design issues associated with EECW reported by the
, licensee. The inspectors interviewed applicable engineering management and
l support personnel. The inspectors also reviewed drawings and design basis
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b. Observations and Findinas i
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On March 3, the licensee identified that the EECW system containment isolatisn !
valves were subject to a single failure because all the valves in a division were i
MOVs powered from the same source. Loss of power would result in both inboard
and outboard valves failing as-is, which would be in the open position during a loss .
of coolant accident. This potentialloss of containment isolation was reported as a
'
condition outside the design basis per 10 CFR 50.72. :
!
- The inspectors noted that the licensee also identified that postulated drywell high '
energy pipe breaks could result in EECW piping being subject to jet impingement
,
loads. The licensee initially determined that some of the EECW piping inside '
l. primary containment could fail since they were not evaluated for structural integrity -
! under jet loads, resulting in degradation or loss of the affected EECW system ;
- function. '
The inspectors reviewed drawings and confirmed that the EECW valves were
i powered from a single electrical division bus, as stated in the UFSAR. Thus all
(
[
j Division 1 and Division 2 EECW containment isolation valves and RBCCW/EECW i
Cross-tie Valves could be affected. In this configuration, the containment design i
i bases would not be met, i
!
l The inspectors reviewed design documentation and noted EECW drywell
penetrations were designed to meet General Design Criterion 56. The inspectors
noted that the EECW connection to RBCCW and that RBCCW piping was group D !'
seismic category 2, and therefore could not be considered a closed system for
accident containment purposes. The design therefore was vulnerable to a single :
failure defeating the containment function.
l
Subsequently, on March 5 the licensee reported that during an Appendix R
L' scenario, Division 1 EECW could have been rendered inoperable because an
i interlock could not be overridden from the Remote Shutdown Panel. The interlock
l prevented the opening of the Makeup Tank isolation Valve until the RBCCW/EECW
! cross-tie valves were shut. However, the RBCCW/EECW cros> tie valves could not i
!
be operated from the Remote Shutdown Panel. This was reported as a condition
that adversely affected the ability of the plant to reach and maintain a safe. -
shutdown condition.
!
The inspectors noted at the end of the inspection period the licensee was l
developing a plant modification plan to resolve the issues above. The licensee was ,
also developing a parallel position to justify continued operation based on the
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licensed design of the system. ;
.
c. Conclusions
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l. The inspectors noted during a subsequent engineering review of the EECW systam, !
! it was determined that the EECW system may not properly align during operation u: >
l specified in the Dedicated Shutdown Procedure for a serious Control Room fire.
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I~ . The inspectors will continue to inspect and evaluate the licensee's efforts to resolve
1
- the EECW issues. The inspectors will continue to evaluate this issue as an j
j' Unresolved item to' determine the extent of having been outside the design basis of l
j the plant. (URI)(50-341/97002-05). The Office of Nuclear Reactor Regulation was l
"
requested to review these issues for applicability to General Design Criteria 4,44, j
i
and 58 (10CFR50, Appendix A). The licensee is issuing LER 97-003 to document j
.
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their corrective actions.
i
) E3.3 Engineering Backloa Reduction (BRG) Effort Comolated !
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1- In September 1995, engineering began a program to reduce the engineering backlog .!
j by assigning a dedicated, multi-disciplined group of 23 engineers to the' task. The i
!- inspectors reviewed the results of the effort with the Backlog Reduction Group
supervisor. !
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4
The BRG screened the engineering bscklog and identified approximately 35,000 !
l man-hours worth of work to be completed by the group. The main thrust of the i
j effort was to eliminate old engineering work and to ensure proper configuration l
i control was maintained for the plant. The remaining work, about 20,000 man- t
! hours, was designated Work in Progress and assigned for normal engineering l
activities. The BRG selected older issues which were mostly started but not
li completed, such as modifications. Additionally, vendor documents, as built [
- documents, parts evaluations and DERs were evaluated and.dispositioned. The ;
l scope of the BRG work increased about 15 percent as related issues were identified ;
'
and dispositioned. The BRG recently completed the work assigned, h'aving l
eliminated the engineering backlog. The effectiveness of these efforts on the ;
j. overall performance of engineering has not been assessed. l
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- E8 Mlacellaneous Enginsedng issues (92902) ,
E8.1 (Onen) Unresolved item 50-341/96018-03: Past Operability of Pnmary $
Containment Oxygen Monitors. The licensee identified in April 1996 that a non- I
y conservative error was introduced when oxygen monitor calibration was performed
with the containment de-inerted, then read inerted, or vice versa. The inspectors
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l had identified that this condition prevented entering Mode 2 or Mode 1 when the
j calibration had been performed de-inerted, as would occur during a prolonged
- shutdown, because the accuracy would not meet the UFSAR tolerances. This
l- accident monitoring instrumentation would then have to be declared inoperable. l
4
{ In response to this issue, the licensee determined that on 9 occasions between
- 1989 and the present, oxygen sensor calibrations were performed de-inerted and
i the plant subsequently entered Mode 1, rendering one or both channels of
containment oxygen monitoring inoperable when containment was inerted.
i Because this condition was unrecognized, TS required actions were not performed. !
l- t
l The vendor acknowledged that a 1 to 2 volume percent non-conservative
J. inaccuracy was introduced as described above. The vendor did not know the exact
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cause, but stated that it could be avoided by calibrating the sensor in the same
environment as it was to be read (e.g. calibrate inerted, read inerted).
The licensee planned to issue LER 97-004 to repon the past inoperability of
containment oxygen monitors due to inadequate calibration techniques. Also, the
licensee was conducting a 10 CFR Part 21 applicebility assessment at the close of
this inspection. At the request of the inspectors, the licensee was investigating
whether the TS 3.6.6.2 containment oxygen concentrations limit was ever violated
due to improper calibration practices.
The inspectors determined that licensee procedures required performing verification
grab samples when the High Containment Oxygen annunciator was received.
However, because the annunciator was set at 3.5 percent, with a calibration error
of 1-2 percent it was therefore possible to exceed the TS 3.6.6.2 limit of less than
4 percent with such a calibration error.
The inspectors identified that the channel check acceptance criteria may have been
inadequate to identify excessive channel disparity because the microprocessor-
based instrumentation truncated values less than the calibrated zero. With one
channel indicating zero, as was the case in April 1996, no meaningful comparison
could be made to that channel.
Also, the inspectors identified that weekly grab samples of containment atmosphere
were not required to be compared to instrument readings. As a result, there was
no acceptance criteria for the grab samples. The inspectors considered that this
was a missed opportunity to confirm the accuracy of the installed instrumentation,
which were calibrated using only gas samples with higher oxygen concentrations
than existed in an inerted containment.
The inspectors determined that system engineering first noticed a potential
accuracy problem in April 1996, because the containment oxygen monitor indicated
zero percent and the system engineer had never before observed such a low
reading. An investigation was initiated in July 1996, system engineering
discussed the issue with Operations management. However, Operations failed to
recognize the operationalimplications of the calibration phenomenon until prompted
by the NRC in December. The operators were satisfied by the reading, attributing
the indication to an exceptional containment purge.
Pending NRC review of past containment oxygen concentrations and the results of
the licensee's Part 21 determination, this URI will remain open. This issue is an
apparent violation of 10 CFR Part 50, Appendix B, Criteria XVI, " Corrective
Action," in that opportunities to correct this condition were not taken in April 1996.
Additionally, operators failed to take corrective action when indications of
containment oxygen concentrations were exceptionally low. This is also an
apparent violation of 10 CFR Part 50, Appendix B, Criterion XVI.
Failure to take prompt corrective action when the drywell oxygen monitor was
found not reading correctly resulted in violating T.S.3.3.7.5.
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'E8.2 Wad) Unreaalved item 50/341/95009-01: Safety Evaluation Screening Process l
May Be inadequate. In the written response to the violations discussed in :
' Inspection Report 50/341-95009, the licensee stated that Fermi's philosophy went j
beyond requiring a safety analysis when the words in the UFSAR were changed. !
The licensee stated that the screening determine whether a change affected the i
function of a system, component or structure as described in the UFSAR,'the ability )
to perform the functions described in the UFSAR, or assumptions made by the '
UFSAR. However, both the inspectors'and the licensee's self-assessments noted . l
tliat very few safety evaluations were performed at Fermi. Since this item is being _
reviewed on a generic basis by the Office of Nuclear Reactor Regulation, a Fermi
specific review is not necessary, and a process violation is not appropriate. This i
,- issue is closed. i
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l E8.3- (Closed) Unresolved item 50/341/95009-03: Feedwater Control System I
L Improvements. Because of the problems caused by the feedwater control
'
modification, the licensee returned the plant to its previous configuration. The
licensee was reconfiguring the computer model and remodeling the system. No
new installation date had been established. The inspectors determined that the
,
licensee's actions appeared reasonable to resolve the design control deficiencies
identified with this modification. However, the failure to perform an adequate
validation of the model prior to installing the modification constitutes a violation of
10 CFR Part 50, Appendix B, Criterion lil, " Design Control," which requires, in part,
l that the design basis was correctly translated into specifications, drawings,
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procedures, and instructions. It further requires that design control measures be
taken to verify or check the adequacy of the design. This minor violation will not
be cited because the requirements of Section IV of NUREG-1600, " General
- Statement of Policy and Procedures for NRC Enforcement Actions" were met.
L (NCV)(50-341/97002-06)-
E8.4 (Closed) Fermi Ooerational Safety insoection Deficiencv 50/341/96201-02: The
Fermi Operational Safety inspection team found that several surveillance -
acceptance criteria were not established. The surveillance procedure for control air
isolation integrity did not specify the correct leakage rate acceptance criteria. The
safety relief valve accumulator check valve surveillance test contained a non
conservative acceptance criteria that was not in agreement with the design
calculation. The "DC Control Cable Voltage Drop Calculation" contained an error
l which resulted in the acceptance criteria for the motor control center load !
l compartment maintenance procedure to be in error. . These examples are violations
of 10 CFR Part 50, Appendix B, Criterion V (50-341/97002-07). i
l
E8.5 (Closed) Fermi Ooerational Safety Insnection Deficiency 50/341/96201-01: The
- Fermi Operational Safety inspection team determined that several DERs were not
written as required by the quality assurance manual. These were examples of ;
failure to adhere to procedure and a violation of 10 CFR Part 50, Apper' dix B, i
Criterion V (50-341/97002-08). i
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IV. Mant Sunnort l
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R1~ Radiological Protection and Chemistry Controls l
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R1.1 Excellent Radiolonical Control Practices Observed Durina Sumo Work (71750) f
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The inspectors observed the calibration of a new sump level probe installed in
l
Reactor Building Floor Drain Sump D076. The work was planned to minimize the :
amount of water used and subsequently pumped to Radwaste. The majority of the l
' time, workers stood outside the contaminated area and used a scope to observe ;
sump levels in order to minimize exposure. This was a new technique suggested by )
the workers. The inspectors observed proper rediological work practices in and :
around the contaminated work area. Radiation protection provided appropriate ' l
support. Detailed radiological surveys were performed prior to work and as needed ;
during work. l
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P1 EP Activities l
!
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P1.1 EP Drill Performance r
!
a. Inspection Scone (82301) !
i
The inspectors evaluated licensee performance in Control Room Simulator and !
Emergsncy Operations Facility (EOF) during the February 12 emergency response i
drill. Communications with state officiais from both these facilities were observed.
Event classification and reporting were evaluated. Operator use of Emergency
Operating Procedures was evaluated, as were command, control, and
communications.
!
b. Findings and Observations
On February 12, the inspectors observed a site emergency drill, which involved :
partial participation of state and local agencies. The scenario simulated multiple :
plant failures due to seismic events which lead to a simulated offsite release of ,
'
radioactivity.
I
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The inspectors observed that control room operators properly implemented the '
emergency operating procedures. The Emergency Director rapidly recognized and
declared the Unusual Event, then upgraded the classification to an Alert due to the i
magnitude of the simulated seismic event. The inspectors verified that notifications 1
to federal, state and local authorities were made within the times required.
Additionally, the site emergency response organization was activated rapidly and ;
transfer of control was conducted smoothly to the Technical Support Center. l
t- Overall performance in the EOF was effective. Facility staffing was rapid and
i effective. The inspectors observed that the Emergency Response Officer (ERO)
i. provided effective briefings at appropriate times, and frequently communicated with
j' counterparts for the state and in the Technical Support Center and simulator control l
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L room. Protective action recommendation options were discussed in anticipation of l
event progression, so that appropriate recommendations were made in a timely -
manner. At one point in the drill, before any radioactive release was simulated, the
- licensee appropriately recommended sheltering in the downwind areas, but the
l- state decided to conservatively evacuate the same areas based on anticipated
progrusion of the event. The licenses then made a prompt recommendation to .
expand the protective action recommendation to the state when the weather ; !
i forecest predicted a shift in wind direction.
l During the early part of the drill, two non-licensed operators investigating
! equipment damage outside the protected area were unsure where to assemble for
accountability. The control room ordered the two to assemble at the closest '
assembly area outside the protected area, despite the fact that they did not need to
i- be accounted for because they were already outside the accountability area. This l
l delayed investigation of plant damage following the first simulated seismic event.
(~
l The licensee's evaluation of the drill was thorough and detailed, and concluded that !
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all drill objectives were met. The following additional deficiencies were identified by
the drill controNors:
e The emergency director mistakenly ordered assembly and accountability in
the owner controlled area instead of the protected area. While this was '
corrected, it caused confusion and resulted in some improper responses.
e The Emergency Director and NSS worked jointly to develop priorities for the i
ERO, but the Operations Support Center (OSC) Coordinator was not included
in this process,
o Plant status reports from the OSC were not consistently made, contributing
to the lack of shared priorities.
e One message to the state of Michigan did not include a dose assessment.
This was important because the message was the first mossage following
the declaration of a General Emergency, and protective actions were
recommended without supplying the data they were based upon. This was
somewhat mitigated by supplying the data verbally.
c. Conclusions
,
- The inspectors concluded that the observed portions of the licensee's response to a
'
simulated radiological emergency as a training evolution was acceptable. The
scenario was detailed and challenging, and appropriate simulations were provided.
Critiques observed were conducted in a prompt and critical manner, accurately
l identifying both strengths and weaknesses.
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81. Security and Safeguards Activities i
The below inspection findings represent additional examples of continuing concerns
about security force effectiveness and communicatico weaknesses noted in t
previous reports.
l S1.1 Imorooer Control of Visitors 1
i
a. Inspection Scone (71750)
i
The inspectors observed a truck delivery in progress, and identified that the driver
was a visitor that was not properly badged and did not appear to be properly J
escorted. After questioning the two visitors and two escorts present and ensuring I
that each visitor was properly controlled, the inspector raised the issue to the l
[ Neurity Shift Supervisor. Corrective actions were reviewed and discussed with
l~ Sv.;urity management.
b. Findinas and Observations
On March 7, the inspectors observed a load of liquid carbon dioxide being delivered
by a vendor truck. A security guard was escorting the truck and driver, and the
guard remained in the cab because the engine had to remain running to complete
-
the transfer. The two workers and a non-licensed operator conducted the transfer
from the back of the semi-trailer, out of view of the guard at times.
' The inspectors noted that one worker had a visitor badge, but the driver was 'not !
wearing any security badge. Upon questioning the visitors, the inspector I
determined that the guard had escort responsibilities for the driver but was not
performing those duties. The guard believed the operator had assumed escort-
j. responsibilities, even though such a transfer of responsibilities was not performed ;
L as required by MGA09, " Access Control." The guard then resumed proper escort l
l duties of the driver, i
l
I The' inspectors discussed the issue with the Security Shift Supervisor and
l determined that the escort of record was the guard. The Security Shift Supervisor ;
'
. promptly went to the truck to investigate. The licensee determined that the truck i
driver had been adequately controlled during the entire time inside the protected
area because the driver was in the sight of either the guard or the operator. The '
inspectors' observations supported that conclusions. The licensee determined that
the guard had been properly assigned as escort for the driver, but had improperly
concluded that escort responsibility was transferred to the operator present during
the work. 1
Security managem recorded this as a loggable event and wrote DER 97-0359. l
Remedial visitor escort training was conducted for the guard prior to performing any
- further escort duties. The driver was instructed to wear the visitor badge at all
- times, and a reminder sign to indicate visitor badges must be worn was hung where
{ visitor badges were issued. . Additionally, a change to the visitor escort procedure ;
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was planned to ensure that guards acting as vehicle escorts transfer control of
visitor workers to a member of the group accepting the delivery if the guard is
unable to perform both duties simultaneously.
c. Conclusions
The inspectors considered that this event constituted improper visitor controls.
After the inspectors identified the issue to security managers, prompt corrective
actions were taken to ensure all requirements were met and all personnel invo vsd
were aware of their responsibilities. This will be tracked as'an Unresolved item
pending review of the licensee's program and performance in the control of visitors
l- ,
by a Region-based security specialist inspector. (URI)(50-341/97002-9) .
S1.2 Imoroner Administrative Control of Desianated Vehicles inside the Protected Area
l During an audit of des!gnated vehicles, Security discovered a vehicle inside un
L protected area that was marked as a Designated . Vehicle (i.e. had a numbered decal
! on the windshield) which was not on the current Designated Vehicle List. Deviation
l Event Report 97-0369 was written to document the event and track corrective
l actions. Further investigation revealed that the vehicle had been processed into the
l protected area as a designated vehicle subsequent to the most recent updating of
the list. However, the vehicle had processed in and out of the protected area five
times since being designated. Each time it entered, security personnel should have
verified that the vehicle was on the Designated Vehicle List. The omission had
been discovered during one of the entries, but the vehicle was not properly reported
l
and updated on the list. This event was a security loggable event. This will be ,
!
tracked as an Unresolved item pending NRC review of designated vehicle control
administration and compliance by a Region-based security specialist inspector.
(URl)(50-341/97002-10)
S1.3 Insoectors identified that a Security Door was Imoronerly Labelled
l
i The inspectors identified that a security door with a card reader that provided
access from outside into a vital area was improperly posted as being electronically
deactivated (blocked). Another sign stated that only emergency passage through
the door was permitted (because this would cause an alarm for a deactivated door).
The inspector determined that the door and card reader were actually fully
i functional. The inspectors reviewed the last 6 months of access information and
found multiple occasions when station personnel used the door for non-emergency
purposes. Security management stated that permission to use the door was ,
granted on occasions which coincided with the access records. The licensee
determined that this door had been improperly labelled since March 1996, when the
f door had been made fully functional. While this practice did not violate any
regulatory requirements, it was considered a poor practice to have improperly
posted security doors.
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V. Management Meetinos
X1 Exit Meeting Summary
l The inspectors presented the inspection results to members of licensee management at the
conclusion of the inspection on March 19,1997. The licensee acknowledged the findings t
.
presented. An supplemental exit meeting was held on March 27 to change the !
I characterization of the issues discussed in Section E8.1 to be apparent violations based on
additional review by the inspectors.
The inspectors asked the licensee whether any materials examined during the inspection
should be considered proprietary. No proprietary information was identified.
,
X2 Pre-decialonal Enforcement Conference Summary
On February 18, a Pre-decisional Enforcement Conference was held in the Region ll1 office
- in Lisle, Illinois, to discuss potential violations documented in Special bspection Report
l 96017. Slides provided by the licensee during this meeting are included with this report as
an enclosure.
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PARTIAL LIST OF PERSONS CONTACTED
Licensee
S. Bartman, Supervisor, Chemistry
- S. Booker, General Supervisor, Electrical Maintenance
l C. Cassise, General Supervisor, Mechanical Maintenance
D. Cobb, Superintendent, Operations
R. Delong, Superintendent, System Engineering
! P. Fessler, Plant Manager, Operations
D. Gipson, Senior Vice President, Generation
T. Haberland, Superintendent, Work Control
R. Matthews, Assistant Superintendent, Maintenance
J. Moyers, Director, NQA
J. Nolloth, Superintendent, Maintenance
N. Peterson, Supervisor, Compliance
J. Plona, Technical Director
W. Romberg, Assistant Vice President and Manager, Technical
T. Schehr, Engineer, Operations
K. Snyder, Nuclear Shift Supervisor, Operations
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lNSPECTION PROCEDURES USED -
IP 37551: Onsite Engineering
IP 40500: Effectiveness of Licensee Controls in Identifying, Resolving, and I
Preventing Problems *
IP 61726: Surveillance Observations
IP 62703:
{
Maintenance Observation
IP 71707: Plant Operations - !
IP 71750: Plant Support Activities I
IP 82301: Evaluation of Exercises for Power Reactors 1
IP 92902: Followup - Engineering i
IP 92903: Followup - Maintenance i
IP 73753: Inservice inspection !
IP 83729: Occupational Exposure During Extended Outages {
IP 83750: Occupational Exposure l
lP 92700: Onsite Followup of Written Reports of Nonroutine Events at Power l
Reactor Facilities '
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ITEMS OPENED, CLOSED, AND DISCUSSED j
Opened l
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50-341/97002-01 NCV Improper seismic restraint of carts i
50-341/97002-02 VIO Lack of procedures for operation of offsite power system !
50-341/97002-03 IFl Troubleshooting practices per MOPO4 j
50-341/97002-04 URI MOV inspection results !
50-341/97002-05 URI Evaluation of EECW outside design basis i
50-341/97002-06 NCV Failure to perform adequate model validation l
50-341/97002-07 VIO Inappropriate acceptance criteria in procedures J
50-341/97002-08 VIO Failure to issue DERs
50-341/97002-09 URI improper visitor control
50-341/97002 10 URI l improper administrative control of designated vehicles
.50-341/97001 LER ' Exceeded licensed max core thermal power
50-341/97002 LER HPCI injection valve failure
50-341/97003 LER EECW outside the design basis
50-341/97004 LER Past inoperability of PCMS oxygen monitors
l Closed
50-341/95009-01 URI Safety Evaluation Screening Process May Be inadequate ;
! 50-341/95009-03 URI Failure to perform adequate model validation
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- Discussed
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l 50-341/96016-03 URI Past inoperability of PCMS oxygen monitors I
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LIST'OF ACRONYMS USED
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CFR Code of Federal Regulations
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CSS Central System Supervisor
CST Condensate Storage Tank
DECO Detroit Edison Company
DER Deviation Event Report
EDG Emergency Diecel Generator
EECW Emergency Equipment Cooling Water
EESW Emergency Equipment Service Water
EOF Emergency Operations Facility
ERO Emergency Response Officer
HPCI High Pressure Coolant injection !
!
I&C Instrumentation and Control I
IEEE Institute of Electrical and Electronic Engineers
IFl Inspection Followup Item
IR Inspection Report
LER Licensee Event Report
MOV Motor Operated Valves
MWth Megawatts (Thermal)
NCV Non-Cited Violation
NIAS Non-interruptible Air Supply
NLO Non-licensed Op6rator
NRC Nuclear Regulatory Commission
NRE Office of Nuclear Reactor Regulation
NSS Nuclear Shift Supervisor
OSC Operations Support Center ,
PCMS Primary Containment Monitoring System l
RBCCW Reactor Building Closed Cooling Water j
RCIC Reactor Coolant Isolation System
RWCU Reactor Water Clean-Up
SBLC Standby Liquid Control l
TAF Top of Active Fuel i
TS Technical Specification
UFSAR Updated Final Safety Analysis Report
URI Unresolved item
VIO Violation !
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Pre-Decisional
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Enforcement Conference
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February 18,1997
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Detroit Edison - Enfo cement Conference February 18,1997 Page 1
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'APR 0 2 SBT
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j e i n tro d u ctio n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P a u l Fe s s le r
i e RH R Reservoir Cross-tie....... .. ... . ....... . ............ .... ...... .. ..........Hal Higgins/ Joe Meyer
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e I n adverte nt Mod e C h a ng e. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .J oe M eye r
! * Control Rod Definition Tech Spec Clarification.................. Joe Meyer/ Peter Smith
e Application of NRC Enforcement Policy.............................................. Peter Smith
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- Detrcit Edison - Enforcement Conference February 18,1997 Page 2
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! RHR Reservoir Cross-tie
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Level
Stem To
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Division 1 Division ll
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Typicalof .
Two Cross
Ball Valve
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Detroit Edison - Enfecement Conference February 18,1997 Page 3
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, y . . . . -, - -- e- -+ , -,,,m m,- , . . ,-w, v.,,.--,s-. -,--v,--..c_,-.-, - - . . ,, . - - - , , -,,,4-,,-,-_m ..---.,-.,,,,,_,.w .,--.3,,, , . . , , , - - , , , - - , - w. v -- --,,- - - - - - . , - - , - - -, ,
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RHR Reservoir Cross-tie ((Continued);
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InitialCondition
Normal Line Up
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Division I i Division II
F601A l F601B
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F602A ! F602B
Detroit Edison - Enforcement Conference February 18,1997 Page 4
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RHR Reservoir Cross-tie (Continued)
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! Line Up at 1941 Hours
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On 10/4/96 (Operations
. Believed Cross-Tie Open)
l Division I i, Division II
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F601A :
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F601B
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- Detroit Edison - Enforcement Conference February 18,1997 Page5
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RHR Reservoir Cross-tie ((Continued)3
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i Line Up at 1549 Hours
- On 10/5/96 (To Support
! . DiverValve inspection)
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Division I i, Division ll
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F601B
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Detroit Edison - Enforcement Conference February 18,1997 Page 6
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RHR Reservoir Cross-tie (Continued)
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e Residual Heat Removal (RHR) Ultimate Heat Sink
Long Term Cooling
n Cross-tie is Contingency For Seismic Induced Crack
n Capacity of Each Division is 3,450,000 Gallons
l e October 4,1996 Sequence of Events
Plant Was in Operational Condition 5, Refueling (RCS 89oF)
1111 Hours; Bus 72ED Shutdown, F602B Made Inoperable.
1920 Hours; Recognized F602B Should Have Been Declared
Inoperable Per TS 3.7.1.5.
Both RHR Reservoirs Were Declared inoperable.
No Loss Of Function
e Shift Turnover at Approximately 1900
Detrait Edison - Enforcement Conference February 18,1997 Page 7
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RHR Reservoir Cross-tie (Continued)
. .
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. Shift Turnover at Approximately 1900
l 1941 Hours; Redundant Cross-Connect Valve F601 A
Opened
F601 A and F601B De-Energized Open, Satisfying TS 3.7.1.5
And Associated Cascading TS Action Requirements.
- Operator Noted That the Divisional Levels Remained Unchanged
by Control Room Indication.
Detroit Fdison - Enforcement Conference February 18,1997 Page 8
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l RHR Reservoir Cross-tie (Continued)
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) e Following Actions Taken:
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Control Room Position Indication Indicates F601A Open.
Locally F601 A Indicates Open.
F601 A Handwheel Manipulated, Twice, to Verify Valve Open.
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Local Reservoir Level Indicators Show Same Level for Both
Divisions.
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Conclusion Was That Field Indication Supported Control
- Room Indication
- Reservoir Was Cross-Connected.
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i Detait Edison - Enforcement Conference February 18,1997 Page 9
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RHR Reservoir Cross-tie (Continued)
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l e October 5,1996 Sequence of Events
i 1549 Hours: F602B Was Opened, F601B Was Closed to
i Support RHR Reservoir Inspection by Divers.
1700 Hours (Approximately): Operations Noticed Division I
- Level Was increasing and the Division 2 Level Was
'
Decreasing.
I Determination Made That Cross-Tie Line Associated With
l F601A&B Had Not Provided a Flow Path
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F602A&B Line Provided Cross-Connect Path
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Detroit Edison - Enforce:nent Conference February 18,1997 Page 10
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RHR Reservoir Cross-tie (Continued)
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Failure to Recognize LCO Condition
l Valve F601 A Had Separated Linkage
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Detroit Edison - Enforcement Conference February 18,1997 Page 11
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) RHR Reservoir Cross-tie (Continued)
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e Corrective Actions
Valve F601 A Repaired
Inspected and Modified All Four Cross-Connect Valves
The SRO That Missed the LCO Requirement Was
Disciplined
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Lessons Learned Reviewed With Operations Shift Personnel
i The Cross-Connect Valve Surveillance Procedure Was
l Revised
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Detroit Edison - Enforcement Conference February 18,1997 Page 12
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j e Low Safety Significance
! Plant Was In Operational Condition 5
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Low Decay Heat Load
i No Loss of Function
- All Division I Pumps Supporting Core Cooling Running or
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Available
l Cross-Connect Path Always Available Via F602A&B
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Low Probability of Seismic Event Causing Damage
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Detroit Edison - Enforcement Conference February 18,1997 Page 13
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! Inadvertent Mode Change
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NSS and RFC Discuss Upcoming Activities
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Action Statement For Inoperable Rod Block NI's Was
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Detroit Edison - Enforcement Conference February 18,1997 Page 14
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Inadvertent Mode Change
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n 1802 Hours: Head Tensioning Operations initiated
! 1927 Hours: First Pass Tensioning at 5400 psig Complete
Approximately 2030 Hours: Last Four Studs Ready to Be
Tensioned to 7200 psig, Advance Preparation for Entry into
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Mode 4
i 2055 Hours: NSS Gives Permission to Tension Last Four
, Studs
2104 Hours: Second Pass Tensioning at 7200 psig
Complete; Operational Condition 4 Declared
2156 Hours: Trim Pass Initiated
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Detroit Edison - Enforcement Conference February 18,1997 Page 15
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Inadvertent Mode Change (Continued)
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e November 5,1996
I Operational Condition 4 Rod Block NI's Were in Progress
l1
At Approximately 0300 Hours, NSS Was Notified of
Following:
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l - 0150 Hours: Trim Pass Complete
- Stud #27 Was Detensioned During Trim Pass
- 0215 Hours: Stud #27 Nut Retensioned to 7200 psig
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Rod Block NI's Surveillance Tests Not Current for
Operational Condition 5
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Detroit Edison - Enforcement Conference February 18,1997 Page 16
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! Inadvertent Mode Change (Continued)
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e Cause
- Transposition Error of Stud Elongation Data Due to Poor
Communication
,
e Corrective Actions
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Refueling Floor Activities Stopped and Lessons Learned
.
Conducted
Evaluation of Stud #27
Operations Procedure Revised to Ensure All Bolting Actions
Complete During Retensioning Prior To Operational Mode 4
'
Declaration
Tensioning Procedure Will Be Revised
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Detroit Edison - Enforcement Conference February 18,1997 Page 17
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e Low Safety Significance
l All Control Rods Fully inserted
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i No Core Alterations in Progress
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Detroit Edison - Enforcement Conference February 18,1997 Page 18
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l Control Rod Definition Tech Spec
! Clarification
!
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i e Operational Condition 5
l e Reactor Vessel Inspection In Progress
e 10 Control Rods Withdrawn With Surrounding Fuel Removed
l
e Refueling Bridge Power Supply Cable Problem
Refueling Bridge Not Over Vessel
Refueling Bridge Interlock TS Surveillance Expires i
i Refueling Bridge Interlocks to be Functionally Tested
.
- Requires Mode Switch in "Startup"
- e TS 3.9.10.2 Requires Mode Switch in Shutdown / Refuel
! e Operations Personnel Checked With Other Plants
. Operations Requests Guidance
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Detroit Edison - Enforcement Conference February 18,1997 Page 19
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Clarification (Continued)
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e Fermi Tech Spec Table 1.2, Note #:
The reactor mode switch may be placed in the Run,
{ Startup/ Hot Standby, or Refuel position to test the switch
l interlock functions and related instrumentation provided that
the control rods are verified to remain fully inserted by a
- second licensed operator or other technically qualified
! member of the unit technical staff.
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f Detroit Edison - Enforcement Conference February 18,1997 Page 20
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_ _ _ _ _ _ _ _ _ __ _ _ . _ . _ _ . _ _ _ _ ___ _ _ . _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ . _ _ . _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ . _ _ _ _ _ _ . . _ - _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ . . _ _ _ _ . - _____._.._____________.___._.__.__._____.._.______________._.____.._.__-,...+m . . . _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _
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! Control Rod Definition Tech Spec
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Clarification (Continued)
!
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i e Fermi TS 3.9.1, Reactor Mode Switch
!
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Mode Switch Locked in Shutdown or Refuel
l When Locked in Refuel
! - Prohibits Control Rod Withdrawal Without Operable
! One-Rod-Out Interlock i
- Prohibits Core Alterations Without Specified Operable
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! Interlocks
e TS 3.9.1, Action
, With Mode Switch Not Locked in Shutdown or Refuel,
l Suspend Core Alterations and Lock Mode Switch in
i Shutdown or Refuel Position
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Detroit Edison - Enforcement Conference February 18,1997 Page 21
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Control Rod Definition Tech Spec
!
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Clarification (Continued)
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e Surveillance 4.9.1.2 and 4.9.1.3
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Channel Functional Test of Interlocks
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- 24 Hours Prior to Start of Core Alterations
- Once Per 7 Days During Core Alterations
'
- Prior to Resuming Core Alterations Following Repair,
'
Maintenance or Replacement
- e Footnote on Surveillances 4.9.1.2 and 4.9.1.3
'
n The Reactor Mode Switch May Be Placed in the Run or
Startup/ Hot Standby Position to Test the Switch Interlock
'
Functions Provided That All Control Rods Are Verified to
Remain Fully inserted by a Second Licensed Operator or
! Other Technically Qualified Member of the Unit Technical
I Staff
l Detroit Edison - Enforcement Conference February 18,1997 Page 22
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l Control Rod Definition Tech Spec
- Clarification (Continued?
!
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e TS 3.9.10.2, Multiple Control Rod Removal
- n Provides Conditions For Removal of Any Number of Control
'
Rods / Drives
,
- Mode Switch Locked in Shutdown or Refuel ,
- Permits Bypass of One-Rod-Out Interlock for Control
,
Rods Removed From Cells Containing No Fuel
! - Requires Control Rods To Be Fully Inserted in Cells That
! Contain One or More Fuel Assemblies
Actions
- - Suspend Removal of Control Rods or Drives
] - Initiate Action to Satisfy Above Requirements
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Surveillances
- - References Surveillance Requirements 4.3.1.1 or 4.9.1.2
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as Applicable
Detroit Edison - Enforcement Conference February 18,1997 Page 23
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-n, , , , .. , , ... --, . . , , , . . , - , . , , , , , ,-,.,n_.,, ,,_,.,,,v.,---_-_,,,n,,-+_,-. -,-----w-
.,,,,.,.,,n..,, .,-..,,,,,,.,,,,,..-,,n, - , - , ,_ .,,,.,e,w.,,,,- . -
-r , - , , ,,
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i Control Rod Definition Tech Spec
l Clarification (Con':inued)
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e Fermi TS 3.9.3, Control Rod Position
- All Control Rods Shall Be Inserted, Except Control Rods
l Removed Per Specification 3.9.10.1 or 3.9.10.2
[ Clarifies What is Meant By All Control Rods
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Detroit Edison - Enforcement Conference February 18,1997 Page 24
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!' Control Rod Definition Tech Spec
,
Clarification (Continued)
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- e Observations; TS 3/4.9.1 and 3/4.9.10.2
- Actions Address Condition Where Mode Switch Not in
Shutdown or Refuel
i Surveillance 4.9.1.3 Requires Post-Maintenance Testing
i TS 3.9.10.2 Explicitly Acknowledges That Control Rods
l Removed From Empty Cells Have No Reactivity Control '
j Function i
4
TS 3/4.9.3 Clarifies What is Meant By All Control Rods
i inserted
) Actions Have No Explicit Time Limits
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Detroit Edison - Enforcement Conference February 18,1997 Page 25
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Control Rod Definition Tech Spec
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Clarification (Continued)
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e TS 3.0.2
l Non-Compliance With A Specification Shall Exist When The
l Requirements of the LCO and Associated Action
l Requirements Are Not Met Within The Specified Time
Interval
e TS 3.9.1 and 3.9.10.2 Actions
i Actions Address Conditions Where LCO is Not Met
- NoTime Intervals Specified
i No Use of Term "Immediate"
i e Actions Were Complied With, Not a Condition Prohibited By TS
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e TS 3/4.9.3 Clarifies What is Meant By All Control Rods Inserted
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Detroit Edison - Enforcement Conference February 18,1997 Page 26
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e
l Control Rod Definition Tech Spec
l Clarification (Continued)
. .,
l e Improved TS
TS 3.10.2, Reactor Mode Switch Interlock Testing
f
! - All Control Rods Fully inserted in Core Cells Containing
One or More Fuel Assemblies
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TS 3.10.6, Multiple Control Rod Withdrawal - Refueling
- - Four Fuel Assemblies Are Removed From Core Cells
Associated With Each Control Rod or CRD to be
1 Removed
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Detroit Edison - Enforcement Conference Februarf 18,1997 Page 27
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Control Rod Definition Tech Spec
Clarification (Continued) ,
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e Definition of Control Rod Tech Spec Clarification Processed
Consistent With ITS
Verified Compliance With Action Statements
OSRO Reviewed TS Clarification Focusing on Safety
Clarifications Consistent With TS 3/4.9.3
e Intent of TS, if Not Literal Requirements of LCO/ Actions Met
Detroit Edison Believes This May Not Be A Violation
Detroit Edison - Enforcement Conference February 18,1997 Page 28
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Control Rod Definition Tech Spec
! Clarification (Continued)
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- Follow-Up Actions
- n Fermi 2 is Committed to implement ITS
Clarification Withdrawn
Other TS Clarifications Reviewed For Similar Problems
! DER Initiated To investigate TS Clarification Guidance
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Detroit Edisca - Enforcement Conference February 18,1997 Page 29
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Control Rod Definition Tech Spec
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l e Low Safety Significance
l Refueling Bridge Never Moved Over Reactor Core
- No Core Alterations or Reactivity Changes
l TS Recognized That Control Rods Removed From Empty
l Cells Have No Reactivity Control Function
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Detroit Edison - Enforcement Conference February 18,1997 Page 30
_ _ _ _ _ _ _ _ _ _ _ - _ - _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ - _ _ _ - _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ - _ - - - _ _ _ _ _ - . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ - _ - _ _ - . - - _ _ _ _ _ - - - _ _ _ _ _ _
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- Apparent Violations of Low Safety Significance
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- No Loss of Safety Function
l One May Not Be a Violation
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e Aggregation
! No Common Underlying Cause for the Apparent Vioiations
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Detroit Edison - Enforcement Conference February 18,1997 Page 31
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Application of NRC Enforcement Policy
i ! Continued;
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e Mitigating Factors
Self-identified
j - Not identified Through " Events"
Appropriate and Timely Corrective Actions Taken
! Not Reasonably Expected to Have Been Prevented By
- Corrective Actions for a Previous Violation Within Last 2
Years
! Not Willful Violations
l Reported Appropriately to NRC .
! Significant Remedial Actions Taken Against an Individual
- Related to One of the Apparent Violations
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Detroit Edison - Enforcement Conference February 18,1997 Page 32
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Detroit Edison
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Other Discussion Items
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Agenda
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l e i ntro d u ctio n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P a u l F e s s l e r
,
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e Operational Excellence Plan Overview
j Personnel Performance improvement (PPI) Initiative......................... Paul Fessler
i O p e ratio n s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D o n C o b b
M ainte n a n ce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .J i m N olloth
As sess m e nt. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bill O' C o n n o r
,
e S B FW/C ST. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P ete r S m it h
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Detroit Edison - Other Discussion Items February 18,1997 Page 2
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Operational Excellence Plan Overview, PPI
Initiatives
.
- Goals
l Improve Operator Performance i
! Improve Communications Within Operations and Between
Operations and Other Work Groups
improve the Planning, Scheduling and Execution of Work
Provide for Assessment of Progress
Integrate the Actions of the Various Plant Organizations ;
Foster Continuous Improvement i
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Operational Excellence Plan, Operations PPI
Initiatives
e Operations Target Areas
Communication of Clear Expectations
n Reinforcement of Expectations
Leadership l
Well Trained Operators
Sound Operational Programs 1
Communication
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Detroit Edison - Other Discussion Items February 18,1997 Page 4
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! Operational Excellence Plan, Operations PPI
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e Operations Management Expectations and Feedback
Written
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Operations Management Conduct Training 1
Major items
- Operating Fundamentals
- Role Clarification
- Operations Philosophy
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Detroit Edison - Other Discussion Items February 18,1997 Page 5
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Operational Excellence Plan, Operations PPI
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Initiatives (Continued)
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- Active Management Participation in Training
l Operator Ownership for Training Needs
3
Operating Crews Exceed Industry Standards
, Conservative and Deliberate Crew Operations
i
improve Operations Training Performance
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Detroit Edison - Other Discussion Items February 18,1997 Page 6
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Operational Excellence Plan, Operations PPI
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- Initiatives (eContinued>3
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e Process Improvements
l n Reduce Challenges to Operations
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Procedure Improvements
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Reduce Secondary Duties
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Configuration Control
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Supervisory Skills
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Work Management
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Detroit Edison - Other Discussion Items February 18,1997 Page 7
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v, , . . ,-,--s -- v+,- -o- --s 4v -e- eme<--,~m.e -w -w v v m-ws-,-v
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Operational Excellence Plan, Operations PPI
Initiatives (Continued)
__ -
e Communications
! Foster Communications Within Operations
- Foster Operations' Communication With Other Work Groups
Provide Consistent Guidance On items Dealing With Crew
Uniformity and Expectations
SRO Depth Site-Wide
Leadership / Supervision
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! Initiatives (Continued)
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l e Assessment
.
Performance indicators
Work Management improvement Committee
- Benchmarking
>
Self-Assessments
! Outside/ Regulatory Assessments
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NQA Operations Assessment Plan
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e increased Management Oversight
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New Assistant Maintenance Superintendent
i 3 Fill the General Supervisor of Electrical Position
4
- * Maintenance Management Expectations
! n Procedures
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Work Packages
Job Briefings
Post-Job Critiques
! Communications and Supervisory Roles
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e Assessments and Oversight
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Procedure Use and Adherence Assessment
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Quality Assurance Oversight of Daily Maintenance Activities
! Assessment of Maintenance Supervisory Effectiveness
n INPO Assist Visit in Work Management
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Detroit Edison - Other Discussion Items February 18,1997 Page 11
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Personnel Performance Improvement -
Assessment of Effectiveness
,
e Nuclear Quality Assurance (NOA) Assessment Plan
Focus Areas
- Quality of Operations
- Management involvement and Effectiveness
- Communications
- Work Control Process
- Corrective Action Process
- Operator Training
n Dedicated Resources
- Lead Auditor
- 4/5 Full Time Auditors
Detmit Edison - Other Discussion items February 18,1997 Page 12
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Personnel Performance Improvement -
Assessment of Effectiveness (Continued)
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e NQA Assessment of Effectiveness - Performance improving
Command and Control (not rushed)
NSS as Manager and Coach
Turnover Adequacy
Proficiency in Use of Three-Way Communication
Outage Work Control (Good Outage Staffing Structure)
Procedure Adherence and Procedure Reviews
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Detroit Edison - Other Discussion items February 18,1997 Page 13
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Personnel Performance Improvement -
Assessment of Effectiveness (Continued)
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! e NQA Assessment of Effectiveness - Attention Required
- Control Room and NSS Logs
j Maintenance Department Communications
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Operator Challenges
Corrective Actions
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- Operations Technical Procedures
! e Conclusion
Operations Excellence Plan is Working To improve
l Performance
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Detroit Edison - Other Discussion Items February 18,1997 Page 14
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SBFW/ CST
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4
Control Room
e TS Requires Operable Flow Path From CST
,
e CST Volume Not Specified in TS
i e Licensing Basis Review identifies Question Regarding CST
Inventory
,
DER Initiated
.
Detroit Edison - Other Discussion Items February 18,1997 Page 15
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SBFW/ CST (Continued)
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. Cause
- Not Recognized in 1984 Appendix R Dedicated S/D Review
e Corrective Actions
l Operating Procedures Revised To Require Sufficient CST
l Inventory
Current Processes Sufficient To Prevent Similar Situation
- UFSAR Detail Will Be Updated
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Detroit Edison - Other Discussion Items February 18,1997 Page 16
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