IR 05000341/2011008: Difference between revisions

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| issue date = 11/15/2011
| issue date = 11/15/2011
| title = IR 05000341-11-008, on 09/27/2011 - 10/7/2011, Fermi Power Plant, Unit 2, Routine Biennial Problem Identification and Resolution Inspection
| title = IR 05000341-11-008, on 09/27/2011 - 10/7/2011, Fermi Power Plant, Unit 2, Routine Biennial Problem Identification and Resolution Inspection
| author name = Giessner J B
| author name = Giessner J
| author affiliation = NRC/RGN-III/DRP/B4
| author affiliation = NRC/RGN-III/DRP/B4
| addressee name = Davis J M
| addressee name = Davis J
| addressee affiliation = Detroit Edison, Co
| addressee affiliation = Detroit Edison, Co
| docket = 05000341
| docket = 05000341
Line 18: Line 18:


=Text=
=Text=
{{#Wiki_filter:UNITED STATES NUCLEAR REGULATORY COMMISSION REGION III 2443 WARRENVILLE ROAD, SUITE 210 LISLE, IL 60532
{{#Wiki_filter:November 15, 2011
-4352 November 15, 2011 Mr. Jack Senior Vice President and Chief Nuclear Officer Detroit Edison Company Fermi 2 - 210 NOC 6400 North Dixie Highway Newport, MI 48166


SUBJECT: FERMI POWER PLANT, UNIT 2, NRC PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 050003 41/2 011008
==SUBJECT:==
FERMI POWER PLANT, UNIT 2, NRC PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 050003 41/2 011008


==Dear Mr. Davis:==
==Dear Mr. Davis:==
Line 29: Line 29:


Based on the inspection sample, the inspection team concluded that the implementation of the corrective action program and overall performance related to identifying, evaluating, and resolving problems was generally effective. Licensee identified problems were entered into the corrective action program at a low threshold. Problems were generally prioritized and evaluated commensurate with the safety significance of the problems
Based on the inspection sample, the inspection team concluded that the implementation of the corrective action program and overall performance related to identifying, evaluating, and resolving problems was generally effective. Licensee identified problems were entered into the corrective action program at a low threshold. Problems were generally prioritized and evaluated commensurate with the safety significance of the problems
. Corrective actions were generally implemented in a timely manner commensurate with their importance to safety and addressed the identified causes of problems. Lessons learned from industry operating experience were effectively reviewed and applied when appropriate. Audits and self
. Corrective actions were generally implemented in a timely manner commensurate with their importance to safety and addressed the identified causes of problems. Lessons learned from industry operating experience were effectively reviewed and applied when appropriate. Audits and self-assessments were effectively used to identif y problems and take appropriate actions.
-assessments were effectively used to identif y problems and take appropriate actions.


No findings were identified during this inspection
No findings were identified during this inspection
. In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, and your response (if any) will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records System (PARS) component of NRC's document system (ADAMS). ADAMS is accessible from the NRC Website at http://www.nrc.gov/reading
. In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, and your response (if any) will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records System (PARS) component of NRC's document system (ADAMS). ADAMS is accessible from the NRC Website at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
-rm/adams.html (the Public Electronic Reading Room).


Sincerely,/RA/ John B. Giessner, Chief Branch 4 Division of Reactor Projects Docket No.
Sincerely,
/RA/ John B. Giessner, Chief Branch 4 Division of Reactor Projects Docket No.


50-3 41 License No.
50-3 41 License No.
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===Enclosure:===
===Enclosure:===
Inspection Report 050003 41/20 11008  
Inspection Report 050003 41/20 11008 w/Attachment: Supplemental Information


===w/Attachment:===
REGION III==
Supplemental Information cc w/encl:
Docket No:
Distribution via ListServ
 
Enclosure U.S. NUCLEAR REGULATORY COMMISSION REGION III Docket No:
50-341 License N o: NPF-43 Report No:
50-341 License N o: NPF-43 Report No:
050003 41/2 011008 Licensee: Detroit Edison Company Facility: Fermi Power Plant, Unit 2 Location: Newport, MI Dates: September 19 to October 7, 2011 Team Lead:
050003 41/2 011008 Licensee: Detroit Edison Company Facility: Fermi Power Plant, Unit 2 Location: Newport, MI Dates: September 19 to October 7, 2011 Team Lead:

Revision as of 06:54, 29 June 2019

IR 05000341-11-008, on 09/27/2011 - 10/7/2011, Fermi Power Plant, Unit 2, Routine Biennial Problem Identification and Resolution Inspection
ML113191310
Person / Time
Site: Fermi DTE Energy icon.png
Issue date: 11/15/2011
From: Jack Giessner
Reactor Projects Region 3 Branch 4
To: Jennifer Davis
Detroit Edison, Co
References
IR-11-008
Download: ML113191310 (26)


Text

November 15, 2011

SUBJECT:

FERMI POWER PLANT, UNIT 2, NRC PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 050003 41/2 011008

Dear Mr. Davis:

On October 7, 2011, the U.S. Nuclear Regulatory Commission (NRC) completed a Problem Identification and Resolution biennial team inspection at your Fermi Power Plant, Unit 2. The enclosed report documents the results of this inspection, which were discussed on October 7, 2011 with J. Plona and other members of your staff.

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

Based on the inspection sample, the inspection team concluded that the implementation of the corrective action program and overall performance related to identifying, evaluating, and resolving problems was generally effective. Licensee identified problems were entered into the corrective action program at a low threshold. Problems were generally prioritized and evaluated commensurate with the safety significance of the problems

. Corrective actions were generally implemented in a timely manner commensurate with their importance to safety and addressed the identified causes of problems. Lessons learned from industry operating experience were effectively reviewed and applied when appropriate. Audits and self-assessments were effectively used to identif y problems and take appropriate actions.

No findings were identified during this inspection

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

Sincerely,

/RA/ John B. Giessner, Chief Branch 4 Division of Reactor Projects Docket No.

50-3 41 License No.

NPF-43

Enclosure:

Inspection Report 050003 41/20 11008 w/Attachment: Supplemental Information

REGION III==

Docket No:

50-341 License N o: NPF-43 Report No:

050003 41/2 011008 Licensee: Detroit Edison Company Facility: Fermi Power Plant, Unit 2 Location: Newport, MI Dates: September 19 to October 7, 2011 Team Lead:

R. Lerch , Project Engineer, RIII Inspectors:

R. Jones, Resident Inspector V. Meghani Reactor Inspector G. O'Dwyer, Reactor Inspector S. Shah , Reactor Engineer Approved by:

J. Giessner, Chief Branch 4 Division of Reactor Projects

Enclosure TABLE OF CONTENTS 4. OTHER ACTIVITIES

.................................................................................

2 4OA2 Problem Identification and Resolution (71152B)

........................................ 2 4OA6 Management Meetings

................................................................

.............

11 SUPPLEMENTAL INFORMATION

.............................................................................................

1 KEY POINTS OF CONTACT

................................

................................................................

.. 1 LIST OF ITEMS OPENED, CLOSED AND DISCUSSED

........................................................

1 LIST OF DOCUMENTS REVIEWED

................................................................

......................

2 LIST OF ACRONYMS USED

................................

................................................................

.. 9 1 Enclosure

SUMMARY OF FINDINGS

Inspection

Report 05000341/201008; 09/2 7/20 11 - 10/7/20 11; Fermi Power Plant, Unit 2; Routine Biennial Problem Identification and Resolution Inspection.

This inspection was performed by four NRC regional inspectors and one resident inspector. The NRC's program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG

-1649, "Reactor Oversight Process," Revision 4, dated December 2006.

On the basis of the sample selected for review, the team concluded that implementation of the Corrective Action Program (CAP) at Fermi was generally effective. The licensee had a low threshold for identifying problems and entering them in the CA P. Items entered into the CA P were screened and prioritized in a timely manner using established criteria and were properly evaluated commensurate with their safety significance. In general, causes for issues were adequately determined and corrective actions were generally implemented in a timely manner, commensurate with the safety significance. Based on engineering issues raised through the assessment period and recurring equipment issues, some licensee evaluations and corrective actions were not comprehensive or rigorous enough

. The team noted that the licensee effectively reviewed operating experience for applicability to station activities. Audits and self-assessments were determined to be effectively performed at an appropriate level to identify deficiencies. Based on the independent assessment of safety culture results, interviews conducted during the inspection, and review of the employee concerns program, employee freedom to raise nuclear safety concerns without fear of reprisal appeared to be demonstrated.

Problem Identification and Resolution A. No items of significance were identified.

NRC-Identified

and Self-Revealed Findings B. No violations of significance were identified.

=

Licensee-Identified Violations===

REPORT DETAILS

OTHER ACTIVITIES

4OA2 Problem Identification and ResolutionThe activities documented in

Sections

.1 through .4 constitute

d one biennial sample of Problem Identification an d Resolution (PI&R) as defined in Inspection Procedure (IP) 71152. (71152B)

.1 a. Assessment of the Corrective Action

Program Effectiveness The inspector s reviewed the licensee's Corrective Action Program (CA P) implementing procedures and attended CA P meetings to assess the implementation of the CA P by site personnel.

Inspection Scope The inspectors reviewed risk and safety significant issues in the licensee's CA P after August 31, 2009

, which was since the last Nuclear Regulatory Commission (NRC) PI&R inspection in September/October 2009

. The selection of issues ensured an adequate review of issues across NRC cornerstones. The inspectors used issues identified through NRC generic communications, department self assessment, licensee audits, operating experience reports, and NRC documented findings as sources to select issues. Additionally, the inspectors reviewed issue reports generated as a result of facility personnel's performance in daily plant activities. In addition, the inspectors reviewed condition reports, which are referred to as Condition Assessment Review Documents (CARDs)and a selection of completed investigations from the licensee's various investigation methods, which included root cause, apparent cause, equipment apparent cause, and common cause investigations.

The inspectors extended the review of the Diesel Fire Pump back 5 years with an emphasis on issues associated with system degradation due to aging aspects. The inspectors also performed a partial system walkdown of the Diesel Fire P ump. During the reviews, the inspectors determined whether the licensee staff's actions were in compliance with the facility's corrective action program and 10 CFR Part 50, Appendix B , requirements. Specifically, the inspectors determined if licensee personnel were identifying plant issues at the proper threshold, entering the plant issues into the station's CA P in a timely manner, and assigning the appropriate prioritization for resolution of the issues. The inspectors also determined whether the licensee staff assigned the appropriate investigation method to ensure the proper determination of root, apparent, and contributing causes. The inspectors also evaluated the timeliness and effectiveness of corrective actions (preventing recurrence if required by Appendix B) for selected issue reports, completed investigations, and NRC findings, including N on-Cited Violations (NCVs).

b.

(1) Assessment In general, problem identification was adequate and at an appropriate threshold. The sample of issues reviewed by inspectors that were entered into the CA P indicated a low threshold, with a steady generation of CA RDs on a monthly basis. Corrective Action Program generation numbers appeared representative of a good problem identification ethic. During the assessment period, the station initiated approximately eight thousand to nine thousand CARDs per year with the majority of the documents classified as a level 3 (an adverse condition that has or would have minimal affect on the safe or reliable operation of the plant or personnel safety) or a level 4 (a condition that is not adverse to quality or a concern, suggestion, or a question that does not represent a condition adverse to quality, nonconformance, or program deficiency). This was consistent with the last biennial NRC inspection.

Other safety conscious wor k environment (SCWE) indicators such as surveys and interviews indicated willingness to identify issues and capture them in the CA P. Effectiveness of Problem Identification Identification of Issues by the NRC and Self Revealing Events Observations Based on the population of issues identified by Component Design Basis Inspection (CDBI) (Fermi Inspection Report 05000341/2010006), the inspections for Independent Spent Fuel Storage Installation (ISFSI) preparations, as well as other issues such as weaknesses in the procedures for the dedicated shutdown panel, the inspectors concluded that there were too many issues that were self-revealed or identified by the NRC. For most issues of this nature, the plant staff had prior opportunities for identification and correction. The licensee had recently initiated a performance metric to measure and track the proportion of conditions identified by organizations outside of the line organization which will provide information on future performance in this area.

No findings were identified.

Findings

(2) The inspectors determined that the overall performance in prioritization and evaluation

of issues was acceptable.

The inspectors determined that the Corrective Action Review Board and Ownership Screening Committee meetings were generally thorough and maintained a high standard for approving and reviewing CARDs. The timeliness of initial classifications and the level of classification (1, 2, 3 or 4) appeared consistent with the licensee's procedures. The inspectors determined that the licensee was generally effective at evaluating equipment functionality, operability, and reporting requirements after a degraded or non

-conforming issue was identified.

Risk consideration was used in prioritizing and evaluating issues.

Effectiveness of Prioritization and Evaluation of Issues While most evaluations were good, inspectors noted that some evaluations lacked depth and rigor. This was evidenced by issues identified during the inspection period where weaknesses were observed by inspectors with ISFSI and CDBI and other issues. In addition, inspectors were concerned with evaluations that characterized issues as "legacy issues". This appeared to inhibit evaluators from delving into the true cause of issues to identify complete resolutions.

Examples of this included the evaluation of the diesel fire pump failure and design calculation issues with ISFSI and CDBI findings.

Examples of a Lack of Comprehensiveness in Evaluations Observations The NRC Region III Division of Reactor Safety (DRS) inspectors commenced reviewing calculations and other design documents that established the basis for the ISFSI project, which did include reviews of reactor building superstructure and crane needed for ISFSI cask lifts.

By June 2010 there were many unresolved technical questions from the DRS inspectors.

There was no evaluation, such as an apparent or common cause, of these issues until fall 2010 when the licensee identified overstresses under seismic loading for the reactor building superstructure and the crane supports.

That apparent cause evaluation (ACE)for (CARD 10-28090) reviewed only the calculation issues related to the use of a concrete compressive strength value of greater than the specified design strength of 4000 psi, and the use of structural steel strength values based on Certified Material Test Reports (CMTRs) rather than the minimum strengths per the American Institute of Steel Construction (AISC) specification. The apparent cause was determined to be legacy by personnel who were no longer at the station.

The evaluation did not capture the broader set of technical issues raised by the DRS inspectors, many of which were associated with more recent calculations. The NRC issued NCV 05000341/2011002

-02: Design Control Measures Failed to Ensure Adequacy of the Design Relating to the Reactor Building Crane Support Structure and Reactor Building Superstructure

, addressing the engineering issues.

The evaluation of the automatic scram received due to degraded main condenser vacuum was reported in Inspection Report 05000341/2011002

. The ACE for CARD 10-29450 determined that the cause of the loss of vacuum was the failure of

  1. 3 steam jet air ejector (SJAE) steam supply to nozzle gasket, which caused steam erosion of the seating surface and loss of capacity.

The evaluation

, done when the operating experience was first received

, did not recognize the causal relationship between the operating experience received from the boiling water reactors owners group (BWROG) Off Gas committee regarding Browns Ferry reporting erosion of the nozzle to steam supply joint and the applicability to Fermi 2

. The evaluation of the monthly tritium sample of r ad waste ventilation that was not taken (CARD 11-20542) assigned the direct cause to failure of multiple personnel to validate the procedure to plant conditions.

While this was a true statement, it combined the specific responsibilities of operations, engineering, and the chemistry technician assigned to the task of sampling all together into one direct cause.

The apparent cause identified the operations responsibilities for reviews and peer checks.

Had the direct cause been separated into specific causes, they could have been individually identified and listed as direct and/or contributing causes in order to avoid masking the specific elements of defenses in depth that failed.

The ACE performed by the licensee for CARD 11-24234 identified that International Transmission Company (ITC) had installed a software feature to their real time contingency analyzer in 2005, which ove r- predicted the generation sources.

The ACE concluded that the direct cause of the event was this software feature, and the apparent cause was that ITC did not recognize this software feature in their real time contingency analyzer. The ACE did not evaluate the period from the installation of this software feature in the ITC analyzer (2005) until November 2010 when Fermi 2 had first given direction to ITC to monitor the grid for predicted voltage drop in case of a plant trip. Further, the ACE did not evaluate a similar event occurring 1 month prior to the April 26, 2011 event (i.e., the CARD), to determine why sufficient investigation had not been performed to determine the magnitude of variation that should be expected between the ITC, Detroit Edison (DTE) Systems Operation Center (SOC), and Midwest independent Transmission Operator (MISO) analyzers.

This value was later determined to be 0.2 percent. Finally, the ACE concluded that even though there is a Memorandum of Understanding (MOU) between Fermi 2 and ITC, that the causes were only related to ITC. As documented in inspection report 05000341/2010006, the CDBI team identified weaknesses in various electrical design calculations. The ACE for CARD 10

-20823 identified that the extent of the observed weaknesses in the engineering process were only present in Plant Support Engineering (PSE) electrical group.

It further concluded that there were no issues with civil calculations.

The extent of condition evaluation failed to include the PSE mechanical

-civil calculations for which many technical issue s were identified by the NRC during the ISFSI inspection s. Further, the associated barrier analysis identified no failure of the engineering process.

No findings were identified.

Findings

(3) The inspectors concluded that corrective actions for identified deficiencies were generally timely and adequately implemented, commensurate with their safety significance. With one notable exception, problems identified using root or apparent cause methodologies were resolved in accordance with licensee program and NRC requirements.

The excepti on was a finding identified in Nuclear Quality Assurance (NQA) audit , NQA 11-0103, which found four examples of "significant conditions adverse to quality" as defined by licensee procedures, did not have the required "corrective actions to prevent recurrence" assigned

. The inspectors reviewed the corrective actions taken by the licensee (CARD 11-22599) and concluded that they were appropriately extensive and thorough. The inspectors also sampled corrective actions assignments for selected NRC documented violations and findings and determined that the actions were generally effective and timely.

The inspectors noted NQA, an onsite independent group, added value in identification of the issue.

The licensee generally used risk insights in prioritizing corrective actions.

Effectiveness of Corrective Actions Repeat Failures of Maintenance Rule Systems Observations The inspectors reviewed CARDs related to the risk significant system, D1100, Radiation Monitors to determine if the CARDS were being closed with incomplete equipment work through closure of work orders. Although the inspectors did not note any such examples, they did, in a few instances, observe that the work performed on equipment was ineffective. Equipment had repetitive failures and the corrective actions were not effective, particularly, those related to the radwaste system particulate iodine and noble gas (SPING) radiation detector equipment (CARDs 0 9-00829, 09-28802, 10-00378, 11-24624, 11-27834), Circulating Water Decant Radiation Monitor (CARDs 11

-25534, 11-28172, 11-20497), and Offgas Radiation monitors (CARDs 09

-27855, 10-21398). The re were not significant conditions adverse to quality.

Examples of a Lack of Effectiveness in Evaluations Potential High Pressure Coolant Injection (HPCI) Failure Recurrence Level 1 CARD 10-32191 documented the December 28 , 2011 failure of the HPCI minimum flow valve due to blown fuses. This card investigated and corrected potential failures, as no specific failure mechanism was identified. There were no corrective actions to prevent recurrence (CATPR) developed/implemented.

This was identified on a subsequent NQA audit NQA 11-0103. Subsequently, on 9/6/2011, the HPCI minimum flow valve fuses again blew (CARD 11-28197). An emergent issue team (EIT) was formed and the HPCI minimum flow valve was repaired and restored to operability.

An ACE investigation was underway.

The inspectors will follow

-up on this issue under the baseline program

. Diesel Fire Pump Failures The inspectors identified several concerns with the ACE and the Equipment Cause Evaluation (EACE) associated with CARD 09

-26811. On September 2, 2009; CARD 09-26811 was issued to document that during a start of the Diesel Fire Pump (DFP) personnel observed a few drops of raw fuel dripping from the first exhaust clamp downstream of the turbocharger.

The fuel oil rapidly burned off as the exhaust line temperature increased with some smoke forming in the room

. Personnel shut down the DFP and investigated the problem. The licensee determined that the fuel line check valve had failed to prevent fuel oil from draining back into the engine cylinder while it was shutdown. When the DFP was started the excess fuel oil was blown unburned out of the cylinder and into the exhaust line with some fuel oil leaking out of the exhaust line clamp and burning

, which produced smoke in the room. The licensee replaced the check valve and the DFP ran correctly during subsequent tests. On September 28, 2009; CARD 09-27514 was issued to document that during another DFP start , personnel observed a larger amount of raw fuel dripping from the first exhaust clamp which burned and produced significant amounts of smoke in the room requiring the operators to shutdown the DFP

. The Shift Manager declared the DFP inoperable and the DFP could not be run because of concern that there could be a fire in the room. The licensee then determined that the reason the check valve had failed in both events was because pieces of a degraded elastomer grommet in the fuel line had wedged under the seat of the valve and allowed the fuel oil backflow. The licensee closed CARD 09-27514 to CARD 09-26811 because the events had been similar and the corrective actions would be the same. The ACE written for the events of CARD 09-26811 and CARD 09-2 7514 was not written clearly

, because sometimes it seemed to combine the two separate events as one event. Also

, Section 6.9 stated that the root cause was that the service life of the grommet was exceeded because there was no Preventive Maintenance (PM) [task] to inspect or replace the grommet. The inspectors questioned why the failure o f the vendor manual drawings to identify that degradable elastomers were used in the fuel lines was not identified as the cause. The licensee wrote a PM to inspect and/or replace the gommet but had decided not to revise the vendor manual. The inspectors questioned why the vendor manual had not been revised to ensure future personnel would be cognizant of the elastomer. The licensee also had decided not to issue an operating experience report (OE) to notify other licensees that there were degrading elastomers in the fuel lines not identified on vendor documentation. The inspectors questioned this decision to not issue an OE because this type of diesel is in use throughout nuclear and non-nuclear industries. The inspectors identified that the CARD had also incorrectly specified that the DFP was both NQ (no quality requirements) and QA1M (augmented quality requirements) and questioned if training on quality classifications was necessary. While reviewing CARD 09

-28611 to respond to the inspector's questions, the licensee identified that an effectiveness review of the corrective actions had not been done. On October 5, 2011, the licensee initiated CARD 11-29057 to clarify the description of events in CARD 09-28611, correct the DFP quality classification in the CARD, consider quality classification training, recommend adding the elastomer locations to the vendor manual, reconsider issuing OE, and perform an effectiveness review of the corrective actions. These issues did not prevent the site from having an adequate fire protection program.

No findings were identified.

Findings

(4) Other Program Observations CARDS as Stand-Alone Documents and Operability Evaluations Observations The inspectors concluded that the station was generally effective at documenting CARDs and including information related to the corrective actions implemented. The timeliness of initial operability/inoperability classifications appeared consistent with th e licensee's procedures and NRC requirements. The inspectors concluded that the licensee was generally effective at evaluating equipment functional requirements after a degraded or non

-conforming issue was identified.

While most operability evaluations were good, some documentation weaknesses were noted. While reviewing certain CARDS, it was not clear to the inspectors whether equipment was operable or inoperable. In cases where equipment was inoperable, the CARDs did not have enough information related to compensatory actions taken. In certain cases, it was difficult to understand what work was performed on equipment before returning it operation. In one specific case, notably an evaluation to leave a face shield in the reactor coolant system, the evaluations, conclusions and compensatory actions implemented were not adequate to ensure component operability N CV 05000341 2010005-01 in the fourth quarter of 2010

). Other cases included conditions when radiation monitors were inoperable. Therefore, CARDs as standalone documents were inadequate, in some cases, in conveying all the measures and corrective actions taken to address unplanned equipment failures

specifically, CARDS 10-00378, 11-28172, 09-28405, 09-00829 and 11

-28739. Failure to Document Root Cause Downgrade As previously reported in inspection report 05000341/2011002, the licensee chartered a root cause team (in August 2010) to conduct a formal root cause evaluation (RCE) under CARD 10-26632, to evaluate the 2010 CDBI results. After 6 months of effort, the team leader of the RCE was changed.

Subsequently, the CARD 10

-26632 title was also revised to Missed Opportunity Review for CDBI Results.

The history of CARD 10

-26632 identified that the management sponsor did not

approve the root cause evaluation report prepared by the root cause evaluation team, approve the change of team membership, nor approve the revision of the level 2 card from a formal root cause evaluation to a missed opportunity review (which is not a formal RCE). MQA12, RCE s , Section 4.3.4 regarding analyses, step 3 advises, if the picture is not complete and cannot be further developed, communicate this issue with the management sponsor and document the basis for ending the investigation and analysis in the RCE Section of the report. The evaluation effort performed over the period from initiation (on August 4, 2010) until revision of the team (on January 18, 2011) was never issued or documented in the CARD.

Corrective Action Program Computer Tracking System The inspectors and some staff had issues with computer searches and issue tracking. Some personnel stated that if a CARD needs a work order (WO) to direct work to correct the identified condition, the CARD may be closed to a WO, however, the conditio n

related the CARD may not have been corrected prior to CARD closure. This makes tracking the actual completion of a particular issue/condition difficult. Inspectors and some plant staff had difficulty with searching the database for WOs and CARDs indica ting that a higher knowledge level was necessary to efficiently navigate the new CARD software system. Entering search criteria that were too broad resulted in a lengthy search time that appeared to lock up the computer

, while there was also no easy way to terminate the CARD search

.

.2 Assessment of the Use of Operating Experience

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

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

.

Assessment The inspectors reviewed the corrective actions implemented by the licensee based on feedback provided by the CDB I Team inspectors. These actions were documented in CARD 10-20898, "2010 CDBI, Operating Experience Review." The licensee's corrective actions included creating a system for quality grading of OE CARD documentation, and including this grade as a contributor to the OE program performance indicator health report. Additional actions included assigning OE CARDs a significance level of 3 or above to ensure that they receive a thorough review from management. The licensee's evaluation concluded that the OE CARD quality improved from a 78 percent pass rate in 2008 to a 92 percent pass rate in 2009

-2010.

Observations The NRC inspectors reviewed OE CARDs 11

-26215, 10-23207, 10-22089 and CARDs 10-31430, 10-22632 and 10

-29450 related to Root Cause evaluations to determine the effectiveness of licensee OE CARD program. The NRC inspectors concluded that the licensee made improvements to the OE review process and the corrective actions were effective.

No findings were identified.

Findings

.3 a. Assessment of Self

-Assessments and Audits The inspectors assessed the licensee staff's ability to identify and enter issues into the CA program, prioritize and evaluate issues, and implement effective corrective actions, through efforts from departmental assessments and audits.

Inspection Scope b. The inspectors concluded that self

-assessments and audits were typically thorough, and effective at identifying issues and enhancement opportunities at an appropriate threshold level. A significant self

-assessment program was scheduled and tracked across station organizations and issues were captured and resolved in the CA program. The inspectors reviewed the self

-assessment performed on the CA program and found no issues with the overall results and conclusions drawn.

Assessment c. No findings were identified.

Findings

.4 a. Assessment of Safety Conscious Work Environment

and Safety Culture The inspectors assessed the licensee's SCWE through the reviews of the facility's employee concern program implementing procedures, discussions with coordinators of the employee concern program, interviews with personnel from various departments, and reviews of issue reports. The inspectors also reviewed the results from a Safety Culture Survey conducted in 2010 and an internal safety culture review performed for the year 2010

. The review was done to ensure there was a free flow of information and determine if there was a reluctance to raise nuclear safety concerns.

Inspection Scope The Employee Concerns Program was accessible to employees and dealing with employee issues. Based on inspector observations of the CA process and discussions with plant staff, the indications were that plant staff felt free to raise issues either with their supervisor, through the CA process, or through the Employee Concerns Program without fear of retaliation.

Assessment of SCWE b. Observations A nuclear safety culture assessment was performed in July of 2010 at Fermi by the Utility Services Alliance organization using a process they have developed involving an anonymous survey

, on-site reviews, observations, and interviews. The inspectors compared the 2008 results with 2010 and discussed the process and results with plant staff. Overall, the survey and plant follow up of the results through the 2010 review constituted a robust look at safety culture and a meaningful response effort to address the weaknesses identified by the assessment

. The inspectors observed that the safety culture survey response rate improved from approximately 49 percent to approximately 66 percent , leaving 34 percent not responding. No reasons were given or proposals made to improve the response rate further. Neutral responses were considered with positive responses in assessing the data. Interpretation of these survey responses was presented with no industry context to indicate how this represented expected results.

Nuclear Safety Culture Assessment The licensee issued Fermi 2 Business practice FBP

-82, "Nuclear Safety Culture Monitoring

" on October 6, 2011. This procedure is intended to monitor the health of the nuclear safety culture at Fermi.

c. No findings were identified.

Findings

4OA6

.1 Management Meetings

On October 7, 2011, the inspectors presented the inspection results to Mr. J. Plona, Site Vice President, and other members of the licensee staff. The licensee acknowledged the issues presented. The inspectors confirmed that none of the potential report input discussed was considered proprietary.

Exit Meeting Summary

ATTACHMENT:

SUPPLEMENTAL INFORMATION

Attachment

SUPPLEMENTAL INFORMATION KEY POINTS OF CONTAC

T

J. Plona, Site Vice President

Licensee

S. Berry, Manager, Systems Engineering
M. Caragher, Manager, Nuclear Engineering
D. Chupurdy, Performance Improvement
K. Clark, Auditor, NQA
M. Clements, Trending Coordinator

-Corrective Action Program

T. Conner, Plant Manager
J. Davis, Nuclear Training Manager
J. Dudlets, Supervisor, PSE Electrical and I&C
R. Eberhardt, Performance Improvement Manager
J. Ellis, Manager, Work Management
J. Fenner, Maintenance CAP coordinator
B. Ford, Manager, Maintenance
L. Green, Quality Assurance, Fermi 3
T. Himebauch, Engineer/Performance Improvement
K. Hullum Lawson, Supervisor, PSE, Mechanical and Civil
J. Korte, Manager, Nuclear Security
R. Johnson, Manager, Nuclear Licensing
J. Louwers, Nuclear Quality Assurance Supervisor
D. Noetzel, Manager, Engineering First Team
S. Oakes, Performance Improvement
J. Pendergast, Principal Engineer

-Licensing

S. Reit h, Performance Improvement Supervisor
B. Rumans, General Supervisor, Radiation Protection
D. Sadowyj, Senior Engineer

-Corrective Action Program

R. Salmon, Compliance Supervisor/Licensing
K. Scott, Director Organizational Effectiveness
G. Strobel, Manager, Operations
T. Thomas, Ombudsman

-Employee Concerns Program

J. Thorson, Lead, Engineering Assurance
J. Giessner, Chief, Branch 4, DRP Region III

Nuclear Regulatory Commission

R. Morris, Senior Resident Inspector

LIST OF ITEMS OPENED, CLOSED AND DISCUSS

ED None

Attachment

LIST OF DOCUMENTS REVIEWED The following is a list of documents reviewed during the inspection. Inclusion on this list does not imply that the NRC inspectors reviewed the documents in their entirety, but rather, that selected sections of portions

of the documents were evaluated as part of the overall inspection effort. Inclusion of a document on this list does not imply NRC acceptance of the document or any part of it, unless this is stated in the body of the inspection report.

PLANT PROCEDURES

Number Description or Title

Date or Revision

FBP-82 Nuclear Safety Culture Monitoring

MGA12 Fermi Employee Concerns Program

MLS04 Operating Experience Program

MQA11 Condition Assessment Resolution Document

MQA12 Root Cause Evaluations

MQA15 Apparent Cause Evaluations

MQA16 Self-Assessment

CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED

Number Description or Title

09-00829 Date or Revision

RW SPING removed itself from service with no operator action

09/30/2009

09-26746 Received Div 2 RHR Service Water Rad Monitor Upscale Alarm

09/01/2009

09-26746 Received Div 2 RHR Service Water Rad Monitor Upscale Alarm

09/01/2009

09-26889 Div 2 RHRSW Rad Monitor Hi and Hi Hi light

on 10/06/2009

09-26889 Div 2 RHRSW Rad Monitor Hi and Hi Hi Light on 09/06/2009

09-26934 D11R601 Off Gas PRMS recorder failure

09/09/2009

09-27058 Mispositioned component, E21F026B found not in service

09/01/2009

09-27068 Mispositioned component: south AB forced draft flow transmitter found valved out of service during attempted aux boiler run

09/09/2009

09-27069 Mispositioned component: north AB atomizing air pressure transmitter found valves out of service during aux boiler test run

09/12/2009

09-27162 Mispositioned component

- incorrect breaker cautioned tagged on dist cab 72J

-2A-3 10/29/2009

09-27267 SS-1 Rad Monitor Causing Spurious Alarms

09/19/2009

09-27483 RHR Duct design does not meet UFSAR licensing basis

09/25/2009

09-27486 Mispositioned component: CTG 11 unit 4 compartment heater circuit

11/21/2009

Attachment

CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED

Number Description or Title

09-27693 Date or Revision

NRC PI&R inspection observations: Effective problem identification in security organization

10/02/2009

09-27855 Off gas rad monitor B showing erratic behavior

10/20/2009

09-27855 Off Gas Rad Monitor B showing erratic behavior 10/08/2009

09-28028 2009 NRC PI&R Inspection Observation

- CARD Initiation for Low Level Issues

10/13/2009

09-28405 D11K601B rest switch operation/condition is degraded 10/28/2009

09-28405 D11K601B Reset switch operation / condition is degraded

10/28/2009

09-28802 RW SPING off line 11/12/2009

09-28802 RW SPING off line

11/12/2009

09-29361 Failure of timer light to illuminate

2/08/2009

09-29818 Printer on SS1 is printing partial data

2/23/2009

10-00378 Radwaste SPING sample pump failed to restart after weekly sample obtained

05/24/2010

10-00378 Radwaste SPING sample pump failed to restart after weekly sample was obtained

05/24/2010

10-00700 RB SPING ball valves are starting to leak by

08/27/2010

10-00844 Div 1 SGTS

SPING valve D1100F039A indicating light is starting to fail

11/04/2010

10-200001 Div 2 RHRSW rad monitor failure light bulb green cover loose in socket

01/01/2010

10-20049 Offgas linear rad monitor off scale high indication

01/04/2010

10-20238 Vendor seismic report in WEBARMS reviewed by EFT 01/11/2010

10-20337 Cooling fan failure on OSSF SPING 01/14/2010

10-20339 OSSF SPING flow and pressure calibration passes marginally

01/14/2010

10-20365 RWCU Leak during startup

01/14/2010

10-20748 CDBI Identified Canceled DC

-5264 may have to be restated

01/28/2010

10-20842 Mispositioned component

- Wrong HCU manipulated while responding to an alarm

2/05/2010

10-20898 2010 CDBI, Operating experience review

2/02/2010

10-21006 Adverse Trend in Personnel Contaminations

2/04/2010

10-21398 B Offgas rad monitor D11K601B has sudden step change from 5.6mr/hr to 3.0 mr/hr

2/15/2010

10-21469 Replace power supply

2/17/2010

10-21733 2010 CDBI DC

-0919 LTC and motor starting

2/25/2010

10-21792 2010 CDBI - EDP 35621 Backfit Mod Issue

2/26/2010

10-21920 2010 CDBI NRC questioned completeness of EFA-R14-10-004 03/03/2010

10-22099 Radwaste effluent radiation monitor inop

03/10/2010

Attachment

CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED

Number Description or Title

10-22364 Date or Revision

Battery hold down strap needs replacement

03/18/2010

10-24214 Trend-PSE CARDs were closed prior to completion of all corrective actions

05/20/2010

10-24235 TB SPING pressure channel failed calibration

05/21/2010

10-24263 Shop work for general atomic RP

-23 power supply 06/30/2010

10-25403 Evaluate EECW heat exchanger design basis function 06/28/2010

10-25526 Removed RP

-23 power supply needs caps replaced 06/30/2010

10-25821 Div 1 RHRSW rad monitor sample pump or motor bearing making whining noise

07/12/2010

10-26745 Inadequate procedures to control the plant from the dedicated shutdown panel

04/29/2011

10-27995 SSI keyboard requires replacement

09/10/2010

10-28055 D11P279 turbine building SPING surveillance functional unsat

09/13/2010

10-28789 Reactor Building 5th floor Superstructure column welds for built

-up section does not meet the drawing

10/02/2010

10-28789 Reactor building 5

th floor superstructure column welds for built

-up section does not meet the drawing

10/02/2010

10-29450 Reactor Scram due to loss of vacuum

10/24/2010

10-31198 Malfunctioning recorder MCR offgas linear

11/26/2010

10-31897 Damaged electrical conduit at D11

-P274Z junction box

2/15/2010

10-31947 Extension for Analysis of Seismic Impact on Channel Bow

- SC 10-21 12/16/2010

10-32219 Generic Letter

2008-01Situational Event Detected Air Void In Core Spray Division 2

2/29/2010

10-32219 Generic Letter 2008

-01 situational event detected air void in core spray division 2

2/29/2010

11-00024 Div 1 RHRSW rad monitor sample pump is not working 01/10/2011

11-00750 Function switch misalignment

08/05/2011

11-20497 Circ Water Decant line radmon trouble in due to low flow

01/18/2011

11-21479 Core Spray Pump Interactions Affecting Minimum Flow Line Effectiveness

2/08/2011

11-21479 Core spray pump interactions affecting minimum flow line effectiveness

2/08/2011

11-21521 Check source not functioning

2/09/2011

11-22599 Audit Finding: Significant conditions Adverse to Quality Do Not Have Corrective Actions to Preclude Recurrence as Required by the

UFSAR 03/11/2011

Attachment

CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED

Number Description or Title

11-22689 Date or Revision

EPG-05 "Fire Protection" GAP Closure Review

03/14/2011

11-23023 NRC Concern: T50N105B Flow Switch Calibration Acceptance

03/24/2011

11-23153 RHR/LCI suction strainer debris headloss potentially more limiting for RMI head loss

than current analyzed debris source term

03/29/2011

11-23687 GSW radiation monitor recorder reads low during surveillance testing

04/11/2011

11-23943 Inadequate Detection in Emergency Diesel Generator Rooms

04/29/2011

11-24624 Battery backup failure during RW SPING functional surveillance

05/05/2011

11-24859 3D27 alarmed and cleared, no abnormal rad readings/indications

05/12/2011

11-24953 D11K601A failed downscale

05/14/2011

11-25534 CW decant line rad monitor low flow alarm

will not clear 06/01/2011

11-26227 EDG Control Panel Neutral Grounding Resistor Inspection Followup

06/28/2011

11-26294 D11K813 inoperative after surveillance

06/28/2011

11-26450 Heat-traced sample tubing insulation is damaged; needs repair/realignment

07/02/2011

11-26471 3D45 Control Center makeup air rad monitor div 2 upscale trip

07/04/2011

11-26518 SGTS Div 2 SPING pump flow is trending low

07/06/2011

11-26739 Display failure on turbine building SPING during surveillance performance

07/14/2011

11-26770 Deficiencies with CARD 10

-29450 identified during engineering PI&R quick hit self assessment

07/15/2011

11-27160 Deficiency with CARD 10

-20982identified during Engineering PI&R QHSA TMES 11

-0023 07/28/2011

11-27538 D11R602 recorder has failed (offgas linear scale PRMS rec)

08/10/2011

11-27834 Rad waste SPING sample pump would not restart after change out of the sample media

08/23/2011

11-28172 Circ water decant rad monitor flow low alarm locked in 09/02/2011

11-28738 Request visual inspection of main steam line rad monitors connectors J1 and J3

09/23/2011

11-28739 Replace main steam line rad monitor B low voltage power supply

09/23/2011

11-28742 Request the training main steam line rad monitor chassis be sent to GE for refurbishment

09/23/2011

Attachment

AUDITS, ASSESSMENTS AND SELF

-ASSESSMENTS

Number Description or Title

Date or Revision

Safety Culture Review January 1, 2010

- December 31, 2010

USA Nuclear Safety Culture Assessment

July 2010 NQA Audit Schedule for 2011

2/14/2010

2011 Self-Assessment Schedule

09/09/2011

2010 Self-Assessment Schedule

03/04/2011

2009 Self-Assessment Schedule

07/20/2010

10-0104 NQA Audit Report

- Evaluation& Corrective Action, and Operating Experience Review Programs

2010 11-0103 NQA Audit Report - Evaluation& Corrective Action, and Operating Experience Review Programs

2011 11-26699 OP.1-1 - Shift Operational Decisions

07/13/2011

11-26702 OP.1-2 - Operability Evaluations

07/13/2011

11-26707 MA.1-3 - Following Written Instructions

07/13/201 1 11-26714 CM.2-1 - Time Operators Need To Mitigate Some Accidents 07/13/2011

11-26721 EP.1-1 - Untimely Activation of Emergency Response Facilities

07/13/2011

11-26997 Self-Assessment Recommendation: Emerging Trend Evaluation on CARD quality

September 2011

NAPI 10-0030 Focused Assessment Report

- Operating Experience Program

09/24/2010

NAPI 11-0088 Focused Assessment Report

- Problem Identification and Resolution Inspection Preparation

7/22/201 1 NPSC-11-0039 Focused Self

-Assessment

- Work Management Critique meeting

05/19/2011

WORK ORDERS

Number Description or Title

Date or Revision

29875903 D11P279 Turbine building SPING surveillance functional UNSAT

2010 30305048 Div 2 RHR Service Water Rad Monitor Upscale Alarm

09/21/2009

30375471 SS-1 Rad Monitor Causing Spurious Alarms

2009 30462243 Off Gas Rad Monitor B showing erratic behavior

2009 30548327 D11K601B reset switch

operation / condition is degraded 2009 30835996 OSSF SPING flow and pressure calibration passes marginally

2010 31320678 TB SPING pressure channel failed Calibration

2009 31714628 RB SPING ball valves are starting to leakby

2010 32368045 Check Source not functioning

2011 32611466 GSW Radiation monitor recorder reads low during surveillance testing

2011 32738767 3D27 alarmed and cleared, no abnormal rad

2011

Attachment

WORK ORDERS

Number Description or Title

Date or Revision

readings/indications

2965549 Heat-traced sample tubing insulation is damaged; needs repair /

realignment

2011 33151644 D11R602 recorder has failed (Off gas linear scale PRMS rec) 2011 33211434 Rad Waste SPING sample pump would not restart after change out of the sample media

2011 CONDITION REPORTS GENERATED DURING INSPECTION

Number Description or Title

Date or Revision

11-29023 NRC PI&R Question CARD lacking action documentation

10/2011 11-29057 NRC Issues Identified during review of EACE/ACE for CARD 09-22811 10/2011 11-29111 NRC PI&R- Electrical Design Calculation

Reconstitution Program Tracking Card

10/06/2011

11-29311 NRC PI&R Inspection Observation on Identification of Problems 10/13/2011

11-29312 NRC PI&R Inspection Observation on Evaluation of Problems 10/13/2011

11-29313 NRC PI&R Inspection Observation on

Effectiveness of Problem Resolution

10/13/2011

11-29315 NRC PI&R Inspection Comment on E

-CARD use 10/13/2011

11-29316 NRC PI&R Inspection Comment on CARD Stand

-alone Quality 10/13/2011

OPERATING EXPERIENCE

Number Description or Title

Date or Revision

10-22089 Evaluate IN 2010

-06 Inadvertent CRD Withdrawal Event While Shutdown

04/05/2010

10-22632 Automatic Reactor Scram due to Turbine Trip

03/29/2010

10-23207 Evaluate NRC Information Notice 2010

-09, Importance of Understanding Circuit Breaker Control Power Indications, for impact to Fermi

04/16/2010

10-29450 Reactor Scram due to Loss of Vacuum

10/24/2010

10-31430 Failure of CFD D Main Drain caused entry into TB Flooding AOP

2/02/2010

11-26215 Document applicability

of NRC Information notice 2011-12, Reactor Trips Resulting from Water Intrusion into Electrical Equipment

06/24/2011

Attachment

MISCELLANEOUS

Number Description or Title

Date or Revision

Fermi 2 Cycle 15 Employee Engagement/Leadership Capability Excellence Plan - Tier 2 06/27/2011

List of Open Long Term Corrective Actions

9/21/2011 CARDs Initiated by Organization/Month

9/01/2011 CARD Ownership/Screening Committee Charter

9/13/2010 Get Well Plan

DFP is in a(1) of Maintenance Rule

Revision 1

Get Well Plan TBHVAC system is in a(1) of Maintenance Rule

Revision 1

System Health Report

Fire protection system 1

st Quarter 2011

Revision 1

System Health Report

Fire protection system 2nd Quarter 2011

Revision 1

System Health Report

TBHVAC system 2nd Quarter

2011 Revision 1

TE-B31-09-077 Evaluate restart of B3101C001A, North RR Pump

9/15/2009

Attachment

LIST OF ACRONYMS USE

D ACE Apparent Cause Evaluation

ADAMS Agencywide Document Access Management System

AISC American Institute of Steel

Construction

BWROG Boiling Water Reactors Owners Group

CAP Corrective Action Program

CARD Condition Assessment Resolution Document

CATPR Corrective Actions to Prevent Recurrence

CDBI Component Design Basis Inspection

DFP Diesel Fire Pump

DRS Division of Reactor Safety

EACE Equipment Apparent Cause Evaluation

EIT Emergent Issue Team

HPCI High Pressure Coolant Injection

IP Inspection Procedure

ITC International Transmission Company

ISFSI Independent Spent Fuel Storage Installation

MISO Midwest Independent Transmission Operator

MOU Memorandum of Understanding

NCV Non-Cited Violation

NRC U.S. Nuclear Regulatory Commission

NQA Nuclear Quality Assurance

OE Operating Experience

PI&R Problem Identification and Resolution

PM Preventive Maintenance

PSE Plant Support

Engineering

RCE Root Cause Evaluation

SCWE Safety Conscious Work Environment

SJAE Steam Jet Air Ejector

SOC Systems Operation Center

SPING System Particulate Iodine and Noble Gas

WO Work Order

J. Davis -2- In accordance with

CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, and your response (if any) will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records

System (PARS) component of NRC's document system (ADAMS). ADAMS is accessible from the NRC Website at http://www.nrc.gov/reading

-rm/adams.html

(the Public Electronic Reading Room). Sincerely, /RA/ John

B. Giessner, Chief

Branch 4 Division of Reactor Projects

Docket No.

50-341 License No.

NPF-43 Enclosure:

Inspection Report 050003

41/20 11008 w/Attachment: Supplemental Information

See Previous Concurrence

DOCUMENT NAME:

G:\DRPIII\FERM\Fermi 2011 008 PI&R.docx

Publicly Available

Non-Publicly Available

Sensitive Non-Sensitive To receive a copy of this document, indicate in the concurrence box "C" = Copy without attach/encl "E" = Copy with attach/encl "N" = No copy

OFFICE RIII RIII NAME RLerch* JGiessner DATE 11/14/11 11/15/11 OFFICIAL RECORD COPY

Letter to J. Davis from J. Giessner dated

November 15, 2011.

SUBJECT: FERMI POWER PLANT, UNIT 2, NRC PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 050003 41/2 011008