On 6/21/2005 in Mode 1 at 100 percent power, CNS determined the Diesel Generator ( DG) Diesel Oil ( DC)) transfer pump in-service test ( IST) flow test performed on 11/5/2004 while in Mode 4 resulted in a condition prohibited by Technical Specifications (TS.) Revision 16 of the surveillance procedure dated 5/14/2004 allowed quarterly exercising of the two normally closed manual cross connects between Fuel Tanks 1 and 2 by disabling fuel transfer pumps (from the main storage tank to the day tank) by placing their switches to the OFF position and then validating cross-connect valve operation. The surveillance was performed on 7/13/2004 and 10/7/2004 in Mode 1, and on 11/5/2004 in Mode 4, without declaring both DG's inoperable. On 12/30/2004, prior to the fourth surveillance performance, operators recognized that steps to place the transfer pump switches to OFF required declaring both DG's inoperable. The procedure was revised to avoid placing both transfer pump switches to OFF, and the surveillance was subsequently performed. A Condition Report (CR) was initiated for the inadequate procedure and noted the 3 prior surveillances. In all 3 cases, there was no loss of safety function. For July and October, the surveillances were completed within the 2 hour2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> TS action limit for Mode 1 which satisfied the TS requirement. However, for November, the TS "immediate" action limit for Mode 4 was exceeded which resulted in a condition prohibited by TS.
The root cause was that Revision 16 of the surveillance procedure was inadequate in that it did not require or caution that performing procedure steps would render both DG's inoperable. The surveillance procedure was revised on 1/22/2005 to correct the inadequacy.
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PLANT STATUS
Cooper Nuclear Station (CNS) was in Mode 1 at 100% power at the time of discovery on 6/21/2005.
BACKGROUND
The standby alternating current (AC) power system (EIIS:EK) consists of two independent on-site diesel generators (DG's) (EIIS:DG) adequate for maintaining the safe shutdown of the reactor following abnormal operational transients and postulated accidents in the event of failure of off-site power. Each DG unit has a fuel day tank (EIIS:DC). Both day tanks are supplied from either of two main fuel storage tanks (EIIS:DC). Both main fuel storage tanks combined are capable of providing sufficient fuel for seven days of operation of one DG unit under postulated accident conditions. Each fuel day tank will provide enough fuel to allow a minimum of five hours of full load operation of the DG unit.
Each of the two diesel fuel oil storage tanks is provided with its own transfer pump and piping connections to its respective fuel oil day tank. Cross-ties are provided such that either DG can be supplied from both fuel oil storage tanks.
CNS Technical Specification (TS) Limiting Condition for Operation (LCO) 3.8.1, AC Sources - Operating, requires two qualified circuits between the offsite transmission network and the onsite Class 1 E AC Electrical Power Distribution System; and two DG's to be OPERABLE in Modes 1 (Power Operation), 2 (Startup) and 3 (Hot Shutdown.) If two DG's are inoperable, the Action Statement requires the restoration of one DG to OPERABLE status in 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />.
LCO 3.8.2, AC Sources — Shutdown, requires one qualified circuit between the offsite transmission network and the onsite Class 1 E AC electrical power distribution subsystem(s) and one DG capable of supplying one division of the onsite Class 1 E AC electrical power distribution subsystem(s) in Modes 4 (Cold Shutdown) and 5 (Refueling). If the required DG is inoperable, the Action Statement requires that action be initiated to restore the required DG to OPERABLE status "Immediately.
CNS TS 1.3 says that when "Immediately" is used as a Completion Time, the Required Action should be pursued without delay and in a controlled manner.
EVENT DESCRIPTION
On 6/21/2005, during an NRC inspection, CNS determined that the DG Diesel Oil (DO) transfer pump in service test (1ST) flow test performed on 11/5/2004 while in Mode 4 resulted in a condition prohibited by TS.
On 5/14/2004, surveillance procedure for DG DO transfer pump 1ST flow test for Division 1 was revised to allow quarterly exercising of the two normally closed manual cross connect valves between DG Fuel Tanks 1 and 2. The new Revision 16 of the procedure allowed both DG fuel transfer pumps (from main storage tank to day tank) to be disabled from automatic start to permit validating cross-connect valve operation. The procedure instructed operators to record both tank level changes while opening these valves, thus validating that the valves have opened. Disabling the fuel transfer pumps was achieved by placing their switches to the OFF position. No steps were included in the procedure to declare both DG's inoperable. Performance of the surveillance takes approximately 30 minutes.
The surveillance was performed on 7/13/2004 and 10/7/2004 while the plant was in Mode 1, and on 11/5/2004 in Mode 4, without declaring both DG's inoperable. On 12/30/2004, as operators were preparing to execute the procedure for the fourth time, operators recognized that the steps to place the transfer pump switches to OFF would require declaring both DG's inoperable. The surveillance procedure was revised to avoid placing both transfer pump switches to OFF, and the surveillance was subsequently performed. A Condition Report (CR) was initiated and referred to the three earlier surveillances when both DG 1 & 2 were rendered inoperable.
During the CR initial reportability review, CNS determined that both DG's were simultaneously inoperable during the three events. In all 3 cases, there was no loss of safety function because DG day tanks will provide enough fuel to allow a minimum of five hours of full load operation of the DG. For July and October, the surveillances were completed within the 2 hour2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> TS action limit for Mode 1 which satisfied the TS requirement. For November, the TS "immediate" action limit for Mode 4 was exceeded, but a condition prohibited by TS was judged to not exist due to the short time it took to execute the surveillance being within the completion time required by TS. CNS then categorized the CR as "Not-Reportable".
In June of 2005, NRC inspectors questioned the reportability determination for the 11/5/2004 event. On 6/21/2005, CNS reviewed the November 2004 event, and agreed that it was a condition prohibited by TS.
BASIS FOR REPORT
This event is being reported as a condition prohibited by plant TS per 10 CFR 50.73(a)(2)(i)(B),
SAFETY SIGNIFICANCE
No Safety System Functional Failure occurred. The inadequate evaluation of reportability is not an equipment or hardware related performance issue. In addition, the required DG was considered available during the surveillance since the restoration of the fuel oil transfer pump is procedurally directed and can be accomplished well within day tank depletion time. The condition did not challenge a reactor fuel, reactor coolant pressure, primary containment, or secondary containment boundary. The condition did not impact the plant's ability to safely shutdown or maintain the reactor in a safe shutdown condition.
As a consequence, the condition has no impact on the baseline Probabilistic Risk Assessment model and results in no change in core damage frequency.
CAUSE
The root cause was that Revision 16 of the surveillance procedure was inadequate in that it did not require or caution that performing procedure steps would render both DG's inoperable.
CORRECTIVE ACTION
Immediate action taken was to counsel individuals involved with the surveillance procedure Revision 16 on adherence to process requirements of changing procedures, attention to detail, and the need for rigor in reviewing and approving procedure changes.
The corrective action taken to prevent recurrence was to revise the surveillance procedure for DG DO transfer pump IST flow test for Division 1 to remove steps that allow both DG's to be simultaneously inoperable. This action was completed on 1/22/2005.
PREVIOUS EVENTS
On April 10,2000, during performance of the System Leakage Test surveillance procedure for refuel outage RE-19, the TS limit for Reactor Coolant System (RCS) heat-up rate was exceeded in Reactor Recirculation (RR) [EIIS:AD] loop B. The failure to meet TS Surveillance Requirement acceptance criteria was not recognized, and the required evaluation to determine if the RCS is acceptable for operation was not performed prior to start up from the RE-19 refuel outage. On March 20, 2003, with CNS in Mode 5 for refuel outage RE-21, a review of the surveillance procedure and past performance of the procedure was performed in support of a modification to replace temperature recorders. During this review the above condition was discovered. This event was the result of inadequate procedural guidance for equalizing RCS temperatures in preparation for starting an idle RR pump, and evaluating available RCS temperature data. This condition was reported to the NRC in LER 2003-03.
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05000328/LER-2005-001 | Unit 2 Reactor Trip Following Closure of Main Feedwater Upon Inadvertent Opening of Control Breakers | 10 CFR 50.73(a)(2)(iv)(A), System Actuation 10 CFR 50.73(a)(2)(v), Loss of Safety Function | 05000388/LER-2005-001 | DDegradation of Primary Coolant Pressure Boundary due to Recirculation Pump Discharge Valve Bonnet Vent Connection Weld Flaw | 10 CFR 50.73(a)(2)(ii)(A), Seriously Degraded | 05000423/LER-2005-001 | | 10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | 05000455/LER-2005-001 | Unit 2 Automatic Reactor Trip Due to Low Steam Generator Level resulting from a Software Fault on the Turbine Control Power Runback Feature | | 05000370/LER-2005-001 | Automatic Actuation of Motor Driven Auxiliary Feedwater Pumps During Outage | | 05000244/LER-2005-001 | Failure of ADFCS Power Supplies Results in Plant Trip | | 05000247/LER-2005-001 | 0Technical Specification Prohibited Condition Due to Exceeding the Allowed Completion Time for One Inoperable Train of ECCS Caused by an Inoperable Auxiliary Component Cooling Water Check Valve | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | 05000529/LER-2005-001 | REACTOR HEAD VENT AXIAL INDICATIONS CAUSED BY DEGRADED ALLOY 600 COMPONENT | 10 CFR 50.73(a)(2)(v), Loss of Safety Function 10 CFR 50.73(a)(2)(ii)(A), Seriously Degraded | 05000336/LER-2005-001 | | | 05000266/LER-2005-001 | | 10 CFR 50.73(a)(2)(ii)(B), Unanalyzed Condition | 05000269/LER-2005-001 | | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | 05000289/LER-2005-001 | | | 05000293/LER-2005-001 | | 10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident | 05000298/LER-2005-001 | Reactor Scram due to Reactor Level Transient and Inadvertent Rendering of High Pressure Coolant Injection Inoperable | 10 CFR 50.73(a)(2)(iv)(A), System Actuation 10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident | 05000331/LER-2005-001 | | 10 CFR 50.73(a)(2)(ii)(B), Unanalyzed Condition | 05000315/LER-2005-001 | Reactor Trip Following Intermediate Range High Flux Signal | | 05000316/LER-2005-001 | Reactor Trip from RCP Bus Undervoltage Signal Complicated by Diesel Generator Output Breaker Failure | 10 CFR 50.73(a)(2)(iv)(A), System Actuation 10 CFR 50.73(a)(2)(v)(A), Loss of Safety Function - Shutdown the Reactor 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | 05000317/LER-2005-001 | Main Feedwater Isolation Valve Inoperability Due to Handswitch Wiring | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | 05000323/LER-2005-001 | TS 3.4.10 Not Met During Pressurizer Safety Valve Surveillance Testing Due to Random Lift Spread | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | 05000333/LER-2005-001 | Inoperable Offsite Circuit In Excess of Technical Specifications Allowed Out of Service Time | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | 05000352/LER-2005-001 | Loss Of Licensed Material In The Form Of A Radiation Detector Calibration Source | | 05000353/LER-2005-001 | Core Alterations Performed With Source Range Monitor Alarm Horn Inoperable | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | 05000306/LER-2005-001 | | 10 CFR 50.73(a)(2)(v)(C), Loss of Safety Function - Release of Radioactive Material 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | 05000361/LER-2005-001 | | 10 CFR 50.73(a)(2)(iv)(A), System Actuation | 05000362/LER-2005-001 | Emergency Diesel Generator (EDG) 3G003 Declared Inoperable Due to Loose Wiring Connection on Emergency Supply Fan | | 05000263/LER-2005-001 | | | 05000456/LER-2005-001 | Potential Technical Specification (TS) 3.9.4 Violation Due to Imprecise Original TS and TS Bases Wording | | 05000454/LER-2005-001 | Failed Technical Specification Ventilation Surveillance Requirements During Surveillance Requirement 3.0.3 Delay Period | | 05000282/LER-2005-001 | | 10 CFR 50.73(a)(2)(ii)(B), Unanalyzed Condition 10 CFR 50.73(a)(2)(v), Loss of Safety Function | 05000286/LER-2005-001 | Plant in a Condition Prohibited by Technical Specifications due to Error Making Control Room Ventilation System Inoperable | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | 05000400/LER-2005-001 | Reactor Auxiliary Building Emergency Exhaust System Single Failure Vulnerability | | 05000395/LER-2005-001 | Emergency Diesel Generator Start and Load Due To A Loss Of Vital Bus | 10 CFR 50.73(a)(2)(iv)(A), System Actuation | 05000382/LER-2005-001 | RCS Pressure Boundary Leakage Due to Primary Water Stress Corrosion Cracking of a Pressurizer Heater Sleeve | 10 CFR 50.73(a)(2)(ii)(A), Seriously Degraded | 05000305/LER-2005-001 | | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | 05000369/LER-2005-001 | Reactor Coolant System Leakage Detection Instrumentation Inoperable | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | 05000266/LER-2005-002 | | 10 CFR 50.73(a)(2)(ii)(B), Unanalyzed Condition | 05000255/LER-2005-002 | | 10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | 05000361/LER-2005-002 | Missing Taper Pins on CCW Valve Cause Technical Specification Required Shutdown | 10 CFR 50.73(a)(2)(i)(A), Completion of TS Shutdown | 05000370/LER-2005-002 | Ice Condenser Lower Inlet Door Failed Surveillance Testing | | 05000353/LER-2005-002 | High Pressure Coolant Injection System Inoperable due to a Degraded Control Power Fuse Clip | 10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident | 05000263/LER-2005-002 | | | 05000454/LER-2005-002 | One of Two Trains of Hydrogen Recombiners Inoperable Longer Than Allowed by Technical Specifications Due to Inadequate Procedure | | 05000244/LER-2005-002 | Emergency Diesel Generator Start Resulting From Loss of Off-Site Power Circuit 751 | | 05000362/LER-2005-002 | Emergency Containment Cooling Inoperable for Longer than Allowed by Technical Specifications | 10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | 05000247/LER-2005-002 | DTechnical Specification Prohibited Condition Due to Exceeding the Allowed Completion Time for One Inoperable Train of ECCS Caused by Gas Intrusion from a Leaking Check Valve | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | 05000306/LER-2005-002 | | 10 CFR 50.73(a)(2)(v)(C), Loss of Safety Function - Release of Radioactive Material 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications 10 CFR 50.73(a)(2)(i)(A), Completion of TS Shutdown | 05000265/LER-2005-002 | Main Steam Relief Valve Actuator Degradation Due to Failure to Correct Vibration Levels Exceeding Equipment Design Capacities | 10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident 10 CFR 50.73(a)(2)(vii), Common Cause Inoperability 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications 10 CFR 50.73(a)(2)(i)(A), Completion of TS Shutdown | 05000286/LER-2005-002 | • Entergy Nuclear Northeast Indian Point Energy Center 450 Broadway, GSB P.O. Box 249Entergy Buchanan. NY 10511-0249 Tel 914 734 6700 Fred Dacimo Site Vice President Administration July 5, 2005 Indian Point Unit No. 3 Docket Nos. 50-286 N L-05-078 Document Control Desk U.S. Nuclear Regulatory Commission Mail Stop O-P1-17 Washington, DC 20555-0001 Subject:L Licensee Event Report # 2005-002-00, "Automatic Reactor Trip Due to 32 Steam Generator Steam Flow/Feedwater Flow Mismatch Caused by Low Feedwater Flow Due to Inadvertent Condensate Polisher Post Filter Bypass Valve Closure." Dear Sir: The attached Licensee Event Report (LER) 2005-002-00 is the follow-up written report submitted in accordance with 10 CFR 50.73. This event is of the type defined in 10 CFR 50.73(a)(2)(iv)(A) for an event recorded in the Entergy corrective action process as Condition Report CR-IP3-2005-02478. There are no commitments contained in this letter. Should you or your staff have any questions regarding this matter, please contact Mr. Patric W. Conroy, Manager, Licensing, Indian Point Energy Center at (914) 734-6668. Sincerely, 4F-/t R. Dacimo Vice President Indian Point Energy Center Docket No. 50-286 NL-05-078 Page 2 of 2 Attachment: LER-2005-002-00 CC: Mr. Samuel J. Collins Regional Administrator — Region I U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commission Resident Inspector's Office Resident Inspector Indian Point Unit 3 Mr. Paul Eddy State of New York Public Service Commission INPO Record Center NRC FORM 3660 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150-0104 EXPIRES: 06/30/2007 (6-2004) Estimated burden per response to comply with this mandatory collection request 50 hours.RReported lessons teamed are incorporated into the licensing process and fed back to Industry. Send comments regarding burden estimate to the Records and FOIA/Privacy Service Branch (T-5 F52), U.S. Nuclear Regulatory Commission, Washington, DC 29555-0001, or by InternetLICENSEE EVENT REPORT (LER) e-mail to Infocoilectsenrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-l0202, (3150-0104), Office of Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not display a currently valid OMB control number, the NRC may not conduct or sponsor, and a person Is not required to respond to, the Information collection. 1. FACIUTY NAME 2. DOCKET NUMBER 3. PAGE INDIAN POINT 3 05000-286 10OF06 4. TITLE Automatic Reactor Trip Due to 32 Steam Generator Steam Flow/Feedwater Flow Mismatch Caused by Low Feedwater Flow Due to Inadvertent Condensate Polisher Post Filter Bypass Valve Closure | 10 CFR 50.73(a)(2)(iv)(A), System Actuation | 05000287/LER-2005-002 | Unit 3 trip with ES actuation due to CRD Modification Deficiencies | 10 CFR 50.73(a)(2)(iv)(A), System Actuation | 05000336/LER-2005-002 | | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications |
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