05000335/LER-2011-003
| St. Lucie Unit 1 | |
| Event date: | 11-03-2011 |
|---|---|
| Report date: | 03-06-2012 |
| Reporting criterion: | 10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident 10 CFR 50.73(a)(2)(ii)(B), Unanalyzed Condition |
| 3352011003R01 - NRC Website | |
FACILITY NAME (1)
DOCKET
Description of the Event
On November 3, 2011, with St. Lucie Unit 1 in Mode 1 at 85% power, the St. Lucie Onsite Review Group determined that the unproceduralized manual actions to mitigate postulated single failures in the St. Lucie Unit 1 hot leg injection (HLI) flow path constituted a reportable condition.
Long-term core cooling and boron precipitation became an issue during the initial licensing of St. Lucie Unit 1. Because the St. Lucie Unit 1 design did not provide dedicated hot leg injection paths, St. Lucie Unit 1 was licensed to develop HLI procedures that utilized the existing low pressure safety injection (LPSI) and/or high pressure safety injection (HPSI) flow paths for hot leg injection. The HLI procedures developed for St. Lucie Unit 1 are described in Chapter 6, Appendix 6C of the Unit 1 Updated Final Safety Analysis Report (UFSAR).
Two HLI flow paths direct the discharge of one LPSI or containment spray (CS) pump through the opposite train LPSI pump 2-inch shutdown cooling (SDC) warm-up line and "backwards" through the opposite train LPSI pump suction line into the hot leg. The cold leg injection is via the normal HPSI pump operation. These flow paths require the availability of both electric trains. Motor operated valves (MOVs) powered from different electric busses must be operated for the flow path to be successful. This single failure vulnerability was mitigated by developing procedures which identified a third success path to ensure that HLI could be achieved. If the LSPI/CS flow paths are not available, the third flow path for HLI is from a HPSI pump, via the connection to the charging pump discharge piping, through the pressurizer auxiliary spray piping to the pressurizer, and down the surge line to the hot leg. Again, the cold leg injection is via the normal HPSI pump operation. These flow paths are shown in Figures 1 through 5.
The St. Lucie Unit 1 Safety Evaluation Report, Supplement 2, documents the NRC review of the HLI procedures. Through a review of the piping and instrument drawings (P&IDs), the NRC concluded that "the two methods proposed for hot leg injection do not meet the single failure criterion individually. However, the two methods complement one another, and the overall ECCS is, therefore, single failure proof.
In 1999, St. Lucie documented in a condition report (CR) that the two complementary HLI methods were not single failure proof. Loss of an electric bus would prevent both the primary and alternative HLI flow paths from being successful. However, a HLI flow path could be restored by the use of temporary jumpers to restore power to the MOVs affected by the loss of an electric train. Even though no procedures were revised and jumpers were not fabricated, long-term HLI was considered fully operable because: 1) jumper fabrication was considered to be within the skill of the craft and, 2) the long-term nature of HLI initiation allowed sufficient time for the emergency response organization to determine where jumpers were needed. Actions were developed to proceduralize the use of the temporary jumpers to mitigate the identified single failure scenarios. In 2008 another CR documented that the previously identified jumpers and procedure changes were not implemented. The 2008 CR credited the 1999 CR with respect to operability and developed new tracking actions for the required procedure changes and jumper fabrication.
Subsequently, St. Lucie applied for increasing reactor power via an extended power uprate (EPU) license amendment. The EPU analysis for HLI required increasing the flow rate. The failure modes and effects analysis (FMEA) performed as part of the 2011 design modification effort identified that: 1) the procedure changes and jumper FACILITY NAME (1)
DOCKET
fabrication identified in the 1999 and 2008 CRs had not been implemented, and 2) the previously identified jumper scope was not adequate to mitigate postulated single failures in the HLI flow path. Additionally, at the time this LER was originally submitted, postulated HLI flow exceeded the heat exchanger shell side design flowrate, and the evaluation to ensure the integrity of the regenerative heat exchanger was not complete. The evaluation for the HLI flow through the regenerative heat exchanger was subsequently completed and the heat exchanger integrity was not compromised by either historical of post-EPU HLI flow rates. The required jumpers were fabricated and required procedure changes implemented. The operable but degraded condition is being tracked as an open RIS 2005-20 issue.
St. Lucie determined that crediting unproceduralized manual actions for maintaining the HLI flow paths as fully operable was non-conservative with respect to RIS 2005- 20, revision 1. Furthermore, the discovery of additional jumper scope called into question the 1999 CR assertion that the emergency response organization would be successful initiating HLI within the required time frame, given a loss of an electrical train. Based on the above, this condition is reportable.
Cause of the Event
The original single failure vulnerability is a legacy design issue.
The failure to implement effective contingency measures once the single failure vulnerability was identified was due to two issues. The first issue was the inadequate operability assessment in the 1999 CR. This CR concluded that the HLI function remained fully operable without the need to proceduralize the required jumpers. Additionally, the engineering rigor applied to the FMEA was inadequate. A 1970's vintage Combustion Engineering letter was used to develop the required jumper scope; this over-reliance on vendor input led to the inadequate FMEA that did not identify the full scope.
The lack of rigor in operability assessments (now referred to as prompt operability/functionality determinations) is considered a legacy human performance issue. An extent of condition review was performed by reviewing the condition reports for the past five years. No issues were found that invalidated the conclusions of the prompt operability/functionality determinations. Additionally, the NextEra Energy (NEE) Fleet procedure platform revised the fleet operability procedure in 2008. The newer process is more formal than the freeform operability assessment performed in 1999, and engineering department personnel have had recent training on the subject.
The second issue that led to the failure to implement effective contingency measures (and represents the second opportunity for discovery) was the inadequate screening of the 2008 CR that documented the untimely corrective actions for the 1999 CR. The 2008 CR was screened as an administrative issue with no plant impact because of the referenced 1999 CR disposition. The CR initial screening team failed to recognize the significance of crediting non-proceduralized manual actions for continued operability. Had the NEE fleet prompt operability determination process been utilized in 2008, this condition would have been classified as at least functional but degraded and the manual actions needed as compensatory measures would have been proceduralized during the prompt operability/functionality determination process.
Subsequent to the 2008 CR, the St. Lucie corrective action program (CAP) was significantly revised as a result of the NRC 95002 inspection following 2008/2009 component cooling water (CCW) air intrusion events. The CR initial screening team FACILITY NAME (1)
DOCKET
and management review committee methods were revised to ensure that CR screening categorization and classification are based on nuclear safety and risk. An extent of condition review was performed on similar CRs screened as administrative in nature over the last five years, and none were found that had unresolved safety issues.
These corrective actions became effective after the 2008 HLI CR.
Analysis of the Event
This condition is reportable pursuant to 10 CFR 50.73(a)(2)(ii)(B) as any event or condition that resulted in the nuclear power plant being in an unanalyzed condition that significantly degraded plant safety. NUREG-1022 states that the discovery of a system that does not meet the single failure criterion is reportable under this section. The NRC SER clearly stated that no single failure would prevent HLI, but the current design requires the use of jumpers to mitigate single failure scenarios.
Additionally, this condition is reportable pursuant to 10 CFR 50.73(a)(2)(v)(D) as any condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.
NUREG-1022 states that it is not required to postulate an additional random single failure in the system. However, only one single failure would be necessary to prevent hot leg injection, a required long-term cooling safety function.
This condition is not applicable to St. Lucie Unit 2 as it has a dedicated HLI flow path as part of its original design.
Analysis of Safety Significance The mechanism for potential boron precipitation is as follows. For a hot leg break, the injection flow passes from the cold legs, through the core, into the hot legs, and out the break. For a hot leg break, core heat removal is via forced flow of the injection water. In contrast, for a cold leg break, after the reflooding is completed, the hydraulic balance will cause most of the injection flow to spill out of the break - the only flow into the core will be that required to make-up for the boil-off in the core that removes the core decay heat. The boron problem arises only during a cold leg break; as borated injection flow enters the core, and only pure water (as steam) leaves the core, the boron concentration in the core region will continue to increase. Once the boron concentration exceeds the solubility limit the boron will precipitate and challenge long-term core cooling capability. The solution to the potential problem is to achieve subcooled flow through the core: when boron in equals boron out, the concentration will not be increasing.
St. Lucie uses simultaneous hot and cold leg injection as the method to achieve forced flow through the core for long-term post-LOCA cooling. With simultaneous hot and cold leg injection, the recirculated sump fluid is injected into the hot legs as well as the cold legs. Regardless of break location, approximately half of the flow will pass through the core on its way to the break (the flow to the side with the break spills directly out of the break into containment, contributing nothing).
In order to preclude boron precipitation, the operators are procedurally required to Operating License HLI analysis required initiation of long-term post-LOCA cooling within 20 hours2.314815e-4 days <br />0.00556 hours <br />3.306878e-5 weeks <br />7.61e-6 months <br /> of the event. FPL committed to initiating HLI within ten hours to preserve the analysis. In 1993, the boron concentration in the boric acid makeup tanks was reduced, and this unofficially increased the initiation of long-term post- LOCA cooling up to 32 hours3.703704e-4 days <br />0.00889 hours <br />5.291005e-5 weeks <br />1.2176e-5 months <br /> after the event. In 1999, the HLI analysis of record was revised to incorporate the NRC accepted CENPD-254-P-A, "Post-LOCA Long Term Cooling Evaluation Model," and the time limit for HLI initiation was reduced from 32 to ten hours. In addition to the maximum time limit to preclude boron precipitation, decay heat and steam formation in the reactor head render HLI flow through the hot leg ineffective for the first four hours post-LOCA; this concern is addressed by the procedural initiation of HLI after the first four hours.
In 2003, the St. Lucie reload analysis added a return to criticality aspect to the HLI analysis. This cycle specific calculation required that HLI be initiated within seven to ten hours to preclude a return to criticality. Once the conservatisms are removed from the return to criticality calculation, the boron precipitation time limit of 10 hours1.157407e-4 days <br />0.00278 hours <br />1.653439e-5 weeks <br />3.805e-6 months <br /> becomes bounding. Based on this, after waiting for the first four hours post-LOCA for HLI flow through the hot leg to become effective, the operators had an approximate six hour window to initiate HLI.
If there was a loss of an electrical bus, even without procedures, the emergency response organization (ERO) problem solving teams in the technical support center (TSC) and emergency response facility (ERF) would be looking ahead and would come to the conclusion that jumpers would be needed to initiate HLI. Because such actions would be knowledge-based instead of rule-based, there is a small probability that HLI would not be initiated in time to preclude boron precipitation, even with the consideration of the relatively long time period needed to establish HLI flow.
A probabilistic safety assessment concluded that the incremental core damage probability associated with the ERO directed actions and jumper fabrication needed to mitigate the failure scenarios was less than 1 X 10-6.
Based on the above, FPL concludes that this event had no adverse effect on the health and safety of the public.
Corrective Actions
The corrective actions listed have been entered into the site CAP. Any changes to the actions below will be processed in accordance with the CAP.
1. The required jumpers were fabricated and required procedure changes implemented.
The operable but degraded condition is being tracked as an open RIS 2005-20 issue.
2. The appropriate long-term solution to the HLI failure vulnerabilities will be implemented no later than the end of the SL1-25 refueling outage.
3. The improvements to the St. Lucie CAP are as described in LER 50-335/2010-001-01, "Air Intrusion From 1A Containment Instrument Air Compressor Into Unit 1 Component Cooling Water (CCW) System.
Similar Events Into Unit 1 Component Cooling Water (CCW) System." This event was the onus for the St. Lucie CAP improvements driven by the NRC 95002 inspection on CCW air intrusion events. The causes for the CCW air intrusion event that are applicable to and bound the current LER on HLI single failure issue include the organization and programmatic weaknesses that existed in the areas of prompt identification, understanding of event significance, and timely corrective actions. As such, the corrective actions for the CCW air intrusion event bound the HLI single failure event.
Failed Components
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