05000416/LER-1990-022, :on 901026,loss of Shutdown Cooling Due to Inadequate Procedure

:on 901026,loss of Shutdown Cooling Due to Inadequate Procedure

ML20062F606
Person / Time
Site:	Grand Gulf
Issue date:	11/23/1990
From:	Cottle W, Summers J ENTERGY OPERATIONS, INC.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
AECM-90-0205, AECM-90-205, LER-90-022, LER-90-22, NUDOCS 9011280073
Download: ML20062F606 (5)

LER-1990-022, on 901026,loss of Shutdown Cooling Due to Inadequate Procedure

Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2)(vii), Common Cause Inoperability
4161990022R00 - NRC Website

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U.S. Nuclear Regulatory Commission Mail Station P1-137 l

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Attention: Document Control Desk y

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Gentlemen:

. SUBJECT:

Grand Gulf Nuclear ~ Station; j

Unit 1 Docket No. 50-416 i

License No. NPF-29.

Loss of Shutdwn Cooling Due to Inadequate Procedure LER 90-022 AECM-90/0205-Attached is Licensee Event Report (LER)90-022 which is a final l

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Mr.R.B.McGehee(w/a))-

Mr. N. S. Reynolds-(w/a L

Mr. H. L. Thomas (w/o)(w/a)

Mr. H.- 0. Christensen Mr. Stewart D. Ebneter.(w/a) l Regional Administrator-1 U.S. Nuclear Regulatory Comission-i Region II

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101 Marietta St., N.W., Suite 2900 i

3 Atlanta,-Georgia-30323 l

Mr. L. L. Kintner, Project Manager.(w/a) i Office of Nuclear Reactor Regulation:

U.S. Nuclear Regulatory Commissioni Mail Stop 11021 Washington, D.C. _20555 i

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On October 26, 1990, breaker 52-153109 which supplies pewer to common suction line isolatien valve E12-F008 was closed. As a result, valve E12-F008 stroked closed from a trip signal that was being sent as aart of an Instrumentation ano Control (I&C) surveillance in progress at t1e time, thereby tripping the Residual Heat Removal (EIIS code: B0) pump _"B" and isolating the Shutdown Cooling System. 'he E12-F008 valve was subsequently reopened and shutdown cooling restored within 15 minutes.

Valve E12-F008 was closed due to inadeqtate procedural guidance on the use of information tags to control in progress test activities.

The lack of verbal communications between the operators involved and the test directors was also a contributing factor.

The Operations Superintendent conducted briefings with the responsible test directors and issued Standing Orders to implement interim guidance on the use of tags on valves, breakers, etc., that are placed out of their normal i

position for testing purposes. An evaluation of current testing l

methodologies will be performed by plant management.

Upon completion, a program will be developed to implement a uniform component tagging system l

to indicate specific testing conditions. This program will'be completed by March 31, 1991, i roonn99 neuon o gRg,.... -

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Reportable Occurrence On October 26, 1990, during performance of two refueling surveillances, a single failure caused two independent channels of the Residual Heat Removal System to become inoperable.

This condition is

. reported pursuant to 50.73(a)(2)(vii).

B.

Initial Condition The plant was operating in Mode 5, Refueling, at the time of this incident.

C.

Description of Occurrence l

On October 26, 1990, Instrument and Control (I&C) technicians were in the process of performing /RHR Shutdown Cooling Isolation) which Surveillance 06-IC-B21-R-0001, Reactor l

Vessel High Pressure (RPS requiredthebreakar(52-153109) for valve E12-F008 to be open. Valve E12-F008 remained open to supply suction for the Residual Heat Removal (RHR) System"B"'(EIIS' Code:B0).

Concurrently with this activity, Operations personnel were in the process of restoring equipment to conclude Loss of Coolant Accident (LOCA)' testing on the Division I Diesel Generator and associated Emergency Core Cooling System (ECCS) equipment when they noticed that the power su? ply breaker-(52-153109) to valve E12-F008 was open.

They assumed brea<er 52-153109 had been opened per their surveillance (06-0P-1P75-R-0003, Standby Diesel Generator 11: 18' Month Functional Test) and requested that it be closed. When breaker 52-153109 was closed, valve E12-F008 stroked closed from a trip signal that was being sent as part of the I&C surveillance in progress at the time, thereby' tripping the RHR pump "B" and isolating the Shutdown Cooling System.

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The E12-F008 valve was subsequently reopened and~ Shutdown Cooling restored within 15 minutes.

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D.

Apparent Cause Shutdown Cooling Isolation Valve E12-F008 inadvertently closed due to inadeluate procedural guidance on the use of information tags to contr(1 in progress test activities. Although existing tagging prograns are in place, no written guidance on their use during testing activities was implemented.

Since the handswitch was not tagged to alert operators of the specific test: activity, they mistakenly concluded that breaker 52-153109 was opened for LOCA testing.

The lack of verbal communications between the operators involved-in this incident and the test directors.in charge was also a contributing.

factor. Operators discussed, among themselves, the fact that the breaker for valve E12-F008 was open, but failed to contact the test-director to verify that-breaker. 52-153109 was not connected to a i

surveillance test in progress.

i E.

Supplemental Actions The Operations Superintendent briefed the test director. responsible for the overall implementation of the surveillance tests.in progress at the time of the shutdown cooling isolation. The purpose of this briefing was to stress the-importance of maintaining complete control-over tests from beginning to restoration of the system.

As an interim measure, Standing Orders were' issued to im)1ement en nce on the use of tags on valves, breakers, etc., t1at are placed ou

,f their normal position for testing purposes. ~ This process will, in part, require placing a tag (e.g., Red Tag,-Work Incomplete Tag, Information Tag, etc.) on the handswitch of the valve affected by the test to denote testing _is in progress.

These guidelines will be incorporated, as appropriate, into a new tagging program for components under test.

An evaluation of current testing methodologies will-be performed by plant management. Upon completion, a program will be developed to implement a uniform-tagging system to indicate specific testing conditions. This program will be completed by March 31, 1991.

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F.

Safets Assessment The Shutdown Cooling System in service was out of operation for 15 tinutes.

Reactor coolant temperature remained at approximately 90 degrees Fahrenheit.

Reactor coolant temperature was not significantly:

affected by the isolation since the reactor cavity was flooded, providing an increased coolant. inventory.

Further, the isolation occurred 26 days after shutdown; therefore, decay heat was minimum, i

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