05000416/LER-1997-001, :on 970312,TS Surveillance of Standby Svc Water Subsystem Was Missed.Caused by Less than Adequate Work Practices.Performed Evaluation of Effect of Installation of non-qualified Annubar in Room Coolers
| ML20141E625 | |
| Person / Time | |
|---|---|
| Site: | Grand Gulf  |
| Issue date: | 05/13/1997 |
| From: | Brooks C, Hagan J ENTERGY OPERATIONS, INC. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| GNRO-97-00041, GNRO-97-41, LER-97-001, LER-97-1, NUDOCS 9705210068 | |
| Download: ML20141E625 (6) | |
| Event date: | |
|---|---|
| Report date: | |
| Reporting criterion: | 10 CFR 50.73(a)(2)(i) 10 CFR 50.73(a)(2)(viii) 10 CFR 50.73(a)(2)(ii) 10 CFR 50.73(a)(2)(x) 10 CFR 50.73(a)(2)(iii) 10 CFR 50.73(a)(2)(iv), System Actuation 10 CFR 50.73(a)(2)(v), Loss of Safety Function 10 CFR 50.73(a)(2)(vii), Common Cause Inoperability |
| 4161997001R00 - NRC Website | |
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Entergy Operation 0,Inc.
PO. Box 756 d
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Port Gibson. MS 39150
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Tel 601437 6408 Fax 601437 2795 Joseph J. Hagan May 13, 1997
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Grand G4 Nuclear Station U.S. Nuclear Regulatory Commission Mail Station P1-37 Washington, D.C. 20555 Attention:
Document Control Desk
SUBJECT:
Grand Gulf Nuclear Station Docket No. 50-416 License No. NPF-29 Standby Service Water Subsystem (Missed Technical Specification Surveillance)
LER 97-001-01 GNRO-97/00041 Gentlemen:
In accordance with the requirements of 10 CFR 50.73, Licensee Event Report (LER)97-001 Supplement 1 (LER 97-00101) for Grand Gulf Nuclear Station is attached. A interim report describing the events herein was submitted by letter dated April 14,1997. Revised text incorporated subsequent to submittal of the interim report is denoted by revision bars in the right-hand margin of Supplement 1. The attached report is being submitted as a final report.
Should you have any questions or require additional clarification of the information herein, please contact the licensee"s representative listed on the LER.
Yours truly, JJH/CEB/
attachment Licen ee E rent Report 97-01-01 (Final Report) cc:
Mr.R.
cGehee (w/a)
Mr. N. S. Reynolds (w/a)
Ms. K. D. Weaver (w/a)
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E Mr. J. W. Yelverton (w/a) f Mr. Ellis W. Merschoff (w/a)
V Regional Administrator U.S. Nuclear Regulatory Commission Region IV
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611 Ryan Plaza Drive Suite 400 Arlington, TX 76011 Mr. J. N. Donohew (w/a)
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@'u.ffice of Nuclear Reactor Regulation S. Nuciear Reguiatory Commission Mail Stop 13H3 lilllllIREllllll 9705210068 970513 PDR ADOCK 05000416 S
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Attachment to GNRO-97/0004) l NRC FORM 366 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150-0104 I")
EXPIRES 04/30/98 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS MANDATORY JNFORMAfiON COLLEC110N REQUEST 500 HRS REPORTED LESSONS LEARNED ARE INCORPORATED INTO THE LICENSING PROCESS AND FED BACK LICENSEE EVENT REPORT (LER)
To 'NDUSTRY. FORWARD COMMENTS REGARDING BURDEN ESTMATE TO THE INFORMATION AND RECORDS MANAGEMENT BRANCH (T4 F33). U S. NUCLEAR 1
REGULATORY COMMIS$10N. WASHINGTON. DC 20555 @ 01. AND TO THE PAPERWORK NEDUCTIO1 PROJECT (3150 0104). OFFICE OF MANAGEMENT AND BUDGET. WASHINGTON. DC 20503 F ACJLITY NAME (1)
DOCKET NUMBER (2)
PAGE (3)
Gr:nd Gulf Nuclear Station 05000-416 1 of 5 nrtaa)
Standby Service Water System Subsystem (Missed Technical Specification Surveillance)
EVENT DATE (5)
LER NUMBER (6)
REPORT DATE (7)
OTHER FACILITIES INVOLVED (8) uuNTH DAf YEAH YEAR hf QUENTA REVISION MONTH DAY YEAR F ACILITY NAME DOCKET NUMBER NousER NuueEa N/A 05000 FACluTY NAME DOCKET NUMBER 03 12
$7 97 001 01 05 13 97 N/A 05000 I
OPERATING THIS REPORT is SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR 5 (Check One Or more)(11)
MODE (9) 1 20.2201(b) 20.2203(a)(2)(v)
X 50.73(a)(2)(i) 50.73(a)(2)(viii)
POWER 20.2203(a)(2)(i) 20.2203(a)(3)(i) 50.73(a)(2)(ii) 50.73(a)(2)(x)
LEVEL (10) 100 20.405(a)(1)(ii) 20.2203(a)(3)(ii) 50.73(a)(2)(iii) 73.71 20.2203(a)(2)(ii) 20.2203(a)(4) 50.73(a)(2)(iv)
OTHER
,' [e 20.2203(a)(2)(iii) 50.36(c)(1) 50.73(a)(2)(v)
"Y " ^"*"3py. or n NRC Form t
20.2203(a)(2)(iv) 50.36(c)(2) 50.73(a)(2)(vii)
LICENSEE CONTACT FOR THIS LER (12)
NAME TELEPHONE NUMBER (include A.ea Code)
Charles E. Brooks / Sr. Licensing Specialist 601-437-6555 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBE 0 IN THIS REPORT (13)
CAUSE
SYSitM COMPONENT MANUF AC TURER REPORTABLE
CAUSE
SYSTEM
' COMPONENT MANUFACTURER REPOHTABLE TO NPRDS
[
TO NPRDS SUPPLEMENTAL REPORT EXPECTED (14)
EXPECTED MONIH DAY YEAR YES X
NO SUBMisslON te o. compime EXPECTED SUBurSSION DATE)
DATE (15) r ABSTRACT (Lirnit to 1400 spaces,6. e., approximately 15 single-spaced typewritten lines) (16)
On March 12,1997 at approximately 0930 hours0.0108 days <br />0.258 hours <br />0.00154 weeks <br />3.53865e-4 months <br />, while operating in OPERATIONAL CONDITION 1 and approximately 100% power, temporary maintenance and testing (M&TE) equipment was installed in the Standby Service Water System (SSW) "A" subsystem' Room Coolers. The temporary M&TE (annubars) was installed to collect cooling water flow rate data in support of thermal performance testing. Standard operating practice, where temporary M&TE is utilized, is to conservatively declare the affected subsystem inoperable and implement the associated Technical Specification ACTIONS until system operability is restored. For this specific testing evolution, the REQUIRED ACTIONS of Technical Specification Limiting Condition for Operation (LCO) 3.7,1, CONDITION D i. e., complete surveillance requirement (SR 3.8.1.1) of LCO l
3 8.1 *AC Sources Operating
- within one hour of declaring the affected subsystem inoperable was applicable. The "A" subsystem was subsequently declared inoperable on March 12,1997 at 1236 hours0.0143 days <br />0.343 hours <br />0.00204 weeks <br />4.70298e-4 months <br /> and the required actions of Technical Specification 3.8.1.1 were immediately implemented, although exceeding the LCO time requirement. The "A" subsystem was retested, with no malfunctions identified and restored to operable status at approximately 1650 hours0.0191 days <br />0.458 hours <br />0.00273 weeks <br />6.27825e-4 months <br /> on March 12, 1997.
Tha *B' Standby Service Water subsystem [BI) was operable and in standby during performance of the testing activities.
Th refore, the ability to achieve and maintain safe shutdown was not adversely impacted, nor was public health and safety compromised by this event.
1
Attachment to GNRO-97/0004.1 l
,U.S. NUCLEAR REGULATORY COMMISSION 9es)
LICENSEE EVENT REPORT (LER) ucm smem ooce m teawounae, u
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Grand Gulf Nuclear Station 05000-416 97 001 01 l
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A.
Reportable Occurrence While performing thermal performance testing of the SSW"A"[Bl] subsystem utilizing temporary M&TE, the requirement to declare the affected subsystem inoperable as directed by the impact statement contained within the approved work instruction was not complied with. As a result, the required Technical Specification surveillance requirement (SR 3.8.1.1) was not performed in the required time limit. This event is reportable pursuant to 10 CFR 50.73(a)(2)(i).
B.
Initial Conditions The plant was in OPERATIONAL CONDITION 1 with reactor power at approximately 100%, with SSW [B1] "A" subsystem (the subsystem with the temporary M&TE insta led) operating and SSW[Bl]"B" operable and in standby.
C.
Description of Occurrence Work orders were written M provide for the installation of M&TE flow instruments (annubars) to measure flow rates for the T46-B004A and T46-B003A room coolers during petformance of required testing. No qualified replacement annubars were available. On 3/10/97, the Operations Surveillance coordinator discussed the impact of the installation of M&TE for room cooler flow measurement with both the Shift Superintendent and the maintenance planner. The work orders were modified to state in the impact statement that SSW (Bl]"A" was inoperable and the actions of LCO 3.7.1 were applicable.
On 3/12/97, the operations flow test was scheduled to occur, and the I&C technicians brought two work orders (Work l
Order Numbers 183761 and 183762) for the installation of temporary flow devices on Room Coolers T46B004A and T46B003A to the control room for Authorization to Start (ATS) at approximately 0145 hours0.00168 days <br />0.0403 hours <br />2.397487e-4 weeks <br />5.51725e-5 months <br />. The Shift Supervisor was performing a review and ATS of work scheduled for the following day and stopped this activity to address these two work ordersL The Shift Supervisor authorized the work orders and did not initiate an LCO to document that the SSW [Bl]'A' subsystem was inoperable, although the impact statement on each work order specifically stated that l
SSW [Bl]'A'should be declared inoperable with the temporary flow elements installed. Shift Supervisor turnover commenced at approximately 0630 hours0.00729 days <br />0.175 hours <br />0.00104 weeks <br />2.39715e-4 months <br /> and some discussion occurred related to the performance of the Room Cooler Flow Test. However no specific discussion addressing the installation of temporary flow elements occurred.
At approximately 0830 hours0.00961 days <br />0.231 hours <br />0.00137 weeks <br />3.15815e-4 months <br /> on 3/12/97, the l&C technician contacted the control room and requested an operator to manipulate the flow element isolation valve to support flow data collection efforts. An operator was dispatched to perform the manipulation and the l&C technician was instructed to return the work package to the control room following completion of the task for further review. The installation of the flow elements was completed at approximately 0930 hours0.0108 days <br />0.258 hours <br />0.00154 weeks <br />3.53865e-4 months <br /> and upon review of the work orders, control room personnel contacted the l&C coordinator and the responsible system engineer to further discuss the impact of the installation of the non-qualified annubars into the system. At 1236 hours0.0143 days <br />0.343 hours <br />0.00204 weeks <br />4.70298e-4 months <br />, the SSW [Bl] 'A' subsystem and the Division I Diesel Generator were l
declared inoperable and the required Technical Specification actions were completed under LCO 97-0320.
Prior to this event, this supervisor had authorized eight work orders over the previous two weeks which performed an inspection / cleaning of room cooler flow annubars which did not require SSW [Bl] to be declared inoperable.
tt chment to GNRO-97/00041 l
.U.S. NUCLEAR REGULATORY COMMISSION He)
LICENSEE EVENT REPORT (LER) f ACillTY NAME O P DOCKEI @
LER NUM80 P (6)
PAGE 0)
- SeY "w'ufa'en" wu Gr:nd Gulf Nuclear Station 05000-416 i
97 001 01 3 OF 5 l
1LAT tW m;we space on venwed, use adartmar ccpes of NRC Form 366A) 07)
D.
Apparent Cause Work Practices error detection practices less than adequate Self checking to ensure that the impact of the work was properly reviewed and understood so that appropriate Limiting Conditions for Operation could be initiated was not performed.
l The inappropriate action that led to the error occurred during a task that falls into the skill based performance area.
When tasks beg;n to increase and seem similar to previously performed tasks, an error likely situation is instituted.
The only program in place at that time to prevent an error is increased awareness and attentiveness on the part of the performer. Identifying error likely situations is a must in preventing errors from occurring in the skill based performance area.
Additional factors identified as being contributors to this occurrence are:
Work Organization and Planning -work planning not coordinated with all departments involved in the task.
The work orders were not originally included in the scheduling process. When the impact statements were modified to require the SSW train to be declared inoperable, the review by the normal process in which work is scheduled did not identify the work as significant.
Written Communications - method of information presentation less than adequate The location of the impact statement within work packages does not allow for easy identification. Impact statements are included as Attachment 11 to work order packages.
Verbal Communications - operations shift turnover less than adequate Shift turnover did not include a detailed discussion of the work to be turned over on the SSW [Bl] 'A' system. A more detailed review of the authorized work may have prompted one of the SROs to question the work.
E.
Corrective Actions
Immediate:
- 1) Nuclear Plant Engineering performed an evaluation of the affect of installation of the non-qualified annubar in T46-8003A and T46-8004A room coolers. Results indicate that the ability of the Ultimate Heat Sink was maintained, however the water spray on the switchgear may result in the loss of the electrical distribution system for the associated switchgear room.
- 2) Operations issued a standing order to ensure that the appropriate actions are taken when temporary flow instrumentation is installed into the system.
- 3) Outage Maintenance and Work Contro! has changed the location of the impact statement for work packages.
The impact statement is now placed immediately after the table of contents in the work order.
- 4) The Shift Supervisor who authorized the SSW[Bl] *A" annubar packages was interviewed to determine if there were any external or internalissues which would impact his ability to perform the required duties No concerns were identified from this interview.
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Attachment to GNRO-97/00041 l
,U.S. NUCLEAR REGULATORY COMMISSION 904 LICENSEE EVENT REPORT (LER)
FAClu!V NA M W DOCKET @
l LEN NUMBEH q6b PAGE (3) l "Ou"En"e'n*
"!Ee$
w GrOnd Gulf Nuclear Station 05000-416 l
97 001 01 4 OF 5
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TLK110 more spete n reqwned, use atMinime copnes of NRG Fwm 366A)(17) 1 The immediate corrective actions have been completed.
Long Term:
- 1) Operations will develop a Principle of Operation to address control of work issues. Specific areas will include turnover of outstanding or planned activities for the next shift and the use of pre-ATS in preparing for day shift activities.
- 2) Outage Management and Work Control will evaluate putting the impact statements for all work orders on page 2 of the work order, and if feasible, determine an implementation date.
- 3) Plant Administrative procedure 01-S-07-1 will be revised to require that revisions to impact statements which change the degree of impact to the plant will be required to be reviewed by either the 1300 hours0.015 days <br />0.361 hours <br />0.00215 weeks <br />4.9465e-4 months <br /> review meeting or other normal planning meetings. This change should not restrict the implementation of emergent work in which the control room / Shift Superintendent is involved. Additionally, plant procedures which allows M&TE to be installed in a system for up to eight hours without a 10CFR50.59 Safety Evaluation will be reviewed and revised, if necessary, to ensure that system " Operability" determination is independent of any time allowed before performing a 50.59 review.
- 4) The procedure for troubleshooting (07-S-01-228) will be reviewed by Maintenance and Outage Management and Work Control (OM&WC) to ensure that requirements for work performed on in-service equipment are adequate.
This review should include cases in which system modifications are required. Any required changes should be communicated to Planning and Scheduling Personnel through the Required Reading Program.
4 i
F.
Safety Assessment
l Operating prudence in declaring SSW"A" [Bl] inoperable during installation of temporary M&TE was based on the j
M&TE utilized lacking the required seismic qualification pedigree. Design engineering performed an assessment to 1
determine if SSW"A"[Bl] was capable of performing its design safety function with unqualified equipment installed.
The results of this assessment are characterized below.
The unquahfieJ annubars were installed in place of 1P41-FEN 068A per WO#0183762 and 1P41-FEN 077A per WO#0183761. The qualified annubars were similar in construction and, based on engineenng judgment, would not l
have failed during a seismic event.1P41-FFN068A (i e., w/ N-stamp) is a Dieterich Standard Model Number DMT-15,2" schedule 80 pipe. Its unqualified temporary replacement was M&TE #A118 which is also a Dieterich Standard Model Number DMT-15. 2" schedule 80 pipe. The qualified annubar for 1P41-FEN 077A (i.e., w/ N-stamp) is a Dieterich Standard Model Number DMT-15,1.5" schedule 80 pipe, its unqualified temporary replacement was M&TE #A110 which is also a Dieterich Standard Model Number DMT-15,2" schedule 80 pipe. The above comparisons show that the unqualified and the qualified annubars are of similar construction and are equally sturdy; therefore, the unqualified annubars would still be able to perform as a pressure boundary just as the qualified annubars would during a seismic event. Also, the piping that the annubars are attached to (HBC-94) will be unaffected since there is insignificant differences in weight and lengths between the annubars.
The pnmary issue is not with the annubars themselves but with the p!astic tubing that connect both of the unqualified annubars with the actual flow equipment. This tubing is 3/8" OD and 1/4" ID rated for 125 psi at 150 Degrees F and spans for approximately 3 feet. It is not expected that this tubing would fail during a seismic event due to its relatively long span sturdy walls, and its flexibility.
1 i Attachment to GNRO-97/00041 l
,U.S. NUCLEAR REGULATORY COMMISSION poo LICENSEE EVENT REPORT (LER)
F ACKITY NAME (1)
DOCKE I (2)
LE R HUMM R #6)
PAGE (3p Tu"u'EI
"'7s'e n" wu Grand Gulf Nuclear Station 05000-416 97 001 01 5 OF 5 l
TE E 1 in now spg e on vmtwred. use etkhtwanal cttnes td NRC Form 366N (17)
F.
Safety Assessment (Continued)
However, if the two lines were to break, there are two concerns: SSW [Bl] inventory losses and spraying of electrical equipment in the immediate vicinity of the annubars.
Because of the innuted size of the tubing, SSW basin inventory loss was calculated not to be an issue under the specific conditions in effect at the time of the event.
The second concern mentioned above addressees the spraying of electrical equipment in the immediate vicinity of the annubars.1P41-FEN 068A is located in Room 1 A309 which houses LC15BA2 and LC15BA4.1P41-FEN 077A is located in Room 1 A410 which houses 1H22P298 (Alternate Shutdown Panel) and MCC15B21. The Grand Gulf UFSAR Section, 3C.3,2.8 states that it has not been proven that the electrical switchgear will remain fully operable upon spraying with water.
The design of the SSW systern P'.Iis such that safe shutdown can be achieved and maintained with one loop of SSW[Bl] operable. While t's abCy of SSW"A"[Bl] to perform its design safety i < ction is questionable with the temporary M&TE installed concurrent with a seismic event, SSW "B"[Bl] was in sta adby and operable through this testing evolution. As such, the health and safety of the public were never compromised as a result of this incident.
G.
Additional Information
Energy industry Identification System (Ells) codes are identified in the text within brackets [ ).
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