05000458/LER-1993-016
| ML20056G617 | |
| Person / Time | |
|---|---|
| Site: | River Bend  |
| Issue date: | 08/27/1993 |
| From: | Booker J, Lorfing D GULF STATES UTILITIES CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| LER-93-016, LER-93-16, RBG-38936, NUDOCS 9309030333 | |
| Download: ML20056G617 (6) | |
| Event date: | |
|---|---|
| Report date: | |
| 4582093016R00 - NRC Website | |
text
o dL - - . G9 GULF STA TES UTILITIES COMPANY
., , n e a ,. % r;:so;ni i mu no um . wouue m 3
/.i i a ( ( b{' ? e. 'f8 + $4 Mf, Ab!. 9 August 27, 1993 RBG-38936 File Nos G9.5, G9.25.1.3 U.S. Nuclear Regulatory Conunission Document Control Desk Washington, D.C. 20555 Gentlemen:
River Bend Station - Unit 1 Docket No. 50-458 Please find enclosed Licensee Event Report No.93-016 for River Bend Station -
Unit 1. This report is submitted pursuant to 10CFR50.73.
Sincerely,
.f M ,
J. E. Booker Manager - Safety Assessment and Quality Verification River Bend Nuclear Group DNL/JPS/FRC/DCH/MLS/kvm 020070 8I',
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. cc: U.S. Nuclear Regulatory Commission 611 Ryan Plaza Drive, Suite 400 !
Arlington, TX 76011 i i
NRC Resident Inspector !
P.O. Box 1051 i St. Francisville, LA 70775 l INPO Records Center l 1100 Circle 75 Parkway [
Atlanta, GA 30339-3064 !
Mr. C.R. Oberg l
Public Utility Commission of Texas l 7800 Shoal Creek Blvd., Suite 400 North !
Austin, TX 78757 I I
Department of Environmental Quality !
Radiation Protection Division ;
P.O. Box 82135 !
Baton Rouge, LA 70884-2135 '
ATIN: Administrator i i
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i eRC FokM 366 U.S. Wi> CLEAR REGULATCRY COPMIS$1CN APPROVED BY (MH t:0. 3150-0104 (5 ,92) EXP!RES 5/31/95 ESTIMATED BURDEN FER RESPONSE TO COMPLY WITH THl$ INFORMATION COLLECTION REQUEST: 50.0 HRS.
, LICENSEE EVENT REPORT ,LER) FORWARD COMMENTS PEGARDING BURDEN E ST IMAT E TO THE INFORMATION AND RECORDS MANAGEME NT BRANCH
' (MNBB 7714), U.S. NUCLE AR REGULATORY COMMISSION, (See r everse f or required nunber of digits / characters f or each block) 6ASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION FROJE CT (3150 0104), OFFICE Of a MANAGFMENT AND BUDGE T, WASHlWGTON. DC 20503.
JACIllTY NAME (1) DOCKET NUMBER (2) PAGE (3)
RIVER BEND STATION 05000458 1 OF 4 T!!![ (4) HlCH PRESSURL CORR SPRAY SYSTEM ACTUATION DUE 10 IMPR0fTRLY PREPARED RE VISION TO A SURVEILLANCE TEST PROCEDURL FVINT DATE (5) I (IR AMBFR (6) RIPORT DATE (7) OTHER I ACIllilE S INVolVrD (B) ;
SEQUE NT I AL FEVISION FAClllTY NAME DOCFET NUMP,ER .
MONTH DAY YE AR YEAR **" ^
NUMBER NUMBER 05000 j FACILITY NAME DOCFET NUMBER i 07 27 93 93 -- 016 -- 00 08 27 93 05000 l GT RAT ING THIS RFMRT IS SuftMITTtD MIRSUANT TO THI REQUIRIMfWTS OF 10 CIR %: (Check one or more) (11) 4 MODE (9) 20.402(b) 20.405(c) X 50. 73(a)(2)( i v) 73.71(b) l PuWE R 20.405(a)(1)(i) 50.36(c)(1) 50.73(o)(2)(v) 73.71(c) ;
trVEL (10) 20.405(a)(1)(ii) 50.36(c)(?) 50.73(a)(2)(vi i ) OTHER !
8 20.405(a)(1)(iii) 50.73(a)(2)(i) 50.73(a)(2)( viii)( A) (Specif y in f A "
20.405(a)(1)(iv) 50.73(a)"2)(ii) 50. 73( a)(2)(vi i i )(B) C 20.405(a)(1)(v) 50. 73(a)(2)(i i i) 50. 73(a)(2)( x ' NRc Form 366A)
- t lCIWSf f C(WT ACT FCE THIS (IR (17) i NAME TELEPHONE NUMBER (Include Area Code)
DAVID N. LORFING, SUPERVISOR - NUCLEAR LICENSING (504) 381-4157 i CIMPlf TE ONE 1INE FOR F ACH CfMPONE NI I AllLRr DISCRIRFD IN THIS RINET (13)
CAUSE $YST[M COMPONENT MANUFACTURER CAUSE SYSTEM COMPONENT MANUFACTURER 0 .
1 J
SUPPL E ME NT AL RIMRT rKPECTfD (14) EXPECTED MONTH DAY YEAR TIS SURMISSION 1
(If yes, congd ete EXPECTED SUBMISSION DATE). X NO DATE (15) l ABSTRACT (L irni t to 1400 sp.:es, i.e., approximately 15 single-spaced typewritten lines) (16)
On July 27,1993. with the plant in Operational Condition 4 (Cold Shutdown), the high pressure core spray (HPCS) l 4
system actuated. A test signal, initiated to perform a partial time response test on the system, resulted in the start of
, the HPCS diesel generator and the HPCS pump. Therefore, this event is reportable pursuant to 10CFk50.73(aM2)(i)(b). He injection valve did not open since it was interlocked closed due to high reactor vessel water level.
The portion of the test being performed at the time of the event was a new test sequence which involved partially l disabling the HPCS initiation logic. In preparing the STP revision to test this circuitry, leads were lifted to prevent ;
the initiation of the remaining logic. This was the only action taken to prevent such an initiation. The primary root cause for this actuation was a personnel error in the development of the STP revision. The procedure did not i explicitly state what was to be done to the leads once they were lifted. The procedure should have required the leads )
to be separated. However, this was not the case, and the leads were taped together, resulting in the actuation. !
Conective actions included revision of the applicable STP, and training for electrical and instrumentation and controls (l&C) technicians.
l NRC FORM 366 (5-92) i
R3 QUIRED NUMBER OF DIGITS / CHARACTERS FOR EACH 3 LUCK l
i BLOCK NUMBER OF NUMBER DIGITS / CHARACTERS TIRE i UP TO 46 FACILITY NAME ,
8 TOTAL DOCKET NUMBER 3 IN ADDITION TO 05000 3 VARIES PAGE NUMBER 4 UP TO 76 TITLE 5 EWNT DATE 2 E CK 7 TOTAL 2 FOR YEAR bN 3 FOR SEQUENTIAL NUMBER ,
s 2 FOR PEVISION NUMBER 7 6 TOTAL REPORT DATE 2 PER BLOCK UP TO 18 -- FACILITY NAME .
OTHER FACILITIES INVULVED 8 TOTAL -- DOCKET NUMP.ER 3 IN ADDITION TO 05000 9 1 OPERATING MODE 10 3 POWER LEVEL REQUIREMENTS OF 10 CFR CHECK Box THAT APPLIES UP TO 50 FOR NAME 12 LICENSEE CONTACT 14 FOR TELEPHONE CAUSE VARIES 2 FOR SYSTEM 13 4 FOR COMPONENT EACH COMPONENT FAILURE 4 FOR MANUFACTURER NPRDS VARIES CHECK BOK THAT APPLIES .
15 EXPECTED SUBMISSION DATE 2 PER OCK r
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WRC FORM 366A U.S. CDCLERR REGULATO7 (DMISSIC APPROVED B7 OMB CD. 3150-0104 (5-72) EXP!RES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.
FORWARD COMMENTS REGARDING BURDEN ESilMATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AND RECORDS MAN AGE ME NT BRANCH TEXT CONTINUATION (MNBB m 4), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.
F AtllITY WAMF (1) DOCKFT N!MBER (2) LER NUMBER (6? PAGE (3)
YEAR SEQUENTIAL REVISION RIVER BEND STATION 05000458 2 OF 4 93 -- 016 -- 0O TEXT (If more space is reouired use additional copies of NRC Form 366A) (17)
REPORTED CONDITION On July 27,1993, with the plant in Operational Condition 4 (Cold Shutdown), the high pressure core spray (HPCS) (*BJ*) system actuated. A test signal, initiated to perform a panial time response test on the system, resulted in the start of the HPCS diesel genemtor (*DG*) and the HPCS pump (*P*). Therefore, this event is reponable pursuant to 10CFR50.73(a)(2)O)(b). The injection valve (*INV*) did not open since it was interlocked closed due to high reactor vessel water level.
INVESTIGATION The HPCS system is designed to deliver cooling water to the reactor vessel due to a loss of coolant accident (LOCA) while the reactor is at high pressure. This condition is detected by monitoring reactor level and drywell pressure for indications of a leak that is causing a significant loss of inventory in the reactor vessel.
On receiving these signals the HPCS diesel generator and pump will start and the injection valve will open.
Also, the test return to suppression pool valve, IE22*MOVF023 (*20*) will close, preventing HPCS from sending part of this water flow back to the suppression pool instead of to the reactor vessel. Valve IE22*MOVF023 is used to test the flow of the HPCS system without injecting water into the reactor vessel.
The surveillance test procedure (STP) to perfonn this test simulates a low level in the reactor vessel in order to cause a ponion of the circuitry that closes IE22*MOVF023 on a HPCS initiation signal to actuate and measure the instrumentation response time.
The ponion of the test being perfonned at the time of the event was a new test sequence which involved partially disabling the HPCS initiation logic. The purpose of this STP was to test the response time of the logic controlling the HPCS test return to suppression pool valve (IE22*MOVF023) as required by Technical Specification (TS) 4.3.2.3 without initiating any other pan of the system logic. The portion of the logic to be tested had not been tested previously due to inadequate implementation of Technical Specification requirements into the STPs. This procedure deficiency was discovered as a result of GSU's review of STPs against the Technical Specification requirements. This corrective action program was initiated as described in LER 93-012.
In revising the STP to test this circuitry, leads were lifted to prevent the initiation of the remaining logic.
This was the only action taken to pn: vent such an initiation. The steps that lifted these leads read in part,
" Lift and tape the leads on TB0036 tenninal 04. .". The leads that were to be lifted were landed on the same side of the terminal board. This step would disable the initiation logic only if the leads that were lifted from this terminal were separated from each other.
NRC FORM 366A (542)
I
WRC FORM 3664 U.S. CUCIEAR REGULA10R7 00PMISS!([] APPROVED BY OM'B WO. 3150-0S04 (5-y2) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION CDLLECTION REQUEST: 50.0 NRS.
50RWARD COMMENTS REGARDING BURDEN ESTIMATE 10 LICENSEE EVENT REPORT (LER) THE INFORMATION AND PECORDS MANAGEMENT BRANCH TEXT CONTINUATION mNss m ), u.s. Nu: LEAR REGULATORY COMMISSION, WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE Of MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.
FACIllTY NAME (1) DOCKET NUMRER (?) trR WUMBER (69 PAGE (3)
YEAR SEQUENTIAL REVISION RIVER BEND STATION 05000458 3 OF 4 93 -- 016 -- 0 TEXT (11 mnre space is required, use additional copies of NRC Form 366AJ (17)
After inteniewing the personnel that perfonned the STP that caused the initiation of the HPCS system, it was discovered that they had interpreted this step as meaning lift and tape together the leads on TB0036 tenninal 04. They assumed that lifting the two leads from the tenninal was the action that would disable the HPCS initiation and that since these leads were landed together on the tenninal board they should be connected to each other once lifted in order to enable the ponion of the logic they were testing.
r Interviews with the personnel who created and reviewed this change to the procedure indicated that they assumed that " Lift and tape the leads on " mermt that the leads were to be lifted and taped separately (not connected to each ether).
ROOT CAUSE The primary mot cause for this actuation was a personnel error in the development of the STP revision.
This created a procedural inadequacy. The procedum did not explicitly state what was to be done to the leads once they were lifted. The procedure should have stated " Lift, separate and tape the leads on...".
This would have left no room for misinterpretation.
A contributing factor to this event was the establishment of only one barrier, the STP, to prevent the system actuation. Plant conditions were such that it would have been practical to place the HPCS diesel in maintenance mode and open the breaker for the HPCS pump to prevent their staning. The absence of an additional barrier pennitted one mistake to cause this ESF.
A review of previous LERs involving procedure deficiencies and ESF actuations revealed several previous events; however, LER 90-043 has the greatest similarity to LER 93-016. In LER 90-043, an error was made in a test procedure for the low pressure core spray (LPCS) actuatien logic for the LPCS injection valve. This resulted in actuation of the 'A' residusi heat removal (RHR) system and the control building emergency filter train.
CORRECTIVE ACTION l
Surveillance test procedure, STP-051-4811 was changed to read " Lift, separate and tape the leads on . " for
^
the steps requiring the lifting of more than one lead on a single tenninal. Additionally, this procedure had steps added to place the HPCS diesel in maintenance mode and rack out the HPCS pump breaker prior to perfonnance of this section of the test. This STP was successfully perfonned on July 28,1993.
t l
NRC FORM 366A (5-92) 1
CRC FORM 36fA U.S. CLCLEcR REGULATOY CupMISSIO APPROVED BY OMB No. 3150 0104 (542) EXPIRES 5/31/95
~
EST1 MATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.
FORWA.RD COMMENTS REGARDING BURDEN EST! MATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AND RECORDS MANAGEMENT ERANCH TEXT CONTINUATION (MNBB 7714), u.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503. _ _ .
FACILITY NAME (1) DOCKET NLMBER (2) (IR NtMBER (6) PAGE (3)
YEAR SE QUE NT I AL REVISION RIVER BEND STATION " "
05000458 93 0 4 OF 4
-- 016 --
TEXT (11 more stiace is reauir ed, use additional copies of NPC Form 366A) (17)
Personnel developing procedures were trained on the requirements to be more explicit in the requirements for lifting and taping multiple leads from a single tenninal point. All electrical and instrumentation and controls (I&C) technicians will be trained to stop any STP that requires lifting more than one lead from a tenninal point and determine if these leads need to be lifted and separated or lifted and taped together.
Once this determination is made, the STP will be changed via change notice to indicate which method is correct. In addition, these instructions are being incorporated into the I&C and electrical maintenance ;
continuing tmining program. This training will be completed by January 31,1994.
Future change notices and revisions to maintenance procedures should include, where pntetical, two barriers to pn vent any ESF actuations. This will be incorporated into Administative Procedure (ADM)-0015 by October 15, 1993.
SAFETY ASSFSSMENT L
Although the 11PCS diesel and pump were started, the injection valve did not open and no water was injected into the reactor vessel. Since the HPCS injection valve did not open, the reactor vessel and its components were not impacted during this actuation. The HPCS system was momentarily initiated and was immediately shutdown manually by the operator. All system parameters were within the normal mnge during the short time the HPCS system was operating.
i t
NRC FDRM 366A (5-92)