IR 05000423/1986039

Insp Rept 50-423/86-39 on 861229-870107.Major Area Inspected:Inoperability of Safety Injection Pump B on 861126-30.Factors Involved Included Procedure & Procedure Review Inadequacy.Corrective Actions in Progress by Util

ML20212Q076
Person / Time
Site:	Millstone
Issue date:	01/13/1987
From:	Mccabe E NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20212Q054	List: IR 05000423/1986039 ML20212Q052
References
50-423-86-39, NUDOCS 8702020134
Download: ML20212Q076 (5)

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U.S. NUCLEAR REGULATORY' COMMISSION

REGION I

Report N /86-39 Docket N License N NPF-49 Licensee: Northeast Nuclear Energy Company P.O. Box 270 Hartford, CT 06101-0270 Facility Name: Millstone Nuclear Power Station, Unit 3 Inspection At: Waterford, Connecticut Inspection Conducted: December 29, 1986 - January 7, 1987 Inspectors: J. T. Shedlosky, Senior Resident Inspector F. A. Casella, Resident Inspector Approved by: $ M i l 13 lB7 E. C. McCabe, Chief, Reactor Projects Section 3B Date Inspection Summary:

Areas Inspected: Special resident inspection (44 hours5.092593e-4 days <br />0.0122 hours <br />7.275132e-5 weeks <br />1.6742e-5 months <br />) of the inoperability of the "B" Safety Injection Pump from November 26-30, 198 Results: Cessation of service water flow from the "B" CCI heat exchanger leaving the "B" Safety Injection Pump inoperable greater than 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> violated plant Technical Specifications. Factors involved in this event included procedure and procedure review inadequacy, inadequate training of the individual who halted ser-vice water flow, improper performance by the individual who halted service water flow, and improper data entry for the surveillance testing involve The problem was reported to the NRC resident inspectors and Licensee Event Report (LER) 86-056-00 was submitted. Corrective actions are in progress. Inspector concerns about related organizational, policy and procedural matters have been discussed with plant managemen PDR ADOCK 05000423 G PDR .

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DETAILS Event Description On November 30, 1986 at 1 AM, a Plant Equipment Operator (PE0) was performing

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a routine weekly preventive maintenance surveillance on Service Water Sy. tem heat exchangers. He discovered that the "B" train Safety Injection Punp Cooler (CCI) service water outlet valve (35WP*V56) was shut. With this valve shut, service water flow through the cooler was stopped and the cooler was inoperable. Since this cooler cools the "B" Safety Injection (SIH) Pump lube oil cooling system (CCI) water and is required for "B" SIH Pump operation, the "B" SIH pump was inoperable. The PE0 immediately opened the outlet valve and informed the Shift Supervisor, who initiated a Plant Incident Report (PIR 86-367).

The plant was in Mode 1 at 95% power at the time of this discovery. Licensee investigation found that the valve was closed during the day shift on November 26, 1986. The "B" SIH pump had therefore been inoperable for over 72 hour8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> Plant Technical Specification Limiting Condition for Operation (LCO) 3.5.2,

" Emergency Core Cooling System Subsystems (ECCS)- T AVG Greater Than Or Equal To 350 Degrees Fahrenheit" requires ~that two independent ECCS subsystems be operable with each subsystem comprised of, in part, one operable safety in-jection pum Operability is defined in Section 1.0 of the Technical Speci-fications. A component is operable when it is capable of performing its specified function, with all necessary attendant cooling or seal water and other auxiliary equipment required for component operation also capable of performing their related functions. Action Statement (a) to LCO 3.5.2 allows one ECCS system to be inoperable for 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> before mandating a plant shut-down. The shut condition of service water valve 3SWP*V56 for greater than 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> therefore violated plant Technical Specification . Event Reportina The licensee notified the resident inspector about this event on December 1, 1986 and submitted Licensee Event Report (LER) 86-056-00 on December 30, 1986 in accordance with 10 CFR 50.73(a)(2)(i)(B).

3. Inspector Review The LER states that the "A" ECCS train remained operable during this perio In addition, the inspector reviewed the Shift Supervisor plant log and shift turnover sheets for the period 11/26-30/86 and found no record of "A" ECCS train component inoperability during the perio Inspector review of the circumstances leading to this violation found that, on November 26, a Shift Supervisor Staff Assistant (SSSA) was performing routine weekly procedure OP3626.13, " Service Water Heat Exchangers Fouling Determination", Rev. O. Part 7.4 of that procedure covers the CCI Heat Ex-changer Fouling Determination; step 7.4.1 specifies reading and recording data from PE0 rounds to cnmplete step 7.4.1 on OPS Form 3626.13-2. That step on

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1 the form has a note stating that a clamp-on flowmeter must be used to deter-

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mine service water _ flow rate. The note was present on the original PORC l'

approved form dated 8/19/86 and has remained through the current change (number 3).

To use a clamp-on flowmeter (Controlotron), the operator must connect the clamped-on transducers to the flow meter, plug the meter in to a 110VAC elec-

trical outlet, stop all flow through the pipe, zero.the device, and reinitiate

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flow to get a readin Stopping flow in this case involved shutting the CCI heat exchanger water outlet valve (3SWP*V56). OP3626.13 did not specify these actions, or any component manipulations. The necessity for stopping flow to j obtain a valid reading was identified to the SSSA through separate training in use of the flow measuring equipment. That training did not address the

specific use for measuring.CCI heat exchanger flow. The SSSA, who had been j trained in the use of the Controlotron by_an In-Service Inspection (ISI).

j Technician, had a basically correct understanding of the use of the instrumen The licensee measures heat exchanger fouling using OP3626.13-to assure ade-

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quate heat transfer capability. That surveillance is a licensee initiative,. i

) not an NRC requirement. Performance of OP3626.13 required no shift supervisor

, concurrence. Its OPS Form Test Authorization block contained the words "not j required." It directed no valve or component manipulations; that contributed j to the shift operations personnel not being appropriately informed about the j valve being shut. This lapse in control circumvented the normally required j formal entry into an LCO action statement and leftsthe licensed operators

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unaware that an ECCS component was inoperabl : Performance of this surveillance procedure was considered by the Assistant l Operations Supervisor to be within the SSSA's capabilities. Administrative i Control Procedure (ACP) 6.01 Rev.18 " Control Room Procedure,'? defines the

responsibilities of the SSSA in part 5.6'as " communications in accordance with l EPIP 4112 and [to] assist the Snift Supervisor as requested." Completion of

] OP3626.13 only specified data gathering from PE0 round sheets, not valve

! manipulation, and therefore was assigned to SSSA's for completion as being

! within the ACP definition of SSSA responsibility. (ACP 6.01 does state in

! part 6.1.7, " Operations Outside the Control Room," that "there will be no j manipulation of valves, controls or instrumentation pertaining to reactor j operations or unit safety without first notifying the Control Room of-the

condition and receiving approval...")

The inspector interviewed the SSSA who had shut 35WP*VS6 on November 26, 1986.

l He is a degreed, entry. level individual without operating experience prior j , to starting work at Millstone. On the day shift on November 26, this indi-i vidual was performing OP3626.13, which he had performed before. He set up

the Controlotron clamp-on flow measuring device on the "B" CCI heat exchanger

service water outlet, connected the meter to the transducers, shut the heat exchanger outlet valve, and turned on the meter to zero it. The 110VAC elec-trical outlet had no power and the flow meter would_not operate. The SSSA

, then moved the meter to the adjacent cubicle and successfully measured flow

through the "A" CCI heat exchanger. Returning to the "B" QSS/SI cubicle, he

!. checked the 110VAC receptacle, which was still without power. Unable to

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locate an alternate power source and being close to the end of the shift, the SSSA put away the flow meter and returned to the Control Room. He did not report the problems encountered to shift management. Also, OP3626.13 was in-adequate in that it neither directed the necessary valve closure nor required verification of system restoratio During the following day shift, this SSSA reviewed the incomplete OPS Form 3626.33-2 and wrote in the value "55" for

"B" CCI heat exchanger service water flo He stated that he had taken this data so many times before that he. thought he remembered taking it on the pre-vious day, and felt that 55 was the correct value. However, during interview by the licensee as well as during the interview by the resident inspector, the SSSA confirmed that he had left valve 35WP*V56 shut. This individual was open and cooperative during his interview by the resident inspecto Section 6.1 of ACP 8.22 " Shift Supervisor Staff Assistant Training" requires training in Emergency Plan Organization, Emergency Procedure Review and Con-trol Room communications equipment and applicable procedures before the SSSA

.. is qualified to perform his jo Once qualified for his basic function, the SSSA is expected to continue his training with Station Orientation, Plant Familiarization, and PE0 Qualification. No systematic method of tracking SSSA training was identified. Moreover, because there are fewer SSSA's (5) than shifts (6), the SSSA's are not continuously supervised by the same shift superviso Further contributing to this lack of specific supervision is a policy of rotating SSSA's through various departments for familiarizatio The subject SSSA stated that, since beginning work in May of 1986, his train-ing has consisted of General Employee Training, Emergency Plan Organization, Emergency Plan Implementing Procedures, and Control Room communications equip-men He is now doing self study and stated that he does not remember reading ACP 6.01, " Control Room Procedure." This training scheme does not appear to provide controls adequate to assure that entry level personnel without a prior operational background will receive training tufficient to assure that they do not manipulate valves, controls, or instrumentation without required authorization and control. This insufficient training is not adequately covered by the corrective action stated in the LER. The licensee stated they plan to conduct additional training on basic safety perspective and the need for accurate and reliable recording of informatio . Measures to Prevent Recurrence The licensee directed that SSSA personnel performance of equipment operational activities be terminated. Operating personnel were briefed on the event and i this correction action. Procedure upgrades were initiated. The licensee l stated that this was the only operational activity that had been assigned to SSSA personnel, and that a review of other surveillance of this nature would be conducted by February 1,1987 to assure that improperly controlled equip-ment manipulations were not involve On January 7,1987, the licensee informed the resident inspectors that they planned to establish an SSSA orientation and evaluation program by January 23, 1987. That program's purpose is to assure that new SSSA hires are trained

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and evaluated to be capable of functioning at the minimum required level prior to assignment to shift duties. The licensee also stated that existing SSSA personnel will be evaluated by February 15, 1987 to confirm acceptable com-pletion of SSSA orientation. Until that confirmation, those personnel will not be released for duty other than emergency communication task . PORC Meetings The inspector attended Plant Operations Review Committee (PORC) meetings on December 29 and 30, 1986. The principle agenda item for each of these meet-ings was the "B" safety injection pump inoperability. LER 86-056-00 was ex-

, tensively reviewed. Root causes and corrective actions were freely discusse The inspector was satisfied that this matter was given sufficient attention.

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5. Manage:nent Meeting An exit interview was conducted with senior site and plant management at the conclusion of this inspection on January 6,1987.

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