IR 05000456/1989020
| ML20247A300 | |
| Person / Time | |
|---|---|
| Site: | Braidwood  |
| Issue date: | 07/16/1989 |
| From: | Hinds J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20247A238 | List: |
| References | |
| 50-456-89-20-EC, 50-457-89-20, NUDOCS 8907210195 | |
| Download: ML20247A300 (22) | |
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U.S. NUCLEAR REGULATORY COMMISSION
REGION III
Repor' ' s. 50-456/89020(DRP); 50-457/89020(DRP)
Docket Nos. 50-456; 50-457 License Nos. NPF-72; NPF-77 Licensee:
Commonwealth Edison Company Post Office Box 767 Chicago, IL 60690 Facility Name:
Braidwood Station, Units 1 and 2 Meeting At:
Region III Office, Glen Ellyn, Illinois Meeting Conducted: July 11, 1989 OD Approved By:
J. M. Hinds, Jr. ', Chief
//!N Reactor Projects Section 1A Date Inspection Summary Meeting on July 11, 1989 (Report Nos 50-456/89020(DRP); 50-457/89020(DRP))
Areas Discussed: An enforcement conference conducted to discuss concerns associated with the operability of the 2B centrifugal charging pump with a manual isolation valve shut in its recirculation line, and previous instances in which the operability of emergency core cooling system equipment was affected by mispositioned valves.
8907210195 890717
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PDR ADOCK 05000456 Q
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DETAILS 1.
Persons Contacted Commonwealth Edison Company (CECO)
T. J. Maiman, Vice President, PWR Operations R. E. Querio, Braidwood Station Manager D. E. O'Brien, Brafdwood Technical Superintendent G. R. Masters, Braidwood Assistant Superintendent - Operations P. Smith, Braidwood Operating Engineer - Unit 1 T. Kovack, Nuclear Licensing Manager S. C. Hunsader, Nuclear Licensing Administrator D. E. Cooper, Braidwood Regulatory Assurance Supervisor P. G. Holland, Braidwood Regulatory Assurance M. Turbak, Performance Improvement Manager L. W. Raney, Braidwood Nuclear Safety Supervisor P. Barnes, PWR Regulatory Assurance Engineer S. Notter, Braidwood Quality Assurance Engineer R. Anderson, Braidwood Operating Steward J. Spangler, Braidwood Nuclear Station Operator Steward T. Coslet, Braidwood Operating Steward D. Brindle, Byron Operating Engineer M. Snow, Byron Regulatory Assurance Supervisor R. Flessner, Administrative Engineer - PWR Operations Nuclear Regulatory Commission A. B. Davis, Regional Administrator, Region III W. Forney, Deputy Director, Division of Reactor Projects, Region III W. Shafer, Chief, Reactor Projects Branch 1, Region III J. Hinds, Chief, Reactor Projects Section 1A, Region III S. Sands, NRR Project Manager for Braidwood T. Tongue, Senior Resident Inspector, Braidwood G. VanSickle, Resident Inspector, Braidwood Others S. Trubatch, Tenera (contractor to Commonwealth Edison)
2.
Enforcement Conference Details The enforcement conference was held to discuss three events within the past two years in which the operability of emergency core cooling system (ECCS) equipment was affected by mispositioned valves, as well as l
conclusions and corrective actions associated with the events.
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Af ter initial remarks by the senior NRC and licensee representative, j
the Braidwood Resident Inspector summarized the three events, consistent
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with findings documented in past inspection reports. Specifically:
A March-June 1989 event in which a manual isolation valve in the recirculation line for the 2B centrifugal charging pump was
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erroneously shut. for more tnan two months,.thereby isolating a pump
protective feature and rendering the pump inoperable. beyond the time-
permitted by Braidwood Technical Specification 3.5.2 (originally l
described in Inspection Report 456/89017; 457/89017).
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'An August 1987 event in which both trains of the Unit.1 residual
heat removal (RHR): system were inoperable beyond the time permitted by Technical. Specification 3.0.3.
With one RRR train already out of-service, a mistakenly shut cross-tie valve rendered the second train
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' inoperable by limiting cold. leg injection from four loops to two
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loops (ori 456/87029;
.457/87027)ginally described in Inspection Report i
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i A March 1988 event in which the 2B safety injection (SI) system I
train was inoperable beyond the time permitted by Technical
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Specification 3.5.2 when a. manual' discharge valve for SI pump 2B was mistakenly shut (originally described in Inspection Report-457/88012).
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a The most recent event heightened NRC concerns associated with ECCS-operability at Braidwood. These concerns were enumerated as follows:
Lack of management attention to ensure operability of the 2B centrifugal charging pump.
Lack of effective management controls to ensure continuous operability of all ECCS equipment.
- Lack of a licensee program or process to independently verify proper valve alignment.
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j The licensee acknowledged that the third instance of valve mispositioning warranted concern for ECCS operability. The licensee noted that',
although the circumstances surrounding the events were different, three occurrences warranted a harder look at station programs and procedures in an effort to minimize further raurrences.
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The licensee provided its account of the'three events, including the
corrective actions taken for each. The licensee concluded that the
safety significance of the most recent event, involving the. isolation of
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the charging pump recirculation line, was minimal in that all other ECCS subsystems were operable and that the station's emergency operating procedures address the potential for charging pump deadheading. The
licensee's proposed long-term corrective actions for this event include the following:
l Expansion of the independent verification program to utilize the
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I component abnormal. position log to include locked safety-related
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l components manipulated during the performance of an operating
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procedure.
(Further discussion by the licensee indicated that existing requirements are sufficient for independent verification of unlocked components.)
The use of unique locks on locked equipment.
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Adopting a practice not to lock safety-related components in their
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abnormal positions unless specifically addressed by other programs or procedures.
- Emphasizing that operators adopt a questioning attitude when they encounter mispositioned components.
Clarification of what is involved in positively identifying a component before operation or. repositioning.
The licensee indicated that these actions are applicable to the scope of concerns associated with all three events.
In its final discussion, the licensee concluded that the corrective actions for the first two events would not have prevented the succeeding events, and that earlier corrective actions were consistent with the licensee's operating experience at that time.
The Station Manager emphasized that the mistakes which contributed to these_ events are part of the learning process for operators running a new plant. He also demonstrated the effectiveness of the licensee's personnel error a
prevention programs by pointing out the station's recent steady decline in personnel errors. The licensee was confident that the measures listed above will provide greater assurance that additional errors will be.
minimized.
In closing, the senior NRC representative acknowledged that the licensee gave a good account of the events and associated issues. He added that the licensee's efforts to reduce errors were consistent with the NRC's continued emphasis on excellence, not just satisfactory compliance, in operation.
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ENFORCEMENT CONFERENCE:.
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BRAIDWOOD STATION
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' JULY 11, 1989.
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CHRONOLOGY OF EVENTS P. A. SMITH
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SAFETY SIGNIFICANCE P. A. SMITH
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CONCLUSION R. E.-QUERIO
CORRECTIVE ACTION R. E.'QUERIO.
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CLOSING T.'J'.
MAIMAN
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PURPOSE ADDRESS CONCERNS ASSOCIATED WITH 2B CV PUMP AND PREVIOUS EVENTS WHERE ECCS EQUIPMENT WAS AFFECTED BY MISPOSITIONED VALVES.
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08/08/87 RH CROSSTIE VALVE 1RH8716A CLOSED
03/13/88 SI DISCHARGE ISOLATION VALVE 2SI8921B FOUND CLOSED
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06/01/89 CV MINI-FLOW ISOLATION VALVE 2CV8473B FOUND CLOSED
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(84892/2)
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RH CROSSTIE VALVE 1RH8716A CLOSEDi(8/8/87)-
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EVENT SUMMARY
ESTABLISHING LINEUP'FOR RH POST-MAINTENANCE'TESTL J
SCRE REVIEWED TECH SPECS
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NOTED ALLOWED CLOSURE'0F SI8809A i
FAILED TO IDENTIFY THIS IS ALLOWED ONLY.IN MODE 3.
DIRECTED NSO TO CLOSE-1RH8716A
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1RH8716A CLOSED, RH TEST COMPLETED AND VALVE REOPENED-
SHIFT CHANGE LOG REVIEWS IDENTIFIED UNACCEPTABLE RH SYSTEM
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ALIGNMENT H
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CAUSE
INADEQUATE REVIEW OF TECH SPEC RESULTED IN UNACCEPTABLE l
DECISION TO CLOSE VALVE VIOLATING THE OPERATING PROCEDURE
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CORRECTIVE ACTIONS CAUTION CARD HUNG ON RH CROSSTIE VALVE CONTROL SWITCHES i
PROPER USE OF TEMPORARY PR0rEDURE CHANGES DISCUSSED WITH
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SHIFT MANAGEMENT PERSONNEL INCIDENT FORMALLY REVIEWED WITH INVOLVED PARTIES l
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l SI DISCHARGE ISOLATION VALVE 2S 8921B FOUND CLOSED (3/13/88)
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EVENT SUMMARY
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2SI8921B LOCKING DEVICE INTERFERED WITH MAINTENANCE
ACTIVITIES; LOCKING DEVICE REMOVED i
NSO LATER INSTRUCTED EA TO REPLACE CHAIN AND " LOCK IT TIGHT" I
EA MISINTERPRETED INSTRUCTIONS AND CLOSED 2SI8921B
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" TIGHTLY" AND LOCKED IT OPERATOR ON ROUTINE ROUNDS IDENTIFIED MISPOSITIONED VALVE;
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CAUSES
MISCOMMUNICATION BETWEEN THE NSO AND EA
FAILURE TO RECOGNIZE CHAIN REMOVAL AS A CHANGE IN VALVE
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CORRECTIVE ACTIONS CLARIFICATION GIVEN TO OPERATORS THAT CHAIN REMOVAL
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i CONSTITUTED A POSITION CHANGE AND MUST BE DOCUMENTED IN THE COMPONENT ABNORMAL POSITION LOG EVENT REVIEWED WITH EACH SHIFT; PROPER COMMUNICATION,
INCLUDING REPEAT BACK, STRESSED l
DURING REQUALIFICATION BOTH LICENSED AND NON-LICENSED
OPERATORS RECEIVE TRAINING ON EFFECTIVE COMMUNICATIONS
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APPLICABILITY TO PREVIOUS EVENT CORRECTIVE ACTIONS ASSOCIATED WITH RH EVENT WOULD NOT HAVE
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l CV MINI-FLOW ISOLATION VALVE 2CV8479B FOUND CLOSED (6/1/89)
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EVENT SUMMARY
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REALIGNMENT OF OPERATING RH PUMPS FROM 2B TO 2A l
REQUIRES OPENING 2RH8734A AND CLOSING 2RH8734B NSO AND EA CONDUCTED PRE-JOB BRIEFING EA NOTED VALVE NUMBERS TO BE OPERATED
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AT 1718 2A RH PUMP STARTED AT 1730 EA OPENED 2RH8734A EA CLOSED AND LOCKED 2CV8479B RATHER THAN 2RH8734B
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SECOND EA IN AREA OBSERVES 2RH8734A AND B OPEN DISCUSSES WITH NSO l
NSO INSTRUCTS SECOND EA TO CLOSE AND LOCK 2RH8734B l
AT 0928 2RH8734B IS CLOSED AND LOCKED
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NO ADDITIONAL CHECKS MADE RECOVERING FROM SURVEILLANCE OUTAGE VALVE LINEUPS FOR 2CV8479B PERFORMED ON MARCH 20,
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1989 (84892/8)
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JUNE 1, 1989 l
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AT 1130 2B CV PUMP STARTED SYSTEM ENGINEER OBSERVED NO RECIRC FLOW ON LOCAL l
INDICATOR
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AT 1145 2CV8479B DISCOVERED LOCKED CLOSED 2CV8479B LOCKED OPEf1 RECIRC FLOW LOCAL INDICATION NORMAL
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CAUSE3 l
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PERSONNEL ERROR IN THE MISIDENTIFICATION OF VALVE j
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MISTAKEN RELIANCE BY EA ON INAPPLICABLE EXPERIENCE FROM UNITL1-
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VALVE TAG AWKWARD TO_ READ AND. PARTIALLY BLOCKED
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CORRECTIVE ACTIONS
2CV8479B REOPENED
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INVESTIGATION INITIATED FORMAL ERROR EVALUATION PRESENTATION HELD WITH EA
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PARTICIPATION EXPANSION OF THE INDEPENDENT VERIFICATION PROGRAM UTILI2ING
THE COMPONENT ABNORMAL POSITION LOG TO INCLUDE LOCKED.
SAFETY RELATED COMPONENTS MANIPULATED DURING THE PERFORMANCE OF AN OPERATING PROCEDURE -
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REVISED LOCKED EQUIPMENT PROGRAM
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UNIQUE LOCKS TO BE INSTALLED i
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SAFETY RELATED COMPONENTS ARE NOT TO BE LOCKED.IN AN i
ABNORMAL POSITION UNLESS SPECIFICALLY ADDRESSED BY j
OTHER PROGRAMS OR PROCEDURES REVIEW OF EVENT WITH OPERATIONS PERSONNEL'BY SENIOR
l MANAGEMENT INCLUDING QUESTIONING ATTITUDE FOR MIS-POSITIONED COMPONENTS
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l CLARIFY WITH OPERATIONS PERSONNEL EXPECTATIONS ON POSITIVE
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l IDENTIFICATION OF COMPONENTS PRIOR TO OPERATION
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ONGOING LABELING PROGRAM (8489Z/10)
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' SAFETY ANALYSIS
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EVENT. CONFIGURATION WITH 11TRA'INLINOPERABLE ENVELOPED BYL
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UFSAR? ANALYSIS:
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DESIGN REQUIRES ASSOCIATED PIPING'AND VALVES.FOR:-
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-3" ACCUMULATORS
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1 SI PUMP'
1 CV PUMP 1 RH PUMP
REDUNDANT.ONSITE EMERGENCY DIESEL GENERATORS
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ASSOCIATED PIPING AND-VALVES AVAILABLE DURING EVENT-FOR:
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4 ACCUMULATORS
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2 SI PUMPS.
1 CV PUMP (2A FULLY' OPERABLE).
i 2 RH PUMPS-REDUNDANT Oi1 SITE EMERGENCY DIESEL GENERATORS
2B CV PUMP ASME PERFORMANCE VERIFIED ON JUNE 2, 1989
2B CV PUMP DID OPERATE AND>WOULD HAVE MITIGATED
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POSTULATED ACCIDENTS E0P'S STRUCTURED TO ADDRESS DEADHEADING CONCERN-
THERE WAS NO SAFETY SIGNIFICANCE
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APPLICABILITY TO PREVIOUS EVENTS CORRECTIVE ACTIONS FROM THE RH AND SI EVENTS WOULD NOT HAVE
PREVENTED THIS EVENT BECAUSE THE EA BELIEVED HE HAD l
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PERFORMED A PROPER VALVE OPERATION l
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CONCLUSIONS
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EVENTS WERE EVALUATED INDIVIDUALLY AND COLLECTIVELY
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INDIVIDUALLY
SAFETY SIGNIFICANCE MINIMAL ROOT / CONTRIBUTING CAUSES IDENTIFIED WITH APPROPRIATE
CORRECTIVE ACTIONS BEING IMPLEMENTED RH CAUTION CARD HUNG ON RH CROSSTIE VALVE CONTROL SWITCHES RH PROPER USE OF TEMPORARY PROCEDURE CHANGES DISCUSSED WITH SHIFT MANAGEMENT PERSONNEL
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SI/CV INCIDENT FORMALLY REVIEWED WITH INVOLVED PARTIES (ERROR EVALUATION PROGRAM PRESENTATION)
SI GUIDANCE ON PROPER USE OF ABNORMAL POSITION LOG PROVIDED TO AND REVIEWED WITH OPERATING SHIFTS SI EVENT REVIEWED WITH EACH SHIFT; PROPER COMMUNICATION, INCLUDING REPEAT BACK STRESSED
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SI BOTH LICENSED AND NON -LICENSED OPERATORS RECEIVE I
TRAINING PROGRAM ON COMMUNICATIONS DURING REQUALIFICATION j
CV STRENGTHEN INDEPENDENT VERIFICATION PROGRAM -
INCLUDES COMPONENT ABNORMAL POSITION LOG CV CLARIFY LOCKING INSTRUCTIONS BY PROCEDURAL CHANGE SI/CV REVIEW OF EVENT WITH OPERATIONS PERSONNEL BY SENIOR MANAGEMENT, STRESSING A QUESTIONING ATTITUDE FOR MISPOSITIONED COMPONENTS CV CLARIFY WITH OPERATIONS PERSONNEL THE EXPECTATIONS ON l
POSITIVE IDENTIFICATION OF COMPONENTS PRIOR TO OPERATION (8489Z/13)
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CONCLUSION (' CONT.)
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COLLECTIVELY
' EVENT ROOT CAUSE
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INAPPROPRIATE'
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INVOLVED ACTION
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RH INADEQUATE REVIEW OF
'SCRE/NS0'
CORRECT ' VALVE --
TECH SPECS FOR MOV.
INTENDED.BUT, IMPROPER POSITION SI POOR COMMUNICATIONS FOR NSO/EA CORRECT; VALVE -
LOCKED VALVE POSITIONING INCORRECT POSITION
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CV MISIDENTIFICATION OF'
- INCORRECT VALVE-
_ LOCKED'_ VALVE INTENDED' POSITION
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EVALUATION l
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NO COMMON ROOT CAUSE
- BASIC PROGRAMS ACCEPTABLE EACH EVENT INVOLVED LACK OF ADEQUATE ATTENTION TO DETAIL
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REVIEWED PERSONNEL ERROR PREVENTION PROGRAMS PROGRAMS DETERMINED TO BE EFFECTIVE.
- PERSONNEL ERROR RATE. CONTINUES TO IMPROVE
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e REVIEW SHOWED EVENTS T0 BE ISOLATED
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CV EVENT ONLY ONE INVOLVING 2 VALVES
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SPECIFIC CORRECTIVE ACTIONS TAKEN HAVE BEEN EFFECTIVE OR
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WILL COVER THE SCOPE OF THE IDENTIFIED EVENTS'
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