Information Notice 1985-75, Improperly Installed Instrumentation, Inadequate Quality Control and Inadequate Postmodification Testing

Improperly Installed Instrumentation, Inadequate Quality Control and Inadequate Postmodification Testing

ML031180355
Person / Time
Site:	Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, 05000000, Zimmer, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant, Skagit, Marble Hill
Issue date:	08/30/1985
From:	Jordan E NRC/IE
To:
References
IN-85-075, NUDOCS 8508270286
Download: ML031180355 (5)

SSINS No.: 6835 IN 85-75 UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF INSPECTION AND ENFORCEMENT

WASHINGTON, D.C. 20555 August 30, 1985 IE INFORMATION NOTICE NO. 85-75: IMPROPERLY INSTALLED INSTRUMENTATION,

INADEQUATE QUALITY CONTROL AND INADEQUATE

POSTMODIFICATION TESTING

Addressees

All nuclear power reactor facilities holding an operating license (OL) or a

construction permit (CP).

Purpose

This information notice is to alert addressees of two recent instances of

improper system modifications, inadequate quality control and inadequate post- modification testing following installation of environmentally qualified

equipment. Recipients are expected to review the information for applicability

to their facilities and consider actions, if appropriate, to preclude similar

problems occurring at their facilities. However, suggestions contained in this

information notice do not constitute NRC requirements; therefore, no specific

action or written response is required.

Description of Circumstances

LaSalle Unit 2 On June 10, 1985, at 11:30 a.m., the licensee informed the NRC Resident

Inspector that for approximately 5 days LaSalle Unit 2 had been without the

capability of automatic actuation of emergency core cooling (ECCS) and that

for approximately 3 days during this period the plant had been without secondary

containment integrity. The major cause of this condition was improper installation

(the variable and reference legs were reversed) of the two reactor vessel level

actuation switches which control Division I automatic depressurization system

(ADS), low pressure core spray (LPCS), and reactor core isolation cooling

(RCIC).

Unit 2 was shut down in February 1985 for an outage that included installation

of environmentally qualified electrical equipment. LaSalle has three divisions

of ECCS equipment. In March 1985, ECCS Division III was taken out of service

for maintenance. On June 5, 1985, ECCS Division II was taken out of service

for modifications. On June 3, 1985, secondary containment was declared inoperable

for maintenance on the reactor building ventilation system. The result of

these scheduled actions was that two of three ECCS divisions and secondary

containment were inoperable, leaving ECCS Division I available for use.

Subsequently, it was discovered that the variable and reference legs to the

8508270286

IN 85-75 August 30, 1985 reactor vessel level actuation switches for ECCS Division I had been accidentally

reversed since June 3, 1985; thus leaving the plant with no ECCS automatic

actuation and no secondary containment.

The cause of the piping reversal was initially the result of incorrect design

drawings which were released to the contractor on April 1, 1985. The licensee's

site personnel recognized the error on April 4, 1985, and issued a Field Change

Request to correct it. However, the isometric drawings being used at the

location of the modification activities were not corrected. Therefore, the

contractor proceeded to connect piping in the reverse order from the correct

configuration. Figure 1 shows the correct configuration and Figure 2 shows the

reversal. This error was not identified by the Quality Control (QC) Program

because the contractor's QC did not assign inspection hold points for either

the electrical or mechanical piping connections for any of the 22 instruments

replaced by the modification. Consequently, the installation adequacy was not

verified against the design drawings, which did include the field change and, therefore, which could reasonably be expected to have revealed the error in the

two instruments that were piped backwards.

Subsequent postmodification testing failed to detect the error because (as

shown in Figure 3) the test shut the instrument block isolation valves and

injected a test pressure source through the installed test connections

downstream from the instrument. This test method isolated the portion of the

piping where the reversal occurred from the test because it was upstream of-the

shut valves.

The error was found as a result of a fortuitous observation by an instrument

technician who was performing an unrelated test. If this technician had not

noticed the error, there was a significant possibility that the plant would

have operated with one division of ECCS unavailable.

The safety significance of these events was reduced because the plant was in a

cold shutdown condition. However, no ECCS equipment was available for automatic

operation in the event of low reactor vessel level. In addition, secondary

containment was allowed to be relaxed because the licensee believed ECCS

Division I was operable. Primary containment also was open. Consequently, had a leak occurred, no ECCS systems would have functioned automatically and

secondary containment would not have been available either'. Technical

specifications required the operability of some ECCS equipment during the time

that the plant was shutdown, and upon loss of ECCS, secondary containment

integrity was subsequently required.

Trojan

On July 20, 1985, the Trojan Nuclear Power Plant tripped from 100% power

because of a turbine trip that was caused by the loss of the unit auxiliary

transformer. All systems functioned normally except that low suction pressure

caused one auxiliary feedwater pump to trip and then the other auxiliary

feedwater pump to trip after restart of the first auxiliary 'feedwater pump.

IN 85-75 August 30, 1985 The cause of the trips of the auxiliary feedwater pumps can be traced back to

improper postmodification adjustment and inadequate postmodification testing

following retrofit of environmentally qualified controllers for the auxiliary

feedwater system. The auxiliary feedwater pump trips on low suction pressure

were caused by excessive combined flow from the two auxiliary feedwater pumps

that draw from a single header from the condensate storage tank. The flow

control valves were open farther than required after new environmentally

qualified controllers had been installed during a recent refueling outage.

When the flow control valves were adjusted following the modification of the

controllers, only one auxiliary feedwater pump was run at a time and used to

adjust the control valve limit switch settings. Consequently, when both pumps

were started following the reactor trip on July 20, 1985, the combined flow was

excessive.

Discussion:

Information Notice 85-23, "Inadequate Surveillance and Postmaintenance and

Postmodification System Testing," described a series of events occurring at

McGuire in November of 1984, where improper system modifications and inadequate

postmodification testing also were involved.

No specific action or written response is required by this information notice.

If you have any questions about this matter, please contact the Regional

Administrator of the appropriate regional office or this office.

ar /'ganD-irector

Divisi of Emergency Preparedness

and Engineering Response

Office of Inspection and Enforcement

Technical Contacts: Eric Weiss, IE

(301) 492-9005 M. Jordan, SRI, LaSalle

(815) 357-8611 Robert Dodds, Region V

(415) 943-3720

Attachments:

1. Figures Illustrating LaSalle Level Instrument Problems

2. List of Recently Issued IE Information Notices

//

A~ttachment 1 IIl 85-75 August 30, 1985 INSTRUMENt INSTRUMENT

_ BLOCK 2TT- BLOCK

HIGH

Figure 1 Figure 2 INS~TRUMENT

_ _ - BLOCK

)SED

,SED

p

EN)

TEST

DEVICE

Figure 3

Attachment 2 IN 85-75 August 30, 1985 LIST OF RECENTLY ISSUED

IE INFORMATION NOTICES

Information Date of

Notice No. Subject Issue Issued to

85-74 Station Battery Problems 8/29/85 All power reactor

facilities holding

an OL or CP

84-70 Reliance On Water Level 8/26/85 All power reactor

Sup. 1 Instrumentation With A facilities holding

Common Reference Leg an OL or CP

85-73 Emergency Diesel Generator 8/23/85 All power reactor

Control Circuit Logic Design facilities holding

Error an OL or CP

85-72 Uncontrolled Leakage Of 8/22/85 All power reactor

Reactor Coolant Outside facilities holding

Containment an OL or CP

85-71 Containment Integrated Leak 8/22/85 All power reactor

Rate Tests facilities holding

an OL or CP

85-70 Teletherapy Unit Full 8/15/85 All material

Calibration And Qualified licensees

Expert Requirements (10 CFR

35.23 And 10 CFR 35.24)

85-69 Recent Felony Conviction For 8/15/85 All power reactor

Cheating On Reactor Operator facilities holding

Requalification Tests an OL or CP

85-68 Diesel Generator Failure At 8/14/85 All power reactor

Calvert Cliffs Nuclear facilities holding

Station Unit 1 an OL or CP

85-42 Loose Phosphor In Panasonic 8/12/85 Materials and fuel

Rev. 1 800 Series Badge Thermo- cycle licensees

luminescent Dosimeter (TLD)

Elements

85-67 Valve-Shaft-To-Actuator Key 8/8/85 All power reactor

May Fall Out Of Place When facilities holding

Mounted Below Horizontal Axis an OL or CP

OL = Operating License

CP = Construction Permit