ML17146A427
| ML17146A427 | |
| Person / Time | |
|---|---|
| Site: | Susquehanna  |
| Issue date: | 06/17/1986 |
| From: | Peleschak S, Strosnider J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML17146A426 | List: |
| References | |
| 50-387-86-06-EC, 50-387-86-6-EC, 50-388-86-04, 50-388-86-4, NUDOCS 8606260258 | |
| Download: ML17146A427 (46) | |
See also: IR 05000387/1986006
Text
U.S.
NUCLEAR REGULATORY COMMISSION
REGION I
Docket No. 50-387/50-388
License
No. NPF-14/NPF-22
Licensee:
Power
& Light Company
2 North Ninth Street
Al 1 entown,
18101
Facility Name:
Susquehanna
Steam Electric Station Units
1 and
2
Meeting At:
U.S.
NRC Region I, King of Prussia,
Meeting Date:
May 30,
1986
Prepared
By:
.
Pe eschak,
Technical
Intern
Date
Approved By:
J. Strosnider,
Chief
Reactor Projects
Section
1B,
Date
Meetin
Summar
An enforcement
conference
was held at
NRC Region I on May 30,
1986, to discuss
the findings of combined Inspection
Report 50-387/86-06;
50-388/86-04.
This
report presents
the findings on the
Scram Discharge
Instrument
Volume (SDIV)
level sensors
limiting condition for operation violation.
The meeting
was attended
by
NRC and
PP&L management
personnel
and lasted
approximately
two hours.
8bObZbOZ58
BbOb19
I
ADOCK 05000387
6
PDR ~
r..
OFFICIAL RECORD
COPY
301STROSNIDER6/12/86
0003.0. 0
06/12/86
DETAILS
1. 1
Penns
lvania Power
& Li ht
Com an
T. H. Crimmins, Jr., Plant Superintendent
B.
D. Kenyon, Senior-Vice President,
Nuclear
H. Palmer,
Supervisor
of Operations
A. Hale,
Manager,
Nuclear Design
W.
E. Barberich,
Manager,
Nuclear Licensing
F. T. Eisenhuth, Staff Assistant
1.2
Nuclear
Re ulator
Commission
T. Hurley, Regional Administrator
J. Gutierrez,
Regional
Counsel
'. Starostecki,
Director, Division of Reactor Projects
H. Kister, Chief, Reactor Projects
Branch
1
J. Strosnider,
Chief, Reactor Projects
Section
1B,
J. Durr, Chief, Engineering
Branch,
R. Jacobs,
Senior Resident
Inspector
L. Plisco,
Resident
Inspector
D. Holody, Enforcement Specialist
L. Doerflein, Project Engineer,
1,
RB 1,
R. Fuhrmeister,
Reactor
Engineer,
1,
RB 1,
S.'eleschak;
Summer Technical
Intern,
1,
RB 1,
2.
~Pur ose
The enforcement
conference
was held at
NRC Region I's request
to discuss
the inoperability of newly installed
Scram Discharge
Instrument
Volume
(SDIV) level transmitters
due to closed isolation valves.
A brief
.
discussion
about the recently failed Emergency
Service Mater (ESW)
pump
preceded
the conference.
3.
Presentation
NRC Region I Regional Administrator, Dr. T. Murley, opened
the conference
by asking the licensee
to present
some perspective
on the recent failure
of the
ESW pumps.
The licensee
presented
t.he most recent history of
events
and corrective actions
being taken to return the
pumps to service.
PP&L gave
a brief overview of the
SDIV level transmitters history.
Mr. F. Eisenhuth, staff assistant
of PP&L, responded
to the
NRC concerns
and addressed
the corrective actions
being taken to alleviate reoccurrence
of this problem.
OFFICIAL RECORD
COPY
301STROSNIDER6/12/86
0004.0. 0
06/17/86
I'he
discussion
which followed focused
on modification close-outs
and check
off list procedures.
The licensee
has committed to providing written
guidance
on close-out reviews, providing two technical
reviews of proce-
dural
changes,
and extending post-modification testing to in-service
checks
and process verification.
Other commitments
include component
inspection,
functional testing
and operational
testing,
as part of post-
modification testing,
and in-service observation
following such testing.
A few concluding
remarks
were
made concerning
the safety significance of
the closed isolation valves
and it was determined
not to be of major
significance.
4.
Concludin
Statements
The licensee
concluded that
a
human error was responsible
for the inoper-
ability of the
SDIV level transmitters.
The licensee
has taken extensive
corrective actions which should alleviate this problem from occurring in
the future.
An extensive investigation
has
shown this to be
an isolated
case that does not exist throughout
the plant.
OFFICIAL RECORD
COPY
301STROSNIDER6/12/86
0005.0. 0
'6/17/86
U.S.
NUCLEAR REGULATORY COMMISSION
REGION I
Docket No. 50-387/50-388
License
No. NPF-14/NPF-22
Licensee:
Power & Light Company
2 North Ninth Street
Al 1 entown,
Penn syl vani a
18101
Facility Name:
Susquehanna
Steam Electric Station Units
1 and
2
Meeting At:
U.S.
NRC Region I, King of Prussia,
Meeting Date:
May 30,
1986
Prepared
By:
Pe eschak,
Technical
Intern
Date
Approved By:
. Strosnider,
Chief
eactor Projects
Section
1B,
Date
Meetin
Summar
An enforcement
conference
was held at
NRC Region I on
May 30,
1986, to discuss
the findings of combined Inspection
Report 50-387/86-06;
50-388/86-04.
This
report presents
the findings on'he
Scram Discharge
Instrument
Volume (SDIV)
level
sensors
limiting condition for operation violation.
The meeting
was attended
by
NRC and
PP8L management
personnel
and lasted
approximately
two hours.
DETAILS
1.1
Penns
lvania
Power
& Li ht
Com an
T. H. Crimmins, Jr, Plant Superintendent
B.
D. Kenyon, Senior-Vice President,
Nuclear
H. Palmer,
Supervisor of Operations
A. Hale, Hanager,
Nuclear Design
W.
E. Barberich,
Hanager,
Nuclear Licensing
F. T. Eisenhuth,
Staff Assistant
1.2
Nuclear
Re ulator
Commission
T. Hurley, Regional Administrator
J. Gutierrez,
Regional
Counsel
R. Starostecki,
Director, Division of Reactor Projects
H. Kister, Chief, Reactor Projects
Branch
1
J. Strosnider,
Chief, Reactor Projects
Section
18,
J. Ourr, Chief, Engineering
Branch,
R. Jacobs,
Senior Resident
Inspector
L. Plisco,
Resident
Inspector
D. Holody, Enforcement Specialist
L. Doerflein, Project Engineer,
RPS 1,
RB 1,
- R. Fuhrmeister,
Reactor
Engineer,
1,
RB 1,
ORP
S.
Peleschak,
Summer Technical
Intern,
1,
RB 1,
2.
~Per ese
The enforcement
conference
was held at
NRC Region I's request
to discuss
the inoperability of newly installed
Scram Discharge
Instrument
Volume
(SDIV) level transmitters
due to closed isolation valves.
A brief
discussion
about the recently failed Emergency
(ESW)
pump
preceded
the conference.
3.
Presentation
NRC Region I Regional Administrator, Dr.
T ~ Hurley, opened
the conference
by asking the licensee
to present
some perspective
on the recent failure
of the
ESW pumps.
The licensee
presented
the most recent history of
events
and corrective actions
being taken to return the
pumps to service.
PP&L gave
a brief overview of the
SOIV level transmitters history.
Hr.
F. Eisenhuth,
staff assistant
of PP&L', responded
to the
NRC concerns
and addressed
the corrective actions
being taken to alleviate reoccurrence
of this problem.
The discussion
which followed focused
on modification close-outs
and check
off list procedures.
The licensee
has committed to providing written
guidance
on close-out
reviews, providing two technical
reviews of proce-
dural
changes,
and extending post-modification testing to in-service
checks
and process verification.
Other
commitments
include component
inspection,
functional testing
and operatiorial testing,
as part of post-
modification testing,
and in-service observation
following such testing.
A few concluding
remarks
were
made concerning
the safety significance of
the closed isolation valves
and it was determined
not to be of major
significance.
4.
Concludin
Statements
The licensee
concluded that
a
human error was responsible
for the inoper-
ability of the
SDIV level transmitters.
The licensee
has
taken extensive
corrective actions which should alleviate this problem from occurring in
the future.
An extensive
investigation
has
shown this to be
an isolated
case that does
not exist throughout
the plant.
ENCLOSURE II
SDV LEVEL TRANSNITTER
ISOLATION VALVES
INCIDENT
SDV LEVEL TRANSNITTER
ISOLATION VALVES INCIDENT
OVERVIEW
0
ON APRIL 10,
1986,
IT WAS DISCOVERED THAT ISOI ATION
VALVES FOR THE "C" AND "D" SDV LEVEL TRANSNITTERS
ON UNIT 1
WERE
LOCKED CLOSED.
0
THESE WERE
TMO OF
FOUR
NEW LEVEL SENSING DEVICES
ADDED TO ENHANCE THE PROTECTION CAPABILITY
FOLLOWING THE 1980
BROWNS FERRY PARTIAL ATMS
EVENT AND OTHER BWR FLOAT SMITCH FAILURES.
0
'HIS VALVE MISPOSITIONING DISABLED 1
REACTOR
PROTECTION SYSTEN INPUT EACH
FROM TRIP SYSTEM
A
AND TRIP SYSTPt B.
HOWEVER. FULL PROTECTION
AGAINST AN SDV HIGH LEVEL CONDITION MAS
MAINTAINED BY THE FOUR fLOAT SWITCHES
ORIGINALLY INSTALLED IN THE PLANT.
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SDV LEVEL TRANSMITTER
ISOLATION VALVES INCIDENT
BASIC CAUSE OF VALVE POSITIONING ERROR
0
IMPROPER
CLOSEOUT OF MODIFICATION
0
OVERALL MODIFICATION CLOSEOUT
PROCESS
IS SOUND,
ISOLATED
ERROR
OCCURRED
IN IMPLEMENTATION OF
ONE STEP
OF THE
PROCESS.
CORRECTIVE ACTIONS
0
MEASURES
ARE BEING TAKEN TO REDUCE THE POSSIBILITY
OF ERROR,
AND TO ENHANCE THE PROBABILITY OF
DETECTION SHOULD ERRORS
OCCUR.
SDV LEVEL TRANSNITTER
ISOLATION VALVES INCIDENT
INITIALDISCOVERY OF CONDITION
0
ON APRIL 10,
1986
A CLASS I BOUNDARY PRESSURE
TEST
ON UNIT 1
MAS IN PROGRESS.
WITH A SCRAN INSERTED,
THE SCRAN DISCHARGE
VOLUNE (SDV)
WAS FILLED WITH WATER.
0
I&C TECHNICIANS WERE PRESENT
IN THE UPPER
RELAY ROOM FOR
OTHER WORK.'ECAUSE OF FANILIARITYWITH THE EQUIPNENT,
THEY
RECOGNIZED THAT THE CONTRADICTORY INDICATIONS FRON NETERS
ON PANEL 1C635
(ONE READING HIGH, ONE LOM) MERE INPROPER.
0
AN OPERATOR
WAS DISPATCHED TO THE REACTOR BUILDING TO
INSPECT THE LEVEL TRANSMITTERS WHICH DRIVE THE NETERS.
HE DISCOVERED THAT THE ISOLATION VALVES FOR LT-C12-1N016C
AND D MERE LOCKED CLOSED.
0
SINCE THEIR INSTALLATION DURING THE UNIT 1 FIRST
REFUELING OUTAGE, THESE TRANSMITTERS WERE REQUIRED TO
BE OPERABLE PER TECHNICAL SPECIFICATIONS, TABLE 3.3.1-1,
FUNCTION 8.A.
SDV LEVEL TRANSNITTER
ISOLATION VALVES INCIDENT
IMNEDIATE ACTIONS
0
THE CURRENT CHECKOFF LIST (PERFORMED 5/27/86)
WAS EXANINED.
THE VALVES WERE POSITIONED
AS SPECIFIED
ON THE COL.
0
A COL PERFORNED
DURING THE UNIT I
FRO
SHOWED BOTH ISOLATION
VALVES FOR
EACH OF THE FOUR TRANSNITTERS LOCKED CLOSED.
THIS MAS APPROPRIATE,
SINCE THE NODIFICATION TO INSTALL THE
TRANSNITTERS MAS INCONPLETE AT THE TINE.
0
THE PROCEDURE
CHANGE WHICH TRANSFERRED THE POSITION
OF THE ISOLATION VALVES OF THE
A AND B TRANSNITTERS FROM
LOCKED CLOSED
TO LOCKED OPEN
MAS EXAtrtINED~
THIS PCAF
WAS
ISSUED
AND PERFORNED,
ON NAY 2,
1985
WHEN THE
NODIFICATION MAS CLOSED
OUT ~
NO CHANGE WAS NADE TO THE POSITION
OF THE
C
D TRANSNITTER
ISOLATION VALVES.
SDV LEVEL TRANSMITTER
ISOLATION VALVES INCIDENT
IRONED IATE ACTIONS (CONTINUED)
0
PCAF 1-86-530
MAS GENERATED TO
CHANGE THE POSITION OF VALVES
147F155C,
D AND 147F160C,
D TO LOCKED OPEN,
AND THIS CHANGE
WAS EXECUTED.
0
THE LEVEL,INDICATION ON PANELS IC635
AND IC636
MAS VERIFIED
TO BE PROPER.
0
THE UNIT 2 SDV LEVEL TRANSNITTER ISOLATION VALVES MERE
VERIFIED OPEN
AND THEIR COL WAS VERIFIED TO REQUIRE THEN
OPEN.
NOTE:
THE UNIT 2 TRANSNITTERS MERE INSTALLED PRIOR TO
INITIALSTARTUP.
'* tt
SDV LEVEL -TRANSNITTER
ISOLATION VALVES INCIDENT
RECONSTRUCTION
OF TIMELINE
PRIOR TO
INITIAL
STARTUP
ISOLATION VALVES AND FLANGES INSTALLED.
2/1/83
REV.
17
TO M-147
SHOWS
A AND B VALVES
LOCKED CLOSED WHILE C
AND D VALVES ARE
SHOWN LOCKED OPEN.
5/31/84
DCP 82-578
TO INSTALL TRANSMITTERS IS
ISSUED.
AN IDCN SHOWS THE ADDED TRANSMITTERS
AND CHANGES THE A AND B ISOLATION VALVES
TO
LOCKED OPEN.
6/20/84
SYSTEM ENGINEER PREPARES
PMP.
ALTHOUGH
CERTAIN OPERATIONS
PROCEDURE
CHANGES ARE
IDENTIFIED, NO
CHANGES TO
COL ARE CALLED
OUT.
1/2/85
SYSTEM ENGINEER SENDS
MEMO TO OPERATIONS
NOTING PROCEDURE
CHANGES HE FEELS WILL BE
REQUIRED TO
PMR 82-578.
SDV LEVEL TRANSMITTER
ISOLATION VALVES INCIDENT
RECONSTRUCTION OF TIMELINE (CONTINUED)
3/23/85 ro
3/26/85
4/20/85
TRANSMITTERS INSTALLED.
VALVES REMAIN
CLOSED
AS SPECIFIED
BY THE PERMIT.
COL PERFORMED.
ISOLATION VALVES VERIFIED
LOCKED CLOSED.
4/23/85 vo
5/1/85
I&C CALIBRATES TRANSMITTERS,
VALVES PRESUMED TO REMAIN SHUT BEFORE,
DURING AND AfTER THE CALIBRATIONS.
5/2/85
OPERATIONAL READINESS
FORM FOR
PNR
82-578
INITIATED.
OPERATIONS
REVIEWS PACKAGE,
AND IDENTIFIES
A NEEDED
CHANGE TO THE COL.
HOWEVER,
THIS CHANGE DOES
NOT INVOLVE THE
TRANSMITTER ISOLATION VAlVES.
THE PMR CLOSEOUT IS COMPLETED,
AND THE
APPROPRIATE
FORMS DELIVERED TO THE
CONTROL
ROOM FOR PLACEMENT IN SERVICE.
FUEL LOADING IS CONSTRAINED BY THIS
PMR CLOSURE..
CONTROL
ROOM PERSONNEL
IDENTIFY THAT
ISOLATION VALVES FOR THE A AND B
TRANSMITTERS NEED TO BE OPENED,
INITIATE PCAF 1-85-562.
AND ACCOMPLISH
THE CHANGE.
SDV LEVEL TRANSMITTER
ISOLATION VALVES INCIDENT
RECONSTRUCTION
OF TIMELINE (CONTINUED)
5/2/85
PCAF 1-85-566
IS
ISSUED
TO
IMPLEMENT CHANGES
TO THE COL NOTED BY THE OPERATIONS ENGINEER.
5/9/85
AN INSERV!CE LEAK TEST IS
PERFORMED
ON THE
NEM INSTALLATION PER SE-155-501.
THERE IS
NO
EVIDENCE THAT VALVE POSITION IS DISTURBED.
0/10/86
THE IMPROPER POSITION OF THE C
AND D
TRANSMITTER ISOLATION VALVES IS NOTED
AND CORRECTIVE ACTIONS TAKEN.
SDV LEVEL TRANSMITTER
ISOLATION VALVES INCIDENT
SAFETY IMPLICATIONS AVAILABILITYOF DIVERSE AND
REDUNDANT INSTRUMENTATION
0
THE FOUR SDV FLOAT SWITCHES
REMAINED OPERABLE,
PROVIDING FULL SCRAM CAPABILITY FOR BOTH SCRAM
DISCHARGE VOLUMES
0
THE TWO SDV LEVEL TRANSMITTERS ON THE UNAFFECTED
VOLUME REMAINED, OPERABLE.
PROVIDING FULL SCRAM
CAPABILITY FOR THAT SCRAM DISCHARGE VOLUME
0
WHILE NO CREDIT IS ASSUMED, THE COMMON VENT AND
DRAIN LINES CONNECTING THE TWO VOLUMES WOULD ALLOW
STABILIZATION OF LEVELS BETWEEN THE VOLUMES FOR
MODERATE LEAKS.
IN SUCH CASES,
THE OPERABLE
LEVEL TRANSMITTERS WOULD PROVIDE FULL SCRAM
CAPABILITY
SDV LEVEL TRANSMITTER
ISOLATION VALVES INCIDENT
SAFETY IMPLICATIONS FAULT TREE ANALYSIS
0
PERFORMED
BY PPRL
SYSTEM ENGINEERING GROUP
BASED
ON
REPORT
N
"TECHNICAL SPECIFICATION
IMPROVEMENT ANALYSES FOR
BWR REACTOR PROTECTION SYSTEM."
0
IN RESPONSE
TO
A VALID SDV HIGH LEVEL EVENT (WITH
NO SIMULTANEOUS REACTOR TRANSIENT), THE CALCULATED
SCRAM FAILURE PROBABILITIES ARE:
ORIGINAL CONFIGURATION
(FOUR FLOAT SWITCHES ONLY)
CURRENT DESIGN
(FOUR FLOAT SWITCHES
PLUS
FOUR LEVEL TRANSMITTERS)
1.5
X 10 5
1.1
X 10-6
(91.5X REDUCTION)
CONFIGURATION DURING
INCIDENT
(FOUR FLOAT SWITCHES
PLUS
"A" AND "B" LEVEL TRANSMITTERS)
2.0
X 10
(80.6X REDUCTION)
SDV LEVEL TRANSMITTER
ISOLATION VALVES INCIDENT
SAFETY IMPLICATIONS PRA ANALYSIS
0
TO PLACE IN PERSPECTIVE,
THIS CHANGE IN SCRAM
FAILURE PROBABILITIES WAS FACTORED
INTO THE
SUSQUEHANNA PRA
0
A WORST CASE ASSUMPTION WAS MADE THAT THE
PROBABILITY OF
A SDV FILL EVENT WAS I.O,
AND
THAT SCRAM FAILURE FROM THIS CAUSE IS COMPLETELY
UNRECOVERABLE.
0
THE CALCULATED CORE NELT FREQUENCIES
ARE:
CURRENT DESIGN
CONFIGURATION DURING
INCIDENT
9.5 X 10
/YR.
9,6
X 10
/YR.
0
CORE MELT FREQUENCIES
BELOW 10
/YR.
ARE CONSIDERED
ACCEPTABLE FOR PROTECT!ON
OF HEALTH AND SAFETY OF THE
PUBLIC
.I4
SDV LEVEL TRANSMITTfR
ISOLATION VALVES INCIDENT
MODIFICATION CLOSEOUT PROCESS
0
SYSTEM ENGINEfR VERIFIES ALL WORK AND TESTING IS
COMPLETE.
MODIFICATION PACKAGE IS ASSEMBLED
CONTAINING (AMONG-OTHER DOCUMENTS):
OPERATIONAL READINESS
FORM
PROCEDURES
REVIEW SHEET
OPERATIONS MODIFICATION INFORMATION SUMMARY SHEET
0
MODIFICATION PACKAGE IS
ROUTED TO MANAGfRS LISTED
ON OPERATIONAL READINESS
FORM.
APPROVAL INDICATES:
UPDATES TO PROCEDURES,
TECHNICAL SPfCIFICATIONS.
FSAR. TRAINING, DOCUMENTATION, ETC.
ARE COMPLETED
MANAGER IS COGNIZANT OF ADDITIONAL CHANGES
REQUIRED AFTER CLOSEOUT
0
MODIFICATION PACKAGf IS SUBMITTED TO THE
SUPERINTENDENT FOR FINAL APPROVAL
0
MODIFICATION IS
RELEASED
FOR SERVICE
OPERATIONAL READINESS
PMR NO.
REVISION
PAGE
of
SYSTEM NO.
EACH SECTION
SHOULD REVIEW THE CHANGES
MADE AS
PART OF THIS MODIFICATION.
EACH SECTION
HEAD SHALL SIGN THE CHECKLIST TO INDICATE THE SECTION"S
AWARENESS
OF THE CHANGES
MADE AND THEIR EFFECTS.
THIS SIGNATURE INDICATES THAT REQUIRED
ACTIONS ARE COMPLETE AND THAT PROCEDURES,
PM's TRAINING, ETC.
BEYOND WHAT IS
REQUIRED WILL BE
PREPARED
AS NECESSARY.
SOME
ITEMS OF
CONCERN ARE LISTED
BELOW.
SECTIONS A,B, AND C MUST BE
COMPLETED PRIOR
TO DECLARING SYSTEM
SECTIONS
D AND E
NEED TO
BE COMPLETED PRIOR
TO
FINAL PMR CLOSE OUT.
(SECTION
F TO
BE COMPLETED IF NECESSARY.)
A.
TECHNICAL
1.
TECHNICAL SECTION PROCEDURE/SPECIFICATION
CHANGES
INCORPORATED.
- 2.
CHEMISTRY SAMPLING/ANALYSIS ROUTINES.
3.
CONSUMABLES (CHEMICALS, RECORDER
PAPER,
ETC.).
4.
TECH SPEC
SURVEILLANCE TESTS
AND/OR OTHER TESTING COMPLETE.
5.
AS BUILT CONFIGURATION.
6.
REVIEW MODIFICATION PACKAGE
FOR
COMPLETENESS.
7.
DEFICIENCIES DISPOSITION.
8.
ALL NCR's
ASSOCIATED WITH THE
PMR ARE DISPOSITIONED.
SEC I
N HEAD
D TE
B.
DOCUMENT CONTROL CENTER
1.
DRAWING UPDATES
ISSUED
(CLASS
1 DRAWINGS).
FORM AD-QA-410-8, REV. 1,
PAGE
1
OF 2
OPERATIONAL READINESS
C.
OPERATIONS
l.
'PERATING PROCEDURES
2.
OPERATING
LOGS
3.
TRAINING
4.
5.
PM SCHEDULES
6.
TAGGING
PMR
NO ~
REV IS ION
PAGE
OF
D.
MAINTENANCE
1.
MAINTENANCE SECTION
PROCEDURES
2.
PM ROUTINES
3.
SPARE
PARTS,
CONSUMABLES
4.
TRAINING
E.
1.
I&C PROCEDURES
2.
PM ROUTINES
3.
SPARE
PARTS/CONSUMABLES
4.
TRAINING
F.
SECURITY
1.
SECURITY PROCEDURES
2
~
SECURITY SPARE
PARTS
3.
TRAINING
FORM AD-QA-410-8,
REV. 1,
PAGE
2 OF 2
SECTION
HEAD
SECTION
HEAD
SECTION
HEAD
SECTION
HEAD
DATE
DATE
DATE
DATE
PROCEDURES
REVIEW SHEET
PMR NO.
>>
REVISION
PAGE
OF
DOCUMENT TYPE
OPERATING
PROCEDURES:
OP,ON,EO,GO
DOCUMENT NO.
REVISION
NEW
REVISE
ALARM PROCEDURES
SURVEILLANCE
OPERATING/
PERFORMANCE TEST:
OTHER DOCUMENTS:
SIMULATED SYSTEM AFFECTED
YES
NO
NUCLEAR PLANT TRAINING AFFECTED
YES
NO
PREPARED
BY
DATE
FORM AD-QA-410-3,
REV. 2,
PAGE
1
OF
1
OPERATIONS MODIFICATION INFORMATION SUMMARY SHEET
OMISS ABSTRACT
PMR NO.
REVISION
PAGE
of
SYS
SUS
NO
NOTE:
GIVE COMPLETE DESCRIPTION; THIS INFORMATION IS
USED
FOR TRAINING
PURPOSES,
AND EQUIPMENT RELEASE
PURPOSES.
SYS. TITLE AND NO'S
FOR ALL
SYS.
AFFECTED
ON THE MOD.
THE MODIFICATION):
- REASON FOR MODIFICATION -
IMPACT ON THE SYSTEM AS PREVIOUSLY DESIGNED
(WHY WAS MODIFICATION NEEDED):
I
- MODIFICATION: (SUMMARY OF THE MODIFICATION INCLUDING CHANGE IN HOW IT NOW
WORKS) GIVE NAMES AND NUMBER OF COMPONENTS, I.E. VALVES,
PUMPS,
FANS,
ETC.
- SYSTEM OPERATING -
PROCEDURES
EFFECTED (IF NOT CLEAR ABOVE, LIST EFFECTS):
- ADDITIONALSHEETS
TO
BE ATTACHED AS
NECESSARY IF MORE SPACE IS NEEDED.
PREPARED
BY
DATE
FORM AD-QA-410-4,
REV. 1,
PAGE
1
OF
1
SDV LEVEL TRANSMITTER
ISOLATION VALVES INCIDENT
FAILURE TO DETECT MISPOSITIONING OF VALVES
SUGGESTED
OPPORTUNITY
COMMENT
OPERATOR
RECOGNIZE
WHILE PERFORMING
NOT EXPECTED
FOR OPERATOR TO
ACHIEVE.
SYSTEM LEAK TEST
VALVES POSITIONED
FOR TEST
PER
OPERATIONS COL.
NOTE:
VALID LEAK TEST
HAS BEEN
PERFORMED SINCE ISOLATION
VALVES WERE OPENED,
MONTHLY CHANNEL
FUNCTIONAL TEST
MONITORING LEVEL
TRANSMITTER INDICATION
POST-SCRAM ANALYSIS
18
MONTH CALIBRATION
ELECTRONICS ONLY
NORMAL LEVEL IS ZERO
TRANSMITTER PERFORMANCE MASKED
BY FLOAT SWITCH RESPONSE
MOST PROBABLE OPPORTUNITY
FOR DETECTION.
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SDV LEVEL TRANSMITTER
ISOLATION VALVES INCIDENT
FAILURE TO DETECT MISPOSITIONING OF VALVES
0
POST-NOD IF ICATION TESTING
SPECIFIED
MAS LINITED TO
INSTRUNENT CALIBRATIONS.
THESE TESTS
MERE CONDUCTED
WITH ISOLATION VALVES CLOSED,
AND DID NOT VERIFY
RESPONSE
OF THE DEVICES TO PROCESS
LEVEL CHANGES.
0
A TRADITIONALLYCONCEIVED TEST WHICH WOULD VERIFY
PROCESS
CONNECTION PROBABLY WOULD NOT HAVE PREVENTED
INCIDENT
SINCE MODIFICATION MAS STILL INCONPLETE, OPERABILITY
WOULD RENAIN AN ISSUE
VALVES WOULD BE CLOSED BEFORE
AND AFTER THE TEST
FINAL OPENING
WOULD BE CONTROLLED BY THE
(INCORRECT)
COL.
0
THE NISSING FACTOR MAS AN INSERVICE CHECK TO VERIFY
EXPECTED
RESPONSE
OF
INSTRUNENTS TO OPERATING CONDITIONS.
A CONVENIENT TEST
FOR THESE TRANSMITTERS MOULD HAVE
BEEN VERIFICATION OF TRIP DURING CONTROL
ROD TINING
SCRANS
AT END OF REFUELING OUTAGE.
.
SDV LEVEL TRANSMITTER
ISOLATION VALVES INCIDENT
SHORT TERM CORRECTIVE ACTIONS
REVIEW OF PREVIOUSLY CLOSED MODIFICATIONS
0
AN EXTENSIVE REVIEW WAS CONDUCTED BY OPERATIONS TO
REVERIFY THE ADEQUACY OF THE MODIFICATION CLOSEOUT
PROCESS
0
THE SCOPE Of REVIEW WAS ALL MODIfICATIONS FROM
JANUARY 1985
TO THE PRESENT
0
THE FIRST STEP
IN THE REVIEW PROCESS
WAS
A SEARCH
OF
THE COMPUTER LISTING OF THE 399 MODIFICATIONS INCLUDED
IN THE SCOPE
77 PMR's
HAD BEEN CANCELLED PRIOR TO INSTALLATION
PACKAGES DESCRIBING CHANGES OBVIOUSLY WITHOUT
OPERATIONS
PROCEDURE
IMPACT (E.6.
TURBINE BUILDING
DRIVEWAY ALTERATIONS) WERE IDENTIFIED AND DROPPED
FROM FURTHER REVIEW.
THIS CUT WAS CONSERVATIVE, WITH ITEMS OF
ANY
POSSIBLE
IMPACT KEPT FOR
COMPLETE REVIEW.
THE PRELIMINARY CUT WAS
REPERFORMED
BY A SECOND
ENGINEER.
ULTIMATELY, 104 PMR's
WERE EXEMPTED FROM
FURTHER REVIEW BY THIS PROCESS.
THE FINAL LIST OF PMR's
TO BE REVIEWED WAS
REVERIFIED BY FOUR
MEMBERS OF THE OPERATIONS STAFF.
SDV LEVEL TRANSNITTER
ISOLATION VALVES INCIDENT
SHORT TERN CORRECTIVE ACTIONS
REVIEW OF PREVIOUSLY CLOSED NODIFICATIONS (com'rNUED)
0
THE RENAINING 218
PACKAGES MERE THEN REVIEWED:
PNR
PACKAGE WAS EXANINED.
ALL DESCRIPTIONS
OF PHYSICAL CHANGES ACHIEVED BY
THE PMR WERE CONSIDERED.
FINDINGS WERE DISCUSSED
BY ENTIRE REVIEW,GROUP TO
NAINTAIN OBJECTIVITY.
SUMNARY DOCUMENTS (ONISS,
PROCEDURES
REVIEW, ETC)
WERE REVIEWED LAST.
AFTER THIS PROCESS
DETEfNINED REQUIRED PROCEDURE/
PROGRAN CHANGES'HOSE
PROGRANS
AND PROCEDURES
WERE
EXANINED FOR
PROPER
INCORPORATION.
0
NO ITENS OF NUCLEAR SAFETY OR OPERATIONAL CONCERN
WERE FOUND.
SDV LEVEL TRANSNITTER
ISOLATION VALVES INCIDENT
SHORT TERN CORRECTIVE ACTIONS
MALKDOWN OF ELECTRICAL PANELS
AND I NSTRUNENT RACKS
0
SELECTED SAFETY SYSTEN ELECTRICAL PANELS
AND INSTRUNENT
RACKS WERE WALKED DOWN TO VERIFY ABSENCE OF NISPOSITIONED
BREAKERS
(OPEN)
INSTRUNENT ISOLATION VALVES (CLOSED).
0
PANELS
WERE SELECTED
FRON
REACTOR PROTECTION SYSTEN.
ISOLATION ACTUATION, ECCS
ACTUATION, ATMS-RPT, ACCIDENT
NONITORING AND FW/NAIN TURBINE TRIP INSTRUNENTATION,
0
60 SEPARATE LOCATIONS WERE INSPECTED.
0
NO DISCREPANCIES
MERE DETECTED.
SDV LEVEL TRANSMITTER
ISOLATION VALVES INCIDENTS
SHORT TERM CORRECTIVE ACTIONS
TASK FORCE
REVIEW
0
A TASK FORCE
WAS APPOINTED TO INVESTIGATE THE
CIRCUMSTANCES SURROUNDING THE INCIDENT, DETERMINE
CAUSES,
AND MAKE RECOMMENDATIONS FOR CORRECTIVE
ACTIONS.
0
FINDINGS OF TASK FORCE
WERE PRESENTED
AT A MEETING
OF THE TECHNICAL SECTION.
0
RECOMMENDATIONS CONTAINED IN TASK FORCE
REPORT
FORM
BASIS FOR
LONG TERM CORRECTIVE ACTIONS.
0
SHORT TERM CORRECTIVE ACTIONS AND TASK FORCE
INVESTIGATION CONFIRMED OUR ANALYSIS OF THE
ROOT CAUSE
SDV LEVEL TRANSNITTER
ISOLATION VALVES INCIDENT
ROOT CAUSE
, 0
THE ROOT CAUSE MAS INPROPER
ClOSEOUT
OF
A
NODIF ICATION
0
INVESTIGATION SHOWED THAT THE CLOSEOUT
PROCESS
IS SOUND.
THE HUMAN ERROR
OCCURRED
IN
INPLENENTATION OF
A SPECIFIC
CLOSEOUT STEP
0
THE NATURE OF THE SPECIFIC
STEP
OF EXTRACTING
PROCEDURE
CHANGES
FROM DESIGN DOCUNENTS NKES IT
SUSCEPTIBLE
TO
ERRORS
0
AT THE TINE THE LEVEL TRANSMITTER NODIFICATION
MAS CLOSED OUT, THE OPERATIONS
CLOSEOUT STEP
WAS NOT
SUFFICIENTLY TOLERANT OF THIS SUSCEPTABILITY
0
THE LIMITED SCOPE Of POST-NODIFICATION TESTING
SPECIFIED
MAS
A CONTRIBUTING FACTOR.
SDV LEVEL TRANSMITTER
ISOLATION VALVES INCIDENT
LONG TERM IMPROVEMENTS TO STRENGTHEN THE MODIFICATION PROCESS
0
FIRST OBJECTIVE IS TO ESTABLISH CONDITIONS WHICH PROMOTE
MINIMIZATIONOF
ERROR
IN MODIFICATION CLOSEOUT PROCESS:
CONDUCT EARLIER PLANNING OF
PROCEDURE
CHANGES
NECESSARY
FOR
CLOSEOUT
PROVIDE WRITTEN DEFINITIVE GUIDANCE TO OPERATIONS
STAFF
ON
CONDUCT OF MODIFICATION CLOSEOUT REVIEWS
CREATE MECHANISMS TO
PROMOTE INTERACTIONS BETWEEN
MODIFICATIONS EXPERT
(SYSTEM ENGINEER)
AND
PROCEDURES
EXPERT
(OPERATIONS ENGINEER)
0
AN ADDITIONAL BARRIER TO IMPLEMENTATION OF
ERRONEOUS
MATERIAL WILL BE PROVIDED BY A SECOND TECHNICAL REVIEW;
OF THE PROCEDURE
CHANGE DETERMINATION.
0
POST-MODIFICATION TESTING PHILOSOPHY WILL BE EXPANDED
TO ADDRESS IN-SERVICE CHECKS
AND PROCESS
VERIFICATION.
SDV LEVEL TRANSMITTERS
ISOLATION VALVES INCIDENT
LONG TERM IMPROVEMENTS TO STRENGTHEN THE MODIFICATION PROCESS
POST MODIFICATION TESTING PHILOSOPHY
0
CURRENT ADMINISTRATIVEPROCEDURES
PROVIDE REQUIREMENT
FOR SYSTEM ENGINEER TO SPECIFY TESTING REQUIREMENTS.
0
SOME DISCUSSION IS PROVIDED REGARDING GUIDELINES FOR
FUNCTIONAL TESTING
AND OPERABILITY TESTING,
AND MORE
COMPLETE STANDARDS FOR
COMPONENT TESTING ARE AVAILABLE.
0
A CLEAR STATEMENT OF TESTING PHILOSOPHY MILL BE
INCORPORATED
INTO THE MODIFICATION ADMINISTRATIVEPROCEDURE.
SDV LEVEL TRANSMITTERS
ISOLATION VALVES INCIDENT
LONG TERM IMPROVEMENTS TO STRENGTHEN THE MODIFICATION PROCESS
0
POST-MODIFICATION TESTING MAY BE SPECIFIED
AS:
COMPONENT INSPECTION
AND TESTING TO VERIFY
EXPECTED
PERFORMANCE
OF INDIVIDUALCOMPONENTS.
EXISTING TEST MATRICES FORM THE BASIS FOR THESE
REQUIREMENTS.
FUNCTIONAL TESTING TO CHECK COMPONENT PERFORMANCE
IN ENERGIZED STATE,
THROUGH THEIR FULL RANGE AND
SCOPE.
OPERATIONAL TESTING TO VERIFY EQUIPMENT AND SYSTEM
PERFORMS
AS EXPECTED
UNDER DYNAMIC CONDITIONS.
INCLUDES REQUIRED SURVEILLANCE TESTS
AND OTHER
SPECIAL TESTS
NEEDED TO VERIFY TECHNICAL
SPECIFICATION OPERABILITY.
IN-SERVICE OBSERVATIONS TO PROVIDE A "COMMON SENSE"
LINE OF DEFENSE
WHERE APPROPRIATE TO ASSURE
COMPONENT
AND SYSTEM OPERATION IS
AS EXPECTED.
THESE ARE
DETERMINED ON
A CASE-BY-CASE BASIS.
0
POST-MODIFICATION TESTING WILL (AS APPROPRIATE)
CONFIRM
THAT THE BASIS FOR SAFETY SIGNIFICANCE AND ORIGINAL INTENT
OF THE MODIFICATION ARE MAINTAINED.
0
VERIFICATION OF
PROPER
PROCESS
CONNECTION/SYSTEM
INTERACTION WILL BE INCORPORATED
INTO APPROPRIATE
TESTING CATEGORY.
A
P
1'
SDV LEVEL TRANSMITTER
ISOLATION VALVES INCIDENT
SUMMARY
1
0
ISOLATION VALVES ON
TWO
NEW SDV LEVEL TRANSMITTERS
WERE LEFT CLOSED
DUE TO
INADEQUATE COMPLETION OF
A
STEP
IN THE MODIFICATION CLOSEOUT
PROCESS
0
IMMEDIATE ACTIONS WERE TAKEN TO RESTORE
THE
INSTRUMENTS TO OPERABILITY AND TO VERIFY OPERABILITY
OF SIMILAR EQUIPMENT
0
SIGNIFICANCE TO PUBLIC HEALTH AND SAFETY WAS
MINIMAL
0
NO OPPORTUNITY PRESENTED
ITSELF FOR EARLIER DETECTION
0
SHORT TERM CORRECTIVE ACTIONS INCLUDED REVIEW OF
399 MODIFICATION PACKAGES
AND WALKDOWN OF ELECTRICAL
PANELS
AND INSTRUMENT RACKS
0
CONSISTENT WITH TASK FORCE
RECOMMENDATIONS, LONG
TERM PROCESS
IMPROVEMENTS ADDRESS THE MAJOR
FACTORS LEADING TO THE VALVE MISPOSITIONING
NORE LEAD TIME WILL BE ALLOTTED FOR
REVIEWS
DEFINITIVE GUIDANCE ON CONDUCT OF
CLOSEOUT REVIEWS
WILL BE PROVIDED TO THE OPERATIONS
ENGINEER
INTERACTION BETWEEN SYSTEM ENGINEER
AND
OPERATIONS ENGINEER WILL BE PROMOTED
SECOND
REVIEW OF
PROCEDURE
CLOSEOUT WILL BE ADDED
POST-MODIFICATION IN SERVICE CHECKS
OF EQUIPMENT
PERFORMANCE WILL BE
INCORPORATED
SDV LEVEL TRANSMITTERS
ISOLATION VALVES INCIDENT
LONG TERM IMPROVEMENTS TO STRENGTHEN THE MODIFICATION PROCESS
0
POST-MODIFICATION TESTING MAY'E SPECIFIED
AS:
COMPONENT INSPECTION
AND TESTING TO VERIFY
EXPECTED
PERFORMANCE
OF INDIVIDUALCOMPONENTS.
EXISTING TEST MATRICES FORM THE BASIS FOR THESE
REQUIREMENTS.
FUNCTIONAL TESTING TO CHECK COMPONENT PERFORMANCE
IN ENERGIZED STATE,
THROUGH THEIR FULL RANGE AND
SCOPE.
OPERATIONAL TESTING TO VERIFY EQUIPMENT AND SYSTEM
PERFORMS
AS EXPECTED
UNDER DYNAMIC CONDITIONS.
INCLUDES REQUIRED SURVEILLANCE TESTS
AND OTHER
SPECIAL TESTS
NEEDED TO VERIFY TECHNICAL
SPECIFICATION OPERABILITY.
IN-SERVICE OBSERVATIONS TO PROVIDE
A "COMMON SENSE"
LINE OF DEFENSE
WHERE APPROPRIATE TO ASSURE
COMPONENT
AND SYSTEM OPERATION IS
AS EXPECTED.
THESE ARE
DETERMINED ON
A CASE-BY-CASE BASIS.
0
POST-MODIFICATION TESTING WILL (AS APPROPRIATE)
CONFIRM
THAT THE BASIS FOR SAFETY SIGNIFICANCE AND ORIGINAL INTENT
Of THE MODIFICATION ARE MAINTAINED.
0
VERIFICATION OF
PROPER
PROCESS
CONNECTION/SYSTEM
INTERACTION WILL BE
INCORPORATED
INTO APPROPRIATE
TESTING CATEGORY,
I