ML17223B373

LER 91-008-00:on 911110 & 11,containment Integrity Not in Compliance W/Tech Specs During Core Alterations.Caused by Personnel Failing to Follow Approved Procedure.Containment Integrity Reestablished & Personnel counseled.W/911209 Ltr

ML17223B373
Person / Time
Site:	Saint Lucie
Issue date:	12/09/1991
From:	Lauver C, Sager D FLORIDA POWER & LIGHT CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
L-91-331, LER-91-008-01, LER-91-8-1, NUDOCS 9112170467
Download: ML17223B373 (6)

Text

ACCELERATED DISIBUTION DEMONS~ION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR: 9112170467 DOC. DATE: 91/12/09 NOTARIZED: NO DOCKET FACIL:50-335 St. Lucie Plant, Unit 1, Florida Power & Light Co. 05000335 AUTH. NAME AUTHOR AFFILIATION LAUVER,C. Florida Power & Light Co.

SAGER,D.A. Florida Power & Light Co.

RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 91-008-00:on 911110 & 11,containment integrity not in

- compliance w/Tech Specs during core alterations. Caused by personnel failing to follow approved procedure.Contai,nment D integrity reestablished & personnel counseled.W/911209 DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR i ENCL TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.

NOTES l SIZE:

ltr.

5 RECIPIENT COPIES RECIPIENT COPIES D ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-2 LA 1 1 PD2-2 PD 1. 1 D

NORRIS,J 1 1 INTERNAL: ACNW 2 2 ACRS 2 2 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DS P 2 2 NRR/DET/ECMB 9H 1 1 NRR/DET/EMEB 7E 1 1 NRR/DLPQ/LHFB10 1 1 NRR/DLPQ/LPEB10 1 1 NRR/DOEA/OEAB 1 1=-

NRR/DREP/PRPB1 1 2 2 NRR/DST/SELB SD 1 1 NRR/DST/SICBSH3 1 1 RRtBPPp48 LBSD1 1 1 NRR/DST/SRXB SE 1 1 E 02 1 1 RES/DSIR/EIB 1 1 RGN2 FILE 01 1 1 EXTERNAL: EG&G BRYCE,J.H 3 3 L ST LOBBY WARD 1 1 NRC PDR 1 1 NSIC MURPHY,G.A 1 ' 1 NSIC POOREiW 1 1 NUDOCS FULL TXT 1 D

D D

NOTE TO ALL "RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE iVASTEI CONTACT THE DOCUMENT CONTROL DESK, ROOil P 1-3 'EXT. 20079) TO ELlb IINATE YOUR NAiIE FROM DISTRIBUTION LISTS FOR DOCUiIENTS YOU DON'T NEED!

FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 33 ENCL 33

I I ~

P.O. Box 128, Ft. Pierce, FL 34954-0128 December 9, 1991 L-91-331 10 CFR 50.73 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555 Gentlemen:

Re: St. Lucie Unit 1 Docket No. 50-335 Reportable Event: 91-08 Date of Event: November 10, 1991 Core Alterations Performed With Containment Integrity Not in Compliance with Technical S ecifications due to Personnel Error The attached Licensee Event Report is being submitted pursuant to the requirements of 10 CFR 50.73 to provide notification of the subject event.

Very truly yours, D. A. ager Vice P esident St. cie Plant DAS/GRM/kw Attachment cc: Stewart D. Ebneter, Regional Administrator, USNRC Region Senior Resident Inspector, USNRC, St. Lucie Plant II DAS/PSL 5581-91 y (s~ Io t 8 D;-,

an fPL Group company

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S1 50 0105A Of ICE OF WAAOEICNTAMISCOOET. WAIIINCTOfl OC 505CI FAG iLITYNAME (1) DOCKET NUMBER (2) PAGE 3 St. Lucie Unit 1 05000'3351 0 0 4

'~ (4) Core Alterations Performed With Containment Integrity Not in Compliance With Technical Specifications due to Personnel Error EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED(8)

DAY YEAR YEAR . S IAL KR DAY YEAR FACILITYNAMES DOCKET NUMBER(S)

N/A 05 000 1 0 9 1 9 1 0 0 8 0 '0 1 2 0 9 9 1 N/A 05000 THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR:

OPERATING Check one or more of the followin (11)

MODE (9) 20.402(b) 20,405(c) 50.73(a)(2)(iv) 73.71(b)

POWER 20.405(a)(1)(i) 50.36(c)(1) 50.73(a)(2)(v) 73.71(c)

LEVEL (10) 0 0 0 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(vii) OTHER (Specify in Abstract 20.405(a)(1)(iii) X 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) below and in Text 20.405(a)(1)(iv) 50.73(a)(2)(viii)(B) NRC Form 366A) 50.73(a)(2) (ii) 20.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x)

LICENSEE CONTACT FOR THIS LER 12 NAME TELEP ONE NUMBER Catherine Lauver, Shift Technical Advisor 4 0 7 465 -3550 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT 13 CAUSE SYSTEM COMPONENT TURER REPORTABLE TO NPRDS . 'AUSE SYSTEM COMPONENT MANUFAC- TURER REPORTABLE TO NPRDS I I I SUPPLEMENTAL REPORT EXPECTED 14 EXPFCTED MONTH DAY YEAR SUBMISSION YES (lfyes, complete EXPECTED SUBMISSION DATE) DATE (15)

ABSTRACT (Limit to 1400 spaces. i.e. approximately fifteen single-space typewritten lines) (16)

Between 1430 on November 10, 1991, and 0210 on November 11, containment integrity was not in compliance with Technical Specifications. St. Lucie Unit 1 was in Mode 6, Refueling, and fuel assemblies were being moved in the reactor core. Containment integrity is required for core alterations.

The cause of the incomplete containment integrity was personnel error by Mechanical Maintenance department personnel for failure to follow an approved procedure. Plant procedure requires that Nuclear Plant Work Orders be approved by the Nuclear Plant Supervisor prior to starting work. Without obtaining this prior approval, maintenance workers removed a relief valve on one side of a containment penetration while a drain valve was open on the other side. This created a direct flow path from containment to the Reactor Auxiliary Building.

Permission to start work was requested after the relief valve had been removed by the previous shift.

Corrective actions were: containment integrity was re-established, the responsible maintenance supervisor was counseled on the need for strict adherence to procedures, and the event will be incorporated into Maintenance journeyman training. This event was also discussed with all maintenance crews and the importance of receiving proper authorization prior to beginning work on plant systems was stressed. An INPO Human Performance Enhancement review of this event was also performed.

FPL Facsimile of NRC Form 366 (6.89)

FPL FscsIITT'Is of .S. NUCLEAR REGULATORY COMMISSION APPFETIEOOIO VlSIIOCTOI NRC Form 666 ESWRES 40000 (6 89)

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YEAR EQUENTIAL REVISION St. Lucie Unit 1 NUMBER NUMBER 0500033591 0 0 8 0 0 0 2 0 4 TEXT (lfmore spaceis required, use additional NRC Form 366A's) (17)

IP Unit 1 was in Mode 6, Refueling. Containment integrity was established as required for fuel movement which started November 7, 1991.

Nuclear Plant Work Order (NPWO) 3836 was written to remove a one-inch Component Cooling Water (CCW) (EIIS:CC) safety relief valve, SR-14-8B, to implement a plant modification. The NPWO was planned November 4, 1991. The NPWO package contained instructions for work performed in the maintenance shop on the new valve and for work performed in the Reactor Containment Building to remove the old valve. Work was started in the maintenance shop on November 7. On November 9, clearance 1-11-113 was authorized and hung to support removal of SR-14-BB. The clearance closed SB-14314 and SB-14320, inlet and outlet CCW isolation valves for the 1B Containment Cooler (HVS-1 B)(EIIS:BK), and opened drain valve V-14319 to remove water from the system. The drain valve is located outside containment between Penetration 21 and isolation valve SB-14320.

V-14319.

SB-14320 SR-1 4-BB SB-14314 22 HVS-1B Reactor Auxiliary Bldg Containment On November 10, 1991, fuel assemblies were being moved in the reactor core. A utility maintenance worker was assigned to work NPWO 3836. He entered containment and removed SR-14-BB at about 1430. Since shop preparation work for the NPWO had been in progress for a few days, the worker mistakenly believed all approvals had been previously acquired. The foreman had signed onto the clearance earlier but had not brought the NPWO to the Control Room to obtain permission to start work. Administrative Procedure 0010432, "Nuclear Plant Work Orders," states that the approval of the Nuclear Plant Supervisor (NPS), Assistant Nuclear Plant Supervisor (ANPS),

or Nuclear Watch Engineer (NWE) is required prior to starting work. The NPWO was turned over to the next shift who brought it to the Control Room for approval. The ANPS reviewed the NPWO and did not approve it, realizing that the removal of the relief valve with the drain valve open should not be permitted. However, he was informed that the valve had already been removed. The ANPS then directed a nonlicensed operator to close the drain valve. Complete containment'integrity was restored at 0210 on November 11, 1991.

A review of the Final Fuel Transfer Record indicates eleven fuel moves were performed in the reactor core between 1400 and 1808 on November 10, 1991.

FPL Facsimile of NRC Form 366 (6.89)

FPL FacsIITT'Io OI .S. NUCLEAR REGULATORY COMMISSION APPROYTO OAR NO SI 5005 0l hRC Form 366 C TPlfRS: lolll5 LICENSEE EVENT REPORT(LER) . TSTAIAT50 OPIOQI PCS IRSPORTS TO CCAP5Y WITN 550$ PPYYNAATICNCCUSCTION WCINIm500 HIS fCRWARO CONNfM0 IROAROWO OJITN TSRNATS TO TIC RT COINS TEXT CONTINUATtON Il ANT IRPORT 0 NANAOTlC M SRANCN (P ICPA S NUCISNI IROIAATCRYONNOOOOKI f

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YEAR EQUENTIAL REVISION St. Lucie Unit 1 NUMBER NUMBER 0 500 0335 9 1 0 0 8 0 0 0 3 0 0 4

.TEXT (Ifmore'siMceis required, use additional NRC Form 366A's) (17)

The root cause of the event is personnel error by utility Mechanical Maintenance department personnel. The error was contrary to approved plant procedure, which requires approval from the NPS, ANPS, or NWE prior to starting work. There are no unusual characteristics of the work location that directly contributed to the error.

As a contributing factor, clearance controls were identified as a weakness. This clearance was written and hung while containment integrity existed and was required for refueling operations.

While the clearance itself did not breach containment integrity, it involved valves known to be containment boundaries and did not provide specific guidance stating that the drain valve needed to be closed before the relief valve was removed.

Technical Specification 3.9.4, "Refueling Operations: Containment Penetrations,N requires each penetration to be closed during core alterations. The removal of SR-14-BB with open drain valve V-14319 created a flow path across Penetration 21 from about 1430 on November 10, 1991, to 0210 on November 11, 1991. Eleven fuel moves were performed in the reactor core during this time interval. This event is reportable per 10 CFR 50.73.a.2.i.B, any condition or operation prohibited by Technical Specfications. Containment integrity is required during fuel movement to restrict radioactive material released from a fuel element rupture. No failures of fuel elements occurred during the time interval containment integrity was breached. In the event of a fuel element rupture, the amount of radioactive material released through a 1R line would be minimal. This is due to the lack of a pressurization potential associated with a refueling accident. Any material released would enter the Reactor Auxiliary Building, not the environment. Therefore, the health and safety of the public was not at risk during this event.

FPL Facsimile of NRC Form 366 (6.89)

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FPI. Facsrrrirs of S. NUCI.EAR REGUlATORY COMMISSION APPRGYEOCAEINEA 51500105 NRC Form 356 ETPNRa 50005 STRIATE 0 500TOEN Pf R RESPONSE TO ~YWlTN TITS 00GRNATTCN CClffCTION (6 89)

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YEAR EQUENTIAL REVISION St. Lucie Unit 1 NUMBER NUMBER 0 500 0335 9 1 0 0 8 0 0 0 4 0 4 TEXT (Ifmore spaceis reguiredf use additional NRC Form 366A's) (17)

(1) Operations closed the drain valve and restored containment integrity.

(2) The responsible foreman was counseled on his failure to follow procedures, i.e., failure to obtain the proper authorization prior to beginning work on plant systems. The event was also discussed with all Mechanical Maintenance crews.

(3) A task team, lead by Operations, is reviewing the clearance procedure. Any necessary changes to the procedure related to this event will be made.

(4) The event will be included as part of In House/Industry Events training, performed every quarter with journeymen, during the first quarter of 1992.

(5)

The Training Department will incorporate this event into the Licensed Operator Requalification Program.

(6) An INPO Human Performance Enhancement System evaluation of this event was performed .

and its conclusions agree with this report.

N There are no component failures associated with this event.,

The most recent prev'ious similar event was submitted in LER 335-81-044. In this event, holes were drilled in piping between the Main Steam Isolation Valve and containment, causing a breach of containment integrity, while fuel moves were being performed.

FPL Facsimile of NRC Form 366 (6-69)