ML17291A314

LER 94-014-00:on 940706,ESF Actuation Occurred Due to Lineup Error.Caused by Noncompliance W/Testing Procedures. Improper Lineup Was corrected.W/940805 Ltr

ML17291A314
Person / Time
Site:	Columbia
Issue date:	08/05/1994
From:	Hugo B, Parrish J WASHINGTON PUBLIC POWER SUPPLY SYSTEM
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
GO2-94-184, LER-94-014, LER-94-14, NUDOCS 9408110241
Download: ML17291A314 (6)

Text

(ACCELERATED RIDS PROCESSIN~

REGULARLY INFORMATION DISTRIBUTI YSTEM (RIDS)

ACCES'iION NBR:9408110241 DOC.DM'E: 94/08/05 NOTARIZED: NO DOCKET FACIL:50-3~7 WPPSS Nuclear Project, Unit 2, Washington Public Powe 05000397 AUTH. INANE AUTHOR AFFILIATION HUGO,B.R. Washington Public Power Supply System PARRISH,J.V. Washington Public Power Supply System RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 94-014-00:on 940706,ESE'ctuation occurred due to lineup error. Caused by noncompliance w/testing procedures.

Improper lineup was corrected.W/940805 ltr.

DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL SIZE:

TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.

NOTES:

RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PDIV-3 PD 1 1 CLIFFORD,J 1 1 INTERNAL: ACRS 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DSP 2 2 NRR/DE/EELB 1 1 NRR/DE/EMEB 1 1 NRR/DORS/OEAB 1 1 NRR/DRCH/HHFB 1 1 NRR/DRCH/HICB 1 1 NRR/DRCH/HOLB 1 1 NRR/DRSS/PRPB 2 2 NRR/DSSA/SPLB 1 1 NRR/DSSA/SRXB 1 1 NRR/PMAS/IRCB-E 1 1 Qg 02 1 1 RES/DSIR/EIB 1 1 RGN4 FILE 01 1 1 EXTERNAL 'G&G BRYCE g J H ~ 2 2 L ST LOBBY WARD 1 1 NRC PDR 1 1 NSIC MURPHY,G.A 1 1 NSIC POOREgW. 1 1 NUDOCS FULL TXT 1 1 NOTE TO ALL"RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE IVASTE! CONTACT THE DOCUMENT CONTROL DESK. ROOM Pl-37 (EAT. 504-2083 ) TO ELIS!!NATE YOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON"I'LED!

FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 27 ENCL 27

WASHINGTON PUBLIC POWER SUPPLY SYSTEM P.O. Box 968 ~ 3000 George Washington Way ~ Richland, Washington 99352-0968 ~ (509) 372-5000 August 5, 1994 G02-94-1 84 Docket No. 50-397 Document Control Desk U.S. Nuclear Regulatory Commission Washington, D.C. 20555

Subject:

NUCLEAR PLANT WNP-2, OPERATING LICENSE NPF-21, LICENSEE EVENT REPORT NO.94-014, REVISION 0 Transmitted herewith is Licensee Event Report No.94-014 for the WNP-2 Plant. This report is submitted in response to the reporting requireinents of 10CFR50.73 and discusses the items of reportability, corrective action taken, and action taken to preclude recurrence.

Should you have any questions or desire additional information, please call me or D.A. Swank at (509) 377-4563.

Sincerely,

. V. Parrish (Mail Drop 1023)

Assistant Managing Director, Operations JVP/BRH Enclosure CC: LJ Callan, NRC-RIV KE Perkins, Jr., NRC-RIV, Walnut Creek Field Office NS Reynolds, Winston & Strawn NRC Sr. Resident Inspector (Mail Drop 927N, 2 Copies)

INPO Records Center - Atlanta, GA DL Williams, BPA (Mail Drop 399) 9408110241 940805 PDR ADOCK 05000397 S PDR

LICENSEE EVENT REPORT (LE FACSITY NAME Ill DOCKKT IRIMSKR ITI ~ ACK rsl Washington Nuclear Plant Unit 2 0 5 0 0 0 3 9 7 1 oF 4 Engineered Safety Feature Actuation Due to Test Lineup Error Caused by Noncompliance with Testing Procedure RftORT DATK Ill OTIrtn FACLIINS BNOLYED ISI MONM DAY SKOVKNllAL DAY YEAR FACLITY NAMES DOCKET IANISERI SI NVMSKR N/A 0 5 0 0 0 07 06 94 94 0 1 4 0 0 08 05 94 0 5 0 0 0 OPKRATNO TIBS RtPORT IS SVBMIITEO PVRSVANT TO TNE RKOVFIEMKNTS OF 10 CFIB Oil MODE lel 4 I 20.402(b) I 20.405c I XI 50.73(s)(2)(iv) I I 73.71(b)

I 20.405(s)(1)(i) I 50.36(c)(l) I 50.73(s)(2)(v) I 73.71(c)

POWER LEVEL IlCl I 20.405(s)(1)(ii) I 50.36(c)(2) I 60.73(a)(2)(vii) I OTHER (Specify in Abstract below and in Text, NAC Form 366A)

P P P I 20.405(a)(l)(iii) I 60.73(s)(2)(i) I 60.73(a)(2)(viii)A I 20.405(s)(1)(iv) I 50.73(s)(2)(ii) I 50.73(s)(2)(viii)B I 20.405(s)(1)(v) ( 50.73(s)(2)(ir<) I 50.73(s](2)(x)

UCKNSKK CONTACT fOR Tres LKR I ITI Bruce R. Hugo, Compliance Engineer AREA CODE 509 377-8593 COMtLKTK ONE LMK FOR KACN COMtONKNT fALVRKDESCRSIKD al Tres RttORT tlsl SYSTEM RIPORTABLE SYSTEM RIPORTABLE TO IPROS TO M'ROS SINPLEMKNTAL RttORT EXFKCTtD ll I

~ EXPECTED MONTH YEAR SVBMISS(ON YES (i( yes, complete EXPECTED SUBMISSION DATE) I XI No DATE (16]

ABSTRACT (ISI At 1236 hours0.0143 days <br />0.343 hours <br />0.00204 weeks <br />4.70298e-4 months <br /> on July 6, 1994, Instrumentation and Control (I&C) technicians were back filling instrument lines to support excess flow check valve testing. Due to a lineup error, the differential pressure sensed by in-service reactor vessel level detectors was increased creating an invalid low level indication which caused several automatic actions including a low pressure core spray system actuation and injection. The control room operator secured the injection after verifying no actual low level condition existed. The cause of the event was the failure of the technicians to follow the back fill procedure.

technicians, discussing the event with the I&C shop, and developing and Corrective actions include counseling the delivering further training to I&C technicians. This event had negligible safety significance since plant safety systems responded as designed, no actual low level condition existed, and the stresses induced by the injection were small due to the small differential temperatures and pressures involved.

LICEN EVENT REPORT (LER) TEXT C NUATION j".,j j $ COVEMIAL f46: IIOIISON NVMIN MVMeN Washington Nuclear Plant Unit 2 0 5 0 0 0 3 9 7 94 014 0 0 oP 4 TEXT (17)

Event

Description:

At 1236 hours0.0143 days <br />0.343 hours <br />0.00204 weeks <br />4.70298e-4 months <br /> on July 6, 1994, with WNP-2 in Operational Condition 4 at 0 percent power, Instrumentation and Control (I&C) technicians were back filling instrument lines to support excess flow check valve [V] testing. Due to a lineup error, the differential pressure sensed by in-service reactor vessel [AD, RCT] level detectors [LI]

was increased creating an invalid low level indication. This caused the following automatic actions: reactor pressure vessel low level half scram, low pressure core spray (LPCS) system [BM] actuation, low pressure coolant injection (LPCI) [BO] 'A'ystem actuation signal, and emergency diesel generator [EK, DG] 1 automatic start.

Due to the residual heat removal (RHR) system being in a shutdown cooling lineup, no LPCI injection to the reactor pressure vessel (RPV) occurred via the RHR system. Injection into the RPV from the suppression chamber did occur due to the LPCS actuation. This injection, which increased RPV level by 20 inches, was secured by the control room operator after he verified using two independent indications that no actual low level condition existed.

By 1327 hours0.0154 days <br />0.369 hours <br />0.00219 weeks <br />5.049235e-4 months <br /> on July 6, 1994, the component actuations and trips resulting from the invalid low level indication had been reset.

Immediate Corrective Action:

The improper lineup that caused the invalid level signal was corrected.

Excess flow check valve testing was stopped pending an investigation of the cause of this event.

Further Evaluation:

This event is reported per 10 CFR 50.73(a)(2)(iv) as an actuation of an Engineered Safety Feature. This event was also reported via the Emergency Notification System at 1354 hours0.0157 days <br />0.376 hours <br />0.00224 weeks <br />5.15197e-4 months <br /> on July 6, 1994.

There were no structures, systems, or components that. were inoperable at the start of the event that contributed to the event.

Root Cause:

The cause of the improper lineup was the failure of the technicians to follow the back filling procedure. The technicians had previously completed a similar back filling operation successfully, and were performing this operation with the procedure in hand up to the point where an attachment identified the back connection point and valves to be operated. The fill technicians pump

LICEN EVENT REPORT (LER) TEXT C NUATION SMLKNTIAL;;c,: REVIQON NVMROI NVMBOI Washington Nuclear Plant Unit 2 05 0 0 0 3 9 7 94 014 0 0 3 o" 4 TEXT (17) incorrectly assumed that this attachment was similar to the one used previously. They then attempted to perform the rest of the operation based on their knowledge of the previous back operations and by tracing piping runs to identify the valves to be fill operated and back fill pump connection point. This resulted in an incorrect lineup to in-service level instruments when they identified the wrong isolation valve.

Further Corrective Actions:

An Incident Review Board was convened with the technicians involved as participants. Extensive discussions were held with the crew involved and the oncoming crew regarding the inappropriate actions taken and the lessons learned from the event.

The technicians were counseled by the Maintenance Production Manager on the importance of strict procedural compliance. The individuals acknowledged their responsibility to meet these requirements.

The Maintenance Production Manager also met with I&C shop personnel to review this event and its causes. The meeting emphasized strict procedural adherence and the importance of self-checking for component identification.

Attention to Detail and Self-checking training is being developed for I&C technicians. This training is scheduled for completion by October 31, 1994.

Safety Significance:

This event had negligible safety significance. Plant safety systems responded as designed to the indicated low RPV level, and no actual low level condition existed. Plant operators secured the unneeded RPV injection after determining that the initiating signal was invalid.

The LPCS system design usage factor assumes 10 occurrences of 40 degree F fluid injection into a 470 degree F, 500 psig RPV. The actual injection temperature was 70 degree F with the RPV at 130 degree F and 106 psig, producing significantly less stress than assumed in the design usage factor calculation.

LICEN EVENT REPORT (LER) TEXT C NUATION YfAR Sf GVOITlll RtVISOH NUM80l NVMBN Washington Nuclear Plant Unit 2 05 0 0 0 3 9 7 94 014 0 0 4 4 TEXT (17)

Previous Similar Events:

LER 93-025 documents an event in which a procedural deficiency caused a Nuclear Steam Supply Shutoff System [JM] isolation during a surveillance test. Corrective actions included changing the procedure and upgrading other Electrical shop surveillance procedures with the same weakness.

LER 89-025 documents three Engineered Safeguards Feature actuations during excess flow check valve testing. Corrective actions included specifying pressure control bands and valve numbers in the test procedure, and caution tagging out of service instruments.

These corrective actions would not be expected to have prevented the event described in this report.