ML17325A103

LER 87-005-00:on 870408,during Cooldown & Depressurization, Pressure/Temp Limits of Tech Spec 3.4.9.1 Exceeded.Caused by Personnel Error.Administrative Controls & Procedural Enhancements incorporated.W/870408 Ltr

ML17325A103
Person / Time
Site:	Cook
Issue date:	04/08/1987
From:	Baker K, Will Smith INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
LER-87-005, LER-87-5, NUDOCS 8705120408
Download: ML17325A103 (8)

Text

REGULATOR% I NFORMATI ON D I STR I BUT I ON S LITEM ( R DS > ~ I ACCESSION NBR: 8705120408 DOC. DATE: 87/04/08 NOTARIZED: NO DOCKET FAC IL: 50-315 Donald C. Cook Nuclear Pouer Plant> Unit ji Indiana 0 05000315 AUTH. NAME AUTHOR AFFILIATION BAKERi K. R. Indiana Zc Michigan Electric Co.

SMITHS'. Q. Indiana 8c Michigan Electric Co.

RECIP. NAME RECIPIENT AFFILIATION SUB JECT: LER 87-005-00: on 870408'uring cooldown 5 depressur izationi pressure/temp limits of Tech Spec 3. 4. 9. 1 exceeded. Caused bg personnel error. Administrative controls Cc erne'n'ts inc orp orated. W/870408 1 tr.

procedural'nhanc DISTRIBUTION CODE: TREED COPIES RECEIVED: LTR I ENCL J SIZE:

TITLE: 50. 73 Licensee Event Report (LER) i Incident Rpti etc.

NOTES:

RECIPIENT COPIES REC IP I ENT COP IES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD3-3 LA 1 1 PD3-3 PD 1 1 WIQQINQTON, D 1 INTERNAL: ACRS MICHELSON 1 1 ACRS MOELLER 1 1 AEOD/DOA 1 1 *EOD/DSP/ROAB 2 2

~

AEOD/DSP/TPAB 1 1 DEDRO 1 NRR/DEST/ADE 0 NRR/DEST/ADS 0 NRR/DEST/CEB 1 1 NRR/DEST/ELB 1 1

, NRR/DEST/ICSB 1 NRR/DEST/MEB 1 NRR/DEST/MTB 1 NRR/DEBT/PSB 1 1 NRR/DEST/RSB 1 1 NRR/DEST/SGB 1 NRR/DLPG/HFB 1 NRR/DLPG/GAB 1 1 NRR/DOEA/EAB 1 1 NRR/DREP/EPB 1 NRR/DREP/R*B 1 NRR/DREP/RPB 2 2 Jg S/ILRB 1 1 NRR/PMAS/PTSB 1 1 REG FIL 02 1 1 RES SPEIST T 1 R FILE 01 1 "1 EXTERNAL: EG1kQ QROHp M 5 5 H ST LOBBY WARD LPDR 1 1 NRC PDR NSIC HARRIS' 1 1 NSIC MAYST G TOTAL NUMBER OF COP I ES REGUI RED: LTTR 42 ENCL 40

NRC Form'366 US. NUCLEAR REGULATORY COMIAISSION (94)3)

APPROVED OMB NO. 31600104 EXPIRES: SI31ISB LICENSEE EVENT REPORT {LER)

FACILITY NAME (I) DOCKET NUMBER l2) PA E 3 D; C. Cook Nuclear Plant, Unit One 0 5 0 0 0 3 ] 5 1 OF 0 4 Technical Specification Reactor Coolant System Pressure/Temperature Limits Exceeded as a Result of Personnel Error EVENT DATE (5) LEA NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (Sl MONTH OAY YEAR YEAR SEQUENTIAL rrol REVSStON MONTH OAY YEAR FACILITYNAMES OOCKFT NUMBER(S)

NUMBER kN NUMBER 0 5 0 0 0 0 4 0 8 8 7 8 7 0 05 00 0 508 87 THIS REPORT IS SUBMITTED PURSUANT T 0 THE REOUIAEMENTS OF 10 CFR ()t (Check ons or mors of ths follorflnpl (11 0 5 0 0 0 OPERATING MODE (9) 60,73( ~ l(2)(lrl 4 20.402(6) 20AOB(c) 73.7)(6)

POWER 20.406( ~ )(1)(B 50.36(c) (I ) 50.73(e) (2)(r) 73.7'I (c)

LEYEL 0 0 0 20.405(el(1)(li) 50.36(c) 12) 60.73(ea2) (ril) OTHER ISpscll) In Ahstrsct trslorr snst In Text, NIIC Form 20A05( ~ )(1)IBI) X 50.73(el(2)(O 50.73(e) 12)(rill)(A) 366AI 20.405( ~ )(1)(lr) 50.7 3(e) (2) (5) 50.73( ~ ) (2) (rlS) (6 l 20A05( ~ Ill)(rl 50.73(e) (2)(ill) 50,73( ~ l(2) (el LICENSEE CONTACT FOR THIS LER (12)

NAME TELFPHONE NUMBER AREA CODE K. R. Baker, 0 erations Su erintendent 61 646 5- 590 1 CAUSE SYSTEM COMPONENT MANUFAC TUAER REPORTABLE ' .';

COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBEO IN THIS REPORT (13)

CAUSE SYSTEM COMPONENT MANUFAC.

TUREA E PORTA 6 LE TO NPRDS

!!ImÃ4)3

(%(%tie: SmNa)I mMR SUPPLEMENTAL REPORT EXPECTED (14) MONTH tEu(YN DAY YEAR EXPECTED SUBMISSION DATE 115)

YES flfyss, complete EXPECTED SUBMISSION DATEI NO ABsTAAOT (Limit to f460 sprees, le.. spproximstsly fifteen slnprsspscs typewritten lined 116)

On April 8, 1987, during a Unit One plant cooldown and depressurization the pressure/temperature limits identified in Technical Specification 3.4.9.1 were exceeded. This event occurred from 1915 hours0.0222 days <br />0.532 hours <br />0.00317 weeks <br />7.286575e-4 months <br /> to 2003 hours0.0232 days <br />0.556 hours <br />0.00331 weeks <br />7.621415e-4 months <br />, a period of 48 minutes while the unit was in Mode 4 (Hot Shutdown).

This event is the result of personnel error on the part of the operating crew involved in this event (both licensed and non-licensed operators).

Upon determining that the pressure/temperature limits had been exceeded the plant was immediately depressurized and restored to within the Technical Specification limits. In addition, Administrative Controls and procedural enhancements have been incorporated to prevent recurrence of this event.

A subsequent evaluation of the pressures and temperatures experienced during this event indicated that these parameters were well within the acceptable operating range for the reactor vessel and therefore the structural integrity of the reactor vessel was not jeopardized.

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~ 0008 870408 PDR ADocH, osooos>>

PDR

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NRC Form 366 ra.art

NRC Form 366A U.S. NUCLEAR REOULATORY COMMISSION

)94)3)

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVED OMB NO. 3150-0104 EXPIRES: 8/31/88 FACILITY NAME (1) DOCKET NUMBER 12) LER NUMBE'R (6) PACE (3)

YEAR <~~~'EOVENTIAL 'C~'EVISION NUMEER '..Xr NUMBER D. C. Cook Nuclear Plant, Unit One 0 5 0 0 0 3 ] 5 8 7 005 0 0 2 OF 0 4 TEXT //P moro 4pooo /4/I///d'or/ Moo ////Ooo/ NRC %%dnrr 35549) (IT) r Conditions Prior to Occurrence Unit One was in Mode 4 (Hot Shutdown) with the Reactor Coolant System pressure and temperature at 1075 psig and 338.5OF respectively.

Descri tion of Event On April 8, 1987, at 1005 hours0.0116 days <br />0.279 hours <br />0.00166 weeks <br />3.824025e-4 months <br /> a plant cooldown and depressurization was commenced. This cooldown was to place the unit in Mode 5 (Cold Shutdown) to facilitate repairs to several Reactor Coolant System leakage sources identified within containment.

At 1830 hours0.0212 days <br />0.508 hours <br />0.00303 weeks <br />6.96315e-4 months <br /> on April 8, 1987, a decision was made to stabilize the plant at a temperature and pressure of approximately 300 F and 1100 psig while remaining within Technical Specification limits so that the repairs could be accomplished without causing undue flexing of the Reactor Coolant Pump (EIIS-AB-P) seal o-rings (EIIS-SEAI).

This information was relayed to the Unit One operating crew,'ho inturn stated that they could forsee no difficulty in reaching these parameters, based on a review of the Plant Safety System Display System (PSSD)

(EIIS-CPU). Therefore at approximately 1845 hours0.0214 days <br />0.513 hours <br />0.00305 weeks <br />7.020225e-4 months <br />, pressure was allowed to slowly increase to achieve the requested 1100 psig pressure; while continuing the cooldown.

During all cooldowns and heatups evolutions, the Reactor Coolant System pressure and temperature parameters are logged and plotted against the Technical Specification temperature/pressure limit curve every fifteen minutes. This function was assigned to a member of the Control Room crew.

At approximately 1910 hours0.0221 days <br />0.531 hours <br />0.00316 weeks <br />7.26755e-4 months <br /> on April 8, 1987, this individual began taking the required shiftly surveillance readings. Due to the additional work load and the fact that the cooldown trend was good, he stopped plotting the parameters against the pressure/temperature curve, however he continued to log these parameters at 15 minute intervals. At 2000 hours0.0231 days <br />0.556 hours <br />0.00331 weeks <br />7.61e-4 months <br /> on April 8, 1987, he resumed plotting these parameters starting 'with the first one not plotted at 1915 hours0.0222 days <br />0.532 hours <br />0.00317 weeks <br />7.286575e-4 months <br />. At this time he realized that the pressure and temperature readings had exceeded the Technical Specification limits and immediately notified the Unit Supervisor. The Unit Supervisor immediately ordered the depressurization of the Reactor Coolant System. The Reactor Coolant System was subsequently restored to within the Technical Specification limits at 2003 hours0.0232 days <br />0.556 hours <br />0.00331 weeks <br />7.621415e-4 months <br /> on April 8, 1987. The largest disparity between actual conditions and the Technical Specification limits was at 306 F and 1160 psig compared to the Technical Specification limit of 306 F and 980 psig.

The Reactor Coolant System pressure and temperature had exeeded the Technical Specification limits for a period on approximately 48 minutes from 1915 hours0.0222 days <br />0.532 hours <br />0.00317 weeks <br />7.286575e-4 months <br /> to 2003 hours0.0232 days <br />0.556 hours <br />0.00331 weeks <br />7.621415e-4 months <br /> on April 8, 1987.

NRC FORM 666A *U.S.OPO:1986 D624 538/455 rO R'll I

NRC Form 356A US. NUCLEAR REGULATORY COMMISSION (94)3)

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVED OMB NO. 3150M(04 EXPIRES: 8/31/88 FACILITY NAME ill DOCKET NUMBER (2) LER NUMBER (8) PAGE (3)

YEAR pj SEGUENTIAL NVMBER jar REVISION Rr'VMBER D. C. Cook Nuclear Plant, Unit One o s o o o3 15 8 7 0 05 87 0 3 QF 0 4 TEXT /Prr>>ro g>>co /e r/O/ro/L oso ////Oo>>/ H/IC Form 388AB/ (IT)

There were no inoperative systems, structures or components that contributed to this event.

Cause of Event This event was the result of personnel error on the part of the operating crew. The Shift Supervisor, Unit Supervisor and Reactor Operator (Utility-licensed operator) failed to verify that the requested pressure and temperature parameters were acheivable by utilizing the Technical Specification pressure/temperature limit curve. Instead they relied upon a Plant Safety System Display terminal display (PSSD)(EIIS-CPU) to insure that the Technical Specification limits would be maintained. This display was subsequently determined to be non-conservative with respect to the Technical Specification parameters.

Secondly the Auxiliary Equipment Operator (utility non-licensed operator) stopped plotting the pressure temperature parameters for a period of approximately 45 minutes. This resulted from the increased work load created by the performance of shiftly surveillance.

that both the Unit Supervisor and Reactor Operator were confident that It should be noted the Auxiliary Equipment Operator was logging and plotting the readings for they had noted him taking these parameters during this time frame.

Anal sis of Event This event was considered reportable under the criteria set forth in 10 CFR 50.73(a)(2)(i).

The RCS pressure and temperature conditions, noted below, were outside the acceptable region of the Technical Specification Cooldown Curve (Figure 3.4-3) which is valid for up to 12 EFPYs of operation.

TIME PRESSURE (PSI) TEMPERATURE F 1915 1110 320.6 1930 1120 316.3 1945 1150 311.0 2000 1160 306.0 An evaluation to determine Reactor Coolant System integrity for continued operation has been performed. A new cooldown curve which reflects the actual conditions existing at the time of occurrence was developed by Southwest Research Institute at our request. The basis of the curve was established using Regulatory Guide 1.99 Rev. 1, a cooldown rate of 20 F/hr and eight EFPYs of reactor operation.

NRC FORM SBBA *U.B.GPO:19864.62E 538/455 IOAI11

(943)

'ICENSEE NRC Form 366A EVENT REPORT (LER) TEXT CONTINUATION V.S. NUCLEAR REGULATORY COMMISSION APPROVED OMB NO, 3150-OICA EXPIRES: 8/31/88 FACILITYNAME (I) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR SEOVENTIAL REVISION h5 NUMBER NUMBER

.D. C. Cook Nuclear Plant, Unit One 0 s o 0 0 3 1 5 8 7 0 5 000 4 oF 0 4 TEXT /4 mrss Rrscs /r nOulat, Irss ~ //Vdorr/ HRC Forrrr 36//AB/ (17)

Review of the curve shows that the pressures and temperatures referenced above were will within the acceptable operating range for the reactor vessel, and therefore the structural integrity of the reactor vessel was not jeopardized.

Based upon the evaluation, it is concluded that this event did not pose a threat to the health and safety of the public.

Corrective Action

1) The pressure and temperature limits were immediately returned to their Technical Specification required parameters.

2) An operations memo has been written which requires that evolutions such as the cooldown/depressurization evolution are to be controlled by one operator who is specifically assigned to that task alone.

3) The PSSD computer display has been corrected to accurately reflect the proper temperature and pressure limits of Technical Specification 3.4.9.1. This has been accomplished on both units.

The graphs of both the heatup and cooldown curves have been redrawn to make them easier to use and more distinct with respect to the required Technical Specification limits.

Failed Com onents Identification None Previous Similar Events RO-50-315/76-18 NRC FORM 36SA *U.S.GPO:1988.DB24 538/455 IMt31

eHaen leatrla INDIANA 8I NICHIGAN EI.ECTRIC CONPANY DONALD C. COOK NUCLEAR PLANT P.O. Box 458, Brldgeman, Mf 49106 Telephone (616) 465 5901 May 8, 1987 United States Nuclear Regulatory Commission Document Control Desk Washington, D.C. 20555 Operating License DPR-58 Docket No. 50-315 Document Control Manager:

In accordance with the criteria established by 10 CFR 50.73 entitled Licensee Event Re ortin S stem, the following report is being submitted:

87-005-0 Sincerely,

'dP!PC'I&A' /.,":

G. Smith, Jr.

Plant Manager

/afh Attachment cc1 John E. Dolan A. B. Davis, Region ITI M. P. Alexich R. F. Kroeger H. B. Brugger R. W. Jurgensen NRC Resident Tnspector R. C. Callen G. Charnoff, Esq.

D. Hahn INPO D. Wigginton, NRC PNSRC A. A. Blind Dottie Sherman, ANI Library File

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