ML17325A882

LER 88-007-00:on 880613,use of Incorrect ISI Ref Values Resulted in Literal Violation of Tech Spec 3.5.2.Event Originally Reported on 871224.Caused by Personnel Error. ISI Documents revised.W/880714 Ltr

ML17325A882
Person / Time
Site:	Cook
Issue date:	07/14/1988
From:	Postlewait T, Will Smith INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
LER-88-007, LER-88-7, NUDOCS 8807250418
Download: ML17325A882 (7)

Text

AC CELE RATED DISTMBUTION DEMON STRA.T10N SYSTEM INFORlLZTZON DZSTRIBUTZOIYSTEN (RIDE)

REGULARLY ACCESSION NBR:8807250418 DOC.DATE: 88/07/14 NOTARIZED: NO DOCKET 4 FACIL:50-316 Donald C. Cook Nuclear Power Plant, Unit 2, Indiana & 05000316 AUTH. NAME AUTHOR AFFILIATION POSTLEWAIT,T.K. Indiana Michigan Power Co.

SMITH,W.G. Indiana Michigan Power Co.

RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 88-007-00:on 871224,use of incorrect ISI ref valves.

Caused by personnel error.

W/8 DISTRIBUTION CODE: IE22D COPIES RECEIVED:LTR ( ENCL J SIZE:

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

NOTES:

RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL h PD3-1 LA 1 1 PD3-1 PD 1 1 STANGFJ 1 1 INTERNAL. ACRS MICHELSON 1 1 ACRS MOELLER 2 2 AEOD/DOA 1 1 AEOD/DSP/NAS 1 1 AEOD/DSP/ROAB 2 2 AEOD/DSP/TPAB 1" 1 ARM/DCTS/DAB 1 1 DEDRO 1 1 NRR/DEST/ADS 7E 1 0 NRR/DEST/CEB 8H 1 1 NRR/DEST/ESB 8D 1 1 NRR/DEST/ICSB 7 1 1 NRR/DEST/MEB 9H 1 1 NRR/DEST/MTB 9H 1 1 NRR/DEST/PSB 8D 1 1 NRR/DEST/RSB 8E 1 1 NRR/DLPQ/HFB 10 NRR/DEST/SGB NRR/DLPQ/QAB NRR/DREP/RAB 8D 10 10 1

1 1

1 1

1 NRR/DOEA/EAB NRR/DREP/RPB ll 10 1

1 2

1 1

2 NRR DRIS/SIB 9A 1 NUDOCS-ABSTRACT 1 1 02 1 1 RES TELFORDFJ 1 1 RES DSIR DEPY 1 1 RES/DSIR/EIB 1 1 RGN3 FILE 01 1 1 EXTERNAL: EGGG WILLIAMSFS 4 4 FORD BLDG HOY,A 1 1 H ST LOBBY WARD 1 1 LPDR 1 1 NRC PDR 1 1 NSIC HARRZSFJ 1 1 9 NSIC MAYSFG 1 1 S

h D

S TOTAL NUMBER OF COPIES REQUIRED: LTTR 45 ENCL 44

NRC Form 388 U.S. NUCLEAR REOULATORY COMMISSION f

ISe)3)

APPROVED OM 5 NO. 31504)Os LICENSEE EVENT REPORT HLER) EXPIRES: SI31ISS FACIUTY NAME (II DOCKET NUMBER (2) PA E 3 D. C. Cook Nuclear Plant - Unit 2 o s o o o 3 1 i OF0 3 Use of Incorrect ISI Reference Values due to Personnel Error Results in Literal Violation of Technical S ecification Action Statement EVENT DATE(5) LER NUMBER (8) REPORT DATE (7) OTHER FACILITIES INVOLVED (8)

MONTH OAY YEAR YEAR SEOVSNTIAL rrcvrcloN MONTH OAY YEAR FACILITYNAMFS DOCKET NUMBER(SI c:N? NVMSEII NUMBER D. C. Cook Unit 1 o s o o o3 15 12 24 8 788 0 0 7 0 0 0 7 1 4 8 8 0 5 0 0 0 OPERATINO THIS REPORT IS SUBMITTED PURSUANT TO THE REOUIREMENTS OF 10 CF R gr ICneck one or more of tne folloylnp) (ll MODE (8) 20A02(bl 73.71(8) 20A05(el 50.73(el(2)(N)

POWER 20A05( ~ l(1)(I) 50.38(c) (1) 50.73(e l(2)(vl 73.71(cl LEYEI.

0 8 0 20A05(e) (I) (8) 50.38(c) (2) 50,73(e)(2) (rS) OTHER ISpecify in AOrtrect trelow enrf In Text, HRC Form 20A05(e l(1) (IIO 50.73(s I (2)(ll 50,73(sl(2)(HBI (Al 388AI 20A05(e l(1)(lv) 50.73(s) (2) (II) 50,73(e I (2)(rIIII (8 I 20A05(s) (1)(vl 50.73(e) (2)(III) 50.73(el(2)(xl LICENSEE CONTACT FOR THIS LER (12)

NAME TELEPHONE NUMBER T. K. Postlewait- AREA CODE Technical Engineering Superintendent 6 164 65- 59 01 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)

CAUSE SYSTEM COMPONENT MANUFAC.

TURER EPORTABLE .

TO NPRDS S Ne'p, CAUSE SYSTEM COMPONENT MANVFAC.

TURER EPORTABLE TO NPRDS RFEe ImL%

SVPPLEMENTAL REPORT EXPECTED (lel MONTH OAY YEAR EXPECTED SU 8 MISSION DATE H5)

YES Ilfyet, complere EXPECTED SVSMISSIOII DA TEI X NO ABSTRACT ILimlt to 1400 rpecet, I e., epproxlmeNly fifteen tlnprecpece typerrrftten liner) (18) it v

On June 13, 1988, was reported that incorrect ISI reference differential pressure (dP) values were being used for the Safety In)ection (SI) Pumps.

Due to 'cognitive personnel error new reference values were not established after completion of a Design Change. Data review identified two occasions when the ISI allowable deviation for high dP had been exceeded. Contrary to ASME XI 1WP-3112, the pumps were not declared inoperable and retested.

On July 13, 1988, it was determined that Plant operation had not been in, literal compliance with Technical Specification 3.5.2 and the associated action statements were not met.

Although the pumps'ecorded dP's exceeded the ISI allowable deviation for high dP, the dP's were acceptable during the next monthly tests without any physical changes to the systems having been made. It is therefore evident that the high readings were not the result" of actual changes in pump performance, but rather, indication of such possible factors as instrumentation deviation and/or errors in reading the instrumentation. At no time were the SI pumps degraded or not able to perform their intended safety function. The associated ISI'documents have been revised to reflect the correct reference values.

8807250418 880714 PDR ADQCI(v 050003ib S PNU NRC Form 388 (903)

NRC Form 366A U.S. NUCLEAR REGULATORY COMMISSION (94)3)

LICENSEE ENT REPORT (LER) TEXT CONTINU ION APPROVEO OMS NO. 3150-0(04 EXPIR ES: 8/31/88 FACILITY NAME (1) DOCKET NUMSER (2) LER NUMBER (6) PACE (3)

D. C. Cook Nuclear Plant- YEAR ~gg SECUENTIAL NUMBER

??hajj REVISION NUM864 Unit 2 p p p p p 3 1 6 8 8 0 0 7 00 02 OF 0 3 TEXT //F rrroro <</ooo/4 te /I//rod, I/oo r//dooo/HRC %%drm 3//6A'4/ (IT)

Conditions Prior to Occurrence Unit 2 in Mode 1 (Power Operation) at 80 percent Rated Thermal Power on December 24, 1987. /

Unit 1 in Mode 1 (Power Operation) at 90 percent Rated Thermal Power on January 7, 1988.

Descri tion of Event On June 13, 1988, it was reported that during a review of ISI pump test data, it was discovered that incorrect reference differential pressure (dP) values were being used for the Safety Injection (SI) Pumps (EIIS-BQ/P).

A complete review of past ISI data determined that the error occurred in June 1984 for Unit 2 and September 1985 for Unit 1, when new reference values were not established after completion of a Design Change which resulted in modified test conditions for the SI pumps. During the period between the above dates it was determined, when using the correct reference values, that on two occasions (December 24, 1987, for the Unit 2 South SI pump and January 7, 1988, for the Unit 1 North SI pump) the ISI allowable deviation for high dP had been exceeded.

Contrary to ASME XI 1WP-3112, the pumps were not declared inoperable nor was corrective action taken. On July 13, 1988, it was determined that Plant operation had not been in literal compliance with Technical Specification 3.5.2, ECCS Subsystems - Tavg M 350'F, which requires that two independent ECCS subsystem be operable. Since the inoperable condition of the pumps was not identified, the associated action statements were not met. The next monthly ISI tests for each unit [on January 21, 1988, (Unit 2) and February 4, 1988 (Unit 1)], indicated that dP's were within the allowable range of test quantities.

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

Cause of Event The root cause of the event was determined to be cognitive personnel error.

In June 1984 and September 1985, for Units 2 and 1 respectively, a design, change was made to the SI systems which altered the test flow characteristics.

During the procedural impact review process, Plant Engineering personnel failed to identify that the design change would result in modified test conditions that would require that new ISI reference values, and allowable ranges of test quantities, be established. This resulted in test data obtained subsequent to the modification incorrectly being compared to reference values established prior to the modification.

NRC FORM 36CfA *U.S.GPO:(986.0-624 538/455 (963)

NRC Form 388A U.S. NUCLEAR REGULATORY COMMISSION (94)3)

LICENSEE ENT REPORT (LER) TEXT CONTINU ION APPROVEO OM8 NO. 3150-0104 EXPIRES: 8/31/88 FACILITY NAME ('ll DOCKET NUMSER (2) LER NUMBER (8) PAGE (3)

D. C. Cook Nuclear Plant- YEAR SEQUENTIAL NUMSER REVISION NUMBER Unit

~

2 o s o o o 3 1 6 8 8 007 0 00 30F 03 TEXT (8'moro Neo lr sr)U)or/, I/so HRC %%dnrr 3814'r/ ((7)

Anal sis of Event This event is considered reportable under the provisions of 10CFR50.73.a.2.i.B, Operations or Condition .Prohibited by T/S.

Although the pumps'ecorded dP's exceeded the ISI allowable deviation for high dP, they were acceptable during the next monthly test without any physical changes to the systems having been made. It is therefore evident that the high readings were not the result of actual changes in pump performance, but rather, indicative of such possible factors as instrumentation deviation and/or errors in reading the instrumentation. The instrumentation situation has been experienced/analyzed on numerous occasions with various pumps in the ISI program and in none of these cases were the pump dP's actually determined to be high or their performance changed. This event is considered a literal violation of Technical Specification requirements. At no time were any of the SI pumps degraded or not able to perform their intended safety function.

Low dP is also tracked by the ISI program to monitor for degraded'pump performance. The use of incorrect dP reference values was conservative in that the ISI program requirements would have caused the pumps to be declared inoperable before actual degradation could have exceeded the allowable deviation.

Based on the details above, it is concluded that no risk to the public health and safety existed.

Corrective Actions The associated ISI documents have been revised to reflect the correct reference values. A review of ISI Pump data encompassing all pumps in the ISI program was performed and no additional examples of incorrect reference values being used were identified. Therefore, it is concluded that this error was limited to the SI Pumps. Furthermore, the cognitive error that occurred as a result of the Design Change review process is concluded to be an isolated occurrence and not indicative of a program deficiency.

The current ISI program requires trending of ISI data to identify adverse trends or abnormal data. This trend program would identify any anomalies for further investigation and would ensure prompt identification and resolution of any similar occurrences.

Failed Com onent Identification None Previous Similar Events None NRC FORM 348A *U.S.GPOI'(988 0824 538/455

((P83)

g Indiana Michigan Power Company Cook Nuc(ear Plant~

P.O, Box 458 Bridgman, Ml 49106 616 465 5901 INDIANA NICHIGiAN POWER July 14, 1988 United States Nuclear Regulatory Commission Document Control Desk Washington, D.C. 20555 Operating License DPR-58 Docket No. 50-316 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:

88-007-00 Sincerely, W. G. Smith, Jr.

Plant Manager WGS:clw Attachment cc: D. H. Williams, Jr.

A. B. Davis, Region III M. P. Alexich P. A. Barrett J. E. Borggren R. W. Jurgensen NRC Resident Inspector J. F. Stang, NRC R. C. Callen G. Charnoff, Esq.

Dottie Sherman, ANI Library D. Hahn INPO PNSRC A. A. Blind S. J. Brewer/B. P. Lauzau

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