ML17326A066

LER 99-017-00:on 990625,noted That Improperly Installed Fuel Oil Return Relief Valve Rendered EDG Inoperable.Caused by Personnel Error.Fuel Oil Return Valve Was Replaced with Valve in Correct Orientation.With 990722 Ltr

ML17326A066
Person / Time
Site:	Cook
Issue date:	07/26/1999
From:	Rencheck M, Snodgrass D INDIANA MICHIGAN POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-99-017, NUDOCS 9907280081
Download: ML17326A066 (6)

Text

~ CATEGORY ~

REGULATORY INFORMATION DISTRIBUTION SYSTEM (RZDS)

ACCESSION NBR:9907280081 DOC.DATE: 99/07/22 NOTARIZED: NO DOCKET ¹ FACXL.'50-315 Donald C. Cook Nuclear Power Plant, Unit 1, Xndiana M 05000315 AUTH. NAME AUTHOR AFFILXATION SNODGRASS,D.D. Indiana Michigan Power Co.

RENCHECK,M.W. Xndiana Michigan Power Co.

RECZP.NAME ,, RECIPIENT AFFZLZATXON

SUBJECT:

LER 99-017-00:on 990625,noted that improperly installed fuel oil return relief valve rendered EDG inoperable. Caused by personnel error. Fuel oil return valve was replaced with valve in correct orientation. With 990722 ltr.

DISTRXBUTION CODE: ZE22T COPIES RECEIVED:LTR ENCL SIZE:

TXTLE: 50.73/50.9 Licensee Event Report (LER), Xncident Rpt, etc.

NOTES:

RECZPXENT COPIES RECIPIENT COPIES 0 ID CODE/NAME LED3.=.1~PD 1, LTTR ENCL 1

ID CODE/NAME STANG,J LTTR ENCL 1 1 R INTERN: FILE CENTER 1 1 NRR/DIPM/ZOLB 1 1 Y NRR~/DRIP"/REXB 1 1 NRR/DSSA/SPLB 1 1 RES/DET/ERAB 1 1 RES/DRAA/OERAB 1 1 RGN3 FXLE Ol 1 1 EXTERNAL: L ST LOBBY WARD 1 1 LMITCO MARSHALL 1 1 NOAC POORE;W. 1 1 NOAC QUEENER,DS 1 1 NRC PDR 1 1 NUDOCS FULL TXT 1 1 D 0

NOTE TO ALL "RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTE. TO HAVE YOUR NAME OR ORGANIZATION REMOVED FROM DISTRIBUTION OR REDUCE THE NUMBER OF COPIES RECEIVED BY YOU OR YOUR ORGANIZATION, CONTACT THE LISTS DOCUMENT CONTROL DESK (DCD) ON EXTENSION 415-2083 FULL TEXT CONVERSION REQUZRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 15 ENCL 15

Indiana Michi Power Company Ctmttwtdcar Rant One Cook Bart M1 491 06 Z

616 465 5901 INDIANA NICHIOIAN

'OWER July 22, 1999 United States Nuclear Regulatory Commission Document Control Desk Washington, DC 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 LER 315/99-017-00, "Improperly Installed Fuel Oil Return Relief Valve Renders Emergency Diesel Generator Inoperable Due to Personnel Error".

There are no commitments identified in this LER.

Sincerely, M. W. Rencheck Vice President- Nuclear Engineering

/mbd Attachment J. E. Dyer, Region III R. P. Powers P. A. Barrett G. P. Arent R. Whale D. Hahn Records Center, INPO NRC Resident Inspector

'i190728008i 'll'ii0722 PDR ADGCK 050003i5 S PDR

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NRC FORM 366 U.S. NUCLEAR REG ORY COMMISSION APPRO BY OMB NO. 3150<104 (8-1993)

EXPIRES 06/30/2001 LICENSEE EVENT REPORT (LER) Esumated burden per response to comply with this mandatory Information (See reverse for required number of digits/characters for each block)

Commission, Washington. DC ~t couecuon request 50 hrs. Reported lessons learned are hcorpxated Into the licenshg process and fed back to ktdustry. Forward

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regarding burden estimate to the Reoxds Management Branch (TA F33). U.S. Nucrear Regubrtory and to Ihe Paperwork ReducUon Pro)oct (31500104). Ctree of Management and Budget, Washkrgton, DC 20503.

If an information coukecuon does not display a currenUy vaud OMB control number, the NRC may not conduct or sponsor, a'nd a person is not required to respond to.

the kdormauon couecuon.

FACILITYNAME (1) DOCKET NUMBER (2) PAGE (3)

Cook Nuclear Plant Unit 1 05000-315 1 OF 3 TITLE (S)

Improperly Installed Fuel Oil Return Relief Valve Renders Emergency Diesel Generator Inoperable Due to Personnel Error EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED(6)

MONTH DAY YEAR YEAR SEQUENTIAL REVISIO MONTH DAY YEAR FAclLITYNAME OOCKET NUMBER NUMBER N 1999 FACILITYNAME DOCKET NUMBER OPERATING THIS REPORT IS SUBMITTED PURSUANT TO THE REQU IREMENTS OF 10 CFR II: (Check one or more) (11)

MODE (9) a v a a vm 20.2203(a)(1) 20.2203(a)(3)(i) X 50.73(a)(2)(ii) 50.73(a)(2)(x)

LEVEL (10) a a n a ul 20.2203(a)(2)(ii) 20.2203(a)(4) 50.73(a)(2)(iv) OTHER a m a v In Abstract below or In ~RE Form 3BBA a rv 50.73(a)(2)(vii)

LICENSEE CONTACT FOR THIS LER (12)

TELEPHONE NUMBER (include Area Code)

Mr. Dennis D. Snodgrass, Compliance Engineer (616) 465-5901 X1627 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DES CRIBED IN THIS REPORT (13)

CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE To EPIX To EPIX SUPPLEMENTAL REPORT EXPECTED 14 EXPECTED MONTH DAY YEAR YES X NO (If yes, complete EXPECTED SUBMISSION DATE).

ABSTRACT (Limit to 1400 spaces, i.e. approximately 15 single-spaced typewritten lines) (16)

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On June 25, 1999 at 2030 hours0.0235 days <br />0.564 hours <br />0.00336 weeks <br />7.72415e-4 months <br /> EST with both units in Mode 5, the Unit 1 CD Diesel Generator (D/G) was determined to be inoperable after the fuel oil return relief valve was identified as being installed backwards. The correct orientation of this valve is important to ensure that fuel oil is continuously circulated around the D/G fuel oil injector pump barrel for cooling. On June 25, 1999 at 2308 hours0.0267 days <br />0.641 hours <br />0.00382 weeks <br />8.78194e-4 months <br /> EST an ENS report was made in accordance with 10CFR 50.72(b)(2)(iii)(D), a condition that alone could have prevented the fulfillment of the safety function of systems that are needed to mitigate the consequences of an accident and 10CFR 50.72(b)(2)(i), a condition found while the reactor is shutdown that had it been found while in operation, would have resulted in the plant being seriously degraded or in an unanalyzed condition. This LER is therefore submitted in accordance with 10CFR 50.73(a)(2)(v)(D) and 10CFR 50.73(a)(2)(ii)(A).

The apparent cause of this condition is personnel error. The valve has been installed backwards since prior to 1986.

Inspection of the corresponding valves on the 1AB, 2AB and 2CD D/Gs determined the valves were installed in the correct orientation. Operations entered the action statements for the applicable Technical Specifications upon declaring the Unit 1 CD D/G inoperable. Following replacement of the valve and D/G surveillance testing the 1CD D/G was declared operable on July 7, 1999 at 2243 hours0.026 days <br />0.623 hours <br />0.00371 weeks <br />8.534615e-4 months <br /> EST.

The successful completion of past Technical Specification (T/S) surveillance testsfor the Unit 1 CD D/G has verified acceptable engine performance, regardless of the incorrect orientation of this valve. A review of maintenance history did not reveal any abnormal D/G operation that could be attributed to the incorrect valve orientation. Therefore, there were minimal implications to the health and safety of the public as a result of this event. If significant changes are identified as a result of completion of the root cause investigation, an update to this LER will be submitted.

NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION (6-1998)

LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION FACILITYNAME (1) DOCKET (2) LER NUMBER (6) PAGE (3)

NUMBER 2 Cook Nuclear Plant Unit 1 05000-315 YEAR SEQUENTIAl.

NUMBER REVISION 2 OF 3 NUMBER 1999 017 00 TEXT (Ifmore spece Is requfred, use edditionel copies of NRC Form 366A) (17)

Conditions Prior To Event Unit 1 Mode 5 in Cold Shutdown Unit 2 Mode 5 in Cold Shutdown Descri tion Of The Event On June 25, 1999 at 2030 hours0.0235 days <br />0.564 hours <br />0.00336 weeks <br />7.72415e-4 months <br /> EST with both units in Mode 5, the Unit 1 CD D/G (EIIS:EK) was determined to be inoperable. White performing inspections of D/G fuel oil lines (EIIS:DC), the Unit 1 CD D/G fuel oil return relief valve (EIIS:DC/FCV) was identified as being installed backwards. The correct orientation of this valve is important to ensure that fuel oil is continuously circulated around the 0/G fuel oil injector pump barrel for cooling. In the as-found orientation, the valve would not have lifted off of its seat at the required setpoint and would not have supplied the designed cooling to the fuel oil injector pump.

The valve is shown in the incorrect orientation on the current revision 3 of a plant isometric drawing. A review of previous revisions of this drawing indicates that the incorrect orientation was incorporated in revision 2, dated 1986. Revision 1 dated 1973, indicated that the relief valve was correctly orientated but installed in a different physical location. A review of documentation provided no reason for the drawing change, other than to reflect "As-Found" conditions.

Inspection of the corresponding valves for the 1AB, 2AB and 2CD D/Gs determined that the valves were installed in the correct location and orientation in the plant. However, the 1AB D/G isometric drawing shows the wrong location for the valve.

Cause Of The Event The apparent cause of this condition is personnel error. Drawing changes and discussion with the vendor indicate that the D/G fuel oil return relief valves were initially supplied skid mounted on the diesel fuel oil return manifold but subsequently moved to the diesel fuel oil day tank room during plant construction. The process used to relocate the valve to its present location and when this occurred could not be determined from available documentation. Therefore; the valve was apparently installed incorrectly during plant construction and drawings were as-built to reflect the incorrect installation.

Subsequent reviews of drawing changes were inadequate in that they did not identify the incorrect field installation.

Anal sis Of The Event On June 25, 1999 at 2308 hours0.0267 days <br />0.641 hours <br />0.00382 weeks <br />8.78194e-4 months <br /> EST an ENS report was made in accordance with 10CFR50.72(b)(2)(iii)(D), a condition that alone could have prevented the fulfillment of the safety function of systems needed to mitigate the consequences of an accident and 10CFR50.72(B)(2)(l), a condition found while the reactor is shutdown that had it been found while in operation, would have resulted in the plant being seriously degraded or in an unanalyzed condition.

The D/G fuel oil return relief valve, set at 15 pounds per square inch pressure, is installed to maintain a fixed fuel pressure differential across the D/G fuel injection pump. This provides the proper fuel flow to achieve the required degree of cooling for the D/G fuel oil injection pump. In the as-found orientation, the valve would not have lifted off of its seat at the required setpoint at low load D/G operating conditions and proper cooling of the D/G fuel oil injection pump could have been affected.

The successful completion of past Technical Specification (T/S) surveillance tests for the Unit 1 CD D/G has verified acceptable engine performance, regardless of the orientation of this valve. A review of maintenance history did.not reveal any abnormal D/G operation that could be attributed to the valve. Therefore, it has been concluded that there were minimal implications to the health and safety of the public as a result of this event.

NRC FORM 866A (6-1 998)

NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION (6.1999)

LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION FACILITYNAME (1) DOCKET (2) LER NUMBER (6) PAGE (3)

NUMBER 2 YEAR SEQUENTIAL REVISION 3 OF 3 Cook Nuclear Plant Unit 1 05000-315 NUMBER NUMBER 1999 017 00 TEXT (Ifmore spaceis required, use additional copies of NRC Form 366A) (17)

CORRECTIVE ACTIONS An Engineering Evaluation was performed to evaluate the as-found condition of the 1CD D/G fuel oil return relief valve and to determine required corrective actions.

Inspection of the corresponding D/G fuel oil return relief valves and the fuel oil supply relief valves on each D/G determined that the extent of condition was limited to the 1CD D/G fuel oil return relief valve.

The vendor was contacted to determine what inspections could be performed to determine if fuel oil injector pump damage had occurred as a result of inadequate cooling. The vendor indicated that there would be no real indication of pump damage until the pump seized. The only possible visible indication of overheating prior to seizure is that the fuel oil would separate and give the pump internals a "varnished" look. To remove and inspect the pumps would require recalibration at the factory due to the tight internal tolerances involved. It was decided not to inspect the pumps, since the pumps have a successful maintenance history and there were no precursors to indicate pump failure.

Design Input Transmittals were issued to revise isometric drawings to reflect the correct 1CD D/G valve orientation and to revise the 1 AB D/G isometric drawing to refiect the correct valve location.

The fuel oil return relief valve was replaced with a valve in the correct orientation. Following surveillance testing, the 1CD D/G was declared op'erable on July 7, 1999 at 2243 hours0.026 days <br />0.623 hours <br />0.00371 weeks <br />8.534615e-4 months <br /> EST.

AEP:NRC:1260GH, "Enforcement Actions98-150, S8-151, S8-152 and 98-186 Reply to Notice Of Violation October 13, 1998", dated March 19, 1999, responded to identified programmatic weaknesses in the plant Design and Licensing Basis, Control of Contractors and the Training and Qualification of personnel. The Engineering Leadership Plan establishes a configuration management program to control plant design and a new design control process, which includes design verification, design document control, vendor technical documentation control and testing of design changes. The Leadership Plan for Control of Contractors insures that workers are qualified for the job, line management is accountable for workers job qualification, monitoring of work performance and performing an adequate review for quality. The Training and Qualification of Personnel Leadership Plan will reinforce a "nuclear safety culture" for site personnel. These plans in whole will help preclude a similar event similar from occurring in the future.

SIMILAREVENTS 315/98-029-00 315/99-015-00, 315/99-016-00 NRC FORM 366A (6-1996)