ML17329A082

LER 91-005-00:on 910614,bolts Removed from Pressurized Essential Svc Water Line Expansion Joints & Water Sprayed from Flanges.Caused by Reversed Component Labels.Joints Reinstalled & Labeling corrected.W/910715 Ltr

ML17329A082
Person / Time
Site:	Cook
Issue date:	07/15/1991
From:	Blind A, Sampson J INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-91-005, LER-91-5, NUDOCS 9107220223
Download: ML17329A082 (8)

Text

~i~r,j ~mian UISIM@JTION DEMONSTRATI N SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:9107220223 DOC.DATE: 91/07/15 NOTARIZED: NO DOCKET FACIL:50-316 Donald C. Cook Nuclear Power Plant, Unit 2, Indiana & 05000316 AUTH. NAME AUTHOR AFFILIATION SAMPSON,J.R. Indiana Michigan Power Co. (formerly Indiana & Michigan Ele BLIND,A.A. Indiana Michigan Power Co. (formerly Indiana & Michigan Ele RECIP.NAME RECIPIENT AFFILIATION R

SUBJECT:

LER 91-005-00:on 910614,bolts removed from pressurized essential svc water line expansion joints & water sprayed from flanges.Caused by reversed component labels.Joe.nts reinstalled & labeling corrected.W/910715 ltr.

DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR J ENCL TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc. 2 SIZE:

NOTES:

RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL D PD3-1 LA 1 1 PD3-1 PD 1 1 COLBURN,T. 1 1 D INTERNAL: ACNW 2 2 AEOD/DOA 1 1 AEOD/DS P/TPAB 1 1 AEOD/ROAB/DS P 2 2 NRR/DET/ECMB 9H 1 1 NRR/DET/EMEB 7E 1 1 NRR/DLPQ/LHFB1 0 1 1 NRR/DLPQ/LPEB10 1 1 NRR/DOEA/OEAB 1 1 NRR/DREP/PRPB11 2 2 NRR/DST/SELB 8D 1 1 NRR/DST/SICB8H3 1 1 NRR/D~ST. SP~B8J)3 1 1 NRR/DST/SRXB 8E 1 1 REG 1 1 RES/DSIR/EIB 1 1 RGN3 FIIE 01 1 1 EXTERNAL: EG&G BRYCE,J.H 3 3 L ST LOBBY WARD 1 1 NRC PDR 1 1 NSIC MURPHYTG A 1 1 NSIC POOREiW 1 1 NUDOCS FULL TXT 1 1 R D

D D

NOTE TO ALL "RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTE! CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT. 20079) TO ELIMINATEYOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!

FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 31 ENCL 31

Indiana Michigan Power Company Cook Nuclear Plant One Cook Place Bridgman, Ml 49106 616 465 5901 vaw~saa NECHf6AH PWKR July 15, 1991 United States Nuclear Regulatory Commission Document Control Desk Rockville, Maryland 20852 Operating Licenses DPR-74 Docket No. 50-316 Document Control Manager:

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

91-005-00 Sincerely, A.A. Blind Plant Manager AAB:sb Attachment co D.H. Williams, Jr.

A.B.

E.E.

Davis, Region Fitzpatrick III P.A. Barrett B.F. Henderson R.F. Kroeger B. Walters - Ft. Wayne NRC Resident Inspector T. Colburn NRC J.G. Keppler M.R. Padgett G. Charnoff, Esp.

D. Hahn INPO S.J. Brewer/B.P. Lauzau B.A. Svensson 9107220223 910715 PDR ADOCK 050003lb S PDR

NAC FORM 366 .S. NUCLEAR REGULATORY COMMISSION (64)9) OVED OMB NO. 31504)104 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLE'CTION REQUEST: 50.0 HRS. FORWARD LICENSEE EVENT REPORT (LER) COMMENTS REGARDING BURDEN ESTILIATE TO THE AECORDS AND REPORTS MANAGEMENT BRANCH IP530), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500104I. OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME HI DOCKET NUMBER (2) PAGE 3 D. C. Cook Nuclear Plant Unit 2 0 5 0 0 0 3 ] 6 1 OFP 5 Bolts Removed from Pressurized Essential Service Water'ine Expansion Joint Due to Reversed Com onent Labels EVE NT OAT E (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (SI MONTH OAY YEAR YEAR  %~6 SEOVENTIAL @~ REVrSION FACILITYNAMES COPr: NUMBER MONTH DAY YEAR DOCKET NUMBER(SI 0 5 0 0 0 0 6 1 4 9 1 9 1 0 0 5 0 0 0 7 1 5 9 1 0 5 0 0 0 THIS REPORT IS SUBMITTED PURSUANT T0 THE RLOUIREMENTS OF 10 CFA ()t ICnectr one or more of the followinp/ (11 OPERATING MODE (9)

] 20.402(tr) 20.405(c) 50,73(s)(2)(iv) 73.7)(II)

POWER LEVEL 20 405(s) (I III) 50.36(c) Ill 50.73( ~ ) l2)(v) 73.71(c) 1 p p 20.405 ( ~ ) (1) Ill) e0.35(c)(2) 60,73(s) (2) (villi(BI (vill oTHER /specify in Aottrecr oslo w enrf ln Test, /Y/IC Form 20.405(sll1)(ill) 60.73( ~ ) l2) II) 60.73(sl(2)(vill)(AI 36SA/

20A05(s)II)(lv) 50,73(s) (2) Ill) 50.73( ~ ) (2) 20.405(s)(1)(vl 60.73 (s I (2) I ill) 60.73( ~ ) l2) (e) Voluntary Report LICENSEE CONTACT FOR THIS LER (12I NAME TFLEPHONE NUMBER AREA CODE J. R. Sam son, 0 erations Superintendent 6 1 6 46 5 5 9 01 COMPLETE ONE LINE FOR EACH COMIIONENT FAILURE DESCRIBED IN THIS REPORT (13)

MANUFAC REPORTABLE /rer CAUSE SYSTEM COMPONENT TURER ""'"";::.

.. 444~4 CAUSE SYSTEM COMPONENT MANUFAC.

TURER EPOATABLE NPRDS

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6 (4 v,v, n MLS 3:(Ã~(e~xii81 I:(4%+0 SUPPLEMENTAL REPORT EXPECTED (14) MONTH DAY YEAR EXPECTED SUBMISSION YES Ilfyer, complete EXPECTED St/64r/SSIOH DATE/ DATE (15)

NO ABSTRACT ILlmit to /400 rpecee, I e., epproeimetely fifteen rlnple specs typewritren liner/ (16)

The west ('W') essential service water (ESW) erain was made inoperable ae 2146 on 6/13/91 in preparation for replacement of an 8-inch expansion joint labelled as 2-XJ-54W. At 0600 on 6/14/91, Maintenance personnel began to remove the flange boles from the expansion joint. All of the flange bolts were removed at about 0700. The expansion joint remained lodged in place and waeer sprayed from the flanges. The water was initially believed to be either from trapped water or isolation point leakby. At 1240, however, identified that the expansion jointed labelled as being on the 'W'SW train it was was actually on the east ('E') ESW train and the bolts were reinstalled at 1317. The Engineering review of this event determined that the water lossed out the flange was insignificant and that the expansion joint would have remained in place during a design basis earehquake. This event is being voluntarily reported as the analysis indicates the 'E'SW train remained operable. The cause of the labelling problem could not be determined. The labeling problem with the 2-XJ-54 expansion joines was corrected on 6/14/91.

A walkdown was performed on similar expansion joines in unit 1 and 2. One additional problem was found and corrected in unit 2 on 6/19/91. The labelling process was reviewed and determined to be adequate with this event being caused by a unique combination of circumstances. A lessons learned memo was issued 7/9/91 to Operations and Maintenance personnel on this event.

NRC Form 366 (64)9)

NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION (64)9) APPROVED OM 8 NO. 31500104 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT (LER) INFORMATION COLLECTION REQUEST: 508) HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE AECOROS TEXT CONTINUATION AND REPOATS MANAGEMENT BRANCH IP.530L U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (I) DOCKET NUMBER (2) LEA NUMBER (6) PAGE (3)

YEAR SEOUENTIAL NUMBER g~ REVISION NUMSER D. C. Cook Nuclear Plant Unit 2 0 5 0 0 0 3 9 1 0 0 50 0 0 2 OF 0 5 TEXT lllmcuu Epucu /4 muvked, u44 udddtouu/HRC fomI 36SA'4/ 07)

Conditions Prior to Occurrence Unit 1 in Mode 1 (Power Operation) at 100 Percent Power Unit 2 in Mode 1 (Power Operation) at 100 Percent Power Descri tion of Event The west ('W') train of essential service water (EIIS/BI) was removed from service at 2146 on 6/13/91 to allow replacement of the expansion joint (EIIS/BI-EXJ) labeled as 2-XJ-54W, which is the 'W'rain ESW supply to the emergency diesel generators (EIIS/EK-DG)(EDG). Maintenance personnel began removing the bolts from the expansion joint at about 0600 on 6/14/91.

The Maintenance personnel had been advised by the Assistant Shift Supervisor that the piping from the expansion joint to the drain point was not visible due to being in concrete so it was not certain that the piping at the expansion joint was completely drained. Based on this information, the Maintenance personnel expected some water to drain, but the drainage which occurred appeared to be at a higher-than-expected pressure. The Assistant Shift Supervisor from the next shift was contacted about this concern. The Maintenance personnel were told that since the expansion joint was located in the lower level of the building, the observed pressure was probably the result of elevation differences.

Originally, some bolts were left in the expansion joint flanges, but due to the flange arrangement it was not possible to spread the gap an appreciable amount without removing bolts. All of the bolts were removed at about 0700 and a tool was used to spread the gap between flange surfaces. This was done to increase the drain rate and minimize the time required to return the train to service. 'W'SW Between 0730 and 1230, there were a series of communications between the Maintenance personnel and Operations personnel regarding the continued drainage from the expansion joint. At one point during this time, an Auxiliary Equipment Operator (AEO) was sent to the area. The Operator reported back to the control room that the header appeared to be pressurized based on the drain rate from the expansion joint. The Unit Supervisor (senior reactor operator licensed) told the AEO he believed the appearance of being pressurized was either caused by the head associated with elevation differences or isolation point leakby.

NAC FoIIR 366A (689)

NRC FORM 366A U.S. NUCLEAR REGULATOAYCOMMISSION (669) APPROVE'D OMB NO. 31500104 E XP I R ES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT ILER) INFORMATION COLLECTION REQUEST: 50JI HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (P430). U.S. NUCLEAR AEGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWOAK REDUCTION PROJECT (3(504104). OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503, FACILITY NAME (I) DOCKET NUMBER (2) LEA NUMBER (61 PAGE (3)

YfAR Na SFQUS NTIAL s??v'EVISION NUMSSR NUM884 D. C. Cook Nuclear Plant Unit 2 0 S 0 0 0 3 9 1 0 0 5 0 0 03oF0 5 TEXT /// more specs it ter/It/red, Irte eddi)r)roe/HRC FemI 36r/A'/ (11)

At about 1230, the Shift Supervisor (senior reactor operator licensed) overheard a conversation between the Assistant Shift Supervisor and the AEO concerning the continued draining. The Shift Supervisor went to the work location and, after observing the water spray from the expansion joint, concluded that the expansion joint labeled as being on the 'W'SW train was actually on the east ('E') train. The Shift Supervisor directed the Maintenance personnel to reinstall the expansion joint flange bolts. The bolts were reinstalled and tightened at 1317.

Cause of Event The cause of the 2-XJ-54E and 2-XJ-54W labels being reversed could not be positively identified. The expansion joints were originally both labelled as 2-XJ-54. In 1986, both the unit 1 and unit 2 XJ-54 expansion joints were given unique north ('N') and south ('S') identifiers l(2)XJ-54N and 1(2)XJ-54S. The piping drawings were changed at this time and new labels were placed. This change was somewhat confusing in that 'E'nd 'W'rain components were given 'N'nd 'S'dentifiers. Also, there was not consistency between the units. In unit 1 the 'W'rain joint was designated as 'S'n the piping drawing and the 'E'rain was designated as 'N'. In unit 2 the 'W'rain joint was designated as 'N'n the piping drawing and the was designated as 'S'.

'E'rain The 'N'nd 'S'abels on the unit 1 expansion joints were identified as being reversed on 7/29/90 when the 'E'rain joint developed a significant leak and the 'W'rain of ESW was first removed from service based on a review of the piping drawing and the installed 1-XJ-54S label. The labels were identified as being reversed when the leak flow did not decrease As a result of this event, the labels on unit 2 were checked by two persons from the Plant labelling staff and verified as being correct. A request was also made at this time to change the identifiers to 'E'nd 'W'.

The expansion joints were subsequently given 'E'nd 'W'dentifiers and the piping drawings were revised. The unit 2 drawing was revised 10/4/90 and the

'N'nd 'S'abels were replaced with 'E'nd 'W'abels. It is not known if the 'N'nd 'S'abels were correctly placed and the 'E'nd 'W'abels were reversed, or if the 'N'nd 'S'abels were incorrectly placed and then replaced one for one with the 'E'nd 'W'abels. There were two other factors which could have contributed to the labelling problem. First, the upstream and downstream piping of the expansion joints is buried in concrete and cannot be visually traced back to the main headers. Second, in unit 1 the main 'E'nd 'W'SW headers are physically 'E'nd 'W', but in unit 2 the is physically located west of the 'W'eader. 'E'eader NRC Form 366A (64)9)

NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION (639) APPROVED 0MB NO. 31500104 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT ILER) INFORMATION COLLECTION REQUEST: 50JI HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH IP4)30), U.S. NUCLEAR REGULATORY COMMISSION. WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (3(504)104). OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, OC 20503.

FACILITY NAME (1I DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR SEQUENTIAL @@ REVISION NUMBER BB NUMBER D. C. Cook Nuclear Plant Unit 2 3 1 6 9 1 0 0 5 0 0 0 40F 0 5 TEXT /I/ mor>> >>p>>4>> /4 r>>BII/r>>d. Ir/>>>>dCk'>>4>>//VRC Form 3664 4/ (17)

In summary, it appears that the labelling problem could have been caused by a combination of f'actors including the two changes in component identifiers, the inconsistency between the drawings when the 'N'nd 'S'dentifiers were established, the piping being buried in concrete, and the difference between the units for the physical location of 'E'nd 'W'SW headers.

The length of time required to identify the problem was increased by a combination of factors. These factors included mindsets regarding isolation point leakby and elevation induced head, buried piping preventing recognition that the drain should have drained the involved section of piping, and failure to communicate all pertinent information to the Unit Supervisor.

Anal sis of Event This event was determined not reportable, but i.s being voluntarily reported.

The 'E'SW expansion joint was initially considered as being inoperable and the event was reported by a phone report under 10CFR50.72(b)(2)(ii)(A) as an unanalyzed condition. The subsequent Engineering analysis, however, determined that the 'E'SW expansion joint remained operable.

With the 'W'SW train isolated and drained, the 'E'SW train was being relied on for ESW associated cooling loads. The involved expansion joint remained in place throughout this event and cooling water was available to the EDGs. The Engineering review of this event determined that the estimated maximum leakage from the expansion joint during the event would not have prevented the 'E'rain from fulfilling its safety function. This review also concluded, based on a seismic analysis, that the expansion joint would have remained in place during a design basis earthquake. Since the Engineering review of this event determined that the 'E'SW train remained capable of fulfilling its safety function, was concluded that the 'E'SW train remained operable.

it Corrective Action The 'E'SW supply expansion joint bolts were reinstalled at 1317 on 6/14/91.

The labelling problem with 2-XJ-54E and 2-XJ-54W was corrected on 6/14/91.

The labelling for the unit 1 ESW supply and return expansion joints to the EDGs was checked and verified to be correct.

NRC Form 366A (689)

NRC FORM366A U.S. NUCLEAR REGULATORY COMMISSION (64)91 APPROVEO OMB NO. 31500104 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT (LER) INFORMATION COLLECTION REQUEST: 500 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH IP430), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31504)104), OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.

FACILITYNAME (I) DOCKET NUMBER LT) LER NUMBER (6) PAGE (3)

YEAR p~g> SEOVENTIAI.

NVMSEA REVISION NVMSEA D C. Cook Nuclear Plant Unit 2 0 6 0 0 0 3 9 1 0 0 5 0 0 0 5 oFo 5 TEXT IIInnvP 4P444 b T49vked, VTP Sddic/)pnel HRC Farm 3664'4/ (IT) 4, The labelling for the unit 2 ESW return expansion joints for the EDGs was checked and found to be reversed. The expansion joints were correctly labelled on 6/19/91.

5. The labelling process was reviewed for adequacy. It was determined that the current process is adequate and that factors that resulted in this event.

it was a unique combination of A lessons learned memo was issued 7/9/91 to Operations and Maintenance personnel on this event.

Failed Com onent Identification None Previous Similar Events The 7/29/90 unit 1 event discussed in the Cause of Event section was similar to this event. The unit 1 event is currently being re-evaluated to confirm that the leak flow from the expansion joint did not render that train of ESW inoperable.

NRC Form 366A (669)