ML17345A257

LER 87-015-01:on 870715 & 16,failure to Deactivate Inoperable Containment Isolation Valve within 4 H as Required by Tech Specs Discovered.Caused by Personnel Error. Procedures revised.W/880706 Ltr

ML17345A257
Person / Time
Site:	Turkey Point
Issue date:	07/06/1988
From:	Conway W, Salamon G FLORIDA POWER & LIGHT CO.
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
L-88-266, LER-87-015, LER-87-15, NUDOCS 8807120057
Download: ML17345A257 (8)

Text

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~ACCESSION NBR:8807120057 DOC.DATE: 88/07/06 NOTARIZED: NO DOCKET FACIL:50-251 Turkey Point Plant, Unit 4, Florida Power and Light C 05000251 AUTH. NAME AUTHOR AFFILIATION SALAMON,G. Florida Power & Light Co.

CONWA,W.F. . Florida Power & Light Co.

RECIP.NAME RECIPIENT AFFZLIATION

SUBJECT:

LER 87-015-01:on 870715,Failure to deactivate inoperable containment isolation valve within 4 h,per Tech Specs.

W/8 S I U ION COD  : 22D CO I S ECEZV D:LTR ~ E CL f SI E:

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

NOTES:

RECIPIENT COPIES RECIPIENT COPIES ZD CODE/NAME LTTR ENCL ZD CODE/NAME LTTR ENCL PD2-2 LA 1 1 PD2-2 PD 1 1 EDISONiG 1 1 INTERNAL: ACRS MICHELSON AEOD/DOA 1

1 ~

1 1"

ACRS MOELLER AEOD/DSP/NAS 2,2 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/DEST/SGB 8D 1 1 NRR/DLPQ/HFB 10 1 1 NRR/DLPQ/QAB 10 1 1 NRR/DOEA/EAB 11 1 1 NRR/DREP/RAB 10 1 1 NRR/DREP/RPB 10 2 2 NRR D S SIB 9A 1 1 NUDOCS-ABSTRACT 1 1 CLEG 02 1 1 RES TELFORD,J 1 1 RES/DE/EIB 1 RES/DRPS DEPY 1 1 RGN2 FILE 01 1 EXTERNAL: EG&G WILLIAMSES 4 4 FORD BLDG HOYgA 1 1 H ST LOBBY WARD 1 1 LPDR 1 1 NRC PDR 1 1 NSIC HARRIS,J 1 1

. NSIC MAYSEG 1 1 h

TOTAL NUMBER OF COPIES REQUIRED: LTTR 45 ENCL 44

UA. NUCLEAR REQULATORY COMMISSION N:1C Form 345 (543) APPROVED OMB NO, 31400104 EXPIRKS: 5/31/55 LICENSEE EVENT REPORT (LER)

DOCKET NUMBER (2) PA FACILITY NAME (1)

Turkey Point Unit 4 o s o o o 251 >oF 05 ai ure o eac iva e nopera e on asnmen so a son a ve 1 )n ours Required by Technical Specifications Due to Personnel Error EVENT DATE (5) LER NVMBKR (4) REPORT DATE (7) OTHER FACILITIES INVOLVED (4) inv'EQUENTIAL 5<<YA II4 VISION MONTH OAY YEAR FACILITYNAMES DOCKET NUMBERIS)

MONTH DAY YEAR R NUM44 tl 'cQ: NUMoote 0 5 0 0 0 0 7 1 5 8 7 7 015 01 07 06 8 8 0 5 0 0 Q THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS Of 10 Cf R f. (Coecp one or moro ol tnc lop~nfl (11)

OPERATINQ MODE (4) 20.402(4) 20.405(cl ~ 50.734) l2I()rl 73.7((4)

POWER 20.405( ~ I) I HO 50M(c) (I I 50.734)(2)(r) 73.71(cl LEYEL DTHER ldpeciry in 4ortrect 1 0 0 20A05( ~ l(1)IN) 50.34(c)(2) 50.73(el(2) (r4)

Oe/ow end in feet, NRC Fomr 20.405( ~ )(1)(SII 50.73(e)(2) (I) 50,73(e) (2)(rIBI(AI 366A) 20A05(e)11)(lr) 50.73(e l(2) I 4) 50.73 (e I (2) fr)5)(S I 20.405(e)() l(rl 50.'734)(2)(III) 50.73(e) 12) (r I LICENSEE CONTACT fOll THIS LER (12)

NAME TELEPHONE NUMBER AREA CODE Gabe Salamon, Compliance Engineer 305 24 6- 65 60 COMP(.ETE ONE I.INE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)

CAUSE SYSTEM COMPONENT MANUFAC TVRER REPORTABLE NPRDS <<o A'O

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<<Lope<<<<y . &i ': we CAUSE SYSTEM COMPONENT MANUF AC.

TURER EPORTABLE TO NPROS B D 8 4 M12 0 SUPPLEMENTAL RKPORT EXI'ECTKO (14 MONTH DAY YEAR EXPECTED SUBMISSION DATE (15)

YES lllyer, complete EXPECTED SVdltlSSIOrt OATE) NO AINTRACT (Limit to ICOO epecee, l.e., epproepnetery lilteen rinprorpoco typerwttten lineel (ISI The solenoid for valve CV-956B was discovered to be causing a ground on July 13, 1987, with Unit 4 in mode 1. The valve was declared out of service (OOS), and the fuse was pulled, in compliance with Technical Specification (TS) 3.3.3, which requires isolation of each affected penetration within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br />. Following repair, power was restored and post~aintenance testing was performed with satisfactory results.

Inservice testing (IST) was completed at 0645, however local verification of valve position as required by procedure, was not performed. A new test was performed at 1805 on July 16, with satisfactory results. As the valve is OOS until completion of a satisfactory IST, valve CV-956B was OOS without complying with TS 3.3.3 between 0318, July 15, and 1805, July 16. The failure to perform the IST within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> was due to personnel error, in that the Shift Technical Advisor (STA) was not notified in a timely manner.

The IST performed at 0645 was also inadequate due to personnel error in that the STA failed to follow procedure OP 0209.1. Two additional instances of a failure to perform IST on a valve following maintenance, with similar. root causes, were identified. The root cause of the events was that the IST program had insufficient checks and balances to prevent a single personnel error from resulting in a missed IST.

8807120057 88070('3 P DR A DQCN O5OOOP 5 1 8 PNLJ NRC Form 345 r4 53 I

NR fons 3ddA U.S. NUCLEAR REQVLATORY COMMISSION

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LICENSEE ENT REPORT (LER) TEXT CONTINU N APPAOVEO OMB NO. 3ISOW)04 EXPIRES: d/31/dd PACILITY NAME ll) OOCKET NUMSER IEI LEA NUMBER Id) PACE I3)

YEAR SEQVENTIAL REVISION

&54 NVMddR NVMddR Turkey Point Unit 4 o 5 o o o 2. 5-1 7 015 1 0 2 oF 05 TEXT lllmort t/rtct /t rtr)witr/, Irtt tr/I/R/orrt/HRC Fonrr Jr/rJA't/ )17)

The solenoid for valve CV-956B, the pressurizer liquid sample isolation control valve (EIIS:BD,KN), was discovered to be causing a hard ground on the 4B D.C. Bus on July 13, 1987, with Unit 4 in Mode 1. Upon discovery of the ground, the valve was declared out of service (OOS) and the fuse was pulled. This was performed in compliance with Technical .Specification 3.3.3, which requires that "with one or more of the isolation valve(s)... inoperable, maintain at least one isolation valve operable in each affected penetration that, is open and: a) restore the inoperable valve to operable status within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br />, or b) isolate each affected penetration within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> by use of at least one deactivated automatic containment isolation valve secured in the isolation position, or.... d) be in at least hot standby within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> ..." A Plant Work Order (PWO) was prepared and repair was initiated at 1530 on July 14. The PWO identified both post~aintenance (PM)>>testing and in-service testing (IST) as being required prior to returning the valve to service .

The cause of the ground was determined to be insulating tape which had deteriorated from normal aging. In the process of cleaning and retaping the connection, the power lead to the solenoid was lifted and then reterminated. Following the repair of the connection, the technician requested restoration of power and performed the required PM testing (cycling of the valve and verification of position indication) with satisfactory results . The fuse was reinstalled by a Reactor Control Operator (RCO) in accordance with .the above request 'at 2318 on July 14. Following cycling of the valve, the fuse was not pulled. At approximately 0630 on July 15, the RCO noticed that the valve was listed as being OOS in the Equipment Out of Service (EOOS) Log. He knew that the fuse had been reinstalled and the work completed.

He immediately realized that IST was needed and notified the Shift Technical Advisor (STA). The STA is the acting IST Coordinator when the plant IST Coordinator is not on site. The IST Coordinator is responsible for determining equipment post-maintenance IST requirements. IST of valve CV-956B requires cycling the valve, local and remote verification of valve position, and satisfactory timing of the valve stroke . The IST was completed at 0645, however local verification of valve position was not performed. The plant IST Coordinator, upon review of the above IST results, identified this discrepancy. A new IST, meeting all requirements, was performed at 1805 on July 16, with satisfactory results. As the valve cannot be considered to be in service until completion of a satisfactory IST, valve CV-956B was technically OOS without complying with the requirements of TS 3.3.3 between 0318, July 15, and 1805, July 16.

Two additional instances of a failure to perform IST on valves prior to returning them to service were discovered during later documentation reviews. The first instance occurred on June 13; 1987. Following maintenance on the actuator switch for valve CV-4-2821, the IST Coordinator should have been notified that the valve was ready for IST. The Plant Work Order indicated that the IST Coordinator was notified, however this could not be verified The next satisfactory IST was performed on September 8, 1987.

The second instance occurred on June 30, 1987. Valve CV-3-2819 was showing dual position indication upon actuation. The limit switches were ad]usted to indicate proper position. Following the ad)ustment, the STA, who was the acting IST NRC SORM dddA I4 431

NR Form 388A U.S. NUC(,EAR REOVLATORY COMMISSION (943)

LICENSEE NT REPORT (LER) TEXT CONTINU N APPROVEO OMS NO. 3150M)04 EXPIR ES: 8/31/88 FACILITY NAME (11 OOCKET NVMSER (2) LER NUMSER (8) PACE LS)

YEAR SEOV ENTIAL REVISION NVM ER NVM ER Turkey- Point Unit 4 /3 1 8'7 0 1 5 0 1 03 oF 0 5 TEXT ///moro Eooco /o oorr/rm/. vro or/didos HRC Fonrr 38SAS/ (IT)

Coordinator, was notified . *IST of the valve requires .cycling the valve, local and remote verification of valve position, and satisfactory timing of the valve stroke.

Post~aintenance testing of the valve was completed, however local verification of valve position and timing of valve stroke was not performed. Unit 3 was in mode 5 when the work was performed, and entered mode 4 on August 20, 1987 . The next satisfactory IST was performed on September 7, 1987.

CAUSE OP EVENT The CV-956B event has two deficiencies:,first, the failure to assure that the IST]

was performed within 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> following restoration of power to valve CV-956B, and second, the failure to assure that post-maintenance IST requirements were met.

The cause of the failure to perform the IST within the 4 hour4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> time limit is personnel error. Procedure AP 0190.28, "Postmaintenance Testing", requires the maintenance foreman/chief or supervisor to notify the IST Coordinator or the STA prior to commencing work. The STA was not notified until approximately seven hours after the fuse was reinstalled. Without receiving the required notification, scheduling the test in order to comply with the Technical Specifications was missed . Primary responsibility for assuring that LCO s are complied with rests with the Plant Supervisor-Nuclear . Even though he was notified via a temporary lift that the fuse was being reinstalled, no programmatic verification of any applicable LCOs was in place . Consequently, the 4 hour4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> LCO which was entered upon installation of the fuse was not emphasized and was missed.

The failure to assure that the initial IST was adequate was also due to personnel error in that the STA failed to follow procedure. Procedure OP 0209.1, "Valve Exercising Procedure", requires both local and remote position indication verification of valve CV-956B after maintenance, in addition to verifying the(

above every 2 years. In order to determine the acceptance criteria for the valve stroke time, the STA reviewed the results of previous tests, and noticed that the valve was tested within the last 2 years. The STA did not review OP 0209.1, which required local position verification after maintenance. As a result, he did not require this to be performed.

The root cause of the events was that the IST program had insufficient checks and balances to prevent a single personnel error from resulting in a missed IST.

The failure to perform IST of valve CV-4-2821 was inadequate communication following completion of work. At the time of this event, unit 3 was in mode 6, and unit 4 was in mode 5. With both units in modes 5 or 6, no STA is required to be on duty. This resulted in difficult communications and subsequent failure to identify the IST requirements'he failure to perform an adequate IST of valve CV-3-2819 was due to oversight by the STA, who was the acting IST Coordinator. The STA most likely did not review OP 0209.1, which required local position verification and valve stroke timing after maintenance . As a result, he did not require this to be performed .

NRC FORM SESA

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NRC Fotm 344A'983)

U.S. NUCLEAR REOULATORY COMMISSION LICENSEE EVENT REPORT {LER) TEXT CONTINUATION APPROVEO OMS NO. 3)9)~IOO EXPIRES: 8/31/48 FACILITY NAME lll OOCKET NUMSER )3) LER NUMSER (4) PACE )3)

YCAR SCQUCNTIAL N9g ACV lt ION NUM Cll Kok NUMOCll Turkey Point Unit 4 o s o o o 8 7 -1 5 01 04 OF 05 TEXT ///moro tpocoit /oco/)od, oto oddidooo/I/RC Form 3////A'/ OT)

ANALYSIS OP EVENT One of the ways in which the release of fission products from the containment is limited is by the isolation of process lines by the Containment Isolation System (CIS). The CIS imposes double barriers in each line which penetrates the containment. While valve CV-956B was technically OOS during this event, it was capable of performing its design function had it been necessary. This was demonstrated by the initial PM test, and confirmed by the initial and final IST s.

Additionally, during the time that valve CV-956B was inoperable, the redundant containment isolation valve, CV-953, was operable.

While valve CV-4-2821 was technically OOS during this event, it was capable of performing its design function had that been necessary. This was confirmed by the regularly scheduled IST which was performed on September 8, 1987. No work was performed on this valve between June 13 and September 8, 1987.

While valve CV-3-2819 was technically OOS during this event, it was capable of performing its design function had that been necessary. This was demonstrated by the initial PM test which was performed on June 30, 1987, and confirmed by the regularly scheduled IST which was performed on September 7, 1987. No work was performed on this valve between June 30 and September 7, 1987.

Based on the above, the health and safety of the public were not affected.

CORRECTIVE ACTIONS The following corrective actions were taken in order to centralize control of post-maintenance IST and to add checks to assure completion of IST prior to the return of equipment to service:

1) Valves CV-4-956B, CV-4-2821, and CV-3-2819 were in-service tested with satisfactory results .

2) Procedures AP 103.2, "Responsibilities of Operators and Shift Technicians on Shift and Maintenance of Operating Logs and Records," AP 190.19, "Control of Maintenance on Safety Related and Quality Related Systems," and AP 190.28, "Post Maintenance'Testing," were revised to assure that )the IST Coordinator or STA is notified prior to the initiation of work which will involve IST components.

3) Procedures 3/4-GOP-503, "Cold Shutdown to Hot Standby," and 3/4-GOP-301, "Hot Standby to Power Operation," were revised to require the IST Coordinator or STA to verify that all required IST has been completed prior to a mode change .

4) Procedure O-ADM-502, "In-Service Testing (IST) Program," was generated to centralize the requirements for all IST in one procedure .

5) Procedure AP 103.4, "In-Plant Equipment Clearance Orders," was revised to require the STA or the IST Coordinator to be named as a clearance holder for all clearances on IST components.

NRC SO/)M 344A Io All

NRC PoNR (SEA US. NUCLEAR REGULA'TORY COMMISSION I

((L(LII LICENSEE lNT REPORT (LERI TEXT CONTINU~N APPROVEO OMS NO, 3150W104 EXPIRESI 8/31/88 PACILITY NAME (ll OOCKET NUMBER (3( LER NUMSER (el PAGE (31 YEAR SEOUENTIAL REVISION NVMSER NUMEER Turkey Point Unit 4 o s o o o 2 5 1 8 7 0 I 5 01 05 OF 0 5 TENT //awe <<>>ee N IEEMSSIE NPP /SNand N/IC %%d/IR 3(ISAE/ (IT(

6) Procedure O-ADM-701, "Plant Work Order Preparation," was revised to require STA or IST Coordinator notification, and to require the Operations Maintenance Coordinator to review post-maintenance testing and IST requirements for Technical Specification Limiting Condition of Operation and Mode applicability.

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ADDITIONAL DETAILS CV-4-956B Valve Operator Manufacturer: Masoneilan International, Inc. Operator Model Number: 38-2057.

Similar occurrences: LER s 251-85-23, 251-86-24 NRC EORM seeA RU S.GPO:Ieeb4 834 538/455 (8$ 3 I

JULY 0 6 1980 L-88-266 10 CFR 50.73 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555 Gentlemen:

Re: Turkey Point Units 3 and 4 Docket Nos. 50-250 and 50-251 Reportable Event: 251-87-15 (Revision 1)

Date of Event: July 15, 1987 Failure to Deactivate Inoperable Containment Isolation Valve Within 4 Hours as Required by Technical S ecifications Due to Personnel Error The attached Licensee Event Report revision is being submitted to discuss two previous incidents found during a recent documentation review. Our original report was issued August 14, 1987 in FPL letter L-87-332.

A two week extension on the submittal of this LER was requested of and granted by the NRC Region more time to analyze the root cause II Staff to allow and take proper corrective actions.

Very truly yours, W. . Conw Senior Vice President Nuclear WFC/SDF/gp Attachment cc: Dr. J. Nelson Grace, Regional Administrator, Region II, USNRC Senior Resident Inspector, USNRC, Turkey Point Plant SDF3Rev1.LER