ML18005A780

LER 89-001-00:on 890116,while Restoring Direct Vent Path to Atmosphere,Turbine Load & Turbine Trip Occurred Due to Low Condenser Vacuum.Caused by Lack of Shift Foreman Clearance on Manual Valve.Personnel counseled.W/890215 Ltr

ML18005A780
Person / Time
Site:	Harris
Issue date:	02/15/1989
From:	Schwabenbauer, Watson R CAROLINA POWER & LIGHT CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
HO-890018-(O), LER-89-001-02, LER-89-1-2, NUDOCS 8902220208
Download: ML18005A780 (8)

Text

AC CE1ZRATED 1STKBU'll ON DEMONS ETIO'.i SYSTEM REGUL . DRY INFORMATION DISTRIBUTE SYSTEM (RIDS)

ACCESSZ~)N NBR:8902220208 DOC.DATE: 89/02/15 NOTARIZED: NO DOCKET S.

FACIL:~50-400 Shearon Harris Nuclear Power Plant, Unit 1, Carolina 05000400 AUTH. NAME AUTHOR AFFILIATION SCHWABENBAUER Carolina Power. & Light Co.

WATSON,R.A. Carolina Power & Light Co*.

RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 89-001-00:on 890116,plant tripped due to low condenser vacuum. Caused by personnel error on valve lineup.

I W/8 ltr.

DISTRIBUTION CODE ZE22D COPIES RECEIVED:LTR / ENCL Q SIZE:

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

NOTES:Application for permit renewal filed. 05000400 RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-1 LA 1 1 PD2-1 PD 1 1 BECKER,D 1 1 INTERNAL: ACRS MICHELSON 1 1 ACRS MOELLER 2 2 ACRS WYLIE 1 1 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DSP 2 2 ARM/DCTS/DAB 1 1 DEDRO 1 1 NRR/DEST/ADE 8H 1 1 NRR/DEST/ADS 7E 1 0 NRR/DEST/CEB 8H 1 1 NRR/DEST/ESB 8D 1 1 NRR/DEST/ZCSB 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 ~

SIB 9A 1 1 NUDOCS-ABSTRACT 1 1 1 1 R RES/DSIR/EZB 1 1 RES/DSR/PRAB 1 1 RGN2 FILE 01 1 1 I EXTERNAL: EG&G WILLIAMS,S 4 4 FORD BLDG HOY,A 1 1 H ST LOBBY WARD 1 1 LPDR 1 1 NRC PDR 1 1 NSIC HARRIS,J 1 1 NSIC MAYS,G 1 1 NVZE 'IO ALL RING" RECIPZENZS:

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TOTAL NUMBER OF COPIES REQUIRED: LTTR 45 ENCL 44

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NRC Form 36d U.S. NUCLEAR REOULATORY COMMISSION (04)3)

APPAOVED OMB NO. 31600104 EXPIRES: 6/31/SS LICENSEE EVENT REPORT ILER)

FACILITY NAME (I) DOCKET NUMBER (2) PACE 3 SHEARON HARRIS NUCLEAR POWER PLANT UNIT ONE 0 5 0 0 04 00 1 OFO 6 Tl'TLE (4)

PLANT TRIP DUE TO LOW CONDENSER VACUUM CAUSED BY PERSONNEL ERROR ON VALVE LINEUP FVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILI'TIES INVOLVED (Sl MONTH DAY YEAR YEAR

<<~~'I sdoUENTIAL DAY YEAR FACILITY,NAMES DOCKET NUMBERIS)

N@ NUMBER 'A~$: NUMSSA MONTH 0 5 0 0 0 0 1 689 89 0 0 1 00 215 89 0 5 0 0 0 THIS REPORT IS SUBMITTED PUASUANT T 0 THE REOUIREMENTS OF 10 CFR (I: (Cheek onr or, more of the follovflnP) (11 OPERATINQ MODE (6) 20.402(d) 20.405(e) 50.73(aH2) Ov) 73.71(d)

POWER 20.405 (a l (I) Ill SOW(e) (I ) 50.73(sH2) (v) 73.71(cl LEYEL 1 0 0 20.405 (s) (I ) (5) 50.36(el(2) 50.73(sl(2)(vill oTHER fSpeclfy In Aottrect INlow rnd In Trit, HRC Ferns 20.405( ~ l(1) Alii d0.73(s) (2)(l) 50.73( ~ ) (2)(alii) (A) 366A) 20,406( ~ l(1) (Iv) 50.73(a) (2)(6) 50.73( ~ ) (2) (vdl l(S) 20.405( ~ l(1) (v) d0.73(a) (2)(ill) 50,73( ~ )(2)(xl LICENSEE CONTACT FOR THIS LER (12)

NAME TELEPHONE NUMBER AREA CODE RICHARD SCHWABENBAUER REGULATORY COMPLIANCE TECHNICIAN 919 36 2-2 6 9

'NjN COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCAIBED IN THIS REPOR'7 (13)

MANUFAC. RE'OR" L gj'j" ""&%P MANUFAC. EPORTABLE CAUSE SYSTEM COMPONENT CAUSE SYSTEM COMPONENT TUBER < TURER TO NPRDS

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SUPPLEMENTAL REPORT EXPECTED 114) MONTH DAY YEAR EXPECTED SU 5 M I 5510 N DATE (161 YES Ilfyer, complete EXPECTED SUBAIISSIDH DATEI NO ABsTRAGT ft.lmlr to ts00 rprcer, I e., epproilmerrly fifteen alnple specs typevwirten hnNI lid)

The plant was operating in Mode 1, Power Operation, at 100 percent reactor power on January 16, 1989. Plant personnel were in the process of removing a clearance on a valve in the Auxiliary Steam Condensate Tank vent line system to the Main Condenser. During the course of the restoration a direct vent path to tlie atmosphere from the Main Condenser was established due to a mispositioned valve and resulted in a rapid loss of condenser vacuum. A reduction of turbine load ensued and a turbine trip at 1518 hours0.0176 days <br />0.422 hours <br />0.00251 weeks <br />5.77599e-4 months <br /> due to low condenser vacuum. The turbine trip was immediately followed by an automatic reactor trip and a plant shutdown.

The Auxiliary Feedwater System actuated on Steam Generator lo-lo level to maintain water levels and the Main Steam Isolation Valves were closed to limit plant cooldown and the plant was stabilized in Mode 3, Hot Standby.

The cause of the event was yersonnel error in not having a shift foreman clearance on a manual valve which was required to be in an abnormal position and providing insufficient restoration details for the proper valve lineup.

Corrective Actions include: the appropriate personnel have been counselled, the event has been discussed stressing the need for good working practices, a shift foreman clearance placed on the manual valve, and valve repair has been completed.

There were no safety consequences as a result of this event as all plant systems functioned as required with the exception of the Turbine Driven Auxiliary Feedwater Pump which tripped after 15 seconds of operation.

This event is being reported in accordance with 10CFR50.73(a)(2)(iv) as an Engineered Safety System Feature and Reactor Protection System actuation.

8'7)02220200 89021 5 PDR ADOCK 05000400 NAC Form Sd6 S PNU (0 53)

NRC Perm 3SBA U.S. NUCLEAR REGULATORY COMMISSION I04)31 e LICENSEE EVENT REPORT ILER) TEXT CONTINUATION APPROVED OMB NO, 3)50&104 EXPIRES: 8/31/88 P*CILITYNAME llI DOCKET NUMBER 12) LER NUMBER (8) PACE 13)

YEAR 838', SSOUSNTIAL >>SVISION SHEARON HARRIS NUCLEAR POWER NUMBER <: 2 IIVM S>>

PLANT UNIT ONE o s o o o 4 0 0 1 0 0 0 2OF0 6 TEXt /8'mOr>> SPPSP N /PS>>PRE WP AS)/d>>d/ //RC An>> 3/)SAT) 117)

DESCRIPTION:

The plant was operating in Mode 1, Power Operation, at 100 percent reactor power on January 16, 1989. Plant personnel were in the process of removing a clearance on valve 1AC-346 (EIIS:SA) which was issued to perform preventive maintenance on the operator for the valve. Personnel were not aware. that valve lAC-346 was not fully shut and proceeded to open valve lAC-345 (EIIS:SA)

(refer to attached sketch) before going to Motor Control Center (MCC)-IE31 (EIIS:ED) to restore power to the valve operator for lAC-346. Opening valve lAC-345 allowed atmospheric pressure to enter the Auxiliary Sl.earn Condensate tanks (EIIS:SA) vents through valve lAC-346 which was approximately one half open. Valve 1AC-349 (EIIS:SA) opened in'n attempt to maintain the required back pressure on the Auxiliary Steam Condensate tanks. This resulted- in a direct path from the atmosphere to the Main Condenser (EIIS:SG). A rapid loss of condenser vacuum followed and Turbine Generator (EIIS:TA) load decreased and at 1518 hours0.0176 days <br />0.422 hours <br />0.00251 weeks <br />5.77599e-4 months <br /> the turbine tripped on low condenser vacuum. The turbine trip was immediately followed by an automatic reactor trip and a plant shutdown. The following is a sequence of events leading to the trip:

HOUR EVENT 14:SO Removal of clearance authorized.

1S'10 Approximate time of opening valve )AC-345.

15'14 Initial reports of turbine load decreasing with reactor power remaining nearly constant. An Auxiliary Operator reported a rapid increase in condenser sight glass level (63" to 68LT in a few moments). The Load Dispatcher reported a plant- load decrease.

15:14:46 High hotwell level alarm.

15:15:15 Low Condenser Vacuum Alarm.

15:15:37 High Hotwell Temperature Alarm. Operators attempted to control turbine load by taking manual control. Load on the DEH system remained stable.

1S:18:15 Turbine trip on low vacuum.

15:18:1S Reactor trip due to turbine trip.

15:23 Approximate time that condenser level reached 100 inches and condenser pressure reached 14.3 psi.

15:40 Radwaste Control Operator removed the clearance tag from the control switch for lAC-346 and placed the switch to "SHUT."

NRC PQ>>M Sddd 1043) ~ U 8OPO 1088 082d 838/d$ 8

NRC form 358A U.S. NUCLEAR REGULATORY COMMISSION 18831 LICENSEE EVENT REPORT ILERI TEXT CONTINUATION APPROVEO OM8 NO. 3150 0104 EXPIRES: 8/31/88 fACILITYNAME Ill OOCKET NUMSER 12l LER NUM8ER ISI ~ AGE 13)

YEAR QP: SSOVSNTIAL

~if IISVISION NVM f II NVMOSFI SHEARONIHARRIS NUCLEAR POWER PLANT UNIT ONE osooo40 8 9 0 0 1 0 003 OF 0 6 TEXT ///moFO FAFCO/F IOOv/FOE MFF Oddheno/H/IC fomI 3/ISA'F/IITI DESCRIPTION: (continued)

All three Auxiliary Feedwater (AFW) Pumps (EIIS:BA) started on Steam Generator (SG) (EIIS:TB) lo-lo level to maintain SG water levels and the Main Steam Isolation Valves (MSIV) (EIIS:SB) were shut to prevent excessive plant cooldown. The plant was then stabilized in Mode 3, Hot Standby.

All plant systems functioned as required with the exception of the, Turbine Driven AFW pump which tripped after 15 seconds of operation. The cause of the Turbine Driven AFW pump trip was excessive moisture in the steam supply line to the pump. A program to periodically drain the line of moisture was instituted and Operations Surveillance Test (OST)-1111, Auxiliary Feedwater Pump 1X-SAB Operability Test Monthly Interval Modes 1-2-3, was performed and successfully completed to verify the operability of the pump.

A normal plant start up followed and the plant was returned to service at 0601 hours0.00696 days <br />0.167 hours <br />9.937169e-4 weeks <br />2.286805e-4 months <br /> on January 17, 1989.

CAUSE'alve 1AC-346 has a history of problems that must be considered in order to understand this event. A valve seat leak was reported by Work Request (WR) 87-ALATl on May 1, 1987, and a torque switch problem documented by WR 86"ABCF2 on January 21, 1986. These job orders are not complete. WR 88-AQSY1 was issued on July 8, 1988, because the valve would not fully shut and gave an intermediate position indication. Operators found that. a slight movement of the manual operator was sufficient to give a fully shut indication so the problem was assumed to be related to the limit switches. A deficiency tag (011882) was placed on the operating switch in the Radwaste Control Room. On August 30, 1988, a Caution Tag (RW88-086) was placed on the control switch.

This tag instructed operators to shut 1AC-345 since 1AC-346 would not fully shut. 1AC-345 is designated a "Normally Open" valve by Operating Procedure (OP)-130.01,- Auxiliary Steam and Condensate System Operating Procedure. On October 30, 1988, valve 1AC-346 was added to the Radwaste Control Room Plant Programs (PLP)-702, Independent Verification, log (entry RW88-071) as requiring independent verification. PLP-702 does not require independent verification of valve lineups for the Auxiliary Steam and Condensate System.

The use of a PLP-702 log entry was elective in this case. This entry was deleted on December 18, 1988, when the plant shutdown for repairs and a subsequent entry was not made when the plant was returned to service.

WR 88-KXY395 was issued in September of 1988 to conduct routine maintenance on the Limitorque valve operator for 1AC-346. This maintenance was scheduled due on September 23, 1988, and overdue February 82 1989. Clearance RW89-63 was requested and issued on January 16, 1989, to accomplish WR 88-KXY395. The work to be performed was routine lubrication of the valve operator.

NIIC FOAM SOFA *U S GPO 1888.0.82O 538/455 1883 I

NRC FOIM 3EEA V.S. NUCLEAR REOULATORY COMMISSION (94)3)

LICENSEE EVENT REPORT {LER) TEXT CONTINUATION APPROVED OM8 NO. 3150&ICE EXPIRES: 8/31/88 FACILITY NAME (I) OOCKET NUMSER (2) LER NUMSER LE) PACE (3)

YEAR EEOUENTIAL AEVIEION Ps/ NUMEEA NUM ER SHEARON HARRIS NUCLEAR POWER UNIT ONE 'LANT o s o o o 4 o 001 00 04 OF TEXT /N //ERE E/MCE /I /EEUPN/, UEP EEM/(NM///RC FERN 355A3/ (17)

CAUSE: (continued)

When clearance RW89-63 was prepared the placement sequence was clearly specified but the existence of a caution tag on valve 1AC-346 was not noted on the clearance and no restoration sequence was, specified. The lubrication maintenance was conducted in a routine manner and should not have affected valve position.

When the clearance was removed, the restoration, sequence consisted of verbal instructions by the Radwaste Control Room to a Radwaste operator. As a result, lAC-345 was opened to place it in the position required by OP-130.01 before any attempt to shut or verify the position of 1AC-346. This caused the loss of condenser vacuum since 1AC-346 was in an undetermined intermediate position.

There are several factors that contributed to this event:

a. When the Caution Tag was initially prepared for 1AC-346, as a minimum a Caution Tag should have also been placed on lAC-345. In retrospect a shift foreman clearance on 1AC-345 would have been preferable.

b. Personnel involved with preparing the clearance did not adequately research the clearance. This research would have revealed the need for

)AC-345 to remain shut.

C ~ The restoration was not correct in that position of lAC 346 was not verified prior to removing the clearance and repositioning 1AC-345. The plants standard practice for motor operated valves is to restore power, confirm correct position or use the control switch to reposition, and then position other manual isolation valves.

ANALYSIS:

There were no safety consequences as a result of this event. All plant systems with the exception of the Turbine Driven AFW pump responded as required and the plant was stabilized in Mode 3 at normal no load temperature and pressure. Normal SG water levels were restored with the Auxiliary Feedwater System. The Turbine Driven AFW pump tripped'fter 15 seconds of operation due to excessive moisture in the steam supply line to the pump. A program to periodically drain the line of moisture was instituted and OST-1111 performed to verify operability of the pump.

This event is being reported in accordance with 10CFR50.73(a)(2)(iv) as an Engineered Safety System Feature (EIIS:JE) and Reactor Protection System (EIIS:ID) actuation.

NRC FORM EEEA (953) R V 5 GPO 1985.0 524 538/E55

NRC Fo?m 3SSA U.S. NUCLEAR REGULATORY COMMISSION (943)

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVEO OMS NO. 3(SCMIOl EXPIRES: 8/31/88 FACILITY NAME (II DOCKET NUMBER (21 LER NUMBER IS) I?AGE (3)

YEAR SEOUENT/AL g/8 REV/SION NUM TR  ??? NQMSTA SHEARON HARRIS NUCLEAR POWER PLANT, UNIT ONE o s o o o 4 0 1 0 0 05 oFO 6 TEXT l/lmo/o F/?Foo /F /Founded, oFF edWo'onal /VRC Fom? 3/ISA'F/ (IT(

ANALYSIS: (continued)

Another event reported involving an incorrect valve restoration lineup and resulting in a plant trip, was reported in LER-87-041-00.

CORRECTIVE ACTION/ACTION TO PREVENT RECURRENCE:

1. The applicable personnel involved were counselled and disciplinary action was taken.

2. The event was discussed by the Operations Manager in a Shift Foreman meeting. The meeting stressed: a) the necessity for adequately researching clearances, b) the necessity for, periodically observing activities being performed outside the control room to insure procedures and good working practices are being implemented properly, and c) the necessity of using a shift foreman clearance when manipulation of a component could result in a challenge to the plant.

3. A shift foreman clearance was placed on valve lAC-345 pending the repair of lAC-346.?

4. The repair of valve 1AC-346 has been completed.

NRC FORM 3SSA F U,SGPO 1088 0.82l 838/lSS (983 I

Auxiliary Steam Condensate System Return Yenting Path Atmosphere 1AC-346 6N piping lhC- 345 PY-0 l 85h 1 0

Main 8" Condenser piping Connection lhC-347 lhC-349 1AC-350 <<169 3AC- 312 3AC--313 3AC- 316 (9 Maintains Auxiliary Condensate Syslem backpreseur'e at I W.P.B. V/.P.B. R.A.B.

ps' huxiliar y Auxiliary Auxiliary Steam Sleam Steam Condensate Condensate Condensate Tank Tank Tank I - 4h 1-4D 1-4:

(2000 gal) (2000 gal) (220 gal)

Carolina Power & Light Company A

HARRIS NUCLEAR PROJECT P.O. Box 165 New Hill, NC 27562 FEB 15 )989 File Number'SHF/10-13510C Letter Number'HO-890018 (0)

U.S. Nuclear Regulatory Commission ATTN: NRC Document Control Desk Washington, DC 20555 SHEARON HARRIS NUCLEAR POWER PLANT UNIT 1 DOCKET NOo 50-400 LICENSE NO. NPF-63 LICENSEE EVENT REPORT 89-001-00 Gentlemen'.

In accordance with Title 10 to the Code of Federal Regulations, the enclosed Licensee Event Report is submitted. This report fulfills the requirement for a written report within thirty (30) days of a reportable occurrence and is in accordance with the format set forth in NUREG-1022, September 1983.

Very truly yours, R. A. Watson Vice President Harris Nuclear Project RJS:acm Enclosure cc'Mr. R. A. Becker (NRR)

Mr. W. H. Bradford (NRC SHNPP)

Mr. M. L. Ernst (NRC RII)

MEM/LER-89-001/1/OS1