ML18005A813

LER 89-001-01:on 890116,plant Tripped Due to Low Condenser Vacuum Caused by Personnel Error on Valve Lineup.Shift Foreman Clearance Placed on Manual Valve & Repair to Motor Operated Valve completed.W/890315 Ltr

ML18005A813
Person / Time
Site:	Harris
Issue date:	03/15/1989
From:	Schwabenbauer, Watson R CAROLINA POWER & LIGHT CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
HO-890027-(O), LER-89-001, LER-89-1, NUDOCS 8903230055
Download: ML18005A813 (9)

Text

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ACCESSION NBR:8903230055 DOC.DATE: 89/03/15 NOTARIZED: NO DOCKET g 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 89-001-01:on 890116,plant trip due to low condenser vacuum caused by personnel error on valve lineup.

W/8 DISTRIBUTION CODE: IE22D COPIES RECEIVED:LTR i ENCL TITLE: 50.73 Licensee Event Report (LER), Incident Rpt, etc.

L SIZE:

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/DS P 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/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 SIB 9A 1 1 NUDOCS-ABSTRACT 1 1 EG F E 02 1 1 RES/DSIR/EIB 1 1 R RAB 1 1 RGN2 FILE 01 1 1 EXTERNAL EG&G WILLIAMSi S 4 4 FORD BLDG HOY i A 1 1 H ST LOBBY WARD 1 1 LPDR 1 1 NRC PDR 1 1 NSIC MAYS,G 1 1 NSIC MURPHY,G.A 1 1 NVZE 'IO ALL "BIDS" BECZPIEMIS:

.S PLEASE HELP US K) REDUCE WASTE! CXNI'ACI'IHE DOCX3NERl'GVIBOL DESK, BOOM Pl-37 (EXT. 20079) TO ELQ4IKQ'E YOUR NAME PRCH DZSXVGBVZZQN LXSTS FOR DOCUKWZS YOU DON'T NEEDt TOTAL NUMBER OF COPIES REQUIRED: LTTR 45 ENCL 44

NRC Form 366 US. NUCLEAR REOULATORY COMMISSION (9.63)

APPROVED OMB NO. 31604104 LICENSEE EVENT REPORT (LER) EXPIRES: 6/31/SS FACILITY NAME (I) DOCKET NUMBER 12) PA E 3 TITLE (el SHEARON HARRIS NUCLEAR POWER PLANT UNIT ONE 050004001OFO PLANT TRIP DUE TO LOW CONDENSER VACUUM CAUSED BY PERSONNEL ERROR ON VALVE LINEUP EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (Sl MONTH DAY YEAA YEAR 66QUENTIAL 69N REVenN MONTH DAY YEAR FACILITYNAMES DOCKET NUMBER(S)

NUMBER NUMBER 0 5 0 0 0 0 1 16 89 89 001 0 1 31 589 0 5 0 0 0 THIS REPORT IS SUBMITTED PURSUANT T 0 THE REQUIREMENTS OF 10 cFR ()I (Check onr or more of the follovfino/ (11 OPERATING MODE (9) 20.4020r) 73.7((h) 20.405(cl 50.73(e) (2) liv)

POWER 20405( ~ ) I I )(I) 50.36(c)(1) 50.73(el(2) (vl 73.71(cl LEVEL (10) 1 0 0 20.405( ~ ) ( I I (6) 50.36 (cl (2) 50.73(el(2) (vill OTHER /Specify /n Ahrrrect hrloyrrnrfln Text. HIIC Form 20.405( ~ ) (I ) (ill) 50.73( ~ l(2)(I) 50.73(o) (2) (vill((A) 3664/

20405(el(1) (Iv) 50.73(o)(2) ill) 50.73(ol(2)(vill) (6)

As@gg4$ ..' '..~ .. Pg: 20.405(e) ( 1 ) (v) 60.73( ~ l(2)(ill) 60.73(el(2)(el LICENSEE CONTACT FOR THIS LEA (121 NAME TELEPHONE NUMBER AREA CODE RICHARD SCHWABENBAUER REGULATORY COMPLIANCE TECHNICIAN 919 362 -2 6 69 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13) y Ornj yr h A CAUSE SYSTEM COMPONENT MANUFAC REPORTABLE MANUFAC EPORTABLE F..

TURER TO NPRDS P CAUSE SYSTEM COMPONENT TVRER TO NPRDS I3e>e L~&5 SUPPLEMENTAL REPOAT EXPECTED (14) MONTH I%WCDAY YEAR EXPECTED SUBMISSION DATE (16)

YES Ill yrr, comp/err EXPECTED SUS4IISSIOH DATE/ X NO ABSTRACT ILlmlt to /AX) rprcrr, I.r., rpproxlmetrly /I/tern I/noir.rpece rypevvrltten llnrrl 116)

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 the 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 personnel error in not having a shift foreman clearance on a manual valve which was required to be in an abnormal pos2.tion, 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 repair to the motor operated valve will be 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. C 7 ~()(355 +908 1 ADOCK 0 'DR NRC Form 366 S lt(

a NRC form 38EA U.S. NUCLEAR REOULATORY COMMISSION (943 I LICENSEE EVENT REPORT ILER) TEXT CONTINUATION APPROVEO OMS NO. 3(SOW(Od EXPIRES: 8/31/88 FACILITY NAME (11 DOCKET NUMSER (21 LER NUMSER LEI PACE (3)

SEQUENTIAL REVISION SHEARON HARRIS NUCLEAR POWER YEAR >>TV' NUMEEA Ajj NUM EA PLANT UNIT ONE 0 5 0 0 0 4 0 0 9 0 0 1 010 2 OF 0 6 TEXT ///moro <<>>o>> /I torrokor/, o>> tr/r/roor>>//YRC %%dnn 30$ A't/117I 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 1AC-346 was not fully shut and proceeded to open valve 1AC-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 1AC-346. Opening valve 1AC-345 allowed atmospheric pressure to enter the Auxiliary Steam Condensate tanks (EIIS:SA) vents through valve 1AC-346 which was approximately one half open. Valve lAC-349 (EIIS:SA) opened in an attempt to maintain the required back pressure on the Auxiliary Steam Condensate tanks. Thi,s resulted in a direct path from the atmosphere to the Main Condenser (EIIS:SG). A rapid loss of condenser vacuum followed and Turbine Generator (EIISlTA) load decreased and at 1S18 hours 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 14:50 Removal of clearance authorized.

15:10 Approximate time of opening valve 1AC-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 68" in a few moments). The Load Dispatcher reported a plant load decrease.

15:14:46 High hotwell level alarm.

15:1S:1S 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.

15:18:15 Turbine trip on low vacuum.

15:18:15 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 1AC-346 and placed the switch to "SHUT."

NAC FQrIM dddA ~ r U.S OPO:19SS 0.5 2d 538/4 65 19531

NRC Form 366A U.S. NUCLEAR REOULATORY COMMISS/ON (983)

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVEO OMS NO. 3150&I 04 EXPIRES: 8/31/88 FACILITY NAME (I ) OOCKET NUMBER LTI LER NUMSER (6) PACE 13)

YEAR yLRI SEQVENTIAL P..S

+Rr REVISION NVM ER NVM ER SHEARON HARRIS NUCLEAR POWER PLANT - UNIT ONE 4 0 8 9 001 01 0 3 OF 0 6 o s o o o TEXT ///more s>>oo 4I SIRI/red, ew acWOo'nsi HRC For/r/38543/(IT)

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 lAC-346 (EIIS:SA) which was issued to perform preventive maintenance on the operator for the valve. Personnel were not aware that valve 1AC-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 1AC-346. Opening valve 1AC-345 allowed atmospheric pressure to enter the Auxiliary Steam Condensate tanks (EIIS:SA) vents through valve 1AC-346 which was approximately one half open. Valve 1AC-349 (EIIS:SA) opened in an 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 14:50 Removal of clearance authorized.

15:10 Approximate time of opening valve 1AC-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 68(E 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.

15:18:15 Turbine trip on low vacuum.

15:18:15 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 1AC-346 and placed the switch to "SHUT."

NRC FORM SEEA *U.S.GPO.)088-0.824 53S/455 (6831

NRC form Sr)SA U.S. NUCLEAR REOULATORY COMMISSION

)943 I LICENSEE EVENT REPORT (LERI TEXT CONTINUATION APPROVED OMS NO, 3)50&)04 EXPIRES: 8/31/88 FACILITY NAME 11I OOCKET NUMSER 12) LER NUMBER (5) PACE IS)

SHEARON HARRIS NUCLEAR POWER YEAR '3 yrrr. SEOVENTIAL NVMSER OOS

>>4 REVISION NVM ER PLANT UNIT ONE OF 0 5 0 0 0 0 8 0 1 0 1 TExT ///moro c/>>oo /c o))cr'orL rr>> a//Coo'ono/I///Ic Form 3///)A'c/ IIT)

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, 1AC-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 lAC-346, as a minimum a Caution Tag should have also been placed on 1AC-345. In retrospect a shift foreman clearance on lAC-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 1AC-345 to remain shut.

C ~ The restoration was not correct in that the position of lAC-346 was not verified prior to removing the clearance and repositioning lAC"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 after 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-,llll 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.

NIIC cORM SOSA *U.S.OPO;1985.0.524 538/E55

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NRC Form 3ddA V.S. NUCLEAR REOULATORY COMMISSION (983 I LICENSEE EVENT REPORT ILER1 TEXT CONTINUATION APPROVEO OMB NO. 3(50&104 EXPIRES: 8/31/BB FACILITY NAME (II DOCKET NUMBER (2) LER NUMBER (8) PACE (3I SEQUENTIAL <rlrj REVISION YEAR (%@

loo:. NUM E rl " y NUM EA SHEARON HARRIS NUCLEAR POWER PLANT UNIT ONE 0 5 0 0 0 4 O 0 8 9 0 0 1 0 1 Os o"0 6 TEXT ///moro dpodo Ir roouuNE uoo ~HRC Form 3//SAY/ (ITI ANALYSIS: (continued)

Another event reported involving an incorrect valve restoration lineup and resulting in a plant trip, was reported in LER-87-041"00 ACTION/ACTION TO PREVENT RECURRENCE: 'ORRECTIVE

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 practi.ces 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 1AC-345 pending the repair of 1AC-346.

4. The repair of valve 1AC-346 will be completed.

NIIC FORM SddA o U.S GPO(9884424 538/d55 (983 I

Auxiliary SLeans Condensale SyslelTI lkeLul.n Vel>t,illg 1)all>

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plplny I AC-305 PY-01 05h 1 Ox I lain Condenser Co nnec llon I AC- 3 ~ 17 I hC- 309 1 hC- 350 <<169 3AC- 312 3AC-313 3AC-316 O'Halnlalns Auxlllary Condansale Syslam backpreseure al I ps' M.P.D. N.l'.D. B.A.D.

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Form 244 C~L Carolina Power 8 Light Company Company CorresponCence HARRIS NUCLEAR PROJECT P.O. Box 165 New Hill, NC 27562 BAR 35 tgsg File Number.'HF/10-13510C Letter Number: HO-890027 (0)

U.S. Nuclear Regulatory Commission ATTN: NRC Document Control Desk Washington, DC 20555 SHEARON HARRIS NUCLEAR POWER PLANT UNIT 1 DOCKET NO. 50-400 LICENSE NO. NPF-63 LICENSEE EVENT REPORT 89-001-01 Gentlemen.'n 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.

Revision 1 is being submitted due to a change in the reported status of valve repair.

Very truly yours, a~/-'.

A. Watson Vice President Harris Nuclear Project RJS:msb Enclosure cc: Mr. R. A. Becker (NRR)

Mr. W. H. Bradford (NRC SHNPP)

Mr. S. D. Ebneter (NRC - RII)

MEM/LER-89-001/1/OS1