ML18005A818

LER 89-001-02:on 890116,w/plant in Mode 1,reduction of Turbine Load Ensued & Turbine Trip Occurred Due to Low Condenser Vacuum Resulting in Automatic Reactor Trip.Caused by Personnel Error.Personnel counselled.W/890323 Ltr

ML18005A818
Person / Time
Site:	Harris
Issue date:	03/23/1989
From:	Schwabenbauer, Watson R CAROLINA POWER & LIGHT CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
HO-890038-(O), LER-89-001, LER-89-1, NUDOCS 8903270363
Download: ML18005A818 (8)

Text

REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:8903270363 DOC.DATE: 89/03/23 NOTARIZED: NO DOCKET FACIL:50-400 Shearon Harris Nuclear Power Plant, Unit 1, Carolina 05000400 AUTH. NAME AUTHOR AFFILIATION SCHWABENBAUER Carolina Power 6 Light Co.

WATSON,R.A. Carolina Power 6 Light Co.

RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 89-001-02:on 890116,plant trip due to low condenser vacuum caused by personnel error on valve lineup.

W/8 ltr.

DISTRIBUTION CODE: IE22D COPIES RECEIVED:LTR ENCL i SIZE: 7 TITLE: 50.73 Licensee Event Report (LER), Inci ent 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/DS P 2 2

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DEDRO NRR/DEST/ADE 8H 1

1 1

1 IRM/DCTS/DAB NRR/DEST/ADS 'E 1 1

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 I NR~R DR~IS S B 9A 1 1 l.

NUDOCS-ABSTRACT 1 1 gKEG~IZ2r > 02 1 RES/DSIR/EIB 1 1 RES/DSR/PRAB 1 1 R RGN2 FILE 01 1 1 I

EXTERNAL: EG&G WILLIAMS,S 4= 4 FORD BLDG HOY g 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 h

NOTE 'IO ALL "RIDS" RECIPIENIS'IZASE HELP US 'IQ REDUCE WASTEl CDNZACr 'IHE DOCUMENT CONTROL DESK ROOM Pl-37 (EXT. 20079) IO ZLG62VZE YOUR NAME FRY DIPHKBVZIGN LISTS FOR DOCUMEÃI'S YOU DGH'T NEED!

TOTAL NUMBER OF COPIES REQUIRED: LTTR 45 ENCL 44

NRC Form 366 U.S. NUCLEAR REGULATORY COMMISSION (0 83)

APPROVED OMB NO. 31604104 EXPIRES: 8/31/88 LICENSEE EVENT REPORT (LER)

DOCKET NUMSER (2) PAGE 3 FACILITY NAME (II SHEARON HARRIS NUCLEAR POWER-PLANT UNIT ONE 0 5 0 0 0 g 1 OF TITLE I ~ I PLANT TRIP DUE TO LOW CONDENSER VACUUM CAUSED BY PERSONNEL ERROR ON VALVE LINE P EVENT DATE (5) LFR NUMBER (6) REPORT'ATE (7) OTHER FACILITIES INVOLVED (8)

MONTH DAY YEAR YEAR SEQUENTIAL rlsvislorr MONTH OAY YEAR FACILITYNAMES DOCKET NUMBER(S)

NVMSER >))r NUMBER 0 5 0 0 0 0 116 8 9 8 9 0 0 1 0 2 03 238 9 0 5 0 0 0 THIS REPORT IS SUBMITTED PURSUANT 7 0 THE REOUIREMENTS OF 10 CFR (): IChech one or more of the follovflnpi (11 OPERATING MODE (6) 20A02(b) 20.405(c) 60.73(a)(2)(lv) 73.7$ (6)

POWER 20AOS ( ~ ) (I ) (I) 50.36(c) (I ) 50.73( ~ )(2)(v) 73.71(c)

LEVEL

00) 1 00 20A06(a) (I) (EI 50.36(c)(2) 50.73(a) (2)(vill)

(2) (vll) OTHER ISPeclfy in Ahrcrect Oelovv ond In Text, NRC Form 20.405(a) (I ) (ill) 50.73( ~ ) (2) (I) 50.73(a) (2) (vill)I A) 366AI h+PcjP/gp 20A06 (a) (I ) (Iv) 60.73(a) (2)(ll) 50.73(a) (8)

)Eke@. 6'. +AN: 20.405( ~ ) (I ) (vl 50.73(a)(2)(ill) 60.73(a)(2)(x)

LICENSEE CONTACT FOR THIS LER (12)

NAME TELFPHONE NUMBER AREA CODE RICHARD SCHWABENBAUER - REGULATORY COMPLIANCE TECHNICIAN 91 936 2-2 66 9 COMPLETE ONE LINE FOR EACI4 COMPONENT FAILURE DESCRIBED IN THIS REPORT (13I MANUFAC. REPORTABLE MANVFAC. REPORTABLE CAUSE SYSTEM COMPONENT CAUSE SYSTEM COMPONENT TURE'R TURER TO NPRDS TO NPRDS KP~)%~'

I,@.PC. X@

ops%(g)'))i~j P,A ~'.ci SUPPLEMENTAL REPORT EXPECTED (14I MONTH DAY YEAR EXPECTED SUBMISSION DATE I15)

YES Ilfyer, complete EXPECTED svBfyflSSIDH DATEI NO ABSTRACT ILimit to f400 rooter, i.e., approximately lilreen rlnple opere rypevyrirten liner) (16)

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 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 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.

8903270363 890323 PDR AD( (CK 050064(.')0 NRC Form 366 PDC FS 83)

NAC Foim 300A U.S, NUCLEAR REOULATOAY COMMISSION (943)

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVED OMS NO. 3(50&100 EXPIRES: 8/31/88 FACILITYNAME (11 DOCKET NUMBER (2) LER NUMSEA 10) ~ AOE (31 YEAR 50ovENT/*L Ioo2 REVISION NVMFER NVM ER SHEARON HARRIS NUCLEAR POWER PLANT UNIT 001 02 02 1

o s o o o4 00 8 9 OF 0 6 TEXT ///moro F/Moo /F /oqvoo//, Moo /AN/'ooo//YRC FCFm 300A'Fl ((7)

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 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 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. 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" in a few moments). The Load Dispatcher reported a plant load decrease.

15:14:46 High hotwell level alarm.

P 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 300A o U S OPO'(980.0.024 530/455 19831

NRC FRIm 3ddA U.S. NUCLEAR REGULATORY COMMISSION (943)

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVEO OMB NO. 3150-0)OE EXPIRES: 8/3l/88 FACILITY NAME 0) DOCKET NUMBER (21 LER NUMBER (5) PAGE (3)

YEAR SEOVENTIAL REV ISION NVMSER NVM ER SHEARON HARRIS NUCLEAR POWER PLANT UNIT ONE oF 0 5 0 0 0 0 TEXT I////RFS FPoco II /odvPRI, VFF FIR/R/ono/ IYRC F(Fm 355A'F I I(T)

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:

Valve lAC-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-ALAT1 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-AQSYl 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 gi've 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 8, 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.

NRC FORM ESSA RU.S GPO.1988 0-82E 538/455 (983)

NRC Form 355A U.S. NUCLEAR REGULATORY COMMISSION I94I3l LICENSEE EVENT REPORT (LERI TEXT CONTINUATION APPROVED OMS NO. 3150&104 EXPIRES; 8/31/88 FACILITY NAME 111 DOCKET NUMSER 12l LER NUMSER ISI ~ AOE 13)

YEAR .'re< sEQUENT/AL ++ip REyrsroN NvM TR To.f NUM eR SHEARON HARRIS NUCLEAR POWER PLANT UNIT ONE o s o o o 4 0 89 00 1 0 2 0 4 QF 0 6 TEXT ///more 4Peee lf /el/rkerL we //o/N/4/ F//IC Frem 3584'4/ IIT)

CAUSE: (continued)

When clearance RW89-63 was prepared the placement sequence was clearly specified but the existence of a caution tag on valve lAC-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 lAC-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 1AC-345 to remain shut.

C ~ The restoration was not correct in that the position'f 1AC-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 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.

NRC FORM 3444 e U.S GPO,1985 0 824 53S/455 19413 I

NRC Form 3ddA U.S, NUCLEAR REGULATORY COMMISSION

/943 I LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVED OMS NO. 3I50M104 EXPIRES: 8/3I/88 FACILITY NAME (II DOCKET NUMBER Ill LER NUMSER (8) PAGE IS)

SHEARON HARRIS NUCLEAR POWER PLANT YEAR IxcE Sf OVS NTIAL Ir>)X NVM SR aX/ Rf VISION NVM f FI UNIT ONE TEXT /// mare u>>ce */II/rkerLIr>>

ANALYSIS:

~ H/IC forrrr 355A'F/ Ill/

(continued) 0 5 0 0 0 4 0 0 Q 9 0 0 1 0 2 0. 5o'0 6 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 1AC-345 pending the repair of 1AC-346.

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

NRC FORM Sddo e U.S GPO.1085-0824 538/f55 ISA)

I ~

Auxiliary Steans Candensate System Return Yenting Path Almosphere 1AC-346 tI 6

piping I AC- 345 PY-0185A 1 ox Hain 8" Condenser pl ping Connecllon 1hC- 3 17 lhC- 349 1 AC- 350 <<169 3AC- 312 3AC-313 3AC-316 O~ Halnlalns Auxiliary Condensale Syslem backpreseure al ps' 1

Vf.P.O. W.P.D. B.A.B.

huxil lar y Auxiliary Auxiliary Sleam Sleam Steam Condenselo Condensolo Condensale Tank Tank Tank 1- 4h 1-40 1-AC (2000 gal) (2000 gal) (220 goi)

CRATE Carolina Power & Light Company J

HARRIS NUCLEAR PROJECT P.O. Box 165 New Hill, NC 27562 NAR 25 1989 File Number.'SHF/10-13510C Letter Number.'O-890038 (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 89-001-02 Gentlemen.'n accordance with Title 10 to the Code of Federal Regulations, the enclosed Licensee Event Report is submitted. The original report fulfilled 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 was submitted due to a change in the reported status of valve repair.

Revision 2 is being submitted due to a page sequence/duplication error.

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

Mr. W. H. Bradford (NRC SHNPP)

Mr. S. D. Ebneter (NRC RII)

MEM/LER-89-001/1/Osl