ML18012A578

LER 96-020-01:on 960906,inadvertent RWST Boron Dilution Event Occurred.Caused by Personnel Error.Operating Procedure Was Revised to Reflect locked-closed Designation for RWST Fill Valve 1DW-5.W/970317 Ltr

ML18012A578
Person / Time
Site:	Harris
Issue date:	03/03/1997
From:	Donahue J, Verrilli M CAROLINA POWER & LIGHT CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
HNP-97-035, HNP-97-35, LER-96-020, LER-96-20, NUDOCS 9703240125
Download: ML18012A578 (8)

Text

REGULATO CATEGORY 1y INFORMATION DISTRIBUTION SYSTEM (RIDS) t )

%ACCESSION NBR:9703240125 DOC.DATE: 97/03/03 NOTARIZED: NO DOCKET FACIL:50-400 Shearon Harris Nuclear Power Plant, Unit 1, Carolina 05000400 AUTH. NAME AUTHOR AFFILIATION VERRILLI,M. Carolina Power & Light Co.

DONAHUE,J.W. Carolina Power & Light Co.

RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 96-020-01:on 960906,inadvertent RWST boron dilution event occurred. Caused by personnel error. Operating procedure was revised to reflect "locked-closed" designation for RWST fill valve lDW-5.W/970317 ltr.

DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL SIZE:

TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc. E NOTES:Application for permit renewal filed. 05000400 RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-1 PD 1 1 LE,N 1 1 INTERNAL: ACRS 1 1 RAB 2 2 AEOD/SPD/RRAB 1 1 FILE CEN 1 1 NRR/DE/ECGB 1 1 NR B 1 1 NRR/DE/EMEB 1 1 NRR/DRCH/HHFB 1 1 NRR/DRCH/HICB 1 1 NRR/DRCH/HOLB 1 1 NRR/DRCH/HQMB 1 1 NRR/DRPM/PECB 1 1 NRR/DSSA/SPLB 1 1 NRR/DSSA/SRXB l. 1 D

RES/DET/EIB 1 1 RGN2 FILE 01 1 1 LITCO BRYCE,J 1 0

EXTERNAL: L ST LOBBY WARD 1 1 H 1 NOAC POOREiW. 1 1 NOAC QUEENERiDS 1 1 NRC PDR 1 1 NUDOCS FULL TXT 1 1 E

N NOTE TO ALL "RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTE! CONTACT THE DOCUMENT CONTROL DESk, ROOM OWFN 5D-5(EXT. 4IS-2083) TO ELIMINATE YOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!

FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 25 ENCL 25

Carolina Power 8 Light Company Harris Nuclear Plant PO Box 165 New Hill NC 27562 MAR 17 1997 U.S. Nuclear Regulatory Commission Serial: HNP-97-035 ATTN: NRC Document Control Desk 10CFR50.73 Washington, DC 20555 SHEARON HARRIS NUCLEAR POWER PLANT UNIT 1 DOCKET NO. 50-400 LICENSE NO. NPF-63 LICENSEE EVENT REPORT 96-020-01 Sir or Madam:

In accordance with Title 10 to the Code of Federal Regulations, the enclosed revision to Licensee Event Report ¹96-020 is submitted. This revision provides additional information related to the safety consequences of the inadvertent boron dilution in the Refueling Water Storage Tank.

Sincerely, J. W. Donahue Director of Site Operations Harris Plant MV Enclosure c: Mr. J. B. Brady (HNP Senior NRC Resident)

Mr. L. A. Reyes (NRC Regional Administrator, Region II)

Mr. N. B. Le (NRC - NRR Project Manager)

'P703240i25 970303 PDR ADQCK 05000400 S PDR IllffIIIIIIIIIIIIIlfff IIIIlIIIIIIIIIIIIIIIIII

".$ 00g g State Road 1134 New Hill NC

U. S. Nuclear Regulatory Commission Document Control Desk / HNP-97-035 Page 2 of 2 CC: Mr. T. C. Bell Mr. R. T. Biggerstaff Ms. P. B. Brannan Mr. H. K. Chernoff (RNP)

Mr. B. H. Clark Mr.-J. M. Collins Mr. G. W. Davis Ms. S. F. Flynn Ms. J. P. Gawron (BNP)

Mr. H. W. Habermeyer Mr. M. D'. Hill Mr. W. J. Hindman Ms. C. W. Hobbs (HEEC)

Ms. W. C. Langston Mr. C. W. Martin (BNP)

Mr. R. D. Martin Mr. J. W. McKay Mr. P. M. Odom (RNP)

Mr. W. R. Robinson Mr. G. A. Rolfson Mr. R. F. Saunders Mr. C. N. Sweely Mr. M. A. Turkall (BNP)

Mr. T. D. Walt Mr. R. L. Warden (RNP)

HNP Real Time Training INPO Harris Licensing File Nuclear Records

f NRC FORM 366 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150.0104 (4.95) EXPIRES 04/30/98 ESTIMATED BURDEN PER RESPONSE TO COMPLY W(TH THIS MANDATORY (NFORMAT)ON COllECTION REOUEST: 500 HRS. REPORTED LESSONS LEARNED ARE LICENSEE EVENT REPORT (LER) INCORPORATED (NTO THE UCENSING PROCESS ANO fEO BACK TO (NOUSTRY.

FORWARD COMMENTS REGARDUIG BURDEN ESTlMATE TO THE (NFORMATIN AND RECORDS MANAGEMENT BRANCH IT@ F33L US. NUCIEAR REGULATORY COMM)SSION.

(See reverse for required number of WASHING'ION, OC 2(555000), ANO TO THE PAPERWORK REOUCT)ON PROJECT (3)50.

digits/characters for each block) 0)04L OffICE OF MANAGEMENT AND BUDGET, WASHINGTON, OC 20503.

FACIUTY NAME (1) DOCKET NUMBER (2) PAGE (3)

Harris Nuclear Plant Unit-1 50-400 1 OF 3 TITLE (4)

Inadvertent RWST boron dilution event caused by personnel error.

EVENT DATE {5) LER NUMBER {6) REPORT DATE (7) OTHER FACILITIES INVOLVED (8)

FACIUTY NAME DOCKET NUMBER MONTH OAY YEAR YEAR'EOUENTULL REVISION MONTH OAY YEAR NUMBER NUMBER 05000 FACIUTY NAME DOCKETNUMBER 9 6 96 96 020 01 3 3 97 05000 OPERATING THIS REPORT IS SUBMITTED PUR SUANT TO THE REQUIREMENTS OF 10 CFR B: {Check one o r more) {11)

MODE (9) 20.2201(b) 20.2203(a)(2) {v) 50.73(a) (2) O) 50.73(a) (2) (viii)

POWER 20.2203(a) (1) 20.2203(a) {3)(i) 50.73(a)(2)(ii) 50.73(a) {2)(x)

LEVEL (10) 0% 20.2203(a)(2) {i) 20.2203(a) (3) (ii) 50.73(a)(2) {lii) 73.71 20.2203(a)(2)(ii) 20.2203{a) (4) 50.73(a)(2)(iv) OTHER 20.2203(a)(2) (iii) 50.36(c) (1) 50.73(a)(2)(v) specify ln Abs(rect below or In NRC Form 366A 20.2203(a)(2) (iv) 50.36{c) (2) 50.73(a)(2)(vii)

LICENSEE CONTACT FOR THIS LER (12)

NAME TELEPHONE NUMBER (lrroiude Area Code)

Michael Verrilli Sr. Analyst - Licensing (919) 362-2303 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)

REPORTABLE REPORTABLE CAUSE SYSTEM COMPONENT MANUFACTURER CAUSE SYSTEM COMPONENT MANUFACTURER TO NPROS TO NPROS

.(Pc, 'PA'ada SUPPLEMENTAL REPORT EXPECTED {14) EXPECTED MONTH OAY 'YEAR YES SUBMISSION

{If yes, complete EXPECTED SUBMISSION DATE). X NO DATE (15)

ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (16)

On September 6, 1996, with the plant shutdown in mode 3 (Hot Standby), at approximately 1920 hours0.0222 days <br />0.533 hours <br />0.00317 weeks <br />7.3056e-4 months <br /> a licensed reactor operator filling the position of an auxiliary operator inadvertently commenced filling the Refueling Water Storage Tank (RWST) with demineralized water. His intent was to fill the Condensate Storage Tank (CST). Initial RWST level was approximately 95% and the inadvertent fill process increased level to greater than 100% and diluted the boron concentration to below the 2400 ppm Technical Specification limit. A RWST high level alarm was observed but not fully investigated. During the time period that the inadvertent RWST fill was in progress, the Boric Acid Tank (BAT) was recirculating for boric acid batching and was not'available as a boron injection flow path. With RWST boron concentration below Technical Specification limits and the BAT unavailable, no boron injection flow paths were available, which violated Technical Specification 3.1.2.2. and required entry into Technical Specification 3.0.3. At 0151 hours0.00175 days <br />0.0419 hours <br />2.496693e-4 weeks <br />5.74555e-5 months <br /> on September 7, 1996, the BAT was returned to service and declared operable, which allowed Technical Specification 3.0.3 to be exited.

The cause of this event was personnel error on the part of the operator that inadvertently opened the RWST fill valve ins{ead of the CST fill valve. The control room operators mvolved also contributed by not providing adequate direction to the auxiliary operator and did not properly respond to the RWST high level alarm.

Corrective actions involved restoring the BAT boron injection flow path, increasing RWST boron concentration counseling the involved operators and providing a briefing on the event to other operations personnel. The RWST fill valve was locked closed and the appropriate ~nerating procedure was be revised to reflect the "locked-closed" designation. A case study on this event was also prov(ued for Operations personnel.

This revision provides the evaluation of safety consequences related to the inadvertent RWST boron dilution event.

NAC FOAM 36BA e US. NUClEAA AEGUlATOAT COMMISSION II-99)

LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION FACIUTT NAME II) DOCKET lER NUMBER IB) PAGE I3)

SEOUENTMl RE+SON NUMBER NUMBEA Shearon Harris Nuclear Plant ~

Unit Nl 50400 2 OF 3 96 - 020 - 01 TEXT IIIsttrt spears sartdtd. tst tdif6tsl sopks tl IFRC Fnne 3SSlU II1)

EVENT DESCRIPTION:

On September 6, 1996, the plant was shutdown in mode 3 (Hot Standby) with primary plaqt temperature and pressure being controlled by the Steam Generator Power Operated Relief Valves. While in this mode, the Auxiliary Feedwater System is used to feed the Steam Generators, which requires periodic refilling of its water source, the Condensate Storage Tank (CST). At approximately 1920 hours0.0222 days <br />0.533 hours <br />0.00317 weeks <br />7.3056e-4 months <br /> a licensed reactor operator filling an auxiliary operator position inadvertently commenced filling the Refueling Water Storage Tank (RWST) with demineralized water instead of filling the CST. Initial RWST level was approximately 95% prior to the inadvertent fill process. The control room staff did observe a high RWST level alarm (98%) at approximately 2345 hours0.0271 days <br />0.651 hours <br />0.00388 weeks <br />8.922725e-4 months <br />, but made an incorrect assumption that the level increase was due to a change in temperature. They did agree to continue to observe RWST level, but no further investigation into the alarm was performed. While taking reactor operator logs approximately 45 minutes later, RWST level was observed to be at 100%. At this time the control room staff investigated the condition and discovered that 1DW-5 had been inadvertently opened instead of the CST fill valve. At 0042 hours4.861111e-4 days <br />0.0117 hours <br />6.944444e-5 weeks <br />1.5981e-5 months <br />, 1DW-5 was shut by the operator.

During the RWST level increase boron concentration decreased from 2476 ppm to approximately 2351 ppm (by calculation), which is below the 2400 ppm Technical Specification limit. While the inadvertent RWST fill was in progress, the Boric Acid Tank (BAT) was recirculating for boric acid batching and was not available as a boron injection flow path. With RWST boron concentration below Technical Specification limits and the BAT unavailable, no boron injection flow paths were available, which violated Technical Specification 3.1.2.2. and required entry into Technical Specification 3.0.3. At 0151 hours0.00175 days <br />0.0419 hours <br />2.496693e-4 weeks <br />5.74555e-5 months <br /> on September 7, 1996, the BAT was returned to service and declared operable, which allowed Technical Specification 3.0.3 to be exited. After increasing the boron concentration back to above 2400 ppm, the RWST was declared operable at 1422 hours0.0165 days <br />0.395 hours <br />0.00235 weeks <br />5.41071e-4 months <br /> on September 7, 1996.

CAUSE:

The cause of this event was personnel error on the part of the operator that inadvertently opened the RWST fill valve (1DW-5) instead of the CST fill valve. Self checking techniques were not adequately applied and the error was not cognitive. The main control room operators involved in the event also failed to implement good working practices by not providing adequate direction to the auxiliary operator for filling the CST and did not properly respond to the RWST high level alarm. They were involved in testing to restore the Normal Service Water System'(reference LER 96-018) and did not apply adequate attention to the alarm. A possible contributing factor to these human performance errors was fatigue. Hurricane Fran had passed over the Harris Plant area early that morning causing home and personal property damage, which prevented the involved shift personnel from resting as usual before coming to work on the evening shift of September 6, 1996.

SAFETY SIGNIFICANCE:

There were no safety consequences as a result of this event. The minimum RWST boron concentration and volume requirements exist to ensure that adequate shutdown margin can be achieved by negative reactivity injection. This ensures that reactor subcriticality can be achieved and maintained during all operating and postulated accident conditions. 'Following the inadvertent dilution, the resulting RWS t'oron concentration was calculated to be approximately 2153 ppm. Based on Operations Curve A-7-22, "Cycle 7 Minimum Shutdown Margin Boron Concentration vs. Moderator Temperature and Exposure" and the Core Operating Limit Report, 2153 ppm RWST boron concentration would provide adequate shutdown margin during Modes 1 through 4 operation throughout fuel cycle 7.

KAC FORM 366A US. NUCLEAA REGULATORY COMMISSION 66-95)

LICENSEE EVENT BEPOBT (LEB)

TEXT CONTINUATION FACILITY KAME II) OOCXET LEA NUMBER I6) PAGE I3)

SEOUEKTIAL KEY)SION YEAR KUM SEA KUMBER Shearon Harris Nuclear Plant ~

Unit Pl 50400 3 OF 3 96 - 020 - 01 TEXT pl mort Aport )r rtrpira( vst trrrtrvmtltopmt ol SAC Form 36atu I) i)

PREVIOUS SIMILAR EVENTS:

There have been no previous Technical Specification 3.0.3 entries due to inadvertently diluting the RWST to a boron concentratiorl'below Technical Specification limits.

CORRECTIVE ACTIONS COMPLETED:

1. The operator that inadvertently opened the RWST fill valve instead of the CST fill valve was counseled and provided a briefing on the event to other operations personnel. This was completed on September 10, 1996.

2. The main control room operators involved in not providing adequate direction to the auxiliary operator and not properly responding to the RWST high level alarm were counseled. This was completed on September 6, 1996.

Operating procedure (OP-112) was revised to reflect the "locked-closed" designation for RWST fill valve 1DW-5. This was completed on November 6, 1996.

4. This event was provided to Operations personnel as a case study to review the inappropriate actions taken by the control room staff. The importance of recognizing the effects of fatigue and informing supervision prior to allowing fatigue to affect work performance was emphasized. This was completed on December 3, 1996.