ML18065B243

Forwards LER 98-007-00,re HPSI Sys Being Rendered Inoperable During Test Performance of TS Surveillance Tp.Commitments Made within Ltr,Listed

ML18065B243
Person / Time
Site:	Palisades
Issue date:	05/13/1998
From:	Thomas J. Palmisano CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.)
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
Shared Package
ML18065B244	List: ML18065B243 ML18065B245
References
NUDOCS 9805200348
Download: ML18065B243 (2)

Text

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Consumers Energy>

• A_ CMS Energy Company Palisades Nuclear.Plant Tel: 616 764 2296 27780 Blue Star Memorial Highway Fax: 616 764 2425 Covert, Ml 49043 J'lloma* J. /l'almluao Site Vice President May 13,-1998 U.S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, DC 20555 DOCKET 50-255 - LICENSE DPR PALISADES PLANT LICENSEE EVENT REPORT 98-007, "HIGH PRESSURE SAFETY INJECTION SYSTEM INOPERABILITY DURING TECHNICAL SPECIFICATION SURVEILLANCE TEST" Licensee Event Report (LER)98-007 is attached. The LER describes a condition where the High Pressure Safety Injection (HPSI) System was rendered inoperable during the performance of a Technical Specification Surveillance Test Procedure. This event is reportable to the NRC in accordance with 10CFR50.73(a)(2)(i), as a condition prohibited by the plant's Technical Specifications and 10CFR50.73(a)(v)(D), as a condition that alone could have prevented the fulfillment of the safety function of .

• structures or systems that are needed to mitigate the consequences of an accident.

In 1988 a Technical Specification SurveillanceTest Procedure was revised, erroneously permitting a test configuration of the High Pressure Safety Injection (HPSI) System /

which would have degraded the system's capability to deliver adequate flow to mitigate certain postulated loss of coolant accident (LOCA) scenarios. The HPSI system was /

briefly in this configuration on five separate occasions during hot shutdown between

• 1988 and 1996, and once during power operation in 1998. It is of serious concern that a significant procedure error could be introduced, and that engineering and operations personnel could fail repeatedly to recognize the error during subsequent procedure revisions and performance of the surveillance procedure.

• Je z,.-i

• When it was discovered during a post-test review that the plant staff had unknowingly

. degraded HPSI in this manner, plant management responded aggressively. The HPSI system was immediately verified to have been restored to the correct valve alignment.

An incident response team was commissioned to investigate the event and implement immediate corrective actions. In addition, a multi-discipline team was established to identify the knowledge, process, and personnel performance weaknesses that permitted the error to occur, and to define appropriate corrective actions to prevent recurrence. .- :.:"\_, .\..J. 1 J.

9805200348 980513 PDR ADOCK 05000255 S PDR

• 2 Our investigation concluded that the procedure error was caused by inadequate _

understanding of the implications of the test configuration on system operability, combined with weaknesses in the procedure revision process and job preparation process. Comprehensive actions are being taken to deal with the identified deficiencies.

i

SUMMARY

OF COMMITMENTS This letter contains three new commitments and no revisions to existing commitments.

The new commitments are:

1. Licensed operators and engineers will be trained to improve operational decision making through more effective use of available resources and personal knowledge.

2. The surveillance procedure preparation process will be strengthened by clarifying individual duties and by providing specific prompts to assure procedure revision.s are reviewed in their entirety to broadly consider the effect of component manipulations on system operability.

3. Performance standards will be clarified and recommunicated to the Operations staff to emphasize maintaining a broad perspective, understanding the effect of component manipulations on system operability, and identifying when the Shift Supe~isor should be involved in decision making.

-~~

Thomas J. Palmisano Site Vice President CC Administrator, Region Ill, USNRC Project Manager, NRR, USNRC NRC Resident Inspector - Palisades Attachment