ML18096A937

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LER 92-018-00:on 920731,discovered That Valves 11 & 12 CS20 & CS6 Found to Be in Closed Position.Caused by Personnel Error Attributed to Poor Work Practice.Individuals Involved Received Appropriate discipline.W/920827 Ltr
ML18096A937
Person / Time
Site: Salem PSEG icon.png
Issue date: 08/27/1992
From: Pollack M, Vondra C
Public Service Enterprise Group
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-92-018, LER-92-18, NUDOCS 9209040037
Download: ML18096A937 (6)
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Public Service Electric and Gas Company P.O. Box 236 Hancocks Bridge, New Jersey 08038 Salem Generating Station August 27, 1992 U. s. Nuclear Regulatory Commission Document Control Desk Washington, DC 20555

Dear Sir:

SALEM GENERATING STATION LICENSE NO. DPR-70 DOCKET NO. 50-272 UNIT NO. 1 LICENSEE EVENT REPORT 92-018-00 This Licensee Event Report is being submitted pursuant to the requirements of the Code of Fede~al Regulations 10CFR

50. 73 (a) (2) (i) (B). This report is required to be issued within thirty (30) days of event discovery.

!* Sincerely yours, C .. A Vondra General Manager -

Salem Operations MJP:pc Distribution

.030019 9209040037 20827

.PDR ADOCK 05000272 S. 9 PDR The Energy People 95-2189 (10M) 12-89

NRC FORM 366 U.S. NUCLEAR REGULATORY COMMISSION (6-891 APPROVED OMB NO. 3150-0104 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD LICENSEE -EVENT REPORT (LER) COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (P-5301, U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON. DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (3150-01041. OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (1 I DOCKET NUMBER (21 I PAuE 1;.tl Salem Generatigg Station - Unit 1 TITLE (41 O 15 Io IO Io I .,, 7 I? 1 loF o1 s Tech Spec 3.0.4 Noncompliance~ Mode Change With Containment Spray Valave Closed.

EVENT DATE (51 LER NUMBER (61. REPORT DATE (71 OTHER FACILITIES INVOLVED (Bl MONTH DAY YEAR YEAR .:tl SE~~~~~~AL () ~~~~~~ MONTH DAY . YEAR FACILITY NAMES DOCKET NUMBERISI 0151010101 I I d 7 3 Io 9 2 91 2 - oI 1 I E- o I o o-1 s 2 7 9I I2 o 151010101 I I OPERATING THIS RE"ORT IS SUBMITTED PURSUANT TO THE R!oQUIREMENTS OF 10 CFR §: (Chock on* or moro of rho following/ (111 MODE (9) 4 20.402(bl 73.71(bl I ,___ 20.405(cl 50.73(11l2Hivl 1-~~--.-~~ ........-+---j I-POWER 20.405(11(11(1) 50.381cll11 60.73lill21M 73.71(cl L~~~L . I I ,...__ 20.405(11(11(111

,___ 50.311lcl !21 60.73(11l21lvlil OTHER IS,,.cify in Absrr1ct

.......... b1/ow ind in Toxr, NRC Form x

llilillll= ::::::::

60.73(11(21(11 50.73(11l21lviiillAI 366A/ .

,___ 150.73(11l21liil 60.73(11l21lviill (Bl I-60.73(11l21lilil 60.73(11l21lxl .

LICENSEE CONTACT FOR THIS LER (121 NAME TELEPHONE NUMBER AREA CODE M.J. Pollack - LER Coordina~or 61-0 19 3 13 19 I - 12 p I 2 12 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (131 MANUFAC- MANUFAC-CAUSE SYSTEM COMPONENT TURER TURER I I I I I I I ii:::::::*:..::::i::::i:::::::::::j::::::::::::-*,:. I I I I 1- I I I I I I I I I I I I I I I I SUPPLEMENTAL REPORT EXPECTED (141 MONTH DAY YEAR EXPECTED n

SUBMISSION DATE (151 YES llf y*s. complot* EXPECTED SUBMISSION DATE/ I I I ABSTRACT (Limit to 1400 spaces, i.e.* approximltBly fiftefln sing/e-spact1 typewfitttm lines) (161 On 7/31/92, at 1345 hours0.0156 days <br />0.374 hours <br />0.00222 weeks <br />5.117725e-4 months <br />, during routine startup operations with the plant in Mode 4 (Hot Shutdown), valves 11 & 12 CS20, "Containment Spray Eductor supply Valves" were found in the closed position. At 1400 hours0.0162 days <br />0.389 hours <br />0.00231 weeks <br />5.327e-4 months <br /> the same day, 11 & 12 CS6 "Containment Spray Header Valves" were also found in the closed position. These valves were found closed during preparation for entry into Mode 3 (Hot Standby). After discovery, the valves were opened and locked in position per Tech. Specs~ Investigation revealed that the valves had been closed in support of maintenance

  • activities* during the recent refueling outage. They were not opened and locked in position prior to entry into Mode 4, on 7/30/92 at 1145 hours0.0133 days <br />0.318 hours <br />0.00189 weeks <br />4.356725e-4 months <br />, contrary to the requirements of Tech. Spec. 3.0.4(a). Upon discovery that both Containment Spray System flow paths were inoperable, Tech.

Spec. 3.0.3 was entered since the Tech. Spec. 3.6.2.1 Action Statement only addresses the actions required if only one fl~w path is inoperable.

Tech. Spec. 3.0.3'was exited at 1446 hours0.0167 days <br />0.402 hours <br />0.00239 weeks <br />5.50203e-4 months <br /> the same day upon opening the CS6 valves. The root cause of this event is personnel error attributed to poor work practice. The Nuclear Shift Supervisor failed to verify that the valves were correctly positioned (locked open) prior to entering Mode 4. Operations Department management has reviewed the circumstances surrounding this event. Individuals involved in this event have received appropriate discipline. The circumstances surrounding this event will be reviewed with applicable Operations Department personnel. Procedure IOP-~ is being enhanced.

NRC Form 366 (6-891

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LICENSEE EVENT REPORT- (LER) TEXT CONTINUATION Sa'lem Generating station DOCKET NUMBER LER NUMBER PAGE Unit 1 5000272 92-018-00 2 of 5 PLANT AND SYSTEM IDENTIFICATION:

Westinghouse ~ Pressurized Water *Reactor Energy Industry Identification System (EIIS) codes are identified in the text as {xx}

IDENTIFICATION OF OCCURRENCE:

Techni.cal Specification 3.0.4 Noncompliance; Mode Change With Containment Spray Valves Closed Due to Personnel Error Event Date: 7/30/92 Discovery Date: 7/31/92 Report Dat.e: 8/27 /92 This report was initiated by Incident Report No.92-477.

CONDITIONS PRIOR TO OCCURRENCE:

Mode 4 (Hot Standby)

DESCRIPTION OF OCCURRENCE:

On July 31, 1992, at 1345 hours0.0156 days <br />0.374 hours <br />0.00222 weeks <br />5.117725e-4 months <br />, during routine startup operations, valves 11 & 12 cs20, "Containment Spray Eductor Supply Valves" were found in the closed position. At 1400 hours0.0162 days <br />0.389 hours <br />0.00231 weeks <br />5.327e-4 months <br /> the same day, 11 & 12 CS6 "Containment Spray Header Valves" were also found in the closed position. These valves were found closed by Work Control center (WCC) personnel during the review of the "Components Off Normal Position Report" in preparation for entry into Mode 3 (Hot Standby).

After this discovery, the valves were opened and locked in position per Technical Specifications 3.6.2.1 and 3.6.2.2.

Investigation *revealed that the valves had been closed in support of maintenance activities during the recently completed refueling outage. They were not opened and locked in position prior to entry into Mode 4, on July 30, 1992 at 1145 hours0.0133 days <br />0.318 hours <br />0.00189 weeks <br />4.356725e-4 months <br />, contrary to the requirements of Technical Specification 3.0.4(a) which state:

"Entry into an OPERATIONAL MODE or other specified condition:

(a) shall not be made when the conditions of the Limiting Condition for Operation are not met and the associated ACTION requires a shutdown if they' are not met within a specified time interval."

Technical Specification 3.6.2.2 states:

"The spray additive system shall be OPERABLE with:

a~ A spray additive tank containing a volume of between 2568

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER.NUMBER PAGE Unit 1 5000272 92-018-00 3 of 5 DESCRIPTION OF OCCURRENCE (cont'd):

and 4000 gallons of between 30 and 32 percent by weight NaOH solution and

b. Two spray additive eductors each capable of adding NaOH solution from the chemical additive tank to a containment spray system pump flow".

Technical Specification 3.6.2.1 states:

"Two independent containment spray systems shall be OPERABLE with each spray system capable of taking suction from the RWST and transferring suction to the RHR pump discharge".

Upon discovery that both Containment Spray System flow paths were inoperable (both CS6 valves found in the closed position), Technical Specification 3.0.3 was entered since the Technical Specification 3.6.2.1 Action Statement only addresses the actions required if only one flow path is inoperable. Technical Specification 3.0.3 was exited at 1446 hours0.0167 days <br />0.402 hours <br />0.00239 weeks <br />5.50203e-4 months <br /> the same day upon opening the CS6 valves.

Technical Specification Action Statement 3.0.3 states:

"When a Limiting Condition for Operation is not met except as provided in the associated ACTION requirements, within one hour action shall be initiated to place the unit in a MODE in which the specification does not apply by placing it, as applicable, in:

1. At least HOT STANDBY within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br />,
2. At least HOT SHUTDOWN within the following 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br />, and
3. At least COLD SHUTDOWN within the subsequent 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.

Where corrective measures are completed that permit operation under the ACTION requirements, the ACTION may be taken in accordance with the specified time limits as measured from the time of failure to meet the Limiting Condition of Operation.

Exceptions to these requirements are stated in the individual specifications."

APPARENT CAUSE OF OCCURRENCE:

The root cause of this event is personnel error attributed to poor work practice. The Nuclear Shift Supervisor (NSS) failed to verify that 11 & 12 CS20 and 11 & 12 CS6 valves were correctly positioned (locked open) prior to entering Mode 4.

The 11 & 12 CS20 and 11 & 12 CS6 valves had been closed to prevent inadvertent initiation of containment spray during refueling activities within the Containment. On July 30, 1992, the unit entered Mode 4 using Integrated Operating Procedure IOP-2, "Cold Shutdown to Hot Standby". Prior to the Mode change, a computer generated tagging release for the 11 & 12 CS20 and 11 & 12 CS6 valves

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER NUMBER PAGE Unit 1 . 5000272 92-018-00 4 of 5 APPARENT CAUSE OF OCCURRENCE: (cont'd) was prepared. The computer was left in Mod,.e 5 operation,

.consequently generating a Mode 5 tagging release not a Mode 4 tagging release. In Mode 5, the normal position for the CSG and cs20 valves .

is closed. The valves were verified to be in the closed position per the tagging release by the Equipment Operator. When the NSS reviewed.

the tagging release he did not realize that* the request had been for Mode 5. Additionally, the CSG and CS20 valve position column was

  • obscured making it difficult to identify the current valve position.

Therefore, the NSS incorrectly assumed that the CS6 and CS20 valves were in their correct position for Mode 4. The NSS signed off the IOP-2 procedure indicating that the valves were correctly positioned (i.e., locked open) allowing the unit to be brought from Mode 5 to Mode 4 with the 11 & 12 CS20 and 11 & 12 CSG valves closed.

IOP-2 clearly specifies via a "NOTE" and procedure steps (which require sign-off) that. the CS6 and the CS20 valves must be in the locked open position to support Mode change from Mode 5 to Mode 4.

ANALYSIS OF OCCURRENCE:

The Containment Spray system is required to be operable in Modes 1, 2, 3, and 4 per Technical Specification 3.G.2.1. The system is 100%

redundant to the Containment Fan Coil Units (CFCUs) in providing containment depressurization and cooling capability in the* event of a Loss of Coolant Accident (LOCA). In addition the Containment Spray System sprays NaOH into the containment atmosphere to enhance iodine removal from the atmosphere after a LOCA. In Mode 5 (Cold Shutdown),

the system is not required to be operable as per the Updated Final*

Safety Analysis Report (UFSAR). The CSG and CS20 valves are locked open in Modes 1 - 4 to prevent inadvertent closure if a design basis accident were to occur.

During the period when the CS6 and CS20 valves were closed, the. CFCUs were available. In the event of a design basis accident, the resulting temperature and pressure transient would have been mitigated. With the reactor just refueled with "new" fuel, the concentration of iodine.in the fuei was minimized This event did not affect the health or safety of the public; however, .since Technical Specifications were not fully complied with, this event is reportable to the Nuclear Regulatory Commission in.accordance with Code of Federal Regulations 10CFR 50.73(a)(2) (i) (B).

CORRECTIVE ACTION:

Operations Department management has reviewed the circumstances surrounding this event. Individuals involved in this event have received appropriate discipline.

The circumstances surrounding this event*will be reviewed with applicable Operations Department personnel.

. *-- ' t.

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER NUMBER PAGE Unit 1 5000272 92-018-00 5 of 5 CORRECTIVE ACTION: (cont'd)

  • IOP-2 is being enhanced to specify that tagging releases, to suppqrt Mode change from Mode 5 to Mode. 4, will be generated with the computer in the "Mo_de 4" operating configuration. Other IOP' s were reviewed. . Simiiar enhancements are not required *

. ~.*~

General Manager -

Salem Operations MJP:pc SORC Mtg.92-094

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