ML19325C473

LER 89-015-00:on 890722,discovered That Neutral Pressure Was Best That Could Be Achieved in Some Required Sys Configurations.Caused by Design Deficiency Due to Design Oversight.Outside Air Ref Point installed.W/891004 Ltr

ML19325C473
Person / Time
Site:	McGuire
Issue date:	09/18/1989
From:	Mcconnell T, Sipe A DUKE POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-89-015, LER-89-15, NUDOCS 8910160295
Download: ML19325C473 (10)

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McGuireNuclearStation -

PO Bat 488-V Cornelius, NC 280310488

'DUKEPOWER

!, . October 4',I1989 U;S.' Nuclear' Regulatory Commission Document Control. Desk'

. Washington, D.C.. 20555'

Subject:

McGuire Nuclear Station Unit 1 and 2 Docket No.' 50-369 L

Licensee' Event Report 369/89-15-01 q

t Gentlemen:

Pursuant to 10,CFRL50.73 Sections-(a)(1) and (d), attached is Licensee Event Report 369/89-15 concerning additional information discovered after submission-of the original LER. 'This report is being submitted in accordance with 10 CFR 53.73(a)(2)(1)(B) and (a)(2)(v).~ This. event is considet ' to be of no y ' significance with respect to the health and safety of th public,

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hO cVery truly yours, l:

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T.L.1McConnell'

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s. xc: Mr. S.D. Ebneter American Nuclear Insurers P " Administrator, Region II c/o Dottie Sherman, ANI Library q U.S. Nuclear Regulatory Commission The Exchange, Suit 245 101 Marietta St., NW, Suite 2900 270 Farmington Avenue f

' Atlanta, GA 30323 Farmington, CT 06032 ~j

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-INPO Records Center Mr. Darl Hood '}

Suite'1500 U.S. Nuclear Regulatory Commission l

1100 Circle 75 Parkway Office of Nuclear Reactor Regulation

? . Atlanta, GA 30339 Washington, D.C. 20555  ;

Mr. P.K. Van Doorn M&M Nuclear Consultants l 1221 Avenue of the Americas NRC Resident Inspector

.New York, NY 10020 McGuire Nuclear Station

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""' The control Room Ventilation System Did Not Meet The Required Positive Pressure

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] v E8 in ,..me., exercreo su,4,,ss,0= 04 re, AuTRACT m or,oruo.e, ,..e-s. e.,,e.,.e.,e.<,,. .e. ,,e,. ..,,e.,nei On July 21, 1989, during post inodification flow balancing of outside air pressure filter train - 2, Performance personnel measured Control Room pressure relative to outside atmosphere and discovered that neutral pressure was the best that could be achieved in some required system configurations. The applicable Technical Specification specifies that the Control Room be maintained at a' positive pressure of at least +0.125 inches water gauge relative to outside atmosphere. The Control Room pressurization has been tested relative to the pressure in the Cable Spreading Room since initial testing and startup. This event is assigned a cause of Design Deficiency because of a design oversight. On August 19, 1989, Design Engineering personnel issued an operability evaluation for the Control Area Ventilation system, The operability evaluation stated that the Control Area Ventilation system is conditionally operable if the Control Room doors are taped and all four outside air i intakes remain open at all times. A permanent outside air reference point will be installed to ensure that future testing is accurate. Unit I was in Mode 1, Power 1- Operation, and Unit 2 was in Mode 6, Refueling, at the time this event was l' discovered.

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i EVALUATION:

Background'

-There are two independent trains of the Control Area Ventilation [EIIS:VI] (VC) i system which are designed to maintain a habitable environment in the Control Room

[EIIS:NA), Control Room Area, and Switchgear Rooms during normal and accident '

conditions. The Control Room is designed to be maintained at a positive pressure-during an accident to prevent the ingress of contaminants.- Two 100 percent

-capacity Outside Air Pressure Filter [EIIS:FLT] Trains (OAPFT) pressurize the Control Room by providing approximately 1000 cubic feet per minute (cfm) of filtered outside air in addition to approximately 1000 cfm of filtered recirculated Control Room air.

Technical Specification (TS) 3/4.7.6 includes requirements that two independent VC '

trains shall-be demonstrated operable at least once each 18 months by verifying.a ,

system flow rate of 2000 cfm +/- 10 percent and a Control Room positive pressure,of

>/= 0.125 inches water gauge (WG), relative to outside atmosphere, during system operation. The VC system draws outside air from 2 locations, on the Unit 1 and Unit 2 roof. According to Final Safety Analysis Report, Section 6.4.2, positive s pressure is required to be maintained with outside intakes open at either of the two locations or both.

Description of Event

!0n_ July 20, 1989, Performance personnel began test procedure TT/0/A/9100/334, Post Modification Testing of CRA-0APFT-2, after implementation of Nuclear Station Modification (NSM)-MG-11905 Rev. O and NSM-MG-52009 Rev.0. On July 21, 1989, at 2315,.during troubleshooting and flow balancing, Performance personnel checked the Control Room pressure relative to outside atmosphere and discovered a pressure difference of -0.025 inches WG compared to a +0.15 inches WG with* respect to the cable spreading room. Performance personnel informed Management and Design Engineering personnel of the discrepancy at that time. Performance personnel wrote Problem Investigation Report (PIR) 0-M89-0163 on July 22, 1989 at 0000, concerning the reference point for the Control Room pressurization test. On July 2,4, 1989, _

Compliance personnel requested that Design Engineering personnel perform an Operability Evaluation for the VC system. On August 5,1989, while testing 0APF"'-1 Performance personnel determined the Interior Doghouse reference point rel.ative to outside atmosphere was neutral. On August 18, 1989, all the Control Room doors except the two doors leading to the Service Building were taped to enhance, sealing capabilities of the Control Room. With the doors taped and all 4 outside air

' intakes open, a positive pressure of >/= 0.125 inches WG was maintained. Design Engineering personnel issued an Operability Evaluation on August 19, 1989, and revised it. on September 14, 1989, stating the VC system was conditionally operable I

i .w ith the conditions of operability being: ,

r l 1) Maintain a tight seal [EIIS: SEAL] on all doors (EIIS:DR] in the Control Room. All of the seams of the Control Room doors (except the two doors l

leading to the Service Building [EIIS:MF], which are pressure doors) are 1 to be t. aped with duct tape. The duct tape can subsequently be removed as a l

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-long as Control Room pressurization requirements are met. The sealed ,

doors are not normally needed for emergency access and can be retaped if  :)

E access:through them is required.

2) All four outside air intakes are to remain open except for TS required -

testing. The operating procedure for the VC system is to be modified to-specify all four intakes to be open during nonnal and accident conditions.. The operators will be required to reopen all intakes if they are closed due to the radiation monitor [EIISiHON]-detecting contaminated- I air in the duct (EIIS: DUCT] in order to maintain Control Room  ;

pressurization requirements.

l Conclusion

~

This event is assigned a cause of, Design Deficiency because of a design oversight that required testing the Control Room positive pressure with respect to the Cable-

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Spreading Room and not outside atmosphere. Since startup and initial testing of, the.VC system, Control Room pressurization had been based'cn pressure differential: ,

using the Cable Spreading Room as the reference point for the outside atmosphere ^.

The Cable Spreading Room was chosen by Design Engineering personnel because it was thought to be representative of outside atmosphere because it was not a pressurized area. . Additional reasons that the Cable-Spreading Room was chosen were that it is' relatively unaffected by outside influences, controlled by a safety related ventilation system, and the majority.of'the penetrations [EIIS: PEN] into the Control Room are from the Cable Spreading Room. The reasoning was that this boundary would be the most conservative because any degradation in pressure seals

'would most likely occur in this boundary and would be discovered during >

surveillance testing. -Also, there are no penetrations of the Control Room that communicate directly to the outside atmosphere; therefore, it was thought prudent to measure pressure with respect to interior boundaries leaking to the Control ,

' Room. However, during post modification testing after testing the Control Room relative to outside atmosphere it was discovered that the Cable Spreading Room was slightly negative with respect to outside atmosphere. The Control Room most likely has been at a negative or neutral pressure referenced to outside atmosphere since startup of the VC system. Performance personnel tested the VC system extensively from the time the PIR was written until Design Engineering issued the Operability Evaluation. Design Engineering personnel issued an Operability Evaluation on

. August 19, 1989 for the VC system, requiring the Control Room doors to remain i taped. Operations personnel issued Special Order 89-16 to instruct Operations personnel to ensure all 4 outside .ntakes are open. Operations personnel in accordance'with procedures OP/1/A/1600/10R and.10Q, Annunciator [EIIS: ANN] Response for Annunciator 1 RAD 1 and IRAD2 respectively, will be required to reopen all air intakes if they close because of the radiation monitor detecting contaminated air in the ductwork. The Control Room doors had been taped prior to special order 89-16 during testing of the VC syste:n.

4 On August 29, 1989, a working group consisting of personnel from Design Engineering, Performance, and Mechanical Engineering Services met to determine corrective actions to resolve problems with the Control Room pressurization. The working group identified several items that will improve Control Room NAC FO.W 36ea *U.S. Gto 1985-540-589 00010 V

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0l1 0 l4 or 0l8 pressurization. Design Engineering personnel and Project Services personnel will coordinate the installation of a permanent stainless steel tubing [EIIS:JBG) to a ,

sheltered outside position to provide an outside atmosphere reference point for the l Control Room. On September 7,1989, Project Services personnel issued Urgent

-Modification MG-52281 to document the installation of the permanent outside air reference point. This reference point will be shielded from the effects of wind and will provide an accurate outside atmosphere reference point to enhance future testing.

To determine if the VC system has problems that diminish air delivery to the ,

Control Room the following items will be done. Mechanical Maintenance personnel J will inspect the tornado valves [EIIS:V) to ensure that no restrictions exist in the outside air intake lines that would restrict free movement and air flow.

Performance personnel will inspect the Control Room Air Handling Unit [EIIS:AHU)

-(AHU) ducts and dampers (EIIS:DMP] for external leakage. The AHUs will be smoke tested from the Control Room AHU discharge and any significant leakage will be corrected. Performance personnel will inspect valves IVC-13 and IVC-14, Outside.

Air Intake Duct Purge Valves to ensure they are closed. Design Engineering

- personnel will evaluate the feasibility of sealing the Control Room penetrations with a non permeable sealant to increase the sealing ability at these penetrations.

The 5 Control Room doors sealed with duct tape will be sealed with RTV to improve sealing capability and seal durability. Administrative controls will be established that will require a Control Room Senior Reactor Operatar's approval prior to accessing the doors or removing the sealant.

Design Engineering and Project Services personnel will evaluate an upgrade to the remaining 4 Control Room doors that require routine access.

The highest priority items identified were replacing the duct tape with RTV and installing an outside air reference point to ensure future testing is accurate.

A review of McGuire Licensee Event Reports (LERs) for the past 12 months revealed one event, LER 369-88/19, with a root cause or contributing cause of Design ,

Oversight. Therefore, this event is considered recurring. LER 369/88-19 documented an event concerning the Hydrogen Skimmer System dampers. Corrective actions as a result of this event would not have prevented this event from l occurring.

l LERs 369/89-06 documented a misplaced solenoid arrangement on valve INV-459, Main Letdown Orifice Isolation, because of a Design Deficiency. LER 369/88-28 documented misplaced solenoid valves on the Main Steam Isolation valves because of

' incorrect' instrument detail drawings. LER 369/89-07 documented misplaced solenoid l valves ~ on the Chilled Water system and the Nuclear Service Water system because of l a Design Deficiency because Design Engineering personnel approved unqualified ,

material for installation. LER 369/88-36 documented a deficiency functional design  !

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of the Diesel Generator Starting Air and Instrument Air systems because of a Design l Deficiency. This is considered a recurring problem.

This event is not Nuclear Plant Reliability Data System (NPRDS) reportable. I L a ._.. .m._ _ .

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s 'There were no personnel injuries, radiation overexposures, or releases of radioactive material as a result of this event.

' CORRECTIVE ACTIONS:

Immediate:- None 'y j

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"Sub'equent:

s 1)' The Control Rocs doors were taped.

2) Operations personnel revised procedures OP/1/A/1600/10R'and I

'10Q,' Annunciator, Response for Annunciator IRAD1 and IRAD2, to  !

instruct Control Room personnel to. ensure all 4 outuide inlets +

are open in-all consitions, q 3)- , Performance personnel inspected the smoke purge _ fan to ensure ,

that no air was being drawn from the Control Room AHU plenum to:

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the-VA system unfiltered exhaust intake through the smoke purge-exhaust fan. No loss of air was identified.

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4) ' Design Engineering personnel submitted a Station Problem Report to evaluate replacing the OAPFT discharge check dampers with dampers that have improved sealing characteristics.

' Planned: 1) A permanent atmosphere reference-point will be installed in'a sheltered area outside in accordance with Urgent Modification MG-52281. '

2) Mechanical Maintenance personnel will inspect the tornado .l valves to ensure no additional restrictions exist in the outside intake lines. ,.

3) Performance personnel will inspect Control Room Air Handling Units'A and B duct / dampers for external leakage. }

4) Performance personnel will inspect the backflush valves IVC-13 and IVC-14 to ensure they are locked closed.

5) Design Engineering and Mechanical Maintenance personnel will evaluate the feasibility of using a non-permeable sealant for cable penetrations into the Control Room.

, 6) Projects, Performance, and Mechanical Maintenance personnel ll will replace the duct tape on the 5 Control Room doors with RTV.

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7) Design Engineering and Projects personnel will evaluate upgrading Control Room doors to provide a leak tight integrity.

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-SAFETY ANALYSIS:

During an accident requiring Control Room pressurization, both trains of OAPFT receive an automatic start signal. With both trains in operation-the Control Room would have been pressurized to meet design basis requirements. If one OAPFT had not started automatically, Operations Emergency procedures would have directed Operations personnel to ensure both OAPFTs were operating.

.In the event that one OAPFT was available in an accident, single train operation would have mair.tained the Control Room positive with respect to the Auxiliary Building. Single train operation would limit air ingress to the Control Room except for personnel ingress and egress.

The principle contaminant ~in air leaking into the Control Room is assumed to be iodine which in very conservatively modeled in dose calculations. Very low amounts

'of iodine would be expected to reach the area-around the Control Room since this requires passage through either Auxiliary or Turbine Building Ventilation systemp or passageways.

Control Room Operator dose would be further reduced by operation of the Auxiliary Building Ventilation system which is not safety related but has been maintained to safety standards.

L In the event that Control Room atmosphere became unbreathable, self contained breathing apparatus respirators provided in the Control Room area could be employed. Radiation monitors in the Control Room would alert Control Room personnel of high radiation levels.

The health and safety of the public were not affected by this event.

Additional Information is provided as a revision to this LER as a result of both trains of the VC/YC system being declared inoperable on September 4, 1989, and

! again on September 15, 1989.

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ADDITIONAL INFORMATION: ,

.On' September 3, 1989 at 0005, Security personnel received a Forced Entry Alarm on l Control Access Door (CAD) 506. CAD 506 is one of the Control Room doors that was  !

required to be taped for the Control Room Ventilation System to be conditionally opa rt.bie . A Security Officer responded to the alarm at 0007, and discovered CAD l 506 open approximately 2 inches, with the duct tape pulled loose. The Security Officer opened CAD 506 at that time to determine if any personnel were on the other side of the door causing the Forced Entry Alarm. The Security Officer found no one )

on the other side of CAD 506 that could have caused the alarm. The Security Officer secured CAD 506 and replaced the duct tape on the door. The Security Officer did not notify Operations personnel.

'On September 4, 1989 at 2200, Operations personnel noticed the duct tape seal on l CAD 506 was broken. Operations personnel declared both trains of the VC/YC system i inoperable and entered Unit 1 into TS 3.0.3. At 2325, Operations personnel using I procedure RP/0/A/5710/10,'NRC Notification Requirements, made a required ,

notification to the NRC. At 2340, Maintenance personnel replaced the duct tape on l CAD 506 and Operations personnel exited Unit I from TS 3.0.3. Unit 2 was in Mode l 5, and was not required to be in TS 3.0.3. , l On September 15, 1989 at 1000, Performance personnel removed the tape from CAD 506 to determine if the Control Room would meet the required positive pressure of 0.125 inches Water Gauge (WG) with the tape missing from CAD 506. Operations personnel declared both trains of VC/YC inoperable and entered Unit I and Unit 2 into TS 3.0.3. Unit I was in Mode 1, and Unit 2 was-in Mode 3. Performance personnel determined that with the tape removed from CAD 506, the Control Room was pressurized to a positive 0.105 inches WG. At 1008, tape on CAD 506 was replaced and Unit 1 and Unit 2 were exited from TS 3.0.3.

Conclusion:

(

This event is assigned a cause of Inappropriate Action because unknown personnel l took improper or inadvertent action by opening CAD 506 and breaking the duct tape l seal. The Security Officer that responded to the Forced Entry Alarm sta,ted that I

CAD 506 was open and the duct tape seal was broken when he arrived. The Security Officer opened CAD 506 to determine if any personnel had initiated the. Forced Entry l Alarm from the other side of CAD 506. The Security Officer did not.see any personnel that could have initiated the Forced Entry Alarm. The electrical lock for CAD 506 had been malfunctioning, and CAD 506 was secured by the mechanical i

lock. However, because of the sealing material added to the Control Room doors to l; enhance the sealing capability of the doors, the mechanical locks do not secure the I

doors as designed, and sometimes fail. It is possible that in this event the mechanical lock failed on CAD 506 and unknown personnel pushed CAD 506 open initiating the Forced Entry Alarm. Performance personnel stated that the duct tape could have held without the mechanical lock being engaged. No al'rms a were received c

by Security personnel to indicate CAD 506 was accessed by any station personnel.

CAD 506 was CAD secured and no personnel attempted to access CAD 506 by placing l their security badge in the Card Reader for CAD 506. Also, no alarms were received by Security personnel to indicate personnel used the Emergency Egress Button to NIC PORM 3e6A CPO 1986 4 20-359 00070 m _ 'U.S. . , _

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0[1 0l8 or 0l8 l TENT it ausse apsse is supuso( ser esWIussW AIGC Fesse WW(1h open the door. The Security Officer that closed CAD 506 stated that he rescaled the duct tape on the door. Operations personnel subsequently discovered the duct

tape seal broken on the door. The duct tape sealing capability was probably

' degraded when the Security Officer opened CAD 506 and came unsealed sometime between September 3, 1989 at 0007, and September 4, 1989 at 2200, when Operations personnel discovered the duct tape seal broken.

This ' event is also assigned a cause of Management Deficiency because Security Management personnel failed to-fully communicate the-importance to Security Officers reporting problems with-Control Room doors sealed with duct tape.

Security Management personnel informed Security personnel that tne Control Room doors were taped because of Control Room ventilation prs lems but did not specifically instruct them to inform Operations personnel of problems with the duct tape on the doors.

On September 15, 1989, Station Management personnel made the decision to remove the seal from CAD 506 to determic.e if the Control Room could be demonstrated to ,

maintain a positive pressure relative to outside air of >/= 0.125 inches WG as required by periodic test PT/0/A/4450/08C, Control Area Ventilation Performance Test. If the Control Area Ventilation Performance Test procedure had demonstrated a Control Room positive pressure of >/= 0.125 inches WG, then Unit I would not have actually been in TS 3.0.3 on September 4, 1989. However, the pressure test revealed a positive pressure of 0.105 inches WG, which was less than the acceptance criteria of periodic test PT/0/A/4450/08C, Control Area Ventilation Performance Test. Both trains of the VC/YC system were declared inoperable from September 15, 1989 at 1000, until 1008 when CAD 506 was-resealed with duct tape. On September 18, 1989,- Mechanical Maintenance personnel completed the placement of RTV on the Control Room dcors that previously were sealed with duct tape. On September 19, 1989, Performance personnel completed periodic test, PT/0/A/4450/08C, Control Area Ventilation Performance Test, and determined the Control Room positive pressure to be greater than 0.125 inches WG with the RTV in place.

As a result of this event, Security Management personnel informed Security l personnel that if they detect any damage to the RTV seal on the Control Room doors, <

to inform the Operations Shift Supervisor immediately.

These events are bound by the safety analysis on page 6 of 8.

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