05000338/LER-1981-037-03, /03L-0:on 810514,insp of Control Room Bottled Air Sys Found Only 83 of 84 Air Bottles Properly Aligned for Discharge While Periodic Test of Control Room Air Bottles Indicated Satisfactory Results.Caused by Personnel Error

/03L-0:on 810514,insp of Control Room Bottled Air Sys Found Only 83 of 84 Air Bottles Properly Aligned for Discharge While Periodic Test of Control Room Air Bottles Indicated Satisfactory Results.Caused by Personnel Error

ML20004F146
Person / Time
Site:	North Anna
Issue date:	06/12/1981
From:	Cartwright W VIRGINIA POWER (VIRGINIA ELECTRIC & POWER CO.)
To:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
Shared Package
ML20004F143	List: 05000338/LER-1981-037, Forwards LER 81-037/03L-0 05000338/LER-1981-037-03, /03L-0:on 810514,insp of Control Room Bottled Air Sys Found Only 83 of 84 Air Bottles Properly Aligned for Discharge While Periodic Test of Control Room Air Bottles Indicated Satisfactory Results.Caused by Personnel Error
References
LER-81-037-03L-01, LER-81-37-3L-1, NUDOCS 8106160557
Download: ML20004F146 (3)

LER-1981-037, /03L-0:on 810514,insp of Control Room Bottled Air Sys Found Only 83 of 84 Air Bottles Properly Aligned for Discharge While Periodic Test of Control Room Air Bottles Indicated Satisfactory Results.Caused by Personnel Error

Event date:
Report date:
3381981037R03 - NRC Website

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O.S. NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT CONTROL BLOCK / / / / / / / (1)

(PLEASE PRINT OR TYPE ALL REQUIRED INFORMATION)

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/V/A/N/A/S/1/ (2)

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/4/1/1/1/1 (4)

/ / / (5)

LICENSEE CODE LICENSE hTMBER LICENSE TYPE CAT

/L/ (6)

/0/5/0/0/0/3/3/8/ (7)

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(8) /n/n/i/3/n/1]_(9)

DOCKET NUMBER EVENT DATE REPORT DATE EVENT DESCRIPTION AND PROBABLE CONSEQUENCES (10)

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/ On May 14, 1981 an inspection of the control room bottled air system revealed

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/ that only 83 air bottles were aligned for discharge rather than 84 as required by/

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/ T.S. 3.7.7.1.

While investigating this event the discovery was made that results/

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/ of a periodic test of control room air bottles indicated satisfactory results.

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/ The tests should have indicated unsatisfactory results. These events are report-/

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/ able pursuant to T.S. 6.9.1.9.b and 6.9.1.9.c respectively. The action state-

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/ ment of the LCO was met.

The public health and safety were not affected.

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SYSTEM

CAUSE

CAUSE COMP.

VALVE CODE CODE SUBCODE COMPONENT CODE SUBCODE SUBCODE

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/S/G/ (11) /A/ (12) /A/ (13) /X/X/X/X/X/X/ (14) /Z/ (15)

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SEQUENTIAL OCCURRENCE REPORT REVISION LER/R0 EVENT YEAR REPORT NO.

CODE TYPE NO.

(17) REPORT

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ACTION FUTURE EFFECT SHUTDOWN ATTACHMENT NPRD-4 PRIME COMP. COMPONENT TAKEN ACTION ON PLANT METHOD HOURS SUBMITTED FORM SUB. SUPPLIER MANUFACTURER [H[ (18) /A/ (19) [Z[ (20) [Z[ (21) /0/0/0/0/ (22) [][/ (23) /N/ (24) /A/ (25) /X/9/9/9/ (26)

CAUSE DESCRIPTION AND CORRECTIVE ACTIONS (27)

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/ Personnel errors caused both events. The control room bottled air system was

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/ realigned to place 84 bottles in service.

Persor.ori have been reinstructed

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/ about bottled air system alignment.

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FACILITY METHOD OF STATUS

% POWER OTHER STATUS DISCOVERY DISCOVERY DESCRIPTION (32)

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[E[ (28)

/1/0/0/ (29) /

NA

/ (30) /B/ (31) /

STA. OBSERVATION

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ACTIVITY CONTENT

- RELEASED OF RELEASE AMOUNT OF ACTIVITY (35)

LOCATION OF RELEASE (36)

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[ZL (33)

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NA

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NA

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PERSONNEL EXPOSURES NUMBER TYPE DESCRIPTION (39)

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NA

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PERSONNEL INJURIES hTMBER DESCRIPTION (41)

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NA

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LOSS OF OR DAMAGE TO FACILITY (43)

TYPE

DESCRIPTION

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PUBLICITY ISSUED DESCRIPTION (45)

NRC USE ONLY

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NA

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NAME OF PREPARER W.

R. CARTWRIGHT PHONE (703) 894-5151 8106160 F37

a Virginia Electric and Power Company North Anna Power Station, Unit 1 Attachment: Page 1 of 2 Docket No. 50-338 Report No. LER 81-037/03L-0

Description of Event

The control room bottled air system has four banks of air bottles with 42 bottles in each bank. When either Unit 1 or Unit 2 is in opera-tional Mode 1, 2, 3, or 4, Technical Specification 3.7.7.1 requires at least 84 bottles pressurized to at least 2300 psig to be aligned to the control room bottled air discharge header. On May 14, 1981 an inspection of the bottled air system showed that only 83 bottles were properly aligned. One bottle in one of the two banks aligned to the control room discharge header had been isolated. Unit I was operating at 100 percent power and Unit 2 was in the cold shutdown condition when the event was discovered. This event is reportable pursuant to T.S. 6.9.1.9.b.

A subsequent investigation of the event conducted on June 9, 1981 revealed that a periodic test (2-PT-76.3) had been performed twice on the Unit 2 portion of the bottled air system after the failure of at least one bottle. The periodic test required verification that 42 are aligned to each bank manifold and verification that the manifold pressure for each bank is at least 2300 psig. The acceptance criteria of the periodic test requires each bank to contain

"...a minimum of 42 bottles of air each pressurized to at least 2300 psig." Both tests indicated satisfactory test results despite comments on one test critique sheet indicating that two bottles were isolated from their respective bank manifolds. This event.is reportable pursuant to T.S. 6.9.1.9.c.

Probable Consequences of Occurrence i

The reduction in system capacity from the loss of one bottle is negligible. A periodic Test (1-PT-76.4) performed on April 1,1981 with only 83 operable bottles proved adequate system capacity.

After discovering that only 83 bottles were aligned properly to bottled air system discharge header, another bank of air bottles was valved in immediately. The Action Statement of the LC0 (T.S. 3.7.7.1) was met.

The public health and safety were not affected.

Cause of Event

Human errors and a failure of administrative control allowed the event to occur. Failure of the rupture discs on the air bottles is attributed to fatique.

Immediate Corrective Action

An additional bank was aligned to the bottled air discharge header for a total of 125 bottles. After a check of the Unit 1 A and B banks, both Unit 2 banks were isolated reducing the number of operable bottles to the required 84 bottles.

L Attachment: Page 2 of 2 Scheduled Corrective Action The failed air bottles will be replaced. Large tags are being made and will be hung on out of service bottles and bank isolation valves that are closed. The tags will enable operators to easily identify isolated bottles and banks which are not in service. The PT will be revised to clarify the bottle requirements.

Actions Taken to Prevent Reccurrence-In addition to the scheduled corrective actions, a description of the event as well as required remedial actions was placed in the control room required reading log.

Generic Implications This event had no generic implications.

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