ML20005D955

LER 89-021-00:on 891124,HPCI Deluge Sys Functional Test Not Completed within Tech Spec Interval of 6 Months.Caused by Mgt Deficiency & Insufficient Procedure.Procedures Revised to Better Control Tech Specs.W/891222 Ltr

ML20005D955
Person / Time
Site:	Quad Cities
Issue date:	12/22/1989
From:	Bax R, Smith E COMMONWEALTH EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-89-021-03, LER-89-21-3, RLB-89-285, NUDOCS 9001030010
Download: ML20005D955 (5)

Text

~6>

WN USOR e ound Cites Nocker Power Sr. tion  !

8 22710 206 Avenue Norm  !

Cordova. Ilknos 61242 9740 }

. . - Telephone 309454 2241 l RLB-89-285 r

December 22, 1989'  !

U. S. Nuclear Regulatory Commi.ssion Document Control Desk  !

Washington, DC 20555  ;

Reference:

Quad Cities Nuclear Power S~.ction Docket Number 50-254, DPR-29. Unit One Enclosed is Licensee Event Report (LER)89-021, Revision 00. for Quad Cities l Nuclear Power Station. ,

This report is submitted in accordance with the requirements of the Code of l Federal Regulations, Title 10, Part 50.73(a)(2)(1)(0): The licensee shall report any operation or condition prohibited by the p.lant's Technical Specifications.

Respectfully, COMMONWEALTH EDISON COMPANY -

QUy]CITIESNUCLEARPOWERSTATION f  !

M R.L.B[Hh)1ldghB '

Station Manager RLB/MJB/ad Enclosure cc: R. Stols R. Higgins INP0 Records Center NRC Region III TE a.A 2511H ' '

9001030010 891222 PDR ADOCK 03000254 S PDC

LICEN$tt (VENT REPORT (LER)

Form Rev 2.0 Factitty hame (1) Docket Number (2) Pane fil h d Cittet Unit One 01 El 01 01 DI fl $l 4 1 of 0 4 Title (4) 44PCI Fire Protection Technical spectfication $urvet11&nct Functional Test Not Cameleted on Time bue to Mananament Def teiency and Intuf ficient Procedure Event Date (1) Ltt Number f61 Reeert Date (7) Other Facilittet Involved fal Month Day Year Year // sequenttal' /// Revision Month Day Year Facility Names Docket Numberft) p/j/,

// Number /

77 j// Number of El 01 01 01 I i

'" ~~~

11 1 21 4 al e al 9 oi2l1 oIo 1 12 21 2 al o el 11 01 01 of I l DPERATING (Check one er more of the followino) fil) 1 20.402(b) 20.405(c) $0.73(a)(2)(iv) 73.7)(b)

POWER , 20.405(a)(1)(1) 50.36(c)(1) 50.73(a)(2)(v) 73.71(c)

Ltytt 20.40$(a)(1)(11) _ 50.36(c)(2) 50.73(a)(2)(vti) Other (specify f101 0!o!0 20.40$(a)(1)(111) X., 50.73(a)(2H1) 50.73(aH2Hvitt)(A) in Abstract i

/ /jj//g//

/ ////j ff //j

//// /// ////

7 f j f g//j f j j /j f77f 20.405(a)(1)(iv) 50.73(a)(2)(it) $0.73(a)(2)(viti)(B) below and in hhhhhhhhhhhhhhhhhhhhhhhhhh 'O'*0$("O ~ ~ O(*'E' ~ O ' I * ' ' '

• E '* _

LICENitt CONTACT FOR THIS LER fill Name TELEPHONt NUMBER AREA C00[

f. Havdan Smith. Technical staff Enoineer. Ext. 2116 310lo 6l El 41 -l 21 21 dl COMPLETE ONE LINE FOR [ ACH CDM FAILURE Dt1CRIBED IN THIS REPORT f131 CAU$t SYSTEM COMPONENT MANUFAC. REPORTABLE ' CAUsE SYSTEM COMPONENT MANUFAC. REPORTABLE l

TURER 70 NPRDS TURfR TO NPRDS I i 1 1 l i I I I i 1 I l I l l I I I I I I I I I I l l

$UPPL[ MENTAL REPORT EXP[tTED f14) Expected Month 1 Day I Year

$ubmission lYet fff vet. comolete EXPECTED SUBMISSION Daft) X l N0 l l1 lI ABSTRACT (Limit to 1400 spaces. 1.e. asproximately fifteen single-space typewritten lines) (16)

At 2330 hours0.027 days <br />0.647 hours <br />0.00385 weeks <br />8.86565e-4 months <br /> on November 24, 1989, Unit One was in the SHUTDOWN mode. At this time, the Shift Engineer (SE) discovered that the High Pressure Coolant Injection (HPCI) Deluge System functional T6st, 005 4100-12, had not been completed within the Technical Specification surveillance interval. He also noted that the test procedure required that only one of the seven detectors be functionally tested every six months, instead of functionally testing all seven detectors as required by Technical Specifications. It was determined that Technical Specification 4.12 had not been met. The Shift Engineer then instructed that all detectors associated alth the HPCI deluge system be functionally tested.

The testing was successfully completed at 0230 hours0.00266 days <br />0.0639 hours <br />3.80291e-4 weeks <br />8.7515e-5 months <br /> on November 25, 1989, using Te11porary Procedure 5994 This event occurred due to management deficiency and an insufficient test procedure. Procedures will be revised to maintain better control of Technical Specification surveillances and the test procedure will be revised to reflect Technical Specification require n nts.

This report is submitted in accordar,ce with 10CFR50.73(a)(2)(1)(B).

l l

l 2460H/069'lZ

'e LifENSEE EVENT REPORT fLER) TEXT CONTINuaf1JW Form Ra'y 2.0 FACILITYh5ME(1) DOCKET NuPS[R (2) LER NLMhER (61 Pane f31 YCar j/// sequential /// Revision

. /// humber jy/

// Number Guid Citiet Unit One 0l110 1 0 l 0 1 21 El 4 8 I9 - 0l 211 - 0l0 Di 2 0F 01 4 ftri Energy Industry Ioentification system (t!!s) cooes are identifieo in the tent as [xxl PLANT AND SYSTEM IDENTIFICATION:

General Electric - Bolling Water Reactor - 2511 MHt rated core thermal power.

EVENT IDENTIFICATION: HPCI Fire Protection Technical Specification Surveillance functional Test Not Completed on Time Due to Management Deficiency and Insufficient Procedure A. CONDITIONS PRIOR TO EVENT:

Unit: One Event Date: November 24, 1989 Event Time: 2330 Reactor Mode: 1 Mode Name: SHUTDOWN Power Level: 00%

This report was initiated by Deviation Report D-4-1-89-110.

SHUTDOWN Mode (1) - In this position, a reactor scram is initiated, power to the control rod drives is removed, and the reactor protection trip systems have been deenergized for 10 seconds prior to permissive for manual reset.

B. DESCRIPTION OF EVENT:

At 2330 hours0.027 days <br />0.647 hours <br />0.00385 weeks <br />8.86565e-4 months <br /> on November 24, 1989, Quad Cities Untt One was in the SHUTDOWN mode.

During a review of normal plant surveillance schedules, the Shift Engineer (SE) discovered that the six-month functional test procedure QOS 4100-12, HPCI (BU Deluge System Functional Test, had not been completed within the Technical Specification surveillance interval.

Prior to this time, Unit One was in a scheduled refuel outage beginning on September 9, 1989, and ending on November 23, 1989, when reactor start-up ,

commenced. At 2330 hours0.027 days <br />0.647 hours <br />0.00385 weeks <br />8.86565e-4 months <br /> on November 23, 1989, Unit One went critical, but was  ;

shut down approximately sixteen hours later at 1454 hours0.0168 days <br />0.404 hours <br />0.0024 weeks <br />5.53247e-4 months <br /> on November 24, 1989, l because of an unrelated problem.

Per Technical Specification 4.12, the HPCI deluge system shall be demonstrated operable at least once per six months whenever the system being protected is required to be operable. The surveillance was last performed on March 13, 1989, 4 and would have normally been performed on September 13, 1989. The HPCI deluge system was taken out of service on September 10, 1989, until November 22, 1989, in

order to perform maintenance on HPCI during the refuel outage. The deluge system 1 functional test is not required to be performed if the HPCI system or the deluge l system are out of service. The surveillance should therefore have been performed prior to declaring the HPCI system operable.

l During a review of the test procedure, it was noted that the surveillance required only one detector (DET) be functionally tested every six months. Technical Specification 4.12.A.1 requires that each of the seven fire protection instruments be demonstrated operable every six months.

2460H/0699Z

LICEmitt [VikT REPORT f LER) TEXT tokT1huATIou Form Rev 2.0 Fact,LITY NAME (1) 00cKIT NUMBER (2) Ltt kunare (6) Pane (1)

Year sequential Revision m, r m.mr

' titiet unit one o I & I o I o I e i 21 si 4 sIe - o12l1 - oIe of 3 or of 4 !

itxt Energy Industry Identification system (t!!s) codes are identified in the text as [XK)

I It was concluded that Technical Specification 4.12 had not been met for either Unit One or Unit Two HPCI systems. At 2330 hours0.027 days <br />0.647 hours <br />0.00385 weeks <br />8.86565e-4 months <br /> on November 24. 1989, both the Unit

! One and Unit Two HPCI deluge systems were declared inoperable, and QOS 4100-02, Fire Detection Instrumentation Outage Report, was initiated. Operating personnel began functional tests of all detectors associated with the HPCI deluge sprinkler system (KP). Testing was successfully completed at 0230 hours0.00266 days <br />0.0639 hours <br />3.80291e-4 weeks <br />8.7515e-5 months <br /> on November 25, 1989, using Temporary Procedure 5994. The deluge systems were declared operable  !

and the Outage Report terminated. l C. APPARENT CAUSE OF EVENT:

)

This report is being submitted in accordance with the requirements of l 10CFR50.73(a)(2)(1)(B) which requires that the licensee report any operation or  !

condition prohibited by the plant's Technical Specifications. l The cause of this event is management deficiency and insufficient procedures. The i surveillance was due once the HPCI system was declared operable; however, there '

cere inadequate procedural controls to assure that the test be performed. The surveillance procedure was also deficient in that it did not require functional testing of all seven detectors as required by Technical Specification 4.12.

D. SAFETY ANALYSIS OF EVENT:

The safety of plant and personnel was not affected by this event. The HPCI deluge l system was declared inoperable; back-up fire suppression and a fire watch were

! established as required by Technical Specifications. Each detector was functionally tested successfully proving the system was fully operable and able to perform its intended function in the event of a fire.

! E. CORRECTIVE ACTIONS:

l The immediate corrective action was to declare the Unit One and Unit Two HPCI deluge systems inoperable and initiate testing of all the detectors.

Testing was successfully completed on November 25, 1989, utilizing Temporary Procedure 5994.

This Temporary Procedure will be made a permanent procedure under QOS 4100-12 (NTS 2542008911001).

As further corrective action, a review of the test procedures for the deluge systems listed in Table 3.12-1 of the Technical Specifications was performed and it was found that all instruments are being tested.

A General Surveillance Program (GSRV) was established to follow completion of all surveillances, especially Technical Specification surveillances. The station has a Surveillance Task Coordinator who is responsible for this. The HPCI Deluge System functional Test had been identified by GSRV before start-up. The Computer Surveillance Tracking System will be made a part of the start-up on-site review.

Implementation of those surveillances into the Prior to Start-Up Checklist will help prevent another missed Technical Specification surveillance (NTS 2542008911002).

.2460H/06992 l

l

I.

s LIf thttf EVthi REPORT (LER) f tXT CONY 1NuaT10M Form Rev 2.0 Fact,LITV'NAME (1)- DOCKET NUMBER (2) LtR NUMhtR f6)_ Pane f11 5

Year fj/j

// sequential //j/ Revision

. /// ^~ r p///

f Mic4 er e

! nuant fit 1et Unit one 0 l 1 1 0 l 0 1 0 l 21 11 4 A l9 - 01211 - 010 01 4 0F 01 4

. itxt Energy 2noustry toentification system (ttts) cooes are ioenttrieo in the text as [xxl In regard to procedures not adequately covering Technical Specification requirements, a detailed study has already been completed and is in the process of being reviewed by the station (NTS 2542008911003).

QGP l-S3, Master Outage Checklist, will be revised to now require not only refuel D outage surveillances but all normal plant surveillance checklists be reviewed for completion prior to start-up (NTS 2542008911004). In regard to the more generic problem of the inability to perform survelliances on schedule, i.e.. when systems are out of service, the Surveillance Task Coordinator will develop a programmatic solution to be incorporated into the computer system for surveillance tracking (NTS 2542008911005).

F. PREVIOUS EVENTS:

Previously, the following LERs have been submitted due to missed Technical Specification surveillances:

LER DESCRIPTION 265/86-02 Monthly Reactor Vent Sample Not Obtained 254/87-02 Missed Fire Protection Surveillance 254/88-06 Missed Weekly Rad Surveillance 254/88-02 Missed Reactor Level Surveillance 254/88-15 Missed Fire Protection Valve Surveillance 265/88-29 Missed Post Accident Monitor Surveillance 265/88-30 Missed Post Accident Monitor Surveillance 265/89-02 Missed 3.25 Interval for MSIV LLRT 254/89-03 Missed Fire Protection Surveillance 254/89-13 Missed Four-Hour Chimney Samples 254/89-17 Missed Reactor Protection System Surveillance In December 1988, cue to other missed Technical Specification surveillances, a Task Force was formed tc. determine the cause and provide solutions for missed Technical Specification surveillances. The only similarity identified among these missed <

surveillances was the lack of sufficient management controls. The actions taken previously, along with the corrective actions now planned, should prevent further occurrences.

G. COMPONENT FAILURE DATA:

No component failures were involved with this event.

2460H/06992 '