ML20005G023

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LER 88-020-01:on 880619,improper Valving Sequence Occurred Which Resulted in Various ESF Actuations.Caused by Inadequate Equipment out-of-svc Procedure.Procedure Revised & Training Lesson Plan developed.W/900102 Ltr
ML20005G023
Person / Time
Site: Quad Cities Constellation icon.png
Issue date: 01/02/1990
From: Bax R, Cravens S
COMMONWEALTH EDISON CO.
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-88-020, LER-88-20, RLB-90-006, RLB-90-6, NUDOCS 9001180004
Download: ML20005G023 (6)
v • d • e


Text

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["'N Commonwealth Edison

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.a' ' ') ound Cites Nuclear Power Station 3 22710 206 Avenue North

\ / Cordova, Illinos 61242 9740 (j Telephone 309/654 2241 i

RLB-90-006- I i

l January 2, 1990 i l

1 U. S. Nuclear Regulatory Commission )

. Document Control Desk l Hashington, DC 20555 ,

A

Reference:

Quad cities Nuclear Power' Station- l Docket Number 50-265, DPR-30, Unit Two i 1

Enclosed is Licensee Event Report (LER)88-020, Revision 01, for-Quad Cities  !

Nucleer Power Station. l l

This report is submitted in accordance with the requirements of the Code of  ?

Federal Regulations, Title 10, Part 50.73(a)(2)(iv). The licensee shall report any event or condition that resulted in manual or automatic actuation of any Engineered Safety Feature (ESF) including the Reactor Protection System (RPS).

  • Respectfully, COMMONWEALTH EDISON COMPANY QUAD CITIES NUCLEAR POWER STATION 3 cePL6 Station Manager RLB/MJB/eb i Enclosure i

cc: R. Stols R. Higgins INPO Records Center NRC Region III /

l 900.11sooo4 pgg,g, _

/

[DR ADOCK 05000265 2527H PDC i 1

.i

c LICENSEE EVENT REPORT (LER)

Form Pev 2.0 Facility Name (1) Docket Number (2) Pane (3)

Quad cities unit Two 01 El DI ol 01 21 61 5 1 ofl0 !5 Titit (4) unit Two Emergency Core Cooling System initiation signal Received Durina Iggtsper Valvino SegggnCg_.gn Reactor Water Level Instrumentation Due to an Inniggutte. Procedure Event Date f$1 LER Number f61 Reoort Date (7) Other Facilitics Involved (B)

Month Day Year Year /// Sequential /,/, / Revision Month Day Year Facility Names Docket Numberfs) '

//,L,jlymber /p// Number 01 51 01 01 01 l L

~ ~ ~ ~

.01 6 11 9 Bl B Bl B 0 L210 0Ii 0I1 012 91 0 01 51 01 01 of I I p THis REPORT !$ SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10CFR lihgtk._gne or more of tDe followinal i111 1 20.402(b) _ 20.405(c) JL 50.73(a)(2)(iv) _ 73.71(b)

POWER ._._ 20.405(a)(1)(1) _ 50.36(c)(1) 50.73(a)(2)(v) . 73.7)(c)

LEVEL 20.405(a)(1)(ti) 50.36(c)(2) ___ 50.73(a)(2)(v11) _, Other (specify f101 0!Ol0 _ 20.405(a)(1)(iii) _ 50.73(a)(2)(1) 50.73(a)(2)(viii)(A) in Abstract

////////////////////////// _. 20.405(a)(1)(iv) 50.73(a)(2)(ii) _ 50.73(a)(2)(viii)(B) below and in

////////////////////////// 20.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x) Text)

LICENSEE CONTACT FOR THIS LER f121 Name TELEPHONE NUMBER AREA CODE

_$uzette Cravens. Technical Staff Enoineer. Extension 2144 3 1019 61 El 41 -l 21 21 41 COMPLETE ONE LINE FOR EACH COMP N N FAILURE DESCRIBED IN THIS REPORT f13)

CAUSE SYSTEM COMP 0NENT MANUFI,C. REPORTABLE CAuSE SYSTEM COMP 0NENT MANUFAC. REPORTABLE TURER TO NPRDS TURER TO NPRDS I i l I i l 1 1 I I l l l l l l 1 l I I I I I I I I I I SUPPLEMENTAL REPORT EXPECTED (141 __ _ Expected Month i Day I Year submission <

lyes (If ves. comolete EXPECTED SUBMISSION DATE) X l NO I l l l l ABSTRACT (Limit to 1400 spaces i.e. approximately fif teen single-space typewritten lines) (16)

ABSTRACT:

On June 19, 1988, Quad Cities Unit Two was at 0 percent thermal power during a refueling outage. At 0058 hours6.712963e-4 days <br />0.0161 hours <br />9.589947e-5 weeks <br />2.2069e-5 months <br />, while returning-to-service Reactor [RCT] Water Level Instrumentation [JB][IL), an improper valving [V) sequence occurred which resulted in various Engineered Safety Feature (ESF) actuations, including an Emergency Core Cooling System (ECCS) [JE] initiation. NRC notification of this event was completed at 0440 hours0.00509 days <br />0.122 hours <br />7.275132e-4 weeks <br />1.6742e-4 months <br /> to comply with the requirements of 10CFR50.72.

The station has completed a root cause analysis. The cause of this event is being attributed to an inadequate equipment out-of-serivce procedure. Corrective actions tsill include a procedure revision, development of a training lesson plan, and an engineering study. This report is provided to comply with the requirements of 10CFR50.73(a)(2)(10.

l 1

l 1418H/04362

a LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Form Rev 2.0 FACILITY NAME (1) DOCKET NuPSER (2) LER NupeER f6) Pane (3)

+

, Year //

j/jj/

//

sequential Number j//

/jp

///

Revision Number

.guad cities Unit Two 0 l E l 0 1 0 1 0 1 21 61 5 Bla - 01210 - 011 of 2 0F 01 $ l TEXT- Energy Industry Identification system (E!!s) codes are identified in the text as [XX]

I PLANT AND SYSTEM IDENTIFICATION:

General Electric - Boiling Water Reactor - 2511 MWt rated core thermal power.  ;

EVENT IDENTIFICATION: Emergency Core Cooling System Initiation Signal Received During Improper Valving Sequence on Reactor Water Level Instrumentation Due to an Inadequate Procedure A. CONDITIONS PRIOR TO EVENT:

Unit: Two Event Date: June 19, 1988 Event Time: 0058  !

Reactor Mode: 1 Mode Name: SHUTDOWN Power Level: 07. l This report was initiated by Deviation Report D-4-2-88-041. j 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 i deenergized for 10 seconds prior to permissive for manual reset. I B. DESCRIPTION OF EVENT:

On June 19, 1988, Quad Cities Unit Two was at 0 percent thermal power during a I refuel outage. At 0058 hours6.712963e-4 days <br />0.0161 hours <br />9.589947e-5 weeks <br />2.2069e-5 months <br />, during a return-to-service of reactor water level ,

instrumentation (Loop A) [JB][LI), an improper valving sequence caused an Emergency l Core Cooling System (ECCS) [JE] initiation signal. This resulted in the following automatic actions: .

Reactor scram [JC] signal (full scram was already in place);

1/2 diesel generator [EK1 started; Standby Gas Treatment [BH] train started; Reactor Building [VA) and Control Room [VI) ventilation isolated; Recirculation Pumps [AD)[P) tripped; Group I, II, III isolations [JE];

ECCS Injection valves aligned, but injection was prevented before it could occur.

l The 2A and 2C Residual Heat Removal (RHR) [B0][P] pumps were already running. The  ;

2B Core Spray pump [BM)[P] was in pull-to-lock. The 28 and 2D RHR pumps and the 2A l Core Spray pump were out-of-service. The Unit Two diesel generator was not available because of testing. (Technical Specifications 3.5.F.2 and 3.9.E.3 permit the conditions described above.)

NRC notification of this event was completed at 0440 hours0.00509 days <br />0.122 hours <br />7.275132e-4 weeks <br />1.6742e-4 months <br /> to comply with the requirements of 10CFR50.72. ,

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l 1418H/04362

LICENitt EVENT REPORT f LERI TEXT CONTINUATION Form Rev 2.0 FACILITY NAME (1) DOCKET NUMBER (2) Ltt Nunatt is) Pane f3)

Year /// sequential // Revision jff

/// Number /pj/j

// Number Quad cities Unit Two o l E l o 1 o l o 1 21 61 5 8iB - 01210 - 0l 1 01 3 0F of E TEXT Energy Industry Identification system (E!!s) codes are identified in the text as [XX]

Previously, on June 18, 1988, excess flow check valve [V) (2-263-2-15A) had been taken out-of-service for repair. This out-of-service (#1660-88) isolated the reactor level instruments for ECCS initiation (LIS 2-263-72A and C), Reactor Protection System [JC] (LT 2-263-57A and B), and main turbine high level trip switches (JJ) (LITS 2-263-59A). When the Out-of-Service Checklist was reviewed for 0_0S (Out-of-Service) Information Verified by the Shift Engineer, he noted that the root valve [RTV) for these instruments should be isolated last and the individual instrument valves be isolated first. He did this by writing in the Special Instructions section, "Do Card I last." The Special Sequence Reautred was marked "No" at this time by the original preparer.

Following completion of the work on June 19, 1988, the Return-to-Service was initiated by the Communication Center Coordinator. It was authorized by the Shift Engineer and taken to the Control Room for disposition. The Station Control Room Engineer (SCRE) initialed the RTS (Return-to-Service) Information Verified portion and thought that since "Do CarTI last" was in the Special Instructions and Special

  • Sequence Required was marked "No," that it must apply to the Return-to-Service. He marked the checklist as such and handed out the job.

An Instrument Maintenance (IM) person and an operator were dispatched to start the i Return-to-Service. The IM was using an Instrument Maintenance procedure for I valving in the instruments and realized that valving in the root valve last with an l empty variable leg would spike the instruments low. The IM called the ontrol Room l to clarify the Return-to-Service and to inform the Shift Engineer of the )

situation. The Shift Engineer told the IM to go ahead with the Return-to-Service j believing that since a full scram was already in place, the. unit would receive only half a trip signal when the instruments were valved in. A short time later, with further thought, the Shift Engineer attempted to contact the IM and the operator over the page system. They did not hear the page and the Engineered Safety Feature ,

(ESF) [JE] actuations occurred.

On the next shift, the Out-of-Service (Master #1673-88) and Return-to-Service for i Loop B of the water level instrumentation, identical to the one done for Loop A, l was completed successfully.

{

C. APPARENT CAUSE OF EVENT:

This report is-submitted in accordance with the Code of Federal Regulations  !

10CFR50.73(a)(2)(lv), which requires the reporting of any event or condition that resulted in manual or automatic actuation of any Engineered Safety Feature,  !

including the Reactor Protection System.  !

I 1418H/04362 i

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LICENSEE EVENT REPORT (LER) TEXT CONTINUAfl0N _ ,_fr.Je Rev 2.0  ;

FAC1,LITY.NAME (1) DOCKET NuPSER (2) LER NUPSER f6) Pana (3) e Year /// sequential Revision

/j/pj/ Number

/p///p//p Number Quad Cities Unit Two 0 1 5 1 0 l 0 1 0 1 21 61 E Rl8 - 01210 - 0i1 of 4 0F _ QJ ,1 TEXT Energy Industry identification system (E!!$) codes are identified in the text as (Xx) l The primary cause of this event is the inadequacy of procedure QAP 300-14, l Equipment Out-of-Service. It does not specifically address where any exceptions or additional sequencing should be written, and if required, whether the Special Sequence Required line should be marked. The "Do Card.1 last" was placed in  !

Special Instructions and not in the Special Sequence Required line, which was ,

marked "No." This action created confustor. during the subsequent l Return-to-Service. At that time, the SCRE noted the "Do Card I last" and thought  ;

it applied to the Return-to-Service, so he changed the Special Sequence Required to ,

"Yes" and drew an arrow to "Do Card i last." He then marked Return-to-Service next i to it and handed the job out. Card I was the instrument penetration valve which should have been opened first. Doing this card last on the Return-to-Service  ;

caused the multiple ESF actuations. A contributing factor was that the Shift Engineer in charge at the time allo'wed the job to continue after the IM voiced his .

concern. Another contributing factor was that personnel were unsure as to the specific instructions on the 00S sheet.

1 D. SAFETY ANALYSIS OF EVENT: j The safety consequences of this event are considered minimal as the unit was shutdown for a refueling outage. Also, cil systems functioned as designed upon receiving the ECCS initiation signal.

E. CORRECTIVE ACTIONS:

The following corrective actions are to be completed:

1. Revise QAP 300-14 to clarify the use of the Special Sequence Reautred line and how to address additions and exceptions to that, and; clarify the use of Special Instractions as an inappropriate place for sequencing. Also revise QAP 300-SS, Master Out-of-Service Checklist, to identify special sequencing required for Out-of-Service or Return-to-Service. INPO Good Practice OP 203 Tagging Procedures for the Protection of Personnel, Components, and Equipment, will be utilized during the procedure revisions (NTS 265200880410lRl).
2. This event will be incorporated into a revised training lesson plan that will address the special sequencing for the Out-of-Service program at Quad Cities (NTS 2652008804102RI).
3. A program to determine departmental training on procedure revisions will be implemented (NTS 2542008804103Rl).
4. An engineering study is scheduled to be performed to address improvements to the existing Gaitronics paging system under the facility improvement program.

FIP, (NTS 2652008804104R1).

1418H/04362

i tirretrr rvtur tipunt ttta) Ytrf contimuAtlam Form tev 2.0 fat!,LITY hAME (1) 00cKET IU sti (2) tra utsette tsi Paam (11 l 1 .- Year se0uential Revision fff yyy ur- {y{f{

f umr j Dund (itigt unit Two e i E l e I e I o I 21 si E aia - o1210 - oi1 of s or el 1 TEXT Energy Industry 16enttf tcation system (t!!$) codes are toentified in the text 45 (XX)

F. PREVIOUS EVENTS:

Licensee Event Report Description 254/84-013 Reactor Scram and ECCS Initiation While Backfilling l New Instrument Lines Caused by Personnel Error 265/87-011 Reactor Scram from Low Level Signal Caused by ,

Personnel Error During Surveillance Test.

254/85-006 Group I Isolation and Reactor Scram from Vibration 1 Caused by Valving in Turbine Pressure Transmitter 254/84-016 Group I Isolation and Reactor Scram Occurred when ,

Main Steam Line High Flow Switch Was Not  :

Prepressurized when it was Returned to Service Based upon the corrective actions to be taken, no further actions are deemed necessary.

G. COMPONENT FAILURE DATA:

There was no component failure identified in this event.

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W 1418H/04362 E

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