LER-1981-021, /01T-0:on 810615,review of Analysis Responding to 10CFR50.44 Determined Inadequate.Mgt Controls Failed to Identify Effect of Rendering post-accident Nitrogen Supply Sys Inoperable.Caused by Inadequate Mgt Controls |
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NRC FORM 366 U. S. RUCLEAR REGULATORY COMMfSSION (7 W )
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}ilol l Inadequate review of the analysis made by BECo in responding to the requirements l IiI pf 10 CFR 50.44 and a failure in management controls to identify the ef# acts of I
12 pendering the Post Accident Nitrogen Supply System inopert.ble.
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r BOSTON EDXSON COMPANY PILGRIM NUCLEAR POWER STATION DOCKET NO. 50-293 Attachment to LER 81-021/0lT-0
Event Description
As required per Technical Specification Section 6.9.B., this narrative material is intended to provide an explanation of the circumstances surrounding the event reported under LER 81-021/0lX-0 regarding analyses dealing with post-LOCA combustible gas control per 10CFR50.44.
The prompt report was issued because BECo Nuclear Operations Department (N0D) personnel had been made aware by off-site support and engineering department personnel that a previous analysis which demonstrated conformance to 10CFR50.44 contained an assumption which could no longer be substantiated.
The assumption involved accessibility to the Reactor Building following a LOCA to mitigate the effects of single active failures and/or postulate! loss of power failures.
The following is a chronology of events leading to the submittal of LER81-021/01X-0:
3/37/81 - Per request of NRR in an attempt to closeout an open item, the Nuclear Engineering Department was asked to provide the analysis which demonstrated compliance to 10CFR50.44.
NRR requested BECo to submit the analysis discussed in BECo letter #79-207, dated 10/19/79 in which BECo stated that an evaluation had been performed which demonstrated that Pilgrim Station equipment satisfied 10CFR50.44 requirements with no modifications required.
J 5/27/81 - At the request of the Nuclear Engineering Department (NED), Pilgrim Station performed an inspection of the nitrogen purge system to ascertain the actual position of two, 1" manually operated nitrogen supply salves.
During this inspection small portions of the two, 1",
post accident nitrogen purge branch supply lines were found cut and capped. The cutting and capping were detertined to have been done on 7/21/80 with Maintenance Request #80-468.
A Field Revision Notice (FRN)
- 81-21-21 was issued to remove the two check valves and replace them with spool pieces.
The Maintenance Request (#80-468) issued to perform the work allowed the pipes to be cut and capped in lieu of installing the spool pieces because of an improperly 1
l processed FRN.
This document control problem is being addressed in-house as a separate issue and will be resolved as part of the overall upgrade of the management controls.
5/28/81 - Failure and Malfunction Report #81-59 was initiated and the Nuclear Operations Manager and the NRC Resident Inspector were notified of the discovery. At this time it was thought that the operational requirements of the Post Accident Nitrogen Supply System were based on NUREG 0737, TAP IIE.4.1 which required the system to be operable by 7/1/81. However, questions raised.egarding the system operability actually being based on the requirements of 10CFR50.44 were discussed between Pilgrim Station and BECo Licensing.
The Nuclear Operations Ma~ ager immediately initiated action to restore n
the system to its intended condition.
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f 5/29/81 - Based on conversations between the NRC Project Manager for Pilgrim and BECo Licensing, Edison management determined that further substantiction of the analytical assumptions would be required prior to submitting the 3/28/80 analysis to NRR.
6/3/81 - Following installation of spool pieces, the Nitrogen Purge System branch supply lines were returned to operational status.
6/13/81 - Subsequent to the substantiation effort alluded to earlier, an evaluation made to determine operational requirements regarding 10CFR50.44 was presented to the ORC.
6/15/81 - boston Edison issued a letter (#81-127) which stated that the results of a recently performed evaluation demonstrate that though rapid access to the Reactor Building for brief periods of time is possible, the calculated upper limit dose rates may preclude personnel access for the extended periods of time projected as necessary to perform equipment maintenance tc assure the single failure criterion is satisfied. Accordingly, system modifications which would have resulted from this awareness were in fact developed and installed during the 1980 Refueling Outage as a result of lessons learned from TMI.
6/16/81 - LER 81-021/0lX-0 was submitted to the NRC.
Cause and Corrective Action The cause of the events described above has been determined to be manager.ent controls which (1) did not provide for a comprehensive review and substantiation of analytical conclusions as set forth in BECo letter #79-207 and (2) did not provide adequate control of systed operability requirements which exceed the bounds of the Technical Specifications.
Corrective actions were discussed at a meeting between Boston Edison and hRC management (NRR and ISE Headquarters) on June 18, 1981.
In addition to describing the current efforts for an overall upgrade of management controls for the Boston Edison nuclear organization, BECo committed to conduct a re-review of previous BECo to NRC correspondence which stated that modifications to systems are not required because existing equipment satisfies specified requirements.
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| 05000293/LER-1981-001, Forwards LER 81-001/03L-0 | Forwards LER 81-001/03L-0 | | | 05000293/LER-1981-001-03, /03L-0:on 801226,unidentified Drywell Leakage Measured at Rate Contrary to Tech Specs.Cause Not Known Excessive Leakage Eliminated by Backstating B Recirculation Pump Suction Valve Mo 202-4B & Discharge Valve Mo 202-5B | /03L-0:on 801226,unidentified Drywell Leakage Measured at Rate Contrary to Tech Specs.Cause Not Known Excessive Leakage Eliminated by Backstating B Recirculation Pump Suction Valve Mo 202-4B & Discharge Valve Mo 202-5B | | | 05000293/LER-1981-002-03, /03L-0:on 810107,main Stack Sample Flow Alarm Received Twice on Panel C903 in Control Room.Caused by Frozen Suction Line (First Occurrence) & Blown Power Supply Fuse (Second Occurrence) | /03L-0:on 810107,main Stack Sample Flow Alarm Received Twice on Panel C903 in Control Room.Caused by Frozen Suction Line (First Occurrence) & Blown Power Supply Fuse (Second Occurrence) | | | 05000293/LER-1981-002, Forwards LER 81-002/03L-0 | Forwards LER 81-002/03L-0 | | | 05000293/LER-1981-003, Forwards LER 81-003/03L-0 | Forwards LER 81-003/03L-0 | | | 05000293/LER-1981-003-03, /03L-0:on 810123,heat Detector Failed in Diesel Generator a Room.Detector Alarm Could Not Be Reset.Cause Not Stated.Jumper Added to Eliminate Alarm on Control Room Panel C-114 Until Sys Repaired.Detector Replaced & Jumper Re | /03L-0:on 810123,heat Detector Failed in Diesel Generator a Room.Detector Alarm Could Not Be Reset.Cause Not Stated.Jumper Added to Eliminate Alarm on Control Room Panel C-114 Until Sys Repaired.Detector Replaced & Jumper Removed | | | 05000293/LER-1981-004, Forwards LER 81-004/01T-0 | Forwards LER 81-004/01T-0 | | | 05000293/LER-1981-004-01, /01T-0:on 810225,review Indicated That If Backup Scram Solenoids Failed,Actuation of ATWS Sys Would Prevent Closure of Scram Discharge Vol Vent & Drain Valves,Violating Primary Containment.Cause Due to Oversight in Design | /01T-0:on 810225,review Indicated That If Backup Scram Solenoids Failed,Actuation of ATWS Sys Would Prevent Closure of Scram Discharge Vol Vent & Drain Valves,Violating Primary Containment.Cause Due to Oversight in Design | | | 05000293/LER-1981-005, Forwards LER 81-005/03L-0 | Forwards LER 81-005/03L-0 | | | 05000293/LER-1981-005-03, /03L-0:on 810202,unidentified Reactor Drywell Coolant Leakage Rates Measured Above Tech Spec Level.Cause Not Stated.Recirculation Pump Suction Valves a & B & Discharge Valves Backseated | /03L-0:on 810202,unidentified Reactor Drywell Coolant Leakage Rates Measured Above Tech Spec Level.Cause Not Stated.Recirculation Pump Suction Valves a & B & Discharge Valves Backseated | | | 05000293/LER-1981-006-01, /01X-0:on 810219,review of Alleged Omission in Scheduling of 11 Once Per Cycle Instrumentation Verified Oversight.Caused by Misinterpretation of Special Circumstances Which Must Be Applied to Testing Definition | /01X-0:on 810219,review of Alleged Omission in Scheduling of 11 Once Per Cycle Instrumentation Verified Oversight.Caused by Misinterpretation of Special Circumstances Which Must Be Applied to Testing Definition | | | 05000293/LER-1981-007-03, /03L-0:on 810217,reactor Coolant Leak Detection Air Sampling Sys Declared Inoperable.Caused by Blown Fuses. Fuses Replaced.Pump Will Be Rebuilt | /03L-0:on 810217,reactor Coolant Leak Detection Air Sampling Sys Declared Inoperable.Caused by Blown Fuses. Fuses Replaced.Pump Will Be Rebuilt | | | 05000293/LER-1981-007, Forwards LER 81-007/03L-0 | Forwards LER 81-007/03L-0 | | | 05000293/LER-1981-008, Forwards LER 81-008/03L-0 | Forwards LER 81-008/03L-0 | | | 05000293/LER-1981-008-03, /03L-0:on 810313,inboard Isolation Valve Mo 2301-5 Was Determined to Be Inoperable.Caused by Manual Operation Disengagement Spring in Limitorque Operator Being Broken & Imbedded in Operator Gear Teeth,Jamming Gears | /03L-0:on 810313,inboard Isolation Valve Mo 2301-5 Was Determined to Be Inoperable.Caused by Manual Operation Disengagement Spring in Limitorque Operator Being Broken & Imbedded in Operator Gear Teeth,Jamming Gears | | | 05000293/LER-1981-009-03, Inboard Isolation Valve Failed to Open & HPCI Sys Declared Inoperable.Caused by Incorrect Min Torque Switch Setting of Motor Operator & Thermal Binding.Torque Switch Set at Max Value | Inboard Isolation Valve Failed to Open & HPCI Sys Declared Inoperable.Caused by Incorrect Min Torque Switch Setting of Motor Operator & Thermal Binding.Torque Switch Set at Max Value | | | 05000293/LER-1981-010, Forwards LER 81-010/04T-0 | Forwards LER 81-010/04T-0 | | | 05000293/LER-1981-010-04, /04T-0:on 810407,rept Received Indicating Excessive Co-60 Concentration in Mussel Sample Taken from Discharge Canal.Cause Not Stated.Dose Insignificant When Compared to Natural Background Dose | /04T-0:on 810407,rept Received Indicating Excessive Co-60 Concentration in Mussel Sample Taken from Discharge Canal.Cause Not Stated.Dose Insignificant When Compared to Natural Background Dose | | | 05000293/LER-1981-011, Forwards LER 81-011/03L-0 | Forwards LER 81-011/03L-0 | | | 05000293/LER-1981-011-03, /03L-0:on 810402,recirculation Pump B Motor Generator Set Tripped Resulting in Drive Motor Trip & Generator Lockout Alarms Sounding.Cause Not Determined.Set Returned to Svc | /03L-0:on 810402,recirculation Pump B Motor Generator Set Tripped Resulting in Drive Motor Trip & Generator Lockout Alarms Sounding.Cause Not Determined.Set Returned to Svc | | | 05000293/LER-1981-012, Forwards LER 81-012/03L-0 | Forwards LER 81-012/03L-0 | | | 05000293/LER-1981-012-03, /03L-0:on 810403,4 Kv Breaker A507,feeding Core Spray Pump P215A,inadvertently Closed During Routine Keep Fill Checks on Low Pressure ECCS Sys.Caused by Inconsistency in Automatic & Close/Trip Sequence Timings | /03L-0:on 810403,4 Kv Breaker A507,feeding Core Spray Pump P215A,inadvertently Closed During Routine Keep Fill Checks on Low Pressure ECCS Sys.Caused by Inconsistency in Automatic & Close/Trip Sequence Timings | | | 05000293/LER-1981-013, Forwards LER 81-013/04T-0 | Forwards LER 81-013/04T-0 | | | 05000293/LER-1981-013-04, /04T-0:on 810430,rept Received from Yankee Atomic Lab Re High Concentration of Co-60 in Irish Moss Sample Taken on 810218.Probably Caused by Fallout from Recent Atmospheric Weapons Tests | /04T-0:on 810430,rept Received from Yankee Atomic Lab Re High Concentration of Co-60 in Irish Moss Sample Taken on 810218.Probably Caused by Fallout from Recent Atmospheric Weapons Tests | | | 05000293/LER-1981-014-03, /03L-0:on 810414,pressure Instrument 261-39B Indicating Needle Went Beyond Mechanical Stop.Caused by Technician Error.Instrument Repaired.Technician Instructed | /03L-0:on 810414,pressure Instrument 261-39B Indicating Needle Went Beyond Mechanical Stop.Caused by Technician Error.Instrument Repaired.Technician Instructed | | | 05000293/LER-1981-014, Forwards LER 81-014/03L-0 | Forwards LER 81-014/03L-0 | | | 05000293/LER-1981-015-03, During Surveillance Testing,Nozzle on 23-ft Level Cardox Sys Hose Reel Failed to Deliver Adequate Stream.Caused by Operator Error.Fire Brigade Training Revised | During Surveillance Testing,Nozzle on 23-ft Level Cardox Sys Hose Reel Failed to Deliver Adequate Stream.Caused by Operator Error.Fire Brigade Training Revised | | | 05000293/LER-1981-016-03, /03L-0:on 810430,reactor Core Isolation Cooling Valve Mo 1301-17 Failed to Close on Demand Following Switch Actuation.Caused by Deteriorated Packing Jammed Between Valve Stem & Packing Gland.Packing Replaced | /03L-0:on 810430,reactor Core Isolation Cooling Valve Mo 1301-17 Failed to Close on Demand Following Switch Actuation.Caused by Deteriorated Packing Jammed Between Valve Stem & Packing Gland.Packing Replaced | | | 05000293/LER-1981-016, Forwards LER 81-016/03L-0 | Forwards LER 81-016/03L-0 | | | 05000293/LER-1981-017-03, /03L-0:on 810503,refuel Floor Exhaust Radiation Monitor 1705-8A Failed Downscale.Caused by Drop in High Voltage Output Due to Failed Capacitor in High Voltage Power Supply Circuit.Capacitor Replaced | /03L-0:on 810503,refuel Floor Exhaust Radiation Monitor 1705-8A Failed Downscale.Caused by Drop in High Voltage Output Due to Failed Capacitor in High Voltage Power Supply Circuit.Capacitor Replaced | | | 05000293/LER-1981-017, Forwards LER 81-017/03L-0 | Forwards LER 81-017/03L-0 | | | 05000293/LER-1981-018, Forwards Updated LER 81-018/03X-1 | Forwards Updated LER 81-018/03X-1 | | | 05000293/LER-1981-018-03, Stack Gas Radiation Monitor 1705-18A Was Downscale & Inoperable Following Lightning Strike Near Main Stack.Caused by Voltage Surge Resulting in Preamplifier & Discriminator Circuits Failure | Stack Gas Radiation Monitor 1705-18A Was Downscale & Inoperable Following Lightning Strike Near Main Stack.Caused by Voltage Surge Resulting in Preamplifier & Discriminator Circuits Failure | | | 05000293/LER-1981-019-03, /03L-0:on 810514,level Recorder 5049 Was Found Indicating High.Caused by Calibr Shift Due to Jarring Instrument Sensing Lines During Installation of Torus Room Staging.Recorder & Transmitters Recalibr | /03L-0:on 810514,level Recorder 5049 Was Found Indicating High.Caused by Calibr Shift Due to Jarring Instrument Sensing Lines During Installation of Torus Room Staging.Recorder & Transmitters Recalibr | | | 05000293/LER-1981-019, Forwards LER 81-019/03L-0 | Forwards LER 81-019/03L-0 | | | 05000293/LER-1981-020, Forwards LER 81-020/03L-0 | Forwards LER 81-020/03L-0 | | | 05000293/LER-1981-020-03, /03L-0:on 810603,fire Protection Engineer Determined That 810224 Fire on 51-ft Elevation,Initially Reviewed Per Orc Meeting 81-39,should Be Reported.Caused by Failure to Follow Combustible Matl Removal Procedures | /03L-0:on 810603,fire Protection Engineer Determined That 810224 Fire on 51-ft Elevation,Initially Reviewed Per Orc Meeting 81-39,should Be Reported.Caused by Failure to Follow Combustible Matl Removal Procedures | | | 05000293/LER-1981-021, Forwards LER 81-021/01T-0 | Forwards LER 81-021/01T-0 | | | 05000293/LER-1981-021-01, /01T-0:on 810615,review of Analysis Responding to 10CFR50.44 Determined Inadequate.Mgt Controls Failed to Identify Effect of Rendering post-accident Nitrogen Supply Sys Inoperable.Caused by Inadequate Mgt Controls | /01T-0:on 810615,review of Analysis Responding to 10CFR50.44 Determined Inadequate.Mgt Controls Failed to Identify Effect of Rendering post-accident Nitrogen Supply Sys Inoperable.Caused by Inadequate Mgt Controls | | | 05000293/LER-1981-022-03, /03L-0:on 810519,reactor Coolant Leak Detection Air Sampling Sys C-19 Pump Motor Overheated & Blew Fuses. Cause Under Investigation | /03L-0:on 810519,reactor Coolant Leak Detection Air Sampling Sys C-19 Pump Motor Overheated & Blew Fuses. Cause Under Investigation | | | 05000293/LER-1981-022, Forwards LER 81-022/03L-0 | Forwards LER 81-022/03L-0 | | | 05000293/LER-1981-023-03, /03L-0:on 810601 & 800721,two Primary Containment Nitrogen Supply Valves Made Inoperable & Valve in Same Line Placed in Isolated Condition.Caused by Lines Cut & Capped Due to Maint on post-accident Nitrogen Supply Sys | /03L-0:on 810601 & 800721,two Primary Containment Nitrogen Supply Valves Made Inoperable & Valve in Same Line Placed in Isolated Condition.Caused by Lines Cut & Capped Due to Maint on post-accident Nitrogen Supply Sys | | | 05000293/LER-1981-023, Forwards LER 81-023/03L-0 | Forwards LER 81-023/03L-0 | | | 05000293/LER-1981-024-03, /03L-0:on 810604,shutdown Transformer Primary & Secondary Breakers Opened Due to Fault in Offsite Power Supply.Caused by Failure of Cable Porcelain Clamps.Clamps removed.Post-type Insulators Installed | /03L-0:on 810604,shutdown Transformer Primary & Secondary Breakers Opened Due to Fault in Offsite Power Supply.Caused by Failure of Cable Porcelain Clamps.Clamps removed.Post-type Insulators Installed | | | 05000293/LER-1981-024, Forwards LER 81-024/03L-0 | Forwards LER 81-024/03L-0 | | | 05000293/LER-1981-025-03, /03L-0:on 810607,technician Failed to Document Jumper Installation.Caused by Shift Turnover During Installation.Personnel Instructed to Remain W/Job Until Completion,Regardless of Shift Times | /03L-0:on 810607,technician Failed to Document Jumper Installation.Caused by Shift Turnover During Installation.Personnel Instructed to Remain W/Job Until Completion,Regardless of Shift Times | | | 05000293/LER-1981-025, Forwards LER 81-025/03L-0 | Forwards LER 81-025/03L-0 | | | 05000293/LER-1981-026-01, /01X-0:on 810707,during Engineering Analyses, Components of Standby Gas Treatment Sys Were Found to Have Insufficient Documentation to Demonstrate Operation During Loca.Documentation Acquired | /01X-0:on 810707,during Engineering Analyses, Components of Standby Gas Treatment Sys Were Found to Have Insufficient Documentation to Demonstrate Operation During Loca.Documentation Acquired | | | 05000293/LER-1981-026, Forwards LER 81-026/01T-0 | Forwards LER 81-026/01T-0 | | | 05000293/LER-1981-027-03, /03L-0:on 810616,while Performing Rod Block Monitor Surveillance Test 8.M.2.3.1,step 31 High Rod Block Came on at 123% Vs 94% Power.Caused by Failed Trip Ref Card. Card Replaced in Kind | /03L-0:on 810616,while Performing Rod Block Monitor Surveillance Test 8.M.2.3.1,step 31 High Rod Block Came on at 123% Vs 94% Power.Caused by Failed Trip Ref Card. Card Replaced in Kind | |
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