LER-1982-097, /03L-0:on 821008,HPCS Pump Declared Inoperable Based on Engineering Review of 821002 Incorrect Valve Lineup.Caused by Insufficient Retesting Following Valve Position Indicator Mod & Failure to Remove Info Tag |
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NRC FORM 366 U. S. NUCLEAR REGULATCY COMMISSION LICENSEE EVENT REPORT Attschm nt to AECM-82/530 Page 1 of 4 COrtTROL BLOCK: l l
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7 8 9 LICENSEE CODE 14 15 LICENSE NUMBER 25 26 LICENSE TYPE JO 67 CAT 68 CON'T lol1l S$RCE ILl@l0l5 10 10 l0l411l6 @l110l0l8l8l2l@l1l1l015I8l2l@
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60 61 DOCKET NU. BER 68 69 EVENT DATE 74 75 REPORT DATE 80 EVENT DESCRIPTION AND PROBABLE CONSEQUENCES h o 2 l With the plant in Cold Shutdown, the HPCS Pump was declared inoperable due to an I
lo lal l engineering review of an incident which occurred on October 2,1982. This incident l
lo l4 l l involved an incorrect valve lineup during the performance of a routine surveillance l
l o l 5 I l on the HPCS System. This left only one ECCS pump, LPCS, operable.
T.S.3.5.2. requires l l 0 l6 l l two ECCS Systems to be operable. This had no effect on the health and safety of the l
- - l 0 l 7 l l public and did not constitute a threat to plant safety. This event is reported as l
- loia, ccquired by T.S.6.9.1.13.b.
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9 10 11 12 13 18 19 20 SEQUENTIAL OCCURRENCE REPORT REVISION L
EVE AT YEAR REPORT No.
CODE TYPE N O.
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1982 van caused by insufficient l I
l roresting following vnive nosition indientors modifiention nnd fn 41 tiro to romnvo nn 1 1 1 7 l information tae on the valve which told the onerator to not rely on th'e position _
- - l Iil3l Qudicator. The information_ tag was removed-and the Retest Control Proegdg e was l
1114I gavised. The system was tested and returned to service.
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% POWER OTHER STATUS IS O RY DISCOVERY DESCRIPTION l1 l 5 I [_.C,.jh h) 1010lhl NA I
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1 7 PERSONNE L INJURIES DESCRIP HON @
NUYCE R li lR I l 01 01 Ol@l NA i
1 8 9 11 12 80 LOSS OF OR DAMAGE TO FACILITY TYPE DESCHlPTION (Jjhl NA I
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Attachment to AECM-82/530 Page 2 of 4 SUPPLEMENTAL INFORMATION TO LER 82-097/03 L-0 Mississippi Power & Light Company Grand Gulf Nuclear Station - Unit 1 Docket No. 50-416 Technical Specification Involved: 3.5.2 Reported Under Technical Specification: 6.9.1.13.b Event Narrative:
On October 2, 1982, with the plant in Cold Shutdown, Operations attempted to perform the HPCS Pump monthly surveillance test to prove operability of the system. The HPCS Pump was 911gned to take suction from the Condensate Storage Tank (CST) and pump thru the HPCS test return line back to the CST (See Figure 1).
When the pump was started, the operator at the HPCS Pump noticed a waterleak from check valve F216. He immediately informed the control room operator of the leak and requested that the HPCS Pump be stopped. The control room operator, who had opened the F010 and F011 valves and established a flow of 5000 gpm, stopped the HPCS pump and closed the F010 and F011 valves.
A walkdown of the system piping was initiated to determine the cause for the leakage at valve F216. The walkdown revealed the top gasket of valve F216 leaking, possibly due to high pressure. Further inspection revealed valve F070 (at the CST) had a stem seal leak. The local position indicator for valve F070 indicated the valve was closed. The operator, who had verified the valve in the OPEN position prior to starting the HPCS Pump, was questioned about the discrepancy. He stated that when he went to valve F070 to verify the valve was open, he found the valve locked and the indicator showing closed. He notified the control room that the valve was indicating closed but there was an Information Tag (#821063) on the valve handle stating that the
" Indicator May Indicate Incorrectly, Do Not Rely On Indicator Pointer". He unlocked the valve and attempted to OPEN the valve. The valve opened about 1/4 turn and stopped. He backed the valve off 1/4 turn and tried to open the valve again. The valve stopped at the same position. With the information tag stating not to rely on the position indicator and his inability to open the valve any further, the operator informed the control room operator that the valve was OPEN but indicated CLOSED.
After the HPCS Pump was shutdown and valve F070 discovered leaking, two operators using a lever arm opened valve F070. The valve had been closed as indicated by the position indicator when the HPCS pump was started.
Previous Similar Events
Further investigation revealed a Design Change (DCP 82/486) had been incorporated on valve F070 under a Maintenance Work Order (MWO M28924) on August 24, 1982 to correct the indicator problem. However, the information tag which was hung on July 28, 1982 stating "Do Not Rely on Indicator Pointer" was not removed following the indicator modification per the design change.
The information tag was verified removed on October 5, 1982.
In addition to valve F070, an additional 60 valves with the Pratt Type MDT-5 Manual Valve Operators supplied with Pratt Butterfly Valves, were modified by the same
Attcchm:nt to AECM-82/530 4
Page 3 of 4 design change. Each of the 60 valves had information tags hung on July 28, 1982, stating "Do Not Rely on Indicator Pointer". All the tags were verified removed on October 5, 1982. Administrative Procedure Protective Tagging System (01-S-06-1) states that any operations personnel may request that an information tag be removed when conditions no longer warrant the need for the information tag, however, the retest requirements should have specified tag removal.
Af ter valves F070 and F216 were found to be leaking, Maintenance Work Orders (MWO M2A695 and M2A696) were issued to correct the leaks. The F070 valve was replaced and the gaskets on F216 were replaced.
In addition to the work orders issued, Operations initiated an Incident Report (82-10-07) documenting "An event happening out of the ordinary which is not a violation of plant operating procedures or Technical Specifications but is important for its historical significance or to prevent future incidents" (Section 5.1.1 and 5.2.4 of Administrative Procedure 01-S-06-5 "Iv.cident Reports / Reportable Events"). This incident was not considered reportable because the section of piping involved was the HPCS Test Line and therefore the HPCS system was still operable.
When the incident report was evaluated by the Engineering Department, Engineering recommended that the HPCS System be declared inoperable until certain additional checks could be completed.
The HPCS system was declared inoperable at 1720 on October 8, 1982 pending the results of the inspection previously described. Declaring the HPCS system inoperable required placing the plant in a Limiting Condition for Operation.
T.S.3.5.2 requires two operable ECCS systems during shutdown. LPCS remained the only operable ECCS System. LPCI "A" was considered inoperable due to being in the shutdown cooling mode. LPCI "B" and "C" were inoperable due to the associated Diesel Generator being out of service. This LC0 (82-0128) resulted in incident report 82-10-14 which required this LER per T.S.6.9.1.13.b.
At 1430 on October 10, 1982, the HPCS system was declared operable following the satisfactory completion of the required tests and inspections.
This event had no ef fect on the health or safety of the public and did not constitute a threat to plant safety.
The root causes of this event are attributed to the lack of adequate retest requirements by the Maintenance Work Order following the work on the F070 valve and improper valve position verification by the operator.
Since the performance of the Maintenance Work Order on August 24, 1982, Technical Section Procedure " Control of Retest Requirements" (09-S-07-6) has been revised to give better guidance to Maintenance Planners on what type of activities require retests and what type of retest are required.
Pratt valves with this type of position indication problem have all been modified and the information tags removed. This is a final report.
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| 05000416/LER-1982-001-01, /01T-0:on 820618,loss of Dc Power to Div II Diesel Generator Control Circuit Detected.Caused by Failure of Main Fuses to Dc Control Panel Due to Fault in Circuitry of Semiconductor Annunciator module,SAM-2.Module Bypassed | /01T-0:on 820618,loss of Dc Power to Div II Diesel Generator Control Circuit Detected.Caused by Failure of Main Fuses to Dc Control Panel Due to Fault in Circuitry of Semiconductor Annunciator module,SAM-2.Module Bypassed | | | 05000416/LER-1982-001, Forwards LER 82-001/01T-0 | Forwards LER 82-001/01T-0 | | | 05000416/LER-1982-002-01, /01T-0:on 820701,two Scrams Initiated by High Flux Spikes on Fuel Loading Chambers Connected to Source Range Monitor Noncoincident Reactor Protection Sys Logic.Probably Caused by Close Proximity of Fuel Bundles to Fuel Chamb | /01T-0:on 820701,two Scrams Initiated by High Flux Spikes on Fuel Loading Chambers Connected to Source Range Monitor Noncoincident Reactor Protection Sys Logic.Probably Caused by Close Proximity of Fuel Bundles to Fuel Chamber | | | 05000416/LER-1982-002, Forwards LER 82-002/01T-0 | Forwards LER 82-002/01T-0 | | | 05000416/LER-1982-003-03, /03L-0:on 820616,during Surveillance Testing, Output Amplifiers for free-field Forced Balanced Accelerometer Found Inoperable.Probably Caused by Lightning Damage.Amplifiers Replaced & Surveillance Test Completed | /03L-0:on 820616,during Surveillance Testing, Output Amplifiers for free-field Forced Balanced Accelerometer Found Inoperable.Probably Caused by Lightning Damage.Amplifiers Replaced & Surveillance Test Completed | | | 05000416/LER-1982-003, Forwards LER 82-003/03L-0 | Forwards LER 82-003/03L-0 | | | 05000416/LER-1982-004-03, /03L-0:on 820616,prior to Initial Fuel Load,Area Radiation Monitoring Sys Failure Alarm Initiated.Probably Caused by Transient Which Allowed Meter to Fall in Downscale Range of Monitor.Sys Tested & Declared Operable | /03L-0:on 820616,prior to Initial Fuel Load,Area Radiation Monitoring Sys Failure Alarm Initiated.Probably Caused by Transient Which Allowed Meter to Fall in Downscale Range of Monitor.Sys Tested & Declared Operable | | | 05000416/LER-1982-004, Forwards LER 82-004/03L-0 | Forwards LER 82-004/03L-0 | | | 05000416/LER-1982-005-01, /01T-0:on 820709,while Performing Refueling Interlock Check,Automatic Interlocks Failed to Stop Refueling Platform Approach to Core.Caused by Malfunction of Interlock Relay.Relay Replaced | /01T-0:on 820709,while Performing Refueling Interlock Check,Automatic Interlocks Failed to Stop Refueling Platform Approach to Core.Caused by Malfunction of Interlock Relay.Relay Replaced | | | 05000416/LER-1982-005, Forwards LER 82-005/01T-0 | Forwards LER 82-005/01T-0 | | | 05000416/LER-1982-006-01, /01T-0:on 820709,violation of Tech Spec 4.7.8 Identified Re Temp Monitoring of Specific safety-related Areas Every 12-h.Caused by Procedural Inadequacy & Personnel Error Re Operating Log Requiring Recording Once Every 24-h | /01T-0:on 820709,violation of Tech Spec 4.7.8 Identified Re Temp Monitoring of Specific safety-related Areas Every 12-h.Caused by Procedural Inadequacy & Personnel Error Re Operating Log Requiring Recording Once Every 24-h | | | 05000416/LER-1982-006, Forwards LER 82-006/01T-0 | Forwards LER 82-006/01T-0 | | | 05000416/LER-1982-008-99, /99X-1:on 820626,during Testing of Carbon Dioxide (CO2) Fire Protection Sys,Ventilation Dampers for Div 1 & 2 Switchgear Rooms Failed to Close Upon CO2 Actuation Signal. Caused by Insufficient Power Supply to Melt Thermal Li | /99X-1:on 820626,during Testing of Carbon Dioxide (CO2) Fire Protection Sys,Ventilation Dampers for Div 1 & 2 Switchgear Rooms Failed to Close Upon CO2 Actuation Signal. Caused by Insufficient Power Supply to Melt Thermal Links | | | 05000416/LER-1982-008, Forwards LER 82-008/99X-1 | Forwards LER 82-008/99X-1 | | | 05000416/LER-1982-009-03, /03L-0:on 820708,observed That Accumulated Hours of Operation for Standby Gas Treatment Sys & Control Room Emergency Filtration Sys Not Recorded.Operators Reinstructed | /03L-0:on 820708,observed That Accumulated Hours of Operation for Standby Gas Treatment Sys & Control Room Emergency Filtration Sys Not Recorded.Operators Reinstructed | | | 05000416/LER-1982-009, Forwards LER 82-009/03L-0.Detailed Event Analysis Submitted | Forwards LER 82-009/03L-0.Detailed Event Analysis Submitted | | | 05000416/LER-1982-010-03, /03L-0:on 820709,Div 2 Control Room Emergency Filtration Automatic Initiation Capability Declared Inoperable.Caused by Sys Isolation Under Brown Tags Due to Freon Leak in Air Conditioning Compressor | /03L-0:on 820709,Div 2 Control Room Emergency Filtration Automatic Initiation Capability Declared Inoperable.Caused by Sys Isolation Under Brown Tags Due to Freon Leak in Air Conditioning Compressor | | | 05000416/LER-1982-010, Forwards LER 82-010/03L-0 | Forwards LER 82-010/03L-0 | | | 05000416/LER-1982-011-01, /01T-0:on 820722,diesel Generator 12 Tripped Due to High Water Jacket Temp.Cooling Water Found Isolated at Outlet Valve.Caused by Faulty Indicator Arrow on Pratt MDT-5 Operator.Indicator Realigned & Design Modified | /01T-0:on 820722,diesel Generator 12 Tripped Due to High Water Jacket Temp.Cooling Water Found Isolated at Outlet Valve.Caused by Faulty Indicator Arrow on Pratt MDT-5 Operator.Indicator Realigned & Design Modified | | | 05000416/LER-1982-011-99, /99X-0:on 830103-24,certain Fire Rated Barriers in Control Bldg & Auxiliary Bldg Opened to Perform Planned Maint.Caused by Cable Routing.Barriers to Be Restored by Apr 1983 | /99X-0:on 830103-24,certain Fire Rated Barriers in Control Bldg & Auxiliary Bldg Opened to Perform Planned Maint.Caused by Cable Routing.Barriers to Be Restored by Apr 1983 | | | 05000416/LER-1982-012-01, /01T-0:on 820722,radioactive Gaseous Effluent Sampler Flow Rates Were Not Being Recorded Daily Per Tech Spec 4.3.7.12-1.Operating Log Did Not Include Sampler Flow Rates.Temporary Change Notice Initiated | /01T-0:on 820722,radioactive Gaseous Effluent Sampler Flow Rates Were Not Being Recorded Daily Per Tech Spec 4.3.7.12-1.Operating Log Did Not Include Sampler Flow Rates.Temporary Change Notice Initiated | | | 05000416/LER-1982-012, Forwards LER 82-012/01T-0 | Forwards LER 82-012/01T-0 | | | 05000416/LER-1982-013, Forwards LER 82-013/03L-0 | Forwards LER 82-013/03L-0 | | | 05000416/LER-1982-013-03, /03L-0:on 820702,one 4.16-kV Bus Undervoltage Trip Channel Setpoint Found to Be Out of Tech Spec Value. Caused by Incorrect Calibr Procedure.Procedure Revised | /03L-0:on 820702,one 4.16-kV Bus Undervoltage Trip Channel Setpoint Found to Be Out of Tech Spec Value. Caused by Incorrect Calibr Procedure.Procedure Revised | | | 05000416/LER-1982-014, Forwards LER 82-014/03L-0 | Forwards LER 82-014/03L-0 | | | 05000416/LER-1982-014-03, /03L-0:on 820713,carbon Dioxide Fire Protection Sys Initiated in Electrical Penetration Room in Auxiliary Bldg W/O Fire.Caused by Faulty Supervisory Relay.Relay Replaced | /03L-0:on 820713,carbon Dioxide Fire Protection Sys Initiated in Electrical Penetration Room in Auxiliary Bldg W/O Fire.Caused by Faulty Supervisory Relay.Relay Replaced | | | 05000416/LER-1982-015, Forwards LER 82-015/03L-0 | Forwards LER 82-015/03L-0 | | | 05000416/LER-1982-015-03, /03L-0:on 820714,limiting Condition of Operation Entered Due to Gaseous Effluent Sampler Being Removed from Svc for Maint.Caused by Inverted Indicator Floats in Meter Tubes Due to Preoperational Testing.Floats Reinstalled | /03L-0:on 820714,limiting Condition of Operation Entered Due to Gaseous Effluent Sampler Being Removed from Svc for Maint.Caused by Inverted Indicator Floats in Meter Tubes Due to Preoperational Testing.Floats Reinstalled | | | 05000416/LER-1982-016-03, /03L-0:on 820702,during Review of Completed Surveillance,One Channel Found Out of Spec.Caused by Delayed Notification to Shift Supervisor of Failure Until 820707 When Test Results Identified as Unacceptable | /03L-0:on 820702,during Review of Completed Surveillance,One Channel Found Out of Spec.Caused by Delayed Notification to Shift Supervisor of Failure Until 820707 When Test Results Identified as Unacceptable | | | 05000416/LER-1982-016, Forwards LER 82-016/03L-0 | Forwards LER 82-016/03L-0 | | | 05000416/LER-1982-017, Forwards LER 82-017/03L-0 | Forwards LER 82-017/03L-0 | | | 05000416/LER-1982-017-03, /03L-0:on 820714,during Fire Door Alarms Check Surveillance Test,Several Doors Failed to Alarm in Secure Position.Caused by Electronic Malfunction & Equipment Out of Adjustment.Equipment Restored to Operable Status | /03L-0:on 820714,during Fire Door Alarms Check Surveillance Test,Several Doors Failed to Alarm in Secure Position.Caused by Electronic Malfunction & Equipment Out of Adjustment.Equipment Restored to Operable Status | | | 05000416/LER-1982-019, Forwards LER 82-019/01T-0 | Forwards LER 82-019/01T-0 | | | 05000416/LER-1982-019-01, /01T-0:on 820801,sampling Required on 820729,30 & 31 Was Not Performed.Caused by Removal of Sampler Pumps for Replacement,Due to Inoperability of Fuel Handling Area Ventilation Effluent Monitoring Sys | /01T-0:on 820801,sampling Required on 820729,30 & 31 Was Not Performed.Caused by Removal of Sampler Pumps for Replacement,Due to Inoperability of Fuel Handling Area Ventilation Effluent Monitoring Sys | | | 05000416/LER-1982-021-99, /99X-1:on 820720,limiting Condition for Operation Entered Due to Quarterly Test of Radioactive Liquid Effluent Monitoring Sys Not Being Performed by 820720.Caused by Inadequate Sys Design.Design Change Implemented | /99X-1:on 820720,limiting Condition for Operation Entered Due to Quarterly Test of Radioactive Liquid Effluent Monitoring Sys Not Being Performed by 820720.Caused by Inadequate Sys Design.Design Change Implemented | | | 05000416/LER-1982-022, Forwards LER 82-022/03L-0 | Forwards LER 82-022/03L-0 | | | 05000416/LER-1982-022-03, /03L-0:on 820721,fuel Handling Area Gaseous Effluent Monitor Inoperable.Caused by Fuse Failure.Fuse Replaced & Monitor re-energized.Samples Taken During Period of Inoperability Found Acceptable | /03L-0:on 820721,fuel Handling Area Gaseous Effluent Monitor Inoperable.Caused by Fuse Failure.Fuse Replaced & Monitor re-energized.Samples Taken During Period of Inoperability Found Acceptable | | | 05000416/LER-1982-023, Forwards LER 82-023/03L-0 | Forwards LER 82-023/03L-0 | | | 05000416/LER-1982-023-03, /03L-0:on 820723,Div 3 Switchgear Room CO2 Fire Protection Sys Declared Inoperable Due to Failure of Latching Mechanism to Secure Door.Caused by Failure of Striker Plate.Striker Plate Adjusted | /03L-0:on 820723,Div 3 Switchgear Room CO2 Fire Protection Sys Declared Inoperable Due to Failure of Latching Mechanism to Secure Door.Caused by Failure of Striker Plate.Striker Plate Adjusted | | | 05000416/LER-1982-024, Forwards LER 82-024/03L-0 | Forwards LER 82-024/03L-0 | | | 05000416/LER-1982-024-03, /03L-0:on 820723,limiting Condition for Operation Was Entered Due to Inoperability of Zone 1006 Flame Detector in HPCS Diesel Generator East Corridor.Cause Not Stated. Detector Cleaned & Tested.Fire Watch Initiated | /03L-0:on 820723,limiting Condition for Operation Was Entered Due to Inoperability of Zone 1006 Flame Detector in HPCS Diesel Generator East Corridor.Cause Not Stated. Detector Cleaned & Tested.Fire Watch Initiated | | | 05000416/LER-1982-025, Forwards LER 82-025/03L-0 | Forwards LER 82-025/03L-0 | | | 05000416/LER-1982-025-03, /03L-0:on 820724,fire Doors 1A309,1A109,1A202 & 1A312 Found Alarming in Closed Position.Cause Not Stated. Fire Watch Established,Magnetic Switch Components Adjusted & Operation Verified | /03L-0:on 820724,fire Doors 1A309,1A109,1A202 & 1A312 Found Alarming in Closed Position.Cause Not Stated. Fire Watch Established,Magnetic Switch Components Adjusted & Operation Verified | | | 05000416/LER-1982-026-03, /03L-0:on 820725,smoke Detector Above Steam Tunnel Area Zone 2-08 Alarmed W/O Fire & Would Not Reset.Caused by Initiated Manual Pull Station.Sys Restored & Hourly Fire Watch Discontinued | /03L-0:on 820725,smoke Detector Above Steam Tunnel Area Zone 2-08 Alarmed W/O Fire & Would Not Reset.Caused by Initiated Manual Pull Station.Sys Restored & Hourly Fire Watch Discontinued | | | 05000416/LER-1982-026, Forwards LER 82-026/03L-0 | Forwards LER 82-026/03L-0 | | | 05000416/LER-1982-027-99, During Special Insp,Seal AV-8D Not Installed in Spare HVAC Penetration to Containment Exhaust Filter Train Room.Caused by Current Drawings Not Requiring Sealing.Design Change Issued | During Special Insp,Seal AV-8D Not Installed in Spare HVAC Penetration to Containment Exhaust Filter Train Room.Caused by Current Drawings Not Requiring Sealing.Design Change Issued | | | 05000416/LER-1982-027-03, /03L-0:on 820727,discovered That Seal AV-8D Not Installed in Spare HVAC Penetration to Containment Exhaust Filter Train Room.Also Found That Current Drawings Do Not Reflect Open Penetration in Secondary Containment | /03L-0:on 820727,discovered That Seal AV-8D Not Installed in Spare HVAC Penetration to Containment Exhaust Filter Train Room.Also Found That Current Drawings Do Not Reflect Open Penetration in Secondary Containment | | | 05000416/LER-1982-028, Forwards LER 82-028/01T-0 | Forwards LER 82-028/01T-0 | | | 05000416/LER-1982-028-01, /01T-0:on 820814,Halon Sys Surveillance Test Revealed That Acceptance Criteria for Change Pressure of Halon Bottles Not Met.Caused by Surveillance Test Performed Prior to Issuance of Ol.Halon Bottles Replaced | /01T-0:on 820814,Halon Sys Surveillance Test Revealed That Acceptance Criteria for Change Pressure of Halon Bottles Not Met.Caused by Surveillance Test Performed Prior to Issuance of Ol.Halon Bottles Replaced | | | 05000416/LER-1982-029, Forwards LER 82-029/03L-0 | Forwards LER 82-029/03L-0 | |
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