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LER 90-014-00:on 900514,containment Penetration Improperly Isolated While Containment Isolation Valve Made Inoperable for Repairs.Caused by Inadequate Review of Work Order. Supervisor Counseled & Shift Order issued.W/900613 Ltr
	ML20043G112
Person / Time
Site:	Comanche Peak
Issue date:	06/13/1990
From:	William Cahill, Mcgee G; TEXAS UTILITIES ELECTRIC CO. (TU ELECTRIC)
To:	; NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
	LER-90-014, LER-90-14, TXX-90211, NUDOCS 9006190073
	Download: ML20043G112 (8)
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-- . Log' # TXX-90211 F9 File # 10200-i, 3 E -

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L NJELECTR/C Ref. f.50.73 (a)(2)(i) ,

at J Edl,E,Yu rm,s,,, June 13,-1990 U. :S. Nuclear Regulatory Commission Attn: Document Control- Desk Washington, D. C.- 20555.- -

SUBJECT:

COMANCHE F'iAK-STEAM ELECTRIC STATION DOCKET NO. 50-445 i CONTAINMENT PENETRATION NOT PROPERLY ISOLATED &

LICENSEE EVENT' REPORT 90-014-00

~ Gentlemen: -

Enclosed is Licensee Event Report 90 014-00 for Comanche Peak Steam Electric Station Unit ~ 1, " Containment Penetration Not Properly Isolated Due to Personnel Error."

Sincerely, y William J. Cahill, Jr.

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l Enclosure -

l c EMr. R. D. Martin, Region IV -

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-Resident Inspectors, CPSES'(3) y I

9006190073 900613 /),

PDR ADOCK 05000443 V S PDC e)O North Olive Street LB81 Dallas, Texas 73201

,e Enclesur,e.to TXX 90211 NRC FORM 366 U.S. NUCLk AR REOut.ATORY COMMISSON APPROVED OWB NO. 3150*0104 l EXPIRE 8:4/3@92 ESTiuATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATON COLLECTON REQUEST: 60bHRS. FORWARD COMWENTS REGARDING SUR EN ESTIMATE T THE RE R S AN REP RT8 MANA EWENT LICENSEE EVENT REPORT (LER) BRANCH (P-630). U.S. NUCLE AR REGULATORY COMMISSON, WASHtNOTON.

DC. 20665, AND TO THE PAPERWORK REDUCTION PROJECT (31540104)

OFFICE OF WANAGEMENT AND BUDGET,WASHINOTON,DC.20503.

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CONTAINMENT PENETRATION NOT PROPERLY ISOL ATED DUE TO PERSONNEL ~r,-,.,-.,

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At 1530 on May 14,1990, it was discovered that a containment penetration had not been properly isolated (for approximately 16 hours1.851852e-4 days 0.00444 hours 2.645503e-5 weeks 6.088e-6 months ) in accordance with Technical Specification 3.6.3 while containment isolation valve 1-HV-2409 was inoperable for repairs. With 1 HV 2409 Inoperable, manual isolation valve 1 MS 0324 had been closed to isolate the containment penetration and to satisfy the Technical Specification Action Statement. Subsequently, the entire clearance for 1-HV-2409 was released (including the opening of 1MS-0324) to allow valve calibration at the completion of the repairs without ensuring that actions would be taken to satisfy the Action Statement.

The root cause of the event is an inadequate review of the work order by the Unit Supervisor prior to authorizing release of the entire clearance rather than authorizing a partial release of the clearance (just the air supply to the valve). Corrective actions include counselling of the Unit Supervisor, issuance of a Shift Order to caution control room operators of the event, and several program enhancements to more readily identify the tie between a clearance and associated Action Statement.

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. Encl:sure to.TXX 90211=

NffC FORM 366A U.S. NUCLE AR REOULATURY COMMISSION APPROVED OMB NO. 31540104 ESTIMATED BURDEN PCR f4E E COMPW WITH THS INFORMATION

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0l0 0l2 OF 017 i..n % . % . - RCr.,m3=A.>on I. DESCRIPTION OF THE REPORTABLE EVENT A. PLANT OPERATING CONDITIONS BEFORE THE EVENT j

! On May 14,1990, Comanche Peak Steam Electric Station (CPSES) Unit 1 was in l

Mode 2 operating at 3 percent reactor power.

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B. STATUS OF STRUCTURES. SYSTEMS. OR COMPONENTS l THAT WERE INOPERABLE AT THE START OF THE EVENT AND THAT CONTRIBUTED TO THE EVENT i

Main Steam Line Drain Pot Isolation Valve (Ells:(ISV)(SB)) 1-HV-2409 had been declared Inoperable on May 12,1990 in order to repair a body to bonnet leak.1-HV-2409 is an air operated automatic containment isolation valve which is normally open but falls closed.

L C. REPORTABLE EVENT CLASSIFICATION Any operation or condition prohibited by the plant's Technical Specifications.

D. NARRATIVE

SUMMARY

OF THE EVENT. INCLUDING DATE AND l APPROXIMATE TIMES in preparation for the performance of corrective maintenance to repair a body-to-bonnet leak on va!ve 1-HV 2409, the appropriate clearance tags were attached and subsequently accepted by the (midnight shift) Shift Technical Advisor (utility, licensed) on May 12,1990 at 0455. The approved clearance required isolating the air suppiy to 1-HV 2409 and closing several manual isolation valves including the upstream manualisolation valve (1MS 0324) (Ells:(ISV)(SB)) for 1-HV 2409. These actions isolated the valve from normal operating pressure and allowed the work order to be performed. !

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1 Enclosure to TXX-90211

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In accordance with Technical Specification 3.6.3, isolation of the containment penetration (Ells:(PEN)(NH)) was required within 4 hours4.62963e-5 days 0.00111 hours 6.613757e-6 weeks 1.522e-6 months of the inoperability of a containment isolation valve associated with that penetration. Closing 1MS 0324 provided isolation of the containment penetration associated with 1 HV 2409. A Limiting Condition for Operation Action Requirement (LCOAR) was initiated to document the entrance into a Technical Specification Action Statement and identify the necessary requirements to restore operability following completion of the work.

Repairs were subsequently completed on the valve with the exception of the required valve calibration (bench set) and a request was made to control room personnel by an Instrument and Control (l&C) Technician to release the clearance on the valve, l&C needed the air supply isolation removed to allow stroking of the valve during the valve calibration. At 2147 on May 13,1990, the (evening shift) Unit Suparvisor (utility, licensed) performed a review of the work order and authorized the release of the entire clearance, including the opening of 1MS 0324, to allow l&C to calit rate the valve. The valve calibration was successfully completed at 0424 on May 14,1990, and at 1039 the same day,1 HV-2409 was successfully stroked by Operations to meet the post work testing requirements. The post work test results were subsequently reviewed, the LCOAR closed out, and 1-HV-2409 was declared operable at 1327.

At 1530 on May 14,1990, it was discovered that 1-HV-2409 had been inoperable without 1 MS-0324 being shut for approximately 16 hours1.851852e-4 days 0.00444 hours 2.645503e-5 weeks 6.088e-6 months (2147, May 13 to 1327, May 14,1990). Therefore, CPSES Unit 1 had been in violation of Technical Specification 3.6.3 since 0147 on May 14,1990 (4 hours4.62963e-5 days 0.00111 hours 6.613757e-6 weeks 1.522e-6 months after the initial release of L the clearance and the subsequent opening of 1MS 0324).

E. THE METHOD OF DISCOVERY OF EACH COMPONENT OR SYSTEM FAILURE OR PROCEDURAL OR PERSONNEL ERROR On May 14,1990, at 1530, just after assuming licensed duties for the evening shift, the Unit Supervisor identified the fact that he had released the clearance and unisolated the containment penetration prior to completion of the required operability testing. The discovery occurred during shift turnover when the status of 1-HV-2409 was being discussed. At the time of the event discovery,1-HV-2409 had already been declared operable.

Enclosure to TXX 90211 U.8, NUCLE AR REQULATORY COMMISSON APPROVED OWB NO. stb 0104 NRC FORM 366A ESTIMATED BURDEN PER RE8 9 COMPW wtTH THIS INFORMATON LICENSEE EVENT REPORT (LER) g,c ,

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1. im - . mo. .. .= NRe f o,m mA.ma ll. COMPONENT OR SYSTEM FAILURES A. FAILURE MODE. MECH ANISM AND E-2ECT OF EACH FAILED COMPONENT Not applicable - no failed components have been identified.

B. CAUSE OF EACH COMPONENT OR SYSTEM FAILURE Not applicable - no component or system failures have been identified.

C. SYSTEMS OR SECONDARY FUNCTIONS THAT WERE AFFECTED BY FAILURE OF COMPONENTS WITH MULTIPLE FUNCTIONS Not applicable - no components failures have been identified.

D. FAILED COMPONENT INFORMATION Not applicable - no failed components have been identified.

Ill.. ANALYSIS OF THE EVENT A. SAFETY SYSTEM RESPONSES TH AT OCCURRED Not applicable - there were no manual or automatic safety system responses as a result of this event.

B. DUR ATION OF SAFETY SYSTEM INOPERABILITY Not applicable - there were no safety systems which were rendered inoperable due to a failure.

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Enclosure to TXX 90211- 1 unc ronu ma v.s. sucana ntowom couuissow ,,gno ,oo,, ,, .

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l C. SAFETY CONSEQUENCES AND IMPLICATIONS OF THE EVENT q

Based on the following discussion, the event did not adversely affect the safe operation of CPSES Unit 1 or the health and safety of the public.

Upon releasing the clearance,1MS-0324 was opened which eliminated the isolation ,

provision established to meet the requirements of Technical Specification 3.6.3.

However, at this time,1 HV-2409 was in the closed position with the exception of several minutes while it was being stroked as part of the valve calibration and as part '

i of the post work operability testing. After the successful completion of the operability L

testing, the valve was left open in its normal operating position for 2 hours2.314815e-5 days 5.555556e-4 hours 3.306878e-6 weeks 7.61e-7 months and 44-minutes until the valve was declared operable. Cumulatively,1 HV 2409 was in the a open position for a maximum of 3 hours3.472222e-5 days 8.333333e-4 hours 4.960317e-6 weeks 1.1415e-6 months and 7 minutes during the time period following the clearance release until it was declared operable. This is less than the 4 hour4.62963e-5 days 0.00111 hours 6.613757e-6 weeks 1.522e-6 months limit allowed by Technical Specification 3.6.3 for an unisolated containment penetration. The reason that credit cannot be taken for 1-HV 2409 meeting the Technical Specification 3.6.3, Action Statement (isolating the penetration) is that it was not " deactivated" and " secured" while in the closed position.

In addition, since the work order did not affect the valve actuator, and the valve calibration as well as the post work operability testing were successfully completed, the valve would have been able to close in response to an isolation signal during the times it was open, if required.

IV. CAUSE OF THE EVENT ROOT CAUSE The root cause of the event is an inadequate review of the work order by the Unit Supervisor (utility, licensed) prior to authorizing release of the entire clearance. Only the release of the air supply to 1-HV-2409 needed to be authorized in order to allow l&C to perform the bench set. The inadequate review is considered a cognitive personnel error.

p (Enclosure to TXX-90211(

NRC FORW 3 sea _ U.S. NUCLE AR REOULATORY COWWISSION APPROVED OM8 NO. 3160104 ESTIMATED BURDEN PER RES E COMPLY WITH TH18 INFORMATION LICENSEE EVENT REPORT (LER) "5T%,g',';

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C V. CORRECTIVE ACTIONS i

A. CORRECTIVE ACTIONS TO PREVENT RECURRENCE The Unit Supervisor was counselled regarding the event and the need for attention to details.

- A Shift Order was issued on May 15,1990 to caution control room operators of the event.

A~ newly developed Impact Review Sheet has been implemented to provide a more thorough and structured review of work orders in order to ensure that any special circumstances related to the work order are identified and highlighted up front.

The shift turnover checklist has been revised to provide a section for logging any active' Limiting Condition of Operations (LCO). This will help provide continued 1 awareness of any epecial circumstances associated with an Action Statement.

The following program enhancements are being implemented to more readily identify the tie between a clearance and associated Action Statement (s), allowing for the appropriate disposition of the clearance by control room personnel.

1. . The LCOAR procedure will be revised to include the requirement that if it is *

' desired to maintain a component in a particular state (i.e., inoperable Containment Isolation Valve shut with power removed) to ensure compliance ,

~

with an Action Statement, the clearance tags hung on the affected components willlist the LCOAR Number and the required component configuration. '

Conversely, clearances being utilized to ensure compliance with an Action Statement will be required to be referenced on the LCOAR.

2. The CPSES Clearar Report Form will be revised to include a line within the placement and release authorization sections where the associated LCOAR

. number shall be documented.

, . Enclosure to TXX-90211 NRC FORM 306A U.S. NUCLE AR RECULATORY COMMISSON APPROVED OMB NO.3150 0104 CSTIMATED BURDEN PER RES 8T COMPLY WITH THIS lNFORMATON 5* *' ' "*

LICENSEE EVENT REPORT (LER) g3,,'%,",5T',';

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! B. CORRECTIVE ACTION TAKEN ON GENERIC CONCERNS IDENTIFIED AS A DIRECT RESULT OF THE EVENT Following the event, a task team was formed to evaluate factors contributing to p Technical Specification noncompliance. The scope of this evaluation included CPSES Licensee Event Reports, Operations Notification and Evaluation (ONE) ,

Forms, and relevant procedures. Based on this evaluation, several actions have I been taken, including 1) the revision of the LCOAR form to require that both the Shift Technical Advisor (Modes 1 thru 4 only) and the affected Unit Supervisor review the form prior to LCO entry and termination (if the Shift Technical Advisor and Unit Supervisor positions are filled by different personnel) and 2) the removal of out of ;

L date information from the Standing Orders, Policy Book, and Lessons Learned Book.

VI. PREVIOUS SIMILAR EVENTS LER 90 000-00 involved a Technical Specification non-compliance resulting from the inadequate review cf a work order package. However, the specific causes of that event and the specific cause of the event described in this LER were sufficiently different such

that the corrective action for LER 90 008 00 was not applicable to the event described in 1 L this LER. The corrective actions discussed in Section V should reduce the potential for j l

Technical Specification non-compliances resulting from both causes.

E l l Vll. AQD.lIlRNAl MQBMAT.lOH The times listed in the report are approximate and Central Daylight Savings Time (CDT).

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ML20043G112

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SUBJECT:

SUMMARY

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