ML20044B382

LER 90-005-01:on 900117,work Request 141610 Initiated Because Flow Meter 2RNP15880 Inoperable.Caused by Mgt Deficiency.Immediate Training Sheet Distributed to All Appropriate personnel.W/900712 Ltr

ML20044B382
Person / Time
Site:	Mcguire
Issue date:	06/18/1990
From:	Mcconnell T, Sipe A DUKE POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-90-005-01, LER-90-5-1, NUDOCS 9007190105
Download: ML20044B382 (8)

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' McCaire NudearStation =

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. July 12,:1990:

U'.S. Nuclear Regulatory Commission 4 Document control Desk =

Washington, D.C. -20555-Subj ect: 'McGuire Nuclear Station Unit 2 Docket No.-50-370 '

4 Licensee Event Report.370/90-05-01 -

-Gentlemen:.

Pursuant to 10 CFR 50.73 Sections (a)(1) and (d), attached'is Licensee Event Report 370/90-05-01 containing additional information for the safety analysis which was submitted in LER 370/90-05 dated June 18, 1990. This report.is being submitted in accordance with 10 CFR 50.73(a)(2)(1)(B). This event is cons,idered to be of no significance with respect to the health and safety of the-public.

Very truly yours, )

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T.L. McConnell-DVE/ADJ/cb1  ?

. Attachment.

• xc:- Mr. S.D. Ebneter -

American Nuclear Insurers Administrator, Region II c/o Dottie Sherman, ANI Library U.S. Nuclear Regulatory Commission The Exchange, Suit 245 4 101 Marietta St., NW, Suite 2900 270 Farmington Avenue

- Atlanta, GA 30323 'Farmington, CT 06032 t

INPO Records' Center Mr. Darl Hood (

, Suite.1500 U.S. Nuclear Regulatory Commission

- 1100 Circle-75 Parkway Office of Nuclear Reactor Regulation

g. - Atlanta, GA '30339 Washington, D.C. 20555 M&M Nuclear Consultants -Mr. P.K. Van Doorn 1221 Avenue of the Americas NRC Resident Inspector y New York, NY 10020 McGuire Nuclear Station p

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l On May 12, 1989, Operations (OPS) personnel received the preimplementation ,

information for Nuclear Station Modification (NSM) MG-20666. On August 1, 1989, new flow transmitters and control board flow meters were installed for indication '

of Nuclear Service Water (RN) system flow to the Containment Spray (NS) system heat exchangers. The t.wiect Services Engineer involved informed OPS personnel that the NSM had been completen to that point. On October 9, 1989, OPS personnel implemented changes to p ocedures used for operation of the RN system and the NS Heat Exchangers accordingly. This placed the NS Heat Exchangers into wet layup. '-

No revisions were made to the Technical Specification (TS) Reference Manual and OPS shift personnal received no training to notify them of the new status of the NS Heat Exchangers and associated RN system flow instrumentation. On January 17, ,

1990, OPS shift personnel initiated work request 141610 because flow meter 2RNPI5880 was inoperable. Since they were unaware of the new status of the NS Heat Exchanger flow instrumentation, and the TS P.eference Manual had not been revised, they failed to declare B train of the NS system inoperable as required. Because of this failure, the work request was processed normally and the flow meter was not returned to service untti January 25, 1990. This exceeded the operability time limit required by TS 3/4.6.2. The event is assigned a cause of Management Deficiency because no program exists to properly update the TS Reference Manual. A contributing cause of Inappropriate Action is assigned because OPS personnel failed to specify required training for OPS Shift personnel. Subsequently, all appropriate OPS persc.nnel have received the proper training. Unit 2 was in Mode 1 (Power Operation) at 100 percent power at the time the event occurred.

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Background

The NS system [EIIStBE] is an Engineered Safety Feature which serves to remove thermal energy from the Containment in the event of a Loss of Coolant Accident (LOCA's . It performs this function in conjunction with the Emergency Core Cooling System (ECCS), which cools the Reactor [EIIS:RCT) core by direct injection. After all the ice from the Ice Condenser has melted, the beat removal capability of the NS system will keep the Containment pressure below the design pressure of 15 psig.

The NS system consists of two pumps [EIIStP) and two heat exchangers (HXs)

[EIIS:HX] in parallel, with associated piping, valves [EIIS:V), and spray headers.

The NS HXs are of the shell and tube type with the tubes welded to the tube sheet.

Borated water from either the Refueling Water [EIIS:DA] Storage Tank [EIIS TK]

(RWST) or the lower compartment of Containment circulates through the tubes while RN system [EIIS:BI] water circulates through the shell side during the recirculation mode of operation. The NS HXs are designed to ensure adequate heat removal capacity from the water during the recirculation mode, i

' The RN system provides assured cooling water for various Auxiliary Building

[EIIS NF], Turbine Building [EIIS:NM], and Reactor Building HXs during all phases of plant operation. Each unit has two redundant essential headers serving equipment necessary for safe plant shutdown and a non-essential header serving equipment not required for safe shutdown.

TS 3/4.6.2 specifies that two independent NS systems shall be operable with each spray system capable of taking suetion from the RWST and trr.nsferring suction to the containment sump. These conditions are applicable in Mode 1, Mode 2 (Startup),

Mode 3 (Hot Standi>y). and Mode 4 (Hot Shutdown). The TS action statement states that with one spray system inoperable, restore the inoperable spray system to operable status within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> or be in at least Hot Standby within the next 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br />; restore the inoperable spray system to operable status within the next 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br />; or be in Cold Shutdown within the following 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />.

Description of Event On May 12, 1989, OPS personnel received the preimplementation information for NSM MG 20666 (Wet Layup for Unit 2 NS HXs). This information included drawings (red-marked to delineate changes) and a detailed description of the modification.

Appropriate OPS personnel reviewed this package.

Vork began on the NSM on June 8, 1989. On August 1, 1989, new flow transmitters

[EIIS:FT], 2RNFT5870 and 2RNFT5880, and indicators [EIIS:FI), 2RNPI5870 and 2RNpI5880, were installed as described by the NSM. The new transmitters and indicators are safety-related and the instrumentation which was replaced was not.

The project Services Engineer involved then informed the appropriate OPS personnel that the NSM was completed to that point.

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requsred valves 2RN-137A, NS HX 2A Control, and 2RN-238B, NS EX 2B Control, to remain closed during normal operation. This placed the NS HXs into wet layup.

This change in valve position was carried on the turnover sheet for the Shift Supervisors and Reactor Operators on October 11, 12, and 13, 1989. However, no '

provisions were made to formally inform OPS Shift personnel of the new operating status of these valves or of the new stat'us of the flow indication loops for RN to NS HX flow.

On January 17, 1990, during the execution of performance test PT/2/A/4403/01B (Nuclear Service Water Train 2B Performance Test), OPS personnel discovered that the flow indication for RN to NS HX 2B had failed low. Subsequently, work request 141610 was initiated for repair of the indication. Since the indicator was inoperable, the corresponding NS HX should have been declared inoperable. Prior to the implementation of NSM MG-20666, the NS EXs were operated with the outlet control valves open to a predetermined setpoint. After the implementation of the modification, the NS HXs were changed to operate with the outlet control valves '

closed. Therefore, to achieve the required flowrate, the outlet valve must be throttled using the Control Room [EIIS:NA) indication. In this case, indicator l

. 2RNPI5880 was inoperable and without this indication the proper throttle position i

for valve 2RN-238B could not have been determined if required in an emergency.

Therefore, the Train B NS HX was inoperable during the time period when the indication loop was inoperable. Becaure OPS Shift personnel involved were not aware of the new status of the indication loop, and no revision had been made to the TS Reference Manual, the work request was written and handled as routine. The NS HX was not declared inoperable.

On January 19, 1990, Planning personnel received the work request and on January 24, 1990, the work request was scheduled to Instrumentation And Electrical (IAE) personnel for repair of the problem. IAE personnel began troubleshooting the problem end immediately discovered that the instruments involved were now safety related because of NSM MG-20666. The work request was returned to the Planning Department and was designated as Safety Related. Appropriate changes were made and proper procedures added before work began.

IAE personnel found the problem to be a loss of power to the flow transmitter.

Subsequent repairs were made and the loop was returned to service on January 25, 1990. However, none of the personnel involved were aware that the NS HX was inoperable during this time period.

On April 20, 1990, Performance personnel discovered while reviewing work requests <

that the indication loop had been inoperable and the corresponding NS HX had not been declared inoperable. Subsequently, Problem Investigation Report 2-M90-0113

• was initiated to resolve the problem.

Upon discovery of this event, OPS personnel generated immediate training for all appropriate OPS Shift personnel. Also, a required reading package was issued on May 21, 1990 to inform all appropriate OPS personnel of the proper actions required if any of the instrument loops for RN flow to the NS HXs are made inoperable.

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1 Conclusion g This event is assigned a root cause of Management Deficiency because of lack of a policy or directive to properly update the TS Reference Manual. At the time of this event, OPS Shift personnel referenced the TS Reference Manual and the RN flow instruments were not listed.

No program or directive exists requiring

• Station personnel reviewing NSM packages or the Project Services personnel involved with NSM packages to update the TS Reference Manual. When the NSM changes the status of instruments as in this NSM and no interim drawings or communications are released, there is no method to update the manual.

On February 8, 1990, a problem with the use of the TS Reference Manual was discovered as documented on Problem Investigation Report (PIR) 0-M90-0042. A Management Deficiency was identified because the TS Reference Manual has been improperly used as a control document when it was not complete or necessarily up to date. A corrective action at that time was to inform all OPS personnel of the potential errors in the TS Reference Manual and that they were to use the manual only as a reference. The manual is not to be used as the only source of r information for determining the operability of a component until the manual has t been revised.

This event is also assigned a contributing cause of Inappropriate Action because of ,

lack of attention to detail by OPS personnel who reviewed the information package for NSM MG-20666. The OPS personnel involved failed to specify training necessary to inform OPS Shift personnel of the new status of instrument flow loops for RN system flow to the NS HXs.

Station Directive 4.4.1 states that prior to declaring a system or component operable after a modification training requirements should be reviewed for adequacy, and the following elements confirmed: ,

5.5.1.4.1 The operational control group has reviewed the impact of the modification and identified that information considered vital to the safe operation of the system / component. The appropriate on duty shift personnel shall have received training on the vital to operation information, and provisions made to assure that oncoming shif ts will be similarly informed.

5.5.1.4.2 Provisions have been made to complete training on the.medification for all appropriate personnel in accordance with.the appropriate training program. These provisions should be documented'either formally or informally.

GPS personnel reviewed the NSM information but failed to specify training for appropriate OPS Shift personnel because of lack of attention to detail.

Subsequently, interim drawings and a nemorandum detailing the partial implementation of NSM MG-20666 were distributed to all appropriate Station seatC 80hM 344. '. 8- D'

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'*** "Mt' "'au McGuire Nuclear Station Unit 2 ojalololel3l7l0 9l0 0l0 l$ 0l1 l5 or l6 text ,, . w. me mumm personnel by Project Services personnel. This memorandum stressed the need to upgrade any affected procedures and to notify individuals who shoi1d know that the instrument loops for RN flow to the NS HXs are now safety related.

Upon discovery of the error, an immediate training notification specifying the actions necessary when any of the instrument loops for RN flow to the NS HXs are declared inoperable was distributed to al,1 appropriate personnel. Also, an additional required reading package was distributed to all appropriate OPS personnel on May 21, 1990, detailing required treatment of the instrument loops for RN flow to the NS HXs.

A review of the Operating Experience Program Data Base for the past twenty-four months prior to this event revealed twenty-four events involving Management Deficiencies because of a lack of an adequate policy or directive, llowever, none of the event particulara were similar to this event. The corrective actions were specific to those events and would not have prevented this event from occurring; therefote, this event is not considered recurring. The problem of TS violations because of Managensent Deficiencies due to lack of an adequate policy or directive is recurring. The problem of improper use of the TS Reference Manual is also recurring.

,* A review of the Operating Experience Program Data Base for the past twenty-four months prior to this event. revealed five events involving TS violations because of inappropriate Actions due to lack of attention to detail. These were Licensee Event Reports (LERs) 369/88-34, 369/89-05, 370/89-10, 369/89-11, and 369/89-13.

However, none of the event particulars were similar to this event. The corrective i actions were specific to those five events and would not have prevented this event from occurring; therefore, this event is not considered recurring. The problem of TS violations because of Inappropriate actions due to lack of attention to detail is recurring.

l This event is not Nuclear Plant Reliability Data System (NPRDS) reportable.

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There were no personnel injuries, radiation overexposures, or uncontrolled relce m of radioactive material as a result of this event.

CORRECTIVE ACTIONS:

Immediate: None Subsequent: 1) An Immediate Training sheet was distributed to all appropriate OPS personnel to det.all actions required whenever any of the instrument loops for RN flow to the NS HXs are declared inoperable.

2) Required Reading package 90-015-LS was distributed to appropriate personnel to detail actions required whenever w.

of the instrument loops for RN flow to the NS HXs are declu -!

inoperable.

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3) Compliance personnel working with OPS personnel and MES j personnel will revise the TS Reference Manual to ensure it 1 lists all applicable TSs for each instrument under PIR i 0-M90-0042. This will ensure that the TS Reference Manual l meets the requirements of a controlled document by Compliance l personnel.

4) OPS personnel were in' formed of the potential for errors in the l' TS Reference Manual and were instructed to use the manual only as a reference under PIR 0-M90-0042. ,

Planned: 1) IAE personnel will update the TS Reference Manual to include ,

the flow instrumentation for RN to NS HX flow.

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2) OPS personnel in conjunction with other Station personnel will >

evaluate the possibility of identifying and tagging all TS i related instrumentation in the Control Room.

SAFETY ANALYSIS:

NS HX Control Room flow indication is required for OPS personnel to throttle the i- outlet control valves for the NS HXs to the proper position during an accident situation. This indication is necessary because the NS HXs are normally isolated with these valves closed. Therefore, to achieve the required RN flow rate the i outlet valves must be throttled using this indication.

In this case, indicator 2RNPI5880 was not functioning. Without this indication. l the proper throttle position for valve 2RN238B could not have been directly l determined. If it. had been necessary for the_ valve to be opened, the flowrate to  ;

other RN cafety related heat exchangers fed by the same RN header could have been l adversely affected. However, this condition would have been noted by OPS personnel due to a change in the discharge flow and pressure indication for the affected RN pump. Also, a change in flow would have been noted on control board indications

.for the associated Nuclear Service Water [EIIStBI) system, Diesel Generator Engine Cooling Water (EIIS LB) system, and Component Cooling [EIIS CC) system HXs. These changes would have prompted corrective actions from OPS personnel to maintain i correct RN system flow balance. In addition, equipment cooled by these HXs have j temperature alarms which would have provided additional indication of a flow j balance problem.

At no time during the period when this indicator was inoperable was the NS 10(

required. No events occurred which challenged the ability of the RN or NS systems to perform their intended safety functions. Also, during this time period, the A Train NS HX was available t.o mitigate possible problems during a LOCA to control containment pressure. )

This event did not affect the health and safety of the public.

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