05000423/LER-1990-021

LER 90-021-00:on 900607,integrated Leak Rate Test Supply & Exhaust Valve 3HVU*V5 Discovered Unlocked & Opened.Caused by Failure to Use Applicable Procedure for Nonroutine Evolution.Valve Closed & locked.W/900716 Ltr

ML20055G990
Person / Time
Site:	Millstone
Issue date:	07/16/1990
From:	Knight G, Scace S NORTHEAST NUCLEAR ENERGY CO., NORTHEAST UTILITIES
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-90-021, LER-90-21, MP-90-699, NUDOCS 9007250024
Download: ML20055G990 (5)

LER-2090-021,

Event date:
Report date:
4232090021R00 - NRC Website

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MP-90-699 ,

Re: 10CFR50.73(a)(2)(i)  !

U.S. Nucleo: Regulatory Commission Document Control Desk Washington, D.C. 20555

Reference:

Faellity Operating License No. NPF-49  ;

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Docket No. 50-423

. Licensee Event Report 90-021-00 Gentlemen:  ;

This letter forwards Licensee Event Report 90-021-00 required to be submitted within thirty (30) days pursuant to 10CFR50.73(a)(2)(i), any operation or condition prohibited -  :

by the Plant s Technical Specifications.

Very truly yours,  !

NORTHEAST NUCLEAR ENERGY COMPAh"I' FOR: Stephen E. Scace Director, Millstone Station BY: ohn P. Stetz Millstcae Unit 1 Director i l

SES/GCK:ljs

Attachment:

LER 90-021-00 cc: T. T. Martin, Region 1 Administrator W. J. Raymond,- Senior Resident Inspector, Millstone Unit Nos.1, 2 and 3 D. H. Jaffe, NRC Project Manager, alillstone Unit No. 3 L

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On June 15,1990, at 1725 hours0.02 days <br />0.479 hours <br />0.00285 weeks <br />6.563625e-4 months <br />, while in Mode 1 at 80'1 power, at 580 degrees Fahrenheit and 2250 psia, the Integrated Leak Rate Test (ILRT) Supply and Exhaust (manual Containment isolation) valve 3HVU'V5, was discovered unlocked and open without tM compensatory Technical Specification actions taken. Normal position for the valve is closed and locked. As pan of the Containment entry evolution on June 7,1990, the Shift Supervisor (SS) initiated steps to facilitate a rapid pressurization of the sub-atmospheric Containment if necessary, One of these steps was unlocking and opening 3HVU'Y5. The evolution was not covered under a plant procedure. The SS subsequently did not log the applicable Technical Specification Limiting Condition of Operation.

The root cause of the event was the failure to use the applicable procedure for a non-routine evolution. In addition there was a cognitive failure to recognize the Technical Specifications imphcations of 3HVU'V5.

As immediate corrective action, the valve was closed and locked upon discovery. The SS has been counseled on procedural usage and communications by the Operations Department Manager. Procedure changes were made to heighten personnel awareness of the contingent actions for rapid Containment pressurization, u"s.'"* *" .

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1. Descrintion of Exent  ;

On June 15,1990, at 1725 hours0.02 days <br />0.479 hours <br />0.00285 weeks <br />6.563625e-4 months <br />, while in hiode 1 at 80e power, r 580 degrees Fahrenheit and 2250 psia, the Integrated Leak Rate Test (ILRT) Supply and Exhaust (manual Containment Isolation) valve.

3HVU'V5, was discovered to be unlocked and in the open position. Normal position for the vah'e is closed and locked.

On June 7,1990, at 1105 hours0.0128 days <br />0.307 hours <br />0.00183 weeks <br />4.204525e-4 months <br />, with the plant shut down in hinde 3 (Hot Standby), eight workers entered the Containment Buildmg to troubleshoot Control Rod cable problems and to perform corrective maintenance on a Containment Isolation Valve. In support of the Containment er,try, the Shift Supervisor (SS) decided to prepare for an event where it would be necessary to quickly pressurize the sub-atmospheric Containment. The contingency plan involved unlocking and opening 3HVU'V5 to un-isolate the pressure test line. A non-licensed operator (PEO) was stationed at the Atmospheric Suction isolation valve 3HVU-Y6 (see attached hgure). This evolution was not directed to be done in the Containment Entry procedure. OP 3212. Abnormal Operating Procedure, AOP 3568. Emergency Breaking of Containment Vacuum, has a similar steps but the SS was not using this procedure as a guide.

When 3HVU'YS was opened, the SS did not log into the Limiting Condition fc ;peration (LCO) for Containment integrity (3.6.1.1). The Supervisory Control Operator (SCO) was aware that a non-licensed operator (PEO) had been stationed near 3HVU-V6, but he was not cognizant of the repositioning of 3HVU'YS.

After the Containment entry was over, the PEO stationed near 3HVU-V6 was released. 3HVU'V5 was left open and unlocked to support a second Containment entry which was scheduled for later that day.

The position of 3HVU'V5 was not discussed during the SS turnover and was not documented in the turnover log. The vahe was left open and unlocked until discovery by a PEO performing a general area mspection as part of his routine rounds. The event duration of approximately 6 days, exceeded Technical Specification (TS) LCO action statement 3.6.1.1 time requirements for compensatory action.

11. Cnme of Event The root caitse of the esent was failure to use the applicable Containment entry procedure for a non-rouune evolution, as outlined in the administrative program. Had the SS used the proper procedure l (i.e., OP 3212, Containment Entry), 3H"U'V5 would not have been opened.

The SS took actions outside of an approved procedure. In addition, the SS did not note the position of 3HVU'V5 on the turnover log and did not recoprure 3HVU'YS as a valve bounded by the plant Technical Specifications. A contributing factor was that the SS did not communicate the valve manipulation to the SCO, who could have provided a barrier in addressing the Technical Specifications implications of the vahe manipulation. ,

y 111, Anahsis of Event This event is being reported in accordance with 10CFR50.73(a)(2)(i), as an operation or condition prohibited by the Plant Technical Specifications.

3HVU'YS is a manually operated Containment Isolation valve and is part of the Containment Int.prity Boundary. 3HVU'V5 is used to rapidly pressurite the sub-atmospheric Containment. 3HVU'V5 is normally opened while in Mode 5 (Cold Shutdown) to break Containment vacuum in accordance with the apphcabie procedure. For the duration 3HVU'YS was open, automatic Containment isolation valve 3HYU*CTV33A was in its closed position. Since 3HVU'CTV33A was sausfactorily local leak rate tested and did not open during the event period, it was capable of maintaining Contamment boundary integrity for its associated piping. Therefore, the health and safety of the public was not jeopardized and the event posed no significant safety consequences.

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the Operations Department Manager. In addition, a change to the Containment entry procedure,  ;

OP 3212 was made to require operating shift review of the Emergency Breaking of Containment Yacuum procedure.

I V. Additionnl Informntion There have been three similar events which diset'ss concerns of proper procedure use for performance of i non-routine or complex evolutions. LER 89-013, **A' Train Loss of Power Signal Due to Personnel Error, discusses an event in which a Train A Loss of Power signal was penerated when control power fuses were replaced in the undervoltare auxibary 4160 VAC circuit after completing calibration and testing of circuit components. While deenergizing the 4160 VAC busses, the control room operator failed to reference the appropriate procedure due to the apparent simplicity of the evolution. As corrective action. the eersonnel involved were coumeled on the requirements outlined in station administrative guidelines as to the use of procedures for non-routine and/or complex evolutions. LER i 90-0!$. "Feedwater Isolation When Opening Main Steam Isolation Valves Due to Incorrect Procedure i Use," discusses an event where opening the Main Steam isolation Valves (MSl\"s) after stroke test _;

completion resulted in a Feedwater Isolation signal. Plant personnel did not use the correct procedure to -

re-open the MSi\"S. As corrective actions, the individuals involved with the event were counseled.

Operations Department personnel were mstructed to refer to the applicable procedure and to be more cautious when performing concurrent actions involving different procedures. LER 90-017, " Loss of Both <

Trains of High Pressure Safety injection Due to Personnel Error," discusses an esent where operation of the Safety injection Cold Leg Master Isolation Yalve due to incorrect procedure use resulted in isolation of Both trains of High Pressure Safety injection, Corrective actions included counseling of the individuals involved, disseminatmp information on the use of dedicated operators and ensuring Technical Specifications issues are communicated to the appropriate levels of supervision.

Basect on the incidence of procedure compliance concerns, the Licensee recognires that additional corrective action / action to prevent recurrence is required to address the subject of procedure compliance and proper use. Therefore, planned corrective action measures will be discussed as part of the corrective action response to the Notice of Violation included in Inspection No $0-423/90-06. The Licensee re'(G.R :o 'he Notice of Violation is scheduled to be submitted by August 3,1990.

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