ML20059E533
| ML20059E533 | |
| Person / Time | |
|---|---|
| Site: | Diablo Canyon  |
| Issue date: | 08/19/1993 |
| From: | AFFILIATION NOT ASSIGNED |
| To: | |
| References | |
| OLA-2-I-MFP-077, OLA-2-I-MFP-77, NUDOCS 9401110264 | |
| Download: ML20059E533 (14) | |
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'93 DCT 28 P6 :10 xAwAGEMzNT s e v On January 22, 1992, during the review of STP Vp3H12i %the m test reviewer noted that the work order for' VENT ~valveiCCWZI-2-RCV-16 for the Component Cooling Water Surge Tank hhd been identified on-PX Alert.
AR # A0281474 still indicated a normal 92 day frequency.
It appears that the Library Work Order R0003733 had not been updated _as indicated.on the PX Alert AR and on the library AR A0037984 #or the subject Work order.
On the next performance of the'STP, completed on January 16, 1993, valve CCW-2-RCV-16 stroked at 1.214 seconds which was 22% of the previous stroke on October 16, 1992 which caused the,PX alert AR A0281471 to be initiated.
A review of all PX alert AR's for pumps and valves was made to verify that the RT Work Orders were correctly _ identified on Alert frequency.
It was then determined that all the RT Work Orders had the correct Alert frequency.
The root cause analysis, determined that exiting PIMS during an active session was the root cause of the recurring task
. scheduler not being updated within a 31 day Alert frequency,_
after review of the information in PIMS on AR A0281474 (PX Alert) and A0037984 (RT Library),
The corrective actions to prevent recurrence are to develop (1) means for PIMS to automatically send a-computer generated E-mail to the surveillance co6rdinator_in the event that there is a PX Alert without' associated Alert STP frequencies in PIMS, and (2) a plan for independent verification of any changes to the frequency'within PIMS.
This draft dated March'3, 1993 contains the minutes from the second TRG meeting held on February 1993.
The TRG is not scheduled to reconvene.
This draft dated March 3, 1993 contains the minutes from the second TRG meeting held on February 1993.
The TRG is not schedule.d to reconvene.
j This NCR will be distributed for comments, signed-off and l sent to the PSRC.
NCR closure ECD: May 31 1993.
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t NCR DC2-93-TS-N005 Rev. 00 DRAFT:
March 3, 1993 j
NCR DC2-93-TS-N005 l
CCW-2-RCV-16 MISSED ALERT FREQUENCY.
l I.
Plant Conditions l
Unit 2 was in Mode 1 (Power Operation) at 100% power.
II.
Descrintion of Event A.
Summary:
On January 22, 1992, during the review of STP V-
- 3H12, the test reviewer noted that the work order for valve CCW-2-RCV-16 had b'een identified on PX l
Alert.
AR # A0281474 still indicated a normal 92 day frequency.
It appears that the Library Work l
Order R0003733 had not been updated as indicated on the PX Alert AR and on the library AR A0037984 for the subject Work Order and the recurring task scheduler had not been updated within a 31 day Alert frequency.
B.
Background:
CCW valves are required to be functionally tested in accordance with STP V-3H12 on a 92 day frequency to meet the requirements of TS 4.0.5.
Valve CCW-2-RCV-16 operability requirements are defined in FSAR 9.2-6 paragraph 9.2.2.2.3.
This FSAR sectior. states the following "The component cooling water surge tank, which is connected to the pump section vital headers, is constructed of carbon steel.
The tank-is internally divided into two compartment = to hold two separate volume of water.
This arrangement provides redundancy for a failure during the recirculation phase following a LOCA.
The surge tank accommodates thermal expansion and contraction, and in-or out-leakage of water from l
the system.
Because the tank normally vents to the atmosphere, radiation monitors are provided in the component cooling water discharge headers.
The monitor actuates an alarm and closes the surge tank vent valve (CCW-2-RCV-16) when a high radiation level is detected in the cooling water circuit."
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4 NCR DC2-93-TS-N005 Rev. 00 DRAFT:
March 3, 1993 ASME section XI, 1977 Edition (Summer 1978 Addenda), Article IWV 3417, " Corrective Action" states that, "If deviations fall within the Alert-Range of Table IWV-3417, the frequency of testing shall be doubled until the cause of the deviation has been determinedLand the condition corrected."
The requirement to increase test frequency ensures that. attention is given by the second reviewer to the parameter that 4e indicated within the acceptable range.
l C.
Event
Description:
On January 22, 1992, during the revi'ew of STP V-
- 3H12, the test reviewer noted that the-work order for the valve had been identified on PX Alert.
- A0281474 still indicated a normal 92 day frequency.
It appears that the Library' Work Order-R0003733 had not-been updated as indicated on the PX Alert AR and on the library AR A0037984 for the subject Work Order.
Investigations are.-in progress to further verify whether this a valid alert surveillance.
l During the next' performance of the STP, completed 2
on January 16, 1993, valve CCW-2-RCV-16 stroked'at 1.214 seconds which is 22% of the previous stroke of October 16, 1992 which. caused the PX alert AR A0281471 to be initiated.
A review of all PX alert AR's-for pumps and valves was made to verify that the~RT Work Orders wa e correctly identified on Alert frequency.
It was l
then determined that all the RT Work Orders had the correct Alert frequency.
After review of the information in PIMS on AR l
A0281474 ~ (PX Alert;.and A0037984 (RT Library), it l
appears that the following sequence of events caused the missed' alert frequency STP:
i o
STP.V-3H12 was performed on October 16, 1992.
The stroke time of'5.506 seconds exceeded the previous stroke time of 1.613 seconds.
A 341%
increase in stroke time o
The surveillance coordinator (SC) reviewed the.
PX alert AR on 10/24/92.
92NCRWP\\93TSN005.PGD Page 3
of 13 l
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NCR DC2-93-TS-N005 Rev. 00 j
DRAFT:
March 3, 1993 l
o Using PIMS split-screen (PFS),.the Surveillance Coordinator-(SC) called up i
library RT Work' Order R0003733 and once in the.
change mode,. changed.tha frequency from a-92 day to a 31 day.
The surveillance coordinator.then. typed AR1to o
After entering the
[
information RE'the PX: Alert onto the library i
AR.
The SC PF4'ed back out..to the RT library Work Order, which was-still on the'PX alert.-
o The SC PF5'ed back'to the PX alert AR to-document the information-in'the PX Alert.AR.
o The SC then created: evaluation,# 2, requesting that the system engineer determine the caurs.!
of the Alert-and initiate the appropriate corrective actions.-
~
The SC then PF4'ed;out'of' evaluation # 2, Land o
returned back to the PX Alert AR to "AR search by number, type".
l o
Then the SC exited PIMS.by using' Help'and PF7.
The RT library.workLorder/ session was left in the change mode and'was thus canceled in the process.
o On November 2, 1992 the.I&C Work planner noted in response;to AR A0281474-evaluation # 11 (requesting to investigatejand repair) that no I&C work was necessary because the~ stroke time satisfied the STP V-3H12's acceptance i
criteria.-
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o On November 3,-1992, the'SC informed'I&C that-a corrective action was necessary~per'ASME-Section XI.
This was documented on the PX' Alert Action' Request'(AR).-# A0281474.
i o
On November 16, 1992 the 31 day alert' 4
frequency on valve CCW-2-RCV-16 was exceeded, o
On January 16, 1993 STP V-3H12 was performed' by operations-on its normal 92 day frequency.
i 92NCRWP\\93TSN005.PGD Page 4
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March 3, 1993 o
On January 22, 1993, the STP reviewer noticed that the STP frequency was 92 days vice 31 days as noted on the PX Alert AR.
Upon review of the situation, the SC initiated this AR.
The STP reviewer also noted that the stroke i
time for CCW-2-RCV-16 was 1.214 seconds, in comparison to 5.506 second previous stroke that initiated the alert.
Based on documented information, it appears that exiting PIMS in an active session is the reason for the recurring tank scheduler nr. to have been updated within the required 31 day Alert frequency.
D.
Inoperable Structures, Components, or Systems that Contributed to the Event:
None.
i E.
Dates and Approximate Times for Major Occurrences:
1.
October 16, 1992:
STP V-3H12 performed on valve CCW-2-RCV-16.
2.
October 24. 1992:
The surveillance coordinator (SC) reviewed the PX alert AR.
3.
November 2, 1992:
The I&C work planner noted in response to AR A0281474 evaluation # 1 (requesting investigate and repair) that no I&C work was necessary because the stroke time satisfied the STP V-3H12's acceptance i
criteria.
4.
- lovember 3, 1992:
The SC informed I&C that a corrective action was necessary per ASME Section i
XI.
5.
November 16, 1992:
Event date.
The 31 day alert frequency on valve CCW-2-RCV-16 was exceeded.
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NCR DC2-93-TS-N005 Rev. 00 s-DRAFT:
March 3, 1993 1
6.
January 16, 1993; STP V-3H12 was performed by operations on its normal 92-day frequency.
7.-
January 22, 1993; The STP reviewer noticed j
that the STP's frequency was 92 days vice 31 days as noted on-the PX Alert AR.
Discovery date.
J F.
Other Systems or Secondary Functions Affected:
l None.
G.
Method of Discovery:
On January 22, 1993, the STP reviewer noticed that the STP's frequency was 92 days vice 31 days as noted on the PX Alert AR.
Upon review of the situation, the SC initiated this AR.
The STP reviewer also noted that the stroke time for CCW-2-RCV-16 was 1.214 seconds, which was the previous 5.506 second stroke that initiated the alert.
H.
Operator Actions:
None.
I.
Safety System Responses:
None.
III.
Cause of the Event A.
Immediate Cause:
The recurring task scheduler was not updated within the 31 day alert frequency schedule.
B.
Determination of Cause:
l See Root Cause Analysis.
92NCRWP\\93TSN005.PGD Page 6
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NCR DC2-93-TS-N005 Rev. 00 DRAFT:
March 3,-1:03-
' l C.
Root Cause:
Personnel error in that PIMS was~ exited during an active session preventing the recurring task scheduler from being' updated within the'31 day alert frequency.
D.
Contributory Causes:
1.
During review o1 TP V-3H12 valve CCW-2-RCV-16 should have been put on alert. frequency.
2.
The recurring' task scheduler was.not updated within the 31' day ~ alert frequency.
IV.
Analysis of the Event A.
Safety Analysis:
On January 16, 1993.STP V-3H12 was satisfactorily-I I
performed on its normal 92. day frequency, providing a reasonable degree of assurance that-valve CCW-2-RCV-16 would:have performed-its intended safety function should it have been called upon to do so during the time period in question, from November 16,'1992Eto January 16, 1993.
Therefore, the health ans safety of the public.
I were~not affected by this-event.
B.
Reportability:
l 1.
Reviewed this event under QAP-15.B and l
determined to be non-conforning in accordance
^
with Section 2.1.4 l
l l
2.
Reviewed this event under 10:CFR 50.72,and 10 l
CFR 50.73 per NUREG 1022 and was determined to l
be-not reportable.
RCV-16 is not covered by.
l Technical Specification 4.0.2.
Therefore, this event is not reportable underL10 CFR' 50.73 (a) (2) (1) (B). '
i 3.
Reviewed-under 10 CFR Part 21-and determined that this problem'will not require a'10 CFR 21 report, since it does not involve' defects in._
vendor-supplied services and/or spare parts in-stock.
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NCR DC2-93-TS-N005 Rev. 00 DRAFT:
March 3, 1993 4.
This problem will not be reported via an INPO Nuclear Network entry.
5.
Reviewed under 10 CFR 50.9 and determined that this event was not reportable under 10 CFR 50.9.
l 6.
Reviewed under the criteria of AP C-29 l
requiring the issue ar.d approval of an OE and determined that an OE is not required.
V.
Corrective Actions l
l A.
Immediate Corrective Actions:
1.
The valve was placed in an accelerated frequency of 31 days.
2.
All PX alert AR's were reviewed and it was determined that the frequencies were correct.
B.
Investigative Actions:
1.
Prepare an LER on the missed surveillance.
RESPONSIBILITY:
P.
Dahan.
DEPARTMENT:
Regulatory Compliance.
Tracking AR:
A0291935, AE # 01 STATUS:
COMPLETE.
'30TE : This event was determined not to be reportable.
2, Research valve FCV 16 history to determine the safety significance of the missed alert frequency.
j i
RESPONSIBILITY:
E. Chaloupka.
DEPARTMENT:
Plant Engineering Tracking AR:
A0291935, AE # 02 STATUS:
RETURN.
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3.
Investigate the proposed PIMS change to l
incorporate the automatic =X which when escaping an active session will ask if the l
transactions should be committed prior l
returning the main menu.
92NCRWP\\93TSN005.PGD Page 8
of 13 e
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i NCR DC2-93-TS-N005 Rev. 00' H
DRAFT:
March 3, 1993
'l
. RESPONSIBILITY:
E. Chaloupka. ECD: Return DEPARTMENT:
Plant Engineering Tracking AR:
A0291935, AE # 03.
C.
Corrective Actions to' Prevent Recurrence:
1.
Develop and implement'means of sending an-E-mail automatically.to_the Surveillance coordinatorLin the event of conflicting'PX alert frequencies in PIMS..-
j RESPONSIBILITY:-E. Chaloupka ECD:. 04/20/93
')
DEPARTMENT:
NUCL. ENG..
Tracking AR: '
A0291935, AE # 04 Outage Related? No' OE Related?-
No i
.NRC Commitment? No CMD Commitment? No i
2.
Develop and" implement ~a plan for routine independent verification of changes to PX alert frequencies.
1 RESPONSIBILITY: E._Chaloupka ECD: 04/20/93 DEPARTMENT:
NUCL. ENG.
l Tracking AR:
A0291935, AE # 05 1
l Outage Related? No OE Related?
No i
t NRC Commitment? No i
CMD Commitment?'No' D.
Prudent Actions-(not required for NCR closure)
None.
VI.
Additional Information l
I A.
Failed Components:
None.
B.
Previous Similar Events:
NCR DC1-92-TP-N052 Missed Alert _ Frequency'STP.
j This NCR covers two-events as'follows:
92NCRWP\\93TSN005.PGD_
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di NCR DC2-93-TS-N005 Rev. 00 DRAFT:
March 3, 1993 l
On August 21 1991, ASW pump 1-2 was declared operable contrary to the requirements of TS 3.7.4.1 and ASME Section XI, Article IWP 3230, since the pump was above the action high level for Differential Pressure (DP). It was determined that ASW pump 2-2 volume 9 curve was used to define the i
action high levels for ASW pump 1-2.
When the proper data was obtained from ASW. pump 1-2 volume 9 curve, it showed that the pump'Was above the high level for DP.
On November 14, 1991, a PG&E surveillance test-reviewer failed to recognize that ASW pump 1-2 should have been placed on alert in.accordance-with TS 4.0.5 and ASME section XI, 1977 Edition (Summer 1978 Addenda), Article IWP 3230.
The STP' P-7B surveillance test reviewer failed to recognize that ASW pump 1-2 was.below the alert low level for DP.
l On October 10, 1992 while reviewing an STP P-7B on ASW pump 1-2, these events were discovered.
The root causes for both events were attributed to personnel errors cognitive: (1) In the first event i
the STA did not ensure that the correct curve from
" volume 9" was used; and (2) In the second event, the second surveillance-test reviewer assumed that the test results were acceptable, since the data was similar to previous test results.
The corrective actions to prevent recurrence include : First Event: (1) Nuclear Engine 7 ring to revise the IST Pump procedures to add an independent verification of volume 9 data entry; (2) Operations to write an incident summary to reemphasize the importance of the Surveillance Test process and train the Operations group in the importance of this problem; (3) Due to its significance,.the Training group to add this event to the operators requalification training; Second event: (1) An ASME Section XI computer trending program has been implemented and will be discussed in the next revision of Administrative Procedure (AP) C-3S1; (2) A training session covering ASME Section XI requirements for Alert frequency tracking was held with the appropriate procedure reviewers.
92NCRWP\\93TSN005.PGD Page 10 of 13
~ _..
1.
1 i
f NCR DC2-93-TS-N005 Rev. 00 I
DRAFT:
March'3; 10:3' 1
The corrective actions of'these-two events listed
'i above would not have-prevented the event in NCR j
93-TS-N005 since the root-cause for this event is I!"
different that the otherJtwo.-
1 C.
Operating Experience Review:.
1.
NPRDS:
i Not applicable.
2.
NRC Information Notices, Bulletins,_ Generic.
Letters:
1 None.
~
'h 3.
None.
i l
Trend Code:
l D.
Responsible _ department TP, and cause. code A3.'
e E.
Corrective Action Tracking:
1.
The tracking action request is A0291135.
2.
Are the corrective actions 1 outage related?
No.
F..
Footnotes and Special. Comments:
l None.-
.i G.
References:
1.
Tracking AR # A0291135.
2.
Initiating Action' Request A0279826.
3.-
TechnicalTSpecification 4.0.'2.
H.
TRG. Meeting Minutes:
1.
On February 2, 1993 the1TRG convened;and~
considered the following:
92NCRWP\\93TSN005.PGD Page 11 of 13 i
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9 NCR DC2-93-TS-N005 Rev. 00
(
DRAFT:
March 3, 1993 l
l l
Review of the circumstances surrounding the event.
l l
Review of the actions including committing the AR.
However, the actions listed in the AR got lost when backing out of the computer screen.
Consequently, the actions were not committed j
in the RT work' order.
l Three investigative actions were established as follows:
1.
Regulatory Compliance to prepare an LER on i
the missed surveillance.
2.
Plant Engineering to research valve FCV '6 history to determine the safety significance of the missed alert frequency.
3.
Plant Engineering to investigate the proposed PIMS change to. incorporate the automatic =X which when escaping an active session will ask if the. transactions should be committed prior returning the main menu.
The following immediate corrective actions were established as follows:
1.
The valve was placed in an accelerated frequency of 30 days.
2.
All PX alert AR's were reviewed and it was determined that the testing frequencies except for the valve in question were correct.
Pump and valve trending is being performed.
Record the proposed corrective actions to understand what the root cause-is.
Such as failure of committing the up-date in the frequency.
Prepare a root cause and effect analysis.
92NCRWP\\93TSN005.PGD Page 12 of 13 i
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'd NCR DC2-93-TS-N005 Rev. 00 DRAFT: ' March 3, 1993 More information on the AR is needed when looking at the past trend and at the safety significance.
THE TRG TO RECONVENE'IN FEBRUARY, 19, 1993 TO REVIEW THE RESULTS OF THE INVESTIGATIVE ACTIONS AND THE ROOT CAUSE ANALYSIS, 2.
The TRG reconvened on February 19, 1993 to review the investigative actions and determine corrective. actions.
Prior.to the meeting, this event had been determined to be not reportable.
The TRG discussed several options for rectifying the PIMS exit' problem,..to include PIMS training, disabling.or remapping the PF7 key, and an automatic feature to turn the-applicable PIMS field red when PX alert frequencies conflict. The TRG ultimately decided on corrective actions l'and 2 above.
l This NCR was assigned a closure date of May l
31, 1993.
l The TRG is not scheduled to reconvene. -The NCR write-up will be routed for review, sign-off and then to the PSRC.
I.
Remarks:
i
- None, l
l 92NCRWP\\93TSN005.PGD Page 13 of 13 l
NCR DC2-93-TS-N005 Rev. 00 DRAFT:
March 3, 1993 DCl-93-TS-N005 Missed Alert Frequency ROOT CAUSE ANALYSIS PAGE 1 OF 1 BARRIER EFFECT EVIDENCE CAUSE The 31 day alert frequency on During review of STP WO R0003733 The Library Work valve CCW-2-RCV-16 was V-3H12, it was noted not updated' Order R0003733 had 1(ha as indicated not been updated as exceeded.
should h put on 31 day alert on PX Alert indicated on the PX frequency.
AR and on AR Alert AR and on the A0037984 for library AR A0037984 the subject for the subject WO.
Work Order.
WHY?
Valve CCW-2-RCV-16 The recurrence task All PX alert The stroke time of should had been put on 31 day sche.luler had not AR's for 5.506. seconds alert frequency during the
$*"31(,
pumps and exceeded the I"
1 review of STP V-3H12.
frequency.
valves previous stroke CC.
reviewed time of 1.613 indicated all seconds.
A 341%
RT Work increase in stroke Orders were time correctly identified for Alert frequency.
WHY?
The recurrence-task Personnel error in sch'eduler had not been updated that PIMS was exited within the 31 day Alert fes[n"p 1
frequency.
r n ing the recurring task CC.
scheduler from being updated within the 31 day alert frequency.
Root Cause.
CC. Contributory Cause.
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