ML20059M791

Intervenor Exhibit I-MFP-42,consisting of 930623 Ncr DC2-93-WP-N025, Corrective Maint on PI-178 W/O PMT Priot to Mode Transition

ML20059M791
Person / Time
Site:	Diablo Canyon
Issue date:	08/18/1993
From:	AFFILIATION NOT ASSIGNED
To:
References
CON-#493-14437 OLA-2-I-MFP-042, OLA-2-I-MFP-42, NUDOCS 9311190324
Download: ML20059M791 (13)

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l NCR DC2-93-WP-N025 CORRECTIVE MAINTENANCE ON PI-178 WITHOUT PMT PRIOR TO MODE TRANSITION MANAGEMENT

SUMMARY

On April 25, 1993, with Unit 2 in Mode 5 (Cold _ Shutdown),

containment personnel hatch pressure gauge PI-178 was serviced and replaced in accordance with work order (W/0) C0114157 (ref.

1) as documented in AR A0305058 (ref. 2).

Technical Specification (TS) 4.6.1.3.b.2) (ref. 3) requires an air lock be demonstrated operable prior to establishing containment integrity when maintenance has been performed on the air lock that could affect the air lock sealing' capability. The post-maintenance testing (PMT) section of ref. 1 specified "N,"

therefore the PMT group did no review of the W/O and no PMT was performed.

On April 25, 1993, Unit 2 entered Mode ' 4 -(Hot Shutdown) . TS 3.6.1.3 (ref. 3), requires each containment air lock operable in Modes 1, 2, 3, and 4. TS 3.0.4 (ref. 4) prohibits entry into a Mode when the limiting conditions for operation for that Mode are not met and the associated action requires a shutdown within a specified interval.

m .m.

Investigation into previous occurrences of G e above event determined that on September 20, 1990, and September 21, 1990, Work Orders C0076097 (2-PI-176) and C0076096 (2 - PI- 17 8 ) ,

respectively, were performed. The components were returned to service without any post-maintenance testing performed.

Subsequently, STP M-8A was performed on October 03, 1990, resulting in operability _ verification for the personnel airlock.

The personnel air lock was inoperable for 13 days, in violation of the requirements of TS 3.6.1.3.b.

This draft, dated June 11, 1993, documents the meeting minutes for the TRG held on May 7, 1993. These events were reported in LER 2-90-011-00 on May 26, 1993.

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June 23, 1993 NCR DC2-93-WP-N025 CORRECTIVE MAINTENANCE ON PI-178 WITHOUT PMT PRIOR TO MODE TRANSITION I. Plant Conditions On September 21, 1990, Unit 2 was in Mode 1 (Power Operation) at 100% power.

On April 5, 1993, Unit 2 was in Mode 4 (Hot Shutdown) at 0%

power. '

II. Description of Event -

A. Summary:

On April 25, 1993, Unit 2 personnel air lock (PAL)

(VA) ( AL) containment (NH) differential pressure (dP)

Gauge (VA) (PI) PI-178 was removed and reinstalled.

Since the work order had'not indicated that post- ,

maintenance testing (PMT) was required, no local leak rate testing (LLRT) of the instrument fittings was performed as required by Technical Specification (TS)  ;

4.6.1.3.b.2. Unit 2 entered Mode 4 with the PAL inoperable, which did not meet TS 3.0.4. During the investigation of this event, the technical review group _

(TRG) discovered a previous occurrence as described below.

On September 20 and 21, 1990, PAL dP-Gauges PI-176 and PI-178, respectively, were-removed from the PAL to be calibrated. The gauges were returned to the PAI. and no PMT was performed to demonstrate PAL operability within the 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> allowed by TS 3.6.1.3, Action b. '

B.

Background:

i The containment PAL provides access to containment while maintaining a pressure boundary between containment and outside atmosphere. . DP Gauges PI-175 and PI-176 are part of the pressure boundary between I atmosphere and the inside of the air lock. PI-178 and PI-181 are part of the pressure boundary between the 1 inside of the air lock and containment. A PMT '

following replacement of one of these.four gauges ensures that the pressure boundary between containment and atmosphere is intact. Failure of a gauge, or its-associated fittings, coul<1 result in leakage between-the inside of the PAL and containment and/or atmosphere.

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DC2-93-WP-N025  ;

June 23, 1993 TS 3.6.1.3 requires each containment air lock be operable in Modes 1, 2 (Startup), 3 (Hot Standby), and

4. Action b requires that with the air lock inoperable, either restore the air lock to operable status within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> or be in Mode 3 within six hours and Mode 5 (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 />.

TS 4.6.1.3.b,2 requires that an air lock be demonstrated operable prior to establishing containment-integrity when maintenance has been performed on the air lock that could affect the air lock sealing capability. Operability shall be demonstrated by conducting an overall air lock leakage test.

TS 3.0.4 prohibits entry into a Mode when the~ limiting conditions for operation for that Mode are not met and the associated action requires a shutdown within a  ;

specified interval.

Surveillance Test Procedure (STP) M-8A, "Overall Leak Rate Testing of the Personnel Air Lock," sacisfies the requirements of TS 4.6.1.3.b.2 as an overall air lock leakage test. This procedure requires that the test be performed prior to establishing containment integrity if the air lock has been opened and maintenance has been performed that could affect the air lock's sealing capability.

STP V-600, " General Containment Isolation Valve Leak Tests," also may be used as an LLRT to satisfy the

"' ~ ~

. requirements of TS 4.6fl.3.b.2. ..

l C. Event

Description:

On April 25, 1993, at approximately 0100 PST, personnel discovered an incorrect reading on Unit 2 PAL dP Gauge l PI-178. During preparation of the verk order to repair this gauge, the work planner specified the PMT as not required, based on no known TS operability concerns  !

I i associated with the pressure gaage.

l l PI-178 was repaired and, at approximately 0800 PST, reinstalled. Since the work order had~not' indicated i that a PMT was required, LLRT of the instrument i fittings was not performed as required by TS 4.6.1.3.b.2.

{

On April 25, 1993, at 1045 PST, TS 3.0.4 was not met j l when Unit-2 entered Mode 4, without performing an LLRT l on the PAL.

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I DC2-93 53D-N025 June 23, 1993 On April 26, 1993, at 0830 PST, during the review of mode transition documentation, the System Engineer discovered that the required PMT had not been performed. An LLRT was initiated, TS 3.6.1.3, Action b was entered, and the outer containment hatch door was locked. At 1200 PST, the LLRT was successfully completed for PI-178 and TS 3.6.1.3, Action b was exited.

Work Planning personnel performed-a history search'of all instances of PAL dP' gauge removal to_ determine if required PMTs had not been performed in the past. The history search determined that PAL gauges had been removed and reinstalled four additional times since original installatiun. Two of the instances of gauge removal occurred during refueling outages and were followed by performances of STP M-8A, fulfilling the PMT requirement prior to transition to Mode 4. PMT was not performed for the other two instances and TS 3.6.1.3, Action b was not met. On May_7, 1993, a TRG l

determined that TS 3.6.1.3, Action b was not' met for

! these two additional instances, which are discussed below.

On September 20, 1990 and September 21, 1990, the Unit 2 PAL containment dP Gauges PI-176 and PI-178,

! respectively, were removed from the PAL to be calibrated. The gauges were reinstalled without performing a PMT, which is required by TS 4.6.1.3.b.2 to demonstrate PAL operability.

On September 21, 1990, TS 3.6.1.3, Action b r.ma not met when a leak rate PMT was not performed on the PAL

! within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. On October 3, 1990,-STP M-8A was performed for reasons unrelated to the maintenance on l the pressure gauges, resulting in an operability ,

l verification for the PAL.

D. Inoperable Structures, Components, or Systems that Contributed to the Event:  :

None.

E. Dates and Approximate Times for Major Occurrences:

1. September 20, 1990: PAL dP Gauge PI-176 was removed from the PAL,-

calibrated, and then returned-to the PAL, without any PMT-performed.

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r DC2-93-WP-N025 June 23, 1993

2. September 21, 1990: Event date (PI-176). The PAL had been inoperable for more than the 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> allowed by TS 3.6.1.3, Action b. PAL dP Gauge PI-178 was removed from the PAL, calibrated, and then returned to the PAL, without any PMT performed.

3. September 22, 1990: Event date (PI-178). The i

PAL had been inoperable-for more than the 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> allowed by TS 3.6.1.3, Action b.

i l 4. April 25, 1993: PAL dP Gauge PI-178 das removed from the PAL, l l

calibrated,'and then i

! returned to the PAL, without any PMT performed.  ;

l l 5. April 25, 1993, at 1045 PDT: Event date (PI-  !

l 178). Unit 2 ]

l entered Mode 4 with the PAL inoperable.

I 6. April 26, 1993: Discovery date. The System Engineer determined that l testing had not been perfo*"ed on PI"178' prior to ""~

, the Mode 4 transition on April 25, 1393.

7. May 7, 1993: Discovery date. The TRG determined that TS.3.6.1.3, Action b was not met for.

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these two previous I

occurrences in September 1990.

i F. Other Systems or Secondary Functions Affected:

None.

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• June 23, 1993 i G. Method of Discovery:

I The April 25, 1993, event was discovered by System Engineering during the review of mode transition documentation. The September, 1990, events were discovered by the TRG during the investigation of the April 25, 1993, event.

H. Operator Actions:

September 21, 1990: None. Event was discovered during investigation into Event 2.

April 25, 1993: TS 3.6.1.3, Action b was entered and the outer containment hatch door was locked.

I. Safety System Responses:

None required.

l III. Cause of the Event A. Immediate Cause:

September 1990: No PMT was performed on PI-176 (or PI-l 178) within the 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> allowed by TS 3.6.1.3, Action b.

l April 25, 1993: No PMT was performed on PI-178 prior to Unit 2 entry into Mode 4.

, B. Determination of Cause:

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1. Human Factors:

a. Communications: None.

l l b. Procedures: No procedure to flag PMT requirements for planner. Rely on planner experience.

j c. Training: None.

t l d. Human Factors: Rush Maintenance, however, l

. determined to have no impact on the event.

e. Management System: Component data base not complete.

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2. Equipment / Material:

a. Material Degradation: N/A.

b. Design: N/A.

c. Installation: N/A.

d. Manufacturing: N/A.

e. Preventive Maintenance: N/A.

f. Testing: N/A. ,

g. End-of-life failure: N/A.

C. Root Cause:

The root causes of these. events are programmatic deficiency. The references used by the I&C work planners to prepare the work order, including the component database, did not' identify that the tubing and fittings associated with the pressure gauges-comprised a containment leakage boundary and that disconnection of the pressure gauges required a leak rate PMT.

D. Contributory Cause:

None.

IV. . Analysis of the Event ,

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A. Safety Analysis: l 1

Subsequent testing of the PAL following both. events l l

demonstrated that leakage was within acceptance I criteria. Therefore, during these events the PAL

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doors were operable and the outside door would have. l contained any pressurization or contamination within- l l the PAL. Thus, this event'did not adversely affect'the I l health and safety of the public.

I B. Reportability:

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1. Reviewed under QAP-15.B, "Nonconformances," and determined to be non-conforming in accordance with Section 2.1.4.

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2. Reviewed under 10 CFR 50.72 and 10 CFR 50.73 per q NUREG 1022 and determined to be reportable in  ;

accordance with 10 CFR 50.73 (a) (2) (1) (B) . '

TS 4.6.1.3.b.2) requires an air lock be demonstrated operable prior to establishing  ;

containment integrity when maintenance has been i performed on the air lock that could affect ~the air j lock sealing cab.bility.

TS 3.6.1.3 requires each containment air lock j operable in Modes 1, 2, 3, and 4. Action b.

requires; With the containment air lock.

inoperable, except as the result of an inoperable air lock door, maintain at lease one air lock door-closed, restore the inoperable air lock to OPERABLE status within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 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 /> and 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 />.

TS 3.0.4 prohibits entry into a Mode when the limiting conditions for operation for that Mode are not met and the associated action requires a shutdown within a specified interval.

These events are reportable in accordance with 10 CFR 50.73 (a) (2) (i)-(B) as violations of TS. These events were reported in LER 2-90-011-00 on May_26, 1993.

3. This problem will not requira a 10 CFR 21 report.

4. This problem will not be reported via an INPO Nuclear Network entry.

5. Reviewed under 10 CFR 50.9 and determinea the event was not reportable.

6. Reviewed under the criteria of administrative procedure (AP) C-29, " Operability Evaluation,"

requiring the issue and approval of_an OE and determined that an OE is not required:

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DC2-93-WP-N025 June 23, 1993 ,

i V. Corrective Actions ,

A. Immediate Corrective Actions:  !

STP M-8A1 was successfully performed on October 3,

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1990, for the PAL, meeting the PMT requirements of TS 4.6.1.3.b.2 for PI-176 and PI-178, and demonstrating PAL operability.

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2. On April 26, 1993, the PAL was declaredLinoperable l and TS 3.6.1.3,' Action b was entered. The outer

! containment hatch door was locked to meet Action b, and an LLRT was performed to meet the PMT

' requirements'of TS 4.6.1.3.b.2-for PI-178 and demonstrate PAL operability. ,

1 l B. Investigative Actions:

1. Investigate records to ' determine'if there have been t previous occurrencescof TS violations due to' missed-l post-maintenance testing for the containment' air l locks.

I RESPONSIBILITY: .C. Wetter l WORK PLANNING CENTER AR A0305684, AE # 02 STATUS: Complete i

2. Determine if there other-air lock instruments that 1 may not have proper post-maintenance requirements i flagged for the planner, n .e:.-  :

RESPONSIBILITY: C. Wetter i WORK PLANNING CENTER l AR A0305684, AE # 3 i l

STATUS: Return  :

C. Corrective Actions.to Prevent Recurrence:

1. Update the component database for'the personnel air l lock gauges (PI-175, PI-176, PI-178, and.PI-181 ; ,

A) update the " Maintenance Technical Notes"'section similar to the following ---- "WPC NOTE: tubing.

and-fittings associated with this instrument

comprise a containment ~ leakage-boundary. .Any l maintenance which results in disconnection' requires a post. maintenance leak rate test to meet the requirements of TS 4.6.1.3.b."; and B) update the l " Procedure" sections to include reference to STPs

! M-8A1 (Overall Leak Rate of the Personnel Airlock) ]

and V-600 (General containment isolation valve leak j

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DC2-93-WP-N025 June 23, 1993 tests.

RESPONSIBILITY: C. Wetter ECD: 06/04/93 DEPARTMENT: Work Planning Tracking AR: A0305684, AE #4 Outage Related? No OE Related? No NRC Commitment? No CMD Commitment? No

2. Prepare a Maintenance Bulletin to Work Planning to train WPC personnel on this event. Distribute information copies to OPS, QC, System Engineering, PMT, and I&C departments.

RESPONSIBILITY: C. Wetter ECD: 06/04/93 DEPARTMENT: Work Planning Tracking AR: A0305684, AE #5 Outage Related? No OE Related? No NRC Commitment? No CMD Commitment? No D. Prudent Actions (not required for NCR closure):

1. Lamacoids were provided'for gauges PI-175, PI-176, PI-178, and PI-181 with wording similar to:

" INSTRUMENT TUBING AND FITTINGS COMPRISE A CONTAINMENT LEAKAGE BOUNDARY. DISCGNNECTION REQUIRES A POST MAINTENANCE LLRT".

RESPONSIBILITY: C. Wetter EDC: 7/31/93 DEPARTMENT: Work Planning Tracking AR: A0307027

2. Determine if removal of gauge PI-178, plugging of the piping connection is prudent during performance of ILRT. After ILRT completion, the-gauge could be.

reinstalled and the V-600 LLRT performed.

RESPONSIBILITY: E. Chaloupka EDC: 7/31/93 DEPARTMENT: Plant Engineering Tracking AR: A0307031 VI. Additional Information A. Failed Components:

None.

B. Previous Similar Events:

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DC2-93-WP-N025 June 23, 1993 t

NCR DC1-88-TN-N064-00, " Missed Surveillance on Containment Emergency Air Lock Due to Incorrect Update- 2 of the Preventive Maintenance and Test Scheduler"  :

This previous NCR reported exceeding.the. allowable, time limit for.the containment emergency air lock surveillance. An STP required for both emergency air

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lock and PAL operability,was performed on the; PAL only.

However, the test was repcrted as complete for both air locks to the Preventive Maintenance.and Test Scheduler.-

The root cause of this previous event wastpersonnel .

error (cognitive). The. corrective actions to prevent' recurrence included reviewing the: event with associated-personnel, implementing a new Recurring TaskLScheduler-System, .and revising-the applicable procedures. 'These '

previous actions'could not have prevented the' events.of .

this current NCR.in that.they address problems?with' regularly scheduled STPs,.not PMT: requirements.

C. Operating Experience Review:

1. NPRDS:

N/A.

2. NRC Information Notices, Bulletins,. Generic Letters:

None.

3. INPO SOERs and SERs: '

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None.

D. Trend Code: ,

Responsible department WP, and~causeJcode A4.

E. Corrective Action Tracking:

1. The tracking action request is A0305684.

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2. Corrective actions a re;not outage:related.  :

F. Footnotes and Special Comments:

None, j G.

References:

1. W/O C0114157.  ;

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DC2-93 WD-N025 June 23, 1993

2. Initiating AR A0305058. j

3. TS 3/4.6.1.3.

4. TS 3.0.4.

5. AR A0304979.

6. Dwg 107723, Rev. 16 shcwi.ng the PAL gauges.

7. Result of Invectigative Action 1: " Potential Missed Surveillance"

8. STP M-8A1, "Overall Leak Rate Testing of the.

Personnel Air Lock"

9. STP V-600, " General Contairment Isolation' Valve Leak Tests"

10. Prudent Action ARs A0307027 and A0307031

11. AR A0193232 and W/O C0076097 for calibration of 2-PI-176 in September of 1990

12. AR A0193231 and W/O C0056096 for calibration of 2-PI-178 in September of 1990 H. TRG Meeting Minutes:

The TRG initial convene was on April 130, 1993. The event as described was determined to be reportable.

Investigative Action No. 1 to determine if t..are have been previous occurrences was sssigned.

The TRG reconvened on May 7,.1993. The-results of Investigative Action No. I were reviewed and it was determined that there was a second' reportable in September of 1990 (Ref. 7). The' root cause analysis was presented and accepted by the TRG. . Investigative Action No. 2, Corrective Actions No. 1 & 2, and Prudent Actions No. 1 & 2 were assigned. The TRG will.

reconvene on June 11, 1993 to review the NCR write-up.

The TRG did not reconvene on June 11, 1993. Signatures will be obtained from voting members and this NCR will be sent to PSRC for review and approval.

I. Remarks:

None.

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J. Attachmentis):

None.

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