ML20079Q877
| ML20079Q877 | |
| Person / Time | |
|---|---|
| Site: | Turkey Point  |
| Issue date: | 10/05/1983 |
| From: | Hays J FLORIDA POWER & LIGHT CO. |
| To: | James O'Reilly NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| Shared Package | |
| ML20079Q872 | List: |
| References | |
| FOIA-83-615 PTP-QC-83-168, RO-251-83-016, RO-251-83-16, NUDOCS 8402010407 | |
| Download: ML20079Q877 (11) | |
Text
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d;16 somoa roasm a unwr comema FTP-QC-83-168 g QCl g . .
Turkey Point Plant ,
October 5, 1983 TO: Mr. J. P. O'ficilly, B(rector, Region II Office of Inspection and Enfon;ssent . . . _ _.
U. 5. Nuclear Regulatory Causission Atlanta, Georgia 30303 FR09: Mr. J. K. Mays, P1 ant Manager - Nucleer-Turkey Point Plant - DPR 31 and 41 Florida Power and Light Company Miami, Florida
SUBJECT:
MENO FOR FACSIMILE TRANSMISSIGH TO CONFIRM
,REPORTABtf OCCURRENCE 251-83-016 This mano confi ms our notification of the subject prompt notification reportable occurrence made Tuesday, October 4,1983, to Mr. H. C. Dance of your office as follows:
OCCURitENCE:
With Unit 4 at 1005 power and diile verifying system line-up in preparation for a routine periodic test of the Unit 4 cntainment spray ptsnps, it was discovered that the manual discharge valves (valves 4-891A and 4-8918) on both the 4A and 48 contaf rasent spray pumps were locked in the closed position, thus isolating the Unit 4 containment spray system. The health and safety of the public were not affected. An investigation into the incident is in progress.
CGtRECTIVE ACTION:
' ~ '
The manual discharge valve for the 48 pissp was inmediately returned to the
.open posicion and locked as required.: The other valve was returned to the open position following completion of the monthly periodic surveillance test of the 4A pump. As a precauticnary measure, flowpath verification of all safety systems on Unit 4 was perfomed following the discovery and results showed all safety systens to be correctly aligned. Results of the investigation mentioned above and necessary corrective actions will be described on the licentee Event Report.
<% N R,3,,,... d. t. ,s P1 ant Manager - Nuclear DEPUTY A DMINISTRAg'-
JDI:DWH:sr INISTRArag Ass 7794 B:80tC-A0 DIRECTOR, ISTRA70R DIRECTOR. EOP '
RECT f..y3E [ ~$, , .._f 8402010407 831116 '
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INT ER-OFFICE CORRESPONDENCE -
PMs 4. of 8 tocav ion Turkey Point Nuclear -
to J. A. Labarraque on*c October 11,1983 rnou 3. L. Balaguero comes To File
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suen cT UNIT 4 CONTAINMENT SPRAY PUMP VALVE MISALIGNMENT The enclosed incident report gives a detailed synopsis of the events that took place leading to the isolation of Unit 4's Containment Spray System. A brief summary of this report follows:
On October 2,1983, B. Jorge, N.O., was performing OP 0205.2 (Cold Shutdown) step 8.16 which directed him to close and tag valves 3-891 A and 3-891B. He actually closed Unit 4's valves (4-S91 A and B) by mistake. The valves were logged as locked closed at S:20 a.m. on October 2 but with no indication as to which unit.
This situation was found by P. J. Faulky and J. P. O'Steen, N.O., on Tuesday, October 4 as they were preparing to perform a monthly periodic test on Unit 4 containment spray pumps (OP 4004.1). While 4-891 A was kept closed in order to do the periodic test, 4-S91B was immediately opened at approximately 10:45 a.m. on October 4 to provide a containment spray flow path. This indicates that the Containment Spray System was isolated for ro more than approximately 50.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br />.
The locked valve list had been recently (09/24/S3) verified correct.
Further investigation revealed that Mr. B. Jorge had been using a field copy of OP 0205.2 when the error was made. For reasons explained in the erclosed report, a different N.O. (J. P. O'Steen) was called to close and tag 3-891 A and B as part of the shutdown clearance at approximately 1:00 p.m. on October 2. Mr. O'Steen was unaware that fdr. 'Jorge had been assigned to close the same valves earlier by procedure. Independent verification of the proper valve lineup was subsequently completed successfully. No one suspected that the Unit 4 valves had been earlier closed by mistake.
Upon discovery, as mentioned earlier, one of the valves (4-891B) was immediately opened. The other valve was returned to the open position following completion of the monthly periodic surveillance test of the 4 A pump. All the normal and emergency containment coolers were available throughout this incident. The health and safety of the public was not in anyway affected. As a precautionary measure, flow path verification of all safety systems on Unit 4 was performed following the discovery. The results showed all safety systems to be correctly aligned (AP 0103.19).
As part of thelinterim corrective ac+indMr. T. A. Finn, Operations Supervisor-N, proceeded to personally discuss the incident with all operating shif ts (except vacationing personneD. Mr. J. W. Williams, Vice President-Nuclear Energy, came on site on Wednesday, October 5, to discuss the occurrence with plant management.
Due to the seriousness of the mistake involved, disciplinary actiorr .cre taken PE OPLE . . SERVING PEOPLE r urm loos (stoc6ed) Rev. efel
, , 3. A. Labarr,aque
- Page '2 October 11,1983 g !
)
against Mr. B. Jorge. These, however, were minimal as a result of Mr. Jorge's j outstanding operating record and the fact that he came forward and admitted the ,
rnistake. , i As part of theliong term corrective action] all the locks associated with th.e Emergency Core Cooling systems (tCCS) were upgraded to a different level. The Plant Supervisor-Nuclear must issue the key to these locks. 'In addition, and to further differentiate between the units, new tumblers were ordered so that, when installed, only Unit 3's key will open Unit 3's locks and Unit 4's key will open Unit 4's locks. The locks for the different units will also be color coded (Red-Unit 3 and Green-Unit 4) with locks on common system valves to have a different color from that of either unit. Also, signs clearly labeling Unit 3 or Unit 4 will be installed (posted) appropriately throughout the auxiliary building.
As mentioned in the enclosed report, the 4A containment spray pump tested satisfactorily. The 4B pump, however, failed the test and was declared out-of-service at 1:13 p.m. Tuesday, October 4. A Licensee Event Report on this is currently being prepared by Ms. Z. E. Berry.
In addition to the above mentioned corrective actions, it is recommended that a clearly defined set of guidelines should be established so the operator can execute clearance orders in conjunction with procedural valve manipulation. Additional training on how to properly execute clearance orders, hang tags, initialing the clearance, etc., as well as how to perform independent verification procedure should be given to all personnel involved.
Should you desire any clarification of the above or have any further questions,
- please call me at Training Department extenstion 413. ,
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/ 'Q,3. C. Ba%guero l ,
Licensing Engineer Supervisor 3CB/awt/T2:10 ,
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3/18/83~ OPERATING PROCEDURE 0205.2, PAGE 6
', ' /
W REACTOR SHUTDOWN HOT SHUTDOWN TO COLD SHUTDOWN CONDITION [ INITIALS t 8.12 Block the high steam flow SI initiating signal after the permissive light LO Tavg BLOCK SI is illuminated. Permissive light STM LINE SAF , INJ BLKD will light when signal is blocked. ,
.13 Block the low pressurizer pressure and the high steam line/ header. delta P SI initiating signals after the permissive light SAFETY INJECT BLOCK TRIPPED is illuminated. Permissive light SAFETY-INJECT BLOCKED will **
light when signal is blocked. NOTES: 1. The three SI initiating signals will be blocked simultaneously if both permissive signals are present when m the block switch is turned to BLOCK.
- 2. The high steam flow signal will be unblocked automatically if TAVG increases to 543* F.
- 3. The low pressurizer pressure and high steam line header delta p signals will be unblocked automatically if the RCS pressure is increased high enough to unblock safety injection. (2000 psig).
4 The signals may be untilocked manually at any time by turning the block switch to UNBLOCK. 8.14 Unlock and close the following 480 V breakers:
,.-- Y 30532 (40733), MOV *-865A Accumulator A to A cold leg
@, 30631 (40532), MOV *-865B Accumulator B to B cold leg M[ 30733 (40631), M0V *-865C Accumulator C to C cold leg 8.15 When the RCS pressure is 1000 psig, close, lock or tag the following accumulator discharge valves:
i k MOV *-865A Accumulator A to cold leg A CLOSED / LOCKED OR TAGGED
-rVA - MOV **865B Accumulator-B to cold leg B CLOSED / LOCKED OR TAGGED l
_ yPV MOV *-865C Accumulator C to cold leg C CLOSED / LOCKED OR TAGGED l CAUTION: The accumulator valves must be closed prior to reaching l 700 psig in the RCS to prevent the accumulators from lr a discharging to the RCS. l 8.16 Close, lock and tag the folloWng valves to isolate the contair. ment spray pumps: l , *-891A A cont. spray pump isolation CLOSED / LOCKED M *-8918 B cont spray pump isolation CLOSED / LOCKED i 8.17 Unlock and close the following breakers, then verify that the valves indicate closed on VPB. v30732 (40732) MOV *-866A HH SI to Looo A Hot Leg l / 30621 (40621) MOV *-866B HH SI to Loop B Hot leg l, ' l-8.18 Prior to cooling below 380 F in RCS, verify closed the f'ol. lowing SIS .. valves and tag the corresponding control switches on VP-B'. MOV *-843A HH SI stop to cold legs CLOSED
/" L MOV *-843B HH SI stop to cold legs CLOSED
/W MOV *-866A HH SI to loop A hot leg . CLOSED 6/ MOV *-866B HH SI (W imp B hat leg CL OSED
~ '
* ' 8/25/83 ADMINISTRATIVE PROCEDURE 0103.2, PAGE 14
- 7 4'
' DUTIES AND RESPONSIBILITIES OF OPERATORS ON SHIFT AND MAINTENANCE OF OPERATING LOGS AND RECORDS The Plant Supervisor - Nuclear (NWE) l(RCO)l shall review all defeated alarms in the Control Room and ensure that PWO's have been submitted for those alarms requiring maintenance. -
8.3.4 Nuclear Operator, Nuclear Turbine Operator and uxiliary Equipment g Operator - The on-coming operator (s) shall review their station's Iog Book for the previous twenty-four hours and curre.nt Iog Sheets , .. ,, then initial "left hand column" next to their shift entry. 8.4 Maintaining Operating logs, Records, and Recorder Charts 8.4.1 General Instructions: When making an entry in a log book keep in mind that the entry should communicate and accurately describe the event that took place. 'Iherefore, entries must be complete, logical, and accurate. Example: 6 : 00 a .m. - PRMS Ch . 14 alarmed
- 1. Why?
- 2. Action taken?
- 3. Who notified?
- 4. Test ,or periodic in progress?
Iog books, log sheets, check sheets and charts are utilized for j legal records, tracking and analyzing transients, trips and developing preventative actions. It is essential that these documents be maintained legible, accurate, and definitive. Iog books should be . maintained in chronological sequence to the t l maximum possible extent. Where entries are out of chronological order they shall be preceded by the words " Late Entry". Iog books, log sheets (except the " Electrical Worksheet"), and s recorder charts entries shall be made in irk or other permanent recording method. 'Ihere shall be no erasures or "ma rk-ov e rs" . Errors shall be lined through once and the correct information entered along side, then initialed and dated by the operator. In
- the case of log sheets, if the date that the correction was made is l the same date the log sheet was completed, no date by the initials shall be required. If the correction occurs after the cocpletion i
l date of the log sheet, a date by the initials shall be required. The exception to this requirement is the l Reactor Control Operator l
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# UNITED STATES
'I*f [pAE8ch,'q
~ NUCLEAR REGULATORY COMMISSION # Ne D
.- " n cEIlON O 3-
$ 101 MARIETTA STREET. N.W.
# ATLANTA. GEORGIA 30303 o
%,..,**/ OCT 141983
~~~ -
~~ ~FloFida' Power and ~ Light Company ATTN: Dr. R. E. Uhrig, Vice President Advanced Systems and Technology P. O. Box 14000 Juno' Beach, FL 33408 Gentlemen:
SUBJECT:
CONFIRMATION OF MEETING - DOCKET N0. 50-251 This confirms the telephone conversation between Mr. J. Williams, Vice President Nuclear Energy, and Mr. R. C. Lewis of my staff on October 12, 1983, concerning an enforcement conference to be conducted at your office in Miami, Florida on October 21, 1983, at 8:30 a.m. We requested this meeting to discuss the inadvertent isolation of the containment spray system at Turkey Point Unit 4. A proposed meeting agenda is enclosed. t Should you have any questions regarding these arrangements, we will be pleased to discuss them. Sincerely, (v,n '? 04 b '. ames P. O'Reilly N
- gional Administrator
Enclosure:
m- \ Proposed Meeting Agenda i x
'N- ,
~
cc w/ encl: l H. E. Yaeger, Site Manager 1 l l l I
$- l j o 3u V h 10
t;.e ENCLOSURE PROPOSED MEETING AGENDA Florida Power and Light Company Meeting with NRC Miami, Florida October 21, 1983 I. Introduction ar.d Purpose of Meeting James P. O'Reilly II. Statement of NRC Findings and Concerns Richard C. Lewis III. Licensee Response <.icensee Representative IV. Discussion of Issues Attendees V. Closing Remarks James P. O'Reilly I l l' l l l i e
* .? J . /
Nec perm ses u.s.NuCtsAn CEcutATcay C:asesissioes C e (7 773 LICENSEE EVENT REPORT CCNTm0L SLoCE: l i 1 l I I I l@ . tetgAsa palNT OR TYPt ALL mEculatD *NPonMATIONI I ! la iil 8l 8FI LIT 8 l P I SI 4 !@l 0101 6aCt%548 CCOE 'e $
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(TITT I With Unit 4 at 100% power and while verifying system lineup in preparation for a I (TTT1 i routine periodic test of the Unit 4 containment spray pumps, it was discovered that I i o .a i I the manual discharge valves (4-891A&B) on both the 4A and 4B containment spray 1 i 3 , s , i pumps were locked in the closed position, thus isolating the Unit 4 containment spray I
! is i I system. This is reportable pursuant to T.S.6.9.2.a.6. The health and safety of the 1 I o # : 1 I oublic were not affected. A similar occurrence was reported under LER 250-83-007. I lo43! l l 7 8 9 SO Sv1TEV CAJSE Caust COue vau g 100E CCOE $48C006 COM*CNENT CODE ti.sc0ct :yec:;g toist 7 8 i SI Cl@ J@ l Bl@ l VI Al LI VI El XI@ l El@ @ @
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LH_J@L.429@ l3@ 25 LZJ@ se l ol 01 o@f 2; .o 01 U@ di l NI@ l Ni@ la At 3 01 0@, 42 as at CAUSE CESCRIPTION AND CORREC.*1va ACTIONS 27 l$ toIiThe root cause was determined to be versonnel error in that the non-licensed ' t , i i l operator assinned to close the same identical valves on Unit 3 (Cold Shutdown) closed i
- i. ,2, I the 4-891 A&B_ valves on Unit 4 (100% power) instead. Upon discoverv the manual p .
- i, 6:j I discharge valve for the 4B oumo was immediatelv returned to the open tosition and I i , , . i i locked as reauired. i e a e de Ia % 8DE R CmtasTATVS 50 v :sc0vimv OC5cnirtiom l li I s l LEj@ l 11 Ol.0j@l N/A I LBJ@l Surveillance Test j 8.A.,y,,, cy:ri,, '2 '2 ~ **
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,c u,g ( OR;**.O N YO l'II CV I:tc! LHj@l N/A i e *' I i i s a 's a n n sAvsor3.epAnt, Jesus Arias, Jr. ,-cN e :
ENODN ME I ^
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, .,- .J Rehvtch'le Occurr:nca 251-83-016 Licensee Event Report Page2 Additional Cause Description and Corrective Actions The other valve (4-891A) was returned to the open position following completion of the .. monthly periodic surveillance test of the 4A pump.
- The total time that the Containment Spray System was isolated did not exceed 50 and 1/2 hours. For the duration of the incident, all the normal and emergency containment
~ ~^
coolerr were availabl.e. On 9-24-83, the locked valve list h'ad been verified to be Correct. A series of corrective actions were delineated. These are:
- 1) A flow path. verification of all safety systems on Unit 4 was performed following the discovery and results showed all safety systerns to be correctly aligned.
- 2) The Operatihns Supervisor-Nuclear proceeded to personally discuss the incident with all operr. ting shifts (except vacationing personnel).
- 3) As part of the long term corrective actions, all the locks associated with the flow path of the Emergency Core Cooling Systems (ECCS) were upgraded to a different level. The Plant Supervisor-Nuclear must issue the key to these locks. In addition, and to further differentiate between the units, new lock turcblers were ordered so that when installed, only Unit 3's key will open Unit 3's lock and Unit 4's key will open Unit 4's locks. The locks for the different units will also bc color coded (Red-Unit 3 and Green-Unit 4) with locks on cornmon system valves to have a different color from that of either unit. Also, signs clearly labeling Unit 3 or Unit 4 will be posted appropriately throughout the auxiliary building.
/
- 4) A clearly defined set of guidelines has been established so that independent verification is performed in conjunction with procedural valve manipulation.
- 5) Additional training on how to properly execute clearance orders, hang tags, initial the clearance, etc., as well as how to perform independent verification procedure will be given to al! Opera'tions personnel.
T14:1
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October 18, 1983 PNS-LI-83-670 Mr. James Pi 0'Reilly Regional Administrator, Region II U.S. Nuclear Regulatory Commission 101 Marietta Street N.W., Suite 2900 Atlanta, Georgia 30303
Dear Mr. O'Reilly:
REPORTABLE OCCURRENCE 251-83-16 TURKEY POINT UNIT 4 DATE OF OCCURRENCE: OCTOBER 4, 1983 TECHNICAL SPECIFICATION 6.9.2.a.6 CONTAINMENT SPRAY SYSTEM The attached Licensee Event Report is being submitted in accordance with Technical Specification 6.9 to provide prompt notification of the subject occurrence. - Very truly yours,
. h)./.// /2+
~ '
J. W. Williams, er. Vice President i Nuclear Energy Department JWW/NWG/js Attachment cc: Director, Office of Inspection and Enforcement (40) Harold F. Reis, Esquire File 933.1 TP 1i
,, .i r/ i.
CONTAlfNENT SPRAY SYSTEM VALVE CLOSURE AGENDA OCTOBER 21,1983, MEETING WITH NRC REGION II I. BRIEF SYSTEM DESCRIPTION: Two motor driven pumps supply containment spray to two independent headers of spray in Unit 4 Containment. Each header has an automatic . motor operated valve, a check valve, and a manual stop valve (4-891A and 4-8918). Activities in Progress: Unit 3: At cold shutdown for refueling outage. Unit 4: At 100% power. 9 II. MISPOSITIONED HEADER STOP VALVES: FINDING: Unit 4 manual pump discharge valves (4-891A and 4-891B) for the containment spray system were found to be closed and locked, (discovered on Tuesday, 10/4/83 about 10:45 a.m.), while preparing to perform the monthly periodic surveillance test of the pumps. IMMEDIATE CORRECTIVE ACTION:
- 1. The 4B pump discharge valve (4-891B) was opened and locked. The 4A pump discharge valve (4-891A) was left closed to allow testing of the 4A pump. Valve 4-851A was . opened after testing the 4A pump.
- 2. Performed monthly safety system flow path verification of all Unit 4 and common systems.
III. INVESTIGATION AND FINDINGS: INVESTIGATION RESULTS:
- 1. The corresponding Unit 3 valves were directed by the Control Rcom to be closed about 8:20 a.m. on 10/2/83 during the Unit 3 shutdown pursuant to Operating Procedure 0205.2 (but were not actually closed then).
- 2. The corresponding Unit 3 valves were actually closed later by operators j hanging the Unit 3 cold shutdown equipment clearance order.
I
- 3. Valves 4-891A and B were accidentally closed by the operator who was i directed to close valves 3-891A and 3-8918. Operating Procedure 0205.2
- did not require independent verification of the closure of valves 3-891A and 3-891B until the cold shutdown clearance tags were hung.
- 4. Following the valve manipulation the operator who closed the valves was L slightly injured and contaminated and was removed from the area for l decor.tamination and first aid.
l
- 5. Valves 4-891A and B were positively verified locked open on September 11 during the monthly safety system flowpath verification.
E: CONT
/L
~
'. '. E C0t(TAIPMENT .SIRAY SYSTEM VALVE CLOSURE AGENDA OCTOBER 21, 1983, MEETING WITH NRC REGION II (cont'd)
- 6. Valves 4-891A and B were positively verified locked open on September 24 during the monthly safety system flowpath verification.
CONCLUSIONS
- 1. Valves 4-891A and 4-891B were closed and locked inadvertently on 10/2/83 about 8:20 a.m. by an operator who should have closed the corresponding Unit 3 valves as directed by the Control Room in accordance with Operating Procedure 0205.2. The operator later remembered closing the wrong valves and immediately informed his supervisor (after discovery of this mispositioning).
- 2. Independent verification of the closure of the valves would have been perfomed when the cold shutdown clearance tags were hung, but was delayed due to the contamination and injury incident.
- 3. When independent verif cation of the cold shutdown clearance was performed, the inadvutent closure of valves 4-891A and 4-891B was not noticed (because the clearance was on Unit 3).
- 4. Closure of valves 4-891A and 4-8918 renders the Unit 4 containment spray system inoperable. The system was inoperable for about 50 hours.
- 5. The Unit 4 emergency containment coolers and filters were operable throughout this time period. These components are completely independent and redundant to the containment spray system.
IV. CORRECTIVE ACTIONS: ItiTERIM: (Al ready accomplished)
- 1. Provided special instructions to operators to clarify independent verification and to add the requirement that independent verification be perfonned after safety related component manipulations not covered by an equipnent clearance order (10/13/83).
- 2. Performed monthly safety -system flowpath verification immediately following the management briefing (10/4/83) (?!o discrepancies).
- 3. Appropriate disciplinary action taken against operator involved.
- 4. Operations management held meetings with all operating shifts to discuss the incident.
- 5. Independent QA assessment was performed and recommendations are being eval uated.
.. , -e , ~
y [ CONTAlfNENT SPRAY SYSTEM VALVE CLOSURE AGENDA OCTOBER 21, ~ 1983',' MEETING WITH NRC REGION II (cont'd) LONG' TERM:
- 1. Install signs identifying Unit 3 and Unit 4 rc, oms and equipment. (In proces s) .
- 2. Instituted . new administrative controls on ECCS locked va'lves (New lock series and key under control of Plant Supervi sor ~ - Nucl ea r) . (Already accomplished)
'3. Installed new locks and keys on locked valves (Unit 3 locks keyed differently than common and Unit 4 locks). (Already acco.T.plished)
- 4. Color coded locks so Unit 3 locks are red, Unit 4 locks are green and common locks are white. ( Already accomplished)
- 5. Review our independent verification policy and the QA assessment of the incidenc and make appropriate changes to preclude recurrence.
9 I* "T
- _ _. _ _ _ _ . _ . . . . _ _ _ . . . . . ~ _
_ - , - -}}