05000265/LER-1997-001-07, :on 970227,instrument Maintenance Dept Was Performing Procedure to Test HPCI Initiation Logic.Caused by Deficient Procedure.Order Was Issued for All non-routine

:on 970227,instrument Maintenance Dept Was Performing Procedure to Test HPCI Initiation Logic.Caused by Deficient Procedure.Order Was Issued for All non-routine

ML20137H691
Person / Time
Site:	Quad Cities
Issue date:	03/27/1997
From:	Peterson C COMMONWEALTH EDISON CO.
To:
Shared Package
ML20137H623	List: 05000265/LER-1997-001, Forwards LER 97-001-00 Re Automatic Actuation of Any Esf. Commitments Made by Ltr,Listed 05000265/LER-1997-001-07, :on 970227,instrument Maintenance Dept Was Performing Procedure to Test HPCI Initiation Logic.Caused by Deficient Procedure.Order Was Issued for All non-routine
References
LER-97-001-07, LER-97-1-7, NUDOCS 9704030025
Download: ML20137H691 (6)

LER-1997-001, on 970227,instrument Maintenance Dept Was Performing Procedure to Test HPCI Initiation Logic.Caused by Deficient Procedure.Order Was Issued for All non-routine

Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2)(iv), System Actuation 10 CFR 50.73(a)(2)(viii)(A) 10 CFR 50.73(a)(2)(ii)
2651997001R07 - NRC Website

text

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a LICENSEE EVENT REPORT (LER)

Form Rev. 2.0 Facility Name (1)

Docket Number (2)

Page (3)

Quad Cities Unit Two ol5l0l0l0l2l6l5 1 l of l o l 6 '

Tith (4) Instrument Mamtenance Surveillance Caused HPCI Initiation Due To A Deficient Procedure.

a f

Event Date (5)

LER Number (6)

Report Date (7).

Other Facihties involved (8) j Month Day Year Year Sequential Revision Month Day Year facihty Dociet Numberts)

Number Number Names i

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l 0l2 2l7 9l7 9l7 0l0l1 0l0 0l3 2

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7 ol5l0l0l0l l

l OPERATING THIS REPORT IS SUBM)TTED PU (SU ANT 70 T iE REQU REN ENTS OF 10CFR MODE (9)

(Ched one or more of the followiry;) (Il}

1 20.402(b >

20.405(c)

X 50.73(a)(2)(iv) 73.71(b) k POWER 20.405(a)(1)d) 50.36(c)(1)

T$0.73(a)(2)(v) 73.71(c)

LEVEL, 20.405(a)(1)0i) 50.36(c)C) 50.73(a)C)(vii)

Other (Specify 4

(10) l9l 5

20.405(a)(1)0ii) 50.73(a>C)c) 50.73(a)(2)(viii)(A) m Abstract 20.405(a)(!)0v) 50.73(a)(2)(ii) 50.73(a)C)(viii)(B) below and in

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20.405(a)(1)(v) 50.73(a)C)6ii) 50.73(a)C)(x)

Text)

LICENSEE CON TACT FOR THis LER (12)

NAME TELEPHONE NUMBER AREA CODE l

Chirles Peterson. Regulatory Affairs Manager, ext. 3609 3l0l9 6l5l4l-l2l2l4l1 I

COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13) j CAU$E SYSTEM COMPON EN T MANUFACTU RER REPORTABLE

CAUSE

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AB5 TRACT (Lama to 1400 spaces. i.e., appronunately himen omgle-space typewnnen Ames) 06) 1

, ABSTRACT:

j At 0242 hours0.0028 days <br />0.0672 hours <br />4.001323e-4 weeks <br />9.2081e-5 months <br /> on 022797, with Unit Two in Mode One at approximately'95% power, the Instrument j Maintenance (IM) Department was performing a procedure to test the High Pressure Coolant

Injection (HPCI) initiation logic.

During performance of the surveillance, the requirements

for the.HPCI logic initiation system were satisfied and HPCI initiated as designed.

Control Room operators verified that the HPCI initiation was not required and tripped the turbine.

The procedure directing this evolution did not include all prerequisite conditions and provided a false sense of security that it could be performed with HPCI operable.

The root cause of this event was poor work practices (cognitive error) during the 1993 procedure rewrite project for conversion of existing procedures into a new format.

The procedure writer and reviewer knew that the unit needed to be in the shutdown or refuel mode and included the words " Refuel Outage" in the title of the procedure.

They did not include this information in the procedure's prerequisites section or impact statement.

Additionally, there is a fundamental misunderstanding by first line supervisors in charge of work.

They do not all realize that they must use some reference other than the procedure to validate that each action performed will provide the expected response.

Corrective actions include revising the surveillance procedure, review the prerequisites of all IM proce'dures, communicate management's expectations for work supervisors to review additional references, and for procedure writers to include 10CFR50.59 safety screening / evaluation restrictions in procedure prerequisites. The safety consequences of this event were minimal.

There was no impact on Control Room personnel or the health and safety of the public.

LER26 7Y4 0025 970327 7

PDR ADOCK 05000265 S

PDR

LICENSEE EVENT REPORTILEI) TEXT CONTINUATION Form Rsv. 2.0 FACILITY NAME (!)

DOC 16T NUMBER (2)

LER NUMBER (6)

PAGE (3)

Year Sequential Revmon Number Number Quad Cities Unit Two 0l5lol0l0{2l6l5 9l7 0l0l1

- l ol0 2 lOFl 0 l 6 TEXT Ersrgy Industry identification System (Ells) codes are identined in the text as [XXl

PLANT AND SYSTEM IDENTIFICATION

General Electric - Boiling Water Reactor - 2511 MWt rated core thermal power.

EVENT IDENTIFICATION:

Instrument Maintenance Surveillance caused HPCI initiation -due to a deficient procedure.

A.

CONDITIONS PRIOR TO EVENT

Unit: Two Event Date:

February 27, 1997 Event Time:

0242 Reactor Mode: 1 Mode Name:

Power Operation Power Level:

95%

This report was initiated by Licensee Event Report 265\\97-001.

Power Operation (1) - Mode switch in the RUN position with average reactor coolant temperature at any temperature.

B.

DESCRIPTION OF EVENT

At 0242 hours0.0028 days <br />0.0672 hours <br />4.001323e-4 weeks <br />9.2081e-5 months <br /> on 022797, with Unit Two in Mode One at approximately 95% power, the Instrument Maintenance (IM) Department was performing Quad Cities Instrument Maintenance Procedure (QCIPM) 0100-10, " Refuel Outage ECCS Instrumentation Check Prior to ECCS Logic Test," to test the High Pressure Coolant Injection (HPCI) (BJ) containment pressure Emergency Core Cooling System (ECCS) initiation logic [JE]. A HPCI initiation signal was produced when performa~nce of procedural steps satisfied the actuation logic for HPCI High Drywell Pressure relays 2-2330-112A, 1128 and 112C.

While testing the 2-1001-89B High Drywell Pressure Switch, the procedure instructs the technician to install a jumper across the 2-1001-890 switch.

Following installation of the jumper, the 2-1001-898 switch was pressurized.

The requirements for the Drywell High Pressure signal to the HPCI logic initiation system were satisfied and HPCI initiated as designed.

Control Room personnel noted the HPCI turbine starting sequence and associated al arms. The operators verified that the HPCI initiation was not required and tripped the turbine approximately 27 seconds after the initiation signal was inserted.

The crew reviewed control room indications and determined there was no evidence of change in reactor power, pressure, or level.

The investigation team later determined that the subsystem injected less than 300 gallons of water into the reactor vessel.

The operating crew directed the IM technicians to immediately stop the surveillance. All equipment was returned to a stable condition, and at 0242 hours0.0028 days <br />0.0672 hours <br />4.001323e-4 weeks <br />9.2081e-5 months <br />, the HPCI subsystem was declared inoperable.

The Automatic Depressurization Subsystem (ADS) was also conservatively considered inoperable for I hour and 41 minutes while the actual status of the initiation logic was verified. At 0429 an Emergency Notification System (ENS) notification was made.

The HPCI subsystem was again declared operable at 0521 hours0.00603 days <br />0.145 hours <br />8.614418e-4 weeks <br />1.982405e-4 months <br /> after taking actions to restore the subsystem to it's standby lineup.

LER265\\97\\001.WPF

e LICENSEE EVENT REPORT (LER) TEXT CONTINU ATION Form Rev. 2 0 F ACILITY N AME (1)

DOCKET NUMBER (2)

LER NUMBER to)

PAGE (3)

Year Sequent al kension Number Number Quad Cities Unit Two 0l5l0l0l0l2l6l5 9l7 0l0l1 0l0 3 lOFl 0 l 6

~

IEXT Energy industry Idenu6catum 6y. tem (CIS) codes are ident:6ed in the text as lXX)

An investigation was started immediately. A stop work order was issued for all non-routine (those that are performed on a frequency of longer than once per quarter) surveillances until a review for proper plant conditions could be comrleted for these scheduled surveillances.

C.

APPARENT CAUSE OF EVENT:

The procedure directing this evolution did not include all prerequisite conditions that shall exist prior to the use of the procedure.

The procedure also contained an impact statement which stated: " instruments are tested one at a time" and "this test will affect one instrument channel at a time." This procedure provided a false sense of security that it could be performed with HPCI operable.

The root cause of this event was poor work practices (cognitive error) during the procedure rewrite project for conversion of existing procedures into a new format.

QCIPM 0100-10 was converted in 1993.

The procedure writers guide in place at the time the procedure was converted, defined prerequisites as: "An identification of those independent actions or procedures that shall be completed and plant conditions that shall exist prior to the use of the procedure. Only conditions that are l

essential for proper execution of the procedure should be included under prerequisites. Desirable but non-essential conditions should not be included." The procedure writer and reviewer knew that the unit needed to be in the shutdown or refuel mode and included the words " Refuel Outage" in the title of the procedure.

They did not include this information in the procedure's prerequisites section or in l

the impact statement.

The 10CFR50.59 safety scree.ning prepared for this procedure l

change stated the unit needed to be in the shutdown or refuel mode.

Additionally, there is a management expectation for the person in charge of the work to review the appropriate documents to ensure confidence that each action performed will provide the expected. response.

This management expectation was not in writing and was not clear to all first line supervisors.

The first line supervisor involved m this event was' unaware of this management expectation.

He.did compare the impact statement to a similar surveillance procedure which he was familiar with performing on line, and found that it was virtually identical.

The first line supervisor improperly concluded that it was acceptable to perform the procedure.

He did not review the electrical prints.

There is a fundamental misunderstanding by first line supervisors in charge of work.

They do not all realize that they must use some reference other than procedures to validate that each action performed will provide the expected response.

LER265\\97\\001.WPF

LICENSEE EVENT REPC'.T (LER) TEXT CONTINUATION Form Rev. 2.0 EACILITY NAME (1)

DOCKET NUMBER (2)

LER NUMBER (6)

PAGE (3) e Year Sequential Revision Number -

Number l

Quad Cides Unit Two 0l5l0l0l0l2l6l5 9l7 0l0l1 0l0 4 lOFl 0 l 6

{

TEXT Enecgy industry identification System (Ells) codes are identified in the text as (XXl A contributing cause of this event was the scheduling of this activity.

This procedure step was historically performed during a refueling outage and this time it was scheduled with the unit running.

The Work Control Scheduler who scheduled this activity was not aware that it was previously performed during an outage.

He reviewed the procedure and the procedure ' impact statement'and incorrectly concluded that the activity could be performed with the unit running.

The activity was then scheduled upon approval by the Work Week Manager who based his decision upon the scheduler's review.

l D.

SAFETY ANALYSIS OF EVENT:

l The safety consequences of this event were minimal. HPCI subsystem injection into the reactor vessel was limited by the prompt action of the operating crew thereby l

l minimizing the reactivity additipn.

This event was bounded by the analysis of an inadvertent HPCI actuation contained in Chapter 15 of the Updated Final Safety Analysis Report.

Additionally, the reactor remains within the designed number of vessel cycles for a partial loss of feedwater heating. A partial loss of feedwater heating is defined to be a change of feedwater temperature where the temperature i

stays above 240 degrees F.

The very small amount of cold water (<300 gallons) i injected by the HPCI subsystem during this event did not cool the feedwater below 240 l

degrees. No other vessel design cycles were affected by this event. The HPCI subsystem responded as designed to the initiation signal that was put into' the logic by performance of step H.5 of OCIPM 0100-10.

HPCI was subsequently made inoperable and unavailable by placing the turbine trip button in the actuated positi.on. The HPCI subsystem was inoperable for 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> and 39 minutes due to this event.

During this time period, ADS would have responded to a design basis event and provided back-l i

up for the HPCI Subsystem which was unavailable.

The Core Spray and Low Pressure Coolant Injection Subsystems were operable during this event.

There was no impact on Control Room personnel or the health and safety of the public.

E.

CORRECTIVE ACTIONS

Corrective Actions S)mpleted:

A stop work order was issued for all non-routine (those that are performed on a frequency of longer than once per quarter) surveillances until a review for proper 1

plant conditions could be completed for these scheduled surveillances.

Tailgates were held with the Operations, Maintenance, Engineering and Radiation i

l Protection / Health Physics procedure writers on the first draft of this report with the intent that they review open/new procedure changes for assurance that appropriate plant prerequisite conditions are included and are in accordance with the 10CFR50.59 i

safety screening / evaluation applicable mode requirements.

(Completed NTS # 2651809700101, 2651809700102, 2651809700103, 2651809700104) i l

i LER265\\97\\001.WPF

_ ~. - _ ~

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Form Ray. 2.0

,e FACILTTY NAME (1)

DOCKET NUMBER (2)

LER NUMBER (63 PAGE (3)

(

Year Sequential kevision l

Number Number Quad Cities Unit Two 0l5l0l0l0l2l6l5 9l7 0l0l1 0l0 5 lOFl 0 l 6 TEXT Energy Industry Identification System (EIIS) codes are identified in the text a, {XXI l

l

.A revision to QCAP 0200-15. " Work Activity Screening," (red sheets) has been initiated to assign specific responsibilities to:

the work group supervisor to ensure that workers understand the work to be l

e performed; the, person authorizing work to question the supervisor in charge of the work or e-the worker to ensure the supervisor / worker is aware of the effects to plant and system operation; the Lead Unit Planner to ensure that scheduled activities on sensitive systems e

can be performed in the scheduled plant mode and in conjunction with other work activities; appropriate personnel to initiate red sheets for all power block activities e

i except work activities performed quarterly or more frequent; The revision also adds a step to review applicable electrical drawings, logic e

diagrams, and piping and instrument drawings when appropriate.

The procedure revision cover sheet states that training is required for this procedure change.

The revision also adds a step that whenever performing a work activity in a mode or condition different from when it has been historically performed, then review all 10CFR50.59 safety screening / evaluations for any procedures used to perform the task.

Review all 10CFR50.59s since the task was first proceduralized to verify all steps of the procedure have been evaluated for the scheduled mode, or i

prepare a new 10CFR50.59 safety screening / evaluation to perform the procedure in the scheduled mode.

(To be effective by April 11, 1997, NTS # 2651809700105).

l Corrective Actions to be Completed:

1.

Communicate the specific management expectation for the person in charge of the work to review the appropriate prints to ensure that he/she is aware of the effects to plant and system operation from the activities performed.

1 (Maintenance, April 5, 1997, NTS # 2651809700106, System Engineering, April 17, 1997, NTS # 2651809700107, Station Support Engineering, April 17 1997, NTS #

l 2651809700108, and Design Engineering, May 1, 1997, NTS # 2651809700109) i i

2.

Communicate the specific management expectation that procedure writers include l

10CFR50.59 safety screening / evaluation requirements in the associated procedure t

i prerequisites. (Operations, April 1, 1997, NTS # 2651809700110, Maintenance, April 15, 1997, NTS # 2651809700111, System Engineering, April 17, 1997, NTS #

2651809700112, Station Support Engineering, April 17, 1997, NTS # 2651809700113, Design Engineering, May 1, 1997, NTS # 2651809700114 and Radiation Protection / Health Physics, April 15, 1997, NTS # 2651809700115).

3.

Revise QCAP 1100-04, " Procedure Revision, Review and Approval" to require the procedure prerequisites be bounded by the 10CFR50.59 safety screening / evaluation mode requirements. Train all departments on this procedure change.

j (Administration, April 27, 1997, NTS # 2651809700116),

t LER26$197\\001,%T*F

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l LICENSEE EVENT REPORT (LER) TEXT COf(TINUATION Form Rev. 2.0

• FACILITY NAME (1)

DCCKET NUMBER (2)

LER NUMBER to)

PAGE (3)

Year Sequential Revision Number Number Quad Cities Unit Two 0l5l0l0l0l2l6l5 9l7 0l0l1 0l0 6 lOFl 0 l 6 l

TEXT, E.norgy Industry identification $ystem (EI.$) codes are identified in the text es (XXj l

4.

The Operations Manager and the Work Control Superintendent will meet with the Lead Unit Planners to provide expectations for Lead Unit Planner, Work Week Manager and Scheduler responsibilities when reviewing and scheduling work.

(Operating, April 30, 1997, NTS # 2651809700117).

5.

Review and revise as necessary the work control procedures and policies to '

incorporate the expectations provided by the.0perations Manager and Work Control Superintendent.

(Work Control, June 1, 1997, NTS # 2651809700118).

6.

Revise QCIPM 0100-10 " Refuel Outage ECCS Instrumentation Check Prior to ECCS Logic Test" to include prerequisites to identify the plant conditions required prior to using each section of this procedure and to clarify each of the individual impact statements.

(Maintenance, April 15, 1997, NTS #

2651809700119).

7.

Instrument Maintenance shall review and establish a priority for revising all of their power block procedures to determine if the impact statement or the l

prerequisite adequately identify the plant conditions that shall exist prior to the use of the procedure.

(Instrument Maintenance, April 30, 1997, NTS # 2651809700120).

F.

PREVIOUS EVENTS:

A search of previous Licensee Event Reports from Quad Cities Station for the past two years revealed two previous events caused by inadequate procedures for an evolution that was performed.outside of its usual mode.

LER l-95-006 The 1A 'RPS EPA relays had.not been tested prior to the mode switch being moved to refuel due to an inadequate written communication.

LER 1-96-006 A local leak rate test (LLRT) was performed outside of its usual mode which caused an entry into Technical Specification 3.0.A.

j There have been three previous HPCI initiations at Quad Cities Station.

On November 6,1977, Unit Two HPCI was manually initiated to maintain reactor water level after a loss of offsite power.

On March 16, 1983, Unit Two HPCI automatically initiated due to procedural inadequacy because it directed a test meter to be placed in a way that allowed an instantaneous short through the test meter, injection was prevented by prompt operator action.

On November 3, 1987, Unit Two HPCI automatically initiated and injected, adding approximately 2 inches of level to the reactor due to a personnel error.

G.

COMPONENT FAILURE DATA

There was no component failure associated with this event.

LER265\\97\\001.%TF