05000254/LER-1997-008-01, :on 970402,high Pressure Coolant Injection Was Inoperable Due to Turning Gear Failure.Turbine Turning Gear Was Manually Engaged

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:on 970402,high Pressure Coolant Injection Was Inoperable Due to Turning Gear Failure.Turbine Turning Gear Was Manually Engaged
ML20138H829
Person / Time
Site: Quad Cities 
Issue date: 04/29/1997
From: Peterson C
COMMONWEALTH EDISON CO.
To:
Shared Package
ML20138H815 List:
References
LER-97-008-01, LER-97-8-1, NUDOCS 9705070298
Download: ML20138H829 (4)


LER-1997-008, on 970402,high Pressure Coolant Injection Was Inoperable Due to Turning Gear Failure.Turbine Turning Gear Was Manually Engaged
Event date:
Report date:
Reporting criterion: 10 CFR 50.73(a)(2)(iv), System Actuation
2541997008R01 - NRC Website

text

LICENSEE EVENT REPCIT (LER)

Form R:v. 2.0 Facihty N.mo (1)

Docket Numbwr (2)

Pags (3)

Quad Cities Unit One 0 l 5 l 0 l 0 l o l 2 l 5 l 4 l 1 l of l 0 l 4 Title (4)

High Pressure Coolant Injection Inoperable Due To Terning Gear Failure.

Event Date (5)

LER Number (6)

Report Date (7)

Other Facihtaa involved (8)

Month Day Year Year Sequential Revision Month Day Year Facihty Docket Numberta)

Number Number Names 0j5l0l0l0l l

l 0l4 ol2 9l7 9l7 0l0l8 0lo 0l4 2l9 9

7 0l5l0l0l0l l

l OPERATING THis REPORT IS SUBMflTED PURSUANT TO THE REQU REN ENTS OF 10CFR MODE (9)

(Check one or more of the following) (11) 1 20A02(b) 20.405(c) 50.73(a)(2)(iv) 73.71(b)

POWER 20.405(a)(1)G) 50.36(c)(1)

T50.73(a)G)(v) 73.71(c)

~

LEVEL

- 20.405(a)(1)Gi) 50.36(c)G)
- 50.73(a)G)(vii)

Other (Specify (10) 1 l0l 0

- 20A05(a)(1)0ii) 50.73(a)c)0) 50.73(a)C)(viii)(A) an Abstract 20.405(a)(1)(iv) 50.73(a)G)(ii) 50.73(a)G)(viii)(B) below and in 20 405(a)(1)(v) 50.73(a)C)0ii) 50.73(a)G)(x)

Text)

~

LICENSEE CON Tact FOR THis LER (la)

NAME TELEPHONE NUMBER AREA CODE Ch.rlis Peterson, Regulatory Affairs Manager. ext. 3609 3

0l9 6l5l4l-l2l2l4l1 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBEL; IN THIS REPORT (13)

CAU$E SYSTEM (X)MPONENT MANUFACTURER REPORTA1.lf.

CAUSE

OSTEM COMPONENT MANUFACTURER REPORTABLE 10 NPRDS 70 NPRDS I

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I SUP "I.EMENTAL REPORT EXPEca t.u (14)

Expected Month Day Year Subnussion lYES (If yes. complete EXPECTED SUBMIS$10N DATE)

~E"]NO Date (15) l l

l ABSTRACT (Lanut to 1400 spaces i.e.. appromanniety fWieen ample-epnee typewrmen imes) (16)

ABSTRACT On 040297 at approximately 1700 hours0.0197 days <br />0.472 hours <br />0.00281 weeks <br />6.4685e-4 months <br /> the High Pressure Coolant Injection (HPCI)[BJ)

Subsystem turbine was shutdown after quarterly flow rata testing. When the turbine came to rest the turning gear railed to automatically engage. After subsequent testing of the turning gear it was determined that there was a problem with the turning gear engage linkage and the Unit 1 HPCI system was declared inoperable at 2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br /> on 040297.

Unit 1 entered a 14 day Limiting condition for Operation per Technical Specification 3.5.A.3 Action 3.

The turning gear engagement linkages were repaired on 040397 and the HPCI Subsystem was declared operable on 040497 after review of the cause of the failure.

The failure was caused by improper adjustments to the turning gear engagement mechanism on 031397 while the reactor was shutdown.

These adjustments were made at the direction of the system engineer who had an improper understanding of the turning gear mechanism. These adjustments were then improperly tested prior to start-up on 031797. Therefore the failure was not detected until the turbine run perfrrmed on 040297.

There was no effect on the public or the control room personnel due to this event and the safety consequences were minimal.

The person involved in providing the instructions for the turning gear adjustments has been counseled on his failure. The procedure used for testing the turning gear will be revised and appropriate turning gear adjustment instructions will be incorporated into the vendor manual.

LER7497\\003.WPF 9705070298 970429 PDR ADOCK 05000254 S

PDR

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Form Rov. 2.0 FACIllTY NAME (1)

DOuxI NUMBER (2)

LER NUMBER (6)

PAGE (3)

Year Sequential Revision Nurnber Number Quad Cities Unit One 0l5l0l0}Oj2l5)4 9l7 0l0l8 0l0 2 lOFl 0 l 4 TEXI Energy Industry identafication 5ystem (EII5) coces are identified in the text es (XXj

PLANT AND SYSTEM IDENTIFICATION

General Electric - Boiling Water Reactor - 2511 MWt rated core thermal power EVENT IDENTIFICATION:

High Pressure Coolant Injection Inoperable due to turning gear failure A.

CONDITIONS PRIOR TO EVENT

Unit: One Event Date: 040297 Event Time: 1700 Reactor Mode: 1 Mode Name: POWER OPERATION Power levei: 100%

This report was initiated by Licensee Event Report 254\\97-008.

POWER OPERATION Mode (1): Mode switch in the RUN position with average reactor coolant temperature at any temperature.

B.

EVENT DESCRIPTION

On 031397 the Unit 1 High Pressure Coolant Injection (HPCI)[BJ) subsystem turbine turning gear was adjusted under Nuclear Work Request (NWR) #9608080571.

This adjustment was made at the direction of the System Engineer. He had consulted with a Maintenance Work Analyst and the available vendor information prior to providing this direction.

This work was tested by performing manipulations under QCOP 2300-13, "HPCI Turning Gear Operation". On 031797 at 0202 hours0.00234 days <br />0.0561 hours <br />3.339947e-4 weeks <br />7.6861e-5 months <br /> Unit I reactor pressure exceeded 150 pounds per square inch gauge (psig) during start-up from forced outage QlF39. The reactor operated above 150 psig until 032297 at 1404 hours0.0163 days <br />0.39 hours <br />0.00232 weeks <br />5.34222e-4 months <br />. Reactor pressure was again increased to greater than 150 psig on 032897 at 2017 hours0.0233 days <br />0.56 hours <br />0.00333 weeks <br />7.674685e-4 months <br />. HPCI is required to be operable per Technical Specification 3.5.A.3 Action 3 any time that the reactor pressure is above 150 psig.

On April 2, 1997 at approximately 1700 hours0.0197 days <br />0.472 hours <br />0.00281 weeks <br />6.4685e-4 months <br /> the HPCI turbine was shutdown after quarterly flow rate testing. When the turbine came to rest, the turning gear failed to automatically engage.

The operator in attendance manually engaged the turbine turning gear by pushing on the engagement lever.

After subsequent testing of the turning gear, it was determined that the automatic engagement feature was inoperable. Since the turning gear was inoperable, the Unit 1 HPCI system was declared inoperable at 2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br /> on 040297.

Unit 1 entered a 14 day Limiting Condition for Operation per Technical Specification 3.5.A.3 Action 3.

On 040397 at about 1315 hours0.0152 days <br />0.365 hours <br />0.00217 weeks <br />5.003575e-4 months <br /> adjustments were completed on the Unit 1 HPCI turning gear and this repair had been tested three times. One additional test, a HPCI Pump Operability run (QCOS 2300-01), was completed at 1650 hours0.0191 days <br />0.458 hours <br />0.00273 weeks <br />6.27825e-4 months <br /> on 040397. The Operating Department declared the HPCI subsystem operable again on 040497 at 1215 hours0.0141 days <br />0.338 hours <br />0.00201 weeks <br />4.623075e-4 months <br /> after verifying that the cause of the turning gear failure had been corrected by the adjustments performed on 040397.

LER254\\9"n008 WPF

I UCENSEE EVENT REPCOT (LER) TEXT CONTINUATION Form Rcv. 2.o FACILrrYJ4AME (1)

DOCKET NUMBER (2)

LER NUMBER (6)

PAGE (3)

Year Sequennal Revision Number Number Quad Cities Unit One 0l5l0l0l0l2l5l4 9l7 0l0l8 0l0 3 lOFl 0 l 4 TEXT Energy Industry idennficanon System (EIIS) coces are identified in the text as [XXj C.

APPARENT CAUSE OF THE EVERT The apparent cause of this event was cognitive personnel error, in that improper instructions were provided by the System Engineer on how to adjust the HPCI turning gear when the work was performed under Nuclear Work Request #960080571 on 031397.

The System Engineer provided these instructions after consulting with a Maintenance Work Analyst and the available vendor information.

Based on this information and his understanding of turning gear operation, the System Engineer then instructed maintenance personnel on how to adjust the turning gear.

These instructions caused the failure of the automatic engagement feature of the turning gear.

This work was performed while the reactor was shutdown due to a forced outage.

Additionally, an inadequate test was performed to verify the operability of the turning gear after these adjustments were made prior to reactor start-up on 031797.

The testing was performed in accordance with station procedure QCOP 2300-13,

" Turning Gear Operation," which does not provide for fully disengaging and re-engaging the turbine turning gear.

D.

SAFETY ANALYSIS OF THE EVENT The consequences of this event were minimal. The Unit 1 HPCI subsystem was available to start automatically from 031797 to 040397 even though the turning gear was inoperable. The turbine rotor had been properly cooled on the turning gear prior to the adjustments made to the gear on 031397. Had a design basis accident occurred while the turning gear was inoperable and HPCI was required to operate, from 031797 to 040397, HPCI would have started and refilled the reactor vessel as designed.

If the operator had taken manual control of HPCI as directed by the emergency procedures, the subsystem would have remained in operation and would have continued to maintain reactor level in the flow control mode and there would have been no reason to use the turbine turning gear. The HPCI subsystem was unavailable for 9 hours1.041667e-4 days <br />0.0025 hours <br />1.488095e-5 weeks <br />3.4245e-6 months <br /> on 040397 while the turning gear was being adjusted to correct this failure.

In the event that the HPCI subsystem tripped with the turbine turning gear inoperable, the turning gear would not have automatically engaged when the turbine coasted to a stop. An operator would have had to be sent to the HPCI room to manually engage the turbine. The HPCI subsystem may have automatically restarted prior to the operator manually engaging the turning gear.

If the turbine restarted without being on turning gear while still hot, severe vibrations and bearing failures may have occurred causing failure of the HPCI subsystem to fulfill its design function.

The Automatic Depressurization System (ADS)[RV] and the Low Pressure Coolant Injection (LPCI)[B0] systems were operable during this event and would also have provided protection for the fuel in the event of a Loss of Coolant Accident.

E.

CORRECTIVE ACTIONS

Immediate corrective actions completed were to manually engage the turbine turning gear when the failure was discovered.

LER254\\97\\008.WPF

\\

LJCENSEE EVENT REPORT (LER) TEXT CONTINUATION Form Rw,2.0 FACILITY NAME (1)

DOurl NUMBER (2)

LER NUMBER (6)

PAGE (3)

Year Sequential Revision f

)

Number Number i

Quad Cities Unit Oae 0l5l0l0l0l2l5l4 9l7 0l0l8 0l0 4 lOFl 0 l 4

'I IAT Energy Industry Identification System (tils) coc es are M

- w in the text as [XX)

Corrective actions which have been completed are:

1.

The turbine turning gear was adjusted on 040397 and tested four times to verify operability of the automatic engagement function.

2.

The engineer who gave the turning gear adjustment instructions has been i

counseled to ensure that the technical information he is providing is correct.

i Future corrective actions are:

1.

Revise QCOP 2300-13 to include steps to fully disengage the turning gear if j

i necessary for testing purposes. (NTS #2541809700801, OPS) This will be

]

completed by 060197.

2.

System Engineer to review with General Electric available information on this type of turning gear to ensure that correct repair instructions are included in the vendor manual and are available for future repairs. (NTS

  1. 2541809700802, SED).

This will be completed by 090197.

i F.

PREVIOUS EVENTS A review of the PIF and LER databases for the last two years revealed the following I

HPCI Turning Gear failures.

There were no LERs caused by inadequate instructions given to maintenance personnel by engineering:

l 1.

LER 2-95-007 Unit 2 HPCI Turning Gear Motor failed to start due to an unknum cause - This turning gear failure could not be recreated. Turning gear i

operation was monitored during multiple HPCI runs with no further failures.

2.

PIF #96-1642 Unit 2 HPCI Turbine Failed to go on Turning Gear after Surveillance - The turbine was immediately placed onto gear by the operator in j

attendance and the inability to place the turbine on gear could not be recreated. This event was attributed to alignment of the ring gear to clash gear when the turbine came to rest. The procedure was changed to require multiple attempts to engage the turning gear from the control room.

G.

COMPONENT FAILURE DATA

1.

Component Description: Turbine Turning Gear Manufacturer:

General Electric Model Number: M 567 LER254\\97\\008.WPF i

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