ML20235E694

Insp Rept 50-301/87-16 on 870819-28.Violation Noted.Major Areas Inspected:Licensee Failure to Meet Tech Specs Re Operability of MSIVs & Licensee Failure to Rept Incident to NRC

ML20235E694
Person / Time
Site:	Point Beach
Issue date:	09/16/1987
From:	Defayette R, Hague R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20235E645	List: ML20235E644 ML20235E694
References
50-301-87-16, NUDOCS 8709280231
Download: ML20235E694 (6)

See also: IR 05000301/1987016

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'U.S. NUCLEAR REGULATORY COMMISSION

REGION III

Report No. 50-301/87016'(DR'P)

Docket'No. 50-301 , License No. DPR-27

Licensee: . Wisconsin Electric Company

231' West' Michigan

Milwaukee, WI 53203

Facility Name: Point Beach Unit 2

Inspection At: Two Creeks, Wisconsin

Inspection Condur',ed: August 19-28, 1987

Inspector:

/odf-

R. L. Hague

fqfhh .

' Approved By: R. DeFayette, Chief

Reactor Projects Section 2B

69//6/8

Date

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~ Inspection Summary

Inspection on August 19-28,'1987 (Report No. 50-301/87016(DRP))'

Areas Inspected: Special, safety inspection by R. L. Hague, of the events

and circumstances surrounding the licensee's failure to meet the' Technical-

Specification related to operability of the main steam isolation valves

and'its deportability to the NRC.

Results: LTwo apparent violations were identified, failure to have all four

methods of steam line isolation operable while the reactor was operating; and

failure to report the event to the NRC in the required time.

B709290231 870916 '

PDR- ADOCM 05000301

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DETAILS

1. Persons Contacted l

• R. W. Brit, President and Chief Operating Officer

• C. W. Fay, Vice President Nuclear Power

• J. J. Zach, Manager, PBNP

• R. J. Bruno, Superintendent, Training

• R. D. Seizert, Project Engineer

T. J. Koehler, General Superintendent

• G. J. Maxfield, Superintendent, Operations

• J. C. Reisenbuechler, Superintendent, EQRS

W. J. Herrman, Superintendent, Maintenance and Construction

• J. E. Knorr, Regulatory Engineer

The inspector also talked with and interviewed members of the

Operation, Maintenance, and Instrument and Control Sections.

• Denotes personnel attending exit interviews.

2. Introduction

During day shift on August 17, 1987, when it became evident that

the inspection of the 2X01 transformer was going to take longer than

anticipated and with the requirement to repair the steam driven auxiliary

feedpump prior to unit criticality, maintenance personnel decided they

had enough time to perform some minor secondary side inspections / repairs

and requested that operations personnel tag the main steam isolation

valves (MSIVs) shut to facilitate this work. The operations supervisor

was quite busy at the time and requested that the Unit 2 reactor operator

fill out the danger tag location sheet and the red tags. When the reactor

operator finished, he provided the sheet to the operations supervisor for

review. The operations supervisor noted tha; the tagout provided for four

tags tagging the two DC control power breakers to the instrument air

solenoid valves open and the two instrument air isolation valves to

the MSIVs shut. He concluded that tagging the instrument air isolation

(stop) valves shut would prevent opening the MSIVs and tagging the DC

control power breakers open would prevent the solenoid valves from being

continually energized with the control room switch in the closed position,

a normal practice during long term outages. He then turned the tags over

to two qualified red taggers to perform the tag out and verification.

Once the tags were hung, one copy of the danger tag locat: )n sheet was

kept in the control room and the other was given to maintenance personnel

as approval to start work.

At about 9:00 p.m. on August 17, 1987, the maintenance foreman notified

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the control room that the secondary side work was completed and the tag

out on the MSIVs could be removed. The swing shift operations supervisor 1

removed the tag out sheet from the log book and assumed from the wording I

that the two instrument air stop valves were tagged shut and that two of

the local vent solenoid valves were tagged open. Because it was

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approaching shift turnover time, he called the auxiliary building auxiliary

operator (AO) and told him to " remove the red tags on the MSIVs and open

the instrument air stop valves." The A0 completed this task and called

- back-to'the control, room reporting, "the red tags have been removed and

the instrument air stops are open.". Again, using his initial assumption,

the operations supervisor assumed that all four red tags had been removed

and he initialed the cleared section of the danger tag location sheet with

a slash and the A0's initials to indicate that the. tags were cleared per

verbal verification. In fact, only two of the four red tags had been

removed.

At 11:05 p.m., August 17, 1987, the mid-shift shift supervisor ordered his

auxiliary building A0 to reset the four instrument air solenoid valves for

each MSIV, thereby opening the MSIVs. At 3:30 a.m., August 18, 1987,

during performance of OP-1C, " Low Power Operation to Normal Power Operation,"

Step 4.1, " Energize Following Circuits," the shift supervisor went to the

DC control power breaker pancls. He opened the door on the first panel

to'look for the circuits by name and noticed the red tag on the "A" MSIV

solenoid power supply. He checked further in another panel and found the

"B" MSIV solenoid power supply was also tagged open. He then checked and

found that the tag series had.been cleared on the previous shift and knew

that there was no secondary maintenance in progress so he removed the red

tags and closed the breakers. He then went on with the normal business

of lighting off the turbine and getting the unit on line.

When the mid-shift shift supervisor took the watch the initial conditions

of OP-1C had been signed off as completed although after Step 3.1 was

completed the MSIVs were tagged shut for maintenance. Step 3.1 required

the performance of applicable portions of OP-13A. The shift supervisor

started reaccomplishing the steps in 0P-13A, " Secondary Systems Startup

and Shutdown," Section 4.5, " Bringing Steam Into Turbine Building."

When he got to Step 4.5.4, "Open and Cycle the MSIVs," he made the decision

that inasmuch as they had already been cycled and IT-280/285, "Inservich

Testing of Main Steam Stop Valves," had been run earlier that day there

was no need to cycle the MSIVs again. Had he not violated procedural

step 4.5.4 the subsequent investigation as to why the MSIVs would not

shut would have disclosed the open breakers.

The mid-shift shift supervisor left a note for the swing shift operations

supervisor stating that he had found the MSIV solenoid breakers tagged

open and that a violation may have been involved. The swing shift

operations supervisor and shift supervisor prepared a nonconformance ,

report detailing the incident. This information did not reach the '

appropriate individuals until the next day at which point they decided

that they had a Technical Specification violation and an LER would be

requi red. However, they wanted more information from the shift supervisor

before making a determination on the emergency notification system (red

phone) deportability to the NRC. Therefore, red phone notification was

delayed until noon on August 20, 1987.

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3. . Sequence of Events

August 16, 1987. .' Lightning strike on Unit 2 transformed 2X01.

e 6:55 p.m. Generator lock-out, Reactor Trip

u August 17, 1987- 2P29, Unit 2 steam' driven auxiliary feedwater

10:35 a.m. pump declared out of service for. thrust bearing

L replacement

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August 17,-1987. Red tag Series87-752 issued to maintenance

During Day Shift department for various secondary side jobs

August 17, 1987 Transformer 2X01 cleared for use

6:55 p.m.

August 17, 1987- Unit 2 steam driven auxiliary f sedwater

9:05 p.m. Pump 2P29 returned to service

August 17, 1987 Unit 2 reactor critical

9:38 p.m.

August 17, 1987 Removed red tags from instrument air valves

10:30 p.m.

August 17, 1987 Relatched solenoid valves, operred main steem i

11:05 p.m. isolation valves, noted steam leak on LP turbine

rupture disc, called in maintenance personnel

August 18, 1987 Steam in Unit 2 turbine hall, Unit 2 reactor

0000 critical at 2.8 x 10 8 amp interme'd ate range,

holding for rupture disc maintenance

August 18, 1987 Unit 2 turbine released by maintenance

1:44 a.m.

August 18, 1987 Commence drawing vacuum

1:58 a.m.

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August 18, 1987 During performance of Procedure OP-1C, " Low

3:30 a.m. Power Operation," Step 4.1, Energize Following

Circuits, the shift supervisor opened DC control I

power breaker Panels D-19 and D-22 and discovered )

control power to the MSIVs tagged open

August 18, 1987 Latch turbine

4:23 a.m.

August 18, 1987 Shift supervisor leaves note to swing shift

7:00 a.m. on what he found stating there may be a possible

violation involved

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l August 18, 1987 Operations supervisor and shift supervisor

Swing Shift prepared nonconformance report for management

review

August 19, 1987 Regulatory engineer informs senior resident ' j

Afternoon inspector of possible LER on Tech. Spec. .]

violations, needed more information from 1

mid-shift shift supervisor i

August 20, 1987 SRI reviews nonconformance report, called

Morning Region III to discuss the event. SRI

questions red phone deportability with

licensee. ' Licensee had already determined

need for 4 hr. report: questioned need for

one hour report pending results on whether

or not they were in an unanalyzed condition.

August 20, 1987 Licensee makes red phone call to NRC

12:00 Noon

4. Document Review

The inspector reviewed the following documents:

• Nonconformance Report No. N-87-140 Unit 2 Main Steam Stop Valves

• Technical Specification 15.3.5 Instrumentation System

• FSAR 14.2.5 Rupture of a Steam Pipe

• OP-1C " Low Power Operation to Normal Operation"

• OP-13A " Secondary System Startup and Shutdown"

• PBNP 4.2.1 " Shift Superintendent"

• PBNP 4.12.1 " Guidelines for Watch Standing"

• PBNP 4.13 " Equipment Isolation Procedure (Danger Tag Location)"

• Point Beach Nuclear Plant Danger Tag Location Sheet

• Incident Investigation 87-04 Preliminary Report

5. Cause

The failure to properly clear the red tags appears to be an isolated case

of poor communications. Contributing factors, although not procedural

violations, were:

1. Danger tag location sheet not specific enough as to tag location.

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2. Failure to specify how many tags were to be removed.

3. Decision that cycling MSIVs'was not necessary.

4. Failure to notify upper management immediately of possible )

violation for deportability determination.

Therefore, the cause appears to be twofold: an equipment isolation j

procedure which is not specific enough; and a prevailing attitude in i

the operations group that the MSIVs are not as significant to safety l

as other safety-related equipment. j

6. Technical Specification and Code .^.ppl*cability

Technical Specification 15.3.5.C requires a minimum number of operable

channels for each of the four methods of steam line isolation. If these

minimum operability requirements cannot be met, the unit must be in hot

shutdown. With no DC control power, none of the minimum operability

requirements were met for the four hours and 35 minutes that the MSIVs i

were open and the reactor was critical at low power.

10 CFR 50.72 (b)(2)(iii)(D), requires that any event or condition that

alone could have prevented the fulfillment of thz safety function of

structures or systems that are needed to: mitigate the consequences

of an accident, shall be reported as soon as practical, and in all

ceees within four hours of the occur ence. This event was not

reported until 79 hours9.143519e-4 days <br />0.0219 hours <br />1.306217e-4 weeks <br />3.00595e-5 months <br /> and 30 minutes after initial discovery.

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7. Exit-Interview

The inspectors met with licensee representatives (denoted in Paragraph 1)

throughout the inspection period and at the conclusion of the inspection

period to summarize the scope and findings of the inspection activities.

The licensee acknowledged the inspectors' comments. The inspectors also

discussed the likely informational content of the inspection report with

regard to documents or processes reviewed by the inspectors during the

inspection. The licensee did not identify any such documents / processes

as proprietary.

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