ML20235E694
| 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: |
| 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
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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
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Inspector:
R. L. Hague
fqfhh .
' Approved By:
R. DeFayette, Chief
69//6/8
Reactor Projects Section 2B
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
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PDR- ADOCM 05000301
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DETAILS
1.
Persons Contacted
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- 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
the control room that the secondary side work was completed and the tag
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out on the MSIVs could be removed.
The swing shift operations supervisor
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removed the tag out sheet from the log book and assumed from the wording
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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
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report detailing the incident.
This information did not reach the
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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.
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6:55 p.m.
Generator lock-out, Reactor Trip
August 17, 1987-
2P29, Unit 2 steam' driven auxiliary feedwater
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10:35 a.m.
pump declared out of service for. thrust bearing
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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
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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
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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
power breaker Panels D-19 and D-22 and discovered
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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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August 18, 1987
Operations supervisor and shift supervisor
Swing Shift
prepared nonconformance report for management
review
August 19, 1987
Regulatory engineer informs senior resident '
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Afternoon
inspector of possible LER on Tech. Spec.
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violations, needed more information from
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mid-shift shift supervisor
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August 20, 1987
SRI reviews nonconformance report, called
Morning
Region III to discuss the event.
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
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violation for deportability determination.
Therefore, the cause appears to be twofold:
an equipment isolation
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procedure which is not specific enough; and a prevailing attitude in
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the operations group that the MSIVs are not as significant to safety
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as other safety-related equipment.
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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
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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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