View source for NRC-90-0048, LER 89-037-01:on 891220,determined That Tech Spec Stroke Time Testing for Outboard Reactor Water Sample Line Isolation Valve Not Performed Prior to Expiration on 891125. Caused by Personnel Error.Procedure revised.W/900322 Ltr

{{Adams
| number = ML20012D642
| issue date = 03/22/1990
| title = LER 89-037-01:on 891220,determined That Tech Spec Stroke Time Testing for Outboard Reactor Water Sample Line Isolation Valve Not Performed Prior to Expiration on 891125. Caused by Personnel Error.Procedure revised.W/900322 Ltr
| author name = Anthony P, Orser W
| author affiliation = DETROIT EDISON CO.
| addressee name = 
| addressee affiliation = NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
| docket = 05000341
| license number = 
| contact person = 
| case reference number = CON-NRC-90-0048, CON-NRC-90-48
| document report number = LER-89-037, LER-89-37, NUDOCS 9003280172
| document type = LICENSEE EVENT REPORT (SEE ALSO AO,RO), TEXT-SAFETY REPORT
| page count = 5
}}

=Text=
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                                                                                          .,a DE              12 L -                                   30CFR50.73 i
Edison      lm=o,.,e,r.,,                                                              =:,6  :
i March 22, 1990                         ;
NRC-90-0048                             '
U. S. Nuclear Regulatory Commission Attention: Document Control Desk                                                     '
Washington, D.C. 20555                                                                ;

==Reference:==
Fermi 2                                                         !
NRC Docket No. 50-341 Facility Operating License No. NPF-43                         .(
Licensee Event Report (LER) No. 89-037 01                      ;

==Subject:==

Please find enclosed LER No. 89-037-01, dated March 22, 1990, for                   l a reportable event that occurred on December 8, 1989. A copy of                      ,
this LER is also being sent to the Regional Administrator, USNRC Region III.                                                                         ;
If you have any questions, please contact Patricia Anthony at (313) 586-1617 Sincerely,                              ,
                                                                 /           ,,
                                                                                                    +

==Enclosure:==
NRC Forms 366,366A cc:     A. B. Davis J. R. Eckert R. W. DeFayette/W. L. Axelson                                               '
W. G. Rogers J. F. Stang Wayne County Emergency Management Division
                                                                                /
9003280172 900322                  D PDR     ADOCK 05000341           ,
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i On December 20, 1989, it was determined that Technical Specification stroke time testing for the outboard Reactor Water                                                                                              ;
Sample Line Isolation Valve, B31-F0?0, had not been performed as required prior to its expiration on November 25, 1989. The valve had been functioning as a protection boundary for maintenance work
* at the time the other valves within the same system were tested.
When the Limiting Condition for Operation log entry for B31-ro20 was combined with another entry on November 23, 1989, the                                                                                                     ,
requirements and actions per Technical Specification 3 6.3 were not clearly indicated in the new entry. Therefore, modes were changed with the valve not having been tested as required.
On December 18, 1989, 831-ro20 was used as an alternate aanple path for the Reactor Water Cleanup System for approximately 18 1/2 hours. During this time, both the outboard and the inboard                                                                          .
isolation valves for this penetration were open.
Upon discovery of the conditionI the valve was tested successfully. Revision to the Limiting Condition for Operation administrative procedure is being ande to prohibit combining entries. A critique of this event was prepared.                                                                                                       j
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   "(,             .                               LICENSEE EVENT REPORT (LER) TEXT CONTINUATION                                                peaovEo ous no p-om EXP6HES: 8'31'88 9 AC64af v IsAest tu                                                  Dockt1 Wunetth m                                      ign gygggn igi                    pact (si
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                                    ' Plant Conditions at Time of Discovery:
Operational Condition: 2 (Startup)
Reactor Power: 4.2 percent                                                                                                                     i Reactor Pressure: 920 psig                                                                                                                   i Reactor Temperature 530 degrees Fahrenheit Description of Occurrence:
On December 20, 1989, at approximately 1300 hours, it was determined                                                                          ;
that the stroke time surveillance testing required by Technical Specification 3 6 3 for-the Reactor Water sample line outboard isolation valve, 831-F020, [(AD)(ISV)] had not been completed by its expiration date and subsequently that plant modes had been changed                                                                            1 with that condition.
On September 15, 1989, a Limiting condition for Operation (LCO) log i                                      entry was written because repairs were needed on the Reactor Recirculation Pump "A" Seal Inboard Containment Isolation Valve, B31-F014A. A work request was generated to perform the repairs during the refueling outage. B31-F020 was used as an isolation boundary for l
the work starting in October of 1989.
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!                                      During the time the work was in progress, the valve could not be                                                                            l' cycled. On November 10, 1989, surveillance test 24.138.02, " Reactor Recirculation Pumps Valve Operability Test", was performed. B31-F020 was being used as a protection boundary, therefore it was unavailable for stroke time testing. An addition was made to the LCO entry specifying that B31-F020 had to be stroke time tested prior to placing the system in service.
On November 23, 1989,.the LC3 tracking B31-F020 was combir.od with another LCO for work on the same system. When the log was rewritten,                                                                         ,
the.new entry did not explicitly indicate that B31-F020 was out of                                                                         j service per Technical Specification 3/4.6 3 and the valve must be                                                                            '
stroke time tested prior to placing the system in service. The critical date for completion of surveillance testing for B31-F020 was November 25, 1989. Since the Lc0 entry was not explicit in regards to                                                                       .
B31-F020's status, it was allowed to expire without being noted as a restriction to changing modes. Entry into Operational Condition 2 was l
i_                                      made on December 6, 1989, without B31-F020 being stroke time tested j                                       for operability.
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1989. The inboard isolation valve had been successfully tested
* already.                                                                                                            j When the failure to complete the testing of B31-F020 was identified on                                              l December 20, 1989, the testing of the valve was successfully completed.
I                                                                                                                                              i i
Cause of Event:                                                                                                      !
This event was caused by personnel error by Operations personnel (licensed-utility) when combining the LCOs. The new LCO did not clearly indicate that the isolation capability must be tested prior to entering Operational Condition 2.                                                                                   ,
A contributing factor to this was an inadequacy in the administrative                                              i procedure governing LCOs which did not preclude the combining of LCOs                                             -}
or require tagging of the equipment that was out of service.                                                       t l
Analysis of Events While the isolation valve had not been tested as required by Technical                                             !
Specification 3/14.6 3 in order to prove it operable, it was functional                                            :
during the time in question. This was demonstrated by the successful completion of the surveillance test when the problem was identified.                                               ,
Therefore, this condition did not adversely impact the isolation capability of primary containment. Additionally, the redundant valve                                               i in the penetration had been tested and proven operable. The health
* and safety of the public and plant personnel were not jeopardized by this condition.                                                                                                    i Corrective Actions:
A critique of this event was developed.                                                              ;
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0 l1         0l4 or 0 ;(4 TsET M newe ausse 4 sugid 4, ese emisseus Ar4C Fonn m W 11h The administrative procedure governing LCO's, NPP-OF1-11, is being revised due to this and other incidents. Planned revisions include prohibiting the combining of LCO's and requiring tagging of specific components that are out of service to enhance tracking of equipment status. This procedure revision will be approved by March 31, 1990 and will be implemented .in early April following                                                                                     ;
training of.the operating crews.
Finally, Detroit Edison has developed an action plan as described in Detroit Edison letter NRC-89-0300, dated December 26, 1989.
This action plan addresses the personnel performance weaknesses discovered during the first refueling outage and during the return to power operation. A foll review of the LCO program was one of the actions in tisis Accountability Action Plan.
Previous Similar Events:
This is the first instance where incorrect combining of Technical Specification LCOs led to the failure to complete Technical Specification required testing.                                                                                                                                   ,
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