ML18012A395

LER 96-020-00:on 960906,inadvertent RWST Boron Dilution Event Occurred.Caused by Personnel Error.Appropriate Operating Procedure Will Be revised.W/961007 Ltr

ML18012A395
Person / Time
Site:	Harris
Issue date:	10/07/1996
From:	DONAHUE J W, VERRILLI M CAROLINA POWER & LIGHT CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
HNP-96-171, LER-96-020, LER-96-20, NUDOCS 9610160058
Download: ML18012A395 (5)

Text

CATEGORY REGUL ORY INFORMATION DISTRIBUT SYSTEM (RIDS)ACCESSION NBR:9610160058 DOC.DATE: 96/10/07 NOTARIZED:

NO FACIL;50-400 Shearon Harris Nuclear Power Plant, Unit 1, Carolina AUTH.NAME AUTHOR AFFILIATION VERRILLIEM.

Carolina Power&Light Co.DONAHUE,J.W.

Carolina Power a Light Co.RECIP.NAME RECIPIENT AFFILIATION DOCKET 05000400

SUBJECT:

LER 96-020-00:on 960906,inadvertent RWST boron dilution event occurred.Caused by personnel error.Appropriate operating procedure will be revised.W/961007 ltr.DZSTRZBUTZON CODE: ZE22T COPZES RECEZVED:LTR (ENCL I SIZE: TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.NOTES:Application for permit renewal filed.05000400 G RECIPIENT ID CODE/NAME PD2-1 PD INTERNAL: ACRS~FILE CE~R R/DE/EELB NRR/DRCH/HHFB NRR/DRCH/HOLB NRR/DRPM/PECB NRR/DSSA/SRXB RGN2 FILE 01 EXTERNAL: L ST LOBBY WARD NOAC MURPHY,G.A NRC PDR COPIES LTTR ENCL 1 1 1 1 1 1 1 1 1 1 1, 1 1 1 1 1 1 1 1 1 1 1 1 1 RECIPIENT ID CODE/NAME LEEN AEOD/SPD/RRAB NRR/DE/ECGB NRR/DE/EMEB NRR/DRCH/HICB NRR/DRCH/HQMB NRR/DSSA/SPLB RES/DSIR/EIB LITCO BRYCEI J H NOAC POORE,W.NUDOCS FULL TXT COPIES LTTR ENCL 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 D U N NOTE TO ALL"RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTE.TO HAVE YOUR NAME OR ORGANIZATION REMOVED FROM DISTRIBUTION LISTS OR REDUCE THE NUMBER OF COPIES RECEIVED BY YOU OR YOUR ORGANIZATION, CONTACT THE DOCUMENT CONTROL DESK (DCD)ON EXTENSION 415-2083 FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 24 ENCL 24 Carolina Power 8 Light Company Harris Nudear Plant PO Box 165 New Hill NC 27562 OCT 7 1996 U.S.Nuclear Regulatory Commission ATTN: NRC Document Control Desk Washington, DC 20555 Serial: HNP-96-171 10CFR50.73 SHEARON HARRIS NUCLEAR POWER PLANT UNIT 1 DOCKET NO.50-400 LICENSE NO.NPF-63 LICENSEE EVENT REPORT 96-020-00 Sir or Madam: In accordance with Title 10 to the Code of Federal Regulations, the enclosed Licensee Event Report is submitted.

This report describes an inadvertent boron dilution in the Refueling Water Storage Tank.Sincerely, J.W.Donahue Director of Site Operations Harris Plant MV Enclosure c: Mr.J.B.Brady (HNP Senior NRC Resident)Mr.S.D.Ebneter (NRC Regional Administrator, Region II)Mr.N.B.Le (NRC-NRR Project Manager)96f0ih0058 96i007 PDR ADOCK 05000400~GO()g g State Road 1134 New Hill NC C'~~~~I~I~~~~'~~~~'~~Il I'III I'I I I.I I I I I I I~I'I I'I I I'I.: 'I I I I I l l I II'I I I I'il l I I'I I I'I II I I I IC l~~l~~~~~~~~~'~mlSRIRI~m mmm'la ERR'~I I g 1 I~1 1~~~~IHmÃm mRm~'~~r~~r~~r~~r~~'~~~~~~~~~~~~~~~~~~~RRRRRNREmmmmi RRRSmmmRR5~

&&MME&WWMW MW&&WAN I I I I I~EWRREm~~~~~l~'l~~I'I~~~1~I~~~I~~~~~~~~~I I~I I I I~I I'~~~'~I~I~I'I I~I I I I~~I I~~I I~~~~I I~~r I~11~I~'~I~~~I I I~I~'~~~~~'I~1~~~~~I~~I'I~1~'I~~~'~I I I>>~'~I'I~>>~~I~I~~I~'~'I~I I~'1~~~'I'~~~~~~~~~~~~.~~I'~I~I~I'I'I~~~~'~~I I I I~I~I I~I~I','~'~~~.~~~~'~~I~~I~11~I~'1~~~~I I~I~~~~~1~I~~'~'I~~I I~~~~'1'~~'~~I~'I~I'~I'~I~~I~~~I'I~~I NRC fORM sddA ides)LICENSEE EVENT BEPOBT (LEB)TEXT CONTINUATION ILS.NUCLEAR REGULATORY COMMISSION f AC!LITT NAME III Shearon Harris Nuclear Plant~Unit Nl OOCNET 50400 LER NUM GER OI)SEOUEKTIAL RENGIOK KUMGER NUMBER 96-020-00 PAGE I3)2 OF 3 TEXT pl sssfs sPsssis ssfsissd ass sdifriml ayis sr h'RC hvm 3NQI II))EVENT DESCRIPTION:

On September 6, 1996, the plant was shutdown in mode 3 (Hot Standby)with primary plant temperature and pressure being controlled by the Steam Generator Power Operated Relief Valves.While in this mode, the Auxiliary Feedwater System is used to feed the Steam Generators, which requires periodic refilling of its water source, the Condensate Storage Tank (CST).At approximately 1920 hours0.0222 days <br />0.533 hours <br />0.00317 weeks <br />7.3056e-4 months <br /> a licensed reactor operator filling an auxiliary operator position inadvertently commenced filling the Refueling Water Storage Tank (RWST)with demineralized water instead of filling the CST.Initial RWST level was approximately 95%prior to the inadvertent fill process.The control room staff did observe a high RWST level alarm (98%)at approximately 2345 hours0.0271 days <br />0.651 hours <br />0.00388 weeks <br />8.922725e-4 months <br />, but made an incorrect assumption that the level increase was due to a change in temperature.

They did agree to continue to observe RWST level, but no further investigation into the alarm was performed.

While taking reactor operator logs approximately 45 minutes later, RWST level was observed to be at 100%.At this time the control room staff investigated the condition and discovered that 1DW-5 had been inadvertently opened instead of the CST fill valve.At 0042 hours4.861111e-4 days <br />0.0117 hours <br />6.944444e-5 weeks <br />1.5981e-5 months <br />, 1DW-5 was shut by the operator.During the RWST level increase boron concentration decreased from 2476 ppm to approximately 2351 ppm (by calculation), which is below the 2400 ppm Technical Specification limit.While the inadvertent RWST fill was in progress, the Boric Acid Tank (BAT)was recirculating for boric acid batching and was not available as a boron injection flow path.With RWST boron concentration below Technical Specification limits and the BAT unavailable, no boron injection flow paths were available, which violated Technical Specification 3.1.2.2.and required entry into Technical Specification 3.0.3.At 0151 hours0.00175 days <br />0.0419 hours <br />2.496693e-4 weeks <br />5.74555e-5 months <br /> on September 7, 1996, the BAT was returned to service and declared operable, which allowed Technical Specification 3.0.3 to be exited.After increasing the boron concentration back to above 2400 ppm, the RWST was declared operable at 1422 hours0.0165 days <br />0.395 hours <br />0.00235 weeks <br />5.41071e-4 months <br /> on September 7, 1996.CAUSE: The cause of this event was personnel error on the part of the operator that inadvertently opened the RWST fill valve (1DW-5)instead of the CST fill valve.Self checking techniques were not adequately applied and the error was not cognitive.

The main control room operators involved in the event also failed to implement good working practices by not providing adequate direction to the auxiliary operator for filling the CST and did not properly respond to the RWST high level alarm.They were involved in testing to restore the Normal Service Water System (reference LER 96-018)and did not apply adequate attention to the alarm.A possible contributing factor to these human performance errors was fatigue.Hurricane Fran had passed over the Harris Plant area early that morning causing home and personal property damage, which prevented the involved shift personnel from resting as usual before coming to work on the evening shift of September 6, 1996.SAFETY SIGNIFICANCE:

The safety consequences related to this event are still under investigation and will be provided in a supplement to this LER.PREVIOUS SIMILAR EVENTS: There have been no previous Technical Specification

3.0.3 entries

due to inadvertently diluting the RWST to a boron concentration below Technical Specification limits.

NRC FORM 344A I4BQ LICENSEE EVENT REPORT (LEH)TEXT CONTINUATION ILS.llUCIEAR REGUIATORT COMMISSION FAcluTT NAME II)Shearon Harris Nuclear Piant~Unit)F1 OOCRET 50400 96-020 00 lER NUMBER IBI SEOUENTIAL REVISION NUMBER NUMBER PAGE En 3 OF 3 TEXT gl near opoooir npwa4 ooo oANeasl oopie of ERC Foldo JBQI (IT)CORRECTIVE ACTIONS COMPLETED:

1.The operator that inadvertently opened the RWST fill valve instead of the CST valve was counseled and provided a briefing on the event to other operations personnel.

This was completed on September 10, 1996.2.The main control room operators involved in not providing adequate direction to the auxiliary operator and not properly responding to the RWST high level alarm were counseled.

This was completed on September 6, 1996.CORRECTIVE ACTIONS PLANNED: 1.The appropriate operating procedure will be revised to reflect the"locked-closed" designation for RWST fill valve 1DW-5.This will be completed by November 15, 1996.This event will be provided to Operations personnel as a case study to review the inappropriate actions taken by the control room staff.The issue of fatigue will also be included in this presentation and will emphasize the importance of recognizing the effects of fatigue and informing supervision prior to allowing fatigue to affect work performance.

This will be completed by January 15, 1997.