ML18065A506

LER 96-004-00:on 960118,SIS Disabled W/Primary Coolant Sys Greater than 300 F.Caused by Personnel Error.Permanent Maint Procedure to Disable/Enable SIS Actuation on Low Pressurizer Pressure Will Be Revised to Align W/Ts

ML18065A506
Person / Time
Site:	Palisades
Issue date:	02/19/1996
From:	MATHEWS C M CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.)
To:
Shared Package
ML18065A504	List: ML18065A503 ML18065A506
References
LER-96-004, LER-96-4, NUDOCS 9602260303
Download: ML18065A506 (5)

Text

, " NRCForm388 U.S. NUCLEAR REGULATORY COMMISSION (9-83) APPROVED OMS NO. 3150-0104 EXPIRES: 8131185 LICENSEE EVENT REPORT (LER) FACILITY NAME (1) DOCKET NUMBER (2) PAGE (3) Consumers Power Company Palisades Plant a I s I a I a I c I 2 I s I s 1 I OF a 1 s TITLE (4) LICENSEE EVENT REPORT 96-004 -SAFETY INJECTION SYSTEM DISABLED WITH PRIMARY COOLANT SYSTEM GREATER THAN 300°F EVENT DATE CSl LER NUMBER I, n REPORT DATE 161 OTHER FACILITTES INVOLVED (8) SEQUENTIAL . REVISION FACILITY NAMES MONTH DAY YEAR YEAR NUMBER NUMBER MONTH DAY YEAR NIA olslololol I 0 I 1 1 I 6 916 -o Io I 4 -olo 012 1 I 9 916 olslololol I 9 6 NIA THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR §: (Check one or mONJ of the following)

(11) OPERATING N MODEC9l 20.402(b) 20.405(c)

50. 73(a)(2)(iv) 73.71(b) ---POWER 20.405(a)(1)(1) 50.38(c)(1)

50. 73(a)(2)(v) 73.71(c) LEVEL -....._ --(10) o I o 0 20.405(a)(1)(1i) 50.38(c)(2)

50. 73(a)(2)(vii)

OTHER (Specify in Abstract ---'t : -20.405(a)(1

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50. 73(a)(2)(viii)(A) below and in Telrt, -/:. -20.405(a)(1)[iv)

-50. 73(a)(2)(1ij

-50. 73(a)(2)(viiij(B)

NRC Form 388A) .. *. 20.405CaH1lM

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LICENSEE CONTACT FOR THIS LER {121 NAME TELEPHONE NUMBER Clayton M Mathews, Licensing Engineer AREACODE I 61116 11614 I -lsl91113 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT 1131 MANUFAC-REPORTABL

....* , > MANUFAC-REPORTABL

• • .* : CAUSE SYSTEM COMPONENT TURER E .) . CAUSE SYSTEM COMPONENT TURER E TONPRDS TONPRDS *.* 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 I I I SUPPLEMENT AL REPORT EXPECTED (14) MONTH DAY YEAR EXPECTED ---, YES (If ve.s. comolete EXPECTED SUBMISSION DA TEI SUBMISSION I I I 0ATE(15) ABSTRACT (Limit to 1400 *pace3, i.e .. approximately fift""n *ing/.,.,,pace typewritten

/in.,.) (18) On January 18, 1996, the reactor was being placed in cold shutdown conditions due to faulted 2400 VAC cables that supply 1 D Bus. The Safety Injection System actuation on low pressurizer pressure was disabled when the Primary Coola.nt System (PCS) temperature was approximately 364°F. This was a violation of Technical Specification section 3.17.2 which requires these Engineered Safety Feature logic channels and associated instrumentation to be operable whenever PCS temperature is greater than or equal to 300°F. 9602260303 960219 POR ADOCK 05000255 S PDR NRC Form 366A (9-83) FACILITY NAME (1) Palisades Plant EVENT DESCRIPTION

• LICENSEE EVENT REPORT (LER) TEXT CONTINUATION DOCKET NUMBER (2) YEAR LER NUMBER (3) SEQUENTIAL NUMBER U.S. NUCLEAR REGULATORY COMMISSION APPROVED OMB NO.

EXPIRES: 8131/85 REVISION NUMBER PAGE(4) 0 I 5 I 0 I 0 I 0 I 2 I 5 I 5 9 I 6 -*) I 0 I 4 -0 I 0 0 I 2 OF 0 I 5 On January 18, 1996, the reactor was being placed in cold shutdown conditions due to faulted 2400 VAC cables that supply 1 D Bus. During the "C" shift (1600-2400 hrs) a work order for disabling the Safety Injection System (SIS) was noted by the Electrical Maintenance Supervisor during his review of upcoming work. A review of the Electrical Maintenance Daily Schedule and the forced outage schedule did not indicate that this work order was to be performed on that shift: After a discussion with the Shift Supervisor, a review of plant conditions, and a review of what were thought to be the applicable requirements, the work order was released at 2046 hours0.0237 days <br />0.568 hours <br />0.00338 weeks <br />7.78503e-4 months <br />. Primary coolant temperature at that time was approximately 364 ° F. The work order activity was completed at 2130 hours0.0247 days <br />0.592 hours <br />0.00352 weeks <br />8.10465e-4 months <br />. Therefore, this work disabled the Safety Injection System actuation on low pressurizer pressure when the Primary Coolant System (PCS) temperature was approximately 364°F. This was a violation of Technical Specification section 3.17.2 which requires these Engineered Safety Feature logic channels and associated instrumentation to be operable whenever PCS temperature is greater than or equal to 300°F. Disabling the low pressurizer pressure safety injection actuation signal at a PCS temperature greater than 300° F went unnoticed until 0615 hours0.00712 days <br />0.171 hours <br />0.00102 weeks <br />2.340075e-4 months <br /> on January 19 when the Planning and Scheduling Manager questioned the completion of the activity.

ANALYSIS OF EVENT Various references provide the necessary information to identify the applicable requirements for disabling SIS. However, all relevant references were not utilized to validate the decision to allow the disabling of the low pressurizer pressure safety injection actuation signal. The applicable Technical Specification requirement was not utilized and the maintenance procedure prerequisites were not met. When the Electrical Maintenance Supervisor noted the work order to disable SIS and went to seek more information as to when it was required, a series of miscommunications, improper verification of plant requirements, and lack of attention to detail resulted in a decision to perform the work order activity prematurely.

The required pre-established plant conditions and sequence were unknowingly altered for this activity.

Various program and process barriers to prevent this occurrence were broken. They were: 1. The Work Order "Technical Specification Involvement" block referenced Technical Specification 3.17. However, this section was not referred to and Technical Section 3.16 was thought to be the applicable requirement.

NRC Form 386A (9-83) FACILITY NAME (1) Palisades Plant LICENSEE EVENT REPORT (LER) TEXT CONTINUATION DOCKET NUMBER (2) YEAR LER NUMBER (3) SEQUENTIAL NUMBER U.S. NUCLEAR REGULATORY COMMISSION APPROVED OMB NO. 3150-0104 EXPIRES: 8131185 REVISION NUMBER PAGE (4) 0500025596-004

-0 0 OJ0F05 2. General Operating Procedure (GOP) 9, Attachment 1 "Plant Cooldown (Hot Standby/Shutdown Checklist)" section 4.4 states "When PCS is less than 210°F (ie, Cold Shutdown), then initiate work order to disable Safety Injection actuation circuits [refer to System Operating Procedure (SOP) 3, step 7. 7.1 ]." This step went unheeded in the decision making process to disable SIS since it appears on page 4 of the checklist and the plant conditions at the time had only proceeded the operating crew through page 2 of the checklist.

3. SOP 3, "Safety Injection And Shutdown Cooling System," section 7.7.1 notes "This procedure shall only be performed when the Reactor is in Cold or Refueling Shutdown ... " This procedure was not referenced for guidance.

4. Electrical Maintenance Procedure, ESS-M-24 "Disable/Enable the Safety Injection System Actuation on Low Pressurizer Pressure," prerequisite section 3.3, specifies plant condition to be "cold shutdown." Procedure step 5.1 requires the assigned supervisor ensure all prerequisites are completed.

The plant condition of cold shutdown was not verified.

5. Technical Specification 3.16 "Engineered Safety Features System Instrumentation Settings" was referenced as the controlling requirement.

Technical Specification 3.16 applicability statement indicates that "Technical Specification 3.16 is applicable when associated ESF or Isolation Function Instrumentation is req'.;.;:;*ad to be operable by Technical Specification 3.17.2 or 3.17.3. Technical Specification 3.17.2 requires SIS to be operable when the PCS is greater than or equal to 300°F. This information was not recognized and verified.

6. The Equipment Safe Shutdown Operations General Outage Information list contained an entry indicating Safety Injection Actuation Signal (SIAS) will be disabled at less than 210° F for low pressure only. Containment High Pressure will still result in a SIAS. This information was available but was not referred to as a reference source. CAUSE OF EVENT All relevant information was not used in the decision making process and pertinent procedures were violated.

Therefore, the root cause of the event was personnel error. SAFETY SIGNIFICANCE There was no safety significant condition which resulted from disabling of the SIS on low pressure during plant cooldown on January 18, 1996. The low pressure signal was blocked by design during plant cooldown before PCS pressure decreased below 1593 psia. The plant average temperature and pressure were 364°F. and less than 600 psia when the maintenance was performed disabling SIS on low PCS pressure.

The Low Temperature Overpressurization Protection (LTOP) -j

. NRC Form 368A (9-83) FACILITY NAME (1) *

• LICENSEE EVENT REPORT (LER) TEXT CONTINUATION DOCKET NUMBER (2) YEAR LER NUMBER (3) SEQUENTIAL NUMBER U.S. NUCLEAR REGULATORY COMMISSION APPROVED OMB NO. 3150-0104 EXPIRES: 8/31/85 REVISION NUMBER PAGE (4) Palisades Plant olslololol2lsls gjs -o lo 14 -o lo ol4 oF o Is setpoint of about 1000 psia would have prevented an auto-reset on increasing pressure above 1593 psia. Whether the SIS on low pressure is available or disabled is not significant to the.plant condition because the plant would have been relying on a Containment High Pressure (CHP) signal or operator action to start High Pressure Safety Injection (HPSI) to maintain or recover PCS inventory for a large break Loss of Coolant Accident (LOCA). The SIS on containment high pressure was still available to start all available safety injection pumps. With the saturation pressure of about 160 psia, the PCS inventory could be quickly recovered with one HPSI pump for both large break and small break LOCAs. At this pressure, Low Pressure Safety Injection (LPSI) pumps would also be able to supply PCS makeup since they remain aligned to the Safety Injection and Refueling Water (SIRW) tank when the PCS temperature is greater than 300°F. The plant response to small break LOCAs with the SIS low pressure signal blocked or disabled requires operator action to start available HPSI and Charging pumps. Throttling of the safety injection pumps would be required to maintain the PCS pressure within the acceptable range below the L TOP set point curve. Also, the probability of a large or small break LOCA occurring after full power operations when the PCS pressure has been reduced to less than 600 psia is very small. The consequences of an accident were not changed by this event. CORRECTIVE ACTIONS The following corrective actions will be taken: 1. Communicate to Shift Supervisors, Control Room Supervisors and Shift Engineers the expectation to validate and verify information using available references (e.g. Work Order information blocks, procedure prerequisite sections) and sources (Technical Specifications, procedures, Daily Orders, schedules, equipment safe shutdown lists, LCO status boards, etc) to assist in achieving informed and accurate decision making. 2. Reinforce the Maintenance Supervisor's responsibility to assure procedure prerequisites are met prior to authorizing a work activity.

3. Conduct training for licensed operators on the purpose of maintaining operability of equipment listed in Technical Specification Table 3.17.2 when the PCS temperature is greater than or equal to 300°F. 4. Revise the Permanent Maintenance Procedure to disable/enable the Safety Injection System actuation on low pressurizer pressure to align with Technical Specifications.

,; NRC Form 366A (9-83) FACILllY NAME (1) Palisades Plant LICENSEE EVENT REPORT (LER) TEXT CONTINUATION DOCKET NUMBER (2) YEAR LER NUMBER (3) SEQUENTIAL NUMBER U.S. NUCLEAR REGULATORY COMMISSION APPROVED OMB NO. 3150-0104 EXPIRES

8/31185 REVISION NUMBER PAGE(4) 0500025596-004

-0 0 050F05 5. Align the following procedures to accurately reflect which procedure controls the activity for disabling SIS. A. General Operating Procedure 9, Attachment 1 "Plant Cooldown (Hot Standby/Shutdown Checklist), step 4.4 which refers to System Operating Procedure 3, step 7.7.1 8. System Operating Procedure 3 "Safety Injection And Shutdown Cooling System" section 7. 7. C. Permanent Maintenance Procedure ESS-E-24, "Disable/Enable the Safety Injection System Actuation On Low Pressurizer Pressure." .