ML17223A229: Difference between revisions

From kanterella
Jump to navigation Jump to search
(Created page by program invented by StriderTol)
(Created page by program invented by StriderTol)
 
(3 intermediate revisions by the same user not shown)
Line 3: Line 3:
| issue date = 07/14/1989
| issue date = 07/14/1989
| title = LER 89-002-00:on 890614,diesel 1B Fuel Oil Transfer Pump Discharge Found in Locked Closed Position.Caused by Personnel Error by Util non-licensed Operator.Valve Reopened & Locked Open & Operators counseled.W/890714 Ltr
| title = LER 89-002-00:on 890614,diesel 1B Fuel Oil Transfer Pump Discharge Found in Locked Closed Position.Caused by Personnel Error by Util non-licensed Operator.Valve Reopened & Locked Open & Operators counseled.W/890714 Ltr
| author name = HOLIFIELD C D, WOODY C O
| author name = Holifield C, Woody C
| author affiliation = FLORIDA POWER & LIGHT CO.
| author affiliation = FLORIDA POWER & LIGHT CO.
| addressee name =  
| addressee name =  
Line 16: Line 16:


=Text=
=Text=
{{#Wiki_filter:REGULATORYINFORMATIONDISTRIBUTIONSYSTEM(RIDS)ACCESSIONNBR:8907250172DOC.DATE:89/07/14NOTARIZED:NOFACIL:50-335St.LuciePlant,'Unit1,FloridaPower&LightCo.AUTHNAME~AUTHORAFFILIATIONHOL1FIELD,C.D.FloridaPower&LightCo.L~0"WOODY,C.O.FloridaPower&LightCo.'ECIP.NAME=~RECIPIENTAFFILIATION
{{#Wiki_filter:REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)
ACCESSION NBR: 8907250172              DOC. DATE:   89/07/14                  NOTARIZED: NO                    DOCKET  N FACIL:50-335 St. Lucie        Plant,'Unit        1, Florida Power                    &   Light        Co.     05000335 AUTH NAME      ~       AUTHOR AFFILIATION HOL1FIELD,C.D.         Florida Power & Light Co.                                           L ~ 0" WOODY,C.O.             Florida Power & Light                                                                              R
                    = ~    RECIPIENT AFFILIATION          Co.'ECIP.NAME I


==SUBJECT:==
==SUBJECT:==
LER89-002-00:on890614,inoperabilityof1Bdieselfueloilsyscausedbymisalignedvalveduetopersonnelerror.W/8DISTRIBUTION.CODE:IE22TCOPIESRECEIVED:LTR~ENCLJSIZE:.TITLE:;50.73/50.'9LicenseeEvent.Report(LER),Incident"Rpt,etc.NOTESDOCKETN05000335RIRECIPIENTIDCODE/NAMEPD2-2LANORRIS,JINTERNAL:ACRSMICHELSONACRSWYLIEAEOD/DSP/TPABDEDRONRR/DEST/ADE8HNRR/DEST/CEB8HNRR/DEST/ICSB7NRR/DEST/MTB'HNRR/DEST/RSB8ENRR/DLPQ/HFB10NRR/DOEA/EAB11NUDOCS-ABSTRACTRES/DSIR/EIBRGN2FILE.01EXTERNALEG&GWILLIAMSPSLSTLOBBYWARDNRCPDRNSICMURPHY,G.A111111111,111111111I111111.11'441111I11COPIESLTTRENCL1111RECIPIENTIDCODE/NAMEPD2-2PDACRSMOELLERAEOD/DOAAEOD/ROAB/DSPIRM/DCTS/DAB,NRR/DEST/ADS7ENRR/DEST/ESB8DNRR/DEST/MEB9HNRR/DEST/PSB8DNRR/DEST/SGB8DNRR/DLPQ/PEB10NRR/REPQRPB10~02,S/DSRPRABFORDBLDGHOYPALPDRNSICMAYS,GCOPIESLTTRENCL1.1221.12'~11-101.11111111122~1.;111111111DSDNOXK'IOALLnRZDSnRZCZE'ZENXSPIZASEHELPUSKOREDUCE%MTELCONZACZ'IHEDOQlME&#xc3;ZCCRZRDLDESK,RXNP1-37(EZZ.20079)mELXKBQXSYOURMNEHKHDISTRIHVTIGN.IZSTSPDRDOCUMERHBYOUDGN~TNEZDfhDSFULLTEXTCONVERSIONREQUIREDTOTALNUMBEROFCOPIESREQUIRED:LTTR43ENCL,42 ox14000,JunoBeach,FL33408.0420JULY.1419B9L-89-24210CFR50.73U.S.NuclearRegulatoryCommissionAttn:DocumentControlDeskWashington,D.C.20555Gentlemen:Re:St.LucieUnit1DocketNo.50-335ReportableEvent:89-02DateofEvent:June14,1989MisalignedValveCausedInoperabilityofthe1BDieselFuelOilSstemDuetoPersonnelErrorTheattachedLicenseeEventReportisbeingsubmittedpursuanttotherequirementsof10CFR50.73toprovidenotificationofthesubjectevent.Verytrulyyours,O.WoodActingSirVicePresident-NuclearCOW/JRH/cmAttachmentcc:StewartD.Ebneter,RegionalAdministrator,RegionII,USNRCSeniorResidentInspector,USNRC,St.LuciePlantp9072lg0f72P90714PDRPDOCK0500033PDCanFPLGroupcompany RCForm3555'33)LICENSEEEVENTREPORTtLERU.S.NUCLEARREQULATORYCOMMISSIONAPPROVEDOMSNO.3150410eEXPIRES:5/31/SSFACILITYNAME(IISt.LucieUnit1"'""'NisalignedValveCausedInoperabilityofthelBD'lFuelpilSstemDuetoPersonnelErrorDOCKETNUMBER(2)050003PAE51OF0EVENTOATSISILKRNUMBERISIREPORTDATEIt)OTHERFACILITIESINVOLVEDI~IMONTHOAY0614YEARYEAR89NNQUNNTIAI.trUMNNR002MONTHSzrP,.NUMNNA-pp07OAY14YEAR89FACILITYHAM55N/ADOCKETHUMBERIS)0500005000OPERATINOMOOt(Sl~OWERLEUEL1PP(10I20A02(bl20AOB(ellll(020AOBIel(1)(Nl20AOB(el(1l(NO20AOB(e)(1)(N)20AOB(e)II)le)20AOB(elSOM(cl(IISOM(cl(2)X50.73lel(2)III50.73Iel(2)IN)50.73lel(2)IN)LICKNSKECONTACTFORTHISLKR(12)50.734)12)IN)50.734)(2l(el50.7341(211rNI50,734)l2)IcNI)(Al50.73(el(2((rBI(IS)50.73(e)l2IIelTHISREPORTISSUBMITTEDPURSUANTT0THKREOUIREMENTSOF10CFRgr/Checttoneormoreofthefo//orfinp/0173.71(II)73.71(clOTHER/SpecifyinAettrectOe/oryenr/inTert,Hf)CForm355l/NAMECharlesD.Holifield,ShiftTechnicalAdvisorTELEPHONENUMBERAREACODE407465-3550COMPLETEOHKLINESOllEACHCOMPONENTFAILUREOKSCRISKDIHTHISREPORT113)CAUSESYSTKMCOMPONENTMANUFAC.TURERTONpROSAjaryfCAUSESYSTKMCOMPONENT:@4%.,YQ,...StolMANUFAC.TUREREPORTABLTOHPRDSNUMENSUPPLEMENTALREPORTEXPECTED(1elEXPECTEDSUBMISSIONDATEIIBI%8~>$MONTHOAYYEARYES/lfyer,completeEXPECTED$(/Sef/SS/OHDATE/NOABBTRAcT/Limittoteo0rptcer,/.e.,epproe/merelyf/freonr/noreopecetypewr/(tonlintel(15)ABSTRACTOnJune14,1989,at1740,withUnit1inMode1at1004power,aroutineweeklyvalvestatuscheckwasperformedinaccordancewithaplantprocedurewhichrecpxiresavalvepositioncheckofvariousemergencydieselsystemvalves.Whileperformingthisvalvestatuscheck,the1Bdieselfueloiltransferpumpdischargevalvewasfoundinthelockedclosedposition.Althoughthe1Bdieselwascapableofstartingandsupplyingpost-accidentloadsduringtheevent,itwasadministrativelyrenderedoutofserviceduetotheinoperabilityofthe1Bdieselfueloiltransferpump,perTechnicalSpecification3.8.1.1.b.3.Themostprobablerootcauseofthemispositionedvalvewaspersonnelerrorbyautilitynon-licensedoperator,thoughtheresponsibleindividualhasnotbeenidentified.Acontributingfactorwasthefailuretorecordthemispositionedvalveinthevalvedeviationlog.Correctiveactionsincludedre-openingandlockingopenthevalve,andcounselingtheoperatorsontheimportanceof,andtheuseof,thevalvedeviationlog.NRCForm355(503I CForm3SSA8831LICENSEE+NTREPORT(LERITEXTCONTINUONU.S.NUCLEARREOUI.ATORYCOMMISSIONAPPROVEDOMBNO.3150WI04EXPIREB:8/31/88FCILITYNAME111DOCKETNUMBERI31LERNUMBER(81YEAR:~<'EQUENTIAI''EViSIONNUMSEA:.>1rrUMS~APACEl31St.LucieUnit1osooo389-002-0002oF03TEXT///rrroroEpocoito//rr'rod.Irwodd/rrorro/H//CForrrr38//AS/lI3)DESCRIONOFHEEVENTOnJune14,1989,at1740,withUnit1inMode1at100%power,aroutineweeklyemergencydieselsystemvalvestatuscheckwasperformedbyautilitynon-licensedoperatorinaccordancewithAdministrativeProcedure1-0010125A.Whileperformingthisvalvestatuscheck,the1Bdieselfueloiltransferpumpdischargevalve(EIIS:ISV)wasfoundinthelockedclosedposition.Thisadministrativelyrenderedthe1Bdieselgeneratoroutofservice,perTechnicalSpecification3.8.1.1.b.3.Thevalvewasunlocked,re-opened,lockedopened,andindependentlyverifiedlockedopen,within5minutesoffindingitclosed.Priortothisevent,thelasttimethepumpdischaxgevalvewasoperatedwasat1015onJune5,1989,toplacethe1Bdieselfueloiltankonrecirculation.Thiswasrequiredforachemistrysampleofthe1Bdieselfueloiltank.Althoughthevalvewasre-openedandlockedopenafterthesamplewascompleted,theclosingandre-openingofthevalvewasnotrecordedintheValveDeviationLoginaccordancewithAdministrativeProcedure1-0010123.Thevalve'slockedopenpositionwasverifiedindependentlyonJune7byautilitynon-licensedoperator,andonJune13byaQCInspector,whenthevalvestatuscheckofAdministrativeProcedure1-0020235Awasperformed.OnJune14,1989,thevalvewasfoundinthelockedclosedposition.CAUSEOFTHEVENTNofueloilsampleswexetakenandnomaintenancewasperformedonthedieselfueloilsystembetween1600onJune13,1989and1740onJune14,1989.OnlyOperationsDepartmentpersonnelhaveaccesstothevalvelockingdevicekey.Therefore,themostprobablerootcauseoftheeventwaspersonnelerrorbyautilitynon-licensedoperator.Afterinvestigation,theresponsibleindividualhasnotbeenidentified.AcontributingfactortotheeventwasthefailuretorecordtherepositioningofthevalveintheValveDeviationLog.NACFOAMSOFAIMSI CForm3SSAJILICENSEENTREPORT(LER)TEXTCONTINONU.S.NUCLEARREGULATORYCOMMISSIONAPPROVEDOMSNO.3150M(04EXPIRES:8/31/88IQCILITTNAME(llSt.LucieUnit1DOCKETNVMSER(3)YEARLERNVMSER(8)~$;SSOUSNTIAL.(NNUMSSRREVISIONNUMSSIIPACE(31TEXT/I/morotpocoitror/u/rorLutotr/I/I(/ooo///RC%%dnrr385l't/(171osooo33589-002-0003oF03ANALYSISOFTHEEVENTThiseventhasbeendeemedreportablepertherequirementsof10CFR50.73(a)(2)(i)(B),anyoperationorconditionprohibitedbytheplant'sTechnicalSpecifications.Sincethe1BDieselwasadministrativelyoutofserviceforaslongas25hours,thesurveillancerequirementsofTechnicalSpecification3.8.1.1.,whichrequiresthattheoperabilityoftheotherDieselbetestedwithin1hourandevery8hoursthereafter,shouldhavebeenperformed.However,thissurveillancewasnotdonebecausetheoperatorswerenotawareoftheoutofservicediesel.Eachemergencydieselisdesignedforfullpost-accidentloadoperationfor75minutesonthedaytanks.Thefueloiltransferpumpstartsandtheinletvalvetothedaytanksopensatadaytanklevelof23inches.Withthefueloiltransferpumpdischargevalveshut,thedieselgeneratorwouldstartifrequired.However,automaticmakeuptothedaytankwouldbeprevented,andthedaytanklevelwoulddecrease.Approximately39minuteslater,atalevelof11inchesinthedaytank,thelowlevelannunciatorwouldalerttheoperatorsoftheproblemlocallyandinthecontrolroom.Thiswouldleaveapproximately36minutestodispatchanoperatortotheareatolocate,unlock,andre-openthepumpdischargevalve.Sincetheemergencydieselwasavailabletoperformitssafetyfunction,thehealthandsafetyofthepublicwerenotaffectedbythisevent.CORRECTIVEACTIONS1)Operationspersonnelre-openedandlockedopenthevalve.2)TheOperationsSupervisorcounselledtheoperatorsontheimportanceof,andtheuseof,thevalvedeviationlog.ADDITIONALNFORMAON1.COMPONENTIDENTIFICATION2~Thiseventwasnotcausedbycomponentfailure.PREVIOUSSIMILAREVENTSForasimilarevent,seeLER5335-82-48,whichpertainstotheinoperabilityofthe1Adieselfueloilpumpduetovalvemispositioningbecauseofimproperrestorationfrommaintenance.NRCSORMSSSA(WA1}}
LER    89-002-00:on 890614,inoperability of 1B                                  diesel fuel oil sys caused by misaligned valve due                              to personnel            error.
W/8 DISTRIBUTION.CODE: IE22T          COPIES RECEIVED:LTR                       ~   ENCL    J        SIZE:.
TITLE:; 50.73/50.'9 Licensee Event. Report (LER), Incident" Rpt, etc.
NOTES RECIPIENT                  COPIES                            RECIPIENT                    COPIES ID  CODE/NAME              LTTR ENCL                      ID  CODE/NAME                LTTR ENCL PD2-2 LA                      1    1          PD2-2 PD                                      1      .1 NORRIS,J                      1    1                                                                            D INTERNAL: ACRS MICHELSON                  1    1        ACRS MOELLER                                  2      2            S ACRS WYLIE                    1    1        AEOD/DOA                                      1    .1 AEOD/DSP/TPAB                  1    1        AEOD/ROAB/DSP                                  2  '
DEDRO                          1    1          IRM/DCTS/DAB                                ~ 1      1-NRR/DEST/ADE 8H                1        I
                                                        ,NRR/DEST/ADS                    7E            1      0 NRR/DEST/CEB 8H                1    1        NRR/DEST/ESB                    8D            1.     1 NRR/DEST/ICSB 7                1    1        NRR/DEST/MEB                    9H            1      1 NRR/DEST/MTB      'H          1    1        NRR/DEST/PSB                    8D            1      1 NRR/DEST/RSB 8E                1    1        NRR/DEST/SGB                    8D            1      1 NRR/DLPQ/HFB 10            ,  1    1        NRR/DLPQ/PEB                    10            1      1 NRR/DOEA/EAB 11                1    1.        NRR/ REPQRPB                    10            2      2  ~
NUDOCS-ABSTRACT                1    1 1'
                                                                                        ~
02,           1.;    1 RES/DSIR/EIB                  1                              S/DSR PRAB                      1      1 RGN2        FILE. 01          1 EXTERNAL  EG&G  WILLIAMS S  P          4    4          FORD BLDG HOY P A                            1      1 L ST LOBBY      WARD          1    1          LPDR                                          1      1 NRC PDR                        1    1        NSIC MAYS,G                                    1      1            D NSIC MURPHY,G.A          I    1    1 h
D NOXK 'IO ALL nRZDSn RZCZE'ZENXS S
PIZASE HELP US KO REDUCE %MTEL CONZACZ 'IHE DOQlME&#xc3;Z CCRZRDL DESK, RXN P1-37 (EZZ. 20079)         m ELXKBQXS YOUR MNE HKH DISTRIHVTIGN.
IZSTS PDR      DOCUMERHB YOU DGN~T NEZDf FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR                                43  ENCL    , 42
 
ox14000, Juno Beach, FL 33408.0420 JULY. 1  4  19B9 L-89-242 10 CFR 50.73 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C.             20555 Gentlemen:
Re:   St. Lucie Unit          1 Docket No. 50-335 Reportable Event: 89-02 Date of Event: June 14, 1989 Misaligned Valve Caused Inoperability of the 1B Diesel Fuel Oil S stem Due to Personnel Error The  attached Licensee Event Report is being submitted pursuant to the requirements of 10 CFR 50.73 to provide notification of the subject event.
Very truly yours, O. Wood Acting  S    i r Vice President    Nuclear COW/JRH/cm Attachment cc:   Stewart D. Ebneter, Regional Administrator, Region Senior Resident Inspector, USNRC, St. Lucie Plant II, USNRC 14 p9072lg0 f 72 P907 0500033 PDR    PDOCK              PDC an FPL Group company
 
U.S. NUCLEAR REQULATORY COMMISSION RC Form 355 5'33)                                                                                                                                                       APPROVED OMS NO. 3150410e EXPIRES: 5/31/SS LICENSEE EVENT REPORT tLER DOCKET NUMBER (2)                              PA E FACILITY NAME (II 0    0    0 3          5        OF 0 St. Lucie Unit                                                                                                              0    5                                  1
"'""'Nisaligned                            1 Inoperability of the lB    D'l EVENT OATS ISI Valve Fuel      pil Caused S stem Due LKR NUMBER ISI to Personnel Error REPORT DATE It)                         OTHER FACILITIES INVOLVED I ~ I NNQUNNTIAI.                               OAY        YEAR            FACILITYHAM55                            DOCKET HUMBERIS)
MONTH        OAY      YEAR    YEAR              trUMNNR SzrP,. NUMNNA MONTH N/A                      0  5    0    0    0 0        614                      8 9            0 0        2 p        p    07          1    4 8 9                                                          0  5    0    0    0 THIS REPORT IS SUBMITTED PURSUANT T0 THK REOUIREMENTS OF 10 CFR gr /Chectt one or more                of the fo//orfinp/ 01 OPERATINO MOOt (Sl                    20A02(bl                                20AOB(el                              50.734)12) IN)                                  73.71(II)
    ~ OWER                          20AOB(elll  l(0                        SOM(cl(II                            50.734) (2 l(el                                 73.71(cl LEUEL (10 I      1    P P          20AOBIel(1) (Nl                        SOM(cl(2)                             50.7341(211rNI                                  OTHER /Specify in Aettrect Oe/ory enr/in Tert, Hf)C Form 20AOB(el(1 l(NO                    X    50.73lel(2)III                        50,734) l2) I cNI) (Al                          355l/
20AOB(e)(1)(N)                          50.73 Ie l(2) IN)                     50.73(el(2((r BI(IS) 20AOB  (e) II ) le)                    50.73lel(2) IN)                       50.73(e) l2 I I el LICKNSKE CONTACT FOR THIS LKR (12)
NAME                                                                                                                                                          TELEPHONE NUMBER AREA CODE Charles          D. Holifield, Shift Technical Advisor                                                                        40 74 65                          -355              0 COMPLETE OHK LINE SOll EACH COMPONENT FAILURE OKSCRISKD IH THIS REPORT 113)
MANUFAC.                                                                                        MANUFAC.           EPORTABL CAUSE      SYSTKM      COMPONENT                                                        y        f  CAUSE SYSTKM  COMPONENT TURER          TO NpROS    Ajar
:@4%.,YQ,     ... Stol TURER            TO HPRDS NUMEN                                                                                              %8~>$
SUPPLEMENTAL REPORT EXPECTED (1el                                                                                MONTH      OAY      YEAR EXPECTED SUBMISSION DATE II BI YES /lf yer, complete EXPECTED $ (/Sef/SS/OH DATE/                                 NO ABBTRAcT /Limit to teo0 rptcer, /.e., epproe/merely f/freon r/noreopece typewr/(ton lintel (15)
ABSTRACT On      June 14, 1989, at 1740, with Unit 1 in Mode 1 at 1004 power, a routine weekly valve status check was performed in accordance with a plant procedure which recpxires a valve position check of various emergency diesel system valves. While performing this valve status check, the 1B diesel fuel oil transfer pump discharge valve was found in the locked closed position. Although the 1B diesel was capable of starting and supplying post-accident loads during the event,           it    was administratively rendered out of service due to the inoperability of the 1B diesel fuel oil transfer pump, per Technical Specification 3.8.1.1.b.3. The most probable root cause of the mispositioned valve was personnel error by a utility non-licensed operator, though the responsible individual has not been identified. A contributing factor was the failure to record the mispositioned valve in the valve deviation log.
Corrective actions included re-opening and locking open the valve, and counseling the operators on the importance of, and the use of, the valve deviation log.
NRC Form 355 (5 03 I
 
C  Form 3SSA                                                                                                                U.S. NUCLEAR REOUI.ATORY COMMISSION 8 831 LICENSEE+NT                      REPORT (LERI TEXT CONTINUON                            APPROVED OMB NO. 3150WI04 EX PIR EB:   8/31/88 F CILITY NAME 111                                                                    DOCKET NUMBER I31              LER NUMBER (81                        PACE l31 YEAR:~<'EQUENTIAI' N UMS E A:.     'EViSION
                                                                                                                                        >1  rr U M S ~ A St. Lucie Unit                      1 o  s  o  o    o 3
89 00            2    00 02oF                      0 3 TEXT ///rrroro Epoco it o//rr'rod. Irw odd/rrorro/H//C Forrrr 38//AS / lI 3)
DESCR                  ION OF                  HE EVENT On      June 14, 1989, at 1740, with Unit 1 in Mode 1 at 100% power, a routine weekly emergency diesel system valve status check was performed by a utility non-licensed operator in accordance with Administrative Procedure 1-0010125A. While performing this valve status check, the 1B diesel fuel oil transfer pump discharge valve (EIIS:ISV) was found in the locked closed position.                                                                                 This administratively rendered the 1B diesel generator out of service, per Technical Specification 3.8.1.1.b.3. The valve was unlocked, re-opened, locked opened, and independently verified locked open, within 5 minutes of finding                                          it  closed.
Prior to this event, the last time the pump dischaxge valve was operated was at 1015 on June 5, 1989, to place the 1B diesel fuel oil tank on recirculation. This was required for a chemistry sample of the 1B diesel fuel oil tank. Although the valve was re-opened and locked open after the sample was completed, the closing and re-opening of the valve was not recorded in the Valve Deviation Log in accordance with Administrative Procedure 1-0010123.
The valve's locked open position was verified independently on June 7 by a utility non-licensed                                              operator, and on June 13 by a QC Inspector, when the valve status check of Administrative Procedure 1-0020235A was performed.
On        June            14,         1989,             the valve      was      found in the locked closed position.
CAUSE OF TH                          EVENT No      fuel          oil samples wexe taken and                              no maintenance was performed on the diesel fuel                                oil system between              1600 on June 13, 1989 and 1740 on June 14, 1989.                                     Only Operations Department personnel have access to the valve locking device key. Therefore, the most probable root cause of the event was personnel error by a utility non-licensed operator. After investigation, the responsible individual has not been identified.                                          A contributing factor to the event was the failure to record the repositioning of the valve in the Valve Deviation Log.
NAC FOAM SOFA IMSI
 
U.S. NUCLEAR REGULATORY COMMISSION C Form 3SSA JI                                        LICENSEE                    NT REPORT (LER) TEXT CONTIN        ON                    APPROVED OMS NO. 3150M(04 EXPIRES: 8/31/88 DOCKET NVMSER (3)                                                   PACE (31 I QCILITT NAME (ll                                                                                                  LER NVMSER (8)
YEAR  ~$
                                                                                                                  .(N
                                                                                                                      ; SSOUSNTIAL NUMSSR REVISION NUMSSII St. Lucie Unit                        1 33 589 0              0 2    0      0      0 3  oF    0 3 o  s  o  o    o TEXT /I/ moro tpoco it ror/u/rorL uto tr/I/I(/ooo///RC %%dnrr 385l't/ (171 ANALYSIS OF THE EVENT This event has been deemed reportable per the requirements of 10 CFR 50.73(a)(2)(i)(B), any operation or condition prohibited by the plant's Technical Specifications.                                                   Since the 1B Diesel was administratively out of service for as long as 25 hours, the surveillance requirements of Technical Specification 3.8.1.1.,
which requires that the operability of the other Diesel be tested within 1 hour and every 8 hours thereafter, should have been performed.                           However, this surveillance was not done because the operators were not aware of the out of service diesel.
Each emergency diesel is designed for full post-accident load operation for 75 minutes on the day tanks. The fuel oil transfer pump starts and the inlet valve to the day tanks opens at a day tank level of 23 inches. With the fuel oil transfer pump discharge valve shut, the diesel generator would start automatic makeup to the day tank would be prevented, and the day if  required. However, tank level would decrease.                                         Approximately 39 minutes later, at a level of 11 inches in the day tank, the low level annunciator would alert the operators of the problem locally and in the control room.
This would leave approximately 36 minutes to dispatch an operator to the area to locate, unlock, and re-open the pump discharge valve.
Since the emergency diesel was available to perform its safety function, the health and safety of the public were not affected by this event.
CORRECTIVE ACTIONS
: 1)             Operations personnel re-opened and locked open the valve.
: 2)             The Operations Supervisor counselled the operators on the importance of, and the use of, the valve deviation log.
ADDITIONAL NFORMA                                        ON
: 1.              COMPONENT                    IDENTIFICATION This event was not caused by component                                    failure.
2  ~           PREVIOUS SIMILAR EVENTS For        a  similar event, see LER 5335-82-48, which pertains to the inoperability of the 1A diesel fuel oil pump due to valve mispositioning because                                    of improper restoration                              from maintenance.
NRC SORM SSSA (WA1}}

Latest revision as of 21:59, 29 October 2019

LER 89-002-00:on 890614,diesel 1B Fuel Oil Transfer Pump Discharge Found in Locked Closed Position.Caused by Personnel Error by Util non-licensed Operator.Valve Reopened & Locked Open & Operators counseled.W/890714 Ltr
ML17223A229
Person / Time
Site: Saint Lucie NextEra Energy icon.png
Issue date: 07/14/1989
From: Holifield C, Woody C
FLORIDA POWER & LIGHT CO.
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
L-89-242, LER-89-002-03, LER-89-2-3, NUDOCS 8907250172
Download: ML17223A229 (5)
v • d • e


Text

REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR: 8907250172 DOC. DATE: 89/07/14 NOTARIZED: NO DOCKET N FACIL:50-335 St. Lucie Plant,'Unit 1, Florida Power & Light Co. 05000335 AUTH NAME ~ AUTHOR AFFILIATION HOL1FIELD,C.D. Florida Power & Light Co. L ~ 0" WOODY,C.O. Florida Power & Light R

= ~ RECIPIENT AFFILIATION Co.'ECIP.NAME I

SUBJECT:

LER 89-002-00:on 890614,inoperability of 1B diesel fuel oil sys caused by misaligned valve due to personnel error.

W/8 DISTRIBUTION.CODE: IE22T COPIES RECEIVED:LTR ~ ENCL J SIZE:.

TITLE:; 50.73/50.'9 Licensee Event. Report (LER), Incident" Rpt, etc.

NOTES RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-2 LA 1 1 PD2-2 PD 1 .1 NORRIS,J 1 1 D INTERNAL: ACRS MICHELSON 1 1 ACRS MOELLER 2 2 S ACRS WYLIE 1 1 AEOD/DOA 1 .1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DSP 2 '

DEDRO 1 1 IRM/DCTS/DAB ~ 1 1-NRR/DEST/ADE 8H 1 I

,NRR/DEST/ADS 7E 1 0 NRR/DEST/CEB 8H 1 1 NRR/DEST/ESB 8D 1. 1 NRR/DEST/ICSB 7 1 1 NRR/DEST/MEB 9H 1 1 NRR/DEST/MTB 'H 1 1 NRR/DEST/PSB 8D 1 1 NRR/DEST/RSB 8E 1 1 NRR/DEST/SGB 8D 1 1 NRR/DLPQ/HFB 10 , 1 1 NRR/DLPQ/PEB 10 1 1 NRR/DOEA/EAB 11 1 1. NRR/ REPQRPB 10 2 2 ~

NUDOCS-ABSTRACT 1 1 1'

~

02, 1.; 1 RES/DSIR/EIB 1 S/DSR PRAB 1 1 RGN2 FILE. 01 1 EXTERNAL EG&G WILLIAMS S P 4 4 FORD BLDG HOY P A 1 1 L ST LOBBY WARD 1 1 LPDR 1 1 NRC PDR 1 1 NSIC MAYS,G 1 1 D NSIC MURPHY,G.A I 1 1 h

D NOXK 'IO ALL nRZDSn RZCZE'ZENXS S

PIZASE HELP US KO REDUCE %MTEL CONZACZ 'IHE DOQlMEÃZ CCRZRDL DESK, RXN P1-37 (EZZ. 20079) m ELXKBQXS YOUR MNE HKH DISTRIHVTIGN.

IZSTS PDR DOCUMERHB YOU DGN~T NEZDf FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 43 ENCL , 42

ox14000, Juno Beach, FL 33408.0420 JULY. 1 4 19B9 L-89-242 10 CFR 50.73 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555 Gentlemen:

Re: St. Lucie Unit 1 Docket No. 50-335 Reportable Event: 89-02 Date of Event: June 14, 1989 Misaligned Valve Caused Inoperability of the 1B Diesel Fuel Oil S stem Due to Personnel Error The attached Licensee Event Report is being submitted pursuant to the requirements of 10 CFR 50.73 to provide notification of the subject event.

Very truly yours, O. Wood Acting S i r Vice President Nuclear COW/JRH/cm Attachment cc: Stewart D. Ebneter, Regional Administrator, Region Senior Resident Inspector, USNRC, St. Lucie Plant II, USNRC 14 p9072lg0 f 72 P907 0500033 PDR PDOCK PDC an FPL Group company

U.S. NUCLEAR REQULATORY COMMISSION RC Form 355 5'33) APPROVED OMS NO. 3150410e EXPIRES: 5/31/SS LICENSEE EVENT REPORT tLER DOCKET NUMBER (2) PA E FACILITY NAME (II 0 0 0 3 5 OF 0 St. Lucie Unit 0 5 1

"'""'Nisaligned 1 Inoperability of the lB D'l EVENT OATS ISI Valve Fuel pil Caused S stem Due LKR NUMBER ISI to Personnel Error REPORT DATE It) OTHER FACILITIES INVOLVED I ~ I NNQUNNTIAI. OAY YEAR FACILITYHAM55 DOCKET HUMBERIS)

MONTH OAY YEAR YEAR trUMNNR SzrP,. NUMNNA MONTH N/A 0 5 0 0 0 0 614 8 9 0 0 2 p p 07 1 4 8 9 0 5 0 0 0 THIS REPORT IS SUBMITTED PURSUANT T0 THK REOUIREMENTS OF 10 CFR gr /Chectt one or more of the fo//orfinp/ 01 OPERATINO MOOt (Sl 20A02(bl 20AOB(el 50.734)12) IN) 73.71(II)

~ OWER 20AOB(elll l(0 SOM(cl(II 50.734) (2 l(el 73.71(cl LEUEL (10 I 1 P P 20AOBIel(1) (Nl SOM(cl(2) 50.7341(211rNI OTHER /Specify in Aettrect Oe/ory enr/in Tert, Hf)C Form 20AOB(el(1 l(NO X 50.73lel(2)III 50,734) l2) I cNI) (Al 355l/

20AOB(e)(1)(N) 50.73 Ie l(2) IN) 50.73(el(2((r BI(IS) 20AOB (e) II ) le) 50.73lel(2) IN) 50.73(e) l2 I I el LICKNSKE CONTACT FOR THIS LKR (12)

NAME TELEPHONE NUMBER AREA CODE Charles D. Holifield, Shift Technical Advisor 40 74 65 -355 0 COMPLETE OHK LINE SOll EACH COMPONENT FAILURE OKSCRISKD IH THIS REPORT 113)

MANUFAC. MANUFAC. EPORTABL CAUSE SYSTKM COMPONENT y f CAUSE SYSTKM COMPONENT TURER TO NpROS Ajar

@4%.,YQ, ... Stol TURER TO HPRDS NUMEN %8~>$

SUPPLEMENTAL REPORT EXPECTED (1el MONTH OAY YEAR EXPECTED SUBMISSION DATE II BI YES /lf yer, complete EXPECTED $ (/Sef/SS/OH DATE/ NO ABBTRAcT /Limit to teo0 rptcer, /.e., epproe/merely f/freon r/noreopece typewr/(ton lintel (15)

ABSTRACT On June 14, 1989, at 1740, with Unit 1 in Mode 1 at 1004 power, a routine weekly valve status check was performed in accordance with a plant procedure which recpxires a valve position check of various emergency diesel system valves. While performing this valve status check, the 1B diesel fuel oil transfer pump discharge valve was found in the locked closed position. Although the 1B diesel was capable of starting and supplying post-accident loads during the event, it was administratively rendered out of service due to the inoperability of the 1B diesel fuel oil transfer pump, per Technical Specification 3.8.1.1.b.3. The most probable root cause of the mispositioned valve was personnel error by a utility non-licensed operator, though the responsible individual has not been identified. A contributing factor was the failure to record the mispositioned valve in the valve deviation log.

Corrective actions included re-opening and locking open the valve, and counseling the operators on the importance of, and the use of, the valve deviation log.

NRC Form 355 (5 03 I

C Form 3SSA U.S. NUCLEAR REOUI.ATORY COMMISSION 8 831 LICENSEE+NT REPORT (LERI TEXT CONTINUON APPROVED OMB NO. 3150WI04 EX PIR EB: 8/31/88 F CILITY NAME 111 DOCKET NUMBER I31 LER NUMBER (81 PACE l31 YEAR:~<'EQUENTIAI' N UMS E A:. 'EViSION

>1 rr U M S ~ A St. Lucie Unit 1 o s o o o 3

89 00 2 00 02oF 0 3 TEXT ///rrroro Epoco it o//rr'rod. Irw odd/rrorro/H//C Forrrr 38//AS / lI 3)

DESCR ION OF HE EVENT On June 14, 1989, at 1740, with Unit 1 in Mode 1 at 100% power, a routine weekly emergency diesel system valve status check was performed by a utility non-licensed operator in accordance with Administrative Procedure 1-0010125A. While performing this valve status check, the 1B diesel fuel oil transfer pump discharge valve (EIIS:ISV) was found in the locked closed position. This administratively rendered the 1B diesel generator out of service, per Technical Specification 3.8.1.1.b.3. The valve was unlocked, re-opened, locked opened, and independently verified locked open, within 5 minutes of finding it closed.

Prior to this event, the last time the pump dischaxge valve was operated was at 1015 on June 5, 1989, to place the 1B diesel fuel oil tank on recirculation. This was required for a chemistry sample of the 1B diesel fuel oil tank. Although the valve was re-opened and locked open after the sample was completed, the closing and re-opening of the valve was not recorded in the Valve Deviation Log in accordance with Administrative Procedure 1-0010123.

The valve's locked open position was verified independently on June 7 by a utility non-licensed operator, and on June 13 by a QC Inspector, when the valve status check of Administrative Procedure 1-0020235A was performed.

On June 14, 1989, the valve was found in the locked closed position.

CAUSE OF TH EVENT No fuel oil samples wexe taken and no maintenance was performed on the diesel fuel oil system between 1600 on June 13, 1989 and 1740 on June 14, 1989. Only Operations Department personnel have access to the valve locking device key. Therefore, the most probable root cause of the event was personnel error by a utility non-licensed operator. After investigation, the responsible individual has not been identified. A contributing factor to the event was the failure to record the repositioning of the valve in the Valve Deviation Log.

NAC FOAM SOFA IMSI

U.S. NUCLEAR REGULATORY COMMISSION C Form 3SSA JI LICENSEE NT REPORT (LER) TEXT CONTIN ON APPROVED OMS NO. 3150M(04 EXPIRES: 8/31/88 DOCKET NVMSER (3) PACE (31 I QCILITT NAME (ll LER NVMSER (8)

YEAR ~$

.(N

SSOUSNTIAL NUMSSR REVISION NUMSSII St. Lucie Unit 1 33 589 0 0 2 0 0 0 3 oF 0 3 o s o o o TEXT /I/ moro tpoco it ror/u/rorL uto tr/I/I(/ooo///RC %%dnrr 385l't/ (171 ANALYSIS OF THE EVENT This event has been deemed reportable per the requirements of 10 CFR 50.73(a)(2)(i)(B), any operation or condition prohibited by the plant's Technical Specifications. Since the 1B Diesel was administratively out of service for as long as 25 hours2.893519e-4 days <br />0.00694 hours <br />4.133598e-5 weeks <br />9.5125e-6 months <br />, the surveillance requirements of Technical Specification 3.8.1.1.,

which requires that the operability of the other Diesel be tested within 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> and every 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> thereafter, should have been performed. However, this surveillance was not done because the operators were not aware of the out of service diesel.

Each emergency diesel is designed for full post-accident load operation for 75 minutes on the day tanks. The fuel oil transfer pump starts and the inlet valve to the day tanks opens at a day tank level of 23 inches. With the fuel oil transfer pump discharge valve shut, the diesel generator would start automatic makeup to the day tank would be prevented, and the day if required. However, tank level would decrease. Approximately 39 minutes later, at a level of 11 inches in the day tank, the low level annunciator would alert the operators of the problem locally and in the control room.

This would leave approximately 36 minutes to dispatch an operator to the area to locate, unlock, and re-open the pump discharge valve.

Since the emergency diesel was available to perform its safety function, the health and safety of the public were not affected by this event.

CORRECTIVE ACTIONS

1) Operations personnel re-opened and locked open the valve.
2) The Operations Supervisor counselled the operators on the importance of, and the use of, the valve deviation log.

ADDITIONAL NFORMA ON

1. COMPONENT IDENTIFICATION This event was not caused by component failure.

2 ~ PREVIOUS SIMILAR EVENTS For a similar event, see LER 5335-82-48, which pertains to the inoperability of the 1A diesel fuel oil pump due to valve mispositioning because of improper restoration from maintenance.

NRC SORM SSSA (WA1

Retrieved from "https://kanterella.com/w/index.php?title=ML17223A229&oldid=2003155"