ML17221A626

LER 87-012-01:on 870609,loss of Component Cooling Water Redundancy Occurred Because of Crosstie Valves Being in Open Position.Caused by Personnel Error.Operator Performed Valve Alignment Verification & Closed valves.W/880209 Ltr

ML17221A626
Person / Time
Site:	Saint Lucie
Issue date:	02/09/1988
From:	Mendoza V, Woody C FLORIDA POWER & LIGHT CO.
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
L-88-44, LER-87-012-01, LER-87-12-1, NUDOCS 8802170141
Download: ML17221A626 (6)

Text

REGULATOR I li<FORMATIGN DISTRIBUTION STBTEM (RIDS)

ACCESSION NBR: 8802170141 DQC. DATE: 88/02/09 NOTARIZED: NO DOCKET FACIL: 50-335 Bt. Lucie Plant Unit 1 ~ Florida Poeer 5 Light Co. 05000335 AUTH. NAME AUTHOR AFF ILI AT ION MENDOZA V N. Flor ida Poeer 8: Light Co.

WOQDYI C. Q. Florida Poeer 5 Light Co.

REC IP. NAME RECIPIENT AFF ILI AT I C}N

SUBJECT:

LER 87-012-01: on 870609'oss oF component cooling eater r edundancg occurred because oF cr osstie valves being in open position. Caused bg personnel error. Close valves. Valve V-14169 estored to locked position. W/880209 ltr.

I DISTR IBUTIOli CODE: IE22D COPIES RECEIVED: LTR i ENCL TITLE; 50, 73 Licensee Event RepoT t (LER) i Incident Rpti etc.

L SIZE:

iNOTES:

REC)P I ENT CGP IES REC IP IENT COPIES ID CODE))NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD '-" LA 1 1 PD2-2 PD 1 TOUR I GNY E 1 1 INTERNAL: ACRS MICHE'LSON 1 ACRS MOELLER 2 2 AEQD/DQA 1 AEOD/DSP/NAS 1 1 AEOD/DSP/ROAB 2 2 AEOD/DSP/TPAH 1 1 ARt'l/DCTS/DAB 1 1 DEDRO 1 1 NRR/DEST/ADS 1 0 NRR/DEBT/CEH 1 1 iRR/DEST/>>LB 1 1 NRR/DEST/ICSH NRR/DEST/t'!EB 1 ERR/DEST/MTB 1 1 NRR/DEST/PSB 1 NRR/DEST/RSB 1 NRR/DEST/SGB 1 1 ERR/DLPG/HFB 1 NRR/DLPG/GAB 1 ERR/DQEA/E*3 1 NRR/DREP/R*B 1 1 ERR/DREP/RPB 2 2 N / ~ SIB ] NRR/PMAS/ ILRB 1 1 REt= F ILF 02 RES TELFQRD, J RES DE/E IB RES/DRPS DIR 1 RGN2 F lLE 0' EXTERNAL: EGhG GRGH.l". 5 5 FORD BLDG HOYi A 1 1 H ST LOBBY WARD 1 LPDR 1 1 NRC PDR 1 NSIC HARB ISr J 1 1 NSIC MAYS~ G 1 1 TOTAL NUMBER OF COPIES REGUIPED: LTTR 46 ENCL 45

NiC Ferro 366 U.S. NUCLEAR REGULATORY COMMiSSIQN iv 83i APPAOVED OMB NO 31500)04 LICENSEE EVENT REPORT (LER) EXPIRES 8 31 88 FACILI'TY NAME DOCKET NUMBER (2) PAGE I3i Il 111 St. Lucie Unit o 5 o o o 335 ioF04 LOSS OF COMPONENT COOLING WATER REDUNDANCY BECAUSE OF CROSSTIE VALVES BEING IN THE OPEN POSITION DUE TO PERSONNEL ERROR.

EVENT DATE IS> LEA NUMBER I61 REPORT DATE (7) OTHER FACILITIES INVOLVED IS)

MONTH QAY YEAR YEAR SEOVS!VTIAL R'Y~~ MOI TH OAV YEAR FACILITY 4AMFS DOCKET IIVMBERISI 4VMOEA NUMBER N/A 0 5 0 0 0 0 6 0 9 8 7 8 7 012 01 0 209 88 0 5 0 0 0 THIS REPORT IS SUBMIT'TED PURSUANT T 0 THE REQUIREMENTS OF 10 CFR $ : (Chef>> One Or molt Of the ferrew nPl (11 OPERATINO MODE I ~ ) 20.402(O) 20.405(c) S0.73(e l(2) (iv) 73.71IOI POWER 20.405( ~ l(1)(il 50.36(c1 I) I S0.73( ~ )(2)(v) 73.71(cl LEYEL 001 1 0 0 20.405(e l(l) I 61 50.36(cl(21 50,73( ~ I(2)(viil OTHER lSoecifv'r'oltrett oeiow end rn Ter t NRC Form 20.408( ~ Ill)(iii) 50.73( ~ l(21(il 50 73( ~ ) 121(viiil(AI 366A) 20.405 ( ~ 111 I liv) 50.73(el(21( ~ ) S0.7 3 I ~ 1(21(w 6 I (81

20. 405 ( ~ I (1 I (el 50.73( ~ I(21(iiil S0.73( ~ I(21(hl LICENSEE CONTACT FOA THIS LER (121 NAME TELEO"ONE NUMBER AREA CODE Victor N. Mendoza, Shift Technical Advisor 0 5 4 6 5 " 3 5 5 0 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (131 MANUFAC. EPQRTABLE CQMPQIIEhrT M A hl ' F A C r EPORTABLE CAUSE SYSTEM CQMPQNENT TVREA TO NPRDS CAUSE SYS EM TVRER TO NORDS SUPPLEMENTAL REPORT EXPECTED I141 EXPECTED VO'P 'EAO SUBMISSION DATE i)5 YES llf yeA comofete ff(PECTEO SVBMISSIOhlDAFEI 40 ABSTRACT fdrrnH to (400 IoeceA I ~ .. eooroerrnetefy fifteen Irnpi ~ .Ioete tyoewnNen hrNI (16)

ABSTRACT On June 19, 1987, St. Lucie Unit Il was in Mode 1, 100% power, and at steady state conditions. All control stations were in normal operating mode. At 0124 hours0.00144 days <br />0.0344 hours <br />2.050265e-4 weeks <br />4.7182e-5 months <br />, the Reactor Control Operator (RCO) was performing a monthly pump surveillance run for the 1B component cooling water (CCW) pump. During this surveillance run, it was discovered that the 1A and 1B CCW heat exchanger outlet cross-tie valves were in the open position. The position for these valves is normally closed. The operator immediately performed a valve alignment verification and closed the valves. The root cause of the event was a cognitive personnel error by utility licensed operators who failed to have proper adminis-trative control on these valves. The immediate corrective action was to close the valves. The event was terminated at 0130 hours0.0015 days <br />0.0361 hours <br />2.149471e-4 weeks <br />4.9465e-5 months <br />. No other system malfunction resulted from this event. This event is reportable under the code of federal regulations 10 CFR 50.73 (a) (2) (i) (B), "Any event or condition prohibited by plant's technical specifications".

8802>70141 88020+ 85000+35 0

PDR ADOCH PDR 8

NRC Fornr 366 r9 8)

NRC Eorm 368A U.S. NUCLEAR REGULATORY COMMISSION IS 831 LICENSEE EVENT REPORT (LER) TEXT CONTINUATION *PPROYEO OMS VO 3150-0104 EXPIRES I 8r 31 I 88 PACILITrY NAME III OOCKET NUMBER 12) LER NUMBER (61 PAGE I3I YEAR O SEGUENTrAL R E Y rS r 0 rr NUNSER NUNISE R St. Lucie Unit 41 0 so oo33 587 0 1 2 0 1 0 2 OF 0 TEXT lllrrhoro spsspis rsohrhroc. rhss scchthorrsl lVRC iorrn 36SA'si I IT)

DESCRIPTION OF EVENT On June 19, 1987, St. Lucie Unit Il was in Node 1, 100% power, and at steady state conditions. At 0124 hours0.00144 days <br />0.0344 hours <br />2.050265e-4 weeks <br />4.7182e-5 months <br />, the Reactor Control Operator (RCO) was performing a monthly pump surveillance run for the 1B component cooling water (CCW) (EIIS:CC) pump. The 1B CCW pump discharge valve was throttled to obtain 4000 GPN flow on the "B" header, as required by the procedure. As the valve was throttled, the RCO noticed that the "A" header flow was also decreasing concurrent with the RBR header. The RCO notified the Assistant Nuclear Plant Supervisor (ANPS) and the ANPS immediately instructed the Nuclear Operator to perform a valve alignment verification. During this verification, it was discovered that the 1A and 1B CCW heat exchanger outlet cross-tie valves V-14169 (which is a normally locked closed valve) and V-14439 (which is a normally closed valve) were in the open position. Both valves were then immediately closed and independently verified to be closed. The normal CCW valve alignment was restored to its normal operations line-up. The pump surveillance run was then resumed and noted as satisfactory. No other abnormalities in the system were noted after the restoration of the CCW system valve alignment. The event was terminated at 0130 on June 19, 1987. No other system malfunctions were observed during the entire event.

CAUSE OF THE EVENT On June 8, 1987, the lB CCW heat exchanger was scheduled for repairs. A clearance was issued for all valves and related equipment required to isolate the lB CCW heat exchanger. The cross-tie valves V-14169 (which is normally locked closed) and V-14439 (which is normally closed) were opened to allow both the "A" and "B" trains of the CCW system (EIIS:CC) to be in service while the 1B CCW heat exchanger was being repaired. Neither of the cross-tie valves were listed on the clearance. The utility licensed operator in charge of reviewing the clearance prior to issuance decided not to include these valves in the clearance as these valves were not required for maintenance boundary isolation.

He opted to administratively control valve V-14169 by listing this valve in the locked valve deviation log as being in the open position. However, the locked valve deviation log was not reviewed by operations personnel. Thus, it was not noted in the clearance that valves V-14169 and V-14489 were not in their normal closed positions. After the repairs to the heat, exchanger were completed on June 9, 1987, all the valves and related equipment on the clearance were released and independently verified as being restored to the required operating positions. Since valves V-14169 and V-14439 were not listed on the clearance, they were not restored to their normal position as part of the clearance release process, nor was independent verification called for.

NRC FOR@I 348A 184131

U.S. NUCLEAR REGULATORY COMMISSION NRC Form 366A I9 BSI UCENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVED OMB 40 3160m3IDE EXPIRES. BI3'I 'BB FACILITY NAME II) DOCKET NUMBER l3) LER NUMBER I6I PAGE l31 YEAR SEOVENTIAL REVrSIO4 NUMBER NVMBEA St. Lucie Unit 61 o 5 o o o 33 58 7 012 0 0 3 OF 0 TEXT llfmont totoo rt ntovrntd, vtt tddroorrtl IVIIC Form 3664'tl IIT)

The root cause of the event was cognitive personnel error by utility licensed-operators who failed to have proper administrative control on valves that were positioned in other than their normal operating positions. There were no unusual characteristics of the work location that directly contributed to this event.

Procedure deficiencies were a contributing factor. Although all actions were justifiable per procedure, the event showed problems with using the locked

'valve deviation log as an alternate method.

ANALYSIS OF THE EVENT The event is reportable under 10 CFR 50.73(a)(2)(i)(B), "Any event or condition prohibited by the plant's technical specifications". Technical Specification 3.7.3 ' requires "at least two independent component cooling water loops shall be operable".

This event resulted in a loss of component cooling system (EIIS:CC) redundancy.

However, the loss of redundancy was discovered within 10 days during performance of a routine monthly surveillance. Redundancy was completely restored within six (6) minutes of discovery. There were no other abnormalities in the system during the event. All plant safety functions were met throughout this event.

At no time during this event was the health and safety of the public endangered.

Additional actions taken included the following: 1) review of and changes to the clearance and administrative control of valves procedures, 2) review of and changes to the frequency of review of the locked valve deviation log, 3) research of previous similar out of service conditions to determine if the problem had occurred before, 4) a failure modes and effects analysis (FLEA) for the system, and 5) review of the effect of the changed system configuration on the effectiveness of the CCW to perform its design function. The PMEA showed that there is no limiting single active failure for the system in this configurations However, a passive failure (pipe rupture) was identified. The effectiveness of the CCW system to perform its function with the cross-tie open versus the cross-tie closed would not significantly change since the reliability of the system in either configuration would be dominated by the active component failures (i.e. pumps and valves).

~ rtlC FOR4r 368A I94ISI

NRC <<>Im 366A U,S. NUCLEAR REGULATORY COMMISSION (9 83(

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVEO OMB NO 3(SO OIO4 EXPIRES: 8/31(88 FACILITY NAME ((l OOCKET NUMBER (2( LER NUMBER (61 PAGE (31 YEAR SEGUENTIAL REVISION NUMBER NUMBER St. Lucie Unit 81 3 3 8 7 0 1 2 01 04 OF 04 0 5 o o o TEXT (lfmoIP 4P444 I4 mdIIddd. IIM PddIIdmd( NRC Fdtm 36SA'4( (ln CORRECTIVE ACTIONS

1. Valve V-14169 was restored to its locked closed position and valve V-14439 was closed. Independent verification of valve proper position was performed.

2. The plant training group will evaluate this item to determine appropriate training requirements and methods.

3. The responsible supervisor has been instructed to include these valves in future clearances to ensure restoration.

4. Procedures were modified to require all valves repositioned to be on the clearance form.

5. The frequency of review of the locked valve deviation log was increased.

6. Research on historical data showed that these valves had been included on the clearance form, and this appeared to be the first time that the locked valve deviation log had been used as an alternate method.

ADDITIONAL INFORMATION Failed component identification: There were no failed components during this event.

PREVIOUS SIMILAR EVENT See LER N335-85-02 for a previous valve mispositioning event.

~ IRC FORM 366A (94(3l

P. O. BOX, JUNO BEACH, PL 33408 0420 FEgRggy 9 L-88-44 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: 87-12 Revision 1 Date of Event: June 9, 1987 Loss of Component Cooling Water Redundancy Because of Crosstie Valves Being in the 0 en Position Due to Personnel Error The attached Licensee Event Report (LER) is being submitted pursuant to the requirements of 10 CFR 50.73 to provide an update on the subject event.

Very truly yours,

, gag, r+cX C. 0.

Execu 'ice President Woo COW/GRM/gp Attachment cc: Dr. J. Nelson Grace, Regional Administrator, Region II, USNRC Senior Resident Inspector, USNRC, St. Lucie Plant an FPL Group company