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| issue date = 12/18/1978
| issue date = 12/18/1978
| title = LER 78-037/01T-1 on 780919:during Sys Insp,Class I Longitudinal Braces on Auxiliary Bldg Ventilation Ducts Were Found Missing.Caused by Unique Combination of Personnel Errors
| title = LER 78-037/01T-1 on 780919:during Sys Insp,Class I Longitudinal Braces on Auxiliary Bldg Ventilation Ducts Were Found Missing.Caused by Unique Combination of Personnel Errors
| author name = SIEBE A
| author name = Siebe A
| author affiliation = FLORIDA POWER & LIGHT CO.
| author affiliation = FLORIDA POWER & LIGHT CO.
| addressee name =  
| addressee name =  
Line 17: Line 17:


=Text=
=Text=
{{#Wiki_filter:UPOATEREPORT0PREVIOUSREPORTDATEOCTOBER2,1978V*NUCLLLRRSCVLATCRV CuNllSSIQN NRCPORM$$4ITTT)LlCEWSE=EVEbl7REIOQRTCCNTRQlSLCCIEIIlrIIQl(PL~0PAINTQRTVPS'ALLRSCUIRKO INPCIRRIATTQN)
{{#Wiki_filter:UPOATE REPORT PREVIOUS REPORT DATE 0
I~l39ucauaatcQQS0$uc<<u54NUMssil15MLLCSN$4TYPSJO$7<<Ai54O~O..OCON'TXQl".::.LJS'''''O~OILLllIS34441QOCXar'IIJMS4AavaNTQ*ra 1$75ASPQATOATS34PIZNTQSSCRIPTICN ANQP.t4$44LKCQNSZCLISNCZS QIQ~02Durin'ssteminsctions66ClassILonitudinalBracesontheRAB~03Ventilation Ductswerefoundtobemissing.Radialrestraints areonlyrequiredintheeventofaLOCA.Anengineering evaluation byourAEindicates thatrestraints existingatthetimeof;theoccurrence were~oa'roerlinstalled.
OCTOBER          2, 1978 N RC PORM $ $ 4                                                                                                                        V *NUCLLLRRSCVLATCRV C uNllSSIQN IT TT)
Theaffectedsaferelatedventilation sstemsarecapableofsustaining theadditional loadsduring"adesignbasisseismic~oaevent34149SYSTKMCA454CA454val.vaCQ04COOS$4SC04ccMNQNSN'rcd04$44CQCS$4$0005~$I<<$L'JS.~$LNSLNS74914III'111'1$1953CUSNTI*I-OCCUAASNCK ASPOATASVISIONLSAIAQAEPOATNOCOOS"TYPS~PIOOniinrii~78~~037~~~01~T~~111111$1427'13191411ACTIONiPUTUASSPPSC044TQOWN*T.ACNMSN1'PROA)AIMSC<<LuS.CQMPCNENTTANSN*CTIONCvPLANTuST7100AQUASQ22$4SMITTSOSCAMNUS.$4PPLISR,uANUPAiUASRInSLISLLSLJS''n-ISLJS<$LANL'-'$113$14SI$131CAUMOESCRIPTIQN ANOCQRRScrlve*cnQNS 0220Aiuco.'tionoferrorsandweaknesses inconstruction administra-..
LlCEWSE= EVEbl7 REIOQRT O~O..
tionandqualityassurance allowedtheomissiontooccur.Installation oftheprev'iously'missing bracesinPSL-lwascompleted onOctober5,1978,~I2andactionstopreventsimilaroccurrences onPSL-2havebeenidentified forimplementation.
CCNTRQl SLCCIEI                          I      l    r    I      I Ql                (PL~0        PAINT QR TVPS'ALLRSCUIRKO INPCIRRIATTQN)
49PACIUTYSTATUSSR7OTHSRSTATUS~CQQISPZCIAL5TSMH%'hI 0<<2+4LOCATIONOPASLSA$4026NA4$+57311111L~CPCRQAMACS0PACIUTY0~.YPS<<SLBIPTICN EKLSJG2aa'oAUdue:m0~l~ma9IoNANACLSP.CNLVdapuoNS{305~5523958NANAAISCPPASPARSR0LJS~$~aIOI'111$$ACTIVITYCONTaur<SLCA$40QPASLSASSAMOUNTQPACTIYITV026~ZQ22fZtQNA13IO11PEASONNSLSXSOSUASS L000<<00IQgrI~ZQS[Illn711I211$$ASCNNSLIN14PIaiuLMSSA<<$$mINTION~AI
I
~iliLL01010l&<<NAaoV901080'4(
                ~l                                      0$                                                                                                                         O CON'T XQl 3
REPORTABLE OCCURRENCE 335-78-37 Rev.lLICENSEEEVENTREPORTPAGETWOAdditional EventDescrition.Thesysteminspections werebeingconducted toverifyplant"asbuilt"designdrawings.
3 9        ucauaat
Thea'ffected safetyrelatedsystems,Control,RoomVentilation, Emergency CoreCoolingSystemsAreaVentilation (including portionsoftheReactorAuxiliary Building-Ventilation supplysystem),andShieldBuilding.
                      ".::. LJS 44 cQQS 41 PIZNTQSSCRIPTICN ANQ P.t4$ 44LK CQNSZCLISNCZS QOCX ar 'IIJMS 4 A QIQ
Ventilation are.onlyrequiredintheeventofa.LOCA.Inorderforthemtopossiblyfailtofulfilltheirfunctions anearthquake wouldalsohavetooccurTheprobability ofthesetwoeventsoccurring in'henearfutureisextremely lowAnengineering evaluation performed bytheAEhasdetermined thattheventilation ductrestraint systemexistingatthe.time'oftheoccurrence, onthesafetyrelatedsysteminquestionwascapableofsustaining theadditional loadsimposeduponitduetotheabsenceofthe66missinglongitudinal bracesduringadesignbasisseismicevent.Otherventilation systemsincontainment andshieldbuildingdonotrequirethelongitudinal bracessoarenotaconcern.Additional CauseDescritionandCorrective Action'ehaveconcluded thatauniquecombination offactorsinvolvedinthecontracting, dxawingsandqualitycontrol.for.theseventilation bracesresultedintheirnotbeinginstalled asrequired.
                                                                                                  'O~OI LLllIS uc<<u54 NUMssil avaNTQ*ra 15      M 1$
Adescription ofthecircumstances isasfollows:a.ItwasnotuntillateintotheSt;LucieUnit1projectthattheventilation systeminstaller, anindependen" contractor, wastobeassignedtheadditional scopeofworkofinstalling thepermanent restraints andbracesforventilation systemducting,whichincludedthe66bracesinquestion.
LLCSN$ 4 TYPS 75 JO ASPQAT OATS
Acommunication errorbetweentheAEandtheventilation systeminstaller apparently contributed totheinstaller notincluding these66bracesontheinstallation
                                                                                                                                                                        $7  <<Ai  54 34
: drawings, eventhoughthesebracesappearedontheArchitect-Engineer's (A-E's)designengineering drawingswhichwereusedasasourcefortheinstallation drawings.
~02                Durin 's stem ins                                ctions            66    Class        I Lon        itudinal            Braces on the                RAB
b.Theinstaller wasalsoresponsible forthequalitycon~1inspections associated withtheventilation systeminstallation; consequently the"as-built"
~03              Ventilation Ducts were found to be missing. Radial restraints are
.condition wasinspected totheinstallation
~oa                'ro erl installed. The affected safe                                                              related ventilation s stems are only required in the event of a LOCA. An engineering evaluation by our AE indicates that restraints existing at the time of;the occurrence were
: drawings, which,asnotedabove,didnotincludethese66braces.Hadtheventilation systembeeninspected byourA-E'sQC,whodidmostoftheotherinspecting, orhadtheinstaller usedtheA-E'sdesigndrawingsforinspec-tion,themissingbracesprobablywouldhavebeenidentified duringtheconstruction phase.
                                                                                                ~$
REPORTMKE OCCURRENCE 335-78-37 Rev.1LICENSEEEVENTREPORTPAGETHREEAdditional CauseDescritionandCorrective Action(continued)
capable of sustaining the additional loads during"a design basis seismic
Althoughtherewereseveralothercontractors participating intheSt.LucieUnit1constzuction whoperformed theirownqualitycontrol,ithasbeendetermined that.noneofthesecontractors usedotherthandesigndrawingsforinstallations andinspections.
~oa               event
Installation ofthepreviously missingbracesinPSL-1was.completed onOctober5,1978.Measuresarebeingestablished topreventasimilaromissionfromoccurring onourStLucieUnit2.Thesemeasuresinclude=aMoreeffective comparison ofinstallation drawingsagainstdesigndrawingsforaccuracyand.completeness priortositeapprovalofinstallation drawings.
                                  ~$ I<<$
bPezforming awalkdownbyPPLQualityContxolpersonnel ofseismicduct.supportstoverifythatthe"as-built" isinaccordance withthedesigndrawings}}
1        4 9                                                                                                                                                                            34 SYSTKM                CA454          CA454 CQ04                COOS          $ 4SC    04              ccMNQN SN'r cd 0 4 val.va
                                                                                                                                          $ 44CQCS         $ 4$ 0005 7        4                        9            14            II L'JS.
I'1              11                              '1$
LNS LNS 19 53CUSNTI*I-                           OCCUAASNCK
                                                              ~
ASPOAT                    A SVI SION
                                                                                                                                                                ~
AEPOATNO                                              "
LSAIAQ                                                                                              COOS On        iinr ii~78                                           ~03          7          ~~               ~01                   ~T TYPS    ~
PIO
                                                                                                                                                                            ~1 11          11                          1$               14      27              '13        19          14
                                                                                                              *T ACNMSN 1'PR OA 11 ACTIONi PUTUAS                  SPPSC            044TQOWN                                                                            )AIMS
                                                                                                                  .                                        C<<LuS.         CQMPCN EN T TANSN *CTION                  Cv PLANT              uST7100                                                                              4PPLISR, AQUAS Q22          4SMITTSO          SCAM NUS.
InSLIS LLS LJS
                                                                                                                $                                      $                 uANUPA iUASR 11          3$                                       14 n-IS LJS SI                $1 LANL'           31 CAUM OESCRIPTIQN ANO                  CQRRScrlve*cnQNS                 022 0          A        i u co. 'tion of errors                                            and weaknesses                    in construction administra-..
                                                        ~
tion and quality assurance allowed the omission to occur. Installation
~I2              of the prev'iously'missing braces in PSL-l was completed on October 5,1978, and actions to prevent similar occurrences on PSL-2 have been identified for implementation.
7 a
4    9 PACIUTY STATUS LJS ACTIVITY CON Taur
                              ~$
IO
          <SLCA$ 40 QP ASLSASS SR I'1      11 OTH SR STATUS AMOUNTQP ACTIYITV026 0
                                                                                                  ~CQQI
                                                                                                  +4 SPZCIAL 5TSMH%'hI LOCATION OP ASLSA$ 4 026 0<<2 1      3
              ~ZQ22 fZ IO tQ      11 NA 4$         +5 NA PEA SONNSL SXSOSUASS L000<<00IQgr I~ZQS[                                      Illn 7                              11      I2            11
~ili 7      3 LL01 1
L~
uLMSSA 010 11 l&<<NA
                  $ $ ASCNNSL IN14PI 11 ai
                                        <<$ $ mINTION~AI CP CR QAMACS 0 PACI UTY                                                                                                                                            ao
              .YPS      <<SLBIPTICN                      0~
EKaa'o        LSJG2                                                  NA AU  due:m NAC LSP. CNLV 0      ~l~m                                                    NA a    9          Io                                                                                                                          da NAAIS CP PASPARSR                                                                                            puoNS        {305~ 552 3958 V  9010 8 0'4 (
 
REPORTABLE OCCURRENCE LICENSEE EVENT REPORT 335-78-37   Rev. l PAGE TWO Additional Event Descri tion.
The system  inspections were being conducted to verify plant "as built" design drawings. The a'ffected safety related systems, Control, Room Ventilation, Emergency Core Cooling Systems Area Ventilation (including portions of the Reactor Auxiliary Building-Ventilation supply system), and Shield Building. Ventilation are. only required in the event of a.
LOCA. In order for  them to  possibly  fail to fulfilltheir functions  an earthquake  would also have to occur        The probability of these two events occurring in'he near future is extremely low An engineering evaluation performed by the AE has determined that the ventilation duct restraint system existing at the. time'of the occurrence, on the safety related system in question was capable of sustaining the additional loads imposed upon it  due to the absence of the 66 missing longitudinal braces during a design basis seismic event. Other ventilation systems in containment and shield building do not require the longitudinal braces so are not a concern.
Additional   Cause Descri  tion  and Corrective  Action'e have concluded that a unique combination of factors involved in the contracting, dxawings and quality control. for .these ventilation braces resulted in their not being installed as required. A description of the circumstances is as follows:
a . It was not until late into the St; Lucie Unit 1 project that the ventilation system installer, an independen"   contractor,   was  to  be assigned the additional scope of work of      installing the permanent restraints and braces for ventilation system ducting, which included the 66 braces in question. A communication error between the AE and the ventilation system installer apparently contributed to the installer not including these 66 braces on the installation drawings, even though these braces appeared on the      Architect-Engineer's (A-E's) design engineering drawings which were used as a source for the installation drawings.
: b. The  installer was also responsible for the quality con~1 inspections associated with the ventilation system installation; consequently the "as-built"
        .condition was inspected to the installation drawings, which, as noted above, did not include these 66 braces.
Had the ventilation system been inspected by our A-E's QC, who did most of the other inspecting, or had the installer used the A-E's design drawings for inspec-tion, the missing braces probably would have been identified during the construction phase.
 
REPORTMKE OCCURRENCE     335-78-37 Rev. 1 LICENSEE EVENT REPORT PAGE THREE Additional  Cause  Descri tion and Corrective Action (continued)
Although there were several other contractors participating in the St. Lucie Unit 1 constzuction who performed their own quality control,   it has been determined that. none of these contractors used other than design drawings for installations and inspections.
Installation of the previously missing    braces in PSL-1 was.
completed on October 5, 1978.
Measures are being established to prevent a similar omission from occurring on our St Lucie Unit 2. These measures include=
a    More  effective comparison of installation drawings against design drawings for accuracy and. completeness prior to site approval of installation drawings.
b  Pezforming a walkdown by PPL Quality Contxol personnel of seismic duct. supports to verify that the "as-built" is in accordance with the design drawings}}

Latest revision as of 10:08, 4 February 2020

LER 78-037/01T-1 on 780919:during Sys Insp,Class I Longitudinal Braces on Auxiliary Bldg Ventilation Ducts Were Found Missing.Caused by Unique Combination of Personnel Errors
ML17266A023
Person / Time
Site: Saint Lucie NextEra Energy icon.png
Issue date: 12/18/1978
From: Siebe A
FLORIDA POWER & LIGHT CO.
To:
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
Shared Package
ML17206A593 List:
References
LER-78-037-01T, LER-78-37-1T, NUDOCS 7901080161
Download: ML17266A023 (3)
v • d • e


Text

UPOATE REPORT PREVIOUS REPORT DATE 0

OCTOBER 2, 1978 N RC PORM $ $ 4 V *NUCLLLRRSCVLATCRV C uNllSSIQN IT TT)

LlCEWSE= EVEbl7 REIOQRT O~O..

CCNTRQl SLCCIEI I l r I I Ql (PL~0 PAINT QR TVPS'ALLRSCUIRKO INPCIRRIATTQN)

I

~l 0$ O CON'T XQl 3

3 9 ucauaat

".::. LJS 44 cQQS 41 PIZNTQSSCRIPTICN ANQ P.t4$ 44LK CQNSZCLISNCZS QOCX ar 'IIJMS 4 A QIQ

'O~OI LLllIS uc<<u54 NUMssil avaNTQ*ra 15 M 1$

LLCSN$ 4 TYPS 75 JO ASPQAT OATS

$7 <<Ai 54 34

~02 Durin 's stem ins ctions 66 Class I Lon itudinal Braces on the RAB

~03 Ventilation Ducts were found to be missing. Radial restraints are

~oa 'ro erl installed. The affected safe related ventilation s stems are only required in the event of a LOCA. An engineering evaluation by our AE indicates that restraints existing at the time of;the occurrence were

~$

capable of sustaining the additional loads during"a design basis seismic

~oa event

~$ I<<$

1 4 9 34 SYSTKM CA454 CA454 CQ04 COOS $ 4SC 04 ccMNQN SN'r cd 0 4 val.va

$ 44CQCS $ 4$ 0005 7 4 9 14 II L'JS.

I'1 11 '1$

LNS LNS 19 53CUSNTI*I- OCCUAASNCK

~

ASPOAT A SVI SION

~

AEPOATNO "

LSAIAQ COOS On iinr ii~78 ~03 7 ~~ ~01 ~T TYPS ~

PIO

~1 11 11 1$ 14 27 '13 19 14

  • T ACNMSN 1'PR OA 11 ACTIONi PUTUAS SPPSC 044TQOWN )AIMS

. C<<LuS. CQMPCN EN T TANSN *CTION Cv PLANT uST7100 4PPLISR, AQUAS Q22 4SMITTSO SCAM NUS.

InSLIS LLS LJS

$ $ uANUPA iUASR 11 3$ 14 n-IS LJS SI $1 LANL' 31 CAUM OESCRIPTIQN ANO CQRRScrlve*cnQNS 022 0 A i u co. 'tion of errors and weaknesses in construction administra-..

~

tion and quality assurance allowed the omission to occur. Installation

~I2 of the prev'iously'missing braces in PSL-l was completed on October 5,1978, and actions to prevent similar occurrences on PSL-2 have been identified for implementation.

7 a

4 9 PACIUTY STATUS LJS ACTIVITY CON Taur

~$

IO

<SLCA$ 40 QP ASLSASS SR I'1 11 OTH SR STATUS AMOUNTQP ACTIYITV026 0

~CQQI

+4 SPZCIAL 5TSMH%'hI LOCATION OP ASLSA$ 4 026 0<<2 1 3

~ZQ22 fZ IO tQ 11 NA 4$ +5 NA PEA SONNSL SXSOSUASS L000<<00IQgr I~ZQS[ Illn 7 11 I2 11

~ili 7 3 LL01 1

L~

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$ $ ASCNNSL IN14PI 11 ai

<<$ $ mINTION~AI CP CR QAMACS 0 PACI UTY ao

.YPS <<SLBIPTICN 0~

EKaa'o LSJG2 NA AU due:m NAC LSP. CNLV 0 ~l~m NA a 9 Io da NAAIS CP PASPARSR puoNS {305~ 552 3958 V 9010 8 0'4 (

REPORTABLE OCCURRENCE LICENSEE EVENT REPORT 335-78-37 Rev. l PAGE TWO Additional Event Descri tion.

The system inspections were being conducted to verify plant "as built" design drawings. The a'ffected safety related systems, Control, Room Ventilation, Emergency Core Cooling Systems Area Ventilation (including portions of the Reactor Auxiliary Building-Ventilation supply system), and Shield Building. Ventilation are. only required in the event of a.

LOCA. In order for them to possibly fail to fulfilltheir functions an earthquake would also have to occur The probability of these two events occurring in'he near future is extremely low An engineering evaluation performed by the AE has determined that the ventilation duct restraint system existing at the. time'of the occurrence, on the safety related system in question was capable of sustaining the additional loads imposed upon it due to the absence of the 66 missing longitudinal braces during a design basis seismic event. Other ventilation systems in containment and shield building do not require the longitudinal braces so are not a concern.

Additional Cause Descri tion and Corrective Action'e have concluded that a unique combination of factors involved in the contracting, dxawings and quality control. for .these ventilation braces resulted in their not being installed as required. A description of the circumstances is as follows:

a . It was not until late into the St; Lucie Unit 1 project that the ventilation system installer, an independen" contractor, was to be assigned the additional scope of work of installing the permanent restraints and braces for ventilation system ducting, which included the 66 braces in question. A communication error between the AE and the ventilation system installer apparently contributed to the installer not including these 66 braces on the installation drawings, even though these braces appeared on the Architect-Engineer's (A-E's) design engineering drawings which were used as a source for the installation drawings.

b. The installer was also responsible for the quality con~1 inspections associated with the ventilation system installation; consequently the "as-built"

.condition was inspected to the installation drawings, which, as noted above, did not include these 66 braces.

Had the ventilation system been inspected by our A-E's QC, who did most of the other inspecting, or had the installer used the A-E's design drawings for inspec-tion, the missing braces probably would have been identified during the construction phase.

REPORTMKE OCCURRENCE 335-78-37 Rev. 1 LICENSEE EVENT REPORT PAGE THREE Additional Cause Descri tion and Corrective Action (continued)

Although there were several other contractors participating in the St. Lucie Unit 1 constzuction who performed their own quality control, it has been determined that. none of these contractors used other than design drawings for installations and inspections.

Installation of the previously missing braces in PSL-1 was.

completed on October 5, 1978.

Measures are being established to prevent a similar omission from occurring on our St Lucie Unit 2. These measures include=

a More effective comparison of installation drawings against design drawings for accuracy and. completeness prior to site approval of installation drawings.

b Pezforming a walkdown by PPL Quality Contxol personnel of seismic duct. supports to verify that the "as-built" is in accordance with the design drawings

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