ML18058A348

LER 92-021-00:on 920314,determined That Containment Integrity Had Been Breached Due to Simultaneous Opening of Sys Boundaries.Caused by Personnel Error.Reiterated to Staff That Work Should Begin on Proper Work orders.W/920413 Ltr

ML18058A348
Person / Time
Site:	Palisades
Issue date:	04/13/1992
From:	Hillman C, Slade G CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.)
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-92-021, LER-92-21, NUDOCS 9204200208
Download: ML18058A348 (5)

Text

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consumers Power* GB Slade General Manager P~WERINli MICHlliAN"S PIUlliRE55.

Palisades Nuclear Plant: 27780 Blue *star Memorial Highway, Coven, Ml 49043.

April 13, 1992 Nu cl ear Regulatory Commi ss. ion

• Document Control Desk Washington, DC 20555

. DOCKET 50-255 - LICENSE DPR PALISADES PLANT LICENSEE EVENT REPORT 92-02l~LOSS OF CONTAINMENT INTEGRITY DURING REFUELING DUE TO SIMULTANEOUS OPENING OF SYSTEM BOUNDARIES Licensee Event Report (LER)92-021 is attached. This event is reportable to the NRC in accordance with 10CFR50.73(a)(2)(i)(B) as a condition p~ohibjted by the plant's technical specifications. *

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Gerald B Slade General Manager CC Administra.tor, Region III, USNRC NRC Resident Inspector. - Palisades Attachment 9204200208 920413

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DATE 1151 . I I I On March 14, 1992, at approximately 1000 hour~, with the plant shutdown and refueling operations in progtess, it was .determined that containment integrity had been breached due the simultaneous opening of the secondary side handholes on the iteam generators and check valve.CK-0729 on the auxiliary feedwater line. All refueling operations were stopped and the mechanical maintenance supervisor was instructed to reassemble the check valve. An unmonitored* release path to the environment*was not created and, therefore, there was no impact on the health and safety of the public. The root cause of this event was personnel error for faiJure to identify the fact that certain plant configurations may result in a breach of* containment integrity. Corrective action for this event includes: Reiterating to both the plant and contractor staff that work should not begin on work orders unless.they have

                            *been properly scheduled; Discussing pr~vention of this ev~nt with the plant and contractor schedulers; Reviewing plant periodic activity and control

( PPAC) work orders to determine whether certain pl ant configurations wil 1 result in a breach of containment integrity; and, Evaluating the need for a control system or process to identify plant configurations which may result in a breach of containment integrity. NAC 18-Bll F--

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EVENT DESCRIPTION On March 14, 1992, at approximately 1060 ho~rs, with the plant shutdown and refueling operations in progress, it was determined that containment integrity

• had been breached due the simultaneous opening of the. secondary side handholes on the steam generators [SB] and check valve CK-0729 on the auxiliary feedwater line [BA;FCVJ. All refueling operations were stopped and the mechanical maintenance supervisor was instructed to reassemble_the check .

valve. All work orders currently released. for repair were reviewed.

• No other work orders, which had been released for repair, were found that could affect containment integrity. *The check valve was re-assembled by 1125 hours on March 14, 1992 .and refueling.operations were ~esumed at 1140 hours on March 14, .1992.
• This event is reportable to.the NRC in accordance with 10CFR50.73(a)(2)(i)(B).

as a ... condition prohibited by the plant's technical specifications. . tAUSE OF THE EVENT. The root cause of this event was the.result of a combination of lack of schedule control, ineffective communications, and p*ersonnel error. 1his event does not involve the failure of any e~uipment i~portant tci safety. ANALYSIS OF THE EVENT The loss of containment integrity on March 14, 1992 was the result of a combination of lack of schedule control, ineffective communications, and personnel error. This conclusion is supported by the fact that (1) the. work. aider for check valve CK-0729 was worked ahead -0f the*scheduled date without the mech~nical maintenance scheduler's knowledge and was, therefore, not sched~led,. (2) mechanical maintenance management and scheduling personnel did not effectively communicate to the valve contractor lead supervisors the limitations on work orders that were in the system window and, (3) the Shift Supervisor released the check valve work order for repair w1thout.taking into consideration that the steam: generator secondary side handhole flanges were removed. Each element is discussed in further detail below. Note: A system window is a block of ti~~ within the outage schedule during which a particular system or component is made available for maintenance*and testing. Work orders on equipment within the defined system boundaries and within the dates and times the system window is open, may be sched~led and worked. All valve ~ontractor and methanical maintenance wbrk orders are scheduled by the Mechanical Maintenance .Scheduler. In preparation for work a plant maintenance supervisor or valve contractor supervisor is ~iven work order packages to review. Additionally, depending upon system windows; the

• s~pervisor may obtain Workman's Protective Tagging prior to the opening of the system window. Prior to this event, it had been the practice of the ~alve
• contractor lead supervisor to look ahead in the schedule for opportunities to

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Palisades Plant T1lrT ,. _ - * ._. - _ , . ........." 1171 01s1010101 2, 515 9 I 2 - 01211 - oI o 013 lo. 0 ,4 I complete work before the scheduled d~te. If the valve ~ontractor lead supervisor had the work order package, Workman's Protective Tagging and Health Physics support, he would request the Shift Supervisor to release the work order package for repair and start the activity earlier in the system window. The mechanical maintenance management endorsed th.is practice, as long as the valve contractor lead supervisor was working in accordance with approved plant procedures, Workman's Protective Tagging requirements, and within the system window.

• Operations Outage S~heduling personnel specifically discussed System Window 281, "Main Steam System" (inside Containment) with ~echanical mai~tenance

           .man~gement and scheduling personnel~         Mechanical maintenance management and*

scheduling personnel were informed that withih System Window 281, only certain _work orders could be worked when the steam generator secondary side handhole flanges were removed. This information was not effectively communicated to the. __yal ve contractor lead supervisors. This event was reviewed with the Shift Supervisor who released the work order on check valve CK-0729 for r~pair. He. indicated that he released the work order based on the fact that the equipment had been properly tagged fdt

          . workman protection and plant conditions were acceptable to permit the work.

He indicated that he did *not take into consideration that the steam generator secondary side hand hole flanges were removed for steam generator sludge lancing. Another control mechanism that could have prevented this event and the could have been utilized in the work order is the section entitled "Effect on Plant tonditions."

• The information in th1s section is provided by the Shift Engineer if the work order is a plant periodic activity and control (PPAC) work order or, by the Operations Planner if th~ work order is not a PPAC work order. The section ~onveys information to the Shift Supervisor regarding the effect(s) on plant conditions when the equipment identified on the work order is released for repair. The PPAC work order for check valve CK~0729 did not contain the information that the disassembly of the check valve may result in the creation of an ~nmonitored release path from the containment when the secondary side of the steam generator was* open.

I Health Physics d~ta for the containment was reviewed for the period of time when the check valve and the steam generator secondary side handholes were open simultaneously. Health Physics air sample data for the containment was retrieved and reviewed. All of the samples showed iodine, particulate, or noble gas activities to be normal for refueling conditions. The Health Physics logbook was reviewed to determine if any unusual activities were recorded during the peri6d of time in question. Nothing unusual was noted in the logbook. *

• Since the check valve (CK-0729)*is located in the component cooling water room of the auxiliary building, a release of radioactivity from the path created by the open steam generator handholes and the check valve would have been contained within the auxiliary building HVAC system and monitored through the feedwater penetration room HVAC radiation monitor RIA 5710. Therefore~ an unmonitored release path to the environment was not created and there was ~o impact on the health and safety of the public.

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CORRECTIVE ACTION Corrective action for this event includes:

1. Reiterating to plant and contractor staff that work should not begiri on work orders unless they have been properly scheduled through the .

rilaintenance*scheduler or, the work order has been released by the.

mechanical maintenance shift manager ..

2. Discussion of this event and ~ow it should be prevented was conducted with the valve contrattor contract coo~dinator, contractor supervision and*contr~ctor scheduler, as well as plant electri~al, instrument and control, and the Nuclear EDgineering and Construction (NECO) schedulers.

3~ Revi~wing PPACs for all SOER (INPO Significant Operating Experience Review) check valves that are directly connected to the secondary side of the steam generators and revise the "Effect on Plant Conditions" section to address whether releasing the equipment *will create an unmonitored release path from the containment.

4. Evaluating the need fot the Operation Department to develop a conttol system or process to identify that the secondary side of the steam

_ generator is open and, as a result, limitations on the release for

                          .repair of other equipment must be implemented.

ADDITIONAL INFORMATION Norie}}