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{{Adams | |||
| number = ML20214N813 | |||
| issue date = 05/26/1987 | |||
| title = Safety Insp Rept 50-295/87-12 on 870508-12.Major Areas Inspected:Events Surrounding Inadvertent Opening of All Four MSIVs & Subsequent Safety Injection on 870430.Event Caused by Communications Error & Failure to Refer to Procedures | |||
| author name = Hinds J | |||
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) | |||
| addressee name = | |||
| addressee affiliation = | |||
| docket = 05000295 | |||
| license number = | |||
| contact person = | |||
| document report number = 50-295-87-12, NUDOCS 8706030086 | |||
| package number = ML20214N792 | |||
| document type = INSPECTION REPORT, NRC-GENERATED, INSPECTION REPORT, UTILITY, TEXT-INSPECTION & AUDIT & I&E CIRCULARS | |||
| page count = 10 | |||
}} | |||
See also: [[see also::IR 05000295/1987012]] | |||
=Text= | |||
{{#Wiki_filter:- | |||
' | |||
. | |||
U.S. NUCLEAR REGULATORY COMMISSION | |||
REGION !!! | |||
Report No. 50-295/87012(DRP) | |||
Docket No. 50-295 License No. OPR-39 | |||
Licensee: Coninonwealth Edison Company | |||
P. O. Box 767 | |||
Chicago, IL 60690 | |||
Facility Name: Zion Nuclear Power Station, Unit 1 | |||
Inspection At: Zion, IL | |||
Inspection Conducted: May 8 through May 12, 1987 | |||
Inspectors: M. M. Holzmer | |||
P. L. Eng | |||
N. Williamsen | |||
" J i L g . c'. | |||
Approved By. M. Hinds, Jr ting Chief f.24 J7 | |||
Reactor Projects Section 1A DTie | |||
Inspection Sunenary | |||
inspection on May 11 thrnugh May 12, 1987 (Report No. 50-295/87012(DRp) | |||
Areas inspected: Special safety inspection of events surroundin | |||
opening of alTTour Unit 1 main steam isolation valves (MSIVs) g inadvertent | |||
and subsequent | |||
safety injection on April 30, 1987. | |||
Resu_I ts: One Unresolved Item was identified regarding this event. The | |||
inspection disclosed that this was a significant event in that all four MSIVs | |||
were open and unable to close automatically or manually from the control room | |||
for approximately 20 minutes. The event was caused by a coninunications error | |||
and by a failure to refer to procedures, | |||
i | |||
l | |||
l | |||
0706030006 070027 | |||
PDH ADUCK 0000029D | |||
PDH | |||
U | |||
_ - - _ - _ | |||
, _____ _____ ___ _ _ __ _______ | |||
' | |||
. | |||
DETAILS | |||
1. Persons Contacted | |||
*G. Plim1, Station Manager | |||
*E. Fuerst, Superintendent, Production | |||
*T. Rieck, Superintendent, Services | |||
*W. Kurth, Assistant Station Superintendent, Operations | |||
L. Pruett, Unit 1 Operating Engineer | |||
N. Valos Unit 2 Operating Engineer ! | |||
R. Cascarano, Technical Staff Supervisor | |||
T. Printz, Assistant Technical Staff Supervisor | |||
*C. Schultz, Regulatory Assurance Administrator | |||
*J. Dallard, Quality Control Supervisor ! | |||
*W. Stone. Quality Assurance Supervisor | |||
*P. LeBlond, Licensing Administrator | |||
*T. Droccolo, Assistant to Assistant Station Superintendent, Operations | |||
*T. Wenig Engineer. Technical Staff | |||
*G. Wagner, Maintenance Manager, Corporate Office | |||
*J. Harbin, Shift Engineer | |||
The inspectors also met with and interviewed shift supervisors, licensed | |||
operators, and non-licensed operators. | |||
* Indicates persons present at exit interview. | |||
2. Safety In'ection JST)_ Due to inadvertent _ Opening of All Four Unit 1 Main | |||
5 team tim atton valves (H51vl | |||
a. _Dackground | |||
The MSIVs at Zion are hydraulically opened, pneumatically shut. 35 | |||
inch globe valves. Hydraulic oil is piped to the underside of the | |||
MSIV actuating piston, and nitrogen pressure is maintained above the | |||
piston (scoAttachment1). When the hydraulic oil pum) is running i | |||
andnohydraulicdrainvalvopathsareopen(seeAttachment2),the ! | |||
MSIV will open. When either one of the two trip solenoid valves l | |||
(D A E in Attachment 2) are open, oli pressure will bleed of f and ! | |||
nitrogen pressure will overcome hydraulle pressure, forcing the MS!V - | |||
closed. The trip solenoid valves aro "energiro to open" valves and - | |||
areenvironmentallyqualified(EQ). To maintain their EQ status, | |||
the licensee has procedurally limited the length of time tno trip i | |||
solenoid valves can remain energized by requiring that the fuses to | |||
the trip solenoid valves will be removed if the M"ilVs are to remain | |||
closed longer than 24 hours, | |||
b. Event _ C_hr_on_o_ logy | |||
On April 30, 1987 UnitIwasinhotshutdown(Mode 3)atnormal | |||
operating temperature and grossure, with all four M$lys closed, j | |||
Operators had just placed OutofService"(005)tagsonthemain | |||
' | |||
2 | |||
L | |||
_ _ _ _ _ _ _ _ _ _ _ | |||
i* , | |||
l | |||
steam system for personnel protection for Unit 1 generator work. | |||
l | |||
Zion procedures require that when the MSIVs are to be closed for | |||
! | |||
more than 24 hours, the fuses for the MSIV trip solenoid valves | |||
l are to be removed in order to de-energize the MS!V trip solenoid | |||
l valves. This is for environmental qualification reasons (See | |||
' | |||
paragraph 2.c). At about 11:00 a.m. due to a communications error | |||
between the Shif t Control Room Engineer (SCRE) and the equipment | |||
l | |||
oaerator (EO), the E0 removed the MSIV trip solenoid fuses before | |||
l | |||
tie MSIV hydraulic pumps were secured. As the fuses for the MSIV | |||
l trip solenoid valves were pulled, all four MSIVs opened sequentially, | |||
pressurizing the main stcam lines. Asafetyinjection(SI) occurred | |||
due to high steam delta prescere for Loop B caused by the sequential | |||
steam readmission. Water was injected by the centrifugal charging | |||
pumps through the boron injection tank to the reactor coolant system | |||
for approximately six minutes. Steam header pressure increased | |||
from approximately 80 psig to about 785 psig in four minutes. 1 | |||
' | |||
Reactor coolant system (RCS) temperature decreased 27'F to about | |||
516*F. | |||
! | |||
The licensee responded to the SI por their Emergency Response | |||
Guidelines (ERGS). The SI was terminated in about six minutes. | |||
An Unusual Event was declared at 11:20 a.m. in accordance with the | |||
licensee's Generating Station's Emergency Plan. The MSIVs remained | |||
open untti the licensee removed power to the four MSIV hydraulic oil | |||
pumps and opened hydraulic valves R8 (see Attachment 2) for each | |||
MSIV to allow nitrogen pressure to close the MSIV. | |||
The Unusual Event was terminated at 11:50 a.m. | |||
c. Root Causes And Other problems | |||
(1) Failure to provide and roccive precise verbal coninunications. | |||
l | |||
' | |||
Poor conrnunications resulted in the E0 interpreting a question | |||
about pulling the MSIV fuses as an order to perform the task. | |||
The SCRE did not intend to provide an order aut was requesting | |||
confirmation of the next sequence of events. Verbal repeat i | |||
back of the order was not required nor was it performed. | |||
(2) Failure to review the applicable system operating instruction ! | |||
prior to removing the MSIVs from service. ! | |||
$1nce System Operating Instruction, 501-31 " Main Steam", was : | |||
not reviewed by the E0 prior to pulling the fuses, the need to | |||
have the MSIV hydraulic pumps de energized was not identified. j | |||
The E0 would nomally perform the removal of the fuses as part l | |||
of $01 31. ! | |||
i | |||
I (3) The design of the MSIV hydraulic system requires that when | |||
the MSIVs are closed the trip solonutd valves must remain | |||
energized. However, to maintain the solenoid environmental : | |||
qualifications, thit length of time during which they must ! | |||
remain energized must be limited. Thus to keep the MS!Vs | |||
closed for long periods of time other measures must bu taken. , | |||
i | |||
l | |||
l | |||
--_ _ ___- _ _ ____ _ ___ _ _ _ _ _ _ _ - _ - - _ _ _ _ _ - _ _ _ - _ _ _ - _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ | |||
r | |||
* | |||
. | |||
(4) The 00S for the main steam system was apparently inadequate | |||
and in violat10n of the licensee's 005 procedure. | |||
(5) The licensee took approximately 25 minutes to close all | |||
four MSIV's by opening the MSIV hydraulic pump breaker and | |||
opening valve R8. The MSIVs could have been more quickly | |||
closed from the control room if the MSIV fuses had been | |||
replaced, | |||
d. Corrective Actions | |||
The licensee stopped all non-esser.tial operations department work, | |||
including 005 tagging and changes to plant conditions until each | |||
operating shif t was briefed regarding the event and interim steps | |||
to prevent recurrence. Briefings were held before each shift was | |||
allowed to resume normal activities. | |||
The licensee's subsequent corrective actions are listed below. | |||
The status of each item is provided. | |||
* | |||
Expedite engineering review of the design of the MSIV system | |||
to include the fail state of the valve as well as the energized | |||
life of the solenoids. | |||
Status: Station Nuclear Engineering Department (SNED) was | |||
requested to perform the review following a station modification | |||
review connittee meeting on May 12, 1987. | |||
* | |||
Install warning plaques on the MSIV trip solenoid fuses and | |||
hydraulic pump motor control centers (MCCs) to ensure the | |||
proper sequence of de-energizing the valves. | |||
Status: Temporary warning si | |||
and MCCs on Saturday, May 2, gns | |||
1987, finalwere placed | |||
Wording Was on the fuses | |||
determined on May 5, 1987, and permanent signs were installed | |||
by May 9, 1987. | |||
* Initiate procedure changes to require operators to log the | |||
procedure and the step numbers that apply to current plant | |||
conditions and evolutions. The changes would also require | |||
that the appropriate section of that procedure be reviewed | |||
by the oncoming operator, prior to shif t change. | |||
Status: In place May 1, 1987 by Standing Order 87-11. | |||
Permanent procedure changes will be made through the normal | |||
process. | |||
" | |||
Require that all completed steps of key procedures be | |||
properly signed off, rather than marked with a check mark. | |||
Status: Inplemented by Night Order May 2, 19075 made permanent | |||
by Standing Order 01 12, May 6, 1907. This was formerly the | |||
4 | |||
. _ - _ _ _ _ _ - _ _-_---__- _ _ ___ __ _ __ _ _ _ _ __- _ _ ______ _ _ _ __ . - _ _ | |||
, _ .___ __--_--_ _ _---- _ _ __..__. | |||
* | |||
. | |||
practice for Periodic Tests (pts) and Maintenance Instructions | |||
(mis). All General Operating Procedures (GOPs) with the | |||
exception of G0P-3 are now corrected per this standing order. | |||
Formal procedure changes will follow through the normal process. | |||
* | |||
Implement and train on formal " repeat-back" communication. | |||
Status: Initially communicated to each shift verbally | |||
immediately following the incident and prior to each shift | |||
performing any shift activities. This was followed by | |||
Standing Order 87-11 on May 1, 1987. Procedure changes will | |||
follow by the normal process. Additional instructions will | |||
be given during each crew's subsequent training weeks. The | |||
first such session will take place on May 15, 1987. | |||
* | |||
Review System Operating Instructions (501's) to determine if | |||
they should be made " mandatory-in-hand" procedures. | |||
Status: Initial review has been completed and the above change | |||
will not be made at this time. However, Standing Order 87-11, | |||
dated May 1, 1987, requires a review of procedures prior to any | |||
particular evolution, to determine whether an S0I (or other | |||
procedure) pertains to the evolution. If a procedure does exist, | |||
it must be reviewed prior to the evolution; if not, then pre- | |||
cautions and limitations of the associated S0I must be reviewed | |||
for applicability. | |||
The above requirement, specified in Standing Order 87-11 | |||
May 1, 1987, will be updated to require the Shift Engineer to | |||
determine whether a procedure is needed, for those evolutions | |||
or conditions where presently there are no procedures. | |||
* | |||
Review the method of control of orders given to operators. | |||
Status: The control of orders given to operators has been | |||
more clearly defined in Standing Order 87-13, dated May 7, | |||
1987. In addition, Standing Order 87-13 changes the division | |||
of responsibilities between the shift Control Room Supervisor | |||
(normally the SCRE) and the shift's Second Licensed Foreman, | |||
in order to distribute the workload more evenly. This change | |||
allows the SCRE to devote more attention to unit operation. | |||
" | |||
Licensing will perform a review to determine whether an | |||
unanalysed condition existed for this event. | |||
Status: The completed review is expected by May 15, 1987. | |||
" Review the shift's actions on April 30, 1987, in response to | |||
the Safety Injection. | |||
, | |||
5 | |||
, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _______ _ _ ___ ________________ ______ _ ______-_____-_ . _ _ | |||
* | |||
. | |||
Status: The operating department management met with the | |||
shift personnel and concluded that the actions taken were | |||
fully consistent with the Emergency Response Guidelines | |||
(ERGS) and that the reclosing of the MSIVs was done in a | |||
conservative and timely fashion. | |||
NRC interviews of shift management and review of plant parameters | |||
from computer graphs revealed that the steam header pressurized | |||
in about 5 to 10 minutes. Thus the event was essentially | |||
terminated prior to closing the MSIVs. Shift management stated | |||
that by the time they had proceeded through the ERGS for SI and | |||
SI termination, they felt they could take more time and be more | |||
deliberate than they could if there was a continuing steam demand. | |||
The shift management stated that there were conflicting | |||
indications, which could out be verified by personnel in the | |||
control room, regarding the position of the MSIV hydraulic | |||
pump breaker. For that reason, they chose to ensure that | |||
the breaker was open prior to opening MSIV hydraulic valve | |||
R8. Because the flow rate through R8 is approximately the | |||
same as the capacity of the hydraulic pump, opening R8 with | |||
the pump energized would not ensure that the MSIV's would close. | |||
* Incorporate the applicable steps of S01-31, " Main Steam", into | |||
the GOPs, where possible. | |||
Status: This is under evaluation and the conclusions will be | |||
documented. | |||
" Review the depth and extent of the Operating Engineer's (0E) | |||
control over the shift, through the Shift Engineer (SE). | |||
Status: This review has been done by the Production | |||
Superintendent and the Assistant Superintendent-0perations | |||
and OE control is deemed adequate. | |||
* Review the out-of-service (005) practices at Zion, since | |||
initially MSIV's were not taken 00S properly. | |||
Status: Although the licensee believes that the improper | |||
005 was not a cause of the SI, 00S practices are still of | |||
concern to the licensee because the MSIV 005 was apparently | |||
not in accordance with Zion's procedures. Initial review | |||
indicated that the 005 problem was confined to the MSIVs. | |||
Zion station procedures stated that "Where it is possible to | |||
energize or liven the equipment from more than one source, | |||
the appropriate Out Of Service Card shall be placed on all | |||
isolating devices (switches, valves, etc.) before the work | |||
is started. It is not sufficient to attach an Out of Service | |||
Card to a remote switch only." The Assistant Superintendent- | |||
Operations had follow-up discussions with each crew regarding | |||
the standing orders issued and this 00S problem on May 6, 1987 | |||
through May 8, 1987. | |||
6 | |||
r | |||
.. | |||
, | |||
* Mandate that the " center desk NS0" issue all 00S jobs to | |||
nonlicensed operators. | |||
Status: This has been the practice at Zion. In the | |||
discussion with the shift crews on May 6, 1987 through May 8, | |||
1987 on 00S practices this was re-emphasized as the accepted | |||
practice for issuing 00S jobs to the A and B operators for | |||
write-up and card hangings. | |||
(e) Safety Significance: | |||
Unit I was in hot shutdown (Mode 3) at normal operating temperature | |||
and pressure. The Reactor Coolant System (RCS) was cooled 27 | |||
degrees during the event. RCS pressure never exceeded 2280 psig. | |||
The licensee determined that 3% of the design SI cycle life had | |||
been used as a result of this transient. The Unit was in a condi- | |||
tion for approximately twenty-five minutes during which all four | |||
MSIVs were open and unable to be closed by an automatic signal, or | |||
by manual action from the control room. | |||
The secondary plant main steam headers were pressurized from 80 | |||
psig to about 800 psig in about four minutes. The main steam | |||
lines saw a total heat up of about 200 degrees during the period | |||
of pressurization. Since the MSIV's were closed only seven hours | |||
earlier, the main steam lines had not cooled significantly from | |||
normal operating temperature of 500 F prior to the re-pressurization. | |||
A walkdown of containment and secondary steam piping did not | |||
identify any damage. There were no personnel injuries as a result | |||
of this event. | |||
Section 14.2.5.3 of the Zion Final Safety Analysis Report (FSAR) | |||
states that the MSIVs are designed to close within 10 seconds of a | |||
large steamline break, and that for any break in any location, no | |||
more than one steam generator (SG) would blowdown, even if one of | |||
the isolation valves fails to close. Had a large steamline break | |||
occurred during the April 30, 1987 event, the MSIVs would have been | |||
incapable of both automatic and manual closure from the engineered | |||
safety feature logic system (ESF). For any steamline break | |||
downstream of the main steam check valves, all four SGs would have | |||
blowndown. This would have constituted an unanalyzed condition. | |||
(f) Inspector Comments | |||
(1) The event occurred at 11:00 a.m. on April 30, 1987. The | |||
event was reported to the NRC at 11:46 a.m. the same day. | |||
This was within the one hour requirement of 10 CFR 50.72 | |||
(a)(3 for declaration of Emergency Classes (eg Unusual | |||
Events . | |||
(2) The licensee's corrective action was prompt as shown by the | |||
stop work, immediate shift briefings, and series of Standing | |||
7 | |||
r | |||
.. | |||
. | |||
Orders. The extent of the corrective actions exceeds that | |||
shown in responses to previous operating events, especially | |||
as it pertains to communications and enforcement of procedural | |||
adherance. | |||
(3) Past performance in the operating area has been average. | |||
Ratings given in NRC's Systematic Assessment of Licensee | |||
Performance have been Category 2 (average) for the last 3 | |||
assessment periods. Communications have been adequate in | |||
most cases, but are generally casual. Adherance to GOPs has | |||
been very good, but S0Is have not been rigorously used. | |||
Several events have occurred since the beginning of the year | |||
involving failure of operators to adhere to procedures, or | |||
erroneous assumptions on the part of operators regarding. plant | |||
conditions or evolutions in progress. | |||
(4) No specific notices had been given to the licensee by licensee | |||
audits, or NRC or industry notification regarding similar | |||
events. | |||
(5) This is the first SI at Zion since January of 1984. Other | |||
violations of operating procedures have occurred, but | |||
their safety significance has been classified as minor. . | |||
(g) Evaluation | |||
; | |||
This is considered an Unresolved Item per. ding review by a Region III 2 | |||
Enforcement Board (295/87012-01(DRP)). | |||
3. Unresolved Items | |||
Unresolved items are matters about which more information is required in | |||
order to ascertain whether they are acceptable items, violations, or | |||
deviations. One Unresolved Item disclosed during this inspection is | |||
discussed in Paragraph 2. | |||
4. Exit Interview | |||
The inspectors met with licensee representatives (denoted in Paragraph 1) | |||
throughout the inspection period and at the conclusion of the inspection | |||
on May 12, 1987, to summarize the scope and findings of the inspection | |||
activities. The licensee acknowledged the inspectors' comments. | |||
The inspectors discussed the likely informational content of the | |||
inspection report with regard to documents or processes reviewed by the | |||
inspectors during the inspection. The licensee did not identify any | |||
documents or processes as proprietary, | |||
i | |||
8 | |||
1 | |||
, -,,-n_,- .n - | |||
. . > , , , - - +-,,w ,g. - - . . . . , ..w--------sr-e. -,n,. --+-- --r e-n - -- m. - | |||
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1 | |||
. | |||
. ATTACHMENT 1 l | |||
' | |||
. | |||
! | |||
OIL FOR SEALING | |||
l\ - - - - ~ ~ - - | |||
l r | |||
*-NITROGEN FILL | |||
IIF - ] ; ---- (FROM MANIFOLD) | |||
STOP TUBE | |||
e | |||
\v !' | |||
s | |||
il e | |||
s | |||
/s ' | |||
l/ | |||
,/ * | |||
/ 9" OIL $ | |||
6 | |||
~ l $ | |||
$ PISTON ' | |||
Y | |||
, | |||
f $ | |||
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5 | |||
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/ s / | |||
/ ' l h | |||
* , / | |||
t | |||
s/ | |||
# 8 | |||
' / | |||
- a Ne | |||
/ | |||
f p | |||
p | |||
j | |||
VO LUM E ' | |||
_ | |||
# | |||
(PISTON SEAL f | |||
INTEGRITY) INSPECTION v | |||
l 5 l | |||
DRAIN VALVE , | |||
81 i | |||
L | |||
Il lI | |||
; O : -JJ l L_ _ __ _ __ _ | |||
L _ _ _ _ _ _ | |||
*--Oi t | |||
1 | |||
NITROGEN RELIEF | |||
FIGURE 2la -H-C2 | |||
MSIV HYDR AU LIC ACTUATOR / ACCUMULATOR | |||
- . . . ._. - _ - . | |||
. | |||
P | |||
ATTACIDIENT 2 , | |||
PT PSH | |||
N MSIV | |||
ACTUATING | |||
PISTON | |||
Na . | |||
G THROTTLE VALVE HYDRAULIC M ANI FOLD | |||
_ ___ | |||
PI | |||
l | |||
l R4 E R2 | |||
. | |||
Y | |||
4 I AL _ h D A | |||
Na | |||
# | |||
- THROTTLE VALVE | |||
>< ;; X | |||
OPENING R7 B M ! | |||
SIDE | |||
ACCUMU- ;; l | |||
LATOR R8 | |||
C R5 | |||
# M ANIFO D | |||
[ | |||
I | |||
X | |||
R6 | |||
?O | |||
A | |||
jN OC | |||
z | |||
{_ | |||
FILTER ]( | |||
2 | |||
^ | |||
> | |||
RESERVOIR | |||
RESERVOIR | |||
CROSS CONNECT | |||
-lSTR A I N ERl | |||
Q- | |||
, | |||
Qi | |||
' | |||
FIGURE 210 -II- ci | |||
-_ _ | |||
}} |
Latest revision as of 14:29, 4 May 2021
ML20214N813 | |
Person / Time | |
---|---|
Site: | Zion File:ZionSolutions icon.png |
Issue date: | 05/26/1987 |
From: | Hinds J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
To: | |
Shared Package | |
ML20214N792 | List: |
References | |
50-295-87-12, NUDOCS 8706030086 | |
Download: ML20214N813 (10) | |
See also: IR 05000295/1987012
Text
-
'
.
U.S. NUCLEAR REGULATORY COMMISSION
REGION !!!
Report No. 50-295/87012(DRP)
Docket No. 50-295 License No. OPR-39
Licensee: Coninonwealth Edison Company
P. O. Box 767
Chicago, IL 60690
Facility Name: Zion Nuclear Power Station, Unit 1
Inspection At: Zion, IL
Inspection Conducted: May 8 through May 12, 1987
Inspectors: M. M. Holzmer
P. L. Eng
N. Williamsen
" J i L g . c'.
Approved By. M. Hinds, Jr ting Chief f.24 J7
Reactor Projects Section 1A DTie
Inspection Sunenary
inspection on May 11 thrnugh May 12, 1987 (Report No. 50-295/87012(DRp)
Areas inspected: Special safety inspection of events surroundin
opening of alTTour Unit 1 main steam isolation valves (MSIVs) g inadvertent
and subsequent
safety injection on April 30, 1987.
Resu_I ts: One Unresolved Item was identified regarding this event. The
inspection disclosed that this was a significant event in that all four MSIVs
were open and unable to close automatically or manually from the control room
for approximately 20 minutes. The event was caused by a coninunications error
and by a failure to refer to procedures,
i
l
l
0706030006 070027
PDH ADUCK 0000029D
PDH
U
_ - - _ - _
, _____ _____ ___ _ _ __ _______
'
.
DETAILS
1. Persons Contacted
- G. Plim1, Station Manager
- E. Fuerst, Superintendent, Production
- T. Rieck, Superintendent, Services
- W. Kurth, Assistant Station Superintendent, Operations
L. Pruett, Unit 1 Operating Engineer
N. Valos Unit 2 Operating Engineer !
R. Cascarano, Technical Staff Supervisor
T. Printz, Assistant Technical Staff Supervisor
- C. Schultz, Regulatory Assurance Administrator
- J. Dallard, Quality Control Supervisor !
- W. Stone. Quality Assurance Supervisor
- P. LeBlond, Licensing Administrator
- T. Droccolo, Assistant to Assistant Station Superintendent, Operations
- T. Wenig Engineer. Technical Staff
- G. Wagner, Maintenance Manager, Corporate Office
- J. Harbin, Shift Engineer
The inspectors also met with and interviewed shift supervisors, licensed
operators, and non-licensed operators.
- Indicates persons present at exit interview.
2. Safety In'ection JST)_ Due to inadvertent _ Opening of All Four Unit 1 Main
5 team tim atton valves (H51vl
a. _Dackground
The MSIVs at Zion are hydraulically opened, pneumatically shut. 35
inch globe valves. Hydraulic oil is piped to the underside of the
MSIV actuating piston, and nitrogen pressure is maintained above the
piston (scoAttachment1). When the hydraulic oil pum) is running i
andnohydraulicdrainvalvopathsareopen(seeAttachment2),the !
MSIV will open. When either one of the two trip solenoid valves l
(D A E in Attachment 2) are open, oli pressure will bleed of f and !
nitrogen pressure will overcome hydraulle pressure, forcing the MS!V -
closed. The trip solenoid valves aro "energiro to open" valves and -
areenvironmentallyqualified(EQ). To maintain their EQ status,
the licensee has procedurally limited the length of time tno trip i
solenoid valves can remain energized by requiring that the fuses to
the trip solenoid valves will be removed if the M"ilVs are to remain
closed longer than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />,
b. Event _ C_hr_on_o_ logy
On April 30, 1987 UnitIwasinhotshutdown(Mode 3)atnormal
operating temperature and grossure, with all four M$lys closed, j
Operators had just placed OutofService"(005)tagsonthemain
'
2
L
_ _ _ _ _ _ _ _ _ _ _
i* ,
l
steam system for personnel protection for Unit 1 generator work.
l
Zion procedures require that when the MSIVs are to be closed for
!
more than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, the fuses for the MSIV trip solenoid valves
l are to be removed in order to de-energize the MS!V trip solenoid
l valves. This is for environmental qualification reasons (See
'
paragraph 2.c). At about 11:00 a.m. due to a communications error
between the Shif t Control Room Engineer (SCRE) and the equipment
l
oaerator (EO), the E0 removed the MSIV trip solenoid fuses before
l
tie MSIV hydraulic pumps were secured. As the fuses for the MSIV
l trip solenoid valves were pulled, all four MSIVs opened sequentially,
pressurizing the main stcam lines. Asafetyinjection(SI) occurred
due to high steam delta prescere for Loop B caused by the sequential
steam readmission. Water was injected by the centrifugal charging
pumps through the boron injection tank to the reactor coolant system
for approximately six minutes. Steam header pressure increased
from approximately 80 psig to about 785 psig in four minutes. 1
'
Reactor coolant system (RCS) temperature decreased 27'F to about
516*F.
!
The licensee responded to the SI por their Emergency Response
Guidelines (ERGS). The SI was terminated in about six minutes.
An Unusual Event was declared at 11:20 a.m. in accordance with the
licensee's Generating Station's Emergency Plan. The MSIVs remained
open untti the licensee removed power to the four MSIV hydraulic oil
pumps and opened hydraulic valves R8 (see Attachment 2) for each
MSIV to allow nitrogen pressure to close the MSIV.
The Unusual Event was terminated at 11:50 a.m.
c. Root Causes And Other problems
(1) Failure to provide and roccive precise verbal coninunications.
l
'
Poor conrnunications resulted in the E0 interpreting a question
about pulling the MSIV fuses as an order to perform the task.
The SCRE did not intend to provide an order aut was requesting
confirmation of the next sequence of events. Verbal repeat i
back of the order was not required nor was it performed.
(2) Failure to review the applicable system operating instruction !
prior to removing the MSIVs from service. !
$1nce System Operating Instruction, 501-31 " Main Steam", was :
not reviewed by the E0 prior to pulling the fuses, the need to
have the MSIV hydraulic pumps de energized was not identified. j
The E0 would nomally perform the removal of the fuses as part l
of $01 31. !
i
I (3) The design of the MSIV hydraulic system requires that when
the MSIVs are closed the trip solonutd valves must remain
energized. However, to maintain the solenoid environmental :
qualifications, thit length of time during which they must !
remain energized must be limited. Thus to keep the MS!Vs
closed for long periods of time other measures must bu taken. ,
i
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l
--_ _ ___- _ _ ____ _ ___ _ _ _ _ _ _ _ - _ - - _ _ _ _ _ - _ _ _ - _ _ _ - _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
r
.
(4) The 00S for the main steam system was apparently inadequate
and in violat10n of the licensee's 005 procedure.
(5) The licensee took approximately 25 minutes to close all
four MSIV's by opening the MSIV hydraulic pump breaker and
opening valve R8. The MSIVs could have been more quickly
closed from the control room if the MSIV fuses had been
replaced,
d. Corrective Actions
The licensee stopped all non-esser.tial operations department work,
including 005 tagging and changes to plant conditions until each
operating shif t was briefed regarding the event and interim steps
to prevent recurrence. Briefings were held before each shift was
allowed to resume normal activities.
The licensee's subsequent corrective actions are listed below.
The status of each item is provided.
Expedite engineering review of the design of the MSIV system
to include the fail state of the valve as well as the energized
life of the solenoids.
Status: Station Nuclear Engineering Department (SNED) was
requested to perform the review following a station modification
review connittee meeting on May 12, 1987.
Install warning plaques on the MSIV trip solenoid fuses and
hydraulic pump motor control centers (MCCs) to ensure the
proper sequence of de-energizing the valves.
Status: Temporary warning si
and MCCs on Saturday, May 2, gns
1987, finalwere placed
Wording Was on the fuses
determined on May 5, 1987, and permanent signs were installed
by May 9, 1987.
- Initiate procedure changes to require operators to log the
procedure and the step numbers that apply to current plant
conditions and evolutions. The changes would also require
that the appropriate section of that procedure be reviewed
by the oncoming operator, prior to shif t change.
Status: In place May 1, 1987 by Standing Order 87-11.
Permanent procedure changes will be made through the normal
process.
"
Require that all completed steps of key procedures be
properly signed off, rather than marked with a check mark.
Status: Inplemented by Night Order May 2, 19075 made permanent
by Standing Order 01 12, May 6, 1907. This was formerly the
4
. _ - _ _ _ _ _ - _ _-_---__- _ _ ___ __ _ __ _ _ _ _ __- _ _ ______ _ _ _ __ . - _ _
, _ .___ __--_--_ _ _---- _ _ __..__.
.
practice for Periodic Tests (pts) and Maintenance Instructions
(mis). All General Operating Procedures (GOPs) with the
exception of G0P-3 are now corrected per this standing order.
Formal procedure changes will follow through the normal process.
Implement and train on formal " repeat-back" communication.
Status: Initially communicated to each shift verbally
immediately following the incident and prior to each shift
performing any shift activities. This was followed by
Standing Order 87-11 on May 1, 1987. Procedure changes will
follow by the normal process. Additional instructions will
be given during each crew's subsequent training weeks. The
first such session will take place on May 15, 1987.
Review System Operating Instructions (501's) to determine if
they should be made " mandatory-in-hand" procedures.
Status: Initial review has been completed and the above change
will not be made at this time. However, Standing Order 87-11,
dated May 1, 1987, requires a review of procedures prior to any
particular evolution, to determine whether an S0I (or other
procedure) pertains to the evolution. If a procedure does exist,
it must be reviewed prior to the evolution; if not, then pre-
cautions and limitations of the associated S0I must be reviewed
for applicability.
The above requirement, specified in Standing Order 87-11
May 1, 1987, will be updated to require the Shift Engineer to
determine whether a procedure is needed, for those evolutions
or conditions where presently there are no procedures.
Review the method of control of orders given to operators.
Status: The control of orders given to operators has been
more clearly defined in Standing Order 87-13, dated May 7,
1987. In addition, Standing Order 87-13 changes the division
of responsibilities between the shift Control Room Supervisor
(normally the SCRE) and the shift's Second Licensed Foreman,
in order to distribute the workload more evenly. This change
allows the SCRE to devote more attention to unit operation.
"
Licensing will perform a review to determine whether an
unanalysed condition existed for this event.
Status: The completed review is expected by May 15, 1987.
" Review the shift's actions on April 30, 1987, in response to
the Safety Injection.
,
5
, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _______ _ _ ___ ________________ ______ _ ______-_____-_ . _ _
.
Status: The operating department management met with the
shift personnel and concluded that the actions taken were
fully consistent with the Emergency Response Guidelines
(ERGS) and that the reclosing of the MSIVs was done in a
conservative and timely fashion.
NRC interviews of shift management and review of plant parameters
from computer graphs revealed that the steam header pressurized
in about 5 to 10 minutes. Thus the event was essentially
terminated prior to closing the MSIVs. Shift management stated
that by the time they had proceeded through the ERGS for SI and
SI termination, they felt they could take more time and be more
deliberate than they could if there was a continuing steam demand.
The shift management stated that there were conflicting
indications, which could out be verified by personnel in the
control room, regarding the position of the MSIV hydraulic
pump breaker. For that reason, they chose to ensure that
the breaker was open prior to opening MSIV hydraulic valve
R8. Because the flow rate through R8 is approximately the
same as the capacity of the hydraulic pump, opening R8 with
the pump energized would not ensure that the MSIV's would close.
- Incorporate the applicable steps of S01-31, " Main Steam", into
the GOPs, where possible.
Status: This is under evaluation and the conclusions will be
documented.
" Review the depth and extent of the Operating Engineer's (0E)
control over the shift, through the Shift Engineer (SE).
Status: This review has been done by the Production
Superintendent and the Assistant Superintendent-0perations
and OE control is deemed adequate.
- Review the out-of-service (005) practices at Zion, since
initially MSIV's were not taken 00S properly.
Status: Although the licensee believes that the improper
005 was not a cause of the SI, 00S practices are still of
concern to the licensee because the MSIV 005 was apparently
not in accordance with Zion's procedures. Initial review
indicated that the 005 problem was confined to the MSIVs.
Zion station procedures stated that "Where it is possible to
energize or liven the equipment from more than one source,
the appropriate Out Of Service Card shall be placed on all
isolating devices (switches, valves, etc.) before the work
is started. It is not sufficient to attach an Out of Service
Card to a remote switch only." The Assistant Superintendent-
Operations had follow-up discussions with each crew regarding
the standing orders issued and this 00S problem on May 6, 1987
through May 8, 1987.
6
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,
- Mandate that the " center desk NS0" issue all 00S jobs to
nonlicensed operators.
Status: This has been the practice at Zion. In the
discussion with the shift crews on May 6, 1987 through May 8,
1987 on 00S practices this was re-emphasized as the accepted
practice for issuing 00S jobs to the A and B operators for
write-up and card hangings.
(e) Safety Significance:
Unit I was in hot shutdown (Mode 3) at normal operating temperature
and pressure. The Reactor Coolant System (RCS) was cooled 27
degrees during the event. RCS pressure never exceeded 2280 psig.
The licensee determined that 3% of the design SI cycle life had
been used as a result of this transient. The Unit was in a condi-
tion for approximately twenty-five minutes during which all four
MSIVs were open and unable to be closed by an automatic signal, or
by manual action from the control room.
The secondary plant main steam headers were pressurized from 80
psig to about 800 psig in about four minutes. The main steam
lines saw a total heat up of about 200 degrees during the period
of pressurization. Since the MSIV's were closed only seven hours
earlier, the main steam lines had not cooled significantly from
normal operating temperature of 500 F prior to the re-pressurization.
A walkdown of containment and secondary steam piping did not
identify any damage. There were no personnel injuries as a result
of this event.
Section 14.2.5.3 of the Zion Final Safety Analysis Report (FSAR)
states that the MSIVs are designed to close within 10 seconds of a
large steamline break, and that for any break in any location, no
more than one steam generator (SG) would blowdown, even if one of
the isolation valves fails to close. Had a large steamline break
occurred during the April 30, 1987 event, the MSIVs would have been
incapable of both automatic and manual closure from the engineered
safety feature logic system (ESF). For any steamline break
downstream of the main steam check valves, all four SGs would have
blowndown. This would have constituted an unanalyzed condition.
(f) Inspector Comments
(1) The event occurred at 11:00 a.m. on April 30, 1987. The
event was reported to the NRC at 11:46 a.m. the same day.
This was within the one hour requirement of 10 CFR 50.72
(a)(3 for declaration of Emergency Classes (eg Unusual
Events .
(2) The licensee's corrective action was prompt as shown by the
stop work, immediate shift briefings, and series of Standing
7
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.
Orders. The extent of the corrective actions exceeds that
shown in responses to previous operating events, especially
as it pertains to communications and enforcement of procedural
adherance.
(3) Past performance in the operating area has been average.
Ratings given in NRC's Systematic Assessment of Licensee
Performance have been Category 2 (average) for the last 3
assessment periods. Communications have been adequate in
most cases, but are generally casual. Adherance to GOPs has
been very good, but S0Is have not been rigorously used.
Several events have occurred since the beginning of the year
involving failure of operators to adhere to procedures, or
erroneous assumptions on the part of operators regarding. plant
conditions or evolutions in progress.
(4) No specific notices had been given to the licensee by licensee
audits, or NRC or industry notification regarding similar
events.
(5) This is the first SI at Zion since January of 1984. Other
violations of operating procedures have occurred, but
their safety significance has been classified as minor. .
(g) Evaluation
This is considered an Unresolved Item per. ding review by a Region III 2
Enforcement Board (295/87012-01(DRP)).
3. Unresolved Items
Unresolved items are matters about which more information is required in
order to ascertain whether they are acceptable items, violations, or
deviations. One Unresolved Item disclosed during this inspection is
discussed in Paragraph 2.
4. Exit Interview
The inspectors met with licensee representatives (denoted in Paragraph 1)
throughout the inspection period and at the conclusion of the inspection
on May 12, 1987, to summarize the scope and findings of the inspection
activities. The licensee acknowledged the inspectors' comments.
The inspectors discussed the likely informational content of the
inspection report with regard to documents or processes reviewed by the
inspectors during the inspection. The licensee did not identify any
documents or processes as proprietary,
i
8
1
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. ATTACHMENT 1 l
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NITROGEN RELIEF
FIGURE 2la -H-C2
MSIV HYDR AU LIC ACTUATOR / ACCUMULATOR
- . . . ._. - _ - .
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FIGURE 210 -II- ci
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