ML17223A229

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
Issue date:	07/14/1989
From:	HOLIFIELD C D, WOODY C O 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)

Text

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

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'IHEDOQlMEÃZCCRZRDLDESK,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:~<'EQUENTIAIEViSIONNUMSEA:.>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