ML17264A592

LER 96-010-00:on 960806,latching of Main Turbine While in Mode 4 Occurred,Due to Defective Procedure,Resulting in Automatic Start of Auxiliary Feedwater Pump.Caused by Defective Maint Procedure.Procedure revised.W/960905 Ltr

ML17264A592
Person / Time
Site:	Ginna
Issue date:	09/05/1996
From:	MARTIN J T, MECREDY R C ROCHESTER GAS & ELECTRIC CORP.
To:	VISSING G S NRC (Affiliation Not Assigned), NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-96-010, LER-96-10, NUDOCS 9609130042
Download: ML17264A592 (9)

Text

cezsUORYREGULORYINFORMATIONDISTRIBUTISYSTEM(RIDS)ACCESSIONNBR:9609130042DOC.DATE:96/09/05NOTARIZED:NODOCKETFACIL:50-244RobertEmmetGinnaNuclearPlant,Unit1,RochesterG05000244AUTH.NAMEAUTHORAFFILIATIONMARTIN,J.T.RochesterGas6ElectricCorp.MECREDY,R.C.RochesterGasSElectricCorp.RECIP.NAMERECIPIENTAFFILIATIONVISSING,G.S.

SUBJECT:

LER96-010-00:on960806,Latchingmainturbinewhileinmode4occurred,duetodefectiveprocedure,resultinginautomaticstartofauxiliaryfeedwaterpump.Causedbydefectivemaintprocedure.Procedurerevised.W/960905ltr.DZSTRZBUTZONCODE:ZE22TCOPZESRECEZVED:LTRIENCL3SZZE:TITLE:50.73/50.9LicenseeEventReport(LER),TncidentRpt,etc,NOTES:LicenseExpdateinaccordancewith10CFR2,2.109(9/19/72).05000244RECIPIENTIDCODE/NAMEPD1-1PDINTERNAL'~ILECENTERNRRDELBNRR/DRCH/HHFBNRR/DRCH/HOLBNRR/DRPM/PECBNRR/DSSA/SRXBRGN1FILE01EXTERNAL:LSTLOBBYWARDNOACMURPHYiG.ANRCPDRCOPIESLTTRENCI112211111111111111111111RECIPIENTIDCODE/NAMEVISSING,G.AEOD/SPD/RRABNRR/DE/ECGBNRR/DE/EMEBNRR/DRCH/HICBNRR/DRCH/HQMBNRR/DSSA/SPLBRES/DSIR/EIBLITCOBRYCE,JHNOACPOORE,W.NUDOCSFULLTXTCOPIESLTTRENCI1111111111111111221111DNNOTETOALL"RIDS"RECIPIENTS:PLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOMOWFN5D-5(EXT.415"2083)TOELIMINATEYOURNAMEFROMDISTRIBUTIONLISTSFORDOCUMENTSYOUDON'TNEED!FULLTEXTCONVERSIONREQUIRTOTALNUMBEROFCOPIESREQUIRED:LTTR25ENCL25 ROCHESTERGASANDEIECTRICCORPORATION+89EASTAVfNUE,ROCHESTER,N.Y.Id6d9.000IAREACODE7I6Sd6.2TOOROBERTC.MECREDYVicePresioeosNvc.'eorOoe~ol.'ooSSeptember5,1996U.S.NuclearRegulatoryCommissionDocumentControlDeskAttn:GuyS.VissingProjectDirectorateI-1Washington,D.C.20555

Subject:

LER96-010,LatchingMainTurbineWhileinMode4,DuetoDefectiveProcedure,ResultsinAutomaticStartofAuxiliaryFeedwaterPumpR.E.GinnaNuclearPowerPlantDocketNo.50-244

DearMr.Vissing:

Inaccordancewith10CFR50.73,LicenseeEventReportSystem,item(a)(2)(iv),whichrequiresareportof,"Anyeventorconditionthatresultedinamanualorautomaticactuationofanyengineeredsafetyfeature(ESF),includingthereactorprotectionsystem(RPS)",theattachedLicenseeEventReportLER96-010isherebysubmitted.Thiseventhasinnowayaffectedthepublic'shealthandsafety.Verytrulyyours,RobertC.Mecredyxc:Mr.GuyS.Vissing(MailStop14C7)PWRProjectDirectorateI-1Washington,D.C.20555JU.S.NuclearRegulatoryCommissionRegionI475AllendaleRoadKingofPrussia,PA19406GinnaSeniorResidentInspector'ssb0'Pi300429b0905PDRADOCK05000244PDR NRCFORM366(4-95)U.S.NUCLEARREGULATORYCOMMISSIOLICENSEEEVENTREPORT(LER)(Seereverseforrequirednumberofdigits/charactersforeachblock)APPROVEDBYOMBNO.3150%104EXPIRES04/30/98ESTIMATEDBURDENPERRESPONSEToCOMPLYWITHTHISMANDATORYINFORMATIONCOLLECTIONREQUEST:50.0HRS.REPORTEDLESSONSLEARNEDAREINCORPORATEDINTOTHELICENSINGPROCESSANDFEDBACKToINDUSTRY.FORWARDCOMMENTSREGARDINGBURDENESTIMATEToTHEINFORMATIONANDRECORDSMANAGEMENTBRANCHIT.BF33),U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON,DC20555-0001,ANDToTHEPAPERWORKREDUCTIONPROJECTFACIUTYNAME(1)R.E.GinnaNuclearPowerPlantDOCKET)IVMSBI(3)05000244PAGE(3)1OF6TITLE(4)LatchingMainTurbineWhileinMode4,DuetoDefectiveProcedure,ResultsinAutomaticStartofAuxiliaryFeedwaterPumpMONTHDAYYEAREVENTDATE(6)LERNUMBER(6)SEQUENTIALREVISIONNUMBERNUMBERMONTHDAYYEARREPORTDATE(7)FAOILITYNAMEOTHERFACILITIESINVOI.VED(8)DOCKETNUMBER08069696-010-00090596FACIUTYNAMEDOCKETNUMBEROPERATINGMODE(9)THISREPORTISSUBMITTEDPURSUANTTOTHEREQUIREMENTSOF10CFRE:(Checkoneor20.2201(b)20.2203(a)(2)(v)50.73(a)(2)(i)morel(11)50.73(a)(2)(viii)POWERLEVEL(10)00020.2203(a)(1)20.2203(a)(2)(i)20.2203(a)(2)(ii)20.2203(a)(2)(iii)20.2203(a)(2)(iv)20.2203(a)(3)(i)20.2203(a)(3)(ii)20.2203(a)(4)50.36(c)(1)50.36(c)(2)LICENSEECONTACTFORTHISLER50.73(a)(2)(ii)50.73(a)(2)(iii)X50.73(a)(2)(iv)50.73(a)(2)(v)50.73(a)(2)(vii)(12)TELEPHONENVM8SR(IrctvdeAreaCode)50.73(a)(2)(x)73.71OTHERSpecrfymAbstractbeloworinNRCForm366AJohnT.St.Martin-TechnicalAssistantCOMPLETEONELINEFOREACHCOMPONENTFAILUREDES(716)771-3641CRIBEDINTHISREPORT(13)CAUSESYSTEMCOMPONENTMANUFACTURERToNPRDSCAUSESYSTEMCOMPONENTMANUFACTURERToNPRDSSUPPLEMENTALREPORTEXPECTED(14)YES(Ifyes.completeEXPECTEDSUBMISSIONDATE).XNOEXPECTEDSUBMISSIONDATE(16)MONTHDAYYEARABSTRACT(Limitto1400spaces,i.e.,approximately15single-spacedtypewrittenlines)(16'.OnAugust6,1996,atapproximately1315EDST,theplantwasinMode4withthereactorcoolantsystembeingmaintainedatatemperatureof340degreesFandapressurizerpressureof350PSIGwithasteambubbleinthepressurizer.Aspartofcompletionofacorrectivemaintenanceactivity,themainturbinewaslatchedperaMaintenanceprocedure.Sincethecircuitbreakersforbothmainfeedwaterpumpswerealreadyopen,thiscreatedlogicforanautostartofthe"A"motor-drivenauxiliaryfeedwaterpump.Immediateactionwastosecurethe"A"auxiliaryfeedwaterpumpandstabilizeauxiliaryfeedwaterflowtobothsteamgenerators.Theunderlyingcauseoftheautostartwasthatthelogicforautostartwascreatedbylatchingtheturbine,duetoadefectiveMaintenanceprocedure.ThiseventisNUREG-1022CauseCode(D).CorrectiveactiontopreventrecurrenceisoutlinedinSectionV.B.NRCFORM366(4.95)

NRCFORM366A(4.95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)YEARSEQUENTIALREVISIONNUMBERNUMBER96-010-00PAGE(3)2OF6TEXTIifmorespaceisrequired,useedditionelcopiesofNRCForm366AI(17)PRE-EVENTPLANTCONDITIONS:OnAugust6,1996,theplantwasinMode4asaresultofavoluntaryplantshutdowntoupgrademotor-operatedvalvesintheresidualheatremoval(RHR)system.DuringthisshutdownanopportunitywasidentifiedbyanInstrumentandControl(l&C)plannertocompleteacorrectivemaintenanceactivityonmainturbinecontrolvalveCV-2.Thereactorcoolantsystem(RCS)wasbeingmaintainedatatemperatureofapproximately340degreesFandapressurizer(PRZR)pressureofapproximately350PSIGwithasteambubbleinthePRZR.The"B"motor-drivenauxiliaryfeedwater(AFW)pumpwasoperatingtomaintainwaterinventoryinbothsteamgenerators(S/G),andthe"A"motor-drivenAFWpumpwasnotoperating.II.DESCRIPTIONOFEVENT:A.DATESANDAPPROXIMATETIMESOFMAJOROCCURRENCES'ugust6,1996,1315EDST:Themainturbineislatched.August6,1996,1315EDST:Eventdateandtime.August6,1996,1315EDST:Discoverydateandtime.August6,1996,1316EDST:ThesecondrunningAFWpumpissecured.B.EVENT:OnAugust6,1996,atapproximately1315EDST,theplantwasinMode4.I&CtechnicianswerepreparingtocalibratemainturbinecontrolvalveCV-2,tocompleteapreviouslyinitiatedcorrectivemaintenanceactivityonthisvalve.I&CtechniciansrequestedtheControlRoomoperatorstolatchthemainturbineperMaintenanceProcedureM-109("A"EHGovernorHighPressureFluidSystemAdjustment,CalibrationandMaintenance).ThisisdonetosupplyEHpressuretothecontrolvalvesinordertostrokethem.AControlRoomoperatorlatchedtheturbineasdirectedbyprocedureM-109.Bothmainfeedwater(MFW)pumpbreakerswereopen.Withthisconditionandtheturbinelatched,anautostartsignalwassuppliedtobothmotor-drivenAFWpumps,whichcausedanautostartofthe"A"AFWpump.Atthistimethe"B"AFWpumpalsoreceivedanautostartsignal,butwasalreadyoperating.TheControlRoomoperatorsobservedtheautostartofthe"A"AFWpumpandpromptlysecuredthe"A"AFWpumptominimizeanexpectedcooldownofthereactorcoolantsystem(RCS).AFWflowwascontrolledatthedesiredflowrateforMode4conditions.DuringthetimetwoAFWpumpswereoperating,therewasaslightcooldownoftheRCSofapproximatelythree(3)degreesF.NRCFORM366A(4-95)

NRCFRM366A(4-95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAME(1)DOCKETLERNUMBER(6)PAGE(3)R.E.GinnaNuclearPowerPlant05000244YEARSEQUENTIALREVISIONNUMBERNUMBER3OF696-010-00TEXTllfmorespaceisrequired,useedditionelcopiesofNRCForm366Al(17)C.INOPERABLESTRUCTURES,COMPONENTS,ORSYSTEMSTHATCONTRIBUTEDTOTHEEVENT:NoneD.OTHERSYSTEMSORSECONDARYFUNCTIONSAFFECTED:NoneE.METHODOFDISCOVERY:Thiseventwasimmediatelyapparentwhenthe"A"AFWpumpautostartedaftertheturbinewaslatched.OPERATORACTION'heControlRoomoperatorfollowedthedirectionofprocedureM-109andlatchedtheturbine.Afterthe"A"AFWpumpautostarted,theControlRoomoperatorstookpromptactionstominimizeanyRCScoo!downandcontrolAFWflow.Theypromptlysecuredthe"A"AFWpump.TheControlRoomoperatorssubsequentlynotifiedhighersupervisionandnotifiedtheNRCper10CFR50.72(b)(2)(ii),non-emergencyfourhournotification,atapproximately1600EDSTonAugust6,1996.G.SAFETYSYSTEMRESPONSES:The"A"AFWpumpautostartedasperdesignduetothemainturbinebeinglatchedwhilebothMFWpumpbreakerswereopen.The"B"AFWpumpalsoreceivedanautostartsignal,butwasalreadyoperating.III.CAUSEOFEVENT:A.IMMEDIATECAUSE:Theimmediatecauseoftheautostartofthe"A"AFWpumpwaslatchingthemainturbinewithbothMFWpumpbreakersopen.B.INTERMEDIATECAUSE:Theintermediatecauseoflatchingthemainturbine,wascompliancewithprocedureM-109,whichhadtechnicalinaccuraciesandwasnotthecorrectproceduretobeusedinthisplantcondition.NACFOAM366A(4-95)

NRCFORM366AI4-S5)LXCENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAMEI1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBERI6)YEARSEQUENTIALREVISIONNUMBERNUMBER96-010-00PAGEI3)4OF6TEXT(Ifmorespeceisrequired,useeddirionalcopiesofNRCForm368AIl17)C.ROOTCAUSE:AHumanPerformanceEnhancementSystem(HPES)evaluationwasinitiatedbecauseofthisevent.TheHPESevaluationconcludedthattheunderlyingcauseoftheautostartofthe"A"AFWpumpwasthatprocedureM-109wasadefectiveprocedure.ThiseventisNUREG-1022CauseCode(D),"DefectiveProcedure".ThreecausalfactorswereidentifiedbytheHPES.OneofthecausalfactorsisWrittenCommunications(technicalinaccuracies).ThesecondcausalfactorisWorkOrganizationandPlanning(jobscopingdidnotidentifyspecialcircumstances/conditionsandworkplanningwasnotcoordinatedwithalldepartmentsinvolvedinthetask)~ThethirdcausalfactorisWorkPractices(generalequipmentconditionnotcheckedbeforestartingworkandself-checkingnotappliedtoensureintendedactioniscorrect).TheautostartoftheAFWpumpdoesnotmeettheNUMARC93-01,"IndustryGuidelineforMonitoringtheEffectivenessofMaintenanceatNuclearPowerPlants",definitionofa"MaintenancePreventableFunctionalFailure".IV.ANALYSISOFEVENT:Thiseventisreportableinaccordancewith10CFR50.73,LicenseeEventReportSystem,item(a)(2)(iv),whichrequiresareportof,"Anyeventorconditionthatresultedinamanualorautomaticactuationofanyengineeredsafetyfeature(ESF),includingthereactorprotectionsystem(RPS)".ThestartofanAFWpumpisanactuationofanESF.Anassessmentwasperformedconsideringboththesafetyconsequencesandimplicationsofthiseventwiththefollowingresultsandconclusions:Therewerenooperationalorsafetyconsequencesorimplicationsattributedtotheautostartofthe"A"AFWpumpbecause:oTheautostartofthe"A"AFWpumpoccurredwiththe"8"AFWpumpalreadyoperatingandwithacceptablelevelsinbothS/Gs.AFWflowwascontrolledtomaintaintheselevels.The"A"AFWpumpwaspromptlysecuredtominimizeanyRCScooldown.ThelimitingcaseforthesupplyofAFWistheLossofFeedwateraccidentat100%power.TheplantconditionatthetimeofthiseventwasMode4withfeedwaterbeingsuppliedbythe"B"AFWpump.NRCFORM366A(4-65)

NRCFORM366AI4-95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAMEI1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBERI6)YEARSEQUENTIALREVISIONNUMBERNUMBER96-010-00PAGEI3)5OF6TEXT(Ifmorespaceisrequired,useaddirionalcopiesofNRCForm386AJl17)oWhentheturbineislatched,themainturbinestopvalvesopenandthemainturbinecontrolvalvesremainclosed.WiththeMSIVbypassvalvesopen,theonlypotentialcooldownpaththroughtheturbineisleakagepastthecontrolvalves.Theamountofleakagewasnotsufficienttorolltheturbineofftheturninggear,andwouldnotcauseamajorcooldownunlessthecontrolvalvesaresubsequentlyopened.Normaloperatingproceduresrequireborationtothecoldshutdownboronconcentration(boronconcentrationtoensureashutdownmargin(SDM)of2.45%at70degreesF)priortocoolingdownbelow500degreesF.Duringthisevent,RCSboronconcentrationwasinexcessofthe2.45%shutdownmarginlevelbyapproximately150partspermillion(PPM).Alsonotethattherequiredboronconcentrationcorrespondingtothe2.45%SDMlimithasanadditional100PPMconservativeallowanceincluded.Thus,anRCScooldowninthisconditionwouldnothavechallengedSDMrequirements,norwouldthereactorapproachcriticality.oAnRCScooldownfromthisconditionwouldaddminimalpositivereactivity.Itisestimatedthattheisothermaltemperaturecoefficient(ITC)islessnegativethan-1pcmperdegreeF,andamajorcooldown(from340degreesFto212degreesF)wouldaddlessthan128pcmofpositivereactivity.Anexcessboronconcentrationofonly12to13PPMwillcompensateforthismuchreactivity.Thus,apotentialcooldownoftheRCSwouldnotpresentasafetyissue.Basedontheabove,itcanbeconcludedthatthepublic'shealthandsafetywasassuredatalltimes.V.CORRECTIVEACTION:A.ACTIONTAKENTORETURNAFFECTEDSYSTEMSTOPRE-EVENTNORMALSTATUS:oAFWflowwascontrolledasdesiredtomaintainS/Glevel.oThe"A"AFWpumpwaspromptlysecuredtominimizeanyRCScooldown.B.ACTIONTAKENORPLANNEDTOPREVENTRECURRENCE:ProcedureM-109willberevisedtoensurethatlatchingofthemainturbineisproperlycontrolledandAFWpumpconcernsareaddressed.Expectationswillbereviewedwithoperators.Emphasiswillbeplacedonfullyunderstandingworkplansandmaintainingaquestioningattitudethroughoutthepre-jobbriefing.NRCFORM366AI4-95)

NRGFORM366A(4-95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAME(I)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)YEARSEQUENTIALREVISIONNUMBERNUMBER96-010-00PAGE(3)6OF6TEXTilfmorespaceisrequired,useadditionalcopiesofNRCForm366Aj(17)VI.ADDITIONALINFORMATION:A.FAILEDCOMPONENTS:NoneB.PREVIOUSLERsONSIMILAREVENTS:AsimilarLEReventhistoricalsearchwasconductedwiththefollowingresults:NodocumentationofsimilarLEReventswiththesamerootcausecouldbeidentified.However,LERs96-004and96-008aresimilareventswithdifferentrootcauses.C.SPECIALCOMMENTS:NoneNACFOAM366A<4-95)