ML17264A542

LER 96-006-00:on 960521,discovered Containment Penetration Not in Required Status.Caused by Personnel Error.Installed Flange Inside Containment Penetration 2.W/960620 Ltr

ML17264A542
Person / Time
Site:	Ginna
Issue date:	06/20/1996
From:	MECREDY R C, ST MARTIN J T ROCHESTER GAS & ELECTRIC CORP.
To:	VISSING G S NRC (Affiliation Not Assigned), NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-96-006, LER-96-6, NUDOCS 9606260154
Download: ML17264A542 (10)

Text

CATEGORY 1 REGULATO Y INFORMATION DISTRIBUTION SYSTEM (RIDS)ACCESS1'ON NBR:9606260154 DOC.DATE: 96/06/20 NOTARIZED:

NO FACIL:50-244 Robert Emmet Ginna Nuclear Plant, Unit 1, Rochester AUTH.NAME AUTHOR AFFILIATION ST.MARTIN,J.T.

Rochester Gas&Electric Corp.MECREDY,R.C.

Rochester Gas&Electric Corp.RECIP.NAME RECIPIENT'AFFILIATION DOCKET G 05000244

SUBJECT:

LER 96-006-00:on 960521,discovered containment penetration not in required status.Caused by personnel error.Installed flange inside containment penetration 2.W/960620 ltr.DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL SIZE: TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.NOTES:License Exp date in accordance with 10CFR2,2.109(9/19/72).

A'5000244 (I RECIPIENT ID CODE/NAME PDl-1 PD INTERNAL: AEOD/SPD/RAB gF'ZEE CENE E NRR/DE/EEL'B NRR/DRCH/HHFB NRR/DRCH/HOLB NRR/DRPM/PECB NRR/DSSA/SRXB RGN1 FILE 01 EXTERNAL: L ST LOBBY WARD NOAC MURPHYFG~A NRC PDR COPIES LTTR ENCL 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 RECIPIENT ID CODE/NAME VISSINGFG.

AEOD/SPD/RRAB NRR/DE/ECGB NRR/DE/EMEB NRR/DRCH/HICB NRR/DRCH/HQMB NRR/DSSA/SPLB RES/DSIR/EIB LITCO BRYCEFJ H NOAC POOREFW.NUDOCS FULL TXT COPIES LTTR ENCL 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 D.N NOTE TO ALL"RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTE!CONTACT THE DOCUMENT CONTROL DESK/ROOM OWFN 5D-5(EXT.415-2083)TO ELIMINATE YOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 25 ENCL 25 AND ROCHESTER GAS AND ElECTRIC CORI@RATION

~89 EAST AVENUE, ROCHESTER, N.Y.IrI64'rr DDT AREA CODE 716 5'-27tXt ROBERT C.MECREDY Vice President Nucte or Operations June 20, 1996 U.S.Nuclear Regulatory Commission Document Control Desk Attn: Guy S.Vissing Project Directorate I-1 Washington, D.C.20555

Subject:

LER 96-006, Containment Penetration Not in Required Status, Due to Personnel Errors, Results in Potential for Uncontrolled Release of Radioactive Material R.E.Ginna Nuclear Power Plant Docket No.50-244 In accordance with 10 CFR 50.73, Licensee Event Report System, items (a)(2)(ii), (a)(2)(v)(C)and (a)(2)(v)(D), which require a report of,"Any operation or condition prohibited by the plant's Technical Specifications" or"Any event or condition that alone could have prevented the fulfillment of the safety function of structures or systems that are needed to...Control the release of radioactive material;or Mitigate the consequences of an accident", the attached Licensee Event Report LER 96-006 is hereby submitted.

This event has in no way affected the public's health and safety.Very ly yours, Robert C.Mecredy xc: U.S.Nuclear Regulatory Commission Mr.Guy S.Vissing (Mail Stop 14C7)PWR Project Directorate I-1 Washington, D.C.,20555 U.S.Nuclear Regulatory Commission Region I 475 Allendale-Road King of Prussia, PA 19406 U.S.NRC Ginna Senior Resident Inspector 9606260i54 960620 PDR ADQCK 05000244 8 PDR y/~JP NRC FORM 366 (4.95)U.S.NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER)(See reverse for required number of digits/characters for each block)APPROVED BY OMB NO.3150-0104 EXPIRES 04/30/BB ESTIMATED BURDEN PER AESPONSE To COMPLY WITH THIS MANDATORY INFORMATION COLLECTION REQUEST: 50.0 HRS.REPOATED LESSONS LEARNED ARE INCORPORATED INTO THE UCENSING PROCESS AND FED BACK To INDUSTRY.FORWARD COMMENTS REGARDING BURDEN ESTIMATE To THE INFORMATION AND RECORDS MANAGEMENT BRANCH IT-6 F33), U.S.NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555.0001, AND To THE PAPEAWORK REDUCTION PROJECT FACILITY kAME (1)R.E.Ginna Nuclear Power Plant OOCKET NUMBER (2)05000244 PAGE (3)1OF8 B (4)A Containment Penetration Not in Required Status, Due to Personnel Errors, Results'in Potential for Uncontrolled Release of Radioactive Material MONTH DAY YEAR 05 21 96 EVENT DATE (5)LER NUMBER (6)SEQUENTIAL REVISION NUMBER., NUMBER 96-006-00 MONTH DAY YEAR 06 20 96 REPORT DATE (7)FACILITY NAME FACILITY NAME OTHER FACILITIES INVOLVED (6)OOCKET NUMBER OOCKET NUMBER OPERATING MODE (9)POWER LEVEL (10)kAME 000 THIS REPORT IS SUBMITTED PUR more)(11)50.73(a)(2)(viii]50.73(a)(2)(x)50.73(a)(2)(i)50.73(a)(2)(ii)20.2203(a)(2)(v) 20.2203(a)(3)(i) 20.2201(b) 20.2203ta) tl)73.71 50.73(a)(2)(iii)50.73(a)(2)(iv)20.2203(a)

(3)(ii)20.2203(a)

(4)20.2203(a)

(2)(i)20.2203(a)(2)(ii)

OTHER Specify in Abstract below or in NRC Form 366A 20.2203(a)(2)(iii)50.36(c)(1) 50.73(a)(2)(v)20.2203(a)

(2)(iv)50.36(c)(2)50.73(a)(2)(vii)

LICENSEE CONTACT FOR THIS LER (12)ELBPIIOkE NUMBER (Include Area Coda>SUANT TO THE REQUIREMENTS OF 10 CFR E: (Check one or John T.St.Martin-Technical Assistant (716)771-3641 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)CAUSE SYSTEM COMPONENT MANUFACTURER AEPOATABLE TO NPADS CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE To NPRDS SUPPLEMENTAL REPORT EXPECTED (14)YES (lf yes, complete EXPECTED SUBMISSION DATE).X NO EXPECTED SUBMISSION DATE (15)MONTH DAY YEAR ABSTRACT (Limit to 1400 spaces, l.e., approximately 15 single-spaced typewritten lines)(16)On May 21, 1996, at approximately 0900 EDST, with the plant in Mode 6 with core alterations and movement of irradiated fuel assemblies within containment in progress, it was discovered that a containment penetration was not in the required status for refueling operations, allowing direct access from the containment atmosphere to the outside atmosphere.

Immediate corrective action was taken in accordance with Ginna Improved Technical Specifications Limiting Conditions for Operation 3.9.3.A.1 and 3.9.3.A.2 to suspend core alterations and suspend movement of irradiated fuel assemblies within containment.

The containment penetration was restored to the required status for refueling operations, and refueling operations were permitted to resume.The underlying cause of the penetration not being in the required status for refueling operations was personnel errors.This event is NUREG-1022 Cause Code (A).Corrective action to prevent recurrence is outlined in Section V.B.NRC FORM 366 (4-95)

NRC FORM 366A I4-95)LICENSEE EVENT REPORT (LER), TEXT CONTINUATION U.S.NUCLEAR REGULATORY COMMISSION FACILITY NAME Il)R.E.Ginna Nuclear Power Plant DOCKET 05000244 LER NUMBER I6)YEAR SEQUENTIAL REVISION NUMBER NUMBER 96-006-00 PAGE I3)2 OF 8 TEXT (If more spaceis required, use additional copies of NRC Form 366A/(17)PRE-EVENT PLANT CONDITIONS:

Containment (CNMT)penetration I)'2 (referred to as P-2)is the"S/G Communications Flange Penetration" normally used for support of routine steam generator (S/G)maintenance and inspection activities during refueling outages.When in Modes 5 or 6, normally routed through P-2 are closed-circuit television (CCTV)cables and other communications cables.For the 1996 Refueling outage, P-2 was also used to provide a route for additional CCTV cables and rigid pipes from'the outside into CNMT, to provide services (communications, air and argon)for activities associated with replacement of the S/Gs.These pipes were a 3" line for service air and a 1 1/2" line for argon.Station Modification procedures SM-10034-10.01 (Temporary Service Air System for SGRP)and SM-10034-'l0.03 (Installation 5 Removal of Temporary CCTV and Communications) were used to control the temporary installation and subsequent removal of these services.On May 19, 1996, in preparation for refueling the reactor, Ginna plant staff checked the configuration of P-2 and verified that the configuration complied with Ginna Improved Technical Specifications (ITS)Limiting Condition for Operation (LCO)3.9.3.c, which states that each penetration providing direct access from the CNMT atmosphere to the outside atmosphere shall be isolated, or closed by an equivalent isolation method.These methods include use of material that can provide a temporary, atmospheric pressure, ventilation barrier.Contractor supervision were subsequently notified not to disturb the configuration of P-2 until after the completion of refueling.

During the dayshift on May 20, 1996, as directed by contractor supervision, contractor maintenance personnel removed much of the temporary service air and argon lines inside CNMT, as directed by procedure SM-10034-10.01.

Contractor supervision had been cautioned by Ginna staff not to remove the 3" and 1 1/2" pipe spoolpieces that were inside the seal for P-2 and the first valves on each side of P-2 inside and outside of CNMT.Nevertheless, at the end of their shift (at approximately 1800 EDST), the contractor maintenance personnel removed these spoolpieces and valves.Additional piping outside CNMT was left in place until the next day.On May 21, 1996, at approximately 0300 EDST, a utility non-licensed operator was performing Operating Procedure 0-15.2 (Valve Alignment for Reactor Head Lift, Core Component Movement, and Periodic Status Checks), in preparation for the start of refueling operations.

As part of this procedure, the operator performed Step 5.2.1 to verify that P-2 was"adequately sealed", and signed off Step 5.2.1 of procedure 0-15.2.Satisfactory completion of this step ensures compliance with ITS LCO 3.9.3.c.NRG FORM 366A I4-95)

NRC FORM 366A (4-95)LXCENSEE EVENT REPORT (LER)TEXT CONTINUATION U.S.NUCLEAR REGULATORY COMMISSION FACILITY NAME (1)R.E.Ginna Nuclear Power Plant DOCKET 05000244 LER NUMBER (6)YEAR SEQUENTIAL REVISION NUMBER NUMBER 96-006-00 PAGE (3)TEXT (If more spaceis required, use additional copies of NRC Form 366A/(17)DESCRIPTION OF EVENT: A.DATES AND APPROXIMATE TIMES OF MAJOR OCCURRENCES:

0 May 19, 1996: Ginna staff verify that the configuration of P-2 meets the required status of ITS LCO 3.9.3.c.May 20, 1996, 1800 EDST: Contractor maintenance personnel remove pipe spoolpieces from inside the seal for P-2.P-2 configuration does not meet the required status of ITS LCO 3.9.3.c.0 May 21, 1996, 0537 EDST: The plant enters Mode 6 and begins core alterations and movement of irradiated fuel asemblies within CNMT.Event date and time.0 May 21, 1996, 0900 EDST: Discovery date and time.0 May 21, 1996, 0937 EDST: All remaining cables are removed from P-2, and P-2 is flanged off.B.EVENT: On May 21, 1996, all preparations for refueling were completed.

Procedure 0-15.2 had been signed off at approximately 0505 EDST, and the Control Room operators notified the Senior Reactor Operator assigned to Refueling (Refueling SRO)to begin refueling.

The plant entered Mode 6 at approximately 0537 EDST and began refueling operations (core alterations and movement of irradiated fuel assemblies within CNMT).On May 21, 1996, at approximately 0800 EDST, contractor maintenance personnel continued their work from the previous day for removal of lines as per SM-10034-10.01.

Since these lines were potentially contaminated, a Radiation Protection (RP)technician was requested to survey the removed lines prior to disposal.On May 21, 1996, at approximateiy 0900 EDST, with the plant in Mode 6 and refueling operations in progress, the RP technician approached P-2 tosurvey some materials and discovered that P-2 was not in the required status for refueling operations.

He observed that P-2 was not completely sealed where the 3" and 1 1/2" spoolpieces had been, appearing to allow direct access from the CNMT atmosphere to the outside atmosphere.

NRC FORM 366A (4.95)

NRC FORM 366A (4.95)LICENSEE EVENT REPORT (LER)TEXT CONTINUATION U.S.NUCLEAR REGULATORY COMMISSION FACILITY NAME (1)R.E.Ginna Nuclear Power Plant DOCKET 05000244 LER NUMBER (6)YEAR SEQUENTIAL REVISION NUMBER NUMBER 96-006-00 PAGE (3)4 OF 8 TEXT llf more space is required, use additional copies of NRC Form 386Ai (17)The RP technician notified his supervision.

RP supervision notified a member of the plant Outage Management staff, who inspected P-2 and confirmed that it was not adequately sealed.The Control Room operators were notified of the status of P-2 as observed from outside CNMT.Immediate actions were taken per ITS LCO ACTIONs 3.9.3.A.1 and 3.9.3.A.2 to suspend core alterations and suspend movement of irradiated fuel assemblies within CNMT.The Refueling SRO inside CNMT was also notified that P-2 needed to be inspected from inside CNMT for the presence of a flange.The Refueling SRO inspected P-2 and confirmed that the penetration was not isolated inside CNMT by use of a material that can provide a temporary, atmospheric pressure, ventilation barrier.The RP technician verified that the actual flow of air was from the outside into CNMT.Ginna and contractor electricians were notified to remove all remaining cables routed through P-2.When the cables were removed and the penetration was unobstructed inside CNMT, Ginna pipefitters installed a flange over P-2.These actions restored P-2 to the required status for refueling operations, and refueling operations were permitted to resume at approximately 0937 EDST on May 21, 1996.C.INOPERABLE STRUCTURES, COMPONENTS, OR SYSTEMS THAT CONTRIBUTED TO THE EVENT: None D.OTHER SYSTEMS OR SECONDARY FUNCTIONS AFFECTED: None E.METHOD OF DISCOVERY:

While performing routine monitoring activities for the removal of potentially contaminated materials from CNMT, a Radiation Protection technician discovered that P-2 was not completely sealed as observed from outside CNMT.The Refueling SRO confirmed that P-2 was not in the required status for refueling operations.

F.OPERATOR ACTION: The Control Room operators, upon being notified that P-2 was not in the required status for refueling operations, immediately complied with the requirements of ITS LCO ACTIONs 3.9.3.A.1.

and 3.9.3.A.2, which require that if one or more CNMT penetrations are not in required status,"Suspend CORE ALTERATIONS" and"Suspend movement of irradiated fuel assemblies within containment".

Subsequently, the Control Room operators notified higher supervision and the NRC Senior Resident Inspector.

At approximately 1226 EDST on May 21, 1996, a 4 hour4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> non-emergency notification was made to the NRC Operations Center as per 10 CFR 50.72 (b)(2)(iii)(C)and 10 CFR 50.72 (b)(2)(iii)(D).NRC FORM 366A (4-95)

NRC FORM 366A (4 95)LICENSEE EVENT REPORT (LER)TEXT CONTINUATION U.S.NUCLEAR REGULATORY COMMISSION FACILITY NAME (1)R.E.Ginna Nuclear Power Plant DOCKET 05000244 LER NUMBER (6)YEAR SEQUENTIAL REVISION NUMBER NUMBER 96-006-00 PAGE (3)TEXT llf more space is required, uso additional copies of NRC Form 366Al (17)G.SAFETY SYSTEM RESPONSES:

None III.CAUSE OF EVENT: A.IMMEDIATE CAUSE: The immediate cause of CNMT penetration P-2 not being in the required status for refueling operations was openings in the foam seal where a 3" pipe and 1 1/2" pipe had been removed.This condition was not identified by Operations personnel during performance of procedure 0-15.2.B.INTERMEDIATE CAUSE: The intermediate cause of the openings in the foam seal for P-2 was the unauthorized removal of the pipe spoolpieces and associated valves from the penetration.

The intermediate cause of not identifying this condition during the performance of 0-15.2 was inadequate verification by Operations personnel.

ROOT CAUSE: The underlying cause of the unauthorized removal of the spoolpieces was personnel error.The underlying cause of the inadequate verification by Operations personnel was also personnel error.A Human Performance Enhancement System (HPES)evaluation was performed to determine the causal factors that contributed to these personnel errors.This event is NUREG-1022 Cause Code (A),"Personnel Error".Personnel errors were made by contractor maintenance personnel and a utility non-licensed operator.These errors were cognitive personnel errors on the part of both groups.The contractor maintenance personnel did not recognize the impact on refueling operations of removing the pipe spoolpieces from P-2.The Operations personnel did not recognize the actual configuration of the foam seal in P-2 during 0-15.2 verifications, perceived that they had accurately verified the configuration, and thought that P-2 was in the required status for refueling operations, when, in fact, P-2 was not adequately sealed.NRC FORM 366A (4-95)

NRC FORM 366A (4-SS)LICENSEE EVENT REPORT (LER)TEXT CONTINUATION U.S.NUCLEAR REGULATORY COMMISSION FACILITY NAME (1)R.E.Ginna Nuclear Power Plant DOCKET 05000244 LER NUMBER (6)SEQUENTIAL REVISION NUMBER NUMBER 96-006-00 PAGE (3)6 OF 8 TEXT iif more space is required, use additional copies of NRC Form 366AJ (17).The contractor maintenance error was contrary to approved procedure SM-10034-10.01, and the operator error was contrary to approved procedure 0-15.2.Unusual conditions present during the performance of 0-15.2 included nighttime darkness, a lightning storm, limited access to P-2 (P-2 was enclosed by a wooden protective enclosure), additional cable routed through P-2 for the 1996 outage, and some of the remaining piping and valves still being within the enclosure around P-2.These environmental factors may have obscured the view of the foam seal from outside CNMT, where the 3" and 1 1/2" spoolpieces had been.Access to view P-2 from inside CNMT was partially blocked, due to equipment inside CNMT for the S/G replacement.

This condition does not meet the NUMARC 93-01,"Industry Guideline for Monitoring the Effectiveness of Maintenance at Nuclear Power Plants", definition of a"Maintenance Preventable Functional Failure".IV.ANALYSIS OF EVENT: This event is reportable in accordance with 10 CFR 50.73, Licensee Event Report System, items (a)(2)(ii), (a)(2)(v)(C)and (a)(2)(v)(D), which require a report of,"Any operation or condition prohibited by the plant's Technical Specifications" or"Any event or condition that alone could have prevented the fulfillment of the safety function of structures or systems that are needed to...Control the release of radioactive material;or Mitigate the consequences of an accident".

Having a CNMT penetration not in the required status for refueling operations with refueling operations in progress is a condition prohibited by the ITS.It is postulated that, in the event of a fuel handling accident at this condition, the resultant radioactive release could be uncontrolled, and that the CNMT could have been ineffective in mitigating the consequences of this postulated accident.i An assessment was performed considering both the safety consequences and implications of this event with the following results and conclusions:

There were no operational or safety consequences or implications attributed to this condition because: 0 Though the CNMT penetration allowed direct access from the CNMT atmosphere to the outside atmosphere, a condition did not exist that could have resulted in an uncontrolled radioactive release.A release to the outside atmosphere would have required CNMT pressurization.

Since the fuel had a low decay heat rate due to a sixty day off load and since there was only a small amount of fuel in the core at the time, the energy source to effect a CNMT pressurization was low, making a pressurized conditions unlikely.It was verified that the actual flow of air was from the outside into CNMT.0 CNMT isolation is not credited in the event of a fuel handling accident per the applicable safety analyses bases for ITS LCO 3.9.3.The Ginna Station Updated Final Safety Analysis Report (UFSAR), Section 15.7.3.3, shows that without credit for CNMT and utilizing the conservative assumptions of NRC Regulatory Guide (RG)1.25, the offsite dose consequences following a fuel handling accident are ninety-six (96)REM thyroid, which is within 10 CFR 100 limits for Ginna Station.NRC FORM 366A (4.65)

NRC FORM 366A (4-95)LICENSEE EVENT REPORT (LER)TEXT CONTINUATION U.S.NUCLEAR REGULATORY COMMISSION FACILITY NAME I1)R.E.Ginna Nuclear Power Plant DOCKET 05000244 LER NUMBER I6)YEAR SEQUENTIAL REVISION NUMBER NUMBER 96-006-00 PAGE I3)7 OF 8 TEXT (lf more speceis required, use eddi tionel copies of NRC Form 366Al (17)0 Ginna Station recently received Amendment 62 to the ITS, which modified the requirements for the CNMT equipment hatch during Mode 6.Included within this ITS amendment request (dated February 9, 1996)was an evaluation of offsite doses, with the following assumptions:

b.CNMT was initially pressurized by 0.5 PSIG above the outside atmosphere for the first three minutes following a fuel handling accident, a CNMT leakage rate, based on extreme temperature differences between the inside and the outside of CNMT, existed for the next two hours, and a hole equivalent to 1.83 square feet existed to the outside atmosphere.

Using these and other assumptions of RG 1.25, the thyroid dose at the exclusion area boundary was calculated to be only 8.1 REM, which is well within 10 CFR 100 limits.The condition of P-2 being open during movement of irradiated fuel assemblies is bounded by this analysis since no fuel handling accident occurred, the CNMT was not pressurized, and the increased leakage path through P-2 was less than 0:1 square foot.Therefore, this condition would not lead to exceeding the dose limits.Based on the above, it can be concluded that the public's health and safety was assured at all times.V.CORRECTIVE ACTION: A.ACTION TAKEN TO RETURN AFFECTED SYSTEMS TO PRE-EVENT NORMAL STATUS: 0 All remaining cables were removed from P-2 and a flange was installed on P-2 inside CNMT, restoring P-2 to compliance with ITS LCO 3.9.3.c.0 Refueling operations were permitted to resume.B.ACTION TAKEN OR PLANNED TO PREVENT RECURRENCE:

0 Procedure 0-15.2 will be revised to require additional controls at P-2, to prevent the configuration of P-2 from being changed during refueling operations.

0 A Nuclear Training Work Request will be initiated to train on the lessons learned from this event.VI.ADDITIONAL INFORMATION:

A.FAILED COMPONENTS:

None IIRC FORM 366A I4.95)

NRC FORM 366A I4-95)LICENSEE EVENT REPORT (LER)TEXT CONTINUATION U.S.NUCLEAR REGULATORY COMMISSION FACILITY NAME I1)R.E.Ginna Nuclear Power Plant DOCKET 05000244 LER NUMBER (6)YEAR SEQUENTIAL REVISION NUMBER NUMBER 96-006-00 PAGE I3)8 OF 8 TEXT (If more spaceis required, use additional copies of NRC Form 366AJ I17)B.PREVIOUS LERs ON SIMILAR EVENTS: A similar LER event historical search was conducted with the following results: No documentation of similar LER events with the same root cause at Ginna Nuclear Power Plant could be identified.

C.SPECIAL COMMENTS: None NAC FOAM 366A I4.95)