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FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFORMATION AND RECORDS MANAGEMENT BRANCH (See reverse for required number of !T-6 F33J, U.S. NUCLEAR REGULATORY COMMISSION. | NRC FORM 366 COMMISSION U.S. NUCLEAR REGULATORY LICENSEE EVENT REPORT (LER) | ||
WASHINGTON. | * APPROVED BY OMB NO. 3150-0104 E;>CPIRES 04/30/98 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS MANDATORY INFORMATION COLLECTION REQUEST: 50.0 HRS. REPORTED LESSONS LEARNED ARE INCORPORATED INTO THE LICENSING PROCESS AND FED BACK TO INDUSTRY. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFORMATION AND RECORDS MANAGEMENT BRANCH (See reverse for required number of !T-6 F33J, U.S. NUCLEAR REGULATORY COMMISSION. WASHINGTON. DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150* | ||
DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150* digits/characters for each block) 01041. OFFICE OF MANAGEMENT AND BUDGET. WASHINGTON. | digits/characters for each block) 01041. OFFICE OF MANAGEMENT AND BUDGET. WASHINGTON. DC 20503. | ||
DC 20503. FACILITY NAME 11 I DOCKET NUMBER (2) PAGE 131 SALEM UNIT 1 05000272 1 OF 6 TITLE 141 Inoperability Of The 12 'Fuel Oil Transfer Pump Due To Installation Of Incorrect Control Switch EVENT DATE 151 LER NUMBER 161 REPORT DATE 171 OTHER FACILITIES INVOLVED 181 | FACILITY NAME 11 I DOCKET NUMBER (2) PAGE 131 SALEM UNIT 1 05000272 1 OF 6 TITLE 141 Inoperability Of The 12 'Fuel Oil Transfer Pump Due To Installation Of Incorrect Control Switch EVENT DATE 151 LER NUMBER 161 REPORT DATE 171 OTHER FACILITIES INVOLVED 181 FACILITY NAME DOCKET NUMBER MONTH DAY YEAR YEAR I SEQUENTIAL NUMBER I REVISION NUMBER MONTH DAY YEAR FACILITY NAME DOCKET NUMBER 02 19 98 98 -- 005 -- 00 03 20 98 OPERATING THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR §: (Check one or morel 1111 MODE 191 4 20.2201lbl 20.2203(a)(2)(v) x 50. 731a112llil 50. 73(a)(2)(viiil POW.ER 20.2203(a)(1) 20.2203(a)(3)(i) 50. 73(a)(2lliil 50. 73(a)(2)(x) | ||
LEVEL (101 000 20.2203(all211il 20.22031all311iil 50. 731all2lliiil 73.71 | |||
- | |||
20.2203(a)(2)(ii) 20.2203(a)(4) 50. 73(a)(2)(iv) OTHER 20.22031all211iiil 50.36(cll 1I 50. 73(a)(2)(v) Specify in Abstract below or in NRC Form 366A 20.2203(a)(2)(iv) 50.36(c)(21 50. 73(a)(2)(vii) | |||
LEVEL (101 000 20.2203(all211il 20.22031all311iil | LICENSEE CONTACT FOR THIS LER 1121 NAME TELEPHONE NUMBER (Include Area Code) | ||
Brooke Knieriem, Licensing Engineer ( 609) 339-1782 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT 1131 CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE TONPRDS TO NPRDS | |||
'YES SUPPLEMENTAL REPORT EXPECTED 114) llf yes. complete EXPECTED SUBMISSION DATE). | |||
OTHER | I x INO EXPECTED SUBMISSION DATE 1151 MONTH DAY YEAR ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) 116) | ||
Specify in Abstract below | This LER documents the inoperability of the Salem Unit 1, 12 Emergency Diesel Generator Fuel Oil Transfer pump (FOTP) due to the installation of an incorrect control switch. The incorrect control switch was configured in a way that did not allow automatic operation of the FOTP. | ||
(2) ( i) (B) I any operation or condition prohibited by the plant's Technical Specifications. | This event is reportable under 10CFR50.73(a) (2) ( i) (B) I any operation or condition prohibited by the plant's Technical Specifications. | ||
Specifically, contrary to Technical Specification (TS) 3.8.1.1, A. c. Sources, and TS 3.0.4, entry into an operational mode or other condition, Salem Unit 1 entered (from Mode 5) and operated in Mode 4 with the 12 inoperable, and without the knowledge of the operators. | Specifically, contrary to Technical Specification (TS) 3.8.1.1, A. c. | ||
The apparent cause of the inoperability of the 12 FOTP was the failure of planning and maintenance personnel to eh sure that the proper configuration the 12 FOTP was maintained by installation of the correct control switch. Additionally, station personnel failed to ensure that an adequate post maintenance retest was performed to verify that the 12 FOTP was restored to operable condition following 9805050346 980427 PDR ADOCK 05000272 S PDR | Sources, and TS 3.0.4, entry into an operational mode or other condition, Salem Unit 1 entered (from Mode 5) and operated in Mode 4 with the 12 FOTP inoperable, and without the knowledge of the operators. | ||
The apparent cause of the inoperability of the 12 FOTP was the failure of planning and maintenance personnel to eh sure that the proper configuration of the 12 FOTP was maintained by installation of the correct control switch. | |||
Additionally, station personnel failed to ensure that an adequate post maintenance retest was performed to verify that the 12 FOTP was restored to an operable condition following the maintenance. | |||
-Pressurized Water Reactor Emergency Diesel Generator | 9805050346 980427 PDR ADOCK 05000272 S PDR | ||
{EK/DG} | |||
* Energy Industry Identification System (EIIS) codes and component function identifier codes appear as {ss/cc} CONDITIONS PRIOR TO OCCURRENCE Hot Shutdown, Mode 4 DESCRIPTION OF OCCURRENCE | NRC FORM 366A (4-95). | ||
*one FOTP is aligned to start at the Regular FODT start level of 33 inches Backup switch in the Regular position, Off-Auto-Manual selector switch in the Auto position) to refill the FODT. The other-FOTP is aligned as the Backup pump (Regular-Backup switch in the Backup position, Off-Auto-Manual selector switch in the Auto position) . In the event that the Regular FOTP fails to start or fails to deliver adequate flow to maintain FODT level, the Backup pump will start when level reaches the FODT low level alarm setpoint. | LICENSEE EVENT REPORT (LER) | ||
On February 18, 1998 Salem Unit 1 entered Mode 4. On the following day, Salem personnel began a 31 day surveillance test of the Auto start feature of the 12 FOTP to verify its operability. | TEXT CONTINUATION | ||
This test is performed under procedure Sl.OP-ST.DG-OOOS(Q), "12 Fuel Oil Transfer System Operability Test". During the test, the 12 FOTP was aligned to start at the Regular FODT start level but failed to start. The pump was then declared inoperable. | * U.S. NUCLEAR REGULATORY COMMISSION FACILITY NAME (1) DOCKET NUMBER (2) LEA NUMBER 161 PAGE 131 YEAR I SEQUENTIAL NUMBER I REVISION NUMBER SALEM UNIT 1 05000272 98 -- 005 -- 00 2 OF 6 TEXT llf more space is required, use additional copies of NRC Form 366A) ( 171 PLANT AND SYSTEM IDENTIFICATION Westinghouse - Pressurized Water Reactor Emergency Diesel Generator {EK/DG} | ||
At the time of the unsatisfactory surveillance, Salem Unit 1 was in Hot Shutdown (Mode 4). TS 3.8.1.1.b.2 requires that in Modes 1-4, two FOTPs be operable. | * Energy Industry Identification System (EIIS) codes and component function identifier codes appear as {ss/cc} | ||
With one of the above required FOTPs inoperable, the action statement requires that the inoperable FOTP be restored to an operable status within seventy-two hours or the unit must be placed in Hot Standby (Mode 3) within the next six hours and in Cold Shutdown (Mode 5) within the following thirty hours. Additionally, contrary to TS 3 .. 0 .4, Unit 1 entered Mode 4 from Mode 5 during the time that the 12 FOTP was inoperable, without the knowledge of the operators. | CONDITIONS PRIOR TO OCCURRENCE Hot Shutdown, Mode 4 DESCRIPTION OF OCCURRENCE During Emergency Diesel Generator (EDG) operation, two FOTPs ~or each unit are used to automatically transfer fuel oil from the Fuel Oil Storage tanks to the Fuel Oil Day Tank (FODT) for each engine. Each of the FOTPs is controlled through a Regular-Backup selector switch and an Off-Auto-Manual selector switch. By alignment of the two switches~ *one FOTP is aligned to start at the Regular FODT start level of 33 inches (Regular-Backup switch in the Regular position, Off-Auto-Manual selector switch in the Auto position) to refill the FODT. The other-FOTP is aligned as the Backup pump (Regular-Backup switch in the Backup position, Off-Auto-Manual selector switch in the Auto position) . In the event that the Regular FOTP fails to start or fails to deliver adequate flow to maintain FODT level, the Backup pump will start when level reaches the FODT low level alarm setpoint. | ||
NRC FORM 366A (4-95) | On February 18, 1998 Salem Unit 1 entered Mode 4. On the following day, Salem personnel began a 31 day surveillance test of the Auto start feature of the 12 FOTP to verify its operability. This test is performed under procedure Sl.OP-ST.DG-OOOS(Q), "12 Fuel Oil Transfer System Operability Test". During the test, the 12 FOTP was aligned to start at the Regular FODT start level but failed to start. The pump was then declared inoperable. | ||
At the time of the unsatisfactory surveillance, Salem Unit 1 was in Hot Shutdown (Mode 4). TS 3.8.1.1.b.2 requires that in Modes 1-4, two FOTPs be operable. With one of the above required FOTPs inoperable, the action statement requires that the inoperable FOTP be restored to an operable status within seventy-two hours or the unit must be placed in Hot Standby (Mode 3) within the next six hours and in Cold Shutdown (Mode 5) within the following thirty hours. Additionally, contrary to TS 3 .. 0 .4, Unit 1 entered Mode 4 from Mode 5 during the time that the 12 FOTP was inoperable, without the knowledge of the operators. | |||
NRC FORM 366A (4-95) | |||
use additional copies of NRC Form 366AI 1171 Description (Cont.) | |||
The correct switch for this application (part number 910PGC513) was identified and installed. | NRC FORM 366A 14-95) | ||
Operability of the 12 FOTP was then verified through satisfactory performance of Sl.OP-ST.DG-OOOS(Q}, and the action statement was exited. In November 1997, station personnel identified that the 12 FOTP Manual switch would not spring return from the Manual to the Auto position. | * LICENSEE EVENT REPORT (LER) | ||
A work order was written to replace the switch. During the planning process for this work order an incorrect switch (part number 910PDD511) was staged and issued for installation. | TEXT CONTINUATION | ||
This part was not adequately verified to be correct by planning and maintenance personnel prior to installation. | * U.S. NUCLEAR REGULATORY COMMISSION FACILITY NAME 111 DOCKET NUMBER 121 LER NUMBER 161 PAGE 131 YEAR I SEQUENTIAL NUMBER I REVISION NUMBER SALEM UNIT 1 05000272 98 -- 005 -- 00 3 OF 6 TEXT (If more space is required. use additional copies of NRC Form 366AI 1171 Description (Cont.) | ||
Upon completion of the maintenance in January 1998, the post-maintenance retest was performed as specified by the work package. The retest required verification that equipment and components disturbed during the performance of the maintenance had been returned to the proper plant configuration. | An inspection of the 12 FOTP Off-Auto-Manual selector switch was performed and it was determined that an incorrect switch was installed for the Off-Auto-Manual selector switch. The incorrect switch (part number 910PDD511) was configured in a manner that did not permit automatic operation. | ||
Since the incorrect switch installation was not discovered, the specified retest was not adequately accomplished. | The correct switch for this application (part number 910PGC513) was identified and installed. Operability of the 12 FOTP was then verified through satisfactory performance of Sl.OP-ST.DG-OOOS(Q}, and the action statement was exited. | ||
Additionally, the post-maintenance retest only required verification that the configuration be verified. | In November 1997, station personnel identified that the 12 FOTP Off-Auto-Manual switch would not spring return from the Manual to the Auto position. A work order was written to replace the switch. During the planning process for this work order an incorrect switch (part number 910PDD511) was staged and issued for installation. This part was not adequately verified to be correct by planning and maintenance personnel prior to installation. | ||
It did not require that testing be performed to verify that the 12 FOTP was operable. | Upon completion of the maintenance in January 1998, the post-maintenance retest was performed as specified by the work package. The retest required verification that equipment and components disturbed during the performance of the maintenance had been returned to the proper plant configuration. Since the incorrect switch installation was not discovered, the specified retest was not adequately accomplished. | ||
A field inspection was performed to verify the configuration of the switches for the 11, 21, and 22 FOTPs. The installed Off-Auto-Manual selector switch for the 21 FOTP was also found to be incorrect (also a part number 910PDD511). | Additionally, the post-maintenance retest only required verification that the configuration be verified. It did not require that testing be performed to verify that the 12 FOTP was operable. | ||
However, up to the time of discovery, the 21 FOTP had been operating satisfactorily as verified by surveillance testing. It appears that this switch was modified to function as an Off-Auto-Manual selector switch. Specifically, a cam roller from part 910PGC513 switch appears to have been installed in a part 910PDD511 switch to make it function as an Off-Auto-Manual switch. The acceptability of this configuration was evaluated and determined to be acceptable. | A field inspection was performed to verify the configuration of the switches for the 11, 21, and 22 FOTPs. The installed Off-Auto-Manual selector switch for the 21 FOTP was also found to be incorrect (also a part number 910PDD511). However, up to the time of discovery, the 21 FOTP had been operating satisfactorily as verified by surveillance testing. It appears that this switch was modified to function as an Off-Auto-Manual selector switch. Specifically, a cam roller from part 910PGC513 switch appears to have been installed in a part 910PDD511 switch to make it function as an Off-Auto-Manual switch. The acceptability of this configuration was evaluated and determined to be acceptable. However, the 21 FOTP Off-Auto-Manual switch will be replaced with the correct switch at the earliest opportunity. | ||
However, the 21 FOTP Off-Auto-Manual switch will be replaced with the correct switch at the earliest opportunity. | APPARENT CAUSE OF OCCURRENCE The apparent cause of this event was the failure of planning and maintenance personnel to verify that the correct replacement switch was identified, staged, and installed for the 12 FOTP Off-Auto-Manual selector switch. | ||
APPARENT CAUSE OF OCCURRENCE The apparent cause of this event was the failure of planning and maintenance personnel to verify that the correct replacement switch was identified, staged, and installed for the 12 FOTP Off-Auto-Manual selector switch. NRC FORM 366A (4-95) | NRC FORM 366A (4-95) | ||
NRC FORM 366A (4-95) | |||
* LICENSEE EVENT REPORT (LER) | |||
The post-maintenance retest also was not adequate in that it did not verify the operability of the FOTP following maintenance. | TEXT CONTINUATION | ||
PRIOR SIMILAR OCCURRENCES A review of LERs Salem Units 1 and 2 issued in the last two years identified one LER which discussed a similar occurrence. | * U.S. NUCLEAR REGULATORY COMMISSION FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER 16) PAGE 13) | ||
LER 311/97-002-00 reported the installation of non-seismically qualified pressure switches in the Auxiliary Building Ventilation system. The cause of this event was not determined. | YEAR I SEQUENTIAL NUMBER I REVISION NUMBER SALEM UNIT 1 05000272 98 -- 005 -- 00 4 OF 6 TEXT (If more space is required, use additional copies of NRC Form 366A) ( 17) | ||
* SAFETY CONSEQUENCES AND IMPLICATIONS During EDG operation, each FOTP has sufficient capacity to ensure that the Fuel Oil Day tanks are kept at the level required to support EDG operation. | APPARENT CAUSE OF OCCURRENCE(cont.) | ||
Normally, one FOTP is arranged to supply the Fuel Oil Day tanks for each EDG. Its operation is controlled by a level switch in the Day Tank. The other FOTP is lined up as the backup, also operating in response to a level switch in the Day Tank. The level switch controlling the backup FOTP also activates the Day Tank low level alarm. Should the regular pump fail to start, the backup pump will start and is capable of supplying sufficient flow to maintain Day Tank levels for all three EDGs. At the time the backup pump starts, the low level alarm is received and will alert operators to the condition. | Additionally, the post-maintenance retest that was specified to.verify that equipment and components disturbed during the performance of the maintenance were returned to the proper plant configuration was not adequately performed because the installation of an incorrect switch was not identified. The post-maintenance retest also was not adequate in that it did not verify the operability of the FOTP following maintenance. | ||
The Day Tank low tank level setpoint is based upon maintaining no less than a sixty minute fuel oil reserve. This would provide operators with adequate time to take manual control of a FOTP and restore Day Tank level should both FOTPs fail to automatically start. Should a single failure of a FOTP (the backup FOTP) occur with the other FOTP inoperable, no means would be available to maintain level in the FODTs during EDG operation. | PRIOR SIMILAR OCCURRENCES A review of LERs ~or Salem Units 1 and 2 issued in the last two years identified one LER which discussed a similar occurrence. LER 311/97-002-00 reported the installation of non-seismically qualified pressure switches in the Auxiliary Building Ventilation system. The cause of this event was not determined. | ||
Under this condition, and in the event of a postulated event (Loss of Coolant Accident coincident with a Loss of Offsite Power), power would not be available to equipment necessary to remove decay heat and to mitigate the consequences of the accident once the FODTs were emptied. NRC FORM 366A (4-95) | * SAFETY CONSEQUENCES AND IMPLICATIONS During EDG operation, each FOTP has sufficient capacity to ensure that the Fuel Oil Day tanks are kept at the level required to support EDG operation. Normally, one FOTP is arranged to supply the Fuel Oil Day tanks for each EDG. Its operation is controlled by a level switch in the Day Tank. The other FOTP is lined up as the backup, also operating in response to a level switch in the Day Tank. The level switch controlling the backup FOTP also activates the Day Tank low level alarm. | ||
Should the regular pump fail to start, the backup pump will start and is capable of supplying sufficient flow to maintain Day Tank levels for all three EDGs. At the time the backup pump starts, the low level alarm is received and will alert operators to the condition. The Day Tank low tank level setpoint is based upon maintaining no less than a sixty minute fuel oil reserve. This would provide operators with adequate time to take manual control of a FOTP and restore Day Tank level should both FOTPs fail to automatically start. | |||
Should a single failure of a FOTP (the backup FOTP) occur with the other FOTP inoperable, no means would be available to maintain level in the FODTs during EDG operation. Under this condition, and in the event of a postulated event (Loss of Coolant Accident coincident with a Loss of Offsite Power), power would not be available to equipment necessary to remove decay heat and to mitigate the consequences of the accident once the FODTs were emptied. | |||
use additional copies of NRC Form 366Al ( 17 I Safety Consequences (Cont.) TS 3.8.1.1.b.2 requires that in Modes 1-4, two.FOTPs be operable. | NRC FORM 366A (4-95) | ||
With one FOTP inoperable, the action statement requires that the inoperable FOTP be restored to an operable status wfthin seventy-two hours or the unit must be placed in Hot Standby (Mode 3) within the next six hours _and in Cold Shutdown (Mode 5) within the following thirty hours. Because the inoperability of the 12 FOTP was identified, corrected and the FOTP restored to operability within the time specified by TS, Unit 1 was not in a condition that would impact the health and safety of the general public. CORRECTIVE ACTIONS 1. A field inspection was performed to verify the configuration of_ the switches for the 11, 21, and 22 FOTPs. The Off-Auto-Manual switch for the 21 FOTP was found to have an incorrect part number. However, this pump was operable based on surveillance test performance since the switch was installed. | |||
This configuration was evaluated by the Operations Department through the performance of an Operability Determination and was found to be acceptable for contin.ued operation. | NRC FORM 366A 14-95) | ||
: 2. The correct Off-Auto-Manual switch (part number 910PGC513) was installed and the operability of the 12 FOTP was verified (WO 00980219074) . 3. The correct Off-Auto-Manual switch (part number 910PGC513) will be installed for the 21 FOTP at the next available opportunity. (WO 00980227082). | * LICENSEE EVENT REPORT (LER) | ||
: 4. The requirement to review drawings to verify that parts being staged are correct has been reinforced with planning personnel. | TEXT CONTINUATION | ||
Planning personnel have also been reminded of their responsibility to specify the appropriate testing requirements on work orders in accordance with; NC.NA-AP.ZZ-0050(Q), "Station Testing Program", NC.NA-TS.ZZ-0050(Q), "Station Testing Program Matrix". 5. All personnel involved have been held accountable in accordance with PSE&G 1 s procedures and policies. | * U.S. NUCLEAR REGULATORY COMMISSION FACILITY NAME ( 1 l DOCKET NUMBER (2) LER NUMBER (6) PAGE 131 YEAR I SEQUENTIAL NUMBER I REVISION NUMBER SALEM UNIT 1 05000272 98 -- 005 -- 00 5 OF 6 TEXT (If more space is required. use additional copies of NRC Form 366Al ( 17 I Safety Consequences (Cont.) | ||
: 6. An inspection will be performed of a random sampling of thirty switches in safety related applications to determine if any other instances of incorrect switch configuration exist. The results of this sampling will serve as the basis for further inspection. (PIR 00980219131, CRCA 02) 7. As a part of second quarter In-service Day training, Maintenance department personnel will receive a rollout discussion on the importance of (i) ensuring that replacement parts are correct by comparing them to NRC FORM 366A (4-95) | TS 3.8.1.1.b.2 requires that in Modes 1-4, two.FOTPs be operable. With one FOTP inoperable, the action statement requires that the inoperable FOTP be restored to an operable status wfthin seventy-two hours or the unit must be placed in Hot Standby (Mode 3) within the next six hours _and in Cold Shutdown (Mode 5) within the following thirty hours. Because the inoperability of the 12 FOTP was identified, corrected and the FOTP restored to operability within the time specified by TS, Unit 1 was not in a condition that would impact the health and safety of the general public. | ||
CORRECTIVE ACTIONS | |||
: 1. A field inspection was performed to verify the configuration of_ the switches for the 11, 21, and 22 FOTPs. The Off-Auto-Manual switch for the 21 FOTP was found to have an incorrect part number. However, this pump was operable based on surveillance test performance since the switch was installed. This configuration was evaluated by the Operations Department through the performance of an Operability Determination and was found to be acceptable for contin.ued operation. | |||
: 2. The correct Off-Auto-Manual switch (part number 910PGC513) was installed and the operability of the 12 FOTP was verified (WO 00980219074) . | |||
: 3. The correct Off-Auto-Manual switch (part number 910PGC513) will be installed for the 21 FOTP at the next available opportunity. (WO 00980227082). | |||
: 4. The requirement to review drawings to verify that parts being staged are correct has been reinforced with planning personnel. Planning personnel have also been reminded of their responsibility to specify the appropriate testing requirements on work orders in accordance with; NC.NA-AP.ZZ-0050(Q), "Station Testing Program", NC.NA-TS.ZZ-0050(Q), | |||
"Station Testing Program Matrix". | |||
: 5. All personnel involved have been held accountable in accordance with PSE&G 1 s procedures and policies. | |||
: 6. An inspection will be performed of a random sampling of thirty switches in safety related applications to determine if any other instances of incorrect switch configuration exist. The results of this sampling will serve as the basis for further inspection. | |||
(PIR 00980219131, CRCA 02) | |||
: 7. As a part of second quarter In-service Day training, Maintenance department personnel will receive a rollout discussion on the importance of (i) ensuring that replacement parts are correct by comparing them to NRC FORM 366A (4-95) | |||
NRC FORM 366A (4-951 | |||
* LICENSEE EVENT REPORT (LER) | |||
TEXT CONTINUATION | |||
* U.S. NUCLEAR REGULATORY COMMISSION FACILITY NAME (1 l DOCKET NUMBER (2) LER NUMBER (6) PAGE (3) | |||
YEAR I SEQUENTIAL NUMBER I REVISION NUMBBI SALEM UNIT 1 05000272 98 -- 005 -- 00 6 OF *5 TEXT (If more space is required, use additional copies of NRC Form 366AI ( 171 CORRECTIVE ACTIONS{Cont.) | |||
the Bill Of Materials and by comparison to the removed parts, (2) verifying the correct contact switch configuration on new contacts, (3) performing modifications to replacement parts only in accordance with approved procedures. (PIR 00980219131, CRCA 01) | |||
: 8. Operations department personnel will receive a rollout discussion to emphasize the importance of reviewing completed work against planned work to ensure that adequate retests are performed in accordance with procedure NC.NA-AP.ZZ-0009{Q}, "Work Control Process". (PIR 00980219131, CRCA 03) -- | |||
NRC FORM 366A (4-95)}} |
Revision as of 08:56, 21 October 2019
ML18106A578 | |
Person / Time | |
---|---|
Site: | Salem ![]() |
Issue date: | 03/20/1998 |
From: | Knieriem B Public Service Enterprise Group |
To: | |
Shared Package | |
ML18106A576 | List: |
References | |
LER-98-005-02, LER-98-5-2, NUDOCS 9805050346 | |
Download: ML18106A578 (6) | |
Text
14-951
.
NRC FORM 366 COMMISSION U.S. NUCLEAR REGULATORY LICENSEE EVENT REPORT (LER)
- APPROVED BY OMB NO. 3150-0104 E;>CPIRES 04/30/98 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS MANDATORY INFORMATION COLLECTION REQUEST: 50.0 HRS. REPORTED LESSONS LEARNED ARE INCORPORATED INTO THE LICENSING PROCESS AND FED BACK TO INDUSTRY. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFORMATION AND RECORDS MANAGEMENT BRANCH (See reverse for required number of !T-6 F33J, U.S. NUCLEAR REGULATORY COMMISSION. WASHINGTON. DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150*
digits/characters for each block) 01041. OFFICE OF MANAGEMENT AND BUDGET. WASHINGTON. DC 20503.
FACILITY NAME 11 I DOCKET NUMBER (2) PAGE 131 SALEM UNIT 1 05000272 1 OF 6 TITLE 141 Inoperability Of The 12 'Fuel Oil Transfer Pump Due To Installation Of Incorrect Control Switch EVENT DATE 151 LER NUMBER 161 REPORT DATE 171 OTHER FACILITIES INVOLVED 181 FACILITY NAME DOCKET NUMBER MONTH DAY YEAR YEAR I SEQUENTIAL NUMBER I REVISION NUMBER MONTH DAY YEAR FACILITY NAME DOCKET NUMBER 02 19 98 98 -- 005 -- 00 03 20 98 OPERATING THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR §: (Check one or morel 1111 MODE 191 4 20.2201lbl 20.2203(a)(2)(v) x 50. 731a112llil 50. 73(a)(2)(viiil POW.ER 20.2203(a)(1) 20.2203(a)(3)(i) 50. 73(a)(2lliil 50. 73(a)(2)(x)
LEVEL (101 000 20.2203(all211il 20.22031all311iil 50. 731all2lliiil 73.71
-
20.2203(a)(2)(ii) 20.2203(a)(4) 50. 73(a)(2)(iv) OTHER 20.22031all211iiil 50.36(cll 1I 50. 73(a)(2)(v) Specify in Abstract below or in NRC Form 366A 20.2203(a)(2)(iv) 50.36(c)(21 50. 73(a)(2)(vii)
LICENSEE CONTACT FOR THIS LER 1121 NAME TELEPHONE NUMBER (Include Area Code)
Brooke Knieriem, Licensing Engineer ( 609) 339-1782 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT 1131 CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE TONPRDS TO NPRDS
'YES SUPPLEMENTAL REPORT EXPECTED 114) llf yes. complete EXPECTED SUBMISSION DATE).
I x INO EXPECTED SUBMISSION DATE 1151 MONTH DAY YEAR ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) 116)
This LER documents the inoperability of the Salem Unit 1, 12 Emergency Diesel Generator Fuel Oil Transfer pump (FOTP) due to the installation of an incorrect control switch. The incorrect control switch was configured in a way that did not allow automatic operation of the FOTP.
This event is reportable under 10CFR50.73(a) (2) ( i) (B) I any operation or condition prohibited by the plant's Technical Specifications.
Specifically, contrary to Technical Specification (TS) 3.8.1.1, A. c.
Sources, and TS 3.0.4, entry into an operational mode or other condition, Salem Unit 1 entered (from Mode 5) and operated in Mode 4 with the 12 FOTP inoperable, and without the knowledge of the operators.
The apparent cause of the inoperability of the 12 FOTP was the failure of planning and maintenance personnel to eh sure that the proper configuration of the 12 FOTP was maintained by installation of the correct control switch.
Additionally, station personnel failed to ensure that an adequate post maintenance retest was performed to verify that the 12 FOTP was restored to an operable condition following the maintenance.
9805050346 980427 PDR ADOCK 05000272 S PDR
NRC FORM 366A (4-95).
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION
- U.S. NUCLEAR REGULATORY COMMISSION FACILITY NAME (1) DOCKET NUMBER (2) LEA NUMBER 161 PAGE 131 YEAR I SEQUENTIAL NUMBER I REVISION NUMBER SALEM UNIT 1 05000272 98 -- 005 -- 00 2 OF 6 TEXT llf more space is required, use additional copies of NRC Form 366A) ( 171 PLANT AND SYSTEM IDENTIFICATION Westinghouse - Pressurized Water Reactor Emergency Diesel Generator {EK/DG}
- Energy Industry Identification System (EIIS) codes and component function identifier codes appear as {ss/cc}
CONDITIONS PRIOR TO OCCURRENCE Hot Shutdown, Mode 4 DESCRIPTION OF OCCURRENCE During Emergency Diesel Generator (EDG) operation, two FOTPs ~or each unit are used to automatically transfer fuel oil from the Fuel Oil Storage tanks to the Fuel Oil Day Tank (FODT) for each engine. Each of the FOTPs is controlled through a Regular-Backup selector switch and an Off-Auto-Manual selector switch. By alignment of the two switches~ *one FOTP is aligned to start at the Regular FODT start level of 33 inches (Regular-Backup switch in the Regular position, Off-Auto-Manual selector switch in the Auto position) to refill the FODT. The other-FOTP is aligned as the Backup pump (Regular-Backup switch in the Backup position, Off-Auto-Manual selector switch in the Auto position) . In the event that the Regular FOTP fails to start or fails to deliver adequate flow to maintain FODT level, the Backup pump will start when level reaches the FODT low level alarm setpoint.
On February 18, 1998 Salem Unit 1 entered Mode 4. On the following day, Salem personnel began a 31 day surveillance test of the Auto start feature of the 12 FOTP to verify its operability. This test is performed under procedure Sl.OP-ST.DG-OOOS(Q), "12 Fuel Oil Transfer System Operability Test". During the test, the 12 FOTP was aligned to start at the Regular FODT start level but failed to start. The pump was then declared inoperable.
At the time of the unsatisfactory surveillance, Salem Unit 1 was in Hot Shutdown (Mode 4). TS 3.8.1.1.b.2 requires that in Modes 1-4, two FOTPs be operable. With one of the above required FOTPs inoperable, the action statement requires that the inoperable FOTP be restored to an operable status within seventy-two hours or the unit must be placed in Hot Standby (Mode 3) within the next six hours and in Cold Shutdown (Mode 5) within the following thirty hours. Additionally, contrary to TS 3 .. 0 .4, Unit 1 entered Mode 4 from Mode 5 during the time that the 12 FOTP was inoperable, without the knowledge of the operators.
NRC FORM 366A (4-95)
NRC FORM 366A 14-95)
- LICENSEE EVENT REPORT (LER)
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- U.S. NUCLEAR REGULATORY COMMISSION FACILITY NAME 111 DOCKET NUMBER 121 LER NUMBER 161 PAGE 131 YEAR I SEQUENTIAL NUMBER I REVISION NUMBER SALEM UNIT 1 05000272 98 -- 005 -- 00 3 OF 6 TEXT (If more space is required. use additional copies of NRC Form 366AI 1171 Description (Cont.)
An inspection of the 12 FOTP Off-Auto-Manual selector switch was performed and it was determined that an incorrect switch was installed for the Off-Auto-Manual selector switch. The incorrect switch (part number 910PDD511) was configured in a manner that did not permit automatic operation.
The correct switch for this application (part number 910PGC513) was identified and installed. Operability of the 12 FOTP was then verified through satisfactory performance of Sl.OP-ST.DG-OOOS(Q}, and the action statement was exited.
In November 1997, station personnel identified that the 12 FOTP Off-Auto-Manual switch would not spring return from the Manual to the Auto position. A work order was written to replace the switch. During the planning process for this work order an incorrect switch (part number 910PDD511) was staged and issued for installation. This part was not adequately verified to be correct by planning and maintenance personnel prior to installation.
Upon completion of the maintenance in January 1998, the post-maintenance retest was performed as specified by the work package. The retest required verification that equipment and components disturbed during the performance of the maintenance had been returned to the proper plant configuration. Since the incorrect switch installation was not discovered, the specified retest was not adequately accomplished.
Additionally, the post-maintenance retest only required verification that the configuration be verified. It did not require that testing be performed to verify that the 12 FOTP was operable.
A field inspection was performed to verify the configuration of the switches for the 11, 21, and 22 FOTPs. The installed Off-Auto-Manual selector switch for the 21 FOTP was also found to be incorrect (also a part number 910PDD511). However, up to the time of discovery, the 21 FOTP had been operating satisfactorily as verified by surveillance testing. It appears that this switch was modified to function as an Off-Auto-Manual selector switch. Specifically, a cam roller from part 910PGC513 switch appears to have been installed in a part 910PDD511 switch to make it function as an Off-Auto-Manual switch. The acceptability of this configuration was evaluated and determined to be acceptable. However, the 21 FOTP Off-Auto-Manual switch will be replaced with the correct switch at the earliest opportunity.
APPARENT CAUSE OF OCCURRENCE The apparent cause of this event was the failure of planning and maintenance personnel to verify that the correct replacement switch was identified, staged, and installed for the 12 FOTP Off-Auto-Manual selector switch.
NRC FORM 366A (4-95)
NRC FORM 366A (4-95)
- LICENSEE EVENT REPORT (LER)
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- U.S. NUCLEAR REGULATORY COMMISSION FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER 16) PAGE 13)
YEAR I SEQUENTIAL NUMBER I REVISION NUMBER SALEM UNIT 1 05000272 98 -- 005 -- 00 4 OF 6 TEXT (If more space is required, use additional copies of NRC Form 366A) ( 17)
APPARENT CAUSE OF OCCURRENCE(cont.)
Additionally, the post-maintenance retest that was specified to.verify that equipment and components disturbed during the performance of the maintenance were returned to the proper plant configuration was not adequately performed because the installation of an incorrect switch was not identified. The post-maintenance retest also was not adequate in that it did not verify the operability of the FOTP following maintenance.
PRIOR SIMILAR OCCURRENCES A review of LERs ~or Salem Units 1 and 2 issued in the last two years identified one LER which discussed a similar occurrence. LER 311/97-002-00 reported the installation of non-seismically qualified pressure switches in the Auxiliary Building Ventilation system. The cause of this event was not determined.
- SAFETY CONSEQUENCES AND IMPLICATIONS During EDG operation, each FOTP has sufficient capacity to ensure that the Fuel Oil Day tanks are kept at the level required to support EDG operation. Normally, one FOTP is arranged to supply the Fuel Oil Day tanks for each EDG. Its operation is controlled by a level switch in the Day Tank. The other FOTP is lined up as the backup, also operating in response to a level switch in the Day Tank. The level switch controlling the backup FOTP also activates the Day Tank low level alarm.
Should the regular pump fail to start, the backup pump will start and is capable of supplying sufficient flow to maintain Day Tank levels for all three EDGs. At the time the backup pump starts, the low level alarm is received and will alert operators to the condition. The Day Tank low tank level setpoint is based upon maintaining no less than a sixty minute fuel oil reserve. This would provide operators with adequate time to take manual control of a FOTP and restore Day Tank level should both FOTPs fail to automatically start.
Should a single failure of a FOTP (the backup FOTP) occur with the other FOTP inoperable, no means would be available to maintain level in the FODTs during EDG operation. Under this condition, and in the event of a postulated event (Loss of Coolant Accident coincident with a Loss of Offsite Power), power would not be available to equipment necessary to remove decay heat and to mitigate the consequences of the accident once the FODTs were emptied.
NRC FORM 366A (4-95)
NRC FORM 366A 14-95)
- LICENSEE EVENT REPORT (LER)
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- U.S. NUCLEAR REGULATORY COMMISSION FACILITY NAME ( 1 l DOCKET NUMBER (2) LER NUMBER (6) PAGE 131 YEAR I SEQUENTIAL NUMBER I REVISION NUMBER SALEM UNIT 1 05000272 98 -- 005 -- 00 5 OF 6 TEXT (If more space is required. use additional copies of NRC Form 366Al ( 17 I Safety Consequences (Cont.)
TS 3.8.1.1.b.2 requires that in Modes 1-4, two.FOTPs be operable. With one FOTP inoperable, the action statement requires that the inoperable FOTP be restored to an operable status wfthin seventy-two hours or the unit must be placed in Hot Standby (Mode 3) within the next six hours _and in Cold Shutdown (Mode 5) within the following thirty hours. Because the inoperability of the 12 FOTP was identified, corrected and the FOTP restored to operability within the time specified by TS, Unit 1 was not in a condition that would impact the health and safety of the general public.
CORRECTIVE ACTIONS
- 1. A field inspection was performed to verify the configuration of_ the switches for the 11, 21, and 22 FOTPs. The Off-Auto-Manual switch for the 21 FOTP was found to have an incorrect part number. However, this pump was operable based on surveillance test performance since the switch was installed. This configuration was evaluated by the Operations Department through the performance of an Operability Determination and was found to be acceptable for contin.ued operation.
- 2. The correct Off-Auto-Manual switch (part number 910PGC513) was installed and the operability of the 12 FOTP was verified (WO 00980219074) .
- 3. The correct Off-Auto-Manual switch (part number 910PGC513) will be installed for the 21 FOTP at the next available opportunity. (WO 00980227082).
- 4. The requirement to review drawings to verify that parts being staged are correct has been reinforced with planning personnel. Planning personnel have also been reminded of their responsibility to specify the appropriate testing requirements on work orders in accordance with; NC.NA-AP.ZZ-0050(Q), "Station Testing Program", NC.NA-TS.ZZ-0050(Q),
"Station Testing Program Matrix".
- 5. All personnel involved have been held accountable in accordance with PSE&G 1 s procedures and policies.
- 6. An inspection will be performed of a random sampling of thirty switches in safety related applications to determine if any other instances of incorrect switch configuration exist. The results of this sampling will serve as the basis for further inspection.
(PIR 00980219131, CRCA 02)
- 7. As a part of second quarter In-service Day training, Maintenance department personnel will receive a rollout discussion on the importance of (i) ensuring that replacement parts are correct by comparing them to NRC FORM 366A (4-95)
NRC FORM 366A (4-951
- LICENSEE EVENT REPORT (LER)
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- U.S. NUCLEAR REGULATORY COMMISSION FACILITY NAME (1 l DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)
YEAR I SEQUENTIAL NUMBER I REVISION NUMBBI SALEM UNIT 1 05000272 98 -- 005 -- 00 6 OF *5 TEXT (If more space is required, use additional copies of NRC Form 366AI ( 171 CORRECTIVE ACTIONS{Cont.)
the Bill Of Materials and by comparison to the removed parts, (2) verifying the correct contact switch configuration on new contacts, (3) performing modifications to replacement parts only in accordance with approved procedures. (PIR 00980219131, CRCA 01)
- 8. Operations department personnel will receive a rollout discussion to emphasize the importance of reviewing completed work against planned work to ensure that adequate retests are performed in accordance with procedure NC.NA-AP.ZZ-0009{Q}, "Work Control Process". (PIR 00980219131, CRCA 03) --
NRC FORM 366A (4-95)