ML18064A504

LER 94-019-00:on 941109,identified Failure to Test Redundant Equipment Per TS 3.3.2.f Prior Ro Removal of Electrical Breakers from Svc for Planned PM Due to Personnel Error. Administrative Procedure 5.14 Revised

ML18064A504
Person / Time
Site:	Palisades
Issue date:	12/07/1994
From:	Gire P CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.)
To:
Shared Package
ML18064A503	List: ML18064A502 ML18064A504
References
LER-94-019, LER-94-19, NUDOCS 9412190217
Download: ML18064A504 (5)

Text

NRC Fcvm 388

• u,s. NUCLEAR REGULATORY COMMISSION (9-83) APPROVED OMB NO. 3150-0104 EXPIRES: 8/31185 LICENSEE EVENT REPORT (LERI

. FACILITY NAME !11 DOCKET NUMBER (21 PAGE 131 0 5 0 0 0 2 .5 5 . OF 0 5 Palisades Plant TITLE 141 FAILURE TO TEST REDUNDANT EQUIPMENT PER TECHNICAL SPECIFICATION 3.3.2.F PRIOR TO REMOVAL OF ELECTRICAL BREAKERS FROM SERVICE FOR PLANNED PREVENTIVE MAINTENANCE * .

. EVENT DATE (6) REPORT DATE (81. OTHER FACILITIES INVOLVED (81 REVISION FACILITY NAMES MONTH DAY YEAR . YEAR NUMBER MONTH DAY YEAR NIA 0 5 0 0 0 1 1 0 9 9 4 9 4 0 1 9 00120794 NIA o 5 *o o o THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR I: (CMcJc OM Ol'mon of the followin(JJ (111 OPERATING N t--..-2-0.-40_2_(b-I-.-----------..--.--20-.4-0-5(-c)-----------.---r~So--.73-(*-ll-2)-(iv_)..;....______......--.--7-3.-71-lb-l------------I MODE (91 20.405l*ll11fil 50.38lcll11 50.73l*H21M 73.71fcl 20.405(*111 lliil 50.38(cl!21 50.73fall2Hviil OTHER !Specify in Abstract 20.405!*111 Hiiil X 50.73.lall2Hil . 50.73(*112HviiiHAJ below and in Text, 20.406(*111 )(iv) 60.73fall2Hiil 50.73faH2Hv.iiilf81 .NRC Form 388Al 20.405l*H11M 50.73(*1l2Hiiil 50.73f*H2Hxl LICENSEE CONTACT FOR THIS LER (121 NAME* 'TEL£PHONE NUMBER AREA CODE PAUL J GIRE, STAFF LICENSING ENGINEER 6 1 6 7 6 4 8 9 3 MANUFAC* REPORTABLE MANUFAC* REPORTABLE CAUSE SYSTEM COMPONENT TUR ER TO NPRDS CAUSE SYSTEM . COMpONENT TUR ER TO NPRDS SUPPLEM_ENTAL REPORT EXPECTED (141 MONTH DAY YEAR

- EXPECTED SUBMISSION YES Uf yH, ,,,,,,,,,,_,.EXPECTED SUBMISSION DATE! NO DATE (15)

ABSTRACT Uimlt II> 1400 -H. I.e.* approx/tn11te/y fifteen flingle--e typewritten line$) (18)

On November 9, 1994, plant personnel identified a .failure to implement a Plant Technical Specification* requirement. The requirement states that prior to initiating repairs to certain safety injection system components that all valves and interlocks in the system, that provide the duplicate furiction,* shall be tested to demonstrate operability._ Contrary to this requirement, on two separate occasions an electrical supply breaker for a Low Pressure Safety Injection Valve was removed from service for preventive maintenance (PM) without prior testing of the three redundant valves. Subsequent testing of the appropriate redundant. valves has determined they had remained operable.

The cause for this event was personnel error during the final processing of a revision to an electrical breaker PM. A data entry error was made in the .controlling document and the second level review of the changes was not adequate. The error led to inadequate testing requirements on the associated work order controlling the breaker wo~k. A contributor to the event was the -

failure by the licensed operators to identify the required testing during approval of the work order, which allowed the work to commence. Corrective actions for this event include; the development of a document to assist operators and planners in the identification of testing requirements for duplicate equipmenf, and a procedure upgra_de to ensure final reviews occur after all changes are .

made to PM documents. -

9412190217 941207 PDR ACOCK 05000255 S -PDR

NRC Farm 388A U.S; NUCLEAR REGULATORY COMMiSSION (9*83) APPROVED OMS NO. 3160-0104 EXPIRES: 8/31/86

- LICENSEE EVENT REPORT (LERI TEXT CONTINUATION*

FACILITY NAME. (1) DOCKET NUMBER !21 LER NUMBER !31 PAGE (41 SEQUENTIAL REVISION YEAR NUMBER NUMBER Palisades Plant 0600026694-0 Ii - 0 0 0 2 . OF 0 6 EVENT DESCRIPTION On November 9, 1994, while the plant was operating at 1OOo/o power; plant personnel identified a failure to implement a Plant Technical Specification requirement. The requirement in section 3.3.2.f. states: * -

_'J4ny valve, interlock or pipe associated with the safety injection and shutdown cooling system and which is not covered under 3.3.2.e above but, which is required to function puring accident conditions, inay be inoperable for a period of no more than 24 _

hours. Prior to initiating repairs, all valves and interlocks in the system that provide the duplicate function shall be tested to demonstrate operability. "

Contrary to this requirement, on two separate occasions an electrical supply breaker for a Low Pressure Safety lnjection,(LPSl),[BPJ, valve was removed from service for preventive maintenance (PM) without prior testing of the duplicate valves_. -Specifically, the electrical supply breaker for one of the four LPSI loop isolation valves, M0-3014, was removed from service on 11 /6/94 for a planned PM activity, without performing the required stroke testing of the remaining LPSI loop isolation valves. At this time there was no other inoperable safety injection equipment and the associated 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> Limiting Condition of Operation (LCO) was properly entered. The PM activity was completed within 3 hour3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br />s* and the valve was successfully stroke tested and declared operable. A similar event o.ccurred on 11 /8/94 for a second LPSI loop isolation valve, M0-3012. The identical PM activity was completed on the asso_ciated electrical breaker for this valve without prior testing of th.e duplic*ate valves. The failure to test the duplicate equipment was discovered on the next shift by on-shift operations personnel during their review of log books.

This event is reportable in accordance with 10CFR50.73(a)(2)(i)(B) as operation of the plant in a condition prohibited by Palisades Technical Specific;:ations.

ANALYSIS OF THE EVENT The Palisades LPSI System includes four separate injection lines with an associated motor operated isolation valve for each line. The Basis Section of Pali$ades Technical Specification 3.3 documents the intent behind the required duplicate e(luipment testing: *

' r"'"'":'-:-:-~~~~~~~~~~---1 NRC Form 388A U.S. NUCLEAR REGULATORY COMMISSION (9*B3) APPROVED OMB NO. 3160-0104 EXPIRES: B/31 /B6

. LICENSEE EVENT REPORT (LERI TEXT CONTINUATION.

FACILITY NAME. .11 l DOCKET NUMBER (2) LER NUMBER (3) PAGE 141 SEQUENTIAL. REVISION YEAR NUMBER NUMBER Palisades Plant 0 6 0 0 0 2 6 6 9 4 - 0 9 - 0 0 0 3 OF 0 6

"... For a single component to be inoperable does not negate the*

ability of the system to perform its function, but it reduces the redundancy provided in the reactor design and thereby limits the ability to tolerate additional equipment failures. To* provide

• maximum assurance that the redundant componentfsJ will operate if required to do SO, the redundant component(s) is to be tested prior to initiating repair of the inoperable component... "

All of the. safety injection components were in an operable status prior to initiating the PM activities for the electrical breakers on the two separate occasions. Also, based on the satisfactory results of the valve operability testing that was completed upon discovery of this

• event, all four LPSI isolation valves were demonstrated to be operable. Thus, three valves were

• functional during the short time period for the breaker PMs, and the LPSI System was functional at all tim,es. *However, there was a failure to maximize our. assurance that the three redundant valves were operable prior to releasing the equipment to maintenance.

CAUSE* OF THE EVENT

• The root cause for this event was a maintenance personnel error, during a revision_ to the breaker PM document. This error inadvertently created a revised PM document that did not identify the applicable redundant equipment testing requirements from Palisades Technical Specification 3.3.2.f. A major contributor to the occurrence of this event was an inadequate second level review of the final changes made during the revision to the PM document.

Another contributor to the event was a lack of attention to detail on the part of licensed operators to recognize and implement the Technical Specification requirement, prior to releasing the breaker for maintenance. At Palisades, preventive maintenance activities are managed by the Periodic and Predetermined Activity Control (PPAC) System. A personnel error occurred during the final processing of a revision-to two PPAC doc.uments, SPS038 and SPS039.

Originally SPS038 performed breaker PMs for various breakers on Motor Control Center (MCC) 1, and SPS039 performed similar activities for breakers on MCC 2. Both .of the PPACs were

• identified for performance only during plant outages. The intent of the PPAC revisions was to place all non-safety related breakers from Motor Control Centers 1 and 2 into PPAC SPS039, and all safety related breakers from the two motor control centers into PPAC SPS038. This could then allow the PPAC SPS039 to be performed at any plant mode,including power*

operations, and not impact plant safety related equipment or Technical Specification requirements.

In June, 1994, the proposed PPAC changes were routed for proper department reviews, and the approved changes were then ready to be incorporated into the on-line system. A personnel error occurred at this point, and inadvertently only the plant outage mode required for the

.*. r-".'::"':'""_ _..;...__ _ _ _ _ _ _--1 NRC Form 366A *u.s*. NU.CLEAR REGULATORY COMMISSION 19-831 . APPROVED OM8 NO. 3160-0104 EXPIRES: 8/31 /86 LICENSEE EVENT REPORT (LERI TEXT CONTINUATION

. *FACILITY NAME (11 DOCKET NUMBER 121 LER NUMBER 131 PAGE 141 SEQUENTIAL REVISiON YEAR NUMBER NUMBER Palisades Plarit 0500025594 -o 9 - 0 0 0 4 .OF 0 6 breaker work. was changed on SPS039; Several safety related breakers on MCC 2 were inadvertently left on SPS039, which could now be performed at any plant mode. This was not

.. the intent of the revision. Thus, the identification of any requjred redundant equipment testing

• prior to work on the safety related breakers, at plant operational modes of reactor critical or above, did not occur. The PPAC revision had created a document thatdid not co!ltain adequate controls over the breaker PM activities.

Palisades Administrative Procedure 5.14, "Periodic *and Predetermined Activity Control,"

Revision 6, required the Responsible Department Head to review the PPAC revision prior to the revision being final, and thus allowing the PPAC to be made available for scheduling. This .

second review did not identify the error that had occurred. The specific method and timing of the second level review was not clearly described in Revision 6 of the procedure.

• The PPAC was scheduled for the supply breaker for LPSI Isolation valve M0-3014 on 11 /6/94.

The oh s_hift operations personnel recognized that the work activity would lead to the entry into a 24. tiour Technical Specification LCO per section 3.3.2.f. However, they did not identify the need to complete the operability verification of the other LPSI valves prior to removing the breaker from its cubicle for the PM activity. A similar event occurred two days later, on

• 11 /8/94, during the PM of the breaker for M0-3012~ A different Shift Supervisor was on shift .

at this time, but the other control room personnel were the same as during the event on _

11 /6/94. The failure to test the duplicate equipment was discovered on the next shift by on-shift operations personnel during their review of log books.

CORRECTIVE ACTIONS The following corrective actions have been taken:

1. Administrative Procedure 5.14, " Periodic and Predetermined Activity Control," was revised on 8/8/94 to clarify the method for the final management review of a PPAC revision. The present requirements ensure that the final review is performed on the actual changes after they are input into the on line version of the PPAC. This change was made in conjunction with other enhancements during the two year periodic update of the administrative procedure.

2. The PPACs scheduled for the time period following the discovery of this event were reviewed by Operations Support personnel to verify that plant conditions were appropriate for the work and that the PPAC identified the proper Technical Specifications requirements.

\* l"'"""."--~~__;,~~~~~~~--J

_NRC Farm 366A U.S. NUCLEAR REGUJ;ATORY COMMISSION

. *111-831 APPROVED OMB NO. 3160-0104 EXPIRES: B/31/86

. LICENSEE EVENT REPORT (LERI TEXT CONTINUATION .

FACILITY NAME.111 DOCKET NUMBER 121 LER NUMBER 131 PAGE 141 SEQUENTIAL REVISION YEAR NUMBER NUMBER Pa.lisades Plant 0500025594-0 9 - 0 0 0 6 OF 0 6

3. The list of safety related electrical breakers that were inadvertently included in the scope of PPAC SPS039, and that have been taken out of service since the revision to PPAC SPS039 on 6/15/94, was reviewed. No additional issues were found relating to Technical Specification requirements.

The following corrective actions will be taken:

1. Develop the necessary guidance that will assist Operations personnel in identifying

• redundant or duplicate components that require testing prior to taking a component_ out of service.

2. Provide the appropriate training to Operations personnel on the guidance being developed for identification of testing of redundant or duplicate components prior to taking a component out of service.

3. Review PPACs scheduled to be performed through December 31, 1994,. to verify appropriate plant conditions and testing requirements are identified. Based on the results

. of this review determine if additional reviews are required of other PPACs.

4. Revise PPACs SPS038 and SPS039 to ensure that proper Technical Specifications requirements are identified*.