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{{#Wiki_filter:ACCELERATEDDISTRIBUTIONDEMONS~TIONSYSTEMREGULATORYINFORMATIONDISTRIBUTIONSYSTEM(RIDS)'ACCESSIONNBR:9105060103DOC.DATE:91/04/30NOTARIZED:NOFACIL:50-389St.LuciePlant,Unit2,Flor'idaPower&LightCo.AUTH.NAMEAUTHORAFFILIATION,LAUVER,C.FloridaPower&LightCo.SAGER,D.A.FloridaPower&LightCo.~RECIP.NAMERECIPIENTAFFILIATIONDOCKET05000389
{{#Wiki_filter:ACCELERATED DISTRIBUTION DEMONS~TION SYSTEMREGULATORY INFORMATION DISTRIBUTION SYSTEM(RIDS)'ACCESSION NBR:9105060103 DOC.DATE:
91/04/30NOTARIZED:
NOFACIL:50-389 St.LuciePlant,Unit2,Flor'idaPower&LightCo.AUTH.NAMEAUTHORAFFILIATION, LAUVER,C.
FloridaPower&LightCo.SAGER,D.A.
FloridaPower&LightCo.~RECIP.NAME RECIPIENT AFFILIATION DOCKET05000389


==SUBJECT:==
==SUBJECT:==
LER91-003-00:on910426,2Ashutdowncoolingheatexchangeroutof.svcduetomispositionedcomponentcoolingwatervalve.Causedbypersonnelerror.Valvecorrectlyrealigned&redundanttrain'svalvechecked.W/910430ltr.DISTRIBUTIONCODE:IE22TCOPIESRECEIVED:LTRJENCLJSIZE:,.TITLE:50.73/50.9LicenseeEventReport(LER),IncidentRpt,etc.1NOTES:ARECIPIENTIDCODE/NAMEPD2-2LANORRIS,JINTERNAL:ACNWAEOD/DOA.AEOD/ROAB/DSPNRR/DET/EMEB7ENRR/DLPQ/LPEB10NRR/DREP/PRPB11'RR/DST/SICB7ENRR/DST/SRXB8ERES/DSIR/EIBEXTERNAL:EG&GBRYCE,J.HNRCPDRNSICPOOREEWCOPIESLTTRENCL1111221122111122111111331111RECIPIENTIDCODE/NAMEPD2-2PDACRS~AEOD/DSP/TPABNRR/DET/ECMB9HNRR/DLPQ/LHFB11NRR/DOEA/OEABNRR/DST/SELB8DNRR/DST2LBBJ31RE0MRGN2FILE01LSTLOBBYWARDNSICMURPHY,G.ANUDOCSFULLTXT'COPIESLTTRENCL11221111111111111111111111DD'DNOTETOALL"RIDS"RECIPIENTS:DDPLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOMP1-37(EXT.20079)TOELIMINATEYOURNAMEFROMDISTRIBUTIONLISTSFORDOCUMENTSYOUDON'TNEED!FULLTEXTCONVERSIONREQUIREDTOTALNUMBEROFCOPIESREQUIRED:LTTR33ENCL33 P.O.Box128,Ft.Pierce,FL34954-0128FPLAPR30199'-91-13310CFR50.73U.S.NuclearRegulatoryCommissionAttn:DocumentControlDeskWashington,D.C.20555Gentlemen:Re:St.LucieUnit2DocketNo.50-389'ReportableEvent91-03DateofEvent:April26,19912AShutdownCoolingHeatExchangerOutofServiceDuetoMispositionedComponentCoolinWaterOutletValveCausedbPersonnelErrorTheattachedLicenseeEventReportisbeingsubmittedpursuanttotherequirementsof10CFR50.73toprovidenotificationofthesubjectevent.Asupplementalreportwillbesubmittedattheusual30daytimeinterval.Verytrulyyours,D.A.SgerVicesidentSt.LuciePlantDAS:GRM:kwAttachmentcc:StewartD.Ebneter,.RegionalAdministrator,USNRCRegionIISeniorResidentInspector,USNRC,St.LuciePlantDAS/PSLN4239g0c0rr0i03910430PDFADOCK0000~89PDR'"~~menFPLGroupcompany:.:.=t.287&gag FPLFacsilliICOI.NRCFNITT666<coyU.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)~AffNOIIOCAONO010041004000%4:lOtH0CSTNHITO000OOIPOIIKKOOCIODC040T00TNTN004Cf0AATTITIDCUECDITIIOITNCD0001000ICNWNCTCCINCNTCIKCNIIOCIITXNCTTAIATCTOTICICDITITTNONEIDNTCIWNAINICNIOIANGNI040ILIALIACITAlIKCIIATOIT~WANNNDDN.DCSXk4AIOTOTINPAOIACITIICDUGTIDNffCICCTI01NI4OC,CfINNCfWNAGTACNTNOILA0GCTWAONIGTDKDCIIIClFACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(2)PAGE3050003891004'(4)2AShutdownCoolingHeatExchangerOutofServiceDuetoMispositionedComponentCoolingWaterValveCausedbyPersonnelErrorEVENTDATE(5)LERNUMBER(6)REPORTDATE(7)OTHERFACILITIESINVOLVED(8)MONTHDAY0426YEAR91.91003YEARSIALMONTHDAY00430YEAR91FACILITYNAMESN/AN/ADOCKETNUMBER(S)50005000.OPERATINGMODE(9)POWERLEVEL,(10)100201402(b)20.405(a)(1)(i)20.405(a)(1)(ii)20.405(a)(1)(iii)201405(a)(1)(iv)20.405(c)50.36(c)(1)50.36(c)(2)50.73(a)(2)(i)50.73(a)(2)(ii)50.73(a)(2)(iv)50.73(a)(2)(v)50.73(a)(2)(vii)50.73(a)(2)(viii)(A)50.73(a)(2)(viii)(B)~THISREPORTISSUBMITTEDPURSUANTTOTHEREQUIREMENTSOF10CFR:Checkoneormoreofthefollowin(11)73.71(b)73.71(c)OTHER(SpecifyinAbstractbeloIvandinTextNRCForm366A)20.405(a)(1)(v)50.73(a)(2)(iii)50.73(a)(2)(x)NAMELICENSEECONTACTFORTHISLER12CatherineLauver,ShiftTechnicalAdvisorTELEPONENUMBERAREACODE407465-3550COMPLETEONELINEFOREACHCOMPONENTFAILUREDESCRIBEDINTHISREPORT13CAUSESYSTEMCOMPONENTMANUFAC-TURERBEISVP340REPORTABLETONPRDSCAUSESYSTEMCOMPONENTIIIREPORTABLETONPRDSSUPPLEMENTALREPORTEXPECTED14YES(Ifyes;completeEXPECTEDSUBMISSIONDATE)NOEXPECTEDMONTHDAYYEARSUBMISSIONDATE(15)05269ABSTRACT(Limittof400spaces.i.e.approximatelyfifteensingle-spacetypewrittenlines)(16)Thisisaninterimreport.Afollowupreportwillbesubmitted.Correctiveactionsinclude:thevalvewascorrectlyrealigned;theredundanttrain'svalvewaschecked;bothunitsperformedafullValveStatusCheck.At0110onApril26,1991,withUnit2at100%power,OperationspersonnelbegansearchingforaDCground.At0400,perplantprocedure,OperationscycledHCV-14-3A,ComponentCoolingWater(CCW)outletfromthe2AShutdownCooling(SDC)HeatExchanger(HX)tode-energizeitssolenoidoperatorinanefforttolocatetheDCground.Afterthevalveopened,noflowthroughtheheatexchangerwasindicated.Uponinvestigation,the2ASDCHXCCWreturnisolationvalveSB-14365wasfoundtobelockedclosed.ThisvalveisrequiredtobeLockedOpen.IthadbeenenteredintotheValveSwitchDeviationLogonOctober23,1990asLockedThrottledandrestoredNovember29,1990.Asthisisthemostrecentdocumentedmanipulationdate,itisassumedtohavebeenmispositionedatthistime.Thevalvepositionpointerwasbrokenandindicatedopen.Thecauseofthemispositioningisunderinvestigation.FPLFacsimileofNRCForm366(6-89)  
LER91-003-00:on 910426,2A shutdowncoolingheatexchanger outof.svcduetomispositioned component coolingwatervalve.Causedbypersonnel error.Valvecorrectly realigned
&redundant train'svalvechecked.W/910430 ltr.DISTRIBUTION CODE:IE22TCOPIESRECEIVED:LTR JENCLJSIZE:,.TITLE:50.73/50.9 LicenseeEventReport(LER),IncidentRpt,etc.1NOTES:ARECIPIENT IDCODE/NAME PD2-2LANORRIS,JINTERNAL:
ACNWAEOD/DOA.AEOD/ROAB/DSP NRR/DET/EMEB 7ENRR/DLPQ/LPEB10 NRR/DREP/PRPB11
'RR/DST/SICB 7ENRR/DST/SRXB 8ERES/DSIR/EIBEXTERNAL:
EG&GBRYCE,J.H NRCPDRNSICPOOREEWCOPIESLTTRENCL1111221122111122111111331111RECIPIENT IDCODE/NAME PD2-2PDACRS~AEOD/DSP/TPABNRR/DET/ECMB 9HNRR/DLPQ/LHFB11 NRR/DOEA/OEAB NRR/DST/SELB 8DNRR/DST2LBBJ31RE0MRGN2FILE01LSTLOBBYWARDNSICMURPHY,G.A NUDOCSFULLTXT'COPIESLTTRENCL11221111111111111111111111DD'DNOTETOALL"RIDS"RECIPIENTS:
DDPLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOMP1-37(EXT.20079)TOELIMINATE YOURNAMEFROMDISTRIBUTION LISTSFORDOCUMENTS YOUDON'TNEED!FULLTEXTCONVERSION REQUIREDTOTALNUMBEROFCOPIESREQUIRED:
LTTR33ENCL33 P.O.Box128,Ft.Pierce,FL34954-0128 FPLAPR30199'-91-133 10CFR50.73U.S.NuclearRegulatory Commission Attn:DocumentControlDeskWashington, D.C.20555Gentlemen:
Re:St.LucieUnit2DocketNo.50-389'Reportable Event91-03DateofEvent:April26,19912AShutdownCoolingHeatExchanger OutofServiceDuetoMispositioned Component CoolinWaterOutletValveCausedbPersonnel ErrorTheattachedLicenseeEventReportisbeingsubmitted pursuanttotherequirements of10CFR50.73toprovidenotification ofthesubjectevent.Asupplemental reportwillbesubmitted attheusual30daytimeinterval.
Verytrulyyours,D.A.SgerVicesidentSt.LuciePlantDAS:GRM:kw Attachment cc:StewartD.Ebneter,.Regional Administrator, USNRCRegionIISeniorResidentInspector, USNRC,St.LuciePlantDAS/PSLN4239g0c0rr0i03 910430PDFADOCK0000~89PDR'"~~menFPLGroupcompany:.:.=t.287&gag FPLFacsilliIC OI.NRCFNITT666<coyU.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)~AffNOIIOCAONO010041004000%4:lOtH0CSTNHITO000OOIPOIIKKOOCIODC040T00TNTN004Cf0AATTITI DCUECDITIIOITNCD0001000ICNWNCTCCINCNTCIKCNIIOCIITXNCTTAIATCTOTICICDITITTNONEIDNTCIWNAINICNI OIANGNI040ILIALIACITAlIKCIIATOIT
~WANNNDDN.
DCSXk4AIOTOTINPAOIACITI ICDUGTIDN ffCICCTI01NI4OC,CfINNCfWNAGTACNT NOILA0GCTWAONIGTDK DCIIIClFACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(2)PAGE3050003891 004'(4)2AShutdownCoolingHeatExchanger OutofServiceDuetoMispositioned Component CoolingWaterValveCausedbyPersonnel ErrorEVENTDATE(5)LERNUMBER(6)REPORTDATE(7)OTHERFACILITIES INVOLVED(8)MONTHDAY0426YEAR91.91003YEARSIALMONTHDAY00430YEAR91FACILITYNAMESN/AN/ADOCKETNUMBER(S) 50005000.OPERATING MODE(9)POWERLEVEL,(10)100201402(b) 20.405(a)(1)(i) 20.405(a)(1)(ii) 20.405(a)
(1)(iii)201405(a)(1)(iv) 20.405(c) 50.36(c)(1) 50.36(c)(2) 50.73(a)(2)(i) 50.73(a)(2)
(ii)50.73(a)(2)(iv) 50.73(a)(2)(v) 50.73(a)(2)(vii) 50.73(a)(2)(viii)(A) 50.73(a)(2)(viii)(B)
~THISREPORTISSUBMITTED PURSUANTTOTHEREQUIREMENTS OF10CFR:Checkoneormoreofthefollowin(11)73.71(b)73.71(c)OTHER(SpecifyinAbstractbeloIvandin TextNRCForm366A)20.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x)
NAMELICENSEECONTACTFORTHISLER12Catherine Lauver,ShiftTechnical AdvisorTELEPONENUMBERAREACODE407465-3550COMPLETEONELINEFOREACHCOMPONENT FAILUREDESCRIBED INTHISREPORT13CAUSESYSTEMCOMPONENT MANUFAC-TURERBEISVP340REPORTABLE TONPRDSCAUSESYSTEMCOMPONENT IIIREPORTABLE TONPRDSSUPPLEMENTAL REPORTEXPECTED14YES(Ifyes;completeEXPECTEDSUBMISSION DATE)NOEXPECTEDMONTHDAYYEARSUBMISSION DATE(15)05269ABSTRACT(Limittof400spaces.i.e.
approximately fifteensingle-space typewritten lines)(16)Thisisaninterimreport.Afollowupreportwillbesubmitted.
Corrective actionsinclude:thevalvewascorrectly realigned; theredundant train'svalvewaschecked;bothunitsperformed afullValveStatusCheck.At0110onApril26,1991,withUnit2at100%power,Operations personnel begansearching foraDCground.At0400,perplantprocedure, Operations cycledHCV-14-3A, Component CoolingWater(CCW)outletfromthe2AShutdownCooling(SDC)HeatExchanger (HX)tode-energize itssolenoidoperatorinanefforttolocatetheDCground.Afterthevalveopened,noflowthroughtheheatexchanger wasindicated.
Uponinvestigation, the2ASDCHXCCWreturnisolation valveSB-14365wasfoundtobelockedclosed.ThisvalveisrequiredtobeLockedOpen.IthadbeenenteredintotheValveSwitchDeviation LogonOctober23,1990asLockedThrottled andrestoredNovember29,1990.Asthisisthemostrecentdocumented manipulation date,itisassumedtohavebeenmispositioned atthistime.Thevalvepositionpointerwasbrokenandindicated open.Thecauseofthemispositioning isunderinvestigation.
FPLFacsimile ofNRCForm366(6-89)  


FPLFacslmraorNROForm666(6-69)~U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONASSASNTOCAOISA$1500105EITfsabaAITI505ssrsfATTOusTWNseatKspQNscTocCANLTwlTHTNsssofsfATcNSouseTISHMOICST:500ISTSICONf505CASAOITSfNCAIONOTASSXNSafWATSTOTINraxSSIiNetcSCTTTSuuNAmSNTTNANCH5Caaua55ASSNTNSOAATNTTofaIASNSNwAsHNCION.oc505faNclToTIcsfsTIINcfNMTTucllQHNT55'ciI'150010150frICCofIMWdDCNfAIST55$5CCTWNSINSTTSAOC5050$FACILITYNAME(1)DOCKETNUMBER(2)LERNUMBER(6)PAGE(3)St.LucieUnit205000389YEAR91EQUENTIALNUMBER003REVISIONNUMBER0002004TEXT(Ifmorespaceisreriuired,useadditionalNRCForm366A's)(17)Thisisaninterimreport.AfollowupreportwillbesubmittedAt0110onApril26,1991,withUnit2at100%power,OperationspersonnelbegantosearchforaDCground.Tofindaground,planttoadsareindividuallyisolated.Perplantprocedure,OperationscycledHCV-14-3A,ComponentCoolingWater(CCW)(EIIS:CC)fromthe2AShutdownCooling(SDC)HeatExchanger(HX)(EIIS:BP).Duringnormaloperationsthereisnoflowthroughtheshutdownheatexchanger;openingthevalveshouldhaveresultedin4000gpmflow.TherewasnoflowindicatedthroughtheHX.Operations.locallyverifiedmovementofHCV-14-3AandpositionofCCWinletisolationvalveSB-14348.CCWoutletisolationvalveSB-14365isrequiredtobeLockedOpen,wasindicatingopenbyitsvalvepositionindicator,butwasinfactLockedClosed.Thevalvewasreopenedtoitsproperposition.Theredundanttrain'sCCWoutletisolationvalvepositionwascheckedasaprecaution.ThevalvewasinitsproperLockedOpenposition,butitspositionindicatorwasalsofaulty.AninvestigationrevealedthatSB-14365wasenteredintotheValveSwitchDeviationLogonOctober23,1990,whenplacedinaLockedThrottledpositiontobalanceCCWflow.OnNovember25,1990,asUnit2wascompletingarefuelingoutage,theCCWsystemwasplacedinitsoperatingalignment.OperatingProcedure2-0310020,"ComponentCoolingWater-NormalOperation,"wasperformed.SB-14365wasverifiedtobeLockedOpenatthistime;OnNovember29,1990,theValveSwitchDeviationLogshowedthatthevalvewasrestoredtoitsLockedOpenposition.AsNovember29isthelastrecordeddatethatSB-14365wasmanipulated,itisassumedthatthevalvehasbeenmispositionedsincethistime.ThelackofanOPERABLE2ASDCHXcausesthe2AtrainoftheContainmentSpraySystem(EIIS:BE)tobeadministrativelyoutofservice.From0455onFebruary19through0315onFebruary20and2208onFebruary20through1700onFebruary21,1991,the2BContainmentSpraySystemwasoutofserviceforroutinemaintenanceandtesting.PlantrecordsarebeingreviewedtoseeifthereareanyotherperiodsoftimewherebothtrainsoftheContainmentSpraySystemwereoutofservice.CCWoutletisolationvalveSB-14365isamanuallyoperatedbutterflyvalvelocatedinahorizontallineabouttwelvefeetabovethefloor.Valvepositionindicationisprovidedbyapointerwhichissupposedtomovewiththevalvestem.Thepointerwasbroken.APlantWorkOrderwaswrittenOctober21,1990torepairthepointerandwasapparentlyworkedJanuary17,1991.Atthetimethemispositioningwasdiscovered,thepointererroneouslyindicatedOpen.Investigationintothisvalvepositionindicatorfailurewillcontinue.AStandingNightOrderstatesthattocheckthepositionofaLockedOpenvalve,thevalveshallbeunlocked,closedslightly,reopened,andrelocked.Whilethepositionindicatedbythepointerwasinaccurateandmisleading,thehandwheelonthevalveindicateswhichwaytoturntoopenthevalve.SinceNovemberof1990,thepositionofthisvalvehasbeencheckedtwiceduringthequarterlyperformanceofAdministrativeProcedure2-0010123,"AdministrativeControlofValves,Locks,andSwitches,"andweeklyduringAdministrativeProcedure2-0010125A,"SurveillanceDataSheets,"FPLFacsimileofNRCForm366(6-69)  
FPLFacslmraorNROForm666(6-69)~U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUATION ASSASNTOCAOISA$1500105EITfsabaAITI505ssrsfATTO usTWNseatKspQNscTocCANLTwlTHTNsssofsfATcN SouseTISHMOICST:500ISTSICONf505CASAOITSfNCAIONOTASSXNSafWATSTOTINraxSSIiNetcSCTTTSuuNAmSNT TNANCH5Caaua55ASSNTNSOAATNTT ofaIASNSN wAsHNCION.
oc505faNclToTIcsfsTIINcfN MTTucllQH NT55'ciI'150010150frICC ofIMWdDCNfAIST55$5CCTWNSINSTTSAOC 5050$FACILITYNAME(1)DOCKETNUMBER(2)LERNUMBER(6)PAGE(3)St.LucieUnit205000389YEAR91EQUENTIAL NUMBER003REVISIONNUMBER0002004TEXT(Ifmorespaceisreriuired, useadditional NRCForm366A's)(17)Thisisaninterimreport.Afollowupreportwillbesubmitted At0110onApril26,1991,withUnit2at100%power,Operations personnel begantosearchforaDCground.Tofindaground,planttoadsareindividually isolated.
Perplantprocedure, Operations cycledHCV-14-3A, Component CoolingWater(CCW)(EIIS:CC) fromthe2AShutdownCooling(SDC)HeatExchanger (HX)(EIIS:BP).
Duringnormaloperations thereisnoflowthroughtheshutdownheatexchanger; openingthevalveshouldhaveresultedin4000gpmflow.Therewasnoflowindicated throughtheHX.Operations.
locallyverifiedmovementofHCV-14-3A andpositionofCCWinletisolation valveSB-14348.
CCWoutletisolation valveSB-14365isrequiredtobeLockedOpen,wasindicating openbyitsvalvepositionindicator, butwasinfactLockedClosed.Thevalvewasreopenedtoitsproperposition.
Theredundant train'sCCWoutletisolation valvepositionwascheckedasaprecaution.
ThevalvewasinitsproperLockedOpenposition, butitspositionindicator wasalsofaulty.Aninvestigation revealedthatSB-14365wasenteredintotheValveSwitchDeviation LogonOctober23,1990,whenplacedinaLockedThrottled positiontobalanceCCWflow.OnNovember25,1990,asUnit2wascompleting arefueling outage,theCCWsystemwasplacedinitsoperating alignment.
Operating Procedure 2-0310020, "Component CoolingWater-Normal Operation,"
wasperformed.
SB-14365wasverifiedtobeLockedOpenatthistime;OnNovember29,1990,theValveSwitchDeviation LogshowedthatthevalvewasrestoredtoitsLockedOpenposition.
AsNovember29isthelastrecordeddatethatSB-14365wasmanipulated, itisassumedthatthevalvehasbeenmispositioned sincethistime.ThelackofanOPERABLE2ASDCHXcausesthe2AtrainoftheContainment SpraySystem(EIIS:BE) tobeadministratively outofservice.From0455onFebruary19through0315onFebruary20and2208onFebruary20through1700onFebruary21,1991,the2BContainment SpraySystemwasoutofserviceforroutinemaintenance andtesting.PlantrecordsarebeingreviewedtoseeifthereareanyotherperiodsoftimewherebothtrainsoftheContainment SpraySystemwereoutofservice.CCWoutletisolation valveSB-14365isamanuallyoperatedbutterfly valvelocatedinahorizontal lineabouttwelvefeetabovethefloor.Valvepositionindication isprovidedbyapointerwhichissupposedtomovewiththevalvestem.Thepointerwasbroken.APlantWorkOrderwaswrittenOctober21,1990torepairthepointerandwasapparently workedJanuary17,1991.Atthetimethemispositioning wasdiscovered, thepointererroneously indicated Open.Investigation intothisvalvepositionindicator failurewillcontinue.
AStandingNightOrderstatesthattocheckthepositionofaLockedOpenvalve,thevalveshallbeunlocked, closedslightly,
: reopened, andrelocked.
Whilethepositionindicated bythepointerwasinaccurate andmisleading, thehandwheel onthevalveindicates whichwaytoturntoopenthevalve.SinceNovemberof1990,thepositionofthisvalvehasbeencheckedtwiceduringthequarterly performance ofAdministrative Procedure 2-0010123, "Administrative ControlofValves,Locks,andSwitches,"
andweeklyduringAdministrative Procedure 2-0010125A, "Surveillance DataSheets,"FPLFacsimile ofNRCForm366(6-69)  


FPLFccEIIIIAIolNR"Form666(649)VU.S.NUCLEARREGUlATORYCOMMrsslONLICENSEEEVENTREPORT(LER)'EXTCONTINUATIONAPPICNTOCAONCk$100010IEPIKR00000ECIPNCTo$$oENPETIfKSPCtSEToCIEPETPRIITIICISP&#xc3;NAATEPICOUECCIPIIET$ECP.$1$100$RANNOCOWRIEIKCAfoRCRTeolECTCIATEToTIEIECOT$$NoIEPOlr$NANIEIEIITNNN001+0$EoCIAAEEAEIKOAATCAP~~.ocPEN,~TooEP~RoccRPRE0EETI$1$001000cffcEcPMNIAEEAENTAIAMxET,sEIPATlcRcc$050$FACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(2)YEAR0500038991LERNUMBER(6)EQUENTIALNUMBER003REVISIONUMBER00PAGE(3)03004TEXT(lfmorespaceisrequired,useadditionalNRCForm366A's)'17)...DataSheet36,IAtalltimesitwasreportedtobeLockedOpen.Therootcauseoftheeventisunderinvestigation.Areviewofplantrecords,includingoperatorlogs,clearances,andPlantWorkOrders,isbeingconducted.Personnelwillbeinterviewedtodeterminethespecificnatureandcauseoftheerror.AnINPOHumanPerformanceEnhancementSystemevaluationwillalsobeperformed.VNTThiseventisreportableundertherequirementsof10CFR50.73.a.2.i.B,anyconditionoroperationprohibitedbyTechnicalSpecifications.TechnicalSpecification3.6.2.1"ContainmentSpraySystem"requirestwoindependentContainmentSpraySystemstobeOPERABLEwithanOPERABLEShutdownCoolingHeatExchanger.AWhiletheexactdateofthemispositioningoftheCCWoutletisolationvalvetothe2ASDCHXisnotyetknown,November29,1990isthelastrecordeddateofamanipulationofthevalveandisassumedtobethedateofthemispositioning.OverathreedayperiodinFebruary1991,the2BContainmentSpraySystemwastakenoutofserviceforroutinemaintenanceandtesting.TheSDCHXisnotuseduntiltherecirculationphasefordecayheatremoval.The2AContainmentSpraySystemwasalwaysavailabletoreceivecoolwaterfromtheRefuelingWaterTankanddeliverittocontainmenttomitigateapost-LOCAcontainmentpressurerise.AnalternatesafetysystemforContainmentHeatRemoval,theContainmentCoolingSystem,isbeingfurtherevaluatedfordecayheatremovalcapability.St.Lucieequipmentsizingissuchthatthefourcontainmentfancoolerswillprovidethecontainmentheatremovalcapabilitynecessarytolimitandreduceaccidentcontainmentpressureandtemperatureduringtherecirculationphase.Additionalanalysisareinprogress,assumingasinglefailure,todemonstratethattwocontainmentfancoolerscanalsoremoveLargeBreakLOCAcontainmentheatloadduringtherecirculationphase.ThisresultisexpectedbecauseofthePSLcontainmentdesigninwhichthefreestandingsteelvesselwilltransferheattotheenvironment.FPLEngineeringhasperformedafirstorderriskassessmentoftheCCWtotheSDCHXvalvebeingintheclosedposition.ForamediumorlargebreakLOCA,thefrequencyassociatedwiththelossofthedecayheatremovalfunctiononlyincreasesfrom3.6E-8perreactoryearwithanormalSDCHXlineup,to5.8E-7perreactoryearwiththeshutdownheatexchangerisolated.Withoperatoractiontoopenthevalve,thefrequencyisreducedto1.5E-7perreactoryear.Therefore,thehealthandsafetyofthepublicwasnotaffectedduringthiscondition.FPLFacsimileofNRCForm366(6-89)  
FPLFccEIIIIAI olNR"Form666(649)VU.S.NUCLEARREGUlATORY COMMrsslON LICENSEEEVENTREPORT(LER)'EXTCONTINUATION APPICNTOCAONCk$100010IEPIKR00000ECIPNCTo$$oENPETIfKSPCtSEToCIEPETPRIITIICISP&#xc3;NAATEPI COUECCIPIIET$ECP.$1$100$RANNOCOWRIEIKCAfoRCRTeolECTCIATEToTIEIECOT$$NoIEPOlr$NANIEIEIIT NNN001+0$
"tIII FPLFocsIITS'ATo.'RCForm666(649)U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUAllON0FFFHOFCOCAOIASSH0410lCSFSHO:AOWTCNSIATtOOACIHFCHFKSFCSOCTOCCAOSTWOHTIESSFOFSAATCIOOUECSOIFCCACSv:a4WTSFCHA1AIOCCAACTOSFHOAFOWOHASHHtSISAAICTOHCFCOrftfSFIATFCFOITSNQACCAASITOIAHCHIF4$$OOSrrltARFHOAAIOHT00$40$CAIWAOOHOCW.OCTl&#xc3;OLFFSTToSICFFCFFINASWSDVCOCHFFTSCCT($110410ASCfFISCOFAAOCACTITAFOIIAXCT,WASHHOTOAOCSH0$FACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(2)YEARLERNUMBER(6)EQUENTIALNUMBERREVISIONNUMBERPAGE(3)0500038991TEXT(Ifmorespaceisrerluired,useadditionalNRCForm366A's)(17)00300040041.OperationsrestoredSB-14365toitsproperpositionandverifiedthepositionoftheredundanttrain'sCCWoutletisolationvalve.2.PlantWorkOrdersweresubmittedtorepairthefaultypointersoneachvalveanddeterminetherootcauseofthefaultypointer.3.AllOperationspersonnelwerecounseledontheuseoftheStandingNightOrder.Operationsisinvestigatingfurthermethodstoenhanceindependentverification.4.OperationsperformedtheentireWeeklyValveStatusCheckonbothUnit1andUnit2.Nofurtherdiscepancieswerenoted.5.AnINPOHumanPerformanceEnhancementSystemevaluationwillbeperformedonthisevent.'hereviewwillincludehumanfactorsandworkconditions.AffectedComponentIdentification:HenryPratt14HButterflyValveNuclearMKIIwithManualOperatorMDT-3HWModelNumber100178SerialNumberC140PreviousSimilarLicenseeEventReports:335-89-002"Inoperable1BDieselGeneratorDuetoFuelOilSystemValveMisalignment"335-87-012"LossofComponentCoolingWaterRedundancy-1Aand1BComponentCoolingWaterCross-tieValvesinOpenPosition"FPLFacsimileofNRCForm366(6-69)}}
EoCIAAEEAEIKOAATCAP
~~.ocPEN,~TooEP~RoccRP RE0EETI$1$001000cffcEcPMNIAEEAENT AIAMxET,sEIPATlcR cc$050$FACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(2)YEAR0500038991 LERNUMBER(6)EQUENTIAL NUMBER003REVISIONUMBER00PAGE(3)03004TEXT(lfmorespaceisrequired, useadditional NRCForm366A's)'17)
...DataSheet36,IAtalltimesitwasreportedtobeLockedOpen.Therootcauseoftheeventisunderinvestigation.
Areviewofplantrecords,including operatorlogs,clearances, andPlantWorkOrders,isbeingconducted.
Personnel willbeinterviewed todetermine thespecificnatureandcauseoftheerror.AnINPOHumanPerformance Enhancement Systemevaluation willalsobeperformed.
VNTThiseventisreportable undertherequirements of10CFR50.73.a.2.i.B, anycondition oroperation prohibited byTechnical Specifications.
Technical Specification 3.6.2.1"Containment SpraySystem"requirestwoindependent Containment SpraySystemstobeOPERABLEwithanOPERABLEShutdownCoolingHeatExchanger.
AWhiletheexactdateofthemispositioning oftheCCWoutletisolation valvetothe2ASDCHXisnotyetknown,November29,1990isthelastrecordeddateofamanipulation ofthevalveandisassumedtobethedateofthemispositioning.
OverathreedayperiodinFebruary1991,the2BContainment SpraySystemwastakenoutofserviceforroutinemaintenance andtesting.TheSDCHXisnotuseduntiltherecirculation phasefordecayheatremoval.The2AContainment SpraySystemwasalwaysavailable toreceivecoolwaterfromtheRefueling WaterTankanddeliverittocontainment tomitigateapost-LOCA containment pressurerise.Analternate safetysystemforContainment HeatRemoval,theContainment CoolingSystem,isbeingfurtherevaluated fordecayheatremovalcapability.
St.Lucieequipment sizingissuchthatthefourcontainment fancoolerswillprovidethecontainment heatremovalcapability necessary tolimitandreduceaccidentcontainment pressureandtemperature duringtherecirculation phase.Additional analysisareinprogress, assumingasinglefailure,todemonstrate thattwocontainment fancoolerscanalsoremoveLargeBreakLOCAcontainment heatloadduringtherecirculation phase.ThisresultisexpectedbecauseofthePSLcontainment designinwhichthefreestandingsteelvesselwilltransferheattotheenvironment.
FPLEngineering hasperformed afirstorderriskassessment oftheCCWtotheSDCHXvalvebeingintheclosedposition.
ForamediumorlargebreakLOCA,thefrequency associated withthelossofthedecayheatremovalfunctiononlyincreases from3.6E-8perreactoryearwithanormalSDCHXlineup,to5.8E-7perreactoryearwiththeshutdownheatexchanger isolated.
Withoperatoractiontoopenthevalve,thefrequency isreducedto1.5E-7perreactoryear.Therefore, thehealthandsafetyofthepublicwasnotaffectedduringthiscondition.
FPLFacsimile ofNRCForm366(6-89)  
"tIII FPLFocsIITS'AT o.'RCForm666(649)U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUAllON 0FFFHOFCOCAOIASSH0410lCSFSHO:AOWTCNSIATtOOACIHFCHFKSFCSOC TOCCAOSTWOHTIESSFOFSAATCIOOUECSOI FCCACSv:a4 WTSFCHA1AIOCCAACTOSFHOAFOWOHASHH tSISAAICTOHCFCOrftfSFIATFCFOITSNQACCAASIT OIAHCHIF4$$OOSrrltAR FHOAAIOHT 00$40$CAIWAOOHOCW.
OCTl&#xc3;OLFFSTToSICFFCFFINASW SDVCOCHFFTSCCT($110410ASCfFISCOFAAOCACTITAFO IIAXCT,WASH HOTOAOCSH0$FACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(2)YEARLERNUMBER(6)EQUENTIAL NUMBERREVISIONNUMBERPAGE(3)0500038991 TEXT(Ifmorespaceisrerluired, useadditional NRCForm366A's)(17)00300040041.Operations restoredSB-14365toitsproperpositionandverifiedthepositionoftheredundant train'sCCWoutletisolation valve.2.PlantWorkOrdersweresubmitted torepairthefaultypointersoneachvalveanddetermine therootcauseofthefaultypointer.3.AllOperations personnel werecounseled ontheuseoftheStandingNightOrder.Operations isinvestigating furthermethodstoenhanceindependent verification.
4.Operations performed theentireWeeklyValveStatusCheckonbothUnit1andUnit2.Nofurtherdiscepancies werenoted.5.AnINPOHumanPerformance Enhancement Systemevaluation willbeperformed onthisevent.'hereviewwillincludehumanfactorsandworkconditions.
AffectedComponent Identification:
HenryPratt14HButterfly ValveNuclearMKIIwithManualOperatorMDT-3HWModelNumber100178SerialNumberC140PreviousSimilarLicenseeEventReports:335-89-002 "Inoperable 1BDieselGenerator DuetoFuelOilSystemValveMisalignment" 335-87-012 "LossofComponent CoolingWaterRedundancy-1A and1BComponent CoolingWaterCross-tie ValvesinOpenPosition" FPLFacsimile ofNRCForm366(6-69)}}

Revision as of 16:26, 29 June 2018

LER 91-003-00:on 910426,2A Shutdown Cooling Heat Exchanger Out of Svc Due to Mispositioned Component Cooling Water Valve.Caused by Personnel Error.Valve Correctly Realigned & Redundant Train Valve checked.W/910430 Ltr
ML17223B170
Person / Time
Site: Saint Lucie NextEra Energy icon.png
Issue date: 04/30/1991
From: LAUVER C, SAGER D A
FLORIDA POWER & LIGHT CO.
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
L-91-133, LER-91-003, LER-91-3, NUDOCS 9105060103
Download: ML17223B170 (9)


Text

ACCELERATED DISTRIBUTION DEMONS~TION SYSTEMREGULATORY INFORMATION DISTRIBUTION SYSTEM(RIDS)'ACCESSION NBR:9105060103 DOC.DATE:

91/04/30NOTARIZED:

NOFACIL:50-389 St.LuciePlant,Unit2,Flor'idaPower&LightCo.AUTH.NAMEAUTHORAFFILIATION, LAUVER,C.

FloridaPower&LightCo.SAGER,D.A.

FloridaPower&LightCo.~RECIP.NAME RECIPIENT AFFILIATION DOCKET05000389

SUBJECT:

LER91-003-00:on 910426,2A shutdowncoolingheatexchanger outof.svcduetomispositioned component coolingwatervalve.Causedbypersonnel error.Valvecorrectly realigned

&redundant train'svalvechecked.W/910430 ltr.DISTRIBUTION CODE:IE22TCOPIESRECEIVED:LTR JENCLJSIZE:,.TITLE:50.73/50.9 LicenseeEventReport(LER),IncidentRpt,etc.1NOTES:ARECIPIENT IDCODE/NAME PD2-2LANORRIS,JINTERNAL:

ACNWAEOD/DOA.AEOD/ROAB/DSP NRR/DET/EMEB 7ENRR/DLPQ/LPEB10 NRR/DREP/PRPB11

'RR/DST/SICB 7ENRR/DST/SRXB 8ERES/DSIR/EIBEXTERNAL:

EG&GBRYCE,J.H NRCPDRNSICPOOREEWCOPIESLTTRENCL1111221122111122111111331111RECIPIENT IDCODE/NAME PD2-2PDACRS~AEOD/DSP/TPABNRR/DET/ECMB 9HNRR/DLPQ/LHFB11 NRR/DOEA/OEAB NRR/DST/SELB 8DNRR/DST2LBBJ31RE0MRGN2FILE01LSTLOBBYWARDNSICMURPHY,G.A NUDOCSFULLTXT'COPIESLTTRENCL11221111111111111111111111DD'DNOTETOALL"RIDS"RECIPIENTS:

DDPLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOMP1-37(EXT.20079)TOELIMINATE YOURNAMEFROMDISTRIBUTION LISTSFORDOCUMENTS YOUDON'TNEED!FULLTEXTCONVERSION REQUIREDTOTALNUMBEROFCOPIESREQUIRED:

LTTR33ENCL33 P.O.Box128,Ft.Pierce,FL34954-0128 FPLAPR30199'-91-133 10CFR50.73U.S.NuclearRegulatory Commission Attn:DocumentControlDeskWashington, D.C.20555Gentlemen:

Re:St.LucieUnit2DocketNo.50-389'Reportable Event91-03DateofEvent:April26,19912AShutdownCoolingHeatExchanger OutofServiceDuetoMispositioned Component CoolinWaterOutletValveCausedbPersonnel ErrorTheattachedLicenseeEventReportisbeingsubmitted pursuanttotherequirements of10CFR50.73toprovidenotification ofthesubjectevent.Asupplemental reportwillbesubmitted attheusual30daytimeinterval.

Verytrulyyours,D.A.SgerVicesidentSt.LuciePlantDAS:GRM:kw Attachment cc:StewartD.Ebneter,.Regional Administrator, USNRCRegionIISeniorResidentInspector, USNRC,St.LuciePlantDAS/PSLN4239g0c0rr0i03 910430PDFADOCK0000~89PDR'"~~menFPLGroupcompany:.:.=t.287&gag FPLFacsilliIC OI.NRCFNITT666<coyU.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)~AffNOIIOCAONO010041004000%4:lOtH0CSTNHITO000OOIPOIIKKOOCIODC040T00TNTN004Cf0AATTITI DCUECDITIIOITNCD0001000ICNWNCTCCINCNTCIKCNIIOCIITXNCTTAIATCTOTICICDITITTNONEIDNTCIWNAINICNI OIANGNI040ILIALIACITAlIKCIIATOIT

~WANNNDDN.

DCSXk4AIOTOTINPAOIACITI ICDUGTIDN ffCICCTI01NI4OC,CfINNCfWNAGTACNT NOILA0GCTWAONIGTDK DCIIIClFACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(2)PAGE3050003891 004'(4)2AShutdownCoolingHeatExchanger OutofServiceDuetoMispositioned Component CoolingWaterValveCausedbyPersonnel ErrorEVENTDATE(5)LERNUMBER(6)REPORTDATE(7)OTHERFACILITIES INVOLVED(8)MONTHDAY0426YEAR91.91003YEARSIALMONTHDAY00430YEAR91FACILITYNAMESN/AN/ADOCKETNUMBER(S) 50005000.OPERATING MODE(9)POWERLEVEL,(10)100201402(b) 20.405(a)(1)(i) 20.405(a)(1)(ii) 20.405(a)

(1)(iii)201405(a)(1)(iv) 20.405(c) 50.36(c)(1) 50.36(c)(2) 50.73(a)(2)(i) 50.73(a)(2)

(ii)50.73(a)(2)(iv) 50.73(a)(2)(v) 50.73(a)(2)(vii) 50.73(a)(2)(viii)(A) 50.73(a)(2)(viii)(B)

~THISREPORTISSUBMITTED PURSUANTTOTHEREQUIREMENTS OF10CFR:Checkoneormoreofthefollowin(11)73.71(b)73.71(c)OTHER(SpecifyinAbstractbeloIvandin TextNRCForm366A)20.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x)

NAMELICENSEECONTACTFORTHISLER12Catherine Lauver,ShiftTechnical AdvisorTELEPONENUMBERAREACODE407465-3550COMPLETEONELINEFOREACHCOMPONENT FAILUREDESCRIBED INTHISREPORT13CAUSESYSTEMCOMPONENT MANUFAC-TURERBEISVP340REPORTABLE TONPRDSCAUSESYSTEMCOMPONENT IIIREPORTABLE TONPRDSSUPPLEMENTAL REPORTEXPECTED14YES(Ifyes;completeEXPECTEDSUBMISSION DATE)NOEXPECTEDMONTHDAYYEARSUBMISSION DATE(15)05269ABSTRACT(Limittof400spaces.i.e.

approximately fifteensingle-space typewritten lines)(16)Thisisaninterimreport.Afollowupreportwillbesubmitted.

Corrective actionsinclude:thevalvewascorrectly realigned; theredundant train'svalvewaschecked;bothunitsperformed afullValveStatusCheck.At0110onApril26,1991,withUnit2at100%power,Operations personnel begansearching foraDCground.At0400,perplantprocedure, Operations cycledHCV-14-3A, Component CoolingWater(CCW)outletfromthe2AShutdownCooling(SDC)HeatExchanger (HX)tode-energize itssolenoidoperatorinanefforttolocatetheDCground.Afterthevalveopened,noflowthroughtheheatexchanger wasindicated.

Uponinvestigation, the2ASDCHXCCWreturnisolation valveSB-14365wasfoundtobelockedclosed.ThisvalveisrequiredtobeLockedOpen.IthadbeenenteredintotheValveSwitchDeviation LogonOctober23,1990asLockedThrottled andrestoredNovember29,1990.Asthisisthemostrecentdocumented manipulation date,itisassumedtohavebeenmispositioned atthistime.Thevalvepositionpointerwasbrokenandindicated open.Thecauseofthemispositioning isunderinvestigation.

FPLFacsimile ofNRCForm366(6-89)

FPLFacslmraorNROForm666(6-69)~U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUATION ASSASNTOCAOISA$1500105EITfsabaAITI505ssrsfATTO usTWNseatKspQNscTocCANLTwlTHTNsssofsfATcN SouseTISHMOICST:500ISTSICONf505CASAOITSfNCAIONOTASSXNSafWATSTOTINraxSSIiNetcSCTTTSuuNAmSNT TNANCH5Caaua55ASSNTNSOAATNTT ofaIASNSN wAsHNCION.

oc505faNclToTIcsfsTIINcfN MTTucllQH NT55'ciI'150010150frICC ofIMWdDCNfAIST55$5CCTWNSINSTTSAOC 5050$FACILITYNAME(1)DOCKETNUMBER(2)LERNUMBER(6)PAGE(3)St.LucieUnit205000389YEAR91EQUENTIAL NUMBER003REVISIONNUMBER0002004TEXT(Ifmorespaceisreriuired, useadditional NRCForm366A's)(17)Thisisaninterimreport.Afollowupreportwillbesubmitted At0110onApril26,1991,withUnit2at100%power,Operations personnel begantosearchforaDCground.Tofindaground,planttoadsareindividually isolated.

Perplantprocedure, Operations cycledHCV-14-3A, Component CoolingWater(CCW)(EIIS:CC) fromthe2AShutdownCooling(SDC)HeatExchanger (HX)(EIIS:BP).

Duringnormaloperations thereisnoflowthroughtheshutdownheatexchanger; openingthevalveshouldhaveresultedin4000gpmflow.Therewasnoflowindicated throughtheHX.Operations.

locallyverifiedmovementofHCV-14-3A andpositionofCCWinletisolation valveSB-14348.

CCWoutletisolation valveSB-14365isrequiredtobeLockedOpen,wasindicating openbyitsvalvepositionindicator, butwasinfactLockedClosed.Thevalvewasreopenedtoitsproperposition.

Theredundant train'sCCWoutletisolation valvepositionwascheckedasaprecaution.

ThevalvewasinitsproperLockedOpenposition, butitspositionindicator wasalsofaulty.Aninvestigation revealedthatSB-14365wasenteredintotheValveSwitchDeviation LogonOctober23,1990,whenplacedinaLockedThrottled positiontobalanceCCWflow.OnNovember25,1990,asUnit2wascompleting arefueling outage,theCCWsystemwasplacedinitsoperating alignment.

Operating Procedure 2-0310020, "Component CoolingWater-Normal Operation,"

wasperformed.

SB-14365wasverifiedtobeLockedOpenatthistime;OnNovember29,1990,theValveSwitchDeviation LogshowedthatthevalvewasrestoredtoitsLockedOpenposition.

AsNovember29isthelastrecordeddatethatSB-14365wasmanipulated, itisassumedthatthevalvehasbeenmispositioned sincethistime.ThelackofanOPERABLE2ASDCHXcausesthe2AtrainoftheContainment SpraySystem(EIIS:BE) tobeadministratively outofservice.From0455onFebruary19through0315onFebruary20and2208onFebruary20through1700onFebruary21,1991,the2BContainment SpraySystemwasoutofserviceforroutinemaintenance andtesting.PlantrecordsarebeingreviewedtoseeifthereareanyotherperiodsoftimewherebothtrainsoftheContainment SpraySystemwereoutofservice.CCWoutletisolation valveSB-14365isamanuallyoperatedbutterfly valvelocatedinahorizontal lineabouttwelvefeetabovethefloor.Valvepositionindication isprovidedbyapointerwhichissupposedtomovewiththevalvestem.Thepointerwasbroken.APlantWorkOrderwaswrittenOctober21,1990torepairthepointerandwasapparently workedJanuary17,1991.Atthetimethemispositioning wasdiscovered, thepointererroneously indicated Open.Investigation intothisvalvepositionindicator failurewillcontinue.

AStandingNightOrderstatesthattocheckthepositionofaLockedOpenvalve,thevalveshallbeunlocked, closedslightly,

reopened, andrelocked.

Whilethepositionindicated bythepointerwasinaccurate andmisleading, thehandwheel onthevalveindicates whichwaytoturntoopenthevalve.SinceNovemberof1990,thepositionofthisvalvehasbeencheckedtwiceduringthequarterly performance ofAdministrative Procedure 2-0010123, "Administrative ControlofValves,Locks,andSwitches,"

andweeklyduringAdministrative Procedure 2-0010125A, "Surveillance DataSheets,"FPLFacsimile ofNRCForm366(6-69)

FPLFccEIIIIAI olNR"Form666(649)VU.S.NUCLEARREGUlATORY COMMrsslON LICENSEEEVENTREPORT(LER)'EXTCONTINUATION APPICNTOCAONCk$100010IEPIKR00000ECIPNCTo$$oENPETIfKSPCtSEToCIEPETPRIITIICISPÃNAATEPI COUECCIPIIET$ECP.$1$100$RANNOCOWRIEIKCAfoRCRTeolECTCIATEToTIEIECOT$$NoIEPOlr$NANIEIEIIT NNN001+0$

EoCIAAEEAEIKOAATCAP

~~.ocPEN,~TooEP~RoccRP RE0EETI$1$001000cffcEcPMNIAEEAENT AIAMxET,sEIPATlcR cc$050$FACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(2)YEAR0500038991 LERNUMBER(6)EQUENTIAL NUMBER003REVISIONUMBER00PAGE(3)03004TEXT(lfmorespaceisrequired, useadditional NRCForm366A's)'17)

...DataSheet36,IAtalltimesitwasreportedtobeLockedOpen.Therootcauseoftheeventisunderinvestigation.

Areviewofplantrecords,including operatorlogs,clearances, andPlantWorkOrders,isbeingconducted.

Personnel willbeinterviewed todetermine thespecificnatureandcauseoftheerror.AnINPOHumanPerformance Enhancement Systemevaluation willalsobeperformed.

VNTThiseventisreportable undertherequirements of10CFR50.73.a.2.i.B, anycondition oroperation prohibited byTechnical Specifications.

Technical Specification 3.6.2.1"Containment SpraySystem"requirestwoindependent Containment SpraySystemstobeOPERABLEwithanOPERABLEShutdownCoolingHeatExchanger.

AWhiletheexactdateofthemispositioning oftheCCWoutletisolation valvetothe2ASDCHXisnotyetknown,November29,1990isthelastrecordeddateofamanipulation ofthevalveandisassumedtobethedateofthemispositioning.

OverathreedayperiodinFebruary1991,the2BContainment SpraySystemwastakenoutofserviceforroutinemaintenance andtesting.TheSDCHXisnotuseduntiltherecirculation phasefordecayheatremoval.The2AContainment SpraySystemwasalwaysavailable toreceivecoolwaterfromtheRefueling WaterTankanddeliverittocontainment tomitigateapost-LOCA containment pressurerise.Analternate safetysystemforContainment HeatRemoval,theContainment CoolingSystem,isbeingfurtherevaluated fordecayheatremovalcapability.

St.Lucieequipment sizingissuchthatthefourcontainment fancoolerswillprovidethecontainment heatremovalcapability necessary tolimitandreduceaccidentcontainment pressureandtemperature duringtherecirculation phase.Additional analysisareinprogress, assumingasinglefailure,todemonstrate thattwocontainment fancoolerscanalsoremoveLargeBreakLOCAcontainment heatloadduringtherecirculation phase.ThisresultisexpectedbecauseofthePSLcontainment designinwhichthefreestandingsteelvesselwilltransferheattotheenvironment.

FPLEngineering hasperformed afirstorderriskassessment oftheCCWtotheSDCHXvalvebeingintheclosedposition.

ForamediumorlargebreakLOCA,thefrequency associated withthelossofthedecayheatremovalfunctiononlyincreases from3.6E-8perreactoryearwithanormalSDCHXlineup,to5.8E-7perreactoryearwiththeshutdownheatexchanger isolated.

Withoperatoractiontoopenthevalve,thefrequency isreducedto1.5E-7perreactoryear.Therefore, thehealthandsafetyofthepublicwasnotaffectedduringthiscondition.

FPLFacsimile ofNRCForm366(6-89)

"tIII FPLFocsIITS'AT o.'RCForm666(649)U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUAllON 0FFFHOFCOCAOIASSH0410lCSFSHO:AOWTCNSIATtOOACIHFCHFKSFCSOC TOCCAOSTWOHTIESSFOFSAATCIOOUECSOI FCCACSv:a4 WTSFCHA1AIOCCAACTOSFHOAFOWOHASHH tSISAAICTOHCFCOrftfSFIATFCFOITSNQACCAASIT OIAHCHIF4$$OOSrrltAR FHOAAIOHT 00$40$CAIWAOOHOCW.

OCTlÃOLFFSTToSICFFCFFINASW SDVCOCHFFTSCCT($110410ASCfFISCOFAAOCACTITAFO IIAXCT,WASH HOTOAOCSH0$FACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(2)YEARLERNUMBER(6)EQUENTIAL NUMBERREVISIONNUMBERPAGE(3)0500038991 TEXT(Ifmorespaceisrerluired, useadditional NRCForm366A's)(17)00300040041.Operations restoredSB-14365toitsproperpositionandverifiedthepositionoftheredundant train'sCCWoutletisolation valve.2.PlantWorkOrdersweresubmitted torepairthefaultypointersoneachvalveanddetermine therootcauseofthefaultypointer.3.AllOperations personnel werecounseled ontheuseoftheStandingNightOrder.Operations isinvestigating furthermethodstoenhanceindependent verification.

4.Operations performed theentireWeeklyValveStatusCheckonbothUnit1andUnit2.Nofurtherdiscepancies werenoted.5.AnINPOHumanPerformance Enhancement Systemevaluation willbeperformed onthisevent.'hereviewwillincludehumanfactorsandworkconditions.

AffectedComponent Identification:

HenryPratt14HButterfly ValveNuclearMKIIwithManualOperatorMDT-3HWModelNumber100178SerialNumberC140PreviousSimilarLicenseeEventReports:335-89-002 "Inoperable 1BDieselGenerator DuetoFuelOilSystemValveMisalignment" 335-87-012 "LossofComponent CoolingWaterRedundancy-1A and1BComponent CoolingWaterCross-tie ValvesinOpenPosition" FPLFacsimile ofNRCForm366(6-69)