05000295/LER-1997-006, :on 970222,Zion Station Exceeded Limiting Condition for Operation Due to Inadequate Procedure Controls.Standing Order to Require Review of TS During OOS Procedure Implementation,Was Issued: Difference between revisions

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{{Adams
#REDIRECT [[05000295/LER-1997-006]]
| number = ML20137F456
| issue date = 03/26/1997
| title = :on 970222,Zion Station Exceeded Limiting Condition for Operation Due to Inadequate Procedure Controls.Standing Order to Require Review of TS During OOS Procedure Implementation,Was Issued
| author name = Brennan N
| author affiliation = COMMONWEALTH EDISON CO.
| addressee name =
| addressee affiliation =
| docket = 05000295
| license number =
| contact person =
| document report number = LER-97-006, LER-97-6, NUDOCS 9704010108
| package number = ML20137F440
| document type = LICENSEE EVENT REPORT (SEE ALSO AO RO), TEXT-SAFETY REPORT
| page count = 6
}}
{{LER
| Title = :on 970222,Zion Station Exceeded Limiting Condition for Operation Due to Inadequate Procedure Controls.Standing Order to Require Review of TS During OOS Procedure Implementation,Was Issued
| Plant =
| Reporting criterion = 10 CFR 50.73(a)(2), 10 CFR 50.73(a)(2)(v), 10 CFR 50.73(a)(2)(1), 10 CFR 50.73(a)(2)(viii)(B), 10 CFR 50.73(a)(2)(x)
| Power level =
| Mode =
| Docket = 05000295
| LER year = 1997
| LER number = 6
| LER revision = 0
| Event date =
| Report date =
| ENS =
| abstract =
}}
 
=text=
{{#Wiki_filter:_.
.m LICENSEE EVENT REPORT (LER)
FACILITY NAME' DOCKET NUMBER PAGE ZION NUCLEAR POWER STATION UNIT 0l5l0l0l0l2l9l5 1 l0Fl 0 l 6 TITLE ZION STATION EXCEEDED A LIMITING CONDITION FOR OPERATION DUE T0 IMDEQUATE PROCEDURE CONTROLS t
EVENT DATE LER NUMBER REPORT DATE OTHER FACILITIES ]NVOLVED MONTH DAY YEAR YEAR SEO.
REV MONTH DAY YEAR FACILITY NAMES DOCKET NUMBER (5) 71nN UNIT ?
0l5l0l0l0l3l0lA niz 212 o l>
917 olols oIo of3 216 917 I I I I I I I THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR 5: (CHECK ONE OR MORE OF THE FOLLOWING)
OPERATING MODE I
3 20.402(b) 20.405(e) 50.73(a)(2)(1v) 73.71(b)
POWER 20.405(a)(1)(1) 50.36(c)(1) 50.73(a)(2)(v) 73.71(c) 0l0l0 LEVEL 20.405(a)(1)(11) 50.36(c)(2) 50.73(a)(2)(v11)
OTHER (Specify in 20.405(a)(1)(111) x 50.73(a)(2)(1) 50.73(a)(2)(v111)(A)
Abstract below l
20.405(a)(1)(iv) 50.73(a)(2)(11) 50.73(a)(2)(viii)(B) 36)
'~
20.405(a)(1)(v) 50.73(a)(2)(111) 50.73(a)(2)(x)
LICENSEE CONTACT FOR THIS LER NAME TELEPHnNE NUMBER Neil Brennan. Ext 2380 81417 714161-121olela COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT
 
==CAUSE==
SYSTEM COMPONENT MANUFACTURER
 
==CAUSE==
SYSTEM COMPONENT MANUFACTURER
^
N l
l I I I II g
l l l l l l 1
I I I I I I I
I I l l l 1 SUPPLEMENTAL REPORT EXPECTED EXPECTED MONTH DAY YEAR SUBMISSION l YES (If yes complete EXPECTED SUBMISSION DATE) 2 NO DATE l
l l
i ABSTRACT (Limit to 1400 spaces. i.e.
approximately fifteen single space typewritten lines).
On Saturday 22-FEB-97. the Unit Supervisor (US) approved and at 1310 the operators began to install an Out Of Service (005) request in conjunction with a Work Request (WR) that had been prepared to repair the instrument sensing line manifold for the Loop A Reactor Coolant System (RCS) flow detector (1FI-414). The WR was included in the forced outage schedule for unit 1. The forced outage began at 1415 hours on 21-FEB-97 when unit 1 entered MODE 3 (HOT SHUTDOWN). The valve manipulations specified by the 005 checklist rendered 3 of 3 Loop A RCS flow instruments INOPERABLE. Technical Specification 3.1
* Reactor Protection Instrumentation and Logic." requires the RCS flow instruments to be OPERABLE in MODES 1.2.3.4 and 7.
The Technical Specification allows for less than 1 flow instrument operable up to 8 hours if the failed channels are placed in the tripped mode. If these conditions are not met, the unit is to be in HOT SHUTDOWN within 24 hours and in COLD SHUTDOWN within the following 24 hours, Although the original failed instrument (IFI-414) had been placed in the tripped mode, the additional instruments that became inoperable as a result of the 005 valve manipulations were not placed in the tripped mode until l
Monday. 24-FEB-97 at 1330 hours. This event was caused by inadequate procedures and inadequate verification pract1ces. This event did not impact plent, personnel nor public safety because the reactor was maintained in the HOT SHUTDOWN MODE with reactor trip breakers open throughout the event and ended with the unit in COLD SHUTDOWN.
I Corrective actions for this event include issuance of a Standing Order to require review of Technical Specifications during OOS procedure implementation, revising appropriate procedures to require Technical l
Specification review in verifying compliance during maintenance. and training for appropriate personnel. (NUREG l
1022 Code E) 9704010108 970326 PDR ADOCK 05000295 S
PDR ZLER\\97006a.ler(1)
I
 
l LICENSEE EVENT REPORT (LER) TEXT CONTINUATION FACILITYNAME DOCKET NUMBER LER NUMBER FAGE YEAR SEO.
REV.
ZION NUCLEAR POWER STATION 0l5l0l0l0l2l9l5 9l7 0l0l6 0l0 0l2 0l6
~
0F TEXT Energy Industry Identification system (Ells) codes are identified in the text as [XX]
A.
PLANT CONDITIONS PRIOR TO EVENT Unit 1 MODE 3 - HOT SHUTDOWN Rx Power M RCS [AB] Temperature / Pressure 548 F/2238 osia Unit 2 MODE 5 - COLD SHUTDOWN Rx Power H RCS [AB] Temperature / Pressure 81 F/63 osia B.
 
==DESCRIPTION OF EVENT==
On 06-JAN-97. while performing a routine CHANNEL CHECK Surveillance, the Nuclear Station Operator (NS0) found the Loop A Reactor Coolant [AB] Flow Indicator (1FI-414) reading was 4 percent different from the two redundant Loop A Flow Indicators.
The channel was declared inoperable in accordance with Technical Specification (3.1.2.c.)
requirements.
The crew entered the Abnormal Operating Procedure (A0P) 7.2. " Operation With A Failed Instrument Channel." manually tripped the channel input bistable relay to Reactor Protection [JC]. initiated the " Inoperable Equipment Surveillance" tracking procedure (PT-14), and initiated an Action Request (AR 970001224) to begin the repair process.
The repair was assigned to the Instrument Maintenance (IM) group.
The IM group determined that Mechanical Maintenance (MM) group support was required to correct the problem, ultimately. The MM group was needed to repair leakage internal to the instrument sensing line manifold, before the IM group could complete calibration of the affected flow instrument. On 23-JAN-97, the original work recuest was added to a Forced Outage Schedule to include the MM work and to be performec in the event of a unit shutdown. On 21-FEB-97. unit 1 was shutdown in accordance with Technical Specification 3.6.1.C., due to a Containment Spray System [BE] pump failure, unrelated to this event.
During the morning of Saturday. 22-FEB-97, a work analyst added the manifold repair task to the original work request.
The Senior Reactor Operator (SRO) assigned to the Work Control outage group initiated an Out Of Service (005) request to protect MM personnel during the ruanifold repair.
The Equipment Attendant on shift identified isolation points for the 005 request and develo)ed the checklist.
The 005 checklist was reviewed and approved by the SR0 Licensed Slift Supervisor (LSS) on shift.
The Work Control outage group directed the on shift SRO Unit Supervisor (US) to install the DOS in accordance with the Forced Outage Schedule (Z1F23).
The US verifled that l
it would be ap3roariate to place the 00S at the time by reviewing the MODE 3 l
surveillance C1ecclist, which he felt would provide evidence of whether the affected l
instruments were required to be OPERABLE in MODE 3.
The instruments were not listed I
in the MODE 3 Surveillance Checklist, and the US concluded the instruments were not required to be OPERABLE in MODE 3.
The US reviewed and approved the 005, and directed the operators to install the 00S.
The operator began valve manipulation in accordance with the 00S at 13:10 on 22-FEB-97.
d i
ZLER\\97006a.leN2)
 
LICENSEE EVENT REPORT (LER) TEXT CONTINUATION FACILITY NAME DOCKET NUMBER LER NUMBER PAGE YEAR SEO.
REV.
I ZION NUCLEAR POWER STATION 0l5l0l0l0l2l9l5 9l7 0l0l6 0l0 0l3 0l6
~
0F TEXT Energy Industry Identification System (EIIS) codes are identified in the text as [XX)
B.
DESCRIPTION OF EVENT (Continued)
Placing the 00S involved closing instrument sersino line isolation valves that rendered all three Loop A RCS Flow instruments inoperable.
Since the unit was in MODE
: 3. the applicable Technical Specification required the instruments to be restored to OPERABLE status within 24 hours, or be in COLD SHUTDOWN within the following 24 hours.
In addition. the channel input bistable relay to Reactor Protection for the three affected channels should have been tripped and because the MINIMUM DEGREE OF REDUNDANCY would be exceeded, a time limit of 8 hours existed to restore the MINIMUM DEGREE OF REDUNDANCY to at least 1 OPERABLE channel. With unit 1 in MODE 3. neither the Work Control organization nor the on shift operations crew categorized the manifold repair as Limiting Condition for Operation (LCO) work.
On Monday. 24-FEB-97. during routine monitoring of the Main Control Board, the unit I l
NS0s questioned why 3 of 3 Loop A Flow instruments were not operating and their l
bistable relays were not tripped. The US evaluated the observation with the NS0s.
Shift Engineer. Regulatory Assurance and Station Management, and concluded the unit had been inadvertently placed in LCOs from Technical Specification Table 3.1-1.
" Reactor Protection System - Limiting Operating Conditions and Setpoints." on 1
Saturday. 22-FEB-97.
The US determined that time limits for MINIMUM DEGREE OF REDUNDANCY and MINIMUM OPERABLE CHANNELS had been exceeded. The crew immediately tripped the channel input bistable relays to Reactor Protection, and properly implemented response and tracking procedures. The Shift Engineer declared an Unusual Event (MU-10: Technical Specification Time Limit Expired), and performed event 1
classification and NRC notification via the Emergency Notification System (ENS)in accordance with Zion Emergency Plan Implementing Procedure (EPIP) 330-1.
" Classification of GSEP Conditions." On 25-FEB-97. the unit reached the COLD SHUTDOWN MODE 5 condition at 2123 hours.
ZLER\\97006a.ler(3)
 
l LICENSEE EVENT REPORT (LER) TEXT CONTINUATION FACILITY NAME
* DOCKET NUMBER LER NUMBER PAGE YEAR SEO.
REV.
ZION NUCLEAR POWER STATION 0l5l0l0l0l2l9ls 9l7 0l0l6 0l0 0l4 0l6
~
0F TEXT Energy Industry Identification System (E!IS) codes are identified in the text as [xX)
C.
 
==CAUSE OF EVENT==
This event was caused by inadequate procedures and inadequate verification practices.
The work control organization failed to classify the manifold repair as Limiting Condition for Operation work because personnel did not review the Technical Specifications and there was no program requirement to perform the necessary evaluation and determination.
Consequently, the work was scheduled to occur in the MODE 3 condition, when the instruments were required to be OPERABLE.
Individuals in the Operating organization did not recognize the Limiting Condition for Operation entry because they did not review the Technical Specifications and were not required to verify formally that scheduled work has been classified and scheduled in accordance with Technical Specifications. An opportunity for verification during the Out of Service arocess failed because the Unit Supervisor used the MODE 3 Surveillance Checklist as a Jasis for determining LCO applicability, rather than referring to the Technical Specifications directly. This technique failed because the Unit Supervisor assumed that Surveillance Requirement MODES of applicability, as reflected in the checklist, were consistent with Limiting Condition for Operation MODES of i
applicability.
Although not previously required by Zion procedures, the Unit Supervisor's verification of the Out of Service acce)tability with respect to Technical Specifications failed because he assumed tlat LCO applicability would be reflected in the MODE 3 Surveillance Checklist.
The Surveillance Requirement is applicable in MODES 1 and 2. and applicability of the LCO is not explicitly stated, but considered applicable in MODES 1.2.3.4 and 7.
D.
 
==SAFETY ANALYSIS==
According to Table 3.1-1 of Technical Specification 3.1. the Low Primary Coolant Flow must have at least 2 channels available and operable.
These flow channels provide a reactor trip signal whenever flow is less than 90% of indicated value.
However, when the reactor power is less than 10%. this trip signal is totally blocked.
On 2/22/97 when the three independent channels were isolated on loop A. the reactor trip breakers were already open and Unit I was already in hot shutdown.
Therefore had an actual low flow condition developed, the Unit was already in a safe condition with the trip i
breakers open and did not jeopardize the safety of the public.
There was no consequence when the Unit did not enter cold shutdown or tria the bistable until 40 hours after isolation of the loop flow transmitters.
T1e flow transmitters provide a reactor trip signal whenever flow is less than 90% of indicated l
value.
Since the Unit was in hot shutdown, this trip signal is blocked.
The reactor I
trip breakers were already open when the loop flow transmitters were isolated.
l Therefore, had an actual low flow condition developed, the Unit had the trip breakers open and did not jeopardize the safety of the public.
ZLER\\97006a ler(4)
 
i LICENSEE EVENT REPORT (LER) TEXT CONTINUATION
\\
FACILfTV NAME*
DOCKET NUMBER LER NUMBER PAGE YEAR SEO.
REV ZION NUCLEAR POWER STATION 0l5l0l0l0l2l9l5 9l7 0l0l6 0l0 0l5 0l6 0F TEXT Er.ergy Industry Identification System (EIIS) codes are identified in the text as [XX]
E.
 
==CORRECTIVE ACTIONS==
i 1.
Operations Management has issued a Standing Order to Licensed personnel directing that Technical Specifications shall be reviewed as follows: Technical Specifications shall be reviewed to ensure 3 roper compliance anytime fechnical Specification related equi) ment is to be tacen Out Of Service.
If there is doubt with respect to whetler the equipment is Technical Specification related.
Technical 5)ecifications will be reviewed to verify the status. This standing order will 3e removed upon completion of corrective actions 2 and 3. below.
2.
The Station will revise appropriate procedures to increase control of Inoperable Equipment Tracking. Out Of Service. Work Request Approval and Scheduling.
These changes will eliminate exceptions to use of key procedures and require review of Technical Specifications by personnel performing key actions within these 1
processes.
)
3.
Appro)riate personnel will participate in training on this Licensee Event Report and t1e resultin', procedure and process changes.
l ZLER\\97006a.ler(5)
 
LICENSEE EVENT REPORT (LER) TEXT CONTINUATION FACILfTY NAME*
DOCKET NUMBER LER NUMBER PAGE YEAR SEO.
REV.
ZION NUCLEAR POWER STATION 0lSl0l0l0l2l9l5 9l7 0l0l6 0l0 0l6 0F 0l6 TEXT Energy Industry Identification System (E!!S) codes are identified in the text as [XX]
F.
PREVIOUS EVENTS SEARCH AND ANALYSIS There were two previous op)ortunities to correct the program deficiencies described above.
In January 1994, t1e Station provided a commitment in respor.se to a Notice of
. Violation (Violation 295(304)/93020-01B in NRC Inspection Report 50-295/93020:50-304/93020 dated December 7, 1993), that addressed weaknesses in tracking the status of work associated with Limiting Conditions for Operation (LCO). The corrective actions intended to improve tracking and verification of the status of all LC0 work.
In June 1996, the station initiated a root cause investigation after detecting an adverse trend in inadvertent LCO entries.
In both cases, the corrective actions were focused 1
more on the performance of personnel assigned to the process.
Consecuently, those actions did not achieve lasting or fundamental program change and dic not clarify responsibility and accountability for LCO compliance.
The corrective actions associated with this Licensee Event Report are intended to eliminate vague program requirements, ensure that the program positively controls LC0 work, and to assign responsibility for LCO compliance to Licensed Operators.
G.
 
==COMPONENT FAILURE DATA==
Component failure did not cause this event.
)
l l
J ZLER\\97006a.ler(6)
}}
 
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