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{{#Wiki_filter:~i~r,j~mianUISIM@JTIONDEMONSTRATINSYSTEMREGULATORYINFORMATIONDISTRIBUTIONSYSTEM(RIDS)ACCESSIONNBR:9107220223DOC.DATE:91/07/15NOTARIZED:NODOCKETFACIL:50-316DonaldC.CookNuclearPowerPlant,Unit2,Indiana&05000316AUTH.NAMEAUTHORAFFILIATIONSAMPSON,J.R.IndianaMichiganPowerCo.(formerlyIndiana&MichiganEleBLIND,A.A.IndianaMichiganPowerCo.(formerlyIndiana&MichiganEleRECIP.NAMERECIPIENTAFFILIATIONR
{{#Wiki_filter:~i~r,j~mianUISIM@JTION DEMONSTRATI NSYSTEMREGULATORY INFORMATION DISTRIBUTION SYSTEM(RIDS)ACCESSION NBR:9107220223 DOC.DATE:
91/07/15NOTARIZED:
NODOCKETFACIL:50-316 DonaldC.CookNuclearPowerPlant,Unit2,Indiana&05000316AUTH.NAMEAUTHORAFFILIATION SAMPSON,J.R.
IndianaMichiganPowerCo.(formerly Indiana&MichiganEleBLIND,A.A.
IndianaMichiganPowerCo.(formerly Indiana&MichiganEleRECIP.NAME RECIPIENT AFFILIATION R


==SUBJECT:==
==SUBJECT:==
LER91-005-00:on910614,boltsremovedfrompressurizedessentialsvcwaterlineexpansionjoints&watersprayedfromflanges.Causedbyreversedcomponentlabels.Joe.ntsreinstalled&labelingcorrected.W/910715ltr.DISTRIBUTIONCODE:IE22TCOPIESRECEIVED:LTRJENCL2SIZE:TITLE:50.73/50.9LicenseeEventReport(LER),IncidentRpt,etc.NOTES:RECIPIENTIDCODE/NAMEPD3-1LACOLBURN,T.INTERNAL:ACNWAEOD/DSP/TPABNRR/DET/ECMB9HNRR/DLPQ/LHFB10NRR/DOEA/OEABNRR/DST/SELB8DNRR/D~ST.SP~B8J)3REGRGN3FIIE01EXTERNAL:EG&GBRYCE,J.HNRCPDRNSICPOOREiWCOPIESLTTRENCL1111221111111111111111331111RECIPIENTIDCODE/NAMEPD3-1PDAEOD/DOAAEOD/ROAB/DSPNRR/DET/EMEB7ENRR/DLPQ/LPEB10NRR/DREP/PRPB11NRR/DST/SICB8H3NRR/DST/SRXB8ERES/DSIR/EIBLSTLOBBYWARDNSICMURPHYTGANUDOCSFULLTXTCOPIESLTTRENCL111122111122111111111111DDRDNOTETOALL"RIDS"RECIPIENTS:DDPLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOMPl-37(EXT.20079)TOELIMINATEYOURNAMEFROMDISTRIBUTIONLISTSFORDOCUMENTSYOUDON'TNEED!FULLTEXTCONVERSIONREQUIREDTOTALNUMBEROFCOPIESREQUIRED:LTTR31ENCL31 IndianaMichiganPowerCompanyCookNuclearPlantOneCookPlaceBridgman,Ml491066164655901July15,1991vaw~saaNECHf6AHPWKRUnitedStatesNuclearRegulatoryCommissionDocumentControlDeskRockville,Maryland20852OperatingLicensesDPR-74DocketNo.50-316DocumentControlManager:Inaccordancewiththecriteriaestablishedby10CFR50.73entitledLicenseeEventReortSstemthefollowingreportisbeingsubmitted:91-005-00Sincerely,A.A.BlindPlantManagerAAB:sbAttachmentcoD.H.Williams,Jr.A.B.Davis,RegionIIIE.E.FitzpatrickP.A.BarrettB.F.HendersonR.F.KroegerB.Walters-Ft.WayneNRCResidentInspectorT.Colburn-NRCJ.G.KepplerM.R.PadgettG.Charnoff,Esp.D.HahnINPOS.J.Brewer/B.P.LauzauB.A.Svensson9107220223910715PDRADOCK050003lbSPDR NACFORM366(64)9).S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)OVEDOMBNO.31504)104EXPIRES:4/30/92ESTIMATEDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATIONCOLLE'CTIONREQUEST:50.0HRS.FORWARDCOMMENTSREGARDINGBURDENESTILIATETOTHEAECORDSANDREPORTSMANAGEMENTBRANCHIP530),U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON,DC20555,ANDTOTHEPAPERWORKREDUCTIONPROJECT(31500104I.OFFICEOFMANAGEMENTANDBUDGET,WASHINGTON,DC20503.FACILITYNAMEHID.C.CookNuclearPlant-Unit2DOCKETNUMBER(2)PAGE3050003]61OFP5BoltsRemovedfromPressurizedEssentialServiceWater'ineExpansionJointDuetoReversedComonentLabelsEVENTOATE(5)LERNUMBER(6)REPORTDATE(7)OTHERFACILITIESINVOLVED(SIMONTHOAYYEARYEAR%~6SEOVENTIALCOPr:NUMBER@~REVrSIONMONTHDAYYEARFACILITYNAMESDOCKETNUMBER(SI05000061491910050007159105000OPERATINGMODE(9)]POWERLEVEL1ppTHISREPORTISSUBMITTEDPURSUANTT50,73(s)(2)(iv)50.73(~)l2)(v)60,73(s)(2)(vill60.73(sl(2)(vill)(AI50.73(~)(2)(villi(BI60.73(~)l2)(e)20.405(c)50.36(c)Ille0.35(c)(2)60.73(~)l2)II)50,73(s)(2)Ill)60.73(sI(2)Iill)20.402(tr)20405(s)(IIII)20.405(~)(1)Ill)20.405(sll1)(ill)20A05(s)II)(lv)20.405(s)(1)(vlLICENSEECONTACTFORTHISLER(12I0THERLOUIREMENTSOF10CFA()tICnectroneormoreofthefollowinp/(1173.7)(II)73.71(c)oTHER/specifyinAottrecroslowenrflnTest,/Y/ICForm36SA/VoluntaryReportNAMEJ.R.Samson,0erationsSuperintendentTFLEPHONENUMBERAREACODE616465-5901COMPLETEONELINEFOREACHCOMIIONENTFAILUREDESCRIBEDINTHISREPORT(13)CAUSESYSTEMCOMPONENTMANUFACTURERREPORTABLE/rer""'"";::.-..444~4CAUSESYSTEMCOMPONENTMANUFAC.TUREREPOATABLE'+'ONPRDScy.v>.rm6(4v,v,nMLS3vc(rbeyn(3:(Ã~(e~xii81I:(4%+0SUPPLEMENTALREPORTEXPECTED(14)YESIlfyer,completeEXPECTEDSt/64r/SSIOHDATE/NOABSTRACTILlmitto/400rpecee,Ie.,epproeimetelyfifteenrlnplespecstypewritrenliner/(16)EXPECTEDSUBMISSIONDATE(15)MONTHDAYYEARThewest('W')essentialservicewater(ESW)erainwasmadeinoperableae2146on6/13/91inpreparationforreplacementofan8-inchexpansionjointlabelledas2-XJ-54W.At0600on6/14/91,Maintenancepersonnelbegantoremovetheflangebolesfromtheexpansionjoint.Alloftheflangeboltswereremovedatabout0700.Theexpansionjointremainedlodgedinplaceandwaeersprayedfromtheflanges.Thewaterwasinitiallybelievedtobeeitherfromtrappedwaterorisolationpointleakby.At1240,however,itwasidentifiedthattheexpansionjointedlabelledasbeingonthe'W'SWtrainwasactuallyontheeast('E')ESWtrainandtheboltswerereinstalledat1317.TheEngineeringreviewofthiseventdeterminedthatthewaterlossedouttheflangewasinsignificantandthattheexpansionjointwouldhaveremainedinplaceduringadesignbasisearehquake.Thiseventisbeingvoluntarilyreportedastheanalysisindicatesthe'E'SWtrainremainedoperable.Thecauseofthelabellingproblemcouldnotbedetermined.Thelabelingproblemwiththe2-XJ-54expansionjoineswascorrectedon6/14/91.Awalkdownwasperformedonsimilarexpansionjoinesinunit1and2.Oneadditionalproblemwasfoundandcorrectedinunit2on6/19/91.Thelabellingprocesswasreviewedanddeterminedtobeadequatewiththiseventbeingcausedbyauniquecombinationofcircumstances.Alessonslearnedmemowasissued7/9/91toOperationsandMaintenancepersonnelonthisevent.NRCForm366(64)9)  
LER91-005-00:on 910614,bolts removedfrompressurized essential svcwaterlineexpansion joints&watersprayedfromflanges.Caused byreversedcomponent labels.Joe.nts reinstalled
&labelingcorrected.W/910715 ltr.DISTRIBUTION CODE:IE22TCOPIESRECEIVED:LTR JENCL2SIZE:TITLE:50.73/50.9 LicenseeEventReport(LER),IncidentRpt,etc.NOTES:RECIPIENT IDCODE/NAME PD3-1LACOLBURN,T.
INTERNAL:
ACNWAEOD/DSP/TPABNRR/DET/ECMB 9HNRR/DLPQ/LHFB1 0NRR/DOEA/OEAB NRR/DST/SELB 8DNRR/D~ST.
SP~B8J)3REGRGN3FIIE01EXTERNAL:
EG&GBRYCE,J.H NRCPDRNSICPOOREiWCOPIESLTTRENCL1111221111111111111111331111RECIPIENT IDCODE/NAME PD3-1PDAEOD/DOAAEOD/ROAB/DS PNRR/DET/EMEB 7ENRR/DLPQ/LPEB10 NRR/DREP/PRPB11 NRR/DST/SICB8H3 NRR/DST/SRXB 8ERES/DSIR/EIB LSTLOBBYWARDNSICMURPHYTGANUDOCSFULLTXTCOPIESLTTRENCL111122111122111111111111DDRDNOTETOALL"RIDS"RECIPIENTS:
DDPLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOMPl-37(EXT.20079)TOELIMINATE YOURNAMEFROMDISTRIBUTION LISTSFORDOCUMENTS YOUDON'TNEED!FULLTEXTCONVERSION REQUIREDTOTALNUMBEROFCOPIESREQUIRED:
LTTR31ENCL31 IndianaMichiganPowerCompanyCookNuclearPlantOneCookPlaceBridgman, Ml491066164655901July15,1991vaw~saaNECHf6AHPWKRUnitedStatesNuclearRegulatory Commission DocumentControlDeskRockville, Maryland20852Operating LicensesDPR-74DocketNo.50-316DocumentControlManager:Inaccordance withthecriteriaestablished by10CFR50.73entitledLicenseeEventReortSstemthefollowing reportisbeingsubmitted:
91-005-00 Sincerely, A.A.BlindPlantManagerAAB:sbAttachment coD.H.Williams, Jr.A.B.Davis,RegionIIIE.E.Fitzpatrick P.A.BarrettB.F.Henderson R.F.KroegerB.Walters-Ft.WayneNRCResidentInspector T.Colburn-NRCJ.G.KepplerM.R.PadgettG.Charnoff, Esp.D.HahnINPOS.J.Brewer/B.P.
LauzauB.A.Svensson9107220223 910715PDRADOCK050003lbSPDR NACFORM366(64)9).S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)OVEDOMBNO.31504)104 EXPIRES:4/30/92ESTIMATED BURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLE'CTION REQUEST:50.0HRS.FORWARDCOMMENTSREGARDING BURDENESTILIATE TOTHEAECORDSANDREPORTSMANAGEMENT BRANCHIP530),U.S.NUCLEARREGULATORY COMMISSION, WASHINGTON, DC20555,ANDTOTHEPAPERWORK REDUCTION PROJECT(31500104I.
OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON, DC20503.FACILITYNAMEHID.C.CookNuclearPlant-Unit2DOCKETNUMBER(2)PAGE3050003]61OFP5BoltsRemovedfromPressurized Essential ServiceWater'ine Expansion JointDuetoReversedComonentLabelsEVENTOATE(5)LERNUMBER(6)REPORTDATE(7)OTHERFACILITIES INVOLVED(SIMONTHOAYYEARYEAR%~6SEOVENTIAL COPr:NUMBER@~REVrSIONMONTHDAYYEARFACILITYNAMESDOCKETNUMBER(SI 05000061491910050007159105000OPERATING MODE(9)]POWERLEVEL1ppTHISREPORTISSUBMITTED PURSUANTT50,73(s)(2)(iv) 50.73(~)l2)(v)60,73(s)(2)(vill60.73(sl(2)(vill)(AI 50.73(~)(2)(villi(BI 60.73(~)l2)(e)20.405(c) 50.36(c)Ille0.35(c)(2) 60.73(~)l2)II)50,73(s)(2)Ill)60.73(sI(2)Iill)20.402(tr) 20405(s)(IIII)20.405(~)(1)Ill)20.405(sll1)(ill) 20A05(s)II)(lv) 20.405(s)(1)(vl LICENSEECONTACTFORTHISLER(12I0THERLOUIREMENTS OF10CFA()tICnectroneormoreofthefollowinp/
(1173.7)(II) 73.71(c)oTHER/specifyinAottrecroslowenrflnTest,/Y/ICForm36SA/Voluntary ReportNAMEJ.R.Samson,0erationsSuperintendent TFLEPHONE NUMBERAREACODE616465-5901COMPLETEONELINEFOREACHCOMIIONENT FAILUREDESCRIBED INTHISREPORT(13)CAUSESYSTEMCOMPONENT MANUFACTURERREPORTABLE
/rer""'"";::.
-..444~4CAUSESYSTEMCOMPONENT MANUFAC.TUREREPOATABLE
'+'ONPRDScy.v>.rm6(4v,v,nMLS3vc(rbeyn(3:(Ã~(e~xii81 I:(4%+0SUPPLEMENTAL REPORTEXPECTED(14)YESIlfyer,completeEXPECTEDSt/64r/SSIOH DATE/NOABSTRACTILlmitto/400rpecee,Ie.,epproeimetely fifteenrlnplespecstypewritren liner/(16)EXPECTEDSUBMISSION DATE(15)MONTHDAYYEARThewest('W')essential servicewater(ESW)erainwasmadeinoperable ae2146on6/13/91inpreparation forreplacement ofan8-inchexpansion jointlabelledas2-XJ-54W.
At0600on6/14/91,Maintenance personnel begantoremovetheflangebolesfromtheexpansion joint.Alloftheflangeboltswereremovedatabout0700.Theexpansion jointremainedlodgedinplaceandwaeersprayedfromtheflanges.Thewaterwasinitially believedtobeeitherfromtrappedwaterorisolation pointleakby.At1240,however,itwasidentified thattheexpansion jointedlabelledasbeingonthe'W'SWtrainwasactuallyontheeast('E')ESWtrainandtheboltswerereinstalled at1317.TheEngineering reviewofthiseventdetermined thatthewaterlossedouttheflangewasinsignificant andthattheexpansion jointwouldhaveremainedinplaceduringadesignbasisearehquake.
Thiseventisbeingvoluntarily reportedastheanalysisindicates the'E'SWtrainremainedoperable.
Thecauseofthelabelling problemcouldnotbedetermined.
Thelabelingproblemwiththe2-XJ-54expansion joineswascorrected on6/14/91.Awalkdownwasperformed onsimilarexpansion joinesinunit1and2.Oneadditional problemwasfoundandcorrected inunit2on6/19/91.Thelabelling processwasreviewedanddetermined tobeadequatewiththiseventbeingcausedbyauniquecombination ofcircumstances.
Alessonslearnedmemowasissued7/9/91toOperations andMaintenance personnel onthisevent.NRCForm366(64)9)  


NRCFORM366A(64)9)U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEDOM8NO.31500104EXPIRES:4/30/92ESTIMATEDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATIONCOLLECTIONREQUEST:508)HRS.FORWARDCOMMENTSREGARDINGBURDENESTIMATETOTHEAECOROSANDREPOATSMANAGEMENTBRANCHIP.530LU.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON,OC20555,ANDTOTHEPAPERWORKREDUCTIONPROJECT(31500104),OFFICEOFMANAGEMENTANDBUDGET,WASHINGTON,DC20503.FACILITYNAME(I)DOCKETNUMBER(2)YEARLEANUMBER(6)SEOUENTIALg~NUMBERREVISIONNUMSERPAGE(3)D.C.CookNuclearPlant-Unit2TEXTlllmcuuEpucu/4muvked,u44udddtouu/HRCfomI36SA'4/07)05000391005-0002OF05ConditionsPriortoOccurrenceUnit1inMode1(PowerOperation)at100PercentPowerUnit2inMode1(PowerOperation)at100PercentPowerDescritionofEventThewest('W')trainofessentialservicewater(EIIS/BI)wasremovedfromserviceat2146on6/13/91toallowreplacementoftheexpansionjoint(EIIS/BI-EXJ)labeledas2-XJ-54W,whichisthe'W'rainESWsupplytotheemergencydieselgenerators(EIIS/EK-DG)(EDG).Maintenancepersonnelbeganremovingtheboltsfromtheexpansionjointatabout0600on6/14/91.TheMaintenancepersonnelhadbeenadvisedbytheAssistantShiftSupervisorthatthepipingfromtheexpansionjointtothedrainpointwasnotvisibleduetobeinginconcretesoitwasnotcertainthatthepipingattheexpansionjointwascompletelydrained.Basedonthisinformation,theMaintenancepersonnelexpectedsomewatertodrain,butthedrainagewhichoccurredappearedtobeatahigher-than-expectedpressure.TheAssistantShiftSupervisorfromthenextshiftwascontactedaboutthisconcern.TheMaintenancepersonnelweretoldthatsincetheexpansionjointwaslocatedinthelowerlevelofthebuilding,theobservedpressurewasprobablytheresultofelevationdifferences.Originally,someboltswereleftintheexpansionjointflanges,butduetotheflangearrangementitwasnotpossibletospreadthegapanappreciableamountwithoutremovingbolts.Alloftheboltswereremovedatabout0700andatoolwasusedtospreadthegapbetweenflangesurfaces.Thiswasdonetoincreasethedrainrateandminimizethetimerequiredtoreturnthe'W'SWtraintoservice.Between0730and1230,therewereaseriesofcommunicationsbetweentheMaintenancepersonnelandOperationspersonnelregardingthecontinueddrainagefromtheexpansionjoint.Atonepointduringthistime,anAuxiliaryEquipmentOperator(AEO)wassenttothearea.TheOperatorreportedbacktothecontrolroomthattheheaderappearedtobepressurizedbasedonthedrainratefromtheexpansionjoint.TheUnitSupervisor(seniorreactoroperatorlicensed)toldtheAEOhebelievedtheappearanceofbeingpressurizedwaseithercausedbytheheadassociatedwithelevationdifferencesorisolationpointleakby.NACFoIIR366A(689)
NRCFORM366A(64)9)U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUATION APPROVEDOM8NO.31500104EXPIRES:4/30/92ESTIMATED BURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:508)HRS.FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHEAECOROSANDREPOATSMANAGEMENT BRANCHIP.530LU.S.NUCLEARREGULATORY COMMISSION, WASHINGTON, OC20555,ANDTOTHEPAPERWORK REDUCTION PROJECT(31500104),
NRCFORM366A(669)U.S.NUCLEARREGULATOAYCOMMISSIONLICENSEEEVENTREPORTILER)TEXTCONTINUATIONAPPROVE'DOMBNO.31500104EXPIRES:4/30/92ESTIMATEDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATIONCOLLECTIONREQUEST:50JIHRS.FORWARDCOMMENTSREGARDINGBURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENTBRANCH(P430).U.S.NUCLEARAEGULATORYCOMMISSION,WASHINGTON,DC20555,ANDTOTHEPAPERWOAKREDUCTIONPROJECT(3(504104).OFFICEOFMANAGEMENTANDBUDGET,WASHINGTON,DC20503,FACILITYNAME(I)DOCKETNUMBER(2)LEANUMBER(61PAGE(3)YfARNaSFQUSNTIALNUMSSRs??v'EVISIONNUM884D.C.CookNuclearPlant-Unit2TEXT///morespecsitter/It/red,Irteeddi)r)roe/HRCFemI36r/A'/(11)0S000391005-0003oF05Atabout1230,theShiftSupervisor(seniorreactoroperatorlicensed)overheardaconversationbetweentheAssistantShiftSupervisorandtheAEOconcerningthecontinueddraining.TheShiftSupervisorwenttotheworklocationand,afterobservingthewatersprayfromtheexpansionjoint,concludedthattheexpansionjointlabeledasbeingonthe'W'SWtrainwasactuallyontheeast('E')train.TheShiftSupervisordirectedtheMaintenancepersonneltoreinstalltheexpansionjointflangebolts.Theboltswerereinstalledandtightenedat1317.CauseofEventThecauseofthe2-XJ-54Eand2-XJ-54Wlabelsbeingreversedcouldnotbepositivelyidentified.Theexpansionjointswereoriginallybothlabelledas2-XJ-54.In1986,boththeunit1andunit2XJ-54expansionjointsweregivenuniquenorth('N')andsouth('S')identifiersl(2)XJ-54Nand1(2)XJ-54S.Thepipingdrawingswerechangedatthistimeandnewlabelswereplaced.Thischangewassomewhatconfusinginthat'E'nd'W'raincomponentsweregiven'N'nd'S'dentifiers.Also,therewasnotconsistencybetweentheunits.Inunit1the'W'rainjointwasdesignatedas'S'nthepipingdrawingandthe'E'rainwasdesignatedas'N'.Inunit2the'W'rainjointwasdesignatedas'N'nthepipingdrawingandthe'E'rainwasdesignatedas'S'.The'N'nd'S'abelsontheunit1expansionjointswereidentifiedasbeingreversedon7/29/90whenthe'E'rainjointdevelopedasignificantleakandthe'W'rainofESWwasfirstremovedfromservicebasedonareviewofthepipingdrawingandtheinstalled1-XJ-54Slabel.ThelabelswereidentifiedasbeingreversedwhentheleakflowdidnotdecreaseAsaresultofthisevent,thelabelsonunit2werecheckedbytwopersonsfromthePlantlabellingstaffandverifiedasbeingcorrect.Arequestwasalsomadeatthistimetochangetheidentifiersto'E'nd'W'.Theexpansionjointsweresubsequentlygiven'E'nd'W'dentifiersandthepipingdrawingswererevised.Theunit2drawingwasrevised10/4/90andthe'N'nd'S'abelswerereplacedwith'E'nd'W'abels.Itisnotknownifthe'N'nd'S'abelswerecorrectlyplacedandthe'E'nd'W'abelswerereversed,orifthe'N'nd'S'abelswereincorrectlyplacedandthenreplacedoneforonewiththe'E'nd'W'abels.Thereweretwootherfactorswhichcouldhavecontributedtothelabellingproblem.First,theupstreamanddownstreampipingoftheexpansionjointsisburiedinconcreteandcannotbevisuallytracedbacktothemainheaders.Second,inunit1themain'E'nd'W'SWheadersarephysically'E'nd'W',butinunit2the'E'eaderisphysicallylocatedwestofthe'W'eader.NRCForm366A(64)9)
OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON, DC20503.FACILITYNAME(I)DOCKETNUMBER(2)YEARLEANUMBER(6)SEOUENTIAL g~NUMBERREVISIONNUMSERPAGE(3)D.C.CookNuclearPlant-Unit2TEXTlllmcuuEpucu/4muvked,u44udddtouu/HRC fomI36SA'4/07)05000391005-0002OF05Conditions PriortoOccurrence Unit1inMode1(PowerOperation) at100PercentPowerUnit2inMode1(PowerOperation) at100PercentPowerDescritionofEventThewest('W')trainofessential servicewater(EIIS/BI) wasremovedfromserviceat2146on6/13/91toallowreplacement oftheexpansion joint(EIIS/BI-EXJ) labeledas2-XJ-54W, whichisthe'W'rainESWsupplytotheemergency dieselgenerators (EIIS/EK-DG)(EDG).
NRCFORM366A(639)U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORTILER)TEXTCONTINUATIONAPPROVED0MBNO.31500104EXPIRES:4/30/92ESTIMATEDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATIONCOLLECTIONREQUEST:50JIHRS.FORWARDCOMMENTSREGARDINGBURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENTBRANCHIP4)30),U.S.NUCLEARREGULATORYCOMMISSION.WASHINGTON,DC20555,ANDTOTHEPAPERWORKREDUCTIONPROJECT(3(504)104).OFFICEOFMANAGEMENTANDBUDGET,WASHINGTON,OC20503.FACILITYNAME(1IDOCKETNUMBER(2)YEARLERNUMBER(6)SEQUENTIAL@@REVISIONNUMBERBBNUMBERPAGE(3)D.C.CookNuclearPlant-Unit2TEXT/I/mor>>>>p>>4>>/4r>>BII/r>>d.Ir/>>>>dCk'>>4>>//VRCForm36644/(17)3169100500040F05Insummary,itappearsthatthelabellingproblemcouldhavebeencausedbyacombinationoff'actorsincludingthetwochangesincomponentidentifiers,theinconsistencybetweenthedrawingswhenthe'N'nd'S'dentifierswereestablished,thepipingbeingburiedinconcrete,andthedifferencebetweentheunitsforthephysicallocationof'E'nd'W'SWheaders.Thelengthoftimerequiredtoidentifytheproblemwasincreasedbyacombinationoffactors.Thesefactorsincludedmindsetsregardingisolationpointleakbyandelevationinducedhead,buriedpipingpreventingrecognitionthatthedrainshouldhavedrainedtheinvolvedsectionofpiping,andfailuretocommunicateallpertinentinformationtotheUnitSupervisor.AnalsisofEventThiseventwasdeterminednotreportable,buti.sbeingvoluntarilyreported.The'E'SWexpansionjointwasinitiallyconsideredasbeinginoperableandtheeventwasreportedbyaphonereportunderlOCFR50.72(b)(2)(ii)(A)asanunanalyzedcondition.ThesubsequentEngineeringanalysis,however,determinedthatthe'E'SWexpansionjointremainedoperable.Withthe'W'SWtrainisolatedanddrained,the'E'SWtrainwasbeingreliedonforESWassociatedcoolingloads.TheinvolvedexpansionjointremainedinplacethroughoutthiseventandcoolingwaterwasavailabletotheEDGs.TheEngineeringreviewofthiseventdeterminedthattheestimatedmaximumleakagefromtheexpansionjointduringtheeventwouldnothavepreventedthe'E'rainfromfulfillingitssafetyfunction.Thisreviewalsoconcluded,basedonaseismicanalysis,thattheexpansionjointwouldhaveremainedinplaceduringadesignbasisearthquake.SincetheEngineeringreviewofthiseventdeterminedthatthe'E'SWtrainremainedcapableoffulfillingitssafetyfunction,itwasconcludedthatthe'E'SWtrainremainedoperable.CorrectiveActionThe'E'SWsupplyexpansionjointboltswerereinstalledat1317on6/14/91.Thelabellingproblemwith2-XJ-54Eand2-XJ-54Wwascorrectedon6/14/91.Thelabellingfortheunit1ESWsupplyandreturnexpansionjointstotheEDGswascheckedandverifiedtobecorrect.NRCForm366A(689)
Maintenance personnel beganremovingtheboltsfromtheexpansion jointatabout0600on6/14/91.TheMaintenance personnel hadbeenadvisedbytheAssistant ShiftSupervisor thatthepipingfromtheexpansion jointtothedrainpointwasnotvisibleduetobeinginconcretesoitwasnotcertainthatthepipingattheexpansion jointwascompletely drained.Basedonthisinformation, theMaintenance personnel expectedsomewatertodrain,butthedrainagewhichoccurredappearedtobeatahigher-than-expected pressure.
NRCFORM366A(64)91U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONAPPROVEOOMBNO.31500104EXPIRES:4/30/92ESTIMATEDBURDENPERRESPONSETOCOMPLYWTHTHISINFORMATIONCOLLECTIONREQUEST:500HRS.FORWARDCOMMENTSREGARDINGBURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENTBRANCHIP430),U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON,OC20555,ANDTOTHEPAPERWORKREDUCTIONPROJECT(31504)104),OFFICEOFMANAGEMENTANDBUDGET,WASHINGTON,DC20503.FACILITYNAME(I)DOCKETNUMBERLT)LERNUMBER(6)PAGE(3)YEARp~g>SEOVENTIAI.NVMSEAREVISIONNVMSEADC.CookNuclearPlant-Unit2TEXTIIInnvP4P444bT49vked,VTPSddic/)pnelHRCFarm3664'4/(IT)060003910050005oFo54,Thelabellingfortheunit2ESWreturnexpansionjointsfortheEDGswascheckedandfoundtobereversed.Theexpansionjointswerecorrectlylabelledon6/19/91.5.Thelabellingprocesswasreviewedforadequacy.Itwasdeterminedthatthecurrentprocessisadequateandthatitwasauniquecombinationoffactorsthatresultedinthisevent.Alessonslearnedmemowasissued7/9/91toOperationsandMaintenancepersonnelonthisevent.FailedComonentIdentificationNonePreviousSimilarEventsThe7/29/90unit1eventdiscussedintheCauseofEventsectionwassimilartothisevent.Theunit1eventiscurrentlybeingre-evaluatedtoconfirmthattheleakflowfromtheexpansionjointdidnotrenderthattrainofESWinoperable.NRCForm366A(669)}}
TheAssistant ShiftSupervisor fromthenextshiftwascontacted aboutthisconcern.TheMaintenance personnel weretoldthatsincetheexpansion jointwaslocatedinthelowerlevelofthebuilding, theobservedpressurewasprobablytheresultofelevation differences.
Originally, someboltswereleftintheexpansion jointflanges,butduetotheflangearrangement itwasnotpossibletospreadthegapanappreciable amountwithoutremovingbolts.Alloftheboltswereremovedatabout0700andatoolwasusedtospreadthegapbetweenflangesurfaces.
Thiswasdonetoincreasethedrainrateandminimizethetimerequiredtoreturnthe'W'SWtraintoservice.Between0730and1230,therewereaseriesofcommunications betweentheMaintenance personnel andOperations personnel regarding thecontinued drainagefromtheexpansion joint.Atonepointduringthistime,anAuxiliary Equipment Operator(AEO)wassenttothearea.TheOperatorreportedbacktothecontrolroomthattheheaderappearedtobepressurized basedonthedrainratefromtheexpansion joint.TheUnitSupervisor (seniorreactoroperatorlicensed) toldtheAEOhebelievedtheappearance ofbeingpressurized waseithercausedbytheheadassociated withelevation differences orisolation pointleakby.NACFoIIR366A(689)
NRCFORM366A(669)U.S.NUCLEARREGULATOAY COMMISSION LICENSEEEVENTREPORTILER)TEXTCONTINUATION APPROVE'D OMBNO.31500104EXPIRES:4/30/92ESTIMATED BURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:50JIHRS.FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENT BRANCH(P430).U.S.NUCLEARAEGULATORY COMMISSION, WASHINGTON, DC20555,ANDTOTHEPAPERWOAK REDUCTION PROJECT(3(504104).
OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON, DC20503,FACILITYNAME(I)DOCKETNUMBER(2)LEANUMBER(61PAGE(3)YfARNaSFQUSNTIALNUMSSRs??v'EVISION NUM884D.C.CookNuclearPlant-Unit2TEXT///morespecsitter/It/red, Irteeddi)r)roe/HRC FemI36r/A'/(11)0S000391005-0003oF05Atabout1230,theShiftSupervisor (seniorreactoroperatorlicensed) overheard aconversation betweentheAssistant ShiftSupervisor andtheAEOconcerning thecontinued draining.
TheShiftSupervisor wenttotheworklocationand,afterobserving thewatersprayfromtheexpansion joint,concluded thattheexpansion jointlabeledasbeingonthe'W'SWtrainwasactuallyontheeast('E')train.TheShiftSupervisor directedtheMaintenance personnel toreinstall theexpansion jointflangebolts.Theboltswerereinstalled andtightened at1317.CauseofEventThecauseofthe2-XJ-54Eand2-XJ-54Wlabelsbeingreversedcouldnotbepositively identified.
Theexpansion jointswereoriginally bothlabelledas2-XJ-54.In1986,boththeunit1andunit2XJ-54expansion jointsweregivenuniquenorth('N')andsouth('S')identifiers l(2)XJ-54N and1(2)XJ-54S.
Thepipingdrawingswerechangedatthistimeandnewlabelswereplaced.Thischangewassomewhatconfusing inthat'E'nd'W'raincomponents weregiven'N'nd'S'dentifiers.
Also,therewasnotconsistency betweentheunits.Inunit1the'W'rainjointwasdesignated as'S'nthepipingdrawingandthe'E'rainwasdesignated as'N'.Inunit2the'W'rainjointwasdesignated as'N'nthepipingdrawingandthe'E'rainwasdesignated as'S'.The'N'nd'S'abelsontheunit1expansion jointswereidentified asbeingreversedon7/29/90whenthe'E'rainjointdeveloped asignificant leakandthe'W'rainofESWwasfirstremovedfromservicebasedonareviewofthepipingdrawingandtheinstalled 1-XJ-54Slabel.Thelabelswereidentified asbeingreversedwhentheleakflowdidnotdecreaseAsaresultofthisevent,thelabelsonunit2werecheckedbytwopersonsfromthePlantlabelling staffandverifiedasbeingcorrect.Arequestwasalsomadeatthistimetochangetheidentifiers to'E'nd'W'.Theexpansion jointsweresubsequently given'E'nd'W'dentifiers andthepipingdrawingswererevised.Theunit2drawingwasrevised10/4/90andthe'N'nd'S'abelswerereplacedwith'E'nd'W'abels.
Itisnotknownifthe'N'nd'S'abelswerecorrectly placedandthe'E'nd'W'abelswerereversed, orifthe'N'nd'S'abelswereincorrectly placedandthenreplacedoneforonewiththe'E'nd'W'abels.
Thereweretwootherfactorswhichcouldhavecontributed tothelabelling problem.First,theupstreamanddownstream pipingoftheexpansion jointsisburiedinconcreteandcannotbevisuallytracedbacktothemainheaders.Second,inunit1themain'E'nd'W'SWheadersarephysically
'E'nd'W',butinunit2the'E'eaderisphysically locatedwestofthe'W'eader.
NRCForm366A(64)9)
NRCFORM366A(639)U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORTILER)TEXTCONTINUATION APPROVED0MBNO.31500104EXPIRES:4/30/92ESTIMATED BURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:50JIHRS.FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENT BRANCHIP4)30),U.S.NUCLEARREGULATORY COMMISSION.
WASHINGTON, DC20555,ANDTOTHEPAPERWORK REDUCTION PROJECT(3(504)104).
OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON, OC20503.FACILITYNAME(1IDOCKETNUMBER(2)YEARLERNUMBER(6)SEQUENTIAL
@@REVISIONNUMBERBBNUMBERPAGE(3)D.C.CookNuclearPlant-Unit2TEXT/I/mor>>>>p>>4>>/4r>>BII/r>>d.
Ir/>>>>dCk'>>4>>//VRC Form36644/(17)3169100500040F05Insummary,itappearsthatthelabelling problemcouldhavebeencausedbyacombination off'actorsincluding thetwochangesincomponent identifiers, theinconsistency betweenthedrawingswhenthe'N'nd'S'dentifiers wereestablished, thepipingbeingburiedinconcrete, andthedifference betweentheunitsforthephysicallocationof'E'nd'W'SWheaders.Thelengthoftimerequiredtoidentifytheproblemwasincreased byacombination offactors.Thesefactorsincludedmindsetsregarding isolation pointleakbyandelevation inducedhead,buriedpipingpreventing recognition thatthedrainshouldhavedrainedtheinvolvedsectionofpiping,andfailuretocommunicate allpertinent information totheUnitSupervisor.
AnalsisofEventThiseventwasdetermined notreportable, buti.sbeingvoluntarily reported.
The'E'SWexpansion jointwasinitially considered asbeinginoperable andtheeventwasreportedbyaphonereportunderlOCFR50.72(b)(2)(ii)(A) asanunanalyzed condition.
Thesubsequent Engineering
: analysis, however,determined thatthe'E'SWexpansion jointremainedoperable.
Withthe'W'SWtrainisolatedanddrained,the'E'SWtrainwasbeingreliedonforESWassociated coolingloads.Theinvolvedexpansion jointremainedinplacethroughout thiseventandcoolingwaterwasavailable totheEDGs.TheEngineering reviewofthiseventdetermined thattheestimated maximumleakagefromtheexpansion jointduringtheeventwouldnothaveprevented the'E'rainfromfulfilling itssafetyfunction.
Thisreviewalsoconcluded, basedonaseismicanalysis, thattheexpansion jointwouldhaveremainedinplaceduringadesignbasisearthquake.
SincetheEngineering reviewofthiseventdetermined thatthe'E'SWtrainremainedcapableoffulfilling itssafetyfunction, itwasconcluded thatthe'E'SWtrainremainedoperable.
Corrective ActionThe'E'SWsupplyexpansion jointboltswerereinstalled at1317on6/14/91.Thelabelling problemwith2-XJ-54Eand2-XJ-54Wwascorrected on6/14/91.Thelabelling fortheunit1ESWsupplyandreturnexpansion jointstotheEDGswascheckedandverifiedtobecorrect.NRCForm366A(689)
NRCFORM366A(64)91U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUATION APPROVEOOMBNO.31500104EXPIRES:4/30/92ESTIMATED BURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:500HRS.FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENT BRANCHIP430),U.S.NUCLEARREGULATORY COMMISSION, WASHINGTON, OC20555,ANDTOTHEPAPERWORK REDUCTION PROJECT(31504)104),
OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON, DC20503.FACILITYNAME(I)DOCKETNUMBERLT)LERNUMBER(6)PAGE(3)YEARp~g>SEOVENTIAI.
NVMSEAREVISIONNVMSEADC.CookNuclearPlant-Unit2TEXTIIInnvP4P444bT49vked,VTPSddic/)pnel HRCFarm3664'4/(IT)060003910050005oFo54,Thelabelling fortheunit2ESWreturnexpansion jointsfortheEDGswascheckedandfoundtobereversed.
Theexpansion jointswerecorrectly labelledon6/19/91.5.Thelabelling processwasreviewedforadequacy.
Itwasdetermined thatthecurrentprocessisadequateandthatitwasauniquecombination offactorsthatresultedinthisevent.Alessonslearnedmemowasissued7/9/91toOperations andMaintenance personnel onthisevent.FailedComonentIdentification NonePreviousSimilarEventsThe7/29/90unit1eventdiscussed intheCauseofEventsectionwassimilartothisevent.Theunit1eventiscurrently beingre-evaluated toconfirmthattheleakflowfromtheexpansion jointdidnotrenderthattrainofESWinoperable.
NRCForm366A(669)}}

Revision as of 08:41, 29 June 2018

LER 91-005-00:on 910614,bolts Removed from Pressurized Essential Svc Water Line Expansion Joints & Water Sprayed from Flanges.Caused by Reversed Component Labels.Joints Reinstalled & Labeling corrected.W/910715 Ltr
ML17329A082
Person / Time
Site: Cook American Electric Power icon.png
Issue date: 07/15/1991
From: BLIND A A, SAMPSON J R
INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-91-005, LER-91-5, NUDOCS 9107220223
Download: ML17329A082 (8)


Text

~i~r,j~mianUISIM@JTION DEMONSTRATI NSYSTEMREGULATORY INFORMATION DISTRIBUTION SYSTEM(RIDS)ACCESSION NBR:9107220223 DOC.DATE:

91/07/15NOTARIZED:

NODOCKETFACIL:50-316 DonaldC.CookNuclearPowerPlant,Unit2,Indiana&05000316AUTH.NAMEAUTHORAFFILIATION SAMPSON,J.R.

IndianaMichiganPowerCo.(formerly Indiana&MichiganEleBLIND,A.A.

IndianaMichiganPowerCo.(formerly Indiana&MichiganEleRECIP.NAME RECIPIENT AFFILIATION R

SUBJECT:

LER91-005-00:on 910614,bolts removedfrompressurized essential svcwaterlineexpansion joints&watersprayedfromflanges.Caused byreversedcomponent labels.Joe.nts reinstalled

&labelingcorrected.W/910715 ltr.DISTRIBUTION CODE:IE22TCOPIESRECEIVED:LTR JENCL2SIZE:TITLE:50.73/50.9 LicenseeEventReport(LER),IncidentRpt,etc.NOTES:RECIPIENT IDCODE/NAME PD3-1LACOLBURN,T.

INTERNAL:

ACNWAEOD/DSP/TPABNRR/DET/ECMB 9HNRR/DLPQ/LHFB1 0NRR/DOEA/OEAB NRR/DST/SELB 8DNRR/D~ST.

SP~B8J)3REGRGN3FIIE01EXTERNAL:

EG&GBRYCE,J.H NRCPDRNSICPOOREiWCOPIESLTTRENCL1111221111111111111111331111RECIPIENT IDCODE/NAME PD3-1PDAEOD/DOAAEOD/ROAB/DS PNRR/DET/EMEB 7ENRR/DLPQ/LPEB10 NRR/DREP/PRPB11 NRR/DST/SICB8H3 NRR/DST/SRXB 8ERES/DSIR/EIB LSTLOBBYWARDNSICMURPHYTGANUDOCSFULLTXTCOPIESLTTRENCL111122111122111111111111DDRDNOTETOALL"RIDS"RECIPIENTS:

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

LTTR31ENCL31 IndianaMichiganPowerCompanyCookNuclearPlantOneCookPlaceBridgman, Ml491066164655901July15,1991vaw~saaNECHf6AHPWKRUnitedStatesNuclearRegulatory Commission DocumentControlDeskRockville, Maryland20852Operating LicensesDPR-74DocketNo.50-316DocumentControlManager:Inaccordance withthecriteriaestablished by10CFR50.73entitledLicenseeEventReortSstemthefollowing reportisbeingsubmitted:

91-005-00 Sincerely, A.A.BlindPlantManagerAAB:sbAttachment coD.H.Williams, Jr.A.B.Davis,RegionIIIE.E.Fitzpatrick P.A.BarrettB.F.Henderson R.F.KroegerB.Walters-Ft.WayneNRCResidentInspector T.Colburn-NRCJ.G.KepplerM.R.PadgettG.Charnoff, Esp.D.HahnINPOS.J.Brewer/B.P.

LauzauB.A.Svensson9107220223 910715PDRADOCK050003lbSPDR NACFORM366(64)9).S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)OVEDOMBNO.31504)104 EXPIRES:4/30/92ESTIMATED BURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLE'CTION REQUEST:50.0HRS.FORWARDCOMMENTSREGARDING BURDENESTILIATE TOTHEAECORDSANDREPORTSMANAGEMENT BRANCHIP530),U.S.NUCLEARREGULATORY COMMISSION, WASHINGTON, DC20555,ANDTOTHEPAPERWORK REDUCTION PROJECT(31500104I.

OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON, DC20503.FACILITYNAMEHID.C.CookNuclearPlant-Unit2DOCKETNUMBER(2)PAGE3050003]61OFP5BoltsRemovedfromPressurized Essential ServiceWater'ine Expansion JointDuetoReversedComonentLabelsEVENTOATE(5)LERNUMBER(6)REPORTDATE(7)OTHERFACILITIES INVOLVED(SIMONTHOAYYEARYEAR%~6SEOVENTIAL COPr:NUMBER@~REVrSIONMONTHDAYYEARFACILITYNAMESDOCKETNUMBER(SI 05000061491910050007159105000OPERATING MODE(9)]POWERLEVEL1ppTHISREPORTISSUBMITTED PURSUANTT50,73(s)(2)(iv) 50.73(~)l2)(v)60,73(s)(2)(vill60.73(sl(2)(vill)(AI 50.73(~)(2)(villi(BI 60.73(~)l2)(e)20.405(c) 50.36(c)Ille0.35(c)(2) 60.73(~)l2)II)50,73(s)(2)Ill)60.73(sI(2)Iill)20.402(tr) 20405(s)(IIII)20.405(~)(1)Ill)20.405(sll1)(ill) 20A05(s)II)(lv) 20.405(s)(1)(vl LICENSEECONTACTFORTHISLER(12I0THERLOUIREMENTS OF10CFA()tICnectroneormoreofthefollowinp/

(1173.7)(II) 73.71(c)oTHER/specifyinAottrecroslowenrflnTest,/Y/ICForm36SA/Voluntary ReportNAMEJ.R.Samson,0erationsSuperintendent TFLEPHONE NUMBERAREACODE616465-5901COMPLETEONELINEFOREACHCOMIIONENT FAILUREDESCRIBED INTHISREPORT(13)CAUSESYSTEMCOMPONENT MANUFACTURERREPORTABLE

/rer""'"";::.

-..444~4CAUSESYSTEMCOMPONENT MANUFAC.TUREREPOATABLE

'+'ONPRDScy.v>.rm6(4v,v,nMLS3vc(rbeyn(3:(Ã~(e~xii81 I:(4%+0SUPPLEMENTAL REPORTEXPECTED(14)YESIlfyer,completeEXPECTEDSt/64r/SSIOH DATE/NOABSTRACTILlmitto/400rpecee,Ie.,epproeimetely fifteenrlnplespecstypewritren liner/(16)EXPECTEDSUBMISSION DATE(15)MONTHDAYYEARThewest('W')essential servicewater(ESW)erainwasmadeinoperable ae2146on6/13/91inpreparation forreplacement ofan8-inchexpansion jointlabelledas2-XJ-54W.

At0600on6/14/91,Maintenance personnel begantoremovetheflangebolesfromtheexpansion joint.Alloftheflangeboltswereremovedatabout0700.Theexpansion jointremainedlodgedinplaceandwaeersprayedfromtheflanges.Thewaterwasinitially believedtobeeitherfromtrappedwaterorisolation pointleakby.At1240,however,itwasidentified thattheexpansion jointedlabelledasbeingonthe'W'SWtrainwasactuallyontheeast('E')ESWtrainandtheboltswerereinstalled at1317.TheEngineering reviewofthiseventdetermined thatthewaterlossedouttheflangewasinsignificant andthattheexpansion jointwouldhaveremainedinplaceduringadesignbasisearehquake.

Thiseventisbeingvoluntarily reportedastheanalysisindicates the'E'SWtrainremainedoperable.

Thecauseofthelabelling problemcouldnotbedetermined.

Thelabelingproblemwiththe2-XJ-54expansion joineswascorrected on6/14/91.Awalkdownwasperformed onsimilarexpansion joinesinunit1and2.Oneadditional problemwasfoundandcorrected inunit2on6/19/91.Thelabelling processwasreviewedanddetermined tobeadequatewiththiseventbeingcausedbyauniquecombination ofcircumstances.

Alessonslearnedmemowasissued7/9/91toOperations andMaintenance personnel onthisevent.NRCForm366(64)9)

NRCFORM366A(64)9)U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUATION APPROVEDOM8NO.31500104EXPIRES:4/30/92ESTIMATED BURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:508)HRS.FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHEAECOROSANDREPOATSMANAGEMENT BRANCHIP.530LU.S.NUCLEARREGULATORY COMMISSION, WASHINGTON, OC20555,ANDTOTHEPAPERWORK REDUCTION PROJECT(31500104),

OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON, DC20503.FACILITYNAME(I)DOCKETNUMBER(2)YEARLEANUMBER(6)SEOUENTIAL g~NUMBERREVISIONNUMSERPAGE(3)D.C.CookNuclearPlant-Unit2TEXTlllmcuuEpucu/4muvked,u44udddtouu/HRC fomI36SA'4/07)05000391005-0002OF05Conditions PriortoOccurrence Unit1inMode1(PowerOperation) at100PercentPowerUnit2inMode1(PowerOperation) at100PercentPowerDescritionofEventThewest('W')trainofessential servicewater(EIIS/BI) wasremovedfromserviceat2146on6/13/91toallowreplacement oftheexpansion joint(EIIS/BI-EXJ) labeledas2-XJ-54W, whichisthe'W'rainESWsupplytotheemergency dieselgenerators (EIIS/EK-DG)(EDG).

Maintenance personnel beganremovingtheboltsfromtheexpansion jointatabout0600on6/14/91.TheMaintenance personnel hadbeenadvisedbytheAssistant ShiftSupervisor thatthepipingfromtheexpansion jointtothedrainpointwasnotvisibleduetobeinginconcretesoitwasnotcertainthatthepipingattheexpansion jointwascompletely drained.Basedonthisinformation, theMaintenance personnel expectedsomewatertodrain,butthedrainagewhichoccurredappearedtobeatahigher-than-expected pressure.

TheAssistant ShiftSupervisor fromthenextshiftwascontacted aboutthisconcern.TheMaintenance personnel weretoldthatsincetheexpansion jointwaslocatedinthelowerlevelofthebuilding, theobservedpressurewasprobablytheresultofelevation differences.

Originally, someboltswereleftintheexpansion jointflanges,butduetotheflangearrangement itwasnotpossibletospreadthegapanappreciable amountwithoutremovingbolts.Alloftheboltswereremovedatabout0700andatoolwasusedtospreadthegapbetweenflangesurfaces.

Thiswasdonetoincreasethedrainrateandminimizethetimerequiredtoreturnthe'W'SWtraintoservice.Between0730and1230,therewereaseriesofcommunications betweentheMaintenance personnel andOperations personnel regarding thecontinued drainagefromtheexpansion joint.Atonepointduringthistime,anAuxiliary Equipment Operator(AEO)wassenttothearea.TheOperatorreportedbacktothecontrolroomthattheheaderappearedtobepressurized basedonthedrainratefromtheexpansion joint.TheUnitSupervisor (seniorreactoroperatorlicensed) toldtheAEOhebelievedtheappearance ofbeingpressurized waseithercausedbytheheadassociated withelevation differences orisolation pointleakby.NACFoIIR366A(689)

NRCFORM366A(669)U.S.NUCLEARREGULATOAY COMMISSION LICENSEEEVENTREPORTILER)TEXTCONTINUATION APPROVE'D OMBNO.31500104EXPIRES:4/30/92ESTIMATED BURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:50JIHRS.FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENT BRANCH(P430).U.S.NUCLEARAEGULATORY COMMISSION, WASHINGTON, DC20555,ANDTOTHEPAPERWOAK REDUCTION PROJECT(3(504104).

OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON, DC20503,FACILITYNAME(I)DOCKETNUMBER(2)LEANUMBER(61PAGE(3)YfARNaSFQUSNTIALNUMSSRs??v'EVISION NUM884D.C.CookNuclearPlant-Unit2TEXT///morespecsitter/It/red, Irteeddi)r)roe/HRC FemI36r/A'/(11)0S000391005-0003oF05Atabout1230,theShiftSupervisor (seniorreactoroperatorlicensed) overheard aconversation betweentheAssistant ShiftSupervisor andtheAEOconcerning thecontinued draining.

TheShiftSupervisor wenttotheworklocationand,afterobserving thewatersprayfromtheexpansion joint,concluded thattheexpansion jointlabeledasbeingonthe'W'SWtrainwasactuallyontheeast('E')train.TheShiftSupervisor directedtheMaintenance personnel toreinstall theexpansion jointflangebolts.Theboltswerereinstalled andtightened at1317.CauseofEventThecauseofthe2-XJ-54Eand2-XJ-54Wlabelsbeingreversedcouldnotbepositively identified.

Theexpansion jointswereoriginally bothlabelledas2-XJ-54.In1986,boththeunit1andunit2XJ-54expansion jointsweregivenuniquenorth('N')andsouth('S')identifiers l(2)XJ-54N and1(2)XJ-54S.

Thepipingdrawingswerechangedatthistimeandnewlabelswereplaced.Thischangewassomewhatconfusing inthat'E'nd'W'raincomponents weregiven'N'nd'S'dentifiers.

Also,therewasnotconsistency betweentheunits.Inunit1the'W'rainjointwasdesignated as'S'nthepipingdrawingandthe'E'rainwasdesignated as'N'.Inunit2the'W'rainjointwasdesignated as'N'nthepipingdrawingandthe'E'rainwasdesignated as'S'.The'N'nd'S'abelsontheunit1expansion jointswereidentified asbeingreversedon7/29/90whenthe'E'rainjointdeveloped asignificant leakandthe'W'rainofESWwasfirstremovedfromservicebasedonareviewofthepipingdrawingandtheinstalled 1-XJ-54Slabel.Thelabelswereidentified asbeingreversedwhentheleakflowdidnotdecreaseAsaresultofthisevent,thelabelsonunit2werecheckedbytwopersonsfromthePlantlabelling staffandverifiedasbeingcorrect.Arequestwasalsomadeatthistimetochangetheidentifiers to'E'nd'W'.Theexpansion jointsweresubsequently given'E'nd'W'dentifiers andthepipingdrawingswererevised.Theunit2drawingwasrevised10/4/90andthe'N'nd'S'abelswerereplacedwith'E'nd'W'abels.

Itisnotknownifthe'N'nd'S'abelswerecorrectly placedandthe'E'nd'W'abelswerereversed, orifthe'N'nd'S'abelswereincorrectly placedandthenreplacedoneforonewiththe'E'nd'W'abels.

Thereweretwootherfactorswhichcouldhavecontributed tothelabelling problem.First,theupstreamanddownstream pipingoftheexpansion jointsisburiedinconcreteandcannotbevisuallytracedbacktothemainheaders.Second,inunit1themain'E'nd'W'SWheadersarephysically

'E'nd'W',butinunit2the'E'eaderisphysically locatedwestofthe'W'eader.

NRCForm366A(64)9)

NRCFORM366A(639)U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORTILER)TEXTCONTINUATION APPROVED0MBNO.31500104EXPIRES:4/30/92ESTIMATED BURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:50JIHRS.FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENT BRANCHIP4)30),U.S.NUCLEARREGULATORY COMMISSION.

WASHINGTON, DC20555,ANDTOTHEPAPERWORK REDUCTION PROJECT(3(504)104).

OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON, OC20503.FACILITYNAME(1IDOCKETNUMBER(2)YEARLERNUMBER(6)SEQUENTIAL

@@REVISIONNUMBERBBNUMBERPAGE(3)D.C.CookNuclearPlant-Unit2TEXT/I/mor>>>>p>>4>>/4r>>BII/r>>d.

Ir/>>>>dCk'>>4>>//VRC Form36644/(17)3169100500040F05Insummary,itappearsthatthelabelling problemcouldhavebeencausedbyacombination off'actorsincluding thetwochangesincomponent identifiers, theinconsistency betweenthedrawingswhenthe'N'nd'S'dentifiers wereestablished, thepipingbeingburiedinconcrete, andthedifference betweentheunitsforthephysicallocationof'E'nd'W'SWheaders.Thelengthoftimerequiredtoidentifytheproblemwasincreased byacombination offactors.Thesefactorsincludedmindsetsregarding isolation pointleakbyandelevation inducedhead,buriedpipingpreventing recognition thatthedrainshouldhavedrainedtheinvolvedsectionofpiping,andfailuretocommunicate allpertinent information totheUnitSupervisor.

AnalsisofEventThiseventwasdetermined notreportable, buti.sbeingvoluntarily reported.

The'E'SWexpansion jointwasinitially considered asbeinginoperable andtheeventwasreportedbyaphonereportunderlOCFR50.72(b)(2)(ii)(A) asanunanalyzed condition.

Thesubsequent Engineering

analysis, however,determined thatthe'E'SWexpansion jointremainedoperable.

Withthe'W'SWtrainisolatedanddrained,the'E'SWtrainwasbeingreliedonforESWassociated coolingloads.Theinvolvedexpansion jointremainedinplacethroughout thiseventandcoolingwaterwasavailable totheEDGs.TheEngineering reviewofthiseventdetermined thattheestimated maximumleakagefromtheexpansion jointduringtheeventwouldnothaveprevented the'E'rainfromfulfilling itssafetyfunction.

Thisreviewalsoconcluded, basedonaseismicanalysis, thattheexpansion jointwouldhaveremainedinplaceduringadesignbasisearthquake.

SincetheEngineering reviewofthiseventdetermined thatthe'E'SWtrainremainedcapableoffulfilling itssafetyfunction, itwasconcluded thatthe'E'SWtrainremainedoperable.

Corrective ActionThe'E'SWsupplyexpansion jointboltswerereinstalled at1317on6/14/91.Thelabelling problemwith2-XJ-54Eand2-XJ-54Wwascorrected on6/14/91.Thelabelling fortheunit1ESWsupplyandreturnexpansion jointstotheEDGswascheckedandverifiedtobecorrect.NRCForm366A(689)

NRCFORM366A(64)91U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUATION APPROVEOOMBNO.31500104EXPIRES:4/30/92ESTIMATED BURDENPERRESPONSETOCOMPLYWTHTHISINFORMATION COLLECTION REQUEST:500HRS.FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHERECORDSANDREPORTSMANAGEMENT BRANCHIP430),U.S.NUCLEARREGULATORY COMMISSION, WASHINGTON, OC20555,ANDTOTHEPAPERWORK REDUCTION PROJECT(31504)104),

OFFICEOFMANAGEMENT ANDBUDGET,WASHINGTON, DC20503.FACILITYNAME(I)DOCKETNUMBERLT)LERNUMBER(6)PAGE(3)YEARp~g>SEOVENTIAI.

NVMSEAREVISIONNVMSEADC.CookNuclearPlant-Unit2TEXTIIInnvP4P444bT49vked,VTPSddic/)pnel HRCFarm3664'4/(IT)060003910050005oFo54,Thelabelling fortheunit2ESWreturnexpansion jointsfortheEDGswascheckedandfoundtobereversed.

Theexpansion jointswerecorrectly labelledon6/19/91.5.Thelabelling processwasreviewedforadequacy.

Itwasdetermined thatthecurrentprocessisadequateandthatitwasauniquecombination offactorsthatresultedinthisevent.Alessonslearnedmemowasissued7/9/91toOperations andMaintenance personnel onthisevent.FailedComonentIdentification NonePreviousSimilarEventsThe7/29/90unit1eventdiscussed intheCauseofEventsectionwassimilartothisevent.Theunit1eventiscurrently beingre-evaluated toconfirmthattheleakflowfromtheexpansion jointdidnotrenderthattrainofESWinoperable.

NRCForm366A(669)