ML061980077

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CNS Snap Shot Assessment SS04030
ML061980077
Person / Time
Site: Cooper Entergy icon.png
Issue date: 02/16/2004
From: Dunesia Clark
Nebraska Public Power District (NPPD)
To: Cook D, Drier R
Nebraska Public Power District (NPPD), Office of Nuclear Reactor Regulation
References
FOIA/PA-2006-0007, R4-5A27
Download: ML061980077 (15)


Text

Flhertyo James R. 6ý3 From: Clark, David P. "Dave"' I'T -.Z/17

/0, Sent: Monday, February 16, 2004 10:18 :AM To: Drier, Ralph F.; Cook, David B.; CNS Shift Managers List Cc: CNS HP Coordinators List; CNS Operations Training List; Flaherty, James R.; Lavigne, //

'Crystal G.; Toline.Bruce C.

Subject:

SS04030 Event Review SWS Gland Water Alignment Importance: High SS04030 - ER SWS Llneup.doc Ralph, As required by Procedure 0-CNS-25.

Shift Managers, For use in briefing your folks pending SCR Evaluation.

Dave Cook, As required by Procedure 0-HP-IMPLEMENT. I will also send minutes that Crystal Lavigne wrote up from the event review (used for this document). Per procedure these are provided for inclusion In CAP documentation for the SCR evaluation.

Dave Montgomery, As required by 0-HP-IMPLEMENT.

Jim F., As requested forproviding to Scott S.

Dave Clark x2898

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Title:

Event Revie~w - Service Water Valve Lineup Date: Event Review 2/11/2004 (Submitted 2/15/2004)

Number: SS04030 Scope of Snapshot:

Collect data regarding the event involving Service Water'Gland Water.System B being lined up to Division 1.Also identify error prccursors and error prevention tools that could have prevented the event (if any). Reference Notification 10295021.

Objective(s):

This review was conducted ,as an Event'Review in accordance with,0-HP-Implement and 0-CNS-

25. Event Review held 02/11/2004 with 2:of 3 involved individuals. (The second NLNPO was interviewed by the:Shill Manager and excluded from hlie eveni review since that NLNPO's part was simply to independently verify release of the clearance order.) The ER reviewed the event and potential corrective actions.

Reviewed error pr~dursors (job site -conditions, organization-alprocesses or values, other process/organizational issues) and error prevention tools (work behaviors) that could have prevented the event.

Results:

Event

Description:

While performing avalvceline-up on the Service Water (SW) Gland.Water.System, Service Water Gland Water Subsystem 'B' was found lined up to Service Water System 'A'. SW-V-ý28 was closed and SW-V-1479 and 1480 were open. It appears Ihis lineup was not properly restored following Maintenance on 'B' Zurn Strainer on January 21,2004.

  • Note-No statements were generated from this event because of the timing (occurred thrccweeks prior).

Sequence of Events:

" On 1/21/2004, the release for clearanceorder, section SWB-1-4324147,SW-STNR-B was verified at 0910, authorized at 1553, lifted at 1636 and completed at 1658.

6. B6th NLNPOs were at prejob brief and feltfcomnfortable they could perform the task.

o <NLNPOs do not recall discussion regarding restoration using 2.2.71. The WCO -couldnot recall briefing the proceduire, but stated that was the nirmal way of doing this (as 2 prcjob briefs).

o Neither NLNPO noted that the front page of the clearance order provided instructions to restorethe'

.system using 2.2.71.

" At 1706 On 1/211041 the following log entry was created:

"Service Water Zurn strainer has been returned 'toservice and Operable -status following strainer cleaning.

This restores Service Water subsystem "B'.and DG2 to OPERABLE status. Exited LCO 3.7.2 condition A and LCO 3.8.1 condition B. Closed LCO order TS03-01-SW ZURN STNR WK 04-04.

" On 2/4/04 at 2140 the Conirol Room received annunciatior A-4/D-7, Service Water Strainer High D/P. The Operators verified that the strainer was baekwashing and D/P was 2psid and lowering. Following backwash the D/P readily returned to a value of 4psid.

" On 2/8/2004 at 1702 the Control Room received annunciator SW GLAND WTR ISUPPLY SYS A TROUBLE, and ANN --ANN-(B-3/E-6), SW GLAND WTR SUPPLY SYS B TROUBLE, Bldg operator reported that the alarmswere due to Low Pressureand they were both clear. The following parameters were noted:

A/C Gland water pressure 18#

SWP A Gland water flow 5.4gpm SWP C Gland water flow 7.Sgpm B/D Gland water pressure 16.5#

SWP B Gland water flow 7.6gpm SWP D Gland water flow 6.3gpm No adjustments were made to the system, no'other alarm were rcceivcd, Notification 10294449 written.

Based on the above alarms, work order 4342773 (a scheduled PM) was moved in the schedule from 2125104 to 2/11/04.

  • Following a discussion between the Engineering Repfesentativc and Operations Manager, the Shift Manager was directed to complete a valvc line-up per 2.2.71A '"Service Water System Component Checklist" prior to tagging the 'A' Service Water Zurn Strainer for Maintenance.

" Before the lineup was performed,-the cross&connect was looked at and appeared to~be closed.

" At 0310 on 2/1 1104, the valve line-up was completed and the discovery was made thatthe system was not in the correct configuration:

  • At 0340 on 2/11/04,'the Service Water System w'is restored to the normal corifiguraition.

" The Shift Managcr took the:Non Licensed Nuclear Plant Operator oui in the field and showed him !he valves that were not in the correct configuration and asked him if he had ever operated the valves and the Non Licensed NuclearPlant Operator answered no.

  • .Management.was contacted and investigations began.

" At 1700 on 02/11/2004, an Event Review was held.

Error.Precursors:

  • Pre Job Brief was not adequate. (Procedure 22171 was not briefed AND the brief was conducted early in the shift while the task was not performed until the end of shift.)
  • First time performer on this evolution (Newly qualified NLNPO). This was the NLNP'"s :first time restoring

.this equipment..

Procedure 2.2.71 was not taken to field during the restoration.

  • Crew had a sense of urgency, imparting Time Pressure. (Crew felt as if this was coming from Crew Management.)

Ilncorrect assumptions were made. (N0PO issiumed that the releasing of the Clearance Order would put the system in the configuration that it needed to be in and therefore did not question any further.)

. Procedure 2.2.71 does not contain performed by/verified sign off. (It should be noted that this was not a causal factor for the event-since the personnel did not reference the procedure during restoration')

. The activities to release the clearance order and hang clearance order for fish return line occurred in quick succession nearend of shift and were not scheduled activities (i.e., were emergent).

o .Push on fish return line before dark and ice would form (high risk profile job).

b Consequently schedule was not man-loaded for all the work going on.

Corrective Actions Taken/Recommended:

  • Create a placard for the Service Water Gland Water (to indicate if system is Cross.tied). (Recel: Notification 10295745)
  • Revise procedure 2.2.71 to-includeplacard and verifications..'(Rec-2: Notification 10295765)

In addition, at the Shift Managers' Meeting on 2/12/2004, this event was discussed. The Operations Manager expressed concern that all crews were not using the same control methods and reauested input from the Shift Managers on method to use going forward. The actions below

are for short-term use as error prevention tools and are not being 'entered in the Corrective Action Program. Use of reverse brief is already~covered by procedure and this signifies a restatement and clarification of expectations. The second action is not required by procedure, but is intended to ensure focus is given to each element of restoration separately.

  • Reverse brief at end ofpre-job brief will be used to demonstrate understanding.
  • Make 2 separate SAP confirmation entries (one'for release of clearance order and one for restoration of system).

This snapshot assessment will be provided to the root cause team for the SCR evaluation.

Areas for Improvement:

Based on review of the error precursors for this event, the following additional actions are recommended pending completion of the SCR evaluation.

" Review whether exposure exist with .other systems that need placards for cross-connect or abnormal lineups. (Rec-3: Notification 10295746)

" Identify any other safety systems whereneed procedure revision to include independent verification for restoration'(and implement process to correct condition if necessary). (Rec-4: Notification 10295747)

Team Members:

Event Review Team: Quorum was met. [All personnels' work location is CNS.]

K.V. Chambliss, Operations Manager - Chairperson [Team Leader]

D. Montgomery, Site HUman Performance Coordinator - Human Performance Represeritative S. Minahan, Site Vice President - Senior Management B. Murphy; Shift Manager- SRO N..Bege-, Control Room Supervisor- SRO N. Egger, !Station Operator -Peer Representative C. Blairi Licensing - Licensing Representative D. Tune, Operations Training Superintendent -Training Representative S. Hoff; Licensed Reactor Operator - NLNP0 Mentor M. Holmes, Operatiofis Trainiiig Liaison-Training Representative J. Weiss, Licensed Reactor Operator -. Work Control Operator C. Carpenter, Station Operator - Non-Licensed Nuclear Plant Operator K. Perry, Root CauseTeam Member -Root Cause Team Representative E-MAIL THE COMPLETED REPORT TO: Ralph Drier- Performance Analysis Department.

Completed reports Will be accessible through 'the Self-Assessment Web Page. Make idditional distribution as you :see fit.

Additional Distribution:

Shift Manager List Operations Training List Dave Cook (SCR Team Leader)

Dave Montgomery (Site Human Performance Coordinator)

Jim Flaherty

Flaherty, James R.

From: Tackett, Michael L.

Sent: Wednesday, February 18, 2004 5:39 PM To: Seeman, Glen A.; Sutton, Kent E.; Flaherty, James R.

Cc: Chambliss, Kevin V.: Schaible, Mairk D.; Holmes, Mark A.; Fleming, Paul V.

Subject:

Time Validation of Loss of 125VDC A from 100% Power With SWGW Cross-tied Time Validation of Loss of 125...

Time validation of a loss of I 25A from 100% power with SWGW crosstied with the A side supplying the B side.

Mike Tackett Operations Supervisor I

Time Validation of Loss of 125VDC A from 100% Power with SWGW Cross-tied Conditions:

4 Got permission from CRS to use his new NLO and his RO. I told him -whyand informed him not to tell his-operators anything except:to work with me.

  • Used anewly qualified NLO (quilified -.3 months)
  • Used.on watch RO. I told him I would be calling him in the future time validating a scenario "and he would need to tell me what hw would do.
  • Informed NLO that we would be performing a time validated's~enario and that we would be simulating. He would need to point to .anything he would be looking at and I would tell him what he sees. If lie would be contacting other people, he would let me know who and what he would ask and I would talk to them.

" Time validation started from the relief crew office.

  • I told him initial conditions ,ofReactor Scram, the Turbine has tripped, a lot of lights are out and thle Control Room has just called you and informed you of a SWGW trouble alarm on the B side.
  • Time started when he understood.

Timeline e .1405 - leftirelief crew office

  • 1407 - in SW Pump room (did notrnm) 9 1407 - asked which alarms were in on SWGW panel
  • 1407 - NLO pulled :alarm card 0 1408 -NLO verified SW-MO-2129 open 11409 - NLO asked Values of SWGW piessure and flows. I told him 0.

, 1410- NLO completed looking for obvious leaks per alarm card.

  • 1411 -1 called the control room per NLO guidance and told the RO the noted

.conditions in the SWP room.

. 1412- RO gave the order to check The lineup'back to 2129 and report status.

  • 1421 - NLO walked down piping and found SW-V-28 closed (simulated).
  • 1422 - I talked to Control Room per NLO guidance and toldlthem I found SW-V-28 closed and that it was the gland waternsupply from the SW Loop B.

11422 - Control Room order:was to open the supply valve :and check and close the cross connect valves. NLO did not know what valves they were and asked for more guidance.

  • 1423.- Guidance from Control Room was -to check closed SW-V-i 479 ýand SW-V-1480 and then open:SW-V-28. NLO repeated back to me.
  • 1425 - SW-V-1479 and 1480 simulated closed S11426 - SW-V-28 open, gland water restored.

Scenario presented by Mark Holmes aissumed 30 minutes to perform the activity. It took 21 minutes with one-of the newest qualified NLOs. A more experience NLO would have done in much quicker due to more familiarity with .operating the system. The RO was a senior RO and it may have taken a little more time with a new RO, but-the new RO may have quickly asked for help from CRS or other RO if he was having difficulty. A small

amount of time was added by me being a third party in all of the communications (-~1 minute). A small amount of time Was -added by him having to ask me what he sees instead of him seeing what he saw and moving on *-I minute).

This time validation was performed by Mike Tackett, Operations Supervisor on 2-18-04.

Risk Assessment of SW GW Issue Issue Gland water for Division II Service Water cross-tied to Division I SW on Jan 21.

Restored on Feb 11.

Failure ofDivision I Service Water results in failure of Division II Service Water (if gland water not restored in 30 minutes).

Purpose Determine risk significance of issue when reviewed using CNS PRA'Model.

Assumptions used to perform risk assessment Will be reviewed by Operations and Plant Engineering.

Assumptions

1. Failure of both Division I SW Pumps'leads to failure ofbothDivision:II SW pumps When GW is being supplied by'Division I pumps to Division I pumps.

Evaluation GW trouble is alarmed in the Control Room. The alarm procedure was reviewed by Operations. This procedure describes the expected conditions of the GW but does not describe the valve lh e -!e refethe )e a FF-e tem Operating procedure which cor ta ns s c io W, an to ve f'the____

.lineup..p The timerequired to restore GW in a plant trip has been estimated by operations to be .60 minutes, including 30 minutes for diagnosis. The present information from tIhe"SW pump vendor is that pump failure would occur if GW is not restored in.30 minutes. The pump vendor has been contacted to determine length of time pump can be run without GW and

,still meet the PRA mission time. Further discussion With the vendor indicates that'loss of

ýGW flow for 60 minutes has been evaluated in the industry. Potential for GW fl6W recovery becomes viable, with expected failure rate of 0.1 given the expected operator

response, To assess the increase in core damage frequency (CDF), gates were added to the Division fl SW pumps which would result in failure if both Division I SW pumps do not operate.

When this dependency is added to the PRA model without recovery, theresulting increased core damage probability (ICDP) appears to be greater than GREEN.

The new CDF was reviewed and it was determined that~'1-80% of the CDF is due to a loss of DC bus A initiating event. The majority of this is due to "twosequences.

The first sequ-ence contains cutsets with failure of HPCI due to room cooling failure (RCIC fails with the initiator). Depressurization is successful but low pressure injection fails - CS due to room cooling failure and LPCI due to other failures (majority =

Page 1 of 2

miscalibration of the initiating switch for lowireactor level Which can be recovered by

-manual initiation of the LPCI pump).

The second sequence contains successful operation of CS for injection, however, core damage occurs long term due to containment heatup. Extended CS injection is possible by aligning the suction to the CST and using containment vent for heat removal (expected ERO response by adapting existing system procedure in.Mode 4.)

Recovery of these two sequences (and bother CDF sequences) is 4provided by the EOPs

I-with 5.2SW arndd.2REC which will provide injection using the available CRD pump.

'Containment venting is still available via the Drywell vent path and the Torus Hard Pipe Vent.

f Operations has reviewed the recovery using the CRD pump and Containment venting and verified using prints and the simulator to ensure they are available.

Adding these recoveries to these sequences would reduce the CDF. In addition, the TDCA initiating event frequency was 'reviewed and compared to the initiating event frequency used in the SPAR model. Both initiating event frequencies are generic data values. The SPAR model uses updated information and is the lower frequency. Use of this updated frequency would also loWer theCDF.

ITDIF1F.

Page 2 of 2

Initiating Condition: LOSS OF 125 VDC Bus "A" from 100% Power LDl(tW- I

Plant' Response:
  • Loss of selected level, both RFPs (Reactor Feed Pumps) transfer to MDEM (Manual Demand Mode), "B" LI sees a high level trip
  • RPV low water level alarm + one RFP seen tripped (due to power loss) - "B" RRMG runs back to 45%

" Actual RPV water level raises rapidly and Main and "B" RFP Turbines trip ("A" will not trip except locally),

resulting In a reactor scram.

  • When Main Turbine trips, 3310 and 3312 open (Field breaker must be opened locally)
  • Breaker lBS will Close, maintaining power to 4160 VAC Busses 1B and 1G. L. "
  • Breaker iBE will see the loss of 4160 "A" Bus voltage and close In. (1AE will not trip)
  • t

., ri 0 iBE will trip on over current condition.

'Division I Electrical Busses will be lost. ¢t

  • Division I SW will be lost.
  • SW-MO-37 will Close due to loss of Division I SWPs SW Loop "B" pump selected to "Auto" will start on low pressure.

Electric Plant Status:

0 4160 VAC Bus iB is powered from SSST (Startup Station Service Transformer).

A, 4160 VAC Bus 1G is powered from 4160 VAC Bus 1B 4160 VAC Busses IA, 1E, and IF arede-energized; Service water System Status:

  • SW-P-A and SW-P-Care not operating

. SW-P-B and SW-P-D are operating.

  • SW-MO-37 is Closed. Auto pump would probably stay running due to low river level conditions (Will not obtain 75 psig.)

Indications:

  • .125 VDC Bus failure alarms on Division :I
  • SWGW Low Pressure alarm RPV Water Level and Pressure control:
  • EOP-1A-,RPV Control
  • 2.4RXLVL - RPV WATER -LEVEL CONTROLTROUBLE Reactor Power Control:
  • 2.1.5 -.REACTOR SCRAM Loss of one Reactor Recirculation Pump:
  • 2.4RR - REACTOR RECIRCULATION ABNORMAL Loss of DC Power:
  • 5.3DC.125 - LOSSOF 125:VDC:

o Place IBE to Pull-To-Lock - Lose backfeed capabilities to 4160 "F" Bus Po Trip !A" RRMG locally

.0 Transfer-4160 "B" to SSSTper 2.2.18 (would have occurred on Main Turbine trip)

ýo Locally open the Generator Field breaker o Locally trip "A"RFP Loss of AC Power:

  • 5.3EMPWR - EMERGENCY POWER:

o Attachment 2 has operator return the SW Zurn strainer(s) to service.

0 NLNPO responding to the SWPR (Service Water Pump Room) will identify that alarm window 1B/A-3 on the "B" SW Gland Water System annunclator panel Is alarming.

A With flow on the operating pump < 1.5 gpm would call the CR to have them start another available pump. CRO would ask NLNPO to verify the other pump is ready to start

,e cu e

  • 7. and response would be that it also has Inadequate gland water flow.
  • Z.._W-ULAND-b - SW GLAND WAI LR SUPPLY PANEL -ANNUNCIATOR 1B provides no additional guidance but does reference SOP 2.2.71. NLNPO will get 2.2.71 in attempts to determine the problem. . "-

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Loss of SW: G6 0 Aax-ys :5 5.2SW - SERVICE WATER CASUALTIES o Start available pumps and IF pressure Is > 38 psig, ensure SW-MO-36 and/or SW-MO-37 are Open.

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Loss of SW Gland Water Pressure:

o Section 10, step 10.2 would be the requisite guidance (Placing SW DischargeSupply-to Gland Water Subsystem B In Service) o Step 10.2.1: would not be applicable (not a planned evolution) o Step 10;2.2: NLNPO (Non-Licensed Nuclear Plant Operator) would inform SM that "B" loop SW pumps are inoperable o step 10.2.3: Would not be applicable because at least one pump should be running.

.o Step 10.2.4: Would not be applicable (FP (Fire Protection) and Riverwell are not supplying GW flow).

o Step 10.2.5: Would see the lights illuminated for SW-MO-2129MV.

0o Step 10.2.6: Would see the Red light on for SW-MO-2129MV, ensuring it is open.

o Step 10.2.7 would find SW-V-28 Shut and would Open it, -estoring Gland Water flow to the et operating Div IISW pump(s)

,\ 0'.Z3 Step 10.2.8 would not be applicable (FP not supplying GW flow).

t. Výý lo Step 10.2.9 would not be applicable (Riverwell not supplying GW flow) a Step 10.2.10 would'not be applicable (FP not supplying GW flow).

'6OhC o Step 10.2111 would inform Control Room of restored flow to B loop pumps.

Reasonable time line'for Operator. response dealing only With the loss of gland water to the Division It Service Water' Pumpsi

  • Time to recognize that the in service SWPs are operating with gland water trouble alarms in .- 30 minutes (This black bezel annunciator will not receive a higher priority for investigatioh due to the other red and yellow alarms and other mitigating actions that are being taken.)

" Time to get an NLNPO into the SWPR - 5 minutes o Time for the NLNPO to recognize the alarm condition and determine that the alarm response card does not restore gland water flow ,,,5 minutes, 'call Control Room and Inform them that SOP 2.2.71 is'needed.

" Time to go to Control Room to get SOP. 2.2.71 and return to the SWPR ,o10 minutes

" Time to go through Section 10, Step 10.2.7 to restore.Gland water ,' 10 ml

.- l/r.

.Questions to answer:

Which REC Heat Exchanger was in service and what wasit's SW flow rate?

  • REC-HX-A was Inserviceduring the entire period of time, with a Maximum flow rate of ,, 2142.86 gpm.

How does REC-AOV-TCV45IA fail on a loss of i25 VDC "A"bus?

. SW-AOV-451A will fail open when MCC-M Is de-energized. Comes from 4160 VAC Bus 1F o (Procedure 5.3AC480 - 480 VAC BUS FAILURE) If REC HX A was the only heat exchanger in service at the time power Was lost, Instructions are also provided to adjust the service water side flow as REC-TIC-451A fails open upon loss of 480V Bus 1F.

How does SW-AOV-TC/2797A fail on a loss of.125 VDC "A" bus?

q A loss of 125 VDC power would result in de-energizing the DG DC Control Power which would result in establishing SW flow through that EDG (Emergency Dlesel Generator).

  • (DCD 01 Service Water.System Design Criteria Document,- Attachment "B", step 5.2.2) The service water flows to the engine through the admissIon valve that Is controlled by diesel control Voltage (125 VDC).

o (Procedure 2.2.20 -.STANDBY AC POWER SYSTEM (DIESEL GENERATOR)) NOTE-- Placing DC.

CONTROL POWER AND MAINTENANCE LOCKOUT switch to OFF will cause SW-AOV-2797A(B) AV, DGI(2) -SUPPLY, to open. This will divert '. 2000 gpm from SW System.

What Is the normal position for SW-V-122 - CRITICAL SW HEADER TO REC HXS CROSSTI/E?

  • Sealed Closed Which Service Water Pumps were selected to "'Auto" during the period of time from :1/2i/2004 to 2/11/2004?
  • This information is not retrievable.
  • SW Pumps are shifted twice per week, arid typically, 'the selector switches are not repositioned.

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&11_1rrV-X I is_6_ý TFollowing the recent configuration control event associated with Service Water Gland Water, Actions to provide additional rigor to the status control of equipment manipulations are being taken.

All components that are manipulated to align systems. for clearance orders that are not part of the clearance order boundary shall be listed on the clearance order as '"No Tag" components. The as-left position of the component will be documented on the Clearance order. Upon release of the clearance order the component will be returned to the normal check off list position.-

All components associated with Safety Related or Essential systems will require independent verification.

When plant componenits are being manipulated in accordance with a station operating procedure with the intent of leaving the components in a configuration that is contrary to the normal check off list position, a narrative log entry should be made identifying the condition. Completing a Component Status Control Check List will provide status control. This checklist will include the reason for the configuration condition, plant system designator, component name, location, normal check off list position, actual position left, performed by and verified by initials. The CRS or the SM -will authorize all component manipulations. When the system components are returned to their normal check off list position the Component Status Control Check List will be completed to show:the restoration positions".

For safety related or essential equipment, independent:verification will be required All individuals performing or verifying actions for a Componeni Status Control Checklist will print their name, provide there initials, and sign and date the checklist.

When the Status Control Check List has been reconciled, the CRS -or SM should affix his/her signature to acknowledge the restoration. A narrative log entry should be made to identify that the system components have been returned to their normal configuration.

When plant compon-ents are being manipulated in accordance with a station operating procedure, and the steps of the procedure that are tobe performed will return the component to its original position, and appropriate verification signatures are imbedded within the procedure, no additional actions are needed. When configuration' sign off steps associated with safety related or essential are not part of the actual procedure then a narrative log entry will be made to indicate that the system has been restored to no-mnal status and Verified by independent means.

)

Component Status ControlCheck List CRS/SM Authorization )ate Reason for Configurnition System Component Description Normal Actual. Performed Date Verified* Date Restored Performed Date Verified* D

,,_Position Position By _ By Position By. By

  • Required for Safety Related'and Essential equipment.

Component Status Control. Check List.

Performers/Verifiers Printed Nameý Initials. Signature/Date Printed Name Initials Signature/Date Printed Name Initials Signature/Date.

Printed Name Initials Signature/Date Printed Name Initials Signature/Date Printed Name Initials Signiature/Date, CRS/SM Acknowledges Restoration Date