ML18096A331

LER 91-003-01:on 910209,steam Generator 14 Steamline Flow Channel I Transmitter Sensing Line Isolated During Investigation of Erroneous Reading.Caused by Personnel Error.Disciplinary Action taken.W/911024 Ltr

ML18096A331
Person / Time
Site:	Salem
Issue date:	10/24/1991
From:	POLLACK M J, VONDRA C A Public Service Enterprise Group
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-91-003-01, LER-91-3-1, NUDOCS 9111050073
Download: ML18096A331 (5)

Text

{{#Wiki_filter:,..,_ r -'. -. e Public Service Electric and Gas Company P.O. Box 236 Hancocks Bridge, New Jersey 08038 Salem Generating Station U. S. Nuclear Regulatory Commission Document Control Desk Washington, DC 20555

Dear Sir:

SALEM GENERATING STATION LICENSE NO. DPR-70 DOCKET NO. 50-272 UNIT NO. l Octo,ber 24, 1991 LICENSEE EVENT REPORT 91-003-01; SUPPLEMENT This Supplemental Licensee Event Report is being submitted pursuant to 16CFR50.73. This supplement enhances the analysis bf as requested by NRC Inspection Report 272/91-05. MJP:pc Distribution The Enerav People 9111050073 911024 PDR ADOCK 05000272 S PDR Sincerely

yours, C. A. Vondra General Manager -Salem Operations 95-2189 (10M) 12-89 NRC Fu'tlM 366 U.S. NUCLEAR REGULATORY COMMISSIOI 16-89) APPROVED OMB NO. 3150*0104 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT (LER) INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH IP*530), U.S. NUCLEAR REGULATORY COMMISSION.

WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT 13150-0104). OFFICE OF MANAGEMENT AND BUDGET. WASHINGTON, DC 20503. FACILITY NAME 111 I DOCKET NUMBE_R (2) PAGE (3) Salem Generating Station -Unit 1 o 1s1oIo1o12 17 I 2 1 loF 014 *TITLE, 141 Tech. Spec. 3.0.3 Entry; 2 Stm Flow Channels for 1 Steamline Inop. Due To Personnel Error EVENT DATE 151 *LER NUMBER 161 REPORT DATE (7) OTHER FACILITIES INVOLVED (81 MONTH DAY YEAR YEAR ?? SEQUENTIAL NUMBER HI REVISION MONTH NUMBER DAY YEAR FACI LlTY NAMES DOCKET NUMBERISJ 0 I 5 IO I 01 o, I I ' 12 0 19 911 -o lo 13 -ol i ii 21 911 0 9 1 0 4 0 I 5 Io Io I o, I I OPERATING THIS REPORT IS SUBMITTED PURSUANT TO THE OF 10 C_FR §:(Chock one or more of rho following) (11) MODE (8) 1 20.402(b) 20.405(cl 50.73(a) (2)(ivl 73.71(b) I -,_ ,__ POWER 20.406l*ll1llil 60.381cll1 I 50.73lall2llvl 73.71(c) LEVEL ..._ --,__ (101 0, 1 ,s 20.406(a)(1 )(iii 60.36(cll21 50.73(a)(2)(viil OTHER in Abmacr --,__ balow *nd in Text. NRC Form I 20.406(*1"(1 )(iii) x 60.731all21 Iii 60,73(a)(2)(vili)(A) 366AJ ,__ -,...._ 20.406 (all1 I (Iv) 60.73(all2lllil 50.73(al 121 (viii) (BJ ---20.406(aJl1 llvl 50.731*1121 (iii) 60.73lall2llxl LICENSEE CONTACT FOR THIS LER (12) NAME TELEPHONE NUMBER AREA CODE M. J. Pollack -LER Coordinator. 61 0 19 313 19 I -12 10 1212 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT 113) MANUFAC* REPORTABLE I:<: .... ,.*.*.-.*.*. .:.:.*.-. }{{ MANUFAC* !REPORTABLE .i:!i*ii*l:i,:.::11:::::::::1::1:*::=*:*:=:-::::**:* CAUSE SYSTEM COMPONENT

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I I I I I I I :-:--:*:* , ..... , ... ;-:-:*:-: SUPPLEMENTAL REPORT EXPECTED (141 MONTH DAY YEAR EXPECTED rn SUBMISSION n YES (If v*s, comp!*<* EXPECTED SUBMISSION DATE) DATE 1151 I I I NO ABSTRACT (Limit to 1400 spsc6s, i.e .. approximntely fifte6n single-space typewrirren Jines) 116) On 2/9/91, during reactor shutdown (in support of the upcoming ninth refueling outage) , a No. 14 Steam Generator (S/G) steamline flow channel I transmitter sensing line was isolated during investigation of a 14 SIG steamline flow channel II erroneous reading. Subsequently, Action Statement 3.0.3 was entered since the Action Statements for Tech. Specs. 3.3.2.1 and 3.3.3.1 do not address required actions with more than one inoperable steamline flow channel for any one S/G. The root cause of this event is personnel error as attributed to inappropriate supervisory direction. The supervisor involved acted upon an invalid assumption. When the tran-smi t ter sensing line would not stop venting (after the root valve was closed) the supervisor incorrectly assumed either the schematic was not read correctly, the valves were mislabled or the schematic was incorrect. The supervisor did not consider that the correct transmitter sensing line root valve was closed but was leaking by (due to it not being closed tight enough) . Contributing to this event was that the schematic drawing, which details component alignment, (for the transmitter sensing lines) was not taken to the job site. Upon notification of the isolation of the Channel I sensing line, the supervisor reopened the wrong root valve and successfully closed the correct root valve (i.e. I the first one closed) and vented the subject sensing line. This event has been reviewed by Maintenance management. Corrective disciplinary action was taken with the supervisor involved. This event has been reviewed with applicable Maintenance personnel. NRC Form 366 (6-89)

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LICENSEE EVENT REPORT. (LER) TEXT CONTINUATION Salem Generating Station Unit 1 DOCKET NUMBER LER NUMBER PAGE PLANT AND SYSTEM IDENTIFICATION:

W_estinghouse -Pressurized Water Reactor Energy Industry Identification System (EIIS) codes are identified in the text as [xx} IDENTIFICATION OF OCCURRENCE: Technical Specification 3.0.3 Entry; Two Steam Flow Channels for One Main Steamline Inoperable Due To Personnel Error Event Date: 2/9/91 Report Date: 10/24/91 This report was initiated by Incident Report Nos. 91-088 and 91-087. CONDITIONS PRIOR TO OCCURRENCE: Mode 1 Reactor Power 18% -Unit Load 145 MWe Unit in the process of shutting down in support of the upcoming 9th refueling outage DESCRIPTION OF OCCURRENCE: On February 8, 1990, at 1955 hours, during reactor shutdown (in support of the upcoming ninth refueling outage), Operations shift personnel observed that No. 14 Steam Generator (S/G) steamline steam flow channel II was greater than 10% above its corresponding feed flow. The channel was declar_ed inoperable and Technical 3.3.2.1 and 3.3.3.1 Action Statements 14 and 7 were entered. In accordance with the Action Statement, channel bistables were tripped. Maintenance-I&C was issued a work *order to investigate (and correct) the cause of invalid reading. On February 9, 1991 at 0845 hours, during reactor shutdown, a transmitter,sensing line, for No. 14 S/G stearnline flow channel I, was isolated during the.channel II investigations. Subsequently, Technical Specification Action Statement 3.0.3 was entered since the Action Statements for Technical Specifications 3.3.2.1 and 3.3.3.1.do not address required actions with more than one inoperable channel per steamline. Technical Specification Action Statement

3.0.3 states

"When a Limiting Condition for Operation is not met except as provided in the ACTION requirements, within one hour action shall be initiated to place the unit in a MODE in which the specification does not apply by placing it, as applicable, in: 1. At least HOT STANDBY within the next 6 hours, 2. At least HOT SHUTDOWN within the following 6 hours, and 3. At least COLD SHUTDOWN within the subsequent 24 hours.

LICE1\fSEE EVENT REPORT ( LER) TEXT CONTINUATION Salem Generating Station Unit 1 DOCKET NUMBER 5000272 , pESCRIPTION OF LER NUMBER 91-003-01 PAGE 3 of 4 Where c6rrective measures are completed that permit *operation urider the ACTION requirements, the ACTION may be taken in accordance with the specified time limits as measured from the time of failure to meet the Condition of Operation. Exceptions to these requirements are stated in the specifications." APPARENT CAUSE OF OCCURRENCE: The root cause of this event is personnel error as attributed to inappropriate supervisory direction. The supervisor involved acted upon an invalid assumption without. fully assessing an situation. To support troubleshooting No. 14 S/G steamline steam flow channel II, the transmitter sensing lines were to be isolated. The high side sensing line was isolated £irst by closing its root valve. The line was then vented; no' difficulties were When the low side sensing line root valve (14MS5) was closed (see schematic below), the line would not stop venting. The supervisor, thinking that he had closed the wrong valve, reopined the 14MS5 root valve and closed a. different root valve (14MS4). When this occurred, the Control Room received indication of the Channel I high failure. The 14MS4 valve isolates a Channel I sensing lirte. Upon notification (from the Operations Shift) of the isolation of the Channel I sensing line, the supervisor had the 14MS4 valve reopened and the 14MS5 valve reclosed. The Channel II sensing line was then successfully vepted. It should be noted that, prior to closing the low side. sensing line valve, the supervisor did have a technician review the schematic to determine which valves were to be closed. This information was relayed (via telecon) to the supervisor.. The correct valves were identified; however, when the low side sensing line would not stop venting, the supervisor incorrectly assumed that either the schematic was not read correctly, the valves were mislabled or the schematic was Flow Transmitter Channel I 14MS4 14MS2 ) ( 14MSS 14MS3 No. 14 S/G Flow Transmitter Channel II ., ..... LICENSEE EVENT*REPORT (LER) TEXT CONTINUATION Salem Generating* S.tation DOCKET-NUMBER LER NUMBER ANALYSIS OF OCCURRENCE: PAGE 4 of 4 incorrect. The supervisor did not consider that the correct valve was closed but leaking by (due to it not being closed tight enough) . Main Steam steamline flow inputs t6 S/G Feed Pump speed and water

• level control. In addition, .steamline flow signals are used as input to steamline isolation, safety. injection (SI), and steam flow mismatch.

Steam flow/feed flow mismatch when coupled with "Low S/G Level" will initiate a reactor t-rip signal. When the No. 14 Steam Geneiator (S/G) steamline steam flow channel II failed, its bistables were placed in the tripped condition in accordance with Technical Action requirements*. This action placed the plant in a conservative condition with regard to applicable Reactor Trip/ESF Solid State System (SSPS) actuating signals. To initiate an SSPS actuating signal, only one (1) of two (2) steam flow channels in a loop must respond to an abnormal condition. With the No. 14 loop Channel II bistable in the tripped position, an SSPS actuating signal would have initiated despite the No. 14 ioop Channel I being made inoperable by closure of its root valve. Therefore, this event did not affect the health or safety of the public. However, since Technical Specification Action Statement

3.0.3 entered

this event* is reportable to the Nuclear Regulatory Commission (NRC) in accordance with Code of Federal Regulations 10CFR 50.73(a) (2) (i) (B). Technical Specification Action Statement 3.0.3 was exited approximately one (1) minute after entry upon restoration of sensing line flow. CORRECTIVE ACTION: This event. has been reviewed by Maintenance Department management. Appropriate corrective disciplinary action was taken with the supervisor involved in this event. The need to fully assess (i.e., understand) and discuss unusual situations prior to taking action and to not manipulate plant components without appropriate documentation review was discussed with the supervisor involved. event has been reviewed with appiicable Maintenance Department personnel. The need to communicate unusual situations (as they arise) with other appropriate personnel, prior to manipulating components, was stressed. General Manager -{,/ -Salem Operations MJP:pc SORC Mtg. 91-108}}