ML18004B950

LER 87-052-00:on 870831,containment Integrity Violated. Caused by Personnel Error Due to Communication Breakdown.Pa Sys & Procedures Being Reviewed for Improvement & Door Operator Being Stationed at door.W/870930 Ltr

ML18004B950
Person / Time
Site:	Harris
Issue date:	09/30/1987
From:	SCHWABENBAUER, WATSON R A CAROLINA POWER & LIGHT CO.
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
HO-870507-(O), LER-87-052, LER-87-52, NUDOCS 8710060404
Download: ML18004B950 (10)

Text

ACCESSION NBR: 8710060404 DOC.DATE: 87/09/30 NOTARIZED:

NO FACIL: 50-400 Shearon Harris Nuclear PoUjer Planti Unit ii CaTolina AUTH.NAME AUTHOR AFFILIATION SCHWABENBAUER Carolina Power 5 Light Co.WATSON'~A.Carolina Poeer&Light Co.RECIP.NAME RECIPIENT AFFILIATION DOCKET 05000400

SUBJECT:

LER 87-052-00:

on 87083li containment integritg violated.Caused bg personnel error due to communication breakdoen.

PA sos 8c pT ocedures being revieeed for improvement 0 door operator being stationed at door.W/870930 ltr.DISTRIBUTION CODE: IE22D COPIES RECEIVED: LTR g ENCL J SIZE: TITLE: 50.73 Licensee Event Report (LER)i Incident Rpti etc.NOTES: Application f or permit reneUJal f iled.a5ao04oo RECIPIENT ID CODE/NAME PD2-1 LA BUCKLEYiB COPIES LTTR ENCL 1 1 1 1 RECIPIENT ID CODE/NAME PD2-1 PD COPIES LTTR ENCL 1 1 INTERNAL: ACRS MICHELSON AEOD/DOA AEOD/DSP/ROAB DEDRO NRR/DEST/CEB NRR/DEST/ICSB NRR/DEST/MTB NRR/DEBT/RSB NRR/DLPG/HFB NRR/DOE*/EAB NRR/DREP/RPB NRR/PMAS/ILRB RES DEPY GI RES/DE/EIB 1 1 1 1 2 2 1 1 1 1, 1 1 1-1 1 1 1 1 1 1 2 2 1 1 1 1 1 1 ACRS MOELLER AEOD/DSP/NAS AEOD/DSP/TP*B NRR/DEST/*DS NRR/DEST/ELB NRR/DEST/MEB NRR/DEST/PSB NRR/DEST/SGB NRR/DLPG/GAB NRR/DREP/RAB SIB REQ F 02 RES TELFORDI J RGN2 FILE 01 2 2 1 1 1 1 1, 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 EXTERNAL: EGS(Q QROHr M LPDR NSIC HARRISI J 5 5 1 1 1 1 H ST LOBBY WARD NRC PDR NSIC MAYSi Q 1 1 1 1 1 1 TOTAL NUMBER OF COPIES REQUIRED: LTTR 44 ENCL 43 e NRC Form 388 (9.83)LICENSEE EVENT REPORT ILER)U.S.NUCLEAR REGULATORY COMMISSION APPROVED OMB NO.3(600104 EXPIRES: 8/31/88 FACILITY NAME (II SHEARON HARRIS NUCLEAR POWER PLANT UNIT 1 DOCKET NUMBER l2)0 5 0 0 0 PA E 3 1 OF CONTAINMENT INTEGRITY BREACH.CAUSED BY PERSONNEL OPENING INNER PERSONNEL ACCESS DOOR WHILE OUTER DOOR WAS DECLARED INOPERABLE DUE TO 0-RING SEAL.EVENT DATE (5)MONTH DAY YEAR YEAR LER NUMBER (6)BEQUENTIAL.Pc3 REvrsloN NUMBER AStv NUMBER REPORT DATE (7)MONTH DAY YEAR FACILITY NAMES DOCKET NUMBER(S)0 5 0 0 0 OTHER FACILITIES INVOLVED (8)0 8 31 8 787 0 5 2 0 0 0 3 0 8 0 5 0 0 0 OPERATINQ MODE (SI POWE R LEVEL 00)000 20.402(B)20.405(~l(1)(I)20.405(~l(1((ill 20.405(~)(1)(iii)20A05(~)(I)(I v)20.405(e)lll(v) 20A05(s)50.38(s)II)50.38(cl(2) 50.73(~)l2)(I)50.73(sl(2)(E) 60.73(s)l2)IIIII I.ICENSEE CONTACT FOR THIS LER (12I 60.73(sl(2) livl 60.73(s)(2)(vl 50.73(s)(2)(vBI 60.73(sl(2)(viii)(AI 50.73(sl(2)(villi(B)60.73(~)(2)(x)THIS REPORT IS SUBMITTED PURSUANT 7 0 THE REQUIREMENTS OF 10 CF R (I: (Check one or more Of the IOIIOvfinf I (11 73.71(B)73.71(c)OTHER fSpecffy In Abstract belovr end In Teat, IEIRC Form 3r)EAI NAME R.SCHWABENBAUER

-REGULATORY COMPLIANCE TELEPHONE NUMBER AREA CODE 91 93 62-6 69 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)CAUSE SYSTEM COMPONENT MANUFAC.TURER EACAEABSE ggg)5E.I CAUSE:rNININNi)IW IIW)NjmII SYSTEM COMPCINENT MANUFAC TURER EPORTABLE TO NPRDS IS%ad%%%Nj P>.,Pea'.).Ski SUPPLEMENTAL REPORT EXPECTED (14)YES ill yas, complete EXPECTED SVShtISSION DATE)NO ABSTRACT (Limit to 1400 spaceL I e., approximately fifteen slnpleepece typecvritten lineal (18)EXPECTED SUBMISSION DATE (16)MONTH DAY YEAR The plant was in Mode 3, Hot Standby, at 0 percent reactor power on August 31, 1987.At 1345 hours0.0156 days <br />0.374 hours <br />0.00222 weeks <br />5.117725e-4 months <br /> a mechanic and a Health Physics (HP)technician were exiting containment through the personnel access hatch.As they opened the outer door, one of the door's o-ring seals fell out of its groove.A mechanic noticed there was no apparent damage to the o-ring so he re-installed it prior to closing the door.Meanwhile, a HP technician on duty at the door notified the Shift Foreman of the situation, who immediately declared the Personnel Access Hatch inoper'able and made an announcement over the site PA system for any personnel in contaInment wh," need to ex'.: '~e he Emergency Access Hatch while repairs were being made to the door.At 1352 hours0.0156 days <br />0.376 hours <br />0.00224 weeks <br />5.14436e-4 months <br /> another mechanic and HP technician, who were inside containment opened the inner door to exit containment while the outer door was still declared inoperable, the inner door was opened for approximately one minute This violated containment integrity and Technical Specifications 3.6.1.3 Action a.The immediate corrective action was a work request was issued to repair the door.The-o-ring was inspected and found to be in satisfactory condition and reinstalled.

A local leak rate was then successfully completed and the airlock declared operable at 1505 hours0.0174 days <br />0.418 hours <br />0.00249 weeks <br />5.726525e-4 months <br />.The cause of the event has been determined to be personnel error due to a communication breakdown, as the personnel in containment'tated they heard an announcement but could not understand it and were unaware the access hatch was declared inoperable.

Actions to prevent recurrence are the containment PA system and procedures are being reviewed for possible improvements.

Also, a door operator is being stationed at the door to ensure proper operation'of the door~and adequate communication exists.8710060404 870930 r"~PDR ADOCX 05000400 S PDR NRC Form 388 sn ls'll r l~NRC Form 368A I94)3)LICENSEE EVENT REPORT (LER)TEXT CONTINUATION U.S.NUCLEAR REOULATORY COMMISSION APPROVED OMB NO.3150-0104 EXP)RES)8/31/88~FACILITY NAME Il)DOCKET NUMBER 12)YEAR LER NUMBER 16)BECUENTIAL NVMSER REvrsroN NVMBER PAGE 13)SHEARON HARRIS NUCLEAR POWER PLANT UNIT 1 TEXT/I/more 4/r444/4 mr/rr/rod, rrw Sdd/dorr4/NRC

/orrlr 36643/117)o s o o o 40 08 7 0 5 2 0 0 0 2 OF 0 DESCRIPTION:

The plant was in Mode 3, Hot Standby, at 0 percent reactor power on August 31, 1987.At 1345 hours0.0156 days <br />0.374 hours <br />0.00222 weeks <br />5.117725e-4 months <br /> a mechanic and a Health Physics (HP)technician were exiting the containment building through the Personnel Access Hatch (EIIS:BD).

The inner door was shut and the'open'uter door signal initiated.

Just as the outer door opened, a loud'pop'as heard and there was the audible sound of escaping air.The o-ring seal was observed to fall out of the retaining grooves as the door opened.The air flow was observed to be from the seal pressurization cavity and continued for one to two minutes until a nearby operator secured air flow by shutting valve 1PP-352 (refer to Figures 1, 2, 3, and 4).The mechanics pushed the seal back into the groove, closed the door, and re"opened valve 1PP-352.There was no indication of any seal leakage.In a normal operating sequence, the open signal shuts valve 1PP-353 to isolate the air supply and opens 1PP-355 to vent any trapped air.Operating experience has demonstrated that the door locking ring will not rotate to the unlocked position when the seal is pressurized.

Valve 1PP-353 either failed to operate or failed to shut fully.When the door opening sequence was repeated, the failure of valve 1PP-353 could not be repeated and no further work was done on it.Meanwhile, a HP technician on duty at the door notified the operations shift foreman of the situation with the access door o-ring.The shift foreman immediately declared the Personnel Access Hatch inoperable and made an announcement via the site PA system, (EIIS:FI)that any personnel in containment to exit through the Emergency Access Hatch if they needed to exit prior to repairs being completed to the airlock door.At 1352 hours0.0156 days <br />0.376 hours <br />0.00224 weeks <br />5.14436e-4 months <br /> another mechanic and HP technician, who were in containment, opened the Personnel Access Hatch inner door while the outer door was still declared inoperable, the inner door was open for approximately one minute which violated containment integrity and Technical Specification 3.6.1.3 Action a.The mechanic and HP technician stated they had heard an announcement over the PA system but could not understand it and were unaware the Personnel Access Hatch had been declared inoperable.

A work request was immediately issued to repair the door seal.The door seal o-rings were inspected and found to be in satisfactory condition and reinstalled on the door.A local leak rate test was successfully completed in accordance with Engineering Surveillance Test (EST)-219, Personnel Air Lock Door Seals Local Leak Rate Test, and the Personnel Access Hatch declared operable at 1505 hours0.0174 days <br />0.418 hours <br />0.00249 weeks <br />5.726525e-4 months <br />.NIIC'FORM 366A B)431*U.B.GPO:I BBB.O824.538/455 NRC Form 368A (943)LICENSEE EVENT REPORT (LER)TEXT CONTINUATION U.S.NUCLEAR REGULATORY COMMISSION APPROVEO OMB NO.3150M)04 EXPIRES: 8/31/88 FACILITY NAME (1I 0OC K ET NUMB E R (2)LER NUMBER (6)PAGE (3)SHEARON HARRIS NUCLEAR POWER PLANT UNIT 1 TEXT W more epece/4//o/rer/

See////oee~//RC Forrrr 3////r43/(IT)CAUSE'0 YEAR Nr~r 8 7 SEGUENTIAL qgo REVISION NUNSEA rrTrr NUNISSA 0 52 00 0 3 OF 0 4 The root cause of the event was the o-ring seal.on the access hatch door falling out of its groove which led to the Personnel Access Hatch being declared inoperable.

This failure in conjunction with the inability to communicate the inoperable status of the outer door led to a violation of Technical Specifications 3.6.1.3 Action a.The cause of the seal failure and communication failure are discussed below.The o-ring seal could be unseated from it's groove by 1)adhering to the door face, 2)air pressure behind the seal forcing the seal out, or 3)a fit such that the o-ring is not properly retained in the groove.None of these can be isolated as the cause of the seal falling out.The investigation into the cause OE the seal failure is still under investigation.

Technical Specification 3.6.1.3 Action a was violated because of the inability to effectively communicate with personnel in containment.

At the time of the event the plant was near normal operating temperature and pressure.Under these conditions, the containment is hot and noisy and personnel inside of containment, which were contacted, stated that PA announcements are not intelligible inside the containment building.ANALYSIS: This event is being reported in accordance with 10CFR50.73 (a)(2)(i)(B) as a breach of containment integrity and a violation of Technical Specifications 3.6.1.3 Action a.In this case only the outer door was declared inoperable and use of the inner door is prohibited pending repairs and testing of the outer door.It has been concluded by the facts (1)the outer door seal o-ring was inspected and found to be in satisfactory condition, and (2)successful completion of local leak rate test, EST-219, that the leakage of the airlock during a postulated accident would have been acceptable.

The worst case would occur during accident conditions where a breach in containment integrity could result in radioactive activity releases in excess of allowable limits.The failure to maintain the operable door shut exposes the plant to the possibility of an accident where the inoperable door will be the barrier relied upon.This exposure is very short.The inner door was open for only a minute and the inner door could not be opened unless the outer door is fully locked shut.The closure of the outer door even with indeterminate seal leakage still presents a significant barrier to the release of radioactive material from containment.

Refer to LER-87-034-00 for a similar event where personnel entered and exited containment when one airlock door was declared'inoperable due to damaged o-rings.FOAM 366A ro ocr o U.S.GPO:10884824 538/455

• NRC Form 366A (943)LICENSEE EVENT REPORT (LER)TEXT CONTINUATION U.S.NUCLEAR REGULATORY COMMISSION APPROVEO OMB NO.3)50-0104 EXPIRES: 8/31/88 r FACILITY NAME (1)DOCKET NUMBER (2)LER NUMBER (6)PAGE (3)SHEARON HARRIS NUCLEAR POIKR PLANT UNIT 1 TEXT///mere e/reer/r ter/Ir/red.

Iree edd/done///RC Fonrr 36643/I IT)CORRECTIVE ACTION: 0 5 0 0 0 4 0 0 YEAR g<+~8 7 SEOUENTIAL NUMSER.;fr/052 REVISION NUMEER 00 04 OF 0 4 The immediate corrective action was to repair the outer door seal o-ring and to declare the outer door operable.ACTIONS TO PREVENT RECURRENCE:

1)The design and installation of, Containment PA system is being reviewed for possible improvement.

2)Alternative communication methods are being investigated.

3)Procedures are being reviewed to see if corrections are required.4)A door operator is now being posted at the airlock door to ensure whenever entries are made into containment that proper operation of door and adequate communication exist when a door is declared inoperable.

erRC'FORM 366A ($83)WU.S.GPO:1986.0 824 538/E65 PERSONNEL AIRLOCK OLITLINE RCB RCB WALL op~~~~p~g~'~4~p,%p,C o Di+~W~o p,~RAB AIRLOCK BARREL C L 0 S E LOCKING RING DOOR TYP.A iP'0 P E e yo d%~y't~4 D~p D DOOR HINGE (TYP.)DOOR SWING HYDRAULIC t1OTOR.{ROTARY ACTUATOR)(TYP.)ATT4'clfgE pl I 75 8 Eg-'p7-ox@"Do FIG.1

~~PERSONNEL AIR LOCK LOCKING RING DETAIL DOOR"~INGS".':::::::::OUTSIDE:::::.:::

::::::::::::AIRLOCK:,'::

AIRLOCK BARREL!!!!l<!!!pl!>!WED BRASS ANTIFRICTION RINGS t1INI/SIZE GAP TO:::::::::::::::::::::::::;:::::::

INCREASE COMPRESSION

'INSIDE::::

AIRLOCK:::::;

AIRLOCK DMR REF.DWG'S 1364" 14804 1364-13383 NOTE;ROTATION OF THE LOCKING RING CAUSES ENGAGEMENT OF WEDGES.ON DOOWLOCKING RING.THIS ENGAGEMENT PUSHES DOOR TOWARD.AIRLOCK BARREL AND C(%PRESSES THE DOOR SEAL~INGS.'I ArNcpma A/7 FIG, 2 VENT TO ATI10SPHERE 1PP-355 Pl 07th Al Pl QTM A2 Pl 0TH LC 1PP-354 FC TO DOOR 4 BREECH TYPE PERSONNEL AIR LOCK Pl 07K AW FC 1PP-353 TO AIRLOCK BARRIER~1PP-4S-F-01 LC 1PP-358 LC 1PP<<357;~I-LC 1PP-35&'PP-352 INSTRUMENT AIR AIR SUPPLY FOR BREECH TYPE PERSONNEL AIR LOCK F16.3.

PERSONNEL AIR LOCK SEAL RING AND GROOVE DETAIL 118 Dia.1/16 l ill llj ll Ijl 3/4 Dia'O'ing Seal 112 1/2" Dia.1/4" Dia.Air Supply Located at.270'P P 1/16 deep x 90 V~notch all around 6.725+.010 90 109 1/2" Dia 108 Dia.FIG.4 Carolina Power 8 Light Company r HARRIS NUCLEAR PROJECT P.O.Box 165 New Hill, NC 27562 SEI'0 198/File Number.'SHF/10-13510C Letter Number'HO-870507 (0)U.S.Nuclear Regulatory Commission ATTN: NRC Document Control Desk Washington, DC 20555 SHEARON HARRIS'NUCLEAR POWER PLANT-UNIT 1 DOCKET NO.50-400 LICENSE NO.NPF-63 LICENSEE EVENT REPORT 87-052-00 Gentlemen'.

In accordance with Title 10 to the Code of Federal Regulations, the enclosed Licensee Event Report is submitted.

This report fulfills the requirement for a written report within thirty (30)days of a reportable occurrence and is in accordance with the format set forth in NUREG-1022, September, 1983.Very truly yours, R.A.Watson Vice President Harris Nuclear Project RAW:skm Enclosure cc: Dr.J.Nelson Grace (NRC-RII)Mr.B.Buckley (NRR)Mr.G.Maxwell (NRC-SHNPP)MEM/LER-87-052/Page 1/OS1