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LER 89-006-00:on 890314,nonlicensed Operator Placed Eductor 2B Spray Additive Tank Suction Throttle Valve 2CS021B in Locked Open Position.Caused by Incorrect Valve Labeling. Valves to Be Provided W/High Visibility labels.W/891117 Ltr
	ML19332C568
Person / Time
Site:	Braidwood
Issue date:	11/17/1989
From:	Querio R, Wagner J; COMMONWEALTH EDISON CO.
To:	; NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
	BW-89-3043, LER-89-006-10, LER-89-6-10, NUDOCS 8911280288
	Download: ML19332C568 (5)
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Brtidwood Nucirr Pow:r St: tion -

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                                                  ', Telephone 815/458-28010                                                        ,
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N; ,_ . November 17,1989- -I L4 BW/89-3043 . U

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                                   ' U. S. Nuclear Regulatory Commission                                                             ,
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                                    ~ Document Control Desk--
                                  - Washington, D.C. 20555
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Dear Sir:

1The enclosed Licensee Event Report from Braidwood Generating .; Station is being transmitted to you in accordance with the requirements of-

                     ,                10CFR50.73(a)(2)(1) which requires a 30-day written report. --                                :

a This report is number 89-006-00; Docket No. 50-457.'

                                                                                                                                     ,
                                                                                         ' Very truly yours,
.[                                                                                                           4                      s
                                                                                                 . E. Querio' Station Manager Braidwood Nuclear Station

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Enclosure:

Licensee Event Report No. 89-006-00

                                   . cc:        NRC Region III Administrator                                                        r NRC Resident Inspector INPO Record Center
                                               ' CECO Distribution List
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8911280288 891117 '

PDR ADOCK 05000457

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LICENSEE EVENT V PORT (LER) 7

Faci.Ilty Naime (1). ,

Docket Number (2) Pane (3) Braidwood 2 0.151 OL 0.LttL4LsL1_1. l ofI O! 4 Title (4)- Fallure to Identify that Containment Spray Valve was Required to be Locked in a Throttled Position < Due to Programmatic Deficiency Event Date (5) LER Number (6) ReogrLQate (7) Other Faellities involved (8) ' Month Day Year Year Sequential //j/ Revision Month Day Year Faellity Name L J2det Number (s)

                                                                        'f Number     ///     Number None           01510101Ol l l
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01 3 11 4 Bl_9 81 9

01016 010 1l1 Il 7 81 9 01 51 01 01 Ol l l' (HIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10CFR OPRM MODE (9) nt_RNt_nwe mom ( m 5 20.402(b) __ 20.405(c) __ 50.73(a)(2)(lv) _ 73.71(b) POWER ._. 20.405(a)(1)(1) __ 50.36(c)(1) _ 50.73(a)(2)(v) _ 73.71(c) LEVEL __ 20.405(a)(1)(11) _ 50.36(c)(2) __ 50.73(a)(2)(vil) _ Other (Specify (101 0!0 !O __ 20.405(a)(1)(lli) _L 50.73(a)(2)(1) _ 50.73(a)(2)(viii)(A) in Abstract

    /,/,// // /,/,/,/ / / /,/,/,/,/,/,/,/,/ / / / / / __    20.405(a)(1)(lv)      __   50.73(a)(2)(II)     _    50.73(a)(2)(vill)(B)        below and in y///// /' ///
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jj/ j j// ' ' ////// ___ 20.405(a)(1)(v) _ 50.73(a)(2)(ill) 50.73(a)(2)(x) Text) LICENSEE CONTACT FOR THIS LER (121 Name TELEPHONE hut @ER AREA CODE Jerry Wagner. Reaulatory_Anurgoce Ext. 2497 8l115 dl 51 81 l 21 8101 COMPLE1[_QHE._LitlE FOR EACH COMPON N FAILUBLQ11(810ED IN THLLREEORT (13) SYSTEM COMPONENT MANUTAC- REPORTABLE CAUSE SYSTEM COMPONENT MANUTAC- REPORTABLE CAUSE TURER TO NPRDS TURER TO NPRQL I I I I l l I N _ l l l l l l l l- 1 I I I l l 1 1 I I I I L SUPPLEMENTAL REPORT EXPECTED (14) Expected tionth llav l ..YeaE Submission

lyes (If.vese.CDeplete EXPECTED S1)QM111[QN DATE) X l NO l ll l ABSTRACT (Limit to 1400 spaces, i.e. approximately fifteen single-space typewritten lines) (16)

On the afternoon shift on March 13,1989 a R0 licensed operator (NS0) identified the return to service

           ' positions for the 2B Containment Spray (CS) pump. One of the valves was the 2CS0218 Eductor 28 Spray Additive Tank Suction Throttle Valve. The NSO determined positions from the Piping and Instrumentation Dlagsams(P&lDs). Directly below the valve symbol appeared the letters "L.O." which meant Locked Open. There was a note on the P&ID sheet that stated the valve should be throttled. Based on the L.O. designation the NSO concluded that the valve should be locked in the full open position. At 1357 on March 14,1989 a non licensed operator (EA) placed the 2CS0210 in the locked open position. On October 18,1989 an EA discovered that the 2CS021B was positioned incorrectly. The valve was immediately repositioned. The cause of this event was that the valve was not Sbeled as a throttle valve. A contributing cause was that the out of service program did not require placing the "as found" positions on the outage form. All " accessible" Unit 2 locked valves were position verified. Unit I locked valves will be verified prior to its return to operation. Locked throttled valves will be provided with high visibility labels. The Out of service form has been modified. The Out of Service Program will be revised to provide guidance concerning throttle valves.

There have been no previous occurrences. 2930m(Ill789)2

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i. tIgg$[11y[NT REPORT f LER) TfJQ_CQNUNy& TION ' Fore Rev 2.0 FACILITY.NAME.(1) .-

_ DOCKET NUMER (2) LER NUPEER (6) Paae (3) [

Sequential Revision

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Year ffj/

                                                                                             //                  //
                                                                                             ///    Number     /j/j f
                                                                                                               //    Number L
                .DrAhlstad _2 -                              0 l 5 LQ l 0 IJLI 41 SLIJ l 9    -
                                                                                                  'oJ _0 LL      -   0Io     el 2 'Or     oi4   .

[[ TEXT 3 Energy Indu'stry Identification System (EIIS) codes are identified in the text as IXX) [.

EA[ PLANT'CONDITIONSPRIORTOEVENT:

Unit: Braidwood 2; Event Date: March 14,1989 ! Event-Time: 1357;-

                   'Hode: S'- Cold Shutdown:- Rx Power: .0%;

RCS [AB) Temperature /. Pressure: 100 degrees F/ 0 psig

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B. DESCRIPTION OF EVENT:

There were no-systems'or components inoperable at the beginning of the event which contributed to the r

severity of the event.

The Unit 2 surveillance outage was in progress. The 2B Containment Spray (CS) (BE) system had been removed

                  'from service for maintenance.

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                   ' Afternoon: shift on March 13, 1989 Th'e return'to service of the 2B CS pump was initiated. .A Nuclear Station Operator (NS0) (R0 licensed operator) identified the return to service positions for the valves that were used as isolation points for-
                   .the out of service. One of the, valves used as an isolation point for the out of service was the 2C50218,
                  - Eductor 28-Spray Additive Tank Suction-Throttle Valve. (his valve is normally locked in a throttled position. 'This position provides 55 gpm sodium hydroxide flow to the suction of the 2B CS pump upon a CS
                   ' initiation. The NSO determined the return to service positions by consulting a controlled copy of the Piping and Instrumentation Diagrams (P& ids).                                                                                      ,

The 2CS021B is drawn on P&ID H-129 Sheet 1A. Directly below the valve symbol appear the letters "L.O ". This designated the valve.as a Locked Open valve. The valve Equipment Part Number (EPN) is approximately one Inch from.the valve symbol with an arrow pointing to the valve symbol. Beside the EPH block is the term " note 3". Note 3 is printed in small print with ten other notes on the right hand portion of the P&lD sheet. Note 3

                  . states "3. Lock valve C5018A & B or CS021 A & B in position to' give 55 GPH flow".

Based on the L.O. designation in the P&ID the NSO concluded that the valve should be locked in the full open

                   . position.'The NSO entered >'open ' as the return to service position for the valve. The return to service positions were independently verified by a second NSO who made the same conclusion.

At 1357 on March 14,1989 an Equipment Attendant (EA) (non licensed operator) placed the 2CS0218 in the incked open position while returning the 2B CS pump to service. At approximately 1100 on October 18,1989 an EA discovered that the 2CS021B was positioned differently then

                  .ECS021A, the equlvalent valve for the 2A f.S pump. The valve was immediately positioned to the proper
                  ' throttle setting.
            .

At'1734 ,on October 20, 1989 after discussions with the NRC Resident Inspectors, an ENS notification was conservatively made pursuant to 10CFR50.72(b)(1)(il). I This event is being reported pursuant to 10CFR50.73(a)(2)(1) - Any operation or condition prohibited by the plants technical specifications. L 2930m(111789)3

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LTGtfSEE EVENT REPORT (LER) TEXT CONT 1! NATION Form Rev 2.0,, FACILITY NAME (1) # DOCKET NUMBER (2) LER NUPBER (6) P g (3) .

                *                 *

f Year // Sequential / Revision

                                                                                        /jj/,
                                                                                        //     Number    //j/j f
                                                                                                         //     Number                     ,

Braldwood 2 0 1 5 l 0 1 0 1 0 l 4L.'iL1 e 1 9 - 01016 - 010 01 3 Or 01 4 ;

TEXT- Energy Industry Identification System (EIIS) codes are identified in the text as (xx)

t C. CAUSE OF EVENT: The' root cause of 'this event was a programmatic deficiency. The existing program for locked throttled valves did not provide specific .information at the point of manipulation identifying that-the valve was required to b3 In a throttled position. { D A contributing cause to the event was the out of service program. The program in effect at the time of the [ cvent did not require placing'the "as found" positions of the components used as isolation points on the outage form.

    - D. SAFETY ANALYS!$:

This event had no effect nn the safety of the plant or the public.

            .The 28 CS pump was. capable of providing spray flow to the Unit 2 Containment at all times. The 2A CS~ pump -

was operable and available as a redundant means of providing spray flow to the Unit 2 Containment had the n;ed for CS initiation occurred. A' Preliminary Engineering Assessment of the ef fects of increased sodium hydroxide flow was performed by 5:rgent & Lundy Engineers (S&L). The calculated maximum sodium hydroxide flow rate with the 2CS0218 full open "w;s 140 GPH. The assessment assumed this flowrate concurrent with a failure of the 2A CS pump to start and thw most. limiting boron and sodium hydroxide concentrations, l' Based on the conclusions of the_ assessment the only potentially significcnt adverse ef fect would be on cquipment environmental qualification. The calculated maximum spray PH would have been 11.2*/. The maximum PH speelfied in the Technical Specification is 11. The maximum duration of this 11.27 PH condition was expected to be an hour. At this time switchover to recirculation would occur and the components would be exposed to an

           .cnvironment below tne Technical Specification maximum.

Calcalations perfonned a suming the operation of the 2A CS pump concurrent with the above assessment have etncluded that the maximum PH would have been 11.05, which is essentially the Technical Specification limit. The.2A CS pump was operable and available throughout the event. E. CORRECTIVE ACTIONS: l The 2C50218 was returned to the correct-throttle position. The valve was locked in that position. The positions of all " accessible" locked valves on the 18 Month Locked Valve Surveillance, 2Bw05 XLE-RI. were i prsition verified. All safety related locked components were found in the correct position. IBw05 XLE R1 will !' b2 completed for Unit I prior to its return to operation from the refuel outage which is currently in progress. This is a normally scheduled requirement. , Valves that are required to be in the locked throttled position will be provided with high visibility labels. l- - These labels will identify that the valve is required to be locked in the throttled position. This action will be tracked to completion by action item 457-200-89-08501. l

    .2930m(111789)4

fE .. ; , 4 LIEENSEE EVENT REPORT (LER) TEXT CONTINUATION Form Rev 2.0 4

         .FACIl.!TY'NAME - ( 1 )     *,
                                          ,

DOCKET NUMBER (2) LER HUtBER (61 Pgae (31'

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               -                                                             Year     /     Sequential /jjj/
                                                                                                         /   Revision
                                                                                    /j/jj/
                                                                                    //       Number    ///    Number

_Braidwood 2 0 1 5 1 0 1 0 1 0 1 41 51 7 8l9 - 01016 - 0l0 01 4 0F 01 4 TEXT Energy Industry Identification System (EIIS) codes are identified in the text as (XX)

_In May of 1989 the Out of service form was modified to require the as found" position to be entered the cutage form when the component is removed from service. This change was requested by the Braidwood Station ; Event frequency Reduction Committee. The committee recommended this change as a part of its ongoing.

           .; valuation of station programs and events.
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The Out of Service Program will be revised to provide additional guidance concerning the use of throttle valves as isolation points for removing equipment from service. This action will be tracked to completion by-attIon Item 457-200-89-08502. F. PREVIOUS OCCURRENCES: There ha've been no previous similar. occurrences of failure to identify that a valve was required to be - throttled. i G. COMPONENT FAILURE DATA: This event was not the result of component failure, nor did any components fail as a result of this event.

2930m(111789)5

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ML19332C568

Text

Dear Sir:

Enclosure:

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