NRC-90-0008, LER 89-037-00:on 891220,determined That Tech Spec Stroke Time Testing for Outboard Reactor Water Sample Line Isolation Valve Not Performed.Caused by Personnel Error. Critique of Event Being developed.W/900119 Ltr

LER 89-037-00:on 891220,determined That Tech Spec Stroke Time Testing for Outboard Reactor Water Sample Line Isolation Valve Not Performed.Caused by Personnel Error. Critique of Event Being developed.W/900119 Ltr

ML19354E102
Person / Time
Site:	Fermi
Issue date:	01/19/1990
From:	Anthony P, Orser W DETROIT EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
CON-NRC-90-0008, CON-NRC-90-8 LER-89-037, LER-89-37, NUDOCS 9001250375
Download: ML19354E102 (5)

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Reference:

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.NRC Docket No; 50-341' .

Facility Operating License No. NPF-43'

Subject:

Licensee Event Report (LER) No. 89-037-00:

Please find enclosed LER No.- 89-037-00, dated. January 19 -

1990, for a reportable: event that occurred on' December

.20, 1990.- A copy.of this LER is also being sent'to'thei-Regional--Administrator, USNRC Region III.

If you have any questions, please contact. Patricia'-

Anthony at (313) 586.1617.

Sincerely, ',

.i Rnclosure: NRC Forms 366, 366A cc: A. B. Davis

>J. R. Eckert R. W. Defayette/W. L. Axelson

. W. G. Rogers J. F. Stang.

' Wayne County Emergency Management Division

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'""' Testing Required by Technical Specifications for the Reactor Water Sample Line Isolation Valve had not been Completed due to Personnel Error EVENT DATE (6) LER Nut 4EER tel REPORT DATE 178 OTHER F AciteTIES INVOLVED tel U

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NAME TELEPHONE NUMBER ARE A CODE Patricia Anthony, Compliance Engineer 3; 1; 3 5 p ;6, i 1 l6 , ll 7  ;

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j On December 20, 1989, it was determined that Technical Specification stroke time testing for the outboard Reactor Water Sample Line Isolation Valve, B31-F020, had not been performed as required prior to its expiration on November 25, 1989. The valve had been functioning as a protection boundary for maintenance work at the time the other valves within the same system were tested.

i When the Limiting Condition for Operation log entry for B31-F020 was combined with another entry on November 23, 1989, the requirements and actions per Technical Specification 3.6 3 were not clearly indicated in the new entry. Therefore, modes were changed with the valve not having been tested as required.

On December 18, 1989, B31-F020 was used as an alternate sample path '

for the Reactor Water Cleanup System for approximately 18 1/2 hours.

During this time, both the outboard and the inboard isolation valves for this penetration were open.

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I Upon discovery of the condition, the valve was tested successfully.

Revision to the Limiting Condition for Operation administrative procedure is being made to prohibit combining entries. A critique of this event is being prepared.

TEXT Plant Conditions at Time of Discovery:

Operational Condition: 2 (Startup)

Reactor Power: 4.2 percent Reactor Pressure: 920 psig Reactor Temperature: 530 degrees Fahrenheit Description of Occurrence:

On December 20, 1989, at approximately 1300 hours0.015 days <br />0.361 hours <br />0.00215 weeks <br />4.9465e-4 months <br />, it was determined that.the! stroke time surveillance testing required by Technical Specification 3.6 3 for the Reactor Water sample line outboard isolation valve, B31-F020, [(AD)(ISV)] had not been completed by its expiration date and subsequently that plant modes had been changed  ;

with that condition.

On September 15, 1989, a Limiting Condition for operation (LCO) log l entry was written because repairs were needed on the Reactor  !

Recirculation Pump "A" Seal Inboard-Containment Isolation Valve, -j B31-F014A. A work request was generated to perform the repairs during -!

the refueling outage. B31-F020 was used as an isolation boundary for-the work starting in October of 1989 During the time the work was in progress, the valve could not be cycled. On November 10, 1989, surveillance test 24.138.02, " Reactor Recirculation Pumps Valve Operability Test", was performed. B31-F020 was being used as a protection boundary, therefore it' was unavailable for. stroke time testing. An addition was made to the LCO entry specifying that B31-F020 had to be stroke. time tested prior to placing the system in service.

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On November 23, 1989, the LOO tracking B31-F020 was combined with another 140 for work on the same system. When the log was rewritten, the new entry did not explicitly indicate that B31 F020 was out of service per Technical Specification 3/4.6 3 and the valve must be stroke time tested prior to placing the system in service. The critical date for completion of surveillance testing for B31-F020 was November 25, 1989, since the LCO entry was not explicit in regards to B31-F020's et,atus, it was allowed to expire without being noted as a restriction to changing modes. Entry into Operational Condition 2 was made on Dtsenber 6, 1989, without B31-F020 being stroke time tested for operability.

Valve B31-F020, along with the inboard isolation valve at the same penetration, was used for an alternate sample path for primary coolant sampling for approximately 18 1/2 hours starting on December 18, 1989 The inboard isolation valve had been successfully tested already.

When the failure to complete the testing of B31-F020 was identified on December 20, 1989, the testing of the valve was successfully completed..

Cause of Eventt This event was caused by personnel error by Operations personnel 9

(licensed-utility) when combining the LCOs. The new LCO did not clearly ledicate that the isolation capability must be tested prior to entering Operational Condition 2.

A contributing factor to this was an inadequacy in the administrative procedure Eoverning LCOs which did not preclude the combining of LCOs orrequiretagpngoftheequipmentthatwasoutofservice.

Analysis of Eveit While the isolation valve had not been tested as required by Technical Specification 3/4.6.3 in order to prove it operable, it was functional '

during the time in question. This was demonstrated by the successful completion of the surveillance test when the problem was identified.

Therefore, this condition did not adwrsely impact the isolation capability of primary containment. Additionally, the redundant valve )

in the penetration had been tested and proven operable. The health i and safety of the public and plant personnel were not jeopardized by this condition.

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complete by the end of January of 1990. l t

The administrative procedure governing LCO's, NPP-0P1-11, is being revised to prohibit the combining of LCO's and to require tagging of f specific components that are out of service to enhance tracking of .

equipment status. This revision will be completed and any changes  !

1mplemented by March 31, 1990.  ;

Finally, Detroit Edison has developed an action plan as described in j

Detroit Edison letter NRC-89-0300, dated December 26, 1989. This action. plan addresses the personnel performance weaknesses discovered  !

during the first refueling outage and during the return to power  !

operation.

Previous Similar Events:- j i

This is the first instance where incorrect combining of Technical  !

Specification LCOs led to the failure to complete Technical Specification required testing. ,

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