ML18106A880

LER 98-013-00:on 980806,operation with TS Required Equipment OOS Was Noted.Caused by Human Error.Reviewed Processes & Practices Re Safety Sys Status Control,Procedure Rev & Extra Training.With 980908 Ltr

ML18106A880
Person / Time
Site:	Salem
Issue date:	09/08/1998
From:	BAKKEN A C, NAGLE J C Public Service Enterprise Group
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-98-013, LER-98-13, LR-N980426, NUDOCS 9809250106
Download: ML18106A880 (5)

Text

\ I w e Public Service Electric and Gas Company P.O. Box 236 Hancocks Bridge, New Jersey 08038-0236 Nuclear Business Unit U.S. Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 SEP 081998 LR-N9B0426 SALEM GENERATING STATION -UNIT 1 FACILITY OPERATING LICENSE NO. DPR-70 DOCKET NO. 50-272 Gentlemen

This Licensee Event Report entitled "Operation with Tech Spec Equipment Out of Service" is being submitted pursuant to the requirements of the Code of Federal Regulations 1OCFR50.73 (a)(2)(i).

Attachment JCN/ c Distribution LER File 3.7 9809250106 980908-PDR ADOCK 05000272 5 PDR The pm\*er is in your hands. Sincerely, General Manager. Salem Operations

' 1. 95-2168 REV. 6/94

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• NRC FORM 366 U.S. NUCLEAR REGUL..!A.Y COMMISSION (6-1998).

-LICENSEE EVENT REPORT (LER) (See reverse for required number of for each block) FACILITY NAME (I) SALEM GENERATING STATION UNIT 1 TITLE(4) APPROVED .B NO. 3150-0104 EXPIRES 06/30/2001 Estimated burd response to comply with this mandatory information collection request: 50 hrs. Reported lessons learned are incorporated into the licensin!;l process and fed back to industry.

Forward comments regarding burden estimate to the Records Management Branch (T-6 F33), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, and to the Paperwork Reduction Project (3150-0104), Office of Management and Budget, Washington.

DC 20503. If an information collection does not display a currently valid OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collectioa.

DOCKET NUMBER (2) PAGE(3) 05000272 1 OF 4 OPERATION WITH TECH SPEC REQUIRED EQUIPMENT OUT OF SERVICE 5) MONTH DAY YEAR YEAR 08 06 98 98 -013 OPERATING pecify in Abstract below or in NAME John CAUSE SYSTEM YES (If yes, complete EXPECTED SUBMISSION DATE). ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (16) 339-3171 EXPECTED MONTH DAY REPORTABLE TO EPIX YEAR On 8/6/98, during functional testing of the RlB radiation monitors, Control Room Emergency Air Conditioning System (CREACS) return air isolation damper (2CAA17) did not open, as required, when accident pressurization mode was tested. Investigation determined that the damper was pinned in the closed position.

The damper was promptly restored to operable condition.

Subsequent investigation determined that the damper had been pinned in preparation for maintenance activities on 8/3/98, based upon direction provided by a licensed operator.

This event was caused by human error due to inadequate procedural adherence.

Contributing causes included inadequate training on modifications which were made to the Control Area Ventilation System, and inadequate procedural guidance for the specific activity being performed and for pinning the dampers. Corrective actions to be completed include a review of processes and practices related to safety system status control, procedure revisions and supplemental training for both Licensed and non-licensed operators.

This event is reportable pursuant to 10CFR50.73(a)2(i) (B) any operation or condition prohibited by the plant's Technical Specifications.

1 .. \ 'I *'" NRC FORM 366A (6-1998) U.S. NUCLEAR GULA TORY COMMISSION LICENSEE EVENT REPORT (LER) TEXT CONTINUATION FACILITY NAME (1) SALEM UNIT 1 TEXT (If more space is required, use additional copies ofNRC Form 366A) (17) PLANT AND SYSTEM IDENTIFICATION DOCKET(2)

NUMBER(2) 05000272 Westinghouse

-Pressurized Water Reactor LER NUMBER (6) PAGE(J) YEAR I 2 OF 98 0 1 3 00 Control Area Ventilation, Control Room Emergency Air Conditioning System {VI/DMP}*

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• Energy Triol.i§'try Identification System { EIIS} codes and component function identifier codes appear as (SS/CCC) CONDITIONS PRIOR TO OCCURRENCE Prior to the occurrence, Salem Unit 1 was operating between 60% and 100% Power and Unit 2 was in Mode 5 at 0% power. DESCRIPTION OF OCCURRENCE During functional testing of the RlB radiation monitors at 0924 on 8/6/98, the Unit 2 Control Room Emergency Air Conditioning System (CREACS) return air isolation damper ( 2CAA1 7) dic;i not open, as required, when Accident Pressurization Mode was tested. Investigation revealed that the damper was pinned in the closed position.

The pin was removed from the 2CAA17 damper at 0950 on 8/6/98 and the damper was satisfactorily tested at 1004 on 8/6/98. Investigation determined that the 2CAA17 damper had been pinned in the closed position when the Control Area Ventilation (CAV) System was placed in the Maintenance Mode at 0450, on 8/3/98. The CAV system was restored.

to the Normal Mode at 1816 on 8/4/98 by personnel from a different shift, who did not realize the 2CAA17 damper had been pinned when the system was placed in maintenance mode. The requirement for system restoration merely confirms that the 2CAA17 damper is closed in the Normal Mode. Units 1 and 2 each supply a single train of the EAC system. The CAV System was placed in the Maintenance Mode on 8/3/98, in preparation for removing the Unit 2 "A" 230/460v AC bus from service which would render the Unit 2 EACs inoperable.

Procedure Sl.OP-SO.CAV-OOOl(Q), "Control Area Ventilation Operation" was used to perform this evolution.

The utility non-licensed operators performing the lineup and independent verification were uncertain if the 2CAA17 damper should be verified closed .remotely or closed and gagged locally. Therefore, a (Licensed) operator was consulted.

This operator determined that the 2CAA17 damper should be closed and gagged locally. Based on an inadequate understanding of the guidance in the CAV procedures related to securing the 1(2)CAA17 damper in the closed position, the Licensed operator directed that 2CAA17 damper be inappropriately secured in the closed position.

NRC FORM 366A (6-1998)

. ! " ., ', . ',/ -NRC FORM 366A (6-1998) U.S. NUCLEAR REGULA TORY COMMISSION FACILITY NAME (1) SALEM UNIT 1 LICENSEE EVENT REPORT (LER) TEXT CONTINUATION DOCKET(2)

NUMBER(2) 05000272 TEXT (//more space is required, use additional copies o/NRC Form 366A) (17) Description (continued)

LER NUMBER (6) PAGE (3) YEAR I SE=w-1 3 OF 4 98 0 1 3 00 Technical Specification 3.7.6, "Control Room Emergency Air Conditioning System" requires two independent air conditioning filtration trains (one from each unit). The installed pin rendered the Unit 2 return air isolation damper (2CAA17) inoperable which in turn caused the Unit 2 CREACS

--to be inoperable.

Therefore, Tech Specs requires alignment for single filtration operation within four hours. The 2CAA17 was inoperable without CREACS being aligned for single filtration operation for approximately 40 hours4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br />. CAUSE OF OCCURRENCE The root cause of this event was human error due to inadequate procedural adherence.

Contributing causes for this event included less than adequate training on the current CAV system design, less than adequate procedural guidance regarding securing the 1(2)CAA17 dampers in the closed position and less than adequate training on circumstances which warrant gagging (pinning) dampers. The instructions in the procedure related to gagging the 1CAA17 in the closed position were merely intended as additional information for locally positioning the damper in the event of an equipment failure. However, the procedure did not specify the conditions under which the damper should be gagged locally. In addition, the format/wording in the procedure implied that the damper was routinely required to be gagged in the closed position.

A further breakdown occurred in that there was a failure to hang an "Off-Normal" tag*on the damper in accordance with Procedure SC.OP-AP.ZZ-0103 "Component Configuration Control".

PRIOR SIMILAR OCCURRENCES 1997 and 1998 LERs were reviewed for similar occurrences.

Similar events of equipment being inadequately returned to service were identified in LERs 354/97-009, and 311/98-012.

These events involved maintenance personnel and were not recognized as programmatic in nature, therefore, the corrective actions would not. have precluded the occurrence of this event. SAFETY CONSEQUENCES AND IMPLICATIONS The 1 ( 2) CAAl 7 damper is required to open for either a fire outside the control room or during accident conditions in order to maximize air recirculation and limit the intake of outside air thus pressurizing the control area. The pin in the 2CAA17 would have prevented the damper from opening, causing an increased quantity of outside air to be drawn into the NRC FORM 366A (6-1998)

FACILITY NAME (1) SALEM UNIT 1 LICENSEE EVENT REPORT (LER) TEXT CONTINUATION DOCKET(2)

NUMBER(2) 05000272 TEXT (Jfmore space is required, use additional copies ofNRC Form 366A) (17) SAFETY CONSEQUENCES AND IMPLICATIONS (continued)

LER NUMBER (6) PAGE (3) NUMBER NUMBER YEAR I SEQUENTIAL I REVISION 4 OF 98 0 1 3 00 control room. The operators would have been alerted to the improper operation of this damper by status lights which indicate EACS in operation and damper positions.

4 Even though the outside air would pass through HEPA and charcoal filters, an increased*petential to adversely affect control room habitability may have existed. Analysis which was performed to support control room habitability is based upon single train operation and worst case source terms. A single train of EAC is sufficient to provide pressurization and support control room habitability.

Although highly unlikely, the increased intake in outside air could result in potentially exceeding the limit in General Design Criteria 19. During the time that the pin was installed the other* train of CREACS remained operable thus minimizing the potential consequences of this event. CORRECTIVE ACTIONS 1. As a result of this event and similar events identified above, a review of Nuclear Business unit programs and processes related to the control of safety system status will be performed to identify programmatic and organizational deficiencies that could compromise the ability of safety systems to carry out their design function.

As part of this review, the recommendations of INPO SOER 98-1 will be implemented. (PIR 980826176)

2. Procedures Sl/S2.0P-SO.CAV-0001(Q) will be revised to clarify the guidance related to securing the l/2CAA17 dampers in the closed position.

This action is scheduled for completion by 11/1/98. 3. Additional training on the current design and operation of CAV System will be covered in the current licensed operator requalif ication segment. This segment is scheduled for completion on 9/24/98. 4. Training on requirements and methods for gagging (pinning) dampers will be provided to non-licensed operators during the next requalification segment which is scheduled for Oct.12, 1998 to December 15, 1998. 5. The responsible individuals have been held accountable for human performance errors in accordance with Corporate policies.

NRC FORM 366A (6-1998) I

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