05000311/LER-1996-015-02, :on 961219,breach of Containment Closure During Core Reload Occurred.Caused by Inadequate Inplementation of Outage Scheduling & Risk Management Requirements.Containment Closure Was Reestablished Using Alternate Isolation Poi

:on 961219,breach of Containment Closure During Core Reload Occurred.Caused by Inadequate Inplementation of Outage Scheduling & Risk Management Requirements.Containment Closure Was Reestablished Using Alternate Isolation Points

ML18102A777
Person / Time
Site:	Salem
Issue date:	01/19/1997
From:	Hassler D Public Service Enterprise Group
To:
Shared Package
ML18102A776	List: 05000311/LER-1996-015, Forwards LER 96-015-00,documenting Event That Occurred at Salem Generating Station,Unit 2 on 961219.Commitments Made within Ltr,Listed 05000311/LER-1996-015-02, :on 961219,breach of Containment Closure During Core Reload Occurred.Caused by Inadequate Inplementation of Outage Scheduling & Risk Management Requirements.Containment Closure Was Reestablished Using Alternate Isolation Poi
References
LER-96-015-02, LER-96-15-2, NUDOCS 9701270047
Download: ML18102A777 (4)

LER-1996-015, on 961219,breach of Containment Closure During Core Reload Occurred.Caused by Inadequate Inplementation of Outage Scheduling & Risk Management Requirements.Containment Closure Was Reestablished Using Alternate Isolation Points

Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2)(v), Loss of Safety Function 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
3111996015R02 - NRC Website

text

'f Nl~CF~M386 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150-0104 (4-05)

EXPIRES 04130198 ESTIMATED BURDEN l'EA REaPONaE TO COIFl.Y WITH THIS MANDATORY INFORMATION COLLECTION REQUEST: 50.0 HRS.

LICENSEE EVENT REPORT (LER)

REPORTED LESSONS LEARNED ARE INCORPORATED INTO THE LICENSING PROCESS AND FED IMCK TO INDUSTm'.

FORWARD COlllENTS REGARDING BURDEN ESTIMATE TO THE INFORMATION (See reverse for required number of AND RECORDS MANAGEMENT BRANCH (T.. =

U.S. NUCLEAR REGULATORY COWISSION~ASHINGTON, DC rlll 0001~D TO digits/characters for each block)

THE PAPERWORK REDU l"ROJECT c;'llCMHM),

E OF lllANAOEMENT AND BUDGET, WASHINGTON, 20ll03.

FACILITY NAME (1)

DOCKET NUMBER (2)

PAGE(3)

SALEM GENERATING STATION UNIT 2 05000311 1 OF 4 TITl.E (4)

BREACH OF CONTAINMENT CLOSURE DURING CORE RELOAD EVENT DATE (5)

LER NUMBER (8)

REPORT DATE (7)

OTHER FACILITIES INVOLVED (8)

YEAR I FACILITY NAME uuCKET NUMBER MONTH DAY YEAR SEQUENTIAL

'REVISION MONTH DAY YEAR NUMBER NU118ER 05000 12 19 96 96 015 00 01 19 97 FACIUTT NAME UQ1;;KET NUMBER OPERATING 6

THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR §: (Check one or more) (11)

MODE(9) 20.2201(b) 20.2203(a)(2)(v) x S0. 73(a)(2)(i)

S0. 73(a)(2)(vlll)

POWER 000 20.2203(a)(1) 20.2203(a)(3)(1)

S0. 73(a)(2)(ii)

50. 73(a)(2)(x)

LEVEL(10) 20.2203(a)(2)(i) 20.2203(a)(3)(ii)

S0. 73(a)(2)(iii) 73.71 20.2203(a)(2)(il) 20.2203(*)(4')

S0. 73(a)(2)(iv)

OTHER 20.2203(a)(2)(iii)

S0.38(c)(1) 50.73(a)(2)(v)

~~In Abetract below or In C Form 388A

~

20.2203(a)(2)(iv) 50.38(c)(2)

50. 73(a)(2)(vii)

LICENSEE CONTACT FOR THIS LER (12)

NAME TELEPHONE NUMBER (Include Ana Code)

Dennis v. Hassler, LER Coordina.tor 609-339-1989 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)

CAUSE

SYSTEM COMPONENT MANUFACTURER REPORTABLE ~*l:

CAUSE

SYSTEM COMPONENT MANUFACTURER REPORTABLE TO NPRDS

~ "~~*

TONPRDS

~:

m~=

=:s:*=:::~*:-:::::~~~~= I SUPPLEMENTAL REPORT EXPECTED (14)

EXPECTED MONTH DAY YEAR IYES XINO SUBMISSION (If yea, complete EXPECTED SUBMISSION DATE).

DATE (15)

ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (16)

Containment closure was established at Salem Unit 2 at 2325 on December 15, 1996.

Containment closure was fully adequate at that time.

Salem Unit 2 entered Mode 6 at 0220.

on December 16, 1996 and fuel movement for core reload was corrmenced.

At 1005 on December 19, 1996 the Senior Nuclear Shift Supervisor (SNSS) was informed by an NRC Resident Inspector that valve 24SW223 was removed from the Service Water piping in the penetration area of Salem Unit 2. The SNSS initiated a review of the tagging boundary for 24 containment Fan Coil Unit (CFCU) which confirmed that valve 24SW223 had been removed from the Service Water piping and a pathway from the Containment atmosphere to the outside atmosphere existed through open vent and drain valves inside Containment and the open piping outside Containment.

At 1018 the SNSS suspended fuel movement.

Further penetration walkdowns identified holes drilled into the Service Water piping for 21 and 24 CFCUs, which constituted additional breach pathways.

The causes of this occurrence are attributed to inadequate implementation of outage scheduling and risk management requirements and inadequate review of work in progress as required by the Containment closure procedure.

Corrective actions include re-establishing containment closure, procedure revisions, and iroplementation controls related to the authorization and scheduling of work.

This event is reportable in accordance with 10 CFR 50.73(a) (2) (i) (B), any condition prohibited by the plant's Technical Specifications.

9701270047 970119 PDR ADOCK 05000311 S

PDR

NRC Fc>Rll 388A U.S. NUCLEAR REGULATORY COMMISSION (4.96)

LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION FACILITY NAllE (1)

DOCKET NUMBER (2)

SALEM GENERATING STATION UNIT 2 05000311 TEXT (If more apace la required, use additional copies of NRC Form 388A) (17) r

PLANT AND SYSTEM IDENTIFICATION

Westinghouse -

Pressurized Water Reactor Containment {-/NH}*

Service Water System {-/BI}

LER NUMBER 1 8)

YEAR I SEQUENTIAL NUMBER REVISION NUMBER 96 -

015 00 PAGE(3) 2 OF 4

• Energy Industry Identification System (EIIS) codes and component function identifier codes appear as {CC/SS}

CONDITIONS PRIOR TO OCCURRENCE At the time of occurrence, Salem Unit 2 was in Mode 6 with fuel movement in progress.

DESCRIPTION OF OCCURRENCE Containment closure was established at Salem Unit 2 at 2325 on December 15, 1996.

Containment closure was fully adequate at that time.

Salem Unit 2 entered Mode 6 at 0220 on December 16, 1996 and fuel movement for core reload was commenced.

At 1005 on December 19, 1996 the Senior Nuclear Shift Supervisor (SNSS) was informed by an NRC Resident Inspector that valve 24SW223 was removed from the Service Water piping in the penetration area of Salem Unit 2.

The SNSS initiated a review of the tagging boundary for 24 Containment Fan Coil Unit (CFCU) which confirmed that valve 24SW223 had been removed from the Service Water piping and a pathway from the Containment atmosphere to the outside atmosphere existed through open vent and drain valves inside Containment and the open piping outside Containment.

At 1018 the SNSS suspended fuel movement.

Further penetration walkdowns identified holes drilled into the Service Water piping for 21 and 24 CFCUs, which constituted additional breach pathways.

The initial breach of Containment occurred on December 16, 1996 (day shift),

when maintenance workers began installation of a modification which required drilling pilot holes into the Service Water piping for 21 CFCU.

This action established a breach of the Containment boundary through the open vent and drain valves located within the Containment and a pilot hole located between the Containment and valve 21SW223.

A second breach of Containment occurred on December 17, 1996 when valve 24SW223 was removed from the Service Water piping for 24 CFCU to facilitate replacing the valve internals.

This presented a second breach of the Containment boundary through the open vent and drain valves located within the Containment and the open piping where valve 24SW223 had been removed.

A third breach of Containment occurred on December 19, 1996, when maintenance workers drilled pilot holes into the Service Water piping for 24 CFCU.

This was performed as part of the same modification identified for the 21 CFCU above.

'.)

NRC FORM 388A (4-96)

U.S. NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION FACILITY NAME (1)

DOCKET NUMBER (2)

LER NUMBER (8)

SALEM GENERATING STATION UNIT 2 05000311 YEAR I SEQUENTIAL I REVISION NUMBER NU11BER 96 -

015 -

00 TEXT (If more space is required, use additional copies of NRC Form 386A) (17)

DESCRIPTION OF OCCURRENCE (Cont'd)

PAGE(3) 3 OF The work described above was authorized prior to Containment closure; however, the work was delayed due to scheduling and plannning conflicts.

The effect of the schedule delays was not reviewed for impact based on exist1ng plant conditions.

CAUSE OF OCCURRENCE 4

The causes of this occurrence are attributed to inadequate implementation of scheduling and outage risk management requirements and inadequate review of work in progress as required by the Containment closure procedure.

PRIOR SIMILAR OCCURRENCES In the past two years there was one similar occurrence.

LER 311/94-013-00 documented a containment breach which involved eight (8) open vent valves and eight (8) open drain valves on the Service Water piping of four CFCU loops.

The cause was stated as personnel error and the corrective actions addressed personnel performance.

SAFETY CONSEQUENCES AND IMPLICATIONS

The potential consequences of this event have been determined to be bounded by the results of an Engineering Evaluation which was performed to support irradiated fuel movement without control area ventilation charcoal filtration.

The results of that evaluation indicate that the whole body gamma dose, beta skin dose and thyroid dose at the control room air intakes are negligible compared to the respective limits.

Thus, the expected offsite doses after a postulated fuel handling accident in Containment would also be negligible.

The health and safety of the public was not affected.

CORRECTIVE ACTIONS

1. Fuel handling activities in the Containment were suspended and the Gate Valve in the fuel transfer canal was closed upon determination that a breach of.

Containment had occurred.

Containment closure was reestablished using alternate isolation points.

NRC FORM 388A (4-95)

U.S. NUCLEAR REGULATORY COMMISSION FACILITY NAME (1)

LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION DOCKETNUMBER(2)

LERNUMBER 8)

PAGE(3)

SALEM GENERATING STATION UNIT 2 05000311 YEAR I SE=~ := 4 OF 4

96 -

015 -

00 TEXT (If more space ia required, use additional copiea of NRC Form 368A) (17)

CORRECTIVE ACTIONS

(Cont'd)

2.

The following actions were taken prior to resuming fuel movement at Unit 2:

3.

4.

5.

6.

7.

8.

a)

Procedure S2.0P-ST.CAN-0007 "Refueling Operations - Containment Closure" was revised to incorporate posting of the penetration areas to restrict work in these areas during Core Alterations, and to provide clarification of criteria for determining that a system is intact.

In addition, the procedure was enhanced to specify a review of any work in progress work orders to clarify the intent of the work irt progress review.

b)

Procedure S2.0P-ST.CAN-0007 was re-performed (following revision) to verify containment closure.

c)

The tagouts possibly affecting Containment closure were reviewed in detail to ensure there was no further impact on Containment closure.

d)

Wor'k was stopped, and the work groups were directed to obtain authorization from the Work Control Center prior to resumption of work.

e)

Shiftly meetings between the Senior Nuclear Shift Supervisor and the work group supervisors were initiated. The meetings provide a mechanism to review planned work for the shift to ensure that current plant conditions support performance of the work.

The Shutdown Safety Plan System Score Card has been added to the key plant schedules to heighten personnel awareness to equipment required to be available for plant safety.

All approved outage work will be re-reviewed against the requirements of the Shutdown Safety Plan prior to Unit 2 entering Mode 4.

Required reading on this event will be issued to Operations, Outage Management and Planning and Scheduling personnel by January 25, 1997.

Outage Management and Planning and Scheduling personnel will be required to review the requirements of the Salem Outage Risk Management Program prior to Unit 2 entry into Mode 4.

A continuing training program will be developed for Outage Management and Planning and Scheduling personnel concerning the Outage Risk Management Program.

This will be complete prior to June 1, 1997.

The Unit 1 Containment closure procedure (Sl.OP-ST.CAN-0007) will be revised prior to its next use to address the changes noted above for the

" Unit 2 procedure.