ML17264A505

LER 96-003-01:on 960308,identified That Both Pressurizer PORVs Inoperable Concurrently Due to Disconnection of Flex Hose to Both PORV Actuators to Install air-sets for Benchset & Limit Switch Activities.Hpes Completed

ML17264A505
Person / Time
Site:	Ginna
Issue date:	05/17/1996
From:	ST MARTIN J T ROCHESTER GAS & ELECTRIC CORP.
To:
Shared Package
ML17264A506	List: ML17264A505 ML17264A507
References
LER-96-003, LER-96-3, NUDOCS 9605300010
Download: ML17264A505 (10)

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NRCFORM366(4-95)U.S.NLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)(Seereverseforrequirednumberofdigits/charactersforeachblock)AROVEDBYOMBNO.3160-0104EXPIRES04/30/96ESTIMATEDBURDENPERRESPONSEToCOMPLYWITHTHISMANDATORYINFORMATIONCOLLECTIONREQUEST:50.0HRS.REPORTEDLESSONSLEARNEDAREINCORPORATEDINTOTHELICENSINGPROCESSANDFEDBACKToINDUSTRY.FORWARDCOMMENTSREGARDINGBURDENESTIMATEToTHEINFORMATIONANDRECORDSMANAGEMENTBRANCHIT-6F33),U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON,DC20555-0001,ANDToTHEPAPERWORKREDUCTIONPROJECTFAGIUTYHAME(1)R.E.GinnaNuclearPowerPlantOOCKETNUMBER(2)05000244PAGE(3)1OF8rrLE(4)BothPressurizerReliefValvesInoperable,ResultsinConditionThatCouldHavePreventedFulfillmentofaSafetyFunctionEVENTDATE(5)LERNUMBER(6)REPORTDATE(7)OTHERFACILITIESINVOLVED(6)MONTHDAYYEARSEQUENTIALREVISIONNUMBERNUMBERYEARFACILITYNAMEOOCKETNUMBER0308OPERATINGMODE(9)POWERLEVEL(10)9600096-003-01051796FACILffYNAMEOOCKETNUMBER20.2201(b)20.2203(a)(1)20.2203(a)(2)(I)20.2203(a)(2)(ii)20.2203(a)(2)(iii)20.2203(a)(2)(iv)20.2203(a)(2)(v)20.2203(a)(3)(i)20.2203(a)(3)(ii)20.2203(a)(4)50.36(c)(1)50.36(c)(2)50.73(a)(2)(i)50.73(a)(2)(ii)50.73(a)(2)(iii)50.73(a)(2)(iv)X50.73(a)(2)(v)50.73(a)(2)(vii)50.73(a)(2)(viii)50.73(a)(2)(x)73.71OTHERSpecifyinAbstractbeloworinNRCForm366Armore)(11)HISREPORTISSUBMITTEDPURSUANTTOTHEREQUIREMENTSOF10CFRE:(CheckoneoNAMELICENSEECONTACTFORTHISLER(12)TELEPHONENUMBER(IrciudeAresCode)JohnT.St.Martin-TechnicalAssistant(716)771-3641COMPLETEONELINEFOREACHCOMPONENTFAILUREDESCRIBEDINTHISREPORT(13)CAUSESYSTEMCOMPONENTMANUFACTURERREPORTABLETONPRDSCAUSESYSTEMCOMPONENTMANUFACTURERREPORTABLETONPRDSSUPPLEMENTALREPORTEXPECTED(14)YES(Ifyes,completeEXPECTEDSUBMISSIONDATE).XNOEXPECTEDSUBMISSIONDATE(15)MONTHDAYYEARABSTRACT(Limitto1400spaces,i.e.,approximately15single-spacedtypawrinenlines)(16)OnMarch8,1996,withtheplantinMode3,itwasidentifiedthatbothpressurizerpower-operatedreliefvalveshadbeeninoperableconcurrently.Thisresultedintheplantbeinginaconditionthatcouldhavepreventedthefulfillmentofasafetyfunction,intheunlikelyeventthatasteamgeneratortuberuptureoccurredcoincidentwithalossofoff-sitepowerevent.Immediatecorrectiveaction(NastorestorebothPORVstooperablestatus.correctiveactiontopreventrecurrenceisoutlinedinNZ/g+g+gjg+Ig~gdonsvrtetregjfg~yjg96053000io9605i7PDRADCICK05000244SPDRNRCFORM366(4.95)

NRCFORM366A(4-95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)YEARSEQUENTIALREVISIONNUMBERNUMBER96-003-01,PAGE(3)2OF8TEXTllfmorespacelsrequired,useadditionalcopiesofNRCForm366Al(17)I.PRE-EVENTPLANTCONDITIONS:OnMarch8,1996,theplantwasinMode3(hotshutdown)asaresultofareactortripthatoccurredonMarch7,1996(reportedinLER96-002).(RefertoGinnaDocketNo.50-244,LER96-002.)Thereactorcoolantsystem(RCS)wasbeingmaintainedatatemperatureof547degreesFandapressureof2235PSIGinanticipationofplantstartup.Theopportunitytoperformmaintenanceandtestingonthetwopressurizer(PRZR)power-operatedreliefvalves(PORV)becameavailable.ThisworkneededtobeperformedtosupportenteringtheLowTemperatureOverpressureProtection(LTOP)conditionduringtheannualrefuelingoutage,whichwasscheduledtobeginApril1,1996.Conditionswerejudgedacceptabletoperformtheseactivitiesduringthisunplannedshutdown.TheseactivitiesconsistofadjustingandverifyingthepropervalvebenchsetforthetwoPORVs,andreadjustmentofvalvelimitswitches.(TheequipmentidentificationnumbersforthePORVsarePCV-430andPCV-431C.)TheInstrumentandControl(IRC)groupwasnotifiedthatthisworkwouldbeperformedwiththeRCSatnormaloperatingpressureof2235PSIG(withasaturationtemperatureinthePRZRofapproximately650degreesF).TheI(ltCgroupexpressedconcernsregardingpersonnelsafetyforworkingintheambienttemperatureconditionsthatexistedinthePRZRcubicleintheContainment(CNMT).Ameetingwasheld~todiscussIRCconcernsandtoreviewthegeneralplan.MaintenanceProcedureM-37.150(Copes-Vulcan/Blaw-KnoxAirOperatedControlValve'sInspectionandRefurbishment)waschangedtoallowworkonbothPORVsconcurrently,inconsiderationoftheheatstressinthePRZRcubicleinCNMT.TheControlRoomoperatorsacknowledgedthesechangestoprocedureM-37.150asacceptable,sinceitwastheirunderstandingthatevenwiththeprocedurechange,thePORVswouldremainoperablepertherequirementsofGinnaStationImprovedTechnicalSpecifications(ITS)LimitingConditionforOperation(LCO)3.4.11.ThiswasbasedontheirassumptionthatnitrogenwouldstillbeconnectedtothePORVactuatorsandavailabletoopenPORVs.Thus,theShiftSupervisordeterminedthatLCO3.4.11ConditionAandLCO3.4.11ConditionFdidnotapply,sincebothPORVsweretoremainoperable.Atapproximately1406ESTonMarch8,1996,theControlRoomoperatorsheldthecontrolswitchesforthePORVblockvalves(MOV-515forPCV-431C,andMOV-516forPCV-430)intheclosep'osition,withpoweravailabletothebreakerforeachMOV.Operatorsunderstoodthatinthisconfigurationtheseholdscouldberemoved,theblockvalvesopened,andthePORVscouldthenbeopened.DESCRIPTIONOFEVENT:A.DATESANDAPPROXIMATETIMESOFMAJOROCCURRENCES:oMarch8,1996,1455EST:Eventdateandtime.Airand'nitrogenisremovedfrombothPORVs.oMarch8,1996,1632EST:AirandnitrogenisrestoredtobothPORVs.NRCFORM366A(4-95)

NRCFORM366AI4-95)LICENSEEEVENTREPORT(LZR)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAMEI1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBERI6)YEARSEQUENTIALREVISIONNUMBERNUMBER96-003-01PAGEI3)3OF8TEXT(Ifmorespaceisrequired,useadditionalcopiesofNRCForm366AII17)0March8,1996:2018EST:AirandnitrogenisremovedfrombothPORVs.0March8,1996:2140EST:AirandnitrogenisrestoredtobothPORVs.0March8,1996:Discoverydate.March28,1996,1408EST:HavingbothPORVsinoperableundertheconditionsonMarch8,1996,isdeterminedtobereportabletotheNRC.0March28,1996,.1640EST:TheNRCOperationsCenterisnotifiedoftheeventsofMarch8,asper10CFR50.72(b)(2)(iii)(D).B.EVENT:OnMarch8,1996,theplantwasinMode3.ThebenchsetsandlimitswitchesforbothPORVswerebeingadjustedandverifiedperatemporarychangetoprocedureM-37.150,andtestedusingSurveillanceTestProcedurePT-2.6.5-SD(RCSOverpressureProtectionSystemPORVOperabilityVerification),whichverifiesthetimingofthePORVstrokeforLTOPrequirements.TheIRCtechniciansenteredtheCNMTatapproximately1445ESTonMarch8,toperformtheseactivities.Byapproximately1455EST,theflexhosethatsuppliesbothinstrumentairandnitrogentothePORVwasremoved(perchangedprocedureM-37.150)forbothPORVs.Inhindsight,thisactionmadebothPORVsinoperableconcurrently,andistheeventdateandeventtime.AtthecompletionoftheadjustmentstothebenchsetandlimitswitchesforeachPORV,theflexhosewasreconnected.Byapproximately1632ESTthiswascompleted(perchangedprocedureM-37.150)forbothPORVs.EachPORVwasstrokedbytheControlRoomoperatorsfromtheMainControlBoard(MCB).TheadjustmentsforbothPORVswereverifiedasacceptableperprocedurePT-2.6.5-SD(atapproximately1759EST).Operationssupervisionhadpreviouslydeterminedthat,sincethebenchsetwaschangedtodecreasetheclosingspringtensionofthePORVs,itwouldbeprudenttoperformaseatleakagecheckonthePORVspriortothecompletionofthemaintenancepackage.Theholdsontheblockvalvecontrolswitcheswerethencleared.BothPORVswereverifiedtobeintheclosedpositionandblockvalveMOV-516(forPCV-430)wasstrokedopenatapproximately1803ESTfortheseatleakagetest.AsMOV-516strokedopen,asubstantialflownoisewasevidentinthePRZRcubicle,anditwasdiscoveredthatseatleakagethroughPCV-430wasinexcessofthepreviouslyobservedleakageofapproximately0;25gallonsperminute(GPM).SincethebenchsethadbeenchangedonbothPORVs,itwasdecidednottoperformaseatleakagetestonPCV-431CbyopeningMOV-515,andtoconservativelyassumethattheseatleakagethroughPCV-431CwascomparabletotheleakagethroughPCV-430.TheControlRoomoperatorsclosedMOV-516atapproximately1804EST,andinitiateddiscussionsconcerningPORVoperabilitywiththisseatleakage.NRCFORM366AI495)

NRCFORM366A(495)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.s.NUCLEARREGULATORYCOMMISSIONFACILITYNAME(1)R.E.GinnaNuclearPowerPlantOOCKET05000244LERNUMBER(6)YEARSEQUENTIALREVISIONNUMBERNUMBER96-003-01PAGE(3)4OF8TEXTilfmorespeceisrequired,useeddirionelcopiesofNRCForm366Ai(17)SubsequenttothelhCtechniciansexitingtheCNMT,detailsoftheactivitieswerediscussedbetweentheIRCtechnicianswhohadperformedtheactivitiesinsidethePRZRcubicleinCNMTandmembersoftheplantstaff.Laterthatevening,membersoftheplantstaffthenrealizedthat,duringthebenchsetactivities,thenitrogensupplyhadbeendisconnectedtobothPORVsconcurrently.Therefore,thediscoverydateisMarch8,1996,lateintheevening.WithbothPORVsinoperable,LCO3.4.11ConditionFrequiresthatimmediateactionbeinitiatedtorestoreatleastonePORVtooperablestatus.However,withnitrogenbeingrestoredtothePORVsatapproximately1632EST,thePORVswereoperableinaccordancewithLCO3.4.11atthetimeofdiscovery.Duringtheperiodof(undeclared)PORVinoperability,LCO3.4.11RequiredActionF.3wasnotmetinthatpowerfortheassociatedblockvalvewasnotremoved.ActivitiesneededtoreducethePORVseatleakagewerereviewed.Theleakageindicationswerereevaluatedbyplantstaff.PreliminaryestimatesindicatedthatleakagewasgreaterthantheRCSoperationalleakageoften(10)GPMidentifiedleakage,asspecifiedbyLCO3.4.13.Atapproximately1940ESTonMarch8,bothPORVsweredeclaredinoperable,solelyduetotheirinabilitytomeettheRCSoperationalleakagelimitsofLCO3.4.13.ActionsweretakenasspecifiedbyLCO3A.11ConditionF.Sincetheblockvalveswerealreadyclosed,theblockvalvecontrolswitchesandbreakerswereheld,andeffortstorestorePORVseatleakagetolessthan10GPMbegan,inaccordancewithLCO3.4.11RequiredActionF.1.TheIRCtechnicianscompletedthereadjustmentstobenchsetandreadjustedthelimitswitchesforthePORVsasperprocedureM-37.150.TheholdswereremovedfromtheblockvalvecontrolswitchesandbreakersusingtheguidanceofLCO3.0.5.Theblockvalveswerestrokedasneeded,andthePORVsweretestedusingprocedurePT-2.6.5-SD.BothPORVsdemonstratedacceptableperformance.Acheckofseatleakagewasconducted,andleakagewasevaluatedtobelessthan10GPM.ThePORVswerethendeclaredoperableatapproximately0123ESTonMarch9,1996,andreturnedtoservice.Uponfurtherevaluationlaterinthemonth,itwasidentifiedthatthenitrogensupplytobothPORVshadbeenconcurrentlydisconnectedontwoseparateoccasionsonMarch8.ThisrenderedthePORVsinoperableperLCO3.4.11eachtime,foracombineddurationofapproximatelylessthanthree(3)hours,withoutbeingdeclaredinoperable.C.INOPERABLESTRUCTURES,COMPONENTS,ORSYSTEMSTHATCONTRIBUTEDTOTHEEVENT:NoneD.OTHERSYSTEMSORSECONDARYFUNCTIONSAFFECTED:NoneNRCFORM366A(4-95)

NRCFORM366A(4-95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)ARSEQUENTIALREVISIONNUMBERNUMBER96-003-01PAGE(3)5.OF8TEXT(Ifmorespaceisrequired,useadditionalcopiesofNRCForm366AI(17)METHODOFDISCOVERY:TheconditionofthePORVswasinvestigatedafterafailedseatleakagecheck.Duringdiscussionsbetweenl&Candplantstaff,membersoftheplantstaffbecameawareofthefullscopeoftheworkthathadbeenperformedduringthebenchset,andthatthePORVshadactuallybeeninoperableduringthebenchsetactivities.ThisinformationwassubsequentlyrelayedtotheShiftSupervisorduringtheeveningofMarch8,1996.F.OPERATORACTION:TheControlRoomoperatorsnotifiedhighersupervision.NuclearSafetyandLicensing(NS&L)wasalsoconsultedconcerningtheseatleakagethroughthePORVs.Thesediscussionsalsoincludedareportabilitydiscussion,butfocusedonthereportabilityofPORVseatleakage.TheControlRoomoperatorsdeclaredbothPORVsinoperable,solelyduetotheirinabilitytomeettheRCSoperationalleakagelimitsofLCO3.4.13whiletheblockvalvewasopen,andisolatedthePORVsinaccordancewithLCO3.4.11ConditionF.Documentationwaspreparedtoinitiateareportabilityevaluation.Atapproximately1408ESTonMarch28,1996,plantstaffdeterminedthatanon-emergencyfourhournotification,per10CFR50.72(b)(2)(iii)(D),shouldbemadetotheNRCOperationsCenter.Thisnotificationwasmadeatapproximately1640ESTonMarch28,1996.G.SAFETYSYSTEMRESPONSES:NoneIII.CAUSEOFEVENT:A.IMMEDIATECAUSE:TheimmediatecauseofbothPORVsbeinginoperableconcurrentlywasduetothedisconnectionoftheflexhosetobothPORVactuatorstoinstallair-setsforthe,benchsetandlimitswitchactivities.RemovalofthisflexhoseremovedthesupplyofinstrumentairandnitrogentobothPORVs.B.INTERMEDIATECAUSE:Iinthisconfiguration,nitrogenwouldstillbeavailabletoopenPORVs.thatNRCFORM366A(4.95)

NRCFORM366A(4-95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAME(1)R.E.GinnaNuclear-PowerPlantDOCKET05000244LERNUMBER(6)YEARSEQUENTIALREVISIONNUMBERNUMBER96-003-01PAGE(3)6OFTEXT(Ifmorespaceisrequired,useeddirionelcopiesofNRCForm366AJ(17)C.ROOTCAUSE:AHumanPerformanceEnhancementSystem(HPES)evaluation'heNUREG-1022CauseCodeforthiseventIV.ANALYSISOFEVENT:AreportabilityevaluationwasperformedbyNSRL.NSRLidentifiedthattheconcurrentinoperabilityofbothPORVscouldhaverenderedtheplantunabletomitigatetheconsequencesofasteamgeneratortuberupture(SGTR)inaccordancewiththeWestinghouseanalysisofrecord,iftheSGTRhadoccurredcoincidentwithalossofoff-sitepowerevent.Thiseventisreportabieinaccordancewith10CFR50.73,LicenseeEventReportSystem,item(a)(2)(v),whichrequiresareportof,"Anyeventorconditionthatalonecouldhavepreventedthefulfillmentofthesafetyfunctionofstructuresorsystemsthatareneededto:...(D)Mitigatetheconsequencesofanaccident".BothPORVsinoperableundertheconditionsthatexistedonMarch8,1996,isaneventthatcouldhavepreventedRCSdepressurizationafteraSGTR,coincidentwithalossofoff-sitepowerevent.NRCFORM366A(4-95)

NRCFORM366A(4-95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAME(1)DOCKETLERNUMBER(6)PAGE(3)R.E.GinnaNuclearPowerPlant05000244YEARSEQUENTIALREVISIONNUMBERNUMBER7OF896-003-01TEXTllfmorespaceisrequired,useaddidonalcopiesofNRCForm366AJ(17)Anassessmentwasperformedconsideringboththesafetyconsequencesandimplicationsofthiseventwiththefollowingresultsandconclusions:TherewerenooperationalorsafetyconsequencesorimplicationsattributedtobothPORVsbeinginoperablebecause:oThePORVsserveastheLTOPprotectiondevicesduringconditionsoflowtemperatureintheRCS.Theplantdidnotenterconditionswherethisprotectionwouldhavebeenrequired.ThePORVsprovideadepressurizationpathforaSGTRwhennormalandauxiliaryPRZRsprayarenotavailable(duringalossofoff-sitepowerevent).Theplantdidnotenterconditionswherealossofoff-sitepoweroccurred.Thus,PRZRspraywasavailable.oIneitheroftheabovesituations,thePORVscouldhavebeenrestoredtoservicetosupporttheserequirements.Basedontheabove,itcanbeconcludedthatthepublic'shealthandsafetywasassuredatalltimes.V.CORRECTIVEACTION:A.ACTIONTAKENTORETURNAFFECTEDSYSTEMSTOPRE-EVENTNORMALSTATUS:0000ThebenchsetforeachPORVwasreadjustedtoreduceseatleakageandlimitRCSleakage.ThePORVlimitswitcheswereverifiedinthepropersetupandconfiguration.ThePORVsweretestedperprocedurePT-2.6.5-SD.ThesupplyofinstrumentairandnitrogenwasreconnectedtotheactuatorforeachPORV.ACTIONTAKENORPLANNEDTOPREVENTRECURRENCE:LessonslearnedhavebeenprovidedtoOperators,PORCIndependentReviewers,andMaintenancePlanners.2.TheHPESw(H-beQ~ggcompleted.3.AsupplementtothisLERwHI-be-g@6gjfpiubmittedbyMay17,1996.NRCFORM366A(4-95)

NRCFORM366A(4-95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)YEARSEQUENTIALREVISIONNUMBERNUMBER96-003-01PAGE(3)8OF8TEXTIifmorespaceisrequired,useaddidonalcopiesofPIRCForm366AI(17)",SEPXSSfSXA~NMX/i$%ÃÃAE~rN&NÃSEsVAAiWEKAXFf9FSÃ5$4PZP8ÃPYY8PP8EgfNJSrWXIÃrfENMW(rf@~~WNXXNfAiEAFWSWiiWÃcWIPPPPIEAÃSfXSXNEWSSSS(fkÃSSMY)EAWSXRWE~N)'AS~'EPXY~ISSSIEEWA/SEFSf/XYXKS)f&EYXHSWYAWPPPYPPPPPPPASCSKVESSFXSNxXESSNÃSAVI.ADDITIONALINFORMATION:A:FAILEDCOMPONENTS:NoneB.PREVIOUSLERsONSIMILAREVENTS:AsimilarLEReventhistoricalsearchwasconductedwiththefollowingresults:IWSÃAAMFW&SYYANÃ/VYKXS@SFKSXÃXYÃXYYWfiWEC.SPECIALCOMMENTS'oneNRCFORM366A(4-95) l'tl