ML17223B170

LER 91-003-00:on 910426,2A Shutdown Cooling Heat Exchanger Out of Svc Due to Mispositioned Component Cooling Water Valve.Caused by Personnel Error.Valve Correctly Realigned & Redundant Train Valve checked.W/910430 Ltr

ML17223B170
Person / Time
Site:	Saint Lucie
Issue date:	04/30/1991
From:	LAUVER C, SAGER D A FLORIDA POWER & LIGHT CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
L-91-133, LER-91-003, LER-91-3, NUDOCS 9105060103
Download: ML17223B170 (9)

Text

ACCELERATEDDISTRIBUTIONDEMONS~TIONSYSTEMREGULATORYINFORMATIONDISTRIBUTIONSYSTEM(RIDS)'ACCESSIONNBR:9105060103DOC.DATE:91/04/30NOTARIZED:NOFACIL:50-389St.LuciePlant,Unit2,Flor'idaPower&LightCo.AUTH.NAMEAUTHORAFFILIATION,LAUVER,C.FloridaPower&LightCo.SAGER,D.A.FloridaPower&LightCo.~RECIP.NAMERECIPIENTAFFILIATIONDOCKET05000389

SUBJECT:

LER91-003-00:on910426,2Ashutdowncoolingheatexchangeroutof.svcduetomispositionedcomponentcoolingwatervalve.Causedbypersonnelerror.Valvecorrectlyrealigned&redundanttrain'svalvechecked.W/910430ltr.DISTRIBUTIONCODE:IE22TCOPIESRECEIVED:LTRJENCLJSIZE:,.TITLE:50.73/50.9LicenseeEventReport(LER),IncidentRpt,etc.1NOTES:ARECIPIENTIDCODE/NAMEPD2-2LANORRIS,JINTERNAL:ACNWAEOD/DOA.AEOD/ROAB/DSPNRR/DET/EMEB7ENRR/DLPQ/LPEB10NRR/DREP/PRPB11'RR/DST/SICB7ENRR/DST/SRXB8ERES/DSIR/EIBEXTERNAL:EG&GBRYCE,J.HNRCPDRNSICPOOREEWCOPIESLTTRENCL1111221122111122111111331111RECIPIENTIDCODE/NAMEPD2-2PDACRS~AEOD/DSP/TPABNRR/DET/ECMB9HNRR/DLPQ/LHFB11NRR/DOEA/OEABNRR/DST/SELB8DNRR/DST2LBBJ31RE0MRGN2FILE01LSTLOBBYWARDNSICMURPHY,G.ANUDOCSFULLTXT'COPIESLTTRENCL11221111111111111111111111DD'DNOTETOALL"RIDS"RECIPIENTS:DDPLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK,ROOMP1-37(EXT.20079)TOELIMINATEYOURNAMEFROMDISTRIBUTIONLISTSFORDOCUMENTSYOUDON'TNEED!FULLTEXTCONVERSIONREQUIREDTOTALNUMBEROFCOPIESREQUIRED:LTTR33ENCL33 P.O.Box128,Ft.Pierce,FL34954-0128FPLAPR30199'-91-13310CFR50.73U.S.NuclearRegulatoryCommissionAttn:DocumentControlDeskWashington,D.C.20555Gentlemen:Re:St.LucieUnit2DocketNo.50-389'ReportableEvent91-03DateofEvent:April26,19912AShutdownCoolingHeatExchangerOutofServiceDuetoMispositionedComponentCoolinWaterOutletValveCausedbPersonnelErrorTheattachedLicenseeEventReportisbeingsubmittedpursuanttotherequirementsof10CFR50.73toprovidenotificationofthesubjectevent.Asupplementalreportwillbesubmittedattheusual30daytimeinterval.Verytrulyyours,D.A.SgerVicesidentSt.LuciePlantDAS:GRM:kwAttachmentcc:StewartD.Ebneter,.RegionalAdministrator,USNRCRegionIISeniorResidentInspector,USNRC,St.LuciePlantDAS/PSLN4239g0c0rr0i03910430PDFADOCK0000~89PDR'"~~menFPLGroupcompany:.:.=t.287&gag FPLFacsilliICOI.NRCFNITT666<coyU.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)~AffNOIIOCAONO010041004000%4:lOtH0CSTNHITO000OOIPOIIKKOOCIODC040T00TNTN004Cf0AATTITIDCUECDITIIOITNCD0001000ICNWNCTCCINCNTCIKCNIIOCIITXNCTTAIATCTOTICICDITITTNONEIDNTCIWNAINICNIOIANGNI040ILIALIACITAlIKCIIATOIT~WANNNDDN.DCSXk4AIOTOTINPAOIACITIICDUGTIDNffCICCTI01NI4OC,CfINNCfWNAGTACNTNOILA0GCTWAONIGTDKDCIIIClFACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(2)PAGE3050003891004'(4)2AShutdownCoolingHeatExchangerOutofServiceDuetoMispositionedComponentCoolingWaterValveCausedbyPersonnelErrorEVENTDATE(5)LERNUMBER(6)REPORTDATE(7)OTHERFACILITIESINVOLVED(8)MONTHDAY0426YEAR91.91003YEARSIALMONTHDAY00430YEAR91FACILITYNAMESN/AN/ADOCKETNUMBER(S)50005000.OPERATINGMODE(9)POWERLEVEL,(10)100201402(b)20.405(a)(1)(i)20.405(a)(1)(ii)20.405(a)(1)(iii)201405(a)(1)(iv)20.405(c)50.36(c)(1)50.36(c)(2)50.73(a)(2)(i)50.73(a)(2)(ii)50.73(a)(2)(iv)50.73(a)(2)(v)50.73(a)(2)(vii)50.73(a)(2)(viii)(A)50.73(a)(2)(viii)(B)~THISREPORTISSUBMITTEDPURSUANTTOTHEREQUIREMENTSOF10CFR:Checkoneormoreofthefollowin(11)73.71(b)73.71(c)OTHER(SpecifyinAbstractbeloIvandinTextNRCForm366A)20.405(a)(1)(v)50.73(a)(2)(iii)50.73(a)(2)(x)NAMELICENSEECONTACTFORTHISLER12CatherineLauver,ShiftTechnicalAdvisorTELEPONENUMBERAREACODE407465-3550COMPLETEONELINEFOREACHCOMPONENTFAILUREDESCRIBEDINTHISREPORT13CAUSESYSTEMCOMPONENTMANUFAC-TURERBEISVP340REPORTABLETONPRDSCAUSESYSTEMCOMPONENTIIIREPORTABLETONPRDSSUPPLEMENTALREPORTEXPECTED14YES(Ifyes;completeEXPECTEDSUBMISSIONDATE)NOEXPECTEDMONTHDAYYEARSUBMISSIONDATE(15)05269ABSTRACT(Limittof400spaces.i.e.approximatelyfifteensingle-spacetypewrittenlines)(16)Thisisaninterimreport.Afollowupreportwillbesubmitted.Correctiveactionsinclude:thevalvewascorrectlyrealigned;theredundanttrain'svalvewaschecked;bothunitsperformedafullValveStatusCheck.At0110onApril26,1991,withUnit2at100%power,OperationspersonnelbegansearchingforaDCground.At0400,perplantprocedure,OperationscycledHCV-14-3A,ComponentCoolingWater(CCW)outletfromthe2AShutdownCooling(SDC)HeatExchanger(HX)tode-energizeitssolenoidoperatorinanefforttolocatetheDCground.Afterthevalveopened,noflowthroughtheheatexchangerwasindicated.Uponinvestigation,the2ASDCHXCCWreturnisolationvalveSB-14365wasfoundtobelockedclosed.ThisvalveisrequiredtobeLockedOpen.IthadbeenenteredintotheValveSwitchDeviationLogonOctober23,1990asLockedThrottledandrestoredNovember29,1990.Asthisisthemostrecentdocumentedmanipulationdate,itisassumedtohavebeenmispositionedatthistime.Thevalvepositionpointerwasbrokenandindicatedopen.Thecauseofthemispositioningisunderinvestigation.FPLFacsimileofNRCForm366(6-89)

FPLFacslmraorNROForm666(6-69)~U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUATIONASSASNTOCAOISA$1500105EITfsabaAITI505ssrsfATTOusTWNseatKspQNscTocCANLTwlTHTNsssofsfATcNSouseTISHMOICST:500ISTSICONf505CASAOITSfNCAIONOTASSXNSafWATSTOTINraxSSIiNetcSCTTTSuuNAmSNTTNANCH5Caaua55ASSNTNSOAATNTTofaIASNSNwAsHNCION.oc505faNclToTIcsfsTIINcfNMTTucllQHNT55'ciI'150010150frICCofIMWdDCNfAIST55$5CCTWNSINSTTSAOC5050$FACILITYNAME(1)DOCKETNUMBER(2)LERNUMBER(6)PAGE(3)St.LucieUnit205000389YEAR91EQUENTIALNUMBER003REVISIONNUMBER0002004TEXT(Ifmorespaceisreriuired,useadditionalNRCForm366A's)(17)Thisisaninterimreport.AfollowupreportwillbesubmittedAt0110onApril26,1991,withUnit2at100%power,OperationspersonnelbegantosearchforaDCground.Tofindaground,planttoadsareindividuallyisolated.Perplantprocedure,OperationscycledHCV-14-3A,ComponentCoolingWater(CCW)(EIIS:CC)fromthe2AShutdownCooling(SDC)HeatExchanger(HX)(EIIS:BP).Duringnormaloperationsthereisnoflowthroughtheshutdownheatexchanger;openingthevalveshouldhaveresultedin4000gpmflow.TherewasnoflowindicatedthroughtheHX.Operations.locallyverifiedmovementofHCV-14-3AandpositionofCCWinletisolationvalveSB-14348.CCWoutletisolationvalveSB-14365isrequiredtobeLockedOpen,wasindicatingopenbyitsvalvepositionindicator,butwasinfactLockedClosed.Thevalvewasreopenedtoitsproperposition.Theredundanttrain'sCCWoutletisolationvalvepositionwascheckedasaprecaution.ThevalvewasinitsproperLockedOpenposition,butitspositionindicatorwasalsofaulty.AninvestigationrevealedthatSB-14365wasenteredintotheValveSwitchDeviationLogonOctober23,1990,whenplacedinaLockedThrottledpositiontobalanceCCWflow.OnNovember25,1990,asUnit2wascompletingarefuelingoutage,theCCWsystemwasplacedinitsoperatingalignment.OperatingProcedure2-0310020,"ComponentCoolingWater-NormalOperation,"wasperformed.SB-14365wasverifiedtobeLockedOpenatthistime;OnNovember29,1990,theValveSwitchDeviationLogshowedthatthevalvewasrestoredtoitsLockedOpenposition.AsNovember29isthelastrecordeddatethatSB-14365wasmanipulated,itisassumedthatthevalvehasbeenmispositionedsincethistime.ThelackofanOPERABLE2ASDCHXcausesthe2AtrainoftheContainmentSpraySystem(EIIS:BE)tobeadministrativelyoutofservice.From0455onFebruary19through0315onFebruary20and2208onFebruary20through1700onFebruary21,1991,the2BContainmentSpraySystemwasoutofserviceforroutinemaintenanceandtesting.PlantrecordsarebeingreviewedtoseeifthereareanyotherperiodsoftimewherebothtrainsoftheContainmentSpraySystemwereoutofservice.CCWoutletisolationvalveSB-14365isamanuallyoperatedbutterflyvalvelocatedinahorizontallineabouttwelvefeetabovethefloor.Valvepositionindicationisprovidedbyapointerwhichissupposedtomovewiththevalvestem.Thepointerwasbroken.APlantWorkOrderwaswrittenOctober21,1990torepairthepointerandwasapparentlyworkedJanuary17,1991.Atthetimethemispositioningwasdiscovered,thepointererroneouslyindicatedOpen.Investigationintothisvalvepositionindicatorfailurewillcontinue.AStandingNightOrderstatesthattocheckthepositionofaLockedOpenvalve,thevalveshallbeunlocked,closedslightly,reopened,andrelocked.Whilethepositionindicatedbythepointerwasinaccurateandmisleading,thehandwheelonthevalveindicateswhichwaytoturntoopenthevalve.SinceNovemberof1990,thepositionofthisvalvehasbeencheckedtwiceduringthequarterlyperformanceofAdministrativeProcedure2-0010123,"AdministrativeControlofValves,Locks,andSwitches,"andweeklyduringAdministrativeProcedure2-0010125A,"SurveillanceDataSheets,"FPLFacsimileofNRCForm366(6-69)

FPLFccEIIIIAIolNR"Form666(649)VU.S.NUCLEARREGUlATORYCOMMrsslONLICENSEEEVENTREPORT(LER)'EXTCONTINUATIONAPPICNTOCAONCk$100010IEPIKR00000ECIPNCTo$$oENPETIfKSPCtSEToCIEPETPRIITIICISPÃNAATEPICOUECCIPIIET$ECP.$1$100$RANNOCOWRIEIKCAfoRCRTeolECTCIATEToTIEIECOT$$NoIEPOlr$NANIEIEIITNNN001+0$EoCIAAEEAEIKOAATCAP~~.ocPEN,~TooEP~RoccRPRE0EETI$1$001000cffcEcPMNIAEEAENTAIAMxET,sEIPATlcRcc$050$FACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(2)YEAR0500038991LERNUMBER(6)EQUENTIALNUMBER003REVISIONUMBER00PAGE(3)03004TEXT(lfmorespaceisrequired,useadditionalNRCForm366A's)'17)...DataSheet36,IAtalltimesitwasreportedtobeLockedOpen.Therootcauseoftheeventisunderinvestigation.Areviewofplantrecords,includingoperatorlogs,clearances,andPlantWorkOrders,isbeingconducted.Personnelwillbeinterviewedtodeterminethespecificnatureandcauseoftheerror.AnINPOHumanPerformanceEnhancementSystemevaluationwillalsobeperformed.VNTThiseventisreportableundertherequirementsof10CFR50.73.a.2.i.B,anyconditionoroperationprohibitedbyTechnicalSpecifications.TechnicalSpecification3.6.2.1"ContainmentSpraySystem"requirestwoindependentContainmentSpraySystemstobeOPERABLEwithanOPERABLEShutdownCoolingHeatExchanger.AWhiletheexactdateofthemispositioningoftheCCWoutletisolationvalvetothe2ASDCHXisnotyetknown,November29,1990isthelastrecordeddateofamanipulationofthevalveandisassumedtobethedateofthemispositioning.OverathreedayperiodinFebruary1991,the2BContainmentSpraySystemwastakenoutofserviceforroutinemaintenanceandtesting.TheSDCHXisnotuseduntiltherecirculationphasefordecayheatremoval.The2AContainmentSpraySystemwasalwaysavailabletoreceivecoolwaterfromtheRefuelingWaterTankanddeliverittocontainmenttomitigateapost-LOCAcontainmentpressurerise.AnalternatesafetysystemforContainmentHeatRemoval,theContainmentCoolingSystem,isbeingfurtherevaluatedfordecayheatremovalcapability.St.Lucieequipmentsizingissuchthatthefourcontainmentfancoolerswillprovidethecontainmentheatremovalcapabilitynecessarytolimitandreduceaccidentcontainmentpressureandtemperatureduringtherecirculationphase.Additionalanalysisareinprogress,assumingasinglefailure,todemonstratethattwocontainmentfancoolerscanalsoremoveLargeBreakLOCAcontainmentheatloadduringtherecirculationphase.ThisresultisexpectedbecauseofthePSLcontainmentdesigninwhichthefreestandingsteelvesselwilltransferheattotheenvironment.FPLEngineeringhasperformedafirstorderriskassessmentoftheCCWtotheSDCHXvalvebeingintheclosedposition.ForamediumorlargebreakLOCA,thefrequencyassociatedwiththelossofthedecayheatremovalfunctiononlyincreasesfrom3.6E-8perreactoryearwithanormalSDCHXlineup,to5.8E-7perreactoryearwiththeshutdownheatexchangerisolated.Withoperatoractiontoopenthevalve,thefrequencyisreducedto1.5E-7perreactoryear.Therefore,thehealthandsafetyofthepublicwasnotaffectedduringthiscondition.FPLFacsimileofNRCForm366(6-89)

"tIII FPLFocsIITS'ATo.'RCForm666(649)U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)TEXTCONTINUAllON0FFFHOFCOCAOIASSH0410lCSFSHO:AOWTCNSIATtOOACIHFCHFKSFCSOCTOCCAOSTWOHTIESSFOFSAATCIOOUECSOIFCCACSv:a4WTSFCHA1AIOCCAACTOSFHOAFOWOHASHHtSISAAICTOHCFCOrftfSFIATFCFOITSNQACCAASITOIAHCHIF4$$OOSrrltARFHOAAIOHT00$40$CAIWAOOHOCW.OCTlÃOLFFSTToSICFFCFFINASWSDVCOCHFFTSCCT($110410ASCfFISCOFAAOCACTITAFOIIAXCT,WASHHOTOAOCSH0$FACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(2)YEARLERNUMBER(6)EQUENTIALNUMBERREVISIONNUMBERPAGE(3)0500038991TEXT(Ifmorespaceisrerluired,useadditionalNRCForm366A's)(17)00300040041.OperationsrestoredSB-14365toitsproperpositionandverifiedthepositionoftheredundanttrain'sCCWoutletisolationvalve.2.PlantWorkOrdersweresubmittedtorepairthefaultypointersoneachvalveanddeterminetherootcauseofthefaultypointer.3.AllOperationspersonnelwerecounseledontheuseoftheStandingNightOrder.Operationsisinvestigatingfurthermethodstoenhanceindependentverification.4.OperationsperformedtheentireWeeklyValveStatusCheckonbothUnit1andUnit2.Nofurtherdiscepancieswerenoted.5.AnINPOHumanPerformanceEnhancementSystemevaluationwillbeperformedonthisevent.'hereviewwillincludehumanfactorsandworkconditions.AffectedComponentIdentification:HenryPratt14HButterflyValveNuclearMKIIwithManualOperatorMDT-3HWModelNumber100178SerialNumberC140PreviousSimilarLicenseeEventReports:335-89-002"Inoperable1BDieselGeneratorDuetoFuelOilSystemValveMisalignment"335-87-012"LossofComponentCoolingWaterRedundancy-1Aand1BComponentCoolingWaterCross-tieValvesinOpenPosition"FPLFacsimileofNRCForm366(6-69)