LER-1982-017, Forwards LER 82-017/03L-0.Detailed Event Analysis Encl |
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March 15, 1982 J
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I Mr. James P. O'Reilly, Regional Administrator U. S. Nuclear Regulatory Commission 4
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101 Marietta Street, Suite 3100 1
Atlanta, Georgia 30303
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Re: McGuire Nuclear Station Unit 1
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Docket No. 50-369
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Dear Mr. O'Reilly:
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j Please find attached Reportable Occurrence Report R0-369/82-1.
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concerns T.S.3.5.1.2, "Each Upper Head Injection Accumulator System shall be operable with: a.
the isolation valves open....".
This incident was considered to be of no significance with respect to'the health and safety of the public.
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William O. Parker,.
i PBN/jfw Attachment j
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Office of Management and Program Analysis Institute of Nuclear Power Operations l
U. S. Nuclear Regulatory Commission 1820 Water Place j
Washington, D. C.
20555 Atlanta, Georgia 30339 Mr. P. R. Bemis i
Senior Resident Inspector-NRC McGuire Nuclear Station
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DUKE POWER COMPANY McGUIRE NUCLEAR STATION
' REPORTABLE OCCURRENCE REP 9RT NO. 82-17 RETORT DATE: March 15, 1982 FACILITY: McGuire Unit 1, Cornelius, NC IDENTIFICATION: The Upper Head Injection Portion of the Emergency Core Cooling System was Rendered Inoperable by the Closing of the Accumulator Discharge Isolation Valves
DESCRIPTION
At 1950 on February 12, 1982, while Unit I was operating at 50%
reactor power, control room alarms alerted operators of the closing of all four Upper Head Injection (UHI) accumulator discharge valves. Operators immediately tried to reopen the valves using control room manual actuators. Safety related Train A valves, NI-243A and NI-245A were successfully reopened, but the Train B valves, NI-242B aad NI-244B remained closed.
Noting a decreasing level in the UHI surge tank, an instrument line leak was suspected.
Investigation discovered an open-ended leak on an impulse line to UHI level switch NILS 5730, which was subsequently isolated. At 2039 the leak had been repaired, and NI-242B and NI-244B were reopened, restoring the system to its nornal configuration.
The occurrence resulted f rom the failure of a Parker-Hannifin fitting to hold an impulse line intact. The failure was apparently the result of an installation deficiency.
EVALUATION: The UHI system is independent of the remainder of the Safety Injection (NI) System.
It is designed to function in the blowdown phast of a loss of coolant accident during which UHI accumulator water delivery continues until actuation of the accumulator level switches. The level switches function to automatically close the UHI discharge '. alves to prevent injecting pressurized nitrogen (the driving force) into the reactor vessel. Thus, the safety function of the system is completely passive. The single active process involved is the isola' tion of the system at the end of the injection, when the system has ful-filled its design function. The additional cooling provided by the UHI System reduces the fuel temperature at the end of blowdown, thereby limiting the peak fuel temperature during the refill and reflood periods following blowdown.
In this event the impulse line leak rendered the UHI System inoperable. All four accumulator level switches actuated; Train A components, NILS 5720 and NILS 5740, operated to close valves NI-245A and NI-243A respectively; likewise.
l Train B components, NILS 5730 and NILS 5750, operated to close valves NT-244B and NI-242B. The valve arrangement is such that either train is capabic of isolating the water accumulator from the reactor vessel head.
The closing of the Train A valves as a result of a Train B instrument line leak was explained by the existance of a " crossover tube" which connects the Train A and Train B sensing lines within the accumulator.
Reportable Occurrence Report No. R0-369/81-171 described a related event which occurred on October 28, 1981.
In that event NI-242B and NI-244B were actuated as a result of a leak on a Train B level switch impulse line. The common train
Report No. 82-17 Page 2 level switches share the same sensing line, which allows a pressure loss o be felt at both instruments. The prior incident involved a much smaller leak in which the pressure loss was not transmitted through the train crossconnect to affect Train A componer.ts.
Both events involve the failure of similar Parker-Hannifin fittings at different locations on the same sensing line.
Parker-Hannifin fittings are used almost exclusively at McGuire and a number of failures have occurred. Of those failures, the large majority have been attributed to installation errors; failure to tighten the Parker-Hannifin nut properly (swage the line), and the installation of a reversed ferrule are the most common.
In this particular instance the repairing technician speculates that the fitting nut had not been properly tightened.
Personnel interviewed expressed a high degree of confidence in the fittings, "when they are installed correctly". With this in mind, a review of the appli-cable procedure was conducted. The procedure " Installation and Fbintenance of Instrument Line Fittings and Tubing" includes Parker-Hannifin fitting maintenance.
The procedure appears to be very complete and a contributing factor for the absence of recurring failures of particular fittings.
Self-loosening of fitting nuts was also considered as a possible mechanism for this failure.
Inspection of the system instrument lines revealed no noticeable vibration; therefore, this possibility seems remote.
Installation deficiency appears the most probable cause for the fitting failure.
At this point in McGuire's operating history, it is expected that the majority of these errors have been identified and corrected.
SAFETY ANALYSIS
The NI System was unchallenged during the event, therefore, the health and safety of the public were unaffected.
A failure of this type would not go unnoticed by the operators and appropriate action would be taken. The possibility of an instrument line failure coincident with a design basis accident is remote. The loss of the system concurrent with the design basis accident could cause an increase in the peak fuel temperatures.
CORRECTIVE ACTION
The impulse line between NILS 5730 and it's manifold valve was found disconnected from it's Parker-Hannifin fitting at the manifold valve.
The repair was made by reconnecting the line to the fitting and swagging the line. The repairing technician then loosened the fitting nut to check the threads for galling, and again tightened the fitting nut.
The line was tested for tightness and then rechecked for Icakage.
In an attempt to prevent recurrence of this incident, Parker-Hannifin fittings associated with UHI instrument lines have been verified installed correctly, in accordance with the procedure, " Installation and Maintenance of Instrument Line Fittings and Tubing".
This action was accomplished during the current Unit 1 outage.
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Report No. 82-17 Page 3 l
t Duke Power Company will analyze the significance of the physical connection of UllI instrumentation trains' relative to station design criteria to determine l
if any changes are necessary or desirable.
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| 05000369/LER-1982-001, Forwards LER 82-001/01T-0.Detailed Event Analysis Encl | Forwards LER 82-001/01T-0.Detailed Event Analysis Encl | | | 05000369/LER-1982-001-01, /01T-0:on 820106,routine Review of Source Document Changes Revealed Class H Piping in Fire Protection Sys in Diesel Generator Room 1A Routed Above One Nuclear safety-related Essential Cable & Instrument Panel | /01T-0:on 820106,routine Review of Source Document Changes Revealed Class H Piping in Fire Protection Sys in Diesel Generator Room 1A Routed Above One Nuclear safety-related Essential Cable & Instrument Panel | | | 05000369/LER-1982-002-03, /03L-0:on 820101,temp Sensing Valve Position Indication Disagreed W/Alternate Position Indication & Declared Inoperable.Caused by Environ Conditions | /03L-0:on 820101,temp Sensing Valve Position Indication Disagreed W/Alternate Position Indication & Declared Inoperable.Caused by Environ Conditions | | | 05000369/LER-1982-002, Forwards LER 82-002/03L-0.Detailed Event Analysis Encl | Forwards LER 82-002/03L-0.Detailed Event Analysis Encl | | | 05000369/LER-1982-003, Forwards LER 82-003/03L-0.Detailed Event Analysis Encl | Forwards LER 82-003/03L-0.Detailed Event Analysis Encl | | | 05000369/LER-1982-003-03, /03L-0:on 820102,average Temp in Upper Containment Was Reduced Below Temp Requirement.Caused by Cold Weather Cooling Bldg.Temp Increased Using Dihydrogen Recombiner Heaters | /03L-0:on 820102,average Temp in Upper Containment Was Reduced Below Temp Requirement.Caused by Cold Weather Cooling Bldg.Temp Increased Using Dihydrogen Recombiner Heaters | | | 05000369/LER-1982-004-03, /03L-0:on 820103,power Operated Relief Valve NC-32 Found Leaking.Cause Unknown.Insp of Valve to Determine Exact Nature of Component Failure Not Yet Possible.Block Valve Closed & de-energized to Prevent Inadvertent Opening | /03L-0:on 820103,power Operated Relief Valve NC-32 Found Leaking.Cause Unknown.Insp of Valve to Determine Exact Nature of Component Failure Not Yet Possible.Block Valve Closed & de-energized to Prevent Inadvertent Opening | | | 05000369/LER-1982-004, Forwards LER 82-004/03L-0 | Forwards LER 82-004/03L-0 | | | 05000369/LER-1982-005-03, /03L-0:on 820105,during Mode 1 Power Escalation, Small Seal on Lower Personnel Air Lock Auxiliary Bldg Failed to Open.Caused by Design Oversight by Door Manufacturer.Seal Replaced & Successfully Passed Leak Rate Test | /03L-0:on 820105,during Mode 1 Power Escalation, Small Seal on Lower Personnel Air Lock Auxiliary Bldg Failed to Open.Caused by Design Oversight by Door Manufacturer.Seal Replaced & Successfully Passed Leak Rate Test | | | 05000369/LER-1982-005, Forwards LER 82-005/03L-0 | Forwards LER 82-005/03L-0 | | | 05000369/LER-1982-006-03, /03L-0:on 820106,flow Gauge on Remote Auxiliary Shutdown Control Panel Indicated No Flow When Corresponding Control Room Gauge Read 100 Gpm.Caused by Water Leaking Into Differential Pressure Transmitter Electronics Housing | /03L-0:on 820106,flow Gauge on Remote Auxiliary Shutdown Control Panel Indicated No Flow When Corresponding Control Room Gauge Read 100 Gpm.Caused by Water Leaking Into Differential Pressure Transmitter Electronics Housing | | | 05000369/LER-1982-006, Forwards LER 82-006/03L-0 | Forwards LER 82-006/03L-0 | | | 05000369/LER-1982-007, Forwards LER 82-007/03L-0.Detailed Event Analysis Encl | Forwards LER 82-007/03L-0.Detailed Event Analysis Encl | | | 05000369/LER-1982-007-03, /03L-0:on 820111,many Instrument Lines Froze W/ Instruments Declared Inoperable Leading to Inadvertent Actuation of ESF Causing Safety Injection,Steamline Isolation & Reactor Trips.Caused by Cold Weather | /03L-0:on 820111,many Instrument Lines Froze W/ Instruments Declared Inoperable Leading to Inadvertent Actuation of ESF Causing Safety Injection,Steamline Isolation & Reactor Trips.Caused by Cold Weather | | | 05000369/LER-1982-008, Forwards LER 82-008/03L-0.Detailed Event Analysis Encl | Forwards LER 82-008/03L-0.Detailed Event Analysis Encl | | | 05000369/LER-1982-008-03, /03L-0:on 820115,exam of Programs on Operator Computer Revealed Equipment Run Time on Fuel Pool Ventilation Sys Exceeded Tech Specs W/O Sample Being Taken from Charcoal Absorber.Caused by Lack of Procedure | /03L-0:on 820115,exam of Programs on Operator Computer Revealed Equipment Run Time on Fuel Pool Ventilation Sys Exceeded Tech Specs W/O Sample Being Taken from Charcoal Absorber.Caused by Lack of Procedure | | | 05000369/LER-1982-009, Forwards LER 82-009/03L-0 | Forwards LER 82-009/03L-0 | | | 05000369/LER-1982-009-03, /03L-0:on 820116,during Review of Surveillance Documentation,Periodic Testing of Diesel Generator Battery Trains Edga & Edgb Not Performed within Test Frequency Required by Tech Specs.Caused by Personnel Error | /03L-0:on 820116,during Review of Surveillance Documentation,Periodic Testing of Diesel Generator Battery Trains Edga & Edgb Not Performed within Test Frequency Required by Tech Specs.Caused by Personnel Error | | | 05000369/LER-1982-010, Forwards LER 82-010/03L-0.Detailed Event Analysis Encl | Forwards LER 82-010/03L-0.Detailed Event Analysis Encl | | | 05000369/LER-1982-010-03, /03L-0:on 820120,while in Mode 1,all Digital Rod Position Indications for Control Rod K-8 Lost.Caused by Cabling to Detectors Susceptible to Conductor Damage Due to Own Weight.Bulkhead Connector Cable Replaced | /03L-0:on 820120,while in Mode 1,all Digital Rod Position Indications for Control Rod K-8 Lost.Caused by Cabling to Detectors Susceptible to Conductor Damage Due to Own Weight.Bulkhead Connector Cable Replaced | | | 05000369/LER-1982-011-03, /03L-0:on 820120,maint Personnel Working on Spent Fuel Pool Cooling Sys (Kf) Heat Exchanger 1A Discharge Throttle Bypass Relief Valve Discovered That Kf Mechanical Snubber Was Removed Rendering Snubber Inoperable | /03L-0:on 820120,maint Personnel Working on Spent Fuel Pool Cooling Sys (Kf) Heat Exchanger 1A Discharge Throttle Bypass Relief Valve Discovered That Kf Mechanical Snubber Was Removed Rendering Snubber Inoperable | | | 05000369/LER-1982-011, Forwards LER 82-011/03L-0 | Forwards LER 82-011/03L-0 | | | 05000369/LER-1982-012-03, /03L-0:on 820119,routine QA Audit of Fire Protection Sys Test Found Three Valves Marked Not Accessible & Had Not Been Checked.Caused by Personnel Error.Periodic Test Performed & Valves Found in Correct Position | /03L-0:on 820119,routine QA Audit of Fire Protection Sys Test Found Three Valves Marked Not Accessible & Had Not Been Checked.Caused by Personnel Error.Periodic Test Performed & Valves Found in Correct Position | | | 05000369/LER-1982-012, Forwards LER 82-012/03L-0.Detailed Event Analysis Encl | Forwards LER 82-012/03L-0.Detailed Event Analysis Encl | | | 05000369/LER-1982-013, Forwards LER 82-013/03L-0.Detailed Event Analysis Encl | Forwards LER 82-013/03L-0.Detailed Event Analysis Encl | | | 05000369/LER-1982-013-03, /03L-0:on 820126,two Upper Head Injection Train a Accumulator Tank Level Switches Miscalibr,Rendering Isolation Valves Inoperable.Caused by Faulty Data Programmed Into Computer Memory.Program Corrected | /03L-0:on 820126,two Upper Head Injection Train a Accumulator Tank Level Switches Miscalibr,Rendering Isolation Valves Inoperable.Caused by Faulty Data Programmed Into Computer Memory.Program Corrected | | | 05000369/LER-1982-014-03, /03L-0:on 820128,process Monitoring Sys Containment Gas Monitor EMF-39(L) Declared Inoperable Due to Scale Low Indication & Loss of Indication.Caused by Failure of Quality Bnn Connector.Sys Repaired | /03L-0:on 820128,process Monitoring Sys Containment Gas Monitor EMF-39(L) Declared Inoperable Due to Scale Low Indication & Loss of Indication.Caused by Failure of Quality Bnn Connector.Sys Repaired | | | 05000369/LER-1982-014, Forwards LER 82-014/03L-0 | Forwards LER 82-014/03L-0 | | | 05000369/LER-1982-015, Forwards LER 82-015/01T-0.Detailed Event Analysis Encl | Forwards LER 82-015/01T-0.Detailed Event Analysis Encl | | | 05000369/LER-1982-015-01, /01T-0:on 820212,both Centrifugal Charging Pumps (CCP) Declared Inoperable When Hydrogen from Reciprocating Charging Pump Suction Dampeners Entered CCP Suction,Causing Cavitation | /01T-0:on 820212,both Centrifugal Charging Pumps (CCP) Declared Inoperable When Hydrogen from Reciprocating Charging Pump Suction Dampeners Entered CCP Suction,Causing Cavitation | | | 05000369/LER-1982-016-03, /03L-0:on 820211,discovered Pivot Pin Missing from safety-related Hanger Located in Centrifugal Charging Pump 1B Room Supporting Pump 4-inch Discharge Line Rendering Hanger Inoperable.Cause Undetermined.New Pin Installed | /03L-0:on 820211,discovered Pivot Pin Missing from safety-related Hanger Located in Centrifugal Charging Pump 1B Room Supporting Pump 4-inch Discharge Line Rendering Hanger Inoperable.Cause Undetermined.New Pin Installed | | | 05000369/LER-1982-016, Forwards LER 82-016/03L-0 | Forwards LER 82-016/03L-0 | | | 05000369/LER-1982-017-03, /03L-0:on 820212,control Room Alarms Indicated Closing of 4 Accumulator Discharge Isolation Valves, Rendering Upper Head Injection Portion of ECCS Inoperable. Cause Probably Due to Installation Deficiency | /03L-0:on 820212,control Room Alarms Indicated Closing of 4 Accumulator Discharge Isolation Valves, Rendering Upper Head Injection Portion of ECCS Inoperable. Cause Probably Due to Installation Deficiency | | | 05000369/LER-1982-017, Forwards LER 82-017/03L-0.Detailed Event Analysis Encl | Forwards LER 82-017/03L-0.Detailed Event Analysis Encl | | | 05000369/LER-1982-018-03, /03L-0:on 820218,control Room Annunciators Indicated Reactor Coolant Loop B Overtemp & Overpower Delta T Alarms.Caused by Faulty Lead/Lag Amplifier Card in Loop B Delta T Section of 7300 Control Sys Cabinets | /03L-0:on 820218,control Room Annunciators Indicated Reactor Coolant Loop B Overtemp & Overpower Delta T Alarms.Caused by Faulty Lead/Lag Amplifier Card in Loop B Delta T Section of 7300 Control Sys Cabinets | | | 05000369/LER-1982-018, Forwards LER 82-018/03L-0 | Forwards LER 82-018/03L-0 | | | 05000369/LER-1982-019-03, /03L-0:on 820228,during Mode 4,performance of RCS Pressure Isolation Valve Leak Rate Test Determined That 3 Valves Failed Test.Caused by Failure of Valves to Seat Properly.Valves Disassembled & Repaired | /03L-0:on 820228,during Mode 4,performance of RCS Pressure Isolation Valve Leak Rate Test Determined That 3 Valves Failed Test.Caused by Failure of Valves to Seat Properly.Valves Disassembled & Repaired | | | 05000369/LER-1982-020-03, /03L-0:on 820304,during Mode 5,operator-trainee Attempted to Address Status of Fire Zone Through Honeywell Fire Detection Sys Operator Terminal & Mistakenly Dumped Central Processing Unit Memory.Caused by Personnel Error | /03L-0:on 820304,during Mode 5,operator-trainee Attempted to Address Status of Fire Zone Through Honeywell Fire Detection Sys Operator Terminal & Mistakenly Dumped Central Processing Unit Memory.Caused by Personnel Error | | | 05000369/LER-1982-020, Forwards LER 82-020/03L-0 | Forwards LER 82-020/03L-0 | | | 05000369/LER-1982-021-03, /03L-0:on 820309,discovered Cold Leg Injection Accumulator Isolation Valves Not Periodically Tested for Correct Response to P-11 Interlock Signal.Caused by Procedural Deficiency.Tests Performed on 820312 | /03L-0:on 820309,discovered Cold Leg Injection Accumulator Isolation Valves Not Periodically Tested for Correct Response to P-11 Interlock Signal.Caused by Procedural Deficiency.Tests Performed on 820312 | | | 05000369/LER-1982-021, Forwards LER 82-021/03L-0 | Forwards LER 82-021/03L-0 | | | 05000369/LER-1982-022-03, /03L-0:on 820310,while in Mode 5,procedure Review Revealed Pressurizer 1 Power Operated Relief Valve (PORV) Had Not Been Timed.Procedure Change on 800915 Failed to Include PORV for Time Test.Procedure Changed | /03L-0:on 820310,while in Mode 5,procedure Review Revealed Pressurizer 1 Power Operated Relief Valve (PORV) Had Not Been Timed.Procedure Change on 800915 Failed to Include PORV for Time Test.Procedure Changed | | | 05000369/LER-1982-022, Forwards LER 82-022/03L-0 | Forwards LER 82-022/03L-0 | | | 05000369/LER-1982-023, Forwards LER 82-023/03L-0.Detailed Event Analysis Encl | Forwards LER 82-023/03L-0.Detailed Event Analysis Encl | | | 05000369/LER-1982-023-03, /03L-0:on 820312,after Filling & Venting of RCS, Sample Indicated Boron Concentration at 1,025 Ppm.Caused by Procedural Deficiency Due to Operating Boric Acid Blender W/O Concentration Verification During Addition to RCS | /03L-0:on 820312,after Filling & Venting of RCS, Sample Indicated Boron Concentration at 1,025 Ppm.Caused by Procedural Deficiency Due to Operating Boric Acid Blender W/O Concentration Verification During Addition to RCS | | | 05000369/LER-1982-024, Forwards LER 82-024/03L-0.Detailed Event Analysis Encl | Forwards LER 82-024/03L-0.Detailed Event Analysis Encl | | | 05000369/LER-1982-024-03, /03L-0:on 820302,while Draining RCS for Insp,Rhr Pump Low Discharge Pressure Alarm Sounded.Caused by Inaccurate Indication of RCS Water Level Due to Misapplication of Control Board Level Gauge Transmitter | /03L-0:on 820302,while Draining RCS for Insp,Rhr Pump Low Discharge Pressure Alarm Sounded.Caused by Inaccurate Indication of RCS Water Level Due to Misapplication of Control Board Level Gauge Transmitter | | | 05000369/LER-1982-025, Forwards LER 82-025/03L-0 | Forwards LER 82-025/03L-0 | | | 05000369/LER-1982-025-03, /03L-0:on 820318,vol Control Tank Makeup Frequency Increased & Containment Floor & Equipment Sump 1A Level Increased During RCS Leak Test.Caused by Failure to Verify Isolation Valves Closed Due to Procedural Deficiency | /03L-0:on 820318,vol Control Tank Makeup Frequency Increased & Containment Floor & Equipment Sump 1A Level Increased During RCS Leak Test.Caused by Failure to Verify Isolation Valves Closed Due to Procedural Deficiency | | | 05000369/LER-1982-026, Forwards LER 82-026/03L-0 | Forwards LER 82-026/03L-0 | |
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