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REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR: 8909190179 DOC. DATE: 89/09/13 NOTARIZED: NO DOCKETFACIL:50-323 Diablo Canyon Nuclear Power Plant, Unit 2, Pacific Ga 05000323

AUTH.NAME AUTHOR AFFILIATIONGREBEL,T.L. Pacific Gas & Electric Co.SHIFFER,J.D. Pacific Gas & Electric Co.

RECIP.NAME RECIPIENT AFFILIATION

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DISTRIBUTION CODE: ZE22T COPIES RECEIVED:LTR ENCL SIZE:TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.NOTES

SUBJECT: LER 88-016-01':on 881111,safety injection pump 2-2 failedafter suction valve'losed. lt

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Pacific Gas and Electric Company 77 Beale Street

San Francisco, CA 94106

415/972 7000TWX910 372 6587 ',

James D. ShifferVice President

Nrjctear Power Generation

September 13, 1989

PGhE Letter No. DCL-89-237

U.S. Nuclear Regulatory CommissionATTN: Document Control DeskNashington, D.C. 20555

Re: Docket No. 50-323, OL-DPR-82Diablo Canyon Unit 2Licensee Event Report 2-88-016-01 (Voluntary)Safety Injection Pump 2-2 Failed After The Suction Valve HasClosed Due To The Effects From An Inadequate Assessment OfClearance Remo'val

Gentlemen:

PGtrE is submitting the enclosed revision to a voluntary LicenseeEvent Report regarding the failure of safety injection pump 2-2.The failure occurred during pump operation when the suction valvewas closed due to an inadequate assessment of clearance removaleffects. This LER is being submitted for information purposes only,as described in item 19 of Supple'ment Number 1 to NUREG-1022. Thisrevision is being submitted to revise the root cause and thecorrective actions taken to prevent recurrence and to clarify theevent description.

This event has in no way affected the public's health and safety.

Kindly acknowledge receipt of this material on the enclosed copy ofthis letter and return it in the enclosed addressed envelope.

Sincerely,/

/i:.3. D. S ffer

cc: J. B. HartinH. M. HendoncaP. P. NarbutH. RoodB. H. VoglerCPUCDiablo DistributionINPO

Enclosure

DC2-88-OP-N129

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This report is being submitted voluntarily for information purposes only asdescribed in item 19 of supplement 1 to NUREG-1022.

On November ll, 1988, at approximately 0040 PST, while filling the accumulators,the assistant control room operator (ACO) noticed that the fill was not progressingas fast as expected. At 0050 PST, the discharge pressure from safety injectionpump 2-2 and motor current were noted as low,. The pump was immediately secured.

The Senior Control Operator (SCO) was dispatched for a local check of the pump. Atapproximately 0055 PST, the SCO reported that the suction valve was closed and thatsome of the paint on the pump was burnt. The pump was replaced, testedsatisfactorily, and returned to service by November 23, 1988.

This event was caused by personnel error, cognitive, in that the suction valvebreaker was racked in with the control room valve control switch in the closedposition due to an inadequate review of a clearance. The valve closed cutting offsuction flow to SI pump 2-2,

Applicable clearance and tagging procedures were revised and a new procedurewritten to provide guidance during filling operations. Operators were counseledwith regard to proper valve and switch alignment when returning equipment toservice

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I. ni i 1 ni inUnit 2 was in Mode 5 (Cold Shutdown) with the reactor coolant system (RCS)(AB)at atmospheric pressure and 108 degrees Fahrenheit.

ri in fA ~ Event:

This report is being submitted voluntarily for information purposes onlyas described in item 19 of supplement 1 to NUREG-1022.

On October 21, 1988, safety injection (SI) pump 2-2 (BQ)(P) motor-operatedsuction valve 8923B (MOV-89238) (BQ)(V) was cleared for maintenance. On

October 22, 1988, clearance tags were removed from the valve handwheel toallow manual positioning of the valve. SI pump 2-2 was operated numeroustimes from October 22, 1988, through November 10, 1988, for surveillancetesting. On November 10, 1988, at 2049 PST, Maintenance removed theclearance on HOV-8923B.

On November 10, 1988, while preparing for entry into Mode 4 (Hot Shutdown)following the Unit 2 second refueling outage, safety injection (SI) pump2-2 was verified to be aligned properly to fill the accumulators(BP)(ACC). The suction valve, motor operator valve (HOV) 8923B, wascleared with the 480 volt breaker open and the control switch (BQ)(33)tagged in the closed position. The valve position was locally verified tobe open. The valve alignment was considered satisfactory, and atapproximately 2109 PST, the pump was started, and the filling ofaccumulators 21, 23, and 24 was initiated. The operators, in accordancewith operations policies, monitored the filling operation closely for thefirst hour, verifying that all parameters were indicating a normal fill,i.e., that accumulator level was increasing at the expected rate. Theoperators then returned to other control room tasks and monitored the filloperation on a periodic basis.

At approximately the same time SI pump 2-2 was started, electricalmaintenance reported off the clearance on the suction valve. Atapproximately 2150 PST, the Senior Control Operator (SCO) removed thecontrol board cautions tags associated with the clearance, including theone on SI pump 2-2 suction valve HOV-8923B and instructed the AuxiliaryOperator (AO) to finish processing the clearance.

At approximately 2230 PST, the AO removed the tags and closed the breakerfor HOV-8923B. Since the control room valve control switch was in the"close" position, the valve closed. At approximately 0040 PST,

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November 11, 1989, an auxiliary control operator (ACO) checking theprogress of the accumulator fill operation noted the filling rate appearedto be very slow. The pump operating conditions were checked and low motorcurrent and low flaw indication were observed. The ACO noted the suctionvalve was closed and immediately secured the pump. The SCO was dispatched.to investigate the pump and found paint burnt on portions of the pumpcasing indicating significant overheating.

The pump is provided with a motor overcurrent trip (BQ)(50), bearing hightemperature alarms (BQ)(TA), pump seal "flush water" high temperaturealarms (BQ)(TA), and a smoke alarm (BQ)(FRA) located in the pump room,However this event involved the loss of pump suction, which resulted inlow motor current, and did not affect the bearing temperature. Thecomponent cooling water was able to remove heat at an adequate rate tomaintain seal temperatures. The smoke alarm was tested and determined tobe operable. The personnel initially on the scene did not observe anyvisible smoke although a very strong burning odor was present. The smallamount of smoke produced'y the burnt paint is believed to have beendiluted and removed by the room ventilation system before it couldactivate the smoke alarm.

B. Inoperable structures, components, or systems that contributed to theevent:

MOV-8923B was cleared for maintenance.

C. Dates and approximate times for major occurrences:

l. October 22, 1988: Tags from valve maintenance clearance removedfrom valve handwheel to allow manual positioningof the valve.

2. October 22, 1988 — SI pump operated numerous times for surveillanceNovember 10, 1988: testing,

3. November 10, 1988,at 2049 PST:

4. November 10, 1988,at 2109 PST:

5. November 10, 1988,at 2150

PST'aintenance

reports off clearance on SI pumpsuction valve MOV-89238.

SI pump 2-2 started. Fill of accumulators 1,3, and 4 started. Pump parameters were monitoredand were normal. Accumulator level was observedto be increasing as expected.

As part of the process of removing theclearance on MOV-89238, the SCO removed thecaution tag from the 89238 control switch withoutnoting that the switch was positioned to close.

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6. November 10, 1988, The clearance tags were removed fromat 2230 PST: breaker 52-2H-71, and the breaker was closed. SI

pump 2-2 suction valve 8923B closed at this timesince the control room valve control switch wasin the "close" position.

7. November ll, 1988; The accumulator fill was observed to notat approximately be progressing as fast as expected.0040 PST:

8. November ll, 1988, SI pump 2-2 secured,at 0050 PST:

D. Other systems or secondary functions affected:

None.

E. Method of Discovery:

Hhile checking the progress of an accumulator filling operation, an ACO

noticed that the fill rate had slowed considerably. This prompted a checkof pump conditions which discovered a low flow rate and low motoramperage. The pump suction valve was found to be closed. The pump wasimmediately secured.

F. Operator actions:

Nhen the pump discharge pressure and motor amperage were discovered to below, the pump was immediately secured. An operator dispatched to checkthe pump locally observed evidence of overheating. ,Maintenance wasrequested to check the condition of the pump.

G. Safety system responses:

None.

A. Immediate cause:

This event was caused by the racking in of the suction valve breaker withthe control room valve control switch in the closed position. The valveclosed, cutting off suction flow to SI pump 2-2.

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B. Root Cause:

The root cause of this event was personnel error, cognitive, failure toimplement administrative procedures, in that the Senior Licensed Operatorremoved the Control Board Caution Tag from the Control Switch forHOV-8923B, but failed to note the switch position or consider its impacton the system.

Contributing causes to this event were:

l. An inadequate review of a clearance was made prior to realigningportions of,the system. Administrative procedure (AP) C-6Sl,"Clearance Request/Job Assignment," did not provide details as to thetype and extent of the review necessary prior to system restorationfollowing a clearance.

C.

The Control Board Caution Tag used for clearance status specifiedthat the proper switch position was to be in the "close" position,preventing switch operation with the tag installed.- Previouslyestablished plant practices were not to specify a "return to service"position on the control board caution tags since these tags wereintended for clearance status only, although, evaluation of return toservice alignment is required by AP C-6Sl.

3. The practices used by the control room operators to monitor theaccumulator filling.operation were not sufficient to identify that a

problem had occurred which stopped any water addition forapproximately 2 hours.

4. No control room alarms existed to alert the operators that the pumphad lost suction.

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The unit was in Hode 5 with the RCS at 108 degrees Fahrenheit and atatmospheric pressure with the redundant SI pump 2-1, both RHR pumps, and thecharging pumps, as well as gravity feed from the refueling water storage tankavailable if the need arose to provide additional water to the RCS. Thus thehealth and safety of the public were not adversely affected by this event.

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A. Immediate Corrective Actions:

2.

A replacement pump was obtained in the event that the damaged pumpcould not be readily repaired.

/

The vendor was contacted and a vendor representative was sent to aidthe on-site attempt to repair the damaged pump.

3. The damaged pump was disassembled and analysis of the as-foundcondition prompted a decision to replace the pump with the newlyobtained replacement while awaiting repair of the damaged pump.

4. The replacement pump was installed, tested satisfactorily, evaluatedby engineering, and declared

operable'.

The damaged pump was sent offsite for examination. This examinationdetermined that refurbishment of the pump was impractical.Therefore, PGhE is in the process of procuring a new SI pump for useas a spare.

B. Corrective Actions to Prevent Recurrence

1. Clearance procedure AP C-6Sl has been revised to include requirementsand guidance for review of clearances installed and removed oninservice systems, and add requirements for listing "return toservice" positions on control board switches.

2. Operating Order OP 0-17, "Hanual Valve Alignment," was developed toprovide generic instructions and guidance during operations involvingfilling or draining vessels.

3. Operating Order OP 0-9, "Hanual Seating of Hotor Operated Valves,"was developed to provide instructions for manual operation of motoroperated valves. This instruction provides proper control switchpositioning.

4. An Engineering Hork Request was initiated to request that "loss offlow" alarms be installed on all ESF pumps.

5. The event was reviewed with operations personnel stressing the needto follow administrative requirements.

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A. Failed components:

SI pump 2-2Manufacturer: Pacific Pump Co.

B. Previous LERs on similar events:

None

C. Additional Information:

None

2776S/0071Ksac ~ oav )44AITES

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