It looks like a severe deterioration of both organizations...
Residual Heat Removal Minimum Flow Valves Out of Position Results in Loss of Safety Function and Condition Prohibited by Technical SpecificationsABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) On February 5, 2017, during a quarterly sealed valve log audit, Residual Heat Removal (RHR) Valves RHR-V-58 and RHR-V-60 were discovered sealed closed. Normal configuration for these valves is sealed opened. Consequently, Operations declared RHR pumps A and C Inoperable at 0756 hours and entered Technical Specifications (TS} Limiting Condition for Operation (LCO) 3.5.1 Condition A, LCO 3.6.1.9 Condition A, and LCO 3.6.2.3 Condition A.Subsequently, the operating crew opened RHR-V-58 and RHR-V-60, independently verified the position of the valves and applied seals to the valves. As such, RHR pumps A and C were declared Operable at 1041 hours on February 5, 2017, and TS LCO 3.5.1 Condition A, LCO 3.6.1.9 Condition A, and LCO 3.6.2.3 Condition A were exited.The root cause is Operations Department standards related to Operator Human Performance and Configuration Control are inadequate and do not meet industry expectations. Licensed and Non-Licensed Operators completed training focused on Standards and Expectations related to attention to detail and configuration control. To prevent recurrence, expectations will be established and institutionalized for Operations Leadership to reinforce consistent application of operator fundamentals and to identify and correct performance gaps for the operating crews.BACKGROUNDThe safety objective of the Residual Heat Removal (RHR) system [EIIS:BO] is to provide core cooling, in conjunction with other Emergency Core Cooling Systems, and to provide containment cooling as required during abnormal operational transients and postulated accidents. The RHR system consists of two heat exchangers [EIIS:HX], four main system pumps [EIIS:P] in two divisions, and associated piping, valves, controls and instrumentation.The motor-operated minimum flow valves automatically provide the necessary flow through the pump in order to prevent pump overheating. The manual isolation valves for the motor-operated minimum flow valves, RHR-V-58 and RHR-V-60, are normally configured open and sealed.RHR pumps A and C provide RHR Loop A safety functions associated with Low Pressure Cooling Injection (LPCI) and Containment Cooling. These pumps also provide RHR Loop A Shutdown Cooling (SDC) function during outage conditions. EVENT DESCRIPTIONOn September 29, 2016, during Refueling Outage 29 (RE29), RHR-V-58 and RHR-V-60 were closed and danger tagged in accordance with a clearance order to support the RHR Loop A Maintenance Window.On October 7, 2016, the danger tags for RHR-V-58 and RHR-V-60 were released and the clearance order directed that both valves be restored to their normal configuration. The danger tags were removed and seals applied to the valves. However, the valves were not opened before placing the seals. Second verification incorrectly verified that the valves were sealed open, when they were sealed closed.A quarterly sealed valve log audit was performed on November 29, 2016, and the seals were verified to be intact. The audit required only that the seals be verified, the audit did not require the valve configuration be checked.On February 5, 2017, during a quarterly sealed valve log audit, it was discovered that RHR-V-58 and RHR-V-60 were sealed closed. Consequently, Operations declared RHR pumps A and C Inoperable at 0756 hours and entered Technical Specification (TS) Limiting Condition for Operation (LCO) 3.5.1 Condition A, LCO 3.6.1.9 Condition A, and LCO 3.6.2.3 Condition A.PREVIOUS EVENTS03/14/17 - Condition Report written to document incorrectly installed seals on two service water valves (SW-V-105 and SW-V-124) that occurred in late February 2017. 01/30/17 - Fuse was installed incorrectly. I 01/10/17- Incorrect bulb installation caused light for Local Power Range Monitor downscale to remain on. I01/14/17-Augmented Off-Gas +34 Glycol pump/compressor switches found in an incorrect position.LER 2016-009-00- On December 7, 2016, a Control Room Emergency Filtration System Fan was removed from service due to human error resulting in a loss of safety function.12/02/16 - Setpoints verified on the Normal Range Kaman instead of the High Range Kaman.11/21/16 - Incorrect log entry resulted in missed surveillance.10/15/16 - Relay was found not reset.10/03/16 - Control Rod Drive high cooling water differential pressure was noticed while making preparations to hang tags. Upon investigation, it was noticed that 75 Hydraulic Control Units (HCUs) were isolated, which left 62 in service for cooling. This is contrary to a precaution statement in a procedure which requires 70 HCUs to be in service.09/30/16 - A CNS Operator and an Entergy Operator entered the steam tunnel to hang tags and inadvertently severed and extracted tubing being used for Local Leak Rate Testing.09/28/16 - While performing rounds, the on watch non-licensed plant Operator adjusted air load pressure to the specifications in their logs, not per the procedure for the current plant condition. This caused Control Room indicators to show a lower Reactor Pressure Vessel level than actual. LER 2014-001-00 - On January 6, 2014, a differential pressure transient occurred in the reactor building due to a non-licensed plant Operator inadvertently opening the wrong drain valve while hanging tags.NRC FORM 366A (04-2017)
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