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414 Niconet Mall Minneapolis, Minnesota 554011927 -
Telephone (612) 330 5500 October 18, 1990 10 CFR Part 50 Section 50.73.
i Director of Nuclear Reac*or Regulation-U S Nuclear Regulatory Commission Attn: Document Control Desk' Washington, DC 20555 i
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PRAIRIE ISLAND NUCLEAR CENERATINC PLANT Docket Nos. 50-282 License Nos.-DPR ' 50-306 DPR-60:
Auto-start of One Train of Control Room Special Ventilation Due to'Inadeauste Work Instructions The Licensee Event Report for this occurrence 'is attached.;
7 This event was reported via the-Emergency Notification System in.accordance with 10 CFR Part 50, Section 50.72', on September 19,1990~.
Please contact 'us if.you
'I require additional information related'to this event.
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Thomas M Parker l
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Manager L
Nuclear Support Services
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c: - Regional Administrator - Region' III,' NRC
.a NRR Project Manager, NRC
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' Senior Resident Inspector, NRC
.MPCA Attn: Dr J V Ferman a
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LiCENS2E EVENT REPORT (LER)
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, n ei On September 18, 1990 Unit I was at 100% power and Unit 2 was at' cold shutdown
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for red:eling. Maintenance was planned for circuit breaker 226. The Shift l
Supervisor had approved commencement of the work after verifying'the Train A chlorine monitors operable and after reviewing the electrical load list.
He warned the Lead Operator that when circuit breaker 226 was turned off, one of the two Train B chlorine monitors would be de-energized, and he could expect a l
chlorine monitor alarm but no other actuation. When circuit breaker'226'was turned off, at 1500, the chlorine monitor alarm was received, No. 122 Control Room Cleanup Fan started automatically and outside air to the control room was isolated.
Investigation showed that the work package contained information alerting the l
operator to the fact that-one Train B chlorine detector would be de energized when circuit breaker 226 was turned off.
Further investigation revealed that, in fact, both Train B chlorine detectors are powered by circuit breaker 226 and were both de-energized when circuit breaker 226 was turned off. This information was missing from the work package because the electrical load-list, which was used to prepare the work package, was in error.
This was a non ESF actuation of ESP equipment.
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EVENT DESCRIPTION
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On September 18, 1990 Unit I was at 100% power and Unit 2 was at cold shutdown for refueling. Maintenance was planned for circuit breaker 226.-The Snift Supervisor had approved commencement of the work af ter verifying the Train A chlorine monitors (EIIS Component Identifier MON) operable and after reviewing the electrical load list.
He warned.the Lead Operator that=when circuit--
breaker 226 was turned off, one'of the two Train B chlorine monitors would be 1
de energi. zed, and he could expect a chlorine monitor alarm but no other actustion. When circuit breaker 226 was turned off, at 1500, the chlorine monitor alarm was received, No. 122 Control Room Cleanup. Fan (EIIS Component Identifier FAN) started automatically and outside air to the control room was isolated. The Lead Operator acknowledged the chlorine monitor alarm but failed to note that the control room cleanup fan had started.. When the l
operator on the following shift did his control board walkdown,-about 10 hours1.157407e-4 days <br />0.00278 hours <br />1.653439e-5 weeks <br />3.805e-6 months <br /> I
later, he discovered the fan running.
When no reason for its' operation was found, the fan was stopped and the isolation dampers;were reopened.
l Investigation showed that the work package contained information alerting the operator to the fact that-one Train B chlorine" detector would be'de-energized when circuit breaker 226 was turned off..Further investigation revealed that,-
in fact, both Train B chlorine detectors are powered by circuit breaker 226 j
and we + ooth de energized when circuit breaker 226 was turned off. This informat.Aon was missing from the work package because the electrical load list, which was used to prepare.the work package, was in error. :Since the circuitry initiates actuation on a 2 out of 2' logic,;de energizing'both detectors caused the actuation.
This was a non-ESF actuation of ESF equipmant.
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CAUSE OF THE EVENT
. I Cause of the event was inadequate work instructions.
The work request I
governing the work on circuit breaker 226 was saplete because there was an error in the electrical load list which was N u to prepare the work package ~.
H A modification to enhance reliability -of th: n.lorine monitoring system had '
j been completed; the modification proces;c 1 af.leda.r. assure that the data file-was updated promptly. A common power supply;fu the monitors was cons!dered 1
acceptable since.long-term corrective actior b replace'the chlorine monitors,
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each with its own power supply, is being r,1wr.ed.
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LICENSEE EVENT REPORT (LER)
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ANAINSIS OF THE EVENT The functional rest.onse of the automatic actuation of the control room cleanup
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fan was according to design. The purpose of this actuation is to protect control room personnel from chlorine leaks.
Since this' event was not triggered by' the presence of chlorine in the atmosphere, there was no threat to the operation of the plant. TneLinadvertent actuation placed the ventilation train in the safe condition. Therefore, this event-did not affect the health and safety of the public.
Since this was an unplanne'd actuation of engineered safety features equipment, this event is reportable pursuant to 10CFR50.73(a)(2)(iv).
CORRECTIVE ACTION
T The electrical load list has.been corrected.
A program is being devel_oped' to provide more-timely updating of plant data files with changes caused by modifications.
1 FAILED COMPONENT IDENTIFICATI0H None.
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PREVIOUS SIMILAR EVENTS
t Auto-starts of the control room special vent system have'been-reportedLas Unit' 1 LER's89-006, 89-009,'89 012,89-015, 89-020 and 90-001.
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| | | Reporting criterion |
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| 05000282/LER-1990-001, :on 900117,technician Mirror Contacted Bare Power Supply Terminal & Shorted Terminal to Ground,Causing Power Supply to Trip & Isolation of Outside Air to Control Room.Exposed Wire Terminal Points Covered |
- on 900117,technician Mirror Contacted Bare Power Supply Terminal & Shorted Terminal to Ground,Causing Power Supply to Trip & Isolation of Outside Air to Control Room.Exposed Wire Terminal Points Covered
| | | 05000306/LER-1990-001-01, :on 900308,relay Failed to Operate Properly During Bus Duct Cooler Local Panel Test.Caused by Failure of Test relay.On-line Testing of Bus Duct Cooler Local Panel Discontinued.Value of on-line Testing Studied |
- on 900308,relay Failed to Operate Properly During Bus Duct Cooler Local Panel Test.Caused by Failure of Test relay.On-line Testing of Bus Duct Cooler Local Panel Discontinued.Value of on-line Testing Studied
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000282/LER-1990-002, :on 900117,review of Cooldown Data Showed That Cooldown Rate of Pressurizer Exceeded Tech Spec Limit.Caused by Procedure Inadequacy.Procedures Revised to Require Use of Water Space Temp to Find Cooldown Rate |
- on 900117,review of Cooldown Data Showed That Cooldown Rate of Pressurizer Exceeded Tech Spec Limit.Caused by Procedure Inadequacy.Procedures Revised to Require Use of Water Space Temp to Find Cooldown Rate
| 10 CFR 50.73(a)(2)(1) | | 05000282/LER-1990-002-01, Forwards LER 90-002-01 Re Excessive Pressurizer Cooldown Rate & Excessive Spray/Pressurizer delta-T.Procedures Will Be Revised to Require Use of Pressurizer Water Temp for Determining Pressurizer Heatup & Cooldown Rates | Forwards LER 90-002-01 Re Excessive Pressurizer Cooldown Rate & Excessive Spray/Pressurizer delta-T.Procedures Will Be Revised to Require Use of Pressurizer Water Temp for Determining Pressurizer Heatup & Cooldown Rates | | | 05000306/LER-1990-002-01, :on 900309,reactor Trip Occurred During Startup.Caused by Failed Reactor Protection Logic Relay. Failed Relays Replaced & Blown Fuse Replaced |
- on 900309,reactor Trip Occurred During Startup.Caused by Failed Reactor Protection Logic Relay. Failed Relays Replaced & Blown Fuse Replaced
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000306/LER-1990-003, :on 900316,reactor Trip Occurred Following Resetting of Rod Control Sys Urgent Failure Alarm.Caused by Personnel Error.Temporary Operating Instructions Issued to Not Reset Alarms Until Consulting W/I&C Dept |
- on 900316,reactor Trip Occurred Following Resetting of Rod Control Sys Urgent Failure Alarm.Caused by Personnel Error.Temporary Operating Instructions Issued to Not Reset Alarms Until Consulting W/I&C Dept
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000282/LER-1990-003-01, :on 900323,automatic Start of Safeguards Cooling Water Pump Occurred Due to Inadequate Procedures. Plant Procedures Revised to Improve Guidance for Detecting Loss of Prime |
- on 900323,automatic Start of Safeguards Cooling Water Pump Occurred Due to Inadequate Procedures. Plant Procedures Revised to Improve Guidance for Detecting Loss of Prime
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000306/LER-1990-004-02, :on 900905,automatic Start of Both Auxiliary Feedwater Pumps Occurred.Caused by Inadequately Reviewed Procedures.Work Control Process Reviewed & Personnel Counseled |
- on 900905,automatic Start of Both Auxiliary Feedwater Pumps Occurred.Caused by Inadequately Reviewed Procedures.Work Control Process Reviewed & Personnel Counseled
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000282/LER-1990-004, :on 900424,discovered That Surveillance Test SP1042, Resistance Temp Detector Bypass Flow Meter Functional Test Not Performed within Required Time Period. Caused by Personnel Error.Test Performed |
- on 900424,discovered That Surveillance Test SP1042, Resistance Temp Detector Bypass Flow Meter Functional Test Not Performed within Required Time Period. Caused by Personnel Error.Test Performed
| 10 CFR 50.73(a)(2)(1) | | 05000306/LER-1990-005-02, :on 900910,turbine-driven Auxiliary Feedwater Pump Started Automatically Due to Personnel Oversight.W/ |
- on 900910,turbine-driven Auxiliary Feedwater Pump Started Automatically Due to Personnel Oversight.W/
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000282/LER-1990-005, :on 900504,control Room Received High Radiation Alarm & Indication of Automatic Start of Spent Fuel Pool Special Exhaust Fan 121 on Two Occasions.Caused by Electrical Spike on Monitor.Modules Replaced |
- on 900504,control Room Received High Radiation Alarm & Indication of Automatic Start of Spent Fuel Pool Special Exhaust Fan 121 on Two Occasions.Caused by Electrical Spike on Monitor.Modules Replaced
| | | 05000306/LER-1990-006-02, :on 900912,excessive Leakage Through Containment Isolation Valve Due to Valve Malfunction Occurred.Caused by Inadequate Work Instructions.Valve Travel Stop Adjusted |
- on 900912,excessive Leakage Through Containment Isolation Valve Due to Valve Malfunction Occurred.Caused by Inadequate Work Instructions.Valve Travel Stop Adjusted
| 10 CFR 50.73(a)(2)(1) | | 05000282/LER-1990-006, :on 900517,electrical Spike on Radiation Monitor R-25 Caused auto-start of Spent Fuel Pool Special Ventilation Sys.Caused by Procedural Inadequacy.Request for Training Issued Re Basics of Procedure Writing |
- on 900517,electrical Spike on Radiation Monitor R-25 Caused auto-start of Spent Fuel Pool Special Ventilation Sys.Caused by Procedural Inadequacy.Request for Training Issued Re Basics of Procedure Writing
| | | 05000282/LER-1990-007, :on 900517,discovered That Several Relays Deenergized & Automatic Start & Loading of Diesel Generator D1 Initiated.Caused by Inadequate Design.Mod Initiated to Install Test Points |
- on 900517,discovered That Several Relays Deenergized & Automatic Start & Loading of Diesel Generator D1 Initiated.Caused by Inadequate Design.Mod Initiated to Install Test Points
| | | 05000306/LER-1990-008-02, :on 900923,auto-start of Component Cooling Water Pump 2 Occurred While Switching RHR Pumps |
- on 900923,auto-start of Component Cooling Water Pump 2 Occurred While Switching RHR Pumps
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000282/LER-1990-008, :on 900627,shield Bldg Exhaust Fan Inadvertently Made Inoperable.Caused by Personnel Error in Turning Off Incorrect Circuit Breaker.Rev Made to Procedures to Involve Personnel in Equipment Isolation |
- on 900627,shield Bldg Exhaust Fan Inadvertently Made Inoperable.Caused by Personnel Error in Turning Off Incorrect Circuit Breaker.Rev Made to Procedures to Involve Personnel in Equipment Isolation
| | | 05000306/LER-1990-009-02, :on 901007,technician Inadvertently Removed Fuses from Intermediate Range Channel Instead of Power Range Channel |
- on 901007,technician Inadvertently Removed Fuses from Intermediate Range Channel Instead of Power Range Channel
| | | 05000282/LER-1990-009-01, :on 900811,automatic Start of Component Cooling Pump Occurred.Caused by Momentary Low Pressure in Component Cooling Water Sys.Procedures to Be Revised to Warn Operator of Possibility of Automatic Pump Starts |
- on 900811,automatic Start of Component Cooling Pump Occurred.Caused by Momentary Low Pressure in Component Cooling Water Sys.Procedures to Be Revised to Warn Operator of Possibility of Automatic Pump Starts
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000306/LER-1990-010-02, :on 901023,inadvertent Operation of Safeguards Logic Train Pushbutton Occurred |
- on 901023,inadvertent Operation of Safeguards Logic Train Pushbutton Occurred
| | | 05000282/LER-1990-010, :on 900629,surveillance Test Missed Because of Rescheduling.Discrepancy Existed Between Due Dates on Master Surveillance Schedule & Radiation Protection Group Schedule. Caused by Personnel Error.Schedules Improved |
- on 900629,surveillance Test Missed Because of Rescheduling.Discrepancy Existed Between Due Dates on Master Surveillance Schedule & Radiation Protection Group Schedule. Caused by Personnel Error.Schedules Improved
| | | 05000282/LER-1990-011, :on 900712,Westinghouse Notified Util of Error in Facility Large Break LOCA Analysis.Peak Cladding Temp Predicted by Code Wcobra/Trac Exceeded 10CFR50.46.Limit Reduced |
- on 900712,Westinghouse Notified Util of Error in Facility Large Break LOCA Analysis.Peak Cladding Temp Predicted by Code Wcobra/Trac Exceeded 10CFR50.46.Limit Reduced
| | | 05000306/LER-1990-011-02, :on 901009,entrance Into Tech Spec 3.0.C During AMSAC post-installation Testing Occurred |
- on 901009,entrance Into Tech Spec 3.0.C During AMSAC post-installation Testing Occurred
| 10 CFR 50.73(a)(2)(1) | | 05000306/LER-1990-012-02, :on 901229,control Room Operators Received Annunciation of Reactor Trip.Caused by Rod Control Sys Failures.Failed Cards in Rod Control Sys Replaced |
- on 901229,control Room Operators Received Annunciation of Reactor Trip.Caused by Rod Control Sys Failures.Failed Cards in Rod Control Sys Replaced
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000282/LER-1990-013, :on 900830,inadvertent Mispositioning of Control Switch of 11 Shield Bldg Ventilation Heater Controls Identified.Caused by Workman Unknowingly Moving Switch. Protective Covers Installed Over Switches |
- on 900830,inadvertent Mispositioning of Control Switch of 11 Shield Bldg Ventilation Heater Controls Identified.Caused by Workman Unknowingly Moving Switch. Protective Covers Installed Over Switches
| 10 CFR 50.73(a)(2)(1) | | 05000282/LER-1990-014-01, :on 900912,auto-start of One Control Room Ventilation Train Occurred |
- on 900912,auto-start of One Control Room Ventilation Train Occurred
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000282/LER-1990-015-01, :on 901018,determined That ASME Section XI Tests Omitted from Testing Procedures During Rev Process.W/ |
- on 901018,determined That ASME Section XI Tests Omitted from Testing Procedures During Rev Process.W/
| 10 CFR 50.73(a)(2)(1) | | 05000282/LER-1990-016-01, :on 901106,shift Supervisor Failed to Establish Continuous Fire Watch When Removing Sprinkler Sys |
- on 901106,shift Supervisor Failed to Establish Continuous Fire Watch When Removing Sprinkler Sys
| 10 CFR 50.73(a)(2)(1) | | 05000282/LER-1990-017-01, :on 901121,discovered That Bus Duct Cooling Fan 11 Not Running & Supply Breaker Tripped,Resulting in Main Generator,Turbine & Reactor Trip.Caused by Inadequate Design.Supply Breaker Replaced |
- on 901121,discovered That Bus Duct Cooling Fan 11 Not Running & Supply Breaker Tripped,Resulting in Main Generator,Turbine & Reactor Trip.Caused by Inadequate Design.Supply Breaker Replaced
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000282/LER-1990-018-01, :on 901130,discovered That Certain Valves Subject to ASME Section XI Testing Found in Design Basis Reconstitution.Cause Will Be Discussed in Supplemental Rept. Valves Cycled to Obtain Baseline Data |
- on 901130,discovered That Certain Valves Subject to ASME Section XI Testing Found in Design Basis Reconstitution.Cause Will Be Discussed in Supplemental Rept. Valves Cycled to Obtain Baseline Data
| | | 05000282/LER-1990-019-01, On 901218,ventilation Filter Testing Requirements Not Being Met.Caused by Personnel Oversight in Developing Procedures.Procedure Revs Have Been Initiated to Address Need for Special Testing | On 901218,ventilation Filter Testing Requirements Not Being Met.Caused by Personnel Oversight in Developing Procedures.Procedure Revs Have Been Initiated to Address Need for Special Testing | 10 CFR 50.73(a)(2)(1) |
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