05000286/LER-2005-003
| Docket Number | |
| Event date: | |
|---|---|
| Report date: | |
| Reporting criterion: | 10 CFR 50.73(a)(2)(iv)(B), System Actuation 10 CFR 50.73(a)(2)(iv)(A), System Actuation |
| 2862005003R00 - NRC Website | |
Note: The Energy Industry Identification System Codes are identified within brackets ( )
DESCRIPTION OF EVENT
On May 16, 2005, at approximately 10:39 hours, while at 100% steady state reactor power, both motor driven auxiliary feedwater (AFW) pumps (BA) automatically started after exceeding the actuation circuit 28 second time delay during performance of the low-low level steam generator water level section of procedure 3-PT-M13B1, "Reactor Protection Logic Channel Functional Test (Reactor Power Greater Than 35%-P8)." Operators recognized the AFW pump start and immediately secured both motor driven AFW pumps. The steam driven AFW pump did not start and was not expected to start during this portion of the test. The test was terminated and a control room stand down performed to review the event. On May 16, 2005, at 1418 hours0.0164 days <br />0.394 hours <br />0.00234 weeks <br />5.39549e-4 months <br />, an eight hour non-emergency notification was made to the NRC for a valid actuation of the AFW system under 10CFR50.72(b)(3)(iv)(A). The event was recorded in the Indian Point Energy Center corrective action program (CAP) as CR-IP3-2005-02626.
On May 16, 2005, two teams of Instrumentation and Control (I&C) technicians were briefed to perform surveillance test 3-PT-M13B1. Test 3-PT-M13B1 demonstrates the operability of the Reactor Protection System (JE) Logic relays (Train B) in accordance with the surveillance requirements of Technical Specification 3.3.1. Surveillance procedure 3-PT-M13B1, at section 4.10.5, requires an arming signal to be inserted.into the actuation circuitry and that the appropriate alarms and indications are verified to occur. The procedure requires the arming signal to be released no later than twenty (20) seconds after introduction. The procedure notes that the logic system will initiate AFW actuation per design after approximately twenty eight (28) seconds. The technicians performing the test were qualified for the test and were advised in a pre-job brief of the possibility of an AFW actuation when performing this portion of the test. Two technicians performed the test with one technician performing arming and the other technician performing timing with a stop watch and verifying annunciators and indications. During performance of the arming portion of the test, the technician with the stop watch stepped into the control room board area to verify an expected first out annunciator. While in the control room board area, a watchstander asked a question to the technician.
The technician responded to a watchstander question and became distracted and allowed the arming signal to exist longer than the procedure required 20 second time frame and the design actuation time of 28 seconds. In accordance with design, the AFWS actuated and the motor driven AFW pumps started.
A review was performed of other sections of procedure 3-PT-M13B1 and other procedures for Unit 2 and 3. Due to design differences, the other Unit 3 train procedures and design determined that Unit 2 design was changed in the past to include test relays that block the test signal from actuating the equipment. No other procedures were found to approach the actuation timing setpoints as is required in procedure 3-PT-M13B1.
CAUSE OF EVENT
The cause of the motor driven AFW pump actuation and start was satisfaction of the actuation logic for pump start. The apparent cause of the inadvertent actuation of the AFW pumps was human error as a result of inadequate work practices. An I&C technician performing a timing function during a section of the test which requires insertion of an arming signal into the actuation circuitry failed to adhere to the procedure and question his actions. The technician allowed himself to be distracted by a question from a control room watchstander. The technician failed to stay focused and therefore did not effectively follow the test procedure. The technician was briefed on the test and was aware that the test had the potential to initiate actuation of the AFW pumps and required the technician to notify another technician to disarm the actuation circuit within 20 seconds. A contributing cause was complacency and a test procedure that operates very close to the actuation setpoints but does not adequately address the human performance requirements for test actions outside the immediate test area.
CORRECTIVE ACTIONS
The following corrective actions have been or will be performed under the CAP to address the causes of this event.
- I&C Maintenance personnel were briefed on the event and counseled on management expectations on a questioning attitude, procedure adherence and use of human performance tools.
- The test procedure 3-PT-M13B1 was revised to eliminate the need to walk out into the control room board area and to minimize the time needed for an arming signal to be present. Completion of the procedure revision is scheduled for July 31, 2005.
- The expectations for I&C Maintenance personnel will be strengthened through high intensity training on selection and use of human performance tools.
Completion of training is scheduled for August 31, 2005.
Event Analysis
The event is reportable under 10CFR50.73(a)(2)(iv)(A). The licensee shall report any event or condition that resulted in manual or automatic actuation of any of the systems listed under 10CFR50.73(a)(2)(iv)(B). Systems to which the requirements of 10CFR50.73(a)(2)(iv)(A) apply for this event include the AFWS.
This event meets the reporting criteria because the AFWS was actuated on a low-low steam generator level signal due to actuation of the logic during testing.
Past Similar Events
A review of the past two years of Licensee Event Reports (LERs) for events that involved an ESF actuation identified no LERs.
Safety Significance
This event had no effect on the health and safety of the public.
There were no actual safety consequences for the event because Operators were aware of the possibility of an inadvertent AFW pump start during testing and have alarms/indications alerting them to AFW pump start. The operators had adequate time to terminate AFW pump operation and limit any addition of AFW into the SGs.
Operators during this event recognized the AFW pump start and took appropriate actions in accordance with plant procedures to limit the effects of an inadvertent AFW actuation. Operators did not observe any reactivity changes as a result of this event.