05000286/LER-2008-004
| Indian Point 3 | |
| 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 10 CFR 50.73(a)(2)(v), Loss of Safety Function |
| 2862008004R00 - NRC Website | |
Note:� The Energy Industry Identification System Codes are identified within the brackets {}.
DESCRIPTION OF EVENT
On August 4, 2008, at approximately 12:00 hours, while at 100% steady state reactor power, both motor driven auxiliary feedwater (AFW) pumps {BA) (AFWP) automatically started during performance of the Low-Low Steam Generator Water Level section of procedure 3-PT-M13B1, "Reactor Protection Logic Channel Functional Test (Reactor Power Greater Than 35%-P8)." At approximately 12:07 hours, Operators recognized the start of the 31 and 33 AFWPs and secured the pumps. AFWP switches in the Control Room (CR) were returned to Auto following verification by I&C that the Auto start signal was no longer present. The steam driven 32 AFWP did not start and was not expected to start during this portion of the test. The test was terminated and troubleshooting initiated to determine the cause of the event. The core reactivity changes due to the event were not significant and resulted in a less than 0.25% increase in reactor power and no rod movement. The reactivity effect as measured by the Power Range Nuclear Instrumentation {IG} was small and SG {AB} level oscillated approximately 1-2% from normal but there was no challenge to automatic control and no SG level alarms were actuated. At approximately 13:22 hours, performance of 3-PT-M13B1 was commenced and after successful performance of the test, Technical Specification (TS) 3.3.1 was exited at approximately 16:09 hours. On August 4, 2008, at 14:17 hours, 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-IP3-2008-01863.
Prior to the event, at approximately 09:59 hours on August 4, 2008, Operations entered TS 3.3.1,"Reactor Protection System Instrumentation," and initiated start of surveillance test 3-PT-M13B1. Instrumentation and Control (I&C) technicians were briefed in the performance of surveillance test 3-PT-M13B1 which demonstrates the operability of the Reactor Protection System {JE} Logic relays {RLY} (Train B) in accordance with the surveillance requirements of TS 3.3.1. During the pre-job brief, use of alligator type jumpers was discussed and the I&C technicians questioned whether the Pomona banana jack adapters had been installed as the space around the terminal lugs was limited. The engineering for this type of adapter had not been completed therefore banana jacks adapters had not been installed. During performance of the test, Instrumentation & Control (I&C) technicians were at the step that tests Low-Low Steam Generator Water Level (SGWL) which required installation of jumper wires on terminal board logic contacts so that logic relays can be functionally tested. A unique testing feature is the AC feed to the logic relays are broken when various Low-Low SG Level logic matrices are tested in order to prevent actuation of the relays which would Auto start the 31 and 33 AFWPs. In order to functionally test the relays, jumpers are installed to bypass test contacts which open during testing.
I&C technicians initially installed the first jumper and during installation of the second jumper noticed that the first jumper had become dislodged. The I&C technicians did not see any sparks or hear any relay actuation so the second jumper installation was completed and the dislodged jumper was reconnected. I&C technicians continued with installing the remaining jumpers.
Cause of Event
The actuation of the 31 and 33 AFWPs was due to the satisfaction of the AFWP Auto start actuation logic when a relay was energized as a result of installation of a jumper on an incorrect terminal of the Low-Low SGWL logic circuit. The incorrect jumper connection was due to personnel error as a result of ineffective use of Human Performance (HP) tools. The ineffective use of HP tools was because standards and expectations have not been adequately reinforced and engrained into I&C technicians by Maintenance supervisors and management.
Interviews of I&C technicians indicated there was confusion on whether they were performing concurrent verification or peer checking. Procedural use and management's expectations require that peer checking be performed during this continuous use procedure. The dislodged jumper may have caused the I&C technicians to become distracted and not use their HP tools during installation of the second jumper. The procedure contains check boxes to place keep installation of each jumper but there was no indication of place keeping for the re-installation of the dislodged jumper. I&C technicians did not effectively use their HP tools such as place keeping, verification practices, questioning attitude, self checking during jumper installation.
Corrective Actions
The following corrective actions have been or will be performed under Entergy's Corrective Action Program to address the cause and prevent recurrence:
- I&C personnel were briefed on the event, lessons learned, traps associated with the event such as distractions, interruptions, physical environment, HP tools that could have been used more effectively and counseled on the expectations and standards for procedure adherence and usage.
- I&C personnel were coached on verification practices, self checking, S.T.A.R.
process and place keeping. Expectations of I&C personnel were reinforced on what it means to stop when unexpected conditions are encountered in the performance of a procedure and what actions are to be taken.
- A Maintenance Stand-down was developed and conducted on details of the root cause events in 2008 to include their causes, contributing causes, HP traps, and HP tools used ineffectively.
- Future job briefs were revised to include the specific actions that I&C technicians are to take should unexpected equipment reactions occur and the cautions related to errors on incorrect jumper installation. The revised brief also includes a discussion of peer checking versus concurrent review roles and performance expectations.
- Human Performance Simulator High Intensity training of I&C, Maintenance, and Performance personnel including supervisors will be performed to include review of appropriate sections of EN-MA-101,"Conduct of Maintenance, EN-AD 102,"Procedure Adherence and Level of Use, EN-HU-102,"Human Performance Tools, and IP-SMM-OP-106,"Procedure Use and Adherence." Training is scheduled to be complete by December 31, 2008.
- A needs analysis will be performed for the frequency of Human Performance refresher training for maintenance personnel in accredited programs. The needs analysis is scheduled to be completed by December 15, 2008.
Event Analysis
The event is reportable under 10CFR50.73(a)(2)(iv)(A). The licensee shall report any event or condition that resulted in the manual or automatic actuation of any system listed in 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 in accordance with design as a result of satisfying the requirements for initiation from the actuation circuitry for the 31 and 33 AFWPs. As a result of the event, there were no safety systems that were not capable of performing their safety function. In accordance with reporting guidance in NUREG-1022, an additional random single failure need not be assumed in that system during the condition. Therefore, there was no safety system functional failure of the AFWS reportable under 10 CFR 50.73(a)(2)(v).
Past Similar Events
A review was performed of Licensee Event Reports (LERs) for the past three years for any events reporting Engineered Safety Feature actuation due to inadvertent actuation during testing. LER-2005-003 reported an inadvertent actuation of the Auxiliary Feedwater (AFW) Pumps on May 16, 2005, during Reactor Protection Logic Channel Functional Testing (3-PT-M13B1). The cause of the event reported in LER-2005-003 was human error due to inadequate work practices were the technician performing the test failed to adhere to the procedure and allowed himself to be distracted and failed to disarm the actuation circuit as required by procedure. The event reported in LER-2005-003 has a similar cause to this event as both were caused by human performance issues. The corrective actions for LER-2005-003 included counseling I&C personnel on management expectations on procedure adherence and use of human performance tools, high intensity training on use of human performance tools. These corrective actions were not sufficiently effective in preventing a reoccurrence of a similar event by I&C personnel being reported in this LER because training on the lessons learned were not continually reinforced.
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 there were no accidents or transients requiring the AFWPs and Operators were aware of the possibility of an inadvertent AFW pump start during testing and have indications alerting them to AFW pump start. The operators had adequate time to terminate AFWP operation and limit the 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 the inadvertent AFW actuation.