05000286/LER-2008-004, Automatic Actuation of the Motor Driven Auxiliary Feedwater Pumps During Surveillance Testing Caused by Incorrect Test Jumper Connection Due to Personnel Error

Automatic Actuation of the Motor Driven Auxiliary Feedwater Pumps During Surveillance Testing Caused by Incorrect Test Jumper Connection Due to Personnel Error

ML082840573
Person / Time
Site:	Indian Point
Issue date:	09/29/2008
From:	Joseph E Pollock Entergy Corp, Entergy Nuclear Operations
To:	Document Control Desk, Office of Nuclear Reactor Regulation
References
NL-08-135 LER 08-004-00
Download: ML082840573 (5)

LER-2008-004, Automatic Actuation of the Motor Driven Auxiliary Feedwater Pumps During Surveillance Testing Caused by Incorrect Test Jumper Connection Due to Personnel Error

Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(1), Submit an LER, Invalid Actuation 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

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Indian Point Energy Center 450 Broadway, GSB P.O. Box 249 1Buchanan, N.Y. 10511-0249 ILLL.Iy Tel (914) 734-6700 J. E. Pollock Site Vice President September 29, 2008 Indian Point Unit No. 3 Docket No. 50-286 NL-08-135 U.S. Nuclear Regulatory Commission ATTN: Document Control Desk Mail Stop O-P1-17 Washington, D.C. 20555-0001

Subject:

Licensee Event Report # 2008-004-00, "Automatic Actuation of the Motor Driven Auxiliary Feedwater Pumps During Surveillance Testing Caused by Incorrect Test Jumper Connection Due to Personnel Error"

Dear Sir or Madam:

Pursuant to 10 CFR 50.73(a)(1), Entergy Nuclear Operations Inc. (ENO) hereby provides Licensee Event Report (LER) 2008-004-00. The attached LER identifies an event where there was an automatic actuation of both motor driven Auxiliary Feedwater Pumps, a system listed in 10 CFR 50.73(a)(2)(iv)(B), which is reportable under 10 CFR 50.73(a)(2)(iv)(A).

This condition was recorded in the Entergy Corrective Action Program as Condition Report CR-IP3-2008-01863.

There are no new commitments identified in this letter.. Should you have any questions regarding this submittal, please contact Mr. Robert Walpole, Manager, Licensing at (914) 734-6710.

Sincerely, J. E. Pollock Site Vice President Indian Point Energy Center cc:

Mr. Samuel J Collins, Regional Administrator, NRC Region I NRC Resident Inspector's Office, Indian Point 3 Mr. Paul Eddy, New York State Public Service Commission INPO Record Center a'

Abstract

On August 4, 2008, during performance of the monthly Reactor Protection Logic Channel Functional Test 3-PT-Ml3BI, Instrumentation & Control (I&C) technicians were testing Low-Low Steam Generator Water Level (SGWL) which required installation of jumper wires on terminal board logic contacts when a jumper became dislodged.

When the I&C technicians completed installation of the second jumper they reinstalled the jumper that became dislodged and continued installation of the remaining jumpers.

At this time Control Room Operators notified the technicians of an automatic start of the motor driven 31 and 33 Auxiliary Feedwater Pumps (AFWPs).

The I&C technicians stopped the test, removed the jumpers, performed troubleshooting and testing and satisfactorily completed the test.

The cause of the event was the AFWP Auto start actuation logic was satisfied 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 because standards and expectations have not been adequately reinforced in I&C technicians.

Corrective actions included coaching I&C personnel on use of HP tools, discussion with I&C Supervision of the event, lessons learned, and management expectations for procedure use and adherence and use of proper clips.

A Maintenance Stand-down was developed and conducted on details of the root cause events in 2008 to include their causes, HP traps, and HP tools used ineffectively.

HP Simulator High Intensity training will be performed.

A needs analysis will be performed for the frequency of Human Performance refresher training.

The event had no effect on public health and safety.

(if more space is required, use additional copies of (If more space is required, use additional copies of NRC Form 366A) (17)

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-Ml3BI).

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.