05000322/LER-1988-001, :on 880128,loss of Continuous Monitoring of Station Ventilation Exhaust Occurred.Caused by Personnel Error.Lead Mechanic to Requalify,Incident Discussed W/Maint Personnel & All Personnel Required to Read LER
| ML20147D993 | |
| Person / Time | |
|---|---|
| Site: | Shoreham File:Long Island Lighting Company icon.png |
| Issue date: | 02/26/1988 |
| From: | Grunseich R, Steiger W LONG ISLAND LIGHTING CO. |
| To: | NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM) |
| References | |
| LER-88-001, LER-88-1, PM-88-052, PM-88-52, NUDOCS 8803040226 | |
| Download: ML20147D993 (6) | |
| Event date: | |
|---|---|
| Report date: | |
| Reporting criterion: | 10 CFR 50.73(a)(2)(i) |
| 3221988001R00 - NRC Website | |
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On January 28, 1988, at approximately 1700, it was discovered by a Radiochemistry technician that the sample pump for the Station Ventilation Exhaust Radiation Monitor was not running.
The plant was in Operational Condition 4 (Cold Shutdown) with the mode switch in Shutdown with all rods inserted in the core.
The root cause of the event was personnel error.
The monitor, 1D11+PNL-021 was being utilized as the auxiliary sampling equipment required to continuously collect iodine and particulate samples to satisfy Action Statement 122 of Tech. Spec. 3.3.7.11 due to the Normal Station Vent Monitor (1D11*PNL-041) being out of service for tecting.
It was determined, upon review of the RMS computer printout, that the pump was turned off at 1422, due to a loss of power to the monitor.
Maintenance mechanics working in the Emergency Diesel Generator (EDG)
Room 102 had opened the breaker while investigating an unrelated problem.
When the breaker was reclosed (approximately three seconds later), power was restored to the monitor. Since the pump automatic start logic requires an RBSYS signal, the pump did not automatically restart.
The operator in the Control Room assumed that panel 21 was back in operation, when in fact, it wasn't.
The pump was turned back on by the Radchem tech, at 1703.
Plant Management was notified and the NRC was notified per License Condition 2.F at 1250 on January 29, 1988.
To prevent recurrence, the lead mechanic had his quals. pulled and administrative controls will be implemented to ensure Operator awarenese when panel 21 is being used to meet the Action Statement for alternate station vent monitoring.
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PLANT AND SYSTEM IDENTIFICATION
General Electric - Boiling Water Reactor Energy Industry Identification System (EIIS) codes are identified in the t6xt as [xx].
IDENTIFICATION OF THE EVENT Loss of continous monitoring / sampling of Station Ventilation exhaust due to a loss of power to the sample pump resulting from personnel error.
Event Date 1/28/88 Report Date:
2/26/88 CONDITIONS PRIOR TO THE EVENT Operational Condition 4
(Cold Shutdown)
Mode Switch - Shutdown RPV Prest,ure : 0 psig RPV Temperature = 100 Degrees F POWER LEVEL - 0 DESCRIPTION OF THE EVENT On January 28, 1988, at approximately 1700, it was discovered by a Radiochemistry technician that the sample pump for the Station Ventilation Exhaust Radiation Monitor was not running.
The monitor, 1D11*PNL-021[VL) was being utilized as the auxiliary sampling equipment required to continuously collect iodine and particulate samples to satisfy Action Statement 122 of Tech. Spec. 3.3.7.11 due to the Normal Station Vent Monitor (1D11*PNL-041) being out of service for testing.
The technician was preparing to take a noble gas grab sample per Tech. Spec. - Action Station Statement 120, when he noticed that the sample pump was off.
He notified his foreman and the Watch Engineer.
He restarted the pump at 1703.
An investigation into the cause of the event ensued.
It was determined, upon review of the RMS computer printout, that the pump was turned off at 1422, due to a loss of power to the monitor. Further investigation revealed that the breaker which supplies power to the panel, was opened momentarily and then closec Maintenance mechanics working in the Emergency Diesel Generator (EDG)
Room 102 had opened the breaker (which is located in IR35*PNL-B3),
while troubleshooting an unrelated problem.
When the breaker was reclosed (approximately three seconds later), power was restored
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w,w, Since the pump automatic start logic requires an to the monitor.the pump did not automatically restart.
The operator RBSYS signal, in the Control Room acknowledged the alarm when it came up on the but this action did not reset the panel.
At 1437, Control Room panel, the detector failure alarm cleared when the operator acknowledged the alarm at the Display Control Module (DCM).
At this time, he assumed that panel 21 was back in operation since the RMS display was green (normal), when in fact, it wasn't.
It was noted that because of the abnormal line-up of panel 21, the operator did not have indication that the pump was not running.
For this reason the cause of the trouble alarm was not investigated and the inop condition went found the pump not running.
unnoticed until the Radchem tech, Administrative controls to identify the particulars of the abnormal panel 21 line-up in support of an LCO Action Statement were inadequate.
The panel was inoperable from 1422 to 1703.
Plant Management was 1250 notified and the NRC was notified per License Condition 2.F. at on January 29, 1988.
CAUSE OF THE EVENT
The root cause of the event was personnel error.
The two maintenance mechanics (A and B) had just completed a task in the EDG101 room which required the de-energization of the starting air compressor.
"A" Mechanic opened the required breaker and the mechanics proceeded The on with the job.
Upon completion, the mechanics were then instructed, to proceed to the EDG102 room to visually investigate by their foreman, a problem with the EDG102 starting air compressor which had stalled The "A" mechanic during the performance of an 18 month surveillance.
instructed the "B" mechanic to open the power supply panel and open the breaker to isolate the power to the compressor.
This action was in violation of station procedures.
The "A" mechanic assumed that the orientation of the breakers in the 102 panel was identical to the 101 panel and instructed the "B" mechanic to open the breaker in the same spot as the breaker in the 101 panel.
When this action did not work (the "A" mechanic was monitoring the current with an ammeter), he reclosed the breaker and opened the breakers below one at a time (and reclosing them) until the correct breaker was found.
He opened approximately three breakers before finding the correct one.
As identified previously, one of the breakers opened was supplying power to 1D11*PNL-21.
Opening the other two breakers for the brief period of time (three seconds) did not adversely affect any other piece of equipment.
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There are other related causes which contributed to the significance of the event.
When Panel 21 lost power, the Operator in the Control Room had acknowledged the alarm and reset the panel.
However, because of the abnormal line-up, he was unaware that the pump had not restarted.
Prior to December 1985, Panel 21 was utilized as a RBSYS low range monitor.
The panel was modified to be utilized as a low range Station Vent Monitor, but the logic for its initiation remained the same.
Since the pump automatic start logic requires an RBSVS signal, the pump did not automatically restart.
This was not realized until the Radchem technicians performed their surveillance.
ANALYSIS OF THE EVENT
This event resulted in the violation of an Action Statement required by Technical Specification requirement 3.3.7.11 and is reportable per 10CFR50.73(a)(2)(i).
There was minimal safety significance to tne event.
Although the panel (21) was inoperable for more than 2 1/2 hours (1422 to 1703), 1D11*PNL-041 (Normal Station Vent Monitor) was running at 1431 and drawing a sample.
Although it was not formally declared operable per Tech. Specs. (awaiting approval of test results and LCO closecut), it was operating correctly.
The sample was collected and analyzed with no radionuclides identified (other than normal gross alpha).
Prior to and after the sample pump shutdown, there were no radionuclides identified.
It is therefore reasonable to assume that there would have been no identified radionuclides during the shutdown.
Had this event occurred under a more severe set of circumstances (5%
power), there would still be minimal safety significance.
CORRECTIVE ACTIONS
To prevent recurrence of the event, the following corrective actions will be or have been taken; 1.
The lead mechanic ("A" Mechanic) involved in the idcident had his qualifications pulled and must requalify.
2.
The incident has been discussed at a tailboard meeting with all maintenance personnel.
3.
The LER will become required reading for all station personnel.
4.
Engineering will be requested to evaluate what changes could be made to enhance panel 21's operation during non normal conditions.
5.
Administrative controls will be established to ensure Operator awareness when Panel 21 it is being utlized to meet the Action Statement for alternate station vent sampling.
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ADDITIONAL INFORMATION
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a. Manufacturer and model number of failed component (s) 1 i
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LER numbers of previous similar events86-012 I
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.i L.ONG ISLAND LIGHTING COMPANY manow b-www.ww.mj SHOREH AM NUCLE AR POWE R ST AT40N
- P.O. 80X 628
- WAOING RIVE R. NEW YORK 11792 T E L. (5161929 8300
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February 26, 1988 PH-88-052
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U.S. Nuclear Regulatory Commission Document Control Desh Washington, D.C. 20555
Dear Sir:
In accordance with 100FR50.73, enclosed is a copy of Shoreham Nuclear Power Station's Licensee Event Report LER 88-001.
Sincerely yours, P
Ofbb y
William E.
te ger, Jr.
Plant Manager WES/pz Enclosure l
cc:
William T. Russell, Regional Administrator i
Frank Crescenzo, Resident Inspector
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Institute of Nuclear Power Operations, Records Center American Nuclear Insurers SR.A21.0200 h
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