05000324/LER-1999-008-02, :on 990920,condenser Pressure Sensing Line Drain Activities Resulted in ESF & RPS Actuation.Caused by Inadequate Implementation of C/A to Previously Identified Condition.Procedures Were Revised.With
05000324/LER-1999-008-02, :on 990920,condenser Pressure Sensing Line Drain Activities Resulted in ESF & RPS Actuation.Caused by Inadequate Implementation of C/A to Previously Identified Condition.Procedures Were Revised.With
AND REPORT $ MANAGtMENT ORANCH IP43ol U S NvCLt AR P AP E RINO RED T I'ON JC 43
$0 iC Of MANAGEMtNT AND DVDGE1,YrASH8NCYON.DC 30603 PAC 6LITY leatet 01 DOCR41 tsunseth up Paar m Brunswick Steam Electric Plant Unit 1 0 l5 l0 jo l0l 3l2 l 5 1 jorl 0l 3 787*' Coincident Inoperability of HPCI and RCIC Placing Unit 1 in Tech. Spec. 3.0.3 for Two Minutes caused by Personnel Error While Researching a' Clearance SVONT DATS (98 LlR 86UhlDim 16)
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l un ninmi eenwan.i Lect 8sBEt CONTACT POR THet Lim 112 Niut TELtPMONE Nubstm ARta CODS T. M. Jones, Regulatory Compliance Specialist 9 l1l9 4lSl7 l-l2l0l3l9 COMPLETE ONE LINE FOR B ACM COtIPONENT F AILURE DitCRISED IN THIS REPORT H31
the event was personnel error on the part of a Senior Reactor Operator who failed to research plant drawings in accordance with the Equipment Clearance Procedure. The failure resulted in the circuit breaker which supplies power to the llPCI inverter being opened under a clearance for RCIC. The circuit has both llPCI and RCIC loads. The involved SRO was counseled, a memo was written q
to licensed personnel highlighting the requirements of the Equipment Clearance Procedure, clearances are currently being researched separately by two NRC i:
licensed personnel and compared for discrepancies prior to approval. This event had minimal safety significance.
The Unit I reactor was operating at 100*4 power. The RCIC system was removed from service for mal'.tenance under Limiting Condition for Operetion (LCO)
Al-89-2341. The HPCI system, the Automatic Depressurization. System (ADS)
Equipment cicarance 1-0002 was being hung on the RCIC system.
Event Description
On January 2, 1990, clearance 1-0002 was being hung to replace the RCIC Supply L
Drain Pot Inboard Drain Valve (EIIS/DN/DRN/V), 1-E 1+V57, body to bonnetgasket.
l At 1542 the 125 volt direct current (vdc) distribut wa panel 3A circuit breaker i
number 2 (EIIS/EI/PL/bRR) was deenergized to remove power to the RCIC Steam Supply Drain Pot Drain valve, 1-E51-F025 (EIIS/BN/DRN/V).
When the circuit breaker was opened power was also removed from the HPCI steam supply drain valves and annunciation was received in the Control Room [1-A-1 l
(2-5) on panel P601) (EIIS/ ANN) indicating that the power to the llPCI inverter (EIIS/BJ/INVT) had been lost.
(Loss of the inverter resulted in the loss of l~
HPCI flow control capability.) The circuit breaker was closed and power was restored to the inverter at approximately 1544.
This event resulted in Unit 1 HPCI being inoperable and being unabic to meet i
the ACTION requirement of Technical Specification (T/S) 3.7.4, which placed the unit in T/S 3.0.3 for approximately two minutes.
LCO Al-90-0001 was initiated and canceled to document the applicability of T/S LCO 3.0.3.
Past similar events include LER 1-89-015, 1-89-008, 2-89-015, 2-89-016.
Event Investigation On December 27, 1989, a clearance was requested on the 1-E51-V57 valve to replace the body to bonnetgasket in accordance with work request and job order (WR/J0) 89-AXUII. The clearance was developed by a Senior Reactor Operator (SRO) in the Clearance Center on January 1, 1990. Contrary to Section 5.3.3.8 of the Equipment Clearance Procedure [ Administrative
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w,.swe.wune r as mun Instruction (AI) 58), applicable plant drawings were not utilized to identify the equipment loads off of the power supply to the 1-E51-F025 which was required to be deenergized for work on the V57 valve.
Instead, the RCIC operating procedure (0P.-16) was utilized. The OP Indicated that the power supply was circuit breaker two of 125 Vdc distribution panel 3A.
It also Indicated that this circuit powered the, RCIC Condensate Pump Discharge Outboard Drain Valve to the Main Condenser (EIIS/BN/DRN/V), 1-E51-F005.
Belleving that the OP was complete, the SRO researchir.g the clearance did not reference plant drawings and consequently f ailed to identify the !!PCI equipment' loads powered from the same breaker.
Root Cause The cause of this event was personnel error on the part of the involved SR0; failure to research plant drawings in accordance with the Equipment Clearance Procedure. A lluman Performance Evaluation was performed which determined that the SRO had used this process in the past for clearance development.
A memorandum was, written from the Operations Manager to 1,1 censed Personnel highlighting the requirement in AI-58 to research plant drawings and not rely on Operating Procedures when researching a clearance.
As a result of this event, standing instruction 90-003 was' issued. The y
instruction dictates that clearances be separately researched and written by l
two NRC licensed individuals if they are on systems which require independent verification (i.e., systems indicated in Administrative Procedure Volume 1 Book 1, Table 11.7.1).
After each individual finalizes the clearance they are compared. Any_ existing dif ferences are resolved prior to authoriz.ing the clearance to be placed. This requirement is to be included in the next revision of Ale 58 which is. expected to be complete by February 28, 1990. The requirement will remain until management decides it is no longer appropriate.
Event Assessment This event had minimal safety significance because of the immediate awareness of the event and its short duration (i.e., approximately two minutes).
A similar occurrence under other reasonable and credible circumstances would not have been more severe because possible involved safety related equipment is designed to either actuate in the fall safe direction or provide a warning o
on 900102,RCIC Removed from Svc & HPCI Rendered Inoperable,Placing Unit in Tech Spec 3.0.3.Caused by Personnel Error.Individual Counseled & Standing Instruction 90-003 Issued
on 900210,determined That Core Spray Loops a & B Inoperable Due to Missed Surveillance.Caused by Lack of Formal Guidelines.Instructions Issued to Personnel
on 900127,common Control Bldg HVAC Sys Isolated & Transferred to Recirculation Mode as Result of Spurious Actuation of Chlorine Detector.Sensor Connection Checked
on 900224,Group I Isolation Occurred When Undervoltage Relay Replaced.Caused by Lack of Recognition of Significance of Having Turbine Reset While Performing Electro Hydraulic Control Evolutions
on 900312,full Group 1 Isolation Signal Received,Resulting in Automatic Closure of Msivs.Caused by Personnel Failing to Follow Procedures.Personnel Counseled & Procedure Separated Into Two Tests
on 900302,HPCI Sys Declared Inoperable to Stop Leak on Steam Supply Drain Line.Caused by Severe Steam Erosion at 90 Degree Elbow.Involved Section of Piping Replaced on Units 1 & 2
on 900312,closure of Main Steam Line Isolation Valves Occurred.Caused by Failure to Reset Half Scram Signal on Channel a Prior to Continuing Test on Channel B of Associated Instrumentation
on 900322,injector Piping Failed on Chlorinator 5 Due to Improper Bonding of Piping.Caused by Sudden Separation of Chlorine Assembly at Junction of Reducing Bushing & Flange Adapter
on 900313,manual Reactor Scram Initiated Due to Failure of Safety/Relief Valve to Close During Startup Testing.Caused by Failure of Solenoid Valve.Valve Replaced
on 900330,Clearance F-2-90-F0096 Placed on Makeup Water Treatment Bldg Sprinkler Sys W/O Meeting Requirements of Tech Spec 3.7.7.2.Oversight Caused by Personnel Error.Fire Watch Established
on 900514,unplanned Closure of HPCI Isolation Valve Occurred During Maint Surveillance Test.Caused by Technician Placing RCIC Instead of HPCI Test Switch to Test Position.Personnel Counseled & Trained
on 900426,hydraulic Perturbation Occurred on Variable Leg of Instrumentation Used to Sense Reactor Water Level,Causing Isolation of RWCU Sys & Initiation of Standby Gas Treatment Sys.Diaphragm Assembly Recalibr
on 900604,hydraulic Perturbation of Reactor Vessel Resulted in Isolation of RWCU Sys.Caused by Increased Differential Pressure.Operations Personnel Restored Affected Sys to Svc
on 900426,hydraulic Perturbation Occurred Causing Reactor Bldg Ventilation Sys to Isolate.Caused by Air in Transmitters During Flushing of Instrument.Procedure Revs Initiated to Change Valving Process
on 900724,unit HPCI Sys Received Three Isolations of Outboard Valve.Caused by Loose Wire Landing on Terminal of Temp Module.Loose Wire Tightened.Request Made to Have Engineering Evaluate Adequacy of Design
on 900511,identified That Damper Would Fail to Close on Loss of Power to Solenoid Valve & on 900526,damper Found Approx 30 Degrees Open.Caused by Failure of Design to Include Fail Safe Damper.Damper Modified
on 900511,identified That Emergency Air Filtration Sys Inlet Damper 2L-D-CB Would Fail to Close on Loss of Power to Damper Solenoid Valve.Caused by Inadequate Damper Design.Damper Secured & Mod Implemented
on 900816,reactor Automatically Shutdown on Turbine Stop Valve Fast Closure Reactor Protection Sys Trip Signal.Caused by Failure of Primary Power Fuse C32-F5.Fuse Replaced
on 900816,reactor Automatically Shutdown on TSV Fast Closure RPS Trip Signal Causing Turbine Trip on Reactor High Water Level.Caused by Failure of Primary Power Fuse.Fuse Replaced
on 900514,HPCI Sys Rendered Inoperable When Control Power Lost to Min Flow Bypass Valve to Suppression Pool.Probably Caused by Design Problem W/Ge Model CR2940 Sockets.Light Bulb & Fuse Replaced
on 900507,determined That Tech Spec 4.6.1.1 Requirements Not Met After Performing Monthly Periodic Test 2.2.4a.Caused by Inadequate Procedure.Recommended Procedure Revs to Prevent Recurrence Being Evaluated
on 900819,ESF Actuation/Rps Trip Occurred While Performing Surveillance Test on Condenser Low Vacuum Instrumentation & Isolation Logic.Caused by Personnel Error. Maint Surveillance Tests Reperformed
on 900822,reactor Protection Sys Bus a Deenergized During Cold Shutdown.Caused by Personnel Error. Operators Disciplined & Clearance Procedure Will Be Revised to Clarify Double/Independent Verification
on 900830,RWCU Sys G31 Received Leak Hi & RWCU Leak Hi Hi Annunciators Although Actual Leak Had Not Occurred.Caused by Air in Instrument 2-G31-FT-N012 Sensing Lines.Investigation to Be Conducted
on 900705,determined That 18-month Surveillance on Battery 1A-1 Exceeded Surveillance Time Interval.Probably Caused by Tech Spec Change & Rescheduling of Outage.Personnel Counseled
on 900830,Unit 2 Reactor Scram Occurred During Reactor Startup.Investigation Continuing.Level Recovered W/O Need for Safety Sys Injection & Unit Designed for Level Transient from Full Power
on 900906,HPCI Declared Inoperable Due to Erratic Performance During Periodic Testing.Caused by Deficient Needle Valve Position.Maint Will Revise Procedures to Enhance Controls for Egr Needle Valve Adjustments
on 900725,determined That Cad/Containment Atmosphere Dilution Subsystem Design Did Not Meet FSAR Re Redundancy of Power Supply for Vaporizer Trains.Caused by Changing Regulatory Commitments.Sys Reviewed
on 900725,containment Atmospheric Control & Containment Atmospheric Dilution Subsystem Design Does Not Meet FSAR Commitments & Design Requirements.Seven Day Tracking Condition for Operator Established
on 900907,reactor Protection Sys Bus a Tripped When Electrical Protection Assembly a Opened on Underfrequency.Caused by Circuit Board Failure.Circuit Board Sent to GE for Analysis
on 900927,generator Voltage Oscillations Experienced Which Resulted in Loss of Main Generator Due to Loss of Excitation.Caused by Unstable Voltage Regulator. Regulator & Circuitry Reset
on 901023,half Trip Signal,Half PCIS Group 1 Isolation Signal & Group 6 Isolation Occurred.Caused by Failure of Kepco Power Supply in Numac Lvps to Radiation Monitor B.Numac Lvps Replaced
on 900927,high Pressure Reactor Scram Occurred While Performing Periodic Test PT-40.2.10 Due to Erroneous Procedure Guidance & Defective Turbine Stop Valve Switches
on 900927,Group 6 Isolation & Standby Gas Treatment Sys Autostart Signal Received as Result of Momentary Loss of Power to Main Stack Radiation Monitor. Caused by Reactor Scram
on 901226,isolation Signal Caused Reactor Water Cleanup Inlet Inboard Isolation Valve to Automatically Close.Caused by de-energized HPCI Isolation Relay.Riley Scam Temp Switch Units Will Be Replaced
on 901002,technician Mistakenly Placed Channel B Detector to Radiation Source,Resulting in Group 6 Valve Isolations.Caused by Personnel Error.Disciplinary Action Taken
on 901226,while Returning HPCI Sys to Svc, Determined That Min Flow Valve Control Power Fuse Blown, Resulting in Inoperability of Valve.Caused by Short in Indicating Light Bulb.Bulb & Fuse Replaced
on 901117,primary & Secondary Containment Isolation Signals Received & Standby Gas Treatment Sys auto- Started.Caused by Scan Overload on Microprocessor.Updated Microprocessor Will Be Obtained