05000364/LER-1993-001, :on 930205,inadvertent Train a Safety Injection Occurred During Performance of FNP-2-STP-33.01 Due to Personnel Error.Individual Involved in Event Disciplined & All STP-33.0 Series Procedures Revised
| ML20034G591 | |
| Person / Time | |
|---|---|
| Site: | Farley  |
| Issue date: | 03/04/1993 |
| From: | Hill R, Woodard J SOUTHERN NUCLEAR OPERATING CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| LER-93-001, LER-93-1, NUDOCS 9303100186 | |
| Download: ML20034G591 (4) | |
| Event date: | |
|---|---|
| Report date: | |
| Reporting criterion: | 10 CFR 50.73(a)(2)(iv), System Actuation 10 CFR 50.73(a)(2)(v), Loss of Safety Function 10 CFR 50.73(a)(2)(vii), Common Cause Inoperability 10 CFR 50.73(a)(2)(1) 10 CFR 50.73(a)(2)(viii)(A) 10 CFR 50.73(a)(2) 10 CFR 50.73(a)(2)(viii)(B) 10 CFR 50.73(a)(2)(x) |
| 3641993001R00 - NRC Website | |
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- r Spathern Nsclear Operating Company Post O*fce Box 1295 Bemin7.am Alabama 35201 Telephone 205 SSS 5086 m
Southem Nudear Operating Company J. D. Woodard
}'cePrgs the southem electnc system t
10 CFR 50.73 March 4,1993 Docket No. 50-364 l
l U. S. Nuclear Regulatory Commission 1
ATTN: Document Control Desk Washington, DC 20555 Joseph M. Farley Nuclear Plant - Unit 2 Licensee Event Report No. LER 93-001-00 Gentlemen:
Joseph M. Farley Nuclear Plant, Unit 2 Licensee Event Report Number LER 93-001-00 is being submitted in accordance with 10 CFR 50.73.
If you have any questions, please advise.
Respectfully submitted, hkwdd
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J.
. Woodard l
BHW:cht-licevent.nrc Enclosure cc:
Mr. S. D. Ebneter Mr. G. F. Maxwell 090090 g;
9303100186 930304 W
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4RC For1h 366 U.S. lALLEAR REBLAT321 COMISSI3d APPR;WED DE 60. 3D0-0104
, (66)
EXPIRES: 4/30/92 LICENSEE EVENT REPORT (LER)
FACIL11V hANE (1)
DOChEl hvMLER (2)
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Joseph M. Farley Nuclear Plant - Unit 2 05000364 1
g,l3 iliLE (4)
Inadvertent Safety Injection Due To Personnel Error i
EVEki DATE (5)
LER'huMbER (6)
REPOR1 DATE (7) 01HER FACILii!ES lhv0LVED (8)
MONiM DAY YEAR YEAR SEQ hum REV MohT F DAY YEAR IACILlif NAMES D00611 huMBER(S) h 05000 l
02 05 93 93 001 00 03 04 93 05000 inl$ utPoR1 15 SusMiiiED PuRSuANI lo tr:E REQUIREMENIS OF 10 CfR (11) gp,,,,
MODE (9) 5 x
20.402(b) 20.405(c) 50.73(a)(2)(iv) 73.71(b)
LEVEL 000 50.73(a)(2)(v) 73.71(c) 20.405(a)(1)(i) 50.36(c)(1e POWER 20.405ca>c1)(ii)
[ 50.36(c)(2) 50.73(a)(2)(vii)
CTHER (Specify in f
20.405(e)(1)(iii) 50.73(a)(2)(1) 50.73(a)(2)(viii)(A)
Abstract EMOW) 20.405(a)(1)(iv) 50.73(a)(2)(ti) 50.73(a)(2)(viii)(B) 20.405(a)(1)(v) 50.73(a)(2)(lii) 50.73(a)(2)(x)
LICENSEE CONTACi f0R THIS LER (ii) l 4AME TELEPHONE NUMEER (REA CODE R. D. Hill. General Manager - Nuclear Plant
'205 899-5156 l
COMPLEIE ChE LihE f0R EACH FAILURE DESCRIBED IN THIS REPORT (13)
CAUSE
SYSTEN COMPONENT MAhU AC-R PORI
CAUSE
SYSTEM COMPONENT MANUFAC-R PORT pgg TURER t
d 1
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i SUPPLEMENIAL kEPORT EXPECIED (14)
MONIH DAY YEAR i
EXPECTED SUBMISSION
] YES(If yes, complete EXPECTED SUBMISSION DATE)
] ND DATE (15)
ABSTRACI (16) i on 2-5-93, preparations were being made for ~.Jnit 2 entry into mode 4 after a cold shutdown outage. At 0344 on 2-5-93, an inadvertent
'A' train safety injection (SI) occurred during the performance of FNP-2-STp-33.0A, " Solid State f
1 Protection System Train A Operability Test".
The control room responded to the l
l inadvertent actuation and subsequently terminated the SI and returned the l
l Engineered Safety Features (ESF) systems to their pre-SI alignment.
All ESF l
equipment functioned properly in response to the
'A'. train S1 signal.
During performance of the surveillance test procedure (STP) with the plant in i
~
Mode 5, the lights on the Bypass and Permissive panel should illuminate when the Iow pressurizer pressure safety injection and low steamline pressure safety l
injection signals are blocked. Een attempting to block these signals the 4
operator noted the lights did not illuminate. He incorrectly concluded this was the correct response and failed to communicate this observation to other crew members and correct the problem before proceeding to'the next step of the procedure.
FNP has concluded that the failure to block the safety injection signals as designed was due to the misoperation of the block-reset hand switches.
l This event was caused by cognitive personnel error. The individual involved in
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this event has been disciplined for failure to use self-verification techniques l
and to effectively communicate with other members of his crew. As an enhancement all STP-33.0 series procedures have been revised to include the i
expected Bypass and Permissive Panel lamp indication based on plant conditions.
l This incident will be covered in licensed operator requalification training.
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". 9%, Form 3bfA U.h. NJR. TAR KLbulMUhl UMuhbaUh M W JVLU 082 W.ubO-M D4 (6-895 EXPIRES: 4/30/92 LICENSEE EVENT REPORT'(LER)
TEXT CONTINUATION
[
rACILITY NAME (1)
DOCKET NUMBER (2)
LER huMBER-(5)
PAGE (3) f TEAR 5EQ hum iiEV j
I Joseph M. Farley Nuclear Plant - Unit 2 05000364 93 001 00 2
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j ILXI
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_ Plant and' System Identification Westinghouse - Pressurized Water Reactor l
Energy Industry Identification System codes are identified in the text as [XX].
I
- - Summary of Event On 2-5-93, preparations were being made for Unit 2 entry into mode 4 after a cold shutdown outage. At 0344 on 2-5-93, an inadvertent
'A' train safety injection (SI) [JG) occurred during the performance of FNP-2-STP-33.0A, " Solid State Protection System Train A Operability Test" due to cognitive personnel error. The control room responded to the inadvertent actuation and subsequently terminated the SI and returned the Engineered Safety Features (ESF) systems to-
}
their pre-SI alignment. All ESF equipment functioned properly in response to the
'A' train SI signal.
i l
Description of Event
On 2-5-93 at 0300, preparations were being made for Unit 2 entry into mode 4 following a cold shutdown outage.
Operations personnel were performing FNP-2-STP-33.0A, " Solid State Protection
[
System Train A Operability Test" The test was successfully completed up to the step in which the operator blocks the low pressurizer pressure and low j
steamline pressure safety injection signals. When these' signals are blocked-with the plant in these conditions (Mode 5), lights on the Bypass and Permissive panel illuminate. When the operator attempted to block the low pressurizer.
i pressure and low steamline pressure safety injection signals, the lights did not l
illuminate. He noted these lights did not illuminate and incorrectly concluded
(
this was the correct response. He failed to communicate this observation to j
~
other crew members and to correct the problem before proceeding to the next step
.[
of the procedure. At approximately 0344, SSPS was returned to normal which j
resulted in-a safety injection on ' A' train.
All ESF equipment functioned properly in response to the
'A' train SI signal.
The control room responded to the inadvertent actuation and subsequently l
terminated the SI and _ returned the ESF systems to their pre-SI alignment.
j i
'FNP has concluded that the failure to block the safety injection signals as-j designed was due to the misoperation of the block-reset hand switches. The operator mistakenly placed the block-reset switches,to the reset position'vice the block position. Had he positioned the switches to block, the bypass and i
permissive panel lights would have illuminated, signifying that the low pressurizer pressure and the low steamline pressure SI signals were blocked.
Subsequent to.the event, the SSPS was extensively tested to verify that there was no equipment malfunction and STP-33.0A was performed successfully prior to
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returning to power.
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W, torin botA u.5. hJLAUn uutAiAt LJNb5idh Arr%Jctil UMo fa a150-Giu4
-, (F69)
EXP]RES: 4/30/92 LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION FAC]hlTY NARE (1)
DOCKET NUMBER (2)
LER NUMBER (5)
PAGE (3)
VEAR 5EQ hum REV i
Joseph M. Farley Nuclear Plant - Unit 2 05000364 93 001 00 3
or 3
IEAT i
Cause of Event
This event was caused by cognitive personnel error. At this step in the surveillance test procedure (STP) and the plant in this condition (Mode 5), the lights on the Bypass and Permissive panel illuminate when the low pressurizer pressure safety injection and low steamline pressure safety injection signals are blocked. The operator noted these lights did not illuminate. He incorrectly concluded this was the correct response and failed to communicate this observation to other crew members and correct the problem before proceeding to the next step of the procedure.
FNP has concluded that the failure to block the safety injection signals as designed was due to the misoperation of the block-reset hand switches.
Reportability Analysis and Safety Assessment This event is reportable due to the actuation of ESF equipment.
All
'A' train ESF equipment functioned properly in response to this event.
The health and safety of the public was not affected.
Corrective Action
The individual involved in this event has been disciplined for failure to use self-verification techniques and to effectively communicate with other members of his crew. As an enhancement all STP-33.0 series procedures have been revised to include the expected Bypass and Permissive Panel lamp indication based on
plant conditions
This incident will be covered in the licensed operator requalification training program.
Additional Information
Similar events involving safety injections caused by personnel error were reported in Units 1 LER 89-006-00, 88-024-00, 92-003-00 and Unit 2 LER 89-005-00.
No components failed during this event, r
This event would not have been more severe if it had occurred under different operating conditions.