05000413/LER-1985-001, :on 850104,during Testing of Turbine Impulse Chamber Pressure,Motor Driven Auxiliary Feedwater Pumps 1A & 1B auto-started,initiating Reactor Trip Signal.Caused by Personnel Error.Procedure Reviewed

:on 850104,during Testing of Turbine Impulse Chamber Pressure,Motor Driven Auxiliary Feedwater Pumps 1A & 1B auto-started,initiating Reactor Trip Signal.Caused by Personnel Error.Procedure Reviewed

ML20106B351
Person / Time
Site:	Catawba
Issue date:	02/01/1985
From:	Ouellette R, Tucker H DUKE POWER CO.
To:	NRC OFFICE OF ADMINISTRATION (ADM)
References
LER-85-001, LER-85-1, NUDOCS 8502110568
Download: ML20106B351 (4)

LER-1985-001, on 850104,during Testing of Turbine Impulse Chamber Pressure,Motor Driven Auxiliary Feedwater Pumps 1A & 1B auto-started,initiating Reactor Trip Signal.Caused by Personnel Error.Procedure Reviewed

Event date:
Report date:
4131985001R00 - NRC Website

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, oe On January 4, 1985, at 1352:56 hours, Motor-Driven Auxiliary Feedwater (CA) Purcps lA and 1B auto-started during testing of the Turbine Impulse Chamber Pressure. The testing initiated an inadvertent reactor trip signal, which in turn, automatically tripped Main Feedwater (CF) pump 1A (CF pump 1B was not running), and started CA Pumps lA and 1B.

At the time of the incident, Unit I was in Mode 3 (Hot Standby), with an average Reactor Coolant terperature (Tave) of 559"F and Pressurizer pressure of approximately 1830 psig. To recover from the incident, the switch was returned to normal, the react'or trip breakers were closed, CA Pumps lA and IB were tripped. CF pumps lA and IB were reset, and CF pump 1B was started.

This incident is classified as a Personnel Error. The Instrument and Electrical (I&E) Supervisor of the test crew N/A'd a step in the Turbine Impulse Pressure Chamber test section of the procedure without thoroughly analyzing the impact on plant operation. If that step would have been performed, this incident would not have occurred.

This incident is reportable pursuant to 10 CFR 50.73, Section (a) (2)

(iv), and 10 CFR 50.72, Section (b)(2)(ii).

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Catawba Nuclear Station. Unit 1 015101010 l411 13 8l5 0l0l1 0l0 nl ? OF 0l 4 TEXT t# snore spere a segured, use e#conar NAC form JSSA'sJ 1171 Instrument Procedure IP/1/A/3222/00B (Analog Channel Operational Test Channel II 7300) is performed by the Instrun.ent and Electrical (ISE) group monthly per Work Request 3634 SWR to satisfy Technical Specification Surveillance Requirements 4.3.1.1 and 4.3.2.1 for Channel II of the Process Control System.

Section 10.8 of the procedure is the test of the Turbine Impulse Chamber Pressure. During that section, the Turbine Impulse Pressure test switch is placed in the test position, which in turn simulates greater than 10% turbine or reactor power. The actuation of one of two impulse pressure channels serves as an input that gives a P-7 Signal, a signal that unblocks "at power" reactor trips it the Reactor Trip Breakers are closed and P-13 status light (Turbine not at power) is lit. A combination of the P-7 signal and any of the following will initiate a Reactor Trip;

1) High Pressurizer Level, 2) Iow Pressurizer pressure, 3) Reactor Coolant Pump Bus Underfrequency,

4) Reactor Coolant Pump Bus Undervoltage, 5) Two Reactor Coolant Loops Loss of Flow.

During the performance of procedure IP/1/A/3222/00B, two significant plant conditions existed.

First, the Unit was in Mode 3 with the pressurizer pressure being maintained at approximately 1830 psig. This was because the Upper Head Injection (UHI) System was out of service due to Nuclear Station Modification (NSM) #CN-10337 and because of a high concentration of entrained gases in the UHI accumulator.

Second, rod drop testing was being performed per IP/0/A/3220/01 (Full length Rod Cluster Control Assembly Drop Timing-IRE System).

On January 4, 1985, at approximately 1300 hours0.015 days <br />0.361 hours <br />0.00215 weeks <br />4.9465e-4 months <br />, Section 10.8 of IP/1/A/3222/00B was started when the I&E Technician notified the Senior Reactor Operator that one Channel of Turbine Impulse Pressure would be tested.

Step 10.8.1 of the procedure gave the following conditions:

If Rx trip breakers are closed and ISI18.14.01 (P-13 Turbine not at power) is on, verify the following annunciators are not in alarm state:

1AD06.01.09 PZR Hi Level Alert IAD06.04.08 PZR Lo Press Alert 1AD06.06.05 UV NC Pump Bus Alert 1AD06.04.05 Under freq. NC Pump Bus Alert Verify that not more than one of the following annunciators are in the alarm state:

1AD06.01.01 Loop A Lo Flow Alert 1AD06.01.02 Loop B Lo Flow Alert 1AD06.01.03 Loop C Lo Flow Alert l

1AD06.01.04 Loop D Lo Flow Alert If any of these conditions exist, DO NOT PROCEED, l

notify I&E Supervisor.

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LER NUMSER (6)

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'. M YEAR Catawba Nuclear Station, Unit 1 015 l 0 l 0 l 01411 l 3 81 5 0 l0l1 0l0 0 13 OF 0l4 TEXT (# swre space a naquesd, ese menonal NAC Forsn J66A'al(ID The I&E Technician found that the Reactor trip breakers were closed for rod drop testing and ISI18.14.01 was lit.

Then he checked the other alarms. He found annunciator 1AD06.04.08 lit.

This was because pressurizer pressure was less than 1945 psig.

The I&E Technician then asked the Shift Technical Advisor (STA) and Nuclear Control Operator (NCO) about the effects on plant operation by continuing with the procedure.

The SIA and NCO related to him the effects on safety injection by continuing with the procedure. The STA told the I&E Technician that safety injection would not be affected.

After this conversation, the I&E Technician discussed the step with I&E Supervisor A.

After further discussing the step with I&E Supervisor B and an I&E Staff Engineer, I&E Supervisor A decided to continue with the procedure and N/A'd step 10.8.1.

This decision was made because low power reactor trips were believed to be blocked due to the indication of status light 1SI18.11.02 (P-7 low power Reactor Trips blocked). Also, the decision was based on the conversations with the STA and NCO.

At 1351:52:872 hours, the Turbine Impulse Pressure test switch was placed in the test position per step 10.8.3 of IP/1/A/3222/00B by the I&E Technician.

Simultaneously, low power reactor trips were unblocked and a pressurizer low pressure reactor trip signal was initiated. The reactor trip breakers opened. Since Tave was low at the time, a combination of low Tave and a Reactor Trip signal gave a Feedwater Isolation signal. This tripped Main Feedwater (CF) pump A (CF pump B was not running but also received a trip signal). Loss of both CF pumps caused the auto-start of both motor-driven Auxiliary Feedwater (CA) pumps.

Immediately after the incident, the I&E Technician placed the Turbine Impulse Pressure test switch in the normal position.

The Reactor Trip breakers were closed, CF pump 1A was reset, and both CA pumps were shutdown by the NCO. When the NCO attempted to return CF pump 1A to service, its discharge valve would not reopen. The NCO then reset and placed CF pump 1B in service to feed the steam generators. A work request was issued to repair CF pump 1A's discharge valve.

This incident is classified as a Personnel Error.

Since I&E Supervisor A N/A'd and initialed step 10.8.1 in IP/1/A/3222/00B, he is responsible for analyzing the impact on plant operation of not performing the step.

However, I&E Supervisor A did not review logic diagrams or drawings

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before making his decision. He was under the assumption that P-7 Reactor Trips were blocked, and was unaware that moving the Turbine Impulse Pressure test switch to the test position would unblock those trips. There was also miscommunication. The I&E Supervisor relied on conversation with the STA and NCO instead of discussing the issue with the appropriate individual, the Shift Supervisor.

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.U S. NUCLEJJ kEIULATORY COMMIS510N UCEN!EE EVENT REPORT (LER) TEXT CONTINUATION ueRovEO oMe No siso-cio4 E XPIR ES. $/31/85 FACILITY NAME (Il DOCKEY NUMBER GI LER NUMBER (61 PAGE131 II Ab I] h YEAR Catawba Nuclear Station, Unit 1 0 l5 l0 l0 l01411 l 3 81 5 0 l0 l1

-- 0l0 0 13 OF gl4 rur a mee wa s mens. m aeww nc ram nwmm The I&E Technician found that the Reactor trip breakers were closed for rod drop testing and ISI18.14.01 was lit.

Then he checked the other alarms, He found annunciator 1AD06.04.08 lit.

This was because pressurizer pressure was less than 1945 psig.

The I&E Technician then asked the Shift Technical Advisor (STA) and Nuclear Control Operator (NCO) about the effects on plant operation by continuing with the procedure.

The STA and NCO related to him the effects on safety injection by continuing with the procedure. The STA told the I&E Technician that safety injection would not be affected. After this conversation, the I&E Technician discussed the step with I&E Supervisor A.

After further discussing the step with I&E Supervisor B and an I&E Staff Engineer, I&E Supervisor A decided to continue with the procedure and N/A'd step 10.8.1.

This decision was made because low power reactor trips were believed to be blocked due to the indication of status light ISI18.11.02 (P-7 low power Reactor Trips blocked). Also, the decision was based on the conversations with the STA and NCO.

__ At 1351:52:872 hours, the Turbine Impulse Pressure test switch was placed

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in the test position-per_ step 10.8.3 of IP/1/A/3222/00B by the I&E Technician.. Simultaneously, low power reactor trips were unblocked and a pressurizer low pressure reactor trip signal was' initiated. The reactor trip breakers opened.

Since Tave was low at the time, a combination of low Tave and a Reactor Trip signal gave a Feedwater Isolation signal. This tripped Main Feedwater (CF) pump A (CF pump B was not running but also received a trip signal). Loss of both CF pumps

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caused the auto-start of both motor-driven Auxiliary Feedwater (CA) pumps.

Immediately after the incident, the I&E Technician placed the Turbine Impulse Pressure test switch in the normal position.

The Reactor Trip breakers were closed, CF pump 1A was reset, and both CA pumps were shutdown by the NCO.

When the NCO attempted to return CF pump 1A to service, its discharge valve would not reopen. The NCO then reset and placed CF pump 1B in service to feed the steam generators. A work request was issued to repair CF pump 1A's discharge valve.

This incident is classified as a Personnel Error. Since I&E Supervisor A N/A'd and initialed step 10.8.1 in IP/1/A/3222/00B, he is responsible for analyzing the impact on plant operation of not performing the step.

However, I6E Supervisor A did not review logic diagrams or drawings before making his decision. He was under the assumption that P-7 Reactor Trips were blocked, and was unaware that moving the Turbine Impulse Pressure test switch to the test position would unblock those trips. There was also miscommunication. The I&E Supervisor relied on conversation with the STA and NCO instead of discussing the issue with the appropriate individual, the Shift Supervisor.

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NRC Perm 366A U.S. NUCLEMt F.EIULATORY COMMIS$10N I"

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION e.PrRovEo oms No. 3 iso-oio4 E XPIRES. 8/3145 FACILITY NAME (1)

DOCKET NUMBER (2)

LER NUMSER (6)

PAGE (3)

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==n Catawba Nuclear Station, Unit 1 0 l5 l0 l0 l0 l4 l 113 81 5 Ol0 l1 010 0l 4 OF 0l4 TEXT (X tmue space e requed, use annonal NRC Form 366A'sn1h It was felt that the procedure was adequate in that it instructed the person to not proceed if any of the conditions were met.

However, the effects of not performing the step were not clearly stated.

CORRECTIVE ACTION

1.

Turbine Impulse Pressure test switch placed in normal position.

2.

Reactor trip breakere closed.

3.

Main Feedwater pumps reset.

4.

CA Pumps shutdown.

5.

Main Feedwater Pump 1B started.

6.

Work Request originated to repair valve ICF10.

7.

I&E will research step 10.8.1 in IP/1/A/3222/00B to see if there are any circumstances that the step can be N/A'd.

If they exist, they will be listed in the procedure step.

If they do not exist, a statement will be added to the step to ensure the individual performing the procedure is aware of the consequences 6f not performing the step.

8.

Personnel will be made aware of the possible effects of N/Aing steps in a procedure through review of this incident.

SAFETY ANALYSIS

All systems functioned as designed upon receipt of a reactor trip signal. Recovery from the incident was achieved promptly.

The health and safety of the public were not affected by this incident.

NRC FOKu 3664

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- DUKE POWER GOMPANY P.O. BOX 33180 CHARLOTTE. N.C. 28242 HALB. TUCKER Tr_LEPH N E vna r.msson.,

(704) 073-4531 February 1, 1985

.m Document Control Desk U. S. Nuclear. Regulatory Commission Washington, D. C.

20555 Subject: Catawba Nuclear Station, Unit 1 Docket No. 50-413 Gentlemen:

Pursuant to 10 CFR 50.73 Section (a) (1) and (d), attached is Licensee Event Report 413/85-01 concerning the auto-start of motor-driven Auxiliary Feedwater pumps during Turbine Impulse Chamber Pressure test. This event was considered to be of no significance with respect to the health and safety of the public.

Very truly yours, h8 Y

/&

Hal B. Tucker RWO: sib l

Attachment cc:

Mr. James P. O'Reilly, Regional Administrator American Nuclear Insurers U. S. Nuclear Regulatory Commission c/o Dottie Sherman, ANI Library Region II The Exchange, Suite 245 101 Marietta-Street, NW, Suite 2900 270 Farmington Avenue Atlanta, Georgia 30323 Farmington, CT 06032 INPO Records' Center Mr. Jesse L. Riley Suite 1500 Carolina Environmental Study Group 1100 Circle 75 Parkway 854 Henley Place Atlanta, Georgia 30339 Charlotte, North Carolina 28207 Palmetto Alliance M&M Nuclear Consultants 2135h Devine Street 1221 Avenue of the Americas Columbia, South Carolina 29205 New York, New York 10020 Robert Guild, Esq.

NRC. Resident Inspector P. O. Box 12097 Catawba Nuclear Station Charleston, So' '~a Carolina 29412

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