Information Notice 1987-25, Potentially Significant Problems Resulting From Human Error Involving Wrong Unit, Wrong Train, or Wrong Component Events
| ML031130574 | |
| Person / Time | |
|---|---|
| Issue date: | 06/11/1987 |
| Revision: | 0 |
| From: | Rossi C E Office of Nuclear Reactor Regulation |
| To: | |
| References | |
| IN-87-025, NUDOCS 9706050211 | |
| Download: ML031130574 (6) | |
SSINS No.: 6835IN 87-25UNITED STATESNUCLEAR REGULATORY COMMISSIONOFFICE OF NUCLEAR REACTOR REGULATIONWASHINGTON, D.C. 20555June 11, 1987NRC INFORMATION NOTICE NO. 87-25: POTENTIALLY SIGNIFICANT PROBLEMS RESULTINGFROM HUMAN ERROR INVOLVING WRONG UNIT,WRONG TRAIN, OR WRONG COMPONENT EVENTS
Addressees
- All nuclear power reactor facilities holding an operating license (OL) or aconstruction permit (CP).
Purpose
- This information notice is provided to inform recipients of potentially signif-icant problems resulting from human error involving wrong unit, wrong train, orwrong component events. It is expected that recipients will review the infor-mation for applicability and consider actions, if appropriate, to precludesimilar problems from occurring at their facilities. Suggestions contained inthis notice do not constitute NRC requirements; therefore, no specific actionor written response is required.
Description of Circumstances
- On April 14, 1987, with Calvert Cliffs Unit, 1 in Mode 5 and electrical terminalboxes open for equipment qualification work, plant personnel were attempting touse a portion of the containment spray system to fill the safety injectiontanks. In preparation for this, an operator had been sent to close a Unit 1containment spray valve. However, the operator mistakenly closed the corre-sponding Unit 2 containment spray valve. The inadvertent containment sprayactuation resulted in approximately 4000 gallons of borated water being in-jected into the Unit 1 containment and created the potential for electricalequipment degradation due to wetting by borated water (boric acid intrusion).Discussion:A large number of reports have been made to the NRC that describe eventsresulting from human error involving actions performed on the wrong unit, wrongtrain, or wrong component. A study published in January 1984 by the NRC Officefor Analysis and Evaluation of Operational Data, "Human Error in Events Involv-ing Wrong Unit or Wrong Train," and supplementary reports on August 8, 1984,February 13, 1986, September 19, 1986, and May 20, 1987, have identified morethan 200 events of this nature that have occurred since 1981. The data indi-cate that there does not appear to be any substantial change in the rate ofoccurrence in events per reactor year, and that the rate of these events at87000 IN 87-25June 11, 1987 plants with little operating experience seems to be higher than that at plantswith more experience. Examples of recent events caused by human error involv-ing the wrong unit, wrong train, or wrong component are described below.A study performed by the Office of Nuclear Reactor Regulation and reported inNUREG-1192, "An Investigation of the Contributors to Wrong Unit or Wrong TrainEvents," indicates that some of the primary causes of the events studied wereinadequate labeling of plant equipment, components, and areas; inadequate personneltraining and experience; and inadequate procedures. Examples of actions takenby licensees to help prevent recurrence of these types of events are also given.Adequate procedures, planning, labeling, and training of personnel usuallyprevent such events from happening. In addition, an independent verificationprogram can assist in promptly identifying and correcting the misalignment ofplant systems. The frequency and number of such events being reported to theNRC suggest that industry needs to increase its attention in these areas.Additional Events:On May 13, 1986, with Kewaunee at power, personnel were performing a surveil-lance procedure on the power range nuclear instrumentation. The protectionsignal bistables had been tripped to test Channel N44; however, a test signalsimulating an increased power level was inadvertently input to Channel N43.This created the necessay 2 out of 4 coincidence logicand the reactor trippedon simulated overpower AT.On January 11, 1986, with St. Lucie 2 at power, an operator was performing theweekly turbine overspeed surveillance. A manual turbine trip (and subsequentreactor trip) occurred when the operator inadvertently actuated the turbinetrip lever instead of the test lever.On March 18, 1985, with Surry 1 and 2 at power, an operator assigned to "lockout" the automatic initiation of CO2 portion of the fire protection system forFire Zone #8 (the Unit 2 containment penetration area) to facilitate construc-tion activities, mistakenly "locked out" the CO2 for Fire Zone #5 (the Unit 1cable vault). This error went undetected for approximately 10 hours1.157407e-4 days <br />0.00278 hours <br />1.653439e-5 weeks <br />3.805e-6 months <br /> andresulted in a violation of the Technical Specifications (no fire watch inaffected area).References:Information on independent verification programs is provided by IE InformationNotice 84-51, "Independent Verification." Information regarding inadvertentdefeat of safety function caused by human error involving wrong unit, wrongtrain, or wrong component events is provided by IE Information Notice 84-58,"Inadvertent Defeat of Safety Function Caused by Human Error Involving WrongUnit, Wrong Train, or Wrong System."
IN 87-25June 11, 1987 No specific action or written response is required by this information notice.If you have any questions about this matter, please contact the RegionalAdministrator of the appropriate regional office or this office.h/ar sz E.Rossi, DirectorDivision of Operational Events AssessmentOffice of Nuclear Reactor Regulation
Technical Contact:
Jack Ramsey, NRR(301) 492-9081
Attachment:
List of Recently Issued NRC Information Notices
---Attachment 2IN 17-13Jlune U, noLIST OP RECENTLY ISSUEDINFORMPATION NOTICES 1987Date of, AnTor2n%10fNetfice No.J7-2487-S3J7-22*7-2187-2085-108Sup. 1864Sup. 185-61Sup. 187-1987-18Sublect tssuenciOperational Exprienceo 1/4/17Involving Lossos ofElct rcal InvertersLoss of Decay Heat Removal 5/27/87During Low Reactor CoolantLevel OperationOperator Licensing Requal- 5/22/87fication Exuainations atNenpower ReactorsShutdown Order Issued Because 51/2187Licensed Operators AsleepWhile on DutyHydrogen Leak In Auxiliary 4/20/87BuildingDegradation of Reactor 4/20/87Coolant System PressureBoundary Resulting fromBoric Acid CorrosionDeficiencies In Upgrade 4/20/87Program for PlantEmergency OperatingProcedures.Nisadministrations to 4/15/87Patients Undergoing ThyroidScansI?glued toAll nuclear powerreactor facilitiesholding an OL or CP.All PWl facilitiesholding an OL or CP.-All research andnonpower reactorfacilities.All nuclear powerfacilities holdingan OL or CP and alllicensed operators.All nuclear powerfacilities holdingan OL or CPAll PWR facilitiesholding an OL or CP.All nuclear powerfacilities holdinga CP or OL.All licenseesauthorized to usebyproduct materialAll Westinghousepower PWN fadTit..holding an OL or CPAll NRC licenseesauthorized to useradioactive materialin toletherapy unitsPerforation and Cracking of 4/9/87Rod Cluit roC-ntrol AsseobliesUnauthorized Service on 4/8/87Telatherapy Units by Non-licensed maintenance PersonnelOL
- Operating LicenseCP -Construction PemitUNITED STATESNUCLEAR REGULATORY COMMISSIONWASHINGTON, D.C. 20556OFFICIAL BUSINESSPENALTY FOR PRIVATE USE. S300FIRST CLASS MAILPOSTAGE & FEES PAIDUSNRCWASH. D.C.PERMIT No. G4n IN 87-25June 11, 1987 No specific action or written response is required by this information notice.If you have any questions about this matter, please contact the RegionalAdministrator of the appropriate regional office or this office.Charles E. Rossi, DirectorDivision of Operational Events AssessmentOffice of Nuclear Reactor Regulation
Technical Contact:
Jack Ramsey, NRR(301) 492-9081
Attachment:
List of Recently Issued NRC Information Notices*See Previous ConcurrenceOGCB:DOEA:NRR*JRamsey06/4/87PPMB:ARM*MHarwell06/4/87C/OGCB:DOEA:NRR*CHBerlinger06/4/87CERossi06/,5/87 IN 87-XXJune xx, 1987 No specific action or written response is required by this information notice.If you have any questions about this matter, please contact the RegionalAdministrator of the appropriate regional office or this office.Charles E. Rossi, DirectorDivision of Operational Events AssessmentOffice of Nuclear Reactor Regulation
Technical Contact:
Jack Ramsey, NRR(301) 492-9081
Attachment:
List of Recently Issued NRC Information NoticesOGC BOEA:NRRJRamsey06/fI /87PP RMMHPrwell06/ 1/87C/ aPEA:NRRCHBerlinger06/ /8706 " 87