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 |
| From: | Rossi C Office of Nuclear Reactor Regulation |
| To: | |
| References | |
| IN-87-025, NUDOCS 9706050211 | |
| Download: ML031130574 (6) | |
SSINS No.: 6835 IN 87-25 UNITED STATES
NUCLEAR REGULATORY COMMISSION
OFFICE OF NUCLEAR REACTOR REGULATION
WASHINGTON, D.C. 20555 June 11, 1987 NRC INFORMATION NOTICE NO. 87-25: POTENTIALLY SIGNIFICANT PROBLEMS RESULTING
FROM HUMAN ERROR INVOLVING WRONG UNIT,
WRONG TRAIN, OR WRONG COMPONENT EVENTS
Addressees
or a
All nuclear power reactor facilities holding an operating license (OL)
construction permit (CP).
Purpose
signif- This information notice is provided to inform recipients of potentiallytrain, or
icant problems resulting from human error involving wrong unit, wrong
infor- wrong component events. It is expected that recipients will review the
mation for applicability and consider actions, if appropriate, to preclude
in
similar problems from occurring at their facilities. Suggestions contained action
this notice do not constitute NRC requirements; therefore, no specific
or written response is required.
Description of Circumstances
terminal
On April 14, 1987, with Calvert Cliffs Unit, 1 in Mode 5 and electrical to
boxes open for equipment qualification work, plant personnel were attempting
use a portion of the containment spray system to fill the safety injection
1 tanks. In preparation for this, an operator had been sent to close a Unit
containment spray valve. However, the operator mistakenly closed the corre- sponding Unit 2 containment spray valve. The inadvertent containment spray
actuation resulted in approximately 4000 gallons of borated water being in- jected into the Unit 1 containment and created the potential for electrical
equipment degradation due to wetting by borated water (boric acid intrusion).
Discussion:
A large number of reports have been made to the NRC that describe events wrong
resulting from human error involving actions performed on the wrong unit, Office
train, or wrong component. A study published in January 1984 by the NRC
for Analysis and Evaluation of Operational Data, "Human Error in Events Involv- ing Wrong Unit or Wrong Train," and supplementary reports on August 8, 1984, more
February 13, 1986, September 19, 1986, and May 20, 1987, have identified indi- than 200 events of this nature that have occurred since 1981. The data
cate that there does not appear to be any substantial change in the rate of
occurrence in events per reactor year, and that the rate of these events at
87000
IN 87-25 June 11, 1987 plants with little operating experience seems to be higher than that at plants
with 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 in
NUREG-1192, "An Investigation of the Contributors to Wrong Unit or Wrong Train
Events," indicates that some of the primary causes of the events studied were
inadequate labeling of plant equipment, components, and areas; inadequate personnel
training and experience; and inadequate procedures. Examples of actions taken
by licensees to help prevent recurrence of these types of events are also given.
Adequate procedures, planning, labeling, and training of personnel usually
prevent such events from happening. In addition, an independent verification
program can assist in promptly identifying and correcting the misalignment of
plant systems. The frequency and number of such events being reported to the
NRC 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 protection
signal bistables had been tripped to test Channel N44; however, a test signal
simulating an increased power level was inadvertently input to Channel N43.
This created the necessay 2 out of 4 coincidence logicand the reactor tripped
on simulated overpower AT.
On January 11, 1986, with St. Lucie 2 at power, an operator was performing the
weekly turbine overspeed surveillance. A manual turbine trip (and subsequent
reactor trip) occurred when the operator inadvertently actuated the turbine
trip lever instead of the test lever.
On March 18, 1985, with Surry 1 and 2 at power, an operator assigned to "lock
out" the automatic initiation of CO2 portion of the fire protection system for
Fire Zone #8 (the Unit 2 containment penetration area) to facilitate construc- tion activities, mistakenly "locked out" the CO2 for Fire Zone #5 (the Unit 1 cable 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 /> and
resulted in a violation of the Technical Specifications (no fire watch in
affected area).
References:
Information on independent verification programs is provided by IE Information
Notice 84-51, "Independent Verification." Information regarding inadvertent
defeat of safety function caused by human error involving wrong unit, wrong
train, or wrong component events is provided by IE Information Notice 84-58,
"Inadvertent Defeat of Safety Function Caused by Human Error Involving Wrong
Unit, Wrong Train, or Wrong System."
IN 87-25 June 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 Regional
Administrator of the appropriate regional office or this office.
h/ar szE.Rossi, Director
Division of Operational Events Assessment
Office of Nuclear Reactor Regulation
Technical Contact:
Jack Ramsey, NRR
(301) 492-9081 Attachment: List of Recently Issued NRC Information Notices
---
Attachment 2 IN 17-13 Jlune U, no
LIST OP RECENTLY ISSUED
INFORMPATION NOTICES 1987
, AnTor2n%10f Date of
Netfice No. Sublect tssuenci I ?glued to -
J7-24 Operational Exprienceo 1/4/17 All nuclear power
Involving Lossos of reactor facilities
Elct rcal Inverters holding an OL or CP.
87-S3 Loss of Decay Heat Removal 5/27/87 All PWl facilities
During Low Reactor Coolant holding an OL or CP.
Level Operation
J7-22 Operator Licensing Requal- 5/22/87 All research and
fication Exuainations at nonpower reactor
Nenpower Reactors facilities.
- 7-21 Shutdown Order Issued Because 51/2187 All nuclear power
Licensed Operators Asleep facilities holding
While on Duty an OL or CP and all
licensed operators.
87-20 Hydrogen Leak In Auxiliary 4/20/87 All nuclear power
Building facilities holding
85-108 Degradation of Reactor 4/20/87 All PWR facilities
Sup. 1 Coolant System Pressure holding an OL or CP.
Boundary Resulting from
Boric Acid Corrosion
864 Deficiencies In Upgrade 4/20/87 All nuclear power
Sup. 1 Program for Plant facilities holding
Emergency Operating a CP or OL.
Procedures.
85-61 Nisadministrations to 4/15/87 All licensees
Sup. 1 Patients Undergoing Thyroid authorized to use
Scans byproduct material
87-19 Perforation and Cracking of 4/9/87 All Westinghouse
Rod Cluit roC-ntrol Asseoblies power PWNfadTit..
87-18 Unauthorized Service on 4/8/87 All NRClicensees
Telatherapy Units by Non- authorized to use
licensed maintenance Personnel radioactive material
in toletherapy units
- Operating License
CP - Construction Pemit
UNITED STATES
NUCLEAR REGULATORY COMMISSION FIRST CLASS MAIL
WASHINGTON, D.C. 20556 POSTAGE & FEES PAID
WASH. D.C.
OFFICIAL BUSINESS PERMIT No. G4n
PENALTY FOR PRIVATE USE. S300
IN 87-25 June 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 Regional
Administrator of the appropriate regional office or this office.
Charles E. Rossi, Director
Division of Operational Events Assessment
Office of Nuclear Reactor Regulation
Technical Contact:
Jack Ramsey, NRR
(301) 492-9081 Attachment: List of Recently Issued NRC Information Notices
- See Previous Concurrence
OGCB:DOEA:NRR* PPMB:ARM* C/OGCB:DOEA:NRR*
JRamsey MHarwell CHBerlinger CERossi
06/4/87 06/4/87 06/4/87 06/,5/87
IN 87-XX
June 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 Regional
Administrator of the appropriate regional office or this office.
Charles E. Rossi, Director
Division of Operational Events Assessment
Office of Nuclear Reactor Regulation
Technical Contact:
Jack Ramsey, NRR
(301) 492-9081 Attachment: List of Recently Issued NRC Information Notices
OGC BOEA:NRR PP RM C/ aPEA:NRR
JRamsey MHPrwell CHBerlinger
06/fI /87 06/ 1/87 06/ /87 06 " 87