05000293/LER-2008-005, HPCI System Declared Inoperable During Surveillance Testing Due to Human Error
| ML090140337 | |
| Person / Time | |
|---|---|
| Site: | Pilgrim |
| Issue date: | 01/08/2009 |
| From: | Bronson K Entergy Nuclear Operations |
| To: | Document Control Desk, Office of Nuclear Reactor Regulation |
| References | |
| 2.09.001 LER 08-005-00 | |
| Download: ML090140337 (6) | |
| Event date: | |
|---|---|
| Report date: | |
| Reporting criterion: | 10 CFR 50.73(a)(2)(i) 10 CFR 50.73(a)(2)(vii), Common Cause Inoperability 10 CFR 50.73(a)(2)(ii)(A), Seriously Degraded 10 CFR 50.73(a)(2)(viii)(A) 10 CFR 50.73(a)(2)(ii)(B), Unanalyzed Condition 10 CFR 50.73(a)(2)(viii)(B) 10 CFR 50.73(a)(2)(iii) 10 CFR 50.73(a)(2)(ix)(A) 10 CFR 50.73(a)(2)(iv)(A), System Actuation 10 CFR 50.73(a)(2)(x) 10 CFR 50.73(a)(2)(v)(A), Loss of Safety Function - Shutdown the Reactor 10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat 10 CFR 50.73(a)(2)(i)(A), Completion of TS Shutdown 10 CFR 50.73(a)(2)(v), Loss of Safety Function 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications |
| 2932008005R00 - NRC Website | |
text
S' Entergy Entergy Nuclear Operations, Inc.
Pilgrim Nuclear Power Station 600 Rocky Hill Road Plymouth, MA 02360 Kevin H. Bronson Site Vice President January 08, 2009 U.S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D.C. 20555
SUBJECT:
Entergy Nuclear Operations, Inc.
Pilgrim Nuclear Power Station Docket No.: 50-293 License No.: DPR-35 Licensee Event Report 2008-005-00 LETTER NUMBER: 2.09.001
Dear Sir or Madam:
The enclosed Licensee Event Report (LER) 2008-005-00, "HPCI System Inoperable Due to Human Error" is submitted in accordance with 10 CFR 50.73.
This letter contains no commitments.
Please do not hesitate to contact Mr. Joseph R. Lynch, (508) 830-8403, if there are any questions regarding this submittal.
Sincerely, RMB/dI Enclosure cc:
Mr. James S. Kim, Project Manager Plant Licensing Branch I-1 Division of Operator Reactor Licensing Office of Nuclear Reactor Regulation U.S. Nuclear Regulatory Commission One White Flint North O-8C2 11555 Rockville Pike Rockville, MD 20852 INPO Records 700 Galleria Parkway Atlanta, GA 30399-5957 Mr. Samuel J. Collins Regional Administrator, Region 1 U.S. Nuclear Regulator Commission 475 Allendale Road King of Prussia, PA 19406 Senior Resident Inspector Pilgrim Nuclear Power Station
'--1F :
NRC Form 366 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150-0104
, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection,
--3. PAGE PILGRIM NUCLEAR POWER STATION 05000-293 1 of 5
- 4. TITLEHPCI System Declared Inoperable During Surveillance Testing due to Human Error
- 5. EVENT DATE
- 6. LER NUMBER
- 7. REPORT DATE
- 8. OTHER FACILITIES INVOLVED SE UENTIAL NUMBER REVISION FACILITY NAME DOCKET NUMBER MONTH DAY YEAR YEAR NUMBER MONTH DAY YEAR N/A 05000 FACILITY NAME DOCKET NUMBER 11 20 2008 2008 005 00 01 08 2009 N/A 05000 [9. OPERATING
- 11. THIS REPORT IS SUBMI'n'ED PURSUANT TO THE REQUIREMENTS OF 10 CFR: (Check all that apply)
MODE 20.2201 (b) 22.2203(a)(3)(i)
I 50.73(a)(2)(i)(C) 50.73(a)(2)(vii)
- 10. POWER 22.2202(d) 20.2203(a)(3)(ii) 50.73(a)(2)(ii)(A) 50.73(a)(2)(viii)(A)
LEVEL 100 20.2203(a)(1) 20.2203(a)(4) 50.73(a)(2)(ii)(B) 50.73(a)(2)(viii)(B) 20.2203(a)(2)(i) 50.36(3)(1 )(i)(A) 50.73(a)(2)(iii) 50.73(a)(2)(ix)(A) 20.2203(a)(2)(ii) 50.36(3)(1)(ii)(A) 50.73(a)(2)(iv)(A) 50.73(a)(2)(x) 20.2203(a)(2)(iii) 50.36(c)(2) 50.73(a)(2)(v)(A) 73.71 (a)(4) 20.2203(a)(2)(iv) 50.46 a 3 ii 50.73(a)(2)(v)(B) 73.71 (a)(5) 20.2203(a)(2)(v) 50.73(a)(2)(i)(A) 50.73(a)(2)(v)(C)
OTHER 20.2203(a)(2)(vi) 50.73(a)(2)(i)(B)
X 50.73(a)(2)(v)(D)
Specify in Abstract below Ior in
EVENT DESCRIPTION
On November 20, 2008, at 1657 hours0.0192 days <br />0.46 hours <br />0.00274 weeks <br />6.304885e-4 months <br />, the HPCI System was declared inoperable with the plant at 100%
power. No other plant equipment was out of service at the time. This action was taken because the HPCI System isolated on a Group IV signal when I&C Technicians were performing a functional test of temperature switches in the HPCI steam leak detection circuitry. This isolation was not part of the planned evolution. All isolations went to completion. HPCI was not operating at the time of the surveillance. The Group IV isolation was reset and HPCI was placed in stand-by line up at 1805 hours0.0209 days <br />0.501 hours <br />0.00298 weeks <br />6.868025e-4 months <br /> on November 20, 2008.
The I&C technicians started the surveillance at the traversing in-core probe (TIP) room. There are four; temperature switches that are tested at this location, two are located in junction box J605, and two are located in junction box J606.
J606 is located on duct work inside the TIP room west wall at elevation 31' approximately 18 inches above the floor. The terminal block does not have "Ponoma jacks" (specialty test connections) installed for easy accessibility and the technicians stated they had problems getting good contact on the terminals. (The terminal strip is a Weidmuller and the leads used were alligator clips.)
As the first temperature switch (TS-2371 D) was heated-up, the technicians stated that it seemed to take a long time to get the actuation of the temperature switch; actuation of the switch is designated by a closure of contacts and verified bycontinuity across the terminal strips designated for this switch. They finally received the closure as shown by zero resistance on the meter. They removed heat from TS-2371 D and verified no continuity across the switch, indicating the switch was open. At this point they reinstalled the temperature switch back into the duct work. The procedure calls for a second check that the temperature switch resets by verifying no voltage is present across the terminals of the next temperature switch to be tested. Heat is next applied to switch TS-2373D and verification of contact closure by observing continuity across the terminals.
The technicians stated that the steps were performed in the proper order and signed off appropriately in the procedure.
The investigation has proved that the isolation happened during the heating of the temperature switch in junction box J606 by verifying a computer point that was actuated by the closure of both these switches.
NOTE: The configuration of these switches is electrically connected in series so that it takes the closure of two switches to initiate an isolation. If the first switch was not reset before heating up the second switch the isolation would occur.
The technicians exited the TIP room and proceeded to the next location of temperature switches. Operations personnel contacted the technicians at this point and informed them of the Group IV isolation.
A Technical Specification 3.5.C.2 limiting condition for operation was entered because the HPCI System was inoperable. The NRC Operations Center was notified of the. event in accordance with 10 CFR 50.72 (b) (3) (v) (D) at 2121 hours0.0245 days <br />0.589 hours <br />0.00351 weeks <br />8.070405e-4 months <br /> on November 20, 2008 via Event Report Number 44672.
CAUSE
The root cause (RC) of this event was less then adequate application of fundamental human performance tools on the part of an I&C Technician, specifically use of situational awareness relative to task analysis, job site review, questioning attitude, and stopping when unsure (STAR technique).
Specifically, the I&C Technician proceeded to the job site with only alligator clips which is contrary to the standard job task of carrying two sets of probes (alligator and pin probes). The technician only carried alligator contacts based on his assumption that there would be installed Ponoma jacks available. Upon recognizing that no Ponoma jacks were installed, the technician continued with the task without questioning what could go wrong with only the alligator clips. Without the Pomona jacks, alligator clips are inappropriate for that work task/environment.
CORRECTIVE ACTION
The following corrective actions have been taken; I&C Technicians verified that all temperature switches that were tested were left in the proper configuration.
Additionally, the subject surveillance test was re-performed satisfactorily. Furthermore, appropriate management attention was directed to the individual(s) involved including disciplinary action.
The following corrective actions are planned; Revision of temperature switch procedures to include concurrent verification enhancements.
These corrective actions are being tracked in the Corrective Action Program (CAP) under Condition Report CR-PNP-2008-3693.
SAFETY CONSEQUENCES
The condition posed no threat to public health and safety.
The event occurred during normal power operation while at 100% power with the mode switch in the RUN position. The reactor vessel pressure was approximately 1030 psig with reactor water temperature at saturation temperature for that pressure.
The Core Standby Cooling Systems (CSCS) consist of the HPCI System, Automatic Depressurization System (ADS), Core Spray System, and the Residual Heat Removal (RHR) System in the Low Pressure Core Coolant Injection (LPCI) mode. Although not part of the CSCS, the Reactor Core Isolation Cooling (RCIC) System is capable of providing water to the reactor vessel for high pressure core cooling, similar to the HPCI System.
The HPCI System provides high pressure makeup water to the reactor vessel after isolation of the vessel.
The HPCI System was inoperable for approximately 67 minutes due to the inadvertent isolation during an I&C Surveillance test. During this time frame the ADS, Core Spray, RHR, and RCIC Systems were operable and met the 14 day Technical Specification 3.5.C.2 limiting condition for operation requirements for operating the plant with an inoperable HPCI System. These systems provided capability to supply makeup water to the vessel and ensured adequate core cooling while the HPCI System was not operable.
The HPCI System was restored to operable status and there was no long term safety significance associated with the event.
REPORTABILITY
This report is submitted in accordance with 10 CFR 50.73(a) (2) (v) (D).
SIMILARITY TO PREVIOUS EVENTS A review was conducted of Pilgrim Station LERs issued since 1998. The review focused on LERs that involved a similar event related to a procedural error or errors in the RCIC or HPCI Systems. The review found LER-2008-003-00 which was recently submitted due an inadvertent RCIC Group V isolation signal during the performance of an I&C surveillance. This event was due to a procedure error and not due to a human error.
ENERGY INDUSTRY IDENTIFICATION SYSTEM (EIIS) CODES The EIlS codes for Components and Systems referenced in this report are as follows:
COMPONENTS CODES Valve, Isolation (MO-2301-4, MO-2301-5)
ISV SYSTEMS High Pressure Coolant Injection (HPCI)
Containment Isolation Control System (PCIS)
BJ JM