ML17222A410

LER 88-005-00:on 880714,inadvertent Start of 1A Diesel Generator During Troubleshooting Occurred.Caused by Personnel Error.Personnel counselled.W/880815 Ltr

ML17222A410
Person / Time
Site:	Saint Lucie
Issue date:	08/15/1988
From:	Conway W, Andrea Johnson FLORIDA POWER & LIGHT CO.
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
L-88-341, LER-88-005-02, LER-88-5-2, NUDOCS 8808190221
Download: ML17222A410 (6)

Text

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AC CELEMTED ÃS7IUBUTION DEMONSTRATION SYSTEM C,

REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:8808190221 DOC.DATE: 88/08/15 NOTARIZED: NO DOCKET g FACIL:50-335 St. Lucie Plant, Unit 1, Florida Power & Light Co. 05000335 AUTH. NAME AUTHOR AFFILIATION JOHNSON,A.B. Florida Power & Light Co.

CONWAY,W.F. Florida Power & Light Co.

RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 88-005-00:on 880714,inadvertent start, of 1A diesel ,R generator during trouble shooting due to personnel error.

W/8 ltr.

DISTRIBUTION CODE: IE22D COPIES RECEIVED:LTR J ENCL ~

TITLE: 50.73 Licensee Event Report. (LER), Incident Rpt, etc.

SIZE:

NOTES: 8 RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-2 LA 1 1 PD2-2 PD 1 1 TOURIGNY,E 1 1 INTERNAL: ACRS MICHELSON 1 1 ACRS MOELLER 2 2 ACRS WYLIE 1 1 AEOD/DOA 1 1 AEOD/DS P/NAS 1 1 AEOD/DSP/ROAB 2 2 AEOD/DS P/TPAB 1 1 ARM/DCTS/DAB 1 . 1 DEDRO 1 1 NRR/DEST/ADS 7E 1 0 NRR/DEST/CEB 8H 1 1 NRR/DEST/ESB 8D 1 ~ 1 NRR/DEST/ICSB 7 1 1 NRR/DEST/MEB 9H 1 1 NRR/DEST/MTB 9H 1 1 NRR/DEST/PSB 8D 1 1 NRR/DEST/RSB 8E 1 1 NRR/DEST/SGB 8D 1 1 NRR/DLPQ/HFB 10 1 1 NRR/DLPQ/QAB 10 1 1 NRR/DOEA/EAB 11 1 1 NRR/DREP/RAB 10 1 1 NRR/DREP/RPB 10 2 2 NRR/DRIS/SIB 9A. 1 1 NUDOCS-ABSTRACT 1 1 y REG~S~ 02 1 1 RES TELFORD,J 1 1 RF~DSXR DEPY 1 1 RES/DSIR/EIB 1 1 RGN2 FILE 01 1 1 EXTERNAL EG&G WILLIAMSg S 4 4 FORD BLDG HOY,A 1 1 H ST LOBBY WARD 1 1 LPDR 1 1 NRC PDR 1 1 NSIC HARRIS,J 1 1 NSIC MAYS,G 1 1 S

A TOTAL NUMBER OF COPIES REQUIRED: LTTR 46 ENCL 45 lf

NAC Foam 388 U.S. NUCLEAR REGULATORY COMMISSION IQ 83 I APPROVED DMS NO, 315041St EXPIRES: SI31l88 LICENSEE EVENT REPORT {LER)

PA 5 3I FACILITY NAME Ill DOCKET NUMSE(l Cll St. Lucie, Unit 1 o 5 o o o33 5~oF03 INADVERTENT START OF 1A DIESEL GENERATOR DURING TROUBLESHOOTING DUE TO, PERSONNEL ERROR EVENT DATE ISI LER NVMSER (N REPORT DATE (7l O'THER FACILI'TIES INVOLVED (SI SQGUQNTI*L AQ"+aGN MDNTH PACILITY NAMES DOCKET NUMBER(SI MONTH DAY YEAR YEAR gy NVMQKII r..s NUMQQA DAY YEAR N/A 0 5 0 0 0 0 7 1 4 8 8 8 8 0 0 5 p p 0 8 1 5 8 8 0 5 0 0 0 THIS REPORT IS SUSMITTKD PVRSV ANT TO THE REOUIAEMKNTS OF 10 CFR (): ICnectt One or more Ol tne IorlornnFI l11 OPERATING 5 MODE I~ ) 20A02( ~ I 20.805(cl 50,73(e) (2) l(r) 73.71(Q)

~ OWER 20AOSI ~ l(1)(0 SOW(cl(II 50.73(eH2)(r) 73.7((c)

LKV EL p p p 20AOS(e) II I(QI 50.38(cl(21 50.73(a) (2)(rQI OTHER ISpecily in Aoatrect in Teat, HI(C Form Oerorr end 20.805( ~ l(IIliQII 50.73(aH2)(I) 50.73( ~ ) 12) (NQI (Al SSSAI 20A08(el(11(trl 50.73(el(2)(Q) 50.73(el(2)(rIQIIS) 20A05(el(I)le) 50.73 I~ ) (2) (IQ) 50.73(el(2) (el LICENSEE CONTACT FOA THIS LER (12)

NAMK TELEPHONE NUMBER AREA CODE A. B. Johnson, Shift Technical Advisor 4 0 3 5 0 COMPLETE ONK LINK FOR EACH COMPONENT FAILURE DESCAISED IN THIS REPORT (13)

MANVFAC AEPOR'TASLK MANUFAC CAUSE SYSTEM COMPONENT TD NPRDS COMPONENT TUAER TVREA X ~ EK 62 A 348 55y3)<VC'E(

ka!A% MONTaa DAY YEAR SUPPLEMENTAL REPORT EXPECTED (ICI EXPECTED SUSMISSIDN DATE (15)

YKS III yet, complete EXPECTED SUSMISSIOH DATEI NO AEETAAcT ILimlt to te00 apecea, I,e.. epprorimetely Iilteen ainpleopece typewritten lineal (18)

On July 14, 1988, the 1A Diesel Generator was inadvertently started at the local Diesel Generator Control Panel. The inadvertent start was a result of testing a relay in the diesel generator start circuits via an electrical jumper. The troubleshooting activity was limited to testing of a designated relay. The starting of the diesel generator was not part of the planned troubleshooting activity.

The root cause of the event was a cognitive personnel error by a utility maintenance supervisor and a utility system engineer who did not fully under-stand the effects of testing the relay.

The personnel involved have been counselled on the need to perform a more thorough review to fully understand the effects on plant systems before testing components in control circuits.

g p~2 88o8>F02 8808iS PDF, ADO<< ~ o>OOO38Z NAC Form 388 a9 83a PDC

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NRC Form 3BEA U.S. NUCLEAR REGULATORY COMMISSION (943)

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVEO OMB NO. 3150M)04 EXPIRES: 8/31/88 FACILITY NAME (1) DOCKET NUMBER (3) LER NUMBER (8) PACE (3)

YEAR em SEQUENTIAL,d . REVISION NUMBER 'F.d NUMBER St. Lucie Unit 1 o s o o o3 35 88 0 05 00 02 OF 0 3 TEXT /// moro F/>>co /I ro//I/rod, FM Fddldor>>/NRC Form 388AM ((7)

DESCRIPTION OF EVENT At 1357 hours0.0157 days <br />0.377 hours <br />0.00224 weeks <br />5.163385e-4 months <br /> on July 14, 1988, with the Unit in Mode 5 and the 1A Diesel Generator (EIIS:EK) out of service, the 1A Diesel Generator was inadvertently started locally from the lA Diesel Generator Control Panel. The inadvertent start was a result of testing a relay in the 1A Diesel Generator Start Circuits via electrical jumper. The electrical jumper not only energized the intended relay for testing but also energized the start relay for the diesel generator.

The purpose of the testing activity was to locate a faulty relay that failed to work properly during the 18 month Engineered Safety Feature (EIISEBE,BP,BQ,EK) surveillance test. The control room was immediately aware of the inadvertent start of the lA Diesel Generator. The Reactor Control Operator secured the diesel generator through its normal shutdown sequence.

CAUSE OF EVENT The root cause of the event was a cognitive personnel error by a utility maintenance supervisor and a utility system engineer who did not fully understand the effects on the system of testing the relay. The troubleshooting activity was covered by an approved Plant Work Order procedure. However, the specific troubleshooting steps were determined in the field. There were no unusual characteristics of the work location that directly contributed to the personnel error.

The faulty relay was identified to be a time delay pickup relay in the diesel generator output breaker closing circuits. Its contacts failed to open after its one second time delay, thus preventing the 1A Diesel Generator output breaker from closing during the 18 Month Engineered Safety Feature test.

ANALYSIS OF EVENT This event is reportable under 10 CFR 50.73 (a)(2)(iv) because it resulted in an automatic actuation of an Engineered Safety Feature that was not part of a preplanned sequence during testing. However, the event was determined to have had a negligible impact on plant safety because only one diesel generator was required to be operable in Mode 5. The 1B Diesel Generator was operable during this event. Furthermore, in the plant Modes when both diesel generators are required, the Technical Specification allows a diesel generator to be placed out of service for maintenance testing provided that the ACTION STATEMENT is met for the Limiting Condition For Operation.,

NRC FORM SBBA 194)3)

NRC Form 366A US. NUCLEAR REOULATORY COMMISSION 1943)

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVED OMB NO. 3150-0)04 EXPIRES: 6/31/BB FACIL1TY NAME 11) DOCKET NUMBER Il) LER NUMBER 16) PACE 13)

YEAR SEOUENTIAL:.rrXi rIEVISION N)(. NUMBEII ~85 NUM EA St. Lucie Unit 1 8 8 005 0 0 3 OF 0 3 0 5 0 0 0 TEXT /lfmoro e/>>cp ie rer)rr/red, rreo eddrTr'orre/HRC %%drm 3BBAB/117)

CORRECTIVE ACTIONS

1. The 1A Diesel Generator was secured through -its normal shutdown sequence.

2. The faulty relay was replaced and the lA Diesel Generator was returned back to service.

3. A Human Performance Evaluation System (HPES) evaluation was performed to determine root causes of the personnel error.

4. The personnel involved have been counselled on the need to perform a more thorough review to fully understand the full effects on plant systems before testing components in control circuits.

ADDITIONAL INFORMATION FAILED COMPONENT INFORMATION:

Manufacturer AMERACE Corp. (Agastat 7000 Series Relay)

Model 8: 7012 PA PREVIOUS SIMILAR EVENTS:

For the most recent LER involving Auto Start of the Emergency Diesel generator due to personnel error, see: LER f335-86-007 NRC FORM 366A M oor

P. O. ~ 14000, JUNO BEACH, FL 33408 0420 hUGUST 1 5 1988 L-88-341 10 CFR 50.73 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555 Gentlemen:

Re: St. Lucie Unit 1 Docket No. 50-335 Reportable Event: 88-05 Date of.: Event July 14, 1988 Inadverh~t"Start of lA Diesel Generator Durin Tr'oubleshootin Due to Personnel Error

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The attached Licensee Event Report is being submitted pursuant to the requirements of 10 CFR 50.73 to provide notification of the subject event.

Very truly yours, W. F. Conway Senior Vice President Nuclear WFC/GRM/cm cc: Dr. J. Nelson Grace, Regional Administrator, Region II, USNRC Senior Resident Inspector, USNRC, St. Lucie Plant GRMLER. Ol an FPL Group company

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