ML17223A324

LER 89-006-00:on 890816,diesel Generator 2B Placed Out of Svc W/Hydrogen Analyzer 2A Also Out of Svc.Caused by Cognitive Personnel Error by util-licensed Operator. Generator & Analyzer Returned to svc.W/890913 Ltr

ML17223A324
Person / Time
Site:	Saint Lucie
Issue date:	09/13/1989
From:	Andrea Johnson, Woody C FLORIDA POWER & LIGHT CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
L-89-335, LER-89-006-02, LER-89-6-2, NUDOCS 8909190116
Download: ML17223A324 (5)

Text

AC CKLERATED D1STRIBUTI ON DEMON STRA,'EON SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:8909190116 DOC.DATE: 89/09/13 NOTARIZED: NO DOCKET FACIL:50-389 St. Lucie Plant, Unit 2, Florida Power & Light Co. 05000389 AUTH. NAME , AUTHOR AFFILIATION JOHNSON,A.B. Florida Power & Light Co.

WOODY,C.O. Florida Power & Light Co.

RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 89-006-00:on 890816,removing DG from svc for PM resulted in condition prohibited by TS due to personnel error.

W/8 ltr.

DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL SIZE-TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.

NOTES RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-2 LA 1 1 PD2-2 PD 1 1 NORRIS,J 1 1 INTERNAL: ACRS MICHELSON 1 1 ACRS MOELLER 2 2 ACRS WYLIE 1 1 AEOD/DOA 1 1 AEOD/DS P/TPAB 1 1 AEOD/ROAB/DS P 2 2 DEDRO 1 1 IRM/DCTS/DAB 1 1 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/PEB 10 1 1 NRR/DOEA/EAB 11 1 1 NR~RDREP/RPB 10 2 2 NUDOCS-ABSTRACT 1 1 ~G FILE

~OP 1 1 RES/DSIR/EIB 1 1 RG 2 01 1 1 EXTERNAL: EG&G WILLIAMS,S 4 4 L ST LOBBY WARD 1 1 R LPDR 1 1 NRC PDR 1 1 NSIC MAYS,G 1 1 NS IC MURPHY I G A 1 1 r NUDOCS FULL TXT 1 1 D

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'QK DOCXMMZ CXÃIBOL DESK, HAMB HKH DIPQGBUTICÃ FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 40 ENCL 40

P.O. Box14000, Juno Beach, FL 33408-0420 SEPTEMSER 1 5 1989 L-89-335 10 CFR 50.73 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555 Gentlemen:

.Re: St..Lucie Unit 2 Docket No. 50-389 Reportable Event: 89-06 Date of Event.: August 16, 1989 Removing Diesel Generators From Service for Preventative Maintenance Resulted in a Condition Prohibited b Technical S ecifications due to Personnel Error 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, C. 0. Woody Acting Senior Vice President Nuclear COW/JRH/cm Attachment cc: Stewart D. Ebneter, Regional Administrator, Region Senior Resident Inspector, USNRC, St. Lucie Plant II, USNRC 85'05'2vv226 O'PO~'2 "

PDF'DOCK 05000389 8 PDC.

rP, an FPL Group company

NRC Form 38d US. NUCLEAR RECULATORY COMMISSION (04)3) APPROVED OMB NO. 31104104 EXPIRES: 8/31/88 LICENSEE EVENT REPORT (LER)

FACILITY NAME (ll DOCKET NUMBER (2) PACE 3 ST. LUCIE, UNIT 2 05000389>OF03 REMOVING DIESEL GENERATOR FROM SERVICE FOR PREVENTATIVE MAINTENANCE RESULTED IN A CONDITION PROHIBITED BY TECHNICAL SPECIFICATION DUE TO PERSONNEL ERROR EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (SI YEAR SEOVENT IAL ~'j;: REVS lON MONTH DAY YEAR FACILITYNAMES DOCKET NUMBER(S)

MONTH DAY YEAR NUMBER NUMBER 0 5 0 0 0 081 6 89 89 0 0 6 0 0 09 13 8 9 BI) 0 5 0 0 0 THIS REPORT IS SUBMITTED PURSUANT 7 0 THE REQUIREMENTB oF 10 cFR (): (chrch onr or mort ol the Iollortinp) I'11)

OPERATINO MODE (8) 20A02(b) 20.405(c) 50,73(e I (2) I Ir) 73.7)Os)

.POWER 20.405(e) II) I I) 80M(c)(I) 60,73(s) l2)(r) 73.71(c)

LEVEL (10) 20.405(e) ill(QI 50.38(c)(2) 50.73(el(2) (rE I OTHER (Sprclly ln Ahstrect hrlow end In Trct, NRC Form 20.406(el(1)(BI) 50.73(el(2)II) 50,73(e) (2) (r (A) 366AI 20A06(el(1 I(lr) 50.73(s)CII(Q) 50.73(sl(2) (rIEHS) 20.406( ~ ) (1) lr) 50.73(sl(2) IIII) 50.73(sl(2)(x)

LICENSEE CONTACT FOR THIS LER (12I NAME TELEPHONE NUMBER A.B. JOHNSON% SHIFT TECHNICAL ADVISOR AREA CODE 407 465 -3 5 5 0 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13) y,9.

CAUSE SYSTEM COMPONENT MANUFAC REPORTABLE SYSTEM COMPONENT MANUFAC. EPORTABLE P

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TURER TO NPRDS

.~se, I' TURER TO NPRDS 9< %

I K A S V V03 0 )rrNsMNC) 4NÃ>: r IWi'.0

%%3~I IR~Eai SUPPLEMENTAL REPORT EXPECTED (14) MONTH DAY YEAR EXPECTFD SUBMISSION DATE (16)

YES Ilfyrs, compirtr EXPECTED SUBMISSION DATE) X NO ABSTRACT (Limit to le00 sprees, I r., rpproximetriy Ii item sinpie spree typrwNNrn hnrsl (18)

On August 16, 1989 with St. Lucie Unit 2 in Mode 1 at 90% power, the Unit was found to be operating in a condition 'prohibited by plant's Technical Specification. The 2B Diesel Generator had been placed out of service with the 2A Hydrogen Analyzer also out of service. This condition is prohibited by Technical Specification by not having all equipment operable on the remaining operable diesel generator (2A). The 2B Diesel Generator was placed out of service to perform preventative maintenance on the air start system.

The root cause of the event was a cognitive personnel error by a utility-licensed operator by not adhering to plant procedure when removing the 2B Diesel Generator from service for preventative maintenance.

Corrective actions taken were: 1) immediately restored the 2B Diesel Generator to operable status; 2) counselled all involved personnel on the need to perform a more thorough review of the equipment status prior to taking safety-related equipment out of service; 3) returned the 2A Hydrogen Analyzer to service.

NRC Form 3dd

'SS3)

NAC Foim 3SSA U.S. NUCLEAR REGULATORY COMMISSION (983)

LICENSEE '. VENT REPORT (LER) TEXT CONTINUATION OMB NO. 3150-0104 'PPROVED EXPIRES: 8/31/88 FACILITY NAME (1) OOCKET NUMBER (3) LER NUMBER (8) PAGE (3)

YEAR SEQUENTIAL REVISION NUMBER NUMBE R ST. LUCIE, UNIT 2 TEXT /i/moro 4/>>co iF BEII/ired, PFF odd ooI>>/I/RC Fo/III 3654'4/ (Ill 0500038989 0 0 6 0 02 QF 03 DESCRIPTION OF EVENT On August 16, 1989, St. Lucie Unit 2 was in Mode 1 at 90% power due to repairs on the 2A Drain Cooler (EIIS:SD). At approximately 0840, the licensed control room supervisor was informed by a Quality Contro'1 inspector that the unit was violating a Technical Specification by having both- the 2B Diesel Generator (EIIS:EK) out of service and the 2A Hydrogen Analyzer (EIIS:IK) out of service simultaneously. The control room supervisor reviewed the plant's Technical Specifications and concurred. The 2B Diesel Generator had been placed out of serxhce at 2324 on August 15 by the previous shift to perform preventative maintenance on the air start system.

- The 2B Diesel Generator was restored to operable -status at 0902 on August 16 to exit the Action Statement of the Technical Specification. The 2A . Hydrogen Analyzer had been out of service since August 10 due to dual indication on a solenoid valve, FSE-27-10, which is part of the Hydrogen Sampling System.

CAUSE OF EVENT The root cause of the event was cognitive personnel error by a utility-licensed operator by not adhering to plant procedure prior to removing the 2B Diesel Generator from service for preventative maintenance. This procedure, "Duties and Responsibilities of Operators On Shift", requires licensed operators to review the Equipment Out Of Service log as part of their shift turnover. The 2B Diesel Generator was removed from service prior to the review of the Equipment Out Of Service log by the licensed operator. There were no unusual characteristics of the work location that directly contributed to the personnel error.

ANALYSIS OF EVENT This event is reportable under 10 CFR 50.73 (a)(2)(i)(B), "any operation or condition prohibited by the plant's Technical Specification". Technical Specification 3.8.1.1 requires that all equipment on the remaining operable diesel generator also to be operable. The 2A Hydrogen Analyzer was the only inoperable "A" "rain component when the 2B Diesel Generator was placed out of service for preventative maintenance. This condition went unnoticed from the time the 2B Diesel Generator was placed out of service at 2324 on August 15 to the time of discovery, at 0840 on August 16.

The function of the Combustible Gas Control System (EIIS:BB) is to detect and control hydrogen gas concentration and maintain the concentration within containment below its flammable limits during post-LOCA conditions. The Combustible Gas Control System has two subsystems to accomplish this safety function. The first subsystem is the Hydrogen Analyzers which serves as the detection portion of the Combustible Gas Control "System. The second subsystem is the Electric Hydrogen Recombiners (EIIS:BB) which serves as the control portion of the Combustible Gas Control System. During the NRC FORM SSBA (983)

NRC Form 3BBF U.S. NUCLEAR REGULATORY COMMISSION (94) 3)

LICENSEE EVENT REPOP I (LER) TEXT CONTINUATION APPROVEO OMB NO. 3150-0104 EXPIRES: B/31/BB FACILITY NAME ('I) OOCKET NUMBER (3) LER NUMBER (d) PAGE (3)

YEAR @i SEQUENTIAL NUMBER O'.a. REVISION xaZ NUMBER ST. LUCIE, UNIT 2 0 5 0 0 0 3 8 9 8 9 0 0 6 00 03 OF 0. 3 TEXT llfmoro 4/roco /4 rogoiod, Iroo odd/dooo/ A/RC Forrrr 3d543/ (17) period the 2B Diesel Generator was out of service, the Hydrogen Analyzer was available only through its normal power supply. In analyzing the worst case LOCA event with the loss of off-site power, the Combustible Gas Control safety function would have been maintained because the hydrogen detection can be achieved via the Post Accident Sampling System (EIIS:IP) and hydrogen control would have been achieved via the hydrogen recombiners. Both trains of Electric Hydrogen Recombiners were operable. Even though the 2A Hydrogen Analyzer was out of service due to the dual indication on FSE-27-10, the Hydrogen Analyzer still had the capability to sample hydrogen concentration at all locations within the containment with the exception of the 2Al Reactor Coolant'ump (RCP)(EIIS:AB) area.

This event was evaluated for safety considerations and was determined not to be significant because the Combustible Gas Control safety function would have been maintained during the worst case conditions.

Consequently, the health and safety of the public was not affected by this event.

CORRECTIVE ACTIONS

1) Immediately after the discovery, the 2B Diesel Generator was returned to operable status.

2) The personnel involved have been counselled on t'e need to perform a more thorough review of the equipment status prior to taking safety-related equipment out of service. In addition, a night order was issued to extend this message to all licensed operators.

3) The failed solenoid valve, FSE-27-10, was replaced and the 2A Hydrogen Analyzer was returned to service on August 23.

ADDITIONAL INFORMATION RAILED COMPONENT:

Manufacturer: VALCOR Solenoid Valve, Model 8 : 52600-515 PREVIOUS SIMILAR EVENTS:

Events involving conditions prohibited by plant's Technical Specification due to lack of emergency power source available or not having the required operable components on the remaining emergency power source due to personnel error, see LER /PS 389-83-001 335-84-010 335-85-001 389-86-001 NRC FORM SSBA (r/4)3)