ML17223B030

LER 90-004-00:on 901109,inadvertent Actuation of Assorted Engineered Safeguards Equipment,Including Emergency Diesel Generator 2A,occurred.Caused by Personnel Error.Personnel counseled.W/901210 Ltr

ML17223B030
Person / Time
Site:	Saint Lucie
Issue date:	12/10/1990
From:	Sager D, Wolaver M FLORIDA POWER & LIGHT CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
L-90-428, LER-90-004-02, LER-90-4-2, NUDOCS 9012170237
Download: ML17223B030 (8)

Text

tI ACCELERATED DIS'IBUTION DEMONST14QION SYSTEM.

REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR: 9012170237 DOC. DATE: 90/12/10 NOTARIZED: NO DOCKET FACIL:50-389 St. Lucie Plant, Unit 2, Florida Power & Light Co. 05000389 AUTH. NAME AUTHOR AFFILIATION WOLAVER,M.W. Florida Power & Light Co.

SAGER,D.A. Florida Power & Light Co.

RECIP.NAME RECIPIENT AFFILIATION R

SUBJECT:

LER 90-004-00:on 901109,inadvertent actuation of assorted engineered safeguards equipment,including emergency diesel D generator 2A,occurred. Caused by personnel error. Personnel counseled.W/901210 ltr.

DISTRIBUTION CODE: IE22T COPIES RECEIVED: LTR i ENCL ( SIZE:

TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.

NOTES:

RECIPIENT COPIES RECIPIENT COPIES D ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-2 LA 1 1 PD2-2 PD 1 1 D NORRIS,J 1 1 INTERNAL: ACNW 2 2 ACRS 2 2 AEOD/DOA 1 1 AEOD/DS P/TPAB 1 1 AEOD/ROAB/DSP 2 2 NRR/DET/ECMB 9H 1 1 NRR/DET/EMEB 7E 1 1 NRR/DLPQ/LHFB11 1 1 NRR/DLPQ/LPEB10 1 1 NRR/DOEA/OEAB 1 1 NRR/DREP/PRPB11 2 2 NRR/DST/SELB 8D 1 1 NRR/DST/SICB 7E 1 1 NRR D /SPLB8D1 1 1 NRR/DST/SRXB 8E 1 1 G FILE 02 1 1 RES/DSIR/EIB 1 1 ILE 01 1 1 EXTERNAL: EG&G BRYCE,J.H 3 3 L ST LOBBY WARD 1 1 NRC PDR 1 1 NSIC MAYS,G 1 1 NSIC MURPHY,G.A 1 1 NUDOCS FULL TXT 1 1 D

A:

D D

NOTE TO ALL "RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTE! CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT. 20079) TO ELIMINATEYOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!

FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 33 ENCL 33

0 n

P.O. Box14000,Juno Beach, FL 33408-0420 December 10, 1990 L-90-428 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: 90-04 Date of Event: November 9, 1990 Inadvertent Actuation of Engineered Safeguards Equipment Durin Time Res onse Testin 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, D. A. S ger Vice esident St. Lucie Plant DAS:GRM:kw Attachment cc: Stewart D. Ebneter, Regional Administrator, USNRC Region Senior Resident Inspector, USNRC, St. Lucie Plant II DAS/PSL N297 90i2X70237 901210 PDR ADOCK 05000389 S PDR an FPL Group company

fpL Facas4s a U.S. NUCLEAR REGULATORY COMMISSION IRc Few a4 Iea1 APPROVEO OMB NO. 31504104 LICENSEE EVENT REPORT (LER) EXPIRES 8/31/85 FACILITYNAME (1) DOCKET NUMBER (2 PAGE 3 St. Lucie Unit 2 0 5000389 1OF03 INADVERTENTACTUATION OF ENGINEERED SAFEGUARDS EQUIPMENT DURING TIME RESPONSE TESTING DUE TO PERSONNEL ERROR EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED(8)

MONTH DAY YEAR YEAR ) NUMBER NUMB R MONTH DAY YEAR FACILITYNAMES N/A DOCKET NUMBER(S) 0 5000 099090004 0 0 1 2 1 0 THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR OPERATING Check one or more of the followin 11 MODE (9) 20.402(b) 20.405(c) 50.73(a)(2)(iv) 73.71(b)

POWER 20.405(a)(1)(i) 50.36(c)(1) 50.73(a)(2)(v) 73.71(c)

LEVEL.

(10) 0 0 0 20.405(a)(1 )(ii) 50.36(c)(2) 50.73(a)(2)(vii) OTHER 20.405(a)(1)(iii) (Specify in Abstract 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) below andin Text 20.405(a)(1)(iv) 50.73(a)(2)(ii) 50.73(a)(2)(viii)(B) NRC Eorm 366A) 20.405(a)(1)(v) 50.73(a)(2)(III) 50.73(a)(2)(x)

LICENSEE CONTACT FOR THIS LER (12)

NAME P N NUMB AREA CODE M. W. Wolaver, Shift Technical Advisor COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT 13 4 0 7 465-3 550 CAUSE SYSTEM COMPONENT MANUFAC- TURER REPORTABLE p+g CAUSE SYSTEM COMPONENT MANUFAC- REPORTABLE TO NPRDS TURER TO NPRDS SUPPLEMENTAL REPORT EXPECTED 14 EXPECTFD MONTH DAY Y AR SUBMISSION YES (Ifyes, complete EXPECTED SUBMISSION DATE) NO DATE (15)

ABSTRACT (Limit to 1400 spaces.i.e. approximately fifteen single-space typewritten lines)(1 6)

On November 9, with Unit 2 in Mode 5 during a refueling outage, an inadvertent actuation of assorted Engineered Safeguards equipment, including the 2A Emergency Diesel Generator, occurred during Engineered Safeguards Features testing. This equipment belongs specifically to the 'A'ide Safety Injection Actuation System/Containment Isolation Actuation System (SIAS/CIAS), Group 5.

The root cause of the event was personnel error. Instrumentation and Control personnel misread information in the testing procedure, and inadvertently actuated the wrong equipment.

Corrective actions: The test procedure was reviewed for errors. The testing was completed satisfactorily following this procedure. A Control Room Engineering Design Integration team reviewed color coding, placement and design of equipment labeling; workspace location and the procedure involved. No deficiencies were noted with respect to the criteria of NUREG 0700. An independent INPO Human Performance Enhancement System review was also performed on this event. The Instrument and Control personnel involved were counseled.

fpLFoeaeNM NlcfeelaipaI

~$

~~

$ PL $ $ $$

$ $$ C $ $$$

U.S. NUCLEAR REGULATORY COMMISSION

/$ APPROI/EO OMB NO. 31504104 LICENSEE EVENT REPORT (LER) TEXT CONTINUATION EXPIRES B/31/85 fACILITYNAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR SEQUENTIAL g~ REVISION NUMBER N NUMBER St. Lucie Unit 2 0500038990 TEXT (t/ more space is rertulred, use additional NRC Form 366A's) (1 7) 0 0 4 0 0 0 2>>0 3 DESCRIPTION OF THE EVENT On November 9, Unit 2 was in Mode 5 during a refueling outage. The Reactor Coolant System (RCS) (EIIS:AB) loops were full and on solid pressure control, with venting in progress. Instrument and Control (l&C) personnel were performing Engineered Safeguards (EIIS:JE) time response testing as per l&C procedure 2-1400053. According to the procedure, the Operations crew were briefed and given a list of equipment that were expected to actuate during that portion of the testing.

~

The equipment listed belonged to the 'A'ide Safety Injection Actuation SignaI/Containment Isolation Signal (SIAS/CIAS) (EIIS:JM), Group 3. However, at 1959 hours0.0227 days <br />0.544 hours <br />0.00324 weeks <br />7.453995e-4 months <br />, l&C personnel depressed the wrong pushbutton and unexpectedly actuated a different group of Engineered Safeguards equipment, the Group 5 equipment. The Operations crew immediately realized that the actuations were incorrect and notified the I&C personnel, then proceeded immediately to review Plant, conditions and realign equipment. The major equipment that actuated included: 2A Emergency Diesel Generator (EIIS:EK), 2A Intake Cooling. Water Pump, 2A Component Cooling Water Pump (EIIS:CC), 2A and 28 Boric Acid Makeup Pumps (EIIS:CA), and the Emergency Borate Valve.

Testing was terminated, the Engineered Safeguards actuations were reset, and Mode 5 operations, were resumed.

CAUSE F THE EVENT A Control Room Engineering Design Integration Team reviewed color coding, placement, labeling, workspace location, and the procedure involved. No deficiencies were noted with respect to the criteria of NUREG 0700. An independent INPO Human Performance Enhancement System (HPES) review was also performed on this event.

The root cause of this event was cognitive personnel error. Utility I&C personnel misread a correct and approved 1&C testing procedure. The wrong pushbutton was depressed on an Engineered Safeguards cabinet actuation module. This caused the actuation of a different group of Engineered Safeguards equipment than anticipated. There were no adverse conditions at the work location that affected the job, and the pushbuttons were clearly and logically labeled.

ANALYSIS OF THE EVENT This event is reportable under the requirements of 10CFR50.73.a.2.iv as an event that resulted in manual or automatic actuation of any Engineered Safeguards Feature.

The portion of the testing being performed at this time concerned the actuation of 'A'ide SIAS/CIAS, Group 3 equipment. As a result of the error, Group 5 equipment was actuated. The Unit was configured in Mode 5 such that these actuations had no affect on Plant operation. All Group 5 equipment actuated correctly and properly as called upon. Therefore, there were no equipment operability concerns.

There is no possibility that this scenario could effect power operations due to the fact that this test is performed only in modes 3,4, 5, or 6.

Thus, the health and safety of the public were not at risk at any time during this event.

$PL $ acaeW $ $ NIC $ ~ $ $ $ $ $ 4$ )

O.

n

foal /~

V WC/ere U.S. NUCLEAR REGULATORY COMMISSION APPROVED 0M B NO. 31500104 5%1145)

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION EXPIRES 8/31/85 FACILITYNAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR SEQUENTIAL NUMBER REVISION NUMBER St. Lucie unit 2 05000389 TEXT (Ifmore space is required, use additional NRC Form 366A's) 9 0 0 0 4 0 0 0 3 OF 0 3 (17)

CORRECTIVE ACTIONS

1. An HPES review was performed on this event.

2. A Control Room Engineering Design Integration Team review was performed on equipment, procedures, and work environment. No deficiencies with respect to NUREG 0700 were noted.

3. The Engineered Safeguards time delay testing was completed satisfactorily.

4. IRC personnel were counseled as to the need to follow test procedures closely.

ADDITIONALINFORMATION ni NONE LER 389-89-003 describes an inadvertent Containment Isolation actuation due to a Licensed Operator mistakenly resetting one channel while a second channel was in the tripped condition.