ML17223B390

LER 91-006-00:on 911129,operator Noted That Unit in Condition Prohibited by Plant Tech Specs.Caused by Cognitive Personnel Error by Utility Licensed Operators.Responsible Licensed Personnel counselled.W/911220 Ltr

ML17223B390
Person / Time
Site:	Saint Lucie
Issue date:	12/20/1991
From:	Sager D, Wachtel P FLORIDA POWER & LIGHT CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
L-91-345, LER-91-006-03, LER-91-6-3, NUDOCS 9112300325
Download: ML17223B390 (6)

Text

ACCELERATED DISTRIBUTION DEMONSTRATION SYSTEM 0

REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR: 9112300325 DOC. DATE: 91/12/20 NOTARIZED: NO DOCKET FACIL:50-389 St. Lucie Plant, Unit 2, Florida Power & Light Co. 05000389 AUTH. NAME AUTHOR AFFILIATION WACHTEL,P.K. Florida Power & Light Co.

SAGER,D.A. Florida Power & Li.ght Co.

RECIP.NAME RECIPIENT AFFILIATION R

SUBJECT:

LER 91-006-00:on 911129,operator noted that unit in condition prohibited by plant Tech Specs. Caused by coqnitive D licensed personnel counselled.W/911220 ltr.

DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR l personnel error by utility licensed operators.Responsible TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.

NOTES:

ENCL i SIZE:

RECIPIENT D RECIPIENT COPIES COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL D

PD2-2 LA 1 1 PD2-2 PD 1 1 NORRIS,J 1 1 INTERNAL ACNW 2 ACRS 2 2 AEOD/DOA 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DSP 2 NRR/DET/ECMB 9H 1 1 NRR/DET/EMEB 7E ' 1 NRR/DLPQ/LHFB10 1 1, NRR/DLPQ/LPEB10 NRR/DOEA/OEAB 1 1 NRR/DREP/PRPBll 2 NRR/DST/SELB 8D 1 1 NRR/DST/SICB8H3 NRR/DST/SRXB 8E RES/DSIR/EIB 1

1 1

~G:~E, NRR/DST/SPLB8Dl RGN2 FILE 02 01 1

1 1

1 1

1 EXTERNAL EG &G BRYCE i J ~ H 3 3 L ST LOBBY WARD 1 1 NRC PDR 1 1 NSIC MURPHY' A ~ 1 1 R NSIC POORE,W. 1 1 NUDOCS FULL TXT 1 1 D

D D

NOTE TO ALL "RIDS" RECIPIEVifS S

DESK, PLEASE HELP US TO REDUCE. iVASTE! CONTACT THE DOCUMENT CONTROL ROOM Pl-37 (EXT. 20079) TO LLINIINATEYOUR NAlvlE FROlvl DISTRIBUTION LISTS FOR DOCUIvlEN fS YOU DON'T NEED!

FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 33 ENCL 33 0

p.o. Box 8, Ft. Prerce, FL 34954-0t28 FPL December 20, 1991 L-91-345 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: 91-06 Date of Event: November 29, 1991 Engineered Safety Features Actuation Channel Out of Service due to Personnel Eiror 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. . Sager Vic resident St. Lucie Plant DAS/JWH/kw Attachment cc: Stewart D. Ebneter, Regional Administrator, USNRC Region II Senior Resident Inspector, USNRC, St. Lucie Plant DAS/PSL f587-91 r~POCV el an FPL Group company

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FPL Facslnfla Ol U.S. NUCLEAR REGULATORY COMM ISS lON CIST NO SIRISIOI EPTTPESl LCLS T NRC Form S66 MATE0 IIPOEN PER RESPONSE TO COMPLY WITH TNS IIEORMATICNCCLLECRCN (e 89)

LICENSEE EVENT REPORT (LER) REOUESTI ICS IPYL PORWAlEI COLRRNTS RECAfOWO SPERM ESRMAIE TO PIC REOIÃETT AIEI REPORTS MANACELRPITINARCH LPSSPf. Ifa IAICLENl RE OIIATORY WASINICTOI,OC EINR PIET TO TNE PAPERWCRR ISEAICTEPI PIEEE CT SIRIS ISIT.OffICE CP ANMKLEIITNO RAXRT.WARINCIEPL CC LOSEL FACILITYNAME (1) DOCKET NUMBER (2) PAGE 3 St. Lucie Unit 2 050003891 0 4 T'TLE (4)

Engineered Safety Features Actuation System Channel Out of Service Resulted in a Condition Prohibited by Technical Specifications due to Personnel Error EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED(8)

MONTH DAY YEAR YEAR S IAL 'R DAY YEAR FACILITYNAMES DOCKET NUMBER(S)

N/A '

p p 1 .1 29 9191 0 0 6 0 0 1 2 2 0 9 1 N/A 05000 THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR:

OPERATING Chad'ne or more of tha 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) 1 0 0 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(vii) OTHER (Specify in Abstract 20.405(a)(1)(iii) X 50,73(a)(2)(j) 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 Form 366A) 20.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x)

LICENSEE CONTACT FOR THIS LER 12 NAME TELEP ONE NUMBER AREA CODE Patricia K. Wachtel, Shift Technical Advisor 4 0 7 465 -3550 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT 13 CAUSE SYSTEM COMPONENT MANUFAC- TURER REPORTABLE TO NPRDS . 'AUSE SYSTEM COMPONENT MANUFAC- 'fURER REPORTABLE TO NPRDS J E R L Y 0 0 6 0 Y I I I SUPPLEMENTAL REPORT EXPECTED 14 EXPECTED MONTH DAY YEAR SUBMISSION YES (Ifyes, complete EXPECTED SUBMISSION DATE) X NO DATE (15)

ABSTRACT (Limit to t400 spaces. i.e. approximately fifteen single-space typewritten lines) (16)

On November 29, 1991, with Unit 2 operating at 100% steady state power, a utility-licensed senior reactor operator noted that the Unit was in a condition prohibited by the Plant's Technical Specifications. Channel 'D'f the Engineered Safety Features Actuation System instrumentation for the Recirculation Actuation Signal had been placed out of service on November 26, 1991 at 0411 and the channel was put in bypass. Technical Specification 3.3.2 requires that with only three channels operable, the inoperable channel must be restored to operable within forty-eight hours or else it should be placed in the tripped condition and the remaining operable channels must be verified to be operable within one hour. However, Channel 'D'emained in bypass until this condition was recognized by a utility-licensed senior reactor operator at approximately 0100 on November 29, 1991, sixty-nine hours after the instrument was placed out of service.

The root cause of this event was cognitive personnel error by utility-licensed operators. The instrumentation had been entered in the equipment out of service log but the return-to-service information was incorrect.

Corrective actions taken included placing the channel in the tripped condition and verifying the remaining channels were operable. Responsible personnel were counselled on the importance of providing accurate information in all of their logs and performing thorough independent verifications of all entries. The Plant Training Department will evaluate this event to determine appropriate training requirements and methods. The procedure governing review of equipment placed out of service will be strengthened. Also, the bypass key for this unique instrument will be modified with a human factors identification tag.

FPL Facsimile of NRC Form 386'(6-89)

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FPL FscsIITTID ol U.S. NUCLEAR REGULATORY COMMISSION fffRCNTDOAO NCA $ 1 I001 fi NRC Form 366 EÃPNNS: AINTIT t6 89I ES TAIATTD RPICEN PER PESPONSE To DINWLTWIINTITS PPOISAARCN COL IECRON LICENSEE EVENT REPORT (LER) RLCSEST: 000 IRS. TCRWATO CCARENT0 TEOARDWO ELAREN ESRNAIE TO TIE IECCTTTS ffD TRtORT 0 NANACEIENT SRANCH PAL LLR IANAEARRECAAATCRT TEXT CONTINUATlON W RNRITON. DC TCTNL ANITO TIC PNPERAESTL PEOVCTION PROECT ITIIOSRO CfRCE Of IlANAIELENT AAO TAOOEE TfJLHHCRCTL DC TRCL FACILITYNAME (1) DOCKET NUMBER (2) LER NUMBER (6). PAGE (3)

YEAR EQUENTIAL REVISION NUMBER NUMBER St. Lucie Unit 2, 0 500 0389 9 1 0 0 6 0 0 0 2 0 4 TEXT (Ifmore spaceis required, use additional NRC Form 366A's) (1/)

On November26,1991, Unit2wasoperatingat100%steadystatepower. At0411,Channel'D'of the Engineered Safety Features Actuation System (ESFAS) (EIIS:JR) instrumentation for the Recirculation Actuation Signal (RAS) Refueling Water Storage Tank (EIIS:BP) was placed out of service due to failure in the Automatic Test Insertion circuitry. ESFAS Channel 'D'AS was placed in bypass and listed in the equipment out of service log by a utility-licensed operator. St. Lucie Unit 2 Technical Specification 3.3.2 was referenced as the Limiting Condition for Operation (LCO) and the return-to-service date was entered as 'not applicable with Channels 'A', 'B', and 'C'perable.'t approximately 0100 on November 29, 1991, a utility-licensed senior reactor operator was reviewing the equipment out of service log when he questioned the entry made for ESFAS Channel

'D 'AS instrumentation. The utility-licensed senior reactor operator concluded that Technical Specification 3.3.2 Table 3.3-3 Action 17, which required the inoperable channel to be restored to operable within forty-eight hours or else it must be placed in the tripped condition and the remaining operable channels must be verified to be operable within one hour, was the applicable action to be taken. Channel 'D'as immediately placed in the tripped condition and the operability of Channels

'A', 'B', and 'C'ere verified.

The root cause of the event was cognitive personnel error by utility-licensed operators in that the return-to-service information for the ESFAS Channel 'D'AS instrumentation which was entered into the equipment out of service logbook was incorrect. The correct action statement for Technical Specification 3.3.2 requires the inoperable channel to be placed in the tripped condition if it is not restored to operable within forty-eight hours. The utility-licensed operators who reviewed the entry made the same error when they reviewed the equipment out of service log and overlooked the incorrect information. The equipment out of service log review process is governed by a plant procedure, but the procedure does not provide sufficient detail. There were no unusual control room environment characteristics which may have contributed to the event. It is noteworthy that for other ESFAS parameters or Reactor Protection System (EIIS:JC) parameters, the LCO allows bypassing the affected channel for an indefinite period. The refueling water tank level has a unique LCO and this circumstance contributed to the incorrect interpretation of the Technical Specification LCO.

E E This event is reportable under 10 CFR 50.73.a.2.i.B as "any operation or condition prohibited by the plant Technical Specifications." As per Technical Specification 3.3.2, the required action to be taken with an ESFAS instrumentation channel for RAS Refueling Water Storage Tank inoperable is to restore the inoperable channel to operable status within forty-eight hours or place the inoperable channel in the tripped condition and verify that the minimum channels operable requirement is demonstrated within one hour. During this event, ESFAS Channel 'D'as in bypass for. sixty-nine hours.

The function of the ESFAS Recirculation Actuation Signal is to automatically transfer the suction of FPL Facsimile of NRC Form 366 (6-89)

FPL FSCNIT51e OI U.S. NUCLEAR REGULATORYCOMMISSION NVVTOVCOOIO NTI 01 5001 Il

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NRC FOrITT S6S ETFNNS: IO00 t l6.89) ESTSIAT EO IAASTEN FEII INSFONIE TO COINLVWITH TIIS SNISSIAllON CCIIECTION LICENSEE EVENT REPORT (LER) IS5SSST: 50S 505$ . fCNWNEICTSNNNT0 FECAICWOOSEXN ESTSIATE TO TIN I%COOS AICIISFONTSIIANACEIKNTSNANCHTFSISLTISIAAAEANIEOAATCNVASMSSSESE TEXT CONTINUATION f WAOINCTCN . OC t0505 N4) TO TIN FNINWIOIVIIECVCTCN FINISCT (51 5001055 CI ICE Of ANI TAOCET WANNATTESE OC tINTE FACILITYNAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR EQUENTIAL REVISION NUMBER , NUMBER St. Lucie Unit 2 0 5 0 0 03 89 -0 0 6 0 0 0 3 0 0 4 TEXT (Ifmore spaceis required, use additional NRC Form 366A's) (17) the high pressure safety injection pumps and the containment spray pumps from the refueling water storage tank to the containment sump to ensure an adequate suction water supply upon emptying of the refueling water tank. The RAS is initiated by low refueling water tank (six feet) level as sensed by a coincidence of two out of four independent refueling tank level transmitters. When Channel 'D'as placed in bypass, the coincidence logic became two out of three but, the system remained fully functional..

A Control Room Annunciator, S-39, indicates when a low level of twenty-eight feet six inches has been reached in the refueling water tank and, in the event of an accident, Plant Emergency Operating Procedures require the verification of the refueling water tank level versus the containment sump and constant monitoring of the refueling water tank., Any abnormal change in level would have been noted during the sixty-nine hours that Channel 'D'as in bypass. Therefore, the health and safety of the public was not affectedby this event.

1. Responsible licensed personnel were counselled by Operations Supervision on the necessity of accurate information and what constitutes acceptable independent verification on entries in the equipment out of service log.

2. The Training Department will evaluate this event to determine appropriate training requirements and methods.

3. The failed bistable was repaired and the system was returned to service

4. The procedural process governing review of equipment placed out of service will be strengthened.

5. The RWT level bypass key will be modified with a human factors identification tag to highlight its unique Technical Specification action statement.

ESFAS Channel 'D'istable BA 405 Manufactured by Eaton Consolidated Controls FPL Facsimile of NRC Form 366 (6.89)

FPL FSCSIITIIOOI U.S. NUCLEAR REGULATORY COMMISSION APPROYTO OLO NCL $1NISTPI NRC Form S66 CPSNNrL Aorwt ff'PSIII LICENSEE EVENT REPORT (LER) TSTPAAT TO SLAAOCN PC R INSPONSS I0 COLNLY WITH TWS SPCÃSTATCN COLLCCTICN IKOLNST:ICS IIYS. IORWNYTCCNLNNTS INOARCHO TAPSICN CSTTNATC TO TIN INCONTS N4>INPORTSNANAOTLNNTSRANCNTP44rrLTLS NUCACARISOAATORYOOMASOCK TEXT CONTINUATION WASrNrOTON. OC TTPNS AN) TO TW'APYRWTSYIRTTACllCWPITOSCT IT1 SCS lrNL OfITCC CP NAOCLNNTANT SATINY,WASNNROrLOC SNAIL FACILITYNAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR EQUENTIAL REVISION NUMBER NUMBER St. Lucie Unit 2 0 5 0 0 03 89 9 1 0 0 6 0 0 0 4 0 4 TEXT (lf more spaceis required, use additional NRC Form 366A's) (17)

Previous events in which Technical Specification equipment was placed out of service incorrectly due to personnel error include:

LER 335-87-009, "Equipment Failure and Personnel Error Result in Technical Specification Radiation Monitors Inoperable" LER 389-89-006, "Removing Diesel Generator from Service for Preventive Maintenance Results in a Condition Prohibited by Technical Specifications due to Personnel Error" LER 335-91-009, "Removal of the Plant Vent Stack Monitors from Service Resulted in a Condition Prohibited by Technical Specifications due to Personnel Error".

FPL Facsimile of NRC, Form 366 (6-69)