ML17228A129

LER 93-003-00:on 930331,1B EDG Inadvertently Started.Caused by Personnel Error.Personnel Involved in Event Counseled About Necessity of Being Careful When Working in & Around Sensitive equipment.W/930419 Ltr

ML17228A129
Person / Time
Site:	Saint Lucie
Issue date:	04/19/1993
From:	Sager D, Sarah Turner FLORIDA POWER & LIGHT CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
L-93-099, L-93-99, LER-93-003-02, LER-93-3-2, NUDOCS 9304230121
Download: ML17228A129 (6)

Text

. ACCELERATED DOCUMENT DISTRIBU'1'lON SYSTEM REGULAT INFORMATION DISTRIBUTZOtYSTEM (RIDE)

ACCESSION NBR:9304230121 DOC.DATE: 93/04/19 NOTARIZED: NO DOCKET FACIL:50-335 St. Lucie Plant, Unit 1, Florida Power & Light Co. 05000335 AUTH. NAME AUTHOR AFFILIATION TURNER,S.E. Florida Power & Light Co.

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

RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 93-003-00:on 930331,1B edg inadvertently started. Caused by personnel error. Personnel involved in event counseled about necessity of being careful when working in & around sensitive equipment.W/930419 ltr.

DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR i ENCL 1 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 F J 1 1 INTERNAL: ACNW 2 2 ACRS 2 2 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DSP 2 2 NRR/DE/EELB 1 1 NRR/DE/EMEB 1 1 NRR/DORS/OEAB 1 1 NRR/DRCH/HHFB 1 1 NRR/DRCH/HICB 1 1 NRR/DRCH/HOLB 1 1 NRR/DRIL/RPEB 1 1 NRR/DRSS/PRPB 2 2 NRR DSSA SPLB 1 1 NRR/DSSA/SRXB 1 1 QEG FILE ~ 02 1 1 RES/DSIR/EIB 1 1 RGN2 -FILE 01 1 1 EXTERNAL EG&G BRYCEF J H 2 2 L ST LOBBY WARD 1 1 NRC PDR 1 1 NSIC MURPHY, G. A 1 1 NSIC POOREFW. 1 1 NUDOCS FULL TXT 1 1 NOTE TO ALL"RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTE! CONTACT THE DOCUMEN'I'ON'I'1<OL DESK, ROOM Pl-37 (EXT. 504-2065) TO ELIMINATEYOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T HEED!

FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 32 ENCL 32

P.O. Box 128, Ft. Pierce, FL 34954.0128 April 19, 1993 L-93-099 10 CFR 50. 73 U. S ~ Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555 Re: St. Lucie Unit 1 Docket No. 50-335 Reportable Event: 9 3-0 03 Date of Event: March 3 1, 1993 Inadvertent Start of the 1B Diesel Generator 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 er Vice P ident St. Lu 'e Plant DAS/JWH/kw Attachment cc: Stewart D. Ebneter, Regional Administrator,: USNRC Region II Senior Resident Inspector, USNRC, St. Lucie Plant DAS/PSL 0898-93 93042301 2 1 9304 1 9 oSO 0.60 PDR ADOCK 05000335 S PDR an FPL Group company

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U.S. NUCLEAR REGULATORY COMMISION AttrtoltoCLEI NrA $ 1100101 FPL Facsirrtls o! ESttNS'C00 I NRC Form X6 EST IAATE0 BJCEN tEIITETNONLE 0 0 CCLNL0 TATH TILE 000SSIATICN ECLLECTCN te.89)

LICENSEE EVENT REPORT (LER) IEEAEST: 000 10TL TONNAICICCLNNNTS IECNEANC ISSOEN ESTNIAIE TO CCNTS No IEAOTTS TIE'N TTINICHrt000L ILTLIANAENIINOAATCTIT tt 1WNNATIOI,CC TEL ttEI TO THE tAEEIIAESNIEOIJCTICN tIEAECT TtII0010IL CtTICE Cf NNNCELSNT NO TLOIRT WANNATNSLCC 00000 FACILITYNAME (1) DOCKET NUMBER (2) PAGE 3 St. Lucie Unit 1 050003351 0 3 T'TLE(4) Inadvertent Start of the 1B Emergency Diesel Generator due to Personnel Error.

EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED(8)

IAL FACILITYNAMES DOCKET NUMBER(S)

DAY YEAR YEAR S MONTH DAY YEAR N/A 0 3 3 1 9 3 9 3 0 0 3 0 0 0 4 1 9 9 3 N/A 05000 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) 20A05(c) X 50.73(a)(2)(iv) 73.71(b)

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

LEVEL (10) 0 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) 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) below and in Text 20.405(a)(1)(iv) 50.73(a)(2)(viii)(B) NRC Form 366A) 50.73(a)(2)(ii) 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 S. E. Turner, Shift Technical Advisor 4 0 7 465 -3550 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT 13 MANUFAC- REPORTABLE MANUFAC- REPORTABLE CAUSE SYSTEM COMPONENT TURER TO NPRDS CAUSE SYSTEM COMPONENT TURER TO NPRDS I I I SUPPLEMENTAL REPORT EXPECTED 14 EXPECTED MOtLriH DAY YEAR SUBMISSION YES (If yes, complete EXPECTED SUBMISSION DATE) NO DATE (15)

ABSTRACT (Limit to 1400 spaces.i.e. approximately fifteen single-space typewritten lines) (16)

On March 31, 1993, at 1311 hours0.0152 days <br />0.364 hours <br />0.00217 weeks <br />4.988355e-4 months <br /> with Unit 1 in Mode 5 for refueling, the 1B Emergency Diesel Generator (EDG) was inadvertently started. While plant maintenance personnel were installing test equipment to be used for the Integrated Safeguards Test one of the undervoltage relays located in the 1B EDG control panel was

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actuated, starting the 1B EDG. The 1B EDG operated as expected with no abnormal conditions obsewed. The 1B3 4160 VAC bus remained powered by the normal off-site source. After operators determined that the EDG had been inadvertently started the 1B EDG was secured.

The root cause of this event was personnel error. Utility personnel inadvertently bumped an undervoltage relay during the installation of test equipment for the Integrated Safeguards Test.

Corrective actions: An INPO Human Performance Enhancement System review (HPES) was performed on this event. The utility personnel were counseled. The procedure inuse during this event was changed to add a precaution for installing test equipment.

FPL Facsimile of NRC Form 366 (6-89)

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FPL Faccllttte ol U.S. NUClEAR REGUlATORY COMMtSSCN PPETIEO IPCI ICE SII001 PI NRC Form 366 EXP000: IO00 t LICENSEE EVENT REPORT (LER) ECTTAATEO IEPCTER PEll IRRPCPCR 'tO COAPE T TP TII TI00 PPCPPAATICR CCAAE CllOR IRCERCTI 100 IPTS, IORWNC$ CCANRIIT0 RECAR000$ IEPOEII CCIPIATC TO TIR IRCCIO0 NO IC PORT 0 UNQCKIR Nt CRANCH TP0RL IAS, IAREEAR IRCPAATCRP TEXT CONTINUATlON WANNATTOR.OCROPE NO TOTIR PNERWCPW meC TOR PROXCT TTII0010IT CPRCE CP NAHAIRIRNTNO SAXXT,WAORRTTCPC Oc Rccrt FACILITYNAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR EQUENTIAL REVISIO St. Lucie Unit 1 NUMBER . NUMBER 0 500 0335 9 3 0 0 3 0 0 0 2 0 3 TEXT (Ifmore spaceis required, use additional NRC Form 366A's) (1/)

On March 31, 1993, at 1311 hours0.0152 days <br />0.364 hours <br />0.00217 weeks <br />4.988355e-4 months <br /> with Unit 1 in Mode 5 preparing for refueling, the 1B Emergency Diesel Generator (EDG)(EIIS:EK) was inadvertently started. While utility maintenance personnel were installing test equipment to be used for the Integrated Safeguards Test one of the undervoltage relays located in the 1B EDG control panel was actuated by inadvertent bumping which started the 1B EDG. The 1B EDG came to rated speed and voltage with no abnormal conditions observed. After the control room operators determined that the EDG had been inadvertently started they stopped the 1B EDG and returned it to the normal standby status.

The root cause of this event was personnel error in the inadvertent operation of an undervoltage relay in the 1B Emergency Diesel Generator (EDG) control circuitry by utility maintenance personnel.

The utility person bumped the undervoltage relay causing the relay to actuate starting the EDG. The utility maintenance personnel were checking installed test equipment in accordance with Maintenance Procedure 1-0950183,

. A contributing factor is that the installation of the test equipment is covered in the procedure; however, the specific steps for checking the test equipment were to be determined in the field. No precaution was in the procedure for those steps on the possibility of an inadvertent EDG start. No unusual characteristics of the work location contributed to the personnel error. There was no valid undervoltage condition present and no undervoltage logic was made up.

This event is reportable under 10CFR50.73(a)(2)(iv) as an event that resulted in the manual or automatic actuation of any Engineered Safety Feature.

The inadvertent starting of the 1B Emergency Diesel Generator had no adverse consequences on the plant because the 1B3 4160VAC bus remained energized and in service during this event, supplied by the normal off-site power supply source. During Mode 5, Technical Specifications require that only one EDG be in service. Both EDGs were in service at the time of this event.

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

FPL Facsimile of NRC Form 366 (6-89)

FPL FSCSIOTIS OI U.S. NUCLEAR REGULATORY COMMISSION APPAOPI CAD N(k 01 0001 01 NRC FOTTTT S66 C SPIPSS. ID00 t 0 0 TWATTDDAIDTN Pf N INSPCNSS TO NSNlT 00 TN TISl SSOISIATIQN DCllfC PION LICENSEE EVENT REPORT (LER) ISTSSST! 000 INS PCNWNO CCPSNNTS ISCANDNO TAPSXN TSTSAATS TO TIN ISCCISD PP00 ISPTPIT 0 NPNNN INNT SNANCN /LlOLIAS IPClfPPI ISTSAATTÃTTTSSNNNSC TEXT CONTINUATlON WASNPTTON.DC TONS PPST TOTIS SPATTINCPN TSTAICDON PAOSCT Ttl ISSITAT CffICC DP NANACCINNT AKICMXCT,WADNPTTTPA OC TOMS FACILllYNAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR EQUENTIAL REVISIO NUMBER NUMBER St. Lucie Unit 1 0 5 0 0 03 35 9 3 0 0 3 0 0 0 3 0 3 TEXT (Ifmore spaceis required, use additional NRC Form 366A's) (17)

1. Operations secured the 1B Emergency Diesel Generator.

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, have been changed to preclude this event from reoccurring, by adding steps to require that the EDG be removed from service when checking the test equipment.

3. The utility personnel involved in this event were counseled about the necessity of being careful when working in and around sensitive equipment.

4. A Human Performance Evaluation System (HPES) review was performed on this event and its results agree with the cause of this event.

5. Unit 2 procedures MP 2-0950183 and MP 2-0950182

, will be changed by Electrical Maintenance to preclude this event from occurring by adding steps to require that the EDG be removed from service when checking the test equipment.

None LER 335-86-007 "Personnel error results in automatic start of a Diesel Generator".

LER 335-88-005 "Inadvertent start of the 1A Diesel Generator during trouble shooting due to personnel error".

FPL Facsimile of NRC Form 366 (6-89)

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