ML17285A732

LER 89-035-00:on 890817,reactor Scram Occurred During Surveillance Testing of Reactor Level Instrument Associated W/Automatic Depressurization Sys.Caused by Personnel Error. Training Improved & Visibility increased.W/890913 Ltr

ML17285A732
Person / Time
Site:	Columbia
Issue date:	09/13/1989
From:	Fies C, Powers C WASHINGTON PUBLIC POWER SUPPLY SYSTEM
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-89-035, LER-89-35, NUDOCS 8909220118
Download: ML17285A732 (6)

Text

REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:8909220118 DOC.DATE: 89/09/13 . NOTARIZED: NO DOCKET FACIL:50-397 WPPSS Nuclear Project, Unit 2, Washington Public Powe 05000397 AUTH. NAME AUTHOR AFFILIATION Washington Public Power Supply System

'IES,C.L.

POWERS,C.M. Washington Public Power Supply System RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 89-035:00:on 890817,reactor scram during ADS surveillance testing personnel error.-

W/8 ltr.

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

L SIZE:

NOTES:

RECIPIENT COPIES RECIPIENT ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD5 LA 1 1 PD5 PD 1 1 SAMWORTH,R 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/DSP 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 MURPHY,G.A'OPIES RPB 10 2 2 NUDOCS-ABSTRACT 1, 1 REG FIL 02 1 1 RES/DSIR/EIB 1 1 GN LE 01 1 1 y"' EXTERNAL EGS(G WILLIAMSg S 4 4 L ST LOBBY WARD 1 1 LPDR 1 1 NRC PDR 1 1 NSIC MAYS,G 1 1 NSIC 1 1 NUDOCS FULL TXT 1 1 MZE K) AIL 'RIES" EKCXE'IHGS:

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FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 40 ENCL 40

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,WASHINGTON PUBLIC POWER SUPPLY SYSTEM P.O. Box 968 ~ 3000 George Washington Way ~ Richland, Washington 99352 Docket No. 50-397 September 13, 1989 Document Control Desk U.S; Nuclear Regulatory Commission Washington, D.C. 20555

Subject:

NUCLEAR PLANT NO. 2 LICENSEE EVENT REPORT NO.89-035

Dear Sir:

Transmitted herewith is Licensee Event Report No.89-035 for the WNP-2 Plant.

This report is submitted in response to the report requirements of 10CFR50.73 and discusses the items of reportability, corrective action taken, and action taken to preclude recurrence.

Very truly yours, m .n C. M. Powers (M/D 927M)

WNP-2 Plant Manager CMP:lr

Enclosure:

Licensee Event Report No.89-035 cc: Mr. John B. Martin., NRC - Region V Mr. C. J. Bosted, NRC Site (M/D 901A)

INPO Records Center - Atlanta, GA Ms. Dottie Sherman, ANI Mr. D. L. Williams, BPA (M/D 399)

NRC Form 36d U.S. NUCLEAR REGULATORY COMMISSION (983) r APPROVED OMB NO. 31604)BC EXPIRES: d/31/88 LICENSEE EVENT REPORT (LER) r DOCKET NUMBER l2) PAGE 3 FACILITY NAME (I)

Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 1 OF TITLE (OI Surveillance Testing - Personnel Error EVENT DATE (6) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (8)

YEAR SEGUENTIAL REYIBION MONTH OAY YEAR FACILITYNAMES DOCKET NUMBER(SI MONTH OAY YEAR NUMBE R NUMBER 0 5 0 0 0 0 8 17 898 9 035 0 0 0 9 1 3 8 9 0 5 0 0 0 THIS REPORT IS SUBMITTED PUASVANT T 0 THE RE CUIR EM 6NTS OF 10 CFR (3: ICnecir one or more of rne foiiowinpf Ill)

OPERATING MODE IB) 20A02(B) 20.4)6(el 50.7 3( ~ I I 2) I N) 73.71(B)

POWE R 20A05(ol(1)(il 60.36(cl(1) 50.73(e) (2)(v) 73.71(cl LEYEL I10) 0 6 7 20A05(o)(1) IBI 50.36(c) (2) 50,73( ~ l(2)(vii) OTHER (Specify In Aorrrect Below end in Teer, IYIIC Form 20.48(ol)1) Rill 50.73(el (2) (i) 60,73(ol(2)Drill(A) 366AI

'~yji!j!'j)Q>g:rrodppgp"'jVo".: 20A06(o l(1 I(iv) 50,73(o) (2 l(ii) 50,73( ~ l(2((villi(BI 20.406 ( ~ I (I I ( v I 50.73( ~ ) (2) l i(i) 50.73(o)(2)(x)

LICENSEE CONTACT FOR THIS LER l12)

NAME TELEPHONE NUMBER AREA CODE C. L.'ies, Compliance Engineer 50 937 7- 50 1 COMPLETE ONE LINE FOR EACH COMPONENT FAILVAE DESCRIBED IN THIS REPORT (13)

MANVFAC REPORTABLE MANVFAC EPORTABLE CAUSE SYSTEM( COMPOIVENT CAUSE SYSTEM COMPONENT TUAER TO NPADS TVREA TO NPAOS

')':oA4P6( " Vx 84~!k 6)I::::::r..":

rjCQQ<o~~~'j5P SUPPLEMENTAL REPORT EXPECTED I IOI MONTH DAY YEAR EXPECTED SUBMISSION DATE (15)

YEs fif yn, comPiere EIIPEcTED s(IBorissIDIY DATE)

ABSTRAGT (Limit to re00 rpecer, Ie., epprooimereiy fifreen rinprerpece rypewrinen Iinnf (16)

At 0819 hours0.00948 days <br />0.228 hours <br />0.00135 weeks <br />3.116295e-4 months <br />, on August 17, 1989, a reactor scram occurred during a surveillance being performed on a reactor level instrument associated with the Automatic Depres-surization System (ADS). The scram occurred when an I8C technician prematurely opened the isolation valve from the reference instrument leg of the device being tested. This caused a pressure transient in the reference and variable instrument lines which initiated a reactor, scram by the Reactor Protection System ( RPS ) on r eactor water level low - Level*3. The root cause of this event was a personnel error and equipment design deficiency. Immediate corrective action included plant shut down to hot standby and a memo from the Plant Maintenance Manager summarizing immediate corrective actions. Further corrective action includes improved training and increased visibility for "Critical" surveillances'. A design study will also be i nitiated to evaluate the design of the level trip system and its interfacing instrumentation. Since all safety systems operated as designed and plant operators acted promptly. to place the plant in a safe shutdown condition, this event posed no threat to the health) and safety of the plant personnel or the public.

NAC Form 366 (8 83l

NRC Form 366A UA. NUCLEAR REOULATORY COMMISSION 1943)

LICENSEE E NT REPORT (LER) TEXT CONTINUATION APPROVED OMB NO. 319)W)04 EXPIRES: 8/31/BB FACILITY NAME Il) DOCKET NUMBER I3) LER NUMBER 16) PACE 13) sdaUBNTIAL w~A RdvrdroN YC% NUMBER NUMBBII Washin ton Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 8 9 0 3 5 0 0 0 2oFO 4 TEXT ///more e/reoe/e redrr/red, rise eddit)rirrr//r//IC %%d 356A3/ IIT)

Pl ant Condi ti ons a) Plant Mode - 1 (Power Operation) b) Power Level - 67K Event Description At 0819 hours0.00948 days <br />0.228 hours <br />0.00135 weeks <br />3.116295e-4 months <br /> on August 17, 1989, the reactor protection system (RPS) initiated a reactor scram on reactor vessel water level - Low, Level 3. The scram occurred during surveillance testing of the ADS Trip System A, reactor water level low-Level 3 Channel Functional Test (CFT)/Channel Calibration (CC). This test involves the functional test of level indicating switch MS-LIS-38A. The testing had proceeded through the isolation and functional check of the instrument and the technicians were in the process of valving the instrument back into service. At this time, an I8C technician opened the isolation valve 'from the reference instru-ment leg (which was at reactor pressure) to the instrument (MS-LIS-38A) which was depressurized.: This caused a pressure transient throughout the variable instrument line (N13A) and the reference instrument line (N14D). The pressure transient impacted level indicating switch MS-LIS-24B which shares both a common variable and reference leg with MS-LIS-38A. Further, the pressure transient affected MS-LIS-24A which has a common variable leg with both MS-LIS-24B and MS-LIS-38A. The pressure transient activated MS-LIS-24A and B causing a scram signal to RPS subchannels Al and Bl.

Immediate Corrective Action The Plant responded in accordance with design and Plant Operators placed hot standby condition. An immediate corrective action memo was issued by the Plant it in the Main)tenance Manager summarizing immediate corrective actions being taken by the Maintenance Department. This included more involvement of supervision in surveil-lance testing.

Further Evaluation and Corrective Action A. Further Evaluation

1. This event is being reported as an event that resulted in automatic actuation of an engineered safety feature per the requirements of 10CFR50.73(A)(2)(iv).

2. The root causes of this event was personnel related caused by lack of attention/concentration and misunderstood verbal communication. Lack of attentio))/concentration was involved since the opening of the isolation valve on instrument rack P026 without the pressures equalized was not in accordance with the procedure. The valve opened was painted red to indi-cate it was a device which could cause a reactor scram. This had been a corrective action resulting from a previous reactor scram that had NRC FORM 366A ~ U.d. CPOr Iddd-S:I-SBO OOO;I IB 83i

NRC+arm 36SA U.S. NUCLEAR REGULATORY COMMISSION (943)

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION AI'PROVED OMB NO. 3150M)04 EXPIAESI 8/31/BB FACILITY NAME (() DOCKET NUMBER (3) LER NUMBER (6) PAGE (3)

YEAR SEGUENTIAI. REVISION NUMBER NUMBER specs/s Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 8 9 0 3 5 000 3 OF 0 4 TEXT /I/ more rer/meed, use eddrbbne/ NRC Form 36$ 4's/ (17) occurred during surveillance testing. Another root cause of the event was the misunderstood verbal communication between I&C technicians. This surveillance was being performed in a contaminated area and required com-munication between the individual inside the area who was manipulating the equipment and the individual, outside the area who had a copy of the pro-cedure and communicated with the control room. The event occurred when the I&C technician inside the contaminated area misunderstood a conversa-tion between the technician outside the area and the control room.

3. A contributing factor to the event was equipment design which allows a reactor scram to be initiated as a result of a single error during the performance of surveillance testing. The shari~ng o the variable leg by all three instruments invol'ved, creates a situation where single errors can initiate a reactor scram.

4.- There were no plant structures, components, or systems inoperable at the start of this event that contributed to the event.

B. Further Corrective Action

l. I8C supervision has developed a plan for further corrective action

, including:

a ~

Identifying UCriticalU surveillance procedures to Operations and Maintenance personnel to allow appropriate precautions to be taken during performance of the surveillance.

b. Development of a work practice training program for I&C Technicians.

c ~ Evaluation of the need for permanent additional supervision during testing activities.

d.. Evaluate the need for a dedicated team for surveillance testing.

2. An Engineering study will be performed to evaluate the design/equipment of the system to see if a practical fix can be identified to prevent reactor scrams as a result of. a single error during surveillance testing.

Safety Significance The plant operators reacted correctly to promptly bring the plant to a safe shutdown condi tion. All Reactor Protection System actions occurred in accordance with design requirements. Accordingly, this event posed no threat to the health and safety of the public or plant personnel.

NRC FORM SSSA 'V.ST CPOs )968 S)0 SS9i00070 (993)

NRC Form 386A V.S, NUCLEAR REOVLATORY COMMISSION (983 I LICENSEE EVENT REPORT ILER) TEXT CONTINUATION APPROVED OMB NO. 3150-OI08 EXPIRES: 8/31/88 FACILITY NAME (1) DOCKET NUMBER (3) LER NUMBER (6) PAGE (3)

YEAR .j%j SEOUENTIAL ?M REVISION NUM88/r SN: NUM88R Washin ton Nuclear Plant -'Unit 2 o s o o o 97 89 0 3 5 0 0 4 OF0 4 TEXT ///more 8/reee /8 re@sr/red, ose edde'encl NRC Form 35543/ lll)

Similar Events Two previous scrams occurred due to common sensing line perturbations. These are documented in LERs85-016 and LER 85-053. The design of the system allows a single error to resul t in a reactor scram.

EI IS Information Text Reference EIIS Reference System ~Com onent Automatic Depressurization System (ADS) SB Reactor Protection System (RPS) JC MS-LIS-38A SB LIS MS-LIS-24B SB LIS MS-L I S-24A SB LIS NRC FORM 388A ~ 8.8, CPCr 1888-S)0-S88~000'70' (9.83)