ML17305A506

LER 89-020-01:on 890907,emergency Diesel Generator B, Essential Spray Pond Pump B & Essential Cooling Water Pump B Started During Removal of Jumpers.Caused by Personnel Error. Maint Procedure revised.W/900131 Ltr

ML17305A506
Person / Time
Site:	Palo Verde
Issue date:	01/31/1990
From:	Bradish T, James M. Levine ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
192-00627-JML, 192-627-JML, LER-89-020, LER-89-20, NUDOCS 9002120182
Download: ML17305A506 (18)

Text

ACCELERATED ISTRJBUTION DEMONEIATION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:9002120182 DOC.DATE: 90/01/31 NOTARIZED: NO DOCKET FACIL:STN-50-528 Palo Verde Nuclear Station, Unit 1, Arizona Publi 05000528 AUTH. NAME AUTHOR AFFILIATION BRADISH,T.R. Arizona Public Service Co. (formerly Arizona Nuclear Power LEVINE,J.M. Arizona Public Service Co. (formerly Arizona Nuclear Power RECZP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 89-020-01:on 890907,voluntary rept of load sequencer actuation.

W/8 ltr.

DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR 2 ENCL TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.

3 SIZE:

NOTES 05000528

/

RECIPIENT COPIES RECIPIENT COPIES ZD CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD5 LA 1 1 PD5 PD 1 1 CHAN,T 1 1 PETERSON,S 1 1 D INTERNAL: ACRS MICHELSON 1 1 ACRS MOELLER 2 2 ACRS WYLIE 1 1 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DS P 2 2 DEDRO 1 1 NRR/DET/ECMB 9H 1 1 NRR/DET/EMEB9H3 1 1 NRR/DET/ESGB 8D 1 1 NRR/DLPQ/LHFB11 1 1 NRR/DLPQ/LPEB10 1 1 NRR/DOEA/OEAB11 1 1 NRR/DREP/PRPB11 2 2 NRR/DST/SELB 8D 1 1 NRR/DST/SICB 7E 1 1 D5X/SPLB8D1 1 1 NRR/DST/SRXB 8E 1 1 EG FI'LE 02 1 1 RES/DSIR/EIB 1 1 RGN LE 01 1 1 EXTERNAL: EG&G WILLIAMS,S 4 4 L ST LOBBY WARD 1 1 LPDR 1 1 NRC PDR 1 1 NSIC MAYS,G 1 1 NSIC MURPHY,G.A 1 1 NUDOCS FULL TXT 1 1 NOTES: 1 1 D 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 39 ENCL 39

1i Arizona Public Service Company PALO VERDE NUCLEAR GENERATING STATION P.O. BOX 52034 ~ PHOENIX. ARIZONA 85072-2034 192-00627-JML/TRB/SBJ JAMES M. LEVINE VICE PRESIDENT January 31, 1990 NUCLEAR PRODUCTION U. S. Nuclear Regulatory Commission NRC Document Control Desk Washington, D.C. 20555

Subject:

Palo Verde Nuclear Generating Station (PVNGS)

Unit 1 Docket No. STN 50-528 (License NPF-41)

Licensee Event Report 89-020-01 File: 89-020-404 Attached please find Supplement Number 1 to voluntary Licensee Event Report (LER) No. 89-020-00. This voluntary report was prepared pursuant to guidance contained within 10 CFR 50.73. In accordance with 10CFR 50.73(d), we are herewith forwarding a copy of this report to the Regional Administrator of the Region V Office.

If you have any questions, please contact T. R. Bradish, (Acting) Compliance Manager at (602) 393-2521.

Very truly yours, JML/TRB/SBJ/kj Attachment CC: W. F. Conway (all w/a)

E. E. Van Brunt J. B. Martin D. H. Coe M. J. Davis A. C. Gehr INPO Records Center 90013i PDR ADOCK 05000528

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NAC FORM 355 U.S. NUCLEAR REGULATORY COMMISSION (54)0) APPROVED OMB NO. 31500)04 CXPIRESr 4I30ig2 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION RE'GUEST: 50.0 HAS. FORWAAD LICENSEE EVENT REPORT {LER) COMMEN'TS REGARDING BUADEN ESTIMATE TO THE AECORDS AND REPORTS MANAGEMENT BRANCH (P030), U.S. NUCLEAR REGULATORY COMMISSION. WASHINGTON. OC 20555, AND TO THE PAPEAWOAK REDUCTION PROJECT (31500104), OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (II DOCKET NUMBER 12) PAGE Palo Verde Unit 1 o 5 o 0 o 52 81OF0 7 TI'1 LE (41 Voluntary Report of Load Sequencer Actuation EVENT DATE (5) LER NUMBER IS) REPORT DATE (7) OTHER FACILITIES INVOLVED (SI MONTH OAY YEAR YEAR cp'e?: 55DUCNTI*L SN AcvrsxN'0NTH DAY YEAR FACILITYNAMSS DOCKE'1 NUMBERISI M~ nNUMBSII 556 NUM55rl N/A 0 5 0 0 0 0 90 789 89 0 2-0 0 10 13 1 9 0 N/A 0 5 0 0 0 IS SUBMITTED PURSUANT 7 0 THE RLOUIREMENTS OF 10 CFA ()r (Cnece one or more Ol rne Iollewinp) (11 THIS REPORT Ill(SI OPERATING MODE <5) 20.402(b) 20.405(cl 50.73(el(2)(rvl 73.7)(51 POWE R 20.405( ~ ) (1)D) 50.35(cl Ill 50.73(s) (2)(v) 73.71( ~ )

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On September 7, 1989 at approximately 2027 HST, Palo Verde Unit 1 was in a refueling outage with the core offloaded when the RBR Emergency Diesel the RBR essential Generator (EDG), the RBA essential spray pond pump, and cooling water pump started while maintenance technicians were removing jumpers from an engineered safety features actuation system (ESFAS) cabinet. The components started as the result of an inadvertent deenergization of a ESFAS actuation relay.

The EDG was stopped at approximately 2105 HST after the'cause of the starting had been confirmed. The essential cooling water pump and spray pond pump were stopped at approximately 2130 HST and 2210 HST, respectively.

The starting of the plant equipment was caused by a cognitive personnel error in that a maintenance technician did not properly install a jumper.

In order to prevent recurrence, the conduct of maintenance procedure has been revised to incorporate guidance on temporary jumper installation. The continuing ISC training has been revised to include work practices for jumper installation/removal. The initial I8C training will also be revised to include work practices for jumper installation/removal.

This is being reported as a voluntary report.

NRC Fores 355 (500)

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FACILITY NAME (11 DOCKET NUMBER (2)

LER NUMBER (0) PAGE (3)

YE*4 X@ SEQUENTIAL NVMBER '~+~<+/ 4EVISION NUMBER Palo Verde Unit 1 o s o o o 5 2 8 89 020 01 02 oFO 7

'tEXT /llI44IP 44444 /4 IN)Iuied. II44 PddIT/NM/l/RC FPI4I 30549/ (I7)

I. DESCRIPTION OF WHAT .OCCURRED:

A. Initial Conditions:

On September 7, 1989 at approximately 2027 HST, Palo Verde Unit 1 was in a refueling outage with the core (AC) off-loaded. At the time of the event the reactor coolant system was at atmospheric pressure with a temperature of approximately 74 degrees Fahrenheit.

B. Reportable Event Description (Including Dates and Approximate Times of Hajor Occurrences):

Event Classification: Voluntary On September 7, 1989 at approximately 2027 HST, APS maintenance technicians (utility, non-licensed) were removing jumpers from an engineered safety features actuation system (ESFAS)(JE) cabinet when the HBR Emergency Diesel Generator (EDG)(EK), the HBR essential spray pond (BS) pump (P), and the HBR essential cooling water (BI) pump started. The event was caused when an actuation relay was inadvertently deenergized during jumper removal simulating an auxiliary feedwater actuation system (AFAS) signal.

On July 7, 1989 a modification to the Unit 1 ESFAS train RBR was commenced in accordance with approved work documents. This modification replaced defective actuation relays as part of the corrective action specified in LER 528/88-018, "Potter & Brumfield Relay Halfunctions". In accordance with the work order, maintenance technicians installed jumpers and lifted leads to prevent inadvertent equipment actuations prior to replacing the relays. On August 26, 1989, the relay replacement work was completed with a few exceptions.

On August 26, 1989, the ESFAS cabinet was energized in preparation for testing of the replacement jumpers and a ground fault indication was received on ESFAS Train RBR power supplies. The ground fault indication was still present after the replacement jumpers were removed and all associated lifted leads were reterminated, The'eplacement jumpers were then reinstalled and wires determinated to prevent inadvertent actuations during troubleshooting of the ground fault. On August 27, 1989 the cause of the ground was isolated to a relay coil wire. All lifted leads with the exception of the wires to the defective relay were reterminated at approximately 0200 HST on August 28, 1989.

Upon completion of HAR Train Integrated Safeguards (ISG) testing on .

September 1, 1989, Unit 1 commenced RBR Train ISG prerequisites.

In parallel with these activities, Unit 1 Work Control and NRC FoRII 300A (009)

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~ NRC FORM 355A US. NUCLEAR REGULATORY COMMISSION (54)9) APPROVEO 0MB NO.3(500(04 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT (LER) INFORMATION COLLECTION REOUESTJ 500 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION ANO REPOR'tS MANAGEMENT BRANCH (F430). U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (31504)104). OFFICE OF MANAGEMENTANO BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (I) DOCKET NUMBER (2) LER NUMBER LBI PAGE (3) yEAR (Iw sEDUENTIAL NUMBER

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Operations evaluated clearance restraints, subsequently releasing, modifying, or temporarily lifting approximately 69 clearances.

On September 7, 1989 at approximately 1630 HST, the integrated safeguards test on the RBR Train was initiated. Thirty-five components failed to respond to the test signal. An inspection of the ESFAS cabinet revealed that the jumpers to prevent inadvertent actuations during the ground fault troubleshooting were still installed.

At approximately 1900 HST on September 7, 1989 maintenance personnel started the removal of temporary jumpers installed for the ground fault troubleshooting. At approximately 2027 HST the Unit 1 Control Room Operator (utility, licensed) noted the diesel generator RB", essential cooling water pump RB", and spray pond pump RBR had started. The operator evaluated the event utilizing procedures 1AO-1ZZ28 (Inadvertent SIAS/CIAS) and 73ST-10G02 (Integrated Safeguards Train RBH). The operator noted that the essential chilled water pump RBR (CC) had not started. At approximately 2105 HST, after the cause of the equipment starting had been confirmed, the RBH DG was shutdown. The HBR essential cooling water pump was stopped at approximately 2130 HST. The HBH spray pond pump was stopped at approximately 2210 HST.

The Shift Supervisor (utility, licensed) stopped the removal of the jumpers and instructed the I&C personnel to return the work order to work control for an amendment that will specify utilization of secondary jumpers to prevent loss of continuity during removal of the remaining jumpers. The need to use secondary jumpers was emphasized to maintenance technicians prior to returning to work on September 8, 1989. Jumper removal was completed on September 8, 1989 at approximately 0900 HST.

In response to the event and the events leading up to the event, the Unit 1 plant manager assigned the outage manager to coordinate an investigation into the events and to establish a method to complete testing of all available ESFAS circuits.

The outage manager had the work orders associated with the replacement of RBH train ESFAS Potter-Brumfield relays reviewed for outstanding items which could impact the resumption of the ISG testing. The removal of the jumpers was verified by reviewing documentation and field verification.

On September 8, 1989, the actions taken were reviewed by the plant manager and approval was given to proceed with the ISG testing, The ISG test was recommenced on September 8, 1989 at approximately N RC Form 355A (54)9)

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NRC FORM 388A U.S. NUCLEAR REGULATORY COMMISSION (84)9) APPROVED 0MB NO. 3)500)04 EXPIRES; 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT ILER) INFORMATION COLLECTION REOUEST: 500 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (P4)30). U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555. AND TO THE PAPERWORK REDUCTION PRO/ECT (31500104), OFFICE OF MANAGEMENTAND BUDGET. WASHINGTON, OC 20503.

FACILITY NAME (I) DOCKET NUMBER (21 LER NUMBER (8) PAGE (3)

YEAR ,'p>: SEQUENTIAL '<'? r)EVISION Px4 NUMSER x' r)UMttrl Palo Verde Unit 1 o s o o o 52,8 89 0 20 01 04 oF0 7 TEXT //l mart <<ra at /4 ttr/attd, rrtt Mdi darrt/HRC Farm 3/I//A'/ (I2) 1651 HST. An evaluation of the test'results identified that six components did not respond as designed. A review of the work orders associated with the ESFAS relay replacement identified that lifted leads from work performed during August 27, 1989 troubleshooting had prevented the equipment actuations. The plant manager placed the ISG testing on hold until a thorough review of the events was completed.

On September 8, 1989 at approximately 2200 HST action assignments to ensure the ESFAS cabinet was ready for testing were made. All wires under the relay replacement work orders were terminated. A 100 percent restoration verification for all ESFAS relay replacement jumpers and lifted leads was performed. All work was completed by approximately 0700 HST on September 9, 1989.

Following the review meeting for the corrective actions, another 100 percent independent restoration verification was performed. At approximately 1200 HST on September 9, 1989, the plant manager gave permission to resume the ISG testing. The ISG testing was completed without further incident on September 9, 1989 at approximately 1530 HST.

C. Status of structures, systems, or components that were inoperable at the start of the event that contributed to the event:

The ESFAS cabinets were inoperable at the time of this event. The ISG test was part of the return to service operability verification. In addition, the work package that installed the temporary jumpers had not been closed at the time of the event.

Closure of this work package required removal of the temporary jumpers prior to returning the system to an operable status.

D. Cause of each component or system failure, if known:

Not applicable - there were no component or system failures.

Failure mode, mechanism, and effect of each failed component, if known:

Not applicable - there were no component failures.

F ~ For failures of components with multiple functions, list of systems or secondary functions that were also affected:

Not applicable - there were no component failures.

NRC Farm 388A (84)9)

OIRC FORM066A US. NUCLEAR REGULATORY COMMISSION (669) APPROVED OMB NO(31500104 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT (LER) INFORMATION COLLECTION RFQUESTI 500 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (P 530), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555. ANO TO THE'APERWORK REDUCTION PROJECT (31500104). OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, OC 20503i FACILITY NAME 11) DOCKE'T NUMBER (2) LER NUMBER IS) PAGE (3)

YEAR I(g $ 6ovSNTIAL NUM ER ASVOION NVMOSA Palo Verde Unit 1 0 s 0 0 0 5 2 8 89 02 0 0 1 05oF 0 7 TEXT /I/ssuuo 4/sssois ssoss)sd. uso sddrs/oosl s/RC Foms 3664'4/117)

G. For failures that rendered a train of a safety system inoperable, estimated time elapsed from the discovery of the failure until the train was returned to service:

Not applicable - there were no equipment failures. The ESFAS cabinets were inoperable prior to the event. The ISG testing was being performed to establish operability of the system.

H. Hethod of discovery of each component or system failure or procedural error:

The initiation of the plant components and the subsequent control room annunciations led to discovery of the jumper removal error.

I. Cause of Event:

The starting of the plant equipment was caused by cognitive personnel error in that the technician failed to install a secondary jumper to ensure circuit continuity prior to removal of the installed jumper.

The secondary jumper provides an alternative path for power to the relay such that a loss of power will not occur if the normal power supply lead is inadvertently disconnected when the primary jumper is removed. Although the use of the secondary jumper was not specifically required in the work order, the use of secondary jumpers is an expected work practice.

The failure to remove replacement jumpers and land lifted leads prior to performance of the ISG test were caused by personnel error. The planner (utility, non-licensed) and instrument and controls supervisor (utility, non-licensed) failed to perform an adequate review of the readiness of ESFAS components for Integrated Safeguards testing when work had not yet been completed.

J. Safety System Response:

The safety system response is detailed in Section I.B.

K. Failed Component Information:

Not applicable - there were no failed components.

II. ASSESSMENT OF THE SAFETY CONSEI0UENCES AND IMPLICATIONS OF THIS EVENT.

This event was initiated by the inadvertent deenergization of a NSSS ESFAS actuation relay during the removal of a jumper. This caused an Auxiliary Feedwater Actuation System (AFAS)(BA) -2 signal to be sensed downstream of the actuation relay. The minimum actuation logic upstream NRC Form 366A (669)

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NR CFORM 366A U.S. NUCLEAR REGULATORY COMMISSION (649) APPROVED OMB NO. 3150010S EXPIRES; 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT (LER) INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMEN'TS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (F430). U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUC'TION PROJECT (31500)04). OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (Il DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

VEAR +~4. SEQUCNT/AL I,'EVISION

'OS NUMOSR NVMOSR Palo Verde Unit 1 52 889 02 0 01 06 o" 0 7 TEXT /// moss spsso/s /sOoked. Vso sddidoos///RC Fono 35((4's) (12) of the actuation relay to initiate an AFAS signal was not completed.

The plant equipment, DG, and load sequencer responded as designed to the sensed signal. The deenergization of the actuation relay caused the diesel generator to start and initiated the load sequencer. The load sequencer started the RBR essential spray pond pump and "B" essential cooling water pump. The load sequencer stopped prior to the starting of the essential chilled water pump because the AFAS signal,was removed.-

The technician had completed the jumper removal which subsequently reenergized the actuation signal and removed the AFAS signal. All equipment responded as designed.

The starting of the plant equipment was caused by an inadvertent actuation of a relay by a maintenance technician and was not caused as a result of a valid actuation signal.

As discussed in Section I.B, the jumpers which were inadvertently left in the ESFAS cabinet during the testing prevented equipment from responding. This condition had no adverse effect on plant safety, as the cabinets were inoperable for the test and our process would require removal of the jumpers in order to close the work order as a necessary prerequisite to declaring the cabinets operable.

Except as discussed above, all equipment functioned as designed during the event. These actuations would not adversely affect the safe operation of shutdown of the reactor. Therefore, the event did not affect the health or safety of the public.

This event was not initiated by the minimum actuation logic for an AFAS. This is being submitted as a voluntary report.

III. CORRECTIVE ACTIONS:

A. Immediate:

The control room operator verified that the starting of the plant equipment did not result from an actual condition, and verified that all components operated as designed. The shift supervisor terminated further work in the ESFAS cabinet until steps were taken to prevent recurrence of the event.

The replacement jumpers were removed and documentation verified complete prior to reperforming the test.

B. Action to Prevent Recurrence:

The maintenance technician was counseled. In order to ensure similar mistakes are not made by other maintenance technicians, the following actions will be completed.

NRC Form 366A (649)

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NRC FOAL) 355A U.S. NUCLEAR REGULATORY COMMISSION

~ 'BB9) APPROVEO OMB NO 3I 500104 EXPIRES: S/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS LICENSEE EVENT REPORT (LER) INFORMaTION COLLECTION REOUESTI 500 HRS. FORwaRD COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS TEXT CONTINUATION AND REPORTS MANAGEMENT BRANCH (F430). U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555, AND TO THE PAPERWORK REDUCTION PROJECT )31504)04). OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, OC 20503.

FACILITY NAME II) DOCKET NUMBER 12) LER NUMBER IS> PAGE LS)

YEAR SEOVENTIAL rI) RS,VISION NUM 5 R <OS NUMBER Palo Verde Unit 1 o s o o o 52 88 9 02 00 1 0 7 oF0 7 TEXT ii/more spsse is reqrdred. ose eddirrorM////IC Form 3654's/ )17)

The conduct of maintenance procedure was revised to incorporate guidance..on temporary jumper installation.

The continuing I&C training was revised to include work practices for jumper installation/removal. The initial training will be revised and implemented by Harch 31, 1990.

A letter describing the lessons learned from this event will be prepared and issued to Unit 1 Work Control personnel and Unit 1 Supervision by February 16, 1990. This letter will also emphasize the application of these lessons to restart activities.

NRC Form 355A IE 59)

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