ML17326B336

LER 88-001-00:on 880113,unit Experienced ESF Actuation. Caused by Personnel Error.Administrative Controls Established to Ensure Proper Equipment Configurations. Personnel Involved in Occurrence counseled.W/880204 Ltr

ML17326B336
Person / Time
Site:	Cook
Issue date:	02/04/1988
From:	Baker K, Will Smith INDIANA MICHIGAN POWER CO. (FORMERLY INDIANA & MICHIG
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
LER-88-001-01, LER-88-1-1, NUDOCS 8802090610
Download: ML17326B336 (6)

Text

REGULAT~ Y INFORMATION DISTRIBUTION YSTEM (RIDS)

ACCESSION PIBR: 880209061 DOC. DATE: 88/02/04 NOTARIZED: NO DOCKET FACIL: 50-315 Donald Cook Nuclear Power Planti Unit ii Indiana 0 05000315 AUTH. NAME BAKERi K. R.

'UTHOR C.

AFFILIATION Indiana Michigan Pacer Co. (formerly Indiana 5 Michigan Ele SMI THi W.

REC IP.

G.'ndiana NAME Michigan Poeer Co.

RECIPIENT AFFILIATION (formerly Indiana 8c Michigan Ele

SUBJECT:

LER 88-001-00: on 8801 i3> Unit 1 experienced engineered safety features actuation. Caused bg personnel error.

Administrative controls established 5 personnel involved counselled. W/880204 1tr.

DISTRIBUTION CODE: IE22D CQP IES RECEIVED: LTR ENCL SIZE:

TITLE: 50. 73 Licensee Event Report (LER)i Incident Rpti etc.

NOTES:

REC IP IENT CQP IES REC IP IENT CQP I ES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD3-3 LA 1 i. PD3-3 PD 1 1 WIGGINGTONi D 1 INTERNAL: ACRS MICHELSON 1 1 ACRS MOELLER AEOD/DOA 1 AEOD/DSP/NAS 1 1 AEOD/DSP/ROAB 2 2 *EOD/DSP/TPAB 1 1 ARM/DCTS/DAB 1 1 DEDRO 1 1 NRR/DEST/ADS 1 0 NRR/DEST/CEB 1 1 NRR/DEST/ELB 1 NRR/DEST/ I CSB 1 1 NRR/DEST/MEB 1 1 NRR/DEST/MTB 1 1 NRR/DEST/PSB 1 NRR/DEST/RSB 1 1 NRR/DEST/SGB 1 1 NRR/DLPG/HFB 1 1 NRR/DLPG/GAB 1 1 NRR/DOEA/EAB 1 1 NRR/DREP/RAB 1 1 NRR/DREP/RPB 2 2 FRQR-I S I B 1 1 NRR/PMAS/ ILRB 1 1 FI 02 1 RES TELFORDi J 1 1 RES/DE/EIB 1 1 RES/DRPS DIR 1 1 RGN3 F ILE 01 1 1 EXTERNAL: EGLG GRQHi M 5 =

5 FORD BLDG HOYLE A 1 1 H ST LOBBY WARD 1 1 LPDR 1 NRC PDR 1 NSIC HARRIS' 1 1 NSIC MAYSi G 1 1 TOTAL NUMBER OF COPIES REQUIRED: LTTR 46 ENCL 45

NRC Form 365 US. NUCLEAR REOULATORY COMMISSION (Bh63)

APPROVED OMS NO. 31604104 LICENSEE EVENT REPORT ILER) EXPIRES: 8/31/88 FACILITYNAME (I) DOCKET NUMBER (2) PA E D. EC. Cook Nuclear Plant Unit One 0 5 0 0 0 3 1 5 1 OF 0 4 Engineered Safety Features Actuation (Reactor Trip) Due to The Inadvertant Opening of a Reactor Trip Breaker as a Result of Personnel Error EVENT DATE (5) LEA NUMSFR (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (8)

MONTH DAY YEAR YEAA SEOUENTIAL Srn'. REVISION FACILITYNAMES NUMSER &rrr'UMBER MONTH DAY YEAR DOCKET NUMBER(SI 0 5 0 0 0 01 13 8 8 8 8 001 0 0 0 2 0 4 8 8 0 5 0 0 0 THIS REPORT IS SUBMITTED PURSUANT T 0 THE REOUIREMENTS OF 10 CFR (): /Check One or mors Of the folios//of/ (11 OPERATING MODE (8) ] 20.402(8) 20A05(c) 60.73(sl(2)(iv) 73,7)(8)

POWER 20.405 (4) (I) I I) SOM(c)/tl 50.73(eH2) (vl 73h71(c)

LEYEL 0 9 0 20.405(e ) I I I I 4) SDM(c)(2)

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50.73(e) (2) (vil) OTHER /Specify /n Ahrtrsct os/ore end In Text, HRC Form 20.405 (e) (I ) (ii)) 60.73 le) (2) II) SOTS(e)(2)(viiillA) SBBA/

hE 20.405(ellll(iv) 50.73(s) (2)(ii) 60,734) l2)(vl8)ISI 4n,'..4 ..R ..: 20AOS(s)II)(v) 60.73( ~ l(2)(iiil 50.73(eltlHx)

LICENSEE CONTACT FOR THIS LER (12)

NAME TELEPHONE NUMBER AREA CODE K. R. Baker, Operations Department Superintendent 61 64'65- 590 1 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCAISED IN THIS REPORl'13) n CAUSE SYSTEM COMPONENT MANUFAC. EPORTABLE MANUFA(r EPOATABLE TUAER TO NPRDS CAUSE SYSTEM COMPONENT TUR ER TO NPADS hh'K>@S,

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SUPPLEMENTAL REPORT EXPECTED (t4) MONTH OAY YEAR EXPECTED SUBMISSION YES /If yer, COmplme EXPECTED S(IBMISSIDI/ DATA DATE H6)

X NO ASSTAACT /Limit to /400 tpscsr, /e., spproximstsly fifteen slntrrospece typewritten linn/ (16)

On January 13, 1988, at 0821 hours0.0095 days <br />0.228 hours <br />0.00136 weeks <br />3.123905e-4 months <br />, Unit One experienced an Engineered Safety Features Actuation (Reactor Trip) as a result'f the inadvertant opening of the Train B Reactor Trip Breaker. At the time of this event the Unit was operating in Mode 1 (Power Operation) at 90. percent rated thermal power.

This event was the result of cognitive personnel error on the part of the licensed operator involved, who attempted to manipulate the Train B Reactor Trip Breaker instead of Reactor 'Zrip Bypass Breaker B during the monthly Solid State Protection System (SSPS) surveillance.

Following the reactor trip all actions and verifications required by the facility emergency operating procedures were complied with and the Unit was stabilized in Mode 3 (Hot Standby).

Administrative c'ontrols have been established to ensure proper equipment configurations and adequate job briefings during surveillance testing.

Procedural enhancements will be made to improve communications and component status verifications, and are tentatively scheluded for completion by April 7, 1988. lastly, appropriate administrative action and counseling has been effected with the personnel involved in this occurrence.

8802090610 880204 PDR ADOCK 05000315 8 PDR NRC Form 386 (84)3)

NRC Form 3ddA V.S. NUCLEAR REOVLATCRY COMMISSION (943)

LICENSEE EVENT REPORT ILER) TEXT CONTINUATION APPROVEO OM8 NO. 3150&104 EXPIRES: 8/31/88 FACILI'TY NAME (11 OOCKET NUMSER (3( LER NUMSER (8) PACE (31 YEAR SEOVENTIAL REVISION NUM ER Pg NVMSER D. C. Cook Nuclear Plant, Unit One o s o o o 3 1 5 8 8 0 0 1 002 oF0 4

'TEXT /l/ more NMIe /I nr/rr/red. we edd/o'ore/H/IC Form 38SA'e/ (17(

Conditions Prior to Occurrence Unit One was operating at 90 percent reactor thermal power .at the time of the event.

Desci tion of Event On January 13, 1988, at 0821 hours0.0095 days <br />0.228 hours <br />0.00136 weeks <br />3.123905e-4 months <br />, Unit One experienced an Engineered Safety Feactures Actuation (Reactor Trip) from 90 percent rated thermal power. The actuation occurred as a result of a licensed operator inadvertantly manipulating a reactor trip breaker (EIIS"JE-BKR) instead of a reactor trip bypass breaker during the monthly Solid State Protection System (SSPS) (EIIS-JG) surveillance on Train B. The operator's intended function during this surveillance was to rack in Reactor Trip Bypass Breaker B.

During performance of the SSPS surveillance the licensed operator erroneously opened the cubicle door (EIIS-JE-CAB) for Reactor Trip Breaker B. Once inside, the operator experienced difficulty in manipulating (racking in) the breaker. I hen analyzing the situation the operator concluded that perhaps the breaker latching mechanism (EIIS-JE-MECH) was impeding breaker movement. By depressing the latching mechanism to facilitate breaker movement,- the mechanical interlock (EIIS-JE-IMEC) with its associated shunt trip (EIIS-JE-17) was actuated thereby tripping the breaker and the Unit One reactor.

Following the trip sequence [opening of the reactor trip breakers (EIIS-JE-BKR), turbine (EIIS-TA-TRB) trip, insertion of the reactor control rods (EIIS-AA-ROD), feedwater isolation (EIIS-JB), automatic starting of the motor'-driven and turbine-driven auxiliary feedwater pumps (EIIS-BA-P))

Operations personnel immediately implemented the Emergency Operating Procedure 1-OHP 4023.E-O to verify proper response of the automatic protection system (EIIS-JC) and to assess plant conditions for initiating appropriate recovery actions. There was no automatic or manual actuation of the safety injection system, (EIIS-BQ).

The Unit was stabilized in Mode. 3 (Hot Standby) at approximately 0835 hours0.00966 days <br />0.232 hours <br />0.00138 weeks <br />3.177175e-4 months <br /> on January 13, 1988. The Nuclear Regulatory Commission was notified of the event via the Emergency Notification System at 0921 hours0.0107 days <br />0.256 hours <br />0.00152 weeks <br />3.504405e-4 months <br />.

There were no inoperative structures, components, or systems that contributed significantly to this event.

NRC fORM Sddo (9 831

NRC Form 3SSA U.S. NUCLEAR REGULATORY COMMISSION 19431 LICENSEE EVENT REPORT {LER) TEXT CONTINUATION APPROVED OMS ND, 3150W104 EXPIIIES: 8/31/88 FACILITY NAME ill DOCKET NUMSER 131 LER NUMSER 181 ~ AOE (3)

YEAR SSOVSNTIAL REVISION NVM SR NVM SR D. C. Cook Nuclear Plant, Unit One o s o o o 3 1 5 8 8 0 1 0 0 0 3 OF 0 4 TEXT //1 moro eoece le reeoPN/, o>> a/oN/ooo/HRC %%drm 3//SA'e/ IITI Cause of Event Cognitive personnel error due to a failure of the licensed operator to properly identify/verify the correct breaker was the cause of this event.

Investigation of this event determined that the breaker cubicles were properly labelled. However, the operator utilized the train designation instead of the breaker functional labelling to identify/locate the breaker.

Contributing to this event were inadequate job briefing and failure to implement standard precautionary measures normally associated with this critical work.

Anal sis of Event This event is being reported in accordance with 10 CFR 50.73(a)(2)(iv) as an event that resulted in an unplanned automatic actuation of an Engineered Safety Feature including the Reactor Protection System.

The automatic protection system responses, including reactor trip and its associated actuations, were verified to have functioned properly as a result of the engineered safety features actuation. Based on the above, it is concluded that the event did not consitute an unreviewed safety question as defined in 10 CFR 50.59(a)(2) nor did the health and safety of the public.

it adversely impact Corrective Actions Immediate corrective action involved Operations personnel implementing plant procedures to verify proper response of the automatic, protection system and to assess plant conditions'or initiation of appropriate recovery actions.

Action taken or to be taken to prevent recurrence:

1) Appropriate administrative action and counseling have been affected with the personnel involved in this occurrence.

2) The SSPS surveillance procedure involved in this event will be revised to improve interaction between operator and the technician. Areas to be improved include communications and status verfication. The tentative completion date for this revision is April 7, 1988

')

Administrative controls have been established to ensure proper equipment configurations and adequate job briefings during surveillance testing.

NRC FORM SSSA 1983 I

NRC form 3eeA U.S. NUCLEAR REQULATORY COMMISSION (843)

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVED OMS NO. 3150&104 EXPIRES: 8/31/88 FACILITYNAME Il) DOCKET NUMSER 12) LER NUMSER IS) PAOE IS) r'(ie SEOVENTIAL rerg YEAR NVMefR " " REVCSION NVMefR D. C. Cook Nuclear Plant, Unit One 0 5 0 o o 3 1 5 8 8 0 0 1 0 0 0 4 QF 0 4 TEXT //fmore eoeoe /e rer/rr/red, ore edd/o/rrre/ NRC forrrr 3////A'e/ II 2)

Failed Com onent Identification None Previous Similar. Events There have been no previous events involving the inadvertant manipulation of the reactor trip breakers during the monthly Solid State Protection System surveillance.

NRC FORM eeeA I8.83)

Indiana Michigan Power Company Cook Nuctear Plant P.Q. Box 458 Bridgman. Ml 49106 616 46'901 IMSIARP, NICHIGAN POMfER February 4, 1988 United States Nuclear Regulatory Commission Document Control Desk Washington, D.C. 20S55 Operating License DPR-58 Docket No. SO-315 Document Control Manager:

In accordance with the criteria established 10 CFR 50.73 entitled Licensee Event Re ortin S stem, theby following report is being submitted:

88-001-00 Sincerely, W. G. Smith, Jr.

Plant Manager WGS:afh Attachment cc: D. H. Williams, Jr.

A. B.

M.

Davis, Region P. Alexich III R. F. Kroeger H. B. Brugger R. W. Jurgensen NRC Resident Inspector D. L. Wigginton, NRC R. C. Callen G. Charnoff, Esq.

Dottie Sherman, ANI Library D. Hahn INPO PNSRC /p0 A. A. Blind P. A. Barrett/P. Lauzau