05000315/LER-1998-003, :on 980107,missed Procedure Step Resulted in Esfa & RPS Actuation Occurring.Caused by Personnel Error. Work on Ssps Stopped & High Priority Job Order Initiated to Restore Ssps to Normal

:on 980107,missed Procedure Step Resulted in Esfa & RPS Actuation Occurring.Caused by Personnel Error. Work on Ssps Stopped & High Priority Job Order Initiated to Restore Ssps to Normal

ML17334B687
Person / Time
Site:	Cook
Issue date:	02/06/1998
From:	Boesch J AMERICAN ELECTRIC POWER CO., INC.
To:
Shared Package
ML17334B686	List: 05000315/LER-1998-003, :on 980107,missed Procedure Step Resulted in Esfa & RPS Actuation Occurring.Caused by Personnel Error. Work on Ssps Stopped & High Priority Job Order Initiated to Restore Ssps to Normal
References
LER-98-003, LER-98-3, NUDOCS 9802130102
Download: ML17334B687 (4)

LER-1998-003, on 980107,missed Procedure Step Resulted in Esfa & RPS Actuation Occurring.Caused by Personnel Error. Work on Ssps Stopped & High Priority Job Order Initiated to Restore Ssps to Normal

Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2)(i) 10 CFR 50.73(a)(2)(iii) 10 CFR 50.73(a)(2)(v), Loss of Safety Function 10 CFR 50.73(a)(2)(vii), Common Cause Inoperability 10 CFR 50.73(a)(2)(viii)(A) 10 CFR 50.73(a)(2)(viii)(B) 10 CFR 50.73(a)(2)(ii) 10 CFR 50.73(a)(2)(x)
3151998003R00 - NRC Website

text

NRC FORH 366 (5-92)

NUCLEAR REGULATORY COMMISSION LXCENSEE EVENT REPORT (LER)

OVED BY OMB NO. 3150-0104 EXPIRES 5/31/95 ESTIMATED BURDEN PER

RESPONSE

To COMPLY MITH THI INFORMATION COLLECTION REOUEST: 50.0 HRS.

FORIJAR COMMENTS REGARDING BURDEN ESTIMATE TO TH INFORMATIOH AND RECORDS MANAGEMENT BRANCH (HNB 7714),

U.ST NUCLEAR REGULATORY COMMISSION, NASHINGTON, DC 20555 0001, AND TO THE PAPERNOR REDUCTION PROJECT (3150.0104),

OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.

FACILITY HAHE (1)

Donald C. Cook Nuctear Plant - Unit 1 DOCKET NUMBER (2) 50-315 Page 1 of 3 TITLE (4)

Missed Procedure Step Results in Engineered Safety Features and Reactor Protection System Actuation MONTH DAY YEAR EVENT DATE 5)

YEAR LER NUMBER (6)

SEOUENTtAL NUHBER REVISION NUMBER MONTH DAY REPORT DATE (7)

FACILITY NAME None DOCKET NUMBER OTHER FACILITIES INVOLVED (8) 01 07 98 98 003 00 02 06 FACILITY NAME 98 DOCKET NUMBER OPERATING MODE (9)

PONER LEYEL (10) 0 THIS REPORT IS SUBHITTED PURSUANT 20 '201(b) 20.2203(a (1

20.2203(a)(2)(i) 20.2203(a (2)(ii) 20.2203(a)(2)(iii) 20'203(a)(2)(iv) 20.2203(a)(3)(i) 20.2203(a)(3)(ii) 20.2203(a)(4) 50.36(c (1

50.36(c)(2) 50.73(a)(2)(i) 50.73(a)(2)(iii) 50.73(a (2)(iv 50.73(a)(2)(v) 50.73(a)(2)(vii) 50.73(a)(2)(viii)(A) 50.73(a)(2)(viii)(B) 73.71(b) 73.71o OTHER (Specify in Abstract below and in TextTO THE REQUIREMENTS OF 10 CFR 5t (Check one or more) (11) 20.2203(a)(2)(v)

NAHE Mr. John Boesch, Maintenance Manager X 50.73(a)(2)(ii)

LICENSEE CONTACT FOR THIS LER (12 50.73(a)(2)(x)

TELEPHONE NUMBER (Include Area Code) 616/465-5901, x2634 C(NPLETE ONE LINE FOR EACH C(NPONEHT FAILURE DESCRIBED IN THIS REPORT 13

CAUSE

SYSTEH COMPONENT MANUFACTURER REPORTABLE TO NPRDS

CAUSE

SYSTEM COMPONENT MANUFACTURER REPORTABLE TO NPRDS ic'eke,'i'iX>:I SUPPLEMENTAL REPORT EXPECTED 14)

YES (If yes, complete EXPECTED SUBMISSION DATE).

X NO EXPECTED SUBHISSI ON DATE (15)

MONTH DAY YEAR ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (16)

On January 7, 1998, while performing 1 IHP 4030.STP.410, "Train 'A'PS and ESF Reactor Trip Breaker and SSPS Automatic Trip/Actuation Logic Functional Test," a step to reposition a test switch within the Solid State Protection System (SSPS) was overlooked.

Several steps later, when the SSPS was restored to normal, an unpla'nned Engineered Safety Features (ESF) actuation and Reactor Protection System (RPS) actuation occurred.

The root cause for this event is personnel error. The Instrumentation and Controls (I&C) procedure reader did not adequately follow an approved procedure.

The I&C reader missed Step 6.5.50 during the performance of 1 IHP 4030.STP.410, "Train 'A'PS and ESF Reactor Trip Breaker and SSPS Automatic Trip/Actuation Logic functional Test."

This event is being reported in accordance with 10 CFR 50.72(a)(2)(iv) as any event or condition that resulted in manual or automatic actuation of any Engineered Safety Feature, including the Reactor Protection System. The safety significance was negligible as the unit was in Mode 5 and the safety function of the actuated systems had already been established prior to the event.

A timeout was held with all l&C crews to discuss the event. The timeout focused on the reporting of unusual indications, self-checking, and I&C worker performance.

9802i30i02 980206 PDR ADQCK 050003f5 S

PDR.

NUCLEAR REGULATORY COMMISSION LICENSEE EVENT CONTINUATION ROVED BY OMB NO. 3150-0104 EXPIRES 5/31/95 ESTIMATED BURDEN PER

RESPONSE

TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.

FORHARD COMMENTS REGARDING BURDEH ESTIMATE TO THE INFORMATION AHD RECORDS MANAGEMENT BRAHCH (MHBB 7714), U.S.

NUCLEAR REGULATORY COMMISSION, llASHINGTON, DC 20555-0001, AHD TO THE PAPERIIORK REDUCTION PROJECT (3150.0104),

OFFICE OF MANAGEMENT AND BUDGET

'WASHINGTON, DC 20503.

FACILITY HAME (1)

DOCKET NUMBER (2)

YEAR LER NUMBER (6)

SEQUENTIAL REVISION PAGE (3)

Cook Nuclear Plant - Unit 1 TEXT (if sere space is required.

use additional NRC Fore 366A's) (17) 50-315 98 003 00 2OF3

Conditions Prior to Event

Unit 1 was in Mode 5, Cold Shutdown Descri tion of Event On January 7, 1998, while performing 1 IHP 4030.STP.410, "Train 'A'PS and ESF Reactor Trip Breaker and SSPS Automatic Trip/Actuation Logic Functional Test," a step to reposition a test switch within the Solid State Protection System (SSPS) was overlooked.

Several steps later, when the SSPS was restored to normal, an unplanned Engineered Safety Features (ESF) and Reactor Protection System (RPS) actuation occurred.

In response to a Westinghouse bulletin which stated that portions of SSPS may not have been completely tested, change sheet 2 to 1 IHP 4030.STP.410 was generated.

Change sheet 2 added Steps 6.5.39 through 6.5.39G to fully test SSPS. SSPS testing began on day shift January 7, 1998.

The partially completed procedure was then turned over to the night shift for completion. However, the turnover of the procedure was not a factor in this event.

The night shift performed a pre-job brief for this activity.

It was mentioned in the pre-job briefing that the usual 2 hour2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> technical specification limiting condition for operation time limit did not apply, but the need to avoid an ESF actuation in any mode was emphasized.

1 IHP 4030.STP.410 is written to be performed in Modes 1, 2, 3, 4, and 5.

Routinely this procedure is performed in Mode 1, thus the l&C crew was familiar with the SSPS response in Mode 1. No consideration was given to differences that might exist in Mode 5, nor were potential differences between Mode 1 and Mode 5 discussed during the pre-job briefing.

Approximately 10 steps in the procedure had been completed by using three (3) Instrumentation and Control (l&C) technicians as is the standard for this procedure.

One was designated as a procedure reader.

A second was a worker (turned switches and took meter reading) and a third was a helper, to allow the first two to remain focused on the incremental steps.

Due to a lack of self-checking, a poor procedure use practice, and poor supervisory oversight, the l&C procedure reader missed Step 6.5.50 which directed "Place MEMORIES in OFF" and preceded to the next step.

Steps 6.5.51 through 6.8.4 were performed with the MEMORIES switch in the wrong position. Unusual SSPS panel indications were noted by both the l&C reader and the l&C worker. They did not stop what they were doing or contact their supervisor.

Instead, they rationalized away the unusual indications to be associated with the performance of the test in Mode 5.

Step 6.8.5 was performed which placed the SSPS back to normal.

This action restored the SSPS system and allowed the test generated trip signals to affect the plant. Shortly thereafter, the l&C crew reported to the Operations Unit Supervisor that their testing was completed.

The Unit Supervisor performed a check of the control room panels and questioned why a safety injection status light was on. A check of the procedure and SSPS revealed the error. With the unit in Mode 5, the only physical equipment response was the opening of the main steam dump valves.

Cause of Event

The root cause for this event is personnel error. The l&C procedure reader did not adequately follow an approved procedure.

The l&C reader missed Step 6.5.50 during the performance of 1 IHP 4030.STP.410, "Train 'A'PS and ESF Reactor Trip Breaker and SSPS Automatic Trip/Actuation Logic Functional Test." The bases for the error was attributed to a lack of self-checking, a poor procedure use practice, and poor supervisory oversight..

NUCLEAR REGULATORY COMMISSION LICENSEE EVENT CONTINUATION OVED BY OMB NO. 3150-0104 EXPIRES 5/31/95 ESTIMATED BURDEN PER

RESPONSE

TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.

FORWARD COMMENTS REGARDING BURDEN ESTIMATE To THE INFORMATION AHD RECORDS MANAGEMENI'RANCH (MHBB 7714), U.S.

NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555 0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150.0104),

OFFICE OF MAHAGEMENT AND BUDGET, IIASHIHGTOH, DC 20503.

FACILITY NAME (1)

Cook Nuclear Plant - Unit 1 TEXT (if sore space is required.

use additional HRC rom 366A's) (17)

DOCKET NUMBER (2) 50-315 YEAR 98 LER NUMBER (6)

SEQUENTIAL 003 REVISION 00 PAGE (3) 3OF3 Anal sis of Event This event is being reported in accordance with 10 CFR 50.72(a)(2)(iv) as any event or condition that resulted in manual or automatic actuation of any Engin'eered Safety Feature, including the Reactor Protection System.

This event occurred in Mode 5, Cold Shutdown, with all control rods already inserted into the core, the reactor protection system removed from service, and the main steam isolation valves closed.

As a consequence, there was negligible impact on safety-related components and systems.

The main steamline isolation valve dump valves opened;.but, as noted above, the associated main steamline isolation valves were already in a closed condition. In summary, the safety function of the actuated systems had already been established prior to the event.

Corrective Actions

Immediate corrective actions consisted of the following:

Work on SSPS was stopped, a high priority job order was initiated to restore SSPS to normal, restoration plans were developed, and SSPS was successfully restored to normal.

Appropriate administrative actions were taken with the responsible l8C crew members.

The l8C supervisor was reminded of his responsibility to include special plant conditions and expected test indications as part of the pre-job briefings.

Immediate preventive actions consisted of the following: A timeout was held with all l&C crews to discuss the event. The timeout focused on the following items:

. The job performance expectations for l8,C workers. Key topics included in this discussion were: Strict Procedure Use and Adherence, Self Checking, Comprehensive Job Briefs, Supervisory Oversight and Teamwork.

The need to stop and resolve unusual indications during task performance.

The need to self-check one's work, especially before high-risk steps.

After determining that the crew clearly understood the expectations for them to successfully complete the procedure, the procedure was completed without incident.

Failed Com onent Identification None

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