ML17348B114

LER 91-004-00:on 910822,inadvertent Start of 3A Diesel Generator Occurred.Caused by Inadequate Communication Between Startup Personnel & Licensed Operators.Procedures Revised & Personnel trained.W/910919 Ltr

ML17348B114
Person / Time
Site:	Turkey Point
Issue date:	09/19/1991
From:	Plunkett T, Dawn Powell FLORIDA POWER & LIGHT CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
L-91-258, LER-91-004-03, LER-91-4-3, NUDOCS 9109240318
Download: ML17348B114 (6)

Text

ACCELERATED ETRIBUTION DEMONSATION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:9109240318 DOC.DATE: 91/09/19 NOTARIZED: NO DOCKET FACIL:50-250 Turkey Poi'nt Plant, Unit 3, Florida Power and Light C 05000250 AUTH. NAME AUTHOR AFFILIATION POWELL,D.R. Florida Power & Light Co.

PLUNKETT,T.F. Florida Power & Light Co.

RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 91-004-00:on 910822,inadvertently start of 3A diesel generator occurred. Touching together of lifted leads, providing rapid start signal. Training of Startup personnel on revs to SFP-2 & SFP-21.W/910919 ltr.

DISTRIBUTION CODE- IE22T COPIES RECEIVED:LTR t ENCL ( 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 AULUCK,R 1 1 INTERNAL: ACNW 2 2 AEOD/DOA 1 1, AEOD/DS P/TPAB 1 1 AEOD/ROAB/DSP 2 2 NRR/DET/ECMB 9H 1 1 NRR/DET/EMEB 7E 1 1 NRR/DLPQ/LHFB10 1 1 NRR/DLPQ/LPEB10 1 1 NRR/DOEA/OEAB 1 . 1 NRR/DREP/PRPB11 2 2 NRR/DST/SELB 8D 1 1 NRR/DST/SICB8H3 1 1 NRR/D T/NZLB8D1 1 1 NRR/DST/SRXB 8E 1 1 1 1 RES/DSIR/EIB 1 1 RGN2 FILE 01 1 1 EXTERNAL EG&G BRYCE i J ~ H 3 3 L ST LOBBY WARD 1 1 NRC PDR 1 1 NSIC MURPHY,G.A 1 1 NSIC POORE,W. 1 1 NUDOCS FULL TXT 1 1 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 31 ENCL 31

P.O. Box 029100, Miami, FL, 33102-9100 APL gFP 1 0 "QQ$

L-91-258 10 CFR 50.73 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555 Gentlemen:

Re: Turkey Point Units 3 and 4 Docket No. 50-250 Reportable Event: 91-004-00 Date of Event: August 22, 1991 Inadvertent Start of 3A Emer enc Diesel Generator The attached Licensee Event Report 250-91-004-00 is being provided in accordance with the requirements of 10 CFR 50.73 (a) (2) (iv) to provide notification of the subject event.

Very truly yours, T. F. Plunkett Vice President Turkey Point Nuclear TFP/CLM/clm Attachment cc: Stewart D. Ebneter, Regional Administrator, Region II, USNRC Senior Resident Inspector, USNRC, Turkey Point Plant 91 F'D~ ~pock'DR

~iso~ 1 g~ 9].X'19 an 0500~-'-'0 fpL Group company

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LICENSEE EVENT REPORT (LER)

FACILITY NAHE (I) TURKEY POINT UNIT 3 DOCKET NIP(BER 2 PACE 3 05000250 1 Or 3 TITLE(6) INADVERTENT START OF 3A EMERGENCY DIESEL GENERATOR EVENT DATE 5 IER NUHBER 6 oTNER rhczz,zTzEs INv. e SEQ 0 Rt )X)N FACILITY NAHES DOCKET l (S) 08 22 91 91 004 00 09 19 91 OPERATZNO NODE (9) N 10 CFR 50.73 A 2 iv PtÃER LEVEL 10) 000 LICENSEE CONTACT FOR THIS LER 12 David R. Powell, Superintendent of Licensing TELEPHONE NUHBER 305-246-6559 COHPLETE ONE LINE FOR EACH COHPONENT FAILURE DESCRIBED IN THZS REPORT 13 CAUSE SYSTEH HANUFACTURER NPRDS2 CAUSE SYSTEH CO PONENT HANUFACTURER NPRDS?

SUPPLEHENTAL REPORT EXPECTED (14) NO 8 EXPECTED SUBHZSSZON DATE (15)

(lt yes, CaaPlete EXPECTED SUBHZSSZON DATE)

ABSTRACT (16)

At 1955 on August. 22, 1991, the 3A Emergency Diesel Generator (EDG) inadvertently started. Startup personnel were performing a scheme verification on wire leads located in a newly replaced cable in the 3A EDG rapid start circuit. When they lifted the rapid start leads the EDG started, due to shorting the leads together. The leads were relanded, and the EDG was shut down. The cause of the event was inadequate communication between Startup personnel and licensed operators. The Nuclear Watch Engineer and the Assistant Plant Supervisor Nuclear knew the work involved the 3A EDG but were unaware that leads would be lifted. The Unit 3 Reactor Control Operator knew that leads would be lifted, but thought the work was on the 3B EDG.

Startup Field Procedures have been revised to require that the Plant Supervisor Nuclear give concurrence, by signature, to perform any scheme verifications on an energized circuit. Startup personnel have been trained on the procedure revisions. Operators will be briefed on this event, and the implications of ineffective communications.

LICENSEE +ENT REPORT (LER) TEXT lTINUATION rACZLITY NAME DOCKET NUMBER LER NUMBER PAGE NO.

TURKEY POINT UNIT 3 05000250 91-004-00 02 Or 03 I. EVENT DESCRIPTION At 1955 on August 22, 1991, the 3A Emergency Diesel Generator (EDG)

(EIIS:EB, Component:DG), was inadvertently started. A cable from the EDG to the Control Room, for the rapid start circuit had been replaced, and Startup personnel (contractor personnel) were to perform a scheme verification.

The Startup personnel discussed their work with the Nuclear Watch Engineer and the Assistant Plant Supervisor Nuclear (both licensed senior operators). Both operators understood that the scheme verification was to be performed on the 3A EDG, but were under the impression that only a visual examination would be done.

The test was also discussed with the Unit, 3 Reactor Control Operator (licensed reactor operator). He understood that leads would be lifted, but thought the work was being done on the 3B EDG. The 3A EDG had been returned to normal standby alignment, and the 3B EDG removed from service, earlier that evening.

The Startup personnel performing the scheme verification knew their work was on the 3A EDG( and that lifting the lead it would cause involved a

lifting leads, rapid start of the but did not expect that EDG.

When the leads for the rapid start circuit were lifted, the 3A EDG underwent a rapid start. The leads were inadvertently shorted together, simulating the depressing of the rapid start push button, which completed the signal path and caused the EDG rapid start.

The 3A EDG was shut down at 2015, and the NRCOC was notified of the significant event at 2023.

II ~ EVENT CAUSE The immediate cause of the 3A EDG autostart was the touching together of lifted leads, providing a rapid start signal.

The root cause of the event was inadequate communication between the licensed operators and the test technicians. Had the proper precautions been taken, such as notification of the PS-N in conjunction with an isolation (clearance or startup blue tag) on the proper control circuits, this event would not have occurred.

III ~ EVENT SAFETY ANALYSIS Unit 3 was shut down and defueled, approaching the end of an extended dual unit outage. The EDGs were not required to be operable, in accordance with the safety evaluation governing plant operations during the dual unit outage. The scheme verification being performed on the 3A EDG was in preparation for a test of the rapid start circuit, so the operability or functionality of the EDG was not affected by the rapid start. Since the EDG was not required to be operable, the inadvertent start did not affect the health or safety of the public.

LXCENSEE ENT REPORT (LER) TEXT llTXNUATXON FACILITY NAME DOCKET NUMBER LER NUMBER PAGE No TURKEY POINT UNIT 3 05000250 91-004-00 03 OF 03 IV CORRECTIVE ACTIONS Procedures SFP-2, Startup Test Control General Guidelines, and SFP-21/

Scheme Verification, were revised to require PS-N notification and concurrence prior to testing equipment which affects, or may affect/

operating systems.

2. In addition, an existing precaution that circuits to be tested must be isolated from operating systems, "as necessary," was revised. SFP-21 now requires the PS-N's signature on the scheme verification test data record if the circuit to be tested is not isolated, or indeterminate.

if isolation is 3 ~ Training of Startup personnel on the revisions to SFP-2 and SFP-21 has begun, and will be completed by September 23, 1991.

Although shorting the leads together is considered an isolated 4 ~

incident, it is indicative of careless work habits. The contractor test technician has been counseled on his carelessness. His supervisor, also a contractor, is no longer on site.

5. This event and its causes will be discussed with all licensed operators as an example of the need for effective communications. The discussions will be completed by October 15, 1991.

Vo ADDITIONAL INFORMATION Licensee Event Report 250-91-002 described a similar inadvertent actuation, attributed to inadequate work controls.