ML17348B138

LER 91-005-00:on 910830,3A Component Cooling Water (CCW) Pump Started Automatically on Low Pressure Due to Personnel Error.Training Brief Will Be Written & Distributed to Appropriate Personnel to Discuss Subj LER.W/910930 Ltr

ML17348B138
Person / Time
Site:	Turkey Point
Issue date:	09/30/1991
From:	Plunkett T, Dawn Powell FLORIDA POWER & LIGHT CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
L-91-249, LER-91-005-02, LER-91-5-2, NUDOCS 9110080350
Download: ML17348B138 (6)

Text

ACCELERATED DISTRIBUTION DEMONSTRATION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:9110080350 DOC.DATE: 91/09/30 NOTARIZED: NO DOCKET FACIL:50-250 Turkey Point 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 R

SUBJECT:

LER 91-005-00:on 910830,3A Component Cooling Water (CCW)

Pump started automatically on low pressure due to personnel error. Training brief will be written & distributed to D appropriate personnel to discuss subj LER.W/910930 ltr.

DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL SIZE:

TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.

NOTES: A RECIPIENT COPIES RECIPIENT COPIES D ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-2 LA 1 1 PD2-2 PD 1 1 D AULUCK,R 1 1

.INTERNAL: ACNW 2 2 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DS P 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 QBWfB -.S LBSDl 1 1 NRR/DST/SRXB 8E 1 1 LE 02 1 1 RES/DSIR/EIB 1 1 RGN2 FILE 01 1 1 EXTERNAL: EG&G BRYCE,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 R I

D S

/

A D

D NOTE TO ALL "RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE iVASTE! CONTACT THE DOCUMENT CONTROL DESK, ROOiiI Pl-37 (EXT. 20079) TO L'Lli!INATE YOUR NAiWIE FROiXI DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!

FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 31 ENCL 31

.. Box 029100, Miami, FL, 33102-9100 SEP 301991 L-91-249 10 CFR 50 '3 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555 Gentlemen:

Re: Turkey Point Unit 3 Docket No. 50-250 Reportable Event: 91-005-00 Date of Event: August 30, 1991 Automatic Start of 3A Component Cooling Water (CCW) Pump on Low CCW Pressure Due to Personnel Error The attached Licensee Event Report 250-91-005-00 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, p/Jg~~

T. F. Plunkett Vice President Turkey Point Nuclear TFP/DPS/ds enclosures cc: Stewart D. Ebneter, Regional Administrator, Region II/

USNRC, Senior Resident Inspector, USNRC, Turkey Point Plant an FPL Group company

LICEN EE EVENT REPOR (LER)

FACILITY NAME (I) DOCKET NUMBER 2 PACE 3 TURKEY POINT UNIT 3 05000250 oF 3 TITLE l ~ )

AUTOMATIC START OF 3A COMPONENT COOLING WATER (CCW) PUMP ON LOW PRESSURE DUE TO PERSONNEL ERROR EVENT DATE 5 LER NUMBER 6 RPT DATE 7 OTHER ACZLITZES INV 8 SEQ S HON DOCKET 4 (S)

FACZLITI NAMES 08 30 91 91 005 00 09 30 91 OPERATZNC NODE (R) 6 10 CFR 50.73 a 2 iv POWER LEVEL 10 000 LICENSEE CONTACT FOR THIS LER (12)

David R. Powell, Superintendent of Licensing TELEPHONE NVHBER 305-246-6559 COHPZZTE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED ZN THZS REPORT 13 CAUSE SYSTEM MANUFACTURER NPRDS2 CAUSE SZ STEM NPRDS2 SVPPLEHENTAL REPORT EXPECTED (16) . NO ZS 0 EXPECTED SUBMISSION HONTH DATE (15)

{ZZ yee, cceplete EXPECTED SVBMZSSION DATE)

ABSTRACT t 16)

At 1250 EDT, on August 30, 1991, with Unit 3 in Mode 6 (Refueling) and Unit. 4 defueled, the 3A Component Cooling Water (CCW) Pump started automatically on a low CCW system pressure signal. After removing the temporary spent fuel pool cooling connections, the CCW piping to and from the spent fuel pool heat exchanger was refilled with CCW water to restore normal spent fuel pool cooling. While refilling these lines, the CCW surge tank level decreased to five percent. At five percent surge tank level, the control room operator stopped the 3A and 3B CCW Pumps to prevent cavitation. The 3A CCW pump restarted automatically.

The 3A CCW pump was immediately secured. Both 3A and 3B CCW pumps were placed in "pull to lock" to prevent another automatic start. After restoring the surge tank level, CCW pump 3A was restarted. A four hour non-emergency report was made to the NRC at 1417 EDT in accordance with 10 CFR 50.72. The root cause of this event was non-cognitive personnel error by plant licensed operators. An inadequate briefing coupled with less than adequate coordination between the personnel involved resulted in a failure to anticipate reduced water inventory. The immediate cause was the failure to place the CCW pumps in "pull-to-lock" when the pumps were secured to prevent cavitation. To prevent recurrence, a series of meetings were held with applicable operations personnel to discuss proper briefings for fill and vent operations.

LICENSEEENT REPORT (LER) TEXT ilTXNUATXON FACILITY NAME DOCKET NUMBER LER NUMBER PAGE NO.

TURKEY POINT UNIT 3 05000250 91-005-00 02 oF 03 I'VENT DESCRIPTION At 1250 EDT, on August 30, 1991, with Unit 3 in Mode 6 (Refueling) and Unit 4 defueled, after removing the temporary spent fuel pool cooling connections, the Component Cooling Water (CCW) piping (CC)(PSP) to and from the spent fuel pool heat exchanger (CC)(HX) was refilled with CCW water to restore normal spent fuel pool cooling. While refilling these lines, the CCW surge tank level decreased to five percent. At five percent surge tank level, the control room operator stopped the 3A and 3B CCW Pumps (CC)(P) to prevent cavitation. The 3A CCW Pump restarted automatically on a low CCW system pressure. The 3A CCW pump was immediately secured to prevent cavitation. Both 3A and 3B CCW pumps were placed in "pull to lock" to prevent another automatic start.

After restoring the surge tank level, CCW pump 3A was restarted.

Although this automatic start was not due to 'n engineered safety feature (ESF) signal', Florida Power and Light conservatively reported this automatic start as an ESF actuation. A four hour non-emergency report was made to the NRC at 1417 EDT in accordance with 10 CFR 50.72.

II'VENT CAUSE The root cause of this event was non-cognitive personnel error by plant licensed operators. The error's include those listed below:

1. Immediate Cause The immediate cause of the automatic start was the failure to place the CCW pumps in "pull-to-lock" when the pumps were secured to prevent cavitation. The only corrective action for low surge tank level listed in procedure 3-0NOP-030, "Component Cooling Water Malfunction," that was applicable for this event was to increase make up to the surge water tank. Procedure 3-ONOP-030 requires that the CCW pumps be stopped and placed in "pull-to-lock," if they are cavitating. The operator did not enter this portion of the procedure prior to the pump autostart because both CCW pumps were stopped as a preventive measure before they cavitated.

2. Root Cause An inadequate briefing coupled with less than adequate coordination between the personnel involved resulted in a failure to anticipate the reduced water inventory. The instructions for releasing the clearance did not provide sufficient guidance to prevent low level in the surge tank upon removal of the clearance.

II'VENT SAFETY ANALYSIS Other than the automatic initiation of CCW pump 3A, there were no other manual or automatic reactor protection system or engineered safety features actuations. No other manual or automatic actions were required or expected. The automatic start of the 3A CCW pump was in accordance with the design of the CCW system for the conditions that, existed at that time (low CCW system pressure). Based on the above, the health and safety of the public were not adversely affected.

LICENSEE ENT REPORT (LER) TEXT PTINUATION FACILITY NAME DOCKET NUMBER LER NUMBER PAGE No.

TURKEY POINT UNIT 3 05000250 91-005-00 03 OF 03 IVi CORRECTIVE ACTIONS series of meetings were held with applicable operations A

personnel operations.

to discuss proper briefings for fill This event and related items were placed in the and 'vent night orders to ensure the on-shift crews were familiar with the event and the requirements for a proper briefing for vent operations.

fill and

2. A post event review of this event was performed with the responsible operators.

3. Shift Supervisors are being counseled on the need to emphasize coordination and communication between personnel for all events.

This event will be 'included in that counseling. This will be completed by October 14, 1991.

4 A training brief will be written and distributed to appropriate personnel for their review. This training brief will discuss

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this Licensee Event Report (LER) and the three LERs listed in the Additional Information section below. This action will be completed by October 31, 1991.

Ve ADDITIONAL INFORMATION LER 250-90-007 describes an automatic start of the 3B CCW pump due to low discharge header pressure after securing one of the pump supply lines as part of a surveillance procedure. This event was caused by an inadequate surveillance procedure.

LER 251-90-006 describes an automatic start of the 4B CCW pump due to low discharge pressure when one of the two operating pumps was secured without reducing the number of components being supplied by CCW. This event was caused by a failure to follow the surveillance procedure which called for the isolation of CCW from the RHR heat exchanger prior to securing the CCW pump.

LER 251-90-007 describes 'an automatic start of the 4A CCW pump due to low discharge pressure during transient conditions while swapping CCW heat exchangers. This event was caused by a cognitive personnel error

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when the calibration data sheet, was not updated to reflect the new low discharge pressure setpoint.

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