ML18052B150

LER 87-016-00:on 870522,reactor Manually Tripped Following Errant Closure of Main Feedwater Pump Turbine Driver Exhaust Valve MV-159FW.Caused by Poor Communication Between Operators While Performing Valve lineup.W/870619 Ltr

ML18052B150
Person / Time
Site:	Palisades
Issue date:	06/19/1987
From:	Johnson B, Kozup C CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.)
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
LER-87-016, LER-87-16, NUDOCS 8706240328
Download: ML18052B150 (5)

Text

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IUPPLIMINT AL llll'OllT IXPICTID I 161 MONTH DAY vi AR IX'ICTID 11 VIS l~f ..-......... IX"ICTID SCJ*tltSJ/ON OATIJ AllTllACT 11..im/r ftl '""'-*i.e.. -*'-~ fl- rlfffl**- ry~n.n /iftml Clll b NO ILllMIUJON DATI C15J I I I On Ma,y 22, 1987 at 0007, Operations personnel manually tripped the reactor from approximately 35 percent of rated power following the errant closure of main feedwater pump turbine driver exhaust valve, MV-159FW. At the time of the event, Operations personnel were redirecting the moisture separator and reheater drain lines from the main condenser to the feedwater heaters. Two Plant Auxiliary Operators (AO) were performing the valve line-up. At approximately 0004, an AO errantly closed the turbine driver's exhaust valve and subsequently, the turbine drivers overpressure protection rupt_ure disc operated causing high temperature steam to be expelled and actuate the local fire protection system sprinklers. Upon personal evaluation of the situation, the SS directed Control Room personnel to trip both the turbine and reactor. At 0013, the Plant was confirmed to be sub-critical and returning to stable conditions. The errant valve closure was the result of poor communication between the AOs performing the valve lineup and inattention to detail on the part of the AO who closed the wrong valve.

Disciplinary time off has been given to the involved AOs. Additionally, the AOs are speaking with each Operations Department shift, describing the event,*

its cause, and how it could have been avoided. All Operations personnel will receive training on effective communications techniques. This personnel error is being independently reviewed by the Human Performance Evaluation System (HPES) Coordinator to determine i f additional actions are warranted.

Plant Safety Engineering's review of this event determined that the resultant Plant transient was relatively minor and that overall Plant response was consistent with normal equipment operation.

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111..31 LER 87-016-NL02~NL04 8706240328 870619 PDR ADOCK 05000255 S PDR

NRC Form l&IA U.S. NUCLEAR REGULATORY COMMISSION 19.SJl LICENSEE EVENT REPORT (LERI TEXT CONTINUATION APPROVED DMB ND 31S0--0104 EXPIRES. 8/31185 FACILITY NAME 111 DOCKET NUMBER 121 LEA NUMaER 191

• PAGE Ill PALISADES NUCLEAR PLANT 0 15 I 0 I 0 I 0 I 2 I 5 15. 817 - 011 I6- 0 I0 0I2 OF 0 Ih TEXT flf mote-io _.,;,wt, 11* - N R C Ftxm .Jl!5oll'11117l Description On May 22, 1987 at 0007, Operations Department personnel manually tripped the reactor from approximately 35 percent of rated power. The trip was initiated following the inadvertent closure of main feedwater pump turbine driver exhaust valve, MV-159FW [SJ;SHV] and the subsequent operation of the rupture disc [SJ;RPD] associated with the turbine driver.

At approximately 2355 on May 21, 1987, Plant Auxiliary Operators (AO) were instructed to redirect the moisture separator and reheater [SB;MSR] drain lines from the main condenser [SG;COND] to the feedwater heaters [SG;HX]. At approximately 0004 on May 22, 1987, while performing the above valve line-up, an AO mistakenly closed turbine driver exhaust valve MV-159FW. Closure of this valve caused the overpressure protection rupture disc, RUD-0504, in the turbine driver (K-7A) [SJ;DRIV] exhaust line to operate at 0005.

Coincident with the rupture disc operation, a low vacuum alarm was received in the Control Room for main feedwater pump P-lA [SJ;P]. Control Room operators alerted the Shift Supervisor (SS) and checked steam generator level and feedwater flow indications. The AOs performing the valve line-up notified the Control Room as to the steam leak and actuation of the fire protection system sprinklers in the area of the main feedwater pump. The SS then left the Control Room to personally evaluate the situation.

At 0006 Control Room operators began reducing reactor power levels in anticipation of maintaining the reactor critical while removing the turbine generator from service. At 0007, reactor power levels had been reduced from 40 to approximately 35 percent of rated power. After reviewing the situation, the SS called the Control Room and directed the Shift Engineer to manually trip both the turbine generator and reactor: Control Room operators immediately completed the trips and initiated appropriate Emergency Operating Procedure actions. At 0009, the SS returned to the Control Room, confirmed all safety related functions had been satisfied and .initiated reactor trip recovery procedures.

At 0013, completion of Emergency Operating Procedure actions was confirmed by verification of reactor shutdown and return to stable conditions.

The redirection of the drain lines was being performed in order to increase the efficiency of the feedwater system during power escalation. The redundant main feedwater train was not in service at the time of this event.

I

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Cause Of The Event During a valve line-up to redirect the moisture separator and reheater drains from the main condenser to the feedwater heaters, an AO mistakenly closed the main feedwater pump turbine driver exhaust valve. This caused the main NFIC FORM 366A 19 31

.s LER 87-016-NL02-NL04

NRC Form JlllA U.S. NUCLEAR REGULATORY COMMISSION 19-831 LICENSEE EVENT REPORT ILER) TEXT CONTINUATION APPROVED OMS NO. 3150~1~

EXPIRES 8/31 /BS

• ~* FACILITY NAME (11 DOCKET NUMllER 121 LEA NUMIEA !Ill PAGE 131 PALISADES NUCLEJ..R PLANT o 1s101010121515 817 - 01116 -01 o Ol3 oFo 14 TEXT 1/f men_. ia 19qUit9d, 11* - N R C FOlm .-.C'i/ 1171 feedwater pump's overpressure protection rupture disc to operate, discharging steam in the east mezzanine area of the Turbine *Building. The high temperature steam being discharged melted several fusible l~nks within fire protection system sprinklers causing them to actuate. Upon personal inspection of the area, the SS directed the manual trip of both the turbine generator and reactor.

Two AOs were performing. the valve line-up* to redirect the moisture separator and reheater drain lines. The AO responsible for secondary side actions was directed by Control Room operators to perform the line-up and given specific valve identification numbers to open and close. The secondary side AO requested assistance of an additional AO in performing the operation.

When arriving at the area where the valves are located (Turbine Building east mezzanine), the responsible, secondary side AO pointed to the first set of drain valves to the condenser and asked the additional AO to close them while he closed the second set. The additional AO then closed the valve he thought the secondary side AO pointed toward. After closing this valve (MV-159FW),

the main feedwater pump rupture disc operated. Shortly thereafter the*SS arrived, evaluated the situation and directed the manual trip of both the turbine generator and reactor. The cause of the AOs errant closure of the turbine driver exhaust valve was first, poor communication during the pre-job brief and, secondly, inattention to detail on the part of the qualified AO who should have recognized that he was operating the wrong valve.

Corrective Actions Appropriate Emergency Operating Procedures were implemented to ensure reactor.

shutdown and conditions stabilized.

A post-trip review was initiated including an assessment of Plant response and conditions prior to and after the manual trip, personnel interviews and Plant Safety Engineering review of the event. The rupture disc was replaced on the main feedwater pump.

• Disciplinary time off was given to the two AOs performing the valve line-up.

Additionally, the AOs involved in the event are speaking with each shift of AOs; describing the event, their failure to properly execute the valve line-up and the sign~ficance of the event. All Operations personnel will receive training on effective communicatio~s techniques.

An independent review of the event is being performed by the Human Performance Evaluation System (HPES) Coordinator to determine if additional actions are warranted to preclude recurrence.

N~C FORM 3815A

~~

1 LER 87-016-NL02-NL04

NRC Form 3MIA U.S. NUCLEAR REGULATORY COMMISSION 19-831 LICENSEE EVENT REPORT (LERI TEXT CONTINUATION APPROVED OMB NO. 3150--0lCl' EXPIRES* 8/31185 FACILITY NAME 111 DOCKET NUMaER 121 LEll NUMHll 181 PALISADES NUCLEAR PLANT TEXT,,, _ _ a _ _. u * - N R C Ftxm.-.*111111 Analysis Of The Event An independent assessment of the Plant trip was performed by Plant Safety Engineering. Their detailed review of the sequence of events from dataloggers, stripcharts and operator statements indicated that; the Plant transient experienced was minor, no Engineered Safety System equipment was.

required to be automatically actuated and that Plant response to the trip was consistent with normal equipment operation.

The evaluation detailed above, redirecting the moisture separator and reheater drain lines from the condenser to the feedwater heaters is performed only when placing the main f eedwater pumps in operation during power escalation. Therefore, this evolution would not occur at a higher power level and no adverse safety consequences exist.

At higher power levels (ie, greater than 50 percent) both main feedwater pumps are normally in operation. Had the inadvertent closure of the turbine driver exhaust valve occurred during a different evolution, at higher power levels, standard operating practice would be to isolate the affected train and follow established Plant Off-Normal procedures. This procedure directs operators to increase flow of the operating feedwater pump and reduce turbine and reactor power level at the maximum rate which will prevent a reactor trip. If steam generator levels still cannot be maintained, operators are directed to trip the reactor. Therefore, as reactor trips from full power are analyzed transients, no adverse safety consequences would exist.

The ruptured disc associated with turbine driver K~7A was replaced on May 22 and the equipment was again operational on May 23 at 2307.

This event is being reported per 10CFRS0.73 (a)(2)(iv) as an event which resulted in the manual actuation of the Reactor Protection System.

N"C FORM l66A 1e-a31 LER 87-016-NL02-NL04

General Offices: 1945 West Parnell Road, Jackson, Ml 49201 * (517) 788-0550 June 19, 1987 Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 DOCKET 50-255 - LICENSE DPR PALISADES PLANT -

LICENSEE EVENT REPORT 87-016 - (ERRANT VALVE CLOSURE RESULTS IN MANUAL REACTOR TRIP)

Licensee Event Report (LER)87-016, (Errant Valve Closure Results in Manual Reactor Trip) is attached. This event is reportable to the NRG per 10CFR50.73(a)(2)(iv).

Brian D Johnson Staff Licensing Engineer CC Administrator, Region III, USNRC NRG Resident Inspector - Palisades Attachment y

~£- l II OC0687-0090-NL04