ML18058A266

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LER 92-009-00:on 920213,control Room Ventilation Sys Inadvertently Switched to Emergency Mode.Caused by Combination of Inadequate Job Planning & Personnel Error. Job Planning Requirements reviewed.W/920306 Ltr
ML18058A266
Person / Time
Site: Palisades Entergy icon.png
Issue date: 03/06/1992
From: Hillman C, Slade G
CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.)
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-92-009, LER-92-9, NUDOCS 9203110250
Download: ML18058A266 (4)
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. consumers 1l Power GB Slade General Manager POWERINli MICHlliAN'S PROliRESS Palisades Nuclear Plant: ~7780 Blue Star Memorial Highway. Coven. Ml 49043

  • March 6, 1992 Nuclear Regulatory Commission Document Control Desk

LICENSEt EVENT REPORT 92~009~INADVERTENT ACTUATION OF THE CONTROL ROOM HVAC SYSTEM DUE TO DAMAGED ELECTRICAL CABLE Lic~nse~ E~ent Report (LER)92-009 is attached: This event is re~ortable to the NRC perlOCFR50.73(a)(2)(iv) as an event that resulted in the automatic

. actuation of an Engineered Safety Feature, the Control Room HVAC.

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Gerald B Slade General Manager CC Administrator, Region Ill, USNRC NRC.Resident Inspector - Palisades Attachment r r.... ,~ ... ' .. : :>

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~RACT fLimlr ro 140IJ.f!>>CW, I.* .. .,,,,roaimareJr fl,,..,, linfl*41>>n ry,c>>wrimn 1;,,.,1 (111 On February 13, 1992, at 1920 hours0.0222 days <br />0.533 hours <br />0.00317 weeks <br />7.3056e-4 months <br />; the control room ventilation system inadvertently switched to the emergency mode. At the time of occurrence, the plant was in cold shutdown and .the primary .coolant system was depressurized.

The control room operators immediately verified that there was riot a valid.

containment high pressure (CHP) or a containment high radiation (CHR) signal*

.present. It was subsequently determined that Electrical Maintenance was replacing damaged fl ex conduit on the CHR relay SR-6 circuit. When the wire on relay SR-6, point 16, was disconnected, the electrical circuit schem*e SlOl

. de-energized causing the "A" train of Control Room HVAC to automatically switch to the emergency mode.

This event was caused by a combination of -inadequate job planning and personnel error.

Corrective action for this event includes (1) in-plant training for electricians, I&C staff and I&C technicians on the importance of job plan and schematics reviews prior .to i nit i at i ng work and (2) a review of job planning-requirements .~nd the importance of post-maintenance testing with the job planners.

NRC For"' . .

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1s I 0 I 0 Io I 21~ 15 9 I 2 - o Io 19 - o 10 o 12 oF o 13 EVENT DESCRIPTION On February 13, 1992, at 1920 hours0.0222 days <br />0.533 hours <br />0.00317 weeks <br />7.3056e-4 months <br />, the control room ventilation system [VI]

inadvertently switched to the emergency mode. At the time of occurrence, the plant was in cold shutdown and the primary coolant system was depressurized.

The control room operators immediately verified that there was not a valid containment high pr~ssure (CHP) or a containment high radiation (CHR) signal present. It was subsequently determined that Electrical Mairitenance was

.replacing damaged flex conduit [IK;CND] on the CHR relay 5R;6 [IK;RLY]

  • circuit~ When the wire on relay 5R~6, point 16, was disconnected, the electrical circuit scheme SlOl de-energized causing the "A" train of Ctintrol Room HVAC to automatically switch to the @mergency mode ..

The Electrical Supervisor was notified.of the actuation. The work described under the work order was completed and circuit was re-terminated.

This event is reportable to the NRC per 10CFR50,J3(a)(2)(iv) as an event that resulted in the automatic actuation of an Engineered Safety Feature, the Cont~ol Room HVAC.

CAUSE OF THE EVENT De-energization of emergency HVAC activation relays by lifting wire in the

. control room emergency HVAC system activation sc.heme (SlOl) was caused by a combination of inadequate job planning and personnel er~or.~

  • This event did not involve the failure of ~ny equipment im~ortant to $afety.

ANALYSIS OF THE EVENT The.job plan for the work order called for.the wi~e on relay SR-6, point 16, to be lifted in order to remove it from a crushed flex conduit. Following removal from the flex conduit the wire was to be inspected for damage. When the wire was lifted, the.continuity of the circuit was broken causing the circuit to de~energize, thereby activating the .relay to automatically switch*

.the control room HVAC to the emergency mode; Although the job plan was incorr.ect in that it did not identify the electrical scheme as a "de-energize to actuate scheme; it did ~efer the electricians to the correct electrical prints (E-271, Sh. 8) whi.ch clearly shows the electrical scheme to be a "de-energiz~ to actuate scheme. Normal electrical maintenance prattice would be to review drawings and check for electrical potential before lifting ~ny wires. This normal practice should have caught the incorrect job plan. Since the qrawings were not reviewed, the error in the job plan went undetected.

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E"'*IS t'."li 15 OOClllT lfUM911'1 121

.... ... ~ ..... ~" '" *&QI iJl Palisades Plant 0 5 0 0 0 2 5 5 9 2 - 0 0 9 _.,._ 0 0 . 0 3 OF 0 3 TUT,. - - * .__ - - /IC_ ...... .-.a*,, 1111 An additional weakness was noted in the job plan in that post maintenance testing was inadequate .. A continuity check of th~ wire was performed, however, more thorough post mai.ntenance testing would be expected following the removal and re-termination of a wire from a safety-related relay.

CORRECTIVE ACTION The f611owing corrective actjons have been completed:

1. Restate expectation that electricians review job plan and prints thoroughly before ariy physical ~ork begin~. Also, point out requirement for check of potential from both a safety and proper work practice standpoint .. Review both actions with the el~ctricians, I&C staff and I&C tec~nicians and document on in-plant training form.
  • 2 .. Review proper job planning requirements with planners to emphasize a review of all prints and the importance of proper post maintenance testing in accordance .with Administrative Procedure 5.19; ADDITIONAL INFORMATION Norie
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