ML18096A384

LER 91-033-00:on 911116,ESF Actuation & Unplanned Diesel Generator 1B Start Occurred.Caused by Improper Use of Test Equipment & Incorrect Labeling of Voltage Indications. Connections Reversed & Personnel counseled.W/911216 Ltr

ML18096A384
Person / Time
Site:	Salem
Issue date:	12/16/1991
From:	Pollack M, Vondra C Public Service Enterprise Group
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-91-033, LER-91-33, NUDOCS 9112190188
Download: ML18096A384 (4)

Text

. e OPS~G Public Service Electric and Gas Company P.O. Box 236 Hancocks Bridge, New Jersey 08038 Salem Generating Station December 16, 1991 U. S. Nuclear Regulatory Commission Document Control Desk Washington, DC 20555

Dear Sir:

SALEM GENERATING STATION LICENSE NO. DPR-70 DOCKET NO. 50-272.

UNIT NO. 1 LICENSEE EVENT REPORT 91-033-00 This Licensee Event Report is being submitted pursuant to the requirements of the Code of Federal Regulations 10CFR 50.73(a) (2) (iv). This report is required to be issued within thirty (30) days of event discovery.

Sincerely yours, o/o-;jJ4r c.~~ra General Manager -

Salem Operations MJP:pc Distribution

. -i.

I ..,.

95-2189 (10M) 12-89

NRC FORM 366 U.S. NUCLEAR REGULATORY COMMISSIO (6-89) APPROVED OMB NO. 3150-0104 EXPIRES: 4/30/92 ESTIMATED BURDEN PER RESPONSE TO COMPLY WTH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD LICENSEE EVENT REPORT (LERI COMMENTS REGARDING BURDEN ESTIMATE TO THE RECORDS AND REPORTS MANAGEMENT BRANCH (P-530). U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.

FACILITY NAME (1) DOCKET NUMBER (2) I PAGE 131 Salem.3ene~ating TITLE (41 Statm©n (Unit 1) 0 I 5 I 0 I 0 I 0 I 21 7 I 2 1 OF I 0I3 ESF Actuation: lB Diesel Generator Start Due To Personnel E~ror EVENT DATE (51 LEA NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (Bl r~r~~ ~@~t YEAR SEQUENTIAL REVISION DAY YEAR FACILITY NAMES DOCKET NUMBER(SI MONTH DAY YEAR NUMBER NUMBER MONTH 01s1010101 I I lll 11 6 s 1 911 - ol 313

- olo ii 2 ii 6 911 0 15 I 0 I 0 I o, I I THIS REPORT IS SUBMITTED PURSUANT TO THE R~QUIREMENTS OF 10 CFR §: (Chsck ons or mors of rhs following) (11 I OPERATING MODE (Bl POWER L~l~~L I

1 0 , 2 I 6 .___

20.402(bl 20.406(*)(1)(i) 20."406(1)(1 )(iii

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20,405(c) 60.38(cl!1) 50.36(c) (2)

,_j 50.73(1)(2){iv) 50.73f1H21M 50.73(1) (21 (vii)

- 73.71(b) 73.71 (cl OTHER (Specify in Abstr*cr

- - bt1low and in TtJxt, NRC Form iill~tll=

20.406(*111 )(iii) 50.73(1)(2llil 60.73(1)(2){vilil(Al 366A) 20."406(1)(1 )(Iv)

- &0.73(1)(2)(ii) 50.73(11(2lfvliil(Bl 20.406(1)(1)(v)

- 50.73(1)(2)(iii) 50.73(1)(2)(x)

LICENSEE CONTACT FOR THIS LEA (121 NAME TELEPHONE NUMBER AREA CODE M. J. Pollack - LER Coordinator 61019 31319 I- 12 IQ I 21?

COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)

MANUFAC* MANUFAC*

CAUSE SYSTEM COMPONENT SYSTEM COMPONENT TUR ER TUR ER I I I I I I I I I I I I I I I I I I I I I I I I I I I I SUPPLEMENTAL REPORT EXPECTED (141 MONTH DAY YEAR EXPECTED n YES (If yss, compl*t* EXPECTED SUBMISSION DATE!

ABSTRACT (Limir ro fxl NO 1400 specss. i.s., *pproxim*rsly fifte*n singls-specs typewritton linss) (161 SUBMISSION DATE (151 I I I On November 16, 1991, at 0105 hours0.00122 days <br />0.0292 hours <br />1.736111e-4 weeks <br />3.99525e-5 months <br />, during the installation of a test recorder to monitor lB Safeguards Equipment Control (SEC) circuitry, a Maintenance Department Electrical Supervisor improperly reconnected test leads, at the recorder, causing an unplanned start of lB Diesel Generator (D/G). The test recorder was being installed in support of lB SEC monitoring. The lB SEC had its chassis replaced as a result of an Auto Test Fault alarm indication. The start of a D/G is an Engineered Safety Feature (ESF). The root cause of this event is personnel error (improper use of test equipment). A contributing factor to this event was the incorrect labeling of the voltage indications on the test recorder. The connections at the recorder were reversed to their correct configuration and the faulty indicator labels were corrected. The Maintenance Supervisor and the applicable Maintenance Department Controls Technicians were counseled about the importance of attention to detail, in the use of test equipment, relative to this event. The event was discussed with the applicable Maintenance Department personnel.

NRC Form 366 (6-89)

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER NUMBER PAGE Unit 1 5000272 91-033-00 2 of 3 PLANT AND SYSTEM IDENTIFICATION:

Westinghouse - Pressurized Water Reactor Energy Industry Identification System (EIIS) codes are identified in the text as {xxl IDENTIFICATION OF OCCURRENCE:

Event Date: 11/16/91 Report Date: 12/16/91 This report was initiated by Incident Report No.91-839.

CONDITIONS PRIOR TO OCCURRENCE:

Mode 1 Reactor Power 26% - Unit Load 232 MWe DESCRIPTION OF OCCURRENCE:

On November 16, 1991, at 0105 hours0.00122 days <br />0.0292 hours <br />1.736111e-4 weeks <br />3.99525e-5 months <br />, during the installation of a test recorder to monitor lB Safeguards Equipment Control (SEC) circuitry, a Maintenance Department Electrical Supervisor improperly reconnected test leads, at the recorder, causing an unplanned start of lB Diesel Generator (D/G) {EKI.

The test recorder was being installed in support of lB SEC monitoring. The lB SEC had its chassis replaced as a result of an Auto Test Fault alarm indication.

The start of a D/G is an Engineered Safety Feature (ESF) {JEI.

Therefore, on November 16, 1991, at 0202 hours0.00234 days <br />0.0561 hours <br />3.339947e-4 weeks <br />7.6861e-5 months <br />, the Nuclear Regulatory Commission (NRC) was notified of the lB D/G start in accordance with Code of Federal Regulations 10CFR 50.72(b) (2) (ii).

APPARENT CAUSE OF OCCURRENCE:

The root cause of this event is personnel error (improper use of test equipment).

As part of the continuing investigation, of potential electrical noise on the lB SEC, a test recorder was installed to monitor voltage on the lB SEC circuit after it was returned to service.

The Maintenance Supervisor and the Technical Department System Engineer, reviewing the voltage readings, determined the readings were too low. The Supervisor disconnected.the test leads at the lB SEC and reversed the connections at the recorder. When the test leads were reconnected in the lB SEC cabinet, a start signal for lB DIG was initiated. The recorder was disconnected immediately following initiation of the lB D/G start signal.

A contributing factor to this event was the incorrect labeling of the voltage indications on the test recorder. The recorder

• ._ _ _ _ _ e a .______ _ ___,,,._!<....--_ _ __

LICENSEE EVENT REPORT (LER} TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER NUMBER PAGE Unit 1 5000272 91-033-00 3 of 3 APPARENT CAUSE OF OCCURRENCE: (cont'd}

labeling stated "O to 30" instead of from "30 to O". Subsequently, the Supervisor and System Engineer suspected a low voltage problem in the circuit, when in fact, the voltages were correct. They read "6 volts" instead of "24 volts".

The connections at the recorder we~e reversed to their correct configuration and the faulty indicator labels were corrected.

ANALYSIS OF OCCURRENCE:

The SEC system is comprised of three trains (A, B, and C}. The system determines the need for accident and/or blackout safety equipment and loads the necessary equipment onto the corresponding Vital Bus.

The other two (2) SEC cabinets were operable during the time period of this troubleshooting of the lB SEC malfunctions. The design basis of the plant is such that in the event of a design basis event (e.g.,

LOCA} the remaining SECs would have brought the plant to a safe condition. Therefore, this event did not affect the health or safety of the public. However, due to the automatic actuation of an ESF function, it is reportable as per Code of Federal Regulations 10CFR

50. 73 (a} (2) (iv}.

CORRECTIVE ACTION:

The Maintenance Supervisor and the applicable Maintenance Department Controls Technicians were counseled about the importance of attention to detail, in the use of test equipment, relative to this event.

The event was discussed with the applicable Maintenance Department personnel.

System Engineering is continuing its review of SEC failures (ref.

LERs 272/90-008-00 and 272/89-026-00) to determine if there are any factors common to the failures. As committed to previously, upon completion of this investigation, appropriate corrective action will be implemented.

BWL:pc SORC Mtg.91-127