05000416/LER-2018-008, Unplanned System Actuation (Diesel Generator) Caused by Inadvertently Opening the Wrong Fuse Drawer
| ML18187A402 | |
| Person / Time | |
|---|---|
| Site: | Grand Gulf  |
| Issue date: | 07/06/2018 |
| From: | Emily Larson Entergy Operations |
| To: | Document Control Desk, Office of Nuclear Reactor Regulation |
| References | |
| GNRO-2018/00033 LER 2018-008-00 | |
| Download: ML18187A402 (7) | |
| Event date: | |
|---|---|
| Report date: | |
| Reporting criterion: | 10 CFR 50.73(a)(2)(viii)(A) 10 CFR 50.73(a)(2)(ii)(B), Unanalyzed Condition 10 CFR 50.73(a)(2)(viii)(B) 10 CFR 50.73(a)(2)(iii) 10 CFR 50.73(a)(2)(ix)(A) 10 CFR 50.73(a)(2)(iv)(A), System Actuation 10 CFR 50.73(a)(2)(x) 10 CFR 50.73(a)(2)(v)(A), Loss of Safety Function - Shutdown the Reactor 10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat 10 CFR 50.73(a)(2)(v), Loss of Safety Function 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications 10 CFR 50.73(a)(2)(vii), Common Cause Inoperability 10 CFR 50.73(a)(2)(i) 10 CFR 50.73(a)(2)(iv), System Actuation |
| 4162018008R00 - NRC Website | |
text
~Entergy GNR0~2018/00033 July 6, 2018 U.S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, DC 20555-0001
SUBJECT:
Licensee Event Report 2018-008-00, Entergy Operations, Inc.
P. 0. Box756 Port Gibson, MS 39150 Eric A. Larson Site Vice President Grand Gulf Nuclear Station Tel. (601) 437-7500 10CFR50.73 Unplanned System Actuation (Diesel Generator) Caused by Inadvertently Opening the Wrong Fuse Drawer Grand Gulf Nuclear Station, Unit 1 Docket No. 50-416 License No. NPF-29
Dear Sir or Madam:
Attached is Licensee Event Report 2018-008-00. This report is being submitted in accordance with 1 OCFR50. 73(a)(2)(iv)(A) as an event or condition that resulted in an unplanned automatic actuation of the Diesel Generator.
This letter contains no new commitments. If you have any questions or require additional information, please contact Douglas Neve at 601-437-2103.
Sincerely, Laci--.
Eric A. Larson Site Vice* President Grand Gulf Nuclear Station
- EAL/jw
Attachment:
Licensee Event Report 2018-008-00 cc: see next page
GNR0-2018/00033 Page 2 of 2 cc:
NRC Senior Resident Inspector Grand Gulf Nuclear Station Port Gibson, MS 39150 U.S. Nuclear Regulatory Commission ATTN: Ms. Usa M. Regner Mail Stop OWFN*8 81 Rockville, MD 20852-2738 U.S. Nuclear Regulatory Commission ATIN: Mr. Kriss Kennedy, NRR/DORL(w2)
Regional Administrator, Region IV 1600 East Lamar Boulevard Arlington, TX 76011-4511
GNR0-2018/00033 Attachment Licensee Event Report 2018-008-00
- U.S. NUCLEAR REGULA TORY COMMISSION APPROVED BY OMB: NO. 3150-0104 EXPIRES: 03/31/2020 (04-2017)
, the NRC may not conduct or
~.-:,'>
~o,e; form sponsor, and a person is not required to respond to, the information collection.
http://www.nrc.gov/reading-rm/doc-collections/nuregs/staff/sr1022/r3/)
, 3. PAGE Grand. Gulf Nuclear Station, Unit 1 05000 416 1 OF4
- 4. TITLE.
Unplanned System Actuation (Diesel Generator) Caused by Inadvertently Opening the Wrong Fuse Drawer
- 6. EVENT DATE
- 6. LER NUMBER
- 7. REPORT DATE
- 8. OTHER FACILITIES INVOLVED I SEQUENTIAL I REV FACILITY NAME DOCKET NUMBER MONTH DAY YEAR YEAR NUMBER NO.
MONTH DAY YEAR NIA
_o_sooo NLA FACILITY NAME DOCKET NUMBER 05 11 2018 2018-08-00 7
- 11. THIS REPORT IS SUBMITTED PURSUANT TO TiiE REQUIREMENTS OF 10 CFR §: (Check all that apply)
- 9. OPERATING MODE D 20.2201(b)
D 20.2203(a)(3)(i)
D 50. 73(a)(2)(ii)(A)
D 50.73(a)(2)(viii)(A) 5 D 20.2201(d)
D 20.2203(a)(3)(ii)
D 50.73(a)(2)(ii)(B)
D 50.73(a)(2)(viii)(B)
D 20.2203(a)(1 >
D 20.2203(a)(4)
D 50.73(a)(2)(iii)
D 50.73(a)(2)(ix)(A)
.Q.20.2203(a)(2)(i)
.Q 50.36(c)(.1)(i)(A)
.l8J 50.73(a)(2)(iv)(A)
.0.50.73(a)(2)(x)
D 20.2203(a)(2)(ii)
D 50.36(c)(1 )(ii)(A)
D 50.73(a)(2)(v)(A)
D 73.71(a)(4)
- 10. POWER LEVEL D 20.2203(a)(2)(iii)
D 50.36(c)(2)
D 50.73(a)(2)(v)(B)
D 73.71(a)(5)
D 20.2203(a)(2)(iv)
D 50.46(a)(3)(ii)
D 50.73(a)(2)(v)(C)
D 73.77(a)(1) 0 D 20.2203(a)(2)(v)
D 50. 73(a)(2)(i)(A)
D 50. 73(a)(2)(v)(D)
D 73.77(a)(2)(i)
D 20.2203(a)(2)(vi)
D 50.73(a)(2)(i)(B)
D 50.73(a)(2)(vii)
D 73.77(a)(2)(ii)
D 50.73(a)(2)(i)(C)
OOTHER Specify in Abstract below or in =
A. PLANT CONDITIONS PRIOR TO THE EVENT Mode 5, Reactor Coolant System Temperature 87 F YEAR I
- 3. LER NUMBER SEQUENTIAL NUMBER 2018-008-00 No inoperable structures, components, or safety systems contributed to this event.
8. DESCRIPTION
I On May 11 2018, at 2327, while performing a Diesel Generator (DG) Functional Test, a Grand
- - GulfNuclear-Station {GGNS) electrical techn*ician inadvertently opened the *fuse (FU) drawer-for the Bus (BU) 15AA Potential Transformer (XPT) fuse instead of the Line XPT fuse drawer. This resulted in an under voltage condition on the 15AA Bus, and an unplanned auto start of the Division 1 Diesel Generator. All systems responded as designed, including Standby Service Water (BS) Pump (P) "A", w,hich failed to start due to the open XPT fuse drawer preventing the Load Shedding and Sequencing panel from sensing power restoration to the 15AA Bus.
Operations secured the Diesel Generator within 90 seconds, since Standby Service Water was not able to provide cooling. There was no change in the DG jacket water cooling temperature.
C.
- REPORTABILITY REV.
NO.
This event is being reported under 10CFR50.73(a)(2)(iv){A), as an event or condition that resulted in an
'unplanned automatic actuation of the Diesel Generator. The event was initially reported under 1 OCFR50. 72(b)(2)(iv)(A), as a valid actuation of the Diesel Generator, on May 12, 2018, via Event Report 53399.
D. CAUSE
The wrong fuse drawer was opened due to a failure to use human performance tools. The technicians failed to meet expectations for procedure use, peer checking, flagging, and job site review (JSR). The technicians lacked the fundamental knowledge of, and sensitivity to, the impact of the evolution on plant operation. In addition, Supervisory oversight was not properly established
- - and. executed.
E. CORRECTIVE ACTIONS
The following actions are completed or planned.
Completed:
Stop work was issued, and the following immediate/interim corrective actions were taken:
NRCFORM (4-2017) 366A U.S. NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT {LER)
CONTINUATION SHEET (See NUREG-1022, R.3 for instruction and guidance for completing this form http://www.nrc.gov/reading-rm/d()C-O)llections/nuregs/staff/sr1022/r30
- 1. FACILITY NAME
- 2. DOCKET APPROVED BY OMB: NO. 3150-0104 EXPIRES: 3/31/2020
, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.
- 3. LER NUMBER YEAR Grand Gulf Nuclear Station, Unit 1 05000 416 I
SEQUENTIAL NUMBER I
REV.
NO.
2018-008-00
- 1) Conducted Maintenance specific and Site wide stand down to review the human performance gaps.
- 2) All Maintenance work was on hold until prompt investigation was completed and actions were in-place.
- 3) Removed qualifications from individuals involved.
- 4) Reviewed recent paired observation data to identify gaps in observation skills.
- 5) Site leadership/Maintenance Superintendents conducted paired observations with Maintenance Supervisors. This was tracked to verify full coverage of observations.
- 6) Implemented a "work ready" challenge to be completed with Maintenance Supervision and the Outage Control -Center-to -validate -work-crews -were -ready -to conduct-work-with -excellence.
- 7) Initiated a Maintenance Standing Order, including requirements for field walkdowns, flagging, peer checks, procedure use, and placekeeping Follow up actions were also performed:
- 1) Delivered Human performance Fundamental refresher training to craft level personnel using the -fleet Think Three -initiative
- 2) Site Leadership and Maintenance Superintendents performed paired observations with each Maintenance Supervisor to analyze intrusiveness and standards. Tracked completion for full coverage of personnel.
- 3) Conducted briefing of prompt investigation findings in all departments on site to reinforce procedure use and adherence.
- 4) Conducted a leadership specific stand down to review leadership _gaps and expectations
- 5)
Revised the Infrequently Performed Tests or Evolutions (IPTE) procedure to clarify that Integrated Emergency Diesel Generator/Engineered Safety Features Test is an identified IPTE.
F. SAFETY SIGNIFICANCE
The actual consequence of this event was an unplanned automatic start of the Division 1 Diesel
.Generator. There.were.no.other.actual.consequences.to.the.general.safety.of.the.public,.nuclear safety, industrial safety and radiological safety for this event.
The potential consequence to the general safety of the public, nuclear safety, industrial safety and radiological safety of this event if the 15AA Bus had not been provided an alternate off-site power source are components powered by Division 1 (15AA Bus) would be without power. The risk for this event is Low.
Operators are regularly trained to respond to a loss of an Engineered Safety Feature Bus, and there are alternate sources to re-energize the Bus. GGNS had all of the offsite power sources, and Division 2 and Division 3 Diesel-Generators available.
(
NRC FORM (4-2017) 366A U.S. NUCLEAR REGULA TORY COMMISSION
- LICENSEE EVENT REPORT (LER)
CONTINUATION SHEET (See NUREG-1022, R.3 for instruction and guidance for completing this form http://www.nrc.gov/reading-rm/doo-collections/nuregs/stalf/sr1022/r30
- 1. FACILITY NAME
- 2. DOCKET Grand Gulf Nuclear Station, Unit 1 05000 416 G. PREVIOUS SIMILAR OCCURRENCES APPROVED BY OMB: NO. 3150-0104 EXPIRES: 3/31/2020
, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.
YEAR I
- 3. LER NUMBER SEQUENTIAL NUMBER 2018-008-00 I REV.
NO.
A similar human performance event [LER 2018-007-00, Potential Loss of Safety Function (Residual Heat Removal) and System Actuation Caused by Inadvertent Valve Opening] happened 10 days prior to this event. The corrective actions for the first event only focused on related tasks and the specific personnel involved. Although the initial event involved a different maintenance team and inappropriate operation of a valve, the causal factors and corrective actions discussed above encompass the previous event.