ML19325C644

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LER 89-019-00:on 890912,capability of Switches 2CA-15A & 2CA-18B Disabled Rendering Feedwater Pumps 2A & 2B Inoperable.Caused by Defective Procedure & Inappropriate Actions.Procedure Revised & Update issued.W/891011 Ltr
ML19325C644
Person / Time
Site: Catawba Duke Energy icon.png
Issue date: 10/11/1989
From: Glover R, Owen T
DUKE POWER CO.
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-89-019-02, LER-89-19-2, NUDOCS 8910170132
Download: ML19325C644 (6)
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LAttachedEisiLicensee Event R nort 414/89-19,. concerning three

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This e' vent was considered to be'of no significance with respect to the I- Jhealth and safetyLof,the public.

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-Atlanta, GA 30323 t &'M Nuclear Consultants Mr. K. Jabbour U. S. Nuclear Regulatory Commission 1221' Avenues of the Americas Office of Nuclear Reactor Regulation

-New' York, NY 10020 Washington. D. C. 20555

[ LINPO Records ranter Suite 1500. Mr. W. T. Orders

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On September 12, 1989, at 1335 hours0.0155 days <br />0.371 hours <br />0.00221 weeks <br />5.079675e-4 months <br />, a control Room Operator (CRO) turned the Close-Auto Open switches for 2CA-15A (CA Pump 2A Suct From RN Isol Valve) and 2CA-18B (CA Pump 2B Suct frc-n RN Isol Valve) f rom the Auto position to the Close position. This action disabled the automatic opening capability of 2CA-15A and 2CA-18B, rendering Auxiliary Feedwater (CA) Pumps 2A and 2B inoperable. The CA Turbine Driven Pump was already inoperable, due to modification work in progress. The audible alarm for the 1.47 Bypass Panel was not heard when the switches were turned. The CRO subsequently noticed that the lights for "CA Train A Bypassed" and "CA Train B Bypassed" on the 1,47 Bypass Panel were lit.

'At 1410 hours0.0163 days <br />0.392 hours <br />0.00233 weeks <br />5.36505e-4 months <br />, after reviewing the appropriate logic diagrams, the CR0 returned PT/2/A/4200/59, RN to CA suction Piping the switches to the Auto position.

Flush, has a step to " Ensure the following valves are closed", and lists 2CA-15A and 2CA-18B. Th.1- incident is attributable to a defective procedure, due to the intent of the st 9 ceing unclear, and to inappropriate actions, for placing both 2CA-15A and 2CA-186 in the Close position, and for turning down the volume level on the 1.47 Bypass Panel audible alarm. PT/2/A/4200/59 has been revised, and an Operator Update has been issued. Unit 2 was in Mode 1. Power Operation, at the time of this incident.

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BACKGROUND l

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The Auxiliary Feedwater [EIIStBA) (CA) System supplies feedwater flow to the .

Steam Generators [EIIStHX] (S/Gs) in the event that Main Feedwater [EIISISJ) l (CF) flow is unavailable, and during Unit startup or shutdown. Upon loss of the i normal suction supplies to the CA Pumps [EIIStP), the suction automatically l aligns to the Nuclear Service Water [EIIS BI} (RN) System. A part of this i automatic alignment is the opening of CA-15A, CA Pump A Suct from RN Isol Valve, l and CA-18B, CA Pump B Suct from RN Isol Valve, which are normally closed in the L Auto position. This automatic opening capability can be defeated by placing the Control Room Close-Auto Open switches in the Close position.

i Technical Specification 3.7.1.2, Auxiliary Feedwater System, specifies that with thrae CA pumps inoperable, immediate corrective action must be taken to restore at least one CA pump to operable status ss soon as possible. The Technical l Specification Bases for the CA S;' stem state that it is to be capable of  :

delivering at least 492 gpm at 1210 psig to at least two S/Gs.

The ESF Lypass Indication (EIIS:JE] (EMA) Syntem provides indication, on the 1.47 Bypass Panel, to Control Room Operators (CRos) when a train of any Safety Related System in inope.able. The EMA System provides operator awareness, to ,

ensure that equipment required to be operabic by Technical Specifications is not ,

inoperable. OP/2/B/6100/07E, Annunciator Response for 1.47 Bypass Panel, is provided to guide the Operators in consulting the appropriate Electrical Elementary diagrams to determine the cause of an alarm.

Operations Management Procedure (OMP) 1-4, Use of Procedures, Section 8.12, Constrained Language, states that " Terms which are commonly used in operating procedures generally have inherent meanings". The definition of " Ensure",

according to the Constrained Language List (OMP 4-1, Procedure Writing Guide, Enclosure 10.6) is to "Take necessary/ appropriate actions to guarantee component, reading, etc., is as specified". The definition of " Verify" on this '

list is to " Determine if in proper condition / status".

PT/2/A/4200/59 RN to CA Suction Piping Flush, is performed periodically to rer:ove Asiatic clams from the RN to CA suction piping. RN flow is established through the RN to CA pump suction piping to the Condenser Circulating Water

[EIIS SG) (RC) System. The Turbine Driven CA Pump (CAPT) is the only CA pump

, rendered inoperable by the performance of this procedure.

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EVENT DESCRIPTION On September 12, 1989, at 0740 hours0.00856 days <br />0.206 hours <br />0.00122 weeks <br />2.8157e-4 months <br />, with Unit 2 in Mode 1, Power Operation, the CAPT was declared inoperable for modification work on the steam inlet piping and turbine control valve [EIIS V) (see LEE 414/89-017). At 1255 hours0.0145 days <br />0.349 hours <br />0.00208 weeks <br />4.775275e-4 months <br />, Operations personnel began performing PT/2/A/4200/59, RN to CA System Piping Flush. Step 12.2.6 of this procedure states to " Ensure the following valves are s-

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ssx, - em . a.< , ,an.- w , mu y on closed" ar.d lists 2CA-15A and 2CA-18B. Both valves were indicating closed, and their Main Control Board switches were in the Auto position. To ensure that these valves _ remained in the closed position, at 1335 hours0.0155 days <br />0.371 hours <br />0.00221 weeks <br />5.079675e-4 months <br />, the CR0 turned their Close-Auto-Open switches from the Auto position to the Close position.

This action defeated the automatic opening capability of the valves, rendering CA Pumps 2A and 2B inoperable, and provided actuation inputs to the 1.47 Bypass Panel logic. 'The audible alarm for the panel did not sound during the incident.

'At approximately 1340 hours0.0155 days <br />0.372 hours <br />0.00222 weeks <br />5.0987e-4 months <br />, the CR0 noticed that the Unit 2, 1,47 Bypass Panel lights for "CA Train A Bypassed" and "CA Train B Bypassed" were lit. Due to other ongoing activities in the Control Room, and the belief that other CA valve manipulations performed in the procedure may have caused these indications, the CR0 did not immediately investigate the cause of the panel lights. At approximately 1400 hours0.0162 days <br />0.389 hours <br />0.00231 weeks <br />5.327e-4 months <br />, an NRC Resident Inspector also noticed the 1.47 Bypass '

Panel indications and consulted the CRO. The CR0 then reviewed the appropriate Electrical Elementary diagrams and found that placing the selector switches for 2CA-15A and 2CA-18B in the Close position would actuate the lights. The CR0 then returned the switches to the Auto position, at approximately 1410 hours0.0163 days <br />0.392 hours <br />0.00233 weeks <br />5.36505e-4 months <br />, on September 13, at 0347 hours0.00402 days <br />0.0964 hours <br />5.737434e-4 weeks <br />1.320335e-4 months <br /> PT/2/A/4200/59 was completed. The modificat' work on the CAPT was compleced and the CAPT was restored to operable status by

2230 hours0.0258 days <br />0.619 hours <br />0.00369 weeks <br />8.48515e-4 months <br />.

CONCLUSION This incident has been attributed to a defective procedure, due to the intent of step 12.2.6 not being clearly stated. The wording of this step was not in compliance with the Constrained Language List of OMP 4-1. The intent of this step was to verify that 2CA-15A and 2CA-18B were closed, using plant indications, not to place their selector switches in the Close position.

Changes have been incorporated into PT/1,2/A/4200/59, changing step 12.2.6 from

" Ensure the following valves" to "Vorify the following valves", and inserting a note before the step, stating that if CA is aligned for standby readiness, these switches are to remain in the Auto position. Operationa procedures will be reviewed to ensure compliance with OMP 4-1 with respect to switch manipulations.

This incident has also been attributed to an inappropriate action, for placing the selector switches for both 2CA-15A and 2CA18B in the Close position at the same time. This incident has been discussed with the CR0 involved, and an Operator Update has been issued, emphasizing the importance of considering the consequences of actions to be taken when performing a procedure. This update

, also emphasizes the importance of taking prompt action when lights are lit on the 1.47 Bypass Panel. Operator training will be enhanced to emphasize that placing these switches in the Close position defeats the RN to CA automatic swap capability, and renders the respective trains of CA inoperable.

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This incident has also been attributed to an inappropirate action, due to the audible alarm for the 1.47 Bypass Panel not sounding at the time of the incident. If an audible alarm had sounded when the switches were turned to the Close poaition, the CR0 voeld have known that this action was providing inputs to the panel. The audible alarm was checked under Work Request 2020 MES, and it was found that the volume had been turned down to a level which could not be heard by the CR0s. The time at which the volume was altered, and the activity responsible for it, have not been identified.

A review of the Operating Experience Program database showed no previous similar events within the past twelve months, in which both trains of CA were rendered inoperable due to a defective procedure.

CORRECTIVE ACTION SUBSEQUENT

1) The CR0 returned the Close-Auto open switches for 2CA-15A and 2CA-18B to Auto.
2) PT/1,2/A/4200/59 were revised to clarify their intent and to include a caution on positioning of the CA 15A and CA-18B switches.
3) The incident was discussed with the CR0 involved.
4) An Operator Update was issued, emphasizing the purpose of the Auto positioa of these switches, the importance of prior to performing a step in a procedure to consider the consequences of taking the l specified actions, and the importance of taking prompt action to l

determine the cause and take actions to correct the situation when 1.47 Bypass Panel lights are lit.

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( 5) The volume for the Unit 2, 1.47 Bypass Panel audible alarm was I increased under Work Request 2020 MES, PLANNED

1) Operations procedures will be reviewed to determine if procedure changes are required to prevent an operator from rendering equipment inoperable in steps involving switches. ,
2) Operator training will be provided to emphasize that placing the Close-Auto-Open switches for CA-15A and CA-18B renders the respective trains of CA inoperable. ,
3) A review will be performed on the use of the 1.47 Bypass Panel to determine if additional training and system modification are required to make it more effectivo and usable for the Operator.

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rsus c a ,a, . m . - - n ce w n m SAFETY ANALYSIS The normal CA suction sources (CA Condensate Storage Tai. , Upper Curge Tanks and Hotwell) were available during this incident. In the event that an accident described in Chapter 15 of the FSAR occurred during the thirty-five minutes that I the switches were in the Close position, the motor driven CA pumps would have supplied the required flow to two S/Gs. The CR0 was fully aware that the switches were in the Close position, and would have had approximately thirty minutes to return them to Auto, if an accident occurred, before the normal suction sources were depleted. The probability of a seismic event of sufficient magnitude to render the normal CA suction sources inoperable, during the thirty-five minutes that the switches were in the Close position is low (on the order of 1.0E-08). Therefore, the health and safety of the public were not affected by this incident.

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