05000282/LER-1989-019, :on 891025,Train a of Auxiliary Bldg Special Ventilation Sys Started Automatically When Power Mistakenly Turned Off.Caused by Personnel Error.Involved Personnel Counseled.Clarifying Revs Made to Procedure

:on 891025,Train a of Auxiliary Bldg Special Ventilation Sys Started Automatically When Power Mistakenly Turned Off.Caused by Personnel Error.Involved Personnel Counseled.Clarifying Revs Made to Procedure

ML19332C700
Person / Time
Site:	Prairie Island
Issue date:	11/20/1989
From:	Hunstad A, Parker T NORTHERN STATES POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM), Office of Nuclear Reactor Regulation
References
LER-89-019, LER-89-19, NUDOCS 8911280435
Download: ML19332C700 (4)

LER-1989-019, on 891025,Train a of Auxiliary Bldg Special Ventilation Sys Started Automatically When Power Mistakenly Turned Off.Caused by Personnel Error.Involved Personnel Counseled.Clarifying Revs Made to Procedure

Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2)(iv), System Actuation
2821989019R00 - NRC Website

text

[{ '-

'.t

~

i Northom 9tmos Power Corigiery

{

t p

414 Nicollet Mall-l U

Minneapolis, Minnesota 55401 1927 -

~

Telephone (612) 330-5500 t

November 21,;1989' 10 CFR Part 50 Section 50.73 Director of Nuclear Reactor Regulation U S Nuclear. Regulatory Commission

' Attn: Document Control Desk Washington, DC 20555 PRAIRIE ISLAND NUCLEAR GENERATING PLANT Docket Nos. 50-282 License Nos. DPR-42 50-306 DPR-60 Auto-start of One Train of Auxiliary Building-Special Ventilation System Due to' Personnel Error L.!.

The Licensee ~ Event Report for this occurrence is attached,

.This event.was reported via the Emergency Notification System in accordance

- with 10 CFR Part 50, Section 50.72, on October 25, 1989.

Please contact us if you require additional information related'to this event.

Thomas'M Parker Manager Nuclear Support Services i-l' c: Regional Administrator - Region III, NRC NRR Project Manager, NRC Senior Resident Inspector, NRC

'MPCA Attn:

Dr J W Ferman l

- Attachment 8911280435 891120 gM i

l PDR ADOCK 05000282 f

L.

S PDC i \\

p 1

l'

"~

9 r

s I

j u.s. NuCLts.a t tauLAf oxv Co= Mission

,,g oy,,,,,,o 3,.u,,,

agp.RM 3es a s e E xPIRES. 4/30/92 j

EstwAf tD suRDEN PER R45PONst TO COMPLv WTM TMis LICENSEE EVENT REPORT (LER)

'Y8Mt""Uo'EDYSA?"D#Es'!,LAr/T"L'mtCE^R i 1

C Ti

' mud',o"4'C Mfit'"A"M"'"NW'N OsL%""#"

l int FAPERwomE REDUCTION PROJECT a16041046. OFFICE OF MANAGE MENT AND SUDGET.WASMINGTON.DC 20603.

2

. ACILITV Naast (13

' pOc K E T Nunast R us

'AG6 53 PRAIRIE ISLAND NUCLEAR GENERATING PLANT UNIT 1 0 l5 ;o ;o l o l2 8 ;2 1 lOFl013 1

1 t d '

Auto-Start of One Train of Auxiliary Building Special Ventilation System Due to Personnel Error IVENT DAf t ISI LlR NUtettR 161 REPORT DATE th OTHER F ACILITit4 INVOLVED let MONTH DAY vtAR-vtAR 88 $$'"

MONTM DAY vtAR

' ACILav ' es Awas DOC 8tti NUMetRi31 Prairie Island Unit 2 0 [ 5 l 010 l 0 l 31016 1l0 2l 5 8

9 8l 9 0l1 l 9

~ 0l0 1 l1 2l 0 8l9

~

0 1 5:0l0 0,

t ;

TMi$ REPORT 88 tusMITTED PUR8UANT TO THE Rh0VIREMENTS OP 10 CFR j #Casca one et snore ed,ne fossew.ng) 011 OrtTATINO N

20 40m 20 aoswi 1

so.nwinn i ts.7imi 2-30.4064eH1tui to.30tsHit to.73aaH2Het 73.711el 1, 0, 0

.. Hi H.,

=,,ug,g.g,

.0...,a,

.0, x. iu H..,

no,

"*""'"d"

""""2"'"^'

m e

'("'

70 408hH1Hwi 90.73teH2Hd) to.73(alGHumHSD 20 405(aH1Het 60.73talO:hin 90.73teH2Hal I

s

• I LICEN8tt CONT ACT FOR TMis LIR 1121 TELEPMONE NUMetR gygg Aata CQQt Arne-A. Hunstad, Staff Engineer 611 12 3 i 81 R I - 11 1 11 ') 11 COMPLitt ONF. LINE FOR 1 ACM COesPONENT F AILURE DESCRIBED IN TMit REPORT 1131 t

M A% AC.

R t,PCRf A AC.

R I

CAU58 SYST EM

. COMPONENT

"*"[g CAust svtT EM COMPONENT g pg 0 PR

~

I i !i i t i i

i i i t i i l

I I I I I I I I

I I I

! I I MONTM DAv ytAR SU8*LEMENTAL REPCRT EXPECTED !14)

SU4 MISSION i

YES fil ver. rewn, vere LXPtcTLC susantss10er DA TEI No l

l l

Assu ACT so, R, em.e-e,, e, es.

e.e,P,,,i.e

,,e.

ue,-.

e., o.i On October 25, 1989, both units were operating at 100% power.

Preventive maintenance procedure 3155-1, Radiation Monitor Sample Pump Quarterly PM, was in progress. The procedure calls for the power to the sample pump for 1R-37, an Auxiliary Building Ventilation Stack Monitor, to be turned off. At 0740, a reactor operator trainee under the supervision of a licensed reactor operator mistakenly turned off the power to the monitor instead of turnin6 off Power to its sample pump.

Prior to operating the switch, the trainee and licensed operator discussed the use of the two switches. When the trainee selected a switch to operate, the licensed operator told the trainee the switch he had selected was correct, when in fact it was not.

The error resulted in an automatic start of Train A of the Auxiliary Building Special Ventilation System. This was a non-ESF actuation of an ESF system. When informed that the Auxiliary Building Special Ventilation System had been actuated, the licensed operator realized what had occurred and restored power to 1R-37 at 0741 hours0.00858 days <br />0.206 hours <br />0.00123 weeks <br />2.819505e-4 months <br />.

Cause of the event was personnel error in that the operator trainee--under the guidance of a licensed operator--turned off power to the monitor instead of its sample pump.

1 N LC f erm38410 491

's

.. >b^

[

^ -=u s,-

{

U.S. NUCL4AR REGULATDRY Consassessose isa 70 mas assa )

E xtiRes; e/30/92

@",,^',',"Av"g,n"oati;tii,%cf"'A',7,"Ja%

LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION

%"A"d',",1G'If'MMf',$'e'"^,'j31 L",'"R"!!

ti",Wa"JJi antc;',a'.=vvAsMise0 TON.DC 20603..i; 08 MANAGEMENT AND suporT SACIL4Tv asAmet in DOCK 47 kVM4ER 62:

484 huangen to PA06 (31

" t ra; P

",'=

viaa s

0 10 Ol2 OF 0l3 Ol119 PrairieLisland' Nuclear Plant Unit 1 o ls j o lo l0 l21812 19 Tro n R

w.

.==== *irac i mw.nm EVENT'DESC'RIPTION i; ^

'On October 25, 1989,.both units were operating at 100% power.

Preventive i

' maintenance procedure.3155-1, Radiation Monitor Sample Pump Quarterly PM, was t.

i in progress. The procedure calls for the power to the sample pump,(EIIS Identifier P) for 1R-37. an Auxiliary Building Ventilation Stack Monitor (EIIS i

. Identifier. MON), to be turned off. At 0740, a reactor operator trainee under the supervision of a licensed reactor operator mistakenly turned off the power to the monitor.instead of turning off power to its sample pump.

Prior to operating the switch, the trainee and licensed operator discussed the use of the two switches. When the trainee selected a switch to operate, the licensed operator told the trainee the switch he had selected was correct, when-in fact it was not.

The error resulted in an automatic start of. Train A of,the Auxiliary. Building Special Ventilation System.

This was a non-ESF actuation of an ESF system. When informed that the Auxiliary Building Special Ventilation System had been actuated, the licensed operator realized what had occurred and restored power to 1R-37 at 0741 hours0.00858 days <br />0.206 hours <br />0.00123 weeks <br />2.819505e-4 months <br />.

t

CAUSE OF THE EVENT

Cause of the event was personnel error.in that the operator trainee--under the guidance of a licensed operator--turned off power to the monitor instead of its sample pump. The licensed operator told the' trainee the-switch he had selected was correct, when in fact it was not.

4 Contributing causes were the lack of clear wording in the procedure and-ambiguous panel labeling.

L l-ANALYSIS OF'THE EVENT l-The functional response of the auto-start actuation of the Auxiliary Building Special Ventilation System was according to design, which is to deactivate the Auxiliary Building Normal Ventilation and actuate the Auxiliary Building Special Ventilation System. The Auxiliary Building Special Ventilation System is used to decrease the impact of a radiological release to the Auxiliary Building through increased filtration and monitoring of the air in the ventilation system.

Since this event was not triggered by a radiological event, there were no radiological concerns and there was no effect on the health and safety of the public.

This event is reportable pursuant to 10CFR50.73(a)(2)(iv).

gL w.:

=,:'

k us.muetsAn asGu6 Atony coMMession

,,,,ov,,,,,,,33,,,,,,.

na conM sesa.

extries 4o041 -

E UCENSEE EVENT REPORT (LER).

'!!n,'?o'u"8'",'e?"o"'!;O d,'.0 fOl,T.",d"'!

I

. !?.7!"le',"d*M'""! Mfg.""/c'"^lME IT/ O!!!'f! '

O!",'^1?.".74 "*.'"4,",a, "Zin'iaM TEXT CONTINUATION-l' OF WANAGEMSNi ANO BWOGET WA$MINGTON,0C 20603 00CKET huMSER 623 -

LlR NumetS A (Gl <

PA06131 FACibatV Namt dia,

a,tvf,y; agt;;',*6 vi,a 010 0h OF 0 l3 0 II l9 Prairie > Island Nuclear Plant Unit 1 0 l5 ] o j o l 0 l 218 l 2 819 TENT ir mise assse a essemer, ese omsome NAC # win Jme W 117) 1 l

)

r 4

' CORRECTIVE ACTION.

Involved personnel were' counseled, Clarifying revisions.will be made to the procedure before it is used again.

Labeling of the' radiation monitor panels will be reviewed. The labeling will be-reviewed and changed by December 31, 1989, FAILED COMPONENT IDENTIFICATION None.

' PREVIOUS SIMILAR EVENTS There have been several auto-starts of the Auxiliary Building Special--

Ventilation System but none from this particular cause.

s w

t

--w-

- hr

,+ --