ML19332E512

LER 89-014-00:on 891030,inadvertent Safety Injection Occurred on Train B During Installation of Card Holders. Caused by Personnel Error Design Deficiency.Sys Mod Request submitted.W/891129 Ltr

ML19332E512
Person / Time
Site:	Braidwood
Issue date:	11/29/1989
From:	Querio R, Wagner J COMMONWEALTH EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
BW-89-3080, LER-89-014-05, LER-89-14-5, NUDOCS 8912070311
Download: ML19332E512 (5)

Text

e _.

g -w Commonwoalth Edison

, ) Br:ldwood Nuclear Power Station

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4 Rout)C1. Box 84

. p .1. * \ -

t Braceville, Illinob 60407 >

7 N Telephone 815/458-2801 lr'. >

November 29,1989 ,

BW/89-3080 'i t

i f

U. S. Nuclear Regulatory Commission l Document Control Desk  ;

Washington, D.C. 20555  !

Dear Sir:

The enclosed Licensee Event Report from Braidwood Generating

• Station is being transmitted to you in accordance with the requirements of 10CFR50.73(a)(2)(iv) which requires a 30-day written report.

This report is number 89-014-00; Docket No. 50-456.

Very truly yours,  ;

d R. E. Quer o Station Manager Braidwood Nuclear Station j

! REQ /JDW/jfe  ;

(7126z) a j u

Enclosure:

Licensee Event Report No. 89-014-00 l

1.

l cc: NRC Region III Administrator  ;

NRC Resident inspector i INPO Record Center L CECO Distribution List  ;

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• t.!CENSEE EVENT REPORT (LER) facility Name (1) Docket Number (2) ,fgge_(31

.Draidntf 1 01 51 01 01 01 41 51 6 1 l efl 0 l 4 Title (4)

__Inadvefit013Bjety Initttien Sinnal s i thJt&Litr_.011Wiltildut_12.f tE19MJ_ Error. __

_[y.tallatt _ (5) LER Nygttr 16) Recort D11t (71 Other facilities _lnVDIYid (B)

Month Day Year Year // Sequential // Revision Month Day Year fattlity Name1_ Dett el_.Hym_htL(.11 >

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// Number

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// __ Number Nott Jj_$l010101 l l 11 0 .31 0 _ Pj_g__ Bl 9 01114

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0_J 0 111 21 9 81 9 01 5}Jj_.01 01 I l THl$ REPORT 15 $UBMITTED PURSUANT 10 THE REQUIREMENi$ OF 10CIR 9pg 1(b.ttk one er more of ibs_.{ellowino) (11) 20.dO2(b) 20.405(c) 2. 50.73(a)(2)(tv) __ 73.7)(b)

POWER _ 20.405(a)(1)(i) __ 50.36(c)(1) _. 50.71(a)(2)(v) _. 73.71(c)

LEVEL 20.405(a)(1)(li) 50.36(c)(2) __ 50.73(a)(2)(vil) __ Other (Specify 0l0 (10) 0 ___. 20.40$(a)(1)(111) 50.73(a)(2)(1) __ 50.73(a)(2)(viii)(A) in Abstract

////////////////////////// 20.40$(a)(1)(iv) ___ 50.73(a)(2)(11) _ 50.73(a)(2)(viii)(B) below and in

////////////////////////// _._ 20.405(a)(1)(v) _ 50.73(a)(2)(iii) _.__ 50.73(a)(2)(x) Text)

Ll(18$[E CONTACT fjR THIS LER (12) iELEpHONE NLPSEp Name AREA CODE

._Jerrv Waant.r. Regulalerr_Asivunce E t _2497 8l115 41 51 81 l 21 81 01 COMPi[li_Qt4121NL LQJLEACH COMPON N FAIWEE DESCRigiDJN Jgl$ REPORT (13)

REPORTABLE CAUSE SYSTEM COMPONENT MANUTAC- REPORTABLE CAUSE SY$i[M COMPONENT MANUFAC-TURER TURER TO NPRD.$,

___TO NPRDS I _

l i 1. 1 I l_ N l _.] l l l I 1 I I I I i 1 1 I I I I I I l

$UPPLEMENI AL RifDE.LL)(PL(JED (141 Espected Month l D.ty_}_hti Submission Date (15) ' '

-lytal}L.3fL_IDeplelt MPEllD }VHMi$$10N DATE) X l N0 l l l l l_

ABSTRACT (Limit to 1400 spaces, i.e. approximately fif teen single-space typewritten lines) (16)

On October 30, 1999 Contractor personnel were installing card holders on lever-type switches in the Main Centrol Room. At 1105 a lever was removed from a switch and placed on the control panel near the Pressuriser

( Low Pressure Safety Injection (SI) Block / Reset switch for Train B. At 1107 the Train B Pressuriser Low pressure $1 Logic Circuit reset. A Train B $1 occurred. The IB Diesel Generator started, the Auxiliary Building Ventilation realigned and a charging pump suction va?ve opened. All other $1 components were removed froe service. The $1 initiated actuation signals for Fuel Handling Building Ventilation. Containment Phase A ! solation. Containment Ventilation Control Room Ventilation, and feedwater Isolation. The root cause of this event was personnel error. It is believed that the contracted electrician inadvertently bumped ,

l the 51 Block / Reset Switch while reaching f or the lever handle that was laying on the control board by the Block / Reset switch. A contributing cause of this event was a design deficiency. The automatic functions

! sere verified upon receipt of the actuation. The equipment was returned to its original status. This event l

was discussed with the Contracted electricians. A method will be devised to block protective functions not l rsquired during Cold Shutdown and Refuel /Defuel modes. No previous occurrences.

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l 2931s(112989)/2

. Lggt($LL.LyENT ktPORT (Ltti TEXT ggtingpH F tw Rev 2.e.

FACILITY NAME (1) DOCKET NVPSER (2) ..LER.Nupe.ER (6) Pane (3)

Year //

fj/j Sequential // Ri'i'"

/// Number /j/u/

/ Number _

araidwood 1 eisIeIeie 1 41 51 6 819 -- ei114 - eie el 2 or el_4 TERT Energy Industry Identification System (E!!$) codes are identified in the text as (KK)

A. PLANT COND; TION $ PR102 TO EVENT:

Unit: Braidwood I; Event Date: October 30, 1989; Event Time: 1107; Cbde: . N-Defurled; Rx Power: 0%;

RC$ (AB) Temperature / Pressure: Amblent/ Atmospheric B. DESCRIPTION Or EVENT:

s There were no systems or components inoperable at the beginning of the event which contributed to the severity t,f  ;

=the event.

The $olid State Protection System ($$PS) (JE) had been maintained functional for various surveillance testing even i though the Reactor was defueled.

On October 30, 1989 Electrical Contr6ctor personnel were installing control switch Out of Service Card holders.

These holders were being installed on all lever-type switches on the Main Control panels of Unit 1. This was part

$f the planned activities for the refueling outage. 10 install the holder the outer portions of the switch were disassembled. The holder device was then placed on the panel. The switch was then reassembled. The installation i process required about 3 minutes to complete.

At 1105 holder installation was initiated on the Pressuriser level Select switch. The switch lever was removed ,

and placed on the control panel about 8 inches from the Pressuriser low Pressure $afety Injection ($1) Block / Reset switch for.frain B.

At 1107'the contractors were at the point in the process where switch lever replacement was the next step to be  !

performed. At this time the Train B Pressurizer low Pressure $afety injection Logic Circuit reset. The

• Fressurl er was completely depressurited. This was bslow the 1829 psig Pressurizer to Pressure $1 setroint. A

' Train B Safety Injection occurred within a fraction of a second after the logic circuit reset. The IB Diesel Generator (CK) started. The Centrifugal Charging Pump (CB) Refueling Water Storage Tank (BQ) saction valve, [

ICV 112E, opened. The Auxiliary Building Charcoal Booster f ats (VA) (Vf) started and dampers repositioned to

• provide flow through the charcoal absorbers. All other components that receive an actuation signal as the result cf a Train B $1 signal were removed from service.

The Safety injection initiated the following actuations signals:

1. Containment Phase A Isolation - No components repositioned because all Phase A components were already isolated.

2. Containment Ventilation (VA) Isolation - This isolated the Containment purge which was in progress.

3. Control Room Ventilation (VC) (VI) Actuation - This caused the B frain of VC to shift to the Mabeup Mode and started the B Hakeur Fan, DVC03CB.

2931 (112989)/3

. LliLM31L.LY[N_ T REPORT (LER) TEXT [0 tin!6E110N igm _l(ty_2J, TACIT!TY NAME (1) 00CKET NUPSIR (e) ,,_LLIL)lUtfER f 6i Page f3)

Year /// Sequential /// Revision fff fff

/// Numb 3r /// Number _ [

.prale = 1 0Is10l0Io141516 e19 - 0l114 - 61.'0 01 3 0F 01 4 f IERT Energy Industry Identification System ([Il$) codes are identified in the text as (KK) 1

5. DE$CRIPi!ON OF [ VENT: (Continued)  ;

4 Feed =ater Isolation (5J) $1gnal - No components repositioned because the feedwater system was isolated.

}; 5. Tuel Handling Building Vent 41stion (VA) (VG) Actuation-This caused f an OVA 04CB to start and repositioned dampers to direct flow through the charcoal adsorbers beds.

Nuclear Statien Operators (Licensed Reactor Operators) verifled automatic actions. The actuation signals were reset. Components that had auto started / repositioned were returned to thvir stendby allynment.

The appropriate NRC notification via the [N$ phone system was made At 124$ pursuant to 10CfR50.72(b)(2)(ll).

This event is being reported pursuant to 10CFR50.73(a)(2)(l*)-any event or condition that resulted in manual ,

cr automatic actuation of any Engineered $afety Feature, including the Reactor Protecilon System. l C. CAUSE Of EVENT:

The rest cause of this event was an apparent personnel error. It is believed that the contracten electrician ,

inadvertently bumped the Low Pressurizer Pressure 51 Block / Reset switch. This occurred while reaching for the lever handle that was laying on the control board approximately 8 inches to the lef t of the Block / Reset '

switch. Both contractors were interviewed. They were at the step in the installation process where picking up the lever handle would have been the next action.

The contractor who would have performed the action stated that he did not believe he had bumped anything. He tas wearing a thick flannel shirt. The cuf f was rolled up 1 fold and was hanging down appro Imately 3

• inches. From the position where the contactor was standing the Block / Reset switch would have been directly '

below the path that his right hand would have taken to reach for the lever handle. And the direction would have moved the Block / Reset switch in the Reset direction.

The Low Pressuriser Pressure SI Block / Reset switch was a Westinghouse OT2 lever type switch. Tests had been ctnducted on this type of switch as part of an investigatien of a previous non-reportable event. Based on these tests the following has been concluded about this type of switch: l

1. The switch will operate with a very small degree of movecent.

2. The awnunt of force required to operate the switch could be undetectable for an inadvertent bump especially if the bump was created by catching it on a piece of clothing.

The $$PS System Technical Expert (5TE) (non-licensed engineer) performed an evaluativn of B Train of $$PS.

Based on this evaluation it has been concluded that the SSPS train was functioning satisf actorily. And the Low Pressuriser Pressure $1 logic circuit reset s'id not occur due te any problem internal to 5$PS. The STE

j. also operated the Block / Reset switch several times. The STE's centlutions were consistent with the OT2 switch tests results discussed above.

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-29312(112889)/4

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. _Ll(Mit EVENT PEPORf (LER) TEXT (9EI14UAT10N Fem Rev 2.0 (ACIL13Y WhME (1) 00CKLT NJ1Br.R (2) ,_LER NUMBER (6) Pane (3)

Year /// Sequential Revision ff

//j/ Number. N aber_

o I s I e I e I o I di 51 6 e19 -

ol114 - oI o el 4 L _g u hahmL1 TEXT Energy Industry Identification $ystem (E!!$) sodes are identified in the text as (KK)

C. CAUSE OF LVENT: (Continued)

A contributing cause of this event was a design deficiency. The outage activities required the $$p$ input Error Inhibit $ witch to be In " Normal" for Instrument Maintenance Surve111ance festing. The $$p$ Output Mode Selector switch was required to be (n *0perate" for Contalament Ventilation Actuation to remain operable. As ,

a result of these requirements protective functions of $$p5 that are only required for higher Modes of ,

Opstation were functional with the Reactor completely defueled.

D .' $ATETY ANALY$l$:

This event had no ef fect on the safety of the plant or its public. The systems that had not been removed from service eperated as designed. The Reactor had been completely defueled. The protective functions provided by a S.iety injection were not required and were inapproorlate for the existing plant conditions.

Discussions on redundant equipment are not appitcable. This $1 actuation was neither required nor desired.

There are not reasonsable and credible alternative conditions that would have been more severe.

E. CORRECTIVE ACTION $ ,

the automatic functions of the $1 and its associated actuations were verified upon receipt of the altre. The actuation signals were reset. The equipment that had actuated was returned to its original status.

This event was discussed with the Contracted electricians by the Superintendent of the contracting compary .

and Coasenwealth Edison Hanagement.

An evaluation of the functional requirements of the $$p$ has been conducted. Based on the results of the evaluation the following has been concluded:

1. The system should be modified to provide the capability to block protective functions that are inappropriate for Mode 5 and 6 while retaining those functions that are desired.

2. This capability could be achieved by either permanent modification or Temporary Alteration that would be installed / removed during each extended shutdown. l A Modification Request has been submitted. This will be tracked to completion by action item 456-200-89-17701.

F. PREVIOU$ OCCURRENCES:

DVR Numbsr Title 20-1-87-043/87-010 Inadvertent Loss of power to Instrument bus 111 resulting in e Reactor Trip due to personnel Error-Contractor

'20-1-89-166/89-012 Containment Vent Isolation and Fuel Handling Bldg f an Start on Homentary loss of power due to personnel Error, t

The corrective actions were implemented addressing both root end centributing causes. Previous ccrrectivt actions are not applicable to this event.

G. COMPONENT FAILURE DATA:

l This event was not the result'of component failure, nor did any components fall as a result of this event.

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