ML19332F676

LER 89-007-00:on 891112,both Motor Driven Auxiliary Feedwater Pumps Failed to Start Manually by Operator.Caused by Cognitive Personnel Error Re Design Change.Wiring Discrepancy Corrected & Pump Returned to svc.W/891212 Ltr

ML19332F676
Person / Time
Site:	Farley
Issue date:	12/12/1989
From:	Hairston W, Dennis Morey ALABAMA POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-89-007-01, LER-89-7-1, NUDOCS 8912180120
Download: ML19332F676 (5)

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Alabsma Power Comp:nf

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. . . - Post Offa Box 1295-

" Birmingham, Alabama 35201 Telephone 205 868-5581 n,

, W. G. Hairston, til Senior Vee President Nuclear Operations

< AlabamaPower the 50Ulten electrC ByStern 10CFR50.73 December 12, 1989 Docket No. 50-346 U. S. Nuclear Regulatory Commission ATTN - Document Control' Desk Washington, D.C. 20555 Dear Sir Joseph M. Farley Nuclear Plant - Unit 1 Licensee ~ Event Report No. LER 89-007-00 Joseph M. Farley Nuclear Plant, Unit 1 Licensee Event Report No. LER '

p 89-007-00 is-being submitted in accordance with 10CFR50.73.

If'you have any questions, please advise.

Respectfully submitted,  !

h, .f W. G. Hairston, III-i, VGH,III/ JAR:md 8.55 Enclosure cc: Mr. S. D. Ebneter Mr. G. F. Maxwell j i

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l At approximately 1830 on 11-12-89, with the unit in Mode 3 (Hot Standby), both motor driven auxiliary feedvater pumps (MDAFVPs) failed to start when the operator tried to start them manually. Just prior to this, the MDAFVPs had started automatically per design, had performed their design function, and then had been stopped by the operator. After the failure of the MDAFVPs to start, the  !

' switches that' defeat the automatic start of the HDAFVPs when both steam generator l feed pumps are tripped were placed in the DEFEAT position and the MDAFVPs were

l. started. The MDAFVPs could then be operated as needed.  ;

This event was caused by cognitive personnel error. While preparing a design change, the designer failed to review all the unit specific documentation associated with the MDAFVP viring and made the erroneous assumption that the Unit 1 and Unit 2 switchgear compartment internal wiring was identical. ~

In fact, the viring for each unit was different. Consequently, when the design change was installed in 1988, it was installed in accordance with the erroneous design.

The viring discrepancy was corrected and the HDAFVPs were tested and returned to service by 0343 on 11-14-89. The appropriate design personnel have been issued written instructions re-emphasizing the importance of reviewing unit specific documentation. Appropriate procedures vill be revised to reflect this requirement and sufficient checks have been made to provide reasonable assurance that this was an isolated personnel error.

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s Summary of Event At approximately 1830 on 11-12-89, with the unit in Mode 3 (Hot Standby), both

- motor driven auxiliary feedvater pumps (MDAFWPs) [BA] failed to start when.the t -  :

operator tried to start them manually. Just prior to this, the MDAFVPs had started automatically per design, had perforred their design function, and then had been stopped by the operator. After the fa W re of the MDAFVPs to start, the switches-that defeat the automatic start of the.MLAFVPs when both steam generator feed pumps are tripped were placed-in the DEFEAT position and the MDAFWPs were started. The MDAFWPs could then be operated as needed.

Description of Event At 1658 on 11-12-89, the MDAFWPs started automatically per design as a result of a safety. injection and reactor trip (LER 89-006-00). After conditions had stabilized, the operator stopped both MDAFVPs so that steam generator blowdown could be established. At approximately 1830, the operator tried to start the MDAFVPs but the pumps vould not start. .The turbine driven auxiliary feedvater pump was unaffected and provided the required feedvater. After a short investigation (less'than ten minutes), the switches that defeat the' automatic start of the HDAFWPs when both steam generator feed pumps are tripped were placed in the DEFEAT position and the MDAFWPs were started. The MDAFVPs could then be operated as l needed.

L On 11-13-89, during troubleshooting, it was determined that the failure of the HDAFWP breakers to close was due to a viring error in the breaker switchgear. This error was created by the designer during the preparation of a design change which was installed during the Cycle 8-9 refueling outage in the spring of 1988.

It'was initially believed that the problem would have affected MDAFWP operation only when the AUT0-DEFEAT switches were in the AUTO position. Thus, plant operation in Mode 1 (Power Operation) only would have been affected. However, after the viring error was discovered, it was found that the MDAFWP breakers would have failed to close whenever:

- An automatic start signal was present, The pumps had been stopped with the automatic start signal present, and

- An attempt was made to close the breaker while the automatic start signal was still present.

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- Since the error affected the MDAFVP breakers only when an unusus.1 set of circumstances occurred, it was not discovered during the post-installation testing of the design change.

This event was discussed at a Plant Operations Review Committee meeting on 11-13-89. The PORC discussed the viring error and approved Minor Departures '

to correct the viring error, r

Cause of Event This event was caused by cognitive personnel error. The designer did not follow established depart:nent practice and failed to use all the unit specific documentation for the Unit 1 switchgear. The erroneous assumption was made that the switchgear compartment internal viring for the Unit 1 breakers was identical to the viring on Unit 2. Due to differences in viring, the problem with-the Unit 1 MDAFWP breakers was created,but such a problem never existed en Unit 2.

Reportability Analysis and Safety Assessment l

This event is reportable since a single cause or condition caused two independent-trains to become inoperable in a single system. This could have affected the capability to remove heat from the reactor coolant system.

The safety significance of this event is lessened by the fact that:

The turbine driven auxiliary feedvater pump (TDAFVP) remained operable throughout this event and supplied water to the steam generators. The TDAFVP has a capacity equal to the combined capacity of the MDAFVPs.

The HDAFVPs operated until they were stopped by the operator. The MDAFVPs were nble to be started after the AUTO-DEFEAT switches were placed in the DEFEAT position.

It took personnel only a few minutes (less then 10 minutes) of troubleshooting to determine the conditions required for operation of the MDAFVP breakers.

l An unusual failed set of circumstances had to occur before the MDAFVPa vould have to start.

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The viring discrepancy was corrected and-the MDAFWPs were tested and returned

.to service by 0343 on 11-14-89.

Designer management has met with design and design review personnel instructing them to ensure that all unit specific documentation is used for design and design verification purposes.

-The appropriate design personnel have been issued written instructions re-emphasizing the importance of reviewing unit specific documentation.

The designer vill revise, by December 29, 1989, project procedures to place additional emphasis on the requirement for using all applicable unit specific documentation for design and design verification purposes.

In addition,.the designer has made sufficient checks to provide reasonable assurance that this was an isolated personnel error.

As an additional precaution, Farley Nuclear Plant's other architect engineer has been requested to review this event with appropriate design personnel emphasizing the importance of using unit specific documentation in performing design and verification functions.

~ Additional Information The design was provided by.Bechtel Power Corporation, 15740 Shady Grove Road, Gaithersburg, Maryland 20877-1454.

This event would not have been more severe under different operating conditions.

No similar LERs have been submitted by FNP.

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