ML19351A430

LER 89-025-00:on 890918,jumper Came Loose & Inadvertently Made Contact W/Sliding Link B-14 Directly Above Link B-15, Resulting in Turbine Driven Feedwater Pump Automatically Starting.Caused by Inappropriate action.W/891018 Ltr

ML19351A430
Person / Time
Site:	McGuire
Issue date:	10/18/1989
From:	Mcconnell T, Sipe A DUKE POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-89-025, LER-89-25, NUDOCS 8910240132
Download: ML19351A430 (7)

Text

'-

'g-o 7,, t

<l. s L-  :. V T ' : .' . -' Dukeltwr Company (7041 875 4 000 f c-McGuire Nuclear Station PO Bax 488  :

L Cornelius, N C 280310488 OUKEPOWER

? <

October 18.-1989 ,

h ,

', .U.S. Nuclear Regulatory Conmission i pl 1 Document Control Desk f

' Washington, D.C. 20555 ,

3

Subject:

McGuire Nuclear Station Unit 1' Docket No. 50-359 ,

Licensee Event Report 369/89-25 I I

Gentlemen - t 8  !

Pursuant to 10 CFR 50.73 Sections (a)(1) and (d), attached is Licensee Event '

E '

Report 369/89-25 concerning an automatic start of the Turbine Driven Auxiliary Feedwater Pump because of an inappropriate action. This report is being submitted

in accordance with 10 CFR 50.73(a)(2)(iv). This event is considered to be of no significance with respect to the health and safety of the public.

jVerytrulyyours, r/p.gcH T.L. McConnell-DVE/ADJ/cb1 Attachment- .

. xc t ' Mr. S.D. Ebneter American Nuclear Insurers -

' Administrator, Region II c/o Dottie Sherman, ANI Library U.S. Nuclear. Regulatory Commission The Exchange, Suit 245 ,

' 101 Marietta St., NW, Suite 2900 270 Farmington Avenue Atlanta, GA. 30323 Farmington, CT 06032  :

Mr. Darl Hood INP0' Records Center Suite 1500 U.S. Nuclear Regulatory Commission 1100 Circle 75 Parkway Office of Nuclear Reactor Regulation Atlanta, GA 30339 Washington, D.C. 20555 c

Mr. P.K. Van Doorn M&M Nuclear Consultants 1221 Avenue of the Americas NRC Resident Inspector New York, NY 10020 McGuire Nuclear Station fgV e*.

8910240132 891018 i\

PDR ADOCK 05000369 j s PDC a

'lj

^

g ,

(!. , ,s

' ' , i-

!.,,..' ', LER' Cover,Lett^r.

- , Page 2' l] -:4. ..; -

< t H bxct B'.W. Bline ,

r.,

A.S. Daughtridge '

i R.C. Futrell 6 R.L. Gill i n R.M. Glover'(CNS).

f.o I

T.D. Curtis (ONS). -

P.R. Herran

[2- S.S. Kilborn (W) ..

S.E.-LeRoy '

R.E. Lopez-Ibanez-L J.J. Maher ,

r I'; . .R.O. Sharpe (MNS) [

t.; G.B. Swindlehurst- J L K.D.-Thomas b: L.E. Weaver "f

R.L. Weber-J.D. Wylie (PSD) -

J.W. Willis

.QA Tech. Services NRC Coordinator (EC 12/55)

MC-815-04 (20) '

P t

b l

.g ,

(

e

,gs

- _ r - v- -

v- r- ,-,-

.j- ,

1 ,

efflC Pw'a m4 U S. NUCLE 1.2 E.touLt. TORY C0ese888510se

' ' APPROVID OMS NO 3196019e LICENSEE EVENT REPORT (LER) exPials mi'm >

. AC.uf, NAM. ni .

oOCatT NvMetR Qi ==m McGuire Nuclear Station, Unit 1 o is i o lo l o [3;6 i 9 i joFI of 5

"tInit 1 Turbine Driven Auxiliary Feedwater Pump Automatically Started Because Of An I

'InannronrLate Action

____ IVleff Oaf t 163 ' LER NueOR tel REPORT DAf t 178 OTHER F ACILITit$ INVOLVED tot MONTH DAY YEAR YEAR 0MN" M,$ MONTH DAY 4 TAR ' AC$6 Yv mawes DOCAET NvvetR4Si N/A o,5;o;ogo, , ,

0l 9 1l 8 89 8l9 0l2l5 0l0 1l 0 1l8 8l 9 o,5,o,o,o, , ,

Tues Report is eveMiTTBo PunsvaNT To Tut R6ouintMcNTs os to CrR 5 <caee. .as e mee e eae r #wso aei nti M006 m I 30 081e1 - 73 711bl 20 40316) X S0.734elGHevi m 30 easteH1Hil 60.30teH11 to.73ieH3Het 73.71 lei nei i i w eesminHei 90 mieiGi nni.iGHval gatygag;ge, 30 eestein Haul 50.734elGH4 60.736elGHvie4Hal Js44) 30 eesteH1 Howl 40.734eH3Het 90.78teH3HethHel s 30.eetteH111=l M73telGHnal l 90 73teH3Hal LICENSEE CONT ACT POR YMIS LtR titi NAME TELEPHONE NUMBER ARE A COD 4 Alan Sipe, Chairman, McGuire Safety Review Group 7,0,4 8, 7 i S i ,4 i 1,8,3 COMPLETE ONE LING FOR S ACM COMPONINT F AILURE DESCRIBs0 IN THit REPO*T 113)

M AC- n ORta E CAust sv5 TEM COMPONENT MA%AC. yo ,Taa CAvst SYSTEM COMPONENT p 6

I I 1 l l 1 I i 1 I i 1 I I l l l l l l l l l l I I I l

$UPPLEMENT AL REPORT E XPECTED Hal MONTw Day vtAR

, SUOMISSION 4 t S ist pen. sempoete EMPICTED SV0ect3SION CA TE) NO l , l AS$TR ACT fOmtf fo IM speces (9. espressviefery Parteen sive spece typeweefwe haesi nSi v On September 18, 1989, at approximately 1130, Performance (PRF) personnel were

. performing a valve stroke timing test for valve ICA-27A, Motor Driven Auxiliary l Feedwater (CA) Pump 1A Recirculation. In the process of the test, PRF Technician A was placing a jumper across sliding link B-15 in the CA Pump 1A Auxiliary Panel.

The jumper came loose and inadvertently made contact with sliding link B-14 i directly above it. The Turbine Driven (T/D) CA Pump automatically started as a r

result of this contact. Operations (OPS) personnel attempted to reset the T/D CA l Pump without success. At 1140, OPS personnel initiated an emergency wor,k request l

to have Instrumentation and Electrical (IAE) personnel troubleshoot the electrical circuitry of the T/D CA Pump. The problem was repaired and OPS personnel secured the T/D CA Pump at 1246. This event is assigned a cause of Inappropriate. Action because proper execution of the test step failed during installation of the jumper because the jumper type chosen failed to hold. Unit I was in Mode 1, Powe.r l Operation, at 100 percent power during the event. This event has been reviewed with appropriate PRF personnel and they have been instructed to use a different type jumper in future tests when possible. Appropriate procedural' changes will be made to PRF test procedures to prevent recurrence of similar events.

l l

l i

- MD I* .

4 l

.2'_

GNIC Perm ageA U.S. NUCLEA3 C.IOUL'TomY COMMISSION i

• UCENSEE EVENT REPORT (LER) TEXT CSNTINUATION 4.**:ovro om No. sino-oio4 .

8 * * .

EXPIRIS: Of$i/W -

PACILITY IsAAA4 tu DOCILEY NUGGER ft) Lln NUMSIR ($1 PA06 (31 n*a "hfM'" "'s,l*n:

Text u McGuire Nuclear Station, Unit 1

., w we P.= anamm o ls j o j o j o l 3 l 6l 9 8l 9 -

0l 2l 5 -

0l 0 0l 2 OF 0l5 EVALUATION:

Background

The Auxiliary Feedwater System (CA) [EIIS:BA] is provided as a backup for the Main Feedwater System (CF) [EIIS:SJ). It is designed as a means to remove heat from the Reactor Coolant System (NC) [EIIS:AB] when normal systems are not available. The CA system contains two motor [EIIS:M0] driven (M/D) pumps [EIIS:P), one turbine

[EIIS:TRB] driven (T/D) pump and their associated piping, valves [EIIS:V] and controls. The T/D CA Pump is capable of supplying feedwater to all four steam generators (S/G) [EIIS:SG)

Description of Event On September 18, 1989, at approximately 1129, Performance (PRF) personnel were performing a valve stroke timing test on valve ICA-27A, M/D CA Pump 1A R.ecircula tion. In the process of the test, PRF Technician A was placing a switched jumper across sliding link B-15 in CA Pump 1A Auxiliary Panel. This was in accordance with step 12.3.10 of procedure PT/1/A/4252/02A, CA Valve Stroke Timing -

Qtarterly 1A M/D Pump Flowpath.

At approximately 1129, PRF TechnAclan A had placed the jumper on one side of link B-15. PRF Technician B verified that the jumper was installed at the proper location. When PRF Technician A then attempted to place the jumper on the other side of the link the alligator type clip on the jumper slipped off af ter being placed. PRF Technician A attempted to grab it as a natural reflex. In this action, he made contact with sliding link B-14 immediately above B-15.

At 1129, the 1/D CA Pump automatically started as a direct result of the contact.

Operations (OPS) personnel then attempted to stop the T/D CA Pump but were unsuccessful in the attempt. OPS personnel implemented the NRC Immediate Notification Requirements procedure, RP/0/A/5700/10, because of actuation of an Engineered Safety Feature (ESF) [EIIS:JE].

At 1140, OPS personnel initiated emergency priority work request number 13,9801, to have Instrumentation and Electrical (IAE) personnel troubleshoot the electrical circuitry of the T/D CA Pump.

At approximately 1240, IAE personnel found and subsequently replaced blown fuses (EIIS:FU) in the control circuitry of the T/D CA Pump. At 1246, OPS personnel were able to stop the T/D CA Pump and return the system to normal.

Conclusion This event is assigned a cause of Inappropriate Action because even though PRF Technician A was following the procedure step as it was written, proper execution failed since the jumper did not hold and caused an inadvertent contact to be made.

The use of a jumper with alligator clips was not the best alternative in this instance.

,om m, . o em m

F *

a .

eelle Poem assa u 8 NucLEA% 2.tivL' Tony COMMaestow "f . ' LICENSEE EVENT REPORT (LER) TEXT C3NTINUATCN A*eaovio oMe no mo-oio4 exeines.s w a f ACILITY esaast ns vocetti NUMBla (28 gga uvMet A top Pact ID s.a "daP." "' Mar McGuire Nuclear Station, Unit 1 o [s [ o l o j o l 3 l 6l 9 8l9 -.

0l 2l5 --

0l0 ol 3 or o l3 vsxT en . =6 =M w aae r am w nn The CA Pump Auxiliary Panels [EIIS:PL] are laid out in such a manner that the sliding-link terminals are located in extremely close proximity to one another. It is also awkward to physically access the panel to install jumpers for various tests PRF personnel are required to perform. PRF personnel are aware of the problems associated with placing jumpers in these panels and have discussed different methods for accomplishing those tasks. Use of jumpers with banana plug connectors is a preferred practice when possible because of the more positive grip achieved

~ with that type connector. However, in some cases, a banana plug connector will not work and other types of jumpers must be used. A banana plug connector and adaptors would have worked in this instance. The PRF personnel involved were aware of the availability of the banana plug type jumpers but there was no requirement by the procedure as to what typa jumper to use and they felt that the alligator clip type jumper was adequate for the job.

When PRF Technician A was placing the jumper across link B-15, the alligator type clip on one end of the jumper he was using slipped off. PRF Technician A stated that.he had attempted to grip the wire at the base of the ring terminal connector where it was secured to the terminal post. This would have allowed the alligator clip on the jumper to achieve a better hold. However, the insulation on the ring terminal prevented the connection to be made there. He then attempted to grip the  ;

post itself and the alligator clip appeared to be secure. Seconds later, it slipped off and he grabbed for it in a reflex action. Since the sliding-link terminals are located so close together and in his effort to grab the jumper, he made contact with link B-14 directly above it. The contact between terminals on B-14 and B-15 caused fuses to blow in the control circuitry of the T/D CA Pump.

The blown fuses caused power to be removed from the solenoid [EIIS: SOL) valves controlling the T/D CA Pump Stop Valves, 1SA-48 and ISA-49 [EIIS:ISV), which failri open and supplied steam to the T/D CA Pump therefore starting the pump.

The PRF personnel involved in the CA Valve Stroke Timing-Quarterly 1A Motor Drnen I Pump Flow Path procedure were qualified pursuant to the McGuire Employee Training and Qualification System. They had performed the test before and were familiar with the equipment involved. On May 2, 1988, PRF personnel performed the initial valve stroke timing test of ICA-27A. (Reference McGuire Licensee Event Report (LER) 369/88-08) In the performance of this test, a lead was lifted from link B-15. In the process of lifting the lead, an inadvertent contact was made with )

link B-16. This contact caused the same end result ESF actuation as described in j the event of September 18, 1989. At that time, the insulator between link B-15 and B-16 was badly chipped. The broken insulator exposed link B-16 and therefore, contributed to the contact. The insulator was subsequently replaced and changes made appropriately to allow testing without lifting the lead from link B-15. The event of May 2, 1988 was reviewed by PRF personnel and the test has been completed successfully until the event of September 18, 1989. Although these two events are similar and the equipment involved is the same, the root cause of the event of May 2, 1988 is different than that of the event of September 18, 1989.

Use of a jumper which employs banana plug connectors and an adaptor should prevent recurrence of this event. Subsequent to this event, PRF Supervisory personnel have stressed the use of the banana plug type jumpers whenever possible to prevent occurrence of similar events. PRF personnel will also initiate a Station Problem

=ace so.u m.

w..

e e IIRC Poem MSA U $ NUCLLIA i.E1ULiTORY COMMISSION

• '"M *

, LICENSEE EVENT l'.EPORT (LER) TEXT CONTINUATION maovio owe no sm-oios exPines ow.

PACILity NAast til poCnti Nutett A tal ggn wyugga (48 PA06 (31 veam 88 g,8

, Q,^4 y,8,y,

McGuire Nuclear Station, Unit 1 ojsjojojol3lq9 8f9 -

0l 2l 5 -

0l 0 ol 4 or 015 j vext a . w. .,. ,w =ne w anu u nn ,

I Report for Project Services personnel to evaluate the permanent installation of banana plug adaptors on the terminal posts in the CA Pump Auxiliary Panels. This would aid .in the performance of future testing requiring jumpers to be installed in the CA Pump Auxiliary Panels, and prevent inadvertent ESF actuations of a type similar to this event. Consideration was given to installation of adaptors in other cabinets but PRF personnel felt that the CA Pump Auxiliary panels are the only ones which should require permanent installation of bana'na plug adaptors at this time.

Step 12.3.10 of procedures PT/1,2/A/4252/02A, CA Valve Stroke Timing-Quarterly 1, l 2A M/D Pump Flcypath, will be changed to allow placement of the jumper with the I switch in the open position. This should prevent shorting of one terminal to I j another if an inadvertent contact is made and; therefore, prevent recurrence of similar events. A review by PRF personnel revealed no other procedures which use a j switched jumper. l l

l The event did not cause any significant operational problems or difficulties. Unit 2 was unaffected by the event.

l A review of McGuire Licensee Event Reports (LERs) for the previous twelve months revealed two events concerning an ESF actuation with a cause of Inappropriate i

! Action. These were 369/88-42 and 369/89-09. However, the Inappropriate Actions .

l involved in these events were not caused by the actions, taken not being the best l alternative; therefore, this event is not considered to be recurring. j

[

l This event is not reportable to the Nuclear Plant Reliability Data System (NPRDS). l There were no injuries, radiation overexposures, or radioactive releases as a I result of this event.

1 CORRECTIVE ACTIONS:

1 Immediate: 1) PRF personnel secured testing of valve ICA-27A. l

2) OPS personnel implemented the NRC Immediate Notifica, tion Requirements procedure, RP/0/A/5700/10.

Subsequent: 1) OPS personnel initiated emergency work request 139801,. to troubleshoot the electrical circuitry of the T/D CA Pump.  !

2) IAE personnel replaced the blown fuses in the electrical control circuitry of the T/D CA Pump.

3) PRF Management personnel reviewed the event with appropriate PRF personnel and stressed use of the banana plug type jumpers and adaptors where possible.

Planned: 1) Step 12.3.10 of procedures PT/1,2/A/4252/02A, CA Valve Stroke Timing

• Quarterly 1, 2A M/D Pump Flowpath, will be changed to

.lf , $ . CFCs 1998 9?'-304 W O 10 FORM 3eeA 3

I 1

use yea' u.s. wuctta s.t:utavony connees o=

• • • ' f ' .

UCENSEE EVENT REPORT (LER) TEXT CONTINUAT12N uP:.ovto ove wo. sito-oim  ;

EMPlRES. S/31/m l PACILITV 8eatet ill Docutt Nunasta tap LIR NuneDGA (6) PAQt (31

'a "22P. h*J:

McGuire Nuclear Station, Unit 1 o l5 l0 lo lo l3 l 6l9 8l9 -

0l 2 l5 -

0l0 0l 5 0F 0l5 vonn . v. . sum mep ms. won {

install the jumper with the switch in the open position;  ;

thereby, preventing recurrence of similar events. ,

2) PRF personnel will initiate a Station Problem Report for Project Services personnel to evaluate the permanent .

installation of banana plug adaptors on the terminal posts in the CA Pump Auxiliary Panels.

SAFETY ANALYSIS:

During the time period of this event, the T/D CA Pump ran for approximately one ,

hour. No other ESF equipment was'affected. At no time was the T/D CA Pump l inoperable or incapable of performing the design function of the pump.

l The M/D 'CA pumps were operable during this time period and were capable of providing adequate feedwater flow at the required pressure and temperature to the S/Gs. ] I I

Therefore, during this event, the operation of the T/D CA Pump did not adversely affect any of the Unit 1 equipment or systems. OPS personnel made the proper  ;

notification to the NRC.  !

This event did not affect the health and safety of the public.

1 l

l l

l l

I

'U.S. CNe iMW- 6' N

NSC FO.M 344A O OM. , .m - - - ~ , , . . . . . . - . . . . . . . . . , . . . ..