ML20005D680

LER 89-007-00:on 891110,w/auxiliary Feedwater Pump 2B Pump Control Switch in Pull Out Per Stated Reasons,Automatic Initiation of Pump Sys Unavailable for 6 Minutes.Caused by Procedural Deficiency.Keys to Be Color coded.W/891208 Ltr

ML20005D680
Person / Time
Site:	Braidwood
Issue date:	12/08/1989
From:	Lau P, Querio R COMMONWEALTH EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
BW-89-3151, LER-89-007-09, LER-89-7-9, NUDOCS 8912140109
Download: ML20005D680 (6)

Text

C lC Commonwealth Edis:n Co.

~

- Braidwood Station

,, _' ' R R 1. Box 81

' Braceville. IL 60407 Telephone 815/458-2801 December 8,1989 BW/89-3151 U. S. Nuclear Regulatory Commission

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)(1) & (v) which requires a 30-day written report.

This report is number 89-007-00; Docket No. 50-457.

Very truly yours, NE R. E. Querlo Station Manager Braidwood Nuclear Station i~

REQ /JDW/sjs (7126z)

Enclosure:

Licensee Event Report No. 89-007-00 l

cc: NRC Region III Administrator NRC Resident Inspector INPO Record Center CECO Distribution List 1 :.

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8912140109 891208 PDR ADOCK 05000457 S PDC

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LICENSEE EVENT REPORT (LER) f arm Rev 2.0 Facill*ty Name (1) Decket Number (2) Pane (3)

JEAldwp9d1 el sl3LOI 01 di3L7 i Ierl0ls iltle (4) Dual Train Inoperability of Auxiliary feedwater System for Six Minutes Due to Procedural Deficiency Event Date (5) LER Nimber (6) Recort Date (7) Other Faellities Involved (8)

Month Day Year Year / Sequential

/jfj/ / Revision Month Day Year Facility Names _Qgdet Naber(s)

/// Nimber //jj/

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// Number NONE 01 51 01 01.01 l l

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11 1 11 0 81 9 81 9 01017 010 .1_ .L2 01 8 81 9 01s1010101 l- 1 p

THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREENTS OF 10CFR (Check one or more of the followino) (11) 1 20.402(b) _ 20.405(c) _ 50.73(a)(2)(iv) _ 73.71(b)

POWER _ 20.405(a)(1)(1) _ 50.36(c)(1) .JL 50.73(e)(2)(v) _ 73.71(c)

LEVEL 20.405(a)(1)(ll) 50.36(c)(2) 50.73(a)(2)(vil) Other (Specify l9 l8 (101 0 __. 20.405(a)(1)(ill) J_ 50.73(a)(2)(1) _ 50.73(a)(2)(viii)(A) in Abstract f' /////////////N/////,/,///// _ 20.405(a)(1)(iv) _ 50.73(a)(2)(ll) _ 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)

LICENSEE CONTACT FOR THIS LER (12)

Name TELEPHONE NU>BER  !

AREA CODE Phli Lw. HPES Coordinaler Ext. 2957 8l115 41 51 Bl -l 21 81 01 COMPLETE ONE LINE FOR EACH COMPON N FAILURE DESCRIBED IN THIS REPORT (13)

CAUSE SYSTEM COMPONENT MANUFAC- REPORTABLE CAUSE SYSTEM COMPONENT MANUFAC- REPORIABLE TURER TO NPRDL TURER TO NPRDS I I I I l l l N l l l l l l l l l l_1 1 1 1 I I I I i 1 -l SUPPLEMENTAL REPORT EXPECTED (14) Expected Month l Day l Year i Submission lyes (If yndomphte EXPECTED SUBMISSION DATE) X l NO l l ll l ABSTRACT (Limit to 1400 spaces, i.e approximately fif teen single-space typewritten lines) (16)

On November 10, 1989 an Instrument Technician (INT) was recalibrating instrument loops for 2A and 28 F

Auxiliary Feedwater Pumps (AF) in accordance with Setpoint/ Scaling Change Requests ($$CR). The calibration l 1s procedurally directed by an Instrument Surveillance that provides for the calibration of both loops. As a {

prerequisite the 2A pump control switch was placed in the ' pull out' position. At 1738 the IMT completed the A loop. At 1927 the pump control switch was returned to the 'after trip' position and the pump was declared trperable. At 2049 the 2B pump control switch was placed in the ' pull out' position. The IMT went to the ,

cabinet where he had been working earlier. At 2137 the IMT placed the A loop in the test. The Reactor Operator identified that the IMT was on the wrong loop. At 2143 the IMT returned the loop to normal. It was discovered during event investigation that by placing the A instrument loop in test the 2A AF pump would have received a trip signal af ter 2.5 seconds of operation. With the 28 AF pump control switch in ' pull out',

automatic initiation of the AF system was unavailable for 6 minutes. The root cause was a procedural deficiency. A contributing cause was the f ailure of the IMT to verify the cabinet. Each AF loop will have a separate procedure. Surveillance cover sheets and cabinet keys will be color coded to match the cabinet doors. Previous corrective actions are not applicable.

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• LIrrmtr EVENT rep 0RT fLER) TEXT tinffitRETION _ Fore Rev 2;d

-FACILift NAE (1) - DOCKET ltfpSER (2) lea laseER (6) Pane (3) l Year // Sequential //j/j Revision

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/// Nimber-sra'id nod 2 o I 5 1 0 I o I o I di 51 7 aI9 - oIo17 - 0l0 01 2 or ol s TEXT Energy Industry Identification System (EIIS) codes are identified in the text as (XX)

A. PLANT C00GITIONS PRIOR TO EVENT:

Uni t : Braidwood 2, Event Date: November 10,'1989; Event Time: 2137; l

Node: .1 - Power Operation; Rx Power: 98%;

RCS (A8) Temperature / Pressure: NOT/NDP;

8.1 DESCRIPTION

OF EVENT:, 1

-l There were no systems or components inoperable at the beginning of the event which contributed to the, severity of' the event,'

. During the af ternoon on Novembe.* 10, 1989 an Instrument Maintenance Technician (IMT) (Non-Licensed instrunent-mechanic) was recalibrating the s. tlon pressure transmitters for the 2A and 28 Auxilialy feedwater Pumps .(AF) -)

l (BA) to new values. The instrument loops were designated as 2PSL-AF051 for the 2A AF pwap and 2PSL-AF055 for the.

28 AF pump ~ This change was in accordance with Setpoint/ Scaling Change Requests (SSCR)89-239 and 89-240 l< rsspectively. The calibration of the AF pump suction pressure transmitters is procedurally directed by Sw!S l' 3.2.1 204, an Instrument Surveillance that provides step by step direction for the calibration of both 2PSL-AF051' cnd 2PSL-AF055. The IMT was using this procedure.

f L -.

' As a prerequisite to performing this procedure the 2A AF purp was declared inoperable and the appropriate  ;

Technical Specification Action Statements vers entered and cceplied with. The motor operated AF suction ~ valves  ;

l- from the Essential Service Water iSX) (BI) System for the 2A AF pump were removed from service. This was to i

- prevent inadvertent opening during the performance of the calibrations. The. pump control switch was also placed l(

in the ' pull out' positien.

At 1738 the INT completed the recalibration of instrument loop 2PSL-AF051. The IMT notified the Shift Control-

Room Engineer ($CRE) (SRO licensed supervisor) that the recalibration was completed. The SCRE initiated action to return the 2A AF pump to operable status. The SCRE was not familiar with the additional procedural requirements cssociated with an SSCR. As a result the SCRE handled the returning of the 2A AF pump to operable in the usual ,;

[

manner for a routine calibration. '

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[ ' At 1927, the return to service of the AF pump suction valves was completed and the pump control switch was returned to the 'after trip' position. The 2A AF pump was declared operable and the Technical Specification

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, Act ba Statement was exited.  :

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At 1049 the 28 AF pump was declared inoperable. The applicable Technical Specification action statements were

• i; .gntered and compiled with. This was part of the preparation to perform the second half of the Bw!S 3.2.1-204, the calibration of the 2PSL-AF055 instrument loop. The suction valves for the 28 AF pump were removed from service tnd the control switch was placed in the ' pull out' position.

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Form Rev 2;8 LICrutrr EVENT REPORT (LER) TEXT CONTIIRIATION 1ACILIT'E NAE (1) DOCKET SU SER (2) LER 1R4SER (6) Pace (3)

Year // Sequtatial /j/j

/ Revision

/j/j/j

/ Number f

/// Number

,graggggd 2 0 l 5101010141517 8l9 - 010l7 - 010 01 3 0F 01.5 TEXT Energy Industry Identification System (E!!S) codes are identified in the text as (XX) l 1

B. DESCRIPTION OF EVENT: (cont'd)

At 2134 the IMT continued with Bwls 3.2.1-204. He proceeded to the Unit 2 Auxilf ary Electric Equipment Kuom {

and established direct communication with the Unit 2 Nuclear Station Operator thS0) (R0 licensed operator). ]

The IMT went to the cabinet where he had been working earlier, the 2PA33J. j i

At 2137 the IMT placed the instrument loop he had been working on earlier, the 2PSL-AF051, in test. The NSO {

questioned the INT to determine if he was on the correct loop. Indication had been lost for the 2A AF pump L suction pressure instead of the 28. The IMT recognized the error and informed the NSO that he was returning the instrument loop to normal. t i'

At 2143 the 2PSL-AF051 instrument loop was returned to normal. The loop had been in test for six minutes.

The event was screened for reportability. It was determined that a 10CFR50.72 ENS notification was not required. The IMT continued with the recalibration. a At 0854 on November 11, 1989 Bw!S 3.2.1-204 was completed.

i At 1535 a Shif t Foreman (SF) (SRO licensed supervisor) was reviewing the status of $$CR 89-240 for the i 2PSL-AF055 instrument loop. The SF discovered that SSCR 89-239 and its associated Nuclear Work request for -f 2PSL-AF051 did not have final completion signof f signatures. The 2A AF pump was conservatively declared inoperable. Limiting Condition for Operation (LCO) 3.0.3 was entered and complied with. The appropriate l;

pe-sonnel to complete the review of $$CR 89-239 were notified.

1 At 1647 the review of $$CR 89-239 was completed and found to be satisfactory. The 2A AF pump was declared ')

i l operable. LCO 3.0.3 was exited.

I j . At 1716 the return to service of the AF pump suction valves for the 2B AF pump had been completed. The pump l control switch had been returned to the 'af ter trip' position. The review of $$CR 89-240 for instrument loop .!

lL 2PSL-AF055 was completed and found to be satisfactory. The 28 AF pump was declared operable, and the l

Technical Specification Action Statement was exited.

l l During the day shift on November 13, 1989 an investigation of this event was conducted by station personnel.

Based on the results of this investigation the following was concluded:

1. Declaring the 2A AF pump operable prior to the completion review of SSCR 89-239 was a deviation from l

i station policy. Based on the fact that the work for SSCR 89-239 was satisfactorily performed and ,

completed the conservative declaration of inoperability of the 2A AF pump and entry into LC0 3.0.3 at  !

! 1535 on November 11, 1989 was unnecessary. f i

!i 2. At 1406 it was discovered that by placing, the 2PSL-AF051 instrument loop in the test position the 2A AF l{ pump would have recelted a trip signal after 2.5 seconds of operation. As a result automatic initiation of the AF system was unavailable during the 6 minutes from 2137 to 2143 on November 10, 1989 when this 4 loop was in test with the 2B AF pump control switch in the ' pull out' position. This was determined to j be a reportable event pursuant to 10CFR50.72(b)(2)(iii).

The appropriate NRC notification via the ENS phone system was made at 1652 pursuant to 10CFR50.72(b)(2)(lii).

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29472(121189)/4

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Jl0 ef 4 ot _ela TEKT Energy Industry Identification System (EII$) codes are tientified in the test as (KX) 9.- 9ESCRIPTION OF EVENT: (cont'd)

- This event is being reported pursuant to:

10Cf R50.73(a)(2)(l) - any opera *.4on or condition prohibited by the plants Technical $pecifications.

10CFR50.72(a)(2)(v) - any event or e ondition that alone could have prevented the fulfillment of the safety function of struttures or systems that are needed to mitigate the consequences of an accident.

Based on the initial informatiot. associated with this event a 'Braidwood $tation Error Evaluation presentation" was held to review this event with the personnel directly involved and their supervisor. 1he c rrective actions addressing both root and contributing causes are detailed below.

C. CAUSE OF EVENT:

s The root cause of this event was a procedural de(Iclency. The calibration of the pressure loops for both trains of AF is performed within the body of one procedure. Being in the same procedure for the performance

$f the calibration of 2P$t-AF055 loop created a mind set for the IMT. This mind set caused the IMI to focus cn returning to the panel he had been in for the first half of the procedure. As a result the IMT returned to the cabinet he had worked in earlier. This deficiency created the error.

A contributing cause to this event was the f ailure of the INT to verify that he was in the correct cabinet.

The cause for the $CRE declaring the 2A AF pump operable prior to the completion review of $$CR 89-239 was a Training deficiency. The SCRE was not familiar with the $$CR program as it related to making setpoint changes during regularly scheduled calibrations.

D. $AFE7Y ANALY$l$:

This event had no af fect on the safety of the plent or the public. Manual initiation of the 28 AF pump was cvailable throughout the event as well as the normal feedwater system (SJ).

Under the worst case condition of extended AF system unavailabilty during an accident scenario, the emergency procedures provide for either the estabitshment of feed te the $ team Generators (AB) from the normal i

fcedwater system or cooldown and depressurization of the RCS to a point where the Residual Heat Removal (BP)

. System can be placed in service using redundant ECC$ components, all of which were operable and available far this event.

E. CORRECTIVE ACTIONS:

The 2PSL-AF051 was immediately returned to operable status upon discovery of the error.

Based on the initial information associated with this event the personnel directly involved with this event l

participated in a "Braldwood Station Error Evaluation Presentation" to identify the root and contributing

! causes'of this event. Based on the conclusions of this presentation the following actions will be taken: '

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' '* LICINKLIYU(T_kEPORT (Ltti TERLCggI1l$gUtu _ rarm Rev 2.0 FA(JtTTE NAE (1) DOCKET Ast[R (2) _ LER _Itse[t 161 Pane _(31 Year g

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TEKi Energy Industry Identification System (E!!$) codes are identified in the text as [KX)

E. CORRECTIVE ACTION $: (cont'd)

Bw!$ 3.2.1-204 will be rewritten as two separate procedures. This action will be tracked to completion by cction item 457-200-89-09101.

The Instrument Surveilleare Data Package cover sheets will be color coded to match the color of the cabinet doors in the Aust11ery Electric Equipment Room which are already color coded. This will help ensure that IMT

! personnel enter the correct cabinets. This action will be tracked to completion by action ites  ;

457-200-89-09102.

The 6eys of the cabinets will also be color coded to match the color of the cabinet doors in the Auxillary Electric Equipment Room which are already color coded. This action will be tracked to completion by action item 457-200-89-09103.

A training tailgate session will be conducted for appropriate Operating Department personnel detalling the r;quirements of the $$CR program. This action will be tracked to completion by action item 457-200-89-09104.

F. FREV1005 OCCURRENCES:

i There was a previous occurrence of performing actions on the opposite train.

DVR No. LER Ho. Title 20-1-88-019 456/88-002 Reactor Trip and Safety Injection Due to Cognitive personnel Error The corrective actions were Implemented addressing both root and contributing causes. Previous corrective actions are not applicable to this event.

'I j G. COMPONENT FAlt0RE DATA:

1 This event was not the result of component failure, nor did any components f all as a result of this event.

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