ML20005E274

LER 89-028-00:on 891204,RHR Shutdown Cooling Suction Header Outboard Isolation Valve Automatically Isolated.Caused by Miscommunication Between Technician & Station Operator.Task Force Developed to Review event.W/891222 Ltr

ML20005E274
Person / Time
Site:	LaSalle
Issue date:	12/22/1989
From:	Crowl D, Diederich G COMMONWEALTH EDISON CO.
To:	Office of Nuclear Reactor Regulation
References
LER-89-028, LER-89-28, NUDOCS 9001040193
Download: ML20005E274 (6)

Text

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'~ ~X Commonwoalth Edison LaSalle County Nuclear Station

- *- f -:) ' Rural Route c1, Box 220

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' Marsellies, Illinois 61341

\ Telephone B15/357 6761 l

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December 22, 1989 4

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Director of Nuclear l<eactor Regulation U.S. Nuclear Regulatory Commission  ;

Mail Station I'l-137 Washington, D.C. 205bS 1 i

Dear Sir:

1.icetince I?vesit Hepo: L l109 028-00, Docket 110b0 'JI3 in iming submitted to your office in accordance with 10CFR50.73(a)(2)(iv). I l

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'G.J.Diederich/2[

S ation iianager I,analle County filat lon GJD/DhC/kg Enclosure xc: Nuclear 1.icensing Administrator NRC Hentdent inspector NRC l(egion 111 Administrator INPO - Itecords Center

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laSalle County Station Unit 1 015101010131713 1lof!0l5 litle (4) Shutdown Cooling Outboard Isolation Valve Automatic Closure Due to M i s cunenu n i ca t l on,Jiror,,,. Du r i no _ i ns t rmen t su rw e l l 1 a nce twent Date (h) LtR Neber (6h ReportDate(7) Other f acilliles involved (8)

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I ll lL On Decenter 4,1959 with Unit 1 in the Refuel Mode (Operational Condition 5) the Ill2-IO00 Residual lleat Reeval Shutdown CoolinD Suction licader Outboard Isolation Valve autonutically isolated durin0 the 1 performance of LaSalle Instrunent Surveillance ll5-NB-lli, ' Unit 1 Reactor lingh Pressure Shutdown C001100 I Is31ation Calibration."

Th) IE12-I000 valve is normully deenergized or closed to prevent an autunatic isolation during the performance of Lis-ND-Ill, but due to a misconmnication between the Instrment Maintenante lechnician r questing the IE12-f000 valve breaker to be de-energized and the Unit 1 Nuclear Station Operator (NSO, licensed Reactor Operator), the breaker was re-energized prior to completing this surveillance.

This event had no effect on shutdown cooling because decay heat rmoval was being provided by an alternate method. Af ter the autonatic isolation of the IE12-f 000 valve, it was Icf t in the closed position and the surveillance was conpleted without any further event.

A task force was developed to review this event and similar events to deterniine what corrective actions will be inplenented to minimize recurrence of miscomnunication events.

This report is being sulnitted pursuant to the requirenents of 10CIR50.73(a)(2)(lv) due to the actuation of an Engineered Safety feature system, I

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LICtW5( L(,Vjui k[POPT (LER) TEXT CONilWUA110N fonn Rev 2.0

!. .IACllllT NAME (1) DOCKL1 NUMBLR (2) LER WUMB[R (6) P40e (3)

Year Sequential Revision *

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Net >cr _ ( Ned>cr i

LaSalle County Station Unit I .0 l 5 1 0 1 0 1 0 l 31 71 3 8l9 0l218 -

.O l 0 01 2 Or 01 5 1LX1 Energy Industry identification System (Ell 5) codes are identified in the text as (XX]

PLANT AND SYSILM 10LWillICA110N l

General Electric - Bolling Water Reactor I

j. Energy Industry Identification System (Ell 5) codes are identified in the text as (XX).

A. COND1110N PRIOR 10 LVLNi i Unit (s): 1- Event Date: 12/04/89 Lvent line: _ 0945 llours l

Reactor Mode (s): 5 Mode (s) Nane: Refuel' Power level (s): DE

8. DL5CRIP110N OF LYLNi On Decent >cr 4,1909 with Unit 1 in Operational Condition 5 (Refuci Mode) the 1[12 4 000 Residual Heat Renoval (RllR, RH) (00) shutdown Cooling Suction lleader Outboard Isolation Valve autunatically 1solated during the perfonnance of LaSalle Instrunent Surveillance LIS-NU-Ill, " Unit 1 Heactor High Pressure Shutdown Cooling Isolatlun Calibration."

Af ter Shif t Engineer (50, licensed Senior Reactor Operator) approval, the Lead Instrunent Maintenance (IM) lechnician approached the Shift Control Room Engineer (SCRC, licensed Senior Reactor Operator) for approval to perfonn L1548-111. After reviewing the Shutdown Cooling system' status, the SCRC determined that the only two isolation valves that were open at the tine which were affected by this procedure were IE124008 and 1L124009 RHR Shutdown Cooling Suction Header inboard and Outboard isolation valves. The SCRE then discussed with the SE the Shutdown Cooling system status and asked if the Ill24000 and 1012 4 009 should be lef t in the open position or taken to the closed riosition to perfonn Ll$-NB-ll).

The 50 deteimined the 10124000 and IE12-F009 should remain open to maintain the shutdown Cooling suction hr.ader in the filled and vented status. The SCRE then attached a tiote to the surveillance attachment to de-energize one valve at a time (IE12-F000 or 1012-1009) when doing this surveillance in

- order to keep one isolation valve operabic in the line while perfonning the surveillance on the pressure switch which would close the other. (this is allowed by the procedure.)

The lead IM then approacteed the Unit 1 Nuclear Station Operator (N50, licensed Reactor Operator) for approval to perform this surveillance and discussed the need to have the 1012-1000 valve de-energized.

At this time the N50 Instructed an Operator to open the 1012 4 008 valve notor operator power supply breaker. -

The lead lH then proceeded to the 1A RilR Pmp Room (which is a high radiation area) at pressure switch IB33-N018A, and the other IM was positioned in the Main Control Room to instruct the NSO to acknowledge and reset alanns or isolation logic as required by the surveillance procedure.

The lead IM instructed the IM in the Main Control Room to have the N50 de-energize the Ill2-f 000 valve breaker, lhe IM in the 1A RHR Pmp Room then connected the deadweight pmp in order to proceed with the surveillance.

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llCINSLE LVIN1_ Rip 0RT (LER) IfXI CONilNILAll0N form Rev 2.0 i ACILilpHAML (1) 00CKL1 NUMBER (2) Page,,{3)

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Year /// Sequential /// Itevision fff f

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/ Nunt>cr Lesa11e County statlpn unit i _ _

0_[ s l_0 1 0 1 0 1 31 11 3 e19 -

0 I 2 1 8- - 0I o 01 3 Or OI 5 itx1 Lnergy industry Identification System (Lil5) codes are identified in the text as [XX)

B. DL5 CHIN 10N Ol [VINI (continued) 1he IM in the Centrol Roum, not knowing the Ill2-f 008 valve was already de-energized, requested the N50 to de-energize Ill2-f008 valve. 1he lead 1H had requested that valve Ill2-f000 be de-energized previously. 1he N50 knowing the Ill?-f 000 was previously de-energired interpreted the instruction from the IM as wanting the power supply for the Ill2-f 008 valve to be re-energlied. The N50 then lustructed an fquipment Attendant (LA, non-licensed Operator) to energlie Ill2.f 000 valve notor power supply breaker.

1he Operator responded to the Unit 1 NSO by paraphrasing that he was requested to turn on the Ill2-f 000 valve breaker and the N50 confinned his response.

1he LA energized the notor operator power supply for the Ill2-f 000 valve breaker and returned to the Control Room.

When the LA returned to the Control Room, the IM responded to the LA by saying, that he had gotten that breaker pretty quickly. Ihc IM in the Control Room then questioned why the it 12-f 006 valve position Indicating Ilghts aniuined lilir:Inated all the time. Ihc LA who energized the breater Mked the SCRL why the valve lights renuin energized and SCRL replied the valve indication has a separate power supply. 1he LA who energlied the Ill2-F000 valve then relayed this infornution to the IM in the Control Roum.

1he IM in the Control Reom did not reallic the Ill2-f 000 valve was re-energlied at this tine.

The IM in the Control Room now knowing that the Ill2 f000 valve indication has a separate power supply, and believing that the Ill2-5000 valve was de-energized, instructed the IM at the IB33-N01BA pressure switch that the Ill2-f 000 was de-energized and testing could continue.

The IM at the pressure switch then pressurized the switch using the deadweight pump, When the switch setpoint isolationpressure signal. was reached the Ill2-f 008 valve autonutically closed due to a high reactor pressure C. APPARENT CAUSL OF LVENT 1he closure of the ill2-f D00 valve was caused by the motor operator power supply for the valve being re-energized prior to the conpletion of the calibration for pressure switch ID33-N010A per Ll$-NH-lli contrary to the procedure. The breaker was re-energized due to a miscunmunication between the IM in the Control Room and the Unit 1 NSO. The Unit 1 NSO misinterpreted the conmunication due to the mindset caused by expecting the next request to perform an action on valve IL12-1000 would be to re-energlie the valve (l.c., change its state). The IM had requested the breaker to be de-energlied prior to beginning the surveillance (which was performed) thus the Unit 1 NSO believed the next step would be to reset the logic and to re-energize the breaker. An hour had elapsed since the lead IM had requested the Unit 1 NSO to initially de-energlie the breaker for the Ill2-f008 valve. 1herefore, when the N50 was requested to take an action on valve Ill2-f 008, he expected it to be re-energizing the valve.

A contributing factor is that the IL12-f008 valve has a separate power supply for the valve position indication, therefore the valve notor epcrator power supply could be de-energlied and the valve position Indicating lights in the Main Control Rotrn would renuin energlied. (This is unique to this valve.)

This also led to the mindset of the IM performing the surveillance that the breaker was off following another misconmunication between the LA who energized the breaker and the IM in the Control Room. The process conputer alarm printer will print valve IL12-f 000 notor power supply breaker status when it chanDes, status, but this nethod is not currently used by the IM personnel to determine valve power supply i

LIClW5f L (VLWT REPORT (LER) 1LX1 COWLINUAll0N f orm Rev,_2,,0_

ipCIL11f NAt'l (1) I DOCKLI NOMIiLR (2) IIR NUMHf R _(6_) , Paoc,_{3)

Year / Sequential /// k#v $i "

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lasalle County Station _tkit.1 0 1 5 1 0,1 0 1 0 l 31 71 3 8IL- 0 l 2_l '8 -

,,0,( 0 01 4 or 01 5 1 EXT Enesgy Industry identification System (Lil5) codes are Identified in the text as (XX)

'C. APPARLNI CAU5L Of- EVLN1 (Continued)

Another contributin) factor was that the lead IM sild not request the N50 to log de-energizing the IL12-F'000 valve tarcaker as required by the surveillance procedure. Also this instrunent surveillance is

-not consistent with other instrunent surveillances which require initiallng procedure steps that repos'ition equipment such as valves or breakers.

An additional contributing factor is that a work practice requiring a warning of the Unit N50 prior to inillatirg a trip signal has not been established. This nuy have warned the Unit I N50 that a trip signal was goinD to be initiated with the Ill2-T000 valvo energized.

Another contributing factor is that no periodic training has been established to instruct station personnel on the requirenents of the LaSalle County Station coppany Policy Guideline for consnunication.

D. $AillY ANALYSIS OF LYLN1 1his event had no ef fect on nnderatur tenperature because the Itllit shutdown cooling systs'rii was shutdown and the Reactor Water Cleanup systen, was lined up for maximum heat renoval as an alternate riethod of decay heat renoval. 1he RitR shutdown cooling high pressure isolation is not required during the Refueling Mode with the vessel head rmoved. The concern for protecting low pressure equipnent during i this mode of operation does not exist in this operating condition.

L. CORRLCllVL ACl10NS 1he Ill24008 valve was left in the closed position and the calibration for pressure switch ID33-N0iBA was conv1rted satisfactorily at 1045 hours0.0121 days <br />0.29 hours <br />0.00173 weeks <br />3.976225e-4 months <br /> without any further event.

The individuals involved were counselled on this event.

A cormninication task force was developed to review the current station coninunication practice and develop reconinendations to inprove caninunication practices. 1he progress of the caninunication task force will be tracked by Action Itun Record (AIR) number 373-200-09-11001, r

lhe Instrisnent Maintenance Departrient will review L15-NB-III and similar procedures to detertnine the need for requiring a si noff D when log entries are required or conponents such as breakers or valves are nanipulated. Also review the need to utilize multiple indications when verifying or re-verifylng conditions prior to perforining a surveillance. AIR nmber 373-200-89-11002 will track this corrective action.

The Instrunent Maintenance Ucpartment is developing a work practice to notify the N50 prior to any 1/2

' scrivn or 1/2 isolation signal by issuing a new vialnteriance rii'ero. By providing the H50 with the warning of an incoming trip signal, the N50 nuy be able to better evaluate the consequences of receiving the trip signal knowing the status of the plant and provide another nochanism for catching an error. This corrective action is being tracked by previously issued AIR nmber 374 200-09-04901.

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7 LICEW5f L_t VJW1 HEPOR1 (LIR) 1(XI_ C_0NilNUA1_10N funn Rev,7._0_ l lACit.111 N ML (1) LKKAll wuhillR (2) (LH WlpyllH_{6) P:ge_(3}___ t Year // Sequential / Revision

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// _Nwidier laSalle Count,y sta H un Unit I_ .0 1 5 1 0 1 0 1 0 1 31 71 3 8l9 Ol_2] 8 - Oj 0 OLsJn 0L5 1LX1 Energy Industry identification System (Ells) codes are identifled in the text as [XXJ F. PRLV1005 f.VLN15 LLH Wund>cr litle 373/84-0$8-00 Inadvertent Start of VC/vE Esnergency Make-up Titter Unit 374/84-027-01 Loss of Reactor Water Cleanup Isolation Leak Detection 373/86 003-00 Missed Surveillance Reactor Water pil Due to Personnel trtor 373/86-016-00 fuel Bundle toaded Without Proper SRM Instrumentation Due to a Personnel Error 373/87-030-00 Reactor Scram While shutdown During Surveillance Due to coninunication Error 374/89-003-01 Engineered Safety f eature Actuation During Performnce of Instrunent Maintenance Iunctional lests Due to Personnel Error G. COMPONENI IAILURL DA1A Not applicable.

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