ML20005E684

LER 89-059-00:on 891206,instrumentation & Controls Technician Inadvertently Grounded Test Jack,Resulting in Blown Fuse.Caused by Personnel Error.Fuse Replaced. Technicians counseled.W/900103 Ltr

ML20005E684
Person / Time
Site:	Limerick
Issue date:	01/03/1990
From:	Endriss C, Mccormick M PECO ENERGY CO., (FORMERLY PHILADELPHIA ELECTRIC
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-89-059, LER-89-59, NUDOCS 9001100102
Download: ML20005E684 (7)

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I tri s) 327.i 200 axv. 2000 January 3, 1990-

'u. 4. u cco nuic a. .; .. . z. . Docket Nos. 50-352 n..,......-

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' 50-353 -

License'.Nos. NPF-39i ,

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, U.Sh Nuclear Regulatory Commission r

. Attn:: Document' Control Desk-l Washington, DC 20555-  !

SUBJECT:

Licensee Event Report Limerick Generating Station - Unit 1 .i This LER reports an actuation of the Primary Containment.

Reactor' Vessel Isolation Control System, an Engineered' Safety Feature, due.to a personnel error resulting from the improper use of test equipment during the performance of a Surveillance Test.

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Reference:

Docket Nos. 50-352-50-353 L-. ' Report Number: 1-89-059

' Revision Number: 00 Event ~Date: December 6, 1989 Report Date: January 3,: 1990 -

Facility: Limerick Generating Station P.O. Box A, Sanatoga, PA 19464

.This LER is being submitted pursuant to the requirements of 10 CFR 50.73(a)(2)(iv).

Very truly yours, p

DMS:ch cc: W. T. Russell, Ao..inistrator, Region I, USNRC T. J. Kenny, USNRC Senior Resident Inspector, LGS l

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Op December 6, 1989, at 0958 hours0.0111 days <br />0.266 hours <br />0.00158 weeks <br />3.64519e-4 months <br />, while Unit 1 was at power and a Unit 2 was shutdown for an outage, an Instrumentation and a Controls (I&C) technician inadvertently grounded a test jack

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which resulted in a blown fuse during the performance of a Unit 1 Surveillance Test. This loss of power caused by the blown fuse resulted in automatic Primary Containment Reactor Vessel Isolation Control System (PCRVICS) actuations of Unit'l and Unit

' 2 isolation valves and systems, Engineered Safety Features. The blown fuse was then replaced by the I&C technicians. All PCRVICS isolations were reset, and normal system operations were restored by.the. Main Control Room operators by 1030 hours0.0119 days <br />0.286 hours <br />0.0017 weeks <br />3.91915e-4 months <br />. The consequences of this event were minimal. The Unit 1 PCRVICS isolation valves and system actuations functioned as. designed..

Unit 2 was shutdown, and there were no adverse consequences.

associated with the valve actuations that occurred on Unit 2.

The cause of this event was a personnel error due to a lack of

' attention to detail by an I&C technician. The IGC technicians involved with this event were counseled. Several corrective

' actions will be implemented to minimize the possibility of similar events.

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-Unit Conditions Prior to the-Event:

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. Unit'l Unit 2

c Operating Condition: lL(Power Operation) 4--(Cold Shutdown)

Power Level: 100% -0% .

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. Unit 2 was shutdown for an outage.

Descriotion of the Event:

On December 6, 1989, Instrumentation and Controls (I&C) .

technicians were performing Unit 1 Surveillance Test-(ST) I

. procedure ST-2-026-618-1, "NSSSS - Reactor Enclosure Ventilation l Exhaust Duct Radiation - High; Division IA, Channel A Functional-Test." At 0958 hours0.0111 days <br />0.266 hours <br />0.00158 weeks <br />3.64519e-4 months <br />, during performance'of thi.C test, an I&C- -

technician inadvertently grounded a test jack which resulted in a )

blown fuse (EIIS:FU), B21-F101A, in the- Auxiliary Equipment Room l (AER) panel'10C622, " Inboard Valve Relays NSSSS Div 1." q This' loss of power caused by the blown fuse resulted in automatic Primary Containment. Reactor Vessel Isolation Control System (PCRVICS) (EIIS:JM) actuations, an Engineered Safety Feature (ESF), closing their outboard primary containment isolation valves; o Unit 1 Primary Containment Instrument Gas (PCIG) Process Lines (EIIS:LK), and o Unit 1 and Unit 2 Primary Containment Nitrogen Inerting Block Valves.

The outboard isolation valves in the following Unit 1 and Unit 2 PCRVICS subsystems received a signal to close, however no valve ,

movement occurred since the associated valves were already closed due to plant conditions prior to the event; o Primary Containment Purge Supply and Exhaust, and o Primary Containment Exhaust to Reactor Enclosure Equipment Compartment Exhaust (REECE).

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' Additionally, the..following' Unit.1 ESF,actuations occurred; o Reactor Enclosure Ventilation (EIIS:VA) System isola.ted, t

o the 'A' train of Reactor Enclosure Recirculation, System.

(RERS)'(EIIS:VA) initiated, and-o the 'A' train of Standby Gas Treatment System-(SGTS)

(EIIStBH) initiated. ,

At 0958 hours0.0111 days <br />0.266 hours <br />0.00158 weeks <br />3.64519e-4 months <br /> on~ December 6, 1989, licensed Main Control Room (MCR) operators observed annunciator indication in the MCR for-isolations of the above-listed PCRVICS valves. Additionally, the l I&C technicians immediately notified the MCR operators that the-test jack was inadvertently grounded.

MCR operators restored the PCIG system at :1004' hours on December 6, 1989', using PCRVICS isolation bypass switches in accordance with General Plant (GP) procedure GP-8, " Primary and Secondary

' Containment Isolation Verification and Reset." The blown fuse was then replaced by the I&C technicians. MCR operators then reset and restored the remaining isolations by 1030 hours0.0119 days <br />0.286 hours <br />0.0017 weeks <br />3.91915e-4 months <br /> on December 6, 1989, using GP-8. All PCRVICS isolations previously-mentioned above.were reset, and normal system operations were restored within 32 minutes. The'I&C technicians then proceeded with the ST, .and completed:it satisfactorily.

A four'(4) hour notification was made to the NRC on December 6, 1989, at 1146 hours0.0133 days <br />0.318 hours <br />0.00189 weeks <br />4.36053e-4 months <br /> in accordance with the requirements of 10 CFR ,

50 72 (b)(2)(ii), since this event resulted in automatic actuations of ESFs. Accordingly, this report is being submitted ~l in accordance with the requirements of 10 CFR 50.73 (a)(2)(iv). )

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j. Consequences'of the Event:

The" consequences of this event were minimal. There was no release of-. radioactive = material to the environment as a result-of  ;

-this event. The Unit-1 PCRVICS isolation valves and system actuations functioned as designed;under the loss of the system i

control logic power condition created by the blown power' supply fuse. The Unit 1 isolations were bypassed or reset.- The affected systems were restored to their pre-transient conditions by operators in accordance with plant procedures within 32 minutes. This prevented any adverse impact on plant systems.

Unit 2 was shutdown for an outage, there were no consequences.

associated with the valve actuations that occurred on Unit 2.

Had Unit 2 been at power, the consequences of only the PCRVICS valve actuations would have been the same as described for Unic 1 above.

Immediate and follow-up actions to this type of event (i.e., loss of logic power) are provided in procedure GP-8. Licensed operators receive requalification training to review and. perform operator responses to transients of this type. This training provides practice on immediate operator actions and minimi::es the length of time certain systems are isolated reducing the adverse impact on the plant. Therefore, as a result.of adequate procedural guidance, training, and prompt operator actions, the ,

event duration was limited and no adverse plant conditions developed.

Additionally, if the fault introduced der  : the performance of ,

the ST had resulted in this logic system he inoperable, the redundant PCRVICS isolation logic channe? ave been available to isolate the PCRVICS system ir Icq * ', The redundant trains of RERS and SGTS were unaffect.e,2 a this event.

Both trains were available if the other train had S iled and an actual. event requiring their use had occurred.

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0; C Og5 op 0 l6 k Cause of the Event:

The cause of this event was a personnel error due to a lack of i attention to, detail by an I&C technician performing procedure ST- I 2-026-618-1. During performance of the ST, a procedural step l L instructs the technician to obtain voltage readings from the i

radiation monitor trip unit test jack. A key switch located l directly above the trip unit test jack is used to place the trip unit from the normal condition to the test condition. The technician inserted the key, which was on a key ring with other i keys, into the trip unit key switch, and turned the key to'the test position. A contributing factor to the cause of this-event was the fact that the voltage meter jumper lead was not long enough to allow the meter to be placed on the AER floor, and the technician had to hold the voltage meter in one hand while performing the ST. As the technician was inserting the voltage meter jumper lead into-the trip unit test jack using his other

.- hand, he-simultaneously contacted one of the keys hanging from the key ring with the test jack, causing a short to ground. This short caused the system control logic power supply fuse, B21-F101A, to blow initiating the previous mentioned isolations and system actuations.

Corrective Actions:

In accordance with procedure GP-8, the Unit 1 PCIG system isolation was bypassed at 1004 hours0.0116 days <br />0.279 hours <br />0.00166 weeks <br />3.82022e-4 months <br /> on December 6, 1989. The I&C technicians then replaced the blown logic power supply fuse.

MCR operators reset and restored the remaining Unit 1 and Unit 2 isolations and systems by 1030' hours on December 6, 1989, in accordance with GP-8, returning both units to pre-transient conditions. The I&C technicians then proceeded with the ST, and completed it satisfactorily.

Actions Taken to Prevent Recurrence:

The I&C technicians involved with this event were counseled to -

stress the importance of a higher level of attention to detail

'while performing work tasks. The following corrective actions will be implemented by January 31, 1990 to minimize the possibility of similar events.

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L 1. Teni(10) foot test' leads will be issued to all I&C b technicians.- This will allow the technician access to difficult-test coint locations, while the associated, test'

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L equipment ~ remains in a safe environment. ,

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2. An I&C test key issuance control program is.being developed. d' This will assure that the test' switch keys are issued singularly for testing purposes. ,

3. This event will be discussed at the next I&C All Hands .

Meeting. This discussion.will also convey the continuous need to use proper techniques while performing testing or ,

troubleshooting and the importance of using precautions to prevent exposed metal surfaces on test leads-and tools from ,

shorting to ground.- Both the proper test lead lengths and l' the I&C. key control program will be discussed at the next meeting.

Additionally,Han I&C task force was assembled following the i occurrence.of LER 2-89-011, which reported a blown fuse in the AER due to personnel error. This task force performed a root j cause analysis of LER 2-89-011, in addition to an analysis of the previous similar LERs listed below. These similar LERs also resulted from personnel errors by I&C technicians working in the AER. On November 16, 1989, the root cause analysis was completed '

and the following corrective action will be implemented.

o An I&C Technician Cood Practice Guideline that provides specific examples of what is considered good work practices has been developed. The Guideline focuses specifically on ,

surveillance testing in the AER. This Guideline has been formulated to enhance technician work practices and to stimulate higher-level thought processes (awareness of the big picture, while performing specific tasks) used by the technicians during the performance of STs. The Guideline will be presented at the next series of I&C continuing training sessions starting on January 9, 1990.

Previous Similar Occurrences:

LERs 1-84-021, 1-84-030, 1-85-011, 1-85-012, 1-85-049, 1-85-074, -

1-86-045, 1-87-021, 1-87-038, 1-89-006, and 2-89-011 also

' reported PCRVICS isolations due to a blown fuse as a result of personnel error.

Tracking Codes: (A) Personnel Error j l

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