ML20006D740

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LER 87-004-01:on 870225,inadvertent Safety Injection Occurred During Maint Troubleshooting.Caused by Cognitive Personnel Error by Control Sys Technician Involved. Disciplinary Action Taken & Counseling done.W/900124 Ltr
ML20006D740
Person / Time
Site: Byron Constellation icon.png
Issue date: 02/05/1990
From: Pleniewicz R, Snow M
COMMONWEALTH EDISON CO.
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
BYRON-90-0130, BYRON-90-130, LER-87-004-02, LER-87-4-2, NUDOCS 9002150012
Download: ML20006D740 (5)
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F N f) 4450 North61010 Byron,litinois G:rm.:n Church load January 24, 1990 Ltra BYRON 90-0130 U. S. Nuclear Regulatory Commission Document Control Desk Washington, D.C. 20555 Dear Sir The enclosed Licensee Event Report from Byron Generating Station is being transmitted to you as a Supplemental Report.

This report is number 87-004; Docket No. 50-454.

Sincerely,

-a ?M '

.d R. Pleniewic  %.

s Station Manager Byron Nuclear PowQ Station

.RP/dm Enclosures Licensee Event Report No.87-004 1

cci A. Bert Davis, NRC Region III Administrator W. Kropp, NR,C Senior Resident Inspector INPO Record' Center CECO Distribution List (0512R/0059R) fgg2]ggy Q 4 /

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, , Li(EN5(E [V[Ni R[ PORT (L(R) facility Name (1) Dock +,t Number (2) ,fane (3) tvron. Unit 1 01 El 01 01 01 41 El 4 1lef!0l4 11tle (4) ,

1%l!y[]LIENT SAFETY IN){LilQtlilVRING MAINTENAN(LlRQU$1LitDQllNG_CAViED BY A PERjQyNEL ERROR

-_11tnLE41tj5) LER Numbitjj) Rgggfl ptle (7) Other Facilitit1Jaralttd (8)

Month Day Year Year fj//j Sequential /jj//

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f Revisto.. Month Day Year 13tility Names DolitLNumktris )

/// Numb.gr Uf,_Nightr.

NONE O!510101Of I l

~ ~

.pl_iL215 81 7 BJ7 01014 01 1 _Q l 2 01.5 Jl 0 01 51 01 01 01 l l_

OtfRATING gggt g9, lihtik one or mate of the fellowing) (111 5 20.402(b) _ 20.40$(c) .1 50.73(a)(2)(iv) 73.7)(b)  :

POWER ,_ 20.405(a)(1)(1) 50.36(c)(1) _ 50.73(a)(2Hv) 73.71(c)

LEvil g g __ 20.40$(a)(1)(II) 50.36( c H 2) __ 50.73(a)(2Hvil) Other ($pecify 1101- _A i 0I Q_._ _ 20.405(e)(1)(lit) _ 50.73(a)(2HI) __ 50.73(a HCHviii)( A) in Abstract

/ /////////// ///// _ 20.405(aH1)(lv) 50.73(a)(2)(li) _ 50.73(a)(2)(viii)(B) below and in

/ ///////////

///// _ 20.40$(a)(1)(v) 50.73(a)(2 Hill) _ 50.73(a)(2Hx) Tent)

LICLN1LLLONIACT FOR THIS LER (12)

Name IELLl't9SLNVMi1LR -

ARLA C000 H. $n0 _Et9W3A LREL811 W C &fli t_IUPR EY110 P E111.2260 B l 1 1 5_ L_j4 l -l_11 41 4lj COMELLIE ONE LINE FOR EACH COM ONEN FAILygLDESCRibED IN THIS REPORT f13) CAUSE SY$ TEM COMPONENT MANUFAC- REPORTABLE CAU$t $Y$ttM COMPONENT MANUTAC- REPORTABLE J UEER TO NPRDS . _ ,,IllRER 10 NPRDS l l !j !I I l __l l l I- I l-l l 1 [ l l I I I l l i I l l . 

                                  $UPPLLt4 ENTAL REPORT EXPECTED (14)                                                  Expected bortthl Day 1.lfA.C Submis: Ion Date (15)              '

_llta 11 Lyt 140mpitie EXPLCILQJUBM131LDtLDAIE) X l NQ l l l I' l AB$fRACT (Limit to 1400 spaces, i.e, approximately fifteen single-space typewritten lines) (16) On February 2$. 1907, Unit I was in Mode 5, Cold Shutdown, in preparation for refueling. Instrument Maintenance (IM) personnel were troubleshooting a problem with the Process Instrumentation and Control System. During this troubleshooting activity, an IM Control $ystem Technician (C$i), not cognizant of all the consequences of the action re-positioned a Solid State Protection System " Memory" switch. The repositioning of the switch unb.ocked an existing Main Steamline Low Pressure Safety Injection signal. A 

              $afety injection occurred at 1614 on February 25. 1987. The root cause of the event was a cognitive personnel error by the C$i involved and procedural personnel errors by all IM's involved in the troubleshooting by not initiating the proper troubleshooting paperwork. All safety systems functioned as designated and the unit was properly recovered without incident. Corrective Actions include disciplinary action against the C$i and counseling all individualt involved. There were two similar previous occurrences reported in LER's 454-05-34 and 85-97.

(0512R/0059R)

o , LICENitt EVENT REPORT (Ltki TEXT CONTINUATION Fe.1n Rev 21 I FACILITY NAME (1) DOCKET NUSER (2) _ LtR NLNelR f 61 Page (31 , 

                                                                                   /// Sequential
                        .                                                  Year                     //  Revision
  • fff
                                                                                   ///    Nua6er  j//j/
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f Number _ , 1 3rren. .Un1 L 1 ILilj 01010 141 $14 s17 - 01014 - 0 11 QLL E_ JLo ' T[XT [nergy Industry Identification System (Il!$) codes are identified in the text as (XX) I A. PLANT CONDITIONS PRIOR.10 EVERI: 

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Unit 1 was in Mode $ (Cold shutdown) in preparation for refueling. RC$ (AB) was less than 200*f and de-pressurised. The $teamline Low Pressure Safety injection ($1)(BA) signal was blocked and the Pressuriser low Pressure $1 signal was blocked. Train B of Solid State Protection System ($$PS) (JE) was out-of-service for maintenance. The Main Control Board Trip Status Light Board (T$LB) was dark and the $$PS Demultiplexer (DEMUX) feeding the TSLB was de-energized.  ; i B. DL1Cl LIE 11QN 0F EVENT: 1 On February 2$. 1987 the Instrument Maintenance (IM) Department was asked to aid the Operating Department in taking channel 3, of the Process Instrumentation and Control System (JL), cabinet IPA 03J. out-of-service. This out-of-service wet needed to install a wiring modification under Modification 

                                                                                                                                                  ]

M6-1-Bd 0246. Operating personnel on shift requested that channel 3 not be taken out-of-service until - indications on the T$LB had been restored so that possible trips from other channels could be identified, i With $$P$ Train B out-of-service the main control board DCMUX had been deenerglaed to remove the "f alse" Train B indications f rom the T$LB. It was determined that to restore the T$LB indications, the OEMUX had to be powered up and the comununication links between Train A and Train B had to be interrupted. l In an attempt to accomplish this, three I.M. personnel, two foremen and one Control System Technician (C$f) 1 (All non-Itcensed), determined that two cables between Train A and Train B needed to be disconnected. This ' l discussion was taken to the Operating $hift personnel and concurrence was given to remove the cables. Disconnecting these cables, however, did not allow the TSLB to operate as desired. At this time, the I.M. personnel returned to the I.M. shop to consult wiring diagrams. While they were in the shop, another C$T  ; who is a system expert, reported for work and offered his assistance in solving the problem. Convinced 1 that the consnvnication links between Train A and Train B had been severed, the two 1.M. foremen and the "new" C$T returned to the Auxiliary Electric Room. In the course of troubleshooting, the three people i proceeded to the Train A (IPA 09J) logic test panel to determine if some mispositioned switch could be , causing the problem. No mispositioned switches were found. The cabinet, IPA 093 contains three General l Warning Ilghts which indicate if there is a problem with either of the two $$PS Trains. An inconsistency  ; in the status of these lights, prompted the CST to suspect a " light" problem. Knowing that repositioning any switch in the cabinet would cause a General Warning, the C$f, on an impulse, then reached up and ) without further discussion repositioned the MEMORY $ witch. The repositioning of this switch unblocked the entsting $teamline ($8] Low Pressure $1 and the Pressurlier Low Pressure $1 signals, and initiated the l Sofety injection. ' l I l The Safety Injection occurred at 1614 on February 25. 1987. Water was injected into the Reactor vessel and Reactor Coolant pressure inceased to 80 psig. No over-pressure protection component was actuated nor I required. 1 Byron Emergency Operating Procedure BEP-0, " Reactor Trip or $afety Injection" was entered, and the Operators proceeded with the designated actions. All safety systems operated as designed. Following the steps. outlined in BEP-0. the $afety injection was reset and the two $1 signals were re-blocked within seven minutes from the inception of the event. l t I (0512R/0059R)

FarnLRer l a. _ LICLnLL iVLNT REPORT (LER) f tKT COM11M)6110N DOCKET NU$tR (2) Ltk NupetR (6) Pane (31 l tACitlTY NAMt (1) Year /j/jj/ Sequential /jj f 

                                                                                                              //   Revision
                  *                                                                  ///          Nysthgr   uf   . Hgight.t_
       .htmJnit 1                              015 l 9101(L1.Albl 4 8I7                -

_A l 0 1 4_ - O l1 QL1_QL _0L4 itX1 Energy Industry Identification System ([11$) codes are identified in the tent as (XX) x C. CMLDLLYCM1: The root causes of the event were a tegnitive personnel error by the C$T (non licensed) and procedural personnel errors by the I.M. Foremen involved for not initiating the proper troubleshooting paperwork. Had the proper paperwork been initiated, to delineste the systematic documentation of actions tc troubleshoot this problem, the safety injection actuation would probably have been prevented. Contributing factors to this event are: The General Warning Ilghts in Cabinet IPA 09J were not working due to an unusual system status because the Reactor Trip breakers were racked out for another work activity. The reduced risk of Reactor Trip /$af eguard actuations while the plant is in Cold $hutdown led to a slightly reduced level of alertness. D. $ArtTY A%LY.$1$1 This event did not affect plant or public safety. All safety systems worked as designed, and all operator actions progressed as anticipated. In addition, the unit was in Cold Shutdown which is a non-applicable mode for Emergency Core Cooling System to be operable. This type of work activity would only be performed with the reactor in a shutdown mode. E. CORELCILYL .*n110N$: Appropriate disciplinary action was taken against the CST involved. Other Instrument Maintenance personnel involved were counseled to re-emphastae the need for proper documentation and pre-planning when performing troubleshooting activities on plant equipment. Also discussed was the constant alertness needed when working on plant equipment, especially safety related equipment in all modes of operation. This report was disseminated to Station Departments to be discussed with their respective personnel. A long tonn solution to modify the $$P$ $ystem to be paced in TEST during an outage was investigated. However, installing a modification of this type would not have prevented a similar event occurring in Modes 1 thru 4. or while in Mode $ with the $$PS cabinets in normal (as required to thange from Mode 5 to Mode 4). In addition, this type of event has not occurred since this event. On-Site Review 89-197 determined the Modification would not be beneficial. BVP 600-3 Placing Both Trains of $$PS In fest While in Mode 5 and 6, was in place for Refueling Outage BIR03. Action Item Record 45$.225-90 01200 will track the completion of the procedure for Unit Two. The procedure will then be available f or f uture use during outages as deemed necessary by the Operating Engineer. (0512R/00$9R)

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  • LittWi(( ty[NT ktPORT (Ltti itKT CONTINUATION FernLRev 2.0 FACit!TY NAME (1) DOCKET NUSER (2) Ltk MuMata (6) Pane (3)

Year 5equential Revision j 

                             '                                                             //{

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                                                                                           ///   Number
                                                                                                            //
                                                                                                            ,/{

f 

                                                                                                            //    Nunea r _

l A ren. Unit 1 0 l 5 1 0 l 0 1 0 l 41 51 4 8I7 - 0l0l4 - 0 l1 01 4 0F OL4 ftKT Energy Industry identification System (E!!b) codes are identified in the text as (XXI

f. RLtuRRINfi_EYLt0S SLAkCH AND ANALYSl$:

LLR.NuteLR 111LE 454-85-34 Manual Safety injection 454-85-97 Inadvertent $afety injection During Surveillance Test G. LQ!i'QNENT FAILURE DATA a) tnNUFACTURLR tiQtCNCLATURE tjQDEL. NUPSLR HrG PART NUtBER No components f ailed b) RLSulis or NPRDS STARCH: Not Appitcable 

         -(0512R/0059R)
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