05000440/LER-1990-032, :on 901116,disconnecting Wires to Test Relay Contact Resulted in RHR a Shutdown Cooling Sys Isolation. Caused by Procedure Deficiency & Inadequate Instructions. Personnel Trained Re Review of Work Orders

:on 901116,disconnecting Wires to Test Relay Contact Resulted in RHR a Shutdown Cooling Sys Isolation. Caused by Procedure Deficiency & Inadequate Instructions. Personnel Trained Re Review of Work Orders

ML20024F741
Person / Time
Site:	Perry
Issue date:	12/14/1990
From:	Hegrat H CENTERIOR ENERGY
To:
Shared Package
ML20024F740	List: 05000440/LER-1990-032, :on 901116,disconnecting Wires to Test Relay Contact Resulted in RHR a Shutdown Cooling Sys Isolation. Caused by Procedure Deficiency & Inadequate Instructions. Personnel Trained Re Review of Work Orders 05000440/LER-1990-033, :on 901120,Train B of Control Room HVAC Sys Actuated Unexpectedly in Emergency Recirculation Mode.Caused by Inadequate Instruction.Procedure Revised Re Correct Guidance During Loss of Power to Bus K-1-N
References
LER-90-032, NUDOCS 9012170123
Download: ML20024F741 (3)

LER-1990-032, on 901116,disconnecting Wires to Test Relay Contact Resulted in RHR a Shutdown Cooling Sys Isolation. Caused by Procedure Deficiency & Inadequate Instructions. Personnel Trained Re Review of Work Orders

Event date:
Report date:
4401990032R00 - NRC Website

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System Isolation.

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.,.,. us........, o e i On November 16, 1990,.at approximately 2243. the performance of an inadequate procedure which required disconnecting wires to test relay contacts, resulted in 1

a Residual Heat Removal (RilR) "A" shutdown cooling system isolation.

The proctdure was a work order to replace a control relay.

Although the steps were performed in the sequence required by the work order, a step to remove a jumper was incorrectly sequenced.

As a tesult of the jumper removalg an RHR "A" shutdown cooling system isolation was initiated. Control Room Operatore discovereo the RHR "A" pump tripped and responded in accordance with approved instructions to restore from the RHR "A" shutdown cooling system isolation.

The cause of this event in a_ procedure deficiency, inadquate instructions. The Instrumentation and Controls (I&C) personnel who -planned and reviewed the work order did not notice that the step to remove the jumper was not in the proper-6 sequence. This resulted in the jumper being removed when the conditions which could cause an RHR "A" shutdown cooling system isolation were still present.

- i The 1&C personnel involved in this event have been involved in the investigation and have been adequately made aware of their errors.

To prevent recurrence, 160 personnel involved with the planning and review of work orders will be trained to this event and to the importance of proper sequencing of actions in all work orders. Additionally, this event will be reviewed by all licensed operators during requalification training.

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On November 16, 1990, at approximately 2243, an inadequate procedure which required disconnecting wires to test relay contacts, resulted in a Residual Heat J

Removal [B0] (RRR) "A" shutdown cooling system isolation. At the time of the event, the plant was in Operational Condition 5 (Refueling) with no core alterations in progress. Reactor coolant temperature was approximately 89 degrees Fahrenheit with reactor vessel [RPV) pressure approximately 0 psig. The Puel Pool Cooling and Cleaning [DA] (FPCC) system was being used to maintain reactor coolant temperature.

On November 16, 1990, at approximately 2100. Instrumentation and Control (16C) technicians began to perform steps of Surveillance Instruction (SVI-E31-T0ll4-A)

" Residual llent Removal Equipment Area 1 Temperature fligh Channel A Functional for IE31-N600A & IE31-N6008A" as part of a work order to replace a control relay.

4 During the performance of the work order, SVI-E31-T0ll4-A was performed in its entirety using specific steps in the work order to establish conditions where the control relay could be replaced and trip verifications made.

The following sequence of actions was established by the work order and performed by the 16C Technicians:

1.

Steps of SVI-E31-T0114-A necesssry to bypass the RilR "A" shutdown cooling system isolation and to deenergize the control relay were performad.

2.

Steps in accordance with the work order were then performed to remove and replace the control relay and the relay was tested as follows:

a. A jumper was installed to prevent the RHR "A" shutdown cooling system isolation when wires were disconnected in the next step.

b. Wires were disconnected from a relay terminal and measuring and test equipment (M&TC) was installed to monitor relay contact operation.

c. The relay was energized and then deenergized while relay contact operation was monitored using the installed M&TE.

d. The jumper was then removed and the Ri!R "A" shutdown cooling isolation occurred.

e. Wires were reconnected to the relay terminal and M&TE was removed.

3.

In accordance with the work order, the SVI-E31-T0114-A was completed satisfactorily and the instrumentation restored to service.

Although the steps were performed in the sequence required by the work order, the

. step to remove the jumper (step' 2.d above) was incorrectly sequenced. The jumper should have been removed af ter the wires were reconnected to the relay terminal (step 2.e above), As a result of the jumper. removal, an RHR "A" shutdown cooling system isolation was initiated on November 16, 1990 at approximately 2243. The isolation was not readily identified to control room operators or I&C technicians because.the annunciator "RCIC & RHR IS01, RHR RM A/B TEMP HI" was already alarming as expected by SVI-E31-T0ll4-A. Additionally the FPCC system was being used to maintain reactor coolant temperature, and the isolation had no ef fect on reactor coolant temperature.

The "RHR PUMP A TRIP" annunciator was not immediately noticed and on November 16, 1990, at approximately 2300, Control Room Operators NEC Perm 3 44 8' gres

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j discovered the RilR "A" pump tripped and took the appropriate actions to restore l

from the Ri!R "A" shutdown cooling system isolation.

1 The cause of this event is inadequate instructions. An 160 planner was L

responsible for assembling materials and constructing the work order, and within It, the job traveler which provided the step-by-step procedure for testing, changing the relay, and retesting the relay. Aoditionally an 16C Supervisor and 16C Engineer reviewed the package to ensure that it could be worked as written.

The 160 personnel who were responsible for the planning and reviewing of the work order did not notice that the step to remove the jumper was not in the proper sequence. This resulted in the jumper being removed when the conditions which could cause an RilR "A" shutdown cooling system isolation were still present.

Leak Detection System (IJ) dual element thermocouples are installed in the RIIR l

"A" equipment area and in the inlet and outlet ventilation ducts to the RilR "A" equipment room f or sensing high ambient or high dif ferential temperature. Either of these high temperatures would be indicative of a reactor coolant leak in the i

Rl!R "A" equipment room. liigh ambient and high differential temperature are alarmed in the control room and provide trip signals for closure of isolation valves for Ri!R "A" to isolate the reactor coolant leak. When the jumper installed by.he work order was removed, the logic for RilR "A" Equipment Area Iligh Differential Temperature was completed to initiate the RilR "A" shutdown cooling system isolation and the system responded in accordance with its design.

The RilR shutdown cooling mode of operation-is designed to remove decay heat from the reactor pressure vessel during shutdown conditions. The plant had entered Operational Condition 4 (Cold Shutdown) approximately seventy days prior to this event and was in Operational Condition 5 (Refueling) as part of a refueling outage when this event occurred.

Prior to this event, RilR "A" had been operating in the shutdown cooling mode with all flow bypassed around the RitR "A" heat exchanger and FPCC system removing decay heat from the reactor.

The RilR "A" shutdown cooling system was promptly restored by Cont M Rcam Oparators and 4

. reactor coolant temperature did-not increase not!coably. Therefore, this event is not considered to be safety significant.

Previous events of RilR shutdown cooling system isolations have been documented by LER 86-032,86-034, 86-048,86-088, 87-025,87-049, 87-068, and 88-005, however, none of these events have-been caused by a deficiency in a work order.

The 160 personnel involved in this event have been involved in the investigation and have adequately been made aware of their errors. To prevent recurrence, 160 personnel involved with the planning and review of work orders will be trained to-this event and to the importance of proper sequencing of actions in all work orders. Additionally, all licensed plant operators will review this event during requalification training, with particular emphasis on the monitoring of plant f

conditions during work activities which disable annunciator functions.

Energy Industry Identification System Codes are identified in the text as [XX).

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