ML20029A682

LER 91-002-00:on 910204,during Surveillance Testing of Train B Safeguards Tests Cabinet,Slave Relay Energized,Causing Steam Inlet Valve to turbine-driven Auxiliary Pump to Open. Caused by Personnel Error.Personnel counseled.W/910225 Ltr

ML20029A682
Person / Time
Site:	Vogtle
Issue date:	02/25/1991
From:	Hairston W, Odom R GEORGIA POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
ELV-02566, LER-91-002-02, NUDOCS 9103010213
Download: ML20029A682 (4)

Text

. .. . - . - . - . - - - . . .-.- . . _ . . . - . - -

Ora'p4 Pow n Ocetg any

• 333 P4rimoz1f Ainnue Adan!h Geo'ga 3ln08 un#m et e.u aos

'. w ,o uuns 43 IfiVI)FDitM Ct78tJt Ia'kw;iy P d O h FLx 1295 D n!wg%vn. A%yre 3$ 01 hh 9ene 205 OM SM1 February 25, 1991 n , n. , ,

W. G Hairston, sti Se-w vu Pm.6a.w us., oowwn ELV-02566 0850 Docket No. 50-424

.U. S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, D. C. 20555 Gentlemen:

V0GTLE ELECTRIC GENERATING PLANT LICENSEE-EVENT REPORT PERSONNEL ERROR RESULTS IN AUXILIARY FEEDWATER SYSTEM = ACTUATION In accordance with 10 CFR 50.73, Georgia Power Company hereby submits the

-enclosed report related to an event which occurred on February 4, 1991.

Sincerely, M

W. G.-Hairsto , Ill WGH,III/NJS/gm

Enclosure:

LER 50-424/1991-002 xc: Sanraia Power ComeABX

'Mr.' C. K. McCoy-Mr. W. E. Shipman-Mr. P..D. Rushton Mr. R. M.-Odom NORMS U. S. Nuclear Reaulatory Commission-Mr.LS. D. Ebneter, Regional. Administrator Mr. 0.: S. .Hoodi Licensing Project Manager, NRR

. Mr. B.- R.- Bonser, Senior Resident. Inspector, :Vogtle f

f.

g3aseM88$r s

'J

- ,- -.-. - - -,, - , , , . ~ , ,, .

-.-. .-.=.- .-.. --.-

gyn 3u, u.S. wctEn unAian cacissia. mgg g m.

, LICENSEE EV2NT REPORT (LER)

FACILITV hake (1) DOCLET humbER (2) F t r. T (T)

VOCr1E E1ICIRIC GE2 EATING PIAVE UNIT 1 05000424 1 g, j 3 illLE (4)

PERSCtNEL ERROR PSSULTS IN ALDCIL1ARY FEEDWATER SYSTEM ACIUATION EVEh1 DATE (5) LER hvMBER (6) REf0Ri DATE (7) OINER FACillilES thv0LVED (B)

M0hlH DAt TEAR YEAR SEQ hum REV Moh1M DAY VEAR fACILl1Y hAMES DOCKEI huMBER(s) 05000 02 04 91 91 002 00 02 25 91 05000 IHis REPORI 15 $UBMI ' LED PURSUAh! 10 iME REQu!REMEhis OF 10 CFR (11)

OPERMING QODE (9) 1 20.402(b) 20.405(c) ^ 50.73(e)(2)(tv) 73.71(b)

PowtR -

20.405(e)(1)(1) -

50.36(c)(1) -

50.73(a)(2)(v) -

73.71(c)

$ LEVEL 100 20.405(e)(1)(ti) _

50.36(c)(2) 50.73(e><2)(vil) OTHER (Specify in 20.405(e)(1)(iii) 50.73(a)(2)(1) 50.73(a)(2)(vill)(A) Abstract below) 20.405(e)(1)(iv) -

50.73(a)(2)(li) -

50.73(a)(2)(vill)(B) 20.405(e)(1)(v) 50.73(a)(2)(lit) 50.73(a)(2)(x) t!CEhSEE CohfACT FOR iMis LER (li)

HAQE IELEPH0ht hum 6ER NREA CODE R. M. 0D04, NUC1 EAR SAFET. Y AND COMPLIANCE 404 826 3201 COMPLETE ONE LlhE FOR EACH FAILURE DESCRIBED th IHis REPORI (13)

CAUSE EYSTEM CONPONENT MANUFAC- R P Rt CAUSE SYSTEM COMP 0hENT MAhuFAC- R P Rt 7URER pp SUPPLEMEh1AL REPQR1 EXPECTED (14) M0hlM DAY TEAR SUBMISSION DATE (15)

]YCS(Ifyes,completeEXPECTEDSUBMIS$10NDATE) ] NO 4BSIRACI (16) t On 2-4-91, plant personnel were performing surveillance testing in the Train B Safeguards Test Cabinet (STC). The Balance of Plant (BOP) Operator and a trainee were in the process of testing a slave relay. The trainee placed his hand on the test button, S935, then removed it to re-verify the step in the procedure. He then erroneously put his hand on the button directly below the proper button, placed it in the test position, and manually depressed it at 0036 CST, before either the trainee or the BOP operator recognized the error. This button (S928) energized a dif ferent slave relay which caused the steam inlet valve to the Turbine Driven Auxiliary Feedwater Pump (TDAFWP) to open, starting the pump. The Reactor Operator (RO) in the control room observed the alarm, checked that steam generator (SG) water levels were normal, and took action to limit the TDAFWP discharge to the SGs. After determining the reason for the TDAFWP actuation, the RO secured the TDAFWP and restored the Auxiliary Feedvater System to standby readiness at 0119 CST.

The trainee committed a personnel error by inadvertently failing to follow procedure and in not employing self checking to verify the button number prior to depressing it. Also, the BOP operator did not exercise sufficient supervision of the trainee. The trainee and the BOP operator have been counseled.

l

i

< inc e mi m u.s. muk nuuw umh5M l MUMf M NQ 5W-W #

LICENSEE EVENT REPORT (LER) l TEXT CONTINUATION l IiclLITYNAM[(1) DOCKET NUMB (R (2) LLR NUMBER ($) PAGE (3)

TIIR SEQ HUM REV V0GT12 ELECIRIC GENERATING Pl>NT UNIT 1 05000424 91 002 00 2 or 3 TEXT 1

A. REQUIREMENT FOR REPORT This report is required per 10 CFR 50.73 (a)(2)(iv) because an unplanned Engineered Safety Feature actuation occurred.

D. UNIT STATUS AT TIME OF EVENT At the time of this event, Unit 1 was operating in Mode 1 (Power Operations) at 100% of rated thermal power. There was no inoperable equipment which contributed to the occurrence of this event.

C. DESCRIPTION OF EVENT on 2-4 91, plant personnel were performing Solid State Protection System (SSPS) surveillance testing in the Train B Safeguards Test Cabinet (STC),

per. procedure _14649 1, "SSPS Slave Relay K746 Train B Test Containment Ventilation Isolation." The Balance of Plant (BOP) Operator and a trainee were in the process of testing a slave relay which is used to actuate containment ventilation isolation. The trainee placed his hand on the correct test button,- S935, then removed it to re-verify the step in the procedure. He then erroneously put his hand on the button directly below the proper button, placed it in the test position, and manually depressed it at 0036 CST, before either the-trainee or the BOP operator recognized the error. This button (S928) energized slave relay K641 and sequentially, the AX2 relay. This created an opening permissive for steam inlet valve 1HV.5106, which started the Turbine Driven Auxiliary Feedwater Pump (TDAFVP). The Reactor Operator (RO) in the control room acknowledged an alarm which indicated that the inlet valve was opening, checked to determined that steam Benerator (S0) water levels were normal,-and took action to limit the TDAFVP discharge to the SGs. This action included

-decreasing the TDAPWP speed and manually closing the TDAFWP dischargo-valves' As a result, there was no noticeable change in steam generator water levels or reactor power as a consequence of.the pump start.

After determining the reason for the TDAFVP actuation, the R0 secured the TDAFWP and restored the Auxiliary Feedwater System (AFW) to standby readiness at 0119 CST.

D. CAUSE OF EVENT The causes of the event are:

1. The Georgia Power Company trainee committed a cognitive personnel error.

by inadvertently failing to follow procedure 14649-1 and in not employing self-checking-to verify the button number prior to depressing L it. The BOP operator committed a cognitive personnel error by failing l to exercise sufficient supervision over the trainee. There were no L unusual characteristics of the work location which contributed to the occurrence of these errors.

• n3MA U 5. hJat/c RiklAiM CJhi551 A / 3 0104 Eig b LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION FACIL*liY NAME (1) DoctET NUMBER (2) LER NUMBER (5) PAGE (3)

YEAR SEQ hvM iiE V V0GriI EiIC~AIC CENERATING P1RTT UNIT 1 05000424 91 002 00 3 0F 3 IEXT

2. Althoagh a lesson plan in self-checking / verification practices had been developed and training was in progress, the trainee was one of a small group of personnel who had not yet attended the associated training class.

3. The display on the STC panel, although properly labeled, was no*. user friendly.

E. ANALYSIS OF EVENT The AW system started as designed and the control room personnel responded properly to throttle flow to the SCs and prevent a plant transient. Based on these considerations, there was no adverse effect on plant safety or the health and safety of the public as a result of this event.

F. CORRECTIVE ACTIONS

1. The trainee has been counseled regarding the importance of self-checking. The BOP operator has been counseled on the importance of exercising proper supervision of trainees and his responsibility for all trainee actions. By 4 1-91, a summary of this event will become required reading, or will be discussed in group meetings, for Operations, Maintenance, HP/ Chemistry and Engineering Support departments' personnt., stressing the importance of self-checking and attention to detail.

2. By 5 1-91, self-checking / verification training will be sequenced into the initial licensed operator training program for on the job training in the control room.

3. Each SSPS actuation switch will be border marked to visually block in its nameplate, switch, and switch number (both units) by 5-1-91.

G. ADDITIONAL INFORMATION

1. Failed Components:

None

2. Previous Similar Events:

LER 50 42L/1987-015, dated 5-13-87.

Corrective actions included counseling.

3. Energy Industry Identification System Code:

Solid State Protection System - JG Auxiliary Feedwater System BA Containment Isolation Control System - JM

- ~ . - . . .. _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ .