ML20042D396

LER 89-024-00:on 891129,RCIC Sys Inoperable for 14 Minutes During Monthly Surveillance Test.Caused by Personnel Error. Outboard Isolation Valve Opened & Critique & Discussion W/ Technicians Held to Increase Event awareness.W/891227 Ltr

ML20042D396
Person / Time
Site:	FitzPatrick
Issue date:	12/27/1989
From:	Fernandez W, Fish H POWER AUTHORITY OF THE STATE OF NEW YORK (NEW YORK
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
JAFP-89-1000, LER-89-024, NUDOCS 9001090081
Download: ML20042D396 (4)

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4 g William Femandez 11

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'Decemb'er 27,~.1989 ^

JAFP-89--1000

' United States Nuclear Regulatory Commission Document Control Desk-cc ' Mail Station P1-137 Washington, D.C. 20555

REFERENCE:

DOCKET NO. 50-333 LICENSEE EVENT REPORT: 89-024-00 1 Reactor Core-Isolation .;

Cooling ,

Inoperable - Human Error

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~ Dear.Siri.

This Licensee Event Report is submitted in accordance with ,

10 CFR-50.73(a)(2)(iv).

-Questions-concerning this' report may be addressed to Mr.(Hamilton Fish at (315) 349-6013. -

Very truly yours,_

/ ./ .

l~ WILLIAM FE MANDEZ .

.WF:HCFilar' Enclosure-1- icc: USNRC, Region I INPO Records Center American Nuclear Insurers

'NRC Resident Inspector l].?

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The Reactor' Core Isolation Cooling (RCIC) [BN] system was rendered inoperable for fourteen minutes at 1:06 P.M. on November 29, 1989 with the reactor operating at 100% power. A monthly surveillance test required by Technical Specifications in Table 4.2-2 was being performed by.an experienced technician. The test functionally checks pressure sensors on the RCIC turbine exhaust line downstream from the overpressure rupture diaphragms. High diaphragm exhaust pressure sends a..close signal to primary containment isolation valves on the RCIC steam supply line. Working from the procedure prerequisite section, the circuit breaker for the INBOARD isolation valve (listed first) was opened in the morning ao that testing would not close the valve and isolate RCIC. After a lunch break the test was continued using the performance section which tests the instruments for the OUTBOARD valve first. The technician signed off a valve circuit breaker verification step assuming that it was for the breaker for the valve he had requested to be open before lunch. However, the step was for the outboard valve. Performing the test closed the outboard valve because the circuit breaker had not been opened. The valve closing was noted by operators who reopened it within 14 minutes. Corrective action included discussion with technicians of the event and ways to prevent reoccurrence. The procedure will be revised to provide a consistent order of the valves and their associated instrumentation.

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! Description

-TheLReactor Core Isolation Cooling (RCIC) [BN] system turbine steam exhaust line is equipped with a diaphragm designed to protect

-downstream components from potential damage in the event of high steam pressure. The diaphragm ruptures, if the exhaust pressure reaches 10 psig, to release the steam in a controlled manner. To stop the continued release of steam during such an event, the turbine steam supply valves must be closed. This is accomplished automatically by two channels of instrumentation which, upon sensing a pressure of 10

.psig, initiate close signals to the two primary containment-(NH]

. isolation valves for the RCIC steam supply line. Technical Specifications in Table 4.2-2, Item 15, provide for a monthly

. functional test of this instrumentation. ,

1 LApproved procedure ISP-22-1, "RCIC Turbine Exhaust Diaphragm High Pressure Instrument Functional Test / Calibration" is used to perform the

' monthly test. Performance of the functional test results in_ generation- '

of a-valve close signal. To prevent actual closure of a steam supply valve (which would render the RCIC system inoperable), the power is p- disconnected for one valve when its associated instruments are being.

. tested. Thus, the valve remains in the open position, ready to supply

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steam to RCIC if required. The other valve is available to close in  ;

i the event'that an isolation signal is received. The procedure is reversed to test the second channel of the instrumentation. In this L

manner, RCIC remains operable at all times during the test.

On November. 29, 1989, the reactor was in the run mode operating at 100%

l- . power. At approximately 11:00 A.M. an Instrument and Control technician prepared to perform ISP-22-1. As part of the prerequisite  !

steps, the technician requested-the shift supervisor to open (rack out) the circuit breaker for the RCIC INBOARD steam line isolation valve (13MOV-15). This is the first valve listed in the prere'quisites. The Operations Department opened the breaker as requested. The instrument technician went to lunch. Following lunch, the Instrument and Control technician reviewed the procedure and proceeded with the test. The first set of instrumentation listed in the procedure controls the OUTBOARD valve. As they proceded with the test, the close signal was generated and the expected control room annunciators were verified to activate. The computer record shows that the OUTBOARD valve closed at 1:06 P.M. This rendered the RCIC system inoperable. At 1:10 P.M. the control room operator observed the red (open) position indicating lamp for the outboard valve to extinguish and the green (close) position lamp to illuminate indicating that the valve was unexpectedly closed.

Performance of the surveillance test was stopped. The outboard valve was opened at 1:20 P.M. restoring RCIC to service approximately 14 minutes after it had unintentionally been rendered inoperable.

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0l0 0 l3 oF vint n R . Ca im Cause Personnel error (Cause Code A) resulted in the unintended isolation of the-RCIC system. The " checklist / data sheet" of the procedure provides ,

for verification for "13MOV-16 Outboard Steam Supply Line Isolation '

Valve and Associated Breaker - OPEN". This stea was initialed. The technician's lack of attention was related to t1at fact that he had-performed this procedure many times before and assumed that the valve which he requested to be racked out before lunch was the correct valve, without actually verifying this after lunch and prior to performance of the test.

Although the procedure is technically' correct, it contains several human engineering deficiencies (Cause Code D) which in effect, set the

• technician up for this failure. The order in which the circuit  :

breakers are listed for isolation is reversed between the prerequisite and performance sections and between the two instrument channel performance sections. The most important verification step for the circuit breaker being open is not clearly identified in a separate step. It is lumped together with valve position indication and as the second rather than first step in the verification process.

Analysis Technical Specifications require that the RCIC system be operable l whenever the reactor pressure is greater than 150 psig. A 7-day LCO is l provided for repair of RCIC if HPCI is operable. The RCIC was returned l to operable status within 14 minutes. During this time period, when l RCIC was not operable, adequate protection of the reactor core

[ continued to be provided by the availability of the High Pressure Coolant Injection (HPCI) [BJ) system and the automatic depressurization system [AD] together with the low pressure Emergency Core Cooling Systems (ECCS) including the two core spray system [BM] and two Low Pressure Coolant Injection subsystems [B0].

Corrective Action Immediate:

-1. The outboard isolation valve was opened.

l 2. Following the event, a critique and discussion with Instrument and

" Control technicians was held to increase the overall awareness of the event and discuss ways to reduce the probability of reoccurrence of similar events.

Near-Term:

The procedure, ISP-22-1, will be revised to correct deficiencies which could contribute to personnel error.

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