ML20042E173

LER 90-005-00:on 900314,observed That Indicator Lights for Actuation Handswitches for Trains a & B of Fuel Handling Bldg Showed Actuation Occurred.Caused by Personnel Error. Operator counseled.W/900411 Ltr

ML20042E173
Person / Time
Site:	Vogtle
Issue date:	04/11/1990
From:	Hairston W, Odom R GEORGIA POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
ELV-01517, ELV-1517, LER-90-005, LER-90-5, NUDOCS 9004200335
Download: ML20042E173 (5)

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• ' Georg:a Vower Company 333 Pcomont Avenue

. klanta. Georgta 30308 ,

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• kle;#ione 404 5?6 3195 '

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40 inveness Confer Pa4way  :

' Post O'hce Box 1295  !

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blephone 205 BGB 55B1  ;

April li, 1990 ve soamm enc s.*m l W. G. Hairston, lf t Sen4or Vcc Presdent Nuclear Operations ELV-01517 i 0326~

i Docket No. 50-424 U. S. Nuclear. Regulatory Commission- ,

ATTN: Document-Control Desk Washington, D. C. 20555 Gentlemen:

V0GTLE ELECTRIC GENERATING PLANT  :

PERSONNEL ERROR LEADS TO FUEL HANDLING BUILDING ISOLATION- i In accordance with 10 CFR 50.73, Georgia Power Company hereby submits the ,

enclosed report related to an event discovered on March 14, 1990, i Sincerely, W.}. //<$w' W. G. Hairston, !!!

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Enclosure:

LER 50-424/1990-05 xc: Georaia Power Company Mr. C. K. McCoy Mr. G. Bockhold, Jr.  ;

Mr. R. M. Odom Mr. P. D. Rushton

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NORMS l '

U. S. Nuclear Reaulatory Commission Mr. S. D. Ebneter, Regional Administrator Mr. T. A. Reed, Licensing Project Manager, NRR

• Mr. R. F. Aiello, Senior Resident Inspector, Vogtle l-o s

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On 3-14-90, at 0018 CST, the Unit Shift Supervisor (USS) observed that both

Train A and B of the fuel Handling Building (FHB) Post Accident Ventilation l System were operating and that the indicator lights associated with the actuation handswitches for both trains showed that an actuation had occurred.

l Previously, only Train A had been in service with Train B in standby. Since l Train B had not been started as part of a preplanned sequence during testing or reactor operation, this was determined to be an automatic actuation of ESF equipment.

l l An automatic FHB isolation and associated alarms will occur on either a high radiation signal or a loss of negative pressure in the FHB. During this event, no alarms were detected by control room personnel. A review of the Train B air flow strip chart indicated that the actuation occurred at approximately 2300 CST on 3-13-90.

Upon investigation, it was determined that a licensed reactor o)erator failed to verify that the low differential pressure actuation signal was )1ocked as >

required by procedure when Train A was put into service on 3-13-90. This cognitive per:onnel error, in conjunction with opening of the doors to the FHB, probably resulted in the actuation, The operator will be counseled regarding the importance of procedural compliance and other licensed operators will be made aware of this event.

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A. REQUIREMENT FOR REPORT i This report is required per 10 CFR 50.73 (a)(2)(iv) because an unplanned actuation of an Engineered Safety Feature (ESF) occurred, i B. UNIT STATUS AT TIME OF EVENT At the time of the event on 3-13-90, Unit I was in Mode 6 (refueling) at 0% i of rated thermal power. There was no inoperable equipment which contributed j to the occurrence of this event. 1 C. DESCRIPTION OF EVENT  :

On 3-14-90, control room personnel were preparing to remove the Train B Emergency Diesel Generator (DG) from service following ttsting. At 0018 i CST, the Unit Shift Supervisor (USS) walked back to the QHVC panel to check the operation of the DG fans. He observed that both trains (A & B) of the <

Fuel Handling Building (FHB) Post Accident Ventilation System were operating and that the indicator lights associated with both A & B Train isolation actuation handswitches indicated an actuation had occurred. Previously, only Train A had been in service with Train B in. standby. Since Train B had not been started as part of a preplanned sequence during testing or reactor >

operation, this was determined to be an automatic actuation of ESF  :

equipment.

An automatic FHB isolation and associated alarms will occur on either a high ,

radiation signal or a loss of rogative pressure in the FhC. During this ,

event, no alarms had been detected by control room personnel. The USS checked radiation monitors to verify that no abnormal radiation condition existed and pressure indicators showed that negative pressure was being l

maintained in the FHB. A review of the Train B air flow strip chart indicated that the actuation occurred at approximately 2300 CST.on 3-13-90.

D. CAUSE OF EVENT An investigation team was formed and extensive testing of the associated differential pressure switches and radiation monitors that initiate a FHB isolation was performed. No anomalies were found. Control room alarms initiated as expected when a differential pressure switch or radiation monitor actuated.

Recorders were placed on the inputs to the actuation relays of the FHB Post

. Accident Ventilation System. The results indicated that Train B will l

actuate due to a pressure differential when doors to the FHB are opened if Train A is in service and the low differential pressure actuation signal is not blocked. The investigation also found that a licensed reactor operator -

failed to verify that the actuation signal was blocked when Train A was put into service on 3-13-90, as required by procedure.

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Based on this information, the investigation team determined that the most probable cause of this event was a cognitive personnel error. The licensed ,

operator failed to follow procedure 13320, " Fuel Handling Building HVAC  :

System," which calls for blocking the low differential pressure actuation of I the FHB Post Accident Ventilation System when a train is in service. An ,

unusual design characteristic of the FHB Post Accident Ventilation System contributed to this error. Use of the doors in the FHB for normal / routine l personnel egress can cause a low differential pressure condition to occur, which will initiate an automatic actuation of the system. To compensate for i this, doors have been posted with signs that warn of a possible HVAC ]

actuation. Also, procedure 13320-C contains a note to alert control room '

operators that an actuation of a standby train of the FHB Post Accident Ventilation System may occur on door opening, and the procedure contains a step to block the low pressure actuation signal for the standby train. The operator did not perform this procedural step. 1his error is not the result -

of any unusual characteristics of the work location. No reason has been found for the lack of a control room alarm identifying the low pressure differential condition.

E. ANALYSIS OF EVENT The actuation resulted in the operation of both trains of the FHB Post ,

l Accident Ventilation System, as would be expected during a normal FHB isolation (as designed, both trains are able to run concurrently with no adverse affects). Additionally, no actual high radiation condition existed.

! Had this event occurred at a higher power level, there would have been no l further consequences. Based on these considerations, there was no adverse impact on plant safety or public health and safety as a result of this event.

F. CORRECTIVE ACTIONS l 1. The operator will os counseled by 4-13-90 regarding the need for '

procedural compliance.

2. A copy of this LER will be placed in the Operations Reading Book for reading by licensed operators on shift.

G. ADDITIONAL INFORMATION

1. Failed Components:

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2. Previous Similar Events:

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3. Energy Industry Identification System Code: t Diesel Generator System - EK Radiation Monitoring System - IL  ;

FHB Post Accident Ventilation System - VG J

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