ML20042E499

LER 90-007-00:on 900318,ESF Actuation Occurred.Caused by Mgt Deficiency in Not Providing Sufficient Guidance for Review of Work Package After Scope Changed.New Work Package Preparation Procedures initiated.W/900417 Ltr

ML20042E499
Person / Time
Site:	Quad Cities
Issue date:	04/17/1990
From:	Bax R, Sibley E COMMONWEALTH EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-90-007-01, LER-90-7-1, RLB-90-113, NUDOCS 9004230288
Download: ML20042E499 (5)

Text

. -. . - ._-

.,. C0fnin0HW98lOn Estisoft

,, Quad Cities Nuclear Power Station 22710 208 Avenue North ]

ooreova,Illinels e1842  !

Telephone 300/064-2841 RLB-90-113 j e

April 17, 1990

. U. S. Nuclear Regulatory Commission '

Document Control Desk ,

Washington, DC 20555 i

Reference:

Quad Cities Nuclear Power Station  :

Docket Number 50-254, DPR-29, Unit One i Enclosed is Licensee Event Report (LER)90-007. Revision 00, for Quad Cities.

Nuclear Power Station, i This report is submitted in accordance with the requirements of the Code of  !

Federal Regulations .Tlt1e 10. Part 50.73(a)(2)(lv): The licensee shall

~,

report any event or condition that resulted in manual or automatic actuation of any Engineered Safety Feature (ESF). '

Respectfully, l 4

COMMONWEALTH EDISON COMPANY i QUAD CITIES NUCLEAR POWER STATION  !

R x Station Manager  !

l RLB/MJB/jlg Enclosure

- cc: R. Stols l T. Taylor INPO Records Center i NRC Region III 2737H /

8R42;ggggggggggo s

f  ;

LICENSEE EVENT REPORT (LER) , ,,, ,,,  ;

Factitty Name (1) Docket Number (2) Pane f3) )

nund citiet unit one of El el 01 01 21 El 4 1 of 0' 4 Tit 10.(4)

Enaineered Safety Feature Actuation Dua to Manacament Deficioney involvine Work Instructiont Event Date (E) LER * * =r f&l Renart Data f71 Other Facilitiet involved (R)

Month Day Year Year Sequential // Revision Month Day Year Facilit y kamat Dacket Numberft1

• ** r ,/j/p

// Number Quad citiet 2 01 11 01.c) 01 21 61 1 ,

~~ '"

of 3 11 a el o el o oIoI7 o10 ol4 117 el 0 of El 01 01 01 I I l TH1$ REPORT !$ SUBMITTED PUR$UANT TO THE RE0u!REMENTS OF 10CFR 0

fehark one or more of the followinal fill 4 20.402(b) , 20.40$(c) _X. 50.73(a)(2)(iv) _ 73.71(b)

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

LEVEL , 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(vii) Other (Specify flo) e!el6 20.405(a)(1)(iii) $0.73(a)(2)(1) _ $0.73(a)(2)(viii)(A) in Abstract

/ ,/,/,/,/,/,/,/,/,/,//,/,,/,/,/,/,//,/,/,/,/,/,

/ / _ 20.405(a)(1)(tv) _ 50.73(a)(2)(ii) _ 50.73(a)(2)(viii)(B) below and in ,

f/?fjj/j' j j j,7/j ff //7 j f /j/j'jj//j/j/7,'j}jjj

/7 f /fff/ ,, ,, 20.40$(a)(1)(v) 50.73(a)(2)(111) 50.73(a)(2)(x) Text)

LICEN1EE CONTAtf FDR THIS LER f121 Name TELEPHONE NUMBER AREA CODE 6 Ed 11hlev. Technical Staf f Enaineer Ext. 2819 3 10le 61 El 41 -l 21 21 41 COMPLETE ONE LINE FOR EACH COMP 0N FAILURE DEstRIBED IN THIS REPORT f13) cAU$E SYSTEM COMPONENT MANUFAC. REPORTABLE CAUSE SYSTEM COMPONENT MANUFAc- REPORTABLE TURER 70 NPRD1 TURER TO NPRD1 1 I l l l l l i I I I l l I I I I I I I I I I l l 1 l I

$UPPLEMENTAL REPORT EXPECTED (141 Expected Month l Day l Year Submission

(

lYet fif vet. comalete EXPECTED SUBMI$110N DATE) X l NO l ll ll ABSTRACT (Limit to 1400 spaces, i.e. approximately fif teen single-space typewritten lines) (16)

ABSTRACT:

On March 18, 1990, Unit one was RUN at 96 percent of rated core thermal power and Unit Two was in SHUTDOWN. At 0738 hours0.00854 days <br />0.205 hours <br />0.00122 weeks <br />2.80809e-4 months <br />, the Electrical Maintenance Department, while performing work in Panel 902-40 in accordance wtth the work package, lifted the leads for the contacts on relays 1705-102 and 106 which resulted in an Engineered Safety Feature (ESF) actuation. An Emergency Notification System (ENS) phone notification was completed in accordance with 10CFR50.72(b)(2)(111)(D).

The cause of the event was management deficiency. Sufficient guidance was not provided for a review of the work package after the scope of the work changed.

Corrective actions will include discussions of the event and procedure revisions.

This report is submitted in accordance with 10CFR50.73(a)(2)(iv).

2677H/

P

tiermeer Evtut arrant f Ltal itxt comitmuattom rara tav 2.0 FACILITY NAfE (1)' DOCKET NUBSER (2) tra naments tal Paan (3) ]

• Year- fj//

/ seguential Reviston I

. . ///

f W*r ///j/

ff

// Me r a m estinn unit one o l E l o 1 0 I o 1 21 El 4 9Io - oIoI7 - oI o of 2 or o la TEXT Energy Industry 16entification system (E!!s) codes are identified in the text as (XK) 1 i PLANT AND SYSTEM IDENTIFICATION:

]

L General Electric - Bolling Water Reactor - 2511 MWt rated core thermal power.

l l EVENT IDENTIFICATION: Engineered Safety feature Actuation Due to Management l Deficiency Involving Work Instructions-A. CONDITIONS PRIOR TO EVENT:

• Unit: One Event Date: March 18, 1990 Event Time: 0738 Reactor Mode: 4 Mode Name: RUN Power Level: 96%

This report was initiated by Deviation Report D-4-1-90-026 RUN Mode (4) - In this position the reactor system pressure is at or above 825 psig, and the reactor protection system is energized, with APRM protection and RBM -

interlocks in service (excluding the 15% high flux scram).

. B. DESCRIPTION OF EVENT:

At 0738 hours0.00854 days <br />0.205 hours <br />0.00122 weeks <br />2.80809e-4 months <br /> on March 18, 1990, Unit One was in the RUN mode at 96 percent of rated core thermal power and Unit Two was in the. SHUTDOWN mode.

Prior to this time, at 0015 hours1.736111e-4 days <br />0.00417 hours <br />2.480159e-5 weeks <br />5.7075e-6 months <br /> on March 18, 1990, the A Standby Gas Treatment (SBGT) (VI] Train had been taken out-of-service (00S) for breaker (BKR][JX]

• replacement. At 0534 hours0.00618 days <br />0.148 hours <br />8.829365e-4 weeks <br />2.03187e-4 months <br />, relays (RLV) 1705-102 and 1705-106 were taken OOS for Work Request 076915 in order to replace the relay coils as part of preventive

' maintenance.

Work package Q76915 had been prepared by the electrical work analyst to replace all of the CR120A relays in panel (PL) 902-40. The work package gave detailed instructions that the electrical leads were to be lifted from the coil as well as the associated contacts for each relay. At the time the work was scheduled to be I

performed, the Operating Department requested that only the coil portion of relays l 1705-102 and 106 be de-energized as part of the out-of-service (005) due to other l ongoing plant operations. Operations discussed the change in the 005 with the electrical planner; however, this information.was not communicated to the electrical analyst or foreman. At 0738 hours0.00854 days <br />0.205 hours <br />0.00122 weeks <br />2.80809e-4 months <br />, the Electrical Maintenance (EM)

Department in accordance with the work package, began lifting the relay leads, which resulted in de-energizing the circuit, and an Engineered Safety Feature (ESF) ,

actuation. This caused the Reactor Building Ventilation and Control Room Ventilation Systems to isolate. The B SBGT train did not receive an initiating signal due to the part of the circuit that was de-energized. Since the A SBGT train was out-of-service, neither train started. The B SBGT train was manually l started.. The Shift Engineer immediately contacted the EM Department and instructed i them~to stop work and determine the cause of the trip. The lead was relanded and

'the Reactor Building and the Control Room HVAC Systems were reset. At 0832 hour0.00963 days <br />0.231 hours <br />0.00138 weeks <br />3.16576e-4 months <br />s-the Nuclear-Regulatory Commission was notified using the Emergency Notification System (ENS) phone system to comply with the requirements of 10CFR50.72(b)(2)(iii)(D).

2677H/

~ _ _ _ _ , . ,. - ,

= . - . - - . . .

tirreur tvant atPont f Ltal Ttri comituuATION Farm aav 2.0 -

FACILITY #4PE (1) DOCKET INSSER (2) LER mtsm88 fa) Paan ft)

.. Y;ar // seguential /pf,/

/ R; vision

,/jj/

// "" r /// m" r i nU ttitet unit one e i t I e 1 o I o 1 21 11 4 eIo - e I o' i 7 - oI o el 1 or el 4 5 ftKT Energy Industry Identification system (t!!s) coces are identified in the text as [XX]  !

C. -APPARENT CAUSE OF EVENT:

This event is being reported according to 10CFR50.73(a)(2)(iv), which requires the reporting of any event or condition that results in manual or automatic actuation of any ESF. t The cause of this event is a management deficiency. The work package had been previously prepared to replace all CR120A relays in panel 902-40. When the work

. package was given to the EM Foreman, it was not apparent to him that there had been a change in conditions, and therefore the work package was not reviewed to~ compare the revised' scope of work with the 00S.

! D. SAFETY ANALYSIS OF EVENT:

i The safety of the plant and personnel was not affected by this event. The B SBGT-train was fully operable during the event and would have started upon receipt of a '

valid signal. ,

E. CORRECTIVE ACTIONS:

The immediate corrective action consisted of manually initiating the B SBGT Train and relanding the lifted lead.

Presently new work package preparation procedures are in the approval process. QAP 1500-T8, Guidelines for Work Instructions, is being revised to enhance the guidance for preparation of work instructions. This will require the work analyst to consider 005 requirements for work to be performed and to clearly define special -

precautions and prerequisites (2542009002601).

The station out-of-service procedure. CAP 300-14, will be reviewed for clarification of department responsibility for technically complicated out-of-services (NTS 2542009002602).

This event was discussed with all station personnel.

F. PREVIOUS EVENTS:

I LER/DIR Numbers Description 88-019/(D4-2-88-038) Rx Building Isolation (Failure to review OOS for possible consequences). The cause of LER 88-019 was personnel error involving '

, Operating Department initial review of an 1

OOS and its possible consequences on plant equipment.

Based on the corrective actions to be completed, no further corrective actions a.re '

deemed necessary.

2677H/

i tif tutf t EVthf tip0RT f Ltki ffET comf f entATION Fare key 2.0 FACILITY IWE (1)- 00CKti le ttR (2) Lta utammte f &1 Paan til n Year // seguential /// Revision  :

e.*. j/j/p

// " " - - ,/j/j/ "~ ^ r  !

nand cities unit one ol E IoIeIo 1 21 11 4 eio - oIeI> - oI o el a or a14 ftxT. Energy Industry Identification System (t!!$) codes are identified in the text as [XX) ,

i 1

l G. COMPONENT' FAILURE DATA:  !

There was no_ component failure associated with this event. ,

i 6

6 i

s

}

I t

1

?

l l

5 Y

2677tt/

-_