ML20042F544

LER 90-003-00:on 900405,inadvertent Train B Safety Injection Initiation Signal Occurred Due to Programmatic Deficiency. Training Developed & Lens Evaluated for Replacement. W/900503 Ltr

ML20042F544
Person / Time
Site:	Braidwood
Issue date:	05/04/1990
From:	Lau P, Querio R COMMONWEALTH EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
BW-90-0484, BW-90-484, LER-90-003-09, LER-90-3-9, NUDOCS 9005090051
Download: ML20042F544 (5)

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Commonweaph Edison .

1* _ Br;idwood Nucint Powir Station Rout 3 #1, B:x 84 Braceville, Illinois 80407

' - . _ Telephone 815/458 2801 -

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i May 3,1990 I BW/90-4484 o

i U. S. Nuclear Regulatory Commission i Document Control Desk j Washington, D.C. 20S55 j

Dear Sir:

The enclosed Licensee Event Report from Braidwood Generating  !

Station is being transmitted to you in accordance with the requirements of 10CFR50.73(a)(2)(iv) which requires a 30-day written report. . j q

This report is number 90-003--00; Docket No. 50-457.

Very truly yours,  !

R. E. Querto i Station Manager i Braidwood Nuclear Station  !

REQ /JDW/jfe l (7126z)

Enclosure:

Licensee Event Report No. 90-003-00 cc: NRC Region III Administrator NRC Resident Inspector INPO Record Center CECO Distribution List 9005090051 900504

,PDR ADOCK 05000437 #4%

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LICENSEE EVENT REPORT (LER)

Form Rev 2.0 factitty,Name (1) Docket Number (2) Paos (3)

_$raithtood 2 01 51 Ql 01 01 41 51 7 1!of!O!4 Title (4)'

Inadvertant Train B Safety Injection due to Programatic Deficiency Event Date (5) LER Number (6) Report Date (7) Other Facilities Involved (B)

Honth Day Year Year // Sequential /j/j

/ Revision Month Day Year Facility Names Docket Number (s)

/j/jj/

/ Number f

/// Number None 0151010101 l l 01 4 01 5 91 0 91 0 0l0l3 Ol 0 015 01 4 91 0 0151010101 I l THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10CFR Khtch_Dat_or more of the followina) (11)

N 20.402(b) _ 20.405(c) .1. 50.73(a)(2)(iv) _ 73.7)(b)-

PUWER _ 20.405(a)(1)(i) __ 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)(vil) (nher (Specify

!0 !O (10) 0 _ 20.405(a)(1)(iii) _ 50.73(a)(2)(1) __ 50.73(a)(2)(viii)(A) in Abstract

///////////,///////,//,///,/,// __ 20.405(a)(1)(iv) _ 50.73(a)(2)(ii) _._ 50.73(a)(2)(viii)(B) below and in v //////////j///////}//' /j//j/'/ //

j _ 20.405(a)(1)(v) _ 50.73(a)(2)(iii) __ 50.73(a)(2)(x) Text)

LICENSEE CONTACT FOR THIS LER (12)

Name TELEP'ONE NUtEER AREA CODE Phil lau. HPES CD.D_rJ_inator Ext. 2957 841l5 415181-1218101 COMPLETE ONE LINE FOR EACH COMEDRE FAILURE DESCRIBED IN THIS REPORT (13)

CAUSE SYSTEM COMPONENT MANUFAC- REPORTABLE CAUSE SYSTEM COMPONENT MANUFAC- REPORTABLE

- IVRER TO NPRDS TURER TO NPRDS I I I I I I I i l l I I I I I I I I I I I I I I l i l I SUPPLEMENTAL REPORT EXPECTED (14) Erpected Month I Day I Year Submission lYes (If ve3. complete EXPICTED SUBMISSION DATE)

X l NO l l l_

ABSTRACT (Limit to 1400 spaces, i.e. approximately fifteen single-space typewritten lines) (16)

L At 0730 on April 6,1990 a Nuclear Station Operator (NS0) placed Train B of the Solid State Protection System I ($$PS) in test for maintenance to troubleshoot a defective test lamp. At 0905 it was identitleo that the

' voltage drop across the relay that was in series with the test lamp was greater than optimum value. This combined with a blue lens cap caused the light to appear dark in the florescent illumination of the room. At 0916 the NSO restored the Train B SSPS to normal by placing the Input Error Inhibit Switch in the " Normal" position and the Output Mode Selector Switch in the " Operate" position. This resulted in a Pressurizer Low Pressure and Main Steamine Low Pressure Safety Injection .(SI) initiation signal for Train B. Restoring inputs to normal prior to reestablishing the blocks with Psessurizer and Steamline pressures below the satpoints initiated an SI signal. The cause of this event was a programatic deficiency. Operating had no formal policy regarding manipulations of SSPS panel components following maintenance. A contributing cause to this event was personnel error. A program will be developed to provide specific guidance for restoring an SSPS train to operable status. Training will be conducted. The lens will be evaluated for replacement. A caution placard will be placed on the SSPS panels. There have been no previous similar occurrences.

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'( _ ' LICENSEE EVENT REPORT f LER)' TEXT'CQt[UMBHON Forn Rev L D_

FACI!.!TY,NAME (1)- DOCKET NUN ER (2) _LER_gggER .f 6) _ _ Pane (3)

Year // Sequential // Revision l

/j/j/j Number j//j/j

, / / NumbE_

Braldaged 2 0 1 5 1 0 1 0 l 0 1 61 51 7 g10 . 0l013 - 01 0 01 2 0F _0) A

, TEXT' Energy Industry Identification System (EIIS) codes are identified in the text as (XX]

Al PLANT CONDITIONS PRIOR TO EVENT:

Unit: Braldwood 2; Event Date: April 6, 1990; Event Time: 0916;

~Hody; N - Defueled; Rx Power: 07.;

~RCS (A0] Temperature / Pressure: Ambient / Atmospheric -

,lB. 'OESCRIPTION OF EVENT: .

There were no systems or components inoperable at the beginning of the event which contributed to the severity of

'th2 event.

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Instrument Maintenance Department Parsonnel were preparing to troubleshoot an apparent defective test lamp circuit in Train B Solid State Protection System (SSPS) (JE).

At approximately 0730 on April 6.1990 the Station Control Room Engineer (SCRE) (Licensed Senior Reactor Operator)-

authorized an Instrument Maintenance Technician (IHT) (non-licensed Instrument Technician) to troubleshot;t the  ;

cause of a defective test lamp in the Train B SSPS panel, 2PA10J. The SCRE assigned an extra Nuclear. Station Operator (NS0) (Licensed Reactor Operator) to assist the IHT.

The IHT and the NSO proceeded to the Unit 2 Auxiliary Electrical Equipment room (AEER) where Panel 2PA10J was'  !

-located. The INT asked the NSO to establish the conditions under which the test lamp was expected to illbainate.

Th) NSO notified the Unit 2 NSO and then pimd the Inpet Error Inhibit Switch -in the " Inhibit" position and the Output Mode Selector Switch in.the " TEST" position. The NSO provided the.IHT with a copy of Unit 2 Braidwood

(*parating Surveillance (2Bw05) 3.1.1-21 Unit Two SSPS, Reactor Trip Breaker, and Reactor Trip Bypass Breaker BI-Monthly (Staggered) Surveillance (Train B) af ter opening the procedure to the spot.where the test lamp dJficiency had been identified. The NSO then returned to the Control Room where he continued the performance of othtr unrelated activities. The INT began troubleshooting in the $$PS. Panel.

=AL,0905 the IHT completed his trouble shooting activities. The IHT Identified that the voltage drop across the

. relay that was in series with the test lamp was 9.47 VDC.. This was greater than the optimum value of 6.54 VDC.

With the slightly larger voltage drop combined with a blue lens cap the light appeared to be dark in the bright l . florescent illumination of the AEER. When the lens cap was shaded by the IHT holding his hand above the light it -

was evident that the bulb was lit, and the test circuit was functioning properly. The INT requested an NSO to perfonn the Post Maintenance Verification in accordance with his work package.

The SCRE assigned the same NSO who had performed the initial setup to assist the IHT. The extra NSD returned to ths AEER several minutes later. f At approximately 0914 the NSO verified that the lamp was illuminating when required during the testing sequence.

Tha IHT informed the NSO that he could restore the Train B $$PS to normal.

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LIEENSEE EVENT REPORT _(LERl TEXT EONTINUATION Form Rev 2.0 g~ FACILIJY NAME (1) DOCKET NUtBER (2) _LER nut 9ER (6) Page (3) j//jj/ Sequential

+

, Year //j/ Revision 4 Number fj/

//

1/f Numbt.E-

.Braldwood 2 0 1 5 l 0 1 0 1 0 1 41 51 7 910 - 0l0l3 - 0l 0 01 3 0F 01 4 TEAf- Energy Industry Identification System (E!IS) codes are identified in the text as (XX)

At 0916 the extra NSO informed the Unit 2 NSO that he was, restoring the Train B SSPS to normal. The extra NSO then placed the Input Error Inhibit Switch in the " Normal" position and the Output Mode Selector $ witch in the " Operate" position. This <esulted in a Pressuriter low Pressure and Main Steamline Low Pressure Safety Injectiun (SI) initiation signal for Train B. Placing the Output Mode Selector switch in the Test

p;sition, as the NSO did to setup the panel for trouble shooting, reset the Pressurizer low Pressure and Main Steamline Low Pressure 51 blocking circuitry for Train B. These circuits are normally blocked during shutdown when Pres?urizer pressure decreases below 1930 psig. Restoring inputs to normal prior to reestablishing the blocks with Pressurizer and Steamline pressures below the setpoints of 1829 psig and 640 psig respectively resulted in Train B $5PS initiating an 51 signal.

All equipment that was operable functioned as designed.

At 0922 the Train B SI was reset.

The appropriate NRC notification via the ENS phone system was made at 1029 pursuant to 10CRF50.72(b)(2)(li).

This event is being reported pursuant to 10CFR50.73(a)(2)(lv) - any event or condition that resulted in manual or automatic actuation of any Engineered Safety Feature. including the Reactor Protection System.

C. CAUSE OF EVENT:

The root cause of this event was a programatic deficiency. Operating Department had no formal policy regarding manipulations of $$PS panel components follo.#ing maintenance or during non-routine evolutions.

While the surveillance procedures provided detailed and accurate steps for normal panel testing they were not will sulted for setup and restoration following trouble shooting activities. During previous similar cctivities Operating personnel had either used the applicable portions of these procedures as guides or had relied on their knowledge and experience. The $$PS panels are complex and require manipulations that must be performed in a specific sequence to provide for the availability of wanted functions and to avoid inadvertant actuation of. undesired functions. Manipulation of components in these panels should only be made within the bounds of a structured policy. The failure to have this policy created the event.

A contributing cause to this event was a cognitive personnel error by the extra NSO. It is the responsibility _of the NSO to verify that actions taken are correct and appropriate prior to performing those ections. The failure of the extra NSO to perform the "self check" responsibility prior to performing actions that would return the Train D SSPS to an operable status contributed to the event.

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LIEENSEE EVENT REPORT (LER) TEXT CONTINUATION Form Rev 2.0 FACILITY, NAM (1) DOCKET NUMBER (2) _LER NUteER (6) Page (3)

J'

• Year ///, Sequential ///

fff Revision fj/

// Jumber /// Nuadi T_ ]

,Ja h wand 2 015101010141517 910 - OjjLl 3 - 01 0 01 4 07 _ _0]_4 TEXT Energy Industry Identification System (Ells) codes are identified its W text as (XX)

-D. SAFETY ANALYSIS:

This event had no ef fect on the safety of the plant or the public. All operable systems performed as d; signed. The reactor vessel was defueled.

Had this event occurred in Mode 1 at 100% power t.bere would still be no ef fect. The Intermediate Range High Flux and the Power Range High Flux Low Setpoint Reactor Trips would be re enabled and a reactor trip would occur. No S! or Main Steamline isolation would occur as Pressurizer Pressure and Main Steamline Pressure would be above the respective setpoints.

E. CORRECTIVE ACTIONS:

Automatic actions for operable systems were verified. it.e SI was reset and those components that rep;sitioned were returned to normal.

B:sid on the initial information associated with this event the personnel directly involved with this participated in a "Braidwood Station Error Evaluation Presentation" to identify root and contributing causes of this event. Based on the cc :lusions of this presentation the following actions will be taken:

1. A program will be daveloped to provide specific guidance for actions taken to remove an $$PS train from operable status and restoring an $$PS train to eperable status. This program will address both startup.

shutdown, and operational modes. This action will be tracked to completion by action item 457-200-90-00801.

2. A training tailgate session will t,e conducted to discuss this event with appropriate Operating personnel.

This action will be tracked to completion by action item 4S7-200-90-00802.

- 3. An evaluation will be conducted to determine if the blue lens on the master relsy test lamp can be replaced with a lens that provides greater visibility. This action will be tracked to completion by action item 457-200-90-00803.

V' 4. A placard will be placed on the $$PS panels cautioning the operator to ensure that the blocks are re-established prior to returning the Input Error Inhibit Switch to normal. This action will be tracked to completion by action item 4S7-200-90-00804.

F. PREVIOUS DCCURRENCES:

Thire have been no previous similar occurrences.

G. COMPONENT FAILURE DATA:

This event was not the result of component f ailure, nor did any components fall as a result of this event.

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