ML20043G071

LER 90-005-00:on 900514,unplanned Closure of HPCI Isolation Valve Occurred During Maint Surveillance Test.Caused by Technician Placing RCIC Instead of HPCI Test Switch to Test Position.Personnel Counseled & trained.W/900613 Ltr

ML20043G071
Person / Time
Site:	Brunswick
Issue date:	06/13/1990
From:	Harness J, Jones T CAROLINA POWER & LIGHT CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
BSEP-90-0441, BSEP-90-441, LER-90-005-03, LER-90-5-3, NUDOCS 9006190021
Download: ML20043G071 (7)

Text

r~

-]

'g*.

Carolina Power & Light Company Brunswick Nuclear Project P. O. Box 10429 Southport, N.C. 28461 0429 June 13, 1990 FILE: B09 13510C 10CFR50.73 SERIAL: BSEP/90 0441 1

U.S. Nuclear Regulatory Commission ATTN: Document Control Desk Washingtou, D. C. 20555 BRUNSWICK STEAM ELECTRIC PLANT UNIT 2 DOCKET NO. 50 324 LICENSE NO. DPR 62 LICENSEE ENENT REPORT 2-90-005 Gentlemen:'

In accordance with Title 10 of the Code of Federal Regulations, the enclosed Licensee Event Report is submitted. This report fulfills the requirement for a written report within thirty (30) days of a reportable occurrence and is submitted in accordance with the format set forth in NUREG-1022, September 1983.

Very truly yours, i dy(*

• J. L. Harness, General Manager Brunswick Nuclear Project l

THJ/

l Enclosure  !

cc: Mr. S. D. Ebneter Mr. N. B. Le BSEP NRC Resident Office i

900613 4 9006190021ADOCK PDR PDC 03000324 l S

'll a

t e, . C .a =m. v ,,,,,,,t o o,,s , ,s .

• 8*' * -

8 2.ais a sow

• Estevattb outr>Ih ,43 gesposest to couhv tYtu TMil To'.f."i, ,iEWo',','o'e*f.o"i.' N!i..

l tE"ti .7To'41 UCENSEE EVENT REPORT (LER)

"Eso",'.'*o".'! a'J?J,"o'. *U"'"*" a'.A L',Ms '"

D'. "ti: "#f,'ont ' f!'.", JJ"t'C%!""

. ,6,t, n, C.i t t. .. -

! Brunswick Steam Electric Plant Unit 2 o l6 l 010 l 0 p l 214 1 l0Fl 0l5 Unplanned Closure of IIPCI Isolation Valve Due to l'ersonnel Error During Surveillance Test.

OvtWt Dart toi Lth esteet h tot 20808tt Datttil OtMtm 8 ACittfitt novotvsp et t#04tm Dat vt A81 VIAh $g"$ n 6 [,",$, WOhtm Det vtam 'at.4evv hawls Docktt huwetatSi 01610l0lo; ; l 0

0l 5 1l4 9 9l0 0l0l5 0l 0 0l6 1l 3 9l0 o l6l0 l0 ioi l l 7

,,,,,,,,,,, tais ateoat n evenimo evneva=, eo tai nioviatut=re c, ie C,a i ,c . . .oa. , ,, ou

"' M 4 216i Se G#tei y se 736.Ittitel 93 >1161 i

g _

m mi.imm

~~'

es mi.im T' = n nsn.i

[ n tu.i r os, i 0, es .se ,n n.,

es .. .,

se ..n . ,

_ g,=,,,, .. .g t m esminn i w twanu u n.uan..nai m ai n aosuninni se ,wo n.i ee n.imi..nei se ess inn.i m twan.i se ni.nrn.

40C60688 CONT ACT 90A TMit tift Hip j was tittenone wvuota i anta Coot Theresa M. Jones, Regulatory Compliance Specialist 9 1 1l9 4 5 17 l-l2 p l3l9 conspiets owt teset toa I ACM teaspoestWT f altunt DieCaletD ne TMel StPont (13i Wa Civlt Sv$ttw COMPDNt ht gC m{0 Pm s' CAUlf Svit t M COW'OhtNt "$N$0 "fo0mia pn go l l

1 o

i I I l l I I i 1 I I I I I l l l l l l l 1 I i l l l 1 il surettutstat mapont empleito nei woht a Dav vt**

, {

eve., won u itS II* v.s remos.n ,RelCtt0 Sven,tSSION Ce fli NO l l l

.nsu. Ct<< -,n,,.oo ... .. . ..,,,. . ,no.

(

At 0840 on May 14, 1990, an unplanned closure of the HPCI Inboard Steam Isolation Valve, 2-E41-F002, occurred during a maintenance j surveillance test (NSTs). The event was caused by inattention to I detail on the part of an I&C technician who placed the RCIC " test" (

switch to test instead of the HPCI " test" as stated in the MST. I Factors that contributed to this event are switch layout, common annunciators for HPCI and RCIC steam leak detection test status and the recent revision of the procedure to utilize the test switches.

The Unit 1 and Unit 2 MSTs will be revised to include an independent verification of the switch placement. In addition, the same or similar action will be evaluated for use on the NSSS/RPS -

panels. During this event the reactor remained at 100% power and the ADS, RHR/LPCI, CS and RCIC systems were operable in standby readiness. This event had minimal safety significance as the plant is analyzed for and designed to respond to a HPCI failure.

1 OfflC Pese We 16 eel

g u ... u m, . e. _ ,, ,,,,,,, ,,,,,,,,

, . , , n,m. .r.

UCENSEE EVENT REPORT (LER) Wo",'d#,%*#iO.MM'5%o'*d,'%i"lTJ.' ,T.",.1"j!

. TEXT CONTINUATION 1*,7' 4 ",'o'A!Tfn'dagi'.';Te'"yj3!!i,".'linifi 0?t.'.'A'Jt"MA"~'.!=?'.41"&.03t*?a OF MAh&GlMENT AND $48DGET hA&MINGTch DC 70

'ACMIT 884884 H6 DOCatt asianeta (I' In NMin $1 pm 3 Brunswick Steam Electric Plant "'" " W a" DJnN vsxt n 0 l6 l 0 l 0 l 0 [3 1 2 L 910 -

0lOl5 -

0l 0 Ol 2 OF 0l5

. sm.wanc s -amawnn EVENT Unplanned closure of the HPCI Inboard 8 team Isolation Valve, 2-E41-FOO2, during maintenance surveillance test (M8T) 2M8T-NPCI13M, HPCI 8 team Leak Detection Channel Functional Test.

INITIAL CONDITIONS ]

On May 14, 1990, the Unit 2 reactor was at 100%, the HPCI, RCIC, ADS, RHR/LPCI and C8 systems were operable in standby readiness.

2M8T-NPCI13M was in progress.

EVENT DESCRIPTION At 0840 on May 14, 1990, an inadvertent isolation signal on the B logic train of the HPCI steam leak detection circuitry resulted in the automatic closure of 2-E41-F002. Operations personnel in the control room received annunciation identifying the isolation and immediately contacted the Instrumentation and Centrol (IEC) personnel performing the M8T. At that time, it was determined that the RCIC steam leak detection system B logic test switch, a switch which requires a key to operate, had been placed in test instead CC l the corresponding HPCI B logic test switch. At 0845 the RCIC test i switch was returned to its appropriate position and at 0857 the  !

HPCI system was returned to standby line up. The MST was continued and completed at 1143, satisfactorily. 1 EVENT INVESTIGATION /CAUSE This event was caused by inattention to detail on the part of the

IEC technician who placed the RCIC test switch to Htest" instead of the NPCI test switch, as stated in step 7.8.1 of the MST.

Subsequent steps dirented the technician to verify that the proper annunciation had alarmed, to lift the positive and negative thermocouple leads associated with the Ambient Temperature Point Module to be tested, E41-TS-N602B in Panel H12-P614, to connect a millivolt source to the positive and negative terminals and to slowly raise the millivolt signal until the module trip indicating

. light illuminated. It was at that point that the HPCI isolation I signal-was generated and the valve, 2-E41-F002, closed. j There are three factors contributing to this error I i

1. Test switch layout.

2. Common annunciators for HPCI and RCIC steam leak detection.

l OfRC F.nn SIGA 16491

=, , a= == = =aa . -, .

IkP6k&$ 4P30Z3 uCENSEE EVENT REPORT (LER) gn',0,f,rgtp,$,,$?;;di,'tej*,7 ,T,"4tig TEXT CONTINUATION $74*Jo'AlttD'M MD',M*10lj,if '",' &gn J

Oft.'l.T.JJi""d,'JE,*,o*N 3"Tc?'MW&,0603M?,li Of MANAGEwtN1 AND DVDGlf.tn ASHINGTO.s.DC WILITV W (1) DOCEtt .sg.neta (16 ten Wmte del P&DS 436 Brunswick Steam Electric Plant vuxv tr =w.n. wwei amamm 0 l5 l 0 l 0 l 0 l 3 2 [. 9 l0 0 l0l 5 0l0 0l3 or 0l5

3. Procedure recently revised to utilise test switches instead of isolating HPCI.

1 The following is a discussion of each factor.

1.) Test switch layout.

The HPCI and RCIC steam leak detection test switches are located on the same panel, alternating, in a straight line (ie, RCIC A, HPCI A, RCIC B, HPCI B). The key cores are identical and the same key fits each. In addition, the labeling is very similar, in that it is the same sise, color and character typs. The combination of these factors combined to create a human factor deficiency which contributed to the positioning of the wrong switch.

2.) Common Annunciators for HPCI and RCIC steam leak detection.

, step 7.a.2 of the MsT directs the technicians performing the test tot verify annunciator STEAM LEAR DET B I4GIC IN TEST STATUS (A-02 2-7) alarms.

HPCI and RCIC share the same annunciators for A and B steam leak detection test switch status, therefore, even though the B Logic alarm was verified to have annunciated it was not possible to tell that the RCIC test switch had been utilised instead of the NPCI switch.

l 3.)

The practice of utilising the test switches is relatively new (ie, since March 15, 1990). It was begun to reduce the amount of time NPCI is out of service because of testing. Each of the involved technicians had performed the test successfully in March and April but minimal experience with the involved switches, the switch layout and an inattention to detail combined to contribute l to the event.

CORRECTIVE ACTIONS Personnel involved with the event have been counseled with an emphasis on attention to detail. Appropriate personnel will receive training on this event. To change the layout of the switches or to separate out the annunciators between HPCI and RCIC ,

steam leak detection logic status is not feasible. The Unit 1 and Unit 2 MSTs will be revised to include an independent verification 1 of the switch placement.

wac e sena .i

=,,,c,,==== v4 a m .u6. .

. . ., s a,m .ws

, uCENSEE EVENT REPORT (LEm glg';',WR,p,$,J'5?d',,vgepi;+g ,w,,ygg

. TEXT CONTINUAT60N  !?,"",',",'o',,%"' anti *taf'JM,'e'"*,'jM"' agn 0?W,'it".'Ji""a'A**:"On?'n*a '7f,1?

OF MANAGlut N1 AND DVDGEY,m A&MINGTON. DC 20ht3

, 94CettTV Inaut au DOCatti seuesta las Pact tai Lle sMth les

,,,, .iovie. 6 ...c..

Brunswick Steam Electric Plant * * "

• o l6 lc l0 l0 l 3l2 f 9l 0 -

0l 0l 5 -

q0 0l4 or 0l5 vixt um . w. ==c w ma.im l

In addition to the above action, the same or similar action will to be evaluated for use on the Nuclear Steam Supply Shutoff (NSSS)/ Reactor Protection System (RPS) panels (P609 and P611). Both panel P609 and P611 have seven, adjacent key lock l switches for each logic train - of seven dif ferent systems (see attached system listing). Panel P609 has the A and C logic test switches and P611 has the B and D logic test switches resulting in fourteen test switches on each panel for seven different systems i that utilire the same key. l 1

EVENT ASSESSMENT This event had minimal safety significance as the plant is an=. lysed for and designed to respond to a HPCI failure. HPOL was returned to service in 17 minutes. Throughout the event, ADS and the low pressure emergency core cooling systems (ie, CS and RHR/LPCI) were available, in standby readiness, as back up systems to HPCI. This is considered an isolated event.

1 i

I wac e as.* meo

= ,== A a .un.Au.2uat _ ,, ,,,,,,, ,, ,,,,,

w.m www

.' uCENSEE EVENT REPORT (LER) g'gn',D,f,,uMJQ,$'M?,"*d? W'7,T,",.',"'!

TEXT CONT 6NUATION f,77,",'A%5 fan"j ag?'.".!!,'c7','!Ji' M' l# tin a'PE3L*?'Ta'S a',!"d'?'b%M, Op anas.AGluthi Atep suDGE1 C

1. ASHthG10h.DC 30603 Mi.li

'AS4lTV GRAME 416 DOCtti peuteln ggi L99 9sWeett 46) P&OR (36 visa " $'f.l'.

, M*.?

Brunswick Steam Electric Plant 0l6jol0l0fl2[+ O0 g Og5 or 0 l5 9l0 _

0 l 0l 5 _

texter w .sse w necs maaw nn SYSTEMS WITH KEYLOCK SWITCHES ON P609 AND Pill RER ISOLATION M8L DRAIN RWCU LOW CONDEN8ER VACUUM REACTOR SAMPLE DW DRAIN GA8 VENT EII8. CODES HPCI High Pressure Coolant Injection BJ RER/LPCI Residual Heat Removal / Low BO Pressure Coolant Injection C8 Core Spray BM RCIC Reactor Core Isolation BN Cooling ADS Automatic Depressurisation None System MSL Main Steam Line hone RWCU Reactor Water Cleanup CE Condenser System SG Reactor Sample System KN DW Drywell Drain System None Ltc tonn 88tA 1649)

............_.__.__ . _ . _ . _ , _