ML20044A158

LER 90-017-00:on 900518,loss of Both Trains of HPSI Occurred.Caused by Cognitive Failure by Licensed Operator. Personnel Counseled on Causes of Event & Importance of Recognizing When Event reportable.W/900618 Ltr

ML20044A158
Person / Time
Site:	Millstone
Issue date:	06/18/1990
From:	Hulme N, Scace S NORTHEAST NUCLEAR ENERGY CO., NORTHEAST UTILITIES
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-90-017, LER-90-17, MP-90-608, NUDOCS 9006280142
Download: ML20044A158 (5)

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10CFR50.73 2 vii)

U.S. Nuclear Regulatory Commission Document Control Desk Washington, D.C. 20555

Reference:

Facility Operating License No. NPF-49 Docket No. 50-423 Licensee Event Report 90-017-00 Gentlemen:

This letter forwards Licensee Event Report 90-017-00 submitted pursuant to:

10CFR50.73(a)(2)(1), any operation or condition prohibited by the plant's Technical Specifications,10CFR50.73(a)(2)(v), any event or condition that alone could have prevented the fulfillment of the safet consequences of an accident, and 10bs function of systems that are needed to mit or condition caused two independent trains to become inoperable in a single system.

Very truly yours, NORTHEAST NUCLEAR ENERGY COMPANY 4)km Steph'en E/kcacew.

Director, Millstone Station SES/NDH:mo -

Attachment:

LER 90-017-00 l l!

u ec: T. T. Martin, Region 1 Administrator '

W. J.-Raymond, Senior Resident inspector, Millstone Unit Nos.1, 2 and 3 D. H. Jaffe, NRC Project Manager, Millstone Unit No. 3 ,

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""] vt s ne v.. eme.i. txpectro sveuissoN DATri 7 No JATE 05) l l l As sin Ac t mma io s.x . c... . . ...,m.i., ,,,i n ..no....... iy,.. i.n ,n.. oo On hiny 16,1990, at 1805 hours0.0209 days <br />0.501 hours <br />0.00298 weeks <br />6.868025e-4 months <br />, while shut down m hiode 3 (Hot Standby), at 460 degrees Fahrenheit and 900 psia, Safety injection Cold Leg hinster Isolation Yahe 3SlH'h1V8835 (MY8835) was closed to fill safety 4 injection accumulators. A licensed operator specifically assigned to the task incorrectly followed a procedure that was meant to be used onh if the reactor is shut down with temperature less than 350 degrees Fahrenheit.  ;

At 1800 hours0.0208 days <br />0.5 hours <br />0.00298 weeks <br />6.849e-4 months <br />, on hiay 18, 1490, the accumulator fill operation was completed, but the operator failed to '

reopen h1V8835 as required by the procedure. The error was discovered at 2:17 hours, Aiay 18,1990, by the Reactor Operator while reviewing the ESF status annunciators. At this time, h1V8835 was reopened. Both High Pressure Safety injection trains were inoperable for 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br />,10 minutes.

The root cause was a cogmtive failure on the part of the beensed operator assigned to the evolution. The operator failed to observe a procedure note which states the procedure can only be utilized while the plant is  !

shut down with temperature less than 350 degrees Fahrenheit. The operator also did not follow the procedure when he failed to reopen h1V8835 after filhng the accumulators. Corrective actions include counseling of the l individuals invoked, disseminaung information on the use of dedicated operators and ensunnp Technical Specification issues are communicated to the appropnate levels of supervision.

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1. Dewmtion of hent On May 18,1990, at 1805 hours0.0209 days <br />0.501 hours <br />0.00298 weeks <br />6.868025e-4 months <br /> with the plant shut down in Mode 3 (Hot Standby), at a temperature of 460 degrees Fahrenheit and a pressure of 900 psia, Safety injection Cold Let Master Isolation Vahe 3SlH'MY8835 (MV8835) was closed to fill safety injection accumulators. A licensed operator specifically assigned to the task incorrectly followed a procedure that was meant to be used only if the reactor b shut down with a temperature less than 350 degrees Fahrenheit. Closure of MY8835 isolated '

the discharge of both safety iniection pumps from the RCS cold leg injection path. This made both High Pressure Safety injection (f! PSI) trains inoperable, and violated the Technical Specihcation Limiting Condition for Operation for Emergency Core Coohng Systems.

I At 1820 hours0.0211 days <br />0.506 hours <br />0.00301 weeks <br />6.9251e-4 months <br />, May 18, 1990, the accumulator fill operation was completed, but the operator failed to reopen MV8835 as required by the procedure. The error was discovered at 2217 hours0.0257 days <br />0.616 hours <br />0.00367 weeks <br />8.435685e-4 months <br />, May 18, 1990, by the Reactor Operator while he was reviewmp the ESF status annunciators. At this time, MV8835 was reopened. The length of time that the high pressure safety injection trains were Anoperable was 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br />, 12 minutes.

11. Cnme of Event The root cause of the event was a cognitive failure on the part of the licensed operator specifically assigned to the evolution. The licensed operator failed to observe a note in the procedure which states the procedure can only be utilized while the plant is shut down with temperature less than 350 degrees Fahrenheit. - The licensed operator also did not follow the procedure when he failed to reopen MYS835 aher filhng the accumulators.

A lapse in communication also contributed to MV8835 remaining closed for over 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br />. The licensed operator who closed MV8835 was assisting the on shift Senior Control Operator (SCO) dunng a busy period in the plant startup. After the evolution had sterted, the SCO recognized that the wrong procedure section was being used. The SCO decided to continue with the evolution because the licensed operator could function as a dedicated operator. The SCO assumed that the licensed operator understood this. However, since this role was not explicitly communicated to him, the licensed opera;or was not aware that he was to assume the role of a dedicated operator.

!!!, Annivsk of Event l This event is reportable pursuant to: 10CFR50.73(a)(2)(i), any event or condition prohibited by the l Technical Specifications,10CFR50.73(a)(2)(v), as an event or condition that alone could have prevented l the fulfillment of the safety function of structures or systems needed to mitigate the consequences of an accident, and 10CFR50.73(a)(2)(vii), any event where a single cause or condition caused two l independent trnins to become inoperable in a single system.

This event was not reported immediately per the requirements of 10CFR50.72(b)(2)(iii) due to an SCO oversight. The SCO on shift at the time MV8835 was found closed did not recognize the reportability potential of this event at the time. After discussions with shift su ervisory personnel, it was evidem that this event required immediate notification. The 10CFR50.72(b)(.p)(iii)noutication was completed at 1450 hours0.0168 days <br />0.403 hours <br />0.0024 weeks <br />5.51725e-4 months <br /> on May 20, 1990.

!- The procedure for safety injection (SI) requires a verification of high pressure $1 flow. MY8835 would i have been opened at this time as the response to a no-flow condition is to align valves. Dunng the time i MV8835 was closed, the reactor had been shut down for 8 days, so there was little decay heat in the I reactor core as compared to that expected for the design basis accident at full power. However, in the event core exit thermocouples chd indicate degraded or inadequate core cooling, the very first step in the procedures for these conditions is to verify proper valve abpnment. Therefore, this event posed no significant danger to the health and safety of the pubhc.

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For long term corrective action, the following measuro were taken:

• Operators directly involved with this event were removed from licensmg duties and counseled by the Operations Manager on the causes of the event and on the importance of recognizing when an event is reportable. Included m the counsehng was the importance of notifying the Shift Supervisor of any conditions that do not fully comply with Technical Specihcations.

Interim guidance was issued to disseminate information on using dedicated operators and to ensure timely resolution of Technical Specification issues.

• The utte for the misused procedure was changed to include the fact it shall be used only if the i reactor is shut down with temperature less than 350 degrees Fahrenheit.

l l Procedures that provide guidance for operators assigned to specific tasks to perform equivalent safety functions will be reviewed and revised as needed. Also, a copy of this LER will be touted to all shift ,

pert.onnel for lessons learned,

\', Additional Inintmntion

There have been no sirnilar events in which a cognitive failure of plant personnel resulted in two trains of l safety related equipment becoming inoperable.

The following LERs discuss events in which equipment was rendered inoperable without logging into the associated action statemem and performing the compensatory action. However, the correcuve actions j taken for these LERs would not have prevented this event from occurring since they were targeted at the underlying concerns of each event. A review of the similar events and associated corrective actions did not indicate an) programmatic shortcomings.

LER No. Title and Desermtion i

SS-006 " Violation of Technicai Specification - Mode Change Without Required ECCS Equipment" On January 30,1986, at 0820 hours0.00949 days <br />0.228 hours <br />0.00136 weeks <br />3.1201e-4 months <br />, while in Mode 3, it was determined that only one centrifugal charging pump was operable. During cooldown, the " A" Charping Pump I started. There was an immediate alarm on the mam board for "A* oil cooler low flow.

An operator sent to check the cooling water imeup discovered that the cooling water was not imed up properly for the " A" Pump. The root cause of the event was procedure inadequacy, compounded by poor communications within the Operations Deparunent, The plant heatup procedure was changed to require that the second pump be declared operable only after it has actually been run. The charging and letdown system procedure l was changed to tequire that when one of the pumps is rendered inoperable, tags will be hung on the main board to identify the inoperable pump.

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• i, At 0333 hours0.00385 days <br />0.0925 hours <br />5.505952e-4 weeks <br />1.267065e-4 months <br /> on April 25.1988, at 350 degrees and 49$ psia, the control switches for both unins of motor driven auxiliary feedwater pumps and train A supplementary leak collection and release *,ystem fan were left in pull-to-lock during a change from hiode 4 (Hot Shutdown) to hiode 3 (Hot Standby). Root cause for each event was operator error.

As corrective action, the plant heatup procedure was modified to sequence the Auxiliary i Feedwater System alignment for system operability and to require a review of bypass annunciators prior to changmg modes. Guidance was provided to ensure that appropriate los entnes are made whenever equipment is placed in PTL. Also on-shift personnel were briefed on proper review of equipment status prior to mode changes.89-007

• Control Building Ventilation Not Placed in Fihered Recirculation Due to Personnel Error

• i On April 3,1989 at 1400 hours0.0162 days <br />0.389 hours <br />0.00231 weeks <br />5.327e-4 months <br />, with the plant in hiode 1. It was discovered that the control building ventilation system was not in filtered recirculation. The root cause of this event was personnel error due to a cognitive failure on the part of the Senior Control Operator.

As corrective action, the Operations Department policy was revised to require any compensatory action required by an LCO Action Statement with a time hmit less than 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br />, be completed pnor to authorizing the work or surveillances.

Ells Codes

$ntgm Comnonents High Pressure Isolation Yalve - ISV Salety injection - BQ i

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