ML20044C923

LER 93-004-00:on 930405,primary Containment & Reactor Vessel Isolation Control Sys Actuation Occurred During Test of NSSSS-refueling Area Ventilation Exhaust Duct.Caused by Personnel Error.Technician counseled.W/930505 Ltr

ML20044C923
Person / Time
Site:	Limerick
Issue date:	05/05/1993
From:	Doering J PECO ENERGY CO., (FORMERLY PHILADELPHIA ELECTRIC
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-93-004-02, LER-93-4-2, NUDOCS 9305140076
Download: ML20044C923 (5)

Text

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10 CFR 50.73 l

PHILADELPHIA ELECTRIC COMPANY UMERICK GENERATING STATTON P. O. BOX 2300 SANATOGA, PA 19464-2300  ;

(215) 327-1200 EXT. 2000 J. DOERING. JR. May 5,1993

$7ja%8,,yg ym Docket No. 50-352 i License No. NPF-39 l

i U.S. Nuclear Regulatory Commission Attn: Document Control Desk  ;

Washington, DC 20555 *

SUBJECT:

Licensee Event Report Limerick Generatina Station - Unit 1 ,

1 This LER reports an inadvertent Primary Containment and Reactor Vessel isolation Control System actuation, an Engineered Safety Feature, as a result of personnel error during performance of a Surveillance Test procedure.

Reference:

Docket No. 50-352 Report Number: 1-93-004 l Revision Number: 00 Evert Date: April 5, 1993 Report Date: May 5,1993 Facility: Limerick Generating Station P.O. Box 2300, Sanatoga, PA 19464-2300 This LER is being submitted pursuant to the requirements of 10 CFR 50.73(a)(2)(iv).

l Very truly yours,  !

DCS:cah cc: T. T. Martin, Administrator, Region I, USNRC N. S. Perry, USNRC Senior Resident Inspector, LGS l

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On April 5, 1993, at 0900 hours0.0104 days <br />0.25 hours <br />0.00149 weeks <br />3.4245e-4 months <br />, while performing Unit 1 Surveillance Test (ST) 1 procedure ST-2-026-624-1, "NSSSS-Refueling Area Ventilation Exhaust Duct Radiation-High; Division II A, Channel C Functional lest (RISH-26-1K610C) " a

, station Instrumentation and Controls (l&C) technicians inadvertently caused a Unit 1 'A' channel Refuel Floor high radiation isolation signal. The isolation ,

signal resulted in automatic actuation of portions of the Primary Containment I

~ and Reactor Vessel Isolation Control System (PCRVICS), an Engineered Safety Feature (ESF). The isolation signal resulted in the automatic closure of

Primary Containment H2/02 Combustible Gas Analyzer' Sample Line Isolation Valves l SV-57-133, 183, and 191. Main Control Room (MCR) personnel verified all j appropriate isolations. The actual and potential consequences of this event were minimal and there was no release of radioactive material to the environment as a result of this event. The cause of this event was personnel error in that l an I&C technician manipulated incorrect equipment during performance of the ST procedure. The contributing components of this personnel error included less than adequate self-checking and failure to utilize repeat back during procedure performance. The involved technician was counseled on the importance of self-checking and proper communications. All I&C technitlans are currently being given a newly implemented On the Job Training module on self-check and self-  ;

verification. I&C supervision hcve increased field observations of technicians '

i to ensure that the principles of self-checking are being implemented.

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Unit Conditions Prior to the Event:

Unit I was in-0pe' rational Condition 1 (Power Operation) at 100% power at the '

time of this event.

• i There were no structures, systems, or components out of service that contributed i to this event. .

Description of the Event:

On April 5, 1993, at 0900 hours0.0104 days <br />0.25 hours <br />0.00149 weeks <br />3.4245e-4 months <br />, while performing Unit 1 Surveillance Test (ST) procedure ST-2-026-624-2, "NSSSS-Refueling Area Ventilation Exhaust Duct Radiation-High; Division II A, Channel C Functional Test (RISH-26-1K610C)," a  ;

station Instrumentation and Controls (I&C) technician inadvertently caused a Unit 1 'A' channel Refuel Floor high radiation isolation signal. The isolation '

signal resulted in an automatic actuation of portions of the Primary Containment ,

and Reactor Vessel Isolation Control System (PCRVICS), an Engineered Safety i Feature (ESF).

"e. isolation signal resulted in the automatic closure of Primary Containment i H2/02 Combustible Gas Analyzer (CGA) (EIIS:BB) Sample Line Isolation Valves SV- '57-133, 183, and 191. This caused the CGA, which monitors the primary containment atmosphere, to isolate and recirculate its gas flows. '

i Main Control Room (MCR) personnel verified all appropriate isolations in ,

accordance with General Plant (GP) procedure GP-8, " Primary And Secondary Containment Isolation Verification and Reset." The 1&C technician involved +

notified the MCR personnel of the nature of the inadvertent isolations. After {

verifying that no high radiation condition existed, MCR personnel reset the isolation signal in accordance with procedure GP-8 at 0916 hours0.0106 days <br />0.254 hours <br />0.00151 weeks <br />3.48538e-4 months <br />. ,

A four hour notification to the NRC was made in accordance with the requirements of 10CFR50.72(a)(2)(ii) at 1132 hours0.0131 days <br />0.314 hours <br />0.00187 weeks <br />4.30726e-4 months <br /> on April 5, 1993, since this event  ;

resulted in the automatic actuation of an ESF. This written report is being- l submitted in accordance with 10CFR50.73(a)(2)(iv).

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Analysis of the Event:

The actual and potential consequences of this event were minimal and there was no release of radioactive material to the environment as a result of this event.

All systems responded as designed in response to the inadvertent high radiation isolation signal. The redundant CGA was operable and available to sample from either the drywell or the suppression pool air space during this event. There were no immediate operator actions required during this event to ensure continued safe operation of the plant and plant equipment.

Immediate and follow-up actions for this type of event, inadvertent Refuel floor  !

high radiation isolation, are provided in procedure GP-8. Licensed MCR goo. a .

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simulated plant transients of this type. This training reinforces immediate i operator actions,~ minimizing the time that systems are isolated, and reducing j the impact on the plant. Therefore, as a result of this adequate procedural  ;

guidance, training, prompt operator actions, and operable redundant equipment, t the actual and potential consequences of this type of event were minimal. .

Cause of the Event:

The cause of this event was personnel error in that an I&C technician  !

manipulated incorrect equipment during performance of the ST procedure. The  !

involved technicians were planning to perform tests cn both Division I and Division II equipment on April 5, 1993. Normal practice is to perform Division {

I testing first. In this instance, however, while the I&C technician in the Auxiliary Equipment Room (AER) was preparing to perform Division I testing, the '

I&C technician in the MCR directed him to perform Division 11 testing first due ,

to the availability of operations support personnel needed to support the  ;

Division 11 task. The technician in the AER acknowledged and understood the  !

direction'but proceeded to implement the test on Division I equipment. This  !

caused the Division I isolation signal and resultant ESF actuations. The  !

contributing components of this personnel error included less than adequate i self-checking and failure to utilize repeat back during procedure performance. l An interview was conducted on April 28, 1993, with 1&C personnel involved in j recent personnel error events, to determine if any additional causal factors  !

could be identified. From the interview we determined that in general the  !

mechanics of self-checking were not clearly defined for the technicians. During  !

the interview, the technician involved recalled having several personal events l which may have contributed to his decreased attentiveness. Interaction between i the technician and supervision did not serve to identify the potential impact of l these events. Additionally the interview revealed that On-the-Job Training '

(0JT) during procedure performance may have resulted in unnecessary distractions <

for the technicians performing the work.

Corrective Actions: i The involved technician was counseled on the importance of self-checking and proper communication. All l&C technicians are currently being given a newly implemented OJT module on self-checking and self-verification. This module reinforces the importance and mechanics of self-checking to reduce the likelihood of these types of events occurring. All 1&C technicians are expected to complete the OJT module by June 30, 1993. Additionally, I&C Supervision will reevaluate the OJT process to ensure minimal impact on the work being performed and observed.

A memorandum will be issued by May 31, 1993, to all first line supervisors at Limerick emphasizing the lessons learned from this event and the need for increased sensitivity to the potential performance impact of external personal i l

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Previous Similar Occurrences:

i Unit 1 LERs 1-92-017,1-91-020, and 1-89-048 reported ESF actuations'due to -

personnel error involving failure to perform self-check. Corrective actions for  :

these events included individual counseling, all hands meetings and enhanced i training. The enhanced training was in the process of being implemented at the ,

time of this event and therefore was not able to prevent this occurrence.

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