ML20044E617

LER 93-006-00:on 930420,Unit 2 Nso Inadvertently Started Unit 1 DG When Attempting to Start Shared (1/2) Dg.Caused by Personnel Error.Unit 1 DG Shut Down & 1/2 DG Started & Loaded successfully.W/930514 Ltr

ML20044E617
Person / Time
Site:	Quad Cities
Issue date:	05/14/1993
From:	Bax R, Laughlin S COMMONWEALTH EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-93-006-03, LER-93-6-3, RLB-93-076, RLB-93-76, NUDOCS 9305250240
Download: ML20044E617 (4)

Text

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/ x Commonwealth Edison ,

a ) Qua:! Cities Nuclear Power Station rg f y 22710 206 Avenue North y *

\ / Corcova. Illinois 61242-9740 '

\_/ Telephone 309/654 2241 RLB-93-076 May 14, 1993 U. S. Nuclear Regulatory Commission -

Document Control Desk Washington, DC 20555

Reference:

Quad Cities Nuclear Power Station Docket Number 50-254, DPR-29, Unit One Enclosed is Licensee Event Report (LER)93-006, Revision 00, for Quad Cities Nuclear Power Station.

This report is submitted in accordance with the requirements of the Code of Federal Regulations, Title 10, Part 50.73(a)(2)(iv). The licensee shall report any event or condition that resulted in manual or automatic actuation of any Engineered Safety Feature.

Respectfully, COMMONWEALTH EDISON COMPANY QUAD CITIES NUCLEAR POWER STATION R. L. Bax h

Station Manager RLB/TB/pim Enclosure cc: J. Schrage T. Taylor 1NPO Records Center NRC Region III 240033 l

STMcR\07693.RLB .

/ I 9305250240 930514 I PDR ADOCK 05000254 v i S ppg

LICENSEE EVENT REPORT (LER)

Term Rev M Focility Name (1) Docket Number (2) .fjoe (3)

Quad Cities Unit One 015101010121514 1!ofl0l3 Title (4)

Inadvertent Start Of The U-1 Diesel Generator Due To A Personnel Error Event Date (S) LER Number (6) Report Date (7) Other Facilities Involved (B)

Month Day Year Year / sequential /// Revision Month Day Year facility Names Docket Number (s)

/j fff Number /// Number 01 51 01 01 01 1 1 01 51 01 01 01 I l

_DJ 4 21 0 91 3 91 3 0l0l6 0l0 015 11 4 91 3 THIs REPORT IS SUBMITTED PUR$uANT TO THE REQUIREMENTS OF 10CFR OPNM MODE (9) 4 20.402(b) _ 20.405(c) _jL 50.73(a)(2)(iv) _ 73.71(b)

POWER _ 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) _ Other (Specify

! 6! 0 (10) 1 __ 20.405(a)(1)(iii) _._ 50.73(a)(2)(i) _ 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

//////}///////////////////

/

f

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

LICENSEE CONTACT FOR THIs LER (12)  !

Mame TELEPHONE NUMBER {

I AREA c0DE Steve Lauchlin. Tech Staff Enoineer Ext. 2029 310l9 615141-l212141 COMPLETE ONE LINE FOR EACH COMFSN NT FAILURE DESCRIBED IN THIs REPORT (13)

CAUsE SYSTEM COMPONENT MANUFAC- REPORfABLE CAusE SYSTEM COMPONENT MANUFAC- REPORTABLE t TURER TO NPPa$._ TURER TO NPRDS j A l l I l l l I l l l 1 l l l f

1 1 I I I I I I I I I I I I SUPPLEMENTAL REPURT EXPECTED (14) Expected Month l Day l YtBI Submission lyes (If ves. complete EXPECTED SUBMISSION DATE) X l NO 1 l1 i 1 [

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

ABSTRACT:

On April 20, 1993, at 0215 hours0.00249 days <br />0.0597 hours <br />3.554894e-4 weeks <br />8.18075e-5 months <br />, Unit One was in the RUN mode at 100 percent of rated core thermal power. At this time, the Unit Two Nuclear Station Operator  ;

(N50) inadvertently started the Unit One Diesel Generator (DG) [EK] when attempting  !

to start the shared (1/2) DG. The Unit One DG was shut down, and the 1/2 DG  ;

subsequently started successfully.

The cause of this event is personnel error. Corrective actions include compiling a list of evolutions where operators can " fall" and operate a wrong switch / breaker, presented to heighten the level of operator awareness at a department tailgate meeting. Further, performing Self Check techniques throughout evolutions will be reinforced. '

This report is submitted in accordance with 10CFP,50.73(a)(2)(iv), which states in )

part that the licensee shall report any event or condition that resulted in manual j or automatic actuation of any Engineered Safety Feature unless the initiation 1 occurred as a result of preplanned operations or testing. '

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-. - - - - , - - . - , - , , . . . , , . , w.., n.-n, ,- ,

I LIrENSEE EVENT REPORT (LER) TEXT r0NTINUATION Form Rev 2.0

, FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) Pace (3) 2 Year j/// sequential /// Revision  ;

ff fff '

/// Number /// Number Ouad Cities Unit One 0 1 5 1 0 1 0 l 0 l 21 51 4 913 - 010l6 - 0l0 01 2 0F 01 3 TEXT Energy Industry Identification system (EIIs) codes are identified in the text as [XX)

PLANT AND SYSTEM IDENTIFICATION: i General Electric - Boiling Hater Reactor - 2511 MHt rated core thermal power.

EVENT IDENTIFICATION: Inadvertent start of the U-l Diesel Generator due to a ,

personnel error.

A. CQ_NDITIONS PRIOR TO EVENIl Unit: One Event Date: April 20, 1993 Event Time: 0215 Reactor Mode: 4 Mode Name: RUN Power Level: 100%

This report was initiated by Deviation Report D-4-1-93-034.

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 157. high flux scram).

B. DESCRIPTION OF EVENT:

On April 20, 1993, at 0215 hours0.00249 days <br />0.0597 hours <br />3.554894e-4 weeks <br />8.18075e-5 months <br />, Unit One was in the RUN mode at 100 percent of  !

rated core thermal power. At this time, the Unit Two Nuclear Station Operator '

(NS0) inadvertently started the Unit One Diesel Generator (DG) [EK] when attempting  ;

to start the shared (1/2) DG.

Following the completion of maintenance on the 1/2 DG, the Unit Two NSO was t assigned to start and load the diesel to bus 23-1. The NSO and the Equipment  ;

Operator (EO) reviewed the procedure, and the E0 departed to the diesel. While -

awaiting the E0, the NSO again reviewed the procedure and instrumentation at the 901-8 panel. After receiving notification from the E0 that the DG was ready to be started, the NSO verified all actions a third time. The NSO hung up the phone, went to the plant page system, announced the impending start of the 1/2 DG, and -!

returned to the panel. The operator then reached down and started the Unit i DG instead of the 1/2 DG. Note that the Unit 1 DG control switch is 19-1/2 inches  ;

from the 1/2 DG control switch. The operator immediately realized his error, shut down the Unit 1 DG, and started the 1/2 DG.

C. APPARENT CAU.5E OF EVENT:

This report is submitted in accordance with 10CFR50.73(a)(2)(iv), which states in f part that the licensee shall report any event or condition that resulted in manual or automatic actuation of any Engineered Safety Feature unless the initiation occurred as a result of preplanned operations or testing.  !

The cause of this event is personnel error. Although the NSO had performed proper "self-checks" prior to the event, he did not follow through with the self check during the entire evolution. Had the NSO performed "self check" just prior to the i operation of the DG control switch, the event would have been prevented.  :

}!

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I DVR 428

O UfENSEE EVENT REPORT (LER) TEXV TJ)NTINUATION rnrm Rev 2.fL

, FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER f6) Pace (3)

Year // sequential /// Revision

,/,,/

// Namber /,/,/j Number >

.Asad cities Unit One 0 1 5 1 0 l 0 1 0 1 21 51 4 913 - 0l0l6 - 0l0 01 3 0F 01 3 ,

TEXT Energy Industry Identification system (EIIs) codes are identified in the text as [XX]

t D. SAFETY ANALYSIS OF EVENT: .

t The safety significance of this event was minimal. The Diesel Generators performed as designed, and there was no threat to plant personnel, equipment, or the public. t E. CORRECTIVE ACTIONS:

The immediate corrective action was to shut down the Unit One DG. The 1/2 DG was then started and loaded successfully.

Operations department has conducted a review with other and former NS0's and compiled a list of evolutions where operators can " fall" and operate a wrong switch / breaker. This list will be presented to heighten the level of operator awareness at a department tailgate meeting (NTS# 2542009303401).

Shift Engineers will reinforce the need for Self Check techniques and the need to perform self check throughout the evolution at crew briefings (NTS# 2542009303402). '

i Training will evaluate the current self check lesson plans to include techniques -

and need for performance of self check throughout the evolution into current lesson plans and stress self check techniques during simulator training (NTS# 2542009303403). ,

F. PREVIOUS EVENTS: ,

In the past fi_ve years, there has been one previous Licensee Event Report (LER) due  ;

to operation of the wrong equipment. LER 2-87-013 documents a full reactor scram '

due to personnel racking out the wrong breaker. There have also been seven other Deviation reports involving problems due to personnel working on the wrong equipment.

G. COMPONENT FAILURE DATA:

There was no component failure associated with this event.

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