05000354/LER-1997-004, :on 970207,B Div Primary Containment Isolation Sys Isolation Occurred.Caused by Personnel Error During Troubleshooting.Failed Optical Isolator Replaced & Channel Calibr Satisfactorily Completed on 970208

:on 970207,B Div Primary Containment Isolation Sys Isolation Occurred.Caused by Personnel Error During Troubleshooting.Failed Optical Isolator Replaced & Channel Calibr Satisfactorily Completed on 970208

ML20136G061
Person / Time
Site:	Hope Creek
Issue date:	03/10/1997
From:	Karrick J Public Service Enterprise Group
To:
Shared Package
ML20136G048	List: 05000354/LER-1997-004, :on 970207,B Div Primary Containment Isolation Sys Isolation Occurred.Caused by Personnel Error During Troubleshooting.Failed Optical Isolator Replaced & Channel Calibr Satisfactorily Completed on 970208
References
LER-97-004, LER-97-4, NUDOCS 9703170180
Download: ML20136G061 (4)

LER-1997-004, on 970207,B Div Primary Containment Isolation Sys Isolation Occurred.Caused by Personnel Error During Troubleshooting.Failed Optical Isolator Replaced & Channel Calibr Satisfactorily Completed on 970208

Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2) 10 CFR 50.73(a)(2)(viii) 10 CFR 50.73(a)(2)(x) 10 CFR 50.73(a)(2)(v), Loss of Safety Function 10 CFR 50.73(a)(2)(iv), System Actuation
3541997004R00 - NRC Website

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NRC FORM 366 U.S. NUCLEAR REOULATORY COMMISSION APPROVED BY OMB NO. 3150-0104 (1 96)

EXPlRES 04/30/98

' 239E"aan",2*lll? nan';liRTWen"aL**J LICENSEE EVENT REPORT (LER)

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(See reverse for required number of jo5g%A$T&Tgg*g RE ON, PRO Q15 wg digits / characters for each block) 20603.

P. CILITY NAME (1)

DOCKET NUMBER (2)

PAGE (3)

Hope Creek Generating Station 05000354 1OF4 TITLE (4) s Division Primary Containment Isolation Due to Personnel Error During Troubleshooting EVENT DATE (5)

LER NUMBER (6)

REPORT DATE (7)

OTHER FACILITIES INVOLVED (8)

MONTH DAY YEAR YEAR sEQU lAL REV 10 MONTH DAY YEAR

' ' ' ' " " " ^ " '

02 07 97 9 7 -- 0 0 4 -- 00 03 10 97 05000 OPERATING g

THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR 5: (Check one or more) (11)

MODE (9) 20.2201(b) 20.2203(a)(2)(v) 50.73(a)(2)U)(B) 50.73(a)(2)(viii)

POWER 100 20.2203(a)(in 20.2203(a)(3)ni 50.73(a)(2iUi) 50.73(a)(2)(x)

LEVEL (10) 20.2203(a)(2)(i) 20.2203(a)(3)DI) 50.73(a)(2)Dii) 73.71 7

20.2203(a)(2)UI) 20.2203(a)(4)

X 50.73(a)(2)Uv)

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20.2203(a)(2)(lv) 50.36(c)(2) 50.73(a)(2)(v61)

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LICENSEE CONTACT FOR THIS LER (12)

NAME TELEPHONE NUMBER pndude Asee Cade)

J:hn W. Karrick, Hope Creek LER Coordinator (609) 339-5298 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)

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system COMPONENT MANUFACTURER R

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SYSTEM COMPONENT MANUFACTURER R

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>s SUPPLEMENTAL REPORT EXPECTED (14)

EXPECTED MONTH DAY YEAR YES NO SUBMISSION (if yes, complete EXPECTED SUBMISSION DATE).

X DATE (15)

ABSTRACT (Limit to 1400 spaces,i.e., approximately 15 single-spaced typewritten lines) (16)

On February 7, 1997, during the performance of a radiation monitoring system channel calibration, an annunciator failed to clear as prescribed by procedure.

During investigation into the cause of the inconsistency, a technician using a Digital Multi-Meter (DtH) to verify the channel status, made contact with the wrong terminal point.

As a result, at 2016 hours0.0233 days <br />0.56 hours <br />0.00333 weeks <br />7.67088e-4 months <br />, a "B" Division Primary Containment Isolation System (PCIS) isolation occurred. The cause was detemined, the isolation was reset, and the effected components were restored at 2129 hours0.0246 days <br />0.591 hours <br />0.00352 weeks <br />8.100845e-4 months <br />.

The effected components performed as designed. A four hour event notification was made to the NRC at 2235 hours0.0259 days <br />0.621 hours <br />0.0037 weeks <br />8.504175e-4 months <br /> pursuant to 10CFR50.72 (b) (2) (ii).

The cause of the event was personnel error.

The cause of the original annunciator problem was the failure of an optical isolator.

Corrective actions include:

comunications of lessons learned, personnel disciplinary actions, implementation of guidance on relay contact verification and the use of IEMs, replacement of the optical isolator, and successful ccmpletion of the channel calibration.

There were no actual safety consequences associated with this event.

9703170180 970310 PDR ADOCK 05000354 S

PDRU.S. NUCLEAR REGULATORY COMMISSION l'A 6)

LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION FACILITY NAME (1)

DOCKET NUMBER (2)

LER NUMBER i 6)

PAGE (3)

• E!IP M.

H:pe Creek Generating Station 05000354 97 oo4 oo 2

OF 4 TEXT (if more space is required, use edditional copies of NRC Form 366A) (17)

PLANT AND SYSTEM IDENTIFICATION

General Electric - Boiling Water Reactor (BWR/4)

Primary Containment Isolation System (PCIS) - EIIS Identifier {JM}

Radiation Monitoring System - EIIS Identifier {IL}

IDENTIFICATION OF OCCURRENCE Discovery date: February 7, 1997 Problem Report: 970207331 CONDITIONS PRIOR TO OCCURRENCE The plant was in OPERATIONAL CONDITION 1 (POWER OPERATION) at 100% of rated thermal power.

There were no other structures, systems, or components that were inoperable at the beginning of the event that contributed to the event.

DESCRIPTION OF OCCURRENCE On day shift, February 7, 1997, an 18 month channel calibration for the Refuel Floor Exhaust and Reactor Building Exhaust Radiation Monitors was in progress in accordance with procedure HC.IC-CC.SP-0035(Q).

During the "A" channel calibration, an annunciator failed to clear as described by the procedure.

Investigation by Instrument and Controls (I&C) technicians (utility non-licensed personnel) revealed an open circuit contact causing the annunciator to remain in the alarmed condition.

To troubleshoot this condition, the "A" channel was placed in a tripped condition and an Action Request (work order) was written.

Troubleshooting plans were developed and executed but did not correct the problem with the annunciator.

During night shift turnover, the oncoming Nuclear Shift Supervisor (NSS-licensed Senior Reactor Operator) questioned whether or not the "A" channel was actually in the tripped condition.

This question arose after the NSS reviewed radiation monitoring system indications (RM-11) in an attempt to verify channel status to assure compliance with Technical Specifications.

To verify the "A" channel was in the tripped condition, a voltage measurement was taken across contacts in the "A" channel using a Digital Multi-Meter (DMM).

The DMM was then selected to the ohms position to measure resistance.

While attempting to measure the resistance, the technician made contact with one terminal point in the "A" channel and, in error, a terminal point in the "B" channel.

The error caused a "B" channel trip which, in combination with the tripped "A" channel, generated a Division "B" Primary Containment Isolation System (PCIS) actuation signal.

The isolation occurred at 2016 hours0.0233 days <br />0.56 hours <br />0.00333 weeks <br />7.67088e-4 months <br />.

NRC FJRJ 366A U.S. NUCLEAR REGULATORY CCMMISSION (4-96)

UCENSEE EVENT REPORT (LER)

TEXT CONTINUATION FACILITY NAME (1)

DOCKET NUMBER (2)

LER NUMBER 16)

PAGE (3) ym SEQUENTIAL fEAMON l

H::pa Creek Generating Station 05000354 97 oo4 oo 3

OF 4 TEXT (if more space is required, use ad,#tional copies of NRC Form 366A) (17)

Operators verified that the isolation was complete and that the effected components performed as designed.

The effected systems included: the Drywell Floor and Equipment Drain Sump, Primary Containment Instrument Gas, Reactor Building Ventilation, Cbntainment Atmosphere Control, and Radioactive Waste systems.

Tha work was stopped, the isolation was reset, and the effected equipment was j

restored at 2129 hours0.0246 days <br />0.591 hours <br />0.00352 weeks <br />8.100845e-4 months <br />.

A four hour event notification was made at 2235 hours0.0259 days <br />0.621 hours <br />0.0037 weeks <br />8.504175e-4 months <br /> j

pursuant to 10CFR50.72 (b) (2) (ii).

This event is being reported pursuant to 10CFR50.73 (a) (2) (iv) as any event or condition that resulted in an j

automatic actuation of an Engineered Safety Feature (ESF).

APPARENT CAUSE OF OCCURRENCE i

Personnel error involving inappropriate work practices, specifically, lack 4

of self-checking, was the cause of the ESF actuation.

The I&C technicians performing the contact verification for the NSS did not apply the Stop, Think, Act, and Review (STAR) principle when taking the resistance measurement.

The STAR principle is the cultural human perfonnance awareness tool used at the Hope Creek Generating Station (HCGS) to implement a self-checking work practice.

The cause of the annunciator lock-in was the failure of an optical isolator (GA Electronics, P/N GA 50012713-001, M/N OD C24) in the circuit.

This failure is considered to be an indirect cause of the event in that the troubleshooting would not have been necessary had the annunciator operated properly.

A review of maintenance history indicates an acceptable failure rate of similar optical isolators.

ASSESSMENT OF SAFETY CONSEQUENCES

The PCIS system is designed to ensure primary containment integrity by initiating closure of non-NSSSS (Nuclear Steam Supply Shutoff System) primary containment isolation valves following specific design basis events.

The ESF actuation associated with this event resulted from the fulfillment of the 2 out of 3 logic initiated through the reactor building and refuel floor exhaust radiation monitors.

There were no actual high radiation conditions, therefore, the ESF signal was invalid.

The cause of the isolation was determined, the isolation was reset, and the effected equipment was returned to i

service in accordance with approved procedures.

There were no actual safety consequences associated with this event.

Variations in plant OPERATIONAL CONDITIONS would not have affected the consequences of this event.

NRC FORM 386A (4-95)

- ~ _

~

NRC FeRM 366A U.S. NUCLEAR REGULATORY COMMISSION (MH) 1 UCENSEE EVENT REPORT (LER)

TEX? CONTINUATION i

FACILITY NAME (1)

DOCKET NUMBER (2)

LER NUMBER 16)

PAGE (3)

• 2' UP

.".u25 A

1 H:pe Creek Generating Station 05000354 g7 oo4 oo 4

OF 4 TEXT (if more space le required, use additional copies of NRC Form 366A) (17) a

PREVIOUS OCCURRENCES

A review of previous LERs at Hope Creek identified LER 95-005-00, which also occurred during the use of a DMM to measure resistance.

The root cause report for LER 95-005-00 included a summary of other previous events caused by I&C technician personnel errors or by the use of M&TE equipment.

The corrective actions from that report were numerous, but it has not been determined whether they should have averted this event.

As a result, corrective actions for this event include a detailed review of the previous events' corrective actions and i

issuing guidance on the use of DMMs.

CORRECTIVE ACTIONS

1.

The failed optical isolator was replaced and the channel calibration was satisfactorily completed on February 8, 1997.

i 2.

PSE&G has evaluated performance deficiencies for personnel involved and implemented disciplinary actions as appropriate.

3.

This event's root cause and corrective actions will be discussed with I&C technicians for lessons learned.

This action will be completed by March 31, 1997.

4.

A detailed review of previous similar events and their corrective actions will be performed to verify implementation and status.

This action will be completed by March 31, 1997.

5.

Guidance for verifying relay contact position and the use of DMMs will be developed and implemented by March 31, 1997.