05000254/LER-1997-009-03, :on 970504,both Trains of Standby Gas Treatment Sys Were Inoperable.Caused by Cognitive Peersonnel Error. Blown Fuse Replaced,A Train of SBGTS Was Tested & Declared Operable & SRO Test Director Counseled

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:on 970504,both Trains of Standby Gas Treatment Sys Were Inoperable.Caused by Cognitive Peersonnel Error. Blown Fuse Replaced,A Train of SBGTS Was Tested & Declared Operable & SRO Test Director Counseled
ML20141J342
Person / Time
Site: Quad Cities Constellation icon.png
Issue date: 05/22/1997
From: Peterson C
COMMONWEALTH EDISON CO.
To:
Shared Package
ML20141J333 List:
References
LER-97-009-03, LER-97-9-3, NUDOCS 9705280042
Download: ML20141J342 (4)
v • d • e


LER-1997-009, on 970504,both Trains of Standby Gas Treatment Sys Were Inoperable.Caused by Cognitive Peersonnel Error. Blown Fuse Replaced,A Train of SBGTS Was Tested & Declared Operable & SRO Test Director Counseled
Event date:
Report date:
2541997009R03 - NRC Website
v • d • e

text

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i LICENSEE EVEN'T REPC" T (LER)

Forrn Rev. 2.0 l

Facihry N.nw(1)

Docket Nurnber G)

Page (3)

Quad Cities Unit One 0l5l0l0l0l2l5l4 1 l of l 0 l 4 Titis (4)

Both Trains of Standby Gas Treatment System inoperable due to Operator fuse replacement error.

Event Date (5)

LER Number (6)

Report Date (7)

Other Facihties involved (8)

Month Day Year Year Sequential Revision Month Day Year Facility Docket Nurnber(s)

Number Nurnber Narnes Quad Citaea Unit 2 ol5l0l0l0l2l6l5

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< 12 ATING THIS REPORT IS SUBM] TrED PU GUANT TO T iE REQU REMENTS OF 10CFR MO.,E (9) fCheck one or snors of the following) (II) 1 20.402(b) 20.405(c) 50.73(a)G)(iv) 73.71(b)

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20.405(a)(1)6v) 50.73(a)G)6i) 50.73(a)G)(viii)(B) below and in 20.405(a)(1)(v) 50.73(a)G)6ii) 50.73(a)G)(x)

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LICENSEE CON TACF FOR THIS LER (11)

NAME TELEPHONE NUMBER AREA CODE Chules Peterson, Regulatory Affairs Manager, ext. 3609 3l0l9 6l5l4l-l2l2l4l1 COMPLLTE ONE LINE FOR EACH COMPONENT FAILURE DEACRIBED IN THis REPORT (13)

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ABSTRACT On 050497, at 2035 hours0.0236 days <br />0.565 hours <br />0.00336 weeks <br />7.743175e-4 months <br />, Unit One was in Power Operation and Unit Two was shutdown and defueled. Operations made both trains of the Standby Gas Treatment System (SBGTS) inoperable for 40 minutes when the 1/2 B SBGTS Train Mode Selector Switch was placed in "0FF" in accordance with a surveillance procedure following the inadvertent installation of a blown fuse, which disabled the autostart capability of the A Train of SBGTS.

The inoperability of the A train of SBGTS was identified when the A Train failed to start in the conduct of the procedure.

Immediate actions were to enter a 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> Limiting Condition for Operation (LCO) because both trains of SBGTS were inoperable, stabilize plant conditions, replace the blown fuse, and reperform the applicable steps of the procedure to ensure the A Train of SBGTS would autostart. At 2115 hours0.0245 days <br />0.588 hours <br />0.0035 weeks <br />8.047575e-4 months <br /> the A Train was declared operable and Operations exited the I hour LCO.

The root cause of this event is a cognitive personnel error by the Senior Reactor Operator (SRO) test director who did not adequately control a binwn fuse and the new replacement fuse to ensure the new fuse was installed.

Corrective actions were to counsel the.SR0 test director and to conduct training on the event.

The safety consequences of this event to on-site personnel and the general public were minimal.

The B Train of SBGTS could have been manually started within 10 minates in the event of a Loss Of Coolant Accident.

LER254\\97\\009.WPF 9705280042 970522 PDR ADOCK 05000254 g

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LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Form Rrv. 2.0 j

Pg u_rIT NAME (1) utNaza NUMamm G)

LER NUkamm (6)

PAGE (3)

Year Sequential Revision Number Number Quad Chise Unk One 0l5l0l0l0l2 5l4 9l7 0l0l9 0l0 2 lOFl 0 l 4' in:A

":., Industry "" ~

_ Byelem trass) M are identified in the text as p AJ

- PLANT AND SYSTEM IDENTIFICATION:

General Electric - Boiling Water Reactor - 2511 MWt rated core thermal power.

EVENT IDENTIFICATLON:

Both Trains' of Standby Gas Treatment System inoperable due to Operator fuse rep'acement error.

A.

C0WITIONS PRIOR TO EVENT:

Unit: 1 Event Date: 050497 Event Time:

2035 Reactor Mode:

1 Mode Name:

Power Operation Power Level: 094 Unit: 2 Event Date: 050497 Event Time:

2035 Reactor Mode:

0 Mode Name:

None Power Level: 000 This report was initiated by Licensee Event Report (LER)254\\97-009.

Power Operation (1) - Mode switch in the RUN position with average reactor coolant temperature at any temperature.

None (0) - Per Technical Specifications, Table 1-2 (Definitions 1.0), when there is no fuel in the reactor vessel, the reactor is considered not to be in any OPERATIONAL MODE.

B.

DESCRIPTION 0F EVENT:

On 050497 at approximately 1830 hours0.0212 days <br />0.508 hours <br />0.00303 weeks <br />6.96315e-4 months <br />, Unit I was in Power Operation at 94% reactor power and Unit 2 was shutdown and defueled. Operations was performing QCOS 1600-13,

" Refueling Outage PCI (Primary Containment Isolation) [NH] Groups 2 and 3 Isolation Test", which includes testing of the Standby Gas Treatment System (SBGTS) [VI). A Senior Reactor Operator (SRO) test director was stationed with an electrician in the plant to install electrical jumpers in accordance with the procedure. Operations had just completed step H.180, Test of SBGTS Train A to Auto-Start in Standby Mode, and was beginning to perform step H.181, Test of SBGTS Train B to Auto-Start in Standby Mode.

In step H.181.a, the 1/2 A SBGTS Train Mode Selector Switch is placed in "0FF".

In step H.181.b, the personnel in the plant would install a jumper around the 2212-29A panel relay 1/2-7541-28A at contacts 11 and 12, verify the 1/2-7541-29A relay was de-energized, and then remove the jumper. When the jumper was being removed, the electrician touched contact 14 with a jumper lead causing an arc. The electrician and SRO investigated and determined the arc blew fuse [FU] 8A in the 2212-29A panel. When fuse 8A blew, the A Train of SBGTS which was already in "0FF" was disabled from starting in Standby Mode, the B Train of SBGTS remained capable of starting and started successfully at step H.181.h. The oncoming Shift determined it would be necessary to replace the blown fuse and repeat steps H.180 and H.181.

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LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Form Rw. 2.o FA,CILffY N AME (1)

DOCKLT NUMBER (2)

LER NUMBER (6)

PAGE (3)

Year sequennal Revision Nuaber Nurser Quad Cities Unit One 0l5l0l0l0l2l5l4 9l7 0l0l9 0l0 3 lOFl 0 l 4 IEXT Energy Industry Idenufication System (EIIS) coc es are idenufied in the text as [XX]

At approximately 1900 hours0.022 days <br />0.528 hours <br />0.00314 weeks <br />7.2295e-4 months <br />, the B Train of SBGTS was running and the A Train was in "0FF".

The oncoming SR0 test director obtained a like-for-like new fuse from the storeroom.

Using the old fuse for comparison, the SR0 inadvertently placed both fuses in the same pocket.

The SR0 proceeded to the plant with electricians and pulled the blown fuse from his pocket unaware there were two fuses in his pocket.

The electrician asked if he could check the fuse and the SRO said it would not be necessary. After the blown fuse 8A was inserted, the testing recommenced at step H.180.

At 2035 hours0.0236 days <br />0.565 hours <br />0.00336 weeks <br />7.743175e-4 months <br />, the crew performed step H.180.b placing B Train of SBGTS Mode Selector Switch in "0FF", and at this time both trains of SBGTS became inoperable as neither train would autostart because the blown 8A fuse prevented the A Train of SBGTS from starting in the Standby Mode. At approximately 2100 hours0.0243 days <br />0.583 hours <br />0.00347 weeks <br />7.9905e-4 months <br />, the Control Room operator performed step H.180.h, initiating a 25 second delayed start of Train A of SBGTS. The Control Room operator notified the SR0 in the plant that Train A did not start.

The SR0 asked the electrician to check fuse 8A and it was the blown fuse. The SR0 found the good fuse still in his pocket and notified the Control Room operator of the problem.

The Shift Engineer reviewed Technical Specification section 3.7.P.2 and determined Unit 1 entered a 1-hour Limiting Condition for Operation (LCO) for having both trains of SBGTS inoperable.

The Control Room operator re-established initial conditions and at 2115 hours0.0245 days <br />0.588 hours <br />0.0035 weeks <br />8.047575e-4 months <br /> exited the 1-hour LCO when the H.180 step was successfully completed.

Both Trains of SBGTS were inoperable for 40 minutes.

The Shift Engineer (SE) reviewed and interpreted the Reportability Manual to state the event was not reportable as Train B was only inoperable for the surveillance and the blown fuse only made Train A inoperable and not the whole SBGTS.

On 050597, the oncoming dayshift SE was reviewing the SE log and noticed the log entry for the SBGTS 1-hour LCO.

The SE contacted Regulatory Assurance and verified the event was reportable at 1315 hours0.0152 days <br />0.365 hours <br />0.00217 weeks <br />5.003575e-4 months <br />.

A 4-hour ENS phone call was made at 1453 hours0.0168 days <br />0.404 hours <br />0.0024 weeks <br />5.528665e-4 months <br />.

C.

CAUSE OF THE EVENT

The root cause of this event is a cognitive personnel error by the SR0 test director who did not adequately control the blown and new fuses to ensure the new fuse was installed.

D.

SAFETY ANALYSIS

The safety consequences of this event to on-site personnel and the general public were minimal. The SBGTS serves to limit both the on-site and off-site dose in the event' of a loss Of Coolant Accident (LOCA) by maintaining the secondary containment at a negative pressure to minimize exfiltration, and by treating air from the secondary containment during emergency conditions. Either train of the SBGTS can deliver the necessary flow rate and filtration capability to meet on-site and off-site dose rate limits in the event of a LOCA.

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  • LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Form Rev. 2.0 FAyILTIT NAME (1)

DOtul NUMutz (2)

LER NUMut.K (6)

PAGE (3)

Year Sequentaal Revision Number Number Quad Cities Unit One 0l5l0l0l0l2l5l4 9l7 0l0l9 0l0 4 lOFl 0 l 4 TEXT Er s.j ladusuy Identification System (tais) w are ident:5ed in the text as [XX]

The most severe condition that could have existed during this event would have been a LOCA at full power.

Since the SBGTS is designed to start during a LOCA with no operator action, the conditions existing at the time of this event would have prevented either train of the SBGTS from starting automatically had a LOCA occurred.

The inability of either train of the SBGTS to automatically start existed from the time the Train B SBGTS Mode Selector Switch was placed in "0FF" at 2035 hours0.0236 days <br />0.565 hours <br />0.00336 weeks <br />7.743175e-4 months <br />, until the 1-hour LCO was exited at 2115 hours0.0245 days <br />0.588 hours <br />0.0035 weeks <br />8.047575e-4 months <br />. Operator action to start the available B l

Train of the SBGTS in the event of an LOCA during this time period would have been required. The actual time needed to perform this action is estimated to have taken i

no more than ten minutes. A ten minute delay in the starting of the available B Train of the SBGTS would have produced negligible increases to either the on-site or off-site dose rates had a LOCA occurred; therefore, the health and safety of on-site personnel or the general public would not have been at a greater risk had a LOCA i

occurred during this event.

E.

CORRECTIVE ACTIONS

l Corrective Actions Completed:

1.

The blown fuse was replaced with the new fuse and the A Train of SBGTS was tested and declared operable.

2.

The SRO test director was counselled on this event.

Corrective Actions To Be Completed:

1.

This event will be includ:d in Licensed Operator Retraining to address l

reportability requirements and to stress importance of attention to detail in all activities.

l (Training - NTS# 2541809700901)

F.

PREVIOUS OCCURRENCES

A search of LER's over the last 2 years associated with self-checking errors found the following events.

265/95-002 Unplanned start of Unit 2 Diesel Generator caused by opening of 4KV potential transformer fuses drawer.

254/97-013 RCIC Area High Temperature Switch would not actuate due to excess

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sealing varnish applied by technician.

G.

COMPONENT FAILURE DATA

Not Applicable.

i l

LER254\\97\\009.WPF

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