NRC-90-0002, LER 89-033-00:on 891207,volt-ohm Meter Connected to Incorrect Terminal,Causing Div II of Emergency Equipment Cooling Water Sys to Actuate.Caused by Personnel Error.Sys Secured & Channel Test Successfully completed.W/900108 Ltr

LER 89-033-00:on 891207,volt-ohm Meter Connected to Incorrect Terminal,Causing Div II of Emergency Equipment Cooling Water Sys to Actuate.Caused by Personnel Error.Sys Secured & Channel Test Successfully completed.W/900108 Ltr

ML20005E860
Person / Time
Site:	Fermi
Issue date:	01/08/1990
From:	Anthony P, Orser W DETROIT EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
CON-NRC-90-0002 LER-89-033, NUDOCS 9001120005
Download: ML20005E860 (4)

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Attention: Document Control Desk ,

Washington, D.C. 20555 ,

Reference:

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NIC Docket No. 50-341 Facility Operating License No. t@F-43

Subject:

Licaname Event Escort (L*'R) No. 89-033-00 ,

Please find enclosed LER No. 89-033-00, dats5 January 8,1990, for a reportable event that occurred on Decenber 7, 1989. A copy of this LER is also being sent to the Regional Administrator, USNIC Region III.  :

If you have any questions, please contact Patricia Anthony at (313) 566-1617.

Sincerely, i

Ihclosures NIC Forms 366, 366A cc: A. B. Davis J. R. Eckert R. W. DefayetteN. L. Axelson L W. G. Rogers J. F. Stang Wayne County Emergency Management Division 9001120003 900108 ,

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During the test, an Instrumentation and Control technician connected his volt-ohm meter to an incorrect terminal. He then disconnected the lead at the meter, changed the range of the meter and reconnected the meter, which caused Division II of the Emergency Equipment Cooling Water System to actuate.

The system responded per its design. The operators secured the system ,

l, and the test was successfully completed. l A fact finding meeting was held for the personnel involved in this event. A Human Performance Evaluation System (HPES) analysis is being performed to identify potential actions to prevent similar events in the future. A description of this event will be given to i Instruraentation and Control shop personnel as required resding. ]

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Initial Plant Conditions Operational Condition: 2 (Startup)

Reactor Power: O percent Reactor Pressure: O psig Reactor Temperature: 185 degrees Fahrenheit Description of Occurrence:

During the performance of surveillance procedure 44.030.299. *

"ECCS-Drywell Pressure-RHR, CSS and HPCI Actuation, Division I, Channel Functional Test", on December 7, 1989, an automatic initiation of Division II of the Emergency Equipment Cooling Water System

[(EECW)(BI)] occurred at 1438 h,.vs.

l An Instrumentation and Control (I&C) repairman connected a volt-ohm meter (MTR) across terminals BB-52 and BB-72 in cabinet H11-P626 instead of BB-52 and BB-71 as specified in step 6.1.21 of the surveillance. The meter reading was 130 volts d.c. when if properly '

connected it should have been 0 volts. The technician disconnected the lead at the meter, switched the meter from the d.c. voltage range to the ohm (resistance) range and reconnected the Icad. This caused a short across the terminals which initiated Division II of EECW. ,

Performance of the surveillance was stopped while the cause of the i

Division II EECW initiation was investigated. The system was restored  ;

to its normal standby mode at 1459 hours0.0169 days <br />0.405 hours <br />0.00241 weeks <br />5.551495e-4 months <br />. The surveillance was then ,

successfully completed at 2146 hours0.0248 days <br />0.596 hours <br />0.00355 weeks <br />8.16553e-4 months <br />.

Cause of Event:

This event was caused by personnel errors on the part of the I&C )

technician. The meter was connected to a terminal other than the one specified in the procedure. Then the technician proceeded with the '

surveillance after obtaining an abnormal reading.

Analysis of Event:

The response of the EECW was per its design. If an event had occurred which had required the safety function of EECW, it was capable of providing adequate cooling to the emergency systems. Therefore, this event did not affect the safe operation of the plant, nor the health and safety of the public.

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Corrective Actions:-

A fact finding meeting was held with the personnel involved. In ,

addition, a Human Performance Evaluation System (HPES) analysis is i being performed for this event in order to identify actions which l could be effective in preventing future similar events. This study is ]

expected to be completed in January of 1990. A description of this 1

event will be given to the I&C shop personnel as required reading in ,

January of 1990.

I Detroit Edison has developed a action plan which is described in  ;

i Detroit Edison letter NRC-89-0300, dated December 26, 1989. This plan will address personnel performance weaknesses discovered during the first refueling outage and during the return to power operation.

Previous Similar Events:

In Licensee Event Reports87-020, 88-024,88-027 and 89-008, svents were reported in which connection to the wrong terminal points in conjunction with use of a volt-ohm meter was cited as the cause. The same survelliance procedure 44.030.299, was being performed during the event described in Licensee Event Report 88 027 and the similar surveillance procedure 44.030 300 for the other division during the event described in Licensee Event Report 89-008.

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