View source for NRC-89-0190, LER 89-023-00:on 890924,personnel Inadvertently Caused Trip of Essential Safety Sys Buses 64B & 64C.Caused by Failure of Personnel Involved to Review Applicable Prints Prior to Performing Test.Event Reviewed w/personnel.W/891024 Ltr

{{Adams
| number = ML19324B133
| issue date = 10/24/1989
| title = LER 89-023-00:on 890924,personnel Inadvertently Caused Trip of Essential Safety Sys Buses 64B & 64C.Caused by Failure of Personnel Involved to Review Applicable Prints Prior to Performing Test.Event Reviewed w/personnel.W/891024 Ltr
| author name = Anthony P, Orser W
| author affiliation = DETROIT EDISON CO.
| addressee name = 
| addressee affiliation = NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
| docket = 05000341
| license number = 
| contact person = 
| case reference number = CON-NRC-89-0190, CON-NRC-89-190
| document report number = LER-89-023, LER-89-23, NUDOCS 8911010100
| document type = LICENSEE EVENT REPORT (SEE ALSO AO,RO), TEXT-SAFETY REPORT
| page count = 6
}}

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October 24   1989              ' ''m J                                                              NRC-89-0190 U. S. Nuclear Regulatory Commission Attention             Document Control Desk Washington, D.C. 205$5 Reference               Fermi 2 NRC Docket No. $0-341 Facility Operating License No. NPF-43 Subject                Licencee Event Report (LER) No. 89-023-00 Please find enclosed LER No. 89-023-00 dated October 24 1989 for a reportable event that occurred on September 24, 1989.            A copy of this LER is also being sent to the Regional Adm!.nistrator. USNRC Region III.
If you have any questions, please contact Patricia Anthony at (313) 586-1617.
Sincerely.
Enclosures            NRC Forms 366   366A cct         A. B. Davis J. R. Eckert R. C. Knop W. G. Rogers J. F. Stang Wayne County Emergency Management Division l
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less of Power to Division I Due to Personnel Error By Belay Division                                                                                                 '
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On September 24 1989 Detroit Edison Relay personnel were performing a check of the 13.2 kv switchgear while the plant was defueled.              While testing a relay string, personnel Inadvertantly caused the trip of Essential Safety System Buses 64B and 640.
This caused various actuations/isolations of engineered safety features, including the start and loading of Emergency Diesel Generator 11.                     In addition. power to other Division I equipment, including the "A" Fuel Pool Cooling Pump, was lost. Operators took prompt actions to restore power to the necessary components and systems.
This event was caused by the failure of the personnel involved to review the applicable prints prior to performing the test. This event was reviewed by the involved personnel and their management.                   Any disciplinary action warranted will be l               cdministered in accordancc with company policy. In order to l               disseminate the lessons learned during this event, it was be l               reviewed during the October Relay monthly meeting.
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Initial Plant conditions:
   !              Operational Conditions. defueled
  ,               Ri, 'or Power             0 parcent t
JR _ ser Pressure: O psis Reactor Temperature                      85 degrees Fahrenheit i
Description ut occurrences
  .               On September 24, 1989. Detroit Edison Relay Division personnel
  !               were performing a check of the 13.2 kv switchgear [(EA)(SWGR))
which is located at Fermi I.                                   Part of the testing includes verifying the function of the. relay controls (RLY) listed on Detroit Edison drawings as circuit positions A. B. C and D.
Foritions b. C and D are tested to verify that under fault conditions where the respective breaker (BKR) does not open. the bus feed to position A does open.                                      This test requires the manual operation of the protective tripping relay and a set of instantaneous operating relays designated as phase-50's (see attached figure). This action energises the coil of a d.c.                                                                                ,
auxiliary relay designated as the 96 relay.                                        In addition, position                                  l D has another relay. 1CJ94 in parallel with relays phase-50 and                                                                           j 96 which does not appear on positions B and C.                                                                                            !
When the technician was manually simulating a fault on the                                                                                i protective relay for position D. he energized relay 1CJ94 which trippel Essential Safety System Buses 64B and 64C (BU) at 1643 hours. As a result, power was lost to Division I and various engineered safety features were actuated / isolated. These                                                                                 I
(                 actuations/isolations included automatic start and loading of                                                                           .
Emergency Diesel Generator 11 [(EK)(DG)). isolation of the                                                                                )
Secondary Containment (NF) and isolation of primary containment valve groups 13 and 14 [(JM)(ISV)).                                       Also, power was lost to the "A" Fuel Pool Cooling Pump [(DA)(P)). Division I Battery Chargers                                                                       ,
[(EI)(BYC)) and Modular Power Unit (EC) 1. Turbine and Radweste Building Heating. Ventilating and Air Conditioning Systems                                                                              ~
[(VH)(VK)) also tripped. Other engineered safety features                                                                                 q P                 received actuation signals but did not respond due to their being                                                                         i out of service during the outages i.e.. the Emergency Diesel                                                                               !
Generator 12 was out of service for maintenance. Control Center                                                                           !
Heating. Ventilating and Air Conditioning System (VI) was already                                                                         l in. recirculation mode and primary containment isolation valve                                                                            i i
groups 2     10   12                 15  16, 17 and 18 were already isolated.                                 A                           !
half-scram signal would have been received due this this event.                                                                            1 l                 but one was already present since the Reactor Protection System                                                                            l (RPS)(JC) was out of service for maintenance.                                                                                             I I
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e Ar 1725 hours. power was restored to RPS motor-generator set "A"                                               .
and Division I of RPS. Ths Shift Technical Advisor verified that                                               !
the proper isolations had occurred.            Fuel Pool Cooling Pump "A"                                      ;
was restarted at 1741 hours.       Power to the battery chargers was                                          :l restored by 1757 hours and Emergency Diesel Generator 11 was                                                   {
un3oaded and shutdown by 1955 hours.                                                                           ,
cause of Event:
This event was caused by personnel error on the part of Relay                                                  [
personnel (non-nuclear division, utility). It was assumed that                                                 .
            .the logic for' circuit position D was identical to that of                                                     ,
positions B and C which had been successfully tected as part of                                                !
the same evolution.                                                                                            !
A contributing factor to this event was the failure to follow                                                  :
normal work practices for Detroit Edison Relay personnel. These                                                i work practices include reviewing the prints and preparing a check                                              i list prior to starting work. The personnel involved did not do                                                 j this for circuit position D.                                                                                   <
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           ' Analysis of Event:
l Since this type of testing is only performed while the plant is                                                !
shutdown, the effects of this event need only be considered under                                              ;
those conditions. The affected components and systems that                                                     !
actuated during this event responded per their design.                      Power to                           !
Division II components was unaffected by this event. Fuel Fool                                                 i Cooling Pump "B". which is powered from Division II. was available                                             i to provide fuel pool cooling.        This is a 100% capacity pump.                       The                   !
ventilating systems were restored to service without any adverse                                               i consequences on the work environment in the plant.                   The systems                               !
such as CCHVAC which did not respond to this event were                                                        j conservatively aligned. The loss of Modular Power Unit 1 did not                                               j adversely impact the operators; ability to respond to this event.                                              j As a result, this event had no impact on the health and safety of                                              L the public or plant personnel or the safe operation of the plant.                                              l i
Corrective Actions:
As described previously, the actuated equipment was restored.                               The                f personnel involved in this event reviewed the sequence of events                                               !
with Relay Division management. Any disciplinary action warranted                                              l will be administered in accordance with company policy.
In order to disseminate the lessons learned during this event, this event was reviewed during the Relay's monthly meeting in                                                  ;
October of 1989.                                                                                               t
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i General Employee Training. Orientation "A". which includes the topic of procedural compliance, will be given to Detroit Edison personnol not normally assigned to Fermi 2 before performing work.          This will be incorporated into Orientation "A" by January 1      1990.
l Previous Similar Events:                                                                                                                                                                   !
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