View source for NRC-90-0018, LER 89-039-00:on 891226,Div I Emergency Equipment Cooling Water & Svc Water Sys Automatically Started Due to Partial Load Shed of Bus 72E.Caused by Personnel Error. Accountability Meeting Held on 900117.W/900125 Ltr

{{Adams
| number = ML20006B452
| issue date = 01/25/1990
| title = LER 89-039-00:on 891226,Div I Emergency Equipment Cooling Water & Svc Water Sys Automatically Started Due to Partial Load Shed of Bus 72E.Caused by Personnel Error. Accountability Meeting Held on 900117.W/900125 Ltr
| author name = Orser W, Pendergast J
| 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-90-0018, CON-NRC-90-18
| document report number = LER-89-039, LER-89-39, NUDOCS 9002020205
| document type = LICENSEE EVENT REPORT (SEE ALSO AO,RO), TEXT-SAFETY REPORT
| page count = 4
}}

=Text=
{{#Wiki_filter:.  .-       ._.            . . -
l'                   ''
   -*f L 4
                               $*5lSe'E?' '
Naclear Ope #ahons 10CFR50.73            ,7;,,.
Dfgj'sonEf$itim                                                                                              2-January 25, 1990 NRC-90-0018 4
U. S. Nuclear Regulatory Commission
                                          . Attention: Document Control Desk Washington, D.C. 20555:

==Reference:==
Fermi 2 NRC Docket No. 50-341 Facility Operating License No. NPF-43.-

==Subject:==
Licensee Event Report (LER) No. 89-039-00 Please find enclosed LER No. 89-039-00, dated January 25, 1990, for a reportable event that. occurred on December-26, 1989. A copy of this LER is also being sent to the' Regional Administrator, USNRC Region III.
If you have any questions, please contact Joseph i                                        Pendergast at (313) 586-1682.
Sincerely,
;                                                                                         /
N Enc 1caure: NRC Forms 366, 366A                                                a
                                                                                                                      -)
cc:       A. B. Davis                                                           l J. R. Eckert R.: W. Defayette/W. L. Axelson W. G. Rogers-                                                         ,
J. F. Stang                                                           '
                                                  . Wayne County Emergency Management Division l
                                                                                                                          \
t i
9002020205 900125                                                                               'I PDR       ADOCK 05000341                                                                          ,
s                               PDC                                                               1
                                                                                                        -((22
                                                                                                                'p.

e,            L C ao,. 3ee .           .                                                                                                          U s. vUCLE Aa a 81ULATuv COnmassioN e
APPROVED OMS EO. 31660104 LICENSEE EVENT REPORT (LER)                                                ' "''a' $ 8'8*                  l F ACILITV NAME 01                                                                                                          DOCKET NUMBER 121                        P'GE G    l Fenni 2                                                                                                 01slo101ol314]1 1 loFl l3                         i t " t * ** '
Partial Load Sheidding of Bus 72E Actuated Emergency Equipment Ccoling                                                                                      )
Water and Emergency Equipment Service Water Due To Personnel Error                                                                                           l
[
tvtNT DATEini                      ttR NUMetR ici                      REPORT oATE tri                    OTHER 7 ACILITit$ INVOLvtD 181 l                                                                                                                                                 poCaET NUMasaisi MONTH        DAv     vtAR     vtAR         " g '''
                                                  .,     ,         ",7fgG MONTH          DAY  vtAR            ' ' c'''' ' h ^ u e s                                              '
0151010101 I l 1
1l22l6               89 8l9                  0 l3 l9           0 l0 0l1             2l5 9l 0                                                  o isio to t oi l l THIS REPORT IS SusMITTED PURSUANT TO TH4 REQUIREMENTS OF 10 CP R $- (Caeck one or more of f*e fe,towmpf 1111 OPE R ATING "00 ' "'          1                                                                                                                        73.71ml 20 402m                               20 40stei                       sonmimt i to 4061sH1H4                          50.381s1111                     50.731sH2Hvl                              73.711sl H06            l5 41          20 40si.iH Hei
                                                                             .0 mi.im
                                                                                                             .Oni.H2H .o
_     gHtgsg. A pge, 20 406(eH1Hdd                         90.73 tall 2Hil                 50.726aH2 Hunill Al                       J66Al 20 406tell1H6vl                       60.73tel(2Het                   50 78teH2Hvuditt 20 408(aH11tvl                        50.73ta H2Hd4                   50.73(sH28Is)
LICEN8tt CONT ACT FOR THIS Ltm 02)
NAME                                                                                                                                         TE LEPHONE NUMBER ARE A CODE Joseph Pendergast, Licensing Engineer                                                                            3;l i 3 586     i i i       i li 6;B2    i COMPLEf t ONE LING FOH 4 ACH COMPONENT F AILURE DESCRISED IN THIS RtPORT 113)
SysTIM                        "#              "                                                                     M      AC-         ORtA CAUSE                 COMPONENT                 E           O NPR $                       CAUlf SYSTtY   COMPONENT                                 hpp I        I I I               I I I                                                   I       i i i                i i I I        I i l               I I I                                                   I       I I I                I I I SUPPLEMENTAL REPORT EXPECTIO 04)                                                                        MONTH   DAY      YEAR SUOMIS$40N vtS (19 ves templete ExetCTEO suestisSION DATil f NO                                                                         l     l        l l   AestxACT (twr so r400 awcer te , sopronmereir erwenv   sirve spece evee=,,rma aness usi l
On December 26, 1989, surveillance 42 302 03, " Functional Check Of 4160 Volt Emergency Bus Division II Undervoltage Circuits", was in progress. At 1254 hours, the Division I Emergency Equipment Cooling Water (EECW) and Emergency Equipment Service Water (EESW) systems automatically started due to a partial load shed of Bus 72E.
By 1304 hours, the EECW and EESW systems were returned to standby. Surveillance 42 302.03 was completed without any l                                    additional problems on December 26, 1989, at 1525 hours.
l
!                                    The cause of this event was personnel error due to lack of attention to detail. A Critique of this event will be written and given to Electrical Maintenance personnel as required reading.
Procedures 42 302.01, " Functional Check Of 4160 Volt Emergency Bus Division 1 Undervoltage Circuits", and 42 302.03 will be revised.
i

i esIId toen anta                                                                                       U.S wuCLt* h C E!ULLTORT COneuest:0h~
V
* WCENSEE EVENT REPORT (LER) TEXT CONTINUATION                                     m:ovgo owe No am-eio4                    !
exmts. .ws:                               .
IA&stetv haast its                                          Docaly wueettatan Lim wuusta sei                               PAos (si
 >                                                                                    viaa      "W!&"           -
                                                                                                                  **#3 Fermi 2                                     o p lo lo lo j 3l 4l1 8l9   -
0l 3l 9    _
0l 0              l2 or         l3 ixw              .         wacw w.nm                                                                                                                :
Initial Plant Conditions                                                                                                    f Operational Condition: 1 (Power Operation)                                                                                  ;
Reactor Power             54 Percent                                                                                        ,
Reactor Pressure             955 psig                                                                                       ,
Reactor Temperature             512 degrees Fahrenheit                                                                      ;
Description of the Event                                                                                                    ,
1 On December 26, 1989, surveillance 42 302.03, " Functional Check Of 4160 Volt Emergency Bus Division 11 Undervoltage Circuits", was in progress. At 1254 hours, an undervoltage condition occurred and a                                                           i l                          partial load shed of 480V Bus 72E resulted. Breakers 72E-2A, 2B,                                                            t 20, 2D, 3A, 3B, 30, 3D and 4A subsequently tripped. As a result of breaker 72E-3B tripping, the South Reactor Building Closed Cooling Water (RBCCW) (CC) pump tripped. The Division I Energency                                                          >
Equipment Cooling Water (EECW) (CC) and Emergency Equipment                                                                 ;
Servloe Water (EESW) (BI) systems automatically started in response to the low RBCCW differential pressure condition.
By 1304 hours, RBCCW was restored to normal and EECW/EESW was back                                                          .
in standby. By 1525 hours, the remaining Balance of Plant loads                                                             !
affected were completely restored. Surveillance 42 302.03 was                                                               .
completed without any additional problems on December 26,1989, at 1525 hours.
l                          Cause of the Event:
The cause of this event was personnel (Utility Non-Licensed) error due to lack of attention to detail. A contributing factor to this event was that Procedure 42 302.03 contains steps with more than one action per sign-off.                                                                                                   3 Step 6 31.1 of the surveillance requires that knife switche 4 and 5 are opened at Bus 72E, Position 1A,                  Review of the surveillance steps determined that while performing Step 6 31.1,                                                           i knife switch 4 had been opened as required, while knife switch 5                                                           ,
was not. Step 6 3 1.1 of the procedurt was only partially                                                                  >
completed, yet signed off.                                                                                                ,
i i
g-                                                                                                            .....m,....,u..m.,

         =ar.... ma
         ""                                                                                          u wuctimaru6cioav commesion
                                 " L4CENSEE EVENT REPORT (LER) TEXT CONTINUATION vexovto ows no vio-me
                               ~
(EPmLS. D'3P8B j        e Acetatv haut m                                   Dock 61 NUMDiatn                                         '
gga gyugga egi                  ,agg g33
                                                                                    "*a      "uma'          wra:
Fermi 2                             o p lo jo lo ] 3l 4l1 8l9                        oj o textua         .: =. : . c uc % mm en, 0l 3l 9    -
l3 or      l3 Analysis of the Event:
The actuations which occurred as a result of this event were per design. The operator's prompt actior. led to a timely restoration of the systems to their noraal line up.       If an event had occurred which had required the EECW/EESW functions in order to respond to an event, these systems were capable of fulfilling their design basis functions. Therefore, this event did not affect the safe operation of the plant, nor the health and safety of the public.
Corrective Actions:
An accountability meeting was held on January 17, 1990, between plant management and the personnel involved to discuss the event.
A critique of this event will be written and given to Electrical Maintenance personnel as required reading. Procedures 42 302.01,
                                  " Functional Check Of 4160 Volt Emergency Bus Division 1 Undervoltage Circuits", and 42 302.03 will be revised. These revisions will assure that there is only one sign-off per action taken in the procedure. These corrective actions will be completed by March 15, 1990.
Detroit Edison has developed an action plan which was described in Detroit Edison letter NRC-89-0300, dated December 26, 1989. This plan addresses personnel performance weaknessec discovered during the first refueling outage and during the return to power operation.
Previous Similar Events:
This.is the first event reported where personnel error caused the actuation of the EECW/EESW systems in this manner. There have been other Licensee Event Reports (LERs) which described the actuation of the EECW/EESW systems due to personnel error while surveillances were in progress. These events were reported in                                          '
LERs 89-033, 89-008, and 88-027.
l 1
        - g, - -                                                                                             ..... m , ........,,,, m ..}}