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| issue date = 10/16/1987
| issue date = 10/16/1987
| title = LER 87-006-00:on 870917,discovered That Test of Emergency Diesel Generator Automatic Load Sequence Relays Incomplete. Caused by Personnel Error.Personnel Immediately Performed Required Surveillance Test Per procedure.W/871016 Ltr
| title = LER 87-006-00:on 870917,discovered That Test of Emergency Diesel Generator Automatic Load Sequence Relays Incomplete. Caused by Personnel Error.Personnel Immediately Performed Required Surveillance Test Per procedure.W/871016 Ltr
| author name = MENDOZA V N, WOODY C O
| author name = Mendoza V, Woody C
| author affiliation = FLORIDA POWER & LIGHT CO.
| author affiliation = FLORIDA POWER & LIGHT CO.
| addressee name =  
| addressee name =  
Line 16: Line 16:


=Text=
=Text=
{{#Wiki_filter:REGULATINFORMATIONDISTRIBUTIOYSTEM<RIDS)ACCESSIONNBRFACIL:50-389AUTH.NAMEMENDOZAIV.N.WOODY'.O.RECIP.NAME8710220113DOC.DATE:87/10/ibNOTARIZED:NOSt.LuciePlantiUnit2iFloridaPoeerhLightCo.AUTHORAFFILIATIONFloridaPower5LightCo.FloridaPoeer5LightCo.RECIPIENT'AFFILIATIONDOCKET&#xb9;05000389
{{#Wiki_filter:REGULAT    INFORMATION DISTRIBUTIO        YSTEM <RIDS)
ACCESSION NBR 8710220113            DOC. DATE:  87/10/ib      NOTARIZED: NO          DOCKET  &#xb9; FAC IL: 50-389    St. Lucie Planti Unit 2i Florida Poeer h Light          Co. 05000389 AUTH. NAME              AUTHOR AFF  ILIAT ION MEN DO Z A I V. N.     Florida  Power 5 Li ght Co.
WOODY'. O.             Florida  Poeer 5 Light Co.
RECIP. NAME            RECIPIENT 'AFFILIATION


==SUBJECT:==
==SUBJECT:==
LER87-00b-00:on870917'estof2ASc2Bemergency'ieselgeneratorautomaticloadsequencerelaysincomplete.Causedbgpersonnelerror.Personnelimmed.iatelgperformedrequiredsurveillancetestinaccordanceUj/procedure.W/8710ibltr.DISTRIBUTIONCODE:IESRDCOPIESRECEIVED:LTRIENCLgSIZE:TITLE:50.73LicenseeEventReport<LER)iIncidentRptietc.NOTES:RECIPIENTIDCODE/NAMEPD2-2LATOURIGNYiEINTERNAL:ACRSMICHELSONAEOD/DOAAEOD/DSP/ROABARM/DCTS/DABNRR/DEST/ADSNRR/DEST/ELBNRR/DEST/MEBNRR/DEST/PSBNRR/DEST/SGBNRR/DLPG/GABNRR/DREP/RABSIB02RESTELFQRDIJRGN2FILE01EXTERNAL:EGLGGRQHiMLPDRNSICHARRISIJCOPIESLTTRENCL111111122111011111111111111111551111*RECIPIENTIDCODE/NAMEPD2-2PDACRSMOELLERAEQD/DSP/NASAEOD/DSP/TPAB.DEDRQNRR/DEST/CEBNRR/DEBT/ICSBNRR/DEST/MTBNRR/DEST/RSBNRR/DLPG/HFBNRR/DOEA/EABNRR/DREP/RPBNRR/PMAS/ILRBRESDEPYGIRES/DE/EIB'STLOBBYWARDNRC'PDRNSICMAYS.GCOPIESLTTRENCL1122111'111:111111111122"11.111'1111TOTALNUMBEROFCOPIESREQUIRED:LTTR45ENCL44 NRCForm344(403)LICENSEEEVENTREPORT(LER)V.S.NUCLEARREGULATORYCOMMISSIONAPPROVEDOMBNO.3150010CEXPIRES,'i3)i45FACILITYNAME(I)ST.LUCIEUNIT2DOCKE'TNUMBER12)PAGEI3i03891OF03''MISSEDSURVEILLANCEONTHE2AAND2BEMERGENCYDIESELGENERATORAUTOMATICLOADSEUENCERELAYSDUETOACOGNITIVEPERSONNELERROR.EVENTDATE(5)LERNUMBER(4)REPORTDATE(7)OTHERFACILITIESINVOLVED(SIMONTHOAYYEARYEARei>.;SEQUENTIALy'-NUMSERSrTNUMSERMONTHDAYR4Vt)KINYEARFACILITYNAMESN/ADOCKETNVMBERISI0500009178787060010168705000OPERATINOMOOK(~I~OWERL'EYEL1020402(4)20A04(e)Ill(0204444)Ii)I4I20A04(~l(1)(SI)2040441(11(lvl204044)llI(v)20404(el50.34IclI)I50.34(cl(1)X50.73(el(2)(II50.73(el(2)(4)50.73(el(2)((BILICENSEECONTACTFORTHISLER(12)50.73(~l(2)(wI50.73(~II2I(v)50.73(e)(2)(vnl50,73Ie)LT)4iil)(Al50.73(~I(2)Ivi)i~)I4I50.73I~)(2IIxlTHISREPORTISSUBMITTEDPURSUANTT0THKREQUIREMENTSOF10CFR(I;fCneceoneormoreOftnefollowing/(1173.71(4)73.71(~IOTHER(SpecifyinapstisctOelOwentrinTert,iVRCperm3544INAMEV.N.Mendoza,ShiftTechnicalAdvisorTELEPHONENUssBERAREACODE305465-:3550COMPLETEONELINKFOREACHCOMPONENTFAILUREDESCRIBEDINTHISREPORT(13)CAUSESYSTEM'COMPONENTNANANAMANUFAC.TVRERNANAc:)Prrrst2wgSYSTKMCOMPONENTMANUFAC.TVRERREPORTABLETONPRDSw'vSUPPLEMENTALREPORTEXPECTEDlle)YESfffyet,CemptetetXptCTEDSVSetfSSIOefOATtfNOABSTRACT(Limittotc00tpeces.f.e..epprosimeNryRfteentingie.specstvpewrNNnfinest(14)EXPECTEDSUBMISSIONDATE(15IMONTNDAYYEARNAAt1900onSeptember17,1987,itwasdeterminedthatthe12monthtestofthe2Aand2BEmergencyDieselGenerator(EDG)automaticloadsequencerelayswasincomplete.Areviewofthesurveillanceprocedure,performedonMay4,1987,indicatedthatonlythecomponentsonthe4160volt2A3and2B3busesweretestedandthatthetestdidnotincludethecomponentsonthe4160volt.2ABbusandthe480voltloadcenters(LC).Therootcauseoftheeventwasacognitivepersonnelerrorbyutilitypersonnelimplementingthemaintenancesurveillanceprocedureandthequalitycontrolpersonnelreviewingtheplantworkorderandthemaintenancesurveillanceprocedureforcompletenessandcompliancetothesurveillancerequirements.'Forcorrectiveactions,theelectricalmaintenancepersonnelimmediately-performedtherequiredsurveillancetestinaccordancewiththeapprovedprocedure.PlantManagementhasre-emphasizedtheimportanceofadequatereviewofplantworkordersandsurveillanceprocedures.Inaddition,thesurveillanceprocedurewasrevisedforclarity.8710@201138710~16389PDRADOCK050$NRCForm344iS43s NRt!Form3EEAO.831LICENSEEEVENTREPORT(LERITEXTCONTINUATIONU.S.NUCLEARRECULATORYCOMMISSIONAPPROUEOOMSNO.3(50-0(0<EXPIRES:8/31/88FACILITYNAME(I)ST.LUCIEUNIT2OOCKETNUMBER(2)YEARLERNUMSER(8)N).SEQUENTIALNUMBERREvrsroNNUMBERPACE(3)TEXT///moree/reooierequired,ueeeddr(r'orre/HRCForrrr3SSA'e/l)2)0500038987006-0'2OF03DESCRIPTIONOPTHEEVENTAtapproximately'1730onSeptember17;1987,operationspersonnel.werenotified~thatanFPLQualityAssuranceaudithaddeterminedthetwelvemonthtestofthe2Aand2Bemergencydieselgenerator(EDG)(EIISSEK)automaticloadsequencerelaysperformedonMay4,1987wasincomplete.Thisprocedurerequiredthatallcomponentsonthethe4160Vbusesandthe480Vloadcenters(LC)betestedforproperloadsequencerelaytiming.Duringthereview,itwasdiscoveredthatonlythecomponentsonthe4160volt2A3and2B3busesweretested.At1900onSeptember17,1987,effortswerestarted"toperformtherequiredsurveillanceteststocomplywiththeTechnicalSpecificationrequirements.By0600onSeptember18,1987,allthecomponentsonthe2AEDG(Train"A")weresatisfactorilytestedandby1453onSeptember18,1987,allofthe2Aand,2BEDGcomponentsweresatisfactorilytested.AlltherelaystestedwerefoundtobewithinthetolerancerequirementsoftheTechnicalSpecifications.St.LucieUnit82remainedatMode1,100%power,throughoutthistimeperiod.rCAUSEOPTHEEVENTTherootcauseoftheeventwasacognitivepersonnelerrorbyutilitymaintenanceandqualitycontrolpersonnelresponsibleforreviewingtheplantworkorder(PWO)toensurecompleteimplementationandcompliancewiththerequirementsofthesurveillanceprocedures.Thecopyoftheprocedureusedbythejourneymanhadhandwrittendirectionsonthe'tepsof,the.procedure.indicatingwheretostart,andwheretostop.'heseinstructionsonlycoveredthe4160volt2A3and2B3components.Consequently,'160volt2ABbusandthe480VLCportionsoftheprocedurewereneverperformed.Thereviewof.thePWOdidnotrevealthisomission.ANALYSISOPTHEEVENTTechnicalSpecifications4.8.1.1.2.drequiresthatwhileoperatinginModes1,2,3,and4eachdieselgeneratorshallbedemonstratedoperablebyverifyingthatatleastonceper12monthstheautomaticloadsequencetimersareoperablewiththeintervalbetweeneachloadblockwithinplus/minusonesecondofitsdesigninterval.SincetheSt.LucieUnitN2wasoperatinginMode'1whentheeventwasdiscovered,thisreportisbeingsubmittedunder10CFR50.73(a)(2)(i)(B),anyoperationorconditionprohibitedbytechnicalspecificat'ionsasdefinedingenericletter87-09.Thelast'urveillancefortheEDG.12-monthtest'ftheautomaticloadsequencerelayswassatisfactorilyperformedinMay1986.ThissurveillanceprocedurewascompletedonSeptember18,1987,approximately18.5dayspastthemaximumallowableextensionof25%ofthetestingintervalafterthesurveillancewas'dueandapproximately22hoursafterthediscoveryofthecondition.Allcomponentstestedsatisfactorily,thusthehealthandsafetyofthegeneralpublicwerenotaffectedbythisevent.NRCFORM3BBA(94)3)
LER  87-00b-00: on 870917'est of 2A 2B emergency'iesel Sc generator automatic load sequence relays incomplete. Caused bg personnel error. Personnel immed.iatelg perf ormed required surveillance test in accordance Uj/procedure. W/8710ib          ltr.
NRCFoehn3ddA(94)3ILICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONAPPROVEOOMBNO.3)9)W)04EXPIRES:8/31/88FACILITYNAME(I)DOCKETNUMBERl3)YEARLERNUMBER(8)SEOVENTIALNVMSSAK'IKIOAEV/SIONNVMSSAPAGE(3IST.LUCIEUNIT2TEXTIII///o/osPscois/odw'red,//sosddio'o/MIHRC%%d////3dSA'4/(17)osooo38987006003OF03CORRECTIVEACTIONS1.AfterOperationspersonnelwerenotifiedofthemissedsurveillancecondition,therequiredsurveillancewasimmediatelyperformedandwasdeemedsatisfactory.2.PlantManagementhasre-emphasizedtoplantpersonneltheimportanceofcompletingalltechnicalspecificationsurveillancesinatimelymannerasrequired.3.TheplantTxainingDepartmentwillevaluatethisitemtodetermineappropriatetrainingrequirementsandmethods..4.ThepersonnelresponsibleforpreparationandreviewoftheabovePWOhave*beencounselledontheimportanceofattentiontodetailinensuringTechnicalSpecificationsurveillancerequirementsaremet.5.Thesurveillanceprocedurewasrevisedforclarity.ADDITIONALINFORMATIONFailedcomponentinformation:Nocomponentorsystemfailuresoccuredduringthisevent.Previous.similarevent:ThemostrecentsimilareventonUnitII2wasamissedsurveillancesubmi.ttedunderLER$389-86-014.N/ICFORMSddA(94)3)
DISTRIBUTION CODE:         IESRD  COPIES RECEIVED: LTR TITLE: 50. 73 Licensee Event Report <LER)i I  ENCL  g Incident Rpti etc.
P.OX14000,JUNOBEAC<.,k.C;.gQ<0~pe.iOBcRi(,1~8(L<7OI7-IOCFR50.73U.S.NuclearRegulatoryCommissionAttn:DocumentControIDeskWashington,D.C.20555GentIemen:Re:St.LucieUnit2DocketNo.50-389ReportableEvent:87-06DateofEvent:Septemberl7,l987MissedSurveillanceonEmergencyDieselGeneratorAutoLoadSeuenceRelasTheattachedLicenseeEventReportisbeingsubmittedpursuanttotherequirmentsofIOCFR50.73.a.toprovidenotificationonthesubjectevent.Verytrulyyours,iI'p,i;o,E~C.0.Wo'odyGroupVicePresidentNuclearEnergyCOW/GRM/gpAttachmentcc:J.NelsonGrace,RegionalAdministrator,RegionII,USNRCSeniorResidentInspector,USNRC,St.LuciePlantGRMI/030/IanFPLGroupcompany}}
SIZE:
NOTES:
RECIPIENT        COPIES
* REC IP IENT        COP  IES ID CODE/NAME      LTTR ENCL        ID CODE/NAME      LTTR ENCL PD2-2 LA              1            PD2-2 PD                1      1 TOURIGNYi E            1    1 INTERNAL: ACRS MICHELSON              1    1      ACRS MOELLER            2      2 AEOD/DOA                1    1      AEQD/DSP/NAS            1      1 AEOD/DSP/ROAB          2    2      AEOD/DSP/TPAB    . 1' ARM/DCTS/DAB                        DEDRQ NRR/DEST/ADS NRR/DEST/ELB 1
1 1
1 0
1 NRR/DEST/CEB NRR/DEBT/ I CSB 1:
1      1 1
1 NRR/DEST/MEB          1    1      NRR/DEST/MTB            1      1 NRR/DEST/PSB          1    1      NRR/DEST/RSB            1      1 NRR/DEST/SGB          1    1      NRR/DLPG/HFB            1      1 NRR/DLPG/GAB          1            NRR/DOEA/EAB NRR/DREP/RAB          1 1
1      NRR/DREP/RPB 1
2      2" 1
SIB        1    1      NRR/PMAS/ ILRB          1      1.
02          1      RES DEPY GI 1      1 RES TELFQRDI  J      1            RES/DE/EIB             1' RGN2    FILE    01          1 EXTERNAL: EGLG GRQHi      M          5    5        ST LOBBY WARD        1 LPDR                  1    1      NRC'PDR                1      1 NSIC HARRISI J        1    1      NSIC MAYS. G                    1 TOTAL NUMBER OF COPIES REQUIRED:         LTTR    45    ENCL    44
 
NRC Form 344                                                                                                                                                  V.S. NUCLEAR REGULATORY COMMISSION (403)
APPROVED OMB NO. 3150010C EXPIRES,' i 3) i45 LICENSEE EVENT REPORT (LER)
FACILITY NAME (I)                                                                                                                                   DOCKE'T NUMBER 12)                             PAGE  I3i 389 1OF03
        ''ST.MISSED  LUCIE UNIT 2                                                                                                                                      0 SURVEILLANCE ON                  THE 2A AND 2B EMERGENCY DIESEL GENERATOR AUTOMATIC LOAD SE UENCE RELAYS DUE TO A COGNITIVE PERSONNEL ERROR.
EVENT DATE (5)                         LER NUMBER (4)                           REPORT DATE (7)                               OTHER FACILITIES INVOLVED (SI MONTH                              YEAR    ei>.; SEQUENTIAL        R 4 Vt)KIN MONTH        DAY        YEAR              FACILITY NAMES                            DOCKET NVMBERISI OAY      YEAR              y'     -
NUMSER      SrT NUMSER N/A                                    0    5    0      0    0 0      9 1 7            8 7 8          7        0Ill(0      6        0010                  1      6 8 7                                    i)i 0    5    0      0    0 THIS REPORT IS SUBMITTED PURSUANT T 0 THK REQUIREMENTS OF 10 CFR (I; fCnece one or more Of tne following/ (11 OPERATINO MOOK    (~ I 20402(4)                                 20404(el                                50.73( ~ l(2)(wI                                    73.71(4)
    ~ OWER L'EY EL 20A04(e)                                  50.34 Icl I)I                            50.73 ( ~ II 2 I( v)                               73.71( ~ I 1 0                20 4444) Ii) I 4 I                        50.34(cl(1)                               50.73(e) (2)(vnl                                  OTHER (Specify in apstisct OelOw entr  in Tert, iVRC perm 20A04( ~ l(1)(SI)                   X    50.73(el(2)(II                            50,7 3 Ie) LT)4iil)(Al                            3544I 2040441(11(lvl                            50.73(el(2)(4)                            50.7 3( ~ I (2) Iv    ) I4 I 204044)    llI (v)                       50.7 3(e l(2)((BI                        50.73I ~ )(2IIxl LICENSEE CONTACT FOR THIS LER (12)
NAME                                                                                                                                                                  TELEPHONE NUssBER AREA CODE V. N. Mendoza,                     Shift Technical Advisor                                                                                    3    054 65-: 3550 COMPLETE ONE LINK FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)
MANUFAC.                                                                                                  MANUFAC.        REPORTABLE CAUSE    SYSTEM      'COMPONENT                                                                              SYSTKM    COMPONENT                      TVRER TVRER                                                                                                                    TO NPRDS c:)Prrrst 2 wg w'v NA          NA            NA                  NA                NA SUPPLEMENTAL REPORT EXPECTED            lle)                                                                               MONTN        DAY      YEAR EXPECTED SUBMISSION DATE (15I YES  fff yet, Cemptete  tXptCTED SVSetfSSIOef OATtf                                      NO                                                                              N A ABSTRACT (Limit to tc00 tpeces. f.e.. epprosimeNry Rfteen tingie.specs tvpewrNNn finest (14)
At 1900 on September 17, 1987,                                                   it        was determined that the 12 month test of the 2A and                        2B      Emergency            Diesel                Generator        (EDG) automatic load sequence relays was incomplete.                                   A    review              of      the    surveillance                          procedure, performed on May 4, 1987,                             indicated            that          only          the    components                      on      the 4160 volt 2A3 and 2B3 buses were                            tested        and        that          the    test    did        not            include            the components on the          4160      volt        . 2AB  bus      and    the        480        volt    load    centers                    (LC).
The        root cause                    of the event was a cognitive personnel error                                                                      by      utility personnel              implementing the maintenance surveillance procedure and                                                                              the quality control personnel reviewing the plant work order and the                                                                                                    maintenance surveillance procedure for completeness and compliance to the                                                                                            surveillance requirements.
              'For corrective actions, the electrical maintenance personnel immediately
              -performed the required surveillance test in accordance with the approved procedure.                   Plant Management has re-emphasized the importance of adequate review of plant work orders and surveillance procedures.                                                                                       In addition, the surveillance procedure was revised for clarity.
8710@20113 8710~16389        050 PDR            ADOCK NRC Form 344 iS 43s
 
U.S. NUCLEAR RECULATORY COMMISSION NRt! Form 3EEA O.831 LICENSEE EVENT REPORT (LERI TEXT CONTINUATION                                                                  APPROUEO OMS NO. 3(50-0(0<
EXPIRES: 8/31/88 FACILITY NAME      (I)                                                               OOCKET NUMBER (2)                       LER NUMSER (8)                                   PACE (3)
YEAR  N). SEQUENTIAL                    REvrsroN NUMBER                      NUMBER ST. LUCIE UNIT 2 0  5    0  0  0  3    898      7        006 0'                                    2 OF      0 3 TEXT /// more e/reoo ie required, uee eddr(r'orre/ HRC Forrrr 3SSA'e/ l)2)
DESCRIPTION OP THE EVENT At approximately '1730                                    on  September        17; 1987, operations personnel. were notified that an FPL Quality
                                      ~                                         Assurance        audit had determined the twelve month test of the 2A and 2B emergency                                      diesel        generator (EDG) (EIISSEK) automatic load sequence relays performed on May 4,                                           1987    was incomplete.         This procedure required that all components on                                        the      the    4160    V  buses    and    the                    480 V load centers (LC) be tested for proper                                          load    sequence      relay    timing.                       During the review,             it      was discovered that only                          the    components      on    the  4160 efforts volt 2A3 were and 2B3 buses were tested.                                       At  1900      on    September      17,     1987, started to perform the required surveillance          tests    to    comply                    with        the Technical Specification                                    requirements.           By    0600    on  September        18,                   1987,         all the components on the 2A EDG (Train "A") were satisfactorily tested and by 1453 on September 18, 1987, all of the 2A and, 2B EDG components were satisfactorily tested. All the relays tested were found to be within the tolerance                requirements                  of the      Technical Specifications.                     St.                   Lucie Unit 82 remained                  at  Mode 1,             100% power,   throughout          this  time  period.
r CAUSE OP THE EVENT The root cause of the event was a cognitive personnel error by utility maintenance and quality control personnel responsible                                                            for reviewing the plant work order (PWO) to ensure complete implementation and compliance with the requirements of the surveillance procedures.                                                             The copy of the procedure used by the journeyman had handwritten directions on the'teps of, the .procedure .indicating where to start, and where to stop.'hese instructions only covered the 4160 volt 2A3 and 2B3 components.                                                         Consequently,'160 volt 2AB bus and the 480 V LC portions of the procedure were never performed. The review of. the PWO did not reveal this omission.
ANALYSIS OP THE EVENT Technical Specifications 4.8.1.1.2.d requires that while operating in Modes 1,2,3,and 4 each diesel generator shall be demonstrated operable by verifying that at least once per 12 months the automatic load sequence timers are operable with the interval between each load block within plus/minus one second of its design interval. Since the St. Lucie Unit N2 was operating in Mode'1 when the event was discovered, this report is being submitted under 10 CFR 50.73(a)
(2)(i)(B), any operation or condition prohibited by technical specificat'ions as defined in generic letter 87-09. The last'urveillance for the EDG .12-month test'f the automatic load sequence relays was satisfactorily performed in May 1986.                 This surveillance procedure was completed on September 18, 1987, approximately 18.5 days past the maximum allowable extension of 25% of the testing interval after the surveillance was'due and approximately 22 hours after the discovery of the condition. All components tested satisfactorily, thus the health and safety of the general public were not affected by this event.
NRC FORM 3BBA (94)3)
 
NRC Foehn 3ddA                                                                                                            U.S. NUCLEAR REGULATORY COMMISSION (94)3 I LICENSEE EVENT REPORT (LER) TEXT CONTINUATION                                      APPROVEO OMB NO. 3)9)W)04 EXPIRES: 8/31/88 FACILITY NAME (I)                                                                 DOCKET NUMBER l3)             LER NUMBER (8)                   PAGE (3I SEOVENTIAL    K
                                                                                                                                    'I AEV/SION YEAR      NVMSSA    KIO    NVMSSA ST. LUCIE UNIT 2 o  s  o  o    o 38 987            006              0        0 3 OF      03 TEXT III///o/o sPsco is /odw'red, //so sddio'o/MIHRC %%d////3dSA'4/ (17)
CORRECTIVE ACTIONS
: 1.       After Operations personnel                          were  notified of the missed surveillance condition, the required surveillance                          was  immediately performed and was deemed satisfactory.
: 2.       Plant Management has re-emphasized to plant personnel the importance of completing all technical specification surveillances in a timely manner as required.
: 3.       The      plant Txaining Department                    will evaluate this      item to determine appropriate training requirements                          and methods..
: 4.       The      personnel responsible for preparation and review of the above PWO have been        counselled on the importance of attention to detail in ensuring Technical Specification surveillance requirements are met.
: 5.       The      surveillance procedure                    was  revised for    clarity.
ADDITIONAL INFORMATION Failed component information:
No component                  or system failures occured during this event.
Previous .similar event:
The most recent similar event on Unit                                  II2 was a missed    surveillance submi.tted under LER $ 389-86-014.
N/IC FORM SddA (94)3)
 
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L<7 OI7-IO CFR 50.73 U.S. Nuclear Regulatory Commission A t tn: Doc umen t Contr o I Desk Washington, D. C. 20555 Gen t I emen:
Re:     St. Lucie Unit 2 Docket No. 50-389 Reportable Event: 87-06 Date of Event: September l7, l 987 Missed Surveillance on Emergency Diesel Generator Auto Load Se uence Rela  s The    attached Licensee Event Report is being submitted pursuant to the requirments of IO CFR 50.73.a. to provide notification on the subject event.
Very truly yours, iI'p,i;o,E~
C. 0. Wo'ody Group Vice President Nuclear Energy COW/GRM/gp Attachment cc:   J. Nelson Grace, Regional Administrator, Region II, USNRC Senior Resident Inspector, USNRC, St. Lucie Plant GRM I /030/I                                                                  an FPL Group company}}

Latest revision as of 14:30, 4 February 2020

LER 87-006-00:on 870917,discovered That Test of Emergency Diesel Generator Automatic Load Sequence Relays Incomplete. Caused by Personnel Error.Personnel Immediately Performed Required Surveillance Test Per procedure.W/871016 Ltr
ML17221A444
Person / Time
Site: Saint Lucie NextEra Energy icon.png
Issue date: 10/16/1987
From: Mendoza V, Woody C
FLORIDA POWER & LIGHT CO.
To:
NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
L-87-417, LER-87-006-03, LER-87-6-3, NUDOCS 8710220113
Download: ML17221A444 (5)


Text

REGULAT INFORMATION DISTRIBUTIO YSTEM <RIDS)

ACCESSION NBR 8710220113 DOC. DATE: 87/10/ib NOTARIZED: NO DOCKET ¹ FAC IL: 50-389 St. Lucie Planti Unit 2i Florida Poeer h Light Co. 05000389 AUTH. NAME AUTHOR AFF ILIAT ION MEN DO Z A I V. N. Florida Power 5 Li ght Co.

WOODY'. O. Florida Poeer 5 Light Co.

RECIP. NAME RECIPIENT 'AFFILIATION

SUBJECT:

LER 87-00b-00: on 870917'est of 2A 2B emergency'iesel Sc generator automatic load sequence relays incomplete. Caused bg personnel error. Personnel immed.iatelg perf ormed required surveillance test in accordance Uj/procedure. W/8710ib ltr.

DISTRIBUTION CODE: IESRD COPIES RECEIVED: LTR TITLE: 50. 73 Licensee Event Report <LER)i I ENCL g Incident Rpti etc.

SIZE:

NOTES:

RECIPIENT COPIES

  • REC IP IENT COP IES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-2 LA 1 PD2-2 PD 1 1 TOURIGNYi E 1 1 INTERNAL: ACRS MICHELSON 1 1 ACRS MOELLER 2 2 AEOD/DOA 1 1 AEQD/DSP/NAS 1 1 AEOD/DSP/ROAB 2 2 AEOD/DSP/TPAB . 1' ARM/DCTS/DAB DEDRQ NRR/DEST/ADS NRR/DEST/ELB 1

1 1

1 0

1 NRR/DEST/CEB NRR/DEBT/ I CSB 1:

1 1 1

1 NRR/DEST/MEB 1 1 NRR/DEST/MTB 1 1 NRR/DEST/PSB 1 1 NRR/DEST/RSB 1 1 NRR/DEST/SGB 1 1 NRR/DLPG/HFB 1 1 NRR/DLPG/GAB 1 NRR/DOEA/EAB NRR/DREP/RAB 1 1

1 NRR/DREP/RPB 1

2 2" 1

SIB 1 1 NRR/PMAS/ ILRB 1 1.

02 1 RES DEPY GI 1 1 RES TELFQRDI J 1 RES/DE/EIB 1' RGN2 FILE 01 1 EXTERNAL: EGLG GRQHi M 5 5 ST LOBBY WARD 1 LPDR 1 1 NRC'PDR 1 1 NSIC HARRISI J 1 1 NSIC MAYS. G 1 TOTAL NUMBER OF COPIES REQUIRED: LTTR 45 ENCL 44

NRC Form 344 V.S. NUCLEAR REGULATORY COMMISSION (403)

APPROVED OMB NO. 3150010C EXPIRES,' i 3) i45 LICENSEE EVENT REPORT (LER)

FACILITY NAME (I) DOCKE'T NUMBER 12) PAGE I3i 389 1OF03

ST.MISSED LUCIE UNIT 2 0 SURVEILLANCE ON THE 2A AND 2B EMERGENCY DIESEL GENERATOR AUTOMATIC LOAD SE UENCE RELAYS DUE TO A COGNITIVE PERSONNEL ERROR.

EVENT DATE (5) LER NUMBER (4) REPORT DATE (7) OTHER FACILITIES INVOLVED (SI MONTH YEAR ei>.; SEQUENTIAL R 4 Vt)KIN MONTH DAY YEAR FACILITY NAMES DOCKET NVMBERISI OAY YEAR y' -

NUMSER SrT NUMSER N/A 0 5 0 0 0 0 9 1 7 8 7 8 7 0Ill(0 6 0010 1 6 8 7 i)i 0 5 0 0 0 THIS REPORT IS SUBMITTED PURSUANT T 0 THK REQUIREMENTS OF 10 CFR (I; fCnece one or more Of tne following/ (11 OPERATINO MOOK (~ I 20402(4) 20404(el 50.73( ~ l(2)(wI 73.71(4)

~ OWER L'EY EL 20A04(e) 50.34 Icl I)I 50.73 ( ~ II 2 I( v) 73.71( ~ I 1 0 20 4444) Ii) I 4 I 50.34(cl(1) 50.73(e) (2)(vnl OTHER (Specify in apstisct OelOw entr in Tert, iVRC perm 20A04( ~ l(1)(SI) X 50.73(el(2)(II 50,7 3 Ie) LT)4iil)(Al 3544I 2040441(11(lvl 50.73(el(2)(4) 50.7 3( ~ I (2) Iv ) I4 I 204044) llI (v) 50.7 3(e l(2)((BI 50.73I ~ )(2IIxl LICENSEE CONTACT FOR THIS LER (12)

NAME TELEPHONE NUssBER AREA CODE V. N. Mendoza, Shift Technical Advisor 3 054 65-: 3550 COMPLETE ONE LINK FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)

MANUFAC. MANUFAC. REPORTABLE CAUSE SYSTEM 'COMPONENT SYSTKM COMPONENT TVRER TVRER TO NPRDS c:)Prrrst 2 wg w'v NA NA NA NA NA SUPPLEMENTAL REPORT EXPECTED lle) MONTN DAY YEAR EXPECTED SUBMISSION DATE (15I YES fff yet, Cemptete tXptCTED SVSetfSSIOef OATtf NO N A ABSTRACT (Limit to tc00 tpeces. f.e.. epprosimeNry Rfteen tingie.specs tvpewrNNn finest (14)

At 1900 on September 17, 1987, it was determined that the 12 month test of the 2A and 2B Emergency Diesel Generator (EDG) automatic load sequence relays was incomplete. A review of the surveillance procedure, performed on May 4, 1987, indicated that only the components on the 4160 volt 2A3 and 2B3 buses were tested and that the test did not include the components on the 4160 volt . 2AB bus and the 480 volt load centers (LC).

The root cause of the event was a cognitive personnel error by utility personnel implementing the maintenance surveillance procedure and the quality control personnel reviewing the plant work order and the maintenance surveillance procedure for completeness and compliance to the surveillance requirements.

'For corrective actions, the electrical maintenance personnel immediately

-performed the required surveillance test in accordance with the approved procedure. Plant Management has re-emphasized the importance of adequate review of plant work orders and surveillance procedures. In addition, the surveillance procedure was revised for clarity.

8710@20113 8710~16389 050 PDR ADOCK NRC Form 344 iS 43s

U.S. NUCLEAR RECULATORY COMMISSION NRt! Form 3EEA O.831 LICENSEE EVENT REPORT (LERI TEXT CONTINUATION APPROUEO OMS NO. 3(50-0(0<

EXPIRES: 8/31/88 FACILITY NAME (I) OOCKET NUMBER (2) LER NUMSER (8) PACE (3)

YEAR N). SEQUENTIAL REvrsroN NUMBER NUMBER ST. LUCIE UNIT 2 0 5 0 0 0 3 898 7 006 0' 2 OF 0 3 TEXT /// more e/reoo ie required, uee eddr(r'orre/ HRC Forrrr 3SSA'e/ l)2)

DESCRIPTION OP THE EVENT At approximately '1730 on September 17; 1987, operations personnel. were notified that an FPL Quality

~ Assurance audit had determined the twelve month test of the 2A and 2B emergency diesel generator (EDG) (EIISSEK) automatic load sequence relays performed on May 4, 1987 was incomplete. This procedure required that all components on the the 4160 V buses and the 480 V load centers (LC) be tested for proper load sequence relay timing. During the review, it was discovered that only the components on the 4160 efforts volt 2A3 were and 2B3 buses were tested. At 1900 on September 17, 1987, started to perform the required surveillance tests to comply with the Technical Specification requirements. By 0600 on September 18, 1987, all the components on the 2A EDG (Train "A") were satisfactorily tested and by 1453 on September 18, 1987, all of the 2A and, 2B EDG components were satisfactorily tested. All the relays tested were found to be within the tolerance requirements of the Technical Specifications. St. Lucie Unit 82 remained at Mode 1, 100% power, throughout this time period.

r CAUSE OP THE EVENT The root cause of the event was a cognitive personnel error by utility maintenance and quality control personnel responsible for reviewing the plant work order (PWO) to ensure complete implementation and compliance with the requirements of the surveillance procedures. The copy of the procedure used by the journeyman had handwritten directions on the'teps of, the .procedure .indicating where to start, and where to stop.'hese instructions only covered the 4160 volt 2A3 and 2B3 components. Consequently,'160 volt 2AB bus and the 480 V LC portions of the procedure were never performed. The review of. the PWO did not reveal this omission.

ANALYSIS OP THE EVENT Technical Specifications 4.8.1.1.2.d requires that while operating in Modes 1,2,3,and 4 each diesel generator shall be demonstrated operable by verifying that at least once per 12 months the automatic load sequence timers are operable with the interval between each load block within plus/minus one second of its design interval. Since the St. Lucie Unit N2 was operating in Mode'1 when the event was discovered, this report is being submitted under 10 CFR 50.73(a)

(2)(i)(B), any operation or condition prohibited by technical specificat'ions as defined in generic letter 87-09. The last'urveillance for the EDG .12-month test'f the automatic load sequence relays was satisfactorily performed in May 1986. This surveillance procedure was completed on September 18, 1987, approximately 18.5 days past the maximum allowable extension of 25% of the testing interval after the surveillance was'due and approximately 22 hours2.546296e-4 days <br />0.00611 hours <br />3.637566e-5 weeks <br />8.371e-6 months <br /> after the discovery of the condition. All components tested satisfactorily, thus the health and safety of the general public were not affected by this event.

NRC FORM 3BBA (94)3)

NRC Foehn 3ddA U.S. NUCLEAR REGULATORY COMMISSION (94)3 I LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVEO OMB NO. 3)9)W)04 EXPIRES: 8/31/88 FACILITY NAME (I) DOCKET NUMBER l3) LER NUMBER (8) PAGE (3I SEOVENTIAL K

'I AEV/SION YEAR NVMSSA KIO NVMSSA ST. LUCIE UNIT 2 o s o o o 38 987 006 0 0 3 OF 03 TEXT III///o/o sPsco is /odw'red, //so sddio'o/MIHRC %%d////3dSA'4/ (17)

CORRECTIVE ACTIONS

1. After Operations personnel were notified of the missed surveillance condition, the required surveillance was immediately performed and was deemed satisfactory.
2. Plant Management has re-emphasized to plant personnel the importance of completing all technical specification surveillances in a timely manner as required.
3. The plant Txaining Department will evaluate this item to determine appropriate training requirements and methods..
4. The personnel responsible for preparation and review of the above PWO have been counselled on the importance of attention to detail in ensuring Technical Specification surveillance requirements are met.
5. The surveillance procedure was revised for clarity.

ADDITIONAL INFORMATION Failed component information:

No component or system failures occured during this event.

Previous .similar event:

The most recent similar event on Unit II2 was a missed surveillance submi.tted under LER $ 389-86-014.

N/IC FORM SddA (94)3)

P. OX 14000, JUNO BEAC<., k .

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L<7 OI7-IO CFR 50.73 U.S. Nuclear Regulatory Commission A t tn: Doc umen t Contr o I Desk Washington, D. C. 20555 Gen t I emen:

Re: St. Lucie Unit 2 Docket No. 50-389 Reportable Event: 87-06 Date of Event: September l7, l 987 Missed Surveillance on Emergency Diesel Generator Auto Load Se uence Rela s The attached Licensee Event Report is being submitted pursuant to the requirments of IO CFR 50.73.a. to provide notification on the subject event.

Very truly yours, iI'p,i;o,E~

C. 0. Wo'ody Group Vice President Nuclear Energy COW/GRM/gp Attachment cc: J. Nelson Grace, Regional Administrator, Region II, USNRC Senior Resident Inspector, USNRC, St. Lucie Plant GRM I /030/I an FPL Group company