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| {{#Wiki_filter:DOCKET05000389ACCELERATED DOCQVIENT DISTRIBUTION SYSTEMREGU~ORYINFORMATION DISTRIBUT | | {{#Wiki_filter:DOCKET 05000389 ACCELERATED DOCQVIENT DISTRIBUTION SYSTEM REGU~ORY INFORMATION DISTRIBUT.SYSTEM (RIDE)!ACCESSION NBR:9306160342 DOC.DATE: 93/06/14 NOTARIZED: |
| .SYSTEM(RIDE)!ACCESSION NBR:9306160342 DOC.DATE: | | NO FACIL:50-389 St.Lucie Plant, Unit 2, Florida Power&Light Co.AUTH.NAME AUTHOR AFFILIATION HURCHALLA,J.A. |
| 93/06/14NOTARIZED: | | Florida Power&Light Co.SAGER,D.A. |
| NOFACIL:50-389 St.LuciePlant,Unit2,FloridaPower&LightCo.AUTH.NAMEAUTHORAFFILIATION HURCHALLA,J.A.
| | Florida Power&Light Co.RECIP.NAME RECIPIENT AFFILIATION |
| FloridaPower&LightCo.SAGER,D.A.
| |
| FloridaPower&LightCo.RECIP.NAME RECIPIENT AFFILIATION
| |
|
| |
|
| ==SUBJECT:== | | ==SUBJECT:== |
| LER93-006-00:on 930513,EDG 2Binadvertently startedduringsafeguards relaytestingduetopersonnel error.Personnel.
| | LER 93-006-00:on 930513,EDG 2B inadvertently started during safeguards relay testing due to personnel error.Personnel. |
| performing testcounseled oncommunications | | performing test counseled on communications |
| &safeguards relaytestingcompleted satisfactorily.W/930611 ltr.DISTRIBUTION CODE:IE22TCOPIESRECEIVED:LTR ENCLSIZE:TITLE:50.73/50.9 LicenseeEventReport(LER),IncidentRpt,etc.NOTES:DRECIPIENT ZDCODE/NAME PD2-2LANORRIS,JINTERNAL: | | &safeguards relay testing completed satisfactorily.W/930611 ltr.DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL SIZE: TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.NOTES: D RECIPIENT ZD CODE/NAME PD2-2 LA NORRIS,J INTERNAL: ACNW AEOD/DOA AEOD/ROAB/DSP NRR/DE/EMEB NRR/DRCH/HICB NRR/DRIL/RPEB NRR/DRSS/PRPB NRR/DSSA/SRXB RES/DSIR/EZB EXTERNAL: EG&G BRYCE,J.H NRC PDR NSIC POOREFW.COPIES LTTR ENCL 1 1 1 1 2 2 1 1 2 2 1 1 1 1 1 1 2 2 1 1 1 1 2 2 1 1 1 1 RECIPIENT ID CODE/NAME PD2-2 PD ACRS AEOD/DSP/TPAB NRR/DE/EELB NRR/DRCH/HHFB NRR/DRCH/HOLB NRR/DRPW/OEAB NRR/DISA SPLB REGLAZE 02 RGN2 FILE 01 L ST LOBBY WARD NSIC MURPHY,G.A NUDOCS FULL TXT COPIES LTTR ENCL 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 D D x$D NOTE TO ALL"RIDS" RECIPIENTS: |
| ACNWAEOD/DOAAEOD/ROAB/DSP NRR/DE/EMEB NRR/DRCH/HICB NRR/DRIL/RPEB NRR/DRSS/PRPB NRR/DSSA/SRXB RES/DSIR/EZB EXTERNAL:
| | PLEASE HELP US TO REDUCE WASTE!CONTACI'HE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT.504-2065)TO ELIMINATE YOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!D FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 32 ENCL 32 FPL June.11, 1993 P.O.Box 128, Ft.Pierce, FL 34954-0128 L-93-157 10.CFR 50.73 U.S.Nuclear Regulatory Commission Attn: Document Control Desk Washington, D.C.20555 Re: St.Lucie Unit 2 Docket No.50-389 Reportable Event: 93-06 Date of Event: May 13, 1993 Inadvertent Start of the 2B Emer enc Diesel Geneiator The attached Licensee Event Report is being submitted pursuant to the requirements of 10 CFR 50.73 to provide notification of the subject event.Very truly yours, D.A.ger Vice sident St.Lucie Plant DAS/JJB/kw Attachment cc: Stewart D.Ebneter, Regional Administrator, USNRC Region II Senior Resident Inspector, USNRC, St.Lucie Plant DAS/PSL 8932-93 l 5008'i'DR ADOCK 05000389 S an FPL Group company gl F P~.FocsTITTTs ol MIC Form SM Psst U.S.NUCLEAR REGULATORY COMMISS CN LICENSEE EVENT REPORT (LER)NTISWEO OIAI HEI$1 ICS 155 EAIHEW ACCS5 ESINATEO IAACE H IEH IKSPONSE To CCINIY WTIH TITS SSOISIAWOH CCIIECTIISI IHOUESTl 50 0 ITIS TarWAITI CaANIIIS ISCNEWIC TAAS5EH ESISIATE To TIC IHCaEIS NEI tEtarrS HNIAOE HE HT WINICH It CTTA IAS IAICIENI IH 55SATOHY~WAWSHH CW.OC 5555!5 NII TO THE ttOTWWTTUI IHOUCTESI RCIXCT oIIS51515aTICEa HAHACEAEHTNAITAeaET esNHATToAOC 5555S FACILITY NAME (1)St.Lucie Unit 2 DOCKET NUMBER (2)PAGE 3 050003891 0 3'~()Inadvertant Start of the 2B Emergency Diesel Generator During Safeguards Relay Testing Due to Personnel Error EVENT DATE (5)MONTH DAY YEAR YEAR I S IAL LER NUMBER (6)REPORT DATE (7)MONTH DAY YEAR FACILITY NAMES N/A DOCKET NUMBER(S)0 5 OTHER FACILITIES INVOLVED (8)0 5 1 3 9393 0 0 6 0 0 0 6 1 4 9 3 N/A 05000 POWER LEVEL (10)1 0 0 OPERATING MODE (9)X 50.73(a)(2)(iv) 20.402(b)20.405(a)(1 |
| EG&GBRYCE,J.H NRCPDRNSICPOOREFW.COPIESLTTRENCL1111221122111111221111221111RECIPIENT IDCODE/NAME PD2-2PDACRSAEOD/DSP/TPAB NRR/DE/EELB NRR/DRCH/HHFB NRR/DRCH/HOLB NRR/DRPW/OEAB NRR/DISASPLBREGLAZE02RGN2FILE01LSTLOBBYWARDNSICMURPHY,G.A NUDOCSFULLTXTCOPIESLTTRENCL11221111111111111111111111DDx$DNOTETOALL"RIDS"RECIPIENTS: | | )(i)20.405(c)50.36(c)(1) 50.73(a)(2)(v) 50.73(a)(2)(vii) 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(viii)(A) 50.73(a)(2)(viii)(B) 50.73(a)(2)(x) 20.405(a)(1)(iii) 20.405(a)(1)(iv) 20.405(a)(1)(v) 50.73(a)(2)(i) 50.73(a)(2)(ii) 50.73(a)(2)(iii) |
| PLEASEHELPUSTOREDUCEWASTE!CONTACI'HE DOCUMENTCONTROLDESK,ROOMPl-37(EXT.504-2065)
| | LICENSEE CONTACT FOR THIS LER 12 THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR: Check one or more of the followin (11)73.71(b)73.71(c)OTHER (Specify in Abstract below andin Text NRC Form 366A)James A.Hurchalla, Shift Technical Advisor TELEP ONE NUMBER AREACODE 4 0 7 4 6 5-3 5 5 0 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT 13 CAUSE SYSTEM COMPONENT MANUFAC-TURER REPORTABLE TO NPRDS CAUSE SYSTEM COMPONENT MANUFAC-REPORTABLE TURER TO NPRDS SUPPLEMENTAL REPORT EXPECTED 14 I I I EXPECTED MONTH DAY YEAR SUBMISSION DATE (15)YFS (If yes, complete EXPECTED SUBMISSION DATE)X NO ABSTRACT (Limit to 1400 spaces.i.e. |
| TOELIMINATE YOURNAMEFROMDISTRIBUTION LISTSFORDOCUMENTS YOUDON'TNEED!DFULLTEXTCONVERSION REQUIREDTOTALNUMBEROFCOPIESREQUIRED:
| | approximately fifteen single-space typewritten lines)(16)On May 13, 1993, at 1920 hours with Unit 2 in Mode 1 at 100%power, Instrument and Control (IBC)personnel were performing the"Engineered Safeguards Relay Test" procedure OP 2-0400053 in coordination with the Unit 2 Operating crew.Operations had set up the initial test conditions including control isolation of the 2B Emergency Diesel Generator (EDG)from the Engineered Safety Features Actuation System (ESFAS).Instrument and Control technicians then connected a multifunction test meter across an ESFAS relay contact which provides an EDG start and injected a trip test signal to check this circuit's actuation. |
| LTTR32ENCL32 FPLJune.11,1993P.O.Box128,Ft.Pierce,FL34954-0128 L-93-15710.CFR50.73U.S.NuclearRegulatory Commission Attn:DocumentControlDeskWashington, D.C.20555Re:St.LucieUnit2DocketNo.50-389Reportable Event:93-06DateofEvent:May13,1993Inadvertent Startofthe2BEmerencDieselGeneiator TheattachedLicenseeEventReportisbeingsubmitted pursuanttotherequirements of10CFR50.73toprovidenotification ofthesubjectevent.Verytrulyyours,D.A.gerVicesidentSt.LuciePlantDAS/JJB/kw Attachment cc:StewartD.Ebneter,RegionalAdministrator, USNRCRegionIISeniorResidentInspector, USNRC,St.LuciePlantDAS/PSL8932-93l5008'i'DR ADOCK05000389SanFPLGroupcompanygl FP~.FocsTITTTs olMICFormSMPsstU.S.NUCLEARREGULATORY COMMISSCNLICENSEEEVENTREPORT(LER)NTISWEOOIAIHEI$1ICS155EAIHEWACCS5ESINATEOIAACEHIEHIKSPONSEToCCINIYWTIHTITSSSOISIAWOH CCIIECTIISI IHOUESTl500ITISTarWAITICaANIIISISCNEWICTAAS5EHESISIATEToTICIHCaEISNEItEtarrSHNIAOEHEHTWINICHItCTTAIASIAICIENIIH55SATOHY~WAWSHHCW.OC5555!5NIITOTHEttOTWWTTUI IHOUCTESI RCIXCToIIS51515aTICEa HAHACEAEHTNAITAeaET esNHATToAOC 5555SFACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(2)PAGE3050003891 03'~()Inadvertant Startofthe2BEmergency DieselGenerator DuringSafeguards RelayTestingDuetoPersonnel ErrorEVENTDATE(5)MONTHDAYYEARYEARISIALLERNUMBER(6)REPORTDATE(7)MONTHDAYYEARFACILITYNAMESN/ADOCKETNUMBER(S) 05OTHERFACILITIES INVOLVED(8)0513939300600061493N/A05000POWERLEVEL(10)100OPERATING MODE(9)X50.73(a)(2)(iv) 20.402(b) 20.405(a)(1
| | When the IRC supervisor did not obtain the desired results he informed the Assistant Nuclear Plant Supervisor that Operations personnel could"reset" following the test.Operations restored the plant to normal including taking the EDG normal/isolate switches back to the normal position thereby unisolating the 2B EDG from the ESFAS.Approximately one minute later the 2B EDG started and performed as expected for an automatic safeguards actuation. |
| )(i)20.405(c) 50.36(c)(1) 50.73(a)(2)(v) 50.73(a)(2)(vii) 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(viii)(A) 50.73(a)(2)(viii)(B) 50.73(a)(2)(x) 20.405(a)(1)(iii) 20.405(a)(1)(iv) 20.405(a)(1)(v) 50.73(a)(2)(i) 50.73(a)(2)(ii) 50.73(a)(2)(iii) | | The 2B EDG was immediately secured and the safeguards relay testing was stopped pending investigation of why the EDG had started.The root cause of the unplanned start of the 2B EDG was due to personnel error.The l8C supervisor intended to perform the test again and only intended for Operations to reset the ESFAS signals to restore the initial test conditions. |
| LICENSEECONTACTFORTHISLER12THISREPORTISSUBMITTED PURSUANTTOTHEREQUIREMENTS OF10CFR:Checkoneormoreofthefollowin(11)73.71(b)73.71(c)OTHER(SpecifyinAbstractbelowandinTextNRCForm366A)JamesA.Hurchalla, ShiftTechnical AdvisorTELEPONENUMBERAREACODE407465-3550COMPLETEONELINEFOREACHCOMPONENT FAILUREDESCRIBED INTHISREPORT13CAUSESYSTEMCOMPONENT MANUFAC-TURERREPORTABLE TONPRDSCAUSESYSTEMCOMPONENT MANUFAC-REPORTABLE TURERTONPRDSSUPPLEMENTAL REPORTEXPECTED14IIIEXPECTEDMONTHDAYYEARSUBMISSION DATE(15)YFS(Ifyes,completeEXPECTEDSUBMISSION DATE)XNOABSTRACT(Limitto1400spaces.i.e.
| | However, based on previous communications following each test, Operations understood the reset request as that the test was complete and that they could secure from the test conditions. |
| approximately fifteensingle-space typewritten lines)(16)OnMay13,1993,at1920hourswithUnit2inMode1at100%power,Instrument andControl(IBC)personnel wereperforming the"Engineered Safeguards RelayTest"procedure OP2-0400053 incoordination withtheUnit2Operating crew.Operations hadsetuptheinitialtestconditions including controlisolation ofthe2BEmergency DieselGenerator (EDG)fromtheEngineered SafetyFeaturesActuation System(ESFAS).Instrument andControltechnicians thenconnected amultifunction testmeteracrossanESFASrelaycontactwhichprovidesanEDGstartandinjectedatriptestsignaltocheckthiscircuit's actuation. | | A contributing factor was a lack of procedural guidance for repeating or securing the test conditions. |
| WhentheIRCsupervisor didnotobtainthedesiredresultsheinformedtheAssistant NuclearPlantSupervisor thatOperations personnel could"reset"following thetest.Operations restoredtheplanttonormalincluding takingtheEDGnormal/isolate switchesbacktothenormalpositiontherebyunisolating the2BEDGfromtheESFAS.Approximately oneminutelaterthe2BEDGstartedandperformed asexpectedforanautomatic safeguards actuation.
| | Corrective actions: 1)Personnel performing the test were counseled on communications. |
| The2BEDGwasimmediately securedandthesafeguards relaytestingwasstoppedpendinginvestigation ofwhytheEDGhadstarted.Therootcauseoftheunplanned startofthe2BEDGwasduetopersonnel error.Thel8Csupervisor intendedtoperformthetestagainandonlyintendedforOperations toresettheESFASsignalstorestoretheinitialtestconditions.
| | 2)The safeguards relay testing was completed satisfactorily.3) |
| However,basedonpreviouscommunications following eachtest,Operations understood theresetrequestasthatthetestwascompleteandthattheycouldsecurefromthetestconditions. | | OP2-0400053 will be changed to ensure test equipment is removed prior to restoring plant equipment. |
| Acontributing factorwasalackofprocedural guidanceforrepeating orsecuringthetestconditions.
| | 4)A Human Performance Enhancement Review was conducted and the conclusions incorporated in this report.5)Training on this event will be provided for appropriate plant personnel. |
| Corrective actions:1)Personnel performing thetestwerecounseled oncommunications. | | FPL FacsimIIe of NRC Form 366 (6-89) |
| 2)Thesafeguards relaytestingwascompleted satisfactorily.3) | | F PL FttcCilrTIIT ol NRC Form S68 ($80)US.NUCLEAR REGULATORY COMMlSSION LICENSEE EVENT REPORT (LER)'EXT CONTINUATtON JTTTITTVT0 CAe NCt St NIT I II CrtTNXN AIIIN t CCTAIATT0 IlNCTN rr II ICSKWX To CCINCTWITN TITS CCCTCAATTCN CCAICCTTCN ICDXCTI 10 A IATl fCÃI WANT COIANNI C CAIATCNII NATXN ISIINATC 10 00 IKCCNTC AtD ICTCITTC NANAtXINNT CNANCH TPCTttA TAN IAITACAN IXCAAATTTTT |
| OP2-0400053 willbechangedtoensuretestequipment isremovedpriortorestoring plantequipment. | | ~WANNICIOI, CC IOSSA NCITOTIC&PI NICTWCTAACTCNITTCtCCI plIACTOIACINCC or NAWATXINNT AI0 MXXT, WANNNITDA CC TNTCA FACILITY NAME (1)St.Lucie Unit 2 DOCKET NUMBER (2)LER NUMBER (6)EQUENTIAL REVISION A NUMBER.NUMBER PAGE (3)05000389 TEXT (//more spaceis required, use additional NRC Form 366A's)(17)9 3-0 0 6 0 0 0 2 0 3 On May 13, 1993, at 1920 hours with Unit 2 in Mode 1 at 100%power, Instrument and Control personnel were performing the"Engineered Safeguards Relay Test" procedure OP 2-0400053 in coordination with the Unit 2 Operating crew.During the performance of this procedure Operations established the initial test conditions and the Instrument and Control personnel performed the relay actuation and verification. |
| 4)AHumanPerformance Enhancement Reviewwasconducted andtheconclusions incorporated inthisreport.5)Trainingonthiseventwillbeprovidedforappropriate plantpersonnel. | | Data sheet¹8 of OP 2-0400053 was being performed to test the cabability of the NB" Safety Injection Actuation SignaVContainment Isolation Actuation Signal (SIAS/CIAS)(EIIS:JE) relay to provide an Emergency Diesel Generator (EDG)(EIIS:EK) start signal.Operations had fulfilled the pretest conditions by placing the 2B EDG normalfisolate switches in the isolate position to isolate that EDG from the safeguards start circuitry during the test to minimize unecessary EDG starts.The Instrument and Control personnel connected a multifunction test meter across the B SIAS/CIAS relay contact and injected the trip test signal to obtain actuation. |
| FPLFacsimIIe ofNRCForm366(6-89)
| | When the Instrument and Control supervisor did not obtain the desired results he informed the Assistant Nuclear Plant Supervisor (ANPS)that Operations personnel could"reset" following the test.Operations restored the plant to normal including taking the EDG normalfisoiate switches back to the normal position thereby unisolating the EDG.During this time the technicians had removed the meter from the test leads to replace it with a different meter as a precautionary measure.The leads were left on the contacts in anticipation of performing the test again.Subsequent to the EDG normaV isolate switches being placed to normal, technicians installed the new meter on the already connected leads.The 2B EDG started but did not load to the 2B3 41 60 VAC bus which is the expected response for an automatic safeguards actuation of the EDG with its safety related bus energized. |
| FPLFttcCilrTIIT olNRCFormS68($80)US.NUCLEARREGULATORY COMMlSSION LICENSEEEVENTREPORT(LER)'EXTCONTINUATtON JTTTITTVT0 CAeNCtStNITIIICrtTNXNAIIINtCCTAIATT0 IlNCTNrrIIICSKWXToCCINCTWITN TITSCCCTCAATTCN CCAICCTTCN ICDXCTI10AIATlfCÃIWANTCOIANNICCAIATCNII NATXNISIINATC1000IKCCNTCAtDICTCITTCNANAtXINNT CNANCHTPCTttATANIAITACANIXCAAATTTTT
| | The 2B EDG was immediately secured and the safeguards relay testing was stopped pending investigation of why the EDG had started.E EV The root cause of the 2B EDG starting was due to personnel error involving inadequate communications. |
| ~WANNICIOI, CCIOSSANCITOTIC&PINICTWCTAACTCNITTCtCCI plIACTOIACINCC orNAWATXINNT AI0MXXT,WANNNITDA CCTNTCAFACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(2)LERNUMBER(6)EQUENTIAL REVISIONANUMBER.NUMBERPAGE(3)05000389TEXT(//morespaceisrequired, useadditional NRCForm366A's)(17)93-006000203OnMay13,1993,at1920hourswithUnit2inMode1at100%power,Instrument andControlpersonnel wereperforming the"Engineered Safeguards RelayTest"procedure OP2-0400053 incoordination withtheUnit2Operating crew.Duringtheperformance ofthisprocedure Operations established theinitialtestconditions andtheInstrument andControlpersonnel performed therelayactuation andverification. | | The Instrument and Control supervisor intended to reperform the test and only intended for Operations to reset the safeguards signals to restore the initial test conditions. |
| Datasheet¹8ofOP2-0400053 wasbeingperformed totestthecabability oftheNB"SafetyInjection Actuation SignaVContainment Isolation Actuation Signal(SIAS/CIAS)(EIIS:JE) relaytoprovideanEmergency DieselGenerator (EDG)(EIIS:EK) startsignal.Operations hadfulfilled thepretestconditions byplacingthe2BEDGnormalfisolate switchesintheisolatepositiontoisolatethatEDGfromthesafeguards startcircuitry duringthetesttominimizeunecessary EDGstarts.TheInstrument andControlpersonnel connected amultifunction testmeteracrosstheBSIAS/CIAS relaycontactandinjectedthetriptestsignaltoobtainactuation.
| | However, based on communications following previous tests, the ANPS understood the reset request as meaning that the test was complete and that they could secure from the test conditions. |
| WhentheInstrument andControlsupervisor didnotobtainthedesiredresultsheinformedtheAssistant NuclearPlantSupervisor (ANPS)thatOperations personnel could"reset"following thetest.Operations restoredtheplanttonormalincluding takingtheEDGnormalfisoiate switchesbacktothenormalpositiontherebyunisolating theEDG.Duringthistimethetechnicians hadremovedthemeterfromthetestleadstoreplaceitwithadifferent meterasaprecautionary measure.Theleadswereleftonthecontactsinanticipation ofperforming thetestagain.Subsequent totheEDGnormaVisolateswitchesbeingplacedtonormal,technicians installed thenewmeteronthealreadyconnected leads.The2BEDGstartedbutdidnotloadtothe2B34160VACbuswhichistheexpectedresponseforanautomatic safeguards actuation oftheEDGwithitssafetyrelatedbusenergized.
| | The proper communication should have included exactly what function was to be restored and the intent to reperform the test.A contributing factor was the lack of explicit procedural guidance to ensure that test equipment was not in place when restoring equipment. |
| The2BEDGwasimmediately securedandthesafeguards relaytestingwasstoppedpendinginvestigation ofwhytheEDGhadstarted.EEVTherootcauseofthe2BEDGstartingwasduetopersonnel errorinvolving inadequate communications.
| | The technicians had removed the meter from the test leads but had not not removed the test leads from the contact since they expected to perform the test again.When the 2B EDG normal/isolate switch was restored to normal the B SIAS/CIAS relay was now capable of providing a start signal upon actuation. |
| TheInstrument andControlsupervisor intendedtoreperform thetestandonlyintendedforOperations toresetthesafeguards signalstorestoretheinitialtestconditions.
| | When the Instrument and Control technician attached the new meter to the test leads it acted as a jumper across the contact providing a start signal.The procedure does not stipulate that test equipment must be removed prior to resetting actuation signals, only the post test status of the normal isolate switch and the note that the EDG should not be started.This allows flexibility within the procedure to reperform the relay actuation and verification if required without having to restore all equipment to normal and set up initial test conditions again.The procedure should preclude leaving test leads in place or relanding them until Operations has communicated that the test may be reperformed. |
| However,basedoncommunications following previoustests,theANPSunderstood theresetrequestasmeaningthatthetestwascompleteandthattheycouldsecurefromthetestconditions. | | There were no unusual characteristics of the work location which contributed to this event.FPL Facsimile of NRC Form 366 (6-89) |
| Thepropercommunication shouldhaveincludedexactlywhatfunctionwastoberestoredandtheintenttoreperform thetest.Acontributing factorwasthelackofexplicitprocedural guidancetoensurethattestequipment wasnotinplacewhenrestoring equipment.
| | ,4 FPL F le OT NAC Fafff%6 t6efrft U.S.NUCLEAR AEGULATO AY CO MMISS fON LICENSEE EVENT REPORT (LER)TEXT CONTINUATION Affnoflo an ICl Sl f0 Sl SI effseL fosse CSTWATTTT TASTCOI fell feSIONSe TO CaNCT WTN TTW SeaWAllCN CafeCTlaf Ieae STl TOS fnf fofNIAITT CONASNT S INCNTCSTO TTAOCN eelWATS lolls fecaSTS ANT WfaTTSNANAcefeNT SNANCNISSTIA ITS IAICTSAN IeaAATaTT~TTANwcfal.cc ffsfe No xone TASNfwfcnf fecucTTCN fnoecf TTI fssfoq,ance Of 0 ANAJJNNT Ne TTNCCT,WASINNITOIA OC fffcS FACILITY NAME (1)St.Lucie Unit 2 DOCKET NUMBER (2)LER NUMBER (6)YEAR I EQUENTIAL'REVISION I NUMBER NUMBER PAGE (3)0 500 0389 TEXT (lf more spaceis required, use additional NRC Form 366A's)(17)9 3 0 0 6 0 0 0 3 0 3 This event is reportable under 10 CFR 50.73.a.2.iv as an event or condition that results in a manual or automatic actuation of any Engineered Safety Feature.The inadvertant starting of the 2B Emergency Diesel Generator (EDG)had no adverse consequences on the plant because the 2B3 4160 VAC Bus remained energized and in service during this event, supplied by its normal offsite power supply source.The 2B EDG performed as expected for an automatic start from a Safety Injection Actuation Signal actuation. |
| Thetechnicians hadremovedthemeterfromthetestleadsbuthadnotnotremovedthetestleadsfromthecontactsincetheyexpectedtoperformthetestagain.Whenthe2BEDGnormal/isolate switchwasrestoredtonormaltheBSIAS/CIAS relaywasnowcapableofproviding astartsignaluponactuation.
| | There was no malfunction of the Engineered Safety Features or of the EDG start circuitry during this event.Therefore, the health and safety of the public were not affected at any time during this event.1)The utility personnel involved in this event were counseled on communications and the necessity of ensuring that test equipment is not installed when securing from a test.2)Upon determining the cause of the event the safeguards relay testing was resumed and completed satisfactorily the next day.3)The NSafeguards Relay Test" (OP 2-0400053) procedure will be changed to ensure that test equipment shall be removed prior to operations resetting any actuations or restoring any equipment to normal operating status.This test is not performed on Unit 1.4)A Human Performance Enhancement Review of this event was performed and the resulting conclusions have been integrated in the root cause determination and corrective actions.5)Training will be provided for the appropriate plant personnel on this event and on enhancing communications to prevent future occurrence. |
| WhentheInstrument andControltechnician attachedthenewmetertothetestleadsitactedasajumperacrossthecontactproviding astartsignal.Theprocedure doesnotstipulate thattestequipment mustberemovedpriortoresetting actuation signals,onlythepostteststatusofthenormalisolateswitchandthenotethattheEDGshouldnotbestarted.Thisallowsflexibility withintheprocedure toreperform therelayactuation andverification ifrequiredwithouthavingtorestoreallequipment tonormalandsetupinitialtestconditions again.Theprocedure shouldprecludeleavingtestleadsinplaceorrelanding themuntilOperations hascommunicated thatthetestmaybereperformed.
| | None LER 335-93-003 Nlnadvertant start of the1 B Diesel Generator due to personnel error" LER 335-88-005 Nlnadvertant start of the 1A Diesel Generator during troubleshooting due to personnel error" FPL Facsimile of NRC Form 366 (6-89)}} |
| Therewerenounusualcharacteristics oftheworklocationwhichcontributed tothisevent.FPLFacsimile ofNRCForm366(6-89)
| |
| ,4FPLFleOTNACFafff%6t6efrftU.S.NUCLEARAEGULATOAYCOMMISSfONLICENSEEEVENTREPORT(LER)TEXTCONTINUATION AffnofloanIClSlf0SlSIeffseLfosseCSTWATTTT TASTCOIfellfeSIONSeTOCaNCTWTNTTWSeaWAllCN CafeCTlaf IeaeSTlTOSfnffofNIAITT CONASNTSINCNTCSTO TTAOCNeelWATSlollsfecaSTSANTWfaTTSNANAcefeNT SNANCNISSTIA ITSIAICTSANIeaAATaTT | |
| ~TTANwcfal.cc ffsfeNoxoneTASNfwfcnf fecucTTCN fnoecfTTIfssfoq,ance Of0ANAJJNNTNeTTNCCT,WASINNITOIA OCfffcSFACILITYNAME(1)St.LucieUnit2DOCKETNUMBER(2)LERNUMBER(6)YEARIEQUENTIAL | |
| 'REVISIONINUMBERNUMBERPAGE(3)05000389TEXT(lfmorespaceisrequired, useadditional NRCForm366A's)(17)93006000303Thiseventisreportable under10CFR50.73.a.2.iv asaneventorcondition thatresultsinamanualorautomatic actuation ofanyEngineered SafetyFeature.Theinadvertant startingofthe2BEmergency DieselGenerator (EDG)hadnoadverseconsequences ontheplantbecausethe2B34160VACBusremainedenergized andinserviceduringthisevent,suppliedbyitsnormaloffsitepowersupplysource.The2BEDGperformed asexpectedforanautomatic startfromaSafetyInjection Actuation Signalactuation. | |
| Therewasnomalfunction oftheEngineered SafetyFeaturesoroftheEDGstartcircuitry duringthisevent.Therefore, thehealthandsafetyofthepublicwerenotaffectedatanytimeduringthisevent.1)Theutilitypersonnel involvedinthiseventwerecounseled oncommunications andthenecessity ofensuringthattestequipment isnotinstalled whensecuringfromatest.2)Upondetermining thecauseoftheeventthesafeguards relaytestingwasresumedandcompleted satisfactorily thenextday.3)TheNSafeguards RelayTest"(OP2-0400053) procedure willbechangedtoensurethattestequipment shallberemovedpriortooperations resetting anyactuations orrestoring anyequipment tonormaloperating status.Thistestisnotperformed onUnit1.4)AHumanPerformance Enhancement Reviewofthiseventwasperformed andtheresulting conclusions havebeenintegrated intherootcausedetermination andcorrective actions.5)Trainingwillbeprovidedfortheappropriate plantpersonnel onthiseventandonenhancing communications topreventfutureoccurrence.
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| NoneLER335-93-003 Nlnadvertant startofthe1BDieselGenerator duetopersonnel error"LER335-88-005 Nlnadvertant startofthe1ADieselGenerator duringtroubleshooting duetopersonnel error"FPLFacsimile ofNRCForm366(6-89)}}
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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML17241A4891999-10-0707 October 1999 LER 99-004-00:on 990912,noted That MSSV Surveillance Was Outside of TS Requirements.Caused by Setpoint Drift.Subject MSSVs Are Being Refurbished & Retested Prior to Unit Startup from SL1-16 Refueling Outage.With 991007 Ltr ML17241A4111999-07-16016 July 1999 LER 99-007-00:on 990610,unplanned Cooldown Transient Occurred Due to Personnel Error.Trained & Briefed Personnel & Revised Procedures.With 990716 Ltr ML17241A4031999-07-0606 July 1999 LER 99-006-00:on 990605,sub-critical Reactor Trip Occurred Due to Inadvertent MSIV Opening.Caused by Personnel Error. Provided Operation Supervision Instruction to Operating Crews,Stand Down Meetings & Operator Aids.With 990706 Ltr ML17241A4041999-07-0606 July 1999 LER 99-005-00:on 990604,CEA Drop Resulted in Manual Reactor Trip.Caused by Procedural Inadequacies.Procedure Changes Are Planned to Correct Lack of Procedural Guidance for CEA Subgroup Power Switch Replacement.With 990706 Ltr ML17241A3941999-06-30030 June 1999 LER 99-004-01:on 990415,as Found Cycle 10 Psv Setpoints Were Outside TS Limits.Caused by Manufacturing Process Defect. All Three Psvs Were Replaced with pre-tested Valves During Cycle 11 Refueling Outage.With 990630 Ltr ML17241A3551999-06-0404 June 1999 LER 99-002-00:on 990505,both Trains of Safety Injection Actuation Were Blocked During Surveillance.Caused by Procedure Error.Procedure Revised.With 990604 Ltr ML17241A3321999-05-17017 May 1999 LER 99-004-00:on 990415,determined That as Found Cycle 10 Psv Setpoints Outside TS Limits.Root Cause Under Investigation.Psvs Replaced with pe-tested Valves During Cycle 11 ML17241A3271999-05-0606 May 1999 LER 99-003-00:on 990406,ECCS Suction Header Leak Resulted in Both ECCS Trains Being Inoperable & Entry Into TS 3.0.3. Caused by Chloride Induced OD Stress Corrosion Cracking of Piping.Made Code Repairs & Coated Piping.With 990506 Ltr ML17229B0791999-04-0707 April 1999 LER 99-001-00:on 990309,discovered Inadequate Design & IST SRs for Iodine Removal Sys (Irs).Caused by Original Design Inadequacies & Personnel Error.Naoh Tank Vent Valve V07233 Was Tagged Open.With 990407 Ltr ML17229B0801999-04-0707 April 1999 LER 99-002-00:on 990311,SG ECT Error Caused Operation with Condition Prohibited by Ts.Caused by Deficiencies in Data Analysis Guideline Instructions.Licensee Will Change Data Analysis Guidelines for Lead Analysts.With 990407 Ltr ML17229B0541999-03-10010 March 1999 LER 99-001-00:on 990211,inadequate TS SRs for SIT & SDC Isolation Valves Were Noted.Caused by Failure to Correctly Implement TS Srs.Submitted LAR to Align Required TS SR with Design Bases Requirements Being Verified.With 990310 Ltr ML17229A9901999-01-20020 January 1999 LER 98-009-00:on 981223,noted That Facility Operated Outside of Design Basis.Caused by non-conservative MSLB Analysis Inputs.Will Review SR Component Differences Between Units & Will re-baseline LTOP Analysis.With 990120 Ltr ML17229A9821999-01-0404 January 1999 LER 98-010-00:on 981207,RCS Boron Sample Frequency Required by Ts,Was Exceeded by Twelve Minutes.Caused by Personnel Error.Equipment Clearance Order Was Lifted to Draw Required Sample & Operations Procedure Was Changed.With 990104 Ltr ML17229A9611998-12-22022 December 1998 LER 97-002-01:on 981204,containment Sump Debris Screen Was Not IAW Design.Caused by Inadequate C/As for Sump Screen Anamolies.All Identified Sump Screen Deficiencies Were Dispositioned &/Or Repaired.With 981222 Ltr ML17229A9561998-12-15015 December 1998 LER 98-008-00:on 981118,missed TS SG U Tube Insp.Caused by Encoding Errors While Using Remote Positioning Fixtures.All SG Tube Surveyed.With 981215 Ltr ML17229A9301998-11-25025 November 1998 LER 98-005-01:on 980807,discovered That New MOV Methodology Caused Past PORV Block Valve Operability Problem.Caused by Inadequacies in Original Vendor MOV Methodology.Planned Valve Mods Will Be Implemented During Cycle 11 1998 Outage ML17229A9021998-11-0404 November 1998 LER 98-008-00:on 981008,inadequate Reactor Protection Sys Trip Bypass TS Was Noted.Caused by Poorly Worded Ts. Submitted LAR to Clarify Power Requirements for High Rate of Power Trips.With 981104 Ltr ML17229A8771998-10-14014 October 1998 LER 98-006-00:on 980918,inadvertent Afas Actuation Was Noted.Caused by Degradation of Multiple Afas Power Supplies. Replaced Afas Power Supplies & Revised Procedures.With 981014 Ltr ML17229A8761998-10-14014 October 1998 LER 98-007-00:on 980918,identified Discrepancies Between Fire Protection Design Requirements & Field Conditions. Caused by Inadequate Translation & Implementation of Fire Protection Requirements.Procedures Revised.With 981014 Ltr ML17229A8511998-09-0202 September 1998 LER 98-005-00:on 980807,discovered That PORV Margins Were Insufficient to Accommodate Addl Conservatism.Caused by Inadequacies in Original Vendor MOV Methodology.Will Implement Planned Valve Actuator mods.W/980902 Ltr ML17229A8201998-07-29029 July 1998 LER 98-007-00:on 980630,inadequate Procedure May Have Resulted in SBO Recovery Complications.Caused by Inadequate Procedures.Attached Caution Tags to Appropriate Control switches.W/980729 Ltr ML17229A7411998-05-28028 May 1998 LER 98-004-00:on 980430,discovered Waste Gas Decay Tank Operation W/O Available Oxygen Analyzers,Which Is Prohibited by Ts.Caused by Inadequate Licensee Review of License Amend. Oxygen Analyzer recalibrated.W/980528 Ltr ML17229A7381998-05-21021 May 1998 LER 98-006-00:on 980421,missed EDG Fuel Oil Sample Surveillance Was Noted.Caused by Personnel Error.Revised Fuel Oil Sampling Service Purchase Order & Revised Site procedure.W/980521 Ltr ML17229A7011998-04-27027 April 1998 LER 98-003-00:on 980326,discovered Containment Pressure Instrumentation Design Single Failure Vulnerability.Caused by Inadequate Design by Personnel Error.Removed RPS & ESFAS Containment Pressure Bypass Keys immediately.W/980427 Ltr ML17229A6761998-04-0202 April 1998 LER 98-005-00:on 980305,identified Two Conditions That Were Outside App R Design Bases.Caused by Design Oversight During Development of Original App R Safe SD Design.Established 30 Minute Roving Fire Watches & Provided training.W/980402 Ltr ML17229A6731998-03-26026 March 1998 LER 98-002-00:on 980224,radiation Monitor Surveillance Inadequacies Led to Operating of Facility Prohibited by Tss. Caused by Congnitive Personnel Error.Permanent Procedure Changes Were implemented.W/980326 Ltr ML17229A6551998-03-0505 March 1998 LER 98-001-00:on 980206,high/low Pressure Shutdown Cooling Interface Was Noted Outside App R Design Bases.Caused by Personnel Error.Addl Guidance Was Provided to Engineering Dept personnel.W/980305 Ltr ML17229A6281998-02-19019 February 1998 LER 98-004-00:on 980121,emergency Lighting Outside App R Design Bases Occurred.Caused by Congnitive Personnel Error During Translation of App R Section Iii.Procedures Onop 1 & 2 ONP-100.01 Were Issued for Use on 980206.W/980219 Ltr ML17229A6211998-02-0909 February 1998 LER 98-003-00:on 980110,manual Rt Due to DEH Leak at Turbine Test Block Was Noted.Caused by o-ring Extrusion.Shortened Bolts by About 0.125 & Reinstalled at Correct Torque values.W/980209 Ltr ML17229A6191998-02-0404 February 1998 LER 98-002-00:on 980105,CIS Bistable in Bypass Resulted in Condition Prohibited by Tss.Caused by Personnel Error. Radiation Monitor Was Restored to service.W/980204 Ltr ML17229A6161998-02-0303 February 1998 LER 98-001-00:on 980104,inadvertent RPS Actuation Occurred Due to Personnel Error.Caused by Procedural Inadequacies & Inadequate self-checking by Licensed Utility Personnel. Placards Have Been Placed in CRs.W/980203 Ltr ML17229A6051998-01-27027 January 1998 LER 97-010-01:on 971027,inadvertent Core Alteration Prohibited by TSs Were Noted Due to Stuck Cea.Caused by Personnel Error.Cea #24 Was Dislodged & Transferred to Spent Pool for insp.W/980127 Ltr ML17229A5501997-12-0505 December 1997 LER 97-008-00:on 971107,inadequate CR Ventilation Surveillance Resulted in Condition Prohibited by Ts.Caused by non-cognitive Personnel Error.Operating Procedure 2-1900050 Was revised.W/971205 Ltr ML17309A9091997-12-0202 December 1997 LER 97-011-00:on 971102,non-conservative RAS Set Point Resulted in Operation Prohibited by Ts.Caused by Inadequate Set Point & Instrument Loop Scaling Process.Revised ESFAS Functional Tp W/Proper Set point.W/971202 Ltr ML17229A5391997-11-26026 November 1997 LER 97-010-00:on 971027,inadvertant Core Alteration Prohibited by TS Occurred.Caused by CEA Failure to Detach from Ugs.Safety Evaluation Was Performed & Procedural Rev Made to Continue Upper Guide Structure move.W/971126 Ltr ML17229A5151997-11-0707 November 1997 LER 97-007-00:on 971008,inoperable Containment Cooling Fan Resulted in Operation of Facility Outside Design Basis. Caused by non-cognitive Personnel Error.Ccs Operation Was Revised & Issued on 971013.W/971107 Ltr ML17229A4991997-10-17017 October 1997 LER 97-009-00:on 970917,inoperable PORV Block Valve Resulted in Operation Prohibited by Tech Specs Occurred.Caused by Plant GL 89-10 Program Plan to Review Plant Manager Action Item Sys.Porv Block Valve V-1403 restored.W/971017 Ltr ML17309A9011997-08-27027 August 1997 LER 97-008-00:on 970728,mechanical Fire Penetrations Were Inoperable & Outside App R Design Bases.Caused by Seal Mfg Not Providing Formal Documentation for Installed Seals. Modified Inoperable Fire penetrations.W/970827 Ltr ML17229A4311997-07-29029 July 1997 LER 97-006-00:on 970630,discovered Inadequate Testing of Engineered Safety Features Subgroup Relays.Caused by Inadequacy in Implementing TS Requirements in Surveillance Procedures.Revised Surveillance procedures.W/970729 Ltr ML17229A4241997-07-25025 July 1997 LER 97-005-00:on 970625,discovered That Hot Shutdown Control Panel Shutdown Cooling Flow indicator,FI-3306 Inoperable. Caused by Weakness in Work Order & Procedure Used to Repair FI-3306.Section Meeting W/I&C Planners held.W/970725 Ltr ML17229A3971997-07-11011 July 1997 LER 97-004-00:on 970611,discovered Incorrect Original Cable Tray Fire Stop Assembly Installation Was Outside App R Design Basis.Caused by Personnel Error.Hourly Fire Watch Patrols Will Be posted.W/970711 Ltr ML17229A3871997-06-19019 June 1997 LER 97-003-00:on 970521,determined Required Post Maint Open Stroke Test for Valve V3245,2B2 SIT Discharge Check Valve, Had Not Been Performed.Caused by Personnel Error.Procedure revised.W/970619 Ltr ML17229A3841997-06-17017 June 1997 LER 97-002-00:on 970518,containment Sump Debris Screen Was Not IAW Design Due to Gaps in Screen Encl.Performed SER to Document Containment Sump Design requirements.W/970617 Ltr ML17229A3751997-06-0202 June 1997 LER 97-006-00:on 970501,operation Was Prohibited by TS Due to Inadequately Tested Degraded Voltage Sys.Revised Unit 1 ESFAS Surveillance Test procedure.W/970602 Ltr ML17229A3611997-05-29029 May 1997 LER 97-007-00:on 970502,reactor Coolant Pump Oil Collection Sys Was Outside App R Design Bases.Identified Leak Sites Were Repaired & Mods to RCP Oil Collection Sys to Capture Any Future Leakage from areas.W/970529 Ltr ML17229A3491997-05-21021 May 1997 LER 97-001-00:on 970423,containment Isolation Actuation Occurred.Caused by Increased Radiation Levels During Removal of Upper Guide Structure.Proper Actuation of Containment Isolation Components Was verified.W/970521 Ltr ML17229A3441997-05-13013 May 1997 LER 97-005-00:on 970419,reactor Was Shutdown Due to Reactor Coolant Pressure Boundary Leakage.Hot Cracking Was Caused by Weld Contamination.Repairs to RCPB Were Completed & 1A SDC Train Was Restored to Svc ML17229A3141997-04-30030 April 1997 LER 97-004-00:on 970402,refueling Machine Was Operating in Manner Prohibited by TS Due to Original Design of Refueling Machine Bypass Feature Conflicting W/Ts Requirements. Eliminated Overload Cut Off Limit bypass.W/970430 Ltr ML17229A2951997-03-31031 March 1997 LER 97-003-00:on 970304,automatic Rt Resulted from Loss of Electrical Power to 1A2 Rc Pump.Rcp Breaker Was Replaced & Pump Was Returned to svc.W/970331 Ltr ML17229A2721997-03-21021 March 1997 LER 97-002-00:on 970221,operation in Excess of Max Rated Thermal Power Occurred Due to Digital Data Processing Sys (Ddps) Calorimetric Error.Verified Acceptable Performance of Ddps Functions & Reviewed Software mods.W/970321 Ltr 1999-07-06
[Table view] Category:RO)
MONTHYEARML17241A4891999-10-0707 October 1999 LER 99-004-00:on 990912,noted That MSSV Surveillance Was Outside of TS Requirements.Caused by Setpoint Drift.Subject MSSVs Are Being Refurbished & Retested Prior to Unit Startup from SL1-16 Refueling Outage.With 991007 Ltr ML17241A4111999-07-16016 July 1999 LER 99-007-00:on 990610,unplanned Cooldown Transient Occurred Due to Personnel Error.Trained & Briefed Personnel & Revised Procedures.With 990716 Ltr ML17241A4031999-07-0606 July 1999 LER 99-006-00:on 990605,sub-critical Reactor Trip Occurred Due to Inadvertent MSIV Opening.Caused by Personnel Error. Provided Operation Supervision Instruction to Operating Crews,Stand Down Meetings & Operator Aids.With 990706 Ltr ML17241A4041999-07-0606 July 1999 LER 99-005-00:on 990604,CEA Drop Resulted in Manual Reactor Trip.Caused by Procedural Inadequacies.Procedure Changes Are Planned to Correct Lack of Procedural Guidance for CEA Subgroup Power Switch Replacement.With 990706 Ltr ML17241A3941999-06-30030 June 1999 LER 99-004-01:on 990415,as Found Cycle 10 Psv Setpoints Were Outside TS Limits.Caused by Manufacturing Process Defect. All Three Psvs Were Replaced with pre-tested Valves During Cycle 11 Refueling Outage.With 990630 Ltr ML17241A3551999-06-0404 June 1999 LER 99-002-00:on 990505,both Trains of Safety Injection Actuation Were Blocked During Surveillance.Caused by Procedure Error.Procedure Revised.With 990604 Ltr ML17241A3321999-05-17017 May 1999 LER 99-004-00:on 990415,determined That as Found Cycle 10 Psv Setpoints Outside TS Limits.Root Cause Under Investigation.Psvs Replaced with pe-tested Valves During Cycle 11 ML17241A3271999-05-0606 May 1999 LER 99-003-00:on 990406,ECCS Suction Header Leak Resulted in Both ECCS Trains Being Inoperable & Entry Into TS 3.0.3. Caused by Chloride Induced OD Stress Corrosion Cracking of Piping.Made Code Repairs & Coated Piping.With 990506 Ltr ML17229B0791999-04-0707 April 1999 LER 99-001-00:on 990309,discovered Inadequate Design & IST SRs for Iodine Removal Sys (Irs).Caused by Original Design Inadequacies & Personnel Error.Naoh Tank Vent Valve V07233 Was Tagged Open.With 990407 Ltr ML17229B0801999-04-0707 April 1999 LER 99-002-00:on 990311,SG ECT Error Caused Operation with Condition Prohibited by Ts.Caused by Deficiencies in Data Analysis Guideline Instructions.Licensee Will Change Data Analysis Guidelines for Lead Analysts.With 990407 Ltr ML17229B0541999-03-10010 March 1999 LER 99-001-00:on 990211,inadequate TS SRs for SIT & SDC Isolation Valves Were Noted.Caused by Failure to Correctly Implement TS Srs.Submitted LAR to Align Required TS SR with Design Bases Requirements Being Verified.With 990310 Ltr ML17229A9901999-01-20020 January 1999 LER 98-009-00:on 981223,noted That Facility Operated Outside of Design Basis.Caused by non-conservative MSLB Analysis Inputs.Will Review SR Component Differences Between Units & Will re-baseline LTOP Analysis.With 990120 Ltr ML17229A9821999-01-0404 January 1999 LER 98-010-00:on 981207,RCS Boron Sample Frequency Required by Ts,Was Exceeded by Twelve Minutes.Caused by Personnel Error.Equipment Clearance Order Was Lifted to Draw Required Sample & Operations Procedure Was Changed.With 990104 Ltr ML17229A9611998-12-22022 December 1998 LER 97-002-01:on 981204,containment Sump Debris Screen Was Not IAW Design.Caused by Inadequate C/As for Sump Screen Anamolies.All Identified Sump Screen Deficiencies Were Dispositioned &/Or Repaired.With 981222 Ltr ML17229A9561998-12-15015 December 1998 LER 98-008-00:on 981118,missed TS SG U Tube Insp.Caused by Encoding Errors While Using Remote Positioning Fixtures.All SG Tube Surveyed.With 981215 Ltr ML17229A9301998-11-25025 November 1998 LER 98-005-01:on 980807,discovered That New MOV Methodology Caused Past PORV Block Valve Operability Problem.Caused by Inadequacies in Original Vendor MOV Methodology.Planned Valve Mods Will Be Implemented During Cycle 11 1998 Outage ML17229A9021998-11-0404 November 1998 LER 98-008-00:on 981008,inadequate Reactor Protection Sys Trip Bypass TS Was Noted.Caused by Poorly Worded Ts. Submitted LAR to Clarify Power Requirements for High Rate of Power Trips.With 981104 Ltr ML17229A8771998-10-14014 October 1998 LER 98-006-00:on 980918,inadvertent Afas Actuation Was Noted.Caused by Degradation of Multiple Afas Power Supplies. Replaced Afas Power Supplies & Revised Procedures.With 981014 Ltr ML17229A8761998-10-14014 October 1998 LER 98-007-00:on 980918,identified Discrepancies Between Fire Protection Design Requirements & Field Conditions. Caused by Inadequate Translation & Implementation of Fire Protection Requirements.Procedures Revised.With 981014 Ltr ML17229A8511998-09-0202 September 1998 LER 98-005-00:on 980807,discovered That PORV Margins Were Insufficient to Accommodate Addl Conservatism.Caused by Inadequacies in Original Vendor MOV Methodology.Will Implement Planned Valve Actuator mods.W/980902 Ltr ML17229A8201998-07-29029 July 1998 LER 98-007-00:on 980630,inadequate Procedure May Have Resulted in SBO Recovery Complications.Caused by Inadequate Procedures.Attached Caution Tags to Appropriate Control switches.W/980729 Ltr ML17229A7411998-05-28028 May 1998 LER 98-004-00:on 980430,discovered Waste Gas Decay Tank Operation W/O Available Oxygen Analyzers,Which Is Prohibited by Ts.Caused by Inadequate Licensee Review of License Amend. Oxygen Analyzer recalibrated.W/980528 Ltr ML17229A7381998-05-21021 May 1998 LER 98-006-00:on 980421,missed EDG Fuel Oil Sample Surveillance Was Noted.Caused by Personnel Error.Revised Fuel Oil Sampling Service Purchase Order & Revised Site procedure.W/980521 Ltr ML17229A7011998-04-27027 April 1998 LER 98-003-00:on 980326,discovered Containment Pressure Instrumentation Design Single Failure Vulnerability.Caused by Inadequate Design by Personnel Error.Removed RPS & ESFAS Containment Pressure Bypass Keys immediately.W/980427 Ltr ML17229A6761998-04-0202 April 1998 LER 98-005-00:on 980305,identified Two Conditions That Were Outside App R Design Bases.Caused by Design Oversight During Development of Original App R Safe SD Design.Established 30 Minute Roving Fire Watches & Provided training.W/980402 Ltr ML17229A6731998-03-26026 March 1998 LER 98-002-00:on 980224,radiation Monitor Surveillance Inadequacies Led to Operating of Facility Prohibited by Tss. Caused by Congnitive Personnel Error.Permanent Procedure Changes Were implemented.W/980326 Ltr ML17229A6551998-03-0505 March 1998 LER 98-001-00:on 980206,high/low Pressure Shutdown Cooling Interface Was Noted Outside App R Design Bases.Caused by Personnel Error.Addl Guidance Was Provided to Engineering Dept personnel.W/980305 Ltr ML17229A6281998-02-19019 February 1998 LER 98-004-00:on 980121,emergency Lighting Outside App R Design Bases Occurred.Caused by Congnitive Personnel Error During Translation of App R Section Iii.Procedures Onop 1 & 2 ONP-100.01 Were Issued for Use on 980206.W/980219 Ltr ML17229A6211998-02-0909 February 1998 LER 98-003-00:on 980110,manual Rt Due to DEH Leak at Turbine Test Block Was Noted.Caused by o-ring Extrusion.Shortened Bolts by About 0.125 & Reinstalled at Correct Torque values.W/980209 Ltr ML17229A6191998-02-0404 February 1998 LER 98-002-00:on 980105,CIS Bistable in Bypass Resulted in Condition Prohibited by Tss.Caused by Personnel Error. Radiation Monitor Was Restored to service.W/980204 Ltr ML17229A6161998-02-0303 February 1998 LER 98-001-00:on 980104,inadvertent RPS Actuation Occurred Due to Personnel Error.Caused by Procedural Inadequacies & Inadequate self-checking by Licensed Utility Personnel. Placards Have Been Placed in CRs.W/980203 Ltr ML17229A6051998-01-27027 January 1998 LER 97-010-01:on 971027,inadvertent Core Alteration Prohibited by TSs Were Noted Due to Stuck Cea.Caused by Personnel Error.Cea #24 Was Dislodged & Transferred to Spent Pool for insp.W/980127 Ltr ML17229A5501997-12-0505 December 1997 LER 97-008-00:on 971107,inadequate CR Ventilation Surveillance Resulted in Condition Prohibited by Ts.Caused by non-cognitive Personnel Error.Operating Procedure 2-1900050 Was revised.W/971205 Ltr ML17309A9091997-12-0202 December 1997 LER 97-011-00:on 971102,non-conservative RAS Set Point Resulted in Operation Prohibited by Ts.Caused by Inadequate Set Point & Instrument Loop Scaling Process.Revised ESFAS Functional Tp W/Proper Set point.W/971202 Ltr ML17229A5391997-11-26026 November 1997 LER 97-010-00:on 971027,inadvertant Core Alteration Prohibited by TS Occurred.Caused by CEA Failure to Detach from Ugs.Safety Evaluation Was Performed & Procedural Rev Made to Continue Upper Guide Structure move.W/971126 Ltr ML17229A5151997-11-0707 November 1997 LER 97-007-00:on 971008,inoperable Containment Cooling Fan Resulted in Operation of Facility Outside Design Basis. Caused by non-cognitive Personnel Error.Ccs Operation Was Revised & Issued on 971013.W/971107 Ltr ML17229A4991997-10-17017 October 1997 LER 97-009-00:on 970917,inoperable PORV Block Valve Resulted in Operation Prohibited by Tech Specs Occurred.Caused by Plant GL 89-10 Program Plan to Review Plant Manager Action Item Sys.Porv Block Valve V-1403 restored.W/971017 Ltr ML17309A9011997-08-27027 August 1997 LER 97-008-00:on 970728,mechanical Fire Penetrations Were Inoperable & Outside App R Design Bases.Caused by Seal Mfg Not Providing Formal Documentation for Installed Seals. Modified Inoperable Fire penetrations.W/970827 Ltr ML17229A4311997-07-29029 July 1997 LER 97-006-00:on 970630,discovered Inadequate Testing of Engineered Safety Features Subgroup Relays.Caused by Inadequacy in Implementing TS Requirements in Surveillance Procedures.Revised Surveillance procedures.W/970729 Ltr ML17229A4241997-07-25025 July 1997 LER 97-005-00:on 970625,discovered That Hot Shutdown Control Panel Shutdown Cooling Flow indicator,FI-3306 Inoperable. Caused by Weakness in Work Order & Procedure Used to Repair FI-3306.Section Meeting W/I&C Planners held.W/970725 Ltr ML17229A3971997-07-11011 July 1997 LER 97-004-00:on 970611,discovered Incorrect Original Cable Tray Fire Stop Assembly Installation Was Outside App R Design Basis.Caused by Personnel Error.Hourly Fire Watch Patrols Will Be posted.W/970711 Ltr ML17229A3871997-06-19019 June 1997 LER 97-003-00:on 970521,determined Required Post Maint Open Stroke Test for Valve V3245,2B2 SIT Discharge Check Valve, Had Not Been Performed.Caused by Personnel Error.Procedure revised.W/970619 Ltr ML17229A3841997-06-17017 June 1997 LER 97-002-00:on 970518,containment Sump Debris Screen Was Not IAW Design Due to Gaps in Screen Encl.Performed SER to Document Containment Sump Design requirements.W/970617 Ltr ML17229A3751997-06-0202 June 1997 LER 97-006-00:on 970501,operation Was Prohibited by TS Due to Inadequately Tested Degraded Voltage Sys.Revised Unit 1 ESFAS Surveillance Test procedure.W/970602 Ltr ML17229A3611997-05-29029 May 1997 LER 97-007-00:on 970502,reactor Coolant Pump Oil Collection Sys Was Outside App R Design Bases.Identified Leak Sites Were Repaired & Mods to RCP Oil Collection Sys to Capture Any Future Leakage from areas.W/970529 Ltr ML17229A3491997-05-21021 May 1997 LER 97-001-00:on 970423,containment Isolation Actuation Occurred.Caused by Increased Radiation Levels During Removal of Upper Guide Structure.Proper Actuation of Containment Isolation Components Was verified.W/970521 Ltr ML17229A3441997-05-13013 May 1997 LER 97-005-00:on 970419,reactor Was Shutdown Due to Reactor Coolant Pressure Boundary Leakage.Hot Cracking Was Caused by Weld Contamination.Repairs to RCPB Were Completed & 1A SDC Train Was Restored to Svc ML17229A3141997-04-30030 April 1997 LER 97-004-00:on 970402,refueling Machine Was Operating in Manner Prohibited by TS Due to Original Design of Refueling Machine Bypass Feature Conflicting W/Ts Requirements. Eliminated Overload Cut Off Limit bypass.W/970430 Ltr ML17229A2951997-03-31031 March 1997 LER 97-003-00:on 970304,automatic Rt Resulted from Loss of Electrical Power to 1A2 Rc Pump.Rcp Breaker Was Replaced & Pump Was Returned to svc.W/970331 Ltr ML17229A2721997-03-21021 March 1997 LER 97-002-00:on 970221,operation in Excess of Max Rated Thermal Power Occurred Due to Digital Data Processing Sys (Ddps) Calorimetric Error.Verified Acceptable Performance of Ddps Functions & Reviewed Software mods.W/970321 Ltr 1999-07-06
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML17241A4891999-10-0707 October 1999 LER 99-004-00:on 990912,noted That MSSV Surveillance Was Outside of TS Requirements.Caused by Setpoint Drift.Subject MSSVs Are Being Refurbished & Retested Prior to Unit Startup from SL1-16 Refueling Outage.With 991007 Ltr ML17241A4951999-09-30030 September 1999 Monthly Operating Repts for Sept 1999 for St Lucie,Units 1 & 2.With 991014 Ltr ML17241A4741999-08-31031 August 1999 Rev 1 to PCM 99016, St Lucie Unit 1,Cycle 16 Colr. ML17241A4591999-08-31031 August 1999 Monthly Operating Repts for Aug 1999 for St Lucie,Units 1 & 2.With 990913 Ltr ML17241A4301999-07-31031 July 1999 Monthly Operating Repts for Jul 1999 for St Lucie Units 1 & 2.With 990805 Ltr ML17241A4111999-07-16016 July 1999 LER 99-007-00:on 990610,unplanned Cooldown Transient Occurred Due to Personnel Error.Trained & Briefed Personnel & Revised Procedures.With 990716 Ltr ML17241A4031999-07-0606 July 1999 LER 99-006-00:on 990605,sub-critical Reactor Trip Occurred Due to Inadvertent MSIV Opening.Caused by Personnel Error. Provided Operation Supervision Instruction to Operating Crews,Stand Down Meetings & Operator Aids.With 990706 Ltr ML17241A4041999-07-0606 July 1999 LER 99-005-00:on 990604,CEA Drop Resulted in Manual Reactor Trip.Caused by Procedural Inadequacies.Procedure Changes Are Planned to Correct Lack of Procedural Guidance for CEA Subgroup Power Switch Replacement.With 990706 Ltr ML17241A4091999-06-30030 June 1999 Monthly Operating Repts for June 1999 for St Lucie,Units 1 & 2.With 990712 Ltr ML17241A3941999-06-30030 June 1999 LER 99-004-01:on 990415,as Found Cycle 10 Psv Setpoints Were Outside TS Limits.Caused by Manufacturing Process Defect. All Three Psvs Were Replaced with pre-tested Valves During Cycle 11 Refueling Outage.With 990630 Ltr ML17355A3681999-06-30030 June 1999 Revised Update to Topical QA Rept, Dtd June 1999 ML17241A3551999-06-0404 June 1999 LER 99-002-00:on 990505,both Trains of Safety Injection Actuation Were Blocked During Surveillance.Caused by Procedure Error.Procedure Revised.With 990604 Ltr ML17241A3631999-05-31031 May 1999 Monthly Operating Repts for May 1999 for St Lucie Units 1 & 2.With 990610 Ltr ML17241A3321999-05-17017 May 1999 LER 99-004-00:on 990415,determined That as Found Cycle 10 Psv Setpoints Outside TS Limits.Root Cause Under Investigation.Psvs Replaced with pe-tested Valves During Cycle 11 ML17241A3271999-05-0606 May 1999 LER 99-003-00:on 990406,ECCS Suction Header Leak Resulted in Both ECCS Trains Being Inoperable & Entry Into TS 3.0.3. Caused by Chloride Induced OD Stress Corrosion Cracking of Piping.Made Code Repairs & Coated Piping.With 990506 Ltr ML17241A3331999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for St Lucie,Units 1 & 2.With 990517 Ltr ML17229B0801999-04-0707 April 1999 LER 99-002-00:on 990311,SG ECT Error Caused Operation with Condition Prohibited by Ts.Caused by Deficiencies in Data Analysis Guideline Instructions.Licensee Will Change Data Analysis Guidelines for Lead Analysts.With 990407 Ltr ML17229B0841999-04-0707 April 1999 Rev 2 to PSL-ENG-SEMS-98-102, Engineering Evaluation of ECCS Suction Lines. ML17229B0791999-04-0707 April 1999 LER 99-001-00:on 990309,discovered Inadequate Design & IST SRs for Iodine Removal Sys (Irs).Caused by Original Design Inadequacies & Personnel Error.Naoh Tank Vent Valve V07233 Was Tagged Open.With 990407 Ltr ML17229B0961999-03-31031 March 1999 Monthly Operating Repts for Mar 1999 for St Lucie,Units 1 & 2.With 990408 Ltr ML17229B0541999-03-10010 March 1999 LER 99-001-00:on 990211,inadequate TS SRs for SIT & SDC Isolation Valves Were Noted.Caused by Failure to Correctly Implement TS Srs.Submitted LAR to Align Required TS SR with Design Bases Requirements Being Verified.With 990310 Ltr ML17229B0461999-02-28028 February 1999 Monthly Operating Repts for Feb 1999 for St Lucie,Units 1 & 2.With 990310 Ltr ML17229B0051999-01-31031 January 1999 Monthly Operating Repts for Jan 1999 for St Lucie,Units 1 & 2.With 990211 Ltr ML17229A9901999-01-20020 January 1999 LER 98-009-00:on 981223,noted That Facility Operated Outside of Design Basis.Caused by non-conservative MSLB Analysis Inputs.Will Review SR Component Differences Between Units & Will re-baseline LTOP Analysis.With 990120 Ltr ML17229A9961999-01-14014 January 1999 SG Tube Inservice Insp Special Rept. ML17229A9821999-01-0404 January 1999 LER 98-010-00:on 981207,RCS Boron Sample Frequency Required by Ts,Was Exceeded by Twelve Minutes.Caused by Personnel Error.Equipment Clearance Order Was Lifted to Draw Required Sample & Operations Procedure Was Changed.With 990104 Ltr ML17229A9831998-12-31031 December 1998 Monthly Operating Repts for Dec 1998 for St Lucie,Units 1 & 2.With 990111 Ltr ML17229A9611998-12-22022 December 1998 LER 97-002-01:on 981204,containment Sump Debris Screen Was Not IAW Design.Caused by Inadequate C/As for Sump Screen Anamolies.All Identified Sump Screen Deficiencies Were Dispositioned &/Or Repaired.With 981222 Ltr ML17229A9561998-12-15015 December 1998 LER 98-008-00:on 981118,missed TS SG U Tube Insp.Caused by Encoding Errors While Using Remote Positioning Fixtures.All SG Tube Surveyed.With 981215 Ltr ML17241A3581998-12-0909 December 1998 Changes,Tests & Experiments Made as Allowed by 10CFR50.59 for Period of 970526-981209. ML17229A9421998-11-30030 November 1998 Monthly Operating Repts for Nov 1998 for St Lucie,Units 1 & 2.With 981215 Ltr ML17229A9301998-11-25025 November 1998 LER 98-005-01:on 980807,discovered That New MOV Methodology Caused Past PORV Block Valve Operability Problem.Caused by Inadequacies in Original Vendor MOV Methodology.Planned Valve Mods Will Be Implemented During Cycle 11 1998 Outage ML17229A9021998-11-0404 November 1998 LER 98-008-00:on 981008,inadequate Reactor Protection Sys Trip Bypass TS Was Noted.Caused by Poorly Worded Ts. Submitted LAR to Clarify Power Requirements for High Rate of Power Trips.With 981104 Ltr ML17241A4931998-11-0101 November 1998 Statement of Account for Period of 981101-990930 for Suntrust Bank,As Trustee for Florida Municipal Power Agency Nuclear Decommissioning Trust (St Lucie Project). ML17229A9051998-10-31031 October 1998 Monthly Operating Repts for Oct 1998 for St Lucie,Units 1 & 2.With 981110 Ltr ML17229A8871998-10-19019 October 1998 Part 21 Rept Re Potential Defect in Swagelok Stainless Steel Front Ferrule,Part Number SS-503-1 Which Was Machined with Improper Length.C/A Includes Insp Equipment That Will 100% Identify Short Length ML17229A8781998-10-19019 October 1998 Part 21 Rept Re Potential Defect in Swagelok Stainless Steel Front Ferrule,Part Number SS-503-1,which Was Machined with Improper Length.Insp Equipment That Will 100% Identify Short Length ML17229A8771998-10-14014 October 1998 LER 98-006-00:on 980918,inadvertent Afas Actuation Was Noted.Caused by Degradation of Multiple Afas Power Supplies. Replaced Afas Power Supplies & Revised Procedures.With 981014 Ltr ML17229A8761998-10-14014 October 1998 LER 98-007-00:on 980918,identified Discrepancies Between Fire Protection Design Requirements & Field Conditions. Caused by Inadequate Translation & Implementation of Fire Protection Requirements.Procedures Revised.With 981014 Ltr ML17229A8721998-09-30030 September 1998 Monthly Operating Repts for Sept 1998 for St Lucie Units 1 & 2.With 981009 Ltr ML17229A8511998-09-0202 September 1998 LER 98-005-00:on 980807,discovered That PORV Margins Were Insufficient to Accommodate Addl Conservatism.Caused by Inadequacies in Original Vendor MOV Methodology.Will Implement Planned Valve Actuator mods.W/980902 Ltr ML17229A8611998-08-31031 August 1998 Monthly Operating Repts for Aug 1998 for St Lucie,Units 1 & 2.With 980911 Ltr ML18066A2771998-08-13013 August 1998 Part 21 Rept Re Deficiency in CE Current Screening Methodology for Determining Limiting Fuel Assembly for Detailed PWR thermal-hydraulic Sa.Evaluations Were Performed for Affected Plants to Determine Effect of Deficiency ML17229A8481998-08-0707 August 1998 Rev 1 to PSL-ENG-SEFJ-98-013, St Lucie Unit 2,Cycle 10 Colr. ML17229A9461998-08-0707 August 1998 Rev 0 to PCM 98016, St Lucie Unit 2,Cycle 11 Colr. ML17229A8301998-07-31031 July 1998 Monthly Operating Repts for July 1998 for St Lucie,Units 1 & 2.W/980814 Ltr ML17229A8201998-07-29029 July 1998 LER 98-007-00:on 980630,inadequate Procedure May Have Resulted in SBO Recovery Complications.Caused by Inadequate Procedures.Attached Caution Tags to Appropriate Control switches.W/980729 Ltr ML17229A7981998-06-30030 June 1998 Monthly Operating Repts for June 1998 for St Lucie,Units 1 & 2.W/980713 Ltr ML17229A7701998-05-31031 May 1998 Monthly Operating Repts for May 1998 for St Lucie,Units 1 & 2.W/980612 Ltr ML17229A7411998-05-28028 May 1998 LER 98-004-00:on 980430,discovered Waste Gas Decay Tank Operation W/O Available Oxygen Analyzers,Which Is Prohibited by Ts.Caused by Inadequate Licensee Review of License Amend. Oxygen Analyzer recalibrated.W/980528 Ltr 1999-09-30
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DOCKET 05000389 ACCELERATED DOCQVIENT DISTRIBUTION SYSTEM REGU~ORY INFORMATION DISTRIBUT.SYSTEM (RIDE)!ACCESSION NBR:9306160342 DOC.DATE: 93/06/14 NOTARIZED:
NO FACIL:50-389 St.Lucie Plant, Unit 2, Florida Power&Light Co.AUTH.NAME AUTHOR AFFILIATION HURCHALLA,J.A.
Florida Power&Light Co.SAGER,D.A.
Florida Power&Light Co.RECIP.NAME RECIPIENT AFFILIATION
SUBJECT:
LER 93-006-00:on 930513,EDG 2B inadvertently started during safeguards relay testing due to personnel error.Personnel.
performing test counseled on communications
&safeguards relay testing completed satisfactorily.W/930611 ltr.DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL SIZE: TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.NOTES: D RECIPIENT ZD CODE/NAME PD2-2 LA NORRIS,J INTERNAL: ACNW AEOD/DOA AEOD/ROAB/DSP NRR/DE/EMEB NRR/DRCH/HICB NRR/DRIL/RPEB NRR/DRSS/PRPB NRR/DSSA/SRXB RES/DSIR/EZB EXTERNAL: EG&G BRYCE,J.H NRC PDR NSIC POOREFW.COPIES LTTR ENCL 1 1 1 1 2 2 1 1 2 2 1 1 1 1 1 1 2 2 1 1 1 1 2 2 1 1 1 1 RECIPIENT ID CODE/NAME PD2-2 PD ACRS AEOD/DSP/TPAB NRR/DE/EELB NRR/DRCH/HHFB NRR/DRCH/HOLB NRR/DRPW/OEAB NRR/DISA SPLB REGLAZE 02 RGN2 FILE 01 L ST LOBBY WARD NSIC MURPHY,G.A NUDOCS FULL TXT COPIES LTTR ENCL 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 D D x$D NOTE TO ALL"RIDS" RECIPIENTS:
PLEASE HELP US TO REDUCE WASTE!CONTACI'HE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT.504-2065)TO ELIMINATE YOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!D FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 32 ENCL 32 FPL June.11, 1993 P.O.Box 128, Ft.Pierce, FL 34954-0128 L-93-157 10.CFR 50.73 U.S.Nuclear Regulatory Commission Attn: Document Control Desk Washington, D.C.20555 Re: St.Lucie Unit 2 Docket No.50-389 Reportable Event: 93-06 Date of Event: May 13, 1993 Inadvertent Start of the 2B Emer enc Diesel Geneiator The attached Licensee Event Report is being submitted pursuant to the requirements of 10 CFR 50.73 to provide notification of the subject event.Very truly yours, D.A.ger Vice sident St.Lucie Plant DAS/JJB/kw Attachment cc: Stewart D.Ebneter, Regional Administrator, USNRC Region II Senior Resident Inspector, USNRC, St.Lucie Plant DAS/PSL 8932-93 l 5008'i'DR ADOCK 05000389 S an FPL Group company gl F P~.FocsTITTTs ol MIC Form SM Psst U.S.NUCLEAR REGULATORY COMMISS CN LICENSEE EVENT REPORT (LER)NTISWEO OIAI HEI$1 ICS 155 EAIHEW ACCS5 ESINATEO IAACE H IEH IKSPONSE To CCINIY WTIH TITS SSOISIAWOH CCIIECTIISI IHOUESTl 50 0 ITIS TarWAITI CaANIIIS ISCNEWIC TAAS5EH ESISIATE To TIC IHCaEIS NEI tEtarrS HNIAOE HE HT WINICH It CTTA IAS IAICIENI IH 55SATOHY~WAWSHH CW.OC 5555!5 NII TO THE ttOTWWTTUI IHOUCTESI RCIXCT oIIS51515aTICEa HAHACEAEHTNAITAeaET esNHATToAOC 5555S FACILITY NAME (1)St.Lucie Unit 2 DOCKET NUMBER (2)PAGE 3 050003891 0 3'~()Inadvertant Start of the 2B Emergency Diesel Generator During Safeguards Relay Testing Due to Personnel Error EVENT DATE (5)MONTH DAY YEAR YEAR I S IAL LER NUMBER (6)REPORT DATE (7)MONTH DAY YEAR FACILITY NAMES N/A DOCKET NUMBER(S)0 5 OTHER FACILITIES INVOLVED (8)0 5 1 3 9393 0 0 6 0 0 0 6 1 4 9 3 N/A 05000 POWER LEVEL (10)1 0 0 OPERATING MODE (9)X 50.73(a)(2)(iv) 20.402(b)20.405(a)(1
)(i)20.405(c)50.36(c)(1) 50.73(a)(2)(v) 50.73(a)(2)(vii) 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(viii)(A) 50.73(a)(2)(viii)(B) 50.73(a)(2)(x) 20.405(a)(1)(iii) 20.405(a)(1)(iv) 20.405(a)(1)(v) 50.73(a)(2)(i) 50.73(a)(2)(ii) 50.73(a)(2)(iii)
LICENSEE CONTACT FOR THIS LER 12 THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR: Check one or more of the followin (11)73.71(b)73.71(c)OTHER (Specify in Abstract below andin Text NRC Form 366A)James A.Hurchalla, Shift Technical Advisor TELEP ONE NUMBER AREACODE 4 0 7 4 6 5-3 5 5 0 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT 13 CAUSE SYSTEM COMPONENT MANUFAC-TURER REPORTABLE TO NPRDS CAUSE SYSTEM COMPONENT MANUFAC-REPORTABLE TURER TO NPRDS SUPPLEMENTAL REPORT EXPECTED 14 I I I EXPECTED MONTH DAY YEAR SUBMISSION DATE (15)YFS (If yes, complete EXPECTED SUBMISSION DATE)X NO ABSTRACT (Limit to 1400 spaces.i.e.
approximately fifteen single-space typewritten lines)(16)On May 13, 1993, at 1920 hours0.0222 days <br />0.533 hours <br />0.00317 weeks <br />7.3056e-4 months <br /> with Unit 2 in Mode 1 at 100%power, Instrument and Control (IBC)personnel were performing the"Engineered Safeguards Relay Test" procedure OP 2-0400053 in coordination with the Unit 2 Operating crew.Operations had set up the initial test conditions including control isolation of the 2B Emergency Diesel Generator (EDG)from the Engineered Safety Features Actuation System (ESFAS).Instrument and Control technicians then connected a multifunction test meter across an ESFAS relay contact which provides an EDG start and injected a trip test signal to check this circuit's actuation.
When the IRC supervisor did not obtain the desired results he informed the Assistant Nuclear Plant Supervisor that Operations personnel could"reset" following the test.Operations restored the plant to normal including taking the EDG normal/isolate switches back to the normal position thereby unisolating the 2B EDG from the ESFAS.Approximately one minute later the 2B EDG started and performed as expected for an automatic safeguards actuation.
The 2B EDG was immediately secured and the safeguards relay testing was stopped pending investigation of why the EDG had started.The root cause of the unplanned start of the 2B EDG was due to personnel error.The l8C supervisor intended to perform the test again and only intended for Operations to reset the ESFAS signals to restore the initial test conditions.
However, based on previous communications following each test, Operations understood the reset request as that the test was complete and that they could secure from the test conditions.
A contributing factor was a lack of procedural guidance for repeating or securing the test conditions.
Corrective actions: 1)Personnel performing the test were counseled on communications.
2)The safeguards relay testing was completed satisfactorily.3)
OP2-0400053 will be changed to ensure test equipment is removed prior to restoring plant equipment.
4)A Human Performance Enhancement Review was conducted and the conclusions incorporated in this report.5)Training on this event will be provided for appropriate plant personnel.
FPL FacsimIIe of NRC Form 366 (6-89)
F PL FttcCilrTIIT ol NRC Form S68 ($80)US.NUCLEAR REGULATORY COMMlSSION LICENSEE EVENT REPORT (LER)'EXT CONTINUATtON JTTTITTVT0 CAe NCt St NIT I II CrtTNXN AIIIN t CCTAIATT0 IlNCTN rr II ICSKWX To CCINCTWITN TITS CCCTCAATTCN CCAICCTTCN ICDXCTI 10 A IATl fCÃI WANT COIANNI C CAIATCNII NATXN ISIINATC 10 00 IKCCNTC AtD ICTCITTC NANAtXINNT CNANCH TPCTttA TAN IAITACAN IXCAAATTTTT
~WANNICIOI, CC IOSSA NCITOTIC&PI NICTWCTAACTCNITTCtCCI plIACTOIACINCC or NAWATXINNT AI0 MXXT, WANNNITDA CC TNTCA FACILITY NAME (1)St.Lucie Unit 2 DOCKET NUMBER (2)LER NUMBER (6)EQUENTIAL REVISION A NUMBER.NUMBER PAGE (3)05000389 TEXT (//more spaceis required, use additional NRC Form 366A's)(17)9 3-0 0 6 0 0 0 2 0 3 On May 13, 1993, at 1920 hours0.0222 days <br />0.533 hours <br />0.00317 weeks <br />7.3056e-4 months <br /> with Unit 2 in Mode 1 at 100%power, Instrument and Control personnel were performing the"Engineered Safeguards Relay Test" procedure OP 2-0400053 in coordination with the Unit 2 Operating crew.During the performance of this procedure Operations established the initial test conditions and the Instrument and Control personnel performed the relay actuation and verification.
Data sheet¹8 of OP 2-0400053 was being performed to test the cabability of the NB" Safety Injection Actuation SignaVContainment Isolation Actuation Signal (SIAS/CIAS)(EIIS:JE) relay to provide an Emergency Diesel Generator (EDG)(EIIS:EK) start signal.Operations had fulfilled the pretest conditions by placing the 2B EDG normalfisolate switches in the isolate position to isolate that EDG from the safeguards start circuitry during the test to minimize unecessary EDG starts.The Instrument and Control personnel connected a multifunction test meter across the B SIAS/CIAS relay contact and injected the trip test signal to obtain actuation.
When the Instrument and Control supervisor did not obtain the desired results he informed the Assistant Nuclear Plant Supervisor (ANPS)that Operations personnel could"reset" following the test.Operations restored the plant to normal including taking the EDG normalfisoiate switches back to the normal position thereby unisolating the EDG.During this time the technicians had removed the meter from the test leads to replace it with a different meter as a precautionary measure.The leads were left on the contacts in anticipation of performing the test again.Subsequent to the EDG normaV isolate switches being placed to normal, technicians installed the new meter on the already connected leads.The 2B EDG started but did not load to the 2B3 41 60 VAC bus which is the expected response for an automatic safeguards actuation of the EDG with its safety related bus energized.
The 2B EDG was immediately secured and the safeguards relay testing was stopped pending investigation of why the EDG had started.E EV The root cause of the 2B EDG starting was due to personnel error involving inadequate communications.
The Instrument and Control supervisor intended to reperform the test and only intended for Operations to reset the safeguards signals to restore the initial test conditions.
However, based on communications following previous tests, the ANPS understood the reset request as meaning that the test was complete and that they could secure from the test conditions.
The proper communication should have included exactly what function was to be restored and the intent to reperform the test.A contributing factor was the lack of explicit procedural guidance to ensure that test equipment was not in place when restoring equipment.
The technicians had removed the meter from the test leads but had not not removed the test leads from the contact since they expected to perform the test again.When the 2B EDG normal/isolate switch was restored to normal the B SIAS/CIAS relay was now capable of providing a start signal upon actuation.
When the Instrument and Control technician attached the new meter to the test leads it acted as a jumper across the contact providing a start signal.The procedure does not stipulate that test equipment must be removed prior to resetting actuation signals, only the post test status of the normal isolate switch and the note that the EDG should not be started.This allows flexibility within the procedure to reperform the relay actuation and verification if required without having to restore all equipment to normal and set up initial test conditions again.The procedure should preclude leaving test leads in place or relanding them until Operations has communicated that the test may be reperformed.
There were no unusual characteristics of the work location which contributed to this event.FPL Facsimile of NRC Form 366 (6-89)
,4 FPL F le OT NAC Fafff%6 t6efrft U.S.NUCLEAR AEGULATO AY CO MMISS fON LICENSEE EVENT REPORT (LER)TEXT CONTINUATION Affnoflo an ICl Sl f0 Sl SI effseL fosse CSTWATTTT TASTCOI fell feSIONSe TO CaNCT WTN TTW SeaWAllCN CafeCTlaf Ieae STl TOS fnf fofNIAITT CONASNT S INCNTCSTO TTAOCN eelWATS lolls fecaSTS ANT WfaTTSNANAcefeNT SNANCNISSTIA ITS IAICTSAN IeaAATaTT~TTANwcfal.cc ffsfe No xone TASNfwfcnf fecucTTCN fnoecf TTI fssfoq,ance Of 0 ANAJJNNT Ne TTNCCT,WASINNITOIA OC fffcS FACILITY NAME (1)St.Lucie Unit 2 DOCKET NUMBER (2)LER NUMBER (6)YEAR I EQUENTIAL'REVISION I NUMBER NUMBER PAGE (3)0 500 0389 TEXT (lf more spaceis required, use additional NRC Form 366A's)(17)9 3 0 0 6 0 0 0 3 0 3 This event is reportable under 10 CFR 50.73.a.2.iv as an event or condition that results in a manual or automatic actuation of any Engineered Safety Feature.The inadvertant starting of the 2B Emergency Diesel Generator (EDG)had no adverse consequences on the plant because the 2B3 4160 VAC Bus remained energized and in service during this event, supplied by its normal offsite power supply source.The 2B EDG performed as expected for an automatic start from a Safety Injection Actuation Signal actuation.
There was no malfunction of the Engineered Safety Features or of the EDG start circuitry during this event.Therefore, the health and safety of the public were not affected at any time during this event.1)The utility personnel involved in this event were counseled on communications and the necessity of ensuring that test equipment is not installed when securing from a test.2)Upon determining the cause of the event the safeguards relay testing was resumed and completed satisfactorily the next day.3)The NSafeguards Relay Test" (OP 2-0400053) procedure will be changed to ensure that test equipment shall be removed prior to operations resetting any actuations or restoring any equipment to normal operating status.This test is not performed on Unit 1.4)A Human Performance Enhancement Review of this event was performed and the resulting conclusions have been integrated in the root cause determination and corrective actions.5)Training will be provided for the appropriate plant personnel on this event and on enhancing communications to prevent future occurrence.
None LER 335-93-003 Nlnadvertant start of the1 B Diesel Generator due to personnel error" LER 335-88-005 Nlnadvertant start of the 1A Diesel Generator during troubleshooting due to personnel error" FPL Facsimile of NRC Form 366 (6-89)