ML19325E633

LER 89-014-00:on 890929,RWCU Sys Isolated on Simulated Steam Line Tunnel High Temp Signal.Caused by Operator Failure to Perform self-verification Prior to Moving Bypass Switch. General Manager Held Briefings w/personnel.W/891027 Ltr

ML19325E633
Person / Time
Site:	Grand Gulf
Issue date:	10/27/1989
From:	Byrd R, Cottle W SYSTEM ENERGY RESOURCES, INC.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
AECM-89-0201, AECM-89-201, LER-89-014, LER-89-14, NUDOCS 8911080156
Download: ML19325E633 (4)

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October 27, 1989 )

hrku crosons U.S. Nuclear Regulatory Commission Mail Station P1-137

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[- Attention: Document Control Desk Gentlemen +

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SUBJECT:

Grand Gulf Nuclear Station Unit 1 Docket No. 50-416 License No. NPF-29 -

t RWCU Isolation During Surveillance z e Due To Personnel Error LER 89-014-00 AECM-89/0201 ,

Attached is Licensee Event Report (LER) 89-014-00 which is a final report.

Yours truly, e:.e> y W P

L WTC:cg Attachment 1'

cc: Mr. D. C. Hintz (w/a)

Mr. T. H. Cloninger (w/a)

Mr. R. B. McGehee (w/a)

Mr. N. S. Reynolds (w/a)

Mr. H. L. Thomas (w/o)

Mr. H. O. Christensen (v/a)

l. Mr. Stewart D. Ebneter (w/a) r Regional Administrator U.S. Nuclear Regulatory Commission U Region II

[ 101 Marietta St., N.W., Suite 2900 Atlanta, Georgia 30323 lL i Mr. L. L. Kintner, Project Manager (w/a)

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] N6 l l l assenneviu=,.,4m a. ,a, .ae. nei On September 29, 1989 during performance of an annual surveillance, the Reactor Water Cleanup (RWCU) system isolated on a simulated steam line tunnel high temperature signal due to personnel error. The performance of the surveillance results in isolation signals to both the Reactor Core Isolation cooling (RCIC) system isolation valves and the RWCU system loolation valves. The isolations are prevented by placing the divisional RCIC bypass switch and the divisional RWCU bypass switch to the BYPASS position. Ilowever, when the surveillance procedure directed the operator to l place the "A" RCIC bypass switch to BYPASS, he mistakenly placed the "A" RWCU bypass switch to NORMAL. This immediately caused an RWCU isolation.

The two switches are adjacent on the same panel.

l As a result of this event and two other recent events involving human performance errors, the plant General Manager held briefings with all available Operations and Instrumentation / Control Supervisors and Superintendents informing them of the incidents and the key elements that could have prevented the occurrences: attention to detail, concise verbal communications, and self-verification. This was also reiterated to all plant personnel in a special plant information newsletter.

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A. Reportable Occurrence On September 29, 1989, during performance of an annual surveillance, the Reactor Water Cleanup (RWCU) system (EIIS system code: CE) isolated on a simulated steam line tunnel high temperature signal. This unplanned -

automatic isolation of the RWCU system containment isolation valves is  ;

reported as an ESF actuation pursuant to 10CFR50.73(a)(2)(iv).

B. I'nitial Conditions The plant was operating,at approximately 100 percent reactor power.

C. Description of Occurrence On September 29, 1989, maintenance personnel were performing the annual calibration and logic functional test of the Steam Line Tunnel High Temperature Trip System (EIIS system code: JM) as required by Technical Specification Table 4.3.2.1-1.5.f. The performance of this surveillance results in' isolation signals to both the Reactor Core Isolation Cooling (RCIC) system isolation vnives and the RWCU system isolation valves. The isolations are prevented by placing the divisional RWCU bypass switch and the divisional RCIC bypass switch to the BYPASS position.

The maintenance Instrumentation and Control (I&C) technician performing the surveillance on Charnel E requested operator support in the Upper Control Room to operate a bypass switch. The procedure step required the operator to place the "A" RCIC isolation bypass switch to BYPASS. The technician showed the operator the required action in the procedure when he arrived. The operator reviewed and initialed the step but erroneously placed the "A" RWCU isolation bypass switch to NORMAL which immediately resulted in an kWCU isolation at 1542.

The maintenance technician recognized that the operator had grasped the wrong switch but was unable to respond in time to stop the action. The operator returned the RWCU bypass switch to BYPASS and also placed the RCIC bypass switch to BYPASS as required. RWCU operation was restored by 1557.

D. Apparent Cause A similar incident occurred on September 28, 1988 (LER 88-017) while performing a monthly functional test. An operator placed the RHR bypass switch to BYPASS rather than the RWCU bypass switch which resulted in an RWCU isolation during subsequent procedural actions. The cause of the previous event was lack of attention to detail by both the operator who operated the switch and the technician who signed the step off as being complete. Licensed personnel and I6C technicians were informed of the event, the importance of effective communication, and the importance of being absolutely sure of what they are doing prior to performing the action.

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In addition, a management standard was issued in January.1989 that

, required personnel to self-verify their actions prior to performing i component manipulations or equipment alterations. The standard also ,

established a systematic method of performing the self-verifications.

t The incident on September 29, 1989 occurred when the licenced operator failed to perform s self-verification prior to performing.the action.

The "A" RCIC bypass switch and the "A" RWCU bypass switch are adjacent i on the same panel. The operator applied inadequate attention to the surveillance action and did not perform a self-verification because he 1 perceived pressure to quickly complete the action. The request for operator support came at the beginning of the Operation's shift at '

approximately'1530. The operator had just received turnover for a  ;

lengthy and involved Standby Service Water system-surveillance and had l received a call,about an unrelated equipment problem. Also, the' operator normally begins the Technical Specification rounds in the Control Room at 1600.'

E. Supplemental Corrective Actions -

An Incident Review Board (IRB) was convened to interview personnel involved'in the incident and to recommend appropriate corrective actions. i At the request of the IRB, a Human Performance Evaluation System (HPES) evaluation was performed to determine causal factors, which are described above, and develop recommendations to preclude recurrence.

i As a result of this event and two other recent events involving human performance errors, the plant General Manager held briefings with all available Operations and I&C Supervisors and Superintendents informing them'of the incidents and the key elements that could have prevented the  ;

occurrences: attention to detail, concise verbal communications, and  ;

self-verification. This was also reiterated to all plant personnel in a special plant information newsletter.

The responsible licensed reactor operator has been assigned to conduct one-on-one training with all other reactor operators. This training includes instruction on how to perform a proper self-verification and .

how it could have prevented this event.

F. Safety Assessment The unplanned RWCU containment isolation had no adverse affect to plant safety. The division 1 RWCU isolation valves responded as designed. The RWCU system was out of service for approximately 15 minutes.

g.oans s PCOM LER 89-014 4

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