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| issue date = 06/14/1993 | | issue date = 06/14/1993 | ||
| title = 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 | | title = 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 | ||
| author name = | | author name = Hurchalla J, Sager D | ||
| author affiliation = FLORIDA POWER & LIGHT CO. | | author affiliation = FLORIDA POWER & LIGHT CO. | ||
| addressee name = | | addressee name = | ||
Line 14: | Line 14: | ||
| page count = 5 | | page count = 5 | ||
}} | }} | ||
=Text= | |||
{{#Wiki_filter:ACCELERATED DOCQVIENT DISTRIBUTION SYSTEM REGU~ORY INFORMATION DISTRIBUT . SYSTEM (RIDE) | |||
ACCESSION NBR:9306160342 DOC.DATE: 93/06/14 NOTARIZED: NO DOCKET FACIL:50-389 St. Lucie Plant, Unit 2, Florida Power & Light Co. 05000389 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. D 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: | |||
RECIPIENT COPIES RECIPIENT COPIES ZD CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL D PD2-2 LA 1 1 PD2-2 PD 1 1 NORRIS,J 1 1 D INTERNAL: ACNW 2 2 ACRS 2 2 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DSP 2 2 NRR/DE/EELB 1 1 NRR/DE/EMEB 1 1 NRR/DRCH/HHFB 1 1 NRR/DRCH/HICB 1 1 NRR/DRCH/HOLB 1 1 NRR/DRIL/RPEB 1 1 NRR/DRPW/OEAB 1 1 NRR/DRSS/PRPB 2 2 NRR/DISA SPLB 1 1 NRR/DSSA/SRXB 1 1 REGLAZE 02 1 1 RES/DSIR/EZB 1 1 RGN2 FILE 01 1 1 EXTERNAL: EG&G BRYCE,J.H 2 2 L ST LOBBY WARD 1 1 NRC PDR 1 1 NSIC MURPHY,G.A 1 1 NSIC POOREFW. 1 1 NUDOCS FULL TXT 1 1 x$ | |||
D D | |||
NOTE TO ALL"RIDS" RECIPIENTS: | |||
PLEASE HELP US TO REDUCE WASTE! CONTACI'HE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT. 504-2065) TO ELIMINATEYOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED! | |||
FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 32 ENCL 32 | |||
P.O. Box 128, Ft. Pierce, FL 34954-0128 June .11, 1993 L-93-157 FPL 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 Senior Resident Inspector, USNRC, St. Lucie Plant II DAS/PSL 8932-93 l 5008'i'DR S | |||
ADOCK 05000389 gl an FPL Group company | |||
~ | |||
F P~. FocsTITTTs ol U.S. NUCLEAR REGULATORY COMMISS CN NTISWEO OIAIHEI $ 1 ICS 155 EAIHEW ACCS5 MIC Form SM ESINATEO IAACEH IEH IKSPONSE To CCINIYWTIHTITS SSOISIAWOH CCIIECTIISI Psst LICENSEE EVENT REPORT (LER) IHOUESTl 50 0 ITIS TarWAITICaANIIIS ISCNEWIC TAAS5EH ESISIATE To TIC IHCaEIS NEI tEtarrS HNIAOE HE HT WINICHItCTTA IAS IAICIENIIH55SATOHY WAWSHH CW . OC 5555!5 NIITO THE ttOTWWTTUIIHOUCTESI RCIXCT oIIS51515aTICEa HAHACEAEHTNAITAeaETesNHATToAOC 5555S FACILITYNAME (1) DOCKET NUMBER (2) PAGE 3 St. Lucie Unit 2 050003891 0 3 | |||
'~ ( ) Inadvertant Start of the 2B Emergency Diesel Generator During Safeguards Relay Testing Due to Personnel Error EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED(8) | |||
DOCKET NUMBER(S) | |||
MONTH DAY YEAR YEAR S I IAL MONTH DAY YEAR FACILITYNAMES N/A 0 5 0 5 1 3 9393 0 0 6 0 0 0 6 1 4 9 3 N/A 05000 THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR: | |||
OPERATING Check one or more of the followin (11) | |||
MODE (9) 20.402(b) 20.405(c) X 50.73(a)(2)(iv) 73.71(b) | |||
POWER 20.405(a)(1 )(i) 50.36(c)(1) 50.73(a)(2)(v) 73.71(c) | |||
LEVEL (10) 1 0 0 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(vii) OTHER (Specify in Abstract 20.405(a)(1)(iii) 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) below andin Text 20.405(a)(1)(iv) 50.73(a)(2)(viii)(B) NRC Form 366A) 50.73(a)(2)(ii) 20.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x) | |||
LICENSEE CONTACT FOR THIS LER 12 TELEP ONE NUMBER AREACODE James A. Hurchalla, Shift Technical Advisor 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- REPORTABLE MANUFAC- REPORTABLE TURER TO NPRDS CAUSE SYSTEM COMPONENT TURER TO NPRDS I I I SUPPLEMENTAL REPORT EXPECTED 14 EXPECTED MONTH DAY YEAR SUBMISSION YFS (Ifyes, complete EXPECTED SUBMISSION DATE) X NO DATE (15) | |||
ABSTRACT (Limit to 1400 spaces.i.e. 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. 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 FttcCilrTIITol NRC Form S68 | |||
($ 80) | |||
LICENSEE EVENT REPORT (LER) | |||
CONTINUATtON US. NUCLEAR REGULATORYCOMMlSSION | |||
'EXT JTTTITTVT0CAe NCt St NITI CrtTNXNAIIIN t II | |||
~ | |||
CCTAIATT0IlNCTNrr II ICSKWXTo CCINCTWITNTITS CCCTCAATTCN CCAICCTTCN ICDXCTI10 A IATlfCÃIWANT COIANNIC CAIATCNIINATXNISIINATC10 00 IKCCNTC AtD ICTCITTC NANAtXINNTCNANCH TPCTttA TAN IAITACANIXCAAATTTTT WANNICIOI,CC IOSSA NCITOTIC &PI NICTWCTAACTCNITTCtCCIplIACTOIACINCC or NAWATXINNTAI0 MXXT,WANNNITDACC TNTCA FACILITYNAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3) | |||
EQUENTIAL REVISION A NUMBER NUMBER St. Lucie Unit 2 05000389 9 3 - 0 0 6 0 0 0 2 0 3 TEXT (//more spaceis required, use additional NRC Form 366A's) (17) | |||
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. Data sheet ¹8 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 flexibilitywithin 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 Affnofloan ICl Sl f0Sl SI | |||
~ | |||
FPL F le OT U.S. NUCLEAR AEGULATO AY CO MMISS fON NAC Fafff %6 effseL fosse t6efrft CSTWATTTT TASTCOI fell feSIONSe TO CaNCT WTN TTW SeaWAllCN CafeCTlaf LICENSEE EVENT REPORT (LER) Ieae STl TOS fnf fofNIAITTCONASNT S INCNTCSTO TTAOCN eelWATS lolls fecaSTS ANT WfaTTSNANAcefeNT SNANCNISSTIA ITS IAICTSAN IeaAATaTT TEXT CONTINUATION TTANwcfal.cc ffsfe No xone TASNfwfcnffecucTTCN fnoecf TTIfssfoq,ance Of 0 ANAJJNNT Ne TTNCCT,WASINNITOIA OC fffcS FACILITYNAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3) | |||
EQUENTIAL REVISION St. Lucie Unit 2 YEAR I NUMBER NUMBER 0 500 0389 9 3 0 0 6 0 0 0 3 0 3 TEXT (lfmore spaceis required, use additional NRC Form 366A's) (17) | |||
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)}} |
Latest revision as of 12:39, 4 February 2020
ML17228A183 | |
Person / Time | |
---|---|
Site: | Saint Lucie |
Issue date: | 06/14/1993 |
From: | Hurchalla J, Sager D FLORIDA POWER & LIGHT CO. |
To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
References | |
L-93-157, LER-93-006, LER-93-6, NUDOCS 9306160342 | |
Download: ML17228A183 (5) | |
Text
ACCELERATED DOCQVIENT DISTRIBUTION SYSTEM REGU~ORY INFORMATION DISTRIBUT . SYSTEM (RIDE)
ACCESSION NBR:9306160342 DOC.DATE: 93/06/14 NOTARIZED: NO DOCKET FACIL:50-389 St. Lucie Plant, Unit 2, Florida Power & Light Co. 05000389 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. D 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:
RECIPIENT COPIES RECIPIENT COPIES ZD CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL D PD2-2 LA 1 1 PD2-2 PD 1 1 NORRIS,J 1 1 D INTERNAL: ACNW 2 2 ACRS 2 2 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DSP 2 2 NRR/DE/EELB 1 1 NRR/DE/EMEB 1 1 NRR/DRCH/HHFB 1 1 NRR/DRCH/HICB 1 1 NRR/DRCH/HOLB 1 1 NRR/DRIL/RPEB 1 1 NRR/DRPW/OEAB 1 1 NRR/DRSS/PRPB 2 2 NRR/DISA SPLB 1 1 NRR/DSSA/SRXB 1 1 REGLAZE 02 1 1 RES/DSIR/EZB 1 1 RGN2 FILE 01 1 1 EXTERNAL: EG&G BRYCE,J.H 2 2 L ST LOBBY WARD 1 1 NRC PDR 1 1 NSIC MURPHY,G.A 1 1 NSIC POOREFW. 1 1 NUDOCS FULL TXT 1 1 x$
D D
NOTE TO ALL"RIDS" RECIPIENTS:
PLEASE HELP US TO REDUCE WASTE! CONTACI'HE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT. 504-2065) TO ELIMINATEYOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!
FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 32 ENCL 32
P.O. Box 128, Ft. Pierce, FL 34954-0128 June .11, 1993 L-93-157 FPL 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 Senior Resident Inspector, USNRC, St. Lucie Plant II DAS/PSL 8932-93 l 5008'i'DR S
ADOCK 05000389 gl an FPL Group company
~
F P~. FocsTITTTs ol U.S. NUCLEAR REGULATORY COMMISS CN NTISWEO OIAIHEI $ 1 ICS 155 EAIHEW ACCS5 MIC Form SM ESINATEO IAACEH IEH IKSPONSE To CCINIYWTIHTITS SSOISIAWOH CCIIECTIISI Psst LICENSEE EVENT REPORT (LER) IHOUESTl 50 0 ITIS TarWAITICaANIIIS ISCNEWIC TAAS5EH ESISIATE To TIC IHCaEIS NEI tEtarrS HNIAOE HE HT WINICHItCTTA IAS IAICIENIIH55SATOHY WAWSHH CW . OC 5555!5 NIITO THE ttOTWWTTUIIHOUCTESI RCIXCT oIIS51515aTICEa HAHACEAEHTNAITAeaETesNHATToAOC 5555S FACILITYNAME (1) DOCKET NUMBER (2) PAGE 3 St. Lucie Unit 2 050003891 0 3
'~ ( ) Inadvertant Start of the 2B Emergency Diesel Generator During Safeguards Relay Testing Due to Personnel Error EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED(8)
DOCKET NUMBER(S)
MONTH DAY YEAR YEAR S I IAL MONTH DAY YEAR FACILITYNAMES N/A 0 5 0 5 1 3 9393 0 0 6 0 0 0 6 1 4 9 3 N/A 05000 THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR:
OPERATING Check one or more of the followin (11)
MODE (9) 20.402(b) 20.405(c) X 50.73(a)(2)(iv) 73.71(b)
POWER 20.405(a)(1 )(i) 50.36(c)(1) 50.73(a)(2)(v) 73.71(c)
LEVEL (10) 1 0 0 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(vii) OTHER (Specify in Abstract 20.405(a)(1)(iii) 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) below andin Text 20.405(a)(1)(iv) 50.73(a)(2)(viii)(B) NRC Form 366A) 50.73(a)(2)(ii) 20.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x)
LICENSEE CONTACT FOR THIS LER 12 TELEP ONE NUMBER AREACODE James A. Hurchalla, Shift Technical Advisor 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- REPORTABLE MANUFAC- REPORTABLE TURER TO NPRDS CAUSE SYSTEM COMPONENT TURER TO NPRDS I I I SUPPLEMENTAL REPORT EXPECTED 14 EXPECTED MONTH DAY YEAR SUBMISSION YFS (Ifyes, complete EXPECTED SUBMISSION DATE) X NO DATE (15)
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 FttcCilrTIITol NRC Form S68
($ 80)
LICENSEE EVENT REPORT (LER)
CONTINUATtON US. NUCLEAR REGULATORYCOMMlSSION
'EXT JTTTITTVT0CAe NCt St NITI CrtTNXNAIIIN t II
~
CCTAIATT0IlNCTNrr II ICSKWXTo CCINCTWITNTITS CCCTCAATTCN CCAICCTTCN ICDXCTI10 A IATlfCÃIWANT COIANNIC CAIATCNIINATXNISIINATC10 00 IKCCNTC AtD ICTCITTC NANAtXINNTCNANCH TPCTttA TAN IAITACANIXCAAATTTTT WANNICIOI,CC IOSSA NCITOTIC &PI NICTWCTAACTCNITTCtCCIplIACTOIACINCC or NAWATXINNTAI0 MXXT,WANNNITDACC TNTCA FACILITYNAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)
EQUENTIAL REVISION A NUMBER NUMBER St. Lucie Unit 2 05000389 9 3 - 0 0 6 0 0 0 2 0 3 TEXT (//more spaceis required, use additional NRC Form 366A's) (17)
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 sheet ¹8 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 flexibilitywithin 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)
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EQUENTIAL REVISION St. Lucie Unit 2 YEAR I NUMBER NUMBER 0 500 0389 9 3 0 0 6 0 0 0 3 0 3 TEXT (lfmore spaceis required, use additional NRC Form 366A's) (17)
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)