ML17263B059

LER 95-003-00:on 950407,inadvertent Automatic SI Actuation Occurred When Technician Unblocked SIAS Due to Misleading Procedural Direction.Pressurizer Pressure Channel P-431 Bistable Proving Switch reinstated.W/950508 Ltr

ML17263B059
Person / Time
Site:	Ginna
Issue date:	05/08/1995
From:	Mecredy R, St Martin J ROCHESTER GAS & ELECTRIC CORP.
To:	Andrea Johnson NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM), Office of Nuclear Reactor Regulation
References
LER-95-003, LER-95-3, NUDOCS 9505220005
Download: ML17263B059 (15)

Text

RIORITY CCI'.LLTIUKTEDRll)S I'ROCI'.SSliG) 1 REGULATORY INFORMATION DISTRIBUTION SYSTEM (RXDS)

ACCESSION NBR:9505220005 DOC.DATE: 95/05/08 NOTARIZED: NO DOCKET FACIL:50-244 Robert Emmet Ginna Nuclear Plant, Unit 1, Rochester G 05000244 AUTH. NAME AUTHOR AFFILIATXON ST MARTIN,J.T. Rochester Gas & Electric Corp.

MECREDY,R.C. Rochester Gas & Electric Corp.

RECIP.NAME RECIPIENT AFFILIATION JOHNSON,A.R. Project Directorate I-1 (PD1-1) (Post 941001)

SUBJECT:

LER 95-003-00:on 950407,an inadvertent automatic SI actuation occurred when technician unblocked SIAS.Caused by misleading procedural dir'ection.Automatic start of engineered safeguards initiated.W/950508 ltr.

DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.

NOTES:License Exp date in accordance with 10CFR2,2.109(9/19/72).

j ENCL i SIZE:

05000244 RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID 'CODE/NAME LTTR ENCL PD1-1 PD 1 1 JOHNSON,A 1 1 INTERNAL: AEOD S~/ B 2 2 AEOD/SPD/RRAB 1 1 CENT 1 1 NRR/DE/ECGB 1 1

/D EELB 1 1 NRR/DE/EMEB 1 1 NRR/DISP/PIPB 1 1 NRR/DOPS/OECB 1 1 NRR/DRCH/HHFB 1 1 NRR/DRCH/HICB 1 1 NRR/DRCH/HOLB 1 1 NRR/DSSA/SPLB 1 1 NRR/DSSA/SPSB/B 1 1 NRR/DSSA/SRXB 1 1 RES/DSIR/EIB 1 1 RGN1 FILE 01 1 1 EXTERNAL: L ST LOBBY WARD 1 1 LITCO BRYCE,J H 2 2 NOAC MURPHY,G.A 1 1 NOAC POORE,W. 1 1 NRC PDR 1 1 NUDOCS FULL TXT 1 1 N

YOTLT 'I 0 ALL"RIDS" RECIPIENTS:

PLE:KSE ISELP I:S TO REDUCE iVKSTE! CON'I ACT'I'IIE DOC!.'if!IY'I'COi'TROI.

DIS'I'RI II I UI'IOY. LIS'I'S I'OR DOCI 'ill'.X'I'S YOI.')OX"I'l DESk. ROO%1 PI-37 (EXT, 504-T083 ) TO I;LIXIIiA1'I'.YOI:R iAi!L:I'i<Oil I'.I)!

FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 26 ENCL 26

. ~

go~ A NO RKH"STEkDAS AIVD8'lk!C CORFOkATIOM 89 EAST AVEIVU, kCiw i,'>75k 6 4n:i,) i; ROBERT C. MECREDY vice pscs~cc~l e'u=iccr Ovesct,css May 8, 1995 U.S. Nuclear Regulatory Commission Control Desk 'ocument Attn: Allen R. Johnson PWR Project Directorate I-1 Washington, D.C. 20555

Subject:

LER 95-003, Unblocking of Safety Injection Actuation Signal While at Low Pressure Conditions, Due to Misleading Procedural Directions, Results in Inadvertent Automatic Safety Injection Actuation R.E. Ginna Nuclear Power Plant Docket No. 50-244 In accordance with 10 CFR 50.73, Licensee Event Report System, item (a) (2) (iv), which requires a report of, "Any event or condition that resulted in a manual or automatic actuation of any engineered safety feature (ESF), including the reactor protection system (RPS)", the attached Licensee Event Report LER 95-003 is hereby submitted.

This event has in no way affected the public's health and safety.

Very trul yours, Robert C. Mecredy xc: U.S. Nuclear Regulatory Commission Mr. Allen R. Johnson (Mail Stop 14B2)

PWR Project Directorate I-1 Washington, D.C. 20555 U.S. Nuclear Regulatory Commission Region I 475 Allendale Road King of Prussia, PA 19406 Ginna USNRC Senior Resident Inspector 2 dsi/!

9'505220005 950508 PDR ADOCK 05000244 S PDR

NRC FORM 366 U.S. NUCLEAR REGULATORY COMHISSION APPROVED BY OMB NO. 3150-0104 (5.92) EXPIRES 5/31/95 ESTIHATED BURDEN PER RESPONSE TO COHPLY 'WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.

L1CENSEE EVENT REPORT (LER) FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFORMATION AND RECORDS MANAGEHENT BRANCH (HHBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, (Sce reverse for required number of digits/characters for each block) WASHIHGTON, DC 20555-0001, AHD TO THE PAPERWORK REDUCTIOH PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET WASHINGTON DC 20503.

FAcILITY NAME (1) R.E. Ginna Nuclear Power Plant DOCKET NUHBER (2) PAGE (3) 05000244 10F 12 TITLE (4) Unblocking of Safety Injection Actuation Signal While at Low Pressure Conditions, Due to Hisleading Procedural'Directions, Results in Inadvertent Automatic Safety Injection Actuation EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (8)

SEQUENTIAL REVISION FACILITY HAME DOCKET NUMBER MONTH DAY YEAR YEAR HONTH DAY YEAR NUMBER NUHBER 04 07 95 95 -003-- 00 05 08 FACILITY NAME DOCKET NUMBER OPERATING N

THIS REPORT IS SUBHITTED PURSUANT TO THE RE(jUIREHENTS OF 10 CFR 5: (Check one or mor e) (ll)

HODE (9) 20.402(b) 20.405(c) 50.73(a)(2)(iv) 73. 71(b)

POWER 20.405(a )(1)(i) 50.36(c)('I) 50.73(a)(2)(v) 73.71(c) 000 LEVEL (10) 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(vii) OTHER 20.405(a)(1)(iii) 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) (Specify in 20.405(a)(1)(iv) 50.73(a)(2)(ii) 50.73(a)(2)(viii)(B) Abstract below and in Text, 20.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x) NRC Form 366A)

LICENSEE CONTACT FOR THIS LER (12)

NAME John T. St. Hartin - Technical Assistant TELEPHONE NUMBER (Include Area Code)

(315) 524-4446 COHPLETE ONE LINE FOR EACH COHPONENT FAILURE DESCRIBED IN THIS REPORT (13)

REPORTABLE REPORTABLE CAUSE SYSTEH COHPONENT HANUFACTURER CAUSE SYSTEM COHPONENT HANUFACTURER TO NPRDS TO NPRDS SUPPLEMENTAL REPORT EXPECTED (14) EXPECTED MONTH DAY YEAR YES SUBMISSION (If yes, complete EXPECTED SUBMISSION DATE). DATE (15)

ABSTRACT (Limit to 1400 spaces, i.e:, approximately 15 single-spaced typewritten lines) (16)

On April 7, 1995 at approximately 0900 EDST, with the plant in the cold shutdown mode for the annual refueling and maintenance outage, an inadvertent automatic Safety Injection Actuation occurred when a technician unknowingly unblocked the Safety Injection Actuation Signal with pressurizer pressure and steam line pressure less than the setpoint for Safety Injection Actuation.

Immediate corrective action was to monitor the automatic start of engineered safeguards features components and secure unneeded equipment.

The underlying cause of the inadvertent automatic Safety Injection Actuation was due to misleading procedural direction. This event is NUREG-1022 Cause Code (D).

Corrective action to preclude repetition is outlined in Section V.B.

NRC FORM 366 (5-92)

NRC FORM 366A U.S. NUCLEAR REGULATORY COHHISS ION APPROVED BY OHB NO. 3150.0104 (5.92) EXPIRES 5/31/95 ESTIHATED BURDEN PER RESPONSE TO COHPLY WITH THIS INFORMATIOH COLLECTION REQUEST: 50.0 HRS.

FORWARD COMMENTS REGARDING BURDEN ESTIHATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AND RECORDS HANAGEHENT BRANCH TEXT CONTINUATION (MHBB 7714), U.S. NUCLEAR REGULATORY COMHISSION, WASHINGTON, DC 20555-0001, AHD TO THE PAPERWORK REDUCTION PROJECT (3150.0104), OFFICE OF MANAGEMENT AND BUDGET WASHINGTON DC 20503.

FACILITY NAHE (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR SEQUENTIAL REVISION R.E. Ginna Nuclear Power Plant 05000244 M

2 OF 12 95 -- 003 pp TEXT (If more space is required, use additional copies of HRC Form 366A) (17)

PRE-EVENT PLANT CONDITIONS:

The plant was in the cold shutdown mode for the annual refueling and maintenance outage. The reactor coolant system (RCS) temperature was approximately 100 degrees F, and the RCS was depressurized. RCS loop levels were at approximately 80 inches, which is a partially drained condition with water level four inches below the reactor vessel flange.

On April 6, 1995, calibrations of individual instrument channels associated with Reactor Protection System (RPS) Channel 3 were started for Nuclear Instrument System (NIS) channel N-43 (using calibration procedure CPI-BISTABLES-N43), pressurizer (PRZR) pressure channel P-431 (using calibration procedure CPI-PT-431), and RCS Average Temperature channel T-403 (using calibration procedure CPI-TAVG-403). These channels were defeated in accordance with procedures. The calibration steps of CPI-PT-431 had been completed, but the P-431 channel could not be reinstated because reinstatement activities also required the completion of calibrations of N-43 and T-403, which were not yet completed. Therefore, procedure steps for reinstating P-431 were not performed at this time.

The calibrations of N-43 and T-403 were completed on April 7'by teams of Instrument and Control (I&C) technicians. An I&C technician working in the Control Room was ready to reinstate the individual instruments associated with RPS Channel 3 (N-43, P-431, and T-403).

He had also been requested to support the IGC technicians assigned to calibrate PRZR pressures by defeating and reinstating pressure channels. The IIC technicians assigned to PRZR pressures were in the Containment Building (CNMT) and requested the IIC technician in the Control Room to defeat P-429, associated with RPS Protection Channel

1. The IEC technicians in CNMT and in the Control Room discussed the sequence of defeating and reinstating, and concluded that expeditious to defeat the P-429 channel and proceed with calibration it was more of PT-429, than to wait for reinstatement of N-43, P-431, and T-403 before defeating P-429.

HRC FORH 366A (5 92)

NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.

FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AHD RECORDS MANAGEMENT BRANCH TEXT CONTINUATION (MNBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET WASHINGTON DC 20503.

FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR SEQUENTIAL REVISION R.E. Ginna Nuclear Power Plant 05000244 UM M 3 OF 12 95 -- 003 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

On previous calibrations that week, and as part of the. pre-job briefings on April 7, the IEC technicians were advised that they could perform work associated with more than one protection channel at a time at this plant mode. Therefore, they concluded that acceptable to defeat P-429 first, and proceeded with the defeat of P-it was 429.

The calibration procedure that Operations perform (CPI-PT-429) initial conditions specified an operability check of the other PRZR pressure channels (but only F).

if Temperature was less than 350 degrees F.

RCS temperature was above 350 degrees Thus, the IIC technician in the Control Room marked this step as "Not'pplicable"

("N/Au) and did not request that the Control Room operators perform operability checks of the other PRZR pressure channels. The IEC technician continued with the defeat of P-429.

As part of the calibration procedure, the IIC technician had to obtain permission from the Shift Supervisor for the defeat of P-429.

The Control Room operators were aware that IEC would be performing activities associated with more than one RPS protection channel, knew that 'the calibration steps of CPI-PT-431 had been completed, and assumed that the P-431 channel had been reinstated the previous day.

Therefore, the Control Room operators gave the IEC technician permission to defeat channel P-429. The I&C technician proceeded to defeat channel P-429 using CPI-PT-429.

II. DESCRIPTION OF EVENT:

A. DATES AND APPROXIMATE TIMES OF MAJOR OCCURRENCES:

April 6, 1995: I&C starts calibrations using CPI-BISTABLES-N43, CPI-PT-431, and CPI-TAVG-403.

April 6, 1995: IRC completes calibration of P-431, but does not reinstate the P-431 PRZR pressure channel.

April 7, 1995, 0830 EDST: IIC completes calibrations of N-43 and T-403.

April 7, 1995, 0845 EDST: IRC obtains permission to defeat P-429 PRZR pressure channel.

NRC FORM 366A (5-92)

NRC FORH 366A U.S. NUCLEAR REGULATORY COHHISS ION APPROVED BY OMB NO. 3150 ~ 0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REOUEST: 50.0 HRS.

FORWARD COMMENTS REGARDING BURDEN ESTIHATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AND RECORDS HANAGEMENT BRANCH TEXT CONTINUATION (MNBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET WASHINGTON DC 20503.

FACILITY NAME (1) DOCKET NUHBER (2) LER NUHBER (6) PAGE (3)

YEAR SEQUENTIAL REVISION R.E. Ginna Nuclear Power Plant 05000244 4 OF 12 95 003 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

April 7, 1995, 0900 EDST: Event date and time.

April 7, 1995, 0900 EDST: Discovery date and time.

April 7, 1995, 0908 EDST: Safety Injection Actuation and Containment Isolation signals are reset.

April 7, 1995, 0915 EDST: Containment Ventilation Isolation signal is reset.

April 7, 1995, 0930 EDST: Pre-event cold shutdown conditions are restored.

B. EVENT:

The plant was in the cold shutdown mode for the annual refueling and maintenance outage. The RCS temperature was approximately 100 degrees F, and the RCS was depressurized. RCS loop levels were at approximately 80 inches, which is a partially drained condition with water level four inches below the reactor vessel flange.

On April 7, 1995, two IRC technicians were in the CNMT for performance of annual calibration of PRZR pressure transmitters.

Another I&C technician was in the Control Room and was assigned to perform the defeating and reinstating of the PRZR pressure channels, as requested by the technicians in CNMT. The I&C technician in the Control Room was defeating channel P-429 using calibration procedure CPI-PT-429. At approximately 0900 EDST, the IEC technician in the Control Room placed the Safety Injection (SI) Unblock Bistable Proving Switch (BSPS) for P-429 to the tripped state.

The SI Actuation Signal (SIAS),is provided with a block signal which prevents a SIAS from occurring for low PRZR pressure and for low steam line pressure. At this time SIAS was blocked, which is a normal configuration when PRZR pressure is intentionally reduced below the SIAS setpoint.

NRC FORH 366A (5-92)

NRC FORH 366A U.S. NUCLEAR REGULATORY COHHISSION APPROVED BY OMB NO. 3150-0104 (5.92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COHPLY WITH THIS INFORHATION COLLECTION REQUEST: 50.0 NRS.

FORWARD COMMENTS REGARDING BURDEN ESTIHATE TO LICENSEE EVENT REPORT (LER) THE INFORHATION AND RECORDS MANAGEMENT BRANCH TEXT CONTINUATION (HNBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555-0001 AND TO THE PAPERWORK REDUCTION PROJECT (3110-0104), OFFICE OF MANAGEMENT AND BUDGET WASHINGTON DC 20503.

FACILITY NAHE (1) DOCKET NUHBER (2) LER NUHBER (6) PAGE (3)

YEAR SEQUENTIAL REVISION R.E. Ginna Nuclear Power Plant 05000244 M

5 OF 12 95 003 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

With the SI Unblock BSPS for channel P-431 state from calibrations completed the previous day, the logic to still in the tripped block SI from low pressure signals was the SIAS was automatically unblocked as soon as the P-429 BSPS still present. However, was placed in the tripped state. PRZR pressure and pressures in both the "A" and "B" steam generators (S/G) were below the setpoint for automatic SI Actuation, resulting in automatic SI Actuation from 2/3 Logic for PRZR pressure less than 1750 PSIG and from 2/3 Logic for S/G pressure less than 514 PSIG.

Automatic SI Actuation caused automatic actuation of CNMT Isolation (CI) and CNMT Ventilation Isolation (CVI) .

All operable Engineered Safeguards Features (ESF) components were observed to function properly, with the exception of valve position indication for MOV-852B (RHR Discharge to Reactor Vessel Deluge valve). 'he valve position indication for MOV-852B did not indicate full travel to the open position. However, subsequent investigation confirmed that the valve did, in fact, travel to the "full open" position. All safeguards busses remained energized from off-site power.

Due to plant conditions, several ESF components were not operable at the start of this event. The "B" D/G was inoperable for annual manufacturer inspection and overhaul. All three SI pumps were rendered inoperable (start switch in "pull-stop") to comply with Ginna Technical Specifications (TS) requirements for low temperature RCS over-pressure protection. Therefore, the "B" D/G did not start "and no SI pumps started. No injection flow from the SI pumps to the RCS occurred.

Initially one Residual Heat Removal (RHR) pump was in service.

The second RHR pump started due to the SIAS. MOV-852A and MOV-852B (valves for reactor vessel deluge from RHR pumps) opened to allow for RHR flow to the top of the reactor vessel, as well as continuing RHR flow via the normal shutdown cooling flowpath.

The total RHR flow was being controlled by flow control valve FVC-626, so no substantial increase in RHR flow occurred. The RCS remained stable at the initial conditions during this event and also during subsequent restoration actions. No disturbance of primary system conditions was noted. The second RHR pump was secured at approximately 0920 EDST.

NRC FORH 366A (5-92)

NRC FORM 366A U.S. NUCLEAR REGULATORY COHHISSION APPROVED BY OHB NO. 3150-0104 (5.92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTIOH REQUEST: 50.0 HRS.

FORWARD COMMENTS REGARDING BURDEN ESTIHATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AND RECORDS MANAGEHENT BRANCH TEXT CONTINUATION (MHBB 7714), U.S. NUCLEAR REGULATORY COMHISSION, WASHINGTON, DC 20555-0001, AHD TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET WASHINGTON DC 20503.

fACILITY NAHE (1) DOCKET NUHBER (2) LER NUMBER (6) PAGE (3)

YEAR SEQUENTIAL REVISION R.E. Ginna Nuclear Power Plant 05000244 NUMB 6 OF 12 95 -- 003 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

C. INOPERABLE STRUCTURES, COMPONENTS, OR SYSTEMS THAT CONTRIBUTED TO THE EVENT:

PRZR pressure activities completed channel P-431 was on April 6, 1995, still defeated from calibration and was inoperable at the start of the event.

D. OTHER SYSTEMS OR SECONDARY FUNCTIONS AFFECTED:

None E. METHOD OF DISCOVERY:

This event was immediately apparent due to numerous Main Control Board Annunciator alarms in the Control room.

F. OPERATOR ACTION:

The Control Room operators responded to the Annunciator alarms, and noted that the standby RHR pump had started and that Motor Control Center (MCC) 1G had tripped. They diagnosed that automatic SI Actuation had occurred, and verified that all previously operable ESF components functioned properly. No immediate actions were required for the RCS, since reactor vessel water level and RHR flow indications remained stable.

After determining the cause of the inadvertent automatic SIAS, the Control room operators reset the SIAS and CI and CVI signals.

Unneeded equipment was secured. All CI valves and CVI components (which changed position due to the SIAS) were returned to their positions prior to the event. Pre-event conditions were restored.

Subsequently, the Control Room operators notified higher supervision and the NRC. The Shift Supervisor notified the NRC Operations Center within four hours, per 10CFR50.72 (b) (2) (ii) .

NRC FORH 366A (5-92)

NRC FORM 366A U.S. NUCLEAR REGULATORY COHHISSION APPROVED BY OHB NO. 3150-0104 (5.92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.

FORWARD COMMENTS REGARDING BURDEN ESTIHATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AHD RECORDS 'HANAGEHENT BRANCH TEXT CONTINUATION (HNBB 7714), U.ST NUCLEAR REGULATORY COMMISSION, WASHINGTON'C 20555 0001 i AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MAHAGEMENT AND BUDGET WASHINGTON DC 20503.

FACILITY NAHE (1) DOCKET NUHBER (2) LER NUHBER (6) PAGE (3)

SEQUENT IAL REVISION R.E. Ginna Nuclear Power Plant 05000244 NUM 7 OF 12 95 -- 003 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

G. SAFETY SYSTEM RESPONSES:

All safety systems and components that were operable responded as designed, except that the valve position indication for MOV-852B did not indicate full travel to the open position. All other operable ESF components were observed to function properly after the automatic SIAS.

III.

CAUSE OF EVENT:

A. IMMEDIATE CAUSE:

The immediate cause of the inadvertent automatic SI Actuation was both from 2/3 logic from PRZR pressure and from 2/3 logic from S/G pressure with SIAS unblocked.

B. INTERMEDIATE CAUSE:

The intermediate cause of automatic SIAS being unknowingly unblocked was placing the SI Unblock BSPS for P-429 to the tripped state with the same BSPS for P-431 already in the tripped state. This was a procedural error and was a direct result of an error in an approved procedure. Calibration procedure CPI-PT-429 had misleading information, in that a step was to be marked "N/A" if RCS temperature was less than 350 degrees F.

step "N/A" allowed the I&C technician to trip the P-429 BSPS Marking this without requesting that the Control Room operators verify that the same BSPS was not tripped in the other PRZR pressure channels. With this step marked "N/A", there was no for IEC to notify the Control Room operators that P-431requirement was still defeated when permission was obtained from the Control Room operators to perform the defeat of P-429.

NRC FORM 366A (5-92)

NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150.0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.

FORWARD COMMENTS REGARDIHG BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AND RECORDS MANAGEMENT BRANCH TEXT CONTINUATION (MNBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET WASHINGTON DC 20503.

FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR SEQUENTIAL REVISION R.E. Ginna Nuclear Power Plant 05000244 8 OF 95 003 pp 12'EXT (If more space is required, use additional copies of NRC Form 366A) (17)

A contributing factor was that the IKC technicians were not aware that SIAS would automatically unblock when two PRZR pressure channels were defeated at the same time. The IEC technicians also believed that Unblock of SI was not a concern at these plant conditions, and were unaware of'the consequences of unblocking SI at these plant conditions. Another contributing factor was that the Control Room operators were made aware that I&C would be performing activities associated with more than one RPS channel, but did not ask which specific channels would be defeated simultaneously.

These actions were both cognitive and procedural errors and were the direct result of an error in an approved procedure. There were no unusual characteristics of the work location (Control Room) that contributed to the error.

C. ROOT CAUSE:

The underlying cause of the misleading information in calibration procedure CPI-PT-429 was the addition of wording that identified operability requirements based upon TS Table 3.5-2, Item 1, when the procedure was upgraded. One of the standards for the procedure upgrade was to more accurately identify the TS issues associated with calibrations.

The underlying cause of the imprecise valve position indication for MOV-852B was the sequence of actuation of valve limit switch rotors. Limit switch contacts on one rotor actuated to deenergize the valve motor before limit switch contacts on a different rotor actuated to extinguish the green light (which is intended to extinguish just prior to the valve reaching the fully open position).

This event is NUREG-1022 Cause Code (D), "Defective Procedure" ~

This event does not meet the NUMARC 93-01, "Industry Guideline for Monitoring the Effectiveness of Maintenance at Nuclear Power Plants", definition of a "Maintenance Preventable Functional Failure", since there was no functional failure.

NRC FORM 366A (5-92)

NRC FORH 366A U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150 ~ 0104 (5-92) EXPIRES 5/31/95 ESTIHATED BURDEN PER RESPONSE TO COMPLY WITH THIS IHFORMATION COLLECTION REQUEST: 50.0 HRS.

FORWARD COMMENTS REGARDING BURDEN ESTIHATE TO LICENSEE EVENT REPORT (LER) THE INFORHATION AND RECORDS HANAGEMENT BRANCH TEXT CONTINUATION (HNBB 7714), U.S. NUCLEAR REGULATORY COHHISSION, WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF HANAGEMENT AND BUDGET WASHINGTON DC 20503.

FACILITY NAHE (1) DOCKET NUHBER (2) LER NUMBER (6) PAGE (3)

YEAR SEQUENTIAL REVISION R.E. Ginna Nuclear Power Plant 05000244 NUM 9 OF 12 95 003 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

IV. ANALYSIS OF EVENT:

This event is reportable in accordance with 10 CFR 50.73, Licensee Event Report System, item (a) (2) (iv), which requires a report of, "Any event or condition that resulted in a manual or automatic actuation of any engineered safety feature (ESF), including the reactor protection system (RPS)". The inadvertent automatic SI Actuation is an automatic actuation of an ESF.

An assessment was performed considering both the safety consequences and implications of this event with the following results and conclusions:

There were no operational or safety consequences or implications attributed to the inadvertent automatic SI Actuation because:

The plant was in the cold shutdown mode with high head SI pumps rendered inoperable in accordance with TS. The RHR system was aligned for decay heat removal, and S/G nozzle dams were in place.

With SI pumps inoperable, the RCS was not subjected to over-pressure conditions when operable ESF components started.

The Refueling Water Storage Tank was not aligned to the suction of the RHR pumps. Therefore, there was no addition of water inventory to the RCS.

RCS temperature continued to be maintained stable via the RHR system. Therefore, reactivity was not affected by RCS temperature changes.

The Service Water System, Component Cooling Water System, and Spent Fuel Cooling System all remained in service during this event.

With Spent Fuel Cooling remaining in service, removal of decay heat from the Spent Fuel Pool was assured.

HRC FORH 366A (5-92)

NRC FORH 366A U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORHATIOH COLLECTION REQUEST: 50.0 HRS.

FORWARD COMHENTS REGARDING BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER) THE INFORHATION AND RECORDS HANAGEHENT BRANCH TEXT CONTINUATION (MNBB 7714), U.S. NUCLEAR REGULATORY COHMISSION, WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF HANAGEMENT AND BUDGET WASHINGTON DC 20503.

FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR SEQUENTIAL REVISION R.E. Ginna Nuclear Power Plant 05000244 UM 95 -- 00 10 OF 12 003 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

~ The RHR cooling capability remained in service and RCS integrity was maintained. Therefore, heat removal from the reactor was assured.

~ Flow through MOV-852B was not limited due to valve position. The valve was, in fact, "full open", despite the indication.

Based on the above, safety was assured at all times.

it can be concluded that the public's health and V. CORRECTIVE ACTION:

A. ACTION TAKEN TO RETURN AFFECTED SYSTEMS TO PRE-EVENT NORMAL STATUS:

PRZR pressure channel P-431 BSPS was reinstated (removed from the trip mode), thus terminating the SI Unblock logic, and allowing the Control Room operators to again block SIAS.

After the cause of the event was identified, the SIAS, CI, and CVI signals were reset. Unneeded ectuipment was secured.

MOV-852B was stroke-tested to the full open position.

All CI valves and CVI components (which changed position due to the SIAS) were returned to their positions prior to the event. Pre-event conditions were restored.

B. ACTION TAKEN OR PLANNED TO PREVENT RECURRENCE:

A Training Work Request (TWR) has been initiated to evaluate the training for I&C technicians relating to SIAS initiation.

Pre-outage training the need to include for IEC technicians will be evaluated for ESF and RPS logic.

Calibration procedures have been reviewed to identify those that have the same misleading information as CPI-PT-429.

Procedures have been changed to remove the misleading information.

NRC FORM 366A (5-92)

NRC FORH 366A U.S. NUCLEAR REGULATORY COHHISSION APPROVED BY OHB NO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.

FORWARD COMMENTS REGARDIHG BURDEH ESTIMATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AND RECORDS MANAGEHENT BRANCH TEXT CONTINUATION (HNBB 7714), U.S. NUCLEAR REGULATORY COHMISSIOH, WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET WASHINGTON DC 20503.

FACILITY NAME (1) DOCKET NUHBER (2) LER NUHBER (6) PAGE (3)

YEAR SEQUENTIAL REVI,SION R.E. Ginna Nuclear Power Plant 05000244 UM 11 OF 12 003 00 TDT (If more space is required, use additional copies of NRC Form 366A) (17)

Methods to visually indicate to Control Room operators which instrument channels are being tested or are defeated will be evaluated.

The limit switch positions for MOV-852B were adjusted to ensure that the limit switch contacts to extinguish the green light actuate before the limit switch contacts that deenergize the valve motor. Limit switch actuation was reviewed for other MOVs, and this was determined to be case. an'solated VI. ADDITIONAL INFORMATION:

A. FAILED COMPONENTS:

None B. PREVIOUS LERs ON SIMILAR EVENTS:

A similar LER event historical search was conducted with the following results:

LER 84-006 described an automatic actuation of SIAS. During plant heatup, PRZR pressure was increased above the automatic setpoint for unblocking SI, with S/G pressure still below the SIAS setpoint, due to operator error. The corrective action to prevent recurrence was to revise operating procedures for plant heatup. This action would not have prevented LER 95-003.

LER 85-004 described an automatic actuation of SIAS. The BSPS for one channel of SI actuation was in the tripped state. During a separate activity, an instrument bus was inadvertently deenergized, causing another bistable to trip, resulting in the logic for SIAS. The corrective action to prevent recurrence was to revise procedures to prevent the inadvertent loss of power to instrument busses'his action would not have prevented LER 95-003.

NRC FORH 366A (5-92)

, ARM 366A U.S. NUCLEAR REGULATORY COMMISSION APPROVEO BY OMB NO. 3150 ~ 0104 (5.92) EXPIRES 5/31/95 ESTIMATED BURDEH PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.

FORWARD COMMENTS REGARDIHG BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AND RECORDS MANAGEMENT BRANCH TEXT CONTINUATION (MHBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET WASHIHGTOH DC 20503.

FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR SEQUENTIAL REVISION R.E. Ginna Nuclear Power Plant 05000244 UM NUMB 12 OF 12 95 003 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

LER 89-003 described an automatic actuation of SIAS. Simulated signals (above the SIAS setpoint) were inserted into two PRZR pressure channels, causing SIAS. The corrective action to prevent recurrence was to provide clearer direction to test technicians when simulating signals. This action would not have prevented LER 95-003.

C. SPECIAL COMMENTS:

None NRC FORM 366A (5-92)

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