ML19325C457
| ML19325C457 | |
| Person / Time | |
|---|---|
| Site: | Callaway  |
| Issue date: | 10/03/1989 |
| From: | Blosser J, Heinlein D UNION ELECTRIC CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| LER-89-010, LER-89-10, ULNRC-2085, NUDOCS 8910160272 | |
| Download: ML19325C457 (8) | |
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1 Washington...DC 20555 l ULNRC-2085' f Gentlemen:'
DOCKET NUMBER 50-483 CALLAWAY PLANT UNIT 1 FACILITY OPERATING LICENSE NPF-30 ~m LICENSEE EVENT REPORT 89-010-01 ENGINEERED SAFETY FEATURES ACTUATION DUE TO A FAILED ;
. POWER SUPPLY AND'AN AUXILIARY FEEDWATER ACTUATION WITH l
SWAPOVER'TO ESSENTIAL SERVICE-WATER DUE TO IMPROPER OPERATOR ACTION The enclo' sed Licensee Event Report is submitted to correct a l typograp_hical error on LER- 89-010-00 submitted via ULNRC-2081 on September 27.-1989. On page-1 of 6 of LER 89-010-00 the LER number was- ,
l mistakenly entered as 89-011-00 in box 6. The attached report has the-b
' data boxes filled-in correctly, J D. Blosser
} anager, Callaway Plant
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Regional Administrator Office of Nuclear Reactor Regulation U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commission-
- Region III .
Mail Stop 13-E-21 799 Roosevelt-Road- Washington, D.C.- 20555 E Glen Ellyn, IL 60137 t.
American. Nuclear Insurers .Mr. 0.-Maynard F
c/o Dottie Sherman, Library Wolf Creek Nuclear Operating Corp.
The Exchange-Suite 245' P. 0. Box 411 270 Farmington Avenue Burlington, KS' 66839
- Farmington, CT 06032-Mr. Merlin Williams p Manager, Electric Department Supt. of Regulatory Quality &
Missouri Public. Service Commission Administrative Services P. 0. Bos 360 Wolf Creek Nuclear Operating Corp.
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Jefferson City, MO 6510? P. O. Box 411 Burlington, KS 66839-Records Center Mr. R. W. DeFayette Institute of. Nuclear Power. Operations Chief, Project Section 3A Suite 1500 U.S. Nuclear Regulatory Commission 1100 Circle 75 Parkway' Region III Atlanta, GA 30339 ~799 Roosevelt Road Glen Ellyn, IL- 60137 NRC Resident Inspector D. F.'Schnell.(400)
G.lL. Randolph R. P. Wendling'(470)
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G. A. Hughes Z170.0003 (QA Record) i Z40LER (Z170.0009 Commercial Record)
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S. L. Auston (470)(NSRB)
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LICENSEE EVENT REPORT (LER) i ' ' " *
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' "Whgineered Saf ety Features Actuations Due To A Failed Fower Supply And An Auxilhary water Actuation With Swapover To Essential Service Water Due To Improper Operator Action REPORT DAf t 47) OTHER f ACILITil8 INVOLVIO (81 EVfNT Daft (Si LER Numstm 45)
F ACILITV N AMt3 DOCKt1 NUM5tRISI MONTH DAY ) YEAR YEAR s "(Q L*' "8fu*,$ MONT H DAY YEAR Ol510l0{0; j l-8l9 j i 0l9 0 l5 8 9 8l 9 0l1 j 0 0 l1 1 l0 0l3 0 g 5i0 i O,0, THis REPORT 18 SUDMITTED PURSUANT ?Q THE REQUIREMENTS OF 10 CFR % (Chece ene or more of fu fo"o**ael 011 OPERATWG X 73 71th)
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TELEPt40NI NUM6tR NAME "N5' coot D. E. Heinlein - Assistant Superintendent of Operations 311 l 4 6 17 p i- i 81 2l0(8 COMPLETE ONE LINE FOR E ACH COMPONENT f ALLURE DESCRISED IN THIS RtPORT (131 ORia E :
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$U9M'SSION Ytt IH ves tomatete EXoECTED SugwSSION DA TED NO 3 l l AssTRACT (tem <r to f 400 spaces s e , saareennerery wreen sme's mece typeererw haev (161 On 9/5/89 at 1531 CDT, Engineered Safety Features (ESF) Containment Purge Isolation, Control Room Ventilation Isolation and Fuel Building Ventilation Isolation actuations were received when a 15VDC power supply failed in the ESF. cabinet for 'B train. At 1939, while attempting to restore the ESF
'B' train cabinet to service following the power supply replacement, a Auxiliary Feedwater Actuation (AFAS) with swapover to Essential Service Water (ESW) was received. The plant was in Mode 1 - Power Operation at 100 percent power.
The second ESF actuations were caused by improper operator action. The restoration of ESF procedure requires tripped logic to be reset prior to placing relay power supply to ON. When the licensed Reactor Operator was unable to reset the tripped logic he misinterpreted the procedure and turned on the power supply thus actuating the AFAS and valve swapover to ESW. Plant procedures required a plant shutdown to Mode 2 - Start Up to restore Steam Generator chemictry. Mode 1 was resumed at 2304 on 9/7/89.
The failed power supply was replaced. The importance of crew communication and conservative judgement was discussed with those involved and will be covered in training. The failure of the tripped logic to reset was evaluated. A review for similar industry experience will be performed.
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I on 9/5/89.at 1531 CDT, Engineered Safety Features (ESF) Containment Purge Isolation (CPIS), Control Room Ventilation Isolation (CRVIS) and Fuel BuildigVentilationIsolation(FBIgactuationswerereceivedwhenapower for the 'B' train. At 1939, while J~ supply failed in the ESF cabinet attempting to restore the ESF cabinet to service, a 'B' train Auxiliary Feedwater A
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j' Water (ESW)gation(AFAS)withsuctionvalveswapovertoEssentialService Additi nally, signals were received for CPIS, CRVIS and FBIS wasreceivekS)werestillintheirsafetylineupfromthe but dampers previous event. Since these ESF actuations were not part of a preplanned sequence-during reactor operation or testing, this event is reported per 10CFR50. 73 (a) (2) (iv) . The unit was initially in Mode 1 - Power Operation, j 100 percent reactor power, at normal operating pressure and temperature.
Description of Events Event 1 On 9/5/89 at 1531 CDT, a CRVIS, CPIS, and FBIS were received. ESF cabinet f indications revealed these ESF actuations were the result of a failed power j supply in the 'B' train ESF actuation system cabinet SA036E located in the j main control room. :
t Utility Instrumentation and Controls (I6C) technicians, under the direction of an I&C engineer, replaced the power supply. When the replacement was complete, the 16C technicians tested the power supply output for proper-operation under the observation of a Quality Control (QC) inspector. ,
Event 2 At approximately 1936, pe* procedure OTS-SA-00001 "De-energizing and !
Energizing Engineered Safety Feature Actuation System", the licensed Reactor Operator (RO) attemp The RO placed the logic power supply switch, g 8N26-1, to energize to the the'On' cabinet.
position. The logic energized in an actuated condition for the CRVIS, CPIS, FBIS, AFAS and Low Suction Pressure (LSP) signals. However,noagationsoccurredat this time because the power supply for the output relays was still de-energized. The presence of the actuated logic condition was displayed by indicator lights (8) on the cabinet's Manual Test and Indication panel. The procedure requires a reset of all bistables and actuation modules which may have tripped during energization. The RO attempted to reset signals from the Main Control Board (MCB)but g AFAS, none ofFBIS, CPIS, and CRVIS the actuation signals reset.
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A cautionary note in the procedure stated that the tripped logic must be resetpriortygtformingthenextprocedurestep(i.e.placingrelaypower 8N28-1 to the 'On' position) in order to prevent ESF supply switch 'l actuations. A procedure note stated: " Tripped logic is indicated by the local' panel lights ON at SA036E." The procedure did not specify which local ~
panel within cabinet SA036E.actually had the relevant fndicator lights. The R0 mistook the lights _ mounted on the actuation modules and bistables to be the indication for the tripped logic. Af ter comparing and verifying cabinet actuation module 11ghts and individual Fistable lights for a tripped condition to be identical on both the 'B' and 'A' ESF trains, the R0 recommended energization of'the relay power supply 8N28-1 stating that he thought this
-would allow resetting of the tripped logic.
The licensed Shift Supervisor (SS) was not aware the AFAS and LSP tripped .,
logic was still energized.- The SS was aware that CRVIS, CPIS, FBIS were 1 already actuated due to the earlier failure of the power supply. There was insufficient discussion between the crew members on how to proceed. Since
, the R0 had attempted to reset the tripped logic from the MCB and failed, the RO thought he should proceed to energize the second power supply, 8N28-1, in order to cluer the lights on the local panel. He misinterpreted the intent of the cautionary note and proceeded to energize the second power supply.
When the power supply was energized at 1939, 'B' g in AFAS actuation signal outputsweregeneratedtggartthe'B'ESWpump , the 'B' Motor Driven AuxigyFeedwaterPump (MDAFP),aghe 'B' train Condensate Storage !
Tank (CST) to ESW LSP suction valve swapover.
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.After seeing the actuations, the crew quickly responded by starting 'A' ESW pump, stopping 'B' MDAFP and attempting to close the automatic ESW suction !
valve, AL-HV-30, to the 'B' MDAFP. An equipm shut the normally locked open valve, AL-V005. The g operator RO triedwas to resetdispatched the to !
actuation signals two more times from the MCB. The reset finally occurred on the second try at 1946. The quick response of the crew after initiation of the event minimized its consequences.
Since the 'B' MDAFP started, and a suction valve swapover occurred to the ESW system W water was injected into the 'A' and 'D' steam generators (S/G). The ESW water caused 'A' and 'D' S/C chemistry to be out of specification (Action Level 3) for cation conductivity (>7pmho/cm) and sodium
(>500 ppb). Per plant procedure APA-ZZ-01021 " Secondary Chemistry Program",
this required a plant shutdown to Mode 2 - Start Up in order to restore the S/G to within chemistry specifications. The plant reached Mode 2 at 0125 on 9/6/89. After re-establishing chemistry in 'A' and 'D' S/G to less than the Action 1 levels, the plant was returned to Mode 1 - Power Operations at 2304 on 9/7/89.
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1 s Root Cause 1 l
Event 1 lThe' initial CPIS, CRVIS and.FBIS actuations occurred as the result of a failed 15VDC power supply in the 'B' train ESF cabinet SA036E. This is:an
- encapsulated power supply and therefore the cause of failure cannot be ,
determined. 1 Event'2 The cauee of the failure of CPIS, FBIS, CRVIS, and AFAS signals to reset on subsequent attempts is indeterminate. The AFAS and suction valve swapover to
'ESW are attributable to improper operator action. The licensed RO, when he was unable'to reset the. tripped logic upon energizing cabinet SA036E, made a .i cognitive error with.an incorrect decision to proceed with energization of.
.the.second power supply.without first fully considering the potential < ;
consequences of his actions.
As contributing factors to this event, there was not sufficient communication-
.within the crew.-
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The SS, as well as the I&C engineer, failed to call a stop ,
to further: activities until the problem was understood.
Corrective Actions i
. Event 1 :
The failed power supply was replaced and tested for proper operation per
- plant procedures. The failed power supply type will be evaluated for
- possible generic concerns which would justify possible replacement on a routine basis or replacement with a different type of power supply.
-Event 2-
- 1. The RO, SS, and I&C engineer involved have demonstrated their understanding of the judgement errors that were made, as well as their failure to speak up and insist on a full understanding of the problem g
before proceeding.
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- 2. The procedure OTS-SA-00001 will be revised to incorporate more specific guidance on resetting various trip actuations.
- 3. The importance of crew communications and conservative judgement will .
4 also be covered in operator, engineer, and I&C training.
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4., The cause of failure of the actuction circuits to reset is'still indeterminate and no further site actions to troubleshoot can be performed. Special test procedure'OTS-SA-T0002 was' written and
- performed twice, subsequent to this event to determine why the logic trip would not reset.- Both times the logic powered.up with the logic in an actuated' condition but the actuations immediately reset on the first
'attempte A' mock-up of the' reset switch'and actuation circuitry was constructed in 'the_ I6C shop. The reset delay,was measured to be on the order of'30 meec.; The R0' involved in the event evaluated the-physical operation of the switch'and' circuitry in the noch-up but no further
. information was identified. Additional efforts to evaluate industrial experience to identify similar failures will be pursued. <
O Safety Signfficance Following the CPIS, CRVIS,.FBIS, AFAE and suction valve swapover to ESW, the ESF: equipment described above was verified as having properly actuated.
Since these actuations were generated within the ESF logic and not by an actual plant. condition, there was no potential threat to the public health and safety.
Previous Occurrences-LER 84-032-00, ULNRC 930 dated 9/19/84 l LER 87- 014-00, ULNRC 1579 dated 8/14/87 !
LER 87-025-00, ULNRC 1638 dated 10/5/87 i
LER 8'4-032-00, LER 87-014-00, and LER 87-025-00 describe similar power -l I
supply failures (Consolidated Jontrols Part No. KYE-1900-1) in ESFAS cabinet SA036D.- The cause of these power supply failures is unknown. This is the
( first power-supply failure in cabinet SA036E. j w
T There are no previous events related to an AFAS with suction valve swapover i
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to ESW..
l Footnot'es I
The system and component codes listed below are from IEEE Standards 805-1983 l and 803A-1983, respectively. i (1) System - JE
'(2) System - JE, Component - RJX (3) System - JE, Component - CAB (4) . System - BI (5) System - JE, Component - DMP (6) System - JE, Component - 33 (7) System - JE, Component - RLY l
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-(11) System - B1, Component - P
-(12) System BA, Component;- P (13) System - KA Component - TK
.(14) System - BA, Component - V (15) System - BA Component - V, (16)' System - AB, Component - SG.
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