IR 05000311/1992081

Submits Addl Info Re Operator Actions Associated W/Loss of Overhead Annunciators That Occurred in Salem Unit 2 CR on 921213,w/respect to Insp Rept 50-311/92-81.Rev 1 to Procedure NC.NA-AP.ZZ-0061(Q) Encl

ML18100A705
Person / Time
Site:	Salem, Hope Creek
Issue date:	11/09/1993
From:	MILTENBERGER S Public Service Enterprise Group
To:	MARTIN T T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
Shared Package
ML18100A706	List: IR 05000311/1992081 ML18100A705 ML18100A707
References
NLR-N93172, NUDOCS 9311180261
Download: ML18100A705 (6)

Text

Public Service Electric and Gas Company .en E. Miltenberger Public Service Electric and Gas Company P.O. Box 236, Hancocks Bridge, NJ 08038 609-339-4199

• Vice President and Chief Nuclear Officer NOVO 9 1993 NLR-N93172 United states Nuclear Regulatory Commission Mr. T. T. Martin Region I Administrator 475 Allendale Road King of Prussia, PA 19406 Gentlemen:

INSPECTION REPORT 92-81 AUGMENTED INSPECTION TEAM SALEM GENERATING STATION UNIT NOS. 1 AND 2 DOCKET NOS. 50-272 AND 50-311 Per request from NRC Region I, Public Service Electric & Gas Company (PSE&G) hereby submits additional information related to the operator actions associated with the loss of Overhead Annunciators (OHA) that occurred in the Salem Unit 2 control room on December 13, 1992. PSE&G is providing a discussion of the investigative techniques used to determine the root cause of the loss of annunciator inciden Using these techniques, PSE&G conducted a complete and thorough investigatio On December 14, 1992, the General Manager -Salem Operations convened a Significant Event Response Team (SERT) in accordance with Nuclear Department Administrative Procedure NC.NA-AP.ZZ-0061(Q)

to investigate the loss of the overhead annunciator system. This procedure describes the scope, function, and processes used in a SERT investigatio Responsibilities of each member of the team are defined. The relationship of the SERT to the Station Manager are also identifie Guidelines for preparing and issuing a SERT report are provided in the procedur NC.NA-AP.ZZ-0061(Q)

is contained as Attachment 1. PSE&G also formed a technical evaluation team. This team was responsible for determining the cause of the OHA lockup. This team with assistance from the manufacturer determined that the system could be locked up from the OHA System keyboard at the logic cabinets * .. t'f"" n '\ ... 9311180261 931109. :DR ADOCK 050003'11 PDR

• Mr. -T. T. Martin NLR-N93172 2 NOVO 9 1993 The SERT convened to investigate this event consisted of a SERT Manager and eight SERT members. A copy of the SERT membership and their normal assignments is included as Attachment 2. The General Manager -Salem Operations provided the SERT with the following charter: 1. Independently determine the root cause of the event. 2. Assess ECG classification and reportability 3. Determine if procedures were adequate and followed 4. Assess adequacy and design of the OHA system 5. Determine corrective actions. The SERT developed an event chronology using printouts from the OHA System, Operator logs and interviews with involved personne The SERT reviewed the safety significance of the loss of the OHA System, and the results of the technical investigation into the loss. The SERT also reviewed the Operator actions with respect to notification and reportabilit The event chronology, and the SERT position on the safety significance, technical investigation, and reportability are included in the SERT report. The SERT conducted interviews with all personnel involve As information became available, some personnel were given second and third interview PSE&G Management had interviewed Operations personnel involved in the loss of OHA prior to the SERT being convene The notes from those interviews were provided to the SERT for use in the investigatio During the initial interviews conducted by PSE&G Management, personnel involved were asked to recreate the sequence of events from December 13, 1993. Interviews were conducted on the night of December 14, 1993 with the Operating Engineer (OE), the Senior Nuclear Shift Supervisor (SNSS), the Nuclear Shift Supervisor (NSS, and the Nuclear Control Operators (NCO). The personnel involved were also asked if they knew of any problems associated with the OHA syste * * Mr. T. T. Martin NLR-N93172 3 NOVO 9 1993 On December 15, 1992, the NCOs involved were interviewed by the SERT Manager and one member of the SERT Team. The NCOs were interviewed separately, but were asked the same questions listed below: What training, either formal or informal have you received on the Annunciator System? What level of training would you expect to receive? There have been significant changes made in the Control Room over the last two outages, is there other systems, components, equipment, etc. that you should be trained on, but haven't (or uncomfortable with level of knowledge)?

Do you ever recall losing the annunciators in the past? Are the Annunciator procedures adequate?

Other than the problems on Sunday, do you recall, anything else abnormal with this system? Is the level of Technical Department activity in the system normal? How long was the A-9 Alarm in when cleared @ 2129? Did the OHA reset cause the SER transfer?

How did you know that resetting the system would clear the A-45 window? How often have you done this? On December 16, 1992, the NCOs involved plus an additional NCO were interviewed together by two members of the SERT. Two questions were asked: Have the operators received training on the BETA (OHA) System reset? Was any instruction provided when the Information Directive for the three button test was routed on March 9, 1992?

• * Mr. T. T. Martin NLR-N93172 4 NOVO 9 1993 Also on December 16, 1992, one of the NCOs involved was interviewed by a member of the SERT. This interview discussed the logic failure alarms that had been indicated on the alarm history printout and the problems with acknowledging alarms. On December 19, 1992, the two NCOs involved were interviewed separately by the SERT. Also, members of the NRC Augmented Inspection Team were present during the interview These interviews discussed the actions the NCOs had taken while at the OHA System keyboard console. The NCOs admitted to trying various combinations of keys in attempting to obtain an alarm history printou In addition to interviews, the SERT reviewed Operator narrative and plant logs, appropriate plant normal, alarm response, abnormal, and emergency procedure The SERT reviewed the Design Change Package that had installed the new ORA System during the previous refuelin The SERT investigated industry experience to determine if a precursor had occurred that would have alerted PSE&G to a potential problem in the OHA System. The SERT performed a root cause analysi This analysis included development of an event and causal factor chart. The chart contained a summary of significant events, inappropriate actions taken, causal factors, and failed or inadequate barriers associated with the event. The SERT determined the root causes to be: The software architecture did not contain adequate security to prevent inadvertent access to software control functions which placed the system in an indefinite "lock up" conditio The failure to follow operating procedure S2.0P-SO.ANN-0001(Q)

by not placing the "black box" switch in the SER-A position and inadvertent entry of "CTRL L" characters twice, where the procedure required entry of "ALT L". Based on the above discussion, PSE&G believes that it conducted a thorough and comprehensive investigation of all the issues related to the Salem overhead Annunciator event .

• Mr. T. T. Martin NLR-N93172 5 NOVO 9 1993 Should there be any questions with regard to this submittal, please do not hesitate to contact us.

Sincerely,c Mr. J. C. Stone Licensing Project Manager Mr. c. Marschall Senior Resident Inspector Mr. T. Martin, Administrator Region I Mr. Kent Tosch, Manager IV New Jersey Department of Environmental Protection Division of Environmental Quality Bureau of Nuclear Engineering CN 415 Trenton, NJ 08625 NLR-N93172

• ATTACHMENT 1 NC.NA-AP.ZZ-006l(Q)

SIGNIFICANT EVENT RESPONSE TEAM MANAGEMENT