ML19332F898

LER 89-036-00:on 891113,incorrect Connection of Source to Terminals Directly Below Correct Terminals Caused Div 1 Isolation of RCIC Sys.Caused by Personnel Error.Personnel Briefed on Need to Use ladders/stools.W/891213 Ltr

ML19332F898
Person / Time
Site:	Clinton
Issue date:	12/13/1989
From:	Holtzscher D, Rasor S ILLINOIS POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-89-036, LER-89-36, U-601567, NUDOCS 8912190273
Download: ML19332F898 (6)

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L December 13, 1989  !

j, 10CFR50.73 t.

!' Docket No. 50 461' U.S. Nuclear Regulatory Commission Document Control Desk Washington, D.C. 20555 i

Subject:

Clinton Power Station . Unit 1 Licensee Event Reoort No. 89 036 00

Dear Sir:

Please find enclosed Licensee Event Report No. 89 036 00:

Failure to Perform Work at Eve Level Results in Connection of Test Eaulement to Incorrect Terminals and Automatic Isolation of Reactor Core Isolation Cooling System. This report is being submitted in accordance with the roquirements of 10CFR50.73.

Sincerely yours, b/ ~

D. L. Holtzscher Acting Manager -

Licensing and Safety RSF/kra I

i~ Enclosure

cc: NRC Resident Office NRC Region III,. Regional A&ainistrator INPO Records Center Illinois Department of Nuclear Safety l NRC Clinton Licensing Project Manager l-ik l 8912190273 891213

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LICENSEE EVENT REPORT (LER) 9 ACILITV NAant til DOCkti NUGADER QI PACE (34 Clinton Power Station 01610 l 0 l 0141611 1 l0Fl0 le; m'* Failure to PerformWork at Eye Level Results in Connection of Test Equipment to I correct Terminals and Automatic Isolation of Reactor Qore Isolation Cooline System SVONT DATS ISI Lt R NUedDE R tel AtPont DAff (71 OTMt h 7 ACILittt$ INVOLVtD ISI MONTH DAv YtAR vlam St,0U k

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NAME tt LtPHONE NUM98R Amt A COD 4 S. E. Resor, Director - Plant Maintenance, extension 3204 2 l 11 7 9I315I-l8I8I811 COMPLtit ONE LINE FOR E ACH COMPONtNT f A8tunt DiscRittD IN TMis atPon? (til MA C. oni "

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E' SUPPLEMENTAL REPORT EXPECTED (141 MONTH DAY YEAR SUSMIS$10N YiS 199 ven. eemente tXPICTLD tvenetSSION DAfte f NO l l l Aest ACT esu.,1, ,e oa wueu e , eeanaav . rnee. e.,.wue avoe mo s. eei ns, l On November 13, 1989, with the plant in HOT SHUTDOWN, Channel Functional l

Testing (CFT) of Division 1 differential temperaturo channel 1E31-N613A, Reactor Water Cleanup Pump "A" Room Differential Temperature, was in progress. The CFT procedure required connection of a millivolt source to the circuit to initiate a trip of channel 1E31-N613A. Control and Instrumentation (C&I) technicians identified and double verified the correct terminals to be connected to the millivolt source. The technician performing the connection looked away from the terminals to double check the procedure, then looked back and inadvertently connected the source to terminals directly below the correct terminals. The 3 incorrect connection caused a Division 1 isolation of the Reactor Core l Isolation Cooling (RCIC) system. The RCIC system was in standby at the time of the isolation. The cause of this event is attributed to the failure of the technician to perform the work at eye level. Contributing factors to the technician's error were the close arrangement of the terminal boards (tbs) and the similarity of the tbs. Corrective action includes briefing personnel on the need to use ladders / stools so that they perform work at eye level, applying various colored tape strips above and below terminal boards to enhance recognition of different terminal boards, and revising surveillance test procedures.

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i DESCRIPTION OF EVENT

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On November 13, 1989, the plant was in Mode 3 (110T Sl!UTDOWN), at 330 degrees Fahrenheit and 107 pounds per square inch pressure, and a planned maintenance outage was'in progress. At 2207 hours0.0255 days <br />0.613 hours <br />0.00365 weeks <br />8.397635e-4 months <br />, an automatic Division 1 isolation of the Reactor Core Isolation Cooling (RCIC) system [BN) occurred because of an RCIC equipment area high differential temperature signal.

On November 13, 1989, utility Control and Instrumentation (C&I) maintenance technicians were preparing to perform Reactor Water Cleanup (RWCU) system [CE)/ Leak Detection (LD) system [IJ) surveillance test ,

procedure 9532.18, "RWCU Ventilation Differential Temperature '

E31-N612A(B) RWCU lleat Exchanger Room West, E31 N613A(B) RWCU Pump "A" Room E31-N613E(F) RWCU Pump "C" Poom E31 N614A(B) RWCU Pump "B" Room, E31-N618A(B) RWCU lleat Exchanger Room. East Channel Functional." The '

channel being tested was Division 1 differential temperature channel 1E31-N613A (RWCU Pump "A" Room Differentici Temperature). Surveillance  ;

9532.18 requires that a trip of channel IE31 N613A be initiated by connecting the output leads of a millivolt source to terminals 4 and 5 of Terminal Board (TB) 018 in cabinet (CAB) lill3 P715E. Normally, a trip of channel IE31 N613A results in a Division 1 isolation of the RWCU system, however, durin6 surveillance 9532.18, this isolation function is i

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On November 13, 1989, at 2159 hours0.025 days <br />0.6 hours <br />0.00357 weeks <br />8.214995e-4 months <br />, the C&I technician responsible for p connecting the millivolt source to the terminals identified the correct terminals to be connected to the millivolt source. A second C&I technician correctly double verified these same terminals as the correct terminals for connecting the millivolt source. At this point, the second 7 C&I technician proceeded to the control room annunciator (ANN) panel (PL) to verify that the trip of channel 1E31-N613A occurred as expected.

At 2207 hours0.0255 days <br />0.613 hours <br />0.00365 weeks <br />8.397635e-4 months <br />, prior to making the connection, the C&I technician responsible for connecting the millivolt source to the terminals looked away from the terminals to double check the procedure. The technician

• looked back at the terminal boards and then inadvertently connected the leads of the millivolt source to terminals 4 and 5 of terminal board TB006 which are directly below terminals 4 and 5 of TB018 in cabinet 1}i13 P715E.

Connecting the leads of the millivolt source to terminals 4 and 5 of TB006 caused a trip of Division 1 differential temperature channel 1E31-N603A (RCIC Equipment Area liigh Differential Temperature) and resulted in an automatic Division 1 isolation of the RCIC system. (The Division 1 isolation function for the RCIC system was not in bypass status at the time of this isolation.) Because of the isolation, as designed, containment isolation valves [ISV] 1E51-F064, Residual lleat

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TEXT M mee apose h regwe( see esWeens/ NAC Farm J854 'st (1M Removal (RHR) [ESj and RCIC Steam Supply Isolation Valve, and 1E51 F031,  ;

RCIC Suppression Pool Suction Valve received signals to close. Valve ~

1E51 F064 closed as designed and valve 1E51-F031 was already closed in accordance with the RCIC system lineup for the standby mode. The isolation had no. adverse impact on the RCIC system since the RCIC system was in standby at the time of the isolation.

The C&I technicians immediately stopped surveillance 9532.18 when the ]

RCIC isolation occurred. At 2239 hours0.0259 days <br />0.622 hours <br />0.0037 weeks <br />8.519395e-4 months <br />, Control. Room Operators reset the

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RCIC isolation signal and pla.ced the RCIC system in the standby mode in

. preparation for use to control Reactor Pressure Vessel [RPV) pressure. .

I No automatic or manually initiated safety system responses were necessary to place the plant in a safe and stable condition. No equipment or components were inoperable at the start of this event such that their inoperable condition contributed to this event. I l

CAUSE OF EVENT The cause of this event is attributed to personnel error by a utility C&I j maintenance technician. The technician identified the correct terminals >

in accordance with surveillance procedure 9532.18 prior to connecting the . )

millivolt source and then inadvertently connected the millivolt source to

=the terminals directly below the correct terminals.

The C&I technician's error was caused by his failure to perform the work at eye level. The terminals of TB018 were above the technicians head and <

therefore he had to reach to make the connection. The technician was familiar with this surveillance and had performed it many times without error prior to this event.

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Contributing factors to the C&I technician's error were the close arrangement of the terminal boards and the similarity of the terminal boards in the cabinet. The terminal boards are mounted horizontally in a column approximately one inch apart. The terminals on the terminal boards are arranged in horizontal rows and are labelled identically which results in columns of terminalc close together with the same terminal numbers in each column.

CORRECTIVE ACTION The C&I maintenance technician who caused this event recognized his error '

in connecting the millivolt source to the wrong terminals; therefore, no specific corrective action was necessary with respect to this specific technician,

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0l 0 0l4 or 0 l5 f tKT t# e.one spese e tooemost esse es@,wist WRC perm Jap W (171 Illinois Power (IP) C&1 maintenance technicians, IP clectrical maintenance technicians, and the electrical personnel of IP's maintenance contractor (Stone and Webster Engineering Corporation) will be briefed on the need to use ladders / stools when working overhead so that they perform work at eye level.- This briefing is scheduled to be completed by December 18, 1989.

Various colored tape strips have been applied above and below the

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terminal strips of terminal boards in cabinets similar to illl3-P715E to enhance recognition of different terminal boards.

To provide additional assurance that an event similar to the event described in this LER will not recur. IP will revise four LD system temperature channel surveillance test procedures (including 9532.18) to include the temperature channels of each division in a single performance of the procedures. These revisions will result in a reduction in the number of times technicians must enter a cabinet to perform the surveillance tests. (The other LD system temperature channel surveillance test procedures are already formatted in this manner.)

These revisions are scheduled to be completed by March 1, 1990.

Additionally, eleven LD system temperature channel surveillance test .

procedures (including 9532.18) that do not require lifting of leads prior to connecting the millivolt source will be revised to require connection of the millivolt source leads and double verification of the connection before the millivolt source is energized. This requirement will provide additional assurance that the test leads are connected to the correct I terminals before signals are initiated to trip the temperature channels.

(The other LD system temperature channel surveillance test procedures that do require lifting of leads prior to connecting the millivolt source do not require this procedure revision, because if the leads are lifted from the wrong terminals, a trip would occur prior to connecting the millivolt source.) These revisions are scheduled to be completed by March 1, 1990.

ANALYSIS OF EVENT This event is reportable under the provisions of 10CFR50.73(a)(2)(iv) because of the automatic isolation of the RCIC system.

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RCIC system responded to the RCIC equipment area high differential  :

temperature signal as designed by isolating the system. The RCIC system was in standby at the time of this event. The High Pressure Core Spray System [BC), the alternate means of providing reactor core cooling under high RPV pressure conditions, was available at the time of this event. .

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ADDITIONAL INPORMATION-

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No other reportable system isolations have occurred due to a similar root cause.

No components failed during this event. l l

For further information regarding this event, contact S. E. Rasor, Director - Plant Maintenance, at (217) 935-8881, extension 3204. l l

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