ML18059A708

LER 94-002-00:on 940126,inadvertent Containment Spray Pump ESF Actuation Occurred During Performance of TS Surveillance Testing.Caused by Inadequate Procedure.Tssp Q0-1 Modified to Warn Operators of CSP start.W/940225 Ltr

ML18059A708
Person / Time
Site:	Palisades
Issue date:	02/25/1994
From:	Hillman C, Rogers D CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.)
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-94-002, LER-94-2, NUDOCS 9403090176
Download: ML18059A708 (5)

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consumers Power David W. Rogers Plant Safety and Licensing Director POWERINii ll/llCHlliAN'S PROliRESS Palisades Nuclear Plant: 27780 Blue Star Memorial Highway, Covert, Ml 49043 February 25, 1994 Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 DOCKET 50-255 - LICENSE DPR PALISADES PLANT -

LICENSEE EVENT REPORT 94-002 - INADVERTENT CONT~INMENT SPRAY PUMP {ENGINEERED SAFETY FEATURE) ACTUATION DURING THE PERFORMANC.E OF TECHNICAL SPECIFICATIONS SURVEILLANCE TESTING BECAUSE OF AN INADEQUATE PROCEDURE Licensee Event Report {LER)94-002 is attached. This event is reportable in accordance with 10CFR50.73{a){2){iv) as an unplanned, manual engineered safety feature (ESF) actuation.

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David W. Rogers Plant Safety and Licensing Director CC Administrator, Region Ill, USNRC NRC Resident Inspector - Palisades Attachment 9403090176 ~~ 855 ~ 25

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• s I , I s 11sl41-lslsl 1IJ COMP\.ETE ONE UNE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (131 MANUFAC* REPORTABLE MANUFAC* REPORTABLE CAUSE SYSTEM COMPONENT TUR ER TO NP!IDS CAUSE SYSTEM COMPONENT TUR ER TO NPllOS I I I I I I I I I I I I I I I I I I I I I I I I I I I I SUPPLEMENTAL REPORT EXPECTED 1141 MONTH CAY YEAR EXPECTED h-i

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• I 11 Ill On January 26, 1994, at 1825 hours0.0211 days <br />0.507 hours <br />0.00302 weeks <br />6.944125e-4 months <br />, with the Plant operating at 100% power, technical specification surveillance procedure (TSSP) Q0-1, "Safety Injection System," was being performed to verify the proper operation of the safety injection actuation system (SIAS) logic. During the performance of one step in the TSSP, the control room operator verifies the white standby lights are illuminated for the containment spray pumps (CSPs)*

P-548 and P-54C, indicating that the SIAS signal is initiated for these CSPs to start.

While performing self-checking to verify that the white light had illuminated, the operator inadvertently depressed the white light/pushbutton resulting in P-548 starting.

P-548 was energized for.approximately one second; however, since both containment spray control valves (CV-3001 and CV-3002) were closed, no borated water was sprayed in containment.

The cause of this event was an inadequate procedure in that the procedure did not warn the operator that depressing the white standby .indicator light/pushbutton will result in a CSP start.

Corrective action for this event includes: modifying TSSP Q0-1 to warn the operators that the CSPs will start if the white standby light/pushbutton is depressed when the I light is illuminated; examining the P-548 standby light/pushbutton to determine if replacement, adjustment, or repair are appropriate due to its apparent sensitivity; investigating the purpose for the standby start design feature, and; performing operator training on this event.

NRC Form 388A U.S. NUCLEAR REGULATORY COMMISSION 19*83) APPROVED OMB NO. 3150--0104 EXPIRES: 8/31/85 LICENSEE EVENT REPORT (LERI TEXT CONTINUATION FACILITY NAME 11 I DOCKET NUMBER 121 LER NUMBER"l3J PAGE 141 SEQUENTIAL REVISION YEAR *NUMBER NUMBER Palisades Plant 0 I 5 I 0 I 0 I 0 I 2*I 5 I 5 9 I4 - 0 I0I2 - 0 I () 0 I2 OF 0 14 EVENT DESCRIPTION*

On January 26, 1994, at 1825 hours0.0211 days <br />0.507 hours <br />0.00302 weeks <br />6.944125e-4 months <br />, with the Plant operating at 100% power, technical specification surveillance procedure (TSSP) Q0-1, "Safety lnj~ction System," was being Ji performed -to verify the proper operation of the safety injection actuation system (SIAS) logic. Section 5.2.1 through 5.2.14 of TSSP Q0-1 verify the operation of SIAS left channel with standby power. During the performance of step 5.2.9 the control room operator verifies the white standby lights ar~ illuminated for the containment spray pumps (CSPs) [8E;P] P-548 and P-54C, indicatjng that the SIAS sigrial is initiated for these CSPs to start. While performing self-checking to verify that the white light had illuminated, the ope~ator placed a part of his finger on the white standby light and part of his finger on the black trim surrounding the light during the verification of this function. (The black trim is slightly recessed below the white light, which is also a pushbutton.) The operator inadvertently depressed the white light/pushbutton

[8E;XI] flush with the black trim as he gestured toward the indication. This resulted in P-548 starting. The operator observed the red (running) light for a P-548 start and immediately stopped the pump. P-548 was energized for ~pproximat~ly one second .

. Illumination of the green light confirmed P-548 had stopped. Since both containment spray control valves (CV-3001 and CV-3002) were closed, no borated water was sprayed in containment. This evolution was observed and confirmed by the Shift Engineer.

This event was initially considered not reportable by the on-shif.t Senior Reactor Operators (SROs) based on their review of the Palisades technical specifications, 10CFR50.72, and the final safety analysis report (FSAR). Therefore, this event was not reported in accordance with the four-hour reporting requirement of 10CFRS0.72. The SROs conc.luded that *the starting of an individual spray pump, without energizing the actuation logic or completing the flow path, was not an engineered safety feature (ESF) actuation. The following morning, a four-hour, non-emergency report was initiated in accordance with 10CFR50.72 because of the unanticipated ESF actuation of the CSP.

TSSP Q0-1 contains no procedure step or warning that aler.ts the operator that the white standby lights are a combination indicator/pushbutton. Furthermore, there is no warning in the procedure that depressing the white standby indicator light/pushbutton will result in a CSP start. Therefore, this event constitutes an unplanned, manual actuation of an engineered safety feature.

This event is reportable to the NRC in accordance with 10CFRS0.73(a)(2)(iv) as an unplanned, manual engineered safety feature (ESF) actuation.

CAUSE OF THE EVENT The cause of this event was an inadequate procedure in that the procedure did not warn the operator that the white indicator light was also a pushbutton and that depressing the white standby indicator light/pushbutton*would result in a CSP start.

NRC Form ltltlA U.S. NUCLEAR REGULATORY COMMISSION 19*831 APPROVED OMB NO. 3160-0104 EXPIRES: 8/31186 LICENSEE EVENT REPORT (LERI TEXT CONTINUATION FACILITY NAME 111 DOCKET NUMB.ER 121 LER NUMBER 131 SEQUENTIAL REVISION YEAR NUMBER NUMBER Palisades Plant 0 I5 I0 I0 I0 I2 I 5 I5 9 I4 - 0 I0I2 - 0 I0 0 I3 OF 0 14 ANALYSIS OF THE EVENT The CSPs are automatically started by* a containment high pressure (CHP) signal, or manually started via the hand switch. :There is no automatic start feature for a CSP resulting from SIAS. The white standby lights for the CSPs will illuminate when an SIAS signal is initiated. The white standby light/pushbutton will only start a containment spray pump if the white standby light/pushbutton is depressed when the white light is illuminated (SIAS present) and both containment spray control valves (CV-3001 and CV-3002) are closed. The stanpby start design feature does not appear to fulfil any safety functi~n. The containment spray syste~ will be actuated when a containment high pressure (CHP) signal (2 out of 4 logic) is received, regardless of whether an SIAS has previously occurred.

TSSP Q0-1 does not address the white standby light/pushbutton start feature for P-548 if the white standby light is illuminated. TSSP Q0-1 identifies the standby light/pushbutton as the "White Standby Light~" and the pushbutton feature is not identified. At no point in TSSP Q0-1 are the operators directed to depress the white standby light/pushbutton.

The same evolution was performed on the Palisades simulator. The white standby light/pushbutton had to be .firmly depressed to start a CSP. The CSP would not start due to inadvertent pressure during a self-checking activity such as occurred during this performance. of TSSP Q0-1.

• Palisades operators are encouraged to self-check during the performance of techni~al specification surveillance procedures. Pointing to a specific label or indicator is a desirable practice to support the self-checking process. The operator and Shift Engineer performing TSSP Q0-1 were not aware that P-548 would start if the white light/pushbutton was depressed. This start feature is unique to the CSPs. The operator did not deliberately depress the white light/pushbutton, and did not depress it fully.

The operator did not expect P-548 to start, but did immediately recognize the undesirable ~ump start and removed the pump from service. Since both containment spray control valves (CV-3001 and CV-3002) were closed, no borated water was sprayed in containment.

• As part of the corrective action for this event other TSSPs were reviewed to determine if a CSP could be inadvertently started. An inadvertent start of a CSP will not occur due to the standby start feature during any of the tests reviewed.

CORRECTIVE ACTION The following corrective action is proposed for this event:

1. Place a precaution in TSSP Q0-1 to warn the operators that th~ CSPs will start if the white standby light/pushbutton is depressed when the light .is illuminated.

f 1 NRC Form 388A U.S. NUCLEAR REGULATORY COMMISSION 19*83) APPROVED OMB NO. 3160-0104 EXPIRES: 8/3I196 LICENSEE EVENT REPORT (LERI TEXT CONTINUATION FACILITY NAME 11 l DOCKET NUMBER 121 LER NUMBER 131 PAGE 141 SEQUENTIAL REVISION YEAR NUMBER NUMBER Palisades Plant 0 5 0 0 0 2 5 5 9 4 - 0 Q 2 - Q Q Q 4 OF 0 4

2. The ~tandby light/pushbutton for P-548 will be exami~ed to determine if replacement, adjustment, or repair is appropriate due* to its apparent sensitivity.

3. Cover the following in Operations training:

A. CSP (P-54A/B/C) standby light/pushbutton operation.

B. Reporting requirements -for ESF actuations, especially unclear situations such as single component starts.

4. Electrical System Engineering will determine the purpose for the-standby start design feature. If the standby start feature has no purpose, disabling the standby pushbutton feature should be considered.

ADDITIONAL INFORMATION None