ML17347A888

LER 88-032-00:on 881202,personnel Error Resulted in Loss of Power to Vital Instrument Bus & Isolation of Stated Ventilation Sys.Operator Counseled.Spare Inverter Relabeled as Spare & Procedures revised.W/881230 Ltr

ML17347A888
Person / Time
Site:	Turkey Point
Issue date:	12/30/1988
From:	Conway W, Lyons E FLORIDA POWER & LIGHT CO.
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
L-88-555, LER-88-032, LER-88-32, NUDOCS 8901030388
Download: ML17347A888 (6)

Text

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'3 ACCELERATED D1SQJBUTlON DEMONSTR+OY . SYS1'Eg

, /'- REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:8901030388 DOC.DATE: 88/12/30 NOTARIZED: NO DOCKET FACIL:50-250 Turkey Point Plant, Unit 3, Florida Power and Light C 05000250 AUTH. NAME AUTHOR AFFILIATION LYONS,E. "

Florida Power' Light Co.,

CONWAY,W.F. Florida Power & Light. Co.

RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 88-032-00:on 881202,personnel error results in loss of power to vital instrument bus & isolation of CR & CV.

W/8 DISTRIBUTION CODE: IE22D COPIES RECEIVED:LTR 'NCL SIZE: 8 TITLE: 50.73 Licensee Event Report (LER)g Incident Rpt, etc.

NOTES RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-2 LA 1 1 PD2-2 PD 1 1 D EDISON,G 1 1 D

INTERNAL: ACRS MICHELSON 1 1 ACRS MOELLER 2. 2 ACRS WYLIE 1 1 AEOD/DOA 1 1 S AEOD/DSP/TPAB 1 1 AEOD/ROAB/DS P 2 2 ARM/DCTS/DAB 1 1 DEDRO 1 1-NRR/DEST/ADS 7E 1 0 NRR/DEST/CEB 8H 1 1 NRR/DEST/ESB SD 1 1 NRR/DEST/ICSB 7 1 1 NRR/DEST/MEB 9H 1 1 NRR/DEST/MTB 9H 1 1 NRR/DEST/PSB SD 1 1 NRR/DEST/RSB 8E 1 1 NRR/DEST/SGB SD 1 1 NRR/DLPQ/HFB 10 1 1 NRR/DLPQ/QAB 10 1 1 NRR/DOEA/EAB 11 1 1 NRR/DREP/RAB 10 1 1 NRR/DREP/RPB 10 2 2 R~R.. IB 9A 1 1 NUDOCS-ABSTRACT 1 1 EG E 02 1 1 RES/DSIR/EIB 1 1 E SR/PRAB 1 1 RGN2 FILE 01 1 1 EXTERNAL EG&G WILLIAMSI S 4 4 FORD BLDG HOY,A 1 1 H ST LOBBY WARD 1 1 LPDR 1 1 NRC PDR 1 1 NSIC HARRIS,J 1 1 NSIC MAYS(G 1 1

~ 'IO ALL t'RIDS" RECZPZENIS'IZASE HELP US 10 REDUCE WASTE! ~CI'IHE DOCUMENI'ONGEAL DESK ROOM Pl-37 (EXT. 20079) KO EZJl62QQ'E YOUR NAME FMH DISTfKBVZIQN LISTS POR DOCUMENZS YOU DOIN'T NEED!

TOTAL NUMBER OF COPIES REQUIRED: LTTR 44 ENCL 43 g(0@

NAC Form 300 U.S. NUCLEAR REOULATORY COMMISSION (903)

APPROVED OMB NO. 31500101 LICENSEE EVENT REPORT {LER) EXPIRES: 0/31/00 FACILITY NAME (I) DOCKET NUMBER (2) PA Turke Point Unit 3 o 5 o o o2 5p >OF03 Personnel Error Results in Loss of Power to Vital Instrument Bus and EVENT DATE (5) LER NUMBER (0) REPORT DATE I7) OTHER FACILITIES INVOLVED (0)

MONTH DAY YEAR YEAR, SEQVENrr*L 'yxx REvrslON MONTH OAY YEAR I'ACI LIT Y NAMES DOCKE'7 NUMBER(s)

NUMBER 2N: NVMSER Turkey Point Unit 4 0 5 0 0 0 251 1 2 0 2 8 8 8 0 3 2 0 12 3088 0 5 0 0 0 THIS REPORT IS SUBMITTED PURSUANT T 0 THE REOUIAEMENTS OF 10 CFA (I: ICnicfr onr or morr of tnr fofforffnffIII)

OPEAATINO MODE (SI 5 20A02(0) 20A05(c) 50.73(e) l2)(lrl 7$ .71DII POWER 20A00(e) II)lil 50M(cl (I) 50.73(el(2)(r) 7$ .71(c)

LEVEL p p p 20A00(elll l(il) 00.30(cl(2) 50,7$ (el(2srlll DTHER ISprclfy In Aotoxct Orrorr rnrf in Tref, ffAC Form 20A00( ~ l(1 I (illI 09.7$ ( ~ )(21(l) 50,7$ ( ~ l(2)(rllll(A) JSSAI 20A00(e l(1)(lrI 00.73(el(2)(EI 50.7$ (el(2)(rlE) (SI 20A00(e I (1)(r) 50.73(e) l2)(ill) 50.73(r) l2)(el LICENSEE CONTACT FOA THIS LER (12)

NAME TELEPHONE NUMBER AREA CODE Edward Lyons, Compliance Engineer 305 2 46 "6 731 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT 1131 CAUSE SYSTEM COMPONENT MANUFAC.

TURER T() NPA()$ i $

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TURER EPOATABL'E ir'ONPADS

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SUPPLEMENTAL REPOAT EXPECTED lie) MONTH DAY YEAR EXPECTED SUBMISSION DATE (15)

YES Iffyrr, COmprrrr EXPECTED $ (ISMISSIOIY DATEI NO ABSTRACT ILfmlt to fc00 cprcn, I r.. rpproxfmrtrfy ffftrrn tfnprrrprcr typrrrrlttrn Snnf (10)

On December 2, 1988, at 0500, with Unit 3 in cold shutdown and Unit 4 defueled, a Nuclear Turbine Operator (NTO) was attempting to remove the 4B normal inverter from service to allow maintenance to be performed.

After transferring load to the "B" spare inverter, the NTO mistakenly opened the output breaker for the "BH spare inverter instead of opening the output breaker for the 4B normal inverter. This resulted in a loss of power to the 120 vital AC bus 4P08 and the process radiation monitoring rack. Loss of the process radiation monitoring rack resulted in the automatic isolation of the Containment Ventilation and Control Room Ventilation systems. The breaker was closed approximately 30 seconds after being opened, and at 0540 the Control Room Ventilation system was returned to its normal alignment. The cause of the event was personnel error in that the NTO opened the output breaker for the "B" spare inverter instead of opening the output breaker for the 4B normal inverter.. Human factors considerations contributed to this event in that the "B" spare inverter was mis-labeled as HB standby inverter." The NTO was counseled following the event. The spare inverters will be re-labeled as spare inverters. In addition, the procedure in use at the time of the event will be revised to require that the oper'ator verify that the inverter to be de-energized is not supplying power to the bus.

rC7 x 89P1PSP:Sc:-,": 12ZP PElh ADOCVi P SPP<)25P PDC NRC Form 300 (9 53)

NRC Form 38SA U.S. NUCLEAR REGULATORY COMMISSION (98'i LICENSEE E NT REPORT HLER) TEXT CONTINUA N APPROVED OMS NO. 3150-0104 EXPIRES: 8/31/88 FACILITY NAME tll DOCKET NUMBER (2) LER NUMBER Ld) PAGE (3)

SEQUENTIAL g+g REVISION YEAR g@ NI/MSER '/8 NVM8ER Turkey Point Unit 3 0 5 0 0 0 88 03 2 00 0 2 0 3 TENT /S'm<<o Nw>>)4 roSI>><</, I>>o<<//Sor>>l HRC Form Sr)SASJ (IT)

DESCRIPTION OF THE EVENT

'n December 2, 1988, at 0500, with Unit 3 in cold shutdown and Unit 4 defueled, a Nuclear Turbine Operator (NTO) (non-licensed utility employee) was attempting to remove the 4B normal inverter (EIIS:EF; component: INVT) from service to allow maintenance to be performed. The NTO had previously transferred the load from the 4B normal inverter to the "B" spare inverter. Following the load transfer, the NTO mistakenly opened the output breaker for the "B" spare inverter, instead of opening the output breaker for the 4B normal 'inverter. This resulted in a loss of power to the 120 volt AC vital'us 4P08. The process radiation monitoring rack is powered from bus 4P08. Therefore, the loss of bus 4P08 resulted in the loss of the process radiation monitoring rack. The loss of the process radiation monitoring rack resulted in the automatic isolation of the Containment Ventilation System (EIIS:VA) and the Control Room Ventilation System (EIIS:VI). Breaker 4P08 was reclosed approximately 30 seconds after being opened. At 0515 the 4B normal inverter was de-energized. At 0540, the Control Room Ventilation System was returned to its normal configuration.

CAUSE OF THE EVENT The cause of the'event was personnel error in that the NTO opened the output breaker for the "B" spare inverter instead of the output breaker for the 4B normal inverter. Human factors considerations contributed to the cause of this event. The section of the procedure used to de-energize an inverter is labeled "De-energizing a Standby Inverter." The procedure requires that the operator "Perform the following steps at the affected inverter panel." In this event, the affected inverter was the 4B normal inverter. In addition, the "B" spare inverter was mis-labeled as "B Standby Inverterou The NTO apparently became confused about which inverter was the "affected inverter" and opened the wrong breaker.

ANALYSIS The Containment Ventilation System and the Control Room Ventilation System isolated as designed on a loss of power to the process radiation monitoring rack. No plant equipment was damaged as a result of this event. Based on the above, this event had no effect on the health and safety of the public.

CORRECTIVE ACTIONS

1) Breaker 4P08 was reclosed, within approximately 30 seconds, restoring power to the bus.

2) The NTO and the other operators on the same shift were counseled on the importance of recognizing the goals of the evolution being performed, and the relationship between those goals and the procedural steps being performed. In addition, a night order was issued to instruct all shifts to verify that an inverter being removed from service is not carrying any load prior to opening the output breaker .

NRC FORM SddA oU.8 GPO:1986 0.624 538r455 (94)3)

NRC Form 3BSA (9 "3) U.S. NUCLEAR REOULATORY COMMISSIO LICENSEE VENT REPORT (LER) TEXT CONTINUATION APPROVED OMB NO. 3150&104 EXPIRES: 8/31/88 FACILITY NAME (I) DOCKET NUMBER (2)

LER NUMBER (8) PACE (3)

YEAR @Q BEOUENTIAL NUMBER j.m REVISION reer NUMBER Turkey Point Unit 3 o s o o o 8 8 032 00 03 OF 0 3 TEXT /8'Rlrro Nwor H /BBoled, I/ro aAWons/HRC %%dri 3854'r/ nl)

3) The spare inverters will be re-labeled as spare inverters. 'This action will be completed by February 24, 1989.

4) Procedure O-OP-003.3 will be revised to require that the operator verify that the inverter to be de-energized is not supplying power by checking the associated ammeter prior to opening the breakers . This action will be completed by February 10, 1989.

ADDITIONAL INFORMATION Similar events:LERs 251-88-002 and 250-87-032 describe similar events.

NRC FORM 34BA *U,S.OPO.'(988 0 824 538/455 (983)

P.O. Box 14000, Juno Beach, FL 33408-0420

. OEGEMBER 5 O ~9<~

L-88-555 10 CFR 50.73 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555 Gentlemen:.

Re: Turkey Point Units 3 and 4 Docket Nos. 50-250 and 50-251 Reportable Event: 250-88-32 Date of Event: December 2, 1988 Personnel Error Results in Loss of Power to Vital Instrument Bus and Automatic Isolation of Control Room and- Containment Ventilation The attached License Event Report (LER) is being submitted pursuant to the requirements of 10 CFR 50.73 to provide notification of the subject event.

Very truly yours, W. F. Conw y Senior Vice President Nuclear WFC/RHF/gp Attachment CC Malcolm L. Ernst, Acting Regional Administrator, Region II, USNRC Senior Resident Inspector, USNRC, Turkey Point Plant an Fpt. Group company