ML19332F869

LER 89-018-00:on 891114,sys High Differential Flow Condition Occurred Causing Actuation of Primary Containment Isolation Sys Valve Group 5 Logic Resulting in Closure of RWCU Valve. Caused by Personnel Error.Personnel counseled.W/891214 Ltr

ML19332F869
Person / Time
Site:	Hatch
Issue date:	12/14/1989
From:	Hairston W, Tipps S GEORGIA POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
HL-868, LER-89-018-02, LER-89-18-2, NUDOCS 8912190238
Download: ML19332F869 (6)

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K b 1 Georgd Power Company. ,

F 333 Piedmont Avenue . 1

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* Attnota Georg a 30308 -

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[ Ftst Ofice Dox 1295 - ~f D rmingham, Alabama 35201 Telephone 205 668 558t

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W. G. Hairston,111 Sernor Vce President . *

, Noctear Operations

'0469V December 14, 1989 t U.S. Nuclear ~ Regulatory Commission ATTN: Document Control Desk

. Washington, D.C. -20555

PLANT HATCH - UNIT 1 NRC DOCKET 50-321' OPERATING LICENSE DPR-57 LICENSEE EVENT REPORT MISCOMMUNICATION DURING SHIFT TURNOVER RESULTS IN~AN ENGINEERED SAFETY FEATURE ACTUATION Gentlemen:

In accordance with the requirements of .10 CFR 50.73(a)(2)(iv),

Georgia Power Company is submitting the enclosed Licensee Event Report v

.(LER) concerning a miscommunication among operations personnel which resulted in an automatic Engin'eered Safety Feature actuation. This event occurred at Plant Hatch - Unit 1. ,

l Sincerely, j (d.h. h H. G. Hairston, III SHR/sb

Enclosure:

LER 50-321/1989-018 c: (See next page.)

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December 14, 1989 Page Two c: 'Georaia Power Company Mr. H. C. Nix, General Manager duelear Plant Mr. J. D. Heldt, Manager Nucl... Engineering and Licensing - Hatch GO-NORMS LLS. Nuclear Regulatory Commission. Washinaton. D.C.

Mr. L. P. Crocker, Licensing Project Manager - Hatch .

U.S. Nuclear Reaulatory Commission. Region II Mr. S. D.- Ebneter, Regional Administrator Mr. J. E. Menning, Senior Resident Inspector - Hatch i

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NAME TELEPHONE NUMOER ARE A CODE Steven B. Tipps, Manager Nuclear Safety and Compliance, Hatch 911 12 31617 l-17 I81511 COMPLETE ONE LINE FOR E ACH COMPONENT F AILURE DESCRISIO IN THIS REPORT 113)

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On 11/14/89, at approximately 1030 CST, Unit 1 was in the Run mode at an approximate power level of 2430-CMWT (approximately 100 percent of rated thermal power). At that time, the Reactor Water Cleanup System (RWCU, EIIS Code CE) was being returned to service following maintenance on a system vent valve. While placing the system into service, a system high differential flow condition occurred causing an actuation of the Primary Containment Isolation System (PCIS, EIIS Code JM) valve Group 5 logic which resulted in automatic closure of RWCU inboard isolation valve 1G31-F001 and outboard isolation valve 1 G31 -F004. Upon closure of the valves, the differential flow condition was abated and the isolation signal was reset by licensed personnel. At approximately 1040 CST, a second attempt to place the system in service also

.resulted in a PCIS actuation and automatic closure of valves 1G31-F001 and F004 on a system high differential flow signal. The RWCU System was subsequently filled and vented and then returned to service without incident at approximately 2100 CST, on 11/14/89.

The root cause of the event was personnel error in that on-coming day shift personnel erroneously believed that the RWCU system had been filled and vented during the previous shift. In fact, the system had not been filled and vented and this resulted in a high differential flow condition upon attempting to L return the system to service.

i Corrective actions for this event included counseling involved personnel and i

issuing a memorandum to operations shift personnel emphasizing the need to effectively communicate plant status during shif t turnover briefings.

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SUMMARY

OF EVENT-

.0n 11/14/89, at approximately 1030 CST, Unit 1 was in the Run mode at an approximate power level of 2430 CMW (approximately 100 percent of rated thermal power). At that time, the Reactor Water Cleanup System (RWCU, EIIS Code CE) was being returned to service following maintenance on a system vent valve. While. placing the system into service, a system high differential flow condition occurred causing an actuation of the Primary Containment Isolation System (PCIS, EIIS Code JM) valve Group S logic which resulted-in automatic closure of RWCU inboard isolation valve 1G31-F001 and outboard isolation valve 1G31-F004. Upon closure of the valves, the differential flow condition was abated and the isolation signal was reset by licensed personnel. At approximately 1040 CST, a second attempt to place the system

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in service also resulted in a PCIS actuation and automatic closure of valves 1G31-F001 and F004 on a system high differential flow signal. The RWCU System was subsequently- f111ed and vented and then returned to service 3 'without incident at approximately 2100 CST, on 11/14/89.

The root cause of the event was personnel error in that on-coming day shif t personnel erroneously believed that the RWCU system had been filled and ,

verted during the previous shift. In fact, the system had not been filled and vented and this resulted in a high differential flow condition upon attempting to return the system to service. '

Corrective actions for this event included counseling involved personnel and

-issuing a memorandum to operations shift personnel emphasizing the need to effectively' comunicate plant. status during shift turnover briefings.

DESCRIPTION OF EVENT

- On 11/14/89, at approximately 1030 CST, Unit 1 was in the Run mode at an approximate power level of 2430 CMW (approximately 100 percent of rated thermal power). At that time, the RWCU System was being returned to service following maintenance on .the system. In accordance with procedure 34S0-G31-003-lS, " Reactor Water Cleanup System," valve 1G31-F001 had been opened and valve 1G31-F004 was being throttled open in order to pressurize the system. - While throttling open valve 1G31-F004, a system leak annunciator alarmed indicating a system high differential flow condition. The system leak annunciation was followed by a PCIS valve Group 5 logic actuation '

resulting in the automatic closure of valves 1G31-F001 and 1G31-F004. Upon

closure of the valves, the high differential flow condition was terminated.

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0l0 Q3 oF 0l4 Operations personnel entered procedure 34AB-0PS-050-lS, "RWCU System Isolation" to recover from the isolation. After procedurally confirming that an actual system leakage condition did not exist, the isolation was reset and a second attempt was made at approximately 1040 CST to place.the system into-service. Again, while-throttling open valve 1G31-F004, a system leak annunciator alarmed followed by a PCIS actuation. In both instances valves 1G31-F001 and F004 functioned as: designed upon receipt of the PCIS actuation signal.

Upon isolation of the system, operations personnel entered procedure 34AB-0PS-050-lS again. Appropriate system checks were made confirming that a 7

system leakage condition did not exist. However, the system leak annunciator L continued to' alarm indicating that air was trapped in the flow

instrumentation piping. Based on this indication operations personnel i decided to fill and vent the system piping and instrumentation prior to

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making another attempt to return the system to service. Following filling I

and. venting of the system piping and instrumentation, the RWCU System was l' returned to service without incident on 11/14/89, at approximately 2100 CST.

! Subsequent investigation determined that a miscommunication during the previous shift turnover meeting resulted in the failure to fill and vent the j system following maintenance, j CAUSE OF THE EVENT L The root cause of the event was cognitive personnel error by licensed Operations personnel. Specifically, a miscommunication occurred during shift turnover in that the on-coming day shift personnel believed that the RWCU >

l system had been filled and vented on the previous shift. Actually, only l certain instruments had been filled and vented, and not the entire system.

1 The RWCU system had been partially drained on 11/13/89 to support maintenance on a system vent valve. Due to the miscommunication, the system was not filled and vented prior to attempting to return the system to service.

l Consequently, each time the system isolation valves were opened, rapid filling of the _ system produced a high differential flow condition resulting

.in a PCIS actuation.

REPORTABILITY ANALYSIS AND SAFETY ASSESSMENT This report is required per 10 CFR 50.73 (a)(2)(iv) because events occurred which resulted in the unplanned automatic actuation of an Engineered Safety Feature (ESF). Specifically, a high differential flow in the RWCU system resulted in an isolation of PCIS valves (or pCIVs) 1G31-F001 and 1G31-F004.

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l The purpose of the RWCU Leak Detection System (LDS, EIIS Code BD) is to detect leakage in the process flow of the RWCU system external to the primary containment and to mitigate the consequences of such leakage. This is accomplished by utilizing leak detection instrumentation which initiates-closure of the PCIVs upon detecting a parameter that is indicative of a j 1 system leak. One of the methods used for detecting system leakage is flow comparison of the RWCU system influent and effluent. If the influent exceeds the effluent by at least 56 gpm for 45 seconds, a- high differential flow condition exists and an isolation of PCIVs 1G31-F001 and 1G31-F004 is initi ated.

In the event addressed in this report, an actual high differential flow condition resulted from rapid filling of system piping upon opening the system isolation valves. Operations personnel confirmed no external leakage )

from the RWCU system. The= PCIS actuated as designed with PCIVs 1G31-F001 and 1G31-F004 automatically closing upon receipt of an isolation signal.

Based on the above information, it is concluded that this event had no adverse impact on nuclear plant safety. This analysis applies to all

operating conditions.

CORRECTIVE ACTIONS .

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1 Personnel involved in the event have been counseled concerning the need for effective, accurate, and complete communication of plant status during shift turn-over briefings.

A memorandum has been issued to operations shift personnel emphasizing the  !

need for effective, accurate, and complete communication of plant status during shift turn-over briefings.

ADDITIONAL'INFORMATION No plant systems other than the RWCU system and PCIS system were affected by this event.

Similar events in which personnel error resulted in an RWCU isolation were reported in LER 50-366/88-15, dated 08/26/88 and in LER 50-321/89-014, dated 11/08/89. Corrective actions resulting from the previous events included counseling of involved personnel and issuing a memorandum to all operations personnel emphasizing the importance of using the repeat-back technique for verifying verbal commands before executing them. Disciplinary action against the responsible individuals would not have prevented this event since the personnel involved in the previous events were not involved in this event.

The memorandum associated with LER 50-321/89-014 had not been issued at the time of this event and dealt with a different aspect of interpersonal communication (i.e., repeat-back techniques vs. complete communication of plant status). Therefore, it would not have prevented the event described in this report.

- NIC FORM 306A 'U,5. CPO: 1968 520-569,00070

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