ML18038B881

LER 97-004-00:on 970414,unplanned Manual Start of EDG During Scheduled Redundant Start Test Occurred.Caused by Personnel Error.Edg 3D Shutdown & Returned to pre-event Configuration. W/970514 Ltr

ML18038B881
Person / Time
Site:	Browns Ferry
Issue date:	05/14/1997
From:	Austin S, Crane C TENNESSEE VALLEY AUTHORITY
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-97-004-02, LER-97-4-2, NUDOCS 9705210262
Download: ML18038B881 (14)

Text

~ CATEGORY REGULATORY INFORiMATION DISTRIBUTION STEM (RIDS)

ACCESSION NBR:9705210262 DOC.DATE:. 97/05/14 NOTARIZED: NO DOCKET FMIL:50-296 Browns Ferry Nuclear .Power Station, Unit 3, Tennessee 05000296 AUTH. NAME AUTHOR AFFILIATION.

AUSTINiS.. Tennessee Valley Authority CRANE,C.M., Tennessee Valley Authority RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 97-004-00:on 970414,unplanned manual start of EDG during.

scheduled redundant start test occurred. Caused by.,personnel error.EDG 3D shutdown a returned'o pre-event configuration.

W/970514 ltr.

DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL SIZE:

TITLE: 50..73/50.9 Licensee Event Report (LER), Incident Rpt, etc.

NOTES:

RECIPIENT. COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL, ID CODE/NAME LTTR ENCL PD2-3-PD 1 1 1 1 WILLIAMS,J'E/QSPE+/NAB INTERNAL'CRS 1 1 2

12 AEOD/SPD/RRAB 1 1 E CENTER~ 1 NRR/DE/ECGB 1 1 NRR/DE/EELB 1 1 NRR/DE/EMEB 1 1 NRR/DRCH/HHFB 1 1 NRR/DRCH/HICB 1 1 NRR/DRCH/HOLB 1 1 NRR/DRCH/HQMB 1 1 NRR/DRPi41/PECB 1 1 NRR/DSSA/SPL'B 1 1 NRR/DSSA/SRXB 1 1 RES/DET/EIB. 1 1 RGN2'ILE 01 1 1 EXTERNAL: L ST L'OBBY WARD 1 1 LITCO 'BRYCE,J H 1 1 NOAC POORE,W'. 1 1 NOAC QUEENERiDS 1 1 NRC 'PDR 1 1 NUDOCS FULL TXT 1 1 NOTE TO ALL "RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTE! CONTACT THE DOCUMENT CONTROL DESK, ROOM OWFN SD-5(EXT. 415-2083) TO 'ELIMINATE YOUR NAME 'FROM DISTRIBUTION 'L'ISTS FOR DOCUMENTS YOU DON'T NEED!

FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 25 ENCL 25

I~ II Tennessee valley Authority. post office Box 2000. Decatur, Alabama 35609-2000 Christopher M. (Chris) Crane Vice President, Browns Feny Nuclear Plant May 14, 1997 U. S. Nuclear Regulatory Commission 10 CFR 50.73 ATTN: Document Control Desk Washington, D.C. 20555

Dear Sir:

BROWNS FERRY NUCLEAR PLANT (BFN) UNITS 1r 2r AND 3 DOCKET NOS. 50- 296 FACILITY OPERATING LICENSE DPR-60 LICENSEE EVENT REPORT 50-296/97004 The enclosed report provides details concerning an unplanned manual start of an emergency diesel generator. This report is submitted in accordance with 10 CFR 50.73 (a)(2)(iv) as a condition that resulted in a manual or an automatic actuation of an engineered safety feature.

Si cerel C. M. ane Enclosure cc (Enclosure):

Mr. Mark S. Lesser, Branch Chief U.S. Nuclear Regulatory Commission Region II 61 Forsyth Street, S.W.

Suite 23T85 Atlanta, Georgia 30323 NRC Resident Inspector Browns Ferry Nuclear Plant 10833 Shaw Road Athens, Alabama 35611 Mr. J. F,. Williams, Pro j.ect Manager U. S. Nuclear Regulatory Commission One White Flint, North "11555 Rockville Pike Rockville, Maryland 20852 97052i0262 970514 PQR ADQCK 05000296 S PDR lllllllllllllllllllllllllllllllllllillll

II 0 NRC FORM 366 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB No. 3150.0104 (4.95) EXPIRES 04/30/98 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS MANDATORY INFORMATION COLLECTION REQUEST: 60.0 LICENSEE EVENT REPORT (LER) HRS. REPORTED LESSONS LEARNED ARE INCORPORATED INTO THE LICENSING PROCESS AND FED BACK TO INDUSTRY. FORWARD COMMENTS REGARDING BURDEN (See reverse for required number of ESTIMATE TO THE INFORMATION AND RECORDS digits/characters for each block) MANAGEMENT BRANCH (T.6 F33), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20566 FACIUTY NAME I II DOCKET NUMBER l2l PAOE Is)

Browns Ferry Unit 3 05000296 1 OF5 Tl'TLE I4)

Unplanned Manual Start of an Emergency Diesel Generator During a Scheduled Redundant Start Test EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (8)

FACILITYNAME OOCKET NUMBER SEQUENTIAL REVISION MONTH DAY YEAR MONTH DAY YEAR NUMBER NUMBER N/A FACILITYNAME DOCKET NUMBER 04 14 97 97 004 00 05 14 97 N/A OPERATING THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR E: (Check one o r more) (11)

MODE (9) 20.2201(b) 20.2203(a)(2) (v) 50.73(a) (2) (i) 50.73(a)(2)(viii)

20. 2203(a)(1) 20.2203(a) (3)(i) 50.73(a)(2) (ii) 50.73(a) (2) (x)

PQWER LEVEL (10) 100 20. 2203(a) (2) (i) 20.2203(a)(3)(ii) 50.73(a) (2)(iii) 73. 71 20.2203(a) (2) (ii) 20.2203(a)(4) X 50.73(a)(2)(iv) OTHER 20.2203(a) (2)(iii) 50.36(c) (1) 50. 73(a) (2) (v) Spocrfy In Abstract bo low or in NRC Form 366A 20.2203(a)(2)(iv) 50.36(c)(2) 50.73(o) (2) (vii)

LICENSEE CONTACT FOR THIS LER (12)

NAME TELEPNONE NUMBER (Include Ares Cedar Steve Austin, Licensing Engineer (205) 729-2070 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)

REPORTABLE, REPORTABLE CAUSE o<<TEM COMPONENT MANUFACTUREP 'O CAUSE SYSTEM COMPONENT MANUFACTURER TO NPRDS NPRDS SUPPLEMENTAL REPORT EXPECTED (14) MONTH DAY YEAR EXPECTED YEs SUBMISSION X No DATE (15)

(If yes, complete EXPECTED SUBMISSION DATE).

ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (16)

On April 14, 1997, at 1142 hours0.0132 days <br />0.317 hours <br />0.00189 weeks <br />4.34531e-4 months <br /> Central Daylight Time (CDT), an unexpected Engineered Safety Feature actuation occurred when Emergency Diesel Generator (EDG) 3D was inadvertently manually started. During the scheduled performance of the Diesel Generator 3C Redundant Start Test, EDG 3D was manually started from the Unit 3 Main Control Room. EDG 3D was returned to the pre-event configuration by 1153 CDT. The root cause of the event was personnel error. During the performance of the redundant start test, the operator was requested to start EDG 3C; however, the individual started EDG 3D. The operator failed to properly utilize touch STA'R ( Stop, Think, Ask, Act, and Review) verification process during the test. Personnel corrective actions were administered to the individual. A briefing on the event was "provided to appropriate plant personnel. The briefing package was reviewed with the shift crews. Personnel activities will be evaluated to ensure management expectations for use of touch STA'R verification process are met. TVA is providing this report in accordance with 10 CFR 50.73 (a)(2)(iv), as any event or condition that resulted in manual or automatic actuation of any engineered safety feature, including the reactor protection system.

NRC FORM 366 (4-95)

0 0 r, II RC FORM 366A U.S. IIUCLEAR REGULATORY COMVllSSION (4%5)

LICENSEE EVENT REPORT (LER)

TEXT CONTZNUATEON FACZLZTX NAME (Z DOCKET LER NUMBER PAGE NUMBER NUMBER Browns Ferry Unit 3 05000296 2 of 5 97'- 004 -- 00 TEX more spree rs require, use a Loons copes arm (17)

Z~ PLANT CONDZTZONS Units 2 and 3 were at approximately 100 Percent Power. Unit 1 was shutdown and defueled.

ZZ ~ DESCRZPTZON OF EVENT A. Event On April 14, 1997, at 1142 hours0.0132 days <br />0.317 hours <br />0.00189 weeks <br />4.34531e-4 months <br /> Central Daylight Time (CDT), an unexpected Engineered Safety Feature (ESF) I.'JE] actuation occurred when Emergency Diesel Generator ("DG) [EK] 3D was inadvertently manually started from the Unit 3 Main Control room.

During the scheduled performance of the Diesel Generator 3C Redundant Start Test, the operator [utility, licensed] was recgxested to start EDG 3C; however, the individual started EDG 3D. Emergency Diesel Generator 3D was in standby alignment, and because there was no low voltage condition present on Shutdown Board 3D [EB], the EDG fast started and ran normally with the output breaker [BKR] open.

The affected, EDG was returned to pre-event configuration by 1153 hours0.0133 days <br />0.32 hours <br />0.00191 weeks <br />4.387165e-4 months <br /> CDT. Al'1 systems responded as expected during the ESF.

This event is reportable in accordance with 10 CFR 50.73 (a)(2)(iv), as any event or condition that resulted in manual or automatic actuation of any engineered safety feature including, the reactor protection system.

B. Zno erable Structures, Co onents, or S stems that Contributed to t e Event:

None.

c. Dates and A roximate Times of Na'or Occurrences:

April 14, 1997 at 1142 CDT Emergency Diesel Generator 3D was inadvertently started.

April 14, 1997 at 1153 CDT The EDG was returned to pre-event status.

April 14, 1997 at 1405 CDT TVA made a 4 hour non-emergency notification to NRC in accordance with 10 CFR 50.72 (b)(2)(ii).

D., Other S stems or Seconda Functions Affected:

None.

NRC FORM 366A (4%5)

0

-NRC:FORM 366A U.S. NUCLEAR REGULATORY COIVMSSION (45)

LICENSEE EVENT REPORT (LER)

TEXT CONTINUATZON FACILITY NAME (Z) DOCKET PAGE NUMBER NUMBER Browns Ferry Unit 3 05000296 3 of 5 97 -- 004 -- 00 TEXT more space is require, use a iuoiia copies orm (17)

E. 'Method of Discove The Unit 3 Operator received an alarm indicating that EDG 3D started.

F. erator Actions:

Operator actions taken during this ESF were as expected.

.G. Safet S stem Res onses:

The EDG responded as expected for this type -of events zzz. CAUSE OF THE EVENT A. Zmmediate Cause:

The immediate cause of the EDG start was that a manual start signal was initiated from the Unit 3 main control zoom.

B. Root Cause:

The root cause of the event was personnel error due to inattention to detail. During performance of the redundant start test, the operator was requested to manually start EDC 3C.

However, the individual instead started EDG 3D. The individual failed to properly utilize the touch STA'R (Stop, Think, Ask, Act, and Review) vezification process prior to starting 'the EDG.

During the starting sequence foz ECG 3C, the operator was performing the self checking verification process. However, prior to completing the process, the individual turned away from the EDG panel to verify the proper step in the procedure. When the individual turned back to start EDG 3C, he inadvertently started EDG 3D. After interrupting himself during the touch STA'R verification process, the individual did not re-perform the verification process to ensure he was about to start the appropriate EDG.

C. Contrihutin Factors:

Training did not adequately address the touch STA'R verification process requirements. The licensed operator zequalification lesson. plan on verification does not include the necessity to completely re-perform the verification process performing a task is interrupted.

if the individual NRC FORM 368A (445)

IO NRC FORM 366A U.S.'NUCLEAR REGULATORY COIVMSSION (4%5)

LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION FACILITY NAME 1) DOCKET PAGE NUMBER NUMBER Browns Ferry Unit of 5 3 05000296 97 -- 004'- 00 4

TEX more space is require, use a moira copies orm (17)

IV. ANALYSIS OF THE EVENT The EDGs are part of the standby AC'power system which provides a highly reliable source of power as required for Emergency Coze Cooling Systems. The EDGs ensure that no credible event can disable the power supply for core standby cooling functions or their supporting systems/components.

In this event the EDG and associated components performed as designed.

Operations, personnel immediately identified the cause of the ESF actuation and took appropriate actions to restore the affected systems to 'the pre-event configuration. Therefore, this event did not affect the health and safety of the plant personnel or the public.

V. CORRECTIVE ACTIONS A. Immediate Corrective Actions:

'Emergency Diesel Generator 3D was shutdown and returned to the pre-event configuration. The individual involved in the EDG start was removed from watch standing position, on Unit 3 and zeassigned'o the nonoperating unit.

B. Corrective Actions to. Prevent Recurrence:

The individual involved in the event received zetraining on the touch STA'R verification process. Personnel corrective actions in accordance with TVA policy were administered. This individual was subsequently returned to an assignment on an operating unit.

His activities will be evaluated to ensure management expectations for use of the touch STA'R verification process are met.

Operations management will perform additional observations to ensure management expectations on the use of the touch STA'R verification process is understood, enforced, and adhered to by shift personnel'.

A briefing package on this event was issued to appropriate BFN personnel. The p'ackage was reviewed with the shift crews by operations management. It emphasized attention to detail and intrusiveness in performance of activities at BFN.

TVA will review the Operator Training in the area of self-TVA does not consider this corrective action a Regulatory Commitment. TVA's cozzective action program will track completion of the action.

NRC FON 366A (4-95)

NRC FORMSCCA U.S. NUCLEAR REGULATORY COMVllSSION (4 95)

LICENSEE EVENT REPORT (LER)

TEXT CONTINUATION FACILITY NAME DOCKET PAGE NUMBER NUMBER Browns Ferry Unit 3 05000296 5 of 5 97 -- 004 -- 00 mora space is require, usa s diuons copies orm 17) checking and, as necessary, revise the training to ensure reperformance of self-checking is required interrupted or if if the .process is the performer is distracted prior to the completion of the step or action'.

i VZ. 'ADDZTZONAL INFORMATION None.

B. Previous LERs on Similar Events:

There have been several LERs issued in which, due to a personnel error, one or more EDGs were inadvertently started. However, no previous events were identified where an operator manually started the wrong EDG during a scheduled test.

VZZ. COMMITMENTS None.

Energy Industry Identification System (EIIS) system and component codes are identified in the text with brackets (e.g., [XX]).

2'VA does not consider this corrective action a Regulatory Commitment.

cozze'ctive action piogzam will track completion of the action.

TVA's NRC FORM 368A (445)

0