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SSINS No.: 6835 IN 84-58 UNITED STATES NUCLEAR REGULATORY COMMISSION OFFICE OF INSPECTION AND ENFORCEMENT WASHINGTON, D.C. 20555 July 25, 1984 Information Notice No. 84-58: INADVERTENT DEFEAT OF SAFETY FUNCTION CAUSED BY HUMAN ERROR INVOLVING WRONG UNIT, WRONG TRAIN, OR WRONG SYSTEM Addressees: All nuclear power reactor facilities holding an operating license (OL) or construction permit (CP). Purpose: This information notice is provided as a notification of potentially significant problems pertaining to inadvertent defeat of safety functions caused by human errors involving the wrong unit, wrong train, or wrong system. It is expected that recipients will review and consider actions, if appropriate, to preclude similar problems occurring at their facilities. However, suggestions contained in this information notice do not constitute NRC requirements and, therefore, no specific action or written response is required. Description of Circumstances: A large number of reports have been made to the NRC that describe events in which safety functions were inadvertently defeated as a result of actions performed on the wrong unit of a multi-unit plant, the wrong train of systems with redundant trains, or a wrong system. In many cases, the loss of safety function was not recognized for a long period of time, resulting in significant degradation of the levels of safety. An example of each type of event, caused by human error involving the wrong unit, wrong train or wrong system, is described below. A sample listing from among at least 50 reports of other similar events that have occurred is contained in Table 1. On October 2, 1983, an operator was dispatched to lock closed a manual valve on the discharge side of each of the redundant containment spray pumps for Turkey Point Unit 3. The activity was required by the procedure for proceeding from hot to cold shutdown in preparation for a refueling outage. The operator, instead of closing the Unit 3 valves, locked closed the valves for Unit 4 which was operating at power. Subsequent to this activity, there was a change in operators. The replacement operator later went to the Unit 3 containment spray pump discharge valves and closed them as he found them to be open. He was 8407230079 . IN 84-58 July 25, 1984 Page 2 of 3 unaware that the Unit 4 valves were closed. It was over a day later before the licensee's technical staff discovered the Unit 4 valves to be locked closed during a monthly periodic test of the containment spray system. Hatch Unit 2 was operating at 100% power on August,17, 1982, with the "B" loop of the residual heat removal service water system (RHRSWS) out of service for maintenance. While removing "B" loop from service, the personnel tasked with closing the "B" loop strainer inlet valve inadvertently closed the "A" loop strainer inlet. This resulted in the total loss of RHRSWS and, thus, the residual heat removal (RHR) system including the postaccident heat removal capability. On February 7, 1984, the FitzPatrick plant was operating at full power when the high-pressure coolant injection (HPCI) system was intentionally tagged out of service to permit general maintenance and modification of the overspeed trip. Tagging out the HPCI system included closing of the motor operated steam supply valves, and racking out the breakers for the valves and oil pumps for the turbine. Before removing HPCI from service, other safety systems were demonstrated operable as required by the Technical Specifications. As a part of the maintenance, technicians were assigned to calibrate the HPCI turbine speed indication which involved disconnecting the speed feedback circuit and thus disabling the HPCI system regardless of any other actions. After completing the calibration on what they thought to be the HPCI turbine speed instrumentation, the technicians reported that the as-found tolerance was over 40% higher than the procedure limit. When the responsible supervisor initiated an investigation of the as-found tolerance, it was discovered that the technicians had calibrated the reactor core isolation cooling (RCIC) speed instrumentation instead of the HPCI instrumentation. This activity had resulted in loss of RCIC with HPCI unavailable. Discussion: A review of the inadvertent defeat of safety function events including those cited above and summarized in Table 1, indicates that many events were highly significant from the standpoint of safety and others would have been significant if they had occurred under different circumstances. The review also indicates that misidentification of equipment by personnel was the primary cause of most events. Other events were caused by inadequate planning, defective procedures, or defective labeling of equipment. Although not the primary cause, design error or failure to perform adequate verification of activities was a contributing factor in some events. In the Turkey Point event, the operator had access to the wrong unit because the access keys were the same for the two units. Also, the valves had identical identification tags for both units. The operator did not carry the tag out sheet with him and thus did not sign it for completion of the activity. Later, the replacement operator closed the correct valves. The closed valves on the operating unit were not discovered for over 28 hours because no verification of the activities was performed. Following the event, the procedural and administrative deficiencies were corrected. A walkdown of the accessible portions of all safety-related flow paths was performed to verify that all valves were in correct positions, the locks for the two units were color coded, and different keys were made for the locks of the two units. . IN 84-58 July 25, 1984 Page 3 of 3 The Hatch Unit 2 event was attributed to personnel error and lack of adequate independent verification. As a part of corrective actions, new identification tags were made and locks were changed so that the, keys for valves in one loop will not open the valves in the other loop. In addition, the personnel responsible were counseled and reprimanded. The FitzPatrick loss of RCIC event with HPCI out of service was caused by personnel error. Following the event, the licensee instituted an awareness program for the technicians in addition to improving the identification of HPCI and RCIC equipment. Adequate procedures, planning, labeling, awareness and training of personnel, and an independent verification program are needed to prevent the occurrences of such events. The frequency and number of such events being reported to the NRC indicates a need for further industry action in these areas. Additional guidance on independent verification programs is provided in Information Notice No. 84-51, "Independent Verification." If you have any questions regarding this matter, please contact the Regional Administrator of the appropriate NRC regional office or this office. Edward L. Jordan Director Division of Emergency Preparedness and Engineering Response Office of Inspection and Enforcement Technical Contact: R. Singh, IE (301) 492-8068 Attachment 1. Sample List of Recent Inadvertent Defeat of Safety Function Events 2. List of Recently Issued IE Information Notices . IN 84-58 July 25, 1984 Page 1 of 1 Table 1: Sample List of Inadvertent Defeat of Safety Function Events Plant/Date Event Summary D.C. Cook An auxiliary equipment operator was 03/14/81 instructed to deenergize breakers for five motor operated valves of the Unit 2 safety injection system. He instead deenergized the breakers of five Unit 1 valves. Calvert Cliffs Electricians began work on Unit 2 control 04/17/82 element assemblies (CEAs) instead of the assigned Unit 1 CEAs. Point Beach An operator was instructed to perform part 04/22/82 of a procedure to drain the reactor coolant of Unit 2 which was shutdown. Instead, he performed the procedure steps on operating Unit 1. North Anna 2 Both trains of the quench spray subsystem 05/28/82 and the recirculation spray system were made inoperable because jumpers were installed in the train "A" instead of the train "B" solid state protection output cabinet. St. Lucie 1 During full power operation, the primary and 06/29/83 back up heat tracing for the boron injection flow paths were isolated for 24 hours. The condition existed because the entire chemical and volume control system heat tracing was isolated rather than only that required for the "A" boric acid piping. Turkey Point 3 With the unit at 100% power and auxiliary 04/19/83 feed water pump "A" out of service, all steam supply valves for "B" and "C" pumps were found to have been closed for five days. The operators had misidentified the valves and independent verification was not performed. D.C. Cook 2 During containment spray system testing, 06/03/83 operators closed a wrong valve which rendered the train not under test inoperable. Kewaunee Both trains of shield building ventilation 03/13/84 were taken out of service for one hour when maintenance personnel began work on the "A" train instead of the "B" train.
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