United States Nuclear Regulatory Commission - Protecting People and the Environment

Information Notice No. 85-51: Inadvertent Loss or Improper Actuation of Safety-related Equipment

                                                           SSINS No.: 6835 
                                                              IN 85-51 

                                UNITED STATES
                        NUCLEAR REGULATORY COMMISSION
                    OFFICE OF INSPECTION AND ENFORCEMENT
                           WASHINGTON, D.C. 20555

                                July 10, 1985

Information Notice No. 85-51:   INADVERTENT LOSS OR IMPROPER ACTUATION OF
                                   SAFETY-RELATED EQUIPMENT 

Addressees: 

All nuclear power reactor facilities holding an operating license (OL) or a 
construction permit (CP). 

Purpose: 

This information notice is provided to alert licensees of potentially 
significant reactor safety problems that may be a byproduct of the normal 
practice of removing fuses or of opening circuit breakers for personnel 
protection during maintenance and plant modification activities. The reactor
safety concern may result when the effects of electrical power interruption 
on all circuits powered by the fuse or breaker are not fully reviewed in 
advance. Errors in the review have resulted in unknowingly disabling safety 
systems and also have caused inadvertent actuation of safety systems. It is 
suggested that recipients review this information for applicability to their
facilities and consider actions, if appropriate, to preclude similar 
problems at their facilities. However, suggestions contained in this 
information notice do not constitute NRC requirements; therefore, no 
specific action or written response is required. 

Description of Circumstances: 

At Susquehanna Unit 2 on July 9, 1984 with the plant at approximately 20% of
full power electricians removed two dc-control power fuses for personnel 
protection during modifications involving the core spray isolation logic. 
The electricians believed that removing these fuses would provide the 
nearest local blocking-point protection needed while performing the 
modification. However, the fuses that were removed were considerably 
"upstream" of the local blocking point and the following situations resulted 
from this improper action: 

1.   Signals to start the pumps and position valves for the A loop of the 
     core spray system were lost. 

2.   One of the diesel generators would not have received a "Start" signal 
     from the Division 1 core spray logic that is provided for a 
     loss-of-coolant accident (LOCA) condition associated with Unit 2. 



8507090268 
.

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3.   The A and C instrumentation channels, sensing reactor water level and 
     drywell pressure, were made inoperable. Because of this, the residual 
     heat removal system and high pressure injection system would not have 
     received an actuation signal from those channels in the event of an 
     accident. However, the B and D channels remained functional. 

4.   A partial isolation signal for drywell cooling was generated. 

5.   The load shedding feature of the A and C 4160 V ac essential buses 
     associated with Units 1 and 2 were disabled, and the instrument air 
     compressors for Unit 2 would not have tripped if a LOCA condition had 
     existed for Unit 2. 

As a result of this event, the licensee instituted training sessions for 
personnel. The training sessions emphasized review and analysis of the 
circuits involved in all current and future construction work orders at the 
Susquehanna facility and included a human factors analysis focusing on the 
adequacy of the status switch features for the core spray system and other 
safety-related systems. 

Discussion: 

Following the event at Susquehanna Unit 2, the NRC conducted a search for 
other licensee event reports (LERs) from 1981 through 1984 that had similar 
cause and effect. This search resulted in the identification of five 
additional events which may be indicative that the problem is widespread. 
The events described in these reports are briefly summarized in Attachment 
1. The event described above and those summarized in Attachment 1 illustrate 
how the practice of removing fuses may result in actuation or disabling of 
safety-related equipment during any mode of plant operation. At the time the
fuses were removed, the involved plant personnel were unaware of the 
resulting actuation and inoperabilities. Similar situations could occur when
electrical circuits are de-energized by operating circuit breakers for 
personnel protection. 

The practice of de-energizing circuitry in order to provide plant personnel 
with appropriate protection is unavoidable. Corrective and preventive 
actions by licensees have emphasized the following items: identification of 
effects on plant equipment or systems, independent verification of the 
evaluation of effects, and utilization of the nearest local fuse or circuit 
breaker to minimize the number of systems affected. 
.

                                                              IN 85-51     
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                                                              Page 3 of 3  

No specific action or written response is required by this information 
notice. If you have any questions about this matter, please contact the 
Regional Administrator of the appropriate regional office or this office. 


                                   Edward L. Jordan Director 
                                   Division of Emergency Preparedness 
                                     and Engineering Response 
                                   Office of Inspection and Enforcement 

Technical Contact:  V. D. Thomas, IE
                    (301) 492-4755

Attachments:
1.   Earlier Events Similar to the One at Susquehanna
2.   List of Recently Issued IE Information Notices
.

                                                              Attachment 1 
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                                                              July 10, 1985 
                                                              Page 1 of 2  

                 EARLIER EVENTS SIMILAR IN NATURE TO THE ONE
                               AT SUSQUEHANNA

Surry Station, September 1981 

In this event, an electrician was attempting to remove a battery in the 
plant's smoke, detector system. The electrician did not wish to leave 
energized wiring exposed and therefore he removed a line, fuse. This action 
disabled the smoke detector panel that provides early detection of fires, 
thereby introducing the potential for damage of safety-related equipment. 

The licensee attributed the cause of this event to personnel error in that 
the electrician did not realize that removing the line fuse would disable 
the smoke detector panel. Corrective action taken to prevent recurrence of 
this event was to revise the labeling of the smoke detector battery chargers 
and associated circuit panels with a caution tag. 

Oyster Creek Station, December 1981 

While performing maintenance activities to repair a faulty electromatic 
relief valve pressure switch, dc-control power fuses were removed, resulting
in the inoperability of one trip system in the automatic depressurization 
system (ADS). The licensee reported that the cause of the loss of ADS trip 
system redundancy was the removal of the power fuses by plant personnel, 
without realizing the consequences on the ADS control logic circuitry. 
However, had a plant condition been present that required the operation of 
the ADS, the redundant trip system would have actuated the four remaining 
relief valves to depressurize the reactor system. 

To prevent recurrence of this reportable occurrence, the licensee 
incorporated it in the required reading program for Shift Operations 
Supervisors and Instrument Department Personnel. Additionally, the power 
fuses that defeat the redundancy of the ADS have been identified with a 
warning label. 

Sequoyah Unit 1, September 1982 

This licensee reported that during modifications to train "B" of the 
solid-state protection system (SSPS), the power fuses were removed to 
facilitate work on the output relays. This caused the train "B" reactor heat
removal (RHR) suction valve to close rendering that system inoperable. A 
review of the drawings associated with the SSPS showed that the power supply
to the output relays also supplied power to a relay that operates the RHR 
suction valve. When this relay is de-energized, the valve automatically 
closes. The operator immediately returned the system to normal operating 
conditions. 

A change was made to the facility work plan covering SSPS modification to 
inform operators that removal of the power fuses isolates the associated 
train of the RHR suction valve. The licensee also reports that caution signs
were placed near the location of the fuses in the SSPS cabinets. 
.

                                                              Attachment 1 
                                                              IN 85-51     
                                                              July 10, 1985 
                                                              Page 2 of 2  

Diablo Canyon Unit 1, May 1983 

The event at Diablo Canyon Unit 1 during May 1983 was similar to the events 
discussed above, in that personnel at the plant removed power fuses to 
perform work activity. This action resulted in disabling of radiation 
monitoring equipment. 

To prevent recurrence, plant personnel have been instructed to ensure that 
all effects on plant equipment are known and recognized before approving 
clearances for work activity. 

Susquehanna Unit 1, April 1984 

This earlier event at Susquehanna Unit 1 also was caused by removing power 
fuses for personnel protection. Plant personnel removed two fuses associated
with the primary containment isolation logic for Unit 2 to perform a 
modification for the logic circuitry. This resulted in the actuation of a 
false high drywell pressure signal, which, in turn, actuated the common 
control room emergency outside air supply and standby gas treatment systems.
The licensee later discovered that an improperly placed wire jumper in 
conjunction with fuse removal actually caused the false actuation. 
Subsequently, the wire jumper was installed properly. 

To prevent recurrence of this event, the subject work activity and 
associated wiring error were reviewed with the work crew involved. During 
this review the licensee also instructed personnel to review and verify 
circuitry before de-energizing power sources to equipment scheduled for 
maintenance or modification. 
Page Last Reviewed/Updated Tuesday, November 12, 2013