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At 0333 hours on April 25, 1988, at 350 degrees and 495 psia, the controlswitches for both trains of Motor Driven Auxiliary Feedwater (MDAFW) pumps andtrain A Supplementary Leak Collection and Release System (SLCRS) fan were left inpull-to-lock (PTL) ''aring a change from Mode 4 (Hot Shutdown) to Mode 3 (HotStandby).

Root cause for each event was operator error. Immediate corrective action by the

operator was to walk down the main control boa,.ds to assure equipment that wasrequired to be operable was operabJe. The Technical Specifications were reviewedto ensure any equipment that was not required to be operable in Mode 3 wasspecifically covered by a procedure step or was verified to be operable. Asaction to prevent recurrence, on-thift personnel have been briefed on properreview of equipment status prior to uode changes. Guidance, in the form of aNight Order, has been provided to ensure that the appropriate log entries aremade wh a ver equipment ia placed in PTL. The plant heatup procedure wasmodified to sequence the Auxiliary Icedwater System alignment for systemoperabilley and to require a review of bypass annunciators prior to changingmob , ,

A and S MDAFW pomps were inoperable for approximately 4 and 6 hoursend the tw in A ELCRi fan was inoperable for about 9 hours, from the

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I. Description of Event

At 0333 hours on April 25, 1988, with the plant at 350 degrees Fahrenheit and495 psia, the control switches for both trains of Motor Driven AuxiliaryFeedwater (MDAFW) Pumps and train A Supplementary Leak Collection and ReleaseSystem (SLCRS) Fan were lef t in pull-to-lock (PTL) during a change from Mode4 (Hot Shutdown) to Mode 3 (Hot Standby).

The train A SLCRS Fan was placed in PTL at 0250 hours on April 25, in orderto perform a routine surveillance on the train B SLCRS Fan. While the trainA SLCRS Fan was in PTL, the train B SLCRS Fan was in service and running.The control switch for the train A SLCRS Fan was initially discovered to bein PTL at 0900 hours. Since the action statements of LCO 3.6.6.1 allowedhaving the control switch of one SLCRS fan in PTL, no immediate operatoraction was necessary in response to this event and it was decided to completethe surveillance.

After discovery of the control switch for the train A SLCRS Fan in PTL, awalkdown of the Main Control Boards was performed to ensure there was noadditional equipment required to be operable that was still inoperable. Thecontrol switch for the B MDAFW Pump was discovered to be in PTL atapproximately 0929 hours, during the walkdown of the Main Control Boards.Immediate operator action was to place the control switch for the train BMDAFW Pump in the AUTO position to comply with the requirements of theTechnical Specifications. A review of the incident indicated that the trainA MDAFW Pump had been in PTL during the mode change but was removed from PTLto feed the steam generators at approximately 0739.

The MDAFW control switches had been placed in PTL during the plant cooldown,which was initiated on April 15, as a convenience to the operators and sincethe AFW pumps were not required to be operable until entry into Mode 3.

The AFW system is normally used to maintain steam generator water levelduring plant heatup. Since little work had been done on the secondary sideof the plant during the shutdown, the Condensate System was being used tomaintain steam generator water level.

With their control switches in PTL, both MDAFW pumps and the train A SLCRSFan are incapable of automatically performing their intended safety function.

II. Cause of Event

The root cause for each event was operator error. In the case of the train A

SLCRS Fan, the system was placed in a condition requiring entry into LCOaction statement 3.6.6.1. However the action statement was never logged. In

the case of the MDAlW pumps, the pumps were not restored to operable statusprior to entry into a mode for which they were required. A contributorycause in the case of the AFW System is that the AFW System is made fullyfunctional in several steps during the plant heatup/ plant startup sequence.

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II. Cause of Event (Continued)

The MDAW pumps is usually used to adjust steam generator level during theplant heatup. During this evolution, AW valves are throttled to controlflow to the steam generators. These valves are required to be full open whenabove 10% Rated Thermal Power and are verified by surveillance procedureprior to exceeding this power level.

III. Analysis of Event

This Licensee Event Report (LER) is being submitted in compliance with10CFR50.73(a)(2)(1) in that the plant was not operated in accordance with theplant's Technical Specifications.

There were no safety consequences due to the inoperable systems as they wereinoperable only by being in manual operator control. Train B SLCRS was inservice and running during this event which satisfied the requirements of itsTechnical Specification. In addition, the control room operators were awarethat prompt operator action would be necessary to provide AW to the steamgenerators due to the throttled position of the AW control valves.

IV. Correctise Action

Upon discovery of the SLCRS Far. in PTL, a walkdown of the Main Control Boardswas performed to ensure thare was no additional equipment required to beoperable that wad still inoperable. This resulted in the discovery of theproblem with the MDAW pumps which was immediately corrected.

In addition an independent Technical Specification review was performed bytwo Senior Reactor Operators to ensure that any equipment not required to beoperable in Modes 3 and 4 but required in Modes 2 (Startup) and 1 (PowerOperation) was specifically covered by a procedure step or was verified to beoperable. No other violations were identified.

As action to prevent recurrence of a similar event, on-shift personnel havebeen briefed on proper review of equipment status prior to mode changes.Guidance, in the form of a Night Order, has been provided to OperationsDepartment personnel to ensure that an entry must be made in the Turnover Logwhenever equipment is placed in PTL, in addition to logging into theappropriate action statement. A change has been made to the plant heatupprocedure to sequence the AW system alignment for system operability andrequire a review of bypass annunciators prior to changing modes.

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IV. Corrective Action (Continued)

LER 86-004 discusses a mode change with a LC0 action statement still ineffect due to personnel error. The sequence of events and circumstancessurrounding LER 86-004 are not related to this LER in that the operator knewhe was in a LCO action statement, but incorrectly assumed that he wasexcluded from the requirements of LCO action statement 3.0.4. Therefore thecorrective action to have all Senior Reactor Operators review the event isconsidered adequate for LER 86-004, but not applicable to this event.

V. Additional Information

There have been three similar events of improper mode changes: LER 86-004,86-020, and 88-006. LER 86-004 was due to human error, while LER 86-020 wasdue to inadequate work control. LER 88-006 was due to procedural inadequacy.

EIIS Codes

Systems Component

Auxiliary Feedwater - BA Pump - PSupplemental Leak Collection and Fan - F

Release System - BH

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| G C # M M 384a e U S GPO iD66 0 624 538 466( e436

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veDRTHEAST UTILITIES o.nerai Ore,c.. . seioen street. seri'n. Connecticui,em o n, rc,a w w . w ,en .sww.i e.w.c cw. . P.O. BOX 270o,m acta w a wa, HARTFORD. CONNECTICUT 06141-0270

L L J. , .e u. i = =a c""', (203) 665 5000.:.....m.--

May 25, 1988MP-11864

Re: 10CFR50. 73(a) (2) (1)

U. S. Nuclear Regulatory CommissionDocument Control DeskWashington, D. C. 20555

Reference: Facility Operating License No. NPF-49Docket No. 50-423Licensee Event Report 88-016-00

Gentlemen:

This letter forwards the Licensee Event Report 88-016-00 required to besubmitted within thirty days pursuant to 10CFR50.73(a)(2)(1) in that theplant was not operated in accordance with the plant's TechnicalSpecifications.

Very truly yours,

NORTHEAST NUCLEAR ENERGY COMPANY

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Station SuperintendentMillstone Nuclear Power Station

SES/NDH:cjh

Attachment: LER 88-016-00

cc: W. T. Russell, Region IW. J. Raymond, Senior Resident Inspector

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