05000254/LER-2006-003
| Docket Numbersequential Revmonth Day Year Year Month Day Yearnumber No. N/A N/A | |
| Event date: | 05-14-2006 |
|---|---|
| Report date: | 11-20-2006 |
| Reporting criterion: | 10 CFR 50.73(a)(2)(iv)(A), System Actuation |
| 2542006003R01 - NRC Website | |
FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6 PAGE (3) Quad Cities Nuclear Power Station Unit 1 05000254 NUMBER NUMBER (If more space is required, use additional copies of NRC Form 366A)(17)
PLANT AND SYSTEM IDENTIFICATION
General Electric - Boiling Water Reactor, 2957 Megawatts Thermal Rated Core Power Energy Industry Identification System (EIIS) codes are identified in the text as [XX].
EVENT IDENTIFICATION
Unexpected start of the Division II Emergency Diesel Generator due to failure to open test switch.
A. CONDITION PRIOR TO EVENT
Unit: 1 Event Date: May 14, 2006 Event Time: 0957 hours0.0111 days <br />0.266 hours <br />0.00158 weeks <br />3.641385e-4 months <br /> Reactor Mode: 5 Mode Name: Refueling Power Level: 000%
B. DESCRIPTION OF EVENT
On May 14, 2006, at 0957 hours0.0111 days <br />0.266 hours <br />0.00158 weeks <br />3.641385e-4 months <br />, an unexpected start of the Unit 1 Division II Emergency Diesel Generator (EDG) [EK] occurred at Quad Cities Nuclear Power Station when the EDG control switch was put in the "AUTO" position. At the time of the event, Unit 1 was in an abnormal electrical lineup such that the Division II emergency 4KV bus was de-energized to allow testing of the Reserve Auxiliary Transformer (RAT). There are three test switches that are required to be open to allow the EDG to be in AUTO with the emergency bus de-energized without causing an automatic start of the EDG. The Operations crew believed that the previous crew had opened these switches. The previous crew had opened two of the switches, but had not realized that the third switch was required to be opened.
C. CAUSE OF EVENT
The root cause of this event was that the crews did not take prudent measures to ensure all activities in progress were integrated into their awareness of plant status. Operator performance could have been improved through both rigorous application of technical human performance behaviors and enhanced process barriers.
Numerous data points (shift logs, procedure in progress book, verbal turnover, Clearance Order (CO) checklist) were available to insure the crew understood plant status during turnover. Imprecise verbal information, inadequate review of the logs, and inadequate review of the procedures in progress, led to a situation where the EDG was inadvertently auto started.
A contributing cause of this event was the inappropriate use of the CO special instruction for the Ul EDG control switch for configuration control. The Unit Supervisor stated that the EDG control switch was put in the "AUTO" position per FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6 PAGE (3) (If more space is required, use additional copies of NRC Form 366A)(17) the turnover and the CO special instruction. The clearance and tagging procedure does not allow configuration control through special instructions.
Additional contributing causes of the event include the lack of an established policy/process for using or reviewing the Procedures-in-Progress (PIP) book, and inconsistent usage of Equipment Status Tags for heightening awareness of procedures in progress.
D. SAFETY ANALYSIS
The safety significance of this event was minimal. This event occurred while the unit was shut down for a refueling outage. The crew immediately recognized that the automatic start was inappropriate and shut down the EDG. The Division I EDG was operable throughout the event.
E. CORRECTIVE ACTIONS
An administrative procedure has been developed and implemented that governs use of the PIP book. In addition, the administrative procedure for the PIP book includes guidance concerning the use of Equipment Status Tags.
Technical Human Performance requirements and use of a questioning attitude have been reinforced through operations crew training.
The Shift Turnover Checklist has been revised to require documented review of the PIP book as part of the shift turnover process.
An Operations Standing Order has been issued clarifying expectations concerning the use of non-carded CO steps and special instructions/notes in COs, pending completion of a permanent procedure revision.
F. PREVIOUS OCCURRENCES
One similar non-reportable previous event at Quad Cities Station was identified.
On October 7, 2004, the 1A Residual Heat Removal Service Water (RHRSW) system was started following maintenance without a discharge flow path established. All of the heat exchanger isolation valves had been tagged closed but were not opened during the final clear. The pump was subsequently re-started two more times within a 10-minute span before it was determined that a discharge flow path had not been established.
The root cause of the event was that during the preparation of the Final Clear for an associated CO, the preparer and the reviewer both made inappropriate assumptions regarding the use of the CO procedure. In particular there were inappropriate assumptions about CO special instructions and configuration control using non carded steps. The Final Clear contained a special instruction concerning positioning of the heat exchanger valves. The Unit Supervisor recalled seeing a FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3) Quad Cities Nuclear Power Station Unit 1 05000254 NUMBER NUMBER (If more space is required, use additional copies of NRC Form 366A)(17) special instruction during authorization but did not remember to take positive action to ensure the special instruction would be performed. The CO was able to be fully completed without performing this instruction. Corrective actions included training on the procedural requirements regarding CO special instructions and the use of non-carded steps for configuration control.
The similarities between the October 7, 2004, event and the May 14, 2006, event relate to the misapplication of a special instruction/note; however, there are several differences between the events. The misapplication in the October 7, 2004, event related to CO development, as the CO Final Clear resulted in the plant being in an unacceptable configuration when completed. The use of non-carded steps for realignment was overlooked and only the special instruction/note was used for configuration control. In the May 14, 2006, event, there is no inherent deficiency in the note; the plant was in an acceptable configuration when the CO was completed. The misapplication was by the crew personnel invoking the special instruction to perform an action outside of procedure. The training performed for the October 7, 2004, event was not effective in preventing the May 14, 2006 event.
COMPONENT FAILURE DATA G.
There were no equipment failures associated with this event.