On June 20, 2003, a differential pressure instrument isolation valve was found isolated, rendering the instrument inoperable. The other three differential pressure switches that provide the one-out-of-two-twice logic to direct injection of the Low Pressure Coolant Injection system to the intact reactor recirculation pipe during a loss of coolant event were verified to be operable. The surveillance in progress was completed, the switch was tested satisfactorily and the manifold valves were returned to the in-service position.
A work history review identified that the valve was left closed following a March 24, 2003, surveillance. A search of the work history involving the individuals that performed the March 24, 2003, surveillance did not identify any discrepancies.
The safety significance of this event was minimal. The remaining three switches were operable and capable of providing the required logic signal. Therefore, there was no loss of safety function associated with this event.
The root cause for this event is a breakdown in the use of human performance tools.
Corrective actions include a revision to Human Performance training and development of a human performance improvement program for the Instrument Maintenance Department. |
FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6 PAGE Say Quad Cities Nuclear Power Station Unit 2 05400265 (if more space Fs reqdred, use additional ociples of NRC Forth 356AX1T)
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
Low Pressure Coolant Injection Differential Pressure Instrument Inoperable due to Misposition of Instrument Valve A. � CONDITION PRIOR TO EVENT Unit: 2 � Event Date: March 24, 2003 � Event Time: 2013 hours0.0233 days <br />0.559 hours <br />0.00333 weeks <br />7.659465e-4 months <br /> Reactor Mode: 1 � Mode Name: Power Operation � Power Level: 100% Power Operation (I) - Mode switch in the RUN position with average reactor coolant temperature at any temperature.
E. � DESCRIPTION OF EVERT On June 20, 2003, during performance of a functional test on the Low Pressure Coolant Injection (LPCI) (B0] recirculation riser differential pressure switches [63], it was discovered that the high-side isolation valve (ISV) for one of the differential pressure switches was closed, rendering the instrument inoperable.
There are four of these differential pressure switches, and they provide a one-out- of-two-twice logic for the LPCI Loop Select System. This system directs the LPCI system to inject to the intact reactor recirculation pipe during a loss of coolant event.
The positions of the manifold valves on the other three switches were inspected, and the valves were found to be in their proper positions. Also, it was determined that no work was performed on these switches between March 24, 2003 and June 20, 2003.
Therefore, with the other three switches operable, the function was not lost.
The surveillance in progress was completed, the switch was tested satisfactorily and the manifold valves were returned to the in-service position.
A work history review identified that the last work performed that would have affected the mispositioned valve was completed on March 24, 2003; therefore, this event in reportable as a condition prohibited by Technical Specifications, since the instrument was inoperable longer than the allowed outage time.
A review of the March 24, 2003 surveillance test found that the steps for restoration and verification of proper restoration were signed. The two individuals who performed the surveillance on March 24, 2003, could not be interviewed, as they were no longer employed with Exelon Generation Company, LLC. A search of the work history involving these two individuals for any safety related work where they acted alone in the field or together with no other support was conducted. This review went back one year. No discrepancies were identified.
Immediate Actions
and Unit 2 were verified to be in the correct position.
All Instrument Maintenance crews were briefed on this issue as they came on shift.
Corrective Actions to be Completed Instrument Maintenance Department UMW Management will review and revise the IMD Human Performance Training Program and Dynamic Learning Activities to include more stringent guidelines and more stringent pass/fail criteria.
IMD Management will conduct paired field observations and provide remediation to personnel upon discovery of inadequate performance in use of the human performance tools.
IMD Management will develop a Human Performance improvement plan to include IND first-line supervisor performance.
F. PREVIOUS OCCURRENCES
No reportable events were identified during the last two years that involved a failure in the IMD to utilize human performance tools.
G. COMPONENT FAILURE DATA
There were no component failures associated with this event.
BAC FORM 366A 17-2001)
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| 05000265/LER-2003-001 | Failure to Reset Residual Heat Removal Injection Valve Containment Isolation Signal due to Inadequate Procedural Development and Review | 10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | | 05000254/LER-2003-001 | Reactor Shutdown due to Reactor Head Vent Steam Leak Constituting Pressure Boundary Leakage | 10 CFR 50.73(a)(2)(i)(A), Completion of TS Shutdown | | 05000265/LER-2003-002 | 1 of 4 | | | 05000254/LER-2003-002 | xe .°.~n® •
Nuclear Exelon Generation Company, LLC
Quad Cities Nuclear Power Station
22710 206th Avenue North
Cordova, IL 61242-9740
www.exeloncorp.com
February 19, 2004
SVP-04-003
U. S. Nuclear Regulatory Commission
ATTN: Document Control Desk
Washington, D.C. 20555
Quad Cities Nuclear Power Station, Unit 1
Facility Operating License No. DPR-29
NRC Docket No. 50-254
Subject: R Licensee Event Report 254/03-002, Revision 1, "Mode Change with Core
Spray Loop Inoperable due to Failure to Properly Fill and Vent"
Enclosed is Licensee Event Report (LER) 254/03-002, Revision 1, "Mode Change with Core
Spray Loop Inoperable due to Failure to Properly Fill and Vent," for Quad Cities Nuclear
Power Station, Unit 1.
The original report was submitted on August 1, 2003, in accordance with the requirements of
the Code of Federal Regulations, Title 10, Part 50.73(a)(2)(i)(B), which requires reporting of
any operation or condition which was prohibited by the plant's Technical Specifications.
This revision is being submitted to include additional system venting events at Quad Cities
Nuclear Power Station in the "Previous Occurrences" section. These additional events were
not previously included since they did not share the same underlying root cause, but for the
sake of completeness are being added at this time.
Should you have any questions concerning this report, please contact Mr. W. J. Beck at
(309) 227-2800.
Respectfully,
othy J. Tulon
ite Vice President
Quad Cities Nuclear Power Station
cc: R Regional Administrator — NRC Region Ill
NRC Senior Resident Inspector — Quad Cities Nuclear Power Station
NRC FORM 366 6 U.S. NUCLEAR REGULATORY
(7-2001)
)
COMMISSION
LICENSEE EVENT REPORT (LER)
APPROVED BY OMB NO. 3150-0104 6 EXPIRES 7-31-2004
Estimated burden per response to comply with this mandatory information collection request: 50
hours. o Reported lessons learned are incorporated into the licensing process and fed back to
industry. Send comments regarding burden estimate to the Records Management Branch (T.6 E6),
U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by Internet e-mail to
bis1@nrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202
(3150-0104), Office of Management and Budget, Washington, DC 20503. If a means used to impose
Information collection does not display a currently valid OMB control number, the NRC may not
mruli int nr snonsnr and a nprsnn is not rennin:4 to rpsrinnd to tha ininrmatinn collection
1. FACILITY NAME
Quad Cities Nuclear Power Station Unit 1
2. DOCKET NUMBER
05000254
3. PAGE
1 of 4
4.-rrrLE o Mode Change with Core Spray Loop Inoperable due to Failure to Properly Fill and Vent | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | | 05000265/LER-2003-003 | | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications | | 05000265/LER-2003-004 | Reactor Shutdown due to Degraded Reactor Steam Dryer as a Result of Increased Steam Velocities from Extended Power Uprate | |
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