05000311/LER-2004-005
| Event date: | 05-27-2004 |
|---|---|
| Report date: | 07-26-2004 |
| Reporting criterion: | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications |
| 3112004005R00 - NRC Website | |
PLANT AND SYSTEM IDENTIFICATION
Westinghouse - Pressurized Water Reactor Safety Injection System {BQ/} * Engineered Safety Features Actuation System {JE/} * Energy Industry Identification System (EIIS) codes and component function identifier codes appear in the text as {SS/CCC).
IDENTIFICATION OF OCCURRENCE
Event Date: May 27, 2004 Discovery Date: May 27, 2004
CONDITIONS PRIOR TO OCCURRENCE
The plant was in Mode 4 (Hot Shutdown), 0% power, at the time of the event.
DESCRIPTION OF OCCURRENCE
Salem Unit 2 entered Mode 4 (ascending) at 0140 hours0.00162 days <br />0.0389 hours <br />2.314815e-4 weeks <br />5.327e-5 months <br /> on May 27, 2004 during restart from a forced outage to replace a failed 230VAC vital transformer. At approximately 0630, Operations personnel observed that the Automatic Safety Injection (Auto SI) block {JE/} {BQ/} blue light was illuminated on Reactor Protection Logic Panel, indicating that Automatic Safety Injection (SI) function was blocked. The Automatic SI function is required to be operable prior to entering Mode 4 per Technical Specification (TS) 3.3.2.1, Table 3.3-3. Integrated Operating Procedure 10P-2, step 5.2.10 re-instates the Auto SI function as the plant transitions from Cold Shutdown to Hot Standby.
This was brought to the attention of the on-watch licensed Control Room Supervisor (CRS) who immediately took action to restore Automatic SI functionality in accordance with Operating Procedures.
Automatic SI was returned to OPERABLE status at 0635. TS 3.0.3 was entered at 0630 and exited at 0635.
Salem Unit 2 was out of compliance with TS 3.3.2.1, Table 3.3-3 from the point of Mode 4 entry (0140 hours0.00162 days <br />0.0389 hours <br />2.314815e-4 weeks <br />5.327e-5 months <br /> on May 27, 2004) until the restoration of Auto SI logic (0635 hours0.00735 days <br />0.176 hours <br />0.00105 weeks <br />2.416175e-4 months <br /> on May 27, 2004).
CAUSE OF OCCURRENCE
The apparent cause of the occurrence was the lack of formal independent verification to ensure TS requirements are met prior to changing plant modes. A contributing cause was the CRS who signed off the step of the 10P misread the step and initialed for Automatic SI Block being ACTIVE, contrary to procedure requirements. Multiple personnel reviewed IOP-2 subsequent to commission of the initial procedure error, but all failed to recognize and correct it, therefore allowing the Mode change to occur.
Another contributing factor to this event is the step to UNBLOCK Automatic SI function is inappropriately sequenced in IOP-2.
PREVIOUS OCCURRENCES
A review of LERs at Salem and Hope Creek Generating Stations for the years 2001 through present identified the following prior occurrence. Hope Creek LER 354/ 2002-007, dated November 13, 2001, reported Core Spray discharge line alarms inoperable. The apparent cause of this event was less than adequate instructions for the restoration and system lineup verification contained in the core spray pump inservice testing procedure. The corrective actions associated with this LER were specific to the core spray inservice test procedure and similar procedures. Those corrective actions would not have prevented this event.
SAFETY CONSEQUENCES AND IMPLICATIONS
There was no impact to the health and safety of the public. Reactor Coolant System (RCS) pressure was approximately 315 psi and RCS temperature was approximately 200 degrees F. Plant parameters were less than the required setpoints for Hi Steam Line Flow coincident with Tavg Lo-Lo or Steam Line Pressure Low, RCS Pressure Low, Steam Line Delta-P and Containment Hi Pressure such that the required Automatic SI feature would not have been required in Mode 4. Containment Isolation Phase "A" for Auto SI is required in Mode 4, but there were no conditions that warranted this actuation during the approximate 5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> when the Auto SI was not reinstated. Additionally, the Pressurizer Over Pressure System (POPS) was armed to protect the RCS boundary integrity.
TS 3.0.3 was entered at approximately 0630 hours0.00729 days <br />0.175 hours <br />0.00104 weeks <br />2.39715e-4 months <br /> after the Auto SI Block was discovered. This action was required because both trains of Automatic Safety Injection were inoperable. Both trains of Auto SI are required operable in Modes 1 through 4. The TS 3.0.3 action statement was exited immediately after both trains of SI were reinstated at approximately 0635 hours0.00735 days <br />0.176 hours <br />0.00105 weeks <br />2.416175e-4 months <br />.
A review of this event determined that a Safety System Functional Failure (SSFF) as defined in the Nuclear Energy Institute (NEI) 99-02 had not occurred.
CORRECTIVE ACTIONS:
1. The outage CRS immediately notified the on-duty CRS of the condition. TS 3.0.3 was entered since both trains of SI were not operable. Actions were immediately taken to reinstate Auto SI. TS 3.0.3 was exited at 0635 after Auto SI interlock had been re-established.
2. Salem Operations performed a stand-down to discuss this and other events. The stand-down was an interactive discussion between Operation's management team and the shift operators.
3. IOP-2, Step 5.2 will be revised to remove ambiguity or confusion in intent. Additionally, an independent verification / additional check of Auto SI Block status to IOP-2, Attachment 1, Section 4.3 will be added.
4. An assessment of managing administrative requirements associated with Mode ascension 10Ps at Salem and Hope Creek Station will be performed to determine if separating administrative requirements from actual operating steps is warranted.
COMMITMENTS
The corrective actions cited in this LER are voluntary enhancements and do not constitute commitments.