05000335/LER-2001-004
| Event date: | |
|---|---|
| Report date: | |
| Reporting criterion: | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications |
| 3352001004R00 - NRC Website | |
Description of the Event
On April 28, 2001, at 1327 hours0.0154 days <br />0.369 hours <br />0.00219 weeks <br />5.049235e-4 months <br />, St. Lucie Unit 1 entered Mode 2 following the spring 2001 refueling outage (SL1-17). Contrary to Technical Specification 3.6.4.2, the [EIIS:BB:RCB] 1B hydrogen recombiner was not in service during the mode change.
On April 20, 2001, at 1102 hours0.0128 days <br />0.306 hours <br />0.00182 weeks <br />4.19311e-4 months <br />, equipment clearance order (ECO) 1-01-04-104 was initiated to de-energize the 1B hydrogen recombiner to allow for a post test megger following scheduled maintenance during the SL1-17 refueling outage. Electrical maintenance completed the post test megger and released control of the ECO on April 22, 2001 at 1945 hours0.0225 days <br />0.54 hours <br />0.00322 weeks <br />7.400725e-4 months <br />. The ECO was turned over to the night shift crew to release.
The release review and approval were completed by the night shift senior reactor operator (SRO) on April 22, 2001 at 1946 and 2029 hours0.0235 days <br />0.564 hours <br />0.00335 weeks <br />7.720345e-4 months <br />, respectively. In the early morning hours of April 23, 2001, prior to the restoration of the 1B hydrogen recombiner, the ECO was inadvertently updated in the equipment out of service (EGOS) log as being released when in fact it had not been physically released in the field.
The 1B hydrogen recombiner was erroneously called back into service on April 23, 2001 at 1315 hours0.0152 days <br />0.365 hours <br />0.00217 weeks <br />5.003575e-4 months <br /> with the ECO still hanging.
On April 28, 2001, at 1327 hours0.0154 days <br />0.369 hours <br />0.00219 weeks <br />5.049235e-4 months <br />, the plant entered Mode 2. On April 29, 2001, at approximately 1345 hours0.0156 days <br />0.374 hours <br />0.00222 weeks <br />5.117725e-4 months <br />, the work control center supervisor discovered that ECO 1- 01-04-104 had not been released in the field. Actions were immediately initiated to release the ECO and restore the 1B hydrogen recombiner to service. The release of ECO 1-01-04-104 was completed on April 29, 2001, at 1430 hours0.0166 days <br />0.397 hours <br />0.00236 weeks <br />5.44115e-4 months <br /> and the 1B hydrogen recombiner was made operable and declared back in service. The lA hydrogen recombiner remained in service during the event.
Cause of the Event
The cause of this event was personnel error in that the EOOS log was erroneously updated to indicate that the ECO for the 1B hydrogen recombiner had been released.
Procedural weaknesses also contributed to this event.
At some point after the EOOS entry for the 1B hydrogen recombiner was updated, the ECO was physically misplaced in the work control center. The ECO paperwork was located in a file cabinet that was designated as a storage area for clearances that have been written but never used. Procedure ADM-09.08, "Operations In-Plant Equipment Clearance Orders," does not have any specific requirements to track the whereabouts of an ECO but relies upon teamwork, communications, and several hand-offs to ensure that an ECO is both executed, released, and closed out properly. Although the ECO paperwork was misplaced, that alone would not have effected the outcome of the event. The electronic copy of the ECO was still intact and located in the ECO database.
In addition, neither procedure 0-NOP-100.01, "Equipment Out Of Service," nor ADM- 09.08 requires that the individual responsible for updating the EOOS log is required to review the ECO paperwork to ensure that the release was completed. Training presented another weakness. A formal training program is not in place to ensure that the various personnel that man the work control center during outages are completely familiar with the responsibilities and the functions for all positions.
Analysis of the Event
This event is reportable under 10 CFR 50.73(a)(2)(i)(B) as operation or a condition prohibited by Technical Specifications because entry into an operational mode was FACILITY NAME (1) NUMB ( BER ER 1 2) LER NUMBER (6) PAGE (3) St. A Lucie Unit 1 05000335 made when the limiting conditions for operation (LCO) A were not met. A Technical Specification 3.6.4.2 states that two independent containment hydrogen recombiner systems shall be OPERABLE in Modes 1 and 2. A Contrary to this requirements, Mode 2 was entered with only the 1A hydrogen recombiner in service.
Analysis of Safety Significance Post accident use of the hydrogen recombiners is not a time critical function and their use is not required for many hours after a design bases event. A Although the 1B hydrogen recombiner was out of service during entry into Mode 2, A it was only inoperable due to its breaker being tagged in the open position; a condition that would have been easily recoverable. A Additionally, the 1A hydrogen recombiner was available during the entire event. A Based on this, A FPL concludes that this condition had no adverse impact on the health and safety of the public.
Corrective Actions
1. Upon discovery, A steps were taken to immediately release the ECO on the hydrogen recombiner and return it to service.
Long-term Corrective Actions:
1. Several changes are in development for procedure ADM-09.08, A "Operations In-Plant Equipment Clearance Orders," to clarify ECO procedural requirements and minimize the procedural weaknesses identified by this event.
A These changes include:
- Revising the procedural steps that describe the sequence of each individual responsibility from preparation of an ECO to the close of the ECO.
- Separate the EOOS log update box of the ECO cover sheet and the release review box to ensure it is understood that these are clearly separate steps.
- Revise section 6.12, A "Clearance Order Removal and Restoration," to ensure that the individual responsible for updating the EOOS log reviews the status of the ECO to ensure it is released prior to updating.
2. Procedure 0-NOP-100.01, A "Equipment Out of Service," is being revised to ensure that the individual responsible for updating the EOOS log reviews the status of the ECO to ensure it is released in the field prior to updating the log.
3. Operations will ensure that individuals assigned to the key operational positions in the work control center are trained on their responsibilities and functions prior to the next refueling outage.
FACILITY NAME (1) DOUCE' NUMBER (2) LER NUMBER (6) PAGE (3) St.
� Lucie Unit 1 05000335
Additional Information
Failed Components Identified Minimum Shut Down Cooling Loop None Similar Events Operation Requirement Violation.