05000335/LER-2010-002

LER-2010-002, Opened ECCS Boundary Door in Violation of Identified Compensatory Measures

Docket Number
Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
3352010002R00 - NRC Website

FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

Description of the Event

On April 4, 2010, St. Lucie Unit 1 was operating in Mode 1 at 100 percent power when Operations requested a copy of the breach permit that was posted on the boundary door to the ECCS ventilation area that was being used to support flushing and draining of a temporary air conditioning unit. Upon review of the breach permit it was discovered the breach permit approval process had not been completed. Identified compensatory measures pertaining to opening and closure of doors, communications between posted individuals and control room operators, closure of doors during work stoppage, unattended doors, etc. had not been met, thereby compromising the ECCS [EIIS: AB] area ventilation pressure boundary. For the period of time the door was opened the ECCS Area Ventilation System could not perform its safety related function.

Cause of the Event

The cause of the event was determined to be a failure to follow procedure, inadequate use of human performance tools and a lack of supervisory oversight. Contributing to the event was a lack of training on the Breach Permit Process.

A new supplemental Maintenance Supervisor, unfamiliar with the breach permit process, was directed to obtain a breach permit for the boundary door to the ECCS ventilation area in the East Pipe Tunnel of the radiological controlled area (RCA.) Following notification from System Engineering that their part of the process was completed the individual retrieved the permit and posted it at the door. However, the next step of the approval process required the implementing group supervisor to approve/concur with the breach permit and obtain Operations Department approval prior to posting the permit and initiating required compensatory measures.

The missed step in the breach permit process contributed to the compensatory measures not being reviewed or initiated which went un-noticed by his supervisor and the night shift supervisor during turnover from dayshift. This was not detected until a request for a copy of the permit was made by Operations Department Supervision.

Analysis of the Event

Failure to follow the established breach permit process, inadequate use of human prevention tools, lack of training and oversight by Supervisory personnel for an employee in a first time evolution, resulted in compromising the ECCS area ventilation pressure boundary. For the period of time the door was opened the ECCS Area Ventilation system could not perform its safety related function.

In accordance with NUREG 1022, Rev. 2, an event which could have prevented the fulfillment of a safety function must be reported in an Licensee Event Report (LER) per 10 CFR 50.73(a)(2) (v) (B). An LER is also required in accordance with 10 CFR 50.73(a)(2) (i)(B) since the condition existed for a time longer than permitted by the technical specification, even if the condition was not discovered until after the allowable time had elapsed and the condition immediately rectified.

FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3) Analysis of Safety Significance When the door is open the ECCS area will not be isolated from the reactor auxiliary building (RAB). This would prevent the ECCS ventilation system from maintaining a slightly negative pressure in the ECCS area with respect to the surrounding areas of the RAB. With the door open, radioactive materials leaking from the ECCS equipment following a loss-of-coolant accident (LOCA) may not be filtered prior to reaching the environment. This is contrary to the assumed operation of the system and the resultant effect on offsite dosage calculations assumed in the accident analysis.

From the time the door was propped open to the time that it was closed, the ECCS Area Ventilation System could not perform its safety related function. However, the probability of a LOCA during the 39 hours4.513889e-4 days <br />0.0108 hours <br />6.448413e-5 weeks <br />1.48395e-5 months <br /> in which the ECCS Area Ventilation System would have been unable to perform its safety function is small; therefore, the associated safety significance of this condition is small.

Corrective Actions

The corrective and supporting actions are entered into the Site Correction Action Program (CAP). Any changes to the proposed actions will be managed under CAP.

1.Actions addressing individual human performance issues are complete.

2.Training to the employees on First Time Evolution, will be developed and implemented for the breach permit process and incorporate a policy that only trained individuals will be allowed to obtain the permits.

3.Incorporate a step into the generic breach work order that requires only trained individuals to sign if a breach permit is needed.

Similar Events A review of condition reports for the past 2 years for similar issues regarding a lack of Breach Permit understanding did not identify any similar events.

Failed Components

None