05000354/LER-2009-005
| Docket Number | |
| Event date: | 05-26-2009 |
|---|---|
| Report date: | 07-23-2009 |
| Reporting criterion: | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications |
| 3542009005R00 - NRC Website | |
PLANT AND SYSTEM IDENTIFICATION
General Electric — Boiling Water Reactor (BWR/4) Emergency Onsite Power Supply System — EIIS Identifier {EK}* Diesel Generator — EIIS Identifier {DG} *Energy Industry Identification System {EIIS} codes and component function identifier codes appear as {SS/CCC}
IDENTIFICATION OF OCCURRENCE
Event Date: May 26, 2009 Discovery Date: May 26, 2009
CONDITIONS PRIOR TO OCCURRENCE
Hope Creek was in Operational Condition 1 at 100% core thermal power (CTP). No other structures, systems or components contributed to the event.
DESCRIPTION OF OCCURRENCE
At 0800 on May 26, 2009, the A EDG {EK/DG} was declared inoperable for installation of a design change to the EDG rectifier section. This required entry into TS 3.8.1.1 action b for one EDG out of service. The action statement requires performance of SR 4.8.1.1.1.a within one hour and at least once every 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> thereafter.
SR 4.8.1.1.1.a was performed satisfactorily at 0828 on May 26, 2009.
The usual control room practice is for the control room supervisor (CRS) to commence the electronic monitoring of the performance in the computer and initiate attachment 3z of HC.OP-DL.ZZ-0026, "Surveillance Log". The control room crew would also set a timer as a reminder for the SR performance.
Neither the electronic tracking system nor the timer were used for this SR.
Tags were released from the A EDG at 1240 and preparations were made to perform the maintenance run on the EDG. The A EDG was successfully started at 1352 and secured at 1403. The A EDG was placed into service for the operability test at 1526 at which point it was determined that the EDG would not load above 600 kW. The control room crew focused on this emergent issue and did not remember to perform SR 4.8.1.1.1.a prior to 1628.
The control room crew was relieved by the on-coming crew. The tracking mechanism for performing SR 4.8.1.1.1.a was not discussed. At 2000 the night shift CRS phoned the day shift CRS at home and inquired about the performance of SR 4.8.1.1.1.a and was informed that it was performed in the morning. The night shift CRS immediately performed SR 4.8.1.1.1.a at 2008 and completed it at 2014 on May 26, 2009.
�
SAFETY CONSEQUENCES AND IMPLICATIONS
Since offsite power sources were continually available during this time, and all other EDGs were operable, there was no impact to the health and safety of the public.
A review of this event determined that a Safety System Functional Failure (SSFF) has not occurred as defined in Nuclear Energy Institute (NEI) 99-02.
CAUSE OF OCCURRENCE
The cause of this event was that the control room crew was distracted from the performance of the SR due to several factors:
(1) Assumption of the CRS that the EDG would be returned to service before the SR would need to be performed.
(2) The emergent malfunction of the EDG's inability to accept load.
(3) The control room crew not using any of the aids available to track the next performance of the SR, other than a notation in the LCO log for the time of the next performance of the SR.
In addition, procedure OP-HC-108-115-1001, "Operability Assessment And Equipment Control Program", is the administrative procedure for entrance and exit into active and tracking TS action statements for inoperable equipment. Procedure guidance is lacking for repetitive TS required surveillance actions or directing a tracking mechanism. Effective guidance would direct or reference the attachment 3z of HC.OP DL.ZZ-0026, "Surveillance Log". This attachment is initiated for SRs that are on an increased frequency due to a TS Action Statement so that the control room crew is aware of the increased frequency requirement and is reminded of the next required performance. The attachment is maintained by the control room for this purpose.
HC.OP-DL.ZZ-0026 Note 3.6 describes the use of attachment 3z "Action Statement Surveillance" which is a generic action statement surveillance sheet. This note states the attachment is to be placed in service by the SM/CRS to satisfy increased surveillances required by TS action statements. Either the 8-hour or 1-hour format may be used, depending on the action statement requirements. Attachment 3z was not implemented by the control room crew.
The CRS made a note in the addendum sheet of the TS action statement log that the next performance of the SR was 1628. Due to the emergent activities regarding the EDG, the CRS did not remember that the SR was required to be performed.
PREVIOUS OCCURRENCES
A review of the corrective action program (CAP) items for the past three years was conducted. There were no other instances noted where a LCO Action Statement SR check was missed due to not properly tracking the recurring performance requirements.
CORRECTIVE ACTIONS
The following corrective actions have been either taken or identified for this event (CAP number 20416830):
(1) Operations Management discussed the performance gaps associated with this event with the CRS and the control room crew.
(2) Operations will revise procedures to implement a SR performance tracking system for SRs that have an increased frequency.
(3) Issued a temporary standing order (TSO) for the CRS to initiate attachment 3z of HC.OP-DL.ZZ 0026(Q) for EDG TSs and to brief the operators on increased SR frequency. Operators to track the SR using attachment 3z. (TSO 2009-14 issued 5-27-09) (4) Issued TSO (2009-14) to direct implementation of increased SR frequency tracking system using a highly visible status board.
(5) The control room crews conducted a 'stand down' for each crew to review and discuss this event with regards to control room teamwork and performance.
COMMITMENTS
This LER contains no commitments.
-NRC FORM 366A (9-2007) PRINTED ON RECYCLED PAPER