05000364/LER-2004-002

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LER-2004-002,
Docket Number
Event date:
Report date:
Reporting criterion: 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
3642004002R00 - NRC Website

Westinghouse -- Pressurized Water Reactor Energy Industry Identification Codes are identified in the text as [XX]

Description of Event

The design function of HV3096A, CCW from Evaporator Packages and H2 Recombiners, is to automatically close on a low-low CCW surge tank level and to isolate the safety related portion of the system from the non-seismic, non-safety related portion of the system. On April 7, 2004, with Unit 2 in Mode 5, HV3096A would not open from the Main Control Board and was opened using its manual operator. A caution tag was placed on the valve documenting the abnormal position, and a work order was written for failure of the valve to open. In Mode 5, an actual LCO Action requirement did not then exist. Personnel who authorized placing the valve on the manual operator did not recognize that the condition made the on service train of CCW inoperable, and therefore did not generate an administrative LCO tracking sheet for the upcoming Mode 4 entry.

Work order review for Mode 4 entry did not detect the condition since the work order did not note that the valve had been placed on its manual operator and opened. Personnel reviewing tagging order status for Mode 4 entry erroneously determined that the valve status given on the tagging order would not constitute an LCO when Mode 4 was entered. Performance of this review is required by procedure, but the process for performing it is not formally defined.

Mode 4 was entered on April 8, 2004, at 1729. The condition was detected on April 8, 2004 at 2200 during the tagging order review for the upcoming Mode 3 entry. The valve was taken off its manual operator and closed, returning it to its fail safe condition.

Cause of Event

This event was due to cognitive personnel error. Personnel who authorized placing the valve on the manual operator did not recognize that the condition made the on service train of CCW inoperable, and therefore did not generate an administrative LCO tracking sheet for the upcoming Mode 4 entry.

Personnel reviewing tagging order status for Mode 4 entry erroneously determined that the valve status given on the tagging order would not constitute an LCO when Mode 4 was entered.

Safety Assessment The other train of CCW remained operable throughout this event.

The health and safety of the public were unaffected by this event.

This event does not represent a Safety System Functional Failure.

Corrective Action Personnel involved have been coached.

A Training Advisory Notice has been sent to Operations personnel informing them of the details of this event.

The Operations staff will be counseled concerning this event during the next training cycle by August 31, 2004.

A formal Mode change tagging order review process will be instituted by July 31, 2004.

Additional Information

The following LERs have been submitted in the past two years concerning Technical Specification violations:

3.4.12 Not Met.

Missile Barrier Not in Place.