05000366/LER-2004-003
| Docket Number(S) | |
| Event date: | 10-03-2004 |
|---|---|
| Report date: | 12-01-2004 |
| Reporting criterion: | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications 10 CFR 50.73(a)(2)(v)(C), Loss of Safety Function - Release of Radioactive Material |
| 3662004003R00 - NRC Website | |
PLANT AND SYSTEM IDENTIFICATION
General Electric - Boiling Water Reactor Energy Industry Identification System codes appear in the text as (EIIS Code XX).
DESCRIPTION OF EVENT
Unit 2 was shutdown on 09/25/2004 at 0106 ET for Safety Relief Valve (SRV) replacement due to seat leakage on SRV 2B21-F013L. The outage was scheduled to last 66 hours7.638889e-4 days <br />0.0183 hours <br />1.09127e-4 weeks <br />2.5113e-5 months <br />. Unit 2 entered cold shutdown at 1100 on 09/25/2004. Primary containment (EIIS Code JM) was originally declared inoperable at 1143 on 09/25/2004 because the drywell door interlocks were defeated. The primary containment was scheduled to be open for approximately 26 hours3.009259e-4 days <br />0.00722 hours <br />4.298942e-5 weeks <br />9.893e-6 months <br />. During this outage, the limit switches for Main Steam Isolation Valve (MSIV) (EIIS Code SB) 2B21-F022D were adjusted. In order to perform this task, the MSIV was stroked open and closed per 52SV-B21-001-2. During valve stroking, the MSIV became bound due to internal galling. As a result of this MSIV damage, the Unit 2 maintenance outage was extended for 5 1/z days.
Following the discovery of the damaged MSIV, Maintenance requested that Operations open the Service Air (SA) (EIIS Code LF) supply to drywell valves 2P51-F512, 2P51-F513, 2P51-F651 and 2P51-F589 in order to support the MSIV repairs. Valves 2P51-F651 and 2P51-F513 are PCIVs. The clearance process at the plant establishes requirements for several different types of tagouts. The clearance process includes danger tagouts, caution tagouts, and operating permit tagouts. In this instance the valves were opened with a caution tag (2-CA-04-2P51-00093). The caution tag was authorized at 0621 on 09/27/2004 and the caution tags were verified as hung at 1100 on 09/27/2004. This caution tag was not added to the primary containment RAS 2- 04-180.
The Unit 2 Mode switch was placed in "STARTUP" at 1535 on 10/01/2004. The Unit 2 generator was tied to the line at 0400 on 10/03/2004. At 0530 on 10/03/2004 with the unit at approximately 20 percent rated thermal power, operations personnel questioned why caution tag 2-CA-04-2P51-00093 was still active.
Primary Containment was declared inoperable upon realizing that both manually operated Primary Containment Isolation Valves (PCIVs) 2P51-F651 and 2P51-F513 were open for penetration 21. Technical Specification 3.6.1.3 Condition B was entered because both manually operated PCIVs for one penetration were open in Mode 1. Required Action Statement (RAS) 2-04-197 was initiated at 0530 on 10/03/2004 which required closing at least one PCIV within 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />. At 0630, Technical Specifications 3.6.1.3 Condition E was entered requiring the plant to be in Mode 3 within 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />. With Maintenance support, the shift was able to close PCIV 2P51-F513 at 0655 on 10/03/2004 isolating penetration 21 and no power reduction was required. RAS 2-04-197 remains active because PCIV 2P51-F651 located inside the drywell remains open.
Valve 2P51-F513 is confirmed closed once every 31 days.
Primary Containment is required to be operable in Modes I, 2 and 3. Primary containment was inoperable prior to the Mode switch being placed in "STARTUP" and remained inoperable until the manually operated outboard PCIV 2P51-F513 was closed. Primary containment was inoperable when required (i.e., Modes 1, 2, and 3) for 39.33 hours3.819444e-4 days <br />0.00917 hours <br />5.456349e-5 weeks <br />1.25565e-5 months <br />.
Procedure 34GO-OPS-028-2, "DRYWELL CLOSEOUT," provides guidance and instructions for performing the final drywell inspection prior to closing the drywell. It should be noted that 34GO-OPS-028-2 requires checking some of the tagouts associated with the clearance process but did not require checking drywell caution tagouts.
Procedure 34GO-OPS-003-2, "START-UP SYSTEM STATUS CHECKLIST," provides instructions for confirming plant systems are in the correct status for a plant startup. The following steps are in the procedure's "Administrative" section:
- Review the danger tagouts and confirm no system and/or component required for startup is under a danger tagout.
- Confirm that all Unit 2 containment access barriers are closed per 34SV-SUV-011-2, Primary and Secondary Containment Integrity Demonstration.
The first step listed was deficient in that there was no requirement to review caution or Operating Permit tagouts. Not including the requirement to check caution tagouts was an oversight when the procedure was drafted. Operating Permit tagouts did not exist when the procedure was drafted.
The second step listed does not specifically state to perform 34SV-SUV-011-2. When the Shift Manager reached this step, the drywell had already been closed and the Drywell Airlock LLRT completed. The Shift Manager contacted the OCC to determine if 34SV-SUV-011-2 had been completed. Based on a log entry on 9/25/2004, the Operations representative in the OCC concluded the surveillance requirement was current.
However, the service air valves had been opened after the procedure had been completed.
A broadness review as result of this event was performed which included reviewing all the tagouts associated with the clearance process for additional valves that might have been manipulated during the maintenance outage. No valves were identified that were manipulated by a tagout associated with the clearance process that were not restored. Plant procedures were reviewed to ensure all primary containment components were returned to their correct position. No valves or blind flanges were identified that might not be in the correct position. Procedure 34SV-SUV-011-2 was performed satisfactorily for the components outside the drywell.
The procedures for drywell close-out, start-up system checklist and plant startup were reviewed for both Unit 1 and Unit 2 to determine if additional requirements were needed. No other requirements were determined to be necessary other than the need to check the tagouts associated with the clearance process. The same requirements that are being added to the Unit 2 procedures will be added to the Unit 1 procedures.
CAUSE OF EVENT
The Unit Shift Supervisor failed to add caution tag number 2-CA-04-2P51-00093 to RAS 2-04-180. As a result, there was no tracking mechanism to alert the shift team that the caution tag had to be restored prior to terminating primary containment RAS 2-04-180.
The requirement to check all manual valves per 34G0-0PS-028-2 is inadequately stated and changes to the procedure arc warranted to assure completion of this action.
The requirement to check all active clearance process tagouts per 34GO-OPS-003-2 is inadequately stated and changes to the procedure arc warranted to assure completion of this action.
Neither 34GO-OPS-003-2 nor 34GO-OPS-028-2 required checking the caution tagouts prior to startup.
REPORTABILITY ANALYSIS AND SAFETY ASSESSMENT
This report is required by 10 CFR 50.73(a)(2)(i)(B) because the plant entered a condition that was prohibited by the plant's Technical Specifications. Specifically, primary containment is required to be operable prior to entering Mode 2. Contrary to this requirement the plant was placed in Mode 2 at 1535 on 10/01/2004 with primary containment inoperable. Technical Specifications Surveillance Requirements for TS LCO 3.6.1.3 require that (SR 3.6.1.3.2) each primary containment isolation manual valve and blind flange that is located outside primary containment and is required to be closed during accident conditions is closed; and that (SR 3.6.1.3.3) each primary containment isolation manual valve and blind flange that is located inside primary containment and is required to be closed during accident conditions is closed. Neither of these surveillance requirements was met when the Mode switch was placed in Mode 2. Additionally, this report is required by 10 CFR 50.73(a)(2)(v)(C) in that with primary containment inoperable there existed a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to control the release of radioactive material.
Primary Containment is required to be operable in Modes 1, 2 and 3. Primary containment was inoperable prior to the Mode switch being placed in "STARTUP" and remained inoperable until manually operated outboard PCIV 2P51-F513 was closed. Primary containment was inoperable when required (i.e., Modes 1, 2, and 3) for 39.33 hours3.819444e-4 days <br />0.00917 hours <br />5.456349e-5 weeks <br />1.25565e-5 months <br />. However, the likelihood of an event requiring PCIV isolation in this short time frame was low. Nonetheless, had an event occurred requiring isolation of the primary containment, all other PCIVs would have closed as designed. If an automatic reactor shutdown was required, the Reactor Protection System (RPS) (EIIS Code JE) was fully Operable, thus capable of placing and maintaining the plant in a safe shutdown condition. The plant service air piping in the diywell is seismic category I between the outboard and inboard PCIVs and is seismic category II downstream of the inboard PCIV. Furthermore, the Secondary Containment (reactor building) (EIIS Code NH) was fully Operable, as was the Standby Gas Treatment System (SBGT) (EIIS Code BH) during the 39.33 hour3.819444e-4 days <br />0.00917 hours <br />5.456349e-5 weeks <br />1.25565e-5 months <br /> period that these PCIVs were open. Therefore, any release of radioactive materials into secondary containment would have been contained in the reactor building and would have been controlled and filtered through the safety related SBGT system. For these reasons, it may be concluded that this event did not adversely impact nuclear safety or the health and safety of the public.
CORRECTIVE ACTIONS
The appropriate procedures will be revised as necessary to state the requirement to add clearance process tagouts to the appropriate RAS. This action will be completed by February 2005.
Procedures 34GO-OPS-003-1/2 will be revised to include the need to check all clearance process tagouts prior to startup. These revisions will be completed prior to the next drywell closeout or by February 2005, whichever is first.
Procedures 34GO-OPS-028-1/2 will be revised to: 1) Confirm all manual valves are in the correct position; 2) Clarify the requirement to address clearance process tagouts) 3) Add signoff steps. These revisions will be completed prior to the next drywell closeout or by February 2005, whichever is first.
ADDITIONAL INFORMATION
Other Systems Affected: No systems other than those already mentioned in this report were affected by this event.
Failed Components Information: No failed components directly caused or resulted from this event.
Commitment Information: This report does not create any permanent licensing commitments.
Previous Similar Events: There has not been any previous similar event in the past two years in which the unit started or operated with its primary containment inoperable.