05000388/LER-2002-001
| Susquehanna Steam Electric Station - Unit 2 | |
| Event date: | 03-11-2002 |
|---|---|
| Report date: | 05-10-2002 |
| Reporting criterion: | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications |
| 3882002001R00 - NRC Website | |
EVENT DESCRIPTION
Background:
The Unit 1 Division 2 125 VDC power sources were declared inoperable at 16:15 on March 11 for upcoming refueling outage work on Unit 1. When the Unit 1 Division 2 125 VDC power sources are inoperable, Unit 2 Technical Specification (TS) Required Actions 3.8.4.E.1 and 3.8.7.H.1 require transfer of associated Unit 1 and common loads to the corresponding Unit 2 125 VDC power source within 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />. If the 2 hour2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> time limit is not met, Unit 2 TS Required Actions 3.8.4.F.1 and 3.8.7.1.1 require the associated common loads to be declared inoperable. At 17:15 on March 11, the equipment alignment procedure for the 125 VDC transfer switches was implemented to comply with TS 3.8.4.E.1 and 3.8.7.H.1. Although the power sources were declared administratively inoperable at 16:15 on March 11, work activities that actually made the power sources inoperable began at approximately 22:00 on March 11.
Event:
At 01:15 on March 12, 2002, with Unit 1 in Mode 5 (Refueling) at 0% power and Unit 2 in Mode 1 (Power Operation) at 100% power, an in-plant operator (Non-licensed, utility) performing rounds discovered that some transfer switches for 125 VDC power sources (EIIS Code: EJ) supplying common loads (i.e., loads that support operation of both units) were in the incorrect position.
After being notified of the condition, a work control center operator (Licensed, utility) determined that a page had been missing from the copy of the equipment alignment procedure that was used to align the transfer switches, and fifteen of the switches were in the incorrect position. At 02:00 on March 12, the applicable common loads were declared inoperable, and an operator was dispatched to properly complete the switch alignment. The common loads that were declared inoperable include:
- 'B' Emergency Diesel Generator Fuel Oil Booster Pump (EllS Code: DE)
- Timers for 'B' Emergency Service Water / Residual Heat Removal Service Water Spray Pond Array (EllS Code: KE) By 03:00 on March 12, all the transfer switches for associated common loads were properly aligned and the common loads were restored to operable status. No 125 VDC loads were without power for the duration of the event, and there were no unmet demands on the 125 VDC system while the transfer switches were mispositioned.
CAUSE OF EVENT
The mispositioned transfer switches were attributed to inadequate control of an attachment in the transfer switch alignment procedure OP-102-002. The error occurred when work control center inadvertently omitted. Attachment L and the incomplete Attachment J were then given to in-plant operators (Non-licensed, utility) to implement.
An investigation of the event showed that operations personnel had less than adequate knowledge of procedure attachment page control. The personnel involved with the event knew that procedure page not aware that attachments had separate page control in the lower left-hand corner of the page (e.g., normally used for performance of administrative tasks such as copying procedures.
ANALYSIS / SAFETY SIGNIFICANCE
This event is reportable as a condition prohibited by the Technical Specifications per 10CFR50.73(a)(2)(i)(B) in that Unit 2 was in a condition prohibited by the Technical Specification Required Actions 3.8.4.E.1 & F.1 and 3.8.7.H.1 & 1.1. The associated Unit 1 and common loads were not transferred to the corresponding Unit 2 125 VDC power source within 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> and the loads were not immediately declared inoperable. Although the Unit 1 Division 2 125 VDC power sources were administratively declared inoperable at 16:15 on March 11, work activities that actually made the power sources inoperable begin at approximately 22:00 on March 11. After the condition was recognized, all of the Unit 2 Technical Specification Required Actions for the affected common loads were entered at 02:00 on March 12 and completed satisfactorily. The actual elapsed time the associated Unit 1 and common loads were not transferred as required was approximately 5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br />. This event did not affect Unit 1 since the affected common loads were not required in Mode 5. There was not a loss of safety function, nor were any 125 VDC loads without power for the duration of the event. There was no unmet demand on the 125 VDC system while the transfer switches were mispositioned, and therefore, there were no actual adverse consequences to the health and safety of the public as a result of this event.
In accordance with guidance in NUREG-1022, Revision 2, the due date for this report is May 13, 2002.
CORRECTIVE ACTIONS
Corrective action that has been completed:
- An Operations stand-down was conducted emphasizing the need to employ self-checking and peer checking techniques when performing administrative tasks.
- An informational bulletin was issued to Operations personnel explaining the differences in procedure page control and attachment page control.
Corrective actions to be completed:
- Include procedure page control and attachment page control in routine Operations training.
- Establish a method to more clearly delineate the beginning and end of Operations procedure attachments in addition to the use of page control in the bottom left hand corner of the page.
- Revise the Operations procedure for standards of error and event prevention to include the use of self-checking and peer checking for administrative tasks.
ADDITIONAL INFORMATION
Past Similar Events: � None Failed Component: � None