05000254/LER-1996-014-03, :on 960927,electrical Distribution Weekly Surveillance Did Not Document Voltage Verification Due to an Inadequate Procedure.Qcos 0005-06 Has Been Revised to Ensure Verification of Proper Voltages

:on 960927,electrical Distribution Weekly Surveillance Did Not Document Voltage Verification Due to an Inadequate Procedure.Qcos 0005-06 Has Been Revised to Ensure Verification of Proper Voltages

ML20129H556
Person / Time
Site:	Quad Cities
Issue date:	10/24/1996
From:	Peterson C COMMONWEALTH EDISON CO.
To:
Shared Package
ML20129H553	List: 05000254/LER-1996-014, Forwards LER 96-014-00.All Personnel Will Be Briefed in Event by 961215,reinforcing Expectations to Initiate Procedure Changes When Needed 05000254/LER-1996-014-03, :on 960927,electrical Distribution Weekly Surveillance Did Not Document Voltage Verification Due to an Inadequate Procedure.Qcos 0005-06 Has Been Revised to Ensure Verification of Proper Voltages
References
LER-96-014-03, LER-96-14-3, NUDOCS 9611010200
Download: ML20129H556 (4)

LER-1996-014, on 960927,electrical Distribution Weekly Surveillance Did Not Document Voltage Verification Due to an Inadequate Procedure.Qcos 0005-06 Has Been Revised to Ensure Verification of Proper Voltages

Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2) 10 CFR 50.73(a)(2)(vii), Common Cause Inoperability 10 CFR 50.73(a)(2)(viii)(A) 10 CFR 50.73(a)(2)(viii)(B) 10 CFR 50.73(a)(2)(x)
2541996014R03 - NRC Website

text

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LICENSEE EVENT REPORT (LER)

Form Rsv. 2.0 Facdary N;me (1)

Dockes Number Q)

Page (3)

Quad Cities Unit One 0l5l0l0l0l2l5l4 1 l of l 0 l 4 Tide (4)

Electrical distribution weekly surveillance did not document voltage verification in accordance with Technical Specification 4.9.E. due to an inadequate procedure.

Event Date (5)

LER Numt.er (6)

Report Date (7)

Other Facdities involved (8)

Month Day Year Year Sequential Revision Month Day Year Facility Docket Number (s)

Number Number Names 0l5l0l0l0l2l6l5 0l9 2l7 9l6 9l6 0l1l4 0l0 1l0 2l4 9l6 0l5l0l0l0l l

l OPERATING THis REPORT !$ $UBM TIED PUR5UANT TO THE REQUIREMENTS OF 10CFR MODE (9)

(Check one or more of the following) (11) 1 20.402(b) 20.405(c) 50.73(a)(2)0v) 73.71(b)

POWER 20.405(s)(I)G) 50.36(c)(I)

- 50.73(a)G)(v) 73.7I(c)

LEVEL 20.405(a)(1)0i)

- 50.36(c)(2) 50.73(a)(2)(vii)

Other (Specify (10) 1 l0l 0

- 20.405(a)(1)0ii)

T50.73(a)(2)0) 50.73(a)(2)(viii)(A) in Abstract 20.405(a)(1)0v)

- 50.73(a)(2)0i)

- 50.73(a)(2)(viii)(B) below and in 20.405(a)(1)(v)

- 50.73(a)(2)0ii) 50.73(a)(2)(x)

Tert)

LICENSEE CON TACT FOR THIS LER (la)

NAME TELEPHONE NUMBER AREA CODE Charles Peterson. Regulatory Affairs Manager, ext. 3602 3l0l9 6l5l4l-l2l2l4l1 COMPLETE ONE LINE FOR EACH COMPONENT F AILURE Dl3CRIBED IN THIS REM >RT (13)

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Expected Month Day Year Submunen lYES Of yes, complete EXPECTED SUBMIS$10N DATE) yo Date 05) l l

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ABSTRACT:

On 9/27/96 at 0000 hours0 days <br />0 hours <br />0 weeks <br />0 months <br />, Unit I and Unit 2 were in Power Operation mode at 100 percent power when a Technical Specification (TS) required surveillance became overdue for both Units. QCOS 0005-06, Weekly Electrical Distribution Breaker and Voltage Verification, is required to be performed weekly in accordance with TS 4.9.E and had last been performed on 9/19/96 for both Units. On 9/26/96, Nuclear Station Operators performed QCOS 0005-06 for both Units, but the surveillance procedure did not have operators document verification of proper voltages in accordance with TS 4.9.E, a requirement implemented with the Upgraded TS on 9/23/96. On 10/02/96 at 2000 hours0.0231 days <br />0.556 hours <br />0.00331 weeks <br />7.61e-4 months <br />, a Unit Supervisor reviewing the 9/26/96 copies of QCOS 0005-06 identified there was no documentation that proper voltages had been verified. A 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> Limiting Condition for Operation (LCO) for completion of the surveillance was entered for both Units in accordance with TS 4.0.C.

A revision to QCOS 0005-06 was expedited, and on 10/03/96 at 1923 hours0.0223 days <br />0.534 hours <br />0.00318 weeks <br />7.317015e-4 months <br />, the revised QCOS 0005-06 was successfully performed and TS 4.0.C LC0 was exited for both Units.

The root cause of this event is an inadequate procedure.

Corrective actions include procedure revision, counselling of personnel involved with the review and approval of the procedure, and briefing all Operations personnel on the event.

The safety significance of this event is minimal as the affected busses and motor control centers were verified as energized and an abnormal voltage would have been identified by operators during rounds or through Control Room alarms.

9611010200 961024 PDR-ADOCK 05000254 S

PDR

LICENSEE EVENT REPCbT (LER) TEXT CONTINUATION Form Rev. 2.0 FACILTTY N AME (1)

DOCKET NUMBER C)

LER NUMBER (6)

PAGE (3)

=

Year sequential Revimon Number Number Quad Cities Unit one 0l5lOj*l0l2 5l4 9l6 0l1l4 0l0 2 lOFl 0 l 4 TEXT Energy Industry Ident 6 cation System (Ells) codes are ident:6e in the text as (XX)

PLANT AND SYSTEM IDENTIFICATION

General Electric - Boiling Water Reactor - 2511 MWt rated core thermal power.

EVENT IDENTIFICATION:

Electrical distribution weekly surveillance did not document voltage verification in accorJance with Technical Specification 4.9.E due to an inadequate procedure.

A.

CONDITIONS PRIOR TO EVENT

Unit: One Event Date:

September 27, 1996 Event Time: 0000 Reactor Mode:

1 Mode Name:

POWER OPERATION Power Level:

100%

Unit: Two Event Date:

September 27, 1996 Event Time: 0000 Reactor Mode:

1 Mode Name:

POWER OPERATION Power Level:

100%

This report was initiated by Licensee Event Report LER254\\96-014.

Power Operation (1) - Mode switch in the RUN position with average reactor coolant temperature at any temperature.

B.

DESCRIPTION OF EVENT

On 4/25/96, a new procedure, QCOS 0005-06, Weekly Electrical Distribution Breaker and Voltage Verification was developed by a Senior Reactor Operator in preparation for implementing the Upgraded Technical Specifications (TSUP).

This procedure was reviewed for technical accuracy by a Shift Engineer and the Operations TSUP Coordinator prior to approval by the Administrative Operating Engineer. On 9/17/96, revision 0 of QCOS 0005-06 was issued prior to implementing the TS. The purpose of this procedure was in part "to verify the onsite distribution system [EB, ED, EJ) is in the correct breaker [BKR] alignment with proper voltages on essential busses [BU]

and motor control centers [MCC], as required by Technical Specifications (TS)." A typical step from revision 0 of this surveillance was to " verify Bus 13-1 (23-1) energized from Bus 13 (23)" without specifying adequate voltage to be checked. TS section 4.9.E states: "Each of the required power distribution system divisions shall be determined energized at least once per 7 days by verifying correct breaker alignment and voltage on the busses /MCCs/ panels."

LER254\\96\\014. WPF

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l LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Form Rav. 2.0 FACILITY NAME 0)

DOCKET NUMBER (2)

LER NUMBER (6)

PAGE (3) s Year Sequential Revision

=

Number Number j

Quad Cities Unit One ol5lo'olol2l5l4 9l6 ol1l4 olo 3 lOFl o l 4 i

TEXT Energy Industry identification System (Ells) codes are identifie< in the text as [XX)

On 9/19/96, QCOS 0005-06 was being performed for the first time on both Units. A j

Nuclear Station Operator (NS0) contacted the Operations TS Coordinator and questioned if the surveillance adequately addressed TSUP 4.9.E if the proper

~

voltages were not verified and documented. The Operations TSUP Coordinator i

recommended that the NSO could verify that there were no undervoltage alarms present on the 901-8 and 902-8 Control Room electrical distribution panels and document the verification in the comments section of QC05 0005-06 if he was concerned with the i

adequacy of the procedure. The Operations TSUP Coordinator stated he would ensure that the procedure concern would be resolved prior to performing the surveillances again (the following week). QCOS 0005-06 was completed for both Units and included i

comments that no alarms were present. The Operations TSUP Coordinator failed to follow through to ensure the procedure concern was resolved as requested.

On 9/23/96, the TSUP was implemented. On 9/26/96, QCOS 0005-06 was performed again for both Units. The NS0's verified the associated busses were energized in accordance with the procedure but no one recognized that the procedure did not meet i

the TS 4.9.E requirement to document the verification of proper voltage. The j

surveillances were completed and no comments were documented.

On 10/02/96 at 2000 hours0.0231 days <br />0.556 hours <br />0.00331 weeks <br />7.61e-4 months <br />, an operator was reviewing documentation for the 9/26/96 i

performances of QCOS 0005-06 for both Units and noted there was no documentation of proper voltage verification as required by TS 4.9.E.

The Unit Supervisor verified no undervoltage annunciator alarms present on the 901-8 and 902-8 Control Room electrical distribution panels. A 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> Limiting Condition for Operation (LCO) for completion of the surveillance was entered effective at 2000 hours0.0231 days <br />0.556 hours <br />0.00331 weeks <br />7.61e-4 months <br /> in accordance with TS 4.0.C.

The Operations TSUP Coordinator was contacted and a revision to QCOS 0005-06 was expedited to ensure the verification of proper voltages was documented.

On 10/03/96 at 1923 hours0.0223 days <br />0.534 hours <br />0.00318 weeks <br />7.317015e-4 months <br />, the revised QCOS 0005-06 was successfully performed and TS 4.0.C LC0 was exited for both Units.

C.

APPARENT CAUSE OF EVENT:

i The root cause of this event was the inadequate review and approval of QCOS 0005-06 which did not recognize that TS 4.9.E required verifications were not documented by l

the procedure. The individuals involved with reviewing and approving the procedure considered the term " verify energized" to encompass and fully satisfy the Technical Specification. All other new or modified surveillances applicable to Power 2

i Operation have been performed and no other TSUP surveillance problems have been

]

identified.

A contributing cause of this event was ineffective tracking of an identified i

problem. The procedural discrepancy was recognized and addressed on 9/19/96 prior to the implementation of the TSUP requirement on 9/23/96, but the necessary changes were not tracked and completed as the Operations TSUP Coordinator perceived the change as a clarification rather than a correction.

i LER254 96\\014. WPF

i LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Form Rav. 2.0 FACILrrY NAME (1)

DOCKET NUMBER (2)

LER NUMBER (6)

PAGE (3)

Year sequential Revision Number Number Qund Cities Unit One 0l5l0l0l0l2l5l4 9l6 0l1l4 0l0 4 lOFl 0 l 4 TEXT Energy ladustry identi6 cation System (Ells) codes are ident:6ed in the text as (XX)

D.

SAFETY ANALYSIS OF EVENT:

The safety significance of this event is minimal. The affected busses and motor control centers were verified as energized on 9/26/96 and although the proper voltages verifications were not documented, an abnormal voltage would have been identified by operators during rounds or through Control Room alarms.

E.

CORRECTIVE ACTIONS

Corrective Actions Completed:

1.

QCOS 0005-06 has been revised to ensure the verification of proper voltages is documented.

2.

The affected Operations personnel were counselled on the failure to identify the procedural inadequacy during the review for procedure approval.

Corrective Actions To Be Completed:

1.

All Operations personnel will be briefed on this event by 12/15/96, reinforcing the expectation to initiate procedure changes when needed.

)

(NTS# 2541809601401 - Operations).

F.

PREVIOUS EVENTS:

A search for LERs in the last 2 years involving missed Technical Specification surveillances revealed the following events 254/94-14, Fire system surveillance went past their critical due date without the j

systems being declared inoperable and compensatory actions put in place due to inadequate training and written communication.

254/95-06, The RPS EPA relays had not been tested prior to the mode switch being moved to Refuel due to an in adequate written communication.

254/96-19, Main steam line radiation monitor functional test not performed within frequency established for Technical Specifications when in Refueling mode due to I

incomplete documentation of a Technical Specification interpretation.

6.

COMPONENT FAILURE DATA

Not applicable.

LER254\\%014. WPF i