ML15099A392

LER 15-001-00 for Wolf Creek Regarding Personnel Error Causes Two Inoperable Residual Heat Removal Trains

ML15099A392
Person / Time
Site:	Docket Number
Issue date:	03/25/2015
From:	Smith S L Wolf Creek
To:	Document Control Desk, Office of Nuclear Reactor Regulation
References
WO-15-0014 LER-15-001-00
Download: ML15099A392 (5)

Text

W9LF CREEKNUCLEAR OPERATING CORPORATION March 25, 2015Stephen L. SmithPlant ManagerWO 15-0014U. S. Nuclear Regulatory Commission ATTN: Document Control DeskWashington, DC 20555

Subject:

Docket No. 50-482: Licensee Event Report 2015-001-00, "Personnel Error CausesTwo Inoperable Residual Heat Removal Trains"Gentlemen:

The enclosed Licensee Event Report (LER) 2015-001-00 is being submitted pursuant50.73(a)(2)(v)(B) regarding an event or condition that could have prevented fulfillment function needed to remove residual heat at Wolf Creek Generating Station.This letter contains no regulatory commitments.

If you have any questions concerning please contact me at (620) 364-4093, or Mr. Steven R. Koenig at (620) 364-4041.

to 10 CFRof a safetythis matter,Sincerely, SLS/rltEnclosure cc: M. L. Dapas (NRC), w/eC. F. Lyon (NRC), w/eN. F. O'Keefe (NRC), w/eSenior Resident Inspector (NRC), w/eP.O. Box 411 / Burlington, KS 66839 / Phone: (620) 364-8831An Equal Opportunity Employer M/F/HC/VET NRC FORM 366 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0104 EXPIRES:

0113112017 (02-201 4) Eshmed Wten per response to oarry v& thts fndtoy coled recluest 80 hours9.259259e-4 days <br />0.0222 hours <br />1.322751e-4 weeks <br />3.044e-5 months <br /> Reportec,less learned ae into the licensing proess and fed back to indusby.

SenconTts regaring burden esrmate to the FOIA, Pivay ard In.fmton CllechonsBrandB NZ (T-5 F53), U.S Regulatory Cormssison, Vbsngton DC 2055&.001, or by interret e-madilLICENSEE EVENT REPORT (LER) to rfct og , a tote Oe r, Ofe ornanon r Re ,o(See Page 2 for required number of Afir NB1-102OZ (315o0104),

Ofce aid BuK VthrngbR DC20503 If a rrears used to irrpose an info collection does not cisplay a aorenily valid aMEdigits/characters for each block) onto nurnber, the NRC ay riot Conduct or sow, and a person is rot requred to respond to,re inflioni ooollectior.

1. FACILITY NAME 2. DOCKET NUMBER 3. PAGEWOLF CREEK GENERATING STATION 05000 482 1 OF 44. TITLE Personnel Error Causes Two Inoperable Residual Heat Removal Trains5. EVENT DATE 6. LER NUMBER 7. REPORT DATE 8. OTHER FACILITIES INVOLVEDSEQUENTIAL REV M FACILITY NAME DOCKET NUMBERMONTH DAY YEAR YEAR NUMBER NO. MONTH DAY YEAR 050001 28 2015 2015 -001 00 03 25 2015 FACILITY NME DOCKNUMBER 050009. OPERATING MODE 11. THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR §: (Check all thai apply)D 20.2201(b)

--20.2203(a)(3)(i)

D 50.73(a)(2)(i)(C)

Li50.73(a)(2)(vii)

[] 20.2201(d)

[] 20.2203(a)(3)(ii)

[] 50.73(a)(2)(ii)(A)

[]50.73(a)(2)(viii)(A)

Li 20.2203(a)(1)

E] 20.2203(a)(4)

[:] 50.73(a)(2)(ii)(B)

[] 50.73(a)(2)(viii)(B) r- 20.2203(a)(2)(i)

[L 50.36(c)(1)(i)(A) 0 50.73(a)(2)(iii)

E] 50.73(a)(2)(ix)(A)

10. POWER LEVEL Li 20.2203(a)(2)(ii) 0 50.36(c)(1)(ii)(A)

L" 50.73(a)(2)(iv)(A)

E] 50.73(a)(2)(x)

Li 20.2203(a)(2)(iii)

E] 50.36(c)(2)

[]50.73(a)(2)(v)(A)

Li 73.71 (a)(4)100 [] 20.2203(a)(2)(iv)

D 50.46(a)(3)(ii)

[-] 50.73(a)(2)(v)(B) 73.71 (a)(5)L 20.2203(a)(2)(v)

D 50.73(a)(2)(i)(A)

E] 50.73(a)(2)(v)(C)

OTHER[_ 20.2203(a)(2)(vi)

E] 50.73(a)(2)(i)(B)

[ 50.73(a)(2)(v)(D)

Specifyoin Abstract below or in12. LICENSEE CONTACT FOR THIS LERFACILITY NAME TELEPHONE NUMBER (Include Area Code)Steven R. Koenig, Manager Regulatory Affairs 620-364-4041

13. COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORTCAUSE SYSTEM COMPONENT REPORTABLE PONENT MANU- REPORTABLE FACTURER TO EPIX FACTURER TO EPIX14. SUPPLEMENTAL REPORT EXPECTED

15. EXPECTED MONTH DAY YEARLi YES (If yes, complete

15. EXPECTED SUBMISSION DATE) 4O SUBMISSION I ~ DATEABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines)On January 28, 2015, the nightshift operations crew implemented a clearance order to support plannedmaintenance on two Residual Heat Removal (RHR) System valves that included closing valves EJHV8716A and EJHV8809A.

At 0534 hours0.00618 days <br />0.148 hours <br />8.829365e-4 weeks <br />2.03187e-4 months <br /> on January 28, 2015, Condition C of Limiting Condition for Operation (LCO)3.5.2 was entered upon determining that less than 100% of the Emergency Core Cooling System (ECCS) flowequivalent to a single OPERABLE ECCS train was available with valve EJHV8716A closed. Entry into LCO3.0.3 in accordance with Required Action C.1 was made on two separate occasions.

Action was taken torestore valves EJHV8716A and EJHV8809A to the open position and exit LCO 3.0.3.The licensed operators involved with the preparation and implementation of the clearance orders did notrecognize that current plant conditions could not support the proposed activity.

The individuals involved withthis event had their qualifications removed until remediation occurred.

Red switch boxes have been placed onthe control boards in the control room on the valves in procedure AP 26C-004, "Operability Determination andFunctionality Assessment,"

Section A.16 that can cause an entry into LCO 3.0.3.NRC FORM 366 (02-2014)

NRC FORM 366A U.S. NUCLEARREGULATORY COMMISSION APPROVED BY OMB: NO.3150-0104 EXPIRES:

01/31/2017 (02-2014)

Estimated burden per response tb comply with this mandatory collection request:

80 hours9.259259e-4 days <br />0.0222 hours <br />1.322751e-4 weeks <br />3.044e-5 months <br />.p0' .Reported lessons learned are inoporated ito the licensing process and fed back to industry.

% Send comments regarding burden estimate to the FOIA, rivacy and Information Collections c;

(T-5 F53), U.S. Nuclear Regulatory Commission, Washington DC 20555-0001, or by..... LICENSEE EVENT REPORT (LER) internet e-mail to Infocollects.Resource@nrc.gov, and to the Desk Officer,Office of Information and Regulatory

Affairs, NEOB-10202, (3150-0104),

Office of Management CONTINUATION SHEET and Budget, Washington, DC 20503. If a means used to impose an information collection doesnot display a currently valid OMB control number, the NRC may not conduct or sponsor, andperson is not required to resoond to. the information collection.

1 2.DOCKET

6. LER NUMBER 3. PAGEYEAR SEQUENTIAL REVWOLF CREEK GENERATING STATION 05000482 NUMBER NO.2 01 2 OF 4j j_2015 -001 -00NARRATIVE PLANT CONDITIONS PRIOR TO THE EVENTMode -1Power- 100%There were no systems, structure or components (SSC) that were inoperable at the start of the event andcontributed to the event.DESCRIPTION In December 2014, clearance orders were prepared to support planned maintenance on valvesEJFCV0610, Residual Heat Removal (RHR) pump A miniflow valve [EELS Code: BP-V], and BNHV8812, Refueling Water Storage Tank (RWST) to RHR pump A suction valve [EELS Code: BP-V]. The clearance orders support isolating all possible flow paths and were prepared by a non-licensed individual.

Theclearance orders as prepared close valve EJHV8809A, RHR cold leg injection loops 1 and 2 [EELS Code:BP-V], and valve EJHV8716A, RHR discharge cross-tie

[EELS Code: BP-V], resulting in isolation of theflow path to two of the four cold leg injection nozzles for the RHR System [EELS Code: BP]. The Technical Specification (TS) 3.5.2 Bases, Limiting Condition for Operation (LCO) Section, specifies that during anevent requiring Emergency Core Cooling System (ECCS) actuation, a flow path is required to provide anabundant supply of water from the RWST to the Reactor Coolant System (RCS) via the ECCS pumps(RHR is a subsystem of the ECCS) and their respective supply headers to each of the four cold leginjection nozzles.

On January 8, 2015, the senior license operator performing the tagging authority reviewof the clearance orders failed to ensure that the clearance orders would not adversely impact the plant.On January 27, 2015, it was identified by the on-shift work control center (WCC) senior licensed operatorreviewing the upcoming schedule that the on-shift operations crew would be hanging the clearance ordersfor taking the 'A' RHR train out of service for planned maintenance starting at 0500 hours0.00579 days <br />0.139 hours <br />8.267196e-4 weeks <br />1.9025e-4 months <br /> on January 28,2015. During the evening, the WCC senior licensed operator reviewed the clearance orders, referencing the drawings in the clearance order detail page and TS 3.5.2. During this review, the WCC senior licensedoperator did not recognize that both trains of RHR would be rendered inoperable with the clearance ordersplace. The WCC senior licensed operator approved for issuing clearance orders at approximately 0310hours on January 28, 2015.On January 28, 2015, an extra licensed operator was assigned to hang the applicable clearance ordertags that were located on the control boards in the control room. The licensed operator compared eachtag to the tag hang list and compared the nomenclature on each valve to the hand switches ensuring thecorrect tag was placed on the correct component.

On hand switch EJHIS8716A

[EELS Code: BP-LIS],

thelicensed operator compared the nomenclature on the tag to the hand switch, and the tag hang list. Thecomponents were then repositioned to obtain the desired configuration for the clearance order. Whilesigning the clearance order tags in electronic clearance order database, the licensed operator identified information in the electronic data base and questioned the Control Room Supervisor (CRS) regarding theacceptability of closing valve EJHV8716A.

The CRS reviewed procedure AP 26C-004, "Operability Determination and Functionality Assessment,"

Section A. 16 of Attachment A, determined that closure ofvalve EJHV8716A results in the entry into LCO 3.0.3.NRC FORM 366A (02-2014)

NRC FORM 366A LICENSEE EVENT REPORT (LER) U.S. NUCLEAR REGULATORY COMMISSION (02-2014)

CONTINUATION SHEET1.FACILITY NAME 2.DOCKET

6. LER NUMBER 3.PAGESEQUENTIAL REVWOLF CREEK GENERATING STATION 05000 482 NUMBER NO. 3 OF 42015 -001 -00NARRATIVE At 0534 hours0.00618 days <br />0.148 hours <br />8.829365e-4 weeks <br />2.03187e-4 months <br /> on January 28, 2015, Condition C of LCO 3.5.2 was entered upon determining that lessthan 100% of the ECCS flow equivalent to a single OPERABLE ECCS train was available with valveEJHV8716A closed. Entry into LCO 3.0.3 in accordance with Required Action C.1 was made at 0535hours. Actions were taken to restore valve EJHV8716A to the open position.

LCO 3.0.3 was exited at0550 hours. A review of Nuclear Plant Information System (NPIS) data determined that EJHV8716A wasclosed for 41 minutes.Further review of this event by the WCC senior licensed operator identified that valve EJHV8809A wasincluded in procedure AP 26C-004, Section A. 16 of Attachment A and that closure of this valve results inentry into LCO 3.0.3. Entry into LCO 3.0.3 in accordance with Required Action C.1 was made at 0635hours. Actions were taken to restore valve EJHV8809A to the open position.

LCO 3.0.3 was exited at0650 hours. A review of NPIS data determined that valve EJHV88809A was closed for 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> and 42minutes.REPORTABILITY With less than 100% of the ECCS flow equivalent to a single OPERABLE ECCS train available, the plantis in a condition outside of the accident analysis.

With both RHR trains inoperable, the plant was in acondition that could have prevented the fulfillment of the safety function of structures or systems that areneeded to remove residual heat. As such, this event is reportable under 10 CFR 50.73(a)(2)(v)(B).

The event was reported (EN#50772) under 10 CFR 50.72(b)(3)(v)(B) for an event that at the time ofdiscovery could have prevented the fulfillment of the safety function of structures or systems that areneeded to remove residual heat.CAUSEThe licensed operators involved with the preparation and implementation of the clearance orders did notrecognize that current plant conditions could not support the proposed activity.

CORRECTIVE ACTIONSThe individuals involved with this event had their qualifications removed until remediation occurred.

OnJanuary 29, 2015, WCGS Standing Order 36, Revision 0, "Tagging Authority Duties,"

was issued thatspecified guidance for clearance orders that affect equipment OPERABILITY.

On February 10, 2015, the electronic clearance order database was modified to identify the valves inprocedure AP 26C-004, Section A.16 that can cause an entry into LCO 3.0.3.On February 19, 2015, procedure AP 21 D-003, "Control of Tagging Information,"

was revised to identifythe use of red switch boxes for the valves in procedure AP 26C-004, Section A. 16 that can cause anentry into LCO 3.0.3. Red switch boxes have been placed on the control boards in the control room onthe valves in procedure AP 26C-004, Section A.16 that can cause an entry into LCO 3.0.3. Theplacement of the red switch boxes provides an awareness to the operator of the significance of the valve.NRC FORM 366A (02-2014)

NRC FORM 366A LICENSEE EVENT REPORT (LER) U.S. NUCLEAR REGULATORY COMMISSION (02-2014)

CONTINUATION SHEET1.FACILITY NAME 2. DOCKET 6. LER NUMBER 3.PAGESEQUENTIAL REVYEARWOLF CREEK GENERATING STATION 05000 482 NUMBER NO. 4 OF 42015 001 00NARRATIVE SAFETY SIGNIFICANCE The event is of low safety significance due to the amount of times the valves were out of their requiredposition and the low probability of an event occurring during this period that would require the RHRSystem. The WCGS Probabilistic Risk Assessment model only requires injection into one RCS cold leg.The 'B' RHR train was capable of injecting into two RCS cold legs.OPERATING EXPERIENCE/PREVIOUS EVENTSNone.NRC FORM 366A (02-2014)