05000348/LER-2003-002

LER-2003-002,

Docket Number
Event date:
Report date:
Reporting criterion:	10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
3482003002R00 - NRC Website

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

Description of Event

On April 22, 2003, at 1745, during routine shift monitoring activities, it was determined that Farley Nuclear Plant Unit I had been operated contrary to Technical Specification 3.4.12, Low Temperature Overpressure Protection System, since 1244 on April 22, 2003 in that the reactor vessel head had been set with three charging pumps capable of injecting into the RCS. Technical Specification 3.4.12 requires that a maximum of one charging pump be operable in Modes 5 and 6 when the reactor vessel head is in place and one or more RCS cold legs is 180°F.

On April 21, 2003, Unit 1 was in a refueling outage with the RCS [AB] drained to the reactor vessel flange and in anticipation of setting the reactor vessel head. Per the normal shift surveillance procedure, a maximum of one charging pump shall be operable whenever the temperature of one or more RCS cold legs is 5 180°F and the Reactor Vessel Head is installed. However, since the reactor head was not set, the procedure step to tag out 2 of the 3 charging pumps was marked not applicable for night shift. At 1244 on dayshift April 22, the reactor head was set. The tag order was in the tagging office ready to implement at the time of the event (setting the reactor head). At 1745 that same evening, while completing the normal shift monitoring activities, the discovery was made that greater than one charging pump was available. The tag order was implemented, and two of the three charging pumps were made incapable of injection into the RCS as required by Technical Specifications by 1821 on April 22, 2003.

Cause of Event

This event was caused by inadequate procedure in that the Unit Operating Procedure for setting the reactor vessel head did not address the limitation on the number of charging pumps available prior to setting the head. A contributing cause was cognitive personnel error in that equipment alignment was insufficiently reviewed prior to setting the head.

Safety Assessment No overpressure condition occurred during this event. During this event, the reactor vessel head, although set in place on the vessel, was not bolted. In the event that a mass injection transient occurred, such as start of all three charging pumps, the head would have lifted off its seating surface thereby preventing an overpressure condition.

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

This event does not represent a Safety System Functional Failure.

Corrective Action The applicable Unit Operating Procedures on both units have been revised to add appropriate information from Technical Specification 3.4.12.

Personnel involved have been coached.

A Training Advisory Notice on this procedure change was sent to Operations personnel. This event has been discussed with Operations personnel in shift briefings.

Additional Information

The following LERs were submitted in the last two years concerning inadequate procedure, standards, or other guidance:

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