05000305/LER-2012-009
| Kewaunee Power Station | |
| Event date: | 12-03-2012 |
|---|---|
| Report date: | 02-07-2013 |
| Reporting criterion: | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications |
| 3052012009R00 - NRC Website | |
Event Description
At 0726 CST on December 3, 2012, while in Mode 1, "B" EDG was made inoperable for "B" train scheduled maintenance and testing. With one EDG inoperable, TS Limiting Condition for Operation (LCO) 3.8.1, "AC Sources — Operating," Condition B, Required Action B.1, requires SR 3.8.1.1, "Verify correct breaker [BKR] alignment and indicated power availability for each offsite circuif, to be performed with a Completion Time of "1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />," and "Once per 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> thereafter.
SR 3.8.1.1 is implemented by procedure OP-KW-OSP-MISC-002, Electrical Power System Weekly Test, and is recorded on Attachment A to that procedure.
At 0742 on December 3, 2012, to satisfy the 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> Completion Time, OP-KW-OSP-MISC-002 was completed in its entirety with acceptable results. Two subsequent performances at 1514 and 2220, each to satisfy the "Once per 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> thereafter Completion Time, were inadvertently not completed in their entirety; one page of the Attachment A was missing in each copy of the procedure and was not discovered during the performance of the SR. The missed step was a check of electrical grid frequency.
At 0411 CST on December 4, 2012, "B" EDG was restored to operable and thus the LCO 3.8.1 was met and Required Action B.1 was no longer applicable.
At 0845 CST on December 5, 2012, to satisfy the routine weekly SR 3.8.1.1 Frequency, OP-KW-OSP-MISC- 002 was completed in its entirety with acceptable results.
At approximately 1100 CST on December 10, 2012, during procedure reviews, operators discovered that one page of Attachment A was missing for each of the 1514 and 2220 performances of OP-KW-OSP-MISC- 002. This incomplete Attachment A was due to human error when copies were not page checked prior to use, and the missing page was not discovered during the performance of the SR. Upon discovery one week later, a prompt review of computer trend data for that time period showed the SR 3.8.1.1 acceptance criteria were met. At this time of discovery, LCO 3.8.1 was met and Required Action B.1 was no longer applicable.
Condition Report CR499645 was initiated to document the incomplete SR 3.8.1.1.
Event and Safety Consequence Analysis At the time of discovery of not having performed the Required Action B.1 within the required Completion Time, the LCO 3.8.1 was met and the Required Action B.1 was no longer applicable. Also, a prompt review of computer trend data for the time period of the missed Required Action showed that the SR 3.8.1.1 acceptance criteria to have been met. Therefore, it was concluded that the safety consequence of this event was minimal.
Cause
An Operations department Human Performance Review Board found the cause of this event to be due to human error when copies of the SR 3.8.1.1 procedure data sheets were not page checked prior to use, and the missing page was not discovered during the performance of the SR.
Corrective Actions
Immediate corrective actions taken were:
1. A prompt review, on December 10, 2012, of computer trend data was performed for the time period of the missed Required Action. That data review showed that the SR 3.8.1.1 acceptance criteria to have been met throughout that time period.
2. Lessons learned from this human performance error were sent out to the Operating Crews on December 10, 2012.
No additional corrective actions are planned.
Similar Events A review of Licensee Event Reports covering the last three years did not identify any similar events.