05000237/LER-2008-001, Regarding Procedure Adherence Issue Results in Violation of Technical Specification
| ML080850904 | |
| Person / Time | |
|---|---|
| Site: | Dresden  |
| Issue date: | 03/17/2008 |
| From: | Wozniak D Exelon Generation Co, Exelon Nuclear |
| To: | Document Control Desk, Office of Nuclear Reactor Regulation |
| References | |
| SVPLTR # 08-0013 LER 08-001-00 | |
| Download: ML080850904 (5) | |
| Event date: | |
|---|---|
| Report date: | |
| Reporting criterion: | 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications 10 CFR 50.73(a)(2)(i) 10 CFR 50.73(a)(2)(vii), Common Cause Inoperability 10 CFR 50.73(a)(2)(ii)(A), Seriously Degraded 10 CFR 50.73(a)(2)(viii)(A) 10 CFR 50.73(a)(2)(ii)(B), Unanalyzed Condition 10 CFR 50.73(a)(2)(viii)(B) 10 CFR 50.73(a)(2)(iii) 10 CFR 50.73(a)(2)(ix)(A) 10 CFR 50.73(a)(2)(iv)(A), System Actuation 10 CFR 50.73(a)(2)(x) 10 CFR 50.73(a)(2)(v)(A), Loss of Safety Function - Shutdown the Reactor 10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat 10 CFR 50.73(a)(2)(i)(A), Completion of TS Shutdown 10 CFR 50.73(a)(2)(v), Loss of Safety Function |
| 2372008001R00 - NRC Website | |
text
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Generation Company, LLC www.exeloncorp.com Nuclear Dresden Nuclear Power Station 6500 North Dresden Road Morris, IL 60450-9765 10 CFR 50.73 SVPLTR # 08-0013 March 17, 2008 U. S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, DC 20555-0001 Dresden Nuclear Power Station, Unit No. 2 Renewed Facility Operating License No. DPR 19 NRC Docket No. 50-237
Subject:
Licensee Event Report 237/2008-001-00, "Procedure Adherence Issue Results in Violation of Technical Specification" Enclosed is Licensee Event Report 237/2008-001-00, "Procedure Adherence Issue Results in Violation of Technical Specification," for Dresden Nuclear Power Station Unit 2. This event is being reported in accordance with 10 CFR 50.73(a)(2)(i)(B), "Any operation or condition which was prohibited by the plant's Technical Specifications." There are no regulatory commitments contained in this submittal.
Should you have any questions concerning this report, please contact Mr. James Ellis, Regulatory Assurance Manager, at (815) 416-2800.
Respectfully, David B. Wozniak Site Vice President Dresden Nuclear Power Station Enclosure cc:
Regional Administrator - NRC Region III NRC Senior Resident Inspector - Dresden Nuclear Power Station
NRC FORM 366 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0104 EXPIRES: 08/31/2010 (9-2007)
, the NRC may digits/characters for each block) not conduct or sponsor, and a person is not required to respond to, the infnrmatinn n*lle.ctinn.
- 3. PAGE Dresden Nuclear Power Station, Unit 2 05000237 1 OF 4
- 4. TITLE Procedure Adherence Issue Results in Violation of Technical Specification
- 5. EVENT DATE
- 6. LER NUMBER
- 7. REPORT DATE
- 8. OTHER FACILITIES INVOLVED SEQUENTIAL REV FACILITY NAME DOCKET NUMBER MONTH DAY YEAR YEAR NUMBER NO.
MONTH DAY YEAR N/A N/A FACILITY NAME DOCKET NUMBER 11 19 2007 2008 001-00 03 17 2008 N/A N/A
- 9. OPERATING MODE
- 11. THIS REPORT IS SUBMIITED PURSUANT TO THE REQUIREMENTS OF 10 CFR §: (Check all that apply)
El 20.2201(b)
El 20.2203(a)(3)(i)
El 50.73(a)(2)(i)(C)
I]
50.73(a)(2)(vii) 2 E] 20.2201(d)
E] 20.2203(a)(3)(ii)
El 50.73(a)(2)(ii)(A)
El 50.73(a)(2)(viii)(A)
[] 20.2203(a)(1)
E] 20.2203(a)(4)
El 50.73(a)(2)(ii)(B)
El 50.73(a)(2)(viii)(B)
El 20.2203(a)(2)(i)
El 50.36(c)(1)(i)(A)
[I 50.73(a)(2)(iii)
El 50.73(a)(2)(ix)(A)
- 10. POWER LEVEL [I 20.2203(a)(2)(ii)
El 50.36(c)(1)(ii)(A)
[E 50.73(a)(2)(iv)(A)
El 50.73(a)(2)(x)
El 20.2203(a)(2)(iii)
El 50.36(c)(2)
[I 50.73(a)(2)(v)(A)
[1 73.71 (a)(4) 010 El 20.2203(a)(2)(iv)
El 50.46(a)(3)(ii)
El 50.73(a)(2)(v)(B)
El 73.71 (a)(5)
El 20.2203(a)(2)(v)
[] 50.73(a)(2)(i)(A)
[E 50.73(a)(2)(v)(C)
El OTHER El 20.2203(a)(2)(vi)
ED 50.73(a)(2)(i)(B)
El 50.73(a)(2)(v)(D)
Specify in Abstract below or in =
Dresden Nuclear Power Station (DNPS) Unit 2 is a General Electric Company Boiling Water Reactors with a licensed maximum power level of 2957 megawatts thermal.
A.
Plant Conditions Prior to Event:
Unit: 02 Event Date: 11-19-2007 Reactor Mode: 2 Mode Name: Startup Power Level: 10 percent Reactor Coolant System Pressure: Approximately 900 psig B.
Description of Event
On January 15, 2008, a DNPS Qualified Nuclear Engineer was performing mentoring with a reactor engineering trainee on control rod sequencing and discussing the reference documents used to prepare a sequence. One of the required reference documents identified was the results from the control rod drop accident analysis. As part of the discussion, the DNPS Unit 2 Cycle 21 and Unit 3 Cycle 20 cycle-specific control rod drop accident analyses were reviewed. During this review it was identified that the control rod sequence used for startup of Unit 2 following the refueling outage in November 2007 did not comply with the control rod drop accident analysis. The control rod pull order used in the analysis did not match the order used for the Unit 2 startup sequence. The analysis used control rod group pull sequence 3-4-1-2-7-8-10-9 while the Unit 2 startup sequence used control rod group pull sequence 3-4-1-2-8-7-10-9. A review of the Unit 2 conditions on November 19, 2007, identified that for approximately 5 1/2 hours the unit did not comply with the requirements of Technical Specification 3.1.6, "Rod Pattern Control."
This event is being reported in accordance with 10 CFR 50.73(a)(2)(i)(B), "Any operation or condition which was prohibited by the plant's Technical Specifications."
C.
Cause of Event
The Root Cause of this event was human performance and was attributed to failure of Dresden Nuclear Power Station personnel to follow procedures due to a lack of understanding of the requirements for using a Level 2 procedure and the qualified individual incorrectly assumed that the "Level 2 - Reference Use" procedures did not need to be reviewed in detail during preparation of the sequence.
The evaluation of this event identified the following:
0 The need for developing a control rod group pull sequence for the startup of DNPS Unit 2 following the November 2007 refuel outage was identified and scheduled to allow adequate time for the preparation, review and approval of the sequence.
0 An adequate pre-job brief was conducted with all individuals involved in the preparation, review and approval of the sequence. The pre-job brief identified the procedures required for the activity including NF-AB-720, "Control Rod Sequence Package Preparation, Review, Revision and Implementation," Revision 2, and NF-DR-721, "Control Rod Sequences and
Forms," Revision 3. Both procedures are classified as "Level 2 - Reference Use." Exelon procedure HU-AA-104-101, Revision 1, "Procedure Use and Adherence," defines the term "Level 2 - Reference Use" as a procedure requiring periodic referencing during the performance of an activity to confirm that all procedure segments of an activity have been performed, performing each step in the sequence specified and, where required, signing appropriate blocks to certify that all segments are completed. The procedure is required to be at the work location. Also, HU-AA-104-101 Step 4.3.2 states that all numbered steps are performed for "Level 1 - Continuous Use" and "Level 2 - Reference Use" procedures in sequence unless otherwise specified within the procedure or work order.
No procedural inadequacies were identified that would prevent an individual from developing a startup sequence that complies with the control rod drop accident analysis as there are a number of references to the control rod drop accident analysis through use of the term "Analyzed Rod Sequence" in NF-AB-720 and NF-DR-721. Analyzed Rod Sequence is defined as the order of rod withdrawal or insertion that has been analyzed to conform to control rod drop accident analysis requirements below the Low Power Setpoint utilizing a NRC approved methodology.
The evaluation did identify that the preparation and independent review of the control rod group pull sequence was flawed because the sequence developed by the DNPS personnel did not follow procedural requirements to develop a sequence that complies with the control rod drop accident analysis.
The following statements provided by DNPS personnel associated with this event confirmed this conclusion.
0 A detailed review of the sequencing procedures was not performed when preparing the startup sequence due to the procedures being Reference Use - Level 2.
A detailed review of the sequencing procedures was not performed when preparing the startup sequence, only selected sections were reviewed because the individual believed they knew how to perform the task and the procedures are 'reference use'. The individual's understanding of 'reference use' meant that all, part, or none of the procedure is reviewed based on the individual's confidence in their ability to perform the task.
0 The sequencing procedures were reviewed during the independent review of the startup sequence. The independent reviewer stated that it was assumed that the control rod drop accident analysis for Unit 2 was the same as Unit 3 and the individual knew what was in the Unit 3 analysis.
The corrective action to prevent recurrence of this event was to counsel and coach the individuals associated with this event.
A review of the control rod group pull sequence for the startup of DNPS Unit 3 following the refuel outage in November 2006 did not identify any flaws.
D.
Safety Analysis
The safety significance of the events is minimal.
A vendor analysis of the control rod group pull sequence used on November 19, 2007 for Unit 2 startup confirmed that the control rod drop accident analysis was met. Therefore, the consequences of the events had minimal impact on the health and safety of the public and reactor safety.
E.
Corrective Actions
The corrective action to prevent recurrence of this event was to counsel and coach the individuals associated with this event.
The requirements for the use of a "Level 2-Reference Use" procedure as specified in procedure HU-AA-104-101 was discussed with the individuals involved in this event.
A sample of documents prepared by DNPS reactor engineering personnel to a "Level 2-Reference Use" procedure will be reviewed for procedure compliance.
F.
Previous Occurrences
A review of DNPS LERs for the last three years did not identify any LERs associated with human performance that was attributed to failure of DNPS personnel to follow procedures due to a lack of understanding of the requirements for using a Level 2 procedure or assuming that the "Level 2 -
Reference Use" procedures did not need to be reviewed in detail during work.
G.
Component Failure Data
NA