07-17-2017 | On May 19, 2017, at 0206 hours0.00238 days <br />0.0572 hours <br />3.406085e-4 weeks <br />7.8383e-5 months <br />, an unexpected Reactor Protection System ( RPS) actuation occurred during pre-startup testing. The reactor was shutdown at the time, with all control rods inserted. The portion of the test that was in progress is designed to actuate the RPS from a loss of load input signal. To facilitate this part of the test with the reactor in a shutdown mode, one of two conditional steps in the procedure is to be taken. The generator motor operated disconnect 389 (MOD-389) is required to be in the open position, or protective trip circuity for the generator is required to be bypassed.
Due to a conditional step of the test procedure being misinterpreted by a Nuclear Control Operator (NCO), MOD-389 was left in the closed position and the generator protective trip circuity was not bypassed. This resulted in the RPS actuation occurring prior to the preplanned sequence. The RPS responded as designed. All components operated as expected for the plant conditions.
The cause of the unexpected RPS actuation was human performance errors during procedure performance, e.g., lack of self-validation/verification, misinterpretation of information, and lack of peer check verification.
Corrective actions from the event include the removal of the NCO's licensed operator qualifications until remediated and initiation of a standing order requiring peer check verification for all procedure conditional steps until the applicable administrative procedure is revised. Additionally, a case study of the event will be included in a 2017 operations high intensity training session. |
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LER-2017-002, Reactor Protection System Actuation While the Reactor was ShutdownPalisades |
Event date: |
05-19-2017 |
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Report date: |
07-17-2017 |
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2552017002R00 - NRC Website |
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Category:Letter
MONTHYEARML24312A2262024-11-0606 November 2024 Letter from C. Nelson, Michigan SHPO Regarding Palisades Nuclear Plant Architectural Survey ML24292A1572024-11-0505 November 2024 Ape Notification to Burt Lake Band Palisades ML24310A0142024-11-0505 November 2024 Ape Notification to Mackinac Bands of Chippewa Palisades ML24310A0132024-11-0505 November 2024 Ape Notification to Grand River Bands of Ottawa Indians Palisades ML24309A2032024-11-0404 November 2024 Ape Notification to Ottawa Tribe of Oklahoma Palisades ML24309A1972024-11-0404 November 2024 Ape Notification to Little Traverse Bay Bands of Odawa Indians Palisades ML24309A1982024-11-0404 November 2024 Ape Notification to Match E Be Nash She Wish Band of Pottawatomi Indians Palisades ML24309A1872024-11-0404 November 2024 Ape Notification to Grand Portage Band of Lake Superior Chippewa Palisades ML24309A2072024-11-0404 November 2024 Ape Notification to Quechan Tribe of the Fort Yuma Indian Reservation Palisades ML24309A1832024-11-0404 November 2024 Ape Notification to Bois Forte Band of the Minnesota Chippewa Tribe Palisades ML24309A2122024-11-0404 November 2024 Ape Notification to Sault Ste. Marie Tribe of Chippewa Indians Palisades ML24309A2042024-11-0404 November 2024 Ape Notification to Pokagon Band of Potawatomi Indians Palisades ML24292A0492024-11-0404 November 2024 Ape Notification to Bad River Band of the Lake Superior Tribe of Chippewa Indians Palisades ML24309A1932024-11-0404 November 2024 Ape Notification to Leech Lake Band of Ojibwe Palisades ML24309A2012024-11-0404 November 2024 Ape Notification to Mille Lacs Band of Ojibwe Palisades ML24309A1922024-11-0404 November 2024 Ape Notification to Lac Vieux Desert Band of Lk Superior Chippewa Indians Palisades ML24309A1892024-11-0404 November 2024 Ape Notification to Hannahville Indian Community Palisades ML24309A2002024-11-0404 November 2024 Ape Notification to Miami Tribe of Oklahoma Palisades ML24309A1952024-11-0404 November 2024 Ape Notification to Little River Band of Ottawa Indians Palisades ML24309A2112024-11-0404 November 2024 Ape Notification to Saint Croix Chippewa Indians of Wisconsin Palisades ML24309A1902024-11-0404 November 2024 Ape Notification to Lac Courte Oreilles Band of Lake Superior Chippewa Palisades ML24309A2022024-11-0404 November 2024 Ape Notification to Nottawaseppi Huron Band of the Potawatomi Palisades ML24309A1852024-11-0404 November 2024 Ape Notification to Citizen Potawatomi Nation Palisades ML24309A2142024-11-0404 November 2024 Ape Notification to White Earth Band of Minnesota Chippewa Tribe Palisades ML24309A2092024-11-0404 November 2024 Ape Notification to Red Lake Band of Chippewa Indians Palisades ML24309A1862024-11-0404 November 2024 Ape Notification to Forest County Potawatomi Community Palisades ML24309A1822024-11-0404 November 2024 Ape Notification to Bay Mills Indian Community Palisades ML24309A2052024-11-0404 November 2024 Ape Notification to Prairie Band Potawatomi Nation Palisades ML24309A2102024-11-0404 November 2024 Ape Notification to Saginaw Chippewa Indian Tribe of Michigan Palisades ML24309A2082024-11-0404 November 2024 Ape Notification to Red Cliff Band of Lake Superior Chippewa Indians Palisades ML24309A1992024-11-0404 November 2024 Ape Notification to Menominee Indian Tribe of Wisconsin Palisades ML24292A0072024-11-0404 November 2024 Ape Notification to Achp Palisades ML24309A1882024-11-0404 November 2024 Ape Notification to Grand Traverse Band of Ottawa and Chippewa Indians Palisades ML24309A1842024-11-0404 November 2024 Ape Notification to Chippewa Cree Indians of the Rocky Boys Reservation of Montana Palisades ML24309A1912024-11-0404 November 2024 Ape Notification to Lac Du Flambeau Band of Lake Superior Chippewa Indians Palisades ML24309A2132024-11-0404 November 2024 Ape Notification to Turtle Mountain Band of Chippewa Indians Palisades ML24309A2062024-11-0404 November 2024 Ape Notification to Prairie Island Indian Community Palisades PNP 2024-014, Request for USNRC to Rescind Approved Exemption Requests for 140.11(a)(4) and 50.54(w)(1), Reduction of Insurances2024-10-0909 October 2024 Request for USNRC to Rescind Approved Exemption Requests for 140.11(a)(4) and 50.54(w)(1), Reduction of Insurances PNP 2024-037, Response to Requests for Additional Information Regarding the Proposed Reauthorization of Power Operations Under Renewed Facility Operating License Number DPR-0202024-10-0404 October 2024 Response to Requests for Additional Information Regarding the Proposed Reauthorization of Power Operations Under Renewed Facility Operating License Number DPR-020 ML24267A2962024-10-0101 October 2024 Summary of Conference Call Regarding Steam Generator Tube Inspections ML24263A1712024-09-20020 September 2024 Environmental Request for Additional Information ML24240A1692024-09-18018 September 2024 Cy 2023 Summary of Decommissioning Trust Fund Status ML24219A4202024-09-12012 September 2024 Change in Estimated Hours and Review Schedule for Licensing Actions Submitted to Support Resumption of Power Operations (Epids L-2023-LLE-0025, L-2023-LLM-0005, L-2023-LLA-0174, L-2024-LLA-0013, L-2024-LLA-0060, L-2024-LLA-0071) IR 05000255/20244022024-09-0606 September 2024 Public: Palisades Nuclear Plant - Decommissioning Security Inspection Report 05000255/2024402 PNP 2024-029, Notice of Payroll Transition at Palisades Nuclear Plant2024-08-15015 August 2024 Notice of Payroll Transition at Palisades Nuclear Plant IR 05000255/20240022024-08-0909 August 2024 NRC Inspection Report No. 05000255/2024002 PNP 2024-030, Update Report for Holtec Decommissioning International Fleet Decommissioning Quality Assurance Program Rev. 3 and Palisades Transitioning Quality Assurance Plan, Rev 02024-08-0202 August 2024 Update Report for Holtec Decommissioning International Fleet Decommissioning Quality Assurance Program Rev. 3 and Palisades Transitioning Quality Assurance Plan, Rev 0 PNP 2024-032, Supplement to License Amendment Request to Revise Selected Permanently Defueled Technical Specifications Administrative Controls to Support Resumption of Power Operations2024-07-31031 July 2024 Supplement to License Amendment Request to Revise Selected Permanently Defueled Technical Specifications Administrative Controls to Support Resumption of Power Operations ML24206A0572024-07-25025 July 2024 PRM-50-125 - Letter to Alan Blind; Docketing of Petition for Rulemaking and Sufficiency Review Status (10 CFR Part 50) PNP 2024-033, Response to Request for Additional Information - License Amendment Request to Revise the Palisades Nuclear Plant Site Emergency Plan to Support Resumption of Power Operations2024-07-24024 July 2024 Response to Request for Additional Information - License Amendment Request to Revise the Palisades Nuclear Plant Site Emergency Plan to Support Resumption of Power Operations 2024-09-06
[Table view] Category:Licensee Event Report (LER)
MONTHYEARML18344A4142018-12-10010 December 2018 LER 1979-037-00 for Palisades Nuclear Plant, Two Manual Three Inch Containment Isolation Valves in Bypass Line Were Discovered to Be Locked Open 05000255/LER-2017-0022017-07-17017 July 2017 Reactor Protection System Actuation While the Reactor was Shutdown, LER 17-002-00 for Palisades Regarding Reactor Protection System Actuation While the Reactor was Shutdown 05000255/LER-2017-0012017-05-24024 May 2017 Inadequate Protection from Tornado Missiles Identified Due to Nonconforming Design Conditions, LER 17-001-00 for Palisades Nuclear Plant Regarding Inadequate Protection from Tornado Missiles Identified Due to Nonconforming Design Conditions PNP 2014-100, Cancellation of Licensee Event Report (LER) 2004-002, Leak Indications Identified in Reactor Pressure Vessel Head Nozzle Penetrations2014-11-19019 November 2014 Cancellation of Licensee Event Report (LER) 2004-002, Leak Indications Identified in Reactor Pressure Vessel Head Nozzle Penetrations PNP 2011-009, Special Report of Inoperability of Main Steam Line Gross Gamma Activity Monitor2011-02-10010 February 2011 Special Report of Inoperability of Main Steam Line Gross Gamma Activity Monitor ML0726101822007-09-14014 September 2007 Cancellation of Licensee Event Report 07-003, Potential for Reduced Component Cooling Water Cooling Capability ML0609002832006-03-30030 March 2006 Cancellation of Licensee Event Report 05-006, Inoperable Containment Due to Containment Air Cooler Through-Wall Flaws ML18347B2971998-05-19019 May 1998 Submit, NPDES Notification Report, Incident No. Pal-98-05-NC138 for NPDES Permit No MI0001457 Re Difference from Daily Maximum Effluent Limitation for Facility ML18348A9021989-02-0707 February 1989 LER 1988-005-01 for Palisades, Inadequate Procedure Results in Valve Testing During Prohibited Conditions ML18346A2471981-06-19019 June 1981 LER 1981-020-00 for Palisades Nuclear Plant, Pcs Unidentified Leakage Greater than 1.0 Gpm ML18346A2481981-05-13013 May 1981 LER 1981-015-00 for Palisades Nuclear Plant, Safety Injection Tank Boron Concentration ML18346A2491981-02-20020 February 1981 LER 1981-005-00 for Palisades Nuclear Plant, Update - Inoperable Diesel Generator ML18346A2501981-02-19019 February 1981 LER 1981-007-00 for Palisades Nuclear Plant, Inoperable Auxiliary Feedwater Pump ML18346A2511981-01-26026 January 1981 LER 1981-002-00 for Palisades Nuclear Plant, Inadequate Mounting of DC Distribution Panel ML18346A2521981-01-16016 January 1981 LER 1981-001-00 for Palisades Nuclear Plant, During Charging of Station Batteries, Output Breakers of Both Batteries Were Inadvertently Opened for Approximately One Hour ML18346A2531981-01-14014 January 1981 LER 1980-046-00 for Palisades Nuclear Plant, Hydraulic Snubber Failure ML18346A2541981-01-0707 January 1981 LER 1980-045-00 for Palisades Nuclear Plant, Low Condensate Makeup Inventory ML18347A8141980-10-10010 October 1980 LER 1980-037-00 for Palisades Nuclear Plant, Pipe Support Sway Struts Identified to Have the Potential of the Bushing Becoming Loose And/Or Disengaged from the Clamp End of the Sway Strut ML18347A8461980-08-27027 August 1980 License Event Report 1980-027-00 Re Gaseous Release, Extended Due Date of Reporting by Region III on 8/26/1980 ML18347A8471980-08-12012 August 1980 License Event Report 1980-024-00 Re Containment High Radiation Monitor ML18347A8481980-08-0808 August 1980 License Event Report 1980-023-00 Re Containment High Radiation Monitor ML18347A8491980-08-0808 August 1980 License Event Report 1980-022-00 Re Inoperable Nuclear Instrumentation ML18347A8501980-08-0606 August 1980 License Event Report 1980-021-00 Re Misaligned Containment Sump Valve ML18347A8521980-07-29029 July 1980 License Event Report 1980-020-00 Re Misaligned Control Rod ML18347B2071980-06-19019 June 1980 Licensee Event Report 80-018 Regarding Oil Level in Snubber No. 2 Found to Be Less than Zero During Routine Testing of Hydraulic Snubbers ML18347B2081980-06-13013 June 1980 Licensee Event Reports 80-014, 80-015, and 80-016 Regarding Oil Level in Snubbers No. 5, 9, and 7 Were Found to Be Less than Zero During Routine Testing of Hydraulic Snubbers ML18347B2091980-05-15015 May 1980 Licensee Event Report 80-012 Regarding Bottom Half of the Barrier for Fire Penetration HO-12 Was Missing During Inspection of Fire Barriers ML18347B2101980-05-14014 May 1980 License Event Report 1980-011-00 Re Improper Return-to-Service of Porv'S ML18348A9071980-05-12012 May 1980 Submittal of LER 1980-006-00 Purge Valve T-Ring Air Supplies ML18348A9051980-05-12012 May 1980 Submittal of LER 1980-008-00 Update of Valve Leakage ML18347B1411978-09-0606 September 1978 LER 1978-029-00 for Palisades Plant Re Lower Level of Hydrazine in Iodine Removal Tank Due to Approximately 6% of Drainage from the Tank T-102 ML18347B1421978-08-18018 August 1978 LER 1978-028-00 for Palisades Plant Re Containment Building Purge Valve T-Ring in CV-1806 Was Not Pressurized ML18347B1441978-08-11011 August 1978 LER 1978-022-00 for Palisades Plant Re Four Incore Alarms Following Reactor Start-up ML18347B1451978-08-10010 August 1978 LER 1978-021-00 for Palisades Nuclear Plant, Containment Purge Supply Valve CV-1808 Failed to Open During Monthly Test ML18347B1491978-07-20020 July 1978 LER 1978-024-00 & LER 1978-025-00 for Palisades Nuclear Plant, Steam Generator Ph Dropped to 8.02 & One of Two Heaters for T-53B (Concentrated Boric Acid Tank) Failed ML18347B1781978-04-28028 April 1978 License Event Report LER-78-000-00 Re Out-of-Sequence Rod Withdrawal ML18347B1801978-04-19019 April 1978 License Event Report 78-008: Cycle 2 Core Axial Power Distribution Limits of TS 3.10.3 Were Exceeded by Approximately 12% for Steady State Operation During Cycle 2 ML18347B1811978-03-27027 March 1978 License Event Report 1978-007-00 Relates to Electrical Connectors Inside of Containment ML18347B1841978-03-13013 March 1978 Two Updated License Event Reports, LER-78-004 & LER-78-006 ML18348A1951978-03-0202 March 1978 License Event Report 1978-006-00 Re Shipping Cask Movement ML18347B1851978-03-0202 March 1978 License Event Report 1978-005-00 Re Steam Generator Level Instrumentation ML18348A1961978-03-0101 March 1978 License Event Report 1978-004-00 Re Steam Generator Pressure Instrumentation ML18348A1981978-02-0101 February 1978 License Event Report 1978-003-00 Re CV-3025 Failed Closed ML18348A1971978-02-0101 February 1978 License Event Report 1977-065-00 Re Operation in a Degraded Mode Permitted by a Limiting Condition for Operation ML18348A1991978-01-20020 January 1978 LER 1977-063-00 Re Iodine Removal System Hydrazene Tank, LER 1978-001-00 Re Containment Door Interlock Failure & LER 1978-002-00 Re Setpoints of Five Valves Were Outside Band ML18348A2001978-01-0606 January 1978 License Event Report 1977-062-00 Re Iodine Removal System Naoh Tank (T-103) ML18348A2011978-01-0606 January 1978 License Event Report 1977-064-00 Re HPSI Pump P-66B ML18348A2021977-12-21021 December 1977 LER 1977-054-00 Re Four Coincident In-Core Alarms, LER 1977-057-00 Re Pressure Set Point for Channel C, & LER 1977-058-00 Re De-Energized R Bus ML18348A2031977-12-16016 December 1977 License Event Report 1977-055-00 Re Loss of Off-Site Power and Plant Trip ML18348A2041977-12-12012 December 1977 License Event Report 1977-056-00 Re Gaseous Waste Discharge 2018-12-10
[Table view] |
Infocollects Resource@nrc gov, and to the Desk Officer, Office of Information and Regulatory Affairs, used to impose an Information collection does not display a currently valid OMB control number, the NRC may not conduct or sponsor, and a person Is not required to respond to, the information collection.
461 05000-255 Palisades
NO
- 00 - 002 2017
EVENT DESCRIPTION
On May 19, 2017, at 0206 hours0.00238 days <br />0.0572 hours <br />3.406085e-4 weeks <br />7.8383e-5 months <br />, an unexpected Reactor Protection System (RPS) actuation occurred during pre-startup testing.
The reactor was shutdown at the time, with all control rods inserted. The portion of the test that was in progress is designed to actuate the RPS on loss of load signal. To facilitate this part of the test with the reactor in a shutdown mode, one of two conditional steps in the procedure is to be taken. The generator motor operated disconnect 389 (MOD-389) is required to be in the open position, or protective trip circuity for the generator is required to be bypassed. Due to a conditional step of the test procedure being misinterpreted by a Nuclear Control Operator (NCO), MOD-389 was left in the closed position and the generator protective trip circuity was not bypassed. This resulted in the RPS actuation occurring prior to the preplanned sequence. The RPS responded as designed. All components operated as expected for the plant conditions. No structures, components, or systems were inoperable at the start of the event that contributed to the event. A Safety System Functional Failure, as defined in Nudear Energy Institute 99-02, "Regulatory Assessment Performance Indicator Guideline," did not occur.
CAUSE OF THE EVENT
A conditional step in the test procedure required the NCO to verify the status of MOD-389. The procedure logic directs the sequence of subsequent test steps based on the open/dose status of MOD-389. If MOD-389 is dosed, opening of a sliding link is required to bypass protective trip circuity for the generator. The NCO failed to correctly identify that MOD-389 was in the dosed position.
Believing MOD-389 was open, the next conditional step in the procedure to bypass the protective trip circuity for the generator was not performed. A subsequent step in the procedure, to manipulate a switch that activates turbine trip output functions, requires a peer check verification to ensure the correct switch is manipulated. The NCO obtained peer check support from a second NCO. As required by the test procedure, the second NCO only peer checked the step that ensures the correct switch was manipulated. The previous conditional step, to ensure MOD-389 was in the open position, did not require peer check verification.
The cause of the unexpected RPS actuation was human performance errors during procedure performance, e.g., lack of self-validation/verification, misinterpretation of information and lack of peer check verification.
ASSESSMENT OF SAFETY CONSEQUENCES
There were no adverse safety consequences as a result of this event. The reactor was shutdown in Mode 5 at the time of the event, with all control rods inserted. The unexpected RPS actuation did not cause the loss of systems or components that are needed to maintain safe shutdown conditions, remove residual heat, control the release of radioactive material, or mitigate the consequences of an accident. All plant systems responded as designed.
CORRECTIVE ACTIONS
Corrective Actions Taken:
The NCO's licensed operator qualifications were removed until formal remediation was completed. A standing order was initiated to immediately require peer check verification of all procedure conditional steps.
Corrective Actions Planned:
Develop criteria that would require peer check verification of procedure conditional steps. Once the criteria are established, the applicable administrative procedure will be revised to add guidance for performance of peer check verifications associated with conditional steps in procedures. Additionally, a case study of the event will be developed and induded in a 2017 operations high intensity training session.
PREVIOUS SIMILAR EVENTS
None.
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05000255/LER-2017-001 | Inadequate Protection from Tornado Missiles Identified Due to Nonconforming Design Conditions LER 17-001-00 for Palisades Nuclear Plant Regarding Inadequate Protection from Tornado Missiles Identified Due to Nonconforming Design Conditions | | 05000255/LER-2017-002 | Reactor Protection System Actuation While the Reactor was Shutdown LER 17-002-00 for Palisades Regarding Reactor Protection System Actuation While the Reactor was Shutdown | |
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