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CNSS913nS2 february 1, 1991 U.S. Nuclear Reguiatory Commission Document Control Desk Washington, D.C.
20555
Dear Sir:
Cooper Nuclear Station Licensee Event Report 91001, Revision 0, is being forwarded as an attachment to this letter.
Sincerely,
)wMAw J
M. Meacham (ik vision Manager of Nuclear Operations Cooper Nuclear Station JMM:bjs Attachment cc:
R. D. Martin G. R. Horn R. E. Wilbur V. L. Wolstenholm D. A. Whitman INP0 Records Center ANI Library NRC Resident Inspector R. J. Singer CNS Training CNS Quality Assurance I l 7
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Unplonned Actuation of Group VI i solat ion Du r i ng.Sur ve illanc e
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On January 7, 1991, at 1:38 pm, with the plant in operation at full power, an unplanned actuation of the Group VI Isolation logic occurred, resulting in isolation of the Secondary Containment and initiation of the Standby Cas j
Treatment (SCT) System.
The actut. tion occurred due to incorrect placement of a jumper during performance of Surveillance Procedure 6.3.7.5, Reactor Building Ventilation Radiation Monitor Source Check, which was being performed by 160 trainees, under the supetvision of qualified 160 Technicians.
The procedure was being conducted as a regularly scheduled surveillance test and as an On.the. Job Training (CJT) exercise.
The cause of the unplanned actuai. ion was the failure of both the qualified Technician, acting as an OJT Instructor, and the trainee to refer to the
- - procedure step prior to installation of the jumper.
Corrective action taken included test termination, jumper removal, reset of the Group VI Isolation, and restoracion of Reactor Building ventilation to normal.
The procedure was eviewed and determined to be satisfactory from a content and human factors standpoint.
Both the qualified I&C Technician and the trainee were counseled.
Further corrective action to be taken includes incorporation of this event in Industry Events training for 160 Technicians, wxc..n,ix.is n,
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Event Description
On January 7,1991, at 1:38 pm, an unplanned Croup VI Isolation occurred while performing surveillance testing.
Surveillance Procedure 6.3.7.$,
Reector Building Ventilation Radiation Monitor Source Check, was being performed as a regularly scheduled surveillance test and as an On.the. Job Training (0JT) exercise. The test had proceeded to the point where the first of the two monitors had been successfully tested, and the trairees had been reassigned to nev " stations",
In setting up for h test of the second monitor, RMP.RM 452B, the trainee in the Control Room was instructed to install a jumper at the location pointed out to him by the qualified Technician. However, neither the qualified Technician nor the trainee referred to the procedure step, nor rechecked
- - their work, to ensure jumper location was correct.
In fact, the jumper was installed where it had previously been installed during testing of RMP.RM.452A.
Consequently, several steps later in the procedure, when monitor RMP.RM-452B was exposed to the source, u trip signal was
. generated in the Group VI ESP logic, resulting in isolation of Secondary Containment and initiation of the Standby Cas rre a t.mont (SGT) System.
. B,'
Plant Status I
The plant was in normal operation at full power.
- - C.
Ensis for Deport An unplanned actuation of an EST (Group VI Isolation), reportable in accordance with 10CFR50,73 (a)(2)(iv).
D.
Cause
Personnel. Neither the qualified 160 Technician nor the trainee consulted the procedure step for exact jumper placement, nor rechecked their work after placement, to' ensure its installation in the correct location.
E.
Safety Significance
No significant effect.
Other than isolation of the Secondary Containment and startup of the SGT System, plant operation was unaffected. The Group VI Isolation ESF functioned as designed.
F.
Safety Two11entions
- - Upon Secondary Containment isolation, ventilation to the Reactor
. Recirculation Pump Motor Generator (RRMG) Sets is lost.
If ventilation is not immediately restored, the RRMG Sets may trip due to high winding temperatures, resulting in loss of the Reactor Recire (RR) Pumps.
This consideration has a high probability of occurrence during hot weather conditions with the plant at full power.
Upon loss of the RR Pumps, a plant trip may result. Regardless, plant recovery will require that the plant be shut down, w:c e ma ine,
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Corrective Action
The surveillance test was terminated, the jumper removed, the isolation signal was reset, at.d normal Reactor Building ventilation was restored.
The procedure was reviewed and determined to be satisfactory frora a content and human factors standpoint. Following confirmation of the cause of the trip and review of the procedure, the surveillance test was satisfactorily completed.
Both the qualified Technician and the trainee were counseled regarding their failures to implement procedural requirements, rurther corrective actions to be taken includes incorporating this event in Industry Events training for 16C Technicians.
II.
Similar Events
88 017 Unplanned Automatic Actuation of Engineered Safety Features Due to llaman Error During Surveillance Testing, uxco m.w>
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| 05000298/LER-1991-001, :on 910107,unplanned Actuation of Group IV Isolation Logic Occurred.Caused by Incorrect Placement of Jumper.Event Incorporated in Industry Events Training for I&C Technicians |
- on 910107,unplanned Actuation of Group IV Isolation Logic Occurred.Caused by Incorrect Placement of Jumper.Event Incorporated in Industry Events Training for I&C Technicians
| | | 05000298/LER-1991-002, :on 910324,reactor Water Cleanup Isolation Occurred Due to High Sys Temp.Caused by Inadequate Design. Design Process for Plant Changes Strengthened Since Design Completed |
- on 910324,reactor Water Cleanup Isolation Occurred Due to High Sys Temp.Caused by Inadequate Design. Design Process for Plant Changes Strengthened Since Design Completed
| | | 05000298/LER-1991-003, :on 910325,unplanned Actuation of Group IV Isolation Occurred During Testing.Caused by Personnel Error & Procedure Deficiency.Procedure Change Being Processed Providing Improved Direction for Action |
- on 910325,unplanned Actuation of Group IV Isolation Occurred During Testing.Caused by Personnel Error & Procedure Deficiency.Procedure Change Being Processed Providing Improved Direction for Action
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000298/LER-1991-004, :on 910326,unplanned Automatic Startup of Diesel Generator 1 Occurred.Caused by Inadequate Planning & Poor Communications.Shutdown Cooling Restored & Sys Realigned Prior to Configuration |
- on 910326,unplanned Automatic Startup of Diesel Generator 1 Occurred.Caused by Inadequate Planning & Poor Communications.Shutdown Cooling Restored & Sys Realigned Prior to Configuration
| | | 05000298/LER-1991-005, :on 910511,unplanned Startup of Diesel Generator Number 2 Occurred Due to Equipment Deficiency During Plant Startup.Caused by Insufficent Action of Breaker.Breaker Shimmed & Reinstalled |
- on 910511,unplanned Startup of Diesel Generator Number 2 Occurred Due to Equipment Deficiency During Plant Startup.Caused by Insufficent Action of Breaker.Breaker Shimmed & Reinstalled
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000298/LER-1991-006, :on 910709,safety Setting for 4,160-volt Loss of Voltage Relays Incorrectly Reflected Original Design Basis Requirements.Caused by Misstatement in Tech Specs. Emergency TS Change Submitted on 910717 |
- on 910709,safety Setting for 4,160-volt Loss of Voltage Relays Incorrectly Reflected Original Design Basis Requirements.Caused by Misstatement in Tech Specs. Emergency TS Change Submitted on 910717
| 10 CFR 50.73(a)(2)(1) | | 05000298/LER-1991-007, :on 910730,fan Coil Units Declared Inoperable. Caused by Inadequacies in Original Design.All Safety Related Fan Coil Units Verified to Be Correctly Supported |
- on 910730,fan Coil Units Declared Inoperable. Caused by Inadequacies in Original Design.All Safety Related Fan Coil Units Verified to Be Correctly Supported
| 10 CFR 50.73(a)(2)(v), Loss of Safety Function 10 CFR 50.73(a)(2) 10 CFR 50.73(a)(2)(1) | | 05000298/LER-1991-008, :on 910826,valve RHR-MO-M057 Exceeded TS Closure Time During Surveillance Testing.On 910917,valve Not Deactivated During Period of Inoperability.Caused by Personnel Failure.Personnel Counseled |
- on 910826,valve RHR-MO-M057 Exceeded TS Closure Time During Surveillance Testing.On 910917,valve Not Deactivated During Period of Inoperability.Caused by Personnel Failure.Personnel Counseled
| 10 CFR 50.73(a)(2)(1) | | 05000298/LER-1991-009, :on 910904 & 09,two Unplanned Group 6 Isolations Occurred Due to Spurious Loss of Power.Caused by Faulty Voltage Regulator Card.Defective Card Replaced.W/ |
- on 910904 & 09,two Unplanned Group 6 Isolations Occurred Due to Spurious Loss of Power.Caused by Faulty Voltage Regulator Card.Defective Card Replaced.W/
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000298/LER-1991-010, :on 911002,group 3 Isolation (RWCU Sys) Occurred Due to High Temp Conditions Downstream of Nonregenerative Hxs.Caused by Hot Water Drawn Into Section of Piping.Procedure Change to Be Processed |
- on 911002,group 3 Isolation (RWCU Sys) Occurred Due to High Temp Conditions Downstream of Nonregenerative Hxs.Caused by Hot Water Drawn Into Section of Piping.Procedure Change to Be Processed
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000298/LER-1991-011, :on 911007,RPS Trip & Actuation of Groups 2 & 3 Isolations Occurred.Caused by Either Air Through Leg Injection Solenoid Valve or Water Leakage Through Solenoid Valve.Backflushing Will Be Conducted |
- on 911007,RPS Trip & Actuation of Groups 2 & 3 Isolations Occurred.Caused by Either Air Through Leg Injection Solenoid Valve or Water Leakage Through Solenoid Valve.Backflushing Will Be Conducted
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000298/LER-1991-012, :on 911015,unplanned ESF Actuations Occurred During Design Change Activities Resulting from Personnel Error,Human Factors & Inadequate Precautions for Work in Sensitive Areas.Written Guidelines Developed |
- on 911015,unplanned ESF Actuations Occurred During Design Change Activities Resulting from Personnel Error,Human Factors & Inadequate Precautions for Work in Sensitive Areas.Written Guidelines Developed
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000298/LER-1991-013, :on 911018,continuous Fire Watch Not Established for Obstructed Fire Door to Steam Tunnel.Caused by Personnel Error & Procedural Deficiency.Roving Fire Watch Initiated & Procedures Upgraded |
- on 911018,continuous Fire Watch Not Established for Obstructed Fire Door to Steam Tunnel.Caused by Personnel Error & Procedural Deficiency.Roving Fire Watch Initiated & Procedures Upgraded
| 10 CFR 50.73(a)(2)(1) | | 05000298/LER-1991-014, :on 911030,unplanned Actuation of Group 6 Isolation Occurred.Caused by Improper Selection of Uninsulated Metal Clip for Surveillance Testing.Uninsulated Metal Clips Replaced During Refueling Outage |
- on 911030,unplanned Actuation of Group 6 Isolation Occurred.Caused by Improper Selection of Uninsulated Metal Clip for Surveillance Testing.Uninsulated Metal Clips Replaced During Refueling Outage
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000298/LER-1991-015, :on 911105,discovered That as-found Setpoint for Safety/Relief Valves Not within Tech Spec Limit of Plus or Minus 1% (11 Psi).Caused by Setpoint Drift.Valves Inspected,Refurbished & Retested |
- on 911105,discovered That as-found Setpoint for Safety/Relief Valves Not within Tech Spec Limit of Plus or Minus 1% (11 Psi).Caused by Setpoint Drift.Valves Inspected,Refurbished & Retested
| | | 05000298/LER-1991-016, :on 911110,spurious RPS Trip Occurred While Shut Down Due to Decontamination Activities.Caused by Programmatic Deficiency in That Precautions Were Not Taken. Pertinent Procedures Will Be Upgraded |
- on 911110,spurious RPS Trip Occurred While Shut Down Due to Decontamination Activities.Caused by Programmatic Deficiency in That Precautions Were Not Taken. Pertinent Procedures Will Be Upgraded
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000298/LER-1991-017, :on 911123,fuse 16A-F21 Blew Upon Removal of Circuit Lead Resulting in Actuation of RCS Primary & Secondary Contaiment Isolation Valves.Cause Unknown.Fused Replaced,Circuit Reenergized & Tested |
- on 911123,fuse 16A-F21 Blew Upon Removal of Circuit Lead Resulting in Actuation of RCS Primary & Secondary Contaiment Isolation Valves.Cause Unknown.Fused Replaced,Circuit Reenergized & Tested
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000298/LER-1991-018, :on 910323,4160 Volt Circuit Breaker 1CN Failed to Open Upon Actuation of Breaker Control Switch Roller Mechanism.Caused by Hardened Lubricant.Trip Latch & Cam Rollers of All 4160 Volt Breakers Removed |
- on 910323,4160 Volt Circuit Breaker 1CN Failed to Open Upon Actuation of Breaker Control Switch Roller Mechanism.Caused by Hardened Lubricant.Trip Latch & Cam Rollers of All 4160 Volt Breakers Removed
| 10 CFR 50.73(a)(2)(v), Loss of Safety Function | | 05000298/LER-1991-019, :on 911209,shutdown Cooling High Suction Pressure Interlock Actuated Due to Momentary Pressure Transient Caused by Starting RHR Pump.Procedure Change Will Be Processed |
- on 911209,shutdown Cooling High Suction Pressure Interlock Actuated Due to Momentary Pressure Transient Caused by Starting RHR Pump.Procedure Change Will Be Processed
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000298/LER-1991-020, :on 911210,drywell Vent Radiation Monitor Gaseous Detector Mounting Bolt Threaded Engagement Failed & Leak Rate Exceeded TS Requirements.Caused by Degraded Shield Chamber.Bolt Holes Retapped |
- on 911210,drywell Vent Radiation Monitor Gaseous Detector Mounting Bolt Threaded Engagement Failed & Leak Rate Exceeded TS Requirements.Caused by Degraded Shield Chamber.Bolt Holes Retapped
| 10 CFR 50.72(b)(3)(ii), Degraded or Unanalyzed Condition 10 CFR 50.73(a)(2)(1) | | 05000298/LER-1991-021, :on 911214,automatic Start of 1 DG & Actuation of Group 2,3,6 & 7 Isolation Occurred.Caused by Inadvertent Failure of Licensed Operator to Perform Specified Action. Personnel Invloved Will Be Counselled |
- on 911214,automatic Start of 1 DG & Actuation of Group 2,3,6 & 7 Isolation Occurred.Caused by Inadvertent Failure of Licensed Operator to Perform Specified Action. Personnel Invloved Will Be Counselled
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000298/LER-1991-022, :on 911221,partial Group 3 Isolation Received, Causing One of Two Inlet Isolation Valves to Close.Caused by Actuation of Differential Pressure Flow Switch.Switch Guard Has Been Installed Around Switch |
- on 911221,partial Group 3 Isolation Received, Causing One of Two Inlet Isolation Valves to Close.Caused by Actuation of Differential Pressure Flow Switch.Switch Guard Has Been Installed Around Switch
| 10 CFR 50.73(a)(2)(iv), System Actuation |
|