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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML17241A4891999-10-0707 October 1999 LER 99-004-00:on 990912,noted That MSSV Surveillance Was Outside of TS Requirements.Caused by Setpoint Drift.Subject MSSVs Are Being Refurbished & Retested Prior to Unit Startup from SL1-16 Refueling Outage.With 991007 Ltr ML17241A4111999-07-16016 July 1999 LER 99-007-00:on 990610,unplanned Cooldown Transient Occurred Due to Personnel Error.Trained & Briefed Personnel & Revised Procedures.With 990716 Ltr ML17241A4031999-07-0606 July 1999 LER 99-006-00:on 990605,sub-critical Reactor Trip Occurred Due to Inadvertent MSIV Opening.Caused by Personnel Error. Provided Operation Supervision Instruction to Operating Crews,Stand Down Meetings & Operator Aids.With 990706 Ltr ML17241A4041999-07-0606 July 1999 LER 99-005-00:on 990604,CEA Drop Resulted in Manual Reactor Trip.Caused by Procedural Inadequacies.Procedure Changes Are Planned to Correct Lack of Procedural Guidance for CEA Subgroup Power Switch Replacement.With 990706 Ltr ML17241A3941999-06-30030 June 1999 LER 99-004-01:on 990415,as Found Cycle 10 Psv Setpoints Were Outside TS Limits.Caused by Manufacturing Process Defect. All Three Psvs Were Replaced with pre-tested Valves During Cycle 11 Refueling Outage.With 990630 Ltr ML17241A3551999-06-0404 June 1999 LER 99-002-00:on 990505,both Trains of Safety Injection Actuation Were Blocked During Surveillance.Caused by Procedure Error.Procedure Revised.With 990604 Ltr ML17241A3321999-05-17017 May 1999 LER 99-004-00:on 990415,determined That as Found Cycle 10 Psv Setpoints Outside TS Limits.Root Cause Under Investigation.Psvs Replaced with pe-tested Valves During Cycle 11 ML17241A3271999-05-0606 May 1999 LER 99-003-00:on 990406,ECCS Suction Header Leak Resulted in Both ECCS Trains Being Inoperable & Entry Into TS 3.0.3. Caused by Chloride Induced OD Stress Corrosion Cracking of Piping.Made Code Repairs & Coated Piping.With 990506 Ltr ML17229B0791999-04-0707 April 1999 LER 99-001-00:on 990309,discovered Inadequate Design & IST SRs for Iodine Removal Sys (Irs).Caused by Original Design Inadequacies & Personnel Error.Naoh Tank Vent Valve V07233 Was Tagged Open.With 990407 Ltr ML17229B0801999-04-0707 April 1999 LER 99-002-00:on 990311,SG ECT Error Caused Operation with Condition Prohibited by Ts.Caused by Deficiencies in Data Analysis Guideline Instructions.Licensee Will Change Data Analysis Guidelines for Lead Analysts.With 990407 Ltr ML17229B0541999-03-10010 March 1999 LER 99-001-00:on 990211,inadequate TS SRs for SIT & SDC Isolation Valves Were Noted.Caused by Failure to Correctly Implement TS Srs.Submitted LAR to Align Required TS SR with Design Bases Requirements Being Verified.With 990310 Ltr ML17229A9901999-01-20020 January 1999 LER 98-009-00:on 981223,noted That Facility Operated Outside of Design Basis.Caused by non-conservative MSLB Analysis Inputs.Will Review SR Component Differences Between Units & Will re-baseline LTOP Analysis.With 990120 Ltr ML17229A9821999-01-0404 January 1999 LER 98-010-00:on 981207,RCS Boron Sample Frequency Required by Ts,Was Exceeded by Twelve Minutes.Caused by Personnel Error.Equipment Clearance Order Was Lifted to Draw Required Sample & Operations Procedure Was Changed.With 990104 Ltr ML17229A9611998-12-22022 December 1998 LER 97-002-01:on 981204,containment Sump Debris Screen Was Not IAW Design.Caused by Inadequate C/As for Sump Screen Anamolies.All Identified Sump Screen Deficiencies Were Dispositioned &/Or Repaired.With 981222 Ltr ML17229A9561998-12-15015 December 1998 LER 98-008-00:on 981118,missed TS SG U Tube Insp.Caused by Encoding Errors While Using Remote Positioning Fixtures.All SG Tube Surveyed.With 981215 Ltr ML17229A9301998-11-25025 November 1998 LER 98-005-01:on 980807,discovered That New MOV Methodology Caused Past PORV Block Valve Operability Problem.Caused by Inadequacies in Original Vendor MOV Methodology.Planned Valve Mods Will Be Implemented During Cycle 11 1998 Outage ML17229A9021998-11-0404 November 1998 LER 98-008-00:on 981008,inadequate Reactor Protection Sys Trip Bypass TS Was Noted.Caused by Poorly Worded Ts. Submitted LAR to Clarify Power Requirements for High Rate of Power Trips.With 981104 Ltr ML17229A8771998-10-14014 October 1998 LER 98-006-00:on 980918,inadvertent Afas Actuation Was Noted.Caused by Degradation of Multiple Afas Power Supplies. Replaced Afas Power Supplies & Revised Procedures.With 981014 Ltr ML17229A8761998-10-14014 October 1998 LER 98-007-00:on 980918,identified Discrepancies Between Fire Protection Design Requirements & Field Conditions. Caused by Inadequate Translation & Implementation of Fire Protection Requirements.Procedures Revised.With 981014 Ltr ML17229A8511998-09-0202 September 1998 LER 98-005-00:on 980807,discovered That PORV Margins Were Insufficient to Accommodate Addl Conservatism.Caused by Inadequacies in Original Vendor MOV Methodology.Will Implement Planned Valve Actuator mods.W/980902 Ltr ML17229A8201998-07-29029 July 1998 LER 98-007-00:on 980630,inadequate Procedure May Have Resulted in SBO Recovery Complications.Caused by Inadequate Procedures.Attached Caution Tags to Appropriate Control switches.W/980729 Ltr ML17229A7411998-05-28028 May 1998 LER 98-004-00:on 980430,discovered Waste Gas Decay Tank Operation W/O Available Oxygen Analyzers,Which Is Prohibited by Ts.Caused by Inadequate Licensee Review of License Amend. Oxygen Analyzer recalibrated.W/980528 Ltr ML17229A7381998-05-21021 May 1998 LER 98-006-00:on 980421,missed EDG Fuel Oil Sample Surveillance Was Noted.Caused by Personnel Error.Revised Fuel Oil Sampling Service Purchase Order & Revised Site procedure.W/980521 Ltr ML17229A7011998-04-27027 April 1998 LER 98-003-00:on 980326,discovered Containment Pressure Instrumentation Design Single Failure Vulnerability.Caused by Inadequate Design by Personnel Error.Removed RPS & ESFAS Containment Pressure Bypass Keys immediately.W/980427 Ltr ML17229A6761998-04-0202 April 1998 LER 98-005-00:on 980305,identified Two Conditions That Were Outside App R Design Bases.Caused by Design Oversight During Development of Original App R Safe SD Design.Established 30 Minute Roving Fire Watches & Provided training.W/980402 Ltr ML17229A6731998-03-26026 March 1998 LER 98-002-00:on 980224,radiation Monitor Surveillance Inadequacies Led to Operating of Facility Prohibited by Tss. Caused by Congnitive Personnel Error.Permanent Procedure Changes Were implemented.W/980326 Ltr ML17229A6551998-03-0505 March 1998 LER 98-001-00:on 980206,high/low Pressure Shutdown Cooling Interface Was Noted Outside App R Design Bases.Caused by Personnel Error.Addl Guidance Was Provided to Engineering Dept personnel.W/980305 Ltr ML17229A6281998-02-19019 February 1998 LER 98-004-00:on 980121,emergency Lighting Outside App R Design Bases Occurred.Caused by Congnitive Personnel Error During Translation of App R Section Iii.Procedures Onop 1 & 2 ONP-100.01 Were Issued for Use on 980206.W/980219 Ltr ML17229A6211998-02-0909 February 1998 LER 98-003-00:on 980110,manual Rt Due to DEH Leak at Turbine Test Block Was Noted.Caused by o-ring Extrusion.Shortened Bolts by About 0.125 & Reinstalled at Correct Torque values.W/980209 Ltr ML17229A6191998-02-0404 February 1998 LER 98-002-00:on 980105,CIS Bistable in Bypass Resulted in Condition Prohibited by Tss.Caused by Personnel Error. Radiation Monitor Was Restored to service.W/980204 Ltr ML17229A6161998-02-0303 February 1998 LER 98-001-00:on 980104,inadvertent RPS Actuation Occurred Due to Personnel Error.Caused by Procedural Inadequacies & Inadequate self-checking by Licensed Utility Personnel. Placards Have Been Placed in CRs.W/980203 Ltr ML17229A6051998-01-27027 January 1998 LER 97-010-01:on 971027,inadvertent Core Alteration Prohibited by TSs Were Noted Due to Stuck Cea.Caused by Personnel Error.Cea #24 Was Dislodged & Transferred to Spent Pool for insp.W/980127 Ltr ML17229A5501997-12-0505 December 1997 LER 97-008-00:on 971107,inadequate CR Ventilation Surveillance Resulted in Condition Prohibited by Ts.Caused by non-cognitive Personnel Error.Operating Procedure 2-1900050 Was revised.W/971205 Ltr ML17309A9091997-12-0202 December 1997 LER 97-011-00:on 971102,non-conservative RAS Set Point Resulted in Operation Prohibited by Ts.Caused by Inadequate Set Point & Instrument Loop Scaling Process.Revised ESFAS Functional Tp W/Proper Set point.W/971202 Ltr ML17229A5391997-11-26026 November 1997 LER 97-010-00:on 971027,inadvertant Core Alteration Prohibited by TS Occurred.Caused by CEA Failure to Detach from Ugs.Safety Evaluation Was Performed & Procedural Rev Made to Continue Upper Guide Structure move.W/971126 Ltr ML17229A5151997-11-0707 November 1997 LER 97-007-00:on 971008,inoperable Containment Cooling Fan Resulted in Operation of Facility Outside Design Basis. Caused by non-cognitive Personnel Error.Ccs Operation Was Revised & Issued on 971013.W/971107 Ltr ML17229A4991997-10-17017 October 1997 LER 97-009-00:on 970917,inoperable PORV Block Valve Resulted in Operation Prohibited by Tech Specs Occurred.Caused by Plant GL 89-10 Program Plan to Review Plant Manager Action Item Sys.Porv Block Valve V-1403 restored.W/971017 Ltr ML17309A9011997-08-27027 August 1997 LER 97-008-00:on 970728,mechanical Fire Penetrations Were Inoperable & Outside App R Design Bases.Caused by Seal Mfg Not Providing Formal Documentation for Installed Seals. Modified Inoperable Fire penetrations.W/970827 Ltr ML17229A4311997-07-29029 July 1997 LER 97-006-00:on 970630,discovered Inadequate Testing of Engineered Safety Features Subgroup Relays.Caused by Inadequacy in Implementing TS Requirements in Surveillance Procedures.Revised Surveillance procedures.W/970729 Ltr ML17229A4241997-07-25025 July 1997 LER 97-005-00:on 970625,discovered That Hot Shutdown Control Panel Shutdown Cooling Flow indicator,FI-3306 Inoperable. Caused by Weakness in Work Order & Procedure Used to Repair FI-3306.Section Meeting W/I&C Planners held.W/970725 Ltr ML17229A3971997-07-11011 July 1997 LER 97-004-00:on 970611,discovered Incorrect Original Cable Tray Fire Stop Assembly Installation Was Outside App R Design Basis.Caused by Personnel Error.Hourly Fire Watch Patrols Will Be posted.W/970711 Ltr ML17229A3871997-06-19019 June 1997 LER 97-003-00:on 970521,determined Required Post Maint Open Stroke Test for Valve V3245,2B2 SIT Discharge Check Valve, Had Not Been Performed.Caused by Personnel Error.Procedure revised.W/970619 Ltr ML17229A3841997-06-17017 June 1997 LER 97-002-00:on 970518,containment Sump Debris Screen Was Not IAW Design Due to Gaps in Screen Encl.Performed SER to Document Containment Sump Design requirements.W/970617 Ltr ML17229A3751997-06-0202 June 1997 LER 97-006-00:on 970501,operation Was Prohibited by TS Due to Inadequately Tested Degraded Voltage Sys.Revised Unit 1 ESFAS Surveillance Test procedure.W/970602 Ltr ML17229A3611997-05-29029 May 1997 LER 97-007-00:on 970502,reactor Coolant Pump Oil Collection Sys Was Outside App R Design Bases.Identified Leak Sites Were Repaired & Mods to RCP Oil Collection Sys to Capture Any Future Leakage from areas.W/970529 Ltr ML17229A3491997-05-21021 May 1997 LER 97-001-00:on 970423,containment Isolation Actuation Occurred.Caused by Increased Radiation Levels During Removal of Upper Guide Structure.Proper Actuation of Containment Isolation Components Was verified.W/970521 Ltr ML17229A3441997-05-13013 May 1997 LER 97-005-00:on 970419,reactor Was Shutdown Due to Reactor Coolant Pressure Boundary Leakage.Hot Cracking Was Caused by Weld Contamination.Repairs to RCPB Were Completed & 1A SDC Train Was Restored to Svc ML17229A3141997-04-30030 April 1997 LER 97-004-00:on 970402,refueling Machine Was Operating in Manner Prohibited by TS Due to Original Design of Refueling Machine Bypass Feature Conflicting W/Ts Requirements. Eliminated Overload Cut Off Limit bypass.W/970430 Ltr ML17229A2951997-03-31031 March 1997 LER 97-003-00:on 970304,automatic Rt Resulted from Loss of Electrical Power to 1A2 Rc Pump.Rcp Breaker Was Replaced & Pump Was Returned to svc.W/970331 Ltr ML17229A2721997-03-21021 March 1997 LER 97-002-00:on 970221,operation in Excess of Max Rated Thermal Power Occurred Due to Digital Data Processing Sys (Ddps) Calorimetric Error.Verified Acceptable Performance of Ddps Functions & Reviewed Software mods.W/970321 Ltr 1999-07-06
[Table view] Category:RO)
MONTHYEARML17241A4891999-10-0707 October 1999 LER 99-004-00:on 990912,noted That MSSV Surveillance Was Outside of TS Requirements.Caused by Setpoint Drift.Subject MSSVs Are Being Refurbished & Retested Prior to Unit Startup from SL1-16 Refueling Outage.With 991007 Ltr ML17241A4111999-07-16016 July 1999 LER 99-007-00:on 990610,unplanned Cooldown Transient Occurred Due to Personnel Error.Trained & Briefed Personnel & Revised Procedures.With 990716 Ltr ML17241A4031999-07-0606 July 1999 LER 99-006-00:on 990605,sub-critical Reactor Trip Occurred Due to Inadvertent MSIV Opening.Caused by Personnel Error. Provided Operation Supervision Instruction to Operating Crews,Stand Down Meetings & Operator Aids.With 990706 Ltr ML17241A4041999-07-0606 July 1999 LER 99-005-00:on 990604,CEA Drop Resulted in Manual Reactor Trip.Caused by Procedural Inadequacies.Procedure Changes Are Planned to Correct Lack of Procedural Guidance for CEA Subgroup Power Switch Replacement.With 990706 Ltr ML17241A3941999-06-30030 June 1999 LER 99-004-01:on 990415,as Found Cycle 10 Psv Setpoints Were Outside TS Limits.Caused by Manufacturing Process Defect. All Three Psvs Were Replaced with pre-tested Valves During Cycle 11 Refueling Outage.With 990630 Ltr ML17241A3551999-06-0404 June 1999 LER 99-002-00:on 990505,both Trains of Safety Injection Actuation Were Blocked During Surveillance.Caused by Procedure Error.Procedure Revised.With 990604 Ltr ML17241A3321999-05-17017 May 1999 LER 99-004-00:on 990415,determined That as Found Cycle 10 Psv Setpoints Outside TS Limits.Root Cause Under Investigation.Psvs Replaced with pe-tested Valves During Cycle 11 ML17241A3271999-05-0606 May 1999 LER 99-003-00:on 990406,ECCS Suction Header Leak Resulted in Both ECCS Trains Being Inoperable & Entry Into TS 3.0.3. Caused by Chloride Induced OD Stress Corrosion Cracking of Piping.Made Code Repairs & Coated Piping.With 990506 Ltr ML17229B0791999-04-0707 April 1999 LER 99-001-00:on 990309,discovered Inadequate Design & IST SRs for Iodine Removal Sys (Irs).Caused by Original Design Inadequacies & Personnel Error.Naoh Tank Vent Valve V07233 Was Tagged Open.With 990407 Ltr ML17229B0801999-04-0707 April 1999 LER 99-002-00:on 990311,SG ECT Error Caused Operation with Condition Prohibited by Ts.Caused by Deficiencies in Data Analysis Guideline Instructions.Licensee Will Change Data Analysis Guidelines for Lead Analysts.With 990407 Ltr ML17229B0541999-03-10010 March 1999 LER 99-001-00:on 990211,inadequate TS SRs for SIT & SDC Isolation Valves Were Noted.Caused by Failure to Correctly Implement TS Srs.Submitted LAR to Align Required TS SR with Design Bases Requirements Being Verified.With 990310 Ltr ML17229A9901999-01-20020 January 1999 LER 98-009-00:on 981223,noted That Facility Operated Outside of Design Basis.Caused by non-conservative MSLB Analysis Inputs.Will Review SR Component Differences Between Units & Will re-baseline LTOP Analysis.With 990120 Ltr ML17229A9821999-01-0404 January 1999 LER 98-010-00:on 981207,RCS Boron Sample Frequency Required by Ts,Was Exceeded by Twelve Minutes.Caused by Personnel Error.Equipment Clearance Order Was Lifted to Draw Required Sample & Operations Procedure Was Changed.With 990104 Ltr ML17229A9611998-12-22022 December 1998 LER 97-002-01:on 981204,containment Sump Debris Screen Was Not IAW Design.Caused by Inadequate C/As for Sump Screen Anamolies.All Identified Sump Screen Deficiencies Were Dispositioned &/Or Repaired.With 981222 Ltr ML17229A9561998-12-15015 December 1998 LER 98-008-00:on 981118,missed TS SG U Tube Insp.Caused by Encoding Errors While Using Remote Positioning Fixtures.All SG Tube Surveyed.With 981215 Ltr ML17229A9301998-11-25025 November 1998 LER 98-005-01:on 980807,discovered That New MOV Methodology Caused Past PORV Block Valve Operability Problem.Caused by Inadequacies in Original Vendor MOV Methodology.Planned Valve Mods Will Be Implemented During Cycle 11 1998 Outage ML17229A9021998-11-0404 November 1998 LER 98-008-00:on 981008,inadequate Reactor Protection Sys Trip Bypass TS Was Noted.Caused by Poorly Worded Ts. Submitted LAR to Clarify Power Requirements for High Rate of Power Trips.With 981104 Ltr ML17229A8771998-10-14014 October 1998 LER 98-006-00:on 980918,inadvertent Afas Actuation Was Noted.Caused by Degradation of Multiple Afas Power Supplies. Replaced Afas Power Supplies & Revised Procedures.With 981014 Ltr ML17229A8761998-10-14014 October 1998 LER 98-007-00:on 980918,identified Discrepancies Between Fire Protection Design Requirements & Field Conditions. Caused by Inadequate Translation & Implementation of Fire Protection Requirements.Procedures Revised.With 981014 Ltr ML17229A8511998-09-0202 September 1998 LER 98-005-00:on 980807,discovered That PORV Margins Were Insufficient to Accommodate Addl Conservatism.Caused by Inadequacies in Original Vendor MOV Methodology.Will Implement Planned Valve Actuator mods.W/980902 Ltr ML17229A8201998-07-29029 July 1998 LER 98-007-00:on 980630,inadequate Procedure May Have Resulted in SBO Recovery Complications.Caused by Inadequate Procedures.Attached Caution Tags to Appropriate Control switches.W/980729 Ltr ML17229A7411998-05-28028 May 1998 LER 98-004-00:on 980430,discovered Waste Gas Decay Tank Operation W/O Available Oxygen Analyzers,Which Is Prohibited by Ts.Caused by Inadequate Licensee Review of License Amend. Oxygen Analyzer recalibrated.W/980528 Ltr ML17229A7381998-05-21021 May 1998 LER 98-006-00:on 980421,missed EDG Fuel Oil Sample Surveillance Was Noted.Caused by Personnel Error.Revised Fuel Oil Sampling Service Purchase Order & Revised Site procedure.W/980521 Ltr ML17229A7011998-04-27027 April 1998 LER 98-003-00:on 980326,discovered Containment Pressure Instrumentation Design Single Failure Vulnerability.Caused by Inadequate Design by Personnel Error.Removed RPS & ESFAS Containment Pressure Bypass Keys immediately.W/980427 Ltr ML17229A6761998-04-0202 April 1998 LER 98-005-00:on 980305,identified Two Conditions That Were Outside App R Design Bases.Caused by Design Oversight During Development of Original App R Safe SD Design.Established 30 Minute Roving Fire Watches & Provided training.W/980402 Ltr ML17229A6731998-03-26026 March 1998 LER 98-002-00:on 980224,radiation Monitor Surveillance Inadequacies Led to Operating of Facility Prohibited by Tss. Caused by Congnitive Personnel Error.Permanent Procedure Changes Were implemented.W/980326 Ltr ML17229A6551998-03-0505 March 1998 LER 98-001-00:on 980206,high/low Pressure Shutdown Cooling Interface Was Noted Outside App R Design Bases.Caused by Personnel Error.Addl Guidance Was Provided to Engineering Dept personnel.W/980305 Ltr ML17229A6281998-02-19019 February 1998 LER 98-004-00:on 980121,emergency Lighting Outside App R Design Bases Occurred.Caused by Congnitive Personnel Error During Translation of App R Section Iii.Procedures Onop 1 & 2 ONP-100.01 Were Issued for Use on 980206.W/980219 Ltr ML17229A6211998-02-0909 February 1998 LER 98-003-00:on 980110,manual Rt Due to DEH Leak at Turbine Test Block Was Noted.Caused by o-ring Extrusion.Shortened Bolts by About 0.125 & Reinstalled at Correct Torque values.W/980209 Ltr ML17229A6191998-02-0404 February 1998 LER 98-002-00:on 980105,CIS Bistable in Bypass Resulted in Condition Prohibited by Tss.Caused by Personnel Error. Radiation Monitor Was Restored to service.W/980204 Ltr ML17229A6161998-02-0303 February 1998 LER 98-001-00:on 980104,inadvertent RPS Actuation Occurred Due to Personnel Error.Caused by Procedural Inadequacies & Inadequate self-checking by Licensed Utility Personnel. Placards Have Been Placed in CRs.W/980203 Ltr ML17229A6051998-01-27027 January 1998 LER 97-010-01:on 971027,inadvertent Core Alteration Prohibited by TSs Were Noted Due to Stuck Cea.Caused by Personnel Error.Cea #24 Was Dislodged & Transferred to Spent Pool for insp.W/980127 Ltr ML17229A5501997-12-0505 December 1997 LER 97-008-00:on 971107,inadequate CR Ventilation Surveillance Resulted in Condition Prohibited by Ts.Caused by non-cognitive Personnel Error.Operating Procedure 2-1900050 Was revised.W/971205 Ltr ML17309A9091997-12-0202 December 1997 LER 97-011-00:on 971102,non-conservative RAS Set Point Resulted in Operation Prohibited by Ts.Caused by Inadequate Set Point & Instrument Loop Scaling Process.Revised ESFAS Functional Tp W/Proper Set point.W/971202 Ltr ML17229A5391997-11-26026 November 1997 LER 97-010-00:on 971027,inadvertant Core Alteration Prohibited by TS Occurred.Caused by CEA Failure to Detach from Ugs.Safety Evaluation Was Performed & Procedural Rev Made to Continue Upper Guide Structure move.W/971126 Ltr ML17229A5151997-11-0707 November 1997 LER 97-007-00:on 971008,inoperable Containment Cooling Fan Resulted in Operation of Facility Outside Design Basis. Caused by non-cognitive Personnel Error.Ccs Operation Was Revised & Issued on 971013.W/971107 Ltr ML17229A4991997-10-17017 October 1997 LER 97-009-00:on 970917,inoperable PORV Block Valve Resulted in Operation Prohibited by Tech Specs Occurred.Caused by Plant GL 89-10 Program Plan to Review Plant Manager Action Item Sys.Porv Block Valve V-1403 restored.W/971017 Ltr ML17309A9011997-08-27027 August 1997 LER 97-008-00:on 970728,mechanical Fire Penetrations Were Inoperable & Outside App R Design Bases.Caused by Seal Mfg Not Providing Formal Documentation for Installed Seals. Modified Inoperable Fire penetrations.W/970827 Ltr ML17229A4311997-07-29029 July 1997 LER 97-006-00:on 970630,discovered Inadequate Testing of Engineered Safety Features Subgroup Relays.Caused by Inadequacy in Implementing TS Requirements in Surveillance Procedures.Revised Surveillance procedures.W/970729 Ltr ML17229A4241997-07-25025 July 1997 LER 97-005-00:on 970625,discovered That Hot Shutdown Control Panel Shutdown Cooling Flow indicator,FI-3306 Inoperable. Caused by Weakness in Work Order & Procedure Used to Repair FI-3306.Section Meeting W/I&C Planners held.W/970725 Ltr ML17229A3971997-07-11011 July 1997 LER 97-004-00:on 970611,discovered Incorrect Original Cable Tray Fire Stop Assembly Installation Was Outside App R Design Basis.Caused by Personnel Error.Hourly Fire Watch Patrols Will Be posted.W/970711 Ltr ML17229A3871997-06-19019 June 1997 LER 97-003-00:on 970521,determined Required Post Maint Open Stroke Test for Valve V3245,2B2 SIT Discharge Check Valve, Had Not Been Performed.Caused by Personnel Error.Procedure revised.W/970619 Ltr ML17229A3841997-06-17017 June 1997 LER 97-002-00:on 970518,containment Sump Debris Screen Was Not IAW Design Due to Gaps in Screen Encl.Performed SER to Document Containment Sump Design requirements.W/970617 Ltr ML17229A3751997-06-0202 June 1997 LER 97-006-00:on 970501,operation Was Prohibited by TS Due to Inadequately Tested Degraded Voltage Sys.Revised Unit 1 ESFAS Surveillance Test procedure.W/970602 Ltr ML17229A3611997-05-29029 May 1997 LER 97-007-00:on 970502,reactor Coolant Pump Oil Collection Sys Was Outside App R Design Bases.Identified Leak Sites Were Repaired & Mods to RCP Oil Collection Sys to Capture Any Future Leakage from areas.W/970529 Ltr ML17229A3491997-05-21021 May 1997 LER 97-001-00:on 970423,containment Isolation Actuation Occurred.Caused by Increased Radiation Levels During Removal of Upper Guide Structure.Proper Actuation of Containment Isolation Components Was verified.W/970521 Ltr ML17229A3441997-05-13013 May 1997 LER 97-005-00:on 970419,reactor Was Shutdown Due to Reactor Coolant Pressure Boundary Leakage.Hot Cracking Was Caused by Weld Contamination.Repairs to RCPB Were Completed & 1A SDC Train Was Restored to Svc ML17229A3141997-04-30030 April 1997 LER 97-004-00:on 970402,refueling Machine Was Operating in Manner Prohibited by TS Due to Original Design of Refueling Machine Bypass Feature Conflicting W/Ts Requirements. Eliminated Overload Cut Off Limit bypass.W/970430 Ltr ML17229A2951997-03-31031 March 1997 LER 97-003-00:on 970304,automatic Rt Resulted from Loss of Electrical Power to 1A2 Rc Pump.Rcp Breaker Was Replaced & Pump Was Returned to svc.W/970331 Ltr ML17229A2721997-03-21021 March 1997 LER 97-002-00:on 970221,operation in Excess of Max Rated Thermal Power Occurred Due to Digital Data Processing Sys (Ddps) Calorimetric Error.Verified Acceptable Performance of Ddps Functions & Reviewed Software mods.W/970321 Ltr 1999-07-06
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML17241A4891999-10-0707 October 1999 LER 99-004-00:on 990912,noted That MSSV Surveillance Was Outside of TS Requirements.Caused by Setpoint Drift.Subject MSSVs Are Being Refurbished & Retested Prior to Unit Startup from SL1-16 Refueling Outage.With 991007 Ltr ML17241A4951999-09-30030 September 1999 Monthly Operating Repts for Sept 1999 for St Lucie,Units 1 & 2.With 991014 Ltr ML17241A4741999-08-31031 August 1999 Rev 1 to PCM 99016, St Lucie Unit 1,Cycle 16 Colr. ML17241A4591999-08-31031 August 1999 Monthly Operating Repts for Aug 1999 for St Lucie,Units 1 & 2.With 990913 Ltr ML17241A4301999-07-31031 July 1999 Monthly Operating Repts for Jul 1999 for St Lucie Units 1 & 2.With 990805 Ltr ML17241A4111999-07-16016 July 1999 LER 99-007-00:on 990610,unplanned Cooldown Transient Occurred Due to Personnel Error.Trained & Briefed Personnel & Revised Procedures.With 990716 Ltr ML17241A4031999-07-0606 July 1999 LER 99-006-00:on 990605,sub-critical Reactor Trip Occurred Due to Inadvertent MSIV Opening.Caused by Personnel Error. Provided Operation Supervision Instruction to Operating Crews,Stand Down Meetings & Operator Aids.With 990706 Ltr ML17241A4041999-07-0606 July 1999 LER 99-005-00:on 990604,CEA Drop Resulted in Manual Reactor Trip.Caused by Procedural Inadequacies.Procedure Changes Are Planned to Correct Lack of Procedural Guidance for CEA Subgroup Power Switch Replacement.With 990706 Ltr ML17241A4091999-06-30030 June 1999 Monthly Operating Repts for June 1999 for St Lucie,Units 1 & 2.With 990712 Ltr ML17241A3941999-06-30030 June 1999 LER 99-004-01:on 990415,as Found Cycle 10 Psv Setpoints Were Outside TS Limits.Caused by Manufacturing Process Defect. All Three Psvs Were Replaced with pre-tested Valves During Cycle 11 Refueling Outage.With 990630 Ltr ML17355A3681999-06-30030 June 1999 Revised Update to Topical QA Rept, Dtd June 1999 ML17241A3551999-06-0404 June 1999 LER 99-002-00:on 990505,both Trains of Safety Injection Actuation Were Blocked During Surveillance.Caused by Procedure Error.Procedure Revised.With 990604 Ltr ML17241A3631999-05-31031 May 1999 Monthly Operating Repts for May 1999 for St Lucie Units 1 & 2.With 990610 Ltr ML17241A3321999-05-17017 May 1999 LER 99-004-00:on 990415,determined That as Found Cycle 10 Psv Setpoints Outside TS Limits.Root Cause Under Investigation.Psvs Replaced with pe-tested Valves During Cycle 11 ML17241A3271999-05-0606 May 1999 LER 99-003-00:on 990406,ECCS Suction Header Leak Resulted in Both ECCS Trains Being Inoperable & Entry Into TS 3.0.3. Caused by Chloride Induced OD Stress Corrosion Cracking of Piping.Made Code Repairs & Coated Piping.With 990506 Ltr ML17241A3331999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for St Lucie,Units 1 & 2.With 990517 Ltr ML17229B0801999-04-0707 April 1999 LER 99-002-00:on 990311,SG ECT Error Caused Operation with Condition Prohibited by Ts.Caused by Deficiencies in Data Analysis Guideline Instructions.Licensee Will Change Data Analysis Guidelines for Lead Analysts.With 990407 Ltr ML17229B0841999-04-0707 April 1999 Rev 2 to PSL-ENG-SEMS-98-102, Engineering Evaluation of ECCS Suction Lines. ML17229B0791999-04-0707 April 1999 LER 99-001-00:on 990309,discovered Inadequate Design & IST SRs for Iodine Removal Sys (Irs).Caused by Original Design Inadequacies & Personnel Error.Naoh Tank Vent Valve V07233 Was Tagged Open.With 990407 Ltr ML17229B0961999-03-31031 March 1999 Monthly Operating Repts for Mar 1999 for St Lucie,Units 1 & 2.With 990408 Ltr ML17229B0541999-03-10010 March 1999 LER 99-001-00:on 990211,inadequate TS SRs for SIT & SDC Isolation Valves Were Noted.Caused by Failure to Correctly Implement TS Srs.Submitted LAR to Align Required TS SR with Design Bases Requirements Being Verified.With 990310 Ltr ML17229B0461999-02-28028 February 1999 Monthly Operating Repts for Feb 1999 for St Lucie,Units 1 & 2.With 990310 Ltr ML17229B0051999-01-31031 January 1999 Monthly Operating Repts for Jan 1999 for St Lucie,Units 1 & 2.With 990211 Ltr ML17229A9901999-01-20020 January 1999 LER 98-009-00:on 981223,noted That Facility Operated Outside of Design Basis.Caused by non-conservative MSLB Analysis Inputs.Will Review SR Component Differences Between Units & Will re-baseline LTOP Analysis.With 990120 Ltr ML17229A9961999-01-14014 January 1999 SG Tube Inservice Insp Special Rept. ML17229A9821999-01-0404 January 1999 LER 98-010-00:on 981207,RCS Boron Sample Frequency Required by Ts,Was Exceeded by Twelve Minutes.Caused by Personnel Error.Equipment Clearance Order Was Lifted to Draw Required Sample & Operations Procedure Was Changed.With 990104 Ltr ML17229A9831998-12-31031 December 1998 Monthly Operating Repts for Dec 1998 for St Lucie,Units 1 & 2.With 990111 Ltr ML17229A9611998-12-22022 December 1998 LER 97-002-01:on 981204,containment Sump Debris Screen Was Not IAW Design.Caused by Inadequate C/As for Sump Screen Anamolies.All Identified Sump Screen Deficiencies Were Dispositioned &/Or Repaired.With 981222 Ltr ML17229A9561998-12-15015 December 1998 LER 98-008-00:on 981118,missed TS SG U Tube Insp.Caused by Encoding Errors While Using Remote Positioning Fixtures.All SG Tube Surveyed.With 981215 Ltr ML17241A3581998-12-0909 December 1998 Changes,Tests & Experiments Made as Allowed by 10CFR50.59 for Period of 970526-981209. ML17229A9421998-11-30030 November 1998 Monthly Operating Repts for Nov 1998 for St Lucie,Units 1 & 2.With 981215 Ltr ML17229A9301998-11-25025 November 1998 LER 98-005-01:on 980807,discovered That New MOV Methodology Caused Past PORV Block Valve Operability Problem.Caused by Inadequacies in Original Vendor MOV Methodology.Planned Valve Mods Will Be Implemented During Cycle 11 1998 Outage ML17229A9021998-11-0404 November 1998 LER 98-008-00:on 981008,inadequate Reactor Protection Sys Trip Bypass TS Was Noted.Caused by Poorly Worded Ts. Submitted LAR to Clarify Power Requirements for High Rate of Power Trips.With 981104 Ltr ML17241A4931998-11-0101 November 1998 Statement of Account for Period of 981101-990930 for Suntrust Bank,As Trustee for Florida Municipal Power Agency Nuclear Decommissioning Trust (St Lucie Project). ML17229A9051998-10-31031 October 1998 Monthly Operating Repts for Oct 1998 for St Lucie,Units 1 & 2.With 981110 Ltr ML17229A8871998-10-19019 October 1998 Part 21 Rept Re Potential Defect in Swagelok Stainless Steel Front Ferrule,Part Number SS-503-1 Which Was Machined with Improper Length.C/A Includes Insp Equipment That Will 100% Identify Short Length ML17229A8781998-10-19019 October 1998 Part 21 Rept Re Potential Defect in Swagelok Stainless Steel Front Ferrule,Part Number SS-503-1,which Was Machined with Improper Length.Insp Equipment That Will 100% Identify Short Length ML17229A8771998-10-14014 October 1998 LER 98-006-00:on 980918,inadvertent Afas Actuation Was Noted.Caused by Degradation of Multiple Afas Power Supplies. Replaced Afas Power Supplies & Revised Procedures.With 981014 Ltr ML17229A8761998-10-14014 October 1998 LER 98-007-00:on 980918,identified Discrepancies Between Fire Protection Design Requirements & Field Conditions. Caused by Inadequate Translation & Implementation of Fire Protection Requirements.Procedures Revised.With 981014 Ltr ML17229A8721998-09-30030 September 1998 Monthly Operating Repts for Sept 1998 for St Lucie Units 1 & 2.With 981009 Ltr ML17229A8511998-09-0202 September 1998 LER 98-005-00:on 980807,discovered That PORV Margins Were Insufficient to Accommodate Addl Conservatism.Caused by Inadequacies in Original Vendor MOV Methodology.Will Implement Planned Valve Actuator mods.W/980902 Ltr ML17229A8611998-08-31031 August 1998 Monthly Operating Repts for Aug 1998 for St Lucie,Units 1 & 2.With 980911 Ltr ML18066A2771998-08-13013 August 1998 Part 21 Rept Re Deficiency in CE Current Screening Methodology for Determining Limiting Fuel Assembly for Detailed PWR thermal-hydraulic Sa.Evaluations Were Performed for Affected Plants to Determine Effect of Deficiency ML17229A8481998-08-0707 August 1998 Rev 1 to PSL-ENG-SEFJ-98-013, St Lucie Unit 2,Cycle 10 Colr. ML17229A9461998-08-0707 August 1998 Rev 0 to PCM 98016, St Lucie Unit 2,Cycle 11 Colr. ML17229A8301998-07-31031 July 1998 Monthly Operating Repts for July 1998 for St Lucie,Units 1 & 2.W/980814 Ltr ML17229A8201998-07-29029 July 1998 LER 98-007-00:on 980630,inadequate Procedure May Have Resulted in SBO Recovery Complications.Caused by Inadequate Procedures.Attached Caution Tags to Appropriate Control switches.W/980729 Ltr ML17229A7981998-06-30030 June 1998 Monthly Operating Repts for June 1998 for St Lucie,Units 1 & 2.W/980713 Ltr ML17229A7701998-05-31031 May 1998 Monthly Operating Repts for May 1998 for St Lucie,Units 1 & 2.W/980612 Ltr ML17229A7411998-05-28028 May 1998 LER 98-004-00:on 980430,discovered Waste Gas Decay Tank Operation W/O Available Oxygen Analyzers,Which Is Prohibited by Ts.Caused by Inadequate Licensee Review of License Amend. Oxygen Analyzer recalibrated.W/980528 Ltr 1999-09-30
[Table view] |
Text
ACCELERATED DISIBUTION DEMONS~ION SYSTEM REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)
ACCESSION NBR: 9112170467 DOC. DATE: 91/12/09 NOTARIZED: NO DOCKET FACIL:50-335 St. Lucie Plant, Unit 1, Florida Power & Light Co. 05000335 AUTH. NAME AUTHOR AFFILIATION LAUVER,C. Florida Power & Light Co.
SAGER,D.A. Florida Power & Light Co.
RECIP.NAME RECIPIENT AFFILIATION
SUBJECT:
LER 91-008-00:on 911110 & 11,containment integrity not in
- compliance w/Tech Specs during core alterations. Caused by personnel failing to follow approved procedure.Contai,nment D integrity reestablished & personnel counseled.W/911209 DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR i ENCL TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.
NOTES l SIZE:
ltr.
5 RECIPIENT COPIES RECIPIENT COPIES D ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-2 LA 1 1 PD2-2 PD 1. 1 D
NORRIS,J 1 1 INTERNAL: ACNW 2 2 ACRS 2 2 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DS P 2 2 NRR/DET/ECMB 9H 1 1 NRR/DET/EMEB 7E 1 1 NRR/DLPQ/LHFB10 1 1 NRR/DLPQ/LPEB10 1 1 NRR/DOEA/OEAB 1 1=-
NRR/DREP/PRPB1 1 2 2 NRR/DST/SELB SD 1 1 NRR/DST/SICBSH3 1 1 RRtBPPp48 LBSD1 1 1 NRR/DST/SRXB SE 1 1 E 02 1 1 RES/DSIR/EIB 1 1 RGN2 FILE 01 1 1 EXTERNAL: EG&G BRYCE,J.H 3 3 L ST LOBBY WARD 1 1 NRC PDR 1 1 NSIC MURPHY,G.A 1 ' 1 NSIC POOREiW 1 1 NUDOCS FULL TXT 1 D
D D
NOTE TO ALL "RIDS" RECIPIENTS:
PLEASE HELP US TO REDUCE iVASTEI CONTACT THE DOCUMENT CONTROL DESK, ROOil P 1-3 'EXT. 20079) TO ELlb IINATE YOUR NAiIE FROM DISTRIBUTION LISTS FOR DOCUiIENTS YOU DON'T NEED!
FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 33 ENCL 33
I I ~
P.O. Box 128, Ft. Pierce, FL 34954-0128 December 9, 1991 L-91-331 10 CFR 50.73 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555 Gentlemen:
Re: St. Lucie Unit 1 Docket No. 50-335 Reportable Event: 91-08 Date of Event: November 10, 1991 Core Alterations Performed With Containment Integrity Not in Compliance with Technical S ecifications due to Personnel Error The attached Licensee Event Report is being submitted pursuant to the requirements of 10 CFR 50.73 to provide notification of the subject event.
Very truly yours, D. A. ager Vice P esident St. cie Plant DAS/GRM/kw Attachment cc: Stewart D. Ebneter, Regional Administrator, USNRC Region Senior Resident Inspector, USNRC, St. Lucie Plant II DAS/PSL 5581-91 y (s~ Io t 8 D;-,
an fPL Group company
FPL Faclirrrls oi UB. NUCLEAR REGULATORY COMMISSION ~PINPIIOCININCI $ 1500105 EXP0%% 5000 5 NRC Farn S66 EST SMTEO IAXENNPOI INSPONSE TO COMPlY WITH TINT PPOISIA JICN COUl CTION (9 89)
LICENSEE EVENT REPORT (LER) f INCINST: 50 0 PITS PRI WAIST OMUINIIISNECAIYXNSIAXCEN ESTXAATE TO HE INO5XOS AICIINPORTS MANA5NANNTSTANCH IP050l Ila I
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S1 50 0105A Of ICE OF WAAOEICNTAMISCOOET. WAIIINCTOfl OC 505CI FAG iLITYNAME (1) DOCKET NUMBER (2) PAGE 3 St. Lucie Unit 1 05000'3351 0 0 4
'~ (4) Core Alterations Performed With Containment Integrity Not in Compliance With Technical Specifications due to Personnel Error EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED(8)
DAY YEAR YEAR . S IAL KR DAY YEAR FACILITYNAMES DOCKET NUMBER(S)
N/A 05 000 1 0 9 1 9 1 0 0 8 0 '0 1 2 0 9 9 1 N/A 05000 THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR:
OPERATING Check one or more of the followin (11)
MODE (9) 20.402(b) 20,405(c) 50.73(a)(2)(iv) 73.71(b)
POWER 20.405(a)(1)(i) 50.36(c)(1) 50.73(a)(2)(v) 73.71(c)
LEVEL (10) 0 0 0 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(vii) OTHER (Specify in Abstract 20.405(a)(1)(iii) X 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) below and in Text 20.405(a)(1)(iv) 50.73(a)(2)(viii)(B) NRC Form 366A) 50.73(a)(2) (ii) 20.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x)
LICENSEE CONTACT FOR THIS LER 12 NAME TELEP ONE NUMBER Catherine Lauver, Shift Technical Advisor 4 0 7 465 -3550 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT 13 CAUSE SYSTEM COMPONENT TURER REPORTABLE TO NPRDS . 'AUSE SYSTEM COMPONENT MANUFAC- TURER REPORTABLE TO NPRDS I I I SUPPLEMENTAL REPORT EXPECTED 14 EXPFCTED MONTH DAY YEAR SUBMISSION YES (lfyes, complete EXPECTED SUBMISSION DATE) DATE (15)
ABSTRACT (Limit to 1400 spaces. i.e. approximately fifteen single-space typewritten lines) (16)
Between 1430 on November 10, 1991, and 0210 on November 11, containment integrity was not in compliance with Technical Specifications. St. Lucie Unit 1 was in Mode 6, Refueling, and fuel assemblies were being moved in the reactor core. Containment integrity is required for core alterations.
The cause of the incomplete containment integrity was personnel error by Mechanical Maintenance department personnel for failure to follow an approved procedure. Plant procedure requires that Nuclear Plant Work Orders be approved by the Nuclear Plant Supervisor prior to starting work. Without obtaining this prior approval, maintenance workers removed a relief valve on one side of a containment penetration while a drain valve was open on the other side. This created a direct flow path from containment to the Reactor Auxiliary Building.
Permission to start work was requested after the relief valve had been removed by the previous shift.
Corrective actions were: containment integrity was re-established, the responsible maintenance supervisor was counseled on the need for strict adherence to procedures, and the event will be incorporated into Maintenance journeyman training. This event was also discussed with all maintenance crews and the importance of receiving proper authorization prior to beginning work on plant systems was stressed. An INPO Human Performance Enhancement review of this event was also performed.
FPL Facsimile of NRC Form 366 (6.89)
FPL FscsIITT'Is of .S. NUCLEAR REGULATORY COMMISSION APPFETIEOOIO VlSIIOCTOI NRC Form 666 ESWRES 40000 (6 89)
LICENSEE EVENT REPORT (LER) ESTAIATTTT TIATOEN PE IT IVSPCNSS To CCAPET SITN TITS PPOAIARCN CCUECTCN IKOIRSn 000 IFTS IORWN00 CCASJENT 0 REOARCWO 00000EN ESTSAATS To nR RE CORRI ANO REPORTS VAN%VACNE SRANCN (0 $ 00A IAS IACEEAR RECAAATCRT OVMWSSEPE TEXT CONTINUATION WASNWOTISI.oC 00000 wo To nO PAFERwr00r INOOCOCN PRIVECT TTT 000 IIATES ROE OF NNACEARNTAN) TAATCET,WAStMOTOR, OC PTCOL FACILITYNAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)
YEAR EQUENTIAL REVISION St. Lucie Unit 1 NUMBER NUMBER 0500033591 0 0 8 0 0 0 2 0 4 TEXT (lfmore spaceis required, use additional NRC Form 366A's) (17)
IP Unit 1 was in Mode 6, Refueling. Containment integrity was established as required for fuel movement which started November 7, 1991.
Nuclear Plant Work Order (NPWO) 3836 was written to remove a one-inch Component Cooling Water (CCW) (EIIS:CC) safety relief valve, SR-14-8B, to implement a plant modification. The NPWO was planned November 4, 1991. The NPWO package contained instructions for work performed in the maintenance shop on the new valve and for work performed in the Reactor Containment Building to remove the old valve. Work was started in the maintenance shop on November 7. On November 9, clearance 1-11-113 was authorized and hung to support removal of SR-14-BB. The clearance closed SB-14314 and SB-14320, inlet and outlet CCW isolation valves for the 1B Containment Cooler (HVS-1 B)(EIIS:BK), and opened drain valve V-14319 to remove water from the system. The drain valve is located outside containment between Penetration 21 and isolation valve SB-14320.
V-14319.
SB-14320 SR-1 4-BB SB-14314 22 HVS-1B Reactor Auxiliary Bldg Containment On November 10, 1991, fuel assemblies were being moved in the reactor core. A utility maintenance worker was assigned to work NPWO 3836. He entered containment and removed SR-14-BB at about 1430. Since shop preparation work for the NPWO had been in progress for a few days, the worker mistakenly believed all approvals had been previously acquired. The foreman had signed onto the clearance earlier but had not brought the NPWO to the Control Room to obtain permission to start work. Administrative Procedure 0010432, "Nuclear Plant Work Orders," states that the approval of the Nuclear Plant Supervisor (NPS), Assistant Nuclear Plant Supervisor (ANPS),
or Nuclear Watch Engineer (NWE) is required prior to starting work. The NPWO was turned over to the next shift who brought it to the Control Room for approval. The ANPS reviewed the NPWO and did not approve it, realizing that the removal of the relief valve with the drain valve open should not be permitted. However, he was informed that the valve had already been removed. The ANPS then directed a nonlicensed operator to close the drain valve. Complete containment'integrity was restored at 0210 on November 11, 1991.
A review of the Final Fuel Transfer Record indicates eleven fuel moves were performed in the reactor core between 1400 and 1808 on November 10, 1991.
FPL Facsimile of NRC Form 366 (6.89)
FPL FacsIITT'Io OI .S. NUCLEAR REGULATORY COMMISSION APPROYTO OAR NO SI 5005 0l hRC Form 366 C TPlfRS: lolll5 LICENSEE EVENT REPORT(LER) . TSTAIAT50 OPIOQI PCS IRSPORTS TO CCAP5Y WITN 550$ PPYYNAATICNCCUSCTION WCINIm500 HIS fCRWARO CONNfM0 IROAROWO OJITN TSRNATS TO TIC RT COINS TEXT CONTINUATtON Il ANT IRPORT 0 NANAOTlC M SRANCN (P ICPA S NUCISNI IROIAATCRYONNOOOOKI f
WAOTNOTCN. OC 50555 AAO TO TIO PAITRWCRN TSOVCTON PROS C5 55'I 500'rill Cf ICC OP IMNAOCI%MtAPSI TAOOCT, WASHNCTOH, OC TONYA FACILITYNAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)
YEAR EQUENTIAL REVISION St. Lucie Unit 1 NUMBER NUMBER 0 500 0335 9 1 0 0 8 0 0 0 3 0 0 4
.TEXT (Ifmore'siMceis required, use additional NRC Form 366A's) (17)
The root cause of the event is personnel error by utility Mechanical Maintenance department personnel. The error was contrary to approved plant procedure, which requires approval from the NPS, ANPS, or NWE prior to starting work. There are no unusual characteristics of the work location that directly contributed to the error.
As a contributing factor, clearance controls were identified as a weakness. This clearance was written and hung while containment integrity existed and was required for refueling operations.
While the clearance itself did not breach containment integrity, it involved valves known to be containment boundaries and did not provide specific guidance stating that the drain valve needed to be closed before the relief valve was removed.
Technical Specification 3.9.4, "Refueling Operations: Containment Penetrations,N requires each penetration to be closed during core alterations. The removal of SR-14-BB with open drain valve V-14319 created a flow path across Penetration 21 from about 1430 on November 10, 1991, to 0210 on November 11, 1991. Eleven fuel moves were performed in the reactor core during this time interval. This event is reportable per 10 CFR 50.73.a.2.i.B, any condition or operation prohibited by Technical Specfications. Containment integrity is required during fuel movement to restrict radioactive material released from a fuel element rupture. No failures of fuel elements occurred during the time interval containment integrity was breached. In the event of a fuel element rupture, the amount of radioactive material released through a 1R line would be minimal. This is due to the lack of a pressurization potential associated with a refueling accident. Any material released would enter the Reactor Auxiliary Building, not the environment. Therefore, the health and safety of the public was not at risk during this event.
FPL Facsimile of NRC Form 366 (6.89)
~
FPI. Facsrrrirs of S. NUCI.EAR REGUlATORY COMMISSION APPRGYEOCAEINEA 51500105 NRC Form 356 ETPNRa 50005 STRIATE 0 500TOEN Pf R RESPONSE TO ~YWlTN TITS 00GRNATTCN CClffCTION (6 89)
LICENSEE EVENT REPORT (LER) fREGIN SR 50 0 505$ IORWAle COULCJA 0 IKCIRONO IAPOEN ESTTNATE TO TIN RfCOPOS Prfr REPORTS IWIAGEIRNTSRANCN IP55PATAS IAICEEARREIRAATCRY TEXT CONTINUATION I WASNINGTON. OC 5055E N05 TO TIN PNE RWOIYT IROVCTION PROIECT (51 5001INA CI ICE CP IAANAGEIAEIITNE5 SUOGET,WARINGTOIE OC 505rrf FACILITYNAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)
YEAR EQUENTIAL REVISION St. Lucie Unit 1 NUMBER NUMBER 0 500 0335 9 1 0 0 8 0 0 0 4 0 4 TEXT (Ifmore spaceis reguiredf use additional NRC Form 366A's) (17)
(1) Operations closed the drain valve and restored containment integrity.
(2) The responsible foreman was counseled on his failure to follow procedures, i.e., failure to obtain the proper authorization prior to beginning work on plant systems. The event was also discussed with all Mechanical Maintenance crews.
(3) A task team, lead by Operations, is reviewing the clearance procedure. Any necessary changes to the procedure related to this event will be made.
(4) The event will be included as part of In House/Industry Events training, performed every quarter with journeymen, during the first quarter of 1992.
(5)
The Training Department will incorporate this event into the Licensed Operator Requalification Program.
(6) An INPO Human Performance Enhancement System evaluation of this event was performed .
and its conclusions agree with this report.
N There are no component failures associated with this event.,
The most recent prev'ious similar event was submitted in LER 335-81-044. In this event, holes were drilled in piping between the Main Steam Isolation Valve and containment, causing a breach of containment integrity, while fuel moves were being performed.
FPL Facsimile of NRC Form 366 (6-69)