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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
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PRIORITY (ACCELERATED RIDS PROCESSING)
REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)
ACCESSION NBR:9510020133 DOC.DATE: 95/09/23 NOTARIZED: NO DOCKET g FACIL:50-335 St. Lucie Plant, Unit 1, Florida Power & Light Co. 05000335 AUTH. NAME AUTHOR AFFILIATION BENKEN,E.J. Florida Power & Light Co.
SAGER,D.A. Florida Power & Light Co.
RECIP.NAME RECIPIENT AFFILIATION
SUBJECT:
LER 95-003-01:on 950708,automatic reactor trip occurred during overspeed surveillance testing due to personnel error. Counselled Operations personnel involved w/event &
made procedure changes.W/950923 ltr.
DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL SIZE:
TITLE: 50.73/50.9 Licensee Event Report (LER), Inciden&Rpt, etc.
NOTES RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-1 PD 1 1 NORRIS,J 1 1 INTERNAL: ACRS 1 1 REOD/SPD B 2 2 AEOD/S PD/RRAB 1 1 LE CENTER+ 1 1 NRR/DE/ECGB 1 1 NRR/DE/EEL'B 1 1 NRR/DE/EMEB 1 1 NRR/DISP/PIPB 1 1 NRR/DRCH/HHFB 1 1 NRR/DRCH/HICB 1 1 NRR/DRCH/HOLB 1 1 NRR/DRPM/PECB 1 .1 NRR/DSSA/SPLB 1 1 NRR/DSSA/SPSB/B 1 -
1 NRR/DSSA/SRXB 1 1 RES/DSIR/EIB 1 1 RGN2 FILE 01 1 1-EXTERNAL: L ST LOBBY WARD 1 1 LITCO BRYCE,J H 2 2 NOAC MURPHY,G.A 1, 1 NOAC POORE,W. 1 1 NRC PDR 1 1 NUDOCS FULL TXT 1 1 NOTE TO ALL "RIDS" RECIP1ENTS:
PLEASE HELP US TO REDUCE WASTE! CONTACT THE DOCUMENT CONTROL DESK, ROOM OWFN 5D8 (415-2083) TO ELIMINATE YOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!
FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 27 ENCL 27
Fiorida Power & Light Company, P.O. Box 128, Fort Pierce, FL 34954.0128 September 23, 1995 L-95-269 10 CFR 50.73 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555
. Re: St. Lucie Unit 1 Docket No. 50-335 Reportable Event: 95-003 Revision 1 Date of Event: July 8, 1995 utomatic Reactor Tri Durin Turbine Overs eed Surveillance Testin 'due to Personnel Error The attached Licensee Event Report is being submitted pursuant to the requirements of 10 CFR 50.73 to provide an update on the subject event.
Very truly yours, JAB' D. A. er Vice sident St. Lucre Plant DAS/EJB Attachment cc: Stewart D. Ebneter, Regional Administrator, USNRC Region II Senior Resident Xnspector, USNRC, St. Lucie Plant
/ 4 ~
9510020133 950923 PDR ADOCK 05000335 8 PDR an FPL Group company
NRC FORM 366 S NUCLEAR REGULATORY C(NMISS I ON PROVED BY (NB KO. 3150-0104 (5-92) EXPIRES 05/31/95 ESTIMATED BURDEH PER RESPONSE TO COMPLY KITH LICENSEE EVENT REPORT (LER) THIS INFORHATIOM COLLECTIOH REQUEST: 50.0 HRS.
FORNARD COMHENTS REGARDING BURDEH ESTIMATE TO THE IHFORMATIOH AMD RECORDS MAMAGEMEHT BRANCH (HMBB 7714), U.S. NUCLEAR REGULATORY COMHISSIOM ~
(See reverse for required nwher of digits/characters for each block) MASHIMGTOH, DC 20555-0001 AND TO THE PAPERIJORK REDUCTION PROJECT (31(0-0104), OFFICE OF MANAGEHENT AMD BUDGET NASKINGTOM DC 20503.
FACILITY NAHE (1) DOCKET NNBER (2) PAGE (3)
St. Lucie Unit 1 05000335 1 OF 5 TITLE (4) Automatic Reactor Trip During Turbine Overspeed Surveillance Testing due to Personnel Error.
EYEMT DATE 5 LER NNBER 6 REPORT DATE 7 OTHER FACILITIES INVOLVED 8 SEQUENTIAL REVISIOM FACILITY NAME DOCKET KLNBER MONTH DAY YEAR YEAR HOKTH DAY YEAR NUMBER KUMBER N/A FACILITY NAME 07 08 95 95 003 09 23 DOCKET KUMBER N/A OPERATING THIS REPORT IS SUBMITTED PURSUAMT TO THE REQUIREMENTS OF 10 CFR : Check one or mor e 11 IKX)E (9) 20.402(b) 20.405(c) 50.73(e)(2)(iv) 73.71(b)
POKER 20.405(a)(1)(i) 50.36(c)(1) 50.73(a)(2)(v) 73.71(c)
LEVEL (10) 100 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(vii) OTHER 20.405(a)(1)(iii) 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) (Specify in 20.405(a)(1)(iv) 50.73(a)(2)(ii) 50.73(a)(2)(viii)(B) Abstract below and in Text, 20.405(a)(1)(v) 50.73(a)(2)(iii,) 50.73(a)(2)(x) NRC Form 366A LICENSEE CONTACT FOR THIS LER 12 NAME Edwin J. Benken, Licensing Engineer TELEPHONE NUHBER (Include Area Code)
(407) 468-4248 C(NPLETE ONE LIME FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT 13 CAUSE SYSTEH REPORTABLE REPORTABLE COMPONENT HANUFACTURER CAUSE SYSTEH COMPONENT MANUFACTURER TO MPRDS TO MPRDS RV D243 SUPPLEMENTAL REPORT EXPECTED 14 MONTH DAY YEAR EXPECTED YES SUBHI S SION (If yes, coaplete EXPECTED SUBMISSIOK DAlE). X KO DATE. (15)
ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 s'ingle-spaced typewritten lines) (16)
On July 8, 1995, Unit 1 was operating at 100 percent reactor power. Operations personnel were conducting a scheduled Turbine overspeed trip surveillance per an approved plant procedure. During the portion of the surveillance that tests a solenoid valve for Overspeed Protection Control (20-1 OPC) a utility non-licensed operator failed to close an isolation valve as directed by the procedure. Failure to close this valve allowed electro-hydraulic (EH) fluid from the Governor valves (GV) and Intercept valves (IV) to drain when the solenoid valve was opened in a subsequent step. Draining of the EH fluid caused closure of the Main Turbine Governor and Intercept valves which resulted in an automatic reactor trip.
The root cause of this event was cognitive personnel error on the part of a utility non-licensed operator who failed to properly implement a procedural step during performance of a surveillance.
Corrective actions for this event: 1) Operations personnel involved with the event were counselled. 2)
Procedure changes are being made to incorporate human factors improvements and additional step verifications. 3) Other load threatening surveillances are being reviewed to determine if generic changes are warranted. 4) A technical subcommittee is evaluating this event for additional corrective actions to prevent reoccurrence. 5) Site management held a trip review meeting open to all disciplines for lessons learned from this event.
MRC FORM ( )
RRC FORH 366A U.S NUCLEAR REGULATORY CQNISSION APPROVED BY QQ NO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COHPLY IIITH THIS INFORHAT IOM COLLECTION REOUEST: 50.0 HRS.
FORNARD COMMENTS REGARDING BURDEN EST IHATE TO THE LICENSEE EVENT REPORT (LER) INFORHATIOM AMD RECORDS HANAGEHENT BRANCH (HMBB TEXT CONTINUATION 7714), UoS. HUCLEAR REGULATORY COHHISSION, NASHINGTON, DC 20555-0001 AND TO THE PAPERMORK REDUCI'ION PROJECT (3130-0104), OFFICE OF HAMAGEHENT AMD BUDGET MASHINGTON DC 20503.
FACILITY NAME 1 DOCKET NNBER 2 LER NWBER 6 PAGE 3 YEAR SEQUENTIAL REVISION St. Lucie Unit 1 20F 05000335 95 003 5 TEXl'f more s ce is r uired use additional co ies of NRC Form 366A ('17)
DESCRIPTION OF THE EVENT On July 8, 1995, St. Lucie Unit 1 was operating at 100 percent Reactor power. A utility non-licensed Operator was performing the monthly turbine overspeed trip test in accordance with an approved plant procedure. The non-licensed operator was performing the steps of the procedure while a utility licensed Operator maintained radio communication with the control room.
During the portion of the test which checks the operability of an Overspeed Protection Control (OPC) solenoid valve, SE22138 (EIIS:TG), the procedure directed the operator to unlock and close V22482 (EIIS:TG), "EH Test Header to 20-1/OPC Isolation." This is the electro-hydraulic (EH) fluid inlet isolation to the OPC solenoid valve. This step ensures that the OPC solenoid valve is isolated from the actual EH fluid system (EIIS:TG) supplying the turbine Governor (GV) and Intercept valves (IV) (EIIS:SB) prior to testing the solenoid. The NPO removed the locking device from isolation valve V22482, but was momentarily distracted by placing the locking device in a secure position, and failed to close the valve as directed by the procedure. When the next step of the procedure was executed (the actual stroke testing of solenoid valve SE22138) EH fluid was drained from the GVs and IVs causing the GVs and IVs to rapidly close. Closure of the turbine valves quickly reduced steam flow through the turbine which resulted in a reactor trip from high pressurizer pressure at 1122 hours0.013 days <br />0.312 hours <br />0.00186 weeks <br />4.26921e-4 months <br />. The maximum RCS pressure reached during this event was approximately 2430 psia. The maximum secondary pressure reached was approximately 1023 psia.
Emergency Operating Procedure (EOP)-1, "Standard Post Trip Actions" was immediately implemented.
Operators observed increasing level in the 1A SG after the trip and closed the 15 percent feedwater bypass valve. Level continued to increase and the Control Room Operators closed the isolation valve for the 1A Feedwater Regulating Valve (EIIS:JB). The 1B Main Feedwater Pump (MFW)(EIIS:SJ) subsequently tripped from a low flow condition, and the 1A MFW Pump tripped due to high level in the 1A SG. The 1B MFW Pump was restarted and SG levels were then controlled within the normal band.
A relief valve in the Letdown Level Control System (EIIS:CB) opened during the event due to the system transient, and subsequently closed when Control Room operators reduced the letdown pressure controller (EIIS:CB) setpoint. The Steam Generator Safety Valves (EIIS:SB) functioned as designed to limit SG pressure during the initial transient. The Steam Bypass Control System (SBCS)
(EIIS: Jl) functioned properly to control RCS temperature during this event.
The Control Room crew completed the actions of EOP-01, Standard Post Trip Actions", and implemented EOP-02, "Reactor Trip Recovery" after diagnosing an uncomplicated trip. Upon completion of the Reactor Trip Recovery procedure, the unit was maintained in a stable, Mode 3 condition for post trip review and event investigation.
HRC- FORH 366A (5 92)
QRC FORM 366A U.S. NUCLEAR REGULATORY CONIISSION APPROVED BZ QQ NO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPOHSE TO COMPLY NITH THIS INFORMATION COLLECT ION REQUEST: 50.0 HRS.
FORIIARD COMMENTS REGARDING BURDEN ESTIMATE TO THE LICENSEE EVENT REPORT (LER) INFORMATION AND RECORDS MANAGEMEHT BRANCH (HNBB TEXT CONTINUATION 7714), U.S. NUCLEAR REGULATORY COMMISSIOH, NASHIHGTON, DC 20555-0001 AND TO THE PAPERNORK REDUCTION PROJECT (3140-0104), OFFICE OF MANAGEMENT AND BUDGET UASHINGTOH DC 20503.
FACILITY NAME 1 DOCKET NNBER 2 LER NOSER 6 PAGE 3 SEOUENT I AL REVISION YEAR St. Lucia Unit 1 05000335 95 003 3 OF 5 TEXT If more s ace is r uired use additionat co ies of NRC Form 366A (17)
CAUSE OF THE EVENT The cause of this event was cognitive personnel error by a utility non-licensed operator who failed to correctly implement a procedural step during performance of a turbine overspeed trip surveillance. The operator.was momentarily distracted by placing a valve locking device in a secure position, and did not close the valve as directed by the procedure.
ANALYSIS OF THE EVENT This event is reportable under the requirements of 10 CFR 50.73.a.2.iv, as "any event that resulted in a manual or automatic action of any Engineered Safety Feature."
The closure of the Main Turbine Governor and Intercept valves caused a rapid reduction in secondary steam flow. The effect of the reduction in secondary steam demand was an increase in SG pressure and temperature, and RCS temperature and pressure. Increasing RCS pressure resulted in an uncomplicated Reactor trip on high pressurizer pressure as designed.
An investigation performed after the event revealed that the calibration on the 1A Main Feedwater Regulating Valve (FCV-9011) electro-pneumatic transducer (E/P) had drifted, so that the feedwater flow control valve did not close fully as expected on the plant trip. This caused the 1A Steam Generator level to increase above the normal value to the high level trip setpoint for the Main Feedwater Pump. Closing the Main Feedwater Block valve secured the flow to the 1A SG from FCV-9011, stabilizing SG level.
This event is bounded by section 15.2.7 of the St. Lucia Unit 1 Updated Final Safety Analysis Report (UFSAR) "Loss of External Electrical Load or Turbine Stop Valve Closure." This section describes a =
rapid, large reduction of power demand on the reactor while operating at full power. The UFSAR states, "When the turbine stop/control valve closes, the steam flow is terminated, causing the secondary system temperature and pressure to increase. The primary-to-secondary heat transfer decreases as secondary system temperature increases. If the reactor is not tripped when the turbine is tripped,...the reactor will trip on high pressurizer pressure, reducing the primary heat source."
In addition to the above, UFSAR section 15.2.7, states that, "The mitigative features of the pressurizer spray, pressurizer relief valves (PORV), and the Steam Bypass System are assumed not to function so as to exacerbate the calculated pressurization of the primary system. The purpose,...is to demonstrate that the primary safety relief capability is sufficient to limit primary pressure to less than 110% of the design pressure (2750 psia), and to demonstrate that the secondary safety relief capacity is sufficient to limit secondary pressure to less than 110% of the design pressure (1100 psia)."
HRC- FORH 366A (5-92)
IRC FORM 366A U.S. NUCLEAR REGULATORY CQIIISSION APPROVED BY QHI HO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY MITH THIS INFORMATION COLLECT IOH REQUEST: 50.0 HRS.
FORHARD COMMENTS REGARDIHG BURDEN ESTIMATE TO THE LICENSEE EVENT REPORT (LER) INFORMATION AHD RECORDS MANAGEMENT BRANCH (HHBB TEXT CONTINUATION 7?14), U.S. NUCLEAR REGULATORY COMMISSION, l!ASHIHGTOH, DC 20555-0001 AHD TO THE PAPERNORK REDUCTIOH PROJECT (3140-0104), OFFICE OF MANAGEMENT AHD BUDGET IIASHIHGTON DC 20503.
FACILITY NAME 1 DOCKET HINBER 2 LER HIHIBER 6 PAGE 3
'EQUENT I AL REVISION St. Lucie Unit 1 05000335 003 4OF 5 TEXT If more s ce is r ired Use additional co ies of HRC Form 366A (17)
ANALYSIS OP THE EVENT continued During this event, the maximum primary pressure reached was approximately 2430 psia, which is below the Pressurizer code safety valve setpoint of 2500 psia. During the initial review of plant data from the reactor trip, it was determined that the PORVs (EIIS:AB) functioned properly to limit primary pressure. This conclusion was based on a review of the primary pressure response and PORV acoustic flow data, and supported by a Quench Tank pressure increase seen during the transient. In August of 1995, the PORV main valves were found to be inoperable due to improper mechanical assembly (Reference LER 335-95-005-00). Subsequent testing, inspection and analysis showed that the PORV main valves most probably did not open during this event. The (SG) code safeties (EIIS:SB) operated to limit SG pressure to 1023 psia and the SBCS functioned as designed. These systems, in conjunction with the Reactor trip, functioned to limit primary system pressure. This event is less limiting than that described in UFSAR section 15.2.7. The health and safety of the public were not affected by this event.
CORRECTIVE ACTIONS
- 1) Operations personnel involved with this event were counseled on the importance of applying self-checking principles.
- 2) The surveillance procedure for conducting this test, OP 1/2-0030150, "Secondary Plant Operating Checks and Tests" will be changed to incorporate format improvements, and to include additional verification that critical steps have been completed.
- 3) Plant Staff will review other load threatening surveillances to determine if additional procedural changes or precautions are necessary to minimize the potential for personnel error.
- 4) A technical subcommittee was formed to evaluate this event for generic implications and provide additional corrective actions to prevent reoccurrence.
- 5) Site management held a trip review meeting, attended by personnel from Operations, Maintenance, Training, Engineering, Technical staff, and senior Nuclear Division management to examine this event.
The meeting was video taped to assure that lessons learned are available to all Operations personnel.
t
- 6) Instrument and Control (I/C) and System Engineers calibrated the 1A Main Feedwater Regulating Valve E/P transducer prior to unit startup. The Main Feedwater Regulating valve positioning components affecting this event are being evaluated for additional corrective actions.
- 7) This Event will be included into Operations training for both licensed and non-licensed Operations personnel.
HRC- FORM 366A (5-92)
IiRC FORM 366A .S. NUCLEAR RECULATORY CQIIISSION PROVED BY 0$ NO. 3150-0104 (5-92) EXPIRES 5/31/95, ESTIMATED BURDEN PER RESPONSE TO COMPLY MITH THIS INFORMATION COLLECTION REQUEST: 50 ~ 0 HRS.
FORMARD COMMENTS REGARDING BURDEH ESTIMATE TO THE LICENSEE EVENT REPORT (LER) IHFORMATION AND RECORDS MANAGEMENT BRANCH (MHBB 7714), U.S. NUCLEAR REGULATORY COMMISSIOH, MASHIHGTOH, DC 20555-0001 AND TO THE PAPERMORK TEXT CONTINUATION REDUCTION PROJECT (3140-0104), OFFICE OF MANAGEMENT AND BUDGETS MASHINGTOH, DC 20503.
FACILITY NAME 1 DOCKET klNBER 2 LER NNBER 6 PACE 3 YEAR SEQUENT IAL REVISION St. Lucie Unit 1 05000335 95 003 5OF5 TEXT If more s ce is r uired use edditionsI co ies of NRC Form 366A (17)
ADDITIONAL INFORMATION F ile m onent Iden ifi i n Manufacturer: Dresser Ind. Vlv 5 Inst Div /Ashcroft Model Number: 31533VX-30 Device: Pressurizer PORV valve Pr vi u imil r Even s LER 389/86-002 describes a Reactor trip initiated by loss of load during Turbine overspeed testing due to cognitive personnel error.
'I NRC- FORM A ( )