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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
CATEGORY 1 REGULATO INFORMATION DISTRIBUTION STEM (RIDS)
ACCESSION'NBR:9907210143 DOC.DATE: 99/07/16 NOTARIZED: NO DOCKET I FACIL:50-389 St. Lucie Plant, Unit 2, Florida Power & Light Co. 05000389 AUTH. NAME AUTHOR AFFILIATION FREHAFER,K.W. Florida Power S Light Co.
STALL,J.A. Florida Power 6 Light Co.
RECIP.NAME RECIPIENT AFFILIATION
SUBJECT:
LER 99-007-00:on 990610,cooldown transient during reactor startup was noted. Caused by personnel error. Trained 6 briefed personnel &. revised procedures. With 990716 ltr.
DI'STRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL SIZE:
TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.
NOTES:
RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL LPD2-2 PD 1 1 GLEAVES,W 1 1 INTERNAL: ACRS 1 CWzzz,.E, CENTER 1 1 NRR/DIPM/IOLB 1 NRR /DRIP/REXB 1- 1 NRR/DSSA/SPLB 1 RES/DET/ERAB 1 1 RES/DRAA/OERAB 1 RGN2 ,FILE 01 1 1 EXTERNAL: L ST LOBBY WARD 1 1 LMITCO MARSHALL 1 1 NOAC POORE,W. 1 1 NOAC QUEENER,DS 1 1 NRC PDR 1 1 NUDOCS FULL TXT 1 1 D
N NOTE TO ALL "RIDS" RECIPIENTS:
PLEASE HELP US TO REDUCE WASTE. TO HAVE YOUR NAME OR ORGANIZATION REMOVED FROM DISTRIBUTION LISTS OR REDUCE THE NUMBER OF COPIES RECEIVED BY YOU OR YOUR ORGANIZATION, CONTACT THE DOCUMENT CONTROL DESK (DCD) ON EXTENSION 415-2083 N FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 16 ENCL 16
Fiorida Power 5 Light Company, 6351 S. Ocean Drive, Jensen Beach, FL 34957
'July 16, 1999 L-99-160 10 CFR $ 50.4 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555 Re: St. Lucie Unit 2 Docket No. 50-389 Reportable Event: 1999-007-00 Date of Event: June 10, 1999 Personnel Error During Reactor Startu Led to Un lanned Cooldown Transient The attached voluntary Licensee Event Report 1999-007 is being submitted to provide notification of the subject event.
Very truly yours, J. A. Stall
, 'Vice President St. Lucie Nuclear Plant JAS/EJW/KWF Attachment cc: Regional Administrator, USNRC, Region H Senior Resident Inspector, USNRC, St. Lucie Nuclear Plant 9'rr072iOX4G 9'rr07i6 PDR ADQCK 05000389 S PDR an FPL Group company
RC FORM 366 U.S. NUC REGULATORY COMMISSION APPROVED BY NO. 3150-0104 EXPIRES 06/30/2001 (8-1 998)
Estimated burden per responso to comply with this mandatory information collection request: 50 hrs. Reported lessons learned are incorporated jnto the licensing process and fed back to Industry. Forvrard comments regarding LICENSEE EVENT REPORT (LER) burden estimate to the Records Management Branch (T-6 F33), U.S. Nuclear Regulatory Commission, Washington, DC 20555~01, and to the Paperwork Reduction Proiect (3t5th0104), Office of Management and Budget, (See reverse for required number of Washington, DC 20503. If an information collection does not display a currently valid OMB control number, the NRC may not conduct or sponsor, digits/characters for each block) and a person is not required to respond to, the information collection.
FACILITY NAME (1) DOCKET NUMBER (2) PAGE (3)
St. Lucie Unit 2 05000389 Page 1 of 5 TITLE (4)
Personnel Error During Reactor Startup Led to Unplanned Cooldown Transient EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (8)
SEQUENTIAL REVISION FACIUTY NAh'IE DOCKET NuhIBER MONTH DAY YEAR MONTH DAY YEAR NUMBER NUMBER FACIUTY NAME DOCKET NUMBER 06 10 1999 1999 - 007 - 00 07 16 1999 OPERATING THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR gt (Check one or moro) (11)
MODE (9) 20.2201 (b) 20.2203(a)(2) (v) 60.73(a) (2) (i) 60.73(a)(2) (viii)
POWER 20.2203(a)(1) 20.2203(a) (3)(i) 50.73(a)(2) (ii) 50.73 (o) (2) (x)
LEVEL (10) 000 20.2203(a) (2)(i) 20.2203 (a) (3) (ii) 50.73(a) (2) (iii) 73.71 20.2203(a)(2) (ii) 20.2203(a)(4) 50.73(a) (2)(iv) OTHER 20.2203 (a) (2) (iii) 50.36(c)(1) 50.73(a)(2) (v) Specify In Abstract below or 20.2203(a)(2)(iv) 60.36(c)(2) 50.73(a)(2) (vii) in NRC Form 380A LICENSEE CONTACT FOR THIS LER 12)
NAME TELEPHONE NUMBEIt (Include Ares Code)
Kenneth W. Erehafer, Licensing Engineer (561) 467 7748 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT 13 CAusE SYSTEM COMPONENT MANUFACTURER REPORTABLE REPORTABLE To EPIX CAUSE SYSTEM COMPONENT MANUFACTURER To EPIX SUPPLEMENTAL REPORT EXPECTED (14) MONTH DAY EXPECTED YES SUBMISSION (If yee, complete EXPECTED SUBMISSION DATE). X NO DATE (16)
ABSTRACT (Limit to 1400 spaces, i.e., approximate/y 15 sing/ewpaced typewritten /ines/ (16)
This voluntary LER describes an unplanned reactor plant: cooldown transient that occurred on June 10, 1999. At 0345 hours0.00399 days <br />0.0958 hours <br />5.704365e-4 weeks <br />1.312725e-4 months <br /> on June 10, 1999, Unit"2 was in Mode 3 at normal operating pressure and normal operating temperature. A reactor startup was in progress, but temporarily suspended to trouble shoot annunciator problems. Licensed control room personnel decided to perform post maintenance testing on the number 3
'throttle valve; an evolution that required latching the turbine.
At 0412 hours0.00477 days <br />0.114 hours <br />6.812169e-4 weeks <br />1.56766e-4 months <br />, the turbine was latched without incident. At approximately 0420 hours0.00486 days <br />0.117 hours <br />6.944444e-4 weeks <br />1.5981e-4 months <br />, the control room was informed that the testing was complete and that the turbine could be tripped. After the turbine was locally tripped, the main feedwater 15 percent bypass valves were checked, but erroneously not reset, because the controller output had not changed. At 0423 hours0.0049 days <br />0.118 hours <br />6.994048e-4 weeks <br />1.609515e-4 months <br />, several annunciators came in which indicated a steam generator overfeed condition including letdown low pressure, steam generator high levels, and pressurizer low level. At that time, the 15 percent valves were reset, the overfeed was terminated, and levels were restored to normal conditions.
This event was caused by the failure to use existing procedural guidance on turbine shutdown. Contributing factors include non-conservative reactivity management decisions, inadequate operator knowledge on the operation of the main feedwater 15 percent bypass valves, and an inadequate pre-evolution brief. Corrective actions include training, briefings, and procedure changes.
NRC FORM 360 I0.1998)
RC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION (6- I 996)
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION DOCKET FACILITY NAME (1) NUMBER (2) LER NUMBER (6) PAGE (3)
YEAR SEQUENTIAL REVISION NUMBER NUMBER St. Lucie Unit 2 05000389 Page 2 of 5 1999 007 - 00 TEXT (Ifmore spece is required, use eddidonel copies of /VRC Form 366A) (17]
Description of the Event At 0345 hours0.00399 days <br />0.0958 hours <br />5.704365e-4 weeks <br />1.312725e-4 months <br /> on June 10, 1999, Unit 2 was in Mode 3 at normal operating pressure and normal operating temperature (NOP/NOT). The main steam isolation valves (MSIVs)
[EIZS:SB:V] were open and vacuum existed in the main condenser. The steam bypass control system was maintaining reactor coolant 'system (RCS) [EIIS:AB] temperature in automatic control and the main feedwater system [EIIS:SJ] was in operation and maintaining steam generator [EZZS:SB:SG] levels automatically on the 15 percent bypass valves [EIIS:SJ:FCV]. The main turbine DEH system had xecently been returned to service following a repair to a leak on the number 3 turbi.ne throttle valve
[EZIS:TA:FCV]. A reactor staztup was in progress. The Unit 2 licensed control zoom staff consisted of the assistant nuclear plant supervisor (ANPS), board reactor control operator (RCO), desk RCO, a RCO dedicated to the startup, and a senior reactor operator (SRO) reactivity manager dedicated to the startup.
I At approximately 0345 hours0.00399 days <br />0.0958 hours <br />5.704365e-4 weeks <br />1.312725e-4 months <br /> the rotating maintenance shift supervisor (RMSS) and system engineer requested that Operations latch the turbine to post maintenance test (PMT) the work performed on the number 3 throttle valve. The ANPS discussed the possibility of delaying the PMT until the turbine startup with the RMSS. The ANPS decided to go ahead with the PMT in order to save time in case a rework on the valve was required. The nuclear plant supervisor (NPS) and reactivity manager were informed of the intention to latch the turbine. A tailboard was conducted for the turbine latch evolution by the ANPS with the board RCO and nuclear watch engineer (NWE). Procedure GOP-201, "Reactor Plant Startup Mode 2 to Mode 1," was used as guidance for the latching evolution. Tripping of the turbine aftez the PMT was not discussed in the brief.
At 0405 hours0.00469 days <br />0.113 hours <br />6.696429e-4 weeks <br />1.541025e-4 months <br />, annunciator P-17, the main steam isolation signal (MSZS) 2A S/G Pressure Low Channel Trip annunciator, alaxmed in the control room and then cleared.
Investigation found that the D channel MSIS block bistable on the engineered safety feature actuation signal (ESFAS) cabinet had also come in. The ANPS/NPS discussed the operability status of the effected channel and decided that since the reactor was still in Mode 3, to temporarily stop the startup. Maintenance personnel would perform a functional check on the affected steam generator pressure channel to ensure operability prior to entry into Mode 2. Control element assembly (CEA) banks A, B, 1, and 2 were fully withdrawn. CEA bank 3 was 57 inches withdrawn. CEA banks 4 and 5 were not withdrawn. The projected entry into -Mode 2 was the next rod withdrawal sequence.
At 0412 hours0.00477 days <br />0.114 hours <br />6.812169e-4 weeks <br />1.56766e-4 months <br />, the turbine was latched without incident. At approximately 0420 hours0.00486 days <br />0.117 hours <br />6.944444e-4 weeks <br />1.5981e-4 months <br />, the watch engineer called the control room and said that the PMT was completed and that the tuzbine could be tripped. The ANPS directed the watch engineer to trip the turbine locally. After the turbine was tripped, the board RCO checked the 15 percent bypass valves, but did not reset the valves because the controller outp'ut had not changed. The ANPS was informed that the contxoller output had not changed and the valves had not been re'set. The watch engineer was also informed that the 15 percent valves had not been reset when he entered the control room.
Shortly thereafter, the ANPS left the surveillance area to discuss the D channel steam'generator low pressure bistable troubleshooting status with, the Operations Manager. The board RCO left the vicinity of the feed station to investigate an annunciator. At 0423 hours0.0049 days <br />0.118 hours <br />6.994048e-4 weeks <br />1.609515e-4 months <br /> several annunciators came in which indicated a steam generator overfeed condition including letdown low pressure, steam generator high NRC FORM 300A (0.1998)
'4RC FORM 366A .S. NUCLEAR REGULATORY COMMISSION 6 i998)
LICENSEE EVENT REPORT (LERj TEXT CONTINUATION DOCKET FACILITY NAME (1) LER NUMBER (6) PAGE (3)
NUMBER (2 SEQUENTIAl REVISION NUMBER NUMBER St. Lucie Unit 2 05000389 007 Page 3 of 5 1999 00 TEXT (Ifmora space is required, use additional copies of NRC Form 366A/ (1 7)
Description of the Event (cont'd) levels, and pressurizer low level. At that time, the 15 percent valves were reset, the overfeed was terminated, and levels were restored to normal conditions. During the transient RCS temperature was reduced from 535'F to 526'F, or approximately 9'F.
Cause of the Event The cause of this event was that the operators did not utilize existing procedural guidance for turbine shutdown. There is no specific procedure to latch and trip the turbine for testing. The operators did use procedural guidance from GOP-201, "Reactor Plant Startup Mode 2 to Mode 1," to latch the turbine. However, tripping of the turbine was not discussed prior to the control room being informed that the PMT was completed. No procedural guidance for tripping the tu'rbine had been considered by the ANPS or board RCO. When notified the turbine was ready to be tripped, the ANPS made the decision to trip the turbine without considering what procedural guidance he was using to do the trip. NOP-2-0030125, "Turbine Shutdown Full Load to Zero Load," steps 7.41.3 7.41.6 provides the guidance for tripping the turbine and specifically addresses resetting the 15 percent bypass valves after tripping the turbine.
Contributing factors to this event were:
~ Conservative Decision-Making: The crew decided to proceed with turbine latch evolution with a reactor startup in progress.
n The ANPS considered the possibility of the adverse effects evolution caused the RCS to cooldown due to turbine valve mispositioning or leak if the turbine latch by. However, he considered this possibility remote and decided the PMT needed to be completed to ensure the turbine roll would not be delayed. The NPS considered the plant stable since the startup was on hold and did not have any problem with the turbine evolution proceeding. However, there was no valid reason to complete this evolution prior to completion of the reactor startup.
~ ..Pre-evolution briefing: The tailboard briefing for the evolution was not adequate.
The ANPS considered the turbine latch a minor evolution with direct procedural
'guidance and therefore, did not consider "Conduct of Operations," CS-9 checklist.
it necessary to use the AP 0010120, The brief did not include all members of the control staff, only the personnel involved in the evolution. The ANPS did not include the desk RCO because he was performing his normal shiftly duties and was behind due to the increased paperwork load of the startup. The ANPS did not include the reactor startup RCO or the reactivity manager because they were dedicated to only the startup. However, because of the possible reactivity effects of the evolution, the individuals involved in the startup should have been included in the brief.
Only the turbine latching evolution was discussed in the prejob brief. The ANPS was focused on ensuring the DEH computer was properly setup for the turbine latch and the proper turbine response on latching. GOP 201, "Reactor Plant Startup-Mode 2 to Mode 1," steps 6.25 6.33 were reviewed and considered appropriate for the evolution. Prior to and during the brief, the ANPS never considered tripping the turbine or the status of the 15 percent bypass valves post-trip.
NRC FOAM 300A (0.1998)
NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION 6-1 998l LICENSEE EVENT REPORT" (LERj TEXT CONTINUATION DQGKET FACILITY NAME (1) NUMBER (2) LER NUMBER (6) PAGE (3)
SEQUENTIAL REVISION NUMBER NUMBER St. Lucie Unit 2 05000389 007 Page 4 of 5 1999 00 TEXT Iifmore space is reriuired, use additional copies of IVRC &rm 366AJ (17)
Cause of the Event (cont'd)
Other members of the control room staff were aware of the post turbine trip status of the 15 percent bypass valves and the importance of resetting the valves. Had the brief included all members of the crew, it is likely someone would have discussed the importance of the promptly resetting the valves and of the procedural guidance to do so.
~ Operator Training/Knowledge Level: The operators misinterpreted the 15 percent bypass valve controller indication after the turbine trip.
The 15 percent bypass valves fail to the 5 percent flow position following a turbine trip. The reactor turbine generator board (RTGB) controller is taken out of the circuit but there is no change in controller output. The operators mistakenly interpreted the normal controller output following the trip as evidence that the valve was still functioning in automatic and that resetting.'he valves'as not necessary.
The three licensed operators involved in the evolution failed to re'cognize the status of 15 percent valves post turbine trip. They misinterpreted controller output not, changing as indication that the valve had not repositioned to the five percent flow position. Had any of the three operators recognized that the controller was out of the circuit, and that controller indica'tion remaining the same was an expected response when the valves had moved to the design post turbine trip position, then the valves would have been reset.
~ Self-Checking: The operators did not adequately follow up on an unexpected plant zesponse.
The operators expected to have to reset the 15 percent bypass valves, but did not follow up when the expected controller response was not obtained. They incorrectly reasoned that since they had tripped the turbine locally, the 15 percent valves did not need to be reset. Other plant parameters that would have confirmed the 15 percent. valve positions, such as steam generator levels, were not
..closely monitored to verify proper operation. The board RCO allowed himself tO become distracted and left to respond to another annunciator. Additionally, other
', .members of the control room staff were not brought into the discussion of the unexpected response of the 15 percent valves.
Analysis of the Event This event is being reported as a voluntary LER.
Analysis of Safety Significance FPL performed an assessment for this event using ABB-CE best estimate standard design calculations and determined that the inadvertent cooldown did not result in Mode 2 conditions. Calculationally, K,qg remained less than 0.99, but because of uncertainties in the calculations and in measurements, it is possible that the reactor entered Mode 2. However, the plant had a reactor,startup in progress and was ready to enter Mode 2.
The decision to perform the PMT on the number 3 throttle valve during a reactor startup was a nonconservative reactivity management decision. Reactivity management is a primary function of the licensed operators in the control room and this decision NBC FORM 3BBA IB-1998)
NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION 6-1998)
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION DOCKET PAGE (3)
FACILiTY NAME (1) NUMBER (2) LER NUMBER (6)
SEQUENTIAL REVISION NUMBER NUMBER St. Lucie Unit 2 05000389 007 Page 5 of 5 1999 00 TEXT (Ifmore spaceis required, use additional copies of NRC Farm 366A) (17)
Analysis of Safety Significance (cont')
demonstrates a lack of sensitivity to reactivity management issues. Although this.
event most probably did not result'in an inadvertent mode change, this event did reveal several failed barriers that should have precluded the cooldown event. The enhancements to these failed barriers are addressed in the corrective actions noted below.
Corrective Actions
- 1. The SRO involved was temporarily removed 'from licensed activities in order to develop the root cause and corrective actions for this event. The SRO was returned to licensed duties after de-briefing the Plant General Manager on the findings.
- 2. Each available Operations department supervisor has signed a letter Acknowledging the requirements for AP 0010120, "Conduct of Operations," check sheet 9 fox prejob briefings and the requirements for procedure usage (with the balance due when the personnel return fzom vacations, etc.).
- 3. Procedure NOP-1/2-0030122, "Reactor Staxtup," is, being changed to include steps and cautions to not perform any evolution which could influence RCS temperature and thus reactivity during the approach to criticality,
- 4. Operations management has briefed all operations control room crews on the incident. The briefing stressed a) the importance of thorough p'rejob briefings using procedure AP 0010120, "Conduct of Operations," check sheet '9; b) the necessity of using the appropriate procedure for every evolution and every part, of every evolution; c) the importance of self-checking and following up on unexpected plant responses by use of diverse indications to ensure equipment status, and; d) the importance of conservative reactivity management during xeactor startup.
- 5. A Training Brief on operation of the 15 percent bypass valves is being issued to ensure all licensed operators know the operation and RTGB indications of the
..valves after a turbine trip.
6.'peration of shutdown/low power feed water control is being incorporated into the
'Licensed Operator Continuing Traini.ng Program to ensure all operators are aware of the operating characteristics and RTGB indications of feed system.
- 7. This event, including the root cause analysis, is being covered in Licensed Operator Continuing Training.
- 8. A video of proper prejob briefing techniques and expectations is being produced for use in Licensed Operator Continuing Training.
Additional Information Failed Com onents Identified None Similar Events None NRC FORM 3BBA IB-1998)