LER 99-007-01:on 990423,reactor Trip Occurred Due to Instrument & Control Technicians Inadvertently Pulling Fuses from Wrong Nuclear Instrument Channel.Setpoint Adjustments Were Completed by Different Crew of TechniciansML17265A718 |
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Ginna |
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Issue date: |
07/23/1999 |
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From: |
St Martin J ROCHESTER GAS & ELECTRIC CORP. |
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Shared Package |
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ML17265A717 |
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References |
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LER-99-007, NUDOCS 9908020082 |
Download: ML17265A718 (10) |
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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML17265A7541999-09-22022 September 1999 LER 99-011-00:on 990823,small Tears Were Discovered in Flexible Duct Work Connector at Inlet of CR HVAC Sys Return Air Fan (AKF08).Caused by in-leakage Greater than That Assumed.Implemented Temporary Mod 99-029.With 990922 Ltr ML17265A7431999-08-24024 August 1999 LER 99-004-01:on 990412,discovered That Containment Recirculation Fan Chevron Separator Vanes Were Installed Backwards.Caused by Improper Assembly by Mfg.Moisture Separator Vanes Were Dismantled & Correctly re-installed ML17265A7181999-07-23023 July 1999 LER 99-007-01:on 990423,reactor Trip Occurred Due to Instrument & Control Technicians Inadvertently Pulling Fuses from Wrong Nuclear Instrument Channel.Setpoint Adjustments Were Completed by Different Crew of Technicians ML17265A7081999-07-22022 July 1999 LER 98-003-02:on 980904,actuations of CR Emergency Air Treatment Sys Was Noted Due to Invalid Causes.Caused by Various Degraded Components in CR RM Sys.Creats Actuation Signal Was Reset & Normal Ventilation Was Restored ML17265A7031999-07-19019 July 1999 LER 99-S01-00:on 990617,determined That Temporary Unescorted Access Had Been Granted to Contractor Employee.Caused by Incomplete Info Re Circumstances of Individual Military Separation.Individual Access Was Revoked.With 990719 Ltr ML17265A7021999-07-15015 July 1999 LER 99-010-00:on 990615,ventilation Isolation of Auxiliary Bldg Occurred When Auxiliary Bldg Gas Radiation Monitor R-14 Reached High Alarm Setpoint.Cr Operators Rest Auxiliary Bldg Ventilation Isolation Signal.With 990715 Ltr ML17265A6851999-06-21021 June 1999 LER 99-001-01:on 990222,deficiencies in NSSS Vendor steam- Line Brake Mass & Energy Release Analysis Results in Plant Being Outside Design Bases Occurred.Caused by Deficiencies in W.Temporary Administrative Replaced.With 990621 Ltr ML17265A6661999-06-0202 June 1999 LER 99-009-00:on 990503,instrumentation Declared Inoperable in Multiple Channels Resulted in Condition Prohibited by Ts. Caused by Unanticipated High Frequency AC Voltage Ripple. Entered TS LCO 3.0.3.With 990602 Ltr ML17309A6541999-05-27027 May 1999 LER 99-008-00:on 990427,overtemperature Delta T Reactor Trip Occurred Due to Faulted Bistable During Calibr of Redundant Channel.Plant Was Stabilized in Mode 3 & Faulted Bistable Was Subsequently Replaced.With 990527 Ltr ML17265A6631999-05-24024 May 1999 LER 99-007-00:on 990423,technicians Inadvertently Pulled Fuses from Wrong Nuclear Instrument Cahnnel,Causing Reactor Trip,Due to High Range Flux Trip.Caused by Personnel Error. Labeling Scheme Improved ML17265A6601999-05-21021 May 1999 LER 99-006-00:on 990421,start of turbine-driven Auxiliary Feedwater Pump Was Noted.Caused by MOV Being Left in Open Position.Closed Manual Isolation Valve to Secure Steam to Pump.With 990521 Ltr ML17265A6441999-05-13013 May 1999 LER 99-005-00:on 990413,undervoltage Signal of Safeguards Bus During Testing Resulted in Automatic Start of B Edg. Caused by Personnel Error.Blown Fuse Was Replaced & Offsite Power Was Restored to Safeguards Bus 17.With 990513 Ltr ML17265A6431999-05-12012 May 1999 LER 99-004-00:on 990412,discovered That Containment Recirculation Fan Moisture Separator Vanes Were Incorrectly Installed,Per 10CFR21.Caused by Improper Assembly by Mfg. Subject Vanes Were Dismantled & Correctly re-installed ML17265A6141999-03-31031 March 1999 LER 99-003-00:on 990301,two Main Steam non-return Check Valves Were Declared Inoperable Due to Exceedance of Acceptance Criteria.Caused by Changes in Methodology & Matls.Packing Gland Torque Will Be Adjusted.With 990331 Ltr ML17265A6131999-03-29029 March 1999 LER 99-002-00:on 990227,discovered That Surveillance Had Not Been Performed at Frequency,Per Ts.Caused by Personnel Error.Procedure O-6.13 Will Be Evaluated for Enhancement Documentation of Completion of ITS Srs.With 990329 Ltr ML17265A6061999-03-24024 March 1999 LER 99-001-00:on 990222,plant Was Noted Outside Design Basis.Caused by Deficiencies in NSSS Vendor Slb Mass & Energy Release.Placed Temporary Administrative Restriction 40 Degrees F Max on Screenhouse Bay Temp ML17265A4951998-12-21021 December 1998 LER 98-005-00:on 981120,loss of 34.5 Kv Offsite Power Circuit 751,resulted in Automatic Start of B Edg.Caused by Faulted Cable Splice.Performed Appropriate Actions of Abnormal Procedure AP-ELEC.1.With 981221 Ltr ML17265A4931998-12-17017 December 1998 LER 98-004-00:on 971030,determined That Improperly Performed Surveillance Resulted in Condition Prohibited by Ts.Caused by Procedure non-adherence.Appropriate Calibr Procedures Were Properly Performed with 24 H of Condition Discovery ML17265A4691998-11-25025 November 1998 LER 98-003-01:on 980904,actuations of CR Emergency Air Treatment Systems (Creats) Occurred.Caused by Radon build-up During Temp Inversion.Creats Actuation Signal Was Reset & Normal Ventilation Was Restored to CR ML17265A4271998-10-0505 October 1998 LER 98-003-00:on 980904,actuations of CR Emergency Air Treatment Sys Occurred.Caused by Radon build-up During Temp Inversion.Air Samples Were Taken & Determined That Source of Radiation Was Naturally Occurring Radon.With 981005 Ltr ML17265A3671998-07-14014 July 1998 LER 98-002-00:on 971019,CR Emergency Air Treatment Sys Actuating Function Was Not Operable.Caused by Mispositioned Switch.Revised Procedure CPI-MON-R37.W/980714 Ltr ML17265A1921998-03-11011 March 1998 LER 98-001-00:on 980209,discovered That Boraflex Degradation in SPF Was Greater than Was Assumed.Caused by Dissolution of Boron on Boraflex Matrix,Per 10CFR50.21.Removed Spent Fuel Assemblies from Selected Degraded Storage Rack Cells ML17265A1641998-02-0606 February 1998 LER 97-007-01:on 971117,reactor Engineer Recognized That Neutron Flux Low Range Trip Circuitry for Channel Was Not in Tripped Condition as Required.Caused by Technical Inadequacies.Channel Defeat Will Be Identified ML17265A1601998-02-0606 February 1998 LER 97-006-01:on 971103,verification of B Concentration Was Not Performed Due to Misinterpretation of Event Sequence. Audible Count Rate Function Was Restored to Operable Status ML17264B1441997-12-17017 December 1997 LER 97-007-00:on 971117,NF Low Range Trip Circuitry for Channel N-44 Was Not Placed in Tripped Condition.Caused by Technical Inadequacies in Procedures.Implemented EWR 4862 to Resolve Design deficiency.W/971217 Ltr ML17264B1291997-12-0303 December 1997 LER 97-006-00:on 971103,NIS Audible Count Rate Function Was Inoperable.Caused by Misinterpretation of Event Sequence Due to Not Verifying Boron Concentration.B Verification Occurred Every 12 H Per ITS LCO Action 3.9.2.C.3.W/971203 Ltr ML17264B1271997-12-0101 December 1997 LER 97-005-00:on 971031,undetected Unblocking of SI Actuation Signal Occurred at Low Pressure Condition,Due to Faulty Bistable Which Resulted in Inadvertent SI Actuation Signal.Sias,Ci & CVI Signals Were Reset ML17264B1211997-11-24024 November 1997 LER 97-004-00:on 971024,radiation Monitor Alarm Were Noted Due to Higher than Normal Radioactive Gas Concentration Resulted in Cvi.New R-12 Alarm Setpoint Was Maintained for Duration of Refueling Outage ML17264B0461997-09-29029 September 1997 LER 97-003-01:on 970730,bistable Instrument Trip Setpoint Could Have Exceeded Allowable Value.Caused by Insufficient Existing Margin Between Trip Setpoint & Allowable Value. Held Switches in Tripped configuration.W/970929 Ltr ML17264B0111997-08-27027 August 1997 LER 97-003-00:on 970730,high Steam Flow Bistable Instrument Setpoint Plus Instrument Uncertainty Could Exceed Allowable Value in ITS Was Identified.Caused by Entry Into ITS LCO 3.0.3.Switches Placed in Tripped configuration.W/970827 Ltr ML17264A9941997-08-19019 August 1997 LER 97-002-00:on 970720,34.5 Kv Offsite Power Circuit 751 Was Lost.Caused by Automatic Actuation of B Emergency DG Due to Undervoltage on Safeguards Buses 16 & 17.Offsite Power Restored to Safeguards Buses 16 & 17.W/970819 Ltr ML17264A9911997-08-11011 August 1997 LER 96-009-02:on 960723,determined That Leak Rate Outside Containment Was Greater than Program Limit.Caused by Weld Defect.Isolated Leak & Cut Out & Replaced Leaking Pipe ML17264A8271997-03-0303 March 1997 LER 97-001-00:on 970131,discovered Service Water Temp Was Less than Specified Value.Caused by non-representative Method of Monitoring.Increased Water Temp in Screenhouse Bay to Greater than 35 Degrees F.W/970303 Ltr ML17264A8071997-01-22022 January 1997 LER 96-015-00:on 961223,discovered Thermally Induced Overpressure Transient Could Occur.Caused by Thermal Expansion of Fluid During Design Basis Accident Condition. Installed Relief Valve on Affected line.W/970122 Ltr ML17264A7471996-11-27027 November 1996 LER 96-013-00:on 961029,circuit Breakers Closed While in Mode 3 & Resulted in Condition Prohibited by TS Due to Personnel Error.Circuit Breakers for MOV-878B & MOV-878D Were re-opened.W/961127 Ltr ML17264A6051996-09-19019 September 1996 LER 96-012-00:on 960820,feedwater Transient Occurred,Due to Closure of Feedwater Regulating Valve,Causing Lo Lo Steam Generator Level Reactor Trip.Sgs Were Restored & Missing Screw in 1/P-476 Was replaced.W/960919 Ltr ML17264A6061996-09-19019 September 1996 LER 96-009-01:on 960723,leakage Outside Containment Occurred,Due to Weld Defect,Resulting in Leak Rate Greater than Program Limits.Source of Leakage Isolated from RWST by Freeze Seal,Allowing Exit from ITS LCO 3.0.3.W/960919 Ltr ML17264A5911996-09-0505 September 1996 LER 96-011-00:on 960807,improper Configuration of Circuit Breaker Occurred,Due to Undetected Internal Interference, Resulting in Automatic Start of Both Auxiliary Feedwater Pumps.Running AFW Pumps Were secured.W/960905 Ltr ML17264A5921996-09-0505 September 1996 LER 96-010-00:on 960806,latching of Main Turbine While in Mode 4 Occurred,Due to Defective Procedure,Resulting in Automatic Start of Auxiliary Feedwater Pump.Caused by Defective Maint Procedure.Procedure revised.W/960905 Ltr ML17264A5891996-08-22022 August 1996 LER 96-009-00:on 960723,determined Leak on Piping Sys Outside Containment Greater than Program Limit.Caused by Weld Defect.Pipe & Socket Welds Were Cut Out & Replaced. W/960822 Ltr ML17264A5781996-08-0606 August 1996 LER 96-008-00:on 960707,main Feedwater Pump Breakers Opened. Caused by Change in Seal Water Differential Pressure Occurred During Sys Realignment.Afw Flow Controlled as Desired to Maintain S/G level.W/960806 Ltr ML17264A5561996-07-12012 July 1996 LER 96-007-00:on 960612,CR Operators Identified Control Rods Misaligned & Not Moving in Proper Sequence.Caused by Faulty Firing Circuit Card in Rod Control Sys.Faulty Firing Circuit Card in 1BD Power Cabinet replaced.W/960712 Ltr ML17264A5421996-06-20020 June 1996 LER 96-006-00:on 960521,discovered Containment Penetration Not in Required Status.Caused by Personnel Error.Installed Flange Inside Containment Penetration 2.W/960620 Ltr ML17264A5411996-06-17017 June 1996 LER 96-005-00:on 960516,PORC Determined Deficient Procedures Do Not Meet SRs for Testing safety-related Logic Circuits. Caused by Inadequancies in Individual Testing Procedures. Procedures Re Improved TSs revised.W/960617 Ltr ML17264A5051996-05-17017 May 1996 LER 96-003-01:on 960308,identified That Both Pressurizer PORVs Inoperable Concurrently Due to Disconnection of Flex Hose to Both PORV Actuators to Install air-sets for Benchset & Limit Switch Activities.Hpes Completed ML17264A4481996-04-0808 April 1996 LER 96-003-00:on 960308,both Pressurizer Relief Valves Inoperable.Hpes Evaluation Is Being Conducted to Determined Cause of Event.C/As:Both PORVs restored.W/960408 Ltr ML17264A4471996-04-0808 April 1996 LER 96-002-00:on 960307,secondary Transient Occurred.Caused by Loss of B Condenser Circulating Water Pump.C/As: Thermography performed.W/960408 Ltr ML17264A4101996-03-18018 March 1996 LER 96-001-00:on 950504,inservice Test Not Performed During Refueling Outage.Caused by Inadequate Tracking of Surveillance Frequency.Valve Test Performed & Disassembled. W/960318 Ltr ML17264A2971995-12-14014 December 1995 LER 95-009-00:on 950817,surveillance Was Not Performed Due to Improper Application of TS Requirements Resulting in TS Violation.Testing of MOV-515 Was Performed on 951115.W/ 951214 Ltr ML17264A1711995-09-25025 September 1995 LER 95-008-00:on 950825,secondary Transient Occurred.Caused by Loss of B Condenser Circulating Water Pump That Resulted in Manual Rt.Returned S/G Levels to Normal Operating levels.W/950925 Ltr 1999-09-22
[Table view] Category:RO)
MONTHYEARML17265A7541999-09-22022 September 1999 LER 99-011-00:on 990823,small Tears Were Discovered in Flexible Duct Work Connector at Inlet of CR HVAC Sys Return Air Fan (AKF08).Caused by in-leakage Greater than That Assumed.Implemented Temporary Mod 99-029.With 990922 Ltr ML17265A7431999-08-24024 August 1999 LER 99-004-01:on 990412,discovered That Containment Recirculation Fan Chevron Separator Vanes Were Installed Backwards.Caused by Improper Assembly by Mfg.Moisture Separator Vanes Were Dismantled & Correctly re-installed ML17265A7181999-07-23023 July 1999 LER 99-007-01:on 990423,reactor Trip Occurred Due to Instrument & Control Technicians Inadvertently Pulling Fuses from Wrong Nuclear Instrument Channel.Setpoint Adjustments Were Completed by Different Crew of Technicians ML17265A7081999-07-22022 July 1999 LER 98-003-02:on 980904,actuations of CR Emergency Air Treatment Sys Was Noted Due to Invalid Causes.Caused by Various Degraded Components in CR RM Sys.Creats Actuation Signal Was Reset & Normal Ventilation Was Restored ML17265A7031999-07-19019 July 1999 LER 99-S01-00:on 990617,determined That Temporary Unescorted Access Had Been Granted to Contractor Employee.Caused by Incomplete Info Re Circumstances of Individual Military Separation.Individual Access Was Revoked.With 990719 Ltr ML17265A7021999-07-15015 July 1999 LER 99-010-00:on 990615,ventilation Isolation of Auxiliary Bldg Occurred When Auxiliary Bldg Gas Radiation Monitor R-14 Reached High Alarm Setpoint.Cr Operators Rest Auxiliary Bldg Ventilation Isolation Signal.With 990715 Ltr ML17265A6851999-06-21021 June 1999 LER 99-001-01:on 990222,deficiencies in NSSS Vendor steam- Line Brake Mass & Energy Release Analysis Results in Plant Being Outside Design Bases Occurred.Caused by Deficiencies in W.Temporary Administrative Replaced.With 990621 Ltr ML17265A6661999-06-0202 June 1999 LER 99-009-00:on 990503,instrumentation Declared Inoperable in Multiple Channels Resulted in Condition Prohibited by Ts. Caused by Unanticipated High Frequency AC Voltage Ripple. Entered TS LCO 3.0.3.With 990602 Ltr ML17309A6541999-05-27027 May 1999 LER 99-008-00:on 990427,overtemperature Delta T Reactor Trip Occurred Due to Faulted Bistable During Calibr of Redundant Channel.Plant Was Stabilized in Mode 3 & Faulted Bistable Was Subsequently Replaced.With 990527 Ltr ML17265A6631999-05-24024 May 1999 LER 99-007-00:on 990423,technicians Inadvertently Pulled Fuses from Wrong Nuclear Instrument Cahnnel,Causing Reactor Trip,Due to High Range Flux Trip.Caused by Personnel Error. Labeling Scheme Improved ML17265A6601999-05-21021 May 1999 LER 99-006-00:on 990421,start of turbine-driven Auxiliary Feedwater Pump Was Noted.Caused by MOV Being Left in Open Position.Closed Manual Isolation Valve to Secure Steam to Pump.With 990521 Ltr ML17265A6441999-05-13013 May 1999 LER 99-005-00:on 990413,undervoltage Signal of Safeguards Bus During Testing Resulted in Automatic Start of B Edg. Caused by Personnel Error.Blown Fuse Was Replaced & Offsite Power Was Restored to Safeguards Bus 17.With 990513 Ltr ML17265A6431999-05-12012 May 1999 LER 99-004-00:on 990412,discovered That Containment Recirculation Fan Moisture Separator Vanes Were Incorrectly Installed,Per 10CFR21.Caused by Improper Assembly by Mfg. Subject Vanes Were Dismantled & Correctly re-installed ML17265A6141999-03-31031 March 1999 LER 99-003-00:on 990301,two Main Steam non-return Check Valves Were Declared Inoperable Due to Exceedance of Acceptance Criteria.Caused by Changes in Methodology & Matls.Packing Gland Torque Will Be Adjusted.With 990331 Ltr ML17265A6131999-03-29029 March 1999 LER 99-002-00:on 990227,discovered That Surveillance Had Not Been Performed at Frequency,Per Ts.Caused by Personnel Error.Procedure O-6.13 Will Be Evaluated for Enhancement Documentation of Completion of ITS Srs.With 990329 Ltr ML17265A6061999-03-24024 March 1999 LER 99-001-00:on 990222,plant Was Noted Outside Design Basis.Caused by Deficiencies in NSSS Vendor Slb Mass & Energy Release.Placed Temporary Administrative Restriction 40 Degrees F Max on Screenhouse Bay Temp ML17265A4951998-12-21021 December 1998 LER 98-005-00:on 981120,loss of 34.5 Kv Offsite Power Circuit 751,resulted in Automatic Start of B Edg.Caused by Faulted Cable Splice.Performed Appropriate Actions of Abnormal Procedure AP-ELEC.1.With 981221 Ltr ML17265A4931998-12-17017 December 1998 LER 98-004-00:on 971030,determined That Improperly Performed Surveillance Resulted in Condition Prohibited by Ts.Caused by Procedure non-adherence.Appropriate Calibr Procedures Were Properly Performed with 24 H of Condition Discovery ML17265A4691998-11-25025 November 1998 LER 98-003-01:on 980904,actuations of CR Emergency Air Treatment Systems (Creats) Occurred.Caused by Radon build-up During Temp Inversion.Creats Actuation Signal Was Reset & Normal Ventilation Was Restored to CR ML17265A4271998-10-0505 October 1998 LER 98-003-00:on 980904,actuations of CR Emergency Air Treatment Sys Occurred.Caused by Radon build-up During Temp Inversion.Air Samples Were Taken & Determined That Source of Radiation Was Naturally Occurring Radon.With 981005 Ltr ML17265A3671998-07-14014 July 1998 LER 98-002-00:on 971019,CR Emergency Air Treatment Sys Actuating Function Was Not Operable.Caused by Mispositioned Switch.Revised Procedure CPI-MON-R37.W/980714 Ltr ML17265A1921998-03-11011 March 1998 LER 98-001-00:on 980209,discovered That Boraflex Degradation in SPF Was Greater than Was Assumed.Caused by Dissolution of Boron on Boraflex Matrix,Per 10CFR50.21.Removed Spent Fuel Assemblies from Selected Degraded Storage Rack Cells ML17265A1641998-02-0606 February 1998 LER 97-007-01:on 971117,reactor Engineer Recognized That Neutron Flux Low Range Trip Circuitry for Channel Was Not in Tripped Condition as Required.Caused by Technical Inadequacies.Channel Defeat Will Be Identified ML17265A1601998-02-0606 February 1998 LER 97-006-01:on 971103,verification of B Concentration Was Not Performed Due to Misinterpretation of Event Sequence. Audible Count Rate Function Was Restored to Operable Status ML17264B1441997-12-17017 December 1997 LER 97-007-00:on 971117,NF Low Range Trip Circuitry for Channel N-44 Was Not Placed in Tripped Condition.Caused by Technical Inadequacies in Procedures.Implemented EWR 4862 to Resolve Design deficiency.W/971217 Ltr ML17264B1291997-12-0303 December 1997 LER 97-006-00:on 971103,NIS Audible Count Rate Function Was Inoperable.Caused by Misinterpretation of Event Sequence Due to Not Verifying Boron Concentration.B Verification Occurred Every 12 H Per ITS LCO Action 3.9.2.C.3.W/971203 Ltr ML17264B1271997-12-0101 December 1997 LER 97-005-00:on 971031,undetected Unblocking of SI Actuation Signal Occurred at Low Pressure Condition,Due to Faulty Bistable Which Resulted in Inadvertent SI Actuation Signal.Sias,Ci & CVI Signals Were Reset ML17264B1211997-11-24024 November 1997 LER 97-004-00:on 971024,radiation Monitor Alarm Were Noted Due to Higher than Normal Radioactive Gas Concentration Resulted in Cvi.New R-12 Alarm Setpoint Was Maintained for Duration of Refueling Outage ML17264B0461997-09-29029 September 1997 LER 97-003-01:on 970730,bistable Instrument Trip Setpoint Could Have Exceeded Allowable Value.Caused by Insufficient Existing Margin Between Trip Setpoint & Allowable Value. Held Switches in Tripped configuration.W/970929 Ltr ML17264B0111997-08-27027 August 1997 LER 97-003-00:on 970730,high Steam Flow Bistable Instrument Setpoint Plus Instrument Uncertainty Could Exceed Allowable Value in ITS Was Identified.Caused by Entry Into ITS LCO 3.0.3.Switches Placed in Tripped configuration.W/970827 Ltr ML17264A9941997-08-19019 August 1997 LER 97-002-00:on 970720,34.5 Kv Offsite Power Circuit 751 Was Lost.Caused by Automatic Actuation of B Emergency DG Due to Undervoltage on Safeguards Buses 16 & 17.Offsite Power Restored to Safeguards Buses 16 & 17.W/970819 Ltr ML17264A9911997-08-11011 August 1997 LER 96-009-02:on 960723,determined That Leak Rate Outside Containment Was Greater than Program Limit.Caused by Weld Defect.Isolated Leak & Cut Out & Replaced Leaking Pipe ML17264A8271997-03-0303 March 1997 LER 97-001-00:on 970131,discovered Service Water Temp Was Less than Specified Value.Caused by non-representative Method of Monitoring.Increased Water Temp in Screenhouse Bay to Greater than 35 Degrees F.W/970303 Ltr ML17264A8071997-01-22022 January 1997 LER 96-015-00:on 961223,discovered Thermally Induced Overpressure Transient Could Occur.Caused by Thermal Expansion of Fluid During Design Basis Accident Condition. Installed Relief Valve on Affected line.W/970122 Ltr ML17264A7471996-11-27027 November 1996 LER 96-013-00:on 961029,circuit Breakers Closed While in Mode 3 & Resulted in Condition Prohibited by TS Due to Personnel Error.Circuit Breakers for MOV-878B & MOV-878D Were re-opened.W/961127 Ltr ML17264A6051996-09-19019 September 1996 LER 96-012-00:on 960820,feedwater Transient Occurred,Due to Closure of Feedwater Regulating Valve,Causing Lo Lo Steam Generator Level Reactor Trip.Sgs Were Restored & Missing Screw in 1/P-476 Was replaced.W/960919 Ltr ML17264A6061996-09-19019 September 1996 LER 96-009-01:on 960723,leakage Outside Containment Occurred,Due to Weld Defect,Resulting in Leak Rate Greater than Program Limits.Source of Leakage Isolated from RWST by Freeze Seal,Allowing Exit from ITS LCO 3.0.3.W/960919 Ltr ML17264A5911996-09-0505 September 1996 LER 96-011-00:on 960807,improper Configuration of Circuit Breaker Occurred,Due to Undetected Internal Interference, Resulting in Automatic Start of Both Auxiliary Feedwater Pumps.Running AFW Pumps Were secured.W/960905 Ltr ML17264A5921996-09-0505 September 1996 LER 96-010-00:on 960806,latching of Main Turbine While in Mode 4 Occurred,Due to Defective Procedure,Resulting in Automatic Start of Auxiliary Feedwater Pump.Caused by Defective Maint Procedure.Procedure revised.W/960905 Ltr ML17264A5891996-08-22022 August 1996 LER 96-009-00:on 960723,determined Leak on Piping Sys Outside Containment Greater than Program Limit.Caused by Weld Defect.Pipe & Socket Welds Were Cut Out & Replaced. W/960822 Ltr ML17264A5781996-08-0606 August 1996 LER 96-008-00:on 960707,main Feedwater Pump Breakers Opened. Caused by Change in Seal Water Differential Pressure Occurred During Sys Realignment.Afw Flow Controlled as Desired to Maintain S/G level.W/960806 Ltr ML17264A5561996-07-12012 July 1996 LER 96-007-00:on 960612,CR Operators Identified Control Rods Misaligned & Not Moving in Proper Sequence.Caused by Faulty Firing Circuit Card in Rod Control Sys.Faulty Firing Circuit Card in 1BD Power Cabinet replaced.W/960712 Ltr ML17264A5421996-06-20020 June 1996 LER 96-006-00:on 960521,discovered Containment Penetration Not in Required Status.Caused by Personnel Error.Installed Flange Inside Containment Penetration 2.W/960620 Ltr ML17264A5411996-06-17017 June 1996 LER 96-005-00:on 960516,PORC Determined Deficient Procedures Do Not Meet SRs for Testing safety-related Logic Circuits. Caused by Inadequancies in Individual Testing Procedures. Procedures Re Improved TSs revised.W/960617 Ltr ML17264A5051996-05-17017 May 1996 LER 96-003-01:on 960308,identified That Both Pressurizer PORVs Inoperable Concurrently Due to Disconnection of Flex Hose to Both PORV Actuators to Install air-sets for Benchset & Limit Switch Activities.Hpes Completed ML17264A4481996-04-0808 April 1996 LER 96-003-00:on 960308,both Pressurizer Relief Valves Inoperable.Hpes Evaluation Is Being Conducted to Determined Cause of Event.C/As:Both PORVs restored.W/960408 Ltr ML17264A4471996-04-0808 April 1996 LER 96-002-00:on 960307,secondary Transient Occurred.Caused by Loss of B Condenser Circulating Water Pump.C/As: Thermography performed.W/960408 Ltr ML17264A4101996-03-18018 March 1996 LER 96-001-00:on 950504,inservice Test Not Performed During Refueling Outage.Caused by Inadequate Tracking of Surveillance Frequency.Valve Test Performed & Disassembled. W/960318 Ltr ML17264A2971995-12-14014 December 1995 LER 95-009-00:on 950817,surveillance Was Not Performed Due to Improper Application of TS Requirements Resulting in TS Violation.Testing of MOV-515 Was Performed on 951115.W/ 951214 Ltr ML17264A1711995-09-25025 September 1995 LER 95-008-00:on 950825,secondary Transient Occurred.Caused by Loss of B Condenser Circulating Water Pump That Resulted in Manual Rt.Returned S/G Levels to Normal Operating levels.W/950925 Ltr 1999-09-22
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML17265A7601999-10-0505 October 1999 Part 21 Rept Re W2 Switch Supplied by W Drawn from Stock, Did Not Operate Properly After Being Installed on 990409. Switch Returned to W on 990514 for Evaluation & Root Cause Analysis ML17265A7621999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for Re Ginna Npp.With 991008 Ltr ML17265A7531999-09-23023 September 1999 Part 21 Rept Re Corrective Action & Closeout of 10CFR21 Rept of Noncompliance Re Unacceptable Part for 30-4 Connector. Unacceptable Parts Removed from Stock & Scrapped ML17265A7541999-09-22022 September 1999 LER 99-011-00:on 990823,small Tears Were Discovered in Flexible Duct Work Connector at Inlet of CR HVAC Sys Return Air Fan (AKF08).Caused by in-leakage Greater than That Assumed.Implemented Temporary Mod 99-029.With 990922 Ltr ML17265A7471999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Re Ginna Npp.With 990909 Ltr ML17265A7431999-08-24024 August 1999 LER 99-004-01:on 990412,discovered That Containment Recirculation Fan Chevron Separator Vanes Were Installed Backwards.Caused by Improper Assembly by Mfg.Moisture Separator Vanes Were Dismantled & Correctly re-installed ML17265A7341999-07-31031 July 1999 Monthly Operating Rept for July 1999 for Re Ginna Npp.With 990806 Ltr ML17265A7291999-07-29029 July 1999 Interim Part 21 Rept Re safety-related DB-25 Breaker Mechanism Procured from W Did Not Pas Degradatin Checks When Drawn from Stock to Be Installed Into BUS15/03A.Holes Did Not line-up & Tripper Pan Bent ML17265A7181999-07-23023 July 1999 LER 99-007-01:on 990423,reactor Trip Occurred Due to Instrument & Control Technicians Inadvertently Pulling Fuses from Wrong Nuclear Instrument Channel.Setpoint Adjustments Were Completed by Different Crew of Technicians ML17265A7081999-07-22022 July 1999 LER 98-003-02:on 980904,actuations of CR Emergency Air Treatment Sys Was Noted Due to Invalid Causes.Caused by Various Degraded Components in CR RM Sys.Creats Actuation Signal Was Reset & Normal Ventilation Was Restored ML17265A7131999-07-22022 July 1999 Special Rept:On 990407,radiation Monitor RM-14A Was Declared Inoperable.Caused by Failed Communication Link from TSC to Plant Process Computer Sys.Communication Link Was re-established & RM-14A Was Declaed Operable on 990521 ML17265A7031999-07-19019 July 1999 LER 99-S01-00:on 990617,determined That Temporary Unescorted Access Had Been Granted to Contractor Employee.Caused by Incomplete Info Re Circumstances of Individual Military Separation.Individual Access Was Revoked.With 990719 Ltr ML17265A7211999-07-19019 July 1999 ISI Rept for Third Interval (1990-1999) Third Period, Second Outage (1999) at Re Ginna Npp. ML17265A7021999-07-15015 July 1999 LER 99-010-00:on 990615,ventilation Isolation of Auxiliary Bldg Occurred When Auxiliary Bldg Gas Radiation Monitor R-14 Reached High Alarm Setpoint.Cr Operators Rest Auxiliary Bldg Ventilation Isolation Signal.With 990715 Ltr ML17265A7661999-06-30030 June 1999 1999 Rept of Facility Changes,Tests & Experiments Conducted Without Prior NRC Approval for Jan 1998 Through June 1999, Per 10CFR50.59.With 991020 Ltr ML17265A7011999-06-30030 June 1999 Monthly Operating Rept for June 1999 for Re Ginna Npp.With 990712 Ltr ML17265A6851999-06-21021 June 1999 LER 99-001-01:on 990222,deficiencies in NSSS Vendor steam- Line Brake Mass & Energy Release Analysis Results in Plant Being Outside Design Bases Occurred.Caused by Deficiencies in W.Temporary Administrative Replaced.With 990621 Ltr ML17265A6761999-06-16016 June 1999 Part 21 Rept Re Defects & noncompliances,10CFR21(d)(3)(ii), Which Requires Written Notification to NRC on Identification of Defect or Failure to Comply. Relays Were Returned to Eaton for Evaluation & Root Cause Analysis ML17265A6661999-06-0202 June 1999 LER 99-009-00:on 990503,instrumentation Declared Inoperable in Multiple Channels Resulted in Condition Prohibited by Ts. Caused by Unanticipated High Frequency AC Voltage Ripple. Entered TS LCO 3.0.3.With 990602 Ltr ML17265A6681999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Re Ginna Nuclear Power Plant.With 990608 Ltr ML17265A6651999-05-27027 May 1999 Interim Rept Re W2 Control Switch,Procured from W,Did Not Operate Satisfactorily When Drawn from Stock to Be Installed in Main Control Board for 1C2 Safety Injection Pump. Estimated That Evaluation Will Be Completed by 991001 ML17309A6541999-05-27027 May 1999 LER 99-008-00:on 990427,overtemperature Delta T Reactor Trip Occurred Due to Faulted Bistable During Calibr of Redundant Channel.Plant Was Stabilized in Mode 3 & Faulted Bistable Was Subsequently Replaced.With 990527 Ltr ML17265A6631999-05-24024 May 1999 LER 99-007-00:on 990423,technicians Inadvertently Pulled Fuses from Wrong Nuclear Instrument Cahnnel,Causing Reactor Trip,Due to High Range Flux Trip.Caused by Personnel Error. Labeling Scheme Improved ML17265A6601999-05-21021 May 1999 LER 99-006-00:on 990421,start of turbine-driven Auxiliary Feedwater Pump Was Noted.Caused by MOV Being Left in Open Position.Closed Manual Isolation Valve to Secure Steam to Pump.With 990521 Ltr ML17265A6591999-05-17017 May 1999 Part 21 Rept Re Relay Deficiency Detected During pre-installation Testing.Caused by Incorrectly Wired Relay Coil.Relays Were Returned to Eaton Corp for Investigation. Relays Were Repaired & Retested ML17265A6441999-05-13013 May 1999 LER 99-005-00:on 990413,undervoltage Signal of Safeguards Bus During Testing Resulted in Automatic Start of B Edg. Caused by Personnel Error.Blown Fuse Was Replaced & Offsite Power Was Restored to Safeguards Bus 17.With 990513 Ltr ML17265A6431999-05-12012 May 1999 LER 99-004-00:on 990412,discovered That Containment Recirculation Fan Moisture Separator Vanes Were Incorrectly Installed,Per 10CFR21.Caused by Improper Assembly by Mfg. Subject Vanes Were Dismantled & Correctly re-installed ML17265A6381999-05-0707 May 1999 Part 21 Rept Re Replacement Turbocharger Exhaust Turbine Side Drain Port Not Functioning as Design Intended.Caused by Manufacturing Deficiency.Turbocharger Was Reaasembled & Reinstalled on B EDG ML17265A6391999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for Re Ginna Nuclear Power Plant.With 990510 Ltr ML17265A6361999-04-23023 April 1999 Part 21 Rept Re Power Supply That Did Not Work Properly When Drawn from Stock & Installed in -25 Vdc Slot.Power Supply Will Be Sent to Vendor to Perform Failure Mode Assessment.Evaluation Will Be Completed by 991001 ML17265A6301999-04-18018 April 1999 Rev 1 to Cycle 28 COLR for Re Ginna Npp. ML17265A6251999-04-15015 April 1999 Special Rept:On 990309,halon Systems Were Removed from Svc & Fire Door F502 Was Blocked Open.Caused by Mods Being Made to CR Emergency Air Treatment Sys.Continuous Fire Watch Was Established with Backup Fire Suppression Equipment ML17265A6551999-04-0909 April 1999 Initial Part 21 Rept Re Mfg Deficiency in Replacement Turbocharger for B EDG Supplied by Coltec Industries. Deficiency Consisted of Missing Drain Port in Intermediate Casing.Required Oil Drain Port Machined Open ML17265A6291999-03-31031 March 1999 Rev 0 to Cycle 28 COLR for Re Ginna Npp. ML17265A6241999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for Ginna Station.With 990409 Ltr ML17265A6141999-03-31031 March 1999 LER 99-003-00:on 990301,two Main Steam non-return Check Valves Were Declared Inoperable Due to Exceedance of Acceptance Criteria.Caused by Changes in Methodology & Matls.Packing Gland Torque Will Be Adjusted.With 990331 Ltr ML17265A6131999-03-29029 March 1999 LER 99-002-00:on 990227,discovered That Surveillance Had Not Been Performed at Frequency,Per Ts.Caused by Personnel Error.Procedure O-6.13 Will Be Evaluated for Enhancement Documentation of Completion of ITS Srs.With 990329 Ltr ML17265A6061999-03-24024 March 1999 LER 99-001-00:on 990222,plant Was Noted Outside Design Basis.Caused by Deficiencies in NSSS Vendor Slb Mass & Energy Release.Placed Temporary Administrative Restriction 40 Degrees F Max on Screenhouse Bay Temp ML17265A5661999-03-0101 March 1999 Rev 26 to QA Program for Station Operation. ML17265A5961999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for Ginna Nuclear Power Plant.With 990310 Ltr ML17265A5371999-01-31031 January 1999 Monthly Operating Rept for Jan 1999 for Re Ginna Nuclear Power Plant.With 990205 Ltr ML17265A5951998-12-31031 December 1998 Rg&E 1998 Annual Rept. ML17265A5001998-12-21021 December 1998 Rev 26 to QA Program for Station Operation. ML17265A4951998-12-21021 December 1998 LER 98-005-00:on 981120,loss of 34.5 Kv Offsite Power Circuit 751,resulted in Automatic Start of B Edg.Caused by Faulted Cable Splice.Performed Appropriate Actions of Abnormal Procedure AP-ELEC.1.With 981221 Ltr ML17265A4931998-12-17017 December 1998 LER 98-004-00:on 971030,determined That Improperly Performed Surveillance Resulted in Condition Prohibited by Ts.Caused by Procedure non-adherence.Appropriate Calibr Procedures Were Properly Performed with 24 H of Condition Discovery ML17265A4761998-11-30030 November 1998 Monthly Operating Rept for Nov 1998 for Re Ginna Nuclear Power Plant.With 981210 Ltr ML17265A4691998-11-25025 November 1998 LER 98-003-01:on 980904,actuations of CR Emergency Air Treatment Systems (Creats) Occurred.Caused by Radon build-up During Temp Inversion.Creats Actuation Signal Was Reset & Normal Ventilation Was Restored to CR ML17265A4531998-10-31031 October 1998 Monthly Operating Rept for Oct 1998 for Re Ginna Nuclear Power Plant.With 981110 Ltr ML17265A4271998-10-0505 October 1998 LER 98-003-00:on 980904,actuations of CR Emergency Air Treatment Sys Occurred.Caused by Radon build-up During Temp Inversion.Air Samples Were Taken & Determined That Source of Radiation Was Naturally Occurring Radon.With 981005 Ltr ML17265A4291998-09-30030 September 1998 Monthly Operating Rept for Sept 1998 for Re Ginna Nuclear Power Plant.With 981009 Ltr 1999-09-30
[Table view] |
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NRC FORM 366 U.S. NUCLEAR REGULATORY COMMISSION N.IBBBI 1Ã4@akelp NLpRS IL%ÃgAa %f4fg coBoction request 50 hra. Reported lessons loomed 'nformation are hcorporated Btto the Bcenafng process and fed back to industry. Forward comments regarding burden estimate to the LICENSEE EVENT REPORT (LER) Records Management Branch (TA F33), U.S. Nuclear Regulatory Commission, Washington, DC 205554001, and to (See reverse for required number of the Paperwork Reduction Pro)ect (31504104), Ofrce of digits/characters for each block) Management and Budget, Washington, DC 20503. If an information coaction does not display a currently valid OMB contml number, the NRC may not conduct or sponsor. and a FACILITYNAME Ill DOCKET NUMBER (2l PAGE I3)
R. E. Ginna Nuclear Power Plant 05000244 1 OF 7 TITlE (at Personnel Error Causes Two Channels to be in Tripped Condition, Resulting in Reactor Trip EVENT DATE IB) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (B)
FACIUTY NAME OOCK ET NUMBER STOUFHTIAL REYISIOH MONTH OAY MOHTH OAlf YEAR HUMBN NUMEN 05000 04 23 1999 1999 - 007 - 01 07 23 1999 FACIUTY NAME DOCKET NUMBER 05000 OPERATING THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR I: (Check one or more) (11)
MODE (B) 20.2201(b) 20.2203(a) (2)(v) 50.I3(a) l2)(i)(B) 50.73(a)(2)(viii)
POWER 20.2203(a) (1) 20.2203(a)(3)(i) 50.73(a)(2)(ii) 50.73(a) l2)(x)
LEVEL (10) 035 20.2203(a)(2)(i) 20.2203(a)(3)(ii) 50.73(a)(2llm) 73.71 20.2203(a) (2)(ii) 20.2203(a) (4) X 50.73(a)(2)(iv) OTHER 20.2203(a) l2) (iii) 50.36(c)(1) 50.73(a)(2l(v) Specify in Abstract below 20.2203(a) (2) (iv) 50.36(c) (2) 50.73(a)(2)(vii) or In NRC Form 386A LICENSEE CONTACT FOR THIS LER (12)
NAME TELEPHONE NUMBEII Bnuudd Ardd Codd)
John T. St. Martin - Technical Assistant (716) 771-3641 REPORTABlE REPORTABlE CAUSE SYSTEM COMPOHFHT MAHUFACTURN CAUSE SYSTEM COMPOHIHT MAIIUFACTURER TO EPIX TO TPIX SUPPLEMEIITAI. REPORT EXPECTED (14) MOHTH OAY EXPECTED YES NO SUBMISSION (lf yes, complete EXPECTED SUBMISSION DATE). X DATE (IS)
ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines} (16)
On April 23, 1999, at approximately 0748 EDST, with the plant in Mode 1 at approximately 35% reactor power and a power escalation in progress after the 1999 refueling outage, Instrument and Control technicians inadvertently pulled fuses from the wrong nuclear instrument channel, causing a reactor trip due to high range flux trip.
The Control Room operators performed the appropriate actions of procedures E-0 and ES-0.1. Following the reactor trip, all systems operated as designed, and the reactor was stabilized in Mode 3.
The underlying cause of the reactor trip was a personnel error, in that fuses were pulled on the wrong nuclear instrument channel. Further evaluation of the event has resulted in more accurately categorizing the root causes.
immediate corrective action was taken to stabilize the plant in Mode 3. Corrective actions to prevent recurrence are outlined in Section V.B.
9908020082 990723 PDR ADQCK 05000244 8 PDR
NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION I8 1888),
LlCENSEE EVENT REPORT (LER)
TEXT CONTINUATION FACILITY NAME I1) DOCKET I2) LER NUMBER I6) PAGE (3) 8E88EtttgL REVISI8)I NIIMRER NJM86I R.E. Ginna Nuclear Power Plant 05000244 1699 007 - 01 2 OF 7 TEXT (lfmore space is rettuired, use additional copies of NRC Form 366A J 117)
I. PRE-EVENT PLANT CONDITIONS:
E On April 23, 1999, the plant was in Mode 1 at approximately 35% reactor power. A power escalation was in progress as the plant started up from the 1999 refueling outage. Instrument and Control (l&C) technicians were in the process of adjusting nuclear instrument system (NIS) power range (PR) trip setpoints for the four (4) PR channels, as required during initial power escalation after a refueling outage.
The I&C technicians had completed adjustments for NIS PR channel N-41 at approximately 0650 EDST, and had defeated channel N-42 at approximately 0700 EDST. Channel defeat involves placing numerous bistables into the tripped condition in protection racks in the Control Room, and results in a similar number of Main Control Board (MCB) annunciator alarms. The l&C technicians then proceeded to the NIS racks (in a different location in the Control Room) to continue with trip setpoint adjustment.
DESCRIPTION OF EVENT:
DATES AND APPROXIMATE TIMES OF MAJOR OCCURRENCES:
April 23, 1999, 0529 EDST: Setpoint adjustment is started for NIS PR channel N-41.
April 23, 1999, 0650 EDST: Setpoint adjustment is completed for NIS PR channel N-41.
April 23, 1999, 0700 EDST: Setpoint adjustment is started for NIS PR channel N-42.
April 23, 1999, 0748 EDST: Event date and time.
April 23, 1999, 0748 EDST: Discovery date and time.
April 23, 1999, 0749 EDST: Control Room operators verify both reactor trip breakers open and verify all control and shutdown rods inserted.
April 23, 1999, 0754 EDST: Control Room operators manually stop the operating main feedwater pump to limit a reactor coolant system cooldown.
April 23, 1999, 0756 EDST: Control Room operators manually close both main steam isolation valves to limit a reactor coolant system cooldown.
April 23, 1999, 0841 EDST: Plant is stabilized in Mode 3.
NRC FORM 36BA U.S. NUCLEAR REGULATORY COMMISSION (B IBBB),
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION FACILITY NAME (1) DOCKET (2) LER NUMBER (6) PAGE (3)
B(RUIN(gl RENSNN MR NUMBBI NUMBBI R.E. Ginna Nuclear Power Plant 05000244 1999 007 01 3 OF 7 TEXT (Ifmore space is required, use additional copies of NRC Form 366A/ (17)
B. EVENT:
On April 23, 1999, the plant was in Mode 1 at approximately 35% reactor power. A power escalation was in progress as the plant started up from the 1999 refueling outage. Instrument and Control (I&C) technicians were in the process of adjusting nuclear instrument system (NIS) power range (PR) trip setpoints for the four (4) PR channels, as required during initial power escalation after a refueling outage. The I&C technicians had completed adjustments for NIS PR channel N-41 at approximately 0650 EDST, and had defeated channel N-42 at approximately 0700 EDST.
Channel defeat involves placing numerous bistables into the tripped condition in protection racks in the Control Room, and results in a similar number of Main Control Board (MCB) annunciator alarms.
The l&C technicians then proceeded to the NIS racks (in a different location in the Control Room) to continue with trip setpoint adjustment.
At approximately 0748 EDST, the I&C technicians prepared to pull the fuses for NIS PR channel N-42 at the N-42 drawer. They approached a drawer (for channel N-43, by mistake) and pulled the fuses. Pulling these fuses tripped the high flux trip bistables for channel N-43. With the channel N-42 bistables already previously tripped, the reactor tripped on 2/4 NIS PR high flux range trip. In addition to the MCB annunciators already in alarm from the N-42 channel defeat, the Control Room operators acknowledged MCB annunciators D-2 (Power Range High Range Reactor Trip 2/4 108%)
and D-10 (Power Range Lo Range Reactor Trip 2/4 24%), indicating a reactor trip from NIS PR channels.
The Control Room operators performed the immediate actions of Emergency Operating Procedure E-0, "Reactor Trip or Safety Injection". They transitioned to Emergency Operating Procedure ES-0.1, "Reactor Trip Response", when it was verified that both reactor trip breakers were open, all control and shutdown rods were inserted, and safety injection was not actuated or required.
During the performance of ES-0.1, the Control Room operators noted that a reactor coolant system (RCS) cooldown was occurring, due to addition of feedwater and a low decay heat level after the recently completed refueling outage. Due to this RCS cooldown, the Control Room operators manually stopped the operating main feedwater (MFW) pump at approximately 0754 EDST (after manually starting the motor-driven auxiliary feedwater (AFW) pumps) and closed both main steam isolation valves (MSIVs) at approximately 0756 EDST. These actions mitigated the RCS coo!down.
The plant was stabilized in Mode 3 at approximately 0841 EST and the Control Room operators transitioned to normal plant operating procedures.
C. INOPERABLE STRUCTURES, COMPONENTS, OR SYSTEMS THAT CONTRIBUTED TO THE EVENT:
None
NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION IS1 998) ~
LlCENSEE EVENT REPORT (LER)
TEXT CONTINUATION FACILITY NAME I1) OOCKET I2) LER NUMBER I6) PAGE I3)
SEQUENTIAL REVISION YEIIR NUMBER NUMBER R.E, Ginna Nuclear Power Plant 05000244 1999 - 007 - 01 4 OF 7
~ TEXT flfmore space is required, use additional copies'f NRC Form 366AI I17)
D. OTHER SYSTEMS OR SECONDARY FUNCTIONS AFFECTED:
None E. METHOD OF DISCOVERY:
This event was immediately apparent due to Main Control Board indication of the reactor trip, due to plant response and alarms and indications in the Control Room.
OPERATOR ACTION:
After the reactor trip, the Control Room operators performed the appropriate actions of Emergency Operating Procedures E-0 and ES-0.1. Both motor-driven auxiliary feedwater pumps were manually started. The MFW pump was stopped and the MSIVs were manually closed to limit further RCS cooldown. The plant was stabilized in Mode 3.
Subsequently, the Control Room operators notified higher supervision and the NRC per 10 CFR 50.72 (b) (2) (ii), non-emergency four hour notification, at approximately 1016 EDST on April 23, 1999.
G. SAFETY SYSTEM RESPONSES:
All safeguards equipment functioned properly.
III~ CAUSE OF EVENT:
A. IMMEDIATECAUSE:
The immediate cause of the reactor trip was achieving the 2/4 reactor protection system (RPS) trip logic for NIS PR high flux range trip.
B. INTERMEDIATE CAUSE:
The intermediate cause of achieving 2/4 RPS trip logic was the bistable for NIS PR channel N-43 high flux range being tripped due to pulling the fuses for channel N-43, with the channel N-42 bistabie already tripped for setpoint adjustment.
NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION I6.1998)
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION FACILITY NAME 11) DOCKET I2) LER NUMBER I6) PAGE 13)
REVISION
~A SEOUENTML NUMBEII NUMBEN R.E. Ginna Nuclear Power Plant 05000244 1999 007 01 6 OF 7 TEXT llfmore spaceis required, use additional copies of NRC Form 366AJ (17)
ROOT CAUSE:
Further evaluation of this event has been conducted. The evaluation concluded that the underlying cause of the pulling of fuses for channel N-43 was a failure to self-check and peer-check during performance of maintenance.
As a result of this failure, ISC technicians initiated activities on the wrong power range channel and caused a reactor trip. Causal factors identified included:
o Written Communication, in that independent verification was not required for the particular steps in the calibration procedure Interface Design, in that the four power range drawers are adjacent to each other with identical configurations Work Practices, in that STAR (stop, think, act, review) and self-verification were used inadequately Verbal Communications, in that the pre-job brief and three-way communications between the two INC technicians who were performing work on channel N-42 were inadequate This error was a cognitive error on the part of two ISC technicians, who intended to pull the fuses on the drawer for NIS PR channel N-42. They approached the second drawer from the west (drawer for channel N-43), rather than the second drawer from the east (drawer for channel N-42),
and did not recognize that they were on the wrong NIS PR drawer. This error was inadvertent, and was contrary to the approved procedure. There are no unusual characteristics of the work location (Control Room).
IV. ANALYSIS OF EVENT:
This event is reportable in accordance with 10 CFR 50.73, Licensee Event Report System, item (a) (2) (iv),
which requires a report of, "Any event or condition that resulted in a manual or automatic actuation of any engineered safety feature (ESF), including the reactor protection system (RPS)" The reactor trip was an
~
actuation of the RPS and AFW pump starts are actuations of an ESF component.
An assessment was performed considering both the safety consequences and implications of this event with the following results and conclusions:
There were no operational or safety consequences or implications attributed to the reactor trip because:
o The two reactor trip breakers opened as required.
NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION (B IBBB)
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION FACILITY NAME I1) DOCKET (2) LER NUMBER {6) PAGE I3)
BEm)EN)ML REVIBION NUMBER NUMBER R.E. Ginna Nuclear Power Plant 05000244 1999 007 - 01 6 OF 7'EXT (Ifmore spaceis required, use edditionel copies of NRC Form 386A/ I17) o All control and shutdown rods inserted as designed.
The plant was stabilized in Mode 3.
The Ginna Station Improved Technical Specifications (ITS) Limiting Conditions for Operation (LCOs) and Surveillance Requirements (SRs) were reviewed with respect to the post trip review data. The following are the results of that review:
a ~ Pressurizer (PRZR) pressure decreased below 2205 PSIG during the transient after the reactor trip. During this time a thermal power step )10o/o occurred due to the reactor trip, which is within the limits of ITS LCO 3A.1. Therefore, compliance with ITS was maintained. The RCS temperature DNB limit (577.5 degrees F) was not approached. Additional mitigation was provided by stopping the MFW pump and closing the MSIVs. Minimum PRZR pressure was approximately 2184 PSIG, and PRZR pressure was restored ) 2205 PSIG within five minutes.
- b. After the reactor trip, the RCS cooled down to approximately 541 degrees F and was subsequently stabilized at 547 degrees F. The cooldown was within the limits of ITS LCO 3.4.3. In addition, the required shutdown margin was maintained at all times during the RCS cooldown.
Based on the above and a review of post trip data and past plant transients, it can be concluded that the plant operated as designed, that there were no unreviewed safety questions, and that the public's health and safety was assured at all times.
V. CORRECTIVE ACTION:
A. ACTION TAKEN TO RETURN AFFECTED SYSTEMS TO PRE-EVENT NORMAL STATUS:
A different crew of IRC technicians was assigned to perform trip setpoint adjustments for NIS PR channels N-42, N-43, and N-44, and the adjustments were completed.
B. ACTION TAKEN OR PLANNED TO PREVENT RECURRENCE:
The two IfkC technicians involved in this event were temporarily relieved of these calibration responsibilities to participate in the event investigation, and were counseled concerning this event.
To address the failure to self or peer-check, a Nuclear Training Work Request (NTWR 99-0504) has been initiated to conduct STAR training for IRC technicians
NRQ FORM 3BBA U S. NUCLEAR REGULATORY COMMISSION
{9 1998l LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION FACILrrY NAME I1) DOCKET I2) LER NUMBER IB) PAGE I3)
R.E. Ginna Nuclear Power Plant 05000244 1999>> 007 - 01 7 OF 7 TEXT (if more space is required, use addi'tional copies of ffRC Form 366AJ I17)
The importance of self and peer-check was discussed at an ILC shop meeting.
To address Written Communication, procedures for calibration of NIS bistables and axial flux monitoring will be revised to add additional independent verification steps.
To address Interface Design, labeling of the NIS cabinets has been improved to include the use of protection channel colors to identify separate cabinets.
The standard for ISC pre-job briefs has been upgraded to include the use of red safety barrier requirements.
0 To address Verbal Communications and Work Practices, toolbox training will be conducted for l&C technicians to reinforce management expectations on work practices and verbal communications.
Should additional corrective actions be identified, a supplement to this LER will be issued.
Vl. ADDITIONALINFORMATION:
A. FAILED COMPONENTS:
None
- 8. PREVIOUS LERs ON SIMILAR EVENTS:
A similar LER event historical search was conducted with the following results: LERs90-012 and S3-007 were similar events (reactor trip) with a similar root cause Ipersonnel error directly caused a reactor trip).
C. SPECIAL COMMENTS:
None
'I