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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML17292B7421999-07-20020 July 1999 LER 99-001-00:on 990628,ESF Signal Closed All Eight MSIVs While Plant Was Shutdown.Caused by Failure of Relay RPS-RLY-K10D.Subject Relay Was Replaced & Tested on 990630. with 990720 Ltr ML17292B4451998-10-27027 October 1998 LER 98-012-01:on 980715,failure to Comply with Requirements of TS SR 3.8.4.7 Was Noted.Caused by Inadequate Work Practices.Training Session Was Held with Personnel.With 981027 Ltr ML17284A7561998-09-0303 September 1998 LER 98-013-00:on 980805,ESF Actuations Were Noted Due to Deenergization of Vital Electrical Bus SM-8.Caused by Inadequate Direction in Troubleshooting Plan.Will Conduct Training for Engineering Personnel.With 980903 Ltr ML17284A7571998-09-0202 September 1998 LER 98-014-00:on 980807,completion of TS 3.8.1.F Required Shutdown Due to Inoperability of EDG-2 Was Noted.Caused by Degraded Voltage Regulator for DG-2.Replaced Voltage Regulator & Associated Scrs.With 980902 Ltr ML17284A7551998-09-0202 September 1998 LER 98-015-00:on 980808,discovered Reactor Coolant Pressure Boundary Leak During Shutdown Conditions.Caused by Leakage from Socket Weld (Fwb 63) on Elbow Connection.Failed Piping Connection Was Replaced.With 980902 Ltr ML17284A7311998-08-17017 August 1998 LER 98-012-00:on 980716,determined That 24-month SR 3.8.4.7 Had Not Been Fulfilled within Specified Frequency.Caused by Inadequate Work Practices.License Requested & Received Enforcement Discretion Re Battery Svc test.W/980817 Ltr ML17284A7121998-07-23023 July 1998 LER 98-006-01:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of 10CFR50,App R Calculations for High Impedance Faults.Caused by Inadequate Work Practices.Implemented Procedural Changes ML17284A6951998-07-17017 July 1998 LER 98-011-00:on 980617,ECCS Pump Room Flooding Was Noted Due to FP Sys Pipe Break.Caused by Inadequate Design of FP Sys.Detailed Review of FP Sys Design Was Conducted. W/980717 Ltr ML17284A6961998-07-15015 July 1998 LER 98-010-00:on 980615,TS Required Shutdown Due to Inoperability of TIP Sys Isolation Valve Was Noted.Caused by Improper Installation of TIP Tubing.Reattached Affected Tubing & Inspected Other TIP tubing.W/980715 Ltr ML17284A6731998-07-0101 July 1998 LER 98-009-00:on 980606,nuclear Steam Supply Shutoff Sys Group 3 & 4 Isolations During Testing Was Noted.Caused by Procedural Deficiency.Counseled Individuals Involved in preparation.W/980701 Ltr ML17284A6651998-06-24024 June 1998 LER 98-007-00:on 980530,inadvertent Full Scram & Division 1 ECCS Injection Was Noted.Caused by Failure to Meet Mgt Work Practice Expectation When Encountering Deficient Procedure. Incident Review Board Convened to Review event.W/980624 Ltr ML17284A6641998-06-24024 June 1998 LER 98-008-00:on 980531,inadvertent Full Scram During RPV Leak Testing in Mode 4 Was Noted.Caused by Change in Mgt Techniques.Revised Procedures to Take Into Account Addl Water Head in Pressure Sensing lines.W/980624 Ltr ML17284A6631998-06-19019 June 1998 LER 98-006-00:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of App R Calculations for High Impedance Fault Analysis.Caused Indeterminate. Implemented Procedural Changes Involving Operator Action ML17284A6551998-06-0404 June 1998 LER 98-005-00:on 980506,potential for Failure of RHR Sys Valve to Close on Isolation Signal Was Noted.Caused by Design Deficiency.Caution Tag Was Placed on RHR-V-40 Control Switch to Inform Plant Operators of limitation.W/980604 Ltr ML17284A6421998-06-0101 June 1998 LER 98-004-00:on 980502,determined That Primary Containment Penetration Overcurrent Protection Does Not Meet Reg Guide 1.63 Requirements.Caused by Inadequate Design Changes. Installed Addl Fuse in RHR-MO-9 circuit.W/980601 Ltr ML17292B3281998-04-0909 April 1998 LER 98-002-00:on 980311,reactor Scram & Plant Transient Occurred,Due to Failed Closed Main Steam Isolation Valve. Caused by Loss of Pneumatic Actuating Supply Pressure. Problem Evaluation Request Written for Failure of MS-V-22D ML17292B3291998-04-0909 April 1998 LER 98-003-00:on 980311,WNP-2 Experienced SCRAM Signal as Result of Low Rpv.Caused by Less than post-SCRAM Operational Strategy for Resetting SCRAM Signal in Conditions.Changes in post-SCRAM Operational Strategy implemented.W/980409 Ltr ML17292B2661998-03-0404 March 1998 LER 98-001-00:on 980203,automatic Start of HPCS EDG Was Noted.Caused by Operator Error.Operations Crew Stabilized Plant at Approximately 75% Reactor Power & Investigation of Event Was initiated.W/980304 Ltr ML17292B1111997-11-10010 November 1997 LER 97-011-00:on 971010,HPCS Battery Charger Failed.Caused by Failure of a Phase Firing Control Circuit Board Due to Aging During 7 Yrs of Use.Hpcs Sys Was Immediately Declared inoperable.W/971110 Ltr ML17292B1151997-11-0707 November 1997 LER 97-010-00:on 970906,discovered That TS SR 3.4.5.1 for Identified Portion of RCS Total Leakage Would Not Be Able to Perform within Time Limits of SR 3.0.2.Caused by Inadequate Methods.Method of Meeting SR 3.4.5.1 Established ML17292B0641997-09-24024 September 1997 LER 97-004-01:on 970327,plant Operators Manually Scrammed Reactor as Required by TS Due to Indication of Entry Into Region a of power-to-flow Map.Caused by Inadequate Attention to Detail.Established Event Evaluation teams.W/970924 Ltr ML17292B0241997-08-18018 August 1997 LER 97-009-00:on 970717,discovered Error in Recently Performed Inservice Testing procedure,OSP-TIP/IST-R701. Caused by Procedure Inadequacy.Plant Procedure OSP/TIP/IST-R701 Will Be changed.W/970818 Ltr ML17292B0291997-08-15015 August 1997 LER 97-008-00:on 970716,wire Seal Used to Lock Containment Instrument Air Pressure Control valve,CIA-PCV-2B,found Not Intact.Cause of Misadjustment of CIA-PCV-2B Unknown.Event Will Be Communicated to Plant employees.W/970815 Ltr ML17292B0201997-08-15015 August 1997 LER 97-S01-00:on 970718,failure to Take Compensatory Measure for Inoperative Microwave Security Zone Occurred. Caused by Personnel Error.Training Will Be Conducted W/ Appropriate Members of Security force.W/970815 Ltr ML17292A9481997-07-23023 July 1997 LER 97-007-00:on 970611,voluntary Rept of Automatic Start of DG-1 & DG-2 Was Experienced.Caused by Undervoltage Condition on Electrical Busses SM-7 & SM-8.Circulating Water Pump CW-P-1C Control Switch Placed in pull-to-lock.W/970723 Ltr ML17292A9201997-06-26026 June 1997 LER 97-006-00:on 970527,non-performance of Surveillance Requirement 3.6.1.3.2 for Blind Fanges,Was Noted.Caused Because Misunderstanding of Intent of Specs.Added Five Structural Assemblies for SP.W/970626 Ltr ML17292A8331997-04-28028 April 1997 LER 97-004-00:on 970327,plant Operators Manually Scrammed Reactor as Required by TS Due to Entry Into Region a of power-to-flow Map Following Planned Trip of Single Mfp. Event Evaluation teams,established.W/970428 Ltr ML17292A8311997-04-28028 April 1997 LER 97-005-00:on 970327,valid Reactor Scram Signal Received Due to Low Water Level Condition During Preparations for SRV Testing.Caused by Risks & Consequences of Decisions Not Completely Identified.Restored Water level.W/970428 Ltr ML17292A8251997-04-21021 April 1997 LER 97-003-00:on 970320,notification of Noncompliance W/Ts as TS SRs for Response Time Testing Were Not Being Met for Specified Instrumentation in Rps,Pcis & Eccs.Requested Enforcement Discretion for One Time exemption.W/970421 Ltr ML17292A7431997-03-20020 March 1997 LER 97-002-00:on 970218,determined That Rod Block Monitor (RBM) Calibr Values Were Not Set IAW Tech Specs.Caused by Calibr Procedures Inadequacies.Revised & re-performed RBM Channel Calibr procedures.W/970330 Ltr ML17292A7401997-03-13013 March 1997 LER 97-001-00:on 970211,reactor Water Cleanup Sys Blowdown Flow Isolation Setpoint Was Slightly Above TS Allowable Valve Occurred Due to Calculation Error.Lds Fss LD-FS-15 LD-FS-16 Were Declared inoperable.W/970313 Ltr ML17292A6641997-01-22022 January 1997 LER 96-009-00:on 961220,miscalculation of Instantaneous Overcurrent Relay Settings Resulted in Inoperability of safety-related Equipment.Caused by Utilization of Inappropriate Design.Testing Was completed.W/970122 Ltr ML17292A6461997-01-0606 January 1997 LER 96-008-00:on 961205,failure to Comply with TS Action Requirement for Emergency Core Cooling Sys Actuation Instrumentation Occurred Due to Unidentified Inoperability Condition.Pmr initiated.W/970106 Ltr ML17292A6371996-12-19019 December 1996 LER 96-007-00:on 961122,electrical Breakers Were Not Seismically Qualified in Test/Disconnect Position.Circuit Breaker Mfg Did Not Consider Raced Out Breaker Position During Testing.Relocated Circuit breakers.W/961217 Ltr ML17292A4121996-08-0808 August 1996 LER 96-006-00:on 960709,average Power Range Monitor Rod Block Downscale Surveillance Not Performed Prior to Entry Into Mode 1.Caused by long-standing Misinterpretation of Requirements of Tss.Procedures revised.W/960808 Ltr ML17292A3801996-07-24024 July 1996 LER 96-004-00:on 960624,plant Was Manually Scrammed by Control Room Personnel Due to Reactor Water Level Transient Experienced During Testing of Digital Feedwater Sys.Caused by Programming Error.Sys Was corrected.W/960724 Ltr ML17292A3771996-07-24024 July 1996 LER 96-005-00:on 960624,determined Missed Surveillance Test Re Channel Check of Average Power Range Monitor.Caused by Inadequate Procedures.Revised Surveillance Procedure Re When APRM Checks Must Be performed.W/960724 Ltr ML17292A3641996-07-12012 July 1996 LER 96-003-00:on 960615,required Surveillance Test Not Performed When Required by TS 3.4.1.3.Caused by Inadequate Procedures.Implementing Surveillance Procedure & Reactor Plant Startup Procedures revised.W/960712 Ltr ML17292A3361996-06-20020 June 1996 LER 96-002-00:on 960504,critical Bus SM-8 Lost Power When Supply Breaker 3-8 Tripped.Caused by Personnel Error. Operators Counselled & Procedures revised.W/960620 Ltr ML17292A2861996-05-24024 May 1996 LER 96-001-00:on 960425,inadvertent ESF Actuations Occurred Due to Tripping of Temporary Power Supply to IN-3.Caused by Personnel Error.Operations Restored to IN-3 Loads & Reset ESF actuations.W/960524 Ltr ML17291B0891995-10-19019 October 1995 LER 95-011-00:on 950919,failed to Comply W/Ts SR for RCIC Sys Due to Analysis Deficiency That Resulted in Inadequate Surveillance Test Procedure.Surveillance Procedure Revised to Correct deficiency.W/951019 Ltr ML17291A9021995-07-0707 July 1995 LER 95-010-00:on 950609,HPCS DG Declared Inoperable Due to Discovery That TS Test Method Incomplete.Caused by Inadequate Testing Procedure.Test Procedure for HPCS DG Reviewed & Special Test Procedures written.W/950707 Ltr ML17291A9031995-07-0707 July 1995 LER 95-009-00:on 950607,inadvertent MSIV Closure Occurred During Surveillance Test Due to Poor Communication Between Test Team.Determined That MSIV Closure Not Valid Because Closure Not Triggered by Plant conditions.W/950707 Ltr ML17291A8501995-06-0808 June 1995 LER 95-006-01:on 950405,reactor Scram Occurred During Surveillance Testing Due to Protective Sys Relay Failure. Replaced Failed Relay Before Plant Startup ML17291A8101995-05-12012 May 1995 LER 95-008-00:on 940125,TS Wording Lead to Potential TS Violation.Caused by Lack of Clarity in Ts.Submitted Improved TS for Plant to Provide Addl clarity.W/950512 Ltr ML17291A7841995-05-0505 May 1995 LER 95-007-00:on 950222,emergency Diesel Start Occurred Due to Voltage Transient on BPA Grid.Confirmation Was Received at 17:51 H That Disturbance Had Originated in BPA Grid ML17291A7801995-05-0404 May 1995 LER 95-006-00:on 950405,main Turbine Trip Occurred During Performance of Surveillance Test Due to Protective Sys Relay Failed.Replaced Failed Relay Before Plant startup.W/950504 Ltr ML17291A7851995-05-0303 May 1995 LER 95-005-00:on 950222,inoperable IRM Had Been Relied Upon to Meet TS Requirements During Reactor Startup.Caused by Lack of Neutron Source to Test Instrumentation. Sys Knowledge Gained Will Be incorporated.W/950503 Ltr ML17291A7071995-03-25025 March 1995 LER 95-004-00:on 950226,malfunction in Main Turbine DEH Control Sys Caused All Four High Pressure Turbine Governor Valves to Rapidly Close.Caused by Blown Fuse.Suspected Faulty Circuit Card replaced.W/950325 Ltr ML17291A7011995-03-20020 March 1995 LER 95-002-00:on 950218,automatic Reactor Scram Occurred. Caused by Erroneous Positioning of Control During Performance of Scheduled Periodic Functional Test.Control repositioned.W/950320 Ltr 1999-07-20
[Table view] Category:RO)
MONTHYEARML17292B7421999-07-20020 July 1999 LER 99-001-00:on 990628,ESF Signal Closed All Eight MSIVs While Plant Was Shutdown.Caused by Failure of Relay RPS-RLY-K10D.Subject Relay Was Replaced & Tested on 990630. with 990720 Ltr ML17292B4451998-10-27027 October 1998 LER 98-012-01:on 980715,failure to Comply with Requirements of TS SR 3.8.4.7 Was Noted.Caused by Inadequate Work Practices.Training Session Was Held with Personnel.With 981027 Ltr ML17284A7561998-09-0303 September 1998 LER 98-013-00:on 980805,ESF Actuations Were Noted Due to Deenergization of Vital Electrical Bus SM-8.Caused by Inadequate Direction in Troubleshooting Plan.Will Conduct Training for Engineering Personnel.With 980903 Ltr ML17284A7571998-09-0202 September 1998 LER 98-014-00:on 980807,completion of TS 3.8.1.F Required Shutdown Due to Inoperability of EDG-2 Was Noted.Caused by Degraded Voltage Regulator for DG-2.Replaced Voltage Regulator & Associated Scrs.With 980902 Ltr ML17284A7551998-09-0202 September 1998 LER 98-015-00:on 980808,discovered Reactor Coolant Pressure Boundary Leak During Shutdown Conditions.Caused by Leakage from Socket Weld (Fwb 63) on Elbow Connection.Failed Piping Connection Was Replaced.With 980902 Ltr ML17284A7311998-08-17017 August 1998 LER 98-012-00:on 980716,determined That 24-month SR 3.8.4.7 Had Not Been Fulfilled within Specified Frequency.Caused by Inadequate Work Practices.License Requested & Received Enforcement Discretion Re Battery Svc test.W/980817 Ltr ML17284A7121998-07-23023 July 1998 LER 98-006-01:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of 10CFR50,App R Calculations for High Impedance Faults.Caused by Inadequate Work Practices.Implemented Procedural Changes ML17284A6951998-07-17017 July 1998 LER 98-011-00:on 980617,ECCS Pump Room Flooding Was Noted Due to FP Sys Pipe Break.Caused by Inadequate Design of FP Sys.Detailed Review of FP Sys Design Was Conducted. W/980717 Ltr ML17284A6961998-07-15015 July 1998 LER 98-010-00:on 980615,TS Required Shutdown Due to Inoperability of TIP Sys Isolation Valve Was Noted.Caused by Improper Installation of TIP Tubing.Reattached Affected Tubing & Inspected Other TIP tubing.W/980715 Ltr ML17284A6731998-07-0101 July 1998 LER 98-009-00:on 980606,nuclear Steam Supply Shutoff Sys Group 3 & 4 Isolations During Testing Was Noted.Caused by Procedural Deficiency.Counseled Individuals Involved in preparation.W/980701 Ltr ML17284A6651998-06-24024 June 1998 LER 98-007-00:on 980530,inadvertent Full Scram & Division 1 ECCS Injection Was Noted.Caused by Failure to Meet Mgt Work Practice Expectation When Encountering Deficient Procedure. Incident Review Board Convened to Review event.W/980624 Ltr ML17284A6641998-06-24024 June 1998 LER 98-008-00:on 980531,inadvertent Full Scram During RPV Leak Testing in Mode 4 Was Noted.Caused by Change in Mgt Techniques.Revised Procedures to Take Into Account Addl Water Head in Pressure Sensing lines.W/980624 Ltr ML17284A6631998-06-19019 June 1998 LER 98-006-00:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of App R Calculations for High Impedance Fault Analysis.Caused Indeterminate. Implemented Procedural Changes Involving Operator Action ML17284A6551998-06-0404 June 1998 LER 98-005-00:on 980506,potential for Failure of RHR Sys Valve to Close on Isolation Signal Was Noted.Caused by Design Deficiency.Caution Tag Was Placed on RHR-V-40 Control Switch to Inform Plant Operators of limitation.W/980604 Ltr ML17284A6421998-06-0101 June 1998 LER 98-004-00:on 980502,determined That Primary Containment Penetration Overcurrent Protection Does Not Meet Reg Guide 1.63 Requirements.Caused by Inadequate Design Changes. Installed Addl Fuse in RHR-MO-9 circuit.W/980601 Ltr ML17292B3281998-04-0909 April 1998 LER 98-002-00:on 980311,reactor Scram & Plant Transient Occurred,Due to Failed Closed Main Steam Isolation Valve. Caused by Loss of Pneumatic Actuating Supply Pressure. Problem Evaluation Request Written for Failure of MS-V-22D ML17292B3291998-04-0909 April 1998 LER 98-003-00:on 980311,WNP-2 Experienced SCRAM Signal as Result of Low Rpv.Caused by Less than post-SCRAM Operational Strategy for Resetting SCRAM Signal in Conditions.Changes in post-SCRAM Operational Strategy implemented.W/980409 Ltr ML17292B2661998-03-0404 March 1998 LER 98-001-00:on 980203,automatic Start of HPCS EDG Was Noted.Caused by Operator Error.Operations Crew Stabilized Plant at Approximately 75% Reactor Power & Investigation of Event Was initiated.W/980304 Ltr ML17292B1111997-11-10010 November 1997 LER 97-011-00:on 971010,HPCS Battery Charger Failed.Caused by Failure of a Phase Firing Control Circuit Board Due to Aging During 7 Yrs of Use.Hpcs Sys Was Immediately Declared inoperable.W/971110 Ltr ML17292B1151997-11-0707 November 1997 LER 97-010-00:on 970906,discovered That TS SR 3.4.5.1 for Identified Portion of RCS Total Leakage Would Not Be Able to Perform within Time Limits of SR 3.0.2.Caused by Inadequate Methods.Method of Meeting SR 3.4.5.1 Established ML17292B0641997-09-24024 September 1997 LER 97-004-01:on 970327,plant Operators Manually Scrammed Reactor as Required by TS Due to Indication of Entry Into Region a of power-to-flow Map.Caused by Inadequate Attention to Detail.Established Event Evaluation teams.W/970924 Ltr ML17292B0241997-08-18018 August 1997 LER 97-009-00:on 970717,discovered Error in Recently Performed Inservice Testing procedure,OSP-TIP/IST-R701. Caused by Procedure Inadequacy.Plant Procedure OSP/TIP/IST-R701 Will Be changed.W/970818 Ltr ML17292B0291997-08-15015 August 1997 LER 97-008-00:on 970716,wire Seal Used to Lock Containment Instrument Air Pressure Control valve,CIA-PCV-2B,found Not Intact.Cause of Misadjustment of CIA-PCV-2B Unknown.Event Will Be Communicated to Plant employees.W/970815 Ltr ML17292B0201997-08-15015 August 1997 LER 97-S01-00:on 970718,failure to Take Compensatory Measure for Inoperative Microwave Security Zone Occurred. Caused by Personnel Error.Training Will Be Conducted W/ Appropriate Members of Security force.W/970815 Ltr ML17292A9481997-07-23023 July 1997 LER 97-007-00:on 970611,voluntary Rept of Automatic Start of DG-1 & DG-2 Was Experienced.Caused by Undervoltage Condition on Electrical Busses SM-7 & SM-8.Circulating Water Pump CW-P-1C Control Switch Placed in pull-to-lock.W/970723 Ltr ML17292A9201997-06-26026 June 1997 LER 97-006-00:on 970527,non-performance of Surveillance Requirement 3.6.1.3.2 for Blind Fanges,Was Noted.Caused Because Misunderstanding of Intent of Specs.Added Five Structural Assemblies for SP.W/970626 Ltr ML17292A8331997-04-28028 April 1997 LER 97-004-00:on 970327,plant Operators Manually Scrammed Reactor as Required by TS Due to Entry Into Region a of power-to-flow Map Following Planned Trip of Single Mfp. Event Evaluation teams,established.W/970428 Ltr ML17292A8311997-04-28028 April 1997 LER 97-005-00:on 970327,valid Reactor Scram Signal Received Due to Low Water Level Condition During Preparations for SRV Testing.Caused by Risks & Consequences of Decisions Not Completely Identified.Restored Water level.W/970428 Ltr ML17292A8251997-04-21021 April 1997 LER 97-003-00:on 970320,notification of Noncompliance W/Ts as TS SRs for Response Time Testing Were Not Being Met for Specified Instrumentation in Rps,Pcis & Eccs.Requested Enforcement Discretion for One Time exemption.W/970421 Ltr ML17292A7431997-03-20020 March 1997 LER 97-002-00:on 970218,determined That Rod Block Monitor (RBM) Calibr Values Were Not Set IAW Tech Specs.Caused by Calibr Procedures Inadequacies.Revised & re-performed RBM Channel Calibr procedures.W/970330 Ltr ML17292A7401997-03-13013 March 1997 LER 97-001-00:on 970211,reactor Water Cleanup Sys Blowdown Flow Isolation Setpoint Was Slightly Above TS Allowable Valve Occurred Due to Calculation Error.Lds Fss LD-FS-15 LD-FS-16 Were Declared inoperable.W/970313 Ltr ML17292A6641997-01-22022 January 1997 LER 96-009-00:on 961220,miscalculation of Instantaneous Overcurrent Relay Settings Resulted in Inoperability of safety-related Equipment.Caused by Utilization of Inappropriate Design.Testing Was completed.W/970122 Ltr ML17292A6461997-01-0606 January 1997 LER 96-008-00:on 961205,failure to Comply with TS Action Requirement for Emergency Core Cooling Sys Actuation Instrumentation Occurred Due to Unidentified Inoperability Condition.Pmr initiated.W/970106 Ltr ML17292A6371996-12-19019 December 1996 LER 96-007-00:on 961122,electrical Breakers Were Not Seismically Qualified in Test/Disconnect Position.Circuit Breaker Mfg Did Not Consider Raced Out Breaker Position During Testing.Relocated Circuit breakers.W/961217 Ltr ML17292A4121996-08-0808 August 1996 LER 96-006-00:on 960709,average Power Range Monitor Rod Block Downscale Surveillance Not Performed Prior to Entry Into Mode 1.Caused by long-standing Misinterpretation of Requirements of Tss.Procedures revised.W/960808 Ltr ML17292A3801996-07-24024 July 1996 LER 96-004-00:on 960624,plant Was Manually Scrammed by Control Room Personnel Due to Reactor Water Level Transient Experienced During Testing of Digital Feedwater Sys.Caused by Programming Error.Sys Was corrected.W/960724 Ltr ML17292A3771996-07-24024 July 1996 LER 96-005-00:on 960624,determined Missed Surveillance Test Re Channel Check of Average Power Range Monitor.Caused by Inadequate Procedures.Revised Surveillance Procedure Re When APRM Checks Must Be performed.W/960724 Ltr ML17292A3641996-07-12012 July 1996 LER 96-003-00:on 960615,required Surveillance Test Not Performed When Required by TS 3.4.1.3.Caused by Inadequate Procedures.Implementing Surveillance Procedure & Reactor Plant Startup Procedures revised.W/960712 Ltr ML17292A3361996-06-20020 June 1996 LER 96-002-00:on 960504,critical Bus SM-8 Lost Power When Supply Breaker 3-8 Tripped.Caused by Personnel Error. Operators Counselled & Procedures revised.W/960620 Ltr ML17292A2861996-05-24024 May 1996 LER 96-001-00:on 960425,inadvertent ESF Actuations Occurred Due to Tripping of Temporary Power Supply to IN-3.Caused by Personnel Error.Operations Restored to IN-3 Loads & Reset ESF actuations.W/960524 Ltr ML17291B0891995-10-19019 October 1995 LER 95-011-00:on 950919,failed to Comply W/Ts SR for RCIC Sys Due to Analysis Deficiency That Resulted in Inadequate Surveillance Test Procedure.Surveillance Procedure Revised to Correct deficiency.W/951019 Ltr ML17291A9021995-07-0707 July 1995 LER 95-010-00:on 950609,HPCS DG Declared Inoperable Due to Discovery That TS Test Method Incomplete.Caused by Inadequate Testing Procedure.Test Procedure for HPCS DG Reviewed & Special Test Procedures written.W/950707 Ltr ML17291A9031995-07-0707 July 1995 LER 95-009-00:on 950607,inadvertent MSIV Closure Occurred During Surveillance Test Due to Poor Communication Between Test Team.Determined That MSIV Closure Not Valid Because Closure Not Triggered by Plant conditions.W/950707 Ltr ML17291A8501995-06-0808 June 1995 LER 95-006-01:on 950405,reactor Scram Occurred During Surveillance Testing Due to Protective Sys Relay Failure. Replaced Failed Relay Before Plant Startup ML17291A8101995-05-12012 May 1995 LER 95-008-00:on 940125,TS Wording Lead to Potential TS Violation.Caused by Lack of Clarity in Ts.Submitted Improved TS for Plant to Provide Addl clarity.W/950512 Ltr ML17291A7841995-05-0505 May 1995 LER 95-007-00:on 950222,emergency Diesel Start Occurred Due to Voltage Transient on BPA Grid.Confirmation Was Received at 17:51 H That Disturbance Had Originated in BPA Grid ML17291A7801995-05-0404 May 1995 LER 95-006-00:on 950405,main Turbine Trip Occurred During Performance of Surveillance Test Due to Protective Sys Relay Failed.Replaced Failed Relay Before Plant startup.W/950504 Ltr ML17291A7851995-05-0303 May 1995 LER 95-005-00:on 950222,inoperable IRM Had Been Relied Upon to Meet TS Requirements During Reactor Startup.Caused by Lack of Neutron Source to Test Instrumentation. Sys Knowledge Gained Will Be incorporated.W/950503 Ltr ML17291A7071995-03-25025 March 1995 LER 95-004-00:on 950226,malfunction in Main Turbine DEH Control Sys Caused All Four High Pressure Turbine Governor Valves to Rapidly Close.Caused by Blown Fuse.Suspected Faulty Circuit Card replaced.W/950325 Ltr ML17291A7011995-03-20020 March 1995 LER 95-002-00:on 950218,automatic Reactor Scram Occurred. Caused by Erroneous Positioning of Control During Performance of Scheduled Periodic Functional Test.Control repositioned.W/950320 Ltr 1999-07-20
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML17284A9001999-10-31031 October 1999 Rev 0 to COLR 99-15, WNP-2 Cycle 15,COLR GO2-99-177, LER 99-S01-00:on 990903,failure to Take Compensatory Measure within Required Time Upon Failure of Isolation Zone Microwave Unit,Was Noted.Caused by Personnel Error.Provided Refresher Training on Compensatory Measures.With1999-10-0101 October 1999 LER 99-S01-00:on 990903,failure to Take Compensatory Measure within Required Time Upon Failure of Isolation Zone Microwave Unit,Was Noted.Caused by Personnel Error.Provided Refresher Training on Compensatory Measures.With ML17284A8941999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for WNP-2.With 991012 Ltr ML17284A8801999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for WNP-2.With 990910 Ltr ML17284A8691999-07-31031 July 1999 Monthly Operating Rept for July 1999 for WNP-2.With 990813 Ltr ML17292B7421999-07-20020 July 1999 LER 99-001-00:on 990628,ESF Signal Closed All Eight MSIVs While Plant Was Shutdown.Caused by Failure of Relay RPS-RLY-K10D.Subject Relay Was Replaced & Tested on 990630. with 990720 Ltr ML17292B7271999-06-30030 June 1999 Monthly Operating Rept for June 1999 for WNP-2.With 990707 Ltr ML17292B6961999-05-31031 May 1999 Monthly Operating Repts for May 1999 for WNP-2.With 990608 Ltr ML17292B6641999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for WNP-2.With 990507 Ltr ML17292B6391999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for WNP-2.With 990413 Ltr ML17292B5871999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for WNP-2.With 990311 Ltr ML17292B5571999-01-31031 January 1999 Monthly Operating Rept for Jan 1999 for WNP-2.With 990210 Ltr ML17292B5621999-01-31031 January 1999 Rev 1 to COLR 98-14, WNP-2 Cycle 14 Colr. ML17292B5341999-01-15015 January 1999 Part 21 Rept Re Incorrect Modeling of BWR Lower Plenum Vol in Bison.Defect Applies Only to Reload Fuel Assemblies Currently in Operation at WNP-2.BISON Code Model for WNP-2 Has Been Revised to Correct Error ML17292B5331999-01-15015 January 1999 Part 21 Rept Re XL-S96 CPR Correlation for SVEA-96 Fuel. Defect Applies Only to WNP-2,during Cycles 12,13 & 14 Operation.Evaluations of Defect Performed by ABB-CE ML17292B4791998-12-31031 December 1998 Washington Public Power Supply Sys 1998 Annual Rept. with 981215 Ltr ML17292B5351998-12-31031 December 1998 Monthly Operating Rept for Dec 1998 for WNP-2.With 990112 Ltr ML17292B5741998-12-31031 December 1998 WNP-2 1998 Annual Operating Rept. with 990225 Ltr ML17284A8231998-11-30030 November 1998 Monthly Operating Rept for Nov 1998 for WNP-2.With 981207 Ltr ML17284A8081998-10-31031 October 1998 Monthly Operating Rept for Oct 1998 for WNP-2.With 981110 Ltr ML17292B4451998-10-27027 October 1998 LER 98-012-01:on 980715,failure to Comply with Requirements of TS SR 3.8.4.7 Was Noted.Caused by Inadequate Work Practices.Training Session Was Held with Personnel.With 981027 Ltr ML17284A7831998-09-30030 September 1998 Monthly Operating Rept for Sept 1998 for WNP-2.With 981007 Ltr ML17284A7491998-09-10010 September 1998 WNP-2 Inservice Insp Summary Rept for Refueling Outage RF13 Spring,1998. ML17284A7561998-09-0303 September 1998 LER 98-013-00:on 980805,ESF Actuations Were Noted Due to Deenergization of Vital Electrical Bus SM-8.Caused by Inadequate Direction in Troubleshooting Plan.Will Conduct Training for Engineering Personnel.With 980903 Ltr ML17284A7571998-09-0202 September 1998 LER 98-014-00:on 980807,completion of TS 3.8.1.F Required Shutdown Due to Inoperability of EDG-2 Was Noted.Caused by Degraded Voltage Regulator for DG-2.Replaced Voltage Regulator & Associated Scrs.With 980902 Ltr ML17284A7551998-09-0202 September 1998 LER 98-015-00:on 980808,discovered Reactor Coolant Pressure Boundary Leak During Shutdown Conditions.Caused by Leakage from Socket Weld (Fwb 63) on Elbow Connection.Failed Piping Connection Was Replaced.With 980902 Ltr ML17284A7681998-08-31031 August 1998 Monthly Operating Rept for Aug 1998 for WNP-2.With 980915 Ltr ML17284A7311998-08-17017 August 1998 LER 98-012-00:on 980716,determined That 24-month SR 3.8.4.7 Had Not Been Fulfilled within Specified Frequency.Caused by Inadequate Work Practices.License Requested & Received Enforcement Discretion Re Battery Svc test.W/980817 Ltr ML17284A7261998-07-31031 July 1998 Monthly Operating Rept for July 1998 for WNP-2.W/980810 Ltr ML17284A7121998-07-23023 July 1998 LER 98-006-01:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of 10CFR50,App R Calculations for High Impedance Faults.Caused by Inadequate Work Practices.Implemented Procedural Changes ML17284A6951998-07-17017 July 1998 LER 98-011-00:on 980617,ECCS Pump Room Flooding Was Noted Due to FP Sys Pipe Break.Caused by Inadequate Design of FP Sys.Detailed Review of FP Sys Design Was Conducted. W/980717 Ltr ML17284A6961998-07-15015 July 1998 LER 98-010-00:on 980615,TS Required Shutdown Due to Inoperability of TIP Sys Isolation Valve Was Noted.Caused by Improper Installation of TIP Tubing.Reattached Affected Tubing & Inspected Other TIP tubing.W/980715 Ltr ML17284A6731998-07-0101 July 1998 LER 98-009-00:on 980606,nuclear Steam Supply Shutoff Sys Group 3 & 4 Isolations During Testing Was Noted.Caused by Procedural Deficiency.Counseled Individuals Involved in preparation.W/980701 Ltr ML17284A6751998-06-30030 June 1998 Ro:On 980617,flooding of RB Northeast Stairwell with Consequential Flooding of Two ECCS Pump Rooms.Caused by Inadequate Fire Protection Sys Design.Pumped Out Water from Affected Areas to Point Below Berm Areas of Pump Rooms ML17284A6641998-06-24024 June 1998 LER 98-008-00:on 980531,inadvertent Full Scram During RPV Leak Testing in Mode 4 Was Noted.Caused by Change in Mgt Techniques.Revised Procedures to Take Into Account Addl Water Head in Pressure Sensing lines.W/980624 Ltr ML17284A6651998-06-24024 June 1998 LER 98-007-00:on 980530,inadvertent Full Scram & Division 1 ECCS Injection Was Noted.Caused by Failure to Meet Mgt Work Practice Expectation When Encountering Deficient Procedure. Incident Review Board Convened to Review event.W/980624 Ltr ML17284A6631998-06-19019 June 1998 LER 98-006-00:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of App R Calculations for High Impedance Fault Analysis.Caused Indeterminate. Implemented Procedural Changes Involving Operator Action ML17284A6551998-06-0404 June 1998 LER 98-005-00:on 980506,potential for Failure of RHR Sys Valve to Close on Isolation Signal Was Noted.Caused by Design Deficiency.Caution Tag Was Placed on RHR-V-40 Control Switch to Inform Plant Operators of limitation.W/980604 Ltr ML17284A6421998-06-0101 June 1998 LER 98-004-00:on 980502,determined That Primary Containment Penetration Overcurrent Protection Does Not Meet Reg Guide 1.63 Requirements.Caused by Inadequate Design Changes. Installed Addl Fuse in RHR-MO-9 circuit.W/980601 Ltr ML17284A6491998-05-31031 May 1998 Rev 0 to COLR 98-14, WNP-2,Cycle 14 Colr. ML17292B4031998-05-31031 May 1998 Monthly Operating Rept for May 1998 for WNP-2.W/980608 Ltr ML17292B3921998-04-30030 April 1998 Monthly Operating Rept for Apr 1998 for WNP-2.W/980513 Ltr ML17292B3291998-04-0909 April 1998 LER 98-003-00:on 980311,WNP-2 Experienced SCRAM Signal as Result of Low Rpv.Caused by Less than post-SCRAM Operational Strategy for Resetting SCRAM Signal in Conditions.Changes in post-SCRAM Operational Strategy implemented.W/980409 Ltr ML17292B3281998-04-0909 April 1998 LER 98-002-00:on 980311,reactor Scram & Plant Transient Occurred,Due to Failed Closed Main Steam Isolation Valve. Caused by Loss of Pneumatic Actuating Supply Pressure. Problem Evaluation Request Written for Failure of MS-V-22D ML17292B3371998-03-31031 March 1998 Monthly Operating Rept for Mar 1998 for WNP-2.W/980409 Ltr ML17292B2641998-03-0404 March 1998 Performance Self Assessment,WNP-2. ML17292B2661998-03-0404 March 1998 LER 98-001-00:on 980203,automatic Start of HPCS EDG Was Noted.Caused by Operator Error.Operations Crew Stabilized Plant at Approximately 75% Reactor Power & Investigation of Event Was initiated.W/980304 Ltr ML17292B2911998-02-28028 February 1998 Monthly Operating Rept for Feb 1998 for WNP-2.W/980313 Ltr ML17284A7971998-02-17017 February 1998 Rev 28 to Operational QA Program Description, WPPSS-QA-004.With Proposed Rev 29 ML17292B3591998-02-12012 February 1998 WNP-2 Cycle 14 Reload Design Rept. 1999-09-30
[Table view] |
Text
PRIORITY ACCELERATED RIDS PROCESSI iG REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)
ACCESSION NBR:9502150115 DOC.DATE: 95/02/07 NOTARIZED- NO DOCKET g FACIL:50-397 WPPSS Nuclear Project, Unit 2, Washington Public Powe 05000397 AUTH. NAME AUTHOR AFFILIATION HUGO,B.R. Washington Public Power Supply System PARRISH,J.V. Washington Public Power Supply System RECIP.NAME RECIPIENT AFFILIATION
SUBJECT:
LER 95-001-00:on 950113,failed to satisfy single failure criteria for containment isolation function due to electrical separation plate in control panel missing.
Replaced misszng barrier.W/950207 ltr.
DISTRIBUTION 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 PD4-2 PD 1 1 CLIFFORD,J 1 1 INTERNAL: ACRS 1 1 AEOD/SP~-RAB 1 1 AEOD/SPD/RRAB 1 1 CFXXiE-CENTERD02 1 1 NRR/DE/ECGB '1 1 NRR/DE/EELB 1 1 NRR/DE/EMEB 1 1 NRR/DIS P/PIPB 1 1 NRR/DOPS/OECB 1 1 NRR/DRCH/HHFB 1 1 NRR/DRCH/HICB 1 1 NRR/DRCH/HOLB 1 1 NRR/DRSS/PRPB "'2 '2 NRR/DSSA/SPLB 1 1 NRR/DSSA/SRXB 1 1 RES/DSIR/EIB 1 1 RGN4 FILE 01 1 1 EXTERNAL L ST LOBBY WARD 1 1 LITCO BRYCE g J H 2 2 NOAC MURPHY,G.A 1 1 NOAC POORE,W. 1 1 NRC PDR 1 1 NUDOCS FULL TXT 1 1 NOTE TO ALL"RIDS" RECIPIENTS:
PLEASE HELP US TO REDUCE iVASTE! CONTACI THE DOCI.'ilENTCONTROL DESK. ROOM P 1-37 (EXT. 504-2083 ) TO ELIMINATEYOUR NAME F ROD!
DISTRIBUTION LISTS FOR DOCI MENTS YOU DON"I'EED!
FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 27 ENCL 27
WASHINGTON PUBLIC POWER SUPPLY SYSTEM P.O. Box 968 ~ 3000 George Washington Way ~ Richland, Washington 99352-0968 ~ (509) 372-5000 February 7, 1995 G02-95-027 Docket No. 50-397 Document Control Desk U.S. Nuclear. Regulatory Commission Washington, D.C. 20555 Gentlemen:
Subject; NUCLEAR PLANT WNP-2, OPERATING LICENSE NPF-21, LICENSEE EVENT REPORT NO.95-001, REVISION 0 Transmitted herewith is Licensee Event Report No.95-001 for the WNP-2 Plant. 'This voluntary report is submitted due to potential NRC interest and discusses the items of reportability, corrective action taken, and action taken to preclude recurrence.
Should you have any questions or desire additional information, please call me or D.A. Swank at (509) 377-4563.
Sincerely,
. V. Parrish (Mail Drop 1023)
Vice-President, Nuclear Operations JVP/BRH Enclosure CC: LJ Callan, NRC-RIV KE Perkins, Jr., NRC-RIV, Walnut Creek Field Office NS Reynolds, Winston & Strawn NRC Sr. Resident Inspector (Mail Drop 927N, 2 Copies)
INPO Records Center - Atlanta, GA DL Williams, BPA (Mail Drop 399) 9502i50ii5 950207 PDR ADOCK 05000397 PDR
+ g8
n LICENSEE EVENT REPORT (LER)
FACE)TV NAME I'l DOCKET NUM<<EN (a PACE (S)
Washington Nuclear Plant Unit 2 0 5 0 0 0 3 9 7 1 o)'
TRLE(s) Inability to Satisfy Single Failure Criteria for Containment Isolation Function Due to Missing Electrical Separation Plate in Control Panel EVENT DATE (S) R(PORT DAIS (I) DTINR FAcs)TKs ervoLY(D (ro SEOUENRAL DOCKET IANISER(s)
FACERY NAMES NLRIs(R N/A 0 5 0 0 0 1 13. 95 95 0 0 0 0 02 07 95 0 5 0 0 0 op(RAT<<(Q TISS R(PORT IS SVdM()T(D PLNSUAN( TO THE REQUNEM(NTS OF 10 Crit (11)
MODE (0) 1 I 20402(b) ) 20.405c ) 60.73(s)(2)(iv) I I 73.71(b)
) 20.405(s)(1)(i) ) 50.36(c)(l) ) 60.73(s)(2)(v) ) 73.71(c)
POW(R LEVEL 20.405 (s) (1) (>>) ) S0.36(c)(2) ) 60.73(s)(2)(vi) ( X ( OTHER(Specify in Abet(oct below srxf IIO) in Text, NRC Form 366A) 20.405(s)(1)(M) ) 50.73(s](2)(i) ) 50.73(s)(2)(vi<<)A P P I Voluntary
) 20.405(s](l)(iv) ) 50.73(s)(2)(ii) ) 60.73(s)(2)(v>>i)B
"'<:Y"': 'b"'?'.'?i:"'.::: "::"',:~;".!.":Nil'! ) 20.405(s)(1)(v) ( 50.73(s)(2](iri) ) S0.73(s)(2)(x)
L)c(NSEE CONTACT FOR TMS LER (Ia TEL(PI)ONE NUMSER Bruce R. Hugo, Compliance Engineer 377-8593 509 COMPLETE ONE LPN Fon EAcH COMP(NNNT FAKURE D(scr>>sro IN T)ss REPoRT (Ia R(PORTASLE SYSTEM R(PORTA(LE TO IPROS TO )PADS S(NPLEMENTAL REPORT EXPECT(D ((S) EXPECTED MONTH YEAR SUBMISSION YES (if yss, complete EXPECTED SUBMISSION DATE) IX I NO DATE (16)
ASSTRACT (ld)
At 1215 hours0.0141 days <br />0.338 hours <br />0.00201 weeks <br />4.623075e-4 months <br /> on December 19, 1994, with WNP-2 at 100% power, an engineering supervisor performing a control panel walkdown discovered a missing electrical separation barrier plate inside the control room Reactor Core 'or Isolation Cooling (RCIC) control panel. With the barrier missing a short fire in the panel could disable the isolation capability of the system. The loss of electrical separation was initially believed to be limited to two steam trap drain line valves. On January 13, 1995, further review revealed that other valves in the system were affected, including the redundant steam supply isolation valves.
The loss of the ability to isolate the RCIC system with an assumed single failure was initially evaluated as rendering the isolation function inoperable. This event was accordingly reported per 10 CFR 50.72. Further investigation, including a review of Generic Letter 91-18, revealed that the actual status of the isolation function was operable but degraded. This event is being reported voluntarily due to potential NRC interest.
Corrective actions included replacement of the missing barrier and a walkdown of other panels. No additional similar problems were found. The cause of the missing plate could not be determined. The event had negligible safety significance due to the low probability of a fault: in the affected panel area.
LICEN EVENT REPORT (LER) TEXT C NUATION YfAR <<<:
< KQVOITIAL Washington Nuclear Plant Unit 2 0 5 0 0 0 3 9 7 95 -00 1 0 0 2 oF 3 TEXT (17)
Event
Description:
At 1215 hours0.0141 days <br />0.338 hours <br />0.00201 weeks <br />4.623075e-4 months <br /> on December 19, 1994, with WNP-2 in Operational Condition 1 (Pow'er Operation) at 1004 power, a Supply System engineering supervisor performing a control panel [CBD] walkdown discovered a missing electrical separation barrier plate inside the control room Reactor Core Isolation Cooling (RCIC) [BN] control panel. The barrier provides electrical separation between redundant division wiring for valve control and isolation logic for the RCIC system, RCIC High Energy Line Break (HELB) mitigation, and RCIC primary and secondary containment isolation functions [JM]. With the barrier missing a short or fire in the panel could disable the isolation capability of the system.
Although the missing plate was discovered on December 19, the loss of electrical separation was initially believed to be limited to two steam trap [TRP] drain [DRN] line valves [ISV]. On January 13, 1995, further review revealed that other valves [V] in the system were affected, including the redundant steam supply isolation valves.
Immediate Corrective Action:
Since the RCIC control panel is in the front of the continuously manned control room, credit for a continuous fire watch was taken.
A replacement barrier was fabricated and installed on December 22, 1994.
Further Evaluation:
The loss of the ability to isolate the RCIC system with an assumed single failure was initially evaluated as rendering the isolation function inoperable. This event was accordingly reported at 0847 hours0.0098 days <br />0.235 hours <br />0.0014 weeks <br />3.222835e-4 months <br /> on January 13, 1995, via the Emergency Notification System per 10 CFR 50.72 (b)(2)(iii) as "Any event or condition that alone could have prevented the fulfillment of the safety function of structures or systems that are needed to: (C) Control the release of radioactive material Further review of this issue, including a review of the guidance in Generic Letter 91-18, revealed that the actual status of the isolation function was operable but degraded. This event is being reported voluntarily due to potential NRC interest.
There were no structures, systems, or components that were inoperable at the start of the event that contributed to the event.
LICENS VENT REPORT (LER) TEXT COL UATION Washington Nuclear Plant Unit 2 05 0 0 0 3 9 7 95 001 0 0 TKCf (17)
Root Cause:
Maintenance records were reviewed to identify work that would'have required removal of the plate; however, no work meeting this criteria was found. Thus the root cause of this problem, which may have existed since initial plant operation, could not be determined.
Further Corrective Actions:
Other control room panels were examined to find similar problems.
No other missing electrical separation barriers were identified.
Safety Significance:
This event had negligible safety significance. Probabilistic Risk Assessment methods were used to estimate the probability of a single failure in the affected panel area disabling the isolation function during an accident. Although the actual distance between cables
[CBL] in the separate divisions was at least 3.5 inches, the cables were conservatively assumed to be in contact for the failure probability calculation. The estimated failure rate was 5 x 10(-7) failures per demand, equivalent to a negligible 5 percent increase in conditional containment failure probability.
Previous Similar Events:
LER 91-10 described wiring separation errors affecting the containment isolation valves for the reactor recirculation system
[AD]. flow control valve [FCV] hydraulic supply. Corrective actions included establishment of a fire tour and correction of the wiring error.
LER 92-31 described an electrical separation deficiency resulting from an inadequate design analysis for a design change. Corrective actions included establishment of a fire tour, a review of other circuits for similar problems, and correction of the separation deficiency.
LER 93-30 describes electrical separation discrepancies due to missing cable tray [TY] covers and other similar deficiencies.
Corrective actions included walkdowns of cable raceways [FA],
correction of deficiencies, and design configuration control program improvements.
These corrective actions would not be expected to have prevented the event described in this report.