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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML17313B0751999-08-27027 August 1999 LER 99-002-00:on 990730,test Mode Trip Bypass for EDG Output Breakers Not Surveilled.Cause Under Investigation.Operations Personnel Conservatively Invoked SR 3.0.3 for SR 3.8.1.13. with 990827 Ltr ML17313B0191999-07-16016 July 1999 LER 99-005-00:on 990618,RT on Low DNBR Was Noted.Caused by Hardware Induced Calculation Error.Cr Operator Was Taken to Place Reactor in Stable Condition IAW Appropriate Operating Procedure ML17313A9281999-05-0707 May 1999 LER 99-004-00:on 990408,PSV Lift Pressures Were Outside of TS Limits.Caused by Lift Pressure Setpoint Drift.Psvs Have Been Tested,Disassembled,Inspected,Reassembled & Certified at Wyle Labs ML17313A8951999-04-14014 April 1999 LER 99-003-00:on 990317,required Surveillance Requirement Not Completed Due to Deficient Procedure,Was Determined. Caused by Cognitive Personnel Error.St Procedures Revised to Require Chiller to Be Operating & Oil Temperature Checked ML17313A8921999-04-13013 April 1999 LER 98-003-01:on 980902,discovered That MSSV as-found Lift Pressures Were Outside TS Limits.Caused by Bonding of Valve Disc to Nozzle Seat.Affected Valves Were Adjusted,Retested & Returned to Svc ML17313A8891999-04-0909 April 1999 LER 99-001-00:on 990310,RT on High Pressurizer Pressure Was Noted.Caused by Loss of Heat Removal.Cr Supervisor Was Removed from Shift Duties for Diagnostics Skills Training. with 990409 Ltr ML17313A8361999-03-0101 March 1999 LER 99-001-00:on 990103,TS Violation for Power Dependent Insertion Limit Alarm Being Inoperable.Caused by Personnel Error.Revised Procedure to Clarify How Computer Point Is to Be Returned to Scan Mode.With 990302 Ltr ML17313A7701999-01-15015 January 1999 LER 96-008-00:on 960507,inadequate Procedure Results in Nuclear Power Channels Not Calibrated During Power Ascension Tests Occurred.Caused by Deficient Procedure.Procedure Revised ML17313A6611998-10-24024 October 1998 LER 98-008-00:on 980729,EQ of Electrical Connectors Were Not Adequately Demonstrated.Caused Because Test Was Conducted with Only Single Lv Connector & Without Fully Ranged Inputs. Revised EQ Requirements ML17313A5961998-09-14014 September 1998 LER 98-002-00:on 980814,B Train H Recombiner Was Noted Inoperable Due to cross-wired Power Receptacle.Cause of Event Is Under investigation.Cross-wired Power Supply Receptacle for B Train H Recombiner Was re-wired ML17313A5761998-09-0808 September 1998 LER 98-003-01:on 980113,discovered That One Channel of RWT Level Sys Had Failed High.Caused by Water Intrusion Into Electrical Termination Pull Box.Weep Holes Were Drilled Into Bottoms of Pull Boxes Nearest Level Transmitters ML17313A5591998-08-28028 August 1998 LER 98-001-00:on 980730,entered TS 3.0.3 Due to Safety Injection Flow Instruments Being Removed from Svc.Caused by Personnel Error.Transmitters Were Unisolated & Returned to svc.W/980828 Ltr ML17313A5201998-07-30030 July 1998 LER 98-004-00:on 980630,personnel Discovered That Pressure Safety Valve Had Not Received Periodic Set Pressure Test for ASME Class 1 Pressure Safety Valve.Caused by Personnel Error.Pressure Safety Valve reviewed.W/980730 Ltr ML17313A4671998-06-19019 June 1998 LER 98-007-00:on 980520,CR Personnel Observed Flow & Pressure Perturbations on Chemical & Vol Control Sys Letdown Sys.Caused by Cyclic Fatigue Due to Dynamic Pressure Transients.Unit Letdown Piping Replaced ML17313A4131998-06-0505 June 1998 LER 98-006-00:on 980507,determined That Plant Was Outside Design Basis Due to SI Discharge Check Valve Reverse Flow. Check Valve Was Disassembled,Examined & Reassembled, Whereupon Valve Met Acceptance Criteria ML17313A3951998-05-26026 May 1998 LER 98-005-00:on 980428,noted That Required Response Time Testing Had Not Been Performed.Caused by Personnel Error. Coached I&C Personnel Responsible for Reviewing Work Authorization Documentation ML17313A3251998-04-0101 April 1998 LER 98-004-00:on 980304,safety Valves as-found Pressures Out of Tolerance.Cause of Event Is Under Investigation.Three Mssv'S & Psv Will Be Replaced W/Refurbished & Recertified Valves During Refueling Outage U1R7 ML17313A3131998-03-21021 March 1998 LER 98-001-00:on 980301,surveillance Test Deficiency Found During Qaa Leads to TS 3.0.3/4.0.3 Entry.Caused by Personnel Error.Personnel Responsible for Inadequately Performed SR Were Coached ML17313A2251998-03-0505 March 1998 LER 93-005-00:on 930309,CR Personnel Discovered Missed TS LCO Action & Subsequently Performed Surveillance Satisfactorily.Caused by Personnel Error.Appropriate Disciplinary Action issued.W/980305 Ltr ML17313A2241998-02-26026 February 1998 LER 98-001-00:on 980130,reactor Protection & ESFAS Instrumentation Not Bypassed within one-hour Allowed by TS Occurred.Caused by Inadequate Procedures.Expectation to Detect Alarm Conditions Was Emphasized to CR Personnel ML17313A2081998-02-10010 February 1998 LER 97-007-00:on 971006,TS Violation Occurred Due to Inadequate Shutdown Cooling Flow During Modes 5 & 6 Operation.Independent Investigation of Event Was Conducted IAW APS CA program.W/980210 Ltr ML17313A2041998-02-0505 February 1998 LER 97-006-00:on 971028,missed TS 4.0.5 SR Was Noted.Caused by Personnel Error.Independent Investigation of Event Is Being Conducted IAW W/Aps Corrective Action Program ML17313A1201997-11-12012 November 1997 LER 97-006-00:on 971020,manual Reactor Trip Occurred Due to Vibration & Bearing Temp Increases in Reactor Coolant Pump. Caused by Failed Lower Journal Bearing.Bearing Assembly Was Disassembled,Inspected & Rebuilt ML17312B7181997-10-0707 October 1997 LER 97-003-00:on 970907,inadvertent Loss of Power & EDG Start Occurred Due to Procedural Error.Changed Train a & Train B Edg/Ist ST Procedures to Consistently Reflect Proper Pretest Staging Hand switches.W/971007 Ltr ML17312B7051997-09-26026 September 1997 LER 97-003-01:on 970215,seven Main Steam Safety Valves Were Found Out of Tolerance Prior to Refueling Outage.Safety Analysis Performed Based Upon as-found MSSV Data Which Demonstrated That MSSVs Would Perform Safety Functions ML17312B5531997-07-0707 July 1997 LER 97-002-00:on 970528,SR for Core Protection Was Not Performed Due to Inadequate Procedures.Revised Procedures ML17312B5501997-07-0707 July 1997 LER 97-003-00:on 970211,notified of Trevitest Activities Indicating That Total of Seven MSSVs Had as-found Lift Set Pressures Greater than 3 Percent Allowed by TS 3.7.1.1. Investigation Conducted.Seven MSSVs replaced.W/970707 Ltr ML17312B4971997-06-13013 June 1997 LER 97-002-00:on 970531,RT Occurred.Caused by Spurious Opening of All Four Rt Switchgear Breakers.Independent Investigation of Event Being Conducted in Accordance W/Util Corrective Action Program ML17312B1461996-12-17017 December 1996 LER 96-007-00:on 961119,surveillance Test Deficiencies Were Found During GL 96-01 Review Leading to TS 3.0.3 Entries. Caused by Increase in Scope of Required Testing.Supplement Will Be submitted.W/961217 Ltr ML17312A9511996-09-0404 September 1996 LER 96-003-00:on 960809,open Auxiliary Bldg Door Caused Full Bldg Essential Filtration Inoperability.Caused by Personnel Error.C/As Under consideration.W/960904 Ltr ML17312A8641996-07-17017 July 1996 LER 96-001-00:on 960621,inaccurate Gas Calculations for Post Accident Sampling Sys Occurred.Caused by Surveillance Test Worksheet Errors.Independent Investigation of Event Being conducted.W/960717 Ltr ML17300B2541996-06-11011 June 1996 LER 96-001-01:on 960404,inappropriate Grounding of Equipment Resulted in Condition Outside Design Basis of Plant. Established Fire Watches Required for Affected Areas ML17312A8081996-06-0909 June 1996 LER 96-002-00:on 960514,Tech Spec Violation Occurred Due to Erroneous Surveillance Requirement.Caused by Incorporation of C-E Generic Ts.Investigation Being conducted.W/960609 Ltr ML17312A7751996-05-17017 May 1996 LER 96-003-00:on 960122,missed Surveillance for Logic Check of Logs 1 & 2 Safety Excore Bypasses.Caused by Procedural Error.Log Power Functional Test Revised to Check Logs 1 & 2 Bypasses Regardless of Power level.W/960517 Ltr ML17312A7511996-05-0606 May 1996 LER 96-001-00:on 960404,smoke Discovered in Back Boards Area of CR by Security Officer,Performing Hourly Fire Watch Tour. Caused by Improperly Grounded Circuit.Investigation for Inappropriate Grounding of Low Voltage Power Sys Initiated ML17312A7241996-04-25025 April 1996 LER 96-002-00:on 960401,inappropriate Work Practice Resulted in Esfa of Train B Edg.Night Order Was Issued to All Three Units Describing event.W/960425 Ltr ML17312A6861996-04-0606 April 1996 LER 95-007-01:on 950512,determined That Bench Settings of air-operated Letdown & Containment Isolation Valves Adversely Affected Ability of Valves to Perform 10CFR50 App R Safety Function.Affected Valves Modified ML17312A5631996-02-22022 February 1996 LER 95-016-00:on 951212,containment Spray TS Violation Occurred Due to Unrecognized Valve Failure.Shim/Band Was Placed Around Stator of 1JSIBUV665 Motor Operator to Maintain Stator in Correct position.W/960222 Ltr ML17311B3381996-01-0909 January 1996 LER 95-014-00:on 951209,reactor Tripped Following Degradation of Main FW Flow.Caused by Malfunction of Fwcs Power supply,NNN-D11,transfer switch.NNN-D11 Aligned to Normal Power supply.W/960109 Ltr ML17311B3331995-12-31031 December 1995 LER 95-013-00:on 951201,AFW Sys Was Outside Design Basis of Plant.Caused by Design Error.Performed Assessment to Demonstrate That Existing Condition Does Not Pose Addl Safety concerns.W/951231 Ltr ML17311B2801995-11-23023 November 1995 LER 95-011-00:on 951018,identified Procedural Deficiency W/Msiv & FWIV ISTs Due to Personnel Error.Verified Operability of MSIVs & FWIVs.W/951123 Ltr ML17311B2531995-10-20020 October 1995 LER 95-002-00:on 950924,identified That Abnormal Blowdown Valves to Blowdown Flash Tank (Bft) Isolated,Resulting in Reactor Core Power Exceeding 3,800 Mwt Due to Personnel Error.Procedure for Aligning Blowdown to Bft Revised ML17311B1991995-09-21021 September 1995 LER 95-010-00:on 950727,equipment Qualification of Air Handling Unit Caused Essential Cw Pump to Be Inoperable. Used Work Orders to Drill Weep Holes in Motor Lead Connection boxes.W/950921 Ltr ML17311B1741995-09-0404 September 1995 LER 95-004-01:on 950329,containment Electrical Penetration Overcurrent Protective Devices Found Outside Design Basis. Caused by Error on Part of Original Architect Engineer. Modified Affected Circuits Critical to Normal Operational ML17311B1561995-08-27027 August 1995 LER 95-003-00:on 950729,switchyard Voltage Dropped Below Administratively Imposed Limit of 524 Kv for Approx 10 Seconds Due to Transient Grid Voltage.No C/A Taken Since Transmission Sys Transient Short duration.W/950827 Ltr ML17311B1551995-08-25025 August 1995 LER 95-002-01:on 950303,identified That Slb Analyses Failed to Consider as Initial Condition One Percent SDM for All Rods in (ARI) Due to Lack of Coordination & Unclear Div of Responsibilities.Ari Core Data Book SDM Curves Modified ML17311B1211995-08-16016 August 1995 LER 95-005-00:on 950717,RT on Low SG Water Level Was Result Following Degradation of MFW Flow.Completed Evaluation of Event ML17311B0841995-07-28028 July 1995 LER 94-005-01:on 941019,completed TS Required Shutdown Due to Expiration of LCO Time Limit.Design Change Options Identified & Will Be Reviewed to Determine If Valve &/Or Motor Operator Replacement or Mod Necessary ML17311B0721995-07-20020 July 1995 LER 95-004-00:on 950706,identified Four Occassions Between 950407 & 0630 When Conditional Surveillance in TS LCO 3.8.4.1 Action a Not Performed Due to Inattention to Detail. CR Copy of Temporary Procedure 40TP-9ZZ04 Corrected ML17311B0081995-07-0606 July 1995 LER 95-003-00:on 950613,TS LCO 3.0.3 Entered Following Loss of Both Trains of Essential Cw Sys & Both Hydrogen Recombiners.Caused by Spurious Actuations Due to Broken EDG Speed Probe Connector.Connector replaced.W/950706 Ltr 1999-08-27
[Table view] Category:RO)
MONTHYEARML17313B0751999-08-27027 August 1999 LER 99-002-00:on 990730,test Mode Trip Bypass for EDG Output Breakers Not Surveilled.Cause Under Investigation.Operations Personnel Conservatively Invoked SR 3.0.3 for SR 3.8.1.13. with 990827 Ltr ML17313B0191999-07-16016 July 1999 LER 99-005-00:on 990618,RT on Low DNBR Was Noted.Caused by Hardware Induced Calculation Error.Cr Operator Was Taken to Place Reactor in Stable Condition IAW Appropriate Operating Procedure ML17313A9281999-05-0707 May 1999 LER 99-004-00:on 990408,PSV Lift Pressures Were Outside of TS Limits.Caused by Lift Pressure Setpoint Drift.Psvs Have Been Tested,Disassembled,Inspected,Reassembled & Certified at Wyle Labs ML17313A8951999-04-14014 April 1999 LER 99-003-00:on 990317,required Surveillance Requirement Not Completed Due to Deficient Procedure,Was Determined. Caused by Cognitive Personnel Error.St Procedures Revised to Require Chiller to Be Operating & Oil Temperature Checked ML17313A8921999-04-13013 April 1999 LER 98-003-01:on 980902,discovered That MSSV as-found Lift Pressures Were Outside TS Limits.Caused by Bonding of Valve Disc to Nozzle Seat.Affected Valves Were Adjusted,Retested & Returned to Svc ML17313A8891999-04-0909 April 1999 LER 99-001-00:on 990310,RT on High Pressurizer Pressure Was Noted.Caused by Loss of Heat Removal.Cr Supervisor Was Removed from Shift Duties for Diagnostics Skills Training. with 990409 Ltr ML17313A8361999-03-0101 March 1999 LER 99-001-00:on 990103,TS Violation for Power Dependent Insertion Limit Alarm Being Inoperable.Caused by Personnel Error.Revised Procedure to Clarify How Computer Point Is to Be Returned to Scan Mode.With 990302 Ltr ML17313A7701999-01-15015 January 1999 LER 96-008-00:on 960507,inadequate Procedure Results in Nuclear Power Channels Not Calibrated During Power Ascension Tests Occurred.Caused by Deficient Procedure.Procedure Revised ML17313A6611998-10-24024 October 1998 LER 98-008-00:on 980729,EQ of Electrical Connectors Were Not Adequately Demonstrated.Caused Because Test Was Conducted with Only Single Lv Connector & Without Fully Ranged Inputs. Revised EQ Requirements ML17313A5961998-09-14014 September 1998 LER 98-002-00:on 980814,B Train H Recombiner Was Noted Inoperable Due to cross-wired Power Receptacle.Cause of Event Is Under investigation.Cross-wired Power Supply Receptacle for B Train H Recombiner Was re-wired ML17313A5761998-09-0808 September 1998 LER 98-003-01:on 980113,discovered That One Channel of RWT Level Sys Had Failed High.Caused by Water Intrusion Into Electrical Termination Pull Box.Weep Holes Were Drilled Into Bottoms of Pull Boxes Nearest Level Transmitters ML17313A5591998-08-28028 August 1998 LER 98-001-00:on 980730,entered TS 3.0.3 Due to Safety Injection Flow Instruments Being Removed from Svc.Caused by Personnel Error.Transmitters Were Unisolated & Returned to svc.W/980828 Ltr ML17313A5201998-07-30030 July 1998 LER 98-004-00:on 980630,personnel Discovered That Pressure Safety Valve Had Not Received Periodic Set Pressure Test for ASME Class 1 Pressure Safety Valve.Caused by Personnel Error.Pressure Safety Valve reviewed.W/980730 Ltr ML17313A4671998-06-19019 June 1998 LER 98-007-00:on 980520,CR Personnel Observed Flow & Pressure Perturbations on Chemical & Vol Control Sys Letdown Sys.Caused by Cyclic Fatigue Due to Dynamic Pressure Transients.Unit Letdown Piping Replaced ML17313A4131998-06-0505 June 1998 LER 98-006-00:on 980507,determined That Plant Was Outside Design Basis Due to SI Discharge Check Valve Reverse Flow. Check Valve Was Disassembled,Examined & Reassembled, Whereupon Valve Met Acceptance Criteria ML17313A3951998-05-26026 May 1998 LER 98-005-00:on 980428,noted That Required Response Time Testing Had Not Been Performed.Caused by Personnel Error. Coached I&C Personnel Responsible for Reviewing Work Authorization Documentation ML17313A3251998-04-0101 April 1998 LER 98-004-00:on 980304,safety Valves as-found Pressures Out of Tolerance.Cause of Event Is Under Investigation.Three Mssv'S & Psv Will Be Replaced W/Refurbished & Recertified Valves During Refueling Outage U1R7 ML17313A3131998-03-21021 March 1998 LER 98-001-00:on 980301,surveillance Test Deficiency Found During Qaa Leads to TS 3.0.3/4.0.3 Entry.Caused by Personnel Error.Personnel Responsible for Inadequately Performed SR Were Coached ML17313A2251998-03-0505 March 1998 LER 93-005-00:on 930309,CR Personnel Discovered Missed TS LCO Action & Subsequently Performed Surveillance Satisfactorily.Caused by Personnel Error.Appropriate Disciplinary Action issued.W/980305 Ltr ML17313A2241998-02-26026 February 1998 LER 98-001-00:on 980130,reactor Protection & ESFAS Instrumentation Not Bypassed within one-hour Allowed by TS Occurred.Caused by Inadequate Procedures.Expectation to Detect Alarm Conditions Was Emphasized to CR Personnel ML17313A2081998-02-10010 February 1998 LER 97-007-00:on 971006,TS Violation Occurred Due to Inadequate Shutdown Cooling Flow During Modes 5 & 6 Operation.Independent Investigation of Event Was Conducted IAW APS CA program.W/980210 Ltr ML17313A2041998-02-0505 February 1998 LER 97-006-00:on 971028,missed TS 4.0.5 SR Was Noted.Caused by Personnel Error.Independent Investigation of Event Is Being Conducted IAW W/Aps Corrective Action Program ML17313A1201997-11-12012 November 1997 LER 97-006-00:on 971020,manual Reactor Trip Occurred Due to Vibration & Bearing Temp Increases in Reactor Coolant Pump. Caused by Failed Lower Journal Bearing.Bearing Assembly Was Disassembled,Inspected & Rebuilt ML17312B7181997-10-0707 October 1997 LER 97-003-00:on 970907,inadvertent Loss of Power & EDG Start Occurred Due to Procedural Error.Changed Train a & Train B Edg/Ist ST Procedures to Consistently Reflect Proper Pretest Staging Hand switches.W/971007 Ltr ML17312B7051997-09-26026 September 1997 LER 97-003-01:on 970215,seven Main Steam Safety Valves Were Found Out of Tolerance Prior to Refueling Outage.Safety Analysis Performed Based Upon as-found MSSV Data Which Demonstrated That MSSVs Would Perform Safety Functions ML17312B5531997-07-0707 July 1997 LER 97-002-00:on 970528,SR for Core Protection Was Not Performed Due to Inadequate Procedures.Revised Procedures ML17312B5501997-07-0707 July 1997 LER 97-003-00:on 970211,notified of Trevitest Activities Indicating That Total of Seven MSSVs Had as-found Lift Set Pressures Greater than 3 Percent Allowed by TS 3.7.1.1. Investigation Conducted.Seven MSSVs replaced.W/970707 Ltr ML17312B4971997-06-13013 June 1997 LER 97-002-00:on 970531,RT Occurred.Caused by Spurious Opening of All Four Rt Switchgear Breakers.Independent Investigation of Event Being Conducted in Accordance W/Util Corrective Action Program ML17312B1461996-12-17017 December 1996 LER 96-007-00:on 961119,surveillance Test Deficiencies Were Found During GL 96-01 Review Leading to TS 3.0.3 Entries. Caused by Increase in Scope of Required Testing.Supplement Will Be submitted.W/961217 Ltr ML17312A9511996-09-0404 September 1996 LER 96-003-00:on 960809,open Auxiliary Bldg Door Caused Full Bldg Essential Filtration Inoperability.Caused by Personnel Error.C/As Under consideration.W/960904 Ltr ML17312A8641996-07-17017 July 1996 LER 96-001-00:on 960621,inaccurate Gas Calculations for Post Accident Sampling Sys Occurred.Caused by Surveillance Test Worksheet Errors.Independent Investigation of Event Being conducted.W/960717 Ltr ML17300B2541996-06-11011 June 1996 LER 96-001-01:on 960404,inappropriate Grounding of Equipment Resulted in Condition Outside Design Basis of Plant. Established Fire Watches Required for Affected Areas ML17312A8081996-06-0909 June 1996 LER 96-002-00:on 960514,Tech Spec Violation Occurred Due to Erroneous Surveillance Requirement.Caused by Incorporation of C-E Generic Ts.Investigation Being conducted.W/960609 Ltr ML17312A7751996-05-17017 May 1996 LER 96-003-00:on 960122,missed Surveillance for Logic Check of Logs 1 & 2 Safety Excore Bypasses.Caused by Procedural Error.Log Power Functional Test Revised to Check Logs 1 & 2 Bypasses Regardless of Power level.W/960517 Ltr ML17312A7511996-05-0606 May 1996 LER 96-001-00:on 960404,smoke Discovered in Back Boards Area of CR by Security Officer,Performing Hourly Fire Watch Tour. Caused by Improperly Grounded Circuit.Investigation for Inappropriate Grounding of Low Voltage Power Sys Initiated ML17312A7241996-04-25025 April 1996 LER 96-002-00:on 960401,inappropriate Work Practice Resulted in Esfa of Train B Edg.Night Order Was Issued to All Three Units Describing event.W/960425 Ltr ML17312A6861996-04-0606 April 1996 LER 95-007-01:on 950512,determined That Bench Settings of air-operated Letdown & Containment Isolation Valves Adversely Affected Ability of Valves to Perform 10CFR50 App R Safety Function.Affected Valves Modified ML17312A5631996-02-22022 February 1996 LER 95-016-00:on 951212,containment Spray TS Violation Occurred Due to Unrecognized Valve Failure.Shim/Band Was Placed Around Stator of 1JSIBUV665 Motor Operator to Maintain Stator in Correct position.W/960222 Ltr ML17311B3381996-01-0909 January 1996 LER 95-014-00:on 951209,reactor Tripped Following Degradation of Main FW Flow.Caused by Malfunction of Fwcs Power supply,NNN-D11,transfer switch.NNN-D11 Aligned to Normal Power supply.W/960109 Ltr ML17311B3331995-12-31031 December 1995 LER 95-013-00:on 951201,AFW Sys Was Outside Design Basis of Plant.Caused by Design Error.Performed Assessment to Demonstrate That Existing Condition Does Not Pose Addl Safety concerns.W/951231 Ltr ML17311B2801995-11-23023 November 1995 LER 95-011-00:on 951018,identified Procedural Deficiency W/Msiv & FWIV ISTs Due to Personnel Error.Verified Operability of MSIVs & FWIVs.W/951123 Ltr ML17311B2531995-10-20020 October 1995 LER 95-002-00:on 950924,identified That Abnormal Blowdown Valves to Blowdown Flash Tank (Bft) Isolated,Resulting in Reactor Core Power Exceeding 3,800 Mwt Due to Personnel Error.Procedure for Aligning Blowdown to Bft Revised ML17311B1991995-09-21021 September 1995 LER 95-010-00:on 950727,equipment Qualification of Air Handling Unit Caused Essential Cw Pump to Be Inoperable. Used Work Orders to Drill Weep Holes in Motor Lead Connection boxes.W/950921 Ltr ML17311B1741995-09-0404 September 1995 LER 95-004-01:on 950329,containment Electrical Penetration Overcurrent Protective Devices Found Outside Design Basis. Caused by Error on Part of Original Architect Engineer. Modified Affected Circuits Critical to Normal Operational ML17311B1561995-08-27027 August 1995 LER 95-003-00:on 950729,switchyard Voltage Dropped Below Administratively Imposed Limit of 524 Kv for Approx 10 Seconds Due to Transient Grid Voltage.No C/A Taken Since Transmission Sys Transient Short duration.W/950827 Ltr ML17311B1551995-08-25025 August 1995 LER 95-002-01:on 950303,identified That Slb Analyses Failed to Consider as Initial Condition One Percent SDM for All Rods in (ARI) Due to Lack of Coordination & Unclear Div of Responsibilities.Ari Core Data Book SDM Curves Modified ML17311B1211995-08-16016 August 1995 LER 95-005-00:on 950717,RT on Low SG Water Level Was Result Following Degradation of MFW Flow.Completed Evaluation of Event ML17311B0841995-07-28028 July 1995 LER 94-005-01:on 941019,completed TS Required Shutdown Due to Expiration of LCO Time Limit.Design Change Options Identified & Will Be Reviewed to Determine If Valve &/Or Motor Operator Replacement or Mod Necessary ML17311B0721995-07-20020 July 1995 LER 95-004-00:on 950706,identified Four Occassions Between 950407 & 0630 When Conditional Surveillance in TS LCO 3.8.4.1 Action a Not Performed Due to Inattention to Detail. CR Copy of Temporary Procedure 40TP-9ZZ04 Corrected ML17311B0081995-07-0606 July 1995 LER 95-003-00:on 950613,TS LCO 3.0.3 Entered Following Loss of Both Trains of Essential Cw Sys & Both Hydrogen Recombiners.Caused by Spurious Actuations Due to Broken EDG Speed Probe Connector.Connector replaced.W/950706 Ltr 1999-08-27
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML17300B3811999-09-30030 September 1999 Monthly Operating Repts for Sept 1999 for Pvngs,Units 1,2 & 3.With 991007 Ltr ML17300B3271999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Pvngs,Units 1,2 & 3 ML17313B0751999-08-27027 August 1999 LER 99-002-00:on 990730,test Mode Trip Bypass for EDG Output Breakers Not Surveilled.Cause Under Investigation.Operations Personnel Conservatively Invoked SR 3.0.3 for SR 3.8.1.13. with 990827 Ltr ML17313B0611999-07-31031 July 1999 Monthly Operating Repts for July 1999 for Pvngs,Units 1,2 & 3.With 990810 Ltr ML17313B0191999-07-16016 July 1999 LER 99-005-00:on 990618,RT on Low DNBR Was Noted.Caused by Hardware Induced Calculation Error.Cr Operator Was Taken to Place Reactor in Stable Condition IAW Appropriate Operating Procedure ML17300B3151999-06-30030 June 1999 Monthly Operating Repts for June 1999 for Pvngs,Units 1,2 & 3.With 990714 Ltr ML17313A9921999-06-21021 June 1999 Special Rept:On 990525,RMS mini-computer Was Removed from Service to Implement Yr 2000 Mod & Was OOS Longer than 72 H Allowed.Caused by Planned Y2K Mods.Preplanned Alternate Sampling Program Was Initiated ML17313A9911999-06-18018 June 1999 Special Rept:On 990510,loose-part Detection Sys Channel 2 Was Declared Inoperable.Caused by Malfunction of Mineral Cable Connector to Accelerometer.Licensee Will Implement Modifications Which Will Enhance loose-part Detection Sys ML17313A9731999-05-31031 May 1999 Monthly Operating Repts for May 1999 for Pvngs,Units 1,2 & 3.With 990608 Ltr ML17313A9281999-05-0707 May 1999 LER 99-004-00:on 990408,PSV Lift Pressures Were Outside of TS Limits.Caused by Lift Pressure Setpoint Drift.Psvs Have Been Tested,Disassembled,Inspected,Reassembled & Certified at Wyle Labs ML17313A9201999-04-30030 April 1999 Monthly Operating Repts for Apr 1999 for Pvngs,Units 1,2 & 3.With 990512 Ltr ML17313A8951999-04-14014 April 1999 LER 99-003-00:on 990317,required Surveillance Requirement Not Completed Due to Deficient Procedure,Was Determined. Caused by Cognitive Personnel Error.St Procedures Revised to Require Chiller to Be Operating & Oil Temperature Checked ML17313A8921999-04-13013 April 1999 LER 98-003-01:on 980902,discovered That MSSV as-found Lift Pressures Were Outside TS Limits.Caused by Bonding of Valve Disc to Nozzle Seat.Affected Valves Were Adjusted,Retested & Returned to Svc ML17313A8891999-04-0909 April 1999 LER 99-001-00:on 990310,RT on High Pressurizer Pressure Was Noted.Caused by Loss of Heat Removal.Cr Supervisor Was Removed from Shift Duties for Diagnostics Skills Training. with 990409 Ltr ML17300B3071999-03-31031 March 1999 Seismic Portion of Submittal-Only Screening Review of Palo Verde Nuclear Generating Station Units Ipeee. ML17313A8801999-03-31031 March 1999 Monthly Operating Repts for Mar 1999 for Pvngs,Units 1,2 & 3.With 990412 Ltr ML20207M9231999-03-12012 March 1999 Amended Part 21 Rept Re Cooper-Bessemer Ksv EDG Power Piston Failure.Total of 198 or More Pistons Have Been Measured at Seven Different Sites.All Potentially Defective Pistons Have Been Removed from Svc Based on Encl Results ML20207H7471999-03-10010 March 1999 1999 Emergency Preparedness Exercise 99-E-AEV-03003 ML17313A8361999-03-0101 March 1999 LER 99-001-00:on 990103,TS Violation for Power Dependent Insertion Limit Alarm Being Inoperable.Caused by Personnel Error.Revised Procedure to Clarify How Computer Point Is to Be Returned to Scan Mode.With 990302 Ltr ML17313A8501999-02-28028 February 1999 Monthly Operating Repts for Feb 1999 for Palo Verde Nuclear Generating Station.With 990311 Ltr ML17313A7791999-02-0505 February 1999 Safety Evaluation Accepting Licensee Rev to Emergency Plan That Would Result in Two Less Radiation Protection Positions Immediatelu Available During Emergencies ML17313A8061999-01-31031 January 1999 Monthly Operating Repts for Jan 1999 for Pvngs,Units 1,2 & 3.With 990218 Ltr ML17313A7701999-01-15015 January 1999 LER 96-008-00:on 960507,inadequate Procedure Results in Nuclear Power Channels Not Calibrated During Power Ascension Tests Occurred.Caused by Deficient Procedure.Procedure Revised ML17313A7381998-12-31031 December 1998 Monthly Operating Repts for Dec 1998 for Palo Verde Nuclear Generating Station,Units 1,2 & 3.With 990113 Ltr ML20206H2101998-12-31031 December 1998 SCE 1998 Annual Rept ML17313A7031998-11-30030 November 1998 Monthly Operating Repts for Nov 1998 for Pvngs,Unit 1,2 & 3. with 981209 Ltr ML17313A6701998-11-0404 November 1998 Rev 2 to PVNGS Unit 2 Colr. ML17313A6741998-10-31031 October 1998 Monthly Operating Repts for Oct 1998 for Pvngs,Units 1,2 & 3.With 981109 Ltr ML17313A6611998-10-24024 October 1998 LER 98-008-00:on 980729,EQ of Electrical Connectors Were Not Adequately Demonstrated.Caused Because Test Was Conducted with Only Single Lv Connector & Without Fully Ranged Inputs. Revised EQ Requirements ML17313A6561998-09-30030 September 1998 Monthly Operating Rept for Sept 1998 for PVNGS Units 1,2 & 3.With 981007 Ltr ML17313A5961998-09-14014 September 1998 LER 98-002-00:on 980814,B Train H Recombiner Was Noted Inoperable Due to cross-wired Power Receptacle.Cause of Event Is Under investigation.Cross-wired Power Supply Receptacle for B Train H Recombiner Was re-wired ML17313A5761998-09-0808 September 1998 LER 98-003-01:on 980113,discovered That One Channel of RWT Level Sys Had Failed High.Caused by Water Intrusion Into Electrical Termination Pull Box.Weep Holes Were Drilled Into Bottoms of Pull Boxes Nearest Level Transmitters ML17313A5591998-08-28028 August 1998 LER 98-001-00:on 980730,entered TS 3.0.3 Due to Safety Injection Flow Instruments Being Removed from Svc.Caused by Personnel Error.Transmitters Were Unisolated & Returned to svc.W/980828 Ltr ML20151S0941998-08-21021 August 1998 Rev 6 to COLR for PVNGS Unit 3 ML20151S0861998-08-21021 August 1998 Rev 4 to COLR for PVNGS Unit 1 ML20151S0901998-08-21021 August 1998 Rev 1 to COLR for PVNGS Unit 2 ML18066A2771998-08-13013 August 1998 Part 21 Rept Re Deficiency in CE Current Screening Methodology for Determining Limiting Fuel Assembly for Detailed PWR thermal-hydraulic Sa.Evaluations Were Performed for Affected Plants to Determine Effect of Deficiency ML17313A5401998-08-13013 August 1998 Special Rept:On 980715,declared PASS Inoperable.Caused by Failure of Offgas Flush/Purge Control Handswitch HS0101. Handswitch Replaced & Post Maintenance Retesting Was Initiated ML17313A5301998-07-31031 July 1998 Monthly Operating Repts for July 1998 for Pvgns,Units 1,2 & 3.W/980812 Ltr ML17313A5201998-07-30030 July 1998 LER 98-004-00:on 980630,personnel Discovered That Pressure Safety Valve Had Not Received Periodic Set Pressure Test for ASME Class 1 Pressure Safety Valve.Caused by Personnel Error.Pressure Safety Valve reviewed.W/980730 Ltr ML17313A5791998-07-0707 July 1998 to PVNGS SG Tube ISI Results for Seventh Refueling Outage Mar & Apr 1998. ML17313A5001998-06-30030 June 1998 Monthly Operating Repts for June 1998 for Palo Verde Nuclear Generating Station,Units 1,2 & 3.W/980710 Ltr ML17313A4671998-06-19019 June 1998 LER 98-007-00:on 980520,CR Personnel Observed Flow & Pressure Perturbations on Chemical & Vol Control Sys Letdown Sys.Caused by Cyclic Fatigue Due to Dynamic Pressure Transients.Unit Letdown Piping Replaced ML17313A4521998-06-19019 June 1998 Rev 5 to COLR for Pvngs,Unit 3. ML17313A4501998-06-19019 June 1998 Rev 4 to COLR for Pvngs,Unit 3. ML17313A4131998-06-0505 June 1998 LER 98-006-00:on 980507,determined That Plant Was Outside Design Basis Due to SI Discharge Check Valve Reverse Flow. Check Valve Was Disassembled,Examined & Reassembled, Whereupon Valve Met Acceptance Criteria ML17313A4211998-05-31031 May 1998 Monthly Operating Repts for May 1998 for Pvngs,Units 1,2 & 3.W/980609 Ltr ML17313A3951998-05-26026 May 1998 LER 98-005-00:on 980428,noted That Required Response Time Testing Had Not Been Performed.Caused by Personnel Error. Coached I&C Personnel Responsible for Reviewing Work Authorization Documentation ML17313A3691998-04-30030 April 1998 Monthly Operating Repts for Apr 1998 for PVNGS.W/980412 Ltr ML17313A3251998-04-0101 April 1998 LER 98-004-00:on 980304,safety Valves as-found Pressures Out of Tolerance.Cause of Event Is Under Investigation.Three Mssv'S & Psv Will Be Replaced W/Refurbished & Recertified Valves During Refueling Outage U1R7 1999-09-30
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ACCEI ERAT DOCUMENT DISTRIBUTION SYSTEM REGULATOR INFORMATION DISTRIBUTION TEM (RIDS)
ACCESSION NBR:9303020339 DOC.DATE: 93/02/24 NOTARIZED: NO DOCKET I FACIL:STIII;50-528 Palo Verde Nuclear Station, Unit 1, Arizona Publi 05000528 AUTH. NAME AUTHOR AFFILIATION BRADISH,T.R. Arizona Public Service Co. (formerly Arizona Nuclear Power LEVINE,J.M. Arizona Public Service Co. (formerly Arizona Nuclear Power RECIP.NAME RECIPIENT AFFILIATION
SUBJECT:
LER 93-001-00:on 930130,main turbine trip occurred 6 manual reactor trip initiated due to failure of moisture separator reheater D drain tank high level controller. Failed high level controller replaced.W/930224 ltr.
DZSTRZBUTZON CODE: ZE22T COPZES RECEZVED:LTR ! ENCL t SZZE: 8 TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.
NOTES:STANDARDIZED PLANT 05000528 RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD5 LA 1 1 PDS PD 1 1 TRAMMELLI C 1 1 INTERNAL: ACNW 2 2 ACRS AEOD/DOA 1 1 AEOD/DSP/TPAB AEOD/ROAB/DSP 2 2 NRR/DE/EELB NRR/DE/EMEB 1 1 NRR/DORS/OEAB NRR/DRCH/HHFBHE 1 1 NRR/DRCH/HICB NRR/DRCH/HOLB 1 1 NRR/DRIL/RPEB NRR/DRSS/PRPB 2 2 NRR -DSSA SPLB NRR/DSSA/SRXB 1 1 FIL'E'~02 RES/DSIR/EIB 1 1 RGN5 FIL EXTERNAL: EGGG BRYCE,J.H 2 2 L ST LOBBY WARD NRC PDR 1 1 NSIC MURPHY,G.A NSIC POORE,W. 1 1 NUDOCS FULL TXT Hi$ DOCUM~N~
gPQN $ CANN~D NOTE TO ALL"RIDS" RECIPIENTS:
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Arizona Public Service Company PALO VERDE NUCLEAR GENERATING STATION P.O. 8OX 52034 ~ PMOENIX. ARIZONA85072-2034 JAMES M. LEVINE 192-00830-JML/TRB/RJR VICE PRESIDENT February 24, 1993 NUCLEAR PAODUCTIDM
'TI303020339 930224 PDR ADOCK 05000528 S PDR U. S. Nuclear Regulatory Commission Attention: Document Control Desk Mail Station Pl-37 Washington, D.C. 20555
Dear Sirs:
Sub) ect: Palo Verde Nuclear Generating Station (PVNGS)
Unit 1 Docket No. STN 50-528 (License No. NPF-41)
Licensee Event Report 93-001-00 File 93-020-404 Attached please find Licensee Event Report (LER) 93-001-00 prepared and submitted pursuant to 10CFR50.73. This LER discusses a manual Reactor trip as a result of an automatic Main Turbine trip. In accordance with 10CFR50.73(d),
a copy of this LER is being forwarded to the Regional Administrator, NRC Region V.
If you have any questions, please contact T. R. Bradish, Nuclear Regulatory Affairs Manager, at (602) 393-5421.
Very truly your JML/TRB/RJR/ap Attachment cc: W. F. Conway (all with attachment)
J. B. Martin J. A. Sloan INPO Records Center
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LICENSEE EVENT REPORT (LER)
FACIUTYNAME (I) DOCKET NUMBER (2) PACE 3 0 5 0 0 0 5 2 Q 1 OF TITLE (4)
Turbine Tri /Reactor Tri on Moisture Se arator Reheater Hi h Level EVENT DATE (6) LER NUMBER (6) REPORT DATE P) OTHER FACtUTIES INVOLVED(8)
DAY YEAR FACILITYNAMES DOCKET NUMBER(S)
DAY YEAR YEAR;.ay", NUMBER NUMBER MONTH N/A 0 5 0 0 0 0 1 3093 93 0 0 1 0 0 THIS REPORT IS SUB MIITEDPURSUANT TO THE REQUIREMENTS OF 10 CFR N/A ft (Check one ot tnote of the foliowkig) (11) 0 5 0 0 0 OPER ATINO MDDE (0) 1 20A02(b) 20AOS(c) 50.73(aX2) (iv) 73.71(b)
POWER 20AOS(aXI Xi) 5086(cXI) 50.73(aX2) (v) 73.71(c)
LEVEL 20,405(aXI~a 50.36(cX2) 50.73(aX2Xvii) OTHER (Spetx7ylnAbsttact below and in Text NRC Fcmt 20AOS(aXI Xii) 50.73(a)(2XI) 50 73(aX2)(vITXA) 36&4) 20AOS(aX I )ov) 50 73(aX2)01) 50.73(aX2)(~SXB) 20AOS(aXI Xv) 50.73(aX2XIII) 50.73(a)(2Xx)
UCENSEE CONTACT FOR THIS LER (12)
NAME TELEPHONE NUMBER Thomas R. Bradish, Nuclear Re ulator Affairs Mana er 60 2 39 3-5 421 COMPLETE ONE UNE FOR EACH COMPONENT FAILURE DESCRIBED IN TIES REPORT (13):
MANUFAC- EPORTABLE MANUFAC CAUSE SYSTEM COMPONENT CAUSE SYSTEM COMPONENT TURER TO NPRDS y@<'.",:,.",@::.,".v':Rx';<',"::
TURER TO NPRDS X:S N L C M040 N SUPPLEMENTAL REPORT EXPECTED (14) MONTH DAY EXPECTED SUBMISSION DATE (15)
YES ftlyss, complete EXPECTED SUBMISSION DATE) X NO ABSTRACT (tlnit to 1400 spars I a, approximately 5Iteen sth6Is space typs<vtfttsn Is>>s) (I 6)
At approximately 0603 MST on January 30, 1993, Palo Verde Unit 1 was in Mode 1 (POWER OPERATION) operating at approximately 96 percent power when a Unit 1 Main Turbine trip occurred. Control Room operators initiated a manual reactor trip after receiving high pressurizer pressure pretrip alarms in anticipation of the Reactor Protection System high pressurizer pressure trip.
At approximately 0615 MST on January 30, 1993, Control Room operators stabilized the plant in Mode 3 (HOT STANDBY). The Shift Supervisor classified the event: as an uncomplicated reactor trip in accordance with Emergency Plan Implementing Procedures. No other safety system responses occurred and none were required.
APS Maintenance personnel have determined that the cause of the Main Turbine trip was due to the failure of Moisture Separator Reheater D Drain Tank high level controller. This resulted in a high level condition in Moisture Separat:or Reheater D which actuated the Main Turbine's electrical trip system.
No previous similar events have been reported pursuant to 10CFR50.73.
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LICENSEE EVENT REPORT (LER) TEXT CONTINUATION FACILITYNAME DOCKETNUMBER LER NUMBER PACE SEQUENTIAL REVISION NUMBER NUMBER Palo Verde Unit 1 0 5 0 0 0 9 3 001 0 0 0 OF I. DESCRIPTION OF WHAT OCCURRED:
A. Initial Conditions:
At 0603 MST on January 30, 1993, Palo Verde Nuclear Generating Station (PVNGS) Unit 1 was in Mode 1 (POWER OPERATION) at approximately 96 percent power.
B. Reportable Event Description (Including Dates and Approximate Times of Major Occurrences):
Event Classification: An event that resulted in a manual actuation of the Reactor Protection System (RPS)(JC).
At approximately 0603 MST on January 30, 1993, a PVNGS Unit 1 Main Turbine (TA) trip occurred. Control Room operators (utili.ty, licensed) initiated a manual reactor (RCT)(AC) trip after receiving the high pressurizer pressure pretrips on RPS channels A, B, and C in anticipation of a RPS high pressurizer (AB) pressure reactor trip. The manual trip functioned as designed by generating a trip signal that opened the Reactor Trip Switchgear Breakers (RTSGB)(AA) causing the Control Element Assemblies (CEA)(AA) to drop.
At approximately 0615 MST, on January 30, 1993, Control Room operators stabilized the plant in Mode 3 (HOT STANDBY). The Shift Supervisor (utility, licensed) classified the event as an uncomplicated reactor trip in accordance wi.th Emergency Plan Implementing Procedures. No other safety system responses were required and none occurred.
Prior to the event, the 6A High Pressure Feedwater Heater (HPFWH)(HX)(SJ) level bridle (JB) was being modified in accordance with an approved Design Change Notice (DCN). This modification was made to permit the control of the water level on the shell side of the heat exchanger at a higher level. To support the modification, Operations personnel (utility, nonlicensed) isolated the extraction steam and feedwater to the A HPFWH train. Part of the isolation procedure required the Moisture Separator Reheater (MSR)(SA) Drain Tank levels to be controlled by their respective high level controllers.
The MSR Drain Tanks are connected to the MSRs and have two level controllers (normal and high). The normal level controller routes the condensate from the MSR Drain Tank, through the Heater Drain Tank and pump, and eventually to the suction of the Main Feedwater (SJ) pump. This flow path supplies a portion of the feedwater flow required at 100 percent power. The MSR Drain Tank high level
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LICENSEE EVENT REPORT (LER) TEXT CONTINUATION DOCKET NUMBER LER NUMBER PAGE FACILITYNAME SEOUENTIAL REVISION YEAR NUMBER NUMBER Palo Verde Unit 1
- o. s o o o 5 2 8.9'3 001 000 oF controller routes the condensate from the MSR Drain Tank directly to the Main Condenser (COND)(SG) on a high level. The MSR Drain Tank high level controller prevents the MSR reheating steam tube bundles from becoming covered with condensate. Covering these bundles reduces the MSR's efficiency and could cause an unacceptable amount of moisture to "carry-over" in the reheated steaIB to the Main Turbine. This "carry-over" could damage the turbine blades'ach MSR drain system has level sensors that actuate the Main Turbine's electrical trip system to prevent any "carry-over." This signal is set at 3 inches below the bottom of the MSR.
To isolate the MSR Drain Tank from the HPFWH'rain, the high level controller setpoint is. lowered below the normal level controller setpoint such that the control valve to the HPFWH train is closed and the dump valve to the Main Condenser is open. After completion of the modification to the 6A HPFWH, an Auxiliary Operator (utility, nonlicensed) was transferring the level control for the D MSR Drain Tank back to normal. While raising the setpoint on the high level controller, a high level condition in MSR D occurred. The normal level controller responded to the increasing level, but the normal level control valve did not open. Also, the high level controller did not respond fast enough to the resulting high level and open the dump valve to the Main Condenser. This caused the level in the D MSR Drain Tank to increase above the Main Turbine trip setpoint for high MSR level, actuating a Main Turbine trip. This caused an increase in the primary plant pressure and the reactor was manually tripped by the Control Room operators.
At approximately 0615 MST, on January 30, 1993, Control Room operators stabilized the plant in Mode 3 (HOT STANDBY). The Shift Supervisor (utility, licensed) classified the event as an uncomplicated reactor trip in accordance with Emergency Plan Implementing Procedures. No other safety system responses were required and none occurred.
C. Status of structures, systems, or components that were inoperable at the start of the event that contributed to the event:
Other than the isolated D MSR Drain Tank normal level control valve identified in Section I.I., no other structures, systems, or components were inoperable at the start of the event that contributed to the event.
D. Cause of each component or system failure, if known:
During troubleshooting, the D MSR Drain Tank high level dump valve controller was determined to be defective. The controller did not operate smoothly and did not control the dump valve properly above
LICENSEE EVENT REPORT (LER) TEXT CONTINUATION LER NUMBER PAOE SEQUENTIAL REVISION NUMBER NUMBER Palo Verde Unit 1 52 89 3 0 0'1 0 0 04oF TEXT 40 percent open. The apparent cause of the failure was determined to be binding of the position carriage or the alignment of internal controller components. APS Engineering personnel are conducting an equipment root cause of failure analysis for the D MSR Drain Tank high level controller as identified in Sections I.I and III.B.
E. Failure known:
mode, mechanism, and effect of each failed component, if As described in Section I.B, failure of the D MSR Drain Tank high level controller resulted in a high level in the D MSR. This resulted in actuation of the Main Turbine's electrical trip system
.on high MSR level resulting in a trip of the Unit 1 Main Turbine.
F. For failures of components with multiple functions, list of systems or secondary functions that were also affected:
Not applicable - no failures of components with multiple functions were involved.
G. For a failure that rendered a train of a safety system inoperable, estimated time elapsed from the discovery of the failure until the train was returned to seMice:
Not applicable - no failures that rendered a train of a safety system inoperable were involved.
H. Method of discovery of each component or system failure or procedural error:
The failure of the D MSR Drain Tank high level control valve high level controller was discovered during troubleshooting. Procedural errors were not identified.
I. Cause of Event:
APS Maintenance personnel (utility, nonlicensed) have determined that the cause of the Main Turbine trip was the failure of the D MSR Drain Tank high level controller. This resulted in a high level condition in D MSR and actuation of the Main Turbine's electrical trip system resulting in a Main Turbine trip.
An investigation of this event was conducted in accordance with the APS Incident Investigation Program. An action plan was developed to determine why the D MSR Drain Tank high level control valve did not prevent a high level in the D MSR. A functional test of the valve, performed by PVNGS Maintenance personnel, identified that the controller was defective. The initial testing determined that the
0 II LICENSEE EVENT REPORT (LER) TEXT CONTINUATION FACILITYNAME DOCKET NUMBER LER NUMBER PACE BED UENTIAL 5js REVIBION NUMBER rc'l NUMBER Palo Verde Unit 05000 9 3 0 0 1: 0 0 0 5 OF controller did not control the dump valve smoothly above 40 percent open and evidence that pliers or vice grips may have been used to turn the setpoint adjustment on the controller because of a loose adjustment knob was found. The faulty controller was replaced (SALP Cause Code E: Component Failure).
APS Engineering personnel are conducting an equipment root cause of failure analysis for the D MSR Drain Tank high level controller.
analysis results differ significantly from the apparent cause, a If supplement to this report will be submitted.
The Investigation Team also evaluated the failure of the D MSR Drain Tank normal level control valve to respond and control level.
Following the event, a walkdown of the system identified a closed unnumbered instrument air valve between the D MSR Drain Tank normal level controller and the associated control valve. This closed air valve prevented the normal level control valve from functioning correctly.
The procedures used to remove and restore the normal level controller and valve were reviewed. No reference to the unnumbered instrument air valve was found. No clearances were found that operated or used this unnumbered instrument air valve as a boundary for work or equipment isolation. Also, no work documents were found that would have operated this unnumbered instrument air valve. The Investigation Team is continuing to review the procedures governing these level controllers to determine procedural adequacy and expectations of operator performance. These issues will be addressed within the Incident Investigation program.
If a procedural or personnel error is identified that would significantly change the readers perception of the cause of the event, a supplement to this LER will be submitted.
J. Safety System Response:
The reactor trip in this event was a manual action in anticipation of a RPS high pressurizer pressure trip following the Main Turbine trip. No other safety system responses occurred and none were necessary.
K. Failed Component Information:
MAGNETROL Modulevel Pneumatic Proportional Level Controller Model 6450-P-6560BSV
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LICENSEE. EVENT REPORT (LER) TEXT CONTINUATION DOCKET NUMBER LER NUMBER PAGE FACILITYNAME SEQUENTIAL REVISION YEAR wg?
NUMBER NUMBER Paio Verde Unit 1 060005 P89 0 0 1 0 0 OF II. ASSESSMENT OF THE SAFETY CONSEQUENCES AND IMPLICATIONS OF THIS EVENT'uclear Fuel Management (NFM) performed an assessment of the event and determined that the equipment and systems assumed in the Updated Final Safety Analysis Report (UFSAR) Chapter 15 were functional and performed as required. Abnormal transients were not identified following the reactor trip. The scenarios defined in UFSAR Chapter 6 concerning the Loss of Coolant Accident (LOCA) were not challenged during this event.
A turbine trip, characterized as a decrease in heat removal, is normally evaluated for peak pressures. The Reactor Coolant System (RCS) peak pressure of 2369 pounds per square inch absolute (psia) in this event is less than the 2742 psia peak RCS pressure for a Loss of Condenser Vacuum (LOCV) event. This is the UFSAR Chapter 15 limiting event in this category. The assessment concluded that this event did not result in a transient more severe than those already analyzed. The event did not cause any violation of Specified Acceptable Fuel Design Limits (SAFDL).
Safety system actuations did not occur and were not required.
The event did not result in any challenges to the fission product barriers or result in any releases of radioactive materials. Therefore, there were no adverse safety consequences or implications as a result of this event. This trip did not adversely affect the safe operation of the plant or the health and safety of the public.
III. CORRECTIVE ACTION A. Immediate:
The failed high level controller was replaced and the new controller was tested and placed in service. The new controller functioned as designed.
Unit 1 Maintenance and Operations personnel functionally tested all of the normal and high level controllers for the High Pressure Feedwater Heaters (SJ), Low Pressure Feedwater Heaters (SJ), MSR Drain Tanks (SN), and First and Second Stage MSR Drain Tanks (SN).
This consisted of manually raising and lowering the carriages on the controllers, watching the control valves stroke, and visually inspecting each pneumatic controller in the system. Only minor problems such as broken and sticking gauges, air regulator settings, air leaks, and worn gaskets were noted. These minor problems were corrected upon discovery.
A complete valve line-up for the Unit 1 Train A High Pressure Feedwater Heater and Extraction Steam was conducted and no other valves were found mispositioned.
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~ ~ C LICENSEE EVENT REPORT (L'ER) TEXT CONTINUATION OOCKETNUMBER LER NUMBER PAOE FACILITYNAME SEQUENTIAL REVISION NUMBER NUMBER Palo Verde Unit 1 0'5 0 0 0 OF TEXT A Night Order was issued to all three units discussing the event and reminding Operations personnel of the need to maintain positive control of plant equipment.
B. Action to Prevent Recurrence:
As discussed in Section I.I, APS Engineering personnel are conducting an equipment root cause of failure analysis to determine the failure mechanism of the high level controller. If the analysis results differ significantly from the apparent cause, a supplement to this report will be submitted to describe .the final root cause of failure. This analysis is expected to be completed by May 28, 1993.
Training personnel will evaluate this event in accordance with approved procedures for inclusion into Industry Events Training for Operations, Maintenance, and Work Control personnel. This evaluation is expected to be completed by July 30, 1993.
IV. PREVIOUS SIMILAR EVENTS:
There are no previous similar events reported pursuant to 10CFR50.73 where a Main Turbine trip, caused by MSR high level, resulted in a manual reactor trip.
ADDITIONAL INFORMATION:
The Plant Review Board, the Management Response Team, and the Plant Manager reviewed the Incident Investigation report and authorized a Unit restart according to approved procedures. Unit 1 entered Mode 2 (STARTUP) at approximately 1220 MST on January 31, 1993 and Mode 1 (POWER OPERATION) at approximately 1602 MST on January 31, 1993. Unit 1 was synchronized to the grid at approximately 0157 MST on February 1, 1993.
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