LER 98-003-00:on 980107,missed Procedure Step Resulted in Esfa & RPS Actuation Occurring.Caused by Personnel Error. Work on Ssps Stopped & High Priority Job Order Initiated to Restore Ssps to NormalML17334B687 |
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Cook |
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Issue date: |
02/06/1998 |
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From: |
Boesch J AMERICAN ELECTRIC POWER CO., INC. |
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Shared Package |
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ML17334B686 |
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References |
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LER-98-003, LER-98-3, NUDOCS 9802130102 |
Download: ML17334B687 (4) |
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Similar Documents at Cook |
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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML17335A5641999-10-18018 October 1999 LER 99-024-00:on 990708,literal TS Requirements Were Not Met by Accumlator Valve Surveillance.Caused by Misjudgement Made in Conversion from Initial DC Cook TS to W Std Ts.Submitted License Amend Request.With 991018 Ltr ML17335A5531999-10-0707 October 1999 LER 99-023-00:on 990907,inadequate TS Surveillance Testing of ESW Pump ESF Response Time Noted.Caused by Inadequate Understanding of Plant Design Basis.Surveillance Tests Will Be Revised & Implemented ML17326A1291999-09-17017 September 1999 LER 99-022-00:on 990609,electrical Bus Degraded Voltage Setpoints Too Low for Safety Related Loads,Was Discovered. Caused by Lack of Understanding of Design of Plant.No Immediate Corrective Actions Necessary ML17326A1121999-08-27027 August 1999 LER 99-021-00:on 990728,determined That GL 96-01 Test Requirements Were Not Met in Surveillance Tests.Caused by Failure to Understand Full Extent of GL Requirements. Surveillance Procedures Will Be Revised or Developed ML17326A1011999-08-26026 August 1999 LER 99-020-00:on 990727,EDGs Were Declared Inoperable.Caused by Inadequate Protection of Air Intake,Exhaust & Room Ventilation Structures from Tornado Missile Hazards. Implemented Compensatory Measures in Form of ACs ML17326A0911999-08-16016 August 1999 LER 99-019-00:on 990716,noted Victoreen Containment Hrrms Not Environmentally Qualified to Withstand post-LOCA Conditions.Caused by Inadequate Design Control.Reviewing Options to Support Hrrms Operability in Modes 1-4 ML17326A0771999-08-0404 August 1999 LER 98-029-01:on 980422,noted That Fuel Handling Area Ventilation Sys Was Inoperable.Caused by Original Design Deficiency.Radiological Analysis for Spent Fuel Handling Accidents in Auxiliary Bldg Will Be Redone by 990830 ML17326A0741999-07-29029 July 1999 LER 99-018-00:on 990629,determined That Valve Yokes May Yield Under Combined Stress of Seismic Event & Static,Valve Closed,Stem Thrust.Caused by Inadequate Design of Associated Movs.Operability Determinations Were Performed for Valves ML17326A0661999-07-26026 July 1999 LER 99-017-00:on 990625,noted That Improperly Installed Fuel Oil Return Relief Valve Rendered EDG Inoperable.Caused by Personnel Error.Fuel Oil Return Valve Was Replaced with Valve in Correct Orientation.With 990722 Ltr ML17326A0651999-07-22022 July 1999 LER 98-014-03:on 980310,noted That Response to high-high Containment Pressure Procedure Was Not Consistent with Analysis of Record.Caused by Inadequate Interface with W. FRZ-1 Will Be Revised to Be Consistent with New Analysis ML17326A0491999-07-13013 July 1999 LER 99-016-00:on 990615,TS Requirements for Source Range Neutron Flux Monitors Not Met.Caused by Failure to Understand Design Basis of Plant.Procedures Revised.With 990713 Ltr ML17326A0331999-07-0101 July 1999 LER 99-004-01:on 971030,failure to Perform TS Surveillance Analyses of Reactor Coolant Chemistry with Fuel Removed Was Noted.Caused by Ineffective Mgt of Tss.Chemistry Personnel Have Been Instructed on Requirement to Follow TS as Written ML17326A0151999-06-18018 June 1999 LER 99-014-00:on 990521,determined That Boron Injection Tank Manway Bolts Were Not Included in ISI Program,Creating Missed Exam for Previous ISI Interval.Caused by Programmatic Weakness.Isi Program & Associated ISI Database Modified ML17325B6311999-06-0101 June 1999 LER 99-S03-00:on 990430,vital Area Barrier Degradation Was Noted.Caused by Inadequate Insp & Maint of Vital Area Barrier.Repairs & Mods Were Made to Barriers to Eliminate Degraded & Nonconforming Conditions ML17325B6421999-06-0101 June 1999 LER 99-013-00:on 990327,safety Injection & Centrifugal Charging Throttle Valve Cavitation During LOCA Could Have Led to ECCS Pump Failure.Caused by Inadequate Original Design Application of Si.Throttle Valves Will Be Developed ML17325B6351999-05-28028 May 1999 LER 99-S02-00:on 990428,vulnerability in Safeguard Sys That Could Allow Unauthorized Access to Protected Area Was Noted. Caused by Inadequate Original Plant Design.Mods Were Made to Wall Opening to Eliminate Nonconforming Conditions ML17265A8231999-05-24024 May 1999 LER 98-037-01:on 990422,determined That Ice Condenser Bypass Leakage Exceeds Design Basis Limit.Caused by Pressure Seal Required by Revised W Design Not Incorporated Into Aep Design.Numerous Matl Condition Walkdowns & Assessments Made ML17325B6001999-05-20020 May 1999 LER 99-012-00:on 990420,concluded That Auxiliary Bldg ESF Ventilation Sys Not Capable of Maintaining ESF Room Temps post-accident.Caused by Inadequate Control of Sys Design Inputs.Comprehensive Action Plan Being Developed ML17325B5861999-05-10010 May 1999 LER 99-002-00:on 990415,discovered That TS 4.0.5 Requirements Were Not Met Due to Improperly Performed Test. Caused by Incorrect Interpretation of ASME Code.App J Testing Will Be Completed & Procedures Will Be Revised ML17325B5811999-05-0404 May 1999 LER 99-011-00:on 990407,air Sys for EDG Will Not Support Long Operability.Caused by Original Design Error.Temporary Mod to Supply Makeup Air Capability in Modes 5 & 6 Was Prepared ML17325B5771999-05-0303 May 1999 LER 99-010-00:on 990401,RCS Leak Detection Sys Sensitivity Not in Accordance with Design Requirements Occurred.Caused by Inadequate Original Design of Containment Sump Level. Evaluation Will Be Performed to Clearly Define Design ML17325B5581999-04-16016 April 1999 LER 99-006-00:on 990115,personnel Identified Discrepancy Between TS 3.9.7 Impact Energy Limit & Procedure 12 Ohp 4030.STP.046.Caused by Lack of Design Basis Control.Placed Procedure 12 Ohp 4030.STP.046 on Administrative Hold ML17325B5471999-04-12012 April 1999 LER 99-009-00:on 990304,as-found RHR Safety Relief Valve Lift Setpoint Greater than TS Limit Occurred.Cause Investigation for Condition Has Not Been Completed.Update to LER Will Be Submitted,Upon Completion of Investigation ML17325B5321999-04-0707 April 1999 LER 99-S01-00:on 990308,discovered That Lock for Vital Gate Leading to Plant 4KV Switchgear Area Was Nonconforming & Vulnerable to Unauthorized Access.Caused by Inadequate Gate Design & Inadequate Procedures.Mods Are Being Made to Gate ML17325B5161999-04-0101 April 1999 LER 99-007-00:on 981020,calculations Showed That Divider Barrier Between Upper & Lower Containment Vols Were Overstressed.Engineers Are Currently Working on Analyses of Loads & Stress on Enclosures ML17325B5221999-03-29029 March 1999 LER 99-001-00:on 960610,degraded Component Cooling Water Flow to Containment Main Steam Line Penetrations,Identified on 990226.Caused by Inadequate Understanding of Design Basis.Additional Investigations Ongoing ML17325B4801999-03-18018 March 1999 LER 99-004-00:on 971030,failure to Perform TS Surveillance Analyses of Rc Chemistry with Fuel Removed Was Noted.Cause of Event Is Under Investigation.Corrected Written Job Order Activities Used to Control SD Chemistry Sampling ML17325B4741999-03-18018 March 1999 LER 99-005-00:on 940512,determined That Rt Breaker Manual Actuations During Rod Drop Testing Were Not Previously Reported.Caused by Lack of Training.Addl Corrective Actions,Including Preventative Actions May Be Developed ML17325B4571999-02-24024 February 1999 LER 99-003-00:on 990107,CR Pressurization Sys Surveillance Test Did Not Test Sys in Normal Operating Condition.Caused by Failure to Recognize Door 12DR-AUX415 as Part of CR Pressure Boundary.Performed Walkdown of Other Doors ML17335A5171999-02-11011 February 1999 LER 99-002-00:on 990112,determined That RCS Pressurizer PORVs Had Not Been Tested,Per Ts.Caused by Inadequate Scheduling Controls Allowing Personnel Error.Surveillance Procedure Was Completed & Updated LER Will Be Submitted ML17335A5141999-02-10010 February 1999 LER 99-001-00:on 990106,noted That GE Hfa Relays Installed in EDGs May Not Meet Seismic Qualification.Caused by Operating Experience Info Incorrectly Dispositioned in 1985. Updated LER Will Be Submitted by 990405 ML17335A5011999-02-0101 February 1999 LER 98-060-00:on 981231,identified That Rt Sys Response Time Testing Did Not Comply with TS Definition.Caused by Inadequate Procedures.Corrective Actions Will Be Developed & Update to LER Will Be Submitted by 990415.With 990201 Ltr ML17335A4951999-01-29029 January 1999 LER 98-059-00:on 981230,interim LER -single Failure in Containment Spray Sys Could Result in Containment Spray Ph Outside Design Occurred.Investigation Into Condition Continuing.Update Will Be Submitted by 990514 Ltr ML17335A4961999-01-27027 January 1999 LER 98-057-00:on 981228,discovered That AFW Valves Were Not Tested IAW Inservice Testing Program.Caused by Failure to Recognize Design Bases Features Re Afws by Personnel. Updated LER Will Be Submittted by 990415.With 990127 Ltr ML17335A4921999-01-19019 January 1999 LER 98-052-01:on 981128,no Analysis for NSR Sc Manual Loader for Tdafwp Could Be Found in Original Design.Cause Due to All Failure Modes Not Considered When Compressed Air Sys Originally Designed.Performed Review of Components ML17335A4721999-01-0606 January 1999 LER 98-055-00:on 981207,potential for Condition Outside of Design Bases for Rod Control Sys Was Noted.Caused by Calibration Error Coupled with Single Rod Failure.Condition Rept Investigation Is Ongoing ML17335A4691999-01-0606 January 1999 LER 98-056-00:on 981211,hot Leg Nozzle Gaps Resulted in Plant Being in Unanalyzed Condition.Analyses Are Being Performed by W to Resolve Problem.Updated LER Will Be Submitted by 990211.With 990106 Ltr ML17335A4661999-01-0505 January 1999 LER 98-049-00:on 981020,emergency Boron Injection Flow Path Was Inoperable.Caused by Original Design Deficiency. Engineering Evaluation of Event Is Continuing ML17335A4631999-01-0404 January 1999 LER 98-054-00:on 981202,discovered That at Least One MSSV Had Not Been Reset as Required by Ts.Engineering Is Continuing Review of Extent of Condition for Event.Updated LER Will Be Submitted by 990129.With 990104 Ltr ML17335A4481998-12-30030 December 1998 LER 98-053-00:on 981130,discovered Use of Inoperable Substitute Subcooling Margin Monitor.Caused by Condition Existing Since Installation of Plant Process Computer in 1992.Updated LER Will Be Submitted.With 981230 Ltr ML17335A4581998-12-28028 December 1998 LER 98-052-00:on 981128,turbine Driven AFW Pump Speed Controller Failure Mode Occurred.Caused Because Not All Failure Modes Were Considered When Compressed Air Sys Was Originally Designed.Verified Current Design Change Process ML17335A4281998-12-22022 December 1998 LER 98-051-00:on 981122,reactor Trip Signal from Manual Safety Injection Not Verified as Required by TS Surveillance,Was Discovered.Maintenance Currently Evaluating Significance & Cause of Event ML17335A4111998-12-17017 December 1998 LER 98-047-00:on 981117,potential for Increase Leakage from Reactor Coolant Pump Seals Was Identified.Util Is Working with W to Resolve Issue.Current Expectations Are to Submit Update to LER by 990215.With 981217 Ltr ML17335A4141998-12-16016 December 1998 LER 98-058-00:on 981216,postulated High Line Break Could Result in Condition Outside Design Bases for AF Occurred. Caused by Deficiencies Associated with Administration of HELB Program.Analysis of AF Will Be Completed by 990122 ML17335A4181998-12-16016 December 1998 LER 98-050-00:on 980814,ancillary Equipment Installed in Ice Condenser Was Not Designed to Withstand Design Basis Accident/Earthquake Loads.Caused by Lack of Established Design Criteria.Developed Design Criteria ML17335A3871998-12-11011 December 1998 LER 98-031-01:on 980610,potential Common Mode Failure of RHR Pumps Were Noted.Caused by Inaccurate Values.Accurate Miniflow Numbers Have Been Determined by Flow Testing ML17335A3821998-12-0808 December 1998 LER 98-039-01 Re EOP Step Conflicts with Small Break LOCA Analysis.Ler 98-039-00 Has Been Canceled.With 981208 Ltr ML17335A3781998-12-0707 December 1998 LER 98-007-00:on 981106,high Energy Line Break Effects in Auxiliary FW Sys Was Noted.Cause of Event Is Under Investigation & Will Be Completed by 990220.Updated LER Will Be Submitted by 990310.With 981207 Ltr ML17335A3771998-12-0303 December 1998 LER 98-046-00:on 981103,determined That Afs Was Unable to Meet Design Flow Requirements During Special Test.Caused by Failure to Consider All Aspects of Sys Operation in Design of Suction Basket Strainers.Sys Will Be Redesigned ML17335A3741998-12-0202 December 1998 LER 97-011-02:on 970822,operation Was Noted Outside Design Bases for ECCS & CSP for Switchover to Recirculation Sump Suction.Caused by Ineffective Change Mgt.Revised Procedure for Switchover 01(02) Ohp 4023.ES-1.3 1999-09-17
[Table view] Category:RO)
MONTHYEARML17335A5641999-10-18018 October 1999 LER 99-024-00:on 990708,literal TS Requirements Were Not Met by Accumlator Valve Surveillance.Caused by Misjudgement Made in Conversion from Initial DC Cook TS to W Std Ts.Submitted License Amend Request.With 991018 Ltr ML17335A5531999-10-0707 October 1999 LER 99-023-00:on 990907,inadequate TS Surveillance Testing of ESW Pump ESF Response Time Noted.Caused by Inadequate Understanding of Plant Design Basis.Surveillance Tests Will Be Revised & Implemented ML17326A1291999-09-17017 September 1999 LER 99-022-00:on 990609,electrical Bus Degraded Voltage Setpoints Too Low for Safety Related Loads,Was Discovered. Caused by Lack of Understanding of Design of Plant.No Immediate Corrective Actions Necessary ML17326A1121999-08-27027 August 1999 LER 99-021-00:on 990728,determined That GL 96-01 Test Requirements Were Not Met in Surveillance Tests.Caused by Failure to Understand Full Extent of GL Requirements. Surveillance Procedures Will Be Revised or Developed ML17326A1011999-08-26026 August 1999 LER 99-020-00:on 990727,EDGs Were Declared Inoperable.Caused by Inadequate Protection of Air Intake,Exhaust & Room Ventilation Structures from Tornado Missile Hazards. Implemented Compensatory Measures in Form of ACs ML17326A0911999-08-16016 August 1999 LER 99-019-00:on 990716,noted Victoreen Containment Hrrms Not Environmentally Qualified to Withstand post-LOCA Conditions.Caused by Inadequate Design Control.Reviewing Options to Support Hrrms Operability in Modes 1-4 ML17326A0771999-08-0404 August 1999 LER 98-029-01:on 980422,noted That Fuel Handling Area Ventilation Sys Was Inoperable.Caused by Original Design Deficiency.Radiological Analysis for Spent Fuel Handling Accidents in Auxiliary Bldg Will Be Redone by 990830 ML17326A0741999-07-29029 July 1999 LER 99-018-00:on 990629,determined That Valve Yokes May Yield Under Combined Stress of Seismic Event & Static,Valve Closed,Stem Thrust.Caused by Inadequate Design of Associated Movs.Operability Determinations Were Performed for Valves ML17326A0661999-07-26026 July 1999 LER 99-017-00:on 990625,noted That Improperly Installed Fuel Oil Return Relief Valve Rendered EDG Inoperable.Caused by Personnel Error.Fuel Oil Return Valve Was Replaced with Valve in Correct Orientation.With 990722 Ltr ML17326A0651999-07-22022 July 1999 LER 98-014-03:on 980310,noted That Response to high-high Containment Pressure Procedure Was Not Consistent with Analysis of Record.Caused by Inadequate Interface with W. FRZ-1 Will Be Revised to Be Consistent with New Analysis ML17326A0491999-07-13013 July 1999 LER 99-016-00:on 990615,TS Requirements for Source Range Neutron Flux Monitors Not Met.Caused by Failure to Understand Design Basis of Plant.Procedures Revised.With 990713 Ltr ML17326A0331999-07-0101 July 1999 LER 99-004-01:on 971030,failure to Perform TS Surveillance Analyses of Reactor Coolant Chemistry with Fuel Removed Was Noted.Caused by Ineffective Mgt of Tss.Chemistry Personnel Have Been Instructed on Requirement to Follow TS as Written ML17326A0151999-06-18018 June 1999 LER 99-014-00:on 990521,determined That Boron Injection Tank Manway Bolts Were Not Included in ISI Program,Creating Missed Exam for Previous ISI Interval.Caused by Programmatic Weakness.Isi Program & Associated ISI Database Modified ML17325B6311999-06-0101 June 1999 LER 99-S03-00:on 990430,vital Area Barrier Degradation Was Noted.Caused by Inadequate Insp & Maint of Vital Area Barrier.Repairs & Mods Were Made to Barriers to Eliminate Degraded & Nonconforming Conditions ML17325B6421999-06-0101 June 1999 LER 99-013-00:on 990327,safety Injection & Centrifugal Charging Throttle Valve Cavitation During LOCA Could Have Led to ECCS Pump Failure.Caused by Inadequate Original Design Application of Si.Throttle Valves Will Be Developed ML17325B6351999-05-28028 May 1999 LER 99-S02-00:on 990428,vulnerability in Safeguard Sys That Could Allow Unauthorized Access to Protected Area Was Noted. Caused by Inadequate Original Plant Design.Mods Were Made to Wall Opening to Eliminate Nonconforming Conditions ML17265A8231999-05-24024 May 1999 LER 98-037-01:on 990422,determined That Ice Condenser Bypass Leakage Exceeds Design Basis Limit.Caused by Pressure Seal Required by Revised W Design Not Incorporated Into Aep Design.Numerous Matl Condition Walkdowns & Assessments Made ML17325B6001999-05-20020 May 1999 LER 99-012-00:on 990420,concluded That Auxiliary Bldg ESF Ventilation Sys Not Capable of Maintaining ESF Room Temps post-accident.Caused by Inadequate Control of Sys Design Inputs.Comprehensive Action Plan Being Developed ML17325B5861999-05-10010 May 1999 LER 99-002-00:on 990415,discovered That TS 4.0.5 Requirements Were Not Met Due to Improperly Performed Test. Caused by Incorrect Interpretation of ASME Code.App J Testing Will Be Completed & Procedures Will Be Revised ML17325B5811999-05-0404 May 1999 LER 99-011-00:on 990407,air Sys for EDG Will Not Support Long Operability.Caused by Original Design Error.Temporary Mod to Supply Makeup Air Capability in Modes 5 & 6 Was Prepared ML17325B5771999-05-0303 May 1999 LER 99-010-00:on 990401,RCS Leak Detection Sys Sensitivity Not in Accordance with Design Requirements Occurred.Caused by Inadequate Original Design of Containment Sump Level. Evaluation Will Be Performed to Clearly Define Design ML17325B5581999-04-16016 April 1999 LER 99-006-00:on 990115,personnel Identified Discrepancy Between TS 3.9.7 Impact Energy Limit & Procedure 12 Ohp 4030.STP.046.Caused by Lack of Design Basis Control.Placed Procedure 12 Ohp 4030.STP.046 on Administrative Hold ML17325B5471999-04-12012 April 1999 LER 99-009-00:on 990304,as-found RHR Safety Relief Valve Lift Setpoint Greater than TS Limit Occurred.Cause Investigation for Condition Has Not Been Completed.Update to LER Will Be Submitted,Upon Completion of Investigation ML17325B5321999-04-0707 April 1999 LER 99-S01-00:on 990308,discovered That Lock for Vital Gate Leading to Plant 4KV Switchgear Area Was Nonconforming & Vulnerable to Unauthorized Access.Caused by Inadequate Gate Design & Inadequate Procedures.Mods Are Being Made to Gate ML17325B5161999-04-0101 April 1999 LER 99-007-00:on 981020,calculations Showed That Divider Barrier Between Upper & Lower Containment Vols Were Overstressed.Engineers Are Currently Working on Analyses of Loads & Stress on Enclosures ML17325B5221999-03-29029 March 1999 LER 99-001-00:on 960610,degraded Component Cooling Water Flow to Containment Main Steam Line Penetrations,Identified on 990226.Caused by Inadequate Understanding of Design Basis.Additional Investigations Ongoing ML17325B4801999-03-18018 March 1999 LER 99-004-00:on 971030,failure to Perform TS Surveillance Analyses of Rc Chemistry with Fuel Removed Was Noted.Cause of Event Is Under Investigation.Corrected Written Job Order Activities Used to Control SD Chemistry Sampling ML17325B4741999-03-18018 March 1999 LER 99-005-00:on 940512,determined That Rt Breaker Manual Actuations During Rod Drop Testing Were Not Previously Reported.Caused by Lack of Training.Addl Corrective Actions,Including Preventative Actions May Be Developed ML17325B4571999-02-24024 February 1999 LER 99-003-00:on 990107,CR Pressurization Sys Surveillance Test Did Not Test Sys in Normal Operating Condition.Caused by Failure to Recognize Door 12DR-AUX415 as Part of CR Pressure Boundary.Performed Walkdown of Other Doors ML17335A5171999-02-11011 February 1999 LER 99-002-00:on 990112,determined That RCS Pressurizer PORVs Had Not Been Tested,Per Ts.Caused by Inadequate Scheduling Controls Allowing Personnel Error.Surveillance Procedure Was Completed & Updated LER Will Be Submitted ML17335A5141999-02-10010 February 1999 LER 99-001-00:on 990106,noted That GE Hfa Relays Installed in EDGs May Not Meet Seismic Qualification.Caused by Operating Experience Info Incorrectly Dispositioned in 1985. Updated LER Will Be Submitted by 990405 ML17335A5011999-02-0101 February 1999 LER 98-060-00:on 981231,identified That Rt Sys Response Time Testing Did Not Comply with TS Definition.Caused by Inadequate Procedures.Corrective Actions Will Be Developed & Update to LER Will Be Submitted by 990415.With 990201 Ltr ML17335A4951999-01-29029 January 1999 LER 98-059-00:on 981230,interim LER -single Failure in Containment Spray Sys Could Result in Containment Spray Ph Outside Design Occurred.Investigation Into Condition Continuing.Update Will Be Submitted by 990514 Ltr ML17335A4961999-01-27027 January 1999 LER 98-057-00:on 981228,discovered That AFW Valves Were Not Tested IAW Inservice Testing Program.Caused by Failure to Recognize Design Bases Features Re Afws by Personnel. Updated LER Will Be Submittted by 990415.With 990127 Ltr ML17335A4921999-01-19019 January 1999 LER 98-052-01:on 981128,no Analysis for NSR Sc Manual Loader for Tdafwp Could Be Found in Original Design.Cause Due to All Failure Modes Not Considered When Compressed Air Sys Originally Designed.Performed Review of Components ML17335A4721999-01-0606 January 1999 LER 98-055-00:on 981207,potential for Condition Outside of Design Bases for Rod Control Sys Was Noted.Caused by Calibration Error Coupled with Single Rod Failure.Condition Rept Investigation Is Ongoing ML17335A4691999-01-0606 January 1999 LER 98-056-00:on 981211,hot Leg Nozzle Gaps Resulted in Plant Being in Unanalyzed Condition.Analyses Are Being Performed by W to Resolve Problem.Updated LER Will Be Submitted by 990211.With 990106 Ltr ML17335A4661999-01-0505 January 1999 LER 98-049-00:on 981020,emergency Boron Injection Flow Path Was Inoperable.Caused by Original Design Deficiency. Engineering Evaluation of Event Is Continuing ML17335A4631999-01-0404 January 1999 LER 98-054-00:on 981202,discovered That at Least One MSSV Had Not Been Reset as Required by Ts.Engineering Is Continuing Review of Extent of Condition for Event.Updated LER Will Be Submitted by 990129.With 990104 Ltr ML17335A4481998-12-30030 December 1998 LER 98-053-00:on 981130,discovered Use of Inoperable Substitute Subcooling Margin Monitor.Caused by Condition Existing Since Installation of Plant Process Computer in 1992.Updated LER Will Be Submitted.With 981230 Ltr ML17335A4581998-12-28028 December 1998 LER 98-052-00:on 981128,turbine Driven AFW Pump Speed Controller Failure Mode Occurred.Caused Because Not All Failure Modes Were Considered When Compressed Air Sys Was Originally Designed.Verified Current Design Change Process ML17335A4281998-12-22022 December 1998 LER 98-051-00:on 981122,reactor Trip Signal from Manual Safety Injection Not Verified as Required by TS Surveillance,Was Discovered.Maintenance Currently Evaluating Significance & Cause of Event ML17335A4111998-12-17017 December 1998 LER 98-047-00:on 981117,potential for Increase Leakage from Reactor Coolant Pump Seals Was Identified.Util Is Working with W to Resolve Issue.Current Expectations Are to Submit Update to LER by 990215.With 981217 Ltr ML17335A4141998-12-16016 December 1998 LER 98-058-00:on 981216,postulated High Line Break Could Result in Condition Outside Design Bases for AF Occurred. Caused by Deficiencies Associated with Administration of HELB Program.Analysis of AF Will Be Completed by 990122 ML17335A4181998-12-16016 December 1998 LER 98-050-00:on 980814,ancillary Equipment Installed in Ice Condenser Was Not Designed to Withstand Design Basis Accident/Earthquake Loads.Caused by Lack of Established Design Criteria.Developed Design Criteria ML17335A3871998-12-11011 December 1998 LER 98-031-01:on 980610,potential Common Mode Failure of RHR Pumps Were Noted.Caused by Inaccurate Values.Accurate Miniflow Numbers Have Been Determined by Flow Testing ML17335A3821998-12-0808 December 1998 LER 98-039-01 Re EOP Step Conflicts with Small Break LOCA Analysis.Ler 98-039-00 Has Been Canceled.With 981208 Ltr ML17335A3781998-12-0707 December 1998 LER 98-007-00:on 981106,high Energy Line Break Effects in Auxiliary FW Sys Was Noted.Cause of Event Is Under Investigation & Will Be Completed by 990220.Updated LER Will Be Submitted by 990310.With 981207 Ltr ML17335A3771998-12-0303 December 1998 LER 98-046-00:on 981103,determined That Afs Was Unable to Meet Design Flow Requirements During Special Test.Caused by Failure to Consider All Aspects of Sys Operation in Design of Suction Basket Strainers.Sys Will Be Redesigned ML17335A3741998-12-0202 December 1998 LER 97-011-02:on 970822,operation Was Noted Outside Design Bases for ECCS & CSP for Switchover to Recirculation Sump Suction.Caused by Ineffective Change Mgt.Revised Procedure for Switchover 01(02) Ohp 4023.ES-1.3 1999-09-17
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML17335A5641999-10-18018 October 1999 LER 99-024-00:on 990708,literal TS Requirements Were Not Met by Accumlator Valve Surveillance.Caused by Misjudgement Made in Conversion from Initial DC Cook TS to W Std Ts.Submitted License Amend Request.With 991018 Ltr ML17335A5531999-10-0707 October 1999 LER 99-023-00:on 990907,inadequate TS Surveillance Testing of ESW Pump ESF Response Time Noted.Caused by Inadequate Understanding of Plant Design Basis.Surveillance Tests Will Be Revised & Implemented ML17335A5631999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for DC Cook Nuclear Plant,Unit 1.With 991012 Ltr ML17335A5621999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for DC Cook Nuclear Plant,Unit 2.With 991012 Ltr ML17335A5481999-09-30030 September 1999 Non-proprietary DC Cook Nuclear Plant Units 1 & 2 Mods to Containment Sys W SE (Secl 99-076,Rev 3). ML17335A5451999-09-28028 September 1999 Rev 1 to Containment Sump Level Design Condition & Failure Effects Analysis for Potential Draindown Scenarios. ML17326A1291999-09-17017 September 1999 LER 99-022-00:on 990609,electrical Bus Degraded Voltage Setpoints Too Low for Safety Related Loads,Was Discovered. Caused by Lack of Understanding of Design of Plant.No Immediate Corrective Actions Necessary ML17326A1481999-09-17017 September 1999 Independent Review of Control Rod Insertion Following Cold Leg Lbloca,Dc Cook,Units 1 & 2. ML17326A1211999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Cook Nuclear Plant, Unit 2.With 990915 Ltr ML17326A1201999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Cook Nuclear Plant, Unit 1.With 990915 Ltr ML17326A1121999-08-27027 August 1999 LER 99-021-00:on 990728,determined That GL 96-01 Test Requirements Were Not Met in Surveillance Tests.Caused by Failure to Understand Full Extent of GL Requirements. Surveillance Procedures Will Be Revised or Developed ML17326A1011999-08-26026 August 1999 LER 99-020-00:on 990727,EDGs Were Declared Inoperable.Caused by Inadequate Protection of Air Intake,Exhaust & Room Ventilation Structures from Tornado Missile Hazards. Implemented Compensatory Measures in Form of ACs ML17326A0911999-08-16016 August 1999 LER 99-019-00:on 990716,noted Victoreen Containment Hrrms Not Environmentally Qualified to Withstand post-LOCA Conditions.Caused by Inadequate Design Control.Reviewing Options to Support Hrrms Operability in Modes 1-4 ML17326A0771999-08-0404 August 1999 LER 98-029-01:on 980422,noted That Fuel Handling Area Ventilation Sys Was Inoperable.Caused by Original Design Deficiency.Radiological Analysis for Spent Fuel Handling Accidents in Auxiliary Bldg Will Be Redone by 990830 ML17335A5461999-08-0202 August 1999 Rev 0 to Evaluation of Cook Recirculation Sump Level for Reduced Pump Flow Rates. ML17326A0871999-07-31031 July 1999 Monthly Operating Rept for July 1999 for DC Cook Nuclear Plant,Unit 1.With 990812 Ltr ML17326A0861999-07-31031 July 1999 Monthly Operating Rept for July 1999 for DC Cook Nuclear Plant,Units 2.With 990812 Ltr ML17326A0741999-07-29029 July 1999 LER 99-018-00:on 990629,determined That Valve Yokes May Yield Under Combined Stress of Seismic Event & Static,Valve Closed,Stem Thrust.Caused by Inadequate Design of Associated Movs.Operability Determinations Were Performed for Valves ML17326A0661999-07-26026 July 1999 LER 99-017-00:on 990625,noted That Improperly Installed Fuel Oil Return Relief Valve Rendered EDG Inoperable.Caused by Personnel Error.Fuel Oil Return Valve Was Replaced with Valve in Correct Orientation.With 990722 Ltr ML17326A0651999-07-22022 July 1999 LER 98-014-03:on 980310,noted That Response to high-high Containment Pressure Procedure Was Not Consistent with Analysis of Record.Caused by Inadequate Interface with W. FRZ-1 Will Be Revised to Be Consistent with New Analysis ML17326A0491999-07-13013 July 1999 LER 99-016-00:on 990615,TS Requirements for Source Range Neutron Flux Monitors Not Met.Caused by Failure to Understand Design Basis of Plant.Procedures Revised.With 990713 Ltr ML17326A0331999-07-0101 July 1999 LER 99-004-01:on 971030,failure to Perform TS Surveillance Analyses of Reactor Coolant Chemistry with Fuel Removed Was Noted.Caused by Ineffective Mgt of Tss.Chemistry Personnel Have Been Instructed on Requirement to Follow TS as Written ML17326A0511999-06-30030 June 1999 Monthly Operating Rept for June 1999 for DC Cook Nuclear Plant,Unit 2.With 990709 Ltr ML17326A0501999-06-30030 June 1999 Monthly Operating Rept for June 1999 for DC Cook Nuclear Plant,Unit 1.With 990709 Ltr ML17326A0151999-06-18018 June 1999 LER 99-014-00:on 990521,determined That Boron Injection Tank Manway Bolts Were Not Included in ISI Program,Creating Missed Exam for Previous ISI Interval.Caused by Programmatic Weakness.Isi Program & Associated ISI Database Modified ML17325B6421999-06-0101 June 1999 LER 99-013-00:on 990327,safety Injection & Centrifugal Charging Throttle Valve Cavitation During LOCA Could Have Led to ECCS Pump Failure.Caused by Inadequate Original Design Application of Si.Throttle Valves Will Be Developed ML17325B6311999-06-0101 June 1999 LER 99-S03-00:on 990430,vital Area Barrier Degradation Was Noted.Caused by Inadequate Insp & Maint of Vital Area Barrier.Repairs & Mods Were Made to Barriers to Eliminate Degraded & Nonconforming Conditions ML17326A0061999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Dcp.With 990609 Ltr ML17326A0071999-05-31031 May 1999 Monthly Operating Rept for May 1999 for DC Cook Nuclear Plant,Unit 2.With 990609 Ltr ML17325B6351999-05-28028 May 1999 LER 99-S02-00:on 990428,vulnerability in Safeguard Sys That Could Allow Unauthorized Access to Protected Area Was Noted. Caused by Inadequate Original Plant Design.Mods Were Made to Wall Opening to Eliminate Nonconforming Conditions ML17265A8231999-05-24024 May 1999 LER 98-037-01:on 990422,determined That Ice Condenser Bypass Leakage Exceeds Design Basis Limit.Caused by Pressure Seal Required by Revised W Design Not Incorporated Into Aep Design.Numerous Matl Condition Walkdowns & Assessments Made ML17325B6001999-05-20020 May 1999 LER 99-012-00:on 990420,concluded That Auxiliary Bldg ESF Ventilation Sys Not Capable of Maintaining ESF Room Temps post-accident.Caused by Inadequate Control of Sys Design Inputs.Comprehensive Action Plan Being Developed ML17325B5861999-05-10010 May 1999 LER 99-002-00:on 990415,discovered That TS 4.0.5 Requirements Were Not Met Due to Improperly Performed Test. Caused by Incorrect Interpretation of ASME Code.App J Testing Will Be Completed & Procedures Will Be Revised ML17325B5811999-05-0404 May 1999 LER 99-011-00:on 990407,air Sys for EDG Will Not Support Long Operability.Caused by Original Design Error.Temporary Mod to Supply Makeup Air Capability in Modes 5 & 6 Was Prepared ML17325B5771999-05-0303 May 1999 LER 99-010-00:on 990401,RCS Leak Detection Sys Sensitivity Not in Accordance with Design Requirements Occurred.Caused by Inadequate Original Design of Containment Sump Level. Evaluation Will Be Performed to Clearly Define Design ML17335A5301999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for DC Cook Nuclear Plant,Unit 1.With 990508 Ltr ML17335A5291999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for DC Cook Nuclear Plant,Unit 2.With 990508 Ltr ML17325B5581999-04-16016 April 1999 LER 99-006-00:on 990115,personnel Identified Discrepancy Between TS 3.9.7 Impact Energy Limit & Procedure 12 Ohp 4030.STP.046.Caused by Lack of Design Basis Control.Placed Procedure 12 Ohp 4030.STP.046 on Administrative Hold ML17325B5471999-04-12012 April 1999 LER 99-009-00:on 990304,as-found RHR Safety Relief Valve Lift Setpoint Greater than TS Limit Occurred.Cause Investigation for Condition Has Not Been Completed.Update to LER Will Be Submitted,Upon Completion of Investigation ML17325B5321999-04-0707 April 1999 LER 99-S01-00:on 990308,discovered That Lock for Vital Gate Leading to Plant 4KV Switchgear Area Was Nonconforming & Vulnerable to Unauthorized Access.Caused by Inadequate Gate Design & Inadequate Procedures.Mods Are Being Made to Gate ML17325B5161999-04-0101 April 1999 LER 99-007-00:on 981020,calculations Showed That Divider Barrier Between Upper & Lower Containment Vols Were Overstressed.Engineers Are Currently Working on Analyses of Loads & Stress on Enclosures ML17325B5491999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for DC Cook Nuclear Plant Unit 2.With 990408 Ltr ML17325B5441999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for DC Cook Nuclear Plant,Unit 1.With 990408 Ltr ML17325B5221999-03-29029 March 1999 LER 99-001-00:on 960610,degraded Component Cooling Water Flow to Containment Main Steam Line Penetrations,Identified on 990226.Caused by Inadequate Understanding of Design Basis.Additional Investigations Ongoing ML17325B4801999-03-18018 March 1999 LER 99-004-00:on 971030,failure to Perform TS Surveillance Analyses of Rc Chemistry with Fuel Removed Was Noted.Cause of Event Is Under Investigation.Corrected Written Job Order Activities Used to Control SD Chemistry Sampling ML17325B4741999-03-18018 March 1999 LER 99-005-00:on 940512,determined That Rt Breaker Manual Actuations During Rod Drop Testing Were Not Previously Reported.Caused by Lack of Training.Addl Corrective Actions,Including Preventative Actions May Be Developed ML17325B5671999-03-0202 March 1999 Summary of Unit 1 Steam Generator Layup Chemistry from 980101 to 990218. ML17325B4631999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for DC Cook Nuclear Power Station,Unit 2.With 990308 Ltr ML17325B4621999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for DC Cook Nuclear Plant,Unit 1.With 990308 Ltr ML17325B4571999-02-24024 February 1999 LER 99-003-00:on 990107,CR Pressurization Sys Surveillance Test Did Not Test Sys in Normal Operating Condition.Caused by Failure to Recognize Door 12DR-AUX415 as Part of CR Pressure Boundary.Performed Walkdown of Other Doors 1999-09-30
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NRC FORH 366 . NUCLEAR REGULATORY COMMISSION OVED BY OMB NO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE To COMPLY MITH THI INFORMATION COLLECTION REOUEST: 50.0 HRS.
LXCENSEE EVENT REPORT (LER) COMMENTS REGARDING BURDEN ESTIMATE TO FORIJAR TH INFORMATIOH AND RECORDS MANAGEMENT BRANCH (HNB 7714), U.ST NUCLEAR REGULATORY COMMISSION, NASHINGTON, DC 20555 0001, AND TO THE PAPERNOR REDUCTION PROJECT (3150.0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.
FACILITY HAHE (1) (2)
Donald C. Cook Nuctear Plant - Unit 1 DOCKET NUMBER Page 1 of 3 50-315 TITLE (4)
Missed Procedure Step Results in Engineered Safety Features and Reactor Protection System Actuation EVENT DATE 5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (8)
SEOUENTtAL REVISION FACILITY NAME DOCKET NUMBER MONTH DAY YEAR YEAR MONTH DAY NUHBER NUMBER None FACILITY NAME DOCKET NUMBER 01 07 98 98 003 00 02 06 98 OPERATING THIS REPORT IS SUBHITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR 5t (Check one or mor e) (11)
(9) 0 20 '201(b)
MODE 20.2203(a)(3)(i) 50.73(a)(2)(iii) 73.71(b)
PONER 20.2203(a (1 20.2203(a)(3)(ii) 50.73(a (2)(iv 73.71o LEYEL (10) 20.2203(a)(2)(i) 20.2203(a)(4) 50.73(a)(2)(v) OTHER 20.2203(a (2)(ii) 50.36(c (1 50.73(a)(2)(vii) (Specify in 20.2203(a)(2)(iii) 50.36(c)(2) 50.73(a)(2)(viii)(A) Abstract below 20 '203(a)(2)(iv) 50.73(a)(2)(i) 50.73(a)(2)(viii)(B) and in Text NRC Form 366A) 20.2203(a)(2)(v) X 50.73(a)(2)(ii) 50.73(a)(2)(x)
LICENSEE CONTACT FOR THIS LER (12 NAHE TELEPHONE NUMBER (Include Area Code)
Mr. John Boesch, Maintenance Manager 616/465-5901, x2634 C(NPLETE ONE LINE FOR EACH C(NPONEHT FAILURE DESCRIBED IN THIS REPORT 13 REPORTABLE REPORTABLE CAUSE SYSTEH COMPONENT MANUFACTURER CAUSE SYSTEM COMPONENT MANUFACTURER TO NPRDS TO NPRDS ic'eke,'i'iX>:I SUPPLEMENTAL REPORT EXPECTED 14) EXPECTED MONTH DAY YEAR YES SUBHI SSI ON (If yes, complete EXPECTED SUBMISSION DATE).
X NO DATE (15)
ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (16)
On January 7, 1998, while performing 1 IHP 4030.STP.410, "Train 'A'PS and ESF Reactor Trip Breaker and SSPS Automatic Trip/Actuation Logic Functional Test," a step to reposition a test switch within the Solid State Protection System (SSPS) was overlooked. Several steps later, when the SSPS was restored to normal, an unpla'nned Engineered Safety Features (ESF) actuation and Reactor Protection System (RPS) actuation occurred.
The root cause for this event is personnel error. The Instrumentation and Controls (I&C) procedure reader did not adequately follow an approved procedure. The I&C reader missed Step 6.5.50 during the performance of 1 IHP 4030.STP.410, "Train 'A'PS and ESF Reactor Trip Breaker and SSPS Automatic Trip/Actuation Logic functional Test."
This event is being reported in accordance with 10 CFR 50.72(a)(2)(iv) as any event or condition that resulted in manual or automatic actuation of any Engineered Safety Feature, including the Reactor Protection System. The safety significance was negligible as the unit was in Mode 5 and the safety function of the actuated systems had already been established prior to the event.
A timeout was held with all l&C crews to discuss the event. The timeout focused on the reporting of unusual indications, self-checking, and I&C worker performance.
9802i30i02 980206 PDR ADQCK 050003f5 S PDR
NRC FORM 366A . NUCLEAR REGULATORY COMMISSION ROVED BY OMB NO. 3150-0104 EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH LICENSEE EVENT CONTINUATION THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.
FORHARD COMMENTS REGARDING BURDEH ESTIMATE TO THE INFORMATION AHD RECORDS MANAGEMENT BRAHCH (MHBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, llASHINGTON, DC 20555-0001, AHD TO THE PAPERIIORK REDUCTION PROJECT (3150.0104), OFFICE OF MANAGEMENT AND BUDGET 'WASHINGTON, DC 20503.
FACILITY HAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)
YEAR SEQUENTIAL REVISION Cook Nuclear Plant - Unit 1 50-315 2OF3 98 003 00 TEXT (if sere space is required. use additional NRC Fore 366A's) (17)
Conditions Prior to Event Unit 1 was in Mode 5, Cold Shutdown Descri tion of Event On January 7, 1998, while performing 1 IHP 4030.STP.410, "Train 'A'PS and ESF Reactor Trip Breaker and SSPS Automatic Trip/Actuation Logic Functional Test," a step to reposition a test switch within the Solid State Protection System (SSPS) was overlooked. Several steps later, when the SSPS was restored to normal, an unplanned Engineered Safety Features (ESF) and Reactor Protection System (RPS) actuation occurred.
In response to a Westinghouse bulletin which stated that portions of SSPS may not have been completely tested, change sheet 2 to 1 IHP 4030.STP.410 was generated. Change sheet 2 added Steps 6.5.39 through 6.5.39G to fully test SSPS. SSPS testing began on day shift January 7, 1998. The partially completed procedure was then turned over to the night shift for completion. However, the turnover of the procedure was not a factor in this event.
The night shift performed a pre-job brief for this activity. It was mentioned in the pre-job briefing that the usual 2 hour2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> technical specification limiting condition for operation time limit did not apply, but the need to avoid an ESF actuation in any mode was emphasized. 1 IHP 4030.STP.410 is written to be performed in Modes 1, 2, 3, 4, and
- 5. Routinely this procedure is performed in Mode 1, thus the l&C crew was familiar with the SSPS response in Mode 1. No consideration was given to differences that might exist in Mode 5, nor were potential differences between Mode 1 and Mode 5 discussed during the pre-job briefing.
Approximately 10 steps in the procedure had been completed by using three (3) Instrumentation and Control (l&C) technicians as is the standard for this procedure. One was designated as a procedure reader. A second was a worker (turned switches and took meter reading) and a third was a helper, to allow the first two to remain focused on the incremental steps. Due to a lack of self-checking, a poor procedure use practice, and poor supervisory oversight, the l&C procedure reader missed Step 6.5.50 which directed "Place MEMORIES in OFF" and preceded to the next step.
Steps 6.5.51 through 6.8.4 were performed with the MEMORIES switch in the wrong position. Unusual SSPS panel indications were noted by both the l&C reader and the l&C worker. They did not stop what they were doing or contact their supervisor. Instead, they rationalized away the unusual indications to be associated with the performance of the test in Mode 5.
Step 6.8.5 was performed which placed the SSPS back to normal. This action restored the SSPS system and allowed the test generated trip signals to affect the plant. Shortly thereafter, the l&C crew reported to the Operations Unit Supervisor that their testing was completed. The Unit Supervisor performed a check of the control room panels and questioned why a safety injection status light was on. A check of the procedure and SSPS revealed the error. With the unit in Mode 5, the only physical equipment response was the opening of the main steam dump valves.
Cause of Event The root cause for this event is personnel error. The l&C procedure reader did not adequately follow an approved procedure. The l&C reader missed Step 6.5.50 during the performance of 1 IHP 4030.STP.410, "Train 'A'PS and ESF Reactor Trip Breaker and SSPS Automatic Trip/Actuation Logic Functional Test." The bases for the error was attributed to a lack of self-checking, a poor procedure use practice, and poor supervisory oversight.
NRC FORM 366A . NUCLEAR REGULATORY COMMISSION OVED BY OMB NO. 3150-0104 EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.
LICENSEE EVENT CONTINUATION FORWARD COMMENTS REGARDING BURDEN ESTIMATE To THE INFORMATION AHD RECORDS MANAGEMENI'RANCH (MHBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, OC 20555 0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150.0104), OFFICE OF MAHAGEMENT AND BUDGET, IIASHIHGTOH, DC 20503.
FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)
YEAR SEQUENTIAL REVISION Cook Nuclear Plant - Unit 1 50-315 3OF3 98 003 00 TEXT (if sore space is required. use additional HRC rom 366A's) (17)
Anal sis of Event This event is being reported in accordance with 10 CFR 50.72(a)(2)(iv) as any event or condition that resulted in manual or automatic actuation of any Engin'eered Safety Feature, including the Reactor Protection System.
This event occurred in Mode 5, Cold Shutdown, with all control rods already inserted into the core, the reactor protection system removed from service, and the main steam isolation valves closed. As a consequence, there was negligible impact on safety-related components and systems. The main steamline isolation valve dump valves opened;.but, as noted above, the associated main steamline isolation valves were already in a closed condition. In summary, the safety function of the actuated systems had already been established prior to the event.
Corrective Actions Immediate corrective actions consisted of the following:
Work on SSPS was stopped, a high priority job order was initiated to restore SSPS to normal, restoration plans were developed, and SSPS was successfully restored to normal.
Appropriate administrative actions were taken with the responsible l8C crew members.
The l8C supervisor was reminded of his responsibility to include special plant conditions and expected test indications as part of the pre-job briefings.
Immediate preventive actions consisted of the following: A timeout was held with all l&C crews to discuss the event. The timeout focused on the following items:
. The job performance expectations for l8,C workers. Key topics included in this discussion were: Strict Procedure Use and Adherence, Self Checking, Comprehensive Job Briefs, Supervisory Oversight and Teamwork.
The need to stop and resolve unusual indications during task performance.
The need to self-check one's work, especially before high-risk steps.
After determining that the crew clearly understood the expectations for them to successfully complete the procedure, the procedure was completed without incident.
Failed Com onent Identification None Previous Similar Events 315/96-005-00 316/96-005-00 315/95-010-00 316/95-006-00 ~
316/94-001-00 316/94-010-00