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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML18017A9181999-10-0808 October 1999 LER 99-008-00:on 991008,CR Emergency Filtration Sys Tech Specs Occurred.Caused by Site Personnel Failed to Recognize That Blocking Open CR Emergency Filtration Sys.Procedures Revised.With 991008 Ltr ML18017A8671999-09-10010 September 1999 LER 99-007-00:on 990811,determined That Cvis ARMs High Alarm Setpoints Were Not within TS Limit.Caused by Not Having Procedure to Verify If Cvis ARM High Alarm Setpoints Were within TS Requirements.Revised Procedures.With 990910 Ltr ML18016B0481999-08-0404 August 1999 LER 99-006-01:on 981124,noted Failure to Comply with TS 4.0.4 & TS 3/4.6.3, Civs. Caused by post-maint Testing That Did Not Adequately Test Control Circuitry & Verify Isolation Time Following Maint.Procedure Was Revised ML18016A9801999-06-0404 June 1999 LER 99-006-00:on 981124,failed to Comply with TS 4.0.4 & TS 3/4.6.3, Civ. Caused by post-maint Testing That Did Not Adequately Test Control Circuitry & Verify Isolation Time Following Maint.Procedure Will Be Revised.With 990604 Ltr ML18016A9111999-04-12012 April 1999 LER 99-005-00:on 990313,plant Exceeded ESFAS TS 3.3.2,Action 21.Caused by Inadequate Procedure Rev Preparation.Licensee Revised Applicable Maint Surveillance Test Procedure (MST-10072) to Identify TS Required Actions.With 990412 Ltr ML18016A8971999-04-0808 April 1999 LER 99-004-00:on 990312,unit Trip Was Noted.Caused by Degraded Condition of SG Water Level Flow Control Valve. Replaced Positioners on All Three FW Regulating Valves.With 990408 Ltr ML18016A8261999-02-22022 February 1999 LER 99-003-00:on 990123,noted That Plant Was Outside Design Basis Due to Isolation of Fire Protection Containment Sprinkler Sys.Caused by Human Error.Restored Containment Sprinkler Sys to Operable Status.With 990222 Ltr ML18016A8111999-02-12012 February 1999 LER 99-002-00:on 990114,RT Due to Not Removing Temporary Device from Relay Following Calibration Was Noted.Caused by Human Error.Counseled Personnel Involved in Event.With 990212 Ltr ML18016A7971999-02-0505 February 1999 LER 99-001-00:on 990106,SF Pool Water Level Was Not Maintained Greater than 23 Feet Above Stored BWR Fuel Assemblies.Caused by Fasteners Bending Under Specific Circumstances.Increased Water Level.With 990205 Ltr ML18016A7941999-01-29029 January 1999 LER 98-004-01:on 980313,identified Design Deficiency Re Potential Runout of Tdafwp.Caused by Inadequate Original AFW Sys Design.Operability Evaluation Was Completed on 980313 & Addl Engineering Analysis Was Performed by Vendor ML18016A7211998-11-17017 November 1998 LER 98-007-00:on 981023,turbine Control Anomaly Caused Manual Rt.Caused by Failure to Incorporate Verbal Vendor Guidance in Operating Procedures.Addl Vendor Guidance Will Be Verified & Added to Procedures.With 981117 Ltr ML18016A4841998-07-0707 July 1998 LER 97-002-01:on 970207,determined That Cold Weather Conditions Resulted in Mfiv Being Potentially Inoperable During Period 970117-20.Caused by Inadequate Design of HVAC Sys.Implemented Mods to Steam Tunnel HVAC Sys ML18016A4701998-06-30030 June 1998 LER 97-021-03:on 980210,discovered That SFP Water Level Had Not Been Verified Greater than 23 Feet Above BWR Fuel Assemblies.Caused by Misinterpretation of TS Requirements. Will Submit TS Change Request to Revise TS 3.9.1.11 ML18016A4491998-06-0808 June 1998 LER 98-006-00:on 980508,failure to Perform Insp & Preventive Maint on MCCB as Required by TS Was Noted.Caused by Inadequate Sps.Tested 9 Pressurizer Heater Bank Breakers by Cycling each.W/980608 Ltr ML18022B0551998-05-20020 May 1998 LER 98-005-00:on 980420,TS Verbatim non-compliance Was Determined.Caused by Misinterpretation of TS Requirements. Issued Memo to Reemphasize Need to Comply W/Literal Meaning of TS Requirements in Verbatim manner.W/980520 Ltr ML18016A4061998-04-30030 April 1998 LER 98-002-01:on 980121,determined Ssps (P-11 Permissive) Testing Deficiency.Caused by Inadequate Review of Initial Ts.Will Revise & Perform Surveillance Test Procedures to Verify Operability of P-11 Permissive ML18016A3841998-04-13013 April 1998 LER 98-004-00:on 980313,design Deficiency Related to Indequate Runout Protection for Turbine Driven AFW Pump Was Identified.Caused by Inadequate Original AFW Sys Design. Evaluation (ESR 98-00100) Will Be completed.W/980409 Ltr ML18016A3441998-03-12012 March 1998 LER 97-021-02:on 980210,identified Failure to Properly Test non-safety Related Pressurizer Porv.Caused by Inadequate Surveillance Test Procedures.Revised Operations Surveillance Test OST-1117 to Include Testing of Subject PORV ML18016A3291998-02-27027 February 1998 LER 98-003-00:on 980129,failure to Perform Shutdown Margin Calculation Required by TS Surveillance Requirements Occurred.Caused by Ambiguity in TS 3.1.3.1.c.Procedures revised.W/980227 Ltr ML18016A3211998-02-20020 February 1998 LER 98-002-00:on 980121,solid State Protection Sys Testing Deficiency Occurred.Caused by Inadequate Review of Initial Tech Specs.Ts Testing Frequency for P-11 Permissive Revised. W/980217 Ltr ML18016A3131998-02-0909 February 1998 LER 98-001-00:on 980109,potential Condition Outside Design Basis Related to Instrument Air Sys Leak Causing SG pre- Heater Bypass Isolation Valves to Be Inoperable Was Noted. Caused by Inadequate Design Control.Generated Jco 98-01 ML18016A2641997-12-18018 December 1997 LER 97-024-00:on 971118,SSPS Testing Deficiency Was Noted. Caused by Inadequate Testing Scheme Provided by Ssps Vendor. Revised procedure.W/971218 Ltr ML18016A2501997-11-24024 November 1997 LER 97-023-00:on 920721,RCS PIV Testing Deficiency Was Noted.Caused by Failure to Consider All Testing Variables During Initial Sp Development.Surveillance Tp OST-1506 Was Revised to Incorporate Correction factor.W/971124 Ltr ML18016A2201997-10-22022 October 1997 LER 97-021-01:on 970922,discovered That Spent Fuel Pool Water Level Was Not Maintained Greater than 23 Feet Above Stored BWR Fuel Assemblies.Caused by Misinterpretation of TS Requirements.Revised Daily Surveillance Procedures ML18016A2081997-10-14014 October 1997 LER 97-016-01:on 970608,reactor Trip Occurred,Due to Personnel Error While Attempting to Adjust Power Range Nuclear Instrumentation Channel Following Performance of Calorimetric.Procedures revised.W/971014 Ltr ML18016A2111997-10-14014 October 1997 LER 96-008-02:on 960425,turbine Trip/Reactor Trip Occurred. Caused by High Resistance Connection Resulting from a Phase Switch Jaw & Blade Contacts.Failed a Phase Disconnect Switch on Breaker 52-7 Replaced ML18016A1931997-09-29029 September 1997 LER 97-022-00:on 970829,TS Required Shutdown Due to Expiration of AFW Lco.Caused by Personnel Error.Completed Repairs TDAFW Pump & Returned Plant to Svc on 970831. W/970926 Ltr ML18016A1891997-09-12012 September 1997 LER 97-020-00:on 970814,inadequate Fire Protection Provided for safety-related EDG Fuel Oil Transfer Pump Cables Resulted in Operation Outside Design Basis.Caused by Engineering Oversight.Established Fire watches.W/970912 Ltr ML18016A1881997-09-12012 September 1997 LER 97-021-00:on 970814,spent Fuel Pool Water Level Was Not Maintained Greater than 23 Feet Above Stored BWR Fuel Assemblies.Caused by Misinterpretation of Ts.Directions Provided to Operations.W/970912 Ltr ML18012A8641997-08-18018 August 1997 LER 97-019-00:on 970720,turbine Trip/Reactor Trip Occurred. Caused by Three Phase Fault That Collapsed Excitation Field in Main Generator,Resulting in Generator Lockout.Exciter Rotor Assembly Was replaced.W/970818 Ltr ML18012A8581997-08-0808 August 1997 LER 96-018-01:on 960903,manual Reactor Trip Occurred Due to Loss of Normal Sw.Caused by Mechanical Failure of B Water Pump & a Normal SW to Remain Running Once Manually Started.Restored a Normal SW Pump to Svc ML18012A8551997-08-0808 August 1997 LER 96-013-02:on 961028,condition Outside of Design Basis Where RWST Had Been Aligned w/non-seismically Qualified Sys Was Identified.Caused by Failure to Reconcile Operating Procedure Lineups.Established Administrative Controls ML18012A8471997-07-31031 July 1997 LER 97-018-00:on 970701,determined That Plant Procedures Had Not Received Proper Reviews & Approvals.Caused by Failure to Comply W/Plant Administrative Procedure AP-006.Counseled Involved individuals.W/970731 Ltr ML18012A8371997-07-24024 July 1997 LER 97-S01-00:on 970405,unescorted Access Inappropriately Granted to Contract Outage Workers Was Determined.Caused by Personnel Error.Access Files for Individuals Inappropriately Granted Unescorted Access Were Placed on Access Hold ML18012A8291997-07-11011 July 1997 LER 97-017-00:on 970612,failed to Recognize Inoperable Reactor Afd Monitor.Caused by Personnel Error.Operators Involved in Event Will Be Counseled Prior to Assuming Shift duties.W/970711 Ltr ML18012A8301997-07-0808 July 1997 LER 97-016-00:on 970608,reactor Trip Occurred Due to Personnel Error in Adjusting Power Range (Pr) Nuclear Instrumentation (Ni).Issued Night Order Prohibiting Pr Ni Adjustment When Redundant Channel inoperable.W/970708 Ltr ML18012A8241997-07-0202 July 1997 LER 97-015-00:on 970602,inadequate Auxiliary Feedwater Sys Flow Control Valve Surveillance Testing Deficiency Was Identified.Caused by Failure to Recognize Impact on TS 4.7.1.2.1.Readjusted AFW FCV Actuator spring.W/970702 Ltr ML18022B0181997-06-13013 June 1997 LER 97-014-00:on 970514,SI Occurred During Ssps Surveillance Testing.Caused by Inattention to Detail During Recent Rev to Surveillance Test Procedure Being Used.Revised Deficient Surveillance procedures.W/970613 Ltr ML18012A8081997-06-0909 June 1997 LER 97-013-00:on 970508,entry Into Mode-6 Without Operable Components,Resulting in TS 3.0.4 Violation Occurred.Caused by Personnel Error.Personnel Involved counseled.W/970609 Ltr ML18012A8021997-06-0606 June 1997 LER 97-023-02:on 961114,design Deficiency Was Identified in Emergency DG Protection Circuitry.Caused by Inadequate Plant Design.Revised Surveillance Test Procedures OST-1013 & OST-1073.W/970606 Ltr ML18012A8011997-06-0404 June 1997 LER 97-012-00:on 970505,determined That Previous Auxiliary Control Panel Had Not Verified Operability of Interposing Relays.Caused by Misinterpretation of Tss.Reviewed Other Remote Shutdown Panel Transfer circuitry.W/970604 Ltr ML18012A7951997-05-29029 May 1997 LER 96-023-01:on 961114,design Deficiency in EDG Protection Circuitry Was Identified.Caused by Inadequate Original Plant Design.Surveillance Test Procedures OST-1013 & OST-1073 revised.W/970529 Ltr ML18012A7891997-05-22022 May 1997 LER 97-011-00:on 970422,inappropriate TS Interpretation Resulted in Violations of ECCS Accumulator TS & Entry Into TS 3.0.3.Caused by Procedural Inadequacy.Tsi 88-001 Cancelled 970508 & Procedures revised.W/970522 Ltr ML18012A7871997-05-19019 May 1997 LER 97-010-00:on 970418,design Deficiency Determined Re Reactor Coolant Pump Motor Oil Collection Sys.Caused by RCP Ocs Design Detail.Rcp Ocs Enclosures for Each of Three Installed RCP Motors Have Been modified.W/970519 Ltr ML18012A7761997-05-0707 May 1997 LER 97-009-00:on 970407,fuse Was Removed from CR Ventilation Isolation Signal Power Supply Circuitry Due to Personnel Error.Individuals Involved Were counseled.W/970507 Ltr ML18012A7751997-05-0505 May 1997 LER 97-008-00:on 970404,safety-related AHU Not Declared Inoperable During Maintenance on Associated Temperature Switches Resulting in Violation of Ts.Caused by Incorrect Interpretation.Operations Night Order issued.W/970505 Ltr ML18012A6291997-04-24024 April 1997 LER 97-007-00:on 970325,inoperable CCW Sys TS 3.0.3 Entry Made.Caused by Combination of Procedural Inadequacies, Improper Use of Procedure Guidance & Poor Communication. Applicable Individuals counseled.W/970423 Ltr ML18022B0151997-04-17017 April 1997 LER 97-006-00:on 970318,breach Was Identified in Thermo-Lag Fire Barrier Wall Due to Inadequate Initial Design,Poor Construction Methods & Incomplete as-built Design.Visual Insp of Thermo-Lag Barrier Walls performed.W/970417 Ltr ML18012A6041997-04-0303 April 1997 LER 97-004-00:on 970304,in-plant Spent Fuel Cask Handling Activities Conducted Outside Design Basis.Caused by Lack of Understanding of Requirements.Operations Placed on Hold Pending NRC Review & Approval of procedures.W/970331 Ltr ML18012A6031997-03-31031 March 1997 LER 97-003-00:on 970227,steam Generator Low Level Protection Circuitry Outside Design Basis Occurred.Caused by Inadequate Failure Modes & Effects Analysis Performed as-built Piping Configuration for S/G Level.Review performed.W/970331 Ltr 1999-09-10
[Table view] Category:RO)
MONTHYEARML18017A9181999-10-0808 October 1999 LER 99-008-00:on 991008,CR Emergency Filtration Sys Tech Specs Occurred.Caused by Site Personnel Failed to Recognize That Blocking Open CR Emergency Filtration Sys.Procedures Revised.With 991008 Ltr ML18017A8671999-09-10010 September 1999 LER 99-007-00:on 990811,determined That Cvis ARMs High Alarm Setpoints Were Not within TS Limit.Caused by Not Having Procedure to Verify If Cvis ARM High Alarm Setpoints Were within TS Requirements.Revised Procedures.With 990910 Ltr ML18016B0481999-08-0404 August 1999 LER 99-006-01:on 981124,noted Failure to Comply with TS 4.0.4 & TS 3/4.6.3, Civs. Caused by post-maint Testing That Did Not Adequately Test Control Circuitry & Verify Isolation Time Following Maint.Procedure Was Revised ML18016A9801999-06-0404 June 1999 LER 99-006-00:on 981124,failed to Comply with TS 4.0.4 & TS 3/4.6.3, Civ. Caused by post-maint Testing That Did Not Adequately Test Control Circuitry & Verify Isolation Time Following Maint.Procedure Will Be Revised.With 990604 Ltr ML18016A9111999-04-12012 April 1999 LER 99-005-00:on 990313,plant Exceeded ESFAS TS 3.3.2,Action 21.Caused by Inadequate Procedure Rev Preparation.Licensee Revised Applicable Maint Surveillance Test Procedure (MST-10072) to Identify TS Required Actions.With 990412 Ltr ML18016A8971999-04-0808 April 1999 LER 99-004-00:on 990312,unit Trip Was Noted.Caused by Degraded Condition of SG Water Level Flow Control Valve. Replaced Positioners on All Three FW Regulating Valves.With 990408 Ltr ML18016A8261999-02-22022 February 1999 LER 99-003-00:on 990123,noted That Plant Was Outside Design Basis Due to Isolation of Fire Protection Containment Sprinkler Sys.Caused by Human Error.Restored Containment Sprinkler Sys to Operable Status.With 990222 Ltr ML18016A8111999-02-12012 February 1999 LER 99-002-00:on 990114,RT Due to Not Removing Temporary Device from Relay Following Calibration Was Noted.Caused by Human Error.Counseled Personnel Involved in Event.With 990212 Ltr ML18016A7971999-02-0505 February 1999 LER 99-001-00:on 990106,SF Pool Water Level Was Not Maintained Greater than 23 Feet Above Stored BWR Fuel Assemblies.Caused by Fasteners Bending Under Specific Circumstances.Increased Water Level.With 990205 Ltr ML18016A7941999-01-29029 January 1999 LER 98-004-01:on 980313,identified Design Deficiency Re Potential Runout of Tdafwp.Caused by Inadequate Original AFW Sys Design.Operability Evaluation Was Completed on 980313 & Addl Engineering Analysis Was Performed by Vendor ML18016A7211998-11-17017 November 1998 LER 98-007-00:on 981023,turbine Control Anomaly Caused Manual Rt.Caused by Failure to Incorporate Verbal Vendor Guidance in Operating Procedures.Addl Vendor Guidance Will Be Verified & Added to Procedures.With 981117 Ltr ML18016A4841998-07-0707 July 1998 LER 97-002-01:on 970207,determined That Cold Weather Conditions Resulted in Mfiv Being Potentially Inoperable During Period 970117-20.Caused by Inadequate Design of HVAC Sys.Implemented Mods to Steam Tunnel HVAC Sys ML18016A4701998-06-30030 June 1998 LER 97-021-03:on 980210,discovered That SFP Water Level Had Not Been Verified Greater than 23 Feet Above BWR Fuel Assemblies.Caused by Misinterpretation of TS Requirements. Will Submit TS Change Request to Revise TS 3.9.1.11 ML18016A4491998-06-0808 June 1998 LER 98-006-00:on 980508,failure to Perform Insp & Preventive Maint on MCCB as Required by TS Was Noted.Caused by Inadequate Sps.Tested 9 Pressurizer Heater Bank Breakers by Cycling each.W/980608 Ltr ML18022B0551998-05-20020 May 1998 LER 98-005-00:on 980420,TS Verbatim non-compliance Was Determined.Caused by Misinterpretation of TS Requirements. Issued Memo to Reemphasize Need to Comply W/Literal Meaning of TS Requirements in Verbatim manner.W/980520 Ltr ML18016A4061998-04-30030 April 1998 LER 98-002-01:on 980121,determined Ssps (P-11 Permissive) Testing Deficiency.Caused by Inadequate Review of Initial Ts.Will Revise & Perform Surveillance Test Procedures to Verify Operability of P-11 Permissive ML18016A3841998-04-13013 April 1998 LER 98-004-00:on 980313,design Deficiency Related to Indequate Runout Protection for Turbine Driven AFW Pump Was Identified.Caused by Inadequate Original AFW Sys Design. Evaluation (ESR 98-00100) Will Be completed.W/980409 Ltr ML18016A3441998-03-12012 March 1998 LER 97-021-02:on 980210,identified Failure to Properly Test non-safety Related Pressurizer Porv.Caused by Inadequate Surveillance Test Procedures.Revised Operations Surveillance Test OST-1117 to Include Testing of Subject PORV ML18016A3291998-02-27027 February 1998 LER 98-003-00:on 980129,failure to Perform Shutdown Margin Calculation Required by TS Surveillance Requirements Occurred.Caused by Ambiguity in TS 3.1.3.1.c.Procedures revised.W/980227 Ltr ML18016A3211998-02-20020 February 1998 LER 98-002-00:on 980121,solid State Protection Sys Testing Deficiency Occurred.Caused by Inadequate Review of Initial Tech Specs.Ts Testing Frequency for P-11 Permissive Revised. W/980217 Ltr ML18016A3131998-02-0909 February 1998 LER 98-001-00:on 980109,potential Condition Outside Design Basis Related to Instrument Air Sys Leak Causing SG pre- Heater Bypass Isolation Valves to Be Inoperable Was Noted. Caused by Inadequate Design Control.Generated Jco 98-01 ML18016A2641997-12-18018 December 1997 LER 97-024-00:on 971118,SSPS Testing Deficiency Was Noted. Caused by Inadequate Testing Scheme Provided by Ssps Vendor. Revised procedure.W/971218 Ltr ML18016A2501997-11-24024 November 1997 LER 97-023-00:on 920721,RCS PIV Testing Deficiency Was Noted.Caused by Failure to Consider All Testing Variables During Initial Sp Development.Surveillance Tp OST-1506 Was Revised to Incorporate Correction factor.W/971124 Ltr ML18016A2201997-10-22022 October 1997 LER 97-021-01:on 970922,discovered That Spent Fuel Pool Water Level Was Not Maintained Greater than 23 Feet Above Stored BWR Fuel Assemblies.Caused by Misinterpretation of TS Requirements.Revised Daily Surveillance Procedures ML18016A2081997-10-14014 October 1997 LER 97-016-01:on 970608,reactor Trip Occurred,Due to Personnel Error While Attempting to Adjust Power Range Nuclear Instrumentation Channel Following Performance of Calorimetric.Procedures revised.W/971014 Ltr ML18016A2111997-10-14014 October 1997 LER 96-008-02:on 960425,turbine Trip/Reactor Trip Occurred. Caused by High Resistance Connection Resulting from a Phase Switch Jaw & Blade Contacts.Failed a Phase Disconnect Switch on Breaker 52-7 Replaced ML18016A1931997-09-29029 September 1997 LER 97-022-00:on 970829,TS Required Shutdown Due to Expiration of AFW Lco.Caused by Personnel Error.Completed Repairs TDAFW Pump & Returned Plant to Svc on 970831. W/970926 Ltr ML18016A1891997-09-12012 September 1997 LER 97-020-00:on 970814,inadequate Fire Protection Provided for safety-related EDG Fuel Oil Transfer Pump Cables Resulted in Operation Outside Design Basis.Caused by Engineering Oversight.Established Fire watches.W/970912 Ltr ML18016A1881997-09-12012 September 1997 LER 97-021-00:on 970814,spent Fuel Pool Water Level Was Not Maintained Greater than 23 Feet Above Stored BWR Fuel Assemblies.Caused by Misinterpretation of Ts.Directions Provided to Operations.W/970912 Ltr ML18012A8641997-08-18018 August 1997 LER 97-019-00:on 970720,turbine Trip/Reactor Trip Occurred. Caused by Three Phase Fault That Collapsed Excitation Field in Main Generator,Resulting in Generator Lockout.Exciter Rotor Assembly Was replaced.W/970818 Ltr ML18012A8581997-08-0808 August 1997 LER 96-018-01:on 960903,manual Reactor Trip Occurred Due to Loss of Normal Sw.Caused by Mechanical Failure of B Water Pump & a Normal SW to Remain Running Once Manually Started.Restored a Normal SW Pump to Svc ML18012A8551997-08-0808 August 1997 LER 96-013-02:on 961028,condition Outside of Design Basis Where RWST Had Been Aligned w/non-seismically Qualified Sys Was Identified.Caused by Failure to Reconcile Operating Procedure Lineups.Established Administrative Controls ML18012A8471997-07-31031 July 1997 LER 97-018-00:on 970701,determined That Plant Procedures Had Not Received Proper Reviews & Approvals.Caused by Failure to Comply W/Plant Administrative Procedure AP-006.Counseled Involved individuals.W/970731 Ltr ML18012A8371997-07-24024 July 1997 LER 97-S01-00:on 970405,unescorted Access Inappropriately Granted to Contract Outage Workers Was Determined.Caused by Personnel Error.Access Files for Individuals Inappropriately Granted Unescorted Access Were Placed on Access Hold ML18012A8291997-07-11011 July 1997 LER 97-017-00:on 970612,failed to Recognize Inoperable Reactor Afd Monitor.Caused by Personnel Error.Operators Involved in Event Will Be Counseled Prior to Assuming Shift duties.W/970711 Ltr ML18012A8301997-07-0808 July 1997 LER 97-016-00:on 970608,reactor Trip Occurred Due to Personnel Error in Adjusting Power Range (Pr) Nuclear Instrumentation (Ni).Issued Night Order Prohibiting Pr Ni Adjustment When Redundant Channel inoperable.W/970708 Ltr ML18012A8241997-07-0202 July 1997 LER 97-015-00:on 970602,inadequate Auxiliary Feedwater Sys Flow Control Valve Surveillance Testing Deficiency Was Identified.Caused by Failure to Recognize Impact on TS 4.7.1.2.1.Readjusted AFW FCV Actuator spring.W/970702 Ltr ML18022B0181997-06-13013 June 1997 LER 97-014-00:on 970514,SI Occurred During Ssps Surveillance Testing.Caused by Inattention to Detail During Recent Rev to Surveillance Test Procedure Being Used.Revised Deficient Surveillance procedures.W/970613 Ltr ML18012A8081997-06-0909 June 1997 LER 97-013-00:on 970508,entry Into Mode-6 Without Operable Components,Resulting in TS 3.0.4 Violation Occurred.Caused by Personnel Error.Personnel Involved counseled.W/970609 Ltr ML18012A8021997-06-0606 June 1997 LER 97-023-02:on 961114,design Deficiency Was Identified in Emergency DG Protection Circuitry.Caused by Inadequate Plant Design.Revised Surveillance Test Procedures OST-1013 & OST-1073.W/970606 Ltr ML18012A8011997-06-0404 June 1997 LER 97-012-00:on 970505,determined That Previous Auxiliary Control Panel Had Not Verified Operability of Interposing Relays.Caused by Misinterpretation of Tss.Reviewed Other Remote Shutdown Panel Transfer circuitry.W/970604 Ltr ML18012A7951997-05-29029 May 1997 LER 96-023-01:on 961114,design Deficiency in EDG Protection Circuitry Was Identified.Caused by Inadequate Original Plant Design.Surveillance Test Procedures OST-1013 & OST-1073 revised.W/970529 Ltr ML18012A7891997-05-22022 May 1997 LER 97-011-00:on 970422,inappropriate TS Interpretation Resulted in Violations of ECCS Accumulator TS & Entry Into TS 3.0.3.Caused by Procedural Inadequacy.Tsi 88-001 Cancelled 970508 & Procedures revised.W/970522 Ltr ML18012A7871997-05-19019 May 1997 LER 97-010-00:on 970418,design Deficiency Determined Re Reactor Coolant Pump Motor Oil Collection Sys.Caused by RCP Ocs Design Detail.Rcp Ocs Enclosures for Each of Three Installed RCP Motors Have Been modified.W/970519 Ltr ML18012A7761997-05-0707 May 1997 LER 97-009-00:on 970407,fuse Was Removed from CR Ventilation Isolation Signal Power Supply Circuitry Due to Personnel Error.Individuals Involved Were counseled.W/970507 Ltr ML18012A7751997-05-0505 May 1997 LER 97-008-00:on 970404,safety-related AHU Not Declared Inoperable During Maintenance on Associated Temperature Switches Resulting in Violation of Ts.Caused by Incorrect Interpretation.Operations Night Order issued.W/970505 Ltr ML18012A6291997-04-24024 April 1997 LER 97-007-00:on 970325,inoperable CCW Sys TS 3.0.3 Entry Made.Caused by Combination of Procedural Inadequacies, Improper Use of Procedure Guidance & Poor Communication. Applicable Individuals counseled.W/970423 Ltr ML18022B0151997-04-17017 April 1997 LER 97-006-00:on 970318,breach Was Identified in Thermo-Lag Fire Barrier Wall Due to Inadequate Initial Design,Poor Construction Methods & Incomplete as-built Design.Visual Insp of Thermo-Lag Barrier Walls performed.W/970417 Ltr ML18012A6041997-04-0303 April 1997 LER 97-004-00:on 970304,in-plant Spent Fuel Cask Handling Activities Conducted Outside Design Basis.Caused by Lack of Understanding of Requirements.Operations Placed on Hold Pending NRC Review & Approval of procedures.W/970331 Ltr ML18012A6031997-03-31031 March 1997 LER 97-003-00:on 970227,steam Generator Low Level Protection Circuitry Outside Design Basis Occurred.Caused by Inadequate Failure Modes & Effects Analysis Performed as-built Piping Configuration for S/G Level.Review performed.W/970331 Ltr 1999-09-10
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML18017A9181999-10-0808 October 1999 LER 99-008-00:on 991008,CR Emergency Filtration Sys Tech Specs Occurred.Caused by Site Personnel Failed to Recognize That Blocking Open CR Emergency Filtration Sys.Procedures Revised.With 991008 Ltr ML18017A9151999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for Shearon Harris Npp. with 991012 Ltr ML20217A9931999-09-30030 September 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data ML18017A8671999-09-10010 September 1999 LER 99-007-00:on 990811,determined That Cvis ARMs High Alarm Setpoints Were Not within TS Limit.Caused by Not Having Procedure to Verify If Cvis ARM High Alarm Setpoints Were within TS Requirements.Revised Procedures.With 990910 Ltr ML18017A8621999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Harris Nuclear Plant.With 990908 Ltr ML18016B0481999-08-0404 August 1999 LER 99-006-01:on 981124,noted Failure to Comply with TS 4.0.4 & TS 3/4.6.3, Civs. Caused by post-maint Testing That Did Not Adequately Test Control Circuitry & Verify Isolation Time Following Maint.Procedure Was Revised ML18017A8361999-07-31031 July 1999 Monthly Operating Rept for July 1999 for Shearon Harris Nuclear Power Plant.With 990811 Ltr ML18016B0151999-06-30030 June 1999 Monthly Operating Rept for June 1999 for Shearon Harris Npp. with 990713 Ltr ML20196H8621999-06-30030 June 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data, June 1999 Rept ML18016A9801999-06-0404 June 1999 LER 99-006-00:on 981124,failed to Comply with TS 4.0.4 & TS 3/4.6.3, Civ. Caused by post-maint Testing That Did Not Adequately Test Control Circuitry & Verify Isolation Time Following Maint.Procedure Will Be Revised.With 990604 Ltr ML18016A9851999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Shearon Harris Nuclear Plant,Unit 1.With 990614 Ltr ML18017A8981999-05-12012 May 1999 Technical Rept Entitled, Harris Nuclear Plant-Bacteria Detection in Water from C&D Spent Fuel Pool Cooling Lines. ML18016A9581999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for Shearon Harris Nuclear Plant,Unit 1.With 990513 Ltr ML18016A9011999-04-12012 April 1999 Part 21 Rept Re Defect in Component of DSRV-16-4,Enterprise DG Sys.Caused by Potential Problem with Connecting Rod Assemblies Built Since 1986,that Have Been Converted to Use Prestressed Fasteners.Affected Rods Should Be Inspected ML18016A9111999-04-12012 April 1999 LER 99-005-00:on 990313,plant Exceeded ESFAS TS 3.3.2,Action 21.Caused by Inadequate Procedure Rev Preparation.Licensee Revised Applicable Maint Surveillance Test Procedure (MST-10072) to Identify TS Required Actions.With 990412 Ltr ML18016A8971999-04-0808 April 1999 LER 99-004-00:on 990312,unit Trip Was Noted.Caused by Degraded Condition of SG Water Level Flow Control Valve. Replaced Positioners on All Three FW Regulating Valves.With 990408 Ltr ML18016A8941999-04-0505 April 1999 Revised Pages 20-25 to App 4A of non-proprietary Version of Rev 3 to HI-971760 ML18016A9101999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for Shearon Harris Nuclear Power Plant.With 990413 Ltr ML18016A8661999-03-31031 March 1999 Shnpp Operator Training Simulator,Simulator Certification Quadrennial Rept. ML18017A8931999-02-28028 February 1999 Risks & Alternative Options Associated with Spent Fuel Storage at Shearon Harris Nuclear Power Plant. ML18016A8551999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for Shearon Harris Npp. with 990312 Ltr ML18016A8261999-02-22022 February 1999 LER 99-003-00:on 990123,noted That Plant Was Outside Design Basis Due to Isolation of Fire Protection Containment Sprinkler Sys.Caused by Human Error.Restored Containment Sprinkler Sys to Operable Status.With 990222 Ltr ML18016A8531999-02-18018 February 1999 Non-proprietary Rev 3 to HI-971760, Licensing Rept for Expanding Storage Capacity in Harris SFP 'C' & 'D'. ML18016A8111999-02-12012 February 1999 LER 99-002-00:on 990114,RT Due to Not Removing Temporary Device from Relay Following Calibration Was Noted.Caused by Human Error.Counseled Personnel Involved in Event.With 990212 Ltr ML18016A7971999-02-0505 February 1999 LER 99-001-00:on 990106,SF Pool Water Level Was Not Maintained Greater than 23 Feet Above Stored BWR Fuel Assemblies.Caused by Fasteners Bending Under Specific Circumstances.Increased Water Level.With 990205 Ltr ML18022B0631999-02-0404 February 1999 Rev 0 to Nuclear NDE Manual. with 28 Oversize Uncodable Drawings of Alternative Plan Scope & 4 Oversize Codable Drawings ML20202J1161999-02-0101 February 1999 SER Accepting Relief Requests Associated with Second 10-year Interval Inservice Testing Program ML18016A8041999-01-31031 January 1999 Monthly Operating Rept for Jan 1999 for Shearon Harris Nuclear Power Plant.With 990211 Ltr ML18016A7941999-01-29029 January 1999 LER 98-004-01:on 980313,identified Design Deficiency Re Potential Runout of Tdafwp.Caused by Inadequate Original AFW Sys Design.Operability Evaluation Was Completed on 980313 & Addl Engineering Analysis Was Performed by Vendor ML18016A7801998-12-31031 December 1998 Monthly Operating Rept for Dec 1998 for Shearon Harris Npp. with 990113 Ltr ML18016A7671998-11-30030 November 1998 Monthly Operating Rept for Nov 1998 for Shnpp,Unit 1.With 981215 Ltr ML18016A9731998-11-28028 November 1998 Changes,Tests & Experiments, for Harris Nuclear Plant.Rept Provides Brief Description of Changes to Facility & Summary & of SE for Each Item That Was Implemented Under 10CFR50.59 Between 970608-981128.With 990527 Ltr ML18016A8351998-11-28028 November 1998 ISI Summary 8th Refueling Outage for Shearon Harris Power Plant,Unit 1. ML18016A7411998-11-25025 November 1998 Rev 1 to Shnpp Cycle 9 Colr. ML18016A7211998-11-17017 November 1998 LER 98-007-00:on 981023,turbine Control Anomaly Caused Manual Rt.Caused by Failure to Incorporate Verbal Vendor Guidance in Operating Procedures.Addl Vendor Guidance Will Be Verified & Added to Procedures.With 981117 Ltr ML18016A7071998-11-0303 November 1998 Rev 0 to Harris Unit 1 Cycle 9 Colr. ML18016A7201998-10-31031 October 1998 Monthly Operating Rept for Oct 1998 for Shearon Harris Nuclear Power Plant.With 981113 Ltr ML20154F8701998-10-0606 October 1998 Safety Evaluation Authorizing Proposed Alternative to Requirements of OMa-1988,Part 10,Section 4.2.2.3 for 21 Category a Reactor Coolant Sys Pressure Isolation Valves ML18016A6201998-09-30030 September 1998 Monthly Operating Rept for Sept 1998 for Harris Nuclear Power Plant.With 981012 Ltr ML18016A5971998-09-21021 September 1998 Rev 1 to Harris Unit 1 Cycle 8 Colr. ML18016A5881998-08-31031 August 1998 Monthly Operating Rept for Aug 1998 for Shnpp,Unit 1.With 980914 Ltr ML18016A5071998-07-31031 July 1998 Monthly Operating Rept for Jul 1998 for Shearon Harris Nuclear Plant.W/980811 Ltr ML18016A9431998-07-0707 July 1998 Rev 1 to QAP Manual. ML18016A4841998-07-0707 July 1998 LER 97-002-01:on 970207,determined That Cold Weather Conditions Resulted in Mfiv Being Potentially Inoperable During Period 970117-20.Caused by Inadequate Design of HVAC Sys.Implemented Mods to Steam Tunnel HVAC Sys ML18016A9371998-06-30030 June 1998 Technical Rept on Matl Identification of Spent Fuel Piping Welds at Hnp. ML18016A4861998-06-30030 June 1998 Monthly Operating Rept for June 1998 for SHNPP.W/980715 Ltr ML18016A4701998-06-30030 June 1998 LER 97-021-03:on 980210,discovered That SFP Water Level Had Not Been Verified Greater than 23 Feet Above BWR Fuel Assemblies.Caused by Misinterpretation of TS Requirements. Will Submit TS Change Request to Revise TS 3.9.1.11 ML18016A4491998-06-0808 June 1998 LER 98-006-00:on 980508,failure to Perform Insp & Preventive Maint on MCCB as Required by TS Was Noted.Caused by Inadequate Sps.Tested 9 Pressurizer Heater Bank Breakers by Cycling each.W/980608 Ltr ML18016A4521998-05-31031 May 1998 Monthly Operating Rept for May 1998 for Shearon Harris Nuclear Power Plant.W/980612 Ltr ML18016A7711998-05-26026 May 1998 Non-proprietary Rev 2 to HI-971760, Licensing Rept for Expanding Storage Capacity in Harris Spent Fuel Pools 'C' & 'D'. 1999-09-30
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REGULATO CATEGORY 1y INFORMATION DISTRIBUTION SYSTEM (RIDS) t )
%ACCESSION NBR:9703240125 DOC.DATE: 97/03/03 NOTARIZED: NO DOCKET FACIL:50-400 Shearon Harris Nuclear Power Plant, Unit 1, Carolina 05000400 AUTH. NAME AUTHOR AFFILIATION VERRILLI,M. Carolina Power & Light Co.
DONAHUE,J.W. Carolina Power & Light Co.
RECIP.NAME RECIPIENT AFFILIATION
SUBJECT:
LER 96-020-01:on 960906,inadvertent RWST boron dilution event occurred. Caused by personnel error. Operating procedure was revised to reflect "locked-closed" designation for RWST fill valve lDW-5.W/970317 ltr.
DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL SIZE:
TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc. E NOTES:Application for permit renewal filed. 05000400 RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD2-1 PD 1 1 LE,N 1 1 INTERNAL: ACRS 1 1 RAB 2 2 AEOD/SPD/RRAB 1 1 FILE CEN 1 1 NRR/DE/ECGB 1 1 NR B 1 1 NRR/DE/EMEB 1 1 NRR/DRCH/HHFB 1 1 NRR/DRCH/HICB 1 1 NRR/DRCH/HOLB 1 1 NRR/DRCH/HQMB 1 1 NRR/DRPM/PECB 1 1 NRR/DSSA/SPLB 1 1 NRR/DSSA/SRXB l. 1 D
RES/DET/EIB 1 1 RGN2 FILE 01 1 1 LITCO BRYCE,J 1 0
EXTERNAL: L ST LOBBY WARD 1 1 H 1 NOAC POOREiW. 1 1 NOAC QUEENERiDS 1 1 NRC PDR 1 1 NUDOCS FULL TXT 1 1 E
N NOTE TO ALL "RIDS" RECIPIENTS:
PLEASE HELP US TO REDUCE WASTE! CONTACT THE DOCUMENT CONTROL DESk, ROOM OWFN 5D-5(EXT. 4IS-2083) TO ELIMINATE YOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!
FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 25 ENCL 25
Carolina Power 8 Light Company Harris Nuclear Plant PO Box 165 New Hill NC 27562 MAR 17 1997 U.S. Nuclear Regulatory Commission Serial: HNP-97-035 ATTN: NRC Document Control Desk 10CFR50.73 Washington, DC 20555 SHEARON HARRIS NUCLEAR POWER PLANT UNIT 1 DOCKET NO. 50-400 LICENSE NO. NPF-63 LICENSEE EVENT REPORT 96-020-01 Sir or Madam:
In accordance with Title 10 to the Code of Federal Regulations, the enclosed revision to Licensee Event Report ¹96-020 is submitted. This revision provides additional information related to the safety consequences of the inadvertent boron dilution in the Refueling Water Storage Tank.
Sincerely, J. W. Donahue Director of Site Operations Harris Plant MV Enclosure c: Mr. J. B. Brady (HNP Senior NRC Resident)
Mr. L. A. Reyes (NRC Regional Administrator, Region II)
Mr. N. B. Le (NRC - NRR Project Manager)
'P703240i25 970303 PDR ADQCK 05000400 S PDR IllffIIIIIIIIIIIIIlfff IIIIlIIIIIIIIIIIIIIIIII
".$ 00g g State Road 1134 New Hill NC
U. S. Nuclear Regulatory Commission Document Control Desk / HNP-97-035 Page 2 of 2 CC: Mr. T. C. Bell Mr. R. T. Biggerstaff Ms. P. B. Brannan Mr. H. K. Chernoff (RNP)
Mr. B. H. Clark Mr.-J. M. Collins Mr. G. W. Davis Ms. S. F. Flynn Ms. J. P. Gawron (BNP)
Mr. H. W. Habermeyer Mr. M. D'. Hill Mr. W. J. Hindman Ms. C. W. Hobbs (HEEC)
Ms. W. C. Langston Mr. C. W. Martin (BNP)
Mr. R. D. Martin Mr. J. W. McKay Mr. P. M. Odom (RNP)
Mr. W. R. Robinson Mr. G. A. Rolfson Mr. R. F. Saunders Mr. C. N. Sweely Mr. M. A. Turkall (BNP)
Mr. T. D. Walt Mr. R. L. Warden (RNP)
HNP Real Time Training INPO Harris Licensing File Nuclear Records
f NRC FORM 366 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150.0104 (4.95) EXPIRES 04/30/98 ESTIMATED BURDEN PER RESPONSE TO COMPLY W(TH THIS MANDATORY (NFORMAT)ON COllECTION REOUEST: 500 HRS. REPORTED LESSONS LEARNED ARE LICENSEE EVENT REPORT (LER) INCORPORATED (NTO THE UCENSING PROCESS ANO fEO BACK TO (NOUSTRY.
FORWARD COMMENTS REGARDUIG BURDEN ESTlMATE TO THE (NFORMATIN AND RECORDS MANAGEMENT BRANCH IT@ F33L US. NUCIEAR REGULATORY COMM)SSION.
(See reverse for required number of WASHING'ION, OC 2(555000), ANO TO THE PAPERWORK REOUCT)ON PROJECT (3)50.
digits/characters for each block) 0)04L OffICE OF MANAGEMENT AND BUDGET, WASHINGTON, OC 20503.
FACIUTY NAME (1) DOCKET NUMBER (2) PAGE (3)
Harris Nuclear Plant Unit-1 50-400 1 OF 3 TITLE (4)
Inadvertent RWST boron dilution event caused by personnel error.
EVENT DATE {5) LER NUMBER {6) REPORT DATE (7) OTHER FACILITIES INVOLVED (8)
FACIUTY NAME DOCKET NUMBER MONTH OAY YEAR YEAR'EOUENTULL REVISION MONTH OAY YEAR NUMBER NUMBER 05000 FACIUTY NAME DOCKETNUMBER 9 6 96 96 020 01 3 3 97 05000 OPERATING THIS REPORT IS SUBMITTED PUR SUANT TO THE REQUIREMENTS OF 10 CFR B: {Check one o r more) {11)
MODE (9) 20.2201(b) 20.2203(a)(2) {v) 50.73(a) (2) O) 50.73(a) (2) (viii)
POWER 20.2203(a) (1) 20.2203(a) {3)(i) 50.73(a)(2)(ii) 50.73(a) {2)(x)
LEVEL (10) 0% 20.2203(a)(2) {i) 20.2203(a) (3) (ii) 50.73(a)(2) {lii) 73.71 20.2203(a)(2)(ii) 20.2203{a) (4) 50.73(a)(2)(iv) OTHER 20.2203(a)(2) (iii) 50.36(c) (1) 50.73(a)(2)(v) specify ln Abs(rect below or In NRC Form 366A 20.2203(a)(2) (iv) 50.36{c) (2) 50.73(a)(2)(vii)
LICENSEE CONTACT FOR THIS LER (12)
NAME TELEPHONE NUMBER (lrroiude Area Code)
Michael Verrilli Sr. Analyst - Licensing (919) 362-2303 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)
REPORTABLE REPORTABLE CAUSE SYSTEM COMPONENT MANUFACTURER CAUSE SYSTEM COMPONENT MANUFACTURER TO NPROS TO NPROS
.(Pc, 'PA'ada SUPPLEMENTAL REPORT EXPECTED {14) EXPECTED MONTH OAY 'YEAR YES SUBMISSION
{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 September 6, 1996, with the plant shutdown in mode 3 (Hot Standby), at approximately 1920 hours0.0222 days <br />0.533 hours <br />0.00317 weeks <br />7.3056e-4 months <br /> a licensed reactor operator filling the position of an auxiliary operator inadvertently commenced filling the Refueling Water Storage Tank (RWST) with demineralized water. His intent was to fill the Condensate Storage Tank (CST). Initial RWST level was approximately 95% and the inadvertent fill process increased level to greater than 100% and diluted the boron concentration to below the 2400 ppm Technical Specification limit. A RWST high level alarm was observed but not fully investigated. During the time period that the inadvertent RWST fill was in progress, the Boric Acid Tank (BAT) was recirculating for boric acid batching and was not'available as a boron injection flow path. With RWST boron concentration below Technical Specification limits and the BAT unavailable, no boron injection flow paths were available, which violated Technical Specification 3.1.2.2. and required entry into Technical Specification 3.0.3. At 0151 hours0.00175 days <br />0.0419 hours <br />2.496693e-4 weeks <br />5.74555e-5 months <br /> on September 7, 1996, the BAT was returned to service and declared operable, which allowed Technical Specification 3.0.3 to be exited.
The cause of this event was personnel error on the part of the operator that inadvertently opened the RWST fill valve ins{ead of the CST fill valve. The control room operators mvolved also contributed by not providing adequate direction to the auxiliary operator and did not properly respond to the RWST high level alarm.
Corrective actions involved restoring the BAT boron injection flow path, increasing RWST boron concentration counseling the involved operators and providing a briefing on the event to other operations personnel. The RWST fill valve was locked closed and the appropriate ~nerating procedure was be revised to reflect the "locked-closed" designation. A case study on this event was also prov(ued for Operations personnel.
This revision provides the evaluation of safety consequences related to the inadvertent RWST boron dilution event.
NAC FOAM 36BA e US. NUClEAA AEGUlATOAT COMMISSION II-99)
LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION FACIUTT NAME II) DOCKET lER NUMBER IB) PAGE I3)
SEOUENTMl RE+SON NUMBER NUMBEA Shearon Harris Nuclear Plant ~
Unit Nl 50400 2 OF 3 96 - 020 - 01 TEXT IIIsttrt spears sartdtd. tst tdif6tsl sopks tl IFRC Fnne 3SSlU II1)
EVENT DESCRIPTION:
On September 6, 1996, the plant was shutdown in mode 3 (Hot Standby) with primary plaqt temperature and pressure being controlled by the Steam Generator Power Operated Relief Valves. While in this mode, the Auxiliary Feedwater System is used to feed the Steam Generators, which requires periodic refilling of its water source, the Condensate Storage Tank (CST). At approximately 1920 hours0.0222 days <br />0.533 hours <br />0.00317 weeks <br />7.3056e-4 months <br /> a licensed reactor operator filling an auxiliary operator position inadvertently commenced filling the Refueling Water Storage Tank (RWST) with demineralized water instead of filling the CST. Initial RWST level was approximately 95% prior to the inadvertent fill process. The control room staff did observe a high RWST level alarm (98%) at approximately 2345 hours0.0271 days <br />0.651 hours <br />0.00388 weeks <br />8.922725e-4 months <br />, but made an incorrect assumption that the level increase was due to a change in temperature. They did agree to continue to observe RWST level, but no further investigation into the alarm was performed. While taking reactor operator logs approximately 45 minutes later, RWST level was observed to be at 100%. At this time the control room staff investigated the condition and discovered that 1DW-5 had been inadvertently opened instead of the CST fill valve. At 0042 hours4.861111e-4 days <br />0.0117 hours <br />6.944444e-5 weeks <br />1.5981e-5 months <br />, 1DW-5 was shut by the operator.
During the RWST level increase boron concentration decreased from 2476 ppm to approximately 2351 ppm (by calculation), which is below the 2400 ppm Technical Specification limit. While the inadvertent RWST fill was in progress, the Boric Acid Tank (BAT) was recirculating for boric acid batching and was not available as a boron injection flow path. With RWST boron concentration below Technical Specification limits and the BAT unavailable, no boron injection flow paths were available, which violated Technical Specification 3.1.2.2. and required entry into Technical Specification 3.0.3. At 0151 hours0.00175 days <br />0.0419 hours <br />2.496693e-4 weeks <br />5.74555e-5 months <br /> on September 7, 1996, the BAT was returned to service and declared operable, which allowed Technical Specification 3.0.3 to be exited. After increasing the boron concentration back to above 2400 ppm, the RWST was declared operable at 1422 hours0.0165 days <br />0.395 hours <br />0.00235 weeks <br />5.41071e-4 months <br /> on September 7, 1996.
CAUSE:
The cause of this event was personnel error on the part of the operator that inadvertently opened the RWST fill valve (1DW-5) instead of the CST fill valve. Self checking techniques were not adequately applied and the error was not cognitive. The main control room operators involved in the event also failed to implement good working practices by not providing adequate direction to the auxiliary operator for filling the CST and did not properly respond to the RWST high level alarm. They were involved in testing to restore the Normal Service Water System'(reference LER 96-018) and did not apply adequate attention to the alarm. A possible contributing factor to these human performance errors was fatigue. Hurricane Fran had passed over the Harris Plant area early that morning causing home and personal property damage, which prevented the involved shift personnel from resting as usual before coming to work on the evening shift of September 6, 1996.
SAFETY SIGNIFICANCE:
There were no safety consequences as a result of this event. The minimum RWST boron concentration and volume requirements exist to ensure that adequate shutdown margin can be achieved by negative reactivity injection. This ensures that reactor subcriticality can be achieved and maintained during all operating and postulated accident conditions. 'Following the inadvertent dilution, the resulting RWS t'oron concentration was calculated to be approximately 2153 ppm. Based on Operations Curve A-7-22, "Cycle 7 Minimum Shutdown Margin Boron Concentration vs. Moderator Temperature and Exposure" and the Core Operating Limit Report, 2153 ppm RWST boron concentration would provide adequate shutdown margin during Modes 1 through 4 operation throughout fuel cycle 7.
KAC FORM 366A US. NUCLEAA REGULATORY COMMISSION 66-95)
LICENSEE EVENT BEPOBT (LEB)
TEXT CONTINUATION FACILITY KAME II) OOCXET LEA NUMBER I6) PAGE I3)
SEOUEKTIAL KEY)SION YEAR KUM SEA KUMBER Shearon Harris Nuclear Plant ~
Unit Pl 50400 3 OF 3 96 - 020 - 01 TEXT pl mort Aport )r rtrpira( vst trrrtrvmtltopmt ol SAC Form 36atu I) i)
PREVIOUS SIMILAR EVENTS:
There have been no previous Technical Specification 3.0.3 entries due to inadvertently diluting the RWST to a boron concentratiorl'below Technical Specification limits.
CORRECTIVE ACTIONS COMPLETED:
- 1. The operator that inadvertently opened the RWST fill valve instead of the CST fill valve was counseled and provided a briefing on the event to other operations personnel. This was completed on September 10, 1996.
- 2. The main control room operators involved in not providing adequate direction to the auxiliary operator and not properly responding to the RWST high level alarm were counseled. This was completed on September 6, 1996.
Operating procedure (OP-112) was revised to reflect the "locked-closed" designation for RWST fill valve 1DW-5. This was completed on November 6, 1996.
- 4. This event was provided to Operations personnel as a case study to review the inappropriate actions taken by the control room staff. The importance of recognizing the effects of fatigue and informing supervision prior to allowing fatigue to affect work performance was emphasized. This was completed on December 3, 1996.