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LICENSEE EVENT REPORT (LER)
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, loF 0 1u PALISADES NUCLEAR PLANT TITLI 161 INADVERTENT CONTAINMENT ISOLATION ACTUATION DURING POST-MODIFICATION TESTING IVINT DATI Ill I.Ill N~ll 111 llll'OllT DATI 171 OTHlll l'ACll.ITIU lllllVOLVID 181 DOCltlT Nt.IMHlllll MONTH QAY Y!All Y!All t/ H~~~~~AL. tt :,: MONTH OAY YEAR N/A N/A Ol'lllATIMI THll llUOllT II 1U9111TTID l'UlllUANT TO THI lllOUllllMINTI 01' 10 Cl'll §: (Chcll -
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LICl,_.I CONTACT 1'011 THll Liii 11111 NAMI TILIPHONI NUMllll CSKozup, Technical Engineer, Palisades AlllA COOi COW'l.ITI Ofll LINI 1'011 IACH COMPONINT l'AILUlll DllCll181D IN TIOI llll'OllT 1111 CAUll IYITIM COWONINT SYSTEM COMl'ONINT MANUl'AC.
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I Abstract On October 1, 1988, at 1305,an inadvertent containment isolation actuation signal was received.
This event occurred during the performance of a post-modification test to verify proper reinstallation of the left channel containment high radiation initiate switch [JE;17].
This switch was being relocated within Control Room pane~ EC-13 as part of the Palisades detailed Control Room design review.
The reactor was in the refueling condition at the time of the event.
After relocation of containment high radiation initiate switch CHRC/CS, a post-modification test was performed to verify proper installation of relocated equipment.
During performance of this test, precautions were taken to prevent inadvertent actuations by rendering relays downstream inoperable.
The root cause of the actuation could not be absolutely identified, however, the most likely cause is felt to be associated with other activities in progress not being performed as part of this event.
8811040135 881031 PDR ADOCK 05000500 S
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19-&31 LER 88019A-LI01-NL04 I
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N"C Form.1laA 19-331 LICENSE ENT REPORT (LERI TEXT CONTINUA 11 N U.I. NUCLEAlll lllEDULATOlllY COMMIDION APPROVED OMS ~0 3150~104 EXPIRES 8131185 FACILITY NAMI 111 DOCKIT NU... 1111 121 LEiii N~llll 111
~ADE 131 PALISADES NUCLEAR PLANT TEXT 11' -
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- Forrrt.-.i'1J 1171 NlllllC FOflllM Ja8A 19-831
Description
On October 1, 1988, at 1305,an inadvertent containment isolation actuation signal was received.
This event occurred during the performance of a post-modification test to verify proper*reinstallation of the left channel containment high radiation initiate switch [JE;l7].
This switch was being relocated within Control Room panel EC-13 as part of the Palisades detailed Control Room design review.
The reactor was in the refueling condition at the time of the event.
The containment isolation control system is designed to isolate the Containment Building upon occurrence of either containment high pressure or containment high radiation.
This system is designed on a two channel (left and right) concept with redundancy and physical separation.
Each channel is capable of initiating a containment isolation.
A containment isolation actuation signal is initiated on containment high radiation with two-out-of-four logic.
Radiation levels are monitored by four detectors located in the lower level of the Containment Building.
Coincident two-out-of-four high-radiation signals will trigger an alarm in the Control Room, close all containment isolation valves not required f~r engineered safety features and isolate the Control Room ventilation.
system.
After relocation of containment high radiation initiate switch CHRL/CS, post-modification test T-FC-760-5-1, Testing of Switch and Light Relocation, on Panel EC-13 was performed.
This test was designed to verify proper installation of relocated equipment without causing system actuations.
During performance of the portion of this test associated with initiate switch CHRL/CS, the containment high radiation relays (5R-l through 5R-8)
[JE;RLY] downstream. of the actuation relays were rendered inoperable to prevent inadvertent actuations.
Initiate switch CHRL/CS was then depressed to simulate a high radiation signal, thereby energizing two of the actuation relays.
However, when initiate switch CHRL/CS was depressed, a right channel containment high radiation signal and a subsequent containment isolation actuation signal was received.
Cause Of The Event
In attempting to identify the cause of this event, the following steps were taken:
- 1.
Operations, Testing and Construction personnel involved with the test were interviewed to ascertain if any anomalies were noted.
No difficulties were noted.
LER 88019A-LI01-NL04
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NllC '""" JMA 19-l!JJ LICENSE ENT REPORT (LER) TEXT CONTINU, ON U.I. NUCLEAll llEQULATOllY COMMIDIO..
APPROVED OMll NO 3150--01~
EXPIRES* 8131185 FACILITY NAMI 111 DOCKET NUMIUI 121 LI II NUMel Ill Ill PAGE Ill PALISADES NUCLEAR PLANT o 1s 1 o 1 o 1 o 12 1 51 5 s1 a_ o 1 11 9 _b 1 o o 1 3 aF o 14
- 2.
The test was re-performed twice, on October 5 and October 7, 1988, with no indication of problems or subsequent inadvertent containment isolation actuations.
- 3.
The Events Recorder and Data Logger outputs were reviewed.
However, no information was available as to whether the inadvertent actuation was initiated by the left or right channel.
The Data Logger did indicate that a right channel Control Room air filter fan had started.
- 4.
Circuit continuity checks were performed to verify the two-out-of-four logic was correctly wired.
All wiring was verified to be correct.
- 5.
Switching and tagging orders for the time period of the test were reviewed to determine if other equipment tagged could have interacted with the actuation logic.
No such equipment was noted.
- 6.
The design of the test was discussed and reviewed with Electrical Maintenance personnel and independently verified by additional Plant Projects Department engineering personnel.
These reviews confirmed that isolation points were adequate to prevent inadvertent actuations.
- 7.
A review of other work in progress or conditions in effect in the area of relays associated with test was performed.
This review revealed that other activities were in progress in the vicinity of these relays at the time of the test. Therefore, it is possible that other personnel working in panel EC-13 may have bumped an associated relay or caused shorting across an actuation relay.
Based on the above investigations, the root cause of this event could not be absolutely identified. However, the most likely cause is felt to be associated with activities not being performed as part of this test.
Corrective Actions
After reviewing all data collected and the direction provided in the test, the test was re~performed on October 5 and October 7, 1988.
Neither of these test performances resulted in inadvertent containment isolation actuation signals.
These efforts further demonstrated the test procedure and circuit lo~ic were adequate.
LER 88019A-LI01-NL04
N,.C Ferm JMA li~JI LICENSEE ENT REPORT (LERI TEXT CONTINUATION U.I. NUCLEA,. IUGULATO,.Y COMMIDION APPROVEO OMll NO 3150--<Jta.
EXPIRES* B/J1185 FACILITY NAMI 111 Liii Nl*all! 111 PAGE 131 PALISADES NUCLEAR PLANT 0 l5IOIOIOl21515818-01119 -b 10 014 OFO 14 TEXT llf"""" -
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-/lillC "- -..'111171 Nll'JC FOll'JM 388A 19~31 Operations Department procedures will be reviewed to determine the need for revision regarding information recovery after inadvertent engineered safety feature actuations.
This review will specifically focus on guidance provided regarding careful and deliberate recovery steps to pressure troubleshooting and root cause determination information.
Analysis Of The Event
During this event, the reactor was in the refueling condition and all required containment isolation features for this condition were in place.
Therefore, no threat to the health and safety of the public was imposed by this inadvertent actuation.
This event is being reported per 10CFR50.73(a)(2)(iv) as an event which resulted in the actuation of an engineered safety feature.
Additional Information
F~r additional information regarding other inadvertent containment isolation signals, reference Licensee Event Reports84-002, 84-005,84-011, 05-030,86-008, 88-014,88-016, 88-017 and 88-018.
LER 88019A-LI01-NL04
consumers Power POWERING MICHlliAN'S PROliRESS General Offices: 1945 West Parnell Road, Jackson, Ml 49201 * (517) 788-0550 October 31, 1988 Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 DOCKET 50-255 - LICENSE DPR PALISADES PLANT -
LICENSEE EVENT REPORT 88-019 - INADVERTENT CONTAINMENT ISOLATION ACTUATION DURING POST-MODIFICATION TESTING Licensee Event Report (LER) 8.8-019, (Inadvertent Containment Isolation Actuation During Post-Modification Testing) is attached.
This event is reportable to the NRC per 10CFR50.73(a)(2)(iv).
Brian D Johnson Staff Licensing Engineer CC Administrator, Region III, USNRC NRC Resident Inspector - Palisades Attachment OC1088-0191-NL04
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| 05000255/LER-1988-001-01, :on 880123,discovered That Pressure Level on Primary Coolant Sys Exceeded 55% Level Required by SOP-1. Caused by Personnel Failing to Maintain Low Temp Overpressure Protection Sys |
- on 880123,discovered That Pressure Level on Primary Coolant Sys Exceeded 55% Level Required by SOP-1. Caused by Personnel Failing to Maintain Low Temp Overpressure Protection Sys
| | | 05000255/LER-1988-002, Forwards Corrected Semiannual Effluent Release & Waste Disposal Rept for Period Jan-June 1988,including LER 88-002 Inadvertently Omitted from Original 880831 Submittal & Supplemental Jul-Dec 1987 Rept | Forwards Corrected Semiannual Effluent Release & Waste Disposal Rept for Period Jan-June 1988,including LER 88-002 Inadvertently Omitted from Original 880831 Submittal & Supplemental Jul-Dec 1987 Rept | | | 05000255/LER-1988-002-01, :on 880209,inservice Waste Gas Decay Tank Lost Approx 26 Psi.Caused by Failure to Hold Gaseous Radwaste for Min of 15 Days Per Tech Specs.Pressure Drop Isolated & Air Samples Taken by Health Physics Personnel |
- on 880209,inservice Waste Gas Decay Tank Lost Approx 26 Psi.Caused by Failure to Hold Gaseous Radwaste for Min of 15 Days Per Tech Specs.Pressure Drop Isolated & Air Samples Taken by Health Physics Personnel
| 10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications 10 CFR 50.73(a)(2)(i) | | 05000255/LER-1988-003-01, :on 880221,23 & 24,secondary Side Contents of Steam Generators E-50A & E-50B Discharged to Lake Michigan as Continuous Release.Samples Disposed of Prior to Required Analyses.Caused by Procedure Deficiency |
- on 880221,23 & 24,secondary Side Contents of Steam Generators E-50A & E-50B Discharged to Lake Michigan as Continuous Release.Samples Disposed of Prior to Required Analyses.Caused by Procedure Deficiency
| 10 CFR 50.73(a)(2)(i) | | 05000255/LER-1988-004, :on 880303,required Dissolved Oxygen Analysis Not Completed.Caused by Personnel Error.Data Sheets Revised to Clearly Identify Analyses Required by Tech Specs & Required Time to Be Completed |
- on 880303,required Dissolved Oxygen Analysis Not Completed.Caused by Personnel Error.Data Sheets Revised to Clearly Identify Analyses Required by Tech Specs & Required Time to Be Completed
| 10 CFR 50.73(a)(2)(i) | | 05000255/LER-1988-005, :on 880304,stroking of Svc Water Containment Isolation Valves Occurred During Prohibited Conditions. Caused by Procedural Deficiencies.Administrative Procedure 9.21 Revised & Tech Spec Tests Reviewed |
- on 880304,stroking of Svc Water Containment Isolation Valves Occurred During Prohibited Conditions. Caused by Procedural Deficiencies.Administrative Procedure 9.21 Revised & Tech Spec Tests Reviewed
| 10 CFR 50.73(a)(2)(i) | | 05000255/LER-1988-006, :on 880327,auxiliary Feedwater Pump Inadvertently Started When Auxiliary Feedwater Actuation Sys Manually Actuated.Caused by Insufficient Guidance Available in Alarm/Response Procedures.Training Provided |
- on 880327,auxiliary Feedwater Pump Inadvertently Started When Auxiliary Feedwater Actuation Sys Manually Actuated.Caused by Insufficient Guidance Available in Alarm/Response Procedures.Training Provided
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000255/LER-1988-007, :on 880429,auxiliary Feedwater Actuation Sys Actuated.Caused by Surveillance Procedure RO-21 Inadequacy That Permitted Input of Test Signal to Result in Quick Open Signal Generation.Procedure Corrected & Tested |
- on 880429,auxiliary Feedwater Actuation Sys Actuated.Caused by Surveillance Procedure RO-21 Inadequacy That Permitted Input of Test Signal to Result in Quick Open Signal Generation.Procedure Corrected & Tested
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000255/LER-1988-008, :on 880512,containment Penetration Declared Inoperable Due to Failure to Complete Required Local Leak Rate Test within Prescribed Time Limitation.Caused by Data Entry Error.Test Schedule Verified |
- on 880512,containment Penetration Declared Inoperable Due to Failure to Complete Required Local Leak Rate Test within Prescribed Time Limitation.Caused by Data Entry Error.Test Schedule Verified
| 10 CFR 50.73(a)(2)(i) | | 05000255/LER-1988-009, :on 880516,failure to Maintain Continuous Fire Watch as Required by Tech Spec 3.22.3 Occurred.Caused by Poor Performance of Security Officer.Review Conducted,Only to Determine Problem as Being Isolated |
- on 880516,failure to Maintain Continuous Fire Watch as Required by Tech Spec 3.22.3 Occurred.Caused by Poor Performance of Security Officer.Review Conducted,Only to Determine Problem as Being Isolated
| 10 CFR 50.73(a)(2)(i) | | 05000255/LER-1988-010, :on 880609,discrepancy Identified in Radiological Consequence Analysis of Plant Fsar,Section 14.22.No Cause Can Be Readily Identified for Failure to Follow Plant Mod Procedures.Analysis Initiated |
- on 880609,discrepancy Identified in Radiological Consequence Analysis of Plant Fsar,Section 14.22.No Cause Can Be Readily Identified for Failure to Follow Plant Mod Procedures.Analysis Initiated
| 10 CFR 50.72(b)(3)(ii), Degraded or Unanalyzed Condition | | 05000255/LER-1988-011, :on 880624,determined That Single Failure Criteria Not Met for All Ac Instrument Bus Alignments. Caused by Personnel Error.Evaluation Performed to Determine Feasibility of Performing Design Mods |
- on 880624,determined That Single Failure Criteria Not Met for All Ac Instrument Bus Alignments. Caused by Personnel Error.Evaluation Performed to Determine Feasibility of Performing Design Mods
| 10 CFR 50.73(a)(2)(v), Loss of Safety Function | | 05000255/LER-1988-012, :on 880808 & 1205,unusual Event Declared Due to Plant Chemistry Notifying Shift Supervisor of Secondary Leak Rate at 0.31 Gpm.Caused by Damaged Tube Due to Either Plate Stress,Plate Growth or Tube Denting |
- on 880808 & 1205,unusual Event Declared Due to Plant Chemistry Notifying Shift Supervisor of Secondary Leak Rate at 0.31 Gpm.Caused by Damaged Tube Due to Either Plate Stress,Plate Growth or Tube Denting
| | | 05000255/LER-1988-013, :on 880822,control Room HVAC Sys Declared Inoperable for Failing to Meet Tech Spec Criteria.Caused by Open Electrical Penetrations in Control Room Floor.Tech Spec Test RO-28 Revised to Correct Fan line-up |
- on 880822,control Room HVAC Sys Declared Inoperable for Failing to Meet Tech Spec Criteria.Caused by Open Electrical Penetrations in Control Room Floor.Tech Spec Test RO-28 Revised to Correct Fan line-up
| 10 CFR 50.73(a)(2)(vi) 10 CFR 50.73(a)(2)(i) 10 CFR 50.72(b)(3)(ii), Degraded or Unanalyzed Condition | | 05000255/LER-1988-014, :on 880903,area Radiation Monitor Inadvertently Struck,Resulting in Automatic Actuation of Containment Isolation Sys.Caused by Workmen Performing Activities from Reactor Cavity Deck.Monitor Reset |
- on 880903,area Radiation Monitor Inadvertently Struck,Resulting in Automatic Actuation of Containment Isolation Sys.Caused by Workmen Performing Activities from Reactor Cavity Deck.Monitor Reset
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000255/LER-1988-015, :on 880903,fuel Bundle Observed Hanging from Bottom of Upper Guide Structure.Caused by Bundle Adhering to Guide Pins.Remainder of Fuel Bundles in Core Visually Inspected |
- on 880903,fuel Bundle Observed Hanging from Bottom of Upper Guide Structure.Caused by Bundle Adhering to Guide Pins.Remainder of Fuel Bundles in Core Visually Inspected
| | | 05000255/LER-1988-016, :on 880911,inadvertent Containment Isolation Signal Received When Temporary Filter Element Carried by Radiation Monitor RIA-231.Caused by Temporary Filter Element Being Removed from Containment.Monitor Reset |
- on 880911,inadvertent Containment Isolation Signal Received When Temporary Filter Element Carried by Radiation Monitor RIA-231.Caused by Temporary Filter Element Being Removed from Containment.Monitor Reset
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000255/LER-1988-017, :on 880911,inadvertent Containment Isolation Signals Received.Caused by Electrical Noise Generated from Starting & Stopping Motor for Temporary Pump Which Seized. Logic Reset & Failed Pump Replaced |
- on 880911,inadvertent Containment Isolation Signals Received.Caused by Electrical Noise Generated from Starting & Stopping Motor for Temporary Pump Which Seized. Logic Reset & Failed Pump Replaced
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000255/LER-1988-018, :on 881027,inadvertent Containment Isolation Signal Received.Caused by Personnel Error & Inadequate Communication.Administrative Procedures 9.05 & 4.03 Revised |
- on 881027,inadvertent Containment Isolation Signal Received.Caused by Personnel Error & Inadequate Communication.Administrative Procedures 9.05 & 4.03 Revised
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000255/LER-1988-019-01, :on 881001,inadvertent Containment Isolation Actuation Signal Received During Performance of post-mod Test to Verify Proper Reinstallation of Left Channel Containment High Radiation Initiate Switch |
- on 881001,inadvertent Containment Isolation Actuation Signal Received During Performance of post-mod Test to Verify Proper Reinstallation of Left Channel Containment High Radiation Initiate Switch
| 10 CFR 50.73(a)(2)(iv), System Actuation | | 05000255/LER-1988-020, :on 881027,as-found Lift Pressure of Pressurizer Safety Valve RV-1039 Exceeded Tech Spec Limits. Cause Unknown & Under investigation.RV-1039 Disassembled, Inspected & Adjusted & Valve Disc Replaced |
- on 881027,as-found Lift Pressure of Pressurizer Safety Valve RV-1039 Exceeded Tech Spec Limits. Cause Unknown & Under investigation.RV-1039 Disassembled, Inspected & Adjusted & Valve Disc Replaced
| 10 CFR 50.73(a)(2)(i) | | 05000255/LER-1988-021, :on 881104,several Spurious Unexplained Svc Water Pump Trips Occurred.Caused by Original Relay Settings Which Did Not Account for Motor Svc Factor Rating.Protective Relays Reviewed |
- on 881104,several Spurious Unexplained Svc Water Pump Trips Occurred.Caused by Original Relay Settings Which Did Not Account for Motor Svc Factor Rating.Protective Relays Reviewed
| 10 CFR 50.73(a)(2)(ii)(B), Unanalyzed Condition 10 CFR 50.72(b)(3)(ii), Degraded or Unanalyzed Condition | | 05000255/LER-1988-022, :on 881202,foreign Matl on Valve Seat Resulted in Inoperable Isolation Valve.Valve CV-1037 Disassembled, Inspected & Repair & Procedures Re Cleanliness Control Upgraded |
- on 881202,foreign Matl on Valve Seat Resulted in Inoperable Isolation Valve.Valve CV-1037 Disassembled, Inspected & Repair & Procedures Re Cleanliness Control Upgraded
| 10 CFR 50.72(b)(3)(ii), Degraded or Unanalyzed Condition | | 05000255/LER-1988-023, :on 881117,component Cooling Water Room Radwaste Drain Line Isolation Valve MV-RW118 Found Not Fully Closed.Caused by Inadequate post-mod Testing of Installed Chain Operator.Valve Operator Modified |
- on 881117,component Cooling Water Room Radwaste Drain Line Isolation Valve MV-RW118 Found Not Fully Closed.Caused by Inadequate post-mod Testing of Installed Chain Operator.Valve Operator Modified
| 10 CFR 50.73(a)(2)(v), Loss of Safety Function | | 05000255/LER-1988-024, :on 881224,14% of Contents of Waste Gas Decay Tank T-68A Released Contrary to Plant Tech Spec 3.24.6. Caused by Operator Error.Sop 18A, Radwaste Sys - Gaseous Revised |
- on 881224,14% of Contents of Waste Gas Decay Tank T-68A Released Contrary to Plant Tech Spec 3.24.6. Caused by Operator Error.Sop 18A, Radwaste Sys - Gaseous Revised
| 10 CFR 50.73(a)(2)(i) | | 05000255/LER-1988-025, :on 881226,reactor Regulating Rod Group 3 Not Fully Withdrawn While Rod Group 4 Withdrawal Continued. Caused by Personnel Error.Event Reviewed w/on-shift Personnel by Operations Superintendent |
- on 881226,reactor Regulating Rod Group 3 Not Fully Withdrawn While Rod Group 4 Withdrawal Continued. Caused by Personnel Error.Event Reviewed w/on-shift Personnel by Operations Superintendent
| 10 CFR 50.73(a)(2)(i) |
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