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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML18066A6271999-09-0202 September 1999 LER 98-011-01:on 981217,inadequate Lube Oil Collection Sys for Primary Coolant Pumps Was Noted.Caused by Design Change Not Containing Appropriate Level of Rigor.Exemption from 10CFR50,App R Was Requested.With 990902 Ltr ML18066A6221999-08-20020 August 1999 LER 99-002-00:on 990722,TS Surveillance Was Not Completed within Specified Frequency.Caused by Failure to Incorporate Revised Frequency Into Surveillance Schedule in Timely Manner.Verified Implementation.With 990820 Ltr ML18066A3781999-01-20020 January 1999 LER 98-013-00:on 981222,safeguards Transfer Tap Changer Failure Caused Inadvertant DG Start.Caused by Failed Motor Contactor.Contactor Was Replaced.With 990120 Ltr ML18068A4851998-10-29029 October 1998 LER 97-011-01:on 971012,starting of Primary Coolant Pump with SG Temps Greater than Cold Leg Temps Occurred.Caused by Inadequate Procedures & Operator Decision.Sop Used for Starting Primary Coolant Pump Enhanced ML18066A2831998-08-18018 August 1998 LER 98-010-00:on 980721,reactor Manually Tripped.Caused by Failure of Coupling Which Drives Feedwater Pump Main Lube Oil Pump.Main Lube Oil Pump Coupling & Associated Components Replaced & Satisfactorily Tested ML18066A2261998-06-30030 June 1998 LER 98-009-00:on 980531,small Pinhole Leak Found on One of Welds,During Leak Test Following Replacement of Pcs Sample Isolation Valves.Caused by Welder Error.Leaking Welds Repaired ML18066A1781998-06-0909 June 1998 LER 98-008-00:on 980511,noted That Procedure Did Not Fully Satisfy Requirement to Test High Startup Rate Trip Function. Caused by Misunderstanding of Testing Requirements.Revised TS Surveillance Test Procedure & Reviewed Other Procedures ML18065B2451998-05-13013 May 1998 LER 98-007-00:on 980413,HPIS Sys Was Noted Inoperable During TS Surveillance Test.Caused by Performance of Flawed Procedure.Operators & Engineers Will Be Trained to Improve Operational Decision Making Through Resources & Knowledge ML18065B1151997-12-0909 December 1997 LER 97-013-00:on 971110,failure to Closure Test Two Check Valves Resulted in Violation of TS 6.5.7 Occurred.Caused by Close Function for Check Valves.Check Valves Tested to Confirm Proper Closure Capability ML18067A7751997-11-11011 November 1997 LER 97-011-00:on 971012,primary Coolant Pump Was Started W/Sg Temperatures Greater than Cold Leg Temperature.Caused by Inadequate Procedures & Operator Decision Making.Critique of Event Conducted W/Operators Involved ML18067A7581997-10-30030 October 1997 LER 97-010-00:on 970930,determined That Inadequacy in App R Analysis Resulted in Condition Outside Design Basis of Plant.Caused by Missing Cable in Circuit & Raceway Schedule. Developed New Evaluation Re ASD Valves Validation ML18067A7461997-10-23023 October 1997 LER 97-009-00:on 970923,discovered Procedure Weakness Re Implementation of App R Shutdown Methodology.Caused by Human Error.Revised Off-Normal Procedure ONP-25.2, Alternate Safe Shutdown Procedure. ML18067A7191997-10-10010 October 1997 LER 97-008-00:on 970912,spurious Valve Operation Could Result in Loss of Shutdown Capabilities Per 10CFR50,App R, Section Iii.L,Was Discovered.Caused by Failure to Validate Info from App R.Design Bases for SW Backup Reviewed ML18067A6951997-09-24024 September 1997 LER 97-007-00:on 970826,discovered Inadequate Testing of DG Sequencer Control Relay Contacts.Caused by Oversight on Part of Personnel Involved in Installation of Facility Change FC-800.Tested 106D-1/XL & 106D-2/XL Relay Contacts ML18067A5651997-06-0303 June 1997 LER 96-013-01:on 961115,DC Breaker Failed During Testing for as-found Trip Setting.Failure Caused by Oversight within Preventive Maint Program.Breaker Was Replaced & Tested ML18067A5461997-05-12012 May 1997 LER 97-006-00:on 970412,overtime Limits Were Exceeded for Radiation Protection Technicians.Caused by Inadequate Design,Review & Proper Verifications of Overtime Work Schedule.Communicate Overtime Limitation Responsibilities ML18067A4431997-03-24024 March 1997 LER 97-004-00:on 970221,trip of High Pressure Safety Injection Pump Occurred While Filling Safety Injection Tank Resulting in TS Violation.Caused by Particle Lodged Between Surface of Indication disk.Y-phase Relay Was OOS ML18067A4391997-03-21021 March 1997 LER 97-005-00:on 961220,operation of Plant Outside Design Basis Occurred Due to an Unacceptable Repair on Main Steam Isolation Valves.Pipe Plugs Permanently Repaired ML18067A4401997-03-21021 March 1997 LER 97-003-00:on 961101,four Piping Lines Were Determined to Be Potentially Susceptible to Pressurization Due to Containment Temperature Increase During an Accident.Cac Discharge Piping Will Be verified.W/970321 Ltr ML18066A8931997-02-21021 February 1997 LER 97-002-00:on 970123,failure to Meet TSs 4.5.2d(1)(b) for Testing of Emergency Escape Airlock Occurred.Caused by Missed Surveillance.Emergency Escape Air Lock Testing Was Completed & Declared operable.W/970221 Ltr ML18066A8751997-02-0505 February 1997 LER 97-001-00:on 970106,TAVE Temp Dropped Below Minimum Temp for Criticality.Caused by Control Rod Withdrawal Rate to Increase Power Not Sufficient to Match Increase in Steam. Turbine Bypass Valve Actuator repaired.W/970205 Ltr ML18066A8041996-12-23023 December 1996 LER 96-014-00:on 961124,class 1E Raychem Cable Splices Were Installed Incorrectly.Caused by Incorrectly Made Electrical Splices.Total of 270 Splices Have Been Replaced within Containment ML18066A7831996-12-16016 December 1996 LER 96-013-00:on 961115,DC Breaker Failure During Testing for as-found Trip Setting Occurred.Cause Under Investigation.All molded-case Circuit Breakers in DC Distribution Panels Were Replaced ML18065A9951996-10-0404 October 1996 LER 96-002-01:on 960116,initiated TS Required Shutdown Due to Safeguards Cable Fault.Both Sets (Six Cables) of Cables Were Replaced & Installed Through Turbine Generator Bldg ML18065A9171996-09-0909 September 1996 LER 95-012-00:on 960809,TS Violation Occurred,Due to No Senior Reactor Operator in Cr.Caused by Extensive Remodeling.Cr Remodeling completed.W/960909 Ltr ML18065A8961996-08-29029 August 1996 LER 96-011-00:on 960730,CR Continuous Air Monitor Alarm Setpoint Improperly Established.Caused by Failure to Utilize Mod Process in 1988 Leading to Failure to Properly Select & Calibrate Instruments ML18065A8811996-08-20020 August 1996 LER 96-005-01:on 960207,determined Fuse on Main Supply to Two Safety Related DC Panels & Panel Branch Circuit Breakers Not Properly Coordinated.Caused by Lack of Thorough Associated Circuits Analysis.Supply Fuse to Panels Replaced ML18065A8741996-08-16016 August 1996 LER 96-010-00:on 960717,high Pressure Safety Injection Pump Tripped While Filling Safety Injection Tank.Caused by Faulty 150/151Y-207 Time Overcurrent Relay.All Similar Relays in Time Overcurrent Application Have Been Inspected ML18065A8651996-08-12012 August 1996 LER 96-009-00:on 960712,identified Penetration Seal Deficiency on Fire Barriers Caused by Failure to Perform & Document Comprehensive Fire Barrier Evaluation.Developed Basis document.W/960812 Ltr ML18065A8601996-08-0202 August 1996 LER 96-006-01 on 960207,discovered Limits of Design Analysis Could Have Been Violated.Subsequent Tests & Analyses Facility Did Not Exceed Basis.Operating Procedures Have Been Revised to Treat 2530 Megawatts Limit as Absolute Limit ML18065A8321996-08-0101 August 1996 LER 96-003-01:on 960115,alternate Shutdown Panel Inverter Resulted in Unavailability of Panel.Replaced Defective Inverter Alarm Logic Board ML18065A7691996-06-12012 June 1996 LER 96-008-00:on 960513,fire Door Not Maintained Open in Accordance W/Design Basis.Cause Under Investigation. Engineering Evaluation Performed & Revised Documents, Surveillance & Test procedures.W/960612 Ltr ML18065A6901996-05-0101 May 1996 LER 95-001-01:on 950302,malfunction of Left Channel DBA Sequencer Resulted in Inadvertent Actuation of Left Channel Safeguards Equipment.Replaced microprocessor.W/960501 Ltr ML18065A6681996-04-22022 April 1996 LER 96-007-00:on 960321,inadequate Emergency Lighting & Ventilation in post-fire Safe Shutdown Areas.Caused by App R Program Documentation Insufficient to Demonstrate Regulatory Compliance.Lighting modified.W/960422 Ltr ML18065A5721996-03-11011 March 1996 LER 96-006-00:on 960207,average Reactor Power Level Exceeded License Limit Due to Insufficient Procedural Guidance. GOP-12 Revised to Treat 2,530 Mwt Limit as Absolute Limit Requiring Immediate Corrective Action If Exceeded ML18065A5261996-03-0101 March 1996 LER 96-005-00:on 960202,fuse on Main Supply to Two SR DC Panels & Panel Branch Circuit Breakers Not Properly Coordinated.Caused by Inadequate Electrical/App R Design Review.Implemented Hourly Fire tours.W/960301 Ltr ML18065A5111996-02-19019 February 1996 LER 94-012-02:on 940427,determined That Internal Ground in Thermal Margin Monitor Causes Nonconformance W/Rps Design Basis.Incorporated RPS Failure Modes & Effects Analysis in Plant DBD.W/960219 Ltr ML18065A5061996-02-19019 February 1996 LER 96-004-00:on 960118,SIS Disabled W/Primary Coolant Sys Greater than 300 F.Caused by Personnel Error.Permanent Maint Procedure to Disable/Enable SIS Actuation on Low Pressurizer Pressure Will Be Revised to Align W/Ts ML18065A5021996-02-15015 February 1996 LER 96-003-00:on 960115,technicians Found Low Voltage cut- Off for Alternate Shutdown Panel Inverter Set That Resulted in Unavailability of Panel.Caused by Inadequate Post Mod. Readjusted Set Point to Minimum setting.W/960215 Ltr ML18065A4581996-01-31031 January 1996 LER 96-001-00:on 960103,failed to Test Duplicate Equipment. Caused by STS No Longer Containing Requirement for cross- Train Testing of Duplicate Components.Will Submit Request to Delete Subj Requirements from TS.W/960131 Ltr ML18065A4421996-01-19019 January 1996 LER 95-016-00:on 951226,did Not Analyze Primary Coolant Samples within 72 H.Caused by Belief Acceptability to Save Pcs Samples for Choride Analysis Past 72 H.Counseled Chemistry Supervision.W/960119 Ltr ML18065A4041996-01-15015 January 1996 LER 95-014-00:on 950119,PCP Oil Collection Deficiencies Created by FC-860 Piping Mod.Caused by Inadequate DBD for Sys & Lack of Review by Experienced Fire Protection Personnel.Updated Design Basis documentation.W/960115 Ltr ML18065A3291995-12-0404 December 1995 LER 95-013-00:on 951103,circuit Fuse Coordination Deficiency Which Affects App R Safe Shutdown Equipment Noted.Design of Fuse Coordination in Potential Transformer Circuits Will Be Evaluated & Modified as required.W/951204 Ltr ML18065A2361995-11-0202 November 1995 LER 95-012-00:on 950701,discovered Unqualified Electrical Connection in Containment SW Outlet Valve Controller.Caused by Failure of Assigned Engineers to Available Info.Replaced Wire Nuts W/Inline Butt connections.W/951102 Ltr ML18065A2051995-10-20020 October 1995 LER 95-008-01:on 950728,discovered That None of Four Containment High Pressure Channels Would Initiate Reactor Trip Due to Programmatic Deficiencies.Administrative Procedure (AP) 9.44,AP 9.45 & AP 10.44 Will Be Revised ML18065A0841995-09-18018 September 1995 LER 95-011-00:on 950817,CR 40 Withdrawal Occurred When Given Insertion Signal Due to skill-based Error in Crimping & Removing Foreign Matl from CRDM Motor Connection Box.Crd Package replaced.W/950918 Ltr ML18065A0681995-09-14014 September 1995 LER 95-010-00:on 950815,ESFA Resulted in Manual Rt Following Isolation of Pcs.Replaced Failed Instrument Line ML18065A0651995-09-0808 September 1995 LER 95-009-00:on 950728,discovered Lack of Procedural Guidance for Pump Repair Following Fire.Proposed Use of Power Supply Breaker Did Not Adequately Address Effect of Loss of Control Power.Performed Independent Assessment ML18064A8781995-08-28028 August 1995 LER 95-008-00:on 950728,discovered During Design Change Testing That None of Four Containment High Pressure Channels Would Initiate Rt.Caused by Programmatic Deficiencies. Reviewed Selected Tests & Mods from Recent Refueling Outage ML18064A8831995-08-21021 August 1995 LER 95-007-00:on 950720,discovered That 12 Instrument Loops Had V-bolted Type Qualified Cable Splices Connected to Wires W/Exposed Kapton Insulation.Caused by Human Error.All V- Bolted Splices Replaced w/in-line design.W/950821 Ltr 1999-09-02
[Table view] Category:RO)
MONTHYEARML18066A6271999-09-0202 September 1999 LER 98-011-01:on 981217,inadequate Lube Oil Collection Sys for Primary Coolant Pumps Was Noted.Caused by Design Change Not Containing Appropriate Level of Rigor.Exemption from 10CFR50,App R Was Requested.With 990902 Ltr ML18066A6221999-08-20020 August 1999 LER 99-002-00:on 990722,TS Surveillance Was Not Completed within Specified Frequency.Caused by Failure to Incorporate Revised Frequency Into Surveillance Schedule in Timely Manner.Verified Implementation.With 990820 Ltr ML18066A3781999-01-20020 January 1999 LER 98-013-00:on 981222,safeguards Transfer Tap Changer Failure Caused Inadvertant DG Start.Caused by Failed Motor Contactor.Contactor Was Replaced.With 990120 Ltr ML18068A4851998-10-29029 October 1998 LER 97-011-01:on 971012,starting of Primary Coolant Pump with SG Temps Greater than Cold Leg Temps Occurred.Caused by Inadequate Procedures & Operator Decision.Sop Used for Starting Primary Coolant Pump Enhanced ML18066A2831998-08-18018 August 1998 LER 98-010-00:on 980721,reactor Manually Tripped.Caused by Failure of Coupling Which Drives Feedwater Pump Main Lube Oil Pump.Main Lube Oil Pump Coupling & Associated Components Replaced & Satisfactorily Tested ML18066A2261998-06-30030 June 1998 LER 98-009-00:on 980531,small Pinhole Leak Found on One of Welds,During Leak Test Following Replacement of Pcs Sample Isolation Valves.Caused by Welder Error.Leaking Welds Repaired ML18066A1781998-06-0909 June 1998 LER 98-008-00:on 980511,noted That Procedure Did Not Fully Satisfy Requirement to Test High Startup Rate Trip Function. Caused by Misunderstanding of Testing Requirements.Revised TS Surveillance Test Procedure & Reviewed Other Procedures ML18065B2451998-05-13013 May 1998 LER 98-007-00:on 980413,HPIS Sys Was Noted Inoperable During TS Surveillance Test.Caused by Performance of Flawed Procedure.Operators & Engineers Will Be Trained to Improve Operational Decision Making Through Resources & Knowledge ML18065B1151997-12-0909 December 1997 LER 97-013-00:on 971110,failure to Closure Test Two Check Valves Resulted in Violation of TS 6.5.7 Occurred.Caused by Close Function for Check Valves.Check Valves Tested to Confirm Proper Closure Capability ML18067A7751997-11-11011 November 1997 LER 97-011-00:on 971012,primary Coolant Pump Was Started W/Sg Temperatures Greater than Cold Leg Temperature.Caused by Inadequate Procedures & Operator Decision Making.Critique of Event Conducted W/Operators Involved ML18067A7581997-10-30030 October 1997 LER 97-010-00:on 970930,determined That Inadequacy in App R Analysis Resulted in Condition Outside Design Basis of Plant.Caused by Missing Cable in Circuit & Raceway Schedule. Developed New Evaluation Re ASD Valves Validation ML18067A7461997-10-23023 October 1997 LER 97-009-00:on 970923,discovered Procedure Weakness Re Implementation of App R Shutdown Methodology.Caused by Human Error.Revised Off-Normal Procedure ONP-25.2, Alternate Safe Shutdown Procedure. ML18067A7191997-10-10010 October 1997 LER 97-008-00:on 970912,spurious Valve Operation Could Result in Loss of Shutdown Capabilities Per 10CFR50,App R, Section Iii.L,Was Discovered.Caused by Failure to Validate Info from App R.Design Bases for SW Backup Reviewed ML18067A6951997-09-24024 September 1997 LER 97-007-00:on 970826,discovered Inadequate Testing of DG Sequencer Control Relay Contacts.Caused by Oversight on Part of Personnel Involved in Installation of Facility Change FC-800.Tested 106D-1/XL & 106D-2/XL Relay Contacts ML18067A5651997-06-0303 June 1997 LER 96-013-01:on 961115,DC Breaker Failed During Testing for as-found Trip Setting.Failure Caused by Oversight within Preventive Maint Program.Breaker Was Replaced & Tested ML18067A5461997-05-12012 May 1997 LER 97-006-00:on 970412,overtime Limits Were Exceeded for Radiation Protection Technicians.Caused by Inadequate Design,Review & Proper Verifications of Overtime Work Schedule.Communicate Overtime Limitation Responsibilities ML18067A4431997-03-24024 March 1997 LER 97-004-00:on 970221,trip of High Pressure Safety Injection Pump Occurred While Filling Safety Injection Tank Resulting in TS Violation.Caused by Particle Lodged Between Surface of Indication disk.Y-phase Relay Was OOS ML18067A4391997-03-21021 March 1997 LER 97-005-00:on 961220,operation of Plant Outside Design Basis Occurred Due to an Unacceptable Repair on Main Steam Isolation Valves.Pipe Plugs Permanently Repaired ML18067A4401997-03-21021 March 1997 LER 97-003-00:on 961101,four Piping Lines Were Determined to Be Potentially Susceptible to Pressurization Due to Containment Temperature Increase During an Accident.Cac Discharge Piping Will Be verified.W/970321 Ltr ML18066A8931997-02-21021 February 1997 LER 97-002-00:on 970123,failure to Meet TSs 4.5.2d(1)(b) for Testing of Emergency Escape Airlock Occurred.Caused by Missed Surveillance.Emergency Escape Air Lock Testing Was Completed & Declared operable.W/970221 Ltr ML18066A8751997-02-0505 February 1997 LER 97-001-00:on 970106,TAVE Temp Dropped Below Minimum Temp for Criticality.Caused by Control Rod Withdrawal Rate to Increase Power Not Sufficient to Match Increase in Steam. Turbine Bypass Valve Actuator repaired.W/970205 Ltr ML18066A8041996-12-23023 December 1996 LER 96-014-00:on 961124,class 1E Raychem Cable Splices Were Installed Incorrectly.Caused by Incorrectly Made Electrical Splices.Total of 270 Splices Have Been Replaced within Containment ML18066A7831996-12-16016 December 1996 LER 96-013-00:on 961115,DC Breaker Failure During Testing for as-found Trip Setting Occurred.Cause Under Investigation.All molded-case Circuit Breakers in DC Distribution Panels Were Replaced ML18065A9951996-10-0404 October 1996 LER 96-002-01:on 960116,initiated TS Required Shutdown Due to Safeguards Cable Fault.Both Sets (Six Cables) of Cables Were Replaced & Installed Through Turbine Generator Bldg ML18065A9171996-09-0909 September 1996 LER 95-012-00:on 960809,TS Violation Occurred,Due to No Senior Reactor Operator in Cr.Caused by Extensive Remodeling.Cr Remodeling completed.W/960909 Ltr ML18065A8961996-08-29029 August 1996 LER 96-011-00:on 960730,CR Continuous Air Monitor Alarm Setpoint Improperly Established.Caused by Failure to Utilize Mod Process in 1988 Leading to Failure to Properly Select & Calibrate Instruments ML18065A8811996-08-20020 August 1996 LER 96-005-01:on 960207,determined Fuse on Main Supply to Two Safety Related DC Panels & Panel Branch Circuit Breakers Not Properly Coordinated.Caused by Lack of Thorough Associated Circuits Analysis.Supply Fuse to Panels Replaced ML18065A8741996-08-16016 August 1996 LER 96-010-00:on 960717,high Pressure Safety Injection Pump Tripped While Filling Safety Injection Tank.Caused by Faulty 150/151Y-207 Time Overcurrent Relay.All Similar Relays in Time Overcurrent Application Have Been Inspected ML18065A8651996-08-12012 August 1996 LER 96-009-00:on 960712,identified Penetration Seal Deficiency on Fire Barriers Caused by Failure to Perform & Document Comprehensive Fire Barrier Evaluation.Developed Basis document.W/960812 Ltr ML18065A8601996-08-0202 August 1996 LER 96-006-01 on 960207,discovered Limits of Design Analysis Could Have Been Violated.Subsequent Tests & Analyses Facility Did Not Exceed Basis.Operating Procedures Have Been Revised to Treat 2530 Megawatts Limit as Absolute Limit ML18065A8321996-08-0101 August 1996 LER 96-003-01:on 960115,alternate Shutdown Panel Inverter Resulted in Unavailability of Panel.Replaced Defective Inverter Alarm Logic Board ML18065A7691996-06-12012 June 1996 LER 96-008-00:on 960513,fire Door Not Maintained Open in Accordance W/Design Basis.Cause Under Investigation. Engineering Evaluation Performed & Revised Documents, Surveillance & Test procedures.W/960612 Ltr ML18065A6901996-05-0101 May 1996 LER 95-001-01:on 950302,malfunction of Left Channel DBA Sequencer Resulted in Inadvertent Actuation of Left Channel Safeguards Equipment.Replaced microprocessor.W/960501 Ltr ML18065A6681996-04-22022 April 1996 LER 96-007-00:on 960321,inadequate Emergency Lighting & Ventilation in post-fire Safe Shutdown Areas.Caused by App R Program Documentation Insufficient to Demonstrate Regulatory Compliance.Lighting modified.W/960422 Ltr ML18065A5721996-03-11011 March 1996 LER 96-006-00:on 960207,average Reactor Power Level Exceeded License Limit Due to Insufficient Procedural Guidance. GOP-12 Revised to Treat 2,530 Mwt Limit as Absolute Limit Requiring Immediate Corrective Action If Exceeded ML18065A5261996-03-0101 March 1996 LER 96-005-00:on 960202,fuse on Main Supply to Two SR DC Panels & Panel Branch Circuit Breakers Not Properly Coordinated.Caused by Inadequate Electrical/App R Design Review.Implemented Hourly Fire tours.W/960301 Ltr ML18065A5111996-02-19019 February 1996 LER 94-012-02:on 940427,determined That Internal Ground in Thermal Margin Monitor Causes Nonconformance W/Rps Design Basis.Incorporated RPS Failure Modes & Effects Analysis in Plant DBD.W/960219 Ltr ML18065A5061996-02-19019 February 1996 LER 96-004-00:on 960118,SIS Disabled W/Primary Coolant Sys Greater than 300 F.Caused by Personnel Error.Permanent Maint Procedure to Disable/Enable SIS Actuation on Low Pressurizer Pressure Will Be Revised to Align W/Ts ML18065A5021996-02-15015 February 1996 LER 96-003-00:on 960115,technicians Found Low Voltage cut- Off for Alternate Shutdown Panel Inverter Set That Resulted in Unavailability of Panel.Caused by Inadequate Post Mod. Readjusted Set Point to Minimum setting.W/960215 Ltr ML18065A4581996-01-31031 January 1996 LER 96-001-00:on 960103,failed to Test Duplicate Equipment. Caused by STS No Longer Containing Requirement for cross- Train Testing of Duplicate Components.Will Submit Request to Delete Subj Requirements from TS.W/960131 Ltr ML18065A4421996-01-19019 January 1996 LER 95-016-00:on 951226,did Not Analyze Primary Coolant Samples within 72 H.Caused by Belief Acceptability to Save Pcs Samples for Choride Analysis Past 72 H.Counseled Chemistry Supervision.W/960119 Ltr ML18065A4041996-01-15015 January 1996 LER 95-014-00:on 950119,PCP Oil Collection Deficiencies Created by FC-860 Piping Mod.Caused by Inadequate DBD for Sys & Lack of Review by Experienced Fire Protection Personnel.Updated Design Basis documentation.W/960115 Ltr ML18065A3291995-12-0404 December 1995 LER 95-013-00:on 951103,circuit Fuse Coordination Deficiency Which Affects App R Safe Shutdown Equipment Noted.Design of Fuse Coordination in Potential Transformer Circuits Will Be Evaluated & Modified as required.W/951204 Ltr ML18065A2361995-11-0202 November 1995 LER 95-012-00:on 950701,discovered Unqualified Electrical Connection in Containment SW Outlet Valve Controller.Caused by Failure of Assigned Engineers to Available Info.Replaced Wire Nuts W/Inline Butt connections.W/951102 Ltr ML18065A2051995-10-20020 October 1995 LER 95-008-01:on 950728,discovered That None of Four Containment High Pressure Channels Would Initiate Reactor Trip Due to Programmatic Deficiencies.Administrative Procedure (AP) 9.44,AP 9.45 & AP 10.44 Will Be Revised ML18065A0841995-09-18018 September 1995 LER 95-011-00:on 950817,CR 40 Withdrawal Occurred When Given Insertion Signal Due to skill-based Error in Crimping & Removing Foreign Matl from CRDM Motor Connection Box.Crd Package replaced.W/950918 Ltr ML18065A0681995-09-14014 September 1995 LER 95-010-00:on 950815,ESFA Resulted in Manual Rt Following Isolation of Pcs.Replaced Failed Instrument Line ML18065A0651995-09-0808 September 1995 LER 95-009-00:on 950728,discovered Lack of Procedural Guidance for Pump Repair Following Fire.Proposed Use of Power Supply Breaker Did Not Adequately Address Effect of Loss of Control Power.Performed Independent Assessment ML18064A8781995-08-28028 August 1995 LER 95-008-00:on 950728,discovered During Design Change Testing That None of Four Containment High Pressure Channels Would Initiate Rt.Caused by Programmatic Deficiencies. Reviewed Selected Tests & Mods from Recent Refueling Outage ML18064A8831995-08-21021 August 1995 LER 95-007-00:on 950720,discovered That 12 Instrument Loops Had V-bolted Type Qualified Cable Splices Connected to Wires W/Exposed Kapton Insulation.Caused by Human Error.All V- Bolted Splices Replaced w/in-line design.W/950821 Ltr 1999-09-02
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML18066A6901999-11-0101 November 1999 Rev 5 to Palisades Nuclear Plant Colr. ML18066A6761999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for Palisades Nuclear Plant ML18066A6271999-09-0202 September 1999 LER 98-011-01:on 981217,inadequate Lube Oil Collection Sys for Primary Coolant Pumps Was Noted.Caused by Design Change Not Containing Appropriate Level of Rigor.Exemption from 10CFR50,App R Was Requested.With 990902 Ltr ML18066A6351999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Palisades Nuclear Plant ML18066A6771999-08-31031 August 1999 Operating Data Rept Page of MOR for Aug 1999 for Palisades Nuclear Plant ML18066A6221999-08-20020 August 1999 LER 99-002-00:on 990722,TS Surveillance Was Not Completed within Specified Frequency.Caused by Failure to Incorporate Revised Frequency Into Surveillance Schedule in Timely Manner.Verified Implementation.With 990820 Ltr ML18066A6061999-07-31031 July 1999 Monthly Operating Rept for July 1999 for Palisades Nuclear Plant.With 990803 Ltr ML18066A5201999-06-30030 June 1999 Monthly Operating Rept for June 1999 for Palisades Nuclear Plant.With 990702 Ltr ML18066A4841999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Palisades Nuclear Plant.With 990603 Ltr ML18066A6371999-04-30030 April 1999 Revised Monthly Operating Rept for Apr 1999 for Palisades Nuclear Plant ML18068A5941999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for Palisades Nuclear Plant.With 990503 Ltr ML18066A4161999-04-0101 April 1999 Rev 4 to COLR, for Palisades Nuclear Plant ML18066A4501999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for Palisades Nuclear Plant.With 990402 Ltr ML18066A4671999-03-31031 March 1999 Rev 0 to SIR-99-032, Flaw Tolerance & Leakage Evaluation Spent Fuel Pool Heat Exchanger E-53B Nozzle Palisades Nuclear Plant. ML18068A5351999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for Palisades Nuclear Plant.With 990302 Ltr ML18066A3931999-01-31031 January 1999 Monthly Operating Rept for Jan 1999 for Palisades Nuclear Plant.With 990202 Ltr ML18066A3781999-01-20020 January 1999 LER 98-013-00:on 981222,safeguards Transfer Tap Changer Failure Caused Inadvertant DG Start.Caused by Failed Motor Contactor.Contactor Was Replaced.With 990120 Ltr ML20206F6131998-12-31031 December 1998 1998 Consumers Energy Co Annual Rept. with ML18066A3651998-12-31031 December 1998 Monthly Operating Rept for Dec 1998 for Palisades Nuclear Plant.With 990105 Ltr ML18066A3421998-11-30030 November 1998 Monthly Operating Rept for Nov 1998 for Palisades Nuclear Plant.With 981202 Ltr ML18066A3301998-11-11011 November 1998 Part 21 Rept Re Potential Safety Hazard Associated with Wrist Pin Assemblies for FM-Alco 251 Engines at Palisades Nuclear Power Plant.Caused by Insufficient Friction Fit Between Pin & Sleeve.Supplier of Pin Will No Longer Be Used ML18068A4921998-10-31031 October 1998 Monthly Operating Rept for Oct 1998 for Palisades Nuclear Plant.With 981103 Ltr ML18068A4851998-10-29029 October 1998 LER 97-011-01:on 971012,starting of Primary Coolant Pump with SG Temps Greater than Cold Leg Temps Occurred.Caused by Inadequate Procedures & Operator Decision.Sop Used for Starting Primary Coolant Pump Enhanced ML18066A3181998-09-30030 September 1998 Monthly Operating Rept for Sept 1998 for Palisades Nuclear Plant ML18066A2901998-08-31031 August 1998 Monthly Operating Rept for Aug 1998 for Palisades Nuclear Power Plant.With 980903 Ltr ML18066A3191998-08-31031 August 1998 Revised Monthly Operating Rept Data for Aug 1998 for Palisades Nuclear Plant ML18066A2831998-08-18018 August 1998 LER 98-010-00:on 980721,reactor Manually Tripped.Caused by Failure of Coupling Which Drives Feedwater Pump Main Lube Oil Pump.Main Lube Oil Pump Coupling & Associated Components Replaced & Satisfactorily Tested ML18066A2771998-08-13013 August 1998 Part 21 Rept Re Deficiency in CE Current Screening Methodology for Determining Limiting Fuel Assembly for Detailed PWR thermal-hydraulic Sa.Evaluations Were Performed for Affected Plants to Determine Effect of Deficiency ML20237E0301998-07-31031 July 1998 ISI Rept 3-3 ML18066A2701998-07-31031 July 1998 Monthly Operating Rept for July 1998 for Palisades Nuclear Plant.W/980803 Ltr ML18066A2311998-06-30030 June 1998 Monthly Operating Rept for June 1998 for Palisades Nuclear Plant ML18066A2261998-06-30030 June 1998 LER 98-009-00:on 980531,small Pinhole Leak Found on One of Welds,During Leak Test Following Replacement of Pcs Sample Isolation Valves.Caused by Welder Error.Leaking Welds Repaired ML18066A3061998-06-18018 June 1998 SG Tube Inservice Insp. ML20249C4951998-06-17017 June 1998 Rev 1 to EA-GEJ-98-01, Palisades Cycle 14 Disposition of Events Review ML18066A1781998-06-0909 June 1998 LER 98-008-00:on 980511,noted That Procedure Did Not Fully Satisfy Requirement to Test High Startup Rate Trip Function. Caused by Misunderstanding of Testing Requirements.Revised TS Surveillance Test Procedure & Reviewed Other Procedures ML18066A1711998-06-0101 June 1998 Part 21 Rept Re Impact of RELAP4 Excessive Variability on Palisades Large Break LOCA ECCS Results.Change in PCT Between Cycle 13 & Cycle 14 Does Not Constitute Significant Change Per 10CFR50.46 ML18066A1741998-05-31031 May 1998 Monthly Operating Rept for May 1998 for Palisades Nuclear Plant.W/980601 Ltr ML18066A2321998-05-31031 May 1998 Revised MOR for May 1998 for Palisades Nuclear Plant ML18068A4701998-05-31031 May 1998 Annual Rept of Changes in ECCS Models Per 10CFR50.46. ML18065B2451998-05-13013 May 1998 LER 98-007-00:on 980413,HPIS Sys Was Noted Inoperable During TS Surveillance Test.Caused by Performance of Flawed Procedure.Operators & Engineers Will Be Trained to Improve Operational Decision Making Through Resources & Knowledge ML18066A2331998-04-30030 April 1998 Revised MOR for Apr 1998 for Palisades Nuclear Plant ML18068A3461998-04-30030 April 1998 Monthly Operating Rept for Apr 1998 for Palisades Nuclear Plant.W/980501 Ltr ML18066A3411998-04-22022 April 1998 Rev 0 to EMF-98-013, Palisades Cycle 14:Disposition & Analysis of SRP Chapter 15 Events. ML18065B2071998-03-31031 March 1998 Monthly Operating Rept for Mar 1998 for Palisades Nuclear Plant.W/980403 Ltr ML20217C2741998-03-31031 March 1998 Independent Review - Is Consumers Energy Method (W Method) of Determining Palisades Nuclear Plant Best Estimate Fluence by Combining Transport Calculation & Dosimetry Measurements Technically Sound & Does It Meet Intent of Pts ML18066A2341998-03-31031 March 1998 Revised MOR for Mar 1998 for Palisades Nuclear Plant ML18068A3041998-02-28028 February 1998 Monthly Operating Rept for Feb 1998 for Palisades Nuclear Plant.W/980302 Ltr ML18066A2351998-02-28028 February 1998 Revised MOR for Feb 1998 for Palisades Nuclear Plant ML18065B1641998-02-0505 February 1998 Rev 0 to Regression Analysis for Containment Prestressing Sys at 25th Year Surveillance. ML18067A8211998-01-31031 January 1998 Monthly Operating Rept for Jan 1998 for Palisades Nuclear Plant.W/980203 Ltr 1999-09-30
[Table view] |
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NRC FORM 366 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150-0104 (4/95) EXPIRES 4/30/98 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS MANDATORY INFORMATION cou.ECTION REQUEST: 50.0 HRS. REPORTED LESSONS LEARNED ARE INCORPORATED INTO THE LICENSING PROCESS AND FED BACK TO INDUSTRY.
LICENSEE EVENT REPORT (LERl FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFORMATION AND RECORDS MANAGEMENT BRANCH (T-8 F33), U.S. NUCLEAR REGULATORY COMMISSION. WASHINGTON, DC 2Q555.0001, AND TO THE PAPERWORK REDUCTION (See reverse for required number of digits/characters for each block) PROJECT (31~104, OFFICE OF MANAGEMENT ANO BUDGET, WASHINGTON, DC 20503 DOCKET NUMBER (2) PAGE(3)
FACILITY NAME (1) CONSUMERS ENERGY COMPANY 05000255 1 of 8 PALISADES NUCLEAR PLANT TITLE (4) Licensing Event Report 98007 - High Pressure Safety Injection System lnoperability Durin~
Technical Specification Surveillance Test EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (8)
MONTH DAY YEAR YEAR I SEQUENTIAL NUMBER REVISION NUMBER MONTH DAY YEAR FACILITY NAME DOCKET NUMBER 05000 FACILITY NAME DOCKET NUMBER 04 13 98 98 007 00 05 13 98 05000 OPERATING THIS REPORT IS SUBMITIED PURSUANT TO TH.E REQUIREMENTS OF 1'0 CFR§: (Check one or morer(11)
. MODE (9) N 20.2201(b) 20.2203(a)(2)(v) x 50.73(a)(2)(i) 50. 73(a)(2)(iii)
POWER 20.2203(a)(1) 20.2203(a)(3)(i) 50. 73(a)(2)(ii) 50. 73(a)(2)(x)
LEVEL (10) 97% 20.2203(a)(2)(i) 20.2203(a)(3)(ii) 50. 73(a)(2)(iii) 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) x 50. 73(a)(2)(v) Specify in Abstract below 20.2203(a)(2)(iv) 50.36(c)(2) 50. 73(a)(2)(viil or in NRC Form 366A LICENSEE CONTACT FOR THIS LER (1i)
NAME . Dale Engle, Licensing Engineer TELEPHONE NUMBER (Include Area Code)
(616) 764-2848 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT. (1.3) . ..
CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE TONPRDS TONPRDS SUPPLEMENTAL REPORT EXPECTED (14) MONTH DAY YEAR I YES If yes, COMPLETE EXPECTED COMPLETION DATE
. x I NO EXPECTED SUBMISSION DATE (15)
ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced.typewritten lines) (16)
On April 13, 1998, with the plant at 97% power, a post implementation review of a Technical Specification Surveillance Test Procedure identified that during the performance of the test on April 10, 1998, the High Pressure Safety Injection (HPSI) System had been rendered inoperable for approximately 90 minutes. The surveillance procedure directed-operations personnel to align both trains of HPSI such that a portion of the flow would be diverted through the Hot Leg Injection (HU) flow path. Since the total flow available to the core would have been less than required for certain postulated loss of coolant accident scenarios, the system safety function was rendered inoperable.
- Technical Specifications require two HPSI pumps to be operable when the primary system is above 325°F. The HU valve manipulations were added to the surveillance procedure in 1988. The procedure has been performed on 5 previous occasions while the plant was in hot shu.tdown wherein it was also not recognized that both trains of HPSI may have been rendered inoperable.
It is likely that the HPSI system was operable with the plant at hot shutdown; however, no analysis has been performed to document that sufficient flow to the core was available at hot shutdown conditions. The event is significant due to the impact on the HPSI system's ability to deliver adequate flow to mitigate certain postulated loss of coolant accident (LOCA) scenarios. Because of the event's significance, plant management responded aggressively. The HPSI system was immediately verified to have been restored to the correct valve alignment. An incident response team was commissioned to investigate the event and implement immediate corrective actions. In addition, a multi-discipline team was established to identify the knowledge, process, and personnel performance weaknesses that permitted the error to occur, and to define appropriate corrective actions to prevent recurrence.
9805200353 980513 PDR ADOCK 05000255.
S PDR
--*-_....,*---*-~"--'-- -***
NRC FORM 366a 4/95 U.S. NUCLEAR REGULA TORY COMMISSION LICENSEE EVENT REPORT (LER) g TEXT CONTINUATION FACILITY NAME 11\ DOCKET12l LER NUMBER 6)
CONSUMERS ENERGY COMPANY 05000255 YEAR I SEQUENTIAL NUMBER REVISION NUMBER 8
PALISADES NUCLEAR PLANT 98 007 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)
EVENT DESCRIPTION On April 13, 1998, with the plant at 97% power, a post test review was performed of Technical Specification Surveillance Test Procedure RT-71 B, "HPSI Train 1 and 2 and SIT System, Class 2 System Functional/lnservice Test". This review determined that prior performance of this surveillance procedure on April 10, 1998, resulted in both trains of the High Pressure Safety Injection (HPSI) system being rendered inoperable. The surveillance procedure directed
.operations personnel to align both trains of the HPSI system into a configuration which would have redirected a portion of the HPSI flow from its normal Cold Leg Injection path to the single Hot Leg Injection (HU) path. During normal operation, HPSI Cold Leg Injection valves M0-3080 & M0-3081 are open while Hot Leg Injection valves M0-3082 & M0-3083 are closed (see figure 1). As part of the actions required by the surveillance procedure, M0-3080 & M0-3081 are closed and M0-3082 & M0-3083 are opened, which connects both trains of HPSI to the single HU path.
This redirection of flow resulted in less than credited flow being available to each of the HPSI Cold Leg Injection paths, rendering both trains inoperable. Additionally, with both trains of HPSI connected to the single HU path, a failure of the HU piping could divert enough flow out the break to prevent both trains of HPSI from performing their intended safety function.
Palisades Technical Specifications do not permit both trains of HPSI to be simultaneously inoperable. The subject HPSI system surveillance procedure alignment placed the plant in an condition which could have prevented the fulfillment of the HPSI safety function needed to mitigate the consequences of an accident. The system was in this configuration for approximately 90 minutes (from approximately 0100 hours0.00116 days <br />0.0278 hours <br />1.653439e-4 weeks <br />3.805e-5 months <br /> to approximately 0230 hours0.00266 days <br />0.0639 hours <br />3.80291e-4 weeks <br />8.7515e-5 months <br />).
The Technical Specification Surveillance Test Procedure was flawed in that the procedure alignment caused two HPSI trains to be concurrently inoperable during testing and in that the procedure failed to identify Technical Specifications implications.
No system or component failures led to this event. In addition, there were no transients or other challenges to plant operations during this event which would have required the HPSI system to perform its safety function.
- The HU valve manipulations were added to the surveillance procedure in 1988. Since that time the procedure has been performed on 5 occasions while the plant was in hot shutdown. It is. likely that the HPSI system was operable at hot shutdown conditions; however, no analysis has been performed to document that sufficient flow to the core was available.
- Therefore both trains of HPSI may have been inoperable each time the test was performed in hot shutdown. This potential for the system to be inoperable was not recognized each time the test was performed.
NRC FORM 366a 4/95 U.S. NUCLEAR REGULA TORY COMMISSION LICENSEE. EVENT REPORT (LER) g TEXT CONTINUATION FACILITY NAME 11\ DOCKETC2l LER NUMBER 6l CONSUMERS ENERGY COMPANY YEAR I SEQUENTIAL NUMBER REVISION NUMBER 05000255 8 PALISADES NUCLEAR PLANT 98 007 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)
ANALYSIS OF THE EVENT The HLI valve manipulations were added to the surveillance procedure in 1988 using the temporary change process described by Palisades Technical Specification 6.8.3 (currently section 6.4.3). In retrospect, the implementation of the..,1988 procedure revision in this manner failed to satisfy the requirements of 10CFR50.59. In 1991, the procedure revision to permanently incorporate the temporary change was made based solely on the previous approval of the 1988 temporary change. A 10CFR50.59 evaluation was considered but deemed unnecessary because the 10CFR50.59 screening process erroneously determined that this procedure revision did not affect Technical Specifications or the FSAR. In 1997 the surveillance procedure was revised to allow the procedure to be performed with the plant at power. Again, a 10CFR50.59 evaluation was considered but deemed unnecessary because the 10CFR50.59 screening process erroneously determined that this procedure revision did not affect Technical Specifications or the FSAR. .
The preparers and reviewers of the 10CFR50.59 process documents did not recognize the effect of the HLI lineup on HPSI operability in hot shutdown. The current 10CFR50.59 evaluation process would require a 50.59 evaluation when a system alignment such as this is introduced into a procedure. The improved computer search tools available now would likely have caused preparers and reviewers to recognize and question the implications of the HLI lineup. It is unlikely that the errors made in 1988 and 1991 would be repeated using the current process. The failure to adequately implement the 10CFR50.59 process for the 1997 Surveillance Test Procedure revision was due to individual knowledge and performance weaknesses. The evaluation of this event concluded that the current 10CFR50.59 evaluation process is adequate.
Operations personnel were familiar with this particular valve alignment as an expected post-accident configuration from their accident mitigation training; however they failed to recognize that during powe*r operation and hot shutdown it was not appropriate to align both HPSI trains to 'the HLI path.
During preparation for the performance of the test on April 10, 1998, the Operations crew understood the HLI alignment, and discussed contingency actions in the event of an accident. The crew did preplan the immediate restoration of these valves to their normal alignment in the event of a plant upset. However, during job preparation, none of the crew who performed this test . -**
questioned the simultaneous train inv.olvement, or that many of the valve manipulations (including HLI alignment) were not required to accomplish the leak check of piping outside containment at system operating pressure, which was the procedure objective for this evolution.
For the April 10, 1998, performance, the Operations crew questioned whether LCO times should be recorded during performance of the test. However, they failed to conclude that the change in valve position affected HPSI system operability. This discussion should have taken place during the job preparation. The Control Room Supervisor and Shift ~ngineer referred to Technical
NRC FORM 366a 4/95 U.S. NUCLEAR REGULA TORY COMMISSION LICENSEE EVENT REPORT (LER) g TEXT CONTINUATION DOCKET12\
I FACILITY NAME l1 l LER NUMBER 6l YEAR SEQUENTIAL REVISION CONSUMERS ENERGY COMPANY NUMBER NUMBER PALISADES NUCLEAR PLANT 05000255 8 98 007 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)
Specifications, Standing Orders and another surveillance test, which manipulated HLI valves.
However, they determined the surveillance procedure was acceptable as written, and there were no applicable Technical Specification implications. Having arrived at a consensus, the crew felt that the issues were straight forward and did not warrant the Shift Supervisor's involvement in the discussions on Technical Specification applicability. The crew's knowledge of Hot Leg Injection System requirements was improperly applied, as demonstrated by their incorrect conclusion.
Involving the Shift Supervisor would have provided another independent evaluation which might have identified the Technical Specification impact.
SAFETY SIGNIFICANCE No system or component failures led to this event. In addition, there were no transients or other challenges to plant operations during this event which would have required the HPSI system to perform its safety function. However, the impact of this event from a design basis accident perspective was significant.
- To assess the effect of the RT-71 B valve line-up on the design basis accident analyses, flow models of the HPSI system were run in the two most limiting configurations directed by the procedure: 1) a short duration (only several minutes) transition line-up with all HLI valves closed and 2) a test line-up which positioned M0-3080 & M0-3081 closed, while M0-3082 & M0-3083 were open. The flow reduction from the transition and test line-ups was then qualitatively assessed against the current accident analysis results, assuming no operator intervention to realign the system.
The results of the assessment indicate that for the analysis of the design basis small break LOCA occurring in a cold leg, the flow reduction resulting from either the transition alignment, or the test alignment would have led to exceeding 10CFR50.46 criteria, with the transition alignment representing the most limiting case. Additionally a third scenario was postulated with the small break occurring in the common portion of the HLI piping, with expected similar results of exceeding 10CFR50.46 criteria.
When evaluated against the design basis large break LOCA, it was determined that the HPSI flow reductions in the short term portion of the event (i.e., pre-recirculation) would not significantly reduce the margin to 10CFR50.46 peak cladding temperature criteria. Evaluation of the test _
alignment determined that HPSI flows would be higher than required for boil-off to remove decay heat after recirculation.. Evaluation of the transition alignment determined that HPSI flows may have been slightly lower than required to provide for initial decay heat removal after recirculation begins if operator intervention was assumed not to occur.
The design basis analyses ofsmall and large break LOCA events utilize many conservative
- assumptions including a high core power history. The safety significance for postulated LOCA events occurring with HPSI in the subject HLI alignments would be most limiting with the plant
NRC FORM 366a 4/95 U.S. NUCLEAR REGULA TORY COMMISSION LICENSEE EVENT REPORT (LER) g TEXT CONTINUATION FACILITY NAME 11 l DOCKET<2l LER NUMBER 6l CONSUMERS ENERGY COMPANY 05000255 YEAR I SEQUENTIAL NUMBER REVISION NUMBER PALISADES NUCLEAR PLANT 8 98 007 00 TEXT {If more space is required, use add1t1onal copies of NRC Form 366A) {17) initially at full power since decay heat removal requirements for events initiated at reduced power are much lower. It is not likely that the 10CFRS0.46 criteria would have been exceeded for small break LOCA events occurring with the HU alignment during hot shutdown. However, a specific analysis of this configuration has not been performed.
Since the operating crew discussed contingency actions and HU valve realignment in the event of an accident as part of their preparations for the surveillance, it is reasonable to conclude that the operator actions would be performed to realign the HPSI system. With operator actions to realign the HPSI system, the event is considered non-risk significant per the Probabilistic Safety Assessment (PSA) Applications Guide.
There were no challenges that required the HPSI function during any of the six occurrences while both HPSI trains were lined up for HU. Therefore, there were no actual consequences from this event.
CAUSE AND CORRECTIVE ACTION The proximate cause of this event was the performance of a flawed procedure. Performance of the flawed procedure has its root in a knowledge issue in which the organization failed to recognize the effect of the HPSI HU valve manipulations on system operability. The staff responsible for this error included both Engineering and Operations personnel involved in procedure development, review, approval, scheduling, and implementation. The barriers provided by both the procedure preparation process and the Operations scheduling and Operations on-shift implementation processes failed to prevent the inadequate procedure from being implemented.
The root cause has three distinct aspects which are described below with planned corrective actions: *
- 1) There was inadequate knowledge of the relationship between component manipulations and train/system operability. This knowledge deficiency occurred in both the procedure preparation/review process, as well as the job preparation phase of actually implementing the surveillance procedure. There was a failure to understand the safety function attributes associated with the HPSI HU valve manipulations, and integration of that information into operability decisions. Both Engineering and Operations staff displayed this knowledge--
d~ficiency.
Corrective Action: Licensed operators and. engineers will be trained to improve operational decision making through more effective use of available resources and personal knowledge.
NRC FORM 366a 4/95 U.S. NUCLEAR REGULA TORY COMMISSION LICENSEE EVENT REPORT (LER) g TExT CONTINUATION I
FACILITY NAME 11 l DOCKET12\ LER NUMBER 6\
YEAR REVISION CONSUMERS ENERGY COMPANY SEQUENTIAL NUMBER NUMBER PALISADES NUCLEAR PLANT 05000255 8 98 007 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)
- 2) The procedure preparation and revision process should have prevented this procedure from
. being approved for use with the equipment manipulation/system alignment flaw~ that have subsequently been identified. The barriers in the procedure preparation process were ineffective for this procedure. The 10CFR50.59 process was not adequately implemented.
Corrective Action: The surveillance procedure preparation process will be strengthened by clarifying individual duties and by providing specific prompts to assure procedure revisions are reviewed in their entirety to broadly consider the effect of component manipulations on system operability.
No changes have been determined to be necessary to the 10CFR50.59 evaluation process.
Action has been completed to discuss the lessons learned from this event with the qualified reviewers of 10CFR50.59 process documents.
- 3) T:he job preparation process by operations was an ineffective barrier for preventing a .
system alignment which rendered both trains oJ HPSI inoperable. There was not an understanding of the fundamental effect of this test on the system. Operations personnel assumed that activities within an approved procedure were technically acceptable.
Corrective actions: Performance standards will be clarified and recommunicated to the Operations staff to emphasize maintaining a broad perspective, understanding the effect of component manipulations on system operability, and identifying when the Shift Supervisor should be involved in decision making.
CORRECTIVE ACTIONS COMPLETED Significant actions already taken in response.to this event include:
- The HPSI system was verified to have been restored to the correct valve alignment.
- Additional surveillance procedures, which were scheduled to be performed in the following two weeks and which manipulated safety systelTI components, were screened to confirm
. appropriate identification of Technical Specification implications.
- Immediate lessons learned from this event were communicated to the Operations Department including information that repositioning the Hot Leg Injection valves renders the associated HPSI train inoperable and the expectation for rigorous job pr~paration.
- An expert panel was formed and chartered to review two high safety significant systems (Auxiliary Feedwater System and Emergency Diesel Generators) and their associated surveillance procedures. The panel developed and applied screening criteria for the review
NRC FORM 366a 4/95 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE EVENT REPORT (LER) g TEXT CONTINUATION FACILITY NAME m DOCKET<2\ LER NUMBER 6\
CONSUMERS ENERGY COMPANY 05000255 YEAR I SEQUENTIAL NUMBER REVISION NUMBER 8
PALISADES NUCLEAR PLANT 98 007 00 TEXT (If more space 1s required, use add1t1onal copies of NRC Form 366A) (17) to ensure all applicable Technical Specifications were appropriately addressed in the procedures. No similar findings were identified.
- Safety and Design Review personnel qualified to review 10CFRS0.59 evaluations were trained in the performance failures that led to this event.
NRC FORM 366a 4/95 U.S. NUCLEAR REGULA TORY COMMISSION LICENSEE EVENT REPORT (LER) g TExT CONTINUATION FACILITY NAME f1\ DOCKETl2\ LER NUMBER 61 CONSUMERS ENERGY COMPANY PALISADES NUCLEAR PLANT 05000255 YEAR I SEQUENTIAL NUMBER REVISION NUMBER 8
98 007 00
- TEXT (If more space is required, use add1t1onal copies of NRC Form 366A) (17)
Figure 1 SIMPLIFIED DIAGRAM OF HPSI I HOT LEG INJECTION
~
LO~:Jm?o~EG . . .f - - - - - - - -....1...4f------il'll--.-~------)-- INJ~g~1&.\'Er:~1~E l REDUNDANT LO'l:J~gi?o~EG ----~------'-~-~ 1 - - - - - 1 1 - - 1~m1&:Er:li'1~E 2 LOOP
- t HOT LEC During normal operation, Cold Leg Injection valves M0-3080 and M0-3081 are open while Hot Leg Injection valves, M0-3082 and M0-3083 are closed. As part of the actions required by the surveillance procedure, M0-3080 and M0-3081 are closed and M0-3082 and M0-3083 are opened, which connects the two HPSI trains to the single HU path and wo_uld redirect some flow from the normal Cold Leg Injection path to Hot Leg Injection path.