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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML18107A5031999-08-26026 August 1999 LER 99-006-00:on 990729,determined That SG Blowdown RMs Setpoint Was non-conservative.Caused by Inadequate ACs for Incorporating Original Plant Licensing Data Into Plant Procedures.Blowdown Will Be Restricted.With 990826 Ltr ML18107A4691999-07-28028 July 1999 LER 99-008-00:on 990714,determined That Limit Switch Cables Were Subject to Multiple Hot Shorts in Same Fire Area.Caused by Inadequate Original Post Fire Safe Shutdown Analysis.All Limit Switch Cables for MOVs Were Reviewed.With 990728 Ltr ML18107A4441999-07-0606 July 1999 LER 99-007-00:on 990605,surveillance for Quadrant Power Tilt Ratio (QPTR) Was Missed.Caused by Human Error.Qptr Calculation Was Performed & Personnel Involved Have Been Held Accountable IAW Pse&G Policies.With 990706 Ltr ML18107A4211999-07-0202 July 1999 LER 99-005-00:on 990605,11 Containment Declared Inoperable. Caused by Valves 11SW72 & 11SW223 Both Leaking.Procedure S1.OP-ST.SW-0010(Q) Was Enhanced to Provide Specific Instructions to Ensure Proper Sequencing.With 990702 Ltr ML18107A4321999-07-0101 July 1999 LER 99-006-01:on 990501,determined That There Was No Flow in One of Four Injection Legs.Caused by Sticking of Valve in Safety Injection Discharge Line to 21 Cold Leg.Valve Was Cut Out of Sys & Replaced.With 990701 Ltr ML18107A4331999-07-0101 July 1999 LER 99-002-01:on 990405,determined That 2SA118 Failed as Found Leakrate Test.Caused by Foreign Matl Found in 2SA118 valve.2SA118 Valve Was Cycled Several Times & Seat Area Was Air Blown in Order to Displace Foreign Matl.With 990701 Ltr ML18107A3951999-06-17017 June 1999 LER 99-004-00:on 990520,reactor Tripped from 100% Power,Due to Negative Flux Trip Signal from Nuclear Instrumentation. Cause Has Not Been Determined.Discoloration Was Identified on One of Penetrations.With 990617 Ltr ML18107A3661999-06-0909 June 1999 LER 99-003-00:on 990513,unplanned Entry Into TS 3.0.3 Was Made.Caused by Human error.Re-positioned Creacs Supply Fan Selector Switches & Revised Procedures S1 & S2.OP-ST.SSP-0001(Q).With 990609 Ltr ML18107A3551999-06-0202 June 1999 LER 99-005-00:on 990504,failure to Meet TS Action Statement Requirements for High Oxygen Concentration in Waste Gas Holdup Sys Occurred.Caused by Inability of Operators. Existing Procedures Will Be Evaluated.With 990602 Ltr ML18107A3541999-06-0101 June 1999 LER 99-006-00:on 990501,HHSI Flow Balance Discrepancy Was Noted During Surveillance.Caused by Sticking of Check Valve in SI Discharge Line to 21 Cold Leg.Valve 21SJ17,was Cut Out of Sys & Replaced.With 990601 Ltr ML18107A2931999-05-12012 May 1999 LER 99-002-00:on 990413,determined That Number 12 Auxiliary Bldg Exhaust Fan Was Rotating Backwards.Caused by mis-wiring of Motor Due to Human Error by Maint technician.Mis-wiring Was Corrected & Fan Was Returned to Svc.With 990512 Ltr ML18107A2781999-05-10010 May 1999 LER 99-004-00:on 990411,automatic Actuation of ESF Occurred During Reactor Vessel Head Removal in Support of Refueling Operations.Caused by High Radiation Condition.Containment Atmosphere Was Monitored.With 990505 Ltr ML18107A2791999-05-0404 May 1999 LER 99-003-00:on 990406,all Salem Unit 2 Chillers Rendered Inoperable.Caused by Human Error.Lessons Learned from Event Were Communicated to All Operators by Including Them in Night Orders.With 990504 Ltr ML18107A2741999-05-0303 May 1999 LER 99-002-00:on 990405,determined That Containment Isolation Valve Failed as Found Leakrate Test.Caused by Foreign Matl Blocking Valves from Closing.Check Valve Mechanically Agitated.With 990504 Ltr ML18107A2351999-04-23023 April 1999 LER 99-001-00:on 990330,MSSV Failed Lift Set Test.Caused by Setpoint Variance Which Is Result of Aging.Valves Were Adjusted & Retested to Ensure TS Tolerance.With 990423 Ltr ML18106B1471999-03-29029 March 1999 LER 99-001-00:on 990228,reactor Scram Was Noted as Result of Turbine Trip.Caused by Operator Error.Lesson Plans Revised to Explicitly Demonstrate Manner in Which Valve Functions. with 990329 Ltr ML18106B0701999-02-16016 February 1999 LER 98-015-00:on 981208,inadvertent Discharge Through RHR Relief Valve During Startup Was Noted.Caused by Operator Performing Too Many Tasks Simultaneously.Appropriate Actions Have Been Taken IAW Policies & Procedures.With 990216 Ltr ML18106B0491999-01-28028 January 1999 LER 98-007-01:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Caused by Transgranular Stress Corrosion Cracking.Replaced Affected Tubing.With 990128 Ltr ML18106B0401999-01-18018 January 1999 LER 98-016-00:on 981219,ECCS Leakage Was Outside of Design Value.Caused by Leakage Past Seat of 21RH34 Manual Drain. Valve 21RH34 Was Reseated.With 990118 Ltr ML18106B0081998-12-24024 December 1998 LER 97-001-01:on 970215,failure to Perform TS Surveillance of Component Cooling Water Sys Check Valves Occurred.Caused by Inadequate Communication Between EOP Group & IST Reviewers.Procedure Revised.With 981224 Ltr ML18106B0021998-12-17017 December 1998 LER 98-015-01:on 980924,improper Installation of Test Equipment to RPS Occurred.Caused by Inadequate 10CFR50.59 Applicability Reviews During Past Revs.Revised Procedures. with 981217 Ltr ML18106A9551998-11-0303 November 1998 LER 96-013-01:on 960711,concluded That Current Gain & Bias Settings Had Rendered Overtemperature Delta Temp Protection Channels Inoperable.Caused by Scaling Error.Licensee Will Revise Scaling Calculations.With 981105 Ltr ML18106A9451998-10-30030 October 1998 LER 97-004-01:on 970408,failure to Comply with TS Action Statement,Dg Start & Inadequate Surveillance Testing,Was Noted.Caused by Inadequate Tracking of Inoperable Equipment. Discussed Event & Lessons Learned.With 981022 Ltr ML18106A9491998-10-22022 October 1998 LER 98-015-00:on 980924,identified Improper Installation of Test Equipment to Rps.Cause Indeterminate.Procedures for Installation of Test Equipment for Collection of State Point Data Were Placed on Administrative Hold.With 981022 Ltr ML18106A9301998-10-21021 October 1998 LER 98-014-00:on 980725,noted Improper Calibr of Liquid Radwaste Effluent Line Radiation Monitor.Caused by Inattention to Detail by Maint Personnel.Channel Calibr Was Successfully Performed on 1R18 on 980821.With 981019 Ltr ML18106A9071998-10-0101 October 1998 LER 98-014-00:on 980918,discovered That Fire Barrier Matl for HVAC Ducts Does Not Meet Required Level of Fire Resistance.Cause Indeterminate.Established Appropriate Compensatory Actions for Fire Barriers.With 981001 Ltr ML18106A8951998-09-28028 September 1998 LER 98-012-01:on 980725,noted That Afs Was Operated with Less than Required Number of Operable AFW Pumps.Caused by Improper Procedure Implementation.Runout Protection Pressure Device for 22 AFW Pumps Was Returned to Svc.With 980928 Ltr ML18106A8821998-09-21021 September 1998 LER 98-013-00:on 980820,noted Surveillance of Containment Penetration Overcurrent Protection Devices Missed.Caused by Human Error.Satisfactorily Tested Apprpriate Breakers & Disciplined Involved Personnel.With 980921 Ltr ML18106A8791998-09-16016 September 1998 LER 96-006-01:on 960717,determined That non-radioactive Liquid Basin Radwaste Monitor Inoperable During Low Head Conditions.Caused by Inadequate Design Change Package.Design Change 1EC3663-01 Has Been Installed.With 980916 Ltr ML18106A8801998-09-0808 September 1998 LER 98-013-00:on 980806,operation with TS Required Equipment OOS Was Noted.Caused by Human Error.Reviewed Processes & Practices Re Safety Sys Status Control,Procedure Rev & Extra Training.With 980908 Ltr ML18106A8531998-08-27027 August 1998 LER 98-007-00:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Cause of Event Has Not Yet Been Determined.Assembled Root Cause Team & Replaced Affected tubing.W/980827 Ltr ML18106A8521998-08-27027 August 1998 LER 98-011-00:on 980803,ESFA During a 4KV Automatic Transfer Test Was Noted.Caused by Premature Release of Control Console Pushbutton Due to Inadequate Procedural Step.Revised procedure.W/980827 Ltr ML18106A8421998-08-24024 August 1998 LER 98-012-00:on 980725,discovered That Plant Had Operated in Modes 1 & 2 w/twenty-two AFW Pumps Inoperable.Caused by Failure to Restore Pump Runout Protection Pressure Device to Svc.Returned Subject Device to svc.W/980824 Ltr ML18106A8431998-08-24024 August 1998 LER 98-009-00:on 980810,failure to Post Continuous Firewatch as Required by Fire Protection Plan Noted.Caused by Failure to Recognize Concurrent Conditions.Continuous Firewatch Was Posted Immediately & Repaired Smoke detectors.W/980824 Ltr ML18106A8141998-08-13013 August 1998 LER 98-010-00:on 980714,determined That Leakage from Boron Injection Tank Exceeded Max Allowable ECCS Leakage from Sources Outside Containment.Caused by Leaking 2SJ404 Manual Sample valve.2SJ404 Valve repaired.W/980813 Ltr ML18106A8201998-08-13013 August 1998 LER 98-012-00:on 980715,potential to Exceed Rating of Piping Due to Isolation of Overpressure Protection Line Was Noted. Caused by Inadequate Procedural Guidance.Appropriate Operations Dept Procedures Have Been revised.W/980813 Ltr ML18106A6931998-06-29029 June 1998 LER 98-003-00:on 980122,inappropriate Plugging of Tubes R9C60 & R10C60 in Salem Unit 2 Sg,Was Performed.Caused by Failure of Qualification,Verification & Validation Process. Tubes Reviewed to Verify No Others Inappropriately Plugged ML18106A6471998-06-0404 June 1998 LER 98-011-00:on 980505,improper Isolation of Single Cell Battery Charger from 125 Vdc Battery Was Noted.Caused by Inadequate 10CFR50.59 Applicability Review.Placed Procedure SC.MD-CM.ZZ-0024(Q) on Administrative hold.W/980604 Ltr ML18106A6421998-06-0101 June 1998 LER 98-010-00:on 931019,reactor Pressure Vessel Insp Plugs Were Out of Configuration,Was Noted.Caused by Personnel Error.Proper Configuration Was Restored Shortly After Discovery Prior to Entering Mode 2.W/980601 Ltr ML18106A6431998-05-29029 May 1998 LER 98-006-01:on 980227,determined Incorrect Scaling Error of First Stage Pressure Transmitter Existed.Caused by Human Error.Revised Setpoint Calculation SC-MS002-01 & Revised Associated Instrument Calibr Database info.W/980529 Ltr ML18106A6141998-05-18018 May 1998 LER 98-008-00:on 970814,failure to Test 21 & 22 AF 40 Valves in Closed Direction as Required by TS 4.0.5 Was Noted.Caused by Inadequate Design Mod Process.Motor Driven 21/22 AF 40 Valves Were Tested IAW Revised procedure.W/980518 Ltr ML18106A5901998-05-0101 May 1998 LER 98-009-00:on 980405,epoxy Missing from Terminals of H Analyzer Was Noted.Caused by Inadequate Development of Procedure.H Analyzers Were Repaired & Review of Other Safety Related Equipment in Containment Was performed.W/980501 Ltr ML18106A5611998-04-20020 April 1998 LER 98-008-00:on 980323,inadequate Testing of Salem Unit 1 Containment Air Locks Resulted in Entering TS 3.0.3.Caused by less-than-adequate Work Practices During Replacement of Equalizing Valve.Salem Unit 2 Airlocks Were Inspected ML18106A6061998-04-0101 April 1998 Corrected LER 98-004-00:on 980302,failure to Comply W/Tss 4.11.1.1.2 & 3.3.3.8 Was Noted.Caused by Organizational Deficiency.Steps Have Been Taken to Correctly Document Safety Factors.Corrects Prior Similar Occurrences ML18106A4451998-04-0101 April 1998 LER 98-004-00:on 980302,failure to Perform TS 4.11.1.1.2 & 3.3.3.8 Was Noted.Caused by Organizational Deficiency.Steps Were Taken to Correctly Document Safety factors.W/980401 Ltr ML18106A4351998-03-30030 March 1998 LER 98-006-00:on 980227,incorrect Scaling of First Stage Turbine Impulse Pressure Transmitters Noted.Cause Indeterminate.Implemented Procedure Changes & re-scaled Affected Turbine Impulse Pressure transmitters.W/980330 Ltr ML18106A3961998-03-20020 March 1998 LER 98-005-00:on 980219,inoperability of Twelve EDG Fuel Oil Transfer Pump (FOTP) Noted.Caused by Installation of Incorrect Control Switch.Installed Correct off-auto-manual Switch & Verified Operability of Twelve FOTP.W/980320 Ltr ML18106A5781998-03-20020 March 1998 Corrected LER 98-005-00:on 980219,inoperability of 12 Fuel Oil Transfer Pump (Fotp),Noted.Caused by Installation of Incorrect Control Switch.Field Insp Performed to Verify Configuration of Switches for 11,21 & 22 FOTPs ML18106A4021998-03-20020 March 1998 LER 98-007-00:on 980218,failure to Establish Containment Integrity (Closure) Prior to Fuel Movement Was Noted.Caused by Failure to Identify & Include Condensate Pot Vent in Appropriate Valve Lineup.Valves identified.W/980320 Ltr ML18106A4031998-03-20020 March 1998 LER 98-006-00:on 980221,ESF Actuation of 11 & 12 Auxiliary Feedwater Pumps Occurred.Caused by Human Error.Operators Promptly Established Feedwater to All SG & Restored Proper Water levels.W/980320 Ltr 1999-08-26
[Table view] Category:RO)
MONTHYEARML18107A5031999-08-26026 August 1999 LER 99-006-00:on 990729,determined That SG Blowdown RMs Setpoint Was non-conservative.Caused by Inadequate ACs for Incorporating Original Plant Licensing Data Into Plant Procedures.Blowdown Will Be Restricted.With 990826 Ltr ML18107A4691999-07-28028 July 1999 LER 99-008-00:on 990714,determined That Limit Switch Cables Were Subject to Multiple Hot Shorts in Same Fire Area.Caused by Inadequate Original Post Fire Safe Shutdown Analysis.All Limit Switch Cables for MOVs Were Reviewed.With 990728 Ltr ML18107A4441999-07-0606 July 1999 LER 99-007-00:on 990605,surveillance for Quadrant Power Tilt Ratio (QPTR) Was Missed.Caused by Human Error.Qptr Calculation Was Performed & Personnel Involved Have Been Held Accountable IAW Pse&G Policies.With 990706 Ltr ML18107A4211999-07-0202 July 1999 LER 99-005-00:on 990605,11 Containment Declared Inoperable. Caused by Valves 11SW72 & 11SW223 Both Leaking.Procedure S1.OP-ST.SW-0010(Q) Was Enhanced to Provide Specific Instructions to Ensure Proper Sequencing.With 990702 Ltr ML18107A4321999-07-0101 July 1999 LER 99-006-01:on 990501,determined That There Was No Flow in One of Four Injection Legs.Caused by Sticking of Valve in Safety Injection Discharge Line to 21 Cold Leg.Valve Was Cut Out of Sys & Replaced.With 990701 Ltr ML18107A4331999-07-0101 July 1999 LER 99-002-01:on 990405,determined That 2SA118 Failed as Found Leakrate Test.Caused by Foreign Matl Found in 2SA118 valve.2SA118 Valve Was Cycled Several Times & Seat Area Was Air Blown in Order to Displace Foreign Matl.With 990701 Ltr ML18107A3951999-06-17017 June 1999 LER 99-004-00:on 990520,reactor Tripped from 100% Power,Due to Negative Flux Trip Signal from Nuclear Instrumentation. Cause Has Not Been Determined.Discoloration Was Identified on One of Penetrations.With 990617 Ltr ML18107A3661999-06-0909 June 1999 LER 99-003-00:on 990513,unplanned Entry Into TS 3.0.3 Was Made.Caused by Human error.Re-positioned Creacs Supply Fan Selector Switches & Revised Procedures S1 & S2.OP-ST.SSP-0001(Q).With 990609 Ltr ML18107A3551999-06-0202 June 1999 LER 99-005-00:on 990504,failure to Meet TS Action Statement Requirements for High Oxygen Concentration in Waste Gas Holdup Sys Occurred.Caused by Inability of Operators. Existing Procedures Will Be Evaluated.With 990602 Ltr ML18107A3541999-06-0101 June 1999 LER 99-006-00:on 990501,HHSI Flow Balance Discrepancy Was Noted During Surveillance.Caused by Sticking of Check Valve in SI Discharge Line to 21 Cold Leg.Valve 21SJ17,was Cut Out of Sys & Replaced.With 990601 Ltr ML18107A2931999-05-12012 May 1999 LER 99-002-00:on 990413,determined That Number 12 Auxiliary Bldg Exhaust Fan Was Rotating Backwards.Caused by mis-wiring of Motor Due to Human Error by Maint technician.Mis-wiring Was Corrected & Fan Was Returned to Svc.With 990512 Ltr ML18107A2781999-05-10010 May 1999 LER 99-004-00:on 990411,automatic Actuation of ESF Occurred During Reactor Vessel Head Removal in Support of Refueling Operations.Caused by High Radiation Condition.Containment Atmosphere Was Monitored.With 990505 Ltr ML18107A2791999-05-0404 May 1999 LER 99-003-00:on 990406,all Salem Unit 2 Chillers Rendered Inoperable.Caused by Human Error.Lessons Learned from Event Were Communicated to All Operators by Including Them in Night Orders.With 990504 Ltr ML18107A2741999-05-0303 May 1999 LER 99-002-00:on 990405,determined That Containment Isolation Valve Failed as Found Leakrate Test.Caused by Foreign Matl Blocking Valves from Closing.Check Valve Mechanically Agitated.With 990504 Ltr ML18107A2351999-04-23023 April 1999 LER 99-001-00:on 990330,MSSV Failed Lift Set Test.Caused by Setpoint Variance Which Is Result of Aging.Valves Were Adjusted & Retested to Ensure TS Tolerance.With 990423 Ltr ML18106B1471999-03-29029 March 1999 LER 99-001-00:on 990228,reactor Scram Was Noted as Result of Turbine Trip.Caused by Operator Error.Lesson Plans Revised to Explicitly Demonstrate Manner in Which Valve Functions. with 990329 Ltr ML18106B0701999-02-16016 February 1999 LER 98-015-00:on 981208,inadvertent Discharge Through RHR Relief Valve During Startup Was Noted.Caused by Operator Performing Too Many Tasks Simultaneously.Appropriate Actions Have Been Taken IAW Policies & Procedures.With 990216 Ltr ML18106B0491999-01-28028 January 1999 LER 98-007-01:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Caused by Transgranular Stress Corrosion Cracking.Replaced Affected Tubing.With 990128 Ltr ML18106B0401999-01-18018 January 1999 LER 98-016-00:on 981219,ECCS Leakage Was Outside of Design Value.Caused by Leakage Past Seat of 21RH34 Manual Drain. Valve 21RH34 Was Reseated.With 990118 Ltr ML18106B0081998-12-24024 December 1998 LER 97-001-01:on 970215,failure to Perform TS Surveillance of Component Cooling Water Sys Check Valves Occurred.Caused by Inadequate Communication Between EOP Group & IST Reviewers.Procedure Revised.With 981224 Ltr ML18106B0021998-12-17017 December 1998 LER 98-015-01:on 980924,improper Installation of Test Equipment to RPS Occurred.Caused by Inadequate 10CFR50.59 Applicability Reviews During Past Revs.Revised Procedures. with 981217 Ltr ML18106A9551998-11-0303 November 1998 LER 96-013-01:on 960711,concluded That Current Gain & Bias Settings Had Rendered Overtemperature Delta Temp Protection Channels Inoperable.Caused by Scaling Error.Licensee Will Revise Scaling Calculations.With 981105 Ltr ML18106A9451998-10-30030 October 1998 LER 97-004-01:on 970408,failure to Comply with TS Action Statement,Dg Start & Inadequate Surveillance Testing,Was Noted.Caused by Inadequate Tracking of Inoperable Equipment. Discussed Event & Lessons Learned.With 981022 Ltr ML18106A9491998-10-22022 October 1998 LER 98-015-00:on 980924,identified Improper Installation of Test Equipment to Rps.Cause Indeterminate.Procedures for Installation of Test Equipment for Collection of State Point Data Were Placed on Administrative Hold.With 981022 Ltr ML18106A9301998-10-21021 October 1998 LER 98-014-00:on 980725,noted Improper Calibr of Liquid Radwaste Effluent Line Radiation Monitor.Caused by Inattention to Detail by Maint Personnel.Channel Calibr Was Successfully Performed on 1R18 on 980821.With 981019 Ltr ML18106A9071998-10-0101 October 1998 LER 98-014-00:on 980918,discovered That Fire Barrier Matl for HVAC Ducts Does Not Meet Required Level of Fire Resistance.Cause Indeterminate.Established Appropriate Compensatory Actions for Fire Barriers.With 981001 Ltr ML18106A8951998-09-28028 September 1998 LER 98-012-01:on 980725,noted That Afs Was Operated with Less than Required Number of Operable AFW Pumps.Caused by Improper Procedure Implementation.Runout Protection Pressure Device for 22 AFW Pumps Was Returned to Svc.With 980928 Ltr ML18106A8821998-09-21021 September 1998 LER 98-013-00:on 980820,noted Surveillance of Containment Penetration Overcurrent Protection Devices Missed.Caused by Human Error.Satisfactorily Tested Apprpriate Breakers & Disciplined Involved Personnel.With 980921 Ltr ML18106A8791998-09-16016 September 1998 LER 96-006-01:on 960717,determined That non-radioactive Liquid Basin Radwaste Monitor Inoperable During Low Head Conditions.Caused by Inadequate Design Change Package.Design Change 1EC3663-01 Has Been Installed.With 980916 Ltr ML18106A8801998-09-0808 September 1998 LER 98-013-00:on 980806,operation with TS Required Equipment OOS Was Noted.Caused by Human Error.Reviewed Processes & Practices Re Safety Sys Status Control,Procedure Rev & Extra Training.With 980908 Ltr ML18106A8531998-08-27027 August 1998 LER 98-007-00:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Cause of Event Has Not Yet Been Determined.Assembled Root Cause Team & Replaced Affected tubing.W/980827 Ltr ML18106A8521998-08-27027 August 1998 LER 98-011-00:on 980803,ESFA During a 4KV Automatic Transfer Test Was Noted.Caused by Premature Release of Control Console Pushbutton Due to Inadequate Procedural Step.Revised procedure.W/980827 Ltr ML18106A8421998-08-24024 August 1998 LER 98-012-00:on 980725,discovered That Plant Had Operated in Modes 1 & 2 w/twenty-two AFW Pumps Inoperable.Caused by Failure to Restore Pump Runout Protection Pressure Device to Svc.Returned Subject Device to svc.W/980824 Ltr ML18106A8431998-08-24024 August 1998 LER 98-009-00:on 980810,failure to Post Continuous Firewatch as Required by Fire Protection Plan Noted.Caused by Failure to Recognize Concurrent Conditions.Continuous Firewatch Was Posted Immediately & Repaired Smoke detectors.W/980824 Ltr ML18106A8141998-08-13013 August 1998 LER 98-010-00:on 980714,determined That Leakage from Boron Injection Tank Exceeded Max Allowable ECCS Leakage from Sources Outside Containment.Caused by Leaking 2SJ404 Manual Sample valve.2SJ404 Valve repaired.W/980813 Ltr ML18106A8201998-08-13013 August 1998 LER 98-012-00:on 980715,potential to Exceed Rating of Piping Due to Isolation of Overpressure Protection Line Was Noted. Caused by Inadequate Procedural Guidance.Appropriate Operations Dept Procedures Have Been revised.W/980813 Ltr ML18106A6931998-06-29029 June 1998 LER 98-003-00:on 980122,inappropriate Plugging of Tubes R9C60 & R10C60 in Salem Unit 2 Sg,Was Performed.Caused by Failure of Qualification,Verification & Validation Process. Tubes Reviewed to Verify No Others Inappropriately Plugged ML18106A6471998-06-0404 June 1998 LER 98-011-00:on 980505,improper Isolation of Single Cell Battery Charger from 125 Vdc Battery Was Noted.Caused by Inadequate 10CFR50.59 Applicability Review.Placed Procedure SC.MD-CM.ZZ-0024(Q) on Administrative hold.W/980604 Ltr ML18106A6421998-06-0101 June 1998 LER 98-010-00:on 931019,reactor Pressure Vessel Insp Plugs Were Out of Configuration,Was Noted.Caused by Personnel Error.Proper Configuration Was Restored Shortly After Discovery Prior to Entering Mode 2.W/980601 Ltr ML18106A6431998-05-29029 May 1998 LER 98-006-01:on 980227,determined Incorrect Scaling Error of First Stage Pressure Transmitter Existed.Caused by Human Error.Revised Setpoint Calculation SC-MS002-01 & Revised Associated Instrument Calibr Database info.W/980529 Ltr ML18106A6141998-05-18018 May 1998 LER 98-008-00:on 970814,failure to Test 21 & 22 AF 40 Valves in Closed Direction as Required by TS 4.0.5 Was Noted.Caused by Inadequate Design Mod Process.Motor Driven 21/22 AF 40 Valves Were Tested IAW Revised procedure.W/980518 Ltr ML18106A5901998-05-0101 May 1998 LER 98-009-00:on 980405,epoxy Missing from Terminals of H Analyzer Was Noted.Caused by Inadequate Development of Procedure.H Analyzers Were Repaired & Review of Other Safety Related Equipment in Containment Was performed.W/980501 Ltr ML18106A5611998-04-20020 April 1998 LER 98-008-00:on 980323,inadequate Testing of Salem Unit 1 Containment Air Locks Resulted in Entering TS 3.0.3.Caused by less-than-adequate Work Practices During Replacement of Equalizing Valve.Salem Unit 2 Airlocks Were Inspected ML18106A6061998-04-0101 April 1998 Corrected LER 98-004-00:on 980302,failure to Comply W/Tss 4.11.1.1.2 & 3.3.3.8 Was Noted.Caused by Organizational Deficiency.Steps Have Been Taken to Correctly Document Safety Factors.Corrects Prior Similar Occurrences ML18106A4451998-04-0101 April 1998 LER 98-004-00:on 980302,failure to Perform TS 4.11.1.1.2 & 3.3.3.8 Was Noted.Caused by Organizational Deficiency.Steps Were Taken to Correctly Document Safety factors.W/980401 Ltr ML18106A4351998-03-30030 March 1998 LER 98-006-00:on 980227,incorrect Scaling of First Stage Turbine Impulse Pressure Transmitters Noted.Cause Indeterminate.Implemented Procedure Changes & re-scaled Affected Turbine Impulse Pressure transmitters.W/980330 Ltr ML18106A3961998-03-20020 March 1998 LER 98-005-00:on 980219,inoperability of Twelve EDG Fuel Oil Transfer Pump (FOTP) Noted.Caused by Installation of Incorrect Control Switch.Installed Correct off-auto-manual Switch & Verified Operability of Twelve FOTP.W/980320 Ltr ML18106A5781998-03-20020 March 1998 Corrected LER 98-005-00:on 980219,inoperability of 12 Fuel Oil Transfer Pump (Fotp),Noted.Caused by Installation of Incorrect Control Switch.Field Insp Performed to Verify Configuration of Switches for 11,21 & 22 FOTPs ML18106A4021998-03-20020 March 1998 LER 98-007-00:on 980218,failure to Establish Containment Integrity (Closure) Prior to Fuel Movement Was Noted.Caused by Failure to Identify & Include Condensate Pot Vent in Appropriate Valve Lineup.Valves identified.W/980320 Ltr ML18106A4031998-03-20020 March 1998 LER 98-006-00:on 980221,ESF Actuation of 11 & 12 Auxiliary Feedwater Pumps Occurred.Caused by Human Error.Operators Promptly Established Feedwater to All SG & Restored Proper Water levels.W/980320 Ltr 1999-08-26
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML20217A9931999-09-30030 September 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data ML18107A5581999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for Salem,Unit 2.With 991014 Ltr ML18107A5571999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for Salem,Unit 1.With 991014 Ltr ML18107A5301999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Salem,Unit 2.With 990913 Ltr ML18107A5311999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Salem,Unit 1.With 990913 ML18107A5031999-08-26026 August 1999 LER 99-006-00:on 990729,determined That SG Blowdown RMs Setpoint Was non-conservative.Caused by Inadequate ACs for Incorporating Original Plant Licensing Data Into Plant Procedures.Blowdown Will Be Restricted.With 990826 Ltr ML18107A5201999-08-12012 August 1999 Rev 0 to Sgs Unit 2 ISI RFO Exam Results (S2RFO#9) Second Interval,Second Period, First Outage (96RF). ML18107A4811999-07-31031 July 1999 Monthly Operating Rept for July 1999 for Salem,Unit 1.With 990813 Ltr ML18107A4821999-07-31031 July 1999 Monthly Operating Rept for July 1999 for Salem,Unit 2.With 990813 Ltr ML18107A4691999-07-28028 July 1999 LER 99-008-00:on 990714,determined That Limit Switch Cables Were Subject to Multiple Hot Shorts in Same Fire Area.Caused by Inadequate Original Post Fire Safe Shutdown Analysis.All Limit Switch Cables for MOVs Were Reviewed.With 990728 Ltr ML18107A4441999-07-0606 July 1999 LER 99-007-00:on 990605,surveillance for Quadrant Power Tilt Ratio (QPTR) Was Missed.Caused by Human Error.Qptr Calculation Was Performed & Personnel Involved Have Been Held Accountable IAW Pse&G Policies.With 990706 Ltr ML18107A4211999-07-0202 July 1999 LER 99-005-00:on 990605,11 Containment Declared Inoperable. Caused by Valves 11SW72 & 11SW223 Both Leaking.Procedure S1.OP-ST.SW-0010(Q) Was Enhanced to Provide Specific Instructions to Ensure Proper Sequencing.With 990702 Ltr ML18107A4331999-07-0101 July 1999 LER 99-002-01:on 990405,determined That 2SA118 Failed as Found Leakrate Test.Caused by Foreign Matl Found in 2SA118 valve.2SA118 Valve Was Cycled Several Times & Seat Area Was Air Blown in Order to Displace Foreign Matl.With 990701 Ltr ML18107A4321999-07-0101 July 1999 LER 99-006-01:on 990501,determined That There Was No Flow in One of Four Injection Legs.Caused by Sticking of Valve in Safety Injection Discharge Line to 21 Cold Leg.Valve Was Cut Out of Sys & Replaced.With 990701 Ltr ML18107A5211999-07-0101 July 1999 Rev 0 to Sgs Unit 2 ISI RFO Exam Results (S2RFO#10) Second Interval,Second Period,Second Outage (99RF). ML18107A4351999-06-30030 June 1999 Monthly Operating Rept for June 1999 for Salem,Unit 1.With 990713 Ltr ML18107A4341999-06-30030 June 1999 Monthly Operating Rept for June 1999 for Salem,Unit 2.With 990713 Ltr ML20196H8621999-06-30030 June 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data, June 1999 Rept ML18107A3951999-06-17017 June 1999 LER 99-004-00:on 990520,reactor Tripped from 100% Power,Due to Negative Flux Trip Signal from Nuclear Instrumentation. Cause Has Not Been Determined.Discoloration Was Identified on One of Penetrations.With 990617 Ltr ML18107A3661999-06-0909 June 1999 LER 99-003-00:on 990513,unplanned Entry Into TS 3.0.3 Was Made.Caused by Human error.Re-positioned Creacs Supply Fan Selector Switches & Revised Procedures S1 & S2.OP-ST.SSP-0001(Q).With 990609 Ltr ML18107A3551999-06-0202 June 1999 LER 99-005-00:on 990504,failure to Meet TS Action Statement Requirements for High Oxygen Concentration in Waste Gas Holdup Sys Occurred.Caused by Inability of Operators. Existing Procedures Will Be Evaluated.With 990602 Ltr ML18107A3441999-06-0101 June 1999 Interim Part 21 Rept Re Premature Over Voltage Protection Actuation in Circuit Specific Application in Dc Power Supply.Testing & Evaluation Activities Will Be Completed on 990716 ML18107A3541999-06-0101 June 1999 LER 99-006-00:on 990501,HHSI Flow Balance Discrepancy Was Noted During Surveillance.Caused by Sticking of Check Valve in SI Discharge Line to 21 Cold Leg.Valve 21SJ17,was Cut Out of Sys & Replaced.With 990601 Ltr ML18107A3681999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Salem Generating Station,Unit 1.With 990611 Ltr ML18107A3721999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Salem Generating Station,Unit 2.With 990611 Ltr ML18107A2931999-05-12012 May 1999 LER 99-002-00:on 990413,determined That Number 12 Auxiliary Bldg Exhaust Fan Was Rotating Backwards.Caused by mis-wiring of Motor Due to Human Error by Maint technician.Mis-wiring Was Corrected & Fan Was Returned to Svc.With 990512 Ltr ML18107A2781999-05-10010 May 1999 LER 99-004-00:on 990411,automatic Actuation of ESF Occurred During Reactor Vessel Head Removal in Support of Refueling Operations.Caused by High Radiation Condition.Containment Atmosphere Was Monitored.With 990505 Ltr ML18107A2791999-05-0404 May 1999 LER 99-003-00:on 990406,all Salem Unit 2 Chillers Rendered Inoperable.Caused by Human Error.Lessons Learned from Event Were Communicated to All Operators by Including Them in Night Orders.With 990504 Ltr ML18107A2741999-05-0303 May 1999 LER 99-002-00:on 990405,determined That Containment Isolation Valve Failed as Found Leakrate Test.Caused by Foreign Matl Blocking Valves from Closing.Check Valve Mechanically Agitated.With 990504 Ltr ML18107A3711999-04-30030 April 1999 Corrected Monthly Operating Rept for Apr 1999 for Salem Generating Station,Unit 1 ML18107A3151999-04-30030 April 1999 Submittal-Only Screening Review of Salem Generating Station Individual Plant Exam for External Events (Seismic Portion), Rev 1 ML18107A2991999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for Salem Unit 1.With 990514 Ltr ML18107A2971999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for Salem Unit 2.With 990514 Ltr ML18107A2351999-04-23023 April 1999 LER 99-001-00:on 990330,MSSV Failed Lift Set Test.Caused by Setpoint Variance Which Is Result of Aging.Valves Were Adjusted & Retested to Ensure TS Tolerance.With 990423 Ltr ML18107A2881999-04-0707 April 1999 Rev 0 to NFS-0174, COLR for Salem Unit 2 Cycle 11. ML18107A1821999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for Salem,Unit 1.With 990414 Ltr ML18107A1831999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for Salem,Unit 2.With 990414 Ltr ML18106B1471999-03-29029 March 1999 LER 99-001-00:on 990228,reactor Scram Was Noted as Result of Turbine Trip.Caused by Operator Error.Lesson Plans Revised to Explicitly Demonstrate Manner in Which Valve Functions. with 990329 Ltr ML18106B1021999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for Salem Unit 2.With 990315 Ltr ML18106B1011999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for Salem Unit 1.With 990315 Ltr ML18106B0931999-02-25025 February 1999 Part 21 Rept Re Possible Defect in Swagelok Pipe Fitting Tee,Part Number SS-6-T.Caused by Crack Due to Improper Location of Heated Bar.Only One Part Out of 7396 Pieces in Forging Lot Was Found to Be Cracked.Affected Util,Notified ML18106B0701999-02-16016 February 1999 LER 98-015-00:on 981208,inadvertent Discharge Through RHR Relief Valve During Startup Was Noted.Caused by Operator Performing Too Many Tasks Simultaneously.Appropriate Actions Have Been Taken IAW Policies & Procedures.With 990216 Ltr ML18106B0551999-02-0101 February 1999 Part 21 Rept Re Possible Matl Defect in Swagelok Pipe Fitting Tee,Part Number SS-6-T.Defect Is Crack in Center of Forging.Analysis of Part Is Continuing & Further Details Will Be Provided IAW Ncr Timetables.Drawing of Part,Encl ML18106B0561999-01-31031 January 1999 Monthly Operating Rept for Jan 1999 for Salem Generating Station,Unit 2.With 990212 Ltr ML18106B0571999-01-31031 January 1999 Monthly Operating Rept for Jan 1999 for Salem Generating Station,Unit 1.With 990212 Ltr ML20205P1671999-01-31031 January 1999 a POST-PLUME Phase, Federal Participation Exercise ML18106B0441999-01-29029 January 1999 Part 21 Rept Re Possible Defect in Swagelok Pipe Fitting Tee Part Number SS-6-T.Caused by Crack in Center of Forging. Continuing Analysis of Part & Will Provide Details in Acoordance with NRC Timetables ML18106B0491999-01-28028 January 1999 LER 98-007-01:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Caused by Transgranular Stress Corrosion Cracking.Replaced Affected Tubing.With 990128 Ltr ML18106B0401999-01-18018 January 1999 LER 98-016-00:on 981219,ECCS Leakage Was Outside of Design Value.Caused by Leakage Past Seat of 21RH34 Manual Drain. Valve 21RH34 Was Reseated.With 990118 Ltr ML18106B0251998-12-31031 December 1998 Monthly Operating Rept for Dec 1998 for Salem Unit 2.With 990115 Ltr 1999-09-30
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-f o*ps~G Public Service Electric and Gas Company P.O_ Box 236 Hancocks Bridge, New Jersey 08038 Salem Generating Station October 09, 1990 U. S. Nucleai Regulatory Commission Document Control Desk Washington, DC 20555
Dear Sir:
SALEM GENERATING STATION LICENSE NO. DPR-70 DOCKET NO. 50-272 UNIT NO. 1 LICENSEE EVENT REPORT 90-030-00 This Licensee Event Report is. being submitted pursuant to the requirements of the Code of Federal Regulations 10CFR 50.73{a) (2) (iv). This report is required within thirty (30) days of discovery.
Sincerely yours,
~&7~~
S. LaBruna General Manager -
Salem Operations MJP:pc Distribution The Energy People ::c !!. ~;).
,, t 95-2189 (10M) ~2-89
NllC for111._ U.I. NUCUAll llEOULATOllY ~llllON 19-831 APl'f'IOVED DUI NO. 31I0~1CM LICENSEE EVENT REPORT CLER) l'ACILITY NAME 111 DOCKET NUMllEll 121 I r-~R la Salem Generating Station - Unit 1 0 I 5 I 0 I 0 I 0 12 I 71 2 I 1 OF 0 17 TITLE l'I Reactor Trip on #13 S/G L-L Level Due to Personnel Error EVENT DATE 1111 LEA NUMBER (Ill AEl'OAT DATE 171 OTHEll' FACILITIES INVOLVED Ill MONTH QAY YEAR YEAR FACILITY NAMES DOCKET NUMllEAISI o19 ii o 9 o 9 Io - o13 I o- o I o i Io o I 9 9 lo OPERATING THll REPORT II IUBMITTEO PURIUANT TO THE REQUIAEMENTI OF 10 CFll §: (CMclc one or,,,,,,.. of lit* followln*} (111
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.._ ll0.73loll211YI ll0.731oll21MHllll ll0.73loll2111UI ao:1:s1.11211x1 LICENSEE CONTACT FOR THIS LEA 1121 NAME TELEPHONE NUMBER AREA CODE M. J. Pollack, LER Coordin~tor 6 10 19 3 13 9 - 2 I 0 2 1 1 1 1 1 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DEICRllEO IN THll llEl'ORT 1131 CAUSE SYSTEM COMPONENT MANUFAC-TURER y N B y I I I I I I I SUPPLEMENTAL REPORT EXPECTED 1141 0 EXPECTED
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- I . *.* *ppraxlmatoly fiftHn 1ln11I*-** rypowr/tron /inn} 1111 h NO SUllMl$SION DATE 1151 I I I On 9/10/90 at 1201 hours0.0139 days <br />0.334 hours <br />0.00199 weeks <br />4.569805e-4 months <br /> a reactor trip on No. 13 Steam Generator (S/G)
Low-Low Level occurred. Prior to the event, the pipe between the No.
11TD900 valve and the main steam line sheared providing a steam flow path to atmosphere. ro reduce the steam flow, the No. 11MS29 valve (MS Governor Valve) was closed. At '80% power, the 14MS29 valve is closed
("partial arc control scheme"}. Both the Nos. 11&14MS29 valves direct steam to the upper half of the Turbine. Therefore, with both valves closed, a significant dp across the HP Turbine developed. Contributing to this dp was opening the 11TD4 valve which resulted in bleeding steam away from the upper half of the HP Turbine. The Turbine shaft deflected creating an elliptical oscillation resulting in destruction of the Aux. speed sensor which generated an overspeed signal causing closure of the MS29 valves. Closure of the MS29 valves led to the trip on No. 13 S/G Low-Low Level. The root cause of this event is attributed to personnel error. Ops. Dep't. management d1d not layout an approved plan of action in addressing the pipe break associated with the 11TD900 valve. Contributing factors were procedural inadequacy and inadequate training. This event has been reviewed by senior management. Those individuals involved in this event have been held accountable.
Procedures have been revised to clearly identify the concerns with Turbine Valve Testing below 85% power. Op~rations Directiv~ procedure OD-15 will be revised. An Operations Department "troubleshooting" procedure will be prepared. Damaged equipment was replaced. This event will be reviewed by the: Nuclear Training Center for incorporation of lessons learned.
f
"' LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER NUMBER PAGE Unit_ i~~~~----'-~~~~~~~~~5~0~0~0~2~7~2"---~~~~=9=0_-~0~3~0~-~0~0o__~~~=2_-=o=f----'-7~~
PLANT AND SYSTEM IDENTIFICATIQN:
Westinghouse - Pressurized Water Reactor Energy Industry Identification System (EIIS) codes are identified in the text as rxxl IDENTIFICATION OF OCCURRENCE:
Reactor Trip from 79% power on 13 Steam Generator Low-Low Level due to personnel error Event Date: 9/10/90 Report Date: 10/09/90 This report was initiated by Incident Report No.90-671.
CONDITIONS PRIOR TO OCCURRENCE:
Mode 1 Reactor Power 79% - Unit Load 900 MWe DESCRIPTION OF OCCURRENCE:
On September 10, 1990 at 1201 hours0.0139 days <br />0.334 hours <br />0.00199 weeks <br />4.569805e-4 months <br />, during normal power operation, a reactor trip on No. 13 Steam Generator (S/G) Low-Low Level occurred.
Prior to the event, the 1/2" Main Steam System {SBI pressure indication line sheared upstream of the No. 11TD900 valve (Turbine Drain Instrument Isolation Valve). This provided a steam flow path to atmosphere. The 1/2" line is located on the No. 11 Steam Inlet Drain Line (1.5") -between the 11MS29 valve (No. 11 Main Steamline Governor Valve) and the High Pressure (HP) Turbine. In an attempt to reduce the steam flow, to assess repair requirements without removing the Unit from service, the No. 11MS29 valve was closed. -operations Procedure III-1.3.3, "Turbine Valve Tests" was used.
A "partial arc control scheme" is used in providing steam to the HP Turbine. In this scheme, the No. 14MS29 governor valve will remain closed until approximately 80% power is achieved. At-80% power, the valve is designed to begin opening to allow a power increase to 100%. When the No. 11MS29 valve was closed, the No. 14MS29 valve began to open; however, since both the No. 11 and No. 14MS29 valves direct steam to flow nozzles on the upper half of the HP Turbine, an unusual steam flow condition occurred. Also, Nos. 12MS29 and 13MS29 valves were opening more (to compensate for the closure of the 11MS29 valve). This condition resulted in a significant differential pressure (dp) across the upper and lower halves of the HP Turbine.
Contributing to this dp was opening the 11TD4 valve (Air Operated Steam Inlet Drain Line Valve). It was opened as an* attempt to reduce steam flow away from the 1/2" line break; however, it resulted in bleeding steam away from the upper half of the HP Turbine.
With the above conditions, the HP Turbine shaft deflected in the
LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER NUMBER PAGE Unit 1 5000272 90-030-00 3 of 7 DESCRIPTION OF OCCURRENCE: (cont'd) direction of the No. 11MS29 valve inlet nozzle. This deflection created a wave like action, traveling outward to the ends of the HP Turbine shaft. This wave was amplified towards the end of the shaft, due to shaft diameter reduction past the main bearing, resulting in an elliptical oscillation.
Located at the end of the shaft are three (3) speed sensors (Main, Auxiliary, and Spare) which are mounted on the Oil Pump approximately 40 mils off the shaft. The shaft elliptical oscillation resulted in damage to the Auxiliary speed sensor and the Main sensor. The Spare sensor remained undamaged. The damage to the Auxiliary speed sensor generated a 103% overspeed signal through the Electro-Hydraulic Control (EHC) electronics. The speed sensors work by producing pulses which are induced by the passing of the shaft gear teeth. A single spike, exceeding the 103% overspeed protection control (OPC) setpoint (1854 rpm) occurred. The OPC signal then latched in for 5 seconds (by design) causing closure initiation (i.e., puffing) of all four (4) MS29 valves.
Control Room alarms received (in addition to the reactor trip alarms) included "EH Speed/Load Ch Failure" and "EH Prot Sys Trbl". Also, a speed monitor channel failure light was observed illuminated, indicating a difference of at least 55 rpm between the Main and Auxiliary speed sensors.
The closure of the MS29 valves resulted in a steam flow/feed flow mismatch which causes the BF19 valves (Feedwater Control Valves) to begin closing. The combination of the "shrink" phenomenon (caused by the closure of the MS29 valves) coupled with the reduction in feedwater flow lead to the reactor trip on No. 13 S/G Low-Low Level.
Following the reactor trip, a main steamline isolation f JE} was manually initiated (from Train B) to maintain Reactor Coolant System (RCS) {AB} Tavg (as per the Emergency Operating Procedure).
Subsequently, the Unit was stabilized in Mode 3 {Hot Standby).
The Nuclear Regulatory Commission (NRC) was notified of the automatic actuation of the Reactor Protection System and the initiation of Main Steamline Isolation (an Engineered Safety Feature) in accordance with the Code of Federal Regulations 10CFR 50.72{B) (2) (ii) on September 10, 1990 at 1233 hours0.0143 days <br />0.343 hours <br />0.00204 weeks <br />4.691565e-4 months <br />.
APPARENT CAUSE OF OCCURRENCE:
The root cause of this event is attributed to personnel error.
Operations Department management did not layout an approved plan of action in addressing the pipe break associated with the 11TD900 valve. Additionally, Operations Department management did not fully utilize available resources (e.g., System Engineering) in making the decision to proceed with Operations Procedure III-1.3.3, even though the reactor power level (79%) did not meet the procedural
LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER NUMBER PAGE Unit 1 5000272 90-030-00 4 of 7 APPARENT CAUSE OF OCCURRENCE: (cont'd) requirements for initial conditions (i.e., 85 to 90% power).
Contributing factors to the cause of this event was procedural inadequacy and inadequate training.
Operations Procedure III-1.3.3 was found to be inadequate. The procedure Precautions section implied that the reason for requiring the plant to be between 85% and 90% power (Initial Conditions section), to perform the procedure, relates to unnecessary load reduction. Therefore, Operations management and shift supervision determined that it was acceptable to close the 11MS29 valve (per the procedure), in attempting to limit steam flow through the pipe break above the 11TD900 valve, even though the Unit was operating at 79%
power. Engineering input was not fully utilized in making the decision to.close the 11MS29 valve, using procedure III-1.3.3, or to open the 11TD4 valve.
A significant contributing factor to this event was Operator training inadequacy. Licensed Operator training includes training operators on Turbine operation. This training includes a discussion of the partial arc control scheme. Procedure III-1.3.3 is reviewed during this training. However, the reasons for the power restriction for use of the procedure is not addressed. It was found that the Westinghouse Turbine technical manual in the Nuclear Training Center library was not the latest revision (the 1981 version of the manual was found in the library). This earlier revision does not contain information relevant to load restriction. The latest revision contains a brief statement that.identifies that Turbine valve testing below 85% power should not be conducted due to a potential for Turbine damage.
A factor which contributed to the inappropriate management decision to proceed with the use of Operations Procedure III-1.3.3 was lack of clear guidance as to the application of Operations Directive procedure OD-15, "Use of Operations Department Procedures". This procedure defines under what circumstances a procedure deviation from initial conditions can be applied. The guidance provided is not specific thereby allowing significant latitude in interpretation.
ANALYSIS OF OCCURRENCE:
The Lpw-Low S/G Level reactor trip prevents operation with the steam generator water level below the minimum volume required for adequate heat removal. The trip is actuated.on two out of three low-low level signals in any S/G. The setpoint ensures adequate S/G inventory, at the time of a reactor trip, to allow for possible starting delays of the Auxiliary Feedwater Pumps fBA}; thus preventing S/G dryout and Reactor Coolant System fABI thermal and hydraulic transients associated with a loss of the heat sink.
The OPC is designed to protect the HP Turbine from overspeed operation during conditions when the plant is not synchronized to the grid. The OPC is part of the EHC System {TGJ. When an overspeed condition is sensed, the auxiliary governor emergency trip solenoids are designed
LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER NUMBER PAGE Unit 1 5000272 90-030-00 5 of 7 ANALYSIS OF OCCURRENCE: (cont'd) to release the operating .fluid from the control emergency trip header. This will result in the closure of the control valves and the intercept valves for ten *(10) seconds and five (5) seconds, respectively. The OPC also functions to electronically provide a close bias signal to decrease the turbine governor demand to zero volts. This closes all four (4) MS29 valves through their hydraulic control valve stopping steam flow in approximately 10 to is seconds.
Investigation found that the OPC auxiliary governor emergency trip solenoid valves would not function (i.e., close the turbine governor and intercept valves). However, the OPC did function by initiating a signal to decrease governor demand to zero volts thereby causing closure of the MS29 valves. The solenoid valves were original equipment.
The RPS functioned as designed and the heat sink was maintained during this event. Therefore, this event involved no .undue risk to the health or safety of the public. However, due to the actuation of the RPS, this event is reportable in accordance with Code of Federal Regulations 10CFR S0.73(a) (2) (iv).
The plant cooldown was greater than anticipated for a reactor trip from 79% power; however, it did not exceed the allowable Technical Specification limit~ Tavg had decreased to approximately. 532° F when main steamline isolation was initiated. Emergency Operating Procedure EOP-TRIP-2 requires main steamline isolation if Tavg has not trended back to 547° F approximately 10 to 15 minutes after a Unit trip.
During the plant cooldown, pressurizer level decreased to 14% and Pressurizer pressure to 1975 psig. Prior to the trip, Pressurizer level was 43% and Pressurizer pressure 2240 psig. The cooldown was compensated for by the manual initiation of Main Steamline Isolation (per the Emergency Operating Procedure).
The excessive cooldown has been attributed to operation of all three (3) Auxiliary Feedwater (AFW) Pumps (2 motor driven and 1 steam driven). The motor driven and turbine driven AFW Pumps started as designed; i.'e., loss of main feedwater, and all four Steam Generators had reached the low-low level setpoint. With all three (3) AFW Pumps operating, approximately twice the design basis AFW flowrate to the Steam Generators is realized (8.8E5 lb./hr instead of 4.4E5 lb./hr). The Turbine Driven Pump is designed to supply 100%
flowrate and the Motor Driven Pumps are designed to provide 50%
flowrate each.
CORRECTIVE ACTION:
This event has been reviewed by senior management. Those individuals involved in this event have been held accountable as applicable.
Procedure III-1.3.3 and other applicable procedures have been revised
LICENSEE EVENT REPORT (LER} TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER NUMBER PAGE Unit 1 5000272 90-030-00 6 of 7
~~~~~~~~~~
CORRECTIVE ACTION: (cont'd}
to clearly identify the concerns with Turbine Valve Testing below 85%
power.
Operations Directive procedure OD-15 will be revised to clearly identify under what conditions the Nuclear Shift Supervisor can authorize deviation from a procedures Initiating Conditions.
An Operations Department procedure will be prepared which will define what actions shift personnel are required to take for abnormal plant conditions that require "troubleshooting" not addressed by existing procedures.
The main, auxiliary, and spare speed sensors were replaced.
The 11TD900 valve sheared piping was replaced. Preliminary analysis of the pipe has indicated that the pipe sheared due to vibration induced metal fatigue. This laboratory analysis is continuing. Upon completion of the analysis, the root cause of the pipe shear will be determined and appropriate corrective actions will be implemented.
An Engineering review of the required AFW System capacity was previously initiated due to similar cooldown rates experienced following reactor trips (reference Unit 2 LER 311/90-029-00). This review is continuing.
This event will be reviewed by the Nuclear Training Center. Lessons learned will be incorporated into applicable training programs.
Investigation as to why the OPC solenoid valves did not function revealed that they were mechanically binding. Subsequently, the OPC solenoid valves and the emergency trip solenoid valve were replaced.
The new valves were tested satisfactorily prior to the Unit synchronization on September 14, 1990. This testing included functional testing during the Unit restart.
A preventive maintenance program for the OPC solenoid valves and the emergency trip solenoid valve, which includes inspection and cleaning, has been established.
The Salem Unit 2 OPC solenoid valves and the emergency trip solenoid valve have been scheduled for replacement during the next outage of sufficient duration.
The Nuclear Training Center will audit the vendor technical manuals in the Nuclear Training Center Library to ensure that the latest revision is present. Additionally, a review of the program for ensuring that the latest revision of applicable technical manuals are obtained and controlled by the Nuclear Training Center Library will be conducted.
Changes to the program will be made as applicable.
On September 13, 1990 at 0546 hours0.00632 days <br />0.152 hours <br />9.027778e-4 weeks <br />2.07753e-4 months <br />, the Unit entered Mode 1 operation. During startup, Turbine instrumentation was closely monitored. This instrumentation includes monitoring for
LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER NUMBER PAGE Unit 1 5000272 90-030-00 7 of 7 CORRECTIVE ACTION: (cont'd) eccentricity, bearing vibration, bearing metal temperature, return lube oil temperature, and 'main oil pump discharge pressure. The observed indications were compared with prior data. No abnormal indications were observed. Synchronization of the turbine-generator occurred on September 14, 1990 at 0519 hours0.00601 days <br />0.144 hours <br />8.581349e-4 weeks <br />1.974795e-4 months <br />.
General Manager -
Salem Operations MJP:pc SORC Mtg.90-139