LER 95-005-00:on 950705,failure to Analyze Second Sample W/ Radiation Monitor Inoperable Occurred.Caused by Personnel Error.Second Sample Analyzed & Determined to Be in Agreement W/First SampleML18101A875 |
Person / Time |
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Site: |
Salem ![PSEG icon.png](/w/images/c/cc/PSEG_icon.png) |
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Issue date: |
08/04/1995 |
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From: |
Suey G Public Service Enterprise Group |
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To: |
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Shared Package |
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ML18101A873 |
List: |
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References |
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LER-95-005-02, LER-95-5-2, NUDOCS 9508100198 |
Download: ML18101A875 (6) |
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Similar Documents at Salem |
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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
[Table view] |
Text
NRC FORM 366 u. ~LEAR REGULATORY COMMISSION ED BY OMB NO. 3150-0104 (5-92) EXPIRES 5/31/95 ES Tl MA TED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD LICENSEE EVENT REPORT (LER) COMMENTS REGARDING BURDEN ESTIMATE TO THE INFORMATION AND RECORDS MANAGEMENT BRANCH (MNBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK (See reverse for required number of digits/characters for each block)
REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.
FACILITY NAME (11 II DOCKET NUMBER (2) PAGE 131 SALEM GENERATING STATION, UNIT 2 0500031 1 1 OF 6 TITLE (4)
Technical Specification Violation: Failure to analvze second samole with Radiation Monitor lnooerable EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (B)
MONTH DAY YEAR YEAR SEQUENTIAL REVISION MONTH DAY YEAR FAOLITY NAME DOCKET NUMBER NUMBER NUMBER 05000 FACILITY NAME DOCKET NUMBER 07 05 95 95 -- 005 -- 00 08 04 95 05000
'~ THIS REPORT JS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR §: (Check one or more) (11)
- (9)
~ 20.402(b) 20.405(c) 50. 73(a)(2)(iv) 73.71 (b)
POWER 20.405(a)( 1)(i) 50.36(c)(1) 50. 73(a)(2)(v) 73.71(c)
LEVEL (1) () Ofn 20.405(a)( 1)(ii) 50.36(c)(2) 50. 73(a)(2)(vii) OTHER
- 20.405(a)(1 )(iii) x 50. 73(a)(2)(i) (B) 50. 73(a)(2)(viii)(A) (Specify in Abstract 20.405(a)(1 )(iv) 50. 73(a)(2)(ii) 50.73(a)(2)(viii)(B) below and in Text,
- !l!!llll!lll:l!!!llll!lll!ll*l!!!!!!!:11111111111111111111111111*111111111111111111!1*11111*1 20.405(a)(1 )(v) 50. 73(a)(2)(iii) 50. 73(a)(2)(x) NRC Form 366A)
LICENSEE CONTACT FOR THIS LER (12)
NAME TELEPHONE NUMBER (Include Area Code)
G. Suey, Chemistry Manager (609) 339-2830 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (131 CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE TO NPRDS TO NPRDS I YES (If yes, complete EXPECTED SUBMISSION DATE).
SUPPLEMENTAL REPORT EXPECTED (14)
ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (161
- x1NO EXPECTED SUBMISSION DATE (15)
MONTH DAY YEAR On July 5, 1995 at approximately 0022 hours2.546296e-4 days <br />0.00611 hours <br />3.637566e-5 weeks <br />8.371e-6 months <br />, a liquid release for 22 eves Monitoring Tank was initiated. The release evolution was completed at 0343 (same day) . Prior to the release, one liquid effluent monitor (2R18) had been inoperable (since 5/6/95) and Technical Specification (TS) Action statement (3.3.3.8, Action B) was entered. This TS Action requires, in part that "prior to initiating a release, at least two independent samples are analyzed. . . ,,
Prior to release, two independent samples were obtained from the monitoring tank. The first sample was analyzed for activity levels and manual release rate calculations were performed and independently verified. Release authorization was provided to Operations without analyzing and comparing the spectrum of the second sample with the first sample. This is in violation of the TS and procedure. Following the release, the technician advised the supervisor of the error on July 5, 1995 at approximately 0730 hours0.00845 days <br />0.203 hours <br />0.00121 weeks <br />2.77765e-4 months <br />. The second sample was immediately analyzed and determined to be in agreement with the spectrum of the first sample. This event is attributed to personnel error. In addition, the procedures were enhanced to minimize the potential for human error. The Chemistry technician involved was disciplined and Chemistry department technicians were provided feedback and training.
NRC FORM 366 (5-92) 9508100198 950803 PDR ADOCK 05000311 S PDR
NRC FORM 366A CLEAR REGULATORY COMMISSION A VED BY OMB NO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ES Tl MA TE TO THE LICENSEE EVENT REPORT (LER) INFORMATION AND RECORDS MANAGEMENT BRANCH (MNBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, TEXT CONTINUATION WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.
FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)
YEAR SEQUENTIAL REVISION SALEM GENERATING STATION, UNIT 2 05000311 NUMBER NUMBER 2 OF 6
--005 -- 000 95 TEXT (If more space is required, use additional copies of NRC Form 366A) 117)
Plant and System Identification:
Westinghouse - Pressurized Water Reactor Energy Industry Identification System (EIIS) codes and component function identifier codes appear in the text as {XX/XX}.
Identification of Occurrence Faiiure to analyze the second independent sample prior to releasing the contents of the Chemical Volume and Control System (CVCS) Monitoring Tank to the Service Water discharge header.
Event Date: July 5, 1995 Report Date July 2 6, 1995 This report was initiated by Incident Report No. 95-1065.
Conditions Prior to Occurrence:
Both Units were in a self-imposed extended shutdown Mode 5 Reactor Power % Unit Load Mwe Description of Occurrence On July 5, 1995 at approximately 0022 hours2.546296e-4 days <br />0.00611 hours <br />3.637566e-5 weeks <br />8.371e-6 months <br />, a liquid release from the 22 CVCS Monitoring Tank (CVCSMT) {IL} was initiated. The release evolution was completed at 0343 (same day). Prior to the release, one liquid effluent monitor (2R18) had been inoperable (since 5/6/95) and Tech Spec Action statement (3.3.3.8, Action B) was entered. For one inoperable liquid effluent monitors, Tech Spec Action statement (3.3.3.8, Action B, Table 3.3-12, Note
- 26) requires, in part that "prior to initiating a release, at least two independent samples are analyzed ... ". Authorization for release of the tank contents was provided to Operations without analyzing and comparing the spectrum of the second sample with the first sample. Failure to perform the analysis of the second sample is in violation of the TS and procedure.
The CVCSMT stores the treated or low activity waste for analysis prior to discharging the waste through a monitored (2R18) line to the service water discharge header and then to the circulating water di~charge. The analysis determines the quantity of radioactivity, with an isotopic breakdown of the constituent radionuclides.
Radiation Monitor (RM) channel 2R18 continuously monitors liquid radwaste released from Salem Unit 2. If a radiation alarm setpoint is exceeded or a NRC FORM 366A (5-92)
NRC FORM 366A U. . CLEAR REGULATORY COMMISSION A ED BY OMB NO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE LICENSEE EVENT REPORT (LER) INFORMATION ANO RECORDS MANAGEMENT BRANCH (MNBB 77141, U.S. NUCLEAR .REGULATORY COMMISSION, TEXT CONTINUATION WASHINGTON, DC 20555-0001, ANO TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.
FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (31 YEAR SEQUENTIAL REVISION SALEM GENERATING STATION, UNIT 2 05000311 NUMBER NUMBER
- 3 OF 6 95 005 -- 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (171 Description of Occurrence (Cont'd) monitor failure occurs, the channel initiates a closure signal to the 2WL51 valve thereby terminating the release in progress.
At the time of this event, the above RM was inoperable. Therefore, prior to initiating a release, two independent samples -were obtained from the monitoring tank in accordance with TS Action statement (3.3.3.8, Action B, Table 3. 3-12, Note 26) . The first sample was *analyzed by the Chemistry technician for activity levels. Manual r~lease rate calculations were performed and independently verified by two independent and technically qualified members of the facility staff. The analysis determined that the quantity of radioactivity was below the allowable technical specification limit for release. The second sample was not analyzed until after the release evolution was completed.
Analysis of Occurrence On July 4, 1~95 at 1303, Chemistry Technicians completed the addition of hydrogen peroxide to Unit One Reactor Coolant System for crud burst in accordance. with Procedure SC.CH-AD.RC-0413 (Q). The purpose of this is to solubilize crud for cleanup via demineralizers, thereby reducing radiation levels. Samples are required approximately one hour after addition and after each start and stop (bump) of the Reactor Coolant Pump. A second addition was made at 1420 and sampling commenced at 1520. Additional samples were taken at 1610, 1635, and 1710 following bumping of each Reactor Coolant Pump (RCP).
One other sample was taken during this shift at 2105.
At approximately 1730 (same day), the -Unit 2 Nuclear Shift Supervisor (NSS) called and inquired about the status of 22 Chemical Volume Control System Monitoring Tank (CVCSMT) release samples. The shift technician was-unaware of a pending need for a release from the. monitor tank. There was no turnover from the previous shift stating release samples were needed (the previous shift technician also was unaware a release was needed) . Once. alerted, the shift technician found the release request in the Primary Chemistry Laboratory. At 1750 two independent samples were obtained from 22 CVCSMT and analysis started at 1757.
The shift technician returned to the Primary Lab and continued working on crud burst sample analysis and data entry while the CVCSMT sample was counting.
The technician left the auxiliary building at approximately 1815 and returned shortly after 1830. Upon returning, .he went to the Counting Room and checked the results of 22 CVCSMT. He prepared the liquid release initiation form in accordance with procedure SC.CH-TI.ZZ-0189(R), and performed the manual release rate calculations for liquid effluents in.accordance with Form SC.CH-TI.ZZ-0189-3. He then forwarded the_ calculation to the other on-site NRC FORM 366A (5-921
NRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION AP VED BY OMB NO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE LICENSEE EVENT REPORT (LER) INFORMATION AND RECORDS MANAGEMENT BRANCH (MNBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, TEXT CONTINUATION WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.
FACILITY NAME (11 DOCKET NUMBER (2) LER NUMBER (61 PAGE (3)
YEAR SEQUENTIAL . REVISION SALEM GENERATING STATION, UNIT 2 05000311 NUMBER NUMBER 4 OF 6 95 -- 005 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)
Analysis of Occurren_ce (Cont'd) qualified chemistry technician to perform the second independent verification of the release rate calculations.
At approximately 1950, the on-call Chemi~try Supervisor was contacted at home by the shift
- technician to give release approval to Operations Department.
The shift technician informed the supervisor that 2R18 RM was inoperable~ The other on site chemistry technician performed the independent verification of the manual calculation. The release contained a warning message requiring the technician to contact a Chemistry Supervisor before proceeding. The warning
. message stated "the release may exceed -projected quarterly dose criteria of T. s. 3. 11. 1. 3 and may require processing prior to release" . The Chemistry Supervisor discussed the technical specification with the technician. He asked the technician to verify the tank had been processed by the Boric Acid Evaporator or the Vendor Demineralizer/Filter. The technician reviewed procedure S2.0P-SO.WL-0002{Q) Attachment 2 page 1 of 12 and verified the tank had been processed. The Chemistry Supervisor provided written authorization for the release. Based on this written authorization, operations authorized and approved the release and the release evolution commenced.
The chemistry technician did not properly comply with all of the procedural requirements of SC.CH-TI.ZZ-0189(R). This procedure requires two independent samples be analyzed prior to initiation of a release.
On July 5, 1995 at approximately 0730, the shift technicians from July 4, 1995 informed the Counting Room Supervisor a mistake was made; the required second independent sample was not analyzed. The superV"isor contacted the Control Room to see if the release of 22 eves MT could be stopped, but was informed the release had already occurred. The second sample was immediately analyzed and determined to be in agreement with the spectrum of the first sample.
Apparent Cause of Occurrence The cause code classification "A", "personnel error" (per NUREG 1022) is attributed to this event. A contributing cause was determined to be self-imposed time pressure.
Prior Similar Occurrence There are no previous similar events associated. with the requirement to analyze the second independent sample prior to release.
Safety Significance This condition is reportable pursuant to 10CFR50. 73 (a) (2) (i) (B) due to the failure to completely satisfy Tec,hnical Specification Action Statement 3.3.3.B(b) "Radioactive Liquid Effluent Monitoring Instrumentation"(Table 3.3-NRC FORM 366A (5-92)
~cronM~
I L W-92)
U.
- CLEAR REGULATORY COMMISSION A ED BY OMB NO. 3150-0104 EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE LICENSEE EVENT REPORT (LER) INFORMATION AND RECORDS MANAGEMENT BRANCH (MNBB 77141, U.S.
- NUCLEAR REGULATORY COMMISSION, TEXT CONTINUATION WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-01041, OFFICE OF .MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.
FACILITY NAME 111 DOCKET NUMBER 12) LER NUMBER 161 PAGE 131 YEAR SEQUENTIAL REVISION SALEM GENERATING STATION, UNIT 2 05000311 NUMBER NUMBER 5 OF 6 95 005 00 TEXT (If more space is required, use additional copies of NRC Form 366A) 1171 Safety Significance (Cont'd) 12, Action 26 (a)) prior to the release. The second sample was analyzed after the release and determined to be in agreement with the spectrum of the first sample. The results of the analysis showed that the CVCSMT low activity waste was below the TS concentration limit for a liquid effluent release.
There was no Industrial Safety, radiological impact, or nuclear safety issues
- associated with this event. The nature of the violation was lirni ted to "failure to analyze the second independent sample prior to initiating the release in accordance with Technical Specifications."
The CVCSMT stores the treated or low activity waste for analysis prior to discharging the waste through a monitored (2Rl8) line to the service water discharge header and then to the circulating water discharge. Channel 2Rl8 continuously monitors liquid radwaste released from Salem Unit 2. If a radiation alarm setpoint is exceeded or a monitor failure occurs, the channel initiates a closure signal to the 2WL51 isolation valve.
The 2Rl8 RM was declared inoperable since May 6, 1995 due to a RM System CPU and Software problem associated with the proper functioning of the overhead annunciator light and alarm. However, the RM was maintained and functional during this period. The RM (2Rl8) was calibrated April 11, 1995 and passed its functional check June. 27,1995. During the release evolution on July 5, 1995 the status of the RM (although declared inoperable) would have isolated the 2WL51 valve as designed upon detection of concentrations in excess of setpoint limits thereby terminating the release in progress. The Control Room would also have received a 2WL51 alarm, acknowledged the alarm and received a printout of the alarm condition.
Corrective Actions Actions to correct the error and preclude future occurrences include the following:
- 1. The second sample was arialyzed and determined to be in agreement with the first sample on July 5, 1995 at 0842 hours0.00975 days <br />0.234 hours <br />0.00139 weeks <br />3.20381e-4 months <br />.
- 2. Chemistry Procedure SC.CH-TI .ZZ-0189 (R), "Radiological Effluent Discharge Report Generation and Completion" has be!=n revised to include a "checkoff" for the technician which states, "verify two independent samples have been analyZed, are in agreement, and spectrum attached" to release documents. This revision applies to both liquid and gaseous releases.
NRC FORM 366A (5-921
NRC FORM 366A U. . UCLEAR REGULATORY COMMISSION A VED BY OMB NO. 3150-0104 (5-92) EXPIRES 5131195 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS .
INFORMATION COLLECTION REQUEST: 50.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE LICENSEE EVENT REPORT (LER) INFORMATION AND RECORDS MANAGEMENT BRANCH (MNBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, TEXT CONTINUATION WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.
FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE 13)
YEAR SEQUENTIAL REVISION SALEM GENERATING STATION, UNIT 2 05000311 NUMBER NUMBER 6 OF 6 95 005 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)
Corrective Actions (Cont'd)
- 3. Operations procedures for liquid and gaseous releases are being revised to require a verification signature. This signature ensures that when a monitor is inoperable, a second independent sample is analyzed. This signature also provides for a second barrier which further precludes the possibility of human error.
- 4. On July 6, 1995 a Chemistry Department Stand-down was conducted for approximately
- 2. 5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> to discuss this event and other less significant events. Technicians provided feedback to supervision as to why they think this event occurred and what Chemistry can do as a department to prevent future events. supervision introduced PARC, (Prioritize, Avoid,- Relaxation, Control) to the technicians and received a cormni tment from them to use this concept . The technicians not present during the stand-down (e.g., vacation, ill, critical activities) were afforded the same opportunity during the Human Error Reduction Training conducted on 7/13 and 7/14/95.
- 5. On July 7, 1995, a "For Your Information (FYI)" bulletin was issued to Salem station personnel concerrP-ng this event. This FYI contained a brief analysis of the event and a discussion of defense barrier breakdowns. FYI's are a vehicle through which iteins considered important to PSE&G management are communicated to all station employees and facilitate supervisor and employee discussions and involvement, as
. applicable.
- 6. A review of the Chemistry workload vs. staffing was performed. Chemistry supervision determined that adequate coverage was available.
- 7. On July 7, 1995 the technician involved was disciplined in accordance with the Positive Discipline Process for inadequate work performance.
- 8. Chemistry Technicians attended Chemistry specific Human Error Reduction Training similar to the training received by PSE&G management . This training provides the
.technicians with coping mechanisms for handling self-imposed and other job related pressures.
- 9. Those technicians who missed the Chemistry specific Human Error Reduction Training will discuss the concept of error reduction with their supervisor after they return.
- 10. Required reading of the LER by all Chemistry Technicians will be conducted upon issuance of the LER.
11.The new chemistry procedure revision will be reviewed with the Chemistry Technicians upon issuance.
NRC FORM 366A (5-92)