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LER-1979-038, /03L-0:on 791214,two Manual Isolation Valves for Refueling Water Storage Tank Chemical Addition Tank Outlet Valve MOV-CS-102B Found Closed.Caused by Operator Procedural Error.Operators Instructed |
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| 2801979038R03 - NRC Website |
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. NRC FORM-366 -------- ~ - -
U.S. NUCLEAR REGULATORY COMMISSION (7a7.J. __,,.
.CENSEE EVENT REPORT
I IG) 6 (PLEASE PRINT OR TYPE ALL REQUIRED INFORMATION)
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I v1 Al s1 Pl s1 1101 ° I O I - I o I o I o I o I o I - Io I o 1014 11 11 11 I 1 101 I 10 7
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LICENSEE CODE 14 15 LICENSE NUMBER 25 26 LICENSE TYPE 30 57 CAT 58 CON'T [ITIJ 7
8
- ~~~~~ ~©I 01 5 1 °I O I O 1218 I 0101 11 21 t*1 41 71 9IG)I 01 11 01 41 sl olG) 60 61 DOCKET NUMBER 68 69 EVENT DATE 74 75 REPORT DATE 80 EVENT DESCRIPTION AND PROBABLE CONSEQUENCES@
I With Unit 1 at steady state operation, two nnnual isolation valves for the RWST
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I Chanical Addition Tank (CAT) outlet valve IVX)~-102B were fourrl to be closed.
((:ill Subsequent to the discovery of this con::lition, a test established the operability
((TI] I of the redurrlant CAT outlet valve, therefore the health am safety of the general
((II] I public were not affected.
The event is reportable in accordance with Technical
(([TI I Specification 6. 6.~-~ b. 3.
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[§))]
7 8 9 SYSTEM
CAUSE
CAUSE COMP.
VALVE CODE CODE SUBCODE COMPONENT CODE SUBCODE SUBCODE [ill]
I sl 8 1@ ~@ L!J@ I z I z I z I z I z I z 18 L?J l!J@
7 8
9 10 11 12 13 18 19 20 SEQUENTIAL OCCURRENCE REPORT
@ LER/RO CVENT YEAR REPORT NO:
CODE TYPE REPORT I 7 J 9 J l.=.l l O I 3 1
l=J NUMBER 21 22 23 24 26 27 28 29 30 31 ACTION FUTURE EFFECT SHUTDOWN r'22)
ATTACHMENT NPAD-4 FOAM SUB.
PRIME C.OMP.
SUPPLI EA 80 REVISION NO.
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32 COMPONENT MANUFACTURER TAK.ff:
ACTl2N ON PLANT METHOD HOURS ~ SUBMITTED
~@L_j@ L.:J@ L:J I O I O I O I I ~@
33 34 35 36 3 7 40 41
~@ LI@ I z 19 19 19 I CAUSE DESCRIPTION AND CORRECTIVE ACTIONS 42 43 44 47 [I12] I The discrepancy in valve al igrment was caused by an operator failirg to follow a ITTIJ I procedure that required the reopeni.rg of manual isolation valves for IDV-CS-102B OJI] I followi~ canpletion of a test. Operators have been explicitly reinstructed on um I the importance of perfonni.rg a periodic test in canplete conformance with the [I]3J I test document.
7 8
9 FACILITY STATUS
% POWER OTHERSTATUS @
METHOD OF A
80 ITE] LI@ I 11 o, 01@11-N-JA ____ ___.
DISCOVERY DISCOVERY DESCRIPTION ~
~@L..I _s_e_n_i_o_r_Re_a_c_t_o_r_Ope-=-_r_a_t_o_r_Ob_se_rv_a_t_i_o_n _ _.
8 9
10 12 11 ACTIVITY CONTENT
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REL~SED OF RELEASE AMOUNT OF ACTIVITY~
[QI] L:J@) ~@.... I _NA 7
8 9
10 11 44 7
45 46 80 44 NA LOCATION OF RELEASE@
45 80 PERSONNEL EXPOSURES r:;;:;,.
NUl;l.BEA.
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TYPE DESCRIPTION~
@TI I o I u I o Jl:J@L----~---------------------,-----'
7 8
9 11 12 13 BO PERSONNEL INJURIES
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ONU~BEA DESCRIPTION 41 Ci:fil I I I O 1@1,._._ ________________________
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7 8
9 11 12 80 LOSS OF OR DAMAGE TO FACILITY '4J'I TZE DESCAIP~ON
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~(s)L--_N~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
7 8
9 10 80 PUBLICITY Q
<Jr-,
NRC USE ONLY IS~EDQ DESC:&\\_TION ~
8 0 Q l O 7 0 7..J O [ill] ~ei..... l ---------------------:' II I I I II I II II I ~
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9 10 68 69 80*0:
NAME OF PREPARER __..w._. *..__.T....,.__.S.LJt_,,ew"""-"i:i'-'r.... t.__ ________ ___
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... Docket No.:
Report No.:
Event Date:
Page 1 Station 50-280 79-038/03L 12/14/79 Title of Event:
MOV-CS-l02B INOPERABLE DUE TO CLOSED MANUAL VALVES l-C.S-39 / 43
- 1.
Description of Event
With Unit 1 at steady state operation, two manual isolation valves l-CS-39/43 for the RWST Chemical Addition Tank (CAT) outlet valve MOV-CS-102B were found to be closed during a plant walk-down by a Senior Reactor Operator.
The manual isolation valves had been closed for 38 hours4.398148e-4 days <br />0.0106 hours <br />6.283069e-5 weeks <br />1.4459e-5 months <br />.
The event is reportable in accordance with Technical Specification
- 2.
Probable Consequences/Status of Redundant Systems:
With MOV-CS-102B isolated, if the redundant parallel CAT outlet valve had failed to open upon the initiation of a CLS Hi Hi signal, sodium hydroxide could not have been added to the containment spray water in the correct proportion as water was pumped out of the *RWST by the con~
tainment spray pumps.
Subsequent to the discovery of the closed manual valves l-CS-39/43, a test established the operability of the redundant CAT outlet valve, therefore the health and safety of the public were*
not affected.
- 3.
Cause
The discrepancy in valve alignment was caused by an operator failing to follow a procedure that required the reopening of manual isolation valves for MOV-CS-102B following the completion of a test.
- 4.
Immediate Corrective Action
Upon the discove~y of the discrepancy in the manual isolation valves alignment, a performance test was conducted to prove the operability of the redundant CAT outlet valve had a CLS Hi Hi signal been initiated while MOV-CS-102B was isolated.
In conformance with the performance test, MOV-CS-102B was then unisolated.
- 5.
Scheduled Corrective Action:
Corrective action was taken upon the discovery of the event by conducting the performance test.
This test proved the operability of the redundant CAT outlet valve and unisolated MOV-CS-102B, therefore no scheduled corrective action is required.
- 6.
Action Taken to Prevent Recurrence:
To prevent recurrence of the event, operators have been explicitly re-instructed on the importance of performing periodic tests in complete conformance with the test document.
- 7.
Generic Implications:
Since this event was caused by a single case of operator error in the performance of a test, there are no generic implications associated with this event.
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| 05000281/LER-1979-001, Forwards LER 79-001/03L-0 | Forwards LER 79-001/03L-0 | | | 05000280/LER-1979-001, Forwards LER 79-001/01X-0 | Forwards LER 79-001/01X-0 | | | 05000280/LER-1979-001-01, /01X-0 on 790102:potential non-conservatism Noted in Calculations Performed in Monitoring Heat Flux Hot Channel Factor.Caused by Failure of Sys & Procedures Used for Relevant Surveillance.Input Values Adjusted | /01X-0 on 790102:potential non-conservatism Noted in Calculations Performed in Monitoring Heat Flux Hot Channel Factor.Caused by Failure of Sys & Procedures Used for Relevant Surveillance.Input Values Adjusted | | | 05000281/LER-1979-001-03, /03L-0 on 790112:personnel Batch Inner Door & Emergency Escape Manway Not Leak Tested within 72-h After Opening Because Escape Manway Safety Lock Believed Broken, Posing Hazard | /03L-0 on 790112:personnel Batch Inner Door & Emergency Escape Manway Not Leak Tested within 72-h After Opening Because Escape Manway Safety Lock Believed Broken, Posing Hazard | | | 05000281/LER-1979-002, Forwards LER 79-002/03L-0 & 79-003/03L-0 | Forwards LER 79-002/03L-0 & 79-003/03L-0 | | | 05000281/LER-1979-002-03, /03L-0 on 790120: During Normal Operation Channel Check Revealed That Pressurizer Pressure Channel I Drifted Above Tech Spec Limit as Compared to Channels II & Iii. Caused by Failure of Channel I Pressure Transmitter | /03L-0 on 790120: During Normal Operation Channel Check Revealed That Pressurizer Pressure Channel I Drifted Above Tech Spec Limit as Compared to Channels II & Iii. Caused by Failure of Channel I Pressure Transmitter | | | 05000280/LER-1979-002-03, /03L-0 on 790115:electrical Penetration Between Turbine Bldg & Emergency Switchgear Room Not Properly Sealed.Caused by Penetration Being Broken During Previous Implementation of Design Change | /03L-0 on 790115:electrical Penetration Between Turbine Bldg & Emergency Switchgear Room Not Properly Sealed.Caused by Penetration Being Broken During Previous Implementation of Design Change | | | 05000280/LER-1979-002, Forwards LER 79-002/03L-0 | Forwards LER 79-002/03L-0 | | | 05000280/LER-1979-003-03, /03L-0 on 790124:error Detected in Calibr Procedures for Steam Flow Instrumentation.Caused by Error Made When Calibr Procedures Changed | /03L-0 on 790124:error Detected in Calibr Procedures for Steam Flow Instrumentation.Caused by Error Made When Calibr Procedures Changed | | | 05000280/LER-1979-003, Forwards LER 79-003/03L-0 | Forwards LER 79-003/03L-0 | | | 05000281/LER-1979-003-03, /03L-0 on 790122: Following Containment Entrance Equipment Hatch Escape Airlock,Outer Door Was Not Proven Sealed within 72-h from Initial Opening.Caused by Problems in Sealing Exterior Hatch | /03L-0 on 790122: Following Containment Entrance Equipment Hatch Escape Airlock,Outer Door Was Not Proven Sealed within 72-h from Initial Opening.Caused by Problems in Sealing Exterior Hatch | | | 05000280/LER-1979-004, Update to LER 79-004/01X-2:on 790309,A/E Notified Util of Possible Nonconservatisms in Pipe Stress Code Used to Analyze Piping Sys & of Innaccurate Valve Weights Used by Error in Pipe Stress Analysis & Valve Weight | Update to LER 79-004/01X-2:on 790309,A/E Notified Util of Possible Nonconservatisms in Pipe Stress Code Used to Analyze Piping Sys & of Innaccurate Valve Weights Used by Error in Pipe Stress Analysis & Valve Weight | | | 05000280/LER-1979-004-01, /01X-1 on 790309:notification Received of Possible Errors in Pipe Stress Code Analyses in Some Facility Piping Sys.Inaccurate Value Weights Were Also Identified. Plants Are Shut Down Pending Evaluation | /01X-1 on 790309:notification Received of Possible Errors in Pipe Stress Code Analyses in Some Facility Piping Sys.Inaccurate Value Weights Were Also Identified. Plants Are Shut Down Pending Evaluation | | | 05000281/LER-1979-004, Forwards LER 79-004/03L-0 | Forwards LER 79-004/03L-0 | | | 05000281/LER-1979-004-03, /03L-0 on 790204:setpoints of Seven Main Steam Safety Valves Not within Tech Spec Limits.Caused by Normal Setpoint Drift | /03L-0 on 790204:setpoints of Seven Main Steam Safety Valves Not within Tech Spec Limits.Caused by Normal Setpoint Drift | | | 05000280/LER-1979-005, Forwards LER 79-005/03L-0 | Forwards LER 79-005/03L-0 | | | 05000281/LER-1979-005-03, /03L-0 on 790204:at Cold Shutdown,Valve MOV-SW-203C Failed to Cycle Electrically.Caused by Slighting Bent Clutch Shaft in Valve Operation.Part Dismantled & Overhauled | /03L-0 on 790204:at Cold Shutdown,Valve MOV-SW-203C Failed to Cycle Electrically.Caused by Slighting Bent Clutch Shaft in Valve Operation.Part Dismantled & Overhauled | | | 05000280/LER-1979-005-03, /03L-0 on 790226:radiation Recorder RR-175 Stopped Printing.Caused by Gummed Gear Shaft Bushing in Print Mechanism.Bushing Was Freed & Print Mechanism Cleaned & Lubricated | /03L-0 on 790226:radiation Recorder RR-175 Stopped Printing.Caused by Gummed Gear Shaft Bushing in Print Mechanism.Bushing Was Freed & Print Mechanism Cleaned & Lubricated | | | 05000280/LER-1979-006, Forwards LER 79-006/03L-0 | Forwards LER 79-006/03L-0 | | | 05000280/LER-1979-006-03, /03L-0 on 790309:fire Seals in Barrier Penetration Were Removed & Not Replaced.Leak Test Not Performed on Other Seals That Had Been Reinstalled.Caused by Inadequate Administrative Control | /03L-0 on 790309:fire Seals in Barrier Penetration Were Removed & Not Replaced.Leak Test Not Performed on Other Seals That Had Been Reinstalled.Caused by Inadequate Administrative Control | | | 05000281/LER-1979-006-03, /03L-0 on 790204:at Cold Shutdown,Valve MOV-SW-203D Failed to Operate Electrically During Functional Test.Caused by Mechanical Binding of Valve.Valve Bearing Was Replaced | /03L-0 on 790204:at Cold Shutdown,Valve MOV-SW-203D Failed to Operate Electrically During Functional Test.Caused by Mechanical Binding of Valve.Valve Bearing Was Replaced | | | 05000280/LER-1979-007-03, /03L-0 on 790320:w/unit Shutdown,Visual Insp Resulted in Declaring One Snubber Inoperable Because of Low Fluid Level.Caused by Leakage from Reservoir Fill Fitting. Snubber Removed & Rebuilt | /03L-0 on 790320:w/unit Shutdown,Visual Insp Resulted in Declaring One Snubber Inoperable Because of Low Fluid Level.Caused by Leakage from Reservoir Fill Fitting. Snubber Removed & Rebuilt | | | 05000280/LER-1979-007, Forwards LER 79-007/03L-0 | Forwards LER 79-007/03L-0 | | | 05000281/LER-1979-007-03, /03L-0 on 790205:during Functional Test,Damper 1-VS-103A Failed to Close on Train a Safety Injection Initiation.Caused by Hang Up in Brake Mechanism Holding Supply Damper Open Against Closed Spring.Damper Closed | /03L-0 on 790205:during Functional Test,Damper 1-VS-103A Failed to Close on Train a Safety Injection Initiation.Caused by Hang Up in Brake Mechanism Holding Supply Damper Open Against Closed Spring.Damper Closed | | | 05000281/LER-1979-008-03, During Surveillance Check,Found Deterioration of Piping on Low Portion of Recirculation Spray Subsystems.Caused by Chloride Stress Corrosion.Piping Replaced W/Nonsensitized Piping | During Surveillance Check,Found Deterioration of Piping on Low Portion of Recirculation Spray Subsystems.Caused by Chloride Stress Corrosion.Piping Replaced W/Nonsensitized Piping | | | 05000281/LER-1979-008, Forwards Updated LER 79-008/03X-1 | Forwards Updated LER 79-008/03X-1 | | | 05000280/LER-1979-008, Forwards LER 79-008/01T-0 | Forwards LER 79-008/01T-0 | | | 05000280/LER-1979-008-01, /01T-0 on 790323:during Load Study of 480 Volts Ac Emergency Bus,Discovered That an under-power Condition Could Exist for Postulated LOCA with or W/O Loss of Offsite Power. 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Caused by Design Deficiencies During Const | | | 05000280/LER-1979-009-01, /01T-0 on 790412:GE Informed Util That Potential Problem Exists in Inside Recirculation Spray Pump Motors.Caused by Possible Overheating of Lower Bearing Due to Clearance Tolerances Allowed on End Shields & Shaft | /01T-0 on 790412:GE Informed Util That Potential Problem Exists in Inside Recirculation Spray Pump Motors.Caused by Possible Overheating of Lower Bearing Due to Clearance Tolerances Allowed on End Shields & Shaft | | | 05000280/LER-1979-009, Forwards LER 79-009/01T-0 | Forwards LER 79-009/01T-0 | | | 05000281/LER-1979-009-03, /03L-0 on 790208:while Performing Penetrant Test 39B-1,mechanic Discovered 3 Snubbers Were Not on Test.Caused by Inadvertent Omission.Change Initiated to Add 3 Snubbers to Penetrant Test 39B-1 | /03L-0 on 790208:while Performing Penetrant Test 39B-1,mechanic Discovered 3 Snubbers Were Not on Test.Caused by Inadvertent Omission.Change Initiated to Add 3 Snubbers to Penetrant Test 39B-1 | | | 05000281/LER-1979-009, Forwards LER 79-009/03L-0 | Forwards LER 79-009/03L-0 | | | 05000280/LER-1979-010-03, /03L-0 on 790323:while in Cold Shutdown, Discrepancies Found in Location & Configuration of Pipe Supports.Caused by Const Deficiencies & Util Maint.Necessary Repairs Will Be Made Prior to Startup | /03L-0 on 790323:while in Cold Shutdown, Discrepancies Found in Location & Configuration of Pipe Supports.Caused by Const Deficiencies & Util Maint.Necessary Repairs Will Be Made Prior to Startup | | | 05000280/LER-1979-010, Forwards LER 79-010/03L-0 | Forwards LER 79-010/03L-0 | | | 05000281/LER-1979-010, Forwards LER 79-010/03L-0 | Forwards LER 79-010/03L-0 | | | 05000281/LER-1979-010-03, /03L-0 on 790306:during tests,19 of 30 Snubbers Did Not Meet Acceptance Criteria.Caused by Setting Drift & non-readjustment to Optimum Settings After Previous Satisfactory Tests.Snubbers Readjusted,Repaired or Replaced | /03L-0 on 790306:during tests,19 of 30 Snubbers Did Not Meet Acceptance Criteria.Caused by Setting Drift & non-readjustment to Optimum Settings After Previous Satisfactory Tests.Snubbers Readjusted,Repaired or Replaced | | | 05000280/LER-1979-011-03, /03X-1 on 790828:process & Ventilation Particulates & Gaseous Monitors Were W/O Power on Two Occasions.Caused by Loose Lug Connection on Power Supply Cable.Loose Connection Repaired & Plants Restored to Svc | /03X-1 on 790828:process & Ventilation Particulates & Gaseous Monitors Were W/O Power on Two Occasions.Caused by Loose Lug Connection on Power Supply Cable.Loose Connection Repaired & Plants Restored to Svc | | | 05000280/LER-1979-011, Forwards LER 79-011/03X-1 | Forwards LER 79-011/03X-1 | | | 05000281/LER-1979-011, Forwards LER 79-011/12T-0 | Forwards LER 79-011/12T-0 | | | 05000281/LER-1979-011-12, /12T-0 on 790414:individual Received Excessive Dose While Inspecting Area Beneath Vessel.Caused by Elevated Radiation Levels Due to Incore Instrumentation Refueling Status.Individual Disciplined | /12T-0 on 790414:individual Received Excessive Dose While Inspecting Area Beneath Vessel.Caused by Elevated Radiation Levels Due to Incore Instrumentation Refueling Status.Individual Disciplined | | | 05000280/LER-1979-012-03, During Shutdown Functional Test of 74 Snubbers Revealed 21 Not Meeting Design Criteria.Caused by Snubbers Not Being Readjusted to Design Conditions.Units Reset | During Shutdown Functional Test of 74 Snubbers Revealed 21 Not Meeting Design Criteria.Caused by Snubbers Not Being Readjusted to Design Conditions.Units Reset | | | 05000280/LER-1979-012, Forwards Updated LER 79-012/03X-1 | Forwards Updated LER 79-012/03X-1 | | | 05000281/LER-1979-012, Forwards LER 79-012/08T-0 | Forwards LER 79-012/08T-0 | | | 05000281/LER-1979-012-08, /08T-0 on 790507:caustic Residue Discovered on 62 New Fuel Assemblies.Caused by Industrial Sabotage. Fuel Removed & Assemblies Rinsed.Investigation Continuing | /08T-0 on 790507:caustic Residue Discovered on 62 New Fuel Assemblies.Caused by Industrial Sabotage. Fuel Removed & Assemblies Rinsed.Investigation Continuing | | | 05000281/LER-1979-013, Forwards LER 79-013/01T-0 | Forwards LER 79-013/01T-0 | | | 05000281/LER-1979-013-01, /01T-0:on 791007,MOV-SW-202B Operated Mechanically & Electrically in Apparent Reverse Manner W/Unit at Cold Shutdown.Caused by Disc Spline of Svc Water Valve Improperly Aligned to Gear Train of Motor Operator | /01T-0:on 791007,MOV-SW-202B Operated Mechanically & Electrically in Apparent Reverse Manner W/Unit at Cold Shutdown.Caused by Disc Spline of Svc Water Valve Improperly Aligned to Gear Train of Motor Operator | | | 05000280/LER-1979-013, Forwards LER 79-013/03L-0 | Forwards LER 79-013/03L-0 | | | 05000280/LER-1979-013-03, /03L-0 on 790410:100 Gallons Released from Boron Recovery Test Tank 1-BR-TK-2B Prior to Obtaining Sample Results.Caused by Improper Valve Lineup for Tank Recirculation in Preparation for Sampling | /03L-0 on 790410:100 Gallons Released from Boron Recovery Test Tank 1-BR-TK-2B Prior to Obtaining Sample Results.Caused by Improper Valve Lineup for Tank Recirculation in Preparation for Sampling | | | 05000280/LER-1979-014-03, /03L-0 on 790422:liquid Waste Disposal Radiation Monitor Failed to Give High Alarm & Trip Release Valve. Caused by Instrument Drift in High Alarm Setpoint.All Liquid Waste Releases Were Secured & Alarm Board Checked | /03L-0 on 790422:liquid Waste Disposal Radiation Monitor Failed to Give High Alarm & Trip Release Valve. Caused by Instrument Drift in High Alarm Setpoint.All Liquid Waste Releases Were Secured & Alarm Board Checked | | | 05000280/LER-1979-015-03, /03L-0 on 790422:liquid Waste Disposal Radiation Monitor Failed to Give High Alarm & Trip Release Valve. Caused by Procedural Inadequacy.Procedures Modified | /03L-0 on 790422:liquid Waste Disposal Radiation Monitor Failed to Give High Alarm & Trip Release Valve. Caused by Procedural Inadequacy.Procedures Modified | |
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