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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML20046C3131993-07-28028 July 1993 LER 93-015-00:on 930630,HPCI Sys Declared Inoperable Due to Indicated Flow During Surveillance.Caused by Foreign Matl That Plugged Portion of Restricting Orifice.Restricting Orifice Removed,Cleaned & reinstalled.W/930728 Ltr ML20046B5241993-07-26026 July 1993 LER 93-007-01:on 930317,automatic Closing of RCIC Sys Turbine Steam Supply Isolation Valves Occurred Due to High Steam Flow Signal.Increased Frequency of Valve Testing from Monthly to weekly.W/930726 Ltr ML20045F8601993-06-30030 June 1993 LER 93-014-00:on 930531,automatic Scram Occurred,Resulting from Operation of Auxiliary Transformer Differential Relay During Power Ascension.Uat Phase B & C Differential Relays Left Interchanged as Investigative aid.W/930630 Ltr ML20045E2301993-06-25025 June 1993 LER 93-013-00:on 930530,RCIC Sys Declared Inoperable & 7 Day TS 3.5.D.2 LCO Entered Due to Speed Oscillations Which Occurred After Several Minutes of steady-state Operation. Caused by Actuator Failure.Actuator replaced.W/930625 Ltr ML20045E2251993-06-25025 June 1993 LER 93-012-00:on 930529,unplanned PCIS Group I Isolation Signal Occurred While Opening MSIV During Startup,Resulting in Automatic Closing of Related Valves.Caused by Licensed Operator Error.Group 1 Isolation reset.W/930625 Ltr ML20045D6941993-06-23023 June 1993 LER 93-011-00:on 930525,determined That Initial as-found Popping Pressures of Pilot Valves for Three Target Rock Main Steam Relief Valves Out of TS Tolerance.Caused by Setpoint Drift.Valves Reworked & Reassembled by Target Rock Corp ML20045D1861993-06-18018 June 1993 LER 93-010-00:on 930519,SUT Became de-energized During Planned Calibr of Turbine/Generator Relays Lockout Test While Shut Down.Caused by Personnel Error.Discussion Conducted W/Personnel Re Attention to detail.W/930618 Ltr ML20044H0441993-06-0202 June 1993 LER 93-009-00:on 930504,circuit Breaker Did Not Close During Planned Bus Transfer Due to Loose Control Circuit Wire.Lug Replaced & Reterminated on 930505 & Post Work Testing Completed W/Satisfactory results.W/930602 Ltr ML20024G7451991-04-24024 April 1991 LER 91-005-00:on 910325,diesel Generator Inoperable,Causing Loss of Ac Power to Train B Components of Safety Sys & Actuating Portions of Primary/Secondary Containment Sys. Caused by Voltage Regulator failure.W/910424 Ltr ML20029A6721991-02-25025 February 1991 LER 91-001-00:on 910125,automatic Primary Containment Isolation Control Sys Group 5 Actuation Occurred,Resulting in Closing of RCIC Turbine Steam Supply Isolation Valves. Caused by High Flow conditions.W/910225 Ltr ML20028G9731990-09-20020 September 1990 LER 89-036-01:on 891122,determined That HPCI Sys Inoperable Due to Inoperable Gland Seal Condenser Blower Motor.Caused by age-related Wear of Motor.Blower Motor Replaced & Blower Tested W/Satisfactory results.W/900920 Ltr ML20028G9121990-09-18018 September 1990 LER 89-037-01:on 891130,primary Containment/Traversing in-core Probe Ball Valve Discovered to Be Almost Full Open. Caused by Damage to Valve Stem Due to Manual Manipulation of Stem.Ball Valve & Solenoid Actuator replaced.W/900918 Ltr ML20043G3541990-06-12012 June 1990 LER 90-008-00:on 900513,automatic Scram Resulting from Load Rejection Occurred While at Full Power,Resulting in Trip of Generator Field Breakers.Caused by Fault on Offsite 345 Kv Transmission sys.Loss-of-field Relay replaced.W/900612 Ltr ML20043F8291990-06-0606 June 1990 LER 90-007-00:on 900507,discovered That Drywell to Suppression Chamber Vacuum Breaker Surveillance Not Performed Prior to Startup in 1988.Caused by Misunderstanding of requirements.W/900606 Ltr ML20042F5911990-04-30030 April 1990 LER 90-006-00:on 900330,determined That Position of Primary Containment Sys Isolation Valve Not Recorded Daily,Per Tech Specs.Review Performed to Determine If Other Problems Existed.Plant Shut Down & Review performed.W/900430 Ltr ML20012F5751990-04-0606 April 1990 LER 90-003-00:on 900311,automatic Actuation of Main Steam Sys Group 1 Portion of Primary Containment Isolation Control Sys Occurred.Caused by False High Reactor Vessel Water Level Signal.Procedure Developed Re backfill.W/900406 Ltr ML20012E9831990-03-30030 March 1990 LER 90-002-00:on 900228,determined That Max Fraction of Limiting Power Density Not Checked Daily During Reactor Power Operation,Per Tech Spec 4.1.B.On 900323,addl Tech Spec Issue Discovered.Tech Specs changed.W/900330 Ltr ML20012C4871990-03-12012 March 1990 LER 90-001-00:on 900209,24 H Limiting Condition for Operation Entered When Two RCS Instrumentation Excess Flow Check Valves Inappropriately Verified Operable During Testing.Cause Undetermined.Two Valves replaced.W/900312 Ltr ML20005G0981990-01-0808 January 1990 LER 89-038-00:on 891208,unplanned Automatic Reactor Protection Sys Scram Signal & Reactor Scram Occurred.Caused by False Low Reactor Vessel Water Level Signal.Local Level Indicators Satisfactorily calibr.W/900108 Ltr ML20005F8481990-01-0808 January 1990 LER 89-039-00:on 891209,automatic Actuation of RHR Sys Portion of Primary Containment Isolation Control Sys Occurred.Caused by Hydrodynamic Transient That Actuated Protective High Pressure switches.W/900108 Ltr ML20005E8551989-12-30030 December 1989 LER 89-037-00:on 891130,discovered That Traversing in-core Probe Ball Valve,Mfg by Consolidated Controls,Inc,Closed,In Violation of Tech Specs.Caused by Damage to Valve Stem.Ball Valve & Actuator replaced.W/891230 Ltr ML20011D1361989-12-11011 December 1989 LER 89-035-00:on 891111,inadvertent Actuation of Portion of Secondary Containment Sys During Surveillance Testing Occurred.Caused by Location of Radiation Isolation Control Sys Channel a Logic Relay.Procedure revised.W/891211 Ltr ML20005D7421989-12-0606 December 1989 LER 89-033-00:on 891106,automatic Actuation of Group 1 Portion of Primary Containment Isolation Control Sys (PCIS) Occurred.Caused by High Reactor Vessel Water Level.Manual Valve Closed & PCIS Logic Circuitry reset.W/891206 Ltr ML19351A4581989-12-0606 December 1989 LER 89-034-00:on 891108,determined That Reactor Pressure Exceeded 150 Psig on 891107 W/O Performing Surveillance Procedure 8.5.4.4, HPCI Valve Operability Test. Caused by Personnel Error.Procedure initiated.W/891206 Ltr ML19332D1421989-11-22022 November 1989 LER 89-031-00:on 891024,closing Times for Two in-series Primary Containment Isolation Valves Exceeded Acceptance Criteria During Shutdown Testing.Cause Undetermined.Closing Time Retested W/Satisfactory results.W/891122 Ltr ML19332D6231989-11-20020 November 1989 LER 89-032-00:on 891020,pneumatic Pressure Drop for Two of Four Automatic Depressurization Sys Accumulators Discovered Greater than Max Acceptable Value.Caused by Leakage from Seat of Supply Check Valves.Seat replaced.W/891120 Ltr ML19324C3181989-11-0909 November 1989 LER 88-002-01:on 880117,full Reactor Protection Sys Scram Trip Signal Occurred During Surveillance Test,Resulting in Incomplete Actuations.Caused by Procedure Inadequacy.Logic Relay Replaced & Procedure revised.W/891109 Ltr ML19324B1131989-10-21021 October 1989 LER 89-030-00:on 890926,control Room High Efficiency Air Filtration Sys Flowrate non-conservative Due to Procedure Error.Caused by Transcription Error.Procedure Revised & Test Reperformed Using Corrected procedure.W/891021 Ltr ML19325D4681989-10-16016 October 1989 LER 89-029-00:on 890914,locked High Radiation Area Door Found to Have Been Unsecured Contrary to Tech Spec 6.13.2. Caused by Failure to Adhere to Approved Procedures. Training on Access Requirements initiated.W/891016 Ltr ML19325D1861989-10-10010 October 1989 LER 89-028-00:on 890907,HPCI Sys Declared Inoperable Because Mechanical Overspeed Trip Occurred During Surveillance Test. Caused by Failure of Ramp Generator Signal Converter Module. Module Removed & Sent to Mfg for exam.W/891010 Ltr ML17277B8221984-07-20020 July 1984 LER 82-049/01X-1:on 821102,main Steam Line Safety Valve a Set W/Nitrogen at Steam Relief Setting.Caused by Personnel Error.Valve Removed & Replaced W/Properly Set Spare Valve. Procedure revised.W/840720 Ltr ML20024C3231983-06-24024 June 1983 Updated LER 82-038/03X-1:on 820817,RCIC Steam Line High Differential Pressure Alarm Received.Caused by Air in Sensing Lines to Pressure Switches.Cross Threaded Cap Found on in-line Snubber.Snubber replaced.W/830624 Ltr ML20024C2211983-06-24024 June 1983 Updated LER 80-053/03X-1:on 800814,0907 & 14,HPCI Turbine Exhaust Line Snubber 23-3-36 Determined Inoperable.Caused by Transient Hydrodynamic Shock During Startup & Shutdown. Snubbers upgraded.W/830624 Ltr ML20024B8451983-06-24024 June 1983 LER 83-031/03L-0:on 830528,HPCI Sys Made Inoperable to Repair Steam Leak on AO 2301-31.Caused by Leaking Stem Packing.Packing Replaced.Valve Tested Satisfactorily.Sys Returned to svc.W/830624 Ltr ML20024B8321983-06-24024 June 1983 LER 83-030/03L-0:on 830527,both HPCI Area Smoke Detection Sys Alarmed in Main Control Room.Caused by Valve A02301-31 Steam Leak Causing False Indications.Valve repaired.W/830624 Ltr ML20024C3101983-06-21021 June 1983 Updated LER 79-007/03X-1:on 790212,while Performing Test 8.7.4.3,valves AO-5033A,CV-5065-10,15,16 & 17 Failed to Give Proper Position Indication When Cycled & to Close within Specified Tolerance.Cause Not stated.W/830621 Ltr ML20024A8861983-06-16016 June 1983 LER 83-027/03L-0:on 830518,during Routine Insp,Folding Fire Door Found Inoperable.Caused by Operating Cable Becoming Detached from Pulley Due to Slack.Cable Reattached & Operating Mechanism adjusted.W/830616 Ltr ML20023D1691983-05-0909 May 1983 Updated LER 82-008/01X-1:on 820331,HPCI Injection Valve MO-2301-8 Failed to Open in Required Manner.Caused by Missing Wire Jumper Intended to Bypass Motor Operator Torque Switch.Jumper Installed & Valve Tested Satisfactorily ML20023D0671983-05-0909 May 1983 LER 83-021/03L-0:on 830411,during Surveillance Test 8.7.4.3, Primary Containment Isolation Valve AO-5033B Failed to Meet 10-s Closing Time Requirements.Caused by Lubricant Infiltrating Solenoid Valve Components.Components Replaced ML20023D0181983-05-0404 May 1983 LER 83-022/03L-0:on 830413,overload on Valve Motor 1301-17 Resulted in Loss of High Pressure Core Cooling Backup Capability.Caused by Oxidation in Motor End Bell & Motor Brushes,Due to Humidity Caused by Leaking Valve Packing ML20028G1591983-01-28028 January 1983 LER 83-002/01T-0:on 830116,flow Ref off-normal Alarm Received.Average Power Range Monitor Flux Scram Trip Settings Affected.Cause Under Investigation.Flow Inputs Monitored & Amplifier B Recalibr ML20028F4121983-01-17017 January 1983 LER 83-002/01X-0:on 830116,while Clearing off-normal Alarm for Flow Comparators,Average Power Range Monitor Flux Scram Trip Settings Found in Nonconservative Direction.Caused by Drifting Proportional Amplifiers.Settings Checked Daily ML20028B0421982-11-16016 November 1982 LER 82-049/01T-0:on 821102,main Steam Line Safety Valve a Set W/Nitrogen at Steam Relief Setting of 1240 Psig, Exceeding Tech Specs.Caused by Personnel Error.Set Valve Removed,Procedure Adherence Stressed & Procedure Revised ML20027C9801982-10-20020 October 1982 LER 82-039/03L-0:on 820920,timing Tests of Three Reactor Water Cleanup Isolation Valves 1201-2,-5 & -80 Not Completed within Allowed Time.Caused by Operational Constraints Requiring Testing at Reduced Power ML20027C9941982-10-20020 October 1982 LER 82-040/03L-0:on 820920,found Reactor Protection Sys Initiation Function of Turbine Stop Valve Completed 1 Day Late.Caused by Decision to Defer Test Due to MSIV D Line Isolation.Tracking Sys Implemented to Prevent Recurrences ML20052B9141982-04-23023 April 1982 LER 82-010/03L-0:on 820326,during Review of Testing Requirements,Surveillance Test 8.I.4 Standby Liquid Control Sys Found Not Verified.Caused by Breakdown in Multidiscipline Review of Results ML20052F2071982-04-14014 April 1982 Updated LER 81-060/03X-1:on 811020,determined Potential Exists to Reduce Number of Operable APRM & IRM Instrument Channels in Rod Block Trip Sys to Below Tech Spec Min ML20050A6321982-03-19019 March 1982 Updated LER 82-055/01T-1:on 810926,during Shutdown,Yarway Level Indicators Started Oscillating.Drywell Temp Was 240 F at 81-ft W/Elevation Coolant Temp 220 F.Caused by Ineffective Drywell Cooling.Ventilation Returned to Svc ML20050A4521982-03-19019 March 1982 LER 82-006/01T-0:on 820304,while Performing Maint Re SIL 352 on Pressure Adjustment Mechanism HPCI Stop Valve,Three Broken cap-screws Found.No Cause Determined.Screws Examined, Replaced & Sys Returned to Svc ML20050A4331982-03-19019 March 1982 Updated LER 81-062/01X-1:on 811116,Wyle Labs Informed Util That Two Target Rock Safety Relief Valves Had Not Passed Setpoint Tests.Caused by Setpoint Shift Due to Changes to Designed Differential Forces from Excessive Pilot Leakage 1993-07-28
[Table view] Category:RO)
MONTHYEARML20046C3131993-07-28028 July 1993 LER 93-015-00:on 930630,HPCI Sys Declared Inoperable Due to Indicated Flow During Surveillance.Caused by Foreign Matl That Plugged Portion of Restricting Orifice.Restricting Orifice Removed,Cleaned & reinstalled.W/930728 Ltr ML20046B5241993-07-26026 July 1993 LER 93-007-01:on 930317,automatic Closing of RCIC Sys Turbine Steam Supply Isolation Valves Occurred Due to High Steam Flow Signal.Increased Frequency of Valve Testing from Monthly to weekly.W/930726 Ltr ML20045F8601993-06-30030 June 1993 LER 93-014-00:on 930531,automatic Scram Occurred,Resulting from Operation of Auxiliary Transformer Differential Relay During Power Ascension.Uat Phase B & C Differential Relays Left Interchanged as Investigative aid.W/930630 Ltr ML20045E2301993-06-25025 June 1993 LER 93-013-00:on 930530,RCIC Sys Declared Inoperable & 7 Day TS 3.5.D.2 LCO Entered Due to Speed Oscillations Which Occurred After Several Minutes of steady-state Operation. Caused by Actuator Failure.Actuator replaced.W/930625 Ltr ML20045E2251993-06-25025 June 1993 LER 93-012-00:on 930529,unplanned PCIS Group I Isolation Signal Occurred While Opening MSIV During Startup,Resulting in Automatic Closing of Related Valves.Caused by Licensed Operator Error.Group 1 Isolation reset.W/930625 Ltr ML20045D6941993-06-23023 June 1993 LER 93-011-00:on 930525,determined That Initial as-found Popping Pressures of Pilot Valves for Three Target Rock Main Steam Relief Valves Out of TS Tolerance.Caused by Setpoint Drift.Valves Reworked & Reassembled by Target Rock Corp ML20045D1861993-06-18018 June 1993 LER 93-010-00:on 930519,SUT Became de-energized During Planned Calibr of Turbine/Generator Relays Lockout Test While Shut Down.Caused by Personnel Error.Discussion Conducted W/Personnel Re Attention to detail.W/930618 Ltr ML20044H0441993-06-0202 June 1993 LER 93-009-00:on 930504,circuit Breaker Did Not Close During Planned Bus Transfer Due to Loose Control Circuit Wire.Lug Replaced & Reterminated on 930505 & Post Work Testing Completed W/Satisfactory results.W/930602 Ltr ML20024G7451991-04-24024 April 1991 LER 91-005-00:on 910325,diesel Generator Inoperable,Causing Loss of Ac Power to Train B Components of Safety Sys & Actuating Portions of Primary/Secondary Containment Sys. Caused by Voltage Regulator failure.W/910424 Ltr ML20029A6721991-02-25025 February 1991 LER 91-001-00:on 910125,automatic Primary Containment Isolation Control Sys Group 5 Actuation Occurred,Resulting in Closing of RCIC Turbine Steam Supply Isolation Valves. Caused by High Flow conditions.W/910225 Ltr ML20028G9731990-09-20020 September 1990 LER 89-036-01:on 891122,determined That HPCI Sys Inoperable Due to Inoperable Gland Seal Condenser Blower Motor.Caused by age-related Wear of Motor.Blower Motor Replaced & Blower Tested W/Satisfactory results.W/900920 Ltr ML20028G9121990-09-18018 September 1990 LER 89-037-01:on 891130,primary Containment/Traversing in-core Probe Ball Valve Discovered to Be Almost Full Open. Caused by Damage to Valve Stem Due to Manual Manipulation of Stem.Ball Valve & Solenoid Actuator replaced.W/900918 Ltr ML20043G3541990-06-12012 June 1990 LER 90-008-00:on 900513,automatic Scram Resulting from Load Rejection Occurred While at Full Power,Resulting in Trip of Generator Field Breakers.Caused by Fault on Offsite 345 Kv Transmission sys.Loss-of-field Relay replaced.W/900612 Ltr ML20043F8291990-06-0606 June 1990 LER 90-007-00:on 900507,discovered That Drywell to Suppression Chamber Vacuum Breaker Surveillance Not Performed Prior to Startup in 1988.Caused by Misunderstanding of requirements.W/900606 Ltr ML20042F5911990-04-30030 April 1990 LER 90-006-00:on 900330,determined That Position of Primary Containment Sys Isolation Valve Not Recorded Daily,Per Tech Specs.Review Performed to Determine If Other Problems Existed.Plant Shut Down & Review performed.W/900430 Ltr ML20012F5751990-04-0606 April 1990 LER 90-003-00:on 900311,automatic Actuation of Main Steam Sys Group 1 Portion of Primary Containment Isolation Control Sys Occurred.Caused by False High Reactor Vessel Water Level Signal.Procedure Developed Re backfill.W/900406 Ltr ML20012E9831990-03-30030 March 1990 LER 90-002-00:on 900228,determined That Max Fraction of Limiting Power Density Not Checked Daily During Reactor Power Operation,Per Tech Spec 4.1.B.On 900323,addl Tech Spec Issue Discovered.Tech Specs changed.W/900330 Ltr ML20012C4871990-03-12012 March 1990 LER 90-001-00:on 900209,24 H Limiting Condition for Operation Entered When Two RCS Instrumentation Excess Flow Check Valves Inappropriately Verified Operable During Testing.Cause Undetermined.Two Valves replaced.W/900312 Ltr ML20005G0981990-01-0808 January 1990 LER 89-038-00:on 891208,unplanned Automatic Reactor Protection Sys Scram Signal & Reactor Scram Occurred.Caused by False Low Reactor Vessel Water Level Signal.Local Level Indicators Satisfactorily calibr.W/900108 Ltr ML20005F8481990-01-0808 January 1990 LER 89-039-00:on 891209,automatic Actuation of RHR Sys Portion of Primary Containment Isolation Control Sys Occurred.Caused by Hydrodynamic Transient That Actuated Protective High Pressure switches.W/900108 Ltr ML20005E8551989-12-30030 December 1989 LER 89-037-00:on 891130,discovered That Traversing in-core Probe Ball Valve,Mfg by Consolidated Controls,Inc,Closed,In Violation of Tech Specs.Caused by Damage to Valve Stem.Ball Valve & Actuator replaced.W/891230 Ltr ML20011D1361989-12-11011 December 1989 LER 89-035-00:on 891111,inadvertent Actuation of Portion of Secondary Containment Sys During Surveillance Testing Occurred.Caused by Location of Radiation Isolation Control Sys Channel a Logic Relay.Procedure revised.W/891211 Ltr ML20005D7421989-12-0606 December 1989 LER 89-033-00:on 891106,automatic Actuation of Group 1 Portion of Primary Containment Isolation Control Sys (PCIS) Occurred.Caused by High Reactor Vessel Water Level.Manual Valve Closed & PCIS Logic Circuitry reset.W/891206 Ltr ML19351A4581989-12-0606 December 1989 LER 89-034-00:on 891108,determined That Reactor Pressure Exceeded 150 Psig on 891107 W/O Performing Surveillance Procedure 8.5.4.4, HPCI Valve Operability Test. Caused by Personnel Error.Procedure initiated.W/891206 Ltr ML19332D1421989-11-22022 November 1989 LER 89-031-00:on 891024,closing Times for Two in-series Primary Containment Isolation Valves Exceeded Acceptance Criteria During Shutdown Testing.Cause Undetermined.Closing Time Retested W/Satisfactory results.W/891122 Ltr ML19332D6231989-11-20020 November 1989 LER 89-032-00:on 891020,pneumatic Pressure Drop for Two of Four Automatic Depressurization Sys Accumulators Discovered Greater than Max Acceptable Value.Caused by Leakage from Seat of Supply Check Valves.Seat replaced.W/891120 Ltr ML19324C3181989-11-0909 November 1989 LER 88-002-01:on 880117,full Reactor Protection Sys Scram Trip Signal Occurred During Surveillance Test,Resulting in Incomplete Actuations.Caused by Procedure Inadequacy.Logic Relay Replaced & Procedure revised.W/891109 Ltr ML19324B1131989-10-21021 October 1989 LER 89-030-00:on 890926,control Room High Efficiency Air Filtration Sys Flowrate non-conservative Due to Procedure Error.Caused by Transcription Error.Procedure Revised & Test Reperformed Using Corrected procedure.W/891021 Ltr ML19325D4681989-10-16016 October 1989 LER 89-029-00:on 890914,locked High Radiation Area Door Found to Have Been Unsecured Contrary to Tech Spec 6.13.2. Caused by Failure to Adhere to Approved Procedures. Training on Access Requirements initiated.W/891016 Ltr ML19325D1861989-10-10010 October 1989 LER 89-028-00:on 890907,HPCI Sys Declared Inoperable Because Mechanical Overspeed Trip Occurred During Surveillance Test. Caused by Failure of Ramp Generator Signal Converter Module. Module Removed & Sent to Mfg for exam.W/891010 Ltr ML17277B8221984-07-20020 July 1984 LER 82-049/01X-1:on 821102,main Steam Line Safety Valve a Set W/Nitrogen at Steam Relief Setting.Caused by Personnel Error.Valve Removed & Replaced W/Properly Set Spare Valve. Procedure revised.W/840720 Ltr ML20024C3231983-06-24024 June 1983 Updated LER 82-038/03X-1:on 820817,RCIC Steam Line High Differential Pressure Alarm Received.Caused by Air in Sensing Lines to Pressure Switches.Cross Threaded Cap Found on in-line Snubber.Snubber replaced.W/830624 Ltr ML20024C2211983-06-24024 June 1983 Updated LER 80-053/03X-1:on 800814,0907 & 14,HPCI Turbine Exhaust Line Snubber 23-3-36 Determined Inoperable.Caused by Transient Hydrodynamic Shock During Startup & Shutdown. Snubbers upgraded.W/830624 Ltr ML20024B8451983-06-24024 June 1983 LER 83-031/03L-0:on 830528,HPCI Sys Made Inoperable to Repair Steam Leak on AO 2301-31.Caused by Leaking Stem Packing.Packing Replaced.Valve Tested Satisfactorily.Sys Returned to svc.W/830624 Ltr ML20024B8321983-06-24024 June 1983 LER 83-030/03L-0:on 830527,both HPCI Area Smoke Detection Sys Alarmed in Main Control Room.Caused by Valve A02301-31 Steam Leak Causing False Indications.Valve repaired.W/830624 Ltr ML20024C3101983-06-21021 June 1983 Updated LER 79-007/03X-1:on 790212,while Performing Test 8.7.4.3,valves AO-5033A,CV-5065-10,15,16 & 17 Failed to Give Proper Position Indication When Cycled & to Close within Specified Tolerance.Cause Not stated.W/830621 Ltr ML20024A8861983-06-16016 June 1983 LER 83-027/03L-0:on 830518,during Routine Insp,Folding Fire Door Found Inoperable.Caused by Operating Cable Becoming Detached from Pulley Due to Slack.Cable Reattached & Operating Mechanism adjusted.W/830616 Ltr ML20023D1691983-05-0909 May 1983 Updated LER 82-008/01X-1:on 820331,HPCI Injection Valve MO-2301-8 Failed to Open in Required Manner.Caused by Missing Wire Jumper Intended to Bypass Motor Operator Torque Switch.Jumper Installed & Valve Tested Satisfactorily ML20023D0671983-05-0909 May 1983 LER 83-021/03L-0:on 830411,during Surveillance Test 8.7.4.3, Primary Containment Isolation Valve AO-5033B Failed to Meet 10-s Closing Time Requirements.Caused by Lubricant Infiltrating Solenoid Valve Components.Components Replaced ML20023D0181983-05-0404 May 1983 LER 83-022/03L-0:on 830413,overload on Valve Motor 1301-17 Resulted in Loss of High Pressure Core Cooling Backup Capability.Caused by Oxidation in Motor End Bell & Motor Brushes,Due to Humidity Caused by Leaking Valve Packing ML20028G1591983-01-28028 January 1983 LER 83-002/01T-0:on 830116,flow Ref off-normal Alarm Received.Average Power Range Monitor Flux Scram Trip Settings Affected.Cause Under Investigation.Flow Inputs Monitored & Amplifier B Recalibr ML20028F4121983-01-17017 January 1983 LER 83-002/01X-0:on 830116,while Clearing off-normal Alarm for Flow Comparators,Average Power Range Monitor Flux Scram Trip Settings Found in Nonconservative Direction.Caused by Drifting Proportional Amplifiers.Settings Checked Daily ML20028B0421982-11-16016 November 1982 LER 82-049/01T-0:on 821102,main Steam Line Safety Valve a Set W/Nitrogen at Steam Relief Setting of 1240 Psig, Exceeding Tech Specs.Caused by Personnel Error.Set Valve Removed,Procedure Adherence Stressed & Procedure Revised ML20027C9801982-10-20020 October 1982 LER 82-039/03L-0:on 820920,timing Tests of Three Reactor Water Cleanup Isolation Valves 1201-2,-5 & -80 Not Completed within Allowed Time.Caused by Operational Constraints Requiring Testing at Reduced Power ML20027C9941982-10-20020 October 1982 LER 82-040/03L-0:on 820920,found Reactor Protection Sys Initiation Function of Turbine Stop Valve Completed 1 Day Late.Caused by Decision to Defer Test Due to MSIV D Line Isolation.Tracking Sys Implemented to Prevent Recurrences ML20052B9141982-04-23023 April 1982 LER 82-010/03L-0:on 820326,during Review of Testing Requirements,Surveillance Test 8.I.4 Standby Liquid Control Sys Found Not Verified.Caused by Breakdown in Multidiscipline Review of Results ML20052F2071982-04-14014 April 1982 Updated LER 81-060/03X-1:on 811020,determined Potential Exists to Reduce Number of Operable APRM & IRM Instrument Channels in Rod Block Trip Sys to Below Tech Spec Min ML20050A6321982-03-19019 March 1982 Updated LER 82-055/01T-1:on 810926,during Shutdown,Yarway Level Indicators Started Oscillating.Drywell Temp Was 240 F at 81-ft W/Elevation Coolant Temp 220 F.Caused by Ineffective Drywell Cooling.Ventilation Returned to Svc ML20050A4521982-03-19019 March 1982 LER 82-006/01T-0:on 820304,while Performing Maint Re SIL 352 on Pressure Adjustment Mechanism HPCI Stop Valve,Three Broken cap-screws Found.No Cause Determined.Screws Examined, Replaced & Sys Returned to Svc ML20050A4331982-03-19019 March 1982 Updated LER 81-062/01X-1:on 811116,Wyle Labs Informed Util That Two Target Rock Safety Relief Valves Had Not Passed Setpoint Tests.Caused by Setpoint Shift Due to Changes to Designed Differential Forces from Excessive Pilot Leakage 1993-07-28
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML20217E3021999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for Pilgrim Nuclear Station.With ML20212C2921999-09-16016 September 1999 SER Accepting Licensee Request for Relief from ASME Code Section XI Requirements as Endorsed by 10CFR50.55a for Containment Insp for Pilgrim Nuclear Power Station ML20216F3511999-09-0808 September 1999 ISI Summary Rept for Refuel Outage 12 at Pnps ML20216E6881999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Pilgrim Nuclear Power Station.With ML20210R3401999-07-31031 July 1999 Monthly Operating Rept for July 1999 for Pilgrim Nuclear Power Station.With ML20209C4731999-07-0707 July 1999 Addendum to SE on Proposed Transfer of Operating License & Matls License from Boston Edison Co to Entergy Nuclear Generation Co ML20209H8251999-07-0101 July 1999 Provides Commission with Evaluation of & Recommendations for Improvement in Processes Used in Staff Review & Approval of Applications for Transfer of Operating Licenses of TMI-1 & Pilgrim Station ML20209E6191999-06-30030 June 1999 Monthly Operating Rept for June 1999 for Pilgrim Nuclear Power Station.With ML20196H2451999-06-29029 June 1999 SER Denying Licensee Proposed Alternative in Relief Request PRR-13,rev 2.Staff Determined That Proposed Alternative Provides Insufficient Info to Determine Adequacy of Scope of Implementation ML20209A8901999-06-28028 June 1999 SER Accepting Licensee Proposed Alternative to Use Code Case N-573 for Remainder of 10-year Interval Pursuant to 10CFR50.55a(a)(3)(i) ML20209B9861999-06-23023 June 1999 Rev 13A to Pilgrim Nuclear Power Station COLR for Cycle 13 ML20217N9061999-06-21021 June 1999 Rept of Changes,Tests & Experiments for Period of 970422-990621 ML20195K3431999-06-15015 June 1999 Safety Evaluation Granting Licensee Request to Use Guidance of GL 90-05 to Repair Flaws in ASME Class 3 Salt Svc Water System Piping for Plant ML20195G8231999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Pnps.With ML20207E7471999-05-27027 May 1999 Safety Evaluation Granting Request Re Reduction of IGSCC Insp of Category D Welds Due to Implementation of HWC to License DPR-35 ML20206M1971999-05-11011 May 1999 SER Accepting Request for Approval to Repair Flaws in ASME Code Class 3 Salt Svc Water Piping at Plant ML20206J6611999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for Pilgrim Nuclear Power Station.With ML20205L0221999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for Pilgrim Nuclear Power Station.With ML20207J5471999-03-0909 March 1999 Training Simulator,1999 4-Yr Certification Rept ML20207F9401999-03-0101 March 1999 Long Term Program Semi-Annual Rept for Pilgrim Nuclear Power Station ML20207H5451999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for Pilgrim Nuclear Power Station.With ML20196E2151998-12-31031 December 1998 1998 Annual Rept for Boston Edison & Securities & Exchange Commission Form 10-K Rept.With ML20206Q2741998-12-31031 December 1998 Monthly Operating Rept for Dec 1998 for Pilgrim Nuclear Power Station.With ML20197J3591998-11-30030 November 1998 Monthly Operating Rept for Nov 1998 for Pilgrim Nuclear Power Station.With ML20195C9951998-10-31031 October 1998 Monthly Operating Rept for Oct 1998 for Pilgrim Nuclear Power Station.With ML20154K0721998-09-30030 September 1998 Monthly Operating Rept for Sept 1998 for Pilgrim Nuclear Power Station.With ML20153D3901998-09-22022 September 1998 Safety Evaluation Granting 970707 Request to Use Guidance in GL 90-05 to Repair Flaws in ASME Class 3 Salt Svc Water Sys Piping for Pilgrim Nuclear Power Station ML20197C5011998-09-0404 September 1998 Rev 12C,Pages 4 & 5 to Pilgrim Nuclear Power Station Colr ML20197C5471998-08-31031 August 1998 Rev 12C to Pilgrim Nuclear Power Station Colr ML20151W8231998-08-31031 August 1998 Monthly Operating Rept for Aug 1998 for Pilgrim Nuclear Power Station.With ML20237E2251998-08-26026 August 1998 Suppl & Revs to SE for Amend 173 for Pigrim Nuclear Power Station ML20237A9941998-07-31031 July 1998 Monthly Operating Rept for Pilgrim Nuclear Power Station ML20236U8201998-07-13013 July 1998 Rev 12B to Pilgrim Nuclear Power Station COLR (Cycle 12) ML20236P0151998-06-30030 June 1998 Monthly Operating Rept for June 1998 for Pilgrim Nuclear Power Station ML20249A3741998-05-31031 May 1998 Monthly Operating Rept for May 1998 for Pilgrim Nuclear Power Station.W/Undated Ltr ML20247H2081998-04-30030 April 1998 Monthly Operating Rept for Apr 1998 for Pilgrim Nuclear Power Station ML20207B7601998-03-31031 March 1998 Final Rept, Pilgrim Nuclear Power Station Site-Specific Offsite Radiological Emergency Preparedenss Prompt Alert & Notification System Quality Assurance Verification, Prepared for FEMA ML20216G3911998-03-31031 March 1998 Monthly Operating Rept for Mar 1998 for Pilgrim Nuclear Power Station ML20216J3741998-03-19019 March 1998 Safety Evaluation Accepting Licensee Request to Evaluate Elevated Tailpipe Temp on Safety Relief Valve SRV 203-3B ML20248L2241998-02-28028 February 1998 Monthly Operating Rept for Feb 1998 for Pilgrim Nuclear Station ML20202G5251998-01-31031 January 1998 Monthly Operating Rept for Jan 1998 for Pilgrim Nuclear Power Station ML20236M8511997-12-31031 December 1997 1997 Annual Rept for Boston Edison & Securities & Exchange Commission Form 10-K Rept ML20198L7701997-12-31031 December 1997 Monthly Operating Rept for Dec 1997 for Pilgrim Nuclear Power Station ML20203D6101997-11-30030 November 1997 Monthly Operating Rept for Nov 1997 for Pilgrim Nuclear Power Station ML20202D5761997-11-0808 November 1997 1997 Evaluated Exercise BECO-LTR-97-111, Monthly Operating Rept for Oct 1997 for Pilgrim Nuclear Power Station1997-10-31031 October 1997 Monthly Operating Rept for Oct 1997 for Pilgrim Nuclear Power Station ML20217D6431997-10-0101 October 1997 Safety Evaluation Granting Request for Approval to Repair Flaws in Accordance W/Gl 90-05 for ASME Class 3 SSW Piping for Pilgrim ML20217H5621997-09-30030 September 1997 Monthly Operating Rept for Sept 1997 for Pilgrim Nuclear Power Station ML20216J4131997-08-31031 August 1997 Monthly Operating Rept for Aug 1997 for Pilgrim Nuclear Power Station ML20210J3321997-07-31031 July 1997 Monthly Operating Rept for Jul 1997 for Pilgrim Nuclear Power Station 1999-09-08
[Table view] |
Text
e ,
10CFR50.73 O,
- 80570W EDf5CN Pilgrim Nuclear Power station Rocky Hill Road Plymouth, Massachusetts o2360 t
( Ralph G. aird October 16, 1989 .
senior Vice President - Nuclear BECo Ltr. 89- 152 U.S. Nuclear Regulatory Commission
! Attn: Document Control Desk l
Hashington, D.C. 20555 Docket No. 50-293 License No. DPR-35 l Dest Sir:
l The enclosed Licensee Event Report (LER) 89-029-00, " Locked High Radiation Area Door to the Condenser Bay Found Unsecured", is submitted in accordance with 10 CFR Part 50.73.
! Please do not hesitate to contact me'if you have any questions regarding this I subject.
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Enclosure:
LER 89-029-00 l
cc: Mr. Hilliam Russell Regional Administrator, Region I U.S. Nuclear Regulatory Commission 475 Allendale Rd.
King of Prussia, PA 19406 Sr. Resident inspector - P 6 grim Station l
Standate BECo LER Distribution 8910240207 891016
.PDR ADOCK 05000293
%2A S PDC iT A '
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l RC Perm 3ee U $ NUCLEta E.11ULATOAY COaWISSION
. APPROYED OMB RO. 3150 01o4 ,
. LICENSEE EVENT REPORT (LER) !
F ACetlTY NAME m COC E R T NUMDE R (31 PAGE G Pilcrim Nuclear Power Station 01510 l o l 012 I ()l 9 1 lorl 0 l7 TITLE tal Innked Hirh Radiation Area Door to the Condenser Flay Found Unsecured 9 YE ET DATE (6) LER NUMBE R ISI fiEPORT DATE (7) OTHER F ACILITIES INVOLVED (Si YEAR 'A L m MONTH DAY YEAR
- ACILl'Y N AMts DOCAE T NUMBERt38 MONTH DAY YEAR 8 '(U ,
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Ol 9 1l4 0 9 8l9 0l 2lc 0l0.1l0 1l6 8l9 N/A o1 5 1 0 1 0 tog l l THIS REPORT 18 SUDMIT'TED PURSUANT TO THE REQUIREMENTS OF to CFR 5- (Cn.ca e.e e, neo,e of ,he reste rmal (111 OPE R ATING M*E m y nem u .oem .o nmmi _
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NAME TELEPHONE NUMSER Brian P. Lunn - Senior Plant Engineer 51018 71417 h 18121411 COMPLETE ONE LINE FOR E ACH COMPONENT FM4URE DESCRIBED IN THl3 REP 3RT H3) 0" CAUSE Sv8 TEM COMPONENT "$[ "fp%,'n"$3' CAUSE sv8 TEM COMPONENT Rf0 NPR k I I I l l 1 1 I I I I I I I I I l i I i l l I l ! I I I SUPPLEMENTAL REPORT E XPECTED 11 1 MONTH DAY Y'AR SV8 Mis 8 TON DATE n6)
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On September 14, 1989, a locked high radiation area (LHRA) access door was found to have been unsecured from about 1120 hours0.013 days <br />0.311 hours <br />0.00185 weeks <br />4.2616e-4 months <br /> to 1235 hours0.0143 days <br />0.343 hours <br />0.00204 weeks <br />4.699175e-4 months <br />. The door latching mechanism was locked but the latch did not extend into tha doorjamb.
The unsecured door provides one of three access points to the Condenser Bay (CB). While unsecured, the door was accessed by two individuals who had not been authorized entry. The dose received was below allowable limits. Pocket dosimeter readings for the entries were logged at 15 milli-rem and'5 milli-rem.
The event was contrary to the requirements of Technical Specification 6.13.2 which required the door to be locked. Also, entry was made without the required dose rate indicating de'tice or dose integrating device with preset alarm, and the two individuals were not accompanied by an individual qualified in radiation protection procedures.
Initial actions taken verified that only two individuals had gained unauthorized access, and that LHRA doors were secure and LHRA door keys were accounted for.
. actions include specialized training on access requirements to high A ni: eas, and the development of a job aid to assure that accessible J , vor- re properly checked upon exiting the applicable area.
n p r . was at 75% power at the time of the event. The reactor mode selector switch was i'i the RUN position, reactor vessel pressure was 995 psig.
and the reactor coohnt temperature was approximately 540 degrees Fahrenheit.
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I LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Arraovio ous =o. aiso-oio4 i
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F ACILITY HAMS 11) DOCK 41 NUMSth (2) LEh NUMetR ISI Pact (3)
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EVENT DESCRIPTION ,
l On 9/14/89, a locked high radiation area (LHRA) access door was found to have been unsecured from about 1120 houis to '235 hours0.00272 days <br />0.0653 hours <br />3.885582e-4 weeks <br />8.94175e-5 months <br />. The door latching mechanism was locked, but the latch did not extend into the doorjamb. The unsecured door provides one of three access points to the Condenser Bay (see i figure I, Pg. 7). While unsecured, the door was accessed by twn individuals i who had not been authorized entry. The dose received was below allowable
, limits. Pocket dosimeter readings for the unauthorized entries were logged at 15 milli-rem and 5 milli-rem. The highest whole bc'j dose rate measured in the Condenser Bay was 1600 milli-rem / hour.
The event was contrary to Technical Specification (T.S.) 6.13.2 which requires l that locked doors be provided for an area with a radiation dose rate greater '
than 1000 milli-rem / hour. Additionally, the two individuals who entered the unsecured docr were not equipped with a radiation dose rate indicating device
- or a dose integrating device with preset alarms, nor were they accocpanied by an individual qualified in radiation protection procedures equipped with a radiation dose rate monitoring device, as required by T.S. 6.13.2 for entry to 4 a LHRA.
REPORTABILITY 3
An unsecured LHRA door and unauthorized access to a LHRA are conditions prohibited by the T.S. and are reportable per 10 CFR 50.73(a)(2)(1)(B).
l Failure and Malfunction Report No.89-351 was written on 9/14/89 to document j the event. i PLANT CONDITI0tl i The event occurred with reactor power at 751.. The reactor mode selector l
- switch was in the RUN position, reactor vessel pressure was 995 psig, and the reactor coolant temperature was approximately 540 degrees Fahrenheit.
CIRCUMSTANCES LEADING To THE EyfRI On September 14,1989, mu'1tiple Condenser Bay (CB) entries occurred for instrument and Control (I&C) work and to define and post a contaminated area.
Access to the CB was being controlled through door 'A' (see Figure I, Pg. 7). )
When the I&C work was completed at approximately 1120 hours0.013 days <br />0.311 hours <br />0.00185 weeks <br />4.2616e-4 months <br />, the I&C Technicians were directed by the Radiological Protection Technician (RPT) #1 l to exit /ia door 'B' to prevent crossing a contaminated area. A contaminated area was created when a floor drain backed up after the I&C Technicians had entered the CB. Upon exiting door 'B', the I&C Technicians failed to check ,
that the door was locked and secured. After the I&C Technicians left, RPT #1 '
checked the door by pulling the door from inside the CB. The door did not open. It wat later determined that although the door latching mechanism was locked, the latch did not extend into the doorjamb.. ,
3
NRC Form 306A U S %UCLEMI F.EEUt&TO2Y CDMM19510N
. LICENSEE EVENT REPORT (LEl'.! TEXT CONTINUATION Arriitoveo ous wo iso 4to.
Exeints: eraum f ACittiv hAME IH DOCKti NUMSER (2l ggg gygggg ggg pggg ggy
'IA" vNa NvsN Pilgrim Nuclear Power Station o p j o l o l o l 2l913 8l9 --
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0l0 013 or 01 7 TPT (2 more space a soured sea eslanesma N#C #een JNL4 s1117)
Meanwhile, preparations were being made to clean the contaminated area (approximately a 30 ft. by 30 ft. area around the floor drain) in the CB.
Three Nuclear Plant Attendents (NPAs) were briefed on Radiation Hork Permit No. 89-14. Two N?As were to provide decontamination support from outside the CB and a third NPA was to perform the decontamination inside the CB. The two support NPAs needed to get additional supplies and were told to meet the RPT at the CB. The RPT #2 and the third NPA prepared for entry to the CB.
At 1235 hours0.0143 days <br />0.343 hours <br />0.00204 weeks <br />4.699175e-4 months <br />, the two NPAs who wer3 to provide outside support went to door
'B' expecting to .neet the RPT #2 and the third NPA. When the two NPAs arrived at door 'B', the RPT #2 was not present. They assumed the RPT was already in the CB and they should enter. One NPA then pushed on door 'B' with his shoulder and it opened. The two NPAs then entered the CB looking for RPT #2. i A few minutes later, the RPT #2 and the third NPA entered the CB through door
'A' finding the other two NPAs already in the CB.
INITIAL ACTIONS TAKEN l
- RPT #2 questioned the two NPAs and determined that they had accessed door 'B' to the CB.
- The NPAs were directed to leave the CB.
- RPT #2 checked door 'B' and determined that it was locked but not !
- latched and then secured door 'B'. RPT #2 also toured the CB and i determined that no other personnel were in the CE.
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- The two NPAs pocket dosimeters were read and indicated doses of 15 milli-rem and 5 milli-rem. '
- Door 'B' was verified locked and secured and appropriate management personnel were informed of the event.
- A guard was posted outside of the CB at door 'B' until its l
i operability was verified.
I e The CB was toured by a second individual to reverify no personnel were in the CB. No personnel were found.
- The three doors to the CB were reverified and all other LHRA doors
- were verified to be secured. ,
- A LHRA key inventory was performed. The inventory revealed all keys to be present and properly controlled.
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LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Anaovao ows wo mo-om EXNRES: Of31/88
' ACeLITY hatet til DOCKlf NUM$th Q) LER NUtit$$ R (6) PAGE DI
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Pilgrim Nuclear Power Station o ls j o lo lo l2 l 913 89 1
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. ,,,.4 w -.am o Pocket docimeter readings for September 14, 1989, were reviewed to verify other personnel had not received unauthorized radiation exposures in the CB. The review determined no additional unauthorized exposures had occurred as a result of the event.
CAUSE Unauthorized P.ccess was caused by a failure to adhere to approved procedures.
Procedure 6.1-012 " Access Control to High Padiation Areas'-requires the RPT who has responsibility for tha issued LHRA key to assure all accessible doors are secure (locked and latched) upon exiting a LHRA. Investigations revealed l RPT #1 did not properly verify door 'B' to be secure when exiting the CB at 1130 hours0.0131 days <br />0.314 hours <br />0.00187 weeks <br />4.29965e-4 months <br />. Additionally, on three seoarate occasions (including the exit at 1130 hours0.0131 days <br />0.314 hours <br />0.00187 weeks <br />4.29965e-4 months <br />) on September 14, 1989, RPT #1 only checked the doors that were accessed as opposed to all accessible doors (door 'C' was not checked). The I&C personnel who exited door 'B' without checking that the door was secured, also failed to meet the requirements of Procedure 6.1-012.
s The failure to check all accessible doors upon exiting a LHRA was a human performance problem. The RPT # 1 had been trained and was generally knowledgeable of the requirements. However, on September 14, 1989, he was focused on properly defin'ng and posting the contaminated area while providing !
health physic; support to wroing s work.
Similarly, the I&C personnel did not fully meet their responsibility to assure door 'B' was properly secured upon egress.
They assumed the door had closed behind them.
Attachment 5 to Procedure 5.1-012 " Standard Requirements for Entry to Locked High Radiation Areas" is attached to each issued RHP for LHRAs. This attachment is intended to be reviewed during the RHP briefing. Hhen interviewed, the two I&C technicians involved in the event, stated they were i not familiar with the requirements of Attachment 5, and could not recall being '
briefed on those requirements on the day of September 14, 1989.
The functioning of the door also contributed to the event. The door was sticking against the doorjamb and would not self close. The door could be opened / closed without using excessive force, but did require greater than ,
normal force I.a strong push / pull). RPT #1 has a small thin build, making it i plausible that the door would have appeared secured when pulled. However, '
because LHRA doors are designed to open from inside an area, it would not be possible to determine if a door was locked from inside the area. '
Entry was made into the CB by the two NPAs without meeting the requirements of T.S. 6.13.2 and Procedure 6.1-022, " Issue Use and Termination of Radiation Hork Permits". Investigations found that the NPAs were not generally knowledgeable of the requirements for entry to high radiation areas. Further ;
investigation revealed that General Employee Training (GET) did not fully '
address '.he requirements for entry to high radiation areas (i.e., dose rate meter, dose integrating device, or coverage by a RPT with a dose rate meter).
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LICENSEE EVENT REPOPT (LER) TEXT CONTINUATION A*paovio ous no am-eio.
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CORRECT"LE ACTIONS TAKEN
- Radiological Operations personnel were required to read Procedure 6.1-012 " Access Control to High Radiation Areas" and to discuss any
, questions with their supervisors.
- Radiological Section Standing Order No. 89-09 was issued allowing only radiological supervisors to exercise LHRA door and key control, ;
and requiring c radiological supervisor to observe and supervise each HRA entry briefing.
- High radiation area (HRA) access was restricted to allow entrier, only for required operator tours and emergencies until the above two actiens were completed.
- Procedure 6.1-012 was revised (Revision 29, approved 9/21/89) to require a job aid that prompts'the person responsible for a LHRA key to check all accessible doors upon exiting an area. A job aid was I prepared identifing the accessible dcors for each LHRA and has a j signature block to be signed for each door that is verified and !
locked.
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- Radiological Operations personnel were trained on Revision 29 to Procedure 6.1-012 (complete 9/21/89) and Standing Order No. 89-09 was ,
recinded. j
,i e A "For Your Information" (FYI) notice was issued on September 16 -
! 1989, to reemphasize and clarify HRA entry requirements for PHPS personnel.
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- The two NPAs who entered the LHRA improperly were restricted from l further HRA entries until retrained and tested in HRA controls. j
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- The other NPAs were also retrained and tested in HRA controls.
- Appropriate maintenance personnel received special training in HRA )
controls, i i l l
- Station supervisors and managers are receiving a special briefing in HRA controls from the Radiological Protection Manager.
- CET was revised on September 22, 1989 to present and emphasize the l requirements for entry to HRAs. '
I
- Maintenance Request No. 89-33-236 has been initiated to repair door ;
'B' to the CB. :
- The radiological technician qualification training prograa was :
reviewed and determined that HRA controle were adequately covered. '
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ac e a see2 u s wuctsan natukafony commissios d UCENSEE EVENT REr' ORT (LER) TEXT CONTINUATION oPxovio ove =o. 3,so-oio.
(KPIRES 4 T e 7 ACiLITY 8eAME (14 DOCKtt NUuttal 428 Lgp NUMeta (el PA0t an venn " M . ' NJ*u: l l- P11rrim Nuclear Power Station o Is lo lo lo l 21913 8l9 -
q 219 -
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no w- .w w we % a w.nm CORRECTIVE ACTIONS TO BE TAKEN d
I
- A Quality Assurance Surveillance on HRA controls will be performed. I
- A Horker Information Program (HIP) presentation is being developed to reemphasize ar.3 clarify HRA and LHRA entry and exit requirements for i all site personnel.
- A review of HRA controls will be incorporated to radiological technician cycle training, at quarterly intervals.
- Procedure 6.1-012 " Access Control for HRAs" will be reviewed to determine if further, improvements and si:nplifications can be made.
The following items are being corsidered.
- Posting the T.S. requireme.its for HRA entry at the entrance to HRAs.
~
- Posting LHRAs in a way that will distinguish them from HRAs.
SAFETY CONSE00ENCES The personnel who had unauthorized access to the CB received 15 milli-rem and 5 milli-rem. Had door 'B' not been accessed, the unlatched condition of the door would have been identified during the routine LHRA door check that is conducted every 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />, minimizing ;he potential for unauthorized entry. A LHRA area door audit was in progress at the time of the event and the auditor arrived at CB door 'B' only minutes after t's event was identified. The event had no potential to adversely impac: the public health and safety.
DREVIOUS SIMILAR REPORTABLE EVENTS A review of Licensee Event Reports (LERs) since 1984 identified a previous similar event recorted in LER 89-005-00. On February 3, 1989, a LHRA access door to the Radwaste Trucklock was found unsecured during the routine (every 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />) LHRA door audit. Investigations :hohad that the door was unknowingly >
opened from inside the trucklock and the door lock striker was stuck in the open position. No unauthorized entry was identified. Procedure No. 6.1-012
" Access Control to High Radiation Areas" was revised to require that all accessible doors to a LHRA be checked upon leaving the area.
ENERGY I"DUSTRY IDENTIFICATION SYSTEM (EIIS) CODES ,
1 COMPONENT CODE 1
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- LICENSEE EVENT REPORT (LER) TEXT CONTINUATION arraoveo u a No. mo-coa (KPIRES: 8/31/88 P ACILeiv NAME (t) DOCKET N4%9ER (21 LtR NUMSER ($1 PAGE(3) s vtAm 58 $8,N,j'g b -"y8Jy'#,Q Pile:rtn !bclear Power Stetion \o 015 l o l o j o l 219 l9 819 -
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FIGURE 1 CONDENSER BAY ACCESS DOOR LOCATIONS
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