LER-1981-042, /01T-0:on 810327,during Investigation of Ctip Machine Isolation Ball Valve Operability,Power to Retract TIP Probe Was Lost.Caused by Design Deficiency Which Allows Removal of Power to Probe Drive Motor While de-energized |
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(91 0 457 0521 NAME OF PREPARER M.
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PHONE:
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l LER 1-81-42 ATTACHMENT Facility: BSEP Unit No.1 Event Date: 32781 1
At 0710 on March 25, 1981, the Unit No. 1 C TIP machine was placed under clearance to troubleshoot and repair problems caused by excessive moisture from steam leaks in the TIP room. This clearance required de-energizing the TIP machine in the Control Room, which removes power from the probe drive mechanism.
When the clearance was placed on the TIP machine, the probe was tagged at position 0001, which was believed to be the "in shield" position. This position actually placed the probe in the indexer mechanism.
While removing the clearance from the tip machine, the Senior Reactor Operator expressed a concern as to the operability of the ball valve. I&C was instructed to investigate and determine the status of this valve with the machine de-energized.
The results of this investigation determined that a design deficiency exists in that while the ball valve would still isolate on an isolation actuation signal, power would be lost to the drive mechanism. With the probe located in the indexer, the ball valve would not be able to isolate under an isolation condition due to the probe cable not being capable of with-drawing to its shield, and primary containment integrity could not be maintained.
A contributing factor to this event is the low level of knowledge on the TIP System by the operators. These machines are operated by the nuclear Engineers with very little operator influence. Also, the operating procedure for the TIP machine does not contain sufficient information or precaution to inform the operator that he could get into a situation where the automatic isolation j
function would be negated.
I An Engineering Work Request has been written requesting that Engineering eval-uate the system and correct this deficiency. Also, the following actions have been or are being taken to correct this problem:
1.
All plant licensed personnel will review this event.
2.
The operating procedure will be revised to provide sufficient instructions and precautions to prevent a reoccurrence.
3.
Caution tags have been placed ca all TIP machines (both units) to warn personnel of the possibilities of an isolation override.
4.
Upgrading the operator training documents and procedures to include TIP machine influence on the isolation ball valve.
5.
Increase operator training on the TIP System.
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| 05000325/LER-1981-001, Forwards LER 81-001/01T-0 | Forwards LER 81-001/01T-0 | | | 05000325/LER-1981-001-01, /01T-0:on 810103,feed Pump Tripped on High Vessel Level Due to safety-relief Valve B21-F013G,Model 67F,lift. Caused by High Second Stage & Pilot Leakage in Valve.Pilot Valve Temporarily Replaced Until Next Scheduled Outage | /01T-0:on 810103,feed Pump Tripped on High Vessel Level Due to safety-relief Valve B21-F013G,Model 67F,lift. Caused by High Second Stage & Pilot Leakage in Valve.Pilot Valve Temporarily Replaced Until Next Scheduled Outage | | | 05000324/LER-1981-001, Forwards LER 81-001/03L-0 | Forwards LER 81-001/03L-0 | | | 05000324/LER-1981-001-03, /03L-0:on 810129,during Surveillance Testing, HPCI Sys Initiation Reactor Level Switch Actuated at Simulated Level Above Tech Spec.Caused by Components Slipping Due to Loose Set Screws on Actuator Pointers | /03L-0:on 810129,during Surveillance Testing, HPCI Sys Initiation Reactor Level Switch Actuated at Simulated Level Above Tech Spec.Caused by Components Slipping Due to Loose Set Screws on Actuator Pointers | | | 05000325/LER-1981-002-03, /03L-0:on 810114 & 0212,reactor Protection Sys Logic relays,C71-K3D & K3E,did Not de-energize When MSIV 1-B21-F028B Was Closed.Caused by Sticking Valve Position Limit Switch Actuator Arm Cam.Switch Replaced | /03L-0:on 810114 & 0212,reactor Protection Sys Logic relays,C71-K3D & K3E,did Not de-energize When MSIV 1-B21-F028B Was Closed.Caused by Sticking Valve Position Limit Switch Actuator Arm Cam.Switch Replaced | | | 05000325/LER-1981-002, Forwards LER 81-002/03L-0 | Forwards LER 81-002/03L-0 | | | 05000324/LER-1981-002-03, /03L-0:on 810104,vacuum Breaker X-18A Had Dual open-close Position Indication While in Open Position. Probably Caused by Problem W/Vacuum Breaker Position Limit Switches.Problem Will Be Resolved During Next Outage | /03L-0:on 810104,vacuum Breaker X-18A Had Dual open-close Position Indication While in Open Position. Probably Caused by Problem W/Vacuum Breaker Position Limit Switches.Problem Will Be Resolved During Next Outage | | | 05000324/LER-1981-002, Forwards LER 81-002/03L-0 | Forwards LER 81-002/03L-0 | | | 05000324/LER-1981-003-03, /03L-0:on 810108,suppression Pool Level Exceeded Specs.Caused by Valve Operator Torque Switch Out of Adjustment Allowing Leakage Into Suppression Pool.Switch Repaired | /03L-0:on 810108,suppression Pool Level Exceeded Specs.Caused by Valve Operator Torque Switch Out of Adjustment Allowing Leakage Into Suppression Pool.Switch Repaired | | | 05000324/LER-1981-003, Forwards LER 81-003/03L-0 | Forwards LER 81-003/03L-0 | | | 05000325/LER-1981-003-03, /03L-0:control Rod 26-35 on 810103,18-51 on 810113,38-31 & 22-15 on 810114 Showed Inaccurate Position Indications.Caused by Buffer Card Failure on 26-35;defective Reed Switches in Others.Card Replaced,Switches Repaired | /03L-0:control Rod 26-35 on 810103,18-51 on 810113,38-31 & 22-15 on 810114 Showed Inaccurate Position Indications.Caused by Buffer Card Failure on 26-35;defective Reed Switches in Others.Card Replaced,Switches Repaired | | | 05000325/LER-1981-003, Forwards LER 81-003/03L-0 | Forwards LER 81-003/03L-0 | | | 05000324/LER-1981-004, Forwards LER 81-004/03L-0 | Forwards LER 81-004/03L-0 | | | 05000324/LER-1981-004-03, /03L-0:on 810110,during Startup,Intermediate Range Monitor a Did Not Respond to Changes in Input Signal.Monitor C Indicated Downscale When on Range 7.On 810111 Monitor E Indicated Downscale While Monitor C Still Inoperable | /03L-0:on 810110,during Startup,Intermediate Range Monitor a Did Not Respond to Changes in Input Signal.Monitor C Indicated Downscale When on Range 7.On 810111 Monitor E Indicated Downscale While Monitor C Still Inoperable | | | 05000325/LER-1981-004, Forwards LER 81-004/03L-0 | Forwards LER 81-004/03L-0 | | | 05000325/LER-1981-004-03, /03L-0:on 810118,during Control Rod Operability Check,Pt 14.1,rod 26-07 Would Not Select.Caused by Loose Solder Joint in Rod Select Switch Due to Frequent Use of Switch.New Solder Joint Made | /03L-0:on 810118,during Control Rod Operability Check,Pt 14.1,rod 26-07 Would Not Select.Caused by Loose Solder Joint in Rod Select Switch Due to Frequent Use of Switch.New Solder Joint Made | | | 05000325/LER-1981-005, Forwards LER 81-005/03L-0 | Forwards LER 81-005/03L-0 | | | 05000325/LER-1981-005-03, /03L-0:on 810101,during Normal Surveillance, Discovered Secondary Containment 20 Ft Elevation Inner Air Lock Door Inoperable Due to Missing Gasket Sealing Matl. 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Caused by High Personnel Traffic.Gasket Replaced | | | 05000324/LER-1981-005-03, /03L-0:on 810113,during Normal Surveillance, Secondary Containment 20-ft Elevation Outer Air Lock Personnel Door Found Not Sealing.Caused by Heavy Personnel Traffic Through Door.Gasket Repaired | /03L-0:on 810113,during Normal Surveillance, Secondary Containment 20-ft Elevation Outer Air Lock Personnel Door Found Not Sealing.Caused by Heavy Personnel Traffic Through Door.Gasket Repaired | | | 05000324/LER-1981-005, Forwards LER 81-005/03L-0 | Forwards LER 81-005/03L-0 | | | 05000324/LER-1981-006-03, /03L-0:on 810115,when Main Steam Line Isolation Valve F028C Reopened During Test P.T.1.3.1P-2,main Steam Line C Indicated Min Flow.Cause Undetermined.Investigation Will Be Performed During Future Outage | /03L-0:on 810115,when Main Steam Line Isolation Valve F028C Reopened During Test P.T.1.3.1P-2,main Steam Line C Indicated Min Flow.Cause Undetermined.Investigation Will Be Performed During Future Outage | | | 05000324/LER-1981-006, Forwards LER 81-006/03L-0 | Forwards LER 81-006/03L-0 | | | 05000325/LER-1981-006, Forwards LER 81-006/03L-0 | Forwards LER 81-006/03L-0 | | | 05000325/LER-1981-006-03, /03L-0:on 810101,containment Atmospheric Monitor, 1-CAC-ATH-1259-2 Found Out of Calibr.Caused by Instrument Drift.Monitor Recalibr & Returned to Svc | /03L-0:on 810101,containment Atmospheric Monitor, 1-CAC-ATH-1259-2 Found Out of Calibr.Caused by Instrument Drift.Monitor Recalibr & Returned to Svc | | | 05000324/LER-1981-007, Forwards LER 81-007/03L-0 | Forwards LER 81-007/03L-0 | | | 05000325/LER-1981-007-03, /03L-0:on 810220,observed 2-inch Discrepancy Between Level Indicators of Suppression Pool Level Transmitters 1-CAC-LT-2601 & 2602.Caused by Insufficient Venting of 2602 Transmitter High Side Sensing Line | /03L-0:on 810220,observed 2-inch Discrepancy Between Level Indicators of Suppression Pool Level Transmitters 1-CAC-LT-2601 & 2602.Caused by Insufficient Venting of 2602 Transmitter High Side Sensing Line | | | 05000325/LER-1981-007, Forwards LER 81-007/03L-0 | Forwards LER 81-007/03L-0 | | | 05000324/LER-1981-007-03, /03L-0:on 810115,Group 1 Isolation Signal Received on Reactor Protection Sys Trip Channel B.Caused by Failure of Relay Coil,Model P/N 12HFAS1A49F Due to Insulation Breakdown.Coil Replaced | /03L-0:on 810115,Group 1 Isolation Signal Received on Reactor Protection Sys Trip Channel B.Caused by Failure of Relay Coil,Model P/N 12HFAS1A49F Due to Insulation Breakdown.Coil Replaced | | | 05000325/LER-1981-008-03, /03L-0:on 810106,while Performing Primary Containment Leak Rate Testing of Personnel Airlock Doors, Discovered That Drywell Exterior Airlock Door Leakage Rate Exceeded Limits.Caused by Tubing Fitting Lodged in Door | /03L-0:on 810106,while Performing Primary Containment Leak Rate Testing of Personnel Airlock Doors, Discovered That Drywell Exterior Airlock Door Leakage Rate Exceeded Limits.Caused by Tubing Fitting Lodged in Door | | | 05000325/LER-1981-008, Forwards LER 81-008/03L-0 | Forwards LER 81-008/03L-0 | | | 05000324/LER-1981-009-04, /04T-0:on 810128,radwaste Sys Liquid Effluent Discharge High Range Indicator/Recorder Found to Have Recorded Release Rate Less than Actual,Causing Tech Spec Limit to Be Exceeded.Caused by Loose Mechanical Linkage | /04T-0:on 810128,radwaste Sys Liquid Effluent Discharge High Range Indicator/Recorder Found to Have Recorded Release Rate Less than Actual,Causing Tech Spec Limit to Be Exceeded.Caused by Loose Mechanical Linkage | | | 05000325/LER-1981-009, Forwards LER 81-009/03L-0 | Forwards LER 81-009/03L-0 | | | 05000325/LER-1981-009-03, /03L-0:on 810115,sys Oil Cooler Inlet Isolation Valve 1-E51-F046 Would Not Open from RTGB Resulting in Reactor Core Isolation Cooling Inoperability.Caused by Incorrect Motor Control Ctr Key Lock Switch Position | /03L-0:on 810115,sys Oil Cooler Inlet Isolation Valve 1-E51-F046 Would Not Open from RTGB Resulting in Reactor Core Isolation Cooling Inoperability.Caused by Incorrect Motor Control Ctr Key Lock Switch Position | | | 05000324/LER-1981-009, Forwards LER 81-009/04T-0 | Forwards LER 81-009/04T-0 | | | 05000325/LER-1981-010, Forwards LER 81-010/03L-0 | Forwards LER 81-010/03L-0 | | | 05000325/LER-1981-010-03, /03L-0:on 810120,upon Auto Initiation After Reactor Scram,Rcic Turbine Failed to Accelerate to Idle Speed,Making RCIC Inoperable.Caused by Dirty Contacts in Turbine Steam Inlet Supply Valve 1-E51-F045.Contacts Cleaned | /03L-0:on 810120,upon Auto Initiation After Reactor Scram,Rcic Turbine Failed to Accelerate to Idle Speed,Making RCIC Inoperable.Caused by Dirty Contacts in Turbine Steam Inlet Supply Valve 1-E51-F045.Contacts Cleaned | | | 05000324/LER-1981-010, Forwards LER 81-010/03L-0 | Forwards LER 81-010/03L-0 | | | 05000324/LER-1981-010-03, /03L-0:on 810120,RHR Svc Water Subsys a Suction valve,2-SW-V101,would Not Open Fully.Caused by Two Hex Nuts on Input Shaft of Valve Motor Operator,Model H3BC-SMB-00, Freezing to Shaft.Nuts & Shaft Reworked & Lubricated | /03L-0:on 810120,RHR Svc Water Subsys a Suction valve,2-SW-V101,would Not Open Fully.Caused by Two Hex Nuts on Input Shaft of Valve Motor Operator,Model H3BC-SMB-00, Freezing to Shaft.Nuts & Shaft Reworked & Lubricated | | | 05000324/LER-1981-011-03, /03L-0:on 810120 & 0123,actual Pool Level Determined in Excess of Upper Tech Spec Limit.Caused by Improper Calibr Data & Calibr Procedure Inadequacy.Procedure Revision Underway & Indicators Correctly Calibr | /03L-0:on 810120 & 0123,actual Pool Level Determined in Excess of Upper Tech Spec Limit.Caused by Improper Calibr Data & Calibr Procedure Inadequacy.Procedure Revision Underway & Indicators Correctly Calibr | | | 05000324/LER-1981-011, Forewards LER 81-011/03L-0 | Forewards LER 81-011/03L-0 | | | 05000325/LER-1981-011-03, /03L-0:on 810121,during Routine Shutdown Operation,Seat Leakage Discovered on Reactor Recirculation Sample Inboard Isolation Valve 1-B32-F019.Cause Unknown. Valve Will Be Inspected & Repaired During Next Outage | /03L-0:on 810121,during Routine Shutdown Operation,Seat Leakage Discovered on Reactor Recirculation Sample Inboard Isolation Valve 1-B32-F019.Cause Unknown. Valve Will Be Inspected & Repaired During Next Outage | | | 05000325/LER-1981-011, Forwards LER 81-011/03L-0 | Forwards LER 81-011/03L-0 | | | 05000324/LER-1981-012-03, /03L-0:on 810320,wiring Deficiency Associated W/ Actuation Switch Discovered That Prevented Switch Operation. Caused by Improper Writing of Field Revision to Plant Mods Requiring Installation of Switches | /03L-0:on 810320,wiring Deficiency Associated W/ Actuation Switch Discovered That Prevented Switch Operation. Caused by Improper Writing of Field Revision to Plant Mods Requiring Installation of Switches | | | 05000325/LER-1981-012-03, /03L-0:on 810122,rod 26-35 Did Not Have Position Indication at Position 03 & Rod 34-35 Did Not Have Position Indication at Position 02.Caused by Defective Rod Position Indication Reed Switches.Corrective Maint Will Be Comple | /03L-0:on 810122,rod 26-35 Did Not Have Position Indication at Position 03 & Rod 34-35 Did Not Have Position Indication at Position 02.Caused by Defective Rod Position Indication Reed Switches.Corrective Maint Will Be Completed | | | 05000325/LER-1981-012, Forwards LER 81-012/03L-0 | Forwards LER 81-012/03L-0 | | | 05000324/LER-1981-012, Forwards LER 81-012/03L-0 | Forwards LER 81-012/03L-0 | | | 05000324/LER-1981-013-03, /03L-0:on 810119,HPCI Sys Component Test Tp 9.3.a Could Not Be Completed.Caused by Failed Motor on CST Suction Valve F004.Motor Sent to Svc Contractor to Be Repaired | /03L-0:on 810119,HPCI Sys Component Test Tp 9.3.a Could Not Be Completed.Caused by Failed Motor on CST Suction Valve F004.Motor Sent to Svc Contractor to Be Repaired | | | 05000324/LER-1981-013, Forwards LER 81-013/03L-0 | Forwards LER 81-013/03L-0 | | | 05000325/LER-1981-013, Forwards LER 81-013/03L-0 | Forwards LER 81-013/03L-0 | | | 05000325/LER-1981-013-03, /03L-0:on 810122,rod Worth Minimizer Sys Rod Blocks Were Received W/Proper Adherence to Control Rod Pattern Pull Sheet.Caused by Inadequate Procedures.Rods Pulled to Correct Position | /03L-0:on 810122,rod Worth Minimizer Sys Rod Blocks Were Received W/Proper Adherence to Control Rod Pattern Pull Sheet.Caused by Inadequate Procedures.Rods Pulled to Correct Position | |
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