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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML20029E3351994-05-10010 May 1994 LER 94-006-00:on 940415,both Trains of CREVS Declared Inoperable.Caused by Tornado Warning & Sighting of Tornado Moving Toward Plant.Tornado Warnings downgraded.W/940510 Ltr ML20029E2021994-05-0909 May 1994 LER 94-004-00:on 940408,determined That TS Pressurizer Cooldown Limit Exceeded on 930618 & Not Restored within Required Timeframe.Caused by Unanticipated Sys Interaction. SI for Check Valve Opening Tests revised.W/940509 Ltr ML20029D8151994-05-0303 May 1994 LER 94-005-00:on 940403,inadvertent Fwis Occurred.Caused by Personnel Failure to Follow Work Document Instructions. Corrective Action:Individuals Were Counseled on Requirements to Follow Work Document Instruction steps.W/940503 Ltr ML20046B8351993-07-30030 July 1993 LER 93-017-00:on 930621,discovered 24-hour Telephone Notification Had Not Been Carried Out as Required by TS LCO 3.7.11.1 Action Statement (b)(2)(a) Due to Personnel Error. NRC Informed of Missed notification.W/930730 Ltr ML20046B8501993-07-30030 July 1993 LER 93-018-00:on 930704,DG Started Due to Improper WO Planning.Restored Power to 1BB Shutdown Board & Stopped Running DGs.W/930730 Ltr ML20046A4691993-07-19019 July 1993 LER 93-016-00:on 930619,Phase A,Auxiliary Bldg & Containment Isolations Manually Initiated as Result of Fuel Assembly Failing to Remain in Upright Position After Being Released. All Fuel Movement stopped.W/930719 Ltr ML20045J0111993-07-14014 July 1993 LER 93-015-00:on 930614,1A Start Bus Alternate Feeder Breaker Tripped Upon Start of Unit 1 RCP Which Resulted in Start of DG Due to Current Transformer Wired Incorrectly. Restored Offsite Power & Secured Final DG.W/930714 Ltr ML20045H0171993-07-12012 July 1993 LER 93-014-00:on 930611,determined That Inadequate Ventilation Design Resulted in Potential Inoperability of Vital Power Equipment.Design Being modified.W/930712 Ltr ML20045B9951993-06-15015 June 1993 LER 93-004-01:on 930222,determined That Blind Flange on Elevation 734 Personnel Airlock Outer Housing Leaking.Due to Improper Installation of Blind Flange.Evaluation Performed of Other 14 Double O-ring Blind flanges.W/930615 Ltr ML20045B9311993-06-10010 June 1993 LER 93-013-00:on 930514,fire Watch Was Not Performed within Time Frame Required by Tech Specs Due to Inadequate Supervision by Fire Protection Foreman.Fire Watch Patrol reestablished.W/930610 Ltr ML20045A7261993-06-0707 June 1993 LER 93-011-00:on 930507,discovered That Fire Barrier Breached W/O Proper Compensatory Measures Established.On 930505,door Leading to Room Housing Containment Spray HX 1A Breached.Roving Fire Watch Established & LCO 3.7.12 Entered ML20044H4501993-06-0303 June 1993 LER 93-012-00:on 930504,apparent Failure to Properly Identify & Plug SG Tube Determined to Exceed TS Plugging Limit.Caused by eddy-current Coordinator Not Ensuring Task requirements.Eddy-current Procedure revised.W/930603 Ltr ML20044H1561993-05-28028 May 1993 LER 93-010-00:on 930430,Westinghouse Identified Error in Development of Calculations for Cold Overpressure Mitigation Sys Setpoints.Caused by Vendor Failure to Consider Elevation Difference.Engineering Evaluation Performed ML20044E6341993-05-17017 May 1993 LER 93-009-00:on 930417,TS Surveillance Not Performed for Three Pipe Support Snubbers Because of Omission of Snubbers from Surveillance Instruction for Visual Insp.Snubbers Visually Inspected & Functionally tested.W/930517 Ltr ML20044B6751993-02-23023 February 1993 LER 93-001-00:on 930124,Unit 1 Ice Bed Temperature Recorder in MCR Declared Inoperable.Caused by Ineffective Communication.Appropriate Personnel Involved W/Event Have Been counseled.W/930223 Ltr ML20044B6141993-01-21021 January 1993 LER 92-026-00:on 921222,determined That Several ASME Section XI Pressure Tests Not Performed Due to Section XI Program Implementation Not Being well-defined,controlled or Documented.Test Expeditiously performed.W/930121 Ltr ML20024H2441991-05-22022 May 1991 LER 91-007-00:on 910422,LCO 3.0.3 Entered When Shaft of Train a Main Control Room Air Handling Unit Failed from Fatigue & Train B Out of Svc for Maint.Caused by Shaft Misalignment.New Shaft installed.W/910522 Ltr ML20029C1761991-03-21021 March 1991 LER 91-002-00:on 910211,unit Operated in Condition Prohibited by Tech Spec 3.3.3.8 Limiting Condition for Operation.Cause Under Investigation.Night Order Issued to Personnel Re Removal of Equipment from svc.W/910321 Ltr ML20029C1231991-03-18018 March 1991 LER 90-016-01:on 901117,determined That Calibr of Nuclear Instrumentation Sys intermediate-range Channels Set Nonconservatively.Caused by Lack of Operability Control for Rod Motion.Action Plan developed.W/910318 Ltr ML20029A6711991-02-25025 February 1991 LER 91-002-00:on 910124,LCOs 3.0.5 & 3.8.1.1 Entered When Both Trains of Emergency Gas Treatment Sys Declared Inoperable.Caused by Blown Fuse & Excessive Cycling of Air Start Sys.Fuse replaced.W/910225 Ltr ML20028H0331990-09-27027 September 1990 LER 90-019-00:on 900828,failure to Update P-250 Plant Computer Constants Resulted in Axial Flux Difference.Caused by Inadequate Procedures & Inappropriate Personnel Actions. Procedure 0-PI-NXX-092-001.0 revised.W/900927 Ltr ML20028G9201990-09-26026 September 1990 LER 90-020-00:on 900829,ventilation Sys Inoperable Due to Train B Diesel Generator Out of Svc.Caused by Stuck Microswitch Contacts on Pressure Switch 0-PS-311-172. Pressure Switch Adjusted & Returned to svc.W/900926 Ltr ML20044A9361990-07-0909 July 1990 LER 90-011-00:on 900608,determined That Actual Nuclear Instrumentation Sys Power Range Detector Currents Were 20% to 31% Lower than Predicted.Caused by Calibr Values Being Incorrectly Calculated.Channels corrected.W/900709 Ltr ML20044A3241990-06-25025 June 1990 LER 90-010-00:on 900526,limiting Condition for Operation Entered Because MSIV Failed to Close When Another MSIV Inoperable for Maint.Cause Attributed to Valve Stem & Valve Guide Binding.Operations Training Ltr issued.W/900625 Ltr ML20043H5091990-06-21021 June 1990 LER 90-009-00:on 900527,automatic Start of Auxiliary Feedwater Pumps Occurred When Both Main Feedwater Pumps Placed in Tripped Condition.Caused by Personnel Error.Trip Circuitry Reset & Operators counseled.W/900621 Ltr ML20043E5401990-06-0707 June 1990 LER 90-008-00:on 900514,two Control Room Isolations Occurred as Result of Spurious Spikes.Caused by Loose Terminations on Relay Socket.Loose Connections Properly terminated.W/900607 Ltr ML20043A4211990-05-16016 May 1990 LER 90-010-00:on 900416,containment Ventilation Isolation Occurred.Caused by Allowing Gaseous Radiation Level to Increase Too Close to Alarm Setpoint.Recovery from Isolation initiated.W/900516 Ltr ML20043A2261990-05-14014 May 1990 LER 90-009-00:on 900404,lower Containment Radiation Monitor Found Inoperable & Lower Containment Atmosphere Aligned to Upper Containment Radiation Monitor During Sampling.Caused by Personnel Error.Chemistry Training revised.W/900514 Ltr ML20043A2271990-05-14014 May 1990 LER 90-006-00:on 900414,auxiliary Bldg Isolation Occurred from Spent Fuel Pit Area Radiation Monitors 0-RM-90-102 & 103.Caused by Personnel Error.Training Ltr Issued to Instrument Mechanics & Operations personnel.W/900514 Ltr ML20043A2201990-05-14014 May 1990 LER 90-007-00:on 900413,discovered That Tech Spec Surveillance Requirement Not Performed within Required Interval.Caused by Personnel Error.Surveillance Successfully Performed Since missed.W/900514 Ltr ML20042G7861990-05-0909 May 1990 LER 90-005-00:on 900409,emergency Start of Four Emergency Diesel Generators Occurred While Attempting Transfer of Power.Caused by Personnel Error.Individuals Reprimanded, Training Initiated & Procedures revised.W/900509 Ltr ML20042G7931990-05-0909 May 1990 LER 90-008-00:on 900410,reactor Trip Occurred Resulting from General Warning Alarm on Both Trains of Solid State Protection Sys.Caused by Personnel Error.Individuals Disciplined & Site Wide Message distributed.W/900509 Ltr ML20042F3741990-05-0202 May 1990 LER 90-003-00:on 900404,control Room Ventilation Sys (CRVS) Transferred to Pressurization Mode.Caused by Electrical Transient in Vital Instrument Ac Bus PY-21A.CRVS Reset & Returned to Normal Operating modes.W/900502 Ltr ML20042E4191990-04-13013 April 1990 LER 90-007-00:on 900317 & 26,containment Ventilation Isolations Occurred During Purge Activities.Caused by Inadequate Procedural Guidance for Setpoint Determination. Alarm & Trip Setpoints increased.W/900413 Ltr ML20042E2021990-04-13013 April 1990 LER 90-005-00:on 900315,inadvertent Containment Vent Isolation Occurred While Preparing to Purge Containment. Caused by Lack of Attention to Detail by Operator.Operator Counseled & Received Administrative reprimand.W/900413 Ltr ML20012F5221990-04-0505 April 1990 LER 90-006-00:on 900307,containment Ventilation Isolation Occurred.Caused by Containment Particulate Level Too Close to Setpoint.Module Replaced.Radiation Alarm Setpoint Increased from 10% to 40% of Tech Spec limit.W/900406 Ltr ML20012D8611990-03-23023 March 1990 LER 90-004-00:on 900221,handswitches Controlling Operation of Isolation Valves on Steam Supply Line to Auxiliary Feedwater Pump Found in Manual Position.Cause Undetermined. Handswitches Placed in P-auto position.W/900323 Ltr ML20012C4271990-03-12012 March 1990 LER 90-003-00:on 900211,inadvertent Containment Vent Isolation Occurred.Caused by Lack of Attention to Detail in That Operator Did Not Look Closely Enough at Switch Designations.Personnel Involved counseled.W/900312 Ltr ML20011F7191990-03-0101 March 1990 LER 89-031-01:on 891205,RHR Pumps Determined to Have Deadheading Problem Identified by NRC Bulletin 88-004.Caused by Inadequate Technical Response to Bulletin.Training Ltr Issued to 10CFR50.59 reviewers.W/900301 Ltr ML20011F7421990-02-26026 February 1990 LER 90-002-00:on 900127,control Room Isolation Occurred When Circuit Breaker Opened Supplying Power to Radiation Monitor. Caused by Failure by Personnel to Exercise Sufficient Caution.Responsible Engineers reinstructed.W/900226 Ltr ML20011F7391990-02-26026 February 1990 LER 90-002-00:on 891122,value for Distance from Floor to Ctr Line of Level Switch 2-LS-87-21 Transposed in Variable Leg Calculation.Caused by Inattention to Detail.Procedure Revised to Replace Incorrect setpoint.W/900226 Ltr ML20006E3311990-02-0909 February 1990 LER 90-001-00:on 900112,Limiting Condition for Operation 3.0.3 Entered When Three of Four Lower Compartment Cooler Fan Motors Exceeded Lubrication Frequency.Caused by Personnel Error.Personnel counseled.W/900209 Ltr ML20006D5341990-02-0707 February 1990 LER 90-001-00:on 900108,discovered That Several ERCW Valves Not Being Periodically Verified to Be Correct.Caused by Personnel Error During Procedure Revs & Workplan Reviews. Info Notice Issued to Workplan reviewers.W/900207 Ltr ML19354E1631990-01-22022 January 1990 LER 89-036-00:on 891221,discovered That Surveillance Test Results Used for Declaring Diesel Generator 1B-B Operable Deficient.Caused by Instruction Not Including 60 Minute Run Time.Event Will Be Reviewed w/supervisors.W/900122 Ltr ML19354D8941990-01-16016 January 1990 LER 89-034-00:on 891215,leak Identified from Fitting on Vol Control Tank Level Transmitter & Auxiliary Bldg Evacuated, Preventing Fire Watch Patrol from Entering Bldg for Hourly Rounds.Fitting tightened.W/900116 Ltr ML19354D9061990-01-16016 January 1990 LER 89-033-00:on 891216,refueling Water Storage Tank Level Transmitters Failed High Due to Freezing from Extremely Cold Weather & Inappropriate Use of Calculations.Engineering Procedures Revised & Heating Installed in encl.W/900116 Ltr ML20005F8851990-01-0909 January 1990 LER 89-035-00:on 891210,turbine/reactor Trip Occurred from hi-hi Feedwater Level of 75% in Steam Generator 3.Caused by Failure of Loop 3 Main Feedwater Regulating Valve to Close. Equipment Adjusted & repaired.W/900109 Ltr ML20005E0801989-12-22022 December 1989 LER 89-032-00:on 891205,RHR Pumps Determined to Have Deadheading Problem,Per NRC Bulletin 88-004,resulting in Plant Operation Outside Design Basis.On 891128,RHR Pump Exceeded Head Criteria.Pumps started.W/891222 Ltr ML20005E0831989-12-22022 December 1989 LER 89-032-00:on 891201,discovered That Tech Spec Surveillance Requirement to Verify That Valves 1-67-748 & 2-67-748 in Open Position Not Met.Caused by Personnel Error.Correct Valve Position verified.W/891222 Ltr ML20005E1161989-12-22022 December 1989 LER 89-030-00:on 891204,fire Suppression Sys Deluge Valve Isolated More than 1 H W/O Required Continuous Fire Watch Establishment.Caused by Personal Communication Breakdown. Valve Opened & Foreman in Charge counseled.W/891222 Ltr 1994-05-09
[Table view] Category:RO)
MONTHYEARML20029E3351994-05-10010 May 1994 LER 94-006-00:on 940415,both Trains of CREVS Declared Inoperable.Caused by Tornado Warning & Sighting of Tornado Moving Toward Plant.Tornado Warnings downgraded.W/940510 Ltr ML20029E2021994-05-0909 May 1994 LER 94-004-00:on 940408,determined That TS Pressurizer Cooldown Limit Exceeded on 930618 & Not Restored within Required Timeframe.Caused by Unanticipated Sys Interaction. SI for Check Valve Opening Tests revised.W/940509 Ltr ML20029D8151994-05-0303 May 1994 LER 94-005-00:on 940403,inadvertent Fwis Occurred.Caused by Personnel Failure to Follow Work Document Instructions. Corrective Action:Individuals Were Counseled on Requirements to Follow Work Document Instruction steps.W/940503 Ltr ML20046B8351993-07-30030 July 1993 LER 93-017-00:on 930621,discovered 24-hour Telephone Notification Had Not Been Carried Out as Required by TS LCO 3.7.11.1 Action Statement (b)(2)(a) Due to Personnel Error. NRC Informed of Missed notification.W/930730 Ltr ML20046B8501993-07-30030 July 1993 LER 93-018-00:on 930704,DG Started Due to Improper WO Planning.Restored Power to 1BB Shutdown Board & Stopped Running DGs.W/930730 Ltr ML20046A4691993-07-19019 July 1993 LER 93-016-00:on 930619,Phase A,Auxiliary Bldg & Containment Isolations Manually Initiated as Result of Fuel Assembly Failing to Remain in Upright Position After Being Released. All Fuel Movement stopped.W/930719 Ltr ML20045J0111993-07-14014 July 1993 LER 93-015-00:on 930614,1A Start Bus Alternate Feeder Breaker Tripped Upon Start of Unit 1 RCP Which Resulted in Start of DG Due to Current Transformer Wired Incorrectly. Restored Offsite Power & Secured Final DG.W/930714 Ltr ML20045H0171993-07-12012 July 1993 LER 93-014-00:on 930611,determined That Inadequate Ventilation Design Resulted in Potential Inoperability of Vital Power Equipment.Design Being modified.W/930712 Ltr ML20045B9951993-06-15015 June 1993 LER 93-004-01:on 930222,determined That Blind Flange on Elevation 734 Personnel Airlock Outer Housing Leaking.Due to Improper Installation of Blind Flange.Evaluation Performed of Other 14 Double O-ring Blind flanges.W/930615 Ltr ML20045B9311993-06-10010 June 1993 LER 93-013-00:on 930514,fire Watch Was Not Performed within Time Frame Required by Tech Specs Due to Inadequate Supervision by Fire Protection Foreman.Fire Watch Patrol reestablished.W/930610 Ltr ML20045A7261993-06-0707 June 1993 LER 93-011-00:on 930507,discovered That Fire Barrier Breached W/O Proper Compensatory Measures Established.On 930505,door Leading to Room Housing Containment Spray HX 1A Breached.Roving Fire Watch Established & LCO 3.7.12 Entered ML20044H4501993-06-0303 June 1993 LER 93-012-00:on 930504,apparent Failure to Properly Identify & Plug SG Tube Determined to Exceed TS Plugging Limit.Caused by eddy-current Coordinator Not Ensuring Task requirements.Eddy-current Procedure revised.W/930603 Ltr ML20044H1561993-05-28028 May 1993 LER 93-010-00:on 930430,Westinghouse Identified Error in Development of Calculations for Cold Overpressure Mitigation Sys Setpoints.Caused by Vendor Failure to Consider Elevation Difference.Engineering Evaluation Performed ML20044E6341993-05-17017 May 1993 LER 93-009-00:on 930417,TS Surveillance Not Performed for Three Pipe Support Snubbers Because of Omission of Snubbers from Surveillance Instruction for Visual Insp.Snubbers Visually Inspected & Functionally tested.W/930517 Ltr ML20044B6751993-02-23023 February 1993 LER 93-001-00:on 930124,Unit 1 Ice Bed Temperature Recorder in MCR Declared Inoperable.Caused by Ineffective Communication.Appropriate Personnel Involved W/Event Have Been counseled.W/930223 Ltr ML20044B6141993-01-21021 January 1993 LER 92-026-00:on 921222,determined That Several ASME Section XI Pressure Tests Not Performed Due to Section XI Program Implementation Not Being well-defined,controlled or Documented.Test Expeditiously performed.W/930121 Ltr ML20024H2441991-05-22022 May 1991 LER 91-007-00:on 910422,LCO 3.0.3 Entered When Shaft of Train a Main Control Room Air Handling Unit Failed from Fatigue & Train B Out of Svc for Maint.Caused by Shaft Misalignment.New Shaft installed.W/910522 Ltr ML20029C1761991-03-21021 March 1991 LER 91-002-00:on 910211,unit Operated in Condition Prohibited by Tech Spec 3.3.3.8 Limiting Condition for Operation.Cause Under Investigation.Night Order Issued to Personnel Re Removal of Equipment from svc.W/910321 Ltr ML20029C1231991-03-18018 March 1991 LER 90-016-01:on 901117,determined That Calibr of Nuclear Instrumentation Sys intermediate-range Channels Set Nonconservatively.Caused by Lack of Operability Control for Rod Motion.Action Plan developed.W/910318 Ltr ML20029A6711991-02-25025 February 1991 LER 91-002-00:on 910124,LCOs 3.0.5 & 3.8.1.1 Entered When Both Trains of Emergency Gas Treatment Sys Declared Inoperable.Caused by Blown Fuse & Excessive Cycling of Air Start Sys.Fuse replaced.W/910225 Ltr ML20028H0331990-09-27027 September 1990 LER 90-019-00:on 900828,failure to Update P-250 Plant Computer Constants Resulted in Axial Flux Difference.Caused by Inadequate Procedures & Inappropriate Personnel Actions. Procedure 0-PI-NXX-092-001.0 revised.W/900927 Ltr ML20028G9201990-09-26026 September 1990 LER 90-020-00:on 900829,ventilation Sys Inoperable Due to Train B Diesel Generator Out of Svc.Caused by Stuck Microswitch Contacts on Pressure Switch 0-PS-311-172. Pressure Switch Adjusted & Returned to svc.W/900926 Ltr ML20044A9361990-07-0909 July 1990 LER 90-011-00:on 900608,determined That Actual Nuclear Instrumentation Sys Power Range Detector Currents Were 20% to 31% Lower than Predicted.Caused by Calibr Values Being Incorrectly Calculated.Channels corrected.W/900709 Ltr ML20044A3241990-06-25025 June 1990 LER 90-010-00:on 900526,limiting Condition for Operation Entered Because MSIV Failed to Close When Another MSIV Inoperable for Maint.Cause Attributed to Valve Stem & Valve Guide Binding.Operations Training Ltr issued.W/900625 Ltr ML20043H5091990-06-21021 June 1990 LER 90-009-00:on 900527,automatic Start of Auxiliary Feedwater Pumps Occurred When Both Main Feedwater Pumps Placed in Tripped Condition.Caused by Personnel Error.Trip Circuitry Reset & Operators counseled.W/900621 Ltr ML20043E5401990-06-0707 June 1990 LER 90-008-00:on 900514,two Control Room Isolations Occurred as Result of Spurious Spikes.Caused by Loose Terminations on Relay Socket.Loose Connections Properly terminated.W/900607 Ltr ML20043A4211990-05-16016 May 1990 LER 90-010-00:on 900416,containment Ventilation Isolation Occurred.Caused by Allowing Gaseous Radiation Level to Increase Too Close to Alarm Setpoint.Recovery from Isolation initiated.W/900516 Ltr ML20043A2261990-05-14014 May 1990 LER 90-009-00:on 900404,lower Containment Radiation Monitor Found Inoperable & Lower Containment Atmosphere Aligned to Upper Containment Radiation Monitor During Sampling.Caused by Personnel Error.Chemistry Training revised.W/900514 Ltr ML20043A2271990-05-14014 May 1990 LER 90-006-00:on 900414,auxiliary Bldg Isolation Occurred from Spent Fuel Pit Area Radiation Monitors 0-RM-90-102 & 103.Caused by Personnel Error.Training Ltr Issued to Instrument Mechanics & Operations personnel.W/900514 Ltr ML20043A2201990-05-14014 May 1990 LER 90-007-00:on 900413,discovered That Tech Spec Surveillance Requirement Not Performed within Required Interval.Caused by Personnel Error.Surveillance Successfully Performed Since missed.W/900514 Ltr ML20042G7861990-05-0909 May 1990 LER 90-005-00:on 900409,emergency Start of Four Emergency Diesel Generators Occurred While Attempting Transfer of Power.Caused by Personnel Error.Individuals Reprimanded, Training Initiated & Procedures revised.W/900509 Ltr ML20042G7931990-05-0909 May 1990 LER 90-008-00:on 900410,reactor Trip Occurred Resulting from General Warning Alarm on Both Trains of Solid State Protection Sys.Caused by Personnel Error.Individuals Disciplined & Site Wide Message distributed.W/900509 Ltr ML20042F3741990-05-0202 May 1990 LER 90-003-00:on 900404,control Room Ventilation Sys (CRVS) Transferred to Pressurization Mode.Caused by Electrical Transient in Vital Instrument Ac Bus PY-21A.CRVS Reset & Returned to Normal Operating modes.W/900502 Ltr ML20042E4191990-04-13013 April 1990 LER 90-007-00:on 900317 & 26,containment Ventilation Isolations Occurred During Purge Activities.Caused by Inadequate Procedural Guidance for Setpoint Determination. Alarm & Trip Setpoints increased.W/900413 Ltr ML20042E2021990-04-13013 April 1990 LER 90-005-00:on 900315,inadvertent Containment Vent Isolation Occurred While Preparing to Purge Containment. Caused by Lack of Attention to Detail by Operator.Operator Counseled & Received Administrative reprimand.W/900413 Ltr ML20012F5221990-04-0505 April 1990 LER 90-006-00:on 900307,containment Ventilation Isolation Occurred.Caused by Containment Particulate Level Too Close to Setpoint.Module Replaced.Radiation Alarm Setpoint Increased from 10% to 40% of Tech Spec limit.W/900406 Ltr ML20012D8611990-03-23023 March 1990 LER 90-004-00:on 900221,handswitches Controlling Operation of Isolation Valves on Steam Supply Line to Auxiliary Feedwater Pump Found in Manual Position.Cause Undetermined. Handswitches Placed in P-auto position.W/900323 Ltr ML20012C4271990-03-12012 March 1990 LER 90-003-00:on 900211,inadvertent Containment Vent Isolation Occurred.Caused by Lack of Attention to Detail in That Operator Did Not Look Closely Enough at Switch Designations.Personnel Involved counseled.W/900312 Ltr ML20011F7191990-03-0101 March 1990 LER 89-031-01:on 891205,RHR Pumps Determined to Have Deadheading Problem Identified by NRC Bulletin 88-004.Caused by Inadequate Technical Response to Bulletin.Training Ltr Issued to 10CFR50.59 reviewers.W/900301 Ltr ML20011F7421990-02-26026 February 1990 LER 90-002-00:on 900127,control Room Isolation Occurred When Circuit Breaker Opened Supplying Power to Radiation Monitor. Caused by Failure by Personnel to Exercise Sufficient Caution.Responsible Engineers reinstructed.W/900226 Ltr ML20011F7391990-02-26026 February 1990 LER 90-002-00:on 891122,value for Distance from Floor to Ctr Line of Level Switch 2-LS-87-21 Transposed in Variable Leg Calculation.Caused by Inattention to Detail.Procedure Revised to Replace Incorrect setpoint.W/900226 Ltr ML20006E3311990-02-0909 February 1990 LER 90-001-00:on 900112,Limiting Condition for Operation 3.0.3 Entered When Three of Four Lower Compartment Cooler Fan Motors Exceeded Lubrication Frequency.Caused by Personnel Error.Personnel counseled.W/900209 Ltr ML20006D5341990-02-0707 February 1990 LER 90-001-00:on 900108,discovered That Several ERCW Valves Not Being Periodically Verified to Be Correct.Caused by Personnel Error During Procedure Revs & Workplan Reviews. Info Notice Issued to Workplan reviewers.W/900207 Ltr ML19354E1631990-01-22022 January 1990 LER 89-036-00:on 891221,discovered That Surveillance Test Results Used for Declaring Diesel Generator 1B-B Operable Deficient.Caused by Instruction Not Including 60 Minute Run Time.Event Will Be Reviewed w/supervisors.W/900122 Ltr ML19354D8941990-01-16016 January 1990 LER 89-034-00:on 891215,leak Identified from Fitting on Vol Control Tank Level Transmitter & Auxiliary Bldg Evacuated, Preventing Fire Watch Patrol from Entering Bldg for Hourly Rounds.Fitting tightened.W/900116 Ltr ML19354D9061990-01-16016 January 1990 LER 89-033-00:on 891216,refueling Water Storage Tank Level Transmitters Failed High Due to Freezing from Extremely Cold Weather & Inappropriate Use of Calculations.Engineering Procedures Revised & Heating Installed in encl.W/900116 Ltr ML20005F8851990-01-0909 January 1990 LER 89-035-00:on 891210,turbine/reactor Trip Occurred from hi-hi Feedwater Level of 75% in Steam Generator 3.Caused by Failure of Loop 3 Main Feedwater Regulating Valve to Close. Equipment Adjusted & repaired.W/900109 Ltr ML20005E0801989-12-22022 December 1989 LER 89-032-00:on 891205,RHR Pumps Determined to Have Deadheading Problem,Per NRC Bulletin 88-004,resulting in Plant Operation Outside Design Basis.On 891128,RHR Pump Exceeded Head Criteria.Pumps started.W/891222 Ltr ML20005E0831989-12-22022 December 1989 LER 89-032-00:on 891201,discovered That Tech Spec Surveillance Requirement to Verify That Valves 1-67-748 & 2-67-748 in Open Position Not Met.Caused by Personnel Error.Correct Valve Position verified.W/891222 Ltr ML20005E1161989-12-22022 December 1989 LER 89-030-00:on 891204,fire Suppression Sys Deluge Valve Isolated More than 1 H W/O Required Continuous Fire Watch Establishment.Caused by Personal Communication Breakdown. Valve Opened & Foreman in Charge counseled.W/891222 Ltr 1994-05-09
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML20212J6311999-10-0101 October 1999 SER Accepting Request for Relief from ASME Boiler & Pressure Vessel Code,Section Xi,Requirements for Certain Inservice Insp at Plant,Unit 1 ML20217G3721999-09-30030 September 1999 Monthly Operating Repts for Sept 1999 for Sequoyah Nuclear Plant.With ML20212F0831999-09-23023 September 1999 Safety Evaluation Granting Relief from Certain Weld Insp at Sequoyah Nuclear Plant,Units 1 & 2 Pursuant to 10CFR50.55a(a)(3)(ii) for Second 10-year ISI Interval ML20212F4761999-09-23023 September 1999 Safety Evaluation Supporting Amends 246 & 237 to Licenses DPR-77 & DPR-79,respectively ML20212C4761999-08-31031 August 1999 Monthly Operating Repts for Aug 1999 for Sequoyah Nuclear Plant.With ML20210L4361999-08-0202 August 1999 Cycle 9 12-Month SG Insp Rept ML20216E3781999-07-31031 July 1999 Monthly Operating Repts for July 1999 for Sequoyah Nuclear Plant,Units 1 & 2.With ML20210L4451999-07-31031 July 1999 Unit-2 Cycle 10 Voltage-Based Repair Criteria 90-Day Rept ML20210G6631999-07-28028 July 1999 Cycle 9 90-Day ISI Summary Rept ML20196H8621999-06-30030 June 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data, June 1999 Rept ML20209H3831999-06-30030 June 1999 Monthly Operating Repts for June 1999 for Sequoyah Nuclear Plant.With ML20211F9031999-06-30030 June 1999 Cycle 9 Refueling Outage ML20196J8521999-06-28028 June 1999 Safety Evaluation Authorizing Proposed Alternative to Use Iqis for Radiography Examinations as Provided for in ASME Section III,1992 Edition with 1993 Addenda,Pursuant to 10CFR50.55a(a)(3)(i) ML20195K2951999-05-31031 May 1999 Monthly Operating Repts for May 1999 for Sequoyah Nuclear Plant,Units 1 & 2.With ML20206Q8951999-05-0505 May 1999 Rev 0 to L36 990415 802, COLR for Sequoyah Unit 2 Cycle 10 ML20206R5031999-04-30030 April 1999 Monthly Operating Repts for April 1999 for Sequoyah Units 1 & 2.With ML20205P9811999-03-31031 March 1999 Monthly Operating Repts for Mar 1999 for Sequoyah Nuclear Plant,Units 1 & 2.With ML20204C3111999-02-28028 February 1999 Monthly Operating Repts for Feb 1999 for Sequoyah Nuclear Plant,Units 1 & 2.With ML20205B6631999-02-28028 February 1999 Underground Storage Tank (Ust) Permanent Closure Rept, Sequoyah Nuclear Plant Security Backup DG Ust Sys ML20203H7381999-02-18018 February 1999 Safety Evaluation of Topical Rept BAW-2328, Blended U Lead Test Assembly Design Rept. Rept Acceptable Subj to Listed Conditions ML20211A2021999-01-31031 January 1999 Non-proprietary TR WCAP-15129, Depth-Based SG Tube Repair Criteria for Axial PWSCC Dented TSP Intersections ML20198S7301998-12-31031 December 1998 Cycle 10 Voltage-Based Repair Criteria 90-Day Rept ML20199G3641998-12-31031 December 1998 Monthly Operating Repts for Dec 1998 for Sequoyah Nuclear Plant,Units 1 & 2.With ML20197J5621998-12-0303 December 1998 Unit 1 Cycle 9 90-Day ISI Summary Rept ML20197K1161998-11-30030 November 1998 Monthly Operating Repts for Nov 1998 for Sequoyah Nuclear Plant,Units 1 & 2.With ML20195F8061998-10-31031 October 1998 Monthly Operating Repts for Oct 1998 for Sequoyah Nuclear Plant.With ML20154H6091998-09-30030 September 1998 Monthly Operating Repts for Sept 1998 for Sequoyah Nuclear Plant,Units 1 & 2.With ML20154H6251998-09-17017 September 1998 Rev 0 to Sequoyah Nuclear Plant Unit 1 Cycle 10 Colr ML20153B0881998-08-31031 August 1998 Monthly Operating Repts for Aug 1998 for Sequoyah Nuclear Plant.With ML20239A0631998-08-27027 August 1998 SER Accepting Licensee Response to GL 95-07, Pressure Locking & Thermal Binding of Safety-Related Power-Operated Gate Valves, for Sequoyah Nuclear Plant,Units 1 & 2 ML20236Y2091998-08-0707 August 1998 Safety Evaluation Accepting Relief Requests RP-03,RP-05, RP-07,RV-05 & RV-06 & Denying RV-07 & RV-08 ML20237B5221998-07-31031 July 1998 Monthly Operating Repts for July 1998 for Snp ML20237A4411998-07-31031 July 1998 Blended Uranium Lead Test Assembly Design Rept ML20236P6441998-07-10010 July 1998 LER 98-S01-00:on 980610,failure of Safeguard Sys Occurred for Which Compensatory Measures Were Not Satisfied within Required Time Period.Caused by Inadequate Security Procedure.Licensee Revised Procedure MI-134 ML20236R0051998-06-30030 June 1998 Monthly Operating Repts for June 1998 for Sequoyah Nuclear Plant ML20249A8981998-05-31031 May 1998 Monthly Operating Repts for May 1998 for Sequoyah Nuclear Plant,Units 1 & 2 ML20247L5141998-04-30030 April 1998 Monthly Operating Repts for Apr 1998 for Sequoyah Nuclear Plant ML20217K4471998-04-27027 April 1998 Safety Evaluation Supporting Requests for Relief 1-ISI-2 (Part 1),2-ISI-2 (Part 2),1-ISI-5,2-ISI-5,1-ISI-6,1-ISI-7, 2-ISI-7,ISPT-02,ISPT-04,ISPT-06,ISPT-07,ISPT-8,ISPT-01 & ISPT-05 ML20217E2221998-03-31031 March 1998 Monthly Operating Repts for Mar 1998 for Sequoyah Nuclear Plant ML20248L2611998-02-28028 February 1998 Monthly Operating Repts for Sequoyah Nuclear Plant,Units 1 & 2 ML20199J2571998-01-31031 January 1998 Cycle 9 Voltage-Based Repair Criteria 90-Day Rept ML20202J7911998-01-31031 January 1998 Monthly Operating Repts for Jan 1997 for Sequoyah Nuclear Plant,Units 1 & 2 ML20199J2441998-01-29029 January 1998 Snp Unit 2 Cycle Refueling Outage Oct 1997 ML20199F8531998-01-13013 January 1998 ASME Section XI Inservice Insp Summary Rept for Snp Unit 2 Refueling Outage Cycle 8 ML20199A2931997-12-31031 December 1997 Revised Monthly Operating Rept for Dec 1997 for Sequoyah Nuclear Plant,Units 1 & 2 ML20198M1481997-12-31031 December 1997 Monthly Operating Repts for Dec 1997 for Sequoyah Nuclear Plant,Units 1 & 2 ML20197J1011997-11-30030 November 1997 Monthly Operating Repts for Nov 1997 for Sequoyah Nuclear Plant,Units 1 & 2 ML20199C2951997-11-13013 November 1997 LER 97-S01-00:on 971017,vandalism of Electrical Cables Was Observed.Caused by Vandalism.Repaired Damaged Cables, Interviewed Personnel Having Potential for Being in Area at Time Damage Occurred & Walkdowns ML20199C7201997-10-31031 October 1997 Monthly Operating Repts for Oct 1997 for Sequoyah Nuclear Plant L-97-215, SG Secondary Side Loose Object Safety Evaluation1997-10-23023 October 1997 SG Secondary Side Loose Object Safety Evaluation 1999-09-30
[Table view] |
Text
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[TTT1 I Unit 2 in Mode 2, 0% power, RCS temperature and pressure at 547 degrees F and g i o ,3 ; l 2235 psig. During unit startup, control rod withdrawal limits established in g La_Lt) ] accordance with the action statement associated with limiting condition for operation l gl 3.1.1.3.were excee'ded. There was no effect upon public health or safety. Previous g "o s l~ occurrences - none. g I 6TT1 I I LO_uu i I sYsitM CAust CAusF COvp. Vatvt CCOc CODF sUSCODE C09'ONENT CODE sueCoct sueCCot 10191
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["iTol i The control rod limitations were not in the appropriate startup Tirocediires. catisino i l operations and engineering personnel to inadvertently omit these limitations diirinc Unit g l 2 startup. Boron concentration and control rod positions were reestablished within oper-
, 3 [ ating limits within one hour after discovery. The withdrawal limits will b'e added to e i,, ,[ appropriate proceilures until reliance on the action statement is no longer necessary.
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- l ANAI.YSTS AND EVAT.UATTON OF T11C DECEMBER 21, 1981 IN WilICll Tile CONTROL R0D WITilDRAWAL LIMITS WERE EXCEEDED 1
PREPARED BY Tile INVESTICATING Co.TIITTEE CONSTSTING OF:
SEQUOYAll NUCLEAlt PLANT Mike :tarding, Supervisor, Compliance Staff i
A. M. Carver, Compliance Section R. I. 11amilton, Supervisor, Quality Assurance Staff Ron Fortenberry, Supervisor, Nucicar Engineering
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-Report Desctiption TVA has concluded a management and technical evaluation of the event discovered on December 22, 1981, involving operation of the Sequoyah Unit 2 reactor outside of the currently established control rod withdrawal limits. This report describes the sequence of events, the causes and contributir.g factors, and the actions taken to preclude recurrence of similar events.
The information and conclusions were obtained through discussions with the shift operations and engineering personnel involved in the event, the reactor engineer, and reviews of appropriate shift logs and records.
All times are Central Standard Time.
Event Description During unit startup with the reactor in Mode 2, RCS temperature at 547 degrees F and RCS pressure at 2235 psig, the control rod withdrawal limits established during low power physics testing to insure a negative moderator temperature coefficient were exceeded.
I Sequence of Events I 11/06/81 - During the performance of Startup Test SU-7.3.1, " Nuclear Design Checklist: Boron Endpoint Determination and Isothermal Temperature Coefficient Measurement," It was determined that the Sequoyah Unit 2 reactor had a positive moderator temperature coefficient at the all rods out configuration.
l This test was performed to comply with Technical Specification l surveillance requirement 4.1.1.3.a.
11/06/81 through 11/10/81 - Startup Test SU-7.3.1 was again performed with control rod bank D fully inserted and with control rod banks C and D fully inserted. With this measured data and the design data, the temporary rod withdrawal limit curves were determined per Technical Specification 3.1.1.3 action n.1. It was also determined at this time that these limitations would only be in effect until a burn up of*
1000 MWD /MTU had been achieved. At this conservative burnup value, t the moderator temperature coefficient (MTC) was predicted to be negative. Due to the fact that these control rod withdrawal limits would only be in effect for a short period of time (1000 MWD /MTU burnup), it was decided not to revise the General Operating Instructions.
The withdrawal limit curve was placed in Technical Instruction 28 and distributed to all appropriate shift operating and engineering personnel. Through this mechanism all appropriate personnel were made aware of these limitations. (During Unit 1 startup a positive MTC had been calculated and the withdrawal limits were handled in the same way. No problems were encountered.)
11/13/81 - Special Report 81-8 was sent to Mr. James P. O'Reilly on November 13, .
1981, in accordance with the technical specification limiting condition for operation 3.1.1.3 action a.3.
11/13/81 through 12/20/81 - The Unit 2 generator exciter had to be disassembled for repair causing considerable delay between the completion of the low power physics testing and ascension to power. The unit was maintained in Modes 4 and 5 during this five and one half week period.
12/21/81 - Following the return to service of the generator exciter, preparations were made for Unit 2 startup. This was the first normal startup following the low power physics testing. As required by General Operating Instruction (G01) 2, the estinated critical l condition was calculated. This calculation was performed by the shift technical advisor (STA) using detailed instructions contained in Technical Instruction (TI) 21. Because the control rod withdrawal limits were not identified in G01-2 or Surveillance Instruction (SI) 38,
" Shutdown Margin Calculation", and due to the long period of inactivity on Unit 2, the STA failed to consider these limitation in his calculations. The estimated critical condition calculated by the STA was performed assuming a constant boron concentration of 1262 ppm.
A bank D rod position of 87 steps was then calculated and given to the reactor operator.
The reactor operators rely on the STA to perform this calculation and therefore did not verify the calculation prior to pulling rods. The reactor operators were aware that upon entering Mode 2, the action statement in Technical Specification 3.1.1.3 would be reentered. Ilowever, when the estimated critical condition calculation was received from the STA they did not think to compare the calculated rod position with the rod limitation curves that had been distributed previously.
The reactor operators began to pull contre i rods and at 1857 hours0.0215 days <br />0.516 hours <br />0.00307 weeks <br />7.065885e-4 months <br /> the reactor went critical at 125 steps on control bank D.
The shift changeover occurred at approximately 2200 hours0.0255 days <br />0.611 hours <br />0.00364 weeks <br />8.371e-4 months <br />.
12/22/81 - At approximately 0330 hours0.00382 days <br />0.0917 hours <br />5.456349e-4 weeks <br />1.25565e-4 months <br /> the reactor operator compared the current rod position against the rod withdrawal limitation curve and discovered that the rods were withdrawn beyond the limits. The operator took immediate steps to dilute the boron concentration in order to reestablish control rod positions within the opcrating limits.
At approximately 0600 hours0.00694 days <br />0.167 hours <br />9.920635e-4 weeks <br />2.283e-4 months <br /> shift turnover occurred and the oncoming shif t was made aware of the incident and subsequent actions which had been taken. The oncoming shift verified that the rods were within the withdrawal limits and the Shif t Engineer directed that an additional dilution be performed for conservatism. The shift began considering reportability requirements but did not begin preparation of the potential reportable occurrence form until later in the shift. At approximately 1400 hours0.0162 days <br />0.389 hours <br />0.00231 weeks <br />5.327e-4 months <br /> this event was determined to be reportabic under Technical Specification 6.9.1.12.b. The NRC was notified by telephone at approximately 1500 hours0.0174 days <br />0.417 hours <br />0.00248 weeks <br />5.7075e-4 months <br /> and by telecopy at approximately 1600 hours0.0185 days <br />0.444 hours <br />0.00265 weeks <br />6.088e-4 months <br />.
12/23/81 - A management and technical investigation of the event was initiated which has culminated in this report.
The control rod withdrawal limit curves submitted in Special Report 81-8 and in use at the plant are based on measured MTC values and are adjusted by 1.0 pcm per degree F for conservatism. The attached graph shows the design and measured MFC and verifles that the moderator temperature coefficient never exceeded a negative value.
The labeled design curve showing the control rod banks D and C configurations were taken from our Technical Instruction (TI) 42
{
Figure 1 (reference Westinghouse WCAP 9516). The all rods out (ARO) i curve was constructed from design data and ARO measured data. An I operating curve at any boron concentration at which criticality occurs I has been drawn by connecting three known points. At the time of criticality on 12/21/81, the boron concentration was measured to be 1262 ppm. This point corresponds to a moderator temperature coef ficient value on the curve of approximately .7 pcm per degree F.
This point is labeled " Operating Value At Criticality".
Evaluations and Conclusions I. Based on the investigation and information described above, it has been determined that the primary cause of this event was the failure to incorporate the rod withdrawal limitations into the appropriate operating procedures and surveillance instructions. This omission resulted in the STA performing the estimated critical point calculation without consideration of the rod withdrawal limits. Additional contributing factors include:
- 1. The five and one half week period of inactivity between low power physics testing (when the positive MTC was discovered) and normal unit startup.
- 2. Routinc startups on Unit 1 are accomplished by pulling rods to maintain operations within acceptable axial flux difference values per Technical Specification 3.2.1.
The above factors contributed to the engineering and operations personnel failure to consider the control rod withdrawal limitations when performing the estimated critical condition calculation and subsequent rod withdrawal to critical.
II. Based on the interviews with operating personnel and the fact that an operator discovered the situation and took appropriate corrective action, it is concluded that no additional training is required on rod withdrawal limits.
III. Based on subsequent calculations it is concluded that the reactor was not operated with a positive moderator temperature coefficient.
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4 IV.
Based on the evaluat!ons performed, instructions 00I-2, COT-5 and SI-38 have been revised. Additionally all startup tests should be reviewed to assure that all relevant findings derived irom the .,ta rtup tyrogram a re factored into operating instruct ions.
Corrective Action,s 1.
The RCS boron concentration was immediately diluted in order to reestablish the appropriate control rod withdrawal limitations.
2.
The NRC was notified per telephone and telecopy within required time limitations.
- 3. An investigation team was established by the plant superintendent to evaluate the occurrence and make approprirste recommendations.
4.
COI-2, C01-5 and SI-38 were revised by 12/24/81 to incorporcte appropriate precautions to assure that rod withdrawal 1 Imitations are not violated again.
5.
All startup test instructions will be reviewed and revised as appropriate to assure that all predefined test results are adequately factored into plant instructions.
This review will be completed by 12/30/81 and plant instructions will be revised, as necessary. Any unexpected findings will be handled as test deficiencies which receive PORC review.of the final disposition. This review process is described in SQA-44 and should result in sny appropriate findings being incorporated into operating instructions.
It addition, steps will be taken to ensure that operating shift personnel are expeditiously procedural changes.informed of, and receive formal training in, the resulting 6.
The operations supervisor will issue a memorandum to all appropriate operations personnel including STAS to ensure that they are aware of this occurrence and the rod withorawal limitations.
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