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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML20046B4841993-07-30030 July 1993 LER 93-006-00:on 930703,auxiliary Feedwater Signal Inadvertently Actuated Due to Personnel Error.Equipment Reset to Normal Lineup & Fuses Removed for Reinstallation Prior to Reactor startup.W/930730 Ltr ML20045H7611993-07-16016 July 1993 LER 93-007-00:on 930626,CR Alarm Received,Indicating Excessive Temp on Reactor Coolant Pump Motor Stator 1-04 & Manual Trip Initiated.Caused by RTD Failure.Rtd Terminations Disconnected & AOP revised.W/930716 Ltr ML20045A9911993-06-11011 June 1993 LER 93-004-00:on 930514,failure to Satisfy TS Surveillance for Verification of Valve Position Due to Valve Discrepancies Discovered During DBD Review.Valve Cap & Clearance installed.W/930611 Ltr ML20045A4681993-06-0303 June 1993 LER 93-003-00:on 930504,manual Reactor Trip Occurred Following Inadvertent Closure of Fwiv.Caused by Instrumentation Channel Error.Maint Performed on Affected Instrumentation channels.W/930603 Ltr ML20044G4071993-05-26026 May 1993 LER 93-006-00:on 930426,failure to Satisfy TS Surveillance Requirement for Primary Plant ESF Exhaust Filtration Unit Noted.Caused by Poor Labeling,Specification of Wrong Procedure & Discrepancy in Parts list.W/930526 Ltr ML20024H1581991-05-21021 May 1991 LER 91-016-00:on 910418,failure of Check Valve to Prevent Backflow Discovered.Caused by Mfg Error in Machining Process of Valve Body Casting.Valves Reassembled & Scheduled to Receive testing.W/910521 Ltr ML20024G7211991-04-25025 April 1991 LER 91-012-00:on 910326,potential Gas Binding of Centrifugal Charging Pumps Due to Voids in Boric Acid Gravity Feed Line Identified.Caused by Hydrogen Coming Out of Solution in Lower Pressure Ccp Suction header.W/910425 Ltr ML20024G6801991-04-22022 April 1991 LER 91-010-00:on 910322,unit 1 Operated Outside Tech Spec Due to Auxiliary Feedwater Sys Test Line Isolation Valve Not Closed.Root Cause Not Determined.Providing Addl Guidance to Operators & Operators Monitoring valves.W/910422 Ltr ML20029B6421991-03-12012 March 1991 LER 91-004-00:on 910210,potential Transformer Drawer Opened at Bottom of Switchgear Bus 1A3 Auxiliary Cubicle,Causing Load Shed Signal & Reactor Trip.Caused by Personnel Error. Labels Attached to Switchgear bus.W/910312 Ltr ML20028G9551990-09-27027 September 1990 LER 90-026-00:on 900828,surveillance Missed Due to Inadequate Procedural Requirements.Caused by Inadequate Manual Surveillance Scheduling Methods.Station Procedures revised.W/900927 Ltr ML20044A1351990-06-26026 June 1990 LER 90-017-00:on 900527,main Feedwater Flow Control Valve Failed Closed,Resulting in Reduced Feedwater Flow & Decreasing Steam Generator Water Level.Caused by Failure of Solenoid Valve Coil.Solenoid Coil replaced.W/900626 Ltr ML20044A3281990-06-22022 June 1990 LER 90-016-00:on 900521,engineering Determined That Three Atmospheric Relief Valves Declared Inoperable Resulting in Entry Into Tech Spec Limiting Condition for Operation 3.0.3. Pneumatic Controls Drifted Out of calibr.W/900622 Ltr ML20043H1971990-06-19019 June 1990 LER 90-015-00:on 900520,chemistry Sample Special Condition Surveillance Missed.Caused by Procedural Error.Procedures Revised to Provide Appropriate Cautions Re Required Sample. W/900619 Ltr ML20043G1121990-06-13013 June 1990 LER 90-014-00:on 900514,containment Penetration Improperly Isolated While Containment Isolation Valve Made Inoperable for Repairs.Caused by Inadequate Review of Work Order. Supervisor Counseled & Shift Order issued.W/900613 Ltr ML20043F1571990-06-0808 June 1990 LER 90-013-00:on 900509,while Installing Jumpers Across Feedwater Pump Speed Controllers,Pump Coastdown Occurred, Resulting in Loss of Feedwater Flow & Reactor Trip.Caused by Inadequate Procedure Review.Review performed.W/900608 Ltr ML20043E4511990-06-0707 June 1990 LER 90-012-00:on 900508,control Room Personnel Failed to Satisfy Time Limit for Completion of Action Required by Tech Specs Re Plant Radiation Monitoring.Caused by Personnel Error.Individual Counseled & Procedure revised.W/900607 Ltr ML20043F4941990-06-0404 June 1990 LER 90-011-00:on 900504,Pressure Instrument Root Isolation Valve 1SI-8961 Open When Procedure Indicated Valve Should Be Locked Closed.Caused by Lack of Clear Instructions Re Definition of Physical Work. Valve locked.W/900604 Ltr ML20043C0201990-05-29029 May 1990 LER 90-010-00:on 900428 & 29,2-h Surveillance Interval, Including 25% Extension Allowed by Tech Spec 4.0.2,exceeded. Caused by Personnel Error.Procedure Enhancements Initiated & Personnel Involved counseled.W/900529 Ltr ML20043A6691990-05-18018 May 1990 LER 90-009-00:on 900421,reactor Trip Occurred Due to Accidental Bumping of Source Range Reactor Trip Reset/Block Previously Bypassed for Power Operation.Order Issued Suspending Cleaning of Control boards.W/900518 Ltr ML20043A6131990-05-16016 May 1990 LER 90-008-00:on 900416,Train a Diesel Generator Rendered Inoperable Due to Failure to Complete post-work Operability Testing on Starting Air Receiver Check Valve 01. Caused by Inadequate Review.Procedure revised.W/900516 Ltr ML20043A6111990-05-16016 May 1990 LER 90-007-00:on 900416,ESF Actuation Signal Occurred, Resulting in Train a of Control Room Air Conditioning Sys Shifting to Emergency Recirculation Mode.Caused by Personnel Error.Handswitch Added to Radiation monitor.W/900516 Ltr ML20043A4201990-05-14014 May 1990 LER 90-006-00:on 900412,P-6 Permissive Signal Received & Source Range Flux Doubling (Srfd) Actuation Occurred.Caused by Inadvertent Reset of Srfd Block.Integrated Plant Operations Procedures changed.W/900514 Ltr ML20012B6491990-03-0909 March 1990 LER 90-001-00:on 900209,reactor Protection Sys Actuation Occurred Due to Spike on Range Channel.Appropriate Source Range Procedures Revised to Require Insertion of Flux Doubling Signal Block Prior to withdrawal.W/900309 Ltr 1993-07-30
[Table view] Category:RO)
MONTHYEARML20046B4841993-07-30030 July 1993 LER 93-006-00:on 930703,auxiliary Feedwater Signal Inadvertently Actuated Due to Personnel Error.Equipment Reset to Normal Lineup & Fuses Removed for Reinstallation Prior to Reactor startup.W/930730 Ltr ML20045H7611993-07-16016 July 1993 LER 93-007-00:on 930626,CR Alarm Received,Indicating Excessive Temp on Reactor Coolant Pump Motor Stator 1-04 & Manual Trip Initiated.Caused by RTD Failure.Rtd Terminations Disconnected & AOP revised.W/930716 Ltr ML20045A9911993-06-11011 June 1993 LER 93-004-00:on 930514,failure to Satisfy TS Surveillance for Verification of Valve Position Due to Valve Discrepancies Discovered During DBD Review.Valve Cap & Clearance installed.W/930611 Ltr ML20045A4681993-06-0303 June 1993 LER 93-003-00:on 930504,manual Reactor Trip Occurred Following Inadvertent Closure of Fwiv.Caused by Instrumentation Channel Error.Maint Performed on Affected Instrumentation channels.W/930603 Ltr ML20044G4071993-05-26026 May 1993 LER 93-006-00:on 930426,failure to Satisfy TS Surveillance Requirement for Primary Plant ESF Exhaust Filtration Unit Noted.Caused by Poor Labeling,Specification of Wrong Procedure & Discrepancy in Parts list.W/930526 Ltr ML20024H1581991-05-21021 May 1991 LER 91-016-00:on 910418,failure of Check Valve to Prevent Backflow Discovered.Caused by Mfg Error in Machining Process of Valve Body Casting.Valves Reassembled & Scheduled to Receive testing.W/910521 Ltr ML20024G7211991-04-25025 April 1991 LER 91-012-00:on 910326,potential Gas Binding of Centrifugal Charging Pumps Due to Voids in Boric Acid Gravity Feed Line Identified.Caused by Hydrogen Coming Out of Solution in Lower Pressure Ccp Suction header.W/910425 Ltr ML20024G6801991-04-22022 April 1991 LER 91-010-00:on 910322,unit 1 Operated Outside Tech Spec Due to Auxiliary Feedwater Sys Test Line Isolation Valve Not Closed.Root Cause Not Determined.Providing Addl Guidance to Operators & Operators Monitoring valves.W/910422 Ltr ML20029B6421991-03-12012 March 1991 LER 91-004-00:on 910210,potential Transformer Drawer Opened at Bottom of Switchgear Bus 1A3 Auxiliary Cubicle,Causing Load Shed Signal & Reactor Trip.Caused by Personnel Error. Labels Attached to Switchgear bus.W/910312 Ltr ML20028G9551990-09-27027 September 1990 LER 90-026-00:on 900828,surveillance Missed Due to Inadequate Procedural Requirements.Caused by Inadequate Manual Surveillance Scheduling Methods.Station Procedures revised.W/900927 Ltr ML20044A1351990-06-26026 June 1990 LER 90-017-00:on 900527,main Feedwater Flow Control Valve Failed Closed,Resulting in Reduced Feedwater Flow & Decreasing Steam Generator Water Level.Caused by Failure of Solenoid Valve Coil.Solenoid Coil replaced.W/900626 Ltr ML20044A3281990-06-22022 June 1990 LER 90-016-00:on 900521,engineering Determined That Three Atmospheric Relief Valves Declared Inoperable Resulting in Entry Into Tech Spec Limiting Condition for Operation 3.0.3. Pneumatic Controls Drifted Out of calibr.W/900622 Ltr ML20043H1971990-06-19019 June 1990 LER 90-015-00:on 900520,chemistry Sample Special Condition Surveillance Missed.Caused by Procedural Error.Procedures Revised to Provide Appropriate Cautions Re Required Sample. W/900619 Ltr ML20043G1121990-06-13013 June 1990 LER 90-014-00:on 900514,containment Penetration Improperly Isolated While Containment Isolation Valve Made Inoperable for Repairs.Caused by Inadequate Review of Work Order. Supervisor Counseled & Shift Order issued.W/900613 Ltr ML20043F1571990-06-0808 June 1990 LER 90-013-00:on 900509,while Installing Jumpers Across Feedwater Pump Speed Controllers,Pump Coastdown Occurred, Resulting in Loss of Feedwater Flow & Reactor Trip.Caused by Inadequate Procedure Review.Review performed.W/900608 Ltr ML20043E4511990-06-0707 June 1990 LER 90-012-00:on 900508,control Room Personnel Failed to Satisfy Time Limit for Completion of Action Required by Tech Specs Re Plant Radiation Monitoring.Caused by Personnel Error.Individual Counseled & Procedure revised.W/900607 Ltr ML20043F4941990-06-0404 June 1990 LER 90-011-00:on 900504,Pressure Instrument Root Isolation Valve 1SI-8961 Open When Procedure Indicated Valve Should Be Locked Closed.Caused by Lack of Clear Instructions Re Definition of Physical Work. Valve locked.W/900604 Ltr ML20043C0201990-05-29029 May 1990 LER 90-010-00:on 900428 & 29,2-h Surveillance Interval, Including 25% Extension Allowed by Tech Spec 4.0.2,exceeded. Caused by Personnel Error.Procedure Enhancements Initiated & Personnel Involved counseled.W/900529 Ltr ML20043A6691990-05-18018 May 1990 LER 90-009-00:on 900421,reactor Trip Occurred Due to Accidental Bumping of Source Range Reactor Trip Reset/Block Previously Bypassed for Power Operation.Order Issued Suspending Cleaning of Control boards.W/900518 Ltr ML20043A6131990-05-16016 May 1990 LER 90-008-00:on 900416,Train a Diesel Generator Rendered Inoperable Due to Failure to Complete post-work Operability Testing on Starting Air Receiver Check Valve 01. Caused by Inadequate Review.Procedure revised.W/900516 Ltr ML20043A6111990-05-16016 May 1990 LER 90-007-00:on 900416,ESF Actuation Signal Occurred, Resulting in Train a of Control Room Air Conditioning Sys Shifting to Emergency Recirculation Mode.Caused by Personnel Error.Handswitch Added to Radiation monitor.W/900516 Ltr ML20043A4201990-05-14014 May 1990 LER 90-006-00:on 900412,P-6 Permissive Signal Received & Source Range Flux Doubling (Srfd) Actuation Occurred.Caused by Inadvertent Reset of Srfd Block.Integrated Plant Operations Procedures changed.W/900514 Ltr ML20012B6491990-03-0909 March 1990 LER 90-001-00:on 900209,reactor Protection Sys Actuation Occurred Due to Spike on Range Channel.Appropriate Source Range Procedures Revised to Require Insertion of Flux Doubling Signal Block Prior to withdrawal.W/900309 Ltr 1993-07-30
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML20217E8021999-10-0707 October 1999 CPSES Unit 1 Cycle 8 Colr ML20217G4151999-09-30030 September 1999 Monthly Operating Repts for Sept 1999 for Cpses,Units 1 & 2 ML20212F7671999-09-24024 September 1999 SER Granting Relief Request C-4 Pursuant to 10CFR50.55a(g)(6)(i) for Unit 2,during First 10-year ISI Interval & Relief Requests B-15,B-16 & B-17 Pursuant to 10CFR50.55a(g)(6)(i) ML20216J5701999-09-16016 September 1999 Rev 2 to CPSES Unit 2 Cycle 5 Colr TXX-9920, Monthly Operating Repts for Aug 1999 for Cpses.With1999-08-31031 August 1999 Monthly Operating Repts for Aug 1999 for Cpses.With ML20211M2981999-08-0606 August 1999 Rev 1 to CPSES Fuel Storage Licensing Rept, CPSES Credit for Soluble Boron & Expansion of Spent Fuel Storage Capacity, Consisting of Revised Title Page and 4-1 ML20210U4081999-07-31031 July 1999 Monthly Operating Repts for July 1999 for Cpses,Units 1 & 2 ML20210D8321999-07-23023 July 1999 Safety Evaluation Accepting Relief Requests Re Use of 1998 Edition of Subsections IWE & Iwl of ASME Code for Containment Insp ML20209H7661999-07-15015 July 1999 Safety Evaluation Accepting GL 95-07, Pressure Locking & Thermal Binding of Safety-Related Power-Operated Gate Valves, for Comanche Peak Steam Electric Station,Units 1 & 2 ML20209H2721999-07-0909 July 1999 2RF04 Containment ISI Summary Rept First Interval,First Period,First Outage ML20209H2631999-07-0909 July 1999 2RF04 ISI Summary Rept First Interval,Second Period,Second Outage ML20209G7501999-07-0808 July 1999 SER Finding That Licensee Individual Plant Exam of External Events Complete with Regard to Info Requested by Suppl 4 to GL 88-20 & That IPEEE Results Reasonable Given Design, Operation & History of Comanche Peak Steam Electric Station ML20196L0191999-07-0808 July 1999 Safety Evaluation Granting Request Relief B-6 (Rev 2),B-7 (Rev2),B-12,B-13,B-14 & C-9,pursuant to 10CFR50.55a(g)(6)(i).Technical Ltr Rept Also Encl ML20210J9391999-06-30030 June 1999 CPSES Commitment Matl Change Evaluation Rept 0003,for 970802-990630 ML20209G0801999-06-30030 June 1999 Monthly Operating Repts for June 1999 for Cpses,Units 1 & 2 ML20196J0621999-06-29029 June 1999 Safety Evaluation Supporting Proposed Changes to Emergency Plan Re Licenses NPF-87 & NPF-89 Respectively ML20195G5141999-05-31031 May 1999 Monthly Operating Repts for May 1999 for Comanche Peak Steam Electric Station,Units 1 & 2.With ML20216E0711999-05-21021 May 1999 1999 Graded Exercise - Comanche Peak Steam Electric Station ML20206Q0091999-05-14014 May 1999 Safety Evaluation Accepting GL 92-08, Thermo-Lag 330-1 Fire Barriers, Dtd 921217,for Comanche Peak Electric Station,Unit 1 ML20206H2061999-05-0606 May 1999 SER Accepting Exemption to App K Re Leading Edge Flowmeter for Plant,Units 1 & 2 ML20196L2241999-04-30030 April 1999 Monthly Operating Repts for Apr 1999 for Cpses,Units 1 & 2 ML20205R5701999-04-14014 April 1999 Rev 6 to ER-ME-067, TU Electric Engineering Rept,Evaluation of Thermo-Lag Fire Barrier Sys ML18016A9011999-04-12012 April 1999 Part 21 Rept Re Defect in Component of DSRV-16-4,Enterprise DG Sys.Caused by Potential Problem with Connecting Rod Assemblies Built Since 1986,that Have Been Converted to Use Prestressed Fasteners.Affected Rods Should Be Inspected ML20205J7831999-04-0101 April 1999 Rev 0 to ERX-99-001, CPSES Unit 2 Cycle 5 Colr ML20205N3101999-03-31031 March 1999 Monthly Operating Repts for Mar 1999 for Cpses,Units 1 & 2 ML20204H6371999-02-28028 February 1999 Monthly Operating Repts for Feb 1999 for Comanche Peak Units 1 & 2 ML20205N1481999-02-28028 February 1999 Corrected Monthly Operating Rept for Feb 1999 for CPSES, Units 1 & 2 ML20203A4881999-02-0303 February 1999 Safety Evaluation Granting Requests for Relief B-3 - B-6,C-2 & C-3 for Plant,Unit 2 ML20210J9201999-02-0101 February 1999 CPSES 10CFR50.59 Evaluation Summary Rept 0008,for 970802- 990201 ML20202D0101999-01-27027 January 1999 Safety Evaluation Supporting First 10-yr Interval ISI Program Plan Requests for Relief B-9,B-10 & B-11 for CPSES, Unit 1 ML20199E9961998-12-31031 December 1998 Monthly Operating Repts for Dec 1998 for Cpses,Units 1 & 2 ML20207D6091998-12-31031 December 1998 1998 Annual Operating Rept for Cpses,Units 1 & 2. with ML20197K2371998-11-30030 November 1998 Monthly Operating Repts for Nov 1998 for Cpses,Units 1 & 2 ML20195F3161998-10-31031 October 1998 Monthly Operating Repts for Oct 1998 for Cpses,Units 1 & 2 ML20154M8841998-09-30030 September 1998 Monthly Operating Repts for Sept 1998 for Cpses,Units 1 & 2 ML20154B5741998-09-30030 September 1998 Safety Evaluation Re Licensee Response to GL 96-05, Periodic Verification of Design-Basis Capability of Safety- Related Motor-Operated Valves. Licensee Has Established Acceptable Program ML20151W0361998-08-31031 August 1998 Monthly Operating Repts for Aug 1998 for Cpses,Units 1 & 2. with ML20151Q1211998-08-14014 August 1998 Rev 0 to Control of Hazard Barriers ML20237C4061998-08-14014 August 1998 Safety Evaluation Supporting Request to Implement Risk Informed IST Program ML20237C6721998-07-31031 July 1998 Monthly Operating Repts for July 1998 for Cpses,Units 1 & 2 ML20236V3121998-07-29029 July 1998 Final Part 21 Rept Re Enterprise DSR-4 & DSRV-4 Edgs.Short Term Instability Was Found During post-installation Testing & Setup as Part of Design mod/post-work Testing Process. Different Methods Were Developed to Correct Problem ML20236R0711998-06-30030 June 1998 Monthly Operating Repts for June 1998 for Cpses,Units 1 & 2 ML20249B2581998-05-31031 May 1998 Monthly Operating Repts for May 1998 for Cpses,Units 1 & 2 ML20248A1671998-05-22022 May 1998 Interim Part 21 Re Enterprise DSR-4 & DSRV-4 Emergency diesel.Post-installation Testing Revealed,High Em/Rfi Levels Affected New Controllers,Whereas Original Controllers Were unaffected.Follow-up Will Be Provided No Later than 980731 ML20247G3241998-04-30030 April 1998 Monthly Operating Repts for Apr 1998 for Cpses,Units 1 & 2 ML20216B8661998-04-0101 April 1998 Rev 0 to ERX-98-001, CPSES Unit 1 Cycle 7 Colr ML20216J3061998-03-31031 March 1998 Monthly Operating Repts for Mar 1998 for Cpses,Units 1 & 2 ML20216J1861998-02-28028 February 1998 Monthly Operating Repts for Feb 1998 for Comanche Peak Steam Electric Station ML20197A6951998-02-24024 February 1998 Inservice Insp Summary Rept,First Interval,Second Period, First Outage ML20199J5391998-02-0202 February 1998 CPSES Commitment Matl Change Evaluation Rept 0002 for 960202-970801 1999-09-30
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Log # TXX-90183
- File # 10200
- C 906.2 C C Ref. # 50.73 (a)(2)(1) 1UELECTRIC June 4, 1990 Entsutove Vice Preudent VOS illuc166F "ulitMy Caseilision utAtta: LBocamat trol-Deski
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SUBJECT:
COMANCHE PEAK STEAM ELECTRIC STATION DOCKET NO. 50-445 CONTAINMENT ISOLATION ROOT VALVE LEFT IN INCORRECT POSITION LICENSEE EVENT REPORT 90 011-00 Gentlemen:
Enclosed is Licensee Event Report 90-011-00 for Comanche Peak Steam Electric Station Unit 1, " Containment Isolation Root Valve left in Incorrect Position as a Result of Procedural Deficiency."
Sincerely,
[ .1 William J. Cahill, Jr.
JRW/daj Enclosure c - Mr. R. D. Martin, Region IV Resident Inspectors, CPSES (3) 9006150064 900604 PDR ADOCK 05000445 s PDC
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M North Ohve Street LB 81 Dallas. Texas 75201 ljl g
Enclosure to TXXo90183 N84C FORM 386 U.S. NUCLE AW REOUL.ATO.Tl COMMIS&lON APPROVED OME NO,31640104 EXPIRES;4'3Wgt ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THS INFORMATON 00L11CTON REQUEST: 60.0 HRS. FORWARD COMMENTS REGARDING BURDEN EMIMATE TO THE RECORDS AND REPORTS MANAGEMENT LICENSEE EVENT REPORT (LER) ORANCH (P 630), U.8, NUCLE AR REGULATORY COMMIS$10N. WASHINGTON.
l 3C. 20555. AND TO THE PAPERWORK REDUCTON PROJECT (3160 0104) i 7FICE OF MANAGEMENT AND BUDGET, WASHINGTON. DC. 20503.
FacHy Name (1) Docket Nurreser (2) Page (33 COMANCHE PEAK - UNIT 1 0l510l0l01414l5 1 I or 10i6 !
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On May 4,1990, during the monthly performance of the Containment Isolation Valve Position Verification, it was identified that a pressure instrument root Isolation valve,1S1-8961, was open when the procedure indicated it should be locked closed. Upon investigation, it was determined that a Design Change Notice (DCN) had been approved and issued to address an NRC concern regarding the position of valve 1SI-8961; however, the field work to change the position of the valve (from open to locked closed) had never been performe'd, Upon discovery of this condition, the valve was immediately shut. The valve had been open, in violation of Technical Specification 3.6.?, since March 12,1990 when Unit 1 had initially entered Mode 4.
i The cause of the event ha.; been determined to be a lack of clear instructions concerning Document Change Only E CNs and the definition of " physical work". A Document Change Only DCN should not result in ohysical changes to the plant (i.e., valve position change). Based on the intent of the Documer.t Change Only DCN process, no closure mechanism was established to ensure that physical ct anges to the plant (resulting from Document Change Only DCNs) were implemented. Several reviews were conducted which verified that this problem is very limited in scope, and the problem will be addressed by training and a revision to the Design Modification Process Procedure.
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Enclosure to TXX 90183 Nsc FORM 3004 U.S. NUCLEAR REQuLATOov COMM4SION APPR06 OMS M SNOW ESTIMATED SURDEN PER RE COMPLY W1TH TH$ INFORMATION LICENSEE EVENT REPORT (LER) fygg,",'M','; y*"l","*ffy,'", W,8,",'ff,'%
TEXT CONTINUATION 'f % i g 'f M ," @ ,7,c g ,'gcQ ","'o,7 f OFFCE OF MANAGEMENT AND BUDGET, WASHINGTON DC.20601 7 acery Name (t) Dcr*ar Number (2) LER Nurrter (6) Page(3) v=~ m *c w a ;m COMANCHE PEAK , UNIT 1 015l0l0101414I5 910 Ol1l1 -
Ol0 012 OF 0lB T.st (a more space e esqueso, use moditona NRG Form 366A e) (17)
- 1. DESCRIPTION OF WHAT OCCURRED ,
A. PLANT OPERATING CONDITIONS BEFORE THE EVENT j At approximately 0100 CST, on March 12,1990, Comanche Peak Steam Electric . l Station (CPSES) Unit 1 initially entered Mode 4, Hot Shutdown. Reactor Coolant System (Ells:(AB)) temperature and pressure were 200 degrees Fahrenheit and 380 pounds per square inch gage (PSIG), respectively.
B. REPORTABLE EVENT DESCRIPTIO.N.flNCLUDING _1ATES AND APPRQXIMATETIMES_OF_MAJOROCC.UBf1ElICES)
Event Classification: Any operation or condition r rohibited by the plant's l Technical Specifications.
Just prior to receipt of the Low Power Facility Operating License on February 8, 1990, the Nuclear Regulatory Commission (NRC) Project Manager for CPSES identified a concern regarding a Final Safety Analysis Report (FSAR) change submitted by CPSES as part of Amendment 66 on January 15,1988. The concern dealt with taking credit for the use of a pressure Indicator on the Safety injection System test line (Ells:(PI)(BP)) as a containment boundary rather than utilizing the pressure indicator's roo. Isolation valve (1 SI-8961) (Ells:(ISV)(BP)) as the containment boundary. In order to resolve the NRC concern, CPSES developed a draft FSAR change allizing valve 1S18961 as the containment boundary. The change was discursed with the NRC Project Manager and it was agreed that the change would bc incorporated in the first FSAR update following issuance of the Low Power Facility Operating License. In addition, CPSES stated that a design change would be implemented to comply with the requirements of 10CFR50, Appendix A, General Design Criteria (GDC) 55, by changing the root isolation valve's position from open to locked closed.
A Document Change Ply Design Change Notice (DCN) (i.e., a DCN which is not included in a Design Modification Package) to change the normal position of 1SI-8961 to locked closed on the station drawings and associated FSAR change request were approved on February 16,1990. The appropriate procedure change notices (PCN) were then initiated for the Operations procedures affected by the DCN.
A revision to the System Operating Procedure was approved and made effective on March 13,1990, and PCNs to the Containment Isolation Valve Position
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' . Enclosure to TXX-90183-NRC FOR;d setA U.S. NUCLEAA REGULATORY COMMn68CN sfPRO NO M04
E4flWATED BURDGN PER RESPONSE TO COMPLY WITH TH$ MORMATON
[ LICENSEE EVENT REPORT (LER) 235*,'",1%,';15" l"Jg,7 ,'*o C ,'jfo",%,
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COMANCHE PEAK , UNIT 01510l01014I4l5 910 1uA.nm 0l111 -
0IO OI3 OF 0I6 u.u,tr.r. - . - u NRcr Verification Forms and the Operations Locked Valve List Forms were approved and made effective on April 11,1990. However, on May 4,1990, at approximately 2300 CST, it was identified that although the DCN and procedure changes had been approved and made effective, the actual position of the valve had never been changed.
C. STATUS OF STRUCTURES. SYSTEMS. OR COMPONENTS THAT WERE INOPER ABLE AT THE START OF THE EVENT AND THAT CONTRIBUTED TO THE EVENT Not applicable - no structures, systems, or components were inoperable at the start of the event that have been determined to have contributed to the event.
D. CAUSE OF EACH COMPONENT OR SYSTEM FAILURE. IF KNOWN Not applicable - no component or system failures have been identified.
E. FAILURE MODE. MECH ANISM. AND EFFECT OF EACH FAILED COMPONENT Not applicable - no failed components have been identified.
F. FOR FAILURES OF COMPONENTS WITH MULTIPLE FUNCTIONS. LIST OF SYSTEMS OR SECONDARY FUNCTIONS THAT WERE ALSO AFFECTED Not applicable - no component failures have been identified.
G. FOR FAILURES THAT RENDERED A TRAIN OF A SAFETY SYSTEM lNOPERABLE. AN ESTIMATE OF THE ELAPSED TIME FROM THE DISCOVERY OF INOPERABILITY UNTIL THE TRAIN WAS RETURNED TO SERVICE Not applicable - no failures were involved.
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0IO OI4 OF 0l6 T.. i. -. - . - . una r ; a., ii 73 H. THE METHOD OF DISCOVERY OF EACH COMPONENT OR SYSTEM FAILURE OR PROCEDUR AL ERROR On May 4,1990, during the monthly performance of the Containment Isolation Valve Position Verification, it was identified that valve 1 SI 8961 was open when the procedure indicated that it should be locked closed.
- 1. CAUSE OF THE EVENT gg,gt Cause There was a lack of clear instructions concerning Document Change Only DCNs and the definition of " physical work". A Document Change Only DCN should not result in physical changes to the plant (i.e., valve position changed). Based on the intent of the Document Change Only DCN process, no closure mechanism was established to ensure that physical changes to the plant (resulting from Document Change Only.
DCNs) were implemented.
J. SAFETY SYSTEM RESPONSES THAT OCCURRED There were no manual cr automatic safety avstem responses as a result of this event.
K. FAILED COMPONENT INFORMATION There were no component failures associated with this event.
II. ASSESSMENT OF THE SAFETY CONSEQUENCES AND_ IMPLICATIONS OF THIS EVENT Each line that is part of the RCS pressure boundary and that penetrates primary reactor containment shall be provided with a containment isolation valve arrangement as specified by 10CFR50, Appendix A, GDC 55 unless it can be demonstrated that the containment isolation provisions for a specific class of lines (e.g., instrument lines) are acceptable on some other defined basis. In accordance with GDC 55, one of the acceptable provisions for containment penetration isolation is to have one automatic isolation valve inside and one locked closed valve outside containment.
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During the period that valve 1SI 8961 was open, CPSES met the requirement to have one automatic isolation valve (Ells:(ISV)(JM)) inside containment (which could close in response to an actuation signal), but did not have the locked closed valve outside containment. The isolation valve inside containment is normally closed and is designed to fall closed.
Although the root isolation valve,1SI 8961, located off of the Safety injection System Test Line, remained open from March 12,1990 to May 4,1990, the associated containment penetration (Ells:(PEN)(NH)) was effectively isolated during that period. The downstream pressure indicator sensing element is dead ended and hydrostatically tested to 3500 PSIG which exceeds the design pressure of the pipe (2735 PSIG). Additionally, the pressure indicator is seismically mounted and located in an area protected from the effects of high energy line breaks.
Based on the above discussion, the event did not adversely affect the safe operation of CPSES Unit 1 or the health and safety of the public.
Ill. CORRECTIVE ACTIONS A. IMMEDIATE CORRECTIVE ACTION Upon discovery of this condition, the containment isolation valve 1SI-8961 was immediately locked closed. in addition, several reviews were conducted which verified that this problem is very limited in scope. One review ensured that there were no additional actions required by CPSES for FSAR change requests which the NRC agreed could be incorporated in the first FSAR update following the issuance of the Low Power Facility Operating License. Sample reviews were conducted to determine whether any other Document Change Only DCNs had resulted in procedure changes and required implementation of a physical change to the plant to reflect the DCN (e.g., valve position changed). These reviews did not identify any additional examples where a physical change to the plant had not been implemented. Lastly, a review was completed to ensure that there were no Technical Specification Surveillance related PCNs that had been approved and ,
implemented without the actual plant change being made. Similarly, no concerns were identified as part of this review.
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Facasy Name (1) Doomst Nunmer (2) LER Nunter S) Peps (3)
Year .g COMANCHE PEAK - UNIT 1 0!51010l0141415 910 -l 011 11 -
010 018 OF 016 1..nn o -. .. NaC F- w.n a B. ACTIONS TO PREVENT RECURRENCE Root Cause There was a lack of clear Instructions conceming Document Change Only DCNs and the definition of " physical work". A Document Change Only DCN should not result in physical changes to the plant (i.e., valve position changed) Based on the intent of the Document Change Only DCN process, no closure mechanism was established to ensure that physical changes to the plant (resulting from Document Change Only DCNs) were implemented.
Corrective Action Additional guidance will be provided in the Design Modifcation Process Station Manual Procedure regarding the Document Change Only DCN process. Training will j be conducted for the appropriate engineering personnel emphasizing that Document Change Only DCNs cannot result in any physical change to the plant.
IV. PREVIOUS SIMILAR EVENTS There have been no previous similar events reported pursuant to 10CFR50.73. ,
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