ML20044A920
| ML20044A920 | |
| Person / Time | |
|---|---|
| Site: | Callaway  |
| Issue date: | 07/10/1990 |
| From: | Blosser J, Sharkey T UNION ELECTRIC CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| LER-90-007, LER-90-7, ULNRC-2247, NUDOCS 9007160378 | |
| Download: ML20044A920 (9) | |
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ULNRC-2247 '
o Gentlement e
'I DOCKET NUMBER 50-483 CALLAWAY PLANT UNIT 1 FACILITY OPERATING LICENSE NPF-30 LICENSEE-EVENT-REPORT 90-007-00 1TWO REACTOR TRIPS DUE TO FAILED INPUT BUFFER CARD
.AND FAULTY SLAVE CYCLER COUNTER CARD AND A MISSED SURVEILLANCE DUE TO COGNITIVE ~ PERSONNEL ERROR. g
'I The enclosed Licensee Event Report is submitted pursuant to
'10 CFR' 50.73(a)(2)(iv) concerning two reactor trips .as 'a result of .
equipment failures?nnd pursuant to.10CFR50.73(a)(2)(1)(B)- concerning a' missed surveillance due to cognitive personnel error.
. W I
. D. Blosser i Manager, Callaway Plant b
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,. cc distributien fcr ULNRC-2247 Mr. A;'Bert Davis Mr. Anthony T. Gody, Jr.- (2 copies)
- Regional Administrator' Office of Nuclear
- Reactor Regulation
,U.S. Nuclear. Regulatory Commission U.S. Nuclear Regulatory Commission-Region III Ma11'Stop 13-E-21
, 799 Roosevelt Road Washington, D.C. 20555 Glen Ellyn, IL 60137 American Nuclear Insurers Mr. 0. Maynard c/o Dottie Sherman, Library Wolf Creek Nuclear Operating Corp.
-The Exchange Suite 245 P. O. Box 411- s 270 Farmington' Avenue Burlington, KS 66839-Farmington, CT 06032 Mr. Merlin. Williams Manager,: Electric Department Supt. of Regulatory Quality &
Missouri Public Service Commission Administrative Services -
,, P. O. Box 360 Wolf Creek Nuclear Operating Corp. ~k Jefferson City, MO 65102 P. O. Box 411 Burlington,'KS 66839 Records Center Mr. R. L. Hague Institute of Nuclear Power Operations Chief, Project Section 3C Suite 1500 U.S. Nuclear Regulatory Commission; 1100 circle 75 Parkway ' Region III Atlanta, CA 30339 799 Roosevelt Road Glen Ellyn. 1137-s
.NRC Senior Resident Inspector l I
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Callaway Plant Unit 1-
"' Two Reactor Trips Due To Failed Input Buffer Card and Faulty Slave Cycler Counter Card and a Missed Surveillance due to Cognitive Personnel Error IVlWT DATI(Si LtR NUMeth (61 mlPORT DAf t t~7i OTHER f ACiLITitt iNVOLyt0 tel YtAR YEAR
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l l l on 6/11/90, at 1016 CDT, a Reactor Protection' System (RPS) reactor trip, a
-Feedwater Isolation (FWIS), and an Auxiliary Feedwater Actuation occurred following simulatenous closure of all four Main Steam Isolation Valves (MSIVs). The plant was in Mode 1 - Power Operations at 100 percent reactor power. The MSIVs closed due to a failed input buffer card in the MSIV manual fast close circuitry in the Main Steam and Feedwater Isolation System control cabinet. The failed input buffer card was replaced.
On 6/12/90, at 0501 CDT, while st.beritical during reactor startup, four Bank
'B' Rod Control Cluster Assemblies dropped. Options were evaluated and at 0545, the reactor trip breakers were opened, manually tripping the reactor.
A FWIS was received as anticipated. The plant was in Mode 2 - Startup (suberitical). A faulty rod control slave cycler counter card for the IBD control rod power cabinet was identified and replaced.
During startup of the plant on 6/12/90, Operations Surveillance Procedure,
" Main Turbine Trip Tests" (OSP-AC-00004), was not performed. This event was discovered on 6/18/90. The plant was in Mode 2 - Startup at 15 percent reactor power. This event was caused by the Shift Technical Advisor mistakenly reading the surveillance schedule book. OSP-AC-00004 was performed satisfactorily on 6/18/90. Notes were added to the surveillance schedule book to provide clarity. Individuals involved will be counseled.
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Basis for Reportability Event One On 6/11/90, at 1016 CDT, a Reactor Protection System (RPS) ( } reactor trip occurred follow L
Valves (MSIVs) g theAssimultaneous. a result of the closure of all four Main RPS actuation, Steam Isolation-a Feedwater Isolation (FWIS) and an Auxiliary Feedwater Actuation -l
.i Since the Engineering Safety Features (ESF) g actuations AS)_were generated were not part by design.
of a preplanned sequence during reactor operation or testing, this event is j' reportable per 10CFR50.73(a)(2)(iv).
Event Two: ;
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- l. ;0n6/12/90at0501CDT,whilesuberiticalduringreactoragtup(fromEvent
- l. One), four Bank 'B'. Rod Control Cluster Assemblies (RCCA) dropped, j Followingevaluationoftheoptionsavailable,itwasdeterminedthatg 1 manual trip should be initiated. 'At 0545, the reactor trip breakers were !
opened, :nanually tripping the reactor. A FWIS was received as anticipated. !
This event is reportable per 10CFR50.73(a)(2)(iv) .
g Event-Three l l
L l Technica1' Specification (T/S):4.3.4.2 requires that the Turbine Overspeed Protection System'shall be maintained, calibrated, tested and inspected in ,
accordance with the Callaway Plant's-Turbine Overspeed Protection Reliability i Program (TOPRP). Adherence to this program shall demonstrate OPERABILITY of I
the system. :
I During the startup of the plant on 6/12/90, Operations Surveillance Proce- !
dure, " Main Turbine Trip Tests" (OSP-AC-00004), was not performed as required 1
, by the TOPRP. This event was discovered on 6/18/90 and is reportable per '
l l -10CFR50.73(a)(2)(1)(B) as a condition prohibited by the plant's T/S. i Plant Conditions at Time of Event Event'One: {
Mode 1 - Power Operations ;
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100 percent Reactor Power Reactor Coolant System (RCS): Temperature (average) - 558 degrees F; Pressure - 2291 psig Event Two:
Mode 2 - Startup (suberitical) l-Event Three:
i Mode 2 - Startup, Reactor Power 15%
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Event One -!
At1016on6/11/90,the'MainStg/MainFeedValvesNotFullOpen' Main Control Board (MCB) annunciator came in as all four Main Steam Isolation Valves (MSIVs) simultaruusly closed. Eight seconds later, the reactor .j L tripped on "High Pressurizer Pressure". The emergency procedures were followed as required to immediately stabillee the plant. FWIS and AFAS ESF actuations were received per design. l Event Two:
L I Following' investigation and determination of root cause for Event One, i, reactor startup conmenced at 0443 on 6/12/90. At 0501, while suberitical f during reactor startup, four Bank 'BRCCA's dropped (F2, B2, K14 & P6).
RCCA K14 did not fully insert, but stopped within six steps of the bottom.
Bank 'B' was at approximately 130 steps when the rods dropped. RCCA K14 fully inserted when the licensed Reactor Operator began manually inserting .a l
control rods. The ' Control Rod Urgent Failure' MCB annunciator was received 'i when the control rods were manually inserted approximately 15 to 20 steps.
UtilityreactorengineersandInstrumenglonandControltechnicianswere' dispatched to the control rod cabinets to investigate,
=Following evaluation of the options available, it was determined by the l licensed operators and plant management that a manual reactor trip should be initiated. Preparations were made for the manual trip (i.e. valve lineups for the anticipated FWIS and voltage readings on the reactor trip breakers).
i .At 0545, the reactor trip breakers were opened, manually tripping the reactor.
Event Thtee:
1 On 6-12-90 at approximately 1800, a reactor startup commenced. At 1943, the '
.PM Shift (1500 - 2300) licensed Shift Supervisor (SS) proceeded with reactor l startup without completion of procedg OSP-AC-00004, Main Tur'Ine Trip i Tests. The main generator breakers were closed at 2200.'
At 0300 on 6-13-90, the non-licensed Shift Technical Advisor (STA) reviewed startup documentation. He concluded that OSP-AC-00004 had been performed within.the last seven days and thus was not required during this startup.
The STA's determination was reviewed and accepted by the SS. On 6/18/90 l during a review of surveillance task sheets, the surveillance tracking l non-licensed engineer discovered that the OSP-AC-00004 surveillance had not l been performed.
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Root Cause-Event One:
The MSIVs closed due to a failed input buffer card (') in the MSIV manual (MSFIS)TIO71rcuitryintheMainSteamandFeedwaterIsolationSystem control cabinet.- The input buffer card had a capacitor !
momentarily short to ground' . Consolidated Controls Corporation (CCC),
manufacturer of the input buffer card, determined that a certain brand of capacitor'(AVX) used in the input section of the-input buffer card exhibited a higher failure rate than other brands specified for this application. The use of AVX capacitors on the input buffer card was discontinued in 1981.
f Event Two:
-Subsequenttroubleshootingg)thecontrolrodsystemidentifiedafaulty slave cycler counter card (Model No. 3360C94G01) for the 1BD control rod power cabinet. 'This resulted in the four Bank 'B' RCCA's dropping, RCCA K14 relatch prior to full insertion, and the Control Rod Urgent Failure annunciator during the manual insertion. !
Event Three:
I The STA mistakenly read the surveillance schedule.
Corrective Actions Event One:
The failed input-buffer card in the MSIV manual fast close MSFIS circuitry was replaced. A subsequent evaluation was performed to determine how many ,
input buffer cards (installed and spares) use the AVX capacitors. The .
evaluation determined that only the MSFIS cabinets have boards with the AVX capacitors. All of the AVX capacitors on the MSFIS input buffer cards will' be replaced with another qualified, more reliable capacitor.
Event Two:
The faulty slave cycler counter card for the IBD control rod power cabinet was replaced. An evaluation is being performed to determine the benefits of ,
testing and/or replacing similar cards in the control rod sysdem. '
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Event Three:
- Surveillance Procedure OSP-AC-00004 was performed satisfactorily on 6/18/90 to satisfy T/S 4.3.4.2.
Notes;were-.added to the surveillance schedule book to clarify the requirements for performing surveillance test OSP-AC-00004.
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Surveillance procedure and scheduling documents are also being evaluated for clarification.
L The individua'18 ! involved will be counseled and the Operations-Department and Independent' Safety Engineering Group will receive training on this event.
Safety Significance The ESF systems involved in. Event One and Event Two performed as required.
' For' Event Two. tho' reactor was suberitical with sufficient shutdown margin-available with the shutdown control rods before the manual reactor trip was
- initiated. There was no detrimental effect on plant equipment as a result of the' actuations. ; 0SP-AC-00004 was performed satisf actorily on 6/18/90 for -
Event Three. 'All equipment functioned as required by plant design. None of.
the events posed a threat to the health and safety of the public Previous Occurrences Event One:
LLER 85-052-00,- transmitted on 1/8/86, via ULNRC-1235.
This:LER detailed a reactor trip on low steam generato g ter level;due.to-closure of the Main Feedwater Isolation Valves (MFIV) . The low steam-
' generator level was a result of the'MFIVs closing due to a failed input buffer card. The card was replaced. Evaluation at that time determined that there was not a significant generic failure mode, so no additional actions were taken.
Although LER 85-052-00 and LER 90-007-00 are similar in that each detail a reactor trip caused by a failed input buffer card in the Main Steam.and Feedwater Isolation System (MSFIS) control cabinet, the corrective action taken-on the previous LER could not have prevented this event.
Event Two:
None.
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-Previous Occurrences (continued)
Event Three:
LER 88-012-00, transmitted on 11/10/88, via ULNRC-1857.
During a 9/4'/88 plant startup, the licensed operators concluded based on their review of surveillance tracking data, that OSP-AC-00004 was current and
- not. required for completion of plant startup. This missed surveillance was discovered on 10/14/88.
This event occurred as a result of the failure to incorporate into the surveillance tracking program, the requirement to perform OSP-AC-00004 on each startup if not performed within the previous seven days.
The 2 to 1 Mode' Change Letter and the surveillance task sheets were revised to incorporate new TOPRP requirements. The appropriate individuals were counseled with respect to their involvement in this event.
Although LER 88-012-00 and LER 90-007-00 are similar in that each detail a missed surveillance from procedure OSP-AC-00004, the correction action taken on the previous LER could not have prevented this event.
Footnotes The system and component. codes below are from the IEEE Standards 805-1983 and 803A-1983,.respectively.
- 1. ; System - JC
- 2. System'- SB, Component - ISV
- 3. . System - JE
- 4. - Syatem - AA, Component - ROD
- 5. System - JC, Component - BKR
- 6. System - IB, Component - ANN
- 8. System - TB, Component - BRK
- 10. System -SB/SJ, Component - CAB
- 11. System - AA.. Component - CTR
- 12. System'- SJ, Component - ISV NE FORM 3egA on,s. GPoe 1986-520-569i00070