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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML20046C2121993-07-30030 July 1993 LER 93-004-01:on 930301,confirmed That Channel D Axial Shape Index (Asi) Being Calculated in Reverse Since 921031-930301 Due to Drawing Discrepancies Associated W/Control Channel B. Temporary Mod 92-078 & Standing Order 0-25 Revised ML20046A8691993-07-26026 July 1993 LER 93-011-00:on 930624,experienced Reactor Trip Due to Loss of Load.Caused by Lack of Proper Job Planning,Lack of Formal Decision Making Process & Incomplete Communications.Training Will Be Provided to Operations personnel.W/930726 Ltr ML20045H2561993-07-12012 July 1993 LER 93-010-00:on 930611,1 of 14 Halon Cylinders Did Not Meet Min Pressure Acceptance Criteria Listed in Semiannual Switchgear Rooms Surveillance Test.Caused by Failure of Test to Include Necessary Steps.Cylinder recharged.W/930712 Ltr ML20045D7201993-06-22022 June 1993 LER 93-009-00:on 930524,apparent Spurious Signal from Pressurizer Level Instrumentation Caused Backup Charging Pumps to Automatically Start,Due to Deterioration of Wiring. Instrument Loop Calibration Will Be performed.W/930622 Ltr ML20045D3741993-06-21021 June 1993 LER 93-008-00:on 930520,determined That TS SR Not Satisfied for Stack Flow Indicator,Per Amend 137 Issued on 910307. Caused by Lack of Attention to Detail.Calibr & Functional Test Procedures developed.W/930621 Ltr ML20044H5261993-06-0101 June 1993 LER 93-007-00:on 930430,unplanned Emergency Generator Start & Rt Signal Occurred.Caused by Inadequate Attention to Detail,Labeling of Fuse Drawers,Caution Signs & Training. Labeling & Caution Signs upgraded.W/930601 Ltr ML20044G4941993-05-26026 May 1993 LER 93-006-00:on 930118,Halon Fire Suppression Sys for Switchgear Rooms Disabled to Allow Repair/Replacement of Halon Sys Piping.On 930427,individual Responsible for Fire Watch Not Present.Individual Relieved of Responsibilities ML20044B6711993-02-22022 February 1993 LER 93-002-00:on 930122,determined That Current SG LP Signal Block Reset Values Greater than Allowed Ts.Caused by Improper Design.Test Procedures Will Be Revised by 930917 to Specify Desired Value for Block function.W/930222 Ltr ML20024G6821991-04-19019 April 1991 LER 91-007-00:on 910320,480 Volt Circuit Breaker Coordination Outside Design Basis.Caused by Deficiencies in Original Sys Design.Breaker/Fuse Coordination Study to Be Completed & Problems Will Be corrected.W/910419 Ltr ML20029C1591991-03-21021 March 1991 LER 91-004-00:on 910212,offsite Power Low Signal Outside Design Basis.Caused by Inadequate Mod Design at Time of Performance of Original Degraded Voltage Analysis. Engineering Analysis EA-FC-91-017 performed.W/910321 Ltr ML20029C1051991-03-18018 March 1991 LER 91-002-00:on 901209,ventilation Isolation Actuation Signal Generated by High Alarm on Process Radiation Monitor RM-062.Caused by Accumulation of Noncondensible Gases in Sample Piping.Valve Packing Leak repaired.W/910318 Ltr ML20029A2981991-02-0808 February 1991 LER 91-001-00:on 910109,determined That Containment Tendon Surveillances Performed in 1981 & 1985 Did Not Reflect Guidance in Tech Specs.Caused by Inadequate Administrative Controls.Testing Program Plan implemented.W/910208 Ltr ML20029A2971991-02-0606 February 1991 LER 90-022-02:on 900907,approx 460 Fire Barrier Penetration seals,60 Fire Dampers & 6 Fire Doors Declared Nonfunctional Per NRC Info Notice 88-004 Due to Lack of Documentation. Plant Outage Required to Implement Repairs/Replacements ML20028G9171990-09-28028 September 1990 LER 90-021-00:on 900829,inadvertent Reactor Protective Sys Actuation Occurred While Operator Changed Power Source. Caused by Operator Not Following Proper Procedures.Operator counseled.W/900928 Ltr ML20044B0131990-07-12012 July 1990 LER 90-018-00:on 900612,reactor Protective Sys (RPS) Trip Units for Axial Power Distribution Determined to Be Inoperable.Caused by Procedural Deficiencies.Procedure Revised & RPS Surveillance Tests reviewed.W/900712 Ltr ML20043F6301990-06-11011 June 1990 LER 90-016-00:on 900511,accident Scenarios Identified by Which Auxiliary Feedwater Piping from Discharge of Turbine Driven Auxiliary Feedwater Pump FW-10 Can Be Overpressurized.Caused by Design deficiency.W/900611 Ltr ML20043F2441990-06-0707 June 1990 LER 90-015-00:on 900507,PORV Variable Setpoints Used for Low Pressure Overpressure Protection Determined to Be Nonconservative for PORV Opening Time.Caused by Design Deficiency.Tech Spec Amend prepared.W/900607 Ltr ML20043C0991990-05-29029 May 1990 LER 90-014-00:on 900427,investigation Revealed That Component Cooling Water Piping to Reactor Coolant Pump Seal Coolers Could Be Targets of High Energy Line Break.Safety Analysis for Operability completed.W/900529 Ltr ML20042G7211990-05-10010 May 1990 LER 90-011-00:on 900402,inadvertent Actuation of Pressurizer Pressure Low Signal Occurred While Performing Calibr Procedure.Caused by Inappropriate Action by Technician Involved.Validation of Procedures reviewed.W/900510 Ltr ML20042E6871990-04-23023 April 1990 LER 90-007-01:on 900228,determined That Several Supports Would Be Overloaded During Seismic Event on Nonsafety Related & safety-related Main Steam Piping.Caused by Design Deficiency.Piping Supports modified.W/900423 Ltr ML20042E6861990-04-23023 April 1990 LER 90-009-00:on 900316,potential Overpressurization of Auxiliary Feedwater Piping Could Have Occurred During Thermal Expansion of Process Fluid Between Closed Valved. Caused by Design deficiencies.W/900423 Ltr ML20012E7641990-03-26026 March 1990 LER 90-005-00:on 900223,determined That Spent Fuel Pool Area Charcoal Filtration Unit VA-66 Was Outside Design Basis. Caused by Insufficient Airflow Into Unit.Affected Updated SAR Analysis Will Be updated.W/900326 Ltr ML20012D0121990-03-19019 March 1990 LER 90-004-00:on 900217,lift Pressures for 6 of 10 Main Steam Safety Valves Found Outside Acceptance Criteria. Caused by Overly Restrictive Operability Criteria.Valves Recalibr & License Amend Submitted to NRC.W/900319 Ltr ML20012D0101990-03-19019 March 1990 LER 90-003-00:on 900216,determined That Auxiliary Feedwater Piping Outside Normal Stress Limits of ASME Code & Design Basis Specified in Updated Sar.Caused by Design Deficiency.Valve Operators Will Be inspected.W/900319 Ltr ML20012B6361990-03-0909 March 1990 LER 89-017-01:on 890624,internal Valve Component from Check Valve Found Lying on Pump Discharge Vane.Repair or Replacement of Valve Internals Could Not Be Accomplished within Time Requirement of Tech Spec.W/900309 Ltr ML20006E1041990-02-0909 February 1990 LER 90-001-00:on 900108,fire Barrier for Wall Between Auxiliary Bldg Rooms 26 & 34 Breached But Hourly Fire Watch Patrol Not Established.Caused by Lack of Sufficient Training for Shift Supervisors.Standing Order revised.W/900209 Ltr ML20011E2691990-02-0505 February 1990 LER 89-024-00:on 891221,determined That Containment Spray Pumps & Suction Header Piping Not Constructed for Use as Backup to LPSI Sys for Shutdown Cooling.Caused by Inadequate Review of Assumptions.Firewatch established.W/900205 Ltr ML20011E2271990-02-0101 February 1990 LER 89-021-00:on 891010,util Informed by C-E of Potential Nonconservative Setpoint in Reactor Protection Sys Thermal Margin/Low Pressure Trip Unit.Caused by Error in Incorporating Transient Setpoint analyses.W/900201 Ltr ML20005F7151990-01-10010 January 1990 LER 89-023-00:on 891211,hourly Firewatch Patrol Entered Posted High Radiation Area W/O Meeting Entry Requirements for Area.Briefings on High Radiation Entry Requirements Held for Personnel W/Assigned dosimetry.W/900110 Ltr ML19354D6381989-12-20020 December 1989 LER 89-022-00:on 890805,change to Surveillance Procedure ST-CEA-1 Became Effective Which Would Have Made Both Emergency Diesel Generators Simultaneously Inoperable During Portion of Test.Change removed.W/891220 Ltr ML19332E7431989-12-0808 December 1989 LER 88-037-01:on 881214,one of Two Supply Headers Supplying Fire Suppression Headers in Auxiliary Bldg Isolated.Caused by Lack of Procedural Guidance & Inadequate Procedural Controls.Standing Order G-58 Will Be revised.W/891208 Ltr ML19332E2681989-12-0101 December 1989 LER 89-016-02:on 890616,for Unknown Period Since 890614, Auxiliary Feedwater Pump FW-10 Operated Outside Design Basis for Certain Accident Conditions.Caused by Inoperable Speed Control Loop.Action Plan implemented.W/891201 Ltr ML19351A4541989-11-22022 November 1989 LER 89-020-00:on 891012,determined That Two of Four Component Cooling Water HXs Simultaneously Inoperable for More than 24 H.Caused by Inadequate Controls Re Return of Equipment to Svc.Standing Order revised.W/891122 Ltr ML19327B5481989-10-24024 October 1989 LER 89-019-00:on 890924,indication of High Temp for Reactor Coolant Pump RC-3A Upper Motor Thrust Bearing Received in Control Room.Caused by Damaged Cable for Bearing Resistive Temp Device.Damaged Cable replaced.W/891024 Ltr ML19325D2471989-10-13013 October 1989 LER 89-012-01:on 890502,main Feedwater Isolation Valve to Steam Generator a Found Inoperable Due to Improperly Set Torque Switch.Caused by Inadequate Program for Maint of Motor Operated Valves.Torque Switches reset.W/891013 Ltr ML20028C7711983-01-0606 January 1983 LER 82-020/03L-0:on 821207,during Main Steam Safety Valve Test,Four Main Steam Safety Valves Had Lift Setpoints Out of Tolerance.Caused by Normal Drift of Valves Over Operating Cycle.Valves Readjusted ML20028B5451982-10-28028 October 1982 LER 82-019/03L-0:on 821024,MSIVs HCV-1041A & HCV-1042A Stopped Three to Four Degrees Off Seat When Signaled to Close.Caused by Binding Between Valve Packing & Shaft. Packings Sprayed W/Penetrant Oil ML20052J0631982-04-27027 April 1982 LER 82-009/03L-0:on 820411,while Exchanging Component Cooling Water Heat Exchangers,Associated Outlet Valves HCV-490B,HCV-491B & HCV-492B Failed to Open.Cause Not stated.HCV-491B Reassembled & Tested ML20052B2361982-04-0707 April 1982 LER 82-006/03L-0:on 820323,during Surveillance Test ST-ISI- WD-1,F.1,valve HCV-506A Failed to Close Via Control Room Switch.Caused by Solenoid Valve Malfunction.Solenoid Valve Disassembled,Cleaned & Reassembled ML20052D9291982-04-0606 April 1982 LER 82-008/03L-0:on 820330,during Performance of ST-FW-1, F.2(b)(6)per Tech Spec 3.9,steam Driven Auxiliary Feedwater Pump Failed to Start.Caused by Back Pressure Trip Lever in Tripped Position.Lever Reset ML20041G1291982-02-22022 February 1982 LER 82-005/03L-0:on 820210,at 98% Power,Control Element 24 Inserted Into Core.Emergency Procedure EP-13,CEDM Malfunctions,Implemented & Power Stabilized at 88%.Caused by Erroneous Operating Instruction.Instruction Changed ML20041F7481982-02-17017 February 1982 LER 82-003/03L-0:on 820203,containment Isolation Valve Associated W/Gas Vent Header HCV-507A Failed to Close on Demand.Caused by Solenoid Valve Plunger Sticking in Energized Position.Plunger Freed ML20041F6251982-02-0505 February 1982 LER 82-004/03L-0:on 820203,small Quantity of Radioactive Gas/Particulate Released to Auxiliary Bldg During Routine Operation.Caused by Failure of Stack Gas Monitor RM-062 to Alarm at Appropriate Setpoint Due to Faulty Alarm Module ML20041B1051982-01-28028 January 1982 LER 82-002/03L-0:on 820114,at 99% Power,Lockout Relay 86B1, Containment Radiation High Signal,Failed to Actuate on Demand by Plant Radiation Monitoring Sys.Caused by Burnt Coil on Lockout Relay.Coil Replaced & Tested Satisfactorily ML20041B1171982-01-19019 January 1982 LER 82-001/03L-0:on 820111,during Normal Operation,Two Fire Barrier Penetrations Found Nonfunctional.Shift Supervisor Immediately Notified;However,Fire Watch Not Posted.Insp & Supervisor Personnel Instructed on Proper Actions ML20039B4561981-12-11011 December 1981 LER 81-011/03L-0:on 811113,containment Isolation Valves Opened & Ventilation Process Initiated W/Containment Air Monitor RM-050/051 Inoperable.Caused by Personnel Error. Valves Closed ML20010H8581981-08-27027 August 1981 LER 81-008/03L-0:on 810813,86B/CRHS (Containment Radiation High Signal) Lockout Relay Failed to Actuate When RM-062 Was Placed in Alarm,Resulting in Failure of 86B1/CRHS Relay to Actuate.Caused by Dirt in Relay Latching Mechanism ML20041F6291981-08-27027 August 1981 LER 81-008/03L-1:on 810813,containment Radiation High Signal 86B Lockout Relay Failed to Actuate When Radiation Monitor RM-062 Placed in Alarm.Caused by Bound Relay Latching Mechanism Due to Dirt & Grease.Latch Cleaned ML20010C2271981-07-0707 July 1981 LER 81-006/03L-0:on 810624,reactor Protection Sys Nuclear Power Recorder Channel B Trip Setpoints Determined to Be Nonconservative.Caused by Faulty Temp Change Power Calculation Due to Grounded Hot Leg Temp Loop ML20004B1111981-05-0606 May 1981 LER 81-005/03L-0:on 810423,dc Sequencer Timers AC-3A (Component Cooling Water Pump) & AC-102A (Raw Water Pump) Failed to Time Out within Prescribed Limit.Cause Unknown Mechanisms Satisfactorily Inspected 1993-07-30
[Table view] Category:RO)
MONTHYEARML20046C2121993-07-30030 July 1993 LER 93-004-01:on 930301,confirmed That Channel D Axial Shape Index (Asi) Being Calculated in Reverse Since 921031-930301 Due to Drawing Discrepancies Associated W/Control Channel B. Temporary Mod 92-078 & Standing Order 0-25 Revised ML20046A8691993-07-26026 July 1993 LER 93-011-00:on 930624,experienced Reactor Trip Due to Loss of Load.Caused by Lack of Proper Job Planning,Lack of Formal Decision Making Process & Incomplete Communications.Training Will Be Provided to Operations personnel.W/930726 Ltr ML20045H2561993-07-12012 July 1993 LER 93-010-00:on 930611,1 of 14 Halon Cylinders Did Not Meet Min Pressure Acceptance Criteria Listed in Semiannual Switchgear Rooms Surveillance Test.Caused by Failure of Test to Include Necessary Steps.Cylinder recharged.W/930712 Ltr ML20045D7201993-06-22022 June 1993 LER 93-009-00:on 930524,apparent Spurious Signal from Pressurizer Level Instrumentation Caused Backup Charging Pumps to Automatically Start,Due to Deterioration of Wiring. Instrument Loop Calibration Will Be performed.W/930622 Ltr ML20045D3741993-06-21021 June 1993 LER 93-008-00:on 930520,determined That TS SR Not Satisfied for Stack Flow Indicator,Per Amend 137 Issued on 910307. Caused by Lack of Attention to Detail.Calibr & Functional Test Procedures developed.W/930621 Ltr ML20044H5261993-06-0101 June 1993 LER 93-007-00:on 930430,unplanned Emergency Generator Start & Rt Signal Occurred.Caused by Inadequate Attention to Detail,Labeling of Fuse Drawers,Caution Signs & Training. Labeling & Caution Signs upgraded.W/930601 Ltr ML20044G4941993-05-26026 May 1993 LER 93-006-00:on 930118,Halon Fire Suppression Sys for Switchgear Rooms Disabled to Allow Repair/Replacement of Halon Sys Piping.On 930427,individual Responsible for Fire Watch Not Present.Individual Relieved of Responsibilities ML20044B6711993-02-22022 February 1993 LER 93-002-00:on 930122,determined That Current SG LP Signal Block Reset Values Greater than Allowed Ts.Caused by Improper Design.Test Procedures Will Be Revised by 930917 to Specify Desired Value for Block function.W/930222 Ltr ML20024G6821991-04-19019 April 1991 LER 91-007-00:on 910320,480 Volt Circuit Breaker Coordination Outside Design Basis.Caused by Deficiencies in Original Sys Design.Breaker/Fuse Coordination Study to Be Completed & Problems Will Be corrected.W/910419 Ltr ML20029C1591991-03-21021 March 1991 LER 91-004-00:on 910212,offsite Power Low Signal Outside Design Basis.Caused by Inadequate Mod Design at Time of Performance of Original Degraded Voltage Analysis. Engineering Analysis EA-FC-91-017 performed.W/910321 Ltr ML20029C1051991-03-18018 March 1991 LER 91-002-00:on 901209,ventilation Isolation Actuation Signal Generated by High Alarm on Process Radiation Monitor RM-062.Caused by Accumulation of Noncondensible Gases in Sample Piping.Valve Packing Leak repaired.W/910318 Ltr ML20029A2981991-02-0808 February 1991 LER 91-001-00:on 910109,determined That Containment Tendon Surveillances Performed in 1981 & 1985 Did Not Reflect Guidance in Tech Specs.Caused by Inadequate Administrative Controls.Testing Program Plan implemented.W/910208 Ltr ML20029A2971991-02-0606 February 1991 LER 90-022-02:on 900907,approx 460 Fire Barrier Penetration seals,60 Fire Dampers & 6 Fire Doors Declared Nonfunctional Per NRC Info Notice 88-004 Due to Lack of Documentation. Plant Outage Required to Implement Repairs/Replacements ML20028G9171990-09-28028 September 1990 LER 90-021-00:on 900829,inadvertent Reactor Protective Sys Actuation Occurred While Operator Changed Power Source. Caused by Operator Not Following Proper Procedures.Operator counseled.W/900928 Ltr ML20044B0131990-07-12012 July 1990 LER 90-018-00:on 900612,reactor Protective Sys (RPS) Trip Units for Axial Power Distribution Determined to Be Inoperable.Caused by Procedural Deficiencies.Procedure Revised & RPS Surveillance Tests reviewed.W/900712 Ltr ML20043F6301990-06-11011 June 1990 LER 90-016-00:on 900511,accident Scenarios Identified by Which Auxiliary Feedwater Piping from Discharge of Turbine Driven Auxiliary Feedwater Pump FW-10 Can Be Overpressurized.Caused by Design deficiency.W/900611 Ltr ML20043F2441990-06-0707 June 1990 LER 90-015-00:on 900507,PORV Variable Setpoints Used for Low Pressure Overpressure Protection Determined to Be Nonconservative for PORV Opening Time.Caused by Design Deficiency.Tech Spec Amend prepared.W/900607 Ltr ML20043C0991990-05-29029 May 1990 LER 90-014-00:on 900427,investigation Revealed That Component Cooling Water Piping to Reactor Coolant Pump Seal Coolers Could Be Targets of High Energy Line Break.Safety Analysis for Operability completed.W/900529 Ltr ML20042G7211990-05-10010 May 1990 LER 90-011-00:on 900402,inadvertent Actuation of Pressurizer Pressure Low Signal Occurred While Performing Calibr Procedure.Caused by Inappropriate Action by Technician Involved.Validation of Procedures reviewed.W/900510 Ltr ML20042E6871990-04-23023 April 1990 LER 90-007-01:on 900228,determined That Several Supports Would Be Overloaded During Seismic Event on Nonsafety Related & safety-related Main Steam Piping.Caused by Design Deficiency.Piping Supports modified.W/900423 Ltr ML20042E6861990-04-23023 April 1990 LER 90-009-00:on 900316,potential Overpressurization of Auxiliary Feedwater Piping Could Have Occurred During Thermal Expansion of Process Fluid Between Closed Valved. Caused by Design deficiencies.W/900423 Ltr ML20012E7641990-03-26026 March 1990 LER 90-005-00:on 900223,determined That Spent Fuel Pool Area Charcoal Filtration Unit VA-66 Was Outside Design Basis. Caused by Insufficient Airflow Into Unit.Affected Updated SAR Analysis Will Be updated.W/900326 Ltr ML20012D0121990-03-19019 March 1990 LER 90-004-00:on 900217,lift Pressures for 6 of 10 Main Steam Safety Valves Found Outside Acceptance Criteria. Caused by Overly Restrictive Operability Criteria.Valves Recalibr & License Amend Submitted to NRC.W/900319 Ltr ML20012D0101990-03-19019 March 1990 LER 90-003-00:on 900216,determined That Auxiliary Feedwater Piping Outside Normal Stress Limits of ASME Code & Design Basis Specified in Updated Sar.Caused by Design Deficiency.Valve Operators Will Be inspected.W/900319 Ltr ML20012B6361990-03-0909 March 1990 LER 89-017-01:on 890624,internal Valve Component from Check Valve Found Lying on Pump Discharge Vane.Repair or Replacement of Valve Internals Could Not Be Accomplished within Time Requirement of Tech Spec.W/900309 Ltr ML20006E1041990-02-0909 February 1990 LER 90-001-00:on 900108,fire Barrier for Wall Between Auxiliary Bldg Rooms 26 & 34 Breached But Hourly Fire Watch Patrol Not Established.Caused by Lack of Sufficient Training for Shift Supervisors.Standing Order revised.W/900209 Ltr ML20011E2691990-02-0505 February 1990 LER 89-024-00:on 891221,determined That Containment Spray Pumps & Suction Header Piping Not Constructed for Use as Backup to LPSI Sys for Shutdown Cooling.Caused by Inadequate Review of Assumptions.Firewatch established.W/900205 Ltr ML20011E2271990-02-0101 February 1990 LER 89-021-00:on 891010,util Informed by C-E of Potential Nonconservative Setpoint in Reactor Protection Sys Thermal Margin/Low Pressure Trip Unit.Caused by Error in Incorporating Transient Setpoint analyses.W/900201 Ltr ML20005F7151990-01-10010 January 1990 LER 89-023-00:on 891211,hourly Firewatch Patrol Entered Posted High Radiation Area W/O Meeting Entry Requirements for Area.Briefings on High Radiation Entry Requirements Held for Personnel W/Assigned dosimetry.W/900110 Ltr ML19354D6381989-12-20020 December 1989 LER 89-022-00:on 890805,change to Surveillance Procedure ST-CEA-1 Became Effective Which Would Have Made Both Emergency Diesel Generators Simultaneously Inoperable During Portion of Test.Change removed.W/891220 Ltr ML19332E7431989-12-0808 December 1989 LER 88-037-01:on 881214,one of Two Supply Headers Supplying Fire Suppression Headers in Auxiliary Bldg Isolated.Caused by Lack of Procedural Guidance & Inadequate Procedural Controls.Standing Order G-58 Will Be revised.W/891208 Ltr ML19332E2681989-12-0101 December 1989 LER 89-016-02:on 890616,for Unknown Period Since 890614, Auxiliary Feedwater Pump FW-10 Operated Outside Design Basis for Certain Accident Conditions.Caused by Inoperable Speed Control Loop.Action Plan implemented.W/891201 Ltr ML19351A4541989-11-22022 November 1989 LER 89-020-00:on 891012,determined That Two of Four Component Cooling Water HXs Simultaneously Inoperable for More than 24 H.Caused by Inadequate Controls Re Return of Equipment to Svc.Standing Order revised.W/891122 Ltr ML19327B5481989-10-24024 October 1989 LER 89-019-00:on 890924,indication of High Temp for Reactor Coolant Pump RC-3A Upper Motor Thrust Bearing Received in Control Room.Caused by Damaged Cable for Bearing Resistive Temp Device.Damaged Cable replaced.W/891024 Ltr ML19325D2471989-10-13013 October 1989 LER 89-012-01:on 890502,main Feedwater Isolation Valve to Steam Generator a Found Inoperable Due to Improperly Set Torque Switch.Caused by Inadequate Program for Maint of Motor Operated Valves.Torque Switches reset.W/891013 Ltr ML20028C7711983-01-0606 January 1983 LER 82-020/03L-0:on 821207,during Main Steam Safety Valve Test,Four Main Steam Safety Valves Had Lift Setpoints Out of Tolerance.Caused by Normal Drift of Valves Over Operating Cycle.Valves Readjusted ML20028B5451982-10-28028 October 1982 LER 82-019/03L-0:on 821024,MSIVs HCV-1041A & HCV-1042A Stopped Three to Four Degrees Off Seat When Signaled to Close.Caused by Binding Between Valve Packing & Shaft. Packings Sprayed W/Penetrant Oil ML20052J0631982-04-27027 April 1982 LER 82-009/03L-0:on 820411,while Exchanging Component Cooling Water Heat Exchangers,Associated Outlet Valves HCV-490B,HCV-491B & HCV-492B Failed to Open.Cause Not stated.HCV-491B Reassembled & Tested ML20052B2361982-04-0707 April 1982 LER 82-006/03L-0:on 820323,during Surveillance Test ST-ISI- WD-1,F.1,valve HCV-506A Failed to Close Via Control Room Switch.Caused by Solenoid Valve Malfunction.Solenoid Valve Disassembled,Cleaned & Reassembled ML20052D9291982-04-0606 April 1982 LER 82-008/03L-0:on 820330,during Performance of ST-FW-1, F.2(b)(6)per Tech Spec 3.9,steam Driven Auxiliary Feedwater Pump Failed to Start.Caused by Back Pressure Trip Lever in Tripped Position.Lever Reset ML20041G1291982-02-22022 February 1982 LER 82-005/03L-0:on 820210,at 98% Power,Control Element 24 Inserted Into Core.Emergency Procedure EP-13,CEDM Malfunctions,Implemented & Power Stabilized at 88%.Caused by Erroneous Operating Instruction.Instruction Changed ML20041F7481982-02-17017 February 1982 LER 82-003/03L-0:on 820203,containment Isolation Valve Associated W/Gas Vent Header HCV-507A Failed to Close on Demand.Caused by Solenoid Valve Plunger Sticking in Energized Position.Plunger Freed ML20041F6251982-02-0505 February 1982 LER 82-004/03L-0:on 820203,small Quantity of Radioactive Gas/Particulate Released to Auxiliary Bldg During Routine Operation.Caused by Failure of Stack Gas Monitor RM-062 to Alarm at Appropriate Setpoint Due to Faulty Alarm Module ML20041B1051982-01-28028 January 1982 LER 82-002/03L-0:on 820114,at 99% Power,Lockout Relay 86B1, Containment Radiation High Signal,Failed to Actuate on Demand by Plant Radiation Monitoring Sys.Caused by Burnt Coil on Lockout Relay.Coil Replaced & Tested Satisfactorily ML20041B1171982-01-19019 January 1982 LER 82-001/03L-0:on 820111,during Normal Operation,Two Fire Barrier Penetrations Found Nonfunctional.Shift Supervisor Immediately Notified;However,Fire Watch Not Posted.Insp & Supervisor Personnel Instructed on Proper Actions ML20039B4561981-12-11011 December 1981 LER 81-011/03L-0:on 811113,containment Isolation Valves Opened & Ventilation Process Initiated W/Containment Air Monitor RM-050/051 Inoperable.Caused by Personnel Error. Valves Closed ML20010H8581981-08-27027 August 1981 LER 81-008/03L-0:on 810813,86B/CRHS (Containment Radiation High Signal) Lockout Relay Failed to Actuate When RM-062 Was Placed in Alarm,Resulting in Failure of 86B1/CRHS Relay to Actuate.Caused by Dirt in Relay Latching Mechanism ML20041F6291981-08-27027 August 1981 LER 81-008/03L-1:on 810813,containment Radiation High Signal 86B Lockout Relay Failed to Actuate When Radiation Monitor RM-062 Placed in Alarm.Caused by Bound Relay Latching Mechanism Due to Dirt & Grease.Latch Cleaned ML20010C2271981-07-0707 July 1981 LER 81-006/03L-0:on 810624,reactor Protection Sys Nuclear Power Recorder Channel B Trip Setpoints Determined to Be Nonconservative.Caused by Faulty Temp Change Power Calculation Due to Grounded Hot Leg Temp Loop ML20004B1111981-05-0606 May 1981 LER 81-005/03L-0:on 810423,dc Sequencer Timers AC-3A (Component Cooling Water Pump) & AC-102A (Raw Water Pump) Failed to Time Out within Prescribed Limit.Cause Unknown Mechanisms Satisfactorily Inspected 1993-07-30
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML20217B5401999-10-0606 October 1999 Safety Evaluation Supporting Amend 193 to License DPR-40 ML20217A9931999-09-30030 September 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data LIC-99-0096, Monthly Operating Rept for Sept 1999 for Fcs,Unit 1.With1999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for Fcs,Unit 1.With ML20211J9321999-09-0202 September 1999 Safety Evaluation Concluding That Licensee Proposed Alternatives Provide Acceptable Level of Quality & Safety. Proposed Alternatives Authorized for Remainder of Third ten- Yr ISI Interval for Fort Calhoun Station,Unit 1 LIC-99-0084, Monthly Operating Rept for Aug 1999 for Fort Calhoun Station.With1999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Fort Calhoun Station.With ML20216E6431999-08-26026 August 1999 Rev 19 to TDB-VI, COLR for FCS Unit 1 ML20210R1961999-07-31031 July 1999 Monthly Operating Rept for July 1999 for Fcs,Unit 1 ML20210G2181999-07-27027 July 1999 Safety Evaluation Supporting Amend 192 to License DPR-40 ML20210D9951999-07-22022 July 1999 Safety Evaluation Supporting Amend 191 to License DPR-40 ML20216E6361999-07-21021 July 1999 Rev 18 to TDB-VI, COLR for FCS Unit 1 ML20210R2081999-06-30030 June 1999 Revised Monthly Operating Rept for June 1999 for Fcs,Unit 1 LIC-99-0065, Monthly Operating Rept for June 1999 for Fort Calhoun Station,Unit 1.With1999-06-30030 June 1999 Monthly Operating Rept for June 1999 for Fort Calhoun Station,Unit 1.With ML20196H8621999-06-30030 June 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data, June 1999 Rept ML20210P5461999-06-0808 June 1999 Rev 0,Vols 1-5 of Fort Calhoun Station 1999 Emergency Preparedness Exercise Manual, to Be Conducted on 990810. Pages 2-20 & 2-40 in Vol 2 & Page 4-1 in Vol 4 of Incoming Submittal Not Included ML20195B4581999-05-31031 May 1999 Rev 3 to CE NPSD-683, Development of RCS Pressure & Temp Limits Rept for Removal of P-T Limits & LTOP Requirements from Ts ML20207H7401999-05-31031 May 1999 Performance Indicators Rept for May 1999 LIC-99-0053, Monthly Operating Rept for May 1999 for Fort Calhoun Station,Unit 11999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Fort Calhoun Station,Unit 1 ML20195B4521999-05-17017 May 1999 Technical Data Book TDB-IX, RCS Pressure - Temp Limits Rept (Ptlr) ML20206L4241999-05-10010 May 1999 Safety Evaluation Supporting Corrective Actions to Ensure That Valves Are Capable of Performing Intended Safety Functions & OPPD Adequately Addressed Requested Actions Discussed in GL 95-07 ML20206M2601999-05-0606 May 1999 SER Concluding That Licensee IPEEE Complete Re Info Requested by Suppl 4 to GL 88-20 & IPEEE Results Reasonable Given FCS Design,Operation & History LIC-99-0047, Monthly Operating Rept for Apr 1999 for Fort Calhoun Station Unit 1.With1999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for Fort Calhoun Station Unit 1.With ML20195E8621999-04-30030 April 1999 Performance Indicators, for Apr 1999 ML20205Q5831999-04-15015 April 1999 Safety Evaluation Supporting Amend 190 to License DPR-40 ML20210J4331999-03-31031 March 1999 Changes,Tests, & Experiments Carried Out Without Prior Commission Approval for Period 981101-990331.With USAR Changes Other than Those Resulting from 10CFR50.59 ML20206G2641999-03-31031 March 1999 Performance Indicators Rept for Mar 1999 LIC-99-0034, Monthly Operating Rept for Mar 1999 for Fcs,Unit 1.With1999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for Fcs,Unit 1.With ML20205J8181999-02-28028 February 1999 Performance Indicators, for Feb 1999 LIC-99-0025, Monthly Operating Rept for Feb 1999 for Fort Calhoun Station,Unit 1.With1999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for Fort Calhoun Station,Unit 1.With ML20207F3291999-01-31031 January 1999 FCS Performance Indicators for Jan 1999 ML20203B0991998-12-31031 December 1998 Performance Indicators for Dec 1998 LIC-99-0026, 1998 Omaha Public Power District Annual Rept. with1998-12-31031 December 1998 1998 Omaha Public Power District Annual Rept. with LIC-99-0003, Monthly Operating Rept for Dec 1998 for Fort Calhoun Station.With1998-12-31031 December 1998 Monthly Operating Rept for Dec 1998 for Fort Calhoun Station.With ML20198S3771998-12-31031 December 1998 Safety Evaluation Supporting Amend 189 to License DPR-40 ML20198S4831998-12-31031 December 1998 Safety Evaluation Supporting Amend 188 to License DPR-40 ML20196G2251998-12-18018 December 1998 Rev 2 to EA-FC-90-082, Potential Over-Pressurization of Containment Penetration Piping Following Main Steam Line Break in Containment ML20198M3141998-11-30030 November 1998 Performance Indicators Rept for Nov 1998 LIC-98-0172, Monthly Operating Rept for Nov 1998 for Fort Calhoun Station,Unit 1.With1998-11-30030 November 1998 Monthly Operating Rept for Nov 1998 for Fort Calhoun Station,Unit 1.With LIC-98-0160, Special Rept:On 981113,MSL RM RM-064 Was Declared Inoperable Due to Leakage Past Isolation Valve HCV-922.Troubleshooting Has Indicated That Leakage Has Stopped & Cause of Leak Continues to Be Investigated1998-11-25025 November 1998 Special Rept:On 981113,MSL RM RM-064 Was Declared Inoperable Due to Leakage Past Isolation Valve HCV-922.Troubleshooting Has Indicated That Leakage Has Stopped & Cause of Leak Continues to Be Investigated ML20203B0721998-11-16016 November 1998 Rev 6 to HI-92828, Licensing Rept for Spent Fuel Storage Capacity Expansion ML20196E4981998-10-31031 October 1998 Performance Indicators Rept for Oct 1998 ML20196G2441998-10-31031 October 1998 Changes,Tests & Experiments Carried Out Without Prior Commission Approval. with USAR Changes Other than Those Resulting from 10CFR50.59 LIC-98-0154, Monthly Operating Rept for Oct 1998 for Fort Calhoun Station,Unit 1.With1998-10-31031 October 1998 Monthly Operating Rept for Oct 1998 for Fort Calhoun Station,Unit 1.With ML20154M4881998-10-19019 October 1998 Safety Evaluation Supporting Amend 186 to License DPR-40 ML20154N2411998-10-19019 October 1998 Safety Evaluation Supporting Amend 187 to License DPR-40 LIC-98-0136, Monthly Operating Rept for Sept 1998 for Fort Calhoun Station,Unit 1.With1998-09-30030 September 1998 Monthly Operating Rept for Sept 1998 for Fort Calhoun Station,Unit 1.With ML20155G4261998-09-30030 September 1998 Performance Indicators for Sept 1998 ML20154A1251998-08-31031 August 1998 Performance Indicators, Rept for Aug 1998 LIC-98-0122, Monthly Operating Rept for Aug 1998 for Fort Calhoun Station Unit 1.With1998-08-31031 August 1998 Monthly Operating Rept for Aug 1998 for Fort Calhoun Station Unit 1.With ML20238F7231998-08-17017 August 1998 Owner'S Rept for Isis ML18066A2771998-08-13013 August 1998 Part 21 Rept Re Deficiency in CE Current Screening Methodology for Determining Limiting Fuel Assembly for Detailed PWR thermal-hydraulic Sa.Evaluations Were Performed for Affected Plants to Determine Effect of Deficiency 1999-09-30
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Omaha Public Power District P.O. Box 399 Hwy.75- North of Ft.Calhoun Fort Calhoun, NE 68C'234399 402/636-2000 July 26, 1993 LIC-93-0190 U. S. Nuclear Regulatory Commission ,
Attn: Document Control Desk '
Mail Station P1-137 Washington, DC 20555
Reference:
Docket No. 50-285 Gentlemen:
Subject:
Licensee Event Report 93-011 for the Fort Calhoun Station Please find attached Licensee Event Report 93-011 dated July 26, 1993. This report is being submitted pursuant to 10 CFR 50.73(a)(2)(iv). If you should have any questions, please contact me. ;
Sincerely, 9 n t. '
k .'h'O]. A y
( W.Vice G. Gates President WGG/jrg i Attachment c: J. L. Milhoan, NRC Regional Administrator, Region IV !
- 5. D. Bloom, NRC Project Manager i R. P. Mullikin, NRC Senior Resident Inspector INPO Records Center i
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FACE.mr NAME (1) DOCKET NUMBER R PAGE p)
Fort Calhoun Station Unit No. 1 05000285 1 OF 10 men Reactor Trip on Loss of Load During Switchyard Maintenance EVENT DATE (5) LER NUMBER (S) REPORT NUMBER (7) OTHER FACIUTIES INVOLVED (S)
SEQUENTAL REVISON f AClurY NAME DOCKET NUMBER NuMaER NuuBE" 05000 FACIUTY NAME DOCKET NUMBER 06 24 93 93 --
011 --
00 07 26 93 05000 OPERATING THIS REPORT IS SUBMITTED PURStP8T TO THE REQUIREMENTS OF 10 CFR 8: (Check one or more) (11) 1 MODE (9) 20.402(b) 20.405(c) X 50.73(a)(2)(iv) 73.71(b)
POWER 20.405(a)(1)(i) 50.36(c)(1) 50.73(a)(2)(v) 73.71(c)
LEVEL (10) 100 20 405(a)(1)m) 50 as(c)(2) 50.73(a)(2)(vii) OTHER 20.405(a)(1)(iii) 50.73(a)(2)(i) 50.73(a)(2)(viii){A) (Ss* city in Atatract 20.405(a)(1)(iv) 50.73(a)(2)(li) 50.73(a)(2)(viii)(B) 20.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x) i UCENSEE CONTACT FOR THIS LER (12)
NAME TELEPHONE NUMBER (include Area Cooe)
Craig E. Booth, Shift Technical Advisor (402) 533-6874 COMPLETE ONE UNE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)
CAusE sYsTEu COMPONENT MANUFACTURER g CAUSE SYSTEM COMPONENT MANUFACTURER O X EA 27 A109 Y X SJ P B580 Y X SD RV K235 Y SUPPLEMENTAL REPORT EXPECTED (14) MONm DAY YEAR EXPECTED yea SUBMISSION p ye., comshte EXPECTED SUBMsSSON DATE) X
ABSTRAOT (Umit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (16)
On June 24, 1993 at 1322, the Fort Calhoun Station (FCS) experienced a reactor trip due to a Loss of Load. Work was in progress in the FCS switchyard involving Type SBFU Static Circuit Breaker Failure Relays, when a door mounted Type AR relay was inadvertently actuated. This, in turn, tripped two breaker failure lock-out relays, which resulted in opening of station output breakers and de-energized both 4.16kV non-vital buses. One non-vital bus failed to properly load shed on the loss of voltage, and as a result breakers remained closed on the bus even though the bus was de-energized. Initial Operator actions, based on Control Room indications that these '
breakers were closed, resulted in a short-term interruption of feedwater and condensate i flow.
This event was determined to have resulted from lack of proper job planning, lack of a formal decision making process, incomplete communications and inadequate implementation of a procedure. l l
Corrective actions include actions to improve the conduct of work within the switchyard, i and training for Operations personnel on use of all available indications in decision l making. l i
l NRC FORM 308 {5-92)
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FACR.!TY NAME 0) DOOKET WJMBER p) LER NUMBER R PAGE @
g SEQUENTIAL REVISON NUMBER NUMBER Fort Calhoun Station Unit No. 1 05000285 2 OF 10 93 -- 011 -- 00 Terr p ma,e spee m reased, use addmonal copies of NRC Form 300A) 07)
BACKGROUND The Fort Calhoun Station (FCS) Main Generator supplies 22kV power to the Main Transformer T1 and to the two Unit Auxiliary Transformers TIA-1 and T1A-2 (see Figure 1). Transformer T1 steps 22kV power from the main generator up to 345kV which is then supplied to the Midcontinent Area Power Pool (MAPP) grid. FCS is connected to the grid via a ring bus in the station switchyard. Connections to three 345kV transmission lines are provided by the ring bus, each of which has the capacity to carry the station output. Breaker arrangement allows each line, as well as FCS, to be isolated from the ring bus. The normal output arrangement has FCS connected to the ring bus via both output breakers, 3451-4 and 3451-5, and all 345kV lines available. Either Breaker 3451-4 or Breaker 3451-5 can be open with the station operating at or above 15%
of rated power. If both breakers are opened above 15% power, a Loss of Load reactor ;
trip will be initiated.
Breakers 3451-4 and 3451-5 each have associated breaker failure relays. These relays are intended to isolate the affected breaker and de-energize all sources that could '
potentially feed into the failed breaker. For Breaker 3451-5, one breaker failure lock-out relay, 86-1/BF5 trips 345kV Breakers 3451-4 and 3451-6, and sends a direct transfer trip to isolate the remote end of Circuit 3424. The second lock-out relay, 86-2/BF5 trips Generator Field Breaker 41E/G1F, Turbine Master Trip 94 MTR, and 4.16kV Breakers 1All, 1A13, 1A22, and 1A24.
The two Unit Auxiliary Transformers, TIA-1 and T1A-2, step down the 22kV power supplied by the Main Generator to 4.16kV. These transformers are the normal power supplies for non-vital 4.16kV Buses 1A1 and 1A2 respectively. The normal power supply for the two vital 4.16kV buses, IA3 and 1A4, is an offsite 161kV line. Although the normal alignment has the non-vital buses supplied from 22kV and the vital buses supplied from 161kV, various arrangements are possible, including all four 4.16kV buses being supplied ,
from 161kV.
EVENT DESCRIPTION OPPD received a Product Advisory Letter dated May 19, 1993, from ASEA Brown Boveri (ABB) that outlined the results of an investigation into a false trip of a Type SBFU Static Circuit Breaker Failure Relay. The letter indicated that a false trip could be caused by an unintentional ground of one or more ZA/RC Zener diode / resistor circuits. The ABB letter indicated that accidental grounding of the components discussed could be prevented by affixing Nomex insulation with an adhesive backing inside the SBFU top cover. In response to the ABB Product Advisory Letter, the OPPD System Protection Department issued work orders to install Nomex insulation in all Type SBFU relays, including five located in the FCS switchyard.
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NRC FORM 306A '
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FAcrJTY NAME (1) DOOKET NUMBER (4 LER NUMBEM M PAGE R SEQUENTIAL REVLSON g
NUMBER NUMBER Fort Calhoun Station Unit No. 1 05000285 3 OF 10 93 -- 011 -- 00 TDCT pf rnore space e requuma, use additbnal copies of NRO Form 366A) (17)
On June 24, 1993, the plant was operating in Mode 1 at a nominal 100's power. The 4.16kV !
buses were in a normal alignment with non-vital Buses 1A1 and 1A2 being powered from 22kV, and vital Buses 1A3 and 1A4 being powered from offsite 161kV. Loading on the 4.16kV buses included the following components:
Bus 1A1 Reactor Coolant Pump RC-3A, Condensate Pump FW-2A, Circulating Water Pump CW-1A '.
Bus 1A2 Reactor Coolant Pump RC-3B, Condensate Pump FW-2B, Feedwater Pump FW-48, Circulating Water Pump CW-1B Bus IA3 Reactor Coolant Pump RC-3C, Raw Water Pump AC-10A Bus 1A4 Reactor Coolant Pump RC-3D, Feedwater Pump FW-4C, Circulating Water Pump CW-1C, Raw Water Pump AC-108.
Buses 1A3 and 1A4 were also supplying the 480V and lower buses in a normal electrical lineup.
At approximately 1245, a Senior Relay Specialist (SRS) and a Dispatching Department Trainee contacted the FCS Control Room via telephone and informed them that they would be working in the switchyard. The nature of the work to be performed, installation of Nomex insulation, was not specifically discussed. The Control Room Operator believed this involved continuation of work, on a non-plant related transformer, which had been started earlier in the day.
After successfully installing Nomex in the Type SBFU Relay for Breaker 3451-6, the SRS proceeded to open the back door of the Type SBFU Relay for Breaker 3451-5. While opening the door, the SRS found the door latch to be "a little tight." Using the same manner as for the previous relay, the SRS operated the door knob button, while the other hand was holding the door surface, and opened the door with both hands. The SRS knew that there was a sensitive Type AR relay mounted on the back side of the door of the Type SBFU Breaker Relay Unit.
As the SRS opened the cabinet door, he heard breakers operate. The motion of operating the door knob button and opening the door apparently caused a localized vibration on the door, closing the contacts of the Type AR relay and tripping Breaker Failure Lock-out Relays 86-1/BF5 and 86-2/BF5. The tripping of the breaker failure lock-out relays resulted in additional actuations which isolated FCS from the grid, isolated the non-vital 4.lokV buses from the Unit Auxiliary Transformers, and initiated a turbine trip and reactor trip. The reactor trip, on Loss of Load, was received at 1322.
Non-vital Buses 1A1 and 1A2 which had been receiving power from the Unit Auxiliary Transformers, were de-energized. Vital Buses 1A3 and 1A4 remained energized.
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FACUTY NAME (1) DOCKET NLMBER R LER NUMBER R PAGE R g SEQUENDAL REVISON NUMBER NUMBER Fort Calhoun Station Unit No. 1 05000285 4 OF 10 93 -- 011 -- 00 Ton e mo,. .p ..o. .ooii.o,.i .op on NRc rom, aeoA> cir3 The loss of voltage on Bus 1A1 resulted in initiation of a load shed signal which opened breakers on Bus 1A1. The corresponding load shed signal for Bus 1A2 failed to actuate.
As a result, the breakers for loads on Bus 1A2 remained closed and the control switch lights in the Control Room indicated that the breakers were closed on the bus.
As a result of the loss of power to Buses 1Al and 1A2, two of four reactor coolant pumps, both running condensate pumps, and one of the two operating feedwater pumps, were de-energized. The third condensate pump, FW-2C, powered from Bus 1A4, automatically started. Both Emergency Diesel Generators started to idle speed and did not load.
Charging Pump CH-1C started due to level deviation in the pressurizer. The Emergency Diesel Generator and charging pump starts were normal and expected responses for this transient.
In response to the reactor trip the Control Room operators immediately entered Emergency Operating Procedure E0P-00, " Reactor Trip Recovery." As part of the standard post-trip actions, at approximately 1323, the Secondary Reactor Operator (RO) selected one feedwater pump and one condensate pump for operation. The R0 selected FW-4B and FW-28 as the pumps for operation and secured FW-4C and FW-2C. This selection of pumps was based on operator training which indicated that FW-48 and FW-2B are the preferred pumps for operation, if available. The Secondary R0 was using only the breaker indication (which showed the breakers for FW-4B and FW-2B were closed on Bus 1A2) when making the selection and did not realize that Bus 1A2 and its associated equipment was de-energized.
At 1326, the Secondary R0 noted that Steam Generator (SG) levels were not recovering as expected. The Secondary R0 determined that no feedwater pumps were in operation. The Operator then started Auxiliary Feedwater Pump FW-6 and re-established feedwater flow from the Emergency Feedwater Storage Tank, through the main feedwater feedring, into the SGs. Feedwater flow was re-established well before an automatic actuation of auxiliary feedwater would be received.
At approximately 1337, the Control Room received a report of steam in the vicinity of Feedwater Heater FW-15A. Non-licensed and relief shift personnel were dispatched to FW-15A to determine the cause. Feedwater Heater Relief Valve FW-1425 was found to have lifted and stuck open. The situation was reported to the Control Room, and actions were taken to isolate the feedwater heater.
The diagnostic actions at the conclusion of E0P-00 were completed and at approximately 1339, E0P-02, " Loss of Offsite Power / Loss of Forced Circulation," was entered.
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011 -- 00 Tm p ,no,. .-. . w,.a. .oaition y.. ., Nac ro,m 3osA> cir3 At approximately 1340, the Control Room began to receive reports of water hammer in the turbine building. The Licensed Senior Operator (LS0) directed the Secondary RO to restart FW-2C, which had been secured during the post trip actions. At approximately 1343, FW-2C was restarted, terminating the water hammer. <
l Feedwater pump seal leakage was also reported to the Control Room during the event. l l
At approximately 1354, Buses 1Al and 1A2 were re-energized. The plant was maintained in !
Hot Shutdown (Mode 3). At 1830, with the plant condition stable, power restored to l 4.16kV Buses 1A1 and 1A2, and the exit conditions for E0P-02 satisfied, the Emergency Operating Procedures were exited.
The NRC was notified of the event on June 24, 1993 at 1421, pursuant to l 10 CFR 50.72(b)(2)(ii). This report is being submitted pursuant to 10 CFR 50.73(a)(2)(iv).
SAFETY ASSESSMENT This event resulted in an actuation of the Reactor Protective System, and a loss of !
power to non-vital 4.16kV buses. It did not, however, pose a danger to the public. !
Loss of Load is an analyzed plant transient and plant response was within the predicted i response parameters.
Equipment challenges that occurred during the course of the event (i.e., loss of power to non-vital 4.16kV buses, failure of Bus 1A2 to load shed, Feedwater Heater Relief Valve FW-1425 sticking open, water hammer in the vicinity of the Steam Packing Exhauster and damage to feedwater pump seals) did not affect the ability to safely shut down the reactor and maintain the reactor in a safe shutdown condition. The Class 1E safety-related 4.16kV buses (1A3 and 1A4) were not affected by the event. The 161kV power source continued to supply power throughout the event to the Class 1E buses and, in addition, the Emergency Diesel Generators started and were available for service.
CONCLUSIONS The post-event investigation addressed both the cause of the Loss of Load and several issues regarding the plant response to the event. The investigation included a Human Performance Enhancement System (HPES) evaluation which focused on switchyard activities, and a Root Cause Analysis (RCA) which focused on several aspects of the plant response to the event.
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TEXT pt more space a requued une adoluoned copies of NRC Form 306A) (17) l The HPES evaluation indicated that the event resulted from inappropriate action, in that opening the door to the Type SBFU relay apparently jarred the Type AR relay which subsequently actuated the lock-out relays. Four causes of the inappropriate action were identified: l 1
- 1. Lack of proper job planning, in that test switches were not placed in the open !
position to disable the output of the lock-out relays,
- 2. Lack of a formal decision making process on what work should/can be done on-line,
- 3. Incomplete communications between personnel in the switchyard and personnel in the Control Room, and
- 4. Inadequate implementation of procedure N0D-QP-36, " Control of Switchyard Activities at Fort Calhoun Station." l With respect to the plant response to the event, the RCA addressed five specific issues.
The first issue addressed by the RCA was to investigate whether non-vital Buses IA1 and ,
IA2 should have automatically transferred to the 161kV power supply following loss of !
the 22kV power supply. Circuitry is provided for two types of automatic transfer, l
" Fast" transfer (designed to occur within 6 to 8 cycles) and " Slow" transfer (designed '
to occur within seven seconds). The review determined that there was no failure in the automatic transfer circuitry.
I Specifically, fast transfer did not occur because station output breakers and the !
generator field breaker were tripped as a result of Breaker Failure Lock-out Relays 86-1/BF5 and 86-2/BF5 being tripped. This prevented the turbine trip lock-out relay 86-1/SVG1 from actuating and, by design, prevented fast transfer. This is to ensure that the buses will not be transferred into a fault as sensed by the breaker failure relays. '
The slow transfer circuitry was also found to have functioned as designed. Two conditions required for a successful slow transfer are a load shed, and the connected source must be de +nergized within a seven second window. The investigation revealed that the auxiliary uniervoltage relays associated with slow transfer did not actuate until the seven secord window had elapsed. This was because the coast-down of the main generator and the irepedance of the transformer load delayed the decay of the secondary transformer voltage mtil the seven second window was closed. In addition, for Bus IA2, l the failure to load shed would have prevented the slow transfer.
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SEQUENTlAL REVISION MR NUMBER NUMBER Fort Calhoun Station Unit No. 1 05000285 7 OF 10 93 -- 011 -- 00 nx1 m. .P- . . .aaiion .on. on Nec ro,m seeA3 05 The second issue addressed by the RCA was the failure of Bus IA2 to load shed after it was de-energized. The failure of Bus 1A2 to load shed could not be reproduced during troubleshooting. Three functional tests of the load shed circuitry were performed and all sensing and actuation relays functioned properly. No abnormalities in the sensing or actuation circuitry were identified. It has been postulated that the Agastat timing relay (27T1/1A2) output contact may have been dirty, thus preventing Bus 1A2 load shed. ,
However, that relay did function properly in subsequent functional tests. The design of i the loss of voltage load shed circuitry for the non-vital buses (1A1 and 1A2) provides less built-in redundancy than circuitry for the vital buses (IA3 and 1A4).
The third issue addressed by the RCA was the failure of relief valve FW-1425 to reseat.
Valve FW-1425 was bench tested to determine the lift setpoint and then inspected to determine why it did not reseat. Th_ bench test showed that no drift '.n setpoint had occurred. The valve lifted at 700 psig as designed. Inspection of the internals j revealed that the failure to reseat was due to a possible misalignment of the disk, stem -
and disk guide; and interference between the disk and the disk guide due to foreign material buildup on moving surfaces.
The fourth issue addressed by the RCA was the occurrence of water hammer in the Condensate System in the vicinity of the Steam Packing Exhauster (SPE). During the event, the Secondary R0 inappropriately tripped the only operating condensate pump.
This action resulted from over-reliance on a single indication (i.e., the breaker i
position indications). The indication used was accurate in that the pump motor breaker was closed on the bus, but misleading in that the bus was not energized. The failure of Bus 1A2 to properly load shed resulted in this situation.
With condensate flow stopped, the water in the SPE tube bundle started to boil. The steam void rose from the SPE until it contacted cooler water in the condensate system.
This collapsed the steam void and accelerated water back towards the SPE. Since the SPE l is the only condensate system component in the area that is anchored (others are free to l move due to thermal expansion / contraction experienced during startup and shutdown) it '
experienced the most damage.
The only identified damage to thc SPE was one broken anchor bolt. The remaining anchor bolts were determined to be adequate to ensure proper operation of the SPE. The inspections made showed that no observable deformation of the piping occurred. The riping movements were judged to be within reasonable limits. Additionally the condensate, main feedwater, and main steam systems were walked down with no additional damage discovered.
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NRo FORM 306A U.S. NUCL EAR REGULATORY CCMMISSION AFPROVED BY OMB NO. 315o4104
~
tem . EXPIRES 5/31/95 ESTIMATED DURDEN PER RESPONSE TO COMPLY WITH THIS m OUt Qy^
LICENSEE EVENT REPORT (LER) gy;ON_COLLE u E
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"uMT::"Nalia%""N&' .W"AT FMXRY NAME (t) DOCKET NUMBER M LER NUMBER M PAGE M yggg sEOUENTIAL HEVISON NUMBER NUMBER Fort Calhoun Station Unit No. 1 05000285 93 -- 011 -- 00 Text ,,oo . . quw. .oomom.o .oP oe Nrc ro,m soo43 ciri-The fifth and final issue addressed by the RCA was the failure of Feedwater Pump FW-4B seals. The seals to FW-4B failed due to a combination of aging and a spike in the feedwater header pressure. The spike occurred when the Secondary R0 established auxiliary feedwater to the Steam Generators. The seals were near the end of their service life at the time of failure and therefore susceptible to failure due to pressure shocks. The failure of these seals was determined to be insignificant to this event. ,
CORRECTIVE ACTIONS With respect to the switchyard activities that initiated the event, the following corrective actions have been or will be completed:
- 1. A memorandum was issued to Operations personnel regarding management expectations with respect to switchyard activities, emphasizing the requirements of NOD-QP-36. Also, on-shift training was provided to Licensed Operators on N00-QP-36.
- 2. Appropriate Electric Operations Division personnel have been briefed on the ,
requirements of N00-QP-36. i 1
- 3. System Operation Danger Tags have been placed on switchyard cabinets that .
contain Type AR relays. These tags will be replaced with permanent tags during the next refueling outage.
- 4. Procedure NOD-QP-36 will be revised by August 15, 1993, to better define the type of woit that can be done on-line and the type of work that is high risk, and to enhance and formalize the communication and work planning / review process among divisions (i.e., the Nuclear Operations Division, the Electric Operations Division and the Production Operations Division). In addition, a checklist will be developed for H0D-QP-36 that will be used by appropriate personnel to assist them in ensuring that they understand the scope of work to take place, and that switchyard issues are properly addressed. In addition, this will ensure that personnel in the switchyard understand the needs of the Control Room when they conduct work on switchyard equipment.
- 5. A key card reader, with an associated alarm, will be installed by August 31, 1993, to restrict entry into the switchyard. As an interim measure, FCS locks, in addition to the already installed OPPD locks, have been installed on switchyard entry gates to ensure that the Control Room is notified prior to switchyard entries.
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NRC F6RM 306A U.S. NUCLEAR REGut.ATORY COMMISSION APPROVED BY OMB NO. 3150-o1o4 M. ~_ EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS LICENSEE EVENT REPORT (LER) =^Enea9 ARON 78uRo7N "? Es% Tits"To @e'iNroETioN
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FACFJTY NAME (1) DOCET NUMBER R LER NUMBER (ii) PAGE R g SEQULfinAL REVISION
, NUMBER NUMBER Fort Calhoun Station Unit No. 1 05000285 93 -- 011 -- 00 TEXT pt more space is seguired, use addmonaJ copies of NRC Form 300A) (17)
- 6. A training program will be established by September 15, 1993 for Electric Operations Division personnel, on the revised version of N0D-QP-36 (see Item 4 above). Completion of this training will be required prior to receiving routine access to the FCS switchyard.
- 7. A training program will be established by September 15, 1993 for Operations p rsonnel, on switchyard equipment and relaying, to enhance their ability to e nluate the risk associated with switchyard activities.
With respect to the plant response to the event, the following corrective actions have been or will be completed:
- 1. As previously noted, troubleshooting was performed with respect to the failure of Bus 1A2 to properly load shed. No abnormalities were identified.
- 2. Feedwater Heater Relief Valve FW-142'; was replaced with a relief valve of improved design. The new valve was bench tested prior to installation. Other feedwater heater tube-side relief valves were bench tested and six of eleven valves f ailed to lif t at their design setpoint. These valves were then repaired as required, and re-installed. A twelfth valve (FW-1465), which could not be isolated for removal, will be tested during the 1993 Refueling Outage. These valves will be included in a Relief Valve Reliability Program by December 31, 1993, which will address periodic testing and maintenance to ensure reliability.
- 3. With respect to water hammer damage, the Steam Packing Exhauster and connected piping were inspected, and the only damage identified was a broken anchor bolt. The remaining bolts were determined to be adequate for operation.
- 4. Training will be provided to Operations personnel by November 1, 1993, emphasizing the importance of using all available indications (e.g., motor breaker position indication and motor amps) to avoid inappropriate actions.
- 5. The seals on Feedwater Pemp FW-4B have been repaired. Feedwater Pump FW-4A had some existing seal leakage prior to the event and was also repaired.
PREVIOUS SIMILAR EVENTS No recent similar events have been identified involving a reactor trip due to switchyard activities.
I NRC FORM 386A U.S. NUCLEAR REGULATORY COMin1SSION APPROVED BY OMB NO. 315o4104 D84 '
EXPIRES 5/31/95 ESTIMATED DURDEN PER RESP'JNSE TO COMPLY WITH THIS !
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