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 Start dateReporting criterionEvent description
05000219/LER-2017-0059 October 2017
3 January 2018
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications

On 10/09/17, during the bi-weekly Emergency Diesel Generator (EDG) #2 Load Test, a Generator Lockout signal (86G) was received which tripped the EDG output breaker. This failure resulted in EDG #2 being declared inoperable, and entry into an unplanned 7-day Limiting Condition for Operation (LCO) at 0312.

Troubleshooting identified a broken electrical ring lug connector on a current transformer that provides an input to the protective relay logic. The investigation determined the connector failure was due to fatigue cracking that was initiated by stresses caused by bending and twisting of the electrical lug beyond limits specified in industry guidelines. The ring lug was most likely distressed during initial installation in the 1990's. The condition that led to the EDG #2 trip existed for greater than the allowed outage time in the plant's Technical Specification (TS) and is reportable under 10 CFR 50.73(a)(2)(i)(B).

05000219/LER-2017-00431 August 201710 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications

On August 31, 2017, during a review of industry Operating Experience (FERMI 2, LER 2017-001) for the use of a Reactor Protection System (RPS) test box during main turbine surveillance testing, it was determined that Oyster Creek station procedures failed to implement the required action specified by Technical Specifications (TS) section 3.1,1. note (nn) during testing. The surveillance tests associated with the Turbine Trip and Generator Load Rejection functions were revised in 2013 to use an RPS test box in order to minimize operational risks associated with the receipt of half scram signals during testing. The installation of the RPS test box caused two of the four required instrument channels for the Turbine Trip Scram function to be bypassed during testing.

In accordance with station Technical Specifications, the required action to verify sufficient channels remained operable was not documented as complete within the action time specified in TS Table 3.1.1, note (nn). This issue was identified under normal operating conditions, and is reportable under 10 CFR 50.73(a)(2)(i)(B).

05000219/LER-2017-0033 July 2017
31 August 2017

On July 3, 2017 at approximately 10:30 hours with the reactor subcritical after a manual scram, an automatic reactor scram occurred due to low Reactor Pressure Vessel (RPV) water level. Prior to this event, Main Control Room (MCR) Operators established reactor water letdown, reset the manual scram and were placing RPV water level control in automatic using a Low Flow Feedwater Regulator Valve (LFRV). Reactor pressure control was automatically being maintained with turbine bypass valves. A low reactor water level occurred when a bypass valve opened as expected to lower reactor pressure.

Operations personnel had reset the scram signal without fully evaluating other plant conditions. Upon resetting the scram with reactor water level not yet stabilized, an automatic scram was received on low reactor water level. The automatic scram initiation signal occurred with the plant in a shutdown mode.

05000219/LER-2017-0023 July 2017
31 August 2017

On July 3, 2017, at approximately 10:15 AM following a grid disturbance, a manual scram was inserted due to degrading main condenser vacuum because of an improper configuration of the Augmented Off-gas (AOG) System.

The loss of main condenser vacuum resulted when Operations personnel failed to execute procedural requirement to align the AOG system into a shutdown lineup. The loss of vacuum was caused by degraded Steam Jet Air Ejectors (SJAE) performance due to a blocked discharge path.

The AOG system tripped 11 hours earlier following a grid disturbance. During the trip, operations personnel failed to re-align the AOG treatment system to a shutdown lineup resulting in the AOG Flame Arrestor siphoning into the inlet piping which filled the lower section of the off-gas hold up line with water.

05000219/LER-2017-0013 May 201710 CFR 50.73(a)(2)(iv)(A), System Actuation

On 11/20/2016 at approximately 0342 EST, an automatic reactor SCRAM occurred at 92% power due to Average Power Range Monitor (APRM) high flux. Oscillations of the turbine control valves and bypass valves were experienced during planned testing of the Turbine Master Trip Solenoid Valve at 95% power. Power was reduced from 95% to 92% by the Main Control Room Operators in an effort to stop the observed oscillations. The control valves did not respond properly during the power reduction, leading to an unexpected rise in reactor pressure and the subsequent scram on high flux.

There were no safety consequences impacting the plant or public safety as a result of this event. All control rods fully inserted and the plant response was as expected. This event is being reported pursuant to 10CFR50.73(a)(2)(iv)(A) due to an actuation of the Reactor Protection System (RPS).

05000219/LER-2016-00519 September 2016
17 November 2016
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications

On September 19, 2016, after achieving Cold Shutdown for the 1R26 Refuel Outage, as found testing was performed on all five (5) Electromatic Relief Valves (EMRVs). The "E" EMRV did not open from the Main Control Room (MCR), and no change in indication was observed. Per the work activity, technicians were dispatched to the Drywell to verify that the valve did not move upon receiving an open signal from the MCR.

A cutout switch in the valve actuator was stuck in the open position, thereby preventing the solenoid from actuating to open the valve. The cutout switch did not operate as required due to, hinge pin washers not installed in the cutout switch assembly. Without the washers installed to the hinge pins interfered with the solenoid frame holes creating mechanical binding. Based on this information it is suspected that the "E" EMRV would have been inoperable for longer than Technical Specification Allowed Out of Service Time (AOT) of 24 hours. Testing and inspections were performed on all EMRVs prior to installation in the plant.

Therefore, this issue is reportable under 10 CFR 50.73(a)(2)(i)(B) as an Operation or Condition which was Prohibited by the plant's Technical Specifications.

05000219/LER-2016-00410 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications

Oyster Creek Nuclear Generating Station was in Cold Shutdown on 09/29/16 for Refueling Outage 1R26 when a condition was discovered during routine laboratory as-found testing that a Safety Valve (SV) (EIIC:RV) removed on 09/27/16 as part of refueling outage maintenance activities did not meet required setpoint tolerances. There were no structures, systems or components out of service that contributed to this event.

In accordance with American Society of Mechanical Engineers (ASME) Operation and Maintenance (O&M) Code requirements, two (2) of the nine (9) SVs installed in the plant were scheduled for removal during the refueling outage (1R26) and sent for as-found laboratory testing. Based on information received from the laboratory performing SV as-found testing, Site Engineering personnel determined that SV setpoint deficiencies existed with one (1) of the two (2) SVs removed and sent for testing. Per ASME O&M Code Mandatory Appendix I Section I- 1320, two additional SVs were removed from the plant and sent for as-found testing and both met the required setpoint acceptance criteria. One (1) of the four (4) SVs tested exceeded the setpoint tolerance of +/-3% (+1-36 psig) as specified in the Technical Specifications (TS), Paragraph 2.3.F. This resulted in a condition prohibited by TS and is considered reportable pursuant to 10 CFR 50.73(a)(2)(i)(B).

05000219/LER-2016-00329 June 201610 CFR 50.73(a)(2)(iv)(A), System Actuation

On April 30, 2016, at 1804 hours, during the plant startup following the 1M38 maintenance outage, a reactor SCRAM was manually inserted by the Control Room Operators during post maintenance testing following work on the 'D' Reactor Recirculation Pump (RRP) mechanical seal. The SCRAM was initiated since leakage was discovered by a rising trend in drywell unidentified leakage during plant startup. The seal had been replaced during the maintenance outage. The SCRAM was selected as the preferred method of shutting down the reactor due to low decay heat conditions following the outage.

ENS 51895 was submitted on April 30, 2016, as required by 10 CFR 50.72 (b)(2)(iv)(B). This issue is reportable under 10 CFR 50.73(a)(2)(iv)(A), for any event or condition that resulted in manual or automatic actuation of any of the systems listed in paragraph 10 CFR 50.73(a)(2)(iv)(B).

05000219/LER-2016-00216 March 2016
23 June 2017
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications

On 03/16/2016, it was identified that isolating or reducing cooling water to the Hydraulic Control Units (HCUs) for three control rods should have been considered a modification since it had the potential to impact the scram times of the control rods. Even though scram time penalties were applied for the three control rods where the cooling water flow was either isolated or reduced, failing to identify the isolation of cooling water to the control rods as a modification as described by the Technical Specifications resulted in the Plant not taking the action to scram time test the affected rods.

By not completing scram time testing for the control rods, whose cooling water was isolated or reduced, the station was in violation of the requirements of Technical Specifications Section 3.2, since the issue was not identified previously and the affected control rods were not declared inoperable and isolated.

  • This event resulted in an Operation or Condition that was Prohibited by the Plant's Technical Specifications (TS) and is therefore being reported under 10CFR50.73(a)(2)(i)(B).
05000219/LER-2016-0014 January 2016
24 January 2017
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications

On January 4, 2016, during the biweekly load test surveillance, the Emergency Diesel Generator (EDG) #1 tripped after 26 minutes of operation and an unexpected Main Control Room alarm was received.

Locally, at the EDG enclosure, it was discovered that the rubber pipe coupling that connects the coolant surge tank to the right bank cooling water pump inlet tee had ruptured and that the EDG #1 control circuitry processed the trip on low coolant pressure.

EDG #1 was declared inoperable and in accordance with Technical Specification (TS) 3.7.C.2 Limiting Condition for Operation (LCO), the unit entered a seven day action period. The EDG #1 was returned to service on January 5, 2016, at 0130 hours, following successful hose replacement and completion of the load test surveillance.

The Root Cause investigation determined that an activity to replace the rubber pipe coupling on a 12-year frequency was not established during the initial implementation of Exelon's Electro-Motive Division Diesel Generator Performance Centered Maintenance (PCM) template.

This event resulted in an Operation or Condition that was Prohibited by the Plant's Technical Specifications and is therefore being reported under 10CFR50.73(a)(2)(i)(B).

05000219/LER-2015-00310 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications

On November 9, 2015, while attempting to commence a #1 Emergency Diesel Generator (EDG) test procedure, the #1 EDG failed to start and the "EDG 1 Disabled' Alarm annunciated in the Main Control Room. Locally, the operator heard relays chattering on the generator end of Diesel Generator #1 and notified the control room that the SEQ alarm was illuminated. Subsequently, a fast start of the #1 Emergency Diesel Generator was attempted but was unsuccessful. The cause of the failure was determined to be a failed zero speed relay (ZSR). The ZSR failure was caused by an internal component fallure'associated with age degradation of the Time Delay Module of the relay assembly.

The identification of this failure resulted in EDG #1 being declared inoperable and entry into an unplanned 7-day LCO at 0348. The repairs concluded on November 10, 2015 at 0400-and the #1 EDG was declared operable at 0634.

This issue is reportable under 10 CFR 50.73(a)(2)(i)(B) as an Operation or Condition which was Prohibited by the plant's Technical Specifications since the likely time of failure would have been during the previous EDG#1 run which was conducted on October 26, 2015.

NRC FORM 388 (014014) ' NRC FORM 35$A U.S. NUCLEAR REGULATORY COM ION X01-2014) P Al; VE Y OM NO. 31 IRE 01/31/2011 Wasiinton, uu 20503. If a means used to impose an information does not dankly a care* valid OMB control minim, the NM may not conduct or sponsor, and a person's not Reportd itasons foamed are incorporated Into the 6c , process and fed back to industry.

Sand comments regard ng burden estimate to the FOfA, Rimy and Intonation Collections Branch (T.5 F53), U.S. Nuclear Riguitary Coovniston, Washington, DC 20655-0001, or. by Internet ameil to Iricceiscis.RoourcsOnrc.gov, and to the Deek Mot, Office of informadon and?Watt/ Mao, NE08-10202, (31500104), Olgen of =Pent end Budget required to respond to, the information collection.

2: DOCKET 05000219, $. LER NUMBER 3. PAGE OF 4 2014 - 003 - 01 '

Description of Event

On November 9, 2016 at 0348, when Operations attempted a normal start of the Emergency Diesel Generator

  • #1 per th&riormal bkveekly.load test, procedure 636.4.003, the:#1EDGrfalled
  • tostart During this attempt; the "Unit Starr fight illuminated; however, the Unit Idling light faited to illuminate, followed by thel.lEDG1 Disabled" ;Mann annunciation and theUnit Start Light for EDG #1 extinguishing.. Locally, the operators heard relays chattering in the generator compartment; however; no starter motor actuation occurred (failed start sequence).

The Operators then notified the Main Control Room that the SEQ alarm Was illuminated. Due to this condition, EDG #1 was declared inoperable and an unplanned risk change to yellow.occurred. Notifications were performed for the unplanned risk change and a prompt investigation was initiated. The station entered a 7-day shutdown Limiting Condition for Operation (LCO) per Technical Specifications 3.7.C.2. As part of this LCO, EDG # 2 operability was verified. EDG #1 was quarantined for troubleshooting.

Complex Troubleshooting identified that the Zero Speed Relay (ZSR) was not de-energized or dropped out as expected from the last EDG #1 load test on 10/26/2015. There is no alarm or panel indication for the failure.

The energized state of the relay would have precluded any start of EDG #1 since that test. The repairs concluded on November 10, 2016 at 0400 and the #1 EDG was declared operable at 0634.

Equipment Dericriptima The Emergency Diesel Generators are designed to start automatically and supply AC power to Class 1 E buses during degraded voltage or loss of voltage conditions on 1E, Loss of Offsite Power (LOOP), or a LOOP with a Loss of Coolant Accident (LOCA), for safe shutdown and coot down.

The ZSR is manufactured by Vapor Corporation under model number 39430622. The relay is mounted in .a control panel enclosure located in the. MG compartment. This location experiences mild temperatures during EDG operations and standby conditions. The most recent replacement of the ZSR relay for both EDG #1 and EDG #2 occurred in 1996. The ZSR is a normally de-energized, time delay relay with a fixed time delay of 2 seconds. Upon an EDG start signal, the relay is energized by ESSB (Engine Speed Sensing relay) when the engine speed increases to 40rpm. The MR prevents the starter motor engagement for next start attempt if the engine has not stopped. The relay contact returns to normal state after 2 seconds timeout following 0 rpm.

This interlock is not bypassed by a fast start signal.

Analysis cif Event The failed relay was sent to Exeton's PowerLabs for functional testing and analysis. PowerLabs' Failure Analysis report (OYS-25105) concluded that the ZSR's time delay unit failed to de-energize, which left voltage on the ZSR coil that was sufficient to prevent ZSR dropout. The cause of the excessive output voltage from the Time Delay Unit is likely attributed to degraded internal components. Attempts were made to identify the specific component(s) that was faulty within the Time Delay Unit. However, when the outer cover of the Time Delay Module was removed the Internal components were found to be encapsulated in a hardened potting compound that prohibited evaluating its components. The environment during the testing was approximately 71-73 degrees F. Powertabs' report indicated that the Time Delay Module would fail to de-energize the relay at ambient temperature.

NR - FO 34 (01.2014) In addition to the ZSR failure, potential leakage through surge suppressing rectifier CR-2A was considered.

This device was replaced with the ZSR replacement. The CR-2A rectifier was also sent to PowerLabs for testing. PowerLabs analysis concluded that the rectifier was free of any deficiencies and did not contribute to the failure mechanism.

Assessment of Safety Consequences

Two diesel generator units serve as the Standby Power Supply for the station by providing an emergency source of power to the 4.16 kV buses 1C and ID In the event of a loss of normal power. The diesel generator units are designed to start and load automatically, if required. Nonessential loads are automatically shed by undervoltage sensing devices on loss of offsite power to ensure that the units are not overloaded. The capacity of the units is sufficient to sequentially energize for starting all safety related pumps and auxiliaries required for a safe shutdown of the reactor in the event of a Design Basis Accident. The diesel generator units are independent of each other, with the exception of a common bulk fuel storage supply, and are provided with auxiliary systems to ensure reliable starting and continuous operation with no operator attention. Power to start the units is self-contained and is not dependent on the availability of any other source of normal plant power at the moment of initiation.

There are two types of automatic start signals to the diesel generator units. The first signal will cause the Units to start and idle. The second signal is called the Fast Start Signal. The Emergency Diesel Generator allowable time response to a Loss of Offsite Power (LOOP) event is 20 seconds as a basis for Core Spray System response to accident conditions. The time response period Includes UV sensor pickup time, emergency bus logic to isolate and actuate the Emergency Diesel Generators and the period to bring the Emergency Buses to normal voltage level.

The failure of the Zero Speed Relay would have precluded the #1 EDG from being able to start and load in the event of a degraded or toss of voltage condition. The #2 EDG would have continued to operate and would have supplied thelD 4160V bus as required to ensure power to the components required to achieve cold shutdown. The #2 EDG was evaluated to not be susceptible to a common cause failure and was maintained in an operable condition in accordance with station procedures.

Cause of Event

The ZSR failed to drop-out and remained energized from the last EDG #1 bi-weekly load test and prevented the fast start of EDG #1 during the current load testing. There Is no alarm or panel indication for a ZSR failure.

Complex troubleshooting identified the energized state of the ZSR; however, there were no visible degraded conditions kientified that would have caused the relay to remain energized. The relay was subsequently replaced and EDG # I was restored to an operable status.

The failed relay was sent to Exelon's Powertabs for functional testing and analysis. PowerLabs' Failure Analysis report (0VS-25105) concluded that the ZSR's time delay unit failed to de-energize, which left voltage on the ZSR coil that was sufficient to prevent ZSR dropout. The cause of the excessive output voltage from the Time Delay Unit is likely attributed to degraded internal components. Attempts were made to identify the specific component(s) that was faulty within the Time Delay Unit. However, when the outer cover of the Time Delay Module was removed the internal components were found to be encapsulated in a hardened potting compound that prohibited evaluating its components. The environment during the testing was approximately 71-73 degrees F. PowerLabs' report indicated that the Time Delay Module would fail to de-energize the relay at ambient temperature.

The apparent cause of the ZSR failure was determined to be en internal component failure associated with age degradation of the Time Delay Module of the relay assembly. Due to the internal components encapsulated in a dense potting material, it was not possible to determine what specific component of the Time Delay Module was failed.

The following immediate actions were taken:

  • Complex Troubleshooting was commenced.
  • The #2 Emergency Diesel Generator was placed in service to eliminate the potential for a common cause failure.

Corrective Actions

In order to address the Apparent Cause the following actions were (or are being) taken:

  • Replaced the zero speed relay and the associated surge suppressor for the #1 EDO.
  • Scheduled the replacement of the #2 EDG ZSR during the next maintenance outage
  • Instituted a requirement to verify the state of the #2 EDG ZSR following each diesel run effective until the replacement of the ZSR is completed.

Previous Occurrences

There have been no previous events resulting from a failure of a normally de-energised Vapor Corporation relay.

Component Data Component IEEE 605 System ID IEEE 8034 Function Emergency Diesel Generator EK DO NRC FORM 2A (01-2014)

05000219/LER-2015-0012 February 201510 CFR 50.73(a)(2)(iv)(A), System Actuation

On March 22, 2015 at 1414, an automatic SCRAM from full power operation occurred at Oyster Creek due to a valid RPS actuation on APRMI-11.1-liflux. The APRM Iii-Hl flux was caused by a rise in reactor pressure due to the failure of the Electric Pressure Regulator (EPR). The backup Mechanical Pressure Regulator (MPR) did not limit reactor pressure.

The scram occurred due to inadvertent contact with degraded wiring during troubleshooting to isolate a DC ground identified within the turbine control indication circuitry. The contact caused a loss of signal from the EPR to its controlling Programmable Logic Controller (PLC) resulting in a loss of the EPR. This loss of signal, concurrent with the MPR being out of position, resulted in the subsequent rise of both reactor pressure and APRM flux that caused the SCRAM.

ENS 50916 was submitted on March 22, 2015 as required by 10 CFR 50.72 (b)(2)(iv)(B). This issue is reportable under 10 CFR 50.73(a)(2)(iv)(A), any event or condition that resulted in manual or automatic actuation of any of the systems listed in paragraph (a)(2)(iv)(B).

NRC FORM 388 (01-2014) Nq LICENSEE EVENT REPORT (LER)

05000219/LER-2014-00610 CFR 50.73(a)(2)(iv)(A), System Actuation

On.October 12, 2014, an automatic SCRAM occurred during the reactor startup evolution following the 1R25 refueling, outage. The SCRAM occurred when a station electrician, in conjunction with a General Electric technician and a site engineer; secured power to the, Main Generator Automatic Voltage. Regulator (AVR). controllers while the Main Turbine warming evolutionmas in progress. The individuals were not authorized to perform ihis action nor did they have procedUres in'the fieid- tO operate the equipment, Their actions resulted in an automatic. reactor SCRAM on law water ,.

level, . . . , ..

. ,.

ENS 50524 was submitted on October 12, 2014, and updated on October 17, 2014: This issue is reportable under 10 CFR 50.73(a)(2)(iv)(A), because it involved an event or condition that resulted in manual or automatic actuation of any - of the systems listed in paragraph.(a)(2)(iv)(13). .

. . ,.

The Root Cause Analysis was completed on January 30, 2015. The cause of this event was determined to be that Station Leadership has inconsistently reinforced Human Performance Error Reduction Tool Use and Procedure Use , and Adherence. This resulted in the breakdown of multiple fundamental practices and standards that led to the event.

..........

  • ., NRC FORM 386 (01-2014) / NRC FORM 306A U.S. NUCLEAR REGULATORY COMMISSION'APAOYE6 EP10118 : NO. 385020104 EXPIRES: 01/31/2017

CONTINUATION SHEET

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Reported lessons darned are incorporated into the licensing 'eosins and fad back to Industry.

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Description of Event

On October 12, 2014, during a planned reactor power ascension with reactor power at approximately 1% of rated thermal power, reactor water level began lowering. An automatic SCRAM occurred at 0251 EDT, moments before operators inserted a manual SCRAM in accordance with station procedures. The SCRAM occurred when an electrical technician reset all three Main Generator Automatic Voltage Regulator (AVR) controllers. This resulted in a Main Turbine trip while warming was in progress.

In this condition, the Turbine Bypass Valves (TBV) are held open by the Bypass Valve Opening Jack (BVOJ) with the internal bypass of the #2 TBV open, admitting steam to the Low Pressure (1.P) turbine. in this state, when the turbine is tripped, Turbine Emergency Trip Oil pressure is dumped, which closes the TSVs and Turbine Control Valves (TCVs). However, because the BVOJ was open, and the pressure wave caused by the TSV closure, the TBVs go to 90% open, which corresponds to a steam flow of approximately 35% Core Thermal Power. Reactor steam flow immediately increased and reactor pressure rapidly lowered. The initial reactor level swell reached 179" Top of Active Fuel (TAF) (Turbine Trip is 175" TAF as a reference) due to the voiding swell while reactor pressure decreases. The Balance of Plant (BOP) Reactor Operator (RO) commenced driving the BVOJ closed in accordance with station procedures in an attempt to reduce the rate of pressure reduction and maintain reactor inventory. This drives a reduction in voiding swell and a level decrease that is compounded by a significant inventory reduction due to the single element control on the 'A' Low Flow Feed Regulating Valve not being capable of providing adequate flow to compensate for this transient. As a result, indicated reactor level rapidly lowers, and the Unit RO performs the manual SCRAM actions in accordance with station procedures. However, the automatic SCRAM was processed moments before by the Reactor Protection System (RPS) reactor low-level signal. The Unit RO was less than one second behind the automatic SCRAM. The reactor water level reached a low point of approximately 107" TAF.

Following the reactor SCRAM, all systems operated as expected.

Analysis of the Event

  • Following the actuation, all systems responded as expected; therefore, this event is of low safety significance.

Cause of Event

On October 12, 2014, an automatic SCRAM occurred during the reactor startup evolution following the 1R25 refueling outage. The SCRAM occurred when a station electrician secured power to the Main Generator AVR controllers while the Main Turbine warming evolution was in progress. The electrician, engineer, and technician were not authorized to perform this action nor did they have procedures in the field to operate the equipment.

Additional barriers had failed in the process sequence that could have prevented this event, including failure to follow the task management process and procedures, failure to conduct proper briefs in accordance with human performance procedures, and gaps in the planning process that resulted in an inadequate work package. These and other failed barriers in this sequence exhibited a commonality of a failure to comply with the applicable process and procedure.

he Root Cause of this event is that Station Leadership has inconsistently reinforced Human Performance Error Reduction Tool Use and Procedure Use and Adherence. A Contributing Cause is that individuals made decisions to deviate from processes, procedures, and human performance tool use because they incorrectly assumed there was no risk involved and they wanted to complete the assigned task to meet schedules.

Corrective Actions

To address the Root Cause, Exelon took (or will take) the following actions:

1. Senior Leadership Team will review at least once per week the station performance observations (i.e., Day in the Field, Daily Observation challenges, meeting observations, etc.) for strengths and gaps in human performance error reduction tool usage and procedure use and adherence to ensure supervision is critically observing performance. Trends and specific observations/direction will be communicated to First-Line Supervisors and above on a weekly basis.

2. Generate and communicate a human performance vision statement to the site.

3. Establish a daily, First-Line Supervisor time in the field expectation of at least two hours and daily observations focused on human performance tool use and procedure use and adherence.

4. Create a template and implement a process for the First-Line Supervisor/Manager Daily Observations and the Senior Leadership Team presentation and challenge. First-Line Supervisors or Managers will present their Daily Observation of human performance error reduction tool use and procedure use and adherence to multiple Senior Leadership Team members. The Senior Leadership Team members will engage the First-Line Supervisors and. Managers to ensure leadership team alignment and supervisor engagement in human performance and procedure use and adherence. The outcome of this interaction will be documented in a performance observation database for that First-Une Supervisor.

5. The Station Leadership Alignment Meeting and the Leader-to-Leader meeting will have agenda items specifically to address observed site behavior for human performance and procedure use and adherence to align on observations and actions.

To address the Contributing Cause, Exelon has taken (or will take) the following actions:

1. Create and implement a Behavior Based Performance Policy to ensure a clear and consistent management approach to procedure use and adherence issues.

2. Site management will discuss with their direct reporting personnel that the expectation is strict compliance with processes and procedures; each instance of non-compliance will be addressed consistently. These discussions are to be documented in the performance observation database or an affirmation letter.

Previous Occurrences

This was the first occurrence of the Automatic Voltage Regulator causing a Main Turbine trip, and the subsequent SCRAM at Oyster Creek. There arre historical Issue Reports (IRs) that documented deficiencies related to procedure use and adherence and the improper use of human performance tools.

05000219/LER-2014-005, Secondary Containment Declared Inoperable19 September 201410 CFR 50.73(a)(2)(v)(C), Loss of Safety Function - Release of Radioactive Material
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications

On September 19, 2014, -during refueling outage 01R26 with the unit in cold shutdown, a technician discovered that a previously authorized and installed Temporary Configuration Change (TCC) had been removed from a penetration in the Outboard Main

  • Steam Isolation Valve Room (Trunnion Room). The purpose of the TCC is to Isolate the penetration from the Reactor Building (RB) to the Trunnion Room to allow the RB Trunnion Room door to be maintained open during refueling outages. Per Technical Specifications (TS) 3.5.8 and 4.5.G, in order to maintain secondary containment integrity with the Trunnion Room door open, four -1 penetrations connecting the Trunnion Room to the RB must be seated. The Trunnion Room door was open when the phi() was found removed from a 6" equipment drain hub. The plug was immediately reinstalled. On September 20, 2014, the Post Maintenance Testing (PMT) for the TCC reinstallation was executed in order to declare secondary containment operable. This PMT revealed that the Standby Gas Treatment System (SBGTS) could not achieve the required minimum differential pressure of - 0.26° water vacuum on the RB. The cause was determined to be an improperly latched personnel access hatch on'the Outer Reactor Building Airlock Door.

ENS 50476 was submitted on September 20, 2014. This issue is reportable under 10 CFR 60.73(a)(2)(v)(C) as an event that could have prevented the fulfillment of the safety function of a system needed to control the release of radioactive material, and 10 CFR 50.73(a)(2)(I)(8) as a condition which was prohibited by the OM'S Technical Specifications.

05000219/LER-2014-00418 September 201410 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications

On September 18, 2014, during refueling outage 01R25 with the unit in cold shutdown, plant personnel performed local leak rate testing (LLRT) of the Main Steam Isolation Valves (MSIVs). During the testing, it was identified that the "B" main steam line inboard isolation valve NSO3B (V-1-8) exceeded the leakage rate limits allowed by the plant's Technical Specifications.

The MSIV (V-1-8) that exhibited excessive leakage was repaired and the as-left leakage rate was verified to be within Technical Specifications leakage limits.

This issue is reportable under 10 CFR 50.73(a)(2)(i)(B) as a condition which was prohibited by the plant's Technical Specifications.

05000219/LER-2014-00111 July 201410 CFR 50.73(a)(2)(iv)(A), System Actuation

On July 11, 2014 at approximately 0312 EDT, during planned reactor power ascension with reactor power at approximately 56% of rated thermal power, main condenser vacuum began to degrade. In accordance with the abnormal operating procedure for degrading vacuum, Operators inserted a manual scram of the reactor at 0314 EDT.

Following the reactor scram, operations and maintenance personnel identified an approximate 2"x6" hole and an approximate 2”x3” hole on the last convolute of the downstream side of Y-1-26 ('B' Condenser Steam Inlet Expansion Joint). It was confirmed to be an active leak and subsequently the source of condenser vacuum degradation. As a corrective action to this event, the expansion joint was replaced.

All control rods fully inserted and plant response was as expected. This event is being reported pursuant to 10CFR50.73(a)(2)(iv)(A) due to an actuation of the Reactor Protection System (RPS).

05000219/LER-2013-00517 December 201310 CFR 50.73(a)(2)(iv)(A), System Actuation

On December 17, 2013 at 1958 EST, while shut down, the plant experienced a reactor SCRAM when taking the Mode Switch from REFUEL to SHUTDOWN. The jumpers required to prevent a full SCRAM for this Mode Switch change were not installed as required by procedure. The actuation was a result of the reactor mode switch being placed from the refuel position to the shutdown position without the scram bypass jumpers installed.

The root cause determined that an unvalidated assumption by the supervisors resulted in a reactor scram while shut down.

Corrective actions include evaluation on requirements, through an Out-of-box Evaluation, to ensure operators understand and can demonstrate the proper use of the human performance fundamental tools that broke down in this instance. In addition, procedures will be enhanced to clarify verification requirements.

There were no safety consequences impacting the plant or public safety as a result of this event. The reactor was subcritical with all rods inserted at the time of the actuation. All systems functioned as designed. This event is being reported pursuant to 10CFR50.73(a)(2)(iv)(B) due to a valid actuation of the Reactor Protection System (RPS).

05000219/LER-2013-00414 December 201310 CFR 50.73(a)(2)(iv)(A), System Actuation

On 12/14/13 at approximately 0336 EST, during quarterly turbine valve testing with reactor power at 95% of rated thermal power, the plant experienced reactor pressure control abnormalities. Turbine Control Valves 2 and 3 failed closed due to the Servo Motor Feedback Support Bracket bolts backing out and falling out thereby requiring a scram. Operators initiated a manual reactor scram due to reactor pressure rising to 1042 psig which approached the scram set point.

These conditions were corrected during 1F33. These were determined during complex troubleshooting as the failures that drove the event. The root cause determined that the manufacturer failed to assemble the Control Valve Hydraulic Enclosure per their design.

There were no safety consequences impacting the plant or public safety as a result of this event. All control rods fully inserted and plant response was as expected. This event is being reported pursuant to 10CFR50.73(a)(2)(iv)(A) due to an actuation of the Reactor Protection System (RPS).

05000219/LER-2013-00317 November 201310 CFR 50.73(a)(2)(v)(C), Loss of Safety Function - Release of Radioactive Material

On 11/17/13 at 1725 EST station personnel simultaneously opened the inner and outer air lock doors from the Reactor Building to the reactor control enclosure (Reactor Building 23 foot elevation North West airlock). Reactor Building secondary containment integrity was momentarily declared inoperable per Technical Specification (TS) 3.5.B.2 due to both containment airlock doors being simultaneously open at the same time. Reactor Building D/P (differential pressure) remained less than negative 0.25 inches water column. The doors were immediately closed within 10 seconds and the Technical Specification condition was exited. The cause was a degraded airlock door interlock.

The secondary containment interlock doors were open for less than ten seconds. Based upon the short duration of the secondary containment doors being opened simultaneously, individuals present in the airlock to close the doors and that the Reactor Building D/P remained less than negative 0.25 inches water column during the course of this event, the safety function was met and this event is of low safety significance.

This event is being reported in accordance with 10 CFR 50.73(a)(2)(v)(C), any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to control the release of radioactive material.

05000219/LER-2013-0026 October 201310 CFR 50.73(a)(2)(iv)(A), System Actuation

On October 6, 2013 at approximately 1040 EDT, during a planned reactor power ascension with reactor power at approximately 20% of rated thermal power, main condenser vacuum began to lower. In accordance with the abnormal operating procedure for degrading vacuum, Operators inserted a manual scram of the reactor at 1130 EDT.

Following the reactor SCRAM, operations and maintenance personnel identified an approximate 1" hole on Y-1-26, 'B' Condenser Steam Inlet Expansion Joint on the south side of 'B' Condenser. It was confirmed to be an active leak and subsequently the source of condenser vacuum degradation. A temporary leak repair was performed.

All control rods fully inserted and plant response was as expected. This event is being reported pursuant to 10CFR50.73(a)(2)(iv)(A) due to an actuation of the Reactor Protection System (RPS).

05000219/LER-2011-001

On May 3, 2011, General Electric Hitachi (GEH) informed Oyster Creek Nuclear Generating Station (OCNGS) of a change in the calculation of Peak Cladding Temperature (PCT) and the Maximum Local Oxidation (MLO) that was based on corrections to errors in the previous calculation of record that were identified by the fuel vendor. On May 4, 2011, OCNGS determined that the multiple 10 CFR 50.46 Notifications resulted in a cumulative increase in analyzed PCT that exceeded the 10 CFR 50.46 PCT acceptance criterion of 2200°F. Also, the identified effect of the model change resulted in an increase in the calculated MLO above the 10 CFR 50.46 acceptance criteria. Further review of 10 CFR 50.46(a)(3)(ii) determined that an 8-hour notification report to the NRC was required under 10 CFR 50.72(b)(3)(ii)(B). The notification was completed as required.

The combined impact on PCT of the errors/changes described above is 115°F for the GE11 fuel and 145°F for the GNF2 fuel. These increases in PCT result in the licensing basis PCT exceeding the 10 CFR 50.46 acceptance criterion of 2200°F. Therefore, the PCT and MLO impact of these notifications has been offset by the calculation and implementation of revised Maximum Average Planar Linear Heat Generation Rate (MAPLHGR) values such that the maximum PCT and MLO values for both the GE11 and GNF2 fuel designs are returned to their original values of 2150°F and 16.5% respectively as documented in the vendor 10 CFR 50.46 notifications. Accordingly, this reanalysis meets the requirements of 10 CFR 50.46.

As a result of the MAPLHGR limit adjustment the current LOCA analysis of record remains applicable and therefore, the offsite dose is still bounded by our current safety analysis. Therefore this event is not significant with respect to the health and safety of the public.

05000219/LER-2010-00210 CFR 50.73(a)(2)(iv)(A), System Actuation

On December 23, 2010, with the reactor critical high in the Intermediate Range in the "Startup" mode, the reactor automatically scrammed on low main condenser vacuum. The cause was due to exceeding the 600 psig bypass reset enabling the low condenser vacuum trip prior to establishing the required vacuum. This bypass allows operation at reduced power below 600 psig during startup until adequate vacuum can be established in the main condenser.

The main condenser low vacuum reactor protection scram signal processed when reactor pressure was raised above the 600 psig bypass function during reactor startup. A procedure requirement for confirming all main condenser low vacuum alarms and trips are reset prior to exceeding 500 psig ensures that a scram signal is not present.

  • The direct cause of the event was determined to be inadequate procedure compliance by the Unit Reactor Operator (URO) in not verifying that all requirements were met prior to proceeding above 500 psig reactor pressure. Corrective actions include enhancement of operating procedures to clearly define key milestones requiring supervisor concurrence prior to continuing with reactor startup or shutdown.

This event is being reported pursuant to: 10CFR50.73(a)(2)(iv)(A) due to an automatic actuation of the Reactor Protection System (RPS).

05000219/LER-2010-00110 CFR 50.73(a)(2)(iv)(A), System Actuation

On October 7, 2010, the No. 2 Emergency Diesel Generator (EDG) automatically started and loaded onto the 'D' 4160V Safety-Related Bus (`D' Bus) due to a valid undervoltage start signal resulting from deenergization of the 'D' Bus. The "D" Bus main breaker opened during test equipment installation while performing a grid undervoltage channel functional test.

The cause of the trip of the 'D' Bus main breaker was test equipment failure from chemical attack on the plastic test jacks.

Further investigation found that the timer connection jack showed signs of electrical pitting and arcing and was internally shorted to ground. After the test equipment was installed and prior to opening the test switch, the voltage on two of the undervoltage relays decreased below the set points for degraded voltage conditions, opening the normal feed breaker resulting in a valid undervoltage start signal for the No. 2 EDG.

Due to the event, the procedure for test equipment installation will be revised to include pre-use testing of the timer to ensure that the battery of the digital timer is acceptable for use and that the terminals are not shorted or grounded. Additionally, a placard will be installed on the timers stating, "Caution - Do not use cleaners or solvents to clean terminals on this unit.

Avoid contact with oil on terminals.

This event is being reported pursuant to 10CFR50.73(a)(2)(iv)(A) as an automatic ESF system actuation.

05000219/LER-2009-00512 July 200910 CFR 50.73(a)(2)(iv)(A), System Actuation
10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident

On July 12, 2009 with the Unit at 100% power in the "Power Operation" mode, a severe electrical storm resulted in multiple lightning strikes on an 'interconnected 34.5 kV offsite transmission line. These lightning strikes in conjunction with a failure of a line breaker to open caused grid disturbances, a main generator trip on over-excitation, an automatic reactor scram due to the load rejection, and a loss of offsite power to the Startup Transformers.

When the plant experienced the loss of offsite power to the Startup Transformers, both Emergency Diesel Generators (EDGs) started and energized their associated safety related buses. During the event, EDG #1 was slow to tie onto its safety-related bus and the erratic "B" Isolation Condenser (IC) level indication resulted in operators declaring the IC inoperable. An Unusual Event was declared for the loss of power to the Startup Transformers for greater than 15 minutes. All declarations and notifications were made correctly and in a timely manner.

This event is being reported pursuant to: 10CFR50.73(a)(2)(iv)(A) due to automatic actuation of the reactor protection system, isolation condensers, and emergency diesel generators; and 10CFR50.73(a)(2)(v)(D) due to loss of offsite power to the Startup Transformers.

05000219/LER-2009-00425 October 200810 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications

During the 1R22 Refueling Outage (Fall 2008), a Temporary Modification was made to the secondary containment so that the trunnion room door could be left open to support maintenance activities. The Temporary Modification moved the barrier for secondary containment from the outer walls and door of the trunnion room to the inner walls, ceiling, floor, and associated penetrations in the trunnion room. A 10 CFR 50.59 Evaluation supported the Temporary Modification based on the determination that secondary containment integrity could be maintained separate from the trunnion room door and concluded that a Technical Specification change was not needed.

During the NRC Plant:Modification Inspection (May 4 through 15, 2009), the determination was made that the Temporary Modification. to open the trunnion room door for extended periods of time during 1 R22 was in noncompliance with Oyster Creek's Technical Specifications. The supporting 10 CFR 50.59 Evaluation inappropriately determined that prior approval from the NRC was not needed in that the secondary containment integrity required by Technical Specification Limiting Condition of Operation (TS LCO) 3.5.B was maintained.

05000219/LER-2008-00110 CFR 50.73(a)(2)(iv)(A), System ActuationMANU- REPORTABLESYSTEM COMPONENT FACTURER TO EPIX N/A N/A N/A N/A
05000219/LER-2007-0017 January 200710 CFR 50.73(a)(2)(iv)(A), System Actuation

On July 17, 2007 at 05:21 while operating at 100% power, an automatic reactor scram occurred due to low reactor water level following a trip of the "C" Reactor Feed Pump (RFP). The cause of the "C" RFP trip is attributed to an electrical fault internal to the motor. This transient led to an automatic scram on

  • low reactor water level and subsequent reactor isolation on a low-low reactor level.

There were no safety consequences impacting plant or public safety as a result of this event. .

This event is being reported pursuant to 10 CFR 50.73(a)(2)(iv)(A) due to the automatic reactor protection system and subsequent ECCS actuations.

05000219/LER-2002-00310 October 200210 CFR 50.73(a)(2)(ii)
  • A void was discovered in an area expected to be filled with sand beneath a portion of the two 480 VAC switchgear rooms. This void created an open area between two 4160 VAC feeder conduits. Because of the void, Appendix R electrical separation criteria were no longer met.

Apparently, sand may not have completely filled the area and/or had settled over time creating this void.

The safety significance of this discovery is minimal, as there Is no combustible material in the void. Both cables are contained in conduit and have sufficient Class 1 E electrical separation.

Immediately upon discovery, a continuous fire watch was stationed. Additional actions were subsequently taken to open communication between the void and adjacent smoke detectors. This would provide early warning early warning of a degraded condition. Adequate separation will be provided by re-filling the void between the two 4160 VAC feeder conduits to meet Appendix R requirements. The sand fill will be monitored. No similar events have occurred.

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05000219/LER-1998-015, Forwards LER 98-015-01,as Original Submittal on 981028 Inadvertently Indicated That Suppl Would Be Submitted.Suppl Should Not Have Been Required as Only Change Is on Cover Page5 April 1999
05000219/LER-1998-012, Forwards LER 98-012-00 Re Actuation of ESF by Test Instrument,Due to Inadequate Procedure.Event Did Not Impact Health & Safety of Public16 October 1998
05000219/LER-1998-011, Forwards LER 98-011-02, Three Small Bore Pipe Lines Did Not Meet Design Bases for Siesmic & Thermal Allowables. Engineering Std Will Not Be Completed Until End of 4th Quarter of 1999 Due to Scheduling Conflicts30 September 1999
05000219/LER-1997-004, Adds Oyster Creek Nuclear Generating Station Rwcs Valve V-16-2 to Scope of GL 89-10,suppl 3 Valves IAW Corrective Actions Identified in LER 97-04,dtd 970425.Description Design Basis Conditions Established for RWCU Valve,Encl5 November 1997
05000219/LER-1993-006, Informs of Change to Submission Date for LER 93-006, Supplemental Rept to 94123125 March 1994
05000219/LER-1990-00823 July 1990
05000219/LER-1989-025, Responds to 901002 Safety Evaluation Re 891216 Event Involving Two Control Rods Moving at Same Time Reported Via LER 89-025.Mod to Reduce Probability of Simultaneous Control Rod Withdrawal Will Be Installed in 13R Refueling Out11 January 1991
05000219/LER-1988-013, Responds to NRC Request for Addl Info Re LER 88-013, MSIV Failure Caused by MSIV Poppet Vibration Dtd 880808.All Four MSIVs Will Be Tested in Two Refueling Cycles.Penetrant Testing Will Be Performed Anytime Valve Stem Removed9 February 1989
05000219/LER-1987-030, Forwards Rev 1 to LER 87-030.Event Date Incorrectly Reported in Two Places on LER Due to Administrative Oversight5 November 1987
05000219/LER-1986-001, Responds to Request for Info Re Reactor Protection Sys Switch Replacement Per Amend 95 to License DPR-16 & LER 86-01.Static-o-ring Switches Will Be Replaced.Tech Spec Change Request Will Be Submitted by 86081527 May 1986
05000219/LER-1985-018, Responds to 860106 Request for Reevaluation of long-term Corrective Actions Re LER 85-018, Emergency Svc Water Pipe Coating Failure. Util Intends to Optically Inspect Essential Svc Water Sys on Refueling Outage Basis15 September 1986
05000219/LER-1984-020, Errata to LER 84-020-01,consisting of Page 4 Re Corrective Actions.Preventive Maint Request Initiated to Store Overload Devices in Vertical Position23 September 1985
05000219/LER-1983-014, Forwards LER 83-014/01T-0.Detailed Event Analysis Encl20 April 1983
05000219/LER-1983-013, Forwards LER 83-013/01T-0.Detailed Event Analysis Encl8 April 1983
05000219/LER-1983-012, Forwards LER 83-012/01T-0.Detailed Event Analysis Encl4 April 1983
05000219/LER-1983-011, Forwards LER 83-011/03L-0.Detailed Event Analysis Encl23 March 1983
05000219/LER-1983-010, Forwards LER 83-010/01T-0.Detailed Event Analysis Encl23 March 1983
05000219/LER-1983-009, Forwards LER 83-009/01T-0.Detailed Event Analysis Encl15 March 1983
05000219/LER-1983-008, Forwards LER 83-008/03L-0.Detailed Event Analysis Encl12 April 1983
05000219/LER-1983-006, Forwards LER 83-006/03L-0.Detailed Event Analysis Encl4 March 1983
05000219/LER-1983-005, Forwards LER 83-005/03L-0.Detailed Event Analysis Encl4 March 1983
05000219/LER-1983-003, Forwards LER 83-003/03L-0.Detailed Event Analysis Encl15 February 1983