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05000395/LER-2017-005Summer7 January 2017
22 December 2017
AUTOMATIC REACTOR TRIP DUE TO MAIN TURBINE TRIP
LER 17-005-00 for V.C Summer, Unit 1, Regarding Automatic Reactor Trip Due to Main Turbine Trip

At 1957 on November 07, 2017, VCSNS Unit 1 was operating. in Mode 1 at 100% reactor power when a turb'ne trip caused an automatic reactor trip. All systems responded as expected, with the exception of 'B' Steani Generator Feedwater Isolation Valve (FW1V) XVG1611B-FW. This valve did not appear to automatically close and was slow to indicate closed from the Main Control Board, however this did not complicate the response. All Control Rods fully inserted and all Emergency Feedwater (Mk') pumps started as required. The Operating crew stabilized the plant, which remained in Mode 3 with decay heat removal via the Steam Dump system to the Main Condenser.

The cause of the turbine trip has been determined to be a loss of Digital Control System (DCS) power to all three Main Feedwater Pumps (FWP), which was caused by the failure of Non-Safety Related Inverter XIT5905.

05000286/LER-2017-004Indian Point3 November 2017
20 December 2017
Reactor Trip Due to Main Generator Loss of Field
LER 17-004-00 for Indian Point Unit 3, Regarding Reactor Trip Due to Main Generator Loss of Field

On November 3, 2017, at 2022 hours, with reactor power at 100 percent, Indian Point Unit 3 experienced an automatic reactor trip on a turbine trip, which was in response to a main generator trip. The main generator trip was initiated by actuation of the Generator Protection System due to a main generator loss of field.

All control rods fully inserted and all required safety systems functioned properly. The plant was stabilized in hot standby with decay heat being removed by the main condenser. The Auxiliary Feedwater System (AFWS) automatically started as expected on steam generator low level to provide feedwater flow to the steam generators. The plant was stabilized in hot standby with decay heat being removed by the main condenser. The direct cause of the loss of main generator field was a failed Thyristor Firing Module drawer which affected proper operation of the redundant Thyristor Firing Module drawer. The root cause was determined to be that the Automatic Voltage Regulator (AVR) Firing Module power supplies have a latent design vulnerability where shared common output nodes are not isolated after a failure. A plant modification is proposed that will eliminate the condition by electrically isolating the AVR Firing Module power supplies upon failure.

This event had no effect on the public health and safety. The event was reported to the Nuclear Regulatory Commission (NRC) on November 3, 2017 under 10 CFR 50.72(b)(2)(iv)(B) and 50.72(b)(3)(iv)(A) as an event that resulted in the automatic actuation of the Reactor Protection System when the reactor is critical and a valid actuation of the AFWS.

05000364/LER-2017-002Farley19 December 2017Main Steam Safety Valve Lift Pressure Outside of Technical Specifications Limits
LER 17-002-00 for Joseph M. Farley, Unit 2, Regarding Main Steam Safety Valve Lift Pressure Outside of Technical Specifications Limits

On November 1, 2017, while in Mode 6 and at 0% power level, one of the C Loop Main Steam Safety Valves (MSSV) as-found lift pressure did not meet the acceptance criteria of +/- 3% of the setpoint (1129 psig) as required by Technical Specifications (TS) Surveillance Requirement (SR) 3.7.1.1. The MSSV lifted at 1171 psig which is 9 psig outside of its acceptance range of 1096 to 1162 psig and 3.72°o above its setpoint. The apparent cause of exceeding the MSSV upper acceptance limit is degradation of the valve spring and/or valve spindle compression screw. The as-found settings remained within analytical bounds; therefore, operation of the facility in this condition had no impact on the health and safety of the public.

TS Limiting Condition for Operation (LCO) 3.7.1, IvISSVs, requires five MSSVs per steam generator to be operable in Modes 1, 2, and 3. Since the failure affected the lift pressure over a period of time, it is assumed that the C Loop MSSV was inoperable for a time greater than allowed by TS. Therefore, this occurrence is considered reportable per 10 CFR 50.73(a)(2)(i)(B) as a condition prohibited by TS.

The C Loop MSSV was replaced on November 5, 2017, while in Mode 5.

05000220/LER-2017-003Nine Mile Point6 September 2017
2 November 2017
Automatic Reactor Scram due to Reactor Vessel Low Water Level
LER 17-003-00 for Nine Mile Point, Unit 1, Regarding Automatic Reactor Scram due to Reactor Vessel Low Water Level

On September 6, 2017 at 1157, Nine Mile Point Unit 1 experienced an 'automatic reactor scram due to reactor vessel low water level. The automatic Reactor Protection System (RPS) actuation and reactor scram is reportable per 10 CFR 50.72 (b)(2)(iv)(B) and 10 CFR 50.73(a)(2)(iv)(A) as any event or condition that resulted in a manual or automatic actuation of any of the systems listed in 10 CFR 50.73(a)(2)(iv)(B). Following the automatic scram all plant systems responded per design including High Pressure Coolant Injection (HPCI) System automatic initiation.

HPCI is a flow control mode of the normal feedwater systems, and is not an Emergency Core Cooling System.

The root cause of the scram was a failed power supply within the Proportional Amplifier, PAM-ID23E. This power supply failure resulted in the output from the module dropping out causing the #13 Feedwater Pump Flow Control Valve to close. The corrective action taken was the replacement of the failed Feedwater Level Control module, PAM- ID23E.

05000397/LER-2017-004Columbia20 August 2017
18 October 2017
MANUAL REACTOR SCRAM DUE TO HIGH MAIN CONDENSER BACK PRESSURE
LER 17-004-00 for Columbia Generating Station Regarding Manual Reactor Scram Due to High Main Condenser Back Pressure

On August 20, 2017 at 1605 PDT, Columbia Generating Station was manually scrammed due to a rise in Main Condenser back pressure. The rise in back pressure was due to the spurious closure of the Main Condenser Air Removal Suction Valve (AR-V-1) as a result of the failure of it's associated solenoid pilot valve. Following the reactor scram and depressurization of the reactor a Level 3 actuation occurred. In addition a startup flow control valve failed which necessitated throttling of the Feedwater start-up level control isolation valve to control Reactor Pressure Vessel level. All other safety systems functioned as expected and all control rods were fully inserted. Reactor decay heat was removed via bypass valves to the main condenser.

The apparent cause was the plant modification to address the single point vulnerability of the closure of AR-V-1 was not implemented in time to prevent a plant shutdown. A temporary modification has been installed to maintain AR-V-1 open for the remainder of the operating cycle.

These events are reportable in accordance with 10 CFR 50.73(a)(2)(iv)(A).

05000219/LER-2017-002Oyster Creek3 July 2017
31 August 2017
Manual Reactor Scram due to Degrading Main Condenser Vacuum
LER 17-002-00 for Oyster Creek Regarding Manual Scram due to Degraded Main Condenser Vacuum

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.

05000247/LER-2017-001Indian Point6 February 2017
22 August 2017
Manual Reactor Trip Due to Decreasing Steam Generator Levels Caused By Main Boiler Feedwater Pump Turbine Low Pressure Governor Valves Failed Closed
LER 17-001-00 for Indian Point, Unit 2 Regarding Manual Reactor Trip Due to Decreasing Steam Generator Levels Caused By Main Boiler Feedwater Pump Turbine Low Pressure Governor Valves Failed Closed

On June 26, 2017, Operations commenced a downpower from 100 percent to 93 percent reactor power to support performance of the Main Turbine Stop and Control Valve Test. With reactor power at 94 percent, the 22 Main Boiler Feed Pump Turbine (MBFPT) speed control trouble alarm annunciated coincident with pump speed swings of 800 revolutions per minute (rpm). The operators ceased the downpower and placed the 22 Main Boiler Feedwater Pump (MBFP) in Manual speed control to control the rpm swings. This was unsuccessful, and the rpm swings continued. The 22 MBFPT low pressure (LP) governor valves were observed to be cycling from full-closed to full-open. The decision was made to take local pneumatic control of the 22 MBFP to stabilize pump speed. Two minutes after establishing local pneumatic control, the LP governor valves went to full closed. With the rapid reduction in 22 MBFP speed, the pump was no longer delivering feedwater flow to the SGs. An automatic main turbine runback signal should have been generated on a low speed signal; however, there was no turbine runback actuation. In response, the operators commenced a manual runback to reduce main turbine load, but the decreasing SG levels reached 15 percent, and at 1531 hours a manual reactor trip was initiated.

All control rods fully inserted and all required safety systems functioned properly. The plant was stabilized in hot standby with decay heat being removed by the main condenser. The direct cause of the reactor trip was that the shoulder screws used on the 22 MBFPT LP governor valve servomotor linkage had backed out and detached. This caused the LP governor valves to fail closed, shutting off the turbine steam supply. This event had no effect on the public health and safety. The event was reported to the Nuclear Regulatory Commission (NRC) on June 26, 2017 under 10 CFR 50.72(b)(2)(iv)(B), 50.72(b)(2)(xi), and 50.72(b)(3)(iv)(A).

05000461/LER-2017-007Clinton10 June 2017
9 August 2017
Manual Reactor SCRAM due to Loss of Feedwater Heating
LER 17-007-00 for Clinton, Unit 1 re Manual Reactor SCRAM due to Loss of Feedwater Heating
On June 10, 2017, at 2256 CDT, Clinton Power Station (CPS) experienced a complete loss of the 'A' feedwater (FW) heater string. The operators received numerous FW trouble alarms on FW string 'A' and low pressure heater 1N1B bypass opened (1CB004). The operators entered procedure CPS 4005.01, "Loss of FW Heating," which directs the operators to restore and maintain power at or below the original power level. The operators lowered core flow and inserted all CRAM rods, and then observed that FW temperature had dropped greater than 100°F. As directed by CPS 4005.01, at 2306 hours the reactor mode switch was placed into the shutdown position and procedure 4100.01, "Reactor Scram," was entered. All systems operated as expected following the scram. At 0100 EDT, June 11, 2017; Event Notification 52800 was made. The loss of FW heating transient was caused by a loss of power to Moore trip units caused by a shorted condition on the Moore trip unit associated with the Hi-Hi level in the 4A FW heater. The root cause is that the design of the FW heater level control trip circuitry was not adequate to prevent scrams due to an unevaluated single point vulnerability. Prior to startup, CPS modified the circuit card locations and thereby diversified the power supplies so that the trip units have less dependency on common fuses. Additional corrective actions include performing an engineering evaluation to determine if there are additional single component failures, operator errors, or events for the FW heating system that could result in a drop in FW temperature of greater than 100°F.
05000391/LER-2017-003Watts Bar23 March 2017
22 May 2017
Automatic Start of Auxiliary Feedwater System Due to Main Condenser Failure
LER 17-003-00 for Watts Bar, Unit 2, Regarding Automatic Start of Auxiliary Feedwater System Due to Main Condenser Failure

On March 23, 2017, at 0014 Eastern Daylight Time (EDT), Watts Bar Nuclear Plant Unit 2 experienced an unplanned trip condition of both Turbine Driven Main Feed Pumps (TDMFPs) following a loss of Main Condenser Vacuum. The trip of both TDMFPs caused an automatic start of both Motor Driven Auxiliary Feed Water Pumps and the Turbine Driven Auxiliary Feed Water Pump as designed.

The plant was performing a normal startup, and had just synchronized the main generator to the grid. Subsequent to the event, the plant was transitioned to Mode 3 by inserting all control rods with a manual trip. All plant safety systems operated as expected.

The loss of condenser vacuum was the result of a significant breach of the Unit 2 main condenser - B zone. This failure is attributed to the main condenser neck support structural design being inadequate to maintain integrity within specification. Repairs to the condenser will be completed prior to Unit 2 returning to service.

05000373/LER-2017-005Lasalle
LaSalle
17 February 2017
18 April 2017
Manual Reactor Scram Resulting From Feedwater Regulating Valve Failure Causing High Reactor Water Level
LER 17-005-00 for LaSalle County, Unit 1, Regarding Manual Reactor Scram Resulting From Feedwater Regulating Valve Failure Causing High Reactor Water Level

On February 17, 2017, at 2353 CST, during Unit 1 power ascension from a previous forced shutdown, operators inserted a manual scram as a result of a high reactor water level condition caused by a rapid change in feedwater flow. The high reactor water level trip occurred due to a failure of the feedwater regulating valve (FRV) 1FW005 positioner arm, which caused the regulating valve to be driven to the full open position. This resulted in a rapid increase of reactor water level that required operators to perform a manual reactor scram. The plant was placed in a stable condition, with no complications in achieving shutdown.

This event is reportable in accordance with 10 CFR 50.73(a)(2)(iv)(A) as an event or condition that resulted in manual or automatic actuation of the reactor protection system (RPS). The safety significance of this condition was minimal, as plant equipment responded as expected for the event. The feedback drive arm and new positioner were installed on the Unit 1 FRV, which allowed the unit to restart following repairs. The FRV positioner feedback assembly had been installed in 2002, during a modification to upgrade of the air-operated valve assembly. This design has proven not to be robust enough for the FRV application.

05000331/LER-2016-003Duane Arnold18 October 2015
6 December 2016
Main Steam Isolation Valve Leakage Exceeded Technical Specification Limit
LER 16-003-00 for Duane Arnold Energy Center Regarding Main Steam Isolation Valve Leakage Exceeded Technical Specification Limit
On October 18, 2016, with the unit shutdown for a planned refueling outage (Mode 5, Refueling, 0% power), an evaluation of data from the scheduled Main Steam Line Isolation Valve (MSIV) (System Code SB) and Main Steam Line Drain valve penetration Local Leak Rate Testing (LLRT) determined the 'as found' maximum pathway leakage for the 'B' Inboard MSIV, CV-4415, and the Outboard Main Steam Line Drain valve, MO-4424, was in excess of the Technical Specification (TS) 3.6.1.3 leakage limit of 100 scfh for a single MSIV and 5 200 scfh for combined pathway leakage. The cause was determined to be a failure to perform periodic internal inspections of the MSIVs and a non-optimal valve design for the steam line drain application. Corrective actions included reworking CV-4415 to restore its leakage limit to below TS limits. Corrective actions are planned to replace MO-4424 with an optimal valve design. This event was of low safety significance had no impact on public health or safety. This event is reportable pursuant to 10CFR50.73(a)(2)(i)(B).
05000528/LER-2016-003Palo Verde21 September 2016Inoperable Containment Isolation Valve SGA-UV-1134 Due to Failure to Close During Testing

On September 21, 2016, at 0142 Mountain Standard Time (MST), containment isolation valve SGA-UV-1134 failed to stroke closed from the control room during containment isolation valve testing. The failure resulted in an unplanned entry into Technical Specification Limiting Condition of Operation (LCO) 3.6.3, Containment Isolation Valves. On September 22, 2016, it was concluded the valve was in a configuration that rendered the pneumatic operator incapable of operating the valve, including remote operation and automatic closure in the event of a main steam isolation system signal. The valve had been in this configuration since last operated on June 28, 2016. Therefore, the valve was inoperable longer than the required 4-hour completion time of LCO 3.6.3 Condition C. On September 22, 2016, at 1457 MST, SGA-UV-1134 was properly closed, declared operable, and LCO 3.6.3 was exited.

This event was caused by human error when procedural guidance was not used to return SGA-UV-1134 to its neutral locked configuration following testing on June 28, 2016. Actions have been initiated to ensure proper procedural guidance is used to lock SGA-UV-1134 in the future.

On June, 26, 2015, LER 50-530/2015-002 reported a condition prohibited by LCO 3.0.4 that occurred on May 1, 2015, when Unit 3 entered Modes 4 and 3 while in the applicability of LCO 3.7.4. On May 2, 2015, automatic dump valve, SGB- HV-178, was stroked with steam while in Mode 3 and discovered to be inoperable due to human error incurred during post- maintenance assembly prior to entering Mode 4.

05000286/LER-2015-007Indian Point8 July 2015
6 September 2016
Manual Reactor Trip Due to Decreasing Steam Generator Water Levels Caused by a Miss- Wired Circuit Board in the Main Feedwater Pump Speed Control System
LER 2015-007-01 for Indian Point, Unit 3 Regarding Manual Reactor Trip Due to Decreasing Steam Generator Water Level Caused by a Miss-Wired Circuit Board in the Main Feedwater Pump Speed Control System

On July 8,2015, during surveillance testing, the Control Room received a 6.9kV motor trip alarm due to 31 Condensate Pump (CP) Motor circuit breaker trip on overcurrent. .

Operators entered Alarm Operating Procedure 3-A0P-FW-1 due to loss of the 31 CP and initiated a load reduction. During this time the Main Boiler Feedwater Pump (MBFP) suction pressure decreased to its suction pressure cutback controller pressure range and its output decreased MBFP speed control to a minimum. The 31 MBFP speed control signal locked in at this minimum speed signal due to actuation of the MBFP Lovejoy speed control system Track and Hold feature. Due to this minimum 31 MBFP condition, the 31 MBFP , recirculation valve opened causing the 31 MBFP check valve to close. With the 31 MBFP unloaded, Steam Generator (SG) water levels decreased and at 15 percent operators manually tripped the reactor. The Auxiliary Feedwater System automatically started as expected due to SG low level from shrink effect. Direct cause was the 31 MBFP entered a Hold condition erroneously due to a miss-wired Track and Hold board in the speed control system. The root cause was the procurement for the MBFP Lovejoy Track and Hold boards was at an insufficient quality level commensurate with its criticality. There was a failure to mandate functional testing and wiring verification requirements on the vendor to ensure the procurement of a quality product. Corrective actions included replacement of MBFP track and hold board and 31 CP motor. A new replacement Track and Hold circuit board for both the 31 and 32 MBFP speed control system with the miss-wiring corrected was installed. The quality levels for the Track and Hold boards were revised from Q4 to Q3.

MBFP Lovejoy speed control maintenance procedures and site vendor manuals were revised to include more detail. The event had no effect on public health and safety.

FACILITY NAME (1) DOCKET (2) LER NUMBER (6) PAGE (3)

05000316/LER-2016-001Cook6 July 2016
31 August 2016
Manual Reactor Trip Due To Moisture Separator Heater Expansion Joint Failure
LER 16-001-00 for Donald C. Cook Nuclear Plant, Unit 2 Regarding Manual Reactor Trip Due To Moisture Separator Heater Expansion Joint Failure

On July 6, 2016, with the Donald C. Cook Nuclear Plant Unit 2 Reactor operating in Mode 1 at 100 percent power, the control room received a report of a steam leak on the Unit 2 B Right Moisture Separator Reheater (MSR)

  • crossover piping and damage to the turbine building structure. This information resulted in a decision by the crew to manually trip the Unit 2 Reactor at 0038. The cause of the steam leak was the sudden failure of the balance bellows on the Unit 2 B Right MSR crossover expansion joint, which also resulted in damage to the west wall of the turbine building.

The Root Cause was determined to be an organizational failure to recognize the risk significance of, and to adequately correct or mitigate, previously identified vibration issues with the Unit 2 B Right MSR crossover expansion joint tie rod and bellows in a timely fashion.

This event is being reported in accordance with 10CFR 50.73(a)(2)(iv)(A) as a manual actuation of the Reactor Protection System and an automatic actuation of the Auxiliary Feedwater system.

05000286/LER-2014-004Indian Point13 August 2014
1 August 2016
Automatic Reactor Trip as a Result of Meeting the Trip Logic for Over Temperature Delta Temperature during Reactor Protection System Pressurizer Pressure Calibration
LER 14-004-01 for Indian Point Unit 3, Regarding Automatic Reactor Trip as a Result of Meeting the Trip Logic for Over Temperature Delta Temperature During Reactor Protection System Pressurizer Pressure Calibration
On August 13, 2014, Instrumentation and Control (I&C) technicians started performance of an 8-hour scheduled surveillance 3-PC-OLO4A (Pressurizer Pressure Loop P-455 Channel Calibration) with Loop I in test and tripped. The test was approved by I&C and operations to be stopped for a break with the bistables still tripped, Channel I in test. During the break, an automatic reactor trip (RT) occurred as a result of meeting the trip logic for Overtemperature Delta Temperature (OTDT). All control rods fully inserted and all required safety systems functioned properly. The plant was stabilized in hot standby with decay heat being removed by the main condenser. The Auxiliary Feedwater System automatically started as expected due to SG shrink effect. No work was being performed at the time of the RT and no actual OTDT existed. The direct cause of the RT was a spurious signal spiking on channel 3 of the OTDT circuitry with another channel tripped for testing. The two possible root causes were 1) a random failure of the OTDT static gain unit (Foxboro Integrator/Converter module QM-431D), 2) loose wiring connection on distribution block DB-4 (output of static gain unit QM-431) due to workmanship issue. Corrective actions included replacement of static gain module QM- 431D and associated PR N-43 isolation amplifies NM306 and NM307, and static gain modules QM-421D, and QM-411D, replacement of three OPDT trip bistables (TC-421 A/B, TC-431 A/B, TC-441 A/B), replacement of setpoint module TM-432B (other setpoint modules had been previously replaced), and replacement of Loop 3 T(avg) E/I converter TM-432R. Procedure IP-SMM-WM-140 revised to include expectation on minimizing break times when a channel is tripped. The event had no effect on public health and safety.
05000237/LER-2016-002Dresden15 July 2016Unit 2 HPCI Inlet Steam Drain Pot Piping Leak Resulting in HPCI Inoperability
LER 16-002-00 for Dresden Nuclear Power Station, Unit 2 Regarding HPCI Inlet Steam Drain Pot Piping Leak Resulting in HPCI Inoperability

On 5/16/2016 at approximately 1120 CDT during planned maintenance on Division II of the Low Pressure Coolant Injection (LPCI) system, a through-wall steam leak was observed in the Unit 2 High Pressure Coolant Injection (HPCI) inlet drain pot drain piping. The leak was identified to be on the Inlet Drain Pot line leading to the Main Condenser upstream of the HPCI Inlet Drain Pot 2A Inboard Drain Valve, Air Operated Valve (AOV) 2-2301-29, which is ASME Code Class 2 piping. The cause of the through-wall leak was liquid droplet impingement erosion thinning of chrome moly piping. HPCI was declared inoperable following isolation of the degraded piping per Technical Requirements Manual (TRM) 3.4.a. This event is of low safety significance.

Corrective Actions included replacing the piping with stainless steel, ensuring similar sections of piping are replaced or scheduled for replacement, and reviewing Extent of Condition.

This event is reportable under 10 CFR 50.73(a)(2)(v)(D), "Any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

05000259/LER-2016-001Browns Ferry22 April 2016
21 June 2016
Failure of 4kV Shutdown Board Normal Feeder Breaker Results in Actuations of Emergency Diesel Generators and Containment Isolation Valves
LER 16-001-00 for Browns Ferry, Unit 1, Regarding Failure of 4kV Shutdown Board Normal Feeder Breaker Results in Actuations of Emergency Diesel Generators and Containment Isolation Valves

On April 22, 2016, at 1358 Central Daylight Time (CDT), during transfer of the 4160 V (4kV) Shutdown Bus from Alternate to Normal, the Normal Feeder Breaker (BKR 1722) failed to close when the Alternate Feeder Breaker was manually tripped. 4kV SD Bus 2 de-energized, resulting in the loss of 1B and 2B Reactor Protection System (RPS) as well as Steam Jet Air Ejector 1B. Emergency Diesel Generators (EDG) C and D started, but did not tie to the 4kV Shutdown Boards due to Operations personnel immediately re-closing the Alternate breaker and re-energizing 4kV Shutdown Bus 2. Invalid actuations of several Containment Isolation Valves also occurred during this event due to the loss of RPS. At 1530 CDT, EDG C and D were shut down. BFN, Unit 1, was returned to normal operating conditions.

The cause of this event was loose wires in the closing control circuit for BKR 1722 due to work in the vicinity of the control circuit termination points. Corrective actions were to terminate loose wires, using a ring type lug instead of a forked spade type lug, in the closing control circuit for BKR 1722; and to verify Shutdown Bus 2 transferred successfully to BKR 1722. A briefing was provided to Electrical personnel who perform modifications to discuss the potential consequences of installing tie wraps and performing other activities that could adversely affect existing wiring.

05000397/LER-2016-001Columbia28 March 2016
24 May 2016
MANUAL REACTOR SCRAM FOLLOWING LOSS OF REACTOR CLOSED COOLING
LER 16-001-00 for Columbia Regarding Manual Reactor Scram Following Loss of Reactor Closed Cooling

At 1322 PDT on March 28, 2016, a manual reactor scram was initiated in response to a loss of Reactor Closed Cooling (RCC). The loss of RCC was due to the opening of a Service Water (SW) valve at the inlet side of the Fuel Pool Cooling heat exchanger during performance of a partial surveillance without proper isolation of the RCC system piping from the heat exchanger. The cross-connection of the two systems caused depressurization and loss of flow from the RCC system into the non-pressurized SW piping. The SW valve was closed and the reactor was scrammed. Safety system responses to the scram signal were normal, with all control rods being fully inserted. Reactor decay heat was removed via bypass valves to the Main Condenser. No safety relief valves lifted and no emergency core cooling systems injected following the reactor scram.

The root cause was determined to be that plant Operators did not properly evaluate plant configuration when performing a partial surveillance including the marking as "N/A" (not applicable) of procedural steps, in accordance with plant procedures. Human performance aspects of the event were quickly addressed and additional corrective actions include reinforcing and monitoring procedure standards, and updating work control procedures at the station.

26158 R6 NRC Form 366 (01-2014)

05000247/LER-2016-001Indian Point4 March 2016
2 May 2016
Technical Specification Prohibited Condition Caused by One Main Steam Safety Valve Outside Its As-Found Lift Set Point Test Acceptance Criteria
LER 16-001-00 for Indian Point 2 RE: Technical Specification Prohibited Condition Caused by One Main Steam Safety Valve Outside Its As-Found Lift Set Point Test Acceptance Criteria

On March 4, 2016, during the performance of surveillance procedure 2-PT-R006, Main Steam Safety Valve (MSSV) MS-45B failed to lift within the Technical Specification (TS) as- ' found required range of +/- 3% of the setpoint pressure. Valve MS-45B lifted at 1125 psig, 29 psig outside its acceptance range of 1034 to 1096 psig and 5.7% above its 1065 psig setpoint. The valve was declared inoperable, then subsequently restored to operability upon two successful lifts within the required setpoint range without the need for adjustment. Nine other MSSVs that were tested lifted within the as-found required setpoint range. The apparent cause for the failure was internal friction due to spindle rod wear, which causes the spindle rod to bind against internal components.

Corrective actions were modification of MS-45B and twelve other MSSVs, and the replacement of their spindle rods. The event had no effect on public health and safety.

05000440/LER-2016-002Perry8 February 2016
8 April 2016
Manual Reactor SCRAM Due to Spurious Opening of Safety Relief Valves
LER 16-002-00 for Perry Regarding Manual Reactor SCRAM Due to Spurious Opening of Safety Relief Valve

On February 8, 2016, at 1503 hours, control room operators initiated a manual reactor protection system (RPS) actuation in response to rising temperature in the suppression pool. All control rods full inserted. Prior to the RPS actuation the plant was in mode 1 at approximately 96 percent rated thermal power. At 1500 hours, multiple safety relief valves (SRVs) partially opened due to an invalid reactor pressure vessel (RPV) pressure signal. Control room indications showed two SRVs remained open resulting in a suppression pool temperature rise. Suppression pool cooling was initiated and a plant cooldown to Mode 4 was initiated.

The direct cause of the event was a momentary pressure perturbation limited to the RPV B reference leg that caused the connected transmitters to sense RPV pressure and level changes that resulted in SRV actuation. Corrective actions include revision to plant procedures for operation of the RPV reference legs and associated purge panels, and changes to the time constants for the affected RPV transmitters.

The safety significance of this event is considered to be very small. This event is being reported in accordance with 10 CFR 50.73(a)(2)(iv)(A) as an event or condition that resulted in a manual actuation of the RPS.

05000333/LER-2016-001FitzPatrick23 January 2016
23 March 2016
System Actuations during Manual Scram in Response to Frazil Ice Blockage and Residual Transfer
LER 16-001-00 for James A. FitzPatrick Regarding System Actuations during Manual Scram in Response to Frazil Ice Blockage and Residual Transfer

On January 23, 2016, James A. FitzPatrick Nuclear Power Plant (JAF) was ascending in power when screenwell water level started to lower. At 89 percent power, at 22:23, Operators began taking compensatory measures to reduce power and mitigate water level lowering. At 22:40, a manual scram was initiated.

The scram was complicated by a residual transfer that resulted in non-vital equipment trips. This event resulted in the manual actuation of the Reactor Protection System, High Pressure Coolant Injection, Reactor Core Isolation Cooling, Main Steam Isolation Valves and automatic actuation of Emergency Diesel Generators, Emergency Service Water, and containment isolations in multiple systems, reportable per 10 CFR 50.73(a)(2)(iv)(A).

The lowering screenwell water level was caused by frazil ice blockage at the intake structure. The frazil ice stopped affecting screenwell water level after the manual scram. Corrective actions include strengthening mitigating actions in response to frazil ice.

The residual transfer was caused by lubrication hardening in the lower control valve assembly of the 71PCB-10042 breaker. Corrective actions included replacing or reworking the lower control valve assembly.

05000247/LER-2015-003Indian Point5 December 2015
3 February 2016
Manual Reactor Trip Due to Indications of Multiple Dropped Control Rods Caused by Loss of Control Rod Power Due to a Power Supply Failure
LER 15-003-00 for Indian Point, Unit 2, Regarding Manual Reactor Trip Due to Indications of Multiple Dropped Control Rods Caused by Loss of Control Rod Power Due to a Power Supply Failure

On December 5, 2015, control room operators initiated a manual reactor trip (RT) after observing indications consistent with multiple dropped control rods (CR) following an alarm for the trip of Motor Control Center (MCC)-24/24A. No Control Rod indication was available due to MCC-24 being de-energized. All primary safety systems functioned properly except the primary rod control cabinet power supply (PS1) which was in a degraded condition prior to the event and failed to function as required. The plant was stabilized in hot standby. There was no radiation release. The Auxiliary FW system automatically started as designed. The direct cause of the event was loss of MCC-24 due to an internal fault at the line side leads at cubicle 2H where they connect to the bucket stab assemblies (load side fault). This caused the supply breaker feed to open per design and clear the fault. The de-energization of MCC-24 removed the functioning backup Control Rod (CR) power supply and the remaining degraded primary power supply failed to function as required. The apparent cause was an unanticipated loss of power to the CR system due to the degradation of the primary CR power supply (PS1) which failed to function when the operating power supply (PS2) was lost. MCC-24/24A was lost due to a design error that allowed the positioning of a mounting plate too'close and obstructing the line side wiring resulting in contact. Vibration over time resulted in degraded wiring insulation which eventually shorted. Corrective actions included inspection and testing of the MCC-24 bus and control wiring. The degraded Rod Contrl power supply (PS1) was replaced. Maintenance procedures will be revised to provide more in-depth inspection criteria. The event had no effect on public health and safety.

FACILITY NAME (1) PAGE (3) DOCKET (2) LER NUMBER (6)

05000263/LER-2015-006Monticello23 November 2015
21 January 2016
- Reactor Scram due to Group 1 Isolation from Foreign Material in the Main Steam Flow Instrument Line
LER 15-006-00 for Monticello Regarding Reactor Scram due to Group 1 Isolation from Foreign Material in the Main Steam Flow Instrument Line

On November 23, 2015, a trip of the # 11 Reactor Recirculation Pump occurred, followed by a Group 1 isolation which resulted in a reactor scram. A post scram troubleshooting investigation determined a large spike in differential pressure occurred in the 'C' main steam flow instrumentation line at the time of the Group 1 initiation event.

The root cause of this event was determined to be legacy foreign material present in the 'C' main steam flow instrumentation line. This foreign material obstructed the instrumentation line and resulted in the momentary sensed high steam flow. The sensed high steam flow was not due to an actual high steam flow condition in the 'C' main steam line.

Since the presence of foreign material in the instrument line is a legacy issue, the corrective action for the root cause was to remove the foreign material. The corrective action for the trip of the reactor recirculation pump, will be to revise the fleet procedure to require verification of torque on accessible electrical connections for critical components which are bench tested and also to ensure that accessible soldered and crimped electrical terminations are inspected for sians of dearadation durina bench testina.

05000316/LER-2015-001Cook
Donald C. Cook Nuclear. Plant Unit 2
23 April 2015
15 January 2016
Manual Reactor Trip Due To A Secondary Plant Transient
LER 15-001-01 for D.C. Cook, Unit 2, Regarding Manual Reactor Trip Due to a Secondary Plant Transient

On April 23, 2015, at 0210, Donald C. Cook Nuclear Plant Unit 2 Reactor was manually tripped from approximately 2 percent of rated thermal power during plant restart following a refueling outage. Unit 2 Reactor was manually tripped due to the inability to maintain Average Reactor Coolant System Temperature above the Technical Specification (TS) required minimum Temperature for Criticality when two newly installed Steam Dump Valves failed open while being manually valved into service. The valves were subjected to, but not designed for, two phase flow.

The Root Cause has been determined to be that the modification process failed to identify and document all system operational vulnerabilities. The corrective action to preclude repetition is an enhancement of the Engineering Modifications procedure to require development and inclusion of a narrative to describe system operation, including key interfacing system operation.

The manual Reactor Protection System (RPS) actuation was reported via Event Notification 51004 in accordance with 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A), and 10 CFR 50.72(b)(2)(i). The valid RPS actuation and the completion of the plant shutdown required by TS are reportable as a Licensee Event Report in accordance with (- 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(2)(i)(A) respectively.

05000354/LER-2015-005Hope Creek28 September 2015
5 January 2016
Reactor Scram Due to Invalid RRCS Actuation
LER 15-005-01 for Hope Creek, Unit 1, Regarding Reactor Scram Due to Invalid RRCS Actuation

On September 28, 2015, at 20:46, with the Hope Creek reactor operating at 100% power, a human error during surveillance testing resulted in the actuation of the Redundant Reactivity Control System (RRCS), and subsequently, an automatic reactor scram on a valid low water level signal. At the time of the transient, a surveillance test of division 1 of the RRCS system was in progress. The test simulates a high reactor pressure signal. Plant data show the signal was entered in both channels of division 1 of the RRCS system. The resulting system actuation caused a trip of both Reactor Recirculation Pumps, and the actuation of the Alternate Rod Insertion (ARI) function of the RRCS system. As a result of these two actuations, reactor power lowered, causing reactor water level to lower to the Reactor Protection System (RPS) trip set point of +12.5 inches. The RPS initiated an automatic reactor scram. Reactor operators recovered water level to within the desired band using the feedwater system. Reactor pressure was maintained using turbine bypass valves discharging to the main condenser.

This report is being submitted under 10 CFR 50.73(a)(2)(iv)(A), as an event or condition that resulted in the actuation of the Reactor Protection System.

05000281/LER-2015-001Surry21 July 2015Unit 2 Reactor Trip During Turbine Testing

On July 21, 2015 at 05:05, with Unit 1 at Hot Shutdown and Unit 2 at approximately 6% power, Unit 2 experienced a reactor trip initiated from a turbine trip during performance of the Turbine Overspeed Protection Control system circuitry testing. The turbine trip was caused by governor valves rapidly opening due to a speed error which had accumulated between the turbine speed and reference setpoint resulting in a rapid increase in impulse pressure. The root cause of this event was inadequate instructions in the Overspeed Protection Control testing section of the operating procedure. The testing will be removed from operating procedures and placed in test procedures that are not performed as part of routine turbine startup.

All systems functioned as required. Initiation of auxiliary or emergency systems was not required. Unit 2 was placed in hot shutdown and the health and safety of the public were not affected.

This report is being submitted pursuant to 10CFR50.73(a)(2)(iv)(A) as an event that resulted in the automatic actuation of the Reactor Protection System.

05000346/LER-2015-002Davis Besse9 May 2015Improper Flow Accelerated Corrosion Model Results in 4-Inch Steam Line Failure and Manual Reactor Trip

On May 9, 2015, with the Davis-Besse Nuclear Power Station (DBNPS) operating in Mode 1 at approximately 100 percent power, a steam leak was identified in the Turbine Building. A rapid shutdown was initiated, and the reactor was manually tripped at 1909 hours from approxjrnately 30 percent power.

The Steam Feedwater Rupture Control System was manually initiated to isolate the leak and start the Auxiliary Feedwater System. The cause of the leak was failure of a four-inch pipe in the Moisture Separator Reheater System due to Flow Accelerated Corrosion (FAC). An incorrect data input caused the FAC software model to underestimate the predicted wear rate, so inspections were not performed to identify the piping wall thinning prior to failure. Additionally, a previous event was not evaluated to ensure the proposed corrective actions would encompass a validation of all critical data inputs. Corrective Actions include improvements in the fidelity of the data in the FAC Software model, and improvements in the Corrective Action Program with respect to Root Cause Evaluations.

This issue is being reported in accordance with 10 CFR 50.73(a)(2)(iv)(A) as a manual actuation of the Reactor Protection System and the Auxiliary Feedwater System.

05000530/LER-2015-002Palo Verde1 May 2015Condition Prohibited by Technical Specification 3.0.4 Due to an Inoperable Atmospheric Dump Valve (ADV)

On May 1, 2015, following completion of refueling activities, PVNGS Unit 3 entered Mode 4 and continued to Mode 3 in preparation for plant startup. On May 2, 2015, when plant conditions needed to test atmospheric dump valves (ADV) with steam were achieved, testing of ADVs was initiated. At 1739 on May 2, 2015, testing determined that ADV SGB-HV-178 (ADV-178) would not stroke more than approximately 13 percent open. Operations personnel declared ADV-178 inoperable and entered Technical Specification Limiting Condition of Operation (LCO) 3.7.4, Atmospheric Dump Valves, Condition A. An investigation determined ADV-178 was inoperable when Unit 3 entered Mode 4.

Inspection of ADV-178 determined internal sealing rings were improperly installed during maintenance performed in the refueling outage. The valve was repaired and tested and declared operable at 0853 on May 7, 2015. The causes of the event were human error by maintenance personnel and inadequacies with the procedure used to perform the valve maintenance. Corrective actions will revise work instructions to provide detailed guidance for valve re- assembly and to require verifications of proper re-assembly.

A similar event was reported in LER 50-529/2012-003-00 which resulted when testing in Mode 3 following refueling activities identified an inoperable steam supply valve for the steam driven auxiliary feedwater pump.

05000414/LER-2015-001Catawba Nuclear Station, Unit 220 April 2015Auxiliary Feedwater (AFW) System Train 2A and Its Automatic Transfer Function to the Nuclear Service Water System (NSWS) Were Determined to Have Been Inoperable in Violation of Technical Specifications (TS)

On April 20, 2015, it was determined that TS 3.7.5, "Auxiliary Feedwater (AFW) System", Condition B had been violated.

Due to the inability to meet a TS Surveillance Requirement, it was determined that AFW System Train 2A had been entered Mode 4 at the start of its End of Cycle 20 Refueling Outage. The cause of the inoperability was the inability of valves 2CA-60 and 2CA-56 (motor driven AFW Train 2A discharge flow control valves to steam generators A and B, respectively) to automatically open to their safe position. It was also determined that TS 3.3.2, "Engineered Safety Feature Actuation System (ESFAS) Instrumentation", had not been met, resulting in TS Limiting Condition for Operation (LCO) 3.0.3 being unknowingly entered and violated. This was due to AFW System Train 2A being unable to automatically transfer to its assured source of supply (the NSWS). The cause of this event was determined to be a failed sliding link. The failed sliding link was replaced during the refueling outage. During this event, the normal feedwater supply to the steam generators remained available and actuation of the AFW System or transfer of its suction to the NSWS was not required. Had actuation of the AFW System been required, valves 2CA-56 and 2CA-60 were open, except for brief periods as described in this LER. Therefore, with the exception of these brief periods, the AFW System would have performed its safety related function. In addition, AFW System Train 2B remained capable of transferring its suction to the NSWS, had it been required to do so. Therefore, this event had no adverse effect upon the health and safety of the public.

05000388/LER-2015-003Susquehanna10 April 2015Unit 2 Automatic Reactor Scram Caused by Main Turbine Trip Due to Loss of Main Condenser Vacuum

On April 10, 2015, at 2100 hours, a planned shutdown for the Susquehanna Unit 2 refueling outage commenced. With shutdown in progress and at approximately 37% power for balance of plant operations, a pre-job brief was conducted in preparation for placing an Auxiliary Boiler in service and placing the Main Turbine Steam Seals on Auxiliary Steam.

At 2129 hours, the 'A' Auxiliary Boiler was placed in service per procedure OP-027-001, "Aux Boiler System," and the Main Turbine Steam Seals were placed on auxiliary steam via valve 221008, "SJAE and Steam Seal Aux Supply !so Vlv." At approximately 2330 hours, the procedure was resumed which directed closure of valve 221008 when Auxiliary Boiler temporary load is no longer needed. At this point, temporary load was no longer needed but auxiliary steam was still flowing through valve 221008, supplying steam to the Unit 2 Main Turbine Steam Seals. The valve was subsquenty closed, which isolated steam to the U2 Main Turbine Steam Seals, allowing air in-leakage into the Main Condenser, causing condenser vacuum to degrade. At 2346 hours, Unit 2 automatically scrammed from approximately 37 percent power due to a the Main Turbine trip on loss of condenser vacuum.

Root Cause: Personnel involved with auxiliary boiler startup did not adhere to Operator Fundamentals and effectively apply appropriate Human Performance error-reduction tools specific to understanding and anticipating the impact of component operation prior to its operation. Completed Action: Procedure OP-027-001, "Auxiliary Boiler System," was revised to caution operators of the potential for isolating auxiliary steam to the Main steam seals and/or Steam Jet Air Ejectors when securing temporary loading of the auxiliary boilers. Key Planned Action: Provide initial licensed and non-licensed operator classroom and job performance measure or dynamic learning activity training with focus on: STAR, Questioning Attitude, Pre job Brief, and understand and anticipate the impact of component operation prior to its operation. Safety Significance: There were no actual consequences to the health and safety of the public as a result of this event.

05000254/LER-2015-004Quad Cities21 March 2015Automatic Depressurization System Trip Logic Failure

On 03/21/15, at 0800, with Unit 1 shutdown for refuel outage Q1R23, the Unit 1 Off-Line Automatic Blowdown Logic Test was being performed when two Electromatic Relief Valves (ERVs) failed to actuate since the 'N trip logic for the automatic function of the Automatic Depressurization System (ADS) did not energize.

Maintenance burnished the 'A' trip logic relay contacts and the 'B' trip logic relay contacts. The as-found data on the 'B' trip logic of ADS was lost during this troubleshooting, and it is unknown if the 'B' trip logic of the automatic function would have functioned. Once the relay contacts were burnished, the continuity was checked and found acceptable.

The apparent cause for the loss of the 'A' trip logic system was due to relay contact oxidation buildup. The oxidation buildup was due to inadequate preventative maintenance instructions.

The immediate corrective action consisted of burnishing the relay contacts. Future corrective actions include updating the preventative maintenance procedure and replacing the two relays on the 'A' trip logic system that had the oxidation buildup.

This report is submitted in accordance with 10 CFR 50.73 (a)(2)(v)(D) which requires the reporting of any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident; and 10 CFR 50.73 (a)(2)(vii)(D) which requires the reporting of any event where a single cause or condition caused two independent channels to become inoperable in a single system designed to mitigate the consequences of an accident.

05000286/LER-2015-002Indian Point27 February 2015Technical Specification Prohibited Condition Caused by Four Main Steam Safety Valves .Outside Their As-Found Lift Set Point Test Acceptance Criteria

On February 27, 2015, during the performance of surveillance procedure 3-PT-R006A, three main steam safety valves (MSSV) (MS-46-2, MS-45-4 and MS-47-4) failed their As-Found lift.

set point test. Per the test, these valves must lift at +/- 30 of their required setting.

During the test, 7 other MSSVs tested passed their As-Found test criteria.

Technical Specification (TS) 3.7.1 (Main Steam Safety Valves) requires the MSSVs to be operable in accordance with TS Table 3.7.1-1 and Table 3.7.1-2.

Due to the number of failures, during power ascension the remaining MSSVs were tested and two failed (MS-46-2, MS-46-3).

MSSV MS-46-2 had previously failed and had maintenance performed therefore the failure was considered a post maintenance test failure.

MS-46-3 failed its first lift test by 0.60 but met test lift criteria on the second and third test.

TS Surveillance Requirement (SR) 3.7.1.1 requires each MSSV be verified to lift per Table 3.7.1-2 in accordance with the In-service Testing Program. Operability of the MSSVs includes the ability to open within the set point tolerances. The direct cause of the failure of these valves was severely worn spindle rods.

The apparent cause for the failure of MS-47-4 and MS-46-2 was internal friction due to spindle vibration.

The apparent cause of the failure of.MS-45-4 was reuse of a worn spindle. The apparent cause of the failure of MS-46-3 is foreign material.

Corrective actions included testing all 20 MSSVs and adjusting their set point to be within +/- 1% of design set pressure. Installed new spindles and bronze wear sleeves on valves MS-46-4, MS-46-2, MS-47-4, MS-48-2, MS-49-2, MS-49-1, MS-49-3, and replaced the spindle on valve MS-45-4. The Unit 3 MSSV test frequency will be changed from 4 years to 2 years until all modifications are implemented and IPEC is confident the issue is resolved. The event had no effect on public health and safety.

FACILITY NAME (1) DOCKET (2) LER NUMBER (6) PAGE (3)

05000390/LER-2015-001Watts Bar21 February 2015Manual Reactor Trip Initiated Due to Rapid Loss of Main Condenser Vacuum

reactor was manually tripped by control room operators due to a decreasing main condenser vacuum. Subsequent to the reactor trip, the Auxiliary Feedwater system actuated. Control and Shutdown rods fully inserted into the reactor core, and safety systems responded as designed. The unit was stabilized in Mode 3, with decay heat removal via Auxiliary Feedwater and the Steam Generator Atmospheric Dump Valves. The Main Steam Isolation Valves were closed and remained closed during the event.

Tennessee Valley Authority (TVA) has determined that the decreasing condenser vacuum was due to a failure of an expansion joint boot seal in the "C" zone of the main condenser. This seal functions as the expansion joint between the condenser and low pressure turbines. The failure of the seal was due to a non-optimal vulcanization process and inadequate overlap in a joint splice, which significantly weakened the seal and allowed seal water to permeate the seal, further weakening the joint. The failed main condenser boot seal was replaced with a new boot seal on the "C" zone of the condenser. As a preventative measure, the boot seals on the "A" and "B" zones were also replaced.

05000461/LER-2015-001Clinton6 February 2015Division 1 and Division 2 Reactor Water Cleanup System High Differential Flow Instruments Become Incapable of Performing Their Safety FunctionOn 2/6/15 at 2300 CST, the Division 1 Reactor Water Cleanup (RT) system differential flow indicator (1E31R614A) was observed to be reading greater than 10 gallons per minute (gpm) different from its sister channel, resulting in it failing its channel check. Operators declared this instrument inoperable in accordance with Clinton Power Station Technical Specification (TS) 3.3.6.1, Primary Containment and Drywell Isolation Instrumentation, requiring placing the channel in trip within 24 hours per Required Action D.1. At 2355, the Division 2 RT differential flow indicator (1E31R614B) indicated out of specification, requiring entry into Required Action E.1 for two channels inoperable. With both channels inoperable, the leakage detection system was incapable of performing its containment isolation function for RT differential flow. At 0036 on 2/7/15, a fill and vent of the Division 1 RT leak detection instrumentation was completed, restoring Division 1 to an operable status. At 0225 on 2/7/15, a fill and vent of the Division 2 RT leak detection instrumentation was completed, restoring Division 2 to an operable status. An eight-hour ENS notification (#50794) was made at 0637 CST in accordance with 10CFR50.72(b)(3)(v)(C). This event is also reportable under 10CFR50.73(a)(2)(v)(C).