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 Start dateReport dateSiteReporting criterionSystemEvent description
05000440/LER-2017-0061 December 2017Perry10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(v)(C), Loss of Safety Function - Release of Radioactive Material
10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident
High Pressure Core Spray

On October 4, 2017 at 0155 hours, while in Mode 1 at 100 percent rated thermal power, inoperability of both A and B trains of Motor Control Center, Switchgear, and Miscellaneous Electrical Equipment Areas Heating, Ventilation, and Air Conditioning System and Battery Rooms Exhaust System (M23/24) occurred. Train A was shutdown and declared inoperable based on excessive drive belt noise and belt malfunction. Train B was inoperable due to ongoing maintenance on its associated chilled water system. The combination of inoperability resulted in a loss of safety function. Technical Specification (TS) 3.0.3 was entered per plant procedures, and at 0250 hours a plant shutdown was commenced. At 0620 hours, the A train of M23/24 was declared operable following belt replacement and TS 3.0.3 was exited. The plant was restored to 100 percent rated thermal power at 0804 hours.

The cause was determined to be inadequate procedural guidance in that the "general tensioning" method described in plant maintenance procedure, V-belt and Sheave Maintenance, is insufficient for restoring components to a reliable condition. Corrective action includes revising the procedure for correct tensioning guidance.

The safety significance of this event is considered to be very small. This event is being reported in accordance with 10CFR50.73(a)(2)(v)(B), 10CFR50.73(a)(2)(v)(C), and 10CFR50.73(a)(2)(v)(D) as an event or condition that could have prevented the fulfilment of a safety function.

NRC FORM 386 (06-2016)

05000346/LER-2017-00213 September 2017
27 November 2017
27 November 2017Davis Besse10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
Steam Generator
Feedwater
Service water
Main Steam Isolation Valve
Auxiliary Feedwater
Main Steam Safety Valve
Decay Heat Removal
Main Steam

On September 13, 2017, with the Davis-Besse Nuclear Power Station operating at approximately 100 percent power, Auxiliary Feed Water (AFW) Pump Turbine 1 experienced high inboard bearing temperature during performance of quarterly Surveillance Testing. The turbine was tripped, and disassembly revealed damage to the journal bearing. The bearirig was replaced, and following successful post maintenance testing, AFW Train 1 was declared Operable on September 16. The cause of the bearing damage was an improperly marked oil sight glass, which allowed operation with improper bearing lubrication. The improper markings were due to the maintenance work instruction for replacing the sight glass not including dimensions or guidance for setting required operational bands.

On September 26, 2017, it was identified that low inboard bearing oil level had likely existed since completion of the previous quarterly surveillance test on June 21, when an oil sample was taken following testing but the bearing was not refilled due to the improperly marked sight glass. This issue is being reported in accordance with 10 CFR 50.73(a)(2)(v)(B) as a condition that could have prevented the fulfillment of the safety function, and in accordance with 10 CFR 50.73(a)(2)(i)(B) as a condition prohibited by Technical Specifications.

05000482/LER-2017-0037 September 2017
2 November 2017
2 November 2017Wolf Creek10 CFR 50.73(a)(2)(ii)(B), Unanalyzed Condition
10 CFR 50.73(a)(2)(v)(A), Loss of Safety Function - Shutdown the Reactor
10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
Steam Generator
Main Steam Isolation Valve
Main Turbine
Main Steam Safety Valve
Main Steam Line
Main Steam

On September 7, 2017, Wolf Creek Generating Station (WCGS) was in Mode 1 at 100 percent power. During evaluation of protection for safety-related equipment from the damaging effects of tornados, WCGS personnel determined that the non safety-related exhaust lines from safety-related atmospheric relief valves (ARVs) and main steam safety valves (MSSVs) could be crimped by tornado generated missiles. If these are crimped completely, these components may be unable to perform their safety functions. The ARVs and MSSVs were declared inoperable and Enforcement Guidance Memorandum (EGM) 15-002, "Enforcement Discretion for Tornado- Generated Missile Protection Noncompliance," Revision 1 was applied. Immediate compensatory measures consistent with EGM 15-002 were implemented within the time allowed by the applicable Technical Specification Limiting Condition(s) for Operation. The ARVs and MSSVs were subsequently declared operable but nonconforming. These tornado missile vulnerabilities existed since the original plant construction. Actions will be taken to establish compliance for these components either by a plant modification or employing a methodology for addressing tornado missile non-conformances.

On April 5, 2017, WCGS personnel provided a 10 CFR 50.72 notification in Event Notification (EN) 52666 concerning tornado missile protection issues known at that time. As stated in EGM 15-002, the NRC will exercise enforcement discretion for subsequent tornado missile 10 CFR 50.72 notifications. Therefore, no 10 CFR 50.72 notification was made for this condition.

05000341/LER-2017-00410 August 2017
9 October 2017
9 October 2017Fermi10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
Service water
Emergency Diesel Generator
Residual Heat Removal
On August 10, 2017, it was determined that inadequate procedural guidance for determining operability for ventilation support systems was being utilized. The Residual Heat Removal (RHR) switchgear and pump rooms have ventilation systems to maintain operability of the equipment in the rooms. Fermi 2 procedures had directed personnel to declare the supported equipment in the rooms inoperable due to nonfunclionality of the ventilation systems only if the room temperature exceeded the operability limit. Following discovery, a review of the RHR switchgear and pump room ventilation systems for the past three years was performed. The review identified multiple instances where the ventilation systems were nonfunctional and should have resulted in entry into applicable Technical Specifications (TS). Many of these instances resulted in operations or conditions prohibited by TS, since TS Required Actions were not completed within the Completion Times for restoration of affected equipment and plant shutdown. In addition, one instance was identified where the plant configuration was such that it could have prevented the fulfillment of the safety function to remove residual heat following a design basis accident. An engineering evaluation of this specific instance was performed and verified that the plant remained within its analyzed design basis. All other instances maintained one fully operable division of heat removal equipment such that no loss of safety function existed. There were no radiological releases associated with this event. The safety significance was determined to he very low. The cause of the event was inadequate procedural guidance. Immediate actions were taken to provide interim guidance related to the procedure. Corrective actions to revise the affected procedure have been completed.
05000286/LER-2017-00330 June 2017
29 August 2017
29 August 2017Indian Point
Indian Point Unit 3
10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(V)(B)
Steam Generator
Feedwater
Service water
Auxiliary Feedwater

Technical Specification 3.7.6. A pinhole sized through wall leak was discovered on the downstream side of CD-123, the 32 Auxiliary Boiler Feed Pump Bearing Cooling Relief Valve, which was unisolable to the Condensate Storage Tank.

The pinhole leak was identified following the performance of 3PT-Q120B, 32 Auxiliary Boiler Feed Pump Functional Test. All Operability and Acceptance Criteria of 3PT-Q120B were sat. The relief valve was removed from the system and sent to a vendor for evaluation. After the vendor evaluation, it was determined that the valve pinhole area leak was due to a casting defect.

This event was determined to be reportable as a Loss of Safety Function pursuant to10 CFR 50.72(b)(3)(v)(B) - Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to remove residual heat.

RC FORM 366 (04-2017)

05000341/LER-2017-00322 May 2017
21 July 2017
21 July 2017Fermi10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(v), Loss of Safety Function
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
Service water
Emergency Diesel Generator
Reactor Pressure Vessel
Residual Heat Removal
Residual Heat Removal Service Water

On May 22, 2017 at 05:10 am (EST), while placing Division 2 Residual Heat Removal Service Water (RHRSW) in service for biocide treatment of the Division 2 Residual Heat Removal (RI IR) Reservoir, the Division 2 RI IRSW Flow Control Valve (FCV) (El 1 50F068B) failed to fully open.

Troubleshooting discovered the direct cause was failure of the anti-rotation bushing stem key. The apparent cause was system operating conditions (high vibration) resulting in the failed tack welds. Previous troubleshooting on an indication issue on May 5, 2017 for the RHRSW FCV was inadequate, and did not identify the failure of the anti-rotation key. As a result, the RHRSW FCV was returned to service at 2:50 pm on May 7, 2017, and subsequently failed on the next on-demand stroke at 5:10 am on May 22, 2017. Seventeen similar Motor Operated Valves (MOVs) were inspected and no MOVs exhibiting the symptoms observed on the E1150F068B prior to the failure of the anti-rotation key were found, and all anti-rotation devices were found to be intact. The Past Operability determination for 131150E068B found that the MOV was unable to perform its design basis functions from May 3. 2017 at 5:48 am, when the RI IRSW FCV was last successfully stroked under dynamic conditions, through May 24. 2017 at 4:04 pun, when the RI IRSW FCV was returned to service. The Division I RI-IRSW was available throughout the event except on two occasions. Division 1 of RHRSW was declared inoperable for Mechanical Draft Cooling Tower (MDCT) Nozzle Cleaning activities on May 9, 2017 from 8:41 am to May 9, 2017 at I I :18 pm. Division I of RI IRSW was again declared inoperable for IVIDCT Nozzle Cleaning activities on May 11, 2017 at 8:35 am through May 11, 2017 at 10:01 pm. The as found condition of the Division 2 RHRSW FCV is a condition prohibited by Technical Specification 3.7.1 and reportable under 10 CFR 50.73 (a)(2)(i)(13) "Operation or Condition Prohibited by Technical Specifications," and 10 CFR 50.73(a)(2)(v)(13) "Any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to: Remove Residual Heat.

05000293/LER-2017-00917 May 2017
17 July 2017
15 November 2017Pilgrim10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
Primary Containment Isolation System
Primary containment
Shutdown Cooling
Residual Heat Removal

On May 17, 2017, during Refueling Outage (RFO)-21 while performing an extent of condition review it was discovered that the contact indicating tabs of relays 16A-K30 and 16A-K54 of the Pilgrim Nuclear Power Station (PNPS) Primary Containment System, were visually hanging in the mid-position (partial travel).

The relays were replaced during RFO-21 along with 16A-K29 and 16A-K53, and all four relays were sent to an offsite vendor for further testing and analysis. Other relays were reviewed but were determined to be outside the scope of this extent of condition review.

PNPS stated at the time that this event was reportable under 10 CFR 50.73(a)(2)(i)(B) - Operation or condition prohibited by Technical Specifications; and potentially reportable in accordance with 10 CFR 50.73(a)(2)(v)(B), (C) and (D) - Any condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to remove residual heat, control the release of radioactive material and mitigate the consequences of an accident. However, additional information provided by our offsite vendor and an engineering evaluation, support the conclusion that there was never a loss of safety function regarding any of the four relays (16A-K29, 16A- K30, 16A-K53 and 16A-K54). Therefore, this event was not reportable under 10 CFR 50.73(a)(2)(i)(B) nor under 10 CFR 50.73(a)(2)(v)(B), (C) or (D).

This event posed no threat to public health and safety.

05000293/LER-2017-0083 May 2017
30 June 2017
2 November 2017Pilgrim10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
Primary containment
Low Pressure Coolant Injection

On May 3, 2017 with the unit shutdown for refueling outage, while performing plant procedure 3.M.3-27, "480V Bus B6 Transfer Test, UV, Degraded Voltage and Timing Relays Calibration and Annunciator Verification," the time delay Agastat relay 27A-B1X/TDDO opened instantaneously, instead of with a time delay. This relay is set to drop out after a 1.25 second time delay after being de-energized. This condition was discovered during the plant's refueling outage when conditions were such that the equipment normally energized/activated by this time delay relay was not required to be operable.

Pilgrim Nuclear Power Station is submitting this Licensee Event Report in accordance with 10 CFR 50.73(a)(2)(i)(B) - Operation or condition prohibited by Technical Specifications; and in accordance with10 CFR 50.73(a)(2)(v)(B), (C) and (D) - Any condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to remove residual heat, control the release of radioactive material and mitigate the consequences of an accident.

This event was not risk significant. There was no threat to public health and safety from this condition.

05000528/LER-2017-00111 April 2017
14 June 2017
14 June 2017Palo Verde
Palo Verde Nuclear Generating Station Unit 1
10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
Auxiliary Feedwater
Containment Spray

On April 17. 2017, the staff identified a low refrigerant level in the Unit 1 train B essential chilled water (EC) system chiller during inspection. Operations personnel immediately declared EC chiller train B inoperable. On April 17, 2017, the leak was corrected and EC chiller train B was refilled with refrigerant to within the manufacturer's specifications. Operations personnel declared the system operable on April 18, 2017. The chiller had been inoperable since April 11. 2017, when the automatic purge system was placed into service. The direct cause of the low refrigerant level was leakage due to prior installation of a fitting on the automatic purge system filter without a plug.

During the 7-day period that EC chiller train B was inoperable, the supported low pressure safety injection (LPSI) system train B was inoperable. LPSI train A was also inoperable for approximately 17 minutes on April 13, 2017, during the performance of a routine surveillance test. This 17-minute period represented a condition that could have prevented the fulfillment of a safety function.

The cause of the leak was determined to be ineffective work instructions that did not identify the appropriate part number to be used during filter replacement. Corrective actions include revision of the work instructions. This change will ensure that the existing plug remains in place during filter element replacement. A leak test was also added to the work instructions to verify that no refrigerant leaks are present following maintenance.

05000313/LER-2016-00324 August 2016
9 June 2017
19 October 2016Arkansas Nuclear10 CFR 50.73(a)(2)(ii)(B), Unanalyzed Condition
10 CFR 50.73(a)(2)(v)(A), Loss of Safety Function - Shutdown the Reactor
10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident
Feedwater
Decay Heat Removal

On August 24, September 11, and September 15, 2016, during performance of an extent of condition evaluation related to the protection of Technical Specification (TS) equipment from external flood hazards, Arkansas Nuclear One, Unit 1 (ANO-1), identified non-conforming plant design conditions such that specific ANO-1 TS equipment was considered to not be adequately protected from tornado missiles. These are legacy design issues.

On August 24, 2016, at 0945, September 11, 2016, at 1504, and September 15, 2016, at 0958, Operations declared the affected components inoperable, implemented Enforcement Guidance Memorandum (EGM) 15-002, "Enforcement Discretion for Tornado-Generated Missile Protection Noncompliance", along with necessary compensatory measures, and subsequently declared the affected equipment operable but non-conforming.

The cause of this issue was unclear and changing regulatory requirements during original plant licensing that led to an inadequate understanding of the regulatory guidance with respect to tornado missile protection design requirements.

Interim corrective actions include implementation of compensatory strategies. Plant modifications and license basis changes are being evaluated to resolve outstanding issues.

05000458/LER-2017-00423 March 2017
22 May 2017
22 May 2017River Bend10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(v)(C), Loss of Safety Function - Release of Radioactive Material
Primary containment
High Pressure Core Spray
On March 23, 2017, at 0028 CDT, with the plant operating at 100 percent power, the high pressure core spray system (HPCS was declared inoperable due to a malfunction of a motor-operated valve (MOV) in the system. During a scheduled test, the HPCS pump test return valve to the suppression pool was given a "close" signal after having been opened for the test. The valve position lights indicated that it fully closed, but system flow parameters did not respond as expected. An operator went to the valve and reported that it appeared that the anti-rotation device on the valve actuator had failed, and that the valve was not fully closed. This valve is a primary containment isolation valve. An examination of the MOV found that a set screw on the actuator had loosened, allowing the anti-rotation device to slip down the valve stem. When the anti-rotation device slipped far enough, the retainer keys fell out, allowing the valve stem to disengage from the anti-rotation device. The maintenance history of the valve was investigated, and it was found that in 1996, the anti-rotation device was loosened during a scheduled maintenance task. A review of the work documentation package found that no torque value was specified for the set screw, whereas the vendor manual requires the set screw to be torqued to 60 ft.-lbs. upon installation. This condition is being reported in accordance with 10 CFR 50.72(b)(3)(v) as a potential loss of safety function of the HPCS system and the primary containment isolation function. An evaluation of the as-found condition has concluded that the HPCS system and primary containment isolation would have been able to perform their design safety function had an actual design basis event occurred during the test.
05000482/LER-2016-00128 January 2016
12 May 2017
10 November 2016Wolf Creek10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
Emergency Diesel Generator

On October 6, 2014, at approximately 1326 Central Daylight Savings Time (CDT) during a scheduled 24-hour Run, the 'B' Emergency Diesel Generator (EDG) unexpectedly tripped and a fire was observed in the electrical cabinet (NE106). This resulted in an unplanned entry into a 72 hour shutdown Limiting Condition of Operation (LCO) and an ALERT emergency classification. The source of the fire was the Power Potential Transformer (PPT). On 1/28/16, a Hardware Failure Analysis concluded that the failure of the PPT was due to overloading which resulted from failure of a diode in the power rectifier of the EDG excitation system. Failure of the diode was induced by a governor actuator malfunction on June 9, 2014.

The PPT and associated cabling were replaced. All power diodes in each power rectifier were replaced. Further corrective actions are being tracked by Condition Report (CR) 88665.

05000412/LER-2017-0013 March 2017
2 May 2017
2 May 2017Beaver Valley10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
Service water
Emergency Core Cooling System

A review of the current licensing basis revealed that intentionally coupling the Seismic Category I Service Water System 'SWS) with the not Seismic CAT I Standby Service Water System (SWE)(KG) is a non-conformance with the current icensing basis, and renders the SWS inoperable. As a result, a review of the SWS Design Basis Accident (DBA) full flow surveillance test revealed that during the past three years performance, there were two trains of SWS concurrently inoperable for a time period, as logged, greater than the seven hour shutdown completion time required by Technical Specification 3.0.3.

This condition is reportable as an operation or condition which was prohibited by the plant's Technical Specifications under 10 CFR 50.73 (a)(2)(i)(B), and could have prevented the fulfillment of a safety function under 10 CFR 50.73(a)(2) (v)(B) for the SWS along with the systems that it supports of Emergency Core Cooling (ECCS), Primary Component Cooling Water System (CCP), and the Recirculation Spray System (RSS) .

The plant was not aligned to this configuration at the time of discovery, and all procedures have been revised to eliminate this condition.

05000298/LER-2017-0015 April 2017Cooper10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
Service water
Shutdown Cooling
Reactor Pressure Vessel
Residual Heat Removal
Low Pressure Cooling Injection
Emergency Core Cooling System
Control Rod

On February 5, 2017, during a quarterly sealed valve log audit, Residual Heat Removal (RHR) Valves RHR-V-58 and RHR-V-60 were discovered sealed closed. Normal configuration for these valves is sealed opened. Consequently, Operations declared RHR pumps A and C Inoperable at 0756 hours and entered Technical Specifications (TS) Limiting Condition for Operation (LCO) 3.5.1 Condition A, LCO 3.6.1.9 Condition A, and LCO 3.6.2.3 Condition A.

Subsequently, the operating crew opened RHR-V-58 and RHR-V-60, independently verified the position of the valves and applied seals to the valves. As such, RHR pumps A and C were declared Operable at 1041 hours on February 5, 2017, and TS LCO 3.5.1 Condition A, LCO 3.6.1.9 Condition A, and LCO 3.6.2.3 Condition A were exited.

The root cause is Operations Department standards related to Operator Human Performance and Configuration Control are inadequate and do not meet industry expectations. Licensed and Non-Licensed Operators completed training focused on Standards and Expectations related to attention to detail and configuration control. To prevent recurrence, expectations will be established and institutionalized for Operations Leadership to reinforce consistent application of operator fundamentals and to identify and correct performance gaps for the operating crews.

This is a Safety System Functional Failure.

05000247/LER-2016-0027 March 2016
28 February 2017
28 February 2017Indian Point10 CFR 50.73(a)(2)(iv)(A), System Actuation
10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
Steam Generator
Reactor Coolant System
Emergency Diesel Generator
Auxiliary Feedwater
Residual Heat Removal
Decay Heat Removal
Main Steam

On March 7, 2016, while performing set-up activities for 2-PT-R084C, "23 EDG 8 Hour Load Test," the normal supply breaker to 480 Volt AC Bus (ED) 3A tripped on overcurrent. This caused 480 Volt AC Buses 3A and 6A to de-energize since, as part of the test set-up activities, the tie breaker (3AT6A) between Buses 3A and 6A was closed and the normal supply breaker for Bus 6A was opened. This resulted in a loss of both 21 and 22 Residual Heat Removal (RHR) (BP) pumps. As 'designed, all Emergency Diesel Generators (EDGs) (EK) received automatic initiation signals to start. All required 480 Volt AC buses automatically re-energized by design, with the exception of Bus 3A, which had an overcurrent lockout. Operators manually started 22 RHR pump to restore RHR cooling.

However, prior to restoring the normal supply power to Bus 3A, 23 EDG tripped on overcurrent which resulted in a second loss of RIM event. The cause for the Bus 3A supply breaker tripping was inadequate procedural guidance resulting in excessive loads being energized on Buses 3A and 6A. The direct cause for 23 EDG tripping was cracked solder joints on the automatic voltage regulator (AVR). Corrective actions included revising 2-PT-R084C and replacing the voltage regulator. The event had no effect on public health and safety.

05000313/LER-2016-00430 September 2016
29 November 2016
29 November 2016Arkansas Nuclear10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident
Reactor Coolant System
Service water
Decay Heat Removal

On September 29, 2016, at Arkansas Nuclear One, Unit 1 (ANO-1), during refueling outage 1R26 with both trains of Decay Heat Removal (DHR) in service, a 0.125 gpm leak was identified in the DHR system at a one-inch drain line.

This leak was on a section of cross-connect piping shared by both trains of the DHR system. The consequence of the leak was that both trains of the DHR system were declared inoperable.

The leakage was due to a fatigue crack caused by vibration of the drain line due to a pipe support that was not designed for system vibration.

Other systems and components in ANO-1 and ANO, Unit 2 (ANO-2) exposed to elevated system vibration were evaluated with respect to this condition. As a result of this evaluation, socket welds on other drains and vents in the ANO-1 DHR system were cut out and replaced, and pipe supports were modified where needed to withstand system vibration.

05000220/LER-2016-00228 July 2016
26 September 2016
26 September 2016Nine Mile Point10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual HeatReactor Protection System

On Thursday July 28, 2016, at approximately 2357 hours with power level at approximately 100 percent, Nine Mile Point Unit 1 (NMP1) experienced a loss of Uninterruptible Power Supply (UPS), UPS 162B which resulted in loss of Reactor Protection System (RPS) Bus 11. Numerous half scram and half isolation signals were generated in addition to the isolation of both # 11 and # 12 Emergency Condensers (ECs).

EC # 12 was returned to standby on 7/29/2016 at 0041 hours and EC # 11 was returned to standby on 7/29/2016 at 0045 hours. The causes of this event were the failure of a UPS capacitor and the bypass power transfer set point being set too low for the type of transient. Corrective actions include immediate replacement of the failed capacitor, installation of new higher temperature rated capacitors and adjusting the low voltage bypass power transfer set point.

This event is reportable under 10CFR50.73(a)(2)(v)(B).

05000293/LER-2016-00515 August 201613 October 2016Pilgrim10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident
Service water
Primary containment
Residual Heat Removal
Circulating Water System

Nuclear Power Station (PNPS) declared the ultimate heat sink (UHS) and salt service water (SSW) system inoperable due to high sea water inlet temperatures greater than 75 degrees Fahrenheit (F). PNPS had already taken action, in accordance with plant procedures, to reduce power from 100 percent in an effort to keep from exceeding the Technical Specification (TS) Limit. PNPS entered a 24-hour shutdown Limiting Condition for Operation Action Statement (LCO-AS) for Salt Service Water (SSW) inlet temperature exceeding the TS limit in TS 3.5.6.4. The LCO-AS was subsequently exited at 1651 hours when the temperature of SSW trended to below the TS limit.

Under certain design conditions, the SSW system is required to provide cooling water to various heat exchangers such as the Reactor Building Closed Cooling Water (RBCCW) and Turbine Building Closed Cooling Water (TBCCW) systems. When the inlet temperature to these supplied loads exceeds the 75 degree F limit established in the TS, the SSW system is conservatively declared inoperable until the temperature trends below this value. This condition existed for 59 minutes reaching a maximum of 75.1 degrees F. The cause of the sea water inlet temperature exceeding the 75 degree F TS criterion was sustained increased sea water surface temperature in Cape Cod Bay due to summer weather conditions and recirculation of water from the plant's discharge due to wind and tidal conditions.

There was no impact to public health and safety from this condition.

05000280/LER-2016-00111 July 2016Surry10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
Reactor Coolant System
Service water
On April 7, 2016 at 0638 hours, with Surry Power Station Units 1 and 2 operating at 100% power, the Emergency Service Water Pump (ESWP) 1B cooling water discharge valve flange was found to be cracked, and the pump was declared inoperable. During flange and valve suppOrt repair activities, four bolts on the cooling water discharge valve support base plate were found to be failed due to corrosion. The flange was replaced and the support base plates were anchored with stainless steel bolts. ESWP 1B was returned to operable status on April 9, 2016 at 1105 hours. The cause of the flange and support failure was corrosion of the base plate and anchor bolts from repetitive exposure to service water. On May 11, 2016, an Engineering evaluation determined that the piping and support had been non-functional for prior operability based on the potential for lateral displacement during a seismic event. Therefore, this report is being submitted, pursuant to 10 CFR 50.73(a)(2)(i)(B), for operations prohibited by Technical Specifications, and pursuant to 10 CFR 50.73(a)(2)(v)(B), an event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to remove residual heat. Based on the risk assessment of this event, the risk impact was determined to be of very low significance, and, as a result, the health and safety of the public were not affected.
05000416/LER-2016-00117 March 2016
16 May 2016
16 May 2016Grand Gulf10 CFR 50.73(a)(2)(iv)(A), System Actuation
10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
Shutdown Cooling
Residual Heat Removal
Decay Heat Removal

At 1515 (CDT) on March 17, 2016, with Unit 1 in Mode 5 for a refueling outage, Grand Gulf Nuclear Station (GGNS) experienced an electrical fault and subsequent undervoltage condition on the 115kV offsite power source supplying the onsite Division 2 Engineered Safety Feature (ESF) transformer, ESF 12, and bus. The fault was present long enough to cause an actuation of the Division 2 Load Shedding and Sequencing (LSS) System and subsequent start of the Division 2 Standby Diesel Generator (SDG). The in-service B train of Residual Heat Removal (RHR) was load shed, as designed, and, within 7 seconds, the Division 2 SDG restored power to the Division 2 bus. RHR B was restored within 3 minutes and 13 seconds. Core alterations, in progress at the time, were suspended and fuel bundles were placed in their proper positions. The ESF 11 transformer was paralleled with SDG 2. The Division 2 bus was then placed back to the ESF 11 offsite electrical feed and the Division 2 SDG was secured. The apparent cause was determined to be that the 115kV line was not equipped with pilot scheme protective relaying. Protective relaying is scheduled to be installed in 2017.

Alternate Heat Decay Removal (ADHR) remained available throughout this time period. No changes in Spent Fuel Pool or Reactor Cavity temperature were observed. All safety systems operated as expected for the loss of power to ESF12 and Division 2 LSS System.

The automatic start of the Division 2 Standby Diesel Generator is being reported pursuant to 10 CFR 50.73(a)(2)(iv)(A) and the temporary loss of RHR (Shutdown Cooling) is being reported pursuant to 10 CFR 50.73(a)(2)(v)(B).

05000454/LER-2016-0013 May 2016Byron10 CFR 50.73(a)(2)(ii)(B), Unanalyzed Condition
10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
Steam Generator
Reactor Coolant System
Feedwater
Auxiliary Feedwater

On March 4, 2016, during the Braidwood NRC Component Design Basis Inspection, a concern was raised regarding why it was acceptable for the diesel driven Auxiliary Feedwater (AF) pump engine combustion air intake to be located in the turbine building, a non-safety related structure. On March 7, 2016, the additional evaluations that were completed for Byron determined that the existing configuration did not adequately support diesel engine operation with high energy line break (HELB) conditions in the turbine building, and at 0400 hours Operations entered Technical Specification Limiting Condition for Operation 3.7.5, "Auxiliary Feedwater (AF) System," Condition A, "One AF train inoperable," for one train (B-train) of AF inoperable for both Units 1 and 2. The AF trains were declared operable following a corrective action to install a temporary configuration change to provide an engine combustion air intake from the auxiliary building.

The cause of the event was insufficient validation of vendor analysis inputs in 1993 while reviewing the AF diesel engine's ability to function during a turbine building HELB event.

The corrective actions planned are to develop and install a permanent modification to re-route the AF diesel engine intakes for Unit 1 and 2.

05000456/LER-2016-0014 March 2016
28 April 2016
28 April 2016Braidwood10 CFR 50.73(a)(2)(ii)(B), Unanalyzed Condition
10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
Steam Generator
Reactor Coolant System
Feedwater
Auxiliary Feedwater

On March 4, 2016, during the NRC Component Design Basis Inspection, a concern was raised regarding why it was acceptable for the diesel driven auxiliary feedwater (AF) pump engine combustion air intake to be located in the turbine building, a non-safety related structure. On March 6, 2016, the additional evaluations that were completed determined that the existing configuration did not adequately support diesel engine operation with high energy line break (HELB) conditions in the turbine building, and at 2000 hours, Operations entered Technical Specification Limiting Condition for Operation 3.7.5, "Auxiliary Feedwater (AF) System," Condition A, "One AF train inoperable," for one train (B-train) of AF inoperable for both Units 1 and 2. The AF trains were declared operable following a corrective action to install a temporary configuration change to provide engine combustion air intake from the auxiliary building.

The cause of the event was insufficient validation of vendor analysis inputs in 1993 while reviewing the AF diesel engine's ability to function during a turbine building HELB event.

The corrective actions planned are to develop and install a permanent modification to re-route the AF diesel engine intakes for Unit 1 and 2.

05000296/LER-2016-00119 January 2016
21 March 2016
21 March 2016Browns Ferry10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual HeatHigh Pressure Coolant Injection
Core Spray
Residual Heat Removal
Automatic Depressurization System
Core Standby Cooling System
Emergency Core Cooling System
Low Pressure Coolant Injection

On January 19, 2016, at approximately 1100 Central Standard Time (CST), during troubleshooting of the Main Control Room (MCR) green light indication on the 3A Residual Heat Removal (RHR) Pump Motor Breaker Transfer Switch (MBTS), it was discovered that the 3A RHR Pump MBTS had malfunctioned, potentially preventing the pump from starting from the MCR. The 3A RHR Pump was declared inoperable.

On January 20, 2016, at approximately 0030 CST, the 3A RHR Pump was declared operable following replacement of the 3A RHR Pump MBTS.

A Past Operability Evaluation concluded that the 3A RHR Pump was inoperable from January 9 to January 20, 2016, exceeding the Technical Specification allowed outage time. During this time, the 3B and 3D RHR Pumps were also inoperable on January 14, 2016, from 0127 to 0215 CST, resulting in a Safety System Function Failure. A Probabilistic Risk Assessment determined there was a negligible increase in risk.

The cause of this event was failure of the transfer switch to fully latch due to binding resulting from the MBTS being installed greater than its twenty-one year service life with no Preventative Maintenance (PM) performed. Corrective actions include verifying similar transfer switches are latched in the NORMAL positon on BFN, Units 1, 2, and 3, and creating a PM activity with a replacement schedule for these switches.

05000331/LER-2015-00231 March 2015
28 January 2016
28 January 2016Duane Arnold10 CFR 50.73(a)(2)(ii)(B), Unanalyzed Condition
10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(vii), Common Cause Inoperability
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
High Pressure Coolant Injection
Reactor Core Isolation Cooling
Primary containment
Core Spray
Residual Heat Removal
Emergency Core Cooling System
On March 31, 2015, while operating at 100% power, with no structures, systems, or components inoperable, an unanalyzed condition regarding the primary containment suppression pool coating was identified. Specifically, during an inspection of suppression pool (torus) during the October 2014 refueling outage, degradation of the torus coating was discovered. Some of the coating had become delaminated. NextEra Energy Duane Arnold took immediate action to restore the coating to within design parameters during the refueling outage and the degraded condition no longer exists. Extensive analysis was performed to determine effect of the delaminated material. Upon completion of this investigation, it was determined that an unanalyzed condition, a condition prohibited by Technical Specifications, an event or condition that could have prevented fulfillment of a safety function and common cause inoperability existed and is reporting the condition under various sections of 10 CFR 50.73. The root causes of this event were less than adequate coating application specification and work instructions and less than adequate project oversight and control.
05000263/LER-2015-00724 November 2015
21 January 2016
21 January 2016Monticello10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual HeatService water
Shutdown Cooling
Reactor Recirculation Pump
Reactor Pressure Vessel
Residual Heat Removal
Reactor Water Cleanup
Decay Heat Removal
Safety Relief Valve
Low Pressure Coolant Injection

On November 24, 2015 at 0534 hours, the Monticello Nuclear Generating Plant was at 0% power in Mode 3 (Hot Shutdown) for a forced outage. While initially placing Shutdown Cooling (SDC) in service, the 12 Residual Heat Removal (RHR) pump tripped approximately 8-10 seconds after start due to the closure of the RHR SDC suction isolation valves. When placing SDC in service, flow rapidly increased after opening the RHR Division 2 Low Pressure Coolant Injection (LPCI) outboard injection valve causing a localized pressure transient in the reactor recirculation pump suction piping that resulted in an isolation of the SDC suction line. Reactor pressure vessel (RPV) pressure remained stable at approximately 30 psig.

Prior to attempting to place 'B' SDC in service, the Condensate system and the 'F' Safety Relieve Valve were in service providing decay heat removal. Immediate actions were taken to restore 'B' RHR SDC to operable status, thus an alternative method of decay heat removal was already established by the Condensate system and `F' Safety Relief Valve.

05000364/LER-2015-0019 January 2015
13 January 2016
14 January 2016Farley10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
Steam Generator
Auxiliary Feedwater
Main Steam Line

On 1/9/2015 at 1255 CST with Unit 2 operating at 100 percent thermal power the Turbine Driven Auxiliary Feedwater (TDAFW) pump was declared inoperable based on a causal investigation for a November 2014 surveillance test failure. The causal analysis identified that a design vulnerability existed which was the cause of both the November failure and a similar April 2014 failure. This vulnerability with the governor control system created a configuration within the software that had the potential for an expected trip signal to be recognized as a shutdown signal during the start sequence. Due to his condition, the TDAFW Pump could not be relied on to start for some plant conditions in the accident analysis for a Main Steam Line Break (MSLB) such that a reasonable assurance of operability could no longer be supported. Other accident analysis conditions were found to be unaffected. The cause of the design error was missing information in the original design documentation which would have provided an opportunity to develop the design change correctly in 2011.

For corrective actions, a temporary modification was made to increase a timer setpoint to eliminate the design vulnerability. This modification will be made permanent through the design change process. Design documents will be revised to add missing information which led to the design vulnerability.

Supplement: A past operability review has been completed and the results are appended to this LER.

05000328/LER-2015-00210 November 2015
6 January 2016
6 January 2016Sequoyah
F
10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual HeatEmergency Core Cooling System
Containment Spray

On November 10, 2015, at 1502 Eastern Standard Time (EST), two cold weather suits were inadvertently dropped into the equipment pit portion of the Sequoyah Nuclear Plant Unit 2 reactor cavity, resulting in two containment recirculation drains being declared inoperable. Technical Specification (TS) Limiting Condition for Operation (LCO) 3.6.15, "Containment Recirculation Drains," and TS LCO 3.0.3 were entered. The first suit was removed from the equipment pit at 1553 EST.

At that time, only one of the drains remained inoperable and LCO 3.0.3 was exited. The remaining suit was removed from the equipment pit at 1556 EST, and LCO 3.6.15 was exited. Plant conditions were restored to normal within the allowed LCO times and no plant shutdown was required. The two cold weather suits in the Unit 2 reactor cavity area created the potential for obstructing the flow path for containment recirculation adversely affecting the safety function of the Containment Spray and Emergency Core Cooling Systems that are needed to mitigate the consequences of a design basis accident. The effect of this condition resulted in an unanalyzed condition that significantly degraded plant safety.

The apparent cause was failure of the Maintenance personnel to identify and mitigate potential hazards and risks during the pre-job briefs, 2-minute rule, and walk downs. Corrective action includes addition of risk mitigation strategies to the containment access control procedure. Unit 1 was unaffected by this event.

05000298/LER-2015-00430 May 201529 July 2015Cooper10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual HeatPrimary containment
Shutdown Cooling
Residual Heat Removal

On May 30, 2015, at 03:27, Cooper Nuclear Station placed the "B" Loop of Residual Heat Removal (RHR) in the Shutdown Cooling (SDC) mode of operations and entered Mode 4, Cold Shutdown, at 04:15. At 04:58, isolation signals from pressure switches (RR-PS-128A and/or RR-PS-128B) were received and, SDC suction isolation valves RHR-MO-17 and RHR-MO-18 closed, resulting in a loss of SDC.

Investigation revealed the event was initiated by steam flashing in the SDC line. This flashing created pressure transients, causing RHR-MO-17 and RHR-MO-18 to close. The steam flashing occurred due to temperature in the SDC line being at or near saturation temperature causing localized boiling then void collapse with coolant being drawn from the reactor vessel thru the reactor recirculation system. SDC was restored at 05:20 on May 30, 2015. The root cause of the event was determined to be a design vulnerability and subsequent operation of the SDC system that resulted in a trip of the SDC suction valves due to sub-cooling and flashing in the RHR or Reactor Recirculation (RR) system. To prevent recurrence, CNS will initiate an Engineering Change request to move the location of the input pressure signals required to meet requirements of Technical Specification 3.3.6.1, Table 3.3.6.1-1, 6(a) from the RR line to the Vessel Steam Dome.

This is a Safety System Functional Failure.

05000263/LER-2015-0022 May 201520 August 2015Monticello10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual HeatService water
Shutdown Cooling
Reactor Pressure Vessel
Residual Heat Removal
Reactor Water Cleanup
Fuel Pool Cooling and Cleanup
Decay Heat Removal

On May 2, 2015, the Monticello Nuclear Generating Plant (MNGP) was in Mode 5 for a refueling outage.

During performance of surveillances of the non-credited 4kV essential Bus, MNGP experienced a loss of the 4kV Bus and essential Load Center due to an improperly landed jumper wire. Loss of the Load Center de- energized the valve position indication on the Residual Heat Removal (RHR) shutdown cooling inboard isolation valve, causing a subsequent trip of the RHR pump operating in shutdown cooling on a pump suction interlock and a loss of normal shutdown cooling. Control Room operators entered the appropriate abnormal procedures and verified alternate decay heat removal was in service until shutdown cooling could be restored.

Immediate corrective actions included suspension of all work pending approval of the shift manager to ensure outage activities did not further degrade plant conditions and electrical work was limited to protect shutdown cooling. The essential Load Centers were cross tied to restore normal shutdown cooling.

Corrective actions include revising procedures to reinforce human performance tools, adequately assess risk involved with electrical work, and ensuring effective barriers are in place to harden residual heat removal function durina shutdown conditions.

05000324/LER-2015-0038 April 20155 August 2015Brunswick10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
Service water
Emergency Diesel Generator
Primary containment
Shutdown Cooling
Residual Heat Removal
Residual Heat Removal Service Water
Decay Heat Removal
On April 8, 2015, at 1639 Eastern Daylight Time (EDT), licensed personnel were informed that oil leakage on the motor for Residual Heat Removal Service Water (RHRSW) system pump 2C exceeded the amount that would be acceptable in order for the pump to meet its 30-day mission time. Event investigators found that sealant had not been applied to mechanical joints in the bearing housings on the horizontal motor, resulting in oil leaking through the unsealed joints. Based on the historical rate of oil additions, engineering personnel concluded that the bearings would not have been able to operate throughout their full mission time, and licensed personnel declared the 2C RHRSW pump inoperable on that basis. The condition resulted in a failure to comply with Technical Specification (TS) 3.7.1, "Residual Heat Removal Service Water (RHRSW)," and with TS Limiting Condition for Operation (LCO) 3.0.4, and also resulted in a loss of the safety function. The direct cause of this event was lack of sealant in mechanical joints of the bearing housings. The root cause was that the process for identifying and updating maintenance procedures impacted by a safety related engineering change was less than adequate, and a contributing cause was a lack of questioning attitude. Corrective actions for this event included applying sealant to the bearing housings, revising procedures to address safety related engineering changes, and discussing the event with appropriate maintenance personnel.
05000293/LER-2015-00212 March 201512 May 2015Pilgrim10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
High Pressure Coolant Injection
Reactor Core Isolation Cooling
Shutdown Cooling
Residual Heat Removal
Automatic Depressurization System
Core Standby Cooling System
Main Steam Line
Safety Relief Valve
Main Steam

On March 12, 2015, after further evaluation of system performance of SRV-3A and SRV-3C, along with results of valve internal conditions identified during physical inspection, the valves were determined to have been inoperable for an indeterminate period during the last operating cycle. Specifically, SRV-3C was determined to be inoperable based on its on-demand performance at low reactor pressures, as well as the visual conditions that were identified during the inspection process. SRV-3A was considered inoperable based on it having similar internal indications as SRV-C when it was disassembled and inspected. SRV-3A Was installed in May 2011 and SRV-3C was installed in October 2013.

Additionally, during an extent of condition review of historical SRV performance, the review identified on March 13, 2015 that SRV-3A had failed to open in response to three manual actuation demands on February 9, 2013.

At the time the valves were declared inoperable the reactor was at 100% power. The valves had been replaced in February 2015 during the forced outage relating to winter storm Juno. This event posed no threat to public health and safety.

05000499/LER-2015-001, Technical Specification Action Statement Time Exceeded Due to Turbine-Driven Auxiliary Feedwater Pump Test Failure Not Recognized4 March 20155 May 2015South Texas10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(i)(B), Prohibited by Technical Specifications
Auxiliary Feedwater

On March 11, 2015 at 1631 hours, a review performed by the Operations Surveillance Coordinator discovered that a surveillance performed on March 4, 2015 on the Unit 2 turbine-driven auxiliary feedwater (AFW) pump 24 did not meet the surveillance acceptance criteria for as-found discharge pressure. An operability review was subsequently performed and on March 12, 2015 it was determined that AFW pump 24 was inoperable as of March 4, 2015 at 1507 hours. As a result, the Technical Specification allowed outage time of 72 hours was exceeded and the Configuration Risk Management Program was not applied; this is reportable per 10CFR50.73(a)(2)(i)(B). During the period of AFW pump 24 inoperability, a second auxiliary feedwater pump was also inoperable on March 9, 2015 resulting in a condition that could have prevented the fulfillment of the safety function of systems that are needed to remove residual heat which is reportable per 10CFR50.73(a)(2)(v)(B). AFW pump 24 was not recognized as inoperable due to human error. As a corrective action, the operators were coached and counseled and remediated by Operations Management.

An actual demand for AFW did not occur during the period of inoperability; therefore, there was no adverse effect on the health and safety of the public.

05000296/LER-2015-001, High Pressure Coolant Injection and Reactor Core Isolation Cooling Inoperable Due To No Suction Source Aligned11 February 201513 April 2015Browns Ferry10 CFR 50.73(a)(2)(v)(A), Loss of Safety Function - Shutdown the Reactor
10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual Heat
10 CFR 50.73(a)(2)(v)(D), Loss of Safety Function - Mitigate the Consequences of an Accident
High Pressure Coolant Injection
Reactor Core Isolation Cooling

On February 11, 2015, at 0820 Central Standard Time, Brown's Ferry Nuclear Plant (BFN), Unit 3, declared the High Pressure Coolant Injection (HPCI) and Reactor Core Isolation Cooling (RCIC) systems inoperable due to no suction source aligned. During surveillance testing, the Condensate Storage Tank (CST) emergency discharge isolation valve energized and closed when the breaker was closed, isolating both systems from their suction source. It was subsequently determined that maintenance task. Operations personnel re-opened the isolation valve using the hand switch in the Control Room, restoring operability to the HPCI and RCIC systems.

The apparent cause of this event was inadequate design review of a 2010 plant modification which allowed latent design vulnerabilities to be introduced into the plant.

The corrective actions to reduce the probability of a similar event occurring in the future were to remove thermal overload heaters from the affected breakers, preventing valve closure when these breakers are closed; to review a sample of recent engineering change packages for quality of Design Review; to repair a faulty hand switch; and to implement a design change for the CST isolation valves for all three BFN units to prevent spurious operation of the isolation valve when the associated breaker is closed.

05000482/LER-2015-001, Personnel Error Causes Two Inoperable Residual Heat Removal Trains28 January 201525 March 2015Wolf Creek10 CFR 50.73(a)(2)(v)(B), Loss of Safety Function - Remove Residual HeatResidual Heat Removal
Emergency Core Cooling System

On January 28, 2015, the nightshift operations crew implemented a clearance order to support planned maintenance on two Residual Heat Removal (RHR) System valves that included closing valves EJHV8716A and EJHV8809A. At 0534 hours on January 28, 2015, Condition C of Limiting Condition for Operation (LCO) 3.5.2 was entered upon determining that less than 100% of the Emergency Core Cooling System (ECCS) flow equivalent to a single OPERABLE ECCS train was available with valve EJHV8716A closed. Entry into LCO 3.0.3 in accordance with Required Action C.1 was made on two separate occasions. Action was taken to restore valves EJHV8716A and EJHV8809A to the open position and exit LCO 3.0.3.

The licensed operators involved with the preparation and implementation of the clearance orders did not recognize that current plant conditions could not support the proposed activity. The individuals involved with this event had their qualifications removed until remediation occurred. Red switch boxes have been placed on the control boards in the control room on the valves in procedure AP 26C-004, "Operability Determination and Functionality Assessment," Section A.16 that can cause an entry into LCO 3.0.3.