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| issue date = 03/01/1999
| issue date = 03/01/1999
| title = LER 99-001-00:on 990103,TS Violation for Power Dependent Insertion Limit Alarm Being Inoperable.Caused by Personnel Error.Revised Procedure to Clarify How Computer Point Is to Be Returned to Scan Mode.With 990302 Ltr
| title = LER 99-001-00:on 990103,TS Violation for Power Dependent Insertion Limit Alarm Being Inoperable.Caused by Personnel Error.Revised Procedure to Clarify How Computer Point Is to Be Returned to Scan Mode.With 990302 Ltr
| author name = MARKS D G, OVERBECK G R
| author name = Marks D, Overbeck G
| author affiliation = ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
| author affiliation = ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
| addressee name =  
| addressee name =  
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=Text=
=Text=
{{#Wiki_filter:~CATEGORY REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)ACCESSION NBR:9903110117 DOC.DATE: 99/03/01.NOTARIZED:
{{#Wiki_filter:~           CATEGORY REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)
NO DOCKET FACZL:STN-50-529 Palo Verde Nuclear Station, Unit 2, Arizona'Publi 05000529 AUTH.N~AUTHOR AFFILIATION MARKS,D.G.
ACCESSION NBR:9903110117             DOC.DATE:   99/03/01. NOTARIZED:       NO                 DOCKET FACZL:STN-50-529 Palo Verde Nuclear Station,               Unit 2, Arizona 'Publi 05000529 AUTH.N~               AUTHOR AFFILIATION MARKS,D.G. '         Arizona Public Service Co.           (formerly Arizona Nuclear Power OVERBECK,G.R.         Arizona Public Service Co.'formerly Arizona Nuclear Po~er RECIP.NAME             RECIPIENT AFFILIATION
'Arizona Public Service Co.(formerly Arizona Nuclear Power OVERBECK,G.R.
Arizona Public Service Co.'formerly Arizona Nuclear Po~er RECIP.NAME RECIPIENT AFFILIATION


==SUBJECT:==
==SUBJECT:==
LER 99-001-00:on 990103,TS violation for power dependent insertion limit alarm being inoperable.
LER     99-001-00:on 990103,TS       violation for     power dependent insertion limit alarm being inoperable. Caused by peronnsel error. Revised procedure to clarify how computer point is to be returned     to scan   mode. With 990302     ltr.
Caused by peronnsel error.Revised procedure to clarify how computer point is to be returned to scan mode.With 990302 ltr.DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR l ENCL j SIZE: tS'ITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.'NOTES:Standardized plant.RECIPIENT ID CODE/NAME PD4-2 PD INTERNAL: ACRS AEOD/S PD/RRAB NRR/DRCH/HOHB NRR/DRPM/PECB RES/DET/EIB EXTERNAL: L ST LOBBY WARD NOAC POORE,W.NRC PDR COPIES LTTR ENCL 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 RECIPIENT ID CODE/NAME FIELDS,M AEOD/SPD/RAB CENTER QMB NRR/DSSA/SPLB RGN4 FILE 01 LMITCO MARSHALL NOAC QUEENER, DS NUDOCS FULL TXT COPIES LTTR ENCL 1 1 2 2, 1 1 1 1 1 1 1 1 1 1 1 1 1 1 05000529 0 D N NOTE TO ALL"RIDS" RECIPIENTS:
DISTRIBUTION CODE: IE22T         COPIES RECEIVED:LTR l ENCL 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.'
PLEASE HELP US TO REDUCE WASTE.TO HAVE YOUR NAME OR ORGANIZATION REMOVED FROM DISTRIBUTION LISTS OR REDUCE THE NUMBER OF COPIES RECEIVED BY YOU OR YOUR ORGANIZATION, CONTACT THE DOCUMENT CONTROL DESK (DCD)ON EXTENSION 415-2083 FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 19 ENCL 19  
j    SIZE:    tS'ITLE:
NOTES:Standardized       plant.                                                               05000529 0
RECIPIENT           COPIES              RECIPIENT            COPIES ID  CODE/NAME        LTTR ENCL          ID CODE/NAME         LTTR ENCL PD4-2 PD                   1    1      FIELDS,M                  1      1 INTERNAL: ACRS                         1    1      AEOD/SPD/RAB              2      2, AEOD/S PD/RRAB             1    1              CENTER            1      1 NRR/DRCH/HOHB             1    1                    QMB          1      1 NRR/DRPM/PECB             1    1      NRR/DSSA/SPLB            1      1 RES/DET/EIB               1    1      RGN4      FILE  01      1      1 D
EXTERNAL: L ST LOBBY WARD             1    1      LMITCO MARSHALL          1      1 NOAC POORE,W.             1     1       NOAC QUEENER, DS         1     1 NRC PDR                    1     1       NUDOCS FULL TXT          1     1 N
NOTE TO ALL "RIDS" RECIPIENTS:
PLEASE HELP US TO REDUCE WASTE. TO HAVE YOUR NAME OR ORGANIZATION REMOVED FROM DISTRIBUTION LISTS OR REDUCE THE NUMBER OF COPIES RECEIVED BY YOU OR YOUR ORGANIZATION, CONTACT THE DOCUMENT CONTROL DESK (DCD) ON EXTENSION 415-2083 FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR               19   ENCL     19


cwenltmeat nnovattm&errt.Palo Verde Nuclear Generatlnli Station Gregg R.Overbeck Vice President Nuclear Production TEL 602/3936t48 FAX 602/3934l077 Mail Station 7602 P.O.Box 52034 Phoenix, AZ 85072-2034 192-01041-GRO/DGM/REB March 2, 1999 U.S.Nuclear Regulatory Commission ATTN: Document Control Desk Mail Station P1-37 Washington, D.C.20555-0001
cwenltmeat nnovattm &errt.
Gregg R. Overbeck                                     Mail Station 7602 Palo Verde Nuclear          Vice President               TEL 602/3936t48         P.O. Box 52034 Generatlnli Station          Nuclear Production            FAX 602/3934l077      Phoenix, AZ 85072-2034 192-01041-GRO/DGM/REB March 2, 1999 U. S. Nuclear Regulatory Commission ATTN: Document Control Desk Mail Station P1-37 Washington, D.C. 20555-0001


==Dear Sirs:==
==Dear Sirs:==


==Subject:==
==Subject:==
Palo Verde Nuclear Generating Station (PVNGS)Unit 2 Docket No.STN 50-529 License No.NPF-51 Licensee Event Report 99-001-00 Attached please find Licensee Event Report (LER)99-001-00 prepared and submitted pursuant to 10 CFR 50.73.This LER reports a condition prohibited by the Technical Specifications in that a required Power Dependent Alarm Circuit was inoperable for longer than the required action completion time.No commitments are being made to the NRC by this letter.In accordance with 10CFR50.73(d), a copy of this LER is being forwarded to the Regional Administrator, NRC Region IV.If you have any questions, please contact Daniel G.Marks, Section Leader, Regulatory Affairs, at (602)393-6492.Sincerely, GRO/DGM/RAB/rlh C<" Attachment cc: E.W.Merschoff J.H.Moorman M.B.Fields INPO Records Center (all with attachment) 9903iiOii7 99030i PDR ADOCK 05000529 8 PDR  
Palo Verde Nuclear Generating Station (PVNGS)
Unit 2 Docket No. STN 50-529 License No. NPF-51 Licensee Event Report 99-001-00 Attached please find Licensee Event Report (LER) 99-001-00 prepared and submitted pursuant to 10 CFR 50.73. This LER reports a condition prohibited by the Technical Specifications in that a required Power Dependent Alarm Circuit was inoperable for longer than the required action completion time.                                 No commitments are being made to the NRC by this letter.
In accordance with 10CFR50.73(d), a copy of this LER is being forwarded to the Regional Administrator, NRC Region IV. If you have any questions, please contact Daniel G. Marks, Section Leader, Regulatory Affairs, at (602) 393-6492.
Sincerely, GRO/DGM/RAB/rlh C<"
Attachment cc:       E. W. Merschoff                   (all with attachment)
J. H. Moorman M. B. Fields INPO Records Center 9903iiOii7 99030i   05000529 PDR     ADOCK 8                             PDR


LICENSEE EVENT REPORT (LER)ACIUTY NAME (1)Palo Verde Unit 2 DOCKET NUMBER (2)PAGE (3)050005291o" 0 (4)TS Violation for Power Dependent Insertion Limit Alarm Inoperable Due to Personnel Error MONTH OAY YEAR REPORT DATE LER NUMBER 6 YEAR SEQUENTIAL IIEVISION MON OTHER FACIUTIES INVOLVED a 0 1 0 3 9 9 9 9-0 0 1-0 0 0 3 0 1 9 9 N/A 0 5 0 0 0 0 5 0 0 0 OPERATING MODE (9)POWER LEvEL(to)1 p p IS REPORT IS SUBMITTED PURSUANT TO 20.402(b)20.405(SXIXI) 20405(SXTXT) 20 405(SXIXE) 20.405(SXt Xiv)20.405(SX I Xv)20.405(c)50.36(cX1) 50.36(cX2) 5O.73(SX2XI) 50 73(SX2Xs1 So.n(SXEXB) 5o.73(SX2XIv) 50.73(aX2Xv) 50.73(aX2Xvio 50.73(aX2Xvis+A) 50.73(SX2Xv~eB) 50.73(SX2Xx)
LICENSEE EVENT REPORT (LER)
THE REQUIREMENTS OF 10 CF R (;(Check tee or more ar the Ooaowino)(11)73,7tg>>73.71(c)OTHER (SpeoTY Irt Abstract bekxv aoo h Text.NRC Form 366A)LICENSEE CONTACT FOR THIS LER (12)Daniel G.Marks, Section Leader, Nuclear Regulatory Affairs LEPHONE NUMBER EA CODE 6 0 2 3 9 3-6 4 9 2 COMPLETE ONE UNE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)CAUSE SYSTEM COMPONENT MANUFAC-TURER REPORTABLE TO NPRDS CAUSE SYSTEM COMPONENT MANUFAC TURER REPORTABLE TO NPRDS SUPPLEMENTAL REPORT EXPECTED (14)X NO YES (N yes, complete EXPECTED SUBMISSION DATE)EXPECTED SUBMISSION DATE (15)MONTH OAY YEAR BBTRAQT (Lsrta to 1400 spaces, lb.~SpproxSbateIY fsteert staolcHlpace tTpevrratert srxrs)(16)On January 31, 1999 at approximately 0219 hours MST with Unit 2 operating at approximately 100 percent power, operations personnel discovered that the Power Dependent Insertion Limit (PDIL)alarm was INOPERABLE.
ACIUTYNAME (1)                                                                                                                     DOCKET NUMBER (2)                         PAGE (3)
This alarm is computer generated and is used to alert the operators to a condition in which the regulating Control Element Assemblies (CEA)may be outside the required insertion limits.The alarm had last been tested satisfactorily on January 3, 1999.However, on restoring from the test the circuit was left in a condition that prevented it from performing its function.When discovered on January 31, the Technical Specification Required Action for the PDIL circuit was completed within the required time limit and all regulating CEA group positions were verified to be within insertion limits.The PDIL alarm was returned to OPERABLE status at 0342 MST on January 31, 1999.The cause of the INOPERABLE alarm was attributed to personnel error in that control room personnel did not recognize the computer was not placed back into the scan mode of operation following the completion of the alarm testing performed on January 3, 1999.As corrective action the procedure has been revised to clarify how the computer point is to be returned to the scan mode.No similar events have been reported pursuant to 10CFR50.73 during the last three years.
Palo Verde Unit 2 (4) 050005291o"                                   0 TS Violation for Power Dependent Insertion Limit Alarm Inoperable Due to Personnel Error LER NUMBER 6                             REPORT DATE                                  OTHER FACIUTIES INVOLVED a MONTH      OAY      YEAR      YEAR            SEQUENTIAL            IIEVISION MON 0 5 0 0 0 0    1   0 3       9 9 9 9               - 0 0           1     - 0 0 0 3 0                     1 9 9                       N/A                       0 5 0 0 0 OPERATING                 IS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10                CF R (; (Check tee or more ar the Ooaowino) (11)
fg LICENSEE EVENT REPORT (LER)TEXT CONTINUATION ACILIlY NAME PaIo Verde Unit 2 DOCKETNUMBER LER NUMBER SEQUENTIAL REVISION NUMBER NUMBER PAGE 0 5 0 0 0 5 2 9 9 9-0 0 1-0 0 0 2 of05 REPORTING REQUIREMENT:
MODE (9)                         20.402(b)                                   20.405(c)                            5o.73(SX2XIv)                         73,7tg>>
This LER 99-001-00 is submitted to report an event that resulted in an operation or condition prohibited by the plant's Technical Specifications (TS)as specified in 10CFR50.73(a)(2)(i)(B).
POWER                                20.405(SXIXI)                               50.36(cX1)                           50.73(aX2Xv)                         73.71(c) 20405(SXTXT)                                 50.36(cX2)
Specifically, on January 31, 1999 at approximately 0219 hours MST with Unit 2 at approximately 100 percent power, operations personnel discovered that the Power Dependent Insertion Limit (PDIL)alarm was INOPERABLE.
LEvEL(to)     1  p p                                                                                                  50.73(aX2Xvio                         OTHER (SpeoTY Irt Abstract 20 405(SXIXE)                                5O.73(SX2XI)                        50.73(aX2Xvis+A)                     bekxv aoo h Text. NRC Form 20.405(SXt Xiv)                              50 73(SX2Xs1                        50.73(SX2Xv~eB)                       366A) 20.405(SX I Xv)                             So.n(SXEXB)                          50.73(SX2Xx)
The alarm had been INOPERABLE since January 3, 1999 at approximately 0121 MST when a computer point had been left in a condition that rendered the alarm incapable of performing its function.This exceeded the one-hour completion time specified for the PDIL alarm circuit in Technical Specification 3.1.7 Required Action D.l.2.EVENT DESCRIPTION:
LICENSEE CONTACT FOR THIS LER (12)
On January 3, 1999 at approximately 0121 MST with Unit 2 at approximately 100 percent power, control room operators performed a 31 day Surveillance Requirement (SR)to verify that the PDIL alarm circuit (IB)was OPERABLE.The surveillance test (ST)procedure required the operators to insert into the plant computer (ID)a value for the lowest control element assembly (CEA)(AA)in regulating group 5 position (LREG5)that was lower than the PDIL alarm setpoint and verify the alarm actuated.With the inserted value the PDIL alarm circuit is INOPERABLE due to the inability of the plant computer to determine the actual lowest CEA in regulating group 5 position.The PDIL alarm circuit was declared INOPERABLE on January', 1999 at 0121 MST when a value of 115 inches was inserted into the plant computer for CEA regulating group 5 position.The PDIL alarm was verified to be functioning at that time.The ST then required the plant computer be restored to the scan mode of operation and an independent verification be performed that the CEA group 5 position was restored.The PDIL alarm circuit was declared OPERABLE at 0123 MST.On January 31, 1999 at approximately 0219 MST, Unit 2 control room operators were performing the next regularly scheduled performance of the PDIL alarm circuit ST when a Reactor Operator observed that the plant computer had an inserted value of 150 inches for the lowest CEA in regulating'group 5 position.The PDIL alarm was declared INOPERABLE and Condition D of TS 3.1.7 was entered.The Required Action for this Condition states that within one hour each regulating CEA group position be verified to be within its insertion limits and once per four hours thereafter.
LEPHONE NUMBER Daniel G. Marks, Section Leader, Nuclear Regulatory Affairs                                                                                EA CODE 6 0 2 3 9 3                - 6 4        9 2 COMPLETE ONE UNE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)
i LICENSEE EVENT REPORT (LER)TEXT CONTINUATION AGILITY NAME~Palo Verde Unit 2 DOCKET NUMBER LER NUMBER yEAR sEaUENTIAL RansIoN NUMBER NUMBER PAGE 0 5 0 0 0 5 2 9 9 9-0 0 1-0 0 0 3 of 0 5 EXT, At 0305 MST the one-hour requirement was completed satisfactorily.
CAUSE SYSTEM          COMPONENT              MANUFAC-         REPORTABLE                          CAUSE  SYSTEM      COMPONENT              MANUFAC       REPORTABLE TURER             TO NPRDS                                                                     TURER         TO NPRDS SUPPLEMENTAL REPORT EXPECTED (14)                                                                 EXPECTED          MONTH      OAY      YEAR SUBMISSION YES (N yes, complete EXPECTED SUBMISSION DATE)                                           NO X                                                    DATE (15)
The operators then attempted to restore the plant computer to the scan mode for the lowest CEA in regulating group 5 position.The operators were successful in placing the plant computer into the scan mode and at 0342 MST the PDIL alarm circuit was declared OPERABLE and Condition D of TS 3.1.7 was exited.Units 1 and 3 control room personnel were contacted and they verified that their plant computers were functioning properly.3.There were no safety system actuations and none were required.ASSESSMENT OF THE SAFETY CONSEQUENCES AND IMPLICATIONS OF THIS EVENT: The power dependent insertion limit (PDIL)alarm circuit is required to be OPERABLE to notify the control room operators that the CEAs are outside the required insertion limits.The insertion limits on regulating CEA sequence, overlap, and physical insertion are maintained to serve the function of preserving power distribution, ensuring that shutdown margin (SDM)is maintained, ensuring that ejected CEA worth is maintained, and ensuring adequate negative reactivity insertion on trip.During the time period the PDIL alarm circuit was INOPERABLE, the CEAs were maintained essentially at the all rods out (ARO)position and no violation of the insertion limits occurred.The core protection calculators and CEA calculators were not affected by the PDIL circuit and remained OPERABLE throughout the event to generate thermal margin trips.In addition, TS surveillance requirement 3.1.7.1 requires that each regulating CEA group position be verified to be within insertion limits every 12 hours.Therefore, the maximum amount of time the regulating CEAs could be inserted beyond the insertion limits, with the PDIL alarm circuit INOPERABLE, would have been 12 hours..The TS bases for the 31 day frequency of verifying the PDIL circuit OPERABLE takes credit for other Surveillances being performed at a shorter frequencies to identify CEA alignments
BBTRAQT (Lsrta to 1400 spaces, lb. ~ SpproxSbateIY fsteert staolcHlpace tTpevrratert srxrs) (16)
.The PDIL alarm remained functional for the other regulating CEA groups and would have alarmed if CEA regulating group 4 had been inserted beyond the insertion limits.Normal sequencing and overlap between groups 4 and 5 is that group 4 remains within approximately 90 inches of regulating group 5.This could have resulted in operation at 100 percent power with group 5 at 60 inches withdrawn for up to 12 hours before the PDIL condition was recognized.
On     January 31, 1999 at approximately 0219 hours MST with Unit 2 operating at approximately 100 percent power, operations personnel discovered that the Power Dependent Insertion Limit (PDIL) alarm was INOPERABLE. This alarm is computer generated and is used to alert the operators to a condition in which the regulating Control Element Assemblies (CEA) may be outside the required insertion limits. The alarm had last been tested satisfactorily on January 3, 1999. However, on restoring from the test the circuit was left in a condition that prevented                   it     from performing its function.
The condition used in the following safety consequence assessment takes no credit for the CEA group deviation alarms that would annunciate as a result of the absolute difference (5.25 inches)between ft I LlGENSEE EVENT REPORT (LER)TEXT GONTlNUATION ACILITV NAME Palo Verde Unit 2 DOCKET NUMBER LER NUMBER YEAR SEQUENTIAl REVISION NUMBER NUMBER PAGE 0 5 0 0 0 5 2 9 9 9-0 0 1-0 0 0 4 of 0 5 the highest CEA in group 5 and the inserted 150 inches for the lowest CEA in group 5.The effect of operating in this condition would not have exceeded safety analysis results for shutdown margin, adequate negative reactivity insertion on a trip, or for an ejected CEA event.Excess SDM of approximately 500 pcm would have been available to ensure reactor shutdown on a trip.The CEA ejection event analysis assumptions use either all rods out or a group fully inserted, therefore the margin of safety would not have been reduced.In addition, although the core operating limit supervisory system may have been non-conservatively impacted by using all rods out radial peaking factors, the CPC system would have operated normally and provided the appropriate trip function.The event did not result in any challenges to the fission product barriers or result in any release of radioactive materials.
When     discovered on January 31, the Technical Specification Required Action for the PDIL circuit was completed within the required time limit and all regulating CEA group positions were verified to be within insertion limits.
Therefore, there were no adverse safety consequences or implications as a result of this event.This event did not adversely affect the safe operation of the plant or health and safety of the public.CAUSE OF THE EVENT: A preliminary evaluation of the event has determined that the cause of the event was personnel error by control room operators (Utility-Licensed Operator).
The PDIL alarm was returned to OPERABLE status at 0342 MST on January 31, 1999.
The ST procedure directed the operator to restore the LREG 5 computer point to the scan mode of operation and to verify the value of LREG 5.When the operator restored the LREGS point to scan the computer point display did not indicate a value.In an attempt to verify the computer point value the operator inadvertently inserted a value of 150 inches.The effect of the inserted value was to leave the point in a condition that rendered it INOPERABLE.
The cause of               the INOPERABLE alarm was attributed to personnel error in that control room               personnel did not recognize the computer was not placed back into the scan mode of operation following the completion of the alarm testing performed on January 3, 1999.
Both the operator who entered the value and the operator who performed the independent verification did not recognize this condition.
As     corrective action the procedure has been revised to clarify how the computer point                   is to be returned to the scan mode. No similar events have been reported pursuant to 10CFR50.73 during the last three years.
If the final evaluation results differ from this determination or if information is developed which would significantly change the readers'nderstanding or perception of event, a supplement to this report will be submitted.
 
No unusual characteristics of the work location (e.g., noise, heat, poor lighting)directly contributed to this event.5.STRUCTURES, SYSTEMS'R COMPONENTS INFORMATION:
fg LICENSEE EVENT REPORT (LER) TEXT CONTINUATION ACILIlYNAME                                    DOCKETNUMBER         LER NUMBER             PAGE SEQUENTIAL   REVISION NUMBER     NUMBER PaIo Verde Unit 2 0 5 0 0 0 5 2 9 9 9   - 0 0     1 - 0 0 0 2   of05 REPORTING REQUIREMENT:
There are no indications that any structures, systems, or components were inoperable at the start of the event that contributed to this event.
This LER 99-001-00 is submitted to report an event that resulted in an operation or condition prohibited by the plant's Technical Specifications (TS) as specified in 10CFR50.73(a)(2)(i)(B).
Ij I LICENSEE EVENT REPORT (LER)TEXT CONTINUATION AOIUTY NAME Palo Verite Unit 2 DOCKETNUMBER LER NUMBER SEOUENTIAL REVISION NUMSER NUMBER PAGE 0 5 0 0 0 5 2 9 9 9-0 0 1-0 0 0 5 of 0 5 No component or system failures were involved.6.CORRECTIVE ACTIONS TO PREVENT RECURRENCE:
Specifically,   on January 31, 1999 at approximately 0219 hours MST with Unit   2 at approximately 100 percent power, operations personnel discovered that the Power Dependent Insertion Limit (PDIL) alarm was INOPERABLE. The alarm had been INOPERABLE since January 3, 1999 at approximately 0121 MST when a computer point had been left in a condition that rendered the alarm incapable of performing its function. This exceeded the one-hour completion time specified for the PDIL alarm circuit in Technical Specification 3.1.7 Required Action D.l.
On January 31, 1999 at approximately 0219 MST, Unit 2 control room operators identified that the computer poi.nt for monitoring CEA group position in the PDIL circuit was not capable of performing its function.The operators declared the PDIL circuit INOPERABLE, complied with the required action of TS 3.1.7, and returned the computer point to i.ts correct condition.
: 2. EVENT DESCRIPTION:
An independent investigation of this event is being conducted in accordance with the PVNGS Corrective Action Program.Actions to prevent recurrence include revising the procedure, which has been completed, to clarify how the computer point is to be returned to the scan mode.In addition, this event will be reviewed in licensed operator continuing training.This training and any other actions developed based upon the results of the investigation will be tracked in the PVNGS corrective action system.7.PREVIOUS SIMILAR EVENTS: No similar events have been reported pursuant to 10CFR50.73 during the last three years.8.ADDITIONAL INFORMATION:
On January 3, 1999 at approximately 0121 MST with Unit 2 at approximately 100 percent power, control room operators performed a 31 day Surveillance Requirement (SR) to verify that the PDIL alarm circuit (IB) was OPERABLE.
The surveillance test (ST) procedure required the operators to insert into the plant computer (ID) a value for the lowest control element assembly (CEA) (AA) in regulating group 5 position (LREG5) that was lower than the PDIL alarm setpoint and verify the alarm actuated. With the inserted value the PDIL alarm circuit is INOPERABLE due to the inability of the plant computer to determine the actual lowest CEA in regulating group 5 position. The PDIL alarm circuit was declared INOPERABLE on January',
1999 at 0121 MST when a value of 115 inches was inserted into the plant computer for CEA regulating group 5 position. The PDIL alarm was verified to be functioning at that time. The ST then required the plant computer be restored to the scan mode of operation and an independent verification be performed that the CEA group 5 position was restored.     The PDIL alarm circuit was declared OPERABLE at 0123 MST.
On January 31, 1999 at approximately 0219 MST, Unit 2 control room operators were performing the next regularly scheduled performance of the PDIL alarm circuit ST when a Reactor Operator observed that the plant computer had an inserted value of 150 inches for the lowest CEA in regulating'group 5 position. The PDIL alarm was declared INOPERABLE and Condition D of TS 3.1.7 was entered. The Required Action for this Condition states that within one hour each regulating CEA group position be verified to be within its insertion limits and once per four hours thereafter.
 
i LICENSEE EVENT REPORT (LER) TEXT CONTINUATION AGILITYNAME ~
DOCKET NUMBER           LER NUMBER               PAGE yEAR   sEaUENTIAL   RansIoN NUMBER     NUMBER Palo Verde Unit 2 0 5 0   0 0 5 2   9 9 9 - 0 0     1 - 0   0 0 3 of 0 5 EXT,           At 0305 MST the one-hour requirement was completed satisfactorily. The operators then attempted to restore the plant computer to the scan mode for the lowest CEA in regulating group 5 position. The operators were successful in placing the plant computer into the scan mode and at 0342 MST the PDIL alarm circuit was declared OPERABLE and Condition D of TS 3.1.7 was exited.
Units 1 and 3 control room personnel   were contacted and they     verified that their plant   computers were functioning properly.
There were no safety system actuations and none were required.
: 3. ASSESSMENT OF THE SAFETY CONSEQUENCES AND IMPLICATIONS OF THIS EVENT:
The power dependent   insertion limit (PDIL) alarm circuit is required to be OPERABLE   to notify the control room operators that the CEAs are outside the required insertion limits. The insertion limits on regulating CEA sequence, overlap, and physical insertion are maintained to serve the function of preserving power distribution, ensuring that shutdown margin (SDM) is maintained, ensuring that ejected CEA worth is maintained, and ensuring adequate negative reactivity insertion on trip.
During the time period the PDIL alarm circuit was INOPERABLE, the CEAs were maintained   essentially at the all rods out (ARO) position and no violation of the insertion limits occurred. The core protection calculators and CEA calculators were not affected by the PDIL circuit and remained OPERABLE throughout the event to generate thermal margin trips.
In addition, TS surveillance requirement 3.1.7.1 requires that each regulating CEA group position be verified to be within insertion limits every 12 hours. Therefore, the maximum amount of time the regulating CEAs could be inserted beyond the insertion limits, with the PDIL alarm circuit INOPERABLE, would have been     12 hours. . The TS bases for the 31 day frequency of verifying the PDIL circuit OPERABLE takes credit for other Surveillances being performed at a shorter frequencies to identify CEA alignments .
The PDIL alarm remained     functional for the other regulating CEA groups and would have alarmed   if CEA regulating group 4 had been inserted beyond the insertion limits. Normal sequencing and overlap between groups 4 and 5 is that group 4 remains within approximately 90 inches of regulating group 5.
This could have resulted in operation at 100 percent power with group 5 at 60 inches withdrawn for up to 12 hours before the PDIL condition was recognized. The condition used in the following safety consequence assessment takes no credit for the CEA group deviation alarms that would annunciate as a result of the absolute difference (5.25 inches) between
 
ft I
 
LlGENSEE EVENT REPORT (LER) TEXT GONTlNUATION ACILITVNAME                                        DOCKET NUMBER         LER NUMBER                             PAGE YEAR   SEQUENTIAl             REVISION NUMBER                   NUMBER Palo Verde Unit 2 0 5 0   0 0   5 2 9 9 9 - 0 0     1 - 0 0 0 4 of 0 5 the highest   CEA   in group 5 and the inserted 150 inches for the lowest                     CEA in group 5.
The effect of operating in this condition would not have exceeded safety analysis results for shutdown margin, adequate negative reactivity insertion on a trip, or for an ejected CEA event. Excess SDM of approximately   500 pcm would have been available to ensure reactor shutdown on a trip. The CEA ejection event analysis assumptions use either                         all rods out or   a group fully inserted, therefore the margin of safety would not have been reduced. In addition, although the core operating limit supervisory system may have been non-conservatively impacted by using all rods out radial peaking factors, the CPC system would have operated normally and provided the appropriate trip function.
The event   did not result in any challenges to the fission product barriers or result in any release of radioactive materials. Therefore, there were no adverse safety consequences or implications as a result of this event.
This event did not adversely affect the safe operation of the plant or health and safety of the public.
CAUSE OF THE EVENT:
A preliminary evaluation of the event has determined that the cause of the event was personnel error by control room operators (Utility-Licensed Operator). The ST procedure directed the operator to restore the LREG 5 computer point to the scan mode of operation and to verify the value of LREG 5. When the operator restored the LREGS point to scan the computer point display did not indicate a value. In an attempt to verify the computer point value the operator inadvertently inserted a value of 150 inches. The effect of the inserted value was to leave the point in a condition that rendered it INOPERABLE. Both the operator who entered the value and the operator who performed the independent verification did not recognize this condition.
If the final evaluation results differ from this determination or if information is developed which would significantly change the or perception of event, a supplement to this report will be readers'nderstanding submitted.
No unusual characteristics of the work location (e.g., noise, heat, poor lighting) directly contributed to this event.
: 5. STRUCTURES,   SYSTEMS'R     COMPONENTS INFORMATION:
There are no   indications that any structures, systems, or components were inoperable   at the start of the event that contributed to this event.
 
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LICENSEE EVENT REPORT (LER) TEXT CONTINUATION AOIUTYNAME                                    DOCKETNUMBER             LER NUMBER             PAGE SEOUENTIAL   REVISION NUMSER     NUMBER Palo Verite Unit 2 0 5 0 0 0   5 2   9 9 9 - 0 0     1 - 0 0 0 5 of 0 5 No component   or system failures were involved.
: 6. CORRECTIVE ACTIONS TO PREVENT RECURRENCE:
On January 31, 1999 at approximately 0219 MST, Unit 2 control room operators identified that the computer poi.nt for monitoring CEA group position in the PDIL circuit was not capable of performing its function.
The operators declared the PDIL circuit INOPERABLE, complied with the required action of TS 3.1.7, and returned the computer point to i.ts correct condition.
An independent investigation of this event is being conducted in accordance with the PVNGS Corrective Action Program. Actions to prevent recurrence include revising the procedure, which has been completed, to clarify how the computer point is to be returned to the scan mode. In addition, this event will be reviewed in licensed operator continuing training. This training and any other actions developed based upon the results of the investigation will be tracked in the     PVNGS   corrective action system.
: 7. PREVIOUS SIMILAR EVENTS:
No similar events have been reported pursuant   to 10CFR50.73     during the last three years.
: 8. ADDITIONAL INFORMATION:
NONE}}
NONE}}

Latest revision as of 07:38, 29 October 2019

LER 99-001-00:on 990103,TS Violation for Power Dependent Insertion Limit Alarm Being Inoperable.Caused by Personnel Error.Revised Procedure to Clarify How Computer Point Is to Be Returned to Scan Mode.With 990302 Ltr
ML17313A836
Person / Time
Site: Palo Verde Arizona Public Service icon.png
Issue date: 03/01/1999
From: Marks D, Overbeck G
ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
192-01041-GRO-D, 192-1041-GRO-D, LER-99-001-01, LER-99-1-1, NUDOCS 9903110117
Download: ML17313A836 (14)


Text

~ CATEGORY REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:9903110117 DOC.DATE: 99/03/01. NOTARIZED: NO DOCKET FACZL:STN-50-529 Palo Verde Nuclear Station, Unit 2, Arizona 'Publi 05000529 AUTH.N~ AUTHOR AFFILIATION MARKS,D.G. ' Arizona Public Service Co. (formerly Arizona Nuclear Power OVERBECK,G.R. Arizona Public Service Co.'formerly Arizona Nuclear Po~er RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 99-001-00:on 990103,TS violation for power dependent insertion limit alarm being inoperable. Caused by peronnsel error. Revised procedure to clarify how computer point is to be returned to scan mode. With 990302 ltr.

DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR l ENCL 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.'

j SIZE: tS'ITLE:

NOTES:Standardized plant. 05000529 0

RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD4-2 PD 1 1 FIELDS,M 1 1 INTERNAL: ACRS 1 1 AEOD/SPD/RAB 2 2, AEOD/S PD/RRAB 1 1 CENTER 1 1 NRR/DRCH/HOHB 1 1 QMB 1 1 NRR/DRPM/PECB 1 1 NRR/DSSA/SPLB 1 1 RES/DET/EIB 1 1 RGN4 FILE 01 1 1 D

EXTERNAL: L ST LOBBY WARD 1 1 LMITCO MARSHALL 1 1 NOAC POORE,W. 1 1 NOAC QUEENER, DS 1 1 NRC PDR 1 1 NUDOCS FULL TXT 1 1 N

NOTE TO ALL "RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTE. TO HAVE YOUR NAME OR ORGANIZATION REMOVED FROM DISTRIBUTION LISTS OR REDUCE THE NUMBER OF COPIES RECEIVED BY YOU OR YOUR ORGANIZATION, CONTACT THE DOCUMENT CONTROL DESK (DCD) ON EXTENSION 415-2083 FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 19 ENCL 19

cwenltmeat nnovattm &errt.

Gregg R. Overbeck Mail Station 7602 Palo Verde Nuclear Vice President TEL 602/3936t48 P.O. Box 52034 Generatlnli Station Nuclear Production FAX 602/3934l077 Phoenix, AZ 85072-2034 192-01041-GRO/DGM/REB March 2, 1999 U. S. Nuclear Regulatory Commission ATTN: Document Control Desk Mail Station P1-37 Washington, D.C. 20555-0001

Dear Sirs:

Subject:

Palo Verde Nuclear Generating Station (PVNGS)

Unit 2 Docket No. STN 50-529 License No. NPF-51 Licensee Event Report 99-001-00 Attached please find Licensee Event Report (LER) 99-001-00 prepared and submitted pursuant to 10 CFR 50.73. This LER reports a condition prohibited by the Technical Specifications in that a required Power Dependent Alarm Circuit was inoperable for longer than the required action completion time. No commitments are being made to the NRC by this letter.

In accordance with 10CFR50.73(d), a copy of this LER is being forwarded to the Regional Administrator, NRC Region IV. If you have any questions, please contact Daniel G. Marks, Section Leader, Regulatory Affairs, at (602) 393-6492.

Sincerely, GRO/DGM/RAB/rlh C<"

Attachment cc: E. W. Merschoff (all with attachment)

J. H. Moorman M. B. Fields INPO Records Center 9903iiOii7 99030i 05000529 PDR ADOCK 8 PDR

LICENSEE EVENT REPORT (LER)

ACIUTYNAME (1) DOCKET NUMBER (2) PAGE (3)

Palo Verde Unit 2 (4) 050005291o" 0 TS Violation for Power Dependent Insertion Limit Alarm Inoperable Due to Personnel Error LER NUMBER 6 REPORT DATE OTHER FACIUTIES INVOLVED a MONTH OAY YEAR YEAR SEQUENTIAL IIEVISION MON 0 5 0 0 0 0 1 0 3 9 9 9 9 - 0 0 1 - 0 0 0 3 0 1 9 9 N/A 0 5 0 0 0 OPERATING IS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CF R (; (Check tee or more ar the Ooaowino) (11)

MODE (9) 20.402(b) 20.405(c) 5o.73(SX2XIv) 73,7tg>>

POWER 20.405(SXIXI) 50.36(cX1) 50.73(aX2Xv) 73.71(c) 20405(SXTXT) 50.36(cX2)

LEvEL(to) 1 p p 50.73(aX2Xvio OTHER (SpeoTY Irt Abstract 20 405(SXIXE) 5O.73(SX2XI) 50.73(aX2Xvis+A) bekxv aoo h Text. NRC Form 20.405(SXt Xiv) 50 73(SX2Xs1 50.73(SX2Xv~eB) 366A) 20.405(SX I Xv) So.n(SXEXB) 50.73(SX2Xx)

LICENSEE CONTACT FOR THIS LER (12)

LEPHONE NUMBER Daniel G. Marks, Section Leader, Nuclear Regulatory Affairs EA CODE 6 0 2 3 9 3 - 6 4 9 2 COMPLETE ONE UNE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (13)

CAUSE SYSTEM COMPONENT MANUFAC- REPORTABLE CAUSE SYSTEM COMPONENT MANUFAC REPORTABLE TURER TO NPRDS TURER TO NPRDS SUPPLEMENTAL REPORT EXPECTED (14) EXPECTED MONTH OAY YEAR SUBMISSION YES (N yes, complete EXPECTED SUBMISSION DATE) NO X DATE (15)

BBTRAQT (Lsrta to 1400 spaces, lb. ~ SpproxSbateIY fsteert staolcHlpace tTpevrratert srxrs) (16)

On January 31, 1999 at approximately 0219 hours0.00253 days <br />0.0608 hours <br />3.621032e-4 weeks <br />8.33295e-5 months <br /> MST with Unit 2 operating at approximately 100 percent power, operations personnel discovered that the Power Dependent Insertion Limit (PDIL) alarm was INOPERABLE. This alarm is computer generated and is used to alert the operators to a condition in which the regulating Control Element Assemblies (CEA) may be outside the required insertion limits. The alarm had last been tested satisfactorily on January 3, 1999. However, on restoring from the test the circuit was left in a condition that prevented it from performing its function.

When discovered on January 31, the Technical Specification Required Action for the PDIL circuit was completed within the required time limit and all regulating CEA group positions were verified to be within insertion limits.

The PDIL alarm was returned to OPERABLE status at 0342 MST on January 31, 1999.

The cause of the INOPERABLE alarm was attributed to personnel error in that control room personnel did not recognize the computer was not placed back into the scan mode of operation following the completion of the alarm testing performed on January 3, 1999.

As corrective action the procedure has been revised to clarify how the computer point is to be returned to the scan mode. No similar events have been reported pursuant to 10CFR50.73 during the last three years.

fg LICENSEE EVENT REPORT (LER) TEXT CONTINUATION ACILIlYNAME DOCKETNUMBER LER NUMBER PAGE SEQUENTIAL REVISION NUMBER NUMBER PaIo Verde Unit 2 0 5 0 0 0 5 2 9 9 9 - 0 0 1 - 0 0 0 2 of05 REPORTING REQUIREMENT:

This LER 99-001-00 is submitted to report an event that resulted in an operation or condition prohibited by the plant's Technical Specifications (TS) as specified in 10CFR50.73(a)(2)(i)(B).

Specifically, on January 31, 1999 at approximately 0219 hours0.00253 days <br />0.0608 hours <br />3.621032e-4 weeks <br />8.33295e-5 months <br /> MST with Unit 2 at approximately 100 percent power, operations personnel discovered that the Power Dependent Insertion Limit (PDIL) alarm was INOPERABLE. The alarm had been INOPERABLE since January 3, 1999 at approximately 0121 MST when a computer point had been left in a condition that rendered the alarm incapable of performing its function. This exceeded the one-hour completion time specified for the PDIL alarm circuit in Technical Specification 3.1.7 Required Action D.l.

2. EVENT DESCRIPTION:

On January 3, 1999 at approximately 0121 MST with Unit 2 at approximately 100 percent power, control room operators performed a 31 day Surveillance Requirement (SR) to verify that the PDIL alarm circuit (IB) was OPERABLE.

The surveillance test (ST) procedure required the operators to insert into the plant computer (ID) a value for the lowest control element assembly (CEA) (AA) in regulating group 5 position (LREG5) that was lower than the PDIL alarm setpoint and verify the alarm actuated. With the inserted value the PDIL alarm circuit is INOPERABLE due to the inability of the plant computer to determine the actual lowest CEA in regulating group 5 position. The PDIL alarm circuit was declared INOPERABLE on January',

1999 at 0121 MST when a value of 115 inches was inserted into the plant computer for CEA regulating group 5 position. The PDIL alarm was verified to be functioning at that time. The ST then required the plant computer be restored to the scan mode of operation and an independent verification be performed that the CEA group 5 position was restored. The PDIL alarm circuit was declared OPERABLE at 0123 MST.

On January 31, 1999 at approximately 0219 MST, Unit 2 control room operators were performing the next regularly scheduled performance of the PDIL alarm circuit ST when a Reactor Operator observed that the plant computer had an inserted value of 150 inches for the lowest CEA in regulating'group 5 position. The PDIL alarm was declared INOPERABLE and Condition D of TS 3.1.7 was entered. The Required Action for this Condition states that within one hour each regulating CEA group position be verified to be within its insertion limits and once per four hours thereafter.

i LICENSEE EVENT REPORT (LER) TEXT CONTINUATION AGILITYNAME ~

DOCKET NUMBER LER NUMBER PAGE yEAR sEaUENTIAL RansIoN NUMBER NUMBER Palo Verde Unit 2 0 5 0 0 0 5 2 9 9 9 - 0 0 1 - 0 0 0 3 of 0 5 EXT, At 0305 MST the one-hour requirement was completed satisfactorily. The operators then attempted to restore the plant computer to the scan mode for the lowest CEA in regulating group 5 position. The operators were successful in placing the plant computer into the scan mode and at 0342 MST the PDIL alarm circuit was declared OPERABLE and Condition D of TS 3.1.7 was exited.

Units 1 and 3 control room personnel were contacted and they verified that their plant computers were functioning properly.

There were no safety system actuations and none were required.

3. ASSESSMENT OF THE SAFETY CONSEQUENCES AND IMPLICATIONS OF THIS EVENT:

The power dependent insertion limit (PDIL) alarm circuit is required to be OPERABLE to notify the control room operators that the CEAs are outside the required insertion limits. The insertion limits on regulating CEA sequence, overlap, and physical insertion are maintained to serve the function of preserving power distribution, ensuring that shutdown margin (SDM) is maintained, ensuring that ejected CEA worth is maintained, and ensuring adequate negative reactivity insertion on trip.

During the time period the PDIL alarm circuit was INOPERABLE, the CEAs were maintained essentially at the all rods out (ARO) position and no violation of the insertion limits occurred. The core protection calculators and CEA calculators were not affected by the PDIL circuit and remained OPERABLE throughout the event to generate thermal margin trips.

In addition, TS surveillance requirement 3.1.7.1 requires that each regulating CEA group position be verified to be within insertion limits every 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />. Therefore, the maximum amount of time the regulating CEAs could be inserted beyond the insertion limits, with the PDIL alarm circuit INOPERABLE, would have been 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />. . The TS bases for the 31 day frequency of verifying the PDIL circuit OPERABLE takes credit for other Surveillances being performed at a shorter frequencies to identify CEA alignments .

The PDIL alarm remained functional for the other regulating CEA groups and would have alarmed if CEA regulating group 4 had been inserted beyond the insertion limits. Normal sequencing and overlap between groups 4 and 5 is that group 4 remains within approximately 90 inches of regulating group 5.

This could have resulted in operation at 100 percent power with group 5 at 60 inches withdrawn for up to 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> before the PDIL condition was recognized. The condition used in the following safety consequence assessment takes no credit for the CEA group deviation alarms that would annunciate as a result of the absolute difference (5.25 inches) between

ft I

LlGENSEE EVENT REPORT (LER) TEXT GONTlNUATION ACILITVNAME DOCKET NUMBER LER NUMBER PAGE YEAR SEQUENTIAl REVISION NUMBER NUMBER Palo Verde Unit 2 0 5 0 0 0 5 2 9 9 9 - 0 0 1 - 0 0 0 4 of 0 5 the highest CEA in group 5 and the inserted 150 inches for the lowest CEA in group 5.

The effect of operating in this condition would not have exceeded safety analysis results for shutdown margin, adequate negative reactivity insertion on a trip, or for an ejected CEA event. Excess SDM of approximately 500 pcm would have been available to ensure reactor shutdown on a trip. The CEA ejection event analysis assumptions use either all rods out or a group fully inserted, therefore the margin of safety would not have been reduced. In addition, although the core operating limit supervisory system may have been non-conservatively impacted by using all rods out radial peaking factors, the CPC system would have operated normally and provided the appropriate trip function.

The event did not result in any challenges to the fission product barriers or result in any release of radioactive materials. Therefore, there were no adverse safety consequences or implications as a result of this event.

This event did not adversely affect the safe operation of the plant or health and safety of the public.

CAUSE OF THE EVENT:

A preliminary evaluation of the event has determined that the cause of the event was personnel error by control room operators (Utility-Licensed Operator). The ST procedure directed the operator to restore the LREG 5 computer point to the scan mode of operation and to verify the value of LREG 5. When the operator restored the LREGS point to scan the computer point display did not indicate a value. In an attempt to verify the computer point value the operator inadvertently inserted a value of 150 inches. The effect of the inserted value was to leave the point in a condition that rendered it INOPERABLE. Both the operator who entered the value and the operator who performed the independent verification did not recognize this condition.

If the final evaluation results differ from this determination or if information is developed which would significantly change the or perception of event, a supplement to this report will be readers'nderstanding submitted.

No unusual characteristics of the work location (e.g., noise, heat, poor lighting) directly contributed to this event.

5. STRUCTURES, SYSTEMS'R COMPONENTS INFORMATION:

There are no indications that any structures, systems, or components were inoperable at the start of the event that contributed to this event.

Ij I

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION AOIUTYNAME DOCKETNUMBER LER NUMBER PAGE SEOUENTIAL REVISION NUMSER NUMBER Palo Verite Unit 2 0 5 0 0 0 5 2 9 9 9 - 0 0 1 - 0 0 0 5 of 0 5 No component or system failures were involved.

6. CORRECTIVE ACTIONS TO PREVENT RECURRENCE:

On January 31, 1999 at approximately 0219 MST, Unit 2 control room operators identified that the computer poi.nt for monitoring CEA group position in the PDIL circuit was not capable of performing its function.

The operators declared the PDIL circuit INOPERABLE, complied with the required action of TS 3.1.7, and returned the computer point to i.ts correct condition.

An independent investigation of this event is being conducted in accordance with the PVNGS Corrective Action Program. Actions to prevent recurrence include revising the procedure, which has been completed, to clarify how the computer point is to be returned to the scan mode. In addition, this event will be reviewed in licensed operator continuing training. This training and any other actions developed based upon the results of the investigation will be tracked in the PVNGS corrective action system.

7. PREVIOUS SIMILAR EVENTS:

No similar events have been reported pursuant to 10CFR50.73 during the last three years.

8. ADDITIONAL INFORMATION:

NONE