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| {{#Wiki_filter:REGULATOR I li<FORMATIGN DISTRIBUTION STBTEM (RIDS)ACCESSION NBR: 8802170141 DQC.DATE: 88/02/09 NOTARIZED: | | {{#Wiki_filter:REGULATOR I li<FORMATIGN DISTRIBUTION STBTEM (RIDS) |
| NO FACIL: 50-335 Bt.Lucie Plant Unit 1~Florida Poeer 5 Light Co.AUTH.NAME AUTHOR AFF IL I AT ION MENDOZA V N.Flor ida Poeer 8: Light Co.WOQDYI C.Q.Florida Poeer 5 Light Co.REC IP.NAME RECIPIENT AFF IL I AT I C}N DOCKET 05000335 | | ACCESSION NBR: 8802170141 DQC. DATE: 88/02/09 NOTARIZED: NO DOCKET FACIL: 50-335 Bt. Lucie Plant Unit 1 ~ Florida Poeer 5 Light Co. 05000335 AUTH. NAME AUTHOR AFF ILI AT ION MENDOZA V N. Flor ida Poeer 8: Light Co. |
| | WOQDYI C. Q. Florida Poeer 5 Light Co. |
| | REC IP. NAME RECIPIENT AFF ILI AT I C}N |
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| ==SUBJECT:== | | ==SUBJECT:== |
| LER 87-012-01: | | LER 87-012-01: on 870609'oss oF component cooling eater r edundancg occurred because oF cr osstie valves being in open position. Caused bg personnel error. Close valves. Valve V-14169 estored to locked position. W/880209 ltr. |
| on 870609'oss oF component cooling eater r edundancg occurred because oF cr osstie valves being in open position.Caused bg personnel error.Close valves.Valve V-14169 I estored to locked position.W/880209 ltr.DISTR IBUTIOli CODE: IE22D COPIES RECEIVED: LTR i ENCL L SIZE: TITLE;50, 73 Licensee Event RepoT t (LER)i Incident Rpti etc.iNOTES: REC)P I ENT ID CODE))NAME PD'-" LA TOUR I GNY E CGP IES LTTR ENCL 1 1 1 1 REC IP IENT ID CODE/NAME PD2-2 PD COPIES LTTR ENCL 1 INTERNAL: ACRS MICHE'L SON AEQD/DQA AEOD/DSP/ROAB ARt'l/DCTS/DAB NRR/DEST/ADS iRR/DEST/>>LB NRR/DEST/t'!EB NRR/DEST/PSB NRR/DEST/SGB NRR/DLPG/GAB NRR/DREP/R*B N/~SIB REt=F ILF 02 RES DE/E IB RGN2 F lLE 0'1 1 2 2 1 1 1 0 1 1 1 1 1 1 1 1 1]ACRS MOELLER AEOD/DSP/NAS AEOD/DSP/TPAH DEDRO NRR/DEBT/CEH NRR/DEST/ICSH ERR/DEST/MTB NRR/DEST/RSB ERR/DLPG/HFB ERR/DQEA/E*3 ERR/DREP/RPB NRR/PMAS/ILRB RES TELFQRD, J RES/DRPS DIR 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 EXTERNAL: EGhG GRGH.l".H ST LOBBY WARD NRC PDR NSIC MAYS~G 5 5 1 1 1 1 FORD BLDG HOYi A LPDR NSIC HARB ISr J 1 1 1 1 1 1 TOTAL NUMBER OF COPIES REGUIPED: LTTR 46 ENCL 45 NiC Ferro 366 iv 83i LICENSEE EVENT REPORT (LER)U.S.NUCLEAR REGULATORY COMMiSSIQN APPAOVED OMB NO 31500)04 EXPIRES 8 31 88 FACILI'TY NAME 111 St.Lucie Unit Il DOCKET NUMBER (2)PAGE I3i o 5 o o o 335 ioF04 LOSS OF COMPONENT COOLING WATER REDUNDANCY BECAUSE OF CROSSTIE VALVES BEING IN THE OPEN POSITION DUE TO PERSONNEL ERROR.EVENT DATE IS>LEA NUMBER I61 REPORT DATE (7)OTHER FACILITIES INVOLVED IS)MONTH 0 6 QAY 0 9 YEAR 8 7 YEAR 8 7 SEOVS!VTIAL 4VMOEA 012 R'Y~~MOI TH OAV NUMBER-01 0 209 YEAR 88 FACILITY 4AMFS N/A DOCKET IIVMBERISI 0 5 0 0 0 0 5 0 0 0 OPERATINO MODE I~)POWER LEYEL 1 0 0 001 NAME 20.402(O)20.405(~l(1)(il 20.405(e l(l)I 61 20.408(~Ill)(iii)20.405 (~111 I liv)20.405 (~I (1 I (el 20.405(c)50.36(c1 I)I 50.36(cl(21 50.73(~l(21(il 50.73(el(21(~)50.73(~I(21(iiil LICENSEE CONTACT FOA THIS LER (121 S0.73(e l(2)(iv)S0.73(~)(2)(v)50,73(~I(2)(viil 50 73(~)121(viiil(AI S0.7 3 I~1(21(w 6 I (81 S0.73(~I(21(hl AREA CODE THIS REPORT IS SUBMIT'TED PURSUANT T 0 THE REQUIREMENTS OF 10 CFR$: (Chef>>One Or molt Of the ferrew nPl (11 73.71IOI 73.71(cl OTHER lSoecifv'r'oltrett oeiow end rn Ter t NRC Form 366A)TELEO"ONE NUMBER Victor N.Mendoza, Shift Technical Advisor COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (131 0 5 4 6 5" 3 5 5 0 CAUSE SYSTEM CQMPQNENT MANUFAC.TVREA EPQRTABLE TO NPRDS CAUSE SYS EM CQMPQIIEhrT M A hl'F A C r TVRER EPORTABLE TO NORDS SUPPLEMENTAL REPORT EXPECTED I141 YES llf yeA comofete ff(PECTEO SVBMISSIOhlDAFEI 40 ABSTRACT fdrrnH to (400 IoeceA I~..eooroerrnetefy fifteen Irnpi~.Ioete tyoewnNen hrNI (16)EXPECTED SUBMISSION DATE i)5 VO'P'EAO ABSTRACT On June 19, 1987, St.Lucie Unit Il was in Mode 1, 100%power, and at steady state conditions. | | I DISTR IBUTIOli CODE: IE22D COPIES RECEIVED: LTR i ENCL TITLE; 50, 73 Licensee Event RepoT t (LER) i Incident Rpti etc. |
| All control stations were in normal operating mode.At 0124 hours, the Reactor Control Operator (RCO)was performing a monthly pump surveillance run for the 1B component cooling water (CCW)pump.During this surveillance run, it was discovered that the 1A and 1B CCW heat exchanger outlet cross-tie valves were in the open position.The position for these valves is normally closed.The operator immediately performed a valve alignment verification and closed the valves.The root cause of the event was a cognitive personnel error by utility licensed operators who failed to have proper adminis-trative control on these valves.The immediate corrective action was to close the valves.The event was terminated at 0130 hours.No other system malfunction resulted from this event.This event is reportable under the code of federal regulations 10 CFR 50.73 (a)(2)(i)(B),"Any event or condition prohibited by plant's technical specifications".
| | L SIZE: |
| 8802>70141 85000+35 88020+PDR ADOCH 0 PDR 8 NRC Fornr 366 r9 8)
| | iNOTES: |
| NRC Eorm 368A IS 831 LICENSEE EVENT REPORT (LER)TEXT CONTINUATION U.S.NUCLEAR REGULATORY COMMISSION
| | REC)P I ENT CGP IES REC IP IENT COPIES ID CODE))NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD '-" LA 1 1 PD2-2 PD 1 TOUR I GNY E 1 1 INTERNAL: ACRS MICHE'LSON 1 ACRS MOELLER 2 2 AEQD/DQA 1 AEOD/DSP/NAS 1 1 AEOD/DSP/ROAB 2 2 AEOD/DSP/TPAH 1 1 ARt'l/DCTS/DAB 1 1 DEDRO 1 1 NRR/DEST/ADS 1 0 NRR/DEBT/CEH 1 1 iRR/DEST/>>LB 1 1 NRR/DEST/ICSH NRR/DEST/t'!EB 1 ERR/DEST/MTB 1 1 NRR/DEST/PSB 1 NRR/DEST/RSB 1 NRR/DEST/SGB 1 1 ERR/DLPG/HFB 1 NRR/DLPG/GAB 1 ERR/DQEA/E*3 1 NRR/DREP/R*B 1 1 ERR/DREP/RPB 2 2 N / ~ SIB ] NRR/PMAS/ ILRB 1 1 REt= F ILF 02 RES TELFQRD, J RES DE/E IB RES/DRPS DIR 1 RGN2 F lLE 0' EXTERNAL: EGhG GRGH.l". 5 5 FORD BLDG HOYi A 1 1 H ST LOBBY WARD 1 LPDR 1 1 NRC PDR 1 NSIC HARB ISr J 1 1 NSIC MAYS~ G 1 1 TOTAL NUMBER OF COPIES REGUIPED: LTTR 46 ENCL 45 |
| *PPROYEO OMS VO 3150-0104 EXPIRES I 8r 31 I 88 PACILITrY NAME III St.Lucie Unit 41 OOCKET NUMBER 12)YEAR LER NUMBER (61 O SEGUENTrAL NUNSER R E Y rS r 0 rr NUNISE R PAGE I3I TEXT lll rrhoro spsspis rsohrhroc.
| | |
| rhss scchthorrsl lVRC iorrn 36SA'si I IT)0 so oo33 587-0 1 2-0 1 0 2 OF 0 DESCRIPTION OF EVENT On June 19, 1987, St.Lucie Unit Il was in Node 1, 100%power, and at steady state conditions.
| | NiC Ferro 366 U.S. NUCLEAR REGULATORY COMMiSSIQN iv 83i APPAOVED OMB NO 31500)04 LICENSEE EVENT REPORT (LER) EXPIRES 8 31 88 FACILI'TY NAME DOCKET NUMBER (2) PAGE I3i Il 111 St. Lucie Unit o 5 o o o 335 ioF04 LOSS OF COMPONENT COOLING WATER REDUNDANCY BECAUSE OF CROSSTIE VALVES BEING IN THE OPEN POSITION DUE TO PERSONNEL ERROR. |
| At 0124 hours, the Reactor Control Operator (RCO)was performing a monthly pump surveillance run for the 1B component cooling water (CCW)(EIIS:CC)pump.The 1B CCW pump discharge valve was throttled to obtain 4000 GPN flow on the"B" header, as required by the procedure.
| | EVENT DATE IS> LEA NUMBER I61 REPORT DATE (7) OTHER FACILITIES INVOLVED IS) |
| As the valve was throttled, the RCO noticed that the"A" header flow was also decreasing concurrent with the RBR header.The RCO notified the Assistant Nuclear Plant Supervisor (ANPS)and the ANPS immediately instructed the Nuclear Operator to perform a valve alignment verification.
| | MONTH QAY YEAR YEAR SEOVS!VTIAL R'Y~~ MOI TH OAV YEAR FACILITY 4AMFS DOCKET IIVMBERISI 4VMOEA NUMBER N/A 0 5 0 0 0 0 6 0 9 8 7 8 7 012 01 0 209 88 0 5 0 0 0 THIS REPORT IS SUBMIT'TED PURSUANT T 0 THE REQUIREMENTS OF 10 CFR $ : (Chef>> One Or molt Of the ferrew nPl (11 OPERATINO MODE I ~ ) 20.402(O) 20.405(c) S0.73(e l(2) (iv) 73.71IOI POWER 20.405( ~ l(1)(il 50.36(c1 I) I S0.73( ~ )(2)(v) 73.71(cl LEYEL 001 1 0 0 20.405(e l(l) I 61 50.36(cl(21 50,73( ~ I(2)(viil OTHER lSoecifv'r'oltrett oeiow end rn Ter t NRC Form 20.408( ~ Ill)(iii) 50.73( ~ l(21(il 50 73( ~ ) 121(viiil(AI 366A) 20.405 ( ~ 111 I liv) 50.73(el(21( ~ ) S0.7 3 I ~ 1(21(w 6 I (81 |
| During this verification, it was discovered that the 1A and 1B CCW heat exchanger outlet cross-tie valves V-14169 (which is a normally locked closed valve)and V-14439 (which is a normally closed valve)were in the open position.Both valves were then immediately closed and independently verified to be closed.The normal CCW valve alignment was restored to its normal operations line-up.The pump surveillance run was then resumed and noted as satisfactory.
| | : 20. 405 ( ~ I (1 I (el 50.73( ~ I(21(iiil S0.73( ~ I(21(hl LICENSEE CONTACT FOA THIS LER (121 NAME TELEO"ONE NUMBER AREA CODE Victor N. Mendoza, Shift Technical Advisor 0 5 4 6 5 " 3 5 5 0 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (131 MANUFAC. EPQRTABLE CQMPQIIEhrT M A hl ' F A C r EPORTABLE CAUSE SYSTEM CQMPQNENT TVREA TO NPRDS CAUSE SYS EM TVRER TO NORDS SUPPLEMENTAL REPORT EXPECTED I141 EXPECTED VO'P 'EAO SUBMISSION DATE i)5 YES llf yeA comofete ff(PECTEO SVBMISSIOhlDAFEI 40 ABSTRACT fdrrnH to (400 IoeceA I ~ .. eooroerrnetefy fifteen Irnpi ~ .Ioete tyoewnNen hrNI (16) |
| No other abnormalities in the system were noted after the restoration of the CCW system valve alignment.
| | ABSTRACT On June 19, 1987, St. Lucie Unit Il was in Mode 1, 100% power, and at steady state conditions. All control stations were in normal operating mode. At 0124 hours, the Reactor Control Operator (RCO) was performing a monthly pump surveillance run for the 1B component cooling water (CCW) pump. During this surveillance run, it was discovered that the 1A and 1B CCW heat exchanger outlet cross-tie valves were in the open position. The position for these valves is normally closed. The operator immediately performed a valve alignment verification and closed the valves. The root cause of the event was a cognitive personnel error by utility licensed operators who failed to have proper adminis-trative control on these valves. The immediate corrective action was to close the valves. The event was terminated at 0130 hours. No other system malfunction resulted from this event. This event is reportable under the code of federal regulations 10 CFR 50.73 (a) (2) (i) (B), "Any event or condition prohibited by plant's technical specifications". |
| The event was terminated at 0130 on June 19, 1987.No other system malfunctions were observed during the entire event.CAUSE OF THE EVENT On June 8, 1987, the lB CCW heat exchanger was scheduled for repairs.A clearance was issued for all valves and related equipment required to isolate the lB CCW heat exchanger.
| | 8802>70141 88020+ 85000+35 0 |
| The cross-tie valves V-14169 (which is normally locked closed)and V-14439 (which is normally closed)were opened to allow both the"A" and"B" trains of the CCW system (EIIS:CC)to be in service while the 1B CCW heat exchanger was being repaired.Neither of the cross-tie valves were listed on the clearance.
| | PDR ADOCH PDR 8 |
| The utility licensed operator in charge of reviewing the clearance prior to issuance decided not to include these valves in the clearance as these valves were not required for maintenance boundary isolation.
| | NRC Fornr 366 r9 8) |
| He opted to administratively control valve V-14169 by listing this valve in the locked valve deviation log as being in the open position.However, the locked valve deviation log was not reviewed by operations personnel.
| | |
| Thus, it was not noted in the clearance that valves V-14169 and V-14489 were not in their normal closed positions.
| | NRC Eorm 368A U.S. NUCLEAR REGULATORY COMMISSION IS 831 LICENSEE EVENT REPORT (LER) TEXT CONTINUATION *PPROYEO OMS VO 3150-0104 EXPIRES I 8r 31 I 88 PACILITrY NAME III OOCKET NUMBER 12) LER NUMBER (61 PAGE I3I YEAR O SEGUENTrAL R E Y rS r 0 rr NUNSER NUNISE R St. Lucie Unit 41 0 so oo33 587 0 1 2 0 1 0 2 OF 0 TEXT lllrrhoro spsspis rsohrhroc. rhss scchthorrsl lVRC iorrn 36SA'si I IT) |
| After the repairs to the heat, exchanger were completed on June 9, 1987, all the valves and related equipment on the clearance were released and independently verified as being restored to the required operating positions.
| | DESCRIPTION OF EVENT On June 19, 1987, St. Lucie Unit Il was in Node 1, 100% power, and at steady state conditions. At 0124 hours, the Reactor Control Operator (RCO) was performing a monthly pump surveillance run for the 1B component cooling water (CCW) (EIIS:CC) pump. The 1B CCW pump discharge valve was throttled to obtain 4000 GPN flow on the "B" header, as required by the procedure. As the valve was throttled, the RCO noticed that the "A" header flow was also decreasing concurrent with the RBR header. The RCO notified the Assistant Nuclear Plant Supervisor (ANPS) and the ANPS immediately instructed the Nuclear Operator to perform a valve alignment verification. During this verification, it was discovered that the 1A and 1B CCW heat exchanger outlet cross-tie valves V-14169 (which is a normally locked closed valve) and V-14439 (which is a normally closed valve) were in the open position. Both valves were then immediately closed and independently verified to be closed. The normal CCW valve alignment was restored to its normal operations line-up. The pump surveillance run was then resumed and noted as satisfactory. No other abnormalities in the system were noted after the restoration of the CCW system valve alignment. The event was terminated at 0130 on June 19, 1987. No other system malfunctions were observed during the entire event. |
| Since valves V-14169 and V-14439 were not listed on the clearance, they were not restored to their normal position as part of the clearance release process, nor was independent verification called for.NRC FOR@I 348A 184131 NRC Form 366A I9 BSI UCENSEE EVENT REPORT (LER)TEXT CONTINUATION U.S.NUCLEAR REGULATORY COMMISSION APPROVED OMB 40 3160m3IDE EXPIRES.BI3'I'BB FACILITY NAME II)DOCKET NUMBER l3)YEAR LER NUMBER I6I SEOVENTIAL NUMBER REVrSIO4 NVMBEA PAGE l31 St.Lucie Unit 61 TEXT llf mont totoo rt ntovrntd, vtt tddroorrtl IVIIC Form 3664'tl IIT)o 5 o o o 33 58 7 012 0 0 3 OF 0 The root cause of the event was cognitive personnel error by utility licensed-operators who failed to have proper administrative control on valves that were positioned in other than their normal operating positions.
| | CAUSE OF THE EVENT On June 8, 1987, the lB CCW heat exchanger was scheduled for repairs. A clearance was issued for all valves and related equipment required to isolate the lB CCW heat exchanger. The cross-tie valves V-14169 (which is normally locked closed) and V-14439 (which is normally closed) were opened to allow both the "A" and "B" trains of the CCW system (EIIS:CC) to be in service while the 1B CCW heat exchanger was being repaired. Neither of the cross-tie valves were listed on the clearance. The utility licensed operator in charge of reviewing the clearance prior to issuance decided not to include these valves in the clearance as these valves were not required for maintenance boundary isolation. |
| There were no unusual characteristics of the work location that directly contributed to this event.Procedure deficiencies were a contributing factor.Although all actions were justifiable per procedure, the event showed problems with using the locked'valve deviation log as an alternate method.ANALYSIS OF THE EVENT The event is reportable under 10 CFR 50.73(a)(2)(i)(B),"Any event or condition prohibited by the plant's technical specifications".
| | He opted to administratively control valve V-14169 by listing this valve in the locked valve deviation log as being in the open position. However, the locked valve deviation log was not reviewed by operations personnel. Thus, it was not noted in the clearance that valves V-14169 and V-14489 were not in their normal closed positions. After the repairs to the heat, exchanger were completed on June 9, 1987, all the valves and related equipment on the clearance were released and independently verified as being restored to the required operating positions. Since valves V-14169 and V-14439 were not listed on the clearance, they were not restored to their normal position as part of the clearance release process, nor was independent verification called for. |
| Technical Specification 3.7.3'requires"at least two independent component cooling water loops shall be operable".
| | NRC FOR@I 348A 184131 |
| This event resulted in a loss of component cooling system (EIIS:CC)redundancy.
| | |
| However, the loss of redundancy was discovered within 10 days during performance of a routine monthly surveillance.
| | U.S. NUCLEAR REGULATORY COMMISSION NRC Form 366A I9 BSI UCENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVED OMB 40 3160m3IDE EXPIRES. BI3'I 'BB FACILITY NAME II) DOCKET NUMBER l3) LER NUMBER I6I PAGE l31 YEAR SEOVENTIAL REVrSIO4 NUMBER NVMBEA St. Lucie Unit 61 o 5 o o o 33 58 7 012 0 0 3 OF 0 TEXT llfmont totoo rt ntovrntd, vtt tddroorrtl IVIIC Form 3664'tl IIT) |
| Redundancy was completely restored within six (6)minutes of discovery.
| | The root cause of the event was cognitive personnel error by utility licensed-operators who failed to have proper administrative control on valves that were positioned in other than their normal operating positions. There were no unusual characteristics of the work location that directly contributed to this event. |
| There were no other abnormalities in the system during the event.All plant safety functions were met throughout this event.At no time during this event was the health and safety of the public endangered.
| | Procedure deficiencies were a contributing factor. Although all actions were justifiable per procedure, the event showed problems with using the locked |
| Additional actions taken included the following:
| | 'valve deviation log as an alternate method. |
| 1)review of and changes to the clearance and administrative control of valves procedures, 2)review of and changes to the frequency of review of the locked valve deviation log, 3)research of previous similar out of service conditions to determine if the problem had occurred before, 4)a failure modes and effects analysis (FLEA)for the system, and 5)review of the effect of the changed system configuration on the effectiveness of the CCW to perform its design function.The PMEA showed that there is no limiting single active failure for the system in this configurations However, a passive failure (pipe rupture)was identified.
| | ANALYSIS OF THE EVENT The event is reportable under 10 CFR 50.73(a)(2)(i)(B), "Any event or condition prohibited by the plant's technical specifications". Technical Specification 3.7.3 ' requires "at least two independent component cooling water loops shall be operable". |
| The effectiveness of the CCW system to perform its function with the cross-tie open versus the cross-tie closed would not significantly change since the reliability of the system in either configuration would be dominated by the active component failures (i.e.pumps and valves).~rtlC FOR4r 368A I94ISI NRC<<>Im 366A (9 83(LICENSEE EVENT REPORT (LER)TEXT CONTINUATION U,S.NUCLEAR REGULATORY COMMISSION APPROVEO OMB NO 3(SO OIO4 EXPIRES: 8/31(88 FACILITY NAME ((l St.Lucie Unit 81 TEXT (lf moIP 4P444 I4 mdIIddd.IIM PddIIdmd(NRC Fdtm 36SA'4((ln OOCKET NUMBER (2(0 5 o o o 3 3 YEAR 8 7 LER NUMBER (61 SEGUENTIAL NUMBER 0 1 2 REVISION NUMBER 01 04 PAGE (31 OF 04 CORRECTIVE ACTIONS 1.Valve V-14169 was restored to its locked closed position and valve V-14439 was closed.Independent verification of valve proper position was performed.
| | This event resulted in a loss of component cooling system (EIIS:CC) redundancy. |
| 2.The plant training group will evaluate this item to determine appropriate training requirements and methods.3.The responsible supervisor has been instructed to include these valves in future clearances to ensure restoration.
| | However, the loss of redundancy was discovered within 10 days during performance of a routine monthly surveillance. Redundancy was completely restored within six (6) minutes of discovery. There were no other abnormalities in the system during the event. All plant safety functions were met throughout this event. |
| 4.Procedures were modified to require all valves repositioned to be on the clearance form.5.The frequency of review of the locked valve deviation log was increased.
| | At no time during this event was the health and safety of the public endangered. |
| 6.Research on historical data showed that these valves had been included on the clearance form, and this appeared to be the first time that the locked valve deviation log had been used as an alternate method.ADDITIONAL INFORMATION Failed component identification:
| | Additional actions taken included the following: 1) review of and changes to the clearance and administrative control of valves procedures, 2) review of and changes to the frequency of review of the locked valve deviation log, 3) research of previous similar out of service conditions to determine if the problem had occurred before, 4) a failure modes and effects analysis (FLEA) for the system, and 5) review of the effect of the changed system configuration on the effectiveness of the CCW to perform its design function. The PMEA showed that there is no limiting single active failure for the system in this configurations However, a passive failure (pipe rupture) was identified. The effectiveness of the CCW system to perform its function with the cross-tie open versus the cross-tie closed would not significantly change since the reliability of the system in either configuration would be dominated by the active component failures (i.e. pumps and valves). |
| There were no failed components during this event.PREVIOUS SIMILAR EVENT See LER N335-85-02 for a previous valve mispositioning event.~IRC FORM 366A (94(3l P.O.BOX, JUNO BEACH, PL 33408 0420 FEgRggy 9 L-88-44 10 CFR 50.73 U.S.Nuclear Regulatory Commission Attn: Document Control Desk Washington, D.C.20555 Gentlemen:
| | ~ rtlC FOR4r 368A I94ISI |
| Re: St.Lucie Unit 1 Docket No.50-335 Reportable Event: 87-12 Revision 1 Date of Event: June 9, 1987 Loss of Component Cooling Water Redundancy Because of Crosstie Valves Being in the 0 en Position Due to Personnel Error The attached Licensee Event Report (LER)is being submitted pursuant to the requirements of 10 CFR 50.73 to provide an update on the subject event.Very truly yours, , gag, r+cX C.0.Woo Execu'ice President COW/GRM/gp Attachment cc: Dr.J.Nelson Grace, Regional Administrator, Region II, USNRC Senior Resident Inspector, USNRC, St.Lucie Plant an FPL Group company}}
| | |
| | NRC <<>Im 366A U,S. NUCLEAR REGULATORY COMMISSION (9 83( |
| | LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVEO OMB NO 3(SO OIO4 EXPIRES: 8/31(88 FACILITY NAME ((l OOCKET NUMBER (2( LER NUMBER (61 PAGE (31 YEAR SEGUENTIAL REVISION NUMBER NUMBER St. Lucie Unit 81 3 3 8 7 0 1 2 01 04 OF 04 0 5 o o o TEXT (lfmoIP 4P444 I4 mdIIddd. IIM PddIIdmd( NRC Fdtm 36SA'4( (ln CORRECTIVE ACTIONS |
| | : 1. Valve V-14169 was restored to its locked closed position and valve V-14439 was closed. Independent verification of valve proper position was performed. |
| | : 2. The plant training group will evaluate this item to determine appropriate training requirements and methods. |
| | : 3. The responsible supervisor has been instructed to include these valves in future clearances to ensure restoration. |
| | : 4. Procedures were modified to require all valves repositioned to be on the clearance form. |
| | : 5. The frequency of review of the locked valve deviation log was increased. |
| | : 6. Research on historical data showed that these valves had been included on the clearance form, and this appeared to be the first time that the locked valve deviation log had been used as an alternate method. |
| | ADDITIONAL INFORMATION Failed component identification: There were no failed components during this event. |
| | PREVIOUS SIMILAR EVENT See LER N335-85-02 for a previous valve mispositioning event. |
| | ~ IRC FORM 366A (94(3l |
| | |
| | P. O. BOX, JUNO BEACH, PL 33408 0420 FEgRggy 9 L-88-44 10 CFR 50.73 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555 Gentlemen: |
| | Re: St. Lucie Unit 1 Docket No. 50-335 Reportable Event: 87-12 Revision 1 Date of Event: June 9, 1987 Loss of Component Cooling Water Redundancy Because of Crosstie Valves Being in the 0 en Position Due to Personnel Error The attached Licensee Event Report (LER) is being submitted pursuant to the requirements of 10 CFR 50.73 to provide an update on the subject event. |
| | Very truly yours, |
| | , gag, r+cX C. 0. |
| | Execu 'ice President Woo COW/GRM/gp Attachment cc: Dr. J. Nelson Grace, Regional Administrator, Region II, USNRC Senior Resident Inspector, USNRC, St. Lucie Plant an FPL Group company}} |
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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML17241A4891999-10-0707 October 1999
LER 99-004-00:on 990912,noted That MSSV Surveillance Was Outside of TS Requirements.Caused by Setpoint Drift.Subject MSSVs Are Being Refurbished & Retested Prior to Unit Startup from SL1-16 Refueling Outage.With 991007 Ltr
ML17241A4111999-07-16016 July 1999
LER 99-007-00:on 990610,unplanned Cooldown Transient Occurred Due to Personnel Error.Trained & Briefed Personnel & Revised Procedures.With 990716 Ltr
ML17241A4031999-07-0606 July 1999
LER 99-006-00:on 990605,sub-critical Reactor Trip Occurred Due to Inadvertent MSIV Opening.Caused by Personnel Error. Provided Operation Supervision Instruction to Operating Crews,Stand Down Meetings & Operator Aids.With 990706 Ltr
ML17241A4041999-07-0606 July 1999
LER 99-005-00:on 990604,CEA Drop Resulted in Manual Reactor Trip.Caused by Procedural Inadequacies.Procedure Changes Are Planned to Correct Lack of Procedural Guidance for CEA Subgroup Power Switch Replacement.With 990706 Ltr
ML17241A3941999-06-30030 June 1999
LER 99-004-01:on 990415,as Found Cycle 10 Psv Setpoints Were Outside TS Limits.Caused by Manufacturing Process Defect. All Three Psvs Were Replaced with pre-tested Valves During Cycle 11 Refueling Outage.With 990630 Ltr
ML17241A3551999-06-0404 June 1999
LER 99-002-00:on 990505,both Trains of Safety Injection Actuation Were Blocked During Surveillance.Caused by Procedure Error.Procedure Revised.With 990604 Ltr
ML17241A3321999-05-17017 May 1999
LER 99-004-00:on 990415,determined That as Found Cycle 10 Psv Setpoints Outside TS Limits.Root Cause Under Investigation.Psvs Replaced with pe-tested Valves During Cycle 11
ML17241A3271999-05-0606 May 1999
LER 99-003-00:on 990406,ECCS Suction Header Leak Resulted in Both ECCS Trains Being Inoperable & Entry Into TS 3.0.3. Caused by Chloride Induced OD Stress Corrosion Cracking of Piping.Made Code Repairs & Coated Piping.With 990506 Ltr
ML17229B0791999-04-0707 April 1999
LER 99-001-00:on 990309,discovered Inadequate Design & IST SRs for Iodine Removal Sys (Irs).Caused by Original Design Inadequacies & Personnel Error.Naoh Tank Vent Valve V07233 Was Tagged Open.With 990407 Ltr
ML17229B0801999-04-0707 April 1999
LER 99-002-00:on 990311,SG ECT Error Caused Operation with Condition Prohibited by Ts.Caused by Deficiencies in Data Analysis Guideline Instructions.Licensee Will Change Data Analysis Guidelines for Lead Analysts.With 990407 Ltr
ML17229B0541999-03-10010 March 1999
LER 99-001-00:on 990211,inadequate TS SRs for SIT & SDC Isolation Valves Were Noted.Caused by Failure to Correctly Implement TS Srs.Submitted LAR to Align Required TS SR with Design Bases Requirements Being Verified.With 990310 Ltr
ML17229A9901999-01-20020 January 1999
LER 98-009-00:on 981223,noted That Facility Operated Outside of Design Basis.Caused by non-conservative MSLB Analysis Inputs.Will Review SR Component Differences Between Units & Will re-baseline LTOP Analysis.With 990120 Ltr
ML17229A9821999-01-0404 January 1999
LER 98-010-00:on 981207,RCS Boron Sample Frequency Required by Ts,Was Exceeded by Twelve Minutes.Caused by Personnel Error.Equipment Clearance Order Was Lifted to Draw Required Sample & Operations Procedure Was Changed.With 990104 Ltr
ML17229A9611998-12-22022 December 1998
LER 97-002-01:on 981204,containment Sump Debris Screen Was Not IAW Design.Caused by Inadequate C/As for Sump Screen Anamolies.All Identified Sump Screen Deficiencies Were Dispositioned &/Or Repaired.With 981222 Ltr
ML17229A9561998-12-15015 December 1998
LER 98-008-00:on 981118,missed TS SG U Tube Insp.Caused by Encoding Errors While Using Remote Positioning Fixtures.All SG Tube Surveyed.With 981215 Ltr
ML17229A9301998-11-25025 November 1998
LER 98-005-01:on 980807,discovered That New MOV Methodology Caused Past PORV Block Valve Operability Problem.Caused by Inadequacies in Original Vendor MOV Methodology.Planned Valve Mods Will Be Implemented During Cycle 11 1998 Outage
ML17229A9021998-11-0404 November 1998
LER 98-008-00:on 981008,inadequate Reactor Protection Sys Trip Bypass TS Was Noted.Caused by Poorly Worded Ts. Submitted LAR to Clarify Power Requirements for High Rate of Power Trips.With 981104 Ltr
ML17229A8771998-10-14014 October 1998
LER 98-006-00:on 980918,inadvertent Afas Actuation Was Noted.Caused by Degradation of Multiple Afas Power Supplies. Replaced Afas Power Supplies & Revised Procedures.With 981014 Ltr
ML17229A8761998-10-14014 October 1998
LER 98-007-00:on 980918,identified Discrepancies Between Fire Protection Design Requirements & Field Conditions. Caused by Inadequate Translation & Implementation of Fire Protection Requirements.Procedures Revised.With 981014 Ltr
ML17229A8511998-09-0202 September 1998
LER 98-005-00:on 980807,discovered That PORV Margins Were Insufficient to Accommodate Addl Conservatism.Caused by Inadequacies in Original Vendor MOV Methodology.Will Implement Planned Valve Actuator mods.W/980902 Ltr
ML17229A8201998-07-29029 July 1998
LER 98-007-00:on 980630,inadequate Procedure May Have Resulted in SBO Recovery Complications.Caused by Inadequate Procedures.Attached Caution Tags to Appropriate Control switches.W/980729 Ltr
ML17229A7411998-05-28028 May 1998
LER 98-004-00:on 980430,discovered Waste Gas Decay Tank Operation W/O Available Oxygen Analyzers,Which Is Prohibited by Ts.Caused by Inadequate Licensee Review of License Amend. Oxygen Analyzer recalibrated.W/980528 Ltr
ML17229A7381998-05-21021 May 1998
LER 98-006-00:on 980421,missed EDG Fuel Oil Sample Surveillance Was Noted.Caused by Personnel Error.Revised Fuel Oil Sampling Service Purchase Order & Revised Site procedure.W/980521 Ltr
ML17229A7011998-04-27027 April 1998
LER 98-003-00:on 980326,discovered Containment Pressure Instrumentation Design Single Failure Vulnerability.Caused by Inadequate Design by Personnel Error.Removed RPS & ESFAS Containment Pressure Bypass Keys immediately.W/980427 Ltr
ML17229A6761998-04-0202 April 1998
LER 98-005-00:on 980305,identified Two Conditions That Were Outside App R Design Bases.Caused by Design Oversight During Development of Original App R Safe SD Design.Established 30 Minute Roving Fire Watches & Provided training.W/980402 Ltr
ML17229A6731998-03-26026 March 1998
LER 98-002-00:on 980224,radiation Monitor Surveillance Inadequacies Led to Operating of Facility Prohibited by Tss. Caused by Congnitive Personnel Error.Permanent Procedure Changes Were implemented.W/980326 Ltr
ML17229A6551998-03-0505 March 1998
LER 98-001-00:on 980206,high/low Pressure Shutdown Cooling Interface Was Noted Outside App R Design Bases.Caused by Personnel Error.Addl Guidance Was Provided to Engineering Dept personnel.W/980305 Ltr
ML17229A6281998-02-19019 February 1998
LER 98-004-00:on 980121,emergency Lighting Outside App R Design Bases Occurred.Caused by Congnitive Personnel Error During Translation of App R Section Iii.Procedures Onop 1 & 2 ONP-100.01 Were Issued for Use on 980206.W/980219 Ltr
ML17229A6211998-02-0909 February 1998
LER 98-003-00:on 980110,manual Rt Due to DEH Leak at Turbine Test Block Was Noted.Caused by o-ring Extrusion.Shortened Bolts by About 0.125 & Reinstalled at Correct Torque values.W/980209 Ltr
ML17229A6191998-02-0404 February 1998
LER 98-002-00:on 980105,CIS Bistable in Bypass Resulted in Condition Prohibited by Tss.Caused by Personnel Error. Radiation Monitor Was Restored to service.W/980204 Ltr
ML17229A6161998-02-0303 February 1998
LER 98-001-00:on 980104,inadvertent RPS Actuation Occurred Due to Personnel Error.Caused by Procedural Inadequacies & Inadequate self-checking by Licensed Utility Personnel. Placards Have Been Placed in CRs.W/980203 Ltr
ML17229A6051998-01-27027 January 1998
LER 97-010-01:on 971027,inadvertent Core Alteration Prohibited by TSs Were Noted Due to Stuck Cea.Caused by Personnel Error.Cea #24 Was Dislodged & Transferred to Spent Pool for insp.W/980127 Ltr
ML17229A5501997-12-0505 December 1997
LER 97-008-00:on 971107,inadequate CR Ventilation Surveillance Resulted in Condition Prohibited by Ts.Caused by non-cognitive Personnel Error.Operating Procedure 2-1900050 Was revised.W/971205 Ltr
ML17309A9091997-12-0202 December 1997
LER 97-011-00:on 971102,non-conservative RAS Set Point Resulted in Operation Prohibited by Ts.Caused by Inadequate Set Point & Instrument Loop Scaling Process.Revised ESFAS Functional Tp W/Proper Set point.W/971202 Ltr
ML17229A5391997-11-26026 November 1997
LER 97-010-00:on 971027,inadvertant Core Alteration Prohibited by TS Occurred.Caused by CEA Failure to Detach from Ugs.Safety Evaluation Was Performed & Procedural Rev Made to Continue Upper Guide Structure move.W/971126 Ltr
ML17229A5151997-11-0707 November 1997
LER 97-007-00:on 971008,inoperable Containment Cooling Fan Resulted in Operation of Facility Outside Design Basis. Caused by non-cognitive Personnel Error.Ccs Operation Was Revised & Issued on 971013.W/971107 Ltr
ML17229A4991997-10-17017 October 1997
LER 97-009-00:on 970917,inoperable PORV Block Valve Resulted in Operation Prohibited by Tech Specs Occurred.Caused by Plant GL 89-10 Program Plan to Review Plant Manager Action Item Sys.Porv Block Valve V-1403 restored.W/971017 Ltr
ML17309A9011997-08-27027 August 1997
LER 97-008-00:on 970728,mechanical Fire Penetrations Were Inoperable & Outside App R Design Bases.Caused by Seal Mfg Not Providing Formal Documentation for Installed Seals. Modified Inoperable Fire penetrations.W/970827 Ltr
ML17229A4311997-07-29029 July 1997
LER 97-006-00:on 970630,discovered Inadequate Testing of Engineered Safety Features Subgroup Relays.Caused by Inadequacy in Implementing TS Requirements in Surveillance Procedures.Revised Surveillance procedures.W/970729 Ltr
ML17229A4241997-07-25025 July 1997
LER 97-005-00:on 970625,discovered That Hot Shutdown Control Panel Shutdown Cooling Flow indicator,FI-3306 Inoperable. Caused by Weakness in Work Order & Procedure Used to Repair FI-3306.Section Meeting W/I&C Planners held.W/970725 Ltr
ML17229A3971997-07-11011 July 1997
LER 97-004-00:on 970611,discovered Incorrect Original Cable Tray Fire Stop Assembly Installation Was Outside App R Design Basis.Caused by Personnel Error.Hourly Fire Watch Patrols Will Be posted.W/970711 Ltr
ML17229A3871997-06-19019 June 1997
LER 97-003-00:on 970521,determined Required Post Maint Open Stroke Test for Valve V3245,2B2 SIT Discharge Check Valve, Had Not Been Performed.Caused by Personnel Error.Procedure revised.W/970619 Ltr
ML17229A3841997-06-17017 June 1997
LER 97-002-00:on 970518,containment Sump Debris Screen Was Not IAW Design Due to Gaps in Screen Encl.Performed SER to Document Containment Sump Design requirements.W/970617 Ltr
ML17229A3751997-06-0202 June 1997
LER 97-006-00:on 970501,operation Was Prohibited by TS Due to Inadequately Tested Degraded Voltage Sys.Revised Unit 1 ESFAS Surveillance Test procedure.W/970602 Ltr
ML17229A3611997-05-29029 May 1997
LER 97-007-00:on 970502,reactor Coolant Pump Oil Collection Sys Was Outside App R Design Bases.Identified Leak Sites Were Repaired & Mods to RCP Oil Collection Sys to Capture Any Future Leakage from areas.W/970529 Ltr
ML17229A3491997-05-21021 May 1997
LER 97-001-00:on 970423,containment Isolation Actuation Occurred.Caused by Increased Radiation Levels During Removal of Upper Guide Structure.Proper Actuation of Containment Isolation Components Was verified.W/970521 Ltr
ML17229A3441997-05-13013 May 1997
LER 97-005-00:on 970419,reactor Was Shutdown Due to Reactor Coolant Pressure Boundary Leakage.Hot Cracking Was Caused by Weld Contamination.Repairs to RCPB Were Completed & 1A SDC Train Was Restored to Svc
ML17229A3141997-04-30030 April 1997
LER 97-004-00:on 970402,refueling Machine Was Operating in Manner Prohibited by TS Due to Original Design of Refueling Machine Bypass Feature Conflicting W/Ts Requirements. Eliminated Overload Cut Off Limit bypass.W/970430 Ltr
ML17229A2951997-03-31031 March 1997
LER 97-003-00:on 970304,automatic Rt Resulted from Loss of Electrical Power to 1A2 Rc Pump.Rcp Breaker Was Replaced & Pump Was Returned to svc.W/970331 Ltr
ML17229A2721997-03-21021 March 1997
LER 97-002-00:on 970221,operation in Excess of Max Rated Thermal Power Occurred Due to Digital Data Processing Sys (Ddps) Calorimetric Error.Verified Acceptable Performance of Ddps Functions & Reviewed Software mods.W/970321 Ltr
1999-07-06
[Table view]
Category:RO)
MONTHYEARML17241A4891999-10-0707 October 1999
LER 99-004-00:on 990912,noted That MSSV Surveillance Was Outside of TS Requirements.Caused by Setpoint Drift.Subject MSSVs Are Being Refurbished & Retested Prior to Unit Startup from SL1-16 Refueling Outage.With 991007 Ltr
ML17241A4111999-07-16016 July 1999
LER 99-007-00:on 990610,unplanned Cooldown Transient Occurred Due to Personnel Error.Trained & Briefed Personnel & Revised Procedures.With 990716 Ltr
ML17241A4031999-07-0606 July 1999
LER 99-006-00:on 990605,sub-critical Reactor Trip Occurred Due to Inadvertent MSIV Opening.Caused by Personnel Error. Provided Operation Supervision Instruction to Operating Crews,Stand Down Meetings & Operator Aids.With 990706 Ltr
ML17241A4041999-07-0606 July 1999
LER 99-005-00:on 990604,CEA Drop Resulted in Manual Reactor Trip.Caused by Procedural Inadequacies.Procedure Changes Are Planned to Correct Lack of Procedural Guidance for CEA Subgroup Power Switch Replacement.With 990706 Ltr
ML17241A3941999-06-30030 June 1999
LER 99-004-01:on 990415,as Found Cycle 10 Psv Setpoints Were Outside TS Limits.Caused by Manufacturing Process Defect. All Three Psvs Were Replaced with pre-tested Valves During Cycle 11 Refueling Outage.With 990630 Ltr
ML17241A3551999-06-0404 June 1999
LER 99-002-00:on 990505,both Trains of Safety Injection Actuation Were Blocked During Surveillance.Caused by Procedure Error.Procedure Revised.With 990604 Ltr
ML17241A3321999-05-17017 May 1999
LER 99-004-00:on 990415,determined That as Found Cycle 10 Psv Setpoints Outside TS Limits.Root Cause Under Investigation.Psvs Replaced with pe-tested Valves During Cycle 11
ML17241A3271999-05-0606 May 1999
LER 99-003-00:on 990406,ECCS Suction Header Leak Resulted in Both ECCS Trains Being Inoperable & Entry Into TS 3.0.3. Caused by Chloride Induced OD Stress Corrosion Cracking of Piping.Made Code Repairs & Coated Piping.With 990506 Ltr
ML17229B0791999-04-0707 April 1999
LER 99-001-00:on 990309,discovered Inadequate Design & IST SRs for Iodine Removal Sys (Irs).Caused by Original Design Inadequacies & Personnel Error.Naoh Tank Vent Valve V07233 Was Tagged Open.With 990407 Ltr
ML17229B0801999-04-0707 April 1999
LER 99-002-00:on 990311,SG ECT Error Caused Operation with Condition Prohibited by Ts.Caused by Deficiencies in Data Analysis Guideline Instructions.Licensee Will Change Data Analysis Guidelines for Lead Analysts.With 990407 Ltr
ML17229B0541999-03-10010 March 1999
LER 99-001-00:on 990211,inadequate TS SRs for SIT & SDC Isolation Valves Were Noted.Caused by Failure to Correctly Implement TS Srs.Submitted LAR to Align Required TS SR with Design Bases Requirements Being Verified.With 990310 Ltr
ML17229A9901999-01-20020 January 1999
LER 98-009-00:on 981223,noted That Facility Operated Outside of Design Basis.Caused by non-conservative MSLB Analysis Inputs.Will Review SR Component Differences Between Units & Will re-baseline LTOP Analysis.With 990120 Ltr
ML17229A9821999-01-0404 January 1999
LER 98-010-00:on 981207,RCS Boron Sample Frequency Required by Ts,Was Exceeded by Twelve Minutes.Caused by Personnel Error.Equipment Clearance Order Was Lifted to Draw Required Sample & Operations Procedure Was Changed.With 990104 Ltr
ML17229A9611998-12-22022 December 1998
LER 97-002-01:on 981204,containment Sump Debris Screen Was Not IAW Design.Caused by Inadequate C/As for Sump Screen Anamolies.All Identified Sump Screen Deficiencies Were Dispositioned &/Or Repaired.With 981222 Ltr
ML17229A9561998-12-15015 December 1998
LER 98-008-00:on 981118,missed TS SG U Tube Insp.Caused by Encoding Errors While Using Remote Positioning Fixtures.All SG Tube Surveyed.With 981215 Ltr
ML17229A9301998-11-25025 November 1998
LER 98-005-01:on 980807,discovered That New MOV Methodology Caused Past PORV Block Valve Operability Problem.Caused by Inadequacies in Original Vendor MOV Methodology.Planned Valve Mods Will Be Implemented During Cycle 11 1998 Outage
ML17229A9021998-11-0404 November 1998
LER 98-008-00:on 981008,inadequate Reactor Protection Sys Trip Bypass TS Was Noted.Caused by Poorly Worded Ts. Submitted LAR to Clarify Power Requirements for High Rate of Power Trips.With 981104 Ltr
ML17229A8771998-10-14014 October 1998
LER 98-006-00:on 980918,inadvertent Afas Actuation Was Noted.Caused by Degradation of Multiple Afas Power Supplies. Replaced Afas Power Supplies & Revised Procedures.With 981014 Ltr
ML17229A8761998-10-14014 October 1998
LER 98-007-00:on 980918,identified Discrepancies Between Fire Protection Design Requirements & Field Conditions. Caused by Inadequate Translation & Implementation of Fire Protection Requirements.Procedures Revised.With 981014 Ltr
ML17229A8511998-09-0202 September 1998
LER 98-005-00:on 980807,discovered That PORV Margins Were Insufficient to Accommodate Addl Conservatism.Caused by Inadequacies in Original Vendor MOV Methodology.Will Implement Planned Valve Actuator mods.W/980902 Ltr
ML17229A8201998-07-29029 July 1998
LER 98-007-00:on 980630,inadequate Procedure May Have Resulted in SBO Recovery Complications.Caused by Inadequate Procedures.Attached Caution Tags to Appropriate Control switches.W/980729 Ltr
ML17229A7411998-05-28028 May 1998
LER 98-004-00:on 980430,discovered Waste Gas Decay Tank Operation W/O Available Oxygen Analyzers,Which Is Prohibited by Ts.Caused by Inadequate Licensee Review of License Amend. Oxygen Analyzer recalibrated.W/980528 Ltr
ML17229A7381998-05-21021 May 1998
LER 98-006-00:on 980421,missed EDG Fuel Oil Sample Surveillance Was Noted.Caused by Personnel Error.Revised Fuel Oil Sampling Service Purchase Order & Revised Site procedure.W/980521 Ltr
ML17229A7011998-04-27027 April 1998
LER 98-003-00:on 980326,discovered Containment Pressure Instrumentation Design Single Failure Vulnerability.Caused by Inadequate Design by Personnel Error.Removed RPS & ESFAS Containment Pressure Bypass Keys immediately.W/980427 Ltr
ML17229A6761998-04-0202 April 1998
LER 98-005-00:on 980305,identified Two Conditions That Were Outside App R Design Bases.Caused by Design Oversight During Development of Original App R Safe SD Design.Established 30 Minute Roving Fire Watches & Provided training.W/980402 Ltr
ML17229A6731998-03-26026 March 1998
LER 98-002-00:on 980224,radiation Monitor Surveillance Inadequacies Led to Operating of Facility Prohibited by Tss. Caused by Congnitive Personnel Error.Permanent Procedure Changes Were implemented.W/980326 Ltr
ML17229A6551998-03-0505 March 1998
LER 98-001-00:on 980206,high/low Pressure Shutdown Cooling Interface Was Noted Outside App R Design Bases.Caused by Personnel Error.Addl Guidance Was Provided to Engineering Dept personnel.W/980305 Ltr
ML17229A6281998-02-19019 February 1998
LER 98-004-00:on 980121,emergency Lighting Outside App R Design Bases Occurred.Caused by Congnitive Personnel Error During Translation of App R Section Iii.Procedures Onop 1 & 2 ONP-100.01 Were Issued for Use on 980206.W/980219 Ltr
ML17229A6211998-02-0909 February 1998
LER 98-003-00:on 980110,manual Rt Due to DEH Leak at Turbine Test Block Was Noted.Caused by o-ring Extrusion.Shortened Bolts by About 0.125 & Reinstalled at Correct Torque values.W/980209 Ltr
ML17229A6191998-02-0404 February 1998
LER 98-002-00:on 980105,CIS Bistable in Bypass Resulted in Condition Prohibited by Tss.Caused by Personnel Error. Radiation Monitor Was Restored to service.W/980204 Ltr
ML17229A6161998-02-0303 February 1998
LER 98-001-00:on 980104,inadvertent RPS Actuation Occurred Due to Personnel Error.Caused by Procedural Inadequacies & Inadequate self-checking by Licensed Utility Personnel. Placards Have Been Placed in CRs.W/980203 Ltr
ML17229A6051998-01-27027 January 1998
LER 97-010-01:on 971027,inadvertent Core Alteration Prohibited by TSs Were Noted Due to Stuck Cea.Caused by Personnel Error.Cea #24 Was Dislodged & Transferred to Spent Pool for insp.W/980127 Ltr
ML17229A5501997-12-0505 December 1997
LER 97-008-00:on 971107,inadequate CR Ventilation Surveillance Resulted in Condition Prohibited by Ts.Caused by non-cognitive Personnel Error.Operating Procedure 2-1900050 Was revised.W/971205 Ltr
ML17309A9091997-12-0202 December 1997
LER 97-011-00:on 971102,non-conservative RAS Set Point Resulted in Operation Prohibited by Ts.Caused by Inadequate Set Point & Instrument Loop Scaling Process.Revised ESFAS Functional Tp W/Proper Set point.W/971202 Ltr
ML17229A5391997-11-26026 November 1997
LER 97-010-00:on 971027,inadvertant Core Alteration Prohibited by TS Occurred.Caused by CEA Failure to Detach from Ugs.Safety Evaluation Was Performed & Procedural Rev Made to Continue Upper Guide Structure move.W/971126 Ltr
ML17229A5151997-11-0707 November 1997
LER 97-007-00:on 971008,inoperable Containment Cooling Fan Resulted in Operation of Facility Outside Design Basis. Caused by non-cognitive Personnel Error.Ccs Operation Was Revised & Issued on 971013.W/971107 Ltr
ML17229A4991997-10-17017 October 1997
LER 97-009-00:on 970917,inoperable PORV Block Valve Resulted in Operation Prohibited by Tech Specs Occurred.Caused by Plant GL 89-10 Program Plan to Review Plant Manager Action Item Sys.Porv Block Valve V-1403 restored.W/971017 Ltr
ML17309A9011997-08-27027 August 1997
LER 97-008-00:on 970728,mechanical Fire Penetrations Were Inoperable & Outside App R Design Bases.Caused by Seal Mfg Not Providing Formal Documentation for Installed Seals. Modified Inoperable Fire penetrations.W/970827 Ltr
ML17229A4311997-07-29029 July 1997
LER 97-006-00:on 970630,discovered Inadequate Testing of Engineered Safety Features Subgroup Relays.Caused by Inadequacy in Implementing TS Requirements in Surveillance Procedures.Revised Surveillance procedures.W/970729 Ltr
ML17229A4241997-07-25025 July 1997
LER 97-005-00:on 970625,discovered That Hot Shutdown Control Panel Shutdown Cooling Flow indicator,FI-3306 Inoperable. Caused by Weakness in Work Order & Procedure Used to Repair FI-3306.Section Meeting W/I&C Planners held.W/970725 Ltr
ML17229A3971997-07-11011 July 1997
LER 97-004-00:on 970611,discovered Incorrect Original Cable Tray Fire Stop Assembly Installation Was Outside App R Design Basis.Caused by Personnel Error.Hourly Fire Watch Patrols Will Be posted.W/970711 Ltr
ML17229A3871997-06-19019 June 1997
LER 97-003-00:on 970521,determined Required Post Maint Open Stroke Test for Valve V3245,2B2 SIT Discharge Check Valve, Had Not Been Performed.Caused by Personnel Error.Procedure revised.W/970619 Ltr
ML17229A3841997-06-17017 June 1997
LER 97-002-00:on 970518,containment Sump Debris Screen Was Not IAW Design Due to Gaps in Screen Encl.Performed SER to Document Containment Sump Design requirements.W/970617 Ltr
ML17229A3751997-06-0202 June 1997
LER 97-006-00:on 970501,operation Was Prohibited by TS Due to Inadequately Tested Degraded Voltage Sys.Revised Unit 1 ESFAS Surveillance Test procedure.W/970602 Ltr
ML17229A3611997-05-29029 May 1997
LER 97-007-00:on 970502,reactor Coolant Pump Oil Collection Sys Was Outside App R Design Bases.Identified Leak Sites Were Repaired & Mods to RCP Oil Collection Sys to Capture Any Future Leakage from areas.W/970529 Ltr
ML17229A3491997-05-21021 May 1997
LER 97-001-00:on 970423,containment Isolation Actuation Occurred.Caused by Increased Radiation Levels During Removal of Upper Guide Structure.Proper Actuation of Containment Isolation Components Was verified.W/970521 Ltr
ML17229A3441997-05-13013 May 1997
LER 97-005-00:on 970419,reactor Was Shutdown Due to Reactor Coolant Pressure Boundary Leakage.Hot Cracking Was Caused by Weld Contamination.Repairs to RCPB Were Completed & 1A SDC Train Was Restored to Svc
ML17229A3141997-04-30030 April 1997
LER 97-004-00:on 970402,refueling Machine Was Operating in Manner Prohibited by TS Due to Original Design of Refueling Machine Bypass Feature Conflicting W/Ts Requirements. Eliminated Overload Cut Off Limit bypass.W/970430 Ltr
ML17229A2951997-03-31031 March 1997
LER 97-003-00:on 970304,automatic Rt Resulted from Loss of Electrical Power to 1A2 Rc Pump.Rcp Breaker Was Replaced & Pump Was Returned to svc.W/970331 Ltr
ML17229A2721997-03-21021 March 1997
LER 97-002-00:on 970221,operation in Excess of Max Rated Thermal Power Occurred Due to Digital Data Processing Sys (Ddps) Calorimetric Error.Verified Acceptable Performance of Ddps Functions & Reviewed Software mods.W/970321 Ltr
1999-07-06
[Table view]
Category:TEXT-SAFETY REPORT
MONTHYEARML17241A4891999-10-0707 October 1999
LER 99-004-00:on 990912,noted That MSSV Surveillance Was Outside of TS Requirements.Caused by Setpoint Drift.Subject MSSVs Are Being Refurbished & Retested Prior to Unit Startup from SL1-16 Refueling Outage.With 991007 Ltr
ML17241A4951999-09-30030 September 1999
Monthly Operating Repts for Sept 1999 for St Lucie,Units 1 & 2.With 991014 Ltr
ML17241A4741999-08-31031 August 1999
Rev 1 to PCM 99016, St Lucie Unit 1,Cycle 16 Colr.
ML17241A4591999-08-31031 August 1999
Monthly Operating Repts for Aug 1999 for St Lucie,Units 1 & 2.With 990913 Ltr
ML17241A4301999-07-31031 July 1999
Monthly Operating Repts for Jul 1999 for St Lucie Units 1 & 2.With 990805 Ltr
ML17241A4111999-07-16016 July 1999
LER 99-007-00:on 990610,unplanned Cooldown Transient Occurred Due to Personnel Error.Trained & Briefed Personnel & Revised Procedures.With 990716 Ltr
ML17241A4031999-07-0606 July 1999
LER 99-006-00:on 990605,sub-critical Reactor Trip Occurred Due to Inadvertent MSIV Opening.Caused by Personnel Error. Provided Operation Supervision Instruction to Operating Crews,Stand Down Meetings & Operator Aids.With 990706 Ltr
ML17241A4041999-07-0606 July 1999
LER 99-005-00:on 990604,CEA Drop Resulted in Manual Reactor Trip.Caused by Procedural Inadequacies.Procedure Changes Are Planned to Correct Lack of Procedural Guidance for CEA Subgroup Power Switch Replacement.With 990706 Ltr
ML17241A4091999-06-30030 June 1999
Monthly Operating Repts for June 1999 for St Lucie,Units 1 & 2.With 990712 Ltr
ML17241A3941999-06-30030 June 1999
LER 99-004-01:on 990415,as Found Cycle 10 Psv Setpoints Were Outside TS Limits.Caused by Manufacturing Process Defect. All Three Psvs Were Replaced with pre-tested Valves During Cycle 11 Refueling Outage.With 990630 Ltr
ML17355A3681999-06-30030 June 1999
Revised Update to Topical QA Rept, Dtd June 1999
ML17241A3551999-06-0404 June 1999
LER 99-002-00:on 990505,both Trains of Safety Injection Actuation Were Blocked During Surveillance.Caused by Procedure Error.Procedure Revised.With 990604 Ltr
ML17241A3631999-05-31031 May 1999
Monthly Operating Repts for May 1999 for St Lucie Units 1 & 2.With 990610 Ltr
ML17241A3321999-05-17017 May 1999
LER 99-004-00:on 990415,determined That as Found Cycle 10 Psv Setpoints Outside TS Limits.Root Cause Under Investigation.Psvs Replaced with pe-tested Valves During Cycle 11
ML17241A3271999-05-0606 May 1999
LER 99-003-00:on 990406,ECCS Suction Header Leak Resulted in Both ECCS Trains Being Inoperable & Entry Into TS 3.0.3. Caused by Chloride Induced OD Stress Corrosion Cracking of Piping.Made Code Repairs & Coated Piping.With 990506 Ltr
ML17241A3331999-04-30030 April 1999
Monthly Operating Rept for Apr 1999 for St Lucie,Units 1 & 2.With 990517 Ltr
ML17229B0801999-04-0707 April 1999
LER 99-002-00:on 990311,SG ECT Error Caused Operation with Condition Prohibited by Ts.Caused by Deficiencies in Data Analysis Guideline Instructions.Licensee Will Change Data Analysis Guidelines for Lead Analysts.With 990407 Ltr
ML17229B0841999-04-0707 April 1999
Rev 2 to PSL-ENG-SEMS-98-102, Engineering Evaluation of ECCS Suction Lines.
ML17229B0791999-04-0707 April 1999
LER 99-001-00:on 990309,discovered Inadequate Design & IST SRs for Iodine Removal Sys (Irs).Caused by Original Design Inadequacies & Personnel Error.Naoh Tank Vent Valve V07233 Was Tagged Open.With 990407 Ltr
ML17229B0961999-03-31031 March 1999
Monthly Operating Repts for Mar 1999 for St Lucie,Units 1 & 2.With 990408 Ltr
ML17229B0541999-03-10010 March 1999
LER 99-001-00:on 990211,inadequate TS SRs for SIT & SDC Isolation Valves Were Noted.Caused by Failure to Correctly Implement TS Srs.Submitted LAR to Align Required TS SR with Design Bases Requirements Being Verified.With 990310 Ltr
ML17229B0461999-02-28028 February 1999
Monthly Operating Repts for Feb 1999 for St Lucie,Units 1 & 2.With 990310 Ltr
ML17229B0051999-01-31031 January 1999
Monthly Operating Repts for Jan 1999 for St Lucie,Units 1 & 2.With 990211 Ltr
ML17229A9901999-01-20020 January 1999
LER 98-009-00:on 981223,noted That Facility Operated Outside of Design Basis.Caused by non-conservative MSLB Analysis Inputs.Will Review SR Component Differences Between Units & Will re-baseline LTOP Analysis.With 990120 Ltr
ML17229A9961999-01-14014 January 1999
SG Tube Inservice Insp Special Rept.
ML17229A9821999-01-0404 January 1999
LER 98-010-00:on 981207,RCS Boron Sample Frequency Required by Ts,Was Exceeded by Twelve Minutes.Caused by Personnel Error.Equipment Clearance Order Was Lifted to Draw Required Sample & Operations Procedure Was Changed.With 990104 Ltr
ML17229A9831998-12-31031 December 1998
Monthly Operating Repts for Dec 1998 for St Lucie,Units 1 & 2.With 990111 Ltr
ML17229A9611998-12-22022 December 1998
LER 97-002-01:on 981204,containment Sump Debris Screen Was Not IAW Design.Caused by Inadequate C/As for Sump Screen Anamolies.All Identified Sump Screen Deficiencies Were Dispositioned &/Or Repaired.With 981222 Ltr
ML17229A9561998-12-15015 December 1998
LER 98-008-00:on 981118,missed TS SG U Tube Insp.Caused by Encoding Errors While Using Remote Positioning Fixtures.All SG Tube Surveyed.With 981215 Ltr
ML17241A3581998-12-0909 December 1998
Changes,Tests & Experiments Made as Allowed by 10CFR50.59 for Period of 970526-981209.
ML17229A9421998-11-30030 November 1998
Monthly Operating Repts for Nov 1998 for St Lucie,Units 1 & 2.With 981215 Ltr
ML17229A9301998-11-25025 November 1998
LER 98-005-01:on 980807,discovered That New MOV Methodology Caused Past PORV Block Valve Operability Problem.Caused by Inadequacies in Original Vendor MOV Methodology.Planned Valve Mods Will Be Implemented During Cycle 11 1998 Outage
ML17229A9021998-11-0404 November 1998
LER 98-008-00:on 981008,inadequate Reactor Protection Sys Trip Bypass TS Was Noted.Caused by Poorly Worded Ts. Submitted LAR to Clarify Power Requirements for High Rate of Power Trips.With 981104 Ltr
ML17241A4931998-11-0101 November 1998
Statement of Account for Period of 981101-990930 for Suntrust Bank,As Trustee for Florida Municipal Power Agency Nuclear Decommissioning Trust (St Lucie Project).
ML17229A9051998-10-31031 October 1998
Monthly Operating Repts for Oct 1998 for St Lucie,Units 1 & 2.With 981110 Ltr
ML17229A8871998-10-19019 October 1998
Part 21 Rept Re Potential Defect in Swagelok Stainless Steel Front Ferrule,Part Number SS-503-1 Which Was Machined with Improper Length.C/A Includes Insp Equipment That Will 100% Identify Short Length
ML17229A8781998-10-19019 October 1998
Part 21 Rept Re Potential Defect in Swagelok Stainless Steel Front Ferrule,Part Number SS-503-1,which Was Machined with Improper Length.Insp Equipment That Will 100% Identify Short Length
ML17229A8771998-10-14014 October 1998
LER 98-006-00:on 980918,inadvertent Afas Actuation Was Noted.Caused by Degradation of Multiple Afas Power Supplies. Replaced Afas Power Supplies & Revised Procedures.With 981014 Ltr
ML17229A8761998-10-14014 October 1998
LER 98-007-00:on 980918,identified Discrepancies Between Fire Protection Design Requirements & Field Conditions. Caused by Inadequate Translation & Implementation of Fire Protection Requirements.Procedures Revised.With 981014 Ltr
ML17229A8721998-09-30030 September 1998
Monthly Operating Repts for Sept 1998 for St Lucie Units 1 & 2.With 981009 Ltr
ML17229A8511998-09-0202 September 1998
LER 98-005-00:on 980807,discovered That PORV Margins Were Insufficient to Accommodate Addl Conservatism.Caused by Inadequacies in Original Vendor MOV Methodology.Will Implement Planned Valve Actuator mods.W/980902 Ltr
ML17229A8611998-08-31031 August 1998
Monthly Operating Repts for Aug 1998 for St Lucie,Units 1 & 2.With 980911 Ltr
ML18066A2771998-08-13013 August 1998
Part 21 Rept Re Deficiency in CE Current Screening Methodology for Determining Limiting Fuel Assembly for Detailed PWR thermal-hydraulic Sa.Evaluations Were Performed for Affected Plants to Determine Effect of Deficiency
ML17229A8481998-08-0707 August 1998
Rev 1 to PSL-ENG-SEFJ-98-013, St Lucie Unit 2,Cycle 10 Colr.
ML17229A9461998-08-0707 August 1998
Rev 0 to PCM 98016, St Lucie Unit 2,Cycle 11 Colr.
ML17229A8301998-07-31031 July 1998
Monthly Operating Repts for July 1998 for St Lucie,Units 1 & 2.W/980814 Ltr
ML17229A8201998-07-29029 July 1998
LER 98-007-00:on 980630,inadequate Procedure May Have Resulted in SBO Recovery Complications.Caused by Inadequate Procedures.Attached Caution Tags to Appropriate Control switches.W/980729 Ltr
ML17229A7981998-06-30030 June 1998
Monthly Operating Repts for June 1998 for St Lucie,Units 1 & 2.W/980713 Ltr
ML17229A7701998-05-31031 May 1998
Monthly Operating Repts for May 1998 for St Lucie,Units 1 & 2.W/980612 Ltr
ML17229A7411998-05-28028 May 1998
LER 98-004-00:on 980430,discovered Waste Gas Decay Tank Operation W/O Available Oxygen Analyzers,Which Is Prohibited by Ts.Caused by Inadequate Licensee Review of License Amend. Oxygen Analyzer recalibrated.W/980528 Ltr
1999-09-30
[Table view] |
Text
REGULATOR I li<FORMATIGN DISTRIBUTION STBTEM (RIDS)
ACCESSION NBR: 8802170141 DQC. DATE: 88/02/09 NOTARIZED: NO DOCKET FACIL: 50-335 Bt. Lucie Plant Unit 1 ~ Florida Poeer 5 Light Co. 05000335 AUTH. NAME AUTHOR AFF ILI AT ION MENDOZA V N. Flor ida Poeer 8: Light Co.
WOQDYI C. Q. Florida Poeer 5 Light Co.
REC IP. NAME RECIPIENT AFF ILI AT I C}N
SUBJECT:
LER 87-012-01: on 870609'oss oF component cooling eater r edundancg occurred because oF cr osstie valves being in open position. Caused bg personnel error. Close valves. Valve V-14169 estored to locked position. W/880209 ltr.
I DISTR IBUTIOli CODE: IE22D COPIES RECEIVED: LTR i ENCL TITLE; 50, 73 Licensee Event RepoT t (LER) i Incident Rpti etc.
L SIZE:
iNOTES:
REC)P I ENT CGP IES REC IP IENT COPIES ID CODE))NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD '-" LA 1 1 PD2-2 PD 1 TOUR I GNY E 1 1 INTERNAL: ACRS MICHE'LSON 1 ACRS MOELLER 2 2 AEQD/DQA 1 AEOD/DSP/NAS 1 1 AEOD/DSP/ROAB 2 2 AEOD/DSP/TPAH 1 1 ARt'l/DCTS/DAB 1 1 DEDRO 1 1 NRR/DEST/ADS 1 0 NRR/DEBT/CEH 1 1 iRR/DEST/>>LB 1 1 NRR/DEST/ICSH NRR/DEST/t'!EB 1 ERR/DEST/MTB 1 1 NRR/DEST/PSB 1 NRR/DEST/RSB 1 NRR/DEST/SGB 1 1 ERR/DLPG/HFB 1 NRR/DLPG/GAB 1 ERR/DQEA/E*3 1 NRR/DREP/R*B 1 1 ERR/DREP/RPB 2 2 N / ~ SIB ] NRR/PMAS/ ILRB 1 1 REt= F ILF 02 RES TELFQRD, J RES DE/E IB RES/DRPS DIR 1 RGN2 F lLE 0' EXTERNAL: EGhG GRGH.l". 5 5 FORD BLDG HOYi A 1 1 H ST LOBBY WARD 1 LPDR 1 1 NRC PDR 1 NSIC HARB ISr J 1 1 NSIC MAYS~ G 1 1 TOTAL NUMBER OF COPIES REGUIPED: LTTR 46 ENCL 45
NiC Ferro 366 U.S. NUCLEAR REGULATORY COMMiSSIQN iv 83i APPAOVED OMB NO 31500)04 LICENSEE EVENT REPORT (LER) EXPIRES 8 31 88 FACILI'TY NAME DOCKET NUMBER (2) PAGE I3i Il 111 St. Lucie Unit o 5 o o o 335 ioF04 LOSS OF COMPONENT COOLING WATER REDUNDANCY BECAUSE OF CROSSTIE VALVES BEING IN THE OPEN POSITION DUE TO PERSONNEL ERROR.
EVENT DATE IS> LEA NUMBER I61 REPORT DATE (7) OTHER FACILITIES INVOLVED IS)
MONTH QAY YEAR YEAR SEOVS!VTIAL R'Y~~ MOI TH OAV YEAR FACILITY 4AMFS DOCKET IIVMBERISI 4VMOEA NUMBER N/A 0 5 0 0 0 0 6 0 9 8 7 8 7 012 01 0 209 88 0 5 0 0 0 THIS REPORT IS SUBMIT'TED PURSUANT T 0 THE REQUIREMENTS OF 10 CFR $ : (Chef>> One Or molt Of the ferrew nPl (11 OPERATINO MODE I ~ ) 20.402(O) 20.405(c) S0.73(e l(2) (iv) 73.71IOI POWER 20.405( ~ l(1)(il 50.36(c1 I) I S0.73( ~ )(2)(v) 73.71(cl LEYEL 001 1 0 0 20.405(e l(l) I 61 50.36(cl(21 50,73( ~ I(2)(viil OTHER lSoecifv'r'oltrett oeiow end rn Ter t NRC Form 20.408( ~ Ill)(iii) 50.73( ~ l(21(il 50 73( ~ ) 121(viiil(AI 366A) 20.405 ( ~ 111 I liv) 50.73(el(21( ~ ) S0.7 3 I ~ 1(21(w 6 I (81
- 20. 405 ( ~ I (1 I (el 50.73( ~ I(21(iiil S0.73( ~ I(21(hl LICENSEE CONTACT FOA THIS LER (121 NAME TELEO"ONE NUMBER AREA CODE Victor N. Mendoza, Shift Technical Advisor 0 5 4 6 5 " 3 5 5 0 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT (131 MANUFAC. EPQRTABLE CQMPQIIEhrT M A hl ' F A C r EPORTABLE CAUSE SYSTEM CQMPQNENT TVREA TO NPRDS CAUSE SYS EM TVRER TO NORDS SUPPLEMENTAL REPORT EXPECTED I141 EXPECTED VO'P 'EAO SUBMISSION DATE i)5 YES llf yeA comofete ff(PECTEO SVBMISSIOhlDAFEI 40 ABSTRACT fdrrnH to (400 IoeceA I ~ .. eooroerrnetefy fifteen Irnpi ~ .Ioete tyoewnNen hrNI (16)
ABSTRACT On June 19, 1987, St. Lucie Unit Il was in Mode 1, 100% power, and at steady state conditions. All control stations were in normal operating mode. At 0124 hours0.00144 days <br />0.0344 hours <br />2.050265e-4 weeks <br />4.7182e-5 months <br />, the Reactor Control Operator (RCO) was performing a monthly pump surveillance run for the 1B component cooling water (CCW) pump. During this surveillance run, it was discovered that the 1A and 1B CCW heat exchanger outlet cross-tie valves were in the open position. The position for these valves is normally closed. The operator immediately performed a valve alignment verification and closed the valves. The root cause of the event was a cognitive personnel error by utility licensed operators who failed to have proper adminis-trative control on these valves. The immediate corrective action was to close the valves. The event was terminated at 0130 hours0.0015 days <br />0.0361 hours <br />2.149471e-4 weeks <br />4.9465e-5 months <br />. No other system malfunction resulted from this event. This event is reportable under the code of federal regulations 10 CFR 50.73 (a) (2) (i) (B), "Any event or condition prohibited by plant's technical specifications".
8802>70141 88020+ 85000+35 0
PDR ADOCH PDR 8
NRC Fornr 366 r9 8)
NRC Eorm 368A U.S. NUCLEAR REGULATORY COMMISSION IS 831 LICENSEE EVENT REPORT (LER) TEXT CONTINUATION *PPROYEO OMS VO 3150-0104 EXPIRES I 8r 31 I 88 PACILITrY NAME III OOCKET NUMBER 12) LER NUMBER (61 PAGE I3I YEAR O SEGUENTrAL R E Y rS r 0 rr NUNSER NUNISE R St. Lucie Unit 41 0 so oo33 587 0 1 2 0 1 0 2 OF 0 TEXT lllrrhoro spsspis rsohrhroc. rhss scchthorrsl lVRC iorrn 36SA'si I IT)
DESCRIPTION OF EVENT On June 19, 1987, St. Lucie Unit Il was in Node 1, 100% power, and at steady state conditions. At 0124 hours0.00144 days <br />0.0344 hours <br />2.050265e-4 weeks <br />4.7182e-5 months <br />, the Reactor Control Operator (RCO) was performing a monthly pump surveillance run for the 1B component cooling water (CCW) (EIIS:CC) pump. The 1B CCW pump discharge valve was throttled to obtain 4000 GPN flow on the "B" header, as required by the procedure. As the valve was throttled, the RCO noticed that the "A" header flow was also decreasing concurrent with the RBR header. The RCO notified the Assistant Nuclear Plant Supervisor (ANPS) and the ANPS immediately instructed the Nuclear Operator to perform a valve alignment verification. During this verification, it was discovered that the 1A and 1B CCW heat exchanger outlet cross-tie valves V-14169 (which is a normally locked closed valve) and V-14439 (which is a normally closed valve) were in the open position. Both valves were then immediately closed and independently verified to be closed. The normal CCW valve alignment was restored to its normal operations line-up. The pump surveillance run was then resumed and noted as satisfactory. No other abnormalities in the system were noted after the restoration of the CCW system valve alignment. The event was terminated at 0130 on June 19, 1987. No other system malfunctions were observed during the entire event.
CAUSE OF THE EVENT On June 8, 1987, the lB CCW heat exchanger was scheduled for repairs. A clearance was issued for all valves and related equipment required to isolate the lB CCW heat exchanger. The cross-tie valves V-14169 (which is normally locked closed) and V-14439 (which is normally closed) were opened to allow both the "A" and "B" trains of the CCW system (EIIS:CC) to be in service while the 1B CCW heat exchanger was being repaired. Neither of the cross-tie valves were listed on the clearance. The utility licensed operator in charge of reviewing the clearance prior to issuance decided not to include these valves in the clearance as these valves were not required for maintenance boundary isolation.
He opted to administratively control valve V-14169 by listing this valve in the locked valve deviation log as being in the open position. However, the locked valve deviation log was not reviewed by operations personnel. Thus, it was not noted in the clearance that valves V-14169 and V-14489 were not in their normal closed positions. After the repairs to the heat, exchanger were completed on June 9, 1987, all the valves and related equipment on the clearance were released and independently verified as being restored to the required operating positions. Since valves V-14169 and V-14439 were not listed on the clearance, they were not restored to their normal position as part of the clearance release process, nor was independent verification called for.
NRC FOR@I 348A 184131
U.S. NUCLEAR REGULATORY COMMISSION NRC Form 366A I9 BSI UCENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVED OMB 40 3160m3IDE EXPIRES. BI3'I 'BB FACILITY NAME II) DOCKET NUMBER l3) LER NUMBER I6I PAGE l31 YEAR SEOVENTIAL REVrSIO4 NUMBER NVMBEA St. Lucie Unit 61 o 5 o o o 33 58 7 012 0 0 3 OF 0 TEXT llfmont totoo rt ntovrntd, vtt tddroorrtl IVIIC Form 3664'tl IIT)
The root cause of the event was cognitive personnel error by utility licensed-operators who failed to have proper administrative control on valves that were positioned in other than their normal operating positions. There were no unusual characteristics of the work location that directly contributed to this event.
Procedure deficiencies were a contributing factor. Although all actions were justifiable per procedure, the event showed problems with using the locked
'valve deviation log as an alternate method.
ANALYSIS OF THE EVENT The event is reportable under 10 CFR 50.73(a)(2)(i)(B), "Any event or condition prohibited by the plant's technical specifications". Technical Specification 3.7.3 ' requires "at least two independent component cooling water loops shall be operable".
This event resulted in a loss of component cooling system (EIIS:CC) redundancy.
However, the loss of redundancy was discovered within 10 days during performance of a routine monthly surveillance. Redundancy was completely restored within six (6) minutes of discovery. There were no other abnormalities in the system during the event. All plant safety functions were met throughout this event.
At no time during this event was the health and safety of the public endangered.
Additional actions taken included the following: 1) review of and changes to the clearance and administrative control of valves procedures, 2) review of and changes to the frequency of review of the locked valve deviation log, 3) research of previous similar out of service conditions to determine if the problem had occurred before, 4) a failure modes and effects analysis (FLEA) for the system, and 5) review of the effect of the changed system configuration on the effectiveness of the CCW to perform its design function. The PMEA showed that there is no limiting single active failure for the system in this configurations However, a passive failure (pipe rupture) was identified. The effectiveness of the CCW system to perform its function with the cross-tie open versus the cross-tie closed would not significantly change since the reliability of the system in either configuration would be dominated by the active component failures (i.e. pumps and valves).
~ rtlC FOR4r 368A I94ISI
NRC <<>Im 366A U,S. NUCLEAR REGULATORY COMMISSION (9 83(
LICENSEE EVENT REPORT (LER) TEXT CONTINUATION APPROVEO OMB NO 3(SO OIO4 EXPIRES: 8/31(88 FACILITY NAME ((l OOCKET NUMBER (2( LER NUMBER (61 PAGE (31 YEAR SEGUENTIAL REVISION NUMBER NUMBER St. Lucie Unit 81 3 3 8 7 0 1 2 01 04 OF 04 0 5 o o o TEXT (lfmoIP 4P444 I4 mdIIddd. IIM PddIIdmd( NRC Fdtm 36SA'4( (ln CORRECTIVE ACTIONS
- 1. Valve V-14169 was restored to its locked closed position and valve V-14439 was closed. Independent verification of valve proper position was performed.
- 2. The plant training group will evaluate this item to determine appropriate training requirements and methods.
- 3. The responsible supervisor has been instructed to include these valves in future clearances to ensure restoration.
- 4. Procedures were modified to require all valves repositioned to be on the clearance form.
- 5. The frequency of review of the locked valve deviation log was increased.
- 6. Research on historical data showed that these valves had been included on the clearance form, and this appeared to be the first time that the locked valve deviation log had been used as an alternate method.
ADDITIONAL INFORMATION Failed component identification: There were no failed components during this event.
PREVIOUS SIMILAR EVENT See LER N335-85-02 for a previous valve mispositioning event.
~ IRC FORM 366A (94(3l
P. O. BOX, JUNO BEACH, PL 33408 0420 FEgRggy 9 L-88-44 10 CFR 50.73 U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, D. C. 20555 Gentlemen:
Re: St. Lucie Unit 1 Docket No. 50-335 Reportable Event: 87-12 Revision 1 Date of Event: June 9, 1987 Loss of Component Cooling Water Redundancy Because of Crosstie Valves Being in the 0 en Position Due to Personnel Error The attached Licensee Event Report (LER) is being submitted pursuant to the requirements of 10 CFR 50.73 to provide an update on the subject event.
Very truly yours,
, gag, r+cX C. 0.
Execu 'ice President Woo COW/GRM/gp Attachment cc: Dr. J. Nelson Grace, Regional Administrator, Region II, USNRC Senior Resident Inspector, USNRC, St. Lucie Plant an FPL Group company
