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| {{#Wiki_filter:Public Service Electric and Gas Company P.O. Box 236 Hancocks Bridge, New Jersey 08038 Salem Generating Station U. S. Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 | | {{#Wiki_filter:.- |
| | Public Service Electric and Gas Company P.O. Box 236 Hancocks Bridge, New Jersey 08038 Salem Generating Station March 20, 1991 U. S. Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 |
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| ==Dear Sir:== | | ==Dear Sir:== |
| SALEM GENERATING STATION LICENSE NO. DPR-70 DOCKET NO. 50-272 UNIT NO. 1 LICENSEE EVENT REPORT 91-011-00 March 20, 1991 This Licensee Event requirements of the 50. 7 3 (a) ( 2) ( i) ( B) | | |
| * thirty (30) days of Report is being submitted pursuant to the Code of Federal Regulations lOCFR MJP:pc Distribution This report is required to be issued within event discovery. | | SALEM GENERATING STATION LICENSE NO. DPR-70 DOCKET NO. 50-272 UNIT NO. 1 LICENSEE EVENT REPORT 91-011-00 This Licensee Event Report is being submitted pursuant to the requirements of the Code of Federal Regulations 10CFR |
| Sincerely | | : 50. 7 3 (a) ( 2) ( i) ( B) |
| : yours, S. LaBruna General Manager -Salem Operations 9104010366 910320 PDR ADOCK 05000272 S PDR Tnc* l::ne1 av r'eop:E:-t .. ,, '1""' -. _}_ 1 .. t :r£:zi. 't t 95-2189 (10M) 12-89 .-
| | * This report is required to be issued within thirty (30) days of event discovery. |
| HllC Forlll 3M 19 .. 31 . U.I. NUCLEAR llEOULATOllY COMMISllO.N | | Sincerely yours, |
| ,_,,.ROVED .OMB NO. 3150-4104 LICENSEE EVENT REPORT (LER) EXPIRES: 1/311115 FACILITY NAME C1l Sa1em Generating station -*unit 1 'DOCKET NUMBER 121 * | | /A'.//0,1f?tw~ |
| * I PAGE 131 o 1 s I o Io I o 12 I 71 2 1 loF o 13 TITLE 141 High Rad Area Found Unlocked/Unguarded Due To Personnel Error EVENT DATE 151 LER NUMBER 181 REPORT DATE 171 OTHER FACILITIES INVOLVED Ill FACILITY NAMES DOCKET NUMBERISI 01s1010101 I i Ol'ERATIHO MOOE Ill 5 THIS REPORT 11 IUBMITTED PURIUANT TO THE REQUIREMENn OF 10 CFR §: (Chock OM Of man of rh* fol/owfngl 1111 20.402lbl 20.CO&lcl | | S. LaBruna General Manager - |
| ---20.CO&l*ll1llll ll0.38iclf11 | | Salem Operations MJP:pc Distribution 9104010366 910320 PDR ADOCK 05000272 S |
| ----73.71i'I 73.711cl POWEii | | Tnc* l::ne1 av r'eop:E:- |
| * 1 LEVEL 1101 Q 10 IQ 20.4081oll1HUl 2o.eo&(1)(1 llllll 11111= :::::::::;'
| | PDR :r£:zi. |
| -ll0.381clf21
| | ~ t .. ,, '1""' - . |
| -ll0.73(1)(21111. | | _}_ ~- 1.. t 't t 95-2189 (10M) 12-89 |
| ll0,7311l12llhrl ll0.731all21M ll0.73(111211.Ul ll0.731alf21MllllAI ll0.73(1lf2llwllllfll . ll0.731111211*1 OTHER (Sp<<Hy In Ab1rr.er -= *nd In T*ld. NRC Fann .........
| | |
| ll0.73(1)(211WI | | HllC Forlll 3M U.I. NUCLEAR llEOULATOllY COMMISllO.N 19..31 . ,_,,.ROVED .OMB NO. 3150-4104 EXPIRES: 1/311115 LICENSEE EVENT REPORT (LER) |
| --ll0.73!all2Hllll LICENSEE CONTACT FOR THIS LER 1121 NAME AREA CODE M. J. Pollack -LER Coordinator COMPLETE ONE LINE FOR E.l,CH COMPONENT FAILURE DESCRIBED IN THll REPORT 1131 . CAUSE SYSTEM COMPONENT I I I I I I I I TURER .I I I I I I SYSTEM I *1 COMPONENT MANUFAC-* TURER I I I I I I I I I I I I TELEPHONE NUMBER IUPPLEMENTAL REl'ORT EXPECTED (141 EXPECTED MOlllTH DAY SUBMISSION DATE 1151 n YES (If yn, comp/tr.
| | FACILITY NAME C1l DOCKET NUMBER 121 * |
| SUBMISSION DA TEI **r-xi NO . I . I On February 20, 19.91 at 1020 hours, the RHE Room was discovered to be unlocked and unguarded by Radiation Protection Department supervision. | | * I PAGE 131 Sa1em Generating station -*unit 1 o 1s I o Io I o 12 I 71 2 1 loF o 13 TITLE 141 High Rad Area Found Unlocked/Unguarded Due To Personnel Error ' |
| The access door to this room was found closed. On February 19, 1991 *at 2300 hours, .during ninth refueling outage activities, the Regenerative Heat Exchanger (RHE) Room High Radiation Area (HRA) key was obtained by a Radiation Protection technician to support work in the area. Work in the area was completed at 0200 hours on February 20, 1991. The area has accessible (by climbing) radiation levels of up to 2.0 R/hr at 18 inches from the heat exchanger. | | EVENT DATE 151 LER NUMBER 181 REPORT DATE 171 OTHER FACILITIES INVOLVED Ill FACILITY NAMES DOCKET NUMBERISI 01s1010101 I i THIS REPORT 11 IUBMITTED PURIUANT TO THE REQUIREMENn OF 10 CFR §: (Chock OM Of man of rh* fol/owfngl 1111 Ol'ERATIHO MOOE Ill ll0,7311l12llhrl 73.71i'I |
| The ground level area radiation levels are less than 1 R/hr. The* root cause of this event is personnel error. The Radiation Protection technician, who was supporting work in the RHB Room, did. not ensure the door was locked after personnel vacated the area. The technician upon closing the door verified it latched closed but did not ensure it was locked (turned the knob). This event has been reviewed.by Radiation.Protection Department management. | | -= |
| Corrective discipline was taken with the technician responsible for this event. This event has been reviewed with applicable Radiation Protection Department personnel stressing the need for ensuring positive control of HRA's. Access logs and personnel dosimetry data were reviewed for the period between February 19, 1991 at 2300 hours to February 20, 1991 at 1200 hours. No inadvertent entry into the RHE room was apparently made. The RHE access door is now chain locked. The door locking mechanism will be replaced with a mechanism that requires key removal for the door to be locked. HRC f<><ft!l :!.U I | | 5 20.402lbl 20.CO&lcl POWEii |
| *
| | * LEVEL 1101 1 |
| * LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station Unit 1 . DOCKET NuMBER 5000272 PLANT AND SYSTEM IDENTIFICATION:
| | Q 10 IQ - 20.CO&l*ll1llll 20.4081oll1HUl |
| Westinghouse | | -- ll0.38iclf11 ll0.381clf21 |
| -Pressurized Water Reactor LER NUMBER 91-011-00 | | -- ll0.731all21M ll0.73(111211.Ul 73.711cl OTHER (Sp<<Hy In Ab1rr.er |
| * PAGE 2 of 3 Energy Industry Identification System (EIIS) codes are identified in
| | .,.,..""""'_.,~i,.,;;~~:..+---1 *nd In T*ld. NRC Fann 11111= : : : : :;' |
| | 2o.eo&(1)(1 llllll ll0.73(1)(21111. ll0.731alf21MllllAI |
| | ~ ......... |
| | ll0.73(1)(211WI ll0.73!all2Hllll - |
| | LICENSEE CONTACT FOR THIS LER 1121 ll0.73(1lf2llwllllfll . |
| | ll0.731111211*1 NAME TELEPHONE NUMBER AREA CODE M. J. Pollack - LER Coordinator COMPLETE ONE LINE FOR E.l,CH COMPONENT FAILURE DESCRIBED IN THll REPORT 1131 . |
| | MANUFAC- SYSTEM COMPONENT MANUFAC-CAUSE SYSTEM COMPONENT TURER |
| | * TURER I I I I .I I I I I I I I I I I I I I I I I *1 I I I I I I IUPPLEMENTAL REl'ORT EXPECTED (141 MOlllTH DAY ~AR EXPECTED SUBMISSION n YES (If yn, comp/tr. E~PECTEO SUBMISSION DA TEI **r-xi NO DATE 1151 |
| | .I .I I On February 20, 19.91 at 1020 hours, the RHE Room was discovered to be unlocked and unguarded by Radiation Protection Department supervision. The access door to this room was found closed. On February 19, 1991 *at 2300 hours, .during ninth refueling outage activities, the Regenerative Heat Exchanger (RHE) Room High Radiation Area (HRA) key was obtained by a Radiation Protection technician to support work in the area. Work in the area was completed at 0200 hours on February 20, 1991. The area has accessible (by climbing) radiation levels of up to 2.0 R/hr at 18 inches from the heat exchanger. The ground level area radiation levels are less than 1 R/hr. The* root cause of this event is personnel error. The Radiation Protection technician, who was supporting work in the RHB Room, did. |
| | not ensure the door was locked after personnel vacated the area. The technician upon closing the door verified it latched closed but did not ensure it was locked (turned the knob). This event has been reviewed.by Radiation.Protection Department management. Corrective discipline was taken with the technician responsible for this event. |
| | This event has been reviewed with applicable Radiation Protection Department personnel stressing the need for ensuring positive control of HRA's. Access logs and personnel dosimetry data were reviewed for the period between February 19, 1991 at 2300 hours to February 20, 1991 at 1200 hours. No inadvertent entry into the RHE room was apparently made. The RHE access door is now chain locked. The door locking mechanism will be replaced with a mechanism that requires key removal for the door to be locked. |
| | HRC f<><ft!l :!.U |
| | |
| | Salem Generating Station LICENSEE EVENT REPORT (LER) TEXT CONTINUATION DOCKET NuMBER LER NUMBER |
| | * PAGE Unit 1 . 5000272 91-011-00 2 of 3 PLANT AND SYSTEM IDENTIFICATION: |
| | I Westinghouse - Pressurized Water Reactor Energy Industry Identification System (EIIS) codes are identified in |
| * the text as {Xxf IDENTIFICATION OF OCCURRENCE: | | * the text as {Xxf IDENTIFICATION OF OCCURRENCE: |
| High Radiation Area found unlocked/unguarded due to personnel error | | High Radiation Area found unlocked/unguarded due to personnel error |
| * Event Date: 2/20/91 Report Date: 3/20/91 This report. was initiated by Incident Report No'. 91-122 * . CONDITIONS PRIOR TO OCCURRENCE: | | * Event Date: 2/20/91 Report Date: 3/20/91 This report. was initiated by Incident Report No'. 91-122 * |
| Mode 5 (Cold Shutdown) | | . CONDITIONS PRIOR TO OCCURRENCE: |
| -gt h Refueling out.age DESCRIPTION OF OCCURRENCE: . On February 19, 1991 at 2300 hours, during .ninth* refueling* | | Mode 5 (Cold Shutdown) - gt h Refueling out.age DESCRIPTION OF OCCURRENCE: |
| outage . activities, the. Regenerative Heat Exchanger (RHE) Room High Radiation Area (BRA) key was obtained by a Radiation Protection technician to support inservice inspection work in the area. Work in the area was completed at 0200 hours on February 20, 1991. This room is a High Radiation. | | . On February 19, 1991 at 2300 hours, during .ninth* refueling* outage . |
| Area. It has accessible (by climbing) radiation leve.ls of up to 2.0 R/hr at 18 inches from the heat exchanger. | | activities, the. Regenerative Heat Exchanger (RHE) Room High Radiation Area (BRA) key was obtained by a Radiation Protection technician to support inservice inspection work in the area. Work in the area was completed at 0200 hours on February 20, 1991. This room is a High Radiation. Area. It has accessible (by climbing) radiation leve.ls of up to 2.0 R/hr at 18 inches from the heat exchanger. The ground level area.radiation levels are less than 1 R/hr. |
| The ground level area.radiation levels are less than 1 R/hr. On February 20, 1991 at 1020 hours, the RHE Room was discovered to be unlocked and unguarded by Radiation Protection* | | On February 20, 1991 at 1020 hours, the RHE Room was discovered to be unlocked and unguarded by Radiation Protection* Department supervision.* The access door to this room was found closed.* |
| Department supervision.* | | Having an unlocked/unguarded HRA, where radiation levels of greater than 1.0 R/hr are accessible (by climbing), is contrary to the requirements of* Technical Specification 6.12 and Radiation Protection Procedure RP 203, "Radiation Protection Ke:f Control System". |
| The access door to this room was found closed.* Having an unlocked/unguarded HRA, where radiation levels of greater than 1.0 R/hr are accessible (by climbing), is contrary to the requirements of* Technical Specification 6.12 and Radiation Protection Procedure RP 203, "Radiation Protection Ke:f Control System". APPARENT CAUSE OF OCCURRENCE: | | APPARENT CAUSE OF OCCURRENCE: |
| The root cause of this.event is personnel error. The Radiation Protection technician, who was supporting the inservice inspection work in the RHE Room, did*not ensure the door was locked after personnel vacated the area (i.e., completion of work activities). | | The root cause of this.event is personnel error. The Radiation Protection technician, who was supporting the inservice inspection work in the RHE Room, did*not ensure the door was locked after personnel vacated the area (i.e., completion of work activities). The technician upon closing the door verified it latched closed but did not ensure it was locked (turned the knob). |
| The technician upon closing the door verified it latched closed but did not ensure it was locked (turned the knob). The RHE Room access door is not necessarily self locking. If the key is turned in one direction it is self locking while the other direction produces the opposite result. Although this factor contributes to the cause of this event, technicians are trained to positively verify that BRA accesses are locked once all personnel have I | | The RHE Room access door is not necessarily self locking. If the key is turned in one direction it is self locking while the other direction produces the opposite result. Although this factor contributes to the cause of this event, technicians are trained to positively verify that BRA accesses are locked once all personnel have |
| .. . -. -* LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station Unit-1 APPARENT CAUSE OF OCCURRENCE: -DOCKET NUMBER 5000272 (cont'd) LER NUMBER 91-011-00 PAGE 3 of 3 _ vacated -the area. . Also, Radiation Protection pro*cedure RP-203, section 6.4,* requires the technician_to verify the door is locked and secure upon exit of the -BRA. ANALYSIS OF OCCURRENCE:
| | |
| Access to HRA's is controlled to prevent personnel from unknowingly entering areas where excessive radiation dose could be The subject BRA contained radiation levels ranging up to 2.0 R/hr (at 18") in reasonably assessable areas. Upon discovery, the RHE access door was locked as required. | | LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station -DOCKET NUMBER LER NUMBER PAGE Unit- 1 5000272 91-011-00 3 of 3 APPARENT CAUSE OF OCCURRENCE: (cont'd) |
| This occurrence involved no undue risk to the health and safety of the public. *However, because this occurrence involves a situation contrary to t_he requirements of the Technical Specifications,. | | _vacated - the area. . Also, Radiation Protection pro*cedure RP-203, section 6.4,* requires the technician_to verify the door is locked and secure upon exit of the -BRA. |
| this event is reportable in with the Code of Federal Regulations lOCFR 50. 73 (a) (2) (i). (B). CORRECTIVE ACTION: . This _event has been reviewed by Radiation Protection Department management. | | ANALYSIS OF OCCURRENCE: |
| Corrective discipline was taken with the technician responsible for this event. This event has been reviewed with applicable Radiation Protection* | | Access to HRA's is controlled to prevent personnel from unknowingly entering areas where excessive radiation dose could be accumulated.- |
| Department personnel stressing the need for ensuring positive control of HRA's. Access logs and personnel data were reviewed the period between February 19, 1991 at 2300 hours to February 20, 1991 at 1200 hours. No inadvertent entry into the RHE room was apparently made. The RHE access door is now chain locked. The door locking mechanism will be_replaced with a mechanism that requires the door_to be locked for-key removal. A review of all other locked HRAs was conducted. | | The subject BRA contained radiation levels ranging up to 2.0 R/hr (at 18") in reasonably assessable areas. |
| No other access locking mechanisms were identified with similar concerns to the RHE -Room door. Past unlocked/unguarded BRA events, occurring within the last four years*, have been reviewed. | | Upon discovery, the RHE access door was locked as required. This occurrence involved no undue risk to the health and safety of the public. *However, because this occurrence involves a situation contrary to t_he requirements of the Technical Specifications,. this event is reportable in ~ccordance with the Code of Federal Regulations 10CFR 50. 73 (a) (2) (i). (B). |
| These other events did not involve the RHE Room access door nor were their root causes similar to this event. MJP:pc SORC Mtg. 91-032 General Manager -Salem Operations}} | | CORRECTIVE ACTION: . |
| | This _event has been reviewed by Radiation Protection Department management. Corrective discipline was taken with the technician responsible for this event. |
| | This event has been reviewed with applicable Radiation Protection* |
| | Department personnel stressing the need for ensuring positive control of HRA's. |
| | Access logs and personnel dosim~try data were reviewed fo~ the period between February 19, 1991 at 2300 hours to February 20, 1991 at 1200 hours. No inadvertent entry into the RHE room was apparently made. |
| | The RHE access door is now chain locked. The door locking mechanism will be_replaced with a mechanism that requires the door_to be locked for-key removal. |
| | A review of all other locked HRAs was conducted. No other access locking mechanisms were identified with similar concerns to the RHE |
| | -Room door. |
| | Past unlocked/unguarded BRA events, occurring within the last four years*, have been reviewed. These other events did not involve the RHE Room access door nor were their root causes similar to this event. |
| | /Jffi/rtk/4'~,___-- |
| | General Manager - |
| | Salem Operations MJP:pc SORC Mtg. 91-032}} |
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LER 98-011-00:on 980505,improper Isolation of Single Cell Battery Charger from 125 Vdc Battery Was Noted.Caused by Inadequate 10CFR50.59 Applicability Review.Placed Procedure SC.MD-CM.ZZ-0024(Q) on Administrative hold.W/980604 Ltr
ML18106A6421998-06-0101 June 1998
LER 98-010-00:on 931019,reactor Pressure Vessel Insp Plugs Were Out of Configuration,Was Noted.Caused by Personnel Error.Proper Configuration Was Restored Shortly After Discovery Prior to Entering Mode 2.W/980601 Ltr
ML18106A6431998-05-29029 May 1998
LER 98-006-01:on 980227,determined Incorrect Scaling Error of First Stage Pressure Transmitter Existed.Caused by Human Error.Revised Setpoint Calculation SC-MS002-01 & Revised Associated Instrument Calibr Database info.W/980529 Ltr
ML18106A6141998-05-18018 May 1998
LER 98-008-00:on 970814,failure to Test 21 & 22 AF 40 Valves in Closed Direction as Required by TS 4.0.5 Was Noted.Caused by Inadequate Design Mod Process.Motor Driven 21/22 AF 40 Valves Were Tested IAW Revised procedure.W/980518 Ltr
ML18106A5901998-05-0101 May 1998
LER 98-009-00:on 980405,epoxy Missing from Terminals of H Analyzer Was Noted.Caused by Inadequate Development of Procedure.H Analyzers Were Repaired & Review of Other Safety Related Equipment in Containment Was performed.W/980501 Ltr
ML18106A5611998-04-20020 April 1998
LER 98-008-00:on 980323,inadequate Testing of Salem Unit 1 Containment Air Locks Resulted in Entering TS 3.0.3.Caused by less-than-adequate Work Practices During Replacement of Equalizing Valve.Salem Unit 2 Airlocks Were Inspected
ML18106A6061998-04-0101 April 1998
Corrected LER 98-004-00:on 980302,failure to Comply W/Tss 4.11.1.1.2 & 3.3.3.8 Was Noted.Caused by Organizational Deficiency.Steps Have Been Taken to Correctly Document Safety Factors.Corrects Prior Similar Occurrences
ML18106A4451998-04-0101 April 1998
LER 98-004-00:on 980302,failure to Perform TS 4.11.1.1.2 & 3.3.3.8 Was Noted.Caused by Organizational Deficiency.Steps Were Taken to Correctly Document Safety factors.W/980401 Ltr
ML18106A4351998-03-30030 March 1998
LER 98-006-00:on 980227,incorrect Scaling of First Stage Turbine Impulse Pressure Transmitters Noted.Cause Indeterminate.Implemented Procedure Changes & re-scaled Affected Turbine Impulse Pressure transmitters.W/980330 Ltr
ML18106A3961998-03-20020 March 1998
LER 98-005-00:on 980219,inoperability of Twelve EDG Fuel Oil Transfer Pump (FOTP) Noted.Caused by Installation of Incorrect Control Switch.Installed Correct off-auto-manual Switch & Verified Operability of Twelve FOTP.W/980320 Ltr
ML18106A5781998-03-20020 March 1998
Corrected LER 98-005-00:on 980219,inoperability of 12 Fuel Oil Transfer Pump (Fotp),Noted.Caused by Installation of Incorrect Control Switch.Field Insp Performed to Verify Configuration of Switches for 11,21 & 22 FOTPs
ML18106A4021998-03-20020 March 1998
LER 98-007-00:on 980218,failure to Establish Containment Integrity (Closure) Prior to Fuel Movement Was Noted.Caused by Failure to Identify & Include Condensate Pot Vent in Appropriate Valve Lineup.Valves identified.W/980320 Ltr
ML18106A4031998-03-20020 March 1998
LER 98-006-00:on 980221,ESF Actuation of 11 & 12 Auxiliary Feedwater Pumps Occurred.Caused by Human Error.Operators Promptly Established Feedwater to All SG & Restored Proper Water levels.W/980320 Ltr
1999-08-26
[Table view]
Category:RO)
MONTHYEARML18107A5031999-08-26026 August 1999
LER 99-006-00:on 990729,determined That SG Blowdown RMs Setpoint Was non-conservative.Caused by Inadequate ACs for Incorporating Original Plant Licensing Data Into Plant Procedures.Blowdown Will Be Restricted.With 990826 Ltr
ML18107A4691999-07-28028 July 1999
LER 99-008-00:on 990714,determined That Limit Switch Cables Were Subject to Multiple Hot Shorts in Same Fire Area.Caused by Inadequate Original Post Fire Safe Shutdown Analysis.All Limit Switch Cables for MOVs Were Reviewed.With 990728 Ltr
ML18107A4441999-07-0606 July 1999
LER 99-007-00:on 990605,surveillance for Quadrant Power Tilt Ratio (QPTR) Was Missed.Caused by Human Error.Qptr Calculation Was Performed & Personnel Involved Have Been Held Accountable IAW Pse&G Policies.With 990706 Ltr
ML18107A4211999-07-0202 July 1999
LER 99-005-00:on 990605,11 Containment Declared Inoperable. Caused by Valves 11SW72 & 11SW223 Both Leaking.Procedure S1.OP-ST.SW-0010(Q) Was Enhanced to Provide Specific Instructions to Ensure Proper Sequencing.With 990702 Ltr
ML18107A4321999-07-0101 July 1999
LER 99-006-01:on 990501,determined That There Was No Flow in One of Four Injection Legs.Caused by Sticking of Valve in Safety Injection Discharge Line to 21 Cold Leg.Valve Was Cut Out of Sys & Replaced.With 990701 Ltr
ML18107A4331999-07-0101 July 1999
LER 99-002-01:on 990405,determined That 2SA118 Failed as Found Leakrate Test.Caused by Foreign Matl Found in 2SA118 valve.2SA118 Valve Was Cycled Several Times & Seat Area Was Air Blown in Order to Displace Foreign Matl.With 990701 Ltr
ML18107A3951999-06-17017 June 1999
LER 99-004-00:on 990520,reactor Tripped from 100% Power,Due to Negative Flux Trip Signal from Nuclear Instrumentation. Cause Has Not Been Determined.Discoloration Was Identified on One of Penetrations.With 990617 Ltr
ML18107A3661999-06-0909 June 1999
LER 99-003-00:on 990513,unplanned Entry Into TS 3.0.3 Was Made.Caused by Human error.Re-positioned Creacs Supply Fan Selector Switches & Revised Procedures S1 & S2.OP-ST.SSP-0001(Q).With 990609 Ltr
ML18107A3551999-06-0202 June 1999
LER 99-005-00:on 990504,failure to Meet TS Action Statement Requirements for High Oxygen Concentration in Waste Gas Holdup Sys Occurred.Caused by Inability of Operators. Existing Procedures Will Be Evaluated.With 990602 Ltr
ML18107A3541999-06-0101 June 1999
LER 99-006-00:on 990501,HHSI Flow Balance Discrepancy Was Noted During Surveillance.Caused by Sticking of Check Valve in SI Discharge Line to 21 Cold Leg.Valve 21SJ17,was Cut Out of Sys & Replaced.With 990601 Ltr
ML18107A2931999-05-12012 May 1999
LER 99-002-00:on 990413,determined That Number 12 Auxiliary Bldg Exhaust Fan Was Rotating Backwards.Caused by mis-wiring of Motor Due to Human Error by Maint technician.Mis-wiring Was Corrected & Fan Was Returned to Svc.With 990512 Ltr
ML18107A2781999-05-10010 May 1999
LER 99-004-00:on 990411,automatic Actuation of ESF Occurred During Reactor Vessel Head Removal in Support of Refueling Operations.Caused by High Radiation Condition.Containment Atmosphere Was Monitored.With 990505 Ltr
ML18107A2791999-05-0404 May 1999
LER 99-003-00:on 990406,all Salem Unit 2 Chillers Rendered Inoperable.Caused by Human Error.Lessons Learned from Event Were Communicated to All Operators by Including Them in Night Orders.With 990504 Ltr
ML18107A2741999-05-0303 May 1999
LER 99-002-00:on 990405,determined That Containment Isolation Valve Failed as Found Leakrate Test.Caused by Foreign Matl Blocking Valves from Closing.Check Valve Mechanically Agitated.With 990504 Ltr
ML18107A2351999-04-23023 April 1999
LER 99-001-00:on 990330,MSSV Failed Lift Set Test.Caused by Setpoint Variance Which Is Result of Aging.Valves Were Adjusted & Retested to Ensure TS Tolerance.With 990423 Ltr
ML18106B1471999-03-29029 March 1999
LER 99-001-00:on 990228,reactor Scram Was Noted as Result of Turbine Trip.Caused by Operator Error.Lesson Plans Revised to Explicitly Demonstrate Manner in Which Valve Functions. with 990329 Ltr
ML18106B0701999-02-16016 February 1999
LER 98-015-00:on 981208,inadvertent Discharge Through RHR Relief Valve During Startup Was Noted.Caused by Operator Performing Too Many Tasks Simultaneously.Appropriate Actions Have Been Taken IAW Policies & Procedures.With 990216 Ltr
ML18106B0491999-01-28028 January 1999
LER 98-007-01:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Caused by Transgranular Stress Corrosion Cracking.Replaced Affected Tubing.With 990128 Ltr
ML18106B0401999-01-18018 January 1999
LER 98-016-00:on 981219,ECCS Leakage Was Outside of Design Value.Caused by Leakage Past Seat of 21RH34 Manual Drain. Valve 21RH34 Was Reseated.With 990118 Ltr
ML18106B0081998-12-24024 December 1998
LER 97-001-01:on 970215,failure to Perform TS Surveillance of Component Cooling Water Sys Check Valves Occurred.Caused by Inadequate Communication Between EOP Group & IST Reviewers.Procedure Revised.With 981224 Ltr
ML18106B0021998-12-17017 December 1998
LER 98-015-01:on 980924,improper Installation of Test Equipment to RPS Occurred.Caused by Inadequate 10CFR50.59 Applicability Reviews During Past Revs.Revised Procedures. with 981217 Ltr
ML18106A9551998-11-0303 November 1998
LER 96-013-01:on 960711,concluded That Current Gain & Bias Settings Had Rendered Overtemperature Delta Temp Protection Channels Inoperable.Caused by Scaling Error.Licensee Will Revise Scaling Calculations.With 981105 Ltr
ML18106A9451998-10-30030 October 1998
LER 97-004-01:on 970408,failure to Comply with TS Action Statement,Dg Start & Inadequate Surveillance Testing,Was Noted.Caused by Inadequate Tracking of Inoperable Equipment. Discussed Event & Lessons Learned.With 981022 Ltr
ML18106A9491998-10-22022 October 1998
LER 98-015-00:on 980924,identified Improper Installation of Test Equipment to Rps.Cause Indeterminate.Procedures for Installation of Test Equipment for Collection of State Point Data Were Placed on Administrative Hold.With 981022 Ltr
ML18106A9301998-10-21021 October 1998
LER 98-014-00:on 980725,noted Improper Calibr of Liquid Radwaste Effluent Line Radiation Monitor.Caused by Inattention to Detail by Maint Personnel.Channel Calibr Was Successfully Performed on 1R18 on 980821.With 981019 Ltr
ML18106A9071998-10-0101 October 1998
LER 98-014-00:on 980918,discovered That Fire Barrier Matl for HVAC Ducts Does Not Meet Required Level of Fire Resistance.Cause Indeterminate.Established Appropriate Compensatory Actions for Fire Barriers.With 981001 Ltr
ML18106A8951998-09-28028 September 1998
LER 98-012-01:on 980725,noted That Afs Was Operated with Less than Required Number of Operable AFW Pumps.Caused by Improper Procedure Implementation.Runout Protection Pressure Device for 22 AFW Pumps Was Returned to Svc.With 980928 Ltr
ML18106A8821998-09-21021 September 1998
LER 98-013-00:on 980820,noted Surveillance of Containment Penetration Overcurrent Protection Devices Missed.Caused by Human Error.Satisfactorily Tested Apprpriate Breakers & Disciplined Involved Personnel.With 980921 Ltr
ML18106A8791998-09-16016 September 1998
LER 96-006-01:on 960717,determined That non-radioactive Liquid Basin Radwaste Monitor Inoperable During Low Head Conditions.Caused by Inadequate Design Change Package.Design Change 1EC3663-01 Has Been Installed.With 980916 Ltr
ML18106A8801998-09-0808 September 1998
LER 98-013-00:on 980806,operation with TS Required Equipment OOS Was Noted.Caused by Human Error.Reviewed Processes & Practices Re Safety Sys Status Control,Procedure Rev & Extra Training.With 980908 Ltr
ML18106A8531998-08-27027 August 1998
LER 98-007-00:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Cause of Event Has Not Yet Been Determined.Assembled Root Cause Team & Replaced Affected tubing.W/980827 Ltr
ML18106A8521998-08-27027 August 1998
LER 98-011-00:on 980803,ESFA During a 4KV Automatic Transfer Test Was Noted.Caused by Premature Release of Control Console Pushbutton Due to Inadequate Procedural Step.Revised procedure.W/980827 Ltr
ML18106A8421998-08-24024 August 1998
LER 98-012-00:on 980725,discovered That Plant Had Operated in Modes 1 & 2 w/twenty-two AFW Pumps Inoperable.Caused by Failure to Restore Pump Runout Protection Pressure Device to Svc.Returned Subject Device to svc.W/980824 Ltr
ML18106A8431998-08-24024 August 1998
LER 98-009-00:on 980810,failure to Post Continuous Firewatch as Required by Fire Protection Plan Noted.Caused by Failure to Recognize Concurrent Conditions.Continuous Firewatch Was Posted Immediately & Repaired Smoke detectors.W/980824 Ltr
ML18106A8141998-08-13013 August 1998
LER 98-010-00:on 980714,determined That Leakage from Boron Injection Tank Exceeded Max Allowable ECCS Leakage from Sources Outside Containment.Caused by Leaking 2SJ404 Manual Sample valve.2SJ404 Valve repaired.W/980813 Ltr
ML18106A8201998-08-13013 August 1998
LER 98-012-00:on 980715,potential to Exceed Rating of Piping Due to Isolation of Overpressure Protection Line Was Noted. Caused by Inadequate Procedural Guidance.Appropriate Operations Dept Procedures Have Been revised.W/980813 Ltr
ML18106A6931998-06-29029 June 1998
LER 98-003-00:on 980122,inappropriate Plugging of Tubes R9C60 & R10C60 in Salem Unit 2 Sg,Was Performed.Caused by Failure of Qualification,Verification & Validation Process. Tubes Reviewed to Verify No Others Inappropriately Plugged
ML18106A6471998-06-0404 June 1998
LER 98-011-00:on 980505,improper Isolation of Single Cell Battery Charger from 125 Vdc Battery Was Noted.Caused by Inadequate 10CFR50.59 Applicability Review.Placed Procedure SC.MD-CM.ZZ-0024(Q) on Administrative hold.W/980604 Ltr
ML18106A6421998-06-0101 June 1998
LER 98-010-00:on 931019,reactor Pressure Vessel Insp Plugs Were Out of Configuration,Was Noted.Caused by Personnel Error.Proper Configuration Was Restored Shortly After Discovery Prior to Entering Mode 2.W/980601 Ltr
ML18106A6431998-05-29029 May 1998
LER 98-006-01:on 980227,determined Incorrect Scaling Error of First Stage Pressure Transmitter Existed.Caused by Human Error.Revised Setpoint Calculation SC-MS002-01 & Revised Associated Instrument Calibr Database info.W/980529 Ltr
ML18106A6141998-05-18018 May 1998
LER 98-008-00:on 970814,failure to Test 21 & 22 AF 40 Valves in Closed Direction as Required by TS 4.0.5 Was Noted.Caused by Inadequate Design Mod Process.Motor Driven 21/22 AF 40 Valves Were Tested IAW Revised procedure.W/980518 Ltr
ML18106A5901998-05-0101 May 1998
LER 98-009-00:on 980405,epoxy Missing from Terminals of H Analyzer Was Noted.Caused by Inadequate Development of Procedure.H Analyzers Were Repaired & Review of Other Safety Related Equipment in Containment Was performed.W/980501 Ltr
ML18106A5611998-04-20020 April 1998
LER 98-008-00:on 980323,inadequate Testing of Salem Unit 1 Containment Air Locks Resulted in Entering TS 3.0.3.Caused by less-than-adequate Work Practices During Replacement of Equalizing Valve.Salem Unit 2 Airlocks Were Inspected
ML18106A6061998-04-0101 April 1998
Corrected LER 98-004-00:on 980302,failure to Comply W/Tss 4.11.1.1.2 & 3.3.3.8 Was Noted.Caused by Organizational Deficiency.Steps Have Been Taken to Correctly Document Safety Factors.Corrects Prior Similar Occurrences
ML18106A4451998-04-0101 April 1998
LER 98-004-00:on 980302,failure to Perform TS 4.11.1.1.2 & 3.3.3.8 Was Noted.Caused by Organizational Deficiency.Steps Were Taken to Correctly Document Safety factors.W/980401 Ltr
ML18106A4351998-03-30030 March 1998
LER 98-006-00:on 980227,incorrect Scaling of First Stage Turbine Impulse Pressure Transmitters Noted.Cause Indeterminate.Implemented Procedure Changes & re-scaled Affected Turbine Impulse Pressure transmitters.W/980330 Ltr
ML18106A3961998-03-20020 March 1998
LER 98-005-00:on 980219,inoperability of Twelve EDG Fuel Oil Transfer Pump (FOTP) Noted.Caused by Installation of Incorrect Control Switch.Installed Correct off-auto-manual Switch & Verified Operability of Twelve FOTP.W/980320 Ltr
ML18106A5781998-03-20020 March 1998
Corrected LER 98-005-00:on 980219,inoperability of 12 Fuel Oil Transfer Pump (Fotp),Noted.Caused by Installation of Incorrect Control Switch.Field Insp Performed to Verify Configuration of Switches for 11,21 & 22 FOTPs
ML18106A4021998-03-20020 March 1998
LER 98-007-00:on 980218,failure to Establish Containment Integrity (Closure) Prior to Fuel Movement Was Noted.Caused by Failure to Identify & Include Condensate Pot Vent in Appropriate Valve Lineup.Valves identified.W/980320 Ltr
ML18106A4031998-03-20020 March 1998
LER 98-006-00:on 980221,ESF Actuation of 11 & 12 Auxiliary Feedwater Pumps Occurred.Caused by Human Error.Operators Promptly Established Feedwater to All SG & Restored Proper Water levels.W/980320 Ltr
1999-08-26
[Table view]
Category:TEXT-SAFETY REPORT
MONTHYEARML20217A9931999-09-30030 September 1999
NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data
ML18107A5581999-09-30030 September 1999
Monthly Operating Rept for Sept 1999 for Salem,Unit 2.With 991014 Ltr
ML18107A5571999-09-30030 September 1999
Monthly Operating Rept for Sept 1999 for Salem,Unit 1.With 991014 Ltr
ML18107A5301999-08-31031 August 1999
Monthly Operating Rept for Aug 1999 for Salem,Unit 2.With 990913 Ltr
ML18107A5311999-08-31031 August 1999
Monthly Operating Rept for Aug 1999 for Salem,Unit 1.With 990913
ML18107A5031999-08-26026 August 1999
LER 99-006-00:on 990729,determined That SG Blowdown RMs Setpoint Was non-conservative.Caused by Inadequate ACs for Incorporating Original Plant Licensing Data Into Plant Procedures.Blowdown Will Be Restricted.With 990826 Ltr
ML18107A5201999-08-12012 August 1999
Rev 0 to Sgs Unit 2 ISI RFO Exam Results (S2RFO#9) Second Interval,Second Period, First Outage (96RF).
ML18107A4811999-07-31031 July 1999
Monthly Operating Rept for July 1999 for Salem,Unit 1.With 990813 Ltr
ML18107A4821999-07-31031 July 1999
Monthly Operating Rept for July 1999 for Salem,Unit 2.With 990813 Ltr
ML18107A4691999-07-28028 July 1999
LER 99-008-00:on 990714,determined That Limit Switch Cables Were Subject to Multiple Hot Shorts in Same Fire Area.Caused by Inadequate Original Post Fire Safe Shutdown Analysis.All Limit Switch Cables for MOVs Were Reviewed.With 990728 Ltr
ML18107A4441999-07-0606 July 1999
LER 99-007-00:on 990605,surveillance for Quadrant Power Tilt Ratio (QPTR) Was Missed.Caused by Human Error.Qptr Calculation Was Performed & Personnel Involved Have Been Held Accountable IAW Pse&G Policies.With 990706 Ltr
ML18107A4211999-07-0202 July 1999
LER 99-005-00:on 990605,11 Containment Declared Inoperable. Caused by Valves 11SW72 & 11SW223 Both Leaking.Procedure S1.OP-ST.SW-0010(Q) Was Enhanced to Provide Specific Instructions to Ensure Proper Sequencing.With 990702 Ltr
ML18107A4331999-07-0101 July 1999
LER 99-002-01:on 990405,determined That 2SA118 Failed as Found Leakrate Test.Caused by Foreign Matl Found in 2SA118 valve.2SA118 Valve Was Cycled Several Times & Seat Area Was Air Blown in Order to Displace Foreign Matl.With 990701 Ltr
ML18107A4321999-07-0101 July 1999
LER 99-006-01:on 990501,determined That There Was No Flow in One of Four Injection Legs.Caused by Sticking of Valve in Safety Injection Discharge Line to 21 Cold Leg.Valve Was Cut Out of Sys & Replaced.With 990701 Ltr
ML18107A5211999-07-0101 July 1999
Rev 0 to Sgs Unit 2 ISI RFO Exam Results (S2RFO#10) Second Interval,Second Period,Second Outage (99RF).
ML18107A4351999-06-30030 June 1999
Monthly Operating Rept for June 1999 for Salem,Unit 1.With 990713 Ltr
ML18107A4341999-06-30030 June 1999
Monthly Operating Rept for June 1999 for Salem,Unit 2.With 990713 Ltr
ML20196H8621999-06-30030 June 1999
NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data, June 1999 Rept
ML18107A3951999-06-17017 June 1999
LER 99-004-00:on 990520,reactor Tripped from 100% Power,Due to Negative Flux Trip Signal from Nuclear Instrumentation. Cause Has Not Been Determined.Discoloration Was Identified on One of Penetrations.With 990617 Ltr
ML18107A3661999-06-0909 June 1999
LER 99-003-00:on 990513,unplanned Entry Into TS 3.0.3 Was Made.Caused by Human error.Re-positioned Creacs Supply Fan Selector Switches & Revised Procedures S1 & S2.OP-ST.SSP-0001(Q).With 990609 Ltr
ML18107A3551999-06-0202 June 1999
LER 99-005-00:on 990504,failure to Meet TS Action Statement Requirements for High Oxygen Concentration in Waste Gas Holdup Sys Occurred.Caused by Inability of Operators. Existing Procedures Will Be Evaluated.With 990602 Ltr
ML18107A3441999-06-0101 June 1999
Interim Part 21 Rept Re Premature Over Voltage Protection Actuation in Circuit Specific Application in Dc Power Supply.Testing & Evaluation Activities Will Be Completed on 990716
ML18107A3541999-06-0101 June 1999
LER 99-006-00:on 990501,HHSI Flow Balance Discrepancy Was Noted During Surveillance.Caused by Sticking of Check Valve in SI Discharge Line to 21 Cold Leg.Valve 21SJ17,was Cut Out of Sys & Replaced.With 990601 Ltr
ML18107A3681999-05-31031 May 1999
Monthly Operating Rept for May 1999 for Salem Generating Station,Unit 1.With 990611 Ltr
ML18107A3721999-05-31031 May 1999
Monthly Operating Rept for May 1999 for Salem Generating Station,Unit 2.With 990611 Ltr
ML18107A2931999-05-12012 May 1999
LER 99-002-00:on 990413,determined That Number 12 Auxiliary Bldg Exhaust Fan Was Rotating Backwards.Caused by mis-wiring of Motor Due to Human Error by Maint technician.Mis-wiring Was Corrected & Fan Was Returned to Svc.With 990512 Ltr
ML18107A2781999-05-10010 May 1999
LER 99-004-00:on 990411,automatic Actuation of ESF Occurred During Reactor Vessel Head Removal in Support of Refueling Operations.Caused by High Radiation Condition.Containment Atmosphere Was Monitored.With 990505 Ltr
ML18107A2791999-05-0404 May 1999
LER 99-003-00:on 990406,all Salem Unit 2 Chillers Rendered Inoperable.Caused by Human Error.Lessons Learned from Event Were Communicated to All Operators by Including Them in Night Orders.With 990504 Ltr
ML18107A2741999-05-0303 May 1999
LER 99-002-00:on 990405,determined That Containment Isolation Valve Failed as Found Leakrate Test.Caused by Foreign Matl Blocking Valves from Closing.Check Valve Mechanically Agitated.With 990504 Ltr
ML18107A3711999-04-30030 April 1999
Corrected Monthly Operating Rept for Apr 1999 for Salem Generating Station,Unit 1
ML18107A3151999-04-30030 April 1999
Submittal-Only Screening Review of Salem Generating Station Individual Plant Exam for External Events (Seismic Portion), Rev 1
ML18107A2991999-04-30030 April 1999
Monthly Operating Rept for Apr 1999 for Salem Unit 1.With 990514 Ltr
ML18107A2971999-04-30030 April 1999
Monthly Operating Rept for Apr 1999 for Salem Unit 2.With 990514 Ltr
ML18107A2351999-04-23023 April 1999
LER 99-001-00:on 990330,MSSV Failed Lift Set Test.Caused by Setpoint Variance Which Is Result of Aging.Valves Were Adjusted & Retested to Ensure TS Tolerance.With 990423 Ltr
ML18107A2881999-04-0707 April 1999
Rev 0 to NFS-0174, COLR for Salem Unit 2 Cycle 11.
ML18107A1821999-03-31031 March 1999
Monthly Operating Rept for Mar 1999 for Salem,Unit 1.With 990414 Ltr
ML18107A1831999-03-31031 March 1999
Monthly Operating Rept for Mar 1999 for Salem,Unit 2.With 990414 Ltr
ML18106B1471999-03-29029 March 1999
LER 99-001-00:on 990228,reactor Scram Was Noted as Result of Turbine Trip.Caused by Operator Error.Lesson Plans Revised to Explicitly Demonstrate Manner in Which Valve Functions. with 990329 Ltr
ML18106B1021999-02-28028 February 1999
Monthly Operating Rept for Feb 1999 for Salem Unit 2.With 990315 Ltr
ML18106B1011999-02-28028 February 1999
Monthly Operating Rept for Feb 1999 for Salem Unit 1.With 990315 Ltr
ML18106B0931999-02-25025 February 1999
Part 21 Rept Re Possible Defect in Swagelok Pipe Fitting Tee,Part Number SS-6-T.Caused by Crack Due to Improper Location of Heated Bar.Only One Part Out of 7396 Pieces in Forging Lot Was Found to Be Cracked.Affected Util,Notified
ML18106B0701999-02-16016 February 1999
LER 98-015-00:on 981208,inadvertent Discharge Through RHR Relief Valve During Startup Was Noted.Caused by Operator Performing Too Many Tasks Simultaneously.Appropriate Actions Have Been Taken IAW Policies & Procedures.With 990216 Ltr
ML18106B0551999-02-0101 February 1999
Part 21 Rept Re Possible Matl Defect in Swagelok Pipe Fitting Tee,Part Number SS-6-T.Defect Is Crack in Center of Forging.Analysis of Part Is Continuing & Further Details Will Be Provided IAW Ncr Timetables.Drawing of Part,Encl
ML18106B0561999-01-31031 January 1999
Monthly Operating Rept for Jan 1999 for Salem Generating Station,Unit 2.With 990212 Ltr
ML18106B0571999-01-31031 January 1999
Monthly Operating Rept for Jan 1999 for Salem Generating Station,Unit 1.With 990212 Ltr
ML20205P1671999-01-31031 January 1999
a POST-PLUME Phase, Federal Participation Exercise
ML18106B0441999-01-29029 January 1999
Part 21 Rept Re Possible Defect in Swagelok Pipe Fitting Tee Part Number SS-6-T.Caused by Crack in Center of Forging. Continuing Analysis of Part & Will Provide Details in Acoordance with NRC Timetables
ML18106B0491999-01-28028 January 1999
LER 98-007-01:on 980730,reactor Coolant Instrument Line through-wall Leak Was Noted.Caused by Transgranular Stress Corrosion Cracking.Replaced Affected Tubing.With 990128 Ltr
ML18106B0401999-01-18018 January 1999
LER 98-016-00:on 981219,ECCS Leakage Was Outside of Design Value.Caused by Leakage Past Seat of 21RH34 Manual Drain. Valve 21RH34 Was Reseated.With 990118 Ltr
ML18106B0251998-12-31031 December 1998
Monthly Operating Rept for Dec 1998 for Salem Unit 2.With 990115 Ltr
1999-09-30
[Table view] |
Text
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Public Service Electric and Gas Company P.O. Box 236 Hancocks Bridge, New Jersey 08038 Salem Generating Station March 20, 1991 U. S. Nuclear Regulatory Commission Document Control Desk Washington, DC 20555
Dear Sir:
SALEM GENERATING STATION LICENSE NO. DPR-70 DOCKET NO. 50-272 UNIT NO. 1 LICENSEE EVENT REPORT 91-011-00 This Licensee Event Report is being submitted pursuant to the requirements of the Code of Federal Regulations 10CFR
- 50. 7 3 (a) ( 2) ( i) ( B)
- This report is required to be issued within thirty (30) days of event discovery.
Sincerely yours,
/A'.//0,1f?tw~
S. LaBruna General Manager -
Salem Operations MJP:pc Distribution 9104010366 910320 PDR ADOCK 05000272 S
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HllC Forlll 3M U.I. NUCLEAR llEOULATOllY COMMISllO.N 19..31 . ,_,,.ROVED .OMB NO. 3150-4104 EXPIRES: 1/311115 LICENSEE EVENT REPORT (LER)
FACILITY NAME C1l DOCKET NUMBER 121 *
- I PAGE 131 Sa1em Generating station -*unit 1 o 1s I o Io I o 12 I 71 2 1 loF o 13 TITLE 141 High Rad Area Found Unlocked/Unguarded Due To Personnel Error '
EVENT DATE 151 LER NUMBER 181 REPORT DATE 171 OTHER FACILITIES INVOLVED Ill FACILITY NAMES DOCKET NUMBERISI 01s1010101 I i THIS REPORT 11 IUBMITTED PURIUANT TO THE REQUIREMENn OF 10 CFR §: (Chock OM Of man of rh* fol/owfngl 1111 Ol'ERATIHO MOOE Ill ll0,7311l12llhrl 73.71i'I
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LICENSEE CONTACT FOR THIS LER 1121 ll0.73(1lf2llwllllfll .
ll0.731111211*1 NAME TELEPHONE NUMBER AREA CODE M. J. Pollack - LER Coordinator COMPLETE ONE LINE FOR E.l,CH COMPONENT FAILURE DESCRIBED IN THll REPORT 1131 .
MANUFAC- SYSTEM COMPONENT MANUFAC-CAUSE SYSTEM COMPONENT TURER
- TURER I I I I .I I I I I I I I I I I I I I I I I *1 I I I I I I IUPPLEMENTAL REl'ORT EXPECTED (141 MOlllTH DAY ~AR EXPECTED SUBMISSION n YES (If yn, comp/tr. E~PECTEO SUBMISSION DA TEI **r-xi NO DATE 1151
.I .I I On February 20, 19.91 at 1020 hours0.0118 days <br />0.283 hours <br />0.00169 weeks <br />3.8811e-4 months <br />, the RHE Room was discovered to be unlocked and unguarded by Radiation Protection Department supervision. The access door to this room was found closed. On February 19, 1991 *at 2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br />, .during ninth refueling outage activities, the Regenerative Heat Exchanger (RHE) Room High Radiation Area (HRA) key was obtained by a Radiation Protection technician to support work in the area. Work in the area was completed at 0200 hours0.00231 days <br />0.0556 hours <br />3.306878e-4 weeks <br />7.61e-5 months <br /> on February 20, 1991. The area has accessible (by climbing) radiation levels of up to 2.0 R/hr at 18 inches from the heat exchanger. The ground level area radiation levels are less than 1 R/hr. The* root cause of this event is personnel error. The Radiation Protection technician, who was supporting work in the RHB Room, did.
not ensure the door was locked after personnel vacated the area. The technician upon closing the door verified it latched closed but did not ensure it was locked (turned the knob). This event has been reviewed.by Radiation.Protection Department management. Corrective discipline was taken with the technician responsible for this event.
This event has been reviewed with applicable Radiation Protection Department personnel stressing the need for ensuring positive control of HRA's. Access logs and personnel dosimetry data were reviewed for the period between February 19, 1991 at 2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br /> to February 20, 1991 at 1200 hours0.0139 days <br />0.333 hours <br />0.00198 weeks <br />4.566e-4 months <br />. No inadvertent entry into the RHE room was apparently made. The RHE access door is now chain locked. The door locking mechanism will be replaced with a mechanism that requires key removal for the door to be locked.
HRC f<><ft!l :!.U
Salem Generating Station LICENSEE EVENT REPORT (LER) TEXT CONTINUATION DOCKET NuMBER LER NUMBER
- PAGE Unit 1 . 5000272 91-011-00 2 of 3 PLANT AND SYSTEM IDENTIFICATION:
I Westinghouse - Pressurized Water Reactor Energy Industry Identification System (EIIS) codes are identified in
- the text as {Xxf IDENTIFICATION OF OCCURRENCE:
High Radiation Area found unlocked/unguarded due to personnel error
- Event Date: 2/20/91 Report Date: 3/20/91 This report. was initiated by Incident Report No'.91-122 *
. CONDITIONS PRIOR TO OCCURRENCE:
Mode 5 (Cold Shutdown) - gt h Refueling out.age DESCRIPTION OF OCCURRENCE:
. On February 19, 1991 at 2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br />, during .ninth* refueling* outage .
activities, the. Regenerative Heat Exchanger (RHE) Room High Radiation Area (BRA) key was obtained by a Radiation Protection technician to support inservice inspection work in the area. Work in the area was completed at 0200 hours0.00231 days <br />0.0556 hours <br />3.306878e-4 weeks <br />7.61e-5 months <br /> on February 20, 1991. This room is a High Radiation. Area. It has accessible (by climbing) radiation leve.ls of up to 2.0 R/hr at 18 inches from the heat exchanger. The ground level area.radiation levels are less than 1 R/hr.
On February 20, 1991 at 1020 hours0.0118 days <br />0.283 hours <br />0.00169 weeks <br />3.8811e-4 months <br />, the RHE Room was discovered to be unlocked and unguarded by Radiation Protection* Department supervision.* The access door to this room was found closed.*
Having an unlocked/unguarded HRA, where radiation levels of greater than 1.0 R/hr are accessible (by climbing), is contrary to the requirements of* Technical Specification 6.12 and Radiation Protection Procedure RP 203, "Radiation Protection Ke:f Control System".
APPARENT CAUSE OF OCCURRENCE:
The root cause of this.event is personnel error. The Radiation Protection technician, who was supporting the inservice inspection work in the RHE Room, did*not ensure the door was locked after personnel vacated the area (i.e., completion of work activities). The technician upon closing the door verified it latched closed but did not ensure it was locked (turned the knob).
The RHE Room access door is not necessarily self locking. If the key is turned in one direction it is self locking while the other direction produces the opposite result. Although this factor contributes to the cause of this event, technicians are trained to positively verify that BRA accesses are locked once all personnel have
LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station -DOCKET NUMBER LER NUMBER PAGE Unit- 1 5000272 91-011-00 3 of 3 APPARENT CAUSE OF OCCURRENCE: (cont'd)
_vacated - the area. . Also, Radiation Protection pro*cedure RP-203, section 6.4,* requires the technician_to verify the door is locked and secure upon exit of the -BRA.
ANALYSIS OF OCCURRENCE:
Access to HRA's is controlled to prevent personnel from unknowingly entering areas where excessive radiation dose could be accumulated.-
The subject BRA contained radiation levels ranging up to 2.0 R/hr (at 18") in reasonably assessable areas.
Upon discovery, the RHE access door was locked as required. This occurrence involved no undue risk to the health and safety of the public. *However, because this occurrence involves a situation contrary to t_he requirements of the Technical Specifications,. this event is reportable in ~ccordance with the Code of Federal Regulations 10CFR 50. 73 (a) (2) (i). (B).
CORRECTIVE ACTION: .
This _event has been reviewed by Radiation Protection Department management. Corrective discipline was taken with the technician responsible for this event.
This event has been reviewed with applicable Radiation Protection*
Department personnel stressing the need for ensuring positive control of HRA's.
Access logs and personnel dosim~try data were reviewed fo~ the period between February 19, 1991 at 2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br /> to February 20, 1991 at 1200 hours0.0139 days <br />0.333 hours <br />0.00198 weeks <br />4.566e-4 months <br />. No inadvertent entry into the RHE room was apparently made.
The RHE access door is now chain locked. The door locking mechanism will be_replaced with a mechanism that requires the door_to be locked for-key removal.
A review of all other locked HRAs was conducted. No other access locking mechanisms were identified with similar concerns to the RHE
-Room door.
Past unlocked/unguarded BRA events, occurring within the last four years*, have been reviewed. These other events did not involve the RHE Room access door nor were their root causes similar to this event.
/Jffi/rtk/4'~,___--
General Manager -
Salem Operations MJP:pc SORC Mtg.91-032
