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| | issue date = 04/07/1999 | | | issue date = 04/07/1999 |
| | title = LER 99-S01-00:on 990308,discovered That Lock for Vital Gate Leading to Plant 4KV Switchgear Area Was Nonconforming & Vulnerable to Unauthorized Access.Caused by Inadequate Gate Design & Inadequate Procedures.Mods Are Being Made to Gate | | | title = LER 99-S01-00:on 990308,discovered That Lock for Vital Gate Leading to Plant 4KV Switchgear Area Was Nonconforming & Vulnerable to Unauthorized Access.Caused by Inadequate Gate Design & Inadequate Procedures.Mods Are Being Made to Gate |
| | author name = BERRY L R | | | author name = Berry L |
| | author affiliation = INDIANA MICHIGAN POWER CO. | | | author affiliation = INDIANA MICHIGAN POWER CO. |
| | addressee name = | | | addressee name = |
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| {{#Wiki_filter:RCFnRM366USNUCLEARREGULATOMMISSION | | {{#Wiki_filter:RC FnRM 366 U S NUCLEAR REGULAT OMMISSION APPROVED MB No. 3150.0104 EXPIRES 06I30I2001 |
| -1998)Thisdocumentdoesnotconteafeguards Information LICENSEEEVENTREPORT(LER)(Seereverseforrequirednumberofdigits/characters foreachblock)APPROVEDMBNo.3150.0104 EXPIRES06I30I2001 Estimated burdenperresponsetocomplywiththismandatory hformation collection request:50hrs.Reportedlessonslearnedareincorporated htothelicensing processandfedbacktobtdustry. | | -1998) This document does not conte afeguards Information Estimated burden per response to comply with this mandatory hformation collection request: 50 hrs. Reported lessons learned are incorporated hto the LICENSEE EVENT REPORT (LER) licensing process and fed back to btdustry. Forward commenls regarding burden estimate to the Records Management Branch (TA F33), U.S. Nuclear Regulatory Commission, Washhgton. DC 205550001, and to the Paperwork Reduction (See reverse for required number of ProJect (31504104). Office of Management and Budget,'Washington, DC 20503. |
| Forwardcommenlsregarding burdenestimatetotheRecordsManagement Branch(TAF33),U.S.NuclearRegulatory Commission, Washhgton.
| | If an Information co lection does not display a cunentfy valid OMB control number. |
| DC205550001, andtothePaperwork Reduction ProJect(31504104).
| | digits/characters for each block) the NRC may not conduct or sponsor. and a person is not required to respond to. |
| OfficeofManagement andBudget,'Washington, DC20503.IfanInformation colectiondoesnotdisplayacunentfyvalidOMBcontrolnumber.theNRCmaynotconductorsponsor.andapersonisnotrequiredtorespondto.theinformation collection.
| | the information collection. |
| FACILITYNAME(1)CookNuclearPlantUnit1DOCKETNUMBER(2)05000-315 PAGE(3)1OF3TrrLB(4)Vulnerability intheLockingMechanism ofFourVitalAreaGatesEVENTDATE(5)LERNUMBER(6)REPORTDATE(7)OTHERFACILITIES INVOLVED(8)MONTHDAYYEAR1999SEQUENTIAL NUMBERREVISIONMONTHDAYYEARNUMBERFACILITYNAMECookNuclearPlantUnit2FAGILrfYNAMEDOCKETNUMBER05000-316 DOCKETNUMBEROPERATING MODE(9)POWERLEVEL(10)0oTHISREPORTIsSUBMITTED PURSUANTToTHEREQU20.2203(a)(2)(v) 20.2201(b) 20.2203(al(3) | | FACILITYNAME (1) DOCKET NUMBER (2) PAGE (3) |
| (i)20.2203(a)(3) | | Cook Nuclear Plant Unit 1 05000-315 1 OF 3 TrrLB (4) |
| (ii)20.2203(a)(1) 20.2203(a)(2)(i) | | Vulnerability in the Locking Mechanism of Four Vital Area Gates EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (8) |
| IREMENTSOF10CFREt(Checkoneormore)(11)50.73(a)(2)(viii) 50.73(a)(2)(i)50.73(a)(2)(x)50.73(a)(2)(ii) 50.73(a)(2l(iii),73.7120.2203(a)
| | MONTH DAY YEAR SEQUENTIAL REVISION MONTH DAY YEAR FACILITYNAME DOCKET NUMBER NUMBER NUMBER Cook Nuclear Plant Unit 2 05000-316 1999 FAG ILrfYNAME DOCKET NUMBER OPERATING THIS REPORT Is SUBMITTED PURSUANT To THE REQU IREMENTS OF 10 CFR Et (Check one or more) (11) |
| (2)(ii)20.2203(a)(2)(iii) 20.2203(a)(2)(iv) 20.2203(a) | | MODE (9) 20.2201(b) 20.2203(a)(2)(v) 50.73(a) (2)(i) 50.73(a)(2)(viii) |
| (4)50.36(c)(1) 50.36(c)(2)LICENSEECONTACTFORTHISLER(12)50.73(a)(2)(iv) 50.73(a)(2)(v)50.73(a)(2)(vii)XOTHERSpecifyinAbstractbeloworinNRCForm366ANAMELyleR.Berry,Regulatory Compliance EngineerTELEPHONE NUMBERIlnciudeAresCode)(616)465-5901X2637CRIBEDINTHISREPORT(13)COMPLETEONELINEFOREACHCOMPONENT FAILUREDESCAUSESYSTEMCOMPONENT MANUFACTURER REPORTABLE TOEPIXCAUSESYSTEMCOMPONENT MANUFACTURER REPORTABLE TOEPIXSUPPLEMENTAL REPORTEXPECTED14YES(Ifyes,completeEXPECTEDSUBMISSION DATE).XNoEXPECTEDMONTHDAYYEARABSTRACT(Limitto1400spaces,i.e.,approximately 15single-spaced typewritten lines)(16)OnMarch8,1999,atapproximately 1400hours,withbothunitsinMode5,thelockforavitalareagateleadingtotheUnit14KVSwitchgear areawasdiscovered bythesecuritycaptainandalocksmith tobenonconforming andvulnerable tounauthorized access.At1546hours,itwasdetermined thatthisconstituted afailure,degradation ordiscovered vulnerability inasafeguard systemthatcouldallowunauthorized orundetected accesstoaprotected area,materialaccessarea,controlled accessarea,vitalareaortransport forwhichcompensatory measureshavenotbeenemployedandwasreportable asasafeguards eventpursuanttotherequirements of10CFR73,AppendixG,paragraph l(c)and10CFR73.71(b)(1). | | POWER 0 o 20.2203(a)(1) 20.2203(al(3) (i) 50.73(a)(2)(ii) 50.73(a) (2)(x) |
| AnEmergency Notification System(ENS)reportwasmadetoNRCat1645hours.Theanalogous vitalareagatefortheUnit24KVSwitchgear wasinspected anddetermined tobeoperable.
| | LEVEL (10) 20.2203(a)(2)(i) 20.2203(a)(3) (ii) 50.73(a) (2l(iii) 73.71 20.2203(a) (2)(ii) 20.2203(a) (4) 50.73(a)(2)(iv) X OTHER 20.2203(a)(2)(iii) 50.36(c)(1) 50.73(a) (2) (v) Specify in Abstract below or in NRC Form 366A 20.2203(a)(2)(iv) 50.36(c) (2) 50.73(a) (2) (vii) |
| Threeadditional gateswerediscovered tobenonconforming duringtheextentofcondition investigation andENSnotification updatesweremade.Theapparentcausesforthiseventwereinadequate gatedesignandinadequate procedures.
| | LICENSEE CONTACT FOR THIS LER (12) |
| Uponidentification ofthenonconforming gates,compensatory measureswerepromptlyimplemented.
| | NAME TELEPHONE NUMBER Ilnciude Ares Code) |
| Gaterepairs/modifications arebeingmadetoeliminate nonconforming conditions.
| | Lyle R. Berry, Regulatory Compliance Engineer (616) 465-5901 X2637 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DES CRIBED IN THIS REPORT (13) |
| Compensatory measureswillremaininplaceuntilthegatesarereturnedtooperable. | | CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE TO EPIX TO EPIX SUPPLEMENTAL REPORT EXPECTED 14 EXPECTED MONTH DAY YEAR YES X No (If yes, complete EXPECTED SUBMISSION DATE). |
| Procedures fortestingandmaintenance ofsecuritygateswillberevisedtopreventrecurrence. | | ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (16) |
| Follow-up investigations confirmed thatthevitalareassecuredbythefourgateswerenotcompromised. | | On March 8, 1999, at approximately 1400 hours, with both units in Mode 5, the lock for a vital area gate leading to the Unit 1 4KV Switchgear area was discovered by the security captain and a locksmith to be nonconforming and vulnerable to unauthorized access. At 1546 hours, it was determined that this constituted a failure, degradation or discovered vulnerability in a safeguard system that could allow unauthorized or undetected access to a protected area, material access area, controlled access area, vital area or transport for which compensatory measures have not been employed and was reportable as a safeguards event pursuant to the requirements of 10CFR73, Appendix G, paragraph l(c) and 10CFR73.71(b)(1). An Emergency Notification System (ENS) report was made to NRC at 1645 hours. The analogous vital area gate for the Unit 2 4 KV Switchgear was inspected and determined to be operable. Three additional gates were discovered to be nonconforming during the extent of condition investigation and ENS notification updates were made. |
| Therefore, therewerenoimplications tothehealthandsafetyofthepublicasaresultofthisevent.'I)904130267 9's)0407PDRADQCK050003i5(sr)p | | The apparent causes for this event were inadequate gate design and inadequate procedures. Upon identification of the nonconforming gates, compensatory measures were promptly implemented. Gate repairs/modifications are being made to eliminate nonconforming conditions. Compensatory measures will remain in place until the gates are returned to operable. |
| | Procedures for testing and maintenance of security gates will be revised to prevent recurrence. |
| | Follow-up investigations confirmed that the vital areas secured by the four gates were not compromised. Therefore, there were no implications to the health and safety of the public as a result of this event. |
| | 'I)904130267 9's) 0407 PDR ADQCK 050003i5(sr)p |
|
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| CFORM366AU.S.NUCLEARRETORYCOMMISSION
| | C FORM 366A U.S. NUCLEAR RE TORY COMMISSION |
| .1999)ThisdocumentdoesnotcontainSefeguards information LICENSEEEVENTREPORT(LER)TEXTCONTINUATION FACILITYNAME(1)CookNuclearPlantUnit1DOCKETI2)05000-315 YEARSEQUENTIAL NUMBERREVISIONNUMBERLERNUMBERI6)PAGEI3)2OF31999S001"00TEXTilfmorespaceisrequired, useadditional copiesofNRCForm366AjI17)Conditions PriorToEventUnit1Mode5at0%powerUnit2Mode5at0%powerDescritionOfTheEventOnMarch8,1999,atapproximately 1400hours,withbothunitsinMode5,thelockforavitalareagateleadingtotheUnit14KVSwitchgear areawasdiscovered, bythesecuritycaptainandalocksmith, tobenonconforming andvulnerable tounauthorized access.At1546itwasdetermined thatthisconstituted afailure,degradation ordiscovered vulnerability inasafeguard systemthatcouldallowunauthorized orundetected accesstoaprotected area,materialaccessarea,controlled accessarea,vitalareaortransport forwhichcompensatory measureshavenotbeenemployed. | | .1999) This document does not contain Sefeguards information LICENSEE EVENT REPORT (LER) |
| AnEmergency Notification System(ENS)reportwasmadetoNRCat1645hours.Theanalogous vitalareagatefortheUnit24KVSwitchgear Unit2wasinspected anddetermined tobeoperable.
| | TEXT CONTINUATION FACILITY NAME (1) DOCKET I2) LER NUMBER I6) PAGE I3) |
| Threeadditional gateswerediscovered tobenonconforming duringtheextentofcondition investigation ofothersafeguard gatesintheplant.Duringthisinvestigation, itwasidentified thattheentrygateintoUnit1UpperContainment couldnotbeinspected, duetoahoseinthegateopening.However,thisgatehashadcompensatory measuresinplacesinceMay1998,insupportofplantactivities whichrequireittobeopen.ThevitalareagatestoUnit2WestMotorDrivenAuxiliary Feedwater PumpRoomAccessandUnit2Essential ServiceWater(ESW)PumpRoomAccesswerediscovered tobenonconforming atapproximately 1637and1706hours,respectively, onMarch8,1999.AnENSupdatereportwasmadetoNRCat1838hours.ThegatetoUnit2AccesstotheSpentFuelPitAreafromtheAuxiliary Cranebaywasdiscovered tobenonconforming atapproximately 0643hoursonMarch9,1999.AsecondENSupdatereportwasmadetoNRCat1139hoursonMarch9,1999.Compensatory measureswereestablished uponIdentification ofeachofthefourgatevulnerabilities.
| | Cook Nuclear Plant Unit 1 05000-315 YEAR SEQUENTIAL NUMBER REVISION 2 OF 3 NUMBER 1999 S001 00 TEXT ilfmore spaceis required, use additional copies of NRC Form 366A j I17) |
| Reviewofalarmrecordsdidnotidentifyuninvestigated alarmsforthesegates.CauseOfTheEventTheapparentcausesforthiseventwereinadequate gatedesignandinadequate procedures.
| | Conditions Prior To Event Unit 1 Mode 5 at 0% power Unit 2 Mode 5 at 0% power Descri tion Of The Event On March 8, 1999, at approximately 1400 hours, with both units in Mode 5, the lock for a vital area gate leading to the Unit 1 4KV Switchgear area was discovered, by the security captain and a locksmith, to be nonconforming and vulnerable to unauthorized access. At 1546 it was determined that this constituted a failure, degradation or discovered vulnerability in a safeguard system that could allow unauthorized or undetected access to a protected area, material access area, controlled access area, vital area or transport for which compensatory measures have not been employed. An Emergency Notification System (ENS) report was made to NRC at 1645 hours. The analogous vital area gate for the Unit 2 4 KV Switchgear Unit 2 was inspected and determined to be operable. |
| Information. | | Three additional gates were discovered to be nonconforming during the extent of condition investigation of other safeguard gates in the plant. During this investigation, it was identified that the entry gate into Unit 1 Upper Containment could not be inspected, due to a hose in the gate opening. However, this gate has had compensatory measures in place since May 1998, in support of plant activities which require it to be open. The vital area gates to Unit 2 West Motor Driven Auxiliary Feedwater Pump Room Access and Unit 2 Essential Service Water (ESW) Pump Room Access were discovered to be nonconforming at approximately 1637 and 1706 hours, respectively, on March 8, 1999. An ENS update report was made to NRC at 1838 hours. |
| Notice88-41,"Physical Protection Weaknesses Identified ThroughRegulatory Effectiveness Reviews"described deficiencies ingatedesignwhichcouldallowcompromise.
| | The gate to Unit 2 Access to the Spent Fuel Pit Area from the Auxiliary Cranebay was discovered to be nonconforming at approximately 0643 hours on March 9, 1999. A second ENS update report was made to NRC at 1139 hours on March 9, 1999. |
| Plantdesignreviewsandgatemodifications performed inresponsetoIN8841werenotadequate.
| | Compensatory measures were established upon Identification of each of the four gate vulnerabilities. Review of alarm records did not identify uninvestigated alarms for these gates. |
| Testprocedures wereinadequate becausetheydidnotincluderequirements ormethodstoverifygateintegrity byprescribing nondestructive attemptstosubvertsecuritysystems.Currenttestprocedures requiresecuritypersonnel totestthefunctionofalarmsystemsassociated witheachgate,butdonotincludestepswhichcouldidentifyothergatevulnerabilities.
| | Cause Of The Event The apparent causes for this event were inadequate gate design and inadequate procedures. |
| Maintenance procedures didnotadequately identifypotential degradation ofvitalareaaccessesandassociated vulnerabilities. | | Information. Notice 88-41, "Physical Protection Weaknesses Identified Through Regulatory Effectiveness Reviews" described deficiencies in gate design which could allow compromise. Plant design reviews and gate modifications performed in response to IN 8841 were not adequate. |
| Securityprocedures thatapplytothepreventive maintenance ofthesegatesdidnotaddressdiscovery ofexternalwearthatcouldprovidetheopportunity forcompromise.
| | Test procedures were inadequate because they did not include requirements or methods to verify gate integrity by prescribing nondestructive attempts to subvert security systems. Current test procedures require security personnel to test the function of alarm systems associated with each gate, but do not include steps which could identify other gate vulnerabilities. |
| NRCFORM366A(6-1999)
| | Maintenance procedures did not adequately identify potential degradation of vital area accesses and associated vulnerabilities. Security procedures that apply to the preventive maintenance of these gates did not address discovery of external wear that could provide the opportunity for compromise. |
| | NRC FORM 366A (6-1999) |
|
| |
|
| IIRCFORM366AU.S.NUCLEARREGULATORY COMMISSION 16.i998)ThisdocumentdoesnotconteinSereguerds Informetion LICENSEEEVENTREPORT(LER)TEXTCONTINUATION FACILITYNAME(1)CookNuclearPlantUnit1DOCKETI2)05000-315 YEAR1999LERNUMBERI6)SEQUENTIAL NUMBERS001PAGEI3)REvlsloN3'OF3NUMBER00TEXT(Ifmorespaceisrequired, useadditional copiesofNRCForm366AJ{17)Currentpreventive maintenance procedures discus'sthepossibility ofthemalfunction ofmechanical components, butdonotspecifically addressvulnerability totampering.
| | IIRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION 16.i 998) This document does not contein Sereguerds Informetion LICENSEE EVENT REPORT (LER) |
| AnalsisOfTheEventCommencing atapproximately 1400hoursMarch8,1999andendingatapproximately 0630hoursMarch9,1999,withUnit1andUnit2bothinMode5,fourvitalareagateswereidentified whichwerenonconforming andvulnerable topossiblecompromise.
| | TEXT CONTINUATION FACILITY NAME (1) DOCKET I2) LER NUMBER I6) PAGE I3) |
| Theidentified conditions constituted afailure,degradation ordiscovered vulnerability inasafeguard systemthatcouldallowunauthorized orundetected accesstoaprotected area,materialaccessarea,controlled accessarea,vitalareaortransport forwhichcompensatory measureshavenotbeenemployed.
| | Cook Nuclear Plant Unit 1 05000-315 YEAR SEQUENTIAL NUMBER REvlsloN 3 'OF 3 NUMBER 1999 S001 00 TEXT (If more spaceis required, use additional copies of NRC Form 366AJ {17) |
| Thiseventwasreportable asasafeguards eventpursuanttotherequirements of10CFR73,'Appendix G,paragraph l(c)and10CFR73.71(b)(1)
| | Current preventive maintenance procedures discus's the possibility of the malfunction of mechanical components, but do not specifically address vulnerability to tampering. |
| (1hourENSreport).ENSreportsweremadetotheNRCOperations Centerat1645hoursand1838hoursonMarch8,1999andat1139hoursonMarch9,1999.Thisreportisbeingmadepursuanttotherequirements of10CFR73,AppendixG,paragraph l(c)and10CFR73.71(d) | | Anal sis Of The Event Commencing at approximately 1400 hours March 8, 1999 and ending at approximately 0630 hours March 9, 1999, with Unit 1 and Unit 2 both in Mode 5, four vital area gates were identified which were nonconforming and vulnerable to possible compromise. The identified conditions constituted a failure, degradation or discovered vulnerability in a safeguard system that could allow unauthorized or undetected access to a protected area, material access area, controlled access area, vital area or transport for which compensatory measures have not been employed. This event was reportable as a safeguards event pursuant to the requirements of 10CFR73,'Appendix G, paragraph l(c) and 10CFR73.71(b)(1) (1 hour ENS report). |
| (30dayreport).Follow-up investigations indicatethatthevitalareassecuredbythefourgateswerenotcompromised. | | ENS reports were made to the NRC Operations Center at 1645 hours and 1838 hours on March 8, 1999 and at 1139 hours on March 9, 1999. This report is being made pursuant to the requirements of 10CFR73, Appendix G, paragraph l(c) and 10CFR73.71(d) (30 day report). |
| Therefore, therewerenoimplications tothehealthandsafetyofthepublicasaresultofthisevent.CCORRECTIVE ACTIONSUponidentification ofthenonconforming gates,compensatory measureswerepromptlyimplemented. | | Follow-up investigations indicate that the vital areas secured by the four gates were not compromised. Therefore, there were no implications to the health and safety of the public as a result of this event. |
| Vitalareaaccessgateswereinspected toinvestigate theextentofcondition anddetermine whethersimilarvulnerabilities existed.Gaterepairs/modifications arebeingmadetoeliminate identified nonconforming conditions.
| | C CORRECTIVE ACTIONS Upon identification of the nonconforming gates, compensatory measures were promptly implemented. Vital area access gates were inspected to investigate the extent of condition and determine whether similar vulnerabilities existed. Gate repairs/modifications are being made to eliminate identified nonconforming conditions. Compensatory measures will remain in place until the gates are returned to operable. |
| Compensatory measureswillremaininplaceuntilthegatesarereturnedtooperable. | | A new Operating Experience (OE) Program is being developed which will reside under the Regulatory Affairs Department. |
| AnewOperating Experience (OE)Programisbeingdeveloped whichwillresideundertheRegulatory AffairsDepartment.
| | The ingredients of the program will include benchmarking from other utilities that have proven, effective OE programs and is intended to better utilize industry operating experience, including information notices. |
| Theingredients oftheprogramwillincludebenchmarking fromotherutilities thathaveproven,effective OEprogramsandisintendedtobetterutilizeindustryoperating experience, including information notices.Securityvitalareaaccesstestprocedures willberevisedtoincorporate appropriate stepsfornon-destructive testingofsecuritysystemssuchasgates.Securitypreventive maintenance procedures willberevisedtoincorporate stepsintendedtoidentifyandcorrectdegradation ofbarrierswhichcouldleadtovulnerability totampering.
| | Security vital area access test procedures will be revised to incorporate appropriate steps for non-destructive testing of security systems such as gates. Security preventive maintenance procedures will be revised to incorporate steps intended to identify and correct degradation of barriers which could lead to vulnerability to tampering. Follow-up investigations were performed to verify that vital areas secured by the four nonconforming gates were not compromised. |
| Follow-up investigations wereperformed toverifythatvitalareassecuredbythefournonconforming gateswerenotcompromised. | | SIMILAR EVENTS 316/97-S001-00, "Control of Vital Area Lost Due to Personnel Error," November 10, 1997. |
| SIMILAREVENTS316/97-S001-00, "ControlofVitalAreaLostDuetoPersonnel Error,"November10,1997.NRCFORM366AI61998)}}
| | NRC FORM 366A I6 1998)}} |
LER 99-S01-00:on 990308,discovered That Lock for Vital Gate Leading to Plant 4KV Switchgear Area Was Nonconforming & Vulnerable to Unauthorized Access.Caused by Inadequate Gate Design & Inadequate Procedures.Mods Are Being Made to Gate| ML17325B532 |
| Person / Time |
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| Site: |
Cook  |
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| Issue date: |
04/07/1999 |
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| From: |
Berry L
INDIANA MICHIGAN POWER CO. |
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| To: |
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| Shared Package |
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| ML17325B531 |
List: |
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| References |
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| LER-99-S01, LER-99-S1, NUDOCS 9904130267 |
| Download: ML17325B532 (6) |
|
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|---|
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LER 99-009-00:on 990304,as-found RHR Safety Relief Valve Lift Setpoint Greater than TS Limit Occurred.Cause Investigation for Condition Has Not Been Completed.Update to LER Will Be Submitted,Upon Completion of Investigation
ML17325B5321999-04-0707 April 1999
LER 99-S01-00:on 990308,discovered That Lock for Vital Gate Leading to Plant 4KV Switchgear Area Was Nonconforming & Vulnerable to Unauthorized Access.Caused by Inadequate Gate Design & Inadequate Procedures.Mods Are Being Made to Gate
ML17325B5161999-04-0101 April 1999
LER 99-007-00:on 981020,calculations Showed That Divider Barrier Between Upper & Lower Containment Vols Were Overstressed.Engineers Are Currently Working on Analyses of Loads & Stress on Enclosures
ML17325B5221999-03-29029 March 1999
LER 99-001-00:on 960610,degraded Component Cooling Water Flow to Containment Main Steam Line Penetrations,Identified on 990226.Caused by Inadequate Understanding of Design Basis.Additional Investigations Ongoing
ML17325B4801999-03-18018 March 1999
LER 99-004-00:on 971030,failure to Perform TS Surveillance Analyses of Rc Chemistry with Fuel Removed Was Noted.Cause of Event Is Under Investigation.Corrected Written Job Order Activities Used to Control SD Chemistry Sampling
ML17325B4741999-03-18018 March 1999
LER 99-005-00:on 940512,determined That Rt Breaker Manual Actuations During Rod Drop Testing Were Not Previously Reported.Caused by Lack of Training.Addl Corrective Actions,Including Preventative Actions May Be Developed
ML17325B4571999-02-24024 February 1999
LER 99-003-00:on 990107,CR Pressurization Sys Surveillance Test Did Not Test Sys in Normal Operating Condition.Caused by Failure to Recognize Door 12DR-AUX415 as Part of CR Pressure Boundary.Performed Walkdown of Other Doors
ML17335A5171999-02-11011 February 1999
LER 99-002-00:on 990112,determined That RCS Pressurizer PORVs Had Not Been Tested,Per Ts.Caused by Inadequate Scheduling Controls Allowing Personnel Error.Surveillance Procedure Was Completed & Updated LER Will Be Submitted
ML17335A5141999-02-10010 February 1999
LER 99-001-00:on 990106,noted That GE Hfa Relays Installed in EDGs May Not Meet Seismic Qualification.Caused by Operating Experience Info Incorrectly Dispositioned in 1985. Updated LER Will Be Submitted by 990405
ML17335A5011999-02-0101 February 1999
LER 98-060-00:on 981231,identified That Rt Sys Response Time Testing Did Not Comply with TS Definition.Caused by Inadequate Procedures.Corrective Actions Will Be Developed & Update to LER Will Be Submitted by 990415.With 990201 Ltr
ML17335A4951999-01-29029 January 1999
LER 98-059-00:on 981230,interim LER -single Failure in Containment Spray Sys Could Result in Containment Spray Ph Outside Design Occurred.Investigation Into Condition Continuing.Update Will Be Submitted by 990514 Ltr
ML17335A4961999-01-27027 January 1999
LER 98-057-00:on 981228,discovered That AFW Valves Were Not Tested IAW Inservice Testing Program.Caused by Failure to Recognize Design Bases Features Re Afws by Personnel. Updated LER Will Be Submittted by 990415.With 990127 Ltr
ML17335A4921999-01-19019 January 1999
LER 98-052-01:on 981128,no Analysis for NSR Sc Manual Loader for Tdafwp Could Be Found in Original Design.Cause Due to All Failure Modes Not Considered When Compressed Air Sys Originally Designed.Performed Review of Components
ML17335A4721999-01-0606 January 1999
LER 98-055-00:on 981207,potential for Condition Outside of Design Bases for Rod Control Sys Was Noted.Caused by Calibration Error Coupled with Single Rod Failure.Condition Rept Investigation Is Ongoing
ML17335A4691999-01-0606 January 1999
LER 98-056-00:on 981211,hot Leg Nozzle Gaps Resulted in Plant Being in Unanalyzed Condition.Analyses Are Being Performed by W to Resolve Problem.Updated LER Will Be Submitted by 990211.With 990106 Ltr
ML17335A4661999-01-0505 January 1999
LER 98-049-00:on 981020,emergency Boron Injection Flow Path Was Inoperable.Caused by Original Design Deficiency. Engineering Evaluation of Event Is Continuing
ML17335A4631999-01-0404 January 1999
LER 98-054-00:on 981202,discovered That at Least One MSSV Had Not Been Reset as Required by Ts.Engineering Is Continuing Review of Extent of Condition for Event.Updated LER Will Be Submitted by 990129.With 990104 Ltr
ML17335A4481998-12-30030 December 1998
LER 98-053-00:on 981130,discovered Use of Inoperable Substitute Subcooling Margin Monitor.Caused by Condition Existing Since Installation of Plant Process Computer in 1992.Updated LER Will Be Submitted.With 981230 Ltr
ML17335A4581998-12-28028 December 1998
LER 98-052-00:on 981128,turbine Driven AFW Pump Speed Controller Failure Mode Occurred.Caused Because Not All Failure Modes Were Considered When Compressed Air Sys Was Originally Designed.Verified Current Design Change Process
ML17335A4281998-12-22022 December 1998
LER 98-051-00:on 981122,reactor Trip Signal from Manual Safety Injection Not Verified as Required by TS Surveillance,Was Discovered.Maintenance Currently Evaluating Significance & Cause of Event
ML17335A4111998-12-17017 December 1998
LER 98-047-00:on 981117,potential for Increase Leakage from Reactor Coolant Pump Seals Was Identified.Util Is Working with W to Resolve Issue.Current Expectations Are to Submit Update to LER by 990215.With 981217 Ltr
ML17335A4141998-12-16016 December 1998
LER 98-058-00:on 981216,postulated High Line Break Could Result in Condition Outside Design Bases for AF Occurred. Caused by Deficiencies Associated with Administration of HELB Program.Analysis of AF Will Be Completed by 990122
ML17335A4181998-12-16016 December 1998
LER 98-050-00:on 980814,ancillary Equipment Installed in Ice Condenser Was Not Designed to Withstand Design Basis Accident/Earthquake Loads.Caused by Lack of Established Design Criteria.Developed Design Criteria
ML17335A3871998-12-11011 December 1998
LER 98-031-01:on 980610,potential Common Mode Failure of RHR Pumps Were Noted.Caused by Inaccurate Values.Accurate Miniflow Numbers Have Been Determined by Flow Testing
ML17335A3821998-12-0808 December 1998
LER 98-039-01 Re EOP Step Conflicts with Small Break LOCA Analysis.Ler 98-039-00 Has Been Canceled.With 981208 Ltr
ML17335A3781998-12-0707 December 1998
LER 98-007-00:on 981106,high Energy Line Break Effects in Auxiliary FW Sys Was Noted.Cause of Event Is Under Investigation & Will Be Completed by 990220.Updated LER Will Be Submitted by 990310.With 981207 Ltr
ML17335A3771998-12-0303 December 1998
LER 98-046-00:on 981103,determined That Afs Was Unable to Meet Design Flow Requirements During Special Test.Caused by Failure to Consider All Aspects of Sys Operation in Design of Suction Basket Strainers.Sys Will Be Redesigned
ML17335A3741998-12-0202 December 1998
LER 97-011-02:on 970822,operation Was Noted Outside Design Bases for ECCS & CSP for Switchover to Recirculation Sump Suction.Caused by Ineffective Change Mgt.Revised Procedure for Switchover 01(02) Ohp 4023.ES-1.3
1999-09-17
[Table view]
Category:RO)
MONTHYEARML17335A5641999-10-18018 October 1999
LER 99-024-00:on 990708,literal TS Requirements Were Not Met by Accumlator Valve Surveillance.Caused by Misjudgement Made in Conversion from Initial DC Cook TS to W Std Ts.Submitted License Amend Request.With 991018 Ltr
ML17335A5531999-10-0707 October 1999
LER 99-023-00:on 990907,inadequate TS Surveillance Testing of ESW Pump ESF Response Time Noted.Caused by Inadequate Understanding of Plant Design Basis.Surveillance Tests Will Be Revised & Implemented
ML17326A1291999-09-17017 September 1999
LER 99-022-00:on 990609,electrical Bus Degraded Voltage Setpoints Too Low for Safety Related Loads,Was Discovered. Caused by Lack of Understanding of Design of Plant.No Immediate Corrective Actions Necessary
ML17326A1121999-08-27027 August 1999
LER 99-021-00:on 990728,determined That GL 96-01 Test Requirements Were Not Met in Surveillance Tests.Caused by Failure to Understand Full Extent of GL Requirements. Surveillance Procedures Will Be Revised or Developed
ML17326A1011999-08-26026 August 1999
LER 99-020-00:on 990727,EDGs Were Declared Inoperable.Caused by Inadequate Protection of Air Intake,Exhaust & Room Ventilation Structures from Tornado Missile Hazards. Implemented Compensatory Measures in Form of ACs
ML17326A0911999-08-16016 August 1999
LER 99-019-00:on 990716,noted Victoreen Containment Hrrms Not Environmentally Qualified to Withstand post-LOCA Conditions.Caused by Inadequate Design Control.Reviewing Options to Support Hrrms Operability in Modes 1-4
ML17326A0771999-08-0404 August 1999
LER 98-029-01:on 980422,noted That Fuel Handling Area Ventilation Sys Was Inoperable.Caused by Original Design Deficiency.Radiological Analysis for Spent Fuel Handling Accidents in Auxiliary Bldg Will Be Redone by 990830
ML17326A0741999-07-29029 July 1999
LER 99-018-00:on 990629,determined That Valve Yokes May Yield Under Combined Stress of Seismic Event & Static,Valve Closed,Stem Thrust.Caused by Inadequate Design of Associated Movs.Operability Determinations Were Performed for Valves
ML17326A0661999-07-26026 July 1999
LER 99-017-00:on 990625,noted That Improperly Installed Fuel Oil Return Relief Valve Rendered EDG Inoperable.Caused by Personnel Error.Fuel Oil Return Valve Was Replaced with Valve in Correct Orientation.With 990722 Ltr
ML17326A0651999-07-22022 July 1999
LER 98-014-03:on 980310,noted That Response to high-high Containment Pressure Procedure Was Not Consistent with Analysis of Record.Caused by Inadequate Interface with W. FRZ-1 Will Be Revised to Be Consistent with New Analysis
ML17326A0491999-07-13013 July 1999
LER 99-016-00:on 990615,TS Requirements for Source Range Neutron Flux Monitors Not Met.Caused by Failure to Understand Design Basis of Plant.Procedures Revised.With 990713 Ltr
ML17326A0331999-07-0101 July 1999
LER 99-004-01:on 971030,failure to Perform TS Surveillance Analyses of Reactor Coolant Chemistry with Fuel Removed Was Noted.Caused by Ineffective Mgt of Tss.Chemistry Personnel Have Been Instructed on Requirement to Follow TS as Written
ML17326A0151999-06-18018 June 1999
LER 99-014-00:on 990521,determined That Boron Injection Tank Manway Bolts Were Not Included in ISI Program,Creating Missed Exam for Previous ISI Interval.Caused by Programmatic Weakness.Isi Program & Associated ISI Database Modified
ML17325B6311999-06-0101 June 1999
LER 99-S03-00:on 990430,vital Area Barrier Degradation Was Noted.Caused by Inadequate Insp & Maint of Vital Area Barrier.Repairs & Mods Were Made to Barriers to Eliminate Degraded & Nonconforming Conditions
ML17325B6421999-06-0101 June 1999
LER 99-013-00:on 990327,safety Injection & Centrifugal Charging Throttle Valve Cavitation During LOCA Could Have Led to ECCS Pump Failure.Caused by Inadequate Original Design Application of Si.Throttle Valves Will Be Developed
ML17325B6351999-05-28028 May 1999
LER 99-S02-00:on 990428,vulnerability in Safeguard Sys That Could Allow Unauthorized Access to Protected Area Was Noted. Caused by Inadequate Original Plant Design.Mods Were Made to Wall Opening to Eliminate Nonconforming Conditions
ML17265A8231999-05-24024 May 1999
LER 98-037-01:on 990422,determined That Ice Condenser Bypass Leakage Exceeds Design Basis Limit.Caused by Pressure Seal Required by Revised W Design Not Incorporated Into Aep Design.Numerous Matl Condition Walkdowns & Assessments Made
ML17325B6001999-05-20020 May 1999
LER 99-012-00:on 990420,concluded That Auxiliary Bldg ESF Ventilation Sys Not Capable of Maintaining ESF Room Temps post-accident.Caused by Inadequate Control of Sys Design Inputs.Comprehensive Action Plan Being Developed
ML17325B5861999-05-10010 May 1999
LER 99-002-00:on 990415,discovered That TS 4.0.5 Requirements Were Not Met Due to Improperly Performed Test. Caused by Incorrect Interpretation of ASME Code.App J Testing Will Be Completed & Procedures Will Be Revised
ML17325B5811999-05-0404 May 1999
LER 99-011-00:on 990407,air Sys for EDG Will Not Support Long Operability.Caused by Original Design Error.Temporary Mod to Supply Makeup Air Capability in Modes 5 & 6 Was Prepared
ML17325B5771999-05-0303 May 1999
LER 99-010-00:on 990401,RCS Leak Detection Sys Sensitivity Not in Accordance with Design Requirements Occurred.Caused by Inadequate Original Design of Containment Sump Level. Evaluation Will Be Performed to Clearly Define Design
ML17325B5581999-04-16016 April 1999
LER 99-006-00:on 990115,personnel Identified Discrepancy Between TS 3.9.7 Impact Energy Limit & Procedure 12 Ohp 4030.STP.046.Caused by Lack of Design Basis Control.Placed Procedure 12 Ohp 4030.STP.046 on Administrative Hold
ML17325B5471999-04-12012 April 1999
LER 99-009-00:on 990304,as-found RHR Safety Relief Valve Lift Setpoint Greater than TS Limit Occurred.Cause Investigation for Condition Has Not Been Completed.Update to LER Will Be Submitted,Upon Completion of Investigation
ML17325B5321999-04-0707 April 1999
LER 99-S01-00:on 990308,discovered That Lock for Vital Gate Leading to Plant 4KV Switchgear Area Was Nonconforming & Vulnerable to Unauthorized Access.Caused by Inadequate Gate Design & Inadequate Procedures.Mods Are Being Made to Gate
ML17325B5161999-04-0101 April 1999
LER 99-007-00:on 981020,calculations Showed That Divider Barrier Between Upper & Lower Containment Vols Were Overstressed.Engineers Are Currently Working on Analyses of Loads & Stress on Enclosures
ML17325B5221999-03-29029 March 1999
LER 99-001-00:on 960610,degraded Component Cooling Water Flow to Containment Main Steam Line Penetrations,Identified on 990226.Caused by Inadequate Understanding of Design Basis.Additional Investigations Ongoing
ML17325B4801999-03-18018 March 1999
LER 99-004-00:on 971030,failure to Perform TS Surveillance Analyses of Rc Chemistry with Fuel Removed Was Noted.Cause of Event Is Under Investigation.Corrected Written Job Order Activities Used to Control SD Chemistry Sampling
ML17325B4741999-03-18018 March 1999
LER 99-005-00:on 940512,determined That Rt Breaker Manual Actuations During Rod Drop Testing Were Not Previously Reported.Caused by Lack of Training.Addl Corrective Actions,Including Preventative Actions May Be Developed
ML17325B4571999-02-24024 February 1999
LER 99-003-00:on 990107,CR Pressurization Sys Surveillance Test Did Not Test Sys in Normal Operating Condition.Caused by Failure to Recognize Door 12DR-AUX415 as Part of CR Pressure Boundary.Performed Walkdown of Other Doors
ML17335A5171999-02-11011 February 1999
LER 99-002-00:on 990112,determined That RCS Pressurizer PORVs Had Not Been Tested,Per Ts.Caused by Inadequate Scheduling Controls Allowing Personnel Error.Surveillance Procedure Was Completed & Updated LER Will Be Submitted
ML17335A5141999-02-10010 February 1999
LER 99-001-00:on 990106,noted That GE Hfa Relays Installed in EDGs May Not Meet Seismic Qualification.Caused by Operating Experience Info Incorrectly Dispositioned in 1985. Updated LER Will Be Submitted by 990405
ML17335A5011999-02-0101 February 1999
LER 98-060-00:on 981231,identified That Rt Sys Response Time Testing Did Not Comply with TS Definition.Caused by Inadequate Procedures.Corrective Actions Will Be Developed & Update to LER Will Be Submitted by 990415.With 990201 Ltr
ML17335A4951999-01-29029 January 1999
LER 98-059-00:on 981230,interim LER -single Failure in Containment Spray Sys Could Result in Containment Spray Ph Outside Design Occurred.Investigation Into Condition Continuing.Update Will Be Submitted by 990514 Ltr
ML17335A4961999-01-27027 January 1999
LER 98-057-00:on 981228,discovered That AFW Valves Were Not Tested IAW Inservice Testing Program.Caused by Failure to Recognize Design Bases Features Re Afws by Personnel. Updated LER Will Be Submittted by 990415.With 990127 Ltr
ML17335A4921999-01-19019 January 1999
LER 98-052-01:on 981128,no Analysis for NSR Sc Manual Loader for Tdafwp Could Be Found in Original Design.Cause Due to All Failure Modes Not Considered When Compressed Air Sys Originally Designed.Performed Review of Components
ML17335A4721999-01-0606 January 1999
LER 98-055-00:on 981207,potential for Condition Outside of Design Bases for Rod Control Sys Was Noted.Caused by Calibration Error Coupled with Single Rod Failure.Condition Rept Investigation Is Ongoing
ML17335A4691999-01-0606 January 1999
LER 98-056-00:on 981211,hot Leg Nozzle Gaps Resulted in Plant Being in Unanalyzed Condition.Analyses Are Being Performed by W to Resolve Problem.Updated LER Will Be Submitted by 990211.With 990106 Ltr
ML17335A4661999-01-0505 January 1999
LER 98-049-00:on 981020,emergency Boron Injection Flow Path Was Inoperable.Caused by Original Design Deficiency. Engineering Evaluation of Event Is Continuing
ML17335A4631999-01-0404 January 1999
LER 98-054-00:on 981202,discovered That at Least One MSSV Had Not Been Reset as Required by Ts.Engineering Is Continuing Review of Extent of Condition for Event.Updated LER Will Be Submitted by 990129.With 990104 Ltr
ML17335A4481998-12-30030 December 1998
LER 98-053-00:on 981130,discovered Use of Inoperable Substitute Subcooling Margin Monitor.Caused by Condition Existing Since Installation of Plant Process Computer in 1992.Updated LER Will Be Submitted.With 981230 Ltr
ML17335A4581998-12-28028 December 1998
LER 98-052-00:on 981128,turbine Driven AFW Pump Speed Controller Failure Mode Occurred.Caused Because Not All Failure Modes Were Considered When Compressed Air Sys Was Originally Designed.Verified Current Design Change Process
ML17335A4281998-12-22022 December 1998
LER 98-051-00:on 981122,reactor Trip Signal from Manual Safety Injection Not Verified as Required by TS Surveillance,Was Discovered.Maintenance Currently Evaluating Significance & Cause of Event
ML17335A4111998-12-17017 December 1998
LER 98-047-00:on 981117,potential for Increase Leakage from Reactor Coolant Pump Seals Was Identified.Util Is Working with W to Resolve Issue.Current Expectations Are to Submit Update to LER by 990215.With 981217 Ltr
ML17335A4141998-12-16016 December 1998
LER 98-058-00:on 981216,postulated High Line Break Could Result in Condition Outside Design Bases for AF Occurred. Caused by Deficiencies Associated with Administration of HELB Program.Analysis of AF Will Be Completed by 990122
ML17335A4181998-12-16016 December 1998
LER 98-050-00:on 980814,ancillary Equipment Installed in Ice Condenser Was Not Designed to Withstand Design Basis Accident/Earthquake Loads.Caused by Lack of Established Design Criteria.Developed Design Criteria
ML17335A3871998-12-11011 December 1998
LER 98-031-01:on 980610,potential Common Mode Failure of RHR Pumps Were Noted.Caused by Inaccurate Values.Accurate Miniflow Numbers Have Been Determined by Flow Testing
ML17335A3821998-12-0808 December 1998
LER 98-039-01 Re EOP Step Conflicts with Small Break LOCA Analysis.Ler 98-039-00 Has Been Canceled.With 981208 Ltr
ML17335A3781998-12-0707 December 1998
LER 98-007-00:on 981106,high Energy Line Break Effects in Auxiliary FW Sys Was Noted.Cause of Event Is Under Investigation & Will Be Completed by 990220.Updated LER Will Be Submitted by 990310.With 981207 Ltr
ML17335A3771998-12-0303 December 1998
LER 98-046-00:on 981103,determined That Afs Was Unable to Meet Design Flow Requirements During Special Test.Caused by Failure to Consider All Aspects of Sys Operation in Design of Suction Basket Strainers.Sys Will Be Redesigned
ML17335A3741998-12-0202 December 1998
LER 97-011-02:on 970822,operation Was Noted Outside Design Bases for ECCS & CSP for Switchover to Recirculation Sump Suction.Caused by Ineffective Change Mgt.Revised Procedure for Switchover 01(02) Ohp 4023.ES-1.3
1999-09-17
[Table view]
Category:TEXT-SAFETY REPORT
MONTHYEARML17335A5641999-10-18018 October 1999
LER 99-024-00:on 990708,literal TS Requirements Were Not Met by Accumlator Valve Surveillance.Caused by Misjudgement Made in Conversion from Initial DC Cook TS to W Std Ts.Submitted License Amend Request.With 991018 Ltr
ML17335A5531999-10-0707 October 1999
LER 99-023-00:on 990907,inadequate TS Surveillance Testing of ESW Pump ESF Response Time Noted.Caused by Inadequate Understanding of Plant Design Basis.Surveillance Tests Will Be Revised & Implemented
ML17335A5631999-09-30030 September 1999
Monthly Operating Rept for Sept 1999 for DC Cook Nuclear Plant,Unit 1.With 991012 Ltr
ML17335A5621999-09-30030 September 1999
Monthly Operating Rept for Sept 1999 for DC Cook Nuclear Plant,Unit 2.With 991012 Ltr
ML17335A5481999-09-30030 September 1999
Non-proprietary DC Cook Nuclear Plant Units 1 & 2 Mods to Containment Sys W SE (Secl 99-076,Rev 3).
ML17335A5451999-09-28028 September 1999
Rev 1 to Containment Sump Level Design Condition & Failure Effects Analysis for Potential Draindown Scenarios.
ML17326A1291999-09-17017 September 1999
LER 99-022-00:on 990609,electrical Bus Degraded Voltage Setpoints Too Low for Safety Related Loads,Was Discovered. Caused by Lack of Understanding of Design of Plant.No Immediate Corrective Actions Necessary
ML17326A1481999-09-17017 September 1999
Independent Review of Control Rod Insertion Following Cold Leg Lbloca,Dc Cook,Units 1 & 2.
ML17326A1211999-08-31031 August 1999
Monthly Operating Rept for Aug 1999 for Cook Nuclear Plant, Unit 2.With 990915 Ltr
ML17326A1201999-08-31031 August 1999
Monthly Operating Rept for Aug 1999 for Cook Nuclear Plant, Unit 1.With 990915 Ltr
ML17326A1121999-08-27027 August 1999
LER 99-021-00:on 990728,determined That GL 96-01 Test Requirements Were Not Met in Surveillance Tests.Caused by Failure to Understand Full Extent of GL Requirements. Surveillance Procedures Will Be Revised or Developed
ML17326A1011999-08-26026 August 1999
LER 99-020-00:on 990727,EDGs Were Declared Inoperable.Caused by Inadequate Protection of Air Intake,Exhaust & Room Ventilation Structures from Tornado Missile Hazards. Implemented Compensatory Measures in Form of ACs
ML17326A0911999-08-16016 August 1999
LER 99-019-00:on 990716,noted Victoreen Containment Hrrms Not Environmentally Qualified to Withstand post-LOCA Conditions.Caused by Inadequate Design Control.Reviewing Options to Support Hrrms Operability in Modes 1-4
ML17326A0771999-08-0404 August 1999
LER 98-029-01:on 980422,noted That Fuel Handling Area Ventilation Sys Was Inoperable.Caused by Original Design Deficiency.Radiological Analysis for Spent Fuel Handling Accidents in Auxiliary Bldg Will Be Redone by 990830
ML17335A5461999-08-0202 August 1999
Rev 0 to Evaluation of Cook Recirculation Sump Level for Reduced Pump Flow Rates.
ML17326A0871999-07-31031 July 1999
Monthly Operating Rept for July 1999 for DC Cook Nuclear Plant,Unit 1.With 990812 Ltr
ML17326A0861999-07-31031 July 1999
Monthly Operating Rept for July 1999 for DC Cook Nuclear Plant,Units 2.With 990812 Ltr
ML17326A0741999-07-29029 July 1999
LER 99-018-00:on 990629,determined That Valve Yokes May Yield Under Combined Stress of Seismic Event & Static,Valve Closed,Stem Thrust.Caused by Inadequate Design of Associated Movs.Operability Determinations Were Performed for Valves
ML17326A0661999-07-26026 July 1999
LER 99-017-00:on 990625,noted That Improperly Installed Fuel Oil Return Relief Valve Rendered EDG Inoperable.Caused by Personnel Error.Fuel Oil Return Valve Was Replaced with Valve in Correct Orientation.With 990722 Ltr
ML17326A0651999-07-22022 July 1999
LER 98-014-03:on 980310,noted That Response to high-high Containment Pressure Procedure Was Not Consistent with Analysis of Record.Caused by Inadequate Interface with W. FRZ-1 Will Be Revised to Be Consistent with New Analysis
ML17326A0491999-07-13013 July 1999
LER 99-016-00:on 990615,TS Requirements for Source Range Neutron Flux Monitors Not Met.Caused by Failure to Understand Design Basis of Plant.Procedures Revised.With 990713 Ltr
ML17326A0331999-07-0101 July 1999
LER 99-004-01:on 971030,failure to Perform TS Surveillance Analyses of Reactor Coolant Chemistry with Fuel Removed Was Noted.Caused by Ineffective Mgt of Tss.Chemistry Personnel Have Been Instructed on Requirement to Follow TS as Written
ML17326A0511999-06-30030 June 1999
Monthly Operating Rept for June 1999 for DC Cook Nuclear Plant,Unit 2.With 990709 Ltr
ML17326A0501999-06-30030 June 1999
Monthly Operating Rept for June 1999 for DC Cook Nuclear Plant,Unit 1.With 990709 Ltr
ML17326A0151999-06-18018 June 1999
LER 99-014-00:on 990521,determined That Boron Injection Tank Manway Bolts Were Not Included in ISI Program,Creating Missed Exam for Previous ISI Interval.Caused by Programmatic Weakness.Isi Program & Associated ISI Database Modified
ML17325B6421999-06-0101 June 1999
LER 99-013-00:on 990327,safety Injection & Centrifugal Charging Throttle Valve Cavitation During LOCA Could Have Led to ECCS Pump Failure.Caused by Inadequate Original Design Application of Si.Throttle Valves Will Be Developed
ML17325B6311999-06-0101 June 1999
LER 99-S03-00:on 990430,vital Area Barrier Degradation Was Noted.Caused by Inadequate Insp & Maint of Vital Area Barrier.Repairs & Mods Were Made to Barriers to Eliminate Degraded & Nonconforming Conditions
ML17326A0061999-05-31031 May 1999
Monthly Operating Rept for May 1999 for Dcp.With 990609 Ltr
ML17326A0071999-05-31031 May 1999
Monthly Operating Rept for May 1999 for DC Cook Nuclear Plant,Unit 2.With 990609 Ltr
ML17325B6351999-05-28028 May 1999
LER 99-S02-00:on 990428,vulnerability in Safeguard Sys That Could Allow Unauthorized Access to Protected Area Was Noted. Caused by Inadequate Original Plant Design.Mods Were Made to Wall Opening to Eliminate Nonconforming Conditions
ML17265A8231999-05-24024 May 1999
LER 98-037-01:on 990422,determined That Ice Condenser Bypass Leakage Exceeds Design Basis Limit.Caused by Pressure Seal Required by Revised W Design Not Incorporated Into Aep Design.Numerous Matl Condition Walkdowns & Assessments Made
ML17325B6001999-05-20020 May 1999
LER 99-012-00:on 990420,concluded That Auxiliary Bldg ESF Ventilation Sys Not Capable of Maintaining ESF Room Temps post-accident.Caused by Inadequate Control of Sys Design Inputs.Comprehensive Action Plan Being Developed
ML17325B5861999-05-10010 May 1999
LER 99-002-00:on 990415,discovered That TS 4.0.5 Requirements Were Not Met Due to Improperly Performed Test. Caused by Incorrect Interpretation of ASME Code.App J Testing Will Be Completed & Procedures Will Be Revised
ML17325B5811999-05-0404 May 1999
LER 99-011-00:on 990407,air Sys for EDG Will Not Support Long Operability.Caused by Original Design Error.Temporary Mod to Supply Makeup Air Capability in Modes 5 & 6 Was Prepared
ML17325B5771999-05-0303 May 1999
LER 99-010-00:on 990401,RCS Leak Detection Sys Sensitivity Not in Accordance with Design Requirements Occurred.Caused by Inadequate Original Design of Containment Sump Level. Evaluation Will Be Performed to Clearly Define Design
ML17335A5301999-04-30030 April 1999
Monthly Operating Rept for Apr 1999 for DC Cook Nuclear Plant,Unit 1.With 990508 Ltr
ML17335A5291999-04-30030 April 1999
Monthly Operating Rept for Apr 1999 for DC Cook Nuclear Plant,Unit 2.With 990508 Ltr
ML17325B5581999-04-16016 April 1999
LER 99-006-00:on 990115,personnel Identified Discrepancy Between TS 3.9.7 Impact Energy Limit & Procedure 12 Ohp 4030.STP.046.Caused by Lack of Design Basis Control.Placed Procedure 12 Ohp 4030.STP.046 on Administrative Hold
ML17325B5471999-04-12012 April 1999
LER 99-009-00:on 990304,as-found RHR Safety Relief Valve Lift Setpoint Greater than TS Limit Occurred.Cause Investigation for Condition Has Not Been Completed.Update to LER Will Be Submitted,Upon Completion of Investigation
ML17325B5321999-04-0707 April 1999
LER 99-S01-00:on 990308,discovered That Lock for Vital Gate Leading to Plant 4KV Switchgear Area Was Nonconforming & Vulnerable to Unauthorized Access.Caused by Inadequate Gate Design & Inadequate Procedures.Mods Are Being Made to Gate
ML17325B5161999-04-0101 April 1999
LER 99-007-00:on 981020,calculations Showed That Divider Barrier Between Upper & Lower Containment Vols Were Overstressed.Engineers Are Currently Working on Analyses of Loads & Stress on Enclosures
ML17325B5491999-03-31031 March 1999
Monthly Operating Rept for Mar 1999 for DC Cook Nuclear Plant Unit 2.With 990408 Ltr
ML17325B5441999-03-31031 March 1999
Monthly Operating Rept for Mar 1999 for DC Cook Nuclear Plant,Unit 1.With 990408 Ltr
ML17325B5221999-03-29029 March 1999
LER 99-001-00:on 960610,degraded Component Cooling Water Flow to Containment Main Steam Line Penetrations,Identified on 990226.Caused by Inadequate Understanding of Design Basis.Additional Investigations Ongoing
ML17325B4801999-03-18018 March 1999
LER 99-004-00:on 971030,failure to Perform TS Surveillance Analyses of Rc Chemistry with Fuel Removed Was Noted.Cause of Event Is Under Investigation.Corrected Written Job Order Activities Used to Control SD Chemistry Sampling
ML17325B4741999-03-18018 March 1999
LER 99-005-00:on 940512,determined That Rt Breaker Manual Actuations During Rod Drop Testing Were Not Previously Reported.Caused by Lack of Training.Addl Corrective Actions,Including Preventative Actions May Be Developed
ML17325B5671999-03-0202 March 1999
Summary of Unit 1 Steam Generator Layup Chemistry from 980101 to 990218.
ML17325B4631999-02-28028 February 1999
Monthly Operating Rept for Feb 1999 for DC Cook Nuclear Power Station,Unit 2.With 990308 Ltr
ML17325B4621999-02-28028 February 1999
Monthly Operating Rept for Feb 1999 for DC Cook Nuclear Plant,Unit 1.With 990308 Ltr
ML17325B4571999-02-24024 February 1999
LER 99-003-00:on 990107,CR Pressurization Sys Surveillance Test Did Not Test Sys in Normal Operating Condition.Caused by Failure to Recognize Door 12DR-AUX415 as Part of CR Pressure Boundary.Performed Walkdown of Other Doors
1999-09-30
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RC FnRM 366 U S NUCLEAR REGULAT OMMISSION APPROVED MB No. 3150.0104 EXPIRES 06I30I2001
-1998) This document does not conte afeguards Information Estimated burden per response to comply with this mandatory hformation collection request: 50 hrs. Reported lessons learned are incorporated hto the LICENSEE EVENT REPORT (LER) licensing process and fed back to btdustry. Forward commenls regarding burden estimate to the Records Management Branch (TA F33), U.S. Nuclear Regulatory Commission, Washhgton. DC 205550001, and to the Paperwork Reduction (See reverse for required number of ProJect (31504104). Office of Management and Budget,'Washington, DC 20503.
If an Information co lection does not display a cunentfy valid OMB control number.
digits/characters for each block) the NRC may not conduct or sponsor. and a person is not required to respond to.
the information collection.
FACILITYNAME (1) DOCKET NUMBER (2) PAGE (3)
Cook Nuclear Plant Unit 1 05000-315 1 OF 3 TrrLB (4)
Vulnerability in the Locking Mechanism of Four Vital Area Gates EVENT DATE (5) LER NUMBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (8)
MONTH DAY YEAR SEQUENTIAL REVISION MONTH DAY YEAR FACILITYNAME DOCKET NUMBER NUMBER NUMBER Cook Nuclear Plant Unit 2 05000-316 1999 FAG ILrfYNAME DOCKET NUMBER OPERATING THIS REPORT Is SUBMITTED PURSUANT To THE REQU IREMENTS OF 10 CFR Et (Check one or more) (11)
MODE (9) 20.2201(b) 20.2203(a)(2)(v) 50.73(a) (2)(i) 50.73(a)(2)(viii)
POWER 0 o 20.2203(a)(1) 20.2203(al(3) (i) 50.73(a)(2)(ii) 50.73(a) (2)(x)
LEVEL (10) 20.2203(a)(2)(i) 20.2203(a)(3) (ii) 50.73(a) (2l(iii) 73.71 20.2203(a) (2)(ii) 20.2203(a) (4) 50.73(a)(2)(iv) X OTHER 20.2203(a)(2)(iii) 50.36(c)(1) 50.73(a) (2) (v) Specify in Abstract below or in NRC Form 366A 20.2203(a)(2)(iv) 50.36(c) (2) 50.73(a) (2) (vii)
LICENSEE CONTACT FOR THIS LER (12)
NAME TELEPHONE NUMBER Ilnciude Ares Code)
Lyle R. Berry, Regulatory Compliance Engineer (616) 465-5901 X2637 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DES CRIBED IN THIS REPORT (13)
CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE TO EPIX TO EPIX SUPPLEMENTAL REPORT EXPECTED 14 EXPECTED MONTH DAY YEAR YES X No (If yes, complete EXPECTED SUBMISSION DATE).
ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (16)
On March 8, 1999, at approximately 1400 hours0.0162 days <br />0.389 hours <br />0.00231 weeks <br />5.327e-4 months <br />, with both units in Mode 5, the lock for a vital area gate leading to the Unit 1 4KV Switchgear area was discovered by the security captain and a locksmith to be nonconforming and vulnerable to unauthorized access. At 1546 hours0.0179 days <br />0.429 hours <br />0.00256 weeks <br />5.88253e-4 months <br />, it was determined that this constituted a failure, degradation or discovered vulnerability in a safeguard system that could allow unauthorized or undetected access to a protected area, material access area, controlled access area, vital area or transport for which compensatory measures have not been employed and was reportable as a safeguards event pursuant to the requirements of 10CFR73, Appendix G, paragraph l(c) and 10CFR73.71(b)(1). An Emergency Notification System (ENS) report was made to NRC at 1645 hours0.019 days <br />0.457 hours <br />0.00272 weeks <br />6.259225e-4 months <br />. The analogous vital area gate for the Unit 2 4 KV Switchgear was inspected and determined to be operable. Three additional gates were discovered to be nonconforming during the extent of condition investigation and ENS notification updates were made.
The apparent causes for this event were inadequate gate design and inadequate procedures. Upon identification of the nonconforming gates, compensatory measures were promptly implemented. Gate repairs/modifications are being made to eliminate nonconforming conditions. Compensatory measures will remain in place until the gates are returned to operable.
Procedures for testing and maintenance of security gates will be revised to prevent recurrence.
Follow-up investigations confirmed that the vital areas secured by the four gates were not compromised. Therefore, there were no implications to the health and safety of the public as a result of this event.
'I)904130267 9's) 0407 PDR ADQCK 050003i5(sr)p
C FORM 366A U.S. NUCLEAR RE TORY COMMISSION
.1999) This document does not contain Sefeguards information LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION FACILITY NAME (1) DOCKET I2) LER NUMBER I6) PAGE I3)
Cook Nuclear Plant Unit 1 05000-315 YEAR SEQUENTIAL NUMBER REVISION 2 OF 3 NUMBER 1999 S001 00 TEXT ilfmore spaceis required, use additional copies of NRC Form 366A j I17)
Conditions Prior To Event Unit 1 Mode 5 at 0% power Unit 2 Mode 5 at 0% power Descri tion Of The Event On March 8, 1999, at approximately 1400 hours0.0162 days <br />0.389 hours <br />0.00231 weeks <br />5.327e-4 months <br />, with both units in Mode 5, the lock for a vital area gate leading to the Unit 1 4KV Switchgear area was discovered, by the security captain and a locksmith, to be nonconforming and vulnerable to unauthorized access. At 1546 it was determined that this constituted a failure, degradation or discovered vulnerability in a safeguard system that could allow unauthorized or undetected access to a protected area, material access area, controlled access area, vital area or transport for which compensatory measures have not been employed. An Emergency Notification System (ENS) report was made to NRC at 1645 hours0.019 days <br />0.457 hours <br />0.00272 weeks <br />6.259225e-4 months <br />. The analogous vital area gate for the Unit 2 4 KV Switchgear Unit 2 was inspected and determined to be operable.
Three additional gates were discovered to be nonconforming during the extent of condition investigation of other safeguard gates in the plant. During this investigation, it was identified that the entry gate into Unit 1 Upper Containment could not be inspected, due to a hose in the gate opening. However, this gate has had compensatory measures in place since May 1998, in support of plant activities which require it to be open. The vital area gates to Unit 2 West Motor Driven Auxiliary Feedwater Pump Room Access and Unit 2 Essential Service Water (ESW) Pump Room Access were discovered to be nonconforming at approximately 1637 and 1706 hours0.0197 days <br />0.474 hours <br />0.00282 weeks <br />6.49133e-4 months <br />, respectively, on March 8, 1999. An ENS update report was made to NRC at 1838 hours0.0213 days <br />0.511 hours <br />0.00304 weeks <br />6.99359e-4 months <br />.
The gate to Unit 2 Access to the Spent Fuel Pit Area from the Auxiliary Cranebay was discovered to be nonconforming at approximately 0643 hours0.00744 days <br />0.179 hours <br />0.00106 weeks <br />2.446615e-4 months <br /> on March 9, 1999. A second ENS update report was made to NRC at 1139 hours0.0132 days <br />0.316 hours <br />0.00188 weeks <br />4.333895e-4 months <br /> on March 9, 1999.
Compensatory measures were established upon Identification of each of the four gate vulnerabilities. Review of alarm records did not identify uninvestigated alarms for these gates.
Cause Of The Event The apparent causes for this event were inadequate gate design and inadequate procedures.
Information. Notice 88-41, "Physical Protection Weaknesses Identified Through Regulatory Effectiveness Reviews" described deficiencies in gate design which could allow compromise. Plant design reviews and gate modifications performed in response to IN 8841 were not adequate.
Test procedures were inadequate because they did not include requirements or methods to verify gate integrity by prescribing nondestructive attempts to subvert security systems. Current test procedures require security personnel to test the function of alarm systems associated with each gate, but do not include steps which could identify other gate vulnerabilities.
Maintenance procedures did not adequately identify potential degradation of vital area accesses and associated vulnerabilities. Security procedures that apply to the preventive maintenance of these gates did not address discovery of external wear that could provide the opportunity for compromise.
NRC FORM 366A (6-1999)
IIRC FORM 366A U.S. NUCLEAR REGULATORY COMMISSION 16.i 998) This document does not contein Sereguerds Informetion LICENSEE EVENT REPORT (LER)
TEXT CONTINUATION FACILITY NAME (1) DOCKET I2) LER NUMBER I6) PAGE I3)
Cook Nuclear Plant Unit 1 05000-315 YEAR SEQUENTIAL NUMBER REvlsloN 3 'OF 3 NUMBER 1999 S001 00 TEXT (If more spaceis required, use additional copies of NRC Form 366AJ {17)
Current preventive maintenance procedures discus's the possibility of the malfunction of mechanical components, but do not specifically address vulnerability to tampering.
Anal sis Of The Event Commencing at approximately 1400 hours0.0162 days <br />0.389 hours <br />0.00231 weeks <br />5.327e-4 months <br /> March 8, 1999 and ending at approximately 0630 hours0.00729 days <br />0.175 hours <br />0.00104 weeks <br />2.39715e-4 months <br /> March 9, 1999, with Unit 1 and Unit 2 both in Mode 5, four vital area gates were identified which were nonconforming and vulnerable to possible compromise. The identified conditions constituted a failure, degradation or discovered vulnerability in a safeguard system that could allow unauthorized or undetected access to a protected area, material access area, controlled access area, vital area or transport for which compensatory measures have not been employed. This event was reportable as a safeguards event pursuant to the requirements of 10CFR73,'Appendix G, paragraph l(c) and 10CFR73.71(b)(1) (1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> ENS report).
ENS reports were made to the NRC Operations Center at 1645 hours0.019 days <br />0.457 hours <br />0.00272 weeks <br />6.259225e-4 months <br /> and 1838 hours0.0213 days <br />0.511 hours <br />0.00304 weeks <br />6.99359e-4 months <br /> on March 8, 1999 and at 1139 hours0.0132 days <br />0.316 hours <br />0.00188 weeks <br />4.333895e-4 months <br /> on March 9, 1999. This report is being made pursuant to the requirements of 10CFR73, Appendix G, paragraph l(c) and 10CFR73.71(d) (30 day report).
Follow-up investigations indicate that the vital areas secured by the four gates were not compromised. Therefore, there were no implications to the health and safety of the public as a result of this event.
C CORRECTIVE ACTIONS Upon identification of the nonconforming gates, compensatory measures were promptly implemented. Vital area access gates were inspected to investigate the extent of condition and determine whether similar vulnerabilities existed. Gate repairs/modifications are being made to eliminate identified nonconforming conditions. Compensatory measures will remain in place until the gates are returned to operable.
A new Operating Experience (OE) Program is being developed which will reside under the Regulatory Affairs Department.
The ingredients of the program will include benchmarking from other utilities that have proven, effective OE programs and is intended to better utilize industry operating experience, including information notices.
Security vital area access test procedures will be revised to incorporate appropriate steps for non-destructive testing of security systems such as gates. Security preventive maintenance procedures will be revised to incorporate steps intended to identify and correct degradation of barriers which could lead to vulnerability to tampering. Follow-up investigations were performed to verify that vital areas secured by the four nonconforming gates were not compromised.
SIMILAR EVENTS 316/97-S001-00, "Control of Vital Area Lost Due to Personnel Error," November 10, 1997.
NRC FORM 366A I6 1998)