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| issue date = 10/17/1994
| issue date = 10/17/1994
| title = LER 94-010-00:on 940916,volt Bus 12B Inadvertenly Tripped. Caused by Defective Procedure.Normal Power Supplies Restored & B Emergency Diesel Generator Stopped & Aligned for Auto standby.W/941017 Ltr
| title = LER 94-010-00:on 940916,volt Bus 12B Inadvertenly Tripped. Caused by Defective Procedure.Normal Power Supplies Restored & B Emergency Diesel Generator Stopped & Aligned for Auto standby.W/941017 Ltr
| author name = MECREDY R C, ST MARTIN J T
| author name = Mecredy R, St Martin J
| author affiliation = ROCHESTER GAS & ELECTRIC CORP.
| author affiliation = ROCHESTER GAS & ELECTRIC CORP.
| addressee name = JOHNSON A R
| addressee name = Johnson A
| addressee affiliation = NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM), NRC OFFICE OF NUCLEAR REACTOR REGULATION (NRR)
| addressee affiliation = NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM), NRC OFFICE OF NUCLEAR REACTOR REGULATION (NRR)
| docket = 05000244
| docket = 05000244
Line 16: Line 16:


=Text=
=Text=
{{#Wiki_filter:F'RIORIY'Y IACCELER.ATED RIDSPROC!%SIXREGULATORY INFORMATION DISTRIBUTION SYSTEM(RIDS)ACCESSION NBR:9410270363 DOC.DATE:
{{#Wiki_filter:F'RIORIY'Y IACCELER.ATED RIDS PROC! %SIX REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)
94/10/17NOTARIZED:
ACCESSION NBR:9410270363                 DOC.DATE: 94/10/17        NOTARIZED: NO          DOCKET  N FACIL:50-244 Robert Emmet Ginna Nuclear Plant, Unit 1, Rochester                         G 05000244 AUTH. NAME              AUTHOR AFFILIATION ST MARTIN,J.T.         Rochester Gas & Electric Corp.
NOFACIL:50-244 RobertEmmetGinnaNuclearPlant,Unit1,Rochester GAUTH.NAMEAUTHORAFFILIATION STMARTIN,J.T.
MECREDY,R.C.           Rochester Gas & Electric Corp.
Rochester Gas&ElectricCorp.MECREDY,R.C.
RECIP.NAME             RECIPIENT AFFILIATION
Rochester Gas&ElectricCorp.RECIP.NAME RECIPIENT AFFILIATION DOCKETN05000244


==SUBJECT:==
==SUBJECT:==
LER94-010-00:on 940916,volt bus12Binadvertenly tripped.Causedbydefective procedure.
LER    94-010-00:on 940916,volt bus 12B inadvertenly tripped.
Normalpowersupple.es restored&"B"emeregency dieselgenerator stopped&alignedforautostandby.W/941017 ltr.DISTRIBUTION CODE:IE22TCOPIESRECEIVED:LTR ENCLSIZE:TITLE:50.73/50.9 LicenseeEventReport(LER),IncidentRpt,etc.NOTES:License Expdateinaccordance with10CFR2,2.109(9/19/72).
Caused by      defective procedure. Normal power supple.es restored "B" emeregency diesel generator stopped
05000244RECIPIENT IDCODE/NAME PD1-3PDINTERNALAEOD/~GAB/DSQ XHXF~02NRR/DE/EMEB NRR/DRCH/HHFB NRR/DRCH/HOLB NRR/DSSA/SPLB NRR/PMAS/IRCB-E RGN1FILE01EXTERNAL:
            &                                                            & aligned for auto standby.W/941017           ltr.
EG&GBRYCE,J.H NOACMURPHY1GANRCPDRCOPIESLTTRENCL112211l.11111111111221111RECIPIENT IDCODE/NAME JOHNSON,A AEOD/SPD/RRAB NRR/DE/EELB NRR/DORS/OEAB NRR/DRCH/HICB NRR/DRSS/PRPB NRR/DSSA/SRXB RES/DSIR/EIB LSTLOBBYWARDNOACPOORE,W.NUDOCSFULLTXTCOPIESLTTRENCL111111'111221111111111NVOTETOALL"RlDS"RECIPIENTS:
DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR                           ENCL      SIZE:
PLEASEHELPL!STOREDUCEiVASTE!CONTACTTIIE DOCL'iIEiTCOiTROL DESK,ROOXIPI-37(EXT,504-2033)TOELIilliATE VOL'RRAMIEPROilDISTRIBL'TIOi LIS'I'SI'ORDOCL'iIEi'I'S 5'OL'Oi"I'L'I'.I)!
TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.
FULLTEXTCONVERSXON REQUIREDTOTALNUMBEROFCOPIESREQUIRED:
NOTES:License Exp date in accordance with 10CFR2,2.109(9/19/72).                           05000244 RECIPIENT                  COPIES              RECIPIENT          COPIES ID  CODE/NAME                LTTR ENCL        ID    CODE/NAME     LTTR ENCL PD1-3 PD                        1      1      JOHNSON,A                1    1 INTERNAL AEOD/~GAB/DSQ                     2      2      AEOD/SPD/RRAB            1    1 XHXF~02                  1      1      NRR/DE/EELB              1    1' NRR/DE/EMEB                      l. 1      NRR/DORS/OEAB                  1 NRR/DRCH/HHFB                    1      1      NRR/DRCH/HICB            1    1 NRR/DRCH/HOLB                    1      1      NRR/DRSS/PRPB            2    2 NRR/DSSA/SPLB                    1      1      NRR/DSSA/SRXB            1    1 NRR/PMAS/IRCB-E                  1      1      RES/DSIR/EIB             1    1 RGN1      FILE 01              1      1 EXTERNAL: EG&G BRYCE,J.H                    2      2      L ST LOBBY WARD          1    1 NOAC MURPHY 1 G A                1      1      NOAC POORE,W.             1    1 NRC PDR                          1      1      NUDOCS FULL TXT          1    1 N
LTTR26ENCL26
VOTE TO ALL"Rl DS" RECIPIENTS:
'
PLEASE HELP L!S TO REDUCE iVASTE! CONTACTTIIE DOCL'iIEiTCOiTROL DESK, ROOXI PI-37 (EXT, 504-2033 ) TO ELIilliATEVOL'R RAMIE PROil DISTRIBL'TIOiLIS'I'S I'OR DOCL'iIEi'I'S 5'OL'Oi "I'L'I'.I)!
r10ecStAICROCHESTER GASANDELECTRICCORPORATION
FULL TEXT CONVERSXON REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR                    26    ENCL    26
~89EASTAVENUE,ROCHESTER N.Y.f4649-000f ROBERTC.MECREDYVicePresident GinnedNuclearProduction TELEPHOME AAEACQM7165462700October17,1994UPS.NuclearRegulatory Commission DocumentControlDeskAttn:AllenR.JohnsonPWRProjectDirectorate I-3Washington, D.C.20555
 
10ec r
StAIC ROCHESTER GAS AND ELECTRIC CORPORATION            ~ 89 EAST AVENUE, ROCHESTER N.Y. f4649-000f ROBERT C. MECREDY                                                                  TELEPHOME Vice President AAEACQM 716 546 2700 Ginned Nuclear Production October 17, 1994 UPS.       Nuclear Regulatory Commission Document            Control Desk Attn:               Allen R. Johnson PWR Project Directorate I-3 Washington, D.C. 20555


==Subject:==
==Subject:==
LER94-010,Lossof4160VoltBus12B,DuetoDefective Procedure, ResultsinAutomatic Startof"B"Emergency DieselGenerator R.E.GinnaNuclearPowerPlantDocketNo.50-244Inaccordance with10CFR50.73,LicenseeEventReportSystem,item(a)(2)(iv),whichrequiresareportof,"anyeventorcondition thatresultedinamanualor"automatic actuation ofanyengineered safetyfeature(ESF),including thereactorprotection system(RPS)",theattachedLicenseeEventReportLER94-010isherebysubmitted.
LER  94-010, Loss of 4160 Volt Bus 12B, Due to Defective Procedure, Results in Automatic Start of "B" Emergency Diesel Generator R.E. Ginna Nuclear Power Plant Docket No. 50-244 In accordance with 10 CFR 50.73, Licensee Event Report System, item (a) (2) (iv), which requires a report of, "any event or condition that resulted in a manual or"automatic actuation of any engineered safety feature (ESF), including the reactor protection system (RPS)", the attached Licensee Event Report                  LER  94-010    is    hereby submitted.
Thiseventhasinnowayaffectedthepublic'shealthandsafety.Verytrulyyours,RobertC.Mecredyxc:U.S.NuclearRegulatory Commission RegionI475Allendale RoadKingofPrussia,PA19406GinnaUSNRCSeniorResidentInspector 9410270363 941017PDRADOCK05000244SPDR NRCFORH366(5-92)U.S.NUCLEARREGULATORY COHHISSION APPROVEDBYOHBNO.3150~0104EXPIRES5/31/95LICENSEEEVENTREPORT(LER)(Seereverseforrequirednumberofdigits/characters foreachblock)ESTIHATED BURDENPERRESPONSETOCOHPLYHITHTHISIHFORHATION COLLECTION REQUEST:50.0HRS.FORHARDCOMMENTSREGARDIHG BURDENESTIHATETOTHEINFORMATION ANDRECORDSHANAGEMENT BRANCH(HNBB7714),U.STNUCLEARREGULATORY COHHISSION
This event has in no way affected the public's health and safety.
~llASHIHGTON, DC20555-0001, ANDTOTHEPAPERNORK REDUCTION PROJECT(3150-0104),
Very truly yours, Robert  C. Mecredy xc:         U.S. Nuclear Regulatory Commission Region I 475      Allendale Road King of Prussia, PA        19406 Ginna      USNRC  Senior Resident Inspector 9410270363 941017 PDR    ADOCK 05000244 S                PDR
OFFICEOFHANAGEMENT ANDBUDGETWASHINGTON DC20503.FACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKETNUHBER(2)05000244PAGE(3)10F10-TITLE(4)Lossof4160VoltBus12B,DuetoDefective Procedure, ResultsinAutomatic Startof"B"Emergency DieselGenerator MONTH09DAYYEAR1694EVENTDATE(5)YEAR94LERNUHBER(6)SEQUENTIAL HUHBER--010--REVISIONNUHBERMONTH0010DAYYEAR1794REPORTDATE(7)FACILITYHAHEFACILITYHAHEDOCKETNUHBERDOCKETHUHBEROTHERFACILITIES INVOLVED(8)OPERATING HODE(9)NTHISREPORTISSUBHITTED PURSUANT20.402(b) e)(11)TOTHEREUIREHENTS OF10CFR5:(Checkoneormor73.71(b)50.73(a)(2)(iv) 20.405(c)
 
PNERLEVEL(10)20.405(a)(1)(i)20.405(a)(1)(ii) 20.405(a)(1)(iii) 20'05(a)(1)(iv) 20.405(a)(1)(v) 50.36(c)(1) 50.36(c)(2) 50.73(a)(2)(i) 50.73(a)(2)(ii) 50.73(a)(2)(III)
NRC FORH    366                                    U.S. NUCLEAR REGULATORY COHHISSION                   APPROVED BY OHB NO.       3150 ~ 0104 (5-92)                                                                                                              EXPIRES  5/31/95 ESTIHATED BURDEN PER RESPONSE TO COHPLY HITH THIS IHFORHATION COLLECTION REQUEST: 50.0 HRS.
LICENSEECONTACTFORTHISLER(12)50.73(a)(2)(v) 50'3(a)(2)(vii) 50.73(a)(2)(viii)(A) 50~73(a)(2)(viii)(0)50.73(a)(2)(x) 73.71(c)OTHER(SpecifyinAbstractbelowandinText,NRCForm366A)NAMEJohnT.St.Martin-Director, Operating Experience TELEPHONE HUHBER(IncludeAreaCode)(315)524-4446COMPLETEONELINEFOREACHCOHPONENT FAILUREDESCRIBED INTHISREPORT(13)CAUSESYSTEHCOHPONENT HANUFACTURER REPORTABLE TOHPRDSCAUSESYSTEMCOHPONENT HANUFACTURER REPORTABLE TONPRDSSUPPLEHENTAL REPORTEXPECTED(14)YES(lfyes,completeEXPECTEDSUBHISSION DATE).XNOEXPECTEDSUBHISSIONDATE(15)HOHTHDAYYEARABSTRACT(Limitto1400spaces,i.e.,approximately 15single-spaced typewritten lines)(16)OnSeptember 16,1994,atapproximately 1018EDST,withthereactoratapproximately 98%steadystatepower,the4160Voltcircuitbreakerthatwassupplying powerto4160Voltbus12Bwasinadvertently tripped.Thisresultedindeenergization ofbus12Bandmomentary lossofpowertouBntrain480Voltsafeguards buses16and17.ThenBnEmergency DieselGenerator startedandreenergized buses16and17,asperdesign.Theunderlying causeoftheinadvertent circuitbreakertripwasadefective procedure.
LICENSEE EVENT REPORT (LER)                                              FORHARD COMMENTS REGARDIHG BURDEN ESTIHATE TO THE INFORMATION AND RECORDS HANAGEMENT BRANCH (HNBB 7714), U.ST NUCLEAR REGULATORY COHHISSION ~
ThiseventisNUREG-1022 CauseCode(D).Corrective actiontoprecluderepetition isoutlinedinSectionV.B.HRCFORM366(5-92)
(See reverse    for required    number  of digits/characters for each block)            llASHIHGTON, DC 20555-0001, AND TO THE PAPERNORK REDUCTION       PROJECT     (3150-0104),       OFFICE    OF HANAGEMENT AND BUDGET        WASHINGTON    DC  20503.
NRCFORH366A(5-92)U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUATION APPROVEDBYOMBNO.3150.0104 EXPIRES5/31/95ESTIMATED BURDENPERRESPONSETOCOMPLY'NITNTHISINFORMATION COLLECTION REQUEST:50.0HRS.FORMARDCOMHENTSREGARDING BURDENESTIHATETOTHEINFORMATION ANDRECORDSHANAGEHENT BRANCH(MNBB7T14),U.S.NUCLEARREGULATORY COHHISSION, llASNINGTON, DC205550001ANDTOTHEPAPERISRK REDUCTION PROJECT(3140.0104),
FACILITY NAME (1)     R. E. Ginna            Nuclear Power Plant                            DOCKET NUHBER      (2)                       PAGE  (3) 05000244                            10F 10-TITLE (4)           Loss  of  4160  Volt  Bus 12B, Due  to Defective Procedure, Results in Automatic Start of "B"             Emergency Diesel Generator EVENT DATE  (5)                   LER NUHBER  (6)               REPORT DATE  (7)                OTHER    FACILITIES INVOLVED (8)
OFFICEOFMANAGEMENT ANDBUDGETllASHINGTON DC20503.FACILITYNAME(1)DOCKETNUMBER(2)LERNUMBER(6)YEARSEQUENTIALREVISIONPAGE(3)R.E.GinnaNuclearPowerPlant0500024494010002OF10TEXT(Ifmorespaceisrequired, useadditional copiesofNRCForm366A)(17)PRE-EVENT PLANTCONDITIONS Theplantwasatapproximately 98%steadystatereactorpower,withnomajoroperational activities inprogress.
SEQUENTIAL       REVISION                            FACILITY HAHE                        DOCKET NUHBER MONTH      DAY      YEAR    YEAR                                    MONTH    DAY    YEAR HUHBER         NUHBER 09        16      94      94        --010--             00        10      17      94 FACILITY HAHE                        DOCKET HUHBER OPERATING                THIS REPORT IS SUBHITTED PURSUANT TO THE        RE UIREHENTS OF 10 CFR    5:    (Check one or mor e) (11)
Alloffsitepowerto4160Voltbuses12Aand12BwasbeingsuppliedfromCircuit767(34.5KVoffsitepowersource).Circuit767wassupplying powerthrough34.5KVto4160Volttransformer 12B(12Btransformer),
HODE   (9)       N          20.402(b)                           20.405(c)                       50.73(a)(2)(iv)                 73.71(b)
via4160Voltcircuitbreakers52/12BY(tobus12A)and52/12BX(tobus12B).(Seetheattachedsketchoftheoffsitepowerdistribution system.)34.5KVto4160Volttransformer 12A(12Atransformer),
PNER                      20.405(a   )(1)(i)                   50.36(c)(1)                     50.73(a)(2)(v)                   73.71  (c)
whichis.supplied fromCircuit751(34.5KVoffsitepowersource),wasdeenergized anddeclaredinoperable topermitpreviously scheduled maintenance andtestingofthe12Atransformer andassociated circuitbreakers.
LEVEL  (10)                 20.405(a)(1)(ii)                     50.36(c)(2)                     50 '3(a)(2)(vii)                OTHER 20.405(a)(1)(iii)                   50.73(a)(2)(i)                   50.73(a)(2)(viii)(A) (Specify in 20 '05(a)(1)(iv)                     50.73(a)(2)(ii)                 50 73(a) (2) (vi i i ) (0) Abstract below
Atthetimeofthisevent,triptestingwasinprogresson4160Voltcircuitbreaker52/12AX(alternate powersupplyfromthe12Atransformer tobus12B),inaccordance withMaintenance Procedure PME-50-04-52/12AX, "Bus12BAlternate PowerSource."Plantelectricians hadjustnotifiedtheControlRoomoperators thatcircuitbreaker12AXwouldbeclosedwhileinthe"test"position.
                                                                                                          ~
II.DESCRIPTION OFEVENTA.DATESANDAPPROXIMATE TIMESOFMAJOROCCURRENCES:
and in Text, 20.405(a)(1)(v)                     50.73(a)(2)(III)                 50.73(a)(2)(x)               NRC  Form 366A)
oSeptember 16,1994,1018EDST:Eventdateandtime.oSeptember 16,1994,1018EDST:Discovery dateandtime.oSeptember 16,1994,1018EDST:ControlRoomoperators verifythe"B"Emergency DieselGenerator (D/G)operation andsafeguards buses16and17energized.
LICENSEE CONTACT FOR THIS LER      (12)
oSeptember 16,1994,1120EDST:Circuit751declaredoperableatthecompletion ofmaintenance andtesting.oSeptember 16,1994,1125EDST:Safeguards buses16and17wereresupplied fromCircuit751.oSeptember 16,1994,1142EDST:The"B"Emergency D/Gwasstoppedandrealigned forautostandby.NRCFORM366A(5-92)  
NAME      John T. St. Martin - Director, Operating Experience                                       TELEPHONE HUHBER       (Include Area Code)
(315) 524-4446 COMPLETE ONE LINE FOR EACH COHPONENT FAILURE DESCRIBED          IN THIS    REPORT  (13)
REPORTABLE                                                                          REPORTABLE CAUSE      SYSTEH    COHPONENT      HANUFACTURER                               CAUSE    SYSTEM      COHPONENT        HANUFACTURER TO HPRDS                                                                          TO NPRDS SUPPLEHENTAL REPORT EXPECTED      (14)                                   EXPECTED              HOHTH        DAY        YEAR YES                                                                                           SUBHISS ION (lf yes,   complete  EXPECTED SUBHISSION    DATE).
X  NO DATE  (15)
ABSTRACT      (Limit to  1400 spaces,   i.e., approximately   15  single-spaced typewritten lines)         (16)
On    September 16, 1994, at approximately 1018 EDST, with the reactor at approximately 98% steady state power, the 4160 Volt circuit breaker that was supplying power to 4160 Volt bus 12B was inadvertently tripped.                                                                           This resulted in deenergization of bus 12B and momentary loss of power to uBn train 480 Volt safeguards buses 16 and 17.
The nBn Emergency                    Diesel Generator started and reenergized buses                                                16 and 17, as per design.
The      underlying cause of the inadvertent circuit breaker trip was a defective procedure. This event is NUREG-1022 Cause Code (D).
Corrective action to preclude repetition is outlined in Section V.B.
HRC FORM    366  (5-92)
 
NRC FORH 366A                              U.S. NUCLEAR REGULATORY COMMISSION               APPROVED BY OMB NO. 3150.0104 (5-92)                                                                                              EXPIRES  5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY 'NITN THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.
FORMARD COMHENTS REGARDING BURDEN ESTIHATE TO LICENSEE EVENT REPORT (LER)                                      THE INFORMATION AND RECORDS HANAGEHENT BRANCH TEXT CONTINUATION                                      (MNBB 7T14), U.S. NUCLEAR REGULATORY COHHISSION, llASNINGTON, DC 20555 0001    AND TO THE PAPERISRK REDUCTION     PROJECT   (3140.0104),     OFFICE  OF MANAGEMENT AND BUDGET llASHINGTON DC 20503.
FACILITY NAME (1)                     DOCKET NUMBER  (2)             LER NUMBER  (6)               PAGE (3)
YEAR SEQUENT IAL    REVISION R.E. Ginna Nuclear Power Plant                              05000244                                                  2 OF 10 94        010            00 TEXT (If more space  is required, use additional copies of NRC Form 366A)   (17)
PRE-EVENT PLANT CONDITIONS The plant was at approximately 98% steady state reactor power, with no major operational activities in progress.                                     All offsite power to 4160 Volt buses 12A and 12B was being supplied from Circuit 767 (34.5 KV offsite power source). Circuit 767 was supplying power through 34.5 KV to 4160 Volt transformer 12B (12B transformer), via 4160 Volt circuit breakers 52/12BY (to bus 12A) and 52/12BX (to bus 12B). (See the attached sketch of the offsite power distribution system.) 34.5 KV to 4160 Volt transformer 12A (12A transformer),
which is .supplied from Circuit 751 (34.5 KV offsite power source),
was deenergized and declared inoperable to permit previously scheduled maintenance and testing of the 12A transformer and associated          circuit      breakers.
At the time of this event, trip testing was in progress on 4160 Volt circuit breaker 52/12AX (alternate power supply from the 12A transformer to bus 12B), in accordance with Maintenance Procedure PME-50-04-52/12AX, "Bus 12B Alternate Power Source." Plant electricians had just notified the Control Room operators that circuit breaker 12AX would be closed while in the "test" position.
II.     DESCRIPTION OF EVENT A. DATES        AND APPROXIMATE TIMES OF MAJOR OCCURRENCES:
o    September        16, 1994, 1018 EDST: Event date and time.
o    September        16, 1994, 1018 EDST: Discovery date and time.
o    September 16, 1994, 1018 EDST: Control Room operators verify the "B" Emergency Diesel Generator (D/G) operation and safeguards buses 16 and 17 energized.
o    September 16, 1994, 1120 EDST: Circuit 751 declared operable                                                  at the completion of maintenance and testing.
o    September 16, 1994, 1125 EDST: Safeguards                                 buses 16 and 17 were resupplied from Circuit 751.
o    September 16, 1994, 1142 EDST: The "B" Emergency D/G was stopped and realigned for auto standby.
NRC FORM 366A  (5-92)
 
NRC FORM 366A                              U.S. NKLEAR REGULATORY COMMISSION              APPROVED BY OMB NO. 3150-0104 (5-92)                                                                                            EXPIRES  5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY lllTH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.
FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER)                                      THE IHFORHATION AND RECORDS HANAGEMENT BRANCH TEXT CONTINUATION                                      (MNBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555-0001    AND TO THE PAPERWORK REDUCTION    PROJECT    (3140.0104),    OFFICE  OF HANAGEHENT AND BUDGET    WASHINGTON  DC  20503.
FACILITY NAME (1)                      DOCKET NUMBER  (2)            LER NUMBER (6)                PAGE  (3)
YEAR SEQUENTIAL      REVISION R.E. Ginna Nuclear Power Plant                            05000244                                                3 OF 10 94    -- 010--            00 TEXT (If more space  is required, use additional copies of NRC Form 366A)  (17)
B.      EVENT:
On  September        16, 1994,        at approximately 1018 EDST, with the reactor at approximately            98~    steady state full power, the Control Room received numerous annunciator alarms. The Control Room operators immediately determined that 4160 Volt bus 12B was deenergized, that "B" train 480 Volt safeguards buses 16 and 17 had lost their power supply from bus 12B, and that the "B" Emergency D/G had started and was tied to safeguards buses 16 and 17.
The    Control Room operators immediately performed the appropriate actions of Abnormal Procedure AP-ELEC.1 (Loss of 12A And/Or 12B Transformer) to stabilize the plant, and verified that the "B" Emergency D/G was operating properly and that safeguards buses 16 and 17 were energized.                  The Control Room operators observed that bus 12B had deenergized and displayed zero (0) voltage, because the circuit breaker supplying power to bus 12B had tripped. The loss of power to bus 12B resulted in undervoltage on safeguards'buses                                                16 and 17, and the "B" Emergency D/G started and reenergized these buses, as per design.
When the scheduled maintenance and testing was completed on the 12A transformer and associated breakers, the Control Room operators cleared the holds on Circuit 751 and th'e 12A transformer. A switching order was used to restore Circuit 751, 12A transformer, and associated breakers to operable status.                                  34.5 KV circuit breaker 75112 was closed, energizing the 12A transformer.
The Control Room operators directed plant electricians to investigate the failure, and there were no anomalies noted. At approximately 1120 EDST, using Equipment Restoration procedure ER-ELEC.1 (Restoration of Offsite Power), the Control Room operators closed circuit breaker 12AX, energizing bus 12B from the 12A
                                                                                                't transformer.
At approximately 1125 EDST, "B" train safeguards buses 16 and 17 were resupplied by offsite power, via Circuit 751                                                approximately 1142 EDST, September 16, 1994, the "B" Emergency D/G was stopped and realigned for auto standby.
NRC FORM 366A (5-92),
 
NRC FORM 366A                              U.S. NUCLEAR REGULATORY COHHISSION                          APPROVED BY OHB NO. 3150 ~ 0104 (5-92)                                                                                                          EXPIRES  5/31/95 ESTIMATED BURDEN PER RESPOHSE TO COHPLY WITH THIS INFORHAT ION COLLECTION REQUEST: 50.0 HRS.
FORWARD COMHENTS REGARDING BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER)                                                  THE INFORHATION AND RECORDS HANAGEHENT BRANCH TEXT CONTINUATION                                                  (HNBB 7714), U.S. NUCLEAR REGULATORY COMHISSION, WASHIHGTON, DC 20555-0001    AND TO THE PAPERWORK REDUCTION    PROJECT    (3140-0104),    OFFICE  OF MANAGEMENT AND BUDGET    WASHINGTON  DC  20503.
FACILITY NAHE (1)                      DOCKET NUHBER      (2)                    LER NUMBER (6)                PAGE  (3)
YEAR SEOUENTIAL      REVISION R.E. Ginna Nuclear Power Plant                              05000244                                                            4 OF 10 010            00 TEXT (tf more space  is required, use additional copies of NRC Form 366A)              (17)
C.      I NOPERABLE STRUCTURES i COMPONENTS i OR SYSTEMS THAT CONTR BUTED TO                                            I THE EVENT:
Circuit        751 was inoperable for scheduled maintenance of the 12A transformer, beginning at approximately 0717 EDST on September 15, 1994, and was restored to service at approximately 1120 EDST on September          16, 1994..
D.      OTHER SYSTEMS OR SECONDARY FUNCTIONS AFFECTED:
The momentary            loss of power caused a loss of program memory for radiation monitor terminal RCT-1 and associated channels R-12A (Containment ventilation effluent), R-14A (Plant ventilation ef fluent), R-31 (>>A>> steam line monitor), and R-32 (B>> steam line monitor)        .
E.      METHOD OF DISCOVERY:
This event was immediately apparent due to Main Control Board alarms and indications in the Control Room when bus 12B was deenergized.
These included Main Control Board annunciators J-5 (gll or gl2 Transformer Out of Synch), J-6 (4KV Main or Tie Breaker Trip), J-7 (480 V Main or Tie Breaker Trip), J-8 (480V MCC Supply Breaker Trip),      and L-28 (12B XFMR              or  12B Bus      Trouble).
F.      OPERATOR ACTION:
Following the undervoltage condition on buses 16 and 17, the >>B>>
Emergency D/G automatically started and energized these buses.                                                              The Control Room operators immediately performed the appropriate actions and verified that the >>B>> Emergency D/G was operating properly, and that safeguards            buses 16 and 17 were                energized.'he Control Room operators cleared the holds on Circuit 751, restored offsite power to buses 16 and 17, stopped the >>B>> Emergency D/G, and realigned                it  for auto standby.
HRC FORM 366A  (5-92)
 
N NRC FORH  366A                              U.S. NUCLEAR REGULATORY COHHISSION              APPROVED BY OHB NO. 3150.0104 (5-92)                                                                                                EXPIRES  5/31/95 ESTIHATED BURDEN PER RESPONSE TO COHPLY WITH THIS INFORHATION COLLECTIOH REQUEST: 50.0 HRS.
FORWARD COHHEHTS REGARDIHG BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER)                                      THE INFORHATION .AHD RECORDS HANAGEMEHT BRANCH TEXT CONTINUATION                                        (MNBB 7714), U.S. NUCLEAR REGULATORY COHHISSIOH ~
                                                                                  'WASHINGTON, DC 20555-0001    AND TO THE PAPERWORK REDUCTION    PROJECT    (3110.0104),    OFF ICE  OF MAHAGEHEHT AHD BUDGET WASHINGTON DC 20503.
FACILITY NAHE (1)                      DOCKET NUHBER  (2)              LER NUHBER (6)                PAGE  (3)
YEAR SEQUENTIAL      REVISION R.E. Ginna Nuclear Power Plant                              05000244                                                  5 OF 10 94        010            00 TEXT  (If more  space  is required, use additionaI copies of HRC Form 366A)  (17)
At approximately 1354 EDST on September 16, 1994, the Shift Supervisor notified the NRC per 10 CFR 50.72 (b) (2) (ii) .
                  ,SAFETY SYSTEM RESPONSES:
The >>B>> Emergency D/G                automatically started due to the undervoltage condition on buses 16 and 17, displayed proper voltage and frequency and closed into safeguards buses 16 and                                                  17 to supply emergency power.
III.      CAUSE OF EVENT IMMEDIATE CAUSE:
The automatic actuation of the .>>B>> Emergency D/G                                    was due        to undervoltage on safeguards buses 16 and 17.
B.      INTERMEDIATE CAUSE:
The undervoltage on safeguards buses 16 and 17 was due to bus                                                  12B being deenergized when circuit breaker 12BX tripped due to an electrical interlock.
C. ROOT CAUSE:
The underlying cause of the tripping of circuit breaker 12BX was a defective procedure.                  During development of this procedure (PME-50-04-52/12AX), the switch development of an elementary wiring diagram (EWD) was not used as a reference in determining post-maintenance operability testing. The procedure is for preventive maintenance of Model P-51000 POWL-VAC metal-clad switchgear, manufactured by Powell Electrical Mfg. Co.
There is a normally open >>s>> contact (52S/12AX) in the trip circuit for breaker 12BX that comes from breaker 12AX, to prevent both 4160 Volt circuit breakers (12AX and 12BX) from being closed simultaneously. Contact 52S/12AX is located in the mechanism-operated cell (MOC) switch of these'ircuit breakers.                                            These >>s>>
contacts change state with movement of the breaker mechanism.
Technical reviewers incorrectly assumed that the cell switch would not function when in "test", and therefore concluded that with breaker 12AX in "test", contact 52S/12AX would not close.
NRC FORM  366A  (5-92)
 
NRC FORM 366A                              U.S. NUCLEAR REGULATORY COHHISSIOH              APPROVED BY OHB NO. 3150-0104 (5-92)                                                                                              EXP I RES 5/31/95 EST IHATED BURDEN    PER    RESPONSE  TO  COHPLY  WITH THIS INFORMATION COLLECTION REQUEST:        50.0  HRS.
FORWARD  COHHEHTS  REGARD IHG BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER)                                      THE INFORMATION AHD RECORDS HAHAGEMENT BRANCH TEXT CONTINUATION                                        (MNBB 7714), U.ST NUCLEAR REGULATORY COHHISSIOH, WASHINGTON, DC 20555-0001        AHD TO THE PAPERWORK REDUCTION    PROJECT      (3140-0104),  OFFICE    OF MANAGEMENT AND BUDGET 'WASHIHGTON DC 20503.
FACILITY NAHE (1)                      DOCKET NUMBER  (2)              LER NUHBER (6)                  PAGE  3)
YEAR      SEQUENTIAL        REVISION R.E. Ginna Nuclear Power Plant                              05000244                                                    6 OF    10 94    -- 010--              pp
                                                                                                                                    ~y TEXT (If more space  is required, use additional copies of  HRC Form 366A)  (17)
There      is another contact in series with the 52S/12AX contact that operates from the synchronizing switch for the circuit breaker.
This contact is closed when the synch switch is in the "Off" position. When reviewing the EWD, technical reviewers misinterpreted the function of this contact, and assumed that the contact was closed when the synch switch was in the "On" position.
Thus, the trip logic for circuit breaker 12BX was made up when the synch switch was in the "Off" position as soon as breaker 12AX closed, causing breaker                  12BX    to  trip    per design.
After further investigation,                      it  was discovered that this same incorrect interpretation of switch contact status was made for circuit breakers 12AX, 12AY, and 12BY. There were a total of eight defective procedures, one preventive and one corrective maintenance procedure for each of the four circuit breakers.
This event is NUREG-1022 Cause Code (D), Defective Procedure.
This loss of power meets the NUMARC 93-01, "Industry Gui'deline for Monitoring the Effectiveness of Maintenance at Nuclear Power Plants", definition of a "Maintenance Preventable Functional Failure".
IV. ANALYSIS OF EVENT:
This event is reportable in accordance with 10 CFR 50.73, Licensee Event Report System, item (a) (2) (iv), which requires a report of, "any event or condition that resulted in a manual or automatic actuation of any engineered safety feature (ESF), including the reactor protection system (RPS)", in that the starting of the "B" Emergency D/G was an automatic actuation of an ESF system.
HRC FORM 366A (5-92)
 
NRC FORH 366A                              UPS. NUCLEAR REGULATORY COHHISSION              APPROVED BY OHB NO. 3150-0104 (5-92)                                                                                              EXPIRES  5/31/95 ESTIHATED BURDEN PER RESPONSE TO COHPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.
FORWARD COHHENTS REGARDING BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER)                                      THE INFORMATION AND RECORDS MAHAGEHEHT BRANCH TEXT CONTINUATION                                        (HHBB 7714), U.ST NUCLEAR REGULATORY COHHISSION, WASHINGTOH, DC 20555-0001    AHD TO THE PAPERWORK REDUCTION    PROJECT    (3140-0104),    OFFICE    OF HANAGEHENT AND BUDGET    WASHINGTON  DC  20503.
FACILITY NAME (1)                      DOCKET NUHBER  (2)            LER NUHBER  (6)                PAGE  (3)
YEAR'EQUENTIAL          REVISION R.E. Ginna Nuclear Power 'Plant                            05000244                                                  7 OF 10 94        010            00 TEXT (If more space  is required, use additional copies of  HRC Form 366A)  (17)
An assessment          was performed considering both the safety consequences and    implications of this event with the following results and conclusions:
o    All reactor control                and    protection systems performed as designed.
o    Circuit breaker 12BX operated as designed and tripped when it received a valid trip signal.
o    The "B" Emergency D/G                operated as designed by starting and supplying emergency power to safeguards buses 16 and 17.
o    Circuit 767 was still in operation supplying power to the "A" train safeguards buses; subsequently Circuit 751 was lined up to supply power to the "B" train safeguards buses as permitted by plant technical specifications.
o    Radiation monitors R-12A and R-14A are redundant to monitors R-12 and R-14. R-12 and R-14 remained operable during this event.
o    Loss of radiation monitors R-31 and R-32 is compensated for by local monitoring of steam line radiation, which would be performed by plant personnel, as specified in emergency operating procedures.
Based on the above, safety wa's assured at all times.
it  can be concluded that the public's health and V.      CORRECTIVE ACTION A. ACTION TAKEN              TO RETURN AFFECTED SYSTEMS TO PRE-EVENT NORMAL STATUS:
o      Safeguards        buses 16 and 17 normal power supplies were restored via Circuit 751, and the "B" Emergency D/G was stopped and aligned for auto standby.
o      Circuit breaker 12BX was cycled to confirm that the breaker responded as designed.
o      The RCT-1        radiation monitor terminal and associated channels R-12A, R-14A, R-31, and R-32 were reprogrammed and declared operable.
HRC FORH 366A (5-92)


NRCFORM366A(5-92)U.S.NKLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUATION APPROVEDBYOMBNO.3150-0104 EXPIRES5/31/95ESTIMATED BURDENPERRESPONSETOCOMPLYlllTHTHISINFORMATION COLLECTION REQUEST:50.0HRS.FORWARDCOMMENTSREGARDING BURDENESTIMATETOTHEIHFORHATION ANDRECORDSHANAGEMENT BRANCH(MNBB7714),U.S.NUCLEARREGULATORY COMMISSION, WASHINGTON, DC20555-0001 ANDTOTHEPAPERWORK REDUCTION PROJECT(3140.0104),
NRC FORH 366A                              U.S. NUCLEAR REGULATORY COHHISSION              APPROVED BY OHB NO. 3150-0104 (5-92)                                                                                              EXP I RES 5/31/95 ESTIHATED BURDEN    PER    RESPOHSE  TO  COHPLY  MITH THIS INFORHATION COLLECTIOH REQUEST:       50.0  HRS.
OFFICEOFHANAGEHENT ANDBUDGETWASHINGTON DC20503.FACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKETNUMBER(2)05000244LERNUMBER(6)YEARSEQUENTIAL 94--010--REVISION00PAGE(3)3OF10TEXT(Ifmorespaceisrequired, useadditional copiesofNRCForm366A)(17)B.EVENT:OnSeptember 16,1994,atapproximately 1018EDST,withthereactoratapproximately 98~steadystatefullpower,theControlRoomreceivednumerousannunciator alarms.TheControlRoomoperators immediately determined that4160Voltbus12Bwasdeenergized, that"B"train480Voltsafeguards buses16and17hadlosttheirpowersupplyfrombus12B,andthatthe"B"Emergency D/Ghadstartedandwastiedtosafeguards buses16and17.TheControlRoomoperators immediately performed theappropriate actionsofAbnormalProcedure AP-ELEC.1 (Lossof12AAnd/Or12BTransformer) tostabilize theplant,andverifiedthatthe"B"Emergency D/Gwasoperating properlyandthatsafeguards buses16and17wereenergized.
FORHARD  COHHENTS  REGARDING BURDEN ESTIHATE TO LICENSEE EVENT REPORT (LER)                                      THE  INFORHATIOH AND RECORDS HANAGEHEHT BRANCH TEXT CONTINUATION                                      (HNBB 7714), U.S. NUCLEAR REGULATORY COHHISSION, HASHINGTOH, DC 20555-0001       AND TO THE PAPERHORK REDUCTION   PROJECT     (3180-0104),   OFFICE    OF HANAGEHENT AND BUDGET      MASHINGTON  DC 20503.
TheControlRoomoperators observedthatbus12Bhaddeenergized anddisplayed zero(0)voltage,becausethecircuitbreakersupplying powertobus12Bhadtripped.Thelossofpowertobus12Bresultedinundervoltage onsafeguards'buses 16and17,andthe"B"Emergency D/Gstartedandreenergized thesebuses,asperdesign.Whenthescheduled maintenance andtestingwascompleted onthe12Atransformer andassociated
FACILITY NAHE (1)                       DOCKET NUHBER  (2)             LER NUHBER (6)                   PAGE  (3)
: breakers, theControlRoomoperators clearedtheholdsonCircuit751andth'e12Atransformer.
YEAR SEQUENTIAL        REVISION R.E. Ginna Nuclear Power Plant                              05000244                                                  8 OF 10 94   -- 010--             00 TEXT (If more space  is required, use additional copies of HRC Form 366A)   (17)
Aswitching orderwasusedtorestoreCircuit751,12Atransformer, andassociated breakerstooperablestatus.34.5KVcircuitbreaker75112wasclosed,energizing the12Atransformer.
B. ACTION TAKEN OR PLANNED TO PREVENT RECURRENCE:
TheControlRoomoperators directedplantelectricians toinvestigate thefailure,andtherewerenoanomalies noted.Atapproximately 1120EDST,usingEquipment Restoration procedure ER-ELEC.1(Restoration ofOffsitePower),theControlRoomoperators closedcircuitbreaker12AX,energizing bus12Bfromthe12Atransformer.
o      All Corrective            Maintenance Electrical (CME), Preventive Maintenance Electrical (PME), and Protective Relay (PRI) procedures associated with Powell circuit breakers were quarantined. This included PME-50-04-52/12AX and the seven other procedures for circuit breakers 12AX, 12AY, 12BX, and 12BY.
Atapproximately 1125EDST,"B"trainsafeguards buses16and17wereresupplied byoffsitepower,viaCircuit751'tapproximately 1142EDST,September 16,1994,the"B"Emergency D/Gwasstoppedandrealigned forautostandby.NRCFORM366A(5-92),
o        The    quarantined procedures                will be        reviewed against the                    EWDs and drawing conventions                to determine interpretation of switch contact status were made during if    any other errors in procedure development. Quarantined procedures that are found to be in error will be revised.
o      A Training Work Request (TWR) has been submitted to incorporate details of this event during Industry Events training, emphasize event details during maintenance training on Preferred Power Sources, and reinforce the requirement to use switch development information during training on EWDs.
o      Electrical Engineering has evaluated the design of the offsite power configuration, and has recommended a method to avoid 4160 Volt circuit breaker trips during breaker testing.
o      The causes and effects of loss of power to the RCT-1 radiation monitor terminal will be reviewed, to determine the need for changes in design or maintenance of the system.
HRC FORH 366A  (5-92)


NRCFORM366A(5-92)U.S.NUCLEARREGULATORY COHHISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUATION APPROVEDBYOHBNO.3150~0104EXPIRES5/31/95ESTIMATED BURDENPERRESPOHSETOCOHPLYWITHTHISINFORHATIONCOLLECTION REQUEST:50.0HRS.FORWARDCOMHENTSREGARDING BURDENESTIMATETOTHEINFORHATION ANDRECORDSHANAGEHENT BRANCH(HNBB7714),U.S.NUCLEARREGULATORY COMHISSION, WASHIHGTON, DC20555-0001 ANDTOTHEPAPERWORK REDUCTION PROJECT(3140-0104),
NRC FORH 366A                              U.S. NUCLEAR REGULATORY COHHISSION             APPROVED BY OHB NO. 3150.0104 (5-92)                                                                                             EXP I RES 5/31/95 l
OFFICEOFMANAGEMENT ANDBUDGETWASHINGTON DC20503.FACILITYNAHE(1)R.E.GinnaNuclearPowerPlantDOCKETNUHBER(2)05000244YEAR01000LERNUMBER(6)SEOUENTIAL REVISIONPAGE(3)4OF10TEXT(tfmorespaceisrequired, useadditional copiesofNRCForm366A)(17)C.INOPERABLE STRUCTURES iCOMPONENTS iORSYSTEMSTHATCONTRIBUTEDTOTHEEVENT:Circuit751wasinoperable forscheduled maintenance ofthe12Atransformer, beginning atapproximately 0717EDSTonSeptember 15,1994,andwasrestoredtoserviceatapproximately 1120EDSTonSeptember 16,1994..D.OTHERSYSTEMSORSECONDARY FUNCTIONS AFFECTED:
ESTIHATED BURDEN PER RESPONSE TO COHPLY WITH THIS IHFORHATION COLLECTIOH REQUEST: 50.0 HRS ~
Themomentary lossofpowercausedalossofprogrammemoryforradiation monitorterminalRCT-1andassociated channelsR-12A(Containment ventilation effluent),
FORWARD COHHENTS REGARDING BURDEN ESTIHATE TO LICENSEE EVENT REPORT (LER)                                      THE INFORHATION AND RECORDS HANAGEHENT BRANCH TEXT CONTINUATION                                      (HNBB 7714), U.S. NUCLEAR REGULATORY COHHISSION, WASHINGTON, DC 20555-0001       AND TO THE PAPERWORK REDUCTION   PROJECT     (3140 0104),   OFFICE  OF HANAGEHENT AND BUDGET WASHINGTON DC 20503.
R-14A(Plantventilation effluent),R-31(>>A>>steamlinemonitor),
FACILITY NAHE (1)                     DOCKET NUHBER  (2)             LER NUHBER (6)                 PAGE (3)
andR-32(B>>steamlinemonitor).E.METHODOFDISCOVERY:
YEAR SEQUENTIAL        REVISION R.E. Ginna Nuclear Power Plant                              05000244                                                  9 OF    10 010--           00 TEXT (If more space  is required, use additional copies of NRC Form 366A)   (17)
Thiseventwasimmediately apparentduetoMainControlBoardalarmsandindications intheControlRoomwhenbus12Bwasdeenergized.
VI.     ADDITIONAL INFORMATION A. FAILED          COMPONENTS:
TheseincludedMainControlBoardannunciators J-5(gllorgl2Transformer OutofSynch),J-6(4KVMainorTieBreakerTrip),J-7(480VMainorTieBreakerTrip),J-8(480VMCCSupplyBreakerTrip),andL-28(12BXFMRor12BBusTrouble).
None B. PREVIOUS LERs ON SIMILAR EVENTS:
F.OPERATORACTION:Following theundervoltage condition onbuses16and17,the>>B>>Emergency D/Gautomatically startedandenergized thesebuses.TheControlRoomoperators immediately performed theappropriate actionsandverifiedthatthe>>B>>Emergency D/Gwasoperating
A    similar LER event historical search was conducted with the following results: No documentation of similar LER events with the'same root cause at Ginna Nuclear Power Plant could be iden-tified. However, LERs 91-002 and 92-007 were similar events (start of a D/G due to loss of 4160 Volt bus or offsite power) with different root causes.
: properly, andthatsafeguards buses16and17wereenergized.'he ControlRoomoperators clearedtheholdsonCircuit751,restoredoffsitepowertobuses16and17,stoppedthe>>B>>Emergency D/G,andrealigned itforautostandby.HRCFORM366A(5-92)
C. SPECIAL COMMENTS:
N NRCFORH366A(5-92)U.S.NUCLEARREGULATORY COHHISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUATION APPROVEDBYOHBNO.3150.0104 EXPIRES5/31/95ESTIHATED BURDENPERRESPONSETOCOHPLYWITHTHISINFORHATION COLLECTIOH REQUEST:50.0HRS.FORWARDCOHHEHTSREGARDIHG BURDENESTIMATETOTHEINFORHATION
None NRC FORM 366A  (5-92)
.AHDRECORDSHANAGEMEHT BRANCH(MNBB7714),U.S.NUCLEARREGULATORY COHHISSIOH
~'WASHINGTON, DC20555-0001 ANDTOTHEPAPERWORK REDUCTION PROJECT(3110.0104),
OFFICEOFMAHAGEHEHT AHDBUDGETWASHINGTON DC20503.FACILITYNAHE(1)R.E.GinnaNuclearPowerPlantDOCKETNUHBER(2)05000244YEAR9401000LERNUHBER(6)SEQUENTIAL REVISIONPAGE(3)5OF10TEXT(Ifmorespaceisrequired, useadditionaI copiesofHRCForm366A)(17)Atapproximately 1354EDSTonSeptember 16,1994,theShiftSupervisor notifiedtheNRCper10CFR50.72(b)(2)(ii).,SAFETYSYSTEMRESPONSES:
The>>B>>Emergency D/Gautomatically startedduetotheundervoltage condition onbuses16and17,displayed propervoltageandfrequency andclosedintosafeguards buses16and17tosupplyemergency power.III.CAUSEOFEVENTIMMEDIATE CAUSE:Theautomatic actuation ofthe.>>B>>Emergency D/Gwasduetoundervoltage onsafeguards buses16and17.B.INTERMEDIATE CAUSE:Theundervoltage onsafeguards buses16and17wasduetobus12Bbeingdeenergized whencircuitbreaker12BXtrippedduetoanelectrical interlock.
C.ROOTCAUSE:Theunderlying causeofthetrippingofcircuitbreaker12BXwasadefective procedure.
Duringdevelopment ofthisprocedure (PME-50-04-52/12AX),
theswitchdevelopment ofanelementary wiringdiagram(EWD)wasnotusedasareference indetermining post-maintenance operability testing.Theprocedure isforpreventive maintenance ofModelP-51000POWL-VACmetal-clad switchgear, manufactured byPowellElectrical Mfg.Co.Thereisanormallyopen>>s>>contact(52S/12AX) inthetripcircuitforbreaker12BXthatcomesfrombreaker12AX,topreventboth4160Voltcircuitbreakers(12AXand12BX)frombeingclosedsimultaneously.
Contact52S/12AXislocatedinthemechanism-operatedcell(MOC)switchofthese'ircuit breakers.
These>>s>>contactschangestatewithmovementofthebreakermechanism.
Technical reviewers incorrectly assumedthatthecellswitchwouldnotfunctionwhenin"test",andtherefore concluded thatwithbreaker12AXin"test",contact52S/12AXwouldnotclose.NRCFORM366A(5-92)  


NRCFORM366A(5-92)U.S.NUCLEARREGULATORY COHHISSIOH LICENSEEEVENTREPORT(LER)TEXTCONTINUATION APPROVEDBYOHBNO.3150-0104 EXPIRES5/31/95ESTIHATEDBURDENPERRESPONSETOCOHPLYWITHTHISINFORMATION COLLECTION REQUEST:50.0HRS.FORWARDCOHHEHTSREGARDIHGBURDENESTIMATETOTHEINFORMATION AHDRECORDSHAHAGEMENT BRANCH(MNBB7714),U.STNUCLEARREGULATORY COHHISSIOH, WASHINGTON, DC20555-0001 AHDTOTHEPAPERWORK REDUCTION PROJECT(3140-0104),
NRC FORN    366A                                                          U.S.     NUCLEAR REGULATORY CONNISSION                                                        APPROVEO BY ONB NO.                   3150.0104 (5-92)                                                                                                                                                                                 EXPIRES          5/31/95 ESTIHATED BURDEN PER RESPONSE TO COHPLY MITH THIS INFORHATION COLLECTION REQUEST: 50.0 HRS.
OFFICEOFMANAGEMENT ANDBUDGET'WASHIHGTON DC20503.FACILITYNAHE(1)R.E.GinnaNuclearPowerPlantDOCKETNUMBER(2)YEAR0500024494LERNUHBER(6)SEQUENTIAL
FORMARD COHHENTS REGARDING BURDEN ESTINATE TO L1CENSEE EVENT REPORT (LER)                                                                                               THE INFORNATIOH AHD RECORDS IIANAGEHENT BRANCH TEXT CONTINUATION                                                                                                (NHBB 7714)1 U.S. NUCLEAR REGULATORY CONHISSIONI MASHINGTON, DC 20555-0001                                 AND .TO THE PAPERMORK REDUCTIOH                  PROJECT             (3140.0104)1           OFFICE              OF HANAGENENT AND BUDGET                            MASHINGTON          DC  20503.
--010--REVISIONPAGE3)pp6OF10~yTEXT(Ifmorespaceisrequired, useadditional copiesofHRCForm366A)(17)Thereisanothercontactinserieswiththe52S/12AXcontactthatoperatesfromthesynchronizing switchforthecircuitbreaker.Thiscontactisclosedwhenthesynchswitchisinthe"Off"position.
FACILITY NAHE (1)                                                               DOCKET NUHBER              (2)                                     NUHBER      (6                           PAGE      (3)
Whenreviewing theEWD,technical reviewers misinterpreted thefunctionofthiscontact,andassumedthatthecontactwasclosedwhenthesynchswitchwasinthe"On"position.
YEAR SEQUENT      IAL          REVISION R.E. Ginna Nuclear Power Plant 10'ER 05000244                                94                                                  pp        10 OF 010 TEXT  (If more      space    is required,             use      additional copies of                      NRC    Form 366A)               (17)
Thus,thetriplogicforcircuitbreaker12BXwasmadeupwhenthesynchswitchwasinthe"Off"positionassoonasbreaker12AXclosed,causingbreaker12BXtotripperdesign.Afterfurtherinvestigation, itwasdiscovered thatthissameincorrect interpretation ofswitchcontactstatuswasmadeforcircuitbreakers12AX,12AY,and12BY.Therewereatotalofeightdefective procedures, onepreventive andonecorrective maintenance procedure foreachofthefourcircuitbreakers.
                                                                                                                                  $ 4 5 <V  IIWtI+XNUNC 51AIION 114                                                  5141ltW  tll N  N                                                            N 74142                                                        7511$
ThiseventisNUREG-1022 CauseCode(D),Defective Procedure.
52/                                                         $ 2/
ThislossofpowermeetstheNUMARC93-01,"Industry Gui'deline forMonitoring theEffectiveness ofMaintenance atNuclearPowerPlants",definition ofa"Maintenance Preventable Functional Failure".
ION2                                                        75112 74741                                                        75111 NC 74 AV OIIS 1                                                $ 4 AV NIS    I 51A  Wl NOICNtNNN 12$                                         SIA AIN <<WONfOSCN 114 4&i IN
IV.ANALYSISOFEVENT:Thiseventisreportable inaccordance with10CFR50.73,LicenseeEventReportSystem,item(a)(2)(iv),whichrequiresareportof,"anyeventorcondition thatresultedinamanualorautomatic actuation ofanyengineered safetyfeature(ESF),including thereactorprotection system(RPS)",inthatthestartingofthe"B"Emergency D/Gwasanautomatic actuation ofanESFsystem.HRCFORM366A(5-92)
                                                                                          $ 4$  N    41N ~ INV                                          $          ~
NRCFORH366A(5-92)UPS.NUCLEARREGULATORY COHHISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUATION APPROVEDBYOHBNO.3150-0104 EXPIRES5/31/95ESTIHATED BURDENPERRESPONSETOCOHPLYWITHTHISINFORMATION COLLECTION REQUEST:50.0HRS.FORWARDCOHHENTSREGARDING BURDENESTIMATETOTHEINFORMATION ANDRECORDSMAHAGEHEHT BRANCH(HHBB7714),U.STNUCLEARREGULATORY COHHISSION, WASHINGTOH, DC20555-0001 AHDTOTHEPAPERWORK REDUCTION PROJECT(3140-0104),
                                                                                                                                                          < ttt>>OO I 2A>
OFFICEOFHANAGEHENT ANDBUDGETWASHINGTON DC20503.FACILITYNAME(1)DOCKETNUHBER(2)LERNUHBER(6)YEAR'EQUENTIAL REVISIONPAGE(3)R.E.GinnaNuclearPower'Plant0500024494010007OF10TEXT(Ifmorespaceisrequired, useadditional copiesofHRCForm366A)(17)Anassessment wasperformed considering boththesafetyconsequences andimplications ofthiseventwiththefollowing resultsandconclusions:
                                                                                                                                                                          ~ IN<<
oAllreactorcontrolandprotection systemsperformed asdesigned.
                                                                                          < tttICO I 2$ >                             CI
oCircuitbreaker12BXoperatedasdesignedandtrippedwhenitreceivedavalidtripsignal.oThe"B"Emergency D/Goperatedasdesignedbystartingandsupplying emergency powertosafeguards buses16and17.oCircuit767wasstillinoperation supplying powertothe"A"trainsafeguards buses;subsequently Circuit751waslineduptosupplypowertothe"B"trainsafeguards busesaspermitted byplanttechnical specifications.
                                                              ~ tSO/1    Sl/                     St/ tt5$/2        ~ ttl/4 $ 1/                     S2/       tt5A/5 IC  115<                    I tll  NC              IC 1151                    11>I      NO Ol/     N/212$ /I ~                                                                                   OI/ Ntttltt/IS 11$    CANON OttONICN                                                                                        CANON ONCANCN 41          I St/   N7511$ /1$             St/     OV512$   /II    52/     S7$ 12$ /2$                                                                                   Sl/   OIISI 24/12 $ 2/ Stlt  Ill/I5           S2/   Otlllll/14 1755  IC                    1555    IC              ~ ISO    NO                                                                                            ~ IAW  IC          1155  IC                      1555 SIAIXNI 501VICC                ~IAIXN 5CNVICC 0  41          II~                                                  IO 41NV            Ill                            5IAlXN SCNVCC                SIAISIN 5OIVICC
oRadiation monitorsR-12AandR-14Aareredundant tomonitorsR-12andR-14.R-12andR-14remainedoperableduringthisevent.oLossofradiation monitorsR-31andR-32iscompensated forbylocalmonitoring ofsteamlineradiation, whichwouldbeperformed byplantpersonnel, asspecified inemergency operating procedures.
                                                                                                                                                                                                                              \CNOINNN WNICAAXN 17 41N
Basedontheabove,itcanbeconcluded thatthepublic'shealthandsafetywa'sassuredatalltimes.V.CORRECTIVE ACTIONA.ACTIONTAKENTORETURNAFFECTEDSYSTEMSTOPRE-EVENT NORMALSTATUS:oSafeguards buses16and17normalpowersupplieswererestoredviaCircuit751,andthe"B"Emergency D/Gwasstoppedandalignedforautostandby.oCircuitbreaker12BXwascycledtoconfirmthatthebreakerresponded asdesigned.
            <tASNSNI I>       CI 41~
oTheRCT-1radiation monitorterminalandassociated channelsR-12A,R-14A,R-31,andR-32werereprogrammed anddeclaredoperable.
                                            <<tAAOSN I 4>>
HRCFORH366A(5-92)
WNIISWhCN 14
NRCFORH366A(5-92)U.S.NUCLEARREGULATORY COHHISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUATION APPROVEDBYOHBNO.3150-0104 EXPIRES5/31/95ESTIHATED BURDENPERRESPOHSETOCOHPLYMITHTHISINFORHATION COLLECTIOH REQUEST:50.0HRS.FORHARDCOHHENTSREGARDING BURDENESTIHATETOTHEINFORHATIOH ANDRECORDSHANAGEHEHT BRANCH(HNBB7714),U.S.NUCLEARREGULATORY COHHISSION, HASHINGTOH, DC20555-0001 ANDTOTHEPAPERHORK REDUCTION PROJECT(3180-0104),
                                                                                                                                                                                                ~ IN NW
OFFICEOFHANAGEHENT ANDBUDGETMASHINGTON DC20503.FACILITYNAHE(1)R.E.GinnaNuclearPowerPlantDOCKETNUHBER(2)05000244LERNUHBER(6)YEARSEQUENTIAL 94--010--REVISION00PAGE(3)8OF10TEXT(Ifmorespaceisrequired, useadditional copiesofHRCForm366A)(17)B.ACTIONTAKENORPLANNEDTOPREVENTRECURRENCE:
                                                                                                                                                                                                <tl>O5541   I >
oAllCorrective Maintenance Electrical (CME),Preventive Maintenance Electrical (PME),andProtective Relay(PRI)procedures associated withPowellcircuitbreakerswerequarantined.
                                                                                                                                                                                                                              ~ IN
ThisincludedPME-50-04-52/12AX andthesevenotherprocedures forcircuitbreakers12AX,12AY,12BX,and12BY.oThequarantined procedures willbereviewedagainsttheEWDsanddrawingconventions todetermine ifanyothererrorsininterpretation ofswitchcontactstatusweremadeduringprocedure development.
                                                                                                                                                                                                                              <t<SNSIOIS>
Quarantined procedures thatarefoundtobeinerrorwillberevised.oATrainingWorkRequest(TWR)hasbeensubmitted toincorporate detailsofthiseventduringIndustryEventstraining, emphasize eventdetailsduringmaintenance trainingonPreferred PowerSources,andreinforce therequirement touseswitchdevelopment information duringtrainingonEWDs.oElectrical Engineering hasevaluated thedesignoftheoffsitepowerconfiguration, andhasrecommended amethodtoavoid4160Voltcircuitbreakertripsduringbreakertesting.oThecausesandeffectsoflossofpowertotheRCT-1radiation monitorterminalwillbereviewed, todetermine theneedforchangesindesignormaintenance ofthesystem.HRCFORH366A(5-92)
IO 52/     NISI  I/II ~                                                                                                                               Sl/  Otlt I 4/I SO 1$     IC                                                                                                                                            I~  NC NOIC:
NRCFORH366A(5-92)U.S.NUCLEARREGULATORY COHHISSION LICENSEEEVENTREPORT(LER)TEXTCONTINUATION APPROVEDBYOHBNO.3150.0104 EXPIRES5/31/95lESTIHATED BURDENPERRESPONSETOCOHPLYWITHTHISIHFORHATION COLLECTIOH REQUEST:50.0HRS~FORWARDCOHHENTSREGARDING BURDENESTIHATETOTHEINFORHATION ANDRECORDSHANAGEHENT BRANCH(HNBB7714),U.S.NUCLEARREGULATORY COHHISSION, WASHINGTON, DC20555-0001 ANDTOTHEPAPERWORK REDUCTION PROJECT(31400104),OFFICEOFHANAGEHENT ANDBUDGETWASHINGTON DC20503.FACILITYNAHE(1)R.E.GinnaNuclearPowerPlantDOCKETNUHBER(2)05000244YEAR010--00LERNUHBER(6)SEQUENTIAL REVISIONPAGE(3)9OF10TEXT(Ifmorespaceisrequired, useadditional copiesofNRCForm366A)(17)VI.ADDITIONAL INFORMATION A.FAILEDCOMPONENTS:
NOS   ~   ONtNIXN NNCN INNI ONC $ 2$ 7$ 144$
NoneB.PREVIOUSLERsONSIMILAREVENTS:AsimilarLEReventhistorical searchwasconducted withthefollowing results:Nodocumentation ofsimilarLEReventswiththe'samerootcauseatGinnaNuclearPowerPlantcouldbeiden-tified.However,LERs91-002and92-007weresimilarevents(startofaD/Gduetolossof4160Voltbusoroffsitepower)withdifferent rootcauses.C.SPECIALCOMMENTS:
St/     NIS IO/I IC                                                                                                                                  52/   Still</ISC CCIAI NO COI ~ I NO Sl/
NoneNRCFORM366A(5-92)
CO I Ol  IC I<IS C<<>>NINIOO     ~                                                                                                                                     NIXO IA ItOOI I O St/   XIIII/1$C                                                                        52/     OIO I 5/2 IC                                        ~ 2/ NIS I 5/21$
NRCFORN366A(5-92)U.S.NUCLEARREGULATORY CONNISSION L1CENSEEEVENTREPORT(LER)TEXTCONTINUATION APPROVEOBYONBNO.3150.0104 EXPIRES5/31/95ESTIHATED BURDENPERRESPONSETOCOHPLYMITHTHISINFORHATION COLLECTION REQUEST:50.0HRS.FORMARDCOHHENTSREGARDING BURDENESTINATETOTHEINFORNATIOH AHDRECORDSIIANAGEHENT BRANCH(NHBB7714)1U.S.NUCLEARREGULATORY CONHISSIONI MASHINGTON, DC20555-0001 AND.TOTHEPAPERMORK REDUCTIOH PROJECT(3140.0104)1 OFFICEOFHANAGENENT ANDBUDGETMASHINGTON DC20503.FACILITYNAHE(1)R.E.GinnaNuclearPowerPlantDOCKETNUHBER(2)YEAR0500024494PAGE(3)010pp10OF10'ERNUHBER(6SEQUENTIALREVISIONTEXT(Ifmorespaceisrequired, useadditional copiesofNRCForm366A)(17)51AIION114NN$45<VIIWtI+XNUNC5141ltWtllN7414252/ION27511$$2/751127474174AVOIIS151AWlNOICNtNNN 12$$4$N41N~INV<tttICOI2$>75111CINC$4AVNISISIAAIN<<WONfOSCN 114$4&i~IN~IN<<<ttt>>OOI2A>~tSO/1Sl/IC115<St/tt5$/2ItllNC~ttl/4$1/IC1151S2/tt5A/511>INO41IOl/N/212$/I~11$CANONOttONICNOI/Ntttltt/ISCANONONCANCNSt/N7511$/1$1755ICSt/OV512$/II1555IC52/S7$12$/2$~ISONOSl/OIISI24/12$2/StltIll/I5~IAWIC1155ICS2/Otlllll/141555SIAIXNI501VICCWNICAAXN1741N<tASNSNII>~IAIXN5CNVICC41~CI<<tAAOSNI4>>041II~IO41NVIll5IAlXNSCNVCCWNIISWhCN 14~INNW<tl>O5541 I>SIAISIN5OIVICC\CNOINNNIO~IN<t<SNSIOIS>
      $ 2/ WSI I/2$ $                                                                                                                                      lit    NO                                                    1$   IC 17                                                      COIN NO                                                                                  CO HRC FORN    366A      (5-92)}}
52/NISII/II~1$ICNOIC:NOS~ONtNIXNNNCNINNIONC$2$7$144$Sl/OtltI4/ISOI~NCSt/NISIO/IICCOI~INO52/Still</ISCCCIAINO$2/WSII/2$$17I<ISC<<>>NINIOO
~ItOOIIOSl/COIOlICSt/XIIII/1$CCOINNO52/OIOI5/2ICCOlitNONIXOIA~2/NISI5/21$1$ICHRCFORN366A(5-92)}}

Latest revision as of 09:31, 4 February 2020

LER 94-010-00:on 940916,volt Bus 12B Inadvertenly Tripped. Caused by Defective Procedure.Normal Power Supplies Restored & B Emergency Diesel Generator Stopped & Aligned for Auto standby.W/941017 Ltr
ML17263A811
Person / Time
Site: Ginna Constellation icon.png
Issue date: 10/17/1994
From: Mecredy R, St Martin J
ROCHESTER GAS & ELECTRIC CORP.
To: Andrea Johnson
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM), Office of Nuclear Reactor Regulation
References
LER-94-010, LER-94-10, NUDOCS 9410270363
Download: ML17263A811 (17)


Text

F'RIORIY'Y IACCELER.ATED RIDS PROC! %SIX REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)

ACCESSION NBR:9410270363 DOC.DATE: 94/10/17 NOTARIZED: NO DOCKET N FACIL:50-244 Robert Emmet Ginna Nuclear Plant, Unit 1, Rochester G 05000244 AUTH. NAME AUTHOR AFFILIATION ST MARTIN,J.T. Rochester Gas & Electric Corp.

MECREDY,R.C. Rochester Gas & Electric Corp.

RECIP.NAME RECIPIENT AFFILIATION

SUBJECT:

LER 94-010-00:on 940916,volt bus 12B inadvertenly tripped.

Caused by defective procedure. Normal power supple.es restored "B" emeregency diesel generator stopped

& & aligned for auto standby.W/941017 ltr.

DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR ENCL SIZE:

TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.

NOTES:License Exp date in accordance with 10CFR2,2.109(9/19/72). 05000244 RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PD1-3 PD 1 1 JOHNSON,A 1 1 INTERNAL AEOD/~GAB/DSQ 2 2 AEOD/SPD/RRAB 1 1 XHXF~02 1 1 NRR/DE/EELB 1 1' NRR/DE/EMEB l. 1 NRR/DORS/OEAB 1 NRR/DRCH/HHFB 1 1 NRR/DRCH/HICB 1 1 NRR/DRCH/HOLB 1 1 NRR/DRSS/PRPB 2 2 NRR/DSSA/SPLB 1 1 NRR/DSSA/SRXB 1 1 NRR/PMAS/IRCB-E 1 1 RES/DSIR/EIB 1 1 RGN1 FILE 01 1 1 EXTERNAL: EG&G BRYCE,J.H 2 2 L ST LOBBY WARD 1 1 NOAC MURPHY 1 G A 1 1 NOAC POORE,W. 1 1 NRC PDR 1 1 NUDOCS FULL TXT 1 1 N

VOTE TO ALL"Rl DS" RECIPIENTS:

PLEASE HELP L!S TO REDUCE iVASTE! CONTACTTIIE DOCL'iIEiTCOiTROL DESK, ROOXI PI-37 (EXT, 504-2033 ) TO ELIilliATEVOL'R RAMIE PROil DISTRIBL'TIOiLIS'I'S I'OR DOCL'iIEi'I'S 5'OL'Oi "I'L'I'.I)!

FULL TEXT CONVERSXON REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 26 ENCL 26

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StAIC ROCHESTER GAS AND ELECTRIC CORPORATION ~ 89 EAST AVENUE, ROCHESTER N.Y. f4649-000f ROBERT C. MECREDY TELEPHOME Vice President AAEACQM 716 546 2700 Ginned Nuclear Production October 17, 1994 UPS. Nuclear Regulatory Commission Document Control Desk Attn: Allen R. Johnson PWR Project Directorate I-3 Washington, D.C. 20555

Subject:

LER 94-010, Loss of 4160 Volt Bus 12B, Due to Defective Procedure, Results in Automatic Start of "B" Emergency Diesel Generator R.E. Ginna Nuclear Power Plant Docket No. 50-244 In accordance with 10 CFR 50.73, Licensee Event Report System, item (a) (2) (iv), which requires a report of, "any event or condition that resulted in a manual or"automatic actuation of any engineered safety feature (ESF), including the reactor protection system (RPS)", the attached Licensee Event Report LER 94-010 is hereby submitted.

This event has in no way affected the public's health and safety.

Very truly yours, Robert C. Mecredy xc: U.S. Nuclear Regulatory Commission Region I 475 Allendale Road King of Prussia, PA 19406 Ginna USNRC Senior Resident Inspector 9410270363 941017 PDR ADOCK 05000244 S PDR

NRC FORH 366 U.S. NUCLEAR REGULATORY COHHISSION APPROVED BY OHB NO. 3150 ~ 0104 (5-92) EXPIRES 5/31/95 ESTIHATED BURDEN PER RESPONSE TO COHPLY HITH THIS IHFORHATION COLLECTION REQUEST: 50.0 HRS.

LICENSEE EVENT REPORT (LER) FORHARD COMMENTS REGARDIHG BURDEN ESTIHATE TO THE INFORMATION AND RECORDS HANAGEMENT BRANCH (HNBB 7714), U.ST NUCLEAR REGULATORY COHHISSION ~

(See reverse for required number of digits/characters for each block) llASHIHGTON, DC 20555-0001, AND TO THE PAPERNORK REDUCTION PROJECT (3150-0104), OFFICE OF HANAGEMENT AND BUDGET WASHINGTON DC 20503.

FACILITY NAME (1) R. E. Ginna Nuclear Power Plant DOCKET NUHBER (2) PAGE (3) 05000244 10F 10-TITLE (4) Loss of 4160 Volt Bus 12B, Due to Defective Procedure, Results in Automatic Start of "B" Emergency Diesel Generator EVENT DATE (5) LER NUHBER (6) REPORT DATE (7) OTHER FACILITIES INVOLVED (8)

SEQUENTIAL REVISION FACILITY HAHE DOCKET NUHBER MONTH DAY YEAR YEAR MONTH DAY YEAR HUHBER NUHBER 09 16 94 94 --010-- 00 10 17 94 FACILITY HAHE DOCKET HUHBER OPERATING THIS REPORT IS SUBHITTED PURSUANT TO THE RE UIREHENTS OF 10 CFR 5: (Check one or mor e) (11)

HODE (9) N 20.402(b) 20.405(c) 50.73(a)(2)(iv) 73.71(b)

PNER 20.405(a )(1)(i) 50.36(c)(1) 50.73(a)(2)(v) 73.71 (c)

LEVEL (10) 20.405(a)(1)(ii) 50.36(c)(2) 50 '3(a)(2)(vii) OTHER 20.405(a)(1)(iii) 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) (Specify in 20 '05(a)(1)(iv) 50.73(a)(2)(ii) 50 73(a) (2) (vi i i ) (0) Abstract below

~

and in Text, 20.405(a)(1)(v) 50.73(a)(2)(III) 50.73(a)(2)(x) NRC Form 366A)

LICENSEE CONTACT FOR THIS LER (12)

NAME John T. St. Martin - Director, Operating Experience TELEPHONE HUHBER (Include Area Code)

(315) 524-4446 COMPLETE ONE LINE FOR EACH COHPONENT FAILURE DESCRIBED IN THIS REPORT (13)

REPORTABLE REPORTABLE CAUSE SYSTEH COHPONENT HANUFACTURER CAUSE SYSTEM COHPONENT HANUFACTURER TO HPRDS TO NPRDS SUPPLEHENTAL REPORT EXPECTED (14) EXPECTED HOHTH DAY YEAR YES SUBHISS ION (lf yes, complete EXPECTED SUBHISSION DATE).

X NO DATE (15)

ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (16)

On September 16, 1994, at approximately 1018 EDST, with the reactor at approximately 98% steady state power, the 4160 Volt circuit breaker that was supplying power to 4160 Volt bus 12B was inadvertently tripped. This resulted in deenergization of bus 12B and momentary loss of power to uBn train 480 Volt safeguards buses 16 and 17.

The nBn Emergency Diesel Generator started and reenergized buses 16 and 17, as per design.

The underlying cause of the inadvertent circuit breaker trip was a defective procedure. This event is NUREG-1022 Cause Code (D).

Corrective action to preclude repetition is outlined in Section V.B.

HRC FORM 366 (5-92)

NRC FORH 366A U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150.0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY 'NITN THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.

FORMARD COMHENTS REGARDING BURDEN ESTIHATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AND RECORDS HANAGEHENT BRANCH TEXT CONTINUATION (MNBB 7T14), U.S. NUCLEAR REGULATORY COHHISSION, llASNINGTON, DC 20555 0001 AND TO THE PAPERISRK REDUCTION PROJECT (3140.0104), OFFICE OF MANAGEMENT AND BUDGET llASHINGTON DC 20503.

FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR SEQUENT IAL REVISION R.E. Ginna Nuclear Power Plant 05000244 2 OF 10 94 010 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

PRE-EVENT PLANT CONDITIONS The plant was at approximately 98% steady state reactor power, with no major operational activities in progress. All offsite power to 4160 Volt buses 12A and 12B was being supplied from Circuit 767 (34.5 KV offsite power source). Circuit 767 was supplying power through 34.5 KV to 4160 Volt transformer 12B (12B transformer), via 4160 Volt circuit breakers 52/12BY (to bus 12A) and 52/12BX (to bus 12B). (See the attached sketch of the offsite power distribution system.) 34.5 KV to 4160 Volt transformer 12A (12A transformer),

which is .supplied from Circuit 751 (34.5 KV offsite power source),

was deenergized and declared inoperable to permit previously scheduled maintenance and testing of the 12A transformer and associated circuit breakers.

At the time of this event, trip testing was in progress on 4160 Volt circuit breaker 52/12AX (alternate power supply from the 12A transformer to bus 12B), in accordance with Maintenance Procedure PME-50-04-52/12AX, "Bus 12B Alternate Power Source." Plant electricians had just notified the Control Room operators that circuit breaker 12AX would be closed while in the "test" position.

II. DESCRIPTION OF EVENT A. DATES AND APPROXIMATE TIMES OF MAJOR OCCURRENCES:

o September 16, 1994, 1018 EDST: Event date and time.

o September 16, 1994, 1018 EDST: Discovery date and time.

o September 16, 1994, 1018 EDST: Control Room operators verify the "B" Emergency Diesel Generator (D/G) operation and safeguards buses 16 and 17 energized.

o September 16, 1994, 1120 EDST: Circuit 751 declared operable at the completion of maintenance and testing.

o September 16, 1994, 1125 EDST: Safeguards buses 16 and 17 were resupplied from Circuit 751.

o September 16, 1994, 1142 EDST: The "B" Emergency D/G was stopped and realigned for auto standby.

NRC FORM 366A (5-92)

NRC FORM 366A U.S. NKLEAR REGULATORY COMMISSION APPROVED BY OMB NO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY lllTH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.

FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER) THE IHFORHATION AND RECORDS HANAGEMENT BRANCH TEXT CONTINUATION (MNBB 7714), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555-0001 AND TO THE PAPERWORK REDUCTION PROJECT (3140.0104), OFFICE OF HANAGEHENT AND BUDGET WASHINGTON DC 20503.

FACILITY NAME (1) DOCKET NUMBER (2) LER NUMBER (6) PAGE (3)

YEAR SEQUENTIAL REVISION R.E. Ginna Nuclear Power Plant 05000244 3 OF 10 94 -- 010-- 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

B. EVENT:

On September 16, 1994, at approximately 1018 EDST, with the reactor at approximately 98~ steady state full power, the Control Room received numerous annunciator alarms. The Control Room operators immediately determined that 4160 Volt bus 12B was deenergized, that "B" train 480 Volt safeguards buses 16 and 17 had lost their power supply from bus 12B, and that the "B" Emergency D/G had started and was tied to safeguards buses 16 and 17.

The Control Room operators immediately performed the appropriate actions of Abnormal Procedure AP-ELEC.1 (Loss of 12A And/Or 12B Transformer) to stabilize the plant, and verified that the "B" Emergency D/G was operating properly and that safeguards buses 16 and 17 were energized. The Control Room operators observed that bus 12B had deenergized and displayed zero (0) voltage, because the circuit breaker supplying power to bus 12B had tripped. The loss of power to bus 12B resulted in undervoltage on safeguards'buses 16 and 17, and the "B" Emergency D/G started and reenergized these buses, as per design.

When the scheduled maintenance and testing was completed on the 12A transformer and associated breakers, the Control Room operators cleared the holds on Circuit 751 and th'e 12A transformer. A switching order was used to restore Circuit 751, 12A transformer, and associated breakers to operable status. 34.5 KV circuit breaker 75112 was closed, energizing the 12A transformer.

The Control Room operators directed plant electricians to investigate the failure, and there were no anomalies noted. At approximately 1120 EDST, using Equipment Restoration procedure ER-ELEC.1 (Restoration of Offsite Power), the Control Room operators closed circuit breaker 12AX, energizing bus 12B from the 12A

't transformer.

At approximately 1125 EDST, "B" train safeguards buses 16 and 17 were resupplied by offsite power, via Circuit 751 approximately 1142 EDST, September 16, 1994, the "B" Emergency D/G was stopped and realigned for auto standby.

NRC FORM 366A (5-92),

NRC FORM 366A U.S. NUCLEAR REGULATORY COHHISSION APPROVED BY OHB NO. 3150 ~ 0104 (5-92) EXPIRES 5/31/95 ESTIMATED BURDEN PER RESPOHSE TO COHPLY WITH THIS INFORHAT ION COLLECTION REQUEST: 50.0 HRS.

FORWARD COMHENTS REGARDING BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER) THE INFORHATION AND RECORDS HANAGEHENT BRANCH TEXT CONTINUATION (HNBB 7714), U.S. NUCLEAR REGULATORY COMHISSION, WASHIHGTON, DC 20555-0001 AND TO THE PAPERWORK REDUCTION PROJECT (3140-0104), OFFICE OF MANAGEMENT AND BUDGET WASHINGTON DC 20503.

FACILITY NAHE (1) DOCKET NUHBER (2) LER NUMBER (6) PAGE (3)

YEAR SEOUENTIAL REVISION R.E. Ginna Nuclear Power Plant 05000244 4 OF 10 010 00 TEXT (tf more space is required, use additional copies of NRC Form 366A) (17)

C. I NOPERABLE STRUCTURES i COMPONENTS i OR SYSTEMS THAT CONTR BUTED TO I THE EVENT:

Circuit 751 was inoperable for scheduled maintenance of the 12A transformer, beginning at approximately 0717 EDST on September 15, 1994, and was restored to service at approximately 1120 EDST on September 16, 1994..

D. OTHER SYSTEMS OR SECONDARY FUNCTIONS AFFECTED:

The momentary loss of power caused a loss of program memory for radiation monitor terminal RCT-1 and associated channels R-12A (Containment ventilation effluent), R-14A (Plant ventilation ef fluent), R-31 (>>A>> steam line monitor), and R-32 (B>> steam line monitor) .

E. METHOD OF DISCOVERY:

This event was immediately apparent due to Main Control Board alarms and indications in the Control Room when bus 12B was deenergized.

These included Main Control Board annunciators J-5 (gll or gl2 Transformer Out of Synch), J-6 (4KV Main or Tie Breaker Trip), J-7 (480 V Main or Tie Breaker Trip), J-8 (480V MCC Supply Breaker Trip), and L-28 (12B XFMR or 12B Bus Trouble).

F. OPERATOR ACTION:

Following the undervoltage condition on buses 16 and 17, the >>B>>

Emergency D/G automatically started and energized these buses. The Control Room operators immediately performed the appropriate actions and verified that the >>B>> Emergency D/G was operating properly, and that safeguards buses 16 and 17 were energized.'he Control Room operators cleared the holds on Circuit 751, restored offsite power to buses 16 and 17, stopped the >>B>> Emergency D/G, and realigned it for auto standby.

HRC FORM 366A (5-92)

N NRC FORH 366A U.S. NUCLEAR REGULATORY COHHISSION APPROVED BY OHB NO. 3150.0104 (5-92) EXPIRES 5/31/95 ESTIHATED BURDEN PER RESPONSE TO COHPLY WITH THIS INFORHATION COLLECTIOH REQUEST: 50.0 HRS.

FORWARD COHHEHTS REGARDIHG BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER) THE INFORHATION .AHD RECORDS HANAGEMEHT BRANCH TEXT CONTINUATION (MNBB 7714), U.S. NUCLEAR REGULATORY COHHISSIOH ~

'WASHINGTON, DC 20555-0001 AND TO THE PAPERWORK REDUCTION PROJECT (3110.0104), OFF ICE OF MAHAGEHEHT AHD BUDGET WASHINGTON DC 20503.

FACILITY NAHE (1) DOCKET NUHBER (2) LER NUHBER (6) PAGE (3)

YEAR SEQUENTIAL REVISION R.E. Ginna Nuclear Power Plant 05000244 5 OF 10 94 010 00 TEXT (If more space is required, use additionaI copies of HRC Form 366A) (17)

At approximately 1354 EDST on September 16, 1994, the Shift Supervisor notified the NRC per 10 CFR 50.72 (b) (2) (ii) .

,SAFETY SYSTEM RESPONSES:

The >>B>> Emergency D/G automatically started due to the undervoltage condition on buses 16 and 17, displayed proper voltage and frequency and closed into safeguards buses 16 and 17 to supply emergency power.

III. CAUSE OF EVENT IMMEDIATE CAUSE:

The automatic actuation of the .>>B>> Emergency D/G was due to undervoltage on safeguards buses 16 and 17.

B. INTERMEDIATE CAUSE:

The undervoltage on safeguards buses 16 and 17 was due to bus 12B being deenergized when circuit breaker 12BX tripped due to an electrical interlock.

C. ROOT CAUSE:

The underlying cause of the tripping of circuit breaker 12BX was a defective procedure. During development of this procedure (PME-50-04-52/12AX), the switch development of an elementary wiring diagram (EWD) was not used as a reference in determining post-maintenance operability testing. The procedure is for preventive maintenance of Model P-51000 POWL-VAC metal-clad switchgear, manufactured by Powell Electrical Mfg. Co.

There is a normally open >>s>> contact (52S/12AX) in the trip circuit for breaker 12BX that comes from breaker 12AX, to prevent both 4160 Volt circuit breakers (12AX and 12BX) from being closed simultaneously. Contact 52S/12AX is located in the mechanism-operated cell (MOC) switch of these'ircuit breakers. These >>s>>

contacts change state with movement of the breaker mechanism.

Technical reviewers incorrectly assumed that the cell switch would not function when in "test", and therefore concluded that with breaker 12AX in "test", contact 52S/12AX would not close.

NRC FORM 366A (5-92)

NRC FORM 366A U.S. NUCLEAR REGULATORY COHHISSIOH APPROVED BY OHB NO. 3150-0104 (5-92) EXP I RES 5/31/95 EST IHATED BURDEN PER RESPONSE TO COHPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.

FORWARD COHHEHTS REGARD IHG BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AHD RECORDS HAHAGEMENT BRANCH TEXT CONTINUATION (MNBB 7714), U.ST NUCLEAR REGULATORY COHHISSIOH, WASHINGTON, DC 20555-0001 AHD TO THE PAPERWORK REDUCTION PROJECT (3140-0104), OFFICE OF MANAGEMENT AND BUDGET 'WASHIHGTON DC 20503.

FACILITY NAHE (1) DOCKET NUMBER (2) LER NUHBER (6) PAGE 3)

YEAR SEQUENTIAL REVISION R.E. Ginna Nuclear Power Plant 05000244 6 OF 10 94 -- 010-- pp

~y TEXT (If more space is required, use additional copies of HRC Form 366A) (17)

There is another contact in series with the 52S/12AX contact that operates from the synchronizing switch for the circuit breaker.

This contact is closed when the synch switch is in the "Off" position. When reviewing the EWD, technical reviewers misinterpreted the function of this contact, and assumed that the contact was closed when the synch switch was in the "On" position.

Thus, the trip logic for circuit breaker 12BX was made up when the synch switch was in the "Off" position as soon as breaker 12AX closed, causing breaker 12BX to trip per design.

After further investigation, it was discovered that this same incorrect interpretation of switch contact status was made for circuit breakers 12AX, 12AY, and 12BY. There were a total of eight defective procedures, one preventive and one corrective maintenance procedure for each of the four circuit breakers.

This event is NUREG-1022 Cause Code (D), Defective Procedure.

This loss of power meets the NUMARC 93-01, "Industry Gui'deline for Monitoring the Effectiveness of Maintenance at Nuclear Power Plants", definition of a "Maintenance Preventable Functional Failure".

IV. ANALYSIS OF EVENT:

This event is reportable in accordance with 10 CFR 50.73, Licensee Event Report System, item (a) (2) (iv), which requires a report of, "any event or condition that resulted in a manual or automatic actuation of any engineered safety feature (ESF), including the reactor protection system (RPS)", in that the starting of the "B" Emergency D/G was an automatic actuation of an ESF system.

HRC FORM 366A (5-92)

NRC FORH 366A UPS. NUCLEAR REGULATORY COHHISSION APPROVED BY OHB NO. 3150-0104 (5-92) EXPIRES 5/31/95 ESTIHATED BURDEN PER RESPONSE TO COHPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.

FORWARD COHHENTS REGARDING BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AND RECORDS MAHAGEHEHT BRANCH TEXT CONTINUATION (HHBB 7714), U.ST NUCLEAR REGULATORY COHHISSION, WASHINGTOH, DC 20555-0001 AHD TO THE PAPERWORK REDUCTION PROJECT (3140-0104), OFFICE OF HANAGEHENT AND BUDGET WASHINGTON DC 20503.

FACILITY NAME (1) DOCKET NUHBER (2) LER NUHBER (6) PAGE (3)

YEAR'EQUENTIAL REVISION R.E. Ginna Nuclear Power 'Plant 05000244 7 OF 10 94 010 00 TEXT (If more space is required, use additional copies of HRC Form 366A) (17)

An assessment was performed considering both the safety consequences and implications of this event with the following results and conclusions:

o All reactor control and protection systems performed as designed.

o Circuit breaker 12BX operated as designed and tripped when it received a valid trip signal.

o The "B" Emergency D/G operated as designed by starting and supplying emergency power to safeguards buses 16 and 17.

o Circuit 767 was still in operation supplying power to the "A" train safeguards buses; subsequently Circuit 751 was lined up to supply power to the "B" train safeguards buses as permitted by plant technical specifications.

o Radiation monitors R-12A and R-14A are redundant to monitors R-12 and R-14. R-12 and R-14 remained operable during this event.

o Loss of radiation monitors R-31 and R-32 is compensated for by local monitoring of steam line radiation, which would be performed by plant personnel, as specified in emergency operating procedures.

Based on the above, safety wa's assured at all times.

it can be concluded that the public's health and V. CORRECTIVE ACTION A. ACTION TAKEN TO RETURN AFFECTED SYSTEMS TO PRE-EVENT NORMAL STATUS:

o Safeguards buses 16 and 17 normal power supplies were restored via Circuit 751, and the "B" Emergency D/G was stopped and aligned for auto standby.

o Circuit breaker 12BX was cycled to confirm that the breaker responded as designed.

o The RCT-1 radiation monitor terminal and associated channels R-12A, R-14A, R-31, and R-32 were reprogrammed and declared operable.

HRC FORH 366A (5-92)

NRC FORH 366A U.S. NUCLEAR REGULATORY COHHISSION APPROVED BY OHB NO. 3150-0104 (5-92) EXP I RES 5/31/95 ESTIHATED BURDEN PER RESPOHSE TO COHPLY MITH THIS INFORHATION COLLECTIOH REQUEST: 50.0 HRS.

FORHARD COHHENTS REGARDING BURDEN ESTIHATE TO LICENSEE EVENT REPORT (LER) THE INFORHATIOH AND RECORDS HANAGEHEHT BRANCH TEXT CONTINUATION (HNBB 7714), U.S. NUCLEAR REGULATORY COHHISSION, HASHINGTOH, DC 20555-0001 AND TO THE PAPERHORK REDUCTION PROJECT (3180-0104), OFFICE OF HANAGEHENT AND BUDGET MASHINGTON DC 20503.

FACILITY NAHE (1) DOCKET NUHBER (2) LER NUHBER (6) PAGE (3)

YEAR SEQUENTIAL REVISION R.E. Ginna Nuclear Power Plant 05000244 8 OF 10 94 -- 010-- 00 TEXT (If more space is required, use additional copies of HRC Form 366A) (17)

B. ACTION TAKEN OR PLANNED TO PREVENT RECURRENCE:

o All Corrective Maintenance Electrical (CME), Preventive Maintenance Electrical (PME), and Protective Relay (PRI) procedures associated with Powell circuit breakers were quarantined. This included PME-50-04-52/12AX and the seven other procedures for circuit breakers 12AX, 12AY, 12BX, and 12BY.

o The quarantined procedures will be reviewed against the EWDs and drawing conventions to determine interpretation of switch contact status were made during if any other errors in procedure development. Quarantined procedures that are found to be in error will be revised.

o A Training Work Request (TWR) has been submitted to incorporate details of this event during Industry Events training, emphasize event details during maintenance training on Preferred Power Sources, and reinforce the requirement to use switch development information during training on EWDs.

o Electrical Engineering has evaluated the design of the offsite power configuration, and has recommended a method to avoid 4160 Volt circuit breaker trips during breaker testing.

o The causes and effects of loss of power to the RCT-1 radiation monitor terminal will be reviewed, to determine the need for changes in design or maintenance of the system.

HRC FORH 366A (5-92)

NRC FORH 366A U.S. NUCLEAR REGULATORY COHHISSION APPROVED BY OHB NO. 3150.0104 (5-92) EXP I RES 5/31/95 l

ESTIHATED BURDEN PER RESPONSE TO COHPLY WITH THIS IHFORHATION COLLECTIOH REQUEST: 50.0 HRS ~

FORWARD COHHENTS REGARDING BURDEN ESTIHATE TO LICENSEE EVENT REPORT (LER) THE INFORHATION AND RECORDS HANAGEHENT BRANCH TEXT CONTINUATION (HNBB 7714), U.S. NUCLEAR REGULATORY COHHISSION, WASHINGTON, DC 20555-0001 AND TO THE PAPERWORK REDUCTION PROJECT (3140 0104), OFFICE OF HANAGEHENT AND BUDGET WASHINGTON DC 20503.

FACILITY NAHE (1) DOCKET NUHBER (2) LER NUHBER (6) PAGE (3)

YEAR SEQUENTIAL REVISION R.E. Ginna Nuclear Power Plant 05000244 9 OF 10 010-- 00 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

VI. ADDITIONAL INFORMATION A. FAILED COMPONENTS:

None B. PREVIOUS LERs ON SIMILAR EVENTS:

A similar LER event historical search was conducted with the following results: No documentation of similar LER events with the'same root cause at Ginna Nuclear Power Plant could be iden-tified. However, LERs91-002 and 92-007 were similar events (start of a D/G due to loss of 4160 Volt bus or offsite power) with different root causes.

C. SPECIAL COMMENTS:

None NRC FORM 366A (5-92)

NRC FORN 366A U.S. NUCLEAR REGULATORY CONNISSION APPROVEO BY ONB NO. 3150.0104 (5-92) EXPIRES 5/31/95 ESTIHATED BURDEN PER RESPONSE TO COHPLY MITH THIS INFORHATION COLLECTION REQUEST: 50.0 HRS.

FORMARD COHHENTS REGARDING BURDEN ESTINATE TO L1CENSEE EVENT REPORT (LER) THE INFORNATIOH AHD RECORDS IIANAGEHENT BRANCH TEXT CONTINUATION (NHBB 7714)1 U.S. NUCLEAR REGULATORY CONHISSIONI MASHINGTON, DC 20555-0001 AND .TO THE PAPERMORK REDUCTIOH PROJECT (3140.0104)1 OFFICE OF HANAGENENT AND BUDGET MASHINGTON DC 20503.

FACILITY NAHE (1) DOCKET NUHBER (2) NUHBER (6 PAGE (3)

YEAR SEQUENT IAL REVISION R.E. Ginna Nuclear Power Plant 10'ER 05000244 94 pp 10 OF 010 TEXT (If more space is required, use additional copies of NRC Form 366A) (17)

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