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| {{#Wiki_filter:CATEGORY1REGULATOYINFORMATIONDISTRIBUTIONSYSTEM(RIDS)ACCESS1'ONNBR:9606260154DOC.DATE:96/06/20NOTARIZED:NOFACIL:50-244RobertEmmetGinnaNuclearPlant,Unit1,RochesterAUTH.NAMEAUTHORAFFILIATIONST.MARTIN,J.T.RochesterGas&ElectricCorp.MECREDY,R.C.RochesterGas&ElectricCorp.RECIP.NAMERECIPIENT'AFFILIATIONDOCKETG05000244 | | {{#Wiki_filter:CATEGORY1REGULATOYINFORMATION DISTRIBUTION SYSTEM(RIDS)ACCESS1'ON NBR:9606260154 DOC.DATE: |
| | 96/06/20NOTARIZED: |
| | NOFACIL:50-244 RobertEmmetGinnaNuclearPlant,Unit1,Rochester AUTH.NAMEAUTHORAFFILIATION ST.MARTIN,J.T. |
| | Rochester Gas&ElectricCorp.MECREDY,R.C. |
| | Rochester Gas&ElectricCorp.RECIP.NAME RECIPIENT |
| | 'AFFILIATION DOCKETG05000244 |
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| ==SUBJECT:== | | ==SUBJECT:== |
| LER96-006-00:on960521,discoveredcontainmentpenetrationnotinrequiredstatus.Causedbypersonnelerror.Installedflangeinsidecontainmentpenetration2.W/960620ltr.DISTRIBUTIONCODE:IE22TCOPIESRECEIVED:LTRENCLSIZE:TITLE:50.73/50.9LicenseeEventReport(LER),IncidentRpt,etc.NOTES:LicenseExpdateinaccordancewith10CFR2,2.109(9/19/72).A'5000244(IRECIPIENTIDCODE/NAMEPDl-1PDINTERNAL:AEOD/SPD/RABgF'ZEECENEENRR/DE/EEL'BNRR/DRCH/HHFBNRR/DRCH/HOLBNRR/DRPM/PECBNRR/DSSA/SRXBRGN1FILE01EXTERNAL:LSTLOBBYWARDNOACMURPHYFG~ANRCPDRCOPIESLTTRENCL112211111111111111111111RECIPIENTIDCODE/NAMEVISSINGFG.AEOD/SPD/RRABNRR/DE/ECGBNRR/DE/EMEBNRR/DRCH/HICBNRR/DRCH/HQMBNRR/DSSA/SPLBRES/DSIR/EIBLITCOBRYCEFJHNOACPOOREFW.NUDOCSFULLTXTCOPIESLTTRENCL1111111111111111221111D.NNOTETOALL"RIDS"RECIPIENTS:PLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK/ROOMOWFN5D-5(EXT.415-2083)TOELIMINATEYOURNAMEFROMDISTRIBUTIONLISTSFORDOCUMENTSYOUDON'TNEED!FULLTEXTCONVERSIONREQUIREDTOTALNUMBEROFCOPIESREQUIRED:LTTR25ENCL25 ANDROCHESTERGASANDElECTRICCORI@RATION~89EASTAVENUE,ROCHESTER,N.Y.IrI64'rrDDTAREACODE7165'-27tXtROBERTC.MECREDYVicePresidentNucteorOperationsJune20,1996U.S.NuclearRegulatoryCommissionDocumentControlDeskAttn:GuyS.VissingProjectDirectorateI-1Washington,D.C.20555 | | LER96-006-00:on 960521,discovered containment penetration notinrequiredstatus.Causedbypersonnel error.Installed flangeinsidecontainment penetration 2.W/960620 ltr.DISTRIBUTION CODE:IE22TCOPIESRECEIVED:LTR ENCLSIZE:TITLE:50.73/50.9 LicenseeEventReport(LER),IncidentRpt,etc.NOTES:License Expdateinaccordance with10CFR2,2.109(9/19/72). |
| | A'5000244(IRECIPIENT IDCODE/NAME PDl-1PDINTERNAL: |
| | AEOD/SPD/RAB gF'ZEECENEENRR/DE/EEL'B NRR/DRCH/HHFB NRR/DRCH/HOLB NRR/DRPM/PECB NRR/DSSA/SRXB RGN1FILE01EXTERNAL: |
| | LSTLOBBYWARDNOACMURPHYFG~ANRCPDRCOPIESLTTRENCL112211111111111111111111RECIPIENT IDCODE/NAME VISSINGFG. |
| | AEOD/SPD/RRAB NRR/DE/ECGB NRR/DE/EMEB NRR/DRCH/HICB NRR/DRCH/HQMB NRR/DSSA/SPLB RES/DSIR/EIB LITCOBRYCEFJHNOACPOOREFW.NUDOCSFULLTXTCOPIESLTTRENCL1111111111111111221111D.NNOTETOALL"RIDS"RECIPIENTS: |
| | PLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK/ROOMOWFN5D-5(EXT. |
| | 415-2083) |
| | TOELIMINATE YOURNAMEFROMDISTRIBUTION LISTSFORDOCUMENTS YOUDON'TNEED!FULLTEXTCONVERSION REQUIREDTOTALNUMBEROFCOPIESREQUIRED: |
| | LTTR25ENCL25 ANDROCHESTER GASANDElECTRICCORI@RATION |
| | ~89EASTAVENUE,ROCHESTER, N.Y.IrI64'rrDDTAREACODE7165'-27tXtROBERTC.MECREDYVicePresident NucteorOperations June20,1996U.S.NuclearRegulatory Commission DocumentControlDeskAttn:GuyS.VissingProjectDirectorate I-1Washington, D.C.20555 |
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| ==Subject:== | | ==Subject:== |
| LER96-006,ContainmentPenetrationNotinRequiredStatus,DuetoPersonnelErrors,ResultsinPotentialforUncontrolledReleaseofRadioactiveMaterialR.E.GinnaNuclearPowerPlantDocketNo.50-244Inaccordancewith10CFR50.73,LicenseeEventReportSystem,items(a)(2)(ii),(a)(2)(v)(C)and(a)(2)(v)(D),whichrequireareportof,"Anyoperationorconditionprohibitedbytheplant'sTechnicalSpecifications"or"Anyeventorconditionthatalonecouldhavepreventedthefulfillmentofthesafetyfunctionofstructuresorsystemsthatareneededto...Controlthereleaseofradioactivematerial;orMitigatetheconsequencesofanaccident",theattachedLicenseeEventReportLER96-006isherebysubmitted.Thiseventhasinnowayaffectedthepublic'shealthandsafety.Verylyyours,RobertC.Mecredyxc:U.S.NuclearRegulatoryCommissionMr.GuyS.Vissing(MailStop14C7)PWRProjectDirectorateI-1Washington,D.C.,20555U.S.NuclearRegulatoryCommissionRegionI475Allendale-RoadKingofPrussia,PA19406U.S.NRCGinnaSeniorResidentInspector9606260i54960620PDRADQCK050002448PDRy/~JP NRCFORM366(4.95)U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)(Seereverseforrequirednumberofdigits/charactersforeachblock)APPROVEDBYOMBNO.3150-0104EXPIRES04/30/BBESTIMATEDBURDENPERAESPONSEToCOMPLYWITHTHISMANDATORYINFORMATIONCOLLECTIONREQUEST:50.0HRS.REPOATEDLESSONSLEARNEDAREINCORPORATEDINTOTHEUCENSINGPROCESSANDFEDBACKToINDUSTRY.FORWARDCOMMENTSREGARDINGBURDENESTIMATEToTHEINFORMATIONANDRECORDSMANAGEMENTBRANCHIT-6F33),U.S.NUCLEARREGULATORYCOMMISSION,WASHINGTON,DC20555.0001,ANDToTHEPAPEAWORKREDUCTIONPROJECTFACILITYkAME(1)R.E.GinnaNuclearPowerPlantOOCKETNUMBER(2)05000244PAGE(3)1OF8B(4)AContainmentPenetrationNotinRequiredStatus,DuetoPersonnelErrors,Results'inPotentialforUncontrolledReleaseofRadioactiveMaterialMONTHDAYYEAR052196EVENTDATE(5)LERNUMBER(6)SEQUENTIALREVISIONNUMBER.,NUMBER96-006-00MONTHDAYYEAR062096REPORTDATE(7)FACILITYNAMEFACILITYNAMEOTHERFACILITIESINVOLVED(6)OOCKETNUMBEROOCKETNUMBEROPERATINGMODE(9)POWERLEVEL(10)kAME000THISREPORTISSUBMITTEDPURmore)(11)50.73(a)(2)(viii]50.73(a)(2)(x)50.73(a)(2)(i)50.73(a)(2)(ii)20.2203(a)(2)(v)20.2203(a)(3)(i)20.2201(b)20.2203ta)tl)73.7150.73(a)(2)(iii)50.73(a)(2)(iv)20.2203(a)(3)(ii)20.2203(a)(4)20.2203(a)(2)(i)20.2203(a)(2)(ii)OTHERSpecifyinAbstractbeloworinNRCForm366A20.2203(a)(2)(iii)50.36(c)(1)50.73(a)(2)(v)20.2203(a)(2)(iv)50.36(c)(2)50.73(a)(2)(vii)LICENSEECONTACTFORTHISLER(12)ELBPIIOkENUMBER(IncludeAreaCoda>SUANTTOTHEREQUIREMENTSOF10CFRE:(CheckoneorJohnT.St.Martin-TechnicalAssistant(716)771-3641COMPLETEONELINEFOREACHCOMPONENTFAILUREDESCRIBEDINTHISREPORT(13)CAUSESYSTEMCOMPONENTMANUFACTURERAEPOATABLETONPADSCAUSESYSTEMCOMPONENTMANUFACTURERREPORTABLEToNPRDSSUPPLEMENTALREPORTEXPECTED(14)YES(lfyes,completeEXPECTEDSUBMISSIONDATE).XNOEXPECTEDSUBMISSIONDATE(15)MONTHDAYYEARABSTRACT(Limitto1400spaces,l.e.,approximately15single-spacedtypewrittenlines)(16)OnMay21,1996,atapproximately0900EDST,withtheplantinMode6withcorealterationsandmovementofirradiatedfuelassemblieswithincontainmentinprogress,itwasdiscoveredthatacontainmentpenetrationwasnotintherequiredstatusforrefuelingoperations,allowingdirectaccessfromthecontainmentatmospheretotheoutsideatmosphere.ImmediatecorrectiveactionwastakeninaccordancewithGinnaImprovedTechnicalSpecificationsLimitingConditionsforOperation3.9.3.A.1and3.9.3.A.2tosuspendcorealterationsandsuspendmovementofirradiatedfuelassemblieswithincontainment.Thecontainmentpenetrationwasrestoredtotherequiredstatusforrefuelingoperations,andrefuelingoperationswerepermittedtoresume.Theunderlyingcauseofthepenetrationnotbeingintherequiredstatusforrefuelingoperationswaspersonnelerrors.ThiseventisNUREG-1022CauseCode(A).CorrectiveactiontopreventrecurrenceisoutlinedinSectionV.B.NRCFORM366(4-95) | | LER96-006,Containment Penetration NotinRequiredStatus,DuetoPersonnel Errors,ResultsinPotential forUncontrolled ReleaseofRadioactive MaterialR.E.GinnaNuclearPowerPlantDocketNo.50-244Inaccordance with10CFR50.73,LicenseeEventReportSystem,items(a)(2)(ii),(a)(2)(v)(C)and(a)(2)(v)(D),whichrequireareportof,"Anyoperation orcondition prohibited bytheplant'sTechnical Specifications" or"Anyeventorcondition thatalonecouldhaveprevented thefulfillment ofthesafetyfunctionofstructures orsystemsthatareneededto...Controlthereleaseofradioactive material; orMitigatetheconsequences ofanaccident", |
| NRCFORM366AI4-95)LICENSEEEVENTREPORT(LER),TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAMEIl)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBERI6)YEARSEQUENTIALREVISIONNUMBERNUMBER96-006-00PAGEI3)2OF8TEXT(Ifmorespaceisrequired,useadditionalcopiesofNRCForm366A/(17)PRE-EVENTPLANTCONDITIONS:Containment(CNMT)penetrationI)'2(referredtoasP-2)isthe"S/GCommunicationsFlangePenetration"normallyusedforsupportofroutinesteamgenerator(S/G)maintenanceandinspectionactivitiesduringrefuelingoutages.WheninModes5or6,normallyroutedthroughP-2areclosed-circuittelevision(CCTV)cablesandothercommunicationscables.Forthe1996Refuelingoutage,P-2wasalsousedtoprovidearouteforadditionalCCTVcablesandrigidpipesfrom'theoutsideintoCNMT,toprovideservices(communications,airandargon)foractivitiesassociatedwithreplacementoftheS/Gs.Thesepipeswerea3"lineforserviceairanda11/2"lineforargon.StationModificationproceduresSM-10034-10.01(TemporaryServiceAirSystemforSGRP)andSM-10034-'l0.03(Installation5RemovalofTemporaryCCTVandCommunications)wereusedtocontrolthetemporaryinstallationandsubsequentremovaloftheseservices.OnMay19,1996,inpreparationforrefuelingthereactor,GinnaplantstaffcheckedtheconfigurationofP-2andverifiedthattheconfigurationcompliedwithGinnaImprovedTechnicalSpecifications(ITS)LimitingConditionforOperation(LCO)3.9.3.c,whichstatesthateachpenetrationprovidingdirectaccessfromtheCNMTatmospheretotheoutsideatmosphereshallbeisolated,orclosedbyanequivalentisolationmethod.Thesemethodsincludeuseofmaterialthatcanprovideatemporary,atmosphericpressure,ventilationbarrier.ContractorsupervisionweresubsequentlynotifiednottodisturbtheconfigurationofP-2untilafterthecompletionofrefueling.DuringthedayshiftonMay20,1996,asdirectedbycontractorsupervision,contractormaintenancepersonnelremovedmuchofthetemporaryserviceairandargonlinesinsideCNMT,asdirectedbyprocedureSM-10034-10.01.ContractorsupervisionhadbeencautionedbyGinnastaffnottoremovethe3"and11/2"pipespoolpiecesthatwereinsidethesealforP-2andthefirstvalvesoneachsideofP-2insideandoutsideofCNMT.Nevertheless,attheendoftheirshift(atapproximately1800EDST),thecontractormaintenancepersonnelremovedthesespoolpiecesandvalves.AdditionalpipingoutsideCNMTwasleftinplaceuntilthenextday.OnMay21,1996,atapproximately0300EDST,autilitynon-licensedoperatorwasperformingOperatingProcedure0-15.2(ValveAlignmentforReactorHeadLift,CoreComponentMovement,andPeriodicStatusChecks),inpreparationforthestartofrefuelingoperations.Aspartofthisprocedure,theoperatorperformedStep5.2.1toverifythatP-2was"adequatelysealed",andsignedoffStep5.2.1ofprocedure0-15.2.SatisfactorycompletionofthisstepensurescompliancewithITSLCO3.9.3.c.NRGFORM366AI4-95) | | theattachedLicenseeEventReportLER96-006isherebysubmitted. |
| NRCFORM366A(4-95)LXCENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)YEARSEQUENTIALREVISIONNUMBERNUMBER96-006-00PAGE(3)TEXT(Ifmorespaceisrequired,useadditionalcopiesofNRCForm366A/(17)DESCRIPTIONOFEVENT:A.DATESANDAPPROXIMATETIMESOFMAJOROCCURRENCES:0May19,1996:GinnastaffverifythattheconfigurationofP-2meetstherequiredstatusofITSLCO3.9.3.c.May20,1996,1800EDST:ContractormaintenancepersonnelremovepipespoolpiecesfrominsidethesealforP-2.P-2configurationdoesnotmeettherequiredstatusofITSLCO3.9.3.c.0May21,1996,0537EDST:TheplantentersMode6andbeginscorealterationsandmovementofirradiatedfuelasemblieswithinCNMT.Eventdateandtime.0May21,1996,0900EDST:Discoverydateandtime.0May21,1996,0937EDST:AllremainingcablesareremovedfromP-2,andP-2isflangedoff.B.EVENT:OnMay21,1996,allpreparationsforrefuelingwerecompleted.Procedure0-15.2hadbeensignedoffatapproximately0505EDST,andtheControlRoomoperatorsnotifiedtheSeniorReactorOperatorassignedtoRefueling(RefuelingSRO)tobeginrefueling.TheplantenteredMode6atapproximately0537EDSTandbeganrefuelingoperations(corealterationsandmovementofirradiatedfuelassemblieswithinCNMT).OnMay21,1996,atapproximately0800EDST,contractormaintenancepersonnelcontinuedtheirworkfromthepreviousdayforremovaloflinesasperSM-10034-10.01.Sincetheselineswerepotentiallycontaminated,aRadiationProtection(RP)technicianwasrequestedtosurveytheremovedlinespriortodisposal.OnMay21,1996,atapproximateiy0900EDST,withtheplantinMode6andrefuelingoperationsinprogress,theRPtechnicianapproachedP-2tosurveysomematerialsanddiscoveredthatP-2wasnotintherequiredstatusforrefuelingoperations.HeobservedthatP-2wasnotcompletelysealedwherethe3"and11/2"spoolpieceshadbeen,appearingtoallowdirectaccessfromtheCNMTatmospheretotheoutsideatmosphere.NRCFORM366A(4.95) | | Thiseventhasinnowayaffectedthepublic'shealthandsafety.Verylyyours,RobertC.Mecredyxc:U.S.NuclearRegulatory Commission Mr.GuyS.Vissing(MailStop14C7)PWRProjectDirectorate I-1Washington, D.C.,20555 U.S.NuclearRegulatory Commission RegionI475Allendale-Road KingofPrussia,PA19406U.S.NRCGinnaSeniorResidentInspector 9606260i54 960620PDRADQCK050002448PDRy/~JP NRCFORM366(4.95)U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)(Seereverseforrequirednumberofdigits/characters foreachblock)APPROVEDBYOMBNO.3150-0104 EXPIRES04/30/BBESTIMATED BURDENPERAESPONSEToCOMPLYWITHTHISMANDATORY INFORMATION COLLECTION REQUEST:50.0HRS.REPOATEDLESSONSLEARNEDAREINCORPORATED INTOTHEUCENSINGPROCESSANDFEDBACKToINDUSTRY. |
| NRCFORM366A(4.95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)YEARSEQUENTIALREVISIONNUMBERNUMBER96-006-00PAGE(3)4OF8TEXTllfmorespaceisrequired,useadditionalcopiesofNRCForm386Ai(17)TheRPtechniciannotifiedhissupervision.RPsupervisionnotifiedamemberoftheplantOutageManagementstaff,whoinspectedP-2andconfirmedthatitwasnotadequatelysealed.TheControlRoomoperatorswerenotifiedofthestatusofP-2asobservedfromoutsideCNMT.ImmediateactionsweretakenperITSLCOACTIONs3.9.3.A.1and3.9.3.A.2tosuspendcorealterationsandsuspendmovementofirradiatedfuelassemblieswithinCNMT.TheRefuelingSROinsideCNMTwasalsonotifiedthatP-2neededtobeinspectedfrominsideCNMTforthepresenceofaflange.TheRefuelingSROinspectedP-2andconfirmedthatthepenetrationwasnotisolatedinsideCNMTbyuseofamaterialthatcanprovideatemporary,atmosphericpressure,ventilationbarrier.TheRPtechnicianverifiedthattheactualflowofairwasfromtheoutsideintoCNMT.GinnaandcontractorelectricianswerenotifiedtoremoveallremainingcablesroutedthroughP-2.WhenthecableswereremovedandthepenetrationwasunobstructedinsideCNMT,GinnapipefittersinstalledaflangeoverP-2.TheseactionsrestoredP-2totherequiredstatusforrefuelingoperations,andrefuelingoperationswerepermittedtoresumeatapproximately0937EDSTonMay21,1996.C.INOPERABLESTRUCTURES,COMPONENTS,ORSYSTEMSTHATCONTRIBUTEDTOTHEEVENT:NoneD.OTHERSYSTEMSORSECONDARYFUNCTIONSAFFECTED:NoneE.METHODOFDISCOVERY:WhileperformingroutinemonitoringactivitiesfortheremovalofpotentiallycontaminatedmaterialsfromCNMT,aRadiationProtectiontechniciandiscoveredthatP-2wasnotcompletelysealedasobservedfromoutsideCNMT.TheRefuelingSROconfirmedthatP-2wasnotintherequiredstatusforrefuelingoperations.F.OPERATORACTION:TheControlRoomoperators,uponbeingnotifiedthatP-2wasnotintherequiredstatusforrefuelingoperations,immediatelycompliedwiththerequirementsofITSLCOACTIONs3.9.3.A.1.and3.9.3.A.2,whichrequirethatifoneormoreCNMTpenetrationsarenotinrequiredstatus,"SuspendCOREALTERATIONS"and"Suspendmovementofirradiatedfuelassemblieswithincontainment".Subsequently,theControlRoomoperatorsnotifiedhighersupervisionandtheNRCSeniorResidentInspector.Atapproximately1226EDSTonMay21,1996,a4hournon-emergencynotificationwasmadetotheNRCOperationsCenterasper10CFR50.72(b)(2)(iii)(C)and10CFR50.72(b)(2)(iii)(D).NRCFORM366A(4-95) | | FORWARDCOMMENTSREGARDING BURDENESTIMATEToTHEINFORMATION ANDRECORDSMANAGEMENT BRANCHIT-6F33),U.S.NUCLEARREGULATORY COMMISSION, WASHINGTON, DC20555.0001, ANDToTHEPAPEAWORK REDUCTION PROJECTFACILITYkAME(1)R.E.GinnaNuclearPowerPlantOOCKETNUMBER(2)05000244PAGE(3)1OF8B(4)AContainment Penetration NotinRequiredStatus,DuetoPersonnel Errors,Results'in Potential forUncontrolled ReleaseofRadioactive MaterialMONTHDAYYEAR052196EVENTDATE(5)LERNUMBER(6)SEQUENTIAL REVISIONNUMBER.,NUMBER96-006-00MONTHDAYYEAR062096REPORTDATE(7)FACILITYNAMEFACILITYNAMEOTHERFACILITIES INVOLVED(6)OOCKETNUMBEROOCKETNUMBEROPERATING MODE(9)POWERLEVEL(10)kAME000THISREPORTISSUBMITTED PURmore)(11)50.73(a)(2)(viii]50.73(a)(2)(x)50.73(a)(2)(i)50.73(a)(2)(ii)20.2203(a)(2)(v) 20.2203(a)(3)(i) 20.2201(b) 20.2203ta) tl)73.7150.73(a)(2)(iii)50.73(a)(2)(iv)20.2203(a) |
| NRCFORM366A(495)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)YEARSEQUENTIALREVISIONNUMBERNUMBER96-006-00PAGE(3)TEXTllfmorespaceisrequired,usoadditionalcopiesofNRCForm366Al(17)G.SAFETYSYSTEMRESPONSES:NoneIII.CAUSEOFEVENT:A.IMMEDIATECAUSE:TheimmediatecauseofCNMTpenetrationP-2notbeingintherequiredstatusforrefuelingoperationswasopeningsinthefoamsealwherea3"pipeand11/2"pipehadbeenremoved.ThisconditionwasnotidentifiedbyOperationspersonnelduringperformanceofprocedure0-15.2.B.INTERMEDIATECAUSE:TheintermediatecauseoftheopeningsinthefoamsealforP-2wastheunauthorizedremovalofthepipespoolpiecesandassociatedvalvesfromthepenetration.Theintermediatecauseofnotidentifyingthisconditionduringtheperformanceof0-15.2wasinadequateverificationbyOperationspersonnel.ROOTCAUSE:Theunderlyingcauseoftheunauthorizedremovalofthespoolpieceswaspersonnelerror.TheunderlyingcauseoftheinadequateverificationbyOperationspersonnelwasalsopersonnelerror.AHumanPerformanceEnhancementSystem(HPES)evaluationwasperformedtodeterminethecausalfactorsthatcontributedtothesepersonnelerrors.ThiseventisNUREG-1022CauseCode(A),"PersonnelError".Personnelerrorsweremadebycontractormaintenancepersonnelandautilitynon-licensedoperator.Theseerrorswerecognitivepersonnelerrorsonthepartofbothgroups.ThecontractormaintenancepersonneldidnotrecognizetheimpactonrefuelingoperationsofremovingthepipespoolpiecesfromP-2.TheOperationspersonneldidnotrecognizetheactualconfigurationofthefoamsealinP-2during0-15.2verifications,perceivedthattheyhadaccuratelyverifiedtheconfiguration,andthoughtthatP-2wasintherequiredstatusforrefuelingoperations,when,infact,P-2wasnotadequatelysealed.NRCFORM366A(4-95) | | (3)(ii)20.2203(a) |
| NRCFORM366A(4-SS)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)SEQUENTIALREVISIONNUMBERNUMBER96-006-00PAGE(3)6OF8TEXTiifmorespaceisrequired,useadditionalcopiesofNRCForm366AJ(17).ThecontractormaintenanceerrorwascontrarytoapprovedprocedureSM-10034-10.01,andtheoperatorerrorwascontrarytoapprovedprocedure0-15.2.Unusualconditionspresentduringtheperformanceof0-15.2includednighttimedarkness,alightningstorm,limitedaccesstoP-2(P-2wasenclosedbyawoodenprotectiveenclosure),additionalcableroutedthroughP-2forthe1996outage,andsomeoftheremainingpipingandvalvesstillbeingwithintheenclosurearoundP-2.TheseenvironmentalfactorsmayhaveobscuredtheviewofthefoamsealfromoutsideCNMT,wherethe3"and11/2"spoolpieceshadbeen.AccesstoviewP-2frominsideCNMTwaspartiallyblocked,duetoequipmentinsideCNMTfortheS/Greplacement.ThisconditiondoesnotmeettheNUMARC93-01,"IndustryGuidelineforMonitoringtheEffectivenessofMaintenanceatNuclearPowerPlants",definitionofa"MaintenancePreventableFunctionalFailure".IV.ANALYSISOFEVENT:Thiseventisreportableinaccordancewith10CFR50.73,LicenseeEventReportSystem,items(a)(2)(ii),(a)(2)(v)(C)and(a)(2)(v)(D),whichrequireareportof,"Anyoperationorconditionprohibitedbytheplant'sTechnicalSpecifications"or"Anyeventorconditionthatalonecouldhavepreventedthefulfillmentofthesafetyfunctionofstructuresorsystemsthatareneededto...Controlthereleaseofradioactivematerial;orMitigatetheconsequencesofanaccident".HavingaCNMTpenetrationnotintherequiredstatusforrefuelingoperationswithrefuelingoperationsinprogressisaconditionprohibitedbytheITS.Itispostulatedthat,intheeventofafuelhandlingaccidentatthiscondition,theresultantradioactivereleasecouldbeuncontrolled,andthattheCNMTcouldhavebeenineffectiveinmitigatingtheconsequencesofthispostulatedaccident.iAnassessmentwasperformedconsideringboththesafetyconsequencesandimplicationsofthiseventwiththefollowingresultsandconclusions:Therewerenooperationalorsafetyconsequencesorimplicationsattributedtothisconditionbecause:0ThoughtheCNMTpenetrationalloweddirectaccessfromtheCNMTatmospheretotheoutsideatmosphere,aconditiondidnotexistthatcouldhaveresultedinanuncontrolledradioactiverelease.AreleasetotheoutsideatmospherewouldhaverequiredCNMTpressurization.Sincethefuelhadalowdecayheatrateduetoasixtydayoffloadandsincetherewasonlyasmallamountoffuelinthecoreatthetime,theenergysourcetoeffectaCNMTpressurizationwaslow,makingapressurizedconditionsunlikely.ItwasverifiedthattheactualflowofairwasfromtheoutsideintoCNMT.0CNMTisolationisnotcreditedintheeventofafuelhandlingaccidentpertheapplicablesafetyanalysesbasesforITSLCO3.9.3.TheGinnaStationUpdatedFinalSafetyAnalysisReport(UFSAR),Section15.7.3.3,showsthatwithoutcreditforCNMTandutilizingtheconservativeassumptionsofNRCRegulatoryGuide(RG)1.25,theoffsitedoseconsequencesfollowingafuelhandlingaccidentareninety-six(96)REMthyroid,whichiswithin10CFR100limitsforGinnaStation.NRCFORM366A(4.65) | | (4)20.2203(a) |
| NRCFORM366A(4-95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAMEI1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBERI6)YEARSEQUENTIALREVISIONNUMBERNUMBER96-006-00PAGEI3)7OF8TEXT(lfmorespeceisrequired,useedditionelcopiesofNRCForm366Al(17)0GinnaStationrecentlyreceivedAmendment62totheITS,whichmodifiedtherequirementsfortheCNMTequipmenthatchduringMode6.IncludedwithinthisITSamendmentrequest(datedFebruary9,1996)wasanevaluationofoffsitedoses,withthefollowingassumptions:b.CNMTwasinitiallypressurizedby0.5PSIGabovetheoutsideatmosphereforthefirstthreeminutesfollowingafuelhandlingaccident,aCNMTleakagerate,basedonextremetemperaturedifferencesbetweentheinsideandtheoutsideofCNMT,existedforthenexttwohours,andaholeequivalentto1.83squarefeetexistedtotheoutsideatmosphere.UsingtheseandotherassumptionsofRG1.25,thethyroiddoseattheexclusionareaboundarywascalculatedtobeonly8.1REM,whichiswellwithin10CFR100limits.TheconditionofP-2beingopenduringmovementofirradiatedfuelassembliesisboundedbythisanalysissincenofuelhandlingaccidentoccurred,theCNMTwasnotpressurized,andtheincreasedleakagepaththroughP-2waslessthan0:1squarefoot.Therefore,thisconditionwouldnotleadtoexceedingthedoselimits.Basedontheabove,itcanbeconcludedthatthepublic'shealthandsafetywasassuredatalltimes.V.CORRECTIVEACTION:A.ACTIONTAKENTORETURNAFFECTEDSYSTEMSTOPRE-EVENTNORMALSTATUS:0AllremainingcableswereremovedfromP-2andaflangewasinstalledonP-2insideCNMT,restoringP-2tocompliancewithITSLCO3.9.3.c.0Refuelingoperationswerepermittedtoresume.B.ACTIONTAKENORPLANNEDTOPREVENTRECURRENCE:0Procedure0-15.2willberevisedtorequireadditionalcontrolsatP-2,topreventtheconfigurationofP-2frombeingchangedduringrefuelingoperations.0ANuclearTrainingWorkRequestwillbeinitiatedtotrainonthelessonslearnedfromthisevent.VI.ADDITIONALINFORMATION:A.FAILEDCOMPONENTS:NoneIIRCFORM366AI4.95) | | (2)(i)20.2203(a)(2)(ii) |
| NRCFORM366AI4-95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIONFACILITYNAMEI1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)YEARSEQUENTIALREVISIONNUMBERNUMBER96-006-00PAGEI3)8OF8TEXT(Ifmorespaceisrequired,useadditionalcopiesofNRCForm366AJI17)B.PREVIOUSLERsONSIMILAREVENTS:AsimilarLEReventhistoricalsearchwasconductedwiththefollowingresults:NodocumentationofsimilarLEReventswiththesamerootcauseatGinnaNuclearPowerPlantcouldbeidentified.C.SPECIALCOMMENTS:NoneNACFOAM366AI4.95)}} | | OTHERSpecifyinAbstractbeloworinNRCForm366A20.2203(a)(2) |
| | (iii)50.36(c)(1) 50.73(a)(2) |
| | (v)20.2203(a) |
| | (2)(iv)50.36(c)(2)50.73(a)(2)(vii) |
| | LICENSEECONTACTFORTHISLER(12)ELBPIIOkE NUMBER(IncludeAreaCoda>SUANTTOTHEREQUIREMENTS OF10CFRE:(CheckoneorJohnT.St.Martin-Technical Assistant (716)771-3641COMPLETEONELINEFOREACHCOMPONENT FAILUREDESCRIBED INTHISREPORT(13)CAUSESYSTEMCOMPONENT MANUFACTURER AEPOATABLE TONPADSCAUSESYSTEMCOMPONENT MANUFACTURER REPORTABLE ToNPRDSSUPPLEMENTAL REPORTEXPECTED(14)YES(lfyes,completeEXPECTEDSUBMISSION DATE).XNOEXPECTEDSUBMISSION DATE(15)MONTHDAYYEARABSTRACT(Limitto1400spaces,l.e.,approximately 15single-spaced typewritten lines)(16)OnMay21,1996,atapproximately 0900EDST,withtheplantinMode6withcorealterations andmovementofirradiated fuelassemblies withincontainment inprogress, itwasdiscovered thatacontainment penetration wasnotintherequiredstatusforrefueling operations, allowingdirectaccessfromthecontainment atmosphere totheoutsideatmosphere. |
| | Immediate corrective actionwastakeninaccordance withGinnaImprovedTechnical Specifications LimitingConditions forOperation 3.9.3.A.1 and3.9.3.A.2 tosuspendcorealterations andsuspendmovementofirradiated fuelassemblies withincontainment. |
| | Thecontainment penetration wasrestoredtotherequiredstatusforrefueling operations, andrefueling operations werepermitted toresume.Theunderlying causeofthepenetration notbeingintherequiredstatusforrefueling operations waspersonnel errors.ThiseventisNUREG-1022 CauseCode(A).Corrective actiontopreventrecurrence isoutlinedinSectionV.B.NRCFORM366(4-95) |
| | NRCFORM366AI4-95)LICENSEEEVENTREPORT(LER),TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION FACILITYNAMEIl)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBERI6)YEARSEQUENTIAL REVISIONNUMBERNUMBER96-006-00PAGEI3)2OF8TEXT(Ifmorespaceisrequired, useadditional copiesofNRCForm366A/(17)PRE-EVENT PLANTCONDITIONS: |
| | Containment (CNMT)penetration I)'2(referred toasP-2)isthe"S/GCommunications FlangePenetration" normallyusedforsupportofroutinesteamgenerator (S/G)maintenance andinspection activities duringrefueling outages.WheninModes5or6,normallyroutedthroughP-2areclosed-circuit television (CCTV)cablesandothercommunications cables.Forthe1996Refueling outage,P-2wasalsousedtoprovidearouteforadditional CCTVcablesandrigidpipesfrom'theoutsideintoCNMT,toprovideservices(communications, airandargon)foractivities associated withreplacement oftheS/Gs.Thesepipeswerea3"lineforserviceairanda11/2"lineforargon.StationModification procedures SM-10034-10.01 (Temporary ServiceAirSystemforSGRP)andSM-10034-'l0.03 (Installation 5RemovalofTemporary CCTVandCommunications) wereusedtocontrolthetemporary installation andsubsequent removaloftheseservices. |
| | OnMay19,1996,inpreparation forrefueling thereactor,Ginnaplantstaffcheckedtheconfiguration ofP-2andverifiedthattheconfiguration compliedwithGinnaImprovedTechnical Specifications (ITS)LimitingCondition forOperation (LCO)3.9.3.c,whichstatesthateachpenetration providing directaccessfromtheCNMTatmosphere totheoutsideatmosphere shallbeisolated, orclosedbyanequivalent isolation method.Thesemethodsincludeuseofmaterialthatcanprovideatemporary, atmospheric |
| | : pressure, ventilation barrier.Contractor supervision weresubsequently notifiednottodisturbtheconfiguration ofP-2untilafterthecompletion ofrefueling. |
| | DuringthedayshiftonMay20,1996,asdirectedbycontractor supervision, contractor maintenance personnel removedmuchofthetemporary serviceairandargonlinesinsideCNMT,asdirectedbyprocedure SM-10034-10.01. |
| | Contractor supervision hadbeencautioned byGinnastaffnottoremovethe3"and11/2"pipespoolpieces thatwereinsidethesealforP-2andthefirstvalvesoneachsideofP-2insideandoutsideofCNMT.Nevertheless, attheendoftheirshift(atapproximately 1800EDST),thecontractor maintenance personnel removedthesespoolpieces andvalves.Additional pipingoutsideCNMTwasleftinplaceuntilthenextday.OnMay21,1996,atapproximately 0300EDST,autilitynon-licensed operatorwasperforming Operating Procedure 0-15.2(ValveAlignment forReactorHeadLift,CoreComponent |
| | : Movement, andPeriodicStatusChecks),inpreparation forthestartofrefueling operations. |
| | Aspartofthisprocedure, theoperatorperformed Step5.2.1toverifythatP-2was"adequately sealed",andsignedoffStep5.2.1ofprocedure 0-15.2.Satisfactory completion ofthisstepensurescompliance withITSLCO3.9.3.c.NRGFORM366AI4-95) |
| | NRCFORM366A(4-95)LXCENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION FACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)YEARSEQUENTIAL REVISIONNUMBERNUMBER96-006-00PAGE(3)TEXT(Ifmorespaceisrequired, useadditional copiesofNRCForm366A/(17)DESCRIPTION OFEVENT:A.DATESANDAPPROXIMATE TIMESOFMAJOROCCURRENCES: |
| | 0May19,1996:Ginnastaffverifythattheconfiguration ofP-2meetstherequiredstatusofITSLCO3.9.3.c.May20,1996,1800EDST:Contractor maintenance personnel removepipespoolpieces frominsidethesealforP-2.P-2configuration doesnotmeettherequiredstatusofITSLCO3.9.3.c.0May21,1996,0537EDST:TheplantentersMode6andbeginscorealterations andmovementofirradiated fuelasemblies withinCNMT.Eventdateandtime.0May21,1996,0900EDST:Discovery dateandtime.0May21,1996,0937EDST:Allremaining cablesareremovedfromP-2,andP-2isflangedoff.B.EVENT:OnMay21,1996,allpreparations forrefueling werecompleted. |
| | Procedure 0-15.2hadbeensignedoffatapproximately 0505EDST,andtheControlRoomoperators notifiedtheSeniorReactorOperatorassignedtoRefueling (Refueling SRO)tobeginrefueling. |
| | TheplantenteredMode6atapproximately 0537EDSTandbeganrefueling operations (corealterations andmovementofirradiated fuelassemblies withinCNMT).OnMay21,1996,atapproximately 0800EDST,contractor maintenance personnel continued theirworkfromthepreviousdayforremovaloflinesasperSM-10034-10.01. |
| | Sincetheselineswerepotentially contaminated, aRadiation Protection (RP)technician wasrequested tosurveytheremovedlinespriortodisposal. |
| | OnMay21,1996,atapproximateiy 0900EDST,withtheplantinMode6andrefueling operations inprogress, theRPtechnician approached P-2tosurveysomematerials anddiscovered thatP-2wasnotintherequiredstatusforrefueling operations. |
| | HeobservedthatP-2wasnotcompletely sealedwherethe3"and11/2"spoolpieces hadbeen,appearing toallowdirectaccessfromtheCNMTatmosphere totheoutsideatmosphere. |
| | NRCFORM366A(4.95) |
| | NRCFORM366A(4.95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION FACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)YEARSEQUENTIAL REVISIONNUMBERNUMBER96-006-00PAGE(3)4OF8TEXTllfmorespaceisrequired, useadditional copiesofNRCForm386Ai(17)TheRPtechnician notifiedhissupervision. |
| | RPsupervision notifiedamemberoftheplantOutageManagement staff,whoinspected P-2andconfirmed thatitwasnotadequately sealed.TheControlRoomoperators werenotifiedofthestatusofP-2asobservedfromoutsideCNMT.Immediate actionsweretakenperITSLCOACTIONs3.9.3.A.1 and3.9.3.A.2 tosuspendcorealterations andsuspendmovementofirradiated fuelassemblies withinCNMT.TheRefueling SROinsideCNMTwasalsonotifiedthatP-2neededtobeinspected frominsideCNMTforthepresenceofaflange.TheRefueling SROinspected P-2andconfirmed thatthepenetration wasnotisolatedinsideCNMTbyuseofamaterialthatcanprovideatemporary, atmospheric |
| | : pressure, ventilation barrier.TheRPtechnician verifiedthattheactualflowofairwasfromtheoutsideintoCNMT.Ginnaandcontractor electricians werenotifiedtoremoveallremaining cablesroutedthroughP-2.Whenthecableswereremovedandthepenetration wasunobstructed insideCNMT,Ginnapipefitters installed aflangeoverP-2.TheseactionsrestoredP-2totherequiredstatusforrefueling operations, andrefueling operations werepermitted toresumeatapproximately 0937EDSTonMay21,1996.C.INOPERABLE STRUCTURES, COMPONENTS, ORSYSTEMSTHATCONTRIBUTED TOTHEEVENT:NoneD.OTHERSYSTEMSORSECONDARY FUNCTIONS AFFECTED: |
| | NoneE.METHODOFDISCOVERY: |
| | Whileperforming routinemonitoring activities fortheremovalofpotentially contaminated materials fromCNMT,aRadiation Protection technician discovered thatP-2wasnotcompletely sealedasobservedfromoutsideCNMT.TheRefueling SROconfirmed thatP-2wasnotintherequiredstatusforrefueling operations. |
| | F.OPERATORACTION:TheControlRoomoperators, uponbeingnotifiedthatP-2wasnotintherequiredstatusforrefueling operations, immediately compliedwiththerequirements ofITSLCOACTIONs3.9.3.A.1. |
| | and3.9.3.A.2, whichrequirethatifoneormoreCNMTpenetrations arenotinrequiredstatus,"SuspendCOREALTERATIONS" and"Suspendmovementofirradiated fuelassemblies withincontainment". |
| | Subsequently, theControlRoomoperators notifiedhighersupervision andtheNRCSeniorResidentInspector. |
| | Atapproximately 1226EDSTonMay21,1996,a4hournon-emergency notification wasmadetotheNRCOperations Centerasper10CFR50.72(b)(2)(iii)(C)and10CFR50.72(b)(2)(iii)(D).NRCFORM366A(4-95) |
| | NRCFORM366A(495)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION FACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)YEARSEQUENTIAL REVISIONNUMBERNUMBER96-006-00PAGE(3)TEXTllfmorespaceisrequired, usoadditional copiesofNRCForm366Al(17)G.SAFETYSYSTEMRESPONSES: |
| | NoneIII.CAUSEOFEVENT:A.IMMEDIATE CAUSE:Theimmediate causeofCNMTpenetration P-2notbeingintherequiredstatusforrefueling operations wasopeningsinthefoamsealwherea3"pipeand11/2"pipehadbeenremoved.Thiscondition wasnotidentified byOperations personnel duringperformance ofprocedure 0-15.2.B.INTERMEDIATE CAUSE:Theintermediate causeoftheopeningsinthefoamsealforP-2wastheunauthorized removalofthepipespoolpieces andassociated valvesfromthepenetration. |
| | Theintermediate causeofnotidentifying thiscondition duringtheperformance of0-15.2wasinadequate verification byOperations personnel. |
| | ROOTCAUSE:Theunderlying causeoftheunauthorized removalofthespoolpieces waspersonnel error.Theunderlying causeoftheinadequate verification byOperations personnel wasalsopersonnel error.AHumanPerformance Enhancement System(HPES)evaluation wasperformed todetermine thecausalfactorsthatcontributed tothesepersonnel errors.ThiseventisNUREG-1022 CauseCode(A),"Personnel Error".Personnel errorsweremadebycontractor maintenance personnel andautilitynon-licensed operator. |
| | Theseerrorswerecognitive personnel errorsonthepartofbothgroups.Thecontractor maintenance personnel didnotrecognize theimpactonrefueling operations ofremovingthepipespoolpieces fromP-2.TheOperations personnel didnotrecognize theactualconfiguration ofthefoamsealinP-2during0-15.2verifications, perceived thattheyhadaccurately verifiedtheconfiguration, andthoughtthatP-2wasintherequiredstatusforrefueling operations, when,infact,P-2wasnotadequately sealed.NRCFORM366A(4-95) |
| | NRCFORM366A(4-SS)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION FACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)SEQUENTIAL REVISIONNUMBERNUMBER96-006-00PAGE(3)6OF8TEXTiifmorespaceisrequired, useadditional copiesofNRCForm366AJ(17).Thecontractor maintenance errorwascontrarytoapprovedprocedure SM-10034-10.01, andtheoperatorerrorwascontrarytoapprovedprocedure 0-15.2.Unusualconditions presentduringtheperformance of0-15.2includednighttime |
| | : darkness, alightning storm,limitedaccesstoP-2(P-2wasenclosedbyawoodenprotective enclosure), |
| | additional cableroutedthroughP-2forthe1996outage,andsomeoftheremaining pipingandvalvesstillbeingwithintheenclosure aroundP-2.Theseenvironmental factorsmayhaveobscuredtheviewofthefoamsealfromoutsideCNMT,wherethe3"and11/2"spoolpieces hadbeen.AccesstoviewP-2frominsideCNMTwaspartially blocked,duetoequipment insideCNMTfortheS/Greplacement. |
| | Thiscondition doesnotmeettheNUMARC93-01,"Industry Guideline forMonitoring theEffectiveness ofMaintenance atNuclearPowerPlants",definition ofa"Maintenance Preventable Functional Failure". |
| | IV.ANALYSISOFEVENT:Thiseventisreportable inaccordance with10CFR50.73,LicenseeEventReportSystem,items(a)(2)(ii),(a)(2)(v)(C)and(a)(2)(v)(D),whichrequireareportof,"Anyoperation orcondition prohibited bytheplant'sTechnical Specifications" or"Anyeventorcondition thatalonecouldhaveprevented thefulfillment ofthesafetyfunctionofstructures orsystemsthatareneededto...Control thereleaseofradioactive material; orMitigatetheconsequences ofanaccident". |
| | HavingaCNMTpenetration notintherequiredstatusforrefueling operations withrefueling operations inprogressisacondition prohibited bytheITS.Itispostulated that,intheeventofafuelhandlingaccidentatthiscondition, theresultant radioactive releasecouldbeuncontrolled, andthattheCNMTcouldhavebeenineffective inmitigating theconsequences ofthispostulated accident. |
| | iAnassessment wasperformed considering boththesafetyconsequences andimplications ofthiseventwiththefollowing resultsandconclusions: |
| | Therewerenooperational orsafetyconsequences orimplications attributed tothiscondition because:0ThoughtheCNMTpenetration alloweddirectaccessfromtheCNMTatmosphere totheoutsideatmosphere, acondition didnotexistthatcouldhaveresultedinanuncontrolled radioactive release.Areleasetotheoutsideatmosphere wouldhaverequiredCNMTpressurization. |
| | Sincethefuelhadalowdecayheatrateduetoasixtydayoffloadandsincetherewasonlyasmallamountoffuelinthecoreatthetime,theenergysourcetoeffectaCNMTpressurization waslow,makingapressurized conditions unlikely. |
| | ItwasverifiedthattheactualflowofairwasfromtheoutsideintoCNMT.0CNMTisolation isnotcreditedintheeventofafuelhandlingaccidentpertheapplicable safetyanalysesbasesforITSLCO3.9.3.TheGinnaStationUpdatedFinalSafetyAnalysisReport(UFSAR),Section15.7.3.3, showsthatwithoutcreditforCNMTandutilizing theconservative assumptions ofNRCRegulatory Guide(RG)1.25,theoffsitedoseconsequences following afuelhandlingaccidentareninety-six (96)REMthyroid,whichiswithin10CFR100limitsforGinnaStation.NRCFORM366A(4.65) |
| | NRCFORM366A(4-95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION FACILITYNAMEI1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBERI6)YEARSEQUENTIAL REVISIONNUMBERNUMBER96-006-00PAGEI3)7OF8TEXT(lfmorespeceisrequired, useedditionelcopiesofNRCForm366Al(17)0GinnaStationrecentlyreceivedAmendment 62totheITS,whichmodifiedtherequirements fortheCNMTequipment hatchduringMode6.IncludedwithinthisITSamendment request(datedFebruary9,1996)wasanevaluation ofoffsitedoses,withthefollowing assumptions: |
| | b.CNMTwasinitially pressurized by0.5PSIGabovetheoutsideatmosphere forthefirstthreeminutesfollowing afuelhandlingaccident, aCNMTleakagerate,basedonextremetemperature differences betweentheinsideandtheoutsideofCNMT,existedforthenexttwohours,andaholeequivalent to1.83squarefeetexistedtotheoutsideatmosphere. |
| | Usingtheseandotherassumptions ofRG1.25,thethyroiddoseattheexclusion areaboundarywascalculated tobeonly8.1REM,whichiswellwithin10CFR100limits.Thecondition ofP-2beingopenduringmovementofirradiated fuelassemblies isboundedbythisanalysissincenofuelhandlingaccidentoccurred, theCNMTwasnotpressurized, andtheincreased leakagepaththroughP-2waslessthan0:1squarefoot.Therefore, thiscondition wouldnotleadtoexceeding thedoselimits.Basedontheabove,itcanbeconcluded thatthepublic'shealthandsafetywasassuredatalltimes.V.CORRECTIVE ACTION:A.ACTIONTAKENTORETURNAFFECTEDSYSTEMSTOPRE-EVENT NORMALSTATUS:0Allremaining cableswereremovedfromP-2andaflangewasinstalled onP-2insideCNMT,restoring P-2tocompliance withITSLCO3.9.3.c.0Refueling operations werepermitted toresume.B.ACTIONTAKENORPLANNEDTOPREVENTRECURRENCE: |
| | 0Procedure 0-15.2willberevisedtorequireadditional controlsatP-2,topreventtheconfiguration ofP-2frombeingchangedduringrefueling operations. |
| | 0ANuclearTrainingWorkRequestwillbeinitiated totrainonthelessonslearnedfromthisevent.VI.ADDITIONAL INFORMATION: |
| | A.FAILEDCOMPONENTS: |
| | NoneIIRCFORM366AI4.95) |
| | NRCFORM366AI4-95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION FACILITYNAMEI1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)YEARSEQUENTIAL REVISIONNUMBERNUMBER96-006-00PAGEI3)8OF8TEXT(Ifmorespaceisrequired, useadditional copiesofNRCForm366AJI17)B.PREVIOUSLERsONSIMILAREVENTS:AsimilarLEReventhistorical searchwasconducted withthefollowing results:Nodocumentation ofsimilarLEReventswiththesamerootcauseatGinnaNuclearPowerPlantcouldbeidentified. |
| | C.SPECIALCOMMENTS: |
| | NoneNACFOAM366AI4.95)}} |
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LER 99-003-00:on 990301,two Main Steam non-return Check Valves Were Declared Inoperable Due to Exceedance of Acceptance Criteria.Caused by Changes in Methodology & Matls.Packing Gland Torque Will Be Adjusted.With 990331 Ltr
ML17265A6131999-03-29029 March 1999
LER 99-002-00:on 990227,discovered That Surveillance Had Not Been Performed at Frequency,Per Ts.Caused by Personnel Error.Procedure O-6.13 Will Be Evaluated for Enhancement Documentation of Completion of ITS Srs.With 990329 Ltr
ML17265A6061999-03-24024 March 1999
LER 99-001-00:on 990222,plant Was Noted Outside Design Basis.Caused by Deficiencies in NSSS Vendor Slb Mass & Energy Release.Placed Temporary Administrative Restriction 40 Degrees F Max on Screenhouse Bay Temp
ML17265A4951998-12-21021 December 1998
LER 98-005-00:on 981120,loss of 34.5 Kv Offsite Power Circuit 751,resulted in Automatic Start of B Edg.Caused by Faulted Cable Splice.Performed Appropriate Actions of Abnormal Procedure AP-ELEC.1.With 981221 Ltr
ML17265A4931998-12-17017 December 1998
LER 98-004-00:on 971030,determined That Improperly Performed Surveillance Resulted in Condition Prohibited by Ts.Caused by Procedure non-adherence.Appropriate Calibr Procedures Were Properly Performed with 24 H of Condition Discovery
ML17265A4691998-11-25025 November 1998
LER 98-003-01:on 980904,actuations of CR Emergency Air Treatment Systems (Creats) Occurred.Caused by Radon build-up During Temp Inversion.Creats Actuation Signal Was Reset & Normal Ventilation Was Restored to CR
ML17265A4271998-10-0505 October 1998
LER 98-003-00:on 980904,actuations of CR Emergency Air Treatment Sys Occurred.Caused by Radon build-up During Temp Inversion.Air Samples Were Taken & Determined That Source of Radiation Was Naturally Occurring Radon.With 981005 Ltr
ML17265A3671998-07-14014 July 1998
LER 98-002-00:on 971019,CR Emergency Air Treatment Sys Actuating Function Was Not Operable.Caused by Mispositioned Switch.Revised Procedure CPI-MON-R37.W/980714 Ltr
ML17265A1921998-03-11011 March 1998
LER 98-001-00:on 980209,discovered That Boraflex Degradation in SPF Was Greater than Was Assumed.Caused by Dissolution of Boron on Boraflex Matrix,Per 10CFR50.21.Removed Spent Fuel Assemblies from Selected Degraded Storage Rack Cells
ML17265A1641998-02-0606 February 1998
LER 97-007-01:on 971117,reactor Engineer Recognized That Neutron Flux Low Range Trip Circuitry for Channel Was Not in Tripped Condition as Required.Caused by Technical Inadequacies.Channel Defeat Will Be Identified
ML17265A1601998-02-0606 February 1998
LER 97-006-01:on 971103,verification of B Concentration Was Not Performed Due to Misinterpretation of Event Sequence. Audible Count Rate Function Was Restored to Operable Status
ML17264B1441997-12-17017 December 1997
LER 97-007-00:on 971117,NF Low Range Trip Circuitry for Channel N-44 Was Not Placed in Tripped Condition.Caused by Technical Inadequacies in Procedures.Implemented EWR 4862 to Resolve Design deficiency.W/971217 Ltr
ML17264B1291997-12-0303 December 1997
LER 97-006-00:on 971103,NIS Audible Count Rate Function Was Inoperable.Caused by Misinterpretation of Event Sequence Due to Not Verifying Boron Concentration.B Verification Occurred Every 12 H Per ITS LCO Action 3.9.2.C.3.W/971203 Ltr
ML17264B1271997-12-0101 December 1997
LER 97-005-00:on 971031,undetected Unblocking of SI Actuation Signal Occurred at Low Pressure Condition,Due to Faulty Bistable Which Resulted in Inadvertent SI Actuation Signal.Sias,Ci & CVI Signals Were Reset
ML17264B1211997-11-24024 November 1997
LER 97-004-00:on 971024,radiation Monitor Alarm Were Noted Due to Higher than Normal Radioactive Gas Concentration Resulted in Cvi.New R-12 Alarm Setpoint Was Maintained for Duration of Refueling Outage
ML17264B0461997-09-29029 September 1997
LER 97-003-01:on 970730,bistable Instrument Trip Setpoint Could Have Exceeded Allowable Value.Caused by Insufficient Existing Margin Between Trip Setpoint & Allowable Value. Held Switches in Tripped configuration.W/970929 Ltr
ML17264B0111997-08-27027 August 1997
LER 97-003-00:on 970730,high Steam Flow Bistable Instrument Setpoint Plus Instrument Uncertainty Could Exceed Allowable Value in ITS Was Identified.Caused by Entry Into ITS LCO 3.0.3.Switches Placed in Tripped configuration.W/970827 Ltr
ML17264A9941997-08-19019 August 1997
LER 97-002-00:on 970720,34.5 Kv Offsite Power Circuit 751 Was Lost.Caused by Automatic Actuation of B Emergency DG Due to Undervoltage on Safeguards Buses 16 & 17.Offsite Power Restored to Safeguards Buses 16 & 17.W/970819 Ltr
ML17264A9911997-08-11011 August 1997
LER 96-009-02:on 960723,determined That Leak Rate Outside Containment Was Greater than Program Limit.Caused by Weld Defect.Isolated Leak & Cut Out & Replaced Leaking Pipe
ML17264A8271997-03-0303 March 1997
LER 97-001-00:on 970131,discovered Service Water Temp Was Less than Specified Value.Caused by non-representative Method of Monitoring.Increased Water Temp in Screenhouse Bay to Greater than 35 Degrees F.W/970303 Ltr
ML17264A8071997-01-22022 January 1997
LER 96-015-00:on 961223,discovered Thermally Induced Overpressure Transient Could Occur.Caused by Thermal Expansion of Fluid During Design Basis Accident Condition. Installed Relief Valve on Affected line.W/970122 Ltr
ML17264A7471996-11-27027 November 1996
LER 96-013-00:on 961029,circuit Breakers Closed While in Mode 3 & Resulted in Condition Prohibited by TS Due to Personnel Error.Circuit Breakers for MOV-878B & MOV-878D Were re-opened.W/961127 Ltr
ML17264A6051996-09-19019 September 1996
LER 96-012-00:on 960820,feedwater Transient Occurred,Due to Closure of Feedwater Regulating Valve,Causing Lo Lo Steam Generator Level Reactor Trip.Sgs Were Restored & Missing Screw in 1/P-476 Was replaced.W/960919 Ltr
ML17264A6061996-09-19019 September 1996
LER 96-009-01:on 960723,leakage Outside Containment Occurred,Due to Weld Defect,Resulting in Leak Rate Greater than Program Limits.Source of Leakage Isolated from RWST by Freeze Seal,Allowing Exit from ITS LCO 3.0.3.W/960919 Ltr
ML17264A5911996-09-0505 September 1996
LER 96-011-00:on 960807,improper Configuration of Circuit Breaker Occurred,Due to Undetected Internal Interference, Resulting in Automatic Start of Both Auxiliary Feedwater Pumps.Running AFW Pumps Were secured.W/960905 Ltr
ML17264A5921996-09-0505 September 1996
LER 96-010-00:on 960806,latching of Main Turbine While in Mode 4 Occurred,Due to Defective Procedure,Resulting in Automatic Start of Auxiliary Feedwater Pump.Caused by Defective Maint Procedure.Procedure revised.W/960905 Ltr
ML17264A5891996-08-22022 August 1996
LER 96-009-00:on 960723,determined Leak on Piping Sys Outside Containment Greater than Program Limit.Caused by Weld Defect.Pipe & Socket Welds Were Cut Out & Replaced. W/960822 Ltr
ML17264A5781996-08-0606 August 1996
LER 96-008-00:on 960707,main Feedwater Pump Breakers Opened. Caused by Change in Seal Water Differential Pressure Occurred During Sys Realignment.Afw Flow Controlled as Desired to Maintain S/G level.W/960806 Ltr
ML17264A5561996-07-12012 July 1996
LER 96-007-00:on 960612,CR Operators Identified Control Rods Misaligned & Not Moving in Proper Sequence.Caused by Faulty Firing Circuit Card in Rod Control Sys.Faulty Firing Circuit Card in 1BD Power Cabinet replaced.W/960712 Ltr
ML17264A5421996-06-20020 June 1996
LER 96-006-00:on 960521,discovered Containment Penetration Not in Required Status.Caused by Personnel Error.Installed Flange Inside Containment Penetration 2.W/960620 Ltr
ML17264A5411996-06-17017 June 1996
LER 96-005-00:on 960516,PORC Determined Deficient Procedures Do Not Meet SRs for Testing safety-related Logic Circuits. Caused by Inadequancies in Individual Testing Procedures. Procedures Re Improved TSs revised.W/960617 Ltr
ML17264A5051996-05-17017 May 1996
LER 96-003-01:on 960308,identified That Both Pressurizer PORVs Inoperable Concurrently Due to Disconnection of Flex Hose to Both PORV Actuators to Install air-sets for Benchset & Limit Switch Activities.Hpes Completed
ML17264A4481996-04-0808 April 1996
LER 96-003-00:on 960308,both Pressurizer Relief Valves Inoperable.Hpes Evaluation Is Being Conducted to Determined Cause of Event.C/As:Both PORVs restored.W/960408 Ltr
ML17264A4471996-04-0808 April 1996
LER 96-002-00:on 960307,secondary Transient Occurred.Caused by Loss of B Condenser Circulating Water Pump.C/As: Thermography performed.W/960408 Ltr
ML17264A4101996-03-18018 March 1996
LER 96-001-00:on 950504,inservice Test Not Performed During Refueling Outage.Caused by Inadequate Tracking of Surveillance Frequency.Valve Test Performed & Disassembled. W/960318 Ltr
ML17264A2971995-12-14014 December 1995
LER 95-009-00:on 950817,surveillance Was Not Performed Due to Improper Application of TS Requirements Resulting in TS Violation.Testing of MOV-515 Was Performed on 951115.W/ 951214 Ltr
ML17264A1711995-09-25025 September 1995
LER 95-008-00:on 950825,secondary Transient Occurred.Caused by Loss of B Condenser Circulating Water Pump That Resulted in Manual Rt.Returned S/G Levels to Normal Operating levels.W/950925 Ltr
1999-09-22
[Table view]
Category:RO)
MONTHYEARML17265A7541999-09-22022 September 1999
LER 99-011-00:on 990823,small Tears Were Discovered in Flexible Duct Work Connector at Inlet of CR HVAC Sys Return Air Fan (AKF08).Caused by in-leakage Greater than That Assumed.Implemented Temporary Mod 99-029.With 990922 Ltr
ML17265A7431999-08-24024 August 1999
LER 99-004-01:on 990412,discovered That Containment Recirculation Fan Chevron Separator Vanes Were Installed Backwards.Caused by Improper Assembly by Mfg.Moisture Separator Vanes Were Dismantled & Correctly re-installed
ML17265A7181999-07-23023 July 1999
LER 99-007-01:on 990423,reactor Trip Occurred Due to Instrument & Control Technicians Inadvertently Pulling Fuses from Wrong Nuclear Instrument Channel.Setpoint Adjustments Were Completed by Different Crew of Technicians
ML17265A7081999-07-22022 July 1999
LER 98-003-02:on 980904,actuations of CR Emergency Air Treatment Sys Was Noted Due to Invalid Causes.Caused by Various Degraded Components in CR RM Sys.Creats Actuation Signal Was Reset & Normal Ventilation Was Restored
ML17265A7031999-07-19019 July 1999
LER 99-S01-00:on 990617,determined That Temporary Unescorted Access Had Been Granted to Contractor Employee.Caused by Incomplete Info Re Circumstances of Individual Military Separation.Individual Access Was Revoked.With 990719 Ltr
ML17265A7021999-07-15015 July 1999
LER 99-010-00:on 990615,ventilation Isolation of Auxiliary Bldg Occurred When Auxiliary Bldg Gas Radiation Monitor R-14 Reached High Alarm Setpoint.Cr Operators Rest Auxiliary Bldg Ventilation Isolation Signal.With 990715 Ltr
ML17265A6851999-06-21021 June 1999
LER 99-001-01:on 990222,deficiencies in NSSS Vendor steam- Line Brake Mass & Energy Release Analysis Results in Plant Being Outside Design Bases Occurred.Caused by Deficiencies in W.Temporary Administrative Replaced.With 990621 Ltr
ML17265A6661999-06-0202 June 1999
LER 99-009-00:on 990503,instrumentation Declared Inoperable in Multiple Channels Resulted in Condition Prohibited by Ts. Caused by Unanticipated High Frequency AC Voltage Ripple. Entered TS LCO 3.0.3.With 990602 Ltr
ML17309A6541999-05-27027 May 1999
LER 99-008-00:on 990427,overtemperature Delta T Reactor Trip Occurred Due to Faulted Bistable During Calibr of Redundant Channel.Plant Was Stabilized in Mode 3 & Faulted Bistable Was Subsequently Replaced.With 990527 Ltr
ML17265A6631999-05-24024 May 1999
LER 99-007-00:on 990423,technicians Inadvertently Pulled Fuses from Wrong Nuclear Instrument Cahnnel,Causing Reactor Trip,Due to High Range Flux Trip.Caused by Personnel Error. Labeling Scheme Improved
ML17265A6601999-05-21021 May 1999
LER 99-006-00:on 990421,start of turbine-driven Auxiliary Feedwater Pump Was Noted.Caused by MOV Being Left in Open Position.Closed Manual Isolation Valve to Secure Steam to Pump.With 990521 Ltr
ML17265A6441999-05-13013 May 1999
LER 99-005-00:on 990413,undervoltage Signal of Safeguards Bus During Testing Resulted in Automatic Start of B Edg. Caused by Personnel Error.Blown Fuse Was Replaced & Offsite Power Was Restored to Safeguards Bus 17.With 990513 Ltr
ML17265A6431999-05-12012 May 1999
LER 99-004-00:on 990412,discovered That Containment Recirculation Fan Moisture Separator Vanes Were Incorrectly Installed,Per 10CFR21.Caused by Improper Assembly by Mfg. Subject Vanes Were Dismantled & Correctly re-installed
ML17265A6141999-03-31031 March 1999
LER 99-003-00:on 990301,two Main Steam non-return Check Valves Were Declared Inoperable Due to Exceedance of Acceptance Criteria.Caused by Changes in Methodology & Matls.Packing Gland Torque Will Be Adjusted.With 990331 Ltr
ML17265A6131999-03-29029 March 1999
LER 99-002-00:on 990227,discovered That Surveillance Had Not Been Performed at Frequency,Per Ts.Caused by Personnel Error.Procedure O-6.13 Will Be Evaluated for Enhancement Documentation of Completion of ITS Srs.With 990329 Ltr
ML17265A6061999-03-24024 March 1999
LER 99-001-00:on 990222,plant Was Noted Outside Design Basis.Caused by Deficiencies in NSSS Vendor Slb Mass & Energy Release.Placed Temporary Administrative Restriction 40 Degrees F Max on Screenhouse Bay Temp
ML17265A4951998-12-21021 December 1998
LER 98-005-00:on 981120,loss of 34.5 Kv Offsite Power Circuit 751,resulted in Automatic Start of B Edg.Caused by Faulted Cable Splice.Performed Appropriate Actions of Abnormal Procedure AP-ELEC.1.With 981221 Ltr
ML17265A4931998-12-17017 December 1998
LER 98-004-00:on 971030,determined That Improperly Performed Surveillance Resulted in Condition Prohibited by Ts.Caused by Procedure non-adherence.Appropriate Calibr Procedures Were Properly Performed with 24 H of Condition Discovery
ML17265A4691998-11-25025 November 1998
LER 98-003-01:on 980904,actuations of CR Emergency Air Treatment Systems (Creats) Occurred.Caused by Radon build-up During Temp Inversion.Creats Actuation Signal Was Reset & Normal Ventilation Was Restored to CR
ML17265A4271998-10-0505 October 1998
LER 98-003-00:on 980904,actuations of CR Emergency Air Treatment Sys Occurred.Caused by Radon build-up During Temp Inversion.Air Samples Were Taken & Determined That Source of Radiation Was Naturally Occurring Radon.With 981005 Ltr
ML17265A3671998-07-14014 July 1998
LER 98-002-00:on 971019,CR Emergency Air Treatment Sys Actuating Function Was Not Operable.Caused by Mispositioned Switch.Revised Procedure CPI-MON-R37.W/980714 Ltr
ML17265A1921998-03-11011 March 1998
LER 98-001-00:on 980209,discovered That Boraflex Degradation in SPF Was Greater than Was Assumed.Caused by Dissolution of Boron on Boraflex Matrix,Per 10CFR50.21.Removed Spent Fuel Assemblies from Selected Degraded Storage Rack Cells
ML17265A1641998-02-0606 February 1998
LER 97-007-01:on 971117,reactor Engineer Recognized That Neutron Flux Low Range Trip Circuitry for Channel Was Not in Tripped Condition as Required.Caused by Technical Inadequacies.Channel Defeat Will Be Identified
ML17265A1601998-02-0606 February 1998
LER 97-006-01:on 971103,verification of B Concentration Was Not Performed Due to Misinterpretation of Event Sequence. Audible Count Rate Function Was Restored to Operable Status
ML17264B1441997-12-17017 December 1997
LER 97-007-00:on 971117,NF Low Range Trip Circuitry for Channel N-44 Was Not Placed in Tripped Condition.Caused by Technical Inadequacies in Procedures.Implemented EWR 4862 to Resolve Design deficiency.W/971217 Ltr
ML17264B1291997-12-0303 December 1997
LER 97-006-00:on 971103,NIS Audible Count Rate Function Was Inoperable.Caused by Misinterpretation of Event Sequence Due to Not Verifying Boron Concentration.B Verification Occurred Every 12 H Per ITS LCO Action 3.9.2.C.3.W/971203 Ltr
ML17264B1271997-12-0101 December 1997
LER 97-005-00:on 971031,undetected Unblocking of SI Actuation Signal Occurred at Low Pressure Condition,Due to Faulty Bistable Which Resulted in Inadvertent SI Actuation Signal.Sias,Ci & CVI Signals Were Reset
ML17264B1211997-11-24024 November 1997
LER 97-004-00:on 971024,radiation Monitor Alarm Were Noted Due to Higher than Normal Radioactive Gas Concentration Resulted in Cvi.New R-12 Alarm Setpoint Was Maintained for Duration of Refueling Outage
ML17264B0461997-09-29029 September 1997
LER 97-003-01:on 970730,bistable Instrument Trip Setpoint Could Have Exceeded Allowable Value.Caused by Insufficient Existing Margin Between Trip Setpoint & Allowable Value. Held Switches in Tripped configuration.W/970929 Ltr
ML17264B0111997-08-27027 August 1997
LER 97-003-00:on 970730,high Steam Flow Bistable Instrument Setpoint Plus Instrument Uncertainty Could Exceed Allowable Value in ITS Was Identified.Caused by Entry Into ITS LCO 3.0.3.Switches Placed in Tripped configuration.W/970827 Ltr
ML17264A9941997-08-19019 August 1997
LER 97-002-00:on 970720,34.5 Kv Offsite Power Circuit 751 Was Lost.Caused by Automatic Actuation of B Emergency DG Due to Undervoltage on Safeguards Buses 16 & 17.Offsite Power Restored to Safeguards Buses 16 & 17.W/970819 Ltr
ML17264A9911997-08-11011 August 1997
LER 96-009-02:on 960723,determined That Leak Rate Outside Containment Was Greater than Program Limit.Caused by Weld Defect.Isolated Leak & Cut Out & Replaced Leaking Pipe
ML17264A8271997-03-0303 March 1997
LER 97-001-00:on 970131,discovered Service Water Temp Was Less than Specified Value.Caused by non-representative Method of Monitoring.Increased Water Temp in Screenhouse Bay to Greater than 35 Degrees F.W/970303 Ltr
ML17264A8071997-01-22022 January 1997
LER 96-015-00:on 961223,discovered Thermally Induced Overpressure Transient Could Occur.Caused by Thermal Expansion of Fluid During Design Basis Accident Condition. Installed Relief Valve on Affected line.W/970122 Ltr
ML17264A7471996-11-27027 November 1996
LER 96-013-00:on 961029,circuit Breakers Closed While in Mode 3 & Resulted in Condition Prohibited by TS Due to Personnel Error.Circuit Breakers for MOV-878B & MOV-878D Were re-opened.W/961127 Ltr
ML17264A6051996-09-19019 September 1996
LER 96-012-00:on 960820,feedwater Transient Occurred,Due to Closure of Feedwater Regulating Valve,Causing Lo Lo Steam Generator Level Reactor Trip.Sgs Were Restored & Missing Screw in 1/P-476 Was replaced.W/960919 Ltr
ML17264A6061996-09-19019 September 1996
LER 96-009-01:on 960723,leakage Outside Containment Occurred,Due to Weld Defect,Resulting in Leak Rate Greater than Program Limits.Source of Leakage Isolated from RWST by Freeze Seal,Allowing Exit from ITS LCO 3.0.3.W/960919 Ltr
ML17264A5911996-09-0505 September 1996
LER 96-011-00:on 960807,improper Configuration of Circuit Breaker Occurred,Due to Undetected Internal Interference, Resulting in Automatic Start of Both Auxiliary Feedwater Pumps.Running AFW Pumps Were secured.W/960905 Ltr
ML17264A5921996-09-0505 September 1996
LER 96-010-00:on 960806,latching of Main Turbine While in Mode 4 Occurred,Due to Defective Procedure,Resulting in Automatic Start of Auxiliary Feedwater Pump.Caused by Defective Maint Procedure.Procedure revised.W/960905 Ltr
ML17264A5891996-08-22022 August 1996
LER 96-009-00:on 960723,determined Leak on Piping Sys Outside Containment Greater than Program Limit.Caused by Weld Defect.Pipe & Socket Welds Were Cut Out & Replaced. W/960822 Ltr
ML17264A5781996-08-0606 August 1996
LER 96-008-00:on 960707,main Feedwater Pump Breakers Opened. Caused by Change in Seal Water Differential Pressure Occurred During Sys Realignment.Afw Flow Controlled as Desired to Maintain S/G level.W/960806 Ltr
ML17264A5561996-07-12012 July 1996
LER 96-007-00:on 960612,CR Operators Identified Control Rods Misaligned & Not Moving in Proper Sequence.Caused by Faulty Firing Circuit Card in Rod Control Sys.Faulty Firing Circuit Card in 1BD Power Cabinet replaced.W/960712 Ltr
ML17264A5421996-06-20020 June 1996
LER 96-006-00:on 960521,discovered Containment Penetration Not in Required Status.Caused by Personnel Error.Installed Flange Inside Containment Penetration 2.W/960620 Ltr
ML17264A5411996-06-17017 June 1996
LER 96-005-00:on 960516,PORC Determined Deficient Procedures Do Not Meet SRs for Testing safety-related Logic Circuits. Caused by Inadequancies in Individual Testing Procedures. Procedures Re Improved TSs revised.W/960617 Ltr
ML17264A5051996-05-17017 May 1996
LER 96-003-01:on 960308,identified That Both Pressurizer PORVs Inoperable Concurrently Due to Disconnection of Flex Hose to Both PORV Actuators to Install air-sets for Benchset & Limit Switch Activities.Hpes Completed
ML17264A4481996-04-0808 April 1996
LER 96-003-00:on 960308,both Pressurizer Relief Valves Inoperable.Hpes Evaluation Is Being Conducted to Determined Cause of Event.C/As:Both PORVs restored.W/960408 Ltr
ML17264A4471996-04-0808 April 1996
LER 96-002-00:on 960307,secondary Transient Occurred.Caused by Loss of B Condenser Circulating Water Pump.C/As: Thermography performed.W/960408 Ltr
ML17264A4101996-03-18018 March 1996
LER 96-001-00:on 950504,inservice Test Not Performed During Refueling Outage.Caused by Inadequate Tracking of Surveillance Frequency.Valve Test Performed & Disassembled. W/960318 Ltr
ML17264A2971995-12-14014 December 1995
LER 95-009-00:on 950817,surveillance Was Not Performed Due to Improper Application of TS Requirements Resulting in TS Violation.Testing of MOV-515 Was Performed on 951115.W/ 951214 Ltr
ML17264A1711995-09-25025 September 1995
LER 95-008-00:on 950825,secondary Transient Occurred.Caused by Loss of B Condenser Circulating Water Pump That Resulted in Manual Rt.Returned S/G Levels to Normal Operating levels.W/950925 Ltr
1999-09-22
[Table view]
Category:TEXT-SAFETY REPORT
MONTHYEARML17265A7601999-10-0505 October 1999
Part 21 Rept Re W2 Switch Supplied by W Drawn from Stock, Did Not Operate Properly After Being Installed on 990409. Switch Returned to W on 990514 for Evaluation & Root Cause Analysis
ML17265A7621999-09-30030 September 1999
Monthly Operating Rept for Sept 1999 for Re Ginna Npp.With 991008 Ltr
ML17265A7531999-09-23023 September 1999
Part 21 Rept Re Corrective Action & Closeout of 10CFR21 Rept of Noncompliance Re Unacceptable Part for 30-4 Connector. Unacceptable Parts Removed from Stock & Scrapped
ML17265A7541999-09-22022 September 1999
LER 99-011-00:on 990823,small Tears Were Discovered in Flexible Duct Work Connector at Inlet of CR HVAC Sys Return Air Fan (AKF08).Caused by in-leakage Greater than That Assumed.Implemented Temporary Mod 99-029.With 990922 Ltr
ML17265A7471999-08-31031 August 1999
Monthly Operating Rept for Aug 1999 for Re Ginna Npp.With 990909 Ltr
ML17265A7431999-08-24024 August 1999
LER 99-004-01:on 990412,discovered That Containment Recirculation Fan Chevron Separator Vanes Were Installed Backwards.Caused by Improper Assembly by Mfg.Moisture Separator Vanes Were Dismantled & Correctly re-installed
ML17265A7341999-07-31031 July 1999
Monthly Operating Rept for July 1999 for Re Ginna Npp.With 990806 Ltr
ML17265A7291999-07-29029 July 1999
Interim Part 21 Rept Re safety-related DB-25 Breaker Mechanism Procured from W Did Not Pas Degradatin Checks When Drawn from Stock to Be Installed Into BUS15/03A.Holes Did Not line-up & Tripper Pan Bent
ML17265A7181999-07-23023 July 1999
LER 99-007-01:on 990423,reactor Trip Occurred Due to Instrument & Control Technicians Inadvertently Pulling Fuses from Wrong Nuclear Instrument Channel.Setpoint Adjustments Were Completed by Different Crew of Technicians
ML17265A7081999-07-22022 July 1999
LER 98-003-02:on 980904,actuations of CR Emergency Air Treatment Sys Was Noted Due to Invalid Causes.Caused by Various Degraded Components in CR RM Sys.Creats Actuation Signal Was Reset & Normal Ventilation Was Restored
ML17265A7131999-07-22022 July 1999
Special Rept:On 990407,radiation Monitor RM-14A Was Declared Inoperable.Caused by Failed Communication Link from TSC to Plant Process Computer Sys.Communication Link Was re-established & RM-14A Was Declaed Operable on 990521
ML17265A7031999-07-19019 July 1999
LER 99-S01-00:on 990617,determined That Temporary Unescorted Access Had Been Granted to Contractor Employee.Caused by Incomplete Info Re Circumstances of Individual Military Separation.Individual Access Was Revoked.With 990719 Ltr
ML17265A7211999-07-19019 July 1999
ISI Rept for Third Interval (1990-1999) Third Period, Second Outage (1999) at Re Ginna Npp.
ML17265A7021999-07-15015 July 1999
LER 99-010-00:on 990615,ventilation Isolation of Auxiliary Bldg Occurred When Auxiliary Bldg Gas Radiation Monitor R-14 Reached High Alarm Setpoint.Cr Operators Rest Auxiliary Bldg Ventilation Isolation Signal.With 990715 Ltr
ML17265A7661999-06-30030 June 1999
1999 Rept of Facility Changes,Tests & Experiments Conducted Without Prior NRC Approval for Jan 1998 Through June 1999, Per 10CFR50.59.With 991020 Ltr
ML17265A7011999-06-30030 June 1999
Monthly Operating Rept for June 1999 for Re Ginna Npp.With 990712 Ltr
ML17265A6851999-06-21021 June 1999
LER 99-001-01:on 990222,deficiencies in NSSS Vendor steam- Line Brake Mass & Energy Release Analysis Results in Plant Being Outside Design Bases Occurred.Caused by Deficiencies in W.Temporary Administrative Replaced.With 990621 Ltr
ML17265A6761999-06-16016 June 1999
Part 21 Rept Re Defects & noncompliances,10CFR21(d)(3)(ii), Which Requires Written Notification to NRC on Identification of Defect or Failure to Comply. Relays Were Returned to Eaton for Evaluation & Root Cause Analysis
ML17265A6661999-06-0202 June 1999
LER 99-009-00:on 990503,instrumentation Declared Inoperable in Multiple Channels Resulted in Condition Prohibited by Ts. Caused by Unanticipated High Frequency AC Voltage Ripple. Entered TS LCO 3.0.3.With 990602 Ltr
ML17265A6681999-05-31031 May 1999
Monthly Operating Rept for May 1999 for Re Ginna Nuclear Power Plant.With 990608 Ltr
ML17265A6651999-05-27027 May 1999
Interim Rept Re W2 Control Switch,Procured from W,Did Not Operate Satisfactorily When Drawn from Stock to Be Installed in Main Control Board for 1C2 Safety Injection Pump. Estimated That Evaluation Will Be Completed by 991001
ML17309A6541999-05-27027 May 1999
LER 99-008-00:on 990427,overtemperature Delta T Reactor Trip Occurred Due to Faulted Bistable During Calibr of Redundant Channel.Plant Was Stabilized in Mode 3 & Faulted Bistable Was Subsequently Replaced.With 990527 Ltr
ML17265A6631999-05-24024 May 1999
LER 99-007-00:on 990423,technicians Inadvertently Pulled Fuses from Wrong Nuclear Instrument Cahnnel,Causing Reactor Trip,Due to High Range Flux Trip.Caused by Personnel Error. Labeling Scheme Improved
ML17265A6601999-05-21021 May 1999
LER 99-006-00:on 990421,start of turbine-driven Auxiliary Feedwater Pump Was Noted.Caused by MOV Being Left in Open Position.Closed Manual Isolation Valve to Secure Steam to Pump.With 990521 Ltr
ML17265A6591999-05-17017 May 1999
Part 21 Rept Re Relay Deficiency Detected During pre-installation Testing.Caused by Incorrectly Wired Relay Coil.Relays Were Returned to Eaton Corp for Investigation. Relays Were Repaired & Retested
ML17265A6441999-05-13013 May 1999
LER 99-005-00:on 990413,undervoltage Signal of Safeguards Bus During Testing Resulted in Automatic Start of B Edg. Caused by Personnel Error.Blown Fuse Was Replaced & Offsite Power Was Restored to Safeguards Bus 17.With 990513 Ltr
ML17265A6431999-05-12012 May 1999
LER 99-004-00:on 990412,discovered That Containment Recirculation Fan Moisture Separator Vanes Were Incorrectly Installed,Per 10CFR21.Caused by Improper Assembly by Mfg. Subject Vanes Were Dismantled & Correctly re-installed
ML17265A6381999-05-0707 May 1999
Part 21 Rept Re Replacement Turbocharger Exhaust Turbine Side Drain Port Not Functioning as Design Intended.Caused by Manufacturing Deficiency.Turbocharger Was Reaasembled & Reinstalled on B EDG
ML17265A6391999-04-30030 April 1999
Monthly Operating Rept for Apr 1999 for Re Ginna Nuclear Power Plant.With 990510 Ltr
ML17265A6361999-04-23023 April 1999
Part 21 Rept Re Power Supply That Did Not Work Properly When Drawn from Stock & Installed in -25 Vdc Slot.Power Supply Will Be Sent to Vendor to Perform Failure Mode Assessment.Evaluation Will Be Completed by 991001
ML17265A6301999-04-18018 April 1999
Rev 1 to Cycle 28 COLR for Re Ginna Npp.
ML17265A6251999-04-15015 April 1999
Special Rept:On 990309,halon Systems Were Removed from Svc & Fire Door F502 Was Blocked Open.Caused by Mods Being Made to CR Emergency Air Treatment Sys.Continuous Fire Watch Was Established with Backup Fire Suppression Equipment
ML17265A6551999-04-0909 April 1999
Initial Part 21 Rept Re Mfg Deficiency in Replacement Turbocharger for B EDG Supplied by Coltec Industries. Deficiency Consisted of Missing Drain Port in Intermediate Casing.Required Oil Drain Port Machined Open
ML17265A6291999-03-31031 March 1999
Rev 0 to Cycle 28 COLR for Re Ginna Npp.
ML17265A6241999-03-31031 March 1999
Monthly Operating Rept for Mar 1999 for Ginna Station.With 990409 Ltr
ML17265A6141999-03-31031 March 1999
LER 99-003-00:on 990301,two Main Steam non-return Check Valves Were Declared Inoperable Due to Exceedance of Acceptance Criteria.Caused by Changes in Methodology & Matls.Packing Gland Torque Will Be Adjusted.With 990331 Ltr
ML17265A6131999-03-29029 March 1999
LER 99-002-00:on 990227,discovered That Surveillance Had Not Been Performed at Frequency,Per Ts.Caused by Personnel Error.Procedure O-6.13 Will Be Evaluated for Enhancement Documentation of Completion of ITS Srs.With 990329 Ltr
ML17265A6061999-03-24024 March 1999
LER 99-001-00:on 990222,plant Was Noted Outside Design Basis.Caused by Deficiencies in NSSS Vendor Slb Mass & Energy Release.Placed Temporary Administrative Restriction 40 Degrees F Max on Screenhouse Bay Temp
ML17265A5661999-03-0101 March 1999
Rev 26 to QA Program for Station Operation.
ML17265A5961999-02-28028 February 1999
Monthly Operating Rept for Feb 1999 for Ginna Nuclear Power Plant.With 990310 Ltr
ML17265A5371999-01-31031 January 1999
Monthly Operating Rept for Jan 1999 for Re Ginna Nuclear Power Plant.With 990205 Ltr
ML17265A5951998-12-31031 December 1998
Rg&E 1998 Annual Rept.
ML17265A5001998-12-21021 December 1998
Rev 26 to QA Program for Station Operation.
ML17265A4951998-12-21021 December 1998
LER 98-005-00:on 981120,loss of 34.5 Kv Offsite Power Circuit 751,resulted in Automatic Start of B Edg.Caused by Faulted Cable Splice.Performed Appropriate Actions of Abnormal Procedure AP-ELEC.1.With 981221 Ltr
ML17265A4931998-12-17017 December 1998
LER 98-004-00:on 971030,determined That Improperly Performed Surveillance Resulted in Condition Prohibited by Ts.Caused by Procedure non-adherence.Appropriate Calibr Procedures Were Properly Performed with 24 H of Condition Discovery
ML17265A4761998-11-30030 November 1998
Monthly Operating Rept for Nov 1998 for Re Ginna Nuclear Power Plant.With 981210 Ltr
ML17265A4691998-11-25025 November 1998
LER 98-003-01:on 980904,actuations of CR Emergency Air Treatment Systems (Creats) Occurred.Caused by Radon build-up During Temp Inversion.Creats Actuation Signal Was Reset & Normal Ventilation Was Restored to CR
ML17265A4531998-10-31031 October 1998
Monthly Operating Rept for Oct 1998 for Re Ginna Nuclear Power Plant.With 981110 Ltr
ML17265A4271998-10-0505 October 1998
LER 98-003-00:on 980904,actuations of CR Emergency Air Treatment Sys Occurred.Caused by Radon build-up During Temp Inversion.Air Samples Were Taken & Determined That Source of Radiation Was Naturally Occurring Radon.With 981005 Ltr
ML17265A4291998-09-30030 September 1998
Monthly Operating Rept for Sept 1998 for Re Ginna Nuclear Power Plant.With 981009 Ltr
1999-09-30
[Table view] |
Text
CATEGORY1REGULATOYINFORMATION DISTRIBUTION SYSTEM(RIDS)ACCESS1'ON NBR:9606260154 DOC.DATE:
96/06/20NOTARIZED:
NOFACIL:50-244 RobertEmmetGinnaNuclearPlant,Unit1,Rochester AUTH.NAMEAUTHORAFFILIATION ST.MARTIN,J.T.
Rochester Gas&ElectricCorp.MECREDY,R.C.
Rochester Gas&ElectricCorp.RECIP.NAME RECIPIENT
'AFFILIATION DOCKETG05000244
SUBJECT:
LER96-006-00:on 960521,discovered containment penetration notinrequiredstatus.Causedbypersonnel error.Installed flangeinsidecontainment penetration 2.W/960620 ltr.DISTRIBUTION CODE:IE22TCOPIESRECEIVED:LTR ENCLSIZE:TITLE:50.73/50.9 LicenseeEventReport(LER),IncidentRpt,etc.NOTES:License Expdateinaccordance with10CFR2,2.109(9/19/72).
A'5000244(IRECIPIENT IDCODE/NAME PDl-1PDINTERNAL:
AEOD/SPD/RAB gF'ZEECENEENRR/DE/EEL'B NRR/DRCH/HHFB NRR/DRCH/HOLB NRR/DRPM/PECB NRR/DSSA/SRXB RGN1FILE01EXTERNAL:
LSTLOBBYWARDNOACMURPHYFG~ANRCPDRCOPIESLTTRENCL112211111111111111111111RECIPIENT IDCODE/NAME VISSINGFG.
AEOD/SPD/RRAB NRR/DE/ECGB NRR/DE/EMEB NRR/DRCH/HICB NRR/DRCH/HQMB NRR/DSSA/SPLB RES/DSIR/EIB LITCOBRYCEFJHNOACPOOREFW.NUDOCSFULLTXTCOPIESLTTRENCL1111111111111111221111D.NNOTETOALL"RIDS"RECIPIENTS:
PLEASEHELPUSTOREDUCEWASTE!CONTACTTHEDOCUMENTCONTROLDESK/ROOMOWFN5D-5(EXT.
415-2083)
TOELIMINATE YOURNAMEFROMDISTRIBUTION LISTSFORDOCUMENTS YOUDON'TNEED!FULLTEXTCONVERSION REQUIREDTOTALNUMBEROFCOPIESREQUIRED:
LTTR25ENCL25 ANDROCHESTER GASANDElECTRICCORI@RATION
~89EASTAVENUE,ROCHESTER, N.Y.IrI64'rrDDTAREACODE7165'-27tXtROBERTC.MECREDYVicePresident NucteorOperations June20,1996U.S.NuclearRegulatory Commission DocumentControlDeskAttn:GuyS.VissingProjectDirectorate I-1Washington, D.C.20555
Subject:
LER96-006,Containment Penetration NotinRequiredStatus,DuetoPersonnel Errors,ResultsinPotential forUncontrolled ReleaseofRadioactive MaterialR.E.GinnaNuclearPowerPlantDocketNo.50-244Inaccordance with10CFR50.73,LicenseeEventReportSystem,items(a)(2)(ii),(a)(2)(v)(C)and(a)(2)(v)(D),whichrequireareportof,"Anyoperation orcondition prohibited bytheplant'sTechnical Specifications" or"Anyeventorcondition thatalonecouldhaveprevented thefulfillment ofthesafetyfunctionofstructures orsystemsthatareneededto...Controlthereleaseofradioactive material; orMitigatetheconsequences ofanaccident",
theattachedLicenseeEventReportLER96-006isherebysubmitted.
Thiseventhasinnowayaffectedthepublic'shealthandsafety.Verylyyours,RobertC.Mecredyxc:U.S.NuclearRegulatory Commission Mr.GuyS.Vissing(MailStop14C7)PWRProjectDirectorate I-1Washington, D.C.,20555 U.S.NuclearRegulatory Commission RegionI475Allendale-Road KingofPrussia,PA19406U.S.NRCGinnaSeniorResidentInspector 9606260i54 960620PDRADQCK050002448PDRy/~JP NRCFORM366(4.95)U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)(Seereverseforrequirednumberofdigits/characters foreachblock)APPROVEDBYOMBNO.3150-0104 EXPIRES04/30/BBESTIMATED BURDENPERAESPONSEToCOMPLYWITHTHISMANDATORY INFORMATION COLLECTION REQUEST:50.0HRS.REPOATEDLESSONSLEARNEDAREINCORPORATED INTOTHEUCENSINGPROCESSANDFEDBACKToINDUSTRY.
FORWARDCOMMENTSREGARDING BURDENESTIMATEToTHEINFORMATION ANDRECORDSMANAGEMENT BRANCHIT-6F33),U.S.NUCLEARREGULATORY COMMISSION, WASHINGTON, DC20555.0001, ANDToTHEPAPEAWORK REDUCTION PROJECTFACILITYkAME(1)R.E.GinnaNuclearPowerPlantOOCKETNUMBER(2)05000244PAGE(3)1OF8B(4)AContainment Penetration NotinRequiredStatus,DuetoPersonnel Errors,Results'in Potential forUncontrolled ReleaseofRadioactive MaterialMONTHDAYYEAR052196EVENTDATE(5)LERNUMBER(6)SEQUENTIAL REVISIONNUMBER.,NUMBER96-006-00MONTHDAYYEAR062096REPORTDATE(7)FACILITYNAMEFACILITYNAMEOTHERFACILITIES INVOLVED(6)OOCKETNUMBEROOCKETNUMBEROPERATING MODE(9)POWERLEVEL(10)kAME000THISREPORTISSUBMITTED PURmore)(11)50.73(a)(2)(viii]50.73(a)(2)(x)50.73(a)(2)(i)50.73(a)(2)(ii)20.2203(a)(2)(v) 20.2203(a)(3)(i) 20.2201(b) 20.2203ta) tl)73.7150.73(a)(2)(iii)50.73(a)(2)(iv)20.2203(a)
(3)(ii)20.2203(a)
(4)20.2203(a)
(2)(i)20.2203(a)(2)(ii)
OTHERSpecifyinAbstractbeloworinNRCForm366A20.2203(a)(2)
(iii)50.36(c)(1) 50.73(a)(2)
(v)20.2203(a)
(2)(iv)50.36(c)(2)50.73(a)(2)(vii)
LICENSEECONTACTFORTHISLER(12)ELBPIIOkE NUMBER(IncludeAreaCoda>SUANTTOTHEREQUIREMENTS OF10CFRE:(CheckoneorJohnT.St.Martin-Technical Assistant (716)771-3641COMPLETEONELINEFOREACHCOMPONENT FAILUREDESCRIBED INTHISREPORT(13)CAUSESYSTEMCOMPONENT MANUFACTURER AEPOATABLE TONPADSCAUSESYSTEMCOMPONENT MANUFACTURER REPORTABLE ToNPRDSSUPPLEMENTAL REPORTEXPECTED(14)YES(lfyes,completeEXPECTEDSUBMISSION DATE).XNOEXPECTEDSUBMISSION DATE(15)MONTHDAYYEARABSTRACT(Limitto1400spaces,l.e.,approximately 15single-spaced typewritten lines)(16)OnMay21,1996,atapproximately 0900EDST,withtheplantinMode6withcorealterations andmovementofirradiated fuelassemblies withincontainment inprogress, itwasdiscovered thatacontainment penetration wasnotintherequiredstatusforrefueling operations, allowingdirectaccessfromthecontainment atmosphere totheoutsideatmosphere.
Immediate corrective actionwastakeninaccordance withGinnaImprovedTechnical Specifications LimitingConditions forOperation 3.9.3.A.1 and3.9.3.A.2 tosuspendcorealterations andsuspendmovementofirradiated fuelassemblies withincontainment.
Thecontainment penetration wasrestoredtotherequiredstatusforrefueling operations, andrefueling operations werepermitted toresume.Theunderlying causeofthepenetration notbeingintherequiredstatusforrefueling operations waspersonnel errors.ThiseventisNUREG-1022 CauseCode(A).Corrective actiontopreventrecurrence isoutlinedinSectionV.B.NRCFORM366(4-95)
NRCFORM366AI4-95)LICENSEEEVENTREPORT(LER),TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION FACILITYNAMEIl)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBERI6)YEARSEQUENTIAL REVISIONNUMBERNUMBER96-006-00PAGEI3)2OF8TEXT(Ifmorespaceisrequired, useadditional copiesofNRCForm366A/(17)PRE-EVENT PLANTCONDITIONS:
Containment (CNMT)penetration I)'2(referred toasP-2)isthe"S/GCommunications FlangePenetration" normallyusedforsupportofroutinesteamgenerator (S/G)maintenance andinspection activities duringrefueling outages.WheninModes5or6,normallyroutedthroughP-2areclosed-circuit television (CCTV)cablesandothercommunications cables.Forthe1996Refueling outage,P-2wasalsousedtoprovidearouteforadditional CCTVcablesandrigidpipesfrom'theoutsideintoCNMT,toprovideservices(communications, airandargon)foractivities associated withreplacement oftheS/Gs.Thesepipeswerea3"lineforserviceairanda11/2"lineforargon.StationModification procedures SM-10034-10.01 (Temporary ServiceAirSystemforSGRP)andSM-10034-'l0.03 (Installation 5RemovalofTemporary CCTVandCommunications) wereusedtocontrolthetemporary installation andsubsequent removaloftheseservices.
OnMay19,1996,inpreparation forrefueling thereactor,Ginnaplantstaffcheckedtheconfiguration ofP-2andverifiedthattheconfiguration compliedwithGinnaImprovedTechnical Specifications (ITS)LimitingCondition forOperation (LCO)3.9.3.c,whichstatesthateachpenetration providing directaccessfromtheCNMTatmosphere totheoutsideatmosphere shallbeisolated, orclosedbyanequivalent isolation method.Thesemethodsincludeuseofmaterialthatcanprovideatemporary, atmospheric
- pressure, ventilation barrier.Contractor supervision weresubsequently notifiednottodisturbtheconfiguration ofP-2untilafterthecompletion ofrefueling.
DuringthedayshiftonMay20,1996,asdirectedbycontractor supervision, contractor maintenance personnel removedmuchofthetemporary serviceairandargonlinesinsideCNMT,asdirectedbyprocedure SM-10034-10.01.
Contractor supervision hadbeencautioned byGinnastaffnottoremovethe3"and11/2"pipespoolpieces thatwereinsidethesealforP-2andthefirstvalvesoneachsideofP-2insideandoutsideofCNMT.Nevertheless, attheendoftheirshift(atapproximately 1800EDST),thecontractor maintenance personnel removedthesespoolpieces andvalves.Additional pipingoutsideCNMTwasleftinplaceuntilthenextday.OnMay21,1996,atapproximately 0300EDST,autilitynon-licensed operatorwasperforming Operating Procedure 0-15.2(ValveAlignment forReactorHeadLift,CoreComponent
- Movement, andPeriodicStatusChecks),inpreparation forthestartofrefueling operations.
Aspartofthisprocedure, theoperatorperformed Step5.2.1toverifythatP-2was"adequately sealed",andsignedoffStep5.2.1ofprocedure 0-15.2.Satisfactory completion ofthisstepensurescompliance withITSLCO3.9.3.c.NRGFORM366AI4-95)
NRCFORM366A(4-95)LXCENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION FACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)YEARSEQUENTIAL REVISIONNUMBERNUMBER96-006-00PAGE(3)TEXT(Ifmorespaceisrequired, useadditional copiesofNRCForm366A/(17)DESCRIPTION OFEVENT:A.DATESANDAPPROXIMATE TIMESOFMAJOROCCURRENCES:
0May19,1996:Ginnastaffverifythattheconfiguration ofP-2meetstherequiredstatusofITSLCO3.9.3.c.May20,1996,1800EDST:Contractor maintenance personnel removepipespoolpieces frominsidethesealforP-2.P-2configuration doesnotmeettherequiredstatusofITSLCO3.9.3.c.0May21,1996,0537EDST:TheplantentersMode6andbeginscorealterations andmovementofirradiated fuelasemblies withinCNMT.Eventdateandtime.0May21,1996,0900EDST:Discovery dateandtime.0May21,1996,0937EDST:Allremaining cablesareremovedfromP-2,andP-2isflangedoff.B.EVENT:OnMay21,1996,allpreparations forrefueling werecompleted.
Procedure 0-15.2hadbeensignedoffatapproximately 0505EDST,andtheControlRoomoperators notifiedtheSeniorReactorOperatorassignedtoRefueling (Refueling SRO)tobeginrefueling.
TheplantenteredMode6atapproximately 0537EDSTandbeganrefueling operations (corealterations andmovementofirradiated fuelassemblies withinCNMT).OnMay21,1996,atapproximately 0800EDST,contractor maintenance personnel continued theirworkfromthepreviousdayforremovaloflinesasperSM-10034-10.01.
Sincetheselineswerepotentially contaminated, aRadiation Protection (RP)technician wasrequested tosurveytheremovedlinespriortodisposal.
OnMay21,1996,atapproximateiy 0900EDST,withtheplantinMode6andrefueling operations inprogress, theRPtechnician approached P-2tosurveysomematerials anddiscovered thatP-2wasnotintherequiredstatusforrefueling operations.
HeobservedthatP-2wasnotcompletely sealedwherethe3"and11/2"spoolpieces hadbeen,appearing toallowdirectaccessfromtheCNMTatmosphere totheoutsideatmosphere.
NRCFORM366A(4.95)
NRCFORM366A(4.95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION FACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)YEARSEQUENTIAL REVISIONNUMBERNUMBER96-006-00PAGE(3)4OF8TEXTllfmorespaceisrequired, useadditional copiesofNRCForm386Ai(17)TheRPtechnician notifiedhissupervision.
RPsupervision notifiedamemberoftheplantOutageManagement staff,whoinspected P-2andconfirmed thatitwasnotadequately sealed.TheControlRoomoperators werenotifiedofthestatusofP-2asobservedfromoutsideCNMT.Immediate actionsweretakenperITSLCOACTIONs3.9.3.A.1 and3.9.3.A.2 tosuspendcorealterations andsuspendmovementofirradiated fuelassemblies withinCNMT.TheRefueling SROinsideCNMTwasalsonotifiedthatP-2neededtobeinspected frominsideCNMTforthepresenceofaflange.TheRefueling SROinspected P-2andconfirmed thatthepenetration wasnotisolatedinsideCNMTbyuseofamaterialthatcanprovideatemporary, atmospheric
- pressure, ventilation barrier.TheRPtechnician verifiedthattheactualflowofairwasfromtheoutsideintoCNMT.Ginnaandcontractor electricians werenotifiedtoremoveallremaining cablesroutedthroughP-2.Whenthecableswereremovedandthepenetration wasunobstructed insideCNMT,Ginnapipefitters installed aflangeoverP-2.TheseactionsrestoredP-2totherequiredstatusforrefueling operations, andrefueling operations werepermitted toresumeatapproximately 0937EDSTonMay21,1996.C.INOPERABLE STRUCTURES, COMPONENTS, ORSYSTEMSTHATCONTRIBUTED TOTHEEVENT:NoneD.OTHERSYSTEMSORSECONDARY FUNCTIONS AFFECTED:
NoneE.METHODOFDISCOVERY:
Whileperforming routinemonitoring activities fortheremovalofpotentially contaminated materials fromCNMT,aRadiation Protection technician discovered thatP-2wasnotcompletely sealedasobservedfromoutsideCNMT.TheRefueling SROconfirmed thatP-2wasnotintherequiredstatusforrefueling operations.
F.OPERATORACTION:TheControlRoomoperators, uponbeingnotifiedthatP-2wasnotintherequiredstatusforrefueling operations, immediately compliedwiththerequirements ofITSLCOACTIONs3.9.3.A.1.
and3.9.3.A.2, whichrequirethatifoneormoreCNMTpenetrations arenotinrequiredstatus,"SuspendCOREALTERATIONS" and"Suspendmovementofirradiated fuelassemblies withincontainment".
Subsequently, theControlRoomoperators notifiedhighersupervision andtheNRCSeniorResidentInspector.
Atapproximately 1226EDSTonMay21,1996,a4hournon-emergency notification wasmadetotheNRCOperations Centerasper10CFR50.72(b)(2)(iii)(C)and10CFR50.72(b)(2)(iii)(D).NRCFORM366A(4-95)
NRCFORM366A(495)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION FACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)YEARSEQUENTIAL REVISIONNUMBERNUMBER96-006-00PAGE(3)TEXTllfmorespaceisrequired, usoadditional copiesofNRCForm366Al(17)G.SAFETYSYSTEMRESPONSES:
NoneIII.CAUSEOFEVENT:A.IMMEDIATE CAUSE:Theimmediate causeofCNMTpenetration P-2notbeingintherequiredstatusforrefueling operations wasopeningsinthefoamsealwherea3"pipeand11/2"pipehadbeenremoved.Thiscondition wasnotidentified byOperations personnel duringperformance ofprocedure 0-15.2.B.INTERMEDIATE CAUSE:Theintermediate causeoftheopeningsinthefoamsealforP-2wastheunauthorized removalofthepipespoolpieces andassociated valvesfromthepenetration.
Theintermediate causeofnotidentifying thiscondition duringtheperformance of0-15.2wasinadequate verification byOperations personnel.
ROOTCAUSE:Theunderlying causeoftheunauthorized removalofthespoolpieces waspersonnel error.Theunderlying causeoftheinadequate verification byOperations personnel wasalsopersonnel error.AHumanPerformance Enhancement System(HPES)evaluation wasperformed todetermine thecausalfactorsthatcontributed tothesepersonnel errors.ThiseventisNUREG-1022 CauseCode(A),"Personnel Error".Personnel errorsweremadebycontractor maintenance personnel andautilitynon-licensed operator.
Theseerrorswerecognitive personnel errorsonthepartofbothgroups.Thecontractor maintenance personnel didnotrecognize theimpactonrefueling operations ofremovingthepipespoolpieces fromP-2.TheOperations personnel didnotrecognize theactualconfiguration ofthefoamsealinP-2during0-15.2verifications, perceived thattheyhadaccurately verifiedtheconfiguration, andthoughtthatP-2wasintherequiredstatusforrefueling operations, when,infact,P-2wasnotadequately sealed.NRCFORM366A(4-95)
NRCFORM366A(4-SS)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION FACILITYNAME(1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)SEQUENTIAL REVISIONNUMBERNUMBER96-006-00PAGE(3)6OF8TEXTiifmorespaceisrequired, useadditional copiesofNRCForm366AJ(17).Thecontractor maintenance errorwascontrarytoapprovedprocedure SM-10034-10.01, andtheoperatorerrorwascontrarytoapprovedprocedure 0-15.2.Unusualconditions presentduringtheperformance of0-15.2includednighttime
- darkness, alightning storm,limitedaccesstoP-2(P-2wasenclosedbyawoodenprotective enclosure),
additional cableroutedthroughP-2forthe1996outage,andsomeoftheremaining pipingandvalvesstillbeingwithintheenclosure aroundP-2.Theseenvironmental factorsmayhaveobscuredtheviewofthefoamsealfromoutsideCNMT,wherethe3"and11/2"spoolpieces hadbeen.AccesstoviewP-2frominsideCNMTwaspartially blocked,duetoequipment insideCNMTfortheS/Greplacement.
Thiscondition doesnotmeettheNUMARC93-01,"Industry Guideline forMonitoring theEffectiveness ofMaintenance atNuclearPowerPlants",definition ofa"Maintenance Preventable Functional Failure".
IV.ANALYSISOFEVENT:Thiseventisreportable inaccordance with10CFR50.73,LicenseeEventReportSystem,items(a)(2)(ii),(a)(2)(v)(C)and(a)(2)(v)(D),whichrequireareportof,"Anyoperation orcondition prohibited bytheplant'sTechnical Specifications" or"Anyeventorcondition thatalonecouldhaveprevented thefulfillment ofthesafetyfunctionofstructures orsystemsthatareneededto...Control thereleaseofradioactive material; orMitigatetheconsequences ofanaccident".
HavingaCNMTpenetration notintherequiredstatusforrefueling operations withrefueling operations inprogressisacondition prohibited bytheITS.Itispostulated that,intheeventofafuelhandlingaccidentatthiscondition, theresultant radioactive releasecouldbeuncontrolled, andthattheCNMTcouldhavebeenineffective inmitigating theconsequences ofthispostulated accident.
iAnassessment wasperformed considering boththesafetyconsequences andimplications ofthiseventwiththefollowing resultsandconclusions:
Therewerenooperational orsafetyconsequences orimplications attributed tothiscondition because:0ThoughtheCNMTpenetration alloweddirectaccessfromtheCNMTatmosphere totheoutsideatmosphere, acondition didnotexistthatcouldhaveresultedinanuncontrolled radioactive release.Areleasetotheoutsideatmosphere wouldhaverequiredCNMTpressurization.
Sincethefuelhadalowdecayheatrateduetoasixtydayoffloadandsincetherewasonlyasmallamountoffuelinthecoreatthetime,theenergysourcetoeffectaCNMTpressurization waslow,makingapressurized conditions unlikely.
ItwasverifiedthattheactualflowofairwasfromtheoutsideintoCNMT.0CNMTisolation isnotcreditedintheeventofafuelhandlingaccidentpertheapplicable safetyanalysesbasesforITSLCO3.9.3.TheGinnaStationUpdatedFinalSafetyAnalysisReport(UFSAR),Section15.7.3.3, showsthatwithoutcreditforCNMTandutilizing theconservative assumptions ofNRCRegulatory Guide(RG)1.25,theoffsitedoseconsequences following afuelhandlingaccidentareninety-six (96)REMthyroid,whichiswithin10CFR100limitsforGinnaStation.NRCFORM366A(4.65)
NRCFORM366A(4-95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION FACILITYNAMEI1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBERI6)YEARSEQUENTIAL REVISIONNUMBERNUMBER96-006-00PAGEI3)7OF8TEXT(lfmorespeceisrequired, useedditionelcopiesofNRCForm366Al(17)0GinnaStationrecentlyreceivedAmendment 62totheITS,whichmodifiedtherequirements fortheCNMTequipment hatchduringMode6.IncludedwithinthisITSamendment request(datedFebruary9,1996)wasanevaluation ofoffsitedoses,withthefollowing assumptions:
b.CNMTwasinitially pressurized by0.5PSIGabovetheoutsideatmosphere forthefirstthreeminutesfollowing afuelhandlingaccident, aCNMTleakagerate,basedonextremetemperature differences betweentheinsideandtheoutsideofCNMT,existedforthenexttwohours,andaholeequivalent to1.83squarefeetexistedtotheoutsideatmosphere.
Usingtheseandotherassumptions ofRG1.25,thethyroiddoseattheexclusion areaboundarywascalculated tobeonly8.1REM,whichiswellwithin10CFR100limits.Thecondition ofP-2beingopenduringmovementofirradiated fuelassemblies isboundedbythisanalysissincenofuelhandlingaccidentoccurred, theCNMTwasnotpressurized, andtheincreased leakagepaththroughP-2waslessthan0:1squarefoot.Therefore, thiscondition wouldnotleadtoexceeding thedoselimits.Basedontheabove,itcanbeconcluded thatthepublic'shealthandsafetywasassuredatalltimes.V.CORRECTIVE ACTION:A.ACTIONTAKENTORETURNAFFECTEDSYSTEMSTOPRE-EVENT NORMALSTATUS:0Allremaining cableswereremovedfromP-2andaflangewasinstalled onP-2insideCNMT,restoring P-2tocompliance withITSLCO3.9.3.c.0Refueling operations werepermitted toresume.B.ACTIONTAKENORPLANNEDTOPREVENTRECURRENCE:
0Procedure 0-15.2willberevisedtorequireadditional controlsatP-2,topreventtheconfiguration ofP-2frombeingchangedduringrefueling operations.
0ANuclearTrainingWorkRequestwillbeinitiated totrainonthelessonslearnedfromthisevent.VI.ADDITIONAL INFORMATION:
A.FAILEDCOMPONENTS:
NoneIIRCFORM366AI4.95)
NRCFORM366AI4-95)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSION FACILITYNAMEI1)R.E.GinnaNuclearPowerPlantDOCKET05000244LERNUMBER(6)YEARSEQUENTIAL REVISIONNUMBERNUMBER96-006-00PAGEI3)8OF8TEXT(Ifmorespaceisrequired, useadditional copiesofNRCForm366AJI17)B.PREVIOUSLERsONSIMILAREVENTS:AsimilarLEReventhistorical searchwasconducted withthefollowing results:Nodocumentation ofsimilarLEReventswiththesamerootcauseatGinnaNuclearPowerPlantcouldbeidentified.
C.SPECIALCOMMENTS:
NoneNACFOAM366AI4.95)
