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| {{#Wiki_filter:ACCELERAT.D DOCUINENT DIST'TION SYSTEM REGULA INFORMATION DISTRIBUTIO SYSTEM (RIDS)ACCESSION NBR:9307220304 DOC.DATE: 93/07/15 NOTARIZED: | | {{#Wiki_filter:ACCELERAT .D DOCUINENT DIST'TION SYSTEM REGULA INFORMATION DISTRIBUTIO SYSTEM (RIDS) |
| NO DOCKET FACIL:50-397 WPPSS Nuclear Project, Unit 2, Washington Public Powe 05000397 AUTH.NAME AUTHOR AFFILIATION FIESPC.L.Washington Public Power Supply System PARRISH,J.V. | | ACCESSION NBR:9307220304 DOC.DATE: 93/07/15 NOTARIZED: NO DOCKET FACIL:50-397 WPPSS Nuclear Project, Unit 2, Washington Public Powe 05000397 AUTH. NAME AUTHOR AFFILIATION FIESPC.L. Washington Public Power Supply System PARRISH,J.V. Washington Public Power Supply System RECIP.NAME RECIP1ENT AFFILIATION |
| Washington Public Power Supply System RECIP.NAME RECIP1ENT AFFILIATION | |
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| ==SUBJECT:== | | ==SUBJECT:== |
| LER 93-025-00:on 930615,Group 1 nuclear steam supply shutoff sys isolation occurred during performance of TS survei'llance test on turbine throttle valves.Caused by procedure deficiency. | | LER 93-025-00:on 930615,Group 1 nuclear steam supply shutoff sys isolation occurred during performance of TS survei'llance test on turbine throttle valves. Caused by procedure deficiency. Procedure changed.W/930715 ltr. |
| Procedure changed.W/930715 ltr.DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR J ENCL Q SIZE: TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.NOTES: RECIPIENT ID CODE/NAME PDV LA CLIFFORDIJ INTERNAL: ACNW AEOD/DOA AEOD/ROAB/DSP NRR/DE/EMEB NRR/DRCH/HHFB NRR/DRCH/HOLB NRR/DRSS/PRPB NRR/DSSA/SRXB RES/DSIR/EIB EXTERNAL: EG6G BRYCE,J.H NRC PDR NSIC POOREPW.COPIES LTTR ENCL 1 1 1 1 2 2 1 1 2 2 1 1 1 1 1 1 2 2 1 1 1 1 2 2 1 1 1 1 RECIPIENT ID CODE/NAME PDV PD ACRS AEOD/DSP/TPAB NRR/DE/EELB NRR/DORS/OEAB NRR/DRCH/HICB NRR/DRIL/RPEB NRR/DSSA/SPLB | | DISTRIBUTION CODE: IE22T TITLE: 50.73/50.9 Licensee Event Report (LER), J IncidentQRpt, etc. |
| ~~gEG~EX-E 02 RGN5 FILE 01 L ST LOBBY WARD NSIC MURPHYPG.A NUDOCS FULL TXT COPIES LTTR ENCL 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 NOTE TO ALL"RIDS" RECIPIENTS: | | COPIES RECEIVED:LTR ENCL SIZE: |
| PLEASE HELP US TO REDUCE WASTEI CONTACT THE DOCUMENT CONTROL DESK.ROOM Pl-37{EXT.504-2065)TO ELIMINATE YOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 32 ENCL 32 WASHINGTON PUBLIC POWER SUPPLY SYSTEM P.O.Box 968~3000 George Washington Way~Richland, Washington 99352 July 15, 1993 G02-93-184 Docket No.50-397 Document Control Desk U.S.Nuclear Regulatory Commission Washington, D.C.20555 Subject NUCLEAR PLANT WNP-2, OPERATING LICENSE NPF-21 LICENSEE EVENT REPORT NO.93-025 Transmitted herewith is Licensee Event Report No.93-025 for the WNP-2 Plant.This report is submitted in response to the report requirements of 10CFR50.73 and discusses the items of reportability, corrective action taken, and action taken to preclude recurrence. | | NOTES: |
| J.V.Parrish (Mail Drop 1023)Assistant Managing Director, Operations JVP/CLF/my Enclosure CC: Mr.B.H.Faulkenberry, NRC-Region V Mr.R.Barr, NRC Resident Inspector (Mail Drop 901A, 2 Copies)INPO Records Center-Atlanta, GA Mr.D.L.Williams, BPA (Mail Drop 399)2XQ006 9307220304 930715 PDR ADDCK 05000397 8 PDR AGILITY NAHE (1)LICENSEE EVA REPORT (LER)Washin ton Nuclear Plant-Unit 2 DOCKET NUMB R ()PAGE (3)0 5 0 0 0 3 9 7 I OF ITLE (4)ENGINEERED SA'FETY FEATURE (ESF)ACTUATION CAUSED BY SURVEILLANCE TESTING EVENT DATE 5)LER NUHBER 6)REPORT DATE (7)OTHER FACILITIES INVOLVED (6)HONTH OAY YEAR YEAR g 8>SEOUENTIAL NUMBER EV I SION UMBER HONTH OAY YEAR FACILITY NAMES CKE 5 0 NUMBE R (5)0 6 1 5 9 3 9 3 0 2 5 0 0 0 7 1 5 9 3 50 PERATING OOE (9)HIS REPORT IS SUBHITTEO PURSUANT TO THE REQUIREMENTS OF 10 CFR E: (Check one or more of the following) | | RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PDV LA 1 1 PDV PD 1 1 CLIFFORDIJ 1 1 INTERNAL: ACNW 2 2 ACRS 2 2 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DSP 2 2 NRR/DE/EELB 1 1 NRR/DE/EMEB 1 1 NRR/DORS/OEAB 1 1 NRR/DRCH/HHFB 1 1 NRR/DRCH/HICB 1 1 NRR/DRCH/HOLB 1 1 NRR/DRIL/RPEB 1 1 NRR/DRSS/PRPB 2 2 NRR/DSSA/SPLB 1 1 NRR/DSSA/SRXB 1 1 ~~gEG ~EX- E 02 1 1 RES/DSIR/EIB 1 1 RGN5 FILE 01 1 1 EXTERNAL: EG6G BRYCE,J.H 2 2 L ST LOBBY WARD 1 1 NRC PDR 1 1 NSIC MURPHYPG.A 1 1 NSIC POOREPW. 1 1 NUDOCS FULL TXT 1 1 NOTE TO ALL"RIDS" RECIPIENTS: |
| (11)4 ONER LEVEL (10)20.402(b)20.405(a)(1)(I)20.405(a)(1)(I I)20.405(a)(I)(i i I)0.405(a)(l)(iv) 0.405(a)(1)(v) 20.405(C)50.36(c)(1) 50.36(c)(2) 50.73(a)(2)(i) 50.73(a)(2)(ii) 50.73(a)(2)(iii) | | PLEASE HELP US TO REDUCE WASTEI CONTACT THE DOCUMENT CONTROL DESK. |
| X 50.73(a)(2)(iv) 50.73(a)(2)(v) 50.73(a)(2)(vii) 50.73(a)(2)(viii)(A) 50.73(a)(2)(viii)(B) 50.73(a)(2)(x) 77.71(b)73.73(c)THER (Specify in Abstract elow and in Text, NRC orm 366A)LICENSEE CONTACT FOR THIS LER (12)C.L.Fies, Licensing Engineer TELEPHONE NUHBER REA CODE 5 0 9 7 7-4 1 4 7 COHPLETE ONE LINE FOR EACH COHPONENT FAILURE DESCRIBED IN THIS REPORT (13)CAUSE SYSTEH COHPONENT HANUFACTURER EPORTABLE 0 NPRDS CAUSE SYSTEM COHPONENT MANUFACTURER REPORTABLE TO NPRDS h SUPPLEMENTAL REPORT EXPECTED (14)YES (If yes, complete EXPECTED SUBMISSION DATE)NO BlACT eel EXPECTED SUBMISSION MONTH DAY YEAR ATE (15)At approximately 1850 hours on June 15, 1993, a Group 1 Nuclear Steam Supply Shutoff System (NS')isolation occurred during the performance of a Technical Specification surveillance test associated with the Turbine Throttle Valves.The test involved calibration of position switches on the valves associated with the NS'ogic.During shutdown conditions there is no main condenser vacuum.The NS4 logic is configured in a manner where exercising each Turbine Throttle valve to the open position initiates a half Group 1 isolation.
| | ROOM Pl-37 {EXT. 504-2065) TO ELIMINATEYOUR NAME FROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED! |
| During the surveillance test a second Throttle Valve was opened without resetting the (NS4)logic after testing the first valve.This resulted in a Group 1 isolation which is considered an ESF actuation. | | FULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 32 ENCL 32 |
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| | WASHINGTON PUBLIC POWER SUPPLY SYSTEM P.O. Box 968 ~ 3000 George Washington Way ~ Richland, Washington 99352 July 15, 1993 G02-93-184 Docket No. 50-397 Document Control Desk U.S. Nuclear Regulatory Commission Washington, D.C. 20555 Subject NUCLEAR PLANT WNP-2, OPERATING LICENSE NPF-21 LICENSEE EVENT REPORT NO. 93-025 Transmitted herewith is Licensee Event Report No. 93-025 for the WNP-2 Plant. This report is submitted in response to the report requirements of 10CFR50.73 and discusses the items of reportability, corrective action taken, and action taken to preclude recurrence. |
| | J. V. Parrish (Mail Drop 1023) |
| | Assistant Managing Director, Operations JVP/CLF/my Enclosure CC: Mr. B. H. Faulkenberry, NRC - Region V Mr. R. Barr, NRC Resident Inspector (Mail Drop 901A, 2 Copies) |
| | INPO Records Center - Atlanta, GA Mr. D. L. Williams, BPA (Mail Drop 399) 2XQ006 9307220304 930715 PDR ADDCK 05000397 8 PDR |
| | |
| | LICENSEE EVAREPORT (LER) |
| | AGILITY NAHE (1) DOCKET NUMB R ( ) PAGE (3) |
| | Washin ton Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 I OF ITLE (4) |
| | ENGINEERED SA'FETY FEATURE (ESF) ACTUATION CAUSED BY SURVEILLANCE TESTING EVENT DATE 5) LER NUHBER 6) REPORT DATE (7) OTHER FACILITIES INVOLVED (6) |
| | HONTH OAY YEAR YEAR g SEOUENTIAL EV I SION HONTH OAY YEAR FACILITY NAMES CKE NUMBER (5) |
| | NUMBER UMBER 8> |
| | 5 0 0 6 5 9 1 3 9 3 0 2 5 0 0 0 7 1 5 9 3 50 PERATING HIS REPORT IS SUBHITTEO PURSUANT TO THE REQUIREMENTS OF 10 CFR E: (Check one or more of the following) (11) |
| | OOE (9) 4 ONER LEVEL 20.402(b) 20.405(C) X 50.73(a)(2)(iv) 77.71(b) |
| | (10) 20. 405(a) (1) ( I ) 50.36(c)(1) 50.73(a)(2)(v) 73.73(c) |
| | : 20. 405(a) (1) ( I I) 50.36(c)(2) 50.73(a)(2)(vii) THER (Specify in Abstract 20.405(a) (I) (i i I) 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) elow and in Text, NRC 0.405(a)(l)(iv) 50.73(a)(2)(ii) 50.73(a)(2)(viii)(B) orm 366A) 0.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x) |
| | LICENSEE CONTACT FOR THIS LER ( 12) |
| | TELEPHONE NUHBER C. L. Fies, Licensing Engineer REA CODE 5 0 9 7 7 - 4 1 4 7 COHPLETE ONE LINE FOR EACH COHPONENT FAILURE DESCRIBED IN THIS REPORT (13) |
| | CAUSE SYSTEH COHPONENT HANUFACTURER EPORTABLE CAUSE SYSTEM COHPONENT MANUFACTURER REPORTABLE 0 NPRDS TO NPRDS h |
| | SUPPLEMENTAL REPORT EXPECTED (14) EXPECTED SUBMISSION MONTH DAY YEAR ATE (15) |
| | YES (If yes, complete EXPECTED SUBMISSION DATE) NO BlACT eel At approximately 1850 hours on June 15, 1993, a Group 1 Nuclear Steam Supply Shutoff System (NS') |
| | isolation occurred during the performance of a Technical Specification surveillance test associated with the Turbine Throttle Valves. The test involved calibration of position switches on the valves associated with the NS'ogic. During shutdown conditions there is no main condenser vacuum. The NS4 logic is configured in a manner where exercising each Turbine Throttle valve to the open position initiates a half Group 1 isolation. During the surveillance test a second Throttle Valve was opened without resetting the (NS4) logic after testing the first valve. This resulted in a Group 1 isolation which is considered an ESF actuation. |
| The root cause of this event was a procedural deficiency. | | The root cause of this event was a procedural deficiency. |
| Immediate corrective action was taken to stop work on the surveillance and investigate the cause.Further corrective action was taken to change the surveillance procedure to require a reset of the logic after the switches on each valve are calibrated. | | Immediate corrective action was taken to stop work on the surveillance and investigate the cause. Further corrective action was taken to change the surveillance procedure to require a reset of the logic after the switches on each valve are calibrated. |
| The event posed no threat to the health and safety of either the public or plant personnel. | | The event posed no threat to the health and safety of either the public or plant personnel. |
| | |
| | LICENSEE EVENT REPOR1kR) |
| | TEXT CONTINUATION AGILITY HAKE (1) OOCKET KUMBER (2) LER HUHBER (8) AGE (3) ear Kumber ev. Ho. |
| | Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 3 025 0 2 OF 5 iTLE (4) |
| | ENGINEERED SAFETY FEATURE ESF ACTUATION CAUSED BY SURVEILLANCE TESTING Pln niin Power Level - 0% |
| | PlantMode -4 Even Descri i n At approximately 1850 hours on June 15, 1993, a Group 1 Nuclear Steam Supply Shutoff System (NS') |
| | isolation occurred during the performance of a Technical Specification surveillance test associated with the Turbine Throttle Valves. The test was being performed in accordance with plant procedure PPM 7.4.3.1.1.18, Turbine Throttle Valves - System A/B - Channel Calibration. The surveillance provides for the calibration of position switches associated with the closure of the Throttle Valves, During power operation, above 30 percent, these switches initiate a scram when the valves are greater than or equal to five percent closed. |
| | These switches are also used as part of the NS4 logic. During shutdown conditions there is no main condenser vacuum. The NS4 logic is configured in a manner where exercising each Turbine Throttle valve to the open position initiates a half Group 1 isolation. During the surveillance test a second Throttle valve was opened without resetting the NS4 logic after testing the first valve. This resulted in a Group 1 isolation involving a closure signal to the Main Steam Line Isolation Valves and the Main Steam Line Drain Valves. |
| | This is an ESF actuation. |
| | mmediate rrec iv Ac ion Immediate corrective action was taken to stop surveillance testing and investigate the cause of the event. |
| | Further Evalu ion R t Cau e and rrective Action A. Further Evaluation |
| | : 1. This event is being reported per the requirements of 10CFR50.73(a)(2)(iv). This event was verbally reported as a non-emergency event under 10CFR50.72(b)(2)(ii) at 2241 hours on June 15, 1993. |
| | : 2. Further evaluation showed the electricians assigned to perform the throttle valve surveillance had not previously performed the surveillance. In a pre-job briefing, the craft supervisor told them that stroking a throttle valve would cause a half scram. They were also told that the control room must be notified before starting the surveillance and after completing calibration of each throttle valve. They notified the control room prior to starting the surveillance and also after completing each valve. The electricians believed they could cause a half scram and they knew the procedure addressed the MSIVs. However, they did not know the difference between a half |
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| | LICENSEE EVENT REPORR) |
| | TEXT CONTINUATION AGILITY KAHE (i) DOCKET HUHBER (2) LER KUHBER (B) ABE (3) |
| | Year umber ev. Ko. |
| | Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 3 025 00 3 OF 5 ITLE (4) |
| | ENGINEERED SAFETY FEATURE ESF ACTUATION CAUSED BY SURVEILLANCE TESTING scram and a half isolation and did not realize that they were effecting two separate logic trains when they manipulated the position switches. Actually, the surveillance cannot cause a half scram because RPS relay contacts for the throttle valves are bypassed when the reactor is below 30% power. |
| | : 3. The precautions and limitations section of the procedure states, "Throttle valve sections may be done in any order however, all steps in each section are to be performed in sequence. Only one instrument channel is to be in a state of test at any time. When a channel is returned to service, verify with the Control Room that all trips, alarms and computer points are cleared before proceeding to the next channel test." In addition, a procedural precaution states in part; "Ifthe RPS-K10 relays are energized with low condenser pressure, MSIVs will get a fast closure signal if more than one throttle valve is open at a time," However, the precaution does not inform the user that a NS'alf isolation occurs when only one throttle valve is open. It is apparent that the procedural instruction intended to inform the control room of the need to reset appropriate logic. |
| | However, the direction was not as specific as it should have been and was not included as a step in the body of the procedure. |
| | : 4. Operations personnel cannot remember when or if the NS'ogic was reset during the throttle valve calibration. At the same time they were conducting several other surveillance tests including Turbine Governor Valve (TGV) Fast Closure Response Time Testing and the MSIV Logic System Functional Test. The TGV fast closure surveillance introduces an actual half scram in the RPS logic and both A and B divisions were tested while the throttle valve procedure was in progress. Performance of these surveillances concurrently should not present a problem but in the absence of specific instruction to reset the logic, other surveillances may have diverted the operator's attention from resetting the NS4 half isolation. Also, an operations shift change occurred near the end of the surveillance. |
| | : 5. A review of procedures that can initiate a scram or isolation revealed that procedures performed by the Instrument and Controls (I & C) shop are written to be logic safe. The I & C procedures separate the divisions so a full scram or isolation cannot be initiated with a single procedure. |
| | There are relatively few procedures of this type performed by the Electrical shop. They have not been subject to this logic safe format. The Maintenance Procedures Department has identified three additional electrical procedures that could possibly cause a full scram or isolation. |
| | : 6. A review was performed of the development of PPM 7.4.3.1.1.18. Revision 0 of the procedure was written in June 1985. In this revision the test was limited to Throttle Valves 1 and 3. In February 1986 the procedure was revised to include all four throttle valves. The statements in the precautions and limitations sections of these early revisions to the procedures are similar to the current version. A formal validation and verification has not been performed on this procedure. Thus, the procedure has been defective since inception. |
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| | LICENSEE EVENT REPORThR) |
| | TEXT CONTINUATION AGILITY NAME (1) OOCKET HUHBER (2) LER HUHBER (8) AGE (3) |
| | Year umber ev. Ho. |
| | Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 3 25 00 4 F 5 rTLE (4) |
| | ENGINEERED SAFETY FEATURE ESF ACTUATION CAUSED BY SURVEILLANCE TESTING B. Root Cause The root cause of this event was a procedural deficiency. The omission of a required action to reset the NS4 logic after completing each valve calibration caused the Group 1 isolation. It is recognized that this problem did not occur during previous performances of this surveillance. As discussed above, under further evaluation, there were additional complications that were present when the event occurred. |
| | C. Further Corrective Actions |
| | : 1. PPM 7.4.3.1.1.18 was changed on June 16, 1993, to include steps in each section of the procedure to reset the NS4 logic and verify the annunciators have cleared before proceeding to the next valve. |
| | : 2. Plant Procedures PPM 7.4,3.1.1.18, 7.4.3.1.1.10A, 7.4.3.7.5.44, and 7,4.3.7.5.45 will be revised into logic safe procedures. This will be completed prior to their use during the next refueling outage. |
| | : 3. An evaluation will be performed to determine the need for additional training for electrical shop personnel involved with Technical Specification Surveillances. This will be completed by Qff October 1, 1993. |
| | This is no safety significance associated with this event. The plant was in mode 4 and the MSIVs were closed prior to the isolation. |
| | imil r Event Group 1 isolations have occurred previously at WNP-2. These events are documented in LERs 87-021 and 88-010. However, these isolations were not caused by surveillance testing associated with the Throttle Valves. |
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| LICENSEE EVENT REPOR1kR)TEXT CONTINUATION AGILITY HAKE (1)Washington Nuclear Plant-Unit 2 OOCKET KUMBER (2)0 5 0 0 0 3 9 7 LER HUHBER (8)ear Kumber ev.Ho.AGE (3)3 025 0 iTLE (4)ENGINEERED SAFETY FEATURE ESF ACTUATION CAUSED BY SURVEILLANCE TESTING 2 OF 5 Pln niin Power Level-0%PlantMode-4 Even Descri i n At approximately 1850 hours on June 15, 1993, a Group 1 Nuclear Steam Supply Shutoff System (NS')isolation occurred during the performance of a Technical Specification surveillance test associated with the Turbine Throttle Valves.The test was being performed in accordance with plant procedure PPM 7.4.3.1.1.18, Turbine Throttle Valves-System A/B-Channel Calibration. | | LICENSEE EVENT REPORTER) |
| The surveillance provides for the calibration of position switches associated with the closure of the Throttle Valves, During power operation, above 30 percent, these switches initiate a scram when the valves are greater than or equal to five percent closed.These switches are also used as part of the NS4 logic.During shutdown conditions there is no main condenser vacuum.The NS4 logic is configured in a manner where exercising each Turbine Throttle valve to the open position initiates a half Group 1 isolation.
| | TEXT CONTINUATION ACIL1TY NAME (1) OOCKET NUMBER (2) LER NUMBER (8) AGE (3) ear umber ev. No. |
| During the surveillance test a second Throttle valve was opened without resetting the NS4 logic after testing the first valve.This resulted in a Group 1 isolation involving a closure signal to the Main Steam Line Isolation Valves and the Main Steam Line Drain Valves.This is an ESF actuation.
| | Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 3 025 00 5 F 5 ITLE (4) |
| mmediate rrec iv Ac ion Immediate corrective action was taken to stop surveillance testing and investigate the cause of the event.Further Evalu ion R t Cau e and rrective Action A.Further Evaluation 1.This event is being reported per the requirements of 10CFR50.73(a)(2)(iv).
| | ENGINEERED SAFETY FEATURE ESF ACTUATION CAUSED BY SURVEILLANCE TESTING EIIS Information T~Rf EIIS Reference |
| This event was verbally reported as a non-emergency event under 10CFR50.72(b)(2)(ii) at 2241 hours on June 15, 1993.2.Further evaluation showed the electricians assigned to perform the throttle valve surveillance had not previously performed the surveillance.
| | ~Stem ~Com anent Nuclear Steam Supply Shutoff System (NS') BD Turbine Throttle Valves SB V Turbine Throttle Valve Position Switches SB 33 Main Steam Line Isolation Valves SB V Main Steam Line Drain Valves SB V}} |
| In a pre-job briefing, the craft supervisor told them that stroking a throttle valve would cause a half scram.They were also told that the control room must be notified before starting the surveillance and after completing calibration of each throttle valve.They notified the control room prior to starting the surveillance and also after completing each valve.The electricians believed they could cause a half scram and they knew the procedure addressed the MSIVs.However, they did not know the difference between a half LICENSEE EVENT REPORR)TEXT CONTINUATION AGILITY KAHE (i)Washington Nuclear Plant-Unit 2 DOCKET HUHBER (2)0 5 0 0 0 3 9 7 Year LER KUHBER (B)umber ev.Ko.ABE (3)3 025 00 ITLE (4)ENGINEERED SAFETY FEATURE ESF ACTUATION CAUSED BY SURVEILLANCE TESTING 3 OF 5 scram and a half isolation and did not realize that they were effecting two separate logic trains when they manipulated the position switches.Actually, the surveillance cannot cause a half scram because RPS relay contacts for the throttle valves are bypassed when the reactor is below 30%power.3.The precautions and limitations section of the procedure states,"Throttle valve sections may be done in any order however, all steps in each section are to be performed in sequence.Only one instrument channel is to be in a state of test at any time.When a channel is returned to service, verify with the Control Room that all trips, alarms and computer points are cleared before proceeding to the next channel test." In addition, a procedural precaution states in part;"If the RPS-K10 relays are energized with low condenser pressure, MSIVs will get a fast closure signal if more than one throttle valve is open at a time," However, the precaution does not inform the user that a NS'alf isolation occurs when only one throttle valve is open.It is apparent that the procedural instruction intended to inform the control room of the need to reset appropriate logic.However, the direction was not as specific as it should have been and was not included as a step in the body of the procedure.
| |
| 4.Operations personnel cannot remember when or if the NS'ogic was reset during the throttle valve calibration.
| |
| At the same time they were conducting several other surveillance tests including Turbine Governor Valve (TGV)Fast Closure Response Time Testing and the MSIV Logic System Functional Test.The TGV fast closure surveillance introduces an actual half scram in the RPS logic and both A and B divisions were tested while the throttle valve procedure was in progress.Performance of these surveillances concurrently should not present a problem but in the absence of specific instruction to reset the logic, other surveillances may have diverted the operator's attention from resetting the NS4 half isolation.
| |
| Also, an operations shift change occurred near the end of the surveillance.
| |
| 5.A review of procedures that can initiate a scram or isolation revealed that procedures performed by the Instrument and Controls (I&C)shop are written to be logic safe.The I&C procedures separate the divisions so a full scram or isolation cannot be initiated with a single procedure.
| |
| There are relatively few procedures of this type performed by the Electrical shop.They have not been subject to this logic safe format.The Maintenance Procedures Department has identified three additional electrical procedures that could possibly cause a full scram or isolation.
| |
| 6.A review was performed of the development of PPM 7.4.3.1.1.18.
| |
| Revision 0 of the procedure was written in June 1985.In this revision the test was limited to Throttle Valves 1 and 3.In February 1986 the procedure was revised to include all four throttle valves.The statements in the precautions and limitations sections of these early revisions to the procedures are similar to the current version.A formal validation and verification has not been performed on this procedure.
| |
| Thus, the procedure has been defective since inception.
| |
| LICENSEE EVENT REPORThR)TEXT CONTINUATION AGILITY NAME (1)Washington Nuclear Plant-Unit 2 OOCKET HUHBER (2)0 5 0 0 0 3 9 7 Year LER HUHBER (8)umber ev.Ho.AGE (3)3 25 00 rTLE (4)ENGINEERED SAFETY FEATURE ESF ACTUATION CAUSED BY SURVEILLANCE TESTING 4 F 5 B.Root Cause The root cause of this event was a procedural deficiency.
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| The omission of a required action to reset the NS4 logic after completing each valve calibration caused the Group 1 isolation.
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| It is recognized that this problem did not occur during previous performances of this surveillance.
| |
| As discussed above, under further evaluation, there were additional complications that were present when the event occurred.C.Further Corrective Actions 1.PPM 7.4.3.1.1.18 was changed on June 16, 1993, to include steps in each section of the procedure to reset the NS4 logic and verify the annunciators have cleared before proceeding to the next valve.2.Plant Procedures PPM 7.4,3.1.1.18, 7.4.3.1.1.10A, 7.4.3.7.5.44, and 7,4.3.7.5.45 will be revised into logic safe procedures.
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| This will be completed prior to their use during the next refueling outage.3.An evaluation will be performed to determine the need for additional training for electrical shop personnel involved with Technical Specification Surveillances.
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| This will be completed by October 1, 1993.Qff This is no safety significance associated with this event.The plant was in mode 4 and the MSIVs were closed prior to the isolation.
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| imil r Event Group 1 isolations have occurred previously at WNP-2.These events are documented in LERs 87-021 and 88-010.However, these isolations were not caused by surveillance testing associated with the Throttle Valves.
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| LICENSEE EVENT REPORTER)TEXT CONTINUATION ACIL1TY NAME (1)Washington Nuclear Plant-Unit 2 OOCKET NUMBER (2)0 5 0 0 0 3 9 7 LER NUMBER (8)ear umber ev.No.3 025 00 AGE (3)5 F 5 ITLE (4)ENGINEERED SAFETY FEATURE ESF ACTUATION CAUSED BY SURVEILLANCE TESTING EIIS Information T~Rf EIIS Reference~Stem~Com anent Nuclear Steam Supply Shutoff System (NS')Turbine Throttle Valves Turbine Throttle Valve Position Switches Main Steam Line Isolation Valves Main Steam Line Drain Valves BD SB SB SB SB V 33 V V}}
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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML17292B7421999-07-20020 July 1999 LER 99-001-00:on 990628,ESF Signal Closed All Eight MSIVs While Plant Was Shutdown.Caused by Failure of Relay RPS-RLY-K10D.Subject Relay Was Replaced & Tested on 990630. with 990720 Ltr ML17292B4451998-10-27027 October 1998 LER 98-012-01:on 980715,failure to Comply with Requirements of TS SR 3.8.4.7 Was Noted.Caused by Inadequate Work Practices.Training Session Was Held with Personnel.With 981027 Ltr ML17284A7561998-09-0303 September 1998 LER 98-013-00:on 980805,ESF Actuations Were Noted Due to Deenergization of Vital Electrical Bus SM-8.Caused by Inadequate Direction in Troubleshooting Plan.Will Conduct Training for Engineering Personnel.With 980903 Ltr ML17284A7571998-09-0202 September 1998 LER 98-014-00:on 980807,completion of TS 3.8.1.F Required Shutdown Due to Inoperability of EDG-2 Was Noted.Caused by Degraded Voltage Regulator for DG-2.Replaced Voltage Regulator & Associated Scrs.With 980902 Ltr ML17284A7551998-09-0202 September 1998 LER 98-015-00:on 980808,discovered Reactor Coolant Pressure Boundary Leak During Shutdown Conditions.Caused by Leakage from Socket Weld (Fwb 63) on Elbow Connection.Failed Piping Connection Was Replaced.With 980902 Ltr ML17284A7311998-08-17017 August 1998 LER 98-012-00:on 980716,determined That 24-month SR 3.8.4.7 Had Not Been Fulfilled within Specified Frequency.Caused by Inadequate Work Practices.License Requested & Received Enforcement Discretion Re Battery Svc test.W/980817 Ltr ML17284A7121998-07-23023 July 1998 LER 98-006-01:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of 10CFR50,App R Calculations for High Impedance Faults.Caused by Inadequate Work Practices.Implemented Procedural Changes ML17284A6951998-07-17017 July 1998 LER 98-011-00:on 980617,ECCS Pump Room Flooding Was Noted Due to FP Sys Pipe Break.Caused by Inadequate Design of FP Sys.Detailed Review of FP Sys Design Was Conducted. W/980717 Ltr ML17284A6961998-07-15015 July 1998 LER 98-010-00:on 980615,TS Required Shutdown Due to Inoperability of TIP Sys Isolation Valve Was Noted.Caused by Improper Installation of TIP Tubing.Reattached Affected Tubing & Inspected Other TIP tubing.W/980715 Ltr ML17284A6731998-07-0101 July 1998 LER 98-009-00:on 980606,nuclear Steam Supply Shutoff Sys Group 3 & 4 Isolations During Testing Was Noted.Caused by Procedural Deficiency.Counseled Individuals Involved in preparation.W/980701 Ltr ML17284A6651998-06-24024 June 1998 LER 98-007-00:on 980530,inadvertent Full Scram & Division 1 ECCS Injection Was Noted.Caused by Failure to Meet Mgt Work Practice Expectation When Encountering Deficient Procedure. Incident Review Board Convened to Review event.W/980624 Ltr ML17284A6641998-06-24024 June 1998 LER 98-008-00:on 980531,inadvertent Full Scram During RPV Leak Testing in Mode 4 Was Noted.Caused by Change in Mgt Techniques.Revised Procedures to Take Into Account Addl Water Head in Pressure Sensing lines.W/980624 Ltr ML17284A6631998-06-19019 June 1998 LER 98-006-00:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of App R Calculations for High Impedance Fault Analysis.Caused Indeterminate. Implemented Procedural Changes Involving Operator Action ML17284A6551998-06-0404 June 1998 LER 98-005-00:on 980506,potential for Failure of RHR Sys Valve to Close on Isolation Signal Was Noted.Caused by Design Deficiency.Caution Tag Was Placed on RHR-V-40 Control Switch to Inform Plant Operators of limitation.W/980604 Ltr ML17284A6421998-06-0101 June 1998 LER 98-004-00:on 980502,determined That Primary Containment Penetration Overcurrent Protection Does Not Meet Reg Guide 1.63 Requirements.Caused by Inadequate Design Changes. Installed Addl Fuse in RHR-MO-9 circuit.W/980601 Ltr ML17292B3281998-04-0909 April 1998 LER 98-002-00:on 980311,reactor Scram & Plant Transient Occurred,Due to Failed Closed Main Steam Isolation Valve. Caused by Loss of Pneumatic Actuating Supply Pressure. Problem Evaluation Request Written for Failure of MS-V-22D ML17292B3291998-04-0909 April 1998 LER 98-003-00:on 980311,WNP-2 Experienced SCRAM Signal as Result of Low Rpv.Caused by Less than post-SCRAM Operational Strategy for Resetting SCRAM Signal in Conditions.Changes in post-SCRAM Operational Strategy implemented.W/980409 Ltr ML17292B2661998-03-0404 March 1998 LER 98-001-00:on 980203,automatic Start of HPCS EDG Was Noted.Caused by Operator Error.Operations Crew Stabilized Plant at Approximately 75% Reactor Power & Investigation of Event Was initiated.W/980304 Ltr ML17292B1111997-11-10010 November 1997 LER 97-011-00:on 971010,HPCS Battery Charger Failed.Caused by Failure of a Phase Firing Control Circuit Board Due to Aging During 7 Yrs of Use.Hpcs Sys Was Immediately Declared inoperable.W/971110 Ltr ML17292B1151997-11-0707 November 1997 LER 97-010-00:on 970906,discovered That TS SR 3.4.5.1 for Identified Portion of RCS Total Leakage Would Not Be Able to Perform within Time Limits of SR 3.0.2.Caused by Inadequate Methods.Method of Meeting SR 3.4.5.1 Established ML17292B0641997-09-24024 September 1997 LER 97-004-01:on 970327,plant Operators Manually Scrammed Reactor as Required by TS Due to Indication of Entry Into Region a of power-to-flow Map.Caused by Inadequate Attention to Detail.Established Event Evaluation teams.W/970924 Ltr ML17292B0241997-08-18018 August 1997 LER 97-009-00:on 970717,discovered Error in Recently Performed Inservice Testing procedure,OSP-TIP/IST-R701. Caused by Procedure Inadequacy.Plant Procedure OSP/TIP/IST-R701 Will Be changed.W/970818 Ltr ML17292B0291997-08-15015 August 1997 LER 97-008-00:on 970716,wire Seal Used to Lock Containment Instrument Air Pressure Control valve,CIA-PCV-2B,found Not Intact.Cause of Misadjustment of CIA-PCV-2B Unknown.Event Will Be Communicated to Plant employees.W/970815 Ltr ML17292B0201997-08-15015 August 1997 LER 97-S01-00:on 970718,failure to Take Compensatory Measure for Inoperative Microwave Security Zone Occurred. Caused by Personnel Error.Training Will Be Conducted W/ Appropriate Members of Security force.W/970815 Ltr ML17292A9481997-07-23023 July 1997 LER 97-007-00:on 970611,voluntary Rept of Automatic Start of DG-1 & DG-2 Was Experienced.Caused by Undervoltage Condition on Electrical Busses SM-7 & SM-8.Circulating Water Pump CW-P-1C Control Switch Placed in pull-to-lock.W/970723 Ltr ML17292A9201997-06-26026 June 1997 LER 97-006-00:on 970527,non-performance of Surveillance Requirement 3.6.1.3.2 for Blind Fanges,Was Noted.Caused Because Misunderstanding of Intent of Specs.Added Five Structural Assemblies for SP.W/970626 Ltr ML17292A8331997-04-28028 April 1997 LER 97-004-00:on 970327,plant Operators Manually Scrammed Reactor as Required by TS Due to Entry Into Region a of power-to-flow Map Following Planned Trip of Single Mfp. Event Evaluation teams,established.W/970428 Ltr ML17292A8311997-04-28028 April 1997 LER 97-005-00:on 970327,valid Reactor Scram Signal Received Due to Low Water Level Condition During Preparations for SRV Testing.Caused by Risks & Consequences of Decisions Not Completely Identified.Restored Water level.W/970428 Ltr ML17292A8251997-04-21021 April 1997 LER 97-003-00:on 970320,notification of Noncompliance W/Ts as TS SRs for Response Time Testing Were Not Being Met for Specified Instrumentation in Rps,Pcis & Eccs.Requested Enforcement Discretion for One Time exemption.W/970421 Ltr ML17292A7431997-03-20020 March 1997 LER 97-002-00:on 970218,determined That Rod Block Monitor (RBM) Calibr Values Were Not Set IAW Tech Specs.Caused by Calibr Procedures Inadequacies.Revised & re-performed RBM Channel Calibr procedures.W/970330 Ltr ML17292A7401997-03-13013 March 1997 LER 97-001-00:on 970211,reactor Water Cleanup Sys Blowdown Flow Isolation Setpoint Was Slightly Above TS Allowable Valve Occurred Due to Calculation Error.Lds Fss LD-FS-15 LD-FS-16 Were Declared inoperable.W/970313 Ltr ML17292A6641997-01-22022 January 1997 LER 96-009-00:on 961220,miscalculation of Instantaneous Overcurrent Relay Settings Resulted in Inoperability of safety-related Equipment.Caused by Utilization of Inappropriate Design.Testing Was completed.W/970122 Ltr ML17292A6461997-01-0606 January 1997 LER 96-008-00:on 961205,failure to Comply with TS Action Requirement for Emergency Core Cooling Sys Actuation Instrumentation Occurred Due to Unidentified Inoperability Condition.Pmr initiated.W/970106 Ltr ML17292A6371996-12-19019 December 1996 LER 96-007-00:on 961122,electrical Breakers Were Not Seismically Qualified in Test/Disconnect Position.Circuit Breaker Mfg Did Not Consider Raced Out Breaker Position During Testing.Relocated Circuit breakers.W/961217 Ltr ML17292A4121996-08-0808 August 1996 LER 96-006-00:on 960709,average Power Range Monitor Rod Block Downscale Surveillance Not Performed Prior to Entry Into Mode 1.Caused by long-standing Misinterpretation of Requirements of Tss.Procedures revised.W/960808 Ltr ML17292A3801996-07-24024 July 1996 LER 96-004-00:on 960624,plant Was Manually Scrammed by Control Room Personnel Due to Reactor Water Level Transient Experienced During Testing of Digital Feedwater Sys.Caused by Programming Error.Sys Was corrected.W/960724 Ltr ML17292A3771996-07-24024 July 1996 LER 96-005-00:on 960624,determined Missed Surveillance Test Re Channel Check of Average Power Range Monitor.Caused by Inadequate Procedures.Revised Surveillance Procedure Re When APRM Checks Must Be performed.W/960724 Ltr ML17292A3641996-07-12012 July 1996 LER 96-003-00:on 960615,required Surveillance Test Not Performed When Required by TS 3.4.1.3.Caused by Inadequate Procedures.Implementing Surveillance Procedure & Reactor Plant Startup Procedures revised.W/960712 Ltr ML17292A3361996-06-20020 June 1996 LER 96-002-00:on 960504,critical Bus SM-8 Lost Power When Supply Breaker 3-8 Tripped.Caused by Personnel Error. Operators Counselled & Procedures revised.W/960620 Ltr ML17292A2861996-05-24024 May 1996 LER 96-001-00:on 960425,inadvertent ESF Actuations Occurred Due to Tripping of Temporary Power Supply to IN-3.Caused by Personnel Error.Operations Restored to IN-3 Loads & Reset ESF actuations.W/960524 Ltr ML17291B0891995-10-19019 October 1995 LER 95-011-00:on 950919,failed to Comply W/Ts SR for RCIC Sys Due to Analysis Deficiency That Resulted in Inadequate Surveillance Test Procedure.Surveillance Procedure Revised to Correct deficiency.W/951019 Ltr ML17291A9021995-07-0707 July 1995 LER 95-010-00:on 950609,HPCS DG Declared Inoperable Due to Discovery That TS Test Method Incomplete.Caused by Inadequate Testing Procedure.Test Procedure for HPCS DG Reviewed & Special Test Procedures written.W/950707 Ltr ML17291A9031995-07-0707 July 1995 LER 95-009-00:on 950607,inadvertent MSIV Closure Occurred During Surveillance Test Due to Poor Communication Between Test Team.Determined That MSIV Closure Not Valid Because Closure Not Triggered by Plant conditions.W/950707 Ltr ML17291A8501995-06-0808 June 1995 LER 95-006-01:on 950405,reactor Scram Occurred During Surveillance Testing Due to Protective Sys Relay Failure. Replaced Failed Relay Before Plant Startup ML17291A8101995-05-12012 May 1995 LER 95-008-00:on 940125,TS Wording Lead to Potential TS Violation.Caused by Lack of Clarity in Ts.Submitted Improved TS for Plant to Provide Addl clarity.W/950512 Ltr ML17291A7841995-05-0505 May 1995 LER 95-007-00:on 950222,emergency Diesel Start Occurred Due to Voltage Transient on BPA Grid.Confirmation Was Received at 17:51 H That Disturbance Had Originated in BPA Grid ML17291A7801995-05-0404 May 1995 LER 95-006-00:on 950405,main Turbine Trip Occurred During Performance of Surveillance Test Due to Protective Sys Relay Failed.Replaced Failed Relay Before Plant startup.W/950504 Ltr ML17291A7851995-05-0303 May 1995 LER 95-005-00:on 950222,inoperable IRM Had Been Relied Upon to Meet TS Requirements During Reactor Startup.Caused by Lack of Neutron Source to Test Instrumentation. Sys Knowledge Gained Will Be incorporated.W/950503 Ltr ML17291A7071995-03-25025 March 1995 LER 95-004-00:on 950226,malfunction in Main Turbine DEH Control Sys Caused All Four High Pressure Turbine Governor Valves to Rapidly Close.Caused by Blown Fuse.Suspected Faulty Circuit Card replaced.W/950325 Ltr ML17291A7011995-03-20020 March 1995 LER 95-002-00:on 950218,automatic Reactor Scram Occurred. Caused by Erroneous Positioning of Control During Performance of Scheduled Periodic Functional Test.Control repositioned.W/950320 Ltr 1999-07-20
[Table view] Category:RO)
MONTHYEARML17292B7421999-07-20020 July 1999 LER 99-001-00:on 990628,ESF Signal Closed All Eight MSIVs While Plant Was Shutdown.Caused by Failure of Relay RPS-RLY-K10D.Subject Relay Was Replaced & Tested on 990630. with 990720 Ltr ML17292B4451998-10-27027 October 1998 LER 98-012-01:on 980715,failure to Comply with Requirements of TS SR 3.8.4.7 Was Noted.Caused by Inadequate Work Practices.Training Session Was Held with Personnel.With 981027 Ltr ML17284A7561998-09-0303 September 1998 LER 98-013-00:on 980805,ESF Actuations Were Noted Due to Deenergization of Vital Electrical Bus SM-8.Caused by Inadequate Direction in Troubleshooting Plan.Will Conduct Training for Engineering Personnel.With 980903 Ltr ML17284A7571998-09-0202 September 1998 LER 98-014-00:on 980807,completion of TS 3.8.1.F Required Shutdown Due to Inoperability of EDG-2 Was Noted.Caused by Degraded Voltage Regulator for DG-2.Replaced Voltage Regulator & Associated Scrs.With 980902 Ltr ML17284A7551998-09-0202 September 1998 LER 98-015-00:on 980808,discovered Reactor Coolant Pressure Boundary Leak During Shutdown Conditions.Caused by Leakage from Socket Weld (Fwb 63) on Elbow Connection.Failed Piping Connection Was Replaced.With 980902 Ltr ML17284A7311998-08-17017 August 1998 LER 98-012-00:on 980716,determined That 24-month SR 3.8.4.7 Had Not Been Fulfilled within Specified Frequency.Caused by Inadequate Work Practices.License Requested & Received Enforcement Discretion Re Battery Svc test.W/980817 Ltr ML17284A7121998-07-23023 July 1998 LER 98-006-01:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of 10CFR50,App R Calculations for High Impedance Faults.Caused by Inadequate Work Practices.Implemented Procedural Changes ML17284A6951998-07-17017 July 1998 LER 98-011-00:on 980617,ECCS Pump Room Flooding Was Noted Due to FP Sys Pipe Break.Caused by Inadequate Design of FP Sys.Detailed Review of FP Sys Design Was Conducted. W/980717 Ltr ML17284A6961998-07-15015 July 1998 LER 98-010-00:on 980615,TS Required Shutdown Due to Inoperability of TIP Sys Isolation Valve Was Noted.Caused by Improper Installation of TIP Tubing.Reattached Affected Tubing & Inspected Other TIP tubing.W/980715 Ltr ML17284A6731998-07-0101 July 1998 LER 98-009-00:on 980606,nuclear Steam Supply Shutoff Sys Group 3 & 4 Isolations During Testing Was Noted.Caused by Procedural Deficiency.Counseled Individuals Involved in preparation.W/980701 Ltr ML17284A6651998-06-24024 June 1998 LER 98-007-00:on 980530,inadvertent Full Scram & Division 1 ECCS Injection Was Noted.Caused by Failure to Meet Mgt Work Practice Expectation When Encountering Deficient Procedure. Incident Review Board Convened to Review event.W/980624 Ltr ML17284A6641998-06-24024 June 1998 LER 98-008-00:on 980531,inadvertent Full Scram During RPV Leak Testing in Mode 4 Was Noted.Caused by Change in Mgt Techniques.Revised Procedures to Take Into Account Addl Water Head in Pressure Sensing lines.W/980624 Ltr ML17284A6631998-06-19019 June 1998 LER 98-006-00:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of App R Calculations for High Impedance Fault Analysis.Caused Indeterminate. Implemented Procedural Changes Involving Operator Action ML17284A6551998-06-0404 June 1998 LER 98-005-00:on 980506,potential for Failure of RHR Sys Valve to Close on Isolation Signal Was Noted.Caused by Design Deficiency.Caution Tag Was Placed on RHR-V-40 Control Switch to Inform Plant Operators of limitation.W/980604 Ltr ML17284A6421998-06-0101 June 1998 LER 98-004-00:on 980502,determined That Primary Containment Penetration Overcurrent Protection Does Not Meet Reg Guide 1.63 Requirements.Caused by Inadequate Design Changes. Installed Addl Fuse in RHR-MO-9 circuit.W/980601 Ltr ML17292B3281998-04-0909 April 1998 LER 98-002-00:on 980311,reactor Scram & Plant Transient Occurred,Due to Failed Closed Main Steam Isolation Valve. Caused by Loss of Pneumatic Actuating Supply Pressure. Problem Evaluation Request Written for Failure of MS-V-22D ML17292B3291998-04-0909 April 1998 LER 98-003-00:on 980311,WNP-2 Experienced SCRAM Signal as Result of Low Rpv.Caused by Less than post-SCRAM Operational Strategy for Resetting SCRAM Signal in Conditions.Changes in post-SCRAM Operational Strategy implemented.W/980409 Ltr ML17292B2661998-03-0404 March 1998 LER 98-001-00:on 980203,automatic Start of HPCS EDG Was Noted.Caused by Operator Error.Operations Crew Stabilized Plant at Approximately 75% Reactor Power & Investigation of Event Was initiated.W/980304 Ltr ML17292B1111997-11-10010 November 1997 LER 97-011-00:on 971010,HPCS Battery Charger Failed.Caused by Failure of a Phase Firing Control Circuit Board Due to Aging During 7 Yrs of Use.Hpcs Sys Was Immediately Declared inoperable.W/971110 Ltr ML17292B1151997-11-0707 November 1997 LER 97-010-00:on 970906,discovered That TS SR 3.4.5.1 for Identified Portion of RCS Total Leakage Would Not Be Able to Perform within Time Limits of SR 3.0.2.Caused by Inadequate Methods.Method of Meeting SR 3.4.5.1 Established ML17292B0641997-09-24024 September 1997 LER 97-004-01:on 970327,plant Operators Manually Scrammed Reactor as Required by TS Due to Indication of Entry Into Region a of power-to-flow Map.Caused by Inadequate Attention to Detail.Established Event Evaluation teams.W/970924 Ltr ML17292B0241997-08-18018 August 1997 LER 97-009-00:on 970717,discovered Error in Recently Performed Inservice Testing procedure,OSP-TIP/IST-R701. Caused by Procedure Inadequacy.Plant Procedure OSP/TIP/IST-R701 Will Be changed.W/970818 Ltr ML17292B0291997-08-15015 August 1997 LER 97-008-00:on 970716,wire Seal Used to Lock Containment Instrument Air Pressure Control valve,CIA-PCV-2B,found Not Intact.Cause of Misadjustment of CIA-PCV-2B Unknown.Event Will Be Communicated to Plant employees.W/970815 Ltr ML17292B0201997-08-15015 August 1997 LER 97-S01-00:on 970718,failure to Take Compensatory Measure for Inoperative Microwave Security Zone Occurred. Caused by Personnel Error.Training Will Be Conducted W/ Appropriate Members of Security force.W/970815 Ltr ML17292A9481997-07-23023 July 1997 LER 97-007-00:on 970611,voluntary Rept of Automatic Start of DG-1 & DG-2 Was Experienced.Caused by Undervoltage Condition on Electrical Busses SM-7 & SM-8.Circulating Water Pump CW-P-1C Control Switch Placed in pull-to-lock.W/970723 Ltr ML17292A9201997-06-26026 June 1997 LER 97-006-00:on 970527,non-performance of Surveillance Requirement 3.6.1.3.2 for Blind Fanges,Was Noted.Caused Because Misunderstanding of Intent of Specs.Added Five Structural Assemblies for SP.W/970626 Ltr ML17292A8331997-04-28028 April 1997 LER 97-004-00:on 970327,plant Operators Manually Scrammed Reactor as Required by TS Due to Entry Into Region a of power-to-flow Map Following Planned Trip of Single Mfp. Event Evaluation teams,established.W/970428 Ltr ML17292A8311997-04-28028 April 1997 LER 97-005-00:on 970327,valid Reactor Scram Signal Received Due to Low Water Level Condition During Preparations for SRV Testing.Caused by Risks & Consequences of Decisions Not Completely Identified.Restored Water level.W/970428 Ltr ML17292A8251997-04-21021 April 1997 LER 97-003-00:on 970320,notification of Noncompliance W/Ts as TS SRs for Response Time Testing Were Not Being Met for Specified Instrumentation in Rps,Pcis & Eccs.Requested Enforcement Discretion for One Time exemption.W/970421 Ltr ML17292A7431997-03-20020 March 1997 LER 97-002-00:on 970218,determined That Rod Block Monitor (RBM) Calibr Values Were Not Set IAW Tech Specs.Caused by Calibr Procedures Inadequacies.Revised & re-performed RBM Channel Calibr procedures.W/970330 Ltr ML17292A7401997-03-13013 March 1997 LER 97-001-00:on 970211,reactor Water Cleanup Sys Blowdown Flow Isolation Setpoint Was Slightly Above TS Allowable Valve Occurred Due to Calculation Error.Lds Fss LD-FS-15 LD-FS-16 Were Declared inoperable.W/970313 Ltr ML17292A6641997-01-22022 January 1997 LER 96-009-00:on 961220,miscalculation of Instantaneous Overcurrent Relay Settings Resulted in Inoperability of safety-related Equipment.Caused by Utilization of Inappropriate Design.Testing Was completed.W/970122 Ltr ML17292A6461997-01-0606 January 1997 LER 96-008-00:on 961205,failure to Comply with TS Action Requirement for Emergency Core Cooling Sys Actuation Instrumentation Occurred Due to Unidentified Inoperability Condition.Pmr initiated.W/970106 Ltr ML17292A6371996-12-19019 December 1996 LER 96-007-00:on 961122,electrical Breakers Were Not Seismically Qualified in Test/Disconnect Position.Circuit Breaker Mfg Did Not Consider Raced Out Breaker Position During Testing.Relocated Circuit breakers.W/961217 Ltr ML17292A4121996-08-0808 August 1996 LER 96-006-00:on 960709,average Power Range Monitor Rod Block Downscale Surveillance Not Performed Prior to Entry Into Mode 1.Caused by long-standing Misinterpretation of Requirements of Tss.Procedures revised.W/960808 Ltr ML17292A3801996-07-24024 July 1996 LER 96-004-00:on 960624,plant Was Manually Scrammed by Control Room Personnel Due to Reactor Water Level Transient Experienced During Testing of Digital Feedwater Sys.Caused by Programming Error.Sys Was corrected.W/960724 Ltr ML17292A3771996-07-24024 July 1996 LER 96-005-00:on 960624,determined Missed Surveillance Test Re Channel Check of Average Power Range Monitor.Caused by Inadequate Procedures.Revised Surveillance Procedure Re When APRM Checks Must Be performed.W/960724 Ltr ML17292A3641996-07-12012 July 1996 LER 96-003-00:on 960615,required Surveillance Test Not Performed When Required by TS 3.4.1.3.Caused by Inadequate Procedures.Implementing Surveillance Procedure & Reactor Plant Startup Procedures revised.W/960712 Ltr ML17292A3361996-06-20020 June 1996 LER 96-002-00:on 960504,critical Bus SM-8 Lost Power When Supply Breaker 3-8 Tripped.Caused by Personnel Error. Operators Counselled & Procedures revised.W/960620 Ltr ML17292A2861996-05-24024 May 1996 LER 96-001-00:on 960425,inadvertent ESF Actuations Occurred Due to Tripping of Temporary Power Supply to IN-3.Caused by Personnel Error.Operations Restored to IN-3 Loads & Reset ESF actuations.W/960524 Ltr ML17291B0891995-10-19019 October 1995 LER 95-011-00:on 950919,failed to Comply W/Ts SR for RCIC Sys Due to Analysis Deficiency That Resulted in Inadequate Surveillance Test Procedure.Surveillance Procedure Revised to Correct deficiency.W/951019 Ltr ML17291A9021995-07-0707 July 1995 LER 95-010-00:on 950609,HPCS DG Declared Inoperable Due to Discovery That TS Test Method Incomplete.Caused by Inadequate Testing Procedure.Test Procedure for HPCS DG Reviewed & Special Test Procedures written.W/950707 Ltr ML17291A9031995-07-0707 July 1995 LER 95-009-00:on 950607,inadvertent MSIV Closure Occurred During Surveillance Test Due to Poor Communication Between Test Team.Determined That MSIV Closure Not Valid Because Closure Not Triggered by Plant conditions.W/950707 Ltr ML17291A8501995-06-0808 June 1995 LER 95-006-01:on 950405,reactor Scram Occurred During Surveillance Testing Due to Protective Sys Relay Failure. Replaced Failed Relay Before Plant Startup ML17291A8101995-05-12012 May 1995 LER 95-008-00:on 940125,TS Wording Lead to Potential TS Violation.Caused by Lack of Clarity in Ts.Submitted Improved TS for Plant to Provide Addl clarity.W/950512 Ltr ML17291A7841995-05-0505 May 1995 LER 95-007-00:on 950222,emergency Diesel Start Occurred Due to Voltage Transient on BPA Grid.Confirmation Was Received at 17:51 H That Disturbance Had Originated in BPA Grid ML17291A7801995-05-0404 May 1995 LER 95-006-00:on 950405,main Turbine Trip Occurred During Performance of Surveillance Test Due to Protective Sys Relay Failed.Replaced Failed Relay Before Plant startup.W/950504 Ltr ML17291A7851995-05-0303 May 1995 LER 95-005-00:on 950222,inoperable IRM Had Been Relied Upon to Meet TS Requirements During Reactor Startup.Caused by Lack of Neutron Source to Test Instrumentation. Sys Knowledge Gained Will Be incorporated.W/950503 Ltr ML17291A7071995-03-25025 March 1995 LER 95-004-00:on 950226,malfunction in Main Turbine DEH Control Sys Caused All Four High Pressure Turbine Governor Valves to Rapidly Close.Caused by Blown Fuse.Suspected Faulty Circuit Card replaced.W/950325 Ltr ML17291A7011995-03-20020 March 1995 LER 95-002-00:on 950218,automatic Reactor Scram Occurred. Caused by Erroneous Positioning of Control During Performance of Scheduled Periodic Functional Test.Control repositioned.W/950320 Ltr 1999-07-20
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML17284A9001999-10-31031 October 1999 Rev 0 to COLR 99-15, WNP-2 Cycle 15,COLR GO2-99-177, LER 99-S01-00:on 990903,failure to Take Compensatory Measure within Required Time Upon Failure of Isolation Zone Microwave Unit,Was Noted.Caused by Personnel Error.Provided Refresher Training on Compensatory Measures.With1999-10-0101 October 1999 LER 99-S01-00:on 990903,failure to Take Compensatory Measure within Required Time Upon Failure of Isolation Zone Microwave Unit,Was Noted.Caused by Personnel Error.Provided Refresher Training on Compensatory Measures.With ML17284A8941999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for WNP-2.With 991012 Ltr ML17284A8801999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for WNP-2.With 990910 Ltr ML17284A8691999-07-31031 July 1999 Monthly Operating Rept for July 1999 for WNP-2.With 990813 Ltr ML17292B7421999-07-20020 July 1999 LER 99-001-00:on 990628,ESF Signal Closed All Eight MSIVs While Plant Was Shutdown.Caused by Failure of Relay RPS-RLY-K10D.Subject Relay Was Replaced & Tested on 990630. with 990720 Ltr ML17292B7271999-06-30030 June 1999 Monthly Operating Rept for June 1999 for WNP-2.With 990707 Ltr ML17292B6961999-05-31031 May 1999 Monthly Operating Repts for May 1999 for WNP-2.With 990608 Ltr ML17292B6641999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for WNP-2.With 990507 Ltr ML17292B6391999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for WNP-2.With 990413 Ltr ML17292B5871999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for WNP-2.With 990311 Ltr ML17292B5571999-01-31031 January 1999 Monthly Operating Rept for Jan 1999 for WNP-2.With 990210 Ltr ML17292B5621999-01-31031 January 1999 Rev 1 to COLR 98-14, WNP-2 Cycle 14 Colr. ML17292B5341999-01-15015 January 1999 Part 21 Rept Re Incorrect Modeling of BWR Lower Plenum Vol in Bison.Defect Applies Only to Reload Fuel Assemblies Currently in Operation at WNP-2.BISON Code Model for WNP-2 Has Been Revised to Correct Error ML17292B5331999-01-15015 January 1999 Part 21 Rept Re XL-S96 CPR Correlation for SVEA-96 Fuel. Defect Applies Only to WNP-2,during Cycles 12,13 & 14 Operation.Evaluations of Defect Performed by ABB-CE ML17292B4791998-12-31031 December 1998 Washington Public Power Supply Sys 1998 Annual Rept. with 981215 Ltr ML17292B5351998-12-31031 December 1998 Monthly Operating Rept for Dec 1998 for WNP-2.With 990112 Ltr ML17292B5741998-12-31031 December 1998 WNP-2 1998 Annual Operating Rept. with 990225 Ltr ML17284A8231998-11-30030 November 1998 Monthly Operating Rept for Nov 1998 for WNP-2.With 981207 Ltr ML17284A8081998-10-31031 October 1998 Monthly Operating Rept for Oct 1998 for WNP-2.With 981110 Ltr ML17292B4451998-10-27027 October 1998 LER 98-012-01:on 980715,failure to Comply with Requirements of TS SR 3.8.4.7 Was Noted.Caused by Inadequate Work Practices.Training Session Was Held with Personnel.With 981027 Ltr ML17284A7831998-09-30030 September 1998 Monthly Operating Rept for Sept 1998 for WNP-2.With 981007 Ltr ML17284A7491998-09-10010 September 1998 WNP-2 Inservice Insp Summary Rept for Refueling Outage RF13 Spring,1998. ML17284A7561998-09-0303 September 1998 LER 98-013-00:on 980805,ESF Actuations Were Noted Due to Deenergization of Vital Electrical Bus SM-8.Caused by Inadequate Direction in Troubleshooting Plan.Will Conduct Training for Engineering Personnel.With 980903 Ltr ML17284A7571998-09-0202 September 1998 LER 98-014-00:on 980807,completion of TS 3.8.1.F Required Shutdown Due to Inoperability of EDG-2 Was Noted.Caused by Degraded Voltage Regulator for DG-2.Replaced Voltage Regulator & Associated Scrs.With 980902 Ltr ML17284A7551998-09-0202 September 1998 LER 98-015-00:on 980808,discovered Reactor Coolant Pressure Boundary Leak During Shutdown Conditions.Caused by Leakage from Socket Weld (Fwb 63) on Elbow Connection.Failed Piping Connection Was Replaced.With 980902 Ltr ML17284A7681998-08-31031 August 1998 Monthly Operating Rept for Aug 1998 for WNP-2.With 980915 Ltr ML17284A7311998-08-17017 August 1998 LER 98-012-00:on 980716,determined That 24-month SR 3.8.4.7 Had Not Been Fulfilled within Specified Frequency.Caused by Inadequate Work Practices.License Requested & Received Enforcement Discretion Re Battery Svc test.W/980817 Ltr ML17284A7261998-07-31031 July 1998 Monthly Operating Rept for July 1998 for WNP-2.W/980810 Ltr ML17284A7121998-07-23023 July 1998 LER 98-006-01:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of 10CFR50,App R Calculations for High Impedance Faults.Caused by Inadequate Work Practices.Implemented Procedural Changes ML17284A6951998-07-17017 July 1998 LER 98-011-00:on 980617,ECCS Pump Room Flooding Was Noted Due to FP Sys Pipe Break.Caused by Inadequate Design of FP Sys.Detailed Review of FP Sys Design Was Conducted. W/980717 Ltr ML17284A6961998-07-15015 July 1998 LER 98-010-00:on 980615,TS Required Shutdown Due to Inoperability of TIP Sys Isolation Valve Was Noted.Caused by Improper Installation of TIP Tubing.Reattached Affected Tubing & Inspected Other TIP tubing.W/980715 Ltr ML17284A6731998-07-0101 July 1998 LER 98-009-00:on 980606,nuclear Steam Supply Shutoff Sys Group 3 & 4 Isolations During Testing Was Noted.Caused by Procedural Deficiency.Counseled Individuals Involved in preparation.W/980701 Ltr ML17284A6751998-06-30030 June 1998 Ro:On 980617,flooding of RB Northeast Stairwell with Consequential Flooding of Two ECCS Pump Rooms.Caused by Inadequate Fire Protection Sys Design.Pumped Out Water from Affected Areas to Point Below Berm Areas of Pump Rooms ML17284A6641998-06-24024 June 1998 LER 98-008-00:on 980531,inadvertent Full Scram During RPV Leak Testing in Mode 4 Was Noted.Caused by Change in Mgt Techniques.Revised Procedures to Take Into Account Addl Water Head in Pressure Sensing lines.W/980624 Ltr ML17284A6651998-06-24024 June 1998 LER 98-007-00:on 980530,inadvertent Full Scram & Division 1 ECCS Injection Was Noted.Caused by Failure to Meet Mgt Work Practice Expectation When Encountering Deficient Procedure. Incident Review Board Convened to Review event.W/980624 Ltr ML17284A6631998-06-19019 June 1998 LER 98-006-00:on 980520,discovered Discrepancies in Low Voltage Bus Calculations During Review of App R Calculations for High Impedance Fault Analysis.Caused Indeterminate. Implemented Procedural Changes Involving Operator Action ML17284A6551998-06-0404 June 1998 LER 98-005-00:on 980506,potential for Failure of RHR Sys Valve to Close on Isolation Signal Was Noted.Caused by Design Deficiency.Caution Tag Was Placed on RHR-V-40 Control Switch to Inform Plant Operators of limitation.W/980604 Ltr ML17284A6421998-06-0101 June 1998 LER 98-004-00:on 980502,determined That Primary Containment Penetration Overcurrent Protection Does Not Meet Reg Guide 1.63 Requirements.Caused by Inadequate Design Changes. Installed Addl Fuse in RHR-MO-9 circuit.W/980601 Ltr ML17284A6491998-05-31031 May 1998 Rev 0 to COLR 98-14, WNP-2,Cycle 14 Colr. ML17292B4031998-05-31031 May 1998 Monthly Operating Rept for May 1998 for WNP-2.W/980608 Ltr ML17292B3921998-04-30030 April 1998 Monthly Operating Rept for Apr 1998 for WNP-2.W/980513 Ltr ML17292B3291998-04-0909 April 1998 LER 98-003-00:on 980311,WNP-2 Experienced SCRAM Signal as Result of Low Rpv.Caused by Less than post-SCRAM Operational Strategy for Resetting SCRAM Signal in Conditions.Changes in post-SCRAM Operational Strategy implemented.W/980409 Ltr ML17292B3281998-04-0909 April 1998 LER 98-002-00:on 980311,reactor Scram & Plant Transient Occurred,Due to Failed Closed Main Steam Isolation Valve. Caused by Loss of Pneumatic Actuating Supply Pressure. Problem Evaluation Request Written for Failure of MS-V-22D ML17292B3371998-03-31031 March 1998 Monthly Operating Rept for Mar 1998 for WNP-2.W/980409 Ltr ML17292B2641998-03-0404 March 1998 Performance Self Assessment,WNP-2. ML17292B2661998-03-0404 March 1998 LER 98-001-00:on 980203,automatic Start of HPCS EDG Was Noted.Caused by Operator Error.Operations Crew Stabilized Plant at Approximately 75% Reactor Power & Investigation of Event Was initiated.W/980304 Ltr ML17292B2911998-02-28028 February 1998 Monthly Operating Rept for Feb 1998 for WNP-2.W/980313 Ltr ML17284A7971998-02-17017 February 1998 Rev 28 to Operational QA Program Description, WPPSS-QA-004.With Proposed Rev 29 ML17292B3591998-02-12012 February 1998 WNP-2 Cycle 14 Reload Design Rept. 1999-09-30
[Table view] |
Text
ACCELERAT .D DOCUINENT DIST'TION SYSTEM REGULA INFORMATION DISTRIBUTIO SYSTEM (RIDS)
ACCESSION NBR:9307220304 DOC.DATE: 93/07/15 NOTARIZED: NO DOCKET FACIL:50-397 WPPSS Nuclear Project, Unit 2, Washington Public Powe 05000397 AUTH. NAME AUTHOR AFFILIATION FIESPC.L. Washington Public Power Supply System PARRISH,J.V. Washington Public Power Supply System RECIP.NAME RECIP1ENT AFFILIATION
SUBJECT:
LER 93-025-00:on 930615,Group 1 nuclear steam supply shutoff sys isolation occurred during performance of TS survei'llance test on turbine throttle valves. Caused by procedure deficiency. Procedure changed.W/930715 ltr.
DISTRIBUTION CODE: IE22T TITLE: 50.73/50.9 Licensee Event Report (LER), J IncidentQRpt, etc.
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NOTES:
RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL PDV LA 1 1 PDV PD 1 1 CLIFFORDIJ 1 1 INTERNAL: ACNW 2 2 ACRS 2 2 AEOD/DOA 1 1 AEOD/DSP/TPAB 1 1 AEOD/ROAB/DSP 2 2 NRR/DE/EELB 1 1 NRR/DE/EMEB 1 1 NRR/DORS/OEAB 1 1 NRR/DRCH/HHFB 1 1 NRR/DRCH/HICB 1 1 NRR/DRCH/HOLB 1 1 NRR/DRIL/RPEB 1 1 NRR/DRSS/PRPB 2 2 NRR/DSSA/SPLB 1 1 NRR/DSSA/SRXB 1 1 ~~gEG ~EX- E 02 1 1 RES/DSIR/EIB 1 1 RGN5 FILE 01 1 1 EXTERNAL: EG6G BRYCE,J.H 2 2 L ST LOBBY WARD 1 1 NRC PDR 1 1 NSIC MURPHYPG.A 1 1 NSIC POOREPW. 1 1 NUDOCS FULL TXT 1 1 NOTE TO ALL"RIDS" RECIPIENTS:
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WASHINGTON PUBLIC POWER SUPPLY SYSTEM P.O. Box 968 ~ 3000 George Washington Way ~ Richland, Washington 99352 July 15, 1993 G02-93-184 Docket No. 50-397 Document Control Desk U.S. Nuclear Regulatory Commission Washington, D.C. 20555 Subject NUCLEAR PLANT WNP-2, OPERATING LICENSE NPF-21 LICENSEE EVENT REPORT NO.93-025 Transmitted herewith is Licensee Event Report No.93-025 for the WNP-2 Plant. This report is submitted in response to the report requirements of 10CFR50.73 and discusses the items of reportability, corrective action taken, and action taken to preclude recurrence.
J. V. Parrish (Mail Drop 1023)
Assistant Managing Director, Operations JVP/CLF/my Enclosure CC: Mr. B. H. Faulkenberry, NRC - Region V Mr. R. Barr, NRC Resident Inspector (Mail Drop 901A, 2 Copies)
INPO Records Center - Atlanta, GA Mr. D. L. Williams, BPA (Mail Drop 399) 2XQ006 9307220304 930715 PDR ADDCK 05000397 8 PDR
LICENSEE EVAREPORT (LER)
AGILITY NAHE (1) DOCKET NUMB R ( ) PAGE (3)
Washin ton Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 I OF ITLE (4)
ENGINEERED SA'FETY FEATURE (ESF) ACTUATION CAUSED BY SURVEILLANCE TESTING EVENT DATE 5) LER NUHBER 6) REPORT DATE (7) OTHER FACILITIES INVOLVED (6)
HONTH OAY YEAR YEAR g SEOUENTIAL EV I SION HONTH OAY YEAR FACILITY NAMES CKE NUMBER (5)
NUMBER UMBER 8>
5 0 0 6 5 9 1 3 9 3 0 2 5 0 0 0 7 1 5 9 3 50 PERATING HIS REPORT IS SUBHITTEO PURSUANT TO THE REQUIREMENTS OF 10 CFR E: (Check one or more of the following) (11)
OOE (9) 4 ONER LEVEL 20.402(b) 20.405(C) X 50.73(a)(2)(iv) 77.71(b)
(10) 20. 405(a) (1) ( I ) 50.36(c)(1) 50.73(a)(2)(v) 73.73(c)
- 20. 405(a) (1) ( I I) 50.36(c)(2) 50.73(a)(2)(vii) THER (Specify in Abstract 20.405(a) (I) (i i I) 50.73(a)(2)(i) 50.73(a)(2)(viii)(A) elow and in Text, NRC 0.405(a)(l)(iv) 50.73(a)(2)(ii) 50.73(a)(2)(viii)(B) orm 366A) 0.405(a)(1)(v) 50.73(a)(2)(iii) 50.73(a)(2)(x)
LICENSEE CONTACT FOR THIS LER ( 12)
TELEPHONE NUHBER C. L. Fies, Licensing Engineer REA CODE 5 0 9 7 7 - 4 1 4 7 COHPLETE ONE LINE FOR EACH COHPONENT FAILURE DESCRIBED IN THIS REPORT (13)
CAUSE SYSTEH COHPONENT HANUFACTURER EPORTABLE CAUSE SYSTEM COHPONENT MANUFACTURER REPORTABLE 0 NPRDS TO NPRDS h
SUPPLEMENTAL REPORT EXPECTED (14) EXPECTED SUBMISSION MONTH DAY YEAR ATE (15)
YES (If yes, complete EXPECTED SUBMISSION DATE) NO BlACT eel At approximately 1850 hours0.0214 days <br />0.514 hours <br />0.00306 weeks <br />7.03925e-4 months <br /> on June 15, 1993, a Group 1 Nuclear Steam Supply Shutoff System (NS')
isolation occurred during the performance of a Technical Specification surveillance test associated with the Turbine Throttle Valves. The test involved calibration of position switches on the valves associated with the NS'ogic. During shutdown conditions there is no main condenser vacuum. The NS4 logic is configured in a manner where exercising each Turbine Throttle valve to the open position initiates a half Group 1 isolation. During the surveillance test a second Throttle Valve was opened without resetting the (NS4) logic after testing the first valve. This resulted in a Group 1 isolation which is considered an ESF actuation.
The root cause of this event was a procedural deficiency.
Immediate corrective action was taken to stop work on the surveillance and investigate the cause. Further corrective action was taken to change the surveillance procedure to require a reset of the logic after the switches on each valve are calibrated.
The event posed no threat to the health and safety of either the public or plant personnel.
LICENSEE EVENT REPOR1kR)
TEXT CONTINUATION AGILITY HAKE (1) OOCKET KUMBER (2) LER HUHBER (8) AGE (3) ear Kumber ev. Ho.
Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 3 025 0 2 OF 5 iTLE (4)
ENGINEERED SAFETY FEATURE ESF ACTUATION CAUSED BY SURVEILLANCE TESTING Pln niin Power Level - 0%
PlantMode -4 Even Descri i n At approximately 1850 hours0.0214 days <br />0.514 hours <br />0.00306 weeks <br />7.03925e-4 months <br /> on June 15, 1993, a Group 1 Nuclear Steam Supply Shutoff System (NS')
isolation occurred during the performance of a Technical Specification surveillance test associated with the Turbine Throttle Valves. The test was being performed in accordance with plant procedure PPM 7.4.3.1.1.18, Turbine Throttle Valves - System A/B - Channel Calibration. The surveillance provides for the calibration of position switches associated with the closure of the Throttle Valves, During power operation, above 30 percent, these switches initiate a scram when the valves are greater than or equal to five percent closed.
These switches are also used as part of the NS4 logic. During shutdown conditions there is no main condenser vacuum. The NS4 logic is configured in a manner where exercising each Turbine Throttle valve to the open position initiates a half Group 1 isolation. During the surveillance test a second Throttle valve was opened without resetting the NS4 logic after testing the first valve. This resulted in a Group 1 isolation involving a closure signal to the Main Steam Line Isolation Valves and the Main Steam Line Drain Valves.
This is an ESF actuation.
mmediate rrec iv Ac ion Immediate corrective action was taken to stop surveillance testing and investigate the cause of the event.
Further Evalu ion R t Cau e and rrective Action A. Further Evaluation
- 1. This event is being reported per the requirements of 10CFR50.73(a)(2)(iv). This event was verbally reported as a non-emergency event under 10CFR50.72(b)(2)(ii) at 2241 hours0.0259 days <br />0.623 hours <br />0.00371 weeks <br />8.527005e-4 months <br /> on June 15, 1993.
- 2. Further evaluation showed the electricians assigned to perform the throttle valve surveillance had not previously performed the surveillance. In a pre-job briefing, the craft supervisor told them that stroking a throttle valve would cause a half scram. They were also told that the control room must be notified before starting the surveillance and after completing calibration of each throttle valve. They notified the control room prior to starting the surveillance and also after completing each valve. The electricians believed they could cause a half scram and they knew the procedure addressed the MSIVs. However, they did not know the difference between a half
LICENSEE EVENT REPORR)
TEXT CONTINUATION AGILITY KAHE (i) DOCKET HUHBER (2) LER KUHBER (B) ABE (3)
Year umber ev. Ko.
Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 3 025 00 3 OF 5 ITLE (4)
ENGINEERED SAFETY FEATURE ESF ACTUATION CAUSED BY SURVEILLANCE TESTING scram and a half isolation and did not realize that they were effecting two separate logic trains when they manipulated the position switches. Actually, the surveillance cannot cause a half scram because RPS relay contacts for the throttle valves are bypassed when the reactor is below 30% power.
- 3. The precautions and limitations section of the procedure states, "Throttle valve sections may be done in any order however, all steps in each section are to be performed in sequence. Only one instrument channel is to be in a state of test at any time. When a channel is returned to service, verify with the Control Room that all trips, alarms and computer points are cleared before proceeding to the next channel test." In addition, a procedural precaution states in part; "Ifthe RPS-K10 relays are energized with low condenser pressure, MSIVs will get a fast closure signal if more than one throttle valve is open at a time," However, the precaution does not inform the user that a NS'alf isolation occurs when only one throttle valve is open. It is apparent that the procedural instruction intended to inform the control room of the need to reset appropriate logic.
However, the direction was not as specific as it should have been and was not included as a step in the body of the procedure.
- 4. Operations personnel cannot remember when or if the NS'ogic was reset during the throttle valve calibration. At the same time they were conducting several other surveillance tests including Turbine Governor Valve (TGV) Fast Closure Response Time Testing and the MSIV Logic System Functional Test. The TGV fast closure surveillance introduces an actual half scram in the RPS logic and both A and B divisions were tested while the throttle valve procedure was in progress. Performance of these surveillances concurrently should not present a problem but in the absence of specific instruction to reset the logic, other surveillances may have diverted the operator's attention from resetting the NS4 half isolation. Also, an operations shift change occurred near the end of the surveillance.
- 5. A review of procedures that can initiate a scram or isolation revealed that procedures performed by the Instrument and Controls (I & C) shop are written to be logic safe. The I & C procedures separate the divisions so a full scram or isolation cannot be initiated with a single procedure.
There are relatively few procedures of this type performed by the Electrical shop. They have not been subject to this logic safe format. The Maintenance Procedures Department has identified three additional electrical procedures that could possibly cause a full scram or isolation.
- 6. A review was performed of the development of PPM 7.4.3.1.1.18. Revision 0 of the procedure was written in June 1985. In this revision the test was limited to Throttle Valves 1 and 3. In February 1986 the procedure was revised to include all four throttle valves. The statements in the precautions and limitations sections of these early revisions to the procedures are similar to the current version. A formal validation and verification has not been performed on this procedure. Thus, the procedure has been defective since inception.
LICENSEE EVENT REPORThR)
TEXT CONTINUATION AGILITY NAME (1) OOCKET HUHBER (2) LER HUHBER (8) AGE (3)
Year umber ev. Ho.
Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 3 25 00 4 F 5 rTLE (4)
ENGINEERED SAFETY FEATURE ESF ACTUATION CAUSED BY SURVEILLANCE TESTING B. Root Cause The root cause of this event was a procedural deficiency. The omission of a required action to reset the NS4 logic after completing each valve calibration caused the Group 1 isolation. It is recognized that this problem did not occur during previous performances of this surveillance. As discussed above, under further evaluation, there were additional complications that were present when the event occurred.
C. Further Corrective Actions
- 1. PPM 7.4.3.1.1.18 was changed on June 16, 1993, to include steps in each section of the procedure to reset the NS4 logic and verify the annunciators have cleared before proceeding to the next valve.
- 2. Plant Procedures PPM 7.4,3.1.1.18, 7.4.3.1.1.10A, 7.4.3.7.5.44, and 7,4.3.7.5.45 will be revised into logic safe procedures. This will be completed prior to their use during the next refueling outage.
- 3. An evaluation will be performed to determine the need for additional training for electrical shop personnel involved with Technical Specification Surveillances. This will be completed by Qff October 1, 1993.
This is no safety significance associated with this event. The plant was in mode 4 and the MSIVs were closed prior to the isolation.
imil r Event Group 1 isolations have occurred previously at WNP-2. These events are documented in LERs87-021 and 88-010. However, these isolations were not caused by surveillance testing associated with the Throttle Valves.
LICENSEE EVENT REPORTER)
TEXT CONTINUATION ACIL1TY NAME (1) OOCKET NUMBER (2) LER NUMBER (8) AGE (3) ear umber ev. No.
Washington Nuclear Plant - Unit 2 0 5 0 0 0 3 9 7 3 025 00 5 F 5 ITLE (4)
ENGINEERED SAFETY FEATURE ESF ACTUATION CAUSED BY SURVEILLANCE TESTING EIIS Information T~Rf EIIS Reference
~Stem ~Com anent Nuclear Steam Supply Shutoff System (NS') BD Turbine Throttle Valves SB V Turbine Throttle Valve Position Switches SB 33 Main Steam Line Isolation Valves SB V Main Steam Line Drain Valves SB V