|
|
| (3 intermediate revisions by the same user not shown) |
| Line 3: |
Line 3: |
| | issue date = 05/24/1996 | | | issue date = 05/24/1996 |
| | title = 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 | | | title = 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 |
| | author name = BEMIS P R, PFITZER B | | | author name = Bemis P, Pfitzer B |
| | author affiliation = WASHINGTON PUBLIC POWER SUPPLY SYSTEM | | | author affiliation = WASHINGTON PUBLIC POWER SUPPLY SYSTEM |
| | addressee name = | | | addressee name = |
| Line 16: |
Line 16: |
|
| |
|
| =Text= | | =Text= |
| {{#Wiki_filter:CATEGORYREGULATORY INFORMATION DISTRIBUTION SYSTEM(RIDS)ACCESSION NBR:9606040015 DOC.DATE: | | {{#Wiki_filter:CATEGORY REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS) |
| 96/05/24NOTARIZED: | | ACCESSION NBR:9606040015 DOC.DATE: 96/05/24 NOTARIZED: NO DOCKET FACIL:50-397 WPPSS .Nuclear Project, Unit 2, Washington Public Powe 05000397 AUTH. NAME AUTHOR AFFILIATION PFITZER,B. Washington Public Power Supply System BEMIS,P.R. Washington Public Power Supply System RECIP.NAME RECIPIENT AFFILIATION |
| NODOCKETFACIL:50-397 WPPSS.NuclearProject,Unit2,Washington PublicPowe05000397AUTH.NAMEAUTHORAFFILIATION PFITZER,B.
| |
| Washington PublicPowerSupplySystemBEMIS,P.R. | |
| Washington PublicPowerSupplySystemRECIP.NAME RECIPIENT AFFILIATION | |
|
| |
|
| ==SUBJECT:== | | ==SUBJECT:== |
| LER96-001-00:on 960425,inadvertent ESFactuations occurredduetotrippingoftemporary powersupplytoIN-3.Caused bypersonnel error.Operations restoredtoIN-3loads&resetESFactuations.W/960524 ltr.DISTRIBUTION CODE:IE22TCOPIESRECEIVED:LTR IENCL)SIZE:TITLE:50.73/50.9 LicenseeEventReport(LER),IncidentRpt,etc.NOTES:ERECIPIENT IDCODE/NAME PD4-2PDINTERNAL:
| | 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. |
| ACRSAEOD/SPD/RRAB NRR/DE/ECGB NRR/DE/EMEB NRR/DRCH/HICB NRR/DRCH/HQMB NRR/DSSA/SPLB RES/DSIR/EIB EXTERNAL:
| | DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR I ENCL ) SIZE: |
| LSTLOBBYWARDNOACMURPHYIG.A NRCPDRCOPIESLTTRENCL111111111111111111111111RECIPIENT IDCODE/NAME COLBURN,T AEODSPDRABCENTNRR/DRCH/HHFB NRR/DRCH/HOLB NRR/DRPM/PECB NRR/DSSA/SRXB RGN4FILE01LITCOBRYCE,JHNOACPOORE,W.NUDOCSFULLTXTCOPIESLTTRENCL1122111111111111112211110DUN4'0IDS"RECPE~VPLEASEHELPUSTOREDUCEWAS~TE!CONTACTHEOCUMENTCONTROLDESK,ROONOWEN5D-5(EXT.4i5-2083:
| | TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc. |
| TOELLi>ENATE OURNATEFROi~!DSTREBUTTON LTSTSFORDOCUNENTS YOUDON'TNEED.'ULL TEXTCONVERSION REQUIREDTOTALNUMBEROFCOPIESREQUIRED:
| | E NOTES: |
| LTTR26ENCL26
| | RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL 0 PD4-2 PD 1 1 COLBURN,T 1 1 INTERNAL: ACRS 1 1 AEOD SPD RAB 2 2 AEOD/SPD/RRAB 1 1 CENT 1 1 NRR/DE/ECGB 1 1 1 1 NRR/DE/EMEB 1 1 NRR/DRCH/HHFB 1 1 NRR/DRCH/HICB 1 1 NRR/DRCH/HOLB 1 1 NRR/DRCH/HQMB 1 1 NRR/DRPM/PECB 1 1 NRR/DSSA/SPLB 1 1 NRR/DSSA/SRXB 1 1 RES/DSIR/EIB 1 1 RGN4 FILE 01 1 1 D EXTERNAL: L ST LOBBY WARD 1 1 LITCO BRYCE,J H 2 2 NOAC MURPHYIG.A 1 1 NOAC POORE,W. 1 1 NRC PDR 1 1 NUDOCS FULL TXT 1 1 U |
| | N 4' 0 IDS" REC PE~V PLEASE HELP US TO REDUCE WAS~TE! CONTAC THE OCUMENT CONTROL DESK, ROON OWEN 5D-5 (EXT. 4i5-2083: TO ELLi>ENATE OUR NATE FROi~! |
| | D STREBUTTON LTSTS FOR DOCUNENTS YOU DON'T NEED.'ULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 26 ENCL 26 |
|
| |
|
| WASHliVGTOiV PUBLICPOWERSUPPLYSYSTEMPO.Box968~3000George1Visshingtott 1Vn)'Richlnrut, 1Vashington 99352.0968
| | WASHliVGTOiVPUBLIC POWER SUPPLY SYSTEM PO. Box 968 ~ 3000 George 1Visshingtott 1Vn)' Richlnrut, 1Vashington 99352.0968 ~ (S09) 372-SOOO May 24, 1996 G02-96-110 Docket No. 50-397 Document Control Desk U,S. Nuclear Regulatory Commission Washington, D.C. 20555 Gentlemen: |
| ~(S09)372-SOOOMay24,1996G02-96-110 DocketNo.50-397DocumentControlDeskU,S.NuclearRegulatory Commission Washington, D.C.20555Gentlemen: | |
|
| |
|
| ==Subject:== | | ==Subject:== |
| NUCLEARPLANTWNP-2,OPERATING LICENSENPF-21,LICENSEEEVENTREPORTNO.96-001-00 Transmitted herewithisLicenseeEventReportNo.96-001-00 forWNP-2.Thisreportissubmitted inresponsetothereporting requirements of10CFR73anddiscusses theitemsofreportability, corrective actiontaken,andactiontakentoprecluderecurrence.
| | NUCLEAR PLANT WNP-2, OPERATING LICENSE NPF-21, LICENSEE EVENT REPORT NO. 96-001-00 Transmitted herewith is Licensee Event Report No. 96-001-00 for WNP-2. This report is submitted in response to the reporting requirements of 10CFR73 and discusses the items of reportability, corrective action taken, and action taken to preclude recurrence. |
| Shouldyouhaveanyquestions ordesireadditional information regarding thismatter,pleasecallmeorMs.LourdesFernandez at(509)377-4147.
| | Should you have any questions or desire additional information regarding this matter, please call me or Ms. Lourdes Fernandez at (509) 377-4147. |
| tfully,y.R.emtsatropE20)VicePresident, NuclearOperations Enclosure cc:LJCallan,NRCRIVJWClifford, NRCKEPerkins,Jr.,NRCRIV,WCFONSReynolds, Winston&StrawnNRCSr.ResidentInspector, MD927N(2)INPORecordsCenter-Atlanta,GADLWilliams, BPA,MD39996060tI0015 960524PDRADQCK05000397Pl3fttg-, | | tfully, y |
| ~jhl' LICENSEEEVENTREPORT(LER)FAcs(TYNAMEll(DOCXETN(AIS(R(atACE(%Washington NuclearPlant-Unit2050003971A4m(E(>>INADVERTENT ESFACTUATIONS DUETOTRIPPINGOFTEMPORARY POWERSUPPLYTOIN-3BYOUTAGEELECTRICIANS EV(NTDAVE(SIR(tORTDATE(11FACE(TVNAM(SN/AOTN(RFACLITI(S t(VOLVTDle(OOCXETIMIS(R(SI000042596960010005249600opERATSIQ MODE(SITHSR(PORTISSVOM(TTED PVRSVANI'O TIIEREOVTI(M(NTS OF10(TILl(11POW(RLLV(L00100020.402(bl 20.405(e)(l)b) | | . R. emts at rop E20) |
| J20.405(e)(l)(ii)
| | Vice President, Nuclear Operations Enclosure cc: LJ Callan, NRC RIV NRC Sr. Resident Inspector, MD927N (2) |
| I20.405(e)()
| | JW Clifford, NRC INPO Records Center - Atlanta, GA KE Perkins, Jr., NRC RIV, WCFO DL Williams, BPA, MD399 NS Reynolds, Winston & Strawn 96060tI0015 960524 ADQCK 05000397 tg-, |
| )(N')(20.405(e)(l
| | PDR P l3ft |
| )(ivl20.405(sl(l | | |
| )(v)(J20.405c(50.38(c)(1(
| | ~ jhl' LICENSEE EVENT REPORT (LER) |
| J50.38(cl(2)
| | FAcs(TY NAME ll( DOCXET N(AIS(R (a tACE(% |
| [50,73(s)(2)(i)
| | Washington Nuclear Plant Unit 2 0 5 0 0 0 3 9 7 1 A 4 m(E(>> INADVERTENT ESF ACTUATIONS DUE TO TRIPPING OF TEMPORARY POWER SUPPLY TO IN-3 BY OUTAGE ELECTRICIANS EV(NT DAVE (SI R(tORT DATE (11 OTN(R FACLITI(S t(VOLVTD le( |
| )50.73(s)(2)(i) | | FACE(TV NAM(S OOCXET IMIS(R(S I N/A 0 0 0 04 25 96 96 0 0 1 0 0 05 24 96 0 0 opERATSIQ THS R(PORT IS SVOM(TTED PVRSVANI'O TIIE REOVTI(M(NTS OF 10 (TIL l(11 MODE (SI 20.402(bl ( J 20.405c ( X ] 50.73(e)(2)(ivl 73.71(b) 20.405(e)(l)b) ( 50.38(c)(1( ) ( 50.73(e)(2)(vl ( 73.71(c) |
| (S0.73(s)(2)(<<)
| | POW(R LLV(L 20.405(e)(l)(ii) J 50.38(cl(2) J 50.73(s)(2)(vi) ) OTHER (Specify in Abstract below end J |
| (X]50.73(e)(2)(ivl | | 001 in Text. NRC Form 388A) 20.405(e)() )(N') 50,73(s)(2)(i) 50.73(e)(2)(vM)A 0 0 0 I [ |
| )(50.73(e)(2)(vl J50.73(s)(2)(vi) 50.73(e)(2)(vM)A J50.73(s)(2)(vsr)B (50.73(s)(2)(xl 73.71(b)(73.71(c))OTHER(SpecifyinAbstractbelowendinText.NRCForm388A)Uc(NS(ECONTACTFORTHSL(R(INBillPfitzer,Licensing EngineerCOMPLETEOICLs(ETO(IEACNCOMPO(CRT FASIMED(SCRN(Ot(THSR(PORT(ISIAR(ACODE509377-2419SVST(MMAIAFACTVRERR(PORTA(XE TOM%05R(PORTA(LE TOI@ROESVPtLEM(NTAL R(to(ITExt(CTEDIHIYES(ifyes,completeEXPECTEDSUBMISSION DATE)ABSTRACr()6)IXINOEXPECTEDSUBMISSION DATE(15)MON(I(V(A(IOnThursday, April25,1996,at0835,withtheplantdefueled, twotemporary plantelectricians inadvertently openedthefuseddisconnect supplying theUninterruptible PowerSupply(UPS)inverterIN-3loads,causingalossofpowertotheloads.Deenergization ofIN-3loadsresultedinEngineered SafetyFeature(ESF)actuations andcontainment isolations whichwereresetwithoutfurtherincidentbycontrolroompersonnel. | | ( 20.405(e)(l )(ivl ) 50.73(s)(2)(i) J 50.73(s)(2)(vsr)B 20.405(sl(l ) (v) ( S0.73(s)(2)(<<) ( 50.73(s)(2)(xl Uc(NS(E CONTACT FOR THS L(R (IN Bill Pfitzer, Licensing Engineer AR(A CODE 509 377-2419 COMPLETE OIC Ls(E TO(I EACN COMPO(CRT FASIME D(SCRN(O t( THS R(PORT (ISI SVST(M MAIAFAC R(PORTA(XE R(PORTA(LE TVRER TO M%05 TO I@ROE EXPECTED MON(I( V(A(I SVPtLEM(NTAL R(to(IT Ext(CTED IHI SUBMISSION YES (if yes, complete EXPECTED SUBMISSION DATE) I XI NO DATE (15) |
| Atthetime,theIN-3loadswerebeingtemporarily suppliedthroughadisconnect switchlocatedonPowerPanelPP-7Athatwaslabeledasasparedisconnect.
| | ABSTRACr () 6) |
| Thedisconnect handlehadacautiontagwhichidentified thedisconnect asONandsupplying temporary powertotheIN-3loads.Alsowrittenonthecautiontagwereinstructions tocontactthecontrolroompriortooperating thedisconnect.
| | On Thursday, April 25, 1996, at 0835, with the plant defueled, two temporary plant electricians inadvertently opened the fused disconnect supplying the Uninterruptible Power Supply (UPS) inverter IN-3 loads, causing a loss of power to the loads. Deenergization of IN-3 loads resulted in Engineered Safety Feature (ESF) actuations and containment isolations which were reset without further incident by control room personnel. |
| Thetwoelectricians statedtheydidnotreadandunderstand thecautiontag.Theyhavebeenrestricted fromworkinthepowerblockfortheremainder oftheoutage,andtheimportance oftheadministrative barriersreiterated tomaintenance personnel.
| | At the time, the IN-3 loads were being temporarily supplied through a disconnect switch located on Power Panel PP-7A that was labeled as a spare disconnect. The disconnect handle had a caution tag which identified the disconnect as ON and supplying temporary power to the IN-3 loads. Also written on the caution tag were instructions to contact the control room prior to operating the disconnect. The two electricians stated they did not read and understand the caution tag. They have been restricted from work in the power block for the remainder of the outage, and the importance of the administrative barriers reiterated to maintenance personnel. |
| EventNotification wasmadetotheNRCpursuanttotherequirements of10CFR50.72(b)(2).
| | Event Notification was made to the NRC pursuant to the requirements of 10 CFR 50.72(b)(2). |
| ~H LICENSVENTREPORT(LER)TEXTCOUATIONTEXT(l7)Washington NuclearPlant-Unit20500039796SEOVCNTIAL NUM80l-001002o"4EvenDescritionOnThursday, April25,1996,at0835,withtheplantdefueled, twotemporary plantelectricians inadvertently openedthefuseddisconnect supplying theUninterruptible PowerSupplyinverter[UJX,INVT] | | |
| IN-3loads,causingalossofpowertotheloads.Atthetime,theIN-3loadswerebeingtemporarily suppliedthroughadisconnect switchlocatedonPowerPanel[PL]PP-7A,andlabeledasasparedisconnect. | | ~ H LICENS VENT REPORT (LER) TEXT CO UATION SEOVCNTIAL NUM80l Washington Nuclear Plant Unit 2 05 0 0 0 3 9 7 96 -00 1 0 0 2 o" 4 TEXT (l7) |
| Deenergization ofIN-3loadsresultedinthefollowing ESFactuations: | | Even Descri tion On Thursday, April 25, 1996, at 0835, with the plant defueled, two temporary plant electricians inadvertently opened the fused disconnect supplying the Uninterruptible Power Supply inverter |
| StartofControlRoomEmergency Filtration systemStartofStandbyGasTreatment system[BH]Isolation ofReactorBuildingVentilation system[VA]Isolation ofthefollowing containment valves:~CSP-V-1[VB,V]andCEP-V-1A[VB,V](containment purgeandexhaust)~RCC-V-5andRCC-V-21[CC,V](containment coolingsupplyandreturn)~EDR-V-395
| | [UJX,INVT]IN-3 loads, causing a loss of power to the loads. At the time, the IN-3 loads were being temporarily supplied through a disconnect switch located on Power Panel [PL] PP-7A, and labeled as a spare disconnect. Deenergization of IN-3 loads resulted in the following ESF actuations: |
| [V]andFDR-V-220 | | Start of Control Room Emergency Filtration system Start of Standby Gas Treatment system [BH] |
| [V](reactorbuildingsumpdischarges toradwaste) | | Isolation of Reactor Building Ventilation system [VA] |
| Atthetimeoftheincident, thepersonnel involvedwerewalkingdownWorkOrderTaskDS34-01inpreparation forreplacing thedisconnect switch.Theirintentwastotakephotographs ofthedisconnect fuseclips,andwhileattempting toopenthecabinetdoortotakethephotostheyinadvertently openedthedisconnect.
| | Isolation of the following containment valves: |
| Immediate orrective ActionOperations restoredpowertoIN-3loadsandresettheESFactuations withoutfurtherincident. | | ~ CSP-V-1 [VB,V] and CEP-V-1A [VB,V] (containment purge and exhaust) |
| 'EventNotification wasmadetotheNRCpursuanttotherequirements of10CFR50.72(b)(2).
| | ~ RCC-V-5 and RCC-V-21 [CC,V] (containment cooling supply and return) |
| Thetemporary electricians involvedwererestricted fromperforming workinthepowerblock.'IManagement expectations concerning equipment cle'arance requirements andtheappropriate approvals neededpriortoenteringpanels,components orsystems,werereiterated duringbriefings withplantandcontractor maintenance personnel regarding thisevent.
| | ~ EDR-V-395 [V] and FDR-V-220 [V] (reactor building sump discharges to radwaste) |
| LICENSVENTREPORT(LER)TEXTCOUATlONTEXT(17)Washington NuclearPlant-Unit20500039796SKIIIIIHTIAI HVMIOI001003o"4FrtherEvaluinThetwoelectricians statedtheyassumedthedisconnect wasopenbecausetheworkinstructions identified thedisconnect asaspare,andtheinstructions madenomentionofthedisconnect beingthetemporary powersupplytoIN-3.Furthermore, theyfoundthebreakerhandleinthemid-positionbetweenOPENandCLOSED.Theelectricians didnotquestionthiscondition becausetheworkinstructions described theproblemas,"cubiclewillnotcloseproperlyandhasmissingparts.Themainbarrierinplacetopreventthisoccurrence wasacautionorderonthedisconnect handlewhichstatedthestatusasON.Thebacksideofthecardread,"Cautiontagthetemporary powersupplybreakertoPP-7A-Aper10.25.1step6.1.14.DonotoperatewithoutCRS/Shift Managerpermission."
| | At the time of the incident, the personnel involved were walking down Work Order Task DS34-01 in preparation for replacing the disconnect switch. Their intent was to take photographs of the disconnect fuse clips, and while attempting to open the cabinet door to take the photos they inadvertently opened the disconnect. |
| Theelectricians statedtheyfailedtonoticethestatusONindication onthefrontofthecard,anddidnotreadtheinformation onthebackofthecard.Anadditional barrierwasprovidedbydirection giveninprocedure PPM1.3.7Gwhichspecifically disallows openingofpanelsbycraftsmen performing walkdownofworkinstructions.
| | Immediate orrective Action Operations restored power to IN-3 loads and reset the ESF actuations without further incident. |
| RootauseTheprimaryrootcauseofthiseventwaspersonnel error.Theelectricians involveddidnotreadandfollowtheinstructions onthecautiontag.Additionally, theelectricians didnotfollowtherequirements ofPPM1.3.7Gwhichspecifically disallows openingofpanelsbycraftsmen performing walkdownofworkinstructions.
| | Event Notification was made to the NRC pursuant to the requirements of 10 CFR 50.72(b)(2). |
| Contributing causeswerelackofaquestioning attitudeandinexperience usingSupplySystemprocedures. | | The temporary electricians involved were restricted from performing work in the power block. |
| Furtherorrective AcinRevisePPM10.25.1toincludetherequirement toprovidefieldidentification ofsparedisconnects whichareproviding temporary power.Reviseapplicable maintenance lessonplansregarding clearance orders(PPM1.3.8)andopeningofpanelsbymaintenance personnel (PPM1.3.7G)toincludelessonslearnedfromthisevent.AsementofSafensuenceThesafetyconsequences ofthiseventareminimalbecausetheplantwasdefueledinMode5.Allexpectedactuations andisolations
| | 'I Management expectations concerning equipment cle'arance requirements and the appropriate approvals needed prior to entering panels, components or systems, were reiterated during briefings with plant and contractor maintenance personnel regarding this event. |
| : occurred, andtheaffectedsystemswererestoredbycontrol'oompersonnel withoutfurtherincident.
| | |
| LICENSVENTREPORT(LER)TEXTCO,UATIONTEXTu7)Washington NuclearPlant-Unit20500039796001004o"4PreviousimilarEventsPreviousLERsdocumenting personnel errorresulting inESForRPSactuation areasfollows:~LER95-002involvedOperations personnel operating thewrongleverduringamainturbinetestresulting inturbinetripandreactorscram.~LER93-024involvedpersonnel errorandfailuretoselfcheckduringrestoration oftheContainment Instrument Air(CIA)system.Improperrestoration resultedinactuation oftheCIAbackupnitrogenbottleprogrammer.
| | LICENS VENT REPORT (LER) TEXT CO UATlON SKIIIIIHTIAI HVMIOI Unit 2 Washington Nuclear Plant 05 0 0 0 3 9 7 96 0 0 1 0 0 3 o" 4 TEXT (17) |
| ~LER93-002-01 involvedpaintersinadvertently actuating ReactorFeedwater PumpRoom"A"fireprotection delugesystemwhichultimately ledtothetripofReactorFeedwater Pump"A"tripandreactorscram.}} | | F rther Evalu i n The two electricians stated they assumed the disconnect was open because the work instructions identified the disconnect as a spare, and the instructions made no mention of the disconnect being the temporary power supply to IN-3. Furthermore, they found the breaker handle in the mid-position between OPEN and CLOSED. The electricians did not question this condition because the work instructions described the problem as, "cubicle will not close properly and has missing parts. |
| | The main barrier in place to prevent this occurrence was a caution order on the disconnect handle which stated the status as ON. The back side of the card read, "Caution tag the temporary power supply breaker to PP-7A-A per 10.25.1 step 6.1.14. Do not operate without CRS/Shift Manager permission." The electricians stated they failed to notice the status ON indication on the front of the card, and did not read the information on the back of the card. An additional barrier was provided by direction given in procedure PPM 1.3.7G which specifically disallows opening of panels by craftsmen performing walkdown of work instructions. |
| | Root ause The primary root cause of this event was personnel error. The electricians involved did not read and follow the instructions on the caution tag. Additionally, the electricians did not follow the requirements of PPM 1.3.7G which specifically disallows opening of panels by craftsmen performing walkdown of work instructions. Contributing causes were lack of a questioning attitude and inexperience using Supply System procedures. |
| | Further orrective Ac i n Revise PPM 10.25.1 to include the requirement to provide field identification of spare disconnects which are providing temporary power. |
| | Revise applicable maintenance lesson plans regarding clearance orders (PPM 1.3.8) and opening of panels by maintenance personnel (PPM 1.3.7G) to include lessons learned from this event. |
| | As e ment of Safe ns uence The safety consequences of this event are minimal because the plant was defueled in Mode 5. All expected actuations and isolations occurred, and the affected systems were restored by control |
| | 'oom personnel without further incident. |
| | |
| | LICENS VENT REPORT (LER) TEXT CO, UATION Washington Nuclear Plant Unit 2 05 0 0 0 3 9 7 96 0 0 1 0 0 4 o" 4 TEXT u7) |
| | Previous imilar Events Previous LERs documenting personnel error resulting in ESF or RPS actuation are as follows: |
| | ~ LER 95-002 involved Operations personnel operating the wrong lever during a main turbine test resulting in turbine trip and reactor scram. |
| | ~ LER 93-024 involved personnel error and failure to self check during restoration of the Containment Instrument Air (CIA) system. Improper restoration resulted in actuation of the CIA backup nitrogen bottle programmer. |
| | ~ LER 93-002-01 involved painters inadvertently actuating Reactor Feedwater Pump Room "A" fire protection deluge system which ultimately led to the trip of Reactor Feedwater Pump "A" trip and reactor scram.}} |
|
|---|
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
CATEGORY REGULATORY INFORMATION DISTRIBUTION SYSTEM (RIDS)
ACCESSION NBR:9606040015 DOC.DATE: 96/05/24 NOTARIZED: NO DOCKET FACIL:50-397 WPPSS .Nuclear Project, Unit 2, Washington Public Powe 05000397 AUTH. NAME AUTHOR AFFILIATION PFITZER,B. Washington Public Power Supply System BEMIS,P.R. Washington Public Power Supply System RECIP.NAME RECIPIENT AFFILIATION
SUBJECT:
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.
DISTRIBUTION CODE: IE22T COPIES RECEIVED:LTR I ENCL ) SIZE:
TITLE: 50.73/50.9 Licensee Event Report (LER), Incident Rpt, etc.
E NOTES:
RECIPIENT COPIES RECIPIENT COPIES ID CODE/NAME LTTR ENCL ID CODE/NAME LTTR ENCL 0 PD4-2 PD 1 1 COLBURN,T 1 1 INTERNAL: ACRS 1 1 AEOD SPD RAB 2 2 AEOD/SPD/RRAB 1 1 CENT 1 1 NRR/DE/ECGB 1 1 1 1 NRR/DE/EMEB 1 1 NRR/DRCH/HHFB 1 1 NRR/DRCH/HICB 1 1 NRR/DRCH/HOLB 1 1 NRR/DRCH/HQMB 1 1 NRR/DRPM/PECB 1 1 NRR/DSSA/SPLB 1 1 NRR/DSSA/SRXB 1 1 RES/DSIR/EIB 1 1 RGN4 FILE 01 1 1 D EXTERNAL: L ST LOBBY WARD 1 1 LITCO BRYCE,J H 2 2 NOAC MURPHYIG.A 1 1 NOAC POORE,W. 1 1 NRC PDR 1 1 NUDOCS FULL TXT 1 1 U
N 4' 0 IDS" REC PE~V PLEASE HELP US TO REDUCE WAS~TE! CONTAC THE OCUMENT CONTROL DESK, ROON OWEN 5D-5 (EXT. 4i5-2083: TO ELLi>ENATE OUR NATE FROi~!
D STREBUTTON LTSTS FOR DOCUNENTS YOU DON'T NEED.'ULL TEXT CONVERSION REQUIRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 26 ENCL 26
WASHliVGTOiVPUBLIC POWER SUPPLY SYSTEM PO. Box 968 ~ 3000 George 1Visshingtott 1Vn)' Richlnrut, 1Vashington 99352.0968 ~ (S09) 372-SOOO May 24, 1996 G02-96-110 Docket No. 50-397 Document Control Desk U,S. Nuclear Regulatory Commission Washington, D.C. 20555 Gentlemen:
Subject:
NUCLEAR PLANT WNP-2, OPERATING LICENSE NPF-21, LICENSEE EVENT REPORT NO. 96-001-00 Transmitted herewith is Licensee Event Report No. 96-001-00 for WNP-2. This report is submitted in response to the reporting requirements of 10CFR73 and discusses the items of reportability, corrective action taken, and action taken to preclude recurrence.
Should you have any questions or desire additional information regarding this matter, please call me or Ms. Lourdes Fernandez at (509) 377-4147.
tfully, y
. R. emts at rop E20)
Vice President, Nuclear Operations Enclosure cc: LJ Callan, NRC RIV NRC Sr. Resident Inspector, MD927N (2)
JW Clifford, NRC INPO Records Center - Atlanta, GA KE Perkins, Jr., NRC RIV, WCFO DL Williams, BPA, MD399 NS Reynolds, Winston & Strawn 96060tI0015 960524 ADQCK 05000397 tg-,
PDR P l3ft
~ jhl' LICENSEE EVENT REPORT (LER)
FAcs(TY NAME ll( DOCXET N(AIS(R (a tACE(%
Washington Nuclear Plant Unit 2 0 5 0 0 0 3 9 7 1 A 4 m(E(>> INADVERTENT ESF ACTUATIONS DUE TO TRIPPING OF TEMPORARY POWER SUPPLY TO IN-3 BY OUTAGE ELECTRICIANS EV(NT DAVE (SI R(tORT DATE (11 OTN(R FACLITI(S t(VOLVTD le(
FACE(TV NAM(S OOCXET IMIS(R(S I N/A 0 0 0 04 25 96 96 0 0 1 0 0 05 24 96 0 0 opERATSIQ THS R(PORT IS SVOM(TTED PVRSVANI'O TIIE REOVTI(M(NTS OF 10 (TIL l(11 MODE (SI 20.402(bl ( J 20.405c ( X ] 50.73(e)(2)(ivl 73.71(b) 20.405(e)(l)b) ( 50.38(c)(1( ) ( 50.73(e)(2)(vl ( 73.71(c)
POW(R LLV(L 20.405(e)(l)(ii) J 50.38(cl(2) J 50.73(s)(2)(vi) ) OTHER (Specify in Abstract below end J
001 in Text. NRC Form 388A) 20.405(e)() )(N') 50,73(s)(2)(i) 50.73(e)(2)(vM)A 0 0 0 I [
( 20.405(e)(l )(ivl ) 50.73(s)(2)(i) J 50.73(s)(2)(vsr)B 20.405(sl(l ) (v) ( S0.73(s)(2)(<<) ( 50.73(s)(2)(xl Uc(NS(E CONTACT FOR THS L(R (IN Bill Pfitzer, Licensing Engineer AR(A CODE 509 377-2419 COMPLETE OIC Ls(E TO(I EACN COMPO(CRT FASIME D(SCRN(O t( THS R(PORT (ISI SVST(M MAIAFAC R(PORTA(XE R(PORTA(LE TVRER TO M%05 TO I@ROE EXPECTED MON(I( V(A(I SVPtLEM(NTAL R(to(IT Ext(CTED IHI SUBMISSION YES (if yes, complete EXPECTED SUBMISSION DATE) I XI NO DATE (15)
ABSTRACr () 6)
On Thursday, April 25, 1996, at 0835, with the plant defueled, two temporary plant electricians inadvertently opened the fused disconnect supplying the Uninterruptible Power Supply (UPS) inverter IN-3 loads, causing a loss of power to the loads. Deenergization of IN-3 loads resulted in Engineered Safety Feature (ESF) actuations and containment isolations which were reset without further incident by control room personnel.
At the time, the IN-3 loads were being temporarily supplied through a disconnect switch located on Power Panel PP-7A that was labeled as a spare disconnect. The disconnect handle had a caution tag which identified the disconnect as ON and supplying temporary power to the IN-3 loads. Also written on the caution tag were instructions to contact the control room prior to operating the disconnect. The two electricians stated they did not read and understand the caution tag. They have been restricted from work in the power block for the remainder of the outage, and the importance of the administrative barriers reiterated to maintenance personnel.
Event Notification was made to the NRC pursuant to the requirements of 10 CFR 50.72(b)(2).
~ H LICENS VENT REPORT (LER) TEXT CO UATION SEOVCNTIAL NUM80l Washington Nuclear Plant Unit 2 05 0 0 0 3 9 7 96 -00 1 0 0 2 o" 4 TEXT (l7)
Even Descri tion On Thursday, April 25, 1996, at 0835, with the plant defueled, two temporary plant electricians inadvertently opened the fused disconnect supplying the Uninterruptible Power Supply inverter
[UJX,INVT]IN-3 loads, causing a loss of power to the loads. At the time, the IN-3 loads were being temporarily supplied through a disconnect switch located on Power Panel [PL] PP-7A, and labeled as a spare disconnect. Deenergization of IN-3 loads resulted in the following ESF actuations:
Start of Control Room Emergency Filtration system Start of Standby Gas Treatment system [BH]
Isolation of Reactor Building Ventilation system [VA]
Isolation of the following containment valves:
~ CSP-V-1 [VB,V] and CEP-V-1A [VB,V] (containment purge and exhaust)
~ RCC-V-5 and RCC-V-21 [CC,V] (containment cooling supply and return)
~ EDR-V-395 [V] and FDR-V-220 [V] (reactor building sump discharges to radwaste)
At the time of the incident, the personnel involved were walking down Work Order Task DS34-01 in preparation for replacing the disconnect switch. Their intent was to take photographs of the disconnect fuse clips, and while attempting to open the cabinet door to take the photos they inadvertently opened the disconnect.
Immediate orrective Action Operations restored power to IN-3 loads and reset the ESF actuations without further incident.
Event Notification was made to the NRC pursuant to the requirements of 10 CFR 50.72(b)(2).
The temporary electricians involved were restricted from performing work in the power block.
'I Management expectations concerning equipment cle'arance requirements and the appropriate approvals needed prior to entering panels, components or systems, were reiterated during briefings with plant and contractor maintenance personnel regarding this event.
LICENS VENT REPORT (LER) TEXT CO UATlON SKIIIIIHTIAI HVMIOI Unit 2 Washington Nuclear Plant 05 0 0 0 3 9 7 96 0 0 1 0 0 3 o" 4 TEXT (17)
F rther Evalu i n The two electricians stated they assumed the disconnect was open because the work instructions identified the disconnect as a spare, and the instructions made no mention of the disconnect being the temporary power supply to IN-3. Furthermore, they found the breaker handle in the mid-position between OPEN and CLOSED. The electricians did not question this condition because the work instructions described the problem as, "cubicle will not close properly and has missing parts.
The main barrier in place to prevent this occurrence was a caution order on the disconnect handle which stated the status as ON. The back side of the card read, "Caution tag the temporary power supply breaker to PP-7A-A per 10.25.1 step 6.1.14. Do not operate without CRS/Shift Manager permission." The electricians stated they failed to notice the status ON indication on the front of the card, and did not read the information on the back of the card. An additional barrier was provided by direction given in procedure PPM 1.3.7G which specifically disallows opening of panels by craftsmen performing walkdown of work instructions.
Root ause The primary root cause of this event was personnel error. The electricians involved did not read and follow the instructions on the caution tag. Additionally, the electricians did not follow the requirements of PPM 1.3.7G which specifically disallows opening of panels by craftsmen performing walkdown of work instructions. Contributing causes were lack of a questioning attitude and inexperience using Supply System procedures.
Further orrective Ac i n Revise PPM 10.25.1 to include the requirement to provide field identification of spare disconnects which are providing temporary power.
Revise applicable maintenance lesson plans regarding clearance orders (PPM 1.3.8) and opening of panels by maintenance personnel (PPM 1.3.7G) to include lessons learned from this event.
As e ment of Safe ns uence The safety consequences of this event are minimal because the plant was defueled in Mode 5. All expected actuations and isolations occurred, and the affected systems were restored by control
'oom personnel without further incident.
LICENS VENT REPORT (LER) TEXT CO, UATION Washington Nuclear Plant Unit 2 05 0 0 0 3 9 7 96 0 0 1 0 0 4 o" 4 TEXT u7)
Previous imilar Events Previous LERs documenting personnel error resulting in ESF or RPS actuation are as follows:
~ LER 95-002 involved Operations personnel operating the wrong lever during a main turbine test resulting in turbine trip and reactor scram.
~ LER 93-024 involved personnel error and failure to self check during restoration of the Containment Instrument Air (CIA) system. Improper restoration resulted in actuation of the CIA backup nitrogen bottle programmer.
~ LER 93-002-01 involved painters inadvertently actuating Reactor Feedwater Pump Room "A" fire protection deluge system which ultimately led to the trip of Reactor Feedwater Pump "A" trip and reactor scram.
