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| {{#Wiki_filter:CATEGORY1~REGULARLYINFORMATIONDISTRIBUTIOF%YSTEM(RIDS)p)*ACCESSIONNBR:9802110012DOC.DATE:98/02/03NOTARIZED:NOFACIL:50-335St.LuciePlant,Unit1,FloridaPower&LightCo.AUTH.NAMEAUTHORAFFILIATIONFREiIXFER,K.W.FloridaPower&LightCo.-STALL,J.A.FloridaPower&LightCo.RECIP.NAMERECIPIENTAFFILIATIONDOCKET¹05000335 | | {{#Wiki_filter:CATEGORY1~REGULARLY INFORMATION DISTRIBUTIOF%YSTEM (RIDS)p)*ACCESSION NBR:9802110012 DOC.DATE: |
| | 98/02/03NOTARIZED: |
| | NOFACIL:50-335 St.LuciePlant,Unit1,FloridaPower&LightCo.AUTH.NAMEAUTHORAFFILIATION FREiIXFER,K.W. |
| | FloridaPower&LightCo.-STALL,J.A. |
| | FloridaPower&LightCo.RECIP.NAME RECIPIENT AFFILIATION DOCKET¹05000335 |
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| ==SUBJECT:== | | ==SUBJECT:== |
| LER98-001-00:on980104,inadvertentRPSactuationoccurredduetopersonnelerror.Causedbyproceduralinadequacies&,inadequateself-checkingby.licensedutilitypersonnel.PlacardshavebeenplacedinCRs.W/980203ltr.DISTRIBUTIONCODE:IE22TCOPIESRECEIVED:LTRENCLSIZE:TITLE:50.73/50.9LicenseeEventReport(LER),IncidentRpt,etc.NOTES:'CRECIPIENTIDCODE/NAMEPD2-3PDINTERNAL:ACRSAEOD/SPD/RRABNRR/DE/ECGBNRR/DE/EMEBNRR/DRCH/HICBNRR/DRCH/HQMBNRR/DSSA/SPLBRES/DET/EIBEXTERNAL:LSTLOBBYWARDNOACPOORE,W.NRCPDRCOPIESLTTRENCL111111111111111111111111RECIPIENTIDCODE/NAMEWIENS,L.CgNRRDEEELBNRR/DRCH/HHFBNRR/DRCH/HOLBNRR/DRPM/PECBNRR/DSSA/SRXBRGN2FILEOlLITCOBRYCE,JHNOACQUEENER,DSNUDOCSFULLTXTCOPIESLTTRENCL112211111111111111111111NOTETOALL"RIDS"RECIPIENTS:PLEASEHELPUSTOREDUCEWASTE.TOHAVEYOURNAMEORORGANIZATIONREMOVEDFROMDISTRIBUTIONLIST>>ORREDUCETHENUMBEROFCOPIESRECEIVEDBYYOUORYOURORGANIZATION,CONTACTTHEDOCUMENTCONTROIDESK(DCD)ONEXTENSION415-2083FULLTEXTCONVERSIONREQUIREDTOTALNUMBEROFCOPIESREQUIRED:LTTR25ENCL25 FloridaPower&LightCompany,6351S.OceanDrive,JensenBeach,FL34957February3,1998L-98-01810CFR50.73U.S.NuclearRegulatoryCommissionAttn:DocumentControlDeskWashington,D.C.20555Re:St.LucieUnit1DocketNo.50-335ReportableEvent:98-001DateofEvent:January4,1998InadvertentRPSActuationDuetoPersonnelErrorTheattachedLicenseeEventReportisbeingsubmittedpursuanttotherequirementsof10CFR50.73.Verytrulyyours,J.A.StallVicePresidentSt.LuciePlantJAS/KWFAttachmentcc:RegionalAdministrator,USNRC,RegionIISeniorResidentInspector,USNRC,St.LuciePlant'ir802ii0012'rr80203PDRADQCK050003358PDRllllllllllllllllllllllllllllllllllllllanFPLGroupcompany NRCFORM366(4.9e)U.S.NUCLEARREGULATORYCOMMISSIONLICENSEEEVENTREPORT(LER)(Seereverseforrequirednumberofdigits/charactersforeachbiock)APPROVEDSVOMBNo.S(60<0(O4EXARES04/30/SSESTIMATEDBURDENPERRESPONSETOCOMPLYWITHTHISMANDATORINFORMATIONCOLLECTIONREOUEST:60.0HRS.REPORTEDLESSONLEARNEDAREINCORPORATEDINTOTHEUCENSINGPROCESSANDFEBACKTOINDUSTRY.FORWARDCOMMENTSREGARDINGBURDENESTIMATTOTHEINFORMATIONANDRECORDSMANAGEMENTBRANCH(TWF33(US.NUCLEARREGIAATORYCOMMISSION,WASHINGTON,DC20666ENOIANDTOTHEPAPERWORKREDUCTIONPROJECT(3(600104I,OFRCE0MANAGEMENTANDBUDGET,WASHINGTON,DC20603.FACIUTYNAMEUISTLUCIEUNIT1TITLE(4IInadvertentRPSActuationDuetoPersonnelErrorDOCKETNINVIB(R(2(05000335PAGE(SI1OF4DAYYEAR498YEARSEOUENTIALREVISIONMONTHNUMBERNUMBER98,-001-0OAYYEAR398FACIUTYNAMEFACIUTYNAMEDOCKETNUMBER05000DOCKETNUMBER05000OPERATINQMODE(9)POWERLEVELl10)20.2201(b)20.2203(a)(2)6)20.2203{a)(2)(iii)20.2203(a)(2)(iv)20.2203(a)l2)(v)20.2203(a)(3)(ii)50.36(c)(1)50.36(c)(2)50.73(a)l2){i)50.73(a)(2)(iii)50.73(a){2){v)50.73(a)(2)(vii)50.73{0)l2)(viii)73.71OTHERSpecifyInAbstractbeloworinNRCForm366ANAMEK.W.Frehafer,LicensingEngineerTELEPHONENUMBERSrc(vdeArtaCodel(561)468-4284CAUSESYSTEMCOMPONENTMANUFACTURERREPORTABLETONPRDSCAUSESYSTEMCOMPONENTMANUFACTURERToNPRDSJCN/AN/AN/AYES{Ityes,completeEXPECTEDSUBMISSIONDATE).XNoEXPECTEDSUBMISSIONDATE(15)MONTHOAYYEARABSTRACT(Umitto1400spaces,l.e.,approximately15single-spacedtYpewrittenlines)(16)OnJanuary4,1998,Unit1wasatzeropercentpower,inMode3,withpressurizerpressurelessthan1750psig.Areactorplantheatuptonormaloperatingtemperatureandpressurefollowingrefuelingwasinprogress.Thereactortripbreakerswereclosedandallreactorcontrolelementassemblieswerefullyinserted.Theoperatorsweredirectedtoremovethezeropowermodebypasskeysforeachchannelofthereactorprotectionsystemoncethefourthreactorcoolantpumpwasstarted.Thereactortripbreakersopenedimmediatelyafterthereactorprotectionsystem'C'hannelzeropowermodebypasswasunbypassed.Thiseventwascausedbyproceduralinadequaciesandinadequateself-checkingbylicensedutilitypersonnel.Theproceduredidnotaddressplantconditionsnecessarytoensurethereactorprotectionsystemthermalmarginflowpressuretripsetpointwasbelowactualsystempressurewhenthezeropowermodebypasskeyswereoperated.Duringtheevent,plantconditionswouldhavesetthethermalmargin/lowpressuretripsetpointat1887psia,andactualreactorcoolantsystempressurewasapproximately1740psiawhenthereactorprotectionsystemzeropowermodebypasswasunbypassed.Additionally,theoperatorcontinuedwiththeunbypassingofthezeropowermodebypassanddidnotgivethecrewtimetoreviewthevalidityofthealarmsandensureallconditionsweresatisfactorypriortocompletingtheprocedure.Correctiveactionsincludedproceduralenhancements,counselingtheoperator,andcrewbriefingsontheevent.NRCFORM366{4.9S) | | LER98-001-00:on 980104,inadvertent RPSactuation occurredduetopersonnel error.Causedbyprocedural inadequacies |
| NRCFORM366AI4.9S)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIOST.LUCIEUNIT105000335YEARSEQUENTIALREVISION98-001-02OF4TEXT/ifmorespeceisrequired,useeddidonelcopiesofNRCForm36@A/I17]OnJanuary4,1998,Unit1wasatzeropercentpower,inMode3,withpressurizerpressurelessthan1750psig.AreactorplantheatuptonormaloperatingtemperatureandpressurefollowingrefuelingwasinprogressinaccordancewithNormalOperatingProcedureNOP-1-0030121,"ReactorPlantHeatup-ColdtoHotStandby."ReactorCoolantSystem(RCS)temperaturewasapproximately510'Fandpressurewasapproximately1700psia.ReactorTripCircuitBreakers(TCBs)[EIIS:JC:BKR]wereclosedandallreactorControlElementAssemblies(CEAs)[EIIS:AA]werefullyinserted.ThefourthReactorCoolantPump(RCP)[EIIS:AB:P],1A1,wassuccessfullystartedinaccordancewithstep6.5.12oftheheatupprocedure.Step6.5.13directsanoperatortoremovetheZeroPowerModeBypass(ZPMB)[EIIS:JC:33]keysforeachchanneloftheReactorProtectionSystem(RPS)[EIIS:JC]oncethefourthRCPisstarted.At1050,thereactoroperatorturnedtheZPMBkeyfrombypasstooffforRPSchannel'A'ndtheThermalMargin/LowPressure(TM/LP)triplockedin.Thereactoroperatorcontinued,withtheprocedureandturnedtheZPMBkeyfrombypasstooffforRPSchannels'B','C',and'D'nsequence.ItwasthennotedthattheTCBshadopened,anditwasconfirmedviatheSequenceofEventsRecorder(SOER)[EIIS:IQ]thattheTCBshadopenedimmediatelyafterRPSchannel'C'asunbypassed.TheoperatorsimmediatelyreturnedtheZPMBkeysbacktothebypassposition.ThiseventwascausedbyproceduralinadequaciesinprocedureNOP1-0030121,"ReactorPlantHeatup-ColdtoHotStandby."Inadequateself-checkingbylicensedutilitypersonnelcontributedtothisevent.ProcedureNOP1-0030121,"ReactorPlantHeatup-ColdtoHotStandby,"step6.5.13,directstheoperatorstoplacetheZPMBkeyfrombypasstooffafterthefourthRCPisstarted.However,theproceduredidnotaddressalltripfunctionspotentiallybypassedbytheZPMBkey.TheZPMBswitchisakeyoperatedswitch,oneforeachRPSchannel.TheZPMBallowstheRPSlowflowandTM/LPtripstobebypassedforsubcriticaltestingofcontrolelementdrivemechanisms;ThisRPSbypassisautomaticallyremovedwhenreactorpowerlevelincreasesaboveonepercentpower.ThelowflowtripisprovidedtoprotectthecoreagainstDeparturefromNucleateBoiling(DNB)intheeventofacoolantflowdecrease.Thelowflowtripisafunctionofmeasureddifferential.pressureacrossthesteamgeneratorsandthenumberofoperatingRCPs.NRCFORM366A(4-9S) y1 NRCFORM366AI4.96)LICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIOST.LUCIEUNIT105000335YEARSEQUENTIALREVISION98-001-03OF4TEXTllfmorespeceisrequired,useedditionelcopiesoffVRCForm3MAII17ICAUSEOFTHEEVENTcont'dTheTIVI/LPtripisprovidedfortwopurposes.Thelowpressurizerpressureportionofthetripfunctionstotripthereactorintheeventofalossofcoolantaccident.Thethermalmarginportionofthetrip,inconjunction.withthelowreactorcoolantflowtrip,isdesignedtopreventthereactorcoresafetylimitonDNBfrombeingviolatedduringanticipatedoperationaloccurrences.TheTM/LPtripsetpointiseitheracalculatedpressurevaluebasedonRCStemperature,powerandflow,oraminimumbiasedpressurevalueof1887psia.Duringtheevent,fourRCPswereoperating(ensuringthatalowflowtripwouldnotbepresent),butexistingplantconditionssettheTM/LPtripsetpointattheminimumbiasedpressurevalueof1887psia,TheZPMBkeyswereplacedfrombypasstooffwhileRCSpressurewasapproximately1740psia,whichresultedintheTM/LPtripandopeningthereactorTCBs.Additionally,personnelerrorbytheoperatorandoperatingcrewresultedinnotinvestigatingthecauseoftheTM/LPalarmswhentheywerereceivedastheRPSchannelZPMBkeysweresequentiallyplacedfrombypasstooff.Theoperatorcontinuedwiththeprocedureanddidnotgivethecrewtimetoreviewthevalidityofthealarmsandensureallconditionsweresatisfactorypriortocompletingtheprocedure.TheTCBsopenedwhenthethirdRPSchannelZPMBkeywasplacedfrombypasstooff,whichcompletedthecoincidencerequirementsfortheTM/LPreactortrip.St.LuciePlantmanagementexpectationsforlicensedoperatorresponsetounexpectedcontrolroomalarmsarethatthelicensedoperatoracknowledgingthealarmannouncethealarmtocontrolroompersonnelas"unexpected,"thatcontrolroomactivitiesstoptopermitinvestigationofthealarm,andthatactionsaretakeninaccordancewithplantalarmresponseprocedurestodeterminethecauseofthealarm.Suchactivitiesdidnotoccurduringthisevent.ThiseventisreportableasavalidactuationoftheRPSper10CFR50.73(a)(2)(iv).SinceremovingthebypassfromtheZPMBrestoredthecapabilityoftheTM/LPtripcircuitrytorespondtoanRCSlowpressurecondition,thiseventisconsideredavalidRPSactuationbasedonactualplantconditions.ItwasreportedtotheNRCasafourhourENSnotificationat1708hoursonJanuary5,1998.ThereactorwasshutdowninHotStandbypriortotheevent.AlthoughtheTCBswereopenedbyavalidRPSsignal,thereactortripsignaldidnotresultinanyphysicalchangetocorereactivitybecausetheCEAswerefullyinsertedpriortothetripsignal.Therefore,thiseventhadnoimpacttothehealthandsafetyofthepublic.NRCFOAM388AI4.96) | | &,inadequate self-checking by.licensedutilitypersonnel. |
| NRCFORM366AI4-9SILICENSEEEVENTREPORT(LER)TEXTCONTINUATIONU.S.NUCLEARREGULATORYCOMMISSIOST.LUCIEUNIT105000335YEARSEQUENTIALREVISION98-001-04OF4TEXT(Ifmorespeceisrequired,useeddilionelcopiesofftVRCRearm366AjI17)2.ProcedurechangestoNOP1-0030121andNOP2-0030121,"ReactorPlantHeatup-ColdtoHotStandby,"wereinitiatedtoensurethatafterthefourthRCPisstarted,theZPMBbypasskeysremaininbypassuntilpressureisgreaterthan1900psiaandnotripsarepresent.iTheoperatorwascounseled,andtheoperatorconductedbriefingsforeachoperatingcrewtodescribetheeventindetail,includingtheseriousnessoftheevent,theuseofselfchecking,andtheneedforinvolvementfromtheoperatingcrewwhenalarmsarereceived.3.PlacardshavebeenplacedinthecontrolroomsthatrequireeitherofthefollowingconditionsbemetpriortoplacingtheZPMBkeysfrombypasstooff:a)thereactorTCBSopen,orb)theunitatnormaloperatingtemperatureandpressure.NoneNoneNRCFORM386AI4.95)}} | | PlacardshavebeenplacedinCRs.W/980203 ltr.DISTRIBUTION CODE:IE22TCOPIESRECEIVED:LTR ENCLSIZE:TITLE:50.73/50.9 LicenseeEventReport(LER),IncidentRpt,etc.NOTES:'CRECIPIENT IDCODE/NAME PD2-3PDINTERNAL: |
| | ACRSAEOD/SPD/RRABNRR/DE/ECGB NRR/DE/EMEB NRR/DRCH/HICB NRR/DRCH/HQMB NRR/DSSA/SPLB RES/DET/EIB EXTERNAL: |
| | LSTLOBBYWARDNOACPOORE,W.NRCPDRCOPIESLTTRENCL111111111111111111111111RECIPIENT IDCODE/NAME WIENS,L.CgNRRDEEELBNRR/DRCH/HHFB NRR/DRCH/HOLB NRR/DRPM/PECB NRR/DSSA/SRXB RGN2FILEOlLITCOBRYCE,JHNOACQUEENER,DS NUDOCSFULLTXTCOPIESLTTRENCL112211111111111111111111NOTETOALL"RIDS"RECIPIENTS: |
| | PLEASEHELPUSTOREDUCEWASTE.TOHAVEYOURNAMEORORGANIZATION REMOVEDFROMDISTRIBUTION LIST>>ORREDUCETHENUMBEROFCOPIESRECEIVEDBYYOUORYOURORGANIZATION, CONTACTTHEDOCUMENTCONTROIDESK(DCD)ONEXTENSION 415-2083FULLTEXTCONVERSION REQUIREDTOTALNUMBEROFCOPIESREQUIRED: |
| | LTTR25ENCL25 FloridaPower&LightCompany,6351S.OceanDrive,JensenBeach,FL34957February3,1998L-98-01810CFR50.73U.S.NuclearRegulatory Commission Attn:DocumentControlDeskWashington, D.C.20555Re:St.LucieUnit1DocketNo.50-335Reportable Event:98-001DateofEvent:January4,1998Inadvertent RPSActuation DuetoPersonnel ErrorTheattachedLicenseeEventReportisbeingsubmitted pursuanttotherequirements of10CFR50.73.Verytrulyyours,J.A.StallVicePresident St.LuciePlantJAS/KWFAttachment cc:RegionalAdministrator, USNRC,RegionIISeniorResidentInspector, USNRC,St.LuciePlant'ir802ii0012 |
| | 'rr80203PDRADQCK050003358PDRllllllllllllllllllllllllll llllllllllll anFPLGroupcompany NRCFORM366(4.9e)U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)(Seereverseforrequirednumberofdigits/characters foreachbiock)APPROVEDSVOMBNo.S(60<0(O4 EXARES04/30/SSESTIMATED BURDENPERRESPONSETOCOMPLYWITHTHISMANDATORINFORMATION COLLECTION REOUEST:60.0HRS.REPORTEDLESSONLEARNEDAREINCORPORATED INTOTHEUCENSINGPROCESSANDFEBACKTOINDUSTRY. |
| | FORWARDCOMMENTSREGARDING BURDENESTIMATTOTHEINFORMATION ANDRECORDSMANAGEMENT BRANCH(TWF33(US.NUCLEARREGIAATORY COMMISSION, WASHINGTON, DC20666ENOIANDTOTHEPAPERWORK REDUCTION PROJECT(3(600104I, OFRCE0MANAGEMENT ANDBUDGET,WASHINGTON, DC20603.FACIUTYNAMEUISTLUCIEUNIT1TITLE(4IInadvertent RPSActuation DuetoPersonnel ErrorDOCKETNINVIB(R(2(05000335PAGE(SI1OF4DAYYEAR498YEARSEOUENTIAL REVISIONMONTHNUMBERNUMBER98,-001-0OAYYEAR398FACIUTYNAMEFACIUTYNAMEDOCKETNUMBER05000DOCKETNUMBER 05000OPERATINQ MODE(9)POWERLEVELl10)20.2201(b)20.2203(a)(2)6)20.2203{a) |
| | (2)(iii)20.2203(a)(2)(iv)20.2203(a) l2)(v)20.2203(a) |
| | (3)(ii)50.36(c)(1)50.36(c)(2)50.73(a)l2){i)50.73(a)(2)(iii)50.73(a){2){v)50.73(a)(2)(vii) 50.73{0)l2)(viii)73.71OTHERSpecifyInAbstractbeloworinNRCForm366ANAMEK.W.Frehafer, Licensing EngineerTELEPHONE NUMBERSrc(vdeArtaCodel(561)468-4284CAUSESYSTEMCOMPONENT MANUFACTURER REPORTABLE TONPRDSCAUSESYSTEMCOMPONENT MANUFACTURER ToNPRDSJCN/AN/AN/AYES{Ityes,completeEXPECTEDSUBMISSION DATE).XNoEXPECTEDSUBMISSION DATE(15)MONTHOAYYEARABSTRACT(Umitto1400spaces,l.e.,approximately 15single-spaced tYpewritten lines)(16)OnJanuary4,1998,Unit1wasatzeropercentpower,inMode3,withpressurizer pressurelessthan1750psig.Areactorplantheatuptonormaloperating temperature andpressurefollowing refueling wasinprogress. |
| | Thereactortripbreakerswereclosedandallreactorcontrolelementassemblies werefullyinserted. |
| | Theoperators weredirectedtoremovethezeropowermodebypasskeysforeachchannelofthereactorprotection systemoncethefourthreactorcoolantpumpwasstarted.Thereactortripbreakersopenedimmediately afterthereactorprotection system'C'hannel zeropowermodebypasswasunbypassed. |
| | Thiseventwascausedbyprocedural inadequacies andinadequate self-checking bylicensedutilitypersonnel. |
| | Theprocedure didnotaddressplantconditions necessary toensurethereactorprotection systemthermalmarginflow pressuretripsetpointwasbelowactualsystempressurewhenthezeropowermodebypasskeyswereoperated. |
| | Duringtheevent,plantconditions wouldhavesetthethermalmargin/low pressuretripsetpointat1887psia,andactualreactorcoolantsystempressurewasapproximately 1740psiawhenthereactorprotection systemzeropowermodebypasswasunbypassed. |
| | Additionally, theoperatorcontinued withtheunbypassing ofthezeropowermodebypassanddidnotgivethecrewtimetoreviewthevalidityofthealarmsandensureallconditions weresatisfactory priortocompleting theprocedure. |
| | Corrective actionsincludedprocedural enhancements, counseling theoperator, andcrewbriefings ontheevent.NRCFORM366{4.9S) |
| | NRCFORM366AI4.9S)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSIO ST.LUCIEUNIT105000335YEARSEQUENTIAL REVISION98-001-02OF4TEXT/ifmorespeceisrequired, useeddidonel copiesofNRCForm36@A/I17]OnJanuary4,1998,Unit1wasatzeropercentpower,inMode3,withpressurizer pressurelessthan1750psig.Areactorplantheatuptonormaloperating temperature andpressurefollowing refueling wasinprogressinaccordance withNormalOperating Procedure NOP-1-0030121, "ReactorPlantHeatup-ColdtoHotStandby." |
| | ReactorCoolantSystem(RCS)temperature wasapproximately 510'Fandpressurewasapproximately 1700psia.ReactorTripCircuitBreakers(TCBs)[EIIS:JC:BKR] |
| | wereclosedandallreactorControlElementAssemblies (CEAs)[EIIS:AA] |
| | werefullyinserted. |
| | ThefourthReactorCoolantPump(RCP)[EIIS:AB:P], |
| | 1A1,wassuccessfully startedinaccordance withstep6.5.12oftheheatupprocedure. |
| | Step6.5.13directsanoperatortoremovetheZeroPowerModeBypass(ZPMB)[EIIS:JC:33] |
| | keysforeachchanneloftheReactorProtection System(RPS)[EIIS:JC] |
| | oncethefourthRCPisstarted.At1050,thereactoroperatorturnedtheZPMBkeyfrombypasstooffforRPSchannel'A'ndtheThermalMargin/Low Pressure(TM/LP)triplockedin.Thereactoroperatorcontinued |
| | ,withtheprocedure andturnedtheZPMBkeyfrombypasstooffforRPSchannels'B','C',and'D'nsequence. |
| | ItwasthennotedthattheTCBshadopened,anditwasconfirmed viatheSequenceofEventsRecorder(SOER)[EIIS:IQ] |
| | thattheTCBshadopenedimmediately afterRPSchannel'C'asunbypassed. |
| | Theoperators immediately returnedtheZPMBkeysbacktothebypassposition. |
| | Thiseventwascausedbyprocedural inadequacies inprocedure NOP1-0030121, "ReactorPlantHeatup-ColdtoHotStandby." |
| | Inadequate self-checking bylicensedutilitypersonnel contributed tothisevent.Procedure NOP1-0030121, "ReactorPlantHeatup-ColdtoHotStandby," |
| | step6.5.13,directstheoperators toplacetheZPMBkeyfrombypasstooffafterthefourthRCPisstarted.However,theprocedure didnotaddressalltripfunctions potentially bypassedbytheZPMBkey.TheZPMBswitchisakeyoperatedswitch,oneforeachRPSchannel.TheZPMBallowstheRPSlowflowandTM/LPtripstobebypassedforsubcritical testingofcontrolelementdrivemechanisms; ThisRPSbypassisautomatically removedwhenreactorpowerlevelincreases aboveonepercentpower.ThelowflowtripisprovidedtoprotectthecoreagainstDeparture fromNucleateBoiling(DNB)intheeventofacoolantflowdecrease. |
| | Thelowflowtripisafunctionofmeasureddifferential. |
| | pressureacrossthesteamgenerators andthenumberofoperating RCPs.NRCFORM366A(4-9S) y1 NRCFORM366AI4.96)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSIO ST.LUCIEUNIT105000335YEARSEQUENTIAL REVISION98-001-03OF4TEXTllfmorespeceisrequired, useedditionel copiesoffVRCForm3MAII17ICAUSEOFTHEEVENTcont'dTheTIVI/LPtripisprovidedfortwopurposes. |
| | Thelowpressurizer pressureportionofthetripfunctions totripthereactorintheeventofalossofcoolantaccident. |
| | Thethermalmarginportionofthetrip,inconjunction. |
| | withthelowreactorcoolantflowtrip,isdesignedtopreventthereactorcoresafetylimitonDNBfrombeingviolatedduringanticipated operational occurrences. |
| | TheTM/LPtripsetpointiseitheracalculated pressurevaluebasedonRCStemperature, powerandflow,oraminimumbiasedpressurevalueof1887psia.Duringtheevent,fourRCPswereoperating (ensuring thatalowflowtripwouldnotbepresent), |
| | butexistingplantconditions settheTM/LPtripsetpointattheminimumbiasedpressurevalueof1887psia,TheZPMBkeyswereplacedfrombypasstooffwhileRCSpressurewasapproximately 1740psia,whichresultedintheTM/LPtripandopeningthereactorTCBs.Additionally, personnel errorbytheoperatorandoperating crewresultedinnotinvestigating thecauseoftheTM/LPalarmswhentheywerereceivedastheRPSchannelZPMBkeysweresequentially placedfrombypasstooff.Theoperatorcontinued withtheprocedure anddidnotgivethecrewtimetoreviewthevalidityofthealarmsandensureallconditions weresatisfactory priortocompleting theprocedure. |
| | TheTCBsopenedwhenthethirdRPSchannelZPMBkeywasplacedfrombypasstooff,whichcompleted thecoincidence requirements fortheTM/LPreactortrip.St.LuciePlantmanagement expectations forlicensedoperatorresponsetounexpected controlroomalarmsarethatthelicensedoperatoracknowledging thealarmannouncethealarmtocontrolroompersonnel as"unexpected," |
| | thatcontrolroomactivities stoptopermitinvestigation ofthealarm,andthatactionsaretakeninaccordance withplantalarmresponseprocedures todetermine thecauseofthealarm.Suchactivities didnotoccurduringthisevent.Thiseventisreportable asavalidactuation oftheRPSper10CFR50.73(a)(2)(iv). |
| | SinceremovingthebypassfromtheZPMBrestoredthecapability oftheTM/LPtripcircuitry torespondtoanRCSlowpressurecondition, thiseventisconsidered avalidRPSactuation basedonactualplantconditions. |
| | ItwasreportedtotheNRCasafourhourENSnotification at1708hoursonJanuary5,1998.ThereactorwasshutdowninHotStandbypriortotheevent.AlthoughtheTCBswereopenedbyavalidRPSsignal,thereactortripsignaldidnotresultinanyphysicalchangetocorereactivity becausetheCEAswerefullyinsertedpriortothetripsignal.Therefore, thiseventhadnoimpacttothehealthandsafetyofthepublic.NRCFOAM388AI4.96) |
| | NRCFORM366AI4-9SILICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSIO ST.LUCIEUNIT105000335YEARSEQUENTIAL REVISION98-001-04OF4TEXT(Ifmorespeceisrequired, useeddilionel copiesofftVRCRearm366AjI17)2.Procedure changestoNOP1-0030121 andNOP2-0030121, "ReactorPlantHeatup-ColdtoHotStandby," |
| | wereinitiated toensurethatafterthefourthRCPisstarted,theZPMBbypasskeysremaininbypassuntilpressureisgreaterthan1900psiaandnotripsarepresent.iTheoperatorwascounseled, andtheoperatorconducted briefings foreachoperating crewtodescribetheeventindetail,including theseriousness oftheevent,theuseofselfchecking, andtheneedforinvolvement fromtheoperating crewwhenalarmsarereceived. |
| | 3.Placardshavebeenplacedinthecontrolroomsthatrequireeitherofthefollowing conditions bemetpriortoplacingtheZPMBkeysfrombypasstooff:a)thereactorTCBSopen,orb)theunitatnormaloperating temperature andpressure. |
| | NoneNoneNRCFORM386AI4.95)}} |
|
---|
Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML17241A4891999-10-0707 October 1999 LER 99-004-00:on 990912,noted That MSSV Surveillance Was Outside of TS Requirements.Caused by Setpoint Drift.Subject MSSVs Are Being Refurbished & Retested Prior to Unit Startup from SL1-16 Refueling Outage.With 991007 Ltr ML17241A4111999-07-16016 July 1999 LER 99-007-00:on 990610,unplanned Cooldown Transient Occurred Due to Personnel Error.Trained & Briefed Personnel & Revised Procedures.With 990716 Ltr ML17241A4031999-07-0606 July 1999 LER 99-006-00:on 990605,sub-critical Reactor Trip Occurred Due to Inadvertent MSIV Opening.Caused by Personnel Error. Provided Operation Supervision Instruction to Operating Crews,Stand Down Meetings & Operator Aids.With 990706 Ltr ML17241A4041999-07-0606 July 1999 LER 99-005-00:on 990604,CEA Drop Resulted in Manual Reactor Trip.Caused by Procedural Inadequacies.Procedure Changes Are Planned to Correct Lack of Procedural Guidance for CEA Subgroup Power Switch Replacement.With 990706 Ltr ML17241A3941999-06-30030 June 1999 LER 99-004-01:on 990415,as Found Cycle 10 Psv Setpoints Were Outside TS Limits.Caused by Manufacturing Process Defect. All Three Psvs Were Replaced with pre-tested Valves During Cycle 11 Refueling Outage.With 990630 Ltr ML17241A3551999-06-0404 June 1999 LER 99-002-00:on 990505,both Trains of Safety Injection Actuation Were Blocked During Surveillance.Caused by Procedure Error.Procedure Revised.With 990604 Ltr ML17241A3321999-05-17017 May 1999 LER 99-004-00:on 990415,determined That as Found Cycle 10 Psv Setpoints Outside TS Limits.Root Cause Under Investigation.Psvs Replaced with pe-tested Valves During Cycle 11 ML17241A3271999-05-0606 May 1999 LER 99-003-00:on 990406,ECCS Suction Header Leak Resulted in Both ECCS Trains Being Inoperable & Entry Into TS 3.0.3. Caused by Chloride Induced OD Stress Corrosion Cracking of Piping.Made Code Repairs & Coated Piping.With 990506 Ltr ML17229B0791999-04-0707 April 1999 LER 99-001-00:on 990309,discovered Inadequate Design & IST SRs for Iodine Removal Sys (Irs).Caused by Original Design Inadequacies & Personnel Error.Naoh Tank Vent Valve V07233 Was Tagged Open.With 990407 Ltr ML17229B0801999-04-0707 April 1999 LER 99-002-00:on 990311,SG ECT Error Caused Operation with Condition Prohibited by Ts.Caused by Deficiencies in Data Analysis Guideline Instructions.Licensee Will Change Data Analysis Guidelines for Lead Analysts.With 990407 Ltr ML17229B0541999-03-10010 March 1999 LER 99-001-00:on 990211,inadequate TS SRs for SIT & SDC Isolation Valves Were Noted.Caused by Failure to Correctly Implement TS Srs.Submitted LAR to Align Required TS SR with Design Bases Requirements Being Verified.With 990310 Ltr ML17229A9901999-01-20020 January 1999 LER 98-009-00:on 981223,noted That Facility Operated Outside of Design Basis.Caused by non-conservative MSLB Analysis Inputs.Will Review SR Component Differences Between Units & Will re-baseline LTOP Analysis.With 990120 Ltr ML17229A9821999-01-0404 January 1999 LER 98-010-00:on 981207,RCS Boron Sample Frequency Required by Ts,Was Exceeded by Twelve Minutes.Caused by Personnel Error.Equipment Clearance Order Was Lifted to Draw Required Sample & Operations Procedure Was Changed.With 990104 Ltr ML17229A9611998-12-22022 December 1998 LER 97-002-01:on 981204,containment Sump Debris Screen Was Not IAW Design.Caused by Inadequate C/As for Sump Screen Anamolies.All Identified Sump Screen Deficiencies Were Dispositioned &/Or Repaired.With 981222 Ltr ML17229A9561998-12-15015 December 1998 LER 98-008-00:on 981118,missed TS SG U Tube Insp.Caused by Encoding Errors While Using Remote Positioning Fixtures.All SG Tube Surveyed.With 981215 Ltr ML17229A9301998-11-25025 November 1998 LER 98-005-01:on 980807,discovered That New MOV Methodology Caused Past PORV Block Valve Operability Problem.Caused by Inadequacies in Original Vendor MOV Methodology.Planned Valve Mods Will Be Implemented During Cycle 11 1998 Outage ML17229A9021998-11-0404 November 1998 LER 98-008-00:on 981008,inadequate Reactor Protection Sys Trip Bypass TS Was Noted.Caused by Poorly Worded Ts. Submitted LAR to Clarify Power Requirements for High Rate of Power Trips.With 981104 Ltr ML17229A8771998-10-14014 October 1998 LER 98-006-00:on 980918,inadvertent Afas Actuation Was Noted.Caused by Degradation of Multiple Afas Power Supplies. Replaced Afas Power Supplies & Revised Procedures.With 981014 Ltr ML17229A8761998-10-14014 October 1998 LER 98-007-00:on 980918,identified Discrepancies Between Fire Protection Design Requirements & Field Conditions. Caused by Inadequate Translation & Implementation of Fire Protection Requirements.Procedures Revised.With 981014 Ltr ML17229A8511998-09-0202 September 1998 LER 98-005-00:on 980807,discovered That PORV Margins Were Insufficient to Accommodate Addl Conservatism.Caused by Inadequacies in Original Vendor MOV Methodology.Will Implement Planned Valve Actuator mods.W/980902 Ltr ML17229A8201998-07-29029 July 1998 LER 98-007-00:on 980630,inadequate Procedure May Have Resulted in SBO Recovery Complications.Caused by Inadequate Procedures.Attached Caution Tags to Appropriate Control switches.W/980729 Ltr ML17229A7411998-05-28028 May 1998 LER 98-004-00:on 980430,discovered Waste Gas Decay Tank Operation W/O Available Oxygen Analyzers,Which Is Prohibited by Ts.Caused by Inadequate Licensee Review of License Amend. Oxygen Analyzer recalibrated.W/980528 Ltr ML17229A7381998-05-21021 May 1998 LER 98-006-00:on 980421,missed EDG Fuel Oil Sample Surveillance Was Noted.Caused by Personnel Error.Revised Fuel Oil Sampling Service Purchase Order & Revised Site procedure.W/980521 Ltr ML17229A7011998-04-27027 April 1998 LER 98-003-00:on 980326,discovered Containment Pressure Instrumentation Design Single Failure Vulnerability.Caused by Inadequate Design by Personnel Error.Removed RPS & ESFAS Containment Pressure Bypass Keys immediately.W/980427 Ltr ML17229A6761998-04-0202 April 1998 LER 98-005-00:on 980305,identified Two Conditions That Were Outside App R Design Bases.Caused by Design Oversight During Development of Original App R Safe SD Design.Established 30 Minute Roving Fire Watches & Provided training.W/980402 Ltr ML17229A6731998-03-26026 March 1998 LER 98-002-00:on 980224,radiation Monitor Surveillance Inadequacies Led to Operating of Facility Prohibited by Tss. Caused by Congnitive Personnel Error.Permanent Procedure Changes Were implemented.W/980326 Ltr ML17229A6551998-03-0505 March 1998 LER 98-001-00:on 980206,high/low Pressure Shutdown Cooling Interface Was Noted Outside App R Design Bases.Caused by Personnel Error.Addl Guidance Was Provided to Engineering Dept personnel.W/980305 Ltr ML17229A6281998-02-19019 February 1998 LER 98-004-00:on 980121,emergency Lighting Outside App R Design Bases Occurred.Caused by Congnitive Personnel Error During Translation of App R Section Iii.Procedures Onop 1 & 2 ONP-100.01 Were Issued for Use on 980206.W/980219 Ltr ML17229A6211998-02-0909 February 1998 LER 98-003-00:on 980110,manual Rt Due to DEH Leak at Turbine Test Block Was Noted.Caused by o-ring Extrusion.Shortened Bolts by About 0.125 & Reinstalled at Correct Torque values.W/980209 Ltr ML17229A6191998-02-0404 February 1998 LER 98-002-00:on 980105,CIS Bistable in Bypass Resulted in Condition Prohibited by Tss.Caused by Personnel Error. Radiation Monitor Was Restored to service.W/980204 Ltr ML17229A6161998-02-0303 February 1998 LER 98-001-00:on 980104,inadvertent RPS Actuation Occurred Due to Personnel Error.Caused by Procedural Inadequacies & Inadequate self-checking by Licensed Utility Personnel. Placards Have Been Placed in CRs.W/980203 Ltr ML17229A6051998-01-27027 January 1998 LER 97-010-01:on 971027,inadvertent Core Alteration Prohibited by TSs Were Noted Due to Stuck Cea.Caused by Personnel Error.Cea #24 Was Dislodged & Transferred to Spent Pool for insp.W/980127 Ltr ML17229A5501997-12-0505 December 1997 LER 97-008-00:on 971107,inadequate CR Ventilation Surveillance Resulted in Condition Prohibited by Ts.Caused by non-cognitive Personnel Error.Operating Procedure 2-1900050 Was revised.W/971205 Ltr ML17309A9091997-12-0202 December 1997 LER 97-011-00:on 971102,non-conservative RAS Set Point Resulted in Operation Prohibited by Ts.Caused by Inadequate Set Point & Instrument Loop Scaling Process.Revised ESFAS Functional Tp W/Proper Set point.W/971202 Ltr ML17229A5391997-11-26026 November 1997 LER 97-010-00:on 971027,inadvertant Core Alteration Prohibited by TS Occurred.Caused by CEA Failure to Detach from Ugs.Safety Evaluation Was Performed & Procedural Rev Made to Continue Upper Guide Structure move.W/971126 Ltr ML17229A5151997-11-0707 November 1997 LER 97-007-00:on 971008,inoperable Containment Cooling Fan Resulted in Operation of Facility Outside Design Basis. Caused by non-cognitive Personnel Error.Ccs Operation Was Revised & Issued on 971013.W/971107 Ltr ML17229A4991997-10-17017 October 1997 LER 97-009-00:on 970917,inoperable PORV Block Valve Resulted in Operation Prohibited by Tech Specs Occurred.Caused by Plant GL 89-10 Program Plan to Review Plant Manager Action Item Sys.Porv Block Valve V-1403 restored.W/971017 Ltr ML17309A9011997-08-27027 August 1997 LER 97-008-00:on 970728,mechanical Fire Penetrations Were Inoperable & Outside App R Design Bases.Caused by Seal Mfg Not Providing Formal Documentation for Installed Seals. Modified Inoperable Fire penetrations.W/970827 Ltr ML17229A4311997-07-29029 July 1997 LER 97-006-00:on 970630,discovered Inadequate Testing of Engineered Safety Features Subgroup Relays.Caused by Inadequacy in Implementing TS Requirements in Surveillance Procedures.Revised Surveillance procedures.W/970729 Ltr ML17229A4241997-07-25025 July 1997 LER 97-005-00:on 970625,discovered That Hot Shutdown Control Panel Shutdown Cooling Flow indicator,FI-3306 Inoperable. Caused by Weakness in Work Order & Procedure Used to Repair FI-3306.Section Meeting W/I&C Planners held.W/970725 Ltr ML17229A3971997-07-11011 July 1997 LER 97-004-00:on 970611,discovered Incorrect Original Cable Tray Fire Stop Assembly Installation Was Outside App R Design Basis.Caused by Personnel Error.Hourly Fire Watch Patrols Will Be posted.W/970711 Ltr ML17229A3871997-06-19019 June 1997 LER 97-003-00:on 970521,determined Required Post Maint Open Stroke Test for Valve V3245,2B2 SIT Discharge Check Valve, Had Not Been Performed.Caused by Personnel Error.Procedure revised.W/970619 Ltr ML17229A3841997-06-17017 June 1997 LER 97-002-00:on 970518,containment Sump Debris Screen Was Not IAW Design Due to Gaps in Screen Encl.Performed SER to Document Containment Sump Design requirements.W/970617 Ltr ML17229A3751997-06-0202 June 1997 LER 97-006-00:on 970501,operation Was Prohibited by TS Due to Inadequately Tested Degraded Voltage Sys.Revised Unit 1 ESFAS Surveillance Test procedure.W/970602 Ltr ML17229A3611997-05-29029 May 1997 LER 97-007-00:on 970502,reactor Coolant Pump Oil Collection Sys Was Outside App R Design Bases.Identified Leak Sites Were Repaired & Mods to RCP Oil Collection Sys to Capture Any Future Leakage from areas.W/970529 Ltr ML17229A3491997-05-21021 May 1997 LER 97-001-00:on 970423,containment Isolation Actuation Occurred.Caused by Increased Radiation Levels During Removal of Upper Guide Structure.Proper Actuation of Containment Isolation Components Was verified.W/970521 Ltr ML17229A3441997-05-13013 May 1997 LER 97-005-00:on 970419,reactor Was Shutdown Due to Reactor Coolant Pressure Boundary Leakage.Hot Cracking Was Caused by Weld Contamination.Repairs to RCPB Were Completed & 1A SDC Train Was Restored to Svc ML17229A3141997-04-30030 April 1997 LER 97-004-00:on 970402,refueling Machine Was Operating in Manner Prohibited by TS Due to Original Design of Refueling Machine Bypass Feature Conflicting W/Ts Requirements. Eliminated Overload Cut Off Limit bypass.W/970430 Ltr ML17229A2951997-03-31031 March 1997 LER 97-003-00:on 970304,automatic Rt Resulted from Loss of Electrical Power to 1A2 Rc Pump.Rcp Breaker Was Replaced & Pump Was Returned to svc.W/970331 Ltr ML17229A2721997-03-21021 March 1997 LER 97-002-00:on 970221,operation in Excess of Max Rated Thermal Power Occurred Due to Digital Data Processing Sys (Ddps) Calorimetric Error.Verified Acceptable Performance of Ddps Functions & Reviewed Software mods.W/970321 Ltr 1999-07-06
[Table view] Category:RO)
MONTHYEARML17241A4891999-10-0707 October 1999 LER 99-004-00:on 990912,noted That MSSV Surveillance Was Outside of TS Requirements.Caused by Setpoint Drift.Subject MSSVs Are Being Refurbished & Retested Prior to Unit Startup from SL1-16 Refueling Outage.With 991007 Ltr ML17241A4111999-07-16016 July 1999 LER 99-007-00:on 990610,unplanned Cooldown Transient Occurred Due to Personnel Error.Trained & Briefed Personnel & Revised Procedures.With 990716 Ltr ML17241A4031999-07-0606 July 1999 LER 99-006-00:on 990605,sub-critical Reactor Trip Occurred Due to Inadvertent MSIV Opening.Caused by Personnel Error. Provided Operation Supervision Instruction to Operating Crews,Stand Down Meetings & Operator Aids.With 990706 Ltr ML17241A4041999-07-0606 July 1999 LER 99-005-00:on 990604,CEA Drop Resulted in Manual Reactor Trip.Caused by Procedural Inadequacies.Procedure Changes Are Planned to Correct Lack of Procedural Guidance for CEA Subgroup Power Switch Replacement.With 990706 Ltr ML17241A3941999-06-30030 June 1999 LER 99-004-01:on 990415,as Found Cycle 10 Psv Setpoints Were Outside TS Limits.Caused by Manufacturing Process Defect. All Three Psvs Were Replaced with pre-tested Valves During Cycle 11 Refueling Outage.With 990630 Ltr ML17241A3551999-06-0404 June 1999 LER 99-002-00:on 990505,both Trains of Safety Injection Actuation Were Blocked During Surveillance.Caused by Procedure Error.Procedure Revised.With 990604 Ltr ML17241A3321999-05-17017 May 1999 LER 99-004-00:on 990415,determined That as Found Cycle 10 Psv Setpoints Outside TS Limits.Root Cause Under Investigation.Psvs Replaced with pe-tested Valves During Cycle 11 ML17241A3271999-05-0606 May 1999 LER 99-003-00:on 990406,ECCS Suction Header Leak Resulted in Both ECCS Trains Being Inoperable & Entry Into TS 3.0.3. Caused by Chloride Induced OD Stress Corrosion Cracking of Piping.Made Code Repairs & Coated Piping.With 990506 Ltr ML17229B0791999-04-0707 April 1999 LER 99-001-00:on 990309,discovered Inadequate Design & IST SRs for Iodine Removal Sys (Irs).Caused by Original Design Inadequacies & Personnel Error.Naoh Tank Vent Valve V07233 Was Tagged Open.With 990407 Ltr ML17229B0801999-04-0707 April 1999 LER 99-002-00:on 990311,SG ECT Error Caused Operation with Condition Prohibited by Ts.Caused by Deficiencies in Data Analysis Guideline Instructions.Licensee Will Change Data Analysis Guidelines for Lead Analysts.With 990407 Ltr ML17229B0541999-03-10010 March 1999 LER 99-001-00:on 990211,inadequate TS SRs for SIT & SDC Isolation Valves Were Noted.Caused by Failure to Correctly Implement TS Srs.Submitted LAR to Align Required TS SR with Design Bases Requirements Being Verified.With 990310 Ltr ML17229A9901999-01-20020 January 1999 LER 98-009-00:on 981223,noted That Facility Operated Outside of Design Basis.Caused by non-conservative MSLB Analysis Inputs.Will Review SR Component Differences Between Units & Will re-baseline LTOP Analysis.With 990120 Ltr ML17229A9821999-01-0404 January 1999 LER 98-010-00:on 981207,RCS Boron Sample Frequency Required by Ts,Was Exceeded by Twelve Minutes.Caused by Personnel Error.Equipment Clearance Order Was Lifted to Draw Required Sample & Operations Procedure Was Changed.With 990104 Ltr ML17229A9611998-12-22022 December 1998 LER 97-002-01:on 981204,containment Sump Debris Screen Was Not IAW Design.Caused by Inadequate C/As for Sump Screen Anamolies.All Identified Sump Screen Deficiencies Were Dispositioned &/Or Repaired.With 981222 Ltr ML17229A9561998-12-15015 December 1998 LER 98-008-00:on 981118,missed TS SG U Tube Insp.Caused by Encoding Errors While Using Remote Positioning Fixtures.All SG Tube Surveyed.With 981215 Ltr ML17229A9301998-11-25025 November 1998 LER 98-005-01:on 980807,discovered That New MOV Methodology Caused Past PORV Block Valve Operability Problem.Caused by Inadequacies in Original Vendor MOV Methodology.Planned Valve Mods Will Be Implemented During Cycle 11 1998 Outage ML17229A9021998-11-0404 November 1998 LER 98-008-00:on 981008,inadequate Reactor Protection Sys Trip Bypass TS Was Noted.Caused by Poorly Worded Ts. Submitted LAR to Clarify Power Requirements for High Rate of Power Trips.With 981104 Ltr ML17229A8771998-10-14014 October 1998 LER 98-006-00:on 980918,inadvertent Afas Actuation Was Noted.Caused by Degradation of Multiple Afas Power Supplies. Replaced Afas Power Supplies & Revised Procedures.With 981014 Ltr ML17229A8761998-10-14014 October 1998 LER 98-007-00:on 980918,identified Discrepancies Between Fire Protection Design Requirements & Field Conditions. Caused by Inadequate Translation & Implementation of Fire Protection Requirements.Procedures Revised.With 981014 Ltr ML17229A8511998-09-0202 September 1998 LER 98-005-00:on 980807,discovered That PORV Margins Were Insufficient to Accommodate Addl Conservatism.Caused by Inadequacies in Original Vendor MOV Methodology.Will Implement Planned Valve Actuator mods.W/980902 Ltr ML17229A8201998-07-29029 July 1998 LER 98-007-00:on 980630,inadequate Procedure May Have Resulted in SBO Recovery Complications.Caused by Inadequate Procedures.Attached Caution Tags to Appropriate Control switches.W/980729 Ltr ML17229A7411998-05-28028 May 1998 LER 98-004-00:on 980430,discovered Waste Gas Decay Tank Operation W/O Available Oxygen Analyzers,Which Is Prohibited by Ts.Caused by Inadequate Licensee Review of License Amend. Oxygen Analyzer recalibrated.W/980528 Ltr ML17229A7381998-05-21021 May 1998 LER 98-006-00:on 980421,missed EDG Fuel Oil Sample Surveillance Was Noted.Caused by Personnel Error.Revised Fuel Oil Sampling Service Purchase Order & Revised Site procedure.W/980521 Ltr ML17229A7011998-04-27027 April 1998 LER 98-003-00:on 980326,discovered Containment Pressure Instrumentation Design Single Failure Vulnerability.Caused by Inadequate Design by Personnel Error.Removed RPS & ESFAS Containment Pressure Bypass Keys immediately.W/980427 Ltr ML17229A6761998-04-0202 April 1998 LER 98-005-00:on 980305,identified Two Conditions That Were Outside App R Design Bases.Caused by Design Oversight During Development of Original App R Safe SD Design.Established 30 Minute Roving Fire Watches & Provided training.W/980402 Ltr ML17229A6731998-03-26026 March 1998 LER 98-002-00:on 980224,radiation Monitor Surveillance Inadequacies Led to Operating of Facility Prohibited by Tss. Caused by Congnitive Personnel Error.Permanent Procedure Changes Were implemented.W/980326 Ltr ML17229A6551998-03-0505 March 1998 LER 98-001-00:on 980206,high/low Pressure Shutdown Cooling Interface Was Noted Outside App R Design Bases.Caused by Personnel Error.Addl Guidance Was Provided to Engineering Dept personnel.W/980305 Ltr ML17229A6281998-02-19019 February 1998 LER 98-004-00:on 980121,emergency Lighting Outside App R Design Bases Occurred.Caused by Congnitive Personnel Error During Translation of App R Section Iii.Procedures Onop 1 & 2 ONP-100.01 Were Issued for Use on 980206.W/980219 Ltr ML17229A6211998-02-0909 February 1998 LER 98-003-00:on 980110,manual Rt Due to DEH Leak at Turbine Test Block Was Noted.Caused by o-ring Extrusion.Shortened Bolts by About 0.125 & Reinstalled at Correct Torque values.W/980209 Ltr ML17229A6191998-02-0404 February 1998 LER 98-002-00:on 980105,CIS Bistable in Bypass Resulted in Condition Prohibited by Tss.Caused by Personnel Error. Radiation Monitor Was Restored to service.W/980204 Ltr ML17229A6161998-02-0303 February 1998 LER 98-001-00:on 980104,inadvertent RPS Actuation Occurred Due to Personnel Error.Caused by Procedural Inadequacies & Inadequate self-checking by Licensed Utility Personnel. Placards Have Been Placed in CRs.W/980203 Ltr ML17229A6051998-01-27027 January 1998 LER 97-010-01:on 971027,inadvertent Core Alteration Prohibited by TSs Were Noted Due to Stuck Cea.Caused by Personnel Error.Cea #24 Was Dislodged & Transferred to Spent Pool for insp.W/980127 Ltr ML17229A5501997-12-0505 December 1997 LER 97-008-00:on 971107,inadequate CR Ventilation Surveillance Resulted in Condition Prohibited by Ts.Caused by non-cognitive Personnel Error.Operating Procedure 2-1900050 Was revised.W/971205 Ltr ML17309A9091997-12-0202 December 1997 LER 97-011-00:on 971102,non-conservative RAS Set Point Resulted in Operation Prohibited by Ts.Caused by Inadequate Set Point & Instrument Loop Scaling Process.Revised ESFAS Functional Tp W/Proper Set point.W/971202 Ltr ML17229A5391997-11-26026 November 1997 LER 97-010-00:on 971027,inadvertant Core Alteration Prohibited by TS Occurred.Caused by CEA Failure to Detach from Ugs.Safety Evaluation Was Performed & Procedural Rev Made to Continue Upper Guide Structure move.W/971126 Ltr ML17229A5151997-11-0707 November 1997 LER 97-007-00:on 971008,inoperable Containment Cooling Fan Resulted in Operation of Facility Outside Design Basis. Caused by non-cognitive Personnel Error.Ccs Operation Was Revised & Issued on 971013.W/971107 Ltr ML17229A4991997-10-17017 October 1997 LER 97-009-00:on 970917,inoperable PORV Block Valve Resulted in Operation Prohibited by Tech Specs Occurred.Caused by Plant GL 89-10 Program Plan to Review Plant Manager Action Item Sys.Porv Block Valve V-1403 restored.W/971017 Ltr ML17309A9011997-08-27027 August 1997 LER 97-008-00:on 970728,mechanical Fire Penetrations Were Inoperable & Outside App R Design Bases.Caused by Seal Mfg Not Providing Formal Documentation for Installed Seals. Modified Inoperable Fire penetrations.W/970827 Ltr ML17229A4311997-07-29029 July 1997 LER 97-006-00:on 970630,discovered Inadequate Testing of Engineered Safety Features Subgroup Relays.Caused by Inadequacy in Implementing TS Requirements in Surveillance Procedures.Revised Surveillance procedures.W/970729 Ltr ML17229A4241997-07-25025 July 1997 LER 97-005-00:on 970625,discovered That Hot Shutdown Control Panel Shutdown Cooling Flow indicator,FI-3306 Inoperable. Caused by Weakness in Work Order & Procedure Used to Repair FI-3306.Section Meeting W/I&C Planners held.W/970725 Ltr ML17229A3971997-07-11011 July 1997 LER 97-004-00:on 970611,discovered Incorrect Original Cable Tray Fire Stop Assembly Installation Was Outside App R Design Basis.Caused by Personnel Error.Hourly Fire Watch Patrols Will Be posted.W/970711 Ltr ML17229A3871997-06-19019 June 1997 LER 97-003-00:on 970521,determined Required Post Maint Open Stroke Test for Valve V3245,2B2 SIT Discharge Check Valve, Had Not Been Performed.Caused by Personnel Error.Procedure revised.W/970619 Ltr ML17229A3841997-06-17017 June 1997 LER 97-002-00:on 970518,containment Sump Debris Screen Was Not IAW Design Due to Gaps in Screen Encl.Performed SER to Document Containment Sump Design requirements.W/970617 Ltr ML17229A3751997-06-0202 June 1997 LER 97-006-00:on 970501,operation Was Prohibited by TS Due to Inadequately Tested Degraded Voltage Sys.Revised Unit 1 ESFAS Surveillance Test procedure.W/970602 Ltr ML17229A3611997-05-29029 May 1997 LER 97-007-00:on 970502,reactor Coolant Pump Oil Collection Sys Was Outside App R Design Bases.Identified Leak Sites Were Repaired & Mods to RCP Oil Collection Sys to Capture Any Future Leakage from areas.W/970529 Ltr ML17229A3491997-05-21021 May 1997 LER 97-001-00:on 970423,containment Isolation Actuation Occurred.Caused by Increased Radiation Levels During Removal of Upper Guide Structure.Proper Actuation of Containment Isolation Components Was verified.W/970521 Ltr ML17229A3441997-05-13013 May 1997 LER 97-005-00:on 970419,reactor Was Shutdown Due to Reactor Coolant Pressure Boundary Leakage.Hot Cracking Was Caused by Weld Contamination.Repairs to RCPB Were Completed & 1A SDC Train Was Restored to Svc ML17229A3141997-04-30030 April 1997 LER 97-004-00:on 970402,refueling Machine Was Operating in Manner Prohibited by TS Due to Original Design of Refueling Machine Bypass Feature Conflicting W/Ts Requirements. Eliminated Overload Cut Off Limit bypass.W/970430 Ltr ML17229A2951997-03-31031 March 1997 LER 97-003-00:on 970304,automatic Rt Resulted from Loss of Electrical Power to 1A2 Rc Pump.Rcp Breaker Was Replaced & Pump Was Returned to svc.W/970331 Ltr ML17229A2721997-03-21021 March 1997 LER 97-002-00:on 970221,operation in Excess of Max Rated Thermal Power Occurred Due to Digital Data Processing Sys (Ddps) Calorimetric Error.Verified Acceptable Performance of Ddps Functions & Reviewed Software mods.W/970321 Ltr 1999-07-06
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML17241A4891999-10-0707 October 1999 LER 99-004-00:on 990912,noted That MSSV Surveillance Was Outside of TS Requirements.Caused by Setpoint Drift.Subject MSSVs Are Being Refurbished & Retested Prior to Unit Startup from SL1-16 Refueling Outage.With 991007 Ltr ML17241A4951999-09-30030 September 1999 Monthly Operating Repts for Sept 1999 for St Lucie,Units 1 & 2.With 991014 Ltr ML17241A4741999-08-31031 August 1999 Rev 1 to PCM 99016, St Lucie Unit 1,Cycle 16 Colr. ML17241A4591999-08-31031 August 1999 Monthly Operating Repts for Aug 1999 for St Lucie,Units 1 & 2.With 990913 Ltr ML17241A4301999-07-31031 July 1999 Monthly Operating Repts for Jul 1999 for St Lucie Units 1 & 2.With 990805 Ltr ML17241A4111999-07-16016 July 1999 LER 99-007-00:on 990610,unplanned Cooldown Transient Occurred Due to Personnel Error.Trained & Briefed Personnel & Revised Procedures.With 990716 Ltr ML17241A4031999-07-0606 July 1999 LER 99-006-00:on 990605,sub-critical Reactor Trip Occurred Due to Inadvertent MSIV Opening.Caused by Personnel Error. Provided Operation Supervision Instruction to Operating Crews,Stand Down Meetings & Operator Aids.With 990706 Ltr ML17241A4041999-07-0606 July 1999 LER 99-005-00:on 990604,CEA Drop Resulted in Manual Reactor Trip.Caused by Procedural Inadequacies.Procedure Changes Are Planned to Correct Lack of Procedural Guidance for CEA Subgroup Power Switch Replacement.With 990706 Ltr ML17241A4091999-06-30030 June 1999 Monthly Operating Repts for June 1999 for St Lucie,Units 1 & 2.With 990712 Ltr ML17241A3941999-06-30030 June 1999 LER 99-004-01:on 990415,as Found Cycle 10 Psv Setpoints Were Outside TS Limits.Caused by Manufacturing Process Defect. All Three Psvs Were Replaced with pre-tested Valves During Cycle 11 Refueling Outage.With 990630 Ltr ML17355A3681999-06-30030 June 1999 Revised Update to Topical QA Rept, Dtd June 1999 ML17241A3551999-06-0404 June 1999 LER 99-002-00:on 990505,both Trains of Safety Injection Actuation Were Blocked During Surveillance.Caused by Procedure Error.Procedure Revised.With 990604 Ltr ML17241A3631999-05-31031 May 1999 Monthly Operating Repts for May 1999 for St Lucie Units 1 & 2.With 990610 Ltr ML17241A3321999-05-17017 May 1999 LER 99-004-00:on 990415,determined That as Found Cycle 10 Psv Setpoints Outside TS Limits.Root Cause Under Investigation.Psvs Replaced with pe-tested Valves During Cycle 11 ML17241A3271999-05-0606 May 1999 LER 99-003-00:on 990406,ECCS Suction Header Leak Resulted in Both ECCS Trains Being Inoperable & Entry Into TS 3.0.3. Caused by Chloride Induced OD Stress Corrosion Cracking of Piping.Made Code Repairs & Coated Piping.With 990506 Ltr ML17241A3331999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for St Lucie,Units 1 & 2.With 990517 Ltr ML17229B0801999-04-0707 April 1999 LER 99-002-00:on 990311,SG ECT Error Caused Operation with Condition Prohibited by Ts.Caused by Deficiencies in Data Analysis Guideline Instructions.Licensee Will Change Data Analysis Guidelines for Lead Analysts.With 990407 Ltr ML17229B0841999-04-0707 April 1999 Rev 2 to PSL-ENG-SEMS-98-102, Engineering Evaluation of ECCS Suction Lines. ML17229B0791999-04-0707 April 1999 LER 99-001-00:on 990309,discovered Inadequate Design & IST SRs for Iodine Removal Sys (Irs).Caused by Original Design Inadequacies & Personnel Error.Naoh Tank Vent Valve V07233 Was Tagged Open.With 990407 Ltr ML17229B0961999-03-31031 March 1999 Monthly Operating Repts for Mar 1999 for St Lucie,Units 1 & 2.With 990408 Ltr ML17229B0541999-03-10010 March 1999 LER 99-001-00:on 990211,inadequate TS SRs for SIT & SDC Isolation Valves Were Noted.Caused by Failure to Correctly Implement TS Srs.Submitted LAR to Align Required TS SR with Design Bases Requirements Being Verified.With 990310 Ltr ML17229B0461999-02-28028 February 1999 Monthly Operating Repts for Feb 1999 for St Lucie,Units 1 & 2.With 990310 Ltr ML17229B0051999-01-31031 January 1999 Monthly Operating Repts for Jan 1999 for St Lucie,Units 1 & 2.With 990211 Ltr ML17229A9901999-01-20020 January 1999 LER 98-009-00:on 981223,noted That Facility Operated Outside of Design Basis.Caused by non-conservative MSLB Analysis Inputs.Will Review SR Component Differences Between Units & Will re-baseline LTOP Analysis.With 990120 Ltr ML17229A9961999-01-14014 January 1999 SG Tube Inservice Insp Special Rept. ML17229A9821999-01-0404 January 1999 LER 98-010-00:on 981207,RCS Boron Sample Frequency Required by Ts,Was Exceeded by Twelve Minutes.Caused by Personnel Error.Equipment Clearance Order Was Lifted to Draw Required Sample & Operations Procedure Was Changed.With 990104 Ltr ML17229A9831998-12-31031 December 1998 Monthly Operating Repts for Dec 1998 for St Lucie,Units 1 & 2.With 990111 Ltr ML17229A9611998-12-22022 December 1998 LER 97-002-01:on 981204,containment Sump Debris Screen Was Not IAW Design.Caused by Inadequate C/As for Sump Screen Anamolies.All Identified Sump Screen Deficiencies Were Dispositioned &/Or Repaired.With 981222 Ltr ML17229A9561998-12-15015 December 1998 LER 98-008-00:on 981118,missed TS SG U Tube Insp.Caused by Encoding Errors While Using Remote Positioning Fixtures.All SG Tube Surveyed.With 981215 Ltr ML17241A3581998-12-0909 December 1998 Changes,Tests & Experiments Made as Allowed by 10CFR50.59 for Period of 970526-981209. ML17229A9421998-11-30030 November 1998 Monthly Operating Repts for Nov 1998 for St Lucie,Units 1 & 2.With 981215 Ltr ML17229A9301998-11-25025 November 1998 LER 98-005-01:on 980807,discovered That New MOV Methodology Caused Past PORV Block Valve Operability Problem.Caused by Inadequacies in Original Vendor MOV Methodology.Planned Valve Mods Will Be Implemented During Cycle 11 1998 Outage ML17229A9021998-11-0404 November 1998 LER 98-008-00:on 981008,inadequate Reactor Protection Sys Trip Bypass TS Was Noted.Caused by Poorly Worded Ts. Submitted LAR to Clarify Power Requirements for High Rate of Power Trips.With 981104 Ltr ML17241A4931998-11-0101 November 1998 Statement of Account for Period of 981101-990930 for Suntrust Bank,As Trustee for Florida Municipal Power Agency Nuclear Decommissioning Trust (St Lucie Project). ML17229A9051998-10-31031 October 1998 Monthly Operating Repts for Oct 1998 for St Lucie,Units 1 & 2.With 981110 Ltr ML17229A8871998-10-19019 October 1998 Part 21 Rept Re Potential Defect in Swagelok Stainless Steel Front Ferrule,Part Number SS-503-1 Which Was Machined with Improper Length.C/A Includes Insp Equipment That Will 100% Identify Short Length ML17229A8781998-10-19019 October 1998 Part 21 Rept Re Potential Defect in Swagelok Stainless Steel Front Ferrule,Part Number SS-503-1,which Was Machined with Improper Length.Insp Equipment That Will 100% Identify Short Length ML17229A8771998-10-14014 October 1998 LER 98-006-00:on 980918,inadvertent Afas Actuation Was Noted.Caused by Degradation of Multiple Afas Power Supplies. Replaced Afas Power Supplies & Revised Procedures.With 981014 Ltr ML17229A8761998-10-14014 October 1998 LER 98-007-00:on 980918,identified Discrepancies Between Fire Protection Design Requirements & Field Conditions. Caused by Inadequate Translation & Implementation of Fire Protection Requirements.Procedures Revised.With 981014 Ltr ML17229A8721998-09-30030 September 1998 Monthly Operating Repts for Sept 1998 for St Lucie Units 1 & 2.With 981009 Ltr ML17229A8511998-09-0202 September 1998 LER 98-005-00:on 980807,discovered That PORV Margins Were Insufficient to Accommodate Addl Conservatism.Caused by Inadequacies in Original Vendor MOV Methodology.Will Implement Planned Valve Actuator mods.W/980902 Ltr ML17229A8611998-08-31031 August 1998 Monthly Operating Repts for Aug 1998 for St Lucie,Units 1 & 2.With 980911 Ltr ML18066A2771998-08-13013 August 1998 Part 21 Rept Re Deficiency in CE Current Screening Methodology for Determining Limiting Fuel Assembly for Detailed PWR thermal-hydraulic Sa.Evaluations Were Performed for Affected Plants to Determine Effect of Deficiency ML17229A8481998-08-0707 August 1998 Rev 1 to PSL-ENG-SEFJ-98-013, St Lucie Unit 2,Cycle 10 Colr. ML17229A9461998-08-0707 August 1998 Rev 0 to PCM 98016, St Lucie Unit 2,Cycle 11 Colr. ML17229A8301998-07-31031 July 1998 Monthly Operating Repts for July 1998 for St Lucie,Units 1 & 2.W/980814 Ltr ML17229A8201998-07-29029 July 1998 LER 98-007-00:on 980630,inadequate Procedure May Have Resulted in SBO Recovery Complications.Caused by Inadequate Procedures.Attached Caution Tags to Appropriate Control switches.W/980729 Ltr ML17229A7981998-06-30030 June 1998 Monthly Operating Repts for June 1998 for St Lucie,Units 1 & 2.W/980713 Ltr ML17229A7701998-05-31031 May 1998 Monthly Operating Repts for May 1998 for St Lucie,Units 1 & 2.W/980612 Ltr ML17229A7411998-05-28028 May 1998 LER 98-004-00:on 980430,discovered Waste Gas Decay Tank Operation W/O Available Oxygen Analyzers,Which Is Prohibited by Ts.Caused by Inadequate Licensee Review of License Amend. Oxygen Analyzer recalibrated.W/980528 Ltr 1999-09-30
[Table view] |
Text
CATEGORY1~REGULARLY INFORMATION DISTRIBUTIOF%YSTEM (RIDS)p)*ACCESSION NBR:9802110012 DOC.DATE:
98/02/03NOTARIZED:
NOFACIL:50-335 St.LuciePlant,Unit1,FloridaPower&LightCo.AUTH.NAMEAUTHORAFFILIATION FREiIXFER,K.W.
FloridaPower&LightCo.-STALL,J.A.
FloridaPower&LightCo.RECIP.NAME RECIPIENT AFFILIATION DOCKET¹05000335
SUBJECT:
LER98-001-00:on 980104,inadvertent RPSactuation occurredduetopersonnel error.Causedbyprocedural inadequacies
&,inadequate self-checking by.licensedutilitypersonnel.
PlacardshavebeenplacedinCRs.W/980203 ltr.DISTRIBUTION CODE:IE22TCOPIESRECEIVED:LTR ENCLSIZE:TITLE:50.73/50.9 LicenseeEventReport(LER),IncidentRpt,etc.NOTES:'CRECIPIENT IDCODE/NAME PD2-3PDINTERNAL:
ACRSAEOD/SPD/RRABNRR/DE/ECGB NRR/DE/EMEB NRR/DRCH/HICB NRR/DRCH/HQMB NRR/DSSA/SPLB RES/DET/EIB EXTERNAL:
LSTLOBBYWARDNOACPOORE,W.NRCPDRCOPIESLTTRENCL111111111111111111111111RECIPIENT IDCODE/NAME WIENS,L.CgNRRDEEELBNRR/DRCH/HHFB NRR/DRCH/HOLB NRR/DRPM/PECB NRR/DSSA/SRXB RGN2FILEOlLITCOBRYCE,JHNOACQUEENER,DS NUDOCSFULLTXTCOPIESLTTRENCL112211111111111111111111NOTETOALL"RIDS"RECIPIENTS:
PLEASEHELPUSTOREDUCEWASTE.TOHAVEYOURNAMEORORGANIZATION REMOVEDFROMDISTRIBUTION LIST>>ORREDUCETHENUMBEROFCOPIESRECEIVEDBYYOUORYOURORGANIZATION, CONTACTTHEDOCUMENTCONTROIDESK(DCD)ONEXTENSION 415-2083FULLTEXTCONVERSION REQUIREDTOTALNUMBEROFCOPIESREQUIRED:
LTTR25ENCL25 FloridaPower&LightCompany,6351S.OceanDrive,JensenBeach,FL34957February3,1998L-98-01810CFR50.73U.S.NuclearRegulatory Commission Attn:DocumentControlDeskWashington, D.C.20555Re:St.LucieUnit1DocketNo.50-335Reportable Event:98-001DateofEvent:January4,1998Inadvertent RPSActuation DuetoPersonnel ErrorTheattachedLicenseeEventReportisbeingsubmitted pursuanttotherequirements of10CFR50.73.Verytrulyyours,J.A.StallVicePresident St.LuciePlantJAS/KWFAttachment cc:RegionalAdministrator, USNRC,RegionIISeniorResidentInspector, USNRC,St.LuciePlant'ir802ii0012
'rr80203PDRADQCK050003358PDRllllllllllllllllllllllllll llllllllllll anFPLGroupcompany NRCFORM366(4.9e)U.S.NUCLEARREGULATORY COMMISSION LICENSEEEVENTREPORT(LER)(Seereverseforrequirednumberofdigits/characters foreachbiock)APPROVEDSVOMBNo.S(60<0(O4 EXARES04/30/SSESTIMATED BURDENPERRESPONSETOCOMPLYWITHTHISMANDATORINFORMATION COLLECTION REOUEST:60.0HRS.REPORTEDLESSONLEARNEDAREINCORPORATED INTOTHEUCENSINGPROCESSANDFEBACKTOINDUSTRY.
FORWARDCOMMENTSREGARDING BURDENESTIMATTOTHEINFORMATION ANDRECORDSMANAGEMENT BRANCH(TWF33(US.NUCLEARREGIAATORY COMMISSION, WASHINGTON, DC20666ENOIANDTOTHEPAPERWORK REDUCTION PROJECT(3(600104I, OFRCE0MANAGEMENT ANDBUDGET,WASHINGTON, DC20603.FACIUTYNAMEUISTLUCIEUNIT1TITLE(4IInadvertent RPSActuation DuetoPersonnel ErrorDOCKETNINVIB(R(2(05000335PAGE(SI1OF4DAYYEAR498YEARSEOUENTIAL REVISIONMONTHNUMBERNUMBER98,-001-0OAYYEAR398FACIUTYNAMEFACIUTYNAMEDOCKETNUMBER05000DOCKETNUMBER 05000OPERATINQ MODE(9)POWERLEVELl10)20.2201(b)20.2203(a)(2)6)20.2203{a)
(2)(iii)20.2203(a)(2)(iv)20.2203(a) l2)(v)20.2203(a)
(3)(ii)50.36(c)(1)50.36(c)(2)50.73(a)l2){i)50.73(a)(2)(iii)50.73(a){2){v)50.73(a)(2)(vii) 50.73{0)l2)(viii)73.71OTHERSpecifyInAbstractbeloworinNRCForm366ANAMEK.W.Frehafer, Licensing EngineerTELEPHONE NUMBERSrc(vdeArtaCodel(561)468-4284CAUSESYSTEMCOMPONENT MANUFACTURER REPORTABLE TONPRDSCAUSESYSTEMCOMPONENT MANUFACTURER ToNPRDSJCN/AN/AN/AYES{Ityes,completeEXPECTEDSUBMISSION DATE).XNoEXPECTEDSUBMISSION DATE(15)MONTHOAYYEARABSTRACT(Umitto1400spaces,l.e.,approximately 15single-spaced tYpewritten lines)(16)OnJanuary4,1998,Unit1wasatzeropercentpower,inMode3,withpressurizer pressurelessthan1750psig.Areactorplantheatuptonormaloperating temperature andpressurefollowing refueling wasinprogress.
Thereactortripbreakerswereclosedandallreactorcontrolelementassemblies werefullyinserted.
Theoperators weredirectedtoremovethezeropowermodebypasskeysforeachchannelofthereactorprotection systemoncethefourthreactorcoolantpumpwasstarted.Thereactortripbreakersopenedimmediately afterthereactorprotection system'C'hannel zeropowermodebypasswasunbypassed.
Thiseventwascausedbyprocedural inadequacies andinadequate self-checking bylicensedutilitypersonnel.
Theprocedure didnotaddressplantconditions necessary toensurethereactorprotection systemthermalmarginflow pressuretripsetpointwasbelowactualsystempressurewhenthezeropowermodebypasskeyswereoperated.
Duringtheevent,plantconditions wouldhavesetthethermalmargin/low pressuretripsetpointat1887psia,andactualreactorcoolantsystempressurewasapproximately 1740psiawhenthereactorprotection systemzeropowermodebypasswasunbypassed.
Additionally, theoperatorcontinued withtheunbypassing ofthezeropowermodebypassanddidnotgivethecrewtimetoreviewthevalidityofthealarmsandensureallconditions weresatisfactory priortocompleting theprocedure.
Corrective actionsincludedprocedural enhancements, counseling theoperator, andcrewbriefings ontheevent.NRCFORM366{4.9S)
NRCFORM366AI4.9S)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSIO ST.LUCIEUNIT105000335YEARSEQUENTIAL REVISION98-001-02OF4TEXT/ifmorespeceisrequired, useeddidonel copiesofNRCForm36@A/I17]OnJanuary4,1998,Unit1wasatzeropercentpower,inMode3,withpressurizer pressurelessthan1750psig.Areactorplantheatuptonormaloperating temperature andpressurefollowing refueling wasinprogressinaccordance withNormalOperating Procedure NOP-1-0030121, "ReactorPlantHeatup-ColdtoHotStandby."
ReactorCoolantSystem(RCS)temperature wasapproximately 510'Fandpressurewasapproximately 1700psia.ReactorTripCircuitBreakers(TCBs)[EIIS:JC:BKR]
wereclosedandallreactorControlElementAssemblies (CEAs)[EIIS:AA]
werefullyinserted.
ThefourthReactorCoolantPump(RCP)[EIIS:AB:P],
1A1,wassuccessfully startedinaccordance withstep6.5.12oftheheatupprocedure.
Step6.5.13directsanoperatortoremovetheZeroPowerModeBypass(ZPMB)[EIIS:JC:33]
keysforeachchanneloftheReactorProtection System(RPS)[EIIS:JC]
oncethefourthRCPisstarted.At1050,thereactoroperatorturnedtheZPMBkeyfrombypasstooffforRPSchannel'A'ndtheThermalMargin/Low Pressure(TM/LP)triplockedin.Thereactoroperatorcontinued
,withtheprocedure andturnedtheZPMBkeyfrombypasstooffforRPSchannels'B','C',and'D'nsequence.
ItwasthennotedthattheTCBshadopened,anditwasconfirmed viatheSequenceofEventsRecorder(SOER)[EIIS:IQ]
thattheTCBshadopenedimmediately afterRPSchannel'C'asunbypassed.
Theoperators immediately returnedtheZPMBkeysbacktothebypassposition.
Thiseventwascausedbyprocedural inadequacies inprocedure NOP1-0030121, "ReactorPlantHeatup-ColdtoHotStandby."
Inadequate self-checking bylicensedutilitypersonnel contributed tothisevent.Procedure NOP1-0030121, "ReactorPlantHeatup-ColdtoHotStandby,"
step6.5.13,directstheoperators toplacetheZPMBkeyfrombypasstooffafterthefourthRCPisstarted.However,theprocedure didnotaddressalltripfunctions potentially bypassedbytheZPMBkey.TheZPMBswitchisakeyoperatedswitch,oneforeachRPSchannel.TheZPMBallowstheRPSlowflowandTM/LPtripstobebypassedforsubcritical testingofcontrolelementdrivemechanisms; ThisRPSbypassisautomatically removedwhenreactorpowerlevelincreases aboveonepercentpower.ThelowflowtripisprovidedtoprotectthecoreagainstDeparture fromNucleateBoiling(DNB)intheeventofacoolantflowdecrease.
Thelowflowtripisafunctionofmeasureddifferential.
pressureacrossthesteamgenerators andthenumberofoperating RCPs.NRCFORM366A(4-9S) y1 NRCFORM366AI4.96)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSIO ST.LUCIEUNIT105000335YEARSEQUENTIAL REVISION98-001-03OF4TEXTllfmorespeceisrequired, useedditionel copiesoffVRCForm3MAII17ICAUSEOFTHEEVENTcont'dTheTIVI/LPtripisprovidedfortwopurposes.
Thelowpressurizer pressureportionofthetripfunctions totripthereactorintheeventofalossofcoolantaccident.
Thethermalmarginportionofthetrip,inconjunction.
withthelowreactorcoolantflowtrip,isdesignedtopreventthereactorcoresafetylimitonDNBfrombeingviolatedduringanticipated operational occurrences.
TheTM/LPtripsetpointiseitheracalculated pressurevaluebasedonRCStemperature, powerandflow,oraminimumbiasedpressurevalueof1887psia.Duringtheevent,fourRCPswereoperating (ensuring thatalowflowtripwouldnotbepresent),
butexistingplantconditions settheTM/LPtripsetpointattheminimumbiasedpressurevalueof1887psia,TheZPMBkeyswereplacedfrombypasstooffwhileRCSpressurewasapproximately 1740psia,whichresultedintheTM/LPtripandopeningthereactorTCBs.Additionally, personnel errorbytheoperatorandoperating crewresultedinnotinvestigating thecauseoftheTM/LPalarmswhentheywerereceivedastheRPSchannelZPMBkeysweresequentially placedfrombypasstooff.Theoperatorcontinued withtheprocedure anddidnotgivethecrewtimetoreviewthevalidityofthealarmsandensureallconditions weresatisfactory priortocompleting theprocedure.
TheTCBsopenedwhenthethirdRPSchannelZPMBkeywasplacedfrombypasstooff,whichcompleted thecoincidence requirements fortheTM/LPreactortrip.St.LuciePlantmanagement expectations forlicensedoperatorresponsetounexpected controlroomalarmsarethatthelicensedoperatoracknowledging thealarmannouncethealarmtocontrolroompersonnel as"unexpected,"
thatcontrolroomactivities stoptopermitinvestigation ofthealarm,andthatactionsaretakeninaccordance withplantalarmresponseprocedures todetermine thecauseofthealarm.Suchactivities didnotoccurduringthisevent.Thiseventisreportable asavalidactuation oftheRPSper10CFR50.73(a)(2)(iv).
SinceremovingthebypassfromtheZPMBrestoredthecapability oftheTM/LPtripcircuitry torespondtoanRCSlowpressurecondition, thiseventisconsidered avalidRPSactuation basedonactualplantconditions.
ItwasreportedtotheNRCasafourhourENSnotification at1708hoursonJanuary5,1998.ThereactorwasshutdowninHotStandbypriortotheevent.AlthoughtheTCBswereopenedbyavalidRPSsignal,thereactortripsignaldidnotresultinanyphysicalchangetocorereactivity becausetheCEAswerefullyinsertedpriortothetripsignal.Therefore, thiseventhadnoimpacttothehealthandsafetyofthepublic.NRCFOAM388AI4.96)
NRCFORM366AI4-9SILICENSEEEVENTREPORT(LER)TEXTCONTINUATION U.S.NUCLEARREGULATORY COMMISSIO ST.LUCIEUNIT105000335YEARSEQUENTIAL REVISION98-001-04OF4TEXT(Ifmorespeceisrequired, useeddilionel copiesofftVRCRearm366AjI17)2.Procedure changestoNOP1-0030121 andNOP2-0030121, "ReactorPlantHeatup-ColdtoHotStandby,"
wereinitiated toensurethatafterthefourthRCPisstarted,theZPMBbypasskeysremaininbypassuntilpressureisgreaterthan1900psiaandnotripsarepresent.iTheoperatorwascounseled, andtheoperatorconducted briefings foreachoperating crewtodescribetheeventindetail,including theseriousness oftheevent,theuseofselfchecking, andtheneedforinvolvement fromtheoperating crewwhenalarmsarereceived.
3.Placardshavebeenplacedinthecontrolroomsthatrequireeitherofthefollowing conditions bemetpriortoplacingtheZPMBkeysfrombypasstooff:a)thereactorTCBSopen,orb)theunitatnormaloperating temperature andpressure.
NoneNoneNRCFORM386AI4.95)