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| * A CA.15" *N*7?GY COMPANV PALISADES NRC Form 388 (9*83) LICENSEE EVENT REPORT (LERI U.s: NUCLEAR REGULATORY COMMISSION APPROVED OMB NO. 3150-<>104 EXPIRES: B/31 /86 FACILITY.NAME (1) DOCKET NUMBER (2) PAGE (3) Palisades Plant . o_ I 5 I 0 I 0 I 0 I 2 I 5 I 5 -1 I OF 0 I 4. rmE <41 LICENSEE. | | * A CA.15" *N*7?GY COMPANV PALISADES NRC Form 388 (9*83) LICENSEE EVENT REPORT (LERI U.s: NUCLEAR REGULATORY COMMISSION APPROVED OMB NO. 3150-<>104 EXPIRES: B/31 /86 FACILITY.NAME (1) DOCKET NUMBER (2) PAGE (3) Palisades Plant . o_ I 5 I 0 I 0 I 0 I 2 I 5 I 5 -1 I OF 0 I 4. rmE <41 LICENSEE. |
| EVENT.REPORT 92-033 INOPERABLE CONTROL ROOM PENETRATION DUE TO INACCURATE AND MISAPPLICATION OF PROCEDURES . EVENT DATE !61 LER NUMBER (81 REP9RT DATE (8) OTHER FACILITIES INVOLVED (Bl ************ | | EVENT.REPORT 92-033 INOPERABLE CONTROL ROOM PENETRATION DUE TO INACCURATE AND MISAPPLICATION OF PROCEDURES . EVENT DATE !61 LER NUMBER (81 REP9RT DATE (8) OTHER FACILITIES INVOLVED (Bl ************ |
| SEQUENTIAL REVISl.ON FACILITY NAMES' MONTH DAY YEAR YEAR NUMBER NUMBER MONTH DAY YEAR N/A 0151010101 912 -ol3l3 -'-olo 615 1 I 5 912 0161010101 014 1 14 9 2 N/A THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS.OF 10 CFR 1: IChttck °""or"""° of tJi. following} | | SEQUENTIAL REVISl.ON FACILITY NAMES' MONTH DAY YEAR YEAR NUMBER NUMBER MONTH DAY YEAR N/A 0151010101 912 -ol3l3 -'-olo 615 1 I 5 912 0161010101 014 1 14 9 2 N/A THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS.OF 10 CFR 1: IChttck °""or"""° of tJi. following} |
| (111 -------NAME 20.4061cl 60.38(cll1 I 60.38(c)(2) 60.731*112)(i) 60.73(o)(2)(iil 60.73(o)(2)(iii) | | (111 -------NAME 20.4061cl 60.38(cll1 I 60.38(c)(2) 60.731*112)(i) 60.73(o)(2)(iil 60.73(o)(2)(iii) |
| LICENSEE CONTACT FOR THIS LER (121 60. 7 31*1 (2 I (viiil!Al | | LICENSEE CONTACT FOR THIS LER (121 60. 7 31*1 (2 I (viiil!Al |
| : 60. 7 3111121(viiil!BI 60.7:iioH2Hxl William L. Roberts, Staff Licensing Engineer COMPLETE ONE LINE FOR EACH CO.MPONENT FAILURE DESCRIBED IN THIS REPORT (131 MANUFAC* REPORTABLE ' ' J | | : 60. 7 3111121(viiil!BI 60.7:iioH2Hxl William L. Roberts, Staff Licensing Engineer COMPLETE ONE LINE FOR EACH CO.MPONENT FAILURE DESCRIBED IN THIS REPORT (131 MANUFAC* REPORTABLE ' ' J |
| * CAUSE SYSTEM COMPONENT TUR ER TO NPRDS CAUSE SYSTEM COMPONENT I I I I I I L | | * CAUSE SYSTEM COMPONENT TUR ER TO NPRDS CAUSE SYSTEM COMPONENT I I I I I I L |
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Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML18066A6271999-09-0202 September 1999 LER 98-011-01:on 981217,inadequate Lube Oil Collection Sys for Primary Coolant Pumps Was Noted.Caused by Design Change Not Containing Appropriate Level of Rigor.Exemption from 10CFR50,App R Was Requested.With 990902 Ltr ML18066A6221999-08-20020 August 1999 LER 99-002-00:on 990722,TS Surveillance Was Not Completed within Specified Frequency.Caused by Failure to Incorporate Revised Frequency Into Surveillance Schedule in Timely Manner.Verified Implementation.With 990820 Ltr ML18066A3781999-01-20020 January 1999 LER 98-013-00:on 981222,safeguards Transfer Tap Changer Failure Caused Inadvertant DG Start.Caused by Failed Motor Contactor.Contactor Was Replaced.With 990120 Ltr ML18068A4851998-10-29029 October 1998 LER 97-011-01:on 971012,starting of Primary Coolant Pump with SG Temps Greater than Cold Leg Temps Occurred.Caused by Inadequate Procedures & Operator Decision.Sop Used for Starting Primary Coolant Pump Enhanced ML18066A2831998-08-18018 August 1998 LER 98-010-00:on 980721,reactor Manually Tripped.Caused by Failure of Coupling Which Drives Feedwater Pump Main Lube Oil Pump.Main Lube Oil Pump Coupling & Associated Components Replaced & Satisfactorily Tested ML18066A2261998-06-30030 June 1998 LER 98-009-00:on 980531,small Pinhole Leak Found on One of Welds,During Leak Test Following Replacement of Pcs Sample Isolation Valves.Caused by Welder Error.Leaking Welds Repaired ML18066A1781998-06-0909 June 1998 LER 98-008-00:on 980511,noted That Procedure Did Not Fully Satisfy Requirement to Test High Startup Rate Trip Function. Caused by Misunderstanding of Testing Requirements.Revised TS Surveillance Test Procedure & Reviewed Other Procedures ML18065B2451998-05-13013 May 1998 LER 98-007-00:on 980413,HPIS Sys Was Noted Inoperable During TS Surveillance Test.Caused by Performance of Flawed Procedure.Operators & Engineers Will Be Trained to Improve Operational Decision Making Through Resources & Knowledge ML18065B1151997-12-0909 December 1997 LER 97-013-00:on 971110,failure to Closure Test Two Check Valves Resulted in Violation of TS 6.5.7 Occurred.Caused by Close Function for Check Valves.Check Valves Tested to Confirm Proper Closure Capability ML18067A7751997-11-11011 November 1997 LER 97-011-00:on 971012,primary Coolant Pump Was Started W/Sg Temperatures Greater than Cold Leg Temperature.Caused by Inadequate Procedures & Operator Decision Making.Critique of Event Conducted W/Operators Involved ML18067A7581997-10-30030 October 1997 LER 97-010-00:on 970930,determined That Inadequacy in App R Analysis Resulted in Condition Outside Design Basis of Plant.Caused by Missing Cable in Circuit & Raceway Schedule. Developed New Evaluation Re ASD Valves Validation ML18067A7461997-10-23023 October 1997 LER 97-009-00:on 970923,discovered Procedure Weakness Re Implementation of App R Shutdown Methodology.Caused by Human Error.Revised Off-Normal Procedure ONP-25.2, Alternate Safe Shutdown Procedure. ML18067A7191997-10-10010 October 1997 LER 97-008-00:on 970912,spurious Valve Operation Could Result in Loss of Shutdown Capabilities Per 10CFR50,App R, Section Iii.L,Was Discovered.Caused by Failure to Validate Info from App R.Design Bases for SW Backup Reviewed ML18067A6951997-09-24024 September 1997 LER 97-007-00:on 970826,discovered Inadequate Testing of DG Sequencer Control Relay Contacts.Caused by Oversight on Part of Personnel Involved in Installation of Facility Change FC-800.Tested 106D-1/XL & 106D-2/XL Relay Contacts ML18067A5651997-06-0303 June 1997 LER 96-013-01:on 961115,DC Breaker Failed During Testing for as-found Trip Setting.Failure Caused by Oversight within Preventive Maint Program.Breaker Was Replaced & Tested ML18067A5461997-05-12012 May 1997 LER 97-006-00:on 970412,overtime Limits Were Exceeded for Radiation Protection Technicians.Caused by Inadequate Design,Review & Proper Verifications of Overtime Work Schedule.Communicate Overtime Limitation Responsibilities ML18067A4431997-03-24024 March 1997 LER 97-004-00:on 970221,trip of High Pressure Safety Injection Pump Occurred While Filling Safety Injection Tank Resulting in TS Violation.Caused by Particle Lodged Between Surface of Indication disk.Y-phase Relay Was OOS ML18067A4391997-03-21021 March 1997 LER 97-005-00:on 961220,operation of Plant Outside Design Basis Occurred Due to an Unacceptable Repair on Main Steam Isolation Valves.Pipe Plugs Permanently Repaired ML18067A4401997-03-21021 March 1997 LER 97-003-00:on 961101,four Piping Lines Were Determined to Be Potentially Susceptible to Pressurization Due to Containment Temperature Increase During an Accident.Cac Discharge Piping Will Be verified.W/970321 Ltr ML18066A8931997-02-21021 February 1997 LER 97-002-00:on 970123,failure to Meet TSs 4.5.2d(1)(b) for Testing of Emergency Escape Airlock Occurred.Caused by Missed Surveillance.Emergency Escape Air Lock Testing Was Completed & Declared operable.W/970221 Ltr ML18066A8751997-02-0505 February 1997 LER 97-001-00:on 970106,TAVE Temp Dropped Below Minimum Temp for Criticality.Caused by Control Rod Withdrawal Rate to Increase Power Not Sufficient to Match Increase in Steam. Turbine Bypass Valve Actuator repaired.W/970205 Ltr ML18066A8041996-12-23023 December 1996 LER 96-014-00:on 961124,class 1E Raychem Cable Splices Were Installed Incorrectly.Caused by Incorrectly Made Electrical Splices.Total of 270 Splices Have Been Replaced within Containment ML18066A7831996-12-16016 December 1996 LER 96-013-00:on 961115,DC Breaker Failure During Testing for as-found Trip Setting Occurred.Cause Under Investigation.All molded-case Circuit Breakers in DC Distribution Panels Were Replaced ML18065A9951996-10-0404 October 1996 LER 96-002-01:on 960116,initiated TS Required Shutdown Due to Safeguards Cable Fault.Both Sets (Six Cables) of Cables Were Replaced & Installed Through Turbine Generator Bldg ML18065A9171996-09-0909 September 1996 LER 95-012-00:on 960809,TS Violation Occurred,Due to No Senior Reactor Operator in Cr.Caused by Extensive Remodeling.Cr Remodeling completed.W/960909 Ltr ML18065A8961996-08-29029 August 1996 LER 96-011-00:on 960730,CR Continuous Air Monitor Alarm Setpoint Improperly Established.Caused by Failure to Utilize Mod Process in 1988 Leading to Failure to Properly Select & Calibrate Instruments ML18065A8811996-08-20020 August 1996 LER 96-005-01:on 960207,determined Fuse on Main Supply to Two Safety Related DC Panels & Panel Branch Circuit Breakers Not Properly Coordinated.Caused by Lack of Thorough Associated Circuits Analysis.Supply Fuse to Panels Replaced ML18065A8741996-08-16016 August 1996 LER 96-010-00:on 960717,high Pressure Safety Injection Pump Tripped While Filling Safety Injection Tank.Caused by Faulty 150/151Y-207 Time Overcurrent Relay.All Similar Relays in Time Overcurrent Application Have Been Inspected ML18065A8651996-08-12012 August 1996 LER 96-009-00:on 960712,identified Penetration Seal Deficiency on Fire Barriers Caused by Failure to Perform & Document Comprehensive Fire Barrier Evaluation.Developed Basis document.W/960812 Ltr ML18065A8601996-08-0202 August 1996 LER 96-006-01 on 960207,discovered Limits of Design Analysis Could Have Been Violated.Subsequent Tests & Analyses Facility Did Not Exceed Basis.Operating Procedures Have Been Revised to Treat 2530 Megawatts Limit as Absolute Limit ML18065A8321996-08-0101 August 1996 LER 96-003-01:on 960115,alternate Shutdown Panel Inverter Resulted in Unavailability of Panel.Replaced Defective Inverter Alarm Logic Board ML18065A7691996-06-12012 June 1996 LER 96-008-00:on 960513,fire Door Not Maintained Open in Accordance W/Design Basis.Cause Under Investigation. Engineering Evaluation Performed & Revised Documents, Surveillance & Test procedures.W/960612 Ltr ML18065A6901996-05-0101 May 1996 LER 95-001-01:on 950302,malfunction of Left Channel DBA Sequencer Resulted in Inadvertent Actuation of Left Channel Safeguards Equipment.Replaced microprocessor.W/960501 Ltr ML18065A6681996-04-22022 April 1996 LER 96-007-00:on 960321,inadequate Emergency Lighting & Ventilation in post-fire Safe Shutdown Areas.Caused by App R Program Documentation Insufficient to Demonstrate Regulatory Compliance.Lighting modified.W/960422 Ltr ML18065A5721996-03-11011 March 1996 LER 96-006-00:on 960207,average Reactor Power Level Exceeded License Limit Due to Insufficient Procedural Guidance. GOP-12 Revised to Treat 2,530 Mwt Limit as Absolute Limit Requiring Immediate Corrective Action If Exceeded ML18065A5261996-03-0101 March 1996 LER 96-005-00:on 960202,fuse on Main Supply to Two SR DC Panels & Panel Branch Circuit Breakers Not Properly Coordinated.Caused by Inadequate Electrical/App R Design Review.Implemented Hourly Fire tours.W/960301 Ltr ML18065A5111996-02-19019 February 1996 LER 94-012-02:on 940427,determined That Internal Ground in Thermal Margin Monitor Causes Nonconformance W/Rps Design Basis.Incorporated RPS Failure Modes & Effects Analysis in Plant DBD.W/960219 Ltr ML18065A5061996-02-19019 February 1996 LER 96-004-00:on 960118,SIS Disabled W/Primary Coolant Sys Greater than 300 F.Caused by Personnel Error.Permanent Maint Procedure to Disable/Enable SIS Actuation on Low Pressurizer Pressure Will Be Revised to Align W/Ts ML18065A5021996-02-15015 February 1996 LER 96-003-00:on 960115,technicians Found Low Voltage cut- Off for Alternate Shutdown Panel Inverter Set That Resulted in Unavailability of Panel.Caused by Inadequate Post Mod. Readjusted Set Point to Minimum setting.W/960215 Ltr ML18065A4581996-01-31031 January 1996 LER 96-001-00:on 960103,failed to Test Duplicate Equipment. Caused by STS No Longer Containing Requirement for cross- Train Testing of Duplicate Components.Will Submit Request to Delete Subj Requirements from TS.W/960131 Ltr ML18065A4421996-01-19019 January 1996 LER 95-016-00:on 951226,did Not Analyze Primary Coolant Samples within 72 H.Caused by Belief Acceptability to Save Pcs Samples for Choride Analysis Past 72 H.Counseled Chemistry Supervision.W/960119 Ltr ML18065A4041996-01-15015 January 1996 LER 95-014-00:on 950119,PCP Oil Collection Deficiencies Created by FC-860 Piping Mod.Caused by Inadequate DBD for Sys & Lack of Review by Experienced Fire Protection Personnel.Updated Design Basis documentation.W/960115 Ltr ML18065A3291995-12-0404 December 1995 LER 95-013-00:on 951103,circuit Fuse Coordination Deficiency Which Affects App R Safe Shutdown Equipment Noted.Design of Fuse Coordination in Potential Transformer Circuits Will Be Evaluated & Modified as required.W/951204 Ltr ML18065A2361995-11-0202 November 1995 LER 95-012-00:on 950701,discovered Unqualified Electrical Connection in Containment SW Outlet Valve Controller.Caused by Failure of Assigned Engineers to Available Info.Replaced Wire Nuts W/Inline Butt connections.W/951102 Ltr ML18065A2051995-10-20020 October 1995 LER 95-008-01:on 950728,discovered That None of Four Containment High Pressure Channels Would Initiate Reactor Trip Due to Programmatic Deficiencies.Administrative Procedure (AP) 9.44,AP 9.45 & AP 10.44 Will Be Revised ML18065A0841995-09-18018 September 1995 LER 95-011-00:on 950817,CR 40 Withdrawal Occurred When Given Insertion Signal Due to skill-based Error in Crimping & Removing Foreign Matl from CRDM Motor Connection Box.Crd Package replaced.W/950918 Ltr ML18065A0681995-09-14014 September 1995 LER 95-010-00:on 950815,ESFA Resulted in Manual Rt Following Isolation of Pcs.Replaced Failed Instrument Line ML18065A0651995-09-0808 September 1995 LER 95-009-00:on 950728,discovered Lack of Procedural Guidance for Pump Repair Following Fire.Proposed Use of Power Supply Breaker Did Not Adequately Address Effect of Loss of Control Power.Performed Independent Assessment ML18064A8781995-08-28028 August 1995 LER 95-008-00:on 950728,discovered During Design Change Testing That None of Four Containment High Pressure Channels Would Initiate Rt.Caused by Programmatic Deficiencies. Reviewed Selected Tests & Mods from Recent Refueling Outage ML18064A8831995-08-21021 August 1995 LER 95-007-00:on 950720,discovered That 12 Instrument Loops Had V-bolted Type Qualified Cable Splices Connected to Wires W/Exposed Kapton Insulation.Caused by Human Error.All V- Bolted Splices Replaced w/in-line design.W/950821 Ltr 1999-09-02
[Table view] Category:RO)
MONTHYEARML18066A6271999-09-0202 September 1999 LER 98-011-01:on 981217,inadequate Lube Oil Collection Sys for Primary Coolant Pumps Was Noted.Caused by Design Change Not Containing Appropriate Level of Rigor.Exemption from 10CFR50,App R Was Requested.With 990902 Ltr ML18066A6221999-08-20020 August 1999 LER 99-002-00:on 990722,TS Surveillance Was Not Completed within Specified Frequency.Caused by Failure to Incorporate Revised Frequency Into Surveillance Schedule in Timely Manner.Verified Implementation.With 990820 Ltr ML18066A3781999-01-20020 January 1999 LER 98-013-00:on 981222,safeguards Transfer Tap Changer Failure Caused Inadvertant DG Start.Caused by Failed Motor Contactor.Contactor Was Replaced.With 990120 Ltr ML18068A4851998-10-29029 October 1998 LER 97-011-01:on 971012,starting of Primary Coolant Pump with SG Temps Greater than Cold Leg Temps Occurred.Caused by Inadequate Procedures & Operator Decision.Sop Used for Starting Primary Coolant Pump Enhanced ML18066A2831998-08-18018 August 1998 LER 98-010-00:on 980721,reactor Manually Tripped.Caused by Failure of Coupling Which Drives Feedwater Pump Main Lube Oil Pump.Main Lube Oil Pump Coupling & Associated Components Replaced & Satisfactorily Tested ML18066A2261998-06-30030 June 1998 LER 98-009-00:on 980531,small Pinhole Leak Found on One of Welds,During Leak Test Following Replacement of Pcs Sample Isolation Valves.Caused by Welder Error.Leaking Welds Repaired ML18066A1781998-06-0909 June 1998 LER 98-008-00:on 980511,noted That Procedure Did Not Fully Satisfy Requirement to Test High Startup Rate Trip Function. Caused by Misunderstanding of Testing Requirements.Revised TS Surveillance Test Procedure & Reviewed Other Procedures ML18065B2451998-05-13013 May 1998 LER 98-007-00:on 980413,HPIS Sys Was Noted Inoperable During TS Surveillance Test.Caused by Performance of Flawed Procedure.Operators & Engineers Will Be Trained to Improve Operational Decision Making Through Resources & Knowledge ML18065B1151997-12-0909 December 1997 LER 97-013-00:on 971110,failure to Closure Test Two Check Valves Resulted in Violation of TS 6.5.7 Occurred.Caused by Close Function for Check Valves.Check Valves Tested to Confirm Proper Closure Capability ML18067A7751997-11-11011 November 1997 LER 97-011-00:on 971012,primary Coolant Pump Was Started W/Sg Temperatures Greater than Cold Leg Temperature.Caused by Inadequate Procedures & Operator Decision Making.Critique of Event Conducted W/Operators Involved ML18067A7581997-10-30030 October 1997 LER 97-010-00:on 970930,determined That Inadequacy in App R Analysis Resulted in Condition Outside Design Basis of Plant.Caused by Missing Cable in Circuit & Raceway Schedule. Developed New Evaluation Re ASD Valves Validation ML18067A7461997-10-23023 October 1997 LER 97-009-00:on 970923,discovered Procedure Weakness Re Implementation of App R Shutdown Methodology.Caused by Human Error.Revised Off-Normal Procedure ONP-25.2, Alternate Safe Shutdown Procedure. ML18067A7191997-10-10010 October 1997 LER 97-008-00:on 970912,spurious Valve Operation Could Result in Loss of Shutdown Capabilities Per 10CFR50,App R, Section Iii.L,Was Discovered.Caused by Failure to Validate Info from App R.Design Bases for SW Backup Reviewed ML18067A6951997-09-24024 September 1997 LER 97-007-00:on 970826,discovered Inadequate Testing of DG Sequencer Control Relay Contacts.Caused by Oversight on Part of Personnel Involved in Installation of Facility Change FC-800.Tested 106D-1/XL & 106D-2/XL Relay Contacts ML18067A5651997-06-0303 June 1997 LER 96-013-01:on 961115,DC Breaker Failed During Testing for as-found Trip Setting.Failure Caused by Oversight within Preventive Maint Program.Breaker Was Replaced & Tested ML18067A5461997-05-12012 May 1997 LER 97-006-00:on 970412,overtime Limits Were Exceeded for Radiation Protection Technicians.Caused by Inadequate Design,Review & Proper Verifications of Overtime Work Schedule.Communicate Overtime Limitation Responsibilities ML18067A4431997-03-24024 March 1997 LER 97-004-00:on 970221,trip of High Pressure Safety Injection Pump Occurred While Filling Safety Injection Tank Resulting in TS Violation.Caused by Particle Lodged Between Surface of Indication disk.Y-phase Relay Was OOS ML18067A4391997-03-21021 March 1997 LER 97-005-00:on 961220,operation of Plant Outside Design Basis Occurred Due to an Unacceptable Repair on Main Steam Isolation Valves.Pipe Plugs Permanently Repaired ML18067A4401997-03-21021 March 1997 LER 97-003-00:on 961101,four Piping Lines Were Determined to Be Potentially Susceptible to Pressurization Due to Containment Temperature Increase During an Accident.Cac Discharge Piping Will Be verified.W/970321 Ltr ML18066A8931997-02-21021 February 1997 LER 97-002-00:on 970123,failure to Meet TSs 4.5.2d(1)(b) for Testing of Emergency Escape Airlock Occurred.Caused by Missed Surveillance.Emergency Escape Air Lock Testing Was Completed & Declared operable.W/970221 Ltr ML18066A8751997-02-0505 February 1997 LER 97-001-00:on 970106,TAVE Temp Dropped Below Minimum Temp for Criticality.Caused by Control Rod Withdrawal Rate to Increase Power Not Sufficient to Match Increase in Steam. Turbine Bypass Valve Actuator repaired.W/970205 Ltr ML18066A8041996-12-23023 December 1996 LER 96-014-00:on 961124,class 1E Raychem Cable Splices Were Installed Incorrectly.Caused by Incorrectly Made Electrical Splices.Total of 270 Splices Have Been Replaced within Containment ML18066A7831996-12-16016 December 1996 LER 96-013-00:on 961115,DC Breaker Failure During Testing for as-found Trip Setting Occurred.Cause Under Investigation.All molded-case Circuit Breakers in DC Distribution Panels Were Replaced ML18065A9951996-10-0404 October 1996 LER 96-002-01:on 960116,initiated TS Required Shutdown Due to Safeguards Cable Fault.Both Sets (Six Cables) of Cables Were Replaced & Installed Through Turbine Generator Bldg ML18065A9171996-09-0909 September 1996 LER 95-012-00:on 960809,TS Violation Occurred,Due to No Senior Reactor Operator in Cr.Caused by Extensive Remodeling.Cr Remodeling completed.W/960909 Ltr ML18065A8961996-08-29029 August 1996 LER 96-011-00:on 960730,CR Continuous Air Monitor Alarm Setpoint Improperly Established.Caused by Failure to Utilize Mod Process in 1988 Leading to Failure to Properly Select & Calibrate Instruments ML18065A8811996-08-20020 August 1996 LER 96-005-01:on 960207,determined Fuse on Main Supply to Two Safety Related DC Panels & Panel Branch Circuit Breakers Not Properly Coordinated.Caused by Lack of Thorough Associated Circuits Analysis.Supply Fuse to Panels Replaced ML18065A8741996-08-16016 August 1996 LER 96-010-00:on 960717,high Pressure Safety Injection Pump Tripped While Filling Safety Injection Tank.Caused by Faulty 150/151Y-207 Time Overcurrent Relay.All Similar Relays in Time Overcurrent Application Have Been Inspected ML18065A8651996-08-12012 August 1996 LER 96-009-00:on 960712,identified Penetration Seal Deficiency on Fire Barriers Caused by Failure to Perform & Document Comprehensive Fire Barrier Evaluation.Developed Basis document.W/960812 Ltr ML18065A8601996-08-0202 August 1996 LER 96-006-01 on 960207,discovered Limits of Design Analysis Could Have Been Violated.Subsequent Tests & Analyses Facility Did Not Exceed Basis.Operating Procedures Have Been Revised to Treat 2530 Megawatts Limit as Absolute Limit ML18065A8321996-08-0101 August 1996 LER 96-003-01:on 960115,alternate Shutdown Panel Inverter Resulted in Unavailability of Panel.Replaced Defective Inverter Alarm Logic Board ML18065A7691996-06-12012 June 1996 LER 96-008-00:on 960513,fire Door Not Maintained Open in Accordance W/Design Basis.Cause Under Investigation. Engineering Evaluation Performed & Revised Documents, Surveillance & Test procedures.W/960612 Ltr ML18065A6901996-05-0101 May 1996 LER 95-001-01:on 950302,malfunction of Left Channel DBA Sequencer Resulted in Inadvertent Actuation of Left Channel Safeguards Equipment.Replaced microprocessor.W/960501 Ltr ML18065A6681996-04-22022 April 1996 LER 96-007-00:on 960321,inadequate Emergency Lighting & Ventilation in post-fire Safe Shutdown Areas.Caused by App R Program Documentation Insufficient to Demonstrate Regulatory Compliance.Lighting modified.W/960422 Ltr ML18065A5721996-03-11011 March 1996 LER 96-006-00:on 960207,average Reactor Power Level Exceeded License Limit Due to Insufficient Procedural Guidance. GOP-12 Revised to Treat 2,530 Mwt Limit as Absolute Limit Requiring Immediate Corrective Action If Exceeded ML18065A5261996-03-0101 March 1996 LER 96-005-00:on 960202,fuse on Main Supply to Two SR DC Panels & Panel Branch Circuit Breakers Not Properly Coordinated.Caused by Inadequate Electrical/App R Design Review.Implemented Hourly Fire tours.W/960301 Ltr ML18065A5111996-02-19019 February 1996 LER 94-012-02:on 940427,determined That Internal Ground in Thermal Margin Monitor Causes Nonconformance W/Rps Design Basis.Incorporated RPS Failure Modes & Effects Analysis in Plant DBD.W/960219 Ltr ML18065A5061996-02-19019 February 1996 LER 96-004-00:on 960118,SIS Disabled W/Primary Coolant Sys Greater than 300 F.Caused by Personnel Error.Permanent Maint Procedure to Disable/Enable SIS Actuation on Low Pressurizer Pressure Will Be Revised to Align W/Ts ML18065A5021996-02-15015 February 1996 LER 96-003-00:on 960115,technicians Found Low Voltage cut- Off for Alternate Shutdown Panel Inverter Set That Resulted in Unavailability of Panel.Caused by Inadequate Post Mod. Readjusted Set Point to Minimum setting.W/960215 Ltr ML18065A4581996-01-31031 January 1996 LER 96-001-00:on 960103,failed to Test Duplicate Equipment. Caused by STS No Longer Containing Requirement for cross- Train Testing of Duplicate Components.Will Submit Request to Delete Subj Requirements from TS.W/960131 Ltr ML18065A4421996-01-19019 January 1996 LER 95-016-00:on 951226,did Not Analyze Primary Coolant Samples within 72 H.Caused by Belief Acceptability to Save Pcs Samples for Choride Analysis Past 72 H.Counseled Chemistry Supervision.W/960119 Ltr ML18065A4041996-01-15015 January 1996 LER 95-014-00:on 950119,PCP Oil Collection Deficiencies Created by FC-860 Piping Mod.Caused by Inadequate DBD for Sys & Lack of Review by Experienced Fire Protection Personnel.Updated Design Basis documentation.W/960115 Ltr ML18065A3291995-12-0404 December 1995 LER 95-013-00:on 951103,circuit Fuse Coordination Deficiency Which Affects App R Safe Shutdown Equipment Noted.Design of Fuse Coordination in Potential Transformer Circuits Will Be Evaluated & Modified as required.W/951204 Ltr ML18065A2361995-11-0202 November 1995 LER 95-012-00:on 950701,discovered Unqualified Electrical Connection in Containment SW Outlet Valve Controller.Caused by Failure of Assigned Engineers to Available Info.Replaced Wire Nuts W/Inline Butt connections.W/951102 Ltr ML18065A2051995-10-20020 October 1995 LER 95-008-01:on 950728,discovered That None of Four Containment High Pressure Channels Would Initiate Reactor Trip Due to Programmatic Deficiencies.Administrative Procedure (AP) 9.44,AP 9.45 & AP 10.44 Will Be Revised ML18065A0841995-09-18018 September 1995 LER 95-011-00:on 950817,CR 40 Withdrawal Occurred When Given Insertion Signal Due to skill-based Error in Crimping & Removing Foreign Matl from CRDM Motor Connection Box.Crd Package replaced.W/950918 Ltr ML18065A0681995-09-14014 September 1995 LER 95-010-00:on 950815,ESFA Resulted in Manual Rt Following Isolation of Pcs.Replaced Failed Instrument Line ML18065A0651995-09-0808 September 1995 LER 95-009-00:on 950728,discovered Lack of Procedural Guidance for Pump Repair Following Fire.Proposed Use of Power Supply Breaker Did Not Adequately Address Effect of Loss of Control Power.Performed Independent Assessment ML18064A8781995-08-28028 August 1995 LER 95-008-00:on 950728,discovered During Design Change Testing That None of Four Containment High Pressure Channels Would Initiate Rt.Caused by Programmatic Deficiencies. Reviewed Selected Tests & Mods from Recent Refueling Outage ML18064A8831995-08-21021 August 1995 LER 95-007-00:on 950720,discovered That 12 Instrument Loops Had V-bolted Type Qualified Cable Splices Connected to Wires W/Exposed Kapton Insulation.Caused by Human Error.All V- Bolted Splices Replaced w/in-line design.W/950821 Ltr 1999-09-02
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML18066A6901999-11-0101 November 1999 Rev 5 to Palisades Nuclear Plant Colr. ML18066A6761999-09-30030 September 1999 Monthly Operating Rept for Sept 1999 for Palisades Nuclear Plant ML18066A6271999-09-0202 September 1999 LER 98-011-01:on 981217,inadequate Lube Oil Collection Sys for Primary Coolant Pumps Was Noted.Caused by Design Change Not Containing Appropriate Level of Rigor.Exemption from 10CFR50,App R Was Requested.With 990902 Ltr ML18066A6351999-08-31031 August 1999 Monthly Operating Rept for Aug 1999 for Palisades Nuclear Plant ML18066A6771999-08-31031 August 1999 Operating Data Rept Page of MOR for Aug 1999 for Palisades Nuclear Plant ML18066A6221999-08-20020 August 1999 LER 99-002-00:on 990722,TS Surveillance Was Not Completed within Specified Frequency.Caused by Failure to Incorporate Revised Frequency Into Surveillance Schedule in Timely Manner.Verified Implementation.With 990820 Ltr ML18066A6061999-07-31031 July 1999 Monthly Operating Rept for July 1999 for Palisades Nuclear Plant.With 990803 Ltr ML18066A5201999-06-30030 June 1999 Monthly Operating Rept for June 1999 for Palisades Nuclear Plant.With 990702 Ltr ML18066A4841999-05-31031 May 1999 Monthly Operating Rept for May 1999 for Palisades Nuclear Plant.With 990603 Ltr ML18066A6371999-04-30030 April 1999 Revised Monthly Operating Rept for Apr 1999 for Palisades Nuclear Plant ML18068A5941999-04-30030 April 1999 Monthly Operating Rept for Apr 1999 for Palisades Nuclear Plant.With 990503 Ltr ML18066A4161999-04-0101 April 1999 Rev 4 to COLR, for Palisades Nuclear Plant ML18066A4501999-03-31031 March 1999 Monthly Operating Rept for Mar 1999 for Palisades Nuclear Plant.With 990402 Ltr ML18066A4671999-03-31031 March 1999 Rev 0 to SIR-99-032, Flaw Tolerance & Leakage Evaluation Spent Fuel Pool Heat Exchanger E-53B Nozzle Palisades Nuclear Plant. ML18068A5351999-02-28028 February 1999 Monthly Operating Rept for Feb 1999 for Palisades Nuclear Plant.With 990302 Ltr ML18066A3931999-01-31031 January 1999 Monthly Operating Rept for Jan 1999 for Palisades Nuclear Plant.With 990202 Ltr ML18066A3781999-01-20020 January 1999 LER 98-013-00:on 981222,safeguards Transfer Tap Changer Failure Caused Inadvertant DG Start.Caused by Failed Motor Contactor.Contactor Was Replaced.With 990120 Ltr ML20206F6131998-12-31031 December 1998 1998 Consumers Energy Co Annual Rept. with ML18066A3651998-12-31031 December 1998 Monthly Operating Rept for Dec 1998 for Palisades Nuclear Plant.With 990105 Ltr ML18066A3421998-11-30030 November 1998 Monthly Operating Rept for Nov 1998 for Palisades Nuclear Plant.With 981202 Ltr ML18066A3301998-11-11011 November 1998 Part 21 Rept Re Potential Safety Hazard Associated with Wrist Pin Assemblies for FM-Alco 251 Engines at Palisades Nuclear Power Plant.Caused by Insufficient Friction Fit Between Pin & Sleeve.Supplier of Pin Will No Longer Be Used ML18068A4921998-10-31031 October 1998 Monthly Operating Rept for Oct 1998 for Palisades Nuclear Plant.With 981103 Ltr ML18068A4851998-10-29029 October 1998 LER 97-011-01:on 971012,starting of Primary Coolant Pump with SG Temps Greater than Cold Leg Temps Occurred.Caused by Inadequate Procedures & Operator Decision.Sop Used for Starting Primary Coolant Pump Enhanced ML18066A3181998-09-30030 September 1998 Monthly Operating Rept for Sept 1998 for Palisades Nuclear Plant ML18066A2901998-08-31031 August 1998 Monthly Operating Rept for Aug 1998 for Palisades Nuclear Power Plant.With 980903 Ltr ML18066A3191998-08-31031 August 1998 Revised Monthly Operating Rept Data for Aug 1998 for Palisades Nuclear Plant ML18066A2831998-08-18018 August 1998 LER 98-010-00:on 980721,reactor Manually Tripped.Caused by Failure of Coupling Which Drives Feedwater Pump Main Lube Oil Pump.Main Lube Oil Pump Coupling & Associated Components Replaced & Satisfactorily Tested 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 ML20237E0301998-07-31031 July 1998 ISI Rept 3-3 ML18066A2701998-07-31031 July 1998 Monthly Operating Rept for July 1998 for Palisades Nuclear Plant.W/980803 Ltr ML18066A2311998-06-30030 June 1998 Monthly Operating Rept for June 1998 for Palisades Nuclear Plant ML18066A2261998-06-30030 June 1998 LER 98-009-00:on 980531,small Pinhole Leak Found on One of Welds,During Leak Test Following Replacement of Pcs Sample Isolation Valves.Caused by Welder Error.Leaking Welds Repaired ML18066A3061998-06-18018 June 1998 SG Tube Inservice Insp. ML20249C4951998-06-17017 June 1998 Rev 1 to EA-GEJ-98-01, Palisades Cycle 14 Disposition of Events Review ML18066A1781998-06-0909 June 1998 LER 98-008-00:on 980511,noted That Procedure Did Not Fully Satisfy Requirement to Test High Startup Rate Trip Function. Caused by Misunderstanding of Testing Requirements.Revised TS Surveillance Test Procedure & Reviewed Other Procedures ML18066A1711998-06-0101 June 1998 Part 21 Rept Re Impact of RELAP4 Excessive Variability on Palisades Large Break LOCA ECCS Results.Change in PCT Between Cycle 13 & Cycle 14 Does Not Constitute Significant Change Per 10CFR50.46 ML18066A1741998-05-31031 May 1998 Monthly Operating Rept for May 1998 for Palisades Nuclear Plant.W/980601 Ltr ML18066A2321998-05-31031 May 1998 Revised MOR for May 1998 for Palisades Nuclear Plant ML18068A4701998-05-31031 May 1998 Annual Rept of Changes in ECCS Models Per 10CFR50.46. ML18065B2451998-05-13013 May 1998 LER 98-007-00:on 980413,HPIS Sys Was Noted Inoperable During TS Surveillance Test.Caused by Performance of Flawed Procedure.Operators & Engineers Will Be Trained to Improve Operational Decision Making Through Resources & Knowledge ML18066A2331998-04-30030 April 1998 Revised MOR for Apr 1998 for Palisades Nuclear Plant ML18068A3461998-04-30030 April 1998 Monthly Operating Rept for Apr 1998 for Palisades Nuclear Plant.W/980501 Ltr ML18066A3411998-04-22022 April 1998 Rev 0 to EMF-98-013, Palisades Cycle 14:Disposition & Analysis of SRP Chapter 15 Events. ML18065B2071998-03-31031 March 1998 Monthly Operating Rept for Mar 1998 for Palisades Nuclear Plant.W/980403 Ltr ML20217C2741998-03-31031 March 1998 Independent Review - Is Consumers Energy Method (W Method) of Determining Palisades Nuclear Plant Best Estimate Fluence by Combining Transport Calculation & Dosimetry Measurements Technically Sound & Does It Meet Intent of Pts ML18066A2341998-03-31031 March 1998 Revised MOR for Mar 1998 for Palisades Nuclear Plant ML18068A3041998-02-28028 February 1998 Monthly Operating Rept for Feb 1998 for Palisades Nuclear Plant.W/980302 Ltr ML18066A2351998-02-28028 February 1998 Revised MOR for Feb 1998 for Palisades Nuclear Plant ML18065B1641998-02-0505 February 1998 Rev 0 to Regression Analysis for Containment Prestressing Sys at 25th Year Surveillance. ML18067A8211998-01-31031 January 1998 Monthly Operating Rept for Jan 1998 for Palisades Nuclear Plant.W/980203 Ltr 1999-09-30
[Table view] |
Text
c*ansumers Power POWERINli MICHlliAN'S PROliRESS
- Palisades Nuclear Plant: 27780 Blue Star Memorial Highway, Covert, *Ml 49043
- May 15, 1992 Nuclear Commission Document Control Desk Washington, DC 20555 DOCKET 50-255 -LICENSE DPR-20* -PALISADES PLANT. -* GB General Manager INFORMATIONAL LICENSEE EVENT REPORT 92-033 INOPERABLE CONTROL ROOM PENETRATION DUE TO INACCURATE AND MISAPPLICATION OF PROCEDURES . Informational Licensee Event Report (LER)92-033 is attached.
This e\1 ent is reported in accordance with plant procedures which require that no control
- room electrical penetrations be ope_ned above cold shutdown or refueling modes of operation.
- General Manager CC Administrator, ill, USNRC NRC Resident Inspector
-Palisades Attachment
- A CA.15" *N*7?GY COMPANV PALISADES NRC Form 388 (9*83) LICENSEE EVENT REPORT (LERI U.s: NUCLEAR REGULATORY COMMISSION APPROVED OMB NO. 3150-<>104 EXPIRES: B/31 /86 FACILITY.NAME (1) DOCKET NUMBER (2) PAGE (3) Palisades Plant . o_ I 5 I 0 I 0 I 0 I 2 I 5 I 5 -1 I OF 0 I 4. rmE <41 LICENSEE.
EVENT.REPORT 92-033 INOPERABLE CONTROL ROOM PENETRATION DUE TO INACCURATE AND MISAPPLICATION OF PROCEDURES . EVENT DATE !61 LER NUMBER (81 REP9RT DATE (8) OTHER FACILITIES INVOLVED (Bl ************
SEQUENTIAL REVISl.ON FACILITY NAMES' MONTH DAY YEAR YEAR NUMBER NUMBER MONTH DAY YEAR N/A 0151010101 912 -ol3l3 -'-olo 615 1 I 5 912 0161010101 014 1 14 9 2 N/A THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS.OF 10 CFR 1: IChttck °""or"""° of tJi. following}
(111 -------NAME 20.4061cl 60.38(cll1 I 60.38(c)(2) 60.731*112)(i) 60.73(o)(2)(iil 60.73(o)(2)(iii)
LICENSEE CONTACT FOR THIS LER (121 60. 7 31*1 (2 I (viiil!Al
- 60. 7 3111121(viiil!BI 60.7:iioH2Hxl William L. Roberts, Staff Licensing Engineer COMPLETE ONE LINE FOR EACH CO.MPONENT FAILURE DESCRIBED IN THIS REPORT (131 MANUFAC* REPORTABLE ' ' J
- CAUSE SYSTEM COMPONENT TUR ER TO NPRDS CAUSE SYSTEM COMPONENT I I I I I I L
- I I I I '* !?**.***:******:
I I I I I I I I*.*.. *:*:.:: *. I I I I SUPPLEMENTAL REPORT EXPECTED (14) I I below and in Text, NRC Form 366AI TELEPHONE NUMBER MANUFAC-TUR ER I I I I MONTH REPORTABLE TO NPRDS DAY EXPECTED I I ******:******:***************
YEAR. n YES Vf yH, complete EXPECTED SUBMISSION DATE) Pl NO SUBMISSION I DATE 1161 I I ABSTRACT (Umit to 1400 spaces, i.e .. approximately fifteen single-space typewritten lines) 1161 On* April 14, 1992, at approximately 0815 hours0.00943 days <br />0.226 hours <br />0.00135 weeks <br />3.101075e-4 months <br />, the plant was in hot stand-by.
with the reactor critical in preparation of beginning low power physics testing. Control room floor penetration FZ-0299 was discovered to be open, with a vacuum cleaner hose and. an electrical extension cord from the cable spreading room, running through the open penetration, to the control room. An immediate operability determination was made that the control room ventilation system remained operable with this condition.
An urgent work order was initiated to cap the opening and to remove the hose and electrical cord from the penetration.
The equipment was and the penetration was capped at 0835 hours0.00966 days <br />0.232 hours <br />0.00138 weeks <br />3.177175e-4 months <br />. *
- Palisades procedures require that no openings to the control room exist when the plant is in any mode other than cold shutdown.
Therefore, when the plant exited cold shutdown with this penetration still open, the procedural limits were *exceeded.
Misapplication of the appropriate procedures and inaccurate procedures caused this event.* A lack of communications between work groups also contributed to the loss of control of this electrical penetration through the control room floor. A lessons learned letter will-be sent to the organizations involved in this incident and the work groups whose work might involve running temporary utilities through penetrations in fire rated walls, floors and ceilings.
This letter will describe that a maintenance work order is required to track the opening and closing of this kind of penetration.
The plant administrative procedure on control of equipment status will be updated to assure that it is clear as to when a work order is n.eeded to control open penetrations.
,* NRC Form 388A 19*831' FACILITY NAME 111 Palisades Plant
- EVENT DESCRIPTION . . LICENSEE EVENT REPORT (LERI TEXT CONTINUATION DOCKET NUMBER 121 YEAR LER NUMBER 131 SEQUENTIAL NUMBER U.S. NUCLEAR REGULATORY COMMISSION APPROVED OMB NO *.
EXPIRES: 8/31 /86 REVISION NUMBER PAGE 141 0 5 0 0 0 2 5 5 . 9 2 -
- 0. 3 3 -0 0 0 2 OF 0 4 On April 14, 1992, at approximately 0815 hours0.00943 days <br />0.226 hours <br />0.00135 weeks <br />3.101075e-4 months <br />, the plant was in hot standby with the reactor critical in preparation of beginning low power physics testing. Control room floor penetration FZ-0299 [Vl;PEN]was discovered to be open, with a vacuum cleaner hose and an electrical*
extension cord routed from the cable spreading room, one floor below the control roorh, through the penetration, to the control room. An immediate operability determination was made that the control room ventilation system remained operable in this condition
... An urgent work order was initiated to cap the opening and to remove the hose and electrical cord from the penetration.
The equipment was .removed and the penetration was capped at 0835 hours0.00966 days <br />0.232 hours <br />0.00138 weeks <br />3.177175e-4 months <br />. System engineering was called. and asked to more formally evaluate the operability .of the control room HVAC system . with an opening of this size. System engineering performed simulating an equivalent size opening and determined that the control room ventilation system remained operable with the penetration open, and would have continued to remain operable if the vacuum cleaner had also been operati_ng.
This event is being reported in accordance with our plant administrative procedures.
The FZ-0299 penetration consists oftwo 2" condufr nipples through the control room floor, which are normally capped. In this instance, one of the two nipples had its end caps removed, and a vacuum h.ose and extension cord routed through the nipple, thus creating an open penetration.
Hisforically, it wa*s common practice during ah outage to run hoses; cords, etc., through these nipples when control room work is ongoing. This allows for vacuum cleaners and welding machines to be placed in the cable spreading room, one floor below, thereby providing less of a noise disruption to the control room while the work is in* progress.
Typically a work group. requiring the penetration to be open would notify the shift supervisor, and* the shift supervisor
- would assure that appropriate fire protection compensatory actions were taken. When the work was completed the work group would notify the shift supervisor that the penetration was closed and the compensatory action would be stopped. This is the same manner in which blocked op.en fire doors are handled under the plants Fire Protection Implementing Procedures (FPIP)-4, "Fire Protection Systems and Fire Protection Equipment." In this instance, the penetration was opened by one work group for work in the control room, and the proper notifications were made .. The first work group completed their work but was asked by a second work group_ to leave the equipment in place for their use. When the second work group's work was completed the hose and electrical cord was left in place as it was thought that control of the opening was the responsibility of the first contractor.
The first .work group assumed that the second work group would remove the hose and electrical cord, close the penetration, and make the appropriate notifications., Thus the penetration did not get closed.
.* . NRC Form 3661>. U.S. NUCLEAR COMMISSION APPROVED 0"!18 NO. 3160-0104 EXPIRES: B/31/86 * (9-93) FACILITY NAME 111 --Palisades Plant LICENSEE EVENT REPORT (LERI TEXT CONTINUATION DOCKET NUMBER 121 LER NUMBER 131 SEQUENTIAL YEAR NUMBER REVISION .NUMBER PAGE 141 0 I 5 I 0 I 0 I
- 0 I 2 I 5 I 5 9 I 2 -0 I 3 I 3 . -0 I 0 0 I 3 OF 0 14 Palisades procedures require that no openings to the control room exist when the plant is in any mode other than cold shutdown.
Therefore, when the plant exited cold shutdown with this . penetration still open, the procedural limits were exceeded.
Fire Protection Implementing Procedure (FPIP) 4, "Fire Protection Systems and Fire Protection Equipment," defines what .constitutes a fire barrier, versus a fire door, and provides requirements for how each is controlled.
_ Fire barriers are confrolled by Issuing a separate work order for each barrier that is opened. With this kind of control the bar_riers are assured to be returned to service when the associated system is returned to service, as all system work orders must be* dispositioned prior to returning a system to service. Previously penetration FZ-0299 had been treated as a fire door in that no repair work was being performed on the barrier. Running cables or h.oses through fire doors does not require a work order. This control mechanism had been shown to work effectively the years. As a result of this occurrence, FZ-0299 will now be treated as a fire barrier with its opening and closing being. controlled under a work order. Administrative Procedure 4.02, "Control of Equipment Status," is used to determine how ec:juipment is controlled
_when it is taken out of service or determined to be inoperable.
At the _ time of this event the section of Administration Procedure 4.02 describing actions to be taken for fire doors and barriers referenced the wrong section of FPIP 4, and also did not confirm that separate work orders are required for each inoperable fire barrier penetration.
CAUSE OF THE EVENT Misapplication of the appropriate procedures and inaccurate procedures caused this event. A lack .of communications between work groups also led to the loss of control of this electrical penetration through the control room floor. ANALYSIS OF THE EVENT At the time of the event, the plant was in hot stand-by with the reactor critical in p_reparation for beginning low power physics testing. Operations initially judged that the control room ventilation system remained operable.
This was confirmed later the same day by confirmation testing completed by system engineering.
To provide confirmation of operability an equivalent opening to the control room was created by opening a control room door a measured distance to simulate the floor penetrations opening. Observation of the control room internal pressure then confirmed that ventilation operability was maintained with this size of opening directly to the-control room. System engineering also concluded that if the vacuum cleaner had also been on, enough margin still existed in the control room ventilation system to that the system would remain operable.
Operability is based on maintaining-a
.125" water gage positive pressure in the control room.
-* '----*-
NRC Form 366A U.S. NUCLEAR REGULATORY COMMISSION, (9*83i APPROVED OMB NO. 3160-0104 LICENSEE EVENT REPORT (LERI TEXT CONTINUATION DOCKET NUMBER 121 LER NUMBER (31 . SEQUENTIAL YEAR _NUMBER EXPIRES: 8/31186 REVISION NUMBER PAGE (41 -Palisades Plant 0 I -5 I* 0 I 0 I 0 I 2 I 5 I 5 9 I 2. -0 I 3 I 3 -0 I 0 0 I 4 OF 0 I 4 During the entire time that the penetration was open, fire protection compensatory measures were in place. A review of the fire tour logs shows that the penetration FZ-0299 was not entered into the fire tour log .. However, fire tours in the area of this penetration were completed during the* entire time FZ-0299 was open. Therefore, no fire protection program limits were exceeded.
As described above it was shown that the opening of this penetration had no significant adverse affect on.the ability of the control room ventilation system to perform its design basis-function
.. CORRECTIVE ACTION A lessons learned letter will be sent to the organizations involved in this incidentand the work groups whose work might involve running temporary utilities through penetrations in fire rated walls, floors and ceilings.
This letter will emphasize that a maintenance work order *is required to track the opening and closing of'this kind of penetration.
- Administrative Procedure 4.02, "Control of Equipment Status," will be updated as necessary to clearly specify when a work order must be_ written to control open penetrations.
The requirements of Administrative Procedure 4.02 and the Fire Protection Implementing Procedures with regard to in_itiating work orders whenever a control room fire barrier penetration is opened, will be reviewed with the Operations Department Personnel.
ADDITIONAL INFORMATION A similar type of event was reported in LER 91-006, dated March 22, 1991.