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| {{#Wiki_filter:~CATEGORY~REGULATORY INFORMATION DISTRIBUTION SYSTEM(RZDS)ACCESSION NBR:9907280081 DOC.DATE: | | {{#Wiki_filter:~CATEGORY~REGULATORY INFORMATION DISTRIBUTION SYSTEM (RZDS)ACCESSION NBR:9907280081 DOC.DATE: 99/07/22 NOTARIZED: |
| 99/07/22NOTARIZED: | | NO DOCKET¹FACXL.'50-315 Donald C.Cook Nuclear Power Plant, Unit 1, Xndiana M 05000315 AUTH.NAME AUTHOR AFFILXATION SNODGRASS,D.D. |
| NODOCKET¹FACXL.'50-315 DonaldC.CookNuclearPowerPlant,Unit1,XndianaM05000315AUTH.NAMEAUTHORAFFILXATION SNODGRASS,D.D.
| | Indiana Michigan Power Co.RENCHECK,M.W. |
| IndianaMichiganPowerCo.RENCHECK,M.W.
| | Xndiana Michigan Power Co.RECZP.NAME |
| XndianaMichiganPowerCo.RECZP.NAME
| | ,, RECIPIENT AFFZLZATXON |
| ,,RECIPIENT AFFZLZATXON | |
|
| |
|
| ==SUBJECT:== | | ==SUBJECT:== |
| LER99-017-00:on 990625,noted thatimproperly installed fueloilreturnreliefvalverenderedEDGinoperable.
| | LER 99-017-00:on 990625,noted that improperly installed fuel oil return relief valve rendered EDG inoperable. |
| Causedbypersonnel error.Fueloilreturnvalvewasreplacedwithvalveincorrectorientation.
| | Caused by personnel error.Fuel oil return valve was replaced with valve in correct orientation. |
| With990722ltr.DISTRXBUTION CODE:ZE22TCOPIESRECEIVED:LTR ENCLSIZE:TXTLE:50.73/50.9 LicenseeEventReport(LER),XncidentRpt,etc.NOTES:RECZPXENT IDCODE/NAME LED3.=.1~PDINTERN:FILECENTERNRR~/DRIP"/REXB RES/DET/ERAB RGN3FXLEOlCOPIESLTTRENCL1,111111111RECIPIENT IDCODE/NAME STANG,JNRR/DIPM/ZOLB NRR/DSSA/SPLB RES/DRAA/OERAB COPIESLTTRENCL111111110RYEXTERNAL:
| | With 990722 ltr.DISTRXBUTION CODE: ZE22T COPIES RECEIVED:LTR ENCL SIZE: TXTLE: 50.73/50.9 Licensee Event Report (LER), Xncident Rpt, etc.NOTES: RECZPXENT ID CODE/NAME LED 3.=.1~PD INTERN: FILE CENTER NRR~/DRIP"/REXB RES/DET/ERAB RGN3 FXLE Ol COPIES LTTR ENCL 1, 1 1 1 1 1 1 1 1 1 RECIPIENT ID CODE/NAME STANG,J NRR/DIPM/ZOLB NRR/DSSA/SPLB RES/DRAA/OERAB COPIES LTTR ENCL 1 1 1 1 1 1 1 1 0 R Y EXTERNAL: L ST LOBBY WARD NOAC POORE;W.NRC PDR 1 1 1 1 1 1 LMITCO MARSHALL NOAC QUEENER,DS NUDOCS FULL TXT 1 1 1 1 1 1 D 0 NOTE TO ALL"RIDS" RECIPIENTS: |
| LSTLOBBYWARDNOACPOORE;W.NRCPDR111111LMITCOMARSHALLNOACQUEENER,DS NUDOCSFULLTXT111111D0NOTETOALL"RIDS"RECIPIENTS:
| | PLEASE HELP US TO REDUCE WASTE.TO HAVE YOUR NAME OR ORGANIZATION REMOVED FROM DISTRIBUTION LISTS OR REDUCE THE NUMBER OF COPIES RECEIVED BY YOU OR YOUR ORGANIZATION, CONTACT THE DOCUMENT CONTROL DESK (DCD)ON EXTENSION 415-2083 FULL TEXT CONVERSION REQUZRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 15 ENCL 15 Indiana Michi Power Company Ctmttwtdcar Rant One Cook Bart M1 491 06 616 465 5901 Z INDIANA NICHIOIAN'OWER July 22, 1999 United States Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 Operating License DPR-58 Docket No.50-315 Document Control Manager: In accordance with the criteria established by 10 CFR 50.73 entitled Licensee Event LER 315/99-017-00,"Improperly Installed Fuel Oil Return Relief Valve Renders Emergency Diesel Generator Inoperable Due to Personnel Error".There are no commitments identified in this LER.Sincerely, M.W.Rencheck Vice President-Nuclear Engineering |
| PLEASEHELPUSTOREDUCEWASTE.TOHAVEYOURNAMEORORGANIZATION REMOVEDFROMDISTRIBUTION LISTSORREDUCETHENUMBEROFCOPIESRECEIVEDBYYOUORYOURORGANIZATION, CONTACTTHEDOCUMENTCONTROLDESK(DCD)ONEXTENSION 415-2083FULLTEXTCONVERSION REQUZREDTOTALNUMBEROFCOPIESREQUIRED:
| | /mbd Attachment J.E.Dyer, Region III R.P.Powers P.A.Barrett G.P.Arent R.Whale D.Hahn Records Center, INPO NRC Resident Inspector'i190728008i |
| LTTR15ENCL15 IndianaMichiPowerCompanyCtmttwtdcar RantOneCookBartM1491066164655901ZINDIANANICHIOIAN
| | 'll'ii0722 PDR ADGCK 050003i5 S PDR NRC FORM 366 U.S.NUCLEAR REG ORY COMMISSION (8-1993)LICENSEE EVENT REPORT (LER)(See reverse for required number of digits/characters for each block)APPRO BY OMB NO.3150<104 EXPIRES 06/30/2001 Esumated burden per response to comply with this mandatory Information couecuon request 50 hrs.Reported lessons learned are hcorpxated Into the licenshg process and fed back to ktdustry.Forward~regarding burden estimate to the Reoxds Management Branch (TA F33).U.S.Nucrear Regubrtory Commission, Washington. |
| 'OWERJuly22,1999UnitedStatesNuclearRegulatory Commission DocumentControlDeskWashington, DC20555Operating LicenseDPR-58DocketNo.50-315DocumentControlManager:Inaccordance withthecriteriaestablished by10CFR50.73entitledLicenseeEventLER315/99-017-00, "Improperly Installed FuelOilReturnReliefValveRendersEmergency DieselGenerator Inoperable DuetoPersonnel Error".Therearenocommitments identified inthisLER.Sincerely, M.W.RencheckVicePresident-NuclearEngineering | | DC~t~and to Ihe Paperwork ReducUon Pro)oct (31500104). |
| /mbdAttachment J.E.Dyer,RegionIIIR.P.PowersP.A.BarrettG.P.ArentR.WhaleD.HahnRecordsCenter,INPONRCResidentInspector | | Ctree of Management and Budget, Washkrgton, DC 20503.If an information coukecuon does not display a currenUy vaud OMB control number, the NRC may not conduct or sponsor, aŽnd a person is not required to respond to.the kdormauon couecuon.FACILITY NAME (1)Cook Nuclear Plant Unit 1 DOCKET NUMBER (2)05000-315 PAGE (3)1 OF 3 TITLE (S)Improperly Installed Fuel Oil Return Relief Valve Renders Emergency Diesel Generator Inoperable Due to Personnel Error EVENT DATE (5)LER NUMBER (6)REPORT DATE (7)OTHER FACILITIES INVOLVED (6)MONTH DAY YEAR YEAR 1999 SEQUENTIAL REVISIO NUMBER N MONTH DAY YEAR FAclLITY NAME FACILITY NAME OOCKET NUMBER DOCKET NUMBER OPERATING MODE (9)LEVEL (10)THIS REPORT IS SUBMITTE 20.2203(a)(1) a D PURSUANT TO THE REQU IREMENTS OF 10 CFR II: (Check one or more)(11)a X 50.73(a)(2)(ii) a ul a v 20.2203(a)(3)(i) a n a vm 50.73(a)(2)(x) 20.2203(a)(2)(ii) a m a rv 20.2203(a)(4) |
| 'i190728008i | | LICENSEE CONTACT FOR THIS LER 50.73(a)(2)(iv) a v 50.73(a)(2)(vii) |
| 'll'ii0722 PDRADGCK050003i5SPDR NRCFORM366U.S.NUCLEARREGORYCOMMISSION (8-1993)LICENSEEEVENTREPORT(LER)(Seereverseforrequirednumberofdigits/characters foreachblock)APPROBYOMBNO.3150<104EXPIRES06/30/2001 Esumatedburdenperresponsetocomplywiththismandatory Information couecuonrequest50hrs.Reportedlessonslearnedarehcorpxated Intothelicenshgprocessandfedbacktoktdustry. | | (12)In~RE Form 3BBA OTHER In Abstract below or Mr.Dennis D.Snodgrass, Compliance Engineer TELEPHONE NUMBER (include Area Code)(616)465-5901 X1627 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DES CRIBED IN THIS REPORT (13)CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE To EPIX CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE To EPIX SUPPLEMENTAL REPORT EXPECTED 14 YES (If yes, complete EXPECTED SUBMISSION DATE).X NO EXPECTED MONTH DAY YEAR ABSTRACT (Limit to 1400 spaces, i.e.~approximately 15 single-spaced typewritten lines)(16)On June 25, 1999 at 2030 hours EST with both units in Mode 5, the Unit 1 CD Diesel Generator (D/G)was determined to be inoperable after the fuel oil return relief valve was identified as being installed backwards. |
| Forward~regarding burdenestimatetotheReoxdsManagement Branch(TAF33).U.S.NucrearRegubrtory Commission, Washington. | | The correct orientation of this valve is important to ensure that fuel oil is continuously circulated around the D/G fuel oil injector pump barrel for cooling.On June 25, 1999 at 2308 hours EST an ENS report was made in accordance with 10CFR 50.72(b)(2)(iii)(D), a condition that alone could have prevented the fulfillment of the safety function of systems that are needed to mitigate the consequences of an accident and 10CFR 50.72(b)(2)(i), a condition found while the reactor is shutdown that had it been found while in operation, would have resulted in the plant being seriously degraded or in an unanalyzed condition. |
| DC~t~andtoIhePaperwork ReducUonPro)oct(31500104). | | This LER is therefore submitted in accordance with 10CFR 50.73(a)(2)(v)(D) and 10CFR 50.73(a)(2)(ii)(A). |
| CtreeofManagement andBudget,Washkrgton, DC20503.Ifaninformation coukecuon doesnotdisplayacurrenUyvaudOMBcontrolnumber,theNRCmaynotconductorsponsor,aŽndapersonisnotrequiredtorespondto.thekdormauon couecuon.
| | The apparent cause of this condition is personnel error.The valve has been installed backwards since prior to 1986.Inspection of the corresponding valves on the 1AB, 2AB and 2CD D/Gs determined the valves were installed in the correct orientation. |
| FACILITYNAME(1)CookNuclearPlantUnit1DOCKETNUMBER(2)05000-315 PAGE(3)1OF3TITLE(S)Improperly Installed FuelOilReturnReliefValveRendersEmergency DieselGenerator Inoperable DuetoPersonnel ErrorEVENTDATE(5)LERNUMBER(6)REPORTDATE(7)OTHERFACILITIES INVOLVED(6)MONTHDAYYEARYEAR1999SEQUENTIAL REVISIONUMBERNMONTHDAYYEARFAclLITYNAMEFACILITYNAMEOOCKETNUMBERDOCKETNUMBEROPERATING MODE(9)LEVEL(10)THISREPORTISSUBMITTE20.2203(a)(1) aDPURSUANTTOTHEREQUIREMENTSOF10CFRII:(Checkoneormore)(11)aX50.73(a)(2)(ii) aulav20.2203(a)(3)(i) anavm50.73(a)(2)(x) 20.2203(a)(2)(ii) amarv20.2203(a)(4)
| | Operations entered the action statements for the applicable Technical Specifications upon declaring the Unit 1 CD D/G inoperable. |
| LICENSEECONTACTFORTHISLER50.73(a)(2)(iv) av50.73(a)(2)(vii)
| | Following replacement of the valve and D/G surveillance testing the 1CD D/G was declared operable on July 7, 1999 at 2243 hours EST.The successful completion of past Technical Specification (T/S)surveillance testsfor the Unit 1 CD D/G has verified acceptable engine performance, regardless of the incorrect orientation of this valve.A review of maintenance history did not reveal any abnormal D/G operation that could be attributed to the incorrect valve orientation. |
| (12)In~REForm3BBAOTHERInAbstractbeloworMr.DennisD.Snodgrass, Compliance EngineerTELEPHONE NUMBER(includeAreaCode)(616)465-5901X1627COMPLETEONELINEFOREACHCOMPONENT FAILUREDESCRIBEDINTHISREPORT(13)CAUSESYSTEMCOMPONENT MANUFACTURER REPORTABLE ToEPIXCAUSESYSTEMCOMPONENT MANUFACTURER REPORTABLE ToEPIXSUPPLEMENTAL REPORTEXPECTED14YES(Ifyes,completeEXPECTEDSUBMISSION DATE).XNOEXPECTEDMONTHDAYYEARABSTRACT(Limitto1400spaces,i.e.~approximately 15single-spaced typewritten lines)(16)OnJune25,1999at2030hoursESTwithbothunitsinMode5,theUnit1CDDieselGenerator (D/G)wasdetermined tobeinoperable afterthefueloilreturnreliefvalvewasidentified asbeinginstalled backwards. | | Therefore, there were minimal implications to the health and safety of the public as a result of this event.If significant changes are identified as a result of completion of the root cause investigation, an update to this LER will be submitted. |
| Thecorrectorientation ofthisvalveisimportant toensurethatfueloiliscontinuously circulated aroundtheD/Gfueloilinjectorpumpbarrelforcooling.OnJune25,1999at2308hoursESTanENSreportwasmadeinaccordance with10CFR50.72(b)(2)(iii)(D),
| | NRC FORM 366A U.S.NUCLEAR REGULATORY COMMISSION (6-1998)LICENSEE EVENT REPORT (LER)TEXT CONTINUATION FACILITY NAME (1)DOCKET (2)NUMBER 2 LER NUMBER (6)PAGE (3)Cook Nuclear Plant Unit 1 05000-315 YEAR SEQUENTIAl. |
| acondition thatalonecouldhaveprevented thefulfillment ofthesafetyfunctionofsystemsthatareneededtomitigatetheconsequences ofanaccidentand10CFR50.72(b)(2)(i),
| | NUMBER 1999 017 REVISION NUMBER 00 2 OF 3 TEXT (If more spece Is requfred, use edditionel copies of NRC Form 366A)(17)Conditions Prior To Event Unit 1 Mode 5 in Cold Shutdown Unit 2 Mode 5 in Cold Shutdown Descri tion Of The Event On June 25, 1999 at 2030 hours EST with both units in Mode 5, the Unit 1 CD D/G (EIIS:EK)was determined to be inoperable. |
| acondition foundwhilethereactorisshutdownthathaditbeenfoundwhileinoperation, wouldhaveresultedintheplantbeingseriously degradedorinanunanalyzed condition.
| | White performing inspections of D/G fuel oil lines (EIIS:DC), the Unit 1 CD D/G fuel oil return relief valve (EIIS:DC/FCV) was identified as being installed backwards. |
| ThisLERistherefore submitted inaccordance with10CFR50.73(a)(2)(v)(D) and10CFR50.73(a)(2)(ii)(A).
| | The correct orientation of this valve is important to ensure that fuel oil is continuously circulated around the 0/G fuel oil injector pump barrel for cooling.In the as-found orientation, the valve would not have lifted off of its seat at the required setpoint and would not have supplied the designed cooling to the fuel oil injector pump.The valve is shown in the incorrect orientation on the current revision 3 of a plant isometric drawing.A review of previous revisions of this drawing indicates that the incorrect orientation was incorporated in revision 2, dated 1986.Revision 1 dated 1973, indicated that the relief valve was correctly orientated but installed in a different physical location.A review of documentation provided no reason for the drawing change, other than to reflect"As-Found" conditions. |
| Theapparentcauseofthiscondition ispersonnel error.Thevalvehasbeeninstalled backwards sincepriorto1986.Inspection ofthecorresponding valvesonthe1AB,2ABand2CDD/Gsdetermined thevalveswereinstalled inthecorrectorientation.
| | Inspection of the corresponding valves for the 1AB, 2AB and 2CD D/Gs determined that the valves were installed in the correct location and orientation in the plant.However, the 1AB D/G isometric drawing shows the wrong location for the valve.Cause Of The Event The apparent cause of this condition is personnel error.Drawing changes and discussion with the vendor indicate that the D/G fuel oil return relief valves were initially supplied skid mounted on the diesel fuel oil return manifold but subsequently moved to the diesel fuel oil day tank room during plant construction. |
| Operations enteredtheactionstatements fortheapplicable Technical Specifications upondeclaring theUnit1CDD/Ginoperable. | | The process used to relocate the valve to its present location and when this occurred could not be determined from available documentation. |
| Following replacement ofthevalveandD/Gsurveillance testingthe1CDD/GwasdeclaredoperableonJuly7,1999at2243hoursEST.Thesuccessful completion ofpastTechnical Specification (T/S)surveillance testsfor theUnit1CDD/Ghasverifiedacceptable engineperformance, regardless oftheincorrect orientation ofthisvalve.Areviewofmaintenance historydidnotrevealanyabnormalD/Goperation thatcouldbeattributed totheincorrect valveorientation. | | Therefore; the valve was apparently installed incorrectly during plant construction and drawings were as-built to reflect the incorrect installation. |
| Therefore, therewereminimalimplications tothehealthandsafetyofthepublicasaresultofthisevent.Ifsignificant changesareidentified asaresultofcompletion oftherootcauseinvestigation, anupdatetothisLERwillbesubmitted. | | Subsequent reviews of drawing changes were inadequate in that they did not identify the incorrect field installation. |
| NRCFORM366AU.S.NUCLEARREGULATORY COMMISSION (6-1998)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION FACILITYNAME(1)DOCKET(2)NUMBER2LERNUMBER(6)PAGE(3)CookNuclearPlantUnit105000-315 YEARSEQUENTIAl.
| | Anal sis Of The Event On June 25, 1999 at 2308 hours EST an ENS report was made in accordance with 10CFR50.72(b)(2)(iii)(D), a condition that alone could have prevented the fulfillment of the safety function of systems needed to mitigate the consequences of an accident and 10CFR50.72(B)(2)(l), a condition found while the reactor is shutdown that had it been found while in operation, would have resulted in the plant being seriously degraded or in an unanalyzed condition. |
| NUMBER1999017REVISIONNUMBER002OF3TEXT(IfmorespeceIsrequfred, useedditionel copiesofNRCForm366A)(17)Conditions PriorToEventUnit1Mode5inColdShutdownUnit2Mode5inColdShutdownDescritionOfTheEventOnJune25,1999at2030hoursESTwithbothunitsinMode5,theUnit1CDD/G(EIIS:EK) wasdetermined tobeinoperable.
| | The D/G fuel oil return relief valve, set at 15 pounds per square inch pressure, is installed to maintain a fixed fuel pressure differential across the D/G fuel injection pump.This provides the proper fuel flow to achieve the required degree of cooling for the D/G fuel oil injection pump.In the as-found orientation, the valve would not have lifted off of its seat at the required setpoint at low load D/G operating conditions and proper cooling of the D/G fuel oil injection pump could have been affected.The successful completion of past Technical Specification (T/S)surveillance tests for the Unit 1 CD D/G has verified acceptable engine performance, regardless of the orientation of this valve.A review of maintenance history did.not reveal any abnormal D/G operation that could be attributed to the valve.Therefore, it has been concluded that there were minimal implications to the health and safety of the public as a result of this event.NRC FORM 866A (6-1 998) |
| Whiteperforming inspections ofD/Gfueloillines(EIIS:DC),
| | NRC FORM 366A U.S.NUCLEAR REGULATORY COMMISSION (6.1999)LICENSEE EVENT REPORT (LER)TEXT CONTINUATION FACILITY NAME (1)Cook Nuclear Plant Unit 1 DOCKET (2)NUMBER 2 05000-315 YEAR LER NUMBER (6)SEQUENTIAL REVISION NUMBER NUMBER PAGE (3)3 OF 3 1999 017 00 TEXT (If more spaceis required, use additional copies of NRC Form 366A)(17)CORRECTIVE ACTIONS An Engineering Evaluation was performed to evaluate the as-found condition of the 1CD D/G fuel oil return relief valve and to determine required corrective actions.Inspection of the corresponding D/G fuel oil return relief valves and the fuel oil supply relief valves on each D/G determined that the extent of condition was limited to the 1CD D/G fuel oil return relief valve.The vendor was contacted to determine what inspections could be performed to determine if fuel oil injector pump damage had occurred as a result of inadequate cooling.The vendor indicated that there would be no real indication of pump damage until the pump seized.The only possible visible indication of overheating prior to seizure is that the fuel oil would separate and give the pump internals a"varnished" look.To remove and inspect the pumps would require recalibration at the factory due to the tight internal tolerances involved.It was decided not to inspect the pumps, since the pumps have a successful maintenance history and there were no precursors to indicate pump failure.Design Input Transmittals were issued to revise isometric drawings to reflect the correct 1CD D/G valve orientation and to revise the 1 AB D/G isometric drawing to refiect the correct valve location.The fuel oil return relief valve was replaced with a valve in the correct orientation. |
| theUnit1CDD/Gfueloilreturnreliefvalve(EIIS:DC/FCV) wasidentified asbeinginstalled backwards.
| | Following surveillance testing, the 1CD D/G was declared op'erable on July 7, 1999 at 2243 hours EST.AEP:NRC:1260GH,"Enforcement Actions 98-150, S8-151, S8-152 and 98-186 Reply to Notice Of Violation October 13, 1998", dated March 19, 1999, responded to identified programmatic weaknesses in the plant Design and Licensing Basis, Control of Contractors and the Training and Qualification of personnel. |
| Thecorrectorientation ofthisvalveisimportant toensurethatfueloiliscontinuously circulated aroundthe0/Gfueloilinjectorpumpbarrelforcooling.Intheas-foundorientation, thevalvewouldnothaveliftedoffofitsseatattherequiredsetpointandwouldnothavesuppliedthedesignedcoolingtothefueloilinjectorpump.Thevalveisshownintheincorrect orientation onthecurrentrevision3ofaplantisometric drawing.Areviewofpreviousrevisions ofthisdrawingindicates thattheincorrect orientation wasincorporated inrevision2,dated1986.Revision1dated1973,indicated thatthereliefvalvewascorrectly orientated butinstalled inadifferent physicallocation.
| | The Engineering Leadership Plan establishes a configuration management program to control plant design and a new design control process, which includes design verification, design document control, vendor technical documentation control and testing of design changes.The Leadership Plan for Control of Contractors insures that workers are qualified for the job, line management is accountable for workers job qualification, monitoring of work performance and performing an adequate review for quality.The Training and Qualification of Personnel Leadership Plan will reinforce a"nuclear safety culture" for site personnel. |
| Areviewofdocumentation providednoreasonforthedrawingchange,otherthantoreflect"As-Found" conditions.
| | These plans in whole will help preclude a similar event similar from occurring in the future.SIMILAR EVENTS 315/98-029-00 315/99-015-00, 315/99-016-00 NRC FORM 366A (6-1996)}} |
| Inspection ofthecorresponding valvesforthe1AB,2ABand2CDD/Gsdetermined thatthevalveswereinstalled inthecorrectlocationandorientation intheplant.However,the1ABD/Gisometric drawingshowsthewronglocationforthevalve.CauseOfTheEventTheapparentcauseofthiscondition ispersonnel error.Drawingchangesanddiscussion withthevendorindicatethattheD/Gfueloilreturnreliefvalveswereinitially suppliedskidmountedonthedieselfueloilreturnmanifoldbutsubsequently movedtothedieselfueloildaytankroomduringplantconstruction. | |
| Theprocessusedtorelocatethevalvetoitspresentlocationandwhenthisoccurredcouldnotbedetermined fromavailable documentation.
| |
| Therefore; thevalvewasapparently installed incorrectly duringplantconstruction anddrawingswereas-builttoreflecttheincorrect installation. | |
| Subsequent reviewsofdrawingchangeswereinadequate inthattheydidnotidentifytheincorrect fieldinstallation. | |
| AnalsisOfTheEventOnJune25,1999at2308hoursESTanENSreportwasmadeinaccordance with10CFR50.72(b)(2)(iii)(D),
| |
| acondition thatalonecouldhaveprevented thefulfillment ofthesafetyfunctionofsystemsneededtomitigatetheconsequences ofanaccidentand10CFR50.72(B)(2)(l),
| |
| acondition foundwhilethereactorisshutdownthathaditbeenfoundwhileinoperation, wouldhaveresultedintheplantbeingseriously degradedorinanunanalyzed condition.
| |
| TheD/Gfueloilreturnreliefvalve,setat15poundspersquareinchpressure, isinstalled tomaintainafixedfuelpressuredifferential acrosstheD/Gfuelinjection pump.ThisprovidestheproperfuelflowtoachievetherequireddegreeofcoolingfortheD/Gfueloilinjection pump.Intheas-foundorientation, thevalvewouldnothaveliftedoffofitsseatattherequiredsetpointatlowloadD/Goperating conditions andpropercoolingoftheD/Gfueloilinjection pumpcouldhavebeenaffected.
| |
| Thesuccessful completion ofpastTechnical Specification (T/S)surveillance testsfortheUnit1CDD/Ghasverifiedacceptable engineperformance, regardless oftheorientation ofthisvalve.Areviewofmaintenance historydid.notrevealanyabnormalD/Goperation thatcouldbeattributed tothevalve.Therefore, ithasbeenconcluded thattherewereminimalimplications tothehealthandsafetyofthepublicasaresultofthisevent.NRCFORM866A(6-1998)
| |
| NRCFORM366AU.S.NUCLEARREGULATORY COMMISSION (6.1999)LICENSEEEVENTREPORT(LER)TEXTCONTINUATION FACILITYNAME(1)CookNuclearPlantUnit1DOCKET(2)NUMBER205000-315 YEARLERNUMBER(6)SEQUENTIAL REVISIONNUMBERNUMBERPAGE(3)3OF3199901700TEXT(Ifmorespaceisrequired, useadditional copiesofNRCForm366A)(17)CORRECTIVE ACTIONSAnEngineering Evaluation wasperformed toevaluatetheas-foundcondition ofthe1CDD/Gfueloilreturnreliefvalveandtodetermine requiredcorrective actions.Inspection ofthecorresponding D/GfueloilreturnreliefvalvesandthefueloilsupplyreliefvalvesoneachD/Gdetermined thattheextentofcondition waslimitedtothe1CDD/Gfueloilreturnreliefvalve.Thevendorwascontacted todetermine whatinspections couldbeperformed todetermine iffueloilinjectorpumpdamagehadoccurredasaresultofinadequate cooling.Thevendorindicated thattherewouldbenorealindication ofpumpdamageuntilthepumpseized.Theonlypossiblevisibleindication ofoverheating priortoseizureisthatthefueloilwouldseparateandgivethepumpinternals a"varnished" look.Toremoveandinspectthepumpswouldrequirerecalibration atthefactoryduetothetightinternaltolerances involved.
| |
| Itwasdecidednottoinspectthepumps,sincethepumpshaveasuccessful maintenance historyandtherewerenoprecursors toindicatepumpfailure.DesignInputTransmittals wereissuedtoreviseisometric drawingstoreflectthecorrect1CDD/Gvalveorientation andtorevisethe1ABD/Gisometric drawingtorefiectthecorrectvalvelocation.
| |
| Thefueloilreturnreliefvalvewasreplacedwithavalveinthecorrectorientation.
| |
| Following surveillance testing,the1CDD/Gwasdeclaredop'erable onJuly7,1999at2243hoursEST.AEP:NRC:1260GH, "Enforcement Actions98-150,S8-151,S8-152and98-186ReplytoNoticeOfViolation October13,1998",datedMarch19,1999,responded toidentified programmatic weaknesses intheplantDesignandLicensing Basis,ControlofContractors andtheTrainingandQualification ofpersonnel. | |
| TheEngineering Leadership Planestablishes aconfiguration management programtocontrolplantdesignandanewdesigncontrolprocess,whichincludesdesignverification, designdocumentcontrol,vendortechnical documentation controlandtestingofdesignchanges.TheLeadership PlanforControlofContractors insuresthatworkersarequalified forthejob,linemanagement isaccountable forworkersjobqualification, monitoring ofworkperformance andperforming anadequatereviewforquality.TheTrainingandQualification ofPersonnel Leadership Planwillreinforce a"nuclearsafetyculture"forsitepersonnel.
| |
| Theseplansinwholewillhelpprecludeasimilareventsimilarfromoccurring inthefuture.SIMILAREVENTS315/98-029-00 315/99-015-00, 315/99-016-00 NRCFORM366A(6-1996)}}
| |
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ML17326A0741999-07-29029 July 1999
LER 99-018-00:on 990629,determined That Valve Yokes May Yield Under Combined Stress of Seismic Event & Static,Valve Closed,Stem Thrust.Caused by Inadequate Design of Associated Movs.Operability Determinations Were Performed for Valves
ML17326A0661999-07-26026 July 1999
LER 99-017-00:on 990625,noted That Improperly Installed Fuel Oil Return Relief Valve Rendered EDG Inoperable.Caused by Personnel Error.Fuel Oil Return Valve Was Replaced with Valve in Correct Orientation.With 990722 Ltr
ML17326A0651999-07-22022 July 1999
LER 98-014-03:on 980310,noted That Response to high-high Containment Pressure Procedure Was Not Consistent with Analysis of Record.Caused by Inadequate Interface with W. FRZ-1 Will Be Revised to Be Consistent with New Analysis
ML17326A0491999-07-13013 July 1999
LER 99-016-00:on 990615,TS Requirements for Source Range Neutron Flux Monitors Not Met.Caused by Failure to Understand Design Basis of Plant.Procedures Revised.With 990713 Ltr
ML17326A0331999-07-0101 July 1999
LER 99-004-01:on 971030,failure to Perform TS Surveillance Analyses of Reactor Coolant Chemistry with Fuel Removed Was Noted.Caused by Ineffective Mgt of Tss.Chemistry Personnel Have Been Instructed on Requirement to Follow TS as Written
ML17326A0151999-06-18018 June 1999
LER 99-014-00:on 990521,determined That Boron Injection Tank Manway Bolts Were Not Included in ISI Program,Creating Missed Exam for Previous ISI Interval.Caused by Programmatic Weakness.Isi Program & Associated ISI Database Modified
ML17325B6311999-06-0101 June 1999
LER 99-S03-00:on 990430,vital Area Barrier Degradation Was Noted.Caused by Inadequate Insp & Maint of Vital Area Barrier.Repairs & Mods Were Made to Barriers to Eliminate Degraded & Nonconforming Conditions
ML17325B6421999-06-0101 June 1999
LER 99-013-00:on 990327,safety Injection & Centrifugal Charging Throttle Valve Cavitation During LOCA Could Have Led to ECCS Pump Failure.Caused by Inadequate Original Design Application of Si.Throttle Valves Will Be Developed
ML17325B6351999-05-28028 May 1999
LER 99-S02-00:on 990428,vulnerability in Safeguard Sys That Could Allow Unauthorized Access to Protected Area Was Noted. Caused by Inadequate Original Plant Design.Mods Were Made to Wall Opening to Eliminate Nonconforming Conditions
ML17265A8231999-05-24024 May 1999
LER 98-037-01:on 990422,determined That Ice Condenser Bypass Leakage Exceeds Design Basis Limit.Caused by Pressure Seal Required by Revised W Design Not Incorporated Into Aep Design.Numerous Matl Condition Walkdowns & Assessments Made
ML17325B6001999-05-20020 May 1999
LER 99-012-00:on 990420,concluded That Auxiliary Bldg ESF Ventilation Sys Not Capable of Maintaining ESF Room Temps post-accident.Caused by Inadequate Control of Sys Design Inputs.Comprehensive Action Plan Being Developed
ML17325B5861999-05-10010 May 1999
LER 99-002-00:on 990415,discovered That TS 4.0.5 Requirements Were Not Met Due to Improperly Performed Test. Caused by Incorrect Interpretation of ASME Code.App J Testing Will Be Completed & Procedures Will Be Revised
ML17325B5811999-05-0404 May 1999
LER 99-011-00:on 990407,air Sys for EDG Will Not Support Long Operability.Caused by Original Design Error.Temporary Mod to Supply Makeup Air Capability in Modes 5 & 6 Was Prepared
ML17325B5771999-05-0303 May 1999
LER 99-010-00:on 990401,RCS Leak Detection Sys Sensitivity Not in Accordance with Design Requirements Occurred.Caused by Inadequate Original Design of Containment Sump Level. Evaluation Will Be Performed to Clearly Define Design
ML17325B5581999-04-16016 April 1999
LER 99-006-00:on 990115,personnel Identified Discrepancy Between TS 3.9.7 Impact Energy Limit & Procedure 12 Ohp 4030.STP.046.Caused by Lack of Design Basis Control.Placed Procedure 12 Ohp 4030.STP.046 on Administrative Hold
ML17325B5471999-04-12012 April 1999
LER 99-009-00:on 990304,as-found RHR Safety Relief Valve Lift Setpoint Greater than TS Limit Occurred.Cause Investigation for Condition Has Not Been Completed.Update to LER Will Be Submitted,Upon Completion of Investigation
ML17325B5321999-04-0707 April 1999
LER 99-S01-00:on 990308,discovered That Lock for Vital Gate Leading to Plant 4KV Switchgear Area Was Nonconforming & Vulnerable to Unauthorized Access.Caused by Inadequate Gate Design & Inadequate Procedures.Mods Are Being Made to Gate
ML17325B5161999-04-0101 April 1999
LER 99-007-00:on 981020,calculations Showed That Divider Barrier Between Upper & Lower Containment Vols Were Overstressed.Engineers Are Currently Working on Analyses of Loads & Stress on Enclosures
ML17325B5221999-03-29029 March 1999
LER 99-001-00:on 960610,degraded Component Cooling Water Flow to Containment Main Steam Line Penetrations,Identified on 990226.Caused by Inadequate Understanding of Design Basis.Additional Investigations Ongoing
ML17325B4801999-03-18018 March 1999
LER 99-004-00:on 971030,failure to Perform TS Surveillance Analyses of Rc Chemistry with Fuel Removed Was Noted.Cause of Event Is Under Investigation.Corrected Written Job Order Activities Used to Control SD Chemistry Sampling
ML17325B4741999-03-18018 March 1999
LER 99-005-00:on 940512,determined That Rt Breaker Manual Actuations During Rod Drop Testing Were Not Previously Reported.Caused by Lack of Training.Addl Corrective Actions,Including Preventative Actions May Be Developed
ML17325B4571999-02-24024 February 1999
LER 99-003-00:on 990107,CR Pressurization Sys Surveillance Test Did Not Test Sys in Normal Operating Condition.Caused by Failure to Recognize Door 12DR-AUX415 as Part of CR Pressure Boundary.Performed Walkdown of Other Doors
ML17335A5171999-02-11011 February 1999
LER 99-002-00:on 990112,determined That RCS Pressurizer PORVs Had Not Been Tested,Per Ts.Caused by Inadequate Scheduling Controls Allowing Personnel Error.Surveillance Procedure Was Completed & Updated LER Will Be Submitted
ML17335A5141999-02-10010 February 1999
LER 99-001-00:on 990106,noted That GE Hfa Relays Installed in EDGs May Not Meet Seismic Qualification.Caused by Operating Experience Info Incorrectly Dispositioned in 1985. Updated LER Will Be Submitted by 990405
ML17335A5011999-02-0101 February 1999
LER 98-060-00:on 981231,identified That Rt Sys Response Time Testing Did Not Comply with TS Definition.Caused by Inadequate Procedures.Corrective Actions Will Be Developed & Update to LER Will Be Submitted by 990415.With 990201 Ltr
ML17335A4951999-01-29029 January 1999
LER 98-059-00:on 981230,interim LER -single Failure in Containment Spray Sys Could Result in Containment Spray Ph Outside Design Occurred.Investigation Into Condition Continuing.Update Will Be Submitted by 990514 Ltr
ML17335A4961999-01-27027 January 1999
LER 98-057-00:on 981228,discovered That AFW Valves Were Not Tested IAW Inservice Testing Program.Caused by Failure to Recognize Design Bases Features Re Afws by Personnel. Updated LER Will Be Submittted by 990415.With 990127 Ltr
ML17335A4921999-01-19019 January 1999
LER 98-052-01:on 981128,no Analysis for NSR Sc Manual Loader for Tdafwp Could Be Found in Original Design.Cause Due to All Failure Modes Not Considered When Compressed Air Sys Originally Designed.Performed Review of Components
ML17335A4721999-01-0606 January 1999
LER 98-055-00:on 981207,potential for Condition Outside of Design Bases for Rod Control Sys Was Noted.Caused by Calibration Error Coupled with Single Rod Failure.Condition Rept Investigation Is Ongoing
ML17335A4691999-01-0606 January 1999
LER 98-056-00:on 981211,hot Leg Nozzle Gaps Resulted in Plant Being in Unanalyzed Condition.Analyses Are Being Performed by W to Resolve Problem.Updated LER Will Be Submitted by 990211.With 990106 Ltr
ML17335A4661999-01-0505 January 1999
LER 98-049-00:on 981020,emergency Boron Injection Flow Path Was Inoperable.Caused by Original Design Deficiency. Engineering Evaluation of Event Is Continuing
ML17335A4631999-01-0404 January 1999
LER 98-054-00:on 981202,discovered That at Least One MSSV Had Not Been Reset as Required by Ts.Engineering Is Continuing Review of Extent of Condition for Event.Updated LER Will Be Submitted by 990129.With 990104 Ltr
ML17335A4481998-12-30030 December 1998
LER 98-053-00:on 981130,discovered Use of Inoperable Substitute Subcooling Margin Monitor.Caused by Condition Existing Since Installation of Plant Process Computer in 1992.Updated LER Will Be Submitted.With 981230 Ltr
ML17335A4581998-12-28028 December 1998
LER 98-052-00:on 981128,turbine Driven AFW Pump Speed Controller Failure Mode Occurred.Caused Because Not All Failure Modes Were Considered When Compressed Air Sys Was Originally Designed.Verified Current Design Change Process
ML17335A4281998-12-22022 December 1998
LER 98-051-00:on 981122,reactor Trip Signal from Manual Safety Injection Not Verified as Required by TS Surveillance,Was Discovered.Maintenance Currently Evaluating Significance & Cause of Event
ML17335A4111998-12-17017 December 1998
LER 98-047-00:on 981117,potential for Increase Leakage from Reactor Coolant Pump Seals Was Identified.Util Is Working with W to Resolve Issue.Current Expectations Are to Submit Update to LER by 990215.With 981217 Ltr
ML17335A4141998-12-16016 December 1998
LER 98-058-00:on 981216,postulated High Line Break Could Result in Condition Outside Design Bases for AF Occurred. Caused by Deficiencies Associated with Administration of HELB Program.Analysis of AF Will Be Completed by 990122
ML17335A4181998-12-16016 December 1998
LER 98-050-00:on 980814,ancillary Equipment Installed in Ice Condenser Was Not Designed to Withstand Design Basis Accident/Earthquake Loads.Caused by Lack of Established Design Criteria.Developed Design Criteria
ML17335A3871998-12-11011 December 1998
LER 98-031-01:on 980610,potential Common Mode Failure of RHR Pumps Were Noted.Caused by Inaccurate Values.Accurate Miniflow Numbers Have Been Determined by Flow Testing
ML17335A3821998-12-0808 December 1998
LER 98-039-01 Re EOP Step Conflicts with Small Break LOCA Analysis.Ler 98-039-00 Has Been Canceled.With 981208 Ltr
ML17335A3781998-12-0707 December 1998
LER 98-007-00:on 981106,high Energy Line Break Effects in Auxiliary FW Sys Was Noted.Cause of Event Is Under Investigation & Will Be Completed by 990220.Updated LER Will Be Submitted by 990310.With 981207 Ltr
ML17335A3771998-12-0303 December 1998
LER 98-046-00:on 981103,determined That Afs Was Unable to Meet Design Flow Requirements During Special Test.Caused by Failure to Consider All Aspects of Sys Operation in Design of Suction Basket Strainers.Sys Will Be Redesigned
ML17335A3741998-12-0202 December 1998
LER 97-011-02:on 970822,operation Was Noted Outside Design Bases for ECCS & CSP for Switchover to Recirculation Sump Suction.Caused by Ineffective Change Mgt.Revised Procedure for Switchover 01(02) Ohp 4023.ES-1.3
1999-09-17
[Table view]
Category:RO)
MONTHYEARML17335A5641999-10-18018 October 1999
LER 99-024-00:on 990708,literal TS Requirements Were Not Met by Accumlator Valve Surveillance.Caused by Misjudgement Made in Conversion from Initial DC Cook TS to W Std Ts.Submitted License Amend Request.With 991018 Ltr
ML17335A5531999-10-0707 October 1999
LER 99-023-00:on 990907,inadequate TS Surveillance Testing of ESW Pump ESF Response Time Noted.Caused by Inadequate Understanding of Plant Design Basis.Surveillance Tests Will Be Revised & Implemented
ML17326A1291999-09-17017 September 1999
LER 99-022-00:on 990609,electrical Bus Degraded Voltage Setpoints Too Low for Safety Related Loads,Was Discovered. Caused by Lack of Understanding of Design of Plant.No Immediate Corrective Actions Necessary
ML17326A1121999-08-27027 August 1999
LER 99-021-00:on 990728,determined That GL 96-01 Test Requirements Were Not Met in Surveillance Tests.Caused by Failure to Understand Full Extent of GL Requirements. Surveillance Procedures Will Be Revised or Developed
ML17326A1011999-08-26026 August 1999
LER 99-020-00:on 990727,EDGs Were Declared Inoperable.Caused by Inadequate Protection of Air Intake,Exhaust & Room Ventilation Structures from Tornado Missile Hazards. Implemented Compensatory Measures in Form of ACs
ML17326A0911999-08-16016 August 1999
LER 99-019-00:on 990716,noted Victoreen Containment Hrrms Not Environmentally Qualified to Withstand post-LOCA Conditions.Caused by Inadequate Design Control.Reviewing Options to Support Hrrms Operability in Modes 1-4
ML17326A0771999-08-0404 August 1999
LER 98-029-01:on 980422,noted That Fuel Handling Area Ventilation Sys Was Inoperable.Caused by Original Design Deficiency.Radiological Analysis for Spent Fuel Handling Accidents in Auxiliary Bldg Will Be Redone by 990830
ML17326A0741999-07-29029 July 1999
LER 99-018-00:on 990629,determined That Valve Yokes May Yield Under Combined Stress of Seismic Event & Static,Valve Closed,Stem Thrust.Caused by Inadequate Design of Associated Movs.Operability Determinations Were Performed for Valves
ML17326A0661999-07-26026 July 1999
LER 99-017-00:on 990625,noted That Improperly Installed Fuel Oil Return Relief Valve Rendered EDG Inoperable.Caused by Personnel Error.Fuel Oil Return Valve Was Replaced with Valve in Correct Orientation.With 990722 Ltr
ML17326A0651999-07-22022 July 1999
LER 98-014-03:on 980310,noted That Response to high-high Containment Pressure Procedure Was Not Consistent with Analysis of Record.Caused by Inadequate Interface with W. FRZ-1 Will Be Revised to Be Consistent with New Analysis
ML17326A0491999-07-13013 July 1999
LER 99-016-00:on 990615,TS Requirements for Source Range Neutron Flux Monitors Not Met.Caused by Failure to Understand Design Basis of Plant.Procedures Revised.With 990713 Ltr
ML17326A0331999-07-0101 July 1999
LER 99-004-01:on 971030,failure to Perform TS Surveillance Analyses of Reactor Coolant Chemistry with Fuel Removed Was Noted.Caused by Ineffective Mgt of Tss.Chemistry Personnel Have Been Instructed on Requirement to Follow TS as Written
ML17326A0151999-06-18018 June 1999
LER 99-014-00:on 990521,determined That Boron Injection Tank Manway Bolts Were Not Included in ISI Program,Creating Missed Exam for Previous ISI Interval.Caused by Programmatic Weakness.Isi Program & Associated ISI Database Modified
ML17325B6311999-06-0101 June 1999
LER 99-S03-00:on 990430,vital Area Barrier Degradation Was Noted.Caused by Inadequate Insp & Maint of Vital Area Barrier.Repairs & Mods Were Made to Barriers to Eliminate Degraded & Nonconforming Conditions
ML17325B6421999-06-0101 June 1999
LER 99-013-00:on 990327,safety Injection & Centrifugal Charging Throttle Valve Cavitation During LOCA Could Have Led to ECCS Pump Failure.Caused by Inadequate Original Design Application of Si.Throttle Valves Will Be Developed
ML17325B6351999-05-28028 May 1999
LER 99-S02-00:on 990428,vulnerability in Safeguard Sys That Could Allow Unauthorized Access to Protected Area Was Noted. Caused by Inadequate Original Plant Design.Mods Were Made to Wall Opening to Eliminate Nonconforming Conditions
ML17265A8231999-05-24024 May 1999
LER 98-037-01:on 990422,determined That Ice Condenser Bypass Leakage Exceeds Design Basis Limit.Caused by Pressure Seal Required by Revised W Design Not Incorporated Into Aep Design.Numerous Matl Condition Walkdowns & Assessments Made
ML17325B6001999-05-20020 May 1999
LER 99-012-00:on 990420,concluded That Auxiliary Bldg ESF Ventilation Sys Not Capable of Maintaining ESF Room Temps post-accident.Caused by Inadequate Control of Sys Design Inputs.Comprehensive Action Plan Being Developed
ML17325B5861999-05-10010 May 1999
LER 99-002-00:on 990415,discovered That TS 4.0.5 Requirements Were Not Met Due to Improperly Performed Test. Caused by Incorrect Interpretation of ASME Code.App J Testing Will Be Completed & Procedures Will Be Revised
ML17325B5811999-05-0404 May 1999
LER 99-011-00:on 990407,air Sys for EDG Will Not Support Long Operability.Caused by Original Design Error.Temporary Mod to Supply Makeup Air Capability in Modes 5 & 6 Was Prepared
ML17325B5771999-05-0303 May 1999
LER 99-010-00:on 990401,RCS Leak Detection Sys Sensitivity Not in Accordance with Design Requirements Occurred.Caused by Inadequate Original Design of Containment Sump Level. Evaluation Will Be Performed to Clearly Define Design
ML17325B5581999-04-16016 April 1999
LER 99-006-00:on 990115,personnel Identified Discrepancy Between TS 3.9.7 Impact Energy Limit & Procedure 12 Ohp 4030.STP.046.Caused by Lack of Design Basis Control.Placed Procedure 12 Ohp 4030.STP.046 on Administrative Hold
ML17325B5471999-04-12012 April 1999
LER 99-009-00:on 990304,as-found RHR Safety Relief Valve Lift Setpoint Greater than TS Limit Occurred.Cause Investigation for Condition Has Not Been Completed.Update to LER Will Be Submitted,Upon Completion of Investigation
ML17325B5321999-04-0707 April 1999
LER 99-S01-00:on 990308,discovered That Lock for Vital Gate Leading to Plant 4KV Switchgear Area Was Nonconforming & Vulnerable to Unauthorized Access.Caused by Inadequate Gate Design & Inadequate Procedures.Mods Are Being Made to Gate
ML17325B5161999-04-0101 April 1999
LER 99-007-00:on 981020,calculations Showed That Divider Barrier Between Upper & Lower Containment Vols Were Overstressed.Engineers Are Currently Working on Analyses of Loads & Stress on Enclosures
ML17325B5221999-03-29029 March 1999
LER 99-001-00:on 960610,degraded Component Cooling Water Flow to Containment Main Steam Line Penetrations,Identified on 990226.Caused by Inadequate Understanding of Design Basis.Additional Investigations Ongoing
ML17325B4801999-03-18018 March 1999
LER 99-004-00:on 971030,failure to Perform TS Surveillance Analyses of Rc Chemistry with Fuel Removed Was Noted.Cause of Event Is Under Investigation.Corrected Written Job Order Activities Used to Control SD Chemistry Sampling
ML17325B4741999-03-18018 March 1999
LER 99-005-00:on 940512,determined That Rt Breaker Manual Actuations During Rod Drop Testing Were Not Previously Reported.Caused by Lack of Training.Addl Corrective Actions,Including Preventative Actions May Be Developed
ML17325B4571999-02-24024 February 1999
LER 99-003-00:on 990107,CR Pressurization Sys Surveillance Test Did Not Test Sys in Normal Operating Condition.Caused by Failure to Recognize Door 12DR-AUX415 as Part of CR Pressure Boundary.Performed Walkdown of Other Doors
ML17335A5171999-02-11011 February 1999
LER 99-002-00:on 990112,determined That RCS Pressurizer PORVs Had Not Been Tested,Per Ts.Caused by Inadequate Scheduling Controls Allowing Personnel Error.Surveillance Procedure Was Completed & Updated LER Will Be Submitted
ML17335A5141999-02-10010 February 1999
LER 99-001-00:on 990106,noted That GE Hfa Relays Installed in EDGs May Not Meet Seismic Qualification.Caused by Operating Experience Info Incorrectly Dispositioned in 1985. Updated LER Will Be Submitted by 990405
ML17335A5011999-02-0101 February 1999
LER 98-060-00:on 981231,identified That Rt Sys Response Time Testing Did Not Comply with TS Definition.Caused by Inadequate Procedures.Corrective Actions Will Be Developed & Update to LER Will Be Submitted by 990415.With 990201 Ltr
ML17335A4951999-01-29029 January 1999
LER 98-059-00:on 981230,interim LER -single Failure in Containment Spray Sys Could Result in Containment Spray Ph Outside Design Occurred.Investigation Into Condition Continuing.Update Will Be Submitted by 990514 Ltr
ML17335A4961999-01-27027 January 1999
LER 98-057-00:on 981228,discovered That AFW Valves Were Not Tested IAW Inservice Testing Program.Caused by Failure to Recognize Design Bases Features Re Afws by Personnel. Updated LER Will Be Submittted by 990415.With 990127 Ltr
ML17335A4921999-01-19019 January 1999
LER 98-052-01:on 981128,no Analysis for NSR Sc Manual Loader for Tdafwp Could Be Found in Original Design.Cause Due to All Failure Modes Not Considered When Compressed Air Sys Originally Designed.Performed Review of Components
ML17335A4721999-01-0606 January 1999
LER 98-055-00:on 981207,potential for Condition Outside of Design Bases for Rod Control Sys Was Noted.Caused by Calibration Error Coupled with Single Rod Failure.Condition Rept Investigation Is Ongoing
ML17335A4691999-01-0606 January 1999
LER 98-056-00:on 981211,hot Leg Nozzle Gaps Resulted in Plant Being in Unanalyzed Condition.Analyses Are Being Performed by W to Resolve Problem.Updated LER Will Be Submitted by 990211.With 990106 Ltr
ML17335A4661999-01-0505 January 1999
LER 98-049-00:on 981020,emergency Boron Injection Flow Path Was Inoperable.Caused by Original Design Deficiency. Engineering Evaluation of Event Is Continuing
ML17335A4631999-01-0404 January 1999
LER 98-054-00:on 981202,discovered That at Least One MSSV Had Not Been Reset as Required by Ts.Engineering Is Continuing Review of Extent of Condition for Event.Updated LER Will Be Submitted by 990129.With 990104 Ltr
ML17335A4481998-12-30030 December 1998
LER 98-053-00:on 981130,discovered Use of Inoperable Substitute Subcooling Margin Monitor.Caused by Condition Existing Since Installation of Plant Process Computer in 1992.Updated LER Will Be Submitted.With 981230 Ltr
ML17335A4581998-12-28028 December 1998
LER 98-052-00:on 981128,turbine Driven AFW Pump Speed Controller Failure Mode Occurred.Caused Because Not All Failure Modes Were Considered When Compressed Air Sys Was Originally Designed.Verified Current Design Change Process
ML17335A4281998-12-22022 December 1998
LER 98-051-00:on 981122,reactor Trip Signal from Manual Safety Injection Not Verified as Required by TS Surveillance,Was Discovered.Maintenance Currently Evaluating Significance & Cause of Event
ML17335A4111998-12-17017 December 1998
LER 98-047-00:on 981117,potential for Increase Leakage from Reactor Coolant Pump Seals Was Identified.Util Is Working with W to Resolve Issue.Current Expectations Are to Submit Update to LER by 990215.With 981217 Ltr
ML17335A4141998-12-16016 December 1998
LER 98-058-00:on 981216,postulated High Line Break Could Result in Condition Outside Design Bases for AF Occurred. Caused by Deficiencies Associated with Administration of HELB Program.Analysis of AF Will Be Completed by 990122
ML17335A4181998-12-16016 December 1998
LER 98-050-00:on 980814,ancillary Equipment Installed in Ice Condenser Was Not Designed to Withstand Design Basis Accident/Earthquake Loads.Caused by Lack of Established Design Criteria.Developed Design Criteria
ML17335A3871998-12-11011 December 1998
LER 98-031-01:on 980610,potential Common Mode Failure of RHR Pumps Were Noted.Caused by Inaccurate Values.Accurate Miniflow Numbers Have Been Determined by Flow Testing
ML17335A3821998-12-0808 December 1998
LER 98-039-01 Re EOP Step Conflicts with Small Break LOCA Analysis.Ler 98-039-00 Has Been Canceled.With 981208 Ltr
ML17335A3781998-12-0707 December 1998
LER 98-007-00:on 981106,high Energy Line Break Effects in Auxiliary FW Sys Was Noted.Cause of Event Is Under Investigation & Will Be Completed by 990220.Updated LER Will Be Submitted by 990310.With 981207 Ltr
ML17335A3771998-12-0303 December 1998
LER 98-046-00:on 981103,determined That Afs Was Unable to Meet Design Flow Requirements During Special Test.Caused by Failure to Consider All Aspects of Sys Operation in Design of Suction Basket Strainers.Sys Will Be Redesigned
ML17335A3741998-12-0202 December 1998
LER 97-011-02:on 970822,operation Was Noted Outside Design Bases for ECCS & CSP for Switchover to Recirculation Sump Suction.Caused by Ineffective Change Mgt.Revised Procedure for Switchover 01(02) Ohp 4023.ES-1.3
1999-09-17
[Table view]
Category:TEXT-SAFETY REPORT
MONTHYEARML17335A5641999-10-18018 October 1999
LER 99-024-00:on 990708,literal TS Requirements Were Not Met by Accumlator Valve Surveillance.Caused by Misjudgement Made in Conversion from Initial DC Cook TS to W Std Ts.Submitted License Amend Request.With 991018 Ltr
ML17335A5531999-10-0707 October 1999
LER 99-023-00:on 990907,inadequate TS Surveillance Testing of ESW Pump ESF Response Time Noted.Caused by Inadequate Understanding of Plant Design Basis.Surveillance Tests Will Be Revised & Implemented
ML17335A5631999-09-30030 September 1999
Monthly Operating Rept for Sept 1999 for DC Cook Nuclear Plant,Unit 1.With 991012 Ltr
ML17335A5621999-09-30030 September 1999
Monthly Operating Rept for Sept 1999 for DC Cook Nuclear Plant,Unit 2.With 991012 Ltr
ML17335A5481999-09-30030 September 1999
Non-proprietary DC Cook Nuclear Plant Units 1 & 2 Mods to Containment Sys W SE (Secl 99-076,Rev 3).
ML17335A5451999-09-28028 September 1999
Rev 1 to Containment Sump Level Design Condition & Failure Effects Analysis for Potential Draindown Scenarios.
ML17326A1291999-09-17017 September 1999
LER 99-022-00:on 990609,electrical Bus Degraded Voltage Setpoints Too Low for Safety Related Loads,Was Discovered. Caused by Lack of Understanding of Design of Plant.No Immediate Corrective Actions Necessary
ML17326A1481999-09-17017 September 1999
Independent Review of Control Rod Insertion Following Cold Leg Lbloca,Dc Cook,Units 1 & 2.
ML17326A1211999-08-31031 August 1999
Monthly Operating Rept for Aug 1999 for Cook Nuclear Plant, Unit 2.With 990915 Ltr
ML17326A1201999-08-31031 August 1999
Monthly Operating Rept for Aug 1999 for Cook Nuclear Plant, Unit 1.With 990915 Ltr
ML17326A1121999-08-27027 August 1999
LER 99-021-00:on 990728,determined That GL 96-01 Test Requirements Were Not Met in Surveillance Tests.Caused by Failure to Understand Full Extent of GL Requirements. Surveillance Procedures Will Be Revised or Developed
ML17326A1011999-08-26026 August 1999
LER 99-020-00:on 990727,EDGs Were Declared Inoperable.Caused by Inadequate Protection of Air Intake,Exhaust & Room Ventilation Structures from Tornado Missile Hazards. Implemented Compensatory Measures in Form of ACs
ML17326A0911999-08-16016 August 1999
LER 99-019-00:on 990716,noted Victoreen Containment Hrrms Not Environmentally Qualified to Withstand post-LOCA Conditions.Caused by Inadequate Design Control.Reviewing Options to Support Hrrms Operability in Modes 1-4
ML17326A0771999-08-0404 August 1999
LER 98-029-01:on 980422,noted That Fuel Handling Area Ventilation Sys Was Inoperable.Caused by Original Design Deficiency.Radiological Analysis for Spent Fuel Handling Accidents in Auxiliary Bldg Will Be Redone by 990830
ML17335A5461999-08-0202 August 1999
Rev 0 to Evaluation of Cook Recirculation Sump Level for Reduced Pump Flow Rates.
ML17326A0871999-07-31031 July 1999
Monthly Operating Rept for July 1999 for DC Cook Nuclear Plant,Unit 1.With 990812 Ltr
ML17326A0861999-07-31031 July 1999
Monthly Operating Rept for July 1999 for DC Cook Nuclear Plant,Units 2.With 990812 Ltr
ML17326A0741999-07-29029 July 1999
LER 99-018-00:on 990629,determined That Valve Yokes May Yield Under Combined Stress of Seismic Event & Static,Valve Closed,Stem Thrust.Caused by Inadequate Design of Associated Movs.Operability Determinations Were Performed for Valves
ML17326A0661999-07-26026 July 1999
LER 99-017-00:on 990625,noted That Improperly Installed Fuel Oil Return Relief Valve Rendered EDG Inoperable.Caused by Personnel Error.Fuel Oil Return Valve Was Replaced with Valve in Correct Orientation.With 990722 Ltr
ML17326A0651999-07-22022 July 1999
LER 98-014-03:on 980310,noted That Response to high-high Containment Pressure Procedure Was Not Consistent with Analysis of Record.Caused by Inadequate Interface with W. FRZ-1 Will Be Revised to Be Consistent with New Analysis
ML17326A0491999-07-13013 July 1999
LER 99-016-00:on 990615,TS Requirements for Source Range Neutron Flux Monitors Not Met.Caused by Failure to Understand Design Basis of Plant.Procedures Revised.With 990713 Ltr
ML17326A0331999-07-0101 July 1999
LER 99-004-01:on 971030,failure to Perform TS Surveillance Analyses of Reactor Coolant Chemistry with Fuel Removed Was Noted.Caused by Ineffective Mgt of Tss.Chemistry Personnel Have Been Instructed on Requirement to Follow TS as Written
ML17326A0511999-06-30030 June 1999
Monthly Operating Rept for June 1999 for DC Cook Nuclear Plant,Unit 2.With 990709 Ltr
ML17326A0501999-06-30030 June 1999
Monthly Operating Rept for June 1999 for DC Cook Nuclear Plant,Unit 1.With 990709 Ltr
ML17326A0151999-06-18018 June 1999
LER 99-014-00:on 990521,determined That Boron Injection Tank Manway Bolts Were Not Included in ISI Program,Creating Missed Exam for Previous ISI Interval.Caused by Programmatic Weakness.Isi Program & Associated ISI Database Modified
ML17325B6421999-06-0101 June 1999
LER 99-013-00:on 990327,safety Injection & Centrifugal Charging Throttle Valve Cavitation During LOCA Could Have Led to ECCS Pump Failure.Caused by Inadequate Original Design Application of Si.Throttle Valves Will Be Developed
ML17325B6311999-06-0101 June 1999
LER 99-S03-00:on 990430,vital Area Barrier Degradation Was Noted.Caused by Inadequate Insp & Maint of Vital Area Barrier.Repairs & Mods Were Made to Barriers to Eliminate Degraded & Nonconforming Conditions
ML17326A0061999-05-31031 May 1999
Monthly Operating Rept for May 1999 for Dcp.With 990609 Ltr
ML17326A0071999-05-31031 May 1999
Monthly Operating Rept for May 1999 for DC Cook Nuclear Plant,Unit 2.With 990609 Ltr
ML17325B6351999-05-28028 May 1999
LER 99-S02-00:on 990428,vulnerability in Safeguard Sys That Could Allow Unauthorized Access to Protected Area Was Noted. Caused by Inadequate Original Plant Design.Mods Were Made to Wall Opening to Eliminate Nonconforming Conditions
ML17265A8231999-05-24024 May 1999
LER 98-037-01:on 990422,determined That Ice Condenser Bypass Leakage Exceeds Design Basis Limit.Caused by Pressure Seal Required by Revised W Design Not Incorporated Into Aep Design.Numerous Matl Condition Walkdowns & Assessments Made
ML17325B6001999-05-20020 May 1999
LER 99-012-00:on 990420,concluded That Auxiliary Bldg ESF Ventilation Sys Not Capable of Maintaining ESF Room Temps post-accident.Caused by Inadequate Control of Sys Design Inputs.Comprehensive Action Plan Being Developed
ML17325B5861999-05-10010 May 1999
LER 99-002-00:on 990415,discovered That TS 4.0.5 Requirements Were Not Met Due to Improperly Performed Test. Caused by Incorrect Interpretation of ASME Code.App J Testing Will Be Completed & Procedures Will Be Revised
ML17325B5811999-05-0404 May 1999
LER 99-011-00:on 990407,air Sys for EDG Will Not Support Long Operability.Caused by Original Design Error.Temporary Mod to Supply Makeup Air Capability in Modes 5 & 6 Was Prepared
ML17325B5771999-05-0303 May 1999
LER 99-010-00:on 990401,RCS Leak Detection Sys Sensitivity Not in Accordance with Design Requirements Occurred.Caused by Inadequate Original Design of Containment Sump Level. Evaluation Will Be Performed to Clearly Define Design
ML17335A5301999-04-30030 April 1999
Monthly Operating Rept for Apr 1999 for DC Cook Nuclear Plant,Unit 1.With 990508 Ltr
ML17335A5291999-04-30030 April 1999
Monthly Operating Rept for Apr 1999 for DC Cook Nuclear Plant,Unit 2.With 990508 Ltr
ML17325B5581999-04-16016 April 1999
LER 99-006-00:on 990115,personnel Identified Discrepancy Between TS 3.9.7 Impact Energy Limit & Procedure 12 Ohp 4030.STP.046.Caused by Lack of Design Basis Control.Placed Procedure 12 Ohp 4030.STP.046 on Administrative Hold
ML17325B5471999-04-12012 April 1999
LER 99-009-00:on 990304,as-found RHR Safety Relief Valve Lift Setpoint Greater than TS Limit Occurred.Cause Investigation for Condition Has Not Been Completed.Update to LER Will Be Submitted,Upon Completion of Investigation
ML17325B5321999-04-0707 April 1999
LER 99-S01-00:on 990308,discovered That Lock for Vital Gate Leading to Plant 4KV Switchgear Area Was Nonconforming & Vulnerable to Unauthorized Access.Caused by Inadequate Gate Design & Inadequate Procedures.Mods Are Being Made to Gate
ML17325B5161999-04-0101 April 1999
LER 99-007-00:on 981020,calculations Showed That Divider Barrier Between Upper & Lower Containment Vols Were Overstressed.Engineers Are Currently Working on Analyses of Loads & Stress on Enclosures
ML17325B5491999-03-31031 March 1999
Monthly Operating Rept for Mar 1999 for DC Cook Nuclear Plant Unit 2.With 990408 Ltr
ML17325B5441999-03-31031 March 1999
Monthly Operating Rept for Mar 1999 for DC Cook Nuclear Plant,Unit 1.With 990408 Ltr
ML17325B5221999-03-29029 March 1999
LER 99-001-00:on 960610,degraded Component Cooling Water Flow to Containment Main Steam Line Penetrations,Identified on 990226.Caused by Inadequate Understanding of Design Basis.Additional Investigations Ongoing
ML17325B4801999-03-18018 March 1999
LER 99-004-00:on 971030,failure to Perform TS Surveillance Analyses of Rc Chemistry with Fuel Removed Was Noted.Cause of Event Is Under Investigation.Corrected Written Job Order Activities Used to Control SD Chemistry Sampling
ML17325B4741999-03-18018 March 1999
LER 99-005-00:on 940512,determined That Rt Breaker Manual Actuations During Rod Drop Testing Were Not Previously Reported.Caused by Lack of Training.Addl Corrective Actions,Including Preventative Actions May Be Developed
ML17325B5671999-03-0202 March 1999
Summary of Unit 1 Steam Generator Layup Chemistry from 980101 to 990218.
ML17325B4631999-02-28028 February 1999
Monthly Operating Rept for Feb 1999 for DC Cook Nuclear Power Station,Unit 2.With 990308 Ltr
ML17325B4621999-02-28028 February 1999
Monthly Operating Rept for Feb 1999 for DC Cook Nuclear Plant,Unit 1.With 990308 Ltr
ML17325B4571999-02-24024 February 1999
LER 99-003-00:on 990107,CR Pressurization Sys Surveillance Test Did Not Test Sys in Normal Operating Condition.Caused by Failure to Recognize Door 12DR-AUX415 as Part of CR Pressure Boundary.Performed Walkdown of Other Doors
1999-09-30
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~CATEGORY~REGULATORY INFORMATION DISTRIBUTION SYSTEM (RZDS)ACCESSION NBR:9907280081 DOC.DATE: 99/07/22 NOTARIZED:
NO DOCKET¹FACXL.'50-315 Donald C.Cook Nuclear Power Plant, Unit 1, Xndiana M 05000315 AUTH.NAME AUTHOR AFFILXATION SNODGRASS,D.D.
Indiana Michigan Power Co.RENCHECK,M.W.
Xndiana Michigan Power Co.RECZP.NAME
,, RECIPIENT AFFZLZATXON
SUBJECT:
LER 99-017-00:on 990625,noted that improperly installed fuel oil return relief valve rendered EDG inoperable.
Caused by personnel error.Fuel oil return valve was replaced with valve in correct orientation.
With 990722 ltr.DISTRXBUTION CODE: ZE22T COPIES RECEIVED:LTR ENCL SIZE: TXTLE: 50.73/50.9 Licensee Event Report (LER), Xncident Rpt, etc.NOTES: RECZPXENT ID CODE/NAME LED 3.=.1~PD INTERN: FILE CENTER NRR~/DRIP"/REXB RES/DET/ERAB RGN3 FXLE Ol COPIES LTTR ENCL 1, 1 1 1 1 1 1 1 1 1 RECIPIENT ID CODE/NAME STANG,J NRR/DIPM/ZOLB NRR/DSSA/SPLB RES/DRAA/OERAB COPIES LTTR ENCL 1 1 1 1 1 1 1 1 0 R Y EXTERNAL: L ST LOBBY WARD NOAC POORE;W.NRC PDR 1 1 1 1 1 1 LMITCO MARSHALL NOAC QUEENER,DS NUDOCS FULL TXT 1 1 1 1 1 1 D 0 NOTE TO ALL"RIDS" RECIPIENTS:
PLEASE HELP US TO REDUCE WASTE.TO HAVE YOUR NAME OR ORGANIZATION REMOVED FROM DISTRIBUTION LISTS OR REDUCE THE NUMBER OF COPIES RECEIVED BY YOU OR YOUR ORGANIZATION, CONTACT THE DOCUMENT CONTROL DESK (DCD)ON EXTENSION 415-2083 FULL TEXT CONVERSION REQUZRED TOTAL NUMBER OF COPIES REQUIRED: LTTR 15 ENCL 15 Indiana Michi Power Company Ctmttwtdcar Rant One Cook Bart M1 491 06 616 465 5901 Z INDIANA NICHIOIAN'OWER July 22, 1999 United States Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 Operating License DPR-58 Docket No.50-315 Document Control Manager: In accordance with the criteria established by 10 CFR 50.73 entitled Licensee Event LER 315/99-017-00,"Improperly Installed Fuel Oil Return Relief Valve Renders Emergency Diesel Generator Inoperable Due to Personnel Error".There are no commitments identified in this LER.Sincerely, M.W.Rencheck Vice President-Nuclear Engineering
/mbd Attachment J.E.Dyer, Region III R.P.Powers P.A.Barrett G.P.Arent R.Whale D.Hahn Records Center, INPO NRC Resident Inspector'i190728008i
'll'ii0722 PDR ADGCK 050003i5 S PDR NRC FORM 366 U.S.NUCLEAR REG ORY COMMISSION (8-1993)LICENSEE EVENT REPORT (LER)(See reverse for required number of digits/characters for each block)APPRO BY OMB NO.3150<104 EXPIRES 06/30/2001 Esumated burden per response to comply with this mandatory Information couecuon request 50 hrs.Reported lessons learned are hcorpxated Into the licenshg process and fed back to ktdustry.Forward~regarding burden estimate to the Reoxds Management Branch (TA F33).U.S.Nucrear Regubrtory Commission, Washington.
DC~t~and to Ihe Paperwork ReducUon Pro)oct (31500104).
Ctree of Management and Budget, Washkrgton, DC 20503.If an information coukecuon does not display a currenUy vaud OMB control number, the NRC may not conduct or sponsor, aŽnd a person is not required to respond to.the kdormauon couecuon.FACILITY NAME (1)Cook Nuclear Plant Unit 1 DOCKET NUMBER (2)05000-315 PAGE (3)1 OF 3 TITLE (S)Improperly Installed Fuel Oil Return Relief Valve Renders Emergency Diesel Generator Inoperable Due to Personnel Error EVENT DATE (5)LER NUMBER (6)REPORT DATE (7)OTHER FACILITIES INVOLVED (6)MONTH DAY YEAR YEAR 1999 SEQUENTIAL REVISIO NUMBER N MONTH DAY YEAR FAclLITY NAME FACILITY NAME OOCKET NUMBER DOCKET NUMBER OPERATING MODE (9)LEVEL (10)THIS REPORT IS SUBMITTE 20.2203(a)(1) a D PURSUANT TO THE REQU IREMENTS OF 10 CFR II: (Check one or more)(11)a X 50.73(a)(2)(ii) a ul a v 20.2203(a)(3)(i) a n a vm 50.73(a)(2)(x) 20.2203(a)(2)(ii) a m a rv 20.2203(a)(4)
LICENSEE CONTACT FOR THIS LER 50.73(a)(2)(iv) a v 50.73(a)(2)(vii)
(12)In~RE Form 3BBA OTHER In Abstract below or Mr.Dennis D.Snodgrass, Compliance Engineer TELEPHONE NUMBER (include Area Code)(616)465-5901 X1627 COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DES CRIBED IN THIS REPORT (13)CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE To EPIX CAUSE SYSTEM COMPONENT MANUFACTURER REPORTABLE To EPIX SUPPLEMENTAL REPORT EXPECTED 14 YES (If yes, complete EXPECTED SUBMISSION DATE).X NO EXPECTED MONTH DAY YEAR ABSTRACT (Limit to 1400 spaces, i.e.~approximately 15 single-spaced typewritten lines)(16)On June 25, 1999 at 2030 hours0.0235 days <br />0.564 hours <br />0.00336 weeks <br />7.72415e-4 months <br /> EST with both units in Mode 5, the Unit 1 CD Diesel Generator (D/G)was determined to be inoperable after the fuel oil return relief valve was identified as being installed backwards.
The correct orientation of this valve is important to ensure that fuel oil is continuously circulated around the D/G fuel oil injector pump barrel for cooling.On June 25, 1999 at 2308 hours0.0267 days <br />0.641 hours <br />0.00382 weeks <br />8.78194e-4 months <br /> EST an ENS report was made in accordance with 10CFR 50.72(b)(2)(iii)(D), a condition that alone could have prevented the fulfillment of the safety function of systems that are needed to mitigate the consequences of an accident and 10CFR 50.72(b)(2)(i), a condition found while the reactor is shutdown that had it been found while in operation, would have resulted in the plant being seriously degraded or in an unanalyzed condition.
This LER is therefore submitted in accordance with 10CFR 50.73(a)(2)(v)(D) and 10CFR 50.73(a)(2)(ii)(A).
The apparent cause of this condition is personnel error.The valve has been installed backwards since prior to 1986.Inspection of the corresponding valves on the 1AB, 2AB and 2CD D/Gs determined the valves were installed in the correct orientation.
Operations entered the action statements for the applicable Technical Specifications upon declaring the Unit 1 CD D/G inoperable.
Following replacement of the valve and D/G surveillance testing the 1CD D/G was declared operable on July 7, 1999 at 2243 hours0.026 days <br />0.623 hours <br />0.00371 weeks <br />8.534615e-4 months <br /> EST.The successful completion of past Technical Specification (T/S)surveillance testsfor the Unit 1 CD D/G has verified acceptable engine performance, regardless of the incorrect orientation of this valve.A review of maintenance history did not reveal any abnormal D/G operation that could be attributed to the incorrect valve orientation.
Therefore, there were minimal implications to the health and safety of the public as a result of this event.If significant changes are identified as a result of completion of the root cause investigation, an update to this LER will be submitted.
NRC FORM 366A U.S.NUCLEAR REGULATORY COMMISSION (6-1998)LICENSEE EVENT REPORT (LER)TEXT CONTINUATION FACILITY NAME (1)DOCKET (2)NUMBER 2 LER NUMBER (6)PAGE (3)Cook Nuclear Plant Unit 1 05000-315 YEAR SEQUENTIAl.
NUMBER 1999 017 REVISION NUMBER 00 2 OF 3 TEXT (If more spece Is requfred, use edditionel copies of NRC Form 366A)(17)Conditions Prior To Event Unit 1 Mode 5 in Cold Shutdown Unit 2 Mode 5 in Cold Shutdown Descri tion Of The Event On June 25, 1999 at 2030 hours0.0235 days <br />0.564 hours <br />0.00336 weeks <br />7.72415e-4 months <br /> EST with both units in Mode 5, the Unit 1 CD D/G (EIIS:EK)was determined to be inoperable.
White performing inspections of D/G fuel oil lines (EIIS:DC), the Unit 1 CD D/G fuel oil return relief valve (EIIS:DC/FCV) was identified as being installed backwards.
The correct orientation of this valve is important to ensure that fuel oil is continuously circulated around the 0/G fuel oil injector pump barrel for cooling.In the as-found orientation, the valve would not have lifted off of its seat at the required setpoint and would not have supplied the designed cooling to the fuel oil injector pump.The valve is shown in the incorrect orientation on the current revision 3 of a plant isometric drawing.A review of previous revisions of this drawing indicates that the incorrect orientation was incorporated in revision 2, dated 1986.Revision 1 dated 1973, indicated that the relief valve was correctly orientated but installed in a different physical location.A review of documentation provided no reason for the drawing change, other than to reflect"As-Found" conditions.
Inspection of the corresponding valves for the 1AB, 2AB and 2CD D/Gs determined that the valves were installed in the correct location and orientation in the plant.However, the 1AB D/G isometric drawing shows the wrong location for the valve.Cause Of The Event The apparent cause of this condition is personnel error.Drawing changes and discussion with the vendor indicate that the D/G fuel oil return relief valves were initially supplied skid mounted on the diesel fuel oil return manifold but subsequently moved to the diesel fuel oil day tank room during plant construction.
The process used to relocate the valve to its present location and when this occurred could not be determined from available documentation.
Therefore; the valve was apparently installed incorrectly during plant construction and drawings were as-built to reflect the incorrect installation.
Subsequent reviews of drawing changes were inadequate in that they did not identify the incorrect field installation.
Anal sis Of The Event On June 25, 1999 at 2308 hours0.0267 days <br />0.641 hours <br />0.00382 weeks <br />8.78194e-4 months <br /> EST an ENS report was made in accordance with 10CFR50.72(b)(2)(iii)(D), a condition that alone could have prevented the fulfillment of the safety function of systems needed to mitigate the consequences of an accident and 10CFR50.72(B)(2)(l), a condition found while the reactor is shutdown that had it been found while in operation, would have resulted in the plant being seriously degraded or in an unanalyzed condition.
The D/G fuel oil return relief valve, set at 15 pounds per square inch pressure, is installed to maintain a fixed fuel pressure differential across the D/G fuel injection pump.This provides the proper fuel flow to achieve the required degree of cooling for the D/G fuel oil injection pump.In the as-found orientation, the valve would not have lifted off of its seat at the required setpoint at low load D/G operating conditions and proper cooling of the D/G fuel oil injection pump could have been affected.The successful completion of past Technical Specification (T/S)surveillance tests for the Unit 1 CD D/G has verified acceptable engine performance, regardless of the orientation of this valve.A review of maintenance history did.not reveal any abnormal D/G operation that could be attributed to the valve.Therefore, it has been concluded that there were minimal implications to the health and safety of the public as a result of this event.NRC FORM 866A (6-1 998)
NRC FORM 366A U.S.NUCLEAR REGULATORY COMMISSION (6.1999)LICENSEE EVENT REPORT (LER)TEXT CONTINUATION FACILITY NAME (1)Cook Nuclear Plant Unit 1 DOCKET (2)NUMBER 2 05000-315 YEAR LER NUMBER (6)SEQUENTIAL REVISION NUMBER NUMBER PAGE (3)3 OF 3 1999 017 00 TEXT (If more spaceis required, use additional copies of NRC Form 366A)(17)CORRECTIVE ACTIONS An Engineering Evaluation was performed to evaluate the as-found condition of the 1CD D/G fuel oil return relief valve and to determine required corrective actions.Inspection of the corresponding D/G fuel oil return relief valves and the fuel oil supply relief valves on each D/G determined that the extent of condition was limited to the 1CD D/G fuel oil return relief valve.The vendor was contacted to determine what inspections could be performed to determine if fuel oil injector pump damage had occurred as a result of inadequate cooling.The vendor indicated that there would be no real indication of pump damage until the pump seized.The only possible visible indication of overheating prior to seizure is that the fuel oil would separate and give the pump internals a"varnished" look.To remove and inspect the pumps would require recalibration at the factory due to the tight internal tolerances involved.It was decided not to inspect the pumps, since the pumps have a successful maintenance history and there were no precursors to indicate pump failure.Design Input Transmittals were issued to revise isometric drawings to reflect the correct 1CD D/G valve orientation and to revise the 1 AB D/G isometric drawing to refiect the correct valve location.The fuel oil return relief valve was replaced with a valve in the correct orientation.
Following surveillance testing, the 1CD D/G was declared op'erable on July 7, 1999 at 2243 hours0.026 days <br />0.623 hours <br />0.00371 weeks <br />8.534615e-4 months <br /> EST.AEP:NRC:1260GH,"Enforcement Actions98-150, S8-151, S8-152 and 98-186 Reply to Notice Of Violation October 13, 1998", dated March 19, 1999, responded to identified programmatic weaknesses in the plant Design and Licensing Basis, Control of Contractors and the Training and Qualification of personnel.
The Engineering Leadership Plan establishes a configuration management program to control plant design and a new design control process, which includes design verification, design document control, vendor technical documentation control and testing of design changes.The Leadership Plan for Control of Contractors insures that workers are qualified for the job, line management is accountable for workers job qualification, monitoring of work performance and performing an adequate review for quality.The Training and Qualification of Personnel Leadership Plan will reinforce a"nuclear safety culture" for site personnel.
These plans in whole will help preclude a similar event similar from occurring in the future.SIMILAR EVENTS 315/98-029-00 315/99-015-00, 315/99-016-00 NRC FORM 366A (6-1996)
